Effects of sevoflurane and propofol on S100ß and neuron-specific enolase protein levels during cardiopulmonary bypass.

AIM: Cardiopulmonary bypass (CPB) is associated with the release of S100ß and neuron-specific enolase (NSE) indicating cerebral cell injury. The purpose of the present study was to evaluate the effect of propofol and sevoflurane on S100ß and NSE levels in patients undergoing coronary artery bypass grafting (CABG). MATERIALS AND METHODS: Twenty male patients undergoing CABG were randomly allocated into two groups. One group received sevoflurane (GS) and the other received propofol (GP). Arterial blood samples for analysis of S100ß and NSE levels were taken preoperatively (T1), 30 min after initiation of CPB (T2), at the end of CPB (T3), 1 (T4), 6 (T5) and 24 h (T6) postoperatively. RESULTS: S100ß level was significantly higher compared to all analyzed times at T3 in both groups (P < 0.001). S100ß level was significantly higher in GP than GS only at T2 (P = 0.002). NSE level was significantly higher at T3, T4 and T5 than T1 in the GP (P = 0.001, 0.002 and 0.023, respectively), while a significant increase was seen at T3 and T4 in GS group (P = 0.001 and 0.047, respectively). CONCLUSION: Our findings showed that both S100ß and NSE levels similarly increased during CPB and immediately after CPB during sevoflurane and propofol based anesthesia.

The effect of intravenous preemptive paracetamol on postoperative fentanyl consumption in patients undergoing open nephrectomy: a prospective randomized study.

AIM: We investigated the efficacy of intravenous (IV) preemptive paracetamol on postoperative total fentanyl consumption and fentanyl-related side effects in patients undergoing open nephrectomy. MATERIALS AND METHODS: A total of 60 patients scheduled for elective open nephrectomy under general anesthesia were included. All patients received Patient-controlled IV analgesia with fentanyl postoperatively. Patients were randomly allocated into three equal groups: The fentanyl group received 100 mL of IV normal saline as a placebo, with the first dose ending 30 min before intubation. In paracetamol group, IV 1 g paracetamol was given to the patients 30 min after extubation with repeated doses every 6 h totally 4 times a day. In preemptive paracetamol group, patients received IV 1 g paracetamol every 6 h, with the first dose ending 30 min before intubation. RESULTS: Postoperative cumulative fentanyl consumption for 24 h was significantly higher in the fentanyl group (1009 ± 139.361 µg) than those of paracetamol (752.25 ± 112.665 µg) and preemptive paracetamol groups (761.10 ± 226.625 µg) (P = 0.001 for both). In early postoperative period (0-4 h); whereas total fentanyl consumption showed no statistically significant difference among groups (P = 0.186), the nausea-vomiting scores were significantly higher in the fentanyl group compared with other groups (P = 0.012). CONCLUSION: In patients undergoing open nephrectomy, use of preemptive or postoperative paracetamol reduces fentanyl related nausea-vomiting without a decrease in total fentanyl consumption in the early postoperative period. Furthermore, use of preemptive or postoperative paracetamol reduces total fentanyl requirements in the first 24 h postoperatively providing a safe and effective postoperative analgesia.

Maternal and neonatal effects of adding morphine to low-dose bupivacaine for epidural labor analgesia.

AIM: Labor is one of the most painful experiences a woman may face during her lifetime. One of the most effective methods used for eliminating this pain is epidural analgesia. The aim of this study to determine the impact of adding morphine to low-dose bupivacaine epidural anesthesia on labor and neonatal outcomes, and maternal side effects. MATERIALS AND METHODS: This is a prospective randomized double-blind study comparing two regimens of anesthetic agents used for epidural anesthesia in labor. A total of 120 pregnant women were randomized into two groups with 60 subjects in each study arm. A catheter was inserted, and 0.1% bupivacaine + 2 µg/mL fentanyl in 15 mL saline were given to Group bupivacaine-fentanyl (Group BF), while 0.0625% bupivacaine + 2 µg/ml fentanyl + 2 mg morphine in 15 mL saline were given to Group bupivacaine-fentanyl-morphine (Group BFM) with no test dosing from the needle. No morphine was added to the subsequent epidural injections in Group BFM. RESULTS: The total dose of bupivacaine was significantly lower in Group BFM relative to Group BF (P = 0.0001). The visual analogu scalescores at 15, 30, and 45 min were significantly lower in Group BF compared to thosein Group BFM (P = 0.0001, P = 0.001, and P = 0.006, respectively). The second stage of labor was significantly shorter in Group BFM relative to Group BF (P = 0.027 and P = 0.003, respectively). The satisfaction with analgesia following the first dose was higher in the nonmorphine group (P = 0.0001). However, maternal postpartum satisfaction was similar in both groups. Either nausea or vomiting was recorded in eight patients in Group BFM. CONCLUSION: We believe that epidural analgesia comprised of a low-dose local anaesthetic and 2 mg morphine provides a painless labor that significantly reducesthe use of local anesthetic without changing the efficiency of the analgesic, ensuring the mother's satisfaction without leading to an adverse effect on the mother or foetus, while mildly (but significantly) shortening the second stage of labor.

Caudal analgesia for prostate biopsy.

BACKGROUND: Although various local anesthesia techniques have been suggested to decrease pain and discomfort during a transrectal ultrasound (TRUS)-guided prostate biopsy, the best method has not yet been defined. The present prospective, double-blind, randomized study aims to investigate the clinical efficacy of 'walking' caudal block compared with an intrarectal lidocaine gel for this procedure. METHODS: One hundred patients were randomly assigned to two groups. In the lidocaine gel group, 10 ml of gel containing 2% lidocaine was given intrarectally. In the caudal group, 20 ml 0.1% bupivacaine with 75 microg fentanyl was injected. Pain scores, anal sphincter tone and patient satisfaction were evaluated. RESULTS: The pain scores were significantly lower in the caudal group at all stages. Verbal rating scores (scale 1-4) during probe insertion, probe maneuver and biopsies were 1 (0-2), 1 (0-2) and 1 (0-2) vs. 3 (0-5), 2 (1-3) and 4 (2-6), respectively (P value <0.0001 at all stages). The anal sphincter was more relaxed in the caudal group than in the gel group (P value <0.0001 in all categories). Highly satisfied patients were more frequently encountered in the caudal group, 34 (68%) vs. 8 (16%), P<0.0001, and unsatisfied patients were more frequently found in the gel group 1 (2%) vs. 12 (24%); P<0.001. All patients were able to walk without any assistance immediately after the procedures. CONCLUSION: 'Walking' caudal analgesia is an efficacious method for relieving the pain during TRUS-guided prostate biopsies in ambulatory practice.

Tropisetron plus subhypnotic propofol infusion is more effective than tropisetron alone for the prevention of vomiting in children after tonsillectomy.

This study evaluated the efficacy of tropisetron compared with tropisetron and a subhypnotic propofol infusion in preventing postoperative vomiting following tonsillectomy. One hundred and forty healthy children, aged four to 12 years, undergoing tonsillectomy were recruited in a randomised, double-blind study. After induction with sevoflurane, anaesthesia was maintained with sevoflurane and nitrous oxide. All patients received tropisetron (0.2 mg/kg up to 5 mg; intravenously) and fentanyl (2 microg/kg; intravenously) and were intubated after atracurium which was reversed with neostigmine (and atropine). The tropisetron-plus-propofol group received a single dose of propofol (1 mg/kg) before intubation and a continuous infusion of propofol throughout surgery at 15 microg/kg/min. Data for postoperative vomiting were grouped into zero to four and four to 24 hour time intervals. A P value of < 0.05 was considered statistically significant. The percentage of patients exhibiting a complete response (no retching or vomiting for 24 hours) was 47.1% (33/70) in the tropisetron-alone group and 72.8% (51/70) in the tropisetron-plus-propofol group (P = 0.002). The 0.257 absolute risk reduction of vomiting with the addition of propofol represents a number needed to treat of 3.87, and a risk ratio of 0.51 (95% CI 0.32 to 0.79). Significantly fewer patients vomited in the tropisetron-plus-propofol group than in the tropisetron-alone group during the zero to four post-surgery interval (P = 0.016), but the difference was not statistically significant for the four to 24 hour postoperative period (P = 0.116). Intraoperative subhypnotic propofol infusion combined with tropisetron is more effective than tropisetron alone in reducing postoperative vomiting after tonsillectomy in children.

Spinal anesthesia with sequential administration of plain and hyperbaric bupivacaine provides satisfactory analgesia with hemodynamic stability in cesarean section.

BACKGROUND: Hypotension during spinal anesthesia is one of the major concerns in cesarean section. To achieve adequate spinal anesthesia with less hypotension, we evaluated the viability of sequential subarachnoid injection of two different baricities of bupivacaine. We used plain bupivacaine 5mg to obtain dense anesthesia of the surgical site, followed by hyperbaric bupivacaine 5mg to achieve spread to T5 anesthesia to address visceral pain. METHODS: In this double-blind prospective study, 72 parturients undergoing cesarean section were randomized to receive either hyperbaric bupivacaine 10mg or 5mg each of plain and hyperbaric bupivacaine sequentially for spinal anesthesia. Loss of pinprick sensation to T6 was regarded as sufficient for cesarean section to proceed. Characteristics of anesthesia, episodes of hypotension, bradycardia and ephedrine use were assessed by blinded observers. RESULTS: Demographic data, characteristics of anesthesia, quality of intraoperative anesthesia and Apgar scores were similar in the two groups. Compared to hyperbaric bupivacaine, the combination of plain and hyperbaric bupivacaine provided a marked decrease in the incidence of hypotension (13.9% vs. 66.7%, P<0.001) and side effects related hypotension such as nausea and vomiting (13.9% vs.52.8%, P<0.001). The amount of ephedrine administered was significantly lower in the plain and hyperbaric bupivacaine group (2.2+/-1.0mg vs. 20.5+/-8.7 mg (P<0.001). CONCLUSIONS: Sequential subarachnoid injection of plain and hyperbaric bupivacaine for cesarean section can provide reliable spinal anesthesia with a lower incidence of hypotension and vomiting.

Effects of reduction of the caudal morphine dose in paediatric circumcision on quality of postoperative analgesia and morphine-related side-effects.

This study compared the efficacy and adverse effects of three low doses of morphine (10, 15 and 30 microg x kg(-1)) for caudal epidural analgesia in children undergoing circumcision. A total of 135 boys undergoing out-patient circumcision were randomly assigned to receive 10, 15 or 30 microg x kg(-1) of caudal morphine. Anaesthesia was induced and maintained with propofol. After induction, the morphine was added to 0.5 ml.kg(-1) 1% lignocaine solution with adrenaline 5 microg.ml(-1) and injected caudally. Anaesthesia quality, postoperative pain and adverse events in a 24-hour period were evaluated. Paracetamol (20 mg.kg(-1) orally) was used as rescue analgesia as required. No patient required paracetamol in the first eight hours after the caudal injections. In the first 24 hours postoperatively no further analgesia was required in 66.7%, 77.8% and 91.1% of the patients in the 10, 15 and 30 microg.kg(-1) groups, respectively (P=0.01 for 10 vs. 30 groups). All patients had excellent analgesia. No respiratory complications were observed. Nausea-vomiting occurred in 13.3%, 20% and 46.7% of the patients in the 10, 15 and 30 gg.kg(-1) groups (P=0.002 for 10 vs. 30 and 0.044 for 15 vs. 30). Pruritus occurred in 8.9%, 11% and 15.6% in the 10, 15 and 30 microg.kg(-1) groups but was localised and did not require treatment. This study was not powered to assess concerns that low dose epidural morphine may rarely be associated with delayed apnoea and is therefore considered unsuitable for outpatient use in many centres. Increases in caudal morphine dose above 10 microg.kg1 produce some 'paracetamol sparing' but no improvement in analgesia, some pruritus and a significant increase in nausea and vomiting.

Iatrogenic vascular injury during to lumbar disc surgery.

We report two patients who sustained vascular injury while undergoing intervertebral disc surgery at the lumbar four and five level. Each patient suffered from massive bleeding and shock, urgent laparatomy was performed, and the vascular injuries were successfully primarily repaired. The experience prompted us to review reports in the literature since 1965 of vascular complications associated with surgical excision of hernia disc via a posterior approach. From our analysis, we highlight the clinical features and management, emphasising that rapid diagnosis and immediate intervention can result in a favourable outcome, as in our patients.

Epidural blood patch with allogeneic blood for post-dural puncture headache.

A parturient suffered post dural puncture headache following accidental dural puncture during attempted epidural anesthesia for cesarean section. Post partum fever was regarded as a contraindication to autologous epidural blood patch; compatible and infection-free allogeneic blood was therefore used with good effect and without apparent complications.

An unusual cause of difficult intubation in a patient with a large cervical anterior osteophyte: a case report.

This report describes a case in which a large anterior osteophyte on the C2 and C3 vertebrae, due to ankylosing spondylitis, resulted in distortion of the anatomy of the upper airway and difficult intubation. Ankylosing spondylitis (AS) is a progressive inflammatory disease, characterized by stiffening of the joints and ligaments. Stiffness of the cervical spine, atlanto-occipital, temporomandibular and cricoarytenoid joints may cause difficult intubation (1). This report describes a case in which a large anterior osteophyte on the C2 and C3 vertebrae, associated with AS, resulted in distortion of the anatomy of the upper airway and difficult intubation.

The effects of bupivacaine and neostigmine on articular cartilage and synovium in the rabbit knee joint.

We investigated the effects of intra-articular injections of bupivacaine and neostigmine on articular cartilage and the synovial membrane of rabbit knee joints. Saline, bupivacaine or neostigmine were each administered intra-articularly into 15 knee joints. Five joints per drug treatment were prepared for histopathological examination 24 h, 48 h and 10 days after injection. A pathologist examined the histological samples for inflammation of the articular cartilage, inflammatory cell infiltration, hypertrophy and hyperplasia of the synovial membrane, in a blinded manner. There no histopathological in the saline-treated control joints. Joints treated with bupivacaine and neostigmine showed significantly more histopathological changes than control joints. Joints treated with neostigmine showed significantly more histopathological changes than those treated with bupivacaine, except for articular cartilage inflammation on day 10. We conclude that intra-articular bupivacaine and neostigmine cause histopathological changes in rabbit knee joints, with neostigmine having a greater effect than bupivacaine.

Comparison of prophylactic anti-emetic effects of ondansetron and dexamethasone in women undergoing day-case gynaecological laparoscopic surgery.

We aimed to determine the effect of ondansetron and dexamethasone on preventing post-operative nausea and vomiting (PONV). Sixty women undergoing laparoscopic gynaecological surgery were randomized to receive ondansetron 4 mg, dexamethasone 8 mg or saline. Drugs were administered 2 min before induction of anaesthesia, and anaesthesia and post-operative analgesic regimens were standardized. The incidence of PONV in the first 24 h after the operation was 35% in the ondansetron group, 55% in dexamethasone group and 85% in the control group. A significant difference between the groups was only seen in the first 3 h post-operatively. In this period, ondansetron was significantly more effective than dexamethasone and saline, but no differences were seen between dexamethasone and saline. In all treatment groups, post-operative visual analogue scale scores, sedation scores and usage of analgesics were similar. In conclusion, ondansetron, but not dexamethasone, prevented PONV in the first 3 h after gynaecological laparoscopic surgery.

Acupressure versus oxybutinin in the treatment of enuresis.

We aimed to assess the efficacy of acupressure for treating nocturnal enuresis, compared with oxybutinin. Acupressure was administered to 12 patients by their parents, who had been taught the technique. Pressure was applied at acupuncture points Gv4, Gv15, Gv20, B23, B28, B32, H7, H9, St36, Sp4, Sp6, Sp12, Ren2, Ren3, Ren6, K3 and K5. Twelve control patients received 0.4 mg/kg oxybutinin. Parents were asked to record incidences of bed-wetting and patients and/or parents completed a questionnaire 15 days and 1, 3 and 6 months after the start of treatment. Complete and partial responses after 6 months of treatment were seen in 83.3% and 16.7%, respectively, of patients treated with acupressure, and in 58.3% and 33.3%, respectively, of children who received oxybutinin. In conclusion, nocturnal enuresis can be partially treated by oxybutinin but acupressure could be an alternative non-drug therapy. Acupressure has the advantages of being non-invasive, painless and cost-effective.