Fatma Saricaoglu

Ketamine sedation during spinal anesthesia for arthroscopic knee surgery reduced the ischemia-reperfusion injury markers.

We studied the effect of ketamine sedation on oxidative stress during arthroscopic knee surgery with tourniquet application by determining blood and tissue malonyldialdehyde (MDA) and hypoxanthine (HPX) levels. Thirty ASA I–II patients undergoing arthroscopic knee surgery with tourniquet were randomly divided into two groups. Spinal anesthesia induced with 12.5 mg bupivacaine was administered to all patients. In the ketamine group, after IV administration of 0.01 mg/kg midazolam, a continuous infusion of ketamine (0.5 mg · kg−1 · h−1) was used until the end of surgery whereas the placebo group received a volume-equivalent placebo infusion. Ramsey Sedation Scale (RSS) was used for assessing the sedation level. Venous blood and synovial membrane tissue samples were obtained before ketamine infusion, at 30 min of tourniquet ischemia, and at 5 min after tourniquet deflation for MDA and HPX measurements. Tissue MDA and HPX levels were significantly less in the ketamine group than the control group after reperfusion. RSS scores were higher in the ketamine group without any adverse effect. We conclude that ketamine sedation attenuates lipid peroxidation markers in arthroscopic knee surgery with tourniquet application.

Propofol offers no advantage over isoflurane anesthesia for cerebral protection during cardiopulmonary bypass: a preliminary study of S-100beta protein levels.

PurposeDespite advances in anesthesia, cardiopulmonary bypass (CPB) and surgical techniques, cerebral injury remains a major source of morbidity after cardiac surgery. We compared the effects of two different anesthetic techniques, isoflurane vs propofol on neurological outcome by serum S-100ß protein and neuropsychological tests after coronary artery bypass grafting (CABG).MethodsTwenty patients undergoing CABG, randomly allocated into two groups, were enrolled in this prospective, controlled, preliminary study. Isoflurane was used in group I and propofol in group R Neurological examination and a neuropsychologic test battery consisting of the mini mental state examination (MMSET) and the visual aural digit span test (VADST) were obtained preoperatively and on the third and sixth postoperative days. Blood samples for analysis of S-100ß protein were collected before anesthesia (T1), after heparinization (T2), 15 min into CPB (T3), after CPB (T4) and at the 24th hr postoperatively (T5).ResultsPostoperative neurological examinations of the patients were normal. VADST performance declined significantly on the third day (P < 0.05) in both groups, and there were no significant differences on VADST and MMSET scores between the two groups. In group P S-100ß protein levels increased significantly at T3 and T4 compared to preoperative and isoflurane levels (P < 0.05).ConclusionsDespite reports about the neuroprotective effects of propofol, S-100ß protein levels were significantly elevated in group R Although there was no deterioration in neuropsychological outcome, propofol appeared to offer no advantage over isoflurane for cerebral protection during CPB in this preliminary study of 20 patients.RésuméObjectifMalgré les progrès de l’anesthésie, la circulation extracorporelle (CEC) et les techniques chirurgicales, les lésions cérébrales demeurent une importante source de morbidité postchirurgie cardiaque. Les effets neurologiques comparés de l’isoflurane et du propofol sont présentés par l’analyse des protéines sériques S-100ß et des test neuropsychologiques après un pontage aortocoronarien (PAC).MéthodeNotre étude préliminaire, prospective et contrôlée a porté sur 20 patients, répartis au hasard en deux groupes, qui devaient subir un PAC. L’isoflurane a été utilisé dans le groupe I et le propofol dans le groupe P L’examen neurologique et une batterie de tests neuropsychologiques, comprenant le mini-examen de l’état mental (MMSET pour mini mental state examination) et le test visuel et auditif de mémoire des chiffres (VADST pour visual aural digit span test), ont été réalisés avant l’opération et aux jours trois et six postopératoires. Les échantillons sanguins nécessaires à l’analyse des protéines S-100ß ont été prélevés avant l’anesthésie (T1), après l’héparinisation (T2), 15 min après le début de la CEC (T3), après la CEC (T4) et 24 h après l’opération (T5).RésultatsLes examens neurologiques postopératoires étaient normaux. La performance au VADST a décliné significativement au jour trois (P < 0,05) chez tous les patients. Il n’y a pas eu de différence intergroupe significative des scores de VADST et de MMSET. Dans le groupe P, les niveaux de protéines S-100ß ont augmenté à T3 et T4, comparés aux niveaux préopératoires et aux niveaux observés avec l’isoflurane (P < 0,05).ConclusionMalgré des études rapportant les effets neuroprotecteurs du propofol, les niveaux de protéines S-100ß ont été significativement élevés dans le groupe P de notre étude. Aucune détérioration neuropsychologiques n’a été observée, mais le propofol ne semble pas offrir d’avantage sur l’isoflurane pour la protection cérébrale pendant la CEC.

The evaluation of propofol dosage for anesthesia induction in children with cerebral palsy with bispectral index (BIS) monitoring

Background:  We designed a randomized prospective study to investigate whether developmentally delayed children with cerebral palsy (CP) need a lower dosage of propofol for induction than normal children using bispectral index (BIS) monitoring criteria.

The efficacy of ketamine for the treatment of postoperative shivering.

BACKGROUND:There are few reports on the utility of ketamine for the prevention of postoperative shivering. We thus established the efficacy of two doses of ketamine compared with meperidine for the treatment of postoperative shivering. METHODS:This is a prospective, randomized double-blind study involving 90 ASA I–II patients after general anesthesia. Patients with shivering grade 3–4 were allocated to receive either meperidine 25 mg, ketamine 0.5 mg/kg, or ketamine 0.75 mg/kg IV. Shivering and side effects were monitored at set time intervals. RESULTS:Shivering grades for the first 4 min after treatment were lower in the ketamine groups; however, nystagmus and feeling like “walking in space” was experienced with both doses of ketamine. CONCLUSION:Ketamine 0.5–0.75 mg/kg is more rapid than meperidine (25 mg) for the reduction of postoperative shivering, but the side effect profile may limit its usefulness.

The Effects of Isoflurane, Sevoflurane, and Desflurane Anesthesia on Neurocognitive Outcome after Cardiac Surgery: A Pilot Study

BACKGROUND Inhalation anesthetics such as isoflurane, sevoflurane, and desflurane are widely used in clinical practice; however, there is no study for comparing these drugs in cardiac surgery with respect to postoperative cognitive outcome and S100 beta protein (S100 BP) levels. In this study, we evaluated the effect of sevoflurane, isoflurane, and desflurane anesthesia on neuropsychological outcome and S100 BP levels in patients undergoing coronary artery bypass grafting (CABG) surgery with cardiopulmonary bypass (CPB). MATERIALS AND METHODS Forty-two male patients were prospectively randomized and classified into 3 groups according to the volatile agents used; isoflurane, sevoflurane, desflurane. All patients had a sufficient education level to participate in neuropsychological testing and a normal carotid Doppler ultrasonography. Blood samples for analysis of S100 BP were collected before anesthesia (T1), before heparinization (T2), 15 minutes into CPB (T3), following protamine administration (T4), postoperatively (T5), 24 hours after the operation (T6), postoperative day 3 (T7), and postoperative day 6 (T8). The neuropsychological tests, including Mini-Mental State Examination (MMSET) and visual-aural digit span test (VADST), were administered 1 day prior to surgery and on the third and sixth postoperative days. RESULTS The postoperative third and sixth day MMSET scores and third day visual-written subtest scores in the sevoflurane group were significantly lower than in the isoflurane and desflurane groups (P < .05). S100 BP levels increased with the beginning of anesthesia in the sevoflurane and desflurane groups. Although S100 BP decreased to baseline levels on postoperative day 1 in the sevoflurane group, this was significantly higher on the third and sixth days postoperatively in the desflurane group (P < .05). In the isoflurane group, the S100 BP level was significantly higher than the baseline level only after CPB (P < .05). CONCLUSION Our study suggests that isoflurane is associated with better neurocognitive functions than desflurane or sevoflurane after on-pump CABG. Sevoflurane seems to be associated with the worst cognitive outcome as assessed by neuropsychologic tests, and prolonged brain injury as detected by high S100 BP levels was seen with desflurane.

Perioperative anxiety and postoperative behavioural disturbances in children : comparison between induction techniques

Background and objective: This study was designed to determine if subhypnotic propofol reduces postoperative behavioural disturbances in children undergoing sevoflurane induction compared with intravenous propofol induction for elective adenoidectomy and tonsillectomy. Methods: Following Ethics Committee approval and parental informed consent, ASA I–II, 120 children (2–10 yr) were recruited. Parents were not allowed to accompany their child. Unpremedicated children were randomly allocated to groups receiving inhalation induction with sevoflurane, 2–2.5 mg kg−1 intravenous propofol induction or inhalation induction with sevoflurane followed by subhypnotic dose of propofol (1 mg kg−1). Anaesthesia was maintained with 2–4% sevoflurane, O2 and N2O. Anxiety on arrival to operating theatre, at anaesthesia induction and 30 min after emergence was assessed. Parents completed a state–trait anxiety inventory test preoperatively and a post hospitalization behaviour questionnaire a week later to assess childrens postoperative behavioural disturbances. Kruskal–Wallis test, Wilcoxon signed rank sum test, Bonferronis test, Paired t‐test, t‐test, Pearson and Spearmans rank correlation test, χ2‐test were used for statistical analysis. Results: The anxiety level at induction was high in all groups (P < 0.05). There was no difference between groups in respect to anxiety at other measurement times. A relation between preoperative anxiety level and postoperative behavioural disturbances was determined (P < 0.05). Some behavioural disturbances as nightmare/night fear and desire of sleeping with parents were rarely seen in intravenous propofol induction group (P < 0.05). Conclusion: Addition of subhypnotic dose of propofol to sevoflurane induction did not reduce the incidence of postoperative behavioural disturbances.

A clinical comparison of etomidate-lipuro, propofol and admixture at induction.

Objective: The purpose of this study was to compare etomidate-lipuro and propofol and 50%, (1:1) admixture of these agents at induction with special reference to injection pain, hemodynamic changes, and myoclonus. Methods: Ninety patients were assigned at random to three groups in which induction was performed with either etomidate-lipuro, propofol or etomidate-lipuro–propofol admixture. After monitorization with bispectral index (BIS) all agents were given with infusion with a perfuser at a constant rate of 200 ml/min till the BIS values decreased to 40. Blood pressure and heart rate were measured every 30 s at this period. Patients were asked for pain at the injection site and observed visually for myoclonus. The time BIS values decreased to 40 (BIS 40 time) and total amounts of induction doses were measured. Results: BIS 40 time measurements were P > E > PE (199.4 ± 40.9, 176.9 ± 31.6, 163.5 ± 20.6 s). The hemodynamic (systolic, diastolic and mean blood pressures, heart rate) changes were minimal in group PE than other two groups (P = 0.017). The intensity of myoclonus was graded as mild in 9, moderate in 12, and severe in 5 patients in the group E (76.3%). Myoclonus was not observed in group PE and group P. There were no injection pain in group PE as the incidence were (83.8%) in group P and in (63.2%) group E. Conclusion: Incidence of hemodynamic changes, myoclonus, and injection pain is significantly lower in group PE. BIS 40 times is least in group PE. We concluded that 1:1 admixture of etomidate-lipuro and propofol is a valuable agent for induction.

Pain on injection of propofol: a comparison of methylene blue and lidocaine.

STUDY OBJECTIVE To investigate whether methylene blue, given before injection of propofol, was effective in reducing the frequency and severity of pain associated with propofol injection. DESIGN Prospective, randomized, double-blinded clinical study. SETTING Operating room of a university hospital. PATIENTS 90 adult, ASA physical status 1 and 2 patients undergoing elective surgery. INTERVENTIONS Patients were randomly allocated to one of three groups of 30 patients each. Group I received 50 mg of methylene blue, Group II received 40 mg of lidocaine, and Group III, the control group, was given normal saline. All drugs were given as a 2.0 mL bolus 45 seconds before propofol administration. MEASUREMENTS Injection pain using vocal responses, facial grimacing, arm withdrawal, tears, and questioning of the patient were noted. A 4-point scale was used for documenting pain. MAIN RESULTS Pain frequency was 90% in the saline group, whereas the frequencies were significantly lower in the lidocaine and methylene blue groups (26.7% and 40%, respectively). CONCLUSIONS Intravenous pretreatment with methylene blue appears to be effective in reducing the pain during propofol injection.

Analgesic effect of intra-articular tramadol compared to morphine after arthroscopic knee surgery

PURPOSE The aim of the study was to compare the analgesic effect of 5 mg intra-articular (IA) morphine with 50 mg IA tramadol. TYPE OF STUDY Prospective double-blind randomized trial. METHODS Seventy-five patients having elective arthroscopic surgery of the knee were randomized to receive IA tramadol 50 mg (tramadol group), IA morphine 5 mg (morphine group), or IA normal saline (control group), in equivalent volumes (20 mL). The tourniquet was released 10 minutes after analgesic administration. Verbal pain rating score between 0 and 10 (VRS), supplemental analgesic requirements, and incidence of side effects were recorded postoperatively. RESULTS Results are given as (median [5-95 percentiles]). The control group had a significantly shorter time to first analgesic request (25 min [15-55]) than morphine group, (34 min [15-158], P < .008) and the tramadol group, (33 min [17-728], P < .008). The patients in the control group complained of more severe pain (VRS 7 [4-10]) when they arrived at the postanesthesia care unit compared with the morphine group (VRS 1 [0-9], P = .002) and with the tramadol group (VRS 0 [0-9], P = .002). These treatment benefits were especially prominent in the patients who had meniscectomy or in the subgroup of patients with more than 6 months of preoperative pain. There was no statistical difference between the tramadol and morphine groups in the time to first analgesia, postoperative pain scores after arrival at the postanesthesia care unit, consumption of rescue analgesic, or side effects. CONCLUSIONS We conclude that 50 mg IA tramadol provides analgesia equivalent to 5 mg IA morphine. LEVEL OF EVIDENCE Level II, randomized controlled trial that shows no significant difference and lacks narrow confidence intervals.

Cardiac arrest in a patient with Larsen syndrome under sevoflurane anesthesia

SIR—We read with interest the report of Morishima et al. who reported three consecutive general anesthetics using sevoflurane in the same patient with Larsen syndrome (1). We would like to report a child with Larsen syndrome who had a cardiac arrest and died during spinal surgery under sevoflurane anesthesia. A 6 year old, 20 kg boy with Larsen syndrome was scheduled for spinal surgery to treat progressive kyphoscoliosis. The patient was examined by the Department of Pediatric Cardiology and they reported, LVEDD: 43 mmHg, LVESD: 31.5, EF: 53%, TR:I-III (RVSP: 50–55 mmHg) MR: I, MVP, AVP, TVP by echocardiography. Anesthesia was induced and maintained with nitrous oxide, oxygen, and sevoflurane at concentrations of 8 and 1.5%, respectively. We did not have trouble with intubation. The larynx was easily seen and intubated with a 5.5 mm reinforced tracheal tube. We administered fentanyl 40 lg (2 lgÆkg) for analgesia at the beginning of the surgery. After induction, a second 16G intravenous canula, a femoral central catheter and arterial line were placed. The patient was then turned prone on a Gardner frame with padded supports for the pelvic and thoracic area. We used controlled ventilation during the operation. Before the skin incision and throughout the procedure, the mean arterial pressure (MAP) was maintained at 60–70 mmHg. Four hours into the procedure, as the blood loss was 320 ml and we had given 200 ml packed-red cells, there was an abrupt fall in the systolic blood pressure from 90 to 48 mmHg. At the same time, the electrocardiogram changed, with T-wave inversion and abrupt fall in heart rate, from 110 to 40 bÆmin. Within 30 s of initial decrease in blood pressure, the patient became asystolic and had no palpable pulse. There was no response to an initial dose of epinephrine (0.5 mg) and atropine (0.5 mg). The patient was turned supine and cardiopulmonary resuscitation was started. We gave three additional doses of epinephrine and sodium bicarbonate (50 mmol each). CPR was maintained for 2 h but no cardiac rhythm returned so attempts were abandoned. The blood loss was not so large as to cause to hypovolemia. We believe that the sudden hypotension and bradycardia was caused by a cardiac complication of Larsen syndrome. We think that patients with Larsen syndrome associated with cardiac problems may not tolerate procedures such as spinal surgery in the prone position even with sevoflorane which has less myocardial depression than other inhalational anesthetic agents. Fatma Sar ıcaoğlu , M D Didem Dal , M D Faculty of Medicine, Department of Anesthesiology and Reanimation, Hacettepe University School of Medicine, Ankara, Turkey (email: fatmasaricao@yahoo.com)