The effect of vitamin D status on different neuromuscular blocker agents reverse time

Background/aim: This study is aimed to investigate the effects of vitamin D levels on sugammadex and neostigmine reversal times. Material and methods: Eighty patients between the ages of 18 and 65 years, with ASA I-III status who were undergoing surgery under general anesthesia were included in the study. A double blind fashion was used to randomly divide all the patients into two groups. At the end of the operation, sugammadex 2 mg/kg was administered to one group (Group sugammadex) and atropine and neostigmine was administered to the other group (Group neostigmine) intravenously. In the data analysis stage, the group was divided into two subgroups according to sugammadex and group neostigmine in itself, with vitamin D levels above and below 30 ng/mL. Statistical analysis was performed on these 4 groups (Group neostigmine and vitamin D < 30 ng/mL), (Group neostigmine and vitamin D ≥ 30 ng/mL), ( Group sugammadex and vitamin D < 30 ng/mL), (Group sugammadex and vitamin D ≥ 30 ng/mL). When two responses to train of four (TOF) stimulation were taken, the following times were recorded until extubation phase. The time until TOF value 50%, 70%, 90%, and extubation were recorded. Results: There were statistically significant differences between Group sugammadex and vitamin D < 30 ng/mL and Group sugammadex and vitamin D ≥ 30 ng/mL (P = 0.007) for extubation times and 50% TOF reach times (P = 0.015). However, there was no difference observed between Group neostigmine and vitamin D < 30 ng/mL and Group neostigmine and vitamin D ≥ 30 ng/mL (P = 0.999). Conclusion: Vitamin D deficiency is important for anesthesiologists in terms of muscle strength and extubation time. Vitamin D deficiency seems to affect sugammadex reverse times but seems not to affect neostigmine reverse times. This conclusion needs further studies.

Anaesthesiologist's Approach to Awake Craniotomy.

Awake craniotomy, which was initially used for the surgical treatment of epilepsy, is performed for the resection of tumours in the vicinity of some eloquent areas of the cerebral cortex which is essential for language and motor functions. It is also performed for stereotactic brain biopsy, ventriculostomy, and supratentorial tumour resections. In some institutions, avoiding risks of general anaesthesia, shortened hospitalization and reduced use of hospital resources may be the other indications for awake craniotomy. Anaesthesiologists aim to provide safe and effective surgical status, maintaining a comfortable and pain-free condition for the patient during surgical procedure and prolonged stationary position and maintaining patient cooperation during intradural interventions. Providing anaesthesia for awake craniotomy require scalp blockage, specific sedation protocols and airway management. Long-acting local anaesthetic agents like bupivacaine or levobupivacaine are preferred. More commonly, propofol, dexmedetomidine and remifentanyl are used as sedative agents. A successful anaesthesia for awake craniotomy depends on the personal experience and detailed planning of the anaesthetic procedure. The aim of this review was to present an anaesthetic technique for awake craniotomy under the light of the literature.

[A comparison of transversus abdominis plane block guided with ultrasonography and local anesthetic infiltration in laparoscopic cholecystectomy operations]. / Laparoskopik kolesistektomi ameliyatlarinda ultrasonografi esliginde uygulanan transversus abdominis plan blogu ile lokal anestezik infiltrasyonu yöntemlerinin karsilastirilmasi.

OBJECTIVES: The aim of this study was to compare a transversus abdominis plane (TAP) block guided with ultrasound (USG) and local anesthetic infiltration (LAI) in terms of the intraoperative and postoperative analgesia efficiency, intraoperative opioid need, and side effects in cases of laparoscopic cholecystectomy. METHODS: A total of 75 patients classified as American Society of Anesthesiologists class I or II were included in this randomized, controlled, prospective study and divided into 3 groups. 20 mL of levobupivacaine 0.5% was applied around the trocar entrance site before the operation to group L (n=25), and 30 mL 0.25% levobupivacaine was applied with a USG-guided TAP block to group T (n=25). No TAP block or LAI was applied to the control group (n=25), group K. In the first 24 hours after surgery, an infusion of tramadol was administered with a controlled analgesia device. The intraoperative fentanyl use was recorded, and a visual analogue scale was administered to assess pain while resting (VASrest) and upon coughing (VAScough) at 1, 2, 4, 8, 12, 16, and 24 hours postoperative. An evaluation of shoulder pain and the consumption of analgesia in 24 hours were also recorded. RESULTS: The VASrest and VAScough values, the dose of fentanyl used intraoperatively, and the total analgesia dose administered in 24 hours were compared between groups and there was no statistically significant difference detected (p>0.05). In group T, the vomiting rate 1 and 2 hours postoperative (20% and 12%, respectively) was significantly lower than in group K (64% and 44%, respectively). CONCLUSION: The efficiency of the analgesia provided after a laparoscopic cholecystectomy with a bilateral TAP block guided with USG and LAI was determined to be similar.

Let us save the brain with cerebral oximeter: Two case reports.

In the neonates, tracheal atresia and tracheoesophageal fistula (TEF) surgery may result in hemodynamic instabilization, leading to cerebral perfusion insufficiency due to the retraction of the pulmonary vessels and truncus brachiocephalicus. We represented one male and one female neonates which were performed thoracoscopic primary repair of TEF through right thoracotomy at the 3th and 4th postpartum day. Anesthesia was induced using sodium thiopental (5 mg/kg), fentanyl 4 mcg, and rocuronium (0.5 mg/kg) given through intravenous route. Sevoflurane 2% and 50% O2in air were used for the maintenance therapy. During the right lung compression to expose posterior esophagus, no value was observed on the pulse oximeter (PO) probe placed on the right hand, and radial artery was not palpated. At the same time, oxygen saturation was observed as 96%-97% on the left foot probe. As the right cerebral oximeter values (rSO2) were rapidly decreased to 31%, the lung compression was ceased. Right pulse oximeter and right rSO2measurements return to the baseline levels. For the second case - different from the first case -both left and right rSO2was rapidly decreased to 40% levels and return to the baseline levels after was removed the retractors. Right PO and right and left cerebral rSO2values returned to baseline immediately when the retractor compression was ended During the operations involving the great vessels in neonates, cerebral perfusion could be preserved using cerebral oximeter. Cerebral oximeter is more efficient than pulse oximeter for detecting cerebral tissue oxygenation and could be helpful to minimize neuronal damage in the neonates.

Effect of Smoking on Reversing Neuromuscular Block.

OBJECTIVE: Rocuronium is a non-depolarising, intermediate-acting, monoquaternary amino steroid and was brought into clinical use as a potentially ideal muscle relaxant. Post-operative residual curarisation (PORC) results from the prolonged effects of non-depolarising neuromuscular blocking agents. This is a common problem and seriously affects patient safety. No recent study has investigated the effects of sugammadex on smokers, which is often used to restore neuromuscular block and avoid PORC. This study compares the severity of the effects of sugammadex used for antagonising rocuronium bromide and antagonism durations in smokers and non-smokers. METHODS: This randomised, prospective study included 40 patients scheduled for elective surgery and belonging to classes I and II based the American Society of Anesthesiologists classification, who were either smokers for at least 10 years or non-smokers. Patients underwent routine and neuromuscular monitoring. At induction, 2 mg kg-1 propofol and 1 mcg kg-1 intravenous fentanyl were applied. After the loss of eyelash reflex, 0.6 mg kg-1 intravenous rocuronium was administered. Patients were intubated at train of four (TOF) 2. Anaesthesia was continued with 50% O2+50% air and 2% sevoflurane. Rocuronium, 0.15 mg kg-1, was administered at TOF 2 during the operation. At the end of the operation, 2 mg kg-1 sugammadex was administered. The times until TOF 0.7, 0.8 and 0.9 were recorded. RESULTS: Intubation time was 132.8±46.4 s for smokers and 127.6±32.7 s for non-smokers. After sugammadex administration, the time to TOF 0.7 was 153.3±54.7 s in smokers and 125±67.2 s in non-smokers. The times were 178.4±58.8 and 146.6±72.6 s for TOF 0.8 and 200.8±55.8 s and 170.4±77.8 s for TOF 0.9 in smokers and non-smokers, respectively. CONCLUSION: Although not statistically significant, the time to reach each TOF was longer for smokers. Larger populations and different perspectives are needed to find if sugammadex use is affected by smoking, which has negative effects on the body.

[The effectiveness of preemptive analgesic techniques on postoperative analgesia in patients undergoing open septorhinoplasty]. / Açik septorinoplasti olgularinda preemptif analjezi uygulamalarinin ameliyat sonrasi analjezideki etkinligi nedir?

OBJECTIVES: A comparison was made of effects of preincisional intravenous (IV) dexketoprofen trometamol and acetaminophen on postoperative pain, analgesic requirement, hemodynamic parameters, postoperative tramadol consumption, and patient satisfaction in patients undergoing elective septorhinoplasty. METHODS: Sixty patients scheduled for elective septorhinoplasty under general anesthesia were divided into 3 groups. Groups were similar with respect to gender, mean age, body weight, mean duration of surgery and anesthesia (p>0.05). Group D (n=20) received 50 mg IV dexketoprofen trometamol, while Group A (n=20) received 1 gr IV acetaminophen before surgical incision. Group K (n=20) received no analgesic. Postoperative analgesia was maintained with IV tramadol infusion, with the aid of patient-controlled analgesia pump. Visual analogue scale (VAS), total tramadol consumption, and patient satisfaction were recorded at 15 and 30 minutes postoperatively, as well as 1, 2, 6, 12, and 24 hours postoperatively. RESULTS: VAS values were highest in Group K and lowest in Group D (p<0.001). There was no difference in tramadol consumption between Group K and Group A, but both groups consumed higher doses of tramadol than Group D (p=0.649 and p<0.05, respectively). First analgesic requirement time and side effects were similar in all groups. CONCLUSION: It was observed that both preemptive IV dexketoprofen trometamol and acetaminophen were effective for postoperative analgesia in early postoperative period in elective septorhinoplasty under general anesthesia; however, preemptive dexketoprofen trometamol was more effective than acetaminophen for postoperative analgesia.

Locomotor stimulation by acute propofol administration in rats: Role of the nitrergic system.

BACKGROUND: The addictive potential of propofol has been scientifically discussed. Drugs' psychostimulant properties that can be assessed via measurements of locomotor activity are linked to their addictive properties. No studies that have investigated the effects of propofol on locomotor activity have been reported to date. The present study sought to investigate the effects and possible mechanisms of action of propofol on locomotor activity in rats. METHODS: Adult male albino Wistar rats (250-330g) were used as subjects. The locomotor activities of the rats were recorded for 30min immediately following intraperitoneal administration of propofol (20 and 40mg/kg), saline or vehicle (n=8 for each group). NG-nitro arginine methyl ester (l-NAME, 15-60mg/kg), a nitric oxide (NO) synthase inhibitor, and haloperidol (0.125-5mg/kg), a non-specific dopamine receptor antagonist, were also administered to other groups of rats 30min prior to the propofol (40mg/kg) injections, and locomotor activity was recorded for 30min immediately after propofol administration (n=8 for each group). RESULTS: Propofol produced significant increases in the locomotor activities of the rats in the first 5min of the observation period [F(2,21)=9.052; p<0.001]. l-NAME [F(4,35)=3.112; p=0.02] but not haloperidol [F(4,35)=2.440; p=0.067] pretreatment blocked the propofol-induced locomotor hyperactivity. l-NAME did not cause any significant change in locomotor activity in naïve rats [F(2,21)=0.569; p=0.57]. CONCLUSIONS: Our results suggest that propofol might cause a short-term induction of locomotor activity in rats and that this effect might be related to nitrergic but not dopaminergic mechanisms.

Comparison of Sugammadex versus Neostigmine Costs and Respiratory Complications in Patients with Obstructive Sleep Apnoea.

OBJECTIVE: To compare sugammadex and neostigmine regarding the efficacy in reversing rocuronium-induced neuromuscular block, the incidence of post-operative respiratory complications and costs in patients undergoing surgery for the treatment of obstructive sleep apnoea (OSA). METHODS: After obtaining ethical approval and patient consent, 74 patients in ASA physical status I or II were randomised into two groups to receive 2-mg kg(-1) sugammadex (Group S) or 0.04-mg kg(-1) neostigmine+0.5-mg atropine (Group N). Groups were compared regarding time to TOF (train-of-four) 0.9, operating room time, post-anaesthesia care unit (PACU) stay, post-operative respiratory complications, costs related to neuromuscular block reversal, anaesthesia care and complication treatment. RESULTS: Patient demographics, anaesthesia, surgical data and total rocuronium doses were similar between groups. Time to TOF 0.9 was shorter for group S [Group N: 8 (5-18) min; Group S: 2 (1.5-6) min (p<0.001)]. Operating room time [Group S: 72.4±14.3 min; Group N: 96.6±22.8 min (p<0.001)] and PACU stay [Group S: 22.9±10.1 dk; Group N: 36.3±12.6 dk (p<0.001)] were also shorter in Group S. After extubation, desaturation was observed in 12 (32.4%) patients in group N and in 4 (8%) patients in group S (p=0.048). In group N, three patients were reintubated; there were eight (21.6%) unplanned intensive care unit (ICU) admissions. There was one unplanned ICU admission in group S. Negative pressure pulmonary oedema was observed in one patient in group N. The results regarding costs were as follows. The reversal cost was higher in the sugammadex group (vial cost 98.14 TL) than that in the neostigmine group (ampoule cost 0.27 TL; total 6147.88 TL vs. 3569.5 TL); however, complication treatment cost and total cost were lower in group S than those in group N (199.5 TL vs. 3944.6 TL) (staff anaesthesia doctor cost was 0.392 TL per min and the cost of nurse anaesthetist was 0.244 TL per min). CONCLUSION: This study confirmed the efficacy of sugammadex over neostigmine for the reversal of rocuronium-induced neuromuscular block. Sugammadex decreases the incidence of post-operative respiratory complications and related costs in patients with OSA.

Effectiveness of preemptive analgesia using a frequency rhythmic electrical modulation system in patients having instrumented fusion for lumbar stenosis.

STUDY DESIGN: A randomized prospective study. PURPOSE: To assess postoperative analgesic requirements after Phyback therapy preemptively in patients undergoing lumbar stabilization. OVERVIEW OF LITERATURE: Frequency Rhythmic Electrical Modulation System is the latest method of preemptive analgesia. METHODS: Forty patients were divided into two groups. Patients who were to receive tramadol were allocated to "group A" and those who were to receive Phyback therapy were allocated to "group B." In patients with a visual analog scale score of >4 or a verbal rating scale score of >2, 75 mg of diclofenac IM was administered. The amount of analgesic consumption, the bolus demand dosage, and the number of bolus doses administered were recorded. Patient satisfaction was evaluated using the visual analog patient satisfaction scale. RESULTS: There were statistically significant differences in the visual analog scale and verbal rating scale scores in the fourth, sixth, 12th, and 24th hours. The number of bolus infusions was significantly lower in group B. The amount of analgesic consumption was higher in group A. There was a significant difference between the two groups in the number of bolus infusions and the total amount of analgesic consumption, and this comparison showed better results for group B. CONCLUSIONS: Application of Phyback therapy reduced postoperative opioid consumption and analgesic demand, and it contributed to reducing patients' level of pain and increased patient satisfaction. Moreover, the application of preemptive Phyback therapy contributed to reducing preoperative pain which may have reduced patient anxiety.

Abuse potential assessment of propofol by its subjective effects after sedation.

OBJECTIVE: In this study, we examined the euphoric effect of propofol and its high satisfaction ratio regarding its liability to be abused, particularly in painless procedures, such as colonoscopy. METHODS: Fifty subjects aged between 18 and 65 years who fulfilled the criteria for ASA 1-2 and were prepared for colonoscopy were enrolled into this study. For intravenous sedation induction, 2 mg/kg propofol was used, and additional injections were administered according to BIS values. After colonoscopy, the subjects were taken to a recovery room and observed for 30 minutes. Patients were interviewed with the modified Brice questionnare regarding the incidence and the content of dreams. A 5-point Likert scale was used to classify their dreams, and the content of the dreams was also recorded. To assess the subjective effects of propofol, the patients were asked to use the Hall and Van der Castle emotion scale; their biological states were also assessed. The patients' feelings regarding propofol were each rated as absent or present. We used the Morphine-Benzedrine Group scale to measure the euphoric effects of propofol. At the end of the study, subjects scored their satisfaction on a five-point scale. RESULTS: There were no statistically significant differences in sex age, weight, propofol dose, or satisfaction ratio (p>0.05) in the groups, although male patients received a higher dose of propofol and had higher satisfaction ratio. Patients reported no residual after-effects. The incidence of dreaming was 42%. There was no statistically significant difference in dreaming between the sexes, but male patients had a higher dreaming ratio. Dreamers received higher propofol doses and had a higher satisfaction ratio (p>0.05). All dreamers reported happy dreams regarding daily life, and their mean MBG score was 10.5. There was no correlation between MBG scores and propofol doses (r= -0.044, p= 0.761). CONCLUSIONS: We conclude that propofol functions as a reward; that patients enjoy its acute effects; and that no residual after-effects should arise. We suggest that propofol may carry potential for abuse, and further abuse liability testing is indicated.

Does premedication with dexmedetomidine provide perioperative hemodynamic stability in hypertensive patients?

BACKGROUND: Perioperative hemodynamic fluctuations are seen more often in hypertensive patients than in normotensive patients. The purpose of our study was to investigate the perioperative hemodynamic effects of dexmedetomidine and midazolam used for premedication in hypertensive patients relative to each other and in comparison to normotensive patients. METHODS: One-hundred-forty female, normotensive or hypertensive patients undergoing myomectomies or hysterectomies. They were randomly enrolled into the subgroups: Group ND (normotensive-dexmedetomidine); Group HD (hypertensive-dexmedetomine); Group NM (normotensive-midazolam); Group HM (hypertensive- midazolam). Dexmedetomidine was administered at a concentration of 0.5 µg.kg(-1), and midazolam was administered at a concentration of 0.025 µg.kg(-1) via intravenous (IV) infusion before the induction of anaesthesia. Haemodynamic parameters were recorded at several times (T(beginning), T(preop5 min), T(preop 10 min), T(induction), T(intubation), T(intubation 5 min), T(initial surgery), T(surgery 15 min), T(surgery 30 min), T(extubation), T(extubation 5 min)). Propofol amount for induction, time between induction and initial surgery, demand of antihypertensive therapy, rescue atropine were recorded. Quantitative clinical and demographic characteristics were compared using One Way ANOVA. The values were compared using One-way Analysis of Variance. Additionally periodic variations were examined by One way Repeated Measures Analysis of Variance for groups separately. RESULTS: SBP was significantly different between normotensive and hypertensive groups at the following time points: T(preop 5 min), T(preop 10 min), T(induction), T(intubation), T(intubation 5 min) and T(initial surgery). MBP was significantly different in the hypertensive groups at T(induction), T(intubation), T(intubation 5 min), T(initial surgery), T(surgery 15 min), T(surgery 30 min), T(extubation) and T(extubation 5 min). The perioperative requirements for antihypertensive drugs were significantly higher in Group HM. CONCLUSION: In the hypertensive patients, dexmedetomidine premedication provides better hemodynamic stability compared with midazolam, and because it decreases the antihypertensive requirements, its use might be beneficial. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02058485.

[Comparison of ilioinguinal-iliohypogastric nerve block versus spinal anesthesia techniques for single sided inguinal herniorrhaphy]. / Tek tarafli inguinal hernilerde ilioinguinal iliohipogastrik sinir blogu ile spinal anestezi yöntemlerinin karsilastirilmasi

OBJECTIVES: The aim of the study is to compare the hemodynamic effects, postoperative analgesia, time to achieve discharge criteria, and patient-surgeon satisfaction of patients who are assigned for single sided inguinal hernia repair operated under iliohypogastric ilioingiinal nerve block (IHNB) or spinal anesthesia. METHODS: Twenty-five ASA I-III patients in Group S received 15 mg 0.5% hyperbaric bupivacaine intrathecally, and 25 ASA I-III patients in Group I received IHNB with 20 mL 0.5% plain bupivacaine. RESULTS: Mean block application duration (16.4±3 vs 6.5±2.1 min), mean sensory block rise time (25.2±5.1 vs 6.9±3.4 min), and time to sensory block termination (262.4±65.2 vs 116.6±102.5 min) was found to longer in Group I with respect to Group S (p<0.001). Mean time to first mobilization (307.1±146.9 vs 456.9±131.7 min), and mean time to meet discharge criteria (4.6±0.8 vs 8.1±2.7 hr) was shorter in group I. Mean VAS scores in postoperative 1, 2, 4 and 6 th and mean tramadole consumption in 24 hr (375.6±113.1 vs 180.5±17.9 mg) were higher in Group S (p<0.001). Hemodynamic parameters, patient and surgeon satisfaction were comparable (p>0.05). CONCLUSION: IHNB provides longer postoperative analgesia and earliar discharge, although takes more time to perform and to produce maximum effect, for single sided inguinal henia repair.

An alternative anterior tension free preperitoneal patch technique by help of the endoscope for femoral hernia repair.

BACKGROUND: Femoral hernias are relatively uncommon and have a higher risk for strangulation and incarceration. We introduce an alternative anterior tension free inlay patch technique by help of the endoscope for femoral hernia repair. METHOD: Characteristics of patients undergoing femoral hernia repair between March 2006-April 2011 and description of the surgical technique is presented. RESULTS: We analyzed our experience with this technique in 26 consecutive patients with femoral hernias (1 bilateral, 15 right, 10 left femoral hernia) in 5 year period. Seven of these 26 femoral hernias were recurrent and 2 of them were concomitant with inguinal hernia. Mean operation time was 30.0 ± 12.1 min. Seroma was seen in 2 patients at postoperative 1st week. There were no; hematoma, wound infection and separation of wound edges and early recurrence at postoperative 1st week and 1st month. The mean follow up period was 41.8 ± 18.2 months. All of 22 patients who were contacted were satisfied with the operation. There was no recurrence, chronic pain and foreign body feeling in any patient at the end of the follow-up period. CONCLUSION: This feasible and safe alternative anterior inlay patch repair might be used in all femoral hernias with the exception of the ones requiring intestinal resection.

The effects of remifentanil, lidocaine, metoclopramide, or ketamine pretreatment on propofol injection pain.

BACKGROUND: Propofol injection pain is a frequent and a well-known complaint distressing for the patients. Although the ethiology of this pain remains obscure, the ideal method for the prevention of propofol injection pain is still controversial. Local anesthetics, opioids, nonsteroidal anti-inflammatory drugs, ketamine, metoclopramide, droperidol have been tested. We aimed to conduct a study comparing various drugs with saline, lidocaine and together at the same time. METHODS: In this randomized, double-blind, prospective trial a total of 250 patients (ASA I-II) undergoing elective surgery with general anesthesia were randomly allocated into five groups. After premedication of 3 mg midazolam im, patients received either 2 mL (0.02 mg) of remifentanil (n = 50, Group R), 2mL (40 mg) of lidocaine (n = 50, Group L), 2 mL (10 mg) of metoclopramide (n = 50, Group M), or 2mL (100 microg/kg) of ketamine (n = 50, Group K) and 2 mL of saline. Pain intensity was evaluated through the use of a verbal rating scale, 0 = none, 1 = mild pain, 2 = moderate pain, and 3 = severe pain. RESULTS: Pretreatment with remifentanil 0.02 mg, % 2 lidocaine 40 mg, metoclopramide 10 mg, and ketamine 100 microg/kg yields propofol induced pain 38%, 76%, 76%, and 58% respectively. Pretreatment with lidocaine or metoclopramide equally and significantly reduced the incidence and severity of propofol induced pain (76%). CONCLUSION: Lidocaine and metoclopramide were equally and the most effective treatments in attenuating pain during intravenous injection of propofol compared to pretreatment with remifentanil and ketamine.

Epidural anesthesia for laparoscopic cholecystectomy in a patient with sickle cell anemia, beta thalassemia, and Crohn's disease -A case report-.

A 37-year-old woman diagnosed with sickle cell anemia (SCA), beta (+) thalassemia, Crohn's disease, and liver dysfunction was scheduled for laparoscopic cholecystectomy (LC) due to acute cholecystitis with gall bladder. Regional anesthesia was performed. An epidural catheter was inserted into the 9-10 thoracal epidural space and then 15 ml of 0.5% bupivacaine was injected through the catheter. The level of sensorial analgesia tested with pinprick test reached up to T4. Here we describe the first case of the combination of sickle cell anemia (SCA), beta (+) thalassemia, and Crohn's disease successful anesthetic management with attention to hemodynamics, particularly with regards to liver dysfunction.