Ayşe Heves Karagöz

Perioperative effects of melatonin and midazolam premedication on sedation, orientation, anxiety scores and psychomotor performance.

Background and objective: To compare the perioperative effects of melatonin and midazolam given in premedication, on sedation, orientation, anxiety scores and psychomotor performance. Methods: Exogenous administration of melatonin not only facilitates the onset of sleep but also improves its quality. A prospective, randomized, double-blind, placebo-controlled study was performed in 66 patients undergoing laparoscopic cholecystectomy. Patients were given melatonin 5 mg, midazolam 15 mg or placebo, 90 min before anaesthesia, sublingually. Sedation, orientation and anxiety were quantified before; 10, 30, 60 and 90 min after premedication; and 15, 30, 60 and 90 min after admission to the recovery room. Neurocognitive performance was evaluated at these times, using the Trail Making A and B and Word Fluency tests. The differences between the groups were analysed by ANOVA. Two-way comparisons were performed by Scheffé analysis. Sedation and amnesia were analysed by the χ2 test. Results: Patients who received premedication with either melatonin or midazolam had a significant increase in sedation and decrease in anxiety before operation compared with controls. After operation, there was no difference in sedation scores of all groups. Whereas, 30, 60 and 90 min after premedication the melatonin and midazolam groups exhibited a significantly poorer performance in Trail Making A and B tests compared with placebo, there were no significant differences among the groups in terms of neuropsychological performance after the operation. Amnesia was notable only in the midazolam group for one preoperative event. Conclusion: Melatonin premedication was associated with preoperative anxiolysis and sedation without postoperative impairment of psychomotor performance.

The effects of sevoflurane and desflurane anesthesia on QTc interval and cardiac rhythm in children

Background:  Inhalational anesthetics may prolong QTc interval (QT interval corrected for heart rate) of the ECG and cause life‐threathening arrythmias. The effects of desflurane on QTc interval and cardiac rhythm have not been reported previously in children. We assessed the effects of desflurane anesthesia on QTc interval and cardiac rhythm and compared them with sevoflurane anesthesia in children.

The effect of inhalational anaesthetics on QTc interval.

Background and objective: The aim of this study was to assess time dependent cumulative effects of three different inhalation anaesthetics on QTc interval during the maintenance of anaesthesia. Method: Seventy‐five ASA I‐II male patients undergoing inguinal herniorrhaphy were randomly allocated into three groups. No premedication was given. Anaesthesia was induced with thiopental and tracheal intubation was facilitated by vecuronium in all groups. Anaesthesia was maintained with 0.8% halothane (Group I) (n = 25), 1% isoflurane (Group II) (n = 25), or 2% sevoflurane (Group III) (n = 25) and 66% nitrous oxide in oxygen. Three lead electrocardiogram recordings were taken before induction, 2, 5, 10, 15, 30 and 45 min after induction and after extubation. Heart rate, systolic, diastolic, mean arterial pressure and SPO2 were recorded at the same time. Heart rate and corrected QT interval were evaluated by using Bazetts formula. Multivariate analysis of variance for repeated measures was used to determine intergroup and intragroup differences. Results: There was no statistically significant difference in the baseline QTc values of the groups. There was no difference between QTc values with halothane and sevoflurane. There was a difference between QTc values with isoflurane and those with the other two inhalation anaesthetics (P < 0.05). Although QTc values in the isoflurane group were higher at all times, the critical value of 440 ms was not exceeded. Conclusion: We conclude that halothane 0.8%, isoflurane 1% and sevoflurane 2% do not prolong QTc interval.

Comparison of dexmedetomidine-propofol vs. fentanyl-propofol for laryngeal mask insertion.

Background and objectives There have been many studies to find the optimum anaesthetics to provide excellent conditions for laryngeal mask insertion. We compared the effects of dexmedetomidine administered before propofol, on laryngeal mask insertion with fentanyl combined with propofol. Methods In all, 52 patients, ASA I–II, scheduled to have minor urological procedures were randomized into two groups. Group F received 1 &mgr;g kg−1 fentanyl (in 10 mL normal saline) and Group D received 1 &mgr;g kg−1 dexmedetomidine (in 10 mL normal saline). We used 1.5 mg kg−1 propofol for induction and 50% N2O and 1.5% sevoflurane in oxygen for maintenance. We observed jaw mobility (1: fully relaxed; 2: mild resistance; 3: tight but opens; 4: closed), coughing or movement (1: none; 2: one or two coughs; 3: three or more coughs; 4: bucking/movement) and other events such as spontaneous ventilation, breath holding, expiratory stridor and lacrimation. In each category, scores <2 were acceptable for laryngeal mask insertion. Results More patients developed apnoea and their apnoea times were longer in Group F than Group D (P < 0.001). Respiratory rates increased in Group D (P < 0.001). Adverse events during laryngeal mask insertion were similar. The reductions in systolic and mean blood pressures were greater in Group F (systolic: P < 0.05, mean: P < 0.01). Emergence times were shorter in Group F than in Group D (P < 0.001). Conclusion Dexmedetomidine, when used before propofol induction provides successful laryngeal mask insertion comparable to fentanyl, while preserving respiratory functions more than fentanyl.

Anesthetic management of a patient with Brugada syndrome

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Anesthesia in Beckwith-Wiedemann syndrome.

Anesthetic management of a 3‐month‐old boy with Beckwith–Wiedemann syndrome for bronchoscopy is reported. Management may be complicated by a difficult airway, congenital heart disease, and hypoglycemia. We did not have difficulty in airway management either with tracheal intubation or rigid bronchoscopy, but we could not extubate the baby because of tracheomalacia.

Anesthesia for congenital insensitivity to pain with anhidrosis

for further care and transferred to a normal baby room 3 days later. The follow-up chest X-ray showed full expansion of the left upper lung lobe without evidence of residual pneumatocele (Figure 2c). When anesthetizing infants with lung lesions, one of the most important questions is whether positive pressure ventilation will cause cardiopulmonary deterioration. For patients with pneumatoceles, spontaneous ventilation and single lung ventilation (SLV) should be considered (2). In the first case, we tried to keep spontaneous respiration before and after intubation and then move the tracheal tube for SLV without muscle relaxants. However, laryngospasm developed after two intubation attempts. In this situation, intermittent positive pressure ventilation could not be avoided to maintain the oxygen saturations and thereafter, tension pneumatoceles expanded with sudden cardiopulmonary collapse. In this case, multiple percutaneous decompressions effectively restored cardiac output. In the second case, we changed the plan of anesthesia. We used a muscle relaxant and applied low pressure ventilation (not higher then 10 cmH2O) so tracheal intubation was smooth. Intentional endobronchial intubation was performed and right side SLV was confirmed by auscultation then fiberoptic bronchoscopy. There was no untoward event during induction or surgery. Although a high frequency oscillator and 14G catheters were available for emergency use, they were not used. Single lung ventilation can be achieved with use of a balloon-tipped bronchial blocker, Univent tube or doublelumen tracheal tube in adults or children. However, a double-lumen tube for infants is usually unavailable (3). Pawar and Marraro (4) reported their experience with small-sized double-lumen tracheal tubes, but these tubes are not widely available. In the second case, SLV was achieved with the use of a normal tube. We deviated the tip to the right and gently pushed the tube into the airway until resistance was felt. In conclusion, anesthesia for infants with pneumatoceles remains a challenge with a risk of possible cardiopulmonary deterioration. Careful planning and successful airway management are keys to successful practice. Chih-Min Liu Chi-Hsiang Huang Hon-Ping Lau Huei-Ming Yeh Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan (email: mhyeh@ha.mc.ntu.edu.tw)

Anesthetic management of a 2‐year‐old male with propionic acidemia

1 Liban E, Kozenitzky IL. Metanephric hamartomas and nephroblastomatosis in siblings. Cancer 1970; 25: 885–888. 2 Perlman M, Goldberg GM, Bar–Ziv J et al. Renal hamartomas and nephroblastomatosis with fetal gigantism: a familial syndrome. J Pediatr 1973; 83: 414–418. 3 Verloes A, Massart B, Dehalleux I et al. Clinical overlap of Beckwith-Wiedemann, Perlman and Simpson-Golabi-Behmel syndromes: a diagnostic pitfall. Clin Genet 1995; 47: 257–262. 4 Coppin B, Moore I, Hatchwell E. Extending the overlap of three congenital overgrowth syndromes. Clin Genet 1997; 51: 375–378. 5 Fahmy J, Kaminsky CK, Parisi MT. Perlman syndrome: a case report emphasizing its similarity to and distinction from Beckwith-Wiedemann and prune-belly syndromes. Pediatr Radiol 1998; 28: 179–182. 6 Chitty LS, Clark T, Maxwell D. Perlman syndrome – a cause of enlarged, hyperechogenic kidneys. Prenat Diagn 1998; 18: 1163–1168. 7 van der Stege JG, van Eyck J, Arabin B. Prenatal ultrasound observations in subsequent pregnancies with Perlman syndrome. Ultrasound Obstet Gynecol 1998; 11: 149–151. 8 Henneveld HT, van Lingen RA, Hammel BCJ et al. Perlman syndrome: four additional cases and review. Am J Med Genet 1999; 86: 439–446. 9 Schilke K, Schaefer F, Waldherr R et al. A case of Perlman syndrome: fetal gigantism, renal dysplasia, and severe neurological deficits. Am J Med Genet 2000; 91: 29–33. 10 DeRoche ME, Craffey A, Greenstein R et al. Antenatal sonographic features of Perlman syndrome. J Ultrasound Med 2004; 23: 561–564.

Anesthesia in Liver Transplantation

Liver transplantation, is the replacement of unhealthy liver with a new liver allograft. This surgical procedure is now widely common all over the world in various medical centers. The major limiting factors of this surgery is the lack of available donors and decreased chance of appropriate patient selection. Anesthetic management of organ donors includes intensive management of heart beating and brain dead donors; however the augmentation of waiting list for liver and inadequate cadaveric organs resulted in elevated living donor transplantation rates especially for the critically ill patients who will not survive waiting until a brain dead donor is provided, resulting in the growing experience in anesthetic techniques for the management of living donors (Pickett et al, 1994; Lutz et al, 2003).

Comparison of efficacy of prophylactic ketamine and dexmedetomidine on postoperative bladder catheter-related discomfort.

Objectives: To compare the effects of prophylactic ketamine and dexmedetomidine on postoperative bladder catheter-related discomfort/pain in patients undergoing cystoscopy. Methods: This prospective study was conducted on 75 American Society of Anesthesiologists (ASA) I-II patients between 18-75 years of age and undergoing cystoscopy between November 2011 and June 2012 at Hacettepe University Hospital, Ankara, Turkey. Patients were randomly assigned to one of the 3 groups to receive 1 µ/kg dexmedetomidine, 250 µ/kg intravenous ketamine, or normal saline. All patients were questioned regarding probe-related discomfort, patient satisfaction, and pain at the end of the operation 0 (t0) and 15 (t1), 60 (t2), 120 (t3), and 360 (t4) minutes postoperatively. Evaluations were performed in person at the post-anesthesia care unit, or in ambulatory surgery rooms, or by phone calls. Results: Pain incidence in the dexmedetomidine and ketamine groups (p=0.042) was significantly lower than that in the control group (p=0.044). The sedation scores recorded at t0 in the dexmedetomidine and ketamine groups (p=0.004) were significantly higher than that of the control group (p=0.017). Patient groups were similar regarding the rate of hallucinations experienced at t1, no patients experienced hallucinations at t2, t3, or t4. Significantly more patients experienced hallucinations at t0 in the ketamine group than in the dexmedetomidine group (p=0.034) and the control group (p=0.005). Conclusion: Dexmedetomidine and ketamine had similar analgesic effects in preventing catheter-related pain; however, dexmedetomidine had a more acceptable side effect profile. To identify the optimal doses of dexmedetomidine and ketamine, more large-scale interventional studies are needed.