Postarthroscopy analgesia using intraarticular levobupivacaine and intravenous dexketoprofen trometamol.

PURPOSE: The aim of this prospective study was to determine the efficacy of intraarticular levobupivacaine with and without intravenous dexketoprofen trometamol for postarthroscopy analgesia. METHODS: Sixty patients who underwent arthroscopic knee surgery were randomly assigned to three treatment groups. When the surgical procedure was completed, patients received the following treatments: group I (n = 20) patients received 20 mL intraarticular normal saline and 2 mL intravenous dexketoprofen trometamol (50 mg); group II (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous normal saline; and group III (n = 20) patients received 20 mL intraarticular 0.5 % levobupivacaine (100 mg) and 2 mL intravenous dexketoprofen trometamol (50 mg). The visual analogue scale (VAS) was used, and the total analgesic consumption was assessed at 1, 2, 4, 6, 12, and 24 h post-operatively. RESULTS: The VAS scores at 1, 2, 4, 6, 12, and 24 h post-operatively were significantly increased in group I and group II compared with group III (p < 0.05). The average VAS score during the first 24 h post-operatively was significantly lower in group III than in group I and group II (p < 0.001). Total meperidine consumption was significantly lower in group III than in groups I and II (p < 0.001). CONCLUSION: Intraarticular levobupivacaine with adjuvant intravenous dexketoprofen trometamol administration provided better pain relief and less analgesic requirement after arthroscopic knee surgery during the first 24 h than that induced by dexketoprofen alone or levobupivacaine intraarticular alone. LEVEL OF EVIDENCE: II.

The effects of different insufflation pressures on liver functions assessed with LiMON on patients undergoing laparoscopic cholecystectomy.

PURPOSE: Laparoscopic cholecystectomy has been accepted as an alternative to laparotomy, but there is still controversy regarding the effects of pneumoperitoneum on splanchnic and hepatic perfusion. We assessed the effects of different insufflation pressures on liver functions by using indocyanine green elimination tests (ICG-PDR). METHODS: We analyzed 43 patients who were scheduled for laparoscopic cholecystectomy. The patients were randomly allocated to two groups. In Group I, the operation was performed using 10 mmHg pressure pneumoperitoneum. In Group II, 14 mmHg pressure pneumoperitoneum was used. The ICG-PDR measurements were made after induction (ICG-PDR 1) and after the end of the operation (ICG-PDR 2). Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels were all recorded preoperatively, 1 hour, and postoperative 24 hours after surgery. RESULTS: The ICG-PDR 1 values for Groups I and II were as follows: 26.78 ± 4.2% per min versus 26.01 ± 2.4% per min (P > 0.05). ICG-PDR 2 values were found to be 25.63 ± 2.1% per min in Group I versus 19.06 ± 2.2% per min in Group II (P < 0.05). There was a statistically significant decrease between baseline and postoperative ICG-PDR values in Group II compared to Group I (P < 0.05). Statistically, there was an increase between baseline and postoperative 1st-hour serum AST and ALT level in Group II (P < 0.05) compared to Group I. No statistical differences were detected on postoperative 24st-hour serum AST and ALT levels and all the time bilirubin between groups (P > 0.05). CONCLUSION: In conclusion, the results show that 14 mmHg pressure pneumoperitoneum decreased the blood flow to the liver and increased postoperative 1st-hour serum AST and ALT levels. We think that 10 mmHg pressure pneumoperitoneum is superior to 14 mmHg pressure pneumoperitoneum in laparoscopic cholecystectomy.

Effects of intra-abdominal pressure on liver function assessed with the LiMON in critically ill patients.

BACKGROUND: Intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) are associated with significant morbidity and mortality in critically ill patients. Our aim was to assess the effects of IAH on liver function using the noninvasive liver function monitoring system LiMON and to assess the prognostic value of IAP in critically ill patients. METHODS: We conducted a retrospective analysis of critically ill patients who were treated in the intensive care unit (ICU). The IAP and indocyanine green plasma disappearance rate (ICG-PDR) measurements were made within 24 hours after admission to the ICU and repeated 12 hours later. Intra-abdominal pressure was measured via a Foley bladder catheter, and ICG elimination tests were conducted concurrently using the LiMON. RESULTS: We included 30 critically ill patients (17 women and 13 men aged 28-89 yr) in our analysis. Statistical analysis showed that the baseline IAP values were significantly higher among nonsurvivors than survivors (19.38 [standard deviation; SD 2.08] v. 13.07 [SD 0.99]). The twelfth-hour IAP values were higher than baseline measurements among nonsurvivors (21.50 [SD 1.96]) and lower than baseline measurements among survivors (11.71 [SD 1.54]); the difference between groups was significant (p < 0.001). The baseline ICG-PDR values were significantly lower among nonsurvivors than survivors (10.86 [SD 3.35] v. 24.51 [SD 6.78]), and the twelfth-hour ICGPDR values were decreased in all groups; the difference between groups was significant (p < 0.001). CONCLUSION: Our results suggest that measurement of ICG-PDR with the LiMON is a good predictor of the effects of IAP on liver function and, thus, can be recommended for the evaluation of critically ill patients.

The effect of celiac plexus block in critically ill patients intolerant of enteral nutrition: a randomized, placebo-controlled study.

BACKGROUND: In this study, we evaluated the efficacy of celiac plexus block for the treatment of feeding intolerance in critically ill patients. METHODS: Nineteen mechanically ventilated medical patients intolerant of enteral nutrition and receiving metoclopramide underwent bilateral celiac plexus block. The anterior procedure was accomplished under sonographic guidance with the injection of either 25 mL bupivacaine 0.25% (celiac group, n = 10) or saline (control group, n = 9) bilaterally. Gastric emptying was assessed by the acetaminophen absorption method. After the block, nasogastric feeding was commenced, and nasogastric aspirates were collected once every 24 hours. Successful feeding was defined as 24-hourly gastric residual volume <250 mL with a feeding rate > or = 40 mL/h. RESULTS: Demographic data were similar for the 2 groups. The area under the plasma paracetamol absorption curve (383.8 +/- 248.1 mg . min . L(-1)) and the peak plasma paracetamol concentration (C(max); 3.28 +/- 2.15 mg/L) in the celiac group were significantly lower than the area under the curve value (1233.5 +/- 771.2) and C(max) value (10.14 +/- 6.04) in controls (P < 0.001 for all). After treatment, celiac plexus block reduced the mean gastric residual volume (celiac group: 430 +/- 32 mL to 205 +/- 30 mL, P < 0.001; control group: 450 +/- 33 mL to 461 +/- 19 mL, P > 0.05) and improved the proportion of patients with successful feeding (celiac block 80% vs controls 0%, P < 0.001). CONCLUSION: In critical illness, celiac plexus block is effective for treating feeding intolerance when IV drug therapy has failed to improve gastrointestinal dysfunction.

Comparison of TruView EVO2 with Miller laryngoscope in paediatric patients.

BACKGROUND: Except for neonates and specific malformations in children, management of the paediatric airway is not a major problem for the anaesthetist. Miller laryngoscope was traditionally used for paediatric intubation. The TruView EVO2 system is a recently introduced device with a unique blade that provides a wide and magnified laryngeal view. OBJECTIVE: To assess the value of the TruView EVO2 laryngoscope with that of Miller laryngoscope in paediatric patients. DESIGN: Prospective analysis. MEASUREMENTS AND RESULTS: Fifty 2-8-year paediatric patients presenting for surgery requiring tracheal intubation were randomly assigned to undergo intubation using a Miller (Group M, n = 25) and TruView EVO2 laryngoscope (Group T, n = 25). Preoperative airway evaluation was performed by using the Mallampati scores. The Intubation Difficulty Scale (IDS), the duration of the tracheal intubation procedure, the rate of successful placement of the endotracheal tube in the trachea, the view of the glottis according to the Cormack and Lehane grading criteria, number of intubation attempts, mean arterial pressure (MAP) and heart rate (HR) before and after intubation, lowest peripheric oxygen saturation during intubation attempts and all complications (minor laseration, dental or other airway trauma) were all recorded. RESULTS: Preoperative Mallampati scores and the IDS scores were similar between the Miller and TruView EVO2 laryngoscope. The average time for laryngoscopy was 6.36 ± 0.99 s in group M and 13.8 ± 7.99 s in group T (P < 0.001). The TruView EVO2 laryngoscope improved the Cormack and Lehane glottic view compared with the Miller laryngoscope. The HR change (difference before and after) in group M was significantly lower than that in group T (P < 0.001). However, the MAP change was similar between groups. The lowest peripheric oxygen saturation during intubation attempts was different between groups, 99.4 ± 0.57% in group M and 97.6 ± 2.41% in group T (P < 0.001). CONCLUSION: The results suggest that when compared with the Miller laryngoscope, the TruView EVO2 laryngoscope appears to improve the view of the larynx but requires a longer time for tracheal intubation. The IDS scores were similar; thus, the TruView EVO2 laryngoscope can be a good alternative to traditionally used Miller laryngoscope.

Late-onset pulmonary edema and disseminated intravascular coagulation due to latex anaphylaxis.

BACKGROUND: Anaphylaxis after the administration of tissue expanders has been reported. Late onset hypotension, thrombocytopenia, disseminated intravascular coagulation (DIC) and pulmonary edema due to the tissue expanders have not been reported. METHODS: In this case report, late onset hypotension, thrombocytopenia, disseminated intravascular coagulation and pulmonary edema due to the administration of tissue expanders were described. RESULTS: The authors report a 16-year-old girl with burn scar deformities scheduled for reconstruction of the scar contractures with insertion of tissue expanders in which the administration of latex tissue expanders was associated with late onset hypotension, thrombocytopenia, disseminated intravascular coagulation and pulmonary edema. Skin tests performed for latex demonstrated strong positive weal and flare reactions. CONCLUSION: Late onset anaphylactic reactions due to latex tissue expanders, an unusual unpredictable adverse reaction, must be kept in mind. Early recognition and proper emergent treatment are essential to reversing this complication.

Intensive care cost and survival analyses of traumatic brain injury.

BACKGROUND: Intensive care of Traumatic Brain Injury (TBI) is associated with substantial morbidity, mortality and cost; however, there is very little published work on this topic. The purpose of this study was to examine direct costs and survival outcomes of patients with TBI admitted to an intensive care unit (ICU). METHODS: A retrospective review of the records of Trakya University Hospital's ICU from 2002-2006 was undertaken. Patients with TBI were determined and assessed regarding costs and survival. RESULTS: The study group consisted of 126 patients, and 27.8% of them had been operated. Male gender (80.2%) was dominant, mean length of stay was 9.8+/-8.7 days, and motor vehicle injury (59.5%) was the major reason for ICU admission. Mortality rate was 50% and the Glasgow Coma Score (GCS) of the patients was 6.1+/-1.9. The average cost per ICU stay was US$ 4846+/-5084. Cost per life saved and per life-year saved were US$ 9533 and US$ 313.60, respectively. Survival rates were significantly different among injury types (p=0.010). GCS appeared to be a prognostic parameter in patient survival (Hazard Ratio: 0.643; 95%CI: 0.529-0.781; p<0.001). CONCLUSION: Intensive care of TBI cases is characterized by high mortality and high cost.

The effect of dexmedetomidine on liver histopathology in a rat sepsis model: an experimental pilot study.

BACKGROUND: In this pilot study, we aimed to investigate the effect of dexmedetomidine on liver tissues during experimental sepsis by histopathological examination. METHODS: The animals were allocated randomly to four groups, two of which received endotoxin. In the Sepsis Group (n:10) and Dexmedetomidine/Sepsis Group (n:10), endotoxemia was induced by E. coli lipopolysaccharide derived from E. coli 0111: B4. Animals in the Control Group (n:10) received an infusion of 0.9% saline (1.0 mL x kg(-1) x hr(-1)) intravenously. The Dexmedetomidine Group (n:10) and Dexmedetomidine/Sepsis Group received a bolus injection of 0.9% saline (1.0 mL/kg), followed by dexmedetomidine administration (infusion at 5 microg x kg(-1) x hr(-1)). All rats were euthanized at the 8th hour of endotoxin infusion. Histopathological examinations were performed on liver tissues. RESULTS: In the liver, central venous congestion, congestion and dilation of the hepatic sinusoids and inflammation of the portal tracts were noted in the Sepsis Group. These parameters were seen slightly in the Sepsis/Dexmedetomidine group. There was a statistically significant difference between the Sepsis and Sepsis/Dexmedetomidine Groups (p<0.001). CONCLUSION: Dexmedetomidine has a protective effect on liver tissues during experimental sepsis in the rat. We propose that dexmedetomidine sedation may be useful in the therapy of the liver dysfunction associated with sepsis and in other diseases related to local or systemic inflammation.

Curcumin attenuates the organ dysfunction caused by endotoxemia in the rat.

OBJECTIVE: Curcumin has antioxidant, antitumor, and anti-inflammatory properties. However, it remains unknown whether curcumin has any protective effects on sepsis. The purpose of this study was to demonstrate whether curcumin prevents organ dysfunction in animals with sepsis. METHODS: Rats were randomized into four groups. The control group (group I, n = 7) did not receive any treatment. The curcumin group (group II, n = 10) only received 1.2 g/kg of curcumin. Escherichia coli were injected into the remaining groups intraperitoneally after general anesthesia. Five hours after injection, 12 rats received placebo (group III), and 10 rats received 1.2 g/kg of curcumin (group IV) for 7 d. All rats were sacrificed on postsepsis day 8 and a midline laparotomy was performed. Livers, kidneys, and small bowels were excised for evaluation of the degree of inflammation and tissue alterations histopathologically. RESULTS: In the liver, widespread hydropic degeneration of hepatocytes were seen in the sepsis group. There was no hydropic degeneration of hepatocytes and no portal inflammation in the sepsis/curcumin group. With respect to the small bowel, the sepsis group showed edema and prominent intraepithelial infiltration of neutrophil leucocytes and plasma cells. Inflammation and hyperemia in the lamina propria in the sepsis/curcumin group were less than those in the sepsis group. With respect to the kidneys, the sepsis group showed severe acute tubular necrosis that was more restricted in the sepsis/curcumin group than in the sepsis group. CONCLUSION: Curcumin reduced organ dysfunction in rats with experimentally formed sepsis. We propose that curcumin may be useful in the therapy of organ dysfunction due to sepsis, shock, and other diseases associated with local or systemic inflammation.

Effect of proton pump inhibitors on gastric juice volume, gastric pH and gastric intramucosal pH in critically ill patients : a randomized, double-blind, placebo-controlled study.

OBJECTIVE: This study aimed to determine the effect of administration of a single-dose proton pump inhibitor (PPI) on gastric intramucosal pH (pHi), gastric juice volume and gastric pH in critically ill patients. METHODS: This prospective, randomized, double-blind, placebo-controlled study included 75 patients who were divided into five groups that received the following treatment: group C (n = 15), saline 100 mL; group O (n = 15), omeprazole 20 mg; group P (n = 15), pantoprazole 40 mg; group E (n = 15), esomeprazole 20 mg; and group R (n = 15), rabeprazole 20 mg. All treatments were administered nasogastrically in 100 mL of physiological saline. Measurements of gastric pHi, gastric juice volume and gastric pH were obtained immediately before and 2, 4 and 6 hours after administration of treatments. In addition, gastric content was aspirated and its volume was recorded. RESULTS: Initial gastric pHi, gastric juice volume and gastric pH values were not statistically significantly different among the groups (p > 0.05). No statistically significant difference in gastric pHi was seen among the groups before or 2, 4 or 6 hours after saline or PPI administration. At hours 2, 4 and 6, gastric pH in the pantoprazole, esomeprazole and rabeprazole groups increased significantly, whereas gastric juice volume decreased significantly, compared with the omeprazole and placebo groups (p < 0.001). No statistically significant differences were seen between the pantoprazole, esomeprazole and rabeprazole groups. CONCLUSION: This is the first study to show that single-dose pantoprazole, esomeprazole and rabeprazole are associated with greater gastric pH increase and greater gastric juice volume decrease than omeprazole in critically ill patients. Our study also suggests that PPIs do not affect gastric pHi measurements in critically ill patients and can be administered during pH monitoring.

Efficacy of levobupivacaine wound infiltration with and without intravenous lornoxicam for post-varicocoele analgesia: a randomized, double-blind study.

BACKGROUND AND OBJECTIVE: The oxicam NSAID lornoxicam is a potent analgesic with excellent anti-inflammatory properties in a range of painful and/or inflammatory conditions, including postoperative pain. Levobupivacaine, the S-(-)-isomer of bupivacaine, is a long-acting local anaesthetic that can be infiltrated into wounds for management of postoperative pain. We assessed the analgesic efficacy of lornoxicam when administered as an adjuvant to levobupivacaine wound infiltration after varicocoele operation. METHODS: Sixty patients who underwent varicocoele surgery were randomly assigned to three different treatment groups. Before skin closure, patients received the following treatments: group I (n=20) patients received normal saline 20 mL wound infiltration and intravenous lornoxicam (Xefo, Nycomed Pharma AS, Roskilde, Denmark) 2 mL (8 mg); group II (n=20) patients received 0.25% levobupivacaine (Chirocaine, Abbott Scandinavia AB, Solna, Sweden) 10mL with normal saline 10 mL wound infiltration and intravenous normal saline 2 mL; group III (n=20) patients received 0.25% levobupivacaine 10 mL with normal saline 10 mL wound infiltration and intravenous lornoxicam 2 mL (8 mg). Pain scores and total pethidine (meperidine) consumption were measured at 1, 2, 4, 6, 12 and 24 hours postoperatively. Time to first analgesic requirement and patient satisfaction were also compared post-surgery. RESULTS: Pain scores during the first 6 hours postoperatively were significantly lower in group III than in group I and group II (p<0.01). Total pethidine consumption was significantly lower in group III (34.0+/-28.0 mg) than in group I (74.0+/-25 mg) and group II (76.0+/-29 mg) [p<0.01]. Time to first analgesic was also significantly longer in group III (14.8+/-8.4 hours) than in group I (6.2+/-5.2 hours) and group II (5.8+/-7.1 hours) [p<0.01]. The incidence of postoperative nausea and vomiting was significantly lower in group III than in group I and group II (p<0.05). More patients in group III described their analgesia as good or excellent than in group I or group II (p<0.01). CONCLUSION: In this study, levobupivacaine wound infiltration with adjuvant intravenous lornoxicam administration was associated with better postoperative analgesia during the early postoperative hours after varicocoele surgery than that induced by lornoxicam alone or levobupivacaine wound infiltration alone.

The prognostic value of atrial and brain natriuretic peptides, troponin I and C-reactive protein in patients with sepsis.

AIM: To investigate the plasma levels of atrial and brain natriuretic peptides (ANP and BNP), cardiac troponin I (cTnI) and C-reactive protein (CRP) as prognostic factors for survival in patients with sepsis. METHOD: Evaluation of serum levels of ANP, BNP, cTnI and CRP of patients on admission to an intensive care unit, two days later, and on the day of discharge from the intensive care unit or on the day of death. RESULTS: ANP levels were significantly higher in the nonsurviving patients (day 1: 70.00+/-49.54 pg/mL; day 2: 138.85+/-143.15 pg/mL; and died/discharged day: 375.70+/-262.66 pg/mL) than surviving patients (day 1: 23.96+/-29.93 pg/mL; day 2: 10.06+/-6.03 pg/mL; died/discharged day: 6.68+/-100.98 pg/mL, P<0.001). The BNP levels were significantly higher in the nonsurvivors (day 1: 254.78+/-308.62 pg/mL; day 2: 383.22+/-307.19 pg/mL; and died/discharged day: 696.47+/-340.33 pg/mL), than survivors (day 1: 13.72+/-12.95 pg/mL; day 2: 7.20+/-5.85 pg/mL; died/discharged day: 4.51+/-4.64 pg/mL, P<0.001). The cTnI levels were significantly higher in the nonsurviving patients (day 2: 0.16+/-0.38 mug/L; died/discharged day: 0.78+/-2.48 mug/L) than surviving patients (day 2: 0.04+/-0.07 mug/L; died/discharged day: 0.02+/-0.01 mug/L, P<0.05). The CRP levels were significantly higher in the nonsurvivors (day 2: 119.3+/-71.5 mg/L; and died/discharged day: 145.7+/-74.7 mg/L) than survivors (day 2: 57.0+/-29.7 mg/L; died/discharged day: 26.8+/-24.0 mg/L, P<0.05). There were no significant differences between nonsurvivors and survivors for cTnI and CRP on day 1. CONCLUSION: With the exception of cTnI and CRP on day 1, all of the parameters were significantly powerful to determine nonsurvivors on all days. Among these variables, BNP was the most powerful diagnostic parameter for the prediction of nonsurvivors on all days.

The preoperative use of gabapentin, dexamethasone, and their combination in varicocele surgery: a randomized controlled trial.

BACKGROUND: We investigated the effects of gabapentin and dexamethasone given together or separately 1 h before the start of surgery on laryngoscopy, tracheal intubation, intraoperative hemodynamics, opioid consumption, and postoperative pain in patients undergoing varicocele operations. METHODS: Patients were randomly divided into four double-blind groups: group C (control, n = 20) received placebo, group G (gabapentin, n = 20) received 800 mg gabapentin, group D (dexamethasone, n = 20) received 8 mg dexamethasone, group GD (gabapentin plus dexamethasone) received both 800 mg gabapentin and 8 mg dexamethasone IV 1 h before the start of surgery. Standard induction and maintenance of anesthesia were accomplished and continued by propofol and remifentanil infusion. Heart rate and arterial blood pressure were recorded before induction and after intubation. Intraoperative total remifentanil consumption was recorded. Hemodynamic variables and visual analog scale were recorded for 24 h. Side effects were noted. RESULTS: Hemodynamics at 1, 3, 5, and 10 min after tracheal intubation, total remifentanil consumption during surgery, postoperative visual analog scale scores at 30 min, 1, 2, 4, 6, and 12 h, and postoperative nausea and vomiting were found to be significantly lower in group GD than in group G and group D (P < 0.05 for both), and substantially lower when compared with group C (P < 0.001). All values in group C were also higher than in groups G and D (P < 0.05). CONCLUSION: Gabapentin and dexamethasone administered together an hour before varicocele surgery results in less laryngeal and tracheal intubation response, improves postoperative analgesia, and prevents postoperative nausea and vomiting better than individual administration of each drug.

High C-reactive protein and low cholesterol levels are prognostic markers of survival in severe sepsis.

STUDY OBJECTIVE: To evaluate serum C-reactive protein and cholesterol as a prognostic factor for survival in patients with severe sepsis. DESIGN: Prospective study. SETTING: University hospital. PATIENTS: The study population consisted of 96 patients (age range, 18-75 years; median, 56 years; men/women ratio, 40:56) in whom severe sepsis was diagnosed. INTERVENTIONS: Patients' serum levels of C-reactive protein and cholesterol were measured upon admission to an intensive care unit, two days later, and on the day of discharge from the intensive care unit or on the day of death. MEASUREMENTS AND MAIN RESULTS: Cholesterol levels were significantly lower among the nonsurviving patients (day 1, 92.2 +/- 25.1 mg/dL; day 2, 92.1 +/- 21.7 mg/dL; death/discharge day, 92.2 +/- 21.7 mg/dL) than surviving patients (day 1, 175.1 +/- 38.6 mg/dL [P < 0.001]; day 2, 173.0 +/- 39.3 mg/dL [P < 0.001]; death/discharge day, 171.8 +/- 39.6 mg/dL [P = 0.010]). Median C-reactive protein levels were significantly higher among the nonsurvivors (day 1, 32 mg/dL [range, 20.5-64.5 mg/dL]; day 2, 33 mg/dL [range, 22-74.5 mg/dL]; death/discharge day, 30 mg/dL [range, 22-57 mg/dL]) than survivors (day 1, 10 mg/dL [range, 6-14 mg/dL]; day 2, 9 mg/dL [range, 5-10 mg/dL]; death/discharge day, 6 mg/dL [range, 3-9 mg/dL]; P < 0.001). CONCLUSION: Serum C-reactive protein and cholesterol are a predictor of survival in patients with severe sepsis. Low cholesterol and high C-reactive protein levels appear as a valuable tool for individual risk assessment in severe sepsis patients and for stratification of high-risk patients in future intervention trials.

Determining the Efficiency of Different Preoperative Difficult Intubation Tests on Patients Undergoing Caesarean Section.

BACKGROUND: Pregnancy-induced anatomical and physiological changes in the airway make airway management difficult in obstetric patients; thus, preoperative evaluation of the airway is important for obstetric patients. AIMS: To determine the effectiveness of the modified Mallampati test; the interincisor, sternomental and thyromental distances and the upper limb bite test. The second aim was to assess the effectiveness of the combination of the upper limb bite test with the other tests in obstetric patients. STUDY DESIGN: Cross-sectional study. METHODS: Pregnant women (n=250) scheduled for caesarean section were analysed. The patients' ages, heights and weights were collected. Preoperative airway evaluation was done by using a modified version of the Mallampati test. The interincisor, sternomental and thyromental distances were measured, and the upper limb bite test was performed. The laryngoscopy difficulty was evaluated by using Cormack-Lehane classification. RESULTS: No statistically significant differences were found between groups in age, height or weight (p>0.05). The modified Mallampati test and interincisor, sternomental and thyromental distances revealed a lower number of easy intubations than that determined by the Cormack-Lehane classification and a higher number of difficult intubations than the actual number of cases (p<0.05). The sensitivity and specificity of the modified Mallampati test, the upper limb bite test, the interincisor distance test and the sternomental and thyromental distance tests were found to be 73.08, 57.69, 84.62, 80.77 and 88.46 and 90.62, 99.11, 83.04, 84.37 and 87.05, respectively. When the combinations were examined, the sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test were found to be 57.69 and 100, respectively. When the upper limb bite test was combined with the interincisor distance, the sensitivity and specificity were 46.15 and 100, respectively. We found a sensitivity and specificity of 93.75 and 95.30, respectively, for the combination of the upper limb bite test with the thyromental distance test. The sensitivity and specificity of the combination of the upper limb bite test with the modified Mallampati test and interincisor distance test were found to be 46.15 and 100, respectively. For combination of all the tests, the sensitivity and specificity was 42.31 and 100, respectively. CONCLUSION: When all combinations are evaluated in the decision of difficult intubation, the combination of the upper limb bite test and thyromental distance test is superior to the use of other methods alone to predict difficult intubation in pregnant women.

[The prognostic value of cerebral oxygen saturation measurement for assessing prognosis after cardiopulmonary resuscitation]. / O valor da medida da saturação cerebral de oxigênio para avaliar o prognóstico após ressuscitação cardiopulmonar.

BACKGROUND: Despite new improvements on cardiopulmonary resuscitation (CPR), brain damage is very often after resuscitation. OBJECTIVE: To assess the prognostic value of cerebral oxygen saturation measurement (rSO2) for assessing prognosis on patients after cardiopulmonary resuscitation. DESIGN: Retrospective analysis. MEASUREMENTS AND RESULTS: We analyzed 25 post-CPR patients (12 female and 13 male). All the patients were cooled to a target temperature of 33-34°C. The Glascow Coma Scale (GCS), Corneal Reflexes (CR), Pupillary Reflexes (PR), arterial Base Excess (BE) and rSO2 measurements were taken on admission. The rewarming GCS, CR, PR, BE and rSO2 measurements were made after the patient's temperature reached 36°C. RESULTS: In survivors, the baseline rSO2 value was 67.5 (46-70) and the percent difference between baseline and rewarming rSO2 value was 0.03 (0.014-0.435). In non-survivors, the baseline rSO2 value was 30 (25-65) and the percent difference between baseline and rewarming rSO2 value was 0.031 (-0.08 to -20). No statistical difference was detected on percent changes between baseline and rewarming values of rSO2. Statistically significant difference was detected between baseline and rewarming GCS groups (p=0.004). No statistical difference was detected between GCS, CR, PR, BE and rSO2 to determine the prognosis. CONCLUSION: Despite higher values of rSO2 on survivors than non-survivors, we found no statistically considerable difference between groups on baseline and the rewarming rSO2 values. Since the measurement is simple, and not affected by hypotension and hypothermia, the rSO2 may be a useful predictor for determining the prognosis after CPR.

Indomethacin-induced pancreatitis: a case report.

CONTEXT: There are no previous reports of acute pancreatitis associated with the use of indomethacin in the general population. Drugs of all types are related to the etiology of pancreatitis in approximately 1.4-2.0% of cases. CASE REPORT: We report the case of a 56-year-old man who presented with acute pancreatitis after a period of indomethacin therapy. Other causes of the disease were ruled out. Due to multiorgan failure, he was in the intensive care unit for 44 days. He made a full recovery. The indomethacin was discontinued. CONCLUSIONS: We report indomethacin as the probable cause of acute pancreatitis in a patient without any known predisposing factors. To our knowledge, this is the rare description of a case of indomethacin-induced pancreatitis. However, the link is difficult to establish and further evidence is required to prove the association.

Predictive value of thyroid hormones on the first day in adult respiratory distress syndrome patients admitted to ICU: comparison with SOFA and APACHE II scores.

BACKGROUND: Thyroid hormone dysfunction could affect outcome and increase mortality in critical illness. Therefore, in a prospective, observational study we analyzed and compared the prognostic accuracy of free tri-iodothyronine (fT3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), along with the APACHE II and SOFA scoring systems in predicting intensive care unit (ICU) mortality in critically ill patients. PATIENTS AND METHODS: Physiology scores were calculated for the first 24 hours after ICU admission in 206 patients with acute respiratory distress syndrome. APACHE II and SOFA scores were employed to determine the initial severity of illness. Thyroid hormones were measured within the first 24 hours. Logistic regression models were created for APACHE II scores, SOFA scores, and thyroid hormone levels. The models predicted high- and low-risk subgroups. Models that showed a good fit were stratified by Kaplan-Meier survival curves. RESULTS: There were 98 (47.6%) survivors and 108 (52.4%) non-survivors. The survivors had a lower APACHE II score (11.50 vs 15.82, P < 0.0005), a lower SOFA score (6.06 vs 9.42, P < 0.0005), a younger age (57 vs 70 years, P = 0.008), a shorter ICU stay (13 vs 16 days, P = 0.012), and a higher fT3 level (2.18 vs 1.72 pg/mL, P = 0.002) than non-survivors. ICU survival was most closely predicted by a model that included age and fT3 and a model that included APACHE II and APACHE II*sex. CONCLUSION: In critically ill patients, serum fT3 concentrations markedly decreased after ICU admission among non-survivors. According to our findings, fT3 levels might have additive discriminatory power to age, SOFA and APACHE II scores in predicting short-term mortality in ARDS patients admitted to ICU.