Erhan Ayan

Intermittent infusion of 0.25% bupivacaine through an intrapleural catheter for post-thoracotomy pain relief

BACKGROUND The present study was designed to evaluate the effectiveness of intrapleural 0.25% bupivacaine delivered by intermittent infusions for post-thoracotomy pain relief. METHODS Forty patients undergoing elective lobectomy were randomly, but equally, placed into two groups. An intrapleural catheter was inserted under direct vision during surgery. Group I received intrapleural 40 mL of 0.25% bupivacaine, group II was administered 40 mL of saline solution as a control group. Diclofenac sodium was administered as an additional analgesic, if required. Postoperative pain was evaluated using a visual analog scale (VAS), and Prince Henry pain scale. Arterial oxygen saturation, heart rate, and systemic arterial pressures were monitored. All observations were recorded 5, 10, 15, 20, 25, and 30 minutes after the injection, and thereafter at hourly intervals through the postoperative 24 hours. RESULTS The mean analgesia times were 5 hours and 2 hours in group I and group II, respectively. Therefore, bupivacaine administrations were repeated every 6 hours in group I, and saline with additional analgesic were administered every 4 hours in group II. The heart rate and arterial pressures did not show a significant difference. While the additional analgesic requirement was 180 +/- 10 mg/d in group II, there was no need for additional analgesic administration in the group I patients. Arterial oxygen was significantly higher in group I than in group II. Arterial carbon dioxide tension of group II was significantly higher than that of group I. While the postoperative atelectasis and pneumonia developed in four patients and one, respectively, in group II, no such complication was observed in group I. CONCLUSIONS The easy placement of an intrapleural catheter and better pain relief observed in the present study suggest that intermittent pleural infusion of 0.25% bupivacaine has proven to be a safe and effective method for relief of post-thoracotomy pain.

Elastofibroma dorsi: Review of eight cases

PurposeElastofibroma dorsi (ED) is a rare, benign soft tissue tumor arising from connective tissue and usually found in the subscapular region. We conducted this retrospective study to contribute to a better understanding of this tumor, the pathogenesis of which is still unclear.MethodsWe reviewed the medical records of eight patients treated for ED at our institution between 2003 and 2008.ResultsAll patients were right-handed and all except one were female. The tumor was located on the right in two patients, on the left in one, and bilaterally in five. All patients underwent complete marginal resections. The resected tumors ranged in size from 5 cm to 12 cm. The only postoperative complication was seroma, observed in two patients. No recurrences have been observed in follow-up ranging from 15 days to 5 years.ConclusionsWe could not establish a relationship between the side of the dominant hand and the tumor location. If this tumor becomes symptomatic, local excision is the best treatment; however, as malignant transformation has not been reported, follow-up is recommended for asymptomatic lesions.

Morphine added to local anaesthetic improves epidural analgesia in minimally invasive Nuss operation for pectus excavatum

Editor—The Nuss operation is a minimally invasive technique for repair of pectus excavatum. However, postoperative pain is the major problem, and meticulous pain management in postoperative period is important to maintain a stable supine position without turning to either side. Thoracic epidural local anaesthetic and morphine are commonly used for postoperative pain management, but patients were randomized without considering the pectus index. In this report, we aimed to discuss the management of three patients with high pectus index, and thoracic epidural local analgesia was insufficient for pain control in two of them who obtained relief by the addition of morphine to local anaesthetic. General anaesthesia was induced with propofol 2 mg kg, fentanyl 0.1 mg, and vecuronium 0.1 mg kg in all patients, before tracheal intubation with a left doublelumen endobronchial tube. The epidural catheter was inserted by a median approach at T8 – 9 space after induction of anaesthesia. After the bar was placed into its position, levo-bupivacaine 0.25% (Chirocaine, Abbott) as a 10 ml bolus followed by 3 ml h (2.5 mg ml solution) infusion was started via epidural catheter. At the end of the operation, if no pneumothorax was seen on a chest X-ray, patients were extubated and sent to the ward. Sufficient pain control could be achieved in the first case with epidural local anaesthetic administration. However, the second and third cases experienced pain after operation, despite suitable epidural technique (Table 1). The pain was successfully managed with additional morphine 2 mg to the thoracic epidural local anaesthetic. Forcing the sternum anteriorly causes significant pain in the chest and back in the skeletally mature patient. The increased pressure on the bar by less flexible chest increases the magnitude of pain which involves dermatomes T1 – 10. Although, thoracic epidural analgesia with local anaesthetic is considered the gold standard for this operation, the high incidence of hypotension related to the complete sympathectomy caused by the large doses of local anaesthetic is the main problem. However, the incidence of side-effects in epidural morphine has limited its routine use. Morphine can be considered as an adjuvant in patients in whom epidural local anaesthetic is insufficient, and could be considered for routine use in patients with a high pectus index.

Management of Parapneumonic Empyema in Children

Empyema is a serious complication of bacterial pneumonia in children. Between July 1992 and July 1998, 53 children aged 7 months to 12 years (mean age, 5.5 years) were treated for empyema complicating pneumonia. After diagnostic thoracentesis, closed tube drainage was carried out with appropriate antibiotic therapy and other treatment strategies such as pleural lavage, intrapleural enzymatic debridement, decortication, or pulmonary resection, according to the effectiveness of drainage and clinical status. There was one death from toxic shock. It was concluded that early decortication in the chronic stage of the disease is a safe and effective treatment modality.

The effect of octreotide, an analog of somatostatin, on bleomycin-induced interstitial pulmonary fibrosis in rats

In this study, octreotide (OCT), a synthetic somatostatin analog, was tested for its beneficial effects in the prevention of interstitial pulmonary fibrosis (IPF) induced by bleomycin (BLM) in rats by histological examination and by evaluating tissue OH-proline levels. Thirty male Wistar rats were divided randomly into three groups: group I: intratracheal (i.t.) BLM (7.5 mg/kg, single dose) + saline solution [0.9% NaCl, subcutaneously (s.c.), once-daily for 7 days]; group II: i.t. BLM (7.5 mg/kg, single dose) + OCT acetate (82.5 µg/kg, s.c., once-daily for 7 days); and the control group. At the end of the 7 days, lung tissues were excised and examined by histopathological methods. Levels of tissue hydroxyproline (OH-proline) were determined. BLM administration resulted in prominent histopathologic findings, such as diffuse alveolar damage and interstitial pulmonary fibrosis, as well as a significant increase in OH-proline level, as compared to controls. OCT application explicitly attenuated the histopathologic changes to a significant extent. OCT decreased paranchymal fibrosis and structural deformities in BLM-induced lung fibrosis. These results suggest that OCT administration to rats with BLM-induced IPF has a protective effect. Further studies are necessary to reveal the molecular mechanism(s) of OCT-induced protective effect.

The role of thoracic trauma in inflammatory responses, apoptosis and bacterial translocation following multiple traumas.

BACKGROUND Blunt chest trauma and its complications are commonly encountered in emergency medicine. Herein, we used a rat model to investigate the role of thoracic trauma in inflammation, apoptosis and bacterial translocation following multiple traumas. METHODS Ninety Wistar rats were divided equally into nine groups. Rats underwent a standardized blunt thoracic and/or head trauma and were sacrificed 24 or 48 hours after the trauma. Specimens from various organs and blood samples were collected and quantitatively cultured for aerobic organisms. Interleukins, TNF-α, and MCP-1 levels were assessed in the sera and markers of apoptosis were detected in the lungs. RESULTS Levels of interleukins, TNF-α and MCP-1 in all of the groups undergoing trauma were significantly higher than those of the control group (p=0.001). Levels of apoptotic cells in the groups undergoing head and thoracic trauma (HTT) were significantly higher than those of the control group (p=0.009). Light microscopic evaluation indicated that damage in the HTT groups was significantly higher than that in the control group. The incidence of bacterial translocation was also significantly higher in the HTT groups (p=0.003). CONCLUSION Multiple inflammatory mediators are activated in multiple traumas (including blunt thoracic trauma), which allow bacterial translocation and apoptotic processes to occur. Our results indicate that thoracic trauma plays a major role in post-traumatic bacterial translocation, inflammation, and apoptosis following multiple traumas.