Mehmet Cesur

Comparison of Prophylactic Anti-Emetic Effects of Ondansetron and Dexamethasone in Women Undergoing Day-Case Gynaecological Laparoscopic Surgery

We aimed to determine the effect of ondansetron and dexamethasone on preventing post-operative nausea and vomiting (PONV). Sixty women undergoing laparoscopic gynaecological surgery were randomized to receive ondansetron 4 mg, dexamethasone 8 mg or saline. Drugs were administered 2 min before induction of anaesthesia, and anaesthesia and post-operative analgesic regimens were standardized. The incidence of PONV in the first 24 h after the operation was 35% in the ondansetron group, 55% in dexamethasone group and 85% in the control group. A significant difference between the groups was only seen in the first 3 h post-operatively. In this period, ondansetron was significantly more effective than dexamethasone and saline, but no differences were seen between dexamethasone and saline. In all treatment groups, post-operative visual analogue scale scores, sedation scores and usage of analgesics were similar. In conclusion, ondansetron, but not dexamethasone, prevented PONV in the first 3 h after gynaecological laparoscopic surgery.

Decreased incidence of headache after unintentional dural puncture in patients with cesarean delivery administered with postoperative epidural analgesia

PurposeTo investigate how subsequent placement of a catheter into the epidural space after unintentional dural puncture for postoperative analgesia for 36–72 h affected the incidence of post-dural puncture headache (PDPH).MethodsThe records of 52 parturients who had had accidental dural puncture in cesarean delivery were reviewed. The parturients were assigned to two groups. Twenty-eight parturients were assigned to the study group, in whom an epidural catheter was inserted and was used for anesthesia and postoperative analgesia. Twenty-four parturients were assigned to the control group, in whom spinal anesthesia (n = 20) or general anesthesia (n = 4) was applied. For postoperative analgesia in patients with incision pain above visual analog scale (VAS) 3, 3 mg morphine in 15 ml saline was administered through the epidural catheter in the study group, while intramuscular meperidine or tramadol was administered in the control group. Once PDPH was observed, conservative treatment was tried first. If the headache persisted despite conservative treatment, an epidural blood patch was applied through the catheter or a reinserted epidural needle.ResultsThe study group demonstrated significant reduction of the incidence of PDPH and reduction in the indication for an epidural blood patch compared to the control group (7.1% vs 58% [P = 0.000] and 3.6% vs 37.5% [P = 0.002], respectively).ConclusionSubsequent catheter placement into the epidural space after unintentional dural puncture in cesarean delivery and leaving the catheter for postoperative analgesia for 36–72 h may reduce the incidence of PDPH.

Subhypnotic propofol infusion plus dexamethasone is more effective than dexamethasone alone for the prevention of vomiting in children after tonsillectomy

Background:  Postoperative vomiting (POV) is a common complication after tonsillectomy. Dexamethasone is known to decrease postsurgical vomiting. In this study, we compared the effects of dexamethasone alone to dexamethasone plus propofol on postoperative vomiting in children undergoing tonsillectomy.

Administration of local anesthetic through the epidural needle before catheter insertion improves the quality of anesthesia and reduces catheter-related complications.

Epidural catheter placement offers flexibility in block management. However, during epidural catheter insertion, complications such as paresthesia and venous and subarachnoid cannulation may occur, and suboptimal catheter placement can affect the quality of anesthesia. We performed this prospective, randomized, double-blind study to assess the effect of a single-injection dose of local anesthetic (20 mL of 2% lidocaine) through the epidural needle as a priming solution into the epidural space before catheter insertion. We randomized 240 patients into 2 equal groups and measured the quality of anesthesia and the incidence of complications. In the needle group (n = 100), catheters were inserted after injection of a full dose of local anesthetic through the needle. In the catheter group (n = 98), the catheters were inserted immediately after identification of the epidural space. Local anesthetic was then injected via the catheter. We noted the occurrence of paresthesia, inability to advance the catheter, or IV or subarachnoid catheter placement. Sensory and motor block were assessed 20 min after the injection of local anesthetic. Surgery was initiated when adequate sensory loss was confirmed. In the catheter group, the incidence of paresthesia during catheter placement was 31.6% compared with 11% in the needle group (P = 0.00038). IV catheterization occurred in 8.2% versus 2% of patients in the catheter and needle groups, respectively (P = 0.048). More patients in the needle group had excellent surgical conditions than the catheter group (89.6% versus 72.9; P < 0.003). We conclude that giving a single-injection dose via the epidural needle before catheter placement improves the quality of epidural anesthesia and reduces catheter-related complications.

Spinal anesthesia with sequential administration of plain and hyperbaric bupivacaine provides satisfactory analgesia with hemodynamic stability in cesarean section

BACKGROUND Hypotension during spinal anesthesia is one of the major concerns in cesarean section. To achieve adequate spinal anesthesia with less hypotension, we evaluated the viability of sequential subarachnoid injection of two different baricities of bupivacaine. We used plain bupivacaine 5mg to obtain dense anesthesia of the surgical site, followed by hyperbaric bupivacaine 5mg to achieve spread to T5 anesthesia to address visceral pain. METHODS In this double-blind prospective study, 72 parturients undergoing cesarean section were randomized to receive either hyperbaric bupivacaine 10mg or 5mg each of plain and hyperbaric bupivacaine sequentially for spinal anesthesia. Loss of pinprick sensation to T6 was regarded as sufficient for cesarean section to proceed. Characteristics of anesthesia, episodes of hypotension, bradycardia and ephedrine use were assessed by blinded observers. RESULTS Demographic data, characteristics of anesthesia, quality of intraoperative anesthesia and Apgar scores were similar in the two groups. Compared to hyperbaric bupivacaine, the combination of plain and hyperbaric bupivacaine provided a marked decrease in the incidence of hypotension (13.9% vs. 66.7%, P<0.001) and side effects related hypotension such as nausea and vomiting (13.9% vs.52.8%, P<0.001). The amount of ephedrine administered was significantly lower in the plain and hyperbaric bupivacaine group (2.2+/-1.0mg vs. 20.5+/-8.7 mg (P<0.001). CONCLUSIONS Sequential subarachnoid injection of plain and hyperbaric bupivacaine for cesarean section can provide reliable spinal anesthesia with a lower incidence of hypotension and vomiting.

Disappearance of phantom limb pain during cauda equina compression by spinal meningioma and gradual reactivation after decompression

UNLABELLED We describe a 65-yr-old woman, whose right lower limb had been amputated at the mid-femoral level because of complicated femur fracture sustained at the age of 5 yr. After amputation, she experienced phantom limb pain (PLP), which gradually decreased in intensity but persisted for 60 yr. At this point the pain diminished progressively, in parallel with the evolution of cauda equina compression caused by an intraspinal tumor. The PLP gradually reappeared over 3 mo after surgical removal of the tumor. IMPLICATIONS We present a case in which phantom limb pain (PLP) in an amputated leg disappeared during cauda equina compression by meningioma and reactivated after surgical decompression. This case suggests that complete compression or blockade of nerves, a nerve plexus, the cauda equina, or the medullary cord may result in suppression of PLP, and decompression of or recovery from the block may cause reactivation.

An unusual cause of difficult intubation in a patient with a large cervical anterior osteophyte: a case report

This report describes a case in which a large anterior osteophyte on the C2 and C3 vertebrae, due to ankylosing spondylitis, resulted in distortion of the anatomy of the upper airway and difficult intubation. Ankylosing spondylitis (AS) is a progressive inflammatory disease, characterized by stiffening of the joints and ligaments. Stiffness of the cervical spine, atlanto‐occipital, temporomandibular and cricoarytenoid joints may cause difficult intubation ( 1 ). This report describes a case in which a large anterior osteophyte on the C2 and C3 vertebrae, associated with AS, resulted in distortion of the anatomy of the upper airway and difficult intubation.

Caudal analgesia for prostate biopsy

Background: Although various local anesthesia techniques have been suggested to decrease pain and discomfort during a transrectal ultrasound (TRUS)‐guided prostate biopsy, the best method has not yet been defined. The present prospective, double‐blind, randomized study aims to investigate the clinical efficacy of ‘walking’ caudal block compared with an intrarectal lidocaine gel for this procedure.

Is methergine alone sufficient in relieving postdural puncture headache

We read a pilot study concerning usefulness of methergine in relieving postdural puncture headache (PDPH) in obstetric patients (1). This study may be useful because of its results. Methergine is routinely used as a uterotonic during the postpartum period. Methergine is used to kill two birds with one stone. That is, methergine can be used both as a uterotonic and for PDPH. However, there are several points limiting the use of methergine Firstly, there are some drugs and methods including theophylline, caffeine, sumatriptan, epidural saline, epidural dextran, and epidural blood patch (EBP) to treat PDPH, but only the EBP has apparent benefits. The reason for the headache is iatrogenic, but the patient is aware of this and may be angry, resentful, and/or depressed. Headache may cause difficulty in caring for the newborn and communicating with other family members. Conservative measures are not likely to be effective in cases where the patient is unlikely to lie flat, such as a mother who has just delivered a baby and will have an over-riding need to get out of bed to care for her newborn. Unfortunately, conservative measures are often inadequate (2). Particularly if the headache is severe, the mother should immediately be relieved. As seen above, because conservative measures like methergine are inadequate, EBP, which has become the gold standard in the treatment of PDPH, should immediately be performed, even if the failed EBP rate is high in the first 24 h. Moreover the authors gave patients bedrest, analgesics, and fluids for 24 h. In the subsequent 24 h they administered methergine to patients. Pain relief with methergine was 16% in the subsequent 24 h, whereas the success rate after EBP is 96% if it is done /24 h after puncture. Secondly, PDPH is a complication that should not be treated lightly. There are some potential risks for considerable morbidity, even death (3). It should not be omitted that intracranial hypotension can result in intracranial hemorrhage through tearing of bridging dural veins (4). Delaying diagnosis and treatment can be extremely dangerous. Thirdly, the cause of PDPH is not entirely clear. The best explanation is that low CSF pressure results from CSF leakage via a dural and arachnoid tear (5). The pain of PDPH may be caused in part by cerebrovasodilation resulting from low CSF pressure and the beneficial effect of cerebral vasoconstrictor drugs, such as caffeine, theophylline sumatriptan, and methergine, supports a vascular cause for PDPH (5). However, that the cause of headache in PDPH is in part explained by cerebrovasodilation suggests to us that methergine is partly sufficient in the treatment of PDPH. Authors showed that 16% of patients were completely treated by methergine in the first 24 h, whereas the success rate after a first EPB is 85% and this rate reaches 98% after the second EBP (5). Finally, the authors did not mention spinal needle diameter, the nature of the tip, and severity of headache. It is well known that the incidence and severity of PDPH are directly related to the size of the needle, and the nature of the tip. The risk of developing PDPH is reported to be as high as 75% in parturient women after accidental dural puncture with a 16-18 gauge epidural needle. With smaller diameter needles and pencil-point needles, the incidence and severity of PDPH is dramatically decreased to an overall range between 0.02% and 3% (6). But after accidental dural puncture with a 16-18 gauge epidural needle, PDPH is severe and methergine may not be sufficient. If PDPH is severe, EBP is recommended (6). In conclusion, considering the mother’s condition and the other complications of PDPH, PDPH is a situation that should be treated immediately. Any time with conservative treatment should not be spared. The gold standard treatment method is EBP and methergine alone cannot provide adequate treatment. We think that methergine alone is not a Acta Obstetricia et Gynecologica. 2006; 85: 632 /634

A plantar flexion response to nerve stimulation indicates needle misplacement in the epidural/spinal space during psoas compartment block

We report two cases of plantar flexion due to epidural misplacement of the needle during psoas compartment block, providing a response feedback for needle position during this procedure. In one case, the response occurred contralaterally, and in the other bilaterally. In the first patient, the cause of contralateral plantar flexion could not be determined and no injection was made. In the second patient, the anteriorposterior-fluoroscopic image showed that the tip of the needle was placed at the midline of the column. At this point, 3 ml of radiopaque medium was injected, and it diffused throughout the epidural space. Subsequently, single-shot epidural anesthesia was achieved by injection through this needle.