Hanife Altunkaya

The postoperative analgesic effect of tramadol when used as subcutaneous local anesthetic.

Recently, it has been shown that tramadol was an effective local anesthetic in minor surgery. In this study, its efficacy for relieving postoperative pain was evaluated. Forty patients undergoing minor surgery (lipoma excision and scar revision) under local anesthesia were included. The patients were randomly allocated into two groups: In group T (n = 20), 2 mg/kg tramadol, and in group L (n = 20), 1 mg/kg lidocaine were given subcutaneously. In both groups, the injection volume was 5 mL containing 1/200,000 adrenalin. The degree of the erythema, burning sensation, and pain at the injection site were recorded. Incision response, which is a degree of the pain sensation during incision, was recorded and graded with the visual analog scale (VAS) 0–10. After incision, VAS values were recorded at 15-min intervals. When the VAS score of the pain during surgery exceeded 4, an additional 0.5 mg/kg of the study drug was injected and this dosage was added to the total amount. Patients were discharged on the same day. Subjects with VAS ≥4 were advised to take paracetamol as needed. No side effects were recorded in either group except for 1 patient complaining of nausea in group T at the 30th min of operation. After 24 h, patients were called and the time of first analgesic use and total analgesic dose taken during the postoperative period were recorded. During the 24 postoperative hours, 18 of 20 (90%) subjects did not need any type of analgesia in group T, whereas this number was 10 (50%) in group L (P < 0.05). The time span before taking first analgesic medication was longer (4.9 ± 0.3 h) in group T than that of group L (4.4 ± 0.7 h) (P < 0.05). We propose that tramadol can be used as an alternative drug to lidocaine for minor surgeries because of its ability to decrease the demand for postoperative analgesia.

Effectiveness of dexmedetomidine in reducing bleeding during septoplasty and tympanoplasty operations.

STUDY OBJECTIVE To determine the effect of dexmedetomidine on intraoperative bleeding during septoplasty and tympanoplasty operations. DESIGN Randomized, placebo-controlled study. SETTING Univesity medical center. PATIENTS 80 ASA physical status I and II patients, aged 18 to 65 years, 40 of whom were scheduled for septoplasty and 40 to undergo tympanoplasty operations. INTERVENTIONS Patients undergoing septoplasty (S) and tympanoplasty (T) operations were randomly divided into 4 groups. Dexmedetomidine (D) was administered to Group SD and Group TD first as a bolus dose of one microg kg(-1), then intraoperative maintenance was supplied with dexmedetomidine 0.7 microg kg(-1) hour(-1). Groups S and T (controls) were given identical amounts of saline. If systolic blood pressure measurements are greater than 20% preoperative values, then fentanyl one microg kg(-1) was given. MEASUREMENTS Intraoperative blood loss was determined with suction volumes and gauze counting. Bleeding was rated according to a 6-point scale. Hemodynamic parameters and fentanyl administration were recorded. MAIN RESULTS Group SD had less bleeding and lower bleeding scores (P < 0.05). In addition, this group received less intraoperative fentanyl (P < 0.05). The only significant difference between Groups TD and T was the amount of intraoperative fentanyl given (35.4 +/- 58.8 vs 110.0 +/- 81.0 microg) (P < 0.05). CONCLUSION Dexmedetomidine reduces bleeding, bleeding scores, and intraoperative fentanyl consumption during general anesthesia in septoplasty operations.

A prospective randomized study comparing perioperative outcome variables after epidural or general anesthesia for lumbar disc surgery.

&NA; General and regional anesthesia (spinal and epidural) can be performed successfully for lumbar disc surgery. The aim of this study was to assess the superiority of general anesthesia or epidural anesthesia techniques in lumbar laminectomy and discectomy. Sixty patients undergoing lumbar partial hemilaminectomy and discectomy were randomly divided into two groups receiving standardized general anesthesia (GA) or epidural anesthesia (EA). Demographically, both groups were similar. Surgical onset time (36.72 ± 5.47 vs. 25.40 ± 7.83 minutes) was longer in the EA group, but total anesthesia time (154.32 ± 35.73 vs. 162.40 ± 26.79 minutes) did not differ between the two groups. Surgical time (118.80 ± 35.42 vs. 139.60 ± 26.80 minutes) was longer in the GA group. The heart rate and mean arterial pressure values of the EA group measured 15, 20, and 25 minutes after local anesthetic administration to the epidural catheter were found to be lower than in the GA group measured after induction of general anesthesia. The frequency of bradycardia (EA vs. GA, 3 vs. 2), tachycardia (3 vs. 7), and hypotension (6 vs. 4) during anesthesia did not differ between the groups, but the occurrence of hypertension (1 vs. 7) was higher in the GA group. Blood loss was less in the EA group than in the GA group (180.40 ± 70.38 vs. 288.60 ± 112.51 mL). Postanesthesia care unit (PACU) heart rate and mean arterial pressure were higher in the GA group. Peak pain scores in PACU and postoperative 24 hours were higher in the GA group when compared with the EA group. Nausea was more common in the GA group both in PACU and 24 hours after surgery. There was no difference between the hospitalization duration of the groups. In conclusion, this study suggests that EA is an important alternative to GA during lumbar disc surgery.

Comparison of ephedrine and ketamine in prevention of injection pain and hypotension due to propofol induction.

Background and objective: This prospective, double‐blind, randomized, placebo‐controlled study compares the effects of ephedrine and ketamine on injection pain, and hypotension from propofol. Methods: After obtaining the approval of the Ethics Commitee, 75 patients (ASA I‐II) scheduled for elective operations with general anaesthesia were divided into three groups. Saline 2 mL (Group S, n = 25), ketamine 0.5 mg kg−1 (Group K, n = 25) or ephedrine 70 μg kg−1 (Group E, n = 25) were administered over 5 s after tourniquet application. After releasing the tourniquet, propofol 2 mg kg−1 was injected in 30 s. Pain was evaluated on a numerical scale (0‐10) where 0 represented no pain and 10 the most severe pain possible. Systolic, diastolic blood pressures and heart rates were recorded preoperatively, 1 min after propofol injection, before intubation and 1, 2 and 3 min after intubation in all patients. Results: The incidences of pain in Groups S, E and K were similar (84%, 80% and 72%, respectively). The mean pain score in Group K (2.1, SD 3.1) was significantly lower than those of Groups S and E (4.9, SD 2.6 and 4.6, SD 3.3, respectively) (P < 0.05). The systolic and diastolic blood pressure values in Group K (120 ± 27 mmHg) and Group E (123 ± 21 mmHg) before intubation were significantly higher than that of Group S (104 ± 25 mmHg) (P < 0.05). There was no significant difference between the mean heart rate values of the groups. Conclusions: Low dose ketamine or ephedrine pretreatment may prevent hypotension due to propofol induction. Despite the reduction in injection pain intensity after ketamine, the study drugs were found to be ineffective in lowering the injection pain incidence.

Does dexmedetomidine reduce the injection pain due to propofol and rocuronium

Background and objectives: This prospective, double‐blind, randomized, placebo‐controlled study was designed to determine the efficacy of dexmedetomidine compared with lidocaine in reducing the pain of propofol and rocuronium injection pain. Methods: One hundred and fifty patients, scheduled for elective surgery with general anaesthesia, were divided into five groups: saline (Group 1), dexmedetomidine 0.25 &mgr;g kg−1 (Group 2), lidocaine 0.5 mg kg−1 (Group 3), dexmedetomidine 0.25 &mgr;g kg−1 plus lidocaine 0.25 mg kg−1 (Group 4) or dexmedetomidine 0.25 &mgr;g kg−1 plus lidocaine 0.5 mg kg−1 (Group 5) were administered at a rate of 0.5 mL s−1 after tourniquet application. The occlusion was released after 1 min and 5 mL of propofol was injected over 20 s. Pain was evaluated by use of a 10‐point verbal analogue scale. Then, the rest of the induction dose of propofol, 3 mL of saline bolus and 0.6 mg kg−1 of rocuronium, was injected. The response to injection of rocuronium was assessed with a four‐point scale (0–3). Results: Groups 1 and 2 were found to have higher propofol injection pain scores than Groups 3, 4 and 5 (P < 0.05). When the study groups were compared according to the overall incidence of withdrawal movements due to rocuronium (⩾1 response) in Groups 1, 2, 3, 4 and 5, they were different (86.7%, 60%, 36.7%, 50% and 40%, respectively) (P < 0.05). Except Group 1, there was no significant difference between the groups according to incidence of withdrawal movement after rocuronium injection (P = 0.325). Conclusions: Pretreatment with dexmedetomidine is not effective in reducing injection pain of propofol, but may attenuate the hand withdrawal associated to rocuronium, as lidocaine does.

Tramadol as a Local Anaesthetic in Tendon Repair Surgery of the Hand

This double-blind pilot study compared the local anaesthetic effects of tramadol plus adrenaline with lidocaine plus adrenaline during surgery to repair hand tendons. Twenty patients were randomly allocated to receive either 5% tramadol plus adrenaline (n = 10) or 2% lidocaine plus adrenaline (n = 10). Injection site pain and local skin reactions were recorded. At 1-min intervals after injection of the anaesthetic agent, the degree of sensory blockade was assessed by the patient reporting the extent to which they felt a pinprick, light touch and a cold sensation. Pain felt during surgical incision was also recorded. There was no difference in the quality of sensory blockade or the incidence of side effects between the two groups. Only patients treated with tramadol did not require additional post-operative analgesia. A combination of tramadol plus adrenaline provided a local anaesthetic effect similar to that of lidocaine plus adrenaline.

Effectiveness of the Jaw-Thrust Maneuver in Opening the Airway: A Flexible Fiberoptic Endoscopic Study

Objective: A prospective study was carried out to find the exact site of obstruction in sleep model and to quantitatively evaluate the effect of Jaw-thrust maneuver (JTM) in opening the obstructed airway using flexible fiberoptic endoscope. Methods: Twenty-eight ASA physical status I or II patients with snoring symptom undergoing elective surgery were included. The patients were held in supine position without hyperextension of the neck. Having induced anesthesia, the base of the tongue and laryngeal inlet and/or epiglottis were visualized using endoscope. The patients’ epiglottides were classified as leaf-shaped, curved (concaved or omega-shaped) and floppy types. We graded the airway opening at the level of epiglottis into six grades and obstruction at the tongue base level into four grades. The grades during inspiration (GrIns), expiration (GrExp) and after JTM (GrJTM) were recorded and compared with Pearson chi-square test. Results: The strictly curved (Ω-shaped or concaved) epiglottis supplied a salvage pathway for airflow that resisted collapsing with the posterior movement of the tongue base in 2 patients. When we compared GrIns with GrExp for epiglottis the difference was statistically significant (χ2 = 0.001), but the difference for tongue base was not (χ2 = 0.152). After JTM, GrJTM for both epiglottis and tongue base were significantly better than GrIns and GrExp (χ2 < 0.001). Conclusion: Tongue base was the principal site of obstruction although during the respiratory cycle the position of epiglottis changed prominently and increased the obstruction in inspiration. JTM alone significantly relieved the obstruction at the tongue base and epiglottis levels and increased the retroglossal airway.

Comparison of satisfaction and pain relief between patients-controlled analgesia and interval analgesia after laparoscopic ovarian cystectomy

Preoperative and postoperative psychological factors, postoperative pain, analgesic consumption, treatment satisfaction were compared in patients treated with intravenous patient-controlled analgesia (IV-PCA) or intramuscular analgesics after laparoscopic ovarian cystectomy. Thirty-one women with laparoscopically operated benign ovarian cysts were recruited in Zonguldak Karaelmas University Faculty of Medicine, Department of Obstetrics and Gynecology. Postoperatively sixteen women received morphine delivered by IV-PCA pump system and 15 women were prescribed another opioid (meperidine) intramuscularly. Two weeks before and one day after the surgery, Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) were self-administered. Afterwards, the operation visual analog scale (VAS) and satisfaction with pain control scale were recorded. Preoperative BDI and BAI scores of both groups were comparable. Postoperative BDI (7.9 ± 7.2 versus 13.8 ± 6.9, P = 0.03) and BAI (11.4 ± 9.1 versus 17.4 ± 6.2, P = 0.045) scores were significantly lower in the IV-PCA group. Morphine usage with PCA resulted in significantly higher pain scores than equivalent doses of meperidine administered intramuscularly (2.94 ± 1.0 versus 1.67 ± 0.7, P = 0.001). Although higher pain scores were obtained from IV-PCA group, self-reported satisfaction rates were higher in this group (8.3 ± 1.1 versus 7.4 ± 1.1, P = 0.04). Involvement of patients in their pain management might increase the awareness of pain but their satisfaction about the control of postoperative pain was significantly improved.

Evaluation of a local anaesthesia regimen using a subphrenic catheter after gynaecological laparoscopy.

Background and objective: The purpose of intraperitoneal local anaesthetic administration is to block visceral nociceptive conduction and to provide an additional route of analgesia. The present study evaluates the effects of sequential injections of bupivacaine on postoperative pain through a subphrenic catheter. Methods: In this double‐blinded controlled study, patients scheduled for gynaecological laparoscopy were randomly divided into two groups. One group received 20 mL of saline with 1: 200 000 epinephrine through a subphrenic catheter before the incision closure and at 4‐hourly intervals for the first postoperative 20 h. The second group received 20 mL of bupivacaine 0.125% with 1: 200 000 epinephrine at the same injection times. Postoperative pain scores and consumption of analgesics were compared. Results: There were no statistical differences in pain scores at rest or incidence of shoulder pain between the two groups, but the patients of the bupivacaine group reported lower pain scores on coughing only in the first hour postoperatively (P = 0.007). Although the patients consumed comparable amounts of metamizole and ondansetron, the number of patients requiring supplemental meperidine and flurbiprofen in the bupivacaine group were significantly lower than in the saline group (P < 0.05). Conclusions: This study demonstrates that intraperitoneal bupivacaine may reduce pain on coughing in the early postoperative period and the consumption of analgesics postoperatively. The subphrenic catheter technique had no impact upon pain at rest and shoulder‐tip pain after gynaecological laparoscopy.