Effects of different doses of remifentanil infusion on hemodynamics and recovery in children undergoing pediatric diagnostic cardiac catheterization.

OBJECTIVE: The present study aimed to compare 2 different doses of remifentanil infusion on hemodynamics, recovery period, and complications in children undergoing diagnostic pediatric cardiac catheterization. DESIGN: A prospective study. SETTING: A university hospital. PARTICIPANTS: Children undergoing diagnostic cardiac catheterization (n = 60). INTERVENTIONS: Children (2-12 years of age) scheduled for elective diagnostic cardiac catheterization under sedation were included in this study. The patients were assigned randomly to 2 groups as follows: patients in group 1 (n = 30) received a remifentanil infusion of 0.1 µg/kg/min, and patients in group 2 (n = 30) received a remifentanil infusion of 0.2 µg/kg/min. Heart rate (HR), systolic and diastolic blood pressures (BPs), oxygen saturation (SpO(2)), respiratory rate (RR), sedation, and recovery scores were recorded. MEASUREMENTS AND MAIN RESULTS: There were no significant differences between the groups in terms of systolic and diastolic BPs, HR, SpO(2), and RR during the study period. Additional drugs were required for 15 children in group 1; however, 27 patients maintained a satisfactory level of sedation with the 0.2-µg/kg/min remifentanil infusion. The time to achieve a recovery score of ≥5 was significantly shorter in group 2 than in group 1 (4.1 ± 0.3 minutes v 6.8 ± 0.8 minutes). No postoperative complications were reported in either group. CONCLUSION: After oral midazolam premedication and local prilocaine infiltration, 0.2 µg/kg/min of remifentanil provided adequate sedation without any hemodynamic compromise during pediatric diagnostic cardiac catheterization.

Effect of intramuscular and intravenous lidocaine on propofol induction dose.

OBJECTIVE: Our purpose was to study whether or not intravenous (IV) administration of lidocaine reduces propofol dose requirement as intramuscular (IM) lidocaine in a placebo-controlled manner. SUBJECTS AND METHODS: Seventy-five adult patients with American Society of Anesthesiologists physical status I and II, aged 20-60 years who were scheduled for surgery under general anaesthesia were included in the study. The patients were randomly allocated to 3 groups: IM: intramuscular administration; IV: intravenous administration and C: control. There were 25 patients in each group. The patients in group IM received lidocaine 1.5 mg · kg(-1) administered into the deltoid muscle 10 min before anaesthesia induction. In group IV, the patients received IV lidocaine 1.5 mg · kg(-1), 2 min before anaesthesia induction. Group C patients served as control group who received only propofol injection. Hypnosis after propofol administration was measured with response to verbal commands. RESULTS: There were no statistical differences between group IM (100.8 ± 26.1 mg) and group IV (110.8 ± 30.1 mg) regarding the induction dose of propofol (p > 0.05). In group C, the required propofol dose (151.2 ± 27.4 mg) for anaesthesia induction was significantly higher than in the other groups (p < 0.001). No side effect was observed in any patients. CONCLUSION: In this study, both IV and IM lidocaine administration were effective in reducing the hypnotic dose of propofol without any side effects. In addition, IV lidocaine may be more comfortable for awake patients.

Feasibility and safety of antegrade radial artery cannulation.

BACKGROUND AND OBJECTIVE: The purpose of this study was to compare thrombosis rates in antegrade (catheter directed toward the hand) versus retrograde (catheter directed toward the elbow) cannulation of the radial artery. Our secondary objectives were to compare these two techniques in terms of success rate, differences in noninvasive versus invasive blood pressure measurement and complications. METHODS: After obtaining the approval of the local ethics committee and written informed consent, the patients were randomly allocated to the antegrade (group A, n=60) or retrograde (group R, n=60) groups. Arterial thrombosis was evaluated by ultrasonography in each patient. Noninvasive and invasive blood pressure measurements and complications were recorded. Data were analysed using Student's t-test, the Mann-Whitney U-test, the categorical chi test, Fisher's exact test and Bland-Altman analysis. RESULTS: Thrombosis rates were similar between groups. The success rates for cannulation were 86.7 and 96.7% in the antegrade and retrograde groups, respectively (P<0.05). Complication rates were similar between groups. Very significant correlation was observed between the invasive and noninvasive methods when simultaneously measuring arterial systolic, diastolic and mean blood pressure. However, antegrade arterial measurements were consistently lower than those obtained via noninvasive methods. CONCLUSIONS: We conclude that antegrade radial artery cannulation has no advantage over the retrograde approach in terms of reducing thrombosis, but it can be used in cases when the retrograde approach has failed.

Fatal fever of unknown origin in acute cervical spinal cord injury: five cases.

BACKGROUND/OBJECTIVE: Patients with traumatic upper thoracic and cervical spinal cord injuries are at increased risk for the development of autonomic dysfunction, including thermodysregulation. Thermoregulation is identified as an autonomic function, although the exact mechanisms of thermodysregulation have not been completely recognized. Quad fever is a hyperthermic thermoregulatory disorder that occurs in people with acute cervical and upper thoracic spinal cord injuries. First described in 1982, it has not been widely discussed in the literature. METHODS: Case reports of 5 patients with cervical spinal cord injury (SCI). RESULTS: Five of 18 patients (28%) with acute cervical SCI who were admitted during a 1-year period had fatal complications caused by persistent hyperthermia of unknown origin. CONCLUSIONS: Patients with acute traumatic cervical and upper thoracic SCI are at risk for thermoregulatory dysfunction. Changes in the hypothalamic axis may be implicated, especially in the light of modification in hypothalamic afferent nerves, but this hypothesis has not yet been explored. Thermodysregulation may be an early sign of autonomic dysfunction. A comprehensive guideline is needed for the management of elevated body temperature in critically ill patients with cervical SCI, because this condition may be fatal.

Unilateral spinal anesthesia in two centenarian patients.

The use of unilateral spinal block with a specific hyperbaric mixture of bupivacaine and fentanyl in two centenarian women is presented. This technique was very effective in restricting sympathetic block, and it provided satisfactory analgesia and hemodynamic stability.

Ulnar artery versus radial artery approach for arterial cannulation: a prospective, comparative study.

STUDY OBJECTIVE: To compare the ease of cannulation, success/failure rate, and complication rate between ulnar and radial arteries. DESIGN: Randomized, controlled study. SETTING: Operating room. PATIENTS: 100 ASA physical status I, II, and III patients undergoing general anesthesia and requiring arterial cannulation. INTERVENTIONS: Patients were divided randomly into two separate groups of 50 patients each according to cannulation site: ulnar artery (group U) or radial artery (group R) group. MEASUREMENTS: The presence and fullness of the arterial pulses (strong/weak/absent), ease of cannulation (cases in which cannulation was successful on the first attempt and those that which required more than one cannulation attempt), success rate of cannulation, and complications (early/late) were all recorded. MAIN RESULTS: The radial artery was stronger in pulse (83% vs 73%). The success rates of cannulations for the ulnar and radial arteries were 82% and 90%, respectively (P > 0.05). The overall success rate of cannulation in the ulnar group with a strong pulse was 100%. There were significant differences in the success rate of cannulation between the patients with strong and weak pulses in the ulnar group (P < 0.0001). Ease of cannulation and complication rates of cannulations were not statistically different in both groups. CONCLUSIONS: The success rate of an arterial cannulation in a patient with a strong ulnar pulse is the same as for radial artery cannulation.

Comparison of ondansetron and meperidine for prevention of shivering in patients undergoing spinal anesthesia.

BACKGROUND AND OBJECTIVES: Perioperative hypothermia is a common problem in anesthesia practice. Regional anesthesia, like general anesthesia, influences the thermoregulatory process. The aim of our study was to compare the efficacy of ondansetron and meperidine in the prevention of shivering during and after spinal anesthesia. METHODS: In this double-blind study, 75 patients were randomized into 3 groups. Group O and Group M were given ondansetron 8 mg and meperidine 0.4 mg/kg intravenously immediately before spinal anesthesia, respectively. Group C received saline at identical times. The core temperatures and the incidence of shivering were recorded. Association between maximum block height and mean rectal temperatures of the patients were also evaluated. RESULTS: The core temperature was preserved in both ondansetron and meperidine groups with respect to the control group. Shivering was observed in 8% of patients in groups O and M and 36% in group C. The correlation between maximum block height and mean rectal temperatures was lost in the ondansetron and meperidine groups. CONCLUSION: Ondansetron and meperidine have similar anti-shivering effects. In addition, both ondansetron and meperidine altered the correlation between the core temperature and block level during spinal anesthesia.

Remifentanil pretreatment reduces myoclonus after etomidate.

STUDY OBJECTIVE: The aim of the study was to compare the effect of pretreatment with remifentanil 1 microg/kg and the effect of gender on the incidence of myoclonus after anesthesia induction with etomidate. DESIGN: This was a randomized, double-blind study. SETTING: The study was conducted at a university hospital. PATIENTS: Sixty patients were pretreated in a randomized double-blinded fashion with remifentanil 1 microg/kg or placebo. Two minutes after remifentanil or placebo injection, etomidate 0.3 mg/kg was given. MEASUREMENTS: Myoclonus was recorded with a scale of 0 to 3. The grade of sedation (none, mild, moderate, severe), nausea, pruritus, and apnea were recorded after injection of both drugs. MAIN RESULTS: The incidence of myoclonus was significantly lower in the remifentanil group (6.7%) than in the placebo group (70%) (P < 0.001). None of the patients experienced sedation, apnea, nausea, or pruritus after injection of both drugs. In the placebo group, male patients were associated with significantly increased incidence of myoclonus after etomidate administration. CONCLUSION: Pretreatment with remifentanil 1 microg/kg reduced myoclonus after etomidate induction without side effects such as sedation, apnea, nausea, or pruritus. Men experience increased incidence of myoclonus than women after etomidate administration.

[Comparison of effects of the administration of intraperitoneal local anesthetics for postoperative analgesia and prevention of shoulder pain]. / Laparoskopi sonrasi analjezi ve omuz agrisinin önlenmesinde intraperitoneal lokal anestezik uygulamasinin etkinliginin karsilastirilmasi.

Postoperative abdominal and shoulder pain are common complications after laparoscopy. The aim of this study is to compare the effects of intraperitoneal local anesthetics on postoperative abdominal and shoulder pain after laparoscopy. 55 women, physical status ASA I, who were undergoing diagnostic or minor gynecologic surgery, was enrolled to the study. In Group 1 (Bupivacaine, n: 17) and Group 2 (Ropivacaine, n: 18), 80 ml solution which contains one of the local anesthetics (60 ml saline and 20 ml %0.5 bupivacaine in Group 1, 60 ml saline and 20 ml %0.75 ropivacaine in Group 2), was injected into the right subdiaphragmatic (30 ml) and abdominopelvic space (50 ml) at the beginning of the surgical procedure. Patients in Group 3 (Control, n: 20) didn't received any solution intraperitoneally. Shoulder and abdominal pain was assessed with a visual analogue scale, and any other complications were noted during the first 24 hours after surgery. Shoulder and abdominal pain intensity and frequency were significantly less in the local anesthetic groups than control group, similar between ropivacaine and bupivacaine groups.

Subdural hematoma as a late complication of spinal anesthesia.

Subdural hematoma is a rare complication of spinal anesthesia. This patient underwent bilateral inguinal herniorrhaphy under spinal anesthesia 40 days prior to admission. Two days after spinal anesthesia, the patient described a typical postdural puncture headache. Oral analgesics, fluid therapy, and lying flat were recommended. Because of prolonged headache, computed tomography scan was performed and demonstrated chronic subdural hematoma in the left fronto-temporo-parietal region. After surgical drainage, the patient fully recovered. Prolonged headache should be regarded as a warning sign of subdural hematoma.

[Seroprevalence of hepatitis B and C infections in surgical personnel and evaluation of predisposing factors]. / Ameliyathane çalisanlarinda hepatit B ve C enfeksiyonu seroprevalansi ve etkileyen faktörlerin irdelenmesi.

The aim of this study was to investigate the seroprevalence of hepatitis B and C infections in the personnel of the operating room of Ondokuz Mayis University Hospital, to detect the carriers and actively infected individuals, to find out the health-workers' behaviours for the prevention from these infections, and to ascertain the risk factors of these diseases. HBsAg, anti-HBc, anti-HBs and anti-HCV antibodies were examined in the serum samples of 190 personnel, and their gender, education, working time (year), the daily working time in operating theatre (part/full time), the history of past hepatitis B infection, hepatitis B immunization, history of a past operation and blood transfusion, and the use of gloves during working (continuously-intermittent) were questioned. As a result, no carrier and/or actively infected personnel with hepatitis B and C were detected, while 36 (18.9%) of them had a history of past hepatitis B infection, and 132 (69.5%) of them had hepatitis B vaccine. The continuous glove use was more common in part-time workers than those of full-time workers, the history of past hepatitis B infection was increasing as the duration of working years increase, and the rates of being vaccinated against hepatitis B was decreasing as the duration of working years increase (p < 0.05).

Conversion of local anesthesia-guided deep brain stimulation of the subthalamic nucleus to general anesthesia.

BACKGROUND: Deep brain stimulation of the subthalamic nucleus (STN) is a widely applied procedure in the treatment of patients with advanced Parkinson disease and is generally performed under local anesthesia. Here we report our experience with the conversion to general anesthesia in two patients with advanced Parkinson disease because of fear reactions intraoperatively. CASE DESCRIPTION: Patients received general anesthesia with propofol and were implanted with electrodes at the level of STN guided by multiple-microelectrode electrophysiological recordings after obtaining informed consent. During the recordings the propofol levels were reduced. Postoperative clinical assessments showed marked improvements of motor disability with significant reductions of dopaminergic medication. CONCLUSION: Our case observations document the possibility of fear reactions intraoperatively and show the possibility of conversion to general anesthesia with a successful outcome.

Hemodynamic responses and upper airway morbidity following tracheal intubation in patients with hypertension: conventional laryngoscopy versus an intubating laryngeal mask airway.

OBJECTIVES: We compared hemodynamic responses and upper airway morbidity following tracheal intubation via conventional laryngoscopy or intubating laryngeal mask airway in hypertensive patients. METHODS: Forty-two hypertensive patients received a conventional laryngoscopy or were intubated with a intubating laryngeal mask airway. Anesthesia was induced with propofol, fentanyl, and cis-atracurium. Measurements of systolic and diastolic blood pressures, heart rate, rate pressure product, and ST segment changes were made at baseline, preintubation, and every minute for the first 5 min following intubation. The number of intubation attempts, the duration of intubation, and airway complications were recorded. RESULTS: The intubation time was shorter in the conventional laryngoscopy group than in the intubating laryngeal mask airway group (16.33 ± 10.8 vs. 43.04 ± 19.8 s, respectively) (p<0.001). The systolic and diastolic blood pressures in the intubating laryngeal mask airway group were higher than those in the conventional laryngoscopy group at 1 and 2 min following intubation (p<0.05). The rate pressure product values (heart rate x systolic blood pressure) at 1 and 2 min following intubation in the intubating laryngeal mask airway group (15970.90 ± 3750 and 13936.76 ± 2729, respectively) were higher than those in the conventional laryngoscopy group (13237.61 ± 3413 and 11937.52 ± 3160, respectively) (p<0.05). There were no differences in ST depression or elevation between the groups. The maximum ST changes compared with baseline values were not significant between the groups (conventional laryngoscopy group: 0.328 mm versus intubating laryngeal mask airway group: 0.357 mm; p = 0.754). The number and type of airway complications were similar between the groups. CONCLUSION: The intense and repeated oropharyngeal and tracheal stimulation resulting from intubating laryngeal mask airway induces greater pressor responses than does stimulation resulting from conventional laryngoscopy in hypertensive patients. As ST changes and upper airway morbidity are similar between the two techniques, conventional laryngoscopy, which is rapid and safe to perform, may be preferred in hypertensive patients with normal airways.

The optimal dose of remifentanil for acceptable intubating conditions during propofol induction without neuromuscular blockade.

STUDY OBJECTIVE: To determine the optimal remifentanil dose required to provide acceptable intubating conditions following induction of anesthesia with propofol without using neuromuscular blockade. DESIGN: Dose-response study. SETTING: Operating room of a university hospital. PATIENTS: 50 ASA physical status 1 men, aged between 20 and 40 years, who were scheduled for general anesthesia. INTERVENTIONS: Intubating conditions were evaluated according to the scoring system described by Viby-Mogensen et al. Successful intubation was defined as excellent or good. MEASUREMENTS: For induction of anesthesia, an intravenous (IV) bolus dose of propofol 2.0 mg/kg was given over 30 seconds followed by the administration of predetermined IV remifentanil over 30 seconds; intubation was performed 90 seconds after completion of the remifentanil administration. The dose of remifentanil used for each patient was determined by the response of the previously tested patients, using the modified Dixon's up-and-down method (using 0.2 µg/kg as a step size). The first patient was tested with remifentanil 1.0 µg/kg. If intubation failed, the remifentanil dose was increased by 0.2 µg/kg; if intubation was successful, the dose was decreased by 0.2 µg/kg. Mean arterial pressure (MAP), heart rate (HR), and peripheral oxygen saturation were recorded during the study period. MAIN RESULTS: According to probit analysis, the effective dose of remifentanil in 50% (ED(50)) and 95% (ED(95)) of patients were 1.40 µg/kg and 2.40 µg/kg, respectively. Preintubation and postinduction HR and MAP values were lower than preinduction values (P < 0.001). CONCLUSION: The optimal bolus dose of remifentanil for acceptable intubating conditions was 2.40 µg/kg (95% confidence interval, 1.90-9.0 µg/kg) in 95% of patients during induction of anesthesia with propofol 2.0 mg/kg without neuromuscular blocking agents.

Spinal-epidural anesthesia versus general anesthesia in the management of percutaneous nephrolithotripsy.

OBJECTIVE: To compare the efficacy between combined spinal-epidural block and general anesthesia in patients undergoing percutaneous nephrolithotripsy (PNL). METHODS: A total of 180 patients undergoing PNL were randomly allocated to receive spinal-epidural anesthesia plus intravenous patient-controlled anesthesia with tramadol or general anesthesia (propofol induction, maintenance with sevoflurane) plus intravenous patient-controlled anesthesia with tramadol (G group). Hemodynamic changes, postanesthesia care unit (PACU) discharge times, times to home readiness, side effects, patient and endoscopist satisfaction, postoperative pain (scored from 0 to 10 on a visual analog scale), and analgesic medication were recorded. RESULTS: Rates of hypotension (p = 0.06) and bradycardia (p = 0.14) did not differ between the groups. Compared with the G group, duration of PACU and the time to home readiness (p = 0.001 for each) were shorter in the spinal-epidural group. The incidence of nausea was higher in the G group (p = 0.001); vomiting and pruritus rates were similar between groups. No patient had respiratory depression. The spinal-epidural group had better patient satisfaction (p = 0.001) and lower pain scores (p = 0.001). The G group required more diclofenac during the first 48 h (p = 0.001). CONCLUSIONS: In patients undergoing PNL, spinal-epidural anesthesia and analgesia gave greater patient satisfaction, shorter times for PACU and home readiness, and less postoperative pain. Spinal-epidural anesthesia is an attractive alternative to general anesthesia in these patients.

Hemodynamic responses and upper airway morbidity following tracheal intubation in patients with hypertension: conventional laryngoscopy versus an intubating laryngeal mask airway

OBJECTIVES: We compared hemodynamic responses and upper airway morbidity following tracheal intubation via conventional laryngoscopy or intubating laryngeal mask airway in hypertensive patients. METHODS: Forty-two hypertensive patients received a conventional laryngoscopy or were intubated with a intubating laryngeal mask airway. Anesthesia was induced with propofol, fentanyl, and cis-atracurium. Measurements of systolic and diastolic blood pressures, heart rate, rate pressure product, and ST segment changes were made at baseline, preintubation, and every minute for the first 5 min following intubation. The number of intubation attempts, the duration of intubation, and airway complications were recorded. RESULTS: The intubation time was shorter in the conventional laryngoscopy group than in the intubating laryngeal mask airway group (16.33 ± 10.8 vs. 43.04±19.8 s, respectively) (p<0.001). The systolic and diastolic blood pressures in the intubating laryngeal mask airway group were higher than those in the conventional laryngoscopy group at 1 and 2 min following intubation (p<0.05). The rate pressure product values (heart rate x systolic blood pressure) at 1 and 2 min following intubation in the intubating laryngeal mask airway group (15970.90 ± 3750 and 13936.76 ± 2729, respectively) were higher than those in the conventional laryngoscopy group (13237.61 ± 3413 and 11937.52 ± 3160, respectively) (p<0.05). There were no differences in ST depression or elevation between the groups. The maximum ST changes compared with baseline values were not significant between the groups (conventional laryngoscopy group: 0.328 mm versus intubating laryngeal mask airway group: 0.357 mm; p = 0.754). The number and type of airway complications were similar between the groups. CONCLUSION: The intense and repeated oropharyngeal and tracheal stimulation resulting from intubating laryngeal mask airway induces greater pressor responses than does stimulation resulting from conventional laryngoscopy in hypertensive patients. As ST changes and upper airway morbidity are similar between the two techniques, conventional laryngoscopy, which is rapid and safe to perform, may be preferred in hypertensive patients with normal airways.

Awake tracheal intubation through the intubating laryngeal mask airway in a patient with halo traction.

PURPOSE: To report a case of awake tracheal intubation through the intubating laryngeal mask airway (ILMA) in a patient with halo traction. CLINICAL FEATURES: A 16-yr-old, 40 kg, boy with atlanto-occipital instability and halo traction was scheduled for surgery under general anesthesia. The head of the patient was fixed in a position of flexion and extension was impossible. Cranial magnetic resonance imaging revealed that pharyngeal and laryngeal axes were aligned, but that the oral axis was in an extreme divergent plane. The tongue and oropharynx were anesthetized with 10% lidocaine spray and bilateral superior laryngeal nerve blockade was performed. Under sedation, awake orotracheal intubation via ILMA was successful. Fibreoptic bronchoscopy has been recommended for awake tracheal intubation in such patients. Other techniques, such as use of the Bullard laryngoscope have been described also but awake tracheal intubation through the ILMA in patients with a halo device in situ has seldom been reported in the medical literature. CONCLUSION: Airway management of patients with cervical spine instability includes adequate preoperative evaluation of the airway and choosing the appropriate intubation technique. We suggest that the ILMA may be an adequate alternative for awake tracheal intubation in patients with an unstable cervical spine and cervical immobilization with a halo device.