Sedation for short hemato-oncologic invasive procedures in children: comparison of propofol-remifentanil and propofol-fentanyl.

INTRODUCTION: Short hemato-oncologic procedures are often painful in children, and sedation should be performed outside the operating room. AIM: : The study aims to compare the effects of remifentanil with those of fentanyl administered during short hemato-oncologic interventions in children. MATERIALS AND METHODS: A prospective, randomized study was planned for 29 ASA I to III children (aged, 2 to 18 y) to undergo a total of 60 short oncologic interventions. The patients were placed into 2 groups: propofol-remifentanil (group PR) and propofol-fentanyl (group PF). Group PR was first administered propofol (2 mg/kg) and then remifentanil bolus (0.5 µg/kg). Group PF was first administered propofol (2 mg/kg) and then fentanyl bolus (0.5 µg/kg). Systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, respiratory rate, peripheral oxygen saturation, and heart rate were recorded every 3 minutes during the intervention and every 5 minutes after the operation. Postanesthetic recovery scores, eye-opening time to speech, and recovery time were recorded. RESULTS: Comparison of diastolic arterial pressure in groups at minute 3 of the procedure showed significant difference (P<0.05). Eye-opening to speech (P=0.043) and recovery times (P=0.002) were shorter in group PR. CONCLUSIONS: During short hemato-oncologic interventions in children, the PR combination is a suitable one for early recovery.

Double Balloon Enteroscopy in a Pregnant Woman with Peutz-Jeghers Syndrome.

Peutz-Jeghers syndrome is an autosomal dominant disorder characterised by multiple hamartomatous polyps and muco-cutaneous pigmentation. Most polyps are found in the small intestine, especially in the jejunum. Enteroscopy with polypectomy is a reliable method to prevent polyp-related complications. A pregnant woman, who was diagnosed as a case of Peutz-Jeghers syndrome with a history of intestinal resection, was admitted to our clinic. Termination was recommended to the patient due to the possibility of polyps, causing obstruction during pregnancy. She underwent double balloon enteroscopy in the second trimester. Large polyps that could cause intussusception were removed and post-polypectomy bleeding was successfully controlled. This procedure was the first double balloon enteroscopy during pregnancy, reported in the literature. The procedure should be performed by experienced endoscopists, who can cope well with the complications in expert centres, as the procedure carries a high risk. Key Words: Double baloon enteroscopy, Pregnancy, Peutz-Jeghers syndrome, Polyps.

Evaluation of Herbal Product Use and Preanaesthetic Questioning of Couples Undergoing In Vitro Fertilisation.

OBJECTIVE: This study aimed to determine the levels of herbal product use among couples in vitro fertilisation (IVF) treatment in Turkey and the status of questioning in terms of herbal product usage. METHODS: After ethics committee approval, the study included 257 people, which were the couples receiving treatment in Dokuz Eylül University IVF units from 1st August, 2018, to 28th February, 2019. The couples were given 16-questions survey form to determine their herbal product use. Vitamin and herbal product use in the past 3 months was separately questioned. RESULTS: Significant differences were identified between women and men only in terms of age group. The rate of answering yes to the question about herbal product use in the study group was 13.6%, whereas 40.8% participants marked at least 1 item on the list of herbal products. Most people stated that they used herbal products by increasing the amounts in daily consumption. The top 5 products included onion, garlic, thyme, cinnamon and carob. Of the female patients being treated with IVF, 62.5% used vitamin supplements and 48.6% used herbal products. Of the men undergoing the same treatment (partners of the female participants), 37.5% used vitamin supplements and 51.4% used herbal products. CONCLUSION: Asking questions to patients receiving infertility treatment or anaesthesia is important in terms of medication interactions and treatment success. For a laborious and costly treatment, such as IVF, detailed history should be taken and herbal product used and cessation times must be searched in detail.

Effects of Propofol and Propofol-Remifentanil Combinations on Haemodynamics, Seizure Duration and Recovery during Electroconvulsive Therapy.

OBJECTIVE: This study aimed to evaluate the effects of adding different doses of remifentanil to propofol treatment compared with propofol alone with regard to parameters, including the seizure duration, haemodynamic changes and recovery time, in patients undergoing electroconvulsive therapy (ECT). METHODS: This study was designed as a self-controlled, prospective, double-blind investigation of 17 patients between the ages of 20 and 65 years who had planned treatment with ECT at a psychiatric clinic. Group P (propofol) was administered 10 mL of normal saline after 0.5 mg kg-1 intravenous (IV) bolus of propofol. Group R I (propofol plus remifentanil-1) was administered 1.5 µg kg-1 of remifentanil, and group R II (propofol plus remifentanil-2) was given 2 µg kg-1 of remifentanil after 0.5 mg kg-1 IV bolus of propofol. The haemodynamic variables after seizure and the seizure duration were recorded. Time to return to spontaneous respiration, eye opening and achieving Aldrete score >9 were recorded. RESULTS: The electroencephalography seizure duration was significantly longer in groups R I (34.7±13 s) and R II (34.9±12) than in group P (24±7.5). Motor seizure duration was longer in groups R I (29.70±12.8) and R II (28.1±10) than in group P (21±7.3). The amount of total propofol was 121±21 mg in group P, 69.4±2 mg in group R I and 67±17 mg in group R II. Times to eye opening, following simple commands, and achieving Aldrete score >9 were significantly shorter in groups R I and R II than in group P. CONCLUSION: ECT is a safe and effective treatment for patients with psychiatric disorders. Propofol-remifentanil anaesthesia prolongs the seizure duration and shortens the recovery time, suggesting that this combination may particularly be well suited for use in this patient group.

Biological markers in cerebrospinal fluid (CSF) and evaluation of in vitro effect of CSF on PC12 cell line viability in Alzheimer's disease.

The definite diagnosis of Alzheimer's disease (AD) is based on post mortem pathological examination. To date, there is no laboratory test that can discriminate AD patients from healthy individuals. In the perspective of recent knowledge, there are three cerebrospinal fluid (CSF) markers which have the highest sensitivity and specificity: A beta(1-40), A beta(1-42), and p-tau. In the present study, 15 'Probable Alzheimer's Disease' (PAD) patients and 15 control subjects were included. PAD patients were selected from the patients of Dokuz Eylül University Neurology Department Dementia outpatient clinic and control subjects were selected from the patients who were undergone epidural anesthesia because of any surgical operation. The concentrations of Ab1-40, Ab1-42, and p-tau in CSF were quantified by using ELISA. Also, the effects of 'PAD patients' CSF on the survival of PC12 cell line were assessed. There was a significant decrease of Ab1-40 and increase of p-tau in patients with AD when compared with controls. Ab1-42 concentration was not significantly different between groups. There was a positive correlation between duration of the disease and CSF of p-tau concentration in patients with AD. There was no significant difference in cell line viability values between groups.

TNF-related apoptosis-inducing ligand level in Alzheimer's disease.

In the present study, we determined the significance of tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) in Alzheimer's disease (AD). We characterized the expression of TRAIL protein in the cerebrospinal fluid (CSF) and serum with ELISA and TRAIL mRNA in the peripheral blood mononuclear cells (PBMCs) with real-time PCR in 22 patients with AD and 20 control cases. We could not find TRAIL protein in the CSF samples. The concentration of TRAIL protein in sera from patients with AD was not different from controls. However, there was an inverse correlation between serum TRAIL levels and Mini-Mental State Examination scores in AD patients. Also we did not find significant difference in TRAIL mRNA in the PBMCs of patients with AD when compared with control group. Our data indicate that TRAIL serum level decreases in the late stage of disease.

Comparison of etomidate-remifentanil and propofol-remifentanil sedation in patients scheduled for colonoscopy.

OBJECTIVE: The aim of the study was to compare haemodynamic responses, recovery and discharge times, and physician satisfaction of etomidate-remifentanil and propofol-remifentanil combinations in patients undergoing elective colonoscopy. METHODS: Sixty patients, aged 18-65 years, scheduled for elective colonoscopy under sedation were prospectively randomized, double blind for the study. Two minutes after the beginning of a continuous remifentanil infusion (0.1 microg kg(-1) min(-1)), etomidate or propofol were administered. Patients in the etomidate group received a 0.05 mg kg(-1) maintenance dose of etomidate after an initial dose of 0.1 mg kg(-1), and patients in the propofol group received a 0.25 mg kg(-1) maintenance dose of propofol after an initial dose of 0.5 mg kg(-1) in order to have a Ramsay sedation score of 3-4. Basal values of heart rate, mean arterial pressure, oxygen saturation, respiratory rate and Ramsay sedation score were recorded. Values were recorded every 2 min for the first 10 min and every 5 min thereafter, until the completion of the procedure. RESULTS: Mean arterial pressure was lower at 4, 6, 8, 10, 15, 20 and 25 min in the propofol group (P = 0.001). Mean respiratory rate in the propofol group at 6, 8, 10, 15, 20, 25 min was also lower (P < 0.05). The incidence of apnoea and hypotension was significantly lower in the etomidate group (P < 0.001). Arrival time into the postoperative care unit and recovery time were shorter in the etomidate group (P = 0.001, P = 0.01, respectively). Physician satisfaction in both groups was similar. CONCLUSION: Etomidate-remifentanil administration for sedation and analgesia during colonoscopy resulted in more stable haemodynamic responses and shorter recovery and discharge times.

Duodenal perforation and bilateral tension pneumothorax following endoscopic sphincterotomy.

Endoscopic sphincterotomy is commonly used for retained bile stones. We report a 24-year-old woman who showed bilateral tension pneumothorax and duodenal perforation following endoscopic sphincterotomy performed under sedation. These complications are rare in the literature have significant mortality and morbidity.

Technetium-99m HMPAO brain SPECT in autistic children and their families.

The purpose of the study was to investigate perfusion patterns in autistic children (AC) and their families. Ten AC (9 boys, 1 girl; mean age: 6.9+/-1.7 years) with autistic disorder defined by DSM-III-R criteria, five age-matched children (3 boys, 2 girls) as a control group, and the immediate family members of eight AC (8 mothers, 8 fathers, 7 siblings; mean ages: 39+/-4 years, 36+/-5 years and 13+/-5 years, respectively) were included in the study. Age- and sex-matched control groups for both the parents and the siblings were also included in the study. Brain perfusion images were obtained 1 h after the intravenous injection of an adjusted dose of Tc-99m HMPAO to children and the adults. Visual and semiquantitative evaluations were performed. Hypoperfusion was seen in the right posterior parietal cortex in three AC, in bilateral parietal cortex in one AC, bilateral frontal cortex in two AC, left parietal and temporal cortex in one AC, and right parietal and temporal cortex in one AC. Asymmetric perfusion was observed in the caudate nucleus in four AC. In semiquantitative analyses, statistically significant hypoperfusion was found in the right inferior and superior frontal, left superior frontal, right parietal, right mesial temporal and right caudate nucleus. In parents of AC, significant hypoperfusion was noted in the right parietal and bilateral inferior frontal cortex. In siblings of AC, perfusion in the right frontal cortex, right nucleus caudate and left parietal cortex was significantly decreased. This preliminary study suggests the existence of regional brain perfusion alterations in frontal, temporal, and parietal cortex and in caudate nucleus in AC and in their first-degree family members.

A cross-over, post-electroconvulsive therapy comparison of clinical recovery from rocuronium versus succinylcholine.

STUDY OBJECTIVE: To evaluate the effect of the neuromuscular blocking agent, rocuronium, on clinical recovery from electroconvulsive therapy (ECT) as compared with succinylcholine. DESIGN: Cross-over study. SETTING: University hospital. PATIENTS: 13 ASA physical status I and II patients, ages 18 to 60 years, receiving ECT three times a week. INTERVENTIONS: Each patient received either succinylcholine before the first ECT session (Group S) and rocuronium before the third ECT session (Group R). Muscle paralysis was produced with succinylcholine one mg kg(-1) intravenously (IV) or rocuronium 0.3 mg kg(-1) IV. Reversal of the residual neuromuscular block (Group R) was accomplished with 10 microg kg(-1)of atropine and 20 microg kg(-1)of neostigmine after completion of the ECT procedure. MEASUREMENTS: Motor seizure duration time, time to first spontaneous breathing, eye opening, head lift, and tongue depressor test were recorded. MAIN RESULT: Motor seizure duration and time to first spontaneous breath was longer (33.6 sec vs. 24.2 sec; 9.46 min vs 8.07 min, respectively) in the rocuronium group than the succinylcholine group. No significant difference was detected between the two groups in eye opening, head lift, or tongue depressor testing. CONCLUSION: Rocuronium, when used in conjunction with a reversal agent, may be an adequate alternative to succinylcholine as a neuromuscular blocker during ECT.

Comparison of the effectiveness of pretreatment by fentanyl and remifentanil on rocuronium induced injection pain.

OBJECTIVE: To compare the efficacy of fentanyl and remifentanil as prodrugs in the prevention of rocuronium injection pain by using a control group. METHODS: In a randomized, double-blinded, controlled study, 102 adult patients aged between 18-60 undergoing elective surgery under general anesthesia and classified into American Society of Anesthesiologists (ASA) I and ASA II risk groups were included in the study. The study was carried out from July 2005 to April 2006 at Dokuz Eylul University, Izmir, Turkey. Unpremedicated patients were randomly allocated to one of 3 groups. Patients received 2 mL (0.02 mg) of remifentanil (n =34), 2 mL of fentanyl 0.1 mg (n =34), and 2 mL of saline (n =34), by injection over 10 seconds. Thirty seconds after prodrug administration, 10 mg (10 mg/mL) intravenous rocuronium bromide was administered over 5 seconds and pain assessment was performed by using a 5-point scale. RESULTS: When the 3 groups of 34 patients were compared in terms of pain assessment scoring, a statistically significant difference was determined (p=0.02). When the groups were paired, it was seen that this difference resulted from the remifentanil and saline groups (p=0.02). CONCLUSION: This study shows that a bolus dose of 0.02 mg of remifentanil is a more effective prodrug administration compared to the application of saline, however, remifentanil and fentanyl have no superiority over one another and the administration of fentanyl is equally effective as saline prodrug administration.

Spinal Epidural and Intracranial Subdural Haemorrhage that is a Complication of Spinal Anaesthesia.

Haemorrhage in the neuraxial region following spinal and epidural interventions is a rare and unexpected complication. Subdural haemorrhage is the most frequently occurring type. A 64-year-old male patient was admitted with complaints of severe headache and intermittent fever after 14 days of spinal anaesthesia and inguinal hernia operation. Neurological examination and systemic examination showed no features other than that for postural tremor. Cranial and spinal magnetic resonance (MR) imaging were requested for the differential diagnosis of the patient with secondary headaches. In MR, subacute subdural haemorrhage adjacent to the dura, limiting the posterior sulcus, and extra axial distance (not clearly distinguishable epidural-subdural distinction) along the entire spinal canal were detected. The patient who had no neurological deficit and no culture recruitment underwent conservative treatment. We would like to emphasize here that the coexistence of both intracranial subdural and spinal subdural-epidural haemorrhage can be seen as a complication after spinal anaesthesia, which has not been previously observed in the literature, along with the importance of headache after regional anaesthesia.

Botulinum toxin A injection for spasticity in diplegic-type cerebral palsy.

Botulinum toxin type A can be both safe and effective in relieving spasticity in pediatric patients with cerebral palsy. In our prospective study, we evaluated the functional effect of botulinum toxin A in spastic diplegic-type cerebral palsy. Patients were examined on enrollment and at 1, 3, and 6 months after injection. Passive dorsiflexion of the ankle joint was measured using a goniometer as an angle of possible maximal dorsiflexion with the knee extended and flexed. Spasticity was graded using the Modified Ashworth Scale. Selective motor control at the ankle was assessed, and observational gait analysis was done. The functional status of the patients was determined by using the gross motor classification system. Botulinum toxin A was injected into the gastrocnemius muscle in all patients, and in four patients with concomitant jump knee gait, a hamstring muscle injection was added. Fourteen patients were included in the study. The mean age was 58.81 +/- 15.34 months. Following injection, spasticity was clinically decreased and statistically significant improvement was noticed in all clinical parameters after 1, 3, and 6 months of injection. The improvement in the clinical parameters decreased after 6 months but not to the baseline. One patient was Level II, four patients were Level III, and six patients were Level IV according to the Gross Motor Function Classification System at baseline. Improvement in the gross motor classification system is continued after 6 months in 12 children. The main goal of spasticity treatment in cerebral palsy is functional improvement. In our study, most of our patients had functional improvement according to the gross motor function classification system and did not change at 6 months.

Sedation Practice Outside the Operating Room for Pediatric Gastrointestinal Endoscopy.

Medical records of the 575 children who underwent gastrointestinal endoscopy outside the operating room were investigated retrospectively. The most frequently used combinations were propofol-midazolam-fentanyl in 83.2% of the procedures and propofol-midazolam in 13.8% of the procedures. 24 (3.4%) of 703 procedures had complications due to sedation anesthesia; 11 had hypoxia and 8 had pain in the injection area. Sedation anesthesia practice provided by an anesthesiologist outside the operating room enables gastrointestional endoscopic procedures to be carried out more safely.

The effects of alfentanil or remifentanil pretreatment on propofol injection pain.

STUDY OBJECTIVE: To compare the efficacy of alfentanil, remifentanil, and saline in minimizing the propofol injection pain. DESIGN: Randomized, double-blind study. SETTING: University hospital. PATIENTS: 175 ASA physical status I and II, adult female patients undergoing minor gynecological procedures with general anesthesia. INTERVENTIONS: Unpremedicated patients were randomly allocated to one of four groups. Patients received 2 mL (1 mg) of alfentanil (n=43), 2 mL of remifentanil 0.01 mg (n = 43), 2 mL of remifentanil 0.02 mg (n=45), or 2 mL of saline (n=44) 30 seconds prior to administration 5 mL of propofol 1%. MEASUREMENTS: Patients were asked whether they had pain due to propofol injection. Their pain scores were evaluated with a Visual Analogue Scale. In the Postanesthesia Care Unit, frequency of postoperative nausea, vomiting, hypotension, and flushing were all determined. MAIN RESULT: The remifentanil and alfentanil groups showed significantly less frequency and severity of pain than the saline group (p <0.05). When the alfentanil group was compared with the remifentanil groups, significant differences in pain relief associated with injection of propofol (p <0.001) were noted. Remifentanil 0.02 mg relieved pain associated with injection of propofol more effectively than remifentanil 0.01 mg (p <0.001). CONCLUSIONS: The remifentanil and alfentanil groups showed significantly less frequency and severity of pain than did the saline group. Remifentanil was effective in preventing propofol injection pain, and should be used at a dose of at least 0.02 mg for this purpose. Remifentanil may be an alternative drug for prevention of propofol injection pain.

The Attitudes and Behaviors of Anaesthesiology and Reanimation Specialists in Anaesthesia Care Applications Outside the Operating Room in Turkey: A Survey Study.

OBJECTIVE: We aimed to investigate the attitudes and behaviors of anaesthesiologists in "non-operating room anaesthesia" applications, which can be described as anaesthesia applications performed outside the operating room, and their reflection on practice all over Turkey. METHODS: Our study was conducted between November 5, 2012 and January 7, 2013 with the approval of the Research Ethics Board. Survey data were obtained through distributing printed questionnaires to be completed either by hand or via the web. The questionnaire consisted of 38 questions. The data obtained were analyzed with the Statistical Package for Social Sciences (SPSS) program. RESULTS: A total of 500 anaesthesiologists replied to our survey; 93% of anaesthesia specialists reported that there was a request that the anaesthesia and anaesthesia outside the operating room was given in their institution. Among anaesthesiologists, 56% reported that there were other sections that can provide sedation other than the anaesthesiology department in their institutions. Anaesthesia care team members; equipment; anaesthetic techniques; monitoring methods; and hypnotic, analgesic, and antagonist agents had statistically significant differences according to the participants' institutions. Equipment used in the anaesthesia practice outside the operating room, anaesthesia, and monitoring methods had statistically significant differences according to geographical distribution (p<0.05). CONCLUSION: Outside the operating room, anaesthesia practices and security measures are compliant with the standards set by the guidelines, the key to the prevention of complications. In our study, the current status of anaesthetic procedures outside the operating room in our country have been analyzed.

Evaluation of myocardial ischemia in coronary artery disease with cardiac MR perfusion method: comparison with the results of catheter or CT angiography.

AIM: To evaluate the efficacy of the Cardiac Magnetic Resonance Perfusion (CMRP) method in detection of Coronary Artery Disease (CAD) by comparing CMRP findings with the results of Coronary Computed Tomography Angiography (CCTA) or Catheter Coronary Angiography (CCA). METHODS: Thirty one patients in whom CMRP was performed along with CCTA or CCA within a month after CMRP between December 2009 and November 2010 were selected for the study. In CMRP, after adenosine administration as a stress agent Balanced TFE sequences were used to gather dynamic images that include the myocardial first pass of contrast media. Image analysis was performed visually. CMRP findings were compared to CCTA or CCA results for each coronary artery territories and for all territories. RESULTS: Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of CMRP test in the identification of patients with significant (≥70%) coronary artery stenosis were 94.7%, 83%, 90.3%, 90%, and 90.9% for all coronary arteries, respectively; 94.4%, 84.6%, 90.3%, 89.4%, and 91.6% for left anterior descending artery, respectively; and 100%, 100%, 100%, 100%, and 100% for circumflex and right coronary artery, respectively. There was no statistically significant difference between angiography methods (CCTA/CCA) and CMRP (p>0.05). Methods had good to perfect consistency (ĸ = 0.79-1.00). CONCLUSION: CMRP test seems to be a reasonable alternative for catheter angiography, which is considered the gold standard for evaluation of CAD and exclusion of significant coronary artery obstruction.

The cooling effect on proinflammatory cytokines interferon-gamma, tumor necrosis factor-alpha, and nitric oxide in patients with multiple sclerosis.

Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system (CNS) in young adults. The proinflammatory cytokines such as interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), and nitric oxide (NO) which are known to be produced by inflammatory cells play a key role in the pathogenesis of MS. Some metabolic changes may have an effect on axonal transmission, and white blood cells NO and other inflammatory mediators such as cytokines may be affected from cooling process. In this study, we evaluated the effects of body cooling procedure on proinflammatory cytokines such as TNF-α, IFN-γ, and NO levels. Twenty patients with MS were evaluated. Thirteen of the patients were women, 7 were men (mean age: 33.6 ± 7.5 yrs.). Body temperature was reduced by an average of 1°C approximately in 1 hour with using the "Medivance Arctic Sun Temperature Management System" device. In our study, the decrease in TNF-α, IFN-γ levels after the cooling procedure has no statistical significance, whereas the decrease in the mean level of NO level after the cooling procedure is 4.63 ± 7.4 µmol/L which has statistical significance (P = 0.002). These results suggested that the decrease in NO level improves conduction block in demyelinated axonal segments after cooling procedure in multiple sclerosis.

Use of laryngeal mask airway in anesthesia for treatment of retinopathy of prematurity.

OBJECTIVE: To review clinical experience of anesthesia management using laryngeal mask airway (LMA) during retinopathy of prematurity (ROP) photocoagulation. METHODS: After obtaining the ethical approval from the Ethics Committee, we retrospectively reviewed the anesthesia records of 85 infants who underwent laser photocoagulation for ROP between June 2004 and June 2010 at the Department of Anesthesiology and Intensive Care, School of Medicine, Dokuz Eylul University, Izmir, Turkey. Anesthesia records were reviewed for airway management and respiratory complications in addition to medical and demographic data. RESULTS: The mean gestational age was 28.61+/-2.62 weeks, birth weight was 1205.24+/-384.51 g, post-conceptional age was 38.21+/-7.01 weeks, and weight at the time of operation was 2323.9+/-588.6 g. Laryngeal mask airway was used with minimal complications in all patients, even in patients with chronic lung disease including bronchopulmonary dysplasia. After the ROP treatment, the LMA was successfully removed in all infants under deep anesthesia and none of the patients needed endotracheal intubation or ventilatory support. CONCLUSION: Laryngeal mask airway is a safe and easy to use alternative for airway management during laser photocoagulation procedure in infants with ROP.