Kerem Inanoglu

Comparison of recovery characteristics, postoperative nausea and vomiting, and gastrointestinal motility with total intravenous anesthesia with propofol versus inhalation anesthesia with desflurane for laparoscopic cholecystectomy: A randomized controlled study

BACKGROUND Clinical effects, recovery characteristics, and costs of total intravenous anesthesia with different inhalational anesthetics have been investigated and compared; however, there are no reported clinical studies focusing on the effects of anesthesia with propofol and desflurane in patients undergoing laparoscopic cholecystectomy. OBJECTIVE The aim of this study was to determine the effects of total intravenous anesthesia with propofol and alfentanil compared with those of desflurane and alfentanil on recovery characteristics, postoperative nausea and vomiting (PONV), duration of hospitalization, and gastrointestinal motility. METHODS Patients classified as American Society of Anesthesiologists physical status I or II undergoing elective laparoscopic cholecystectomy due to benign gallbladder disease were enrolled in the study. Patients were randomly assigned at a 1:1 ratio to receive total intravenous anesthesia with propofol (2-2.5 mg/kg) and alfentanil (20 μg/kg) or desflurane (4%-6%) and alfentanil (20 μg/kg). Perioperative management during premedication, intraoperative analgesia, relaxation, ventilation, and postoperative analgesia were carried out identically in the 2 groups. Extubation time, recovery time, PONV, postoperative antiemetic requirement, time to gastrointestinal motility and flatus, duration of hospitalization, and adverse effects were recorded. Postoperative pain was assessed using a visual analogue scale. RESULTS Sixty-eight patients were assessed for inclusion in the study; 5 were excluded because they chose open surgery and 3 did not complete the study because they left the hospital. Sixty patients (33 women, 27 men) completed the study. Recovery time was significantly shorter in the propofol group (n = 30) compared with the desflurane group (n = 30) (8.0 [0.77] vs 9.2 [0.66] min, respectively; P < 0.005). Fifteen patients (50.0%) in the propofol group and 20 patients (66.7%) in the desflurane group experienced nausea during the first 24 hours after surgery. The difference was not considered significant. In the propofol group, significantly fewer patients had vomiting episodes compared with those in the desflurane group (2 [6.7%] vs 16 [53.3%]; P < 0.005). Significantly fewer patients in the propofol group required analgesic medication in the first 24 hours after surgery compared with those in the desflurane group (10 [33.3%] vs 15 [50.0%]; P < 0.005). Patients in the propofol group experienced bowel movements in a significantly shorter period of time compared with patients in the desflurane group (8.30 [1.67] vs 9.76 [1.88] hours; P = 0.02). The mean time to flatus occurred significantly sooner after surgery in the propofol group than in the desflurane group (8.70 [1.79] vs 9.46 [2.09] hours; P = 0.01). The duration of hospitalization after surgery was significantly shorter in the propofol group than in the desflurane group (40.60 [3.49] vs 43.60 [3.56] hours; P = 0.03). CONCLUSION Total intravenous anesthesia with propofol and alfentanil was associated with a significantly reduced rate of PONV and analgesic consumption, shortened recovery time and duration of hospitalization, accelerated onset of bowel movements, and increased patient satisfaction compared with desflurane and alfentanil in these patients undergoing laparoscopic surgery who completed the study.

Comparison between ultrasound-guided sciatic–femoral nerve block and unilateral spinal anaesthesia for outpatient knee arthroscopy

Objective To compare unilateral spinal anaesthesia (USA) and ultrasound-guided combined sciatic–femoral nerve block (USFB) in ambulatory arthroscopic knee surgeries in terms of haemodynamic stability, nerve block quality, bladder function, adverse events and time-to-readiness for discharge (TRD). Methods Patients undergoing ambulatory arthroscopic knee surgery were randomly assigned to one of two groups. The USA group received 2 ml (10 mg) of 0.5% levobupivacaine and the USFB group received a 25 ml mixture consisting of 10 ml of 2.0% lidocaine, 10 ml of 0.5% levobupivacaine and 5 ml of saline (15 ml for the femoral and 10 ml for the sciatic nerve block). Preparation time (PT), surgical anaesthesia time (SAT), operation time, total anaesthesia time, time-to-first spontaneous urination, time-to-first analgesia, TRD, adverse events and patient satisfaction were recorded. Results A total of 40 patients were enrolled in the study (n = 20 per group). PT, SAT, total anaesthesia time and time-to-first analgesia were significantly shorter in the USA group than the USFB group; time-to-first spontaneous urination and TRD were significantly longer in the USA group than the USFB group. Conclusions USFB provided sufficient duration of sensory blockade and it reduced the TRD and the rate of adverse events.

Effects of Intravenous Small Dose Ketamine and Midazolam on Postoperative Pain Following Knee Arthroscopy

Background:  The aim of this randomized, double blind, controlled study was to assess the effect of intravenous coadministration of small dose midazolam with ketamine on postoperative pain and spinal block level.

Comparison of Combined (Deep and Superficial) and Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy

OBJECTIVES Carotid endarterectomy under regional anesthesia may be performed by using superficial, intermediate, deep or combined cervical plexus block. The authors compared the combined and intermediate cervical plexus block by use of ultrasound guidance in patients undergoing carotid endarterectomy. DESIGN A prospective, randomized, double-blinded trial. SETTING Education and research hospital. PARTICIPANTS Adult patients undergoing carotid artery surgery. INTERVENTIONS Forty-eight patients were randomized to receive either combined cervical plexus block (deep plus superficial) or intermediate cervical plexus block by use of ultrasound guidance for carotid endarterectomy. The primary outcome measure was the amount of supplemental 1% lidocaine used by the surgeon. Secondary outcome measures were the time for the first analgesic requirement after surgery, block-related complications, postoperative visual analog scale score, and patient and surgeon satisfaction. MEASUREMENTS AND MAIN RESULTS Intraoperative supplemental lidocaine requirements were 3.0±1.9 mL in the combined-block group and 7.8±3.8 mL in the intermediate block group. These differences were statistically significant. There were no significant differences between the 2 groups in block-related complications and the time between the block completion and the first administration of the first dose of intravenous analgesic. In the combined-block group, maximum visual analog scale score was lower at 3 hours (2.2 [1-5] v 5.3 [3-8]), and patient satisfaction score was higher than the intermediate-block group (4.3 [3-5] v 3.1 [1-4]). One regional anesthesia procedure was converted to general anesthesia in the combined-block group. CONCLUSIONS Ultrasound-guided combined cervical plexus block compared to intermediate cervical plexus block led to less additional analgesic use, lower visual analog scale score, and higher patient satisfaction.

Periprostatic nerve blockage reduces postoperative analgesic consumption and pain scores of patients undergoing transurethral prostate resection.

Introduction: To evaluate the effects of periprostatic bupivacaine administration on pain control and analgesic consumption after transurethral prostate resection (TURP). Materials and Methods: The study included 40 male patients with benign prostatic hyperplasia who underwent TURP, and they were divided randomly into two groups. All patients were operated under general anesthesia. The study group patients (n = 20) received periprostatic bupivacaine (0.5% 20 ml) injection (group I), and the control patients (n = 20) received only saline (NaCl 0.9% 20 ml) injection (group II). All injections were performed bilaterally into the periprostatic areas immediately after the TURP procedure via the transperineal route. In the postoperative period, all patients (groups I and II) received tramadol using a patient-controlled analgesia device. Postoperative pain was assessed and recorded using the visual analog scale (VAS) at postoperative hours 1, 2, 3, 4, 5, 6, 7, 8, 12, 16, 20, 24, and 48. Total tramadol consumptions and additional analgesic requirements were also recorded and compared between groups. Results: There was no difference in demographic data between the two groups (p > 0.05). VAS scores of the patients at hours 1, 3, 4, 5, 7, 8, and 12 were found to be significantly lower in group I than in group II (p < 0.05). Total tramadol consumption and patient-controlled analgesia demands of groups I and II were 153.5 ± 52.4 vs. 465.0 ± 55.1 mg and 17.1 ± 7.7 vs. 77.8 ± 7.5 mg, respectively (p < 0.001). No side effect was observed regarding bupivacaine injections. Conclusions: Periprostatic bupivacaine administration was a useful and safe method for postoperative pain control and reduced analgesic consumption in patients undergoing TURP.

The effect of anesthetic agents on perioperative bleeding during tonsillectomy: Propofol-based versus desflurane-based anesthesia

OBJECTIVE: Hemorrhage during tonsillectomy is related to the surgical technique, management of bleeding, and choice of anesthetic agent. This study evaluated the effects of anesthetic agents on hemorrhage during tonsillectomy with standardized surgical techniques and management of bleeding. STUDY DESIGN: Double-blind, randomized controlled trial. SUBJECTS AND METHODS: Sixty patients, aged 3 to 12 years, who were scheduled for elective tonsillectomy were enrolled in the study. Propofol-based anesthesia was administered to the first group; desflurane-based anesthesia, to the second. The amount of blood loss due to hemorrhage was measured. RESULTS: Propofol-based anesthesia significantly decreased bleeding during tonsillectomy. CONCLUSION: Propofol-based anesthesia is a reliable method for use in children who undergo tonsillectomy.

Disease activity in rheumatoid arthritis as a predictor of difficult intubation

Background and objectives: Rheumatoid arthritis is a lifelong systemic disease that can affect any joint with a synovium. Managing intubation in patients with rheumatoid disease is a special challenge in these patients especially if specific joints, which play an important role during intubation, are affected. We aimed to investigate if there was a correlation between the activity and duration of the disease and the commonly used predictors of difficult intubation in rheumatoid arthritis. Methods: Sixty‐six patients with the diagnosis of rheumatoid arthritis and 60 control patients were included in the study. Patient characteristics were recorded. Body mass index, disease activity scores, Mallampati classification, sternomental distance, thyromental distance, inter‐incisor distance and atlanto‐occipital joint extension were measured for each patient. Every patient was asked to complete the Stanford Health Assessment Questionnaire (HAQ score). Disease activity score (DAS 28 score) including 28 joints was used to assess the activity of the disease. Correlation between the predictors of difficult intubation and activity was assessed and was compared with the control group. Results: Mallampati scores were higher (P = 0.000), sternomental distance (P = 0.005) and inter‐incisor distance (P = 0.003) were shorter and also occlusal surface‐upper teeth angle (P = 0.000) and mouth corner‐tragus line angle were smaller in the rheumatoid arthritis group compared with controls (P = 0.000). We did not observe a correlation between the disease activity scores and the Mallampati score (P = 0.619), sternomental distance (P = 0.195), thyromental distance (P = 0.174), inter‐incisor distance (P = 0.764), angle I (P = 0.372) and angle II (P = 0.609). There was no correlation between the HAQ score and the Mallampati score (P = 0.872), sternomental distance (P = 0.455), thyromental distance (P = 0.841), inter‐incisor distance (P = 0.162), angle I (P = 0.768) and angle II (P = 0.287). There was no correlation between the duration of the disease and the Mallampati score (P = 0.619), sternomental distance (P = 0.505), thyromental distance (P = 0.426), inter‐incisor distance (P = 0.813), angle I (P = 0.377) and angle II (P = 0.600). Conclusion: Tests of disease activity and the duration of the disease were not found to be correlated with the predictors of difficult intubation in this study. Thus, performing the predictive tests for difficult intubation especially in patients with very low scores or short disease is recommended.

A randomised controlled trial examining the effect on the addition of the mandibular block to cervical plexus block for carotid endarterectomy

OBJECTIVES Although the cervical plexus block generally provides adequate analgesia for carotid endarterectomy, pain caused by metal retractors on the inferior surface of the mandible is not prevented by the cervical block. Different pain relief methods can be performed for patients who experience discomfort in these areas. In this study, the authors evaluated the effect of mandibular block in addition to cervical plexus block on pain scores in carotid endarterectomy. DESIGN A prospective, randomized, controlled trial. SETTING Training and research hospital. PARTICIPANTS Patients who underwent a carotid endarterectomy. INTERVENTIONS Patients scheduled for carotid endarterectomy under cervical plexus block were randomized into 2 groups: group 1 (those who did not receive a mandibular block) and group 2 (those who received a mandibular block). The main purpose of the study was to evaluate the mandibular block in addition to cervical plexus block in terms of intraoperative pain scores. MEASUREMENTS AND MAIN RESULTS Intraoperative visual analog scale scores were significantly higher in group 1 (p = 0.001). The amounts of supplemental 1% lidocaine and intraoperative intravenous analgesic used were significantly higher in group 1 (p = 0.001 and p = 0.035, respectively). Patient satisfaction scores were significantly lower in group 1 (p = 0.044). The amount of postoperative analgesic used, time to first analgesic requirement, postoperative visual analog scale scores, and surgeon satisfaction scores were similar in both groups. There was no significant difference between the groups with respect to complications. No major neurologic deficits or perioperative mortality were observed. CONCLUSIONS Mandibular block in addition to cervical plexus block provides better intraoperative pain control and greater patient satisfaction than cervical plexus block alone.

Comparação de diferentes métodos de inserção de sonda nasogástrica em pacientes anestesiados e intubados

BACKGROUND Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding. MATERIAL AND METHODS 200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted. RESULTS Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG. CONCLUSION Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients.

Anesthesia Management in Rare Case: Osteogenesis Imperfecta

Osteogenesis imperfecta is a rare genetic disorder and a collagen tissue disease for which preoperative preparation and intra-operative anesthesia management must be performed with great care on patients. An operation was planned for a 5-year old female patient with Type I osteogenesis imperfecta due to a right femoral fracture. Her medical history showed that she had been operated due to a left femoral fracture 5 months ago under sevoflurane inhalation anesthesia without any complications. On her physical examination, she was observed to be a short child with growth deficiency, kyphoscoliosis, and bone and shape deformities on her extremities. Her modified Mallampati score was III and neck extension was limited. Preoperative echocardiography, complete blood cell count, coagulation profile, and biochemical values were found in normal limits. She was taken into the Case Study Karaveli et al.; BJPR, 15(5): 1-5, 2017; Article no.BJPR.31703 2 operation theatre and monitorized. Pressure points were supported by silicon peds. Vascular access could not be established at first because of her agitation, and then it was achieved after the patient’s anesthesia induction was performed with sevoflurane. Her neck was kept stable and laryngeal mask was placed in the mouth in the first intervention. Anesthesia was provided through 50% O2 + 50% air and 2% sevoflurane. At the end of the operation that took 90 min, the patient was extubated unevenBtfully, and taken to the recovery room. Main anesthetic problems in patients with osteogenesis imperfecta are the difficulties in maintaining the airway management and malign hyperthermia. We used sevoflurane both at the induction and at the maintenance of anaesthesia due to the difficult vascular access of the patient, and we did not encounter any problems. Inhalation anesthesia such as sevoflurane as well as TIVA could be used for the anesthesia for the patients with osteogenesis imperfecta. Great care must be given because of difficult airway in such patients, and necessary precautions must be taken. Laryngeal mask airway could be preferred in order to secure the airway and avoid traumatic complications.