Ozkan Onal

Prophylactic Ozone Administration Reduces Intestinal Mucosa Injury Induced by Intestinal Ischemia-Reperfusion in the Rat.

Objectives. Intestinal ischemia-reperfusion injury is associated with mucosal damage and has a high rate of mortality. Various beneficial effects of ozone have been shown. The aim of the present study was to show the effects of ozone in ischemia reperfusion model in intestine. Material and Method. Twenty eight Wistar rats were randomized into four groups with seven rats in each group. Control group was administered serum physiologic (SF) intraperitoneally (ip) for five days. Ozone group was administered 1 mg/kg ozone ip for five days. Ischemia Reperfusion (IR) group underwent superior mesenteric artery occlusion for one hour and then reperfusion for two hours. Ozone + IR group was administered 1 mg/kg ozone ip for five days and at sixth day IR model was applied. Rats were anesthetized with ketamine∖xyzlazine and their intracardiac blood was drawn completely and they were sacrificed. Intestinal tissue samples were examined under light microscope. Levels of superoxide dismutase (SOD), catalase (CAT), glutathioneperoxidase (GSH-Px), malondyaldehide (MDA), and protein carbonyl (PCO) were analyzed in tissue samples. Total oxidant status (TOS), and total antioxidant capacity (TAC) were analyzed in blood samples. Data were evaluated statistically by Kruskal Wallis test. Results. In the ozone administered group, degree of intestinal injury was not different from the control group. IR caused an increase in intestinal injury score. The intestinal epithelium maintained its integrity and decrease in intestinal injury score was detected in Ozone + IR group. SOD, GSH-Px, and CAT values were high in ozone group and low in IR. TOS parameter was highest in the IR group and the TAC parameter was highest in the ozone group and lowest in the IR group. Conclusion. In the present study, IR model caused an increase in intestinal injury.In the present study, ozone administration had an effect improving IR associated tissue injury. In the present study, ozone therapy prevented intestine from ischemia reperfusion injury. It is thought that the therapeutic effect of ozone is associated with increase in antioxidant enzymes and protection of cells from oxidation and inflammation.

Spinal anaesthesia for orthopaedic surgery in children with cerebral palsy: Analysis of 36 patients

Background and Objective: Cerebral palsy is one of the most common childhood neuromuscular diseases in the world. Spinal anaesthesia in children is an evolving technique with many advantages in perioperative management. The aim of this retrospective study was to provide first-hand reports of children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia. Methods: Records of the children with cerebral palsy who underwent orthopaedic surgery under spinal anaesthesia between May 2012 and June 2013 at Selcuk University Hospital were investigated. In all patients, lumbar puncture was performed in lateral decubitus position with mask sevoflurane-nitrous oxide anaesthesia. In patients who were calm prior the spinal block, inhalation anaesthesia was terminated. In patients who were restless before the spinal block, anaesthesia was combined with light sevoflurane anaesthesia and a laryngeal mask. From anaesthesia records, the number of attempts required to complete the lumbar puncture, and the success rates of spinal anaesthesia and perioperative complications were noted. Data were expressed as numbers and percentages. Results: The study included 36 patients (20 girls and 16 boys). The mean age was 71 months. The rate of reaching subarachnoid space on first attempt was 86%. In all patients, spinal anaesthesia was considered successful. In 26 patients, laryngeal mask and light sevoflurane anaesthesia were required to maintain ideal surgical conditions. No major perioperative complications were observed. Conclusion: Spinal anaesthesia alone or combined with light sevoflurane anaesthesia is a reliable technique with high success rates in children with cerebral palsy undergoing orthopaedic surgery.

Pulsed Radiofrequency of Dorsal Root Ganglia for the Treatment of Complex Regional Pain Syndrome in an Adolescent with Poliomyelitis Sequel: A Case Report

OBJECTIVE Complex regional pain syndrome (CRPS) is a painful and disabling syndrome in which the patient presents with neuropathic pain, edema, or vasomotor or pseudomotor abnormalities that are often refractory to treatment. Polio paralysis is caused by the damage or destruction of motor neurons in the spine, which lead to corresponding muscle paralysis. This report is a case report on the application of a pulsed radiofrequency (PRF) current to dorsal root ganglia (DRG) for the treatment of CRPS type 1 in an adolescent patient. DESIGN Single case report. SETTING Selcuk University Hospital. PATIENT A 16-year-old girl who suffered from CRPS type 1 secondary to surgeries for the sequelae of poliomyelitis. INTERVENTIONS PRF current application to the lumbar 4 and lumbar 5 DRG. OUTCOME MEASURES Pain reduction. RESULTS The patient had complete resolution of her symptoms, which was maintained at a 6-month follow-up. CONCLUSIONS This case illustrates that PRF applied to lumbar 4 and lumbar 5 DRG may play a significant role in CRPS type 1 management after the surgical treatment of poliomyelitis sequelae in adolescent patients. Further randomized, controlled studies are needed to support this argument.

The protective effect of prophylactic ozone administration against retinal ischemia-reperfusion injury.

Abstract Introduction: Retinal ischemia-reperfusion (IR) injury is associated with many ocular diseases. Retinal IR injury leads to the death of retinal ganglion cells (RGCs), loss of retinal function and ultimately vision loss. The aim of this study was to show the protective effects of prophylactic ozone administration against retinal IR injury. Materials and methods: A sham group (S) (n = 7) was administered physiological saline (PS) intraperitoneally (i.p.) for 7 d. An ischemia reperfusion (IR) group (n = 7) was subjected to retinal ischemia followed by reperfusion for 2 h. An ozone group (O) (n = 7) was administered 1 mg/kg of ozone i.p. for 7 d. In the ozone + IR (O + IR) group (n = 7), 1 mg/kg of ozone was administered i.p. for 7 d before the IR procedure and at 8 d, the IR injury was created (as in IR group). The rats were anesthetized after second hour of reperfusion and their intracardiac blood was drawn completely and they were sacrificed. Blood samples were sent to a laboratory for analysis of superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), malondialdehyde (MDA), total oxidant score (TOS) and total antioxidant capacity (TAC). The degree of retinal injury was evaluated according to changes in retinal cells and necrotic and apoptotic cells using the TUNEL method. Data were evaluated statistically with the Kruskal-Wallis test. Results: The number of RGCs and the inner retinal thickness were significantly decreased after ischemia, and treatment with ozone significantly inhibited retinal ischemic injury. In the IR group, the degree of retinal injury was found to be the highest. In the O + IR group, retinal injury was found to be decreased in comparison to the IR group. In the ozone group without retinal IR injury, the retinal injury score was the lowest. The differences in the antioxidant parameters SOD, GSH-Px and TAC were increased in the ozone group and the lowest in the IR group. The oxidant parameters MDA and TOS were found to be the highest in the IR group and decreased in the ozone group. Discussion: IR injury is also positively correlated with the degree of early apoptosis. This study demonstrated that ozone can attenuate subsequent ischemic damage in the rat retina through triggering the increase of the antioxidant capacity.

Myocardial Infarction in a Young Patient After Acute Exposure to Carbon Monoxide

Carbon monoxide (CO) is an odorless, colorless, clear gas that attaches to the hemoglobin (Hb). Its affinity for Hb is approximately 200 times higher than that of oxygen, and CO blocks the capacity of Hb to carry oxygen (1). One of the most important effects of CO is tissue hypoxia, especially in the parts of tissues with the highest demand for oxygen and the lowest metabolic stores, such as the brain and heart, which are therefore more vulnerable. CO intoxications are usually expressed as neurological events, but cardiological events can also occur (2). Myocardial injury may arise via electrical, functional, and morphological changes in the heart through severe general tissue hypoxia; there may be a direct toxic effect on the myocardial mitochondria promptly after exposure, or this may be delayed for several days (3). CO can induce a tendency toward coronary vasospasm and thrombus formation by slowing the bloodstream, increasing the permeability of the vessel walls, and increasing platelet aggregability and polycythemia; these factors are also responsible for myocardial damage in patients with CO poisoning (4). In addition, oxygen radical formation and subsequent lipid peroxidation, as well as induction of cellular apoptosis, are also potential explanations for the cardiotoxicity of CO (2, 5). Cardiac involvement encompassing angina attack, myocardial infarction, heart failure, cardiogenic shock, and arrhythmias, such as ventricular extrasystoles, atrial fibrillation, bradycardia, and atrioventricular block in CO poisoning was first noted by Lippi (5). However, 50% or more of the circulating form of carboxyhemoglobin can lead to patchy myocardial necrosis, a CO-Hb level of ≥ 25% is considered an indication for the use of hyperbaric oxygen or advanced treatment (6, 7). Acute myocardial infarction (AMI) is a clinical condition occurring suddenly but resulting from a long-term decrease in the amount of oxygen present in the myocardium. Its most common cause is atherosclerotic disease of the coronary arteries. AMI associated with CO poisoning occurs very rarely. In this letter, a young person who did not have known coronary atherosclerotic disease and had AMI due to exposure to CO is presented with the aim of drawing attention to the fact that CO poisoning which occurs commonly throughout the world may lead to AMI. A 27-year-old male patient lost consciousness while struggling against fire in the workplace and entered cardiac arrest. After undergoing resuscitation by the 112 emergency service, he was brought to emergency intubated with unconscious and admitted. Upon admission to the hospital, ventilation with 100% oxygen was continued. The patient’s Glasgow coma score was 4, and noradrenaline infusion was initiated owing to hypotension. Arterial blood gas analysis was performed, and a CO-Hb value of 22% was detected. On initial electrocardiogram (ECG), ventricular tachycardia and other alterations were observed. The patient was diagnosed with anteroseptal AMI. Emergency angiographic and primary percutaneous interventions were performed; it was observed that Left anterior descending (LAD) as completely obstructed, (Figures 1 and 2) and a stent was placed (Figures 3 and 4). The patient further stabilized and was prepared for and transferred to hyperbaric oxygen therapy. Thorax computed tomography (CT) was taken and pneumothorax and trachea rupture was observed, probably due to resuscitation. No intervention was considered necessary except for chest tube insertion by the Chest Surgery Department The patient was extubated on the 11th day after admission to intensive care unit and transferred to the infectious diseases clinic. Identifying cardiotoxicity in patients with CO poisoning can be difficult. This report of a rare case should remind physicians

Comments on “Local Anesthetic Systemic Toxicity”

We read with interest the article by Dickerson and Apfelbaum entitled “Local Anesthetic Systemic Toxicity.”1 The local anesthetics in clinical practice today are of 2 classes: amino esters and amino amides.2,3 These 2 classes differ not only in chemical structure but also in metabolism and potential for allergic reaction and toxicity.2 Esters include cocaine, procaine, 2-chloroprocaine, tetracaine, and benzocaine. …

The effectiveness of trendelenburg positioning on the cross-sectional area of the right internal jugular vein in obese patients.

Objective: Trendelenburg positioning is a common approach used during internal jugular vein (IJV) cannulation. No evidence indicates that Trendelenburg positioning significantly increases the cross-sectional area (CSA) of the IJV in obese patients. The primary aim of this study was to determine the effectiveness of Trendelenburg positioning on the CSA of the right internal jugular vein assessed with ultrasound measurement in obese patients. Methods: Forty American Society of Anesthesiologists II patients with body mass index ≥30 kg/m2 undergoing various elective surgeries under general endotracheal anesthesia were enrolled. Ultrasound images of the right IJV were obtained in a transverse orientation at the cricoid level. We measured the CSA of the right IJV two different conditions in a sealed envelope were applied in random order: State 0, table flat (no tilt), with the patients in the supine position, and State T, in which the operating table was tilted 20° to the Trendelenburg position. Results: The change in the CSA of the IJV from the supine to the Trendelenburg position (1.80 cm2 vs 2.08cm2) was not significantly different. The CSA was paradoxically decreased in 10 of 36 patients when the position changed from State 0 to State T. Conclusions: Trendelenburg positioning does not significantly increase the mean CSA of the right IJV in obese patients. In fact, in some patients, this position decreases the CSA. The use of the Trendelenburg position for IJV cannulation in obese patients can no longer be supported.

Caudal Anesthesia for Open Bladder Surgery in High-Risk Adolescent With Scoliosis and Neural Tube Defect

Dear Editor, This letter describes the successful use of caudal anesthesia for open bladder surgery, in a patient with advanced scoliosis and a severe form of spina bifida cystica, which had been operated during childhood. He had preserved neurological function, without neurogenic bladder. A 16-year-old boy weighing 40 kg, conscious, cooperative and oriented, Mallampati class І, American Society of Anesthesiologists (ASA) physical status ІІІ, who had restricted lung function, because of advanced scoliosis (forced vital capacity below 45% and scoliotic curves exceeding 90 - 100°), required the open bladder operation because of recurrent calculus formation. He had been operated for neural tube defect and hydrocephalus, when he was one year old, and he had advanced scoliosis. Before the surgery, as we considered that extubation of trachea, after using muscle relaxants and anesthetics, in such a weak and deformed chest, with impaired mechanics, would be very difficult, regional anesthesia was planned (Figure 1). Regional anesthesia is kept in mind for children who are at high risk from general anesthesia (1). The parents were given information on regional and general anesthesia and their written informed consent was obtained. In the operating room, the patient underwent continuous electrocardiogram, pulse oximetry and noninvasive blood pressure monitoring. Patient’s preoperative vital signs and laboratory tests were normal. Parameters were recorded every 5 minutes. Hydration was started with lactated ringers intravenously at a rate of 100 mL/hour, considering that the excess fluid may impair lung function even more. Due to the presence of advanced scoliosis and the history of a neural tube defect operation, spinal anesthesia was not attempted. Bearing in mind that general anesthesia would be risky, although the operation was vital, and in view of the probability of the caudal space not being closed, a caudal block was attempted. The caudal space was entered with a 20-gauge needle and a 1:1 mixture of 25 mL of 0.25% bupivacaine (0.5% Marcaine, Zentiva, Istanbul, Turkey) with physiologic serum was injected slowly, after sedation with 30 mg propofol. Surgery was initiated 10 minutes from the block, after it was confirmed by pinprick that the patient did not feel pain in the subumbilical area, and the operation lasted for two hours. Approximately 50 cc blood loss was seen and no intraoperative impairment was encountered. For sedation and amnesia, 2 mg midazolam (Dormicum, Roche, Istanbul, Turkey) were administered. Spontaneous breathing was maintained with supplementary oxygen through a facemask, during the operation. The patient was asleep during the procedure and did not require additional sedation. Paracetamol (Parol, Atabay, Istanbul, Turkey) 20 mg/kg was infused for postoperative antipyretic effect, during the first 20 minutes of surgery and for postoperative analgesia. No perioperative complications (such as hypertension, tachycardia, bradycardia, hypoxemia, or apnea) were observed during surgery, and the patient felt no pain for 8 hours postoperatively, while caudal block returned after 8 hours. The patient was discharged from the hospital uneventfully, the day after the operation. Scoliosis is a disease in which anesthetic management is often difficult, as a result of muscle weakness and hypersensitivity to neuromuscular blocking agents. Patients with spinal deformities are at high risk for morbidity, because of immobilization hypercalciuria, recurrent nephrolitiasis, urinary stasis, and urinary tract infection (2). Recurrent urinary tract stones are a difficult problem in patients with spinal deformities, because of the higher rate of complications and technical difficulties (3). Pain control choices are limited for individuals with spinal dysraphism, who undergo major urologic procedures (4). Viscomi et al. (5) suggested spinal anesthesia for operations in patients with myelomeningocele. However, this suggestion viable only for patients who will undergo spina bifida operations, and not for patients who require operations for spina bifida or who have spina bifida without recommendation for surgery, or those in whom operations are planned for other reasons. As our patient had undergone surgery on the lumbar region, because of neural tube defect, and there was no problem that would prevent injection in the sacral region, caudal anesthesia was the choice. Schwartz et al. (6) implicated that caudal anesthesia is a safe method in patients with spina bifida occulta. Additionally, Johr and Berger (7) stated that caudal anesthesia is the single most simple, safe, and important anesthetic technique to provide pain relief, under the umbilicus. Figure 1. Image of Our Patient In conclusion, for operations under the umbilicus, caudal anesthesia can be a good alternative in children who are at high risk from general anesthesia, because of restricted lung function, and who cannot undergo spinal anesthesia because of having myelomeningocele. In young patients such as ours, who undergo operations for myelomeningocele and have scoliosis, it is our belief that caudal anesthesia may be used reliably and effectively since it provides effective pain control in the intraoperative and postoperative periods. However, we should keep in mind the possibility of epidural adhesions at the site of previous spina bifida cystica repair, as we would not be sure that the drug should be received to the desired level in every similar cases.

Randomization in a Crossover Design Is Not to Be a Minor Issue

To the Editor Recently, Downey et al. 1 reported internal jugular vein size measured incrementally (but not randomly) in patients anesthetized at 3-minute intervals with positive end-expiratory pressures (PEEPs) of 0, 5, and 10 cm H2O. They found that 6 of 24 patients (25%) did not tolerate PEEP at 10 cm H2O because of systemic hypotension, concluding that PEEP was poorly tolerated because of hypotension. This finding may contribute to the safety of daily anesthesia practice. However, general anesthesia without surgical stimulation may cause hypotension, exactly as reported in the study by Downey et al.1 The increase in the overall duration of anesthesia without surgical stimulation was associated with increased probability of hypotension. We recently performed a study that evaluated the effects of the Trendelenburg position (without PEEP) on the internal jugular vein in obese patients. Approximately 5 minutes after intubation, 4 of 40 (10%) patients experienced hypotension during the last measurements. When patients had been under general anesthesia for at least 9 minutes without any surgical stimulation, they may experience hypotension as observed by Downey et al.1 The researchers should randomize the study to obtain strongly balanced groups that are comparable in distribution of potential confounding factors including increasing duration of anesthesia. The results of the study by Downey et al.1 implies that PEEP is poorly tolerated in obese anesthetized adults. However, it may be simply 10 minutes without surgical stimulation that causes the hypotension. Without a randomized crossover design, it is hard to differentiate the effects of PEEP from the effects of time without surgical stimulation.

Tur Syndrome Developing Under Spinal Anesthesia

Transurethral Prostate Resection (TUR) opens large venous network and allows irrigation fluid to be absorbed into systemic circulation. The absorption of 2000 ml or more fluid causes a syndrome known as TUR-P syndrome and presents with head ache, restlessness, confusion, cyanosis, dyspnea, arrhythmia, hypotension and convulsions. The most important point in treatment is early diagnosis. When suspected, serum sodium levels of the patients should be measured. In cases with large prostate whose operation is estimated to last long, perioperative sodium measurement should be made routinely. Compared to general anesthesia, regional anesthesia decreases the incidence of postoperative venous thrombosis and the probability of symptoms being masked. Regional anesthesia enables earlier recognition and faster and more efficient treatment of TUR syndrome.