Obturator Nerve Block Performed Blinded Versus by Ultrasound-guidence for Transurethral Resection of Bladder Tumors: A Randomized Controlled Trial.

PURPOSE: The primary outcome of this study is to compare the success rates of ONB techniques performed either with ultrasound guidance or with the blind technique. The second outcome is to compare the incidences of perioperative bleeding and the presence of recurrent tumors in the control cystoscopy performed in the 3rd postoperative month in both groups. MATERIALS AND METHODS:  The study was conducted in the urology operating room of Mugla Sitki Kocman Training and Research Hospital between December 2019 and March 2023. A total of 122 patients were included in the study: 22 females with a mean age of 56.63 ± 12.99 years and 100 males with a mean age of 63.18 ± 8.00 years. In one group (group 1), ONB was performed under ultrasound guidance by the same anesthesiologist, and in another group (group 2), ONB was performed blindly based on anatomical signs by the same urologist. RESULTS: Adductor muscle contraction was not observed in 53 patients (91.4%) in group 1 and in 49 patients (76.6%) in group 2 (p = 0.027). CONCLUSION: The success rate of ONB was higher when using an ultrasound-guided technique than when using a blind technique.

Comparison of the genotoxicity of propofol and desflurane using the comet assay in the lymphocytes of patients who underwent lumbar discectomy: A randomized trial.

OBJECTIVES: To compare the genotoxic effects of desflurane and propofol using comet assay in patients undergoing elective discectomy surgery. METHODS: This was a randomized controlled study. Patients who underwent elective lumbar discectomy under general anesthesia with propofol or desflurane were included in the study. Venous blood samples were obtained at 4 different time points: 5 minutes before anesthesia induction (T1), 2 hours after the start of anesthesia (T2), the first day after surgery (T3), and the fifth day following surgery (T4). Deoxyribonucleic acid damage in lymphocytes was assessed via the comet assay. RESULTS: A total of 30 patients, 15 in each group, were included in the analysis. The groups were similar in terms of age and gender distribution. There were no significant differences in demographics, duration of surgery, total remifentanil consumption, and total rocuronium bromide consumption. The comet assay revealed that head length, head intensity, tail intensity, tail moment at T1 were similar in the desflurane and propofol groups. Head length, tail length and tail moment measured in the desflurane group at T4 were significantly higher compared to the propofol group. Tail lengths of the desflurane group at T1, T2 and T3 were significantly higher than the corresponding values in the propofol group. CONCLUSION: Propofol and desflurane do not appear to induce DNA damage in lymphocytes. However, when the quantitative data were compared, it was determined that propofol had relatively lower genotoxic potential than desflurane.ClinicalTrials.gov Reg. No.: NCT05185167.

Rider sitting position widens lumbar intervertebral distance: a prospective observational study

Abstract Background: Reduced lumbar lordosis may make the process of identifying the intervertebral distance easier. The primary aim of this study was to measure the L3-L4 intervertebral space in the same patients undergoing spinal anesthesia in three different sitting positions, including the classic sitting position (CSP), hamstring stretch position (HSP) and rider sitting position (RSP). The secondary aim was to compare ultrasonographic measurements of the depth of the ligamentum flavum and intrathecal space in these three defined positions. Methods: This study is a single-blinded, prospective, randomized study. Ninety patients were included in final analysis. the patients were positioned on the operating table in three different positions to perform ultrasonographic measurements of the spinal canal. The intervertebral distance (IVD), the distance between the skin and the ligamentum flavum (DBSLF) and the intrathecal space (IS) were measured in the L3 -L4 intervertebral space in three different positions. Results: The RSP produced the largest mean distance between the spinous processes. The RSP yielded a significantly larger IVD than did the CSP (p < 0.001) and HSP (p < 0.001). The DBSP was larger in the CSP than in the HSP (p = 0.001). The DBSLF was significantly larger in the RSP than in the HSP (p = 0.009). Conclusions: Positioning the patient in the RSP significantly increased the intervertebral distance between L3 -L4 vertebrae compared to the CSP and HSP, suggesting easier performance of lumbar neuraxial block.

The Shining Star of the Last Decade in Regional Anesthesia Part-II: Interfascial Plane Blocks for Cardiac, Abdominal, and Spine Surgery.

The sine qua non of enhanced recovery after surgery protocols designed to improve the perioperative experiences and outcomes of patients is to determine the most appropriate analgesia management. Although many regional techniques have been tried over the years in this purpose, interfacial plane blocks have become more popular with the introduction of ultrasound technology into daily practice and they have great potential to support effective postoperative pain management in many surgeries. The current article focuses on the benefits, techniques, indications, and complications of interfascial plane blocks applied in cardiac, abdominal, and spine surgeries.

Comparing ultrasound-guided modified thoracoabdominal nerves block through perichondrial approach with oblique subcostal transversus abdominis plane block for patients undergoing laparoscopic cholecystectomy: a randomized, controlled trial.

BACKGROUND: Laparoscopic cholecystectomy(LC) causes significant postoperative pain. Oblique subcostal transversus abdominis plane(OSTAP) block was described for postoperative analgesia, especially for upper abdominal surgeries. Modified thoracoabdominal nerves block through perichondrial approach(M-TAPA) block is a new technique defined by the modification of the thoracoabdominal nerves through perichondrial approach (TAPA) block, in which local anesthetics are delivered only to the underside of the perichondral surface. The primary aim of this study was to evaluate the effect of M-TAPA and OSTAP blocks as part of multimodal analgesia on postoperative opioid consumption in patients undergoing LC. METHOD: The present study was designed as a randomized, controlled, prospective study. Seventy-six adult patients undergoing LC were randomly assigned to receive either bilaterally M-TAPA or OSTAP block after the induction of anesthesia and before surgery using bupivacaine 0.25%, 25 ml. The primary outcome was assessed as postoperative 24 h opioid consumption, between groups were compared. Secondary outcomes were Numerical Rational scale(NRS) scores, time to first opioid analgesia, patient recovery, using the Quality of Recovery-15 (QoR-15) scale, nausea and vomiting, sedation score, metoclopramide consumption, and evaluating the analgesic range of dermatome. RESULTS: The mean tramadol consumption at the postoperative 24th hour was higher in the group OSTAP than in group M-TAPA (P = 0.047). NRS movement score at 12th hour was statistically significantly lower in group M-TAPA than in group OSTAP (P = 0.044). Dermatomes showed intense sensory analgesia between T7-11 in both groups, and it was determined that there was proportionally more involvement in the group M-TAPA. There were no differences between the groups in terms of other results. CONCLUSIONS: After the LC surgery, ultrasound-guided M-TAPA block effectively reduced opioid consumption, postoperative pain, and QoR-15 scores similar to OSTAP block. CLINICAL TRIAL REGISTRATION: The study was registered prospectively at clinicaltrials.gov (trial ID: NCT05108129 on 4/11/2021).

Erector Spinae Plane Block for anesthesia of open ventral hernia repair in severe Ankylosing Spondylitis.

Ankylosing spondylitis is a challenging disease for anesthesiologist due its airway and axial skeleton involvement. A 55 years old male patient suffering from severe ankylosing spondylitis, admitted to Anesthesiology Clinic. He was planned to receive a midline open ventral hernia repair. We decided to perform bilateral ultrasound-guided erector spinae plane (ESP) block at the level of T8 with 0.4 mcg kg-1 hour-1 dexmedetomidine sedation for complete anesthesia of the surgery. We performed ESP block with 25 mL of 0.25% bupivacaine and repeated the same procedure at the contralateral side. Twenty minutes later, the skin incision was started. We didn't need to apply an additive anesthetic or analgesic drug throughout the surgery. ESP block provides analgesia for different dermatomes by effecting ventral rami and rami communicantes of spinal nerves depending on the level of injection site. When performed between T7-T9 levels, it has been reported to effectively attenuate postoperative pain after different types of surgeries.

Early and late blood flow changes in the brachial artery following brachial plexus block.

BACKGROUND: A nerve block causes various hemodynamic changes in the vessel system. The primary objective of the present study is to examine the volume flow values in the brachial artery in the early and late period following an infraclavicular brachial plexus block. The secondary objective is to evaluate arterial diameter, forearm temperature and other Doppler ultrasound measurements in the late period. METHODS: An infraclavicular brachial plexus block was performed in ASA class I-II patients aged 18-65 years who were to undergo upper extremity surgery. Hemodynamic measurements and the measurement of the Doppler ultrasound parameters at five minutes before and five, 15, 30 minutes, 24, 48 hours after the block. RESULTS: Volume flow was increased at the 30th min after nerve block. A 47.17% decrease in the collected volume flow data was noted between the 30th min and 24th hour, and this change was found to be statistically significant. It is also worth highlighting the decrease in volume flow at 24 hours and 48 hours, which became closer to the volume flow value at time 0, but was still relatively higher than the value at time 0. CONCLUSIONS: The increase in volume flow following a change in the flow morphology after an infraclavicular nerve block persists for at least 24 hours. This may be the explanation for clinical advantage in all types of surgery and in particular after fractures, graft and reimplantation surgery.

Evaluation of the effect of the mouth gag use on optic nerve sheath diameter of pediatric patients undergoing tonsillectomy or Adenotonsillectomy: An observational study.

BACKGROUND: A mouth gag is usually used during tonsillectomy and adenotonsillectomy surgeries, cleft palate repair, obstructive sleep apnea surgery, and intraoral tumor excision. The placement of the gag causes hemodynamic changes similar to laryngoscopy. The aim of this study was to evaluate the effect of mouth gag placement on the optic nerve sheath diameter (ONSD) of pediatric patients. The secondary aim was to assess the relationship between neck extension and changes in ONSD. METHODS: The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618000551291) on 12.04.2018. This prospective, observational study was performed in a tertiary university hospital operating room between 01.05.2018-01.07.2018. Thirty-five children aged < 18 years, with ASA I status, who were scheduled for tonsillectomy and adenotonsillectomy surgeries were prospectively included in the study. Measurements of ONSD were performed (T0) after induction of anesthesia, (T1) after endotracheal intubation, (T2) after mouth gag placement, and (T3) 20 min after mouth gag placement. After the mouth gag was placed and the head was positioned for surgery, the degree of neck extension was calculated. RESULTS: All participants completed the study. There were significant differences in ONSD values at time points T1, T2, and T3 (p < 0.001, CI: - 0.09,-0.05; p < 0.001, CI: - 0.09,-0.05; p < 0.001, CI: - 0.05,-0.02; respectively). The maximum increase in ONSD was after intubation (0.69 ± 0.06 mm) and immediately after mouth gag placement (0.67 ± 0.07 mm). ONSD values continued to increase 20 min after gag placement (0.36 ± 0.04). There was no relation between the degree of neck extension and ONSD values (ß = 0.63, p = 0.715). CONCLUSIONS: The use of a mouth gag causes significant increases in ONSD measurements of children. Therefore, attention to the duration of mouth gag placement should be considered during surgery. TRIAL REGISTRATION: The trial was prospectively registered to the Australian New Zealand Clinical Trials Registry (Trial ID: ACTRN12618000551291 ) on 12.04.2018.

Effects of different anesthesia techniques on intraoperative blood loss in acetabular fractures undergoing the Modified Stoppa approach.

BACKGROUND: This study aims to evaluate the effects of the anesthesia technique on the intraoperative blood loss in acetabular fracture patients undergoing the Modified Stoppa approach. METHODS: We retrospectively identified 63 patients who underwent a Modified Stoppa approach for acetabular fracture from January 2014 to July 2018. A total of 20 patients were excluded from this study for the following reasons: bilateral acetabular fractures (n=6), undergoing antiaggregant treatment (n=3), incomplete anesthesia records (n=3), emergency pelvic surgery due to hemodynamic instability (n=5), splenic rupture (n=2), and liver laceration (n=1). The patients were divided into two groups as follows: patients undergoing general anesthesia (GA) (n=22) and patients undergoing combined epidural-general anesthesia (CEGA) (n=21). The main outcome measurements studied were the intraoperative blood loss and the need for intraoperative and/or postoperative blood transfusions. RESULTS: No statistically significant differences were found between the groups concerning the age, gender, type of fracture, mechanism of injury, time from injury to surgery, Injury Severity Score, associated injuries, and comorbidities (p>0.05). The mean intraoperative blood losses were 717.27 ml (300-1.600 ml) in the GA group and 473.81 ml (150-1.020 ml) in the CEGA group (p<0.001). In the cases with only an isolated acetabular fracture, the intraoperative blood transfusion means were 2.43 units (1-5 units) in 14 patients in the GA group and 1.27 units (1-4 units) in 15 patients in the CEGA group (p<0.001). CONCLUSION: Less intraoperative bleeding was seen in those patients undergoing CEGA when compared to those undergoing GA. This is a significant advantage for acetabular surgery, which has a long learning curve and a high risk of bleeding.

Evaluation of ultrasound-guided rhomboid intercostal nerve block for postoperative analgesia in breast cancer surgery: a prospective, randomized controlled trial.

BACKGROUND AND OBJECTIVES: Mastectomy has many potential sources of pain. Rhomboid intercostal block (RIB) is a recently described plane block. The primary hypothesis of the study is that ultrasound-guided RIB combined with general anesthesia would accelerate global quality of recovery scores of patients following mastectomy surgery. Secondary hypothesis is that RIB would reduce postoperative opioid consumption, pain scores, and the need for rescue analgesia. METHODS: Patients aged between 18 and 70 years, with American Society of Anesthesiologists physical status I-II and scheduled for an elective unilateral modified radical mastectomy surgery with axillary lymph node dissection were enrolled to the study. Following endotracheal intubation, patients were randomly allocated into two groups. Patients in the first group (group R) received ultrasound-guided RIB with 30 mL 0.25% bupivacaine. In the control group (group C), no block intervention was applied. All patients received intravenous dexamethasone 8 mg, dexketoprofen trometamol 50 mg intraoperatively and tramadol 1 mg/kg 30 min before the end of surgery for postoperative analgesia. All patients received intravenous morphine patient-controlled analgesia device at the arrival to the recovery room. RESULTS: The descriptive variables of the patients were comparable between group R and group C. Mean quality of recovery-40 score at 24 hours was 164.8±3.9 in group R and 153.5±5.2 in group C (mean difference 11.4 (95% CI 8.8 to 13.9; p<0.001). At 24th hour, median morphine consumption was 5 mg (IQR 4-7 mg) in group R and 10 mg (IQR 8-13 mg) in group C, p<0.001. Intraoperative fentanyl administration, pain scores and the need for rescue postoperative analgesia was similar between groups. CONCLUSIONS: In the current study, ultrasound-guided RIB promoted enhanced recovery and decreased opioid consumption after mastectomy surgery. TRIAL REGISTRATION NUMBER: ACTRN12619000879167.

The effect of preoperative anxiety level on mean platelet volume and propofol consumption.

BACKGROUND: The mean platelet volume (MPV) is an important indicator of platelet function with large platelets showing higher enzymatic and metabolic activity than other platelets. There can be a relationship between increased platelet activity and anxiety and depression. Our primary hypothesis was that patients with high anxiety scores would have higher MPV, and the secondary hypothesis was that propofol induction time and total propofol consumption within the first 30 min of surgery would be higher in patients with higher anxiety scores. METHODS: The Beck Anxiety Inventory (BAI) was administered to the participating patients 1 day before surgery to evaluate the level of anxiety. Based on the scores from the BAI, 40 patients with an anxiety score of < 8 were assigned to the non-anxious group (Group NA) and 40 patients with an anxiety score of ≥8 were assigned to the anxious group (Group A). At the anesthesia induction the mean time to achieve an entropy value below 60 (T1) was recorded. The total intraoperative propofol consumption within the first 30 min was recorded. RESULTS: There was a statistically significant difference between the groups in terms of preoperative MPV and demographic data, including age and sex. The mean total propofol consumption at 30 min after induction in the groups was statistically significant. The cut-off value for MPV was calculated as 9.65. CONCLUSIONS: The preoperative MPV values and propofol consumption at 30 min among patients with high preoperative anxiety scores were high. We suggest that MPV is helpful in the clinical practice in predicting the amount of anesthetic agents required for the 30 mins of anesthesia.

The effects of early femoral nerve block intervention on preoperative pain management and incidence of postoperative delirium geriatric patients undergoing trochanteric femur fracture surgery: A randomized controlled trial.

BACKGROUND: Hip fracture is a common clinical problem which causes severe pain in geriatric patients. However, severe pain following fracture may bring on mental disorders and delirium. A neuroinflammatory response with IL-6 and IL-8 has been shown to be associated with the pathophysiology of delirium. In this study, our primary hypothesis is that preoperative femoral nerve block (FNB) intervention in geriatric patients will more effectively attenuate pain following trochanteric femur fracture than the preoperative paracetamol application. Our secondary hypothesis is that interleukin levels (IL-6, IL-8) in cerebrospinal fluid (CSF) will be lower in the femoral nerve block group than the paracetamol group. Our tertiary hypothesis is that the incidence of postoperative delirium will be lower in the femoral nerve block group. METHODS: The patients over 65 years of age with ASA status II-IV and admitted to the Emergency Service for femur fracture were included in this study. Recommendations of the 'delirium prevention table' were applied to all of the patients at arrival. In the first group, 15 mg/kg paracetamol was administered intravenously every eight hours. In the second group, femoral nerve blockage was performed, and a catheter was placed. Then, 0.5 mL/kg bupivacaine 0.25% was applied every eight hours. In both groups, pain scores four hours after interventions were recorded. All patients were operated within 48 hours under spinal anesthesia. During spinal anesthesia, 2 mL of CSF samples were taken from all patients for analysis of IL-6 and IL-8 cytokines, and pain scores during positioning were recorded. RESULTS: VAS scores four hours after the first preoperative pain treatment and during the positioning for regional anesthesia were significantly lower in the femoral nerve block group. IL-8 levels are significantly lower in the femoral nerve block group but not in IL-6 levels. The incidence of delirium was less in the femoral nerve block group, but the difference was not statistically significant. CONCLUSION: The femoral nerve block was more effective in preoperative pain management of trochanteric femur fracture and preventing pain during regional anesthesia application. The mean IL-8 level was lower in the femoral nerve block group when compared to the paracetamol group. There is no difference in the postoperative delirium incidence between groups.

[Comparison of pressure-controlled volume-guaranteed ventilation and volume-controlled ventilation in obese patients during gynecologic laparoscopic surgery in the Trendelenburg position]. / Comparação entre ventilação garantida por volume controlado por pressão e ventilação controlada por volume em pacientes obesos durante cirurgia laparoscópica ginecológica na posição de Trendelenburg.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the efficacy of the pressure-controlled, volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) modes for maintaining adequate airway pressures, lung compliance and oxygenation in obese patients undergoing laparoscopic hysterectomy in the Trendelenburg position. METHODS: Patients (104) who underwent laparoscopic gynecologic surgery with a body mass index between 30 and 40kg.m-2 were randomized to receive either VCV or PCV-VG ventilation. The tidal volume was set at 8mL.kg-1, with an inspired oxygen concentration of 0.4 with a Positive End-Expiratory Pressure (PEEP) of 5mmHg. The peak inspiratory pressure, mean inspiratory pressure, plateau pressure, driving pressure, dynamic compliance, respiratory rate, exhaled tidal volume, etCO2, arterial blood gas analysis, heart rate and mean arterial pressure at 5minutes after induction of anesthesia in the and at 5, 30 and 60minutes, respectively, after pneumoperitoneum in the Trendelenburg position were recorded. RESULTS: The PCV-VG group had significantly decreased peak inspiratory pressure, mean inspiratory pressur, plateau pressure, driving pressure and increased dynamic compliance compared to the VCV group. Mean PaO2 levels were significantly higher in the PCV-VG group than in the VCV group at every time point after pneumoperitoneum in the Trendelenburg position. CONCLUSIONS: The PCV-VG mode of ventilation limited the peak inspiratory pressure, decreased the driving pressure and increased the dynamic compliance compared to VCV in obese patients undergoing laparoscopic hysterectomy. PCV-VG may be a preferable modality to prevent barotrauma during laparoscopic surgeries in obese patients.

Efficacy of ultrasound-guided erector spinae plane block for analgesia after laparoscopic cholecystectomy: a randomized controlled trial / Eficácia do bloqueio do plano do músculo eretor da espinha guiado por ultrassom para analgesia após colecistectomia laparoscópica: um estudo controlado randômico

Abstract Background and objectives: The primary aim of this study is to assess the effect of ultrasoung-guided erector spinae block on postoperative opioid consumption after laparoscopic cholecystectomy. The secondary aims are to assess the effects of erector spinae plane block on intraoperative fentanyl need and postoperative pain scores. Methods: Patients between 18-70 years old, ASA I-II were included in the study and randomly allocated into two groups. In Group ESP, patients received bilateral US-ESP with 40 ml of 0.25% bupivacaine at the level of T7, while in Group Control, they received bilateral US-ESP with 40 ml of saline before the induction of anesthesia. Then a standard general anesthesia procedure was conducted in both groups. NRS scores at the postoperative 15th, 30th, 60th minutes, 12th and 24th hours, intraoperative fentanyl need and total postoperative tramadol consumption were recorded. Results: There were 21 patients in Group ESP and 20 patients in Group Control. Mean postoperative tramadol consumption was 100 ± 19.2 mg in Group ESP, while it was 143 ± 18.6 mg in Group Control (p < 0.001). The mean intraoperative fentanyl need was significantly lower in Group ESP (p = 0.022). NRS scores at the postoperative 15th, 30th min, 12th hour and 24th hour were significantly lower in ESP group (p < 0.05). According to repeated measures analysis, NRS score variation over time was significantly varied between two groups (F[1, 39] = 24.061, p < 0.0005). Conclusions: Bilateral US-ESP block provided significant reduction in postoperative opioid consumption, intraoperative fentanyl need and postoperative pain scores of patients undergoing laparoscopic cholecystectomy.

Resumo Justificativa e objetivos: O objetivo primário deste estudo foi avaliar o efeito do bloqueio do plano do músculo eretor da espinha guiado por ultrassom (US-ESP) sobre o consumo de opioides no pós-operatório após colecistectomia laparoscópica. Os objetivos secundários foram avaliar os efeitos do bloqueio do plano eretor da espinha sobre a necessidade de fentanil no intraoperatório e nos escores de dor pós-operatória. Métodos: Pacientes entre 18 e 70 anos, ASA I-II, foram incluídos no estudo e alocados randomicamente em dois grupos. No Grupo ESP, os pacientes receberam o bloqueio bilateral US-ESP com 40 mL de bupivacaína a 0,25% no nível de T7, enquanto no Grupo Controle os pacientes receberam o bloqueio bilateral US-ESP com 40 mL de solução salina antes da indução da anestesia. Em seguida, um procedimento-padrão de anestesia geral foi feito em ambos os grupos. Os escores da NRS aos 15, 30 e 60 minutos e em 12 e 24 horas de pós-operatório, a necessidade de fentanil no intraoperatório e o consumo total de tramadol no pós-operatório foram registrados. Resultados: O grupo ESP foi constituído por 21 pacientes e o Grupo Controle por 20. O consumo médio de tramadol no pós-operatório foi de 100 ± 19,2 mg no Grupo ESP e de 143 ± 18,6 mg no grupo controle (p < 0,001). A necessidade média de fentanil no intraoperatório foi significativamente menor no grupo ESP (p = 0,022). Os escores da NRS aos 15, 30 e 60 minutos e em 12 e 24 horas de pós-operatório foram significativamente menores no grupo ESP (p < 0,05). De acordo com a análise de medidas repetidas, a variação do escore NRS ao longo do tempo foi estatisticamente significativa entre dois grupos (F [1,39] = 24,061, p < 0,0005). Conclusões: O bloqueio bilateral US-ESP reduziu de forma significativa o consumo de opioides no pós-operatório, a necessidade de fentanil no intraoperatório e os escores de dor no pós-operatório dos pacientes submetidos à colecistectomia laparoscópica.

An Unexpected Complication Due to Metformin Use After Femur Fracture Operation: Metabolic Acidosis Without Lactic Acidosis.

A 74-year- old male, who was known to have hypertension, chronic obstructive lung disease, and benign prostate hyperplasia, was evaluated preoperatively in our clinic for a femur fracture. In addition, it was found that the patient was using 1000 mg of metformin per oral due to type 2 diabetes. At the preoperative cardiology evaluation, the ejection fraction was 60% with normal systolic ventricular function. Routine laboratory tests were normal. Metformin was held 24 hours before surgery. Spinal anesthesia was applied with 10 mg bupivacaine and 20 mcg fentanyl. Total blood loss at surgery was 150 cc. After an uneventful surgery, the patient was observed at the surgical postanesthesia care unit. Cardiac and respiratory physical examinations seemed normal but the patient had minimal acidosis and hypoxia in the arterial blood gas analysis. Twelve hours after the operation, compensated high anion gap ( 30 mEq/l) metabolic acidosis emerged, but lactate was normal. The patient's urea and creatinine levels were normal in the control blood tests, and the patient's urine output was above 0.5 ml/kg. Within this period, glucose levels were around 80-140 mg/dl. To overcome metabolic acidosis, bolus intravenous 8.4 % bicarbonate solution was administered. Bicarbonate infusion was started on the continuation of metabolic acidosis and base loss despite the bolus bicarbonate treatment. Since there was no other reason for the metabolic acidosis, metformin usage was considered to cause metabolic acidosis. During this treatment period, despite high anion gap acidosis, there was no lactate elevation. The patient had normal laboratory and hemodynamic values and was discharged from the intensive care unit at postoperative Day 3.

Bi-level erector spinae plane block for the control of severe back pain related to vertebral metastasis.

Pain is the most common reason for emergency department visits. Traditionally, pain management has been provided by narcotics, non-steroidal anti-inflammatory drugs and non-narcotics. Erector spinae plane block is a new interfascial plane block that has been successfully used for acute pain control in different surgeries. Two female patients with severe back pain related to breast cancer metastasis applied to emergency department. The pain scores of the patients were between 8 and 10. We performed bilateral erector spinae plane block at the levels of T3 and T6. The pain scores decreased under 2 within 30 min and none of the patients required additional analgesic agent for 24 hours. Previously erector spinae plane block was used for rib and spine fractures in emergency department. Different from previous cases, we performed bi-level blocks to cover a larger area and the block abruptly and effectively reduced pain scores of the patients with breast cancer.

Effect of melatonin on the daytime sleepiness side-effect of gabapentin in adults patients with neuropathic pain / Efeito da melatonina sobre o efeito colateral de sonolência diurna da gabapentina em pacientes adultos com dor neuropática

Abstract Background and objectives: Gabapentin is an antiepileptic drug. Widely used for the management of neuropathic pain. Although it is known to be well tolerated, somnolence and dizziness are the most frequent adverse effects. In this study, we aimed to evaluate the effect of melatonin on daytime sleepiness side effect of gabapentin, sleep quality and pain intensity of patients with neuropathic pain. Methods: Patients suffering from "neuropathic pain" and planed to receive gabapentin therapy were randomly divided into two groups. Group 1 received melatonin 3 mg and gabapentin 900 mg orally, group 2 received matching placebo capsule and gabapentin 900 mg. The Epworth Sleepiness Scale, the Pittsburgh sleep quality index for assessment of sleep quality and Verbal Rating Scale were completed at the 0th, 10th and 30th days of treatment. Additive analgesic drug requirements were recorded. Results: Eighty patients were enrolled to the study; age, gender, ratio of additive analgesic consumption, baseline Epworth Sleepiness Scale, Pittsburg Sleep Quality index and Verbal Rating Scale scores were similar between the groups. Epworth Sleepiness Scale scores, Pittsburgh sleep quality index scores and Verbal Rating Scale scores in Group 1 were significantly lower than group 2 at the 10th day of treatment (p = 0.002, p = 0.003, p = 0.002 respectively). At the 30th day of treatment, Epworth Sleepiness Scale scores and Verbal Rating Scale scores were significantly lower in Group 1 (p = 0.002, p = 0.008 respectively). However, Pittsburgh sleep quality index scores did not significantly differ between the groups (p = 0.0566). Conclusions: Melatonin supplementation rapidly and significantly improved daytime sleepiness side-effect of gabapentin, however sleep quality of the patients with neuropathic pain was similar between groups.

Resumo Justificativa e objetivos: Gabapentina é um agente antiepiléptico, amplamente utilizado para o tratamento da dor neuropática. Embora conhecida por ser bem-tolerada, sonolência e tontura são os seus efeitos adversos mais frequentes. Neste estudo, nosso objetivo foi avaliar o efeito da melatonina sobre o efeito colateral de sonolência diurna da gabapentina, a qualidade do sono e a intensidade da dor em pacientes com dor neuropática. Métodos: Os pacientes que sofriam de "dor neuropática" e com prescrição para receber terapia com gabapentina foram divididos aleatoriamente em dois grupos. O Grupo 1 recebeu 3 mg de melatonina e 900 mg de gabapentina por via oral, o Grupo 2 recebeu uma cápsula de placebo correspondente e 900 mg de gabapentina. A escala de sonolência de Epworth (ESS), o índice de qualidade do sono de Pittsburgh para avaliação da qualidade do sono (PSQI) e a escala de avaliação verbal (VRS) foram aplicados nos dias 0, 10 e 30 de tratamento. A necessidade de medicamentos analgésicos adicionais foi registrada. Resultados: Oitenta pacientes foram incluídos no estudo; idade, sexo, quantidade de analgésico adicional consumida e os escores basais de ESS, PSQI e VRS foram semelhantes entre os grupos. Os escores ESS, PSQI e VRS do Grupo 1 foram significativamente menores que os do Grupo 2 no décimo dia de tratamento (p = 0,002, p = 0,003, p = 0,002, respectivamente). No trigésimo dia de tratamento, os escores ESS e VRS foram significativamente menores no Grupo 1 (p = 0,002, p = 0,008, respectivamente). No entanto, os escores PSQI não diferiram significativamente entre os grupos (p = 0,0566). Conclusões: A suplementação de melatonina melhorou de forma rápida e significativa o efeito colateral de sonolência diurna da gabapentina, mas a qualidade do sono dos pacientes com dor neuropática foi semelhante entre os grupos.