Nermin Kelebek Girgin

Intrathecal morphine in anesthesia for cesarean delivery: dose-response relationship for combinations of low-dose intrathecal morphine and spinal bupivacaine

STUDY OBJECTIVE To evaluate the quality of analgesia and the severity of side effects of intrathecal morphine administered for a dose range of 0.0 to 0.4 mg for postcesarean analgesia with low-dose bupivacaine. DESIGN Double-blind, randomized study. SETTING University hospital. PATIENTS 100 ASA physical status I and II term parturients undergoing cesarean delivery with spinal anesthesia in the operating room. INTERVENTIONS Patients were randomized to one of 5 groups to receive 0.0, 0.1, 0.2, 0.3, or 0.4 mg intrathecal morphine in addition to low-dose (7.5 mg) heavy bupivacaine. Each patient received intravenous (IV) patient-controlled analgesia (PCA) with morphine after the operation. MEASUREMENTS 24-hour IV PCA morphine use and visual analog scores for pain were recorded. The severity score (4-point scale) of nausea, vomiting, and pruritus were assessed intraoperatively and at 4-hour intervals during the first 24 hours postoperatively. MAIN RESULTS PCA morphine use was higher in the control group (0.0 mg) than in groups receiving 0.1, 0.2, 0.3, or 0.4 mg intrathecal morphine. There was no difference in IV PCA morphine use between the 0.1 and 0.4-mg groups, despite a 4-fold increase in intrathecal morphine dose. There was no difference between groups in nausea and vomiting, but pruritus increased in direct proportion to the dose of intrathecal morphine (linear regression, P = 0.0001). CONCLUSIONS The dose of 0.1 mg intrathecal morphine produces analgesia comparable with doses as high as 0.4 mg, with significantly less pruritus when combined with low-dose bupivacaine.

The Combination of Low-Dose Levobupivacaine and Fentanyl for Spinal Anaesthesia in Ambulatory Inguinal Herniorrhaphy

This study investigated whether the addition of 25 μg intrathecal fentanyl to levobupivacaine spinal anaesthesia for outpatient inguinal herniorrhaphy allows a sub-anaesthetic levobupivacaine dose to be used. Forty patients were assigned to receive 5 mg levobupivacaine 0.5% mixed with 25 μg fentanyl (group LF) or 7.5 mg levobupivacaine 0.5% (group L). The highest sensory block levels achieved were T7 (range T5 – T9) and T6 (range T4 – T9) in groups LF and L, respectively. The times to two-segment regression, S2 regression, ambulation, urination and discharge were all significantly shorter in group LF than group L. These results indicate that, for outpatient inguinal herniorrhaphy, intrathecal fentanyl combined with low-dose levobupivacaine provides good quality spinal anaesthesia and minimizes the need for intra-operative analgesia. This protocol is well suited for the outpatient setting because it features rapid recovery of full motor power, sensory function and bladder function.

Combination of Ultra-Low Dose Bupivacaine and Fentanyl for Spinal Anaesthesia in Out-Patient Anorectal Surgery

This study investigated whether the addition of 25 μg fentanyl to an ultra-low (sub-anaesthetic) dose of intrathecal bupivacaine provides adequate anaesthesia for out-patient anorectal surgery, without increasing side-effects or delaying hospital discharge. Patients were randomly allocated to receive 2.5 mg 0.5% bupivacaine plus 25 μg fentanyl (group BF, n = 18) or 5 mg 0.5% bupivacaine alone (group B, n = 17). There were no significant differences in intra-operative outcomes, but mean recovery and discharge times were significantly shorter in group BF. There were no between-group differences in hypotension, bradycardia or respiratory depression and post-operative complications were comparable, apart from pruritus which was significantly more frequent in group BF. Fewer patients requested analgesic medication in the early post-operative period in group BF than in group B. In conclusion, 25 μg intrathecal fentanyl added to ultra-low dose (2.5 mg) bupivacaine provided good-quality spinal anaesthesia and reduced post-operative analgesic requirement in patients undergoing ambulatory anorectal surgery.

Guillain-Barré Syndrome and Human Immunodeficiency Virus

Guillain-Barré syndrome (GBS) is an acute disease characterised by symmetrical muscle weakness, loss of sensation and reflex. There is usually a viral infection at the beginning of the disease. Here, we report a GBS case which did not respond to any treatment strategy at first and was diagnosed as Human Immunodeficiency Virus positive (HIV+) during the search for the aetiology. A 32-year-old male patient who presented to a medical centre with symptoms of gait disturbance and arm and leg numbness was found to have albuminocytologic dissociation upon cerebrospinal fluid examination. After the diagnosis of GBS, immunoglobulin G (IVIG) therapy (400 mg kg(-1) day(-1) 5 days) was started as a standard therapy. This therapy was repeated due to a lack of improvement of symptoms. During this therapy, the patient was sent to our clinic with symptoms of respiratory failure and tetraplegia. He was conscious, cooperative, haemodynamically stable and his arterial blood gas analyses were: pH: 7.28, PaO2: 74.4 mmHg, PCO2: 63.8 mmHg. He was intubated, mechanically ventilated and underwent plasmapheresis. After the investigation of aetiology, HIV(+), CD4/CD8: 0.17, absolute CD4: 71 cells mL(-1) were detected and antiretroviral therapy was started. The patient died from multiple organ failure due to sepsis on day 35. In conclusion, HIV infection should be kept in mind in GBS patients, especially those not responding to routine treatment. As a result, not only could the patient receive early and adequate treatment, but also HIV infection transmission would be avoided.

Delayed pneumothorax and contralateral hydrothorax induced by a left subclavian central venous catheter: a case report

The placement of central venous catheters (CVCs) has become a ubiquitous practice in intensive care units (ICUs).1,2 The use of CVCs is often a necessity for the measurement of hemodynamic variables and the administration of fluids, medications, blood products, and parenteral nutrition in critically ill patients; however, catheterization may occasionally be associated with complications, such as pneumothorax, hemothorax, cardiac tamponade, sepsis, and thrombosis.1–4 These complications may be life-threatening, even when the procedure is performed under the most ideal circumstances.3,4 Although the incidence of delayed pneumothorax and hydrothorax after central venous catheterization is low, such complications of catheterization can sometimes be associated with significant morbidity and mortality. We searched Medline reports from the last 30 years and found very few cases that reported delayed pneumothorax and hydrothorax caused by catheterization. Most of these reported cases observed pneumothorax and/or hydrothorax on the same side as the CVC,3,5,6 and only one case developed hydrothorax as a delayed complication on the opposite side as the catheter.7 We did not detect the simultaneous occurrence of delayed pneumothorax and contralateral hydrothorax in a single case. Here, we report a case wherein left pneumothorax and right hydrothorax were simultaneously detected as delayed complications induced by a left subclavian CVC.

Küçük ve Orta Cerrahi Girişimlerde Preoperatif Rutin Laboratuar Testleri Gerekli midir

The aim of this study was to determine the effect of carbamazepine onserum lipid levels in epileptic patients who were on long-termcarbamazepine monotherapy. The study group were comprised of 30epileptic patients (10 female, 20 male) who have been on carbamazepinemonotherapy for at least one year whereas control group consisted of 30 ageand sex matched healthy controls. Serum cholesterol (total cholesterol,HDL cholesterol, LDL cholesterol) and triglyceride levels were measuredand LDL/HDL ratio was calculated in all subjects. Serum HDL cholesteroland triglyceride levels of study group were significantly higher than controlgroup whereas serum LDL cholesterol levels and LDL/HDL ratios of studygroup were lower than control group. Mean total cholesterol level of studygroup was lower than control group, however the difference did not reachstatistical significance level. Because of its effect on cholesterol levels, longterm carbamazepine could possibly have a positive influence in decreasingthe risk of developing aterosclerosis and coronary heart disease. Long termprospective follow-up studies would be helpful to us in enlightening this issuedefinitely.

Lumbar epidural lysis: a cranio-caudal lateral intralaminar approach

AbstractThe standard approach for epidural lysis is reaching to the problematic area through the caudal canal. If the symptoms do not cease and no improvement is seen, a cranio-caudal approach can be tried. In a patient with back pain due to failed back surgery syndrome for six months, epidurography was performed using caudal approach under fluoroscopy in the first intervention. A catheter was progressed to fibrotic tissue for epidural lysis. But the pain regression was not satisfactory at the L4 dermatome. After 3 weeks, a second intervention was planned with the lateral cranio-caudal approach at the L3-4 level and a catheter was placed around the fibrotic tissue and lysis was applied. The patients back pain totally disappeared and neurological symptoms started to decrease at the end of the first week. We suggest that, for patients with low back pain due to failed back surgery syndrome, a cranio-caudal approach may be applied after caudal epidural lysis.

Persistent hypoxemia during extracorporeal membrane oxygenation in delayed diagnosed paraquat intoxication

Paraquat is a highly toxic herbicide used in agriculture worldwide that causes progressive pulmonary fibrosis (PF) due to selective accumulation in the lungs. Paraquat intoxication can result in death due to multi-organ failure within a few days or respiratory failure due to PF within a few weeks. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) is currently a widely used therapeutic strategy for acute respiratory distress syndrome (ARDS). Presently described is case of a 46-year-old man who was hospitalized with ARDS and treated with V-V ECMO. Expected oxygenation levels could not be attained despite ECMO support. When excluding causes for hypoxia in this patient on ECMO, detailed medical history revealed exposure to paraquat 3 weeks previously. Severe hypoxemia persisted during V-V ECMO and the patient died on sixth day after admission. The aim of this study was to examine probable causes of persistent hypoxemia during V-V ECMO observed in this case.

Comparison Of The Effects Of Propofol and Dexmedetomidine Sedation On Axillary Block

Uzm. Dr. Canan Yilmaz, Bursa Şevket Yilmaz Egitim ve Arastirma Hastanesi Yildirim Bursa Turkiye, Tel. 0224 295 50 00 Email. dr_cnnylmz@yahoo.com Gelis Tarihi: 25.04.2014 • Kabul Tarihi: 01.03.2015 ABSTRACT AIM: We aimed to compare the effects of propofol and dexmedetomidine on intra-operative sedation, hemodynamic parameters and post-operative analgesia during fore-arm surgery with axillary block.

A Rare Cause of a Pressure Ulcer: A Single Hair

Pressure ulcers are the loss of tissue and remain a common problem in critically ill patients. These patients are at high risk for developing pressure ulcers because of their hemodynamic instability, malnutrition, and strictly limited physical activity and mobility due to neurological damage or drugs such as sedatives and muscle relaxants. Pressure is the most important cause of pressure ulcers. Contact surfaces such as patient’s bed or wheelchair, and some medical devices such as pulse oximetry probe and urethral catheter can result in pressure. The case is reported here of a very rare cause of a pressure ulcer, which was a single hair on the patient’s face.