Nesrin Erciyes

A clinical comparison of equal concentration and volume of ropivacaine and bupivacaine for interscalene brachial plexus anesthesia and analgesia in shoulder surgery

Background and Objectives The aim of this study was to compare the same volume and concentration of bupivacaine and ropivacaine for interscalene brachial plexus block anesthesia and postoperative analgesia in shoulder surgery. Methods Forty-four patients scheduled for elective shoulder surgery were prospectively randomized to receive in a double-blind fashion 30 mL of either 0.5% bupivacaine or ropivacaine for interscalene block. The block was prolonged after surgery by using a patient-controlled interscalene analgesia with 0.15% of either bupivacaine or ropivacaine. The mean onset times of surgical blocks were determined after interscalene block. Pain relief was regularly assessed by using a visual analog scale, side effects were noted, and the patients were asked to rate their satisfaction at the end of the study. Results Two patients with bupivacaine and 1 with ropivacaine failed to achieve surgical block and were excluded. The mean onset times of surgical blocks were 18 ± 12 minutes with ropivacaine and 21 ± 13 minutes with bupivacaine. The pain scores, total volume infused of local anesthetics, incremental dose requested and received, total rescue analgesic, and side effects were similar between the groups. Postoperative pain control was similarly effective and patient satisfaction was high in both groups. Conclusions This study shows that the same volume and concentration of bupivacaine and ropivacaine (30 mL of 0.5%) for interscalene brachial plexus block anesthesia produce similar surgical block. When prolonging the block with a patient-controlled interscalene analgesia infusion, 0.15% bupivacaine or ropivacaine provide adequate pain relief, similar side effects, and high patient satisfaction after shoulder surgery.

A Comparison of Sister Chromatid Exchanges in Lymphocytes of Anesthesiologists to Nonanesthesiologists in the Same Hospital

An increased incidence of sister chromatid exchanges (SCEs) in peripheral lymphocytes of operating room personnel exposed to waste anesthetic gases has been reported. We investigated whether the increase of SCEs in anesthesiologists was reversible. Twenty-five anesthesiologists exposed to waste anesthetic gases such as sevoflurane and nitrous oxide were compared with nonexposed internists working in the same hospital. The concentrations of sevoflurane and nitrous oxide in the operating rooms were measured. The incidence of SCE was measured in lymphocytes cultures of anesthesiologists before and after a 2-mo leave from the operating room. These values of SCE were compared with those of nonexposed physicians. Occupational exposure to sevoflurane and nitrous oxide in the operating rooms were above the threshold values. There was a significant difference in SCE values of the anesthesiologists compared with the nonexposed physicians (11.9 ± 4.4 versus 4.2 ± 1.1, P < 0.001). After a 2-mo leave from the operating room, the SCE values of the anesthesiologists were significantly lower compared with those taken before the leave (4.8 ± 1.8 and 11.9 ± 4.4, respectively, P < 0.001). We conclude that the increase of SCE in anesthesiologists exposed to increased environmental concentrations of waste anesthetics gases, such as sevoflurane and nitrous oxide, are reversible if they work free from exposure for 2 mo.

A Patient with Glanzmann's Thrombasthenia for Emergent Abdominal Surgery

Glanzmann’s thrombasthenia is a rare autosomal recessive disease characterized by potentially major mucocutaneous complications and nose bleeds. It is considered hazardous for these surgical patients to conceive, with a high risk of urgent surgery. The treatment of bleeding or prevention of hemorrhage for surgery or invasive procedures is based on platelet transfusion. However, platelet transfusions may be responsible for the development of alloimmunization, with a high risk of future platelet refractoriness. We report a surgical case of Glanzmann’s thrombasthenia complicated by nasopharyngeal bleeding and managed with platelet transfusions, recombinant activated factor VII, and postoperative airway management in the intensive care unit.

Acute stress bleeding prophylaxis with sucralfate versus ranitidine and incidence of secondary pneumonia in intensive care unit patients

Sir: It is well established that alkalinization of the gastric juice with H2-receptor antagonists causes colonization of the stomach with aerobic Gram-negative bacilli, which then facilitate colonization of the hypopharynx and tracheo-bronchial tree [1] leading to an increased risk of pneumonia [2]. Therefore an alternative approach of stress bleeding prophylaxis would be with a method which has little or no effect on gastric pH. So thirty one critically ill patients were studied prospectively in intensive care unit (ICU) to determine the frequency of stress ulceration bleeding, and secondary pneumonia. The patients were randomly assigned to receive either sucralfate (n = 15) 2 g every 6 hrs via the nasogastric tube or ranitidine (n = 16) intravenously (100 mg every 8 h). Patients who received sucralfate had an unexpectedly high mean gastric pH 4.9. This finding may be partially due to gastric exocrine failure which occurs in such patients [3]. Ranitidine therapy still produced a significantly more alkaline mean gastric pH 6.1 and this was statistically significant as compared with sucralfate treated patients (p < 0.01). The more alkaline gastric pH in ranitidine treated-patients permitted more frequent gastric colonization by Gram-negative bacilli as compared to sucralfate-treated patients (50 versus 26%) but this was not significant statistically (p > 0.05). The colonization of the oropharynx (56.2~ versus 40%) and the tracheostomy (68.7 versus 53%) in patients treated with ranitidine was more frequent than that of sucralfatetreated patients, and the difference between two groups was not significant statistically (p > 0.05). The colonization of the oropharynx and the tracheostomy were obviously more frequent than the bacterial colonization of the stomach, this could be attributed to uncontrolled exogenous contamination and frequent cross-infection in patient of ICU. The incidence of secondary pneumonia was more frequent in ranitidine-treated patient group compared with sucralfate-treated patients (56 versus 20%) and the difference between the two groups was statistically significant (p<0.05) but the isolated microorganism from tracheostomy and endotracheal tube samples was not necessary of the gastric origin. Only three patients treated with ranitidine (18.5%), and one patient treated with sucratfate (6.5070) have had secondary pneumonia caused by the same bacterial agent isolated for the stomach. There was only one case of gastro-intestinal bleeding due to stress gastritis in ranitidine-treated group, detected clinically, which was treated conservatively with no requirement of surgical intervention. These results are comparable with that of other investigators [4, 5] who demonstrated an increased frequency of pneumonia in ranitidine-treated patients. In ICU patients, sucralfate is as effectice as ranitidine, in the prevention of stress ulceration. However, gastric bacterial colonization is significantly reduced with substantial reduction in the frequency of secondary pneumonias. Therefore, the routine use of sucralfate as prophylaxis for stress ulceration and gastrointestinal bleeding in ICU patients is recommended.

Morphine/prilocaine combination for intravenous regional anesthesia

In this study we aimed to investigate clinically whether morphine acts on the peripheral nervous system directly. Twenty adult patients, who were scheduled for upper extremity surgery under tourniquet, had intravenous regional anesthesia. They were divided into two groups: one group was given 30 ml of 1% prilocaine plus 10 ml of 0.9% sodium chloride (P group) and the other group was given 30 ml of 1% prilocaine plus 6 mg morphine sulfate in 10 ml of 0.9% sodium chloride (P/M group). The onset of analgesia and anesthesia and recovery from anesthesia and analgesia were investigated in both groups. In the P/M group, the onset of analgesia and anesthesia was statistically faster and the recovery from anesthesia and analgesia was statistically slower than in the P group (P<0.05). We conclude that morphine is clinically effective in the peripheral nervous system at this dosage range.

Delayed respiratory depression after risperidone overdose.

Risperidone is an atypical antipsychotic drug used for the treatment of schizophrenia. Both positive and negative symptoms are prominent with its use. Metabolism occurs mainly in the liver, where risperidone is changed by CUP2D6 to an active metabolite, 9-hydroxyrisperidone. The half-lives of risperidone and its metabolite are 3 and 7 h, respectively. Genetic polymorphism is seen in the 6%-8% of white patients who are considered poor metabolizers. In poor metabolizers, the half-life extends to 20-30 h. We present an unusual case of unanticipated delayed respiratory depression after risperidone overdose.

Multiple Dose-Activated Charcoal as a Cause of Acute Appendicitis

We presented a case of a 55-year-old woman who intentionally ingested an unknown amount of carbosulfan, a carbamate insecticide. On admission, her clinical findings were coma, pinpoint pupils, hypersalivation, respiratory failure, bradycardia, and hypotension. Her trachea was intubated after suction of secretions, and atropine was administered intravenously. After gastric lavage, multiple doses of activated charcoal were instilled through the nasogastric tube over five days (total doses of 840 g). On the fourteenth day, she developed right-lower quadrant abdominal pain, anorexia, nausea, and vomiting, and she underwent an appendectomy. On pathologic examination of the specimen, particles of activated charcoal were seen within the dilated part of the appendiculer lumen. The patient was discharged from the hospital after antidepressant therapy at the psychiatry clinic. This case documents that multiple doses of activated charcoal may be associated with acute appendicitis.