Thoracic paravertebral block for video-assisted thoracoscopic surgery: single injection versus multiple injections.

OBJECTIVE: Thoracic paravertebral blocks (PVBs) have been shown to be effective for analgesia after video-assisted thoracoscopic surgery (VATS) with single- and multiple-injection techniques. The efficacy of single-injection PVB was compared with multiple-injection PVB on postoperative analgesia in VATS was studied. DESIGN: Prospective, randomized study. SETTING: Single university hospital. PARTICIPANTS: Fifty patients undergoing VATS. INTERVENTIONS: A nerve stimulator-guided PVB was performed in the sitting position before surgery using a solution of 20 mL 0.5% bupivacaine with 1:200,000 epinephrine by a single injection at T6 (group S, n = 25) or by 5 injections of 4 mL each at T4 to T8 (group M, n = 25). MEASUREMENTS AND MAIN RESULTS: A successful PVB was achieved in all patients. The times to perform the blocks were 6.8 ± 1.9 minutes in the S group and 17.9 ± 3.0 minutes in the M group (p < 0.001). The times to block onset were 8.3 ± 1.8 minutes in the S group and 7.2 ± 0.9 minutes in the M group (p = 0.014). The numbers of anesthetized dermatomes were 5.8 ± 0.8 for the S group and 6.6 ± 1.1 for the M group (p = 0.009). The postoperative pain scores and morphine consumption with patient-controlled analgesia were comparable in the two groups. There were no significant differences in times to the first mobilization and hospital discharge for two groups. Patient satisfaction with the analgesic procedure was greater in the S group (p < 0.05). No complications were attributed to the blocks. CONCLUSIONS: The two techniques provided comparable postoperative analgesia. However, single-injection PVB may represent an advantage over multiple-injection PVB in patients undergoing VATS, with greater patient satisfaction associated with a shorter procedure and the likelihood of decreased complications.

Uncomplicated prior right ventricular perforation due to a pacemaker lead - an incidental finding during coronary artery bypass surgery.

An elective coronary artery bypass grafting (CABG) surgery was performed on a 50-year-old male with an implanted two-chamber pacemaker in our clinic. Right ventricular adhesion to the inferior pericardium was detected following pericardiotomy. After the institution of cardiopulmonary bypass (CPB), careful preparation of the adhesion revealed prior perforation due to an indwelling ventricular pacemaker lead.

Effects of inhaled nitric oxide following lung transplantation.

BACKGROUND: Lung transplantation offers an established therapeutic option for end-stage lung disease. It is associated with several complications, and early allograft failure is one of the most devastating among all. Different studies are focused on an attempt to minimize these complications, especially transplant failure. We aimed to evaluate the effects of inhaled nitric oxide (iNO) treatment in patients receiving lung transplantation. METHODS: Nine patients (six female, three male; mean age 42.9 +/- 15.8) requiring lung transplantation for end-stage pulmonary disease--chronic obstructive pulmonary disease (three patients), cystic fibrosis (three patients), scleroderma and systemic sclerosis (two patients), Eisenmenger's syndrome (one patient), and treated with iNO were included in this retrospective study. Hemodynamic data (mean arterial pressure, mean pulmonary arterial pressure, heart rate) and respiratory parameters were analyzed. Pretreatment data were compared with the post-iNO treatment data at 6-8 hours and 12-14 hours. RESULTS: The inhalation of nitric oxide was started with an initial dose of 40 parts per million (ppm) and the dose was gradually decreased until hemodynamic and pulmonary stability was achieved. Six patients underwent double-lung transplantation and three single-lung transplantations were performed. Cardiopulmonary bypass was used in seven patients. The iNO therapy was started before transplantation in five patients, after the procedure in four patients. Mean iNO therapy duration was 83.2 +/- 74.4 hours. The administration of iNO resulted in a significant reduction in mean pulmonary arterial pressure (36.8 +/- 15.8 mm Hg to 22 +/- 6.8 mm Hg at 6-8 hours and 22.8 +/- 7.96 mm Hg at 12-14 hours). Mean systemic arterial pressure slightly increased at 6-8 hours and significantly increased at 12-14 hours (70.2 +/- 6.3 mm Hg to 90.1 +/- 11.96 mm Hg). Heart rate was not significantly affected with the treatment. Arterial oxygenation improved with the treatment. All patients except one showed improvement of overall respiratory functions. The mean duration of mechanical ventilation was 12.8 +/- 10.9 days. Mortality occurred in one patient due to neurologic injury. NO(2) and methemoglobin levels were closely monitored during the treatment. Methemoglobinemia did not occur and NO(2) levels remained between 0.1 and 0.4 ppm. CONCLUSION: Nitric oxide inhalation for the prevention and treatment of early allograft failure in lung transplant recipients is encouraging. It is superior to other vasodilators with its selectivity to the pulmonary vasculature, while having no significant side effects on systemic circulation. It appears to improve gas exchange and oxygenation properties. Further prospective randomized studies will aid to standardize inhalation nitric oxide therapy.

Cardiac hydatid cyst of the interatrial septum.

Echinococcal involvement of the heart is a rare occurrence. We report a case of a 46-year-old man with a four-month history of exertional dyspnea and symptoms of atypical angina pectoris, who had a hydatid cyst located in the interatrial septum as well as in the right upper pulmonary lobe. The diagnosis was made by echocardiography, X-ray, and computed tomography. After surgical resection the cyst was opened, its contents were drained, and membranous structures were completely removed. Postoperative albendozol treatment yielded a definite cure with the relief of all symptoms one year postoperatively.

A Comparision of the Effect of Sugammadex on the Recovery Period and Postoperative Residual Block in Young Elderly and Middle-Aged Elderly Patients.

BACKGROUND: The importance of the characteristics of anesthesia and postoperative residual curarization (PORC) in the elderly population should be a growing concern in this century. AIMS: To investigate the effect of sugammadex on the duration of the recovery from neuromuscular blocking agents and postoperative residual curarization in the young elderly and middle-aged elderly patients who underwent elective laparoscopic cholecystectomy, followed by a train of four (TOF) watch monitorization. STUDY DESIGN: Prospective clinical trial study. METHODS: Sixty patients over the age of 65 with American Society of Anesthesiologists I-III were divided into two groups according to their age (65-74 years old and ≥75 years old). Patients received sugammadex (2.0 mg/kg iv) at the reappearance of the second twitch of the TOF as an agent for reversal of neuromuscular blockage at the end of surgery. Patients were extubated at the time of TOF ≥0.9. The patients' TOF responses were evaluated with regards to PORC in at the 5th minute and were followed up for one hour in the recovery room. Reintubation was applied for those patients who developed PORC and had peripheric oxygen saturation <90% despite being given 6 L oxygen per min with a face mask. RESULTS: The onset time of neuromuscular blocking agent and time from T2 to achieve TOF ratio 90% (the duration of sugammadex effect) or over were found to be longer in the middle-aged elderly group than in the young elderly group. A statistically significant relationship was found between age and the duration of TOF ratio to reach 0.9 in the same direction. The PORC incidence and rate of reintubation were found to be 1.7% in all patients. CONCLUSION: In our opinion, it is necessary to remember that the duration of sugammadex effect on the recovery period is prolonged for patients who are aged ≥75 years compared to patients aged between 65-74 years. (ClinicalTrials.gov Identifier: ACTRN12615000758505).

Mobbing Exposure of Anaesthesiology Residents in Turkey.

OBJECTIVE: In recent years, psychological problems that are caused by working conditions, like burn out syndrome, are more commonly observed. In our study, we aimed to evaluate mobbing exposure, factors causing mobbing and precautions for mobbing in residency students who are educated in anaesthesiology and reanimation clinics in Turkey. METHODS: After obtaining consent from the ethics committee, we sent our questionnaires to the secretariats of the departments by postal mail. Completed questionnaires were collected in our department's secretariat blindly and randomly mixed. One hundred and one participants were returned the questionnaires. Data was statistically analysed in SPSS 21.0 software programme. RESULTS: During residency programme, sated to have experienced mobbing one or more time. Interestingly, 5.9% participants complained of physical mobbing. Mobbing exposure was more common in females. The most serious new onset psychosomatic symptoms stated during residency were committing suicide (2%), addiction (16%), severe depression (18%), panic attack (8%), more accidents (7%) and tendency of violence (15%). In mobbing group there was statistically significant dissatisfaction rate. CONCLUSION: In professions where mobbing is common, incidences of psychiatric diseases and suicide attempts are high are increased. Who are under risk for experiencing mobbing should be noticed carefully to ensure good judgement and problems should be inspected objectively in a detailed manner. Anesthesiology societies and other medical professional societies should establish mobbing committees. Thus, mobbing problems can be resolved and healthy career oppurtunities can be presented to residents.