Thoracic paravertebral block for postoperative pain management in percutaneous nephrolithotomy patients: a randomized controlled clinical trial.

OBJECTIVE: To investigate the effect of thoracic paravertebral block (PVB) on pain control and morphine consumption in percutaneous nephrolithotomy operations. SUBJECTS AND METHODS: This randomized controlled clinical study was performed on 60 American Society of Anesthesiologists (ASA) I-II patients between the ages of 18 and 60 years who underwent percutaneous nephrolithotomy with approval of the ethical committee and written consent of the patients. Patients were randomly allocated into two groups: group P had 4 ml of 0.5% levobupivacaine injected at each of the T10, T11, and T12 paravertebral spaces and a standard PVB, and group C received 4 ml of 0.9% NaCl solution. All patients were given standard general anesthesia. The follow-up of saturation, heart rate, peripheral oxygen, and blood pressure values was recorded before induction, intraoperatively, and postoperatively. At postoperative 1, 2, 6, 12, and 24 h, the visual analog scale (VAS), Ramsey sedation score, respiratory rate, and 24-hour total morphine consumption were recorded. In addition, side effects and satisfaction of patients were recorded. RESULTS: VAS scores and total morphine consumption were lower in group P than in group C: 2.3 vs. 4.3 and 22.3 vs. 43.2 mg, respectively (p < 0.05). The level of satisfaction was higher in group P than group C. Differences between groups in other parameters were not significant. CONCLUSIONS: Thoracic PVB with levobupivacaine provided a good postoperative analgesia and increased patient satisfaction for those who underwent percutaneous nephrolithotomy.

Acute amitraz intoxication: retrospective analysis of 45 cases.

OBJECTIVE: To present special clinical and laboratory features of 45 cases (44 adult cases) who were intoxicated through oral route. DESIGN: Retrospective study. SETTING: Intensive care unit (ICU) of a university hospital. PATIENTS: Forty-five patients admitted to the ICU of Cumhuriyet University Hospital. RESULTS: Forty-five patients between 4 and 97 years of age were evaluated. Intoxication was the result of a suicide attempt in 67% of cases and accidental in 33% of cases. Unconsciousness, nausea and vomiting were the common initial symptoms. The major clinical findings in the ICU were bradycardia, myosis, hypothermia, hyperglycemia, hypotension, coma and respiratory depression. Blood glucose level was increased in 64% of cases. No problem was noted in the patient or the fetus in a pregnant, 27-year-old patient, who was intoxicated with 10 mL of 12.5% amitraz. The length of stay in the ICU was between 2 and 15 days. None of the patients died. All patients were discharged without neurological sequela. CONCLUSION: The prognosis of amitraz intoxications through oral route is benign and results in complete healing; however, we suggest that these cases should be well monitored and followed-up in ICUs.

Cerebral arterial air embolism associated with mechanical ventilation and deep tracheal aspiration.

Arterial air embolism associated with pulmonary barotrauma has been considered a rare but a well-known complication of mechanical ventilation. A 65-year-old man, who had subarachnoid hemorrhage with Glasgow coma scale of 8, was admitted to intensive care unit and ventilated with the help of mechanical ventilator. Due to the excessive secretions, deep tracheal aspirations were made frequently. GCS decreased from 8-10 to 4-5, and the patient was reevaluated with cranial CT scan. In CT scan, air embolism was detected in the cerebral arteries. The patient deteriorated and spontaneous respiratory activity lost just after the CT investigation. Thirty minutes later cardiac arrest appeared. Despite the resuscitation, the patient died. We suggest that pneumonia and frequent tracheal aspirations are predisposing factors for cerebral vascular air embolism.

Hypotensive anaesthesia with remifentanil combined with desflurane or isoflurane in tympanoplasty or endoscopic sinus surgery: a randomised, controlled trial.

OBJECTIVE: To compare the effect of remifentanil combined with desflurane or isoflurane on the quality of the operative field and surgical conditions, blood loss, and recovery during tympanoplasty or endoscopic sinus surgery. DESIGN: Randomised, double-blinded clinical study. SUBJECTS: Sixty-four patients were scheduled for elective tympanoplasty or endoscopic sinus surgery. The patients were randomly divided into two groups: desflurane or isoflurane. After anaesthesia induction, all patients received a continuous remifentanil infusion of 0.2-0.5 microg/kg/min until a mean arterial pressure of 65-75 mmHg was achieved. Heart rate and mean arterial pressure were recorded throughout anaesthesia. Blood loss was measured at the end of surgery. Achievement of a bloodless operative field was rated on a 100 mm visual analogue scale. Following completion of surgery, the time to extubation and to achievement of an Aldrete score of nine or more was recorded. RESULTS: Sixty-three patients were evaluated. The total dose of remifentanil and the total blood loss were similar in both groups (p > 0.05). Time to extubation and to an Aldrete score of nine or more for the desflurane group was significantly less than for the isoflurane group (p 0.05). CONCLUSION: Although desflurane and isoflurane both enabled good surgical conditions (in terms of quality of operative field) and convenient induction of hypotension for tympanoplasty and endoscopic sinus surgery, the recovery characteristics of desflurane were better than those of isoflurane. Therefore, desflurane may be preferable to isoflurane in such circumstances.

Remifentanil compared with morphine for postoperative patient-controlled analgesia after major abdominal surgery: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: This randomized, double-blinded clinical study was designed to compare the efficacy and safety of remifentanil and morphine administered using intravenous (i.v.) patient-controlled analgesia (PCA) for postoperative analgesia after major abdominal surgery during the first 24 postoperative hours. METHODS: Sixty-nine patients were randomly allocated into two groups, each receiving remifentanil or morphine. The first group received i.v. remifentanil PCA with a loading dose of 45 microg, a maintenance dose of 1 microg min(-1), a bolus dose of 15 microg and a lockout interval of 10 min during the first 24 postoperative hours. The second group received i.v. morphine PCA with a loading dose of 5 mg, a maintenance dose of 0.3 mg h(-1), a bolus dose of 1 mg and a lockout interval of 15 min. Age, weight, sex, history of general anaesthesia, duration of surgery and time spent in the post-anaesthesia care unit were recorded. Preoperative pulse rate, systolic and diastolic blood pressures (BP), respiration rate and arterial blood gases were collected. Pulmonary function was tested before induction of anaesthesia, as well as at 4 and 26 h after operation. Pulse rate, systolic and diastolic BP, respiration rate, arterial blood gases, sedation and visual analogue scores, and presence of side-effects in the recovery room and on the ward for 24 h were recorded at 0, 1, 2, 4, 6, 12, 18 and 24 h after operation. Total drug use, number of boluses delivered, number of boluses demanded and delivery/demand ratio were collected. RESULTS: Sixty patients were evaluated. The groups did not differ in age, weight, sex, history of general anaesthesia, duration of surgery or time spent in the recovery unit. There were also no clinically relevant differences between the groups with regard to haemodynamic and respiratory parameters as well as sedation and visual analogue scores (P > 0.05). More bolus doses were demanded and delivered and the delivery/demand ratio was significantly higher in the remifentanil group (P < 0.05). There was no finding suggesting acute opioid tolerance during remifentanil or morphine PCA. CONCLUSION: The i.v. remifentanil PCA with the chosen dosage regimen after abdominal surgery produces postoperative analgesia and has cardiovascular side-effects similar to those achieved with i.v. morphine. Special attention must be given to respiratory depression during establishment of PCA with remifentanil.