Evaluation of the effects of subcostal transversus abdominis plane block on acute and subacute pain development following inguinal herniography: Randomized clinical study.

OBJECTIVES: The effect of subcostal transversus abdominis plane (TAP) block on postoperative pain is contradictive. The aim of this study was to evaluate the effect of subcostal TAP block on subacute pain in patients who have undergone inguinal herniography. METHODS: Patients aged between 18 and 75 years with American Society of Anesthesiologists 1-3 and who were to undergo elective unilateral inguinal herniography with mesh under general anesthesia were included. Fifty patients were under an intravenous analgesic regimen (group I) and 50 patients underwent subcostal TAP block postoperatively in addition to the intravenous analgesic regimen (group II). The primary outcome measure was pain scores 1 month postoperatively by comparing Numerical Rating Scale values with the Mann-Whitney U test between groups I and II. Secondary outcome measures were life qualification scores 1 month postoperatively and pain scores 24 h and 15 days postoperatively. RESULTS: Postoperative 15th-min; 1st-, 6th-, 12th-, and 24th-h; 15th-day (p=0.00); and 1st-month Numerical Rating Scale values were significantly lower in group II than in group I (p=0.02). No significant difference was observed between the groups in terms of LQS 15 days postoperatively (p=0.013). On group comparison, LQS was higher in the 1st month than at the 15th day postoperatively in group I (p=0.201). CONCLUSION: Subcostal TAP block provides an effective postoperative pain treatment in the acute period and in the 1st postoperative month in patients undergoing inguinal herniography.

Pudendal Nerve Block Versus Penile Nerve Block in Children Undergoing Circumcision.

PURPOSE: Penile nerve block is the most popular nerve block for the circumcision in pediatric patients. This study aimed to compare the analgesic efficiency of penile nerve block and the pudendal nerve block on postoperative pain and additional analgesic requirements in children undergoing circumcision. MATERIAL AND METHODS: This prospective randomized double-blind study enrolled 85 children, aged 1 to10 years, undergoing circumcision. The patients were randomly divided into two groups either receiving dorsal penile block group (PNB-Group) or pudendal nerve block (PDB-Group). In the PNB-Group, 0.3 ml/kg 0.25 % bupivacaine was used; and, in the PDB-Group, 0.3 ml/kg bupivacaine was applied with nerve stimulator at a concentration of 0.25%. In the postoperative period, the modified CHEOPS pain scale scoring and additional analgesic demand were evaluated at the 5th and 30th minutes and at the 1st and 2nd hours. The subsequent pain evaluations were made by the parents at home, at the postoperative 6th, 12th, 18th and 24th hours. RESULTS: Seven patients were excluded from the study, and seventy eight patients were evaluated for analysis. Patients in PDB-Group had significantly lower postoperative pain intensity and lower mCHEOPS scores (3.83 ± 0.98) when compared to the PNB-Group (6.47 ± 0.91) (P < .01) at all measurement times and none of patients in PDB-Group had additional analgesic requirements up to 24 hours. Patients in the PNB-Group had significantly more analgesic requirements at all measurements times except at the 1st, 2nd, 24th hours. 3.8%, 30.8%, 46.2% and 59% of the patients in the PNB group needed additional analgesia respectively at 5th, 6th, 12th and 18th hours. CONCLUSION: Pudendal nerve block provided additional analgesic free period and had better analgesic efficiency compared to the penile nerve block lasting until 24 hours after operation.

The Assessment of Risk Factors for Difficult Intubation in Thyroid Patients.

OBJECTIVES: We aimed to assess possible risk factors related to difficult intubation in patients undergoing thyroid surgery. METHODS: We prospectively collected data of 200 patients scheduled for thyroid surgery. Clinical risk factors were defined as: Mallampati score, interincisor gap, thyromental distance, sternomental distance, range of neck motion, body mass index, neck circumference, goiter, the presence of radiological findings suggesting compression and thyroid weight. All evaluations were performed with Macintosh assessed for Cormack and Lehane (CL) classification and modified intubation difficulty scale (MIDS). RESULTS: It was observed that the proportion of patients with a thyroid weight ≥40 g, goiter, a Macintosh CL score = 3-4 and the mean neck circumference were significantly higher in the group with a MIDS score >5 (p = 0.018, p = 0.011, p < 0.001, respectively). CONCLUSION: The presence of a palpable goiter, thyroid weight ≥40 g and thyromental distance <6.5 cm were risk factors associated with difficult intubation in the multivariate regression model.

Restoration of pulmonary compliance after laparoscopic surgery using a simple alveolar recruitment maneuver.

STUDY OBJECTIVE: To test the hypothesis that a pulmonary maneuver designed to recruit additional alveoli (thereby decreasing atelectasis) applied before extubation can restore pulmonary compliance to baseline values. DESIGN: Cohort study. SETTING: Operating room of a university hospital. PATIENTS: 20 ASA physical status I and II patients scheduled to undergo laparoscopic radical nephrectomy. INTERVENTIONS: Participants received a balanced general anesthesia using intermittent positive pressure ventilation. A pulmonary recruitment maneuver was performed as a single manual inflation of the lungs to 40 cm H(2)O, maintained for 10 seconds after release of pneumoperitoneum. MEASUREMENTS: Respiratory mechanics including dynamic compliance were measured continuously using the VenTrak respiratory mechanics monitor (VenTrak; Novametrix, Wallingford, CT, USA). Respiratory measures were recorded together with arterial blood gases after induction (T1), with the patient placed in the lateral "jackknife" position (T2), 10 and 120 minutes after CO(2) insufflation (T3 and T4), immediately after desufflation in the lateral and supine positions (T5 and T6), and 10 minutes after a pulmonary recruitment maneuver at the conclusion of surgery (T7). Outcome data were analyzed using analysis of variance for repeated measures; P < 0.05 was defined as statistically significant. MAIN RESULTS: On average, compliance decreased from an initial value of 63.5 to 52.6 mL/cm H(2)O when patients were turned from the supine to the lateral position (T1 vs. T2; P < 0.001), and decreased further to 31.07 mL/cm H(2)O after CO(2) insufflation (T2 vs. T3; P < 0.001). Compliance increased to 50.8 mL/cm H(2)O after desufflation and 54.4 mL/cm H(2)O after turning the patient to the supine position, but did not return to baseline levels until after performance of the pulmonary recruitment maneuver, 64.3 mL/cm H(2)O (T6 vs. T7; P < 0.001, and T1 vs. T7; P = 0.73). CONCLUSIONS: Respiratory mechanics do not fully return to baseline levels after desufflation following laparoscopy; however, lung compliance can be fully restored using a simple alveolar recruitment maneuver.

Interscalene brachial plexus block with bupivacaine and ropivacaine in patients with chronic renal failure: diaphragmatic excursion and pulmonary function changes.

In this randomized, double-blind study, we compared the anesthetic characteristics and pulmonary function changes of 0.33% bupivacaine and 0.33% ropivacaine used for interscalene brachial plexus (IBP) anesthesia in patients with chronic renal failure. Forty-two patients undergoing IBP anesthesia for creation of arteriovenous fistulas were randomly allocated to receive either 30 mL of 0.33% bupivacaine (Group B) or 0.33% ropivacaine (Group R). Block onset time, diaphragmatic excursion (ultrasonographic evaluation), and free plasma concentrations of bupivacaine and ropivacaine were evaluated. Negative motion or immobility of the ipsilateral hemidiaphragm and a decrease of >10 mm in positive motion were defined as diaphragmatic paresis. The pulmonary function variables were measured by bedside spirometry equipment. Seven patients needed supplemental local anesthetic, one with total spinal block; these patients were excluded from the study. The success rate was 80.9%. Block quality was similar in the two groups. Ipsilateral hemidiaphragmatic excursion was decreased in both groups compared with baseline values (P < 0.05). Diaphragmatic paresis was identified in 10 of 16 patients and 8 of 18 patients in Groups B and R, respectively (P > 0.05). Pulmonary function significantly decreased from baseline in both groups (forced vital capacity (FVC) 30%, forced expiratory volume at 1 second (FEV(1)) 32%, and peak expiratory flow (PEF) 31% in Group B and FVC 17%, FEV(1) 17%, and PEF 5% in Group R) (P < 0.001). The decreases in Group B were larger than those in Group R (P < 0.05). Three patients in Group B and one in Group R had mild respiratory problems (P > 0.05). Concentrations of bupivacaine and ropivacaine were below toxic levels rather than "normal range." We conclude that pulmonary function decreased more after IBP with 0.33% bupivacaine than with 0.33% ropivacaine.

Effectiveness of morphine via thoracic epidural vs intravenous infusion on postthoracotomy pain and stress response in children.

BACKGROUND: Thoracotomy causes severe pain in the postoperative period. The aim was to evaluate effectiveness of two pain treatment methods with morphine on postthoracotomy pain and stress response. METHODS: Thirty-two children undergoing major thoracotomy for noncardiac thoracic surgery were allocated to receive either single dose of thoracic epidural morphine 0.1 mg x kg(-1) in 0.2 ml x kg(-1) saline (TEP group, n = 16) or morphine infusion at 0.02 mg x kg(-1) h(-1) (INF group, n = 16) following bolus dose of 0.05 mg x kg(-1) postinduction. Pain and sedation scores and incidence of complications were recorded for 24 h and cortisol, blood glucose, insulin and morphine serum levels were evaluated following induction, 1, 8, 12, and 24 h after initial morphine administration. RESULTS: Five patients in TEP and one in INF required rescue morphine. The cortisol, insulin and blood glucose increased during the study and returned to normal levels at 24th hour (P < 0.05), similarly in both groups (P > 0.05). The morphine levels were variable within and between groups (P < 0.05). A common complication was nausea and vomiting with both the techniques (P > 0.05). CONCLUSION: Single dose TEP morphine offers no advantage over INF for pain treatment for thoracotomy in children and neither technique provided suppression of stress hormones in the first 24 h postoperatively.

Effects of systemic and epidural morphine on antidiuretic hormone levels in children.

BACKGROUND: Although the use of opioids during general anaesthesia suppresses stress response to surgery and pain, the effects on antidiuretic hormone (ADH) are controversial. The aim of this study was to find the effects of morphine with either intravenous infusion or epidural route on ADH and other stress hormones. METHODS: Fifty children aging (1-15 years) undergoing major genito-urinary or abdominal operations were included in this study. The patients were allocated randomly to two groups receiving either a single dose of epidural morphine 0.1 mg.kg-1 (EP group, n = 25) postinduction or morphine infusion (INF group; n = 25) at 0.02 mg.kg-1.h-1 following 0.05 mg.kg-1 bolus. Blood samples were withdrawn for plasma ADH, osmolality, glucose, cortisol, insulin and morphine level analysis following induction and 1, 5, 12 and 24 h after initial morphine administration. RESULTS: The two groups were similar in demographic factors, pain scores, sedation scores, and incidence of nausea and vomiting. The amount of morphine received was different between groups and the changes in serum levels of morphine were statistically significant in EP group ( P < 0.05). The changes in cortisol, blood glucose and insulin levels were insignificant in both groups (P > 0.05). The changes of ADH levels were significant at time-points in both groups, reaching control levels at the 24th hour (P < 0.05). CONCLUSION: Despite the effective pain therapy and suppression of cortisol and insulin response to surgical stimulus, the increase in ADH secretion is not effected by systemic or epidural morphine administration.