Successful Treatment of a Patient with Cardiac Arrest Due to Hyperkalemia by Prolonged Cardiopulmonary Resuscitation along with Hemodialysis: A Case Report and Review of the Literature.

Severe hyperkalemia is a potentially life threatening cardiac emergency, especially in patients with renal failure, and can lead to fatal arrhythmias such as ventricular fibrillation or asystole, leading to cardiac arrest. We report a case of a 39-year-old woman who developed sudden cardiac arrest secondary to hyperkalemia (9.95 mEq/L) with renal insufficiency. Despite 20 min of cardiopulmonary resuscitation (CPR) and conventional treatment for hyperkalemia, the cardiac arrest persisted. Hemodialysis was then initiated via the right femoral vein during CPR, and the patient restored spontaneous heartbeat 40 min later. Hemodialysis should be considered in the course of CPR in severe hyperkalemia induced cardiac arrest if conventional therapies fail.

Preoperative carbohydrate nutrition reduces postoperative nausea and vomiting compared to preoperative fasting.

BACKGROUND: The aim of this prospective, randomized, single-blinded study was to compare the effects of a carbohydrate drink 400 mL given 2 h before the surgery with preoperative overnight fasting on the gastric pH and residual volume, postoperative nausea and vomiting (PONV) and antiemetic consumption in patients undergoing laparoscopic cholecystectomy. MATERIALS AND METHODS: Forty American Society of Anesthesiologists physical status I-II patients who underwent elective laparoscopic cholecystectomy. Randomized, prospective, controlled study, Gulhane Medical Faculty and Guven Hospital Department of Anesthesiology and Reanimation. Patients were randomly assigned into two groups: Pre-operative carbohydrate drink group (group C, n = 20) and preoperative fasting group (group F, n = 20). Group C was given a 400 mL carbohydrate drink 2 h before to the surgery. The patients of group F were fasted 8 h before the surgery. Both groups were operated under general anesthesia with volatile anesthetics. RESULTS: Hemodynamic parameters, demographic data, gastric acidity and residual volumes were similar for both groups. No complications were observed. PONV and antiemetic consumption was lower in group C compared to group F (P = 0.001). Patient's satisfaction was higher in group C (P < 0.001). CONCLUSION: This study showed that pre-operative carbohydrate drink may be used safely and also improves patient's satisfaction and comfort in patients undergoing laparoscopic cholecystectomy.

Efficacy of different concentrations of sevoflurane administered through a face mask for magnetic resonance imaging in children.

BACKGROUND: The main aim of this study was to use a non-invasive method such as a face mask to maintain anesthesia in children during magnetic resonance imaging (MRI). The secondary aim was to ascertain hemodynamic-respiration parameters, recovery time and complications of anesthesia with the administration of different concentrations of sevoflurane. METHODS: This prospective and randomized study included 96 ASA I-II children, aged 1-10, scheduled to undergo MRI with anesthesia with sevoflurane through a face mask. All patients were administered midazolam 0.5 mg·kg(-1) orally 30 min before anesthesia induction. Sevoflurane 8% was given to induce anesthesia under assisted-controlled ventilation for 2 min, and an intravenous route was opened on the hand. Three different concentrations of sevoflurane were administered through a face mask under spontaneous respiration to maintain anesthesia. A mixture of sevoflurane, oxygen, and air of 5 l·min(-1) was given through a face mask for anesthesia. Group 1 (n = 32) received 1.5% sevoflurane, Group 2 (n = 32) 1.25% sevoflurane, and Group 3 (n = 32) 1.0% sevoflurane. Recovery time, removal from the MRI room, postanesthesia care unit discharge data, and complications were also recorded. Heart rate, mean arterial pressure (MAP), peripheral oxygen saturation (SpO(2)), respiration rate, and anesthesia adequacy were recorded every 5 min from the time of induction until completion of the MRI. RESULTS: All three groups were similar in demographic and hemodynamic respiratory features. MRI was successfully performed in 96.6% of all patients without additional intervention. Sevoflurane concentrations were increased for a short time in one patient in Group 1 and in two patients in Group 3. Oxygen flow was increased in one patient in Group 1 and in one patient in Group 2 as SpO(2) was lower than 95%. The mean time to eye opening (from discontinuation of sevoflurane to eye opening) was 155.8 ± 50.0 s in Group 1, 89.5 ± 16.0 s in Group 2, and 53.5 ± 10.0 s in Group 3; differences between the groups were statistically significant (P = 0.001). Airways were not used on any of the patients, and none vomited or required endotracheal intubation or laryngeal mask anesthesia. CONCLUSIONS: We believe that the administration of sevoflurane at a concentration of 1% via a face mask under spontaneous respiration may provide light anesthesia without complications to induce an unarousable sleep for children during MRI.

[Pain treatment practice according to the WHO analgesic ladder in cancer patients: eight years experience of a single center]. / Kanser hastalarinda WHO analjezik basamak tedavisine göre agri tedavisi. Bir merkezin sekiz yillik deneyimi.

In this study we evaluated the results of pain treatment practices according to the World Health Organization analgesic ladder treatment. and other treatment modalities in cancer patients who were admitted to an anesthesiology-based pain service. Patient characteristics, distribution of the patients according to the primary pathologic sites, initial and last distribution of the patients according to analgesic ladder treatment, other invasive or non-invasive treatment modalities, side effects, and other data related with the patients were examined. 416 of 475 (87.5%) patients were treated using the WHO analgesic ladder treatment, 57 patients (12 %) were treated by invasive techniques. The number of successfully treated patients in step I, II and III were 49 (11.77%), 307 (73.79%) and 60 (14.42) respectively. 181 of 416 (43.50%) patients used anticonvulsants or neuroleptics, 341 of 416 (81.97%) patients used antidepressants. In 31 of 416 patients (7.5%), non-invasive or invasive treatment modalities had become necessary to augment the WHO analgesic ladder treatment. Over the entire treatment period, side effects were reported in 17.05% of the patients. The follow-up time for the patients was 42 +/- 109.7 days, the mean interview number was 5.6+/-7.6, the longest follow-up time was 1380 days, and the maximum number of the interviews made by the same patient was 68. In conclusion, we think that, using the World Health Organization analgesic ladder treatment and administering appropriate analgesics and adjuvants in appropriate oral doses determined for appropriate subjects could successfully treat a great number of these patients.

Topical cannabinoid antinociception: synergy with spinal sites.

Analgesic effects of cannabimimetic compounds have been known to be related to their central effects. Cannabinoid receptors also exist in the periphery but their role in pain perception has been remained to be clarified. Therefore, we assessed topical antinociceptive effects of WIN 55, 212-2, a mixed CB(1) and CB(2) receptors agonist, in mice using tail-flick test. Immersion of the tail of mouse into the WIN 55, 212-2 solution produced dose-dependent antinociception. This antinociceptive activity was limited to the portion of the tail exposed to WIN 55, 212-2. The antinociceptive response was dependent on duration of exposure to WIN 55, 212-2 solution. The topical antinociceptive effects of WIN 55, 212-2 were dose dependently blocked by topical pretreatment of CB(1) receptor-selective antagonist, AM 251. Thus, topical antinociceptive action of WIN 55, 212-2 involve CB(1) receptors. Intrathecal (i.th.) administration of WIN 55, 212-2 produced a dose-dependent antinociceptive effect. Interestingly, ineffective i.th. doses of WIN 55, 212-2 produced a marked antinociception when combined with topical application of WIN 55, 212-2 and topical antinociceptive effect was potentiated. The dose-response curve of i.th. WIN 55, 212-2 was shifted to the left 15-fold by topical WIN 55, 212-2. This finding suggests that there is an antinociceptive synergy between peripheral and spinal sites of cannabinoid action and it also implicates that local activation of cannabinoid system may regulate pain initiation in cutaneous tissue. Our findings support that cannabinoid system participates in buffering the emerging pain signals at the peripheral sites in addition to their spinal and supraspinal sites of action. In addition, an antinociceptive synergy between topical and spinal cannabinoid actions exists. These results also indicate that topically administered cannabinoid agonists may reduce pain without the dysphoric side effects and abuse potential of centrally acting cannabimimetic drugs.

Cannabinoids blocks tactile allodynia in diabetic mice without attenuation of its antinociceptive effect.

Diabetic neuropathic pain is one of the most commonly encountered neuropathic pain syndromes. However, the treatment of diabetic neuropathic pain is challenging because of partial effectiveness of currently available pain relievers. It is well known that diabetic animals are less sensitive to the analgesic effect of morphine, and opioids are found to be ineffective in the treatment of diabetic neuropathic pain. Cannabinoids are promising drugs and they share a similar pharmacological properties with opioids. It has been reported that cannabinoid analgesia remained intact and to be effective in some models of nerve injury. Thus, we investigated antinociceptive efficacy and the effects of cannabinoids on behavioral sign of diabetic neuropathic pain in diabetic mice by using WIN 55, 212-2, a cannabinoid receptor agonist. Diabetes was induced by streptozotocin (STZ) (200mg/kg) and animals were tested between 45 and 60 days after onset of diabetes. Antinociception was assessed using the radiant tail-flick test. Mechanical and thermal sensitivities were measured by Von Frey filaments and hot-plate test, respectively. Tactile allodynia, but not thermal hyperalgesia developed in diabetic mice. Systemic WIN 55, 212-2 (1, 5 and 10mg/kg) produced a dose-dependent antinociception both in diabetic and control mice. WIN 55, 212-2-induced antinociception were found to be similar in diabetic mice when compared to controls suggesting efficacy of cannabinoid antinociception was not diminished in diabetic mice. WIN 55, 212-2 also produced a dose-dependent antiallodynic effect in diabetic mice. This study suggests that cannabinoids have a potential beneficial effect on experimental diabetic neuropathic pain.

Major surgery and anesthetic technique in epidermolysis bullosa.

Epidermolysis bullosa is a hereditary rare condition characterized with local and generalized lesions and autosomal dominant trait with variable penetrance. It was decided to amputate the left leg under the knee of a female patient with epidermolysis bullosa with squamous cell carcinoma. The smallest trauma may cause formation of serious bullous in the skin in epidermolysis bullosa. Surgeons, dermatologists, and anesthesiologists must evaluate the cases. During preoperative, intraoperative, and postoperative periods, all interventions that may cause interruption in circulation of the tissues cause irritation, or delay healing of the wounds must be avoided.

Pain relief during dressing changes of major adult burns: ideal analgesic combination with ketamine.

Pain management during burn dressing changes is a critical part of treatment in acute burn injuries. Although several treatment options have been suggested, it is still a challenge in a clinical setting. This study is aimed at finding out an ideal analgesic, sedative and/or anxiolytic combination that would minimise the unwanted effects of ketamine. A total of 24 patients, with burns up to 20-50% of total body surface area (TBSA), were included in the study and randomly divided into three groups. In group I, 2 mg kg(-1) ketamine was administered. In group II, 1 mg kg(-1) tramadol was administered and 30 min later, 1 microg kg(-1) dexmedetomidine and 2 mg kg(-1) ketamine was administered. In group III, 1 mg kg(-1) tramadol was applied and 30 min later, 0.05 mg kg(-1) midazolam and 2 mg kg(-1) ketamine was administered. The evaluation was performed with cardiopulmonary monitoring, sedation and visual analogue pain scores and overall patient satisfaction. Any adverse effects of ketamine were recorded. The results showed that group II had better outcomes with respect to pain management during dressing changes. As a conclusion, the use of the combination of ketamine, tramadol and dexmedetomidine was found to be a good treatment option for the prevention of the procedural pain suffered by adult patients during dressing changes.

Pressure-controlled vs volume-controlled ventilation during laparoscopic gynecologic surgery.

STUDY OBJECTIVE: To quantify and compare the effects of conventional volume-controlled ventilation (VCV) with the alternative mode, pressure-controlled ventilation (PCV), on respiratory mechanics and noninvasive hemodynamic parameters in patients undergoing laparoscopic gynecologic surgery. DESIGN: Randomized controlled trial (Canadian Task Force classification I). SETTING: Respiratory mechanics and hemodynamic parameters were recorded for each patient at time T1, 10 minutes after induction, in the supine position; T2, 15 minutes after pneumoperitoneum, in the Trendelenburg position; and T3, 10 minutes after pneumoperitoneum withdrawal, in the supine position. PATIENTS: Sixty women, aged 20 to 50 years, undergoing laparoscopic gynecologic surgery, with American Society of Anesthesiologists classes I and II disease. INTERVENTIONS: Patients were randomly allocated to 1 of 2 groups. In the VCV group (n = 30), ventilation mode was maintained, whereas in the PCV group (n = 30), ventilation mode was changed to PVC. MEASUREMENTS AND MAIN RESULTS: Both groups were comparable insofar as patient characteristics, operating time, pneumoperitoneum time, anesthesia time, and mean operative time. VCV was associated with a significant increase in peak airway pressure, plateau pressure, and airway resistance at T2 (p < .05). Compliance was significantly higher in the PCV group at T2 (p < .05). No other statistically significant differences were found between the groups. CONCLUSIONS: Both VCV and PCV seem to be equally suited for use in patients undergoing laparoscopic gynecologic surgery. However, lower peak airway pressure, plateau pressure, and airway resistance, and higher compliance are observed with PCV in laparoscopic gynecologic surgery.

Congenital Cervical Teratoma:Anaesthetic Management (The EXIT Procedure).

SUMMARY: Ex utero intrapartum treatment (EXIT) is a procedure performed during caesarean section with preservation of fetal-placental circulation, which allows the safe handling of fetal airways with risk of airways obstruction. This report aimed at describing a case of anaesthesia for EXIT in a fetus with cervical teratoma. A 30-year-old woman, 70 kg, 160 cm, gravida 2, para 1, was followed because of polyhydramniosis diagnosed at 24 weeks' gestation. During a routine ultrasonographic examination at 35 weeks' gestation, it was noticed that the fetus had a tumoral mass on the anterior neck, the mass had cystic and calcified components and with a size of was 10 x 6 x5 cm. The patient with physical status ASA I, was submitted to caesarean section under general anaesthesia with mechanically controlled ventilation for exutero intrapartum treatment (EXIT). Anaesthesia was induced in rapid sequence with fentanyl propofol and rocuronium and was maintained with isoflurane in 2.5 at 3 % in O and N O (50%). After hysterotomy, fetus was partially released assuring uterus-placental circulation, followed by fetal laryngoscopy and tracheal intubation. The infant was intubated with an uncuffed, size 2.5 endotracheal tube. Excision of the mass was performed under general anaesthesia. After surgical intervention, on the fourth postoperative day, the infant was extubated and the newborn was discharged to the pediatric neonatal unit and on the seventh day postoperatively to home without complications. Major recommendations for EXIT are maternal-fetal safety, uterine relaxation to maintain uterine volume and uterus-placental circulation, and fetal immobility to help airway handling. We report one case of cervical teratoma managed successfully with EXIT procedure.

Comparison of the local anesthetic effects of chlorpheniramine, midazolam, lidocaine, and normal saline after intradermal injection.

BACKGROUND: Local anesthetic effects of antihistamines are well known, but have been tested more for diphenhydramine than for chlorpheniramine. Midazolam, a benzodiazepine gamma-aminobutyric acid type A receptor agonist, induces spinally mediated analgesia. However, the local anesthetic effects of chlorpheniramine and midazolain have not been adequately studied. The purpose of this study was to assess the infiltration pain and the local anesthetic effects of intradermial chlorpheniramine and midazolam. MATERIAL/METHODS: This prospective, double-blind study compared the effects of intradermal chlorpheniramine, midazolam, lidocaine, and saline for pain on injection and degree of local anesthesia in adult volunteers. Each received 0.5 ml of the four solutions as intradermal injections in a standardized manner on the volar side of the forearm. Pain on injection and the degree of local anesthesia (tested by pinprick, light touch, and cold) at each site was evaluated on a 0-3 scale at designated time intervals. RESULTS: Pain on injection of chlorpheniramine was more intense than saline (p=0.047) and lidocaine (p<0.001). Midazolam was significantly more painful than lidocaine (p<0.001), but not different from saline (p=0.170). Lidocaine caused a significant reduction in sensation to pinprick, touch, and cold during the study period compared with saline and midazolam. Chlorpheniramine also produced a significant reduction in sensation to pinprick and cold until the 120th minute and in sensation to touch until the 90th minute compared with saline. CONCLUSIONS: Intradermal chlorpheniraline, but not midazolam, produced a local anesthetic effect; however, the duration of this effect of chlorpheniramine was shorter than that of lidocaine.