Urinary lipid and protein oxidation products upon halothane, isoflurane, or sevoflurane anesthesia in humans: potential biomarkers for a subclinical nephrotoxicity.

OBJECTIVE: To investigate whether lipid and protein oxidation products are elevated and correlated with routine clinical markers of hepatic and renal function in patients anesthetized with halothane, isoflurane, or sevoflurane. METHODS: Urine and blood samples were collected from patient groups. Excretion of aldehydes, acetone, and o,o'-dityrosine was measured before and after anesthesia. Blood samples were analysed for clinical markers. RESULTS: Urinary concentrations of aldehydes, acetone, o,o'-dityrosine and glucose were significantly increased after anesthesia in halothane and sevoflurane groups earlier than clinical markers. Significant correlations were found in sevoflurane group. CONCLUSION: Lipid and protein oxidation contributes to subclinical sevoflurane nephrotoxicity. Oxidation products may serve as early biomarkers.

The effects of non-leukoreduced red blood cell transfusions on microcirculation in mixed surgical patients.

BACKGROUND: The impact of the storage process on oxygen-carrying properties of red blood cells and the efficacy of red blood cell (RBC) transfusions concerning tissue oxygenation remain an issue of debate in transfusion medicine. Storage time and leukocyte content probably interact since longer storage duration is thought to cause greater accumulation of leukocyte-derived cytokines and red blood cell injury. OBJECTIVES: The aim of this study was to investigate the effects of storage and the efficacy of fresh (stored for less than 1 week) versus aged (stored for more than 3 weeks) non-leukoreduced RBC transfusions on sublingual microvascular density and flow in mixed surgical patients. METHODS: Eighteen surgical patients were included in this study. Patients were randomly assigned into two groups receiving fresh (Group A) and aged (Group B) RBC transfusions. Sublingual microcirculatory functional capillary density (FCD) and microvascular flow index (MFI) were assessed using orthogonal polarization spectral (OPS) imaging. Measurements and collection of blood samples were performed after induction of general anesthesia, before RBC transfusion and 30 min after the RBC transfusion ended. RESULTS: In both groups RBC transfusions caused an increase in hemoglobin concentration (p<0.001). RBC transfusions increased FCD in Group A (p<0.001), while FCD remained unaffected in Group B. Changes in MFI following RBC transfusion in both groups remained unaltered. CONCLUSIONS: Fresh non-leukoreduced RBC transfusions but not RBCs stored for more than 3weeks, were effective in improving microciruculatory perfusion by elevating the number of perfused microvessels in mixed surgical patients.

Retrospective evaluation of quality of life in patients undergoing sacroiliac joint denervation with simplicity.

OBJECTIVES: The sacroiliac joint (SIJ) is the third most common cause of low back pain. The treatment of SIJ-induced pain is often conservative. When conservative treatments fail, interventional treatment methods, such as intra-articular injection or radiofrequency (RF) denervation are applied. Recently, in addition to the success of this interventional treatment applied, increased patient satisfaction and quality of life after treatment have also gained importance. The aim of this retrospective study was to evaluate pain management and improvement in the quality of life in patients with SIJ pain who underwent RF denervation with the simplicity probe. METHODS: The files of patients with SIJ degeneration on Ferguson X-ray, who underwent diagnostic intra-articular block for SIJ and had more than 50% reduction in pain were screened, and 38 cases in which simplicity RF neurotomy was applied were identified. The age, sex, and numerical rating scale (NRS) and short form (SF)-36 scores of the remaining 30 patients were recorded before and at 6 months after the procedure. RESULTS: There was a statistically significant decrease in NRS between the pre-procedure and post-procedure (6-month) values. The decrease in NRS did not significantly differ according to sex. A statistically significant improvement in all the domains of SF-36 in the post-procedure period compared to the pre-procedure period. There was no significant sex-related difference in the improvement of the SF-36 domains, except for the emotional role functioning domain, for which the scores were significantly higher in women than in men. CONCLUSION: In patients with SIJ pain who positively respond to steroid injection, the application of Simplicity III achieves long-term pain management and increases patient comfort and satisfaction pain without any complications.

Low-dose ropivacaine or levobupivacaine walking spinal anesthesia in ambulatory inguinal herniorrhaphy.

PURPOSE: The purpose of our study was to compare the equipotent doses of ropivacaine and levobupivacaine for walk-out criteria and the characteristics of spinal anesthesia in inguinal herniorrhaphy surgery. METHODS: Combined spinal-epidural anesthesia was performed. Adult patients were randomly allocated to receive 5 mg 0.5% ropivacaine plus 25 µg fentanyl (group RF, n = 25) or 3.75 mg 0.75% levobupivacaine plus 25 µg fentanyl (group LF, n = 25). Each solution was hypobaric, and the same volume, 3 ml, was administered. Sensory and motor block characteristics, hemodynamic changes, side effects, number of patients having ability to stand and walk at the end of the operation, time to first analgesic requirement, time to urination, time to getting out of bed (ambulation), and time to home discharge were determined. RESULTS: Sensory block onset time and time to reach the T6 dermatome were significantly shorter in group LF, whereas time to the two-segment regression and time to first analgesic requirement were significantly shorter in group RF. All patients in group LF were Bromage 0. Time to home discharge was shorter in group LF, but this difference was not statistically significant. CONCLUSION: We suggest that both local anesthetics can be used in walking spinal technique. Levobupivacaine may be an alternative local anesthetic for walking spinal anesthesia as it provides minimum motor block and a long duration of postoperative analgesia, even if its use is not associated with a shorter home discharge time.

Spinal 5-HT7 receptors play an important role in the antinociceptive and antihyperalgesic effects of tramadol and its metabolite, O-Desmethyltramadol, via activation of descending serotonergic pathways.

BACKGROUND: Tramadol is an analgesic drug, and its mechanism of action is believed to be mediated by the mu-opioid receptor. A further action of tramadol has been identified as blocking the reuptake of serotonin (5-HT). One of the most recently identified subtypes of 5-HT receptor is the 5-HT7 receptor. Thus, the authors aimed to examine the potential role of serotonergic descending bulbospinal pathways and spinal 5-HT7 receptors compared with that of the 5-HT2A and 5-HT3 receptors in the antinociceptive and antihyperalgesic effects of tramadol and its major active metabolite O-desmethyltramadol (M1) on phasic and postoperative pain models. METHODS: Nociception was assessed by the radiant heat tail-flick and plantar incision test in male Balb-C mice (25-30 g). The serotonergic pathways were lesioned with an intrathecal injection of 5,7-dihydroxytryptamine. The selective 5-HT7, 5-HT2, and 5-HT3 antagonists; SB-269970 and SB-258719; ketanserin and ondansetron were given intrathecally. RESULTS: Systemically administered tramadol and M1 produced antinociceptive and antihyperalgesic effects. The antinociceptive effects of both tramadol and M1 were significantly diminished in 5-HT-lesioned mice. Intrathecal injection of SB-269970 (10 microg) and SB-258719 (20 microg) blocked both tramadol- and M1-induced antinociceptive and antihyperalgesic effects. Ketanserin (20 mumicrog) and ondansetron (20 microg) were unable to reverse the antinociceptive and antihyperalgesic effects of tramadol and M1. CONCLUSIONS: These findings suggest that the descending serotonergic pathways and spinal 5-HT7 receptors play a crucial role in the antinociceptive and antihyperalgesic effects of tramadol and M1.

The addition of metamizole to morphine and paracetamol improves early postoperative analgesia and patient satisfaction after lumbar disc surgery.

AIM: Combined analgesic regimens produce sufficient analgesia by additive or synergistic effects, and reduce the total dose of analgesics and minimise adverse effects. We investigated the metamizole, paracetamol and morphine combination with respect to postoperative pain treatment in lumbar disc surgery. MATERIAL AND METHODS: After Ethics Committee approval and informed consent, 63 patients were allocated to three treatment groups; as Group paracetamol: paracetamol (1 g), Group paracetamol-metamizole: paracetamol (1 g) and metamizole (1 g), and Group placebo: no analgesic. All the patients received intravenous (i.v.) morphine with a patient-controlled analgesia device (PCA) as the rescue analgesic. Pain was assessed by the numerical pain rating scale (NRS, 0-3). Total morphine consumption at 24 hours, patient satisfaction and side effects were investigated. RESULTS: NRS of Group paracetamol-metamizole was low at 15th min, 30th min and 1st hour, and the difference reached statistical significance at 30th min (p=0.033). Patient satisfaction at the same measurement times was high in this group. Total morphine consumption and side effects were not statistically different between the three groups. CONCLUSION: Addition of metamizole to paracetamol along with iv morphine PCA offers an advantage over single iv morphine PCA and paracetamol, with respect to early postoperative pain treatment and patient satisfaction.

Do Stabilization Exercises Increase the Effects of Lumbar Facet Radiofrequency Denervation?

AIM: To investigate the effects of lumbar stabilization exercises on pain severity, functional disability, and physical performance after two weeks following radiofrequency denervation in patients with lumbar facet joint syndrome (LFJS). MATERIAL AND METHODS: Thirty-nine patients diagnosed with LFJS and had radiofrequency denervation were assigned to study and control groups. The study group (n=20) received a six-week stabilization exercise program and was informed about spine biomechanics, while the control group (n=19) received only informations about spine biomechanics. Pain severity with visual analogue scale, perceived disability with Oswestry disability index, physical performance with physical performance tests and gait speed test were applied before and after radiofrequency denervation, and after six weeks of intervention program. RESULTS: Despite the similar improvements were shown in terms of all outcomes in both groups following radiofrequency denervation (p > 0.05), the improvements were more in favor of study group after six week intervention program (p < 0.05). CONCLUSION: These results indicate that radiofrequency denervation is effective in improving the pain, disability, and physical performance in patients with LFJS and this effect is further enhanced by the stabilization exercises following this procedure. Adding stabilization exercises to radiofrequency denervation yielded positive outcomes and these exercise are strongly advised in physiotherapy and rehabilitation program.

Influence of sevoflurane and desflurane on neurological and adaptive capacity scores in newborns.

OBJECTIVES: To evaluate maternal and neonatal effects of desflurane compared with the sevoflurane for general anesthesia for cesarean section. METHODS: The study was conducted as a prospective randomized blind study between January 2003 to January 2004 at the Hacettepe University, Ankara, Turkey. One hundred and two American Society of Anesthesiologists (ASA) I patients aged between 20-35 at 37-42 weeks of pregnancy were randomly allocated into 2 groups. All patients received thiopental and succinylcholine for induction. Patients assigned to the first group received desflurane 2.5%, and the second group sevoflurane 1.5% combined with 50% nitrous oxide and oxygen. Maternal blood loss, umbilical arterial blood gas values, delivery intervals, Apgar scores, and neurologic and adaptive capacity score (NACS) on the fifteenth minute, second hour, and twenty-fourth hour of age were evaluated to assess the neonatal status. RESULTS: One hundred and two (52 sevoflurane group, 50 desflurane group) parturients were included in the study. In the desflurane group, NACS were significantly better on the fifteenth minute and second hour evaluations. There were no statistically significant differences in twenty-fourth hour NACS evaluations, Apgar scores, umbilical arterial blood gas values, delivery times, and maternal blood loss between the groups. CONCLUSION: Desflurane anesthesia offers more favorable results compared to sevoflurane in newborns delivered by elective cesarean section under general anesthesia in the early hours after delivery.

Effectiveness of physiotherapy and minimal invasive technics on functional status and quality of life in geriatric patients with low back pain.

The aim of the study was to determine the effect of physiotherapy and minimal invasive technics (MIT) on pain, quality of life and functional disability in geriatric patients with chronic low back pain. According to previous files, 61 geriatric patients who received MIT and physiotherapy allocated to group 1, the patient who received physiotherapy alone allocated to group 2. All patients received soft tissue mobilizations, muscle-energy technics and spinal stabilization exercises. Pain severity, functional disability, life quality, and fear avoidance were assessed with visual analogue scale, Oswestry Disability Index (ODI), Nottingham Health Profile (NHP) and Fear Avoidance Beliefs Questionnaire, respectively. Improvements in ODI and NHP were seen in favor of group 2 after treatment as to baseline (P<0.05). Although both treatments showed pain relief, functional restoration, and improvement in quality of life; there was no additional improvement in patients received MIT different from the patients received physiotherapy alone.

Comparison of midazolam, propofol and fentanyl combinations for sedation and hemodynamic parameters in cataract extraction.

OBJECTIVE: Midazolam, propofol and fentanyl were compared in terms of sedation during cataract extraction. Hemodynamic parameters, sedation level, postoperative satisfaction, and side effects were investigated. METHODS: The study was carried out in Hacettepe University Hospitals Ophthalmology Operating Theatres in 2005. The patients received only midazolam (0.02 mg kg-1), or midazolam (0.02 mg kg-1) + propofol (0.2 mg kg-1), or midazolam (0.02 mg kg-1) + fentanyl (1 microgram kg-1), or midazolam (0.02 mg kg-1) + propofol (0.2 mg kg-1) + fentanyl (1 microgram kg-1). The sedation level of patients was measured according to a physician questionnaire. Postoperative nausea/vomiting, headache, and patient satisfaction were determined via a patient's evaluation scale. RESULTS: In the groups receiving fentanyl, the hemodynamic response to peribulbar block insertion was minimal (p<0.05) and the sedation level was best (p<0.05). Respiration rate and O2 saturation of patients receiving midazolam, propofol, and fentanyl decreased after sedation (p<0.01) and postoperative satisfaction was high in this group (p<0.01). Patients in the midazolam group showed a prominent reaction to peribulbar block insertion while movement during the operation was obvious (p<0.05). CONCLUSION: The combination of midazolam, propofol, and fentanyl should be preferred to other study groups as the sedation level is suitable for cataract extraction with high postoperative patient satisfaction and without any side effects.

Effect of body temperature on peripheral venous pressure measurements and its agreement with central venous pressure in neurosurgical patients.

Previous studies suggest a correlation of central venous pressure (CVP) with peripheral venous pressure (PVP) in different clinical settings. The effect of body temperature on PVP and its agreement with CVP in patients under general anesthesia are investigated in this study. Fifteen American Society of Anesthesiologists I-II patients undergoing elective craniotomy were included in the study. CVP, PVP, and core (Tc) and peripheral (Tp) temperatures were monitored throughout the study. A total of 950 simultaneous measurements of CVP, PVP, Tc, and Tp from 15 subjects were recorded at 5-minute intervals. The measurements were divided into low- and high-Tc and -Tp groups by medians as cutoff points. Bland-Altman assessment for agreement was used for CVP and PVP in all groups. PVP measurements were within range of +/-2 mm Hg of CVP values in 94% of the measurements. Considering all measurements, mean bias was 0.064 mm Hg (95% confidence interval -0.018-0.146). Corrected bias for repeated measurements was 0.173 +/- 3.567 mm Hg (mean +/- SD(corrected)). All of the measurements were within mean +/- 2 SD of bias, which means that PVP and CVP are interchangeable in our setting. As all the measurements were within 1 SD of bias when Tc was > or = 35.8 degrees C, even a better agreement of PVP and CVP was evident. The effect of peripheral hypothermia was not as prominent as core hypothermia. PVP measurement may be a noninvasive alternative for estimating CVP. Body temperature affects the agreement of CVP and PVP, which deteriorates at lower temperatures.

Effect of catheter site on the agreement of peripheral and central venous pressure measurements in neurosurgical patients.

STUDY OBJECTIVE: Previous studies suggest a correlation of central venous pressure (CVP) with peripheral venous pressure (PVP) in different clinical setups. The aim of this study was to investigate the effect of measurement site on PVP and its agreement with CVP in patients undergoing general anesthesia. DESIGN: Prospective randomized study. SETTINGS: University hospital. PATIENTS: Thirty patients of American Society of Anesthesiologists physical status I and II undergoing elective craniotomy. INTERVENTIONS: Patients were randomly assigned into Group A (antecubital; n=15) and Group D (dorsum hand; n=15) for antecubital and hand dorsum catheterization sites, respectively. Central venous pressure and PVP were monitored throughout the study. A total of 1925 simultaneous measurements were recorded at 5-minute intervals. Bland-Altman assessment for agreement was used for CVP and PVP in 2 groups. MEASUREMENTS: Peripheral venous pressure measurements were within the range of +/-2 mm Hg of CVP values, in 93.9% of the measurements in Group A, and in 91.2% of the measurements in Group D. Considering all measurements, mean bias was -0.072 mm Hg (95% CI, -0.134 to -0.010). Group A measurements showed a bias (CVP-PVP) of 0.173+/-3.557 mm Hg, whereas the bias was -0.122+/-4.322 mm Hg (mean+/-SDcorrected for repeated measurements) in Group D. All of the measurements were within mean+/-2SD of bias, which means that PVP and CVP are interchangeable in our clinical setting. CONCLUSION: Peripheral venous pressure measurement may be a noninvasive alternative for estimating CVP in patients undergoing elective neurosurgical operations. Measuring PVP from hand dorsum does not interfere with the agreement of CVP and PVP.

Airway management of mucopolysaccharidosis with cervical spine involvement.

Mucopolysaccharidoses are a group of inherited disorders occasionally accompanied by cervical spine involvement complicating tracheal intubation. In this study, we review and discuss 5 cases of mucopolysaccharidosis with cervical spinal involvement.

Anesthesia and perioperative care of newborns with obstetrical brachial plexus injuries.

OBJECTIVE: The perioperative period is a particularly dangerous time for babies with serious obstetrical brachial plexus injuries undergoing microsurgical reconstruction. The aim of this study was to evaluate the perioperative and early postoperative problems in these patients. METHODS: Anesthetic management and pre and postoperative medical records were retrospectively reviewed for infants who underwent microsurgical nerve reconstruction (n=46) at the Hacettepe University, Ankara, Turkey from 1995 to 2003. RESULTS: Anesthetic considerations include the positioning, long duration of operation, fluid administration, intra and postoperative fever, tachycardia and respiratory complications. CONCLUSION: Respiratory management and fluid administration are the most important factors in anesthesia for brachial injuries. Care must also be taken for the long duration of the surgery, temperature, and loss of airway.

Acute parotitis following sitting position neurosurgical procedures: review of five cases.

Acute bacterial parotitis subsequent to major abdominal surgery is well documented, reportedly occurring in as many as 0.1% of patients. Postoperative parotitis has been reported between 1 to 15 weeks after surgery, commonly appearing within 2 weeks of the procedure. However, postoperative parotitis has not been reported previously after neurosurgical procedures. The authors report five cases of postoperative parotitis after neurosurgical operations in the sitting position with mild flexion and rotation of the head. This group of patients accounted for 0.16% of all craniotomy and 1.9% of all sitting position neurosurgical procedures performed in the authors' institution from 1996 through 2001. Neck flexion and head tilt in the sitting position might have an influence on acute parotitis. The authors found that the side of the parotitis was on the opposite side of the head rotation. Dehydration therapy may also be a contributing factor. The objective of this paper is to state that parotitis is a possible complication in neurosurgical patients operated on in sitting position and to discuss its pathophysiology and treatment options.

Anterograde endotracheal intubation with a laryngeal mask airway and guidewire in an infant with micrognathia.

Tracheal intubation through a laryngeal mask airway is an alternative to secure the ventilation in patients with difficult airway. Different techniques have been described to intubate these patients. A case of micrognathia in remote location anesthesia is reported. Endotracheal intubation was unsuccessful with the conventional methods. A soft tip angiography guidewire was advanced through a laryngeal mask airway. The position of the catheter was confirmed by fluoroscopy. Laryngeal mask airway was removed after endotracheal tube was inserted over the guidewire. This technique is recommended as an alternative where fiberoptic bronchoscopy is unavailable and in emergency situations.

Multilevel acute spinal epidural hematoma in a patient with chronic renal failure--case report.

A 47-year-old female with diabetic nephropathy presented with acute onset of severe back pain and progressive weakness in both lower extremities. Neuroimaging revealed a spinal epidural hematoma extending from the T-3 vertebra to the sacrum. Removal of all or every other lamina on levels with epidural hematoma and emergent evacuation of the hematoma were planned. T-9 and T-10 laminectomies were performed, but excessive bleeding during the operation prompted us to abandon the procedure. Plasma and desmopressin administration controlled the bleeding from the drain 8 hours after the operation. Follow-up neuroimaging one month later revealed total resolution of the hematoma with improved neurological status. Acute spinal epidural hematomas extending over more than 15 segments are extremely rare and the surgical treatment is still challenging. Coexisting hemorrhagic diathesis creates more problems. Conservative treatment may be the best option.

The analgesic efficacy of intra-articular acetaminophen in an experimental model of carrageenan-induced arthritis.

BACKGROUND: Acetaminophen is one of the most common drugs used for the treatment of pain and fever. OBJECTIVES: To examine the effects of intra-articular (IA) acetaminophen on carrageenan-induced arthritic pain-related behaviour and spinal c-Fos expression in rats. METHODS: The present study was performed using 20 Sprague Dawley rats. Forty microlitres of IA 0.9% NaCl was injected in the control group, and 40 µL of IA carrageenan was injected in the carrageenan group. One hour after carrageenan injection, 400 µg of IA acetaminophen was injected in the IA acetaminophen group, and 400 µg of intraperitoneal (IP) acetaminophen was injected in the IP acetaminophen group. One day before injection, and 4 h and 8 h after injection, diameters of both knee joints, motility of the rat, paw loading and joint mobility were assessed. After the rats were euthanized, L3 and L4 spinal segments were excised for c-Fos assessment. RESULTS: IA acetaminophen decreased both the severity and distribution of c-Fos expression. IP acetaminophen decreased only the distribution of c-Fos expression. IA acetaminophen decreased knee diameter at 8 h. IA and IP acetaminophen increased rat motility and paw loading scores. Joint mobility scores of IP acetaminophen were similar to saline at 8 h. CONCLUSIONS: Results of the present study indicate an analgesic and/or possible anti-inflammatory effect of IA acetaminophen and provide further evidence on the efficacy of systemic acetaminophen injection in reducing arthritic pain.

Doctors' opinions, knowledge and attitudes towards cancer pain management in a university hospital.

Cancer pain management is still reported to be inadequate despite of recent developments in medicine, resulting in serious outcomes. This study is to evaluate opinions, knowledge and attitudes of doctors working and/or being trainedg in surgical and medical departments in our university hospital, towards cancer pain management via a questionnaire. Of all doctors approached, eighty percent could be reached and 83% of them completed the questionnaire. In this group of doctors, reportedly 60% evaluating cancer patients with pain at least once in a week, most had not have any formal education about cancer pain management during their medical school or residency training and the ones reporting "any" education, described this as "limited in quality and as hours of lessons" and were not satisfied. The results of this survey suggest specific targets for the strategic and educational projects to overcome some of the barriers against the optimal cancer pain management. Most of the doctors believe that barriers originating from health professionals and systems are more important than the ones resulting from patients and give high priority to treatment of cancer pain relative to the treatment of cancer; but still half of them report that legal regulations have some influence on opioid prescription; and almost three quarters of them believe that opioid use may cause high rates of psychological addiction or abuse. Two thirds of the doctors feel themselves "insufficient" in cancer pain management, being more prominent in tasks requiring knowledge, skill, education and experience about opioid use.