Mefkur Bakan

Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study

BACKGROUND AND OBJECTIVES Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting. METHODS 80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6h after surgery. The primary outcome variable was postoperative fentanyl consumption. RESULTS Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75 ± 59 μg and 120 ± 94 μg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need. CONCLUSION Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting.

Management of esophageal perforation secondary to caustic esophageal injury in children

PurposeTo review our management of esophageal perforation in children with caustic esophageal injury.MethodWe reviewed the medical records of 22 children treated for esophageal perforations that occurred secondary to caustic esophageal injury.ResultsThere were 18 boys and 4 girls (mean age, 5 years; range, 2–12 years). Three children were treated for perforation during diagnostic endoscopy and 19 were treated for a collective 21 episodes of perforation during balloon dilatation. One child died after undergoing emergency surgery for tracheoesophageal fistula and pneumoperitoneum. Another patient underwent esophagostomy and gastrostomy. Twenty patients were treated conservatively with a nasogastric tube, broad spectrum antibiotics, and tube thoracostomy, 16 of whom responded but 4 required esophagostomy and gastrostomy. Although the perforation healed in 21 patients, 20 were left with a stricture. Two children were lost to follow-up, 8 underwent colonic interposition, and 10 continued to receive periodic balloon dilatations. Two of these 10 patients underwent colonic interposition after a second perforation. The other 8 became resistant to dilatations: 4 were treated by colon interposition; 2, by resection and anastomosis; and 2, by an esophageal stent.ConclusionsEsophageal perforation can be managed conservatively. Because strictures tend to become resistant to balloon dilatation, resection and anastomosis is preferred if they are up to 1 cm in length, otherwise colonic interposition is indicated.

Anestesia venosa total livre de opioides, com infusões de propofol, dexmedetomidina e lidocaína para colecistectomia laparoscópica: estudo prospectivo, randomizado e duplo-cego

BACKGROUND AND OBJECTIVES Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting. METHODS 80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6h after surgery. The primary outcome variable was postoperative fentanyl consumption. RESULTS Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75±59μg and 120±94μg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need. CONCLUSION Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting.

Psychological effects of repeated general anesthesia in children

Background:  Although methods for reducing preoperative anxiety have been a major interest of pediatric anesthesiologists, there are no reports of the effects of repeated anesthesia on psychological development of children.

Effects of systemic and epidural morphine on antidiuretic hormone levels in children.

Background: Although the use of opioids during general anaesthesia suppresses stress response to surgery and pain, the effects on antidiuretic hormone (ADH) are controversial. The aim of this study was to find the effects of morphine with either intravenous infusion or epidural route on ADH and other stress hormones.

Effectiveness of morphine via thoracic epidural vs intravenous infusion on postthoracotomy pain and stress response in children

Background : Thoracotomy causes severe pain in the postoperative period. The aim was to evaluate effectiveness of two pain treatment methods with morphine on postthoracotomy pain and stress response.

Anesthesia management with short acting agents for bilateral pheochromocytoma removal in a 12‐year‐old boy

A 12‐year‐old boy with bilateral adrenal pheochromocytoma pretreated with furosemide, nifedipine, prazosin, and propranolol underwent surgical removal of the tumors. General anesthesia with desflurane, remifentanil infusion and thoracic epidural analgesia was performed. To control the blood pressure (BP), remifentanil up to 1 μg·kg−1·min−1 infusion rate, sodium nitroprusside, and esmolol infusions were administered successfully. Following the ligation of the adrenal veins, hemodynamic parameters were stable and neither inotropic support nor corticosteroid replacement was required. We concluded that remifentanil‐based anesthesia combined with low‐dose desflurane and thoracic epidural analgesia may reduce the need for vasoactive drugs in the anesthesia management of pheochromocytoma. This combination may not prevent the hemodynamic fluctuations during tumor manipulation, but appears to facilitate a rapid and stable postoperative recovery.

Anesthetic management of a child with Arnold–Chiari malformation and Klippel–Feil syndrome

1 Tariq M, Beg MH. A foreign body in the bronchus still presents problems. Int J Clin Pract 1999; 53: 81–82. 2 Brett CM, Zwass MS. Eyes ears nose throat and dental surgery. In: Gregory GA, ed. Pediatric Anesthesia, 4th edn. Philadelphia, PA: Churchill Livingstone, 2002: 663–705. 3 Bossoe HH, Boe J. Broken tracheostomy tube as a foreign body. Lancet 1960; 1: 1006–1007. 4 Sood RK. Fractured tracheostomy tube. J Laryngol Otol 1973; 87: 1033–1034. 5 Kemper BI, Rosica N, Myers EN et al. Migration of the inner cannula. An unusual foreign body. Eye Ear Nose Throat Mon 1972; 51: 257–258. 6 Kakar PK, Saharia PS. An unusual foreign body in the tracheobronchial tree. J Laryngol Otol 1972; 86: 1155–1157. 7 Ward CF, Benumof JL. Anesthesia for airway foreign body extraction in children. Anesth Rev 1977; 4: 13.

Remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy: comparison of adjuvant propofol and ketamine

OBJECTIVE: Laryngoscopy and stimuli inside the trachea cause an intense sympatho-adrenal response. Remifentanil seems to be the optimal opioid for rigid bronchoscopy due to its potent and short-acting properties. The purpose of this study was to compare bolus propofol and ketamine as an adjuvant to remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy. MATERIALS AND METHODS: Forty children under 12 years of age who had been scheduled for a rigid bronchoscopy were included in this study. After midazolam premedication, a 1 µg/kg/min remifentanil infusion was started, and patients were randomly allocated to receive either propofol (Group P) or ketamine (Group K) as well as mivacurium for muscle relaxation. Anesthesia was maintained with a 1 µg/kg/min remifentanil infusion and bolus doses of propofol or ketamine. After the rigid bronchoscopy, 0.05 µg/kg/min of remifentanil was maintained until extubation. Hemodynamic parameters, emergence characteristics, and adverse events were evaluated. RESULTS: The demographic variables were comparable between the two groups. The decrease in mean arterial pressure from baseline values to the lowest values during rigid bronchoscopy was greater in Group P (p = 0.049), while the reduction in the other parameters and the incidence of adverse events were comparable between the two groups. The need for assisted or controlled mask ventilation after extubation was higher in Group K. CONCLUSION: Remifentanil-based total intravenous anesthesia with propofol or ketamine as an adjuvant drug along with controlled ventilation is a viable technique for pediatric rigid bronchoscopy. Ketamine does not provide a definite advantage over propofol with respect to hemodynamic stability during rigid bronchoscopy, while propofol seems more suitable during the recovery period.

Penile erection during remifentanil anesthesia in children

oxidation of fatty acids (2). This disorder is often diagnosed because it can precipitate hypoglycemia, seizures and coma. Our patient was a 2-year-old male who was presented for dental rehabilitation surgery. His past medical history was positive for hypoglycemia and seizures which led to the diagnosis of MCAD. He was being treated with carnitine (Carnitor) with good control. His past surgical history included bilateral myringotomy tubes and tooth extractions of which there were no anesthetic complications. He had a recent history of croup syndrome 3 weeks prior to this admission and was being treated with amoxicillin. As he had been NPO for 8 h prior to arriving at the hospital, an intravenous line was placed and 5% dextrose in lactated Ringer’s was started in the day surgery unit. An accucheck done preoperatively revealed a blood glucose of 5.5 mmolÆl (100 mgÆdl). After premedication with 8 mg of oral midazolam, the patient was taken to the operating room where standard ASA monitors including electrocardiogram, noninvasive blood pressure, and pulse oximetry were placed. Anesthesia was induced with propofol and a nasotracheal tube was placed without difficulty and maintained with oxygen, air, and sevoflurane. Following an uneventful intraoperative course his trachea was extubated when he was fully awake. Postoperatively an accucheck revealed a blood glucose of 7.7 mmolÆl (140 mgÆdl). His postoperative course was uneventful and he was discharged home the same day. Clinical symptoms of MCAD often present in children 2–3 years of age and are often precipitated by periods of fasting greater than 12 h and/or viral infections. Vomiting and lethargy can progress to seizures, coma and in extreme cases, cardiorespiratory collapse (1). Liver enlargement may occur secondary to fatty deposition (1). Hypoglycemia is often present during acute episodes as well as low urinary ketone concentrations. A secondary carnitine deficiency may be seen when plasma and tissue concentrations of carnitine are reduced by 25–50% (1). Treatment of acute illnesses includes intravenous fluids containing dextrose. Chronic therapy includes prevention of prolonged fasting, restriction of dietary fat and carnitine (1). Review of the literature reveals no reports of anesthesia in children with MCAD deficiency. Although, treatment with carnitine is controversial and many times ineffective, with our patient carnitine therapy appeared to be therapeutic. MCAD is one of the many acyl-CoA dehydrogenases, which are mitochondrial enzymes that are required for beta-oxidation of fatty acids (2). The mechanism of hypoglycemia in these patients is evident during periods of starvation when fat becomes the body’s major fuel source (1). Although our experience is limited with MCAD patients, we offer the following recommendations for anesthesia management: (i) limit NPO status to 2–4 h; (ii) preoperative intravenous catheter placement; (iii) 5% dextrose in lactated Ringer’s solution preoperatively; and (iv) close perioperative blood glucose monitoring.