Ayşe Karci

Dilution of rocuronium to 0.5 mg/mL with 0.9% NaCl eliminates the pain during intravenous injection in awake patients.

In a randomized, double-blinded, controlled study, we evaluated the effect of diluting rocuronium 10 mg/mL to 1 or 0.5 mg/mL with 0.9% NaCl on the pain associated with IV administration of rocuronium with small doses given before succinylcholine or nondepolarizing agent administration. One hundred fifty patients undergoing surgical procedures that required general anesthesia were randomized into three groups. Group 1 received rocuronium 10 mg/mL. Groups 2 and 3 received 1 and 0.5 mg/mL of rocuronium, respectively. Patient demographics, pain scores, osmolality, and the pH of the solutions were recorded. Group 1 had the most intense and frequent pain response. Eighty percent of patients in this group reported pain on injection. In Group 2, the incidence and intensity of pain were significantly less when compared with those of Group 1. In this group, 38% of patients reported pain during injection. In Group 3, none of the patients experienced pain on injection. The pH values and osmolalities of study solutions were not significantly different among groups. In conclusion, in awake patients, dilution of rocuronium 10 mg/mL at small doses given before succinylcholine or nondepolarizing agent administration of 0.06 mg/kg to 0.5 mg/mL with 0.9% NaCl is a simple and cost-effective strategy for preventing pain during IV rocuronium injection.

A new method for estimating arterial occlusion pressure in optimizing pneumatic tourniquet inflation pressure.

To reduce pressure-related injuries resulting from pneumatic tourniquet use, the lowest possible inflation pressure is recommended. Arterial occlusion pressure (AOP) is a measure of the cuff pressure required to maintain a bloodless surgical field. However, its determination method is time consuming, requires operator skill, and is therefore seldom used in current practice. An AOP estimation can be made by knowing the pressure transmitted to the underlying soft tissues. We measured upper and lower extremity tissue pressures under the tourniquet cuff at 100, 200, and 300 mm Hg of tourniquet inflation pressures in 30 anesthetized living adult patients. All patients received general anesthesia with neuromuscular relaxation. A Stryker intra-compartmental pressure monitor was used to measure tissue pressures under the tourniquet cuff. In all patients, the soft tissue pressures were consistently lower than the applied tourniquet inflation pressures. Our results revealed tissue padding coefficients for extremities 20 to 75 cm in circumferences. An estimation method of AOP was developed [AOP = (systolic blood pressure + 10)/Tissue padding coefficient]. The new AOP estimation method may be a simple, rapid, and clinically practical alternative to the AOP determination method.

The analgesic effect of morphine on postoperative pain in diabetic patients

Background:  Many clinical and experimental studies have suggested that diabetes or hyperglycemia alter opioid responsiveness. However, little information is available on the effects of diabetes mellitus on opioid requirements in the postoperative period.

Ischaemic preconditioning attenuates haemodynamic response and lipid peroxidation in lower-extremity surgery with unilateral pneumatic tourniquet application: A clinical pilot study

Introduction: The harmful effects of ischaemia-reperfusion on skeletal muscle during extremity surgery can be diminished by using medications or ischaemic preconditioningMethods: Twenty patients undergoing lower-limb surgery with use of a tourniquet for at least 1 hour were included in the study and randomised into two groups: a control group with only tourniquet application (T group; n =10); and an ischaemic preconditioning plus tourniquet group (IP-T group; n =10). Blood samples were obtained from the femoral vein of the relevant extremity before tourniquet application (baseline), immediately after tourniquet deflation (TD), at 10 minutes after the tourniquet deflation (TD 10min ) in the T group and additionally after ischaemic preconditioning in the IP-T group. Venous blood pH, partial oxygen pressure (P vO2 ), partial carbon dioxide pressure (P vCO2 ), lactate, potassium, sodium and glucose levels were analysed using a blood gas analyser. Plasma thiobarbituric acid reactive substances (TBARS) level, an index of lipid peroxidation and oxidative stress, was measured. Heart rate, noninvasive mean arterial pressure (MAP) and spontaneous breathing rate (SBR) were recorded at baseline, at TD, and TD 1min , TD 5min and TD 10minResults: MAP decreased and SBR increased significantly at TD, TD 1min and TD 5min compared with baseline, and venous blood TBARS level significantly increased at TD and TD 10min compared with baseline in the T group (all P <0.05). No significant changes were observed in the IP-T group. Ischaemic preconditioning caused a rise in P vO2 and a decrease in venous blood pH, P vCO2 , and lactate levels, which was significant compared with baseline ( P <0.05)Conclusion: Ischaemic preconditioning attenuates haemodynamic response and lipid peroxidation during lower-extremity surgery with unilateral tourniquet application

The barrier effect of laminae : laminotomy versus laminectomy

Study design: An experimental study to investigate whether replacement of the laminae (laminotomy) after subliminal procedures can prevent the invasion of scar tissue towards the dura.Setting: Izmir, Turkey.Methods: Laminectomy and laminotomy were performed at different levels on seven rats. Their spinal columns were investigated histopathologically after a period of 3 months.Results: The histopathological evaluation revealed that the dura and spinal cord were involved by scar tissue at laminectomy area. However, this invasion was not observed at laminotomy levels. This study showed the barrier effect of laminae against fibroblastic activity.Conclusion: The barrier effect of lamina may affect the surgical outcome related to epidural fibrosis.

Cerebral venous thrombosis initially considered as a complication of spinal-epidural anaesthesia

Cerebral venous thrombosis is an unusual condition characterized by headache, nausea, vomiting, focal deficits and epileptic seizures. In this case report we describe a patient who presented with headache and focal motor deficits after an uneventful Caesarean section, performed using combined spinal-epidural anaesthesia. Magnetic resonance imaging was performed because of the pronounced neurological symptoms, and a diagnosis of cerebral venous thrombosis was made. The patient was treated with anticoagulant agents and made a complete recovery. This case emphasizes the importance of considering cerebral venous thrombosis in the differential diagnosis of headache in the post-partum period prior to instituting conventional therapy.

Antithrombin III pretreatment reduces neutrophil recruitment into the lung in a rat model of abdominal sepsis

Background:  Antithrombin III (AT III) is a serine protease inhibitor and the mechanism of its anti‐inflammatory action is still not understood. In the present study, we aimed to investigate the anti‐inflammatory action of AT III on lung injury in a rat model of sepsis.

Evaluation of quality in patient-controlled analgesia provided by an acute pain service.

Institutions with quality management programs need to evaluate the quality of perioperative pain management as well as other aspects of the health service. With the development of anesthesia-based pain services, improvement in this field has been reported. In this prospective study performed in a university hospital, we used a Postoperative Pain Therapy Assessment Questionnaire to quantify the effectiveness of pain therapy and factors affecting the degree of satisfaction and also to pinpoint areas that need improvement. A total of 915 patients who received patient-controlled analgesia for postoperative pain were included in the study; it seems to be the largest patient population from a single hospital. Data were collected as part of the hospital’s quality improvement activities. By analyzing the questionnaires, we found that patients were satisfied with the pain therapy performed under the guidance of anesthesiologists, but predictors of satisfaction such as pain intensity and side effects (nausea, vomiting, constipation and difficulty in walking) decreased patient satisfaction considerably. Patients are aware of the fact that health care givers take postoperative care seriously and they do not want any untoward effects interrupting their postoperative care. They are trying to participate in the decision making and also to learn more about pain medicine.

Comparison of the effect of sevoflurane and propofol on oxygenation during gradual transition to one-lung ventilation

BACKGROUND It is known that hypoxic pulmonary vasoconstriction increases as a result of intermittent regional hypoxic challenges. The aim of this study was to compare the effects of sevoflurane and propofol on oxygenation and shunt fraction during one-lung ventilation in a novel model of hypoxic preconditioning before one-lung ventilation. METHODS Sixteen Wistar-albino rats were anesthetized intra-peritoneally before venous and arterial cannulations and tracheotomized. The animals were randomly allocated to receive either sevoflurane 2% or 10mg/kg/h propofol infusion and ventilated with 100% oxygen at an inspiratory rate of 80 breaths/min for 30min. Three cycles of one-lung ventilation and two-lung ventilation were performed and one-lung ventilation was continued for 15min. Arterial blood gas samples were obtained as follows: after cannulation and tracheotomy, following 30min of treatment with sevoflurane or propofol, and at the 5th and 15th min of one-lung ventilation. RESULTS The PaO2 levels were higher and shunt fractions were lower in rats receiving propofol compared to rats treated with sevoflurane but the difference was not significant; the two groups were comparable in terms of PaCO2. CONCLUSIONS The similar effects of sevoflurane and propofol on PaO2 during one-lung ventilation following hypoxic preconditioning may be due to other causes beside the inhibition of hypoxic pulmonary vasoconstriction. Gradual transition to one-lung ventilation is a novel technique for preconditioning experiments for one-lung ventilation.

Perfusion index as a predictor of successful neuraxial anesthesia

Background: Gastric surgical resection with adequate lymphadenectomy remains the only potentially curative therapeutic approach for patients with gastric cancer. Laparoscopic gastrectomy has recently been recognized worldwide as a viable alternative to conventional open gastrectomy; yet, one of the hot issues in laparoscopic gastric surgery has been whether the indication can be safely extended to advanced gastric cancer.Background: Associated with intra-abdominal adhesions, there are post-operative peritoneal adhesions, abdominal adhesive disease, and adhesive intestinal obstruction. Regarding abdominal adhesions, 1% of patients that underwent through surgery are re-admitted with the mentioned condition, and in 50 to 75% of these patients, there is development of adhesive intestinal obstruction. Conservative treatment has proved to be ineffective. Moreover, there is relapse in 32-71% in abdominal adhesions operations. Much of the etiology, pathogenesis, morphology, classification, prevention and treatment of peritoneal adhesion are still under discussion. A promising direction in prevention of adhesions and its complications is the use of implants with a barrier effect.Objectives: Local anesthesia infiltration is widely used as an effective method for post operative pain relief after operations. The aim of this study was to evaluate the effectiveness of continuous wound infusion of ropivacaine for post operative pain relief, incidence of nausea and vomiting, bowel movement after panniculectomy and abdominoplasty operation. Materials & Methods: 50 patients undergoing abdominoplasty were enrolled in this prospective, randomized, double blinded, placebo controlled trial. Patients were divided into two groups, group S (control group, 0.9% saline infusion group n=25) and group R (ropivacaine group n=25). The measured outcomes postoperatively were pain score at rest and movement, postoperative morphine consumption, the incidence of nausea and vomiting, time to bowel recovery, mean hospital stay and patient satisfaction postoperatively. Results: Pain scores, incidence of nausea and vomiting and hospital stay were significantly reduced in ropivacaine infusion group. Conclusion: Surgical wound infusion with ropivacaine after panniculectomy and abdominoplasty operation can improve pain relief at rest and accelerate recovery and patient discharge.Results: In the first 24 h after surgery, the incidence of postoperative sore throat was 66%, 30%, and 20%; cough was 20%, 20%, and 0%; and hoarseness of voice was 10%, 0%, and 0%, for groups C, M and B respectively. The incidence of postoperative sore throat, cough, and hoarseness of voice was significantly lower in the budesonide and magnesium group compared with the control group (P=0.05). Conclusion: Pre-operative budesonide inhalation significantly decreases the incidence of postoperative sore throat, cough and hoarseness of voice, where pre-operative magnesium sulphate inhalation decreases post-operative sore throat only with no effect on cough or hoarseness of voice.Introduction: Endoscopic trans-canal stapes surgery is new approach for treatment of conductive hearing loss due to otosclerosis that requires bloodless field in completely sedated patients. There are few published articles discussing anesthesia in patients undergoing this kind of new surgery. In addition, general anesthesia carries a greater cost to the hospital and the patients recovery in the immediate postoperative period is more symptomaticResults: Pulmonary tuberculous cases compose 33.8% vs. 66.2% extra-pulmonary cases (pleural 40.8%, mediastinal lymph nodes 12.6%, chest wall 9.1%, pericardial 3.8%). The proportion of thoracoscopic interventions was 37%: Majority of them were diagnostic (61.5%), whereas the proportion of traditional thoracic interventions was 63%: majority of them were therapeutic (75.4%) to manage complicated or neglected or incorrectly treated cases.The diagnosis of tuberculosis was not confirmed in 81% of patients at admittance. The majority of cases (88.9%) had active tuberculosis vs. 11.1% only had sequela of previous tuberculous infection. Morbidity rate was 9.2% and mortality rate was 1.3%.G tuberculosis is a major problem in the developing world and has rising trend in developed countries. It is characterized by long-lasting abdominal symptoms, which are usually confused with other conditions, and the diagnosis is usually delayed; mostly diagnosed after its complications. Surgical intervention is usually indicated for the treatment of complications and for obtaining a specimen for histopathological diagnosis. During a 4-year period, we treated 11 cases of abdominal TB in children presented as acute abdomen. Data was collected retrospectively including age, sex, clinical presentations, diagnostic investigations, treatment, outcome, etc., and analyzed. Diagnosis was confirmed on the basis of isolation of acid fast bacilli or pathognomonic histology, or positive PCR/raised ADA level and on classical operative findings. There were 5 female and 6 male patients. The median age of presentation was 12 years. Ten patients were operated while one female patient needed intervention for tissue diagnosis. There was no mortality. Contact history was traced in 5 patients. The most common clinical presentations included fever (11/11), abdominal pain (11/11), and weight loss (10/11). 3 patients operated elsewhere in which 2 patients presented as fecal fistula and one with adhesive bowel obstruction. Two patients were explored but abdominal cavity could not be accessed because of plastered dense bowel adhesions but they responded well with empirical antitubercular drugs. The diagnosis of abdominal TB was suspected initially in only 6 patients; the others were not diagnosed until 6-38 days (mean=19 days) after hospitalization. Abdominal tuberculosis has non-specific presentation and no single laboratory investigation is pathognomonic. Diagnosis is often delayed till acute crisis. Surgery is temporary measure in acute crisis and full course of ATT is definitive. An algorithmic approach is needed. Prompt surgical intervention; vigilant postoperative care and early ATT are required for success.Background: Defects larger than one half of the lip cannot be closed primarily; therefore, tissue transfer is necessary. The recommended surgical techniques for these defects are Cross lip flaps which include Abbe-Sabatini and Estlander flaps. Patients and Methods: Ten patients with squamous cell carcinoma at lower lip not reaching angle of mouth excised with safety margin ranging from 0.5cm to 1cm in each side and the excision not including angle of mouth. The size of the defects in all patients after excision of the tumour was ranging from 1/2 to 2/3 the size of the lower lip. Reconstruction was done in all patients using Abbe-Sabattini cross lip flap and separation of the flap was done after three weeks. Results: The mean age of the patients was 56.5 years (ranging from 47-70 years). Seven patients were males and three patients were females. In all patients the flaps were survived completely. We evaluate the Abbe-Sabattini cross lip flap regarding the functional and aesthetic aspects. AbbeSabatini cross lip flap had a good functional outcome regarding Oral continence to food, fluids, and air and Oral mobility and adequate oral access. In seven patients the sensations were gained completely within six months, but in the remaining three patients there were slight hypothesia after one year. We found also that Abbe-Sabatini cross lip flap had a good aesthetic outcome. Conclusion: Abbe-Sabatini cross lip flap is an ideal versatile flap to reconstruct the defects of lower lip ranging from 1/2 to 2/3 of the size of the lower lip not including angle of the mouth with very good functional and aesthetic outcome. INTRODUCTION Defects larger than one half of the lip cannot be closed primarily without undue wound tension. Strategies for closure involve borrowing tissue either from the opposite lip or from the cheek. Tissue borrowing from the opposing lip was first described by Sabattini in 1838, and is commonly known as the Abbe cross lip flap (Fig. 1). The flap width should be approximately one half of the width of the excised tissue. This width 97 will reduce the size of both upper and lower lip by the same amount. Two centimeters is the maximum recommended width size of the flap, which is pedicled on the labial artery. The pedicle is divided 10 to 21 days later [1]. The Estlander flap is similar to the Abbe flap, but involves rotating the upper lip tissue around the lateral edge of the mouth (Fig. 2). It is best used in situations where the defect involves the oral commissure, so that the flap not only repairs the lower lip defect, but is the first step in commissure reconstruction [2]. Fig. (1): Abbe-Sabattini cross lip flap [3]. Fig. (2): Estlander flap [3]. A B A