Guner Dagli

A Comparison of Gabapentin and Ketamine in Acute and Chronic Pain After Hysterectomy

BACKGROUND: Gabapentin and ketamine are popular analgesic adjuvants for improving perioperative pain management. We designed this double-blind, placebo-controlled study to test and compare the preventive effects of perioperative ketamine and gabapentin on early and chronic pain after elective hysterectomy. METHODS: Sixty patients undergoing abdominal hysterectomy were randomly assigned to 1 of the following 3 groups: control group received oral placebo capsules and bolus plus infusion of saline; ketamine group received oral placebo capsules and, before incision, 0.3 mg/kg IV bolus and 0.05 mg·kg−1·h−1 infusion of ketamine until the end of surgery; and gabapentin group received oral gabapentin 1.2 g and bolus plus infusion of saline. The anesthetic technique was standardized, and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Patients were questioned at 1, 3, and 6 mo after surgery for chronic postoperative pain. RESULTS: Postoperative pain scores were significantly lower in the gabapentin group compared with the ketamine and control groups, and patient-controlled analgesia morphine use was significantly reduced in both treatment groups (versus control group) (P < 0.001). Total patient-controlled analgesia morphine use was decreased by 35% and 42% in the ketamine and gabapentin groups, respectively, compared with the control group (P < 0.001). Patient satisfaction with pain treatment was significantly improved in the ketamine and gabapentin groups compared with the control group (P < 0.001). The incidence of incisional pain and related pain scores at the 1-, 3-, and 6-mo follow-up were significantly lower in the gabapentin group compared with the ketamine and control groups (P < 0.001). CONCLUSION: Gabapentin and ketamine are similar in improving early pain control and in decreasing opioid consumption; however, gabapentin also prevented chronic pain in the first 6 postoperative months.

The effects of gabapentin on acute and chronic pain after inguinal herniorrhaphy.

Background and objective To find out whether preoperative gabapentin use had a favourable effect on long-term postoperative pain in patients undergoing inguinal herniorrhaphy. Methods Sixty male patients – aged 20–40 years – who were scheduled for unilateral inguinal herniorrhaphy under spinal anaesthesia were included in this prospective, randomized, double-blind study. The patients were randomly allocated to two groups: the gabapentin group (n = 30) received single-dose 1.2 g oral gabapentin 1 h before surgery, and the placebo group received a placebo capsule instead. Spinal anaesthesia was performed with heavy bupivacaine, and all operations were performed by the same surgeon with the same technique. Postoperative analgesia was evaluated during sitting and lying with a visual analogue scale. Assessment of postoperative pain at 1, 3 and 6 months was carried out with an 11-point numerical rating scale; 0 indicating ‘no pain’ and 10 indicating ‘worst pain imaginable’. Patients who had numerical rating scale scores of more than 0 were further evaluated with regard to the impact of pain on their daily activities. Results When compared with the placebo group, the gabapentin group displayed significantly lower visual analogue scale scores (lying and sitting) and total tramadol consumption at 8, 12, 16, 20 and 24 h after surgery (P < 0.05) and higher postoperative patient satisfaction scores (P < 0.05). Numerical rating scale scores at 1, 3 and 6 months after surgery were lower in the gabapentin group than in the placebo group (P < 0.05). The number of patients whose daily activities were adversely affected by pain was smaller in the gabapentin group at the first month; however, the two groups were found to be similar at 3 and 6 months. Conclusion We conclude that preoperative single-dose gabapentin decreases the intensity of acute postoperative pain, tramadol consumption and the incidence and intensity of pain in the first 6 months after inguinal herniorrhaphy.

A comparison of dexmedetomidine versus midazolam for sedation, pain and hemodynamic control, during colonoscopy under conscious sedation.

Objective The intent of our study was to compare the effects of dexmedetomidine versus midazolam on perioperative hemodynamics, sedation, pain, satisfaction and recovery scores during colonoscopy. Material and methods A total of 60 ASA I–II patients, between 20 and 80 years of age were included in the study. Patients were randomly assigned to two groups. Midazolam 0.05 mg kg−1 and fentanyl citrate 1 μg kg−1 were administered intravenously to cases in Group I (n = 30). An initial loading dose of 1 μg kg−1 dexmedetomidine was administered intravenously in 10 min to cases in Group II (n = 30) before the procedure and as a continuous infusion dose of 0.5 μg kg−1 h−1 just before the procedure started. Also 1 μg kg−1 fentanyl citrate was administered intravenously immediately before the procedure. Peripheral oxygen saturation (SpO2), mean arterial pressure (MAP), heart rate (HR), Ramsay Sedation Scale (RSS), Numeric Rating Scale (NRS) scores and colonoscopist satisfaction scores of the cases were recorded. Results Although statistically significant values were not detected between the two groups with regard to mean arterial pressure, in Group I heart rates were higher and Spo2 scores were lower in a statistically significant manner. When the groups were compared with regard to RSS, the RSS scores of Group I at the 10th and 15th minutes were significantly lower than Group II. There was no statistically significant difference between the two groups when compared with regard to NRS scores. Satisfaction scores were significantly lower in Group II. Conclusion Dexmedetomidine provides more efficient hemodynamic stability, higher Ramsay sedation scale scores, higher satisfaction scores and lower NRS scores in colonoscopies. According to our results we believe that dexmedetomidine can be used safely as a sedoanalgesic agent in colonoscopies.

The Analgesic Effect of Paracetamol When Added to Lidocaine for Intravenous Regional Anesthesia

BACKGROUND: In this study, we evaluated the effect of paracetamol on sensory and motor block onset time, tourniquet pain, and postoperative analgesia, when added to lidocaine in IV regional anesthesia (IVRA). METHODS: Sixty patients undergoing hand surgery were randomly and blindly divided into three groups. All groups received IVRA lidocaine (3 mg/kg) diluted with saline to a total volume of 40 mL. Group 1 received IVRA lidocaine plus IV saline, Group 2 received IVRA lidocaine and paracetamol (300 mg) admixture plus IV saline, and Group 3 received IVRA lidocaine plus IV paracetamol (300 mg). Sensory and motor block onset time, tourniquet pain, and analgesic use were assessed during operation. After tourniquet deflation, visual analog scale (VAS) scores at 1, 2, 4, 6, 12, and 24 h, the time to first analgesic requirement, total analgesic consumption in first 24 h, and side effects were noted. RESULTS: Onset of motor block was shorter and recovery of motor and sensory block was significantly longer in Group 2 (P < 0.05). Intraoperative VAS scores at intraoperative 20, 30, and 40 min were significantly lower in Group 2 (P < 0.05). Intraoperative fentanyl consumption (78 ± 12, 58 ± 14, 78 ± 11 &mgr;g, respectively) and the number of patients who required fentanyl for tourniquet pain (13 patients, 3 patients, 9 patients, respectively) were significantly less in Group 2 (P < 0.05). Time to postoperative fentanyl administration was also prolonged (15 ± 6, 25 ± 5, 15 ± 4 min, respectively) in Group 2 (P < 0.05). The quality of surgical anesthesia was better in Group 2 (P < 0.05). Postoperative VAS scores and time of initial analgesic requirement were similar among groups; however, the total amount of diclophenac use was less in Group 2 (P < 0.05). CONCLUSION: The addition of paracetamol during IVRA with lidocaine decreased tourniquet pain, increased anesthesia quality, and decreased postoperative analgesic consumption.

The Comparison of the Effects of Different Doses of Levobupivacaine Infiltration on Wound Healing

Introduction-Aim: The easiest method in postoperative analgesia is the infiltration of the wound with local anesthetic drugs. Although many local anesthetic drugs have been used for this type of infiltration, studies on levobupivacaine are rare. The aim of this study was to investigate the effects of different concentrations of levobupivacaine infiltration on wound healing. Method: Forty female Wistar-Albino rats (280–300 g) were included in the study, which were randomly separated into four groups. Rats were infiltrated with 1.25 mg/mL levobupivacaine in group L1.25 (n = 10), with 2.50 mg/mL levobupivacaine in group L2.5 (n = 10), with 3.75 mg/mL levobupivacaine in group L3.75 (n = 10), and with normal saline in control group (n = 10). Breaking-strength measurements, levels of hydroxyproline, and fibrotic index were evaluated in the tissue samples taken from the rats. Results: When the breaking-strength measurements were evaluated, we have found a significant difference between the control and the study groups (p < 0.05). In the intergroup comparison the difference between groups L1.25 and L3.75 was statistically significant (p < 0.05). In all of the levobupivacaine groups the levels of hydroxyproline were higher compared to the control group. Also significant differences were observed between groups L1.25 and L2.5 and groups L1.25 and L3.75 (p < 0.05). The levels of tissue fibrotic index were higher in all of the levobupivacaine groups compared to the control group (p < 0.05) and also a difference was observed between groups L1.25 and L3.75 in terms of tissue fibrotic index (p < 0.05). Conclusion: We have concluded that levobupivacaine used in clinical doses have a significant effect on the fastening of wound healing and this effect increases with an increase in the concentration of the levobupivacaine. We believe that levobupivacaine will be more widely preferred in the near future in the postoperative analgesia.

Ecthyma-gangrenosum-like lesions associated with methicillin-resistant Staphylococcus aureus infection.

Ecthyma gangrenosum (EG) manifests as a skin lesion and is commonly associated with Pseudomonas aeruginosa septicemia in immunocompromised patients. Other viral, fungal and bacterial agents can also cause EG. The first clinical observation is grouped vesicles with surrounding erythema. Within a few days, they evolve into a gangrenous ulcer with a black/gray eschar surrounded by an erythematous halo. Herein, we present a patient with chronic obstructive pulmonary disease who developed EG-like lesions due to methicillin-resistant Staphylococcus aureus infection while he was in the intensive care unit.

A complication during caudal steroid injection

BACKGROUND AND OBJECTIVE Epidural injections in the lumbar spine are provided by caudal, lumbar interlaminar or transforaminal routes. Caudal epidural steroid injections are often used for low back pain. Fluoroscopic guidance has been frequently cited as a requirement for this procedure. In this case report, we demonstrate the importance of fluoroscopic guidance during caudal epidural injection. CASE REPORT A 60 years old male patient was admitted to our Algology Department for low back pain. After physical examination caudal epidural steroid injection was planned. The caudal space was identified under fluoroscopic control initially using an anteroposterior projection. After the resultant epidurogram demonstrated vascular spread along the caudal epidural space the needle was withdrawn and the procedure was completed after reinserting the needle. CONCLUSION A careful real time fluoroscopic monitoring should be applied with the injection of opaque material to minimize the risk of vascular injection.

Anesthesia in a child with massive thyroid enlargement

SIR—‘Cretinism’ is a congenital deficiency of thyroid hormones, retarding mental and physical growth. The tongue is large and the neck is short and thick. Intubation can be difficult. Tracheomalacia and hematoma formation can complicate the postoperative course, but can be minimized by an experienced surgical team. A 19-year-old, mentally and growth retarded girl who was 1.27 m high and weighed 31 kg was scheduled for elective thyroidectomy for giant diffuse goiter (Figure 1). The right thyroid lobe was 16 · 15 · 8 cm and the left lobe was 20 · 15 · 8 cm. In her preoperative examination, difficulty in breathing, tachycardia (120–130 bÆmin), minimal mitral regurgitation and minimal tricuspid insufficiency was determined. Because the patient could not cooperate, respiratory function tests, indirect and fiberoptic laryngoscopic examination could not be performed and Mallampati scoring could not be determined. The neck was short and thick. Sternomental distance could not be measured because of the thyroid gland. Thyromental distance was measured as 4.0 cm, and the trachea could not be palpated. Under these conditions, it was decided that the case carried a high risk of difficult airway. Anesthesia induction was provided with 1 mg midazolam, 1 lgÆkg fentanyl, 1.5 mgÆkg lidocaine and incremental doses of 10 mg propofol (total 70 mg) until eyelash reflex was lost. During induction of anesthesia manually assisted spontaneous mask ventilation was maintained for 3 min with 100% oxygen. Direct laryngoscopy was performed. Direct view of the glottic area and vocal cords was obtained and a size 5.5 cuffed tracheal tube was inserted orally. After the endotracheal intubation 0.1 mgÆkg vecuronium was given for muscle relaxation. After the successful operation, the patient was transferred to our intensive care unit for mechanical ventilation and further monitoring. She was extubated and observed closely especially for the complications of tracheamalacia and bleeding for 24 h. The postoperative course was uneventful then she was discharged to the ward without any complications. When the masses that were dissected during the operation were weighed and measured right thyroid and left thyroid lobe was found 460 g in weight and 16 · 15 · 8 cm wide, 775 g in weight and 20 · 15 · 8 cm wide respectively weighing 1235 g in total. In the literature, one study claimed that the rate of difficult airway is 11.1% (2). However, another study found no association between goiter and difficult intubation in patients undergoing thyroidectomy, and the rate of difficult airway was 5.3% (3). Agarwal et al. (4) suggest that patients with longstanding goiter, even when benign, are more prone to develop tracheomalacia. On the basis of their experience they (a)

The Effect of Ultrasound Guided Transversus Abdominis Plane Block for Cesarean Delivery on Postoperative Analgesic Consumption

Backgraund and aim: In our study we evaluated the postoperative analgesic consumption and analgesic efficacy of ultrasound guided transversus abdominis plane (USG-TAP) block in patients undergoing caesarean section (CS). Methods: Seventy ASA I-II patients undergoing CS following spinal anaesthesia were included in our study. The patients were divided into two groups randomly: Group T (TAP Block group) (n:35) and Group C (Control group) (n:35). At the end of the surgery Group T patients received USG-TAP block using 20 ml of 0.25% levobubivacaine. All participants received standart analgesic regime of tramadol via intravenous patient controlled analgesia (IV-PCA). Patients were assessed at 1, 4, 6, 12, 18 and 24 h after TAP block for hemodynamic parameters, verbal numerical rating pain scores (VNRS) (pain at rest and coughing), total amount of IV-PCA tramadol demand and consumption, time to first rescue analgesia, total amount of rescue analgesic demands, sedation, nausea, vomitting and satisfaction by a blinded investigator. Results: The VRNS scores both at rest and coughing were found significantly lower in TAP block group with levobupivacaine compared to control group at all check points. Total amount of IV-PCA tramadol demand and consumption, number of rescue analgesic demands and consumption were significantly lower in TAP block group. Time to first rescue analgesia was longer in TAP group. Patient satisfaction was significantly higher in TAP group. Conclusions: In our study USG-TAP block provided effective postoperative analgesia and we consider this technique as a safe and effective method for postoperative pain control after Caesarean delivery.

Respiratory Depression Caused by Heroin Use

Summary Heroin is a semisynthetic narcotic analgesic and heroin abuse is common due to its pleasure-inducing effect. For the last 30 years heroin abuse has become an important worldwide public health problem. Heroin can be administered in many different ways as preferred. Heroin affects many systems including respiratory system, cardiovascular system and particulary the central nervous system. Overdose use of heroin intravenously can be fatal due to respiratory depression. In this letter, we wanted to engage attention to respiratory depression caused by heroin abuse and potential benefits of using naloxone.