Isik Alper

Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade.

PurposeAdministration of remifentanii followed by propofol provides adequate conditions for tracheal intubation without muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. Intubating conditions with remifentanil followed by propofol, thiopentone or etomidate are compared in this study.MethodsIn a randomized, double-blind study 45 healthy males were assigned to one of three groups (n = 15). After iv atropine, remifentanil 3 μg· kg−1 were injected over 90 sec followed by propofol 2 mg· kg−1 (Group I), thiopentone 6 mg· kg−1 (Group II) or etomidate 0.3 mg· kg−1 (Group III), Ninety seconds after the administration of the hypnotic agent, laryngoscopy and intubation were attempted, Intubating conditions were assessed as excellent, good or poor on the basis of ease of ventilation, jaw relaxation, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff.ResultsOne patient in Group I, three patients in Group II and five patients in Group III could not be intubated on the first attempt. Clinically acceptable intubating conditions were observed in 93.3%, 66.7%, 40.0% of patients in Groups I, II and III, respectively. Overall conditions at intubation were significantly (P < 0,05) better, and the frequency of excellent conditions was significantly (P < 0.05) higher in the propofol group compared with the thiopentone and etomidate groups. No patient was treated for hypotension or bradycardia.ConclusionPropofol 2 mg· kg−1 was superior to thiopentone 6 mg· kg−1 and etomidate 0.3 mg· kg−1 for tracheal intubation when combined with remifentanil 3 μg· kg−1 and no muscle relaxant.RésuméObjectifL’administration de rémifentanil suivie de propofol permet des conditions satisfaisantes d’intubation endotrachéale sans myorelaxants. D’autres hypnotiques n’ont pas encore été testés dans ces circonstances. Nous avons donc voulu comparé les conditions d’intubation avec le rémifentanil suivi du propofol, du thiopental ou de l’étomidate.MéthodeL’étude randomisée et à double insu a été réalisée auprès de 45 hommes en bonne santé, répartis en trois groupes (n = 15). Après l’administration iv d’atropine, l’injection de 3 μg· kg−1 de rémifentanil, pendant 90 sec, a été suivie de 2 mg· kg−1 de propofol (Groupe I), de 6 mg· kg−1 de thiopentai (Groupe II) ou de 0,3 mg· kg−1 d’étomidate (Groupe III). Quatre-vingt-dix secondes après l’administration de l’agent hypnotique, la laryngoscope et l’intubation ont été tentées. Les conditions d’intubation ont été évaluées comme excellentes, bonnes ou pauvres d’après la facilité de ventilation, du relâchement de la mâchoire, la position des cordes vocales et la réponse du patient à l’intubation et au gonflement lent du ballonnet du tube endotrachéal.RésultatsUn patient du Groupe I, trois du Groupe II et cinq du Groupe III n’ont pu être intubés au premier essai. Des conditions d’intubation acceptables ont été observées chez 93,3 %, 66,7 % et 40,0 % des patients des Groupes I, II et III. Dans l’ensembie, les conditions d’intubation ont été signifiativement (P < 0,05) meilleures, et la fréquence de conditions excellentes a été signifeativement (P < 0,05) plus élevée, avec le propofol, comparé au thiopentai et à l’étomidate. Aucun patient n’a dû recevoir de traitement pour hypotension ou bradycardie.ConclusionLes conditions d’intubation endotrachéale ont été meilleures avec l’usage de 2 mg· kg−1 de propofoi, comparés à 6 mg· kg−1 de thiopental et à 0,3 mg· kg−1 d’étomidate, combinés à 3 μg· kg−1de remifentanil et sans myorelaxants.

Tracheal intubation without muscle relaxants: remifentanil or alfentanil in combination with propofol

Background and objective: In some situations, the use of muscle relaxants (neuromuscular blocking drugs) are undesirable or contraindicated. We compared intubating conditions without muscle relaxants in premedicated patients receiving either alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 followed by propofol 2 mg kg−1. Methods: In a randomized, double-blind study, 80 healthy patients were assigned to one of four groups (n = 20). After intravenous atropine, alfentanil 40 μg kg−1 or remifentanil 2, 3 or 4 μg kg−1 were injected over 90 s followed by propofol 2 mg kg−1. Ninety seconds after administration of the propofol, laryngoscopy and tracheal intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of lung ventilation, jaw relaxation, laryngoscopy, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. Results: Seven patients who received remifentanil 2 μg kg−1 and one patient who received remifentanil 3 μg kg−1 could not be intubated at the first attempts. Excellent intubating conditions (jaw relaxed, vocal cords open and no movement in response to tracheal intubation and cuff inflation) were observed in those who received either alfentanil 40 μg kg−1 (45% of patients) or remifentanil in doses of 2 μg kg−1 (20%), 3 μg kg−1 (75%) or 4 μg kg−1 (95%). Overall, intubating conditions were significantly better (P < 0.05), and the number of patients showing excellent conditions were significantly higher (P < 0.05) in patients who received remifentanil 4 μg kg−1 compared with those who received alfentanil 40 μg kg−1 or remifentanil 2 μg kg−1. No patient needed treatment for hypotension or bradycardia. Conclusions: Remifentanil 4 μg kg−1 and propofol 2 mg kg−1 administered in sequence intravenously provided good or excellent conditions for tracheal intubation in all patients without the use of muscle relaxants.

Remifentanil versus alfentanil in total intravenous anaesthesia for day case surgery.

Background and objective: We assessed the intraoperative haemodynamic responses and recovery profiles of total intravenous anaesthesia with remifentanil and alfentanil for outpatient surgery. Methods: Patients in Group 1 (n = 20) received alfentanil 20 μg kg−1 followed by 2 μg kg−1 min−1 intravenously; patients in Group 2 (n = 20) received remifentanil 1 μg kg−1 followed by 0.5 μg kg−1 min−1 intravenously. Both groups then received propofol 2 mg kg−1 followed by 9 mg kg−1 h−1 intravenously. Five minutes after skin incision, infusion rates were decreased, and at the end of surgery, all infusions were discontinued. Early recovery was assessed by the Aldrete score, whereas intermediate recovery was assessed with the postanaesthetic discharge scoring system (PADS). Results: Perioperative arterial pressure was similar in both groups; heart rate was lower in Group 2 (P < 0.05). The times to spontaneous and adequate respiration, response to verbal commands, extubation and times for Aldrete score ⩾9 were shorter in Group 2 patients (P < 0.05). Pain scores were higher in Group 2 patients (P < 0.05). Overall times for postanaesthetic discharge scores ⩾9 were similar. Conclusions: Early recovery of patients after day surgery is significantly shorter after total intravenous anaesthesia with remifentanil compared with that with alfentanil but postoperative pain management must be planned ahead.

Effects of sociodemographic factors and maternal anxiety on preoperative anxiety in children

Objective To investigate the effects of sociodemographic factors and maternal anxiety levels on behaviour in children undergoing surgery. Methods This study included children aged 3–12 years who were scheduled for surgery, and their respective mothers. Each mother completed a questionnaire concerning sociodemographic and economic characteristics. Maternal anxiety was assessed using the State-Trait Anxiety Inventory (STAI) form Tx-1, following transfer of the child to the operating room. An anaesthesiologist rated preoperative anxiety in each child using the Frankl Behaviour Rating Scale (FBRS) and Venham Picture Test (VPT). Results One hundred children (mean ± SD age 7 ± 2.7 years) who received dental (47%), plastic (39%) or urological (14%) surgery, and 100 mothers (mean ± SD age 34 ± 6.6 years) were included. A statistically significant difference between maternal STAI Tx-1 scores and children’s VPT scores was revealed. There was no significant difference between maternal STAI Tx-1 scores and children’s FBRS scores. Maternal education level and socioeconomic status had no effect on FBRS, VPT and STAI Tx-1 scores. Conclusion Maternal knowledge and experience of anaesthesia, and high levels of maternal anxiety, may be related to increased anxiety in children undergoing surgery.

Effects of cardiac valve dysfunction on perioperative management of liver transplantation.

OBJECTIVE Our aim was to investigate the effects of cardiac valve dysfunction on perioperative management of orthotopic liver transplantation (OLT) among a retrospective cohort. PATIENTS AND METHODS Three hundred forty-six patients underwent echocardiographic (ECHO) examination prior to OLT. Data of patients with valvular dysfunctions were compared to subjects with normal ECHO. We evaluated patient characteristics, operation variables, hemodynamic course, blood products, fluid and drug requirements, extubation, and mortality rates. RESULTS Ninety-five patients (27.5%) with cardiac valve dysfunction were classified as mitral valve insufficiency (MVI; n = 32), tricuspid valve insufficiency (TVI; n = 23), or both MVI and TVI (n = 40). One hundred fifty-two patients displayed normal ECHO examinations (control). Ninety-nine patients with other pathologies were excluded from the study. Systemic vascular resistance was significantly lower among the MVI group, and cardiac output (CO) significantly higher in the MVI and both MVI and TVI groups compared with controls. More MVI and both MVI and TVI patients required epinephrine compared with controls. The number of patients who required blood transfusion was higher in the MVI than the control group (P < .05). Patient characteristics, end-stage liver failure scores, duration of operations, hemodynamic variables, incidence of postreperfusion syndrome, mean doses of ephedrine and epinephrine, red blood cells, fresh frozen plasma and fluid requirements, number of patients extubated immediately after surgery, and mortality rates were not different between the groups. CONCLUSIONS Our study demonstrated that cardiac valve dysfunction may be associated with end-stage liver disease among patients undergoing OLT. Patients with MVI or both MVI and TVI required more care in perioperative management.

Soluble cytokeratin 18 biomarkers may provide information on the type of cell death during early ischemia and reperfusion periods of liver transplantation.

Ulukaya S, Ulukaya E, Alper I, Yilmaztepe‐Oral A, Kilic M. Soluble cytokeratin 18 biomarkers may provide information of the type of cell death during early ischemia and reperfusion periods of liver transplantation. 
Clin Transplant 2010: 24: 848–854.

Reabsorption of ascites and the factors that affect this process in cirrhosis.

Ascites is one of the main features of liver decompensation in cirrhosis, and it is considered to be a dynamic process. In this study, we aimed to (1) measure the reabsorption rate of ascites; (2) evaluate whether these findings were related to features of ascites, hemodynamics, and serum measurements; and (3) examine morphologic changes in the diaphragm of cirrhotic patients. In all, 42 cirrhotic patients with ascites were enrolled in the study to comprise our study group. Using the dextran 70 test, patient ascites volumes and reabsorption rates were measured. Biopsies from the peritoneal side of the diaphragm were also processed for scanning electron microscopy and lymphatic immunohistochemical studies from the cirrhotic patients and control cadavers. The mean ascites reabsorption rate was 4.5 +/- 4.5 (0.18-14.6) mL/min, which correlated significantly with the calculated ascites volume (r = 0.75, P < 0.001). The mean ascites viscosity was 1.07 +/- 0.07 (0.99-1.17) centipoise, which demonstrated a high degree of negative correlation with the ascites reabsorption rate (r = -0.77, P < 0.001). Patients with a history of spontaneous bacterial peritonitis had significantly lesser ascites reabsorption rates than patients without this particular history. The size of lymphatic stomata in scanning electron microscopy depictions was increased, and lymphatic lacunae were dilated in immunohistochemical studies in the cirrhotic patients with ascites. However, these findings were not uniform in every cirrhotic patient with ascites. The volume and viscosity of ascites seem to influence its reabsorption rate. Additionally, previous episodes of spontaneous bacterial peritonitis may be responsible for the decreased ascites reabsorption rates observed in certain patient populations.

Comparison of Acute and Chronic Pain after Open Nephrectomy versus Laparoscopic Nephrectomy: A Prospective Clinical Trial.

AbstractWe evaluated postoperative pain intensity and the incidence of chronic pain in patients with renal cell carcinoma undergoing laparoscopic or open radical nephrectomy.In this prospective study, 27 laparoscopic nephrectomy (Group LN) and 25 open nephrectomy (Group ON) patients were included. All patients received paracetamol infusion and intramuscular morphine 30 minutes before the end of the operation and intravenous patient controlled analgesia with morphine postoperatively. Data including patients’ demographics, visual analog scale (VAS) pain scores at postoperative 0.5, 1, 2, 4, 6, 12, and 24 hours, postoperative morphine consumption, analgesic demand, analgesic delivery, number of patients requiring rescue analgesics, side effects because of analgesic medications, and overall patient satisfaction were recorded and compared between the two groups. Two and 6 months after the operation, patients were evaluated for chronic postsurgical pain (CPSP).Postoperative average VAS pain scores were not different between the two groups. However, only at 2 hours postoperatively, pain score was significantly higher in Group ON than in Group LN. In both groups, the highest pain scores were recorded at 30 minutes and 1 hour after surgery. Ninety-six percent of group ON patients and 88% of group LN patients required additional analgesia in the early postoperative period (P = 0.33). Postoperative morphine consumption and analgesic demand were found to be similar between the two groups. CPSP at 2 months after surgery was observed in 4 out of 25 patients (16%) in the ON group and 3 out of 27 patients (11.1%) in the LN group (P = 0.6). Chronic pain at 6 months after surgery was observed in 1 ON patient (4%) and 1 LN patient (3.7%, P = 0.9).This study demonstrated that postoperative acute pain scores were not different after laparoscopic or open nephrectomy and patients undergoing laparoscopic or open nephrectomy were at equal risk of developing CPSP. Pain control should be carefully planned in order to reduce early postoperative pain and also potentially prevent CPSP.

Laparoscopic cholecystectomy pain: effects of the combination of incisional and intraperitoneal levobupivacaine before or after surgery.

OBJECTIVES We aimed to investigate whether the timing of administration, using a combination of incisional and intraperitoneal levobupivacaine (0.25%), has an effect on the postoperative pain after laparoscopic cholecystectomy in a prospective, randomized, and controlled study. METHODS Sixty six patients were allocated to one of the three groups. Group BS received levobupivacaine before trocar site incision and intraperitoneal levobupivacaine immediately after pneumoperitoneum. Group AS received intraperitoneal levobupivacaine before trocars were withdrawn and incisional levobupivacaine administered at the end of surgery. Group C received no treatment. Data of intraoperative variables, postoperative pain relief, rescue analgesic consumption, and patient satisfaction were compared. RESULTS The intraoperative fentanyl consumption was found lower in Group BS, compared to Groups AS and C (p<0.05). VAS scores were lower in both Groups BS and AS, compared to Group C immediately after the operation (p<0.05). VAS scores were significantly decreased during the first two hours in Group AS, compared to Group C. The mean doses and number of patients needing rescue meperidine were lower in Group AS, compared to the Groups BS and C (p<0.05). CONCLUSION The combination of incisional and intraperitoneal levobupivacaine administered before or after surgery can reduce postoperative pain and analgesic and antiemetic consumption together with improved patient satisfaction. However, administering levobupivacaine before surgery might be advantageous for less intraoperative fentanyl consumption, while levobupivacaine after surgery is advantageous for less postoperative rescue analgesic requirement.

The Effects of Preoperative Anxiety on Anesthetic Recovery and Postoperative Pain in Donor Nephrectomy

Introduction Kidney transplant is the most effective choice of treatment for patients with end-stage kidney failure. About 20-25% of all the kidney transplants performed come from living donors. No prospective study is readily available regarding the effects of preoperative anxiety on anesthetic recovery and postoperative pain in donor nephrectomy. We aimed to investigate the effects of preoperative anxiety on anesthetic recovery and postoperative pain in patients who will undergo donor nephrectomy in this prospective study. Methods 48 volunteers who were scheduled for donor nephrectomy, aged between 18‐60 years, with an ASA physical status score of I or II were included in the study. The anxiety levels of the patients were measured using STAI (State Trait Anxiety Inventory) scale during preoperative period. All of the patients were administered general anesthesia following routine monitoring in operating rooms. Morphine PCA was used to provide postoperative analgesia. Correlation of preoperative STAI scores of the patients with demographic data, post anesthesia recovery data and postoperative pain scores were investigated. Results STAI scores of the patients showed no statistically significant correlations with demographics, ASA scores, history of prior surgery, chronic pain, degree of kinship with recipient, educational status, monthly income and smoking status of the patients. STAI I score was found to be significantly correlated with spontaneous respiration time, adequate respiration time, extubation time and the MAS ≥9 time(p<0,01). STAI scores were found to be significantly correlated with the VAS scores of the 30th minute,1st hour,2nd hour,4th hour,8th hour, 12th hour and 24th hour(p<0,05). A significant correlation was established between the STAI I and STAI II scores and the total amount of analgesic administered in 24hours(p<0,05). Conclusion It is suggested that 38-45% of the patients scheduled for surgery under anesthesia experience anxiety in preoperative period. Effect of anxiety levels on postanesthetic recovery and postoperative pain intensity is still a matter of discussion. Our study showed that patients with high preoperative anxiety levels had a late recovery from anesthesia and high postoperative pain scores. Thus, we suggest that postoperative anxiety levels should be measured preoperatively as adequate planning towards amelioration of excessive anxiety may contribute to anesthetic recovery and postoperative pain intensity. Figure. No caption available. Figure. No caption available. References 1. Kälble T, Lucan M, Nicita G, Sells R, Burgos Revilla FJ, Wiesel M. European Association of Urology. EAU guidelines on renal transplantation. Eur Urol. 2005 Feb;47(2):156–66. 2. Ali A, Altun D, Oguz BH, Ilhan M, Demircan F, Koltka K. The effect of preoperative anxiety on postoperative analgesia and anesthesia recovery in patients undergoing laparascopic cholecystectomy. J Anesth. 2014 Apr;28(2):222–7. 3. Kehlet H, Jensen ST, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. Lancet: 2006; 371618–125.