Ismail Aydin Erden

Upper cervical vertebrae movement during intubating laryngeal mask, fibreoptic and direct laryngoscopy: a video-fluoroscopic study

Background and objective: Minimizing cervical vertebrae motion during endotracheal intubation is important in patients with cervical instability. The aim of this study was to compare upper cervical spine extension during endotracheal intubation using three different techniques. Methods: Duration of intubation and movement of upper cervical vertebrae during endotracheal intubation were compared in 33 patients undergoing lumbar laminectomy. Patients requiring tracheal intubation under general anaesthesia and neuromuscular blockade were randomly allocated into three groups - direct laryngoscopy, intubating laryngeal mask (LM) airway and fibreoptic laryngoscopy. The procedure was recorded by video-fluoroscopy and analysed with computer-assisted measurements. The maximum movement of the C1/C2 and C2/C3 vertebrae during intubation were obtained. Data were analysed using one-way analysis of variance with Bonferroni and Kruskal-Wallis tests. Results: We found statistically significant movement between the first and second, but not between the second and third cervical vertebrae. The mean (±SD) movement at C1/C2 was 10.2 ± 7.3° with direct laryngoscopy, 5.0 ± 6.3° with LM and 1.6 ± 3.2° with fibreoptic laryngoscopy. This difference was statistically significant (P = 0.01) between the direct and fibreoptic laryngoscopy groups. The maximum movement at C2/C3 was 2.2 ± 10.1° with direct laryngoscopy, 3.5 ± 5.1° with LM and 0.5 ± 3.2° with fibreoptic laryngoscopy. Duration of intubation was significantly longer in the intubating LM group (P < 0.001). Conclusion: We conclude that fibreoptic laryngoscopy is the more suitable intubation technique when cervical spine movement is not desired.

Anesthetic management of a patient with Brugada syndrome

1 Steinherz PG. Transient and severe hyperlipidemia in patients with acute lymphoblastic leukaemia treated with prednisone and asparaginase. Cancer 1994; 74: 3234–3239. 2 Tozuka M, Yamauchi K, Hjidaka H et al. Characterization of hypertriglycerideamia induced by L-asparaginase therapy for acute lymphoblastic leukaemia and malignant lymphoma. Ann Clin Lab Sci 1997; 27: 351–357. 3 Kroll MH, Elin RJ. Interference with clinical laboratory analyses. Clin Chem 1994; 40: 1996–2005. 4 Preckel B, Bolten J. Pharmacology of modern volatile anaesthetics. Best Pract Res Clin Anaesthesiol 2005; 19: 331–348. 5 Wasan KM. Modifications in plasma lipoprotein concentration and lipid composition regulate the biological activity of hydrophobic drugs. J Pharmacol Toxicol Methods 1996; 36: 1–11.

The addition of metamizole to morphine and paracetamol improves early postoperative analgesia and patient satisfaction after lumbar disc surgery.

AIM Combined analgesic regimens produce sufficient analgesia by additive or synergistic effects, and reduce the total dose of analgesics and minimise adverse effects. We investigated the metamizole, paracetamol and morphine combination with respect to postoperative pain treatment in lumbar disc surgery. MATERIAL AND METHODS After Ethics Committee approval and informed consent, 63 patients were allocated to three treatment groups; as Group paracetamol: paracetamol (1 g), Group paracetamol-metamizole: paracetamol (1 g) and metamizole (1 g), and Group placebo: no analgesic. All the patients received intravenous (i.v.) morphine with a patient-controlled analgesia device (PCA) as the rescue analgesic. Pain was assessed by the numerical pain rating scale (NRS, 0-3). Total morphine consumption at 24 hours, patient satisfaction and side effects were investigated. RESULTS NRS of Group paracetamol-metamizole was low at 15th min, 30th min and 1st hour, and the difference reached statistical significance at 30th min (p=0.033). Patient satisfaction at the same measurement times was high in this group. Total morphine consumption and side effects were not statistically different between the three groups. CONCLUSION Addition of metamizole to paracetamol along with iv morphine PCA offers an advantage over single iv morphine PCA and paracetamol, with respect to early postoperative pain treatment and patient satisfaction.

The growth of bacteria in infusion drugs: propofol 2% supports growth when remifentanil and pantoprazole do not

BACKGROUND AND OBJECTIVES Contamination risks of propofol 2%, remifentanil, and pantoprazole; and in vitro effects of these drugs on the growth of common infective agents in intensive care units were evaluated. METHODS For detection of contamination risk, drugs were prepared ready to use under intensive care unit conditions, were tested. Effects of these three drugs on bacterial growth were also investigated. Drugs were prepared at the concentrations used in the intensive care unit and inoculated with common pathogens after which they were incubated at 4°C, 22°C and 36°C. Subcultures were made at 0, 2, 4 and 8h and colony counts were evaluated. Minimum inhibitory concentration values were determined for all drugs at 4°C, 22°C and 36°C. RESULTS No growth was observed in the drugs prepared in the intensive care unit. Propofol tended to support while remifentanil inhibited bacterial growth. Effect of pantoprozole differed according to the bacteria tested. None of the drugs showed antibacterial activity at the maximum concentrations which may be achieved in blood of the patients. CONCLUSION Propofol strongly supports the growth of the microorganisms tested, although remifentanil and pantoprazole do not. Therefore, it is important to follow the strict aseptic techniques for the preparation of propofol.

The effect of intravenous paracetamol for the prevention of rocuronium injection pain

Rocuronium is a nondepolarizing neuromuscular blocking agent used in anesthesia induction and is associated with considerable discomfort and burning pain during injection, which is reported to occur in 50–80% of patients. This study was carried out to investigate the effectiveness of intravenous paracetamol pretreatment compared with lidocaine and normal saline to prevent rocuronium injection pain. The study included 150 ASA I–II patients undergoing elective orthopedic, gastrointestinal, and gynecological procedures under general anesthesia. They were allocated into three groups according to pretreatment drugs: lidocaine (40 mg) (n = 50), paracetamol (n = 50), and normal saline group (n = 50). Before anesthesia induction with propofol, all patients were pretreated with rocuronium. The pain caused by the injection was evaluated. Local signs were assessed on the arm at the end of the injection, as well as 24 hours after recovery from anesthesia. There were no patients with blurred speech or vision and there was no respiratory depression in any group after pretreatment with the study drug. The level of pain on injection was statistically lower in those who had received paracetamol compared to normal saline (p = 0.009). There were more patients in the saline group with severe pain (p < 0.001). Paracetamol relieved the rocuronium injection pain better than normal saline but lidocaine was the best of the three drugs (p < 0.001).

Comparison of Flexiblade and Macintosh laryngoscopes: cervical extension angles during orotracheal intubation.

The FlexibladeTM is a new laryngoscope with a flexible blade, a handle and a lever, allowing gradual flexion over the distal half of the blade. In this study, we aimed to compare cervical vertebral movements during tracheal intubation with the Flexiblade and Macintosh laryngoscope in 32 patients undergoing elective surgery requiring general anaesthesia (n = 16 per group). Fluoroscopic images of cervical movement were captured before, during and after intubation and evaluated by a radiologist. C1–C2 cervical vertebral movement was significantly reduced during the intubation in the Flexiblade group (p < 0.0001). C2–C3 cervical movement was similar in both groups (p = 0.81). No significant differences were noted in success rates for intubation, oxygen saturation levels, haemodynamic variables or intubation‐related injury. The decreased extension angle between C1–C2 during Flexiblade laryngoscopy compared with Macintosh laryngoscopy may be an advantage where neurological damage with cervical movement is a concern.

Effectiveness of preemptive intra-articular levobupivacaine on pain relief after arthroscopic knee surgery

Background and Aim: Severe pain and comfortlessness may be seen in patients after arthroscopic knee surgery despite various commonly administered analgesic methods, particularly based on local anesthetics. The aim of this study was to determine the effect of intraarticular levobupivacaine injected preoperatively on pain relief and time to first analgesic request during the postoperative period. Material and Methods: 40 adult-patients, ASA I and II, undergoing elective arthroscopic surgery were included in the study. Patients in the levobupivacaine group received intra-articular levobupivacaine at 5mg/ml dosages and 20 ml total volume 30 min before the procedure. Patients in the control group received 20 ml of normal saline. Visual analogue scale (VAS) scores were assessed at the 1st, 2nd, 4th, 8th, 12th and 24th hour postoperatively. Time to first analgesic request and total analgesics used over the course of 24 hours after the surgery were recorded. All patients received continuous morphine infusion via patient controlled analgesia (PCA) devices postoperatively. Additionally, patients’ pain satisfaction scores were recorded. Results: Lower VAS scores at the 1st, 2nd, 4th and 8th hours postoperatively - both at rest and during motion - were found in the levobupivacaine group compared to the normal saline group (p

Lack of effect of N-acetylcysteine treatment to ameliorate the progression of multiple organ failure: A-672

OBJECTIVE To investigate whether prolonged infusion of the oxygen free radical scavenger N-acetylcysteine (NAC) that is commenced immediately after admission to intensive care unit (ICU) could ameliorate the development or progression of multiple organ failure (MOF). METHODS After receiving ethical committee approval, a prospective randomized, double-blind, placebo controlled study was performed in the Anesthesiology and Reanimation Intensive Care Unit, Hacettepe University Hospital, Ankara, Turkey between December 2002 and May 2003. Twenty-six patients were randomized to receive either NAC in 5% dextrose 40 mg/kg/day or the same volume of 5% dextrose both in 4 divided doses. Two patients were withdrawn due to ICU stay <24 hours. Treatment effect on organ function was assessed by the sequential organ failure assessment (SOFA) scores according to physiological parameters of respiratory, hematological, hepatic, cardiovascular, central nervous system (CNS) and renal system scores that were obtained on admission, then daily. Chi-square, Mann Whitney U tests were used for statistical analysis. RESULTS There was no significant difference between the 2 groups in any of the 5 organ dysfunction parameters, total maximum SOFA, delta SOFA length of intensive care stay, days of mechanical ventilation and mortality. In the NAC treatment group, the maximum SOFA coagulation score was higher than the control group (p<0.05). CONCLUSION N-acetylcysteine (40 mg/kg/day) that was commenced immediately after admission to ICU did not ameliorate the progression of MOF in this small cohort of patients. We believe routine prophylactic use of low-dose NAC in all critically ill patients does not provide positive protection.