Effect of carboxyhemoglobin on postoperative complications and pain in pediatric tonsillectomy patients.

BACKGROUND: Carbon monoxide (CO) is a product of burning solid fuel in stoves and smoking. Exposure to CO may provoke postoperative complications. Furthermore, there appears to be an association between COHb concentrations and pain. We thus tested the primary hypothesis that children with high preoperative carboxyhemoglobin (COHb) concentrations have more postoperative complications and pain after tonsillectomies, and secondarily that high-COHb concentrations are associated with more pain and analgesic use. METHODS: 100 children scheduled for elective tonsillectomy were divided into low and high carbon monoxide (CO) exposure groups: COHb ≤3 or ≥4 g·dl(-1) . We considered a composite of complications during the 7 days after surgery which included bronchospasm, laryngospasm, persistent coughing, desaturation, re-intubation, hypotension, postoperative bleeding, and reoperation. Pain was evaluated with Wong-Baker Faces pain scales, and supplemental tramadol use recorded for four postoperative hours. RESULTS: There were 36 patients in the low-exposure group COHb [1.8 ± 1.2 g·dl(-1) ], and 64 patients were in the high-exposure group [6.4 ± 2.1 g·dl(-1) ]. Indoor coal-burning stoves were reported more often by families of the high- than low-COHb children (89% vs 72%, P < 0.001). Second-hand cigarette smoke exposure was reported by 54% of the families with children with high COHb, but only by 24% of the families of children with low COHb. Composite complications were more common in patients with high COHb [47% vs 14%, P = 0.0001, OR:7.4 (95% Cl, lower = 2.5-upper = 21.7)], with most occurring in the postanesthesia care unit. Pain scores in postanesthesia care unit and one hour after surgery were statistically significantly lower in the low-exposure group [respectively, P = 0.020 (95%CI, lower = -1.21-upper = -0.80), P = 0.026 (95% CI, lower = -0.03-upper = 0.70)], and tramadol use increased at 4 h (3.5 (interquartile range: 0-8) vs 6 (5-9) mg, P = 0.012) and 24 h (3.5 (0-8) vs 6 (5-9) mg, P = 0.008). CONCLUSION: High preoperative COHb concentrations are associated with increased postoperative complications and pain.

Cost-Conscious of Anesthesia Physicians: An awareness survey.

OBJECTIVE: Increasing competitive pressure and health performance system in the hospitals result in pressure to reduce the resources allocated. The aim of this study was to evaluate the anesthesiology and intensive care physicians awareness of the cost of the materials used and to determine the factors that influence it. METHODS: This survey was conducted between September 2012 and September 2013 after the approval of the local ethics committee. Overall 149 anesthetists were included in the study. Participants were asked to estimate the cost of 30 products used by anesthesiology and intensive care units. RESULTS: One hundred forty nine doctors, 45% female and 55% male, participated in this study. Of the total 30 questions the averages of cost estimations were 5.8% accurate estimation, 35.13% underestimation and 59.16% overestimation. When the participants were divided into the different groups of institution, duration of working in this profession and sex, there were no statistically significant differences regarding accurate estimation. However, there was statistically significant difference in underestimation. In underestimation, there was no significant difference between 16-20 year group and >20 year group but these two groups have more price overestimation than the other groups (p=0.031). Furthermore, when all the participants were evaluated there were no significant difference between age-accurate cost estimation and profession time-accurate cost estimation. CONCLUSION: Anesthesiology and intensive care physicians in this survey have an insufficient awareness of the cost of the drugs and materials that they use. The institution and experience are not effective factors for accurate estimate. Programs for improving the health workers knowledge creating awareness of cost should be planned in order to use the resources more efficiently and cost effectively.

Transversus Abdominis Plane Block Following Cesarean Section: A Prospective Randomized Controlled Study Comparing the Effects on Pain Levels of Bupivacaine, Bupivacaine + Dexmedetomidine, and Bupivacaine + Dexamethasone.

Background: The transversus abdominis plane (TAP) block is providing effective postoperative analgesia in patients undergoing cesarean section (CS). This study aims to evaluate and compare the effects on pain levels of bupivacaine alone versus bupivacaine combined with dexmedetomidine and bupivacaine combined with dexamethasone in ultrasound-guided TAP block for postoperative pain after CS. Material and Method: In this randomized controlled trial, 120 patients with American Society of Anesthesiologists (ASA) physical status I and II scheduled for elective cesarean section under spinal anesthesia were randomly divided into three groups. At the end of the surgery, an ultrasound-guided TAP block was performed on all patients: bupivacaine 0.5% (Group B), bupivacaine 0.5% + dexmedetomidine (1 µg/kg) (Group BD), and bupivacaine 0.5% + dexamethasone (4 mg) (Group BDx). Postoperatively, all patients were evaluated at 0, 1, 4, 8, 16, and 24 h for visual analog scores VASs, tramadol consumption, complications, and patient satisfaction. A p value of < 0.05 is statistically significant. Results: At 0 h, VASs in the sitting and supine positions were significantly higher in the BDx group (0.85 ± 1.61 and 0.85 ± 1.36, respectively) compared to the B group (0.05 ± 0.32 in both positions) and the BD group (0.15 ± 0.48 in both positions) (p = 0.005 and p = 0.001, respectively). At the 24th hour, VASs in the sitting and supine positions were significantly lower in the BDx group (1.7 ± 1.2 and 1.43 ± 1.05) compared to the B group (2.3 ± 0.68 and 2.2 ± 0.72) and the BD group (2.57 ± 1.01 and 2.28 ± 0.78) (p = 0.005 and p = 0.001, respectively). At 0 h, the tramadol requirement was highest in the BDx group at 12.5%, while it was not required in the B and BD groups (p = 0.005). At 0 h, the rate of nausea and vomiting was highest in the BDx group at 17.5%, compared to 2.5% in the BD group and 0% in the B group (p = 0.003). Patient satisfaction scores were higher in the dexamethasone group compared to the other groups. This was significant between Group B and Group BDx (p = 0.009 < 0.05). Conclusions: Adding dexmedetomidine or dexamethasone to bupivacaine in ultrasound-guided TAP blocks reduces postoperative pain and increases patient satisfaction after cesarean sections. Dexamethasone, due to its delayed onset but extended duration, achieves lower pain scores and higher satisfaction. Further research is necessary to confirm these findings.

Comparison of the postoperative effects of the erector spinae plane block and local infiltration analgesia in patients operated with lumbotomy surgery incision: Randomized clinical study.

BACKGROUND: Our aim was to observe the effects of local infiltration analgesia (LIA) or erector spinae plane block (ESPB) methods, which we applied preemptively in patients who were scheduled for surgery with a lumbotomy surgical incision and on intraoperative remifentanil consumption, and to compare the postoperative numerical rating scale (NRS), morphine demand, consumption, and pain degrees. METHODS: Sixty American Society of Anesthesiologists I to III patients aged 18 to 75 years who were due to be operated on with a lumbotomy surgical incision were included in the study. The present study was conducted via prospective, randomized controlled, double-blind trials. After the induction of standard anesthesia, LIA was applied to 30 patients and ESPB was applied to 30 patients preemptively. The dose of remifentanil consumed in the intraoperative period was measured, and the hemodynamic parameters were measured every 5 minutes. Morphine bolus treatment with the postoperative patient-controlled analgesia and rescue analgesia with paracetamol were planned for the patients. Postoperative morphine and additional analgesia consumption, NRS, hemodynamic parameters, and complications were recorded for 48 hours. RESULTS: There was no difference between the groups in terms of demographic and hemodynamic data. The mean consumption of remifentanil was measured as 455 ±â€…165.23 µg in the intraoperative ESPB group and 296.67 ±â€…110.59 µg in the LIA group, and a statistical difference was observed (P = .001). In the postoperative follow-ups, the ESPB group drug consumption and NRS score averages were significantly lower at all times (P = .01; patient-controlled analgesia-morphine, 41.93 ±â€…14.47 mg vs 57.23 ±â€…15.5 mg and additional analgesic-paracetamol: 2.1 ±â€…1.06 vs 4.27 ±â€…1.14 g). The mean duration of additional analgesic intake of the groups was 10.6 ±â€…8.1 in the LIA group, while it was 19.33 ±â€…8.87 in the ESPB group, a significant difference. The patient satisfaction questionnaire was also significantly in favor of ESPB (P = .05). CONCLUSIONS: In conclusion, it has been shown that the intraoperative LIA method is more effective in terms of remifentanil consumption and in controlling pain in operations performed with a flank incision, but the ESPB method provides longer and more effective pain control in postoperative follow-ups.

Evaluation of nosocomial infections and risk factors in critically ill patients.

BACKGROUND: Nosocomial infections are one of the most serious complications in intensive care unit patients because they lead to high morbidity, mortality, length of stay and cost. The aim of this study was to determine the nosocomial infections, risk factors, pathogens and the antimicrobial susceptibilities of them in intensive care unit of a university hospital. MATERIAL/METHODS: The patients were observed prospectively by the unit-directed active surveillance method based on patient and the laboratory. RESULTS: 20.1% of the patients developed a total of 40 intensive care unit-acquired infections for a total of 988 patient-days. The infection sites were the lower respiratory tract, urinary tract, bloodstream, wound, and the central nervous system. The respiratory deficiency, diabetes mellitus, usage of steroid and antibiotics were found as the risk factors. The most common pathogens were Enterobacteriaceae, Staphylococcus aureus, Candida species. No vancomycin resistance was determined in Gram positive bacteria. Imipenem and meropenem were found to be the most effective antibiotics to Enterobacteriaceae. CONCLUSIONS: Hospital infection rate in intensive care unit is not very high. The diabetes mellitus, length of stay, usage of steroids, urinary catheter and central venous catheter were determined as the risk factors by the final logistic regression analysis. These data, which were collected from a newly established intensive care unit of a university hospital, are important in order to predict the infections and the antimicrobial resistance profile that will develop in the future.

Perioperative Effects of Induction with High-dose Rocuronium during Laparoscopic Cholecystectomy.

OBJECTIVE: We aimed to investigate the effects of high-dose rocuronium administration on intra-abdominal pressure (IAP) and surgical conditions during anaesthesia induction and laparoscopic cholecystectomy anaesthesia induction, respectively. Further, we aimed to determine postoperative nausea and vomiting (PONV) and pain scores following the laparoscopic cholecystectomy. METHODS: Patients with American Society of Anesthesiologists (ASA) score of I-III, aged 18 to 75 years and who were scheduled for surgery under general anaesthesia were included in the study. Patients were randomised and a high-dose of 1.2 mg kg-1 rocuronium was given to Group A and 0.6 mg kg-1 rocuronium to Group B. The intraoperative train of four (TOF) ratio and post-tetanic count (PTC) were measured. Surgery was initiated with a low IAP of 7 mmHg. The surgeon evaluated surgical conditions with a 4-step surgical field scale and increased the IAP when necessary. PONV at 4, 12 and 24 hours and postoperative pain at 2 and 24 hours and 3 days were evaluated. RESULTS: There were no significant differences in the demographic and haemodynamic parameters between the groups. In high-dose rocuronium Group A, IAP values were significantly lower in the first 20 minutes compared to Group B. The duration of operations was significantly shorter in Group A (29.00±7.39 minute vs. 34.63±12.00 minute, p=0.044). PONV in the first 12 hours was significantly lower in Group A (p<0.05). CONCLUSION: High-dose rocuronium-induced deep neuromuscular block helped perform laparoscopic cholecystectomy operations with lower values of IAP compared to a normal dose rocuronium. It also shortened duration of operation and reduced PONV and pain.

Magnesium sulfate reduces postoperative morphine requirement after remifentanil-based anesthesia.

BACKGROUND: The aim was to investigate the effect of magnesium sulfate on postoperative pain and analgesic consumption after remifentanil-based anesthesia. MATERIAL/METHODS: Forty women 18 to 65 years old were enrolled in this prospective, randomized, double-blinded clinical study. The study solutions were randomly preoperatively prepared for groups M (magnesium) and R (normal saline). A bolus of 0.2 ml/kg of study solution (30 mg/kg magnesium or saline) was given before induction of anesthesia and infusion was started at a rate of 3.3 ml/h (500 mg/h magnesium or saline). A 1 microg/kg loading dose of remifentanil following infusion was started at a rate of 0.25 micro g/kg/min, subsequently increasing stepwise by 0.05 micro g/kg/min increments if insufficient anesthesia was suspected. All postoperative outcome data were collected by an anesthesiologist who was blinded to the anesthetic regimen. Pain intensity using a visual analogue scale (VAS) was recorded for 24 hours postoperatively. RESULTS: Hemodynamic and respiratory variables such as diastolic and systolic blood pressure, heart rate, and oxygen saturation were similar in both groups. The mean intraoperative remifentanil consumption in groups M and R was similar. The VAS score was significantly lower in the magnesium group at 15 and 30 minutes postoperatively. Total morphine consumption was significantly lower in the magnesium group than in the remifentanil-alone group. CONCLUSIONS: It was concluded that magnesium sulfate decreased the postoperative morphine requirement when remifentanil was used for intraoperative analgesia.

Intravenous ketamine and local bupivacaine infiltration are effective as part of a multimodal regime for reducing post-tonsillectomy pain.

BACKGROUND: The aim of this study was to investigate the effects of a multimodal analgesic regimen, including intravenous ketamine and peritonsillar infiltration of bupivacaine, on post-tonsillectomy pain in children. MATERIAL/METHODS: Ninety children aged 2-12 years, undergoing tonsillectomy, were enrolled in this randomized, controlled and double-blinded study. Group I (n=30) received intravenous and peritonsillar saline, group II (n=30) received intravenous saline and peritonsillar bupivacaine, and group III (n=30) received intravenous 0.5 mg/kg ketamine and peritonsillar 0.25% bupivacaine (3-5 ml per tonsil). Pain was evaluated using a modified Children's Hospital of Eastern Ontario Pain Scale (mCHEOPS) recorded 15 min and 1, 4, 12, 16, and 24 h postoperatively. RESULTS: No difference was found in the demographic data among the groups. Group I patients who received intravenous and peritonsillar saline solution as placebo had higher pain scores at 15th min, and 1st and 4th h than group II, and at all time intervals, than group III (P<0.05). Patients in group III also had significantly lower pain scores than group II at all time intervals except at 15th min (P<0.05). Analgesic requirements and the time to first analgesia were also significantly (P<0.05) better in the ketamine group. CONCLUSIONS: Intravenous ketamine and peritonsillar infiltration with bupivacaine are safe and effective as part of a multimodal regime in reducing post-tonsillectomy pain.

Is there an advantage in using low-dose intrathecal bupivacaine for cesarean section?

PURPOSE: Spinal anesthesia for cesarean section is associated with a high incidence of maternal hypotension. The aim of this study was to assess the efficacy of low-dose bupivacaine with fentanyl to reduce the incidence of hypotension in spinal anesthesia for cesarean section. METHODS: Forty pregnant women undergoing elective cesarean section were randomly allocated to two groups; those receiving 10 mg bupivacaine to group B (n = 20) and those receiving 4 mg bupivacaine plus 25 microg fentanyl to group BF (n = 20); the agents were given intrathecally with patients in the sitting position, with a combined spinal-epidural technique. RESULTS: Sensory block was adequate for surgery in all patients. Hypotension occurred in all patients in group B (100%) and in 15 patients in group BF (75%). The incidence of hypotension, number of ephedrine treatments, and need for ephedrine were significantly greater in group B than group BF. Three patients in group BF required i.v. fentanyl supplementation after delivery. In 1 of these patients, i.v. fentanyl was not adequate, and epidural supplementation of 1% lidocaine was required. CONCLUSION: The development of hypotension after spinal block in subjects undergoing cesarean section was not prevented despite low-dose (4 mg) bupivacaine plus 25 microg fentanyl, but the severity of maternal hypotension, and the number of ephedrine treatments and the total dose of ephedrine were decreased.

Comparison of recovery characteristics, postoperative nausea and vomiting, and gastrointestinal motility with total intravenous anesthesia with propofol versus inhalation anesthesia with desflurane for laparoscopic cholecystectomy: A randomized controlled study.

BACKGROUND: Clinical effects, recovery characteristics, and costs of total intravenous anesthesia with different inhalational anesthetics have been investigated and compared; however, there are no reported clinical studies focusing on the effects of anesthesia with propofol and desflurane in patients undergoing laparoscopic cholecystectomy. OBJECTIVE: The aim of this study was to determine the effects of total intravenous anesthesia with propofol and alfentanil compared with those of desflurane and alfentanil on recovery characteristics, postoperative nausea and vomiting (PONV), duration of hospitalization, and gastrointestinal motility. METHODS: Patients classified as American Society of Anesthesiologists physical status I or II undergoing elective laparoscopic cholecystectomy due to benign gallbladder disease were enrolled in the study. Patients were randomly assigned at a 1:1 ratio to receive total intravenous anesthesia with propofol (2-2.5 mg/kg) and alfentanil (20 µg/kg) or desflurane (4%-6%) and alfentanil (20 µg/kg). Perioperative management during premedication, intraoperative analgesia, relaxation, ventilation, and postoperative analgesia were carried out identically in the 2 groups. Extubation time, recovery time, PONV, postoperative antiemetic requirement, time to gastrointestinal motility and flatus, duration of hospitalization, and adverse effects were recorded. Postoperative pain was assessed using a visual analogue scale. RESULTS: Sixty-eight patients were assessed for inclusion in the study; 5 were excluded because they chose open surgery and 3 did not complete the study because they left the hospital. Sixty patients (33 women, 27 men) completed the study. Recovery time was significantly shorter in the propofol group (n = 30) compared with the desflurane group (n = 30) (8.0 [0.77] vs 9.2 [0.66] min, respectively; P < 0.005). Fifteen patients (50.0%) in the propofol group and 20 patients (66.7%) in the desflurane group experienced nausea during the first 24 hours after surgery. The difference was not considered significant. In the propofol group, significantly fewer patients had vomiting episodes compared with those in the desflurane group (2 [6.7%] vs 16 [53.3%]; P < 0.005). Significantly fewer patients in the propofol group required analgesic medication in the first 24 hours after surgery compared with those in the desflurane group (10 [33.3%] vs 15 [50.0%]; P < 0.005). Patients in the propofol group experienced bowel movements in a significantly shorter period of time compared with patients in the desflurane group (8.30 [1.67] vs 9.76 [1.88] hours; P = 0.02). The mean time to flatus occurred significantly sooner after surgery in the propofol group than in the desflurane group (8.70 [1.79] vs 9.46 [2.09] hours; P = 0.01). The duration of hospitalization after surgery was significantly shorter in the propofol group than in the desflurane group (40.60 [3.49] vs 43.60 [3.56] hours; P = 0.03). CONCLUSION: Total intravenous anesthesia with propofol and alfentanil was associated with a significantly reduced rate of PONV and analgesic consumption, shortened recovery time and duration of hospitalization, accelerated onset of bowel movements, and increased patient satisfaction compared with desflurane and alfentanil in these patients undergoing laparoscopic surgery who completed the study.

Effects of intravenous small dose ketamine and midazolam on postoperative pain following knee arthroscopy.

BACKGROUND: The aim of this randomized, double blind, controlled study was to assess the effect of intravenous coadministration of small dose midazolam with ketamine on postoperative pain and spinal block level. METHODS: Sixty patients undergoing arthroscopic knee surgery under spinal anesthesia were randomized into three groups: Group I (saline control); group II (ketamine 0.15 mg/kg i.v.); and group III (ketamine 0.15 mg/kg + midazolam 0.01 mg/kg i.v.). Sedation scores, visual analogue scores, time to first postoperative analgesic, total meperidine consumption, patient satisfaction, sensory and motor block levels, and two segments regression times were assessed. RESULTS: Sedation scores were significantly lower in group I when compared with groups II and III at 1, 3, 5, and 10 minutes after administration of the spinal anesthetic (P = 0.001). Sensory block was significantly higher in group III (P = 0.001) in comparison with group II. Two segment regression time was significantly longer in group II than group I, whereas no difference was found between groups II and III. Total meperidine consumption was significantly higher in group I (P = 0.001). Patient satisfaction was significantly higher in group III compared with group I (P = 0.001), but no difference was found between groups II and III (P = 0.3). CONCLUSION: Ketamine improved the postoperative pain patient satisfaction, increased the maximal sensory level, and was associated with lower sedation scores in the first 15 minutes after administration. Group I was also associated with decreased total meperidine consumption and delayed the time to first recue analgesic administration. Coadministration of ketamine and midazolam did not provide any further benefit over ketamine alone.

Lidocaine for prevention of propofol injection-induced pain: A prospective, randomized, double-blind, controlled study of the effect of duration of venous occlusion with a tourniquet in adults.

BACKGROUND: Many patients experience pain on injection of propofol. The use of lidocaine to prevent propofol injection pain is common. The analgesic effect of pre-injected lidocaine has been found to increase when a tourniquet is used. OBJECTIVE: The aim of this study was to compare the effectiveness of various venous occlusion times with lidocaine analgesia to prevent pain during propofol injection. METHODS: In this prospective, randomized, double-blind, controlled study, women aged 18 to 45 years, classifed as American Society of Anesthesiologists physical sta- tus I or II, who were scheduled to undergo elective surgery under general anesthesia induced with propofol, were randomly assigned to 1 of 5 groups: group 1, 2% lidocaine 20 mg in saline in a total volume of 10 mL and no venous occlusion; group 2, 2% lidocaine 20 mg in saline in a total volume of 10 mL plus venous occlusion for 15 seconds; group 3, 2% lidocaine plus venous occlusion for 30 seconds; group 4, 2% lidocaine plus venous occlusion for 60 seconds; and group 5, saline 10 mL and no venous occlusion. When the first 25% of the calculated propofol dose was administered, patients were asked about propofol-induced pain using a verbal pain scale (0 = no pain; 1 = mild pain; 2 = moderate pain; and 3 = severe pain). All patients and the anesthesiologist who evaluated pain severity were blinded to the study preparation being used. RESULTS: The study comprised 100 women who were randomly divided into 5 groups of 20 patients each. Significantly more patients in group 5 (18 [90%] patients; P < 0.05) reported pain compared with the other treatment groups. In groups 2, 3, and 4, in which venous occlusion was applied, pain was reported during propofol injection in 6 (30%), 7 (35%), and 2 (10%) patients, respectively. The incidence of reported pain was significantly greater in group 1 (lidocaine without venous occlusion) than in group 4 (P < 0.05); however, the incidence of pain was similar in group 1 compared with groups 2 and 3. CONCLUSIONS: The present study found that pretreatment with lidocaine 20 mg with or without venous occlusion significantly reduced the incidence and the severity of pain during the injection of propofol when compared with the group with no venous occlusion administered saline. In addition, pretreatment with lidocaine 20 mg plus venous occlusion for 60 seconds significantly reduced the incidence of propofol-induced pain compared with lidocaine without venous occlusion.

Acetaminophen reduces acute and persistent incisional pain after hysterectomy.

OBJECTIVE: Acetaminophen is effective for acute surgical pain, but whether it reduces persistent incision pain remains unknown. We tested the primary hypothesis that patients given perioperative acetaminophen have less incisional pain three months after surgery. Our secondary hypotheses were that patients randomized to acetaminophen have less postoperative pain and analgesic consumption, and better functional recovery at three months. METHODS: 140 patients having abdominal hysterectomy were randomly assigned to: 1)intravenous acetaminophen (4 g/day for 72 postoperative hours); or, 2) saline placebo. The primary outcome was incisional pain visual analog scale (VAS) at three months after surgery. The secondary outcomes were (1, 2) postoperative VAS scores while laying and sitting and (3) total patient-controlled intravenous tramadol consumption during the initial 24 hours, (4) DN4 questionnaires and (5) SF-12 at three months after surgery. RESULTS: The persistent incisional pain scores at three months were significantly lower in acetaminophen (median [Q1, Q3]: 0 [0, 0]) as compared with saline group (0 [0, 1]) (P = 0.002). Specifically, 89%, 9%, and 2% of acetaminophen patients with VAS pain score at three months of 0, 1, and 2 or more, as compared with 66%, 23%, and 10% in the saline group (odds ratio: 2.19 (95% CI: 1.33, 3.59), P = 0.002). Secondly, postoperative pain scores both laying and sitting were significantly lower in the acetaminophen group. Acetaminophen group had significantly better DN4 score and mental health related but not physical health related quality of life. CONCLUSIONS: Our results suggest that acetaminophen reduces the risk and intensity of persistent incisional pain. However, there are other mechanisms by which acetaminophen might reduce persistent pain. KEY WORDS: Anesthesia, acetaminophen, Persistent surgical pain, Postoperative acute pain.

Acetaminophen Reduces acute and persistent incisional pain after hysterectomy.

OBJECTIVE: Acetaminophen is effective for acute surgical pain, but whether it reduces persistent incision pain remains unknown. We tested the primary hypothesis that patients given perioperative acetaminophen have less incisional pain three months after surgery. Our secondary hypotheses were that patients randomized to acetaminophen have less postoperative pain and analgesic consumption, and better functional recovery at three months. METHODS: 140 patients having abdominal hysterectomy were randomly assigned to: 1)intravenous acetaminophen (4 g/day for 72 postoperative hours); or, 2) saline placebo. The primary outcome was incisional pain visual analog scale (VAS) at three months after surgery. The secondary outcomes were (1, 2) postoperative VAS scores while laying and sitting and (3) total patient-controlled intravenous tramadol consumption during the initial 24 hours, (4) DN4 questionnaires and (5) SF-12 at three months after surgery. RESULTS: The persistent incisional pain scores at three months were significantly lower in acetaminophen (median [Q1, Q3]: 0 [0, 0]) as compared with saline group (0 [0, 1]) (P = 0.002). Specifically, 89%, 9%, and 2% of acetaminophen patients with VAS pain score at three months of 0, 1, and 2 or more, as compared with 66%, 23%, and 10% in the saline group (odds ratio: 2.19 (95% CI: 1.33, 3.59), P = 0.002). Secondly, postoperative pain scores both laying and sitting were significantly lower in the acetaminophen group. Acetaminophen group had significantly better DN4 score and mental health related but not physical health related quality of life. CONCLUSIONS: Our results suggest that acetaminophen reduces the risk and intensity of persistent incisional pain. However, there are other mechanisms by which acetaminophen might reduce persistent pain. KEY WORDS: Anesthesia, acetaminophen, Persistent surgical pain, Postoperative acute pain.

The effect of ondansetron on analgesic efficacy of acetaminophen after hysterectomy: A randomized double blinded placebo controlled trial.

OBJECTIVES: To determine that perioperative ondansetron reduces the analgesic efficacy of acetaminophen. DESIGN: Randomized, double-blinded study. PATIENTS: 120 patients ASA I-II who underwent abdominal hysterectomy. INTERVENTIONS: All the patients were given 1g acetaminophen at skin closure. Patients were divided into two groups; ondansetron HCl (8mg, 2ml IV) (Group I, N=60) and saline (2ml IV) (Group II, N=60) at the skin closure. MEASUREMENT: Postoperative pain scores (VAS) while resting in bed and sitting, total opioid consumption were noted. MAIN RESULTS: Patients randomized to ondansetron had significantly worse pain scores upon arrival to the recovery unit [by 1.7 (99.7% CI: 0.75, 2.59) cm] and at 1h [by 1.3 (0.5, 2.1) cm] while resting in bed. Pain scores while sitting were also significantly greater in ondansetron group at arrival in PACU by 0.6 (99.7% CI: 0.1, 1.0) cm. Thereafter, pain scores did not differ significantly. Median total opioid (tramadol) consumption was 441 [Q1, Q3: 280, 578] mg in the ondansetron group and 412 [309, 574] mg in the placebo group, P=0.95. CONCLUSIONS: Ondansetron significantly decreased the analgesic effect of acetaminophen during the initial postoperative period. Our results thus confirm that acetaminophen analgesia is partially mediated by serotonin receptors. However, the reduction was of marginal clinical importance and short-lived.

[Broken Racz catheter during application (case report)]. / Uygulama esnasinda kopan Racz kateter (olgu sunumu).

The most important complication of lumber disc hernia operations is Failed Back Surgery Syndrome (FBSS), which goes with fibrotic adhesions at the surgical site. The primary treatment applied to the cases that develop FBSS is the placement of Racz catheter under floroscopy and application of epidural neuroplasty which is a three-day procedure. However, this intervention, from which patients benefit a great deal, has some important complications during and after the application. One of these complications is that some pieces of Racz catheter may be broken out and retain at some levels of epidural space and subcutaneous tissue during placement and removal. General approach is to remove the retaining piece surgically. However, there is a less common view that, instead of removing the retaining piece, the patient should be followed up strictly and regularly in terms of neurologic complications. In our case, we decided to perform epidural neuroplasty to the patient diagnosed as FBSS. However, during the placement of the catheter, it was trapped in the left side of L5-S1 foramen by accident due to dense fibrotic tissues, and the subcutaneus part retained in the epidural space. Monthly follow-ups for 12 month were proposed to the patient, while surgery was not recommended. At the end of this period, no sign of infection was observed and neurologic and radiologic findings of the patient did not worsen. It is also interesting that a remarkable recovery was observed in the patient's clinical situation.

Is It Possible to Maintain Consciousness and Spontaneous Ventilation with Chest Compression in the Early Phase of Cardiac Arrest?

Chest compression is important in cardiopulmonary resuscitation. However, life support algorithms do not specify when chest compression should be initiated in patients with persistent spontaneous normal breathing in the early phase after cardiac arrest. Here we describe the case of a 69-year-old man who underwent femoral bypass surgery and was extubated at the end of the procedure. After extubation, the patient's breathing pattern and respiratory rate were normal. The patient subsequently developed ventricular fibrillation, evident on two monitors. Because defibrillation was ineffective, chest compression was initiated even though the patient had spontaneous normal breathing and defensive motor reflexes, which were continued throughout resuscitation. He regained consciousness and underwent tracheal extubation without neurological sequelae on postoperative day 1. This case highlights the necessity of chest compression in the early phase of cardiac arrest.

Transversus abdominis plane block as a component of multimodal analgesia for laparoscopic cholecystectomy.

OBJECTIVE: To evaluate and compare intercostal-iliac transversus abdominis plane (TAP) and oblique subcostal TAP (OSTAP) blocks for multimodal analgesia in patients receiving laparoscopic cholecystectomy. DESIGN: A prospective, randomized, double-blinded clinical study. SETTING: Operating room, postoperative recovery area, and ward. PATIENTS: In total, 60 laparoscopic cholecystectomy patients (43 women, 17 men, American Society of Anesthesiologists grades I-II) were enrolled from the general surgery department of our tertiary care center. INTERVENTION: The patients were assigned to 1 of the 3 groups. Group 1 received TAP blocks (n=20), group 2 received OSTAP blocks (n=20), and group 3 patients were used as controls and received patient-controlled analgesia (PCA) only (n=20). After the induction of anesthesia, blocks were performed bilaterally in study groups 1 and 2, using 20mL of lidocaine (5mg/mL). PCA with intravenous tramadol was routinely provided for all patients during the first 24hours. MEASUREMENTS: The intraoperative use of remifentanil, postoperative visual analog scale (VAS) scores, demand for PCA, and total analgesic consumption were recorded. MAIN RESULTS: The patients in the control group had greater analgesic demands and analgesic consumption than did those in groups 1 and 2. However, patients in the OSTAP group had lower VAS scores than did those in groups 1 and 3. RESULTS: The demand for analgesia was greater in the control group than in groups 1 and 2. Moreover, lower VAS scores were recorded in the OSTAP group than in groups 1 and 3 and were positively correlated with total PCA consumption among all patients. However, postoperative VAS scores were negatively correlated with the total intraoperative consumption of remifentanil at 24hours. CONCLUSIONS: TAP and OSTAP blocks improved postoperative analgesia in patients receiving laparoscopic cholecystectomy, which resulted in lower VAS scores and reduction in total analgesic consumption.

Comparison of sugammadex and neostigmine-atropine on intraocular pressure and postoperative effects.

During surgery, changes in intraocular pressure (IOP) can be observed resulting from several factors, such as airway manipulations and drugs used. We aimed to investigate the effects of sugammadex and neostigmine on IOP, hemodynamic parameters, and complications after extubation. Our study comprised 60 patients, aged 18-65 years, with a risk status of the American Society of Anesthesiologists I-II who underwent arthroscopic surgery under general anesthesia. The patients were randomly assigned into two groups. At the end of the surgery, the neuromuscular block was reversed using neostigmine (50 µg/kg) plus atropine (15 µg/kg) in Group 1, and sugammadex (4 mg/kg) in Group 2. Neuromuscular blockade was monitored using acceleromyography and a train-of-four mode of stimulation. IOP was measured before induction and at 30 seconds, 2 minutes, and 10 minutes after extubation. A Tono-Pen XL applanation tonometer was used to measure IOP. This showed that elevation in IOP of patients reversed using sugammadex was similar to that recorded in patients reversed using neostigmine-atropine. When heart rate was compared, there was a significant difference between basal values and those obtained at 30 seconds and 10 minutes after extubation in the neostigmine-atropine group. Extubation time (time from withdrawal of anesthetic gas to extubation) was significantly shorter in the sugammadex group (p = 0.003) than in the neostigmine-atropine group. The postextubation IOP values of the sugammadex group were similar to the neostigmine-atropine group. Extubation time (time from withdrawal of anesthetic gas to extubation) was significantly shorter in the sugammadex group (p = 0.003) than in the neostigmine-atropine group.

Comparison of sugammadex and conventional reversal on postoperative nausea and vomiting: a randomized, blinded trial.

STUDY OBJECTIVE: To determine whether the new selective binding agent sugammadex causes less postoperative nausea and vomiting (PONV) than the cholinesterase inhibitor neostigmine. DESIGN: Prospective, randomized, double-blinded study. SETTING: University-affiliated hospital. PATIENTS: One hundred American Society of Anesthesiologists physical status 1 and 2 patients scheduled for extremity surgery. INTERVENTIONS: Patients were randomly assigned to neostigmine (70 µg/kg) and atropine (0.4 mg per mg neostigmine) or sugammadex 2 mg/kg for neuromuscular antagonism at the end of anesthesia, when 4 twitches in response to train-of-four stimulation were visible with fade. MEASUREMENTS: We recorded PONV, recovery parameters, antiemetic consumption, and side effects. MAIN RESULTS: Nausea and vomiting scores were lower in the sugammadex patients upon arrival in the postanesthesia care unit (med: 0 [min-max, 0-3] vs med: 0 [min-max, 0-3]; P < .05), but thereafter low and comparable. Postoperative antiemetic and analgesic consumption were similar in each group. Extubation (median [interquartile range], 3 [1-3.25] vs 4 [1-3.25]; P < .001) first eye opening (4 [3-7.25] vs 7 [5-11]; P < .001), and head lift (4 [2-7.25] vs 8 [11-25]; P < .001) in minutes were shorter in patients given sugammadex. Postoperative heart rates were significantly lower in all measured times patients given neostigmine. CONCLUSIONS: Nondepolarizing neuromuscular blocking antagonism with sugammadex speeds recovery of neuromuscular strength but only slightly and transiently reduces PONV compared with neostigmine and atropine.