Mehmet Turan Inal

Intravenous paracetamol reduced the use of opioids, extubation time, and opioid-related adverse effects after major surgery in intensive care unit ☆

BACKGROUND This study assessed the analgesic efficacy, side effects, and time to extubation of intravenous paracetamol when administered as an adjuvant to intravenous meperidine after major surgery in intensive care unit (ICU). MATERIAL Patients were randomized postoperatively into 2 groups in ICU. Patients received either 100 mL of serum saline intravenous (IV) every 6 hours and IV meperidine (n = 20 group M) or IV paracetamol 1 g every 6 hours and IV meperidine (n = 20, group MP) into a peripheral vein for 24 hours. Behavioral Pain Scale (BPS) is used until extubation, and visual analog score (VAS) is used after extubation. When BPS and VAS values were more than 4, meperidine, 1 mg/kg IV, was administered and noted in 2 groups. Pain scores, total meperidine consumption, time to extubation, sedation scores, and side effects are 24-hour postoperatively noted. RESULTS Behavioral Pain Scale and VAS scores are significantly lower in group paracetamol-meperidine at 24 hours (P < .05). In group MP, postoperative meperidine consumption (76.75 ± 18.2 mg vs. 198 ± 66.4 mg) and extubation time (64.3 ± 40.6 min vs. 204.5 ± 112.7 min) were lower than in group M (P < .01). In addition to, postoperative nausea-vomiting and sedation scores were significantly lower in group MP when compared with group M (P < .05). CONCLUSION We have demonstrated important clinical benefits by the addition of 4 g/d of paracetamol to meperidine after major surgery. This benefit has been shown in a range of patients under routine clinical conditions and therefore has important practical consequences in ICU. These data suggest that intravenous paracetamol is a useful component of the multimodal analgesia model, especially after major surgery.

The effects of levosimendan vs dobutamine added to dopamine on liver functions assessed with noninvasive liver function monitoring in patients with septic shock

BACKGROUND Septic shock is the leading causes of death in intensive care units. In addition to generous fluid administration, inotropic agents are commonly used to improve cardiac output. The effects of inotropic agents on regional blood flow remains unknown. OBJECTIVE The aim of this study was to assess the effects of levosimendan vs dobutamine added to dopamine on liver functions assessed using noninvasive liver function monitoring (LiMON) in patients with septic shock. DESIGN Prospective analysis. MEASUREMENTS AND RESULTS We analyzed 30 patients with septic shock who were treated in an intensive care unit. Indocyanine green plasma disappearance rate (ICG-PDR) was conducted concurrently using the LiMON system. A dose of 0.3 mg/kg ICG was given through a cubital fossa vein as a bolus. RESULTS Statistical analysis showed that the variation of hemodynamic variables was different between groups. In our results, the increase in systolic blood pressure, diastolic blood pressure, and mean arterial pressure was significantly higher in levosimendan group than in dobutamine group (P < .05). There was a decrease in before- and after-infusion ICG-PDR values in dobutamine group (20.38 ± 4.83 vs 20.34 ± 5.30), and no statistical difference was detected (P = .649). There was an increase in before- and after-infusion ICG-PDR values in levosimendan group (18.70 ± 2.59 vs 21.65 ± 3.20), and a statistical difference was detected (P = .001). There was statistical difference between groups (P = .000). CONCLUSION These results suggest that levosimendan added to dopamine improves systemic hemodynamics and increases splanchnic perfusion assessed using the user-friendly noninvasive bedside system LiMON in patients with septic shock compared with dobutamine.

Prognostic value of indocyanine green elimination assessed with LiMON in septic patients

BACKGROUND Sepsis is the most frequent infection with high mortality rates in intensive care units (ICUs), and the prediction of outcome is important in the decision-making process. OBJECTIVE To assess the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II) and indocyanin green (ICG) plasma disappearance rate (ICG-PDR) in septic patients. DESIGN Retrospective analysis. MEASUREMENTS AND RESULTS We analyzed 40 septic patients (17 female and 23 male; age range, 20-89 years) who were treated in our ICU. The ICG-PDR measurement and APACHE II score measurement were made within 24 hours after admission to the ICU. Indocyanine green elimination tests were conducted concurrently using the noninvasive liver function monitoring system (LiMON, Pulsion Medical Systems, Munich, Germany). A dose of 0.3 mg/kg ICG was given through a cubital fossa vein as a bolus. RESULTS Statistical analysis showed that ICG-PDR was significantly lower in nonsurvivors (n = 18) than in survivors (n = 22) (mean, 12.1% +/- 7.6%/min; median, 9%/min, vs mean, 21.2% +/- 10.1%/min; median, 20%/min, respectively [P = .004]). The area under the curve as a measure of accuracy was 0.765 for ICG-PDR and 0.692 for APACHE II. Mortality was 80% in patients with ICG-PDR below 8% per minute, and survival was approximately 89% in patients with ICG-PDR above 24% per minute. CONCLUSION The results suggest that ICG-PDR, assessed with a user-friendly noninvasive bedside LiMON device, is a good predictor of survival in septic patients. Sensitivity and specificity of the noninvasive measurement of ICG-PDR on ICU admission was comparable to that obtained by APACHE II scores.

Effects of intra-abdominal pressure on liver function assessed with the LiMON in critically ill patients

BACKGROUND Intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) are associated with significant morbidity and mortality in critically ill patients. Our aim was to assess the effects of IAH on liver function using the noninvasive liver function monitoring system LiMON and to assess the prognostic value of IAP in critically ill patients. METHODS We conducted a retrospective analysis of critically ill patients who were treated in the intensive care unit (ICU). The IAP and indocyanine green plasma disappearance rate (ICG-PDR) measurements were made within 24 hours after admission to the ICU and repeated 12 hours later. Intra-abdominal pressure was measured via a Foley bladder catheter, and ICG elimination tests were conducted concurrently using the LiMON. RESULTS We included 30 critically ill patients (17 women and 13 men aged 28-89 yr) in our analysis. Statistical analysis showed that the baseline IAP values were significantly higher among nonsurvivors than survivors (19.38 [standard deviation; SD 2.08] v. 13.07 [SD 0.99]). The twelfth-hour IAP values were higher than baseline measurements among nonsurvivors (21.50 [SD 1.96]) and lower than baseline measurements among survivors (11.71 [SD 1.54]); the difference between groups was significant (p < 0.001). The baseline ICG-PDR values were significantly lower among nonsurvivors than survivors (10.86 [SD 3.35] v. 24.51 [SD 6.78]), and the twelfth-hour ICGPDR values were decreased in all groups; the difference between groups was significant (p < 0.001). CONCLUSION Our results suggest that measurement of ICG-PDR with the LiMON is a good predictor of the effects of IAP on liver function and, thus, can be recommended for the evaluation of critically ill patients.

Comparison of TruView EVO2 with Miller laryngoscope in paediatric patients.

Background Except for neonates and specific malformations in children, management of the paediatric airway is not a major problem for the anaesthetist. Miller laryngoscope was traditionally used for paediatric intubation. The TruView EVO2 system is a recently introduced device with a unique blade that provides a wide and magnified laryngeal view. Objective To assess the value of the TruView EVO2 laryngoscope with that of Miller laryngoscope in paediatric patients. Design Prospective analysis. Measurements and results Fifty 2–8-year paediatric patients presenting for surgery requiring tracheal intubation were randomly assigned to undergo intubation using a Miller (Group M, n = 25) and TruView EVO2 laryngoscope (Group T, n = 25). Preoperative airway evaluation was performed by using the Mallampati scores. The Intubation Difficulty Scale (IDS), the duration of the tracheal intubation procedure, the rate of successful placement of the endotracheal tube in the trachea, the view of the glottis according to the Cormack and Lehane grading criteria, number of intubation attempts, mean arterial pressure (MAP) and heart rate (HR) before and after intubation, lowest peripheric oxygen saturation during intubation attempts and all complications (minor laseration, dental or other airway trauma) were all recorded. Results Preoperative Mallampati scores and the IDS scores were similar between the Miller and TruView EVO2 laryngoscope. The average time for laryngoscopy was 6.36 ± 0.99 s in group M and 13.8 ± 7.99 s in group T (P < 0.001). The TruView EVO2 laryngoscope improved the Cormack and Lehane glottic view compared with the Miller laryngoscope. The HR change (difference before and after) in group M was significantly lower than that in group T (P < 0.001). However, the MAP change was similar between groups. The lowest peripheric oxygen saturation during intubation attempts was different between groups, 99.4 ± 0.57% in group M and 97.6 ± 2.41% in group T (P < 0.001). Conclusion The results suggest that when compared with the Miller laryngoscope, the TruView EVO2 laryngoscope appears to improve the view of the larynx but requires a longer time for tracheal intubation. The IDS scores were similar; thus, the TruView EVO2 laryngoscope can be a good alternative to traditionally used Miller laryngoscope.

The Effects of Different Insufflation Pressures on Liver Functions Assessed with LiMON on Patients Undergoing Laparoscopic Cholecystectomy

Purpose. Laparoscopic cholecystectomy has been accepted as an alternative to laparotomy, but there is still controversy regarding the effects of pneumoperitoneum on splanchnic and hepatic perfusion. We assessed the effects of different insufflation pressures on liver functions by using indocyanine green elimination tests (ICG-PDR). Methods. We analyzed 43 patients who were scheduled for laparoscopic cholecystectomy. The patients were randomly allocated to two groups. In Group I, the operation was performed using 10 mmHg pressure pneumoperitoneum. In Group II, 14 mmHg pressure pneumoperitoneum was used. The ICG-PDR measurements were made after induction (ICG-PDR 1) and after the end of the operation (ICG-PDR 2). Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), and total bilirubin levels were all recorded preoperatively, 1 hour, and postoperative 24 hours after surgery. Results. The ICG-PDR 1 values for Groups I and II were as follows: 26.78 ± 4.2% per min versus 26.01 ± 2.4% per min (P > 0.05). ICG-PDR 2 values were found to be 25.63 ± 2.1% per min in Group I versus 19.06 ± 2.2% per min in Group II (P < 0.05). There was a statistically significant decrease between baseline and postoperative ICG-PDR values in Group II compared to Group I (P < 0.05). Statistically, there was an increase between baseline and postoperative 1st-hour serum AST and ALT level in Group II (P < 0.05) compared to Group I. No statistical differences were detected on postoperative 24st-hour serum AST and ALT levels and all the time bilirubin between groups (P > 0.05). Conclusion. In conclusion, the results show that 14 mmHg pressure pneumoperitoneum decreased the blood flow to the liver and increased postoperative 1st-hour serum AST and ALT levels. We think that 10 mmHg pressure pneumoperitoneum is superior to 14 mmHg pressure pneumoperitoneum in laparoscopic cholecystectomy.

Effects of polygeline and hydroxyethyl starch solutions on liver functions assessed with LIMON in hypovolemic patients

BACKGROUND Hypovolemia is a common clinical entity in critical patients, and adequate volume replacement therapy seems to be essential for maintaining tissue perfusion. However, it is still uncertain which solution is most appropriate for fluid resuscitation. OBJECTIVE The aim of this study was to investigate the effects of fluid resuscitation with 3.5% polygeline versus 6% hydroxyethyl starch solutions on hemodynamic functions and liver functions assessed with a noninvasive liver function monitoring system (LIMON) in hypovolemic patients. DESIGN This study is a prospective randomized clinical trial. MEASUREMENTS AND RESULTS Thirty hypovolemic patients (intrathoracic blood volume index, <850 mL/m(2)) were randomized into hydroxyethyl starch (mean molecular weight, 130,000 Da) and polygeline (mean molecular weight, 30,000 Da) groups (15 patients each). Indocyanine green plasma disappearance elimination (ICG-PDR) were conducted concurrently using LIMON. A dose of 0.3 mg/kg ICG was given through a cubital fossa vein as a bolus. For fluid resuscitation, 500 mL of colloid was given to the patients. Repeated hemodynamic and ICG-PDR measurements were done at baseline, after infusion, and then at 30 minutes after infusion. RESULTS Intrathoracic blood volume index and systolic, diastolic, and mean blood pressures increased significantly after infusion and remained elevated for 30 minutes after infusion, but there was no significant difference between the 2 groups. Indocyanine green plasma disappearance elimination values were similar in both groups with no significant difference between the two. CONCLUSION Increasing intrathoracic blood volume index and hemodynamic variables by fluid loading is not associated with a significant change in ICG-PDR.

Late-Onset Pulmonary Edema and Disseminated Intravascular Coagulation Due to Latex Anaphylaxis

BackgroundAnaphylaxis after the administration of tissue expanders has been reported. Late onset hypotension, thrombocytopenia, disseminated intravascular coagulation (DIC) and pulmonary edema due to the tissue expanders have not been reported.MethodsIn this case report, late onset hypotension, thrombocytopenia, disseminated intravascular coagulation and pulmonary edema due to the administration of tissue expanders were described.ResultsThe authors report a 16-year-old girl with burn scar deformities scheduled for reconstruction of the scar contractures with insertion of tissue expanders in which the administration of latex tissue expanders was associated with late onset hypotension, thrombocytopenia, disseminated intravascular coagulation and pulmonary edema. Skin tests performed for latex demonstrated strong positive weal and flare reactions.ConclusionLate onset anaphylactic reactions due to latex tissue expanders, an unusual unpredictable adverse reaction, must be kept in mind. Early recognition and proper emergent treatment are essential to reversing this complication.

Mad Honey Poisoning: Case Report

DOI: 10.4328/JCAM. 617 Received: 16.02.2011 Accepted: 05.03.2011 Printed: 01.01.2013 J Clin Anal Med 2013;4(1): 58-60 Corresponding Author: Mehmet Turan Inal, Trakya Universitesi Tip Fakultesi, Anesteziyoloji ve Reanimasyon AD, 22030, Edirne, Turkiye. T.: +9

The effect of celiac plexus block in critically ill patients intolerant of enteral nutrition: a randomized, placebo-controlled study.

BACKGROUND In this study, we evaluated the efficacy of celiac plexus block for the treatment of feeding intolerance in critically ill patients. METHODS Nineteen mechanically ventilated medical patients intolerant of enteral nutrition and receiving metoclopramide underwent bilateral celiac plexus block. The anterior procedure was accomplished under sonographic guidance with the injection of either 25 mL bupivacaine 0.25% (celiac group, n = 10) or saline (control group, n = 9) bilaterally. Gastric emptying was assessed by the acetaminophen absorption method. After the block, nasogastric feeding was commenced, and nasogastric aspirates were collected once every 24 hours. Successful feeding was defined as 24-hourly gastric residual volume <250 mL with a feeding rate > or = 40 mL/h. RESULTS Demographic data were similar for the 2 groups. The area under the plasma paracetamol absorption curve (383.8 +/- 248.1 mg . min . L(-1)) and the peak plasma paracetamol concentration (C(max); 3.28 +/- 2.15 mg/L) in the celiac group were significantly lower than the area under the curve value (1233.5 +/- 771.2) and C(max) value (10.14 +/- 6.04) in controls (P < 0.001 for all). After treatment, celiac plexus block reduced the mean gastric residual volume (celiac group: 430 +/- 32 mL to 205 +/- 30 mL, P < 0.001; control group: 450 +/- 33 mL to 461 +/- 19 mL, P > 0.05) and improved the proportion of patients with successful feeding (celiac block 80% vs controls 0%, P < 0.001). CONCLUSION In critical illness, celiac plexus block is effective for treating feeding intolerance when IV drug therapy has failed to improve gastrointestinal dysfunction.