Effects of Haemodynamic Changes Caused by Different Pneumoperitoneum Pressures on Cerebral Oxygenation in Laparoscopic Cholecystectomy: Prospective Randomised Controlled Trial.

OBJECTIVE: To evaluate the role of different pneumoperitoneum pressure ranges on cerebral oxygenation. STUDY DESIGN: Prospective, randomised controlled trial. Place and Duration of the Study: Karadeniz Technical University, Turkiye, from January to September 2020. METHODOLOGY: Seventy patients (aged 18-65 years, ASA I-IIII) scheduled for laparoscopic cholecystectomy were divided into two groups; low pressure (LP, 10-12 mmHg) and high pressure (HP, 13-15 mmHg). The heart rate, peripheral oxygen saturation, systolic, diastolic, and mean arterial pressure, BIS, end-tidal carbon dioxide, and left and right regional cerebral oxygen saturation (rSO2) were recorded during induction, at the beginning, and after 5, 10, 15, 30, 60, and 90th minutes of pneumoperitoneum, after the surgical and anaesthesia procedures. RESULTS: The findings did not demonstrate a significant difference between the haemodynamic parameters of the groups. However, there were differences (fifth [p=0.022], fifteenth minutes [p=0.035], at the end [p=0038] of pneumoperitoneum in right rSO2, and similarly at the end [p=0.038] of pneumoperitoneum in left rSO2 between mean variation of rSO2 when compared to the baseline; cerebral oxygenation was better preserved in LP. While no patient had more than 20% rSO2 reduction in LP, a total of three patients had cerebral desaturation in HP. CONCLUSION: Although <15 mmHg pressure for pneumoperitoneum was usually well-tolerated by patients, it had been observed that cerebral oxygenation may be affected with this range. The pathophysiological effects of pneumoperitoneum and possible consequences of this situation should be considered while performing laparoscopy. KEY WORDS: Cerebrovascular circulation, Haemodynamics, Laparoscopic cholecystectomy, Near- infrared spectroscopy, Pneumoperitoneum.

The effect of the endotracheal tube cuff shape on post-operative sore throat in surgeries longer than 120 min in supine position.

BACKGROUND: This study aimed at comparing the effects of cylindrical- and conical-cuff endotracheal tubes (ETTs) inflated with saline on cuff pressures, post-operative sore throat, and post-operative analgesic consumption in surgeries taking longer than 120 min. OBJECTIVE: This study aimed at comparing the effects of cylindrical- and conical-cuff endotracheal tubes (ETTs) inflated with saline on cuff pressures, post-operative sore throat, and post-operative analgesic consumption in surgeries taking longer than 120 min. METHODS: The study was performed on a total of 100 patients, aged 18-65 years, in the ASA I-III risk group, with cylindrical cuff (Group C, n = 50) and conical cuff (Group T, n = 50) ETT patients. Cuff pressure values of all patients were recorded. RESULTS: The cuff pressure values at all measurement times and maximum cuff pressure value were significantly lower in Group T than in Group C (p < 0.05). In the post-operative 24-h period, sore throat and total analgesic consumption were significantly lower in Group T than in Group C (p < 0.05). CONCLUSION: conical cuff ETTs prevent the increase in intraoperative cuff pressures, reduce the incidence of post-operative sore throat, and accordingly reduce post-operative analgesic consumption compared to cylindrical cuff ETTs.

ANTECEDENTES: El objetivo de este estudio fue comparar los efectos de los tubos endotraqueales (ETT) de manguito cilíndrico y cónico inflados con solución salina sobre las presiones del manguito, el dolor de garganta postoperatorio y el consumo de analgésicos postoperatorios en cirugías de más de 120 min de duración. OBJETIVO: Comparar los efectos de los tubos endotraqueales de manguito cilíndrico y cónico inflados con solución salina sobre las presiones del manguito, el dolor de garganta posoperatorio y el consumo de analgésicos posoperatorios en cirugías de más de 120 minutos de duración. MÉTODO: El estudio se realizó en 100 pacientes con edades entre 18 y 65 años, con riesgo ASA I-III, con tubo endotraqueal de manguito cilíndrico (grupo C, n = 50) o manguito cónico (grupo T, n = 50). RESULTADOS: Los valores de presión del manguito en todos los tiempos de medición y el valor máximo de presión del manguito fueron significativamente más bajos en el grupo T que en el grupo C (p < 0.05). En el período de 24 horas del posoperatorio, el dolor de garganta y el consumo total de analgésicos fueron significativamente menores en el grupo T que en el grupo C (p < 0.05). CONCLUSIONES: Los tubos endotraqueales de manguito cónico previenen el aumento de las presiones intraoperatorias del manguito, reducen la incidencia de dolor de garganta posoperatorio y, en consecuencia, disminuyen el consumo de analgésicos posoperatorios en comparación con los de manguito cilíndrico.

The effect of different anesthesia techniques on cerebral oxygenation in thoracic surgery.

OBJECTIVE: One-lung ventilation may cause negative changes in the oxygenation of cerebral tissue which results in post-operative cognitive dysfunction. We compared the potential effects of total intravenous anesthesia and inhalation general anesthesia techniques on cerebral tissue oxygenation. MATERIALS AND METHODS: In this prospective double-blind trial, patients whose standard anesthesia induction was done were randomly divided into two groups as group total intravenous anesthesia using propofol (Group T, n = 30) and group inhalation general anesthesia using sevoflurane (Group I, n = 30) based on anesthesia maintenance. The intraoperative cerebral oxygen saturation and pre-post-operative mini-mental status test scores of the patients were monitored and recorded. RESULTS: Baseline characteristics were similar between the two groups. The decrease of cerebral oxygen saturation more than 20% in total intravenous anesthesia group was significantly higher than inhalation group (p < 0.05). In both groups, the mini-mental status test values at the post-operative 3rd h were significantly lower than the pre-operative and post-operative 24th h values (p < 0.05). CONCLUSIONS: Inhalation general anesthesia provided better cerebral tissue oxygenation in thoracic surgery with one-lung ventilation compared to total intravenous anesthesia. However, there was no significant correlation between the presence of desaturation and post-operative cognitive dysfunction.

OBJETIVO: La ventilación unipulmonar puede provocar cambios negativos en la oxigenación del tejido cerebral que se traduce en una disfunción cognitiva postoperatoria. Comparamos los efectos potenciales de la anestesia total intravenosa y las técnicas de anestesia general por inhalación en relación con la oxigenación del tejido cerebral. MATERIAL Y MÉTODOS: En este ensayo prospectivo doble ciego, los pacientes en los que se realizó una inducción estándar de anestesia se dividieron aleatoriamente en dos grupos: grupo de anestesia intravenosa total con propofol (Grupo T, n = 30) y grupo de anestesia general por inhalación con sevoflurano (Grupo I, n = 30) basados en el mantenimiento de la anestesia. Se controlaron y registraron la saturación de oxígeno cerebral intraoperatoria y las valoraciones de la miniprueba de estado mental preoperatoria de los pacientes. RESULTADOS: Las características de base fueron similares entre los dos grupos. La disminución de la saturación de oxígeno cerebral de más del 20% en el grupo de anestesia intravenosa total fue significativamente mayor que en el grupo de inhalación (p < 0.05). En ambos grupos, los valores de la mini prueba del estado mental al cabo de la 3a. hora del período posoperatorio fueron significativamente más bajos que los valores preoperatorios y posoperatorios registrados al cabo de 24 horas (p < 0.05). CONCLUSIONES: La anestesia general por inhalación facilitó una mejor oxigenación del tejido cerebral en la cirugía torácica con ventilación unipulmonar en comparación con la anestesia intravenosa total. Sin embargo, no hubo una correlación significativa entre la presencia de desaturación y la disfunción cognitiva posoperatoria.

THE EFFECTS OF PATIENT POSITION ON EARLY COMPLICATIONS OF SPINAL ANESTHESIA INDUCTION IN ARTHROSCOPIC KNEE SURGERY.

Spinal anesthesia is widely used in different patient positions to create efficient and rapid anesthesia induction in surgical interventions. Early and late complications of spinal anesthesia may vary according to the type of needle, drug dose and concentration, patient weight and height, puncture technique, and position of the patient. This study aimed to prospectively compare early complications of spinal anesthesia between patients in sitting and lateral decubitus positions with motor block onset time and sensory block time to T10 level. Spinal anesthesia was performed in 100 ASA I-II patients aged 18-65 years (group S=48; and group L=52) undergoing arthroscopic knee surgery. Hemodynamic data, early complications, sensory and motor block onset times were recorded. Systolic, diastolic and mean arterial pressures were significantly lower in lateral decubitus position as compared to sitting position after spinal anesthesia induction. Arterial blood pressure values decreased significantly in lateral decubitus position as compared with sitting position. Motor block onset time and sensory block onset time were shorter in lateral decubitus position than in sitting position. Accordingly, sitting position could be suggested during induction of spinal anesthesia because it was associated with less pronounced decrease in blood pressures.

Cholecystectomy with Thoracic Epidural Anesthesia in Geriatric Patients.

OBJECTIVE: To determine the outcome of thoracic epidural anaesthesia in open cholecystectomy procedures of comorbid advanced elderly patients. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Faculty of Medicine, Karadeniz Technical University Hospital, Trabzon, Turkey during 2014-2019. METHODOLOGY: This study included 103 geriatric patients of over 65 years, who underwent open cholecystectomy under thoracic epidural anaesthesia during the study period. Patient files, anaesthesia registration forms, early postoperative follow-up, and discharge process were retrospective. RESULTS: The mean age of the patients included in the study was 79.42 ± 9.03 years, while the mean operation time was 68.02 ± 17.44 minutes. While only 7 (6.8%) patients had a chronic disease, the number of patients with two or three comorbid diseases was 67 (65%). The number of patients with 4 or more comorbidities was 29 (28.2%). The most common intraoperative complications were hypotension (n = 22, 21.4%) and bradycardia (n = 19, 18.4%). Intraoperative desaturation was observed in 7 (6.8%) patients; and oxygen and bronchodilator therapy was effective. The median discharge time was 6.5 (5.0-8.25) days; whereas, 5 (4.9%) patients died postoperatively. CONCLUSION: In open cholecystectomy operations on comorbid advanced elderly patients, thoracic epidural anaesthesia can be preferred to general anaesthesia. Key Words: Geriatrics, Cholecystectomy, Anesthesia, Thoracic epidural, Comorbidity.

A comparison of ketamine-midazolam combination and propofol-fentanyl combination on procedure comfort and recovery process in pediatric colonoscopy procedures.

OBJECTIVE: To compare the efficacy and safety of midazolam-ketamine combination versus fentanyl-propofol combination in pediatric diagnostic colonoscopy. METHODS: This is a retrospective study of 68 children undergoing diagnostic gastroenterology with midazolam-ketamine combination (Group-K) or with fentanyl-propofol combination (Group-P) in the pediatric gastroentology department at a Turkish tertiary hospital between January 2015 and June 2017. An intravenous midazolam was administered one minute before ketamine administration in Group K. Intravenous fentanyl was given to Group P, followed by intravenous propofol. RESULTS: There were statistically no significant differences between the groups as for age, gender, weight, duration of colonoscopy and complications observed during procedure. Ramsay sedation score was significantly higher in Group K. Recovery time and the rate of complications during the recovery of Group-K (23 patients, 65.7%) was significantly higher than that of Group P (8 patients, 24.2%) (p= 0.001). CONCLUSIONS: Colonoscopy procedures can be quite comfortable in children when using the midazolam-ketamine combination. However, adverse effects related to ketamine were observed during recovery.

Sedoanalgesia modality during laser photocoagulation for retinopathy of prematurity: Intraoperative complications and early postoperative follow-up.

BACKGROUND: Laser photocoagulation (LPC) is a surgical procedure used in the treatment of premature retinopathy that may cause retinal detachment and blindness if not diagnosed and treated early. The anesthesia method used in LPC varies from sedoanalgesia to general anesthesia and airway management varies from spontaneous ventilation to endotracheal intubation. In this study, we aimed to evaluate the effectiveness of sedoanalgesia applications and this anesthesia procedure concerning intraoperative and postoperative complications by avoiding intubation and mechanical ventilation in premature infants with a fragile population. METHODS: This retrospective study included 89 patients who underwent laser photocoagulation under anesthesia for premature retinopathy. Patients' demographic characteristics, preoperative risk factors, anesthesia technique, especially airway management, changes in ventilation status during surgery, intraoperative complications, postoperative complications, and intensive care follow-up, were recorded and analyzed statistically. RESULTS: Two of the 89 patients who underwent laser photocoagulation were excluded from this study because they were followed up intubated. The number of patients who received mask ventilation due to intraoperative complications was 12 (13.8%). The mean operation time was 36.2±10.1 minutes. In 86.2% (n=75) of the patients, the surgical procedure was completed with sedoanalgesia while maintaining spontaneous ventilation. CONCLUSION: Sedoanalgesia application during the surgical intervention of patients with Retinopathy of Prematurity (ROP) requiring early diagnosis and emergency treatment will minimize intraoperative and postoperative complications. We believe that sedoanalgesia as an anesthetic method can be applied as an effective alternative method while preserving spontaneous ventilation.

A comparison of sedation with midazolam-ketamine versus propofol-fentanyl during endoscopy in children: a randomized trial.

PURPOSE: We aimed to compare the efficacy and safety of midazolam plus ketamine versus fentanyl plus propofol combination administered to children undergoing upper gastrointestinal endoscopy (UGE) and to determine the most appropriate sedation protocol. MATERIALS AND METHODS: This prospective, randomized, single-blind study included patients between the ages of 4 and 17 years who underwent UGE for diagnostic purposes. Patients were divided randomly into groups A (midazolam-ketamine combination, n=119) and B (fentanyl plus propofol combination, n=119). The effectiveness of the sedation and complications during the procedure and recovery period were recorded. RESULTS: The processes started without an additional dose of the drug for 118 patients (99.1%) in group A and for 101 patients (84.8%) in group B (P=0.001). The average dose of ketamine administered to the patients in group A was 1.03±0.15 mg/kg and the average dose of propofol administered to the patients in group B was 1.46±0.55 mg/kg. None of the patients stopped the endoscopic procedure in group A, but one patient (0.8%) had to discontinue the endoscopic procedure in group B. 27 patients in group A (22.7%) and 41 patients (34.5%) in group B developed complications during the procedure (P=0.044). The rate of complications during the recovery of group A (110 patients, 92.4%) was significantly higher than that in group B (48 patients, 40.3%) (P=0.001). CONCLUSION: In children, UGE procedures can be quite comfortable when using the midazolam-ketamine combination. However, adverse effects related to ketamine were observed during recovery.

Cost analysis and evaluation of nosocomial infections in intensive care units.

BACKGROUND/AIM: The purpose of this study was to evaluate nosocomial infections occurring in our hospital intensive care units (ICUs) and the risk factors for these, and to determine the effect of these infections on mortality and cost. MATERIALS AND METHODS: This retrospective study was performed via infection control committee surveillance data, ICU records, and information processing data between 1 January and 31 December 2013 at the Kanuni Education and Research Hospital. RESULTS: A total of 309 nosocomial infections were observed in 205 out of 566 patients. The density of nosocomial infections was 25.4 in 1000 patient days. Hospitalization was prolonged, and APACHE II and Charlson comorbidity scores were high in patients developing nosocomial infections (P < 0.001). Of the patients diagnosed with a nosocomial infection, 170 died. Infections were determined as the cause of death in 62 (36.5%) of the nonsurviving patients with a nosocomial infection. Acinetobacter baumannii was identified in 46 (74.2%) of the patients that died from nosocomial infections. The mean cost in patients developing a nosocomial infection was 15,229.30 Turkish lira (TL), compared to 9648.00 TL in patients without a nosocomial infection (P = 0.002). CONCLUSION: Regular infection control education sessions need to be held and the number of nurses needs to be increased in order to be able to reduce this high mortality, morbidity, and cost.

Staff education aimed at reducing ventilator-associated pneumonia.

Mechanical ventilation is a life-saving invasive procedure performed in intensive care units (ICUs) where critical patients are given advanced support. The purpose of this study was to assess the effect of personnel training on the incidence of ventilator-associated pneumonia (VAP). The study, performed prospectively in the ICU, was planned in two periods. In both periods, patient characteristics were recorded on patient data forms. In the second period, ICU physicians and assistant health personnel were given regular theoretical and practical training. Twenty-two cases of VAP developed in the pre-training period, an incidence of 31.2. Nineteen cases of VAP developed in the post-training period, an incidence of 21.0 (P<0.001). Training reduced development of VAP by 31.7 %. Crude VAP mortality was 69 % in the first period and 26 % in the second (P<0.001). Statistically significant risk factors for VAP in both periods were prolonged hospitalization, increased number of days on mechanical ventilation, and enteral nutrition; risk factors determined in the first period were re-intubation, central venous catheter use and heart failure and, in the second period, erythrocyte transfusion >5 units (P<0.05). Prior to training, compliance with hand washing (before and after procedure), appropriate aseptic endotracheal aspiration and adequate oral hygiene in particular were very low. An improvement was observed after training (P<0.001). The training of personnel who will apply infection control procedures for the prevention of healthcare-associated infections is highly important. Hand hygiene and other infection control measures must be emphasized in training programmes, and standard procedures in patient interventions must be revised.

An assessment of ventilator-associated pneumonias and risk factors identified in the Intensive Care Unit.

OBJECTIVES: Ventilator-associated pneumonia (VAP) is a significant cause of hospital-related infections, one that must be prevented due to its high morbidity and mortality. The purpose of this study was to evaluate the incidence and risk factors in patients developing VAP in our intensive care units (ICUs). METHODS: This retrospective cohort study involved in mechanically ventilated patients hospitalized for more than 48 hours. VAP diagnosed patients were divided into two groups, those developing pneumonia (VAP(+)) and those not (VAP(-)).\. RESULTS: We researched 1560 patients in adult ICUs, 1152 (73.8%) of whom were mechanically ventilated. The MV use rate was 52%. VAP developed in 15.4% of patients. The VAP rate was calculated as 15.7/1000 ventilator days. Mean length of stay in the ICU for VAP(+) and VAP(-) patients were (26.7±16.3 and 18.1±12.7 days (p<0.001)) and mean length of MV use was (23.5±10.3 and 12.6±7.4 days (p<0.001)). High APACHE II and Charlson co-morbidity index scores, extended length of hospitalization and MV time, previous history of hospitalization and antibiotherapy, reintubation, enteral nutrition, chronic obstructive pulmonary disease, cerebrovascular disease, diabetes mellitus and organ failure were determined as significant risk factors for VAP. The mortality rate in the VAP(+) was 65.2%, with 23.6% being attributed to VAP. CONCLUSION: VAPs are prominent nosocomial infections that can cause considerable morbidity and mortality in ICUs. Patient care procedures for the early diagnosis of patients with a high risk of VAP and for the reduction of risk factors must be implemented by providing training concerning risk factors related to VAP for ICU personnel, and preventable risk factors must be reduced to a minimum.

The effects of single-dose rectal midazolam application on postoperative recovery, sedation, and analgesia in children given caudal anesthesia plus bupivacaine.

BACKGROUND: This study aimed to compare the effects of rectal midazolam addition after applying bupivacaine and caudal anesthesia on postoperative analgesia time, the need for additional analgesics, postoperative recovery, and sedation and to find out its adverse effects in children having lower abdominal surgery. METHODS: 40 children between 2 and 10 years of ASA I-II were randomized, and they received caudal anesthesia under general anesthesia. Patients underwent the application of caudal block in addition to saline and 1 mL/kg bupivacaine 0.25%. In the postoperative period, Group C (n = 20) was given 5 mL saline, and Group M (n = 20) was given 0.30 mg/kg rectal midazolam diluted with 5 mL saline. Sedation scale and postoperative pain scale (CHIPPS) of the patients were evaluated. The patients were observed for their analgesic need, first analgesic time, and adverse effects for 24 hours. RESULTS: Demographic and hemodynamic data of the two groups did not differ. Postoperative sedation scores in both groups were significantly lower compared with the preoperative period. There was no significant difference between the groups in terms of sedation and sufficient analgesia. CONCLUSIONS: We conclude that caudal anesthesia provided sufficient analgesia in peroperative and postoperative periods, and rectal midazolam addition did not create any differences. This trial is registered with ClinicalTrials.gov NCT02127489.

Conduta no perioperatório de paciente pediátrico com trombastenia de glanzmann durante adenoidectomia / Perioperative management of a pediatric patient with glanzmann's thrombasthenia during adenoidectomy / Conducta en el perioperatorio de paciente pediátrico con trombastenia de glanzmann durante la adenoidectomía

JUSTIFICATIVA E OBJETIVOS: Trombastenia de Glanzmann (TG) é uma doença autossômica recessivamente hereditária das plaquetas. Não há nenhum tratamento específico. A transfusão de plaquetas é atualmente o tratamento padrão quando o sangramento não responde a medidas locais e/ou a medicamentos antifibrinolíticos, podendo, entretanto, resultar em aloimunização. O fator VII recombinante ativado (rFVIIa) pode ser usado para evitar a transfusão recorrente de plaquetas. RELATO DE CASO: Apresentamos um tratamento precoce com dose baixa de rFVIIa associada à transfusão de plaquetas em um caso pediátrico (cinco anos de idade), com diagnóstico de TG e apresentando sangramento prolongado durante adenoidectomia eletiva. Uma dose total de 1.200 mg (60 µg.kg-1) de rFVIIa obteve sucesso em estancar o sangramento, o que pode ser aceito como uma dose baixa. CONCLUSÕES: Relatos de casos podem encorajar o uso de tratamento precoce com baixas doses de rFVIIa em hemorragias graves que não estacam a despeito da transfusão de plaquetas e na prevenção de sangramento em procedimentos cirúrgicos em pacientes com TG. Estudos adicionais são necessários para definir a dose mínima eficaz. Portanto, as tentativas para determinar a dose eficaz mais baixa desse composto devem ser incentivadas consideando o resultado deste caso em face de restrições financeiras no sistema de saúde.

BACKGROUND AND OBJECTIVE: Glanzmann's thrombasthenia (GT) is an autosomal recessively inherited platelet disorder. There is not any specific treatment. Platelet transfusion is currently the standard treatment when bleeding does not respond to local measures and/or antifibrinolytic treatment, although it may result in alloimmunization. Recombinant activated factor VII (rFVIIa) might be used to avoid recurrent platelet transfusion. CASE REPORT: We present early treatment with low-dose rFVIIa additional to platelet transfusion in a 5-year-old pediatric case with diagnosis of GT who developed prolonged bleeding under an elective adenoidectomy surgery. A total dose of 1,200 µg (60 µg.kg-1) rFVIIa could successfully stop bleeding, what can be accepted as low dose usage. CONCLUSIONS: Such case reports may encourage the use of early treatment with low doses of rFVIIa in severe bleeds that did not stop despite of platelet transfusion, as well as in preventing bleeding in surgical procedures in patients with GT. Actually, additional studies are needed to define the minimal effective dose and attempts to determine the lowest effective dose may be encouraged by the result of this case, considering financial restrictions in the health care system.

JUSTIFICATIVA Y OBJETIVOS: La Trombastenia de Glanzmann (TG) es una enfermedad autosómica recesivamente hereditaria de las plaquetas. No hay ningún tratamiento específico. La transfusión de plaquetas es hoy por hoy, el tratamiento estándar cuando el sangramiento no responde a medidas locales y/o a medicamentos antifibrinolíticos, pudiendo sin embargo, resultar en una aloinmunización. El factor VII recombinante activado (rFVIIa) puede ser usado para evitar la transfusión recurrente de plaquetas. RELATO DE CASO: Presentamos aquí un rápido tratamiento con una dosis baja de rFVIIa asociada a la transfusión de plaquetas en un caso pediátrico (5 años de edad), con diagnóstico de TG y presentando un sangramiento prolongado durante la adenoidectomía electiva. Una dosis total de 1.200 mg (60 µg.kg-1) de rFVIIa tuvo éxito al estancar el sangramiento, lo que puede aceptarse como una dosis baja. CONCLUSIONES: Relatos de casos pueden estimular el uso de tratamiento rápido con bajas dosis de rFVIIa en las hemorragias graves que no estancan, pese a la transfusión de plaquetas y a la prevención de sangramiento en los procedimientos quirúrgicos en pacientes con TG. Sin embargo, estudios adicionales se hacen necesarios para definir la dosis mínima eficaz. Por tanto, los intentos para determinar la dosis eficaz más baja de un compuesto tan caro deben ser incentivados debido al resultado de este caso cuando existan restricciones financieras en el sistema de Sanidad.

Perioperative management of a pediatric patient with Glanzmann's thrombasthenia during adenoidectomy.

BACKGROUND AND OBJECTIVE: Glanzmann's thrombasthenia (GT) is an autosomal recessively inherited platelet disorder. There is not any specific treatment. Platelet transfusion is currently the standard treatment when bleeding does not respond to local measures and/or antifibrinolytic treatment, although it may result in alloimmunization. Recombinant activated factor VII (rFVIIa) might be used to avoid recurrent platelet transfusion. CASE REPORT: We present early treatment with low-dose rFVIIa additional to platelet transfusion in a 5-year-old pediatric case with diagnosis of GT who developed prolonged bleeding under an elective adenoidectomy surgery. A total dose of 1,200µg (60µg.kg(-1)) rFVIIa could successfully stop bleeding, what can be accepted as low dose usage. CONCLUSIONS: Such case reports may encourage the use of early treatment with low doses of rFVIIa in severe bleeds that did not stop despite of platelet transfusion, as well as in preventing bleeding in surgical procedures in patients with GT. Actually, additional studies are needed to define the minimal effective dose and attempts to determine the lowest effective dose may be encouraged by the result of this case, considering financial restrictions in the health care system.

Effects of topical alkane vapocoolant spray on pain intensity prior to digital nerve block for ingrown nail surgery.

Needle penetration and local anesthetic infiltration are 2 painful steps that cause considerable stress and anxiety during digital nerve block, which is the most frequently used regional anesthesia for ingrown nail surgery. The purpose of this study was to evaluate the effectiveness of topical alkane vapocoolant spray in decreasing pain during digital nerve block for ingrown nail surgery. The authors conducted a prospective, randomized clinical trial with 62 patients who underwent big toenail surgery. Prior to the digital block, alkane vapocoolant spray was applied to patients who were selected by flipping a coin. A visual analog scale (VAS) was used for assessment of pain during the skin needle penetration and during the infiltration of the anesthetic product. VAS scores during needle penetration were significantly lower in the intervention group. However, VAS scores during infiltration were similar statistically. Alkane vapocoolant spray has no noticeable clinical benefit in decreasing pain intensity during digital nerve block in patients undergoing toenail surgery.