Variables affecting mortality rates in patients undergoing emergency abdominal surgery: A retrospective cross-sectional study.

BACKGROUND: Patients operated under emergency conditions have a higher risk of death and complications than those per-formed under elective conditions. Especially the patient group with high comorbidity needs to be evaluated more specifically. Accord-ing to the surgical risk and American Society of Anesthesiologists (ASA) scoring, the perioperative risk should be determined quickly, and the relatives of the patients should be informed. This study aimed to evaluate the factors affecting mortality and morbidity in patients undergoing emergency abdominal surgery. METHODS: A total of 1065 patients aged 18 years and older who underwent emergency abdominal surgery in 1 year were included in the study. The primary aim of this study was to determine the mortality rates in the first 30 days and 1 year and the variables af-fecting these rates. RESULTS: Of 1065 patients, 385 (36.2%) were female and 680 (63.8%) were male. The most common procedure was appendectomy (70.8%), followed by diagnostic laparotomy (10.2%), peptic ulcus perforation (6.7%), herniography (5.5%), colon resection (3.6%), and small bowel resection (3.2%). There was a significant difference between the age of the patients and mortality (p<0.05). There is no statistically significant relationship between gender and mortality. A statistically significant correlation was found between ASA scores, perioperative complication, perioperative blood product use, reoperation, intensive care unit admission, hospitalization time, periop-erative complication, and 30-day mortality and 1-year mortality. There is a significant relationship between trauma and only 30-day mortality (p=0.030). CONCLUSION: The morbidity and mortality of patients operated on under emergency conditions increased compared to elective surgical operations, especially those over age 70. The 30-day mortality rate of patients who underwent emergency abdominal surgery is 3%, while the 1-year mortality rate is 5.5%. Mortality rates are higher in patients with a high ASA risk score. However, mortality rates in our study were found to be higher than the mortality rates in ASA risk scoring.

Evaluation of immunomodulatory nutrients in critically ill patients in the intensive care unit.

OBJECTIVE: Glutamine and omega-3 fatty acids have been shown to decrease infection rates, antibiotic use, and hospital length of stay. However, whether giving immunonutrients to critically ill patients is beneficial remains controversial. In our study, we aimed to look at the effectiveness of parenteral unsaturated (omega-3) fatty acids and amino acid glutamine in patients with serious conditions in the intensive care unit (ICU). METHODS: The data of patients, who received parenteral amino acid glutamine and unsaturated fatty acids (omega-3) in the ICU, were retrospectively analyzed. Eighty-four patients were classified with regard to the length of the immune modulatory nutrient treatment. Groups were constructed according to the length of the treatment in days: 9 days or more (Group I), 3-9 days (Group II), and <3 days (Group III). Demographic data, Acute Physiologic Assessment and Chronic Health Evaluation II Scores (APACHE-II), ICU and hospitalization periods, inotropic medication, 60th-day mortality, serum biochemistry, and bacterial culture results were recorded. 60th-day mortality, bacterial culture results, and number of days stayed in ICU were primary outcomes of interest. RESULTS: Demographic data of the patients and APACHE-II scores among the groups were not significantly different from each other. ICU stay length, hospitalization length, positivity in bacterial cultures, and use of inotropic agents were significantly higher in Group I compare with other groups. CONCLUSION: In the ICU, it was observed that patients with multiorgan failure using parenteral unsaturated fatty acids and amino acid glutamine had longer hospital and intensive care stay. It can be said that long-term use of antioxidants and immunonutrition does not have a beneficial effect in patients with multiple organ failure with high APACHE-II scores.

Analgesic effects of ultrasound-guided transverse abdominis plane block using different volumes and concentrations of local analgesics after laparoscopic cholecystectomy.

Objective To evaluate the effects of an ultrasound-guided transverse abdominis plane (US-TAP) block used for postoperative pain relief by comparing the efficacy of two different volumes/concentrations of the local anaesthetic bupivacaine in patients undergoing laparoscopic cholecystectomies. Methods This randomized study enrolled patients undergoing laparoscopic cholecystectomies. They were randomized to two groups: group A received a 20 ml US-TAP block (50 mg bupivacaine +10 ml saline solution) and group B received a 30 ml US-TAP block (50 mg bupivacaine + 20 ml saline solution). The intraoperative consumption of remifentanil, the requirement for postoperative rescue analgesics, patient satisfaction scores, postoperative complications, and postoperative pain as measured by a visual analogue scale at 20 min, 12 h, and 24 h were recorded. Results A total of 60 patients enrolled in the study. There were no differences between the two groups with respect to demographic characteristics, duration of anaesthesia and patient satisfaction scores. The intraoperative consumption of remifentanil, postoperative VAS scores (20 min, 12 h and 24 h) and the requirement for postoperative analgesics were all significantly lower in group B who received a larger volume but a lower concentration of local anaesthetic solution compared with group A. Conclusion A US-TAP block can form part of a balanced postoperative analgesic regimen following laparoscopic cholecystectomy.

Erythropoietin diminishes isoflurane-induced apoptosis in rat frontal cortex.

BACKGROUND: During the brain growth spurt, anesthetic drugs can cause cellular and behavioral changes in the developing brain. The aim of this study was to determine the neuroprotective effect of erythropoietin after isoflurane anesthesia in rat pups. METHODS: A total of 42, 7-day-old Wistar rats were divided into three groups. Control group (GC; n = 14): Rats breathed 100% oxygen for 6 h; Isoflurane group (GI; n = 14): Rats were exposed to 1.5% isoflurane in 100% oxygen for 6 h; Isoflurane + erythropoietin group (GIE; n = 14): 1000 IU·kg(-1) (intraperitoneal; IP) Erythropoietin was administered after isoflurane anesthesia. Each group was divided into two groups for pathology and learning and memory tests. Silver, caspase-3, and fluoro-jade C staining were used for detecting apoptotic cells in frontal cortex, striatum, hippocampus, thalamus, and amygdala. Morris water maze was used to evaluate learning and memory. RESULTS: There was a significant increase in apoptotic cell count after isoflurane anesthesia in the frontal cortex when compared with control group (29.0 ± 9.27 vs 3.28 ± 0.75 [P = 0.002], 20.85 ± 10.94 vs 2.0 ± 0.81 [P = 0.002] and 24.57 ± 10.4 vs 5.14 ± 0.69 [P = 0.024] with silver, caspase-3, and fluoro-jade C staining, respectively). The apoptotic cell count in the frontal cortex was significantly higher in GIE than GC with caspase-3 staining (9.14 ± 3.13 vs 2.0 ± 0.81, P = 0.002). The apoptotic cell count in GIE was significantly reduced in the frontal cortex when compared with GI (4.0 ± 0.81 vs 29.0 ± 9.27 [P = 0.002], 9.14 ± 3.13 vs 20.85 ± 10.94 [P = 0.04] and 4.0 ± 1.63 vs 24.57 ± 10.4 [P = 0.012] with silver, caspase-3, and fluoro-jade C staining, respectively). CONCLUSIONS: A total of 1000 IU·kg(-1) IP erythropoietin diminished isoflurane-induced neuroapoptosis. Further experimental studies have to be planned to reveal the optimal dose and timing of erythropoietin before adaptation to clinical practice.

[Chronic pain following spine surgery]. / Omurga cerrahisi sonrasi kronik agri

There has been an increasing trends in the procedures of spine surgery in recent years. Postoperative chronic pain in spine surgery can be caused by damage or instability of spinal column; pressure on nerves or segment of spinal cord; or can be due to long lasting nociception caused by inflammation, infection or tumour. Pain that lasts longer than 3-6 months after surgery can be define as postoperative chronic pain. The incidence of postoperative chronic pain after surgical procedures, was between 10-50%. Coping with any type of chronic pain is quite difficult. Chronic postoperative pain can be treated with: NSAIDs, paracetamol, opioids, anticonvulsants and invasive technics such as nerve blocs, central blocs.

The efficacy of caudal morphine or bupivacaine combined with general anesthesia on postoperative pain and neuroendocrine stress response in children.

BACKGROUND: The aim of this study was to compare the effectiveness of caudal morphine and bupivacaine usage on surgical stress response in children undergoing abdominal and genitourinary surgery while keeping anesthesia depth constant utilizing the bispectral index analysis (BIS). METHODS: Following the approval of Institutional Review Board and informed parental consent, 28 children with ages ranging between 4 and 16 years with ASA physical status I and II , undergoing elective lower abdominal and genitourinary surgery were included in this study. Patients were randomized and separated into two subgroups. Before induction of anesthesia, patients were monitored for BIS. Epidural injection of 30 microg.kg(-1) morphine in 1 ml.kg(-1) saline for the first group (group M) and the same volume of (0.25%) bupivacaine for second group (group B) were administered via the sacral hiatus. We analyzed serum cortisol and glucose concentrations for evaluation of the stress response in the patients. Blood samples for cortisol and glucose were withdrawn at the beginning of induction (first samples), 40 min after surgical incision (second samples), and 40 min after end of the surgery (third samples). BIS scores of the patients were kept between 40 and 60 during the surgical procedure. RESULTS: Group B had significantly lower levels of cortisol than group M in the second samples. There was a significant increase in serum glucose level in group M compared with group B during the intraoperative and postoperative periods. CONCLUSIONS: We conclude that, caudal administration of bupivacaine is more effective than morphine for attenuating intraoperative and postoperative stress response to surgery in children.

Hemodynamic and electrolyte changes in patients undergoing neuroendoscopic procedures.

OBJECTS: Intraoperative hemodynamic alterations and postoperative electrolyte disturbances related to endoscopic third ventriculostomy (E3V) have been reported. We aimed to evaluate prospectively those changes in patients undergoing neuroendoscopic procedures. METHODS: This study was carried out in 24 patients who underwent neuroendoscopic intervention. Sevoflurane was used for the induction and maintenance of anesthesia. Heart rate (HR), mean arterial pressure (MAP), peripheral oxygen saturation, end-tidal CO2, and body temperature values were recorded according to the stages of the operation. Blood gas and blood chemistry analyses were performed before and after endoscopic procedure and were repeated on the third postoperative day. CONCLUSIONS: There were no significant differences in intraoperative HR and MAP. Bradycardia occurred only in 1 of the 24 patients during the dilatation. In conclusion, we suggest the use of 0.9% NaCl for intravenous fluid replacement and a warm lactated ringer solution for ventricular irrigation during E3V to prevent intraoperative hemodynamic changes and postoperative electrolyte disturbances.

Treatment of slow-flow (type I) perimedullary spinal arteriovenous fistulas with special reference to embolization.

Embolization of type I perimedullary spinal arteriovenous fistulas (AVFs) can be difficult, because of tortuosity and the small diameter of the feeder and distal location of the fistula site. The 1.5F flow-directed catheter in conjunction with a hydrophilic guidewire has been used in fistula embolization with cyanoacrylate glue for spinal vascular malformations at our institution. This combination has improved our success rate in achieving superselective catheterization of the fistula. Thus, 4 of 5 patients with type I perimedullary AVFs could be cured with this technique. Like type II and type III perimedullary AVFs, the endovascular approach may also be the first line of treatment in type I perimedullary spinal AVF.

Old method, new drugs: comparison of the efficacy of sevoflurane, isoflurane, and desflurane in achieving controlled hypotension in spinal surgery.

This study compared the efficacy of isoflurane, sevoflurane, and desflurane in achieving hemodynamic stability in spinal procedures using moderate levels of controlled hypotension. After obtaining ethics committee approval and written informed consent, 32 American Surgical Association I-II patients were randomly allocated to receive isoflurane (n=12), sevoflurane (n=10), or desflurane (n=10) in O2-N2O (1:1) for maintenance of anesthesia. The induction of anesthesia, fentanyl dosage, and initial and maintenance volume replacements were standardized. Blood pressure was invasively monitored and maintained within a target systolic blood pressure (SBP) range of 80 to 90 mm Hg during the study. SBP outside this range was recorded. Volatile anesthetic concentration was adjusted according to the same protocol for all 3 agents. SPB control was maintained better with sevoflurane and isoflurane than desflurane; median SBP was outside the target range during 32% (range, 15%-55%) of study time with isoflurane, 26% (12%-42%) with sevoflurane, and 44% (20%-80%) with desflurane. Total blood loss did not differ among the groups. Sevoflurane and isoflurane administered in 2 L/min fresh gas flow were more effective than desflurane in achieving controlled hypotension in spinal surgery.

Adverse effects of anesthesia in interventional radiology.

PURPOSE: The aim of the study was to evaluate adverse events related to the use of anesthesia and anesthetic procedures associated with interventional radiology. MATERIALS AND METHODS: We retrospectively evaluated 124 interventional radiological procedures performed with anesthesia within a one-year period. Patients were separated into four groups according to the duration of procedure, the type of procedure performed, anesthetic agents used, and complications associated with anesthesia. RESULTS: Of the 124 patients, 59 had neurovascular procedures, 10 underwent implantation of a tracheal stent, and 19 had painful procedures. Fifteen of 36 pediatric patients had diagnostic angiography, and 21 had interventional procedures. Two patients in the neurovascular intervention group had cerebral hemorrhage and cerebral infarctions, and anaphylactic reaction developed in one patient, who underwent percutaneous hepatic hydatic cyst drainage. CONCLUSION: Interventional radiological procedures seem to be safe from an anesthesiologist's point of view. However, morbidity and mortality in this patient population can be reduced when the potential complications associated with interventional radiology are well understood by the anesthesia team.

Ventricular/paraventricular small arteriovenous malformations: role of embolisation with cyanoacrylate.

Arteriovenous malformations (AVMs) located in or near to ventricles have proven difficult to treat. We report the safety and efficacy of embolisation of these deep central lesions and describe the contribution of embolisation to multimodality treatment. Fourteen consecutive patients with small (less than 3 cm) ventricular/paraventricular AVMs arranged for possible embolisation to their nidi. All patients presented with intracranial haemorrhage. The AVMs ranged in size from 10 to 30 mm (average, 17 mm). Embolisations were performed using liquid adhesive (cyanoacrylate and iodised oil mixture at a ratio of less than 1:4) delivered by flow-guided microcatheters with the patient under general anaesthesia. One patient (7.1%) was considered unsuitable for embolisation, and another (7.1%) was not able to undergo embolisation because of the morphological features of the AVM feeders, while the remaining 12 could be embolised successfully. Six of 12 patients who underwent embolisation achieved complete occlusion of their AVMs (overall occlusion rate, 42.9%), while the remaining 6 were embolised partially with a 60-95% (mean = 80%) size reduction. One (8%) permanent neurological deficit resulted from embolisation. Endovascular therapy seems to make a significant contribution to the multimodality treatment of small AVMs located in the ventricle or paraventricular deep area. Embolisation alone permits complete cure in a large number of patients. It results in obliteration of a significant volume of the nidus in most of the remaining patients, which makes those nidi more vulnerable to subsequent multimodal therapy.

Can antiemetics really relieve pain?

The analgesic properties of 2 antiemetic agents--metoclopramide and ondansetron--were investigated in studies which showed that metoclopramide may decrease postoperative opioid requirements, but the analgesic effect of ondansetron is controversial. The postoperative effects of metoclopramide and ondansetron on pain in patients undergoing laminectomy were evaluated. Forty six patients were randomized into 3 groups: group M, which consisted of 15 patients who received intravenous (IV) metoclopramide 0.5 mg 30 minutes before surgery; group O, which consisted of 16 patients who received ondansetron IV 0.1 mg 30 minutes before surgery; and group C, which consisted of 15 patients who received the same volume of saline IV 30 minutes before surgery. The efficacy and duration of analgesia were assessed using a visual analogue scale (VAS) at 0, 0.5, 1, 3, 6, and 24 hours after surgery. Hemodynamic parameters, additional analgesic requirements, and adverse effects were recorded for the study groups. Diclofenac 75 mg was administered intramuscularly as a rescue analgesic during the postoperative period. VAS scores were lower in the metoclopramide group than in the ondansetron and control groups (P<.05, each). The patients in the ondansetron and control groups required much more diclofenac than the patients in the metoclopramide group (P<.05). Metoclopramide administered preoperatively provided postoperative analgesia in patients undergoing elective laminectomy.