Analgesic effect of erector spinae plane block after cesarean section: A randomized controlled trial.

Background: Ultrasound-guided bilateral erector spinae plane block is also a technique for providing analgesia after a cesarean section. Aim: We hypothesized that bilateral erector spinae plane block applied from the transverse process of T9 who underwent elective cesarean section could provide effective postoperative analgesia. Patients and Methods: Fifty parturients who were scheduled to undergo elective cesarean section under spinal anesthesia were included in the study. Group SA (n = 25) was categorized as the group in which spinal anesthesia alone (SA) was performed, and Group SA+ESP (n = 25) was categorized as the group in which SA + ESP block was performed. All patients were given a solution containing 7 mg isobaric bupivacaine + 15 µg fentanyl intrathecally through spinal anesthesia. In the SA + ESP group, the bilateral ESPB was performed at level T9 with 20 ml 0.25% bupivacaine + 2 mg dexamethasone immediately after the operation. Total fentanyl consumption in 24 h, the visual analogue scale for pain, and time to the first analgesic request were evaluated postoperatively. Results: The total fentanyl consumption in 24 h was statistically significantly lower in the SA + ESP group than the SA group (279 ± 242.99 µg vs. 423.08 ± 212.55 µg, respectively, P = 0.003). The first analgesic requirement time was statistically significantly shorter in the SA group than the SA + ESP group (150.20 ± 51.83 min vs. 197.60 ± 84.49 min, respectively, P = 0.022). Postoperative VAS scores at 4th, 8th, and 12th h at rest were statistically significantly lower in group SA + ESP than in group SA (P = 0.004, P = 0.046, P = 0.044, respectively). VAS scores during the postoperative 4th, 8th, and 12th h cough were statistically significantly lower in group SA + ESP than in group SA (P = 0.002, P = 0.008, P = 0.028, respectively). Conclusion: Ultrasound-guided bilateral ESP provided adequate postoperative analgesia and significantly decreased postoperative fentanyl consumption in patients having cesarean section. Also, it has a longer analgesia time than the control group, and it has been shown to delay the first analgesic requirement.

Development of an intranasal formulation containing indomethacin and xylometazoline for rhinosinusitis treatment.

OBJECTIVE: Use of the nasal route of drug administration dates back many years and is used both to achieve topical treatments and to allow systemic absorption. The objective was to develop a formulation with novel features which enhance prolonged contact with the nasal and sinusal lining, since this should increase any therapeutic benefit. The anti-inflammatory drug selected was indomethacin, which was combined with xylometazoline, an effective nasal decongestant agent. MATERIALS AND METHODS: 28 Sprague-Dawley rats were used. They were then allocated at random to one of the four groups of equal size. All rats received a nasal application of 50mL of the platelet-activating factor solution at a concentration of 16 µg/mL and had induced rhinosinusitis. Indomethacin or xylometazoline HCl or both were dissolved in the oily phase of the solution and then a magnetic stirrer was used to homogenize the solution for 60 min at room temperature. All the O/W solutions exhibited stability and remained at neutral pH for the entire duration of the experiment. The only intervention was application of inactive 0.9% saline in group 1. The intervention was nasal application of xylometazoline and indomethacin in the combined formulation in group. The intervention was nasal application of xylometazoline only in group 3. The intervention was nasal application of indomethacin only in group 4. RESULTS: For the animals in group 1 (the controls), the mucosa had sustained a significant level of damage and the vessels were highly congested. Inflammatory cells were extensively infiltrating the mucosa. (Figure 1 - A1, 2, 3). In group 2, by contrast, the vessels were hardly congested and there were very few infiltrates. The epithelium appeared completely intact (Figure 1 - B1, 2, 3). Furthermore, when groups 1 and 2 were compared in terms of congested vessels, inflammatory cellular infiltrates and injury to the epithelium, the differences reached statistical significance, with p-values of <0.01, >0.001 and <0.001, respectively. Comparison of groups 2 and 4 with the control group also revealed statistically significant differences in terms of cellular infiltrates (p<0.001) and damage to the epithelium (p<0.001). For the degree of congestion of the vessels, however, the difference between groups was not at the level of statistical significance (p<0.071). Groups 3 and 4 differed at a statistically significant level in terms of degree of congested vessels, cellular infiltrates, and damage to the epithelium (p<0.025 and p<0.001). The sections from rats in groups 2 and 3 had a lower degree of congested vessels, which may be due to the actions of xylometazoline. CONCLUSIONS: In the future, topically applied intranasal NSAIDs will be valuable formulations. Innovative types of formulation, such as those demonstrating thixotropic behavior, permit the agent to remain in prolonged contact with the nasal and sinusal lining. Alongside increased efficacy, these preparations will also improve the side effect profile of NSAIDs, largely eliminating systemic effects.

The Effect of Pre-emptive Dexketoprofen Administration on Postoperative Pain Management in Patients with Ultrasound Guided Interscalene Block in Arthroscopic Shoulder Surgery.

Background: Postoperative pain is an important problem for patients undergoing shoulder surgery. Our study investigated analgesic efficacy, duration of analgesia, postoperative analgesic use and patient satisfaction with the use of preemptive intravenous dexketoprofen for interscalene block in addition to general anesthesia in arthroscopic shoulder surgery. Methods: 60 patients, scheduled for arthroscopic shoulder surgery were randomized (30 patients each) into either: - control group (Group1) or dexketoprofen group (Group 2). Patients were followed for 48 hours to compare both groups for; post-operative pain scores, effectiveness of postoperative analgesia, duration of analgesia, and analgesia consumption. Duration of postoperative sensory block of the shoulder joint was defined as time to onset of pain at the incision site. Duration of postoperative motor block of the shoulder joint was defined as time to onset of first shoulder movement. Results: While no significant difference was determined for motor block time, sensory block time was significantly longer in the dexketoprofen group (p < 0.05).VAS scores were significantly lower at all times in the dexketoprofen group (p < 0.05).Total PCA fentanyl consumption was 274.16 ± 314.89 (µg) in the dexketoprofen group, and 490.00 ± 408.98 (µg) in the control group, the difference was statistically significant (p < 0.05). No significant difference was observed between the groups' demographic and hemodynamic data. Conclusion: Pre-emptive IV dexketoprofen may be a good option for arthroscopic shoulder surgery and provides effective analgesia.

Effect of 6% hydroxyethyl starch 130/0.4 on kidney and haemostatic function in cardiac surgical patients: a randomised controlled trial.

Whether third-generation hydroxyethyl starch solutions provoke kidney injury or haemostatic abnormalities in patients having cardiac surgery remains unclear. We tested the hypotheses that intra-operative administration of a third-generation starch does not worsen postoperative kidney function or haemostasis in cardiac surgical patients compared with human albumin 5%. This triple-blind, non-inferiority, clinical trial randomly allocated patients aged 40-85 who underwent elective aortic valve replacement, with or without coronary artery bypass grafting, to plasma volume replacement with 6% starch 130/0.4 vs. 5% human albumin. Our primary outcome was postoperative urinary neutrophil gelatinase-associated lipocalin concentrations, a sensitive and early marker of postoperative kidney injury. Secondarily, we evaluated urinary interleukin-18; acute kidney injury using creatinine RIFLE criteria, coagulation measures, platelet count and function. Non-inferiority (delta 15%) was assessed with correction for multiple comparisons. We enrolled 141 patients (69 starch, 72 albumin) as planned. Results of the primary analysis demonstrated that postoperative urine neutrophil gelatinase-associated lipocalin (median (IQR [range])) was slightly lower with hydroxyethyl starch (5 (1-68 [0-996]) ng.ml-1 ) vs. albumin (5 (2-74 [0-1604]) ng.ml-1 ), although not non-inferior [ratio of geometric means (95%CI) 0.91 (0.57, 1.44); p = 0.15] due to higher than expected variability. Urine interleukin-18 concentrations were reduced, but interleukin-18 and kidney injury were again not non-inferior. Of 11 individual coagulation measures, platelet count and function, nine were non-inferior to albumin. Two remaining measures, thromboelastographic R value and arachidonic acid-induced platelet aggregation, were clinically similar but with wide confidence intervals. Starch administration during cardiac surgery produced similar observed effects on postoperative kidney function, coagulation, platelet count and platelet function compared with albumin, though greater than expected variability and wide confidence intervals precluded the conclusion of non-inferiority. Long-term mortality and kidney function appeared similar between starch and albumin.

The advantages of combination therapy on hypertension: development of immediate release perindopril-indapamide tablet and assessment of bioequivalence studies.

Hypertension has a major associated risk for organ damage and mortality, which is further heightened in patients with prior cardiovascular events, comorbid diabetes mellitus, microalbuminuria and renal impairment. Convers Plus tablet including perindopril erbumine (PE), which is an angiotensin converting enzyme (ACE) inhibitor, and indapamide, which is diuretic, was designed as a combined tablet to succes in the treatment of hypertension. Physico-pharmaceutical properties and characterization studies were evaluated in vitro conditions. Later on in vivo study was planned as a cross-designed, randomized, open-labeled, single-dose, single-center study via peroral route in 24 healthy male subjects. In this study, bioequivalence with primary pharmacokinetical target parameters reference (Bipreterax 4/1.25 mg Tablet-S.A.Servier Benelux N.V.) and test (Convers Plus 4/1.25 mg Tablet-ARGESAN Pharmaceutical Company) tablets have been found bioequivalent. The results of pharmacokinetic parameters for perindopril, perindoprilat and indapamide were found as Cmax = 23.179 µg/mL, tmax = 0.729 h, t1/2 = 1.429 h; AUC0-t = 26.998 µgs/mL, AUC0-inf = 27.117 µgs/mL; Cmax = 1.834 µg/mL, tmax = 8.792 h, t1/2 = 40.699 h; AUC0-t = 54.828 µgs/mL, AUC0-inf = 77.113 µgs/mL; Cmax = 18.994 µg/mL, tmax = 3.417 h, t1/2 = 16.626 h and AUC0-t = 385.829 µgs/mL, AUC0-inf = 410.728 µgs/mL respectively. In conclusion, physico-pharmaceutical properties and results of clinical trials show that Convers Plus tablets have been found as bioequivalent for perindopril, perindoprilat and indapamide in terms of AUC and Cmax, in 90% confidence limits.

The effect of colloid preload versus prophylactic ephedrine administration on QTc intervals during cesarean delivery: A randomized controlled study.

AIM: We aimed to investigate the effect of colloid infusion immediately before the spinal anesthesia, and the prophylactic intravenous (IV) infusion of ephedrine after injection of intrathecal bupivacaine on hemodynamic parameters, QT, The QT interval corrected for heart rate (QTc), and dispersion of QTc (QTcDisp) intervals in women undergoing the elective cesarean section. MATERIALS AND METHODS: Sixty women scheduled for elective cesarean delivery with spinal anesthesia were allocated randomly to receive either IV fluid preloading with 0.5 L of 6% w/v hydroxyethyl starch solution immediately before the spinal anesthesia (colloid group, n = 30) or prophylactic IV infusion of 15 mg ephedrine (diluted with 10 ml saline, n = 30) over 1-min period after the injection of intrathecal bupivacaine (ephedrine group). Electrocardiography (ECG) tracings were recorded before anesthesia procedure at baseline (T0), 5 min (T1), 10 min (T2), 30 min (T3), 60 min (T4), and 120 min (T5) after the spinal anesthesia. Systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation (SpO2) values were also recorded at the same time intervals. RESULTS: There were no significant differences between groups with respect to MAP, HR, SpO2, QT, and QTc intervals at any time points (P > 0.05). When compared with the colloid group, the QTcDisp interval at T1was significantly longer in the ephedrine group (P < 0.05). CONCLUSION: Both methods have similar effects on the ECG and hemodynamic parameters during cesarean section. So, both methods may be used in patients undergoing elective cesarean delivery under spinal anesthesia.

Anesthetic Management in Children with Congenital Lobar Emphysema.

BACKGROUND: The cause of congenital lobar emphysema (CLE) is unknown and characterized by hyperinflation of one or more lobes of the lung. The purpose of this retrospective study was to present the anesthetic management of children with congenital lobar emphysema (CLE) receiving treatment in our center. METHODS: Ten children underwent CLE-related surgical treatment in our center between March 1995 and August 2014. All cases were diagnosed on the basis of postero-anterior chest radiography and computerized tomography. Age, sex, preoperative clinical findings, location of lesions, surgical and anesthetic procedures, results of anesthesia and duration of hospitalization were evaluated. RESULTS: Six patients were male (60%) and four female (40%). Their ages ranged from 40 days to 6 years. Dyspnea was present in all cases and severe in four of them. Four patients had emphysema in the left upper lobe, three in the right middle lobe, one in the right upper lobe and one in the left lower lobe. All patients were extubated in the operating room and none experienced post-operative respiratory distress. Post-operative analgesia was provided via the previously placed intrapleural catheter. All the patients were extubated in the operation room. There was no post-operative mortality or morbidity. CONCLUSIONS: Anesthetic management of patients with CLE is challenging. In these patients the surgical team and -anesthetists should collaborate closely and the time between anesthesia induction and thoracotomy should be as short as possible.

Unusual localization of a primary superficial venous aneurysm: a case report.

OBJECTIVES: Primary aneurysms of superficial venous system are rare and frequently misdiagnosed as varicose veins. Clinical presentation is variable depending on the presence of compression to surrounding structures. We report a rare case of primary cephalic vein aneurysm presented with wrist pain due to radial nerve compression. METHOD/CASE: A 61-year-old woman was admitted with right wrist pain and localized mass. Physical and imaging examinations showed a localized cephalic vein aneurysm compressing radial nerve. Simple excision was performed successfully. RESULTS: Cosmetic and clinical results at the first month follow-up were successful. DISCUSSION: Although primary superficial venous aneurysms of upper extremities are very rare, the treatment of choice is most commonly same as the ones in lower limbs. Simple excision is the best approach in the most of the cases, while sclerotherapy could be preferred in order to obtain better cosmesis or to avoid injuries to surrounding structures.

Validation of cardiac output measurement with the LiDCO™ pulse contour system in patients with impaired left ventricular function after cardiac surgery.

After cardiac surgery, patients with low left ventricular ejection fraction probably benefit the most from accurate monitoring of continuous cardiac output. Thirty patients with impaired ventricular function were studied, and intermittent bolus thermodilution and continuous pulse contour (LiDCO plus™) cardiac output compared. Following lithium dilution calibration, a total of 220 paired results were recorded. Thermodilution and LiDCO measurements ranged from 2.3 to 11.0 and 2.6 to 10.8 l.min(-1), respectively. Corresponding means (SD) were 6.1 (1.6) and 6.2 (1.9) l.min(-1), with coefficients of variance of 26 and 31%, respectively. The correlation coefficient was 0.82, bias 0.28 l.min(-1) with upper and lower limits of agreement 1.96 and -1.41 l.min(-1); the percentage error was 27%. LiDCO showed good correlation, marginal bias and acceptable limits of agreement and percentage error. It could therefore potentially replace thermodilution as a means of measuring cardiac output in the ICU, particularly when determination of pulmonary artery pressure is not required.

Effects of Pinus brutia bark extract and Pycnogenol in a rat model of carrageenan induced inflammation.

The present study was conducted to explore the anti-inflammatory activities of Pinus brutia bark extract and Pycnogenol in a rat model of carrageenan-induced inflammation. Firstly, the compositions of both samples were determined using HPLC. Then, carrageenan-induced paw edema was used to assess anti-inflammatory activity in mice. Paw volume was measured before and 1, 2, 3, 4, 5 and 6h after the injection of carrageenan. Intraperitoneal administration of both the extract and Pycnogenol inhibited paw swelling dose-dependently at 2, 3, 4, 5 and 6h after carrageenan injection. Both samples exhibited significant anti-inflammatory activities at doses of 75 and 100 mg/kg body wt. between 2 and 4 hours after administration (p<0.05), respectively. Additionally, P. brutia bark extract showed significantly better activity at doses of 75 and 100mg/kg body wt. than indomethacine at the dose of 10mg/kg body wt. (p<0.05). No acute toxicity was identified in intraplantar injection of the extract at a dose of 2000 mg/kg body wt.. Therefore, P. brutia bark extract possessing 3.3-fold more total catechins and 9.8-fold more taxifolin than Pycnogenol can be utilized as an anti-inflammatory agent.

Theophylline granule formulation prepared by the wet granulation method: comparison of in vitro dissolution profiles and estimation of in vivo plasma concentrations.

The primary and secondary objectives of this study were to develop and evaluate the predictability of in vitro-in vivo correlation models for theophylline sustained release (SR) granules. Theophylline SR granules meeting the USP Drug Release Test criteria were prepared using ethyl cellulose (EC) and/or stearyl alcohol (SA) and the wet granulation method. In vitro dissolution studies of granule formulation were performed, and a commercial dosage form was prepared using USP XXIII apparatus II at pH 4.5. Differences and similarities between in vitro dissolution curves were compared using both model-dependent (t-test) and -independent (f1, f2 test) statistical techniques, and it was shown that the three dissolution profiles i.e model-dependent, model-independent, and methods based on ANOVA were very similar. The in vivo performance of the commercial dosage form was tested by oral route using male rabbits and in vitro-in vivo correlations were established. This study indicates that the dosage forms with similar in vitro dissolution profiles may have a similar in vivo performance, and that this performance could be estimated using appropriate correlation equations.

Hypericum triquetrifolium Turra. extract exhibits antinociceptive activity in the mouse.

The aim of the present study was to investigate the antinociceptive activity of Hypericum triquetrifolium Turra. extract. The lyophilized extract was administered to male Swiss mice. Formalin paw test and tail flick tests were used for the evaluation of the antinociceptive activity. Plant extract (10, 25, 50 and 60 mg kg(-1), i.p.) (n = 16-24 for each group) or vehicle (n = 27) was administered 30 min before the subplantar formalin injection. In the tail flick test, mice were examined for latency to withdraw their tails from a noxious thermal stimulus using a tail flick meter (n = 8 for each group). The effects of the extract on sensorimotor performance was also assessed (n = 16-24 for each group). The extract caused a significant dose-related inhibition of the first phase (50, 60 mg kg(-1), i.p.) and second phase (10, 25, 50 and 60 mg kg(-1), i.p.) of formalin induced hindpaw licking. Additionally, the extract administration (50, 60 mg kg(-1), i.p.) increased the tail flick latencies. No significant change was observed in any of the treatment groups in the sensorimotor performance test. The observed antinociceptive activity of the extract may be due to its noradrenaline and serotonin reuptake blocking activity. Moreover, the probable antiinflammatory activity of the extract may play a role in the dose-related inhibition of the second phase of formalin paw test.