The Effect of Different Propofol-Ketamine Combinations on Emergence Delirium in Children Undergoing Adenoidectomy and Tonsillectomy Surgery.

PURPOSE: Emergence delirium (ED) after sevoflurane anesthesia remains a serious issue in children. We aimed to compare different ratios of propofol-ketamine combinations to determine a better option for preventing ED. DESIGN: A prospective, randomized clinical trial. METHODS: In this study, 112 children aged between 3 and 12 years who underwent adenoidectomy and tonsillectomy were recruited. Propofol 1 mg kg-1 + ketamine 1 mg kg-1 (1:1 ratio), propofol 1.5 mg kg-1 + ketamine 0.75 mg kg-1 (2:1 ratio), propofol 2 mg kg-1 + ketamine 0.66 mg kg-1 (3:1 ratio), and propofol 3 mg kg-1 were applied at induction of anesthesia for Groups I, II, III, and IV, respectively. Fentanyl 1 mcg kg-1 and rocuronium 0.6 mg kg-1 were applied at induction, and anesthesia was maintained with sevoflurane and O2/N2O mixture for all participants. Intravenous morphine 0.1 mg kg-1 was applied for postoperative analgesia in the last 10 minutes of surgery. ED was defined as a Watcha score of ≥3. Demographics, hemodynamics, extubation time, Watcha scores, the Face, Legs, Activity, Cry, and Consolability scores, length of stay in the postanesthesia care unit (PACU), rescue analgesic requirement, and postoperative complications were recorded. FINDINGS: ED was significantly higher at 10 and 20 minutes in Group IV. Eighteen children experienced ED in PACU, (3, 2, 2, and 11 children in Groups I, II, III, and IV, respectively). Face, Legs, Activity, Cry, and Consolability scores were significantly different at all times. Rescue analgesics were required by 3 children (10.7%) in Group I, 2 (7.1%) in Group II, 2 (7.1%) in Group III, and 10 (35.7%) in Group IV (P = .012). The PACU stay was 21.9 ± 6.4 in Group I, 18.7 ± 6.3 in Group II, 16.7 ± 5.8 in Group III, and 17.4 ± 5.8 in Group IV. Nystagmus was observed in three children in Group I. CONCLUSIONS: To addition of ketamine to propofol during the induction of sevoflurane anesthesia can reduce the ED and analgesic requirements in children. A propofol-to-ketamine ratio of 3:1 provided better postoperative recovery with less pain and ED, without prolonging the PACU length of stay.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Perioperative Analgesia in Breast Reduction Surgery: A Prospective Randomized and Controlled Trial.

BACKGROUND: Ultrasound-guided erector spinae plane block (ESPB) is an interfascial plane block used for analgesia of the chest and abdominal wall. This study aimed to evaluate the perioperative analgesic efficacy of bilateral single-shot ESPB at T5 vertebral level in breast reduction surgery. MATERIALS AND METHODS: Sixty adult female patients scheduled for breast reduction surgery were included and randomly allocated to two groups to receive either preoperative ESPB with a local anesthetic mixture of 10 mL 0.5% bupivacaine, 5 mL 2% lidocaine, and 5 mL saline, or sham block. Patients in both groups received intraoperative remifentanil infusion and, postoperatively, morphine via the patient-controlled analgesia (PCA) device. The primary outcome was 24-h total morphine consumption, and secondary outcomes included intraoperative opioid consumption, postoperative pain intensity, time to first PCA request, supplement analgesic requirements, functional recovery, patient satisfaction, length of hospital stay, and side effects and complications. RESULTS: The 24-h total morphine consumption was significantly lower in the ESPB group vs. the sham group (mean ± SD, 6.7 ± 3.9, and 13.9 ± 5.7 mg, respectively, p < 0.001). Compared with sham block, ESPB reduced pain scores, intraoperative opioid consumption, supplement analgesic requirements, delayed time to first PCA request, and improved functional recovery and patient satisfaction. CONCLUSION: In breast reduction surgery, preoperative single-shot ESPB reduces perioperative opioid consumption and provides adequate pain relief within 24 h postoperatively compared to systemic analgesics alone. TRIAL REGISTRATION NUMBER: NCT03621345 LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of Ketamine Infusion on Oxygenation in Patients with Chronic Obstructive Pulmonary Disease Undergoing Lung Cancer Surgery.

OBJECTIVE: Ketamine changes respiratory mechanics, provides airway relaxation, and alleviates bronchospasm in patients with pulmonary disease. This study investigated the effect of a continuous infusion of ketamine during thoracic surgery on arterial oxygenation (PaO2/FiO2) and the shunt fraction (Qs/Qt) in patients with chronic obstructive pulmonary disease. METHODS: Thirty patients older than 40 years, diagnosed with chronic obstructive pulmonary disease, and undergoing lobectomy were recruited for this study. Patients were allocated randomly to 1 of 2 groups. At the induction of anaesthesia, group K received intravenous (iv) 1 mg kg-1 ketamine as a bolus and followed by 0.5 mg kg-1 h-1 infusion until the end of the operation. Group S received the same amount of 0.9% saline as a bolus at induction and followed by a 0.5-mL kg-1 h-1 infusion of 0.9% saline until the end of the operation. PaO2 and PaCO2 values, FiO2 levels, PaO2/FiO2 ratio, peak airway pressure (Ppeak), plateau airway pressure (Pplat), dynamic compliance, and shunt fraction (Qs/Qt) were recorded during two-lung ventilation as a baseline and at 30 (one-lung ventilation, OLV-30) and 60 (OLV-60) minutes during one-lung ventilation. RESULTS: PaO2, PaCO2, PaO2/FiO2 values, and Qs/Qt ratio were similar between the 2 groups at OLV-30 minute (P = .36, P = .29, P = .34). However, at OLV-60 minute, PaO2, PaO2/FiO2 values were significantly increased, and Qs/Qt ratios were significantly decreased in group K than in group S (P = .016, P = .011, P = .016). CONCLUSIONS: Our data suggest that a continuous infusion of ketamine and desflurane inhalation in patients with chronic obstructive pulmonary disease during one-lung ventilation increase arterial oxygenation (PaO2/FiO2) and decrease shunt fraction.

The Anti-Inflammatory and Antioxidant Effects of Propofol and Sevoflurane in Children With Cyanotic Congenital Heart Disease.

OBJECTIVE: The authors aimed to compare the anti-inflammatory and antioxidant effects of propofol and sevoflurane in children with cyanotic congenital heart disease (CCHD) undergoing cardiac surgery with cardiopulmonary bypass. DESIGN: Prospective, randomized, double-blind study. SETTING: Single center, university hospital. PARTICIPANTS: Children ages 1-10 years with CCHD undergoing elective cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Children were randomized to receive general anesthesia with either sevoflurane (group S) or propofol (group P). Systemic inflammatory response syndrome (SIRS) occurrence was assessed at the end of the surgery and at the sixth, 12th, and 24th postoperative hours. Blood samples were obtained at 4 times: after anesthesia induction (T0), after release of the aortic cross-clamp (T1), at the end of the surgery (T2), and at the postoperative 24th hour (T3). The serum levels of interleukin 6 and tumor necrosis factor alpha, and the total antioxidant status (TAS) and total oxidant status, were analyzed. RESULTS: SIRS was more common in group S than in group P at all times (p = 0.020, p = 0.036, p = 0.004, p = 0.008). There were no significant differences between the groups in the mean tumor necrosis factor alpha and interleukin 6 levels at any time. The TAS level at T2 was higher in group P than group S (p = 0.036). The serum TAS level increased at T2 compared with T0 in group P, but it decreased in group S (p = 0.041). CONCLUSION: The results showed that propofol provided a greater antioxidant effect and reduced SIRS postoperatively more than sevoflurane in children with CCHD undergoing cardiac surgery.

Bilateral erector spinae plane blocks in children undergoing cardiac surgery: A randomized, controlled study.

STUDY OBJECTIVE: We aimed to test the hypothesis that erector spinae plane block (ESPB) provides efficient analgesia and reduces postoperative morphine consumption in children undergoing cardiac surgery with median sternotomy. DESIGN: A prospective, blinded, randomized, controlled study. SETTING: A tertiary university hospital, operating room and intensive care unit. PATIENTS: Forty children aged 2-10 years, who underwent cardiac surgery with median sternotomy. The patients were randomly divided into the block group (Group B) and the control group (Group C). INTERVENTIONS: Group B (n = 20) were treated with ultrasound-guided bilateral ESPB at the level of the T4-T5 transverse process, whereas no block was administered in Group C (n = 20). In all children, intravenous morphine at 0.05 mg/kg was used whenever the modified objective pain score (MOPS) ≥4 for postoperative analgesia. MEASUREMENTS: The MOPS and Ramsay sedation score (RSS) were assessed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20 and 24 h postoperatively. Total morphine consumption at 24 h, extubation time and length of intensive care unit (ICU) stay was also evaluated and recorded. MAIN RESULTS: Bilateral ESPB significantly decreased the consumption of morphine in the first 24 h, postoperatively. During the postoperative 24-h follow-up, 11 children in Group C requested morphine and the cumulative dose of morphine was 0.83 ± 0.91 mg, while 4 children in Group B requested morphine and the cumulative dose of morphine was 0.26 ± 0.59 mg (p = 0.043). There was no significant difference between Groups B and C in terms of MOPS and RSS values, extubation time or length of ICU stay. CONCLUSION: Ultrasound-guided bilateral ESPB with bupivacaine provides efficient postoperative analgesia and reduces postoperative morphine consumption at 24 h in children undergoing cardiac surgery.

Point-of-care ultrasound assessment of the inferior vena cava distensibility index in mechanically ventilated children in the operating room

Background and aim: Point-of-care ultrasound imaging of the inferior vena cava distensibility index is a potential indicator for determining fluid overload and dehydration in the mechanically ventilated patients. Data on inferior vena cava distensibility index and inferior vena cava distensibility variability are limited in mechanically ventilated pediatric patients. That is why our aim in this study was to measure inferior vena cava distensibility index and to obtain mean values in pediatric patients, ventilated in the operating room before the ambulatory surgical procedure started. Materials and methods: This crosssectional study was performed between February 2019 and February 2020. Ultrasonographic measurements were performed in a total of 125 children. Results: In a period of 13 months, the measurements were performed in a total of 125 children, of which 120 (62.5% male) met the criteria and were included in the study. Overall inferior vena cava distensibility index (%): mean ± SD: 6.8 ± 4.0, median (min­max): 5.7 (1.4­19.6), IQR: 3.8­8.7. Overall inferior vena cava distensibility variability (%): mean ± SD: 6.5 ± 3.7, median (min­max): 5.5 (1.4­17.8), IQR: 3.7­8.4. Conclusion: Our study is the largest series of children in the literature in which inferior vena cava distensibility index measurements were investigated.

Comparison of the effects of preoperative melatonin or vitamin C administration on postoperative analgesia.

The analgesic benefit of melatonin and vitamin C as primary or adjuvant agents has been reported in various studies; however, their analgesic effects in the treatment of postoperative pain remain unclear. Thus, we aimed to evaluate the effect of single preoperative dose of oral melatonin or vitamin C administration on postoperative analgesia. In this study, we recruited 165 adult patients undergoing elective major abdominal surgery under general anesthesia. Patients were randomly divided into three equal (n = 55) groups. One hour before surgery, patients received orally melatonin (6 mg) in group M, vitamin C (2 g) in group C, or a placebo tablet in group P. Pain, sedation, patient satisfaction, total morphine consumption from a patient-controlled analgesia device, supplemental analgesic requirement, and the incidence of nausea and vomiting were recorded throughout 24 h after surgery. The mean pain score and total morphine consumption were found significantly lower in both M and C groups compared with group P (p < 0.001). There were no significant differences between group M and C with respect to pain scores (p = 0.117) and total morphine consumption (p = 0.090). Patients requested less supplemental analgesic and experienced less nausea and vomiting in groups M and C compared with group P. In conclusion, preoperative oral administration of 6 mg melatonin or 2 g vitamin C led to a reduction in pain scores, total morphine consumption, supplemental analgesic requirement, and the incidence of nausea and vomiting compared with placebo.

Retrospective Analysis of Eighty-Nine Caesarean Section Cases with Abnormal Placental Invasion.

OBJECTIVE: Abnormal placental invasion (API) is defined as an abnormal adherence of the placenta to the underlying uterine wall. Undiagnosed API may result in catastrophic maternal haemorrhage during delivery. In the present retrospective analysis, anaesthetic and surgical records were evaluated in patients with API who had undergone caesarean delivery (CD). METHODS: Clinical records of 89 patients with API who had undergone CD were retrospectively reviewed in our clinic between April 2010 and February 2017. RESULTS: Amongst the patients, 87 (97.8%) had a history of previous CD and 68 (76.4%) had placenta previa. In regression analysis, weak positive correlation was found between an increase in packed red blood cell (PRBC) (r=0.420, p=0.001) and fresh frozen plasma (FFP) (r=0.476, p=0.022) transfusions and time of hospital stay. PRBC and FFP consumptions were significantly greater in intensive care unit (ICU) patients than in non-ICU patients (p<0.001). ICU requirement were significantly greater in patients who had more than average crystalloid (p=0.004) and colloid (p<0.001) infusions. Elective CD was performed in 81 (91%) patients and emergency CD in 8 (9%). PRBC transfusions were 7±4.3 U in patients undergoing emergency CD and 3.85±3 U in patients undergoing elective CD (p=0.034). The number of patients requiring care in ICU was 4 (50%), who underwent emergency CD and 12 (14%) who underwent elective CD, (p=0.032). CONCLUSION: It is crucial that the anaesthesiologist should be familiar with the risk factors and diagnosis of API because of the potential risk of massive haemorrhage. Multidisciplinary approach with surgery and blood bank decreases the amount of bleeding, blood transfusion requirement, ICU and hospital stay in patients with API.