Jale Bengi Celik

Methylprednisolone prevents inflammatory reaction occurring during cardiopulmonary bypass: effects on TNF-α, IL-6, IL-8, IL-10:

Objective: This study examined the correlation between tumour necrosis factor-alfa (TNF-α), interleukin (IL)-6 and IL-8, IL-10 and methylprednisolone pretreatment. Methods: This is a prospective, randomized and double-blinded study. Sixty patients undergoing coronary artery bypass grafting (CABG) were randomized to receive either intravenous methylprednisolone (n=30, Group M) or intravenous placebo (n=30, Group S). The patients received intravenously either 30 mg/kg methylprednisolone (Group M) or placebo (Group S) 10 min before and after cardiopulmonary bypass (CPB). In an intensive care unit (ICU), four additional doses were given at 6-hourly intervals. Blood samples for the measurements of TNF-α, IL-6, IL-8 and IL-10 were obtained before induction of anaesthesia (T0=control value), after induction (T1), before starting CPB (T2), after aortic declamping (T3), at the end of CPB (T4) and 6 hours (T5), 12 hours (T6) and 24 hours (T7) after skin closure. Creatine kinase (CK) and creatine kinase isoenzyme MB (CK-MB) were evaluated at the following intervals: T0, T5, T6 and T7. Results: When compared with the control value, TNF-α, IL-6 and IL-8 significantly increased in Group S and Group M (p B-0.05), but these values were significantly greater in Group S than in Group M (p B-0.05). In comparison with the control value, IL-10 increased in both groups (p B-0.05), but was significantly greater in Group M than in Group S (p B-0.05). CK and CK-MB were increased in both groups in postoperative values compared to control values. In Group S, CK and CK-MB levels were significantly lower than in Group M (p B-0.05). Conclusion: In this study, we have found that pre-operative administration of methylprednisolone has decreased TNF-α, IL-6 and IL-8 release, and increased the perfusing IL-10 levels after CPB. Thus, methylpredniso-lone may decrease the inflammatory response during the CPB procedure.

Effect of off-pump and on-pump coronary artery bypass grafting on renal function.

Background. Coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) has the risk of renal dysfunction. The cause of renal dysfunction after CPB is multifactorial, such as nonpulsatile flow, renal hypoperfusion, hypothermia, and duration of CPB. This study compared off-pump technique with on-pump technique on renal function in patients who underwent CABG. Methods. Sixty patients with normal preoperative renal functions undergoing CABG were randomly assigned to conventional revascularization with CPB (on-pump) or beating heart revascularization (off-pump). Renal functions were assessed up to 10 days postoperatively. Results. Creatinine clearance was found to be significantly higher in the off-pump group than in the on-pump group (p < .05). The off-pump group had significantly less increase in creatinine levels when compared with the on-pump group (p < .05). The free water clearance values decreased similarly in both groups; however, the recovery was more prompt in the off-pump group (p < .05). No significant differences were found in the prevalence of postoperative hemodialysis. Conclusion. The off-pump technique may provide a positive contribution and sufficient protection on postoperative renal functions in patients undergoing CABG.

Renal effects of coronary artery bypass graft surgery in diabetic and non-diabetic patients: a study with urinary neutrophil gelatinase-associated lipocalin and serum cystatin C.

Background/Aims: Cardiac surgery and diabetes are major causes of acute kidney injury (AKI). We aimed to investigate the value of urinary neutrophil gelatinase-associated lipocalin (NGAL) and serum cystatin C, as early biomarkers for prediction of AKI in diabetic and non-diabetic adult patients undergoing cardiac surgery. Methods: 15 non-diabetic and 15 diabetic adult patients undergoing cardiac surgery were enrolled. Peri-operative clinical and laboratory variables were recorded. Urinary NGAL, serum cystatin C, serum creatinine (Cre) and blood urea nitrogen (BUN) were evaluated. Results: AKI was detected in 4 patients in non-diabetic group and 12 patients in diabetic group. Urinary NGAL levels of diabetic and non-diabetic patients and serum cystatin C levels of diabetic patients exceed upper normal limits or cutoff values much earlier than BUN and Cre. cystatin C levels of non-diabetic patients remain unchanged. Cystatin C and NGAL levels of patients meeting AKI criteria and NGAL levels of patients not meeting AKI criteria exceeded upper normal limits or cut off values much earlier in than BUN and Cre. Conclusions: Measurement of cystatin C level in both diabetic and non-diabetic patients may reveal AKI earlier than NGAL and BUN. In diabetic patients, measurement of urinary NGAL and serum cystatin C levels may indicate AKI signs earlier than BUN and Cre.

Is a neutral head position as effective as head rotation during landmark-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial.

OBJECTIVE Central venous access remains a cornerstone procedure for a variety of clinical conditions. Ultrasound studies suggest that rotation of the head increases the magnitude of the overlap of the internal jugular vein with the carotid artery. The authors assessed whether a neutral position of the head during anatomic landmark-guided cannulation of the internal jugular vein (IJV) was an attractive alternative to rotating the neck to a >45° head turn. DESIGN A prospective, randomized, controlled study. SETTING An education and research hospital and a university-affiliated hospital. PARTICIPANTS Eighty patients requiring central venous catheterization in the right IJV. INTERVENTIONS Under general anesthesia, patients were positioned in the Trendelenburg position with extension of the neck. In the rotated group, the head was rotated to the left at >45°. In the neutral group, the head was placed in the neutral position. Right IJV cannulation was performed using the central approach with the needle angled toward the ipsilateral nipple. The primary outcome variable was the cumulative success rate, which was defined as IJV puncture achieved in the first 3 attempts using a finder needle. A p value of <0.05 was considered statistically significant. MEASUREMENTS AND MAIN RESULTS Groups were similar in terms of demographic data. The success rates of finder needle passes into the IJV on the first attempt were 87.5% and 37.5% (p < 0.05), and the cumulative success rates on the first 3 attempts were 97.5% and 57.5% in the rotated and neutral groups, respectively (p < 0.05). Carotid artery puncture only occurred in 2 patients in the rotated group. CONCLUSIONS Because of the lower success rate, the neutral head position is not an attractive alternative for IJV catheterization when compared with the rotated head position in a central landmark IJV approach.

Intraarticular local anesthetics: primum non nocere

We are following with interest that the papers concerning the use of intraarticular local anesthetics during arthroscopic procedures in Knee Surgery Sports Traumatology Arthroscopy [2, 4]. The study by Campo et al. [2] re-ignites the debate on the safety of intraarticular local anesthetics. The authors claim that, ‘‘If the effect of the intra-articular anaesthetic is proven not clinically relevant this would be a definite argument to stop the administration of these agents’’. Their results show small improvement on patient comfort; therefore, they advise to use systemic anesthetic instead of intraarticular bupivacaine or ropivacaine for pain relief after knee arthroscopy. We appreciate Campo et al. [2] for their efforts for better patient safety. However, we have substantial concerns on the issue and feel very strongly to ask what was the need for further research when some evidence is so obvious? Firstly, as Campo et al. [2] state there is no level 1 evidence in current literature about the effectiveness of intraarticular local anesthetic administration on postoperative pain in patients undergoing arthroscopy. Secondly, the safety of intraarticularly administered local anesthetics is a major concern. Farkas et al. [3] report that bupivacaine is cytotoxic, because it induces almost 100% cell necrosis after 24 h of exposure in cultured human chondrocytes. Likewise the two distinct steroid preparations, betamethasone and prednisolone show similar characteristics in inducing cell death, reaching 20% of cell death by 24 h. Finally, in the clinical setting, concern has been raised following reports of dramatic chondrolysis following shoulder arthroscopy in which infusion of the local anesthetic was employed [1]. We are in the opinion that, bearing in mind the risk of cell necrosis, intraarticalar local anesthetics should only be used for circumstances like arthroplasty and grade IV osteoarthritis in which the hyaline articular cartilage has been destroyed considerably. Until further evidence, we should think twice before using bupivacaine for arthroscopic procedures or designing such research.

The Effects of Intrathecal Morphine on Patient-Controlled Analgesia, Morphine Consumption, Postoperative Pain and Satisfaction Scores in Patients Undergoing Gynaecological Oncological Surgery

OBJECTIVE: Gynaecological oncological surgery (GOS) includes a wide variety of surgical procedures and postoperative pain is a major concern. This study compared the impact of intrathecal morphine (ITM) plus patient-controlled analgesia (PCA) with PCA alone on morphine consumption, pain relief and patient satisfaction after GOS. METHODS: Sixty women undergoing GOS under general anaesthesia were randomized to receive either 0.3 mg ITM or placebo. On arrival at the postanaesthesia care unit each patient received a morphine PCA pump. The three primary outcome measures were pain, patient satisfaction scores evaluated using a 100-mm visual analogue scale and cumulative PCA morphine consumption. RESULTS: No significant differences were observed in the demographic data. Cumulative PCA morphine consumption was significantly lower in the ITM group compared with the control group. Fatigue scores were lower in the ITM group compared with the control group but did not reach statistical significance. Pain, sedation and patient satisfaction scores, and the rate of side-effects were similar for the two groups. CONCLUSIONS: Administering ITM in GOS could improve postoperative analgesia and reduce morphine consumption without serious side-effects.

Spinal anaesthesia for orthopaedic surgery in children with cerebral palsy: Analysis of 36 patients

Background and Objective: Cerebral palsy is one of the most common childhood neuromuscular diseases in the world. Spinal anaesthesia in children is an evolving technique with many advantages in perioperative management. The aim of this retrospective study was to provide first-hand reports of children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia. Methods: Records of the children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia between May 2012 and June 2013 at Selcuk University Hospital were investigated. In all patients, lumbar puncture was performed in lateral decubitus position with mask sevoflurane-nitrous oxide anaesthesia. In patients who were calm prior the spinal block, inhalation anaesthesia was terminated. In patients who were restless before the spinal block, anaesthesia was combined with light sevoflurane anaesthesia and a laryngeal mask. From anaesthesia records, the number of attempts required to complete the lumbar puncture, and the success rates of spinal anaesthesia and perioperative complications were noted. Data were expressed as numbers and percentages. Results: The study included 36 patients (20 girls and 16 boys). The mean age was 71 months. The rate of reaching subarachnoid space on first attempt was 86%. In all patients, spinal anaesthesia was considered successful. In 26 patients, laryngeal mask and light sevoflurane anaesthesia were required to maintain ideal surgical conditions. No major perioperative complications were observed. Conclusion: Spinal anaesthesia alone or combined with light sevoflurane anaesthesia is a reliable technique with high success rates in children with cerebral palsy undergoing orthopaedic surgery.

A comparison of the effects of intraoperative tramadol and ketamine usage for postoperative pain relief in patients undergoing tonsillectomy

OBJECTIVES We aimed to compare the effects of ketamine and tramadol administered intraoperatively on postoperative pain and analgesic demand in children undergoing tonsillectomy operations. METHODS Ninety children undergoing tonsillectomy, aging 5-15 years old, with ASA I - II , were included in this study. Cases were arranged in three groups and given standardized general anesthesia. After coagulation, ketamine (0.5 mg.kg-1) was administered intravenously (iv) in the ketamine group, and tramadol iv (2 mg.kg-1) was given in the tramadol group and the control group received a physiologic iv. The duration of anesthesia, duration of operation, and length of stay in the PACU were recorded. NRS and CHEOPS scales were used to assess postoperative pain. Paracetamol (15 mg.kg-1) was given rectally in the first 6 hours (hrs) and orally over the subsequent 6 hrs, if NRS greater than 3 and CHEOPS greater than 8 were observed. All data were recorded concerning the initial and total dosage of analgesic and the presence of complications within 24 hrs. RESULTS Demographic data, duration of anesthesia, duration of operation, and duration of stay in the PACU were similar between groups (p>0.05). The number of patients requiring additive analgesic was higher in the control group. No differences were found between the tramadol and ketamine groups (p>0.05). Additional analgesic was given earlier in the control group (p<0.05), but the need for additional analgesic was similar in tramadol and ketamine groups (p>0.05). Paracetamol dosage was significantly higher in the control group (p<0.05), but similar between the tramadol and ketamine groups (p>0.05). The frequency of nausea and vomiting was found to be significantly higher in tramadol and ketamine groups compared to the control group (p<0.05). CONCLUSION Postoperative pain was effectively managed using 2 mg.kg-1 tramadol and 0.5 mg.kg-1 ketamine in pediatric tonsillectomies.

Management of postdural puncture headache with epidural saline patch in a 10-year-old child after inguinal hernia repair: A case report

Spinal anesthesia (SA) is becoming increasingly popular among pediatric anesthetists. Postdural puncture headache (PDPH) has been reported in children. PDPH generally spontaneously resolves within a few days with bed rest and nonopioid analgesics, but it may last for several days. If the symptoms persist, an epidural blood patch is considered as an effective treatment. We describe the successful use of an epidural saline patch in a 10 year-old child with PDPH who did not respond to conservative treatment.

Pulsed Radiofrequency of Dorsal Root Ganglia for the Treatment of Complex Regional Pain Syndrome in an Adolescent with Poliomyelitis Sequel: A Case Report

OBJECTIVE Complex regional pain syndrome (CRPS) is a painful and disabling syndrome in which the patient presents with neuropathic pain, edema, or vasomotor or pseudomotor abnormalities that are often refractory to treatment. Polio paralysis is caused by the damage or destruction of motor neurons in the spine, which lead to corresponding muscle paralysis. This report is a case report on the application of a pulsed radiofrequency (PRF) current to dorsal root ganglia (DRG) for the treatment of CRPS type 1 in an adolescent patient. DESIGN Single case report. SETTING Selcuk University Hospital. PATIENT A 16-year-old girl who suffered from CRPS type 1 secondary to surgeries for the sequelae of poliomyelitis. INTERVENTIONS PRF current application to the lumbar 4 and lumbar 5 DRG. OUTCOME MEASURES Pain reduction. RESULTS The patient had complete resolution of her symptoms, which was maintained at a 6-month follow-up. CONCLUSIONS This case illustrates that PRF applied to lumbar 4 and lumbar 5 DRG may play a significant role in CRPS type 1 management after the surgical treatment of poliomyelitis sequelae in adolescent patients. Further randomized, controlled studies are needed to support this argument.