Memduh Yetim

Ultrasound-guided pulsed radio frequency treatment in Morton's neuroma.

BACKGROUND Mortons neuroma is a perineural fibrosis of an intermetatarsal plantar nerve. Burning, numbness, paresthesia, and tingling down the interspaces of involved toes may also be experienced. Taking into account all of this information, we designed a prospective open-label study to evaluate the efficacy of pulsed radio frequency on Mortons neuroma. METHODS Twenty patients with Mortons neuroma were experiencing symptomatic neuroma pain in the foot not relieved by routine conservative treatment. All of the patients had been evaluated by a specialized orthopedist and were offered pulsed radio frequency as a last option before having surgery. Initially, pain level (numerical rating scale), successful pain control (a ≥50% pain decrease was accepted as successful pain control), comfort when walking (yes or no), and satisfaction level (satisfied or not satisfied) were evaluated. RESULTS We found a decrease in the pain level in 18 of 20 patients, successful pain control in 12, and wearing shoes and walking without pain in 16. Overall, satisfaction was rated as excellent or good by 12 patients with Mortons neuroma in this series. CONCLUSIONS This evidence indicates that ultrasound-guided pulsed radio frequency is a promising treatment modality in the management of Mortons neuroma pain.

Low-Dose Ketamine Infusion for Managing Acute Pain.

We read with great interest the article “Short (low-dose) ketamine infusion for managing acute pain in the ED: case-report series” by Goltser et al [1]. We believe that this original study provides a new and insightful approach to pain management in emergency departments, particularly in terms of ensuring the comfort of the patients. To add to the results of this study, we propose that midazolam be used before the administration of anesthesia to reduce the side effects of ketamine infusion and thereby lead to the increased comfort of the patient. Ketamine is a nonselective supraspinal N-methyl-D-aspartate receptor antagonist, which can be safely administered in operation rooms and emergency departments. The potential analgesic effects of ketamine are formed by the reduction of neuronal signaling through the inhibition of these receptors. Common areas of usage are sedoanalgesia [2], induction before intubation [3], hyperalgesia because of opioid, analgesia [4-7], and postanesthetic shivering treatment [8]. Ketamine, however, frequently causes hallucinations and nightmares. Low-dose midazolam (1-2 mg) should be administered beforehand to avoid these side effects of ketamine [9]. Furthermore, ketamine indirectly increases the rate of nausea and vomiting in patients through the increase in secretions; therefore, to ensure patient comfort, antiemetic should be applied prophylactically [9]. To summarize, we suggest that low-dose midazolam and antiemetic prophylaxis should be used before applying ketamine to reduce unwanted side effects and increase patient comfort.

Effects of general and spinal anesthetic techniques on endothelial adhesion molecules in cesarean section

Background The aim of this study was to investigate the effects of anesthetic techniques used during general anesthesia (GA) and spinal anesthesia (SA) on endothelial adhesion molecules in the fetal circulation of healthy parturients undergoing elective cesarean section. Methods Patients were randomly assigned to either the general anesthesia (n = 20) or spinal anesthesia (n = 20) group. Maternal and cord blood neopterin, sE-selectin, and sL-selectin levels were measured in both groups. Results Cord blood neopterin concentrations in the SA group were not different from those in the GA group, but maternal neopterin levels in the SA group were different from those in the GA group. Maternal blood levels of sE-selectin and sL-selectin were not different between the two groups. Similarly, the cord blood levels of sE-selectin and sL-selectin were not different between the two groups. We found an increased inflammatory process in the fetal circulation depending on the anesthetic method used. Conclusions These results indicate the effects of general and spinal anesthetic techniques on serum sL-selectin, sE-selectin, and neopterin levels in neonates and parturients undergoing elective cesarean section. sE-selectin and neopterin concentrations and leukocyte counts were higher in the fetal circulation than in the maternal circulation during both GA and SA.

Ultrasound-guided peripheral vein cannulation

We read with great interest the article “Higher Success Rates and Satisfaction inDifficult VenousAccess Patientswith aGuideWire–Associated Peripheral Venous Catheter”written by Chiricolo et al [1].We believe that this original study provides a new approach to difficult venous access in emergency departments (EDs), particularly in terms of ensuring the comfort of the patients. To add to the results of this study, we think that ultrasound (US) is a useful tool for peripheral vein cannulation in patientswith difficult venous access leading to the increased comfort of the patient. Peripheral intravenous (PIV) access is a common procedure in the ED. Performing PIV access in patients with difficult vascular access because of obesity, history of IV drug use, dialysis, sickle cell disease, chemotherapy, vascular pathology, and other chronic medical conditions is a commonly encountered problem in the ED. Traditionally, patients with difficult PIV access have been subjected to more attempts by multiple clinicians and nurses or central catheter placement [2–4]. Central venous catheterization is often placed at significant risk to the patient. Placement of a central venous catheter is associated with a greater than 15% rate of significant complications, including arterial puncture, pneumothorax, deep vein thrombosis, and infection [5]. Ultrasound may be a useful tool for peripheral vein cannulation in patientswith difficult venous access, allowing to identify anatomic locations of peripheral vessels and guide the procedure. Compared with blind technique, US-guided technique showed a higher successful cannulation rate. Also, US guidance decreases time to cannulation and number of skin punctures and improves patient satisfaction [6]. We propose that bedside US in the ED may be used to facilitate placement of peripheral IVs in patients who have failed traditional landmark techniques, and avoidance of central venous catheterization, with its related risks, may be one benefit of US-guided peripheral IV access. Also a guide wire–associated peripheral venous catheter and US may be used together to achieve more success rate.

Momento propício para traqueostomia percutânea em unidade de terapia intensiva

We read with great interest the article of Duran et al.1 concerning timing of percutaneous tracheotomies in adult intensive care unit. We congratulate them on the presentation of the article. However, we would like to add some comments. Tracheotomy is a common procedure for patients who require prolonged ventilation. It may be beneficial by lowering airway resistance, improving oral hygiene, and improving pulmonary toilet and airway security and may also be associated with less sedative administration, less time of sedation, enhanced patient comfort, and fewer pulmonary infections.2 We agree with author about that early percutaneous tracheotomies shorten mechanical ventilation time, ICU and hospital stay times and result in less damage to the airways. Studies showed the efficiency of early tracheotomy on mechanical ventilation time, ICU stay times and preventing the airway damage in critically ill patients. However, the optimal timing (early vs. late) of the tracheotomy in critically ill patients requiring prolonged MV remains unclear.3 The National Association of Medical Directors of Respiratory Care recommended that tracheotomy should replace endotracheal intubation in patients who still require mechanical ventilation 3 weeks after admission; and noted that identification of the optimal time for a tracheotomy to be performed is one of the most important criteria when deciding to perform the procedure.4 Analyses of some study groups showed that the rates and timing of tracheotomy varied significantly across ICUs.5 A preconceived opinion of efficacy (in the absence of any evidence to support an optimal time for a tracheotomy) has been argued for explaining this incompatibility between the widespread use of tracheotomy and its incoherent and non-homogenous clinical use.6 This may be of particular clinical importance because patients receiving a tracheotomy require a large amount of care resources after the procedure. B n atient and illness in two groups. We think that patient ondition and severity of illness may affect tracheotomy iming and outcomes. Thus groups formed should be more omogenous.

Ultrasound-guided facet block.

e read the article ‘‘Ultrasound-guided facet block to low ack pain: a case report’’ written by Ana Ellen Q. Saniago et al.1 with interest. The authors have reported a ase report about a patient with bilateral facet osteoarthrois and performing facet block with ultrasound-guided.1 hanks to the authors for conducting such a great study, hich is successfully designed and well documented. We elieve that these findings will enlighten further studies bout ultrasound-guided facet block and comparing ultraound and fluoroscopy in pain therapies. Lumbar facet osteoarthrosis is one of the major causes f low back pain and it also cause referred pain in the lower imb. This source of pain cannot be diagnosed by only clinical xamination or radiologic findings.2 The facet joint block is erformed for patients with low back pain and with imaging tudies determining facet osteoarthrosis.1 The facet joint lock is usually performed under fluoroscopy or computed omography (CT). The block performed under CT or fluorocopic guidance enhances the accuracy and success rate, but here are disadvantages such as the exposure to radiation nd the high cost as compared with ultrasonography.3 Recent advances in ultrasound improved significantly pinal sonoanatomy. Therefore, currently ultrasound can e used to determine or guide central neuroaxial blocks nd also peripheral regional blocks with greater success,4 ecause ultrasound is a non-invasive, safe, and simple ool and it also does not involve exposure to radiation, esides providing real-time images, and it does not have ide effects.5 Many studies comparing ultrasound and fluoroscopy at acet joint block reported that ultrasound-guided facet lock can be performed with a high success rate and clinial outcome comparable with that of a fluoroscopic-guided lock and also the advantages of not involving exposure to adiation provides the potential for use of ultrasound guidnce as an alternative to the conventional method.2,3,6 We think that ultrasound-guided identification of the orrect segment for facet nerve block has not been fully h

Postoperative analgesia after total knee arthroplasty

We read with great interest the article of Wang et al.1 concerning the use of continuous local anesthetic infusion via catheters placed with ultrasound guided and nerve stimulator beside femoral nerve for postoperative analgesia after total knee arthroplasty (TKA). We congratulate them on the presentation of the article. However, we would like to add some comments. We agree with author that rehabilitation after TKA is an important determinant of post-operative functional reconstruction of knee.1 Physical therapy with early joint mobilization is also an important aspect to achieve good results. Therefore pain management after TKA is essential and may effect success rate of surgery. Regional analgesia is commonly used for TKA as it has lesser side-effects and better analgesia when compared with traditional oral analgesics.2 Among the regional analgesia techniques, continuous epidural analgesia and continuous femoral block analgesia are preferred to use after TKA.3 Continuous epidural analgesia has definite effectiveness, and a few systemic side effects. It has been widely applied in clinical practice. However, this procedure still causes respiratory depression, hemodynamic instability, intestinal obstruction, urinary retention, pruritus, motor block, and walk limitation.4 Continuous femoral nerve block has special advantage for the analgesia in postoperative pain.5,6 It is that this technique may have less side effects than the others but continuous epidural analgesia may be more successful with postoperative pain management. Anatomically, the knee joint takes its nerve supply primarily from the femoral nerve; however, there seems to be an important component from the sciatic nerve that evinces as pain related to calf and leg.2 Previous studies are inconclusive concerning the necessity of sciatic nerve block and also there are nearly an equal number of studies discussing adequate and inadequate block with femoral nerve block alone.7 However a study of Zugliani et al. 8

Bloqueio da faceta guiado por ultrassom

Lemos com interesse o artigo ‘‘Bloqueio facetário guiado por ultrassom para lombalgia: relato de caso’’ escrito por Ana Ellen Q. Santiago et al.1 Os autores relataram o caso clínico de uma paciente com osteoartrose facetária bilateral e fizeram um bloqueio facetário guiado por ultrassom.1 Agradecemos aos autores pelo estudo tão esclarecedor, que foi muito bem desenhado e documentado. Acreditamos que esses resultados serão de grande contribuição para estudos futuros sobre o bloqueio facetário guiado por ultrassom que comparem ultrassom e fluoroscopia em terapias para a dor. Osteoartrose facetária lombar é uma das principais causas de lombalgia e também causa dor refratária em membro inferior. Essa fonte de dor não pode ser diagnosticada por meio de exame apenas clínico ou achados radiológicos.2 O bloqueio facetário é feito em pacientes com dor lombar e com exames de imagem que determinam osteoartrose facetária.1 O bloqueio da articulação facetária é geralmente feito com o uso de fluoroscopia ou tomografia computadorizada (TC). O bloqueio com monitoração por TC ou fluoroscópica aumenta a taxa de precisão e sucesso, mas há desvantagens, como a exposição à radiação e o alto custo, em comparação com a ultrassonografia.3 Recentes avanços em ultrassom melhoraram de forma significativa a sonoanatomia da coluna vertebral. Portanto, atualmente, o ultrassom pode ser usado para determinar ou monitorar bloqueios neuroaxiais centrais e também bloqueios regionais periféricos com mais sucesso,4 pois se trata de uma ferramenta não invasiva, segura, simples e que não envolve exposição à radiação, além de proporcionar imagens em tempo real e não ter efeitos colaterais.5 Muitos estudos que compararam ultrassom e fluoroscopia em bloqueio facetário relataram que o bloqueio facetário guiado por ultrassom pode ser feito com uma alta taxa de sucesso e evolução clínica comparável ao blo-

Risk of transfusion-related acute lung injury after blood products transfusions

We readwith great interest the article “A Fresh Frozen Plasma toRed Blood Cell Transfusion Ratio of 1:1 Mitigates Lung Injury in a Rat Model of Damage Control Resuscitation for Hemorrhagic Shock” written by Zhao et al [1]. We believe that this original study provides an important approach to blood products transfusions for hemorrhagic shock. Use of blood products has not only many benefits but also many disadvantages. Therefore, we support to use blood products carefully and as many as necessary. We think that awareness of the risk of transfusionrelated acute lung injury (TRALI) after unnecessary blood products transfusions is needed. Massive transfusion is necessary for patients with hemorrhagic shock. An important component of massive transfusion guidelines is the amount of fresh frozen plasma (FFP) transfused. Some studies reported that administration ratio of FFP to red blood cells (PRBCs) has been important, but the optimal ratio during resuscitation has also been questioned. FFP transfusion may be an independent risk factor for acute lung injury and acute respiratory distress syndrome [2]. Some studies reported that there was a 2 times greater risk of acute respiratory distress syndrome due to a high FFP/PRBC ratio, and also, intensive care unit and hospital lengths of stay were significantly longer for patients who had received a high FFP/PRBC ratio [1,3,4]. Risks commonly associated with plasma transfusion include TRALI, transfusionassociated circulatory overload, allergic transfusion reactions, and infectious disease transmission. Recent studies have made comment about FFP transfusion and morbidity/mortality [5]. Transfusion-related acute lung injury is a clinical syndrome associated with all types of blood components transfusion containing plasma that usually includes dyspnea, hypoxemia, and bilateral pulmonary edema [6,7]. The diagnosis of TRALI is based on clinical findings developed within 6 hours after a blood product transfusion in the absence of another risk factor for the development of lung injury. The mechanism of TRALI has commonly been clarified by the transfusion of a blood product that includes anti–human leukocyte antigen or anti– human neutrophil antigen antibodies [8]. Treatment of TRALI should be supportive, with low tidal volumes for mechanical ventilation and maintenance of euvolemia. Some guidelines suggest steroid therapy. However, steroid therapy is controversial [9]. Compliance to current guidelines for blood components, especially for plasma, is essential to decrease risk for patients. A restrictive transfusion strategymay be associatedwith decreasing incidence of TRALI. Optimal transfusion guidelines should provide sufficient amount of blood products to improve clinical outcomes while avoiding complications such as TRALI [8]. However, standard resuscitation practice avoids plasma transfusions until after infusing crystalloid and red cells. The need for FFP transfusion should be assessed by laboratory coagulation tests

Postoperative pain in total hip arthroplasty

Dear Editor, We read the article “Factors associated with severe postoperative pain in patients with total hip arthroplasty” written by Petrovic et al. with great interest.[1] In this study, they aimed to determine risk factors for the development of postoperative pain following total hip arthroplasty. We would like to thank the authors for their contribution, with a successfully designed and documented study. We believe that these findings will enlighten further studies regarding risk factors for the development of postoperative pain following total hip arthroplasty. Total hip arthroplasty is a common orthopedic procedure, and postoperative pain is one of the most common concerns of patients undergoing total hip arthroplasty.[2] As underlined by the authors, many risk factors may influence the severity of pain after total hip arthroplasty. However, we realized that 2 important factors are not included in the list as risk factors: 1. Anesthetic technique—The intensity of postoperative pain is found to be less severe following regional techniques like spinal or epidural blocks[3] when compared to general anesthetic technique.[4–6] 2. Intraoperative analgesic use—In particular, preemptive analgesia is found to be an effective method in terms of reducing postoperative pain.[7] To summarize, we believe that anesthetic technique and intraoperative use of analgesics should be included in the list of risk factors for the development of postoperative pain following total hip arthroplasty. DOI: 10.3944/AOTT.2015.15.0151 This abstract belongs to the un-edited version of the article and is only for informative purposes. Published version may differ from the current version.