Gamze Sarkilar

Effect of gabapentin on postoperative pain: A randomized, placebo-controlled clinical study

Background: Both clinical and experimental studies suggest that gabapentin (GBP) has analgesic effects in neuropathic pain. The aim of the study was to investigate the effect of gabapentin on postoperative pain. Methods: This study was performed on 45 (ASA I-II) patients planned for major orthopaedic surgery. 45 patients were randomized into three equal groups. Patients received 1200 mg GBP (Group I), 800 mg GBP (Group II) or placebo (Group III) 1 h before surgery. Anaesthesia was standardized for all patients. Morphine by intravenous patient-controlled analgesia was applied as 1 mg bolus dose and 7 min lockout time for postoperative analgesia. The pain was evaluated at the first 2 and 4 h after operation. The amount of morphine used was recorded at the same hours. Results: In all groups, there were no significant differences in the demographic characteristics, duration of surgery and anaesthesia, or dose of fentanyl received in the operating room. Pain scores and side effects were similar in all groups. Morphine consumption was lower in the Groups I and II than in the Group III at 2 h and 4 h postoperatively ( p< 0.05). Morphine consumption was lower in the Group I than in the Group II at 2 h and 4 h ( p< 0.05). Conclusion: Our results demonstrate that a single dose of 1200 or 800 mg oral gabapentin reduces morphine consumption in the early postoperative period. However, gabapentin 1200 mg is more effective than gabapentin 800 mg for pre-emptive analgesic effect. summary

Determination of optimum time for intravenous cannulation after induction with sevoflurane and nitrous oxide in children premedicated with midazolam

It has been shown that early placement of an intravenous line in children administered sevoflurane anesthesia increased the incidence of laryngospasm and movement. However, the optimal time for safe cannulation after the loss of the eyelash reflex during the administration of sevoflurane and nitrous oxide is not known.

Post-Spinal a Rare Complication and Treatment: Tinnitus and Epidural Blood Patch

Dear Editor, Rare auditory symptoms such as tinnitus after spinal anaesthesia have been observed (1–4). It can be accompanied by headache (1, 4) and can become chronic and affect a patient’s quality of life. In this case, we aimed to present our clinical experience regarding the relief of symptoms by an epidural blood patch in a patient who developed headache and bilateral tinnitus following spinal anaesthesia. A 31-year-old female patient, who was 58 kg in weight and 169 cm in height, was scheduled for operation under spinal anaesthesia due to venous stasis. Informed written consent was obtained. The spinal space was accessed with a 25-G Quincke needle on the first try through the L4–5 interspinous space. On observing a clear cerebrospinal fluid leak, 12.5 mg of hyperbaric bupivacaine and 15 μg of fentanyl were intrathecally administered in a volume of approximately 3 mL. The patient was admitted to the hospital on the first postoperative day due to severe headache that started from the nape of the neck and that involved the entire head. The headache was accompanied by tinnitus (ringing in both ears and motor noise) and nausea–vomiting and was more prominent in the standing and sitting positions. The patient was chiefly discomforted by the tinnitus. The headache diminished while in the lying position, but the tinnitus did not subside. An intravenous access was established in the patient, and she was hydrated. An oral caffeinated analgesic and antiemetic were started. The headache alleviated on the second day of admission, but the tinnitus remained. The patient was unable to sleep and expressed that she was extremely discomforted by this. Given that it was accompanied by headache, we thought that the patient could benefit from an epidural blood patch. Following appropriate site cleaning, approximately 12 mL of the blood patch was epidurally administered by accessing the same space. The tinnitus in the left ear immediately improved following the injection, while it disappeared within approximately 12 h in the right ear. Additionally, the complaint of pain, which lost its severity with the medical treatment, completely disappeared. Aetiology regarding symptoms related to hearing following spinal anaesthesia is not very clear. One of the proposed hypotheses is the decrease in intra-labyrinth pressure. The cochlear duct provides an anatomical connection between the cochlea and the subarachnoid distance. The composition of the perilymph in the cochlea closely resembles the cerebrospinal fluid. One of the proposed views is that a decrease in cerebrospinal fluid pressure causes a decrease in intra-labyrinth pressure and that this causes functional inability in the ear in transmitting sounds (5). Symptoms could spontaneously subside; however, there are patients who became chronic. The relationship of chronic cases with spinal anaesthesia can only be revealed by obtaining a good medical history. These patients can benefit from an epidural blood patch (1, 2, 4). In a patient who developed tinnitus following spinal anaesthesia (4 years), it was learned, upon obtaining medical history by the ear, nose and throat specialist, that the complaint started 24 h after spinal anaesthesia, and the patient was directed to an anaesthetist. The tinnitus was successfully treated by administering 20 mL of an epidural blood patch to the patient (2). A patient with postspinal 8 years tinnitus complaint underwent epidural anaesthesia for another surgical operation. The tinnitus recovered by the epidural administration of 27 mL of bolus, followed by a local anaesthetic performed by continuous infusion (3). Due to the high rate of success and ease of application, an epidural blood patch is the accepted gold standard treatment in treating postspinal headache when conservative treatments have failed. It is a treatment whose major side effects are (usually temporary) rare, and it is safe and effective. Side effects are low back pain or radicular pain during injection, generally related to the administered volume (6). For evaluating these cases, the epidural administration of any application-blood, normal saline or local anaesthetics-appears to be effective in improving auditory symptoms. In conclusion, the accompaniment of nausea–vomiting and tinnitus with headache that develops after spinal anaesthesia negatively affects the quality of life. Therefore, we think that administering an epidural blood patch without delay in the presence of auditory symptoms accompanying headache will improve the comfort of patients.

The Potential Effect of Epidural Anesthesia on Mesenteric Injury after Supraceliac Aortic Clamping in a Rabbit Model

BACKGROUND Epidural anesthesia is known to increase blood flow by producing vasodilatation on mesenteric circulation. In this experimental study, we aim to examine the effect of epidural anesthesia on mesenteric ischemic-reperfusion (IR) injury induced by supracoeliac aortic occlusion in a rabbit model. METHODS Twenty-eight male white New Zealand rabbits were assigned into 4 separate groups, with 7 rabbits in each group: group I, control group; group II, IR-only group; group III, IR plus epidural anesthesia group; group IV, epidural anesthesia-only group. IR model was produced by clamping supraceliac aorta with an atraumatic vascular clamp for 60 min, followed by reperfusion for 120 min. An epidural catheter was placed via Th12-L1 intervertebral space by using open technique before aortic clamping in those assigned to epidural anesthesia. IR injury was assessed using blood markers interleukin-6 and IMA and tissue markers superoxide dismutase and malondialdehyde. Also histopathological examination was performed to evaluate the degree of injury. RESULTS All biochemical markers in group II were significantly elevated in comparison with the other 3 groups (p < 0.05). This was paralleled by a more severe histopathological injury in IR- only group (group II). The group receiving IR plus epidural anesthesia (group III) had lower biochemical marker levels as compared with the IR-only group (group II). CONCLUSIONS Mesenteric IR injury that can occur during abdominal aorta surgery can be reduced by epidural anesthesia, which is commonly used during or after major operations for pain control. Controlled clinical studies are required to evaluate these findings.

Response to Makkar and Singh's comment on our article 'Determination of optimum time for intravenous cannulation after induction with sevoflurane and nitrous oxide in children premedicated with midazolam'.

SIR—We thank Drs. Makkar and Singh for their interest in our article ‘Determination of optimum time for intravenous cannulation after induction with sevoflurane and nitrous oxide in children premedicated with midazolam’ (1). The only previous study to determine the time for intravenous cannulation during sevoflurane induction was conducted by Joshi et al. (2). They found that successful time for intravenous cannulation in 50% children was 1.90 min (95% confidence limits, 1.24–2.41 min) and in 95% children it was 3.32 min (95% confidence limits, 2.68–6.77 min) after induction. According to these results, Makkar and Singh (3) advocated that selecting a starting time below 1.9 min according to Dixon’s up-and-down methodology could reduce the sample size. For a couple of reasons, cannulation time was determined to be 4 min for the first child. First, a thorough examination of the individual responses of the children in the study by Joshi et al. reveals that nine children with a cannulation time below 1.9 min reacted in response to cannulation attempts. The extremity movements after cannulation result in failed attempts, repeated needle punctures, and even laryngospasm. The present study was conducted on potentially vulnerable pediatric patients during the induction of anesthesia that could result in complications. Because of these safety concerns, safe induction timing was selected rather than the minimum induction time that would induce a response according to Dixon’s method. We attempted to maintain the cannulation time for the first patient above 3.5 min as recommended by the authors. Second, Joshi et al. (2) used sevoflurane in their study and they selected a cannulation starting time of 5 min for the first child. One of the objectives of the present study was to redetermine optimal cannulation time after addition of midazolam premedication and nitrous oxide. The addition of nitrous oxide to anesthesia induction with sevoflurane resulted in faster loss of consciousness and reduced excitatory movement. According to these results and adhering to the methodology used by Joshi et al., we planned to keep the cannulation time below 5 min for the first patient. Third, after publication of the study results of Joshi et al. (2), there was still a debate over the optimal cannulation time. In relevance to the study by Joshi et al., Kaul et al. (4) reported that not all patients were ready at 3.5 min for cannulation. They advocated that pupils became central approximately 4 or 5 min after induction and that intravenous cannulation attempts after the appearance of this eye sign would not cause any reaction. Similarly, Duboıs et al. (5) reported that the pupils became central 230 43 s (mean around 4 min) after induction of anesthesia with the mixture of sevoflurane and nitrous oxide. Taking into consideration all these findings, we selected cannulation starting time of 4 min for the first child after induction of anesthesia with sevoflurane/ nitrous oxide, and the timing was incrementally reduced until the appearance of response to cannulation. The results showed that it was not necessary to wait 4 or 5 min for the centralization of the pupils to determine the optimal cannulation time. We consider that our findings would make contribution to end the debate over this subject.

Anaesthetic Management of a Child with Limb-Girdle Muscular Dystrophy

Limb-girdle muscular dystrophies are a group of disorders with wide genetic and clinical heterogeneity. These disorders may lead to an increase in life-threatening complications related to surgery and anaesthesia. In this case, the anaesthetic management of a child with limb-girdle muscular dystrophy is presented.

Ultrason Rehberliğinde Kanulasyon Sırasında Saptanan Radiyal ArterVaryasyonu

zamanli US esliginde uygulanmasi kolaylasmaktadir. Sonuc olarak, radiyal arter kanulasyonu sirasinda farkli anatomik varyasyonlarin olabileceginin akilda tutulmasi gerektigi, kanulasyonun US rehberliginde yapilmasinin varyason saptanmasinda yararli olabile- cegi kanisindayiz