Comparison of Dynamic Measures in Intraoperative Goal-Directed Fluid Therapy of Patients with Morbid Obesity Undergoing Laparoscopic Sleeve Gastrectomy.

INTRODUCTION: Obesity increases the risk of morbidity and mortality during surgical procedures. Goal-directed fluid therapy (GDFT) is a new concept for perioperative fluid management that has been shown to improve patient prognosis. This study aimed to investigate the role of the Pleth Variability Index (PVI), systolic pressure variation (SPV), and pulse pressure variation (PPV) in maintaining tissue perfusion and renal function during GDFT management in patients undergoing laparoscopic sleeve gastrectomy (LSG). MATERIALS AND METHODS: Two hundred ten patients were enrolled in our prospective randomized controlled clinical trial. Demographic data, hemodynamic parameters, biochemical parameters, the amount of crystalloid and colloid fluid administered intraoperatively, and the technique of goal-directed fluid management used were recorded. Patients were randomly divided into three groups: PVI (n = 70), PPV (n = 70), and SPV (n = 70), according to the technique of goal-directed fluid management. Postoperative nausea and vomiting, time of return of bowel movement, and hospital stay duration were recorded. RESULTS: There was no statistically significant difference between the number of crystalloids administered in all three groups. However, the amount of colloid administered was statistically significantly lower in the SPV group than in the PVI group, and there was no significant difference in the other groups. Statistically, there was no significant difference between the groups in plasma lactate, blood urea, and creatinine levels. CONCLUSION: In LSG, dynamic measurement techniques such as PVI, SPV, and PPV can be used in patients with morbid obesity without causing intraoperative and postoperative complications. PVI may be preferred over other invasive methods because it is noninvasive.

Effect of Patient State Index Monitoring on the Recovery Characteristics in Morbidly Obese Patients: Comparison of Inhalation Anesthesia and Total Intravenous Anesthesia.

PURPOSE: Obese patients have a significantly higher risk of adverse effects associated with general anesthesia. The purpose of this study was to evaluate the effects of Patient State Index (PSI) monitoring on recovery from anesthesia and the incidence of any postoperative complications among patients undergoing bariatric surgery with total intravenous anesthesia (TIVA) and inhalational anesthesia. DESIGN: This prospective, double-blind, and randomized controlled trial was conducted between February 2017 and August 2017 and included 120 morbidly obese patients (body mass index >40 kg/m2). METHODS: Patients were randomly divided into four groups; group P-PSI (n = 30): TIVA with PSI monitoring; group P (n = 30): TIVA without PSI monitoring; group D-PSI (n = 30): desflurane with PSI monitoring; and group D (n = 30): desflurane without PSI monitoring. The discharge time from the postanesthesia care unit (PACU), postoperative complications, and hemodynamic parameters were recorded and evaluated. FINDINGS: No significant differences were found in demographic data, duration of anesthesia, admittance to PACU, discharge from PACU, modified Aldrete scores, and perioperative mean blood pressure and heart rate. Nausea and vomiting scores were significantly lower in group P-PSI, group P, and group D-PSI compared with group D. CONCLUSIONS: Although TIVA and inhalational anesthesia can be safely used for obese patients, intraoperative PSI monitoring may decrease the discharge time from PACU and reduces incidence of postoperative nausea and vomiting caused by inhalation anesthetics.

Evaluation of the Effect of Erector Spinae Plane Block in Patients Undergoing Belt Lipectomy Surgery.

BACKGROUND: The interest in and demand for post-bariatric surgery have increased along with the increase in obesity surgery. Belt lipectomy, during which a circular correction is made in the center of the trunk, is the most commonly performed among these surgical techniques. Postoperative pain is an important problem due to the size of the surgical site and stretched closure. In this study, it was aimed to evaluate the intraoperative and postoperative narcotic analgesic consumption, postoperative analgesic requirement, postoperative visual analog scale (VAS) scores, postoperative nausea and vomiting (PONV), and the first mobilization time in patients with and without erector spinae plane block (ESPB). METHODS: The files of patients who had undergone belt lipectomy between 2016 and 2019 in our hospital were retrospectively reviewed. Patients who received ESPB were called group 1, and those who did not undergo ESPB were called group 2. Their demographic characteristics, intraoperative and postoperative narcotic and non-narcotic analgesic consumption, VAS scores, PONV, and the first mobilization times were recorded. RESULTS: The files of a total of 51 patients, including 23 patients in group 1 and 28 patients in group 2, were reviewed. It was determined that intraoperative and postoperative narcotic analgesic consumption (p < 0.005), PONV (p < 0.005), and the first mobilization time (p < 0.005) were significantly lower in group 1 compared with group 2. CONCLUSION: The use of the ESP block in belt lipectomy surgeries significantly reduces intraoperative and postoperative narcotic analgesic consumption and pain scores. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Procalcitonin levels among patients with fever secondary to severe intracerebral infection. A cross-sectional study.

BACKGROUND: Making the differential diagnosis between central fever and infectious fever is critically important among intracerebral hemorrhage patients followed up in intensive care units (ICUs). Serum procalcitonin (PCT) has been found to be a promising biomarker for the initial diagnosis of infection, even before culturing results. OBJECTIVES: To investigate the relationship between PCT and both fever etiologies and C-reactive protein (CRP) levels among critically ill patients with suspected intracerebral hemorrhage. DESIGN AND SETTING: Cross-sectional study in a public university hospital in Elazig, Turkey. METHODS: ICU patients diagnosed with intracerebral hemorrhage and normal procalcitonin levels were included in this study. From clinical assessments and cultures, they were classified as presenting either infectious or central fever. The sensitivity and specificity of PCT and CRP for predicting infection were calculated using a receiver operating characteristic (ROC) curve. RESULTS: There were 98 ICU patients with diagnoses of intracerebral hemorrhage. The median (interquartile range) PCT levels of patients with infectious and central fever were 4 (0.9-11) and 0.1 (0.1-0.4) ng/ml, respectively, with a statistically significant intergroup difference (P < 0.001). The areas under the ROC curve for predicting infectious or central fever PCT and CRP were 0.958 (P < 0.001) and 0.816 (P < 0.001), respectively. A statistically significant positive correlation was detected between PCT and CRP levels in patients with infectious fever (rho: 0.461; P = 0.003), but not in patients with central fever. CONCLUSIONS: PCT can possibly be used as a biomarker to differentiate between infectious and central fever among ICU patients.

The Relationship Between the Preoperative Neutrophil-to-Lymphocyte Ratio and Postoperative Nausea and Vomiting in Patients Undergoing Septorhinoplasty Surgery.

BACKGROUND: Postoperative nausea and vomiting (PONV) is one of the most common complications during the postoperative period. In the literature, there are many factors associated with PONV risk, but it is claimed that inflammation increases this risk. The neutrophil-to-lymphocyte ratio (NLR) is a cheap parameter to use in the diagnosis and follow-up of systemic inflammatory diseases. In this study, we aimed to investigate whether the preoperative NLR was a marker for PONV and to determine its relation with antiemetic use. METHODS: Eighty patients who were planned to undergo elective septorhinoplasty and were in ASA I-II were prospectively included in the study. The NLR value was calculated by dividing the number of neutrophils by the number of lymphocytes obtained from the preoperative complete blood count. The patients were divided into two groups of 40 patients: patients with an NLR < 2 (group 1) and patients with an NLR > 2 (group 2). Nausea and vomiting during the first 24 h in the recovery room and in the related clinic and antiemetic requirement were recorded. RESULTS: The rate of nausea-vomiting in the recovery room and in the postoperative 24-h period in group 1 was significantly lower than in group 2 (p < 0.05). The rate of use of antiemetics in the recovery room and in the postoperative 24-h period in group 1 was significantly lower than in group 2 (p < 0.05). CONCLUSION: NLR values above 2 calculated in the preoperative period may be an indicator of PONV risk. Antiemetic prophylaxis may be given according to this value. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy of Goal-Directed Fluid Therapy via Pleth Variability Index During Laparoscopic Roux-en-Y Gastric Bypass Surgery in Morbidly Obese Patients.

BACKGROUND: There is no well-recognized guideline for intraoperative fluid management in bariatric surgery. Goal-directed fluid therapy (GDFT) is a new concept of perioperative fluid management which was shown to improve patients' prognoses. Dynamic indicators may better predict fluid response compared to static indicators. In this study, we aimed to assess effects of administering GDFT protocol via Pleth Variability Index (PVI) in morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) surgery. METHODS: The study included 60 patients who underwent elective laparoscopic RYGB surgery. Subjects were randomized to two groups as being managed with either standard fluid regimen (control group) or PVI (PVI group) during intraoperative period. After induction of general anesthesia, control group received 500 ml crystalloid bolus followed by 4-8 ml/kg/h infusion. Fluid management of the control group was guided by central venous pressure and mean arterial pressure. PVI group received 500 ml crystalloid bolus followed by 2 ml/kg/h infusion. If PVI had been > 14%, 250 ml colloid was administered. Norepinephrine was given by infusion to keep mean arterial pressure > 65 mmHg, if needed. Perioperative lactate levels, hemodynamic parameters, and renal functions were recorded. RESULTS: In PVI group, volume of crystalloid and total fluid infusion during intraoperative period was significantly lower than the control group (p < 0.05). The groups did not significantly differ in terms of lactate or creatinine levels before or after the surgery (p > 0.05). CONCLUSIONS: There is no need to administer extra volume of fluid to obese patients undergoing laparoscopic bariatric surgery. Use of dynamic indicators like PVI helps to decrease intraoperative volume of infused fluids with no effects on either intraoperative or postoperative lactate levels in laparoscopic bariatric interventions.

The effect of preoperative consumption of potatoes on succinylcholine-induced block and recovery from anesthesia.

Potatoes contain solanaceous glycoalkaloids (SGAs), which inhibit both butyrylcholinesterase (BuChE) and acetylcholinesterase (AChE). The present study investigated the effect of preoperative consumption of potatoes on succinylcholine-induced block and recovery from anesthesia. ASA I-II, adult patients, scheduled for elective surgery, were included in a randomized, blind and controlled study. Patients were randomly divided into two groups. Patients in Group P (n = 21) ate a standard portion of potatoes in their last meal prior to pre-operative fasting, while patients in Group C (n = 23) ate food not containing SGAs. Patients were premedicated with midazolam. Anesthesia was induced with thiopental and fentanyl, and maintained with sevoflurane in 50 % O2/air and fentanyl, as needed. Succinylcholine 1 mg kg(-1) was administered to facilitate endotracheal intubation. Duration of succinylcholine blockade, awakening and recovery times from anesthesia were measured. Serum BuChE levels were also measured at baseline and 4 time-points within 24 h post-consumption. Duration of succinylcholine-induced neuromuscular block, awakening and recovery time from anesthesia was significantly longer in Group P than in Group C (p < 0.05). Serum BuChE levels decreased at 6 h after consumption start in Group P. In addition, in both groups, BuChE levels markedly decreased after succinylcholine blockade, increased thereafter, but did not return to baseline within 24 h of consumption start. None of these differences observed in BuChE levels was statistically significant. This study suggests that potatoes eaten before anesthesia can prolong the duration of succinylcholine-induced neuromuscular block and delay recovery from anesthesia.

Ketamine in post-tonsillectomy pain.

OBJECTIVE: There has yet been no ideal method for postoperative analgesia in children. Ketamine demonstrates a potent analgesic effect by central blockage of perception of pain with sub-anesthetic doses. Preoperative intramuscular administration of ketamine for sedation decreases the pain during swallowing after tonsillectomy, while it provides long-term analgesia when applied around the incision. The aim of this study is to compare the effectiveness of ketamine administered to the tonsillar region following tonsillectomy for postoperative pain management. METHODS: After obtaining consent from the local ethics committee and the parents, 60 patients from the ASA groups I and II, between 3 and 7 years of age, planned for adenotonsillectomy as outpatients, were included in the study. Subjects were randomly assigned to two equal groups and 2ml 0.9% saline for group S, and 0.5mgkg(-1) ketamine and saline 2ml in volume for group K were administered into the tonsillar region. All subjects were monitored in a standard manner and SpO(2), systolic arterial pressure (SAP), and cardiac pulse rates were recorded in 5min intervals. The CHEOPS and Wilson sedation scale were used to evaluate pain levels and sedative condition, respectively. Nausea and vomiting scores of the subjects were also noted. The time of the first analgesic administration and the total amount of analgesics in an 8-hour period were recorded. Student-T and Chi-Square tests were used for the statistical evaluation of the data and a p value of <0.05 was accepted as significant. RESULTS: There were no significant differences between groups according to age, sex, weight, intermittent SAP and cardiac pulse rates. However, the CHEOPS value, the first analgesic need and the total amount of analgesic need were in favor of ketamine (p<0.05). CONCLUSIONS: In previous studies, no significant differences were demonstrated in pre-emptive analgesia with ketamine, magnesium, morphine, and clonidine. The dose of ketamin and the volume used in this study caused no sedation or nausea and provided a high level of analgesia. Ketamine infiltration into the tonsillar region after tonsillectomy was found to be easy and effective.

Effects of ondansetron and granisetron on postoperative nausea and vomiting in adult patients undergoing laparoscopic cholecystectomy: a randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) are common and potentially distressing adverse events (AEs) associated with surgery and anesthesia. In patients undergoing laparoscopic cholecystectomy (LC) without antiemetic prophylaxis, the incidence of PONV can be as high as 72%. OBJECTIVE: The aim of this study was to investigate the prophylactic antiemetic effects of ondansetron and granisetron in patients undergoing LC when these agents are administered before the end of surgery. METHODS: Patients classified by the American Society of Anesthesiologist's physical status as I or II who were scheduled for elective LC were included in this randomized, double-blind, placebo-controlled study. Anesthesia was induced with thiopental 5 mg/kg and fentanyl 2 µg/kg, and was maintained with isoflurane 1% to 3% in 50% oxygen and 50% nitrous oxide and fentanyl as needed. Approximately 20 to 30 minutes before the end of the surgery, the patients randomly received either IV ondansetron 100 µg/kg (group O), IV granisetron 40 µg/kg (group G), or normal saline (group P). Plasma levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were determined preoperatively and 24 hours postoperatively. The patients were observed for 24 hours for PONV and other possible AEs. Postoperative pain intensity was determined using a 10-cm visual analogue scale. Four-point satisfaction scores were determined at 24 hours. RESULTS: Ninety patients (69 women, 21 men) participated in the study. Demographic characteristics and operative data (duration of surgery and anesthesia and amount of intraoperative fentanyl) were similar in the 3 groups. The only AE reported by patients during the 24-hour observation period was nonsevere headache. The number of patients experiencing headache was similar in group P, group O, and group G (10 [33%] patients, 6 [20%], and 10 [33%], respectively). No significant changes were found in presurgical and postsurgical plasma levels of ALT and AST in any group. The mean (SD) satisfaction scores in group O and group G (3.0 [0.4] and 3.0 [0.6], respectively) were significantly higher than those in group P (2.5 [0.5]; both, P < 0.01). Immediately after surgery (period 0), significantly more patients in the placebo group (21 [70%]) experienced PONV compared with those in the ondansetron group (9 [30%]; P < 0.05) and the granisetron group (7 [23%]; P < 0.01). During the 24-hour observation period, a significantly greater number of patients in group P (18 [60%]) required a single dose of a rescue antiemetic drug compared with those in groups O and G (9 [30%] and 6 [20%], respectively; both, P < 0.01). CONCLUSIONS: Patients administered ondansetron 100 µg/kg or granisetron 40 µg/kg 20 to 30 minutes before the end of LC had significantly higher PONV control during the 24-hour postoperative observation period than patients receiving placebo. However, there were no significant differences between the active treatment groups in the incidence of PONV, patient satisfaction, or AEs.

The effects of two different anaesthesia techniques on bispectral index values and awareness during off-pump coronary artery bypass grafting.

OBJECTIVE: The aim of this study was to evaluate Bispectral Index values and awareness during two different anaesthesia regimens (fentanyl-propofol and fentanyl-midazolam) in patients undergoing off-pump CABG surgery. METHODS: Fifty patients were included in the study. Patients were premedicated with midazolam and were randomly divided into two groups. Anaesthesia was induced with fentanyl (7-15 microg/kg), with either propofol (2 - 2.5 mg/kg, Group I) or midazolam (0.1 - 0.3 mg/kg, Group II) and vecuronium (0.1 mg/kg). Anaesthesia was maintained with fentanyl (15 microg/kg/h) together with either propofol (6 mg/kg/h) or midazolam (0.1 mg/kg/h). Depth of anaesthesia was adjusted according to clinical signs and haemodynamic responses. The level of sedation was monitored with Bispectral index continuously, but these levels were not shown to the attending anaesthetist. Bispectral index values were recorded for nine phases. Twenty-four hours after the operation, the patients were interviewed to determine intraoperative awareness and recall. RESULTS: In all patients, Bispectral index values were found to decrease after induction (in Group I, p = 0.005, in Group II, p = 0.008) with the mean values remaining below 60 for all phases. The differences between the groups were not statistically significant in inter-group comparison. No patients were noted to recall the sounds presented during the operation and the preoperative events. CONCLUSIONS: BIS monitoring with clinical signs may be used to assess the adequacy of both types of anaesthesia techniques as well as to detect awareness during off-pump CABG surgery.

[The efficacy of droperidol, metoclopramide, propofol, and ondansetron for the prevention of nausea and vomiting following middle ear surgery]. / Orta kulak cerrahisi sonrasinda olusan bulanti ve kusmada droperidol, metoklopramid, propofol ve ondansetronun etkinligi.

OBJECTIVES: The efficacy and reliability of prophylactic antiemetic therapy with low dose propofol, droperidol, metoclopramide, and ondansetron were evaluated in a randomized, double-blind, and prospective design. PATIENTS AND METHODS: A total of 101 ASA I-II patients (34 females, 67 males; age range 16 to 53 years) undergoing middle ear surgery for chronic otitis media or its sequelae were randomly assigned to receive prophylactic antiemetic therapy with propofol (n=21, 0.5 mg/kg), droperidol (n=19, 20 mg/kg), metoclopramide (n=23, 0.2 mg/kg), ondansetron (n=21, 4 mg), and placebo (n=20, 0.9% NaCl). All drugs were administered intravenously five minutes before extubation. RESULTS: In the early postoperative period (0 to 3 hours), the percentages of patients free from nausea and vomiting were 100% with droperidol, 71.4% with ondansetron and propofol, 52.1% with metoclopramide, and 35% with placebo. Ondansetron (90.4%) was found the most effective to prevent and control nausea and vomiting during the postoperative 3 to 24 hours, followed by droperidol (84.2%), propofol (57.1%), metoclopramide (47.8%), and placebo (40%). Compared with controls, the number of patients without nausea and vomiting was significantly greater in each treatment group but metoclopramide (p<0.05). No significant differences were detected with respect to adverse effects. CONCLUSION: Droperidol and ondansetron seem to exert the highest efficacy to prevent nausea and vomiting during the postoperative 0 to 3 hours and 3 to 24 hours, respectively.