Anis Aribogan

Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia.

PURPOSE We analyzed the results of patients who underwent percutaneous nephrolithotomy (PCNL) for management of kidney stone disease under combined spinal-epidural anesthesia and compared surgical parameters and outcomes with a matched control group who underwent PCNL under general anesthesia. PATIENTS AND METHODS A total of 82 patients were studied in two groups. Group 1 (n = 45) consisted of the patients who underwent general anesthesia, and group 2 (n = 37) comprised those who received combined spinal-epidural anesthesia. RESULTS The mean ages of patients in groups 1 and 2 were 45 +/- 15 and 44 +/- 15 years, respectively. The mean areas of the stones in groups 1 and 2 were 734 +/- 386 mm(2) and 731 +/- 394 mm(2), respectively. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, operative time, irrigation fluids, fluoroscopy time, delta hemoglobin, and hospitalization time (P = 0.439). At the end of the surgery, stone-free rates were 76% in group 1 and 81% in group 2; clinically insignificant residue fragments rates were 24% in group 1 and 19% in group 2. The difference was statistically insignificant between the groups (P = 0.543). CONCLUSIONS We consider that combined spinal-regional anesthesia is a feasible technique in PCNL operations because the efficacy and safety were not affected. Further investigations with larger series are needed.

Patient-controlled intravenous analgesia with remifentanil in nulliparous subjects in labor

Objective: in this study we controlled the efficiency and safety of using remifentanil combined with two different supplementary background infusions for labor analgesia in nulliparous patients. Research design and methods: 60 subjects were allocated to two groups. After programming the patient-controlled analgesia device to deliver a fixed load and demand doses of intravenous remifentanil for all subjects, group r (n = 30) received a background infusion of remifentanil 0.1 μg/kg/min and group R (n = 30) received a supplementary infusion of remifentanil 0.15 μg/kg/min. Visual analogue scale for analgesia, hemodynamic parameters, sedation scales and fetal heart rates were recorded at the 5th, 10th, 20th and 30th min of the study and measurements continued every 15 min during 90 min of labor and delivery. Side effects, Apgar and satisfaction scores were obtained for every subject. Results: visual analogue scale scores of group R were significantly lower than those of group r throughout labor and delivery (p < 0.05). Hemodynamic parameters and fetal heart rates of the two groups were not different (p > 0.05). Most subjects were awake and only nausea was obtained (p > 0.05). The increase in the Apgar and satisfaction scores was not statistically significant (p > 0.05). Conclusion: it was determined that remifentanil with a 15-μg demand dose and 0.15 μg/kg/min supplementary continuous infusion is an effective choice for patient-controlled analgesia during labor in nulliparous subjects.

Children on phenobarbital monotherapy requires more sedatives during MRI.

Background:  Phenobarbital induces specific hepatic cytochrome P‐450 enzyme pathways causing increased clearance of hepatically metabolized drugs. In this study, we investigated the duration and additional anesthetic requirement during Magnetic resonance imaging (MRI) in epileptic children with or without phenobarbital monotherapy.

The effect of paracetamol on postoperative nausea and vomiting during the first 24 h after strabismus surgery: a prospective, randomised, double-blind study.

Context Strabismus surgery is one of the most common ophthalmic surgical procedures in children and is associated with significant postoperative nausea and vomiting (PONV). Objective We evaluated the effect of intravenous paracetamol on PONV in children after strabismus surgery. Design Prospective, placebo-controlled, randomised double-blind study. Setting University hospital. Patients Ninety children, between 2 and 14 years scheduled for strabismus surgery, were recruited. Eighty-six completed the study. Interventions After induction of anaesthesia, intravenous dexamethasone 0.1 mg kg−1 was administered to all. The patients were enrolled to receive either intravenous physiological saline (group S) or paracetamol 15 mg kg−1 (group P). Main outcome measure Incidence of PONV in the first 24 h postoperatively. Results General and clinical characteristics of the children were similar in both groups. PONV during the first 24 h was significantly higher in group S in comparison with group P (group S vs. group P, 33 vs. 14.6%, respectively, P = 0.038 for nausea; 24.4 vs. 7.3%, respectively, P = 0.030 for vomiting). The number of analgesic administrations during the first 24 h was higher in group S compared with group P (1.31 ± 0.85 and 0.73 ± 0.6, respectively, P = 0.001). The repeat number of postoperative analgesic administrations was significantly different between groups during the first 24 h (P = 0.005), but during 24–48 h was not significant. Conclusion Intraoperative administration of intravenous paracetamol decreases the incidence of PONV during the first 24 h in children after strabismus surgery.

A combination of ketamine and dexmedetomidine sedation with caudal anesthesia during incarcerated inguinal hernia repair in three high-risk infants

indicated because of a suspected intestinal perforation. His general condition was bad, tachypnoic, with an enlarged abdomen. His BW was 3350 g. Laboratory results were normal, but for a low level of thrombocytes. He received one dose of platelets before the operation. We performed balanced anesthesia. For fluid replacement, besides cristaloids with albumin 20%, he received erythrocytes, FFP and HES 130 ⁄ 0.4, 20 mLÆh. The operation lasted 4 h. The patient was stable during the operation. Laboratory values and coagulation status remained unchanged. Hydroxyethyl starch 130 ⁄ 0.4 is a relatively new colloid, approved by the FDA on 27 December 2007. It is a poly (O-2-hydroxyethyl) starch in 0.9% NaCl, with an average molecular weight of 130 000 D and a degree of substitution of 0.4 (HES 130 ⁄ 0.4) and osmolality 308 mOsmol l. When compared with albumin, it is seven times cheaper. Standl et al. (1) reported that there is no difference regarding perioperative stabilization of hemodynamics, coagulation parameters, blood gas analyses and other laboratory values between albumin and HES 130 ⁄ 0.4 in children. Moreover they claimed no significant differences in the amount of red blood cells, fresh frozen plasma or platelet concentrations in the two groups. We report two neonates who underwent major surgeries and received HES 130 ⁄ 0.4 along with albumin. Patients were stable during and after the operation. There were no changes in the coagulation status (platelet count, bleeding time, coagulation time, prothrombin time and partial thromboplastin time), although some larger investigations reported some changes (2). No other adverse events occurred. A question remains on the use of colloids vs crystalloids for fluid resuscitation in cricitally ill patients (3), and also which colloid solution is the best (4), particularly in relation to newborns. This case report shows that using HES 130 ⁄ 0.4 can be useful in newborns who undergo major surgeries, with no significant adverse effects, especially in a situation when one does not have other preferable colloids and blood or blood products at one’s disposal. Further studies are needed in this regard. Irina Milojevic* Dusica Simic† Marija Markovic* Ivana Budic *Department of Anesthesiology, University Children’s Hospital, Belgrade, Serbia †ICU, University Children’s Hospital, Belgrade, Serbia ‡Department of Anesthesiology, Children’s Hospital, Nis, Serbia (email: mirina@sbb.co.yu) References

Dexmedetomidine as an adjunct to epidural analgesia after abdominal surgery in elderly intensive care patients: A prospective, double-blind, clinical trial.

BACKGROUND The ideal postoperative analgesia management of elderly surgical patients in intensive care units (ICUs) is continually being investigated. OBJECTIVE The purpose of this study was to assess the effectiveness and tolerability of IV administration of dexmedetomidine as an adjunct to a low-dose epidural bupivacaine infusion for postoperative analgesia after abdominal surgery in elderly patients in the ICU. METHODS ICU patients aged >70 years undergoing abdominal surgery were eligible for the study. A lumbar epidural catheter was inserted at the beginning of the surgery with no medication. On arrival at the ICU, the catheter was loaded with 0.25% bupivacaine 25 mg at the T8 to T10 sensory level, and a continuous infusion of 0.125% bupivacaine was started at 4 to 6 mL/h in combination with patient-controlled epidural analgesia (PCEA) of fentanyl (4 μg/bolus) for pain treatment. Patients in the treatment group received dexmedetomidine as an IV loading dose of 0.6 pg/kg for 30 minutes followed by continuous infusion at 0.2 μg/kg · h(-1). Patients in the control group were not administered dexmedetomidine. The effectiveness of the pain relief was determined using a visual analog scale (VAS) (0 = no pain to 10 = worst pain imaginable) at rest. VAS score, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure, and arterial blood gases were monitored periodically for 24 hours after surgery. If required, tenoxicam (20-mg IV bolus) was used to ensure a VAS score of ≤3. The number of times PCEA and tenoxicam were administered and the occurrence of adverse events (AEs) were also recorded. RESULTS Sixty patients (34 men, 26 women; mean [SD] age, 75.96 [4.25] years; mean [SD] weight, 74.13 [10.62] kg) were included in the study. VAS scores were significantly lower in the dexmedetomidine group compared with the control group at hours 1, 2, and 12 (VAS [hour 1]: 2.8 [0.4], P < 0.001; VAS [hour 2]: 2.7 [0.5], P < 0.001; and VAS [hour 12]: 0.9 [0.7], P 0.044). The mean number of administrations of fentanyl via PCEA was significantly greater in the control group compared with the dexmedetomidine group (2.20 vs 6.63 times; P < 0.001). The mean number of administrations of tenoxicam was significantly lower in the treatment group than the control group (0.27 vs 1.07 times; P < 0.001). In the control group, the decreases in sedation at 0, 8, 12, 16, and 20 hours were significant compared with baseline (P = 0.024, P = 0.001, P = 0.020, P < 0.001, and P = 0.005, respectively). Mean HR, SBR and AEs (eg, bradycardia [HR <60 beats/min], respiratory depression [respiratory rate <8 breaths/min], hypotension \SBP <90 mm Hg], oversedation, hypoxia, and hypercapnia) decreased significantly in the dexmedetomidine group (all, P < 0.05). Significantly more patients in the dexmedetomidine group rated their satisfaction with postoperative pain control as excellent compared with the control group (12 vs 6 patients; P = 0.014). CONCLUSION Intravenous dexmedetomidine was effective and generally well tolerated as an analgesic adjunct to epidural low-dose bupivacaine infusion for pain treatment, with lower need for opioids after abdominal surgery in these elderly intensive care patients than in the control group.

Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study

UNLABELLED Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management. OBJECTIVE In this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children. METHOD 120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted. RESULTS No significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study. CONCLUSION Intravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

An Alternative Central Venous Route for Cardiac Surgery: Supraclavicular Subclavian Vein Catheterization

OBJECTIVE To evaluate the clinical success rate, safety, and usefulness for intraoperative central venous pressure monitoring, and the intravenous access of the supraclavicular subclavian vein approach when compared with the infraclavicular subclavian vein approach and the internal jugular vein approach for central venous catheterization during open-chest cardiac surgery. DESIGN A prospective, randomized, single-center study. SETTING A university hospital. PARTICIPANTS One hundred ninety-five patients scheduled for open-chest cardiac surgery. INTERVENTIONS The study population consisted of patients for whom central vein catheterization was intended during cardiac surgery. Patients were randomized to 3 groups according to the route of central vein catheterization: the supraclavicular group: the supraclavicular approach for the subclavian vein (n = 65); the infraclavicular group: the infraclavicular approach for the subclavian vein (n = 65); and the jugular group: the internal jugular vein approach (n = 65). After the induction of anesthesia, central venous catheterization was performed according to the assigned approach. MEASUREMENTS AND MAIN RESULTS The success rates for the assigned approach were 98%, 98%, and 92% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). The success rates in the first 3 attempts in patients who were catheterized successfully according to the assigned approach were 96%, 100%, and 96% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). There was no difference among groups in catheter insertion time (p > 0.05). After sternal retraction, central venous pressure trace loss and difficulty in fluid infusion were significantly more frequent in the infraclavicular group (21%) when compared with the supraclavicular (3%) and jugular groups (0%) (p = 0.01). There was no difference among groups in terms of catheter malposition, complications during catheterization, and rate of catheter-related infection. CONCLUSION The supraclavicular approach for subclavian vein catheterization is an acceptable alternative for central venous access during cardiac surgery in terms of procedural success rate, ease of placement, rate of complications, and usability after sternal retractor expansion.

Is There a Place for β-Mimetics in Clinical Management of Neuropathic Pain? Salbutamol Therapy in Six Cases

THE Adrenergic system, because of its reported implication in pain mechanisms, may be a potential target for chronic pain treatment. A genetic polymorphism of catechol-O-methyltransferase, an enzyme that metabolizes catecholamines, is related with higher pain perception and persistent pain conditions because patients with higher pain sensitivity are more likely to develop chronic pain conditions. Moreover, catechol-O-methyltransferase inhibition increases pain sensitivity through augmented catecholamines and activation of -adrenergic ( -AR) receptors. Furthermore, a polymorphism of 2-adrenoceptors ( 2-AR) has been associated with the risk for developing musculoskeletal pain disorders. In agreement, clinical studies reported that -AR antagonists were effective in chronic musculoskeletal pain conditions, such as fibromyalgia or temporomandibular disorder. This effect on myalgic pain was observed in patients with altered sympathetic nervous function. In addition to musculoskeletal pain disorders, neuropathic pain is another major type of chronic pain. Neuropathic pain arises as a direct consequence of a lesion or a disease affecting the somatosensory system. The prevalence of neuropathic pain has been reported to be around 6.9 and 8.2% in two large prevalence studies, and the annual incidence rate was estimated at 1%. Even though patients with neuropathic symptoms are rather frequent, neuropathic pain is often challenging to treat and is generally resistant to commonly used therapeutics. Treatment difficulties may be due to various underlying pathophysiologic mechanisms. Indeed, neuropathic pain can be initiated not only by various diseases such as diabetes or cancer but also by trauma, postsurgical injuries, or drug treatment of cancer or human immunodeficiency virus infection. Currently, antidepressants are one of the first-line treatment options in neuropathic pain management. These drugs are indirect adrenergic agonists because they act through the blockade of aminergic reuptake sites and thus increase endogenous levels of noradrenaline. Recent studies on the action mechanisms of antidepressants in neuropathic pain revealed the critical role played by 2-AR. 13,14 The absence or blockade of 2-ARs suppresses the antiallodynic effects of a chronic antidepressant treatment in a neuropathic pain model. Interestingly, preclinical studies have also reported that the chronic direct stimulation of 2-ARs by agonists can alleviate neuropathic pain symptoms in a murine neuropathic pain model, whereas a -AR antagonist had no effect. Thus, these findings differ from what was observed in musculoskeletal pain. In this report, we show that the use of salbutamol, a shortacting 2-AR agonist, provided satisfying symptom management in six patients with severe neuropathic pain resistant to previous therapy.

Abnormal Uterine Bleeding: Is It an Under‐Reported Side Effect after Epidural Steroid Injection for the Management of Low Back Pain?

To the Editor, We read Dr. Gitkinds report with great interest [1]. Since epidural steroid injection (ESI) is a rational treatment approach for radicular pain due to herniated nucleus pulposus and lumbar stenosis [2], its popularity is rising. It is reported to decrease surgical rates and self-reported pain and disability [3]. Corticosteroids contribute to pain treatment with their ability to decrease inflammation by inhibiting production of prostaglandins and excitation of c-fibers, which is mainly responsible for pain generation. However, ESI is not an option free of side effect due to intervention itself and the drugs used [4]. Here, we describe two patients with abnormal uterine …