Hakan Bayır

Effect of pregabalin and dexamethasone on postoperative analgesia after septoplasty.

Objectives. The aim of this study was to explore effect of a combination of pregabalin and dexamethasone on pain control after septoplasty operations. Methods. In this study, 90 patients who were scheduled for septoplasty under general anesthesia were randomly assigned into groups that received either placebo (Group C), pregabalin (Group P), or pregabalin and dexamethasone (Group PD). Preoperatively, patients received either pregabalin 300 mg one hour before surgery, dexamethasone 8 mg intravenously during induction, or placebo according to their allocation. Postoperative pain treatment included tramadol and diclofenac sodium 30 minutes before the end of the operation. Numeric rating scale (NRS) for pain assessment, side effects, and consumption of tramadol, pethidine, and ondansetron were recorded. Results. The median NRS score at the postoperative 0 and the 2nd h was significantly higher in Group C than in Group P and Group PD (P ≤ 0.004 for both). The 24 h tramadol and pethidine, consumptions were significantly reduced in Groups P and PD compared to Group C (P < 0.001 and P < 0.001). The incidence of blurred vision was significantly higher in Group PD compared to Group C within both 0–2 h and 0–24 h periods (P = 0.002 and P < 0.001, resp.). Conclusions. We conclude that administration of 300 mg pregabalin preoperatively may be an adequate choice for pain control after septoplasty. Addition of dexamethasone does not significantly reduce pain in these patients.

Ultrasound-guided femoral and sciatic nerve blocks combined with sedoanalgesia versus spinal anesthesia in total knee arthroplasty.

Background Although regional anesthesia is the first choice for patients undergoing total knee arthroplasty (TKA), it may not be effective and the risk of complications is greater in patients who are obese or who have spinal deformities. We compared the success of ultrasound-guided femoral and sciatic nerve blocks with sedoanalgesia versus spinal anesthesia in unilateral TKA patients in whom spinal anesthesia was difficult. Methods We enrolled 30 patients; 15 for whom spinal anesthesia was expected to be difficult were classified as the block group, and 15 received spinal anesthesia. Regional anesthesia was achieved with bupivacaine 62.5 mg and prilocaine 250 mg to the sciatic nerve, and bupivacaine 37.5 mg and prilocaine 150 mg to the femoral nerve. Bupivacaine 20 mg was administered to induce spinal anesthesia. Hemodynamic parameters, pain and sedation scores, and surgical and patient satisfaction were compared. Results A sufficient block could not be obtained in three patients in the block group. The arterial pressure was significantly lower in the spinal group (P < 0.001), and the incidence of nausea was higher (P = 0.017) in this group. Saturation and patient satisfaction were lower in the block group (P < 0.028), while the numerical pain score (P < 0.046) and the Ramsay sedation score were higher (P = 0.007). Conclusions Ultrasound-guided sciatic and femoral nerve blocks combined with sedoanalgesia were an alternative anesthesia method in selected TKA patients.

A case of anesthesia mumps after general anesthesia

To the Editor: We report a 57-year-old female patient who underwent a correction of surgical scar and sagging of the abdominal skin by plastic surgeons. She was 155 cm and 95 kg, with body mass index 37.5 kg/m. She had a history of arterial hypertension for 5 years. General anesthesia was induced by propofol 3 mg/kg and fentanyl 1 lg/kg. Endotracheal intubation was performed with muscle relaxation using rocuronium bromide 0.6 mg/kg after assisted ventilation and induction. Maintenance of anaesthesia was achieved with sevoflurane (2–3 vol%) in 50% O2 and 50% air. The patient was extubated without any problems at the end of the surgery. In the recovery room, a painless swelling on the left pre-auricular and post-auricular areas extending up to the angle of the mandible was detected (Fig. 1). In addition, there was crepitation on palpation. There was no evidence of inflammation. The left parotid gland swelling was decreased in the next 24 h and resolved completely in 2 days. Pneumoparotitis is a postoperative complication of general anesthesia characterized by acute transient swelling of the parotid gland that is defined as ‘‘anesthesia mumps.’’ Anesthesia mumps is a rare and interesting clinical entity. However, the phenomenon is a clinical condition well known to experienced anesthesiologists. This clinical entity results from air refluxing into the parotid ductal system via an incompetent Stensen duct orifice [1]. These swellings usually resolve spontaneously over a period of a few hours to a few days without any known sequelae [2]. The exact mechanism of the development of pneumoparotitis in not fully understood. Stensen’s duct leaves the lateral surface of the parotid gland, passes lateral to the masseter muscle, and enters the oral cavity through the buccal tissues adjacent to the maxillary first and second molars [3]. Possible explanations include positive pressure ventilation during general anesthesia and increased pressure in the oral cavity. Pneumoparotitis has been reported in the following situations or maneuvers in the literature: wind instrumentalists, balloon and glass blowers, bicycle tire inflation by mouth, dental procedures using air-powered equipment, cough in chronic obstructive pulmonary disease and cystic fibrosis, nose blowing, whistling, valsalva maneuver to clear ears, and spirometry [4]. We thought that the clinical picture in the present case may have resulted from intra-oral pressure increase via mask ventilation during general anesthesia. Medical history and physical examination are important in the differential diagnosis of the disease. Obstructive, inflammatory, metabolic, and neoplastic causes of parotid gland enlargement should be ruled out. Crepitation on palpation is diagnostic for pneumoparotitis, but it can be mistaken in up to 50% of the patients [4]. Gland swelling, erythema, and tenderness on palpation may be detected in pneumoparotitis as a consequence of inflammation and infection [5]. In our case; the clinical examination showed swelling of the gland and crepitation on palpation, but erythema and pain were not observed. In conclusion, parotid gland enlargement with air after general anesthesia is a rare condition. Medical history, physical examination, and radiologic studies may play an important role in the differential diagnosis and management of the condition. U. Y. Tekelioglu (&) A. Akkaya A. Demirhan H. Bayır H. Kocoglu Department of Anesthesiology and Reanimation, Abant Izzet Baysal University Medical School, Bolu, Turkey e-mail: drtekelioglu@yahoo.com

Antiemetic effects of dexamethasone and ondansetron combination during cesarean sections under spinal anaesthesia

BACKGROUND Nausea and vomiting are frequently seen in patients undergoing cesarean section (CS) under regional anesthesia. We aimed to compare the antiemetic efficacy of ondansetron and dexamethasone combination with that of the use of each agent alone to decrease the incidence of post-delivery intraoperative nausea and vomiting (IONV) during CS under spinal anesthesia. OBJECTIVE To compare the antiemetic efficacy of ondansetron and dexamethasone combination with that of the single use of each agent to decrease the incidence of postdelivery IONV during CS under spinal anesthesia. METHODS A randomized, prospective, double blind study was performed on 90 patients undergoing planned CS under spinal anesthesia. Patients received 4mg ondansetron in Group O, 8mg dexamethasone in GroupD, 4mg ondansetron+8mg dexamethasone in Group OD intravenously within 1-2 minutes after the umbilical cord was clamped. Frequency of postdelivery IONV episodes was recorded. RESULTS A total of 86 eligible patients were included in the study. There were 29 patients in Group O, 29 patients in Group D and 28 patients in Group OD. There were no statistically significant difference between the groups in terms of baseline characteristics and intraoperative managements. Frequency of intraoperative nausea, retching and vomiting experiences were similar between the groups (p>0.05). CONCLUSION Single dose 4mg ondansetron, 8mg dexamethasone, or combined use of 8mg dexamethasone+4mg ondansetron, given intravenously is all effective agents for the control of postdelivery IONV. Combined use of dexamethasone and ondansetron for the same indication does not seem to increase the antiemetic efficacy.

Role of Ultrasonography in Detecting the Localisation of the Nasoenteric Tube

OBJECTIVE In this study, we aimed to determine the success rate of nasoenteric tube (NET) insertion into the postpyloric area using ultrasonography (USG) and compare with the commonly used method direct abdominal graphy. METHODS A single anaesthesiologist placed all the NETs. The NET was visualised by two radiologists simultaneously using USG. The localisation of the tube was confirmed using an abdominal graph in all patients. RESULTS The blind bedside method was used for NET insertion into 34 patients. Eleven of the tubes were detected passing through the postpyloric area using USG. In one case, the NET could not be visualised in the postpyloric area using USG; however, it was detected in the postpyloric area through control abdominal radiography. In 22 patients, NETs were detected in the stomach using control abdominal radiography. The rate of imaging post pyloric using USG was 91.6%. When all cases were considered, catheter localisation was detected accurately using USG by 97% (33 in 34 patients). CONCLUSION USG is a reliable and practical alternative to radiography, which can be used to detect localisation of the nasogastric tube and NET.

Achalasia case detected during endoscopy application accompanied by anaesthesia

Achalasia is an uncommon dysfunctional neuromus-cular disease of the oesophagus. General anaesthesia might be required for its diagnosis and treatment. During the anaesthesia, complications such as oesoph-agus dilatation-perforation and tracheal aspiration in oesophagus content might be seen. In order to ensure the security of the respiratory tract, rapid intubation might be required [1]. When anaesthesia is required in endoscopy units for diagnosis, equipment and devices standardised for outpatient anaesthesia applications by American Society of Anaesthesiologists (ASA) should immediately be ready [2]. A 41-year-old male patient, who applied to the Gas-troenterology Polyclinic due to gastric complaints and had lymphadenopathy detected in his abdomen ultra-sonography, was scheduled for conscious endoscopy. He was unable to tolerate the endoscopy which was applied following twelve-hour fasting, and he vomited. Endoscopy with anaesthesia was then planned, rescheduled with two weeks of strict liquid food diet and pineapple juice application. The patient was taken to the endoscopy unit following 24 h of fasting, and was monitored with ECG and pulse oximeter. Intubation was then planned. Anaesthesia induction was conducted with 50 mg of remifentanil and 100 mg of propofol. While O 2 was provided with a mask, the intraoral and oropharyngeal area was filled with liquid. Despite rapid aspiration, the contents continuously flowed to intra-oral area, and the patients saturation dropped. He was immediately intubated. In the meantime, the amount of aspired liquid content was 900 ml. Having reached normal levels of saturation and haemodynamic values in the patient, endoscopy operation began with propo-fol addition. Significant achalasia and duodenal ulcers were detected. When the patients respiration was sufficient, he was extubated. The patient, who did not have respiratory problems and whose haemodynamics were stable, was sent to the service without a problem upon observation at the patient recovery room. In outpatient anaesthesia applications, various mortality rates and complications have been reported. During operation, complications may occur such as; allergic reactions, nausea-vomiting, aspiration of the gastric content, and damaging of the team according to the environment with hypovolaemia. It has been reported that respiratory problems have been encountered in old patients the most, and complications have been encountered mostly in the gastroenterology unit [3]. One of the factors that increases mortality and morbidity during anaesthesia applications is gastric content aspiration. In ASA guides, it has been deemed suitable for adult patients to apply 6 h of fasting after 2 h of clear liquid consumption, following light food consumption …

A difficult intensive care unit monitorization case: a suicidal attempt at 13 years of age by hanging -

Suicide among young population is a global challenge increasing over time. Family problems, drug addiction, increased risk of childhood depression may lead to suicidal attempts by hanging with a rope, which is a rarely selected method at younger ages. Increased suicidal attempt rates cause increased rates of intensive care unit monitorization. Psychosocial support is quite important at this age group. In this report, a 13 years old girl, who was monitorized at the intensive care unit after she attempted suicide by hanging, would be discussed.

A pediatric case of anesthesia mumps after general anesthesia

Sir/Madam, We would like to report an 8-year-old child with swelling of the right parotid gland after general anesthesia. He weighed 18 kg and underwent adenoidectomy and bilateral tympanostomy tube insertion operation. Preoperatively, he was normal and he also had no other medical problem. Anesthesia induction was performed with 2 mg/kg of propofol, 1 mcg/kg of fentanyl, and 0.5 mg/kg of rocuronium. After endotracheal intubation, maintenance of anesthesia was achieved with sevoflurane (2-3 vol%) in 50% O2 and 50% air. The surgical procedure lasted for 35 min. The patient was extubated without any problems at the end of the surgery. After the extubation period, we noticed a painless swelling on the right parotid gland extending the angle of the mandible [Figures ​[Figures11 and ​and2].2]. There was no sign of inflammation. The right parotid gland swelling disappeared in the next 24 h without any sequelae. Figure 1 Adenoid face of patient and swelling of right parotid gland Figure 2 Swelling of right parotid gland Acute transient swelling of the parotid gland related to anesthesia, defined as “anesthesia mumps,” is a rare complication. It is a benign and noninfectious complication.[1] This usually occurs immediately after surgery and resolves spontaneously over a period of a few hours to a few days without any known sequelae.[2] It was more rarely seen in the pediatric population compared to adults. Although the exact mechanism of anesthesia mumps is not fully explained, different explanations have been suggested including obstruction of Wharton or Stensen ducts from patient positioning and endotracheal tube placement, positive pressure ventilation during and increased pressure in the oral cavity, and thickened oral secretions secondary to salivary stasis.[3] We thought that the clinical picture in our case may have resulted from intraoral pressure increase by mask ventilation or from obstruction of ducts due to head positioning during bilateral tympanostomy tube insertion. Our patient had an adenoid face (a narrow upper dental arch, increased anterior face height, a steep mandibular plane angle, and a retrognathic mandible). Manual ventilation on mask was not comfortable due to poorly fitting mask during the induction. Also, the patient had a relative microgratia. On the other hand, tympanostomy tube insertion was made when the head rotated to the left side and right side. Anesthesia mumps usually resolves spontaneously over a period without any treatment. In some cases, hydration and warm compresses may be helpful in relieving the symptoms.[2,4] In our case, we managed the swelling conservatively by the advice of otolaryngology clinic. The swelling decreased and resolved completely in 24 h. Additionally, there was no radiologic image for this patient. The swelling of the parotid gland resolved gradually and also, the otolaryngologists did not anticipate any other pathology due to signs of swelling. We did not want to perform an x-ray examination of this child patient for benign swelling. In conclusion, anesthesia mumps may occur immediately after general anesthesia in pediatric patients and they fully recover. Also, we hope that the reporting of such pediatric cases would increase the awareness among anesthesiologists regarding this benign complication.

Suicide Attempt with Rodenticide Including Zinc Phosphide Case Report

Zinc phosphide is a toxic chemical agent used as a rodenticide. The effects are on heart, lung, kidney and gastrointestinal tract. Metabolic acidosis, high amylase, liver damage, hypotension, shock and cardiac arrhythmia is observed. Forty-year-old male patient evaluated with a history of taking zinc phosphide containing rat poison in order to commit suicide. Respiratory distress, arrhythmias, commonly involuntary muscle contraction, metabolic acidosis, coagulation disorders, amylase, AST and LDH levels were determined. Term follow-up after intensive care unit and was discharged favor. In this paper, for the purpose of suicide zinc phosphide our experiences in the field of public information in the cases of ICU follow-up treatment process is intended to share the accompaniment.

Submental Orotracheal Intubation in Maxillofacial Fracture Surgery: Report of Two Cases.

Two patients, aged 18 and 28 years, with maxillofacial trauma due to motor vehicle accident, were operated upon by a team of plastic surgeons. In this report we aimed to present our experience with submental intubation procedure in these cases, in which orotracheal or nasotracheal intubation was impossible due to panfacial fracture.