Comparison of the Effect of Ketamine and Dexmedetomidine Combined with Total Intravenous Anesthesia in Laparoscopic Cholecystectomy Procedures: A Prospective Randomized Controlled Study.

This randomized prospective clinical study aimed to investigate the effects of dexmedetomidine or ketamine administration to total intravenous anesthesia (TIVA) on postoperative analgesia in subjects undergoing elective laparoscopic cholecystectomy procedures. 90 adults, American Society of Anesthesiologists (ASA) physical status 1 and II patients, who underwent elective laparoscopic cholecystectomy procedures were included in the study and randomized into three groups equally. Remifentanil, propofol, and rocuronium infusions were used for TIVA guided by the bispectral index. In group KETA, 10 µg/kg/min ketamine was added to TIVA before surgery, and in group DEX, 0.5 µg/kg/h dexmedetomidine was added to TIVA before surgery. Normal saline infusions were infused in the control group. Postoperative analgesia was provided with intravenous patient-controlled analgesia (PCA) morphine (1 mg bolus morphine, 5 min lockout time). Hemodynamic parameters, scores of visual analogue scale (VAS) for pain, rescue morphine requirements, and side effects such as sedation, nausea, and vomiting were recorded for 48 hours after surgery. Postoperative first analgesic requirement time was longer in group KETA (P < 0.001), and it was longer in group DEX than in the control group (P < 0.001). Pain scores were lower in group KETA and group DEX than in the control group at all corresponding times throughout the 48 h period of observation. Intravenous PCA morphine consumptions were higher in the control group than in group KETA (P < 0.001 for all followed-up times), and they were higher in group DEX than in group KETA (P < 0.001 for all followed-up times). It is concluded that the use of dexmedetomidine or ketamine infusions can be suitable as an additive for TIVA in the intraoperative period. Furthermore, the addition of both drugs to the TIVA protocol may improve postoperative pain relief and decrease opioid consumption.

Determination of the thickness of the safe enamel for laminate veneer preparation and orthodontic stripping by CBCT.

AIM: The purpose of this study is to determine the thickness and limitation of the safe enamel for laminate veneers and orthodontic stripping applications. Enamel thickness (ET) was determined in detail for each tooth and also it was examined whether there was a relationship between the mesiodistal crown width of the teeth and the thickness of the enamel and whether there was a sexual dimorphism. SUBJECTS AND METHODS: CBCT records of 101 subjects (mean age: 20.88 ± 2.48 years) were examined. ET was measured both mesial and distal region of maxillary and mandibular incisors, canines, and premolars in different levels as cervical, middle, and incisal (occlusal) 1/3. Paired t-test, student t-test, Mann-Whitney U-test and Pearson correlation coefficients a simple linear regression analysis used for statistical analysis. RESULTS: ET of mandibular first premolars and canines was thicker at right side. Mesial enamel of maxillary first premolars, canines, lateral incisors and mandibular premolars and canines were significantly thicker than distal enamel. The mesial enamel of mandibular first premolars was significantly thicker in females. Also, males' maxillary laterals were significantly larger. All premolars had a correlation between mesio-distal crown widths and ET. CONCLUSIONS: Mesial and distal ET was unique for each one tooth at different levels. The relationship between ET and crown dimensions of all premolar teeth was also determined.

Detecting coagulability status by thromboelastography in women with the history of preeclampsia and inherited thrombophilia.

OBJECTIVE: To assign tendency to thrombosis in patients with preeclampsia and inherited thrombophilia using thromboelastography (TEG), and therefore to evaluate possible relationship between thrombophilia and preeclampsia. MATERIALS AND METHODS: Kinetics of clot formation was assessed with TEG analyzer in 49 patients with severe preeclampsia, 54 cases with previous diagnosis of inherited thrombophilia, and 31 controls. RESULTS: 'r, 'k', TMA, coagulation index (CI) parameters were found statistically discrete between patients with inherited thrombophilia and controls. The difference between preeclampsia and control groups was not statistically significant. The difference in a angle was statistically significant between thrombophilics and preeclamptics (p = 0.01), and between thrombophilics and controls (p = 0.004). CI was found statistically lower in thrombophilia group than control group (p = 0.006). Particularly, clot lysis time (CLT) was measured to shorten in preeclampsia when compared with controls and patients with thrombophilia (p = 0.032, p = 0.028, respectively). CONCLUSIONS: Not only the inherited thrombophilia group but also preeclampsia group demonstrated elongated clot initiation patterns when compared to the controls. Moreover, apart from the patients with inherited thrombophilia, preeclamptics exposed shorter CLT values indicating a possible increment in clot turn over, which eventually results in increased depletion of coagulation substrates, and thus, increased frequencies of oxidative cycle injury.

Effect of seed sludge microbial community and activity on the performance of anaerobic reactors during the start-up period.

In this study, two laboratory-scale anaerobic batch reactors started up with different inoculum sludges and fed with the same synthetic wastewater were monitored in terms of performance and microbial community shift by denaturant gradient gel electrophoresis fingerprinting and subsequent cloning, sequencing analysis in order to reveal importance of initial quality of inoculum sludge for operation of anaerobic reactors. For this purpose, two different seed sludge were evaluated. In Reactor1 seeded with a sludge having less diverse microbial community (19 operational taxonomic unit (OTU's) for Bacterial and 8 OTU's for Archaeal community, respectively) and a methanogenic activity of 150 ml CH(4) g TVS(-1) day(-1), a chemical oxygen demand (COD) removal efficiency of 78.8 ± 4.17% was obtained at a substrate to microorganism (S/X) ratio of 0.38. On the other hand, Reactor2, seeded with a sludge having a much more diverse microbial community (24 OTU's for Bacterial and 9 OTU's for Archaeal communities, respectively) and a methanogenic activity, 450 ml CH(4) g TVS(-1) day(-1), operated in the same conditions showed a better start-up performance; a COD removal efficiency of over 98% at a S/X ratio of 0.53. Sequence analysis of Seed2 revealed the presence of diverse fermentative and syntrophic bacteria, whereas excised bands of Seed1 related to fermentative and sulfate/metal-reducing bacteria. This study revealed that a higher degree of bacterial diversity, especially the presence of syntrophic bacteria besides the abundance of key species such as methanogenic Archaea may play an important role in the performance of anaerobic reactors during the start-up period.

The effects of colloid pre-loading on thromboelastography prior to caesarean delivery: hydroxyethyl starch 130/0.4 versus succinylated gelatine.

This prospective, randomized, double-blind study compared the effects on thromboelastography (TEG) of pre-loading with two different colloid fluids prior to spinal anaesthesia for caesarean section. Healthy full-term parturients received either 500 ml 6% hydroxyethyl starch 130/0.4 (HES, n = 25) or 500 ml 4% succinylated gelatine (GEL, n = 25) prior to spinal anaesthesia. TEG parameters including reaction time (r-time), clot formation time (k-time), clot formation rate (α-angle) and maximum amplitude (MA) were measured immediately before and after pre-loading. Both groups had significantly shorter r-time and lower MA after pre-loading. The α-angle was significantly decreased after pre-loading with HES but not with GEL. No significant differences in k-time were induced pre-loading. In conclusion, pre-loading with HES or GEL was associated with a mild hypocoagulable effect in healthy parturients presenting for elective caesarean section; however, all TEG parameters in both groups remained within or very close to the normal range after pre-loading.

Effect of domperidone on the QTc interval in premature infants.

OBJECTIVE: To evaluate the effect of domperidone use on corrected QT interval in premature infants. STUDY DESIGN: A prospective study of premature infants receiving domperidone was included in this study. A baseline electrocardiogram was obtained just before and 3, 7 and 14 days after initiation of domperidone. Corrected QT was considered prolonged if it exceeded the upper limit for age. RESULT: A total of 40 premature infants were enrolled in this study. The mean birth weight of 1109+/-332 g, mean gestational age of 28.8+/-2.4 years and mean age at the onset of domperidone were 32.8+/-2 days. No difference in corrected QT interval was observed between just before and 3, 7 and 14 days after the start of the treatment. Two infants had corrected QT interval prolongation without any clinical side effect that resolved spontaneously. CONCLUSION: Our experience suggests that domperidone administered cautiously in modest doses does not result in arrhythmias or conduction defects in premature infants statistically. Additional data are needed to give optimal advice regarding the safety of domperidone treatment in premature infants.

The combination of low-dose levobupivacaine and fentanyl for spinal anaesthesia in ambulatory inguinal herniorrhaphy.

This study investigated whether the addition of 25 microg intrathecal fentanyl to levobupivacaine spinal anaesthesia for outpatient inguinal herniorrhaphy allows a sub-anaesthetic levobupivacaine dose to be used. Forty patients were assigned to receive 5 mg levobupivacaine 0.5% mixed with 25 microg fentanyl (group LF) or 7.5 mg levobupivacaine 0.5% (group L). The highest sensory block levels achieved were T7 (range T5 - T9) and T6 (range T4 - T9) in groups LF and L, respectively. The times to two-segment regression, S2 regression, ambulation, urination and discharge were all significantly shorter in group LF than group L. These results indicate that, for outpatient inguinal herniorrhaphy, intrathecal fentanyl combined with low-dose levobupivacaine provides good quality spinal anaesthesia and minimizes the need for intra-operative analgesia. This protocol is well suited for the outpatient setting because it features rapid recovery of full motor power, sensory function and bladder function.

Combination of ultra-low dose bupivacaine and fentanyl for spinal anaesthesia in out-patient anorectal surgery.

This study investigated whether the addition of 25 microg fentanyl to an ultra-low (sub-anaesthetic) dose of intrathecal bupivacaine provides adequate anaesthesia for out-patient anorectal surgery, without increasing side-effects or delaying hospital discharge. Patients were randomly allocated to receive 2.5 mg 0.5% bupivacaine plus 25 microg fentanyl (group BF, n = 18) or 5 mg 0.5% bupivacaine alone (group B, n = 17). There were no significant differences in intra-operative outcomes, but mean recovery and discharge times were significantly shorter in group BF. There were no between-group differences in hypotension, bradycardia or respiratory depression and post-operative complications were comparable, apart from pruritus which was significantly more frequent in group BF. Fewer patients requested analgesic medication in the early post-operative period in group BF than in group B. In conclusion, 25 microg intrathecal fentanyl added to ultra-low dose (2.5 mg) bupivacaine provided good-quality spinal anaesthesia and reduced post-operative analgesic requirement in patients undergoing ambulatory anorectal surgery.

A dilemma: prophylaxis for pulmonary embolism after surgical or invasive interventions for hemodialysis.

AIM: This study was designed to investigate if it needs to do prophylaxis for pulmonary embolism in the patients treated with different kinds of dialysis or not, and if it is, to find a proper method for prophylaxis. METHODS: Ten numbers of patients with central venous catheters (CVC group), 13 numbers of patients with arteriovenous fistula (AVF group) were enrolled in this study. Eleven patients treated with peritoneal dialysis (PD group) were utilized as a control group. Clinical and laboratory examinations to exclude pulmonary embolism were carried out in both AVF and PD groups at the onset and after three months. Same examinations were performed in CVC group at the onset and after 3 weeks (mean: 21 days). Examinations to exclude pulmonary embolism consist of medical history, clinical examinations, d-dimer measures, chest x-ray, respiratory function tests, blood gas analyses, ventilation-perfusion scintigraphies. RESULTS: Neither clinical nor laboratory findings in any stages reflected any suspicion for pulmonary embolism. None of the patients in any groups was admitted with pulmonary embolism in any period of follow-up. There was not any statistically difference between the outcomes of all first examinations and of all second ones (P>0.005). Neither obvious nor subclinical pulmonary embolism was detected in any case. None of the patients had deep venous thrombosis in any stage of follow-up. CONCLUSIONS: Conventional techniques of haemodialysis do not lead to pulmonary embolism unless deep venous thrombosis due to any intervention occurs in the patients. Thus, prophylactic anticoagulant usage to prevent pulmonary embolism is not necessary in haemodialysis patients. To shorten the length of stay of central venous catheters is the most important factors for pulmonary embolism prophylaxis in haemodialysis patients.

Intrathecal epinephrine in combined spinal-epidural analgesia for labor: dose-response relationship for epinephrine added to a local anesthetic-opioid combination.

BACKGROUND: The purpose was to investigate the dose-response relationship for intrathecally administered epinephrine added to a local anesthetic-opioid combination in combined spinal-epidural analgesia for labor, in order to evaluate analgesia and side-effects. PATIENTS AND METHODS: The subjects were 100 consecutive ASA I or II parturients at 37 weeks' gestation, who received combined spinal-epidural analgesia during labor. Each woman was randomly assigned to one of five groups that received 2-mL volumes of different spinal solutions. The control group received an intrathecal injection of bupivacaine 2.5 mg and fentanyl 25 microg only. The others received epinephrine 12.5, 25, 50 or 100 microg added to this intrathecal regimen. Maternal arterial pressure, heart rate and pain scores were recorded before and 5, 10, 15 and 30 min after intrathecal injection. Level of sensory blockade, motor blockade score, duration of intrathecal analgesia, side effects, fetal heart rate, and 1- and 5-min Apgar scores were also assessed. RESULTS: Compared to the control group, all four epinephrine groups had significantly longer duration of intrathecal analgesia, but the durations were similar. The frequencies of side effects were similar in all five groups. CONCLUSION: The results suggest that adding epinephrine to a combination of standard intrathecal doses of bupivacaine and fentanyl in combined spinal-epidural analgesia for labor significantly prolongs spinal analgesia. Of the four epinephrine doses tested, the lowest one (12.5 microg) was optimal for this clinical setting.

Effects of adding epinephrine plus fentanyl to low-dose lidocaine for spinal anesthesia in outpatient knee arthroscopy.

BACKGROUND: This study investigated whether addition of 15 microg epinephrine plus 25 microg fentanyl to lidocaine spinal anesthesia for outpatient knee arthroscopy makes it possible to use a subanesthetic lidocaine dose. The aim was to assess the quality of anesthesia and the suitability of this protocol for outpatient knee arthroscopy. METHODS: Seventy-five outpatients scheduled for knee arthroscopy were randomly assigned to one of three spinal anesthetic protocols: Group L10F25 received 10 mg of lidocaine plus 25 micro g fentanyl; Group L10F25E15 received 10 mg of lidocaine plus 25 microg fentanyl plus 15 microg epinephrine; and Group L20F25 received 20 microg lidocaine plus 25 microg fentanyl. Tourniquet pain and surgical pain were assessed using a visual analog scale. If spinal anesthesia was inadequate despite supplementary intravenous analgesia and sedation, the patient was converted to general anesthesia. Recovery times and side-effects in the early postoperative period were recorded. RESULTS: The highest level of sensory block was above the T12 dermatome in all patients. Compared with the other groups, significantly more patients in Group L10F25 converted to general anesthesia. Group L10F25 had a significantly higher mean surgical pain score than the other groups. The mean tourniquet pain score was significantly higher in Group L20F25 than Group L10F25E15. Group L10F25E15 had a significantly shorter time to discharge than the other groups. Post-operative nausea and vomiting and drowsiness were more frequent in Group L10F25 than in the other groups. CONCLUSION: The combination of 10 mg lidocaine and 25 microg fentanyl plus 15 microg epinephrine provides adequate spinal anesthesia and has favorable recovery characteristics for outpatient knee arthroscopy.

Comparison of the catheter-technique psoas compartment block and the epidural block for analgesia in partial hip replacement surgery.

BACKGROUND: The aim of this study was to compare the intra- and postoperative analgesia provided by the catheter-technique psoas compartment block and the epidural block in hip-fractured patients. We also compared hemodynamic stability, motor blockade, ease of performing the technique, and complications. METHODS: Thirty patients who underwent partial hip replacement surgery were included in this prospective single-blind study. Subjects were randomly assigned to Group E (n=15; general anesthesia plus epidural block with 15 ml of 0.5% bupivacaine) or Group P (n=15; general anesthesia plus psoas compartment block with 30 ml of 0.5% bupivacaine). Hemodynamic parameters were recorded at 10-min intervals intraoperatively. Regional anesthesia procedure time, number of attempts at block, intraoperative blood loss, and need for supplemental fentanyl and/or ephedrine were noted. Postoperatively, a patient-controlled analgesia device delivered an infusion and boluses of bupivacaine/fentanyl. Pain, motor blockade, ambulation time, patient satisfaction with analgesia, and complications were recorded postsurgery. RESULTS: The epidural required significantly more attempts than the psoas block, thus procedure time was longer in this group. Group E also showed significantly greater drops in mean arterial blood pressure from baseline at 30, 40 and 50 min after the start of general anesthesia. Significantly more Group E patients required epinephrine supplementation. The groups were similar regarding pain scores (at rest and on movement) and patient satisfaction, but Group E had higher motor blockade scores, longer ambulation time, and significantly more complications. CONCLUSION: The continuous psoas compartment block provides excellent intraoperative and postoperative analgesia with a low incidence of complications for partial hip replacement surgery

Comparison of the efficacy of 2 mg versus 5 mg tropisetron in the management of post-operative nausea and vomiting.

A randomized, double-blind, placebo-controlled study was carried out to investigate the efficacy of 2 mg versus 5 mg tropisetron in the prevention of post-operative nausea and vomiting. Patients between 22 and 64 years old who were undergoing surgery under general anaesthesia and who had been classified according to the American Society of Anesthesiologists criteria with physical status I or II were included in this trial. Sixty female patients were recruited and divided into three groups (n = 20 in each group). Patients in group 1 received saline solution as control, whereas in groups 2 and 3, 2 mg or 5 mg tropisetron, respectively, was administered intravenously as a single dose during the induction of anaesthesia. The number of patients vomiting within the first 2 h following the operation was significantly less in groups 2 and 3 compared with that in group 1 (one of 20 for each of the groups 2 and 3 versus 12 of 20 in group 1). Three patients required rescue anti-emetic medication in each of the groups 2 and 3. In conclusion, 2 mg tropisetron appears to be equally as efficacious as 5 mg in preventing post-operative nausea and vomiting.

Intravenous immunoglobulin in adult varicella pneumonia complicated by acute respiratory distress syndrome.

Pneumonia is a rare but serious complication of varicella in adults. We report a case of a previously healthy 32-year-old man with varicella pneumonia that was complicated by acute respiratory distress syndrome. He was treated successfully with acyclovir and intravenous immunoglobulin in addition to mechanical ventilation. We conclude that intravenous immunoglobulin, in combination with acyclovir, is a safe and probably effective therapy for adult varicella pneumonia that is complicated by acute respiratory distress syndrome.

The effects of beta-blockers on ocular blood flow in patients with primary open angle glaucoma: a color Doppler imaging study.

PURPOSE: To evaluate the effects of four commonly used beta-blockers on ocular blood flow in patients with primary open angle glaucoma (POAG). METHODS: Eighty eyes of 40 subjects with POAG were included in the study. Subjects were randomly divided into four groups given timolol maleate 0.50%, betaxolol HCl 0.50%, carteolol 1% or levobunolol 0.50% drops, applied twice daily (one drug to each group). Before beginning the treatment and at the end of the first month ocular blood flow velocity was measured using the color Doppler imaging (CDI) method. In the ophthalmic artery (OA), central retinal artery (CRA) and temporal posterior ciliary artery (TPCA) the peak systolic (PS) and end-diastolic (ED) blood flow velocities were measured and resistive index (RI) values were calculated. The results within each group were analysed using the matched paired student's t-test. The data between groups was compared with one-way analysis of variance (ANOVA) and Tukey-Kramer multiple comparison tests. RESULTS: The timolol group showed a significant increase in RI values of TPCA. In the betaxolol group RI decreased significantly in CRA and TPCA, whereas in the carteolol group there was a significant decrease only in CRA. In the levobunolol group there was no change in any artery. CONCLUSIONS. Betaxolol seemed to have a greater vasodilator effect than carteolol, and levobunolol had no effect on the retinal and choroidal vasculature. Timolol may have some vasoconstrictive effect in the ciliary vasculature.

Diode laser cyclophotocoagulation in refractory glaucoma: comparison between pediatric and adult glaucomas.

OBJECTIVE: To evaluate the outcome of contact transscleral diode laser cyclophotocoagulation (CTDC) in eyes with advanced glaucoma and to compare the efficacy in pediatric and adult patients. PATIENTS AND METHODS: Included in the study were 41 eyes (39 patients) with advanced glaucoma (15 eyes of 13 pediatric patients and 26 eyes of 26 adult patients). The patients were followed at least for six months or until failure of the procedure, if shorter than 6 months. The mean follow-up of all patients was 10 months (median 8 months, range 3-24 months); the mean pretreatment intraocular pressure (IOP) was 34.5+/-10.9 mm Hg for all cases, 36.2+/-12.6 mm Hg in adult cases and 31.6+/-6.5 mm Hg in pediatric cases. RESULTS: At last follow-up after first treatment, there was significant decrease in IOP and the mean reduction in IOP was 12.11+/-10.5 mm Hg for all eyes. The mean reduction in IOP adult (13.6+/-11.8 mm Hg) and (9.9+/-6.8 mm Hg) patients. While the success rate after the first diode laser therapy was 59%, it increased to 75% after retreatments. The most common complications were conjunctival hyperemia and anterior chamber reaction. There was no difference in the complication rate between the pediatric and adult cases. CONCLUSION: CTDC is a safe and effective therapy in eyes with advanced refractory glaucoma in the short term. But multiple applications may be needed in the long term. The results in adult and pediatric patients were found to be similar in efficacy and safety.