Characteristics of Advanced Cancer Patients Admitted to the Palliative Care Unit from the Emergency Department.

AIM: People with cancer frequently present to emergency departments (EDs) because of exacerbation of the existing problems and new symptoms, complications of treatments, or difficulties with care and support systems. The aim of the study was to determine the presenting symptoms and demographic characteristics of advanced cancer patients and their caregivers admitted to the palliative care (PC) unit from the ED. METHODS: After approval, 139 cancer patients admitted to the ED and referred for PC consultation were included in the study. The medical records of PC unit for all patients and their primary caregivers were retrospectively evaluated. Demographic characteristics, cancer site and metastasis, reasons and frequency for ED admissions, symptoms, duration of hospitalization, and outcomes were recorded. The association between the characteristics of caregivers and emergency visits was also evaluated. RESULTS: Among all patients, 61.9% were >60 years old, 58.3% were male, and 71.2% were married. The most frequent site of cancer was gastrointestinal system (39.6%), lungs (18.7%), and genitourinary system (12.2%). The reasons for emergency visits were found as inadequate symptom control (65.5%), dying patient (30.2%), lack of psychosocial support (3.6%), and symptom of other comorbidities (0.7%). The most frequent symptoms were feeling of not well-being, tiredness, and lack of appetite. There was no difference in the number of admissions according to caregivers. Ninety-seven patients (69.8%) died at the PC unit and 42 (30.2%) were discharged. CONCLUSION: PC system needs to be integrated into all health-care disciplines including EDs. While improving a community- and home-based PC, education of patients, caregivers, and health professionals must also be provided.

Comparison Between the Two-Injection Technique and the Four-Injection Technique in Axillary Brachial Plexus Block with Articaine.

OBJECTIVE: In this study, we aimed to compare axillary brachial plexus block using the two-injection and four-injection techniques assisted with ultrasonography (USG) and nerve stimulator in patients operated for carpal tunnel syndrome with articaine. To evaluate which technique is more effective, we compared the onset time, effectiveness, and duration of block procedures, patient satisfaction, adverse effect of the drug, and complication rates of the motor and sensory blocks. METHODS: Sixty patients were randomly divided into two groups. A mixture of physiologic serum added to articain with NaHCO3 (30 mL) was injected into the patients' axilla in both the groups. After the blockage of the musculocutaneous nerve in both the groups, the median nerve in the two-injection group and the median nerve, ulnar nerve, and radial nerve in the four-injection group were blocked. In brachial plexus nerves, sensorial blockage was evaluated with pinprick test, and motor block was evaluated by contraction of the muscles innervated by each nerve. The adverse effects and complications, visual analog scale (VAS) values during the operation, and post-operative patient satisfaction were recorded. RESULTS: Sufficient analgesia and anaesthesia were achieved with no need for an additional local anaesthetics in both the groups. Furthermore, additional sedation requirements were found to be similar in both the groups. A faster rate and a more effective complete block were achieved in more patients from the four-injection group. In the two-injection group, the block could not be achieved for N. radialis in one patient. All other nerves were successfully blocked. Whereas the blockage procedure lasted longer in the four-injection group, the VAS values recorded during the blockage procedure were higher in the four-injection group. No statistical difference was found with regard to patient satisfaction, and no adverse effects and complications were observed in any group. CONCLUSION: Although the multi-injection method takes more time, it provides faster anaesthesia and more complete blockage than the two-injection method used with articain. The two-injection method can also be used in specific surgery such as for carpal tunnel syndrome, as an alternative to multi-injection method.

[Opioid use and the management of cancer patient pain in palliative care clinic]. / Palyatif bakim kliniginde yatan kanser hastalarinda agri tedavisi ve opioid kullanimi.

OBJECTIVES: Pain is one of the most important symptoms in palliative care, and has a major impact on the quality of life of cancer patients. In developing countries, difficult access to opioids and the lack of well-established palliative care organizations result in undertreatment of pain. Turkey is one of the countries with statistical evidence of inadequate morphine consumption per capita. In 2010, the adequacy of opioid analgesic consumption was only 7%, based on a per capita consumption of 14.31 mg morphine equivalents. The present study analyzed and described patterns of opioid use among cancer patients in the palliative care clinic. METHODS: The data of 418 cancer patients who received palliative care at the palliative care clinic in 2014 were evaluated retrospectively. RESULTS: Of the total, 183 (44%) of the patients studied were female and 235 (56%) were male. Age ranged from 18 to 93 years (61±15 years). No opioids had been prescribed for 9% of patients, 26% of patients were using weak opioids, and 65% were using strong opioids. Daily oral morphine equivalent dosage per patient was 172±58 mg (range: 40-328 mg). Indications for opioid use were pain (61%), dyspnea (19%), and both dyspnea and pain (20%). CONCLUSION: Although there is a limited variety of opioids currently available in this country, it is thought that a more effective and adequate level of pain management can be obtained through education of health practitioners about pain management and opioid use. The relatively high incidence of weak opioid use may be associated with the lack of available rapid release opioids in the country.

[Symptoms seen in inpatient palliative care and impact of palliative care unit on symptom control]. / Palyatif bakim kliniginde yatan hastalarda görülen semptomlar ve palyatif bakimin semptom kontrolüne etkisi.

OBJECTIVES: The purpose of this study was to determine the symptoms observed during admission to palliative care in patients that would be provided palliative support, to measure their intensity, and to evaluate the effect of palliative care on patient symptoms by recording changes during the first week after admission to hospital. METHODS: The sample of the study was determined as 108 according to the population mean significance test conducted by using preliminary application data. Patients who were able to complete the Edmonton Symptom Assessment Scale during admission to hospital, on the 3(rd) and 7(th) days of hospitalization were included into the evaluation. The Introductory Characteristics Questionnaire, Edmonton Symptom Assessment Scale and Palliative Performance Scale were used for the collection of the data. RESULTS: While 50% of the patients defined pain intensity as 5 and over during admission, this rate was determined to be 6.5% on the 7(th) day. Mean values of the symptoms of pain, insomnia, loss of appetite, and status of well-being decreased significantly on the 3(rd) and 7(th) days after admission compared to the time of admission to the hospital. Besides, no statistically significant difference was found among the symptoms of nausea, anxiety, shortness of breath, and constipation. CONCLUSION: In this study, it was determined that the intensity of symptoms deteriorating the life quality of cancer patients such as pain, fatigue, insomnia, loss of appetite, and status of well-being improved rapidly with palliative care support.

Comparison of the effects of low volume prilocaine and alkalinized prilocaine for the regional intravenous anesthesia technique in hand and wrist surgery.

AIM: Comparing the effectivity of prilocaine and prilocaine alkalinized with 8.4% NaHCO3 in terms of sensory and motor block onset and termination durations in RIVA technique considering patients' satisfaction and tolerance with application of tourniquet undergoing hand-wrist surgery. MATERIALS AND METHODS: 64 patients were randomised into two groups. First group (Group P) was administered prilocaine and second group (Group PN) was administered prilocaine + %8.4 NaHCO3. Sensory and motor block onset and termination times and onset of tourniquet pain were recorded. RESULTS: No significant difference was found between the two groups in terms of onset and termination of sensory block and the onset of motor block. The duration of the motor block was longer in Group PN than in Group P (P < 0.05). Tourniquet pain was more intense in Group P (P = 0.036). In Group PN, the use of additional drugs was recorded at a lower rate and patients' satisfaction was higher than Group P. CONCLUSION: In the present study, it was established that alkalinization of prilocaine had no effect on the duration of sensory block and it prolonged the duration of motor block, increased patients' satisfaction, and decreased tourniquet pain. It is our suggestion that future studies should be carried out on the issue by using different volumes.

Postoperative analgesia after modified radical mastectomy: the efficacy of interscalene brachial plexus block.

PURPOSE: In the present study, we evaluated the effects of interscalene brachial plexus block on postoperative pain relief and morphine consumption after modified radical mastectomy (MRM). METHODS: Sixty ASA I-III patients scheduled for elective unilateral MRM under general anesthesia were included. They were randomly allocated into two groups: group 1 (n = 30), single-injection ipsilateral interscalene brachial plexus block; group 2 (n = 30), control group. Postoperative analgesia was provided with IV PCA morphine during 24 h postoperatively. Pain intensity was assessed with the visual analogue scale (VAS). Morphine consumption, side effects of opioid, antiemetic requirement, and complications associated with interscalene block were recorded. RESULTS: VAS scores were significantly lower in group 1, except in the first postoperative 24 h (p < 0.007). The patients without block consumed more morphine [group 1, 5 (0-40) mg; group 2, 22 (6-48) mg; p = 0.001]. Rescue morphine requirements were also higher in the postoperative first hour in group 2 (p = 0.001). Nausea and antiemetic requirements were significantly higher in group 2 (p = 0.03 and 0.018). Urinary retention was observed in 1 patient in group 2 and signs of Horner's syndrome in 2 patients in group 1. CONCLUSIONS: The optimal method has not been defined yet for acute pain palliation after MRM. Our study demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively. The block can be a good alternative to other invasive regional block techniques used for postoperative pain management after MRM.

The effects of magnesium sulphate on desflurane requirement, early recovery and postoperative analgesia in laparascopic cholecystectomy.

PURPOSE: we evaluated the effects of magnesium sulphate infusion on anesthetic requirement, early recovery and postoperative analgesia in desflurane-remifentanil-based, balanced anaesthesia. METHODS: 60, ASA (American Society of Anesthesiologists) group 1-2 patients who were scheduled for laparoscopic cholecystectomy were randomly divided into two groups. Before anesthesia, the magnesium-treated group (n = 30) received a 15 min infusion of 40 mg/kg of magnesium sulphate followed by 10 mg/kg/h by continuous i.v. infusion during the operation. The same volume of isotonic saline was administered to the control group (n = 30). Anesthesia was induced with propofol, remifentanil and vecuronium, and maintained with desflurane 3-6%, O(2)/air and remifentanil infusion. Desflurane was titrated to maintain BIS (bispectral index) values of 40-60. The times from cessation of anesthesia to spontaneous breathing, eye opening, extubation, reaching BIS 70, and Aldrete scores were recorded. After surgery, patients received a patient-controlled, morphine analgesia device. RESULTS: demographic variables were similar. During the 15 min infusion of magnesium sulphate, the BIS value was significantly lower in the magnesium sulphate-treated group. The amounts of propofol and desflurane used were less in the magnesium sulphate-treated group, by 18% and 22% respectively (p<0.05). The groups did not differ with respect to the time taken to reach BIS 70, spontaneous breathing, eye opening and extubation. Alderete and VAS (visual analogue scale) pain scores, and total morphine consumption were significantly lower in the magnesium sulphate-treated group. There were no differences in side effects, but the rate of re-intubation was higher in the group receiving magnesium sulphate (p = 0.03). CONCLUSION: perioperative use of magnesium sulphate reduced propofol and desflurane consumption, and the postoperative morphine requirement, while causing a delay in recovery by decreasing the Aldrete score.

The analgesic efficacy of two different approaches to the lumbar plexus for patient-controlled analgesia after total knee replacement.

This study assessed the efficacy of a patient-controlled regional analgesia technique for either psoas compartment block or femoral nerve block after total knee replacement in 68 patients who were randomly divided into these two groups. All patients received 40 ml of 0.25% bupivacaine via femoral or psoas catheters before general anesthesia, and then, as patient-controlled regional analgesia, 10-ml boluses of 0.125% bupivacaine, with a lockout time of 60 min over 48 h. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, and side effects were recorded. All measured parameters were comparable in the two groups. Both techniques achieved a good quality of analgesia and satisfaction without any major side effect.

A placebo-controlled comparison of bupivacaine and ropivacaine instillation for preventing postoperative pain after laparoscopic cholecystectomy.

PURPOSE: The aim of this study was to determine the effect of local anesthetic instillation, to compare bupivacaine and ropivacaine in patients undergoing a laparoscopic cholecystectomy. METHODS: A total of 80 patients were randomly assigned to four groups to receive the intraperitoneal instillation of 21 ml of either 100 mg bupivacaine (Group B), 100 mg ropivacaine (Group R1), 150 mg ropivacaine (Group R2) or saline with epinephrine 1/200,000 at the end of the surgery. The postoperative pain was evaluated and the analgesic requirement was also assessed. RESULTS: The intraperitoneal instillation of 100 mg bupivacaine, 100 mg ropivacaine, or 150 mg ropivacaine at the end of a laparoscopic cholecystectomy significantly reduced the morphine consumption during the first 24 h. For preventing postoperative pain 150 mg ropivacaine proved to be significantly more effective than either 100 mg bupivacaine or 100 mg ropivacaine. CONCLUSION: We herein showed that the intraperitoneal instillation of local anesthetic during laparoscopic cholecystectomy is a noninvasive, rapid, safe and simple analgesic technique that reduces the total morphine consumption during first 24 h.

Epidural ropivacaine or sufentanil-ropivacaine infusions for post-thoracotomy pain.

OBJECTIVE: The aim of this study was to compare the analgesic efficacy and side effects of continuous epidural infusions of ropivacaine and ropivacaine-sufentanil mixtures after thoracotomy. METHODS: Sixty-two patients scheduled for thoracic surgery were allocated in this prospective double-blinded randomised study. They received an epidural catheter inserted from thoracic 5-6 (Th(5-6)) interspace a day before surgery and were randomly assigned into two groups, sufentanil-ropivacaine group (Group SR, n=31) and ropivacaine group (Group R, n=31). Bolus dose of the study drugs, ropivacaine 0.2% or ropivacaine 0.2% and sufentanil 0.75 microg/ml calculated in ml according to the patient's height was given through the epidural catheter before surgery. One hour after anaesthesia induction, another bolus was given and the epidural infusion was started (4.5-8 ml). Whenever visual analogue scale (VAS) scores were > or =4 during function, the patients received additional boluses and the infusion rate was increased by 1 ml/h. If the pain was not relieved after administration of two boluses, the patient was excluded from the study. RESULTS: VAS at rest and during function was lower in ropivacaine-sufentanil group and the need for additional boluses and infusion rate increase was high in ropivacaine group (P<0.05). Ropivacaine-sufentanil infusion rate was decreased due to nausea and vomiting in two patients and due to CO(2) retention in one patient. There was no statistically significant difference between the incidences of side effects except pruritus significantly higher in Group SR. The total epidural solution volume was more in Group R (P<0.05). CONCLUSIONS: The continuous epidural infusion of ropivacaine with sufentanil provided superior pain relief than ropivacaine alone without causing any severe side effect or post-operative pulmonary impairment.

Anterior spinal artery syndrome after thoracic surgery.

Spinal cord infarction is a rare complication following thoracic surgery. We present a case who developed paraplegia on the first postoperative day of thoracotomy. A 76-year-old man with a history of atherosclerotic cardiovascular disease was operated for bronchial carcinoma. An epidural infusion of ropivacaine and sufentanil was used for postoperative pain. Eight hours after the surgery, he had an episode of hypotension and respiratory depression. One hour later, he described paraplegia and Ischemia of the spinal cord was found on MRI. There was no recovery during the follow-up.

A low-dose bupivacaine: a comparison of hyperbaric and hypobaric solutions for unilateral spinal anesthesia.

BACKGROUND AND OBJECTIVES: The injection of small doses of local anesthetic solutions through pencil-point directional needles and maintaining the lateral decubitus position for 15 to 30 minutes after the injection have been suggested to facilitate the unilateral distribution of spinal anesthesia. We evaluated the effects of hypobaric and hyperbaric bupivacaine in attempting to achieve unilateral spinal anesthesia for patients undergoing lower limb orthopedic surgery. METHODS: Fifty patients were randomly allocated into 2 groups to receive either 1.5 mL hyperbaric bupivacaine 0.5% (7.5 mg; n = 25) or 4.2 mL hypobaric bupivacaine 0.18% (7.5 mg; n = 25). Drugs were administered at the L3-4 interspace with the patient in the lateral position. Patients remained in this position for 15 minutes before turning supine for the operation. Spinal block was assessed by pinprick and modified Bromage scale on both sides. RESULTS: Unilateral spinal block was observed in 20 patients in the hyperbaric group (80%) and in 19 patients in the hypobaric group (76%) while in the lateral position. However, 15 minutes after patients were turned supine, unilateral spinal anesthesia decreased to 68% of cases in the hyperbaric group and 24% of cases in the hypobaric group (P <.05). The motor block was more intense during the first 5 and 10 minutes (P <.05), but at the end of operation there was no difference between the groups. The hemodynamic changes were similar between the groups. CONCLUSION: As a result, unilateral spinal anesthesia with hyperbaric and hypobaric bupivacaine provided a rapid motor and sensory recovery and good hemodynamic stability, but more unilateral spinal block was achieved in patients in the hyperbaric group when compared with patients in the hypobaric group.