Rider sitting position widens lumbar intervertebral distance: a prospective observational study

Abstract Background: Reduced lumbar lordosis may make the process of identifying the intervertebral distance easier. The primary aim of this study was to measure the L3-L4 intervertebral space in the same patients undergoing spinal anesthesia in three different sitting positions, including the classic sitting position (CSP), hamstring stretch position (HSP) and rider sitting position (RSP). The secondary aim was to compare ultrasonographic measurements of the depth of the ligamentum flavum and intrathecal space in these three defined positions. Methods: This study is a single-blinded, prospective, randomized study. Ninety patients were included in final analysis. the patients were positioned on the operating table in three different positions to perform ultrasonographic measurements of the spinal canal. The intervertebral distance (IVD), the distance between the skin and the ligamentum flavum (DBSLF) and the intrathecal space (IS) were measured in the L3 -L4 intervertebral space in three different positions. Results: The RSP produced the largest mean distance between the spinous processes. The RSP yielded a significantly larger IVD than did the CSP (p < 0.001) and HSP (p < 0.001). The DBSP was larger in the CSP than in the HSP (p = 0.001). The DBSLF was significantly larger in the RSP than in the HSP (p = 0.009). Conclusions: Positioning the patient in the RSP significantly increased the intervertebral distance between L3 -L4 vertebrae compared to the CSP and HSP, suggesting easier performance of lumbar neuraxial block.

C-reactive protein-albumin ratio and procalcitonin in predicting intensive care unit mortality in traumatic brain injury.

BACKGROUND: Prediction of intensive care unit (ICU) mortality in traumatic brain injury (TBI), which is a common cause of death in children and young adults, is important for injury management. Neuroinflammation is responsible for both primary and secondary brain injury, and C-reactive protein-albumin ratio (CAR) has allowed use of biomarkers such as procalcitonin (PCT) in predicting mortality. Here, we compared the performance of CAR and PCT in predicting ICU mortality in TBI. METHODS: Adults with TBI were enrolled in our study. The medical records of 82 isolated TBI patients were reviewed retrospectively. RESULTS: The mean patient age was 49.0 ± 22.69 years; 59 of all patients (72%) were discharged, and 23 (28%) died. There was a statistically significant difference between PCT and CAR values according to mortality (P<0.05). The area under the curve (AUC) was 0.646 with 0.071 standard error for PCT and 0.642 with 0.066 standard error for CAR. The PCT showed a similar AUC of the receiver operating characteristic to CAR. CONCLUSIONS: This study shows that CAR and PCT are usable biomarkers to predict ICU mortality in TBI. When the determined cut-off values are used to predict the course of the disease, the CAR and PCT biomarkers will provide more effective information for treatment planning and for preparation of the family for the treatment process and to manage their outcome expectations.

COVID-19 Pneumonia during Hydroxychloroquine Treatment of Rheumatoid Arthritis.

The recently emerged and novel coronavirus, severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2), that caused the current global pandemic was detected for the first time in Turkey in March 2020. While it continues to spread rapidly worldwide, there are still many uncertainties in the prevention and treatment of new coronavirus disease. We report a case of coronavirus disease 2019 (COVID-19) pneumonia in a patient under hydroxychloroquine (HCQ) treatment for rheumatoid arthritis. A 38-year female patient developed severe respiratory distress with SARS-CoV-2 infection and was treated in Intensive Care Unit (ICU). With this report, we aim to discuss the place of HCQ in prophylaxis in the light of the literature with a case presentation of COVID-19 pneumonia under HCQ treatment. Key Words: Coronavirus, Hydroxychloroquine, Prophylaxis, Rheumatoid arthritis, COVI-19.

Pain Management for Traumatic Rib Fractures with ESP Block in ICU.

Rib fractures are common injuries in blunt chest trauma, that cause severe thoracic pain, which limits patients' ability to cough and breathe deeply, which can lead to atelectasis and pneumonia. Various treatments for pain management of rib fractures have been described such as analgesics and regional anaesthesia. The ultrasound-guided erector spinae plane block (ESP) is a novel myofascial plane block for thoracic analgesia after thoracic or abdomen surgery. It is simple to perform the block because the key landmarks of tip of transverse processes and erector spinae muscle are easily visualised on ultrasound. This also allows to treat patients more easily in intensive care unit (ICU). We present a case that used ESP for pain management related to traumatic multiple rib fractures and prevented pulmonary complications with ESP block in ICU.

[Comparison of pressure-controlled volume-guaranteed ventilation and volume-controlled ventilation in obese patients during gynecologic laparoscopic surgery in the Trendelenburg position]. / Comparação entre ventilação garantida por volume controlado por pressão e ventilação controlada por volume em pacientes obesos durante cirurgia laparoscópica ginecológica na posição de Trendelenburg.

BACKGROUND AND OBJECTIVES: The aim of this study was to investigate the efficacy of the pressure-controlled, volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) modes for maintaining adequate airway pressures, lung compliance and oxygenation in obese patients undergoing laparoscopic hysterectomy in the Trendelenburg position. METHODS: Patients (104) who underwent laparoscopic gynecologic surgery with a body mass index between 30 and 40kg.m-2 were randomized to receive either VCV or PCV-VG ventilation. The tidal volume was set at 8mL.kg-1, with an inspired oxygen concentration of 0.4 with a Positive End-Expiratory Pressure (PEEP) of 5mmHg. The peak inspiratory pressure, mean inspiratory pressure, plateau pressure, driving pressure, dynamic compliance, respiratory rate, exhaled tidal volume, etCO2, arterial blood gas analysis, heart rate and mean arterial pressure at 5minutes after induction of anesthesia in the and at 5, 30 and 60minutes, respectively, after pneumoperitoneum in the Trendelenburg position were recorded. RESULTS: The PCV-VG group had significantly decreased peak inspiratory pressure, mean inspiratory pressur, plateau pressure, driving pressure and increased dynamic compliance compared to the VCV group. Mean PaO2 levels were significantly higher in the PCV-VG group than in the VCV group at every time point after pneumoperitoneum in the Trendelenburg position. CONCLUSIONS: The PCV-VG mode of ventilation limited the peak inspiratory pressure, decreased the driving pressure and increased the dynamic compliance compared to VCV in obese patients undergoing laparoscopic hysterectomy. PCV-VG may be a preferable modality to prevent barotrauma during laparoscopic surgeries in obese patients.

[Efficacy of ultrasound-guided erector spinae plane block for analgesia after laparoscopic cholecystectomy: a randomized controlled trial]. / Eficácia do bloqueio do plano do músculo eretor da espinha guiado por ultrassom para analgesia após colecistectomia laparoscópica: um estudo controlado randômico.

BACKGROUND AND OBJECTIVES: The primary aim of this study is to assess the effect of ultrasoung-guided erector spinae block on postoperative opioid consumption after laparoscopic cholecystectomy. The secondary aims are to assess the effects of erector spinae plane block on intraoperative fentanyl need and postoperative pain scores. METHODS: Patients between 18-70 years old, ASA I-II were included in the study and randomly allocated into two groups. In Group ESP, patients received bilateral US-ESP with 40ml of 0.25% bupivacaine at the level of T7, while in Group Control, they received bilateral US-ESP with 40ml of saline before the induction of anesthesia. Then a standard general anesthesia procedure was conducted in both groups. NRS scores at the postoperative 15th, 30th, 60th minutes, 12th and 24th hours, intraoperative fentanyl need and total postoperative tramadol consumption were recorded. RESULTS: There were 21 patients in Group ESP and 20 patients in Group Control. Mean postoperative tramadol consumption was 100±19.2mg in Group ESP, while it was 143±18.6mg in Group Control (p<0.001). The mean intraoperative fentanyl need was significantly lower in Group ESP (p=0.022). NRS scores at the postoperative 15th, 30th min, 12th hour and 24th hour were significantly lower in ESP group (p<0.05). According to repeated measures analysis, NRS score variation over time was significantly varied between two groups (F[1,39]=24.061, p< 0.0005). CONCLUSIONS: Bilateral US-ESP block provided significant reduction in postoperative opioid consumption, intraoperative fentanyl need and postoperative pain scores of patients undergoing laparoscopic cholecystectomy.

Comparison of pressure-controlled volume-guaranteed ventilation and volume-controlled ventilation in obese patients during gynecologic laparoscopic surgery in the Trendelenburg position / Comparação entre ventilação garantida por volume controlado por pressão e ventilação controlada por volume em pacientes obesos durante cirurgia laparoscópica ginecológica na posição de Trendelenburg

Abstract Background and objectives: The aim of this study was to investigate the efficacy of the pressure-controlled, volume-guaranteed (PCV-VG) and volume-controlled ventilation (VCV) modes for maintaining adequate airway pressures, lung compliance and oxygenation in obese patients undergoing laparoscopic hysterectomy in the Trendelenburg position. Methods: Patients (104) who underwent laparoscopic gynecologic surgery with a body mass index between 30 and 40 kg.m-2 were randomized to receive either VCV or PCV-VG ventilation. The tidal volume was set at 8 mL.kg-1, with an inspired oxygen concentration of 0.4 with a Positive End-Expiratory Pressure (PEEP) of 5 mmHg. The peak inspiratory pressure, mean inspiratory pressure, plateau pressure, driving pressure, dynamic compliance, respiratory rate, exhaled tidal volume, etCO2, arterial blood gas analysis, heart rate and mean arterial pressure at 5 minutes after induction of anesthesia in the and at 5, 30 and 60 minutes, respectively, after pneumoperitoneum in the Trendelenburg position were recorded. Results: The PCV-VG group had significantly decreased peak inspiratory pressure, mean inspiratory pressur, plateau pressure, driving pressure and increased dynamic compliance compared to the VCV group. Mean PaO2 levels were significantly higher in the PCV-VG group than in the VCV group at every time point after pneumoperitoneum in the Trendelenburg position. Conclusions: The PCV-VG mode of ventilation limited the peak inspiratory pressure, decreased the driving pressure and increased the dynamic compliance compared to VCV in obese patients undergoing laparoscopic hysterectomy. PCV-VG may be a preferable modality to prevent barotrauma during laparoscopic surgeries in obese patients.

Resumo Justificativa e objetivos: O objetivo deste estudo foi investigar a eficácia dos modos de ventilação garantida por volume controlado por pressão (PCV-VG) e ventilação controlada por volume (VCV) para manter pressões adequadas nas vias aéreas, complacência pulmonar e oxigenação em pacientes obesos submetidos à histerectomia laparoscópica na posição de Trendelenburg. Métodos: Cento e quatro pacientes submetidos à cirurgia ginecológica laparoscópica, com índice de massa corporal entre 30 e 40 kg.m-2, foram randomizados para receber ventilação com VCV ou PCV-VG. O volume corrente foi fixado em 8 mL.kg-1, com uma concentração inspirada de oxigênio de 0,4 e pressão positiva expiratória final (PEEP) de 5 mmHg. Registramos os seguintes parâmetros: pressão de pico inspiratório, pressão inspiratória média, pressão de platô, driving pressure, complacência dinâmica, frequência respiratória, volume corrente expirado, etCO2, gasometria arterial, frequência cardíaca e pressão arterial média aos 5, 30 e 60 minutos, respectivamente, após o pneumoperitônio na posição de Trendelenburg. Resultados: O grupo PCV-VG apresentou uma redução significativa da pressão de pico inspiratório, pressão inspiratória média, pressão de platô, driving pressure e aumento da complacência dinâmica comparado ao grupo VCV. Os níveis médios de PaO2 foram significativamente maiores no grupo PCV-VG do que no grupo VCV em todos os momentos após o pneumoperitônio na posição de Trendelenburg. Conclusões: O modo de ventilação PCV-VG limitou a pressão de pico inspiratório, diminuiu a driving pressure e aumentou a complacência dinâmica, comparado ao VCV em pacientes obesas submetidas à histerectomia laparoscópica. O PCV-VG pode ser uma modalidade preferida para prevenir o barotrauma durante cirurgias laparoscópicas em pacientes obesos.

The analgesic efficacy of oblique subcostal transversus abdominis plane block after laparoscopic hysterectomy: A randomized, controlled, observer-blinded study.

BACKGROUND: We aimed to assess whether an ultrasound (US)-guided oblique subcostal transversus abdominis plane (OSTAP) block would improve the postoperative pain scores and decrease the tramadol consumption after a laparoscopic hysterectomy. METHODS: Sixty-six female patients with American Society of Anesthesiologists I, II, or III, aged 18 to 65 years who were scheduled for laparoscopic hysterectomy for benign gynecologic pathologies were recruited in this randomized, controlled, observer-blinded trial. Sixty patients completed the study. Patients were randomized into 2 groups. In the OSTAP group, the patients received a bilateral OSTAP block with 40 mL of 0.375% bupivacaine and in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. All patients received tramadol patient-controlled analgesia for the first 24th hour. Patients in the Sham group received an US-guided bilateral OSTAP with 40 mL of 0.9% saline. The primary outcome was the 24th hour tramadol consumption. The secondary outcomes included visual analog scale (VAS) scores during movement, the tramadol consumption at the 1st, 4th, and 12th postoperative hours, and nausea scores at the 24th hour postoperatively. RESULTS: At all time points, tramadol consumption of the OSTAP group remained significantly lower when compared with Sham group. The OSTAP group showed a statistically significant reduction at the postoperative 24th hour tramadol consumption (mean difference 22 mg, 95% confidence interval -38.4 to -5.6 mL; P = .009). Compared with the Sham group, OSTAP block reduced the VAS scores at all time points during movement. Nausea scores at the 24th postoperative hour were significantly lower in the OSTAP group compared with the Sham group CONCLUSION:: We concluded that bilateral US-guided OSTAP blocks reduced 24th hour tramadol requirements and VAS scores after laparoscopic hysterectomy. The OSTAP block is a promising technique for producing effective and prolonged postoperative analgesia in patients undergoing laparoscopic hysterectomy surgeries.