Comparison of ultrasound and ultrasound plus nerve stimulator guidance axillary plexus block.

OBJECTIVE: To evaluate the characteristics of axillary plexus blockade applied using ultrasound only and using ultrasound together with nerve stimulator in patients undergoing planned forearm, wrist or hand surgery. METHODS: This randomised, prospective, double-blinded, single-centre study was conducted at Ankara Numune Training and Research Hospital, Ankara, Turkey, from November 2014 to August 2015, and comprised patients undergoing forearm, wrist or hand surgery. Participants were separated into 2 groups. In Group 1, the nerve roots required for the surgical site were located one by one and local anaesthetic was applied separately to each nerve for the block. In Group 2, the vascular nerve bundle was located under ultrasound guidance and a total block was achieved by administering all the local anaesthetic within the nerve sheath. In the operating room, standard monitorisation was applied. Following preparation of the skin, the axillary region nerve roots and branches and vascular structures were observed by examination with a high-frequency ultrasound probe. In both groups, a 22-gauge, 5cm block needle was entered to the axillary region with visualisation of the whole needle on ultrasound and 20ml local anaesthetic of 0.5% bupivacaine was injected. SPSS 19 was used for data analysis. RESULTS: Of the 60 participants, there were 30(50%) in each group. The mean age was 39.1±15 years in the group 1 which was the ultrasound nerve stimulation group, and 41.5±14.3 years in group 2. The duration of the procedure was longer in group I than in group 2 (p<0.05). Patient satisfaction values during the procedure were higher in group 2(p<0.05). In the ulnar sensory examination, the values of the patients in group 1were higher at 10, 15, 20 and 25 minutes (p<0.05). In the median, radial and ulnar motor examination, the values of the patients in group 1were higher at 15 and 20 minutes (p<0.05). CONCLUSIONS: Brachial plexus blockade via axillary approach guided by ultrasound offered excellent quality of sensory and motor block equivalent to that of the nerve stimulator-guided technique.

Phenytoin induced toxic epidermal necrolysis.

Toxic Epidermal Necrolysis (TEN) which is characterized by the detachment of the epidermis from the dermis is a rare (1.89/1.000.000 annually) and potentially life-threatening condition. The overall mortality is 20 - 30%. TEN is characterized by sudden apoptosis of keratinocytes leading to mucous membrane erosions and epidermal detachment; detachment of less than 10% of the total body surface area defines Stevens-Johnson Syndrome (SJS); when greater than 30%, it defines TEN, while intermediate cases are called SJS/TEN overlap. Many drugs, including prednisolone, cyclosporin, and intravenous immunoglobulin (IVIG), have been used in an attempt to halt the disease process. The use of phenytoin as a prophylactic anticonvulsant after brain surgery, particularly for brain tumors, is a common practice, regardless of whether the patient has a previous history of convulsions. This report described a case of haemorrhagic stroke where phenytoin use induced TEN.

Intraoperative low-dose ketamine infusion reduces acute postoperative pain following total knee replacement surgery: a prospective, randomized double-blind placebo-controlled trial.

OBJECTIVE: To evaluate the effect of intraoperative low-dose ketamine with general anesthesia on postoperative pain after total knee replacement surgery. STUDY DESIGN: A randomized, double-blind comparative study. PLACE AND DURATION OF STUDY: Ankara Numune Training and Research Hospital, Turkey, from January and June 2011. METHODOLOGY: Sixty adults undergoing total knee arthroplasty were enrolled in this study. The patients were randomly allocated into two groups of equal size to receive either racemic ketamine infusion (6 µg/kg/minute) or the same volume of saline. A visual analogue scale (VAS) was used to measure each patient's level of pain at 1, 3, 6, 12, and 24 hours after surgery. Time to first analgesic request, postoperative morphine consumption and the incidence of side effects were also recorded. RESULTS: Low-dose ketamine infusion prolonged the time to first analgesic request. It also reduced postoperative cumulative morphine consumption at 1, 3, 6, 12, and 24 hours postsurgery (p < 0.001). Postoperative VAS scores were also significantly lower in the ketamine group than placebo, at all observation times. Incidences of side effects were similar in both study groups. CONCLUSION: Intraoperative continuous low-dose ketamine infusion reduced pain and postoperative analgesic consumption without affecting the incidence of side effects.

A comparison of intra cuff pressures in high-flow and low-flow nitrous oxide anesthesia.

OBJECTIVE: To investigate intra cuff pressure changes in low-flow anesthesia (LFA) and high-flow (HFA) N2O anesthesia during moderate-duration surgical procedures. METHODS: We carried out this prospective, randomized, single blind study at Numune Educational and Research Hospital, Ankara, Turkey between January to December 2005. Seventy patients aged between 18-65 years, American Society of Anesthesiologists (ASA) physical status grades I-III, undergoing elective surgery were enrolled in this study. Following a standardized induction, anesthesia was maintained with isoflurane (end-tidal 0.9-1%) at 4 L/minute for the HFA group, or 1 L/minute for the LFA group fresh gas flows. Endotracheal tube cuff (intra cuff) pressures were measured continuously with a pressure manometer, and inspired oxygen and N2O levels were noted every 10 minutes throughout the study. RESULTS: There was no significant difference between HFA and LFA groups for initial (first) cuff pressures (mean+/-SD, HFA=20.9+/-4.19, LFA=20.4+/-4.11, cmH2O), and maximum cuff pressures (MCP) (mean+/-SD, HFA=32.3+/-18.74, LFA=33.5+/-8.89, cmH2O) (p>0.05). The time to reach the maximum intra cuff pressure was significantly shorter in the LFA group (77.4+/-20.33 minutes), than the HFA group (89.3+/-23.94 minutes), (p=0.038). Between the tenth and nineteenth minutes, inspired oxygen level was significantly higher in the HFA group (p=0.001), whereas inspired N2O was significantly higher in the LFA group (p=0.001). CONCLUSION: The intra cuff pressures should be monitored carefully during LFA, since the duration to reach the maximum intra cuff pressures was shorter than that of HFA.

The effect of ethyl pyruvate on oxidative stress in intestine and bacterial translocation after thermal injury.

BACKGROUND: Thermal injury causes a breakdown in the intestinal mucosal barrier due to ischemia reperfusion injury, which can induce bacterial translocation (BT), sepsis, and multiple organ failure in burn patients. The aim of this study was to investigate the effect of ethyl pyruvate (EP) on intestinal oxidant damage and BT in burn injury. MATERIALS AND METHODS: Thirty-two rats were randomly divided into four groups. The sham group was exposed to 21 degrees C water and injected intraperitoneal with saline (1 mL/100 g). The sham + EP group received EP (40 mg/kg) intraperitoneally 6 h after the sham procedure. The burn group was exposed to thermal injury and given intraperitoneal saline injection (1 mL/100 g). The burn + EP group received EP (40 mg/kg) intraperitoneally 6 h after thermal injury. Twenty-four hours later, tissue samples were obtained from mesenteric lymph nodes, spleen, and liver for microbiological analysis and ileum samples were harvested for biochemical analysis. RESULTS: Thermal injury caused severe BT in burn group. EP supplementation decreased BT in mesenteric lymph nodes and spleen in the burn + EP group compared with the burn group (P < 0.05). Also, burn caused BT in liver, but this finding was not statistically significant among all groups. Thermal injury caused a statistically significant increase in malondialdehyde and myeloperoxidase levels, and EP prevented this effects in the burn + EP group compared with the burn group (P < 0.05). CONCLUSION: Our data suggested that EP can inhibit the BT and myeloperoxidase and malondialdehyde production in intestine following thermal injury, suggesting anti-inflammatory and anti-oxidant properties of EP.

The protective effect of ethyl pyruvate on lung injury after burn in rats.

OBJECTIVE: To investigate the effects of administered ethyl pyruvate (EP), a novel anti-inflammatory agent, on oxidoinflammatory and apoptotic pathways in the lung tissue of rats in a full-thickness burn model. METHODS: The study took place in Ankara Research and Training Hospital Animal Laboratory, Turkey in June 2006. Thirty-two rats were randomly divided into 4 groups in equal numbers as sham, burn, sham+EP, and burn+EP. The burn model, used produced a full thickness burn of the 30-35% of the total body surface area. Ethyl pyruvate was administered as 40 mg/kg intraperitoneally. Rats were sacrificed after 24 hours, acute lung injury (ALI) was evaluated by direct light microscopy and apoptosis was evaluated by caspase-3 staining. Oxidoinflammatory events were evaluated by determining the tissue levels of myeloperoxidase (MPO), lipid peroxidation products, and nitrite. RESULTS: No significant difference was observed in lung tissue nitrite and malondialdehyde levels among the study groups. Histopathological results revealed that ALI and apoptosis were significantly higher in the burn group and EP prevented this effect. Similar results were obtained in tissue MPO levels. CONCLUSION: Ethyl pyruvate is a novel, potent anti-inflammatory agent. This agent prevented leukocyte infiltration, ALI, and apoptotic loss of the lung tissue in thermal injury.

Myasthenia gravis and sevoflurane--a case report.

Myasthenia gravis is characterized by weakness and easy fatiguability of voluntary muscles. Myasthenic patients are sensitive to non-depolarizing relaxants. Sevoflurane, as an alternative, can be used to achieve good tracheal intubation. In this report, we present our experiences.