Semih Baskan

Postoperative Mortality after Hip Fracture Surgery: A 3 Years Follow Up

Background and Aims To determine mortality rates and predisposing factors in patients operated for a hip fracture in a 3-year follow-up period. Methods The study included patients who underwent primary surgery for a hip fracture.The inclusion criteria were traumatic, non-traumatic, osteoporotic and pathological hip fractures requiring surgery in all age groups and both genders. Patients with periprosthetic fractures or previous contralateral hip fracture surgery and patients who could not be contacted by telephone were excluded. At 36 months after surgery, evaluation was made using a structured telephone interview and a detailed examination of the hospital medical records, especially the documents written during anesthesia by the anesthesiologists and the documents written at the time of follow-up visits by the orthopaedic surgeons. A total of 124 cases were analyzed and 4 patients were excluded due to exclusion criteria. The collected data included demographics, type of fracture, co-morbidities, American Society of Anesthesiologists (ASA) scores, anesthesia techniques, operation type (intramedullary nailing or arthroplasty; cemented-noncemented), peroperative complications, refracture during the follow-up period, survival period and mortality causes. Results The total 120 patients evaluated comprised 74 females(61.7%) and 46 males(38.3%) with a mean age of 76.9±12.8 years (range 23–95 years). The ASA scores were ASA I (0.8%), ASA II (21.7%), ASA III (53.3%) and ASA IV (24.2%). Mortality was seen in 44 patients (36.7%) and 76 patients (63.3%) survived during the 36-month follow-up period. Of the surviving patients, 59.1% were female and 40.9% were male.The survival period ranged between 1–1190 days. The cumulative mortality rate in the first, second and third years were 29.17%, 33.33% and 36.67% respectively. The factors associated with mortality were determined as increasing age, high ASA score, coronary artery disease, congestive heart failure, Alzheimer’s disease, Parkinson’s disease, malignancycementation and peroperative complications such as hypotension (p<0.05). Mortality was highest in the first month after fracture. Conclusion The results of this study showed higher mortality rates in patients with high ASA scores due to associated co-morbidities such as congestive heart failure, malignancy and Alzheimer’s disease or Parkinson’s disease. The use of cemented prosthesis was also seen to significantly increase mortality whereas no effect was seen from the anesthesia technique used. Treatment of these patients with a multidiciplinary approach in an orthogeriatric ward is essential. There is a need for further studies concerning cemented vs. uncemented implant use and identification of the best anesthesia technique to decrease mortality rates in these patients.

Combined lumbar plexus and sciatic nerve block for hip fracture surgery in a patient with severe aortic stenosis

To the Editor: In the elderly population, the prevalence of symptomatic cardiac disease, including aortic stenosis, is increased. Despite impressive advances in anesthesiological and surgical techniques, morbidity and mortality in patients with severe aortic stenosis remains high [1]. Patients undergoing hip arthroplasty usually are elderly and present with different associated comorbidities [2]. We report successful management of a patient with aortic stenosis, hypertension, cerebrovascular disease, and a temporary pacemaker who underwent hip fracture surgery. A 75-year-old woman (60 kg, 155 cm) had fallen, resulting in a closed fracture of the right trochanter. She had cerebrovascular disease, aortic stenosis, and hypertension. Preoperative physical examination revealed findings consistent with her valvular heart disease and cardiac pulse of 35/min; the electrocardiogram showed complete atrioventricular (AV) block and left ventricular hypertrophy. A temporary pacemaker had been placed. The echocardiogram revealed an aortic valve area of 1 cm and concentric left ventricular hypertrophy. Aortic valve pressure gradient was 40 mmHg. We decided that one of the best anesthetic procedures for her was combined lumbar plexus and sciatic nerve blockade, which would provide stable hemodynamic parameters. Combined paravertebral lumbar plexus and sciatic nerve block produces adequate anesthesia of the ipsilateral lower limb for surgical repair of hip fracture in the elderly [3]. In the operating room, lumbar plexus block was performed using the Chayen’s approach [4]. In brief, the patient was turned to the left lateral position with right hip and knee flexed to approximately 45 . A puncture point was identified 4 cm lateral from midline of the L5 spinous process along the intercristal line. A 110-mm, 22-G stimulating needle (Contiplex D; B. Braun, Melsungen, Germany) connected to a nerve stimulator (Stimuplex HNS 11, B. Braun) was advanced perpendicular to all planes, and a motor stimulus was seen in the quadriceps distribution. Sciatic nerve blockade was performed using the classic Labat’s approach [5]. Briefly, the needle was inserted 5 cm below the midpoint of a line connecting the posterior superior iliac spine and the greater trochanter. After an appropriate stimulus was localized in the sciatic distribution, 10 ml levobupivacaine 0.25% was injected and the patient was returned to the supine position. Combined block developed in approximately 30 min for qualitative anesthesia. Her blood pressure was between 160/100 and 110/70 mmHg throughout the 60 min of surgery. Estimated blood loss and intraoperative urine output were 250 and 200 ml, respectively, and 1,000 ml of lactated Ringer’s solution was administered. Following surgery she was taken to the postanesthesia care unit. The effective time of the nerve blocks was 20 h. She was discharged from hospital 6 days after her operation. General anesthesia could have been an option in our patient. However, general anesthetic agents can depress the myocardium, produce vasodilatation, and can be associated with wide changes in hemodynamic variables by an intense stimulus as tracheal intubation or extubation. Epidural block or spinal block commonly results in hypotension, which may be exacerbated and have negative implications in patients with severe aortic stenosis. M. Gamli O. Sacan (&) S. Baskan S. Ozciftci N. Gogus Department of Anesthesiology and Reanimation, Ankara Numune Training and Research Hospital, Samanpazarı, Ankara 06100, Turkey e-mail: ozlemsacan@hotmail.com

The Effect of Systemic and Regional Use of Magnesium Sulfate on Postoperative Tramadol Consumption in Lumbar Disc Surgery

Aim. To investigate the effect of magnesium administered to the operative region muscle and administered systemically on postoperative analgesia consumption after lumbar disc surgery. Material and Method. The study included a total of 75 ASA I-II patients aged 18–65 years. The patients were randomly allocated into 1 of 3 groups of 25: the Intravenous (IV) Group, the Intramuscular (IM) Group, and the Control (C) Group. At the stage of suturing the surgical incision site, the IV Group received 50 mg/kg MgSO4 intravenously in 150 mL saline within 30 mins. In the IM Group, 50 mg/kg MgSO4 in 30 mL saline was injected intramuscularly into the paraspinal muscles. In Group C, 30 mL saline was injected intramuscularly into the paraspinal muscles. After operation patients in all 3 groups were given 100 mg tramadol and 10 mg metoclopramide and tramadol solution was started intravenously through a patient-controlled analgesia device. Hemodynamic changes, demographic data, duration of anesthesia and surgery, pain scores (NRS), the Ramsay sedation score (RSS), the amount of analgesia consumed, nausea- vomiting, and potential side effects were recorded. Results. No difference was observed between the groups. Nausea and vomiting side effects occurred at a rate of 36% in Group C, which was a significantly higher rate compared to the other groups (p < 0.05). Tramadol consumption in the IM Group was found to be significantly lower than in the other groups (p < 0.05). Conclusion. Magnesium applied to the operative region was found to be more effective on postoperative analgesia than systemically administered magnesium.

Anesthesia and Analgesia Methods that We Used on Pediatric Patients

Amac: Cocuklarin fizyolojik, anatomik ve farmakolojik ozellikleri eriskinden ve gelisim durumlarina gore birbirlerinden farklidir. Bu nedenle pediatrik hastalarda anestezi uygulamalari sirasinda bu farkli-liklar goz onunde bulundurulmalidir. Bu calismada klinigimizde pediatrik hastalardaki cerrahilerde uygulanan anestezi ve analjezi yontemlerini tespit etmek amaciyla yapildi. Materyal ve Metot: Ankara Numune Egitim ve Arastirma Hastanesi Anestezi ve Reanimasyon Kliniginde Ocak 2011-Şubat 2012 doneminde ameliyat olan pediatrik hastalarin kayitlari geriye donuk olarak degerlendirildi. Hastalarla ilgili demografik veriler, uygulanan ameliyat, premedikasyon, kullanilan anestezik ve analjezik ajanlar, aletler kaydedildi. Bulgular: Bu donemde 967 hastanin operasyona alindigi, %2,1 ile en fazla alinan vaka grubunu sunnetlerin olusturdugu bulundu. Operasyon sureleri ortalama 60,4 dakikaydi. Genel anestezi uygulanan hastalarin %96,1’ine anestezi idamesinde inhalasyon ajani, %55,1’ine de entubasyon oncesi kas gevsetici ajan kullanilmistir. Hastalara %63,5 oraninda sedasyon ve anksiyolitik amacli benzodiazepinlerin operasyon odasinda uygulandigi, peroperatif analjezik olarak opioid analjeziklerin %78,1 oraninda kullanildigi bulunmustur. Sonuc: Klinigimizde pediatrik hastalara uygulanann anestezi yontemlerinin literaturle benzer oldugunu, premedikasyon uygulamalarinin ve postoperatif analjezi icin rejyonel yontem uygulamalarinin artmasi gerektigi sonucuna varildi.

Comparison of continuous interscalene block and subacromial infusion of local anesthetic for postoperative analgesia after open shoulder surgery

Purpose: This study compared the efficacy of continuous interscalene block (CISB) and subacromial infusion of local anesthetic (CSIA) for postoperative analgesia after open shoulder surgery. Methods: This randomized, prospective, double-blinded, single-center study included 40 adult patients undergoing open shoulder surgery. All patients received a standardized general anesthetic. The patients were separated into group CISB and group CSIA. A loading dose of 40 mL 0.25% bupivacaine was administered and patient-controlled analgesia was applied by catheter with 0.1% bupivacaine 5 mL/h throughout 24 h basal infusion, 2 mL bolus dose, and 20 min knocked time in both groups postoperatively. Visual analog scale (VAS) scores, additional analgesia need, local anesthetic consumption, complications, and side effects were recorded during the first 24 h postoperatively. The range of motion (ROM) score was recorded preoperatively and in the first and third weeks postoperatively. Results: A statistically significant difference was determined between the groups in respect of consumption of local anesthetic, VAS scores, additional analgesia consumption, complications, and side effects, with lower values recorded in the CISB group. There were no significant differences in ROM scoring in the preoperative and postoperative third week between the two groups but there were significant differences in ROM scoring in the postoperative first week, with higher ROM scoring values in the group CISB patients. Conclusion: The results of this study have shown that continuous interscalene infusion of bupivacaine is an effective and safe method of postoperative analgesia after open shoulder surgery.

Post-thoracotomy pain relief with subpleural analgesia or thoracic epidural analgesia: randomized clinical trial

CONTEXT AND OBJECTIVE Post-thoracotomy pain is a severe and intense pain caused by trauma to ribs, muscles and peripheral nerves. The current study aimed to compare subpleural analgesia (SPA) with thoracic epidural analgesia (TEA) in patients undergoing thoracotomy. DESIGN AND SETTING Randomized study at Ankara Numune Education and Research Hospital, in Turkey. METHODS Thirty patients presenting American Society of Anesthesiologists physical status I-III were scheduled for elective diagnostic thoracotomy. The patients were randomized to receive either patient-controlled SPA or patient-controlled TEA for post-thoracotomy pain control over a 24-hour period. The two groups received a mixture of 3 µg/ml fentanyl along with 0.05% bupivacaine solution through a patient-controlled analgesia pump. Rescue analgesia was administered intravenously, consisting of 100 mg tramadol in both groups. A visual analogue scale was used to assess pain at rest and during coughing over the course of 24 hours postoperatively. RESULTS In the SPA group, all the patients required rescue analgesia, and five patients (33%) required rescue analgesia in the TEA group (P < 0.05). Patients who received subpleural analgesia exhibited higher visual analogue scores at rest and on coughing than patients who received thoracic epidural analgesia. None of the patients had any side-effects postoperatively, such as hypotension or respiratory depression. CONCLUSION Thoracic epidural analgesia is superior to subpleural analgesia for relieving post-thoracotomy pain. We suggest that studies on effective drug dosages for providing subpleural analgesia are necessary.

Tabagismo e efeito de dexmedetomidina e fentanil na intubação traqueal

JUSTIFICATIVA Y OBJETIVOS: Comparar los efectos de la dexmedetomidina y del fentanil sobre las alteraciones hemodinamicas en fumadores cronicos del sexo masculino. METODOS: Este es un estudio prospectivo, randomico y ciego. Sesenta pacientes del sexo masculino, fumadores cronicos, con edades entre los 16 y los 60 anos, fueron seleccionados. Los pacientes fueron divididos aleatoriamente en dos grupos: Grupo D (n = 30) recibio 1 µg.kg-1 de dexmedetomidina o 3 µg.kg-1 de fentanil, y el Grupo F (n = 30) que recibio 150 mL de solucion salina normal, con inicio 10 minutos antes de la induccion de la anestesia. Antes de la intubacion, se mensuraron la frecuencia cardiaca y la presion arterial de los pacientes. Despues de la induccion de la anestesia para la intubacion endotraqueal, la frecuencia cardiaca y los valores de la presion arterial fueron medidos uno, tres y cinco minutos despues de la intubacion. RESULTADOS: La frecuencia cardiaca estaba baja en el Grupo D antes de la induccion de la anestesia, de la intubacion y en el primero y tercer minutos posintubacion. La presion arterial sistolica estaba baja en el Grupo F antes de la intubacion. Aunque la presion arterial diastolica fuese menor antes de la induccion de la anestesia y a los cinco minutos despues de la intubacion en ambos grupos, ella ya estaba baja en el Grupo F antes incluso de la intubacion. Mientras la presion arterial promedio estaba baja en el Grupo D antes de la induccion anestesica, estaba baja tambien en el Grupo F antes de la intubacion. Los valores para el doble producto (frecuencia cardiaca por la presion arterial sistolica), eran bajos en el Grupo D antes de la induccion y en el 1o y 3o minutos despues de la intubacion. CONCLUSIONES: Descubrimos pues, que la dexmedetomidina, que fue aplicada en fumadores cronicos del sexo masculino via infusion a una dosis de 1 µg.kg-1 10 minutos antes de la induccion anestesica, controla mejor las elevaciones de la frecuencia cardiaca y del doble producto a uno y tres minutos despues de la intubacion, comparado al grupo que recibio 3 µg.kg-1 de fentanil.

Cigarette smoking and the effect of dexmedetomidine and fentanyl on tracheal intubation

BACKGROUND AND OBJECTIVES To compare the effect of dexmedetomidine and fentanyl on hemodynamic changes in chronic male smokers. METHODS This is a prospective, randomized, blinded study. Were selected 60 chronic male smokers (aged 16 to 60 years). The patients were randomly divided into two groups: Group D (n=30) received 1μg.kg(-1) dexmedetomidine and Group F (n=30) received 3μg.kg(-1) fentanyl in 150mL of normal saline, beginning 10 minutes before anesthesia induction. Before intubation, the heart rate and blood pressure of patients were measured. After anesthesia induction for endotracheal intubation, heart rate and blood pressure values were measured at 1, 3, and 5 minutes after intubation. RESULTS Heart rate was low in Group D before anesthesia induction, intubation, and at the 1st and 3rd minutes after intubation. Systolic arterial pressure was low in Group F before intubation. Although diastolic arterial pressure was lower before anesthesia induction and at 5 minutes after intubation in both groups, it was already low in Group F before intubation. Whereas the mean arterial pressure was low in Group D before anesthesia induction, it was low in Group F before intubation. The values for rate-pressure product were low in Group D before induction and at 1 and 3 minutes after intubation. CONCLUSIONS Dexmedetomidine, which was applied via infusion at a loading dose of 1μg.kg(-1) 10 minutes before anesthesia induction in chronic male smokers, better suppressed increases in heart rate and rate-pressure product at 1 and 3 minutes after intubation compared to the group receiving 3μg.kg(-1) fentanyl.