Kaan Katircioglu

Comparison of Tools for Nutrition Assessment and Screening for Predicting the Development of Complications in Orthopedic Surgery

BACKGROUND Malnutrition in hospitalized patients is a significant problem. The purpose of this study was to compare 2 assessment tools-the Nutritional Risk Screening 2002 (NRS 2002) and subjective global assessment (SGA)-in predicting development of complications in patients undergoing orthopedic surgery. METHODS Nutrition status was assessed by the SGA, and nutrition screening was performed using the NRS 2002 in 256 consecutively admitted patients scheduled for orthopedic surgery. Additional information recorded for all patients included age, gender, body mass index, and American Society of Anesthesiologists (ASA) physical status. Patient outcomes (postoperative complications), mortality rate, and length of hospital stay (LOS) were investigated. RESULTS Malnourished or nutritionally at-risk patients were significantly older than nonmalnourished or not at-risk patients according to the SGA and NRS 2002. Also, ASA physical status was correlated with malnutrition or malnutrition risk. Malnourished and at-risk patients in both the SGA and NRS 2002 groups showed longer LOS and higher morbidity and mortality rates. Sensitivity was 50% with the SGA and 69% with the NRS 2002; specificity was 77% with the SGA and 80% with the NRS 2002. Agreement between 2 methods was 0.672. The odds ratio for the association between malnutrition or risk of malnutrition and the occurrence of complications was 3.5 (1.7-7.1) for the SGA and 4.1 (2.0-8.5) for NRS 2002. CONCLUSIONS Age and ASA physical status are risk factors for malnutrition. In patients undergoing orthopedic surgery, NRS 2002 predicted development of complications better than the SGA. Malnutrition also increased length of hospital stay.

Bupivacaine Infusion Above or Below the Fascia for Postoperative Pain Treatment After Abdominal Hysterectomy

BACKGROUND:We evaluated in which anatomic layer (above the fascia [AF] or below the fascia [BF]) wound infusion of bupivacaine has the best effect on postoperative pain after abdominal hysterectomy. METHODS:Sixty-two ASA physical status I and II patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy were enrolled into this prospective randomized, double-blind study. A standard general anesthetic was administered. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above (group AF, n = 29) or below (group BF, n = 31) the superficial abdominal fascia and 0.25% bupivacaine was administered via a patient-controlled analgesia device, programmed to deliver 9.0 mL with a 60-min lockout interval for 24 h. During the first 6 h after surgery, rescue IV fentanyl (25 &mgr;g) was administered to achieve a visual analog scale score of <4 cm. Total bupivacaine consumption, total rescue fentanyl consumption, pain scores (with resting, coughing, and leg raising), and patient satisfaction scores were compared in both groups. RESULTS:Total bupivacaine consumption over 24 h was significantly lower in group AF rather than group BF (90 ± 26 mL vs 104 ± 28 mL, respectively, P < 0.05). The total fentanyl consumption during the first 6 h after surgery was 109 ± 59 &mgr;g in group AF and 166 ± 70 &mgr;g in group BF (P < 0.01). Pain scores were lower in group AF at rest and coughing for the first 5 h and for the first 12 h with leg raise (P < 0.05 for all measurements). Thirteen patients (68%) in group AF defined their satisfaction as excellent whereas six patients (32%) in group BF defined their satisfaction as excellent (P = 0.034). CONCLUSION:We conclude that bupivacaine wound infusion AF provides better postoperative analgesia compared with infusion BF in the first 12 h after abdominal hysterectomy.

A retrospective review of 34,109 epidural anesthetics for obstetric and gynecologic procedures at a single private hospital in Turkey.

BACKGROUND: We examined the safety of the routine use of epidural anesthesia by an experienced anesthetic team in a select group of obstetric and gynecologic patients. METHODS: All anesthetic records and an obstetric department database from 1993 to 2006 were retrospectively reviewed (n = 35,628 cases). Success rate, major complication rates, and mortality rates were the major end-points of the study. RESULTS: We performed 34,109 epidural blocks in obstetric and gynecologic anesthesia. The epidural rate increased from 57% to 96% over a 14-yr period. Permanent neurological sequel, cardiac arrest, or mortality and maternal mortality were not seen during this period. CONCLUSIONS: Epidural anesthesia/analgesia, as performed in a private hospital in Turkey by five experienced anesthesiologists for a select group of patients, was a reliable and safe procedure.

Intraoperative fetal heart rate monitoring during emergency neurosurgery in a parturient.

Malignant brain tumors during pregnancy are rare, and these patients seldom require immediate surgical intervention. A 27-year-old pregnant woman underwent emergency craniotomy. Anesthesia was induced with intravenous thiopental-fentanyl; it was maintained with isoflurane in oxygen and continuous intravenous remifentanil infusion. We used full stomach precautions but omitted succinylcholine for fear of increasing the intracranial pressure during induction of anesthesia. To detect fetal hypoxia and the effects of anesthesia on fetal hemodynamics, the fetal heart rate (FHR) was monitored using a fetal Doppler ultrasonography unit fixed to the mothers abdominal wall. Intraoperative and recovery periods were uneventful. Use of an isoflurane and remifentanil combination provided stable hemodynamics with adequate arterial blood pressure to avoid uterine hypoperfusion and fetal hypoxia. In this case, using FHR monitoring we found that craniotomy can be performed safely under isoflurane/remifentanil based-general anesthesia during the second trimester of pregnancy.

Airway management of a patient with Forestier's disease

Forestiers disease, also called diffuse idiopathic skeletal hyperostosis (DISH), is a noninflammatory enthesopathy, ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Intubation difficulty and spinal cord injury are potential problems when managing the airway in DISH patients. We report a patient with Forestiers disease who was admitted for osteophyte resection. After taking a detailed history, we evaluated the airway carefully. Also, preparation for difficult intubation was done. After a rapid sequence induction, we performed mask ventilation and laryngoscopy without hyperextension of the neck, to prevent spinal cord injury. Although the worldwide standard for management of the airway in DISH patients is awake fiberoptic intubation, we chose conventional laryngoscopy because a fiberoptic bronchoscope was not available.

The Effects of An Epidural Infusion of Ropivacaine Versus Saline on Sensory Block After Spinal Anesthesia

Background and Objectives: Several investigators have described the effect of bolus injections on sensory block during combined spinal epidural anesthesia. This study investigates the effects of the immediate epidural infusion of 0.2% ropivacaine versus 0.9% saline on spinal anesthesia. Methods: Forty‐four patients undergoing partial hip replacement were randomly assigned to 2 groups, receiving epidural infusion of 0.2% ropivacaine 10 mL/h (group R, n = 22) or 0.9% NaCl 10 mL/h (group S, n = 22), immediately after spinal anesthesia with 7.5 mg 0.5% hyperbaric bupivacaine. Postoperative analgesia was provided in both groups using a ropivacaine patient‐controlled epidural analgesia technique. Sensory block, motor block, postoperative pain scores, ropivacaine consumption, and patient satisfaction were recorded. Results: There was no difference between the 2 groups in the characteristics of the sensory block. The duration of motor block was prolonged in group R (312 ± 95 minutes vs 198 ± 78 minutes; P < .001). Postoperative pain scores and 24‐hour ropivacaine consumption were similar among groups. Demand/delivery ratio was 1.6 in group R and 3.5 in group S (P = .048). A significantly higher number of patients in group R described their satisfaction as excellent (20 patients vs 6 patients; P < .001). Conclusions: Epidural infusion of ropivacaine 0.2% initiated immediately after spinal anesthesia prolonged the regression of motor block but not the regression of sensory block when compared with saline infusion.

Reversal of prilocaine epidural anesthesia using epidural saline or ringer's lactate washout.

Background and Objectives: Several investigators have described the phenomena of epidural saline washout using bolus injections. This study was designed to determine whether epidural block could be reversed more effectively by infusion of crystalloid solutions via the epidural catheter. Methods: One hundred male patients scheduled for outpatient surgery were enrolled in this study. After 30 min of 2% prilocaine epidural anesthesia, patients were randomly assigned to receive 45 mL of study solution as follows: (1) normal saline bolus (group NSB); (2) Ringers lactate bolus (group RLB); (3) normal saline infusion (group NSI); (4) Ringers lactate infusion (group RLI). Patients in the control group received no washout fluid. Motor, sensory blockade and side effects were compared among 5 groups. Ambulation time is defined as the recovery time. Results: In the control group, ambulation time (139 ± 15 min) was significantly longer than in the washout groups (NSB 90 ± 10, RLB 88 ± 10, NSI 85 ± 8, RLI 91 ± 6 minutes) (P < .001). Two-segment sensory regression time in the control group (86 ± 15 min) was significantly longer than in groups NSB, RLB, NSI and RLI (55 ± 8, 51 ± 4, 58 ± 8, and 53 ± 10 minutes, respectively) (P < .001). Conclusions: We concluded that a more rapid recovery of motor and sensory blockade in patients undergoing epidural anesthesia may be achieved by the use of an epidural washout with either bolus or infusion of 45 mL normal saline or Ringers lactate.

Brachial plexus block for the child with Kartagener's syndrome.

itant to Seckel syndrome, which has not yet defined. Because of the differences of the face structure at Seckel syndrome, it is said that airway maintenance and determining the size of tracheal tube could be difficult and tracheal tube that is 1 or 1.5 smaller size should be used instead of generally used for the same age (1). We encountered no difficulty with ventilating the patient during mask induction. For airway maintenance we used LMA. Although the size of LMA appropriate for his weight was 1.5–2 (according to LMA Classic Selection Guidelines) size 1 LMA was used and enough airway control was obtained by inflating balloon with 4 ml of air. Like determining the size of endotracheal tube, smaller then expected size of LMA was used for the patient. Complex cardiac defects, patent ductus arteriosus and hypertension are reported to be concomitant to Seckel syndrome (1,3). Atrioventricular (AV) complete block with Seckel syndrome is not defined previously. In our case, AV complete block was diagnosed besides Seckel syndrome and permanent cardiac pace maker was implanted. At patients who have permanent cardiac pace maker, patient monitoring must include the ability to ensure that myocardial electrical activity is converted to mechanical systoles (4). For this reason, besides routine ECG monitoring, the synchronization of peripheral pulses with ECG was monitorized by pulse oximetry. It was reported that unipolar cautery used at surgery of patients who have permanent cardiac pace maker cause more electromagnetic interference than the bipolar ones (4). In our case we used bipolar cautery to overcome this problem. We encountered no intraoperative pacemaker problem. For well control of depth of the anesthesia and decrease probable cardiac effects we used sevoflurane– remifentanil anesthesia by BIS monitoring. Anesthesia depth arranged to hold BIS value between 40 and 60. At this depth of anesthesia we encountered no cardiac or hemodynamic problem. In conclusion in cases such as Seckel syndrome, which probability of difficult intubation and difficult airway is high, LMA is a good alternative to maintain the airway opening. BIS monitoring, especially with pediatric patients who have cardiac problems like this patient, enables a smooth anesthesia and early recovery.

Anesthetic management in a child with Diamond-Blackfan anemia

21 months–18 years) undergoing elective outpatient surgery, we are anecdotally impressed by the smooth uncomplicated gaseous inductions achieved using iPhone distraction. Only one child had to be returned to the preoperative holding area for administration of oral anxiolytic premedication. Children were introduced to the device at the preanesthetic visit, shown its basic functions and offered a choice of viewing. Animated films made by Pixar Animation Studios (particularly Ice Age and Finding Nemo) seemed especially popular. The child would be given the device to hold and the film started as the child was transported (without parental presence) from the preoperative holding area to the operating theatre by the anesthetist, either carried or in a wheelchair. It is an interesting observation that the device has not been dropped by any child to date. The iPhone is held within a case manufactured by Incase , this would provide some protection in such an event. Both the iPhone and the case can been cleaned with a standard alcohol wipe. Its intuitive ease of use and current popularity also meant that children frequently became absorbed by scrolling through its menus and investigating its other functions. The program was continued as the child was placed on the operating table in the operating theatre and routine monitoring attached. Gaseous anesthesia was induced using a combination of oxygen in nitrous oxide plus incremental sevoflurane, delivered through a scented facemask. The anesthetist would hold the facemask with one hand, and the iPhone in their other hand during the induction to ensure the device was not dropped (see Figure 1). The film was discontinued as the child’s eyes closed. An alternative to the iPhone would be the newly released Apple iPod touch which features the same multimedia capability and high resolution screen. Anesthetists are typically a technology-friendly group and are often early adopters. We anticipate high popularity of the device particularly amongst younger trainees despite the cost. We are not aware of any interference with either monitoring equipment or other operating theatre electronics caused by use of iPhone. Indeed, the web-browser facility of the device means the answer to any question arising is almost instantly available via access to the world wide web, enhancing the educational experience of the trainee. Daniel K. Low M R C P C H F R C A Andrew P. Pittaway F R C A Department of Anesthesiology, Childrens Hospital and Regional Medical Centre, Seattle, WA, USA (email: daniel.low1@mac.com)

Effects of immediately initiating ropivacaine infusion on unilateral spinal anaesthesia: A-425

at 80 and 70 during observation. Results: The minimum BIS at 1 g/Ml Ce was 86.9 11.3 (Group 1), 80.5 8.5 (Group 2), 66.9 15.5 (Group 3) and the minimum BIS at 1.5 g/Ml Ce was 76.0 13.4, 62.9 12.4, 48.5 13.7 respectively. The Ce of propofol with BIS 80 was checked initially 1.4 0.5 g/Ml (Group 1), 1.1 0.3 g/Ml (Group 2) and 0.8 0.3 g/Ml (Group 3). The Ce of propofol with BIS 70 was 1.8 0.6 g/Ml, 1.4 0.3 g/Ml and 1.0 0.3 g/Ml respectively. Conclusions: Spinal anesthesia and intrathecal clonidine reduce the requirement of propofol for conscious sedation, and the Ce of propofol for conscious sedation is 1.4–1.8 g/Ml at local anesthesia, 1.1–1.4 g/Ml at spinal anesthesia with 0.5% hyperbaric bupivacaine, 0.6–1.0 g/Ml at spinal anesthesia with 0.5% hyperbaric bupivacaine and 75 g clonidine. References: 1 Tverskoy M, et al. Anaesthesia 1996; 51: 652–3. 2 De Kock M, et al. Anesthesiology 2001; 94: 574–8.