Intravenous Lidocaine for Postoperative Analgesia in 90 patients After Total Knee Arthroplasty and Limb Fractures.

BACKGROUND The aim of this research was to investigate the analgesic effects of intravenous lidocaine on postoperative pain management in orthopedic patients after total joint arthroplasty and fractures of the limbs and to compare lidocaine efficacy between these orthopedic surgical procedures. MATERIAL AND METHODS Ninety patients scheduled for elective orthopedic surgery were recruited: 46 patients with total knee arthroplasty, and 35 patients with femoral fractures. Patients in the lidocaine group received lidocaine during the induction phase of anesthesia as a bolus injection of 1.5·kg⁻¹·mg over 10 min, followed by intravenous infusion of 1.5 mg·kg⁻¹·h⁻¹ for 24 postoperative hours. Patients in the control group received an equal volume of saline as placebo administered at the same rate. Pain scores were assesed at intervals of 0, 15, 30, 60 min, and 6, 12, and 24 h postoperatively. The reduction rate of additional analgesics, total analgesic use, incidence of nausea and vomiting, mobilization, length of hospital stay, adverse effects, and hemodynamic parameters were secondary outcomes. RESULTS Pain scores at rest and during movement were significantly lower in the lidocaine group compared to those in controls starting at 30 min (P=0.03), the first postoperative hour, and also at 6, 12, and 24 h (P<0.001). Additional analgesics were administered at a significantly lower rate in the lidocaine group (P<0.05). Total analgesic use in the postoperative period was significantly higher in the control group (P<0.001). CONCLUSIONS This study showed that intravenous lidocaine provided adequate postoperative analgesia for orthopedic patients undergoing elective total joint arthroplasty and limb fracture repair.

REGIONAL ANESTHESIA IN SPINAL SURGERY: COULD IT BE THE SOLUTION FOR DIFFICULT INTUBATION.

This article includes two topics - anesthesia for spinal surgery and difficult airway, both of them are linked with the same topic, which is regional anesthesia. In recent years, regional anesthesia for spinal surgery has gained a great popularity, where neuraxial blocks are the first choice. Regional anesthesia seems to have benefits against general anesthesia due to lower rate of perioperative and postoperative complications, lower cost and length of stay. This is more evident in elderly population or patients with comorbidities. On the other hand, difficult airway is the life threatening condition and requires increased attention. There are many methods and tools for managing difficult airways, but there are few supporters of regional anesthesia as an option or solution in these cases. Of course, special attention is required during regional anesthesia in a patient with difficult airway, the decision must be correct, and an anesthesiologist must have a preformulated strategy for airway management. However, does not the same happen even when we apply general anesthesia?

Advanced ovarian dysgerminoma infiltrating both ovaries and uterus in a 7-year-old girl.

Introduction. Ovarian dysgerminoma is a rare malignant ovarian germ cell tumor with its peak incidence in young women. Abdominal pain, abdominal distention, and the presence of a palpable mass are common symptoms at presentation. Depending on the FIGO stage at presentation the prognosis of dysgerminomas after surgical treatment, adjuvant chemotherapy, and radiotherapy is promising. Case Presentation. A 7-year-old girl was presented at our clinic with abdominal pain in all abdominal quadrants. Later the pain localized in the region of her right ovary. CT scan revealed a massive formation which was connected to her right ovary. Conclusion. Although malignant ovarian germ cell tumours are rare in children, physicians must always consider the possibility of MOGT-occurrences. The clinical symptoms might not be specific: abdominal pain, abdominal distention, nausea, and vomiting. In order to make a correct diagnosis the patients should undergo a complete clinical examination including radiological scans. Initial management is frequently surgery, followed by adjuvant chemotherapy and radiotherapy. Although disgerminoma is malignant tumor, the prognosis is promising.

Choledochal cyst - presentation and treatment in an adult.

CONFLICT OF INTEREST: NONE DECLARED Choledochal cyst is a congenital cystic dilation of a part of bile duct that occurs most commonly in the main part of common bile duct. Diagnosis of choledochal cyst is concluded upon disproportionate expansion of extrahepatic bile duct. Symptom trias are: abdominal pain, jaundice and abdominal mass represent clinical guideline signs of diagnosis. Furthermore, hepato-biliary diseases in adults can conceal the primary condition. In addition to this, ultrasound, CT, MRI, cholangiopancreatography (ERCP), transhepatic percutane cholangiography (PTC) guide us for a detailed examination in order to verify the diagnosis. Active endoscopic cholangiography represents an important technique that provides needed anatomic solution and details in diagnosis of choledochal cyst.

Intrathoracal cholecystitis calculosa in a right-sided posttraumatic diaphragmatic hernia: a case report.

INTRODUCTION: Injuries of the diaphragm were first described in 1541 by Sennertus and the initial repair was performed by Riolfi in 1886. Posttraumatic diaphragmatic hernia in adults is usually caused by blunt trauma and may remain asymptomatic and undiagnosed for many years. Right-sided tears are significantly less likely than left-sided tears because of the protective effect of the liver. They are associated with high mortality and morbidity. The rupture of the right side of the diaphragm and the presence of an inflamed gallbladder in the thoracic cavity are uncommon. CASE PRESENTATION: We present the case of a 57-year-old Albanian man with prolapses of his gallbladder and other abdominal organs into the thoracic cavity through the herniation of his right hemidiaphragm due to trauma. The diaphragmatic hernia and gallstones seen in the thorax computed tomography scan were diagnostic. The organs herniated to the thoracic cavity were placed back into the abdominal cavity, a cholecystectomy was performed and the defect in the diaphragm was repaired with a prolene mesh graft during the operation. The patient was discharged 10 days after the surgical procedure, and no complications were reported. CONCLUSION: Diaphragmatic hernia should be considered as a possible diagnosis in patients with respiratory disorders or unusual shadows in the thoracic region after recently sustained injury or with a history of injury. The prolapse of a gallbladder is rare. The symptoms are uncharacteristic and patients with this disease may remain without symptoms for a long period. Treatment is surgical.

Postoperative analgesia in children after propofol versus sevoflurane anesthesia.

OBJECTIVE: Postoperative analgesia remains a problem, especially in pediatric patients. We hypothesize that patients anesthetized with sevoflurane have more postoperative pain than with propofol. DESIGN: Randomized, prospective, double-blind study. SETTING: University teaching hospital. SUBJECTS: The subjects were 88 premedicated children, aged 3-6 years, and American Society of Anesthesiologists (ASA) Physical Status I or II. INTERVENTIONS: Subjectsunderwent hernia repair surgery. METHODS: Anesthesia was maintained with propofol (group P, N = 46) or sevoflurane (group S, N = 42) and fentanyl was administered during surgery. All children before surgical incision received 40 mg/kg paracetamol, rectally. Prior to wound closure, the margins were infiltrated with 0.5% bupivacaine. OUTCOME MEASURES: The primary outcome was pain score assessed by Faces Pain Scale (FPS) 2 hours postoperatively. The secondary outcomes included recovery time and adverse events within the first 2 hours. RESULTS: Group S had a significantly higher proportion of patients who exhibited postoperative pain than group P (24.3% vs 4.5%, respectively; P < 0.05). FPS score in group P was 1.2 ± 0.6, compared with 3.4 ± 1.5 in group S (P < 0.001). Mean recovery time in group S was significantly shorter than the corresponding mean for group P (10.1 ± 1.3 vs 16.5 ± 5.4 minutes, respectively; P < 0.001). CONCLUSION: In children, anesthesia maintenance with propofol was associated with a significantly lower incidence of postoperative pain than with sevoflurane.

Preemptive analgesic effects of midazolam and diclofenac in rat model.

The aim of the present study was to investigate the preemptive analgesic effects of intraperitoneally administrated midazolam and diclofenac, before acute and inflammatory induced pain in rat model. One hundred twenty-eight (n=8 in each group) male Sprague Dawley rats were included in the study. Paw movements in response to thermal stimulation or paw flinching in response to formalin injection were compared after midazolam (0.1, 1, 5 and 10 mg/kg) and diclofenac (10 mg/kg), intraperitoneal administration. Saline was used as a control. Preemptive analgesic effect was significant in both tests when diclofenac and midazolam was administrated before the pain stimuli (p<0.01 and p<0.001). Intraperitoneal injection of midazolam in doses 5 and 10 mg/kg, increase the response time in hot plate test and decrease the number of flinches in formalin test (p<0.01 vs. p<0.001). ED50 of midazolam (with diclofenac) in hot plate test was 2.02 mg/kg (CI95% =-3.47-5.03 mg); and, 0.9 mg/kg (CI95% =-0.87-4.09 mg) in phase I and 0.7 mg/kg (CI95% = 0.48-6.63 mg) in phase II, in formalin test.Intraperitoneally administered midazolam and diclofenac had preemptive analgesic effects on acute thermal, and inflammatory induced pain in rats.

Preemptive analgesic effect of diclofenac: experimental study in rats.

BACKGROUND: Preemptive analgesia is an antinociceptive treatment that prevents central sensitization. Antinociceptive effects of diclofenac are well-known. The aim of this study was to investigate preemptive analgesic effects of intraperitoneally administrated diclofenac, before and after acute and inflammatory induced pain in rat model. METHODS: Forty eight male Sprague Dawley rats were included in the study. The rats are divided in five groups (n=8 per each group); Group A, diclofenac at 10 mg/kg given ip, 30 min before the nociceptive stimulus realized with hot plate test; Group B, diclofenac at 10 mg/kg given ip, 5 min after the nociceptive stimulus, realized with hot plate test; Group C, diclofenac at 10 mg/kg given ip, 30 min before the nociceptive stimulus realized with formalin test, and; Group D, diclofenac at 10 mg/kg given ip, 5 min after the nociceptive stimulus, realized with formalin test. Saline was used as a control. Paw movements in response to induced pain with hot plate test and formalin test were measured during 60 minutes. RESULTS: Preemptive analgesic effect was significant in both groups when diclofenac was administrated before the pain stimuli (P < 0.01 and P < 0.001). The significant decrease in paw movements started in 15 min after pain stimuli in group A and in 25 min, in group C. CONCLUSION: Intraperitoneally administered diclofenac had preemptive analgesic effects on acute thermal, and inflammatory induced pain in rats. Our results contain the preemptive analgesic effect of systematically administrated diclofenac.

Presenting colorectal carcinoma cases in our department.

BACKGROUND: Colorectal carcinoma is second commonest cancer causing death in Kosova. METHODOLOGY: In our study we present diagnostic methods, treatment, localization and laboratory findings in 155 patients, during 4 year period in patients with colorectal carcinomas treated in our clinic. RESULTS: Ninety four 94 (61.4%) of patients were male gender and 59 (38.6%) were female. Eritrosedimentation was elevated in 103 (67.3%) of patients, number of white blood cells was increased in 21 (7.2%) of patients and high level of glycemia is present in 11 (7.2%) of patients. The most involved age is from 41-50 years. The most common site of involvement was the rectum in 79 (51.6%), localization in sigma was in 37 (23.5%), the transverse colon in 21 (13.7%) of cases and the ascendant colon in 18 (11.1%) patients. Adenocarcinoma (98%) was the most common histiotype. CONCLUSION: We concluded, that all patients, especially with positive familial history must begin screening in age 40, during which colorectal carcinoma can be diagnosed in an early stage.

A pin in appendix within Amyand's hernia in a six-years-old boy: case report and review of literature.

INTRODUCTION: Presence of vermiform appendix (non-inflamed or inflamed) in inguinal hernia is called Amyand's hernia in honor to surgeon C. Amyand who published the first case of perforated appendicitis within inguinal hernia in a boy caused by ingested pin. This presentation of foreign body Amyand's hernia appendicitis is very rare, and here we present such a case. CASE PRESENTATION: A 6-year-old boy, white Kosovar ethnicity, presented with right groin pain, swelling and redness. Two days before admission the patient was injured by football during a children game in the right lower abdomen and the next day he complained of pain in the right inguinal area.On admission patient had a painful non-reducible mass in the right inguinal region and cellulitis. Plain abdominal x-ray showed no fluid-air levels, but a metallic foreign body (pin) under right superior pubic ramus was apparent. With preoperative diagnosis of suspect incarcerated inguinal hernia with cellulitis the patient was operated on under general anaesthesia in December 2, 2006. Intraoperatively we found the inflamed vermiform appendix perforated by a pin in the hernial sac. Appendectomy and herniotomy were performed. The wound was primary closed, without any post-operative complications and follow up for the patient is three years long. CONCLUSION: Foreign body (pin) Amyand's hernia appendicitis seems to be extremely rare, maybe once in a century (Amyand 1735, Hall 1886, and our case in 2006). In patients with clinical signs of incarcerated inguinal hernia, with locally inflammatory signs, but without signs of intestinal obstruction Amyand's hernia appendicitis in differential diagnosis must be considered. In our case, it is possible that the injury during the football game might have induced perforation of the vermiform appendix with the foreign body in it.

Thrombosis of the superior sagittal sinus.

Thrombosis of the sinuses is a distinct cerebrovascular disorder that, unlike arterial stroke, most often affects young adults and children. The symptoms and clinical course are highly variable. During the past decade, increased awareness of the diagnosis, improved neuro-imaging techniques, and more effective treatment have improved the prognosis. More than 80% of all patients now have a good neurologic outcome. This review summarizes recent insights into the pathogenesis of sinus thrombosis, risk factors, and clinical and radiological diagnosis and discusses the current evidence and controversies about the best treatment.

Management of child with acute airway obstruction: a case report.

INTRODUCTION: Laryngotracheobronchitis is a rare, but in severe cases may lead to laryngeal edema progressing to complete closure of the subglottis within a few hours, without prompt treatment. CASE PRESENTATION: We present the case of acute airway obstruction caused by laryngotracheobronchitis in a 6-year-old boy, initially misdiagnosed and treated as foreign body aspiration. The treatment of airway obstruction in the child was managed with algorithm used in our institution. CONCLUSION: The aims of management of acute airway obstructions are firstly, to maintain and secure the airway and than, to establish a diagnosis. Institutions should have algorithms to manage children with acute airway obstruction.

Emergence agitation in children after propofol versus halothane anesthesia.

BACKGROUND: The administration of anesthetic agents is associated with a high incidence of emergence agitation in children. Halothane and propofol appear to cause much less emergence agitation. The aim of this study was to compare the incidence of emergence agitation in children receiving either propofol or halothane anesthesia for a variety of surgical treatments using the Pediatric Anesthesia Emergence Delirium (PAED) scale. MATERIAL/METHODS: The subjects were 83 premedicated children aged 1 to 6 years who underwent surgical procedures with propofol (group P, n=41) or with halothane (group H, n=42) anesthesia. The mean dose during maintenance of anesthesia with propofol was 9.0 mg/kg/h or halothane 1.5-2% and fentanyl at a total dose of 5 microg/kg administered during surgery. Recovery time, preoperative anxiety, postoperative pain, and emergence agitation were noted. Adverse effects during and after operation were also recorded. RESULTS: Group P had a significantly higher proportion of patients who exhibited emergence agitation than group H (29.3% vs. 9.5%, respectively, P<0.05). The PAED scale score in group H was 4 (range: 0-16) and in group P 8 (range: 2-20). The mean recovery time in group P was significantly shorter than in group H (16.1+/-4.3 vs. 20.5+/-5.4 minutes, respectively, P<0.01). CONCLUSIONS: In children, the administration of propofol maintenance anesthesia is associated with a significantly higher incidence of emergence agitation than halothane maintenance anesthesia.

Misdiagnosed fracture of Th-7 vertebrae in intensive care unit.

We report the case an 18-year-old girl admitted in intensive care unit (ICU) in severe clinical condition after a car crash. She arrived at ICU around 04.50 in the morning and was conscious, with abnormally fast respiratory rate, low blood pressure, and tachycardia. After the supine radiograph of the chest, right hemathopneumothorax was evident and thoracic drainage was performed. After four hours, during morning physical examination, the coming intensivist discovered the loss of motor and sensible sensations in the lower and upper extremities. The patient became quadriplegic. In emergent radiograph of vertebral column, the fracture of thoracic 7th vertebra, and complete dislocation of spinal cord at the level Th 7-Th 8, was revealed. Patient died the same day before the arrival in operating room. The detail imaging of vertebral column and immobilization of patient failed. On the early morning, the intensivist was very exhausted and low concentration was evident. After the consequences of this specific case, the hours of duty in intensive care unit in our country were reduced from 24 work hours to 12 work hours. The question remains... Is it possible that the exhaustion and the inadequate organization are enough reasons to cause a young girl's death?