Plethysmographic variability index and perfusion index in patients with axillary brachial plexus nerve catheters: An observational study.

Axillary nerve blocks are commonly using for forearm and hand surgery. Especially for finger replacement it has been shown continuous plexus blockade improves microcirculation. Addition to that benefit continuous blockade provides adequate analgesia. In this study perfusion index (PI) and plethysmographic variability index (PVI) changes were used to evaluate in blocks success. The PVI and PI values were detected by a Radical-7TM finger pulse oximetry device (Massimo Corp, USA) in both fingers of 50 plastic surgery patients, who received an axillary brachial plexus catheter before surgery. Data recorded at baseline, during catheter replacement, after catheter replacement, and before surgery. All periods hemodynamic data, visual analog scala, Ramsey sedation score and patient satisfaction score were collected. In all 110 patients blocks were successfully applied, PI values in blocked arm increased after local analgesic application (during catheter replacement), (P < .05), PVI values were decreased in the same period but there were no statistical significance. The PI increases after peripheral plexus blockade and may be used as an indicator for successful block placement in awake patient. And also, it may be used as an indicator for catheter effectiveness after surgery. But PVI values cannot detect that kind of relation with nerve blockade.

Coexistence of familial Mediterranean fever and Behçet's disease: a case report.

Behçet's disease (BD) is a chronic, multi-systemic vasculitis, characterized by a triad of recurrent aphthous stomatitis, genital aphthae, and uveitis. It is common in the Eastern Mediterranean, Middle East, and Eastern Asian countries. Familial Mediterranean fever (FMF) is an autosomal recessive autoinflammatory disorder, which is common seen in the Turkish, Armenian, Arabic, and Sephardic Jewish populations. It is characterized by recurrent episodes of fever, peritonitis, pleuritis, arthritis, and erysipelas-like skin lesions. Behçet's disease and FMF have common clinical features and geographic distribution. Herein, we present a 19-year-old female patient with coexistence of FMF and BD in the light of literature data.

Long-Term Changes in Subfoveal Choroidal Thickness After Cataract Surgery.

BACKGROUND Cataract surgery is associated with the development of late-onset age-related macular degeneration (AMD). The pathogenic mechanism is still not fully established. The purpose of this study was to evaluate the possible changes in central macula thickness (CMT) and subfoveal choroid thickness (SCT) after uneventful cataract surgery. MATERIAL AND METHODS A total of 65 eyes of 65 patients who underwent phacoemulsification and intracapsular lens implantation were included in this prospective study. Patients had not undergone previous ocular surgery and had no other ocular abnormality. CMT and SCT were measured at baseline and postoperatively at week 1 and months 1, 3, 6 and 12 via spectral domain optical cohorence tomography (SD-OCT). RESULTS CMT was 252.4±27.6 µm (mean ±SD) preoperatively, then 253.5±29.8, 256.1±28.7, 257.4±27.2, 253.18±23.7, and 252.8±21.7 µm at postoperative week 1 and postoperative months 1, 3, 6, and 12, respectively. There were insignificant changes in CMT, and it returned to baseline at six months after surgery (all p>0.05). SCT was 237.4±21.6 µm preoperatively, and 240.5±24.8, 241.2±25.7, 242.7±26.3, 243.1±24.2, and 244.2±21.4 µm at postoperative week 1 and postoperative months 1, 3, 6, and 12, respectively. Although there was an increase in SCT during follow-up, the difference between preoperative and postoperative values was not significant (p>0.05). CONCLUSIONS Uncomplicated phacoemulsification induces subclinical changes in CMT, probably due to the inflammatory insult of surgery, and CMT returns to baseline value. There were slight, insignificant increases in choroid thickness during follow-up, and this did not return to baseline during follow-up. Changes in the choroid after cataract surgery may provide clues to the development of late-onset AMD.

Dry eye in vitamin D deficiency: more than an incidental association.

AIM: The aim of this article is two-fold: (i) to demonstrate the relation between vitamin D deficiency and dry eye and impaired tear function; and (ii) to investigate the possible associations among clinical parameters of hypovitaminosis D with dry eye parameters. METHOD: Fifty premenopausal women with vitamin D deficiency (serum vitamin D levels < 20 ng/mL) and 48 controls were included. Participants were assessed by Schirmer's test, tear break-up time test (TBUT), ocular surface disease index (OSDI), Stanford Health Assessment Questionnaire (HAQ), fatigue severity scale (FSS), and visual analogue scale-pain (VAS-pain). RESULTS: Lower scores in Schirmer's test and TBUT, and higher in OSDI were detected in patients with vitamin D deficiency than in controls (P < 0.05). FSS was negatively correlated with Schirmer's test (r = -0,29; P = 0.038) and TBUT scores (r = -0,43; P = 0.002); VAS-pain was negatively correlated with TBUT scores (r = -0.32; P = 0.023). HAQ scores showed no significant correlation with dry eye parameters (P > 0.05). Vitamin D level was negatively correlated with OSDI (r = -0.49; P < 0.001), and positively with Schirmer's test (r = 0.45; P = 0.001) and TBUT scores (r = 0.30; P = 0.029). CONCLUSION: Dry eye and impaired tear function in patients with vitamin D deficiency may indicate a protective role of vitamin D in the development of dry eye, probably by enhancing tear film parameters and reducing ocular surface inflammation. Patients with vitamin D deficiency should be evaluated for dry eye syndromes.

Coexistence of Familial Mediterranean Fever With Ankylosing Spondylitis and Sjogren's Syndrome: A Rare Occurrence.

Familial Mediterranean fever is an autosomal recessive disease characterized by recurrent episodes of fever, peritonitis, synovitis, pleuritis, and erysipelas-like skin lesions. Sjogren's syndrome is a chronic autoimmune disorder characterized by dry eyes, dry mouth, and musculoskeletal involvement. Ankylosing spondylitis is an autoinflammatory rheumatic disease which affects mainly the axial skeleton. To our knowledge, coexistence of familial Mediterranean fever with ankylosing spondylitis and Sjogren's syndrome has not been reported previously in the literature. In this article, we report an unusual case of three autoinflammatory diseases in one patient.

Comparison of the effect of sevoflurane and propofol on oxygenation during gradual transition to one-lung ventilation.

BACKGROUND: It is known that hypoxic pulmonary vasoconstriction increases as a result of intermittent regional hypoxic challenges. The aim of this study was to compare the effects of sevoflurane and propofol on oxygenation and shunt fraction during one-lung ventilation in a novel model of hypoxic preconditioning before one-lung ventilation. METHODS: Sixteen Wistar-albino rats were anesthetized intra-peritoneally before venous and arterial cannulations and tracheotomized. The animals were randomly allocated to receive either sevoflurane 2% or 10mg/kg/h propofol infusion and ventilated with 100% oxygen at an inspiratory rate of 80 breaths/min for 30min. Three cycles of one-lung ventilation and two-lung ventilation were performed and one-lung ventilation was continued for 15min. Arterial blood gas samples were obtained as follows: after cannulation and tracheotomy, following 30min of treatment with sevoflurane or propofol, and at the 5th and 15th min of one-lung ventilation. RESULTS: The PaO2 levels were higher and shunt fractions were lower in rats receiving propofol compared to rats treated with sevoflurane but the difference was not significant; the two groups were comparable in terms of PaCO2. CONCLUSIONS: The similar effects of sevoflurane and propofol on PaO2 during one-lung ventilation following hypoxic preconditioning may be due to other causes beside the inhibition of hypoxic pulmonary vasoconstriction. Gradual transition to one-lung ventilation is a novel technique for preconditioning experiments for one-lung ventilation.

Use of airway exchange catheter for bronchoscopy of a patient with Down's syndrome.

Tracheobronchial injuries (TBI) are highly fatal, and early diagnosis and repair are crucial for survival. The anesthesiologist and the surgeon must secure the integrity and patency of the airway for these cases. These injuries remain infrequent, and are becoming less fatal due to the availability of the resources necessary to achieve a secure airway, and thus some of them can be managed conservatively. We report an unusual case of upper airway compromise and extensive subcutaneous emphysema due to traumatic bronchial rupture and its conservative repair in a patient with Down's syndrome.

A new technique for long time catheterization of sacral epidural canal in rabbits.

INTRODUCTION: In this study we aimed to develop a simple and practical technique for chronic sacral epidural catheterization of rabbits. METHODS: We included ten rabbits weighing 2-2.5 kg in the study. After anesthesia and analgesia, we placed an epidural catheter by a 2 cm longitudinal skin incision in the tail above the sacral hiatus region. We confirmed localization by giving 1% lidocaine (leveling sensory loss and motor function loss of the lower extremity). The catheter was carried forward through a subcutaneous tunnel and fixed at the neck. RESULTS: Chronic caudal epidural catheter placement was succesful in all rabbits. The catheters stayed in place effectively for ten days. We encountered no catheter complications during this period. The localization of the catheter was reconfirmed by 1% lidocaine on the last day. After animals killing, we performed a laminectomy and verified localization of the catheter in the epidural space. CONCLUSIONS: Various methods for catheterization of the epidural space in animal models exist in the literature. Epidural catheterization of rabbits can be accomplished by atlanto-occipital, lumbar or caudal routes by amputation of the tail. Intrathecal and epidural catheterization techniques defined in the literature necessitate surgical skill and knowledge of surgical procedures like laminectomy and tail amputation. Our technique does not require substantial surgical skill, anatomical integrity is preserved and malposition of the catheter is not encountered. In conclusion, we suggest that our simple and easily applicable new epidural catheterization technique can be used as a model in experimental animal studies.

Ischaemic preconditioning attenuates haemodynamic response and lipid peroxidation in lower-extremity surgery with unilateral pneumatic tourniquet application: a clinical pilot study.

INTRODUCTION: The harmful effects of ischaemia-reperfusion on skeletal muscle during extremity surgery can be diminished by using medications or ischaemic preconditioning METHODS: Twenty patients undergoing lower-limb surgery with use of a tourniquet for at least 1 hour were included in the study and randomised into two groups: a control group with only tourniquet application (T group; n=10); and an ischaemic preconditioning plus tourniquet group (IP-T group; n=10). Blood samples were obtained from the femoral vein of the relevant extremity before tourniquet application (baseline), immediately after tourniquet deflation (TD), at 10 minutes after the tourniquet deflation (TD(10min)) in the T group and additionally after ischaemic preconditioning in the IP-T group. Venous blood pH, partial oxygen pressure (P(vO2)), partial carbon dioxide pressure (P(vCO2)), lactate, potassium, sodium and glucose levels were analysed using a blood gas analyser. Plasma thiobarbituric acid reactive substances (TBARS) level, an index of lipid peroxidation and oxidative stress, was measured. Heart rate, noninvasive mean arterial pressure (MAP) and spontaneous breathing rate (SBR) were recorded at baseline, at TD, and TD(1min), TD(5min) and TD(10min). RESULTS: MAP decreased and SBR increased significantly at TD, TD(1min) and TD(5min) compared with baseline, and venous blood TBARS level significantly increased at TD and TD(10min) compared with baseline in the T group (all P<0.05). No significant changes were observed in the IP-T group. Ischaemic preconditioning caused a rise in PvO2 and a decrease in venous blood pH, P(vCO2), and lactate levels, which was significant compared with baseline (P<0.05) CONCLUSION: Ischaemic preconditioning attenuates haemodynamic response and lipid peroxidation during lower-extremity surgery with unilateral tourniquet application.

The safe limits of mechanical factors in the apnea testing for the diagnosis of brain death.

Apneic oxygenation is an apnea testing method in the diagnosis of brain death. In this method, oxygen (O2) is delivered into the trachea via an O2 catheter (O2C). However, barotrauma may develop during O2 insufflation into the trachea. Oxygen catheter diameters, O2 catheter tip position in the trachea, and O2 flow rate have been proposed as causes of barotrauma. This study was designed to highlight the airway pressure changes during apneic oxygenation in a model consisting of an anesthesia bag, which was connected to a pressure transducer and to an endotracheal tube (ETT). The pressure of the system was monitored while delivering O2 continuously to the system through O2C of different diameters, which were placed in the ETT. Tested variables were ETT/O2C ratio, O2C tip position in ETT (proximal 1/3 of the ETT, mid point of the ETT, and distal 1/3 of the ETT) and O2 flow rate (6, 8, and 10 L min(-1)). The increase in the airway pressure significantly correlated with O2C tip position in ETT (p = 0.017). ETT/O2C ratio smaller than 1.75 caused significantly high airway pressures (p < 0.05). The pressure was significantly higher at the flow rate of 10 L min(-1) O2 compared with the flow rate of 6 L min(-1) O2 (p < 0.01). Thus, ETT/O2C ratio, O2C tip position in ETT and O2 flow rate are the important factors that determine the airway pressure in the trachea during O2 insufflation. In conclusion, overlooked mechanical factors dangerously increase airway pressure during apnea testing.

A new method for estimating arterial occlusion pressure in optimizing pneumatic tourniquet inflation pressure.

To reduce pressure-related injuries resulting from pneumatic tourniquet use, the lowest possible inflation pressure is recommended. Arterial occlusion pressure (AOP) is a measure of the cuff pressure required to maintain a bloodless surgical field. However, its determination method is time consuming, requires operator skill, and is therefore seldom used in current practice. An AOP estimation can be made by knowing the pressure transmitted to the underlying soft tissues. We measured upper and lower extremity tissue pressures under the tourniquet cuff at 100, 200, and 300 mm Hg of tourniquet inflation pressures in 30 anesthetized living adult patients. All patients received general anesthesia with neuromuscular relaxation. A Stryker intra-compartmental pressure monitor was used to measure tissue pressures under the tourniquet cuff. In all patients, the soft tissue pressures were consistently lower than the applied tourniquet inflation pressures. Our results revealed tissue padding coefficients for extremities 20 to 75 cm in circumferences. An estimation method of AOP was developed [AOP = (systolic blood pressure + 10)/Tissue padding coefficient]. The new AOP estimation method may be a simple, rapid, and clinically practical alternative to the AOP determination method.

Dilution of rocuronium to 0.5 mg/mL with 0.9% NaCl eliminates the pain during intravenous injection in awake patients.

In a randomized, double-blinded, controlled study, we evaluated the effect of diluting rocuronium 10 mg/mL to 1 or 0.5 mg/mL with 0.9% NaCl on the pain associated with IV administration of rocuronium with small doses given before succinylcholine or nondepolarizing agent administration. One hundred fifty patients undergoing surgical procedures that required general anesthesia were randomized into three groups. Group 1 received rocuronium 10 mg/mL. Groups 2 and 3 received 1 and 0.5 mg/mL of rocuronium, respectively. Patient demographics, pain scores, osmolality, and the pH of the solutions were recorded. Group 1 had the most intense and frequent pain response. Eighty percent of patients in this group reported pain on injection. In Group 2, the incidence and intensity of pain were significantly less when compared with those of Group 1. In this group, 38% of patients reported pain during injection. In Group 3, none of the patients experienced pain on injection. The pH values and osmolalities of study solutions were not significantly different among groups. In conclusion, in awake patients, dilution of rocuronium 10 mg/mL at small doses given before succinylcholine or nondepolarizing agent administration of 0.06 mg/kg to 0.5 mg/mL with 0.9% NaCl is a simple and cost-effective strategy for preventing pain during IV rocuronium injection.

Controlled hypotension and minimal inflation pressure: a new approach for pneumatic tourniquet application in upper limb surgery.

UNLABELLED: Minimal inflation pressures are recommended for limb surgery to eliminate complications attributable to high inflation pressures with the pneumatic tourniquets. We applied controlled hypotension and a minimal inflation pressure (CHAMIP) technique to provide a bloodless surgical field. Thirty-six patients scheduled for upper extremity surgery were randomized equally to receive either normotensive anesthesia and conventional inflation pressures or controlled hypotension (systolic arterial blood pressure of 80-100 mm Hg and mean arterial blood pressure >60 mm Hg) and minimum inflation pressures. Anesthesia was induced with propofol IV bolus and remifentanil IV continuous infusion and maintained with propofol and remifentanil IV continuous infusion. To determine the minimal inflation pressure, the digital plethysmograph was applied to the second finger at the side of the operation and the tourniquet was inflated slowly until the arterial pulsations disappeared on the oscilloscope. A bloodless surgical field was obtained in almost all patients, even though systolic arterial blood pressures (100-138 mm Hg versus 80-100 mm Hg) and applied tourniquet inflation pressures (270 mm Hg versus 110-140 mm Hg) were significantly lower in the hypotensive group. No complications associated with controlled hypotension were encountered. In conclusion, CHAMIP may be a safe and reliable method for upper extremity surgery performed with pneumatic tourniquets. IMPLICATIONS: Pneumatic tourniquets are associated with adverse effects resulting from high inflation pressures. Therefore, minimal inflation pressures are recommended in extremity surgery. To reach real minimal inflation pressure the patient's blood pressure must be reduced. We used controlled hypotension with remifentanil and propofol to reach minimal inflation pressures.