Fatma Nur Kaya

Internal jugular vein cannulation: an ultrasound-guided technique versus a landmark-guided technique.

OBJECTIVES To compare the landmark-guided technique versus the ultrasound-guided technique for internal jugular vein cannulation in spontaneously breathing patients. METHODS A total of 380 patients who required internal jugular vein cannulation were randomly assigned to receive internal jugular vein cannulation using either the landmark- or ultrasound-guided technique in Bursa, Uludag University Faculty of Medicine, between April and November, 2008. Failed catheter placement, risk of complications from placement, risk of failure on first attempt at placement, number of attempts until successful catheterization, time to successful catheterization and the demographics of each patient were recorded. RESULTS The overall complication rate was higher in the landmark group than in the ultrasound-guided group (p < 0.01). Carotid puncture rate and hematoma were more frequent in the landmark group than in the ultrasound-guided group (p < 0.05). The number of attempts for successful placement was significantly higher in the landmark group than in the ultrasound-guided group, which was accompanied by a significantly increased access time observed in the landmark group (p < 0.05 and p < 0.01, respectively). Although there were a higher number of attempts, longer access time, and a more frequent complication rate in the landmark group, the success rate was found to be comparable between the two groups. CONCLUSION The findings of this study indicate that internal jugular vein catheterization guided by real-time ultrasound results in a lower access time and a lower rate of immediate complications.

Rib approximation without intercostal nerve compression reduces post-thoracotomy pain: a prospective randomized study

OBJECTIVE One of the most important considerations in the care of thoracic surgery patients is the control of pain, which leads to increased morbidity and relevant mortality. METHODS Between February and May 2009, 60 patients undergoing full muscle-sparing posterior minithoracotomy were prospectively randomized into two groups, according to the thoracotomy closure techniques. In the first group (group A), two holes were drilled into the sixth rib using a hand perforator, and sutures were passed through the holes in the sixth rib and were circled from the upper edge of the fifth rib, thereby compressing the intercostal nerve underneath the fifth rib. In the second group (group B), the intercostal muscle underneath the fifth rib was partially dissected along with the intercostal nerve, corresponding to the holes on the sixth rib. Two 1/0 polyglactin (Vicyrl) sutures were passed through the holes in the sixth rib and above the intercostal nerve. RESULTS There were 30 patients in each group. The visual analog score, observer verbal ranking scale (OVRS) scores for pain, and Ramsay sedation scores were used to follow-up on postoperative analgesia and sedation. The von Frey hair test was used to evaluate hyperalgesia of the patients. The patients in group B had lower visual analog scores at rest and during coughing. The patients in group B had lower OVRS scores than group A patients. The groups were not statistically different in terms of the Ramsay sedation scores and von Frey hair tests. CONCLUSIONS Thoracotomy closure by a technique that avoids intercostal nerve compression significantly decreases post-thoracotomy pain.

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.

Induction of anesthesia in coronary artery bypass graft surgery: the hemodynamic and analgesic effects of ketamine

OBJECTIVE The aim of this prospective, randomized study was to evaluate the hemodynamic and analgesic effects of ketamine by comparing it with propofol starting at the induction of anesthesia until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery. INTRODUCTION Anesthetic induction and maintenance may induce myocardial ischemia in patients with coronary artery disease. A primary goal in the anesthesia of patients undergoing coronary artery bypass grafting surgery is both the attenuation of sympathetic responses to noxious stimuli and the prevention of hypotension. METHODS Thirty patients undergoing coronary artery bypass grafting surgery were randomized to receive either ketamine 2 mg.kg−1 (Group K) or propofol 0.5 mg.kg−1 (Group P) during induction of anesthesia. Patients also received standardized doses of midazolam, fentanyl, and rocuronium in the induction sequence. The duration of anesthesia from induction to skin incision and sternotomy, as well as the supplemental doses of fentanyl and sevoflurane, were recorded. Heart rate, mean arterial pressure, central venous pressure, pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, systemic and pulmonary vascular resistance indices, stroke work index, and left and right ventricular stroke work indices were obtained before induction of anesthesia; one minute after induction; one, three, five, and ten minutes after intubation; one minute after skin incision; and at one minute after sternotomy. RESULTS There were significant changes in the measured and calculated hemodynamic variables when compared to their values before induction. One minute after induction, mean arterial pressure and the systemic vascular resistance index decreased significantly in group P (p<0.01). CONCLUSION There were no differences between groups in the consumption of sevoflurane or in the use of additional fentanyl. The combination of ketamine, midazolam, and fentanyl for the induction of anesthesia provided better hemodynamic stability during induction and until the end of sternotomy in patients undergoing coronary artery bypass grafting surgery.

Comparison of peritonsillar levobupivacaine and bupivacaine infiltration for post-tonsillectomy pain relief in children: placebo-controlled clinical study.

OBJECTIVES To compare the effects of preincisional peritonsillar infiltration of levobupivacaine and bupivacaine on post-tonsillectomy pain in children. METHODS Sixty children undergoing elective tonsillectomy or adenotonsillectomy were randomly allocated into three groups before tonsillectomy: peritonsillar infiltrations with 0.25% levobupivacaine with 1:200,000 epinephrine (group levobupivacaine, n=20), 0.25% bupivacaine with 1:200,000 epinephrine (group bupivacaine, n=20), and normal saline (group saline, n=20) were applied. Pain was evaluated by using a modified Childrens Hospital of Eastern Ontario Pain Scale (mCHEOPS). Choice of additional analgesic was acetaminophen for all patients. RESULTS mCHEOPS values at 0th (immediately) and 30th minute after arrival the PACU were lower in both the local anesthetics groups than the saline group (p<0.001, p<0.01 for the group levobupivacaine; p<0.001, p<0.05 for the group bupivacaine, respectively). In addition, mCHEOPS values at 1st hour in the ward was lower in the group bupivacaine when compared to the group saline (p<0.05). Analgesic requirements and the time to first analgesia required, were also significantly different between the local anesthetic and saline groups (p<0.05 for both local anesthetics groups). Time to first mobilization was shorter in both local anesthetic groups when compared to the saline group (p<0.05 for both local anesthetic groups). CONCLUSION Preincisional peritonsillar infiltration with levobupivacaine or bupivacaine before tonsillectomy, are effective than saline, in reducing early post-tonsillectomy pain, where as bupivacaine had slightly longer effect. Compared to saline, with both anesthetic infiltrations, lesser medication for analgesia is required. The clinical trial registration number (Research Ethics Committee of Medical Faculty, Uludag University): 2008-4/36, 19 February 2008.

Bloqueio dos nervos ílio‐hipogástrico/ilioinguinal em correção de hérnia inguinal para tratamento da dor no pós‐operatório: comparação entre a técnica de marcos anatômicos e a guiada por ultrassom

OBJECTIVES The purpose of this study is to compare the efficacy of iliohypogastric/ilioinguinal nerve blocks performed with the ultrasound guided and the anatomical landmark techniques for postoperative pain management in cases of adult inguinal herniorrhaphy. METHODS 40 patients, ASA I-II status were randomized into two groups equally: in Group AN (anatomical landmark technique) and in Group ultrasound (ultrasound guided technique), iliohypogastric/ilioinguinal nerve block was performed with 20ml of 0.5% levobupivacaine prior to surgery with the specified techniques. Pain score in postoperative assessment, first mobilization time, duration of hospital stay, score of postoperative analgesia satisfaction, opioid induced side effects and complications related to block were assessed for 24h postoperatively. RESULTS VAS scores at rest in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p<0.01 or p<0.001). VAS scores at movement in the recovery room and all the clinical follow-up points were found significantly less in Group ultrasound (p<0.001 in all time points). While duration of hospital stay and the first mobilization time were being found significantly shorter, analgesia satisfaction scores were found significantly higher in ultrasound Group (p<0.05, p<0.001, p<0.001 respectively). CONCLUSION According to our study, US guided iliohypogastric/ilioinguinal nerve block in adult inguinal herniorrhaphies provides a more effective analgesia and higher satisfaction of analgesia than iliohypogastric/ilioinguinal nerve block with the anatomical landmark technique. Moreover, it may be suggested that the observation of anatomical structures with the US may increase the success of the block, and minimize the block-related complications.

The Use of the Laryngeal Mask Airway in Children with Subglottic Stenosis

Patients with tracheal stenosis have a high incidence of difficult or failed tracheal intubation. Airway management with the laryngeal mask airway during fibreoptic laryngoscopy was used in two children with acquired subglottic stenosis during spontaneous breathing. The laryngeal mask airway may be superior to tracheal intubation or use of a face mask during anaesthesia management in severe subglottic stenosis. Ventilation may be improved and the use of a laryngeal mask airway can reduce or eliminate some of the problems associated with the other methods of airway management, such as further damage to stenotic tissue and gastric distention.

Comparison of postoperative analgesic efficacy of intraoperative single-dose intravenous administration of dexketoprofen trometamol and diclofenac sodium in laparoscopic cholecystectomy

STUDY OBJECTIVE The aim of this study is to compare the effects of intravenous single-dose dexketoprofen trometamol and diclofenac sodium 30 minutes before the end of the surgery on relief of postoperative pain in patients undergoing laparoscopic cholecystectomy. DESIGN A randomized fashion. SETTING AND PATIENTS Sixty (American Society of Anesthesiologist class I-II) patients undergoing laparoscopic cholecystectomy were divided into 2 groups INTERVENTION Patients in group DT received 50 mg dexketoprofen trometamol, whereas patients in group DS received 75 mg diclofenac sodium, intravenously 30 minutes before the end of surgery. MEASUREMENTS Postoperative pain intensity, morphine consumption with patient-controlled analgesia, time to first analgesic requirement, complications, rescue analgesic (intravenous tenoxicam 20 mg) requirement, and duration of hospital stay were recorded. MAIN RESULTS Postoperative pain visual analog scale scores were similar in the follow-up periods (P > .05). Patient-controlled analgesia morphine consumption was significantly less in group DT compared with group DS in all postoperative follow-up periods (2 and 4 hours: P < .01; 8, 12, 18, and 24 hours: P < .001). In the postoperative period, the first analgesic requirement time was significantly longer in group DT compared with group DS (P < .01). In addition, the number of patients requiring rescue analgesic was higher in group DS compared with group DT (P < .01). Other follow-up parameters were similar. CONCLUSION In our study, administration of intravenous single-dose dexketoprofen trometamol 30 minutes before the end of surgery provided effective analgesia with reduced consumption of opioids and requirement for rescue analgesic compared with diclofenac sodium in patients undergoing laparoscopic cholecystectomy. For this reason, we believe that, as a part of multimodal analgesia, dexketoprofen trometamol provides more effective analgesia than diclofenac sodium in patients undergoing laparoscopic cholecystectomy.

Comparison of SPECT findings and neuropsychological sequelae in carbon monoxide and organophosphate poisoning

Abnormal regional cerebral blood flow in patients with acute carbon monoxide (CO) and organophosphate (OP) poisoning was examined using 99m Tc-hexamethylpropylene amine oxime (HMPAO) brain single photon emission computed tomography (SPECT) in fourteen patients. We evaluated the predictive significance of acute phase brain SPECT findings for long-term neuropsychological sequelae. Changes were found in the frontal, temporal, parietal lobes within the first week after both types of poisoning. The distribution of the hypoperfused cerebral areas as demonstrated by 99m Tc-HMPAO imaging was similar in the two groups during the acute phase. Neuropsychological sequelae developed in five patients poisoned with OP and six with CO. Patients who had SPECT findings heterogeneously or in the temporal or frontal lobes displayed disorientation. Those with fronto-parietal and frontal lobe changes displayed mental confusion. Parkinsonism also was observed in patients with parieto-occipital, parietal and frontal lobe lesions. The distribution of these lesions appears to predict the long term sequelae of these poisonings, though additional studies with larger numbers of patients are needed to confirm the role of SPECT imaging in both OP and CO poisonings.

Comparison of Esmolol to Nitroglycerine in Controlling Hypotension During Nasal Surgery

OBJECTIVE The aim of this study was to compare esmolol to nitroglycerine in terms of effectiveness in controlling hypotension during nasal surgery. MATERIALS AND METHODS After approval by our institutional Ethics Committee, 40 patients were recruited and randomized into two drug groups: esmolol (Group E) and nitroglycerine (Group N). In group E, a bolus dose of 500 μg/kg esmolol was administered over 30 sec followed by continuous administration at a dose of 25-300 μg/ kg/min to maintain systolic arterial pressure at 80 mmHg. In group N, nitroglycerine was administered at a dose of 0.5-2 μg/kg/min. RESULTS During the hypotensive period, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, and heart rate were decreased 24%, 33%, 27% and 35%, respectively, in group E (p<0.001, p<0.001, p<0.001, p<0.001) and were decreased 30%, 33%, 34% and 23%, respectively, in group N (p<0.001, p<0.001, p<0.001, p<0.001). The decrease in heart rate was higher in group E during the hypotensive period (p=0.048). During the recovery period, diastolic arterial pressure and heart rate were decreased 9% and 18%, respectively, in group E (p=0.044, p<0.001). Systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure were decreased 7%, 3% and 7%, respectively, in group N (p=0.049, p=0.451, p=0.045). CONCLUSION Esmolol provides hemodynamic stability and good surgical field visibility and should be considered as an alternative to nitroglycerine.