Omer Karaca

Effects of Single-Dose Preemptive Pregabalin and Intravenous Ibuprofen on Postoperative Opioid Consumption and Acute Pain after Laparoscopic Cholecystectomy

ABSTRACT Purpose: Non-opioid medications as a part of multimodal analgesia has been increasingly suggested in the management of acute post-surgical pain. The present study was planned to compare the efficacy of the combination of pregabalin plus ıv ibuprofen. Methods: 58 patients were included in this prospective, randomized, double-blinded study. The pregabalin group (Group P, n = 29) received 150 mg pregabalin, the pregabalin plus ibuprofen group (Gropu PI, n = 29) received 150 mg pregabalin and 400mg ıv ibuprofen before surgery. Postoperative fentanyl consumption, additional analgesia requirements and PACU stay were recorded. Postoperative analgesia was performed with patient-controlled IV fentanyl. Results: VAS scores in the group PI were statistically lower at PACU, 1and 2 hours at rest, at PACU, 1, 2, 4, 12 and 24 hours on movement compared to the group P (P < 0.05). Opioid consumption was statistically significantly higher in the group P compared to the group PI (130.17 ± 60.27 vs 78.45 ± 60.40 μq, respectively, P < 0.001) and reduced in the 4th 24 hours by 55% in group PI. Rescue analgesia usage was statistically significantly higher in the group P than in the group PI (16/29 vs 7/29, respectively, P < 0.001). Four patient in the group PI did not need any opioid drug. Besides, PACU stay was shorter in the group PI than the group P (10.62 ± 2.38 vs 15.59 ± 2.11 min, respectively, P < 0.001). Conclusion: Preemptive pregabalin plus ıv ibuprofen in laparoscopic cholecystectomy reduced postoperative opioid consumption. This multimodal analgesic aproach generated lower pain scores in the postoperative period.

Efficacy of ultrasound-guided modified thoracolumbar interfascial plane block for postoperative analgesia after spinal surgery: a randomized-controlled trial

To the Editor, Surgery of the lumbar spine is characterized by diffuse and severe postoperative pain. Pre/postoperative oral opioids, gabapentinoids, nonsteroidal antiinflammatory drugs, and intraoperative ketamine are frequently included in multimodal analgesia for spinal surgery, while regional anesthetic techniques such as neuraxial anesthesia, paravertebral blocks, and local anesthetic infiltration of the wound are less frequently used. Interfascial plane blocks have the potential to provide long-lasting postoperative analgesia and reduce opioid consumption while minimizing the motor block associated with neuraxial and plexus blocks. The thoracolumbar interfascial plane (TLIP) block, first described by Hand et al., targets the dorsal roots of the thoracolumbar nerves by depositing local anesthetic at the level of third lumbar vertebra between the multifidus and longissimus muscles. We modified Hand’s TLIP technique by injecting between the longissimus and iliocostalis muscles. We believe this is simpler to perform and reduces the risk of neuraxial puncture. The aim of this study was to investigate the effect of the modified TLIP block on postoperative opioid consumption and pain scores in patients undergoing spinal surgery. The study was registered with ClinicalTrials.gov (NCT03079076). Following approval by the Ataturk University Medical Ethics Board (Erzurum, Turkey, 24.10.2016/7) written, informed consent was obtained from 40 patients, aged 1865 yrs, American Society of Anesthesiologists physical status I-III, scheduled for twoor three-level posterior lumbar instrumentation surgery. Patients were randomly assigned to control or TLIP groups using a computer software program. Those in the control group (n = 20) received bilateral ultrasound-guided injections of 2 mL 0.9% saline subcutaneously; those in the TLIP group (n = 20) received ultrasound-guided bilateral modified TLIP block with 20 mL 0.25% bupivacaine as described here. A successful block was defined as loss of cold sensation in the T7-L1 dermatomes 20 min after block application. All patients received a standardized anesthetic and following surgery were offered patient-controlled analgesia (PCA) using fentanyl. The PCA was programmed with a 25-lg bolus and ten-minute locked time, without basal infusion, and continued for 24 hr. The primary outcome was fentanyl consumption at 24 hr. Secondary outcomes included visual analogue pain scores on arrival to the postanesthesia care unit, then at one, two, four, eight, 12, and 24 hr after surgery. Requests for supplementary analgesia and the occurrence of nausea and vomiting were also recorded. The primary outcome was compared using an unpaired Student’s t test. Visual analogue scale scores over time were compared with repeated measurements analysis of A. Ahiskalioglu, MD (&) O. Doymus, MD K. Selvitopi, MD H. A. Alici, MD Department of Anaesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey e-mail: aliahiskalioglu@hotmail.com

Can neutrophil-lymphocyte ratio be a predictor of cerebral vasospasm in patients with subarachnoid hemorrhage?

This study aimed to investigate the relationship between neutrophil-lymphocyte ratio (NLR) and development of vasospasm in patients with aneurysmal subarachnoid hemorrhage (SAH). Materials and Methods The study was performed by retrospectively analyzing the data of 170 aneurysmal SAH patients who admitted to the intensive care unit of our hospital between 2011 and 2017. We investigated the ability of NLR values calculated from the blood samples taken at the time of admission to predict for vasospasm. Results Thirty-five percent of the patients developed vasospasm. NLR values were associated with the development of vasospasm (OR 1.15; 95% confidence interval, 1.09-1.22; p

The effect of spinal versus general anesthesia on intraocular pressure in lumbar disc surgery in the prone position: A randomized, controlled clinical trial

OBJECTIVE To compare IOP changes between spinal anesthesia (SA) and general anesthesia (GA) in patients who underwent lumbar disc surgery in the prone position. DESIGN Prospective, randomized, controlled trial. SETTING Operating room. PATIENTS Forty ASA I-II patients scheduled for lumbar disc surgery in prone position. INTERVENTION Patients were randomly allocated to the SA or GA groups. MEASUREMENTS IOP was measured before anesthesia (IOP1), 10 min after spinal or general anesthesia in supine position (IOP2), 10 min after being placed in the prone position (IOP3), and at the end of the operation in the prone position (IOP4). MAIN RESULTS There was no significant difference between baseline IOP1 (group GA = 19.4 ± 3.2 mmHg; group SA = 18.6 ± 2.4 mmHg) and IOP2 values (group GA = 19.7 ± 4.1 mmHg; group SA = 18.4 ± 1.9 mmHg) between and within the groups. IOP values after prone positioning and group GA measurements (IOP3 = 21.6 ± 3.1 mmHg; IOP4 = 33.9 ± 3.1 mmHg) were significantly higher when compared with the SA group (IOP3 = 19.3 ± 2.7 mmHg, IOP4 = 26.9 ± 2.4 mmHg) (p = 0.018 and p < 0.001, respectively). Furthermore, IOP3 was significantly increased when compared with IOP2 in the GA group but not in the SA group (p = 0.019 and p = 0.525, respectively). In both groups, IOP4 values were significantly higher than the other three measurements (p < 0.001). CONCLUSION The results indicated that IOP increase is significantly less in patients who undergo lumbar disc surgery in the prone position under SA compared with GA.

The Efficacy of Ultrasound-guided Type-I and Type-II Pectoral Nerve Blocks for Postoperative Analgesia after Breast Augmentation: A Prospective, Randomised Study

PURPOSE The present study was planned to evaluate the efficacy and safety of ultrasound-guided Pecs I and II blocks for postoperative analgesia after sub-pectoral breast augmentation. METHODS Fifty-four adult female patients undergoing breast augmentation were randomly divided into two groups: the control group (Group C, n=27) who were not subjected to block treatment and Pecs group (Group P, n=27) who received Pecs I (bupivacain 0.25%, 10mL) and Pecs II (bupivacain 0.25%, 20mL) block. Patient-controlled fentanyl analgesia was used for postoperative pain relief in both groups, and the patients were observed for the presence of any block-related complications. RESULTS The 24-h fentanyl consumption was smaller in Group P [mean±SD, 378.7±54.0μg and 115.7±98.1μg, respectively; P<0.001]. VAS scores in Group P were significantly lower at the time of admission to the post-anaesthetic care unit and at 1, 2, 4, 8, 12, and 24h (P<0.001). The rates of nausea and vomiting were higher in Group C than in Group P (9 vs 2, P=0.018). Hospital stay duration was shorter in Group P than in Group C (24.4±1.2h vs 27.0±3.1h, P<0.001). No block-related complications were recorded. CONCLUSIONS Combine used of Pecs I and II blocks provide superior postoperative analgesia in patients undergoing breast augmentation and shortens hospital stay.

Effects of Addition of Preoperative Intravenous Ibuprofen to Pregabalin on Postoperative Pain in Posterior Lumbar Interbody Fusion Surgery

Objective Ibuprofen and pregabalin both have independent positive effects on postoperative pain. The aim of the study is researching effect of 800 mg i.v. ibuprofen in addition to preoperative single dose pregabalin on postoperative analgesia and morphine consumption in posterior lumbar interbody fusion surgery. Materials and Methods 42 adult ASA I-II physical status patients received 150 mg oral pregabalin 1 hour before surgery. Patients received either 250 ml saline with 800 mg i.v. ibuprofen or saline without ibuprofen 30 minutes prior to the surgery. Postoperative analgesia was obtained by morphine patient controlled analgesia (PCA) and 1 g i.v. paracetamol every six hours. PCA morphine consumption was recorded and postoperative pain was evaluated by Visual Analog Scale (VAS) in postoperative recovery room, at the 1st, 2nd, 4th, 8th, 12th, 24th, 36th, and 48th hours. Results Postoperative pain was significantly lower in ibuprofen group in recovery room, at the 1st, 2nd, 36th, and 48th hours. Total morphine consumption was lower in ibuprofen group at the 2nd, 4th, 8th, 12th, and 48th hours. Conclusions Multimodal analgesia with preoperative ibuprofen added to preoperative pregabalin safely decreases postoperative pain and total morphine consumption in patients having posterior lumbar interbody fusion surgery, without increasing incidences of bleeding or other side effects.

A Forgotten but Important Drug on Preanaesthetic Evaluation: Amiodarone

Dear Editor, The purpose of preoperative evaluation is to reduce perioperative morbidity and mortality by guiding the anaesthesia plan. All the medications that the patient has used recently and the allergic reactions should be completely known for an effective preoperative evaluation. In this case, we attempted to emphasize that the patients using amiodarone in the preoperative period are under the risk of thyroid dysfunction, and the thyroid functions are absolutely required to be evaluated before surgery. A 50-year-old male patient applied to our anaesthesia polyclinic for a pre-anaesthetic visit for the purpose of elective cholecystectomy. Although the patient did not have any known thyroid dysfunction previously, he had a history of the use of amiodarone among the drugs he used previously; thus, the thyroid functions were examined and the results were as follows: TSH: 0.04 μIU mL−1 (0.34–5.36), fT4: 2.28 ng dL−1 (0.61–1.12) and fT3: 3.36 pg dL−1 (2.5–3.9). When the medical records of the patient were checked, it was observed that he was hospitalized in the cardiology clinic because of ventricular tachycardia 6 months ago, and the thyroid functions were normal during hospitalization. Intravenous amiodarone infusion was administered to the patient with ventricular arrhythmias and continued for 3 days. Then, a 200-mg tablet was prescribed to be used for 3 months. After the patient used amiodarone 200 mg for 3 months, the medication was discontinued under the supervision of a cardiologist. The patient did not use amiodarone for 3 months. Considering that thyroid dysfunction was associated with amiodarone, after the consultation of endocrinology specialists, antithyroid treatment was started and the elective surgery procedures were not selected until the patient became euthyroid. Amiodarone is an antiarrhythmic drug that is widely used, has a broad spectrum, is used in the treatment of all ventricular and atrial arrhythmias and contains iodine. The medicament that is the derivative of benzofuran contains iodine as much as 37% of its weight and is structurally similar to the thyroid hormone (1). After taking a 200-mg tablet that contains approximately 75 mg of iodine, 6 mg of iodine release is achieved per day. Normally, if the recommended daily intake of iodine is considered, the 200-mg tablet causes approximately 20 times more iodine release than the daily iodine intake. Because it is fat-soluble, it has a half-life that may take up to approximately 100 days. After the discontinuation of the drug, its effect still continues. Thyroid dysfunction may develop in 2%–10% of the patients using amiodarone. This rate may be higher in communities where the iodine intake is low (2). Thyrotoxicosis associated with amiodarone may generally develop in the early periods of amiodarone therapy or months or even years after the discontinuation of medication. Two types of thyrotoxicosis related to amiodarone have been identified. Type 1 generally occurs in those with thyroid disease, generally on the basis of nodular or diffuse goitre. Synthesis of T3 and T4 has increased. Perchlorate and methimazole are used in Type 1 amiodarone hyperthyroidism. Type 2 occurs in patients who had no thyroid function disorder previously. Excessive secretion of T3 and T4 occurs because of destructive thyroiditis (3). If the clinical picture is progressing slightly in Type 2, for a period, spontaneous remission can be awaited. If a much more severe clinical picture than the beginning has developed and a sufficient improvement is not seen, corticosteroid therapy is initiated. In the literature, because of amiodarone-induced thyrotoxicosis, cases that show a fatal course during anaesthesia have been reported (4). Thyroidectomy may be necessary in patients in whom medical therapy has failed. There are patients who underwent thyroidectomy with regional anaesthesia techniques in the literature (5). Before and during the amiodarone treatment, thyroid function tests of the patients should be viewed and checked in intervals of at least 3 months. As the total body iodine stores remain high for 9 months after the amiodarone therapy is discontinued, the follow-up period should increase to at least up to 9 months. Because thyroid dysfunction may develop after the discontinuation of the treatment, it is recommended that the thyroid function tests should be performed at least once a year. Hyperthyroidism caused by amiodarone can develop in patients with underlying thyroid disease with a single dose in the early stages, and it may develop months after the discontinuation of amiodarone therapy, as in our patient. The history of an antiarrhythmic drug such as amiodarone should be questioned during the pre-anaesthetic visit. Thyroid function tests of the patients taking amiodarone should absolutely be assessed regardless of the type of surgery that they will undergo.

Malposition of Subclavian Vein Catheter: A case report and review of literature -

The insertion of central venous catheter (CVC) is used for different purposes among the patients. Seldinger method is the most common percutaneous access method for CVC insertion. During this procedure, direction of the catheter to an unwanted vein is a rare, but a serious complication. In order to reduce complications, it is essential that the staff applying the central venous catheterization should be experienced; use the accurate technique and the location of the catheter be displayed by using radiological method after the procedure. We aimed to discuss the malposition of the CVC in two cases in the light of the information in the literature.

Can ondansetron be used in the treatment of subdural block

Caudal epidural block is an adjunct to general anesthesia to provide postoperative analgesia particularly in pediatric patients undergoing infraumbilical, perineal and lower extremity surgery [1]. As with other neuroaxial techniques, subdural block can also occur associated with caudal anesthesia. However, there are no clear guidelines in the treatment of subdural block [2]. This report presents a pediatric case with subdural block that showed rapid recovery after IV ondansetron administration.