Effects of different analgesic methods used for vaginal delivery on mothers and fetuses

Background/aim: Knowledge regarding pain relief during labor remains insufficient. We aimed to determine and compare the effectiveness and safety of epidural analgesia, combined spinal­epidural analgesia, and parenteral meperidine on both mothers and fetuses. Materials and methods: This study was designed as an observational case-control study. We collected prospective data from patients whose labor pain management was conducted with meperidine in addition to retrospective cohort data of neuraxial methods; 138 patients were enrolled. Epidural analgesia group consisted of 68 patients, whereas combined spinal-epidural (CSE) analgesia group and meperidine group consisted of 50 and 20 patients, respectively. We compared the delivery patterns, labor durations, pain levels, side effects, maternal satisfaction levels, and neonatal outcomes of the various pain management methods. Results: Patient demographics, duration of first, second, and third labor stages, and instrumental delivery rates were comparable among groups (P > 0.05). Cesarean section tended to be less frequent in the CSE group. In the meperidine group, visual analog scale (VAS) values and sedation were significantly higher (P < 0.001) and maternal satisfaction lower (P < 0.001). Hypotension tended to be more frequent in the meperidine group. APGAR scores at the 1st and 5th min were similar among the groups and between meperidine subgroups defined by three different administration times (<1 h, 1‒4 h, ≥4 h; P > 0.05). Conclusion: Neuraxial methods had no effect on instrumental delivery rates. CSE represented a near significant risk reduction in cesarean section. Our results demonstrated that regional analgesia methods were reasonably safe for both mother and fetus, and regional analgesia methods resulted in greater maternal satisfaction and pain control compared to meperidine.

Body Surface Area Is Not a Reliable Predictor of Tracheal Tube Size in Children.

OBJECTIVES: The age-based Cole formula has been employed for the estimation of endotracheal tube (ETT) size due to its ease of use, but may not appropriately consider growth rates among children. Child growth is assessed by calculating the body surface area (BSA). The association between the outer diameter of an appropriate uncuffed-endotrachealtube (ETT-OD) and the BSA values of patients at 24-96 months of age was our primary outcome. METHODS: Cole formula, BSA, age, height, weight and ultrasound measurement of subglottic-transverse-diameter were evaluated for correlations with correct uncuffed ETT-OD. The Cole formula, BSA, and ultrasound measurements were analyzed for estimation rates in all patients and age subgroups. The maximum allowed error for the estimation of ETT-OD was ≤0.3 mm. Patients' tracheas were intubated with tubes chosen by Cole formula and correct ETT-OD values were determined using leak test. ETT exchange rates were recorded. RESULTS: One-hundred twenty-seven patients were analyzed for the determination of estimation rates. Thirteen patients aged ≥72 months were intubated with cuffed ETT-OD of 8.4 mm and were accepted to need uncuffed ETT-OD >8.4 mm in order to be included in estimation rates, but excluded from correlations for size analysis. One-hundred fourteen patients were analyzed for correlations between correct ETT-OD (determined by the leak test) and outcome parameters. Cole formula, ultrasonography, and BSA had similar correct estimation rates. All three parameters had higher underestimation rates as age increased. CONCLUSION: The Cole formula, BSA, and ultrasonography had similar estimation rates in patients aged 24≤ to ≤96 months. BSA had a correct estimation rate of 40.2% and may not be reliable in clinical practice to predict uncuffedETT-size.

Evaluation of the stability and stratification of propofol and ketamine mixtures for pediatric anesthesia.

BACKGROUND: The combination of propofol and ketamine is commonly used for total intravenous anesthesia. These drugs can be delivered in different syringes or in the same syringe. We hypothesized that the drugs might separate and different concentrations of each drug could be found in different parts of the syringe during the procedure period when they were mixed in 1 syringe. METHODS: Twelve 60-mL polypropylene syringes were prepared by mixing propofol and ketamine as 4 groups on the basis of propofol/ketamine mixture ratios (5:1 and 6.7:1) and propofol solution concentrations. Syringes were placed upright in the vertical position into a rack and kept at room temperature (21.5-22.5°C), in daylight conditions and were not moved for 360 minutes. Samples of the mixture were taken from both the top and the bottom of the syringe. The first 1 mL of the samples was discarded, the following second 1 mL of the samples was filtered using 0.2-µm polytetrafluoroethylene filters and measured twice (n = 6). Samples were taken at the following time intervals: T0, T10, T30, T60, T90, T120, T180, T240, T300, and T360 min. Syringes were checked visually for any color change and separation lines between the drugs. RESULTS: There were no significant differences between the propofol and ketamine concentrations of the top and bottom samples in all 4 groups. In addition, there were no statistically significant changes of propofol and ketamine concentrations of samples over 360 minutes in any of the 4 groups. No visual changes were observed during 6 hours' observation. CONCLUSION: The results of our measurements demonstrated that mixtures of propofol (1% and 2%) and ketamine at 5:1 and 6.7:1 ratios could be used in terms of mixture homogeneity and stability in a polypropylene syringe during a 6-hour period at room temperature.

Anesthetic practices for patients with preeclampsia or HELLP syndrome: A survey.

OBJECTIVE: Substantial controversy exists regarding anesthetic management for patients with preeclampsia or hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. Experts, researchers, clinicians, and residents in Turkey were surveyed about their practices. MATERIAL AND METHODS: Questionnaires were distributed to attendees at a national conference, and they were filled out immediately. Anonymous 10-item paper surveys were administered to both residents and non-residents. Descriptive statistics were used in the analysis. Agreement among ≥75% of the respondents was considered a majority opinion. Surveys with missing responses were used to analyze the non-response bias. The Chi-square test was used for comparisons. A historical cohort of obstetricians-gynecologists was used for comparison with anesthesiologists. RESULTS: Of 339 surveys distributed, 288 were returned (84.9% response rate). Among the returned surveys, the completion rate was 96.1%. The job experience in years among clinicians and residents was 9±5 and 3±1, respectively. General anesthesia was still significantly preferred by 36.1% among patients with preeclampsia with platelet counts of ≥100,000/µL. Compared to obstetricians-gynecologists, anesthesiologists more often preferred general anesthesia. With platelet counts of <50,000/µL or eclampsia, most respondents preferred general anesthesia 94.4% for very low platelets and 89.5% for eclampsia. CONCLUSION: A preferential trend toward general anesthesia for patients with preeclampsia or HELLP syndrome exists among anesthesiologists in Turkey, particularly for patients with severe thrombocytopenia and/or eclampsia. There exists a need for well-designed and well-executed prospective clinical trials to provide evidence for the best consensus practice.

The effect of HES (130/0.4) usage as the priming solution on renal function in children undergoing cardiac surgery.

BACKGROUND: Experience with hydroxyethyl starch (HES) in children is limited. This study was conducted to observe the effects of HES or Ringer's lactate (RL) usage as the priming solution on renal functions in children undergoing cardiac surgery. METHODS: After ethical committee approval and parent informed consent, 24 patients were included in this prospective, randomized study. During cardiopulmonary bypass (CPB), Group I received RL and Group II received HES (130/0.4) as priming solution. Serum creatinine, blood urea nitrogen (BUN), ß2-microglobulin, cystatin C, and urinary albumin and creatinine, serum, and urine electrolytes were analyzed after the induction (T1), before CPB (T2), during CPB (T3), after CPB (T4), at the end of the operation (T5), on 24th hour (T6), and on 48th hour postoperatively (T7). Fractional sodium excretion (FENa), urinary albumin/creatinine ratio, and creatinine clearance were calculated. Drainage, urine output, inotropes, diuretics, and blood requirements were recorded. RESULTS: In both the groups, ß2-microglobulin was decreased during CPB and cystatin C was decreased at T3,T4, and T5 periods (p < 0.05) and the levels remained within the normal range. Creatinine clearance did not differ in the HES group, but increased in the RL group (p < 0.05). Urine albumin/creatinine ratio was increased (p < 0.05) after CPB in the HES group, and it increased at T3, T4, and T5 in the RL group (p < 0.05). There were no differences in cystatin C, ß2-microglobulin, FENa, urine albumin/creatinine ratio, creatinine clearance, total fluid amount, urine output, drainage, and inotropic and diuretic requirements between the groups. CONCLUSION: We conclude that usage of HES (130/0.4) did not have negative effects on renal function, and it can be used as a priming solution in pediatric patients undergoing cardiac surgery.

Comparison of the effects of sevoflurane, isoflurane, and desflurane on microcirculation in coronary artery bypass graft surgery.

OBJECTIVE: This investigation was performed to compare the effects of inhalation agents on microcirculation in coronary artery bypass grafting (CABG) using orthogonal polarization spectral imaging. DESIGN: This prospective and randomized study was performed in patients scheduled for CABG surgery from March through September 2010. SETTING: Tertiary care university hospital. PARTICIPANTS: Thirty patients undergoing elective CABG. INTERVENTIONS: Patients were assigned to sevoflurane, desflurane, or isoflurane. MEASUREMENTS AND MAIN RESULTS: Orthogonal polarization spectral imaging was used to evaluate the sublingual microcirculation. Hemodynamic variables (heart rate, mean arterial pressure, central venous pressure, cardiac output, and pulmonary capillary wedge pressure), laboratory parameters (hematocrit, lactate, and potassium), and microcirculatory variables (total vascular density [TVD] [mm/mm(2)], microvascular flow index [MFI] [arbitrary units], perfused vessel density [PVD] [mm/mm(2)], and proportion of perfused vessels [PPV] [percentage] were obtained before induction, after induction, during cardiopulmonary bypass, at the end of surgery, and 24 hours after surgery. The greatest alterations in microcirculation parameters were found during cardiopulmonary bypass. In the sevoflurane group, TVD (14.7%), PVD (22%), PPV (5.97%, p < 0.05), and MFI (7.69%, p > 0.05) were decreased. In the isoflurane group, TVD (14.7%) and PVD (20.3%) were decreased, whereas PPV (1.69%) and MFI (17.99%) were increased (p < 0.05). In the desflurane group, there were no changes in TVD and PVD, but MFI (8.99%, p > 0.05) and PPV (1.48%, p < 0.05) were increased in the small vessels. These changes returned to their initial values 24 hours postoperatively. CONCLUSIONS: Sevoflurane had a negative effect on the microcirculation. Isoflurane decreased vascular density and increased flow. Desflurane produced stable effects on the microcirculation. These inhalation agents induced transient alterations in microvascular perfusion.

The effects of sevoflurane anesthesia and cardiopulmonary bypass on renal function in cyanotic and acyanotic children undergoing cardiac surgery.

BACKGROUND: There are few data on the effects of anesthesia and cardiopulmonary bypass (CPB) on perioperative renal function in children with cyanotic congenital heart disease undergoing open heart surgery. This study aims to investigate the perioperative renal function in cyanotic versus acyanotic children undergoing sevoflurane anesthesia for open heart surgery. METHODS: After receiving ethical committee approval, 12 acyanotic patients (preoperative oxygen saturation: SaO(2) > 85%) and 12 cyanotic children (SaO(2) < 85%) were included. Sevoflurane was administered at concentration levels of 2% before CPB and 1-2% during CPB after standard anesthesia induction. Inorganic fluoride, electrolytes, creatinine, urea nitrogen in serum and urine samples, and N-acetyl-ß-d-glucosaminidase (NAG) in urine samples were measured before induction, before CPB, during CPB, after CPB, at the end of surgery, and at 24th h postoperatively. RESULTS: The levels of serum uric acid levels were higher in the cyanotic group (p < 0.05). There were no differences in the levels of serum creatinine and urine creatinine, urea nitrogen, and electrolytes between the two groups. Serum inorganic fluoride levels were always higher in the acyanotic group than in the cyanotic group, but these differences between the groups reached statistical significance at two measurement times (before CPB and end of surgery) (p < 0.05). Urinary inorganic fluoride levels increased with time in both groups. Although urinary NAG increased significantly after the CPB in the cyanotic group, the differences between the two groups did not reach statistical significance. CONCLUSIONS: We have concluded that renal function was not affected during open heart surgery with sevoflurane anesthesia, in both cyanotic and acyanotic children.

[Entrapment of a Swan-Ganz catheter within the right pulmonary artery ligature during right pneumonectomy]. / Sag pnömonektomi cerrahisinde sag pulmoner arterde dikilen Swan-Ganz kateteri.

Entrapment of a pulmonary artery catheter in the pulmonary artery is a rare and severe complication that may lead to fatal complications such as pulmonary artery injury. We describe entrapment of a Swan-Ganz catheter within the right pulmonary artery ligature in a patient undergoing right pneumonectomy. This situation resulted with removal of catheter safely without any complication. We concluded that with early recognition of the complication during thoracotomy, is golden standard in preventing pulmonary artery catheter entrapment and surgeons should be aware of the risk of accidentally transfixing pulmonary artery catheter in every type of operation that takes place in thorax.

The effects of isoflurane, sevoflurane, and desflurane anesthesia on neurocognitive outcome after cardiac surgery: a pilot study.

BACKGROUND: Inhalation anesthetics such as isoflurane, sevoflurane, and desflurane are widely used in clinical practice; however, there is no study for comparing these drugs in cardiac surgery with respect to postoperative cognitive outcome and S100 beta protein (S100 BP) levels. In this study, we evaluated the effect of sevoflurane, isoflurane, and desflurane anesthesia on neuropsychological outcome and S100 BP levels in patients undergoing coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB). MATERIALS AND METHODS: Forty-two male patients were prospectively randomized and classified into 3 groups according to the volatile agents used; isoflurane, sevoflurane, desflurane. All patients had a sufficient education level to participate in neuropsychological testing and a normal carotid Doppler ultrasonography. Blood samples for analysis of S100 BP were collected before anesthesia (T1), before heparinization (T2), 15 minutes into CPB (T3), following protamine administration (T4), postoperatively (T5), 24 hours after the operation (T6), postoperative day 3 (T7), and postoperative day 6 (T8). The neuropsychological tests, including Mini-Mental State Examination (MMSET) and visual-aural digit span test (VADST), were administered 1 day prior to surgery and on the third and sixth postoperative days. RESULTS: The postoperative third and sixth day MMSET scores and third day visual-written subtest scores in the sevoflurane group were significantly lower than in the isoflurane and desflurane groups (P < .05). S100 BP levels increased with the beginning of anesthesia in the sevoflurane and desflurane groups. Although S100 BP decreased to baseline levels on postoperative day 1 in the sevoflurane group, this was significantly higher on the third and sixth days postoperatively in the desflurane group (P < .05). In the isoflurane group, the S100 BP level was significantly higher than the baseline level only after CPB (P < .05). CONCLUSION: Our study suggests that isoflurane is associated with better neurocognitive functions than desflurane or sevoflurane after on-pump CABG. Sevoflurane seems to be associated with the worst cognitive outcome as assessed by neuropsychologic tests, and prolonged brain injury as detected by high S100 BP levels was seen with desflurane.

The effect of halothane, isoflurane, sevoflurane and propofol infusion on renal function after coronary artery bypass surgery.

Renal insufficiency after cardiac surgery is associated with increased mortality, morbidity, and length of stay in the intensive care unit. We investigated the effect of isoflurane, halothane, sevoflurane and propofol anesthesia on perioperative renal function following elective coronary artery surgery. The medical records of 224 patients, in the Hacettepe University Medical Faculty Hospital who had undergone cardiac surgery in one year, were retrospectively reviewed. 65 (29%) patients received isoflurane, 68 (30%) patients received halothane, 64 (29%) patients received sevoflurane, and 27 (12%) patients received propofol infusion as part of maintenance anesthesia for coronary artery bypass surgery. Patient characteristics (age, sex, preoperative ejection fraction), operative data (duration of CPB, duration of operation, number of distal anastomoses, usage of diuretic, intraoperative crystalloid and blood transfusion), intraoperative urinary output, preoperative and postoperative (6th hours and 24th hours) BUN and plasma creatinine levels, were not statistically significant between and within groups. Intraoperative inotropic agent (dopamine) was used in 8 (12.3%) patients in the isoflurane group, in 10 (14.7%) patients in the halothane group, in 11 (17.2%) patients in sevoflurane group and in 9 (33.3%) patients in the propofol group. Postoperatively fluid and blood transfusion, postoperative drainage, urinary output, diuretic usage were smiliar between the four groups (p>0,05). Inotropic agent was used in 8 (12.3%) patients in the isoflurane group, in 9 (13.2%) patients in the halothane group, in 16 (25%) patients in the sevoflurane group and in 7 (25.9%) patients in the propofol group. It is concluded that, halothane, isoflurane, sevoflurane and propofol infusion anesthesia as part of anesthesia maintenance for elective coronary artery bypass surgery does not affect early postoperative renal functions.

The role of antifibrinolytic agents in gynecologic cancer surgery.

OBJECTIVE: To compare the effects of crystalloid and colloid solutions, tranexamic acid and epsilon-aminocaproic acid on the need for allogenic blood transfusion and on coagulation and fibrinolysis parameters. METHODS: We conducted the study in the Anesthesiology and Reanimation Department of Hacettepe University Medical Faculty, Ankara, Turkey between March 2004 and April 2005. The study included 105 patients, classified by the American Society of Anesthesiology as physical status groups I-II, undergoing gynecologic cancer treatment. We divided them into 5 groups: group I (crystalloid) received crystalloid solutions, group II (colloid) received colloid solutions, group III (tranexamic acid) received 10 mg x kg(-1) tranexamic acid, and group 5 (epsilon-aminocaproic acid) received 100 mg x kg(-1) epsilon-aminocaproic acid. All patients bleeding amount was measured and recorded perioperatively, and at the 12th and 24th hours postoperatively. We then evaluated the patients' hemoglobin, hematocrit, activated thromboplastin time, international normalized ration, fibrinogen, and thrombocyte count and symptoms of pulmonary embolism. RESULTS: In comparing the amount of bleeding, the bleeding in the tranexamic acid group was 30.8% less than the crystalloid group (p<0.05), 33.3% less than the colloid group (p<0.05), and 23.9% less than the epsilon-aminocaproic acid group (p<0.05). CONCLUSION: When the negative effects of blood transfusions were considered, tranexamic acid administration can be recommended for decreasing the need for blood transfusion in gynecologic cancer surgery.

Magnesium sulfate pretreatment reduces myoclonus after etomidate.

Myoclonic movements and pain on injection are common problems during induction of anesthesia with etomidate. We investigated the influence of pretreatment with magnesium and two doses of ketamine on the incidence of etomidate-induced myoclonus and pain. A prospective double-blind study was performed on 100 ASA physical status I-III patients who were randomized into 4 groups according to the pretreatment drug: ketamine 0.2 mg/kg, ketamine 0.5 mg/kg, magnesium sulfate (Mg) 2.48 mmol, or normal saline. Ninety seconds after the pretreatment, anesthesia was induced with etomidate 0.2 mg/kg. Vecuronium 0.1 mg/kg was used as the muscle relaxant. An anesthesiologist, blinded to group allocation, recorded the myoclonic movements, pain, and sedation on a scale between 0-3. Nineteen of the 25 patients receiving Mg (76%) did not have myoclonic movements after the administration of etomidate, whereas 18 patients (72%) in the ketamine 0.5 mg/kg, 16 patients (64%) in the ketamine 0.2 mg/kg, and 18 patients (72%) in the control group experienced myoclonic movements (P < 0.05). We conclude that Mg 2.48 mmol administered 90 s before the induction of anesthesia with etomidate is effective in reducing the severity of etomidate-induced myoclonic muscle movements and that ketamine does not reduce the incidence of myoclonic movements.

Infusion and bolus administration of cisatracurium--effects on histamine release.

The purpose of this study is to evaluate the usefulness of Cisatracurium Besilat (CB), and the method of its administration during laparotomies on adult patients, to determine whether CB caused cutaneous, systemic or chemical evidence of histamine release. This study was conducted as a randomized, double-blind clinical trial on 38 patients (ASA I-II). After a standard anesthetic induction with fentanyl and propofol, patients received an i.v. bolus CB (0.15 mg/kg in Group A (n=20) or Group B (n=18). In Group B, 0.18 mg/kg/h infusion was started. Following reaching stable muscle relaxations for intraabdominal operation and for recovery, Group A (Bolus group) and Group B (Infusion group) were compared. Train-of-four fade during recovery of block were recorded after administration of CB. The heart rate and arterial blood pressure were monitored noninvasively. There were no significant hemodynamic differences among the groups. 25%-75% spontaneous recoveries were (mean+/-s) 12.75+/-4.52, 16.11+/-9.20 minutes for Group A, Group B. 70% TOF Ratios were (mean+/-s) 1.07+/-0.13, 1.39+/-0.38 hours for the same groups. There was no consistent correlation between hemodynamic changes, cutaneous manifestations and histamine concentrations. We conclude that CB does not cause systemic or cutaneous histamine release. The infusion method of cisatracurium has a stable level of curarization without side effect and there were no significant recovery time differences between the groups.

The effect of premedication on preoperative anxiety.

The aim of this study was to evaluate the effect of premedication on anxiety, cortisol, residual gastric volume and gastric pH. Following the approval of the institutional Clinical Research Ethics Committee, 100 patients in ASA I-II scheduled for elective gynecologic surgery, were included into a double blind study. Patients were randomly allocated into two groups; the placebo and the premedicated. Oral 10 mg diazepam in the evening before surgery and 1.5 mg midazolam at least 15 min before surgery. The same anesthetic procedure was applied for both groups. Anxiety levels of patients were assessed by using Spielberger State-Trait Anxiety Inventory Scale (STAIs). Blood samples for cortisol measurements were obtained at the preoperative visits, preanesthesia and intraoperative phases. Gastric contents were collected through an orally inserted gastric tube, acidity was measured by using Merck's pH paper. In placebo group, the preanesthetic STAIs values were increased compared to the values obtained at preoperative visit (p < 0.001). The preanesthetic STAIs values were decreased in premedicated group (p < 0.001). The changes of preanesthetic and preoperative visit values were statistically different (p < 0.001). The preanesthetic and intraoperative cortisol values were increased in both groups compared to values of preoperative visit. The augmentation was significantly higher in the placebo group (p < 0.05). Positive correlation was observed between basal state anxiety and basal cortisol values and preanesthetic STAIs and cortisol values in the placebo group (r = 0.325, p < 0.05). These data support that preoperative sedation suppresses the preoperative anxiety and the cortisol augmentation resulting from surgery and stress.