Perioperative Analgesic Effects of Preemptive Ultrasound-Guided Subcostal Transversus Abdominis Plane Block for Percutaneous Nephrolithotomy: A Prospective, Randomized Trial.

Background and Objectives: Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure for removing kidney stones, but patients still suffer from moderate postoperative pain. The aim of this study is to evaluate the perioperative analgesic effect of ultrasound-guided subcostal transversus abdominis plane (TAP) block performed before PCNL procedure. Materials and Methods: Patients scheduled for elective PCNL were randomized into two groups: Group TAP and Group IV. General anesthesia was induced with propofol, fentanyl, and rocuronium and maintained with sevoflurane, fentanyl, and rocuronium. Unilateral ultrasound-guided TAP block was performed with total of 30 mL volume of local anesthetic solution (20 mL bupivacaine 0.125% plus 10 mL lidocaine 1%) after intubation but before surgery to the Group TAP patients. Paracetamol 1 g was given to the Group IV. Tramadol 100 mg and morphine IV-patient-controlled analgesia were applied to both groups. Perioperative fentanyl consumption, postoperative verbal analog scale (VAS), morphine consumption, and additional analgesic drug requirement were assessed. Chi square with Yates correction and Mann-Whitney U tests were used for statistical analysis. Results: Eighty patients were assessed for enrollment. One patient developed septicemia at the recovery room so data of 79 patients were collected for statistical analysis. Total morphine consumption at 48th hour after the surgery was lower at Group TAP (p = 0.022). Perioperative fentanyl consumption was lower at Group TAP (p < 0.001). Additional analgesic requirement and VAS were comparable between groups. Conclusions: Preemptive unilateral ultrasound-guided subcostal TAP block decreases perioperative fentanyl and postoperative total morphine consumption in PCNL patients compared to IV analgesic management.

Correlation of Neck Circumference with Difficult Mask Ventilation and Difficult Laryngoscopy in Morbidly Obese Patients: an Observational Study.

PURPOSE: Mask ventilation and laryngoscopy can be challenging in morbidly obese patients because of excessive fat tissue. There are studies suggesting that neck circumference is associated with difficult mask ventilation, difficult laryngoscopy, and difficult intubation. The primary aim of our study is to evaluate predictive value of neck circumference for difficult mask ventilation and difficult laryngoscopy in female and male morbidly obese patients separately. METHODS: This observational cross-sectional study was performed in the period between March 2015 and December 2015. One hundred and twenty (37 male and 83 female) patients undergoing elective surgery were included. Neck circumference, BMI, Mallampati scores, neck movements, dentition, upper lip bite test, breast, thorax, waist, hip circumferences, mouth opening, and sternomental and thyromental distances were evaluated preoperatively. Mask ventilation was graded using four-grade classification. Laryngoscopy was evaluated by Cormack Lehane score. RESULTS: The incidence of difficult mask ventilation was 13.5% in male and 3.6% in female patients. Mouth opening ≤ 6.5 cm and inadequate flexion were found as significant predictors for difficult mask ventilation in male patients. The incidence of difficult laryngoscopy was 10.8% in male and 4.8% in female patients. Mallampati score > II was found as a significant predictor for difficult laryngoscopy in both male and female patients. Sternomental distance ≤ 16 cm and inadequate flexion were also significant predictors for difficult laryngoscopy in male patients. Neck circumference was not found statistically significant predictor for difficult mask ventilation and laryngoscopy in morbidly obese patients in our study. CONCLUSION: Neck circumference is not a statistically significant predictor for difficult mask ventilation and laryngoscopy in morbidly Turkish obese male and female patients. CLINICAL TRIALS REGISTRATION NUMBER: NCT02589015.

Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats / Avaliação da lesão do nervo ciático após injeção intraneural de bupivacaína, levobupivacaína e lidocaína em ratos

ABSTRACT OBJECTIVE: The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS: Sixty Wistar rats weighing 200-350 g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2 mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS: There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION: In all groups, histopathological damage frequency and severity were more than the motor deficiency.

RESUMO OBJETIVO: Os anestésicos locais podem causar neurotoxicidade. Nosso objetivo foi comparar o potencial neurotóxico de diferentes anestésicos locais, os danos induzidos aos nervos e as alterações patológicas de um nervo periférico. MÉTODOS: Foram estudados 60 ratos Whistler com 200-350 g. Os ratos foram divididos em três grupos, uma agulha de calibre 26 foi inserida no nervo ciático esquerdo, com o uso de ampliação, e 0,2 mL de bupivacaína a 0,5%, levobupivacaína a 5% e lidocaína a 2% foram injetados por via intraneural. Um colaborador, cego para os conteúdos das injeções, monitorou a função neurológica no primeiro dia de pós-operatório e depois diariamente. O exame neurológico incluiu a avaliação da presença e da gravidade da nocicepção e dos reflexos de agarrar. No sétimo dia, uma amostra do nervo ciático foi colhida para avaliar as alterações histopatológicas. RESULTADOS: Não houve diferença estatística entre os grupos em relação ao reflexo de agarrar e à avaliação histopatológica. Dois casos no grupo bupivacaína, um no grupo levobupivacaína e dois no grupo lidocaína apresentaram um leve reflexo de agarrar; também no grupo lidocaína, um caso não apresentou reflexo de agarrar no sétimo dia. Degeneração axonal grave foi observada em todos os grupos: quatro casos no grupo bupivacaína (20%), três no grupo levobupivacaína 3 (15%) e seis no grupo lidocaína (30%). CONCLUSÃO: Em todos os grupos, a frequência de dano histopatológico e de gravidade foi maior do que a deficiência motora.

Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats.

OBJECTIVE: The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS: Sixty Wistar rats weighing 200-350g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS: There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION: In all groups, histopathological damage frequency and severity were more than the motor deficiency.

[Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats]. / Avaliação da lesão do nervo ciático após injeção intraneural de bupivacaína, levobupivacaína e lidocaína em ratos.

OBJECTIVE: The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS: Sixty Wistar rats weighing 200-350g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS: There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION: In all groups, histopathological damage frequency and severity were more than the motor deficiency.

Comparison and Evaluation of the Effects of Administration of Postoperative Non-Invasive Mechanical Ventilation Methods (CPAP and BIPAP) on Respiratory Mechanics and Gas Exchange in Patients Undergoing Abdominal Surgery.

OBJECTIVE: The aim of our study is to investigate the effect of two different methods of continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP) and oxygen support under spontaneous ventilation on respiration mechanics, gas exchange, dry mouth and face mask lesion during an early postoperative period in patients undergoing upper abdominal surgery. METHODS: Eighty patients undergoing elective abdominal surgery with laparotomy, between the age of 25 and 75 years and American Society of Anesthesiologists Physical Status score (ASA) II-III with chronic obstructive pulmonary disease (COPD) diagnosis were included to the study. Subjects were randomly allocated in to four groups. During the first postoperative hour, the first group received BIPAP, second group received high-flow CPAP, third group received low-flow CPAP and fourth group received deep breathing exercises, respiratory physiotherapy and O2 therapy. Preoperative, postoperative before and after treatment PaO2, PaCO2, SpO2, tidal volume (TV), respiratory rate (RR) levels were recorded. Subjects with dry mouth or face mask lesion were recorded. RESULTS: In all groups, PaO2 and TV measurements were higher at the postoperative first hour than the postoperative zero hour. We found that low-flow CPAP increased PaO2 and SpO2 values more, and TV levels were higher in the postoperative period than the preoperative period. PaCO2 levels were elevated at the zero hour postoperatively and at the end of the first hour; they decreased approximately to preoperative values, except in the fourth group. CONCLUSION: Administration of prophylactic respiratory support can prevent the deterioration of pulmonary functions and hypoxia in patients with COPD undergoing upper abdominal surgery. In addition, we found that low-flow CPAP had better effects on PaO2, SpO2, TV compared to other techniques.

The effects of intravenous, enteral and combined administration of glutamine on malnutrition in sepsis: a randomized clinical trial.

Our aim was to compare the effects of intravenous, enteral, and enteral plus intravenous supplemented glutamine on plasma transferrin, nitrogen balance, and creatinine/height index in septic patients with malnutrition. Blood and urine samples were collected for transferrin, urea and creatinine measurements. Samples, SOFA score and protein-calorie intake values were repeated on days 7 and 15. Patients (n:120) were randomly divided into 4 groups. Group I received 30 g/day IV glutamine, group II received 30 g/day enteral glutamine, group III received 15 g/day IV and 15 g/day enteral glutamine. Group IV received only enteral feeding as a control group. Transferrin levels decreased in group IV (p<0.01 0-7 days, p<0.01 7-15 days, p<0.01 0-15 days). Nitrogen balance levels were highest in group IV when compared with group I (p<0.05, p<0.001), group II (p<0.001), and group III (p<0.05, p<0.001) on days 7-15. Creatinine/height indexes increased in group I (p<0.001), group II (p<0.001), group III (p<0.001), and group IV (p<0.05) on day 15. In group III the creatinine/height index was higher than in groups I and II (p<0.05). In group IV, creatinine/height index was lower than in group I (p<0.01) and group II (p<0.001). Protein-calorie intake in group IV was higher than others on day 7 (p<0.05). SOFA scores of group IV were higher than the other groups on day 15 (p<0.05). This study demonstrated, that combined route of gln supplementation resulted in the most positive outcome to transferrin, creatine/height index and nitrogen balance (on days 7 and 15) during the catabolic phase of septic patients with malnutrition.

The Effect of BIS Usage on Anaesthetic Agent Consumption, Haemodynamics and Recovery Time in Supratentorial Mass Surgery.

OBJECTIVE: In this study, we aimed to compare Bispectral Index (BIS) monitoring with the conventional anaesthesia approach based on haemodynamic changes in terms of anaesthetic agent consumption, haemodynamic recordings, recovery time and cost. METHODS: This study was performed in 82 patients, aged 20 to 60 years, who were operated for supratentorial mass and were graded ASA I or II. Cases were randomly divided into two equal groups. In the standard control group haemodynamic parameters were used to determine depth of anaesthesia and in the BIS group, BIS monitoring was applied. In the BIS group the BIS values were kept between 40 and 60; in the control group haemodynamic changes within the range of +/-20% of initial values were controlled using appropriate anaesthetic practice. Haemodynamic parameters, awakening conditions and drug usage were recorded. RESULTS: The difference between the two groups in terms of timing of eye opening and initial spontaneous breath was not statistically significant. The 'Aldrete' score at the 20(th) postoperative minute for the BIS group was significantly higher than the score calculated for the control group (p<0.05). Rocuronium consumption (mg kg(-1) hr(-1)) was significantly lower in the BIS group than the control group (p<0.05). Although a statistically significant difference (p<0.05) was found between the two groups in terms of initial heart rate and SpO2 values, there was no clinically significant difference in other haemodynamic parameters. CONCLUSION: Although using BIS monitoring to evaluate depth of anaesthesia does not bring much benefit versus the use of haemodynamic parameters, it may be beneficial for selected surgeries such as awake craniotomy, for patients with a history of awareness and in haemodynamically unstable patients.

Efficacy of intravenous paracetamol and dexketoprofen on postoperative pain and morphine consumption after a lumbar disk surgery.

BACKGROUND: We compared the analgesic effects of intravenous (IV) paracetamol with that of dexketoprofen on postoperative pain and morphine consumption during the first 24 hour after a lumbar disk surgery. METHODS: This prospective, placebo-controlled, double blind study investigated the analgesic effects of IV paracetamol and dexketoprofen on postoperative pain, morphine consumption, and morphine-related side effects after a lumbar disk surgery. Sixty American Society of Anesthesiologists 1 or 2 status patients scheduled for elective lumbar disk surgery under general anesthesia were included in the study. Patients were treated using patient-controlled analgesia with morphine for 24 hours after a lumbar disk surgery and randomized to receive IV paracetamol 1 g, dexketoprofen 50 mg, or isotonic saline (placebo). The primary endpoint was pain intensity measured by the visual analogue scale, and secondary endpoints were morphine consumption and related side effects. RESULTS: Pain intensity was lower in the dexketoprofen group (P=0.01) but not in the paracetamol group (P=0.21) when compared with the control group. Cumulative morphine consumption and morphine-related side effects did not reveal significant differences between the groups. CONCLUSIONS: The study showed that pain intensity during 24 hours after the lumbar disk surgery was significantly lowered by dexketoprofen, but not with paracetamol, as a supplemental analgesic to morphine patient-controlled analgesia when compared with controls.

Perioperative Temperature Monitoring and Patient Warming: A Survey Study.

OBJECTIVE: Hypothermia is defined as the decrease of core body temperature under 36°C. Hypothermia is observed at a rate of 50-90% in the perioperative period. In our study, we aimed to measure the perception of hypothermia in our country, to evaluate the measures taken by physicians to intercept hypothermia, to determine the frequency and the methods used to monitor body temperature and the techniques used in warming the patients. Another aim was to develop a guideline for preventing perioperative hypothermia. METHODS: The questionnaire consisted of 26 multiple-choice questions. The time needed to answer the questions was 8-10 minutes. RESULTS: Of the 1380 individuals, 312 (22.6%) answered the questions in the questionnaire. Of these, 148 (47.4%) declared they were working in university hospitals, 80 (25.6%) in training and research hospitals, 51 (16.4%) in government hospitals and 33 (10.6%) in various private hospitals. Of the 312 individuals, 134 (42.9%) were specialists, 107 (34.3%) were resident physicians, 71 (22.8%) were academics. In addition, 212 (67.9%) reported working in operating rooms, 49 (15.7%) in intensive care units and 42 (13.5%) both in operating rooms and intensive care units. In the answers, there was variation among the hospital types in applications of body temperature monitoring and warming the patient. Another finding was that the individuals had different approaches to the concepts on perioperative hypothermia and its consequences. CONCLUSION: The perceptions of physicians and the allied health personnel in government and private hospitals should be enhanced by informing them about the passive and active heating systems to prevent hypothermia. Although the situation in university and training and research hospitals seems to be better, defects are still observed in practice. Preparation of a national guideline for prevention of perioperative hypothermia is needed.

Comparison of the Effects of Different Concentrations of Rocuronium on Injection Pain and Hemodynamics Using Isolated Forearm Technique.

OBJECTIVE: We aimed to evaluate Visual-Analogue-Scale (VAS) scores, hand-withdrawal, rash and skin eruptions after injections of different concentrations of rocuronium in intubation doses in alert patients using the isolated-forearm technique. METHODS: Eighty ASA I-II patients were included in a randomized, controlled, single-blinded study. Two 20 G cannulas were inserted into the dorsum of the left and right hand in each patient. A tourniquet was applied to the left arm and inflated to 50 mm Hg above the patient's systolic blood pressure. Group 1 (n=20) received 2.5 mg mL(-1) rocuronium diluted with 0.9% NaCl, Group 2 (n=20) received 5 mg mL(-1) rocuronium diluted with 0.9% NaCl, Group 3 (n=20) received 10 mg mL(-1) rocuronium and 0.4 mg mL(-1) lidocaine mixture, and Group 4 (n=20) received 10 mg mL(-1) rocuronium via a cannula on the left hand, provided that a dose of 0.6 mg mL(-1) were given to all groups of patients. VAS0-VAS60 values, hand-withdrawal, rash and skin eruptions were assessed in patients who were administered rocuronium but not under the effects of hypnotic or neuromuscular agents. Hemodynamic values were recorded both before and after the administration of hypnotic-neuromuscular agents. RESULTS: VAS0 values were significantly higher in Group 4 when compared to Groups 1, 2 and 3 (p=0.032). No significant difference was observed between VAS0 and VAS60 values in Groups 1, 2 and 3. In Group 4, VAS0 values were significantly higher than VAS60 values (p=0.003). No significant difference was observed between groups in terms of side effects and hemodynamic values. CONCLUSION: In conclusion, we determined that using rocuronium diluted with 0.9% NaCl was more effective in preventing injection pain than using a rocuronium-lidocaine mixture.

An infrarenal abdominal aortic coarctation.

We describe a case of infrarenal abdominal coarctation in a 44-year-old woman who presented with severe uncontrolled hypertension. She had no signs of lower limb ischemia with normal distal pulses. Electron beam tomography revealed abdominal aortic coarctation extending from the superior mesenteric artery to the inferior mesenteric artery with a diameter of 9 mm. Also, at the level of coarctation, the aortic branches including the renal arteries were in a serpentine shape.

The effects of different weaning modes on the endocrine stress response.

INTRODUCTION: The aim of the present study was to investigate the effects of the stress response on plasma insulin, cortisol, glucose, and urinary vanilmandelic acid during weaning and after extubation, using pressure support (PS), continuous positive airway pressure (CPAP) and T-piece modes. METHODS: Sixty patients were randomly divided into three groups (n = 20). The PS group received FiO2