Dusica Simic

The effects of different anesthesia techniques on free radical production after tourniquet-induced ischemia-reperfusion injury at children's age.

BACKGROUND/AIM Reperfusion of previously ischemic tissue leads to injuries mediated by reactive oxygen species. The aim of the study was to investigate the effects of different anesthesia techniques on oxidative stress caused by tourniquet-induced ischemia-reperfusion (IR) injury during extremity operations at childrens age. METHODS The study included 45 patients American Society of Anesthesiologists (ASA) classification I or II, 8 to 17 years of age, undergoing orthopedic procedures that required bloodless limb surgery. The children were randomized into three groups of 15 patients each: general inhalational anesthesia with sevoflurane (group S), total intravenous anesthesia with propofol (group T) and regional anesthesia (group R). Venous blood samples were obtained at four time points: before peripheral nerve block and induction of general anesthesia (baseline), 1 min before tourniquet release (BTR), 5 and 20 min after tourniquet release (ATR). Postischemic reperfusion injury was estimated by measurement of concentration of malondialdehyde (MDA) in plasma and erythrocytes as well as catalase (CAT) activity. RESULTS Plasma MDA concentration in the group S was significantly higher at 20 min ATR in comparison with the groups T and R (6.78 +/- 0.33 micromolL-1(-1) vs. 4.07 +/- 1.53 and 3.22 +/- 0.9. micromolL-1(-1), respectively). There was a significant difference in MDA concentration in erytrocythes between the groups S and T after 5 min of reperfusion (5.88 +/- 0.88 vs. 4.27 +/- 1.04 nmol/mlEr, p < 0.05). Although not statistically significant, CAT activity was slightly increased as compared to baseline in both groups S and R. In the group T, CAT activity decreased at all time points when compared with baseline, but the observed decrease was only statistically significant at BTR (34.70 +/- 9.27 vs. 39.69 +/- 12.91 UL-1, p < 0.05). CONCLUSION Continuous propofol infusion and regional anesthesia techniques attenuate lipid peroxidation and IR injury connected with tourniquet application in pediatric extremity surgery.

The current place of nitrous oxide in clinical practice An expert opinion-based task force consensus statement of the European Society of Anaesthesiology

Nitrous oxide (N2O) has been used for years as an essential part of general anaesthesia. During the past few decades, however, its use in general anaesthesia has steadily declined. Parallel to this evolution, we witness a growing interest in the use of N2O by nonanaesthesiologists, mainly as a sedative and adjuvant for pain therapy during procedural interventions.1–4 In line with this paradigm shift, heated debates, frequently blurred by strong emotional viewpoints, are questioning the current place of N2O during anaesthesia and during procedural sedation.5 In an attempt to search for up-to-date answers to these issues, the European Society of Anaesthesiology (ESA) convened a number of clinical experts to debate specifically on the following questions. 1. What is the place of N2O in todays perioperative anaesthesia management? 2. What is the place of N2O in procedural analgesia and sedation? 3. Is administration of N2O associated with a health risk for patients and/or providers? Members of the task force consisted of the chairs of the ESA Scientific Committee and Research Committee, and the chairs of the scientific subcommittees on Pharmacology, Paediatrics, and Monitoring, Ultrasound and Equipment. In addition, Western and Eastern European key opinion leaders on the use and place of N2O in adult and paediatric anaesthesia were asked to join the task force. The present consensus statement is the result of an intensive debate based on the available literature and the expert opinion of the task force members.

Unpredictable drug reaction in a child with Cornelia de Lange syndrome

Case descriptionPreoperative use of midazolam sedation is mandatory during induction of anesthesia in noncooperative and hyperactive children to prevent possible obstacles. Unusual drug reactions rarely occur in patients undergoing anesthesia or in intensive care unit. This report describes an unpredictable drug reaction after a routine midazolam premedication in a patient with no history of allergy. There has been no literature data yet to show that midazolam can provoke respiratory problems in patients with Cornelia de Lange Syndrome.ConclusionIn our opinion midazolam should be avoided in patients with Cornelia de Lange Syndrome, which we enforced after first unpredictable reaction.

Tourniquet-induced ischemia-reperfusion injuries during extremity surgery at children's age: impact of anesthetic chemical structure

Abstract Objectives The aim of this study was to determine the relationship between the antioxidant profile of anesthetics and its relation to total antioxidant capacity (TAC) of plasma in children who underwent tourniquet-induced ischemia-reperfusion (IR) injury during extremity operations. Methods Children were randomized into three groups: general inhalational anesthesia with sevoflurane (group S), total intravenous anesthesia (TIVA) with propofol (group T), and regional anesthesia (group R). Venous blood samples were obtained before peripheral nerve block and induction of general anesthesia (baseline), 1 minute before tourniquet release (BTR), and 5 and 20 minutes after tourniquet release (ATR). Plasma TAC as well as antioxidant potential of propofol, thiopental, and bupivacaine were measured using the 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay. Results Plasma TAC in group T was increased significantly at 20 minutes ATR in comparison with basal and BTR values, and also was significantly higher in comparison with plasma TAC in groups S and R measured at the same time point. The radical scavenging activity of anesthetics in vitro indicated that only propofol possessed a significant antioxidative activity in the reaction with DPPH radical in comparison with thiopental and bupivacaine. Discussion These data confirm that TIVA with propofol attenuates oxidative stress related to tourniquet-induced ischaemia-reperfusion injury in children.

The intraoperative use of recombinant FVIIa in child with hemophilia A with antibodies

Patients with hemophilia A that developed inhibitors to FVIII represent a problem for bleeding control especially during surgical procedures. We report the use of bolus injections of rFVIIa during one intervention that included synoviectomy on the right knee, cholecystectomy and appendicectomy in a child with high titer of inhibitors to FVIII. rFVIIa was administered at the start (120 μg·kg−1) and then every 2 h (90 μg·kg−1) during the procedure. ε‐aminocapronic acid was also administered as an antifibrinolytic every 3 h. We monitored aPTT (activated partial thromboplastin time) and PT (prothrombin time) and they were within reference values. Surgery lasted 7 h without significant hemorrhage. Postoperatively the dose of rFVIIa was slowly reduced and after ten days the patient was discharged home in good condition. In our case rFVIIa helped a child with hemophilia A with antibodies to undergo major surgery but each case should be treated individually and the cost of rFVIIa has also to be taken into account.

Psychometric Properties of the Serbian Version of the Maslach Burnout Inventory-Human Services Survey: A Validation Study among Anesthesiologists from Belgrade Teaching Hospitals

We report findings from a validation study of the translated and culturally adapted Serbian version of Maslach Burnout Inventory-Human Services Survey (MBI-HSS), for a sample of anesthesiologists working in the tertiary healthcare. The results showed the sufficient overall reliability (Cronbachs α = 0.72) of the scores (items 1–22). The results of Bartletts test of sphericity (χ 2 = 1983.75, df = 231, p < 0.001) and Kaiser-Meyer-Olkin measure of sampling adequacy (0.866) provided solid justification for factor analysis. In order to increase sensitivity of this questionnaire, we performed unfitted factor analysis model (eigenvalue greater than 1) which enabled us to extract the most suitable factor structure for our study instrument. The exploratory factor analysis model revealed five factors with eigenvalues greater than 1.0, explaining 62.0% of cumulative variance. Velicers MAP test has supported five-factor model with the smallest average squared correlation of 0,184. This study indicated that Serbian version of the MBI-HSS is a reliable and valid instrument to measure burnout among a population of anesthesiologists. Results confirmed strong psychometric characteristics of the study instrument, with recommendations for interpretation of two new factors that may be unique to the Serbian version of the MBI-HSS.

Acute myocarditis during anesthesia after rubella infection

Electrophysiological studies revealed partial axonal injury on the lateral division of right sciatic nerve consistent with a partial sciatic nerve injury. Then he was immediately started on gabapentin 100 mg three times daily introduced over a 3-day period to avoid possible side effects. At the same time, tramadol was given in a dose of five drops (12.5 mg) as a rescue medication. One week after his first evaluation, his pain intensity was 5 on NRS with gabapentin 300 mg three times daily and tramadol 37.5 mg per day. However, he still had allodynia and foot drop. He reported a decrease in pain intenstiy especially during the first 5 h after medication intake. No side effects were seen. Thereupon, gabapentin dose was increased to 400 mg three times daily and tramadol was given five drops as a rescue medication. At the end of 2 weeks, his pain intensity was 2 on NRS. He continued this medical treatment for 2 months and at 2 months follow-up he used no rescue medications and his pain described as burning, stabbing and shooting was completely controlled with gabapentin 400 mg three times daily. He felt only the cold and heat allodynia (he said that he felt his foot painful only during taking shower). Thereafter, gabapentin doses were decreased gradually to 300 mg three times daily and offered to continue for 1 month. Nerve conduction studies and EMG performed 3 months after injury showed partial axonal injury on the peroneal division of right sciatic nerve with sign of reinnervation. The regeneration potentials could not reach the right extensor digitorum brevis muscle yet. At 3 months follow-up he had no pain but still had cold and heat allodynia on his right foot then he was advised to continue gabapentin 100 mg three times daily. Nerve conduction studies and EMG 6 months after the sciatic nerve injury showed reinnervation of the right extensor digitorum brevis muscle. He had still no neuropathic pain but had allodynia on his right toe so that the treatment continued with gabapentin 100 mg three times daily. At 8 months follow-up, he had no neuropathic pain and allodynia so that gabapentin treatment was stopped. New nerve conduction studies and EMG were not needed. In the literature there is no detailed information about drugs used in medical treatment of postinjection sciatic nerve injury pain. Our child suffered from neuropathic pain due to sciatic nerve injury with burning and stabbing in quality. So that we started gabapentin in a dosage of 300–400 mg three times daily in our child that was the first line and standard treatment of neuropathic pain (3). In the literature, there are also several reports reporting that gabapentin is used safely in dosage of 200–500 mg three times daily in children without side effects (4,5). In our child gabapentin reduced his burning and stabbing pain sensation in big toe and at the bottom of right foot and shooting pain going down his right leg for several months, while postinjection sciatic nerve injury resolved spontaneously in several months. In conclusion, gabapentin was able to control neuropathic pain symptoms in this pediatric case of sciatic nerve injury following i.m. injection without any side effects and can be recommended for the safe and effective treatment of neuropathic pain in pediatric ages of 8 years. Kader Keskinbora* Is ik Aydinli† *Anesthesiology Department, Cerrahpasa Medical Faculty, Algology Clinic, Istanbul University, Istanbul, Turkey and †Anesthesiology Department, Cerrahpasa Medical School, Algology Clinic, Istanbul University, Istanbul, Turkey (email: kader@istanbul.edu.tr)

Nutritive support in short Bowel syndrome (sbs)

Short bowel syndrome most commonly result after bowel resection for necrosis of the bowel. It may be caused by arterial or venous thrombosis, volvolus and in children, necrotizing enterocolitis. The other causes are Crohn,s disease intestinal atresia. The factors influencing the risk on short bowel syndrome are the remaining length of the small bowel, the age of onset, the length of the colon, the presence or absence of the ileo-coecal valve and the time after resection. Besides nutritional deficiencies there some other consequences of extensive resections of the small intestine (gastric acid hypersecretion, d-lactic acidosis, nephrolithiasis, cholelithiasis), which must be diagnosed, treated, and if possible, prevented. With current therapy most patients with short bowel have normal body mass index and good quality of life.

A Comparison of Three Different Volumes of Levobupivacaine for Caudal Block in Children Undergoing Orchidopexy and Inguinal Hernia Repair

Objective: The aim of this study was to compare the efficacy of 3 different volumes of 0.25% levobupivacaine caudally administered on the effect of intra- and postoperative analgesia in children undergoing orchidopexy and inguinal hernia repair. Subjects and Methods: Forty children, aged 1-7 years, American Society of Anesthesiologists (ASA) physical status I and II, were randomized into 3 different groups according to the applied volumes of 0.25% levobupivacaine: group 1 (n = 13): 0.6 mL∙kg-1; group 2 (n = 10): 0.8 mL∙kg-1; and group 3 (n = 17): 1.0 mL∙kg-1. The age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were compared among the groups. The time to first use of the analgesic and the number of patients who required analgesic 24 h after surgery in the time intervals within 6 h, between 6 and 12 h, and between 12 and 24 h postoperatively were evaluated among the groups. Statistical analyses were performed with a Dunnett t test, ANOVA, or Kruskal-Wallis test and χ2 test. Logistic regression analysis was used in order to examine predictive factors on duration of postoperative analgesia. Results: Age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were similar among the groups. The time to first analgesic use did not differ among the groups, and logistic regression modelling showed that using the 3 different volumes of levobupivacaine had no predictive influence on duration of postoperative analgesia. The numbers of patients who required analgesics within 6 h (3/2/3), between 6 and 12 h (3/1/3), and between 12 and 24 h (1/0/2) after surgery were similar among the groups. Conclusion: The 3 different volumes of 0.25% levobupivacaine provided the same quality of intra- and postoperative pain relief in pediatric patients undergoing orchidopexy and inguinal hernia repair.

The role of octreotide in the treatment of pancreatic pseudocyst in pediatric patients: 10AP3-6

demografic data, duration of scan and hemodynamic parameters. There was no significant difference in imaging quality between study groups. No significant differences were found in the incidence of PONV. Induction times and recovery times were significantly shorter in the sevoflurane group than in the propofol group (p 0.05). Conclusion: Propofol or sevoflurane with larengeal mask provides satisfactory anesthesia during MRI in children. Sevoflurane provides more rapid induction and recovery than propofol.