Nesrin Bozdogan

Efficacy of lornoxicam for acute postoperative pain relief after septoplasty: a comparison with diclofenac, ketoprofen, and dipyrone

STUDY OBJECTIVES To compare the efficacy of injectable lornoxicam with diclofenac, ketoprofen, and dipyrone for acute postoperative pain. DESIGN Prospective, randomized, placebo-controlled, double-blind study. SETTING University hospital. PATIENTS 200 ASA physical status I patients who were scheduled for elective septoplasty with general anesthesia. INTERVENTIONS Patients were divided into 5 groups according to the intramuscularly administered analgesic drug: lornoxicam 8 mg (twice daily), diclofenac 75 mg (twice daily), ketoprofen 100 mg (twice daily), dipyrone 1 g (three times daily), and placebo (twice daily). MEASUREMENTS Pain intensity was evaluated with a 0 to 100 mm Visual Analog Scale (VAS) at the 2nd, 4th, 6th, 8th, 12th, 16th, 20th, and 24th hour postoperatively. Intramuscular pethidine 1 mg/kg was administered to patients requiring additional analgesia, and treatment-related adverse effects were noted. MAIN RESULTS Pethidine requirement was found to be significantly higher in the placebo group (1.8 mg/kg per 24 hours; 95% confidence interval, 1.5-2.2) than in the other groups (P = 0.001). No significant difference in opioid requirement was found among the treated groups (P > 0.05). Postoperative VAS scores were significantly lower at specific hours in the treatment groups when compared with placebo group (P < 0.05). No statistically significant difference in adverse effects was found among the groups studied (P > 0.05). CONCLUSIONS Efficacy of lornoxicam in the management of acute postoperative pain was not superior to that of other nonopioid analgesics used in this study.

Femoral and sciatic nerve block with 0.25% bupivacaine for surgical management of diabetic foot syndrome: an anesthetic technique for high-risk patients with diabetic nephropathy

A case series of patients with diabetic nephropathy, who underwent lower limb debridement or amputation below the knee during successful combined sciatic and femoral nerve block with bupivacaine 0.25%, is presented. Because impaired nerve conduction in diabetes mellitus results in lower local anesthetic agent requirement, a dose-sparing, minimal effective concentration for surgical anesthesia for peripheral nerve blockade may be more favorable for patients with diabetes and chronic renal disease.

Oral versus intranasal midazolam premedication for infants during echocardiographic study

Movement and anxiety during echocardiographic study may reduce the reliability and affect the quality of echocardiographic images. Thus, sedation is an essential component when it is performed in infants. This randomized, single-blinded, placebo-controlled study was undertaken to evaluate the acceptability and effectiveness of intranasal midazolam (INM) versus oral midazolam (OM) in infants during transthoracic echocardiography. Eighty patients between the ages of 6 mo and 3 y who presented for elective echocardiographic study were divided into 3 groups: the OM group received 0.4 mg/kg of injectable midazolam mixed with an equal volume of cherry juice, the INM group received 0.2 mg/kg as drops, and the control group was given oral cherry juice or intranasal serum physiologic. A blinded clinician assessed and scored the level of sedation and comfort during the procedure for each child, and a score for ease of administration was recorded by the nurse. The intranasal route was more acceptable to infants than the oral route (P<.001). No significant difference in the effects of sedation was observed between the OM group and the INM group (P=.583), but significant differences were observed between the sedated groups and the control group (P<.001). The procedure was significantly more comfortable in groups given OM and INM than in the control group (P<.001). Although no difference in sedation score was seen between the oral and nasal routes, INM was better accepted by infants than OM. Echocardiography was performed more reliably and comfortably in those given midazolam than in those in the control group.

A combination of ketamine and dexmedetomidine sedation with caudal anesthesia during incarcerated inguinal hernia repair in three high-risk infants

indicated because of a suspected intestinal perforation. His general condition was bad, tachypnoic, with an enlarged abdomen. His BW was 3350 g. Laboratory results were normal, but for a low level of thrombocytes. He received one dose of platelets before the operation. We performed balanced anesthesia. For fluid replacement, besides cristaloids with albumin 20%, he received erythrocytes, FFP and HES 130 ⁄ 0.4, 20 mLÆh. The operation lasted 4 h. The patient was stable during the operation. Laboratory values and coagulation status remained unchanged. Hydroxyethyl starch 130 ⁄ 0.4 is a relatively new colloid, approved by the FDA on 27 December 2007. It is a poly (O-2-hydroxyethyl) starch in 0.9% NaCl, with an average molecular weight of 130 000 D and a degree of substitution of 0.4 (HES 130 ⁄ 0.4) and osmolality 308 mOsmol l. When compared with albumin, it is seven times cheaper. Standl et al. (1) reported that there is no difference regarding perioperative stabilization of hemodynamics, coagulation parameters, blood gas analyses and other laboratory values between albumin and HES 130 ⁄ 0.4 in children. Moreover they claimed no significant differences in the amount of red blood cells, fresh frozen plasma or platelet concentrations in the two groups. We report two neonates who underwent major surgeries and received HES 130 ⁄ 0.4 along with albumin. Patients were stable during and after the operation. There were no changes in the coagulation status (platelet count, bleeding time, coagulation time, prothrombin time and partial thromboplastin time), although some larger investigations reported some changes (2). No other adverse events occurred. A question remains on the use of colloids vs crystalloids for fluid resuscitation in cricitally ill patients (3), and also which colloid solution is the best (4), particularly in relation to newborns. This case report shows that using HES 130 ⁄ 0.4 can be useful in newborns who undergo major surgeries, with no significant adverse effects, especially in a situation when one does not have other preferable colloids and blood or blood products at one’s disposal. Further studies are needed in this regard. Irina Milojevic* Dusica Simic† Marija Markovic* Ivana Budic *Department of Anesthesiology, University Children’s Hospital, Belgrade, Serbia †ICU, University Children’s Hospital, Belgrade, Serbia ‡Department of Anesthesiology, Children’s Hospital, Nis, Serbia (email: mirina@sbb.co.yu) References

A Prospective Randomized Double-Blind Study to Determine the Effect of Thoracic Epidural Neostigmine on Postoperative Ileus After Abdominal Aortic Surgery

BACKGROUND: Postoperative ileus is a major gastrointestinal complication of abdominal aortic surgery leading to increased rates of morbidity and mortality, longer lengths of hospital stay, and higher costs. In this study, we evaluated the effect of epidurally administered neostigmine on postoperative ileus after abdominal aortic surgery. METHODS: We enrolled 45 patients who were scheduled for elective abdominal aortic surgery at our institution. All patients received identical general and epidural anesthesia. Before the induction of general anesthesia, an epidural catheter was placed at the T7–T8 intervertebral space, and 20 mL bupivacaine (0.5%) was injected over 15 min. Patients were randomized into two groups. Patients received a 5 mL bolus of neostigmine (1 &mgr;g/kg) diluted with normal saline (Group 1) or a 5 mL bolus of normal saline (Group 2) via an epidural catheter at the end of surgery and 8 h postoperatively. Times of bowel sounds were recorded postoperatively in the intensive care unit. Times of daily passage of flatus and defecation also were recorded. RESULTS: Times to the first bowel sounds and the first flatus were significantly shorter in Group 1 than they were in Group 2 (11.6 ± 11.2 h vs 22.6 ± 12.8 h and 21.8 ± 15.6 h vs 36.6 ± 19.1 h, respectively, P < 0.05). The times to first defecation were similar in both groups (P > 0.05). Nausea was more frequent in patients in Group 2 than in Group 1 (P < 0.05). The incidence of postoperative complications was similar between the groups (P > 0.05). CONCLUSIONS: Thoracic epidural neostigmine enables faster restoration of bowel sounds and shortens duration of postoperative ileus after abdominal aortic surgery.

Intravenous paracetamol and dipyrone for postoperative analgesia after day-case tonsillectomy in children: a prospective, randomized, double blind, placebo controlled study

UNLABELLED Tonsillectomy is associated with severe postoperative pain for which, several drugs are employed for management. OBJECTIVE In this double-blind, placebo-controlled study we aimed to evaluate the efficacy of intravenous paracetamol and dipyrone when used for post-tonsillectomy analgesia in children. METHOD 120 children aged 3-6 yr, undergoing tonsillectomy with or without adenoidectomy and/or ventilation tube insertion were randomized to receive intraoperative infusions of paracetamol (15 mg/kg), dipyrone (15 mg/kg) or placebo (0.9% NaCl). Evaluation was carried out at 0.25, 0.50, 1, 2, 4, 6h postoperatively. Pethidine 0.25 mg/kg was utilized as rescue analgesic. Cumulative pethidine requirement was the primary outcome. Pain intensity measurement, pain relief, sedation level, nausea and vomiting, postoperative bleeding and any other adverse effects were noted. RESULTS No significant difference was found in pethidine requirement between paracetamol and dipyrone groups. Cumulative pethidine requirement was significantly less in paracetamol and dipyrone groups vs. placebo. No significant difference was observed between groups in postoperative pain intensity scores throughout the study. CONCLUSION Intravenous paracetamol is found to have a similar analgesic efficacy as intravenous dipyrone and they both help to reduce the opioid requirement for postoperative analgesia in pediatric day-case tonsillectomy.

An Alternative Central Venous Route for Cardiac Surgery: Supraclavicular Subclavian Vein Catheterization

OBJECTIVE To evaluate the clinical success rate, safety, and usefulness for intraoperative central venous pressure monitoring, and the intravenous access of the supraclavicular subclavian vein approach when compared with the infraclavicular subclavian vein approach and the internal jugular vein approach for central venous catheterization during open-chest cardiac surgery. DESIGN A prospective, randomized, single-center study. SETTING A university hospital. PARTICIPANTS One hundred ninety-five patients scheduled for open-chest cardiac surgery. INTERVENTIONS The study population consisted of patients for whom central vein catheterization was intended during cardiac surgery. Patients were randomized to 3 groups according to the route of central vein catheterization: the supraclavicular group: the supraclavicular approach for the subclavian vein (n = 65); the infraclavicular group: the infraclavicular approach for the subclavian vein (n = 65); and the jugular group: the internal jugular vein approach (n = 65). After the induction of anesthesia, central venous catheterization was performed according to the assigned approach. MEASUREMENTS AND MAIN RESULTS The success rates for the assigned approach were 98%, 98%, and 92% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). The success rates in the first 3 attempts in patients who were catheterized successfully according to the assigned approach were 96%, 100%, and 96% for the supraclavicular, infraclavicular, and jugular groups, respectively (p > 0.05). There was no difference among groups in catheter insertion time (p > 0.05). After sternal retraction, central venous pressure trace loss and difficulty in fluid infusion were significantly more frequent in the infraclavicular group (21%) when compared with the supraclavicular (3%) and jugular groups (0%) (p = 0.01). There was no difference among groups in terms of catheter malposition, complications during catheterization, and rate of catheter-related infection. CONCLUSION The supraclavicular approach for subclavian vein catheterization is an acceptable alternative for central venous access during cardiac surgery in terms of procedural success rate, ease of placement, rate of complications, and usability after sternal retractor expansion.

Does left molar approach to laryngoscopy make difficult intubation easier than the conventional midline approach

Background and objective It has been reported that the left molar approach of laryngoscopy can make difficult intubation easier. The aim of this study was to investigate whether left molar approach to laryngoscopy provided a better laryngeal view in cases of unexpected difficult intubation. Methods Following the approval of local Ethics Committee and written informed consent from the patients, out of 1386 patients who underwent general anaesthesia for surgery, 20 patients who could be ventilated by face mask but could not be intubated with conventional midline approach on the first attempt were included in the study. Those 20 patients, who had Grade III‐IV laryngeal views on laryngoscopy by conventional midline approach, were subjected to left molar laryngoscopy, and their laryngeal views were evaluated. The external laryngeal compression was routinely used to improve the laryngeal view. When endotracheal intubation failed by left molar laryngoscopy, we performed the conventional midline approach again. All data were recorded. Results Of the 20 patients studied, 18 had a Grade III laryngeal view and two had a Grade IV laryngeal view. Eighteen of them had a better laryngeal view with left molar laryngoscopy. Eleven of the 20 patients underwent successful intubation with the left molar laryngoscopy, which provided a significantly better laryngeal view and success rate of tracheal intubation than did the conventional midline approach (P < 0.01 and P < 0.01, respectively). Conclusions Left molar laryngoscopy can make unexpected difficult intubation easier and should be attempted in cases of difficult intubation.

Spinal anesthesia for inguinal hernia repair in 8-year-old child with myasthenia gravis

SIR—Myasthenia gravis (MG) is an autoimmune disease characterized by weakness and fatigue of the voluntary muscles, because of the presence of acetylcholine receptor antibodies (1). The incidence is 2–10 ⁄ 100 000 cases per year (2). Children account for 11–29% of all patients with MG (3). Anesthesia concerns for MG patients focus on avoiding muscle relaxants and monitoring for postoperative respiratory failure. The use of regional or local anesthesia seems warranted whenever possible. Spinal anesthesia has advantages of reduced drug dosage, profound sensory and motor block, lack of systemic effects, avoidance of tracheal intubation and decreased need for opioid administration (4). Although spinal anesthesia is widely used in the pediatric age group, surprisingly we have not seen any report concerning its use in a myasthenic child. This report describes a pediatric case with MG, who underwent successful inguinal hernia repair under spinal anesthesia. An 8-year-old, 25-kg girl with MG presented for inguinal hernia repair. She had MG for 3 years and was classified as Osserman (5) Grade IIa with obvious ptosis and mild generalized weakness. She was taking pyridostigmine 15 mg five times daily. On the day of surgery, the morning dose of pyridostigmine was continued and no other premedication was given. An infusion of 0.5% dextrose and 0.2% sodium NaCl was given at a rate of 5 mlÆkg hÆ6 h before anesthesia and continued throughout the operation. Following the establishment of routine monitoring, the patient was sedated with 2-mg midazolam i.v. Oxygen was administered at 3 lÆmin by facemask. She was placed in a lateral decubitus position and after an additional doses of 1-mg midazolam, lumbar puncture was performed using a midline approach at the L5-S1 intervertebral space with a 27 gauge 90-mm Whitacare pencil point spinal needle (Becton Dickinson, S. Agustin del Guadalix, Madrid, Spain); 1.6 ml 0.5% hyperbaric bupivacaine was given intrathecally. In the supine position, bilateral motor block occurred within 2 min and sensory block was achieved approaching T6-7 level verified by pin prick test after 5 min. She remained comfortable and hemodynamically stable throughout the 45 min of surgery, which was uneventful. Postoperatively, she was monitored in the recovery room until regression of the sensory block and after complete resolution of the sedation she was transferred to the pediatric surgery ward. Sensory and motor function completely recovered 2 h after the surgical procedure. The patient had only one episode of nausea in the postoperative first hour and was discharged from the hospital 6 h later. Overall no complication occurred. Several studies have been published on the use of spinal anesthesia in high-risk newborns and infants at risk of postoperative apnea (6,7) and also for older children with muscular and neuromuscular disease which increase risk of postoperative respiratory failure (4). Caudal-epidural block with inhalation anesthesia is the most commonly used regional anesthetic technique in children. However, this requires a higher volume of local anesthetic and the use of inhalation anesthesia (8). Potentiation of neuromuscular blocking drugs by local anesthetics has been reported. These agents decrease the sensitivity of the postjunctional membrane to acetylcholine, which causes weakness in myasthenia. Ester anesthetics, which are metabolized by cholinesterase, may cause problems particularly in patients taking anticholinesterases. Regional and local anesthesia should be performed using reduced doses of amide, rather than ester, local anesthetics to avoid high blood levels of drug in circulation (1). Spinal anesthesia produces excellent block with light sedation levels maintaining protective airway reflexes (8) and provides an appropriate alternative regional anesthesia method. However, high-spinal anesthesia should be particularly avoided in patients with MG because it may lead to deterioration of intercostal muscle movement. Using intrathecal opioids should be avoided to minimize the risk of respiratory muscle weakness and central respiratory depression in these patients. It is controversial whether anticholinesterase therapy should be maintained or discontinued before surgery (9,10). Anticholinesterases may potentiate vagal responses and increase bronchial secretions. Anticholinesterase drugs can also inhibit plasma cholinesterase activity with a subsequent decrease in the metabolism of ester local anesthetics (9). We decided to continue anticholinesterase therapy before surgery in this patient. As the block level did not rise higher than the T6 level and respiratory reflexes were intact throughout, we did not need to administer atropine and this prevented any complication that might arise secondary to this drug. In children, sufficient duration of anesthesia for surgery is consistently less than seen in adults. In the report of Dohi et al. (11), motor function returned after a mean of 114 min in children aged over 5 years compared with 336 min in adults. The reasons are unclear but presumably include age-related differences in cerebrospinal fluid volume, diameter and surface area of the spinal cord and nerve roots and rate of absorption of local anesthetic from 1220 CORRESPONDENCE

Our experiences with spinal anesthesia in pediatric patients

OBJECTIVES The aim of this study was to evaluate the characteristics of spinal anesthesia, including its efficacy, adverse effects and complications, in order to determine if it can be applied safely in pediatric patients at high-risk for general anesthesia. We emphasize our positive outcomes in children undergoing lower abdominal surgery in our previous experience. METHODS The perioperative data of 86 pediatric patients who received spinal anesthesia between 2007 and 2008 were scanned retrospectively. Demographic data, operation types, anesthetic applications, duration of surgery, motor blockade degree, two dermatomes regression time, postoperative analgesic requirements, adverse effects, and complications were recorded. RESULTS The operation time and two dermatomes regression times were found as 49.8 ± 24.1 minutes and 73.0 ± 21.9 minutes, respectively. At the end of the operation, motor blockade had disappeared in 17 patients and persisted in 68 patients. Block time was measured as 67.3 ± 16.2 minutes in these patients. During the intraoperative period, hypotension was observed in two patients, and bradycardia occurred in one patient. Except for these, hemodynamic parameters did not change more than 20% from control values at any time. In three children, surgery was continued under general anesthesia. Forty-six patients required additional analgesic doses in the postoperative period. The time to first analgesic requirement was 2.3 ± 1.2 hours. During the postoperative period, no hemodynamic or respiratory complications were observed. CONCLUSION Spinal anesthesia continues to gain acceptance as an alternative to general anesthesia in children. However, we conclude that accumulated experience is required in order to apply this technique safely in pediatric patients. We emphasize the positive outcomes, adverse events and complications observed in our experience.