Fatih Ugur

Desflurane anaesthesia increases sister chromatid exchanges in human lymphocytes

Background:  We investigated genotoxic effects of desflurane on the frequency of sister chromatid exchange (SCE) in peripheral blood lymphocytes of patients during and after anaesthesia.

Intrathecal infusion therapy with dexmedetomidine-supplemented morphine in cancer pain.

Sir, Pain is one of the most important symptoms of end-stage cancer that needs to be controlled. Dexmedetomidine is an alpha2 agonist with sedative and analgesic properties (1). Intrathecal dexmedetomidine for the relief of cancer pain has not been reported in the literature previously. In this communication, the use of intrathecal dexmedetomidine-supplemented morphine is reported in a patient with cancer. A 65-year-old man diagnosed with lung cancer was admitted to our pain clinic at Erciyes University Hospital, Kayseri, Turkey. Initially, oral medical treatment (500 mg paracetamol, 500 mg metamizole, 30 mg codeine and 10 mg dionine), in addition to a 100-mg transdermal fentanyl patch, was started. One month later, a cervical epidural catheter was placed because of unbearable pain. Pain relief lasted for 3 months, but then worsened again. On the fifth month, cervical chordotomy was performed by neurosurgery. However, the analgesic effect obtained disappeared within 2 weeks. Infusion therapy was then started via a cervical intrathecal catheter at a dose of 5 mg morphine/day. Analgesic failure was experienced 1 month later as the patient became morphine tolerant. Finally, after Ethics Committee approval and informed consent from the patient, 15 mg dexmedetomidine/day was added to morphine therapy. Pain relief was almost complete with VAS1⁄4 0–1 (on a visual analogue scale (VAS), 0 refers to no pain and 10 refers to extreme pain) with no adverse effect, and lasted for 2 months until death with VAS 1⁄4 2–3. Intrathecal dexmedetomidine may be beneficial as an adjuvant drug in cancer pain. The analgesic effect of dexmedetomidine may be advantageous in palliative care for cancer patients. Further studies are required to reveal the effects of intrathecal dexmedetomidine treatment.

Oral ketamine for pain relief in a child with abdominal malignancy.

Oral ketamine has been found to be effective during invasive procedures in children with malignancy. To the best of our knowledge, analgesic effects of oral ketamine have not been reported in pediatric cancer pain management. We described a patient with end-stage cancer pain that was resistant to opioids and was relieved by oral ketamine.

The Effects of Dexmedetomidine Added to Spinal Levobupivacaine for Transurethral Endoscopic Surgery

BACKGROUND Intrathecal α2 agonists prolong the duration of action of local anesthetics and reduce the required dose. Dexmedetomidine is an α2 receptor agonist and its α2/α1 selectivity is 8 times higher than that of clonidine. AIMS In this study, we aimed to investigate the effect of adding dexmedetomidine to intrathecal levobupivacaine on the onset time and duration of motor and sensory blocks. STUDY DESIGN Randomized controlled study. METHODS Patients were randomly assigned into two groups. Group L (n= 30) patients received 3 mL (15 mg) of 0.5% levobupivacaine +0.3 mL normal saline and Group LD (n= 30) patients received 3 mL (15 mg) of 0.5% levobupivacaine + 0.3 mL (3 μg) dexmedetomidine. Sensory block onset time, block reaching time to T10 dermatome, the most elevated dermatome level, two dermatome regression time, sensory block complete regression time as well as motor block onset time, reaching Bromage 3 and regressing to Bromage 0 were recorded. RESULTS Sensory and motor block onset times were shorter in Group LD than in Group L (p<0.001). The regression of the sensory block to S1 dermatome and Bromage 0 were longer in Group LD than Group L (p<0.001). The two dermatome regression time was longer in Group LD than Group L (p< 0.001). There were no statistically significant differences between groups in blood pressure and heart rate. There was no statistically significant difference between groups when adverse effects were compared. CONCLUSION We conclude that intrathecal dexmedetomidine addition to levobupivacaine for spinal anaesthesia shortens sensory and motor block onset time and prolongs block duration without any significant adverse effects.

Celiac plexus block with the long stylet needle technique.

Neurolytic celiac plexus block has been used successfully in the treatment of patients with intractable intra-abdominal pain due to malignancy or to benign pain syndromes. A new technique is described here for blocking the celiac plexus through the retrocrural approach with a special long stylet needle inserted under fluoroscopic guidance. Celiac blocks were performed in 2 groups of patients. In the first group (n=7), the classic technique was performed with the use of 2 needles; in the second group (n=5), 1 needle and 2 stylets were used to complete the block through the long guided needle approach. Parameters evaluated in each group consisted of the number of attempts, defined as the number of skin punctures, and fluoroscopy injection time, defined as time from the beginning offluoroscopy to completion of successful needle insertion into the celiac area. Patients who had abdominal pain resulting from pancreatic cancer underwent celiac plexus block performed by the long guided needle technique. In the classic technique group, fluoroscopy injection time was 13±3 min and the number of attempts was 5.3±3; values in the long guided needle group were 8.9±3 min and 4.9±2, respectively. The difference in fluoroscopy injection times was significant (P < .05). The long guided needle technique for celiac plexus block may be an effective and appropriate method for beginners or for practitioners who are not knowledgeable about imaging techniques used in various medical specialties.

Does spinal anesthesia decrease the incidence of phantom pain

Abstract The objective of this retrospective study is to evaluate the effects of anesthesia type on phantom pain or sensation. A questionnaire of ten questions on phantom pain and sensation was sent by mail to patients who underwent lower extremity amputation surgery between 1996 and 2003 at Erciyes University Hospital. A total of 40 patients (age 51.0 ± 10.7 years, 80% male) who had general anesthesia and 27 patients (age 56.3 ± 14.0 years, 78% male) who had spinal anesthesia returned the questionnaire.Phantom pain incidences were defined as 33% in the spinal anesthesia group and 65% in the general anesthesia group and the difference was statistically significant. Phantom sensation incidences were 74% in the spinal anesthesia group and 77% in the general anesthesia group and the difference was not statistically significant. In conclusion, phantom pain incidence was lower in amputees treated with spinal anesthesia.

Skin marking for stellate block with fluoroscopic guidance.

To the Editor: We describe here a simple and noninvasive technique for identification of the correct needle position for stellate ganglion block under fluoroscopic guidance. We used external stick-on markers to predict the position of the cervical vertebral processes. We believe this occasion is the first time that such skin localization for procedures carried out under fluoroscopic guidance has been described. The patient is placed in the sitting position on a specially made chair with a head support that is covered by a round pillow. The head support minimizes head movement and avoids the risk of inaccurate skin marking because of changes in the degree of neck extension. The transverse process of the 6th vertebra (Chassaignac’s tubercle), which corresponds to the puncture site, is preoperatively identified on an anteroposterior fluoroscopic view and marked with external stick-on markers (Fig 1). These markers are used to indicate all the landmarks of the operational site (4 4 cm2) by the first preoperative fluoroscopic scan. The use of letters avoids misunderstanding between operator and radiographer and facilitates both fluoroscopy and needle direction during the procedure. The marker consists of an adhesive band on which radiolucent letters are symmetrically placed. The letters have no special importance in themselves, although the letter C is usually placed on the 7th cervical vertebra. Fluoroscopic views of the lower cervical region are taken with the patient in the sitting position (Fig. 2). The data derived from the external skin markers are used to predict the direction required to reach Chassaignac’s tubercle. Skin localization is usually easy, and the vertebral target is quickly identified. Next, the puncture site is chosen after fluoroscopic scans, and the spread of the contrast agent is visualized. A 25-gauge spinal needle is inserted at an angle, and the needle tip advanced to the anteroinferior aspect of Chassaignac’s tubercle. After negative aspiration, 7 mL of 1% lidocaine is injected. Injection therapy plays a major role in the management of painful conditions.1,2 This report suggests that stellate-block procedures can be performed by use of a paratracheal approach with the patient in the sitting position and use of external markers that provide greater accuracy without marking the skin. Classically, the procedure to locate the level of a cervical tubercle involves several sequential fluoroscopic scans and counting the vertebrae.3 Preoperative marking with adhesive skin stickers facilitates positioning, and, thus, decreases the number of exposures. Preoperative marking is especially preferable with anatomic abnormalities. The technique ensures accurate identification of Chassaignac’s tubercle, which sig-