Ayşe Çiğdem Tütüncü

Efficacy of intravenous paracetamol, metamizol and lornoxicam on postoperative pain and morphine consumption after lumbar disc surgery.

Background and objective The combination of opioids with supplemental analgesics is commonly used for additive or synergistic analgesic effects. We aimed to determine the most advantageous supplemental analgesic for postoperative pain relief after lumbar disc surgery. Methods This prospective, placebo-controlled, randomized, double-blind study compared the effects of intravenous metamizol, paracetamol and lornoxicam on postoperative pain control, morphine consumption and side effects after lumbar disc surgery. Eighty patients with American Society of Anesthesiologists classification 1 or 2 scheduled for elective lumbar disc surgery under general anaesthesia were treated using patient-controlled analgesia with morphine until 24 h postoperatively and randomized to receive additional intravenous injections of metamizol 1 g, paracetamol 1 g, lornoxicam 8 mg or isotonic saline 0.9% (placebo). The primary endpoint was pain over 24 h after surgery measured by visual analogue scale. Secondary endpoints were morphine consumption and side effects. Results During the 24 h study period, pain was reduced in the metamizol (P = 0.001) and paracetamol (P = 0.04) groups, but not in the lornoxicam (P = 0.20) group compared with the control group. Further analysis revealed that pain scores in the metamizol group were significantly lower than in the lornoxicam group (P = 0.031). Although the rate of morphine consumption in the paracetamol group was decreased over time (P < 0.001), the total amounts of morphine consumed in 24 h were not different between groups. No significant differences with respect to morphine-related side effects were observed between groups. Conclusion Metamizol or paracetamol, but not lornoxicam, provides effective analgesia following lumbar disc surgery.

Efficacy of intravenous paracetamol and dexketoprofen on postoperative pain and morphine consumption after a lumbar disk surgery.

Background: We compared the analgesic effects of intravenous (IV) paracetamol with that of dexketoprofen on postoperative pain and morphine consumption during the first 24 hour after a lumbar disk surgery. Methods: This prospective, placebo-controlled, double blind study investigated the analgesic effects of IV paracetamol and dexketoprofen on postoperative pain, morphine consumption, and morphine-related side effects after a lumbar disk surgery. Sixty American Society of Anesthesiologists 1 or 2 status patients scheduled for elective lumbar disk surgery under general anesthesia were included in the study. Patients were treated using patient-controlled analgesia with morphine for 24 hours after a lumbar disk surgery and randomized to receive IV paracetamol 1 g, dexketoprofen 50 mg, or isotonic saline (placebo). The primary endpoint was pain intensity measured by the visual analogue scale, and secondary endpoints were morphine consumption and related side effects. Results: Pain intensity was lower in the dexketoprofen group (P=0.01) but not in the paracetamol group (P=0.21) when compared with the control group. Cumulative morphine consumption and morphine-related side effects did not reveal significant differences between the groups. Conclusions: The study showed that pain intensity during 24 hours after the lumbar disk surgery was significantly lowered by dexketoprofen, but not with paracetamol, as a supplemental analgesic to morphine patient-controlled analgesia when compared with controls.

Evaluation of sciatic nerve damage following intraneural injection of bupivacaine, levobupivacaine and lidocaine in rats

OBJECTIVE The local anesthetics may cause neurotoxicity. We aimed to compare the neurotoxic potential of different local anesthetics, local anesthetic induced nerve damage and pathological changes of a peripheral nerve. METHODS Sixty Wistar rats weighing 200-350g were studied. Rats were assigned into 3 groups and 26-gauge needle was inserted under magnification into the left sciatic nerve and 0.2mL of 0.5% bupivacaine, 5% levobupivacaine, and 2% lidocaine were injected intraneurally. An individual who was blind to the specifics of the injection monitored the neurologic function on postoperative 1st day, and daily thereafter. Neurologic examination included assessment for the presence and severity of nociception and grasping reflexes. At the 7th day sciatic nerve specimen was taken for evaluation of histopathologic changes. RESULTS There was no statistical difference detected among groups regarding grasping reflex and histopathologic evaluation. Two cases in bupivacaine group, 1 case in levobupivacaine group and 2 cases in lidocaine group had slight grasping, while 1 case in lidocaine group had no grasping reflex on the seventh day. Severe axonal degeneration was observed in all groups, respectively in bupivacaine group 4 (20%), levobupivacaine group 3 (15%), and lidocaine group 6 (30%). CONCLUSION In all groups, histopathological damage frequency and severity were more than the motor deficiency.

Pudendal Versus Caudal Block in Children Undergoing Hypospadias Surgery: A Randomized Controlled Trial.

Background and Objectives Postoperative pain management after hypospadias surgery is often challenging. Caudal block is used for analgesia but has limitations. This study compares the analgesic efficiency of pudendal block with that of caudal block in pediatric patients undergoing hypospadias repair surgery. Methods This prospective, double-blind, randomized, controlled study enrolled 84 patients receiving pudendal block or caudal block before hypospadias surgery. In the pudendal group, the pudendal nerve was identified using a nerve stimulator, and the block consisted of 0.25% bupivacaine 0.5 mL/kg. In the caudal group, the caudal block used 0.2% bupivacaine 1 mL/kg. Our primary outcome was pain intensity within 24 hours postoperatively. The trial was registered at ClinicalTrials.gov (number: NCT02390388). Results For the primary outcome, patients in the pudendal group had lower postoperative pain intensity when compared with the caudal group (P < 0.001). Three patients in the pudendal group and all of the patients in the caudal group needed additional analgesia within 24 hours after the surgery (P < 0.001). The family satisfaction rate was significantly higher in the pudendal group (P < 0.001). Conclusions For the pudendal group, the pain scores for the first 24 hours after the surgery were significantly lower and the duration of analgesia was longer.

Ultrasound-assisted transversus abdominis plane block vs wound infiltration in pediatric patient with inguinal hernia: randomized controlled trial

STUDY OBJECTIVE To compare the analgesic efficacy of ultrasound-assisted transversus abdominis plane (TAP) block and wound infiltration during the first postoperative 24hours. DESIGN A prospective, observer-blinded, randomized, and controlled study SETTING Operating room of a university hospital. PATIENTS Forty patients received a TAP block (TAP group) and 40 patients received wound infiltration (INF group) at the end of the surgery. INTERVENTIONS Patients were randomized to receive a TAP block or wound infiltration. Postoperative analgesics were administered on request and selected based on pain severity. MEASUREMENTS Pain scores, analgesic drug requirement, and side effects were observed for 24hours. MAIN RESULTS Postoperative pain scores were lower in TAP group compared to INF group (P<.001). Analgesic consumption was significantly higher at the 5th minute and 1st, 6th, and 12th hours in the INF group (P<.001). The frequency of additional analgesic use in home and the total analgesic used during the postoperative 24hours were significantly higher in INF group (P<.001). Side effects were lower in the TAP group. Parents satisfaction scores were higher in TAP group. CONCLUSION Transversus abdominis plane block is effective method with convenient technique, drug dosage, and volume in pediatric patients undergoing inguinal hernia surgery.

Anaesthetic Management of a Patient with Synchronous Kartagener Syndrome and Biliary Atresia

Kartagener syndrome is an autosomal recessive disorder characterized by primary ciliary dyskinesia accompanied by sinusitis, bronchiectasis, and situs inversus. Synchronous extrahepatic biliary atresia and Kartagener syndrome are very rare. During the preoperative preparation of patients with Kartagener syndrome, special attention is required for the respiratory and cardiovascular system. It is important to provide suitable anaesthetic management to avoid problems because of ciliary dysfunction in the perioperative period. Further, maintaining an effective pain control with regional anaesthetic methods reduces the risk of pulmonary complications. Infants with biliary atresia operated earlier have a higher chance of survival. Hepatic dysfunction and decrease in plasma proteins are important for the kinetics of drugs. In this presentation, the anaesthetic management of patients with synchronous Kartagener syndrome and biliary atresia, both of which are rare diseases, is evaluated.

Author’s Reply: The Assessment of Risk Factors for Difficult Intubation in Thyroid Patients

This study aimed to identify the risk factors for difficult intubation in thyroid patients [1]. As the authors Liu et al. noted, a difficult intubation is a result of a combination of many factors. The patient’s specific risk factors, techniques, equipment, experience of the anesthetist, and concomitant factors create its complexity. For this reason, it would be a weak determinative indicator to use only the American Society of Anesthesiologists’ (ASA) description for difficult intubations in this study: ‘‘Tracheal intubation requires multiple attempts, in the presence or absence of tracheal pathology’’ [2]. We preferred to use the modified intubation difficulty scale (MIDS), which includes multiple parameters related to the operator, the procedure used, and other variables to describe its difficulty [3]. In our manuscript, the number of additional attempts, the Cormack– Lehane scale, the pressure applied during laryngoscopy, extra laryngeal pressure, and difficulty passing the tube through the larynx were all evaluated to define intubation difficulty with the MIDS scoring system. The number of intubation attempts, which is also recommended by the ASA for difficult cases, has already been used as a parameter in our study. Patients classified according to the MIDS data were compared with additional difficult intubation criteria. There is not a test or assessment method that has high sensitivity and specificity to define a difficult intubation in its own right [4]. In our study, we used certain tests (thyromental distance, sternomental distance, interincisor gap, mandibular protrusion, and the Cormack–Lehane score) that have been already used in routine anesthesia practice to determine risk factors [2]. Along with these parameters, the study included neck circumference, presence of goiter, thyroid weight, presence of malignancy, with radiological and clinical compression findings as potential risks to assess any intubation within the thyroid group. All these data obtained from the patients with multiple tests and measurements were evaluated to predict the possible difficult intubation in thyroid patients. In our study, laryngoscopy was performed by the same anesthesiologist with a Macintosh-type laryngoscope to preclude induced bias in the practitioner, which was carefully emphasized in Materials and Methods section of the manuscript. Cormack–Lehane scores obtained from a Macintosh laryngoscope were also used in statistical comparisons; the anesthetist, the materials used, and the position of the patient were standardized in this study. The main purpose of this study was to determine possible risk factors leading to complicated intubation in thyroid patients. We wanted to evaluate the factors which are important for identifying difficult intubation in thyroid patients both in preoperative measurements and factors specific to these type of patients. As such, it is appropriate to use the expression ‘‘difficult intubation’’ in the title of this study.

Pudendal Nerve Block Versus Penile Nerve Block in Children Undergoing Circumcision

PURPOSE Penile nerve block is the most popular nerve block for the circumcision in pediatric patients. This study aimed to compare the analgesic efficiency of penile nerve block and the pudendal nerve block on postoperative pain and additional analgesic requirements in children undergoing circumcision. MATERIAL AND METHODS This prospective randomized double-blind study enrolled 85 children, aged 1 to10 years, undergoing circumcision. The patients were randomly divided into two groups either receiving dorsal penile block group (PNB-Group) or pudendal nerve block (PDB-Group). In the PNB-Group, 0.3 ml/kg 0.25 % bupivacaine was used; and, in the PDB-Group, 0.3 ml/kg bupivacaine was applied with nerve stimulator at a concentration of 0.25%. In the postoperative period, the modified CHEOPS pain scale scoring and additional analgesic demand were evaluated at the 5th and 30th minutes and at the 1st and 2nd hours. The subsequent pain evaluations were made by the parents at home, at the postoperative 6th, 12th, 18th and 24th hours. RESULTS Seven patients were excluded from the study, and seventy eight patients were evaluated for analysis. Patients in PDB-Group had significantly lower postoperative pain intensity and lower mCHEOPS scores (3.83 ± 0.98) when compared to the PNB-Group (6.47 ± 0.91) (P < .01) at all measurement times and none of patients in PDB-Group had additional analgesic requirements up to 24 hours. Patients in the PNB-Group had significantly more analgesic requirements at all measurements times except at the 1st, 2nd, 24th hours. 3.8%, 30.8%, 46.2% and 59% of the patients in the PNB group needed additional analgesia respectively at 5th, 6th, 12th and 18th hours. CONCLUSION Pudendal nerve block provided additional analgesic free period and had better analgesic efficiency compared to the penile nerve block lasting until 24 hours after operation.

Anaesthetic Management of a Child with a Massive Mediastinal Mass

Mediastinal masses are benign or malignant tumours that originate from the thymus, thyroid, lung, lymphoid system, pleura, or pericardium. Cardiovascular and respiratory symptoms may occur because of the compression of surrounding tissues along with growing mass. In this study, we present the anaesthetic management of a 6-month-old child having a massive anterior mediastinal mass that had a compressing effect.

Does the real-time ultrasound guidance provide safer venipuncture in implantable venous port implantation?:

Aim: To examine whether the real-time ultrasound-guided venipuncture for implantable venous port placement is safer than the traditional venipuncture. Methods: The study analyzed the results of 2153 venous ports placed consecutively from January 2009 to January 2016. A total of 922 patients in group 1 and 1231 patients in group 2 were admitted with venous port placed using the traditional landmark subclavian approach and real-time ultrasound-guided axillary approach, respectively. Sociodemographic characteristics of patients, early (pneumothorax, pinch-off syndrome, arterial puncture, hematoma, and malposition arrhythmia) and late (deep vein thrombosis, obstruction, infection, erosion-dehiscence, and rotation of the port chamber) complications and the association of these complications with the implantation method were evaluated. Results: There were no significant differences in the sociodemographic characteristics of the patients between the two groups. The overall and early complications in group 2 were significantly lower than those in group 1. Pinch-off syndrome only developed in group 1. Seven patients and two patients had pneumothorax in groups 1 and 2, respectively. Puncture number was significantly associated with the development of the overall complications. Conclusion: The ultrasound-guided axillary approach may be preferred as a method to reduce the risk of both early and late complications. Large, randomized, controlled prospective trials will be helpful in determining a safer implantable venous port implantation technique.