Effects of Erector Spinae Plane Block on Postoperative Pain and Quality of Recovery Questionnaire Scores in Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Study.

OBJECTIVES: Opioid-free anesthesia with erector spinae plane block (ESPB) has the potential to decrease perioperative opioid need, thereby potentially reducing related complications. This study aimed to compare opioid-free anesthesia with ESPB and standard opioid-based balanced anesthesia in patients undergoing video-assisted thoracic surgery (VATS) in terms of postoperative opioid need (through patient control analgesia) as well as postoperative pain management, recovery quality, and opioid-related side effects. METHODS: Seventy-four patients, ranging in age from 18 to 75 years, who underwent lobectomy with VATS were included in this randomized-controlled study. The opioid-free group had ESPB, and no opioid was used during anesthesia maintenance. The opioid group received standard anesthesia with opioid use. Postoperative morphine requirement, postoperative pain as measured by the visual analog scale (VAS), intraoperative vital parameters, recovery quality using the Quality of Recovery-40 (QoR-40) questionnaire, and opioid-related complications were compared between groups. RESULTS: The opioid-free group received a significantly lower total dose of morphine during the first 24 postoperative hours through patient-controlled analgesia (PCA) when compared to the opioid group (7.3±3.4 vs. 21.7±7.9 mg, p<0.001). In addition, the opioid-free group had significantly better postoperative pain scores and QoR-40 scores (184.3±7.5 versus 171.2±6.4, p<0.001), shorter times to mobilization (5.5±0.8 versus 8.1±1.1 hours, p<0.001), and oral intake (5.8±0.6 versus 6.4±0.6 hours, p<0.001), as well as less frequent opioid-related side effects. CONCLUSION: The findings of this study suggest that opioid-free anesthesia with ESPB represents a promising option for patients undergoing lobectomy with VATS. It has the potential to decrease postoperative opioid need, improve postoperative pain management, and reduce opioid-related unwanted consequences.

Comparative efficacy of finger versus forehead Plethysmographic Variability Index monitoring in pediatric surgical patients.

INTRODUCTION: The Plethysmographic Variability Index can be measured by both finger and forehead probes. Vasoconstriction may jeopardize the reliability of finger PVI measurements in pediatric patients undergoing surgery. However, forehead vasculature exhibits more marked resistance to alterations in the vasomotor tonus. OBJECTIVE: Our aim was to compare the Plethysmographic Variability Index measured via finger or forehead probes in mechanically ventilated pediatric surgery patients in terms of their ability to predict fluid responsiveness as well as to determine the best cut-off values for these two measurements. MATERIALS AND METHODS: A total of 50 pediatric patients undergoing minor elective surgery were included after provision of parental consent and ethics committee approval. Perfusion index measured at the finger or forehead and Plethysmographic Variability Index monitoring comprised the primary assessments. Hemodynamic parameters monitored included perfusion index, Plethysmographic Variability Index, and cardiac output. A ≥ 15% increase in cardiac output following passive leg raise maneuver was considered to show fluid responsiveness. Two groups were defined based on fluid responsiveness: Group R (responsive) and Group NR (non-responsive). Student's t-test, Mann-Whitney U test, DeLong test, and ROC were used for statistical analysis. RESULTS: The area under curve for finger and forehead Plethysmographic Variability Index prior to passive leg raise maneuver were 0.699 (p = .011) and 0.847 (p < .001), respectively. The sensitivity for finger and forehead measurements at a cut-off value of ≤14% was 92.9% and 96.4%, and 45.4% and 72.7%, respectively. CONCLUSION: Although forehead and finger Plethysmographic Variability Index monitoring were similarly sensitive in predicting fluid responsiveness in pediatric surgical patients, the former method provided higher specificity. The best cut-off value for PVI measurements with forehead and finger probes was found to be 14%.

Targeted Bleeding Management Guided by Non-Invasive Haemoglobin Measurement in Surgical Patients.

OBJECTIVE: To assess blood transfusion decisions in blood losses using a continuous total haemoglobin (SpHb) and non-invasive haemoglobin (Hb) device. STUDY DESIGN: Double-blinded randomised controlled trial. PLACE AND DURATION OF STUDY: Marmara University Hospital, Istanbul, Turkey, from March 2018 to December 2019. METHODOLOGY: One hundred and twenty adult patients scheduled for elective major surgery and expected to experience a blood loss greater than 20% of their total blood volume were divided into two groups. These groups were compared for bleeding management with conventional blood gas sampling (Group Hb, the control group) according to Hb monitoring versus SpHb measurement (Group SpHb, the study group). RESULTS: In the postoperative measurement, there were fewer red blood cells (RBC) in the SpHb group than in the Hb group (p=0.020). There was a greater change in the amount of RBC from the perioperative to the postoperative period in the SpHb group compared to the Hb group (p<0.001). Postoperative Hb levels of patients in the intensive care unit (ICU) were higher in the SpHb group than in the Hb group (p<0.05). CONCLUSION: SpHb can provide effective patient blood management in cases of major surgery. It does not cause a delay in the decision of blood transfusion during surgery. KEY WORDS: Haemorrhage, Anaemia, Blood transfusion, General surgery.

The Effects of Perioperative Factors on Early Postoperative Morbidity in Bariatric Surgery.

PURPOSE: This study aims to examine the predictive role of obesity-type-related indexes and perioperative intraabdominal pressure measurements for early postoperative complications following bariatric surgery. MATERIALS AND METHODS: Sixty-seven female patients with obesity who underwent bariatric surgery (laparoscopic sleeve gastrectomy or gastric bypass) were included in this study. Obesity-related indexes (BMI, waist/hip ratio, and waist/height ratio) were calculated using patient data. Intraoperative hemodynamic measurements and intraabdominal pressure measurements were done at the beginning and at the end of the operation. Intraabdominal pressure measurements were done using both bladder port and trocar port. Patients were followed for early postoperative complications. RESULTS: Among 67 patients included, 22 developed early postoperative complications (32.8%), mostly pulmonary (20.9%). Trans-trocar IAP measured at the beginning of the operation emerged as the single independent predictor of postoperative complications (OR, 40.3; p = 0.002). Based on ROC analysis, AUC for predicting complications was 0.955 (p < 0.01). Optimal cutoff point (≥ 14.5 mmHg) was associated with 100% sensitivity and 82% specificity. In addition, there were weak but significant positive correlations between trans-trocar IAP-beginning and BMI (r = 0.443, p < 0.001), waist/hip ratio (r = 0.434, p < 0.001), and waist/height ratio (r = 0.539, p < 0.001). CONCLUSION: Findings of this study suggest that a high baseline intraabdominal pressure predicts a higher risk for early postoperative complications following bariatric surgery. This information would help improve patient care. Further large studies are warranted.

The outcomes of using high oxygen concentration in pediatric patients.

Oxygen reserve index, available as part of Masimo Rainbow SET pulse oximetry, is a noninvasive and continuous variable intended to provide insight into a patient's oxygen status in the moderate hyperoxic range (PaO2 > 100 and ≤ 200 mm Hg), defined as a patient's oxygen "reserve". When used in conjunction with pulse oximetry, ORi extends the knowledge on a patient's oxygen status providing clinically important information helping to prevent hyperoxemia and hypoxemia. There are limited data on patients undergoing craniosynostosis surgery. Our primary goal was to evaluate the effects of different concentrations of inspiratory oxygen (FiO2) on patient oxygenation status by monitoring ORi. Thirty patients scheduled for craniosynostosis were included in this observational cohort study. Patients were randomized into two equal groups: Group 1 received a fraction of inspired oxygen of 0.8 and group 2 received a FiO2 of 0.6 during induction of anaesthesia. In addition to standard haemodynamic variables with ORi were recorded at baseline 1 min, 5 min, 60 min, and 120 min after intubation. Postoperative complications, length of stay in the intensive care unit and hospital were recorded. In total, 14 patients were evaluated in each group. Gender, age, BMI, ASA scores were similar between groups (p > 0.05). In Group 1, ORi values were significantly higher when compared to group 2 at baseline (0.86 ± 0.21 vs 0.45 ± 0.32, p = 0.001), one minute (0.61 ± 0.24 vs 0.27 ± 0.21, p = 0.001), and 5 min (0.34 ± 0.31 vs 0.10 ± 0.13, p = 0.033). High inspired oxygen concentration during induction of anesthesia in pediatric patients is associated with higher levels of ORi. Therefore, ORi may provide the means to safely reduce the inspired oxygen fraction during inhalational induction in paediatric patients.

Neutrophil gelatinase associated lipocalin in predicting postoperative acute kidney injury in elderly.

BACKGROUND: Elderly patients are at increased risk of developing acute kidney injury (AKI) following major surgery and rapid diagnosis is essential. AIM: This study aimed to examine the potential utility of plasma neutrophil gelatinase associated lipocalin levels in early prediction of AKI in geriatric patients undergoing laparotomic oncological surgery. METHODS: This prospective single-center cohort study included 60 geriatric patients (≥ 65 years of age) that underwent major oncologic surgery with laparotomy. Perioperative measurements of plasma creatinine, blood urinary nitrogen, plasma lactate, urine output, and neutrophil gelatinase associated lipocalin (NGAL) were made. Patients were followed for AKI development, which is the primary outcome measure, and predictive role of NGAL was investigated. RESULTS: At 48 h follow-up, AKI developed in 13 patients (21.7%). Significant differences in creatinine (p < 0.001), NGAL (p < 0.001), and urine output levels (p = 0.001) were evident over time between the two groups. High NGAL measurements at 6 and 24 h after surgery seem to be highly predictive of AKI development. At 6 h, a plasma NGAL level greater than 71.8 ng/mL has a sensitivity and specificity of 85% and 81% in predicting subsequent AKI development. CONCLUSIONS: Plasma NGAL levels seem to represent an early and reliable marker for AKI in elderly patients undergoing laparotomic surgery with the potential to allow early diagnosis and prevent further renal deterioration. Further confirmatory studies are warranted. TRIAL REGISTRATION: The study was registered to ClinicalTrials.gov (number, NCT05030727). IMPLICATION STATEMENT: Elderly patients are at increased risk of postoperative acute kidney injury (AKI). This study shows that plasma neutrophil gelatinase associated lipocalin is a helpful marker to predict AKI in elderly patients undergoing laparotomic major surgery, which will allow early diagnosis and prevent further renal deterioration in this vulnerable patient group.

Effect of Ultrasound-Guided Erector Spinae Plane Block on Postoperative Pain and Intraoperative Opioid Consumption in Bariatric Surgery.

BACKGROUND: Bariatric surgery is often associated with moderate to severe pain. In patients with obesity, opioids have the potential to induce ventilatory impairment; thus, opioid use needs to be limited. This study aimed to compare the novel ultrasound-guided erector spinae plane block (ESPB) technique with controls in terms of intraoperative opioid consumption and postoperative pain control. METHODS: A total of 63 patients with morbid obesity who underwent laparoscopic bariatric surgery were included in this randomized study. Patients were randomly assigned to the bilateral erector spinae plane block (ESPB) group or the control group. To evaluate perioperative pain and to adjust opioid dose, analgesia nociception index (ANI) was monitored during surgery. Total opioid dose was recorded for each patient. In addition, pain was evaluated using visual analogue scale (VAS) scores for 24 h following the operation. RESULTS: Total intraoperative remifentanil dose was significantly lower in the ESPB group when compared to controls (1356.3 ± 177.8 vs. 3273.3 ± 961.9 mcg, p < 0.001). In the ESPB group, none of the patients required additional analgesia during follow-up. In contrast, all control patients required analgesia. ESPB group had significantly lower VAS scores at all postoperative time points (p < 0.001 for all). CONCLUSION: Bilateral ultrasound-guided ESPB appears to be a simple and effective technique to improve perioperative pain control and reduce intraoperative opioid need in patients with morbid obesity undergoing bariatric surgery.

Traumatic Avulsion of Upper Eyelid Skin Following Surgery in a Patient With Multiple Myeloma and Amyloid Light-chain Amyloidosis.

Multiple myeloma (MM) is a common hematologic malignancy. Primary systemic amyloidosis or amyloid light-chain (AL) amyloidosis is a rare disease. PURPOSE: This article presents the case of a patient with MM and AL amyloidosis who experienced a severe case of medical adhesive-related skin injury. CASE STUDY: A 64-year-old man with MM, AL amyloidosis, and diabetes presented with a necrotic wound on his left heel that required surgical debridement. The patient experienced a traumatic avulsion of the right upper eyelid skin during the removal of the corneal abrasion preventive tape as well as traumatic avulsion of the left upper eyelid skin while the patient's face was being cleansed. The avulsed right upper eyelid skin above the tarsus was repaired with a full-thickness skin graft. The partly avulsed left upper eyelid skin was repositioned, and an excisional biopsy was taken. Both upper eyelids healed uneventfully. The biopsy specimen revealed increased amyloid deposition in the dermis, subcutaneous tissue, and areas surrounding the veins and sweat glands. CONCLUSION: This case illustrates the increased risk of medical adhesive-related skin injury and other skin damage in patients with MM and AL amyloidosis. In these patients, the use of tape should be avoided to prevent intraoperative corneal abrasion.

Effect of the "Recruitment" Maneuver on Respiratory Mechanics in Laparoscopic Sleeve Gastrectomy Surgery.

PURPOSE: LSG surgery is used for surgical treatment of morbid obesity. Obesity, anesthesia, and pneumoperitoneum cause reduced pulmoner functions and a tendency for atelectasis. The alveolar "recruitment" maneuver (RM) keeps airway pressure high, opening alveoli, and increasing arterial oxygenation. The aim of our study is to research the effect on respiratory mechanics and arterial blood gases of performing the RM in LSG surgery. MATERIALS AND METHODS: Sixty patients undergoing LSG surgery were divided into two groups (n = 30) Patients in group R had the RM performed 5 min after desufflation with 100% oxygen, 40 cmH2O pressure for 40 s. Group C had standard mechanical ventilation. Assessments of respiratory mechanics and arterial blood gases were made in the 10th min after induction (T1), 10th min after insufflation (T2), 5th min after desufflation (T3), and 15th min after desufflation (T4). Arterial blood gases were assessed in the 30th min (T5) in the postoperative recovery unit. RESULTS: In group R, values at T5, PaO2 were significantly high, while PaCO2 were significantly low compared with group C. Compliance in both groups reduced with pneumoperitoneum. At T4, the compliance in the recruitment group was higher. In both groups, there was an increase in PIP with pneumoperitoneum and after desufflation this was identified to reduce to levels before pneumoperitoneum. CONCLUSION: Adding the RM to PEEP administration for morbidly obese patients undergoing LSG surgery is considered to be effective in improving respiratory mechanics and arterial blood gas values and can be used safely.

A Simple Food-Diverting Operation for Type 2 Diabetes Treatment. Preliminary Results in Humans with BMI 28-32 kg/m2.

BACKGROUND: The feasibility of a simple side-to-side jejunoileal anastomosis (SJA) in non-morbidly obese individuals to control type 2 diabetes mellitus (T2DM) was studied in six diabetic patients with BMI 28-32. This novel procedure was performed in two Academic Centers and preliminary data is presented. METHODS: SJA bypassing a significant part of the small bowel and diverting food and biliopancretic secretions to the distal ileum was performed laparoscopically in six diabetic patients with BMI 28-32 kg/m2. SJA was performed at a distance of 100 cm from the Treitz ligament and 150 cm from the ileocecal valve, thus a total bowel alimentary and biliopancreatic loop length of 2.5 m was created. RESULTS: Three of the patients (two female, one male) experienced complete remission of diabetes from the immediate postoperative period and up to 3 years after the procedure. Two other patients remained medication-free after the operation experiencing partial diabetes remission, and the third patient significantly reduced his daily insulin requirements immediately after surgery. There were no early or late postoperative complications. CONCLUSIONS: A simple SJA, diverting the food and biliopancreatic secretion to the distal small bowel, was able to control T2DM in all patients offering total or partial remission of the disease soon after the procedure. Those preliminary data and the simplicity of the operation are encouraging and promising. However, further studies are in progress in both Institutions to reveal the possible mechanism of diabetes control and investigate the effect of this operation on larger number of patients, with longer follow-up period.

Comparison of SpO2 values from different fingers of the hands.

Pulse oximetry is a frequently used tool in anesthesia practice. Gives valuable information about arterial oxygen content, tissue perfusion and heart beat rate. In this study we aimed to provide the comparison of peripheral capillary hemoglobin oxygen saturation (SpO2) values among every finger of the two hands. Thirty-seven healthy volunteers from operative room stuffs between the ages of 18-30 years were enrolled in the study. They were monitored after 5 min of rest. After their non invasive blood pressure, heart rate, fasting time and body temperature were measured, SpO2 values were obtained from every finger and each of two hands fingers with the same pulse oximetry. All the SpO2 values were obtained after at least 1 min of measurement period. A total of 370 SpO2 measurements from 37 volunteers were obtained. The highest average SpO2 value was measured from right middle finger (98.2 % ± 1.2) and it was statistically significant when compared with right little finger and left middle finger. The second highest average SpO2 value was measured from right thumb and it was statistically significant only when compared with left middle finger (the finger with the lowest average SpO2 value) (p < 0.05). SpO2 measurement from the fingers of the both hands with the pulse oximetry, the right middle finger and right thumb have statistically significant higher value when compared with left middle finger in right-hand dominant volunteers. We assume that right middle finger and right thumb have the most accurate value that reflects the arterial oxygen saturation.

The effects of preoperative oral pregabalin and perioperative intravenous lidocaine infusion on postoperative morphine requirement in patients undergoing laparatomy.

OBJECTIVES: To evaluate and compare the effects of preoperative oral pregabalin and perioperative intravenous lidocaine infusion on postoperative morphine requirement, adverse effects, patients' satisfaction, mobilization, time to first defecation and time to discharge in patients undergoing laparotomy. METHODS: Eighty patients (18 to 65 years of age) undergoing elective laparotomy were randomly divided into four groups (n=20 in each group): group C, placebo capsules and normal saline infusion perioperatively (control); group L, placebo capsules and lidocaine 1 mg/kg intravenous bolus dose followed by 2 mg/kg/h infusion until skin closure; group P, 150 mg oral pregabalin and normal saline infusion perioperatively; and group PL, 150 mg oral pregabalin and lidocaine 2 mg/kg/h infusion until skin closure. Hemodynamic parameters, visual analogue scale (VAS) scores, analgesic consumption, side effects, time to mobilization, time to first defecation, time to discharge and patients' satisfaction were recorded. RESULTS: VAS scores of group L, group P and group PL were lower than group C (P<0.05). Morphine consumption of group P and group PL was lower than group C (P<0.05). Incidence of nausea in group C was higher than group L and group PL. Time to first defecation and mobilization were shorter in group L and group PL compared with group C (P<0.05). CONCLUSION: Preoperative oral pregabalin and perioperative intravenous lidocaine infusion decreased postoperative VAS scores. Preoperative oral pregabalin decreased morphine requirement and perioperative intravenous lidocaine infusion hastened gastrointestinal motility and mobilization, and decreased the incidence of nausea in patients undergoing laparotomy. Therefore, preoperative pregabalin with or without lidocaine provides superior pain relief in patients undergoing laparatomy.