The effect of preoperative TSH levels on perioperative complications in patients undergoing pituitary surgery.

INTRODUCTION: Pituitary surgery involves special conditions for the anaesthetist due to the anatomical localisation and the role of the pituitary gland in hormonal balance. The aim of this study was to retrospectively investigate the effect of TSH levels on perioperative complication rates in patients undergoing pituitary surgery. METHODS: In this study, patients who underwent pituitary surgery at Izmir Katip Celebi University Ataturk Training and Research Hospital between January 2017 and November 2022 were retrospectively screened. Two patients out of the 137 were excluded from the study as they underwent simultaneous aneurysm surgery along with pituitary tumor surgery. A total of 135 patients meeting the criteria were analyzed. Patients were divided into three groups according to TSH levels. Perioperative complication rates and mortality rates were compared between the three groups. FINDINGS: The study included a total of 135 patients, with an age range of 16-76 years. Among the groups with low-normal-high TSH levels, there were no statistically significant difference observed, in postoperative complications, such as epistaxis, rhinorrhea, postoperative nausea/vomiting, seizures, hypertension, and hypotension. When looking at the incidence of postoperative diabetes insipidus, a significant difference was found between the groups. When examining the mortality rates on the 28th day, a significant difference was found between the groups, with a mortality rate of 25% in the high TSH group (p < 0.5). CONCLUSIONS: The risk of perioperative mortality is higher in patients with TSH levels above normal.

Association of intraoperative lactate elevation and postoperative mortality and morbidity in patients undergoing craniotomy: retrospective analysis.

BACKGROUND: Intraoperative lactate levels increase in patients undergoing craniotomy, but the reason is not yet fully known. High levels of intraoperative lactate are associated with mortality and morbidity in patients with septic shock and abdominal and cardiac surgery. OBJECTIVES: Investigate whether intraoperative lactate elevation is associated with postoperative systemic and neurological complications and mortality in craniotomy. DESIGN: Retrospective study SETTING: University hospital in Turkey. PATIENTS AND METHODS: In this study, we included patients who underwent elective intracranial tumor surgery in our hospital between 1 January 2018, and 31 December 2018. According to the level of intraoperative lactate, patients were divided into two groups: high (≥2.1 mmol/L) and normal (<2.1 mmol/L). The groups were compared by the presence of postoperative new neurological deficits, postoperative surgical and medical complications, mechanical ventilation duration, 30-day mortality, in-hospital mortality, and hospital stay length. Cox regression analysis was performed for the 30-day mortality outcome. MAIN OUTCOME MEASURES: Association between intraoperative lactate levels and postoperative 30-day mortality. SAMPLE SIZE: 163 patients with lactate data. RESULTS: While no significant difference was found between the groups regarding age, gender, ASA score, tumor location, operation time and pathology results, preoperative neurologic deficits were higher in the high intraoperative lactate group (P=.017). No statically significant difference was found between the groups for postoperative neurological deficit, need for prolonged mechanical ventilation, and hospital stay length. The postoperative 30-day mortality rate was higher in the group with high intraoperative lactate (P=.028). High lactate and medical complications were significant in the Cox analysis. CONCLUSION: Intraoperative lactate elevation was associated with postoperative 30-day mortality in patients undergoing craniotomy. The intraoperative level of lactate is an important mortality predictor in patients undergoing craniotomy. LIMITATIONS: Retrospective design and single-centered, missing most data for several variables. CONFLICT OF INTEREST: None.

Effect of preoperative hospitalisation period on postoperative cognitive dysfunction in patients undergoing hip surgery under regional anaesthesia.

AIM OF THE STUDY: The main objective of this prospective and observational study was to investigate the effect of the preoperative hospitalisation period on early postoperative cognitive dysfunction (POCD) development in patients undergoing total hip replacement surgery under regional anaesthesia. MATERIALS AND METHODS: Between November 2013 and September 2014, 64 patients were enrolled in the study. Mini Mental Test (MMT) scores were obtained on the initial admission day (MMT1), 24 hours prior to the surgery (MMT2) and 24 hours after the surgery (MMT3). The patients were divided into two groups according to the MMT scores: 'no cognitive dysfunction' (group 1) and 'cognitive dysfunction' (group 2). Differences between the groups were evaluated statistically. The statistical significance level was set as P < .05 in a 95% confidence interval. RESULTS: The POCD incidence rate was calculated as 43.8% in all patients. The preoperative hospitalisation duration was significantly longer in patients with POCD than in patients without POCD (P < .001). The factors that affected POCD development were found to be advanced age (P < .001), high American Society of Anesthesiologists scores (P = .004), the presence of comorbid disease (P = .025), durations of surgery (P = .018) and decreased postoperative haematocrit levels (P = .014). CONCLUSION: In this study, we observed that patients with early POCD had relatively longer preoperative hospitalisation periods than those in patients without POCD. We consider that prolonged preoperative hospitalisation may contribute to increased POCD incidence rates in patients with risk factors.

The effects of tramadol on cancer stem cells and metabolic changes in colon carcinoma cells lines.

Opioids are widely used in the treatment of cancer related pain. They mainly exert their effects on opioid receptors. The most common opioid in the treatment of pain is morphine. Previous studies show that they may have effects on cancer cell behavior. These may include apoptosis, angiogenesis, invasion, inflammation and immune reactions. Tramadol, also an opioid is widely used in the treatment of cancer pain and is not well studied in cancer behavior. We aimed to investigate the effects of tramadol on cancer stem cells and metabolic changes in colon carcinoma cells. We used Colo320 (ATCC, CCL-220), Colo741 (ECACC, 93052621) and HCT116 (ATCC, CCL-247) colon cancer cell lines. CD133 was considered colon cancer stem cell marker and used to sort CD133+ and CD133- cells by magnetic cell sorting. MTT (mitochondria-targeted therapeutics) technique was used to detect tramadol's cytotoxic effect on cells in the study groups. Cells were treated with 1 mg/kg, 1.5 mg/kg and 2 mg/kg tramadol for 24 h at 37 °C and 5% CO2.Caspase-3, Ki-67, Bcl-2 and VGEF distributions were performed using indirect immunoperoxidase staining for immunohistochemical analysis. The study showed that tramadol has triggering effect on apoptosis in Colo320 colon cancer stem cells.

Radiological Evaluation of the Line Between the Crista Iliaca (Tuffier's line) in Elderly Patients.

OBJECTIVE: Tuffier's line is defined as the line connecting the highest points of both iliac crests, which generally passes through either the body of the fourth lumbar vertebra or the intervertebral space between fourth and fifth vertebrae. In this study, we assessed the radiological correlation of the level of Tuffier's line with changes in age and sex. METHODS: In this study, antero-posterior pelvic X-rays of 590 patients aged 18 and older were retrospectively analyzed. It is revealed that Tuffier's line crosses the vertebral column at one of three levels, which are the L4 vertebral body, L4-L5 vertebral interspace and L5 vertebral body. Patients' sex, age and vertebral level of the Tuffier's line were recorded. Data was analyzed using the chi-square test. RESULTS: The assessment of the X-rays of 317 female patients showed that Tuffier's Line passes through the L4 vertebral body in 115 (37.8%), through the L4-L5 intervertebral space in 126 (40%) and through the L5 vertebral body in 76 (22.2%) patients. A Tuffier's line passing through the level of the L5 vertebral body was found to be statistically significant in female patients (p=0.00). No significant relevance was found between male gender and the level of Tuffier's line in 273 male patients. It is found that the height of the vertebral levels that Tuffier's line crosses does not correlate with mean age of the groups (p=0.939). CONCLUSION: It should be considered that Tuffier's line can cross at vertebral levels other than anticipated. The level of Tuffier's line should be precisely determined with supplementary radiological methods, such as AP pelvic X-ray in addition to physical examination, to reduce the complications in association with regional anaeshesia and to achieve sensorial block levels sufficient to sustain a comfortable surgery, particularly in female patients who carry higher cardiac and respiratory risks.

Bilateral chylhotorax after falling from height.

Chylothorax is accumulation of chyle in the pleural cavity due to disruption of the thoracic duct. The causes can be classified as neoplastic, traumatic (iatrogenic or noniatrogenic), congenital, sporadic, spontaneous, and miscellaneous. A 22-year-old man with no feature in his history and family history was referred to emergency department with the case of falling from height. Abdominal computed tomogram (CT) revealed laceration of liver, grade 5 splenic laceration, fracture of the left acetabulum, and dislocation of the left hip. He was optimized for emergency splenectomy and close left hip reduction. On the 2nd day of the operation, bilateral chylotorax revealed. The treatment depends on its etiology, the amount of drainage, and the clinical picture. Treatment can be classified into 3 categories treatment of the underlying condition, conservative management (such as bed rest, nil by mouth or low fat medium chain triglycerides by mouth and total parenteral nutrition), and surgical management by ligation or clipping of the thoracic duct with open thoracotomy or video-assisted thoracoscopic surgery. The main purpose of surgical treatment is to stop the chylous leak.

Comparison of tools for nutrition assessment and screening for predicting the development of complications in orthopedic surgery.

BACKGROUND: Malnutrition in hospitalized patients is a significant problem. The purpose of this study was to compare 2 assessment tools-the Nutritional Risk Screening 2002 (NRS 2002) and subjective global assessment (SGA)-in predicting development of complications in patients undergoing orthopedic surgery. METHODS: Nutrition status was assessed by the SGA, and nutrition screening was performed using the NRS 2002 in 256 consecutively admitted patients scheduled for orthopedic surgery. Additional information recorded for all patients included age, gender, body mass index, and American Society of Anesthesiologists (ASA) physical status. Patient outcomes (postoperative complications), mortality rate, and length of hospital stay (LOS) were investigated. RESULTS: Malnourished or nutritionally at-risk patients were significantly older than nonmalnourished or not at-risk patients according to the SGA and NRS 2002. Also, ASA physical status was correlated with malnutrition or malnutrition risk. Malnourished and at-risk patients in both the SGA and NRS 2002 groups showed longer LOS and higher morbidity and mortality rates. Sensitivity was 50% with the SGA and 69% with the NRS 2002; specificity was 77% with the SGA and 80% with the NRS 2002. Agreement between 2 methods was 0.672. The odds ratio for the association between malnutrition or risk of malnutrition and the occurrence of complications was 3.5 (1.7-7.1) for the SGA and 4.1 (2.0-8.5) for NRS 2002. CONCLUSIONS: Age and ASA physical status are risk factors for malnutrition. In patients undergoing orthopedic surgery, NRS 2002 predicted development of complications better than the SGA. Malnutrition also increased length of hospital stay.

Bupivacaine infusion above or below the fascia for postoperative pain treatment after abdominal hysterectomy.

BACKGROUND: We evaluated in which anatomic layer (above the fascia [AF] or below the fascia [BF]) wound infusion of bupivacaine has the best effect on postoperative pain after abdominal hysterectomy. METHODS: Sixty-two ASA physical status I and II patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy were enrolled into this prospective randomized, double-blind study. A standard general anesthetic was administered. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above (group AF, n = 29) or below (group BF, n = 31) the superficial abdominal fascia and 0.25% bupivacaine was administered via a patient-controlled analgesia device, programmed to deliver 9.0 mL with a 60-min lockout interval for 24 h. During the first 6 h after surgery, rescue i.v. fentanyl (25 microg) was administered to achieve a visual analog scale score of <4 cm. Total bupivacaine consumption, total rescue fentanyl consumption, pain scores (with resting, coughing, and leg raising), and patient satisfaction scores were compared in both groups. RESULTS: Total bupivacaine consumption over 24 h was significantly lower in group AF rather than group BF (90 +/- 26 mL vs 104 +/- 28 mL, respectively, P < 0.05). The total fentanyl consumption during the first 6 h after surgery was 109 +/- 59 microg in group AF and 166 +/- 70 microg in group BF (P < 0.01). Pain scores were lower in group AF at rest and coughing for the first 5 h and for the first 12 h with leg raise (P < 0.05 for all measurements). Thirteen patients (68%) in group AF defined their satisfaction as excellent whereas six patients (32%) in group BF defined their satisfaction as excellent (P = 0.034). CONCLUSION: We conclude that bupivacaine wound infusion AF provides better postoperative analgesia compared with infusion BF in the first 12 h after abdominal hysterectomy.

The effects of an epidural infusion of ropivacaine versus saline on sensory block after spinal anesthesia.

BACKGROUND AND OBJECTIVES: Several investigators have described the effect of bolus injections on sensory block during combined spinal epidural anesthesia. This study investigates the effects of the immediate epidural infusion of 0.2% ropivacaine versus 0.9% saline on spinal anesthesia. METHODS: Forty-four patients undergoing partial hip replacement were randomly assigned to 2 groups, receiving epidural infusion of 0.2% ropivacaine 10 mL/h (group R, n = 22) or 0.9% NaCl 10 mL/h (group S, n = 22), immediately after spinal anesthesia with 7.5 mg 0.5% hyperbaric bupivacaine. Postoperative analgesia was provided in both groups using a ropivacaine patient-controlled epidural analgesia technique. Sensory block, motor block, postoperative pain scores, ropivacaine consumption, and patient satisfaction were recorded. RESULTS: There was no difference between the 2 groups in the characteristics of the sensory block. The duration of motor block was prolonged in group R (312 +/- 95 minutes vs 198 +/- 78 minutes; P < .001). Postoperative pain scores and 24-hour ropivacaine consumption were similar among groups. Demand/delivery ratio was 1.6 in group R and 3.5 in group S (P = .048). A significantly higher number of patients in group R described their satisfaction as excellent (20 patients vs 6 patients; P < .001). CONCLUSIONS: Epidural infusion of ropivacaine 0.2% initiated immediately after spinal anesthesia prolonged the regression of motor block but not the regression of sensory block when compared with saline infusion.

Reversal of prilocaine epidural anesthesia using epidural saline or ringer's lactate washout.

BACKGROUND AND OBJECTIVES: Several investigators have described the phenomena of epidural saline washout using bolus injections. This study was designed to determine whether epidural block could be reversed more effectively by infusion of crystalloid solutions via the epidural catheter. METHODS: One hundred male patients scheduled for outpatient surgery were enrolled in this study. After 30 min of 2% prilocaine epidural anesthesia, patients were randomly assigned to receive 45 mL of study solution as follows: (1) normal saline bolus (group NSB); (2) Ringer's lactate bolus (group RLB); (3) normal saline infusion (group NSI); (4) Ringer's lactate infusion (group RLI). Patients in the control group received no washout fluid. Motor, sensory blockade and side effects were compared among 5 groups. Ambulation time is defined as the recovery time. RESULTS: In the control group, ambulation time (139 +/- 15 min) was significantly longer than in the washout groups (NSB 90 +/- 10, RLB 88 +/- 10, NSI 85 +/- 8, RLI 91 +/- 6 minutes) (P < .001). Two-segment sensory regression time in the control group (86 +/- 15 min) was significantly longer than in groups NSB, RLB, NSI and RLI (55 +/- 8, 51 +/- 4, 58 +/- 8, and 53 +/- 10 minutes, respectively) (P < .001). CONCLUSIONS: We concluded that a more rapid recovery of motor and sensory blockade in patients undergoing epidural anesthesia may be achieved by the use of an epidural washout with either bolus or infusion of 45 mL normal saline or Ringer's lactate.

Airway management of a patient with Forestier's disease.

Forestier's disease, also called diffuse idiopathic skeletal hyperostosis (DISH), is a noninflammatory enthesopathy, ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Intubation difficulty and spinal cord injury are potential problems when managing the airway in DISH patients. We report a patient with Forestier's disease who was admitted for osteophyte resection. After taking a detailed history, we evaluated the airway carefully. Also, preparation for difficult intubation was done. After a rapid sequence induction, we performed mask ventilation and laryngoscopy without hyperextension of the neck, to prevent spinal cord injury. Although the worldwide standard for management of the airway in DISH patients is awake fiberoptic intubation, we chose conventional laryngoscopy because a fiberoptic bronchoscope was not available.