Berrin Günaydin

Pulmonary microvascular injury following general anaesthesia with volatile anaesthetics - halothane and isoflurane: a comparative clinical and experimental study

Pulmonary microvascular injury has become a recently studied phenomenon that may be responsible for most of the complications associated with the lungs. Thirty patients undergoing partial hemilaminectomy or discectomy due to hernia of nucleus pulposus underwent Tc-99m HMPAO lung clearance as well as Tc-99m pertechnetate lung scintigraphy pre-operatively, and following general anaesthesia with halothane and isoflurane (third, fourth and tenth post-operative days). The results were compared with conventional techniques and haemodynamic parameters during the peri-operative period. In order to demonstrate acute phase changes under general anaesthesia and to perform pathological examinations, 21 New Zealand rabbits underwent radionuclide studies with Tc-99m HMPAO or Tc-99m pertechnetate. Lung biopsies were also performed. Despite no significant differences in any of the conventional diagnostic techniques, Tc-99m pertechnetate lung scintigraphy was performed for both the halothane and isoflurane groups, and Tc-99m HMPAO lung clearance was performed for the isoflurane group pre- or post-operatively. Tc-99m HMPAO lung clearance was impaired significantly in the halothane group on the third post-operative day (half time: 6.4 +/- 1.6 pre-operative and 13.76 +/- 3.3 s, P < 0.001) decreasing to pre-operative levels on the tenth post-operative day. Acute phase exposure to halothane was characterized with extremely abnormal Tc-99m HMPAO lung clearance in rabbits with respect to isoflurane, diminishing to control levels on the third day (half time: 8.7 +/- 86 control and 28.65 +/- 4.6, P < 0.001). Pathological examinations also demonstrated endothelial damage on acute exposure in the halothane group. General anaesthesia with halothane may give rise to alveolar microvascular injury, which generally seems to be underdiagnosed and may lead to serious post-operative complications.

Intermittent pneumatic sequential compression of the lower extremities restores the cerebral oxygen saturation during laparoscopic cholecystectomy

BackgroundPneumoperitoneum causes intracranial pressure elevation and blood stasis at lower extremities. This study investigates cerebral oxygen saturation changes during laparoscopy and the effects of intermittent sequential compression (ISC) of the lower extremities in patients during elective laparoscopic cholecystectomy.Patients and methodSixty patients were randomly divided into two groups according to the application of ISC to the lower extremities. Group I served as control group whereas ISC was applied to group II. Cerebral oxygen saturation, peripheral blood oxygen saturation, heart rate, mean blood pressure, and associated changes have been recorded during the operation.ResultsPeripheral blood oxygen saturation and mean blood pressure values did not change significantly after pneumoperitoneum. Cerebral oxygen saturation levels of the group II patients were higher in than the group I patients and the difference between the groups was statistically significant (p = 0.0001). The difference became more prominent following the 35th minute of the operation. Mean heart rate of the patients in group II was lower than the patients in group I and the difference was also statistically significant (p = 0.0001).ConclusionIn this study, it was found that the decrease in cerebral oxygen saturation was recovered with ISC application. This simple and reliable technique helps to restore cerebral oxygen saturation levels while increasing blood return from the lower extremities.

Intrathecal hyperbaric or isobaric bupivacaine and ropivacaine with fentanyl for elective caesarean section

Objective. We aimed to investigate the efficacy of either plain or hyperbaric solutions of intrathecal bupivacaine and ropivacaine on maternal block characteristics, complications, side effects and neonatal parameters to find out which is superior in a single study. Methods. One hundred and three term parturients were randomly assigned to receive intrathecal 10 mg hyperbaric bupivacaine (Group Bh), 10 mg plain bupivacaine (Group Bp), 15 mg hyperbaric ropivacaine prepared with dextrose 30% (Group Rh) or 15 mg plain ropivacaine (Group Rp) coadministered with fentanyl 20 μg. Sensory and motor block characteristics, analgesia duration, ephedrine consumption, and neonatal and maternal parameters were recorded. Results. Time to maximum cephalad spread of sensory block was longer in Group Rp than both bupivacaine groups. Time to achieve sensory block at T6 dermatome was similar between both hyperbaric groups (Group Bh:4.5 ± 1.6, Group Rh:4.6 ± 1.1, p > 0.05) but Group Rp needed significantly longer time (7.5 ± 5.5 min, p = 0.003) than both hyperbaric groups. Duration of motor block was shorter in ropivacaine groups (Group Rh: 90.6 ± 17.3, Group Rp 121.6 ± 33.7) vs. bupivacaine groups (Group Bh: 140.2 ± 33.3, Group Bp: 149.7 ± 46.0); Group Rh being shorter than Group Rp (p < 0.05). Ephedrine consumption was less in Groups Rh (20.0 ± 11.9 mg) and Rp (18.3 ± 12.4 mg) vs. Groups Bh (30.0 ± 14.9 mg) and Bp (27.8 ± 15.4 mg) (p = 0.006). Conclusions. Intrathecal hyperbaric ropivacaine 15 mg with fentanyl 20 μg for CSE is suitable since it provides early motor recovery leading to faster patient ambulation, rapid onset of sensory block with less ephedrine.

Effect of high-dose lidocaine treatment on superoxide dismutase and malon dialdehyde levels in seven diabetic patients

Background and Objectives: We report on the use of intravenous (IV) high‐dose lidocaine to relieve diabetic neuropathic pain, and the techniques effects on clinical measures of lipid peroxidation. Methods: Under continuous electrocardiogram monitoring, IV lidocaine (5 mg kg−1 in 100 mL saline) was administered over 30 minutes to 7 non‐insulin‐dependent diabetic patients suffering from neuropathic pain who reported increased pain within the preceding 6 months. This treatment was performed once a week for 1 month. Blood samples were collected from the contralateral limb to determine plasma superoxide dismutase (SOD) and malondialdehyde (MDA) levels on admission and following the final lidocaine administration. Results: Plasma MDA concentrations significantly decreased after the final IV lidocaine treatment (P < .05, paired t‐test), whereas SOD levels did not show a statistically significant difference compared with baseline levels. Conclusions: High‐dose lidocaine treatment lessens MDA levels, a marker of free‐radical‐mediated cell damage. This suggests that one of lidocaines mechanism of action may be its effect on oxygen free radicals, which in turn impacts lipid peroxidation.

A comparison of three different target-controlled remifentanil infusion rates during target-controlled propofol infusion for oocyte retrieval

OBJECTIVE: To evaluate the effects of three different target-controlled remifentanil infusion rates during target-controlled propofol infusion on hemodynamic parameters, pain, sedation, and recovery score during oocyte retrieval. METHODS: Sixty-nine women were scheduled for oocyte retrieval. Target-controlled propofol infusion at an effect-site concentration of 1.5 µg/mL was instituted. The patients were randomly allocated to receive remifentanil at an effect-site concentration of either 1.5 (group I, n = 23), 2 (group II, n = 23) or 2.5 ng/mL (group III, n = 23). Hemodynamic variables, sedation, pain, the Aldrete recovery score, and side effects were recorded. RESULTS: Hemodynamic variables, sedation and pain scores and the number of patients with the maximum Aldrete recovery score 10 min after the procedure were comparable among the groups. The number of patients in group III with the maximum Aldrete recovery score 5 min after the procedure was significantly lower than that in groups I and II. One patient in group II and one patient in group III suffered from nausea. CONCLUSION: Similar pain-free conscious sedation conditions without significant changes in hemodynamic parameters were provided by all three protocols. However, target controlled infusion of remifentanil at 1.5 or 2 ng/mL proved superior at providing early recovery compared to 2.5 ng/mL.

Recombinant activated factor VII and epsilon aminocaproic acid treatment of a patient with Glanzmann's thrombasthenia for nasal polipectomy.

bleeding could be controlled by local measures such as compression or the use of a gelatin sponge or gauze alone or dipped in tranexamic acid or topical thrombin, and it has also been reported that there was a possibility of the development of a vicious cyle of rebleeding [4]. Therefore, we administered a second dose of rFVIIa in order to stop bleeding when we observed apparent nosebleed from the gauzes in the recovery room. Because the preoperative hemoglobin decreased from 16.7 to 7.7 g·dl-1 and the platelet count decreased from 249 to 130 ¥ 109 · l-1, third and fourth doses were given at 2-h intervals, and a fifth dose was given simultaneously with one pack of platelets in the ward. When hemoglobin and platelets returned to normal baseline values, the patient was discharged. Anesthesiologists are rarely faced with patients having GT undergoing surgery. Vaginal hysterectomy, pediatric open cardiac surgery, and herniorrhaphy were some of the reported procedures requiring anesthesia in such patients, and were treated with similar immediate preand postoperative effective therapeutic regimens [5–7]. Although platelet transfusion therapy has been an accepted treatment of GT bleeding for years, it may result in the development of antibodies to GP IIb/IIIa, rendering further transfusions ineffective [1,2]. The optimal dose and mode of rFVIIa administration are still under investigation at the present time, and bolus infusions of 80–85mg·kg-1 or more at 2-h intervals have been recommended, if one to three doses were not sufficient to arrest the bleeding, more doses were given according to the current treatment strategies [4]. In conclusion, in patients with GT, the present therapy protocol, including rFVIIa and tranexamic, acid could be safely used, without adverse effects (particularly thrombotic events), in combination with platelet transfusion, based on the case reported here.

SEASONAL VARIATION IN THE EFFECT OF A FIXED DOSE OF HEPARIN ON ACTIVATED CLOTTING TIME IN PATIENTS PREPARED FOR OPEN-HEART SURGERY*

We investigated the effect of an injected bolus of 5 mg kg− heparin at one circadian stage (08:30 to 11:00) on blood coagulation during different months of the year. Activated clotting times (ACTs) were assessed before and 5 min after heparin dosing to ensure extracorporeal circulation during open-heart surgery. The ACT data of 1083 presumably day-active Turkish patients (816 men and 267 women, mostly older than 46 years) who underwent coronary bypass surgery between 08:30 and 11:00 in the years from 1994 to 1997 were analyzed for annual rhythmicity. The ACT values obtained just before and 5 min after heparinization were subjected to cosinor analysis using a 365.25-day period to assess seasonality in basal ACT level and heparin effect. A small-amplitude annual rhythm with a wintertime peak was documented in the morning ACT in the group of 1083 patients. Rhythms of similar magnitude and staging were also detected in heparin effect on ACT in the 1083 patients and in subgroups categorized by gender. Circannual rhythmicity in the heparin effect on ACT was also documented in the elderly (≥ 45 years old), but not young (18–45 years old) patients. The annual mean effect of heparin on the ACT was statistically significantly greater in younger than older patients. The relatively low-amplitude circannual rhythm in heparin effect on ACT (∼10% of the annual mean) is not viewed as being meaningful in patient preparation for bypass surgery for the 5 mg kg−1 level of heparin dosing. (Chronobiology International, 18(5), 865–873, 2001)

Effects of tetracaine and bupivacaine on chemiluminescence generated by formyl-methionyl-leucyl-phenylalanine-stimulated human leukocytes and cell-free systems.

We investigated the abilities of an ester-type local anesthetic tetracaine and an amide-type local anesthetic bupivacaine to inhibit reactive oxygen and/or nitrogen species generated by either human leukocytes or cell-free systems via luminol- and lucigenin-enhanced chemiluminescence (CL). Tetracaine (96+/-1%, n=6, 1 mM) and bupivacaine (97+/-0.4%, n=5, 1 mM) significantly inhibited FMLP-induced-CL in leukocyte assay. In cell-free experiments, CL due to superoxide production was significantly inhibited by tetracaine (23+/-2%, n=6) and bupivacaine (25+/-4%, n=6) at 1 mM. Although bupivacaine was ineffective on H(2)O(2)-induced CL, tetracaine activated H(2)O(2)-induced luminol CL. Additionally, tetracaine inhibited FeSO(4)-induced CL (42+/-2%, n=6, 1 mM). In hypochlorous acid (HOCl)-induced CL assay, 70+/-10% (n=5) and 57+/-4% (n=15) inhibitions were observed by tetracaine and bupivacaine, respectively. Peroxynitrite-induced luminol (54+/-7%, n=7, tetracaine, and 26+/-5%, n=8, bupivacaine, at 1 mM) and lucigenin CL (58+/-3%, n=6, tetracaine, and 22+/-14%, n=9, bupivacaine, at 1 mM) were markedly inhibited. Tetracaine interacted with superoxide, hydroxyl radical, HOCl and peroxynitrite, while bupivacaine scavenged superoxide, HOCl and peroxynitrite. These direct scavenging properties of these drugs might be involved in the inhibition observed in leukocyte free radical release. In general, a decrease in CL-response was seen with higher concentrations (0.1-1 mM) of the local anesthetics, it is likely that tetracine and bupivacaine at therapeutic concentrations do not suppress leukocyte function in vivo.

Anesthetic management of a child with Rubinstein-Taybi syndrome for cervical dermoid cyst excision

which are characteristics of this syndrome (Fig. 1). Thyroid ultrasonography showed a multilocular cystic 33 3 20mm mass anterior to the thyroid gland. There was no mass activity on thyroid scintigraphy. The total blood count and other laboratory test results were within normal ranges. No gastroesophageal reflux was observed on esophagogastrography. The right testis had not descended, and the left testis was retractile. The results of cranial computerized tomography and chromosomal analysis were normal. He had no cardiac defects. He was diagnosed as having the autosomal dominant mutagenic form of RTS. There was an uneventful history of operation and anesthesia for a midline neck mass diagnosed as a thyroglossal cyst that was performed at another center 1 year previously. On this occasion, the midline neck mass was above the previous one and was thought to be a recurrent thyroglossal cyst preoperatively. The patient’s height was 90cm (,3 percentile), and his weight was 14kg (3–10 percentiles). He fasted for 8h and was not premedicated before induction of anesthesia. His heart rate was 130 beats·min21 and his SpO2 was 99%. After preoxygenation, anesthesia was induced by 50% N2O/O2 mixture in sevoflurane via a face mask. After intravenous access had been obtained, 0.5mg kg21 of atracurium was injected, and endotracheal intubation was performed without difficulty with an uncuffed tube that had an internal diameter of 4.5mm. Anesthesia was maintained with 50% N2O/O2 mixture in sevoflurane. The neck mass was excised. At the end of anesthesia, spontaneous ventilation was promptly reestablished. After reversal of residual muscle paralysis with 0.5mg of neostigmine and 0.25mg of atropine, the endotracheal tube was removed. Rectal paracetamol was administered for postoperative pain. No significant problem was encountered during induction, maintenance, and extubation. The pathologic diagnosis of the mass was dermoid cyst.

The effects of delivery route and anesthesia type on early postnatal weight loss in newborns: the role of vasoactive hormones

Abstract Objective: To investigate the effects of delivery route and maternal anesthesia type and the roles of vasoactive hormones on early postnatal weight loss in term newborns. Methods: Ninety-four term infants delivered vaginally (group 1, n=31), cesarean section (C/S) with general anesthesia (GA) (group 2, n=29), and C/S with epidural anesthesia (EA) (group 3, n=34) were included in this study. All infants were weighed at birth and on the second day of life and intravenous (IV) fluid infused to the mothers for the last 6 h prior to delivery was recorded. Serum electrolytes, osmolality, N-terminal proANP (NT-proANP), brain natriuretic peptide (BNP), aldosterone and plasma antidiuretic hormone (ADH) concentrations were measured at cord blood and on the second day of life. Results: Our research showed that postnatal weight loss of infants was higher in C/S than vaginal deliveries (5.7% vs. 1.3%) (p<0.0001) and in EA group than GA group (6.8% vs. 4.3%) (p<0.0001). Postnatal weight losses were correlated with IV fluid volume infused to the mothers for the last 6 h prior to delivery (R=0.814, p=0.000) and with serum NT-proANP (R=0.418, p=0.000), BNP (R=0.454, p=0.000), and ADH (R=0.509, p=0.000) but not with aldosterone concentrations (p>0.05). Conclusion: Large amounts of IV fluid given to the mothers who were applied EA prior to the delivery affect their offsprings’ postnatal weight loss via certain vasoactive hormones.