Bahar Kuvaki

Anesthesia with EMLA® Cream for Botulinum A Toxin Injection into Eyelids

We investigated the efficacy of an eutectic mixture of local anesthetics (EMLA®) in reducing the pain of a botulinum toxin injection into eyelids. 17 patients with facial dyskinesia (9 blepharospasm and 8 hemifacial spasm) who had been treated regularly with botulinum toxin injections received EMLA cream and placebo. The pain was assessed by the ophthalmologist and the patient. Injection with EMLA cream showed lower pain scores (mean 1.82 ± 2.13, median 1) than injection with placebo (8.76 ± 2.17; p = 0.0001). Percutaneous anesthesia induced by EMLA cream is an effective and safe method which improves the comfort in patients who need repeated botulinum toxin injections for their facial dyskinesia.

Radial nerve injury after general anaesthesia in the lateral decubitus position

A 43‐year‐old female patient underwent pyelolithotomy in the left lateral decubitus position. Her upper right arm was placed on a padded armboard. Surgery lasted for 240 min. Postoperatively, she complained of numbness of the dorsal part of her right hand and wrist drop. Neurological examination revealed hypoaesthesia of the dermatome of the right forearm and hand innervated by the radial nerve. Electromyography revealed advanced axonal degeneration of the radial nerve below the level of the elbow. Treatment with diclofenac, vitamin B and physiotherapy was started. Her symptoms improved gradually and at the 60th postoperative day, motor weakness had completely resolved. In order to prevent peri‐operative nerve injury, careful positioning of every patient on the operating table with proper padding is essential, with attention paid to time‐dependent risks. If an injury occurs, diagnosis and treatment should be started as rapidly as possible.

The influence of epidural volume extension on spinal block with hyperbaric or plain bupivacaine for Caesarean delivery.

Background and objective: Epidural volume extension via a combined spinal‐epidural is the enhancement of a small‐dose intrathecal block by an epidural injection of physiological saline solution. We evaluated the effect of epidural volume extension on the combined spinal‐epidural technique of providing spinal anaesthesia for Caesarean section with hyperbaric or plain 0.5% bupivacaine. Methods: Patients (n = 240) with height >163 cm received 9 mg and patients <163 cm received 8 mg of bupivacaine. Each study drug was combined with 20 &mgr;g fentanyl. Using the combined spinal‐epidural technique, Group A (n = 60) received hyperbaric bupivacaine, and Group B (n = 60) received hyperbaric bupivacaine and 10 mL saline epidurally 5 min after subarachnoid injection. Group C (n = 60) received plain bupivacaine and Group D (n = 60) received plain bupivacaine and 10 mL saline epidurally 5 min after subarachnoid injection. An anaesthetist blinded to the anaesthetic solution injected examined the level of analgesia by the pinprick method and motor block with the modified Bromage scale for 30 min after subarachnoid injection, during the intraoperative period and subsequently every 15 min for 135 min during the recovery period. Results: Time to reach a sensory block at T4 was significantly shorter in Groups C and D than in Groups A (P = 0.003 and 0.017) and B (P = 0.006 and 0.048), respectively. During the intraoperative period, sensory block levels were significantly higher in Group C than in Group A. Recovery was similar in all groups; only onset was faster in Groups C and D. Conclusion: There was no effect of epidural volume extension on the profile of spinal anaesthesia with the combined spinal‐epidural technique for Caesarean section using hyperbaric or plain bupivacaine.

Bilateral massive choroidal hemorrhage secondary to Glanzmann's syndrome

Characteristics of intraocular bleeding and its management in association with blood dyscrasias are discussed. We present a patient with massive bilateral choroidal hemorrhage secondary to Glanzmanns syndrome. Magnetic resonance imaging and ultrasonographic findings were ordered. During the clinical course, bilateral intravitreal hemorrhage and tractional retinal detachment occurred. Left pars plana vitrectomy was performed under general anaesthesia. The procedure was unsuccessful because of intraoperative uncontrolled bleeding.

The Soft Seal disposable laryngeal mask airway in adults: comparison of two insertion techniques without intra-oral manipulation

We investigated whether insertion of the disposable Soft Seal laryngeal mask airway (SSLM) was successful without intra‐oral digital manipulation. One hundred patients undergoing anaesthesia using the SSLM were randomly assigned into two groups. Insertion was performed by either a direct or a rotational technique, both without intra‐oral digital manipulation. The primary outcome measure was successful insertion at first attempt. Other outcomes included insertion time, fibreoptic assessment of the airway view and airway morbidity. The first attempt success rate was higher (98%) with the direct technique than with the rotational technique (75%; p = 0.002) but insertion time was faster with the latter method (mean [range] 15 [8–50] s) than with the direct method (20 [8–56] s; p = 0.035). Fibreoptic assessment and airway morbidity were similar in both groups. We conclude that the SSLM can be successfully inserted without intra‐oral digital manipulation.

EMLA® does not permit pain‐free retrobulbar injection*

Background:  Retrobulbar injection can be associated with significant pain, due to both needle insertion and deposition of the local anaesthetic solution. The local anaesthetic cream EMLA® (eutectic mixture of local anaesthetics) which contains a mixture of lignocaine and prilocaine has been shown to reduce the pain associated with skin puncture. The efficacy of EMLA® in alleviating the pain of retrobulbar injection for cataract surgery was assessed in this study.

Evaluation of Public Awareness, Knowledge and Attitudes about Cardiopulmonary Resuscitation: Report of İzmir.

OBJECTIVE Early initiation of cardiopulmonary resuscitation (CPR) by witnesses increases survival after cardiac arrest. In Turkey, our country, it is rare that basic life support (BLS) is initiated by a layperson. In our study, we aimed to use a survey to research awareness, level of knowledge and attitudes of the public to CPR and BLS. METHODS A 21-question survey was administered to individuals aged ≥18 years on a busy street in a city of a western region of Turkey. Topics such as knowledge about cardiac arrest findings, previous experience of CPR, knowledge of BLS and concerns related to CPR were questioned. RESULTS The fully completed forms of 533 people were evaluated. There were 40.7% who stated that they had received training in CPR. For signs of cardiac arrest, 40.7% answered loss of consciousness, 49.3% answered cessation of breathing and 60.7% answered cessation of circulation. It was found that 35.5% could perform only chest compressions, 27.6% could perform mouth-to-mouth ventilation and 28.7% able to perform both. While 52.0% knew the location for performing chest compressions, 34.3% knew the correct depth and 15.6% knew the correct compression-ventilation rate. Bystander CPR was performed by 3.6%. CONCLUSION In conclusion, 40.7% of people living in a highly educated region in the western part of Turkey had received CPR training and 3.6% performed bystander CPR. A majority of participants stated that they were willing to correct and develop their knowledge and skills related to CPR. Effective public CPR training programmes may increase the knowledge and awareness of CPR in the adult population.

Comparação de diferentes estiletes usados para intubação com o videolaringoscópio C‐MAC D‐Blade®: um estudo randômico e controlado

OBJECTIVE The angle of the C-MAC D-Blade® videolaryngoscope, which is used for difficult airway interventions, is not compatible with routinely used endotracheal tubes. METHODS A prospective randomized crossover study was performed comparing five intubation methods for use with standardized airways, including using different stylets or no stylet: Group HS, hockey-stick stylet; Group DS, D-blade type stylet; Group CS, CoPilot® videolaryngoscope rigid stylet®; Group GEB, gum elastic bougie; and Group NS, no stylet. A manikin was used to simulate difficult intubation with a Storz C-MAC D-Blade® videolaryngoscope. The duration of each intubation stage was evaluated. RESULTS Participants in this study (33 anesthesiology residents and 20 anesthesiology experts) completed a total of 265 intubations. The number of attempts made using no stylet was significantly greater than those made for the other groups (p<0.05 for group NS- group GEB, group NS- group DS, group NS- group CS and group NS- group HS). The duration to pass the vocal cords significantly differed among all groups (p<0.001). The total intubation duration was shortest when using D-blade stylet, CoPilot stylet and hockey stick stylet. Although no difference was observed between stylet groups, a significant difference was found between each of these three and no stylet and gum elastic bougie (p<0.05 and p<0.001, respectively). CONCLUSION Use of the correct stylet leads to a more efficient use of the Storz C-MAC D-Blade®. In our study, the use of the D-blade stylet, the CoPilot stylet and the hockey stick stylet provided quicker intubation, allowed easier passage of the vocal cords, and decreased the total intubation duration. To confirm the findings of our study, randomized controlled human studies are needed.

Effectiveness of sugammadex for cerebral ischemia/reperfusion injury

Cerebral ischemia may cause permanent brain damage and behavioral dysfunction. The efficacy and mechanisms of pharmacological treatments administered immediately after cerebral damage are not fully known. Sugammadex is a licensed medication. As other cyclodextrins have not passed the necessary phase tests, trade preparations are not available, whereas sugammadex is frequently used in clinical anesthetic practice. Previous studies have not clearly described the effects of the cyclodextrin family on cerebral ischemia/reperfusion (I/R) damage. The aim of this study was to determine whether sugammadex had a neuroprotective effect against transient global cerebral ischemia. Animals were assigned to control, sham‐operated, S 16 and S 100 groups. Transient global cerebral ischemia was induced by 10‐minute occlusion of the bilateral common carotid artery, followed by 24‐hour reperfusion. At the end of the experiment, neurological behavior scoring was performed on the rats, followed by evaluation of histomorphological and biochemical measurements. Sugammadex 16 mg/kg and 100 mg/kg improved neurological outcome, which was associated with reductions in both histological and neurological scores. The hippocampus TUNEL (terminal deoxynucleotidyl transferase dUTP nick end labeling) and caspase results in the S 16 and S 100 treatment groups were significantly lower than those of the I/R group. Neurological scores in the treated groups were significantly higher than those of the I/R group. The study showed that treatment with 16 mg/kg and 100 mg/kg sugammadex had a neuroprotective effect in a transient global cerebral I/R rat model. However, 100 mg/kg sugammadex was more neuroprotective in rats.

Ruptured Hepatic Artery Aneurysm: A Rare Fatal Cause of Obstructive Jaundice

Background: Hepatic artery aneurysms (HAA) are rare vascular lesions, often with a nonspecific clinical presentation and difficult to diagnose before rupture. We present a case of radiologically diagnosed ruptured HAA that cause obstructive jaundice. Case Report: A 56-yearold woman presented with a 2-month history of upper abdominal pain and progressive jaundice. Physical examination showed hypotension, tachycardia, icteric sclera, pale conjunctiva, epigastric tenderness, and hypoactive bowel sound. Laboratory findings were compatible with obstructive jaundice. Abdominal ultrasonography revealed a cyst-like lesion at the porta hepatis and dilated intrahepatic biliary ducts. Subsequently, contrast-enhanced CT of the upper abdomen showed a well-circumscribed lesion with a density similar to that of the contrast medium-filled abdominal aorta suggesting aneursym of the hepatic artery, and a perianeurysmal hypodensity reflecting leakage of the ruptured aneurysm. During the radiological procedure, the patient’s condition deteriorated. Angiography was planned but could not be performed due to technical problems. Thereafter, emergency operation was done 5 h after admission, but the patient died intraoperatively due to massive intraabdominal bleeding. Conclusion: HAA is a rare vascular lesion that should be considered in cases of unexplained obstructive jaundice.