Pinar Ergenoglu

Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia.

PURPOSE We analyzed the results of patients who underwent percutaneous nephrolithotomy (PCNL) for management of kidney stone disease under combined spinal-epidural anesthesia and compared surgical parameters and outcomes with a matched control group who underwent PCNL under general anesthesia. PATIENTS AND METHODS A total of 82 patients were studied in two groups. Group 1 (n = 45) consisted of the patients who underwent general anesthesia, and group 2 (n = 37) comprised those who received combined spinal-epidural anesthesia. RESULTS The mean ages of patients in groups 1 and 2 were 45 +/- 15 and 44 +/- 15 years, respectively. The mean areas of the stones in groups 1 and 2 were 734 +/- 386 mm(2) and 731 +/- 394 mm(2), respectively. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, operative time, irrigation fluids, fluoroscopy time, delta hemoglobin, and hospitalization time (P = 0.439). At the end of the surgery, stone-free rates were 76% in group 1 and 81% in group 2; clinically insignificant residue fragments rates were 24% in group 1 and 19% in group 2. The difference was statistically insignificant between the groups (P = 0.543). CONCLUSIONS We consider that combined spinal-regional anesthesia is a feasible technique in PCNL operations because the efficacy and safety were not affected. Further investigations with larger series are needed.

Comparison of Intrathecal Levobupivacaine Combined with Sufentanil, Fentanyl, or Placebo for Elective Caesarean Section: A Prospective, Randomized, Double-Blind, Controlled Study ☆

Background The addition of opioids to local anesthetics contributes to the quality of spinal anesthesia and postoperative analgesia. Objective In our prospective, randomized, double-blind, controlled study, our aim was to compare the effect of low-dose sufentanil plus levobupivacaine or a fentanyl plus levobupivacaine mixture on anesthesia quality, block characteristics, newborn and mother well-being, surgeon satisfaction, and duration of postoperative analgesia. Methods Ninety-three patients were randomized into 3 groups (n = 31). Patients in Group C received 0.5% levobupivacaine (2.2 ± 0.2 mL), Group S received 2.5 µg sufentanil plus 0.5% levobupivacaine (2.2 ± 0.2 mL), and Group F received 10 µg fentanyl plus 0.5% levobupivacaine (2.2 ± 0.2 mL) intrathecally completed to a volume of 3 mL with the addition of saline in all groups. Patients’ demographics, sensory and motor block characteristics, hemodynamics, Apgar scores, umbilical blood gas values, maternal side effects, surgeon satisfaction score, time to first analgesia requirement, and additional analgesic use within 24 hours were recorded. Results In Group S and Group F, target levels of sensory and motor block were achieved more rapidly (P < 0.001). The hemodynamic values were lower (P < 0.05), and the duration of sensory blockade and the time of first analgesic requirement were longer (P < 0.001) in Group S. Additional analgesic requirement during first 24-hour period was lowest in Group S, and highest in Group C (P < 0.001). Apgar scores and umbilical blood gas samples were similar between groups. Postoperative pruritus was more frequent in Group S (P < 0.001) and surgeon satisfaction score was significantly lower in Group C (P = 0.003). Conclusions We suggest that the addition of sufentanil and fentanyl to intrathecal levobupivacaine during caesarean section surgery is more effective than the administration of levobupivacaine alone. The addition of sufentanil to levobupivacaine allowed rapid onset time for sensory and motor block levels. It also extended the duration of postoperative analgesia and led to a decrease in total analgesic requirement. ClinicalTrials.gov identifier: NCT01858090.

Effect of Intraoperative Paracetamol on Catheter-Related Bladder Discomfort: A Prospective, Randomized, Double-Blind Study

BACKGROUND The insertion of urinary catheters during urinary surgical interventions may lead to catheter-related bladder discomfort (CRBD) in the postoperative period. OBJECTIVE We aimed to evaluate the effect of single-dose intravenous paracetamol on CRBD. METHODS In this randomized, controlled, double-blind study, 64 patients (age >18 years, American Society of Anesthesiologists Physical Status I-II) requiring urinary bladder catheterization for percutaneous nephrolithotomy were assigned to groups that received either intravenous paracetamol (15 mg/kg) (group P) or NaCl 0.9% solution (control group [group C]) 30 minutes before the end of surgery. Patients received patient-controlled analgesia (10-mg bolus of meperidine, without infusion, 20-minute lock out) postoperatively. CRBD and pain status were assessed at 30 minutes and 1, 2, 4, 6, and 12 hours postoperatively. Postoperative meperidine requirement and patient and surgeon satisfaction were assessed. RESULTS Group P had significantly lower CRBD scores at all time points except at 12 hours postoperatively compared with group C (P < 0.05). Total meperidine consumption was significantly higher in group C (P < 0.05). Patient and surgeon satisfaction scores were significantly higher in group P (P < 0.05). CONCLUSIONS Intraoperative single-dose paracetamol was found to be effective in reducing the severity of CRBD and pain in urologic surgery. We suggest that it may be an efficient, reliable, easy-to-apply drug for CRBD. ClinicalTrials.gov identifier: NCT01652183.

Effect of low dose dexmedetomidine premedication on propofol consumption in geriatric end stage renal disease patients

BACKGROUND AND OBJECTIVE Sedation in dialysis dependent end-stage renal disease patients requires caution as a result of performing high doses of sedatives and its complications. Multidrug sedation regimens might be superior and advantage on lesser drug consumption and by the way adverse events which occur easily in end-stage renal disease patients. We evaluated the effects of dexmedetomidine premedication on propofol consumption, sedation levels with Observers Assessment of Alertness and Sedation scores and the bispectral index and the hemodynamic changes, potential side effects in geriatric patients with end-stage renal disease who underwent hip fracture surgery under spinal anesthesia. METHOD In this randomized, controlled, double-blind study 60 elderly patients (age≥65 years) with end-stage renal disease and hip fracture scheduled for anterograde femoral intramedullary nailing were assigned to groups that received either intravenous saline infusion (Group C) or dexmedetomidine 0.5μg/kg/10min infusion for premedication (Group D). All the patients received propofol infusion after the induction of the spinal anesthesia. RESULTS Total propofol consumption, propofol dose required for targeted sedation levels according to Observers Assessment of Alertness and Sedation scores and bispectral index levels, recovery times were significantly lower in Group D (p<0.001). The time to reach to Observers Assessment of Alertness and Sedation score 4 and to achieve bispectral index≤80 was significantly lower in Group C compared with Group D (p<0.001). Adverse events were similar in both groups. CONCLUSION Dexmedetomidine premedication lowers intraoperative propofol consumption to maintain targeted level of sedation. Therefore low dose dexmedetomidine premedication in addition to propofol infusion might be an alternative in geriatric patients with end-stage renal disease for sedation.

Anesthesia management and sugammadex experience in a neonate for Galen vein aneurysm

Galen vein aneurysm (GVA) is a symptomatic cerebrovascular malformation in neonates, and interventional aneurysm treatment is gaining popularity in this patient group.We aimed to present our anesthesia management and experience with sugammadex in a neonate who underwent endovascular intervention for GVA. An 11-day-old term newborn was referred to the anesthesia clinic for GVA (Fig. 1). Echocardiography showed right ventricular and pulmonary arterial dilatation, pulmonary hypertension, 3° to 4°TY, and ejection fraction of 55% with normal laboratory values. Anesthesia induction was achieved by the inhalation of sevoflurane, 0.6 mg/kg rocuronium, and 1 μg/kg fentanyl, and maintenance was achieved by 1.5% sevoflurane with 50%/50% oxygen-air. Jugular vein catheter and arterial line were applied. Dexamethasone 0.5 mg/kg, mannitol 0.5 mg/kg, furosemide 1 mg/kg, and ranitidine 1 mg/kg were administered preoperatively. Sugammadex 2 mg/kg was administered initially, and 1 mg/kg additional dose was used to achieve proficiency in respiratory effort. Then the patient was extubated without any complication and transferred to the neonatal intensive care unit. Patients with GVA have an increased risk of cerebral ischemia and infarction during anesthesia. For this reason, agents should be carefully selected. Medications protecting hemodynamics and reducing cerebral metabolic rate and oxygen consumption should be given preference. According to studies, we preferred sevoflurane due to its pharmacokinetic properties for induction and maintenance of anesthesia [1]. We also avoid using nitrogen to reduce the risk of small air embolism. Anesthesiamanagement should also aim to provide andmaintain cardiovascular stability and prevent sudden volume shifts in circulation. Another issue to consider during anesthesia management of these cases is hypothermia. These patients are administered great amounts of fluids as required by endovascular procedures. Care should be taken to administer these fluids after heating to an adequate temperature, to warm up patients. The nextmain stage of anesthesia is the extubation phase in aneurysm procedures. A smooth extubation plan to reduce complication such as hypertension and obtain a full recovery to assess the neurologic status at the operating table should be themain aim of the anesthesiologist. During interventional aneurysmprocedures,

Inappropriate Use of Anticoagulant Drugs in Older Adults

I or inappropriate drug use in older adults is a common and serious problem that can increase mortality and morbidity as a result of deterioration of bodily functions (Fu, Liu, & Christensen, 2004). Inappropriate use of anticoagulant drugs has recently gained interest due to the potential risk of hemorrhage. Warfarin (Coumadin®), which is used for atrial fibrillation, mechanical heart valves, and ischemic attacks, is the most commonly implicated drug of emergency hospitalizations for adverse drug reactions in older adults. Approximately 50% of these hospitalizations involve adults older than 80, with hemorrhage being the primary adverse event (Budnitz, Lovegrove, Shehab, & Richards, 2011). Inappropriate use of warfarin can cause serious hemorrhage in the intracranial area and gastrointestinal system, as well as in the respiratory and genitourinary systems, with risk for fatality. Interestingly, anticoagulant-related major hemorrhage is observed more frequently in older patients (age >75) than in younger patients (Levine, Raskob, Beyth, Kearon, & Schulman, 2004). The mechanism of how aging causes hemorrhage is unknown, but increasing evidence supports that age is an independent factor for major hemorrhage (Levine et al., 2004). Although novel anticoagulant agents (e.g., dabigatran [Pradaxa®], rivaroxaban [Xarelto®], and apixaban [Eliquis®]) have long been anticipated as alternatives to warfarin, the lack of reversal agents, increased risk of gastrointestinal bleeding, and limited evidence in the older adult population are serious concerns (Ogbonna & Clifford, 2013). Inappropriate drug use has also been observed among hospitalized patients and can affect length of stay (Onder et al., 2003). We present one such case from our hospital. An 82-year-old man was hospitalized to undergo total knee arthroplasty. His medical history revealed atrial fibrillation, with irregular use of metoprolol succinate 50 mg and warfarin sodium 5 mg; however, the patient stated he had not used either medication in the previous 5 days. Preoperative tests, including international normalized ratio (INR), were within normal limits. The chosen anesthetic plan was combined spinal/ epidural anesthesia. The operation was completed uneventfully. A continuous epidural infusion of bupivacaine 0.25% was administered for postoperative analgesia. The epidural catheter was scheduled to be removed on the third postoperative day; however, catheter removal was delayed due to an INR of 4.2. The patient was closely monitored for signs of spinal hematoma. Repeated, detailed, and insistent questioning by nurses revealed that he had taken warfarin sodium 5 mg tablets for 3 days during the postoperative period, assuming it to be an analgesic. His cognitive functions were normal, but he was resistant to cooperate. He did not realize the importance of the potential complications due

Pneumorrhachis and Pneumocephalus with Severe Chest Pain Symptom: A Rare Complication of Epidural Steroid Injection

Dear Editor, Pneumorrhachis and pneumocephalus are unusual complications of inadvertent dural puncture. We present the case of pneumorrhachis and pneumocephalus in a patient with lumbar spinal stenosis who was performed epidural steroid injection by using loss of resistance technique to air. A 37-year-old man with the history of spinal stenosis, low back pain, bilateral leg pain, and neurogenic claudication was performed epidural steroid (80 mg metil prednisolone) injection in another pain clinic. He complained of severe chest pain and headache aproximately 1 hour after epidural injection in the recovery room. The anesthesiologist who attempt epidural steroid …

A patient with Churg-Strauss syndrome complicated with pulmonary hemoptysis

Churg-Strauss Syndrome (CSS) is an extremely rare necrotizing vasculitis characterized by allergic rhinitis, asthma, and eosinophilia [1]. Skin, lung, and kidney involvement is usually more pronounced, but cardiovascular, gastrointestinal, and central nervous systems may also be involved [1]. Overall survival in this syndrome has been improved dramatically by the early use of corticosteroids and immunosuppressive drugs [2]. Anesthesia management of the patients with CSS is important owing to airway hypersensitivity and possible multiple-organ dysfunctions. Unfortunately, there are a few reports related to anesthesia management of CSS in the literature. A 25-year-old male patient weighing 67 kg was evaluated under urgent conditions for bronchial arteriography and embolization for massive hemoptysis. He had a history of asthma and allergic rhinitis since childhood and had CSS diagnosis for 2 years. He had also undergone mitral valve repair for mitral valvular insufficiency approximately 3 months ago. After the diagnosis, he was treated with methyl prednisolone for a year and discontinued it; he had been using budesonide-formoterol inhaler, metoprolol 50 mg, and ramipril 5 mg since then. On physical examination, he had bilateral diffuse rhonchi and rales, and otherwise, systemic examination was normal. Airway evaluation demonstrated a Mallampati score of I. Laboratory tests were all normal except for eosinophilia in complete blood count. Echocardiogram showed left ventricular hypertrophy and global hypokinesis, with a left ventricular ejection fraction of 54%. Anesthesia induction was performed by midazolam 2 mg, propofol 100 mg, sevoflurane 3%-4%, fentanyl 100 μg, and rocuronium 35 mg, and he was then intubated slightly. Anesthesia maintenance was achieved by sevoflurane (1%-2%) in the mixture of 50%/ 50% oxygen-nitrogen. Bronchial angiography indicated irregularities and active bleeding from both right and left bronchial arteries (Figure). Embolization procedure was performed successfully to stop bleeding. The procedure lasted for 1 hour, and a total of 45 mg rocuronium was

Anesthesia management of a patient with Jervell and Lange-Nielsen syndrome

The success of sedation forMRIwasmeasured by 2 factors: (a) the safety without any adverse events and (b) the effectiveness of the procedure completion. The main difficulties were keeping a profound sedation with hemodynamic and respiratory stability and the limiting access to the patient during the exam. Therefore, the appropriate drugs needed to be selected and titrated to achieve these objectives. Dex was a potent, highly selective α2-adrenoreceptor agonist, declared by the American Society of Anesthesiologists to be a sedative [2], and provided profound levels of sedationwithout affecting cardiovascular and respiratory stability, in contrast to other hypnotics such as propofol [3]. InMRI, Dex was used only for pediatric patients [4]. Candiotti et al [4] showed that the use of Dex for procedures requiring monitored anesthesia care was safe and superior to the combination of midazolam and fentanyl. Arain and Ebert [5] showed that Dex provided a better sedation profile than propofol. To Mahmoud et al [6], Dex might be the preferred drug for anesthesia during MRI in children with a history of severe OSA and offered benefits to children with sleep disordered breathing. The problem was particularly worse in patients with OSA because they were sensitive to the respiratory depressant effects of sedative and hypnotic drugs and were especially vulnerable to the development of pharyngeal hypotonia with upper airway obstruction during sedation [7,8]. In contrast to other sedative drugs, Dex provided a natural sleep and pledged an effective sedation, without significant central and cardiorespiratory depressant activity [6,7]. These advantages made Dex an attractive drug for sedating patients with OSA for MRI [6]. As some authors reported that Dex did not affect RR, SpO2, and EtCO2 [9], however, some respiratory complications such as irregular respiration, apnea, slight hypoxemia, and hypercapnia were reported with large and rapid initial loading doses (over 2 minutes) [10]. Despite the safety profile of Dex, any sedative agent could result in deleterious cardiorespiratory effects, so appropriate monitoring, equipment and easy access to medications were recommended. In summary, Dex could be a favorable sedative drug for MRI scanning in claustrophobic patients with OSA. Further research and experience were required for procedural sedation during radiological imaging.

992 ANESTHESIA MANAGEMENT OF A PATIENT WITH SAMTER'S SYNDROME FOR EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (ESWL)

Background and Aim: ESWL is an effective method of treatment for urinary calculi, and a mildly painful procedure that requires conscious sedation. Intravenous sedoanalgesia techniques are preferred. Bronchial asthma, nasal polyposis, and intolerance to aspirin are determined as Samter’s Syndrome. We present a regional anesthesia choice instead of sedoanalgesia technique for an ESWL patient with Samter’s syndrome. Case: A 38-year-old woman was admitted with a mild pain on left lumbar side. Left renal stone (15×9mm) was diagnosed and ESWL was planned. History and physical examination revealed Samter’s Syndrome, panic disorder and morbid obesity (BMI = 42kg/m). Spinal anesthesia was preferred to prevent pain during ESWL although sedoanalgesia technique is widely performed in our clinic. After midazolam (2mg, IV) administration, oxygen and standard monitoring was applied. Spinal anesthesia was performed using midline technique (L3–4) with a 25-gauge needle (Quincke). After bupivacaine (0.5%, 3 cc) injection, spinal needle was withdrawn. No supplemental IV opioids were required and patient was comfortable during anesthesia. Recovery period was uneventful, sensory and motor blockade was resolved completely following 180 minute of anesthesia and the patient was discharged when all criteria were met. Discussion and Conclusion: The potential advantages of regional anesthesia include minimal airway intervention, less cardiopulmonary depression, effective postoperative analgesia, less postoperative nausea and vomiting, and shorter hospital stay. In conclusion, we suggest that spinal anesthesia should be considered as an option of successful anesthesia management for an ESWL patient who is suffering from Samter’s syndrome, extreme obesity, irritable airway and panic disorder.