The Effect of Topical Benzydamine Hydrochloride and Cuff Pressure Monitorization on Postoperative Sore Throat Due to Intubation.

OBJECTIVE: Postoperative sore throat (POST) is the most common discomfort after endotracheal intubation. Damage to the tracheal mucosa caused by inappropriate endotracheal tube (ETT) cuff pressure has been shown as the major factor. Monitoring the ETT cuff pressure at a certain value reduces this damage. Benzydamine hydrochloride (BH) has proven to be effective on sore throat and studies have shown that it is also effective on POST. In this study, the efficacy of BH and ETT cuff pressure monitoring on POST was evaluated. MATERIALS AND METHODS: After ethics committee approval 210 patients in the ASA (American Society of Anesthesiologists) I-III risk group undergoing elective surgery were included in the study. Routine anesthesia monitoring, induction, and maintenance were provided. Patients were randomly divided into three groups. Thirty minutes before surgery, the posterior pharyngeal wall was sprayed with BH in group 1 and distilled water in groups 2 and 3. Intraoperatively, the first and second groups were monitored to keep the ETT cuff pressure between 22 and 26 cmH2O, while no intervention was performed in the third group. The incidence and severity of postoperative dysphagia, hoarseness, and POST were questioned. RESULTS: There was no difference between demographic data, and gender was not associated with POST. There was a statistically significant difference between the first and second groups and the third group in terms of all three symptoms questioned (p<0.01). No difference was observed between the first and second groups. Side effect rates were similar. Smoking was not found to be associated with symptoms. CONCLUSION: The incidence and severity of POST, dysphagia, and hoarseness are reduced when the ETT cuff is inflated with a pressure of 22-26 cmH2O after intubation with a manometer and maintained at this pressure range throughout the operation. There was no beneficial effect of BH.

The Effect of Perioperative Lidocaine Infusion on Postoperative Pain and Postsurgical Recovery Parameters in Gynecologic Cancer Surgery.

OBJECTIVES: The primary objective of this prospective nonblinded randomized study was to investigate the effect of perioperative systemic lidocaine infusion on pain control after major gynecologic oncology surgery. Patient-reported outcomes, postoperative recovery parameters, and complications were secondary endpoints of the study. MATERIALS AND METHODS: Seventy-five patients with American Society of Anesthesiologists I-III were divided into 3 groups based on perioperative analgesia methods-(1) opioid group: patient-controlled analgesia (PCA) with morphine; (2) lidocaine group: perioperative intravenous lidocaine infusion, plus PCA with morphine; and (3) the epidural group: PCA with bupivacaine. The Visual Analog Scale (VAS) was recorded postoperatively. In addition, nausea-vomiting, time to first oral intake, time to first ambulation, time to first flatus, and length of hospital stay were recorded. RESULTS: VAS scores (rest) at 24 hours and VAS scores (cough) at 12 and 24 hours were significantly lower in the epidural group than in the opioid group (P<0.05). VAS scores were found to be similar between the lidocaine and epidural group. The nausea-vomiting incidence was lower in the lidocaine group than in the opioid group (P˂0.05). Compared with the other 2 groups, the first flatus time was shorter in the lidocaine group (P<0.05). DISCUSSION: Perioperative lidocaine infusion is effective as epidural analgesia, which is often advocated as the gold-standard analgesic technique for abdominal surgery and is superior to the others in terms of time to first flatus and the incidence of nausea-vomiting.

Delirium Frequency and Risk Factors Among Patients With Cancer in Palliative Care Unit.

Introduction: Delirium is a complex but common disorder in palliative care with a prevalence between 13% and 88% but a particular frequency at the end of life yet often remains insufficiently diagnosed and managed. The aim of our study is to determine the frequency of delirium and identify factors associated with delirium at palliative care unit. METHODS: Two hundred thirteen consecutive inpatients from October 1, 2012, to March 31, 2013, were studied prospectively. Age, gender, Palliative Performance Scale (PPS), Palliative Prognostic Index (PPI), length of stay in hospital, and delirium etiology and subtype were recorded. Delirium was diagnosed with using Delirium Rating Scale (DRS) and Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Text Revision ( DSM-IV TR) criteria. RESULTS: The incidence of delirium among the patients with cancer was 49.8%. Mean age was 60.3 ± 14.8 (female 41%, male 59%, PPS 39.8%, PPI 5.9 ± 3.0, length of stay in hospital 8.6 ± 6.9 days). Univariate logistic regression analysis indicated that use of opioids, anticonvulsants, benzodiazepines, steroids, polypharmacy, infection, malnutrition, immobilization, sleep disturbance, constipation, hyperbilirubinemia, liver/renal failure, pulmonary failure/hypoxia, electrolyte imbalance, brain cancer/metastases, decreased PPS, and increased PPI were risk factors. Subtypes of delirium included hypoactive 49%, mixed 41%, and hyperactive 10%. CONCLUSION: The communicative impediments associated with delirium generate distress for the patient, their family, and health care practitioners who might have to contend with agitation and difficulty in assessing pain and other symptoms. To manage delirium in patients with cancer, clinicians must be able to diagnose it accurately and undertake appropriate assessment of underlying causes.

[Opioid use and the management of cancer patient pain in palliative care clinic]. / Palyatif bakim kliniginde yatan kanser hastalarinda agri tedavisi ve opioid kullanimi.

OBJECTIVES: Pain is one of the most important symptoms in palliative care, and has a major impact on the quality of life of cancer patients. In developing countries, difficult access to opioids and the lack of well-established palliative care organizations result in undertreatment of pain. Turkey is one of the countries with statistical evidence of inadequate morphine consumption per capita. In 2010, the adequacy of opioid analgesic consumption was only 7%, based on a per capita consumption of 14.31 mg morphine equivalents. The present study analyzed and described patterns of opioid use among cancer patients in the palliative care clinic. METHODS: The data of 418 cancer patients who received palliative care at the palliative care clinic in 2014 were evaluated retrospectively. RESULTS: Of the total, 183 (44%) of the patients studied were female and 235 (56%) were male. Age ranged from 18 to 93 years (61±15 years). No opioids had been prescribed for 9% of patients, 26% of patients were using weak opioids, and 65% were using strong opioids. Daily oral morphine equivalent dosage per patient was 172±58 mg (range: 40-328 mg). Indications for opioid use were pain (61%), dyspnea (19%), and both dyspnea and pain (20%). CONCLUSION: Although there is a limited variety of opioids currently available in this country, it is thought that a more effective and adequate level of pain management can be obtained through education of health practitioners about pain management and opioid use. The relatively high incidence of weak opioid use may be associated with the lack of available rapid release opioids in the country.

The Incidence of Delirium at the Postoperative Intensive Care Unit in Adult Patients.

OBJECTIVE: In this study, we aimed to determine the risk factors and the incidence of delirium in patients who were followed postoperatively in our surgical intensive care unit for 24 h using the confusion assessment method (CAM). METHODS: After obtaining approval from the ethics committee, 250 patients were included in the study. Patients who were operated under general anaesthesia or regional anaesthesia and followed in the surgical intensive care unit were evaluated by the Ramsay Sedation Scale on the first postoperative day. CAM was applied to the patients who had a Ramsey Sedation Score of ≤4. Patients' age, gender, American Society of Anesthesiologists (ASA) scores, preoperative risk factors, type of anaesthesia, operation time, intra-operative procedures, pain scores evaluated by the visual analogue scale (VAS) and postoperative analgesia methods were recorded. RESULTS: The incidence of delirium was found to be 18.4%. The average age of patients who developed delirium was greater than the others (68.8±12.7 and 57.6±12, p=0.001, respectively). It was observed that a one-unit increase in the ASA score resulted in a 3.3-fold increase in the risk of delirium. The incidence of delirium in patients undergoing regional anaesthesia was 34.6%, whereas it was 16.5% in patients receiving general anaesthesia (p=0.024). The existence of preoperative diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) was shown to improve the development of delirium (p<0.05). Delirium incidence was significantly higher in patients who were administered meperidine for postoperative analgesia (p=0.013). The VAS scores of patients who developed delirium were found to be significantly higher (p=0.006). CONCLUSION: As a result, we found that older age, high ASA score, preoperative DM and COPD are important risk factors for the development of delirium. Regional anaesthesia, high postoperative pain scores and meperidine use were observed to be associated with the development of delirium. In the postoperative period, addition of CAM, a simple measurement technique, to the daily follow-up forms can provide the early recognition of delirium, which is often underdiagnosed. We think that identification and prevention of effective risk factors have the primary importance for postoperative delirium.

Postoperative analgesia after modified radical mastectomy: the efficacy of interscalene brachial plexus block.

PURPOSE: In the present study, we evaluated the effects of interscalene brachial plexus block on postoperative pain relief and morphine consumption after modified radical mastectomy (MRM). METHODS: Sixty ASA I-III patients scheduled for elective unilateral MRM under general anesthesia were included. They were randomly allocated into two groups: group 1 (n = 30), single-injection ipsilateral interscalene brachial plexus block; group 2 (n = 30), control group. Postoperative analgesia was provided with IV PCA morphine during 24 h postoperatively. Pain intensity was assessed with the visual analogue scale (VAS). Morphine consumption, side effects of opioid, antiemetic requirement, and complications associated with interscalene block were recorded. RESULTS: VAS scores were significantly lower in group 1, except in the first postoperative 24 h (p < 0.007). The patients without block consumed more morphine [group 1, 5 (0-40) mg; group 2, 22 (6-48) mg; p = 0.001]. Rescue morphine requirements were also higher in the postoperative first hour in group 2 (p = 0.001). Nausea and antiemetic requirements were significantly higher in group 2 (p = 0.03 and 0.018). Urinary retention was observed in 1 patient in group 2 and signs of Horner's syndrome in 2 patients in group 1. CONCLUSIONS: The optimal method has not been defined yet for acute pain palliation after MRM. Our study demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively. The block can be a good alternative to other invasive regional block techniques used for postoperative pain management after MRM.

The effects of magnesium sulphate on desflurane requirement, early recovery and postoperative analgesia in laparascopic cholecystectomy.

PURPOSE: we evaluated the effects of magnesium sulphate infusion on anesthetic requirement, early recovery and postoperative analgesia in desflurane-remifentanil-based, balanced anaesthesia. METHODS: 60, ASA (American Society of Anesthesiologists) group 1-2 patients who were scheduled for laparoscopic cholecystectomy were randomly divided into two groups. Before anesthesia, the magnesium-treated group (n = 30) received a 15 min infusion of 40 mg/kg of magnesium sulphate followed by 10 mg/kg/h by continuous i.v. infusion during the operation. The same volume of isotonic saline was administered to the control group (n = 30). Anesthesia was induced with propofol, remifentanil and vecuronium, and maintained with desflurane 3-6%, O(2)/air and remifentanil infusion. Desflurane was titrated to maintain BIS (bispectral index) values of 40-60. The times from cessation of anesthesia to spontaneous breathing, eye opening, extubation, reaching BIS 70, and Aldrete scores were recorded. After surgery, patients received a patient-controlled, morphine analgesia device. RESULTS: demographic variables were similar. During the 15 min infusion of magnesium sulphate, the BIS value was significantly lower in the magnesium sulphate-treated group. The amounts of propofol and desflurane used were less in the magnesium sulphate-treated group, by 18% and 22% respectively (p<0.05). The groups did not differ with respect to the time taken to reach BIS 70, spontaneous breathing, eye opening and extubation. Alderete and VAS (visual analogue scale) pain scores, and total morphine consumption were significantly lower in the magnesium sulphate-treated group. There were no differences in side effects, but the rate of re-intubation was higher in the group receiving magnesium sulphate (p = 0.03). CONCLUSION: perioperative use of magnesium sulphate reduced propofol and desflurane consumption, and the postoperative morphine requirement, while causing a delay in recovery by decreasing the Aldrete score.

The analgesic efficacy of two different approaches to the lumbar plexus for patient-controlled analgesia after total knee replacement.

This study assessed the efficacy of a patient-controlled regional analgesia technique for either psoas compartment block or femoral nerve block after total knee replacement in 68 patients who were randomly divided into these two groups. All patients received 40 ml of 0.25% bupivacaine via femoral or psoas catheters before general anesthesia, and then, as patient-controlled regional analgesia, 10-ml boluses of 0.125% bupivacaine, with a lockout time of 60 min over 48 h. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, and side effects were recorded. All measured parameters were comparable in the two groups. Both techniques achieved a good quality of analgesia and satisfaction without any major side effect.

Epidural ropivacaine or sufentanil-ropivacaine infusions for post-thoracotomy pain.

OBJECTIVE: The aim of this study was to compare the analgesic efficacy and side effects of continuous epidural infusions of ropivacaine and ropivacaine-sufentanil mixtures after thoracotomy. METHODS: Sixty-two patients scheduled for thoracic surgery were allocated in this prospective double-blinded randomised study. They received an epidural catheter inserted from thoracic 5-6 (Th(5-6)) interspace a day before surgery and were randomly assigned into two groups, sufentanil-ropivacaine group (Group SR, n=31) and ropivacaine group (Group R, n=31). Bolus dose of the study drugs, ropivacaine 0.2% or ropivacaine 0.2% and sufentanil 0.75 microg/ml calculated in ml according to the patient's height was given through the epidural catheter before surgery. One hour after anaesthesia induction, another bolus was given and the epidural infusion was started (4.5-8 ml). Whenever visual analogue scale (VAS) scores were > or =4 during function, the patients received additional boluses and the infusion rate was increased by 1 ml/h. If the pain was not relieved after administration of two boluses, the patient was excluded from the study. RESULTS: VAS at rest and during function was lower in ropivacaine-sufentanil group and the need for additional boluses and infusion rate increase was high in ropivacaine group (P<0.05). Ropivacaine-sufentanil infusion rate was decreased due to nausea and vomiting in two patients and due to CO(2) retention in one patient. There was no statistically significant difference between the incidences of side effects except pruritus significantly higher in Group SR. The total epidural solution volume was more in Group R (P<0.05). CONCLUSIONS: The continuous epidural infusion of ropivacaine with sufentanil provided superior pain relief than ropivacaine alone without causing any severe side effect or post-operative pulmonary impairment.

A low-dose bupivacaine: a comparison of hyperbaric and hypobaric solutions for unilateral spinal anesthesia.

BACKGROUND AND OBJECTIVES: The injection of small doses of local anesthetic solutions through pencil-point directional needles and maintaining the lateral decubitus position for 15 to 30 minutes after the injection have been suggested to facilitate the unilateral distribution of spinal anesthesia. We evaluated the effects of hypobaric and hyperbaric bupivacaine in attempting to achieve unilateral spinal anesthesia for patients undergoing lower limb orthopedic surgery. METHODS: Fifty patients were randomly allocated into 2 groups to receive either 1.5 mL hyperbaric bupivacaine 0.5% (7.5 mg; n = 25) or 4.2 mL hypobaric bupivacaine 0.18% (7.5 mg; n = 25). Drugs were administered at the L3-4 interspace with the patient in the lateral position. Patients remained in this position for 15 minutes before turning supine for the operation. Spinal block was assessed by pinprick and modified Bromage scale on both sides. RESULTS: Unilateral spinal block was observed in 20 patients in the hyperbaric group (80%) and in 19 patients in the hypobaric group (76%) while in the lateral position. However, 15 minutes after patients were turned supine, unilateral spinal anesthesia decreased to 68% of cases in the hyperbaric group and 24% of cases in the hypobaric group (P <.05). The motor block was more intense during the first 5 and 10 minutes (P <.05), but at the end of operation there was no difference between the groups. The hemodynamic changes were similar between the groups. CONCLUSION: As a result, unilateral spinal anesthesia with hyperbaric and hypobaric bupivacaine provided a rapid motor and sensory recovery and good hemodynamic stability, but more unilateral spinal block was achieved in patients in the hyperbaric group when compared with patients in the hypobaric group.