Dilek Karaaslan

Preemptive Analgesia in Laparoscopic Cholecystectomy: A Randomized Controlled Study

Abstract:  In pain control after laparoscopic cholecystectomy, subhepatic administration of bupivacaine immediately after the creation of pneumoperitoneum has been shown to be more effective than administration before the withdrawal of the trocars. We aimed to investigate the effect of intraperitoneal bupivacaine administration to the subhepatic area before the creation of the pneumoperitoneum. Eighty patients undergoing elective laparoscopic cholecystectomy under general anesthesia were included in a prospective, randomized study. Patients received 20 mL of 0.5% bupivacaine in the subhepatic area just after intubation, before pneumoperitoneum (group 1), immediately after the creation of the pneumoperitoneum (group 2), just before the removal of the trocars (group 3), or received no local anesthetic (group 4). The degree of the postoperative pain was assessed at 0, 4, 8, 12, and 24 hours after the surgery. The consumption of analgesics (diclofenac sodium) was also recorded. The pain scores and analgesic consumption did not differ among groups 1, 3, and 4. The pain scores of group 2 were lower at each time point compared to the other groups (P < 0.001). Postoperative analgesic consumption in group 2 was reduced compared to the other groups (23.4 ± 35.9 mg vs. 80.0 ± 66.3 mg, P = 0.005 [group 1], 69.6 ± 62.2 mg, P = 0.026 [group 3], and 70.0 ± 59.9 mg, P = 0.022 [group 4]). The subhepatic infiltration of 20 mL of 0.5% bupivacaine offers good postoperative analgesia when applied just after the creation of the pneumoperitoneum, not before the pneumoperitoneum or after the termination of the pneumoperitoneum.

External Jugular Vein Catheterization Using 'Intra-Atrial Electrocardiogram'

Purpose To investigate the reliability of intra-atrial electrocardiogram (ECG) use for external jugular vein (EJV) catheterization. Materials and Methods Patients undergoing open heart surgery in Suleyman Demirel University Hospital between February and June 2006 were included in the study. Using a sterile Seldinger technique, a triple lumen polyurethane central venous catheter was introduced (Certofix® Trio V 720, length 20 cm, 7 French) under intra-atrial ECG guidance. The presence of an increase in P-wave size was recorded. Just after the surgery, a portable chest X-ray was taken. The method was considered to be successful when a change in P-wave could be seen and the catheter was in the superior vena cava, as well as when there was no change in P-wave and the catheter was not in the superior vena cava. Results In six patients (12%), we were not able to advance the guidewire. In the remaining 44 patients, the catheter was inserted without problem. Eight of these 44 catheters were positioned in the innominate vein, with a malposition ratio of 18%. The success rate of external jugular vein cannulation with intra-atrial ECG was 95%. No complications occured related to the EJV cannulation. Conclusion Considering that it is easily accessed without complication, and the malposition is successfully detected by intra-atrial ECG, EJV is a suitable access for central venous cannulation when internal jugular vein (IJV) is not usable.

The role of nitric oxide on the analgesic effect of tramadol

Abstract Aims: The involvement of NO modulation in tramadols mechanism of action is demonstrated indirectly by the alteration of the effect with the use of nitric oxide synthase inhibitor nitroG-L-arginine methyl ester (L-NAME). We aimed to investigate the alterations in serum and spinal cord NO levels following tramadol used alone or in combination with L-NAME or specific neuronal nitric oxide synthase (NOS) inhibitor 7-nitroindazole (7-NI), beside the changes in tail immersion reponses. Methods: Seventy-seven rats were randomly allocated into 7 groups. Group 1: sham group; Group 2: no drug; Group 3: tramadol 10 mg kg−1; Group 4: L-NAME 5 mg kg−1 + tramadol 10 mg kg−1; Group 5: L-NAME 10 mg kg−1 + tramadol 10 mg kg−1; Group 6: 7-NI 50 mg kg−1 + tramadol 10 mg kg−1; Group 7: 7-NI 100 mg kg−1 + tramadol 10 mg kg−1. Apart from Group 1, all the animals were exposed to a tail immersion test before medications (baseline) and 15 min after the tramadol injection. Following the tail-immersion test, a blood sampl...

Effectiveness of sevoflurane or propofol combined with remifentanil for intubation without muscle relaxants

Objectives: We aimed to investigate the reliability of the hypothesis that whether sevoflurane-remifentanil could offer equivalent intubation conditions with propofol-remifentanil in the absence of muscle relaxants. Materials and methods: Total of 80 patients of ASA grades I and II scheduled for elective surgery were randomly allocated into two groups. Patients in group I received an infusion of remifentanil 1 mcg/kg/min and inhalation of sevoflurane 8% until the Bispectral index (BIS) being less than 60. Patients in group II received a co-infusion of remifentanil 1 mcg/kg/min and propofol 1 mg/kg/ min until BIS is <60. Intubation was attempted when BIS is <60. Intubation conditions were assessed as optimal, good, marginal, and poor using jaw relaxation, vocal cord opening, and limb movement. The heart rate and mean arterial blood pressure (ABP) were recorded before and during the induction, and thereafter, 1, 2 and 5 minutes following intubation. The time for BIS to be <60 was recorded. Results: Optimal intubation conditions were achieved more often in group II than in group I (90% versus 45%, p=0.002). The ratio of patients showing optimal or good intubating conditions was 80% in group I and 100% in group II (p=0.035). Time required for BIS to be <60 was shorter in group II than in group I (47.1±27.2 sec vs. 111.9±60.6 sec, p<0.001). In both groups, there was a decrease in heart rate and mean ABP compared to baseline. Conclusion: Under BIS monitorization, propofol-remifentanil combination offered better intubation conditions and shorter anesthesia induction period compared with sevoflurane-remifentanil. J Clin Exp Invest 2011;2(2):13843

Artroskopik girişimlerde ünilateral spinal levobupivakain, levobupivakain-fentanyl ve levobupivakain-morfin kombinasyonlarının analjezik ve hemodinamik etkilerinin karşılaştırılması

Objectives: Aim of the study was to compare the analgesic and hemodynamic effects of levobupivacaine, levobupivacaine-fentanyl, levobupivacaine-morphine for arthroscopic knee surgery under unilateral spinal anesthesia. Methods: A total of 44 ASA I/II patients scheduled for arthroscopy were included in the study. After prehydration patients kept in a lateral position on the nondependent side. Spinal puncture was performed at L3n4/L4n5 intervertebral space. Patients divided into three subgroups: Group L (n=14) received 0.5% levobupivacaine 1 ml+1 ml distilled water; Group LF (n=15), 25 mcg fentanyl (0.5 ml)+0.5 ml distilled water; and Group LM (n=15), 0.01 mg morphine (0.5 ml)+0.5 ml distilled water. Patients remained in that position for 15 minutes. Blood pressure and heart rate were recorded before and 1st, 3rd, 5th, 10th, 15th, 20th and 30th minutes after the block and every 15 minutes during the operation. Motor blockade and sensorial level, side effects, motor block regression time (MBRT), first urination time and first analgesic need (FAN) were recorded. Results: Group LM had the longest MBRT, but difference with other groups did not reach to a significant level (p>0.05). Group LM had significantly longer FAN time compare with other groups (p

Unusual obstruction of nasotracheal tube

SIR—General anesthesia is often needed to provide dental care to children and for mentally handicapped patients. Nasal intubation may be preferred to offer to the dentist a large exposure in the mouth, but sometimes it brings some unusual complications. A 13-year-old female patient with mental retardation was scheduled for dental extraction under general anesthesia. After induction with thiopental and succinylcholine, a wire reinforced flexible 6.5 mm tube was easily inserted through the nose and placed into the trachea under direct vision using Magill forceps. After inflation of the cuff, an extremly high airway pressure prevented ventilation of the patient. The cuff was deflated but inflation of the lungs remained impossible. Any visible obstruction related to the tube was not seen. Then the patient was extubated and the lungs were easily inflated using a facemask. Nasotracheal intubation was reperformed via the same nares using another tube. The examination of the first tube revealed total obstruction of the lumen (Figure 1). When the tube was cut a corn grain appeared to be responsible for the obstruction (Figure 2). Conversation with the parents revealed that they had eaten corn about 1 week previously. Children or mentally handicapped adults are prone to insert foreign bodies into the nose or the ear. Many authors reported nasal foreign bodies discovered incidentally on routine dental radiographs (1–2). The foreign body must be radiopaque by its nature or from the encasing calculus-like material in order to be visible on dental radiographs (3). In our department of dentistry, orthopantomographic and periapical imagings are routinely required for patients with dental caries, but as this patient was extremely uncooperative it was not possible to perform a radiographic examination. Our patient had inserted the corn grain in the nose about 1 week ago, insufficent time for the formation of calcified material, and it would not be visible on the radiograph. Mayumi et al. (4) reported a case in which the nasotracheal tube was obstructed completely by a dislodged bone fragment after nasotracheal intubation. As in the current case, if this foreign body had not totally obstructed the tube lumen, it could have been transported into the trachea or perhaps to the bronchial tree. The authors were reminded that when normal ventilation is impossible immediately after nasotracheal intubation, the only method to improve the situation is to remove the tube, keeping in mind that the airway obstruction may be the result of a dislodged foreign body. In conclusion, if children or mentally handicapped patients are scheduled for an oral surgical procedure under general anesthesia, the diagnosis of a nasal foreign body is important because the foreign body may be transported into the trachea during nasal intubation. Careful examination of these patients may prevent further complications. Dilek Karaaslan* Tulay Tunçer Peker* Ays e Ilknur Karaduman† Nuh Tufan Alt ıN D I Ş* Esin Oğuzhanoğlu* *Department of Anesthesiology, Suleyman Demirel University School of Medicine, Isparta, Turkey †Department of Oral and Maxillofacial Surgery, DDS, Süleyman Demirel University School of Dentistry, Isparta, Turkey (email: dilek@med.sdu.edu.tr) Figure 2 The corn grain responsible of the intubation tube obstruction.