Burak Onan

The Effects of Gabapentin on Acute and Chronic Postoperative Pain After Coronary Artery Bypass Graft Surgery

OBJECTIVES The purpose of this study was to evaluate the analgesic effects of perioperative gabapentin on postoperative acute and chronic pain after coronary artery bypass graft (CABG) surgery with median sternotomy and internal mammary artery harvesting. DESIGN A double-blind randomized clinical study. SETTING A single-academic hospital. PARTICIPANTS Patients with ischemic heart disease who were scheduled to undergo CABG surgery. INTERVENTIONS Forty patients were allocated randomly into 2 groups; the gabapentin group (n = 20) received 1.2 g/d of oral gabapentin before and for 2 days after surgery, and the placebo group (n = 20) received a placebo capsule instead. The primary outcome was to evaluate the effects of gabapentin on acute and chronic pain after surgery. The postoperative evaluation included the assessment of pain at rest and when coughing, intravenous tramadol usage, postoperative morbidities, and side effects of gabapentin. Postoperative analgesia at 6, 12, 18, 24, 48, and 72 hours after extubation and at discharge was evaluated with the visual analog scale. The assessment of postoperative pain at the 1- and 3-month follow-ups was performed using a numeric rating scale. MAIN RESULTS Postoperative pain scores at 1, 2, and 3 days were significantly lower in the gabapentin group when compared with the placebo group (p < 0.05). Pain scores at 1 and 3 months postoperatively were lower in the gabapentin group than in the placebo group (p > 0.05). Consumption of intravenous tramadol given as rescue analgesic within 24 hours after extubation in the gabapentin group was 99.0 ± 53.8 mg versus 149.4 ± 72.5 mg in the placebo group (p < 0.05). There were no differences in the incidence of side effects and time to extubation between the groups. CONCLUSIONS Gabapentin significantly reduced the intensity of pain and tramadol consumption in the early postoperative period after CABG surgery. Pain scores at 1 and 3 months after surgery were low in both groups, with no significant difference between the groups.

Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience

Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. In this retrospective study, we present our 10-year experience in the management and clinical outcome of 4205 cases with chest trauma associated with blunt and penetrating injuries in a level I trauma hospital in Turkey. In 66% of the cases, blunt injury mostly related to traffic accidents was the cause of chest trauma. Additional organ injuries were found in 35% (n=1471). Conservative treatment was administered for most patients. Tube thoracostomy was administered in 40% of all cases, whereas thoracotomy was performed in 6% (n=252), of which 209 were early interventions (P=0.001). The morbidity rate in all victims was 25.2%. The mortality rate was 9.3% for all patients and was 6.8% in blunt, 1.4% in penetrating, and 17.7% in associated organ injuries. Mortality and injury severity score (ISS) increased in patients having early surgery (P=0.001). Although most patients could be managed with conservative approaches, early thoracotomy was required in some cases. We believe that urgent hospital admission, early diagnosis, and multidisciplinary approach are very important to improve outcome.

Cardiac Tamponade and Pulmonary Embolism as a Complication of Percutaneous Vertebroplasty

Percutaneous vertebroplasty is a useful and safe therapeutic intervention to stabilize vertebral fractures. Rarely, cement leakage into the paravertebral venous system may result in embolization of its particles into the right cardiac chambers and pulmonary artery. We experienced a case of a 64-year-old woman who was diagnosed through echocardiography as having cardiac tamponade. Previously, the patient was treated for pulmonary cement embolization after percutaneous vertebroplasty. Prompt diagnosis and urgent surgery, in which a few linear cement particles of 1-cm to 2-cm long were discovered within the pericardial space, which resulted in a favorable outcome.

Cilostazol, a Type III Phosphodiesterase Inhibitor, Reduces Ischemia/Reperfusion-Induced Spinal Cord Injury

BACKGROUND Spinal cord injury is still a devastating complication after surgical repair of thoracoabdominal aortic pathologies. In this study, we investigated the protective effect of cilostazol, a type III phosphodiesterase inhibitor, against ischemia/reperfusion (I/R)-induced spinal cord injury in rats. METHODS Twenty-four rats were assigned to 3 experimental study groups: the control group (sham operation, n = 8); the ischemia group (nontreated, n = 8), which underwent aortic occlusion without pharmacologic intervention; and the cilostazol-treated group (n = 8), which received 20 mg/kg cilostazol per day orally for 3 days before spinal ischemia. All animals underwent a 45-minute period of spinal cord ischemia via clamping of the abdominal aorta between the left renal artery and the aortic bifurcation; removal of the aortic clamp was followed by reperfusion. Neurologic status was assessed before spinal ischemia and at 48 hours after the operation. All animals were sacrificed at 48 hours after the operation. Spinal cords were harvested for histopathologic examination and biochemical analyses for the malondialdehyde (MDA) level and superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) activities. RESULTS Tarlov scores at postoperative hour 48 tended to be higher in the cilostazol-treated group than in the nontreated ischemia group (mean ± SD, 3.66 ± 0.40 versus 2.32 ± 0.80; P = .08). Spinal cord tissue MDA levels (per gram protein) were lower in the cilostazol-treated group than in the nontreated ischemia group (0.27 ± 0.01 mmol/g versus 0.33 ± 0.04 mmol/g, P = .026), and the cilostazol-treated group had higher activities of tissue SOD (519.6 ± 56.3 U/g versus 438.9 ± 67.4 U/g, P = .016) and GSH-Px (4.07 ± 1.37 U/g versus 3.21 ± 1.02 U/g, P = .47) than the nontreated ischemia group. Histopathologic analyses demonstrated that cilostazol treatment attenuated I/R-induced cellular damage. CONCLUSION Administration of cilostazol before spinal cord ischemia reduced neurologic injury and produced clinical improvement by attenuating oxidative stress in this rat spinal cord I/R model.

Sequential In Situ Left Internal Thoracic Artery Grafting to the Circumflex and Right Coronary Artery Areas

BACKGROUND Several bilateral internal thoracic artery (ITA) grafting patterns have been proposed to enhance 3-vessel coronary artery revascularization. We present the outcomes of sequential in situ left ITA grafting to the circumflex and right coronary artery (RCA) areas. METHODS Between January 2001 and September 2007, 102 patients with 3-vessel coronary artery disease underwent arterial myocardial revascularization with bilateral in situ ITA grafts. The circumflex and distal RCA branches were revascularized sequentially with the left ITA. The left anterior descending artery area was grafted with the right ITA. RESULTS Ninety-nine patients (97.0%) were monitored for 37.2 ± 2.9 months, and 77 (75.4%) underwent postoperative coronary imaging after 27.8 ± 5.8 months. The bilateral ITA grafts were 97.1% patent (FitzGibbon grade A+B) overall. The sequential anastomoses of the left ITA to the circumflex and RCA territories were 96.7% patent overall, with competitive flow (FitzGibbon grade B) in 3 patients. The patency rates of sequential anastomoses to the circumflex and RCA branches were 98.0% and 95.0%, respectively. The right posterolateral and right descending posterior artery anastomoses were 91.8% and 100% patent, respectively. The in situ right ITA grafts to the left anterior descending artery area were 98.0% (FitzGibbon grade A+B) patent overall. Angina recurred in 1 patient (0.9%) 6 months after the operation. Percutaneous coronary interventions were performed in 3 patients (3.8%). No cardiac deaths occurred during the follow-up period. CONCLUSIONS Sequential in situ left ITA grafting to the circumflex and RCA areas yields acceptable midterm results in selected patients with 3-vessel disease.

Cerebral Perfusion During Cardiopulmonary Bypass in Children: Correlations Between Near‐Infrared Spectroscopy, Temperature, Lactate, Pump Flow, and Blood Pressure

Near-infrared spectroscopy (NIRS) is a noninvasive modality to monitor regional brain oxygenation (rSO(2) ). In this study, we aimed to investigate the correlation between cerebral rSO(2) and lactate, pump flow, hematocrit, pCO(2) , and mean blood pressure (MBP) during cardiopulmonary bypass (CPB). Between March and September 2011, 50 pediatric patients who underwent congenital heart surgery were enrolled into the study. Ages ranged from 6 days to 168 months (median 14 months). A NIRS sensor (Somanetics 5100B, Troy, MI, USA) was placed on the right forehead of patients. CPB period was divided into five stages: 1-at the beginning of CBP, 2-cooling at 32°C, 3-at final hypothermic temperature, 4-rewarming at 32°C, 5-before weaning from CPB. Data collection included measurements of each parameter at five stages of CPB. Data were analyzed using multivariate analysis within groups and Spearmans correlation to test association between parameters. Lactate levels increased significantly from stage 1 to stage 5 during CPB (P < 0.05). There was no significant correlation between cerebral rSO(2) and MBPs, pump flows, hematocrit, or pCO(2) during CPB. Cerebral rSO(2) levels showed changes between the stages; there was a significant increase during cooling period, compared to stage 1 (P < 0.05). Significant changes during cooling stage did not happen for other parameters. At stage 3, there was a negative correlation between lactate level and MBP. At stage 4, there was no significant change in cerebral rSO(2) levels despite decreased MBP. At the warming stage, low MBPs, but normal rSO(2) values, are observed despite increased pump flows. Increased rSO(2) levels despite insignificant changes at other parameters during the cooling stage of CPB may show that optimal pump flow with adequate intravascular volume may provide effective cerebral perfusion even without changes in MBP. Considering normal rSO(2) values during CPB in this study, it may be speculated that brain protection can be assessed by using NIRS and applying a standard bypass protocol.

Pulmonary Artery Pseudoaneurysm After a Vascular Access Port Catheter Implantation

Pulmonary artery pseudoaneurysm is an unusual complication of surgically implantable central venous port catheters. We experienced a case of a 57-year-old man with gastric malignancy, in which a port catheter had been previously implanted for chemotherapy. Because of a puncture site that was also medial for the subclavian vein, the catheter tip fractured between the first rib and the clavicle, and embolized in the left pulmonary artery, which caused a 5 x 4 cm pseudoaneurysm that mandated surgical resection with a lobectomy. The diagnostic work-up and a review of the literature are presented.

Extracorporeal Life Support Experiences of a New Congenital Heart Center in Turkey

Extracorporeal life support (ECLS) provides mechanical support following cardiac surgery when respiratory and cardiac failure occurs. We retrospectively reviewed medical records of patients who needed ECLS at a new congenital heart center in Turkey. Between December 2009 and February 2012, 616 congenital heart operations were performed. A total of 13 patients (seven female) underwent ECLS. The ages of the patients ranged between 16 days and 33 years. There were two neonatal, seven infant, three pediatric, and one adult congenital cases. Medos DPII ECLS system was used in all patients. Mean duration of ECLS was 6.2 ± 5.8 days (ranged from 29 h to 24 days). While central vascular access with aorta and right atrial cannulation was used in 11 patients, neck vessels were used in the other patients. Four patients (30.7%) weaned successfully from ECLS (two infant, two pediatric cases). Three of them had ECLS intraoperatively. In all patients, two (15.4%) were discharged from the hospital. One of them had mild neurologic deficit. Bleeding from the surgical and cannulation sites was the most common complication. Thrombus was detected in pump head and changed uneventfully in three patients. Arterial pH and lactate levels at the beginning of ECLS were significantly lower in patients who were successfully weaned from ECLS than nonsurvivors (P = 0.04 and P = 0.02, respectively). ECLS can be a lifesaving modality in the perioperative period. It may be more beneficial if ECLS is used before the development of severe acidosis and high lactate levels.

Peroneal Nerve Palsy Caused by Popliteal Pseudoaneurysm in A Child with Hereditary Multiple Exostosis

A 12-year-old boy with a family history of hereditary multiple exostosis presented with a 3-week history of progressive knee swelling. The clinical examination revealed drop foot and a loss of extension in his right knee. Evaluation with color duplex ultrasonography, computed tomography angiography, and magnetic resonance imaging revealed a popliteal artery pseudoaneurysm associated with exostosis from the distal femur. This patient was diagnosed as having peroneal neuropathy caused by popliteal artery pseudoaneurysm compressing the nerve in the right popliteal fossa. The pseudoaneurysm was repaired primarily, and the exostosis was excised during the operation. Pain and knee contracture resolved after surgery. The patient was then referred to physical therapy for the management of drop foot.

Effects of Thoracic Epidural Anesthesia on Flow and Endothelium of Internal Thoracic Artery in Coronary Artery Bypass Graft Surgery

OBJECTIVES The internal thoracic artery (ITA) is the preferred conduit for coronary artery bypass graft (CABG) surgery. The authors investigated whether thoracic epidural anesthesia (TEA) as an adjunct to general anesthesia (GA) can increase the blood flow of the ITA. DESIGN A prospective randomized study. SETTING A university hospital. PARTICIPANTS Patients with ischemic heart disease. INTERVENTIONS Thirty patients scheduled for elective CABG surgery were randomized to receive either GA (n = 15) or GA + TEA (n = 15) after receiving institutional review board approval. Demographics showed similarity between the groups. The epidural catheter was inserted in the thoracic region between T1 and T5 levels. In the GA + TEA group, the patients received a 20-mg bolus of 0.25% bupivacaine through epidural catheters 1 hour before surgery, and this was followed by the infusion (20 mg/h) of 0.25% bupivacaine. In all patients, ITA free blood flow was measured before cardiopulmonary bypass and without the administration of any vasodilatory agent. A short segment of ITA was excised for histologic examination; immunocytochemistry analysis was performed using antirabbit polyclonal VEGF antibody, rabbit polyclonal inducible nitric oxide synthase (i-NOS) antibody, and adenosine anti-A2B receptor antibody. The immunoreactivity rates then were evaluated. MAIN RESULTS The mean ITA free flow in the GA + TEA group was significantly higher than in the GA group (56.0 ± 9.0 mL/min v 39.6 ± 14 mL/min, p = 0.001). Immunostaining intensity in the sections after incubation with each primary antibody increased in the GA + TEA group compared with the GA group. CONCLUSIONS The results of this study indicated that TEA increased ITA free blood flow significantly via increased VEGF, i-NOS, and adenosine-A2B receptor expressions. Therefore, the use of TEA as an adjunct to GA might be considered as an alternative to vasoactive agents for increasing ITA flow in CABG surgery.