Huseyin Yildiz

Sedation During Noninvasive Mechanical Ventilation With Dexmedetomidine or Midazolam: A Randomized, Double-Blind, Prospective Study

BACKGROUNDnEffective noninvasive mechanical ventilation (NIV) requires a patient to be comfortable and in synch with the ventilator, for which sedation is usually needed. Choice of the proper drug for sedation can lead to improved clinical outcomes.nnnOBJECTIVEnThe aim of this study was to compare the effectiveness of dexmedetomidine and midazolam on sedation and their effects on hemodynamics and gas exchange.nnnMETHODSnIn this randomized, double-blind study, intensive care unit patients with acute respiratory failure due to acute exacerbations of chronic obstructive pulmonary disease undergoing NIV were equally randomized to receive a loading dose of 1 μg/kg IV dexmedetomidine or 0.05 μg/kg midazolam over 10 minutes followed by a maintenance infusion of 0.5 μg/kg/h dexmedetomidine (group D) or 0.1 mg/kg/h midazolam (group M). The following parameters were measured by a blinded clinician at baseline and 1, 2, 4, 6, 8, 12, and 24 hours after the loading dose was administered: Ramsay Sedation Score (RSS), Riker Sedation-Agitation Scale (RSAS), Bispectral Index (BIS), arterial blood gases, and vital signs. A second blinded investigator determined dosing changes according to the outcome of maintaining a target sedation level of RSS 2 to 3, RSAS 3 to 4, and BIS >85.nnnRESULTSnA total of 45 patients were assessed for enrollment in the study; 4 did not meet the inclusion criteria and 1 refused to participate (men/women 19/21; mean age 58/60; all patients were receiving bronchodilators, steroids, antibiotics, and mucolytics). In both groups (n = 20), RSS significantly increased and RSAS levels and BIS values significantly decreased after the loading dose, compared with baseline (P < 0.05). RSS levels were significantly lower beginning at 4 hours in group D compared with group M (P < 0.05). RSAS levels were not significantly different between the 2 groups in the first 8 hours. However, RSAS levels were significantly higher at 8 hours after the loading dose was administered in group D compared with group M (P < 0.01). BIS was significantly higher in group D throughout the study period (P < 0.05). Respiratory rates and gas exchange values were not significantly different between the Accepted for publication April 7, 2010. 2 groups. The number of times a change in infusion dose was needed was significantly lower in group D (2 patients with 1 change each) than in group M (3 patients with 1 change, 1 patient with 2 changes, and 3 patients with 3 changes each) (P < 0.01).nnnCONCLUSIONSnDexmedetomidine and midazolam are both effective sedatives for patients with NIV. Dexmedetomidine required fewer adjustments in dosing compared with midazolam to maintain adequate sedation.

Re-Protective Effects of Pre- and Post-Laparoscopy Conditioning, Zinc, Pentoxifylline, and N-acetylcysteine in an Animal Model of Laparoscopy-Induced Ischemia/Reperfusion Injury of the Kidney

Background. Pneumoperitoneum (P) created to facilitate laparoscopy (L) is associated with splanchnic hypoperfusion, ischemia/reperfusion (I/R) injury, and oxidative stress. Aim. This study investigated the effects of pre- and post-laparoscopic conditioning, zinc, pentoxifylline (PTX), and N-acetylcysteine (NAC) on markers of I/R injury in an animal model. Methods. Sprague-Dawley male rats (nu2009=u200956, weight range 300–350 g) were randomly placed in one of seven treatment groups. Except for group C (control group who underwent a sham operation without pneumoperitoneum), pneumoperitoneum was created in all using CO2 insufflation under a pressure of 15 mmHg. Group L (laparoscopy) was subjected to 60 min of pneumoperitoneum. Group Lpre (laparoscopic preconditioning plus laparoscopy) was subjected to 5 min of insufflation and 5 min of desufflation followed by 60 min of pneumoperitoneum. Group Lpost (laparoscopy plus laparoscopic post-conditioning) was subjected to 60 min of pneumoperitoneum and 60 min of desufflation followed by 5 min of insufflation and 5 min of desufflation. The laparoscopy plus zinc (LZ), PTX (LP), and NAC (LNAC) groups received a single intraperitoneal injection of zinc (50 mg/kg), pentoxifylline (50 mg/kg), or N-acetylcysteine (150 mg/kg) 5 min before the desufflation period. Animals were sacrificed at the end of the experiments, and kidney samples were tested for malondialdehyde (MDA), catalase (CAT), glutathione peroxidase (GPX), and superoxide dismutase (SOD). Results. MDA levels, as an indicator of oxidative stress in kidney tissue samples, were significantly higher in all pneumoperitoneum groups compared to Group C, except for Group Lpre. The pattern of change in tissue levels of SOD, GPX, and catalase was variable in the different treatment groups. Conclusions. In this animal model of renal ischemia/reperfusion injury, laparoscopy caused renal ischemia as evidenced by elevated markers of tissue ischemia-reperfusion injury. This effect was significantly attenuated by post-laparoscopy conditioning, zinc, pentoxifylline, and N-acetylcysteine, but not by pre-laparoscopy conditioning.

Thiopental improves renal ischemia–reperfusion injury

Ischemia/reperfusion (I/R) occurs in a number of pathological conditions, including myocardial infarction, stroke, aortic surgery, cardiopulmonary bypass surgery, organ transplantation, resuscitation, and critical care. Massive and abrupt release of oxygen-free radicals after reperfusion triggers oxidative damage. Before critical operations or after resuscitation, it would be wise to find a suitable prophylactic treatment to avoid I/R damage. We aimed to determine whether several commonly used intravenous anesthetics protect against renal I/R injury. Methods: Animals were randomly divided into seven groups, each consisting of six animals: sham group, control group, thiopental group, propofol group, intralipid group, etomidate group, and ketamine group. At the end of the 60-min ischemic period, 60 min reperfusion was established and the materials administered 15 min before the reperfusion. At the end of the reperfusion period, the samples of blood and tissue were reaped for biochemical and serological evaluation. Results: I/R procedure significantly increased malondialdehyde (MDA) levels, decreased catalase (CAT) activities, and superoxide dismutase (SOD) levels. The lowest MDA mean level was in the thiopental group and the highest MDA mean level was in control group. The lowest CAT mean level was in the intralipid group and the highest CAT mean level was in the etomidate group. The lowest SOD mean level was in the control group and the highest SOD mean level was in the propofol group. Conclusion: Thiopental and propofol, especially thiopental, are more effective to protect renal I/R injury.

Oral carbohydrate supplementation reduces preoperative discomfort in laparoscopic cholecystectomy.

ABSTRACT The aim of this study was to investigate the effects of oral carbohydrate solution (CHO) on perioperative discomfort, biochemistry, hemodynamics, and patient satisfaction in elective surgery patients under general anesthesia. Sixty cases in ASA I-II group who were planned to have operation under general anesthesia were included in the study. The cases were randomly divided into two groups having 30 subjects in each. The patients in the study group were given CHO in the evening prior to the surgery and 2–3 hr before the anesthesia while routine fasting was applied in the control group. In the study group; 2–3 hr before the surgery; malaise, thirst, hunger, and weakness; just before the surgery malaise, thirst, hunger, and fatigue; 2 hr after the operation thirst, hunger, weakness, and concentration difficulty; 24 hr after the operation malaise and weakness were found significantly lower. Fasting blood glucose (FBG) level was found to be higher in the control group at the 90th min of the operation. Gastric volumes were higher in the control group; gastric pH values were found significantly higher in the study group. The level of anxiety and depression risk rate were found lower in the study group. In conclusion, preoperative CHO reduces perioperative discomfort and improves perioperative well being when compared to overnight fasting.

Effect of Zofenopril on regeneration of sciatic nerve crush injury in a rat model

Background Zofenopril is an antioxidant agent which has been shown to have beneficial effects in hypertension and heart failure. The aim of this study was to test the effects of Zofenopril on nerve regeneration and scarring in a rat model of peripheral nerve crush injury. Methods Twenty-one adult Sprague-Dawley rats underwent a surgical procedure involving right sciatic nerve crush injury. 15 mg/kg Zofenopril was administered orally to seven rats in group Z for seven days. Seven rats in group S received saline orally for seven days. Seven rats in the control group C received no drug after crush injury. Fourteenth and 42nd days after injury, functional and electromyography assessments of nerves were performed. Functional recovery was analyzed using a walking track assessment, and quantified using the sciatic functional index (SFI). After these evaluations, all rats were sacrificed and microscopic evaluations were performed. Results The Sciatic functional Index (SFI) in group Z on 14th day is different significantly from group S and group C (p = 0.037). But on 42nd day there was no difference between groups (p = 0.278). The statistical analyses of electromyelographic (EMG) studies showed that the latency in group Z is significantly different from group S (p = 0.006) and group C (p = 0.045). But on 42nd day there was no difference between groups like SFI (p = 0.147). The amplitude was evaluated better in group Z than others (p < 0.05). In microscopic evaluation, we observed the highest number of nerve regeneration in the group Z and the lowest in the group C. But it was not significant statistically. Conclusion Our results demonstrate that Zofenopril promotes the regeneration of peripheral nerve injuries in rat models.

Protective effects of zinc, pentoxifylline, and N-acetylcysteine in an animal model of laparoscopy-induced ischemia/reperfusion injury of the small intestine.

BACKGROUNDnPneumoperitoneum induced to facilitate laparoscopy is associated with splanchnic hypoperfusion, ischemia/reperfusion (I/R) injury, and oxidative stress.nnnAIMnThis study investigated the effects of pre- and postlaparoscopic conditioning, zinc, pentoxifylline, and N-acetylcysteine on markers of I/R injury of the small intestine in an animal model.nnnMETHODSnMale Sprague-Dawley rats (n=56) were randomized to 1 of 7 treatment groups. Except for group 7 (control group that underwent sham surgery without pneumoperitoneum), pneumoperitoneum was induced in all by use of carbondioxide insufflation under a pressure of 15u2009mmHg. Group 1 (laparoscopic I/R) was subjected to 60 minutes of pneumoperitoneum. Group 2 (laparoscopic preconditioning plus laparoscopy) was subjected to 5 minutes of insufflation and 5 minutes of desufflation followed by 60 minutes of pneumoperitoneum. Group 3 (laparoscopy plus laparoscopic postconditioning) was subjected to 60 minutes of pneumoperitoneum and 60 minutes of desufflation followed by 5 minutes of insufflation and 5 minutes of desufflation. Group 4 (zinc), group 5 (pentoxifylline), and group 6 (N-acetylcysteine) received a single intraperitoneal injection of zinc (50u2009mg/kg), pentoxifylline (50u2009mg/kg), or N-acetylcysteine (150u2009mg/kg), respectively, 5 minutes before the desufflation period. Animals were killed at the end of the experiments, and small intestine samples were tested for malondialdehyde (MDA), catalase (CAT), glutathione peroxidase (GPX), and superoxide dismutase (SOD).nnnRESULTSnThere was no significant difference for MDA levels between each other in the groups 1, 2, and 3. But MDA levels were higher significantly in groups 1, 2, and 3 than those of groups 4, 5, 6, and 7. SOD and GPX levels of group 3 were significantly higher than those of groups 1, 2, 4 through 7. According to the SOD levels, there was no significant difference between each other in those of groups 1, 2, 4 through 7. GPX levels of group 3 were significantly higher than those of groups 1, 2, 4 through 7. GPX levels of group 1 were significantly lower than those of groups 5 and 7. The mean CAT level of groups 1 and 2 was significantly lower than that of groups 3, 6, and 7. The mean CAT level of group 3 was significantly higher than that of groups 1, 2, 4 through 7.nnnCONCLUSIONSnIn this animal model of small intestine I/R injury, laparoscopy caused small intestine ischemia as evidenced by elevated markers of tissue I/R injury. This effect was significantly attenuated by zinc, pentoxifylline, and N-acetylcysteine, but not by prelaparoscopy conditioning and postlaparoscopy conditioning.

Effects of Epidural-and-General Anesthesia Combined Versus General Anesthesia Alone on Femoral Venous Flow During Laparoscopic Cholecystectomy

BACKGROUND AND OBJECTIVEnThe pneumoperitoneum has been shown to decrease femoral blood flow, resulting in venous stasis. We analyzed the effects of the pneumoperitoneum and epidural analgesia on femoral vein diameter and the peak flow rate of femoral vein during laparoscopic cholecystectomy.nnnPATIENTS AND METHODSnForty patients were randomly allocated to receive either combined epidural analgesia (EA) and general anesthesia (GA) (group EA/GA) or GA alone (group GA). Laparoscopic cholecystectomy was the standard operation for the selected patients. Then, 10 mL of 1% lidocaine in group EA/GA or physiologic serum in group GA was injected via epidural catheter. Peak flow rates (PFRs) of femoral vein cross-sectional areas (CSAs) were measured from the right femoral vein at three different times: after induction of anesthesia, during the pneumoperitoneum, and after abdominal deflation, but prior to reversal of anesthesia.nnnRESULTSnThe two groups were similar in age, sex, body mass index, and duration of operation. The CSA slightly increased after the induction of anesthesia, compared with the previous measurements, although there was no statistical significance between them for both groups (P > 0.05). The PFR decreased, whereas the CSA increased during the pneumoperitoneum in each group. The PFR values after basal measurements were significantly higher in the EA/GA than in the GA group (P < 0.05). Group EA/GA had significantly lower heart-rate and blood-pressure levels during surgery than those in group GA (P < 0.05).nnnCONCLUSIONSnAbdominal insufflation during laparoscopic cholecystectomy results in dilation and decreased flow in the common femoral vein. Epidural analgesia added to the GA partially compensated for the reduction in femoral PFR.

Laparoscopic Sleeve Gastrectomy in Situs Inversus Totalis: a Case Report and Comprehensive Literature Review

The aim of this study is to review the reliability of laparoscopic obesity operations in patients with situs inversus totalis(SIT). A new case of SIT was presented together with a literature review of published English language studies on laparoscopic gastric banding (LAGB), laparoscopic gastric bypass (LRYGB), laparoscopic sleeve gastrectomy (LSG), laparoscopic obesity surgery (LOS), and SIT, accessed via PubMed and Google Scholar databases. The case is presented of a 21-year-old female patient who underwent LSG due to SIT. A total of 12 publications in literature matched the search criteria for LAGB, LRYGB, LSG, LOS, and SIT, which reported LAGB in five cases, LRYGB in four cases, and LSG in four cases. In the rare event of SIT, LOS can be safely used following good evaluation.

Anesthesia for a patient with Fanconi anemia for developmental dislocation of the hip: a case report

Fanconi anemia is a rare autosomal recessive inherited bone marrow failure syndrome with congenital and hematological abnormalities. Literature regarding the anesthetic management in these patients is limited. A management of a developmental dislocation of the hip was described in a patient with fanconi anemia. Because of the heterogeneous nature, a patient with fanconi anemia should be established thorough preoperative evaluation in order to diagnose on clinical features. In conclusion, we preferred caudal anesthesia in this patient with fanconi anemia without thrombocytopenia, because of avoiding from N2O, reducing amount of anesthetic, existing microcephaly, hypothyroidism and elevated liver enzymes, providing postoperative analgesia, and reducing amount of analgesic used postoperatively.

Comparison of Enflurane and Propofol in Electroconvulsive Therapy, a Randomized Crossover Open Preliminary Study on Seizure Duration and Anaesthetic Recovery

BACKGROUND AND OBJECTIVESnElectroconvulsive therapy (ECT) is commonly used for treatment of depression, mania and affective disorders. Anaesthetics for general anaesthesia during ECT should have rapid onset, rapid emerge, not interfere with seizure activity and not shorten seizure duration. The aim of this study is to compare effects of enflurane, a pro-convulsive anaesthetic agent, and propofol on seizure durations, postictal suppression index and recovery times during electroconvulsive therapy.nnnMETHODSnUnpremedicated subjects were divided into two groups according to induction of anaesthesia. Patients were induced for ECT with 5% enflurane in group E and 1.2mg.kg(-1) propofol in group P until loss of consciousness. The durations of electroencephalogram (EEG) and motor seizures, postictal suppression index, time to spontaneous breathing, duration of eye opening, and obeying commands were recorded.nnnRESULTSnThere was no statistically significant difference between the groups regarding motor and EEG seizure times and postictal suppression index on the EEG records. Recovery times (times of starting spontaneous breathing, eye opening, and obeying command) were significantly shorter in group E compared to group P. No nausea or vomiting were observed and no ECG abnormality was noted except transient sinus bradycardia and sinus tachycardia.nnnCONCLUSIONSnAlthough sufficient seizure for the treatment was provided during enflurane anaesthesia, any additional benefit was not revealed regarding seizure times or postictal suppression index when compared to propofol anaesthesia. On the other hand, recovery times after enflurane anaesthesia were shorter than propofol anaesthesia. However, there is still a need for further study in different ETCO(2) levels.