Tailored Therapeutic Doses of Dexmedetomidine in Evolving Neuroinflammation after Traumatic Brain Injury.

BACKGROUND: Understanding the secondary damage mechanisms of traumatic brain injury (TBI) is essential for developing new therapeutic approaches. Neuroinflammation has a pivotal role in secondary brain injury after TBI. Activation of NLRP3 inflammasome complexes results in the secretion of proinflammatory mediators and, in addition, later in the response, microglial activation and migration of the peripheral immune cells into the injured brain are observed. Therefore, these components involved in the inflammatory process are becoming a new treatment target in TBI. Dexmedetomidine (Dex) is an effective drug, widely used over the past few years in neurocritical care units and during surgical operations for sedation and analgesia, and has anti-inflammatory effects, which are shown in in vivo studies. The aim of this original research is to discuss the anti-inflammatory effects of different Dex doses over time in TBI. METHODS: Brain injury was performed by using a weight-drop model. Half an hour after the trauma, intraperitoneal saline was injected into the control groups and 40 and 200 µg/kg of Dex were given to the drug groups. Neurological evaluations were performed with the modified Neurological Severity Score before being killed. Then, the mice were killed on the first or the third day after TBI and histopathologic (hematoxylin-eosin) and immunofluorescent (Iba1, NLRP3, interleukin-1ß, and CD3) findings of the brain tissues were examined. Nonparametric data were analyzed by using the Kruskal-Wallis test for multiple comparisons, and the Mann-Whitney U-test was done for comparing two groups. The results are presented as mean ± standard error of mean. RESULTS: The results showed that low doses of Dex suppress NLRP3 and interleukin-1ß in both terms. Additionally, high doses of Dex cause a remarkable decrease in the migration and motility of microglial cells and T cells in the late phase following TBI. Interestingly, the immune cells were influenced by only high-dose Dex in the late phase of TBI and it also improves neurologic outcome in the same period. CONCLUSIONS: In the mice head trauma model, different doses of Dex attenuate neuroinflammation by suppressing distinct components of the neuroinflammatory process in a different timecourse that contributes to neurologic recovery. These results suggest that Dex may be an appropriate choice for sedation and analgesia in patients with TBI.

Factors affecting the preference of anesthesia residents regarding subspecialty training.

BACKGROUND: There is scant information about the factors that influence the career decisions of anesthesia residents in Turkey. The aim of this study was to determine the preferences of anesthesia residents in Turkey regarding future career and subspecialty training plans and practice location, and to determine the factors that influence those preferences. METHODS: A 21-item e-questionnaire was administered to anesthesia residents who were registered with at least one of the two societies of anesthesiologists in Turkey. Data were collected on demographics and preferences regarding subspecialty training and future practice location. RESULTS: The response rate of the survey was 41.04%. The percentages of participants who intended to pursue a fellowship in intensive care and algology were 12.1 and 23.1%, respectively; 21.7% of participants did not intend to pursue any fellowship training and the decision of 43.1% of the participants was uncertain. The most popular reasons for pursuing a fellowship were to perform compulsory service in a better place (47.2%) and improve earning potential (43.1%). Forty-two percent of participants did not intend to pursue any fellowship training because of their attention to general anesthesiology practice and 15.2% because of the additional compulsory service obligation following the training. CONCLUSIONS: This study showed that the desirability of sub-specialization among anesthesia residents in Turkey could be accepted as low. This result seems to be associated with the additional compulsory service obligation.

Duties of Anaesthetists and Assessment of Awareness, Concerns, and Expectations on Anaesthesia Practices.

Objective: Numerous studies performed worldwide indicate that the public has limited knowledge of anaesthesia practices and anaesthetists' duties and responsibilities. This study aimed to identify the level of knowledge about anaesthetists and anaesthesia practices, and to assess the reasons for anxiety about anaesthesia of the population admitted to our hospital, which is tertiary in Turkey. The secondary aim was to analyze their differences according to sex, education level, and acquired anaesthesia experience. Methods: A survey comprising 23 questions was administered to 400 patients and/or their relatives, aged 18-85 years, who presented to our clinic for preoperative anaesthesia evaluation and for whom elective surgery was planned from March through October 2017. Results: Of the 400 participants, 213 were women and 187 were men. Of all participants in the survey, 51.2% were patients and 48.8% were patient relatives; 64.2% had anaesthesia experience and 35.8% had never had anaesthesia before. The survey group's level of knowledge about anaesthesia was generally low. According to education level, there was a statistically significant difference in the anaesthesia recognition level. However, the acquired anaesthesia experience did not affect the anaesthesia recognition level. Conclusion: To raise the level of knowledge about this topic, anaesthetists must provide patients with more detailed information during preoperative and postoperative visits, which would significantly reduce their anxiety levels. Further, we determined that increasing the use of methods such as media-based brochures, booklets, and videos to inform patients may increase knowledge levels and reduce anxiety levels.

Benign cerebellar pilocytic astrocytomas in children.

AIM: Cerebellar astrocytomas are benign tumors of the central nervous system. They represent 10% of all pediatric intracranial brain tumors and 30% of all pediatric posterior fossa tumors especially in the first two decades of life. MATERIAL AND METHODS: We reviewed the medical records of patients; age at the time of surgery, pre- and post operative magnetic resonance imaging (MRI), localisation of the tumor, hydrocephalus, surgical approach, pre- and post operative neurological status, post operative adjuvant therapy and outcome were documented. RESULTS: The male to female ratio was 20/11. Age at the time of evaluation ranged from 3 to 23 years. Age at the time of surgery ranged from 1 to 18 years. Follow-up duration after surgery was 1-12 years. 55% of these tumors were located at the cerebellar vermis and 45% were at the cerebellar hemispheres. Complete surgical resection was done in 74% of these patients. 5 patients had a second operation because of residual tumor. Ventriculoperitoneal shunt insertion was performed in 3 of 31 patients because of symptomatic hydrocephalus and 1 patient had an endoscopic third ventriculostomy pre-operatively. 90% of these patients had no neurological sequelae at follow-up evaluation. CONCLUSION: Cerebellar astrocytomas are benign tumors where total resection is possible in the majority of cases with an excellent outcome.

Ketamine, but not priming, improves intubating conditions during a propofol-rocuronium induction.

PURPOSE: Both ketamine and priming may shorten the onset time of rocuronium. This study investigates the effects of ketamine and priming as components of a propofol induction on intubating conditions and onset of neuromuscular block. METHODS: This prospective randomized double-blind study was performed in 120 American Society of Anesthesiologists (ASA) I-II patients who were assigned to one of four groups of 30 patients each: control, priming, ketamine, and ketamine-priming. Ketamine 0.5 mg x kg(-1) or saline was given before priming and induction. Rocuronium 0.06 mg x kg(-1) or saline was injected 2 min before propofol 2.5 mg x kg(-1). This was followed by rocuronium 0.6 mg x kg(-1) or by rocuronium 0.54 mg x kg(-1) if priming was given. Intubation was performed one minute later. Intubating conditions were graded as excellent, good, or poor. Heart rate, noninvasive blood pressure, and train-of-four (TOF) response were monitored. RESULTS: Intubating conditions were graded excellent in 20% of the control group, 30% of the priming group, 47% of the ketamine group, and 57% of the ketamine-priming group. Analysis using forward stepwise regression indicated that ketamine improved intubating conditions (P = 0.001) but priming did not (P = 0.35). Time to reach a TOF count of zero was shortened by ketamine (P = 0.001) but not by priming (P = 0.94): 216 +/- 20 s in the control group, 212 +/- 27 s in the priming group, 162 +/- 18 s in the ketamine group, and 168 +/- 22 s in the ketamine-priming group. CONCLUSION: A low-dose ketamine used with a propofol-rocuronium induction improved intubating conditions and shortened onset time. Priming did not influence intubating conditions or onset time.

The addition of metamizole to morphine and paracetamol improves early postoperative analgesia and patient satisfaction after lumbar disc surgery.

AIM: Combined analgesic regimens produce sufficient analgesia by additive or synergistic effects, and reduce the total dose of analgesics and minimise adverse effects. We investigated the metamizole, paracetamol and morphine combination with respect to postoperative pain treatment in lumbar disc surgery. MATERIAL AND METHODS: After Ethics Committee approval and informed consent, 63 patients were allocated to three treatment groups; as Group paracetamol: paracetamol (1 g), Group paracetamol-metamizole: paracetamol (1 g) and metamizole (1 g), and Group placebo: no analgesic. All the patients received intravenous (i.v.) morphine with a patient-controlled analgesia device (PCA) as the rescue analgesic. Pain was assessed by the numerical pain rating scale (NRS, 0-3). Total morphine consumption at 24 hours, patient satisfaction and side effects were investigated. RESULTS: NRS of Group paracetamol-metamizole was low at 15th min, 30th min and 1st hour, and the difference reached statistical significance at 30th min (p=0.033). Patient satisfaction at the same measurement times was high in this group. Total morphine consumption and side effects were not statistically different between the three groups. CONCLUSION: Addition of metamizole to paracetamol along with iv morphine PCA offers an advantage over single iv morphine PCA and paracetamol, with respect to early postoperative pain treatment and patient satisfaction.

Comparison of midazolam, propofol and fentanyl combinations for sedation and hemodynamic parameters in cataract extraction.

OBJECTIVE: Midazolam, propofol and fentanyl were compared in terms of sedation during cataract extraction. Hemodynamic parameters, sedation level, postoperative satisfaction, and side effects were investigated. METHODS: The study was carried out in Hacettepe University Hospitals Ophthalmology Operating Theatres in 2005. The patients received only midazolam (0.02 mg kg-1), or midazolam (0.02 mg kg-1) + propofol (0.2 mg kg-1), or midazolam (0.02 mg kg-1) + fentanyl (1 microgram kg-1), or midazolam (0.02 mg kg-1) + propofol (0.2 mg kg-1) + fentanyl (1 microgram kg-1). The sedation level of patients was measured according to a physician questionnaire. Postoperative nausea/vomiting, headache, and patient satisfaction were determined via a patient's evaluation scale. RESULTS: In the groups receiving fentanyl, the hemodynamic response to peribulbar block insertion was minimal (p<0.05) and the sedation level was best (p<0.05). Respiration rate and O2 saturation of patients receiving midazolam, propofol, and fentanyl decreased after sedation (p<0.01) and postoperative satisfaction was high in this group (p<0.01). Patients in the midazolam group showed a prominent reaction to peribulbar block insertion while movement during the operation was obvious (p<0.05). CONCLUSION: The combination of midazolam, propofol, and fentanyl should be preferred to other study groups as the sedation level is suitable for cataract extraction with high postoperative patient satisfaction and without any side effects.

Comparative assessment of induction efficacy of propofol preparations.

OBJECTIVE: To compare the hypnotic effects (using Bispectral Index [BIS]), hemodynamic parameters, injection pain and quality of anesthesia during induction of anesthesia of the 3 commercial propofol preparations (Abbott Propofol, Abbott Laboratories), Pofol (Dongkook Pharm. Co. Ltd.), and Propofol 1% Fresenius (Fresenius Kabi). METHODS: After Ethics Committee Approval, a prospective, randomized, double-blind study was designed in Hacettepe University Hospitals Operating Theaters in 2005. The patients aged 18-65 years, American Society of Anesthesiologists (ASA) grades I and II scheduled for elective surgery under general anesthesia with orotracheal intubation. Ninety patients were randomized into 3 groups with 30 patients in each group. Propofol infusion rate was 2.5 mg. seconds(-1). Induction time and doses to reach BIS level of 50+/-10, injection pain, BIS values and hemodynamic parameters were recorded every minutes for the first 7 minutes and than every 2 minutes for 15 minutes. We used a special chart to assess the induction quality. RESULTS: Demographical parameters and ASA Physical status were similar in all groups. There were no significant differences in induction quality, induction time and doses, injection pain, BIS values and hemodynamic parameters. CONCLUSION: Abbott Propofol, Pofol and Propofol 1% Fresenius have similar effects on anesthesia induction quality and the cost should be taken into consideration when choosing the type of commercial formulation propofol emulsions.

The effect of intravenous paracetamol for the prevention of rocuronium injection pain.

Rocuronium is a nondepolarizing neuromuscular blocking agent used in anesthesia induction and is associated with considerable discomfort and burning pain during injection, which is reported to occur in 50-80% of patients. This study was carried out to investigate the effectiveness of intravenous paracetamol pretreatment compared with lidocaine and normal saline to prevent rocuronium injection pain. The study included 150 ASA I-II patients undergoing elective orthopedic, gastrointestinal, and gynecological procedures under general anesthesia. They were allocated into three groups according to pretreatment drugs: lidocaine (40 mg) (n = 50), paracetamol (n = 50), and normal saline group (n = 50). Before anesthesia induction with propofol, all patients were pretreated with rocuronium. The pain caused by the injection was evaluated. Local signs were assessed on the arm at the end of the injection, as well as 24 hours after recovery from anesthesia. There were no patients with blurred speech or vision and there was no respiratory depression in any group after pretreatment with the study drug. The level of pain on injection was statistically lower in those who had received paracetamol compared to normal saline (p = 0.009). There were more patients in the saline group with severe pain (p < 0.001). Paracetamol relieved the rocuronium injection pain better than normal saline but lidocaine was the best of the three drugs (p < 0.001).

Asymptomatic vallecular cyst: case report.

A 56-year-old man presented himself for an intracranial glioblastoma multiforme excision. After being routinely monitored, he was preoxygenated. We induced anesthesia and paralysis with 200 mg propofol, 50 µg fentanyl and 9 mg vecuronium. Direct laryngoscopy with a Macintosh 3 blade revealed a 2x2 cm cyst, pedunculated, arising from the right side of the vallecula preventing the endotracheal intubation. While the patient remained anesthetized, we urgently consulted an otolaryngologist and aspirated the cyst with a 22-gauge needle and syringe under direct laryngoscopy. We aspirated 10 cc of liquid content. This was followed by an uneventful tracheal intubation with a 9.0 enforced spiral cuffed tube. An alternative to fiberoptic intubation may be careful cyst aspiration to facilitate the intubation.

A clinical comparison of etomidate-lipuro, propofol and admixture at induction.

OBJECTIVE: The purpose of this study was to compare etomidate-lipuro and propofol and 50%, (1:1) admixture of these agents at induction with special reference to injection pain, hemodynamic changes, and myoclonus. METHODS: Ninety patients were assigned at random to three groups in which induction was performed with either etomidate-lipuro, propofol or etomidate-lipuro-propofol admixture. After monitorization with bispectral index (BIS) all agents were given with infusion with a perfuser at a constant rate of 200 ml/min till the BIS values decreased to 40. Blood pressure and heart rate were measured every 30 s at this period. Patients were asked for pain at the injection site and observed visually for myoclonus. The time BIS values decreased to 40 (BIS 40 time) and total amounts of induction doses were measured. RESULTS: BIS 40 time measurements were P > E > PE (199.4 ± 40.9, 176.9 ± 31.6, 163.5 ± 20.6 s). The hemodynamic (systolic, diastolic and mean blood pressures, heart rate) changes were minimal in group PE than other two groups (P = 0.017). The intensity of myoclonus was graded as mild in 9, moderate in 12, and severe in 5 patients in the group E (76.3%). Myoclonus was not observed in group PE and group P. There were no injection pain in group PE as the incidence were (83.8%) in group P and in (63.2%) group E. CONCLUSION: Incidence of hemodynamic changes, myoclonus, and injection pain is significantly lower in group PE. BIS 40 times is least in group PE. We concluded that 1:1 admixture of etomidate-lipuro and propofol is a valuable agent for induction.

Dexmedetomidine as a substitute for remifentanil in ambulatory gynecologic laparoscopic surgery.

OBJECTIVE: To compare dexmedetomidine with remifentanil in desflurane based ambulatory gynecologic laparoscopic surgery, in respect to its effects on orientation, discharge time, nausea-vomiting, and postoperative analgesic need. METHODS: Sixty 20-40 year old ASA I-II patients undergoing gynecologic laparoscopic surgery were randomized into 2 groups. This study was performed in the operating theaters of the Hacettepe University Faculty of Medicine, Hacettepe, Turkey in 2004 as a prospective, randomized, and double blinded study. The remifentanil group (group R), and dexmedetomidine group (group D) received a bolus of 1 microg/kg over 10 minutes, followed by 0.2 microg/kg/minute peroperative infusion of remifentanil, and 0.4 microg/kg/hour of dexmedetomidine. Hemodynamic parameters, time to extubation, and to orientation to person, place, and date, postoperative nausea, vomiting, pain, analgesic requirement at home, and satisfaction with anesthesia were recorded. RESULTS: Demographic, hemodynamic data, postoperative pain scores, and discharge time were similar in both groups. Time to extubation, to orientation to person, to place and date were shorter in group R. Postoperative nausea, vomiting, and analgesic requirements at home were less in group D. CONCLUSION: This study demonstrated that dexmedetomidine infusion causes a relatively slow recovery with reduced postoperative nausea, vomiting, and analgesic requirements, and similar hemodynamics compared to remifentanil in ambulatory laparoscopic surgeries. It may be an alternative to remifentanil in ambulatory anesthesia.

Cisto assintomático em região da valécula: relato de caso / Asymptomatic vallecular cyst: case report / Quiste valecular asintomático: relato de caso

Paciente do sexo masculino, 56 anos, apresentou-se para excisão de glioblastoma intracraniano multiforme. Após ser rotineiramente monitorado, o paciente foi pré-oxigenado. Anestesia e paralisia foram induzidas com propofol (200 mg), fentanil (50 µg) e vecurônio (9 mg). Laringoscopia direta com lâmina Macintosh número 3 revelou um cisto pedunculado de 2x2 cm, que surgia do lado direito da valécula e impedia a intubação endotraqueal. Enquanto o paciente permanecia anestesiado, consultamos rapidamente um otorrinolaringologista e o cisto foi aspirado por uma seringa com agulha de calibre 22G sob laringoscopia direta. Aspiramos 10 cc de líquido. Intubação traqueal foi feita em seguida sem intercorrências com sonda de 9,0 aramada e com balão. Uma opção para a intubação com fibra óptica pode ser a aspiração cuidadosa do cisto para facilitar a intubação.

A 56-year-old man presented himself for an intracranial glioblastoma multiforme excision. After being routinely monitored, he was preoxygenated. We induced anesthesia and paralysis with 200 mg propofol, 50 µg fentanyl and 9 mg vecuronium. Direct laryngoscopy with a Macintosh 3 blade revealed a 2x2 cm cyst, pedunculated, arising from the right side of the vallecula preventing the endotracheal intubation. While the patient remained anesthetized, we urgently consulted an otolaryngologist and aspirated the cyst with a 22-gauge needle and syringe under direct laryngoscopy. We aspirated 10 cc of liquid content. This was followed by an uneventful tracheal intubation with a 9.0 enforced spiral cuffed tube. An alternative to fiberoptic intubation may be careful cyst aspiration to facilitate the intubation.

Un paciente del sexo masculino, de 56 años, llegó para una resección de glioblastoma intracraneal multiforme. Posteriormente a la rutina de monitorización, el paciente fue pre-oxigenado. La anestesia y la parálisis se indujeron con propofol (200 mg), fentanilo (50 µg) y vecuronio (9 mg). La laringoscopia directa con lámina 3 Macintosh arrojó un quiste pedunculado de 2x2 cm que surgía al lado derecho de la valécula e impedía la intubación endotraqueal. Mientras el paciente permanecía anestesiado, consultamos rápidamente un otorrinolaringólogo y el quiste fue aspirado por una jeringa con una aguja calibre 22G bajo laringoscopia directa. Aspiramos 10 cc de líquido. La intubación traqueal se hizo enseguida sin intercurrencias con una sonda de 9,0 y un alambre en espiral y con balón. Una opción para la intubación con fibra óptica puede ser la aspiración cuidadosa del quiste para facilitar la intubación.

Doctors' opinions, knowledge and attitudes towards cancer pain management in a university hospital.

Cancer pain management is still reported to be inadequate despite of recent developments in medicine, resulting in serious outcomes. This study is to evaluate opinions, knowledge and attitudes of doctors working and/or being trainedg in surgical and medical departments in our university hospital, towards cancer pain management via a questionnaire. Of all doctors approached, eighty percent could be reached and 83% of them completed the questionnaire. In this group of doctors, reportedly 60% evaluating cancer patients with pain at least once in a week, most had not have any formal education about cancer pain management during their medical school or residency training and the ones reporting "any" education, described this as "limited in quality and as hours of lessons" and were not satisfied. The results of this survey suggest specific targets for the strategic and educational projects to overcome some of the barriers against the optimal cancer pain management. Most of the doctors believe that barriers originating from health professionals and systems are more important than the ones resulting from patients and give high priority to treatment of cancer pain relative to the treatment of cancer; but still half of them report that legal regulations have some influence on opioid prescription; and almost three quarters of them believe that opioid use may cause high rates of psychological addiction or abuse. Two thirds of the doctors feel themselves "insufficient" in cancer pain management, being more prominent in tasks requiring knowledge, skill, education and experience about opioid use.