F. Ertugrul

A comparison of the efficacies of different pre-treatment drugs in resolving the injection pain of rocuronium.

Efficacies of pre-treatment with lidocaine, remifentanil and metoclopramide in the reduction of pain and withdrawal movements induced by rocuronium injection were evaluated. Forty-four adult patients, American Society of Anesthesiologists (ASA) Physical Status I–II, undergoing elective surgery were randomly assigned to four groups. Each patient received intravenously either 10 mg metoclopramide, 50 mg lidocaine, 1 μg/kg remifentanil or 3 ml of 0.9% sodium chloride (control group); followed by occlusion with a tourniquet on the forearm. After 10 s, occlusion stopped and a priming dose of 0.06 mg/kg rocuronium was injected. The patients response to rocuronium was graded using a four-point scale in a double-blind manner. All groups had significantly lower incidences of pain compared with the control group. After loss of consciousness with sodium thiopental, 0.6 mg/kg rocuronium was administered for intubation and withdrawal movements were assessed. The number of patients in whom withdrawal movements were lowest was in the lidocaine-treated group. Although there was no difference among the study drugs in the prevention of rocuronium-induced pain, lidocaine and remifentanil seemed to be clinically more effective than metoclopramide.

Pain Relief for Children after Adenotonsillectomy

Effective pain relief following adenotonsillectomy in children remains a challenge. This study evaluated the effects of intramuscular 0.5 mg/kg ketamine, 1 mg/kg tramadol or 1 mg/kg meperidine on post-operative pain and recovery in 45 children aged 1-7 years undergoing adenotonsillectomy. Anaesthesia was induced with thiopental or sevoflurane (with succinylcholine for intubation) and was maintained with sevoflurane in oxygen and nitrous oxide. Post-operative pain was scored blind using a modified Toddler–Preschooler Post-Operative Pain Scale 30, 60, 120 and 240 min after tracheal extubation. Post-operative agitation scores were also recorded. Mean post-operative pain score was significantly higher in the tramadol-treated group compared with the meperidine-treated group 120 min after extubation. At all other time-points after extubation, mean post-operative pain scores were similar for the three treatment groups. Ketamine was associated with a significantly higher mean agitation score compared with tramadol and meperidine. We conclude that the effects of ketamine, meperidine and tramadol on post-operative pain following adenotonsillectomy in children were similar.

In Vitro Effects of Opioids on Pregnant Uterine Muscle

Opioids are often used for obstetric analgesia. Ideal obstetric analgesia is attained with optimal pain relief and minimal risk for the parturient. Therefore, investigators in the present study explored the effects of different opioids on the myometrium of pregnant rats. Myometrial strips were exposed to increased concentrations of fentanyl (10-8 M to 10-6 M), alfentanil (10-8 M to 10-4 M), remifentanil (10-8 M to 10-4 M), and meperidine (10-8 M to 10-4M). Decreased contractile activity was observed in myometrial strips isolated from pregnant rats at cumulative concentrations of fentanyl, alfentanil, remifentanil, and meperidine. The amplitude of contractions was reduced with increasing concentrations of opioids; this effect was statistically significant at a concentration of 10-4 M. When administered at higher concentrations, opioids may decrease contractions in pregnant rat myometrium.

Combined spinal-epidural anesthesia with epidural volume extension causes a higher level of block than single-shot spinal anesthesia

BACKGROUND AND OBJECTIVES We evaluated the effects of epidural injection with levobupivacaine or serum physiologic, epidural volume extension (EVE), when using combined spinal-epidural anesthesia (CSEA) for cesarean delivery. METHODS One-hundred and thirty-eight patients with a full-term pregnancy of 37-42 weeks that were scheduled for cesarean delivery were included. Group 1 (n=48) received single-shot spinal anesthesia (SSS), group 2 (n=45) received CSEA-EVE with saline, group 3 received CSEA-EVE with levobupivacaine. The characteristics of motor and sensory block, the effects on maternal hemodynamic changes and the effects on the newborn were compared. RESULTS Time to reach maximum sensory block was significantly shorter in groups 3 than in group 1 and 2 (p<0.05). Two-segment regression time of sensory block was significantly shorter in group 1, whereas it was significantly longer in group 3 than in group 2 (p<0.05). Time to onset of motor block was significantly longer in group 1 than in groups 2 and 3 (p<0.05). Time to reach maximum motor block was significantly shorter in group 3 than in groups 1 and 2 (p<0.05). Time to recovery of motor block was significantly longer in group 3 than in groups 1 and 2 (p<0.05). The time to first analgesic was significantly longer in group 3 (p<0.05). CONCLUSIONS Sufficient and rapid motor and sensory block was achieved in all the patients in the present study; however, motor and sensory block had faster onset, lasted longer, and was of a higher level in groups 2 and 3; these effects were more pronounced in the group 3.

Uterine Preservation and Vaginal Reconstruction in a Patient with Congenital Vaginal Agenesis Presenting with Cyclic Menouria

Herein we report the case of a patient with primary amenorrhea and cyclic menouria. The patient was a 20-year-old woman with primary amenorrhea and inability to achieve sexual intercourse. Clinical examination revealed normally developed labia majora and minora, clitoris, and external urethral orifice, but no vaginal opening. A mature female pubic hair pattern was present, and axillary hair development was normal. Breasts were normally developed. Abdominopelvic magnetic resonance imaging demonstrated a remnant upper vagina and unicornuate uterus filled with fluid, and left-sided renal agenesis. Intraoperatively, a congenital vesicouterine fistulous tract was observed. The fistulous tract was completely resected. Vaginal reconstruction using a sigmoid colon pedicled flap was performed. The proximal part of the neovagina was connected to the remnant cervix, and a Foley catheter was left in the uterine cavity for 7 days to prevent obstruction. The patient has been menstruating regularly since the operation. Menouria might be an early sign of congenital vesicouterine fistula. Resection of the fistulous tract with uterine preservation might be considered in patients with vaginal agenesis.

O bloqueio combinado raqui-peridural com extensão do volume peridural causa nível mais alto de bloqueio do que a raquianestesia com dose única

JUSTIFICATIVA E OBJETIVOS: Avaliamos os efeitos da administracao peridural de levobupivacaina ou solucao salina, extensao do volume peridural (EVE), em bloqueio combinado raqui-peridural (BCRP) para cesariana. METODOS: Foram incluidas no estudo 138 pacientes com gravidez a termo de 37-42 semanas programadas para cesariana. O Grupo 1 (n = 48) recebeu raquianestesia com dose unica (RADU), o Grupo 2 (n = 45) recebeu BCRP-EVE com solucao salina e o Grupo 3 recebeu BCRP-EVE com levobupivacaina. As caracteristicas do bloqueio motor e sensorial os efeitos nas alteracoes hemodinâmicas maternas e nos recem-nascidos foram comparados. RESULTADOS: O tempo para atingir o bloqueio sensorial maximo foi significativamente menor no Grupo 3 do que nos grupos 1 e 2 (p < 0,05). O tempo de regressao do bloqueio sensorio em dois segmentos foi significativamente menor no Grupo 1, enquanto foi significativamente maior no Grupo 3 em relacao ao Grupo 2 (p < 0,05). O tempo de inicio do bloqueio motor foi significativamente maior no Grupo 1 do que nos grupos 2 e 3 (p < 0,05). O tempo para atingir o bloqueio motor maximo foi significativamente menor no Grupo 3 do que nos grupos 1 e 2 (p < 0,05). O tempo de recuperacao do bloqueio motor foi significativamente maior no Grupo 3 do que nos grupos 1 e 2 (p < 0,05). O tempo para o primeiro analgesico foi significativamente maior no Grupo 3 (p < 0,05). CONCLUSAO: Bloqueio sensorio-motor rapido e adequado foi obtido em todas as pacientes do presente estudo; no entanto, o bloqueio sensorio-motor teve inicio mais rapidamente, foi mais prolongado e atingiu um novel mais alto nos grupos 2 e 3; esses efeitos foram mais acentuados no Grupo 3.

Comparison of epidural and combined spinal-epidural analgesia in the management of labour without pain.

The effects of combined spinal–epidural analgesia (CSEA) and epidural analgesia (EA) were studied in 50 healthy parturients randomly allocated to receive bupivacaine plus fentanyl either epidurally, or intrathecally and epidurally. Significant differences from baseline values were seen in systolic blood pressure at all time-points except for 4 h in the EA group and at 3 and 4 h in the CSEA group. Significant differences from baseline values were seen in diastolic blood pressure at 1, 2, 3 and 4 h in the EA group, whereas no significant differences from baseline were seen in the CSEA group. Pain scores in both groups were significantly decreased compared with baseline and all scores, except at 2h, were significantly lower in the CSEA group compared with the EA group. The duration of labour and total amount of drugs used were significantly decreased and cervical dilatation was faster with CSEA compared with EA. In conclusion, CSEA was associated with more rapid onset of analgesia and faster progress in cervical dilatation compared with EA, and can be used safely for labour analgesia.

Intrathecal bupivacaine or levobupivacaine: Which should be used for elderly patients?

Objectives To compare two intrathecal anaesthetics, bupivacaine and levobupivacaine, for their effects on motor and sensory blockade and haemodynamics in patients aged ≥65 years undergoing transurethral resection of the prostate (TUR-P) or transurethral resection of the urinary bladder (TUR-M). Methods Patients scheduled to undergo TUR-P or TUR-M were randomized to receive either 3 ml (15 mg) 0.5% isobaric levobupivacaine (group L) or 3 ml (15 mg) of 0.5% hyperbaric bupivacaine (group B) for spinal anaesthesia. The onset time, maximum level and time to reach the maximum level of sensory and motor blockade were recorded. Changes to haemodynamic parameters were also recorded. Results The study randomized 100 patients: 57 to group L and 43 to group B. Levobupivacaine did not cause any significant changes in haemodynamic parameters, including systolic blood pressure, and showed a similar sensory block onset time compared with bupivacaine, but it had a significantly longer motor block onset time compared with bupivacaine. Conclusion These current findings suggest that levobupivacaine can be used as a substitute for bupivacaine for spinal anaesthesia in elderly patients ≥65 years of age undergoing elective TUR-P or TUR-M operations.

Effect of nerve localization using a pen device on the success of axillary brachial plexus block

Objective The effectiveness of axillary brachial plexus block (ABPB) performed using peripheral nerve stimulation (PNS) alone was compared with PNS preceded by nerve localization using a pen device, enabling nerve mapping without puncturing the skin. Methods Patients undergoing unilateral hand or forearm surgery suitable for ABPB were randomly assigned to receive either PNS alone (pen − group) or PNS preceded by nerve localization using a pen device (pen + group). Parameters related to the block procedure and patient comfort were assessed. Results Thirty patients were included in each group. The block performance time was longer in the pen + group than the pen − group despite a reduced number of needle insertions. The complete block rate was higher and intraoperative analgesic usage lower in the pen + group compared with the pen − group. Patient satisfaction and complication rates were similar in the two groups. Conclusion The pen device seems to be a helpful addition to PNS for ABPB, with improved results in terms of block success and patient comfort, but further studies are needed to confirm these findings.

P931 Fluid overload during operative hysteroscopy: a case report

polycystic ovarian syndrome (PCOS) and determine the efficacy of metformin in treatment of (AN). Materials and Methods: 69 obese females having (AN) were categorized into Group I: 32 (AN) with PCOS; Group II: 37 (AN) without PCOS. On the other hand, Group III as control: 35 obese females without (AN) nor PCOS. (AN) patients were treated with metformin (500mg t.i.d.) for 24 weeks. Body mass index (BMI), Waist to hip ratio (WHR); serum fasting glucose (FG), fasting insulin (FI), IGF-1, IGFBP-1, and IR were assessed by Homeostasis Model (HOMA-IR). Results: FI & HOMA-IR were significantly elevated while IGFBP-1 was significantly lower in (AN), and in PCOS than control group. These changes were positively correlated with severity of (AN) in both groups. Metformin led to a significant reduction in BMI, WHR, IR and in the severity of (AN) in both groups. A non significant decrease in plasma IGF-1 and a significant increase in plasma IGFBP-1 were also found. Conclusions: Metformin not only improved (AN) lesions but also restores normal levels of insulin and decreases the free-bioactive IGF-1 by increasing the circulating IGFBP-1 in (AN); with and without PCOS. Therefore, hyperinsulinemic women with (AN) + PCOS may benefit from metformin for improvement of (AN).