Pınar Kendigelen

Pudendal Versus Caudal Block in Children Undergoing Hypospadias Surgery: A Randomized Controlled Trial.

Background and Objectives Postoperative pain management after hypospadias surgery is often challenging. Caudal block is used for analgesia but has limitations. This study compares the analgesic efficiency of pudendal block with that of caudal block in pediatric patients undergoing hypospadias repair surgery. Methods This prospective, double-blind, randomized, controlled study enrolled 84 patients receiving pudendal block or caudal block before hypospadias surgery. In the pudendal group, the pudendal nerve was identified using a nerve stimulator, and the block consisted of 0.25% bupivacaine 0.5 mL/kg. In the caudal group, the caudal block used 0.2% bupivacaine 1 mL/kg. Our primary outcome was pain intensity within 24 hours postoperatively. The trial was registered at ClinicalTrials.gov (number: NCT02390388). Results For the primary outcome, patients in the pudendal group had lower postoperative pain intensity when compared with the caudal group (P < 0.001). Three patients in the pudendal group and all of the patients in the caudal group needed additional analgesia within 24 hours after the surgery (P < 0.001). The family satisfaction rate was significantly higher in the pudendal group (P < 0.001). Conclusions For the pudendal group, the pain scores for the first 24 hours after the surgery were significantly lower and the duration of analgesia was longer.

Ultrasound-assisted transversus abdominis plane block vs wound infiltration in pediatric patient with inguinal hernia: randomized controlled trial

STUDY OBJECTIVE To compare the analgesic efficacy of ultrasound-assisted transversus abdominis plane (TAP) block and wound infiltration during the first postoperative 24hours. DESIGN A prospective, observer-blinded, randomized, and controlled study SETTING Operating room of a university hospital. PATIENTS Forty patients received a TAP block (TAP group) and 40 patients received wound infiltration (INF group) at the end of the surgery. INTERVENTIONS Patients were randomized to receive a TAP block or wound infiltration. Postoperative analgesics were administered on request and selected based on pain severity. MEASUREMENTS Pain scores, analgesic drug requirement, and side effects were observed for 24hours. MAIN RESULTS Postoperative pain scores were lower in TAP group compared to INF group (P<.001). Analgesic consumption was significantly higher at the 5th minute and 1st, 6th, and 12th hours in the INF group (P<.001). The frequency of additional analgesic use in home and the total analgesic used during the postoperative 24hours were significantly higher in INF group (P<.001). Side effects were lower in the TAP group. Parents satisfaction scores were higher in TAP group. CONCLUSION Transversus abdominis plane block is effective method with convenient technique, drug dosage, and volume in pediatric patients undergoing inguinal hernia surgery.

Comparison of Transversus Abdominis Plane Block and IV Patient-Controlled Analgesia after Lower Abdominal Surgery.

OBJECTIVE We aimed to compare the first 24-hour postoperative analgesic efficiency of ultrasound (USG)-assisted transversus abdominis plane (TAP) block to IV morphine patient-controlled analgesia (PCA) in patients undergoing lower abdominal surgery. METHODS Fifty ASA I-III patients were included into this randomised, prospective clinical study. At end of surgery, Group 1 received 1 mg kg(-1) 0.5% bupivacaine and 1 mg kg(-1) 1% lidocaine in a 30-mL volume during TAP-block. Group 2 received 1 mg kg(-1) tramadol IV 10 minutes before extubation, and PCA was started with 1 mL morphine IV at a concentration of 1 mg kg(-1) and a 10-min lock time. Visual analogue scale (VAS), heart rate (HR), respiratory rate, peripheral oxygen saturation (SpO2), additional analgesic need and nausea-vomiting at the postoperative 30(th) minute and 1, 2, 3, 6, 12, and 24 hours were evaluated. In both groups, when VAS values were >4, patients were given 1 mg kg(-1) tramadol IV in first evaluation at the 30(th) minute or 15 mg kg(-1) paracetamol at other evaluations. RESULTS No difference was observed between groups in terms of VAS values. No difference was observed in terms of HR in the within-group comparison, but Group 1 HR values were lower compared to Group 2 (p<0.01). No difference was observed in additional analgesic need at any times. Nausea-vomiting score was higher in Group 2 in the between-group comparison at the 30(th) minute (p<0.04), but no difference was observed after the 1(st) hour. CONCLUSION Transversus abdominis plane block is effective as IV morphine-PCA in postoperative pain therapy in lower abdominal surgery, when given in a 30-mL volume. It may be preferable to IV-PCA, as the analgesic effect starts earlier and decreases the systemic effect of the morphine used in PCA.

Anaesthetic Management of a Patient with Synchronous Kartagener Syndrome and Biliary Atresia

Kartagener syndrome is an autosomal recessive disorder characterized by primary ciliary dyskinesia accompanied by sinusitis, bronchiectasis, and situs inversus. Synchronous extrahepatic biliary atresia and Kartagener syndrome are very rare. During the preoperative preparation of patients with Kartagener syndrome, special attention is required for the respiratory and cardiovascular system. It is important to provide suitable anaesthetic management to avoid problems because of ciliary dysfunction in the perioperative period. Further, maintaining an effective pain control with regional anaesthetic methods reduces the risk of pulmonary complications. Infants with biliary atresia operated earlier have a higher chance of survival. Hepatic dysfunction and decrease in plasma proteins are important for the kinetics of drugs. In this presentation, the anaesthetic management of patients with synchronous Kartagener syndrome and biliary atresia, both of which are rare diseases, is evaluated.

Pudendal Nerve Block Versus Penile Nerve Block in Children Undergoing Circumcision

PURPOSE Penile nerve block is the most popular nerve block for the circumcision in pediatric patients. This study aimed to compare the analgesic efficiency of penile nerve block and the pudendal nerve block on postoperative pain and additional analgesic requirements in children undergoing circumcision. MATERIAL AND METHODS This prospective randomized double-blind study enrolled 85 children, aged 1 to10 years, undergoing circumcision. The patients were randomly divided into two groups either receiving dorsal penile block group (PNB-Group) or pudendal nerve block (PDB-Group). In the PNB-Group, 0.3 ml/kg 0.25 % bupivacaine was used; and, in the PDB-Group, 0.3 ml/kg bupivacaine was applied with nerve stimulator at a concentration of 0.25%. In the postoperative period, the modified CHEOPS pain scale scoring and additional analgesic demand were evaluated at the 5th and 30th minutes and at the 1st and 2nd hours. The subsequent pain evaluations were made by the parents at home, at the postoperative 6th, 12th, 18th and 24th hours. RESULTS Seven patients were excluded from the study, and seventy eight patients were evaluated for analysis. Patients in PDB-Group had significantly lower postoperative pain intensity and lower mCHEOPS scores (3.83 ± 0.98) when compared to the PNB-Group (6.47 ± 0.91) (P < .01) at all measurement times and none of patients in PDB-Group had additional analgesic requirements up to 24 hours. Patients in the PNB-Group had significantly more analgesic requirements at all measurements times except at the 1st, 2nd, 24th hours. 3.8%, 30.8%, 46.2% and 59% of the patients in the PNB group needed additional analgesia respectively at 5th, 6th, 12th and 18th hours. CONCLUSION Pudendal nerve block provided additional analgesic free period and had better analgesic efficiency compared to the penile nerve block lasting until 24 hours after operation.

Anaesthetic Management of a Child with a Massive Mediastinal Mass

Mediastinal masses are benign or malignant tumours that originate from the thymus, thyroid, lung, lymphoid system, pleura, or pericardium. Cardiovascular and respiratory symptoms may occur because of the compression of surrounding tissues along with growing mass. In this study, we present the anaesthetic management of a 6-month-old child having a massive anterior mediastinal mass that had a compressing effect.

ÇOCUKLUK ÇAĞI TÜMÖRLERİNİN AKCİĞER METASTAZLARINA CERRAHİ YAKLAŞIM

Amac: Cocukluk cagi solid tumorlerinin akciger metastazlarinda klinigimizin cerrahi yaklasiminin degerlendirilmesidir. Olgular ve Yontem: Akciger metastazi nedeniyle 1978-2016 arasinda basvuran ve cerrahi girisim yapilan olgular geriye donuk olarak incelendi. Yas, cinsiyet, primer tani, akciger metastazinin ortaya cikis zamani, cerrahi tedavi yontemi, patolojik tani ve takip acisindan degerlendirme yapildi. Primer tumoru kontrol altina alinan, baska uzak organ metastazi olmayan ve akciger metastazi icin cerrahi tedavi uygulanan olgular calismaya alindi. Bulgular: Onsekiz olgunun (K/E:11/7) yas ortalamasi 8,1 yil (1,5-14 yas) idi. Primer tumorler; Wilms tumoru (n:9,%50), Ewing sarkomu (n:3,%17), osteosarkom (n:2,%11), hepatoblastom (n:1,%5,5), fibrosarkom (n:1,%5,5), rabdomyosarkom (n:1,%5,5) ve endodermal sinus tumoru (n:1,%5,5) idi. Olgularin 4’unde ilk basvuru aninda akciger metastazi mevcuttu. Onaltisinda metastazin ortaya cikis zamani ortalama 16, 5 ay (7ay-4 yil) idi. Radyolojik degerlendirme tum olgularda preoperatif donemde akciger grafisi ve bilgisayarli tomografi (BT) ile yapildi. Onsekiz olguya toplam 23 torakotomi yapildi. Yirmibir wedge rezeksiyon, 1 lobektomi, 1 lobektomi ve kot rezeksiyonu uygulandi. Patolojik incelemede cikarilan lezyonlarin 3’u inflamatuar reaksiyon olarak degerlendirildi. Toraks dreni alinma suresi ortalama 5,2 gun(3-8), hastanede kalis suresi 7,3 gun(5-10 gun) idi. Cerrahi girisime bagli komplikasyon gorulmedi. Takipte 6 olgu ilerleyici primer hastalik nedeniyle kaybedildi. Sonuc: Cocukluk cagi tumorlerinde akciger metastazlari basvuru sirasinda ve/veya takipte gorulebilir. Cerrahi tedavisinde sinirli rezeksiyon yeterli gorunmektedir. Torakotomi bu olgularda tum lezyonlarin degerlendirilmesini saglamaktadir ve guvenle uygulanmaktadir. Radyolojik incelemeler tumor metastazini desteklese de kesin tani patolojik inceleme ile konulmaktadir.

Does Previous Open Renal Stone Surgery Affect the Outcome of Extracorporeal Shockwave Lithotripsy Treatment in Adults with Renal Stones

PURPOSE To evaluate the effects of previous ipsilateral open renal stone surgery (ORSS) on outcomes of extracorporeal shockwave lithotripsy (SWL) in adults with renal stones. MATERIALS AND METHODS A total of 2097 renal units with renal stones underwent SWL treatment at our institution between March 1997 and February 2013. One thousand eight hundred thirty-nine (87.7%) of these had no history of ORSS and were categorized as group 1, and 258 (12.3%) patients having history of ipsilateral ORSS were categorized as group 2. Characteristics of patients, stone and treatment, stone-free, and complications rates were documented in detail and compared in each group. These groups were also subclassified into four subgroups according to the stone location. RESULTS The stone-free rates were statistically higher in group 1 than group 2 (73.2% and 61.6%, respectively). There were no differences between groups regarding the complications and steinstrasse. The stone-free rate of SWL for stones located at lower calix has significant difference according to groups 1 and 2 (64% vs 48.4%, p = 0.001). Logistic regression analysis showed that history of ORSS increased SWL failure rate 1.39 times. CONCLUSION Overall stone-free rates after SWL treatment was found to be significantly lower in patients with the history of ORSS than in patients without, and this finding was significantly prominent for lower calix stones. We believe that retrograde intrarenal surgery or mini- /micro-percutaneous nephrolithotripsy, despite its possible difficulties in accessing due to anatomical changes, might be a good alternative for SWL.

Use of Continuous Brachial Plexus Blockade for Treatment of Accidental Intra-Arterial Injection

Introduction: Unintentional intra-arterial injection of drugs has serious problems and morbidity such as pain, ischemia, gangrene, and infection. Aberrant vascularization is a frequent cause of intra-arterial injection.Case Report: We describe a pediatric case of accidental cannulation of aberrant arterial vessel during venous insertion and our brachial plexus block treatment to obtain continuous vasodilatation to prevent ischemic effects.Conclusion: Sympatholysis with peripheral nerve blocks may decrease morbidity providing an additional benefit to pharmacological treatment by increasing blood flow to the tissue after the intra-arterial injection

Ultrasound-Guided Thoracic Paravertebral Block Experience in a Child

Dear Editor, Postoperative pain treatment is very important in childhood. In addition to classical blocks, paravertebral block is unilaterally or bilaterally used for analgesia during and after thoracal and abdominal surgeries. The paravertebral space contains neural structures, including anterior and posterior branches of the intercostal nerves, the nerves of the sympathetic chain, rami communicantes and Luschka nerves supplying the intervertebral disc. These bare nerve endings are easily affected by local anaesthetics. Paravertebral block is performed with the conventional loss of resistance technique. However, its use in children is limited compared to adults because it is difficult to predict the distance to the pleura and the loss of resistance in children, particularly during thoracic paravertebral block practice. With the use of ultrasonography in peripheral nerve blocks, paravertebral block can now be performed by direct observation through ultrasound. Ultrasound-guided paravertebral block practices have been reported in children (1, 2). We aimed to share our first experience in ultrasound-guided paravertebral block application. A 3.5-year-old girl, who weighed 16 kg and presented with a complaint of cough and who was pre-diagnosed with hereditary right cystic lung disease, was taken to the operating room primarily for bronchoscopy and then, if necessary, for thoracotomy. The patient was premedicated by administering midazolam 1 mg intravenously (iv). Following monitorization, induction was performed with propofol and rocuronium and bronchoscopy was initiated. During the procedure with a rigid bronchoscope, anaesthesia was continued with a sevoflurane/air and remifentanil infusion. Abundant mucopurulent secretion was aspirated because of chronic lung infection. It was decided to perform lobectomy with thoracotomy from the right fourth intercostal space. Bronchoscopy was stopped, and the patient was placed in the left lateral decubitus position. High-frequency linear probe (MyLab5-LA523E, Esaote SpA, Italy) was placed in the paravertebral space in the longitudinal and paramedian position and at the thoracal 7 level, and transverse process, intercostal ligaments, the seashore sign, the pleura and the pleural space were observed (Figure 1). A Stimuplex A 50 mm (B.Braun, Melsungen, Germany) was pushed forward from a lateral to medial direction using the in-plane method and was advanced towards the paravertebral space. While passing through tissues with the needle under the guidance of ultrasound for anatomic coordination, 1 mL 0.9% NaCl was administered twice and the level of the needle tip in the tissues was identified (Figure 2). After entering into the targeted area, aspiration was performed and then the block was performed by administering 0.5 mL kg−1 bupivacaine (0.25%). Meanwhile, the ‘step sign’, which indicates the collapse of the pleura, was observed by expanding the paravertebral space with fluid under ultrasound guidance (Figure 2). During blockade, no blood aspiration was observed and no hypotension occurred. After the beginning of the surgery, remifentanil infusion was discontinued. The anaesthesia of the patient, who was haemodynamically stable for 2.5 h, was maintained with a 2% concentration of sevoflurane (in oxygen/air) and rocuronium. After the operation, the patient was monitored in the recovery room for 1 h following extubation. She experienced pain in her throat due to the rigid bronchoscopy but did not complain of incision pain, and her respiratory depth was adequate. The patient was monitored with the Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS) (4: no pain; 13: very severe) for 24 h. During the 6 h following the moment of blockade, she experienced no pain. It was observed that she was comfortable in the clinic, and she did not have any complications. In the 6th hour, she began to complain of pain, and her pain evaluation score was 7. Therefore, she was administered 15 mg kg−1 paracetamol iv After 1 h, her pain score was evaluated to be 9, and she was administered 20 mg tramadole iv. The same dose was repeated again after 6 h. The CHEOPS pain scores were between 4 and 9 (the score of 9 was observed just once) during 24 h. Figure 1 Before block A: processus transversus, B: pleura, C: intercostal membrane, D: paravertebral space Figure 2 After block A: processus transversus, B:pleura, D: paravertebral space 1,2: 0.9% NaCl was given for control There was no need for additional analgesia during surgery in the space in which many derivations innervated with a single-dose drug, easy extubation and respiration due to adequate analgesia after thoracotomy occur; hence, this plus the maintenance of 6-h analgesia are important gains. If paravertebral block is to be performed, patient comfort can be increased with the routine use of systemic analgesics before the end of analgesia time. In our case, if an opioid had been administered instead of paracetamol at the 6th hour, i.e. when her pain began, and additional paracetamol had been administered every 6 h, better pain scores would have been obtained. In a case report of a 10-year-old child (weight, 40 kg), a lateral spread between the T4–5 and T10–11 levels and parallel to the spine, which covers the longitudinal and intercostal nerves, was observed with 10 mL contrast substance injected into the paravertebral space through a catheter inserted at the level of T10 (3). On the other hand, in a study performed on cadaver babies, a strong relationship was reported between the volume injected as a paravertebral single-dose at the thoracolumbar level and the number of segments with spread. It has been specified that the most appropriate volume to cover the segments between T10 and L1 is 0.2–0.3 mL kg−1 (4). Hence, it was possible to provide analgesia in the thoracal segments with the volume of 0.5 mL kg−1 given from the T7 level in our case. Paravertebral block can be performed through a unilateral or bilateral single dose or catheter. The analgesic action time of single-dose paravertebral block practice is not clearly reported in previous studies. It is reported that the addition of other drugs to a local anaesthetic for prolonging the duration of analgesia obtained by administering a single-dose into the paravertebral space does not provide an advantage (5). It is possible to obtain analgesia for days by providing continuous infusion through the insertion of a catheter. However, because the paravertebral space is too close to the skin in young children (less than 1 cm), the drug administered may leak from the skin and the catheter may easily change place and may be accidentally displaced. Therefore, if it is planned to insert a catheter in young children, these possibilities must be considered. Some complications such as pneumothorax, pleural puncture and vascular injury are possible, but ultrasound guidance reduces these risks. To avoid the side effects of central block in patients who use an anti-coagulant and whose anatomy is not suitable, paravertebral block can be used in the early postoperative period because it provides adequate analgesia. It is an effective analgesia method that can be preferred for providing patient comfort and respiratory rehabilitation provided that a proper combination is established with systematic analgesics. The use of ultrasound makes this block more effective and safer for use in children.