Cagla Bali

Effect of low dose dexmedetomidine premedication on propofol consumption in geriatric end stage renal disease patients

BACKGROUND AND OBJECTIVE Sedation in dialysis dependent end-stage renal disease patients requires caution as a result of performing high doses of sedatives and its complications. Multidrug sedation regimens might be superior and advantage on lesser drug consumption and by the way adverse events which occur easily in end-stage renal disease patients. We evaluated the effects of dexmedetomidine premedication on propofol consumption, sedation levels with Observers Assessment of Alertness and Sedation scores and the bispectral index and the hemodynamic changes, potential side effects in geriatric patients with end-stage renal disease who underwent hip fracture surgery under spinal anesthesia. METHOD In this randomized, controlled, double-blind study 60 elderly patients (age≥65 years) with end-stage renal disease and hip fracture scheduled for anterograde femoral intramedullary nailing were assigned to groups that received either intravenous saline infusion (Group C) or dexmedetomidine 0.5μg/kg/10min infusion for premedication (Group D). All the patients received propofol infusion after the induction of the spinal anesthesia. RESULTS Total propofol consumption, propofol dose required for targeted sedation levels according to Observers Assessment of Alertness and Sedation scores and bispectral index levels, recovery times were significantly lower in Group D (p<0.001). The time to reach to Observers Assessment of Alertness and Sedation score 4 and to achieve bispectral index≤80 was significantly lower in Group C compared with Group D (p<0.001). Adverse events were similar in both groups. CONCLUSION Dexmedetomidine premedication lowers intraoperative propofol consumption to maintain targeted level of sedation. Therefore low dose dexmedetomidine premedication in addition to propofol infusion might be an alternative in geriatric patients with end-stage renal disease for sedation.

Anesthesia management and sugammadex experience in a neonate for Galen vein aneurysm

Galen vein aneurysm (GVA) is a symptomatic cerebrovascular malformation in neonates, and interventional aneurysm treatment is gaining popularity in this patient group.We aimed to present our anesthesia management and experience with sugammadex in a neonate who underwent endovascular intervention for GVA. An 11-day-old term newborn was referred to the anesthesia clinic for GVA (Fig. 1). Echocardiography showed right ventricular and pulmonary arterial dilatation, pulmonary hypertension, 3° to 4°TY, and ejection fraction of 55% with normal laboratory values. Anesthesia induction was achieved by the inhalation of sevoflurane, 0.6 mg/kg rocuronium, and 1 μg/kg fentanyl, and maintenance was achieved by 1.5% sevoflurane with 50%/50% oxygen-air. Jugular vein catheter and arterial line were applied. Dexamethasone 0.5 mg/kg, mannitol 0.5 mg/kg, furosemide 1 mg/kg, and ranitidine 1 mg/kg were administered preoperatively. Sugammadex 2 mg/kg was administered initially, and 1 mg/kg additional dose was used to achieve proficiency in respiratory effort. Then the patient was extubated without any complication and transferred to the neonatal intensive care unit. Patients with GVA have an increased risk of cerebral ischemia and infarction during anesthesia. For this reason, agents should be carefully selected. Medications protecting hemodynamics and reducing cerebral metabolic rate and oxygen consumption should be given preference. According to studies, we preferred sevoflurane due to its pharmacokinetic properties for induction and maintenance of anesthesia [1]. We also avoid using nitrogen to reduce the risk of small air embolism. Anesthesiamanagement should also aim to provide andmaintain cardiovascular stability and prevent sudden volume shifts in circulation. Another issue to consider during anesthesia management of these cases is hypothermia. These patients are administered great amounts of fluids as required by endovascular procedures. Care should be taken to administer these fluids after heating to an adequate temperature, to warm up patients. The nextmain stage of anesthesia is the extubation phase in aneurysm procedures. A smooth extubation plan to reduce complication such as hypertension and obtain a full recovery to assess the neurologic status at the operating table should be themain aim of the anesthesiologist. During interventional aneurysmprocedures,

Inappropriate Use of Anticoagulant Drugs in Older Adults

I or inappropriate drug use in older adults is a common and serious problem that can increase mortality and morbidity as a result of deterioration of bodily functions (Fu, Liu, & Christensen, 2004). Inappropriate use of anticoagulant drugs has recently gained interest due to the potential risk of hemorrhage. Warfarin (Coumadin®), which is used for atrial fibrillation, mechanical heart valves, and ischemic attacks, is the most commonly implicated drug of emergency hospitalizations for adverse drug reactions in older adults. Approximately 50% of these hospitalizations involve adults older than 80, with hemorrhage being the primary adverse event (Budnitz, Lovegrove, Shehab, & Richards, 2011). Inappropriate use of warfarin can cause serious hemorrhage in the intracranial area and gastrointestinal system, as well as in the respiratory and genitourinary systems, with risk for fatality. Interestingly, anticoagulant-related major hemorrhage is observed more frequently in older patients (age >75) than in younger patients (Levine, Raskob, Beyth, Kearon, & Schulman, 2004). The mechanism of how aging causes hemorrhage is unknown, but increasing evidence supports that age is an independent factor for major hemorrhage (Levine et al., 2004). Although novel anticoagulant agents (e.g., dabigatran [Pradaxa®], rivaroxaban [Xarelto®], and apixaban [Eliquis®]) have long been anticipated as alternatives to warfarin, the lack of reversal agents, increased risk of gastrointestinal bleeding, and limited evidence in the older adult population are serious concerns (Ogbonna & Clifford, 2013). Inappropriate drug use has also been observed among hospitalized patients and can affect length of stay (Onder et al., 2003). We present one such case from our hospital. An 82-year-old man was hospitalized to undergo total knee arthroplasty. His medical history revealed atrial fibrillation, with irregular use of metoprolol succinate 50 mg and warfarin sodium 5 mg; however, the patient stated he had not used either medication in the previous 5 days. Preoperative tests, including international normalized ratio (INR), were within normal limits. The chosen anesthetic plan was combined spinal/ epidural anesthesia. The operation was completed uneventfully. A continuous epidural infusion of bupivacaine 0.25% was administered for postoperative analgesia. The epidural catheter was scheduled to be removed on the third postoperative day; however, catheter removal was delayed due to an INR of 4.2. The patient was closely monitored for signs of spinal hematoma. Repeated, detailed, and insistent questioning by nurses revealed that he had taken warfarin sodium 5 mg tablets for 3 days during the postoperative period, assuming it to be an analgesic. His cognitive functions were normal, but he was resistant to cooperate. He did not realize the importance of the potential complications due

Pneumorrhachis and Pneumocephalus with Severe Chest Pain Symptom: A Rare Complication of Epidural Steroid Injection

Dear Editor, Pneumorrhachis and pneumocephalus are unusual complications of inadvertent dural puncture. We present the case of pneumorrhachis and pneumocephalus in a patient with lumbar spinal stenosis who was performed epidural steroid injection by using loss of resistance technique to air. A 37-year-old man with the history of spinal stenosis, low back pain, bilateral leg pain, and neurogenic claudication was performed epidural steroid (80 mg metil prednisolone) injection in another pain clinic. He complained of severe chest pain and headache aproximately 1 hour after epidural injection in the recovery room. The anesthesiologist who attempt epidural steroid …

Sugammadex given for rocuronium-induced neuromuscular blockade in infants: a retrospectıve study

STUDY OBJECTIVE To evaluate the efficacy and safety of sugammadex in reversing profound neuromuscular block induced by rocuronium in infant patients. DESIGN Retrospective observational study. SETTING University teaching hospital. PATIENTS Twenty-six infants (2-12 months of age; 3-11 kg) with an American Society of Anesthesiologists classification I, II, or III who were scheduled to undergo neurosurgical procedures were included in the study. INTERVENTIONS Anesthesia was induced with 5 mg/kg thiopental, 1 μg/kg fentanyl and 0.6 mg/kg rocuronium. Sevoflurane was administered to all patients after intubation. METHODS The neuromuscular block was monitored with acceleromyography using train-of-four (TOF) stimuli. Patients received additional doses of rocuronium to maintain a deep block during surgery. If profound neuromuscular block (TOF, 0) persisted at the end of the surgery, 3mg/kg sugammadex was administered. MEASUREMENTS The demographic data, surgeries, and anesthetic agents were recorded. The time from sugammadex administration to recovery of neuromuscular function (TOF ratio, >0.9) and complications during and after extubation were also recorded. MAIN RESULTS Twenty-six infants who had a deep neuromuscular block (TOF, 0) at the end of surgery received 3 mg/kg sugammadex. The mean recovery time of the T4/T1 ratio of 0.9 was 112 seconds. No clinical evidence of recurarization or residual curarization was observed. CONCLUSIONS The efficacy and safety of sugammadex were confirmed in infant surgical patients for reversal of deep neuromuscular block induced by rocuronium.

Congenital insensitivity to pain: how should anesthesia be managed?

Özmete Ö, Şener M, Bali Ç, Çalışkan E, Arıboğan A. Congenital insensitivity to pain: How should anesthesia be managed? Turk J Pediatr 2017; 59: 87-89. Congenital insensitivity to pain syndrome is a rare, sensorial and autonomic neuropathy characterized by unexplained fever, insensitivity to pain and anhidrosis. Patients may require anesthesia even for minor surgical procedures due to mental retardation and trauma arising from self- mutilating behavior. A child diagnosed with congenital insensitivity to pain syndrome was scheduled for gastric endoscopy under sedation due to suspected ingestion of a household cleaning disinfectant. Deep sedation was achieved, and spontaneous respiration was maintained. We did not encounter any complications. There is limited data regarding the safe anesthesia management in these patients because of the rarity of the disease. Therefore, we think that more clinical experience, case reports and studies are needed to establish the appropriate anesthesia management.

A patient with Churg-Strauss syndrome complicated with pulmonary hemoptysis

Churg-Strauss Syndrome (CSS) is an extremely rare necrotizing vasculitis characterized by allergic rhinitis, asthma, and eosinophilia [1]. Skin, lung, and kidney involvement is usually more pronounced, but cardiovascular, gastrointestinal, and central nervous systems may also be involved [1]. Overall survival in this syndrome has been improved dramatically by the early use of corticosteroids and immunosuppressive drugs [2]. Anesthesia management of the patients with CSS is important owing to airway hypersensitivity and possible multiple-organ dysfunctions. Unfortunately, there are a few reports related to anesthesia management of CSS in the literature. A 25-year-old male patient weighing 67 kg was evaluated under urgent conditions for bronchial arteriography and embolization for massive hemoptysis. He had a history of asthma and allergic rhinitis since childhood and had CSS diagnosis for 2 years. He had also undergone mitral valve repair for mitral valvular insufficiency approximately 3 months ago. After the diagnosis, he was treated with methyl prednisolone for a year and discontinued it; he had been using budesonide-formoterol inhaler, metoprolol 50 mg, and ramipril 5 mg since then. On physical examination, he had bilateral diffuse rhonchi and rales, and otherwise, systemic examination was normal. Airway evaluation demonstrated a Mallampati score of I. Laboratory tests were all normal except for eosinophilia in complete blood count. Echocardiogram showed left ventricular hypertrophy and global hypokinesis, with a left ventricular ejection fraction of 54%. Anesthesia induction was performed by midazolam 2 mg, propofol 100 mg, sevoflurane 3%-4%, fentanyl 100 μg, and rocuronium 35 mg, and he was then intubated slightly. Anesthesia maintenance was achieved by sevoflurane (1%-2%) in the mixture of 50%/ 50% oxygen-nitrogen. Bronchial angiography indicated irregularities and active bleeding from both right and left bronchial arteries (Figure). Embolization procedure was performed successfully to stop bleeding. The procedure lasted for 1 hour, and a total of 45 mg rocuronium was

Protective Effect of Curcumin on Carbapenem-Resistant Escherichia coli–Induced Lung Injury in Rats

Curcumin has remarkable anti-inflammatory and antioxidant properties. The aim of this study was to investigate the protective effects of curcumin on a rat model of carbapenem-resistant Escherichia coli–induced acute lung injury (ALI). Thirty-two rats were randomly allocated to 4 groups to induce an ALI: negative control group (rats not infected with E coli with no antibiotic treatment), positive control group (rats infected with E coli with no antibiotic treatment), imipenem group (rats infected with E coli that received intraperitoneal injection of imipenem), and the imipenem+curcumin group (rats infected with E coli that received intraperitoneal injection of imipenem and were fed on curcumin).The rats were killed, and lung tissues samples were harvested for biochemical analyses and histopathologic examination. Total antioxidant status (TAS), total oxidant status (TOS), tumor necrosis factor α (TNFα), and interleukin-6 (IL6) were measured. TOS increased in the positive control group (P < 0.001) and decre...

Anesthesia management of a patient with Jervell and Lange-Nielsen syndrome

The success of sedation forMRIwasmeasured by 2 factors: (a) the safety without any adverse events and (b) the effectiveness of the procedure completion. The main difficulties were keeping a profound sedation with hemodynamic and respiratory stability and the limiting access to the patient during the exam. Therefore, the appropriate drugs needed to be selected and titrated to achieve these objectives. Dex was a potent, highly selective α2-adrenoreceptor agonist, declared by the American Society of Anesthesiologists to be a sedative [2], and provided profound levels of sedationwithout affecting cardiovascular and respiratory stability, in contrast to other hypnotics such as propofol [3]. InMRI, Dex was used only for pediatric patients [4]. Candiotti et al [4] showed that the use of Dex for procedures requiring monitored anesthesia care was safe and superior to the combination of midazolam and fentanyl. Arain and Ebert [5] showed that Dex provided a better sedation profile than propofol. To Mahmoud et al [6], Dex might be the preferred drug for anesthesia during MRI in children with a history of severe OSA and offered benefits to children with sleep disordered breathing. The problem was particularly worse in patients with OSA because they were sensitive to the respiratory depressant effects of sedative and hypnotic drugs and were especially vulnerable to the development of pharyngeal hypotonia with upper airway obstruction during sedation [7,8]. In contrast to other sedative drugs, Dex provided a natural sleep and pledged an effective sedation, without significant central and cardiorespiratory depressant activity [6,7]. These advantages made Dex an attractive drug for sedating patients with OSA for MRI [6]. As some authors reported that Dex did not affect RR, SpO2, and EtCO2 [9], however, some respiratory complications such as irregular respiration, apnea, slight hypoxemia, and hypercapnia were reported with large and rapid initial loading doses (over 2 minutes) [10]. Despite the safety profile of Dex, any sedative agent could result in deleterious cardiorespiratory effects, so appropriate monitoring, equipment and easy access to medications were recommended. In summary, Dex could be a favorable sedative drug for MRI scanning in claustrophobic patients with OSA. Further research and experience were required for procedural sedation during radiological imaging.