Ayda Turkoz

Comparison of preemptive analgesic effects of a single dose of nonopioid analgesics for pain management after ambulatory surgery: A prospective, randomized, single-blind studyin Turkish patients

BACKGROUND Preemptive analgesia used for postsurgical pain management has been shown to reduce the requirements of postoperative analgesics. OBJECTIVE The aim of this study was to compare the preemptive analgesic effects of diflunisal, naproxen sodium, meloxicam, acetaminophen, and rofecoxin (no longer available in some markets) in patients undergoing ambulatory dental surgery and the need for postoperative pain management in these patients. METHODS This prospective, randomized, single-blind study was conducted at the Departments of Anesthesiology and Reanimation and Oral and Maxillofacial Surgery, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey. Turkish outpatients aged ≥ 16 years with American Society of Anesthesiologists physical status 1 (ie, healthy) and scheduled to undergo surgical extraction of an impacted third molar were enrolled. Patients were randomly assigned to receive diflunisal 500 mg, naproxen sodium 550 mg, meloxicam 7.5 mg, acetaminophen 500 mg, or rofecoxib 12.5 mg. All medications were administered orally 1 hour before surgery as preemptive analgesia and after surgery if needed, up to the maximum recommended dose. Surgery was performed with the patient under local anesthesia (articaine hydrochloride). Pain intensity was assessed using a 100-mm visual analog scale (VAS) (0 = none to 100 = worst possible pain) at 2, 4, 6, and 12 hours after ambulatory surgery. The use of additional analgesics was recorded for 24 hours using patient diaries. Postoperative adverse events were recorded using the diaries. RESULTS One hundred fifty patients (108 women, 42 men; mean [SE] age, 26.8 [0.6] years; 30 patients per group) had data available for analysis. Demographic data were similar between the 5 groups. No significant differences in mean VAS scores were found between the 5 groups at any time point. All mean VAS scores indicated minor pain. The rate of additional postoperative analgesics required was significantly lower in the diflunisal group compared with groups receiving naproxen sodium, meloxicam, acetaminophen, and rofecoxib (3 [10%] patients vs 11 [37%], 15 [50%], 15 [50%], and 14 [47%] patients, respectively; all, P < 0.05). Bleeding at the surgical site was reported in 2 patients each in the diflunisal, naproxen sodium, meloxicam, and acetaminophen groups, and in 1 patient in the rofecoxib group; the between-group differences were not significant. No significant differences in the prevalences of other adverse effects (eg, nausea, vomiting, allergy, gastrointestinal symptoms) were found between the 5 treatment groups. CONCLUSIONS In the present study in patients undergoing third molar extraction, adequate preemptive analgesia, based on VAS scores, was found with all of the nonopioid analgesic agents used. Fewer patients required rescue medication with diflunisal. All 5 study drugs were similarly well tolerated.

Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy

A case series of patients with diabetic nephropathy, who underwent lower limb debridement or amputation below the knee during successful combined sciatic and femoral nerve block with bupivacaine 0.25%, is presented. Because impaired nerve conduction in diabetes mellitus results in lower local anesthetic agent requirement, a dose-sparing, minimal effective concentration for surgical anesthesia for peripheral nerve blockade may be more favorable for patients with diabetes and chronic renal disease.

A Prospective Randomized Double-Blind Study to Determine the Effect of Thoracic Epidural Neostigmine on Postoperative Ileus After Abdominal Aortic Surgery

BACKGROUND: Postoperative ileus is a major gastrointestinal complication of abdominal aortic surgery leading to increased rates of morbidity and mortality, longer lengths of hospital stay, and higher costs. In this study, we evaluated the effect of epidurally administered neostigmine on postoperative ileus after abdominal aortic surgery. METHODS: We enrolled 45 patients who were scheduled for elective abdominal aortic surgery at our institution. All patients received identical general and epidural anesthesia. Before the induction of general anesthesia, an epidural catheter was placed at the T7–T8 intervertebral space, and 20 mL bupivacaine (0.5%) was injected over 15 min. Patients were randomized into two groups. Patients received a 5 mL bolus of neostigmine (1 &mgr;g/kg) diluted with normal saline (Group 1) or a 5 mL bolus of normal saline (Group 2) via an epidural catheter at the end of surgery and 8 h postoperatively. Times of bowel sounds were recorded postoperatively in the intensive care unit. Times of daily passage of flatus and defecation also were recorded. RESULTS: Times to the first bowel sounds and the first flatus were significantly shorter in Group 1 than they were in Group 2 (11.6 ± 11.2 h vs 22.6 ± 12.8 h and 21.8 ± 15.6 h vs 36.6 ± 19.1 h, respectively, P < 0.05). The times to first defecation were similar in both groups (P > 0.05). Nausea was more frequent in patients in Group 2 than in Group 1 (P < 0.05). The incidence of postoperative complications was similar between the groups (P > 0.05). CONCLUSIONS: Thoracic epidural neostigmine enables faster restoration of bowel sounds and shortens duration of postoperative ileus after abdominal aortic surgery.

On-pump/beating-heart myocardial protection for isolated or combined coronary artery bypass grafting in patients with severe left ventricle dysfunction : assessment of myocardial function and clinical outcome

BACKGROUND Myocardial protection in coronary artery bypass grafting (CABG) with severe left ventricular (LV) dysfunction is still a surgical dilemma. Preoperative myocardial infarction (MI) and postoperative low output syndrome are serious complications in cases of inadequate protection of the heart, which has limited myocardial reserve. The aim of this study was to evaluate myocardial function and clinical outcome after on-pump/beating-heart CABG in patients with severe LV dysfunction. METHODS Between March 2001 and March 2004, clinical, operative, and postoperative data were prospectively collected from patients with LV ejection fraction (EF) < 30% who underwent on-pump/beating-heart CABG and associated procedures. RESULTS There were 46 patients and the mean patient age was 58.38 +/- 9.23. The mean EF was 25.6 +/- 2.8%. Operating time was 275 +/- 63 minutes. The frequency of distal anastomosis was 3.06 +/- 1.04. Twenty-four patients required aneurysmectomy in addition to CABG, and 2 of the 24 required mitral repairs. Inotropic support was required in 14 patients (30%) and 5 of them (10.9%) also required IABP. The LV EF improved significantly after the operation when compared to preoperative measurements (25.6 +/- 2.8 versus 33.64 +/- 4.69, P < .05). Hospital mortality rate was 4.3% (2 of the 46 patients). No mortality was observed at a mean followup of 16 months after discharge from the hospital. CONCLUSIONS On-pump/beating-heart CABG technique is effective in protecting myocardial functions in patients with severe LV dysfunction. The main advantage of the on-pump/beating-heart technique is the ability it provides one to perform complete revascularization, and intracavitary procedures with low morbidity and mortality even in impaired LV function.

Does left molar approach to laryngoscopy make difficult intubation easier than the conventional midline approach

Background and objective It has been reported that the left molar approach of laryngoscopy can make difficult intubation easier. The aim of this study was to investigate whether left molar approach to laryngoscopy provided a better laryngeal view in cases of unexpected difficult intubation. Methods Following the approval of local Ethics Committee and written informed consent from the patients, out of 1386 patients who underwent general anaesthesia for surgery, 20 patients who could be ventilated by face mask but could not be intubated with conventional midline approach on the first attempt were included in the study. Those 20 patients, who had Grade III‐IV laryngeal views on laryngoscopy by conventional midline approach, were subjected to left molar laryngoscopy, and their laryngeal views were evaluated. The external laryngeal compression was routinely used to improve the laryngeal view. When endotracheal intubation failed by left molar laryngoscopy, we performed the conventional midline approach again. All data were recorded. Results Of the 20 patients studied, 18 had a Grade III laryngeal view and two had a Grade IV laryngeal view. Eighteen of them had a better laryngeal view with left molar laryngoscopy. Eleven of the 20 patients underwent successful intubation with the left molar laryngoscopy, which provided a significantly better laryngeal view and success rate of tracheal intubation than did the conventional midline approach (P < 0.01 and P < 0.01, respectively). Conclusions Left molar laryngoscopy can make unexpected difficult intubation easier and should be attempted in cases of difficult intubation.

Thoracic Epidural Anesthesia and Analgesia During the Perioperative Period of Thoracic Surgery: Levobupivacaine Versus Bupivacaine

OBJECTIVES To compare the effects of thoracic epidural anesthesia with levobupivacaine or bupivacaine on block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery. DESIGN A prospective, randomized, and double-blind study. SETTING A university hospital. PARTICIPANTS Fifty patients undergoing thoracic surgery. INTERVENTIONS Patients received thoracic epidural catheterization either with levobupivacaine or bupivacaine. A bolus of 0.1 mL/kg of 0.25% levobupivacaine or 0.25% bupivacaine was administered, and infusion of the same drug with 0.25% concentration was started at 0.1 mL/kg/h. General anesthesia was induced after assessing the sensory block and maintained with 0.3% to 0.8% isoflurane and 50% O(2) in air. Epidural patient-controlled analgesia with the same agent was started at the end of the operation for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS Sensory block features such as onset time and spread were assessed for the next 20 minutes after the bolus dose. Heart rate and systolic, diastolic, and mean arterial blood pressures were recorded intraoperatively and postoperatively. Pain at rest and activity was evaluated by the visual analog scale (VAS) for 48 hours after the operation. All patients were comparable with respect to the demographic data. Onset time of the block and the number of blocked dermatomes and hemodynamic parameters were similar in both groups. All VAS assessments were comparable between groups except VAS at the 36th hour postoperative, which was higher in the levobupivacaine group (p = 0.039). CONCLUSIONS Thoracic epidural anesthesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery.

Anesthesia management with single injection paravertebral block for aorta coarctation in infant

Thoracotomy causes severe pain in the postoperative period. Perioperative thoracic paravertebral block reduces pain score and may improve outcome after pediatric cardiac surgery. This prospective study was designed for the efficacy and duration of a single level, single injection ultrasound–guided thoracic paravertebral block (TPVB) for fifteen infants undergoing aortic coarctation repair.

Istanbul Symposium on Neonatal and Pediatric Cardiopulmonary Bypass Procedures

Last summer, after organizing two Istanbul symposiums on pediatric extracorporeal life support systems, the third one was held on December 17, 2011 at the American Hospital in Istanbul, Turkey (1). The main topic of the third symposium was “minimizing adverse effects of cardiopulmonary bypass procedures in neonates and pediatric cardiac patients.”The objective of this editorial is to present the outcomes of the third symposium and suggest more topics for future symposiums in 2012. The third symposium is dedicated to honor Prof. Dr. Aydın Aytaç for his lifelong contributions as a pioneering surgeon and educator of the development of pediatric cardiac surgery in Turkey (Fig. 1) (2–6).

Spinal anesthesia for inguinal hernia repair in 8-year-old child with myasthenia gravis

SIR—Myasthenia gravis (MG) is an autoimmune disease characterized by weakness and fatigue of the voluntary muscles, because of the presence of acetylcholine receptor antibodies (1). The incidence is 2–10 ⁄ 100 000 cases per year (2). Children account for 11–29% of all patients with MG (3). Anesthesia concerns for MG patients focus on avoiding muscle relaxants and monitoring for postoperative respiratory failure. The use of regional or local anesthesia seems warranted whenever possible. Spinal anesthesia has advantages of reduced drug dosage, profound sensory and motor block, lack of systemic effects, avoidance of tracheal intubation and decreased need for opioid administration (4). Although spinal anesthesia is widely used in the pediatric age group, surprisingly we have not seen any report concerning its use in a myasthenic child. This report describes a pediatric case with MG, who underwent successful inguinal hernia repair under spinal anesthesia. An 8-year-old, 25-kg girl with MG presented for inguinal hernia repair. She had MG for 3 years and was classified as Osserman (5) Grade IIa with obvious ptosis and mild generalized weakness. She was taking pyridostigmine 15 mg five times daily. On the day of surgery, the morning dose of pyridostigmine was continued and no other premedication was given. An infusion of 0.5% dextrose and 0.2% sodium NaCl was given at a rate of 5 mlÆkg hÆ6 h before anesthesia and continued throughout the operation. Following the establishment of routine monitoring, the patient was sedated with 2-mg midazolam i.v. Oxygen was administered at 3 lÆmin by facemask. She was placed in a lateral decubitus position and after an additional doses of 1-mg midazolam, lumbar puncture was performed using a midline approach at the L5-S1 intervertebral space with a 27 gauge 90-mm Whitacare pencil point spinal needle (Becton Dickinson, S. Agustin del Guadalix, Madrid, Spain); 1.6 ml 0.5% hyperbaric bupivacaine was given intrathecally. In the supine position, bilateral motor block occurred within 2 min and sensory block was achieved approaching T6-7 level verified by pin prick test after 5 min. She remained comfortable and hemodynamically stable throughout the 45 min of surgery, which was uneventful. Postoperatively, she was monitored in the recovery room until regression of the sensory block and after complete resolution of the sedation she was transferred to the pediatric surgery ward. Sensory and motor function completely recovered 2 h after the surgical procedure. The patient had only one episode of nausea in the postoperative first hour and was discharged from the hospital 6 h later. Overall no complication occurred. Several studies have been published on the use of spinal anesthesia in high-risk newborns and infants at risk of postoperative apnea (6,7) and also for older children with muscular and neuromuscular disease which increase risk of postoperative respiratory failure (4). Caudal-epidural block with inhalation anesthesia is the most commonly used regional anesthetic technique in children. However, this requires a higher volume of local anesthetic and the use of inhalation anesthesia (8). Potentiation of neuromuscular blocking drugs by local anesthetics has been reported. These agents decrease the sensitivity of the postjunctional membrane to acetylcholine, which causes weakness in myasthenia. Ester anesthetics, which are metabolized by cholinesterase, may cause problems particularly in patients taking anticholinesterases. Regional and local anesthesia should be performed using reduced doses of amide, rather than ester, local anesthetics to avoid high blood levels of drug in circulation (1). Spinal anesthesia produces excellent block with light sedation levels maintaining protective airway reflexes (8) and provides an appropriate alternative regional anesthesia method. However, high-spinal anesthesia should be particularly avoided in patients with MG because it may lead to deterioration of intercostal muscle movement. Using intrathecal opioids should be avoided to minimize the risk of respiratory muscle weakness and central respiratory depression in these patients. It is controversial whether anticholinesterase therapy should be maintained or discontinued before surgery (9,10). Anticholinesterases may potentiate vagal responses and increase bronchial secretions. Anticholinesterase drugs can also inhibit plasma cholinesterase activity with a subsequent decrease in the metabolism of ester local anesthetics (9). We decided to continue anticholinesterase therapy before surgery in this patient. As the block level did not rise higher than the T6 level and respiratory reflexes were intact throughout, we did not need to administer atropine and this prevented any complication that might arise secondary to this drug. In children, sufficient duration of anesthesia for surgery is consistently less than seen in adults. In the report of Dohi et al. (11), motor function returned after a mean of 114 min in children aged over 5 years compared with 336 min in adults. The reasons are unclear but presumably include age-related differences in cerebrospinal fluid volume, diameter and surface area of the spinal cord and nerve roots and rate of absorption of local anesthetic from 1220 CORRESPONDENCE

The effect of tramadol plus paracetamol on consumption of morphine after coronary artery bypass grafting

STUDY OF OBJECTIVE To compare the effects of oral tramadol+paracetamol combination on morphine consumption following coronary artery bypass grafting (CABG) in the patient-controlled analgesia (PCA) protocol. DESIGN A prospective, double-blind, randomized, clinical study. SETTING Single-institution, tertiary hospital. PATIENTS Fifty cardiac surgical patients undergoing primary CABG surgery. INTERVENTIONS After surgery, the patients were allocated to 1 of 2 groups. Both groups received morphine according to the PCA protocol after arrival to the coronary intensive care unit (bolus 1 mg, lockout time 15 minutes). In addition to morphine administration 2 hours before operation and postoperative 2nd, 6th, 12th, 18th, 24th, 30th, 36th, 42th, and 48th hours, group T received tramadol+paracetamol (Zaldiar; 325 mg paracetamol, 37.5 mg tramadol) and group P received placebo. Sedation levels were measured with the Ramsay Sedation Scale, whereas pain was assessed with the Pain Intensity Score during mechanical ventilation and with the Numeric Rating Scale after extubation. If the Numeric Rating Scale score was ≥3 and Pain Intensity Score was ≥3, 0.05 mg/kg morphine was administered additionally. MEASUREMENTS Preoperative patient characteristics, risk assessment, and intraoperative data were similar between the groups. MAIN RESULTS Cumulative morphine consumption, number of PCA demand, and boluses were higher in group P (P<.01). The amount of total morphine (in mg) used as a rescue analgesia was also higher in group P (5.06±1.0), compared with group T (2.37±0.52; P<.001). The patients who received rescue doses of morphine were 8 (32%) in group T and 18 (72%) in group P (P<.001). Duration of mechanical ventilation in group P was longer than group T (P<.01). CONCLUSION Tramadol+paracetamol combination along with PCA morphine improves analgesia and reduces morphine requirement up to 50% after CABG, compared with morphine PCA alone.