A prospective, randomized comparison of the effects of thiopental and propofol on bispectral index during caesarean section till delivery of newborn.

BACKGROUND: Since in caesarean operations skin incision to delivery time is very short, induction agent could be still effective on BIS level till the time of delivery. Therefore this study was designed to analyze the effect on maintaining adequate bispectral index levels till delivery of neonate of propofol and thiopental as an induction agent for caesarean section. METHODS: Eighty two patients undergoing caesarean section were allocated into two groups. In the group T anesthesia induction was performed with thiopental (5 mg/kg) and in the group P with propofol (2.5 mg/kg). Anesthesia was maintained with sevoflurane. Heart rates, blood pressures and BIS values during significant events of surgery and anesthesia till delivery, durations of surgery, induction to skin incision and to delivery and Apgar scores were recorded. For statistical analysis T-test was used for comparison of means of independent samples. RESULTS: The groups were comparable with respect to age, weight and gestational age. The patients in the group P had significantly lower levels of bispectral index values during uterus incision; 40.6 vs. 59.5 (p = 0.019) and delivery; 41 vs. 62.9 (p = 0.018). CONCLUSION: Anesthesia induction with propofol in a dose of 2.5 mg/kg maintains lower levels of heart rate, blood pressure and BIS till delivery when compared with thiopental in a dose of 5 mg/kg. There is no financial support taken from any kind of company or person. There are no financial relationships between authors and commercial interests with a vested interest in the outcome of study.

The effect of timing and temperature of oral fluids ingested after minor surgery in preschool children on vomiting: a prospective, randomized, clinical study.

BACKGROUND: The time at which children should resume oral intake after surgery is controversial. No information has been published about the relationship between postoperative vomiting and the temperature of the fluid ingested. This study was designed to analyze the effect on postoperative vomiting of the timing and temperature of the fluids ingested in the first oral intake. METHODS: Two hundred and thirty-seven male children aged 2-7 years, scheduled for correction of inguinal hernia or undescended testis under general anesthesia and were allocated into four groups. The patients in groups C1 and C2 received clear fluids at room temperature or at body temperature, respectively, 2 h after emergence. The patients in groups E1 and E2 received clear fluids at room temperature or at body temperature, respectively, 1 h after emergence. Vomiting was assessed at intervals of 30 min for 6 h postoperatively, starting from 10 min after emergence. RESULTS: The incidence of vomiting was higher in groups C1 (25%) (P = 0.016) and E1 (26.7%) (P = 0.011) than in groups C2 (6.9%) and E2 (10.2%). The incidence was found to be increased significantly 40 min after oral intake in groups C1 (P = 0.012) and E1 (P = 0.010) compared with earlier measurements in the same groups. CONCLUSION: A first oral intake in children 1 h after anesthesia for minor surgery seems not to increase the incidence of vomiting as long as the ingested fluid is at body temperature.

Effects of hydroxyzine-midazolam premedication on sevoflurane-induced paediatric emergence agitation: a prospective randomised clinical trial.

BACKGROUND AND AIM: Anaesthesia with sevoflurane leads to a high prevalence of emergence agitation in paediatric patients. This study investigates the effects of combining hydroxyzine and midazolam on sevoflurane-induced emergence agitation in paediatric patients undergoing infraumbilical surgery with a caudal block. PATIENTS AND METHODS: Eighty-four children 1-7 years of age undergoing general anaesthesia with sevoflurane and caudal block were assigned to two groups. Children in group M (n = 42) were premedicated with 0.5 mg kg oral midazolam and children in group MH (n = 42) were premedicated with 0.5 mg kg oral midazolam and 1 mg kg hydroxyzine given 30 min before anaesthesia induction. A caudal epidural block was performed following anaesthesia induction. Induction quality, parental separation scores and emergence agitation were evaluated. Emergence agitation was evaluated with the PAED score (Paediatric Anesthesia Emergence Delirium) every 5 min during the first 30 min after admission to recovery room. Induction quality and parental separation were assessed with 4-point scores. Postoperative pain was evaluated with the 10-point Children's and Infants' Postoperative Pain Scale. RESULTS: Median parental separation (3 vs. 2; P = 0.01), induction quality (2 vs. 2; P = 0.03) and sedation scores (3 vs. 2; P = 0.003) were significantly better in the MH group compared to the M group. Median PAED score of group M (15) was higher than that of group MH (11; P < 0.001) and the number of children with PAED scores more than 16 was also higher in group M (n = 16) compared to group MH (n = 2; P < 0.001). None of the children had a pain score more than 3 throughout the study period. CONCLUSION: The incidence of sevoflurane-induced emergence agitation was significantly lower in children premedicated with a midazolam and hydroxyzine combination compared to those premedicated with midazolam only. Furthermore, the midazolam and hydroxyzine combination provided better premedication quality than midazolam alone.

Post-procedure elevated amylase and lipase levels after double-balloon enteroscopy: relations with the double-balloon technique.

BACKGROUND: Small elevations of pancreatic enzymes are recently recognized complications of double-balloon enteroscopy (DBE). AIMS: The aim of this study was to check the post-procedure pancreatic enzyme (p-amylase, lipase) levels and to disclose their relationships with technical features of DBE. METHODS: Peroral (48) and peranal (8) DBEs were performed in 56 patients, and the p-amylase and lipase levels were measured just before and after the procedure. Patients were also evaluated for abdominal pain after DBE using a visual analog scale (VAS). The route-total duration of the procedure, the total insertion length of the scope, the insertion length where the overtube balloon was inflated for the first time, and the duration between the first and second inflations were also noted. RESULTS: Pancreatitis was observed in 6 of 48 (12.5%) peroral DBE patients. A VAS score above 5 at 4 h had a sensitivity of 100% and specificity of 96% for developing post-DBE pancreatitis. Significant correlations were noted between the levels of pancreatic enzymes after DBE and the total insertion length, duration, and duration between the first and second inflations of the balloon, and an inverse correlation was observed between the levels of these enzymes and insertion length at the first inflation, but an age-sex-adjusted regression analysis only disclosed the duration between the first and second inflations as an independent predictor of post-DBE pancreatitis (P = 0.012). CONCLUSIONS: Hyperamylasemia and hyperlipasemia after DBE seems to be a complication of peroral DBE, which might be prevented by reducing the time between the first and second inflations of the overtube balloon.

Hemophilia-Specific Quality of Life Index (Haemo-QoL and Haem-A-QoL questionnaires) of children and adults: result of a single center from Turkey.

The aim of this study is to describe the health status, health care received, and their impact on the quality of life in patients with hemophilia. Patients with severe factor VIII or IX deficiency without inhibitors or other chronic disease were enrolled. Turkish version of the Hemophilia-Specific Quality of Life Index (Haemo-QoL) questionnaire was administered to the pediatric patients aged 4 to 16 years and Haem-A-QoL to the adult patients. Joints were evaluated according to the World Federation of Hemophilia (WFH) orthopedic joint scores.Thirty-nine children/adolescents and 31 adult patients were enrolled. Mean Haemo-QoL scores were 39.6 +/- 15.0 for the children and mean Haem-A-QoL 47.4 +/- 14.1 for the adult patients, respectively. Internal consistency reliability was generally sufficient. Total Cronbach's alpha coefficient was >.70 (range .77-.96) in all the age groups. Mean total WFH orthopedic joint scores were 1.83 +/- 2.7, 4.9 +/- 4.96, and 6.94 +/- 6.15 in 4-7, 8-12, and 13-16-year-old groups, respectively. They were more impaired in the adult patients (16.23 +/-14.12). These results show that the Turkish version of the Haemo-QoL and Haem-A-QoL are reliable instruments to measure the quality of life in the pediatric and adult patients with severe hemophilia. When compared to the Haemo-QoL scores of an international multicenter West European study of children, quality of life in the Turkish patients were more impaired in the subscales of physical health, feeling, view, school and sport, and treatment as well as more impaired WFH joint scores. The authors recommend primary factor prophylaxis and encouraging the patients to learn home treatment to improve joint scores and quality of life.

The effects of propofol infusion on hepatic and pancreatic function and acid-base status in children undergoing craniotomy and receiving phenytoin.

BACKGROUND: In this study, we investigated the effects of propofol infusion on hepatic and pancreatic enzymes and acid-base status compared with baseline values in children undergoing craniotomy who were receiving phenytoin for antiepileptic prophylaxis. METHODS: In this prospective clinical study, we measured the serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), pancreatic amylase, lipase, and triglyceride levels of 30 children ranging from 4 to 12 yr. All children received propofol anesthesia and were taking phenytoin for antiepileptic prophylaxis. Patients already receiving phenytoin were continued on their medication. Peroral 5 mg x kg(-1) x d(-1) phenytoin was started in patients who were not receiving phenytoin. Serum AST, ALT, GGT, ALP, bilirubin, pancreatic amylase, lipase, and triglyceride levels were studied on admission to the hospital, 1 day before surgery, and on postoperative Days 1, 3, 5, and 7. Arterial blood gas samplings were taken after tracheal intubation, during the operation (2nd and 4th h), just after extubation, and 1, 2, 6, and 12 h after extubation. RESULTS: Serum AST, ALT, GGT, ALP, pancreatic amylase, lipase, and triglyceride levels were increased significantly in the postoperative period compared with baseline with a peak value on postoperative Day 1 and returned to normal values within a week. Base excess levels after extubation were significantly decreased compared with baseline. They were in the normal range, however, and returned to baseline values by 6 h after surgery. There were no clinical signs of hepatitis or pancreatitis. Bilirubin levels were normal. None of the children developed complications related to the liver or pancreas during the 4-6 mo after surgery. CONCLUSIONS: Despite the slightly increased pancreatic and hepatic enzyme levels during the postoperative period, anesthesia maintenance with propofol in children undergoing craniotomy had no significant clinical effect on the acid-base status or pancreas or liver enzymes.

Internal jugular vein diameter in pediatric patients: are the J-shaped guidewire diameters bigger than internal jugular vein? An evaluation with ultrasound.

AIM: This study investigates whether the diameters of right internal jugular vein (RIJV) are suitable for the use of 'big radius curved J-tip' Seldinger wires in pediatric patients. METHODS: One-hundred and thirty-five children, 1 month to 15 years of age, scheduled for pediatric surgery were divided into four subgroups according to their age (0-12 months, 1-2 years, 2-6 years old, and >6 years). Patients in the 0-12 months group were further divided into two groups as 0-6 months and 7-12 months of age to evaluate RIJV characteristics in detail. Following anesthesia induction, depth, diameter, and area of RIJV were measured with ultrasound at the level of cricoid cartilage and sterno-clavicular junction in supine and Trendelenburg position. RESULTS: Infants in the 0-6 months of age group had the least mean diameter of RIJV at both the cricoid cartilage and the sternoclavicular junction level (0.484 +/- 0.132 and 0.499 +/- 0.136 cm). The aforementioned diameter was significantly lower than the values of other age groups (P < 0.05). Trendelenburg position did not increase RIJV diameter in children below 6 and cross-sectional area below 2 years old. Correlations between age, height, weight, head circumference and RIJV diameter, cross-sectional area, depth from the skin were weak. CONCLUSION: The diameter of the IJV in pediatric patients, especially infants, is often smaller than the diameter of the J-tip guidewire curve. We speculate that this may lead to impeded guidewires and failed cannulation. It must also be kept in mind that the Trendelenberg position might not facilitate IJV cannulation in children <2 years of age.

The effect of 2 different concentrations of rectal ketamine on its premedicant features in children.

OBJECTIVE: To investigate whether changing concentration and volume of ketamine for rectal premedication would change the premedication and recovery characteristics. METHODS: A prospective, randomized, clinical study was designed in Yeditepe University Hospital, Istanbul, Turkey in 2006-2007. The study group included children weighing 10-20 kg, American Society of Anesthesiologists grade I, scheduled for inguinal hernia repair or circumcision under general anesthesia with orotracheal intubation and caudal blockade. Children were rectally premedicated with 10 mg.kg-1 ketamine 5% in group K, and 2.5% in the Group K1/2, 45 minutes before anesthesia. Anesthesia was induced and maintained by inhalation. Sedation scores at 15 minutes intervals in the preinduction area, parental separation scores, induction and recovery characteristics, time to discharge and a questionnaire at 24th postoperative hour were recorded. RESULTS: One hundred children were randomized into 2 groups of 50. Thirty minutes 1.2 versus 0.48, p=0.018 and 45 minutes 2.24 versus 1.8, p=0.027 following premedication group K1/2 had significantly lower mean sedation scores than group K. Separation, induction quality scores, induction duration, secretion scores either during induction or postoperative period, and recovery characteristics were all comparable in both groups. CONCLUSION: Although adequate sedation was obtained for most of the children in both groups, rectal premedication with 5% ketamine resulted in higher levels of sedation appearing earlier than that of 2.5% ketamine, while change of volume and concentration had no effect on recovery characteristics.

Groin flap immobilization by axillary brachial plexus block anesthesia.

Pedicled groin flaps are still widely used as soft tissue coverage in hand surgery. Various methods have been described for immobilization of flaps, such as Ace wraps, plaster, and external fixators. The hands of 5 females and 12 males, totaling 17 patients, with severe injury were reconstructed with groin flaps between 2001 and 2005. Patients were operated on under a combination of axillary block and general anesthesia. Motor block effect of axillary anesthesia was used for immobilization of the upper extremities at groin flap coverage. A combination of axillary brachial plexus block plus general anesthesia had advantages in the prevention of pedicle tension or torsion during the initial recovery period. Reduction of general anesthesia time and improvement of postoperative pain were also observed. Axillary brachial plexus block and general anesthesia are a preferred combination for patients undergoing groin flap operations.

Double-balloon enteroscopy: the diagnosis and management of small bowel diseases.

BACKGROUND/AIMS: Double-balloon enteroscopy is a novel endoscopic technique developed to investigate small bowel diseases. The aim of this study was to evaluate the diagnostic and therapeutic impact of double-balloon enteroscopy in patients with suspected or documented small bowel disease who were referred to our tertiary center, which was the first to introduce the double-balloon enteroscopy system in Turkey. METHODS: This is a single-center prospective study. A total of 216 double-balloon enteroscopy procedures (168 antegrade, 48 retrograde) were done in 188 patients who were referred to our center for suspected small bowel disease. The main outcome measurements were complications, insertion depth and duration, and diagnostic and therapeutic rates. RESULTS: Indications included obscure gastrointestinal system bleeding, iron deficiency anemia, abnormality on radiographic evaluation, abdominal pain, diarrhea, and suspected celiac disease. A diagnosis was established in 130 (69%) patients. The most common pathologic findings included angiodysplasias (29%), ulcerations (16%) and Crohn's disease (9%). Mean time±standard deviation to perform the examination using the antegrade route was 116.4±7.17 min, and the average±standard deviation insertion length was 310.65±90.3 cm (beyond the pylorus). Therapeutic interventions were performed in 66 patients (56 angiodysplasias, 4 ulcers, 4 strictures, and 2 polyps), and the success rate was 97%. No serious complication was observed, although pancreatitis occurred in 6 of 48 (12.5%) patients who were followed up for post-procedure pancreatic enzyme levels. CONCLUSIONS: Our prospective analysis suggests that double-balloon enteroscopy is a feasible and useful technique for the diagnosis as well as treatment of small intestinal disorders.

Combination effect of low dose fentanyl and propofol on emergence agitation in children following sevoflurane anesthesia.

OBJECTIVE: To investigate the combination effect of low dose fentanyl and subhypnotic dose of propofol on emergence agitation in children receiving sevoflurane for adenotonsillectomy procedure. METHODS: After ethical approval, a prospective, randomized, clinical study was performed in Saad Specialist Hospital, Al-Khobar, Kingdom of Saudi Arabia in 2007-2008. One hundred and twenty children in physical status of I according to the American Society of Anesthesiologists, aged 2-6 years, scheduled for adentonsillectomy under general anesthesia were allocated into 3 groups randomly. Anesthesia was induced and maintained by sevoflurane in all groups. Children received 0.1 ml.kg-1 normal saline at the end of surgery in group C (n=40), 1.5 mcg.kg-1 fentanyl during induction, and 0.1 ml.kg-1 normal saline at the end of surgery in group F (n=40), and 1.5 mcg.kg-1 fentanyl during induction and 1 mg.kg-1 propofol at the end of surgery in group FP (n=40). Postoperative agitation was recorded, if any, for the first postoperative hour. RESULTS: Three groups were comparable with regard to demographic data. Twenty-one patients (53%) in the control group, 14 patients (35%) in group F and 7 (18%) patients in group FP experienced postoperative agitation. CONCLUSION: The combination of low dose fentanyl before surgery and propofol at the end of surgery decreases the incidence and level of emergence agitation in children after adenotonsillectomy procedure under sevoflurane anesthesia.

Comparison of the effect of sevoflurane and halothane anesthesia on the fall in heart rate as a predictor of successful single shot caudal epidural in children.

OBJECTIVE: To investigate the effect of sevoflurane anesthesia on heart rate HR fall with the injection of the initial drug in caudal space to confirm the correct needle placement. METHODS: After the ethical approval was obtained from the hospital's ethics committee, a prospective, randomized, clinical study was designed in Yeditepe University Hospital, in 2007. Children aged 1-12 years, scheduled for infraumbilical surgery under general anesthesia, and caudal block were included in the study. Anesthesia was induced, and maintained by sevoflurane in group S (n=85), and by halothane in group H (n=82). Baseline HR was recorded before the caudal block was performed. The HR changes during the initial dose, and total drug injection were recorded followed by 2 more HR recordings taken 5, and 10 minutes after caudal injection. The success of the block was recorded by a blind observer. RESULTS: There were 167 children included in the study. Caudal block success was 96.5% in group S, and 97.6% in group H. Basal HR was 110.9 +/- 10.9 in group S, and 105.9 +/- 10.1 in group H. Following the initial drug injection, mean HR was 109.8 +/- 10.9 in group S, and 102.9 +/- 9.9 in group H. It was significantly lower than the baseline in group H. The only significant decrease in the HR of the patients in group S was at the tenth minute following caudal injection. CONCLUSION: The decrease in HR with drug injection has no value to predict the success of caudal block under sevoflurane anesthesia.

When to add supplemental rectal paracetamol for postoperative analgesia with caudal bupivacaine in children? A prospective, double-blind, randomized study.

BACKGROUND: The aim of this study was to investigate whether a supplemental dose of rectal paracetamol at the third or fourth hour would enhance the quality of analgesia provided by caudal epidural blockade in children. METHODS: Two hundred and two ASA I patients aged 1-12 years undergoing inguinal surgery were randomized into three groups in the postanesthesia care unit by drawing lots. Patients in the control group did not receive any analgesic until they had a pain score of 5 or higher, patients in the group P3 received rectal paracetamol (20-25 mg x kg(-1)) at the third hour, and patients in the group P4 received the same dose of rectal paracetamol at the fourth hour after caudal epidural injection. Pain was assessed by VAS (Visual Analog Scale) and supplementary rescue analgesic need was recorded. RESULTS: There was no difference between the demographic data or the duration and variety of surgery among the groups. A significantly lower number of patients required rescue analgesia at the sixth postoperative hour in group P3 and also lower pain scores were again obtained in group P3 at the sixth and eighth postoperative hours. CONCLUSIONS: Supplemental rectal paracetamol at the third hour of caudal blockade enhances the quality of postoperative analgesia better than its addition at the fourth hour in children undergoing inguinal surgery.