Elif Basagan Mogol

Thoracic Paravertebral Block for Video-Assisted Thoracoscopic Surgery: Single Injection Versus Multiple Injections

OBJECTIVE Thoracic paravertebral blocks (PVBs) have been shown to be effective for analgesia after video-assisted thoracoscopic surgery (VATS) with single- and multiple-injection techniques. The efficacy of single-injection PVB was compared with multiple-injection PVB on postoperative analgesia in VATS was studied. DESIGN Prospective, randomized study. SETTING Single university hospital. PARTICIPANTS Fifty patients undergoing VATS. INTERVENTIONS A nerve stimulator-guided PVB was performed in the sitting position before surgery using a solution of 20 mL 0.5% bupivacaine with 1:200,000 epinephrine by a single injection at T6 (group S, n = 25) or by 5 injections of 4 mL each at T4 to T8 (group M, n = 25). MEASUREMENTS AND MAIN RESULTS A successful PVB was achieved in all patients. The times to perform the blocks were 6.8 ± 1.9 minutes in the S group and 17.9 ± 3.0 minutes in the M group (p < 0.001). The times to block onset were 8.3 ± 1.8 minutes in the S group and 7.2 ± 0.9 minutes in the M group (p = 0.014). The numbers of anesthetized dermatomes were 5.8 ± 0.8 for the S group and 6.6 ± 1.1 for the M group (p = 0.009). The postoperative pain scores and morphine consumption with patient-controlled analgesia were comparable in the two groups. There were no significant differences in times to the first mobilization and hospital discharge for two groups. Patient satisfaction with the analgesic procedure was greater in the S group (p < 0.05). No complications were attributed to the blocks. CONCLUSIONS The two techniques provided comparable postoperative analgesia. However, single-injection PVB may represent an advantage over multiple-injection PVB in patients undergoing VATS, with greater patient satisfaction associated with a shorter procedure and the likelihood of decreased complications.

Deksmedetomidin ve esmololün derlenme döneminde oluşan artmış hemodinamik yanıt tedavisindeki etkinliklerinin karşılaştırılması

Objectives: Our aim was to compare effectiveness of esmolol and dexmedetomidine in the treatment of increased hemodynamic response during anesthesia recovery period. Materials and methods: 60 ASA I-II patients whom scheduled for elective surgery with endotracheal intubation were randomized before extubation according to their hemodynamic parameters that were increased 20% of their baseline values in order to receive 1mg/kg esmolol (Group Esmolol, n= 30) or 0.5 µg/kg dexmedetomidine (Group Dexmedetomidine, n= 30). Heart rate (HR), systolic and diastolic blood pressures (SBP,DBP), peripheral oxygen saturation (SpO 2 ), end tidal carbon dioxide (ETCO 2 ) values, extubation time, recovery time were recorded. The duration till having pain requiring analgesic was recorded and cognitive functions were evaluated with short memory orientation concentration test at 20th and 50th minutes. Results: After drug, HR reductions were significant at all periods in group Dexmedetomidine (Z2-Z10: p<0.001, Z11:p=0.001, Z12, p=0.006). In group Dexmedetomidine SBP value was high at 3rd min after drug (p<0.001), and SBP values were lower in all periods before and after extubation (Z6- Z10: p<0.001, Z11: p=0.02, Z12: p=0.04). In group Dexmedetomidine DBP value was higher at 1st min after drug (p=0.001), DBP values were lower at 10th min after drug and before extubation (p= 0.045, p=0.001). The duration of pain requiring analgesic and recovery period were longer in dexmedetomidine group (p<0.001, p<0.001). Conclusions: Although esmolol and dexmedetotimidine attenuated hemodynamic response during recovery period, dexmedetotimidine was more effective in hemodynamic stabilization and the duration of pain requiring analgesic was longer. Esmolol provided faster recovery time. J Clin Exp Invest 2012; 3(1): 53-60

Do metoclopramide and ondansetrone alter mivacurium-induced neuromuscular blockade? - a randomised trial

BACKGROUND We aimed to investigate the effects of metoclopramide and ondansetrone on mivacurium neuromuscular blockade. METHODS Seventy five, ASA I-II patients, aged 18-65 and scheduled for elective surgery requiring tracheal intubation were included in the study. The patients received metoclopramide 10 mg, ondansetrone 4 mg or normal saline 5 mL; group M, group O, group NS (n=25), respectively. Before anesthesia study drugs were administered in a volume of 5 mL. The level of plasma cholinesterase were obtained before and 5 minutes after the administration of study drugs and 5 minutes after the administration of mivacurium. Onset time, T25, T75, T25-75, T90 levels were compared with each other and differences between each patients were investigated. After recording T90, the study was terminated and surgery was started. RESULTS Onset time was significantly shorter in group M, than the other two groups. Onset time in group O was significantly shorter than in group NS. In Group M T25, T75, T90 and recovery indices were significantly greater than in Group NS (p<0.001). In Group O T25, T75 were greater than Group NS (p<0.01 and p<0.05, respectively). In Group M T75, T90 and emergence indices were significantly higher than Group O (p<0.001, p<0.01, p<0.001, respectively). In Groups M and O, plasma cholinesterase levels decreased significantly (p<0.001) after administration of study drugs and mivacurium. Plasma cholinesterase also was reduced in Group NS 5 minutes after the administration of mivacurium (p<0.001). CONCLUSION Ondansetrone is believed to be more reliable agent than metoclopramide when used with mivacurium.

The combination of psoas compartment, sciatic nerve and T12-L1 paravertebral blocks for femoropopliteal bypass surgery in a high risk patient: P-124

and Reanimation, Antalya, Turkey Case Report: A 68-year-old male patient presented to the emergency service with dysphagia. In a local hospital, three months previously, he had been diagnosed as having an oesophageal carcinoma. In that hospital an oesophageal stent [1] had been inserted and then chemoembolization had been performed. He was now suspected of having a tracheoesophageal fistula. Bronchoscopy was performed to confirm the diagnosis of tracheoesophageal fistula. First the fibreoptic bronchoscope was inserted into a leftsided double-lumen endobronchiall tube. After anaesthetic induction, the left-sided double-lumen tube with fibreoptic bronchoscope, was moved forward slowly. The fistula was seen at 8 cm beyond the vocal chords. The oesophageal stent, seen by bronchoscopy, divided the trachea into two at the site of the fistula. The bronchoscope was advanced to the left main bronchus carefully, on the tracheal side related to the stent. The double-lumen tube was then slid over the bronchoscope into to the left main bronchus. Then the cuffs of bronchial and tracheal were inflated. Confirmation of the endobronchial tube placement was made by auscultation. With the patient in the left lateral position, right thoracotomy was performed and left single lung ventilation used. The oesophagus was explored. Oesophageal and tracheal defects, approximately 2 cm in length, were seen 3 cm above the azygos vein. The oesophageal stent was removed and the tracheal defect repaired. Thirty-five cm of the thoracic oesophagus was resected as far as the hiatus. The hiatus was freed and bleeding controlled. The patient was moved to the supine position and laparotomy performed. The double-lumen endobronchial tube was then changed to a normal single lumen tube using the fibreoptic bronchoscope. The patient was transferred to ICU. He was extubated one day after the operation. Discussion: In patients who have a tracheoesophageal fistula, there is a risk that an endotracheal tube may pass through the fistula and into the oesophagus by mistake if a fibreoptic bronchoscope is not used. We conclude that these patients should be intubated with the assistance of a fibreoptic bronchoscope to avoid inadvertent oesophageal intubation through the fistula and damage to the oesophagus and trachea. Reference: 1 Kozarek R, Raltz S, Brugge WR, et al. Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula. Gastrointest Endosc 1996, 44: 562–567.

Preoperative multiple-injection paravertebral block reduces postoperative pain and analgesic requirements after video-assisted thoracic surgery: A-892

Preoperative multiple-injection paravertebral block reduces postoperative pain and analgesic requirements after video-assisted thoracic surgery F.N. Kaya1, G. Turker1, E.B. Mogol1, S. Goren1, S. Bayram2, C. Gebitekin2 1Department of Anaesthesiology and Reanimation, 2Department of Thoracic Surgery, Hospital of Uludag University, Turkey Background and Goal of Study: Thoracoscopic surgery can be associated with considerable postoperative pain. We tested the hypothesis that preoperative multiple-injection paravertebral block (PVB) reduces opioid requirements and promotes early ambulation after video-assisted thoracic surgery (VATS) procedures. Materials and Methods: 50 ASA I–III consenting patients undergoing elective VATS were included in this prospective, randomized, double-blind, placebocontrolled study. 45 patients completed the study. They were randomly allocated to two groups: the PVB group (n 23) received i.v. patient-controlled analgesia (PCA) with morphine plus multiple-injection thoracic paravertebral block (T4–T8 levels) with bupivacaine 0.5% containing epinephrine 1:200,000 (4 mL for each level). The placebo group (n 22) received preoperative multiple subcutaneous saline injections at the same levels plus PCA morphine. The main recorded data were pain scores using the visual analogue scale (VAS, 0–10) and cumulative PCA morphine consumption during 48 h after surgery, and times to first mobilization and hospital discharge. Results: Intraoperative fentanyl consumption was lower in the PVB group (p 0.01). The time to first analgesic requirement and pain scores at this time were less in the PVB group (p 0.05 and p 0.01, respectively). Postoperative pain scores both at rest and with coughing were lower during the first 4 hours in the PVB group than those in the placebo group (p 0.01 for 0 h, p 0.05 for 1, 2, and 4 h). Cumulative morphine consumption was significantly less in the PVB group at all time points (p 0.01 for 12 h and p 0.001 for all other time points), but there were no significant differences in sedation scores between the two groups. There were no complications with the blocks. In the PVB group, patient satisfaction with the analgesia was significantly greater (p 0.01) and first mobilization and hospital discharge were quicker (p 0.01 and p 0.05, respectively). Conclusion(s): Preoperative multiple-injection PVB with bupivacaine containing epinephrine provided effective pain relief and a significant reduction in opioid requirements. This regime may also contribute to earlier postoperative ambulation after VATS.