Bilge Celebioglu

Magnesium sulfate pretreatment reduces myoclonus after etomidate.

Myoclonic movements and pain on injection are common problems during induction of anesthesia with etomidate. We investigated the influence of pretreatment with magnesium and two doses of ketamine on the incidence of etomidate-induced myoclonus and pain. A prospective double-blind study was performed on 100 ASA physical status I–III patients who were randomized into 4 groups according to the pretreatment drug: ketamine 0.2 mg/kg, ketamine 0.5 mg/kg, magnesium sulfate (Mg) 2.48 mmol, or normal saline. Ninety seconds after the pretreatment, anesthesia was induced with etomidate 0.2 mg/kg. Vecuronium 0.1 mg/kg was used as the muscle relaxant. An anesthesiologist, blinded to group allocation, recorded the myoclonic movements, pain, and sedation on a scale between 0–3. Nineteen of the 25 patients receiving Mg (76%) did not have myoclonic movements after the administration of etomidate, whereas 18 patients (72%) in the ketamine 0.5 mg/kg, 16 patients (64%) in the ketamine 0.2 mg/kg, and 18 patients (72%) in the control group experienced myoclonic movements (P < 0.05). We conclude that Mg 2.48 mmol administered 90 s before the induction of anesthesia with etomidate is effective in reducing the severity of etomidate-induced myoclonic muscle movements and that ketamine does not reduce the incidence of myoclonic movements.

The effect of tenoxicam on intraperitoneal adhesions and prostaglandin E2 levels in mice

UNLABELLED We determined whether tenoxicam administered intraperitoneally in the preoperative period had an effect on the development of postoperative intraabdominal adhesions (IAA). For this purpose, 100 albino mice were divided into four random groups. Mice in Group 1 were given only 1 mL of 0.9% NaCl intraperitoneally, whereas in Group 2, 1 mL of tenoxicam (150 microg = 5 mg/kg) was administered. After the induction of anesthesia, a median laparotomy was performed, and the bowels were traumatized by touching them with powdered gloves before the incision was closed in Groups 3 and 4. Intraperitoneal tenoxicam was administered to mice in Group 4 after skin closure. All mice were killed after 14 days to determine macroscopic and microscopic IAA; prostaglandin E2 levels were also measured. Postoperative evaluation revealed a reduced IAA formation and a parallel decrease in tissue prostaglandin E2 levels in Group 1 and 2 mice. We conclude that intraperitoneal tenoxicam decreased IAA formation with no peritoneal reaction in the postoperative period. IMPLICATIONS Postoperative intraabdominal adhesions can cause intestinal obstruction, pelvic pain, or infertility. In this study, we showed that intraperitoneally administered tenoxicam decreases tissue prostaglandin E2 levels and intraabdominal adhesions in mice.

The Effect of HES (130/0.4) Usage as the Priming Solution on Renal Function in Children Undergoing Cardiac Surgery

Background: Experience with hydroxyethyl starch (HES) in children is limited. This study was conducted to observe the effects of HES or Ringer’s lactate (RL) usage as the priming solution on renal functions in children undergoing cardiac surgery. Methods: After ethical committee approval and parent informed consent, 24 patients were included in this prospective, randomized study. During cardiopulmonary bypass (CPB), Group I received RL and Group II received HES (130/0.4) as priming solution. Serum creatinine, blood urea nitrogen (BUN), β2-microglobulin, cystatin C, and urinary albumin and creatinine, serum, and urine electrolytes were analyzed after the induction (T1), before CPB (T2), during CPB (T3), after CPB (T4), at the end of the operation (T5), on 24th hour (T6), and on 48th hour postoperatively (T7). Fractional sodium excretion (FENa), urinary albumin/creatinine ratio, and creatinine clearance were calculated. Drainage, urine output, inotropes, diuretics, and blood requirements were recorded. Results: In both the groups, β2-microglobulin was decreased during CPB and cystatin C was decreased at T3,T4, and T5 periods (p < 0.05) and the levels remained within the normal range. Creatinine clearance did not differ in the HES group, but increased in the RL group (p < 0.05). Urine albumin/creatinine ratio was increased (p < 0.05) after CPB in the HES group, and it increased at T3, T4, and T5 in the RL group (p < 0.05). There were no differences in cystatin C, β2-microglobulin, FENa, urine albumin/creatinine ratio, creatinine clearance, total fluid amount, urine output, drainage, and inotropic and diuretic requirements between the groups. Conclusion: We conclude that usage of HES (130/0.4) did not have negative effects on renal function, and it can be used as a priming solution in pediatric patients undergoing cardiac surgery.

The Effects of Isoflurane, Sevoflurane, and Desflurane Anesthesia on Neurocognitive Outcome after Cardiac Surgery: A Pilot Study

BACKGROUND Inhalation anesthetics such as isoflurane, sevoflurane, and desflurane are widely used in clinical practice; however, there is no study for comparing these drugs in cardiac surgery with respect to postoperative cognitive outcome and S100 beta protein (S100 BP) levels. In this study, we evaluated the effect of sevoflurane, isoflurane, and desflurane anesthesia on neuropsychological outcome and S100 BP levels in patients undergoing coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB). MATERIALS AND METHODS Forty-two male patients were prospectively randomized and classified into 3 groups according to the volatile agents used; isoflurane, sevoflurane, desflurane. All patients had a sufficient education level to participate in neuropsychological testing and a normal carotid Doppler ultrasonography. Blood samples for analysis of S100 BP were collected before anesthesia (T1), before heparinization (T2), 15 minutes into CPB (T3), following protamine administration (T4), postoperatively (T5), 24 hours after the operation (T6), postoperative day 3 (T7), and postoperative day 6 (T8). The neuropsychological tests, including Mini-Mental State Examination (MMSET) and visual-aural digit span test (VADST), were administered 1 day prior to surgery and on the third and sixth postoperative days. RESULTS The postoperative third and sixth day MMSET scores and third day visual-written subtest scores in the sevoflurane group were significantly lower than in the isoflurane and desflurane groups (P < .05). S100 BP levels increased with the beginning of anesthesia in the sevoflurane and desflurane groups. Although S100 BP decreased to baseline levels on postoperative day 1 in the sevoflurane group, this was significantly higher on the third and sixth days postoperatively in the desflurane group (P < .05). In the isoflurane group, the S100 BP level was significantly higher than the baseline level only after CPB (P < .05). CONCLUSION Our study suggests that isoflurane is associated with better neurocognitive functions than desflurane or sevoflurane after on-pump CABG. Sevoflurane seems to be associated with the worst cognitive outcome as assessed by neuropsychologic tests, and prolonged brain injury as detected by high S100 BP levels was seen with desflurane.

Comparison of the Effects of Sevoflurane, Isoflurane, and Desflurane on Microcirculation in Coronary Artery Bypass Graft Surgery

OBJECTIVE This investigation was performed to compare the effects of inhalation agents on microcirculation in coronary artery bypass grafting (CABG) using orthogonal polarization spectral imaging. DESIGN This prospective and randomized study was performed in patients scheduled for CABG surgery from March through September 2010. SETTING Tertiary care university hospital. PARTICIPANTS Thirty patients undergoing elective CABG. INTERVENTIONS Patients were assigned to sevoflurane, desflurane, or isoflurane. MEASUREMENTS AND MAIN RESULTS Orthogonal polarization spectral imaging was used to evaluate the sublingual microcirculation. Hemodynamic variables (heart rate, mean arterial pressure, central venous pressure, cardiac output, and pulmonary capillary wedge pressure), laboratory parameters (hematocrit, lactate, and potassium), and microcirculatory variables (total vascular density [TVD] [mm/mm(2)], microvascular flow index [MFI] [arbitrary units], perfused vessel density [PVD] [mm/mm(2)], and proportion of perfused vessels [PPV] [percentage] were obtained before induction, after induction, during cardiopulmonary bypass, at the end of surgery, and 24 hours after surgery. The greatest alterations in microcirculation parameters were found during cardiopulmonary bypass. In the sevoflurane group, TVD (14.7%), PVD (22%), PPV (5.97%, p < 0.05), and MFI (7.69%, p > 0.05) were decreased. In the isoflurane group, TVD (14.7%) and PVD (20.3%) were decreased, whereas PPV (1.69%) and MFI (17.99%) were increased (p < 0.05). In the desflurane group, there were no changes in TVD and PVD, but MFI (8.99%, p > 0.05) and PPV (1.48%, p < 0.05) were increased in the small vessels. These changes returned to their initial values 24 hours postoperatively. CONCLUSIONS Sevoflurane had a negative effect on the microcirculation. Isoflurane decreased vascular density and increased flow. Desflurane produced stable effects on the microcirculation. These inhalation agents induced transient alterations in microvascular perfusion.

Fatal mesenteric artery thrombus following oocyte retrieval.

The patient was a 38 year old woman (ASA I, 157 cm height, 61 kg weight) with a 14-year history of secondary infertility due to endometriosis who had undergone in vitro fertilisation and embryo transfer after ovarian stimulation with gonadotrophins. Between 1989 and 2003, she had two-third trimester and six first and second trimester miscarriages. Her clotting profile studies, including protein-C activation, the resistance of active protein-C and LIA test free protein-S, were all normal. All her autoimmune tests were negative. Her homocysteine level was 10.89 Amol L 1 and normal. Her anti-toxoplasma IgG–IgM, anti-CMV IgM and HSV-IgM were negative but anti-CMV IgG and HSV-1 IgG were positive. Thyroid function tests were normal. Her fasting blood glucose level was 96 mg dL 1 and after 75 g oral glucose tolerance test, type II DM was detected and she was put on a diabetic diet. Diagnostic laparoscopy and hysteroscopy were performed. The right fallopian tube was obstructed. There were no pelvic adhesions. Endometritis and adenomyosis were found in an endometrial biopsy. Semen analysis of the husband was normal. After these tests were performed, she was treated with in vitro fertilisation and embryo transfer. The patient had her first cycle of in vitro fertilisation– embryo transfer in October 2003 when 50 IU 27 1⁄4 1350 units of human menopausal gonadotrophin (HMG) (Pergonal; Serono, Geneva, Switzerland) were administered. After 12 days of stimulation, the patient developed 17 follicles with a diameter of 12–17 mm. Follicle aspiration was carried out 36 hours after administration of 10,000 IU of human chorionic gonadotrophin (hCG) while the oestradiol concentration was 2337 PG mL 1 and seven oocytes were obtained. She had not had any procedures under anaesthesia or embryo transfer prior to this time. After the oocyte pick-up procedure the patient was discharged from hospital, but a few hours later she came to the emergency service with acute abdominal pain and in poor general condition. Her heart rate was 130 minute , blood pressure 110/70 mmHg, fever 36jC and respiration rate 24 minute . On physical examination she had abdominal tenderness and rebound. Bowel sounds were hypoactive, there was costovertebral angle tenderness. On rectal examination, the cervix was rigid, and no blood or melena was detected. Flat and upright abdominal X-rays showed air– fluid levels. Ultrasonography showed massive fluid in the left paracolic area and minimal fluid was seen behind the bladder. At culdocentesis no fluid was aspirated. Laboratory findings are shown in Table 1. She was treated conservatively with intravenous infusion of 8 Litre/ day crystalloids. A few hours later she developed restlessness, tachycardia (heart rate 1⁄4 180 minute ), hypotension (80/60 mmHg), hypercapnia (respiratory rate 1⁄4 44 minute ), leucocytosis, and her temperature was 38jC. In view of these findings indicative of sepsis, the infectious disease consultant recommended intravenous sulbactam– ampicillin 4 1.5 g and ciprofloxasin 2 400 mg. The patient was transferred to the intensive care unit (ICU), ECG, heart rate, invasive blood pressure, respiratory rate, temperature and central venous pressure and urine output were all continuously monitored. Twelve hours later, she had cardiac arrest and cardiopulmonary resuscitation was started. Defibrillation was ineffective and no heart rhythm returned. Intracardiac 1.2 lmg adrenaline was given after which, cardiac rhythm was noted. Cardiopulmonary resuscitation was performed for 17 minutes. After resuscitation, her blood pressure was 39/25 mmHg and dopamine infusion (10 Ag kg 1 minute ) was started. The blood pressure increased to 63/56 mmHg. On neurological examination, she was unconscious and there was no response to verbal or noxious stimulation. Bilateral plantar reflexes were weak. Pupil diameter was 4 mm/2 mm and pupillary light reflex was sluggish. She was intubated and put on mechanical ventilation. On electrocardiography, sinus tachycardia, ST segment depression in all derivatives and incomplete right bundle branch block were noted. BJOG: an International Journal of Obstetrics and Gynaecology November 2004, Vol. 111, pp. 1301–1304

CASE REPORT: Fatal mesenteric artery thrombus following oocyte retrieval

The patient was a 38 year old woman (ASA I, 157 cm height, 61 kg weight) with a 14-year history of secondary infertility due to endometriosis who had undergone in vitro fertilisation and embryo transfer after ovarian stimulation with gonadotrophins. Between 1989 and 2003, she had two-third trimester and six first and second trimester miscarriages. Her clotting profile studies, including protein-C activation, the resistance of active protein-C and LIA test free protein-S, were all normal. All her autoimmune tests were negative. Her homocysteine level was 10.89 Amol L 1 and normal. Her anti-toxoplasma IgG–IgM, anti-CMV IgM and HSV-IgM were negative but anti-CMV IgG and HSV-1 IgG were positive. Thyroid function tests were normal. Her fasting blood glucose level was 96 mg dL 1 and after 75 g oral glucose tolerance test, type II DM was detected and she was put on a diabetic diet. Diagnostic laparoscopy and hysteroscopy were performed. The right fallopian tube was obstructed. There were no pelvic adhesions. Endometritis and adenomyosis were found in an endometrial biopsy. Semen analysis of the husband was normal. After these tests were performed, she was treated with in vitro fertilisation and embryo transfer. The patient had her first cycle of in vitro fertilisation– embryo transfer in October 2003 when 50 IU 27 1⁄4 1350 units of human menopausal gonadotrophin (HMG) (Pergonal; Serono, Geneva, Switzerland) were administered. After 12 days of stimulation, the patient developed 17 follicles with a diameter of 12–17 mm. Follicle aspiration was carried out 36 hours after administration of 10,000 IU of human chorionic gonadotrophin (hCG) while the oestradiol concentration was 2337 PG mL 1 and seven oocytes were obtained. She had not had any procedures under anaesthesia or embryo transfer prior to this time. After the oocyte pick-up procedure the patient was discharged from hospital, but a few hours later she came to the emergency service with acute abdominal pain and in poor general condition. Her heart rate was 130 minute , blood pressure 110/70 mmHg, fever 36jC and respiration rate 24 minute . On physical examination she had abdominal tenderness and rebound. Bowel sounds were hypoactive, there was costovertebral angle tenderness. On rectal examination, the cervix was rigid, and no blood or melena was detected. Flat and upright abdominal X-rays showed air– fluid levels. Ultrasonography showed massive fluid in the left paracolic area and minimal fluid was seen behind the bladder. At culdocentesis no fluid was aspirated. Laboratory findings are shown in Table 1. She was treated conservatively with intravenous infusion of 8 Litre/ day crystalloids. A few hours later she developed restlessness, tachycardia (heart rate 1⁄4 180 minute ), hypotension (80/60 mmHg), hypercapnia (respiratory rate 1⁄4 44 minute ), leucocytosis, and her temperature was 38jC. In view of these findings indicative of sepsis, the infectious disease consultant recommended intravenous sulbactam– ampicillin 4 1.5 g and ciprofloxasin 2 400 mg. The patient was transferred to the intensive care unit (ICU), ECG, heart rate, invasive blood pressure, respiratory rate, temperature and central venous pressure and urine output were all continuously monitored. Twelve hours later, she had cardiac arrest and cardiopulmonary resuscitation was started. Defibrillation was ineffective and no heart rhythm returned. Intracardiac 1.2 lmg adrenaline was given after which, cardiac rhythm was noted. Cardiopulmonary resuscitation was performed for 17 minutes. After resuscitation, her blood pressure was 39/25 mmHg and dopamine infusion (10 Ag kg 1 minute ) was started. The blood pressure increased to 63/56 mmHg. On neurological examination, she was unconscious and there was no response to verbal or noxious stimulation. Bilateral plantar reflexes were weak. Pupil diameter was 4 mm/2 mm and pupillary light reflex was sluggish. She was intubated and put on mechanical ventilation. On electrocardiography, sinus tachycardia, ST segment depression in all derivatives and incomplete right bundle branch block were noted. BJOG: an International Journal of Obstetrics and Gynaecology November 2004, Vol. 111, pp. 1301–1304

Anesthetic practices for patients with preeclampsia or HELLP syndrome: A survey

OBJECTIVE Substantial controversy exists regarding anesthetic management for patients with preeclampsia or hemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome. Experts, researchers, clinicians, and residents in Turkey were surveyed about their practices. MATERIAL AND METHODS Questionnaires were distributed to attendees at a national conference, and they were filled out immediately. Anonymous 10-item paper surveys were administered to both residents and non-residents. Descriptive statistics were used in the analysis. Agreement among ≥75% of the respondents was considered a majority opinion. Surveys with missing responses were used to analyze the non-response bias. The Chi-square test was used for comparisons. A historical cohort of obstetricians-gynecologists was used for comparison with anesthesiologists. RESULTS Of 339 surveys distributed, 288 were returned (84.9% response rate). Among the returned surveys, the completion rate was 96.1%. The job experience in years among clinicians and residents was 9±5 and 3±1, respectively. General anesthesia was still significantly preferred by 36.1% among patients with preeclampsia with platelet counts of ≥100,000/μL. Compared to obstetricians-gynecologists, anesthesiologists more often preferred general anesthesia. With platelet counts of <50,000/μL or eclampsia, most respondents preferred general anesthesia 94.4% for very low platelets and 89.5% for eclampsia. CONCLUSION A preferential trend toward general anesthesia for patients with preeclampsia or HELLP syndrome exists among anesthesiologists in Turkey, particularly for patients with severe thrombocytopenia and/or eclampsia. There exists a need for well-designed and well-executed prospective clinical trials to provide evidence for the best consensus practice.

The Effects of Sevoflurane Anesthesia and Cardiopulmonary Bypass on Renal Function in Cyanotic and Acyanotic Children Undergoing Cardiac Surgery

Background: There are few data on the effects of anesthesia and cardiopulmonary bypass (CPB) on perioperative renal function in children with cyanotic congenital heart disease undergoing open heart surgery. This study aims to investigate the perioperative renal function in cyanotic versus acyanotic children undergoing sevoflurane anesthesia for open heart surgery. Methods: After receiving ethical committee approval, 12 acyanotic patients (preoperative oxygen saturation: SaO2 > 85%) and 12 cyanotic children (SaO2 < 85%) were included. Sevoflurane was administered at concentration levels of 2% before CPB and 1–2% during CPB after standard anesthesia induction. Inorganic fluoride, electrolytes, creatinine, urea nitrogen in serum and urine samples, and N-acetyl-β-d-glucosaminidase (NAG) in urine samples were measured before induction, before CPB, during CPB, after CPB, at the end of surgery, and at 24th h postoperatively. Results: The levels of serum uric acid levels were higher in the cyanotic group (p < 0.05). There were no differences in the levels of serum creatinine and urine creatinine, urea nitrogen, and electrolytes between the two groups. Serum inorganic fluoride levels were always higher in the acyanotic group than in the cyanotic group, but these differences between the groups reached statistical significance at two measurement times (before CPB and end of surgery) (p < 0.05). Urinary inorganic fluoride levels increased with time in both groups. Although urinary NAG increased significantly after the CPB in the cyanotic group, the differences between the two groups did not reach statistical significance. Conclusions: We have concluded that renal function was not affected during open heart surgery with sevoflurane anesthesia, in both cyanotic and acyanotic children.

Evaluation of the stability and stratification of propofol and ketamine mixtures for pediatric anesthesia

The combination of propofol and ketamine is commonly used for total intravenous anesthesia. These drugs can be delivered in different syringes or in the same syringe. We hypothesized that the drugs might separate and different concentrations of each drug could be found in different parts of the syringe during the procedure period when they were mixed in 1 syringe.