Nezih Sertoz

Relationship Between Glycosylated Hemoglobin Level and Sciatic Nerve Block Performance in Diabetic Patients

Background: The objective of the present study was to explore the effects of deficiencies in glucose regulation on the onset, regression, and block performance times in a group of patients with diabetes-related foot problems. Methods: Forty-eight patients with American Society of Anesthetists physical status 2-4 undergoing foot and ankle surgery with a popliteal fossa block were prospectively studied. Patients were stratified into cohorts based on 3 groups according to their HbA1c levels: group 1 (n = 15), HbA1c 5%-6%; group 2 (n = 16), HbA1c 7%-8%; group 3 (n = 17), HbA1c 9%-10%. A standardized local anesthetic mixture containing 10 mL of 2% prilocaine and 10 mL of 0.5% levobupivacaine was used in all study groups. The primary outcome of the study was the time for regression of the sensory block. Results: The onset times of sensory and motor blocks in group 3 were significantly longer than those in groups 2 and 1. Motor block regression time differed significantly between groups (P = .04), being longer in group 3 compared with group 1. In group 3, the sensory block regression time and the time of first analgesic use were significantly longer than the times in groups 1 and 2. Conclusions: We found that sensory block regression time was longer in diabetic patients with poor glycemic control than in the patients with better glycemic control. Longer block performance time, probably due to reduction in sensory and motor conduction velocity in diabetic patients with poor glycemic control, should be taken into consideration when peripheral nerve blocks are used. Level of Evidence: Level II, prospective comparative study.

The Effect of Head Rotation on Intraocular Pressure in Prone Position: a Randomized Trial

BACKGROUND AND OBJECTIVES The increased intraocular pressure (IOP) - which decreases perfusion pressure on the optic nerve - increases by prone positioning (1). The aim of our study was to compare the effect of head rotation 45° laterally in prone position on the increase in IOP of upper placed and lower placed eyes in patients undergoing percutaneous nephrolithotomy (PCNL). METHODS Forty-five patients were randomly divided into 2 Groups. IOP of the patients were recorded bilaterally in supine position before the operation had started. Patients were turned to prone position. The head was placed on a prone headrest without external direct compression to both eyes. Patients in Group I were kept in strictly neutral prone position where as patients in Group II were placed prone with their heads rotated 45° laterally to the right side. At the end of the operation, patients were turned to supine position and their IOP was measured immediately. RESULTS There was no difference related to demographics, duration of surgery, blood loss and fluid input data. IOP values after surgery in prone position increased significantly compared to preoperative values in both groups (p < 0.05). After surgery in prone position IOP values of the upper positioned eyes in Group II were significantly lower than Group I and lower positioned eyes in Group II (p < 0.05). CONCLUSION prone positioning increases IOP. In patients with prone position with a head rotation of 45° laterally, IOP in the upper positioned eye was significantly lower.

Effects of preoperative gabapentin on postoperative pain after radical retropubic prostatectomy.

Objective: The impact of preoperative gabapentin on tramadol consumption using patient-controlled analgesia (PCA) and postoperative pain was assessed in patients undergoing radical retropubic prostatectomy (RRP). Methods: In this prospective, randomized trial, 51 patients undergoing RRP were randomized into two groups: the gabapentin group received 900 mg gabapentin orally 2 h before surgery; the control group did not receive gabapentin. Postoperative analgesia was provided by tramadol PCA. Pain was assessed using a visual analogue scale for 24 h, postoperatively. Results: Mean cumulative tramadol consumption at 24 h was comparable in the two groups. Pain scores at 45 min, 60 min and 2 h postoperatively, and the number of patients who required rescue analgesia, were significantly lower in the gabapentin group than in the control group. Side-effects were similar in the two groups. Conclusions: Preoperative administration of 900 mg gabapentin did not decrease tramadol consumption, but was associated with lower pain scores in the early postoperative phase and a reduced need for rescue analgesia, compared with controls, in patients undergoing RRP.

Anesthetic approach to a patient with multiple pterygium (Escobar) syndrome.

SIR—We read with interest the article by Lee et al. (1) on optimum time for intravenous cannulation after induction with sevoflurane. We feel that their recommendation of 3.5 mins of sevoflurane induction after loss of eyelash reflex for problem-free intravenous cannulation may not be appropriate in all patients. This is because all patients may not be ready for cannulation at 3.5 mins as it may occasionally be prolonged depending on variables such as depth of spontaneous breathing and occasional periods of breath holding. We have been placing supraglottic device and performing intravenous cannulation in pediatric patients depending on the eye signs. We begin with gradually increasing concentrations of sevoflurane induction. While this is in progress, we watch for the eyeball movement. During initial period of induction, the eyeballs are roving from the midline and are often pulled up/down or are divergent. As anesthesia deepens, eye balls become gradually central. This generally takes 4–5 mins. It is at this stage of eye sign, which is most suited for intravenous cannulation or placement of supraglottic device without any unwanted reaction from the patient. This technique is independent of patient breathing variables and provides a clear end point for safe intervention which is tailored to the specific patient.

Peripheral nerve block in a patient with amyotrophic lateral sclerosis

To the Editor: We have used lumbar plexus and sciatic nerve blocks in an ALS patient with a collum femoris fracture. The patient was 55-year-old female who had been followed-up for the past 1.5 years for ALS with bulbar onset and upper and lower motor neuron involvement. On physical examination, jaw opening was limited, the patient was dysphonic, and, because of dysphagia, a nasogastric tube was inserted. Preoperative ALS severity score was 17 (speech, 5: frequent repeating required; swallowing, 4: supplemental tube feeding; lower extremity and walking, 4: able to support weight; upper extremity dressing and hygiene, 4: attendant assists patient) [1]. Her ALSSS score the first month postoperatively was 13. The anatomical reference points were marked for lumbar plexus and sciatic nerve blocks by the posterior approach (Winnie’s technique). An 8-cm, 17-gauge Touhy needle (Arrow, USA) was inserted and attached to a nerve stimulator (Stimuplex HNS 11, BBraun). When twitch of the quadriceps muscle and patella at 0.5 mA current was observed, a 60-cm stimulating peripheral nerve catheter (Stimucath, Arrow, International PA, USA) was placed by the lumbar plexus. A mixture of local anesthetics comprising 15 ml 0.25% levobupivacaine (Chirocaine 0.5%, Abbott, Turkey) ? 10 ml 1% prilocaine (Citanest 2%, Astra Zeneca, Turkey) was administered to the lumbar plexus via the catheter, monitoring the nerve motor response. Then, a 21-gauge, 100 mm long Stimuplex needle (Stimuplex A, BBraun, Germany) was inserted to the sciatic nerve sheet. A 0.5 mA current was given by nerve stimulator (Stimuplex HNS 11, BBraun) until plantar flexion was observed then a mixture of 10 ml 0.25% levobupivacaine and 10 ml 1% prilocaine was injected. At 20 min of the procedure, motor block score using the bromage scale was 3, and at 25 min the sensory level (T10) was determined by pin-prick and cold tests. At the fourth hour postoperatively the motor block resolved. Follow-up control visit at 3 months showed no neurological progression in terms of ALS. In neurological diseases such as ALS, regional techniques are relatively contraindicated because of mechanical trauma induced by needle or catheter, nerve ischemia as a result of supplementation of vasoconstrictor agents, and toxic effects of local anesthetics. However, more recently, researchers argue that regional techniques may be used in patients with neurological disease on the basis of risk– benefit analysis [2]. In ALS, peripheral nerve blocks have advantages over other anesthesia techniques in terms of prevention of respiratory failure due to weakness of the respiratory muscles, protection of the laryngeal reflexes, and maintaining of the hemodynamic stability [3]. Lumbar plexus and sciatic nerve blocks have disadvantages attributable to being technically challenging, late onset of anesthesia compared with neuraxial anesthesia, insufficient anesthesia, and toxicity due to use of more local anesthetic than for neuraxial anesthesia. In conclusion, we suggest that peripheral nerve blocks can be chosen as an alternative technique to neuraxial blocks and general anesthesia in ALS patients undergoing surgery on their extremities. Although we performed peripheral nerve block with a stimulating nerve catheter, ultrasound-guided nerve block with nerve stimulation could be best for regional anesthesia in ALS patients. N. Sertoz (&) S. Karaman Department of Anesthesiology and Reanimation, Ege University, School of Medicine, Izmir 35100, Turkey e-mail: nezihsertoz@mynet.com

Distal tourniquet or leg position after injection enhances the efficacy of sciatic nerve blockade by the popliteal approach.

BACKGROUND: In this study, we hypothesized that leg positioning and distal tourniquet application, when compared with neutral positioning of the leg, alters the efficacy of sciatic nerve block performed by the double-stimulation technique. METHODS: Ninety randomized, consecutive, ASA physical status I to III patients undergoing foot and ankle surgery with a popliteal fossa block (using a double-stimulation technique with the patient in prone position) were prospectively studied. Patients were randomized to have the blocked leg either kept in a neutral position immediately after the patient was turned supine (group 1), flexed 45 degrees at the thigh and maintained in that position for 15 minutes (group 2), or have a distal tourniquet applied with the leg in a neutral position and inflated during injection of the local anesthetic with the patient supine (group 3). A standardized local anesthetic mixture containing 15 mL of 2% prilocaine and 15 mL of 0.5% levobupivacaine was used in all study groups. RESULTS: The onset times for sensory and motor blocks were shorter, and the time to recovery of blocks was longer, postprocedure in both group 2 and 3. CONCLUSIONS: Similar beneficial effects might be reached with the application of a distal tourniquet during injection or elevating the patients leg turned supine immediately after sciatic nerve block with a popliteal approach by a double-injection technique. We suggest that using the leg-up position or application of a distal tourniquet for sciatic nerve block may lead to a more proximal distribution of the local anesthetic and may result in a faster onset of sensory and motor blocks as well as longer duration of blockade.

Comparison of lornoxicam and fentanyl when added to lidocaine in intravenous regional anesthesia.

BACKGROUND AND OBJECTIVES In this study, our goal was to compare intraoperative and postoperative analgesic effects of lornoxicam and fentanyl when added to lidocaine Intravenous Regional Anesthesia (IVRA) in a group of outpatients who underwent hand surgery. METHODS This is a double blind randomized study. A total of 45 patients were included, randomized into three groups. Patients in Group I (L) received 3mg.kg(-1) of 2% lidocaine 40 mL; patients in Group II (LL) received 3mg.kg(-1) lidocaine 38 mL + 2 mL lornoxicam; patients in Group III (LF) received 3mg.kg(-1) lidocaine 38 mL + 2 mL fentanyl. Our primary outcome was first analgesic requirement time at postoperative period. RESULTS Lornoxicam added to lidocaine IVRA increased the sensory block recovery time without increasing side effects and increased first analgesic requirement time at the postoperative period when compared to lidocaine IVRA (p < 0.001, p < 0.001 respectively) and fentanyl added to lidocaine IVRA (p < 0.001, p < 0.001 respectively). In addition, we also found that fentanyl decreased tourniquet pain (p < 0.01) when compared to lidocaine but showed similar analgesic effect with lornoxicam (p > 0.05) although VAS scores related to tourniquet pain were lower in fentanyl group. Lornoxicam added to lidocaine IVRA was not superior to lidocaine IVRA in decreasing tourniquet pain. CONCLUSIONS Addition of fentanyl to lidocaine IVRA seems to be superior to lidocaine IVRA and lornoxicam added to lidocaine IVRA groups in decreasing tourniquet pain at the expense of increasing side effects. However, lornoxicam did not increase side effects while providing intraoperative and postoperative analgesia. Therefore, lornoxicam could be more appropriate for clinical use.

Comparação de lornoxicam e fentanil adicionados à lidocaína em anestesia regional intravenosa

BACKGROUND AND OBJECTIVES In this study, our goal was to compare intraoperative and postoperative analgesic effects of lornoxicam and fentanyl when added to lidocaine Intravenous Regional Anesthesia (IVRA) in a group of outpatients who underwent hand surgery. METHODS This is a double blind randomized study. A total of 45 patients were included, randomized into three groups. Patients in Group I (L) received 3 mg.kg-1 of 2% lidocaine 40 mL; patients in Group II (LL) received 3 mg.kg-1 lidocaine 38 mL + 2 mL lornoxicam; patients in Group III (LF) received 3 mg.kg-1 lidocaine 38 mL + 2 mL fentanyl. Our primary outcome was fi rst analgesic requirement time at postoperative period. RESULTS Lornoxicam added to lidocaine IVRA increased the sensory block recovery time without increasing side effects and increased fi rst analgesic requirement time at the postoperative period when compared to lidocaine IVRA (p < 0.001, p < 0.001 respectively) and fentanyl added to lidocaine IVRA (p < 0.001, p < 0.001 respectively). In addition, we also found that fentanyl decreased tourniquet pain (p < 0.01) when compared to lidocaine but showed similar analgesic effect with lornoxicam (p > 0.05) although VAS scores related to tourniquet pain were lower in fentanyl group. Lornoxicam added to lidocaine IVRA was not superior to lidocaine IVRA in decreasing tourniquet pain. CONCLUSIONS Addition of fentanyl to lidocaine IVRA seems to be superior to lidocaine IVRA and lornoxicam added to lidocaine IVRA groups in decreasing tourniquet pain at the expense of increasing side effects. However, lornoxicam did not increase side effects while providing intraoperative and postoperative analgesia. Therefore, lornoxicam could be more appropriate for clinical use.