Hülya Erolçay

Comparison of Intrapleural Versus Intravenous Morphine for Postthoracotomy Pain Management

OBJECTIVE To compare the analgesic effects of intrapleural and intravenous morphine administration for postthoracotomy pain management. DESIGN Randomized, prospective trial. SETTING University teaching hospital. PARTICIPANTS Twenty-eight consenting patients scheduled for elective thoracotomy operations. INTERVENTIONS Patients were randomly allocated into two groups to receive either 20 mg of intrapleural morphine (IPM group) or 20 mg of intravenous morphine (IVM group) at the end of the operation. Plasma morphine levels, arterial pressures, heart rate, verbal analog scale (VAS), respiratory rate, and PaCO2 levels were compared in two groups. MEASUREMENTS AND MAIN RESULTS Plasma morphine levels were significantly higher in the IVM group at the 5th minute until the 2nd postoperative hour. VAS was significantly higher in the IVM group. Respiratory rates were significantly higher in the IPM group, whereas PaCO2 remained significantly lower than in the IVM group. CONCLUSIONS IPM achieved better analgesia than IVM and this effect is probably attributable to peripheral effects of morphine.

Anesthesia in a child with Maroteaux-Lamy syndrome undergoing mitral valve replacement

Mucopolysaccharidoses (MPSs) are a group of metabolic diseases transmitted in an autosomal recessive fashion. MPSs are due to deficiencies of the specific enzymes responsible for the catabolism of dermatan sulfate, heparin sulfate, and keratan sulfate, resulting in the accumulation of glycosaminoglycans (GAGs). MPSs have a chronic, progressive course with multisystemic involvement. The incidence of MPSs is approximately 1/50,000 (1). As GAGs begin to accumulate in lysosomes, functional disturbances occur in cells, tissues, and organs. Diagnosis is based on elevated mucopolysaccharide levels in the urine and enzyme deficiencies in the serum or in fibroblast cultures (2). MPS type VI (Maroteaux-Lamy syndrome) is characterized by a deficiency of N-acetylgalactosamine-4-sulfatase, which is responsible for the catabolism of dermatan sulfatase. The clinical features of MPSs include coarse face, short stature, kyphoscoliosis, upper airway thickening, hearing loss, corneal opacity, hepatosplenomegaly (3), and symptoms that vary according to the GAG accumulation sites (1). Sinus tachycardia, atrial dilatation, valve involvement, endocarditis, myocarditis, and ventricular aneurysms might be observed due to cardiovascular system involvement (4,5). In contrast to the other types of MPSs, there is no mental retardation in patients with MPS type VI. There are only a limited number of reports of heart surgery in patients with MPSs (6,7). To the best of our knowledge, the literature is devoid of any reports of pediatric patients with Maroteaux-Lamy syndrome undergoing valve replacement surgery. Herein, we present the anesthetic management of a pediatric patient with Maroteaux-Lamy syndrome during mitral valve replacement surgery and a discussion based on the literature.

Epidural anesthesia may attenuate lipid peroxidation during aorto-femoral surgery

PurposeTo determine the effect of epidural anesthesia (EP) on oxygenation of the chronically ischemic limb in patients undergoing aorto-femoral bypass grafting and to assess whether it produces an alteration of lipid peroxidation and antioxidant status following revascularization.MethodsIn this prospective, randomized, single-blinded study 40 ASA II or III patients undergoing elective aorto-femoral bypass grafting were allocated to receive general anesthesia (group GA,n = 20), or epidural + GA (group EP,n = 20) during surgery. Femoral venous blood-gas status, activities of the protecting antioxidant enzymes superoxide dismutase (SOD), glutathione peroxidase (GSH-px), glutathione reductase (GSH-rd), glutathione (GSH) and thiobarbituric acid-reactive substances (TBARS) as a marker of lipid peroxidation were determined in blood samples taken from the femoral vein at different intervals before and after revascularization.ResultsBefore the induction of anesthesia in group EP, femoral venous PO2 [mean (standard deviation), 95% confidence interval] increased after achieving an adequate level of blockade by EP extending to the dermatomal level of T6-8 [29.32 (4.6), 26.34–32.30 to 36.29 (4.6), 33.37–39.22 mmHg,P < 0.05]. Femoral venous PO2 was similar in both groups thereafter. In the GA group a significant increase in erythrocyte TBARS was observed immediately after restoration of blood flow when compared with baseline values [221.32 (102), 148.35-294-29 to 337.26 (123) 248.99-425.53 nmol·g−1 hemoglobin,P < 0.01] but not at any other moment. In the EP group TBARS did not increase throughout the study. Within group comparisons revealed no significant differences in GSH, GSH-px, GSH-rd and SOD.ConclusionIn patients with atherosclerotic aorto-iliac occlusive disease EP may possibly attenuate lipid peroxidation following revascularization but has no effect on antioxidant enzyme activities.RésuméObjectifDéterminer l’effet de l’anesthésie péridurale (AP) sur l’oxygénation du membre soumis à l’ischémie chez les patients qui subissent un pontage aorto-fémoral et évaluer si elle produit une altération de la peroxydation lipidique et de l’état antioxydant à la suite de la revascularisation.MéthodeUne étude prospective, randomisée et à simple insu a été menée auprès de 40 patients d’état physique ASA II ou III qui devaient subir un pontage aorto-fémoral sous anesthésie générale (groupe AG, n = 20) ou anesthésie péridurale + AG (groupe AP, n = 20). La gazométrie du sang veineux fémoral, les activités des enzymes protecteurs antioxydants superoxyde dismutase (SOD), glutathion peroxydase (GSH-px), glutathion réductase (GSH-rd), glutathion (GSH) et les substances réactives à l’acide thiobarbiturique (SRATB), comme marqueur de la peroxydation lipidique, ont été mesurés dans les échantillons sanguins prélevés de la veine fémorale à différents intervalles avant et après la revascularisation.RésultatsAvant l’induction de l’AP, la PO2 veineuse fémorale [moyenne (écart type), intervalle de confiance de 95%] s’est élevée après le blocage péridural adéquat s’étendant au niveau du dermatome T6-8 [29,32 (4,6) 26,34-32,30 à 36,29 (4,6) 33,37-39,22 mmHg, P< 0,05]. La PO2 veineuse fémorale a été similaire dans les deux groupes par la suite. Dans le groupe AG, une hausse significative d’érythrocyte SRATB, en comparaison avec les valeurs de base, a été notée immédiatement et seulement après la restauration du débit sanguin [221,32 (102) 148,35-294-29 à 337,26 (123) 248,99-425,53 nmol·g−1 hémoglobine, P < 0,01]. Dans le groupe AP, les SRATB n’ont pas augmenté pendant l’étude. Aucune différence intragroupe significative de GSH, GSH-px, GSH-rd et SOD n’a été notée.ConclusionChez les patients atteints d’occlusion aorto-iliaque, l’AP peut atténuer la peroxydation lipidique à la suite de la revascularisation, mais n’a pas d’effet sur les activités antioxydantes des enzymes.