The Effect of Apical Vertebra Position on Growing Rod Treatment: A Clinical and Finite Element Study.

BACKGROUND: Growing rods (GRs) is a commonly utilized technique for the management of early-onset scoliosis. The significance of the position of the apical vertebrae relative to the rods is not known. The purpose of this study is to analyze the potential effects of the position of the apical vertebrae in relation to the GRs on deformity control through plain radiographs and finite element analysis (FEA) modeling. METHODS: We identified 140 patients treated with GR between 2000 and 2018. Patients who had a congenital vertebral anomaly or <2-year follow-up were excluded. Curve magnitude, traction radiograph under general anesthesia (TRUGA) flexibility, apical rotation, the lengths of T1-12, T1-S1, and the instrumented segments were recorded. Patients were divided into 3 groups according to the apical position on the postoperative radiographs: group 1 (both pedicles are between the rods), group 2 (convex rod is between the apical vertebra pedicles), group 3 (both pedicles are lateral to the convex rod). FEA models were created simulating the 3 groups. Both radiographic and FEA data were analyzed to compare the deformity control and growth in each group. RESULTS: Fifty-eight patients were included in the final analyses (mean age 84 mo; range: 38 to 148). Ten patients (17%) were in group 1, 34 (59%) in group 2, and 14 (24%) in group 3. Difference between TRUGA flexibilities was statistically insignificant. Group 3 was the least successful in terms of both height gain and rotational control. FEA showed a decrease in rotation and displacement for every group, however, the residual rotation and displacement was highest in group 3. CONCLUSIONS: Bringing the apex in line with the GR increases the capacity of growth preservation as it results in largest height gain and better deformity control. FEA model demonstrated that distraction alone is inadequate for controlling rotation, and with increasing apical translation, residual rotation after distraction also increases. LEVEL OF EVIDENCE: Level III.

Impar ganglion radiofrequency application in successful management of oncologic perineal pain.

Impar ganglion is a solitary ganglion located retroperitoneally at the end of paravertebral sympathetic chain and usually in front of sacrococcygeal joint. Solitary or metastatic tumour in the surrounding tissues causes poorly localized pain. This case report presents a 75-year old male patient with colon cancer, whose severe pain during defecation could not be controlled with conventional high-dose opioid application but with transcoccygeal radiofrequency thermocoagulation. Radiofrequency thermocoagulation is promising not only for chronic pelvic pain control but also in pelvic pain secondary to malignancy particularly when the ganglion is localized by radiologic imaging techniques.

Comparative evaluation of two different volumes of lidocaine in intravenous regional anesthesia.

BACKGROUND: This study was conducted to compare low concentration-high volume intravenous regional anesthesia (IVRA) method with local anesthetic method in upper extremity surgery in terms of efficiency and adverse effects. MATERIAL AND METHODS: Thirty-nine patients were divided into 2 groups; the first group received a 2% concentration of 12-15 mL lidocaine (Group 1) and the second group received a 0.5% concentration of 30-50 mL lidocaine (Group 2). Intraoperative hemodynamic data of patients (systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate, and peripheral oxygen saturation- SpO2) was recorded before and after anesthesia at 1, 5, 10, 15, 20, and 40 minutes. RESULTS: The intergroup and intragroup comparisons did not reveal any significant differences in hemodynamic data. The onset time of sensorial block was shorter and the regression time of sensorial block was longer in Group 1 than Group 2. Group 1 had shorter onset time of motor block and longer regression time of motor block than Group 2. There were no significant differences between the study groups in terms of the time of tourniquet and postoperative analgesia time. CONCLUSIONS: IVRA technique applied with 2% concentration and volume of 12-15 mL lidocaine may be suggested as a safe option.

Effects of high thoracic epidural anesthesia on mixed venous oxygen saturation in coronary artery bypass grafting surgery.

BACKGROUND: To investigate possible effects of high thoracic epidural anesthesia (HTEA) on mixed venous oxygen saturation (SvO2) in coronary artery bypass grafting surgery (CABGS) MATERIAL AND METHODS: Sixty-four patients scheduled for CABGS were randomly assigned to either test (HTEA) or control group. Standard balanced general anesthesia was applied in both groups. Mean arterial blood pressure (MAP), heart rate (HR), oxygen saturation (SpO2), central venous pressure (CVP), cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), mean pulmonary arterial pressure (PAP), pulmonary capillary wedge pressure (PCWP), pulmonary compliance (C), bispectral index (BIS), body temperature, SvO2, hematocrit values were recorded before induction. Postoperative hemodynamic changes, inotropic agent, need for vasodilatation, transfusion and additional analgesics, recovery score, extubation time, visual analogue scale (VAS) values, duration of stay in intensive care unit (ICU) and hospital were recorded. RESULTS: Study groups were similar in SpO2, CVP, PCWP, PAP, C, body temperature, BIS values, development of intraoperative bradycardia. In HTEA group, intraoperative MAP, SVR, PVR, need for transfusion were lower, whereas CO, CI, SvO2, hematocrit values were higher (p<0.05). Postoperative MAP, HR, hypertension development, need for vasodilatator, transfusion, analgesics, extubation time, recovery data, duration of stay in ICU, hospital were lower in HTEA group (p<0.05). VAS score decreased in 30 minutes and 12 hours following extubation in HTEA and control group, respectively. CONCLUSIONS: HTEA may improve balance between oxygen presentation and usage by suppressing neuroendocrin stress response; provide efficient postoperative analgesia, more stabile hemodynamic, respiratory conditions, lower duration of stay in ICU, hospital.

Preservation of pleural integrity in patients undergoing coronary artery bypass grafting: effect on postoperative bleeding and respiratory function.

OBJECTIVE: The purpose of this study was to evaluate the influence of preserved integrity of pleura on postoperative bleeding and respiratory function in patients undergoing coronary artery bypass grafting (CABG). METHODS AND RESULTS: Seventy-two CABG patients who received pedunculated IMA graft without opening the pleura (group of intact pleura, group IP) between July 2002 and September 2004 were matched to 72 CABG patients who received pedunculated IMA graft with opened pleura (group of opened pleura, group OP). To match the patients with IP and unique patients with OP, logistic regression was used to develop a propensity score. The C statistic for this model was 0.79. Patients with IP were matched to unique patients with OP with an identical 5-digit propensity score. If this could not be done, we proceeded to a 4-, 3-, 2-, or 1-digit match. Patients characteristics were well matched. There were no differences in preoperative and peroperative variables between the groups. The incidence of postoperative pleural effusion and thoracentesis were significantly lower in group IP than group OP (pleural effusion in 15.2 versus 30.5%; p = 0.029, thoracentesis in 5.5 versus 18.5%; p = 0.036). Other pulmonary complications such as prolonged ventilation, reintubation, pneumothorax, atelectasis, diaphragmatic paralysis were similar in both groups. Patients with IP had significantly lower blood loss (520 versus 870 ml; p < 0.001) and whole blood unit transfusion (26.3 versus 41.6%, p = 0.036). Also, intensive care unit and hospital stay were similar in both groups. CONCLUSIONS: Meticulous internal mammary artery harvesting and preservation of the pleural integrity significantly reduces postoperative bleeding and pleural effusion.

Evaluation of several clinical scoring tools in organophosphate poisoned patients.

OBJECTIVE: The aim of this study was to evaluate the Acute Physiology and Chronic Health Evaluation (APACHE) II, III and Simplified Acute Physiology Score II (SAPS II) as predictors of severity of organophosphate poisoning (OPP). METHODS: This is a retrospective study of 48 patients with OPP who were admitted to the intensive care unit (ICU) for at least 24 h between 1997 and 2004. Demographic, laboratory, survival data and on day one APACHE II, III, SAPS II and Glasgow Coma Scale (GCS) were recorded, and correlations between these scores and severity of poisoning were performed. RESULTS: Forty-eight patients were evaluated. Mechanical ventilation was required by 58% of patients. The mean APACHE II, III and SAPS II values were 11.5 +/- 7.21, 42.1 +/- 24.49 and 25.1 +/- 15.76, respectively. Total dose and duration of atropine and of pralidoxime therapy, length of ICU stay and mortality all correlated with these clinical scoring tools. CONCLUSIONS: The APACHE II, III and SAPS II clinical scoring tools seem to predict the severity of organophosphate poisoning, and may have prognostic value.

Comparison of simultaneous antegrade/vein graft cardioplegia with antegrade cardioplegia for myocardial protection.

Antegrade cardioplegic delivery via the aorta ensures distribution of cardioplegic solution through open arteries, but distribution may not be adequate beyond a stenotic coronary artery. This potential problem can be overcome by direct delivery of cardioplegia via a vein graft. The purpose of this study was to compare simultaneous antegrade/vein graft cardioplegia with antegrade cardioplegia during coronary artery bypass surgery. Twenty patients were divided into 2 groups. In group 1, intermittent antegrade cardioplegia was provided (n=10). In group 2, intermittent antegrade cardioplegia was supplemented by antegrade perfusion of vein grafts after distal anastomoses were completed (n=10). Data on enzyme release and hemodynamics were obtained preoperatively, before the induction of anesthesia, just before cross-clamping, immediately after aortic unclamping, and at 1, 6, 12, 24, and 48 h after unclamping. Enzyme release (creatinine phosphokinase-isoenzyme MB, cardiac troponin I, myoglobin) was similar in both groups (P>.05). Furthermore, no significant difference was noted in the incidence of postoperative low cardiac output syndrome, perioperative myocardial infarction, or ventricular arrhythmia (P>.05). In conclusion, both techniques permitted rapid postoperative recovery of myocardial function. Supplementation of antegrade perfusion of vein grafts with antegrade cold blood cardioplegia offered no advantage to study patients.However, hemostasis of a distal anastomosis may be controlled by this technique.

[APACHE II, APACHE III, SOFA scoring systems, platelet counts and mortality in septic and nonseptic patients]. / Septik ve nonseptik hastalarda APACHE II, APACHE III, SOFA skorlama sistemleri, trombosit düzeyleri ve mortalite.

BACKGROUND: The aim of the current prospective study was to examine the prognostic value of APACHE II, APACHE III (Acute Physiology and Chronic Health Evakuation II and III) and SOFA (Sepsis-related Organ Failure Assessment) scores and platelet counts in septic and nonseptic patients hospitalized and treated in ICU units. METHODS: One hundred and twenty ICU patients were included in this study. Patients were grouped as septic survivors, septic nonsurvivors, nonseptic survivors and nonseptic nonsurvivors. The SOFA, APACHE II and III scores, and platelet counts were recorded at the admission in the ICU units and discharge.from the hospital. RESULTS: Patients were grouped as septic survivors (n=42), septic nonsurvivors (n=14), nonseptic survivors (n=48) and nonseptic nonsurvivors (n=16). The highest SOFA, APACHE II and III scores and the lowest platelet counts were observed in septic nonsurvivors when compared with the other patient groups. All score values and platelet counts were found to be significant in prediction of mortality in septic patients. CONCLUSIONS: According to our results obtained in septic and non-septic patients, we concluded that SOFA, APACHE II and III scores and platelet counts might be used in the prediction of mortality in septic patients.

Combinations of fentanyl and levobupivacaine for post-thoracotomy pain.

The aim of the present study is to evaluate the analgesic activity, patient satisfaction, and side effect profile of different concentrations of levobupivacaine plus fentanyl administered through thoracic epidural patient-controlled analgesia in patients undergoing thoracotomy. The study included 60 patients who were randomly divided into three groups. At the end of the surgery, group I (n = 20) received 0.125% levobupivacaine plus 3 mg fentanyl, group II received 0.1% levobupivacaine plus 3 mg fentanyl, and group III received 0.05% levobupivacaine plus 3 mg fentanyl via an epidural catheter placed at the level of T(10-11) or T(11-12). For all groups, the patient-controlled analgesia device was programmed to deliver a loading dose of 14 mL at an infusion rate of 4 mL/h, and a bolus dose of 2 mL/h, with a locked out interval of 15 minutes and 60 mL of a 4-hour limit. The following parameters were evaluated at 5, 10, 15, 20, 30, and 40 minutes and at 1, 2, 4, 8, 16, and 24 hours after admission to the intensive care unit, at which nausea and vomiting scales, Visual Analog Scale I-II, Ramsay sedation scale, Bromage scale, pupil diameter, arterial blood pressure, heart rate, respiratory rate, and SpO(2) were measured and recorded. Any side effect was also documented. As the result of the evaluation, visual Analog Scale I-II scores, patient satisfaction scores, mean arterial blood pressure, and heart rate significantly differed in group I as compared with groups II and III. No side effects were encountered except mild nausea, which was seen in group III and did not require treatment. Motor blockage, pupil size, respiratory rate, and SpO(2) were not monitored in any of the patients in all groups. In conclusion, our study suggested that the use of 0.125% levobupivacaine, together with 3 mg/mL fentanyl, constitutes a good combination, and can be used safely without causing hemodynamic change and motor block.

Catheter entrapment during balloon angioplasty in patient with in-stent restenosis: an unusual complication and its surgical management.

Entrapment of coronary angioplasty hardware is one of the rare complications of percutaneous coronary artery interventions. We reported herein a case of 58-year-old man with an entrapped balloon catheter and guidewire within the right coronary artery during the application of a conventional balloon angioplasty for in-stent restenosis. Surgical removal of the entrapped balloon catheter and guidewire was performed successfully with a coronary artery bypass grafting to the affected vessel. The application of the balloon angioplasty for in-stent restenosis requires every caution against such type of complications.

Intracerebral hemorrhage treated with external ventricular drainage following coronary bypass surgery.

BACKGROUND: Intracerebral hemorrhagic brain injury after open heart surgery is a rare complication. We report a case of acute intraventricular hemorrhage after coronary bypass surgery. METHODS: The brain computed tomography revealed intraventricular bleeding in the patient and urgent external ventricular drainage was performed by neurosurgeons. RESULTS: The clinical findings disappeared after the drainage. CONCLUSION: Early diagnosis and treatment is important in preventing organic brain damage in this complication.

Laparoscopic presacral neurolysis for endometriosis-related pelvic pain.

BACKGROUND: Some patients with endometriosis are candidates for sympathectomy of the superior hypogastric plexus. The objective of this paper is to describe our technique of laparoscopic presacral neurolysis for sympathectomy and to report 1 year results of the first 15 cases. METHODS: To achieve this objective in a prospective observational study of 1 year follow-up; we performed laparoscopic presacral chemical neurolysis with phenol in 15 patients with pelvic pain and minimal-moderate endometriosis. The main outcome measures were: the impact of treatment on pelvic symptom resolution, non-opioid analgesic consumption during menses, sexual performance and observed complications and side effects during 1 year follow-up. RESULTS: We noted a significant reduction in total pelvic symptom score as compared with baseline mean (SD) of 9.04 (1.2). The mean difference [95% confidence interval (CI)] of reduction was 5.7 (4.9-6.5), 5.8 (5.0-6.6) and 5.8 (4.9-6.6) from the baseline at the 3rd, 6th and 12th postoperative month (P < 0.001). We observed a significant improvement in Sabbatberg Sexual Rating Scale as compared with baseline mean (SD) of 30.9 (4.3). The mean difference (95% CI) of increase was 33.4 (30.3-36.4), 33.2 (30.1-36.2) and 33.2 (30.1-36.3) from the baseline at the 3rd, 6th and 12th postoperative month. We observed a significant reduction in analgesic consumption during menses in terms of total naproxen sodium tablets as compared with baseline mean (SD) of 8.9 (1.1). The mean difference (95% CI) of reduction in the total number of naproxen sodium 250 mg tablets was 6.5 (5.5-7.5), 6.7 (5.7-7.7) and 6.6 (5.6-7.6) from the baseline at the 3rd, 6th and 12th postoperative month. The most common side effect was constipation. CONCLUSION: Laparoscopic presacral neurolysis is feasible and simple. More data is needed to support its efficacy and safety.

The role of elevated liver transaminase levels in children with blunt abdominal trauma.

The role of serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) levels on intra-abdominal injury in children has not been adequately studied. In this report, the accuracy of these tests in predicting the degree and extend of intra-abdominal and hepatic injury in children with blunt abdominal trauma was investigated.Eighty-seven haemodynamically stable children with multiple trauma were prospectively evaluated. The SGOT and SGPT of patients with and without abdominal trauma (Groups I and II) were compared. Patients with and without radiologically verified intra-abdominal injury were further compared (Groups Ib and Ia). There was significant difference in SGOT and SGPT levels of Groups I and II. SGOT and SGPT levels were 333.6+/-283.8 and, 197.5+/-192.5 U/l, respectively in Group Ib; but 84.2+/-55.9, 43+/-29.8 U/l in Group Ia (P<0.001). In all patients with radiologically detected intra-abdominal pathology SGOT and SGPT levels were above 110.5 and 63.5 U/l, respectively. In patients with hepatic injury SGOT level was above 500 U/l and, SGPT level was above 300 U/l. Statistically significant positive correlation was found between radiologically detected intra-abdominal pathology and increased SGOT (above 110.5 U/l) and SGPT (above 63.5 U/l) levels (P<0.05). These data indicated that the SGOT and SGPT levels were significantly higher in patients with intra-abdominal injury even in the absence of hepatic injury. We suggest that liver function tests may be used as screening tests in children with blunt abdominal trauma in addition to physical abdominal examination. A sudden rise up to 110.5 U/l in SGOT and 63.5 U/l in SGPT indicate an intra-abdominal injury and severe hepatic injury should be suspected with higher levels of SGOT and SGPT.

Assessing propofol induction of anesthesia dose using bispectral index analysis.

UNLABELLED: In this study we sought to determine the propofol requirement and hemodynamic effects as guided by bispectral index (BIS) analysis during induction of anesthesia. Sixty patients were enrolled in this study. Propofol, 2 mg/kg, was given to Group I for induction. Propofol was administered for induction until loss of response to verbal commands and until BIS values were around 50 to Groups II and III. After induction, the smallest BIS value was different in Group I. Decreases in total propofol dose were 36% and 43% in Groups II and III respectively as compared with Group I. The dose of propofol assessed by BIS analysis results in an important reduction of propofol requirement without side effects. IMPLICATIONS: Hypotension during induction of anesthesia with propofol is common. This study has shown that propofol requirement assessed by bispectral index analysis during anesthesia induction may decrease the dose and side effects and provide for satisfactory depth of anesthesia.

Effects of low dose ketamine before induction on propofol anesthesia for pediatric magnetic resonance imaging.

BACKGROUND: We aimed to investigate effects of low dose ketamine before induction on propofol anesthesia for children undergoing magnetic resonance imaging (MRI). METHODS: Forty-three children aged 9 days to 7 years, undergoing elective MRI were randomly assigned to receive intravenously either a 2.5 mg x kg(-1) bolus of propofol followed by an infusion of 100 microg x g(-1) x min(-1) or a 1.5 mg x kg(-1) bolus of propofol immediately after a 0.5 mg x kg(-1) bolus of ketamine followed by an infusion of 75 microg x kg(-1) x min(-1). If a child moved during the imaging sequence, a 0.5-1 mg x kg(-1) bolus of propofol was given. Systolic and diastolic blood pressures, heart rate, peripheral oxygen saturation and respiratory rates were monitored. Apnea, the requirement for airway opening maneuvers, secretions, nausea, vomiting and movement during the imaging sequence were noted. Recovery times were also recorded. RESULTS: Systolic blood pressure and heart rate decreased significantly in the propofol group, while blood pressure did not change and heart rate decreased less in the propofol-ketamine group. Apnea associated with desaturation was observed in three patients of the propofol group. The two groups were similar with respect to requirements for airway opening maneuvers, secretions, nausea-vomiting, movement during the imaging sequence and recovery time. CONCLUSIONS: Intravenous administration of low dose ketamine before induction and maintenance with propofol preserves hemodynamic stability without changing the duration and the quality of recovery compared with propofol alone.

Usefulness of procalcitonin for diagnosis of sepsis in the intensive care unit.

INTRODUCTION: The diagnosis of sepsis in critically ill patients is challenging because traditional markers of infection are often misleading. The present study was conducted to determine the procalcitonin level at early diagnosis (and differentiation) in patients with systemic inflammatory response syndrome (SIRS) and sepsis, in comparison with C-reactive protein, IL-2, IL-6, IL-8 and tumour necrosis factor-alpha. METHOD: Thirty-three intensive care unit patients were diagnosed with SIRS, sepsis or septic shock, in accordance with the American College of Chest Physicians/Society of Critical Care Medicine consensus criteria. Blood samples were taken at the first and second day of hospitalization, and on the day of discharge or on the day of death. For multiple group comparisons one-way analysis of variance was applied, with post hoc comparison. Sensitivity, specificity and predictive values of PCT and each cytokine studied were calculated. RESULTS: PCT, IL-2 and IL-8 levels increased in parallel with the severity of the clinical condition of the patient. PCT exhibited a greatest sensitivity (85%) and specificity (91%) in differentiating patients with SIRS from those with sepsis. With respect to positive and negative predictive values, PCT markedly exceeded other variables. DISCUSSION: In the present study PCT was found to be a more accurate diagnostic parameter for differentiating SIRS and sepsis, and therefore daily determinations of PCT may be helpful in the follow up of critically ill patients.

The addition of droperidol or clonidine to epidural tramadol shortens onset time and increases duration of postoperative analgesia.

PURPOSE: To compare tramadol alone and the combinations of either tramadol-clonidine or tramadol-droperidol with regard to analgesic and adverse effects. METHODS: After Ethic's Committee approval and patient informed consent were obtained, epidural catheters were inserted preoperatively at the L(3-4) interspace in 90 ASA physical status I-II adult patients undergoing lower abdominal surgery. Anesthesia was standardized. Patients were randomly assigned to one of three groups. Group I (T) patients received tramadol 75 mg, Group II (TD) patients received tramadol 75 mg plus droperidol 2.5 mg, and Group III (TC) patients received tramadol 75 mg plus clonidine 150 microg in a total volume of 10 mL administered as a single epidural injection in the postanesthesia care unit. The onset time of analgesia and duration of analgesia, visual analogue pain scores, sedation, nausea scores, vital signs and side effects were recorded. RESULTS: Duration of analgesia was similar in both the TD and TC groups, and significantly longer than in the T group (P < 0.001). Group TC patients displayed a significant increase in sedation scores and decrease in blood pressure and heart rate when compared with other groups (P < 0.001). No adverse effects were observed in Group TD, while nausea scores were high in both the T and TC groups (P < 0.001). Pain score, respiration rate, and SpO(2) values were similar in all study groups. CONCLUSION: We conclude that epidural tramadol in combination with droperidol or clonidine prolongs the duration of analgesia; however, droperidol appears to be a better alternative when adverse effects and antiemetic properties are taken into consideration.