Mert Senturk

Effects of volatile and intravenous anesthesia on the alveolar and systemic inflammatory response in thoracic surgical patients.

Background:One-lung ventilation (OLV) results in alveolar proinflammatory effects, whereas their extent may depend on administration of anesthetic drugs. The current study evaluates the effects of different volatile anesthetics compared with an intravenous anesthetic and the relationship between pulmonary and systemic inflammation in patients undergoing open thoracic surgery. Methods:Sixty-three patients scheduled for elective open thoracic surgery were randomized to receive anesthesia with 4 mg · kg−1 · h−1 propofol (n = 21), 1 minimum alveolar concentration desflurane (n = 21), or 1 minimum alveolar concentration sevoflurane (n = 21). Analgesia was provided by remifentanil (0.25 &mgr;g · kg−1 · min−1). After intubation, all patients received pressure-controlled mechanical ventilation with a tidal volume of approximately 7 ml · kg−1 ideal body weight, a peak airway pressure lower than 30 cm H2O, a respiratory rate adjusted to a Paco2 of 40 mmHg, and a fraction of inspired oxygen lower than 0.8 during OLV. Fiberoptic bronchoalveolar lavage of the ventilated lung was performed immediately after intubation and after surgery. The expression of inflammatory cytokines was determined in the lavage fluids and serum samples by multiplexed bead-based immunoassays. Results:Proinflammatory cytokines increased in the ventilated lung after OLV. Mediator release was more enhanced during propofol anesthesia compared with desflurane or sevoflurane administration. For tumor necrosis factor-&agr;, the values were as follows: propofol, 5.7 (8.6); desflurane, 1.6 (0.6); and sevoflurane, 1.6 (0.7). For interleukin-8, the values were as follows: propofol, 924 (1680); desflurane, 390 (813); and sevoflurane, 412 (410). (Values are given as median [interquartile range] pg · ml−1). Interleukin-1&bgr; was similarly reduced during volatile anesthesia. The postoperative serum interleukin-6 concentration was increased in all patients, whereas the systemic proinflammatory response was negligible. Conclusions:OLV increases the alveolar concentrations of proinflammatory mediators in the ventilated lung. Both desflurane and sevoflurane suppress the local alveolar, but not the systemic, inflammatory responses to OLV and thoracic surgery.

Ventilatory Protective Strategies during Thoracic Surgery Effects of Alveolar Recruitment Maneuver and Low-tidal Volume Ventilation on Lung Density Distribution

BACKGROUND The increased tidal volume (V(T)) applied to the ventilated lung during one-lung ventilation (OLV) enhances cyclic alveolar recruitment and mechanical stress. It is unknown whether alveolar recruitment maneuvers (ARMs) and reduced V(T) may influence tidal recruitment and lung density. Therefore, the effects of ARM and OLV with different V(T) on pulmonary gas/tissue distribution are examined. METHODS Eight anesthetized piglets were mechanically ventilated (V(T) = 10 ml/kg). A defined ARM was applied to the whole lung (40 cm H(2)O for 10 s). Spiral computed tomographic lung scans were acquired before and after ARM. Thereafter, the lungs were separated with an endobronchial blocker. The pigs were randomized to receive OLV in the dependent lung with a V(T) of either 5 or 10 ml/kg. Computed tomography was repeated during and after OLV. The voxels were categorized by density intervals (i.e., atelectasis, poorly aerated, normally aerated, or overaerated). Tidal recruitment was defined as the addition of gas to collapsed lung regions. RESULTS The dependent lung contained atelectatic (56 ± 10 ml), poorly aerated (183 ± 10 ml), and normally aerated (187 ± 29 ml) regions before ARM. After ARM, lung volume and aeration increased (426 ± 35 vs. 526 ± 69 ml). Respiratory compliance enhanced, and tidal recruitment decreased (95% vs. 79% of the whole end-expiratory lung volume). OLV with 10 ml/kg further increased aeration (atelectasis, 15 ± 2 ml; poorly aerated, 94 ± 24 ml; normally aerated, 580 ± 98 ml) and tidal recruitment (81% of the dependent lung). OLV with 5 ml/kg did not affect tidal recruitment or lung density distribution. (Data are given as mean ± SD.) CONCLUSIONS The ARM improves aeration and respiratory mechanics. In contrast to OLV with high V(T), OLV with reduced V(T) does not reinforce tidal recruitment, indicating decreased mechanical stress.

Vascular Reconstruction in Buerger's Disease : Is it Feasible?

Abstract.Purpose: Thromboangiitis obliterans (Buergers disease) is a clinical syndrome characterized by segmental occlusions of the distal vessels. Although a cessation of using nicotine products usually helps, nevertheless a surgical revascularization may be needed in cases of stage III and IV limbs. Because of the distal and segmental nature of the disease, these procedures are rarely feasible. This article focuses on the feasibility of performing a vascular reconstruction in thromboangiitis obliterans. Methods: Thirty-six of 94 patients (38.3%) who were followed by the Peripheral Vascular Unit of Istanbul Medical Faculty were selected for revascularization and 27 of 36 (81%) patients underwent revascularization procedures. Results: During a 36-month follow-up, the patency rates at the 12th, 24th, and 36th months were 59.2%, 48%, and 33.3%, respectively. The limb salvage rate was 92.5%. Conclusions: Since patients affected by Buergers disease consist a group of young population who are still in their productive stages, every effort should be taken to obtain a limb salvage in the ischemic period. Although the patency rates do not seem promising, the limb salvation rate was quite satisfactory.

Rocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomy

The use of neuromuscular blocking agents is still controversial in myasthenic patients but rocuronium could be useful after the introduction of sugammadex as a selective antagonist. The aim of the study was to evaluate the use of rocuronium‐sugammadex in myasthenic patients undergoing thoracoscopic thymectomy.

Mivacurium in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy

8 ml h rate was begun for postoperative analgesia. The surgery was uneventful with the patient awake, using standard monitoring. The first dose of enoxaparin 4000 UI was given 10 h after perineural catheter placement. On the first postoperative day (POD), a Doppler study showed thrombosis of the right tibial posterior vein. Elastic-compressive stockings had been worn by the patient and enoxaparin 4000 UI was given twice a day. The perineural catheter was removed on the second POD, 12 h after the last enoxaparin dose, and the subsequent dose was administered 3 h after the catheter removal. On the fourth POD, the patient complained of left iliac fossa pain without sensory-motor deficit. The patient’s condition was stable and a computed tomography (CT) scan diagnosed a 15 12 cm haematoma of the left psoas muscle (Fig. 1). Laboratory exam: leucocyte count 14.3 10, erythrocyte 2.9 10, Hb 8.6 g dl, and Ht 26%. All the other biochemical measurements were within the normal range. The patient was continuously monitored, enoxaparin was discontinued, and antibiotic therapy was prescribed. By the fifth POD, the general condition was stable, the CT with contrast scan of abdomen and pelvis re-confirmed the haematoma, and a full blood count reported erythrocyte 2.15 10, Hb 6.4 g dl, and Ht 19%. Four units of concentrate red blood cells were transfused. Over the following days, the patient’s general condition was improving and psoas haematoma was progressively reducing. Enoxaparin 4000 UI once a day was recommenced on the 18th POD for treatment of the DVT. The patient was discharged on the 25th POD and a CT scan performed 2 weeks after hospital discharge showed almost complete resorption of the haematoma. Other authors reported renal subcapsular or psoas haematoma 2 after several attempts at placing a PCB block. Both Winnie and colleagues and Chayen and colleagues described needle insertion at fixed distance from iliac crest line and the vertebral column. Capdevila and colleagues proposed a point ‘1 cm cephalad from the point at the junction of the lateral third and medial two-thirds of a line between the spinous process of L4 and a line parallel to the spinal column passing through the posterior superior iliac spine’. Since these landmarks take in consideration the anatomical dimension of the individual patient, they may be more precise and thus avoid multiple attempts at placement, but this hypothesis has not been studied. Although CPCB offers a more complete block of the thigh and knee, no clinical evidence on better analgesia is reported in comparison with continuous femoral nerve block after major knee surgery. We suggest that it be a more reasonable and less risky analgesia technique than CPCB after major knee surgery.

WHO Needs High FIO2

World Health Organization and the United States Center for Disease Control have recently recommended the use of 0.8 FIO2 in all adult surgical patients undergoing general anaesthesia, to prevent surgical site infections. This recommendation has arisen several discussions: As a matter of fact, there are numerous studies with different results about the effect of FIO2 on surgical site infection. Moreover, the clinical effects of FIO2 are not limited to infection control. We asked some prominent authors about their comments regarding the recent recommendations.

Open Lung in Lateral Decubitus With Differential Selective Positive End-Expiratory Pressure in an Experimental Model of Early Acute Respiratory Distress Syndrome.

Objective:After lung recruitment, lateral decubitus and differential lung ventilation may enable the titration and application of optimum-selective positive end-expiratory pressure values for the dependent and nondependent lungs. We aimed at compare the effects of optimum-selective positive end-expiratory pressure with optimum global positive end-expiratory pressure on regional collapse and aeration distribution in an experimental model of acute respiratory distress syndrome. Design:Prospective laboratory investigation. Setting:University animal research laboratory. Subjects:Seven piglets. Interventions:A one-hit injury acute respiratory distress syndrome model was established by repeated lung lavages. After replacing the tracheal tube by a double-lumen one, we initiated lateral decubitus and differential ventilation. After maximum-recruitment maneuver, decremental positive end-expiratory pressure titration was performed. The positive end-expiratory pressure corresponding to maximum dynamic compliance was defined globally (optimum global positive end-expiratory pressure) and for each individual lung (optimum-selective positive end-expiratory pressure). After new maximum-recruitment maneuver, two steps were performed in randomized order (15 min each): ventilation applying the optimum global positive end-expiratory pressure and the optimum-selective positive end-expiratory pressure. CT scans were acquired at end expiration and end inspiration. Measurements and Main Results:Aeration homogeneity was evaluated as a nondependent/dependent ratio (percent of total gas content in upper lung/percent of total gas content in lower lung) and tidal recruitment as the difference in the percent mass of nonaerated tissue between expiration and inspiration. At the end of the 15-minute optimum-selective positive end-expiratory pressure, compared with the optimum global positive end-expiratory pressure, resulted in 1) decrease in the percent mass of collapse in the lower lung at expiratory CT (19% ± 15% vs 4% ± 5%; p = 0.03); 2) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-expiratory-CT and optimum-selective positive end-expiratory pressure-expiratory-CT (3.7 ± 1.2 vs 0.8 ± 0.5; p = 0.01); 3) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-inspiratory-CT and optimum-selective positive end-expiratory pressure-inspiratory-CT (2.8 ± 1.1 vs 0.6 ± 0.3; p = 0.01); and 4) less tidal recruitment (p = 0.049). Conclusions:After maximum lung recruitment, lateral decubitus and differential lung ventilation enabled the titration of optimum-selective positive end-expiratory pressure values for the dependent and the nondependent lungs, made possible the application of an optimized regional open lung approach, promoted better aeration distribution, and minimized lung tissue inhomogeneities.

Perioperative dexketoprofen or lornoxicam administration for pain management after major orthopedic surgery: a randomized, controlled study.

OBJECTIVE Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for multimodal postoperative pain management. The purpose of this study was to evaluate the postoperative pain relief and opioid-sparing effects of dexketoprofen and lornoxicam after major orthopedic surgery. METHODS After obtaining ethical committee approval and informed consent, 120 patients undergoing elective hip or knee replacement under general anesthesia were randomized to receive two intravenous injections of 50 mg dexketoprofen (GD), 8 mg lornoxicam (GL) or saline as placebo (GP) intravenously. Postoperatively, patient-controlled analgesia (PCA) morphine was started as a 0.01 mg.kg-1 bolus dose, with lockout time of 10 minutes without continuous infusion. Pain assessment was made using the Visual Analogue Scale (VAS) at rest or during movement at postoperative 1, 2, 4, 6, 8, 12, and 24 hours. RESULTS The three groups were similar in terms of age, gender, American Society of Anesthesiologists (ASA) class, number of patients who underwent hip or knee surgery, weight, height, and operation duration. Patients in GD and GL demonstrated significantly reduced pain scores at rest and active motion compared to GP, with lower scores in the dexketoprofen group. Patients in GD and GL used significantly less morphine in the postoperative period compared to GP. The total morphine consumption of patients in GD was lower than in GL. CONCLUSION Intravenous application of 50 mg dexketoprofen twice a day and 8 mg lornoxicam twice a day improved analgesia and decreased morphine consumption following major orthopedic surgery. When the two active drugs were compared, it was found that dexketoprofen was superior to lornoxicam in terms of analgesic efficacy and opioid consumption.

Misoprostol as a Therapeutic Option for Trigeminal Neuralgia in Patients with Multiple Sclerosis

Dear Editor, Trigeminal neuralgia (TN) is characterized by attacks of recurring, paroxysmal, shock-like pain within the distribution of one or more branches of the trigeminal nerve [1]. About 2% of all TN patients have multiple sclerosis (MS); similarly, about 2% of all MS patients present with TN symptoms [2]. The combination of TN and MS is one of the rare, so-called “symptomatic” forms of TN. We present three cases of “therapy-resistant MS-related” TN, in which misoprostol therapy was successful. Case 1 reports of a 65-year-old female patient with a 32-year history of MS and a 4-year history of TN (V2 only). Further findings were a hemiparesis and hemiplegia lasting 1 year and a history of hypertension. She was suffering from pain attacks with a visual analog scale (VAS) of 10/10, which made eating impossible. The bouts appeared 20 times per day and lasted approximately 10 minutes. During the neurological follow-up, she received carbamazepine (CBZ) and nutrients parenterally. Increasing the doses of CBZ caused complications such as intermittent hyponatremia and hypocalcemia. She received additional administrations of 3–4 × 10 mg/day morphine subcutaneously. As the pain attacks persist, the medication was broadened to baclofen 4 × 5 mg/day, morphine retard 3 × 10 mg/day, and gabapentin at …

Anaesthesia for thymectomy in adult and juvenile myasthenic patients.

Purpose of review Myasthenia gravis, a chronic disease of the neuromuscular junction, is associated with an interaction with neuromuscular blocking agents (NMBAs). As thymectomy is often the method of choice for its treatment, anaesthetic management requires meticulous preoperative evaluation, careful monitoring, and adequate dose titration. The frequency of video-assisted thoracoscopic extended thymectomy (VATET) is also increasing, making the use of NMBA obligatory. The number of cases of the juvenile form has also increased over years; airway management in juvenile one-lung ventilation is another challenge. Recent findings Sugammadex appears to be a safe choice to avoid prolonged action of NMBA also in patients with myasthenia gravis, although this information has to be confirmed in further series. The number of VATETs is increasing so that the experience with sugammadex will also increase in time. In non-VATET operations, use of NMBA should and can be avoided as much as possible. New scoring systems are defined to predict a postoperative myasthenic crisis. For VATET in juvenile cases, blockers can be a good option for the airway management. Summary Anaesthetic management of thymectomy in myasthenia gravis requires experience concerning different approaches. Sugammadex should be considered as a possible further step toward postoperative safety.