Huseyin Sen

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.

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.

Histologic analysis of the effects of three different support materials within rat middle ear

Objective: To investigate histologic changes in the mucosa of rat middle ear after implantation of three different support materials. Study Design: A prospective, controlled animal study. Subjects and Methods: Three types of absorbable materials were implanted into the middle ear cavity of rats: (1) Gelfoam (purified gelatin) (Pharmacia & Upjohn Company, New York, NY), (2) Sepragel (viscoelastic gel composed of cross-linked polymers of hyaluronan) (GENZYME Corp, Ridgefield, NJ), and (3) Nasopore (a biodegradable/fragmentable, synthetic polyurethane foam) (Polyganics, Groningen, The Netherlands). Rats were sacrificed after 3 and 20 days to ascertain early and late histologic changes. The bulla of each rat was excised and prepared for microscopic examination. The histologic changes were evaluated by observation of the middle ear cavity and mucosa in terms of polymorphonuclear leucocytes (PMNL), macrophages, giant cells, fibroblasts and other cells, fibrosis, and remnant materials. Results: The histologic appearance of gelfoam-treated middle ears was characterized by more severe acute inflammation in the short-term and prominent fibrosis in the long-term in comparison with sepragel- and nasopore-treated groups. Nasopore appeared to be prone to remnant formation and reorganization by means of fibroblastic activity. Conclusion: Compared with gelfoam, both sepragel and nasopore caused less histologic alterations.

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.

Severe burn injury associated with misuse of forced-air warming device

To the Editor:A 64-year-old male was admitted to our department witha third-degree burn on his left ankle. His medical historyrevealed type 2 diabetes of 12 years’ duration and coronarybypass surgery 3 weeks previously. The patient claimedthat he had noticed large blisters on his left ankle when heawoke from anesthesia after coronary bypass surgery. Afterdetailed questioning it became evident that because thepatient began complaining of cold after surgery, he washeated with a forced-air warming system. The nozzle of thedevice was not connected to the blanket, however, and hotair at 40–43 C was blown directly on to the patient’s legsfor nearly 2 h. On examination, a third-degree burn of12 9 5 cm in size and surrounding hyperemia was docu-mented (Fig. 1). His pedal pulses were absent bilaterally.The 10-g-Semmes–Weinstein monofilament test revealedreduced sensation suggestive of diabetic peripheral neu-ropathy. The patient required 3 months of wound care andhyperbaric oxygen therapy to heal the wound.Forced-air warming is one of the most frequently usedmethods of patient warming in the operating room [1]. Thisdevice comprises an electrical heater unit, a hose, and ablanket. Hot air generated by the electrical heater istransferred to the blanket via the hose. Burn injuriesassociated with forced-air warming systems are extremelyrare when the device is used according to the manufac-turer’s instruction [2]. However, improper use of thedevices exposes patients to a considerable risk of burninjury [3]. Moreover, even if the device had been usedadequately, the connection could have come off acciden-tally. General misuse of this system is detaching the hosefrom the blanket and blowing hot air directly on to thepatient’s skin. This practice is called ‘‘hosing’’. Hosingcauses concentration of hot air at a single spot for anextended time period. Although a few cases including asevere burn injury of lower extremities have been reported[4], the dangers of ‘‘hosing’’ are not known by everyone.The Food and Drug Administration has issued a warningand requested submission of hosing-associated hazards [5].In addition, one of the manufacturers has started a cam-paign by posting a website (http://stophosing.com)toinform clinicians about the dangers of the use of forced-airwarming units without blankets [4].Our patient had both diabetic angiopathy and sensoryneuropathy. We think that diabetes also increased the riskof burn injury in our patient. Diabetic angiopathy andneuropathy makes skin more vulnerable to injuries.Because of diabetic sensory neuropathy in his lowerextremities, the patient did not perceive the temperature ofthe hot air correctly and hence could not warn the techni-cian to stop hosing.

Posttreatment with Aminoguanidine Attenuates Renal Ischemia/Reperfusion Injury in Rats

Acute renal failure secondary to ischemia/reperfusion (I/R) injury is associated with significant mortality and morbidity. Aminoguanidine (AG), an inducible nitric oxide synthase inhibitor with antioxidant properties, has been reported beneficial in renal I/R injury. The aim of the present study was to investigate the effect of AG on renal I/R injury and compare the effectiveness of different AG treatment modalities. Sprague-Dawley rats were randomly assigned to one of four groups. The control group (n = 6) received sham operation. The I/R group (n = 6), AG-I group (n = 8), and AG-II group (n = 8) received bilateral renal ischemia for 45 min followed by 24 hours of reperfusion. The AG-I group received AG (50 mg/kg) intraperitoneally four hours and 10 minutes before the induction of ischemia. The AG-II group received AG (50 mg/kg) intraperitoneally four hours and 10 minutes after the initiation of reperfusion. Serum urea and creatinine levels increased significantly in the I/R and AG-I groups compared to the control group. Kidney samples from rats in the I/R and AG-I groups revealed severe tubular damage at histopathological examination. Posttreatment with AG significantly reduced serum urea and creatinine levels and improved histopathological lesions compared with the I/R group. Although pretreatment with AG failed to protect kidneys against I/R injury in this experimental model, posttreatment with AG attenuated renal dysfunction and histopathological changes after I/R injury.

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.

Effects of dexpanthenol and N-acetylcysteine pretreatment in rats before renal ischemia/reperfusion injury

Abstract Background: We investigated the anti-inflammatory and protective effects of concomitant use of dexpanthenol (DXP) and N-acetylcysteine (NAC) induced ischemia/reperfusion (I/R) injury of kidney. Methods: Forty rats were randomly divided into 5 groups. In all groups except for Group 1(Sham), renal arteries bilaterally occluded with vascular clamp for IR injury. Group 1(Sham), received a single dose of 10 mL/kg isotonic saline daily by intraperitoneal (IP) injection for three days. Group 2(IR), received a single dose of 10 mL/kg isotonic saline daily by IP injection for three days. Group 3(IR + NAC), received 300 mg/kg NAC daily by IP injection for three days. Group 4(IR + DXP), received 500 mg/kg DXP daily by IP injection for three days. Group 5(IR + NAC + DXP), received 500 mg/kg DXP and 300 mg/kg NAC daily by IP injection for three days. Serum urea (BUN), creatinine (Cr) and neutrophil gelatinase-associated lipocalin (NGAL, lipocalin 2, siderocalin) levels were measured as kidney function tests. TNF-α levels were measured as inflammatory marker. Tissue sections were evaluated histopathologically under light microscopy. Results: IR + NAC + DXP group received both NAC and DXP before induction of renal I/R and as the biochemical and histopathological data revealed the results of the IR + NAC + DXP group and sham group were similar. Biochemically and histopathologically, combined use of NAC and DXP has better results when each of them used alone. Conclusion: We concluded that concomitant use of DXP and NAC plays a major role against I/R injury and may be useful in acute treatment of I/R induced renal failure.