Comparison of Different Local Anesthetic Volumes for Saddle Block Anesthesia in Ambulatory Surgery: A Prospective Randomized Trial.

INTRODUCTION: Saddle block anesthesia (SBA) is a frequently preferred method for ambulatory anorectal surgery. This study aimed to observe the effects of two different dose SBAs on discharge times and perioperative block characteristics in patients undergoing ambulatory anorectal surgery. METHODS: The study was conducted as a prospective, randomized controlled study. Patients over the age of 18 who were scheduled for ambulatory anorectal surgery and had American Society of Anaesthesiologists (ASA) physical status I and II were included in the research. Patients were divided into two groups: 5 mg hyperbaric bupivacaine 0.5% (Group I; n=34) and 3 mg hyperbaric bupivacaine 0.5% (Group II; n=34). The primary outcome was discharge time. Characteristics of the spinal block like time to reach S4 blockade, maximum blocked dermatome, regression time of sensorial, first analgesic need time, voiding time, mobilization time, and side effects were the secondary outcomes. RESULTS: Sixty-eight patients were included in the study. The groups were similar in terms of demographic and surgical characteristics (p > 0.05). In Group II, S4 sensory dermatome blockade time was statistically longer (p: 0.007) and the time to the disappearance of the sensory block was statistically shorter (p < 0.001). Also, voiding time and discharge times were statistically shorter in Group II (p: 0.049, p < 0.001, respectively). CONCLUSION: SBA provided adequate anesthesia, and the complication rates were limited. Saddle block can be considered an advantageous technique because of conditions that adversely affect recoveries, such as postoperative cognitive problems, nausea, and vomiting due to general anesthesia. In addition, better recovery results and optimal surgical condition with 3 mg hyperbaric bupivacaine in our study suggest that this dose may be a good alternative.

Does Practitioner Experience Affect Intraocular Pressure After Endotracheal Intubation?

AIM:  Intraocular pressure (IOP) may decrease or increase during general anesthesia, depending on various factors. This study aimed to investigate the effects of the level of provider training period on post-intubation IOP values and hemodynamic response. METHODS: This study was a cross-sectional observational study. Before inclusion in the study, informed consent was obtained from all participants. The study was approved by the local ethical committee. The study included 120 adult patients, both sexes, aged between 18 and 65, with physical statuses according to the American Society of Anesthesiologists (ASA) I or II, Mallampati score I. The research included 120 anesthesiologist resident doctors who received their training in our clinic. In this study, anesthesiology resident doctors were divided into three separate seniority groups (group 1, less than one-year residents in anesthesiology who had performed fewer than 10 intubations; group 2, one- to three-year residents; and group 3, more than three-year residents). After receiving a standard intravenous induction, direct laryngoscopy and endotracheal intubation techniques were performed. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and IOP were measured and recorded before pre-induction (T1), the first minute after induction (T2), and the first minute after laryngoscopy and intubation (T3). RESULTS:  There was no statistically significant difference (p > 0.05) between groups in the values of IOP, SBP, DBP, and HR measured at T1, T2, and T3. Measurements at T1, T2, and T3 were similar in all three groups. Comparisons within the groups revealed that IOP values at all measurement times (T1, T2, and T3) were different from each other in less than three-year resident groups. This difference was statistically significant (p < 0.001). The measurement values at T2 were the lowest and T3 were the highest in less than three-year resident groups. There was a significant increase in IOP after endotracheal intubation (T3) compared to baseline levels (T1) in less than three-year resident groups. IOP values at T2 were also significantly lower than the values at T1 and T3 (p < 0.001) in the more than three-year resident group (group 3). However, when we compared IOP measurements at T1 and T3 among themselves in the more than three-year resident group, no significant difference was found (p > 0.05). CONCLUSION:  This study showed that endotracheal intubation in general anesthesia practice is performed most effectively by resident doctors with more than three years of anesthesiology training, without changing the IOP value.

Effects of different intraabdominal pressures on internal jugular vein, liver and kidney functions in obese patients undergoing laparoscopic sleeve gastrectomy.

OBJECTIVE: The aim of this study was to investigate whether there was a difference in laparoscopic sleeve gastrectomy (LSG) performed with either 10 mmHg or 13 mmHg intraabdominal pressures. Effects of these pressures on the internal jugular vein (IJV) diameter and flow along with the liver and kidney function tests were evaluated. MATERIALS AND METHODS: The patients were divided into two groups with respect to the intraabdominal pressure performed during LSG (either 10 or 13 mmHg). The patients' age, comorbidities, surgical history, height, weight, body mass index, family history, duration of surgery, length of hospital stay, serum liver and kidney function tests (Urea, creatinine, Aspartate transaminase, Alanine transaminase, Gamma-glutamyltransferase, Alkaline phosphatase, bilirubin) and the right IJV diameter and flow measured by Duplex ultrasound before intubation (t1), 10 min after insufflation (t2), and at the end of insufflation (t3) were recorded. RESULTS: Preoperative and postoperative kidney and liver function values of the patients in both groups were within the reference range. In both groups, there was a significant decrease in the IJV diameter and flow measurement values at t2 compared to t1, and a significant increase was observed at t3 compared to t2 (p < 0.05). The mean IJV diameter and flow were significantly higher in the 10 mmHg pressure group compared to the 13 mmHg group (p < 0.05). CONCLUSION: Neither of the peak pressures performed intraabdominal during LSG caused an adverse effect on liver or kidney functions. Our study emphasizes that low insufflation pressure does not have an advantage in terms of liver and kidney functions. But laparoscopic sleeve gastrectomy with low intra-abdominal pressure may be beneficial especially in patients who require central vein catheterization during the operation. We consider that LSG performed with CO2 pneumoperitoneum at 10 mmHg is a safe, effective and feasible method that can facilitate the insertion of the intraoperative central venous catheter due to lesser charges in the IJV diameter and flow compared to the standard technique.

Effects of hydrodissection on anesthesia characteristics in ultrasound guided infraclavicular brachial plexus blockade.

BACKGROUND: The development of ultrasonography technology and its widespread application have increased peripheral nerve block applications, especially in limb surgeries, since it reduces complication rates and increases success rates in peripheral nerve block applications. However, even experienced physicians need to direct a large number of needles and injections for adequate local anesthetic spread, which can cause accidental vascular puncture and local anesthetic systemic toxicity. Such complications can be prevented by hydrodissection and a safer and successful anesthesia can be provided to patients in this study, it was aimed to investigate the effects of hydrodissection on anesthesia characteristics in the infraclavicular brachial plexus blockade. MATERIALS AND METHODS: Ninety patients were included in our study after approval by the Ethics Committee. These patients were randomly divided into 2 groups (Group I: Infraclavicular brachial plexus blockade with normal method and Group II: infraclavicular brachial plexus blockade with hydrodissection). After obtaining patient consent, monitoring and vascular access were provided. Group I patients were mixed with 30 mL of local anesthetic mixture (15 mL of distilled water and 15 mL of 0.5% bupivacaine), and Group II patients were treated with 15 mL of distilled water by hydrodissection and 15 mL of 0.5% bupivacaine anesthesia resident. Block characteristics were evaluated and recorded every 5 minutes for the first 30 minutes by a blinded observer. The sensory block score was 7, the total score was 14 or above, and the block was considered successful, and the patient was ready for surgery. Postoperative block removal times, analgesia, and complications were evaluated and recorded. RESULTS: A significant difference was found between the sensory and motor block onset times and postoperative VAS scores between the normal and hydrodissection groups (P < .05). There were no significant differences in terms of block application times, postoperative block removal times, and complications between the groups. CONCLUSION: In this study, it has been shown that hydrodissection in peripheral nerve blocks does not lag in terms of block success and characteristics compared to normal methods, whereas anesthetists with less experience in peripheral nerve block experience obtain safer and more successful results in practice.

Should the Erector Spinae Plane Block Be Applied in the Pain Management of Percutaneous Nephrolithotomy?

Introduction This prospective, randomized controlled study aimed to investigate the efficacy and respiratory effects of postoperative pain management with an erector spinae plane block in patients undergoing percutaneous nephrolithotomy. Methods Sixty American Society of Anesthesiologists (ASA) I-II patients aged 18-65 years, scheduled to undergo percutaneous nephrolithotomy, were randomized either to the erector spinae plane block (ESPB) or control group. Fifteen mL 0.5% bupivacaine at the T11 level was administered preoperatively using the in-plane technique in the ESPB group. In both groups, 1 gr of intravenous paracetamol was administered intraoperatively. Postoperative pain and agitation were evaluated using the visual analog scale (VAS), dynamic VAS at zero, six, and 24 hours, and the Riker sedation-agitation scale at the 0th hour after surgery. Peak expiratory flow rate (PEFR) and oxygen saturation (SpO2) were measured in preoperative examination and at the 0th, 6th, and 24th hours postoperatively. The time and number of the analgesic requirement, mobilization, and discharge time were also recorded. Results A significantly lower VAS and dynamic VAS were observed at the 0th, 6th, and 24th hours in the ESPB group (p<0.05 for each timepoint). The postoperative/preoperative PEFR ratio was lower and there were more agitated patients in the control group (p<0.05). Conclusion An erector spinae plane block may have additional clinical advantages while providing effective analgesia in patients who underwent percutaneous nephrolithotomy compared to intravenous analgesia.

Determination of the minimum effective volume of bupivacaine for ultrasound-guided infraclavicular brachial plexus block: a prospective, observer-blind, controlled study.

BACKGROUND: We aimed to determine the minimum effective volume (MEV) of 0.5% bupivacaine for infraclavicular brachial plexus block. METHODS: We assigned patients to volume groups consisting of five consecutive patients. Local anesthetic was sequentially reduced from a starting dose of 30 mL by 2 mL to form the volume groups. Five patients were included in each volume group, and at least 3 of 5 injections had to be successful to consider the volume of the anesthetic as sufficient. The study ended when the anesthetic volume of a group was determined to be unsuccessful (two or fewer successful blocks). Block was successful if the patient reported a sensorial block score of 7 or more on an 8-point scale and sensorial and motor block's total score of 14 on a 16-point scale. RESULTS: The MEV of 0.5% bupivacaine for infraclavicular brachial plexus block was 14 mL. A successful block was achieved in all patients (n = 45) in 9 volume groups, which received 30 mL down to 14 mL. Three blocks were unsuccessful in the 12-mL group. Time to onset of block and time to first postoperative anesthetic administration was 15 (10-15) min and more than 24 h in the 30-mL bupivacaine group, but 40 (30-45) min and 14 (10-24) h were determined for the 14-mL group, respectively. CONCLUSIONS: The MEV of 0.5% bupivacaine for ultrasound-guided infraclavicular brachial plexus block was 14 mL. However, this low-dose block has a long onset time of 40 (30-45) min on average.

Is Jedi Grip efficient and effective in ultrasound-guided peripheral nerve blocking? A prospective, randomized, observer-blinded study.

BACKGROUND: In this prospective, randomized, controlled observer-blinded study, we aimed to compare the efficacy of a single-operator technique called the Jedi Grip and a conventional technique requiring a double operator in ultrasound-guided axillary brachial plexus blocking. METHODS: Ninety-two patients (ASA I-II; aged 18-65 years old) who underwent elective hand, wrist and forearm surgery were randomly assigned to Group Conventional (C) or Group Jedi (J). In both groups, axillary plexus blockade was performed by applying 5 cc of a mixture of 10 cc of 0.5% bupivacaine and 10 cc of 2% prilocaine to the ulnar, radial, median, and musculocutaneous nerves. Parameters such as the performance time and number of needle passes were recorded during the procedure. Subsequently, a blinded observer evaluated and recorded parameters related to the blockade success. The main outcome variables were the performance time and success rate (surgical anesthesia). RESULTS: The block performance time of the Jedi technique was slightly longer than that of the conventional technique (220 (50), 202 (78) s, respectively) (median (IQR); p = 0.05). No significant difference was found between groups in terms of blocking success; 9 (20%) from the conventional group and 3 (6.4%) from the Jedi group were unsuccessful (p = 0.053). No differences were found in terms of arterial puncture, and no other complications occurred in either group. The motor-sensory block onset and termination times and initial analgesia requirements were similar. CONCLUSION: The Jedi technique may be applied safely with similar block success and performance results as the conventional technique.

Comparison of Postoperative Cognitive Decline Using the Mini-Mental State Examination and Montreal Cognitive Assessment After Minor Elective Surgery in Elderly.

Introduction and aim Postoperative cognitive dysfunction (POCD) is an important complication associated with increased morbidity, mortality, and reduced quality of life. Generally, studies have focused on major surgery so there is little evidence of the incidence of cognitive dysfunction in minor surgery. We aimed to compare the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) in terms of detecting cognitive decline in elderly patients after elective inguinal herniorrhaphy procedure with general or spinal anesthesia. Material and methods This observational study was conducted from June 2014 to March 2015 at Ankara Numune Education and Research Hospital. The type of anesthesia was determined according to the anesthesiologist's preference who is blind to the study. Patients were grouped according to anesthesia received: general or spinal anesthesia. The MMSE and MoCA were evaluated presurgery and 24 hours after the operation. Results The postoperative (24th hour) MMSE scores of patients (26.23±2.77) were significantly lower than the preoperative scores (27.17±1.93) in only the general anesthesia group (p =0.003). The postoperative (24th hour) MoCA scores (22.87±3.88 for general and 23.13±4.08 for spinal anesthesia) were significantly lower than the preoperative scores (24.32±3.19 for general and 24.35±2.84 for spinal anesthesia) in both the general and spinal anesthesia groups (p =0.000 and 0.019, respectively). The incidence of postoperative cognitive dysfunction was 32.9% using the MoCA and 15.2% using the MMSE (p=0,018). Conclusion Early POCD is an important problem after elective minor surgeries, even with spinal anesthesia, in elderly patients. The MoCA is an alternative tool that can be more sensitive than the MMSE to identify cognitive decline in elderly patients undergoing minor surgeries under both general and spinal anesthesia.

What Is the Minimum Effective Volume of Local Anaesthetic Applied in Brachial Plexus Blockage With an Axillary Approach Under Ultrasonography Guidance?

Peripheral nerve blocks with the use of ultrasonography (USG) allow visualisation of both the structures and nerves and make the block administrations safe, quick, and comfortable. However, few publications concerning the minimum local anesthetic (LA) volume are capable of providing blocks. This study aimed to find the minimum effective LA volume in brachial plexus blockage administrations with an axillary approach accompanied by ultrasonography in hand, elbow, and forehand operations. Materials and Method The study included a total of 55 patients (classified as American Society of Anesthesiologists (ASA) I-II) who underwent hand surgery by administering USG-guided axillary brachial plexus blockage. The ulnar, median, and radial nerves were located, and the minimum effective LA volume was investigated starting with a total of 21 ml of bupivacaine 0.5%. After accomplishing the blockage, the volume was decreased by 0.5 ml for each nerve. Block administration time, block onset times, anesthesia times, and time to first analgesic requirement were recorded. Results The minimum effective LA volume for each nerve was 2.5 ml for a total of 7.5 ml. In comparing block administration times, there were no differences between high or low volume groups. It was found that sensory block onset time was 17 minutes for 7.5 ml and 11 minutes for 21 ml; sensory block regression time was six hours for 7.5 ml and 10.4 hours for 21 ml, respectively. This regression was statistically significant. The first analgesic requirement was 5.8 - 16.6 hours, respectively, for each group. Conclusion In the administration of an USG-guided axillary block, sufficient anesthesia can be achieved by administering 2.5 ml of bupivacaine 0.5% for each nerve. However, it might be kept in mind that motor and sensory block onset time will be extended and regression time and time to the first analgesic requirement will be shorter with this volume. In addition, more advanced studies must be done for the determination of the optimum volume which can be used.

Comparison of intraoral mask and classic face mask in terms of ventilation success and practitioners' workload assessments: A randomised crossover study.

AIM: Providing effective ventilation of the unconscious patient is an essential skill in every specialty dealing with airway management. In this randomised crossover study aimed to compare intraoral and classic face mask in terms of ventilation success of patients, practitioners' workload and anxiety assessments. Also we analysed potential risk factors of difficult mask ventilation for both masks. METHODS: In all, 24 anaesthesiology residents and 12 anaesthesiologists participated in the study. Each of the practitioners ventilated four patients with both masks at settled pressure and frequency. Practitioners rated their workload and anxiety related to masks with National Aeronautics and Space Administration Task Load Index score and State Trait Anxiety Inventory scale. Ventilation success was evaluated with Han scale, expiratory tidal volume and leak volume. We analysed potential risk factors of difficult mask ventilation with anthropometric characteristics and STOP-Bang score. RESULTS: Ventilation success rate was superior with intraoral mask comparing to classic face mask in terms of successful ventilation (P = .000) and tidal volume (P = .000). Leak volume in in intraoral mask ventilation was significantly lower than classic face mask (P = .000). Difficult mask ventilation risk factors for classic face mask were high weight (P = .011), neck circumference (95% CI, OR = 1.180, P = .002), Mallampati score (P = .029) and high risk of OSAS (P = .001). Difficult mask ventilation risk factors for intraoral mask were high body mass index (95% CI, OR 1.162 P = .006) and Mallampati score (P = .043). The anxiety ratings of practitioners were similar between two masks. The workload rating is higher with intraoral mask comparing to classic face mask. CONCLUSION: Intraoral mask may be an effective alternative device for bag-valve mask ventilation.

Comparison of local infiltration analgesia and interscalene block for postoperative pain management in shoulder arthroscopy: a prospective randomized controlled trial

Background/aim: The aim of this study was to compare the effects of local infiltration analgesia and interscalene brachial plexus block techniques on postoperative pain control and shoulder functional scores in patients undergoing arthroscopic rotator cuff repair. Materials and methods: Sixty patients who underwent arthroscopic rotator cuff repair were prospectively included in the study. Patients were randomly divided into two groups. Group 1 was comprised of patients who had interscalene brachial plexus block, while group 2 was comprised of patients who had local infiltration analgesia. In group 1, interscalene block was applied with 20 mL 0.5% bupivacaine. In group 2, the Ranawat cocktail was used for local infiltration analgesia. Sixty milliliters of Ranawat cocktail was applied to the subacromial space and glenohumeral joint in equal amounts. Postoperative pain was assessed by the VAS score. Functional scores of the shoulder were also evaluated by Constant­Murley and UCLA scores. The time of first analgesic requirement and total analgesic consumption in the postoperative period were assessed. Results: The first analgesic requirement was significantly late in the interscalene brachial plexus block group (p = 0.000). There was no statistically significant difference between the groups in terms of total analgesic consumption (p = 0.204). In the postoperative 6th h, the VAS score was 2.43 in the interscalene brachial plexus block group, whereas 2.86 in the local infiltration analgesia group (p = 0.323). There was no statistically significant difference between the groups in terms of Constant­Murley shoulder and UCLA scores in the 3rd postoperative month (respectively, p = 0.929, p = 0.671). Besides, postoperative VAS scores and functional scores were negatively correlated (p < 0.01). Conclusion: Local infiltration analgesia is an effective alternative to interscalene brachial plexus block for postoperative pain management and total analgesic consumption in arthroscopic rotator cuff repair. However, the interscalene brachial plexus block provides a longer postoperative painless period.

Comparison of the Efficacy of Local Anesthesia Methods and Caudal Regional Anesthesia in Prostate Biopsy Applied Under Transrectal Ultrasonography: A Randomized Controlled Study.

PURPOSE: To evaluate the efficacy of caudal regional anesthesia and local anesthesia methods in prostate biopsy applied under transrectal ultrasonography. Matherials and Methods: This prospective study included a total of 160 patients randomly separated into 4 equal groups as intrarectal local anesthesia (IRLA), periprostatic local anesthesia (PPLA), combined local anesthesia (IRLA+PPLA), and caudal regional anesthesia (CRA). The patients were evaluated using the pain scores on a visual analog scale. RESULTS: The pain score during anesthesia induction was significantly higher in the CRA group than in the IRLA and IRLA+PPLA groups (p<0.001). The pain score during entry of the probe to the rectum and movement was significantly lower in the CRA group than the IRLA groups (p=0.014). The pain score on penetration of the needle to the prostate and at 30 mins after the biopsy was significantly higher in the IRLA group (p<0.001). At 2 hours after the biopsy, the pain score in the CRA group was significantly lower than IRLA groups (p=0.015). CONCLUSION: The PPLA alone can be applied more quickly than CRA, causes less pain during the application, and has similar efficacy in reducing pain during and after the prostate biopsy procedure.

Comparison of ultrasound and ultrasound plus nerve stimulator guidance axillary plexus block.

OBJECTIVE: To evaluate the characteristics of axillary plexus blockade applied using ultrasound only and using ultrasound together with nerve stimulator in patients undergoing planned forearm, wrist or hand surgery. METHODS: This randomised, prospective, double-blinded, single-centre study was conducted at Ankara Numune Training and Research Hospital, Ankara, Turkey, from November 2014 to August 2015, and comprised patients undergoing forearm, wrist or hand surgery. Participants were separated into 2 groups. In Group 1, the nerve roots required for the surgical site were located one by one and local anaesthetic was applied separately to each nerve for the block. In Group 2, the vascular nerve bundle was located under ultrasound guidance and a total block was achieved by administering all the local anaesthetic within the nerve sheath. In the operating room, standard monitorisation was applied. Following preparation of the skin, the axillary region nerve roots and branches and vascular structures were observed by examination with a high-frequency ultrasound probe. In both groups, a 22-gauge, 5cm block needle was entered to the axillary region with visualisation of the whole needle on ultrasound and 20ml local anaesthetic of 0.5% bupivacaine was injected. SPSS 19 was used for data analysis. RESULTS: Of the 60 participants, there were 30(50%) in each group. The mean age was 39.1±15 years in the group 1 which was the ultrasound nerve stimulation group, and 41.5±14.3 years in group 2. The duration of the procedure was longer in group I than in group 2 (p<0.05). Patient satisfaction values during the procedure were higher in group 2(p<0.05). In the ulnar sensory examination, the values of the patients in group 1were higher at 10, 15, 20 and 25 minutes (p<0.05). In the median, radial and ulnar motor examination, the values of the patients in group 1were higher at 15 and 20 minutes (p<0.05). CONCLUSIONS: Brachial plexus blockade via axillary approach guided by ultrasound offered excellent quality of sensory and motor block equivalent to that of the nerve stimulator-guided technique.

Comparison of continuous interscalene block and subacromial infusion of local anesthetic for postoperative analgesia after open shoulder surgery.

PURPOSE: This study compared the efficacy of continuous interscalene block (CISB) and subacromial infusion of local anesthetic (CSIA) for postoperative analgesia after open shoulder surgery. METHODS: This randomized, prospective, double-blinded, single-center study included 40 adult patients undergoing open shoulder surgery. All patients received a standardized general anesthetic. The patients were separated into group CISB and group CSIA. A loading dose of 40 mL 0.25% bupivacaine was administered and patient-controlled analgesia was applied by catheter with 0.1% bupivacaine 5 mL/h throughout 24 h basal infusion, 2 mL bolus dose, and 20 min knocked time in both groups postoperatively. Visual analog scale (VAS) scores, additional analgesia need, local anesthetic consumption, complications, and side effects were recorded during the first 24 h postoperatively. The range of motion (ROM) score was recorded preoperatively and in the first and third weeks postoperatively. RESULTS: A statistically significant difference was determined between the groups in respect of consumption of local anesthetic, VAS scores, additional analgesia consumption, complications, and side effects, with lower values recorded in the CISB group. There were no significant differences in ROM scoring in the preoperative and postoperative third week between the two groups but there were significant differences in ROM scoring in the postoperative first week, with higher ROM scoring values in the group CISB patients. CONCLUSION: The results of this study have shown that continuous interscalene infusion of bupivacaine is an effective and safe method of postoperative analgesia after open shoulder surgery.

Postoperative Mortality after Hip Fracture Surgery: A 3 Years Follow Up.

BACKGROUND AND AIMS: To determine mortality rates and predisposing factors in patients operated for a hip fracture in a 3-year follow-up period. METHODS: The study included patients who underwent primary surgery for a hip fracture.The inclusion criteria were traumatic, non-traumatic, osteoporotic and pathological hip fractures requiring surgery in all age groups and both genders. Patients with periprosthetic fractures or previous contralateral hip fracture surgery and patients who could not be contacted by telephone were excluded. At 36 months after surgery, evaluation was made using a structured telephone interview and a detailed examination of the hospital medical records, especially the documents written during anesthesia by the anesthesiologists and the documents written at the time of follow-up visits by the orthopaedic surgeons. A total of 124 cases were analyzed and 4 patients were excluded due to exclusion criteria. The collected data included demographics, type of fracture, co-morbidities, American Society of Anesthesiologists (ASA) scores, anesthesia techniques, operation type (intramedullary nailing or arthroplasty; cemented-noncemented), peroperative complications, refracture during the follow-up period, survival period and mortality causes. RESULTS: The total 120 patients evaluated comprised 74 females(61.7%) and 46 males(38.3%) with a mean age of 76.9±12.8 years (range 23-95 years). The ASA scores were ASA I (0.8%), ASA II (21.7%), ASA III (53.3%) and ASA IV (24.2%). Mortality was seen in 44 patients (36.7%) and 76 patients (63.3%) survived during the 36-month follow-up period. Of the surviving patients, 59.1% were female and 40.9% were male.The survival period ranged between 1-1190 days. The cumulative mortality rate in the first, second and third years were 29.17%, 33.33% and 36.67% respectively. The factors associated with mortality were determined as increasing age, high ASA score, coronary artery disease, congestive heart failure, Alzheimer's disease, Parkinson's disease, malignancycementation and peroperative complications such as hypotension (p<0.05). Mortality was highest in the first month after fracture. CONCLUSION: The results of this study showed higher mortality rates in patients with high ASA scores due to associated co-morbidities such as congestive heart failure, malignancy and Alzheimer's disease or Parkinson's disease. The use of cemented prosthesis was also seen to significantly increase mortality whereas no effect was seen from the anesthesia technique used. Treatment of these patients with a multidiciplinary approach in an orthogeriatric ward is essential. There is a need for further studies concerning cemented vs. uncemented implant use and identification of the best anesthesia technique to decrease mortality rates in these patients.

Post-thoracotomy pain relief with subpleural analgesia or thoracic epidural analgesia: randomized clinical trial / Alívio da dor pós-toracotomia com analgesia subpleural ou analgesia epidural torácica: ensaio clínico randomizado

ABSTRACT CONTEXT AND OBJECTIVE: Post-thoracotomy pain is a severe and intense pain caused by trauma to ribs, muscles and peripheral nerves. The current study aimed to compare subpleural analgesia (SPA) with thoracic epidural analgesia (TEA) in patients undergoing thoracotomy. DESIGN AND SETTING: Randomized study at Ankara Numune Education and Research Hospital, in Turkey. METHODS: Thirty patients presenting American Society of Anesthesiologists physical status I-III were scheduled for elective diagnostic thoracotomy. The patients were randomized to receive either patient-controlled SPA or patient-controlled TEA for post-thoracotomy pain control over a 24-hour period. The two groups received a mixture of 3 µg/ml fentanyl along with 0.05% bupivacaine solution through a patient-controlled analgesia pump. Rescue analgesia was administered intravenously, consisting of 100 mg tramadol in both groups. A visual analogue scale was used to assess pain at rest and during coughing over the course of 24 hours postoperatively. RESULTS: In the SPA group, all the patients required rescue analgesia, and five patients (33%) required rescue analgesia in the TEA group (P < 0.05). Patients who received subpleural analgesia exhibited higher visual analogue scores at rest and on coughing than patients who received thoracic epidural analgesia. None of the patients had any side-effects postoperatively, such as hypotension or respiratory depression. CONCLUSION: Thoracic epidural analgesia is superior to subpleural analgesia for relieving post-thoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.

RESUMO CONTEXTO E OBJETIVO: Dor pós-toracotomia é severa e intensa, causada por trauma de nervos periféricos, músculos e costelas. O objetivo foi comparar analgesia subpleural (SPA) com analgesia epidural torácica (TEA) em pacientes submetidos à toracotomia. TIPO DE ESTUDO E LOCAL: Estudo randomizado no Hospital Educação e Pesquisa de Numune, em Ancara, Turquia. MÉTODOS: Trinta pacientes com o estado físico I-III da Sociedade Americana de Anestesiologistas foram agendados para toracotomia diagnóstica eletiva e escolhidos aleatoriamente para receber, num período de 24 horas, SPA ou TEA, ambas controladas pelo próprio paciente, para controle da dor pós-toracotomia. Os dois grupos receberam mistura de 3 ug/ml de fentanil com solução de 0,05% de bupivacaína por meio de bomba de analgesia controlada pelo paciente. Foi administrada analgesia de resgate por via intravenosa, com 100 mg de tramadol, nos dois grupos. No pós-operatório, a escala visual analógica foi utilizada para medir presença de dor durante a tosse ou em repouso, ao longo de 24 horas. RESULTADOS: No grupo SPA, todos os pacientes necessitaram de analgesia de resgate. Cinco pacientes (33%) necessitaram de analgesia de resgate no grupo TEA (P < 0,05). Os pacientes com SPA exibiram pontuações superiores na escala visual analógica, em repouso e ao tossir, em comparação aos que receberam TEA. Nenhum dos pacientes teve quaisquer efeitos secundários no pós-operatório, como hipotensão ou depressão respiratória. CONCLUSÃO: A analgesia peridural torácica é superior à analgesia subpleural no alívio da dor pós-toracotomia. Consideramos que estudos sobre a dosagem de drogas eficazes para proporcionar analgesia subpleural são necessários.

The Effect of Systemic and Regional Use of Magnesium Sulfate on Postoperative Tramadol Consumption in Lumbar Disc Surgery.

AIM: To investigate the effect of magnesium administered to the operative region muscle and administered systemically on postoperative analgesia consumption after lumbar disc surgery. MATERIAL AND METHOD: The study included a total of 75 ASA I-II patients aged 18-65 years. The patients were randomly allocated into 1 of 3 groups of 25: the Intravenous (IV) Group, the Intramuscular (IM) Group, and the Control (C) Group. At the stage of suturing the surgical incision site, the IV Group received 50 mg/kg MgSO4 intravenously in 150 mL saline within 30 mins. In the IM Group, 50 mg/kg MgSO4 in 30 mL saline was injected intramuscularly into the paraspinal muscles. In Group C, 30 mL saline was injected intramuscularly into the paraspinal muscles. After operation patients in all 3 groups were given 100 mg tramadol and 10 mg metoclopramide and tramadol solution was started intravenously through a patient-controlled analgesia device. Hemodynamic changes, demographic data, duration of anesthesia and surgery, pain scores (NRS), the Ramsay sedation score (RSS), the amount of analgesia consumed, nausea- vomiting, and potential side effects were recorded. RESULTS: No difference was observed between the groups. Nausea and vomiting side effects occurred at a rate of 36% in Group C, which was a significantly higher rate compared to the other groups (p < 0.05). Tramadol consumption in the IM Group was found to be significantly lower than in the other groups (p < 0.05). CONCLUSION: Magnesium applied to the operative region was found to be more effective on postoperative analgesia than systemically administered magnesium.

Post-thoracotomy pain relief with subpleural analgesia or thoracic epidural analgesia: randomized clinical trial.

CONTEXT AND OBJECTIVE: Post-thoracotomy pain is a severe and intense pain caused by trauma to ribs, muscles and peripheral nerves. The current study aimed to compare subpleural analgesia (SPA) with thoracic epidural analgesia (TEA) in patients undergoing thoracotomy. DESIGN AND SETTING: Randomized study at Ankara Numune Education and Research Hospital, in Turkey. METHODS: Thirty patients presenting American Society of Anesthesiologists physical status I-III were scheduled for elective diagnostic thoracotomy. The patients were randomized to receive either patient-controlled SPA or patient-controlled TEA for post-thoracotomy pain control over a 24-hour period. The two groups received a mixture of 3 µg/ml fentanyl along with 0.05% bupivacaine solution through a patient-controlled analgesia pump. Rescue analgesia was administered intravenously, consisting of 100 mg tramadol in both groups. A visual analogue scale was used to assess pain at rest and during coughing over the course of 24 hours postoperatively. RESULTS: In the SPA group, all the patients required rescue analgesia, and five patients (33%) required rescue analgesia in the TEA group (P < 0.05). Patients who received subpleural analgesia exhibited higher visual analogue scores at rest and on coughing than patients who received thoracic epidural analgesia. None of the patients had any side-effects postoperatively, such as hypotension or respiratory depression. CONCLUSION: Thoracic epidural analgesia is superior to subpleural analgesia for relieving post-thoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.