Mahmut Alp Karahan

Effects of sevoflurane and desflurane on oxidative stress during general anesthesia for elective cesarean section

SummaryBackgroundAnesthetic agents might considerably influence maternal-fetal oxidative stress and antioxidants during cesarean section (CS). The aim of this study was to investigate the effects of desflurane and sevoflurane on oxidative stress parameters both in mothers and newborns undergoing elective CS.Materials and methodsEighty ASA physical status I–II, term parturients undergoing elective CS under general anesthesia were randomized to desflurane (Group D) and sevoflurane (Group S) groups. Blood samples were collected from mothers before operation and postoperatively and umbilical artery samples were obtained at delivery. Total oxidant status (TOS), total antioxidant capacity (TAC) status, lipid hydroperoxide (LOOH), and free sulfhydryl (–SH) levels were measured and oxidative stress index was calculated. Secondary outcomes included maternal hemodynamics.ResultsPreoperative LOOH, TOS, OSI, TAC, and –SH levels were similar among groups. Postoperative maternal serum LOOH, TOS, and OSI levels were significantly increased in Group D compared to Group S (p = 0.003, p = 0.005, p = 0.04; respectively). Postoperative umbilical artery LOOH, TOS, OSI levels were also significantly increased in Group D compared to Group S (p = 0.04, p = 0.02, p = 0.01; respectively). Postoperative TOS (p = 0.001, < 0.001 respectively) and OSI (p = 0.003, < 0.001 respectively) levels in both Group D and Group S were statistically significantly decreased compared to preoperative levels. Postoperative LOOH and –SH levels in Group S (p = 0.04, 0.029 respectively) were statistically significantly decreased compared to preoperative levels. There were no significant differences in TAC and –SH levels among groups (p = nonsignificant [n.s.]). Maternal perioperative mean blood pressure and heart rate were similar among groups (p = n.s.).ConclusionOxidative stress indices might be modified with preferred anesthetic agent and sevoflurane showed more favorable effects than desflurane in view of oxidative stress.ZusammenfassungHintergrundAnästhetika könnten den materno-fötalen oxidativen Stress und Antioxidantien während einer Sectio Caesarea (CS) erheblich beeinflussen. Ziel der vorliegenden Studie war es, die Wirkungen von Desfluran und Sevofluran auf Parameter des oxidativen Stresses sowohl bei Müttern, die sich einer elektiven CS unterziehen, als auch bei deren Neugeborenen zu untersuchen.Material und MethodenAchtzig zum Termin mittels elektiver CS unter Allgemeinnarkose Gebärende im ASA physikalischen Status I–II wurden randomisiert entweder Desfluran (Gruppe D) oder Sevofluran (Gruppe S) zugeteilt. Blutproben wurden von den Müttern prä- und postoperativ abgenommen, Nabelschnurblut bei der Geburt. Der Gesamt-Oxidations-Status (TOS), die totale antioxidative Kapazität (TAC), Lipid Hydroperoxid (LOOH) sowie die freien Sulfhydrylgruppen (–SH) wurden bestimmt. Der oxidative Stress Index (OSI) wurde berechnet. Die Hämodynamik der Mutter war ein sekundäres Outcome.ErgebnisseDie präoperativen LOOH, TOS, OSI, TAC und –SH Konzentrationen waren bei beiden Gruppen ähnlich. Die postoperativen mütterlichen LOOH, TOS, OSI Serum Konzentrationen waren in Gruppe D im Vergleich zur Gruppe S signifikant erhöht (p = 0,003, p = 0,005, p = 0,04; respektive). Postoperative Nabelschnur-Arterien Werte von LOOH, TOS, OSI waren in Gruppe D im Vergleich zur Gruppe S auch signifikant erhöht (p = 0,04, p = 0,02, p = 0,01; respektive). Postoperative TOS (p = 0,001, < 0,001 respektive) und OSI (p = 0,003,< 0,001 respektive) Werte waren sowohl in Gruppe D als auch Gruppe S statistisch signifikant im Vergleich zu den präoperativen Werten erniedrigt. Postoperative LOOH und –SH Konzentrationen waren in Gruppe S (p = 0,04, 0,029 respektive) im Vergleich zu präoperativen Werten statistisch signifikant erniedrigt. Auch die postoperative LOOH und –SH Werte der Gruppe S (p = 0,04, 0,029 respektive) waren im Vergleich zu den präoperativen Werten statistisch signifikant erniedrigt. Es bestand kein signifikanter Unterschied der TAC und –SH Werte zwischen den Gruppen (p = nicht signifikant [n.s.]). Auch der mittlere perioperative Blutdruck und die Herzfrequenz waren bei beiden Gruppen ähnlich (p = n.s).SchlussfolgerungenOxidative Stress Indikatoren können durch das bevorzugte Anästhetikum beeinflusst werden. Sevofluran zeigte bezüglich oxidativen Stress günstigere Wirkungen als Desfluran.

Oxigênio Suplementar em Cesariana Eletiva sob Raquianestesia: Manejar um Punhal com Cuidado

BACKGROUND AND OBJECTIVES We aimed to investigate the effect of 21% and 40% oxygen supplementation on maternal and neonatal oxidative stress in elective cesarean section (CS) under spinal anesthesia. METHODS Eighty term parturients undergoing elective CS under spinal anesthesia were enrolled in the study. We allocated patients randomly to breathe 21% (air group) or 40% (oxygen group) oxygen from the time of skin incision until the end of the operation. We collected maternal pre- and post-operative and umbilical artery (UA) blood samples. Total antioxidant capacity (TAC), total oxidant status (TOS) and the oxidative stress index (OSI) were measured. RESULTS Age, weight, height, parity, gestation week, spinal-skin incision time, skin incision-delivery time, delivery time, operation time, 1st and 5th minutes Apgar scores, and birth weight were similar between the groups (p > 0.05 for all comparisons). There were no differences in preoperative TAC, TOS, or OSI levels between the groups (p > 0.05 for all comparisons). Postoperative maternal TAC, TOS and OSI levels significantly increased in the oxygen group (p = 0.047, < 0.001 and 0.038, respectively); umbilical artery TAC levels significantly increased in the oxygen group (p = 0.003); and umbilical artery TOS and OSI levels significantly increased in the air group (p = 0.02 and < 0.001, respectively). CONCLUSIONS The difference in impact on maternal and fetal oxidative stress of supplemental 40% compared to 21% oxygen mandates further large-scale studies that investigate the role of oxygen supplementation during elective CS under spinal anesthesia.

Curcumin and dexmedetomidine prevents oxidative stress and renal injury in hind limb ischemia/reperfusion injury in a rat model

Abstract Curcumin and dexmedetomidine have been shown to have protective effects in ischemia–reperfusion injury on various organs. However, their protective effects on kidney tissue against ischemia–reperfusion injury remain unclear. We aimed to determine whether curcumin or dexmedetomidine prevents renal tissue from injury that was induced by hind limb ischemia–reperfusion in rats. Fifty rats were divided into five groups: sham, control, curcumin (CUR) group (200 mg/kg curcumin, n = 10), dexmedetomidine (DEX) group (25 μg/kg dexmedetomidine, n = 10), and curcumin–dexmedetomidine (CUR–DEX) group (200 mg/kg curcumin and 25 μg/kg dexmedetomidine). Curcumin and dexmedetomidine were administered intraperitoneally immediately after the end of 4 h ischemia, just 5 min before reperfusion. The extremity re-perfused for 2 h and then blood samples were taken and total antioxidant capacity (TAC), total oxidative status (TOS) levels, and oxidative stress index (OSI) were measured, and renal tissue samples were histopathologically examined. The TAC activity levels in blood samples were significantly lower in the control than the other groups (p < 0.01 for all comparisons). The TOS activity levels in blood samples were significantly higher in Control group and than the other groups (p <  0.01 for all comparison). The OSI were found to be significantly increased in the control group compared to others groups (p < 0.001 for all comparisons). Histopathological examination revealed less severe lesions in the sham, CUR, DEX, and CUR–DEX groups, compared with the control group (p < 0.01). Rat hind limb ischemia–reperfusion causes histopathological changes in the kidneys. Curcumin and dexmedetomidine administered intraperitoneally was effective in reducing oxidative stress and renal histopathologic injury in an acute hind limb I/R rat model.

Supplemental oxygen in elective cesarean section under spinal anesthesia: Handle the sword with care.

BACKGROUND AND OBJECTIVES We aimed to investigate the effect of 21% and 40% oxygen supplementation on maternal and neonatal oxidative stress in elective cesarean section (CS) under spinal anesthesia. METHODS Eighty term parturients undergoing elective CS under spinal anesthesia were enrolled in the study. We allocated patients randomly to breathe 21% (air group) or 40% (oxygen group) oxygen from the time of skin incision until the end of the operation. We collected maternal pre- and post-operative and umbilical artery (UA) blood samples. Total antioxidant capacity (TAC), total oxidant status (TOS) and the oxidative stress index (OSI) were measured. RESULTS Age, weight, height, parity, gestation week, spinal-skin incision time, skin incision-delivery time, delivery time, operation time, 1(st) and 5(th) minutes Apgar scores, and birth weight were similar between the groups (p > 0.05 for all comparisons). There were no differences in preoperative TAC, TOS, or OSI levels between the groups (p > 0.05 for all comparisons). Postoperative maternal TAC, TOS and OSI levels significantly increased in the oxygen group (p = 0.047, < 0.001 and 0.038, respectively); umbilical artery TAC levels significantly increased in the oxygen group (p = 0.003); and umbilical artery TOS and OSI levels significantly increased in the air group (p = 0.02 and < 0.001, respectively). CONCLUSIONS The difference in impact on maternal and fetal oxidative stress of supplemental 40% compared to 21% oxygen mandates further large-scale studies that investigate the role of oxygen supplementation during elective CS under spinal anesthesia.

Acute Respiratory and Renal Failure due to Hypermagnesemia, Induced by Counter Laxatives in an Elderly Man.

Sir, Increased serum magnesium levels are generally iatrogenic and rare clinical situations with significant cardiovascular, neurological and neuromuscular effects. Patients with bowel disorders, renal insufficiency, and patients with old age are especially at high risk for hypermagnesemia. The treatment of hypermagnesemia includes discontinuing the magnesium intake, gastrointestinal decontamination, intravenous calcium gluconate and hemodialysis [1]. Herein, we report a life threating hypermagnesemia situation induced by a magnesium containing product, used for the treatment of chronic constipation. A 70-year-old man presented with constipation, chest tightness and dyspnea. He had a history of chronic obstructive pulmonary disease, chronic kidney failure and diabetes mellitus. Contrast enema was planned on the first hospital day. The patient became lethargic in the second day of hospitalization. Abdominal pain with diminished bowel sounds was observed. The neurological examination showed symmetric decrease in muscle tone and in deep tendon reflexes. Mechanical ventilation was initiated according to arterial blood gas results. Biochemical results were as follows; magnesium, 9.07 (1.5–2.6) mEq/L; calcium, 7.78 (8.4–10.2) mEq/L, sodium, 140 (135–145) mEq/L; potassium, 5.5 (3.5–5.1) mEq/L; creatine, 3.85 (0.2–1.2) mg/dL; blood urine nitrogen, 202.5 (70–105) mg/dL. Calcium gluconate was infused for antagonizing most of the clinical effects of toxicity. A nasogastric and rectal tube were inserted for gastrointestinal decontamination. Emergency continuous veno-venous haemodialysis (CVVHD) for hypermagnesemia was performed and continued during 48 hours. Finally, after a 48 hour CVVHD treatment, the Mg level decreased to 2.0 mEq/L) and the patient was extubated. The follow up period was uneventful. Magnesium is an important intracellular cation that functions as a co-factor in several enzyme pathways. The magnesium plasma value is generally between 1.4 and 2.1 mEq/L and closely regulated through interaction of the gastrointestinal absorption, bone store and kidney excretion [2]. Hypermagnesemia can occur with various processes such as renal failure, Addison disease, milk alkali syndrome, hypothyroidism and with lithium therapy. Decreased elimination, magnesium overdose and increased absorption are the main causes of hypermagnesemia. Our patient had both decreased elimination as a consequence of kidney failure and magnesium overdose due to laxative usage [3]. Clinical manifestations of hypermagnesemia vary according to the serum Mg concentration. Symptomatic hypermagnesemia typically presents with neurological, neuromuscular and cardiac manifestations including hyporeflexia, sedation, muscle weakness and respiratory depression but many physicians are relatively unfamiliar with these conditions [4]. Especially elder patients are at high risk of magnesium toxicity as the kidney function declines with age [5]. Relationship between hypermagnesemia and laxative usage should induce physicians to pay more attention to hypermagnesemia especially in this subgroup of patients and urgent CVVHD is highly effective in preventing significant morbidity and mortality.

Adição de 75 mg de pregabalina ao regime analgésico reduz escores de dor e consumo de opiáceos em adultos após nefrolitotomia percutânea

BACKGROUND AND OBJECTIVES Adding novel adjunctive drugs like gabapentinoids to multimodal analgesic regimen might be reasonable for lessening postoperative pain scores, total opioid consumption and side effects after percutaneous nephrolithotomy. We aimed to evaluate the effect of pregabalin on postoperative pain scores, analgesic consumption and renal functions expressed by creatinine clearance (CrCl) and blood neutrophil gelatinase-associated lipocalin (NGAL) and cystatin C (Cys C) levels in patients undergoing percutaneous nephrolithotomy (PCNL). METHODS 60 patients undergoing elective PCNL were enrolled in the study. Patients were randomized to oral single dose 75 mg pregabalin group and a control group. Visual Analog Scale pain scores (VAS), postoperative intravenous morphine consumption during the first 24 postoperative hours, serum NGAL, Cys C levels and creatinine clearance (CrCl) was measured preoperatively and post-operatively at 2nd and 24th hour. RESULTS Postoperative VAS scores were significantly decreased in the pregabalin group at the postoperative 30th min, 1st, and 2nd hour (p = 0.002, p = 0.001 and p = 0.027, respectively). Postoperative mean morphine consumption was statistically significantly decreased for all time intervals in the pregabalin group (p = 0.002, p = 0.001, p = 0.001, p = 0.001, p < 0.001, respectively). No statistically significant differences were found between the two groups with regard to CrCl, or Cys C at preoperative and postoperative 2nd and 24th hour. Postoperative 24th hour NGAL levels were significantly decreased in the pregabalin group (p = 0.027). CONCLUSIONS Oral single-dose preemptive 75 mg pregabalin was effective in reducing early postoperative pain scores and total analgesic consumption in patients undergoing PCNL without leading to hemodynamic instability and side effects.

Intraperitoneal Administration of Silymarin Protects End Organs from Multivisceral Ischemia/Reperfusion Injury in a Rat Model

Objective To determine whether intraperitoneal silymarin administration has favorable effects on the heart, lungs, kidney, and liver and on oxidative stress in a rat model of supraceliac aorta ischemia/reperfusion injury. Methods Thirty male Wistar albino rats were divided equally into three groups: sham, control, and silymarin. The control and silymarin groups underwent supraceliac aortic occlusion for 45 min, followed by a 60 min period of reperfusion under terminal anesthesia. In the silymarin group, silymarin was administered intraperitoneally during ischemia at a dose of 200 mg/kg. Rats were euthanized using terminal anesthesia, and blood was collected from the inferior vena cava for total antioxidant capacity, total oxidative status, and oxidative stress index measurement. Lungs, heart, liver and kidney tissues were histologically examined. Results Ischemia/reperfusion injury significantly increased histopathological damage as well as the total oxidative status and oxidative stress index levels in the blood samples. The silymarin group incurred significantly lesser damage to the lungs, liver and kidneys than the control group, while no differences were observed in the myocardium. Furthermore, the silymarin group had significantly lower total oxidative status and oxidative stress index levels than the control group. Conclusion Intraperitoneal administration of silymarin reduces oxidative stress and protects the liver, kidney, and lungs from acute supraceliac abdominal aorta ischemia/reperfusion injury in the rat model.

Laparoscopic retroperitoneal radical nephrectomy in a pregnant woman with retrocaval artery

follow-up. She had already had six births, with no previous illness and/or comorbidities. She was in the 16th week of her pregnancy. A mass 10 cm in diameter was determined in her right kidney, following detailed clinical and radiological evaluations (Fig. 1). Moreover, there were no pathological findings in her posterior–anterior lung X-ray. The foetal heart rate was followed up by our institute’s obstetric clinic and the foetus was alive. Additionally, magnetic resonance imaging (MRI) showed retrocaval renal artery on the right side (Fig. 1c–e). We consulted the patient with clinics of obstetric and anaesthesiology, before operation. After signed consent forms were obtained from patient and her husband, laparoscopic retroperitoneal radical right nephrectomy was performed. The operation duration was 46 min and the estimated blood loss was 20 cc (Fig. 2). We used only three trocars during the laparoscopic procedure, but had to perform a Gibson-shaped incision (Fig. 2e). Pathology reported renal cell carcinoma with Fuhrman grade II. There was no complication during follow-up. The foetal heart rate was monitored after operation as well as during follow-up. Although renal cell carcinoma is extremely rare in pregnancy, this is one of the most often reported urological tumours during pregnancy [3]. MRI and US are used for the diagnosis of tumours, in terms of avoiding X-ray exposure, during pregnancy [4]. Surgical treatment options are dependent on the surgeons’ experience. However, laparoscopic, or even retroperitoneal laparoscopic, fashion should be used for pregnant women considering the well-known benefits of laparoscopic surgery. O’Connor et al. [5] reported the first laparoscopic radical nephrectomy in a pregnant woman in the published literature. Additionally, Stroup et al. [6] reported retroperitoneal laparoscopic radical nephrectomy as a first in the literature. Recently, Domján et al. [1] contributed to the Dear Editor,

Are multiple repeated cesarean sections really as safe

Abstract Aim: Surgical complications were compared between patients with three or less prior cesarean deliveries and four or more prior cesarean deliveries. Materials and methods: Records of 120 patients who had undergone cesarean sections (CSs) in our Department of Obstetrics and Gynecology, between August and November 2015, were retrospectively studied. Cases were reviewed on the basis of age, type of operation, type of anesthesia, number of CSs, time of hospitalization, and intra-operative and post-operative complications. Results: Cesarean sections had been performed on 62 (51.7%) patients whose cesarean number was three or less, while 58 (48.3%) patients had multiple CSs four or more. Patients with four or more prior cesareans had an increased rate of intra-abdominal adhesions, compared with the other group. There was no significant difference in the gestational weeks, neonatal admission rate, incidence of cesarean hysterectomy, uterine scar rupture, placenta previa with placental invasion anomalies, bladder and bowel injuries, incidence of peripartum hemorrhage and blood transfusion rate between the two groups. Conclusion: There is no greater risk of maternal complications in patients with four or more prior cesareans, excepting intra-abdominal adhesions.

Anesthetic management of pediatric patient with spinal muscular atrophy

Spinal muscular atrophies are a group of mostly inherited neuromuscular disorders selectively affecting the lower motor neuron resulting in progressive proximal manifestation of muscle weakness. The clinical features ranged from weakness of proximal muscles of the lower limb to dysphagia and respiratory dysfunction. Anesthetic management is often difficult in these patients as a result of muscle weakness, respiratory dysfunction, difficult airway management and hypersensitivity to neuromuscular blocking agents. In this case report we describe a child patient with type II Spinal muscular atrophies for left inguinal hernia repair. We decided to use a caudal technique and propofol infusion. We review the available literature and discuss the potential anaesthetic problems in the management of pediatric patients with this degenerative neuromuscular disorder. Pam Med J 2016;9(1):57-61