Semih Küçükgüçlü

Multiple-Dose Activated Charcoal in an Accidental Vancomycin Overdose

BACKGROUND Multiple-dose activated charcoal may enhance the enterocapillary clearance of vancomycin. CASE REPORT A 17-day-old female neonate born with congenital meningomyelocele and Arnold-Chiari malformation was iatrogenically overdosed with a 500 mg intravenous bolus of vancomycin during a shunt operation. The Red Mans Syndrome developed within minutes, characterized by sudden hypotension, skin rash and cyanosis. Serum vancomycin level at one hour after the injection was 165.7 micrograms/mL, as measured by an enzyme immunoassay method (EMIT). Multiple dose activated charcoal, 1 g/kg, was first given five hours after injection, and continued every four hours for 12 doses. The half-life of vancomycin during charcoal administration was calculated to be 9.4 h or less than the reported 13.4-33.7 h half-life in normal neonates. The neonates renal function tests and brainstem auditory responses remained normal. CONCLUSIONS Gastrointestinal dialysis with multiple-dose activated charcoal without cathartics appeared to shorten the elimination half-life of vancomycin.

Neuroprotective effects of ketorolac tromethamine after spinal cord injury in rats: an ultrastructural study.

IntroductionThe aim of this study was to investigate the effects of intrathecally administered ketorolac tromethamine on ultrastructural changes of the spinal cord in spinal cord-traumatised rats.MethodsMale Wistar rats were used and divided into three groups for this study. The rats in Group S (n=6) were control animals and received 10 μl of saline. Groups K50 (n=6) and K400 (n=6) received intrathecally 50 μg and 400 μg of ketorolac tromethamine, respectively, immediately after trauma was induced. All rats underwent laminectomy and the spinal cord was traumatised using the clip-compression technique. Electron microscopic examination of the cord samples was carried out 3 days after spinal cord injury.ResultsUltrastructural findings showed severe injury with extensive axoplasmic and cytoplasmic oedema in Group S. Minor neural damage occurred in Group K50 and increased ultrastructural protection was observed in the Group K400.ConclusionThis study demonstrates that intrathecal administration of ketorolac tromethamine protects the spinal cord following injury in rats.

Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit.

AbstractThe aim was to evaluate the nutritional situation of patients admitted to the Postoperative Acute Care Unit using classic methods of objective anthropometry, systemic evaluation methods, and Nutrition Risk in Critically Ill (NUTRIC) score, and to compare them as a predictor of morbidity and mortality.At admission to the postoperative care unit, patients undergoing various surgeries were assessed for the following items: Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Nutritional Risk Screening (NRS)-2002, Mini Nutritional Assessment (MNA), Charlson comorbidity index (CCI), and NUTRIC score, anthropometric measurements, serum total protein, serum albumin, and lymphocyte count. Patients were monitored for postoperative complications until death or discharge. Correlation of complications with these parameters was also analyzed.A total of 152 patients were included in the study. In this study a positive correlation was determined between mortality and NRS-2002, SGA, CCI, Acute Physiology and Chronic Health Evaluation , Sepsis-related Organ Failure Assessment, and NUTRIC score, whereas a negative correlation was determined between mortality and NRI. There was a correlation between NUTRIC score and pneumonia, development of atrial fibrillation, delirium, renal failure, inotrope use, and duration of mechanical ventilation. In our study group of postoperative patients, MNA had no predictive properties for any complication, whereas SGA had no predictive properties for any complications other than duration of hospital stay and mortality.The NUTRIC score is an important indicator of mortality and morbidity in postoperative surgical patients. NRI correlated with many postoperative complications, and though SGA and NRS were correlated with mortality, they were not correlated with the majority of complications. MNA was determined not to have any correlation with any complication, mortality, and duration of hospital stay in our patient group.

In vivo proton magnetic resonance spectroscopic examination of benzodiazepine action in humans

In an examination of the effect of benzodiazepines on brain chemistry, 44 healthy controls underwent a short echo-time proton magnetic resonance spectroscopy ((1)H MRS) session after induced sedation with intravenous midazolam (0.03mg/kg) plus fentanyl (2μg/kg). The regions of interest were the anterior cingulate cortex, right basal ganglia, right frontal lobe, and right hippocampus. Twenty-five of these subjects underwent the second (1)H MRS session while awake. The measured (1)H MRS metabolites included N-acetyl-aspartate, creatine-containing compounds (PCr+Cr), choline-containing compounds, myo-inositol, and glutamate plus glutamine, which were quantified both as absolute values and metabolite/PCr+Cr ratios. The results were analyzed using independent group t tests and repeated measures analysis of variance (ANOVA, with alpha values set at 0.025 to minimize the risk of false-positive findings arising from multiple comparisons. No significant difference between subjects under midazolam plus fentanyl induced sedation and awake could be detected with unpaired analyses. Paired comparisons by ANOVA with repeated measures found that neither drug (midazolam plus fentanyl) nor the drug by time (interval between two scan times) interaction had a significant effect on the quantified metabolites. These findings encourage utilization of benzodiazepine-induced brief sedation during in vivo (1)H MRS experiments of the brain, and may help with elucidation of state-dependent neurochemical alterations during the course of bipolar and schizoaffective disorders.

Effects of CO2 Pneumoperitoneum on Nephrotoxicity of Sevoflurane: An Experimental Study in Rabbits

Background: The purpose of this study is to evaluate the nephrotoxicity of sevoflurane inhalation anesthesia applied during carbon dioxide pneumoperitoneum (CO2- PNP) which is conducted for a laparoscopic surgery treatment. Materials and Methods: 14 New Zealand white rabbits were used in this study. Initially, anesthesia was induced using 3.7% concentrated sevoflurane + 50% O2/N2O. Then, a tracheotomy was performed, and the rabbits were mechanically ventilated. The first group (n = 7) was subjected to CO2-PNP for 90 min with a constant intraabdominal pressure of 12 mm Hg, the second (control group ) (n = 7) was exempted. The serum inorganic fluoride (IF-) concentration was measured. The rabbits were sacrificed after 72 h, and one kidney each was immediately extracted for histopathological examination. Results: Serum IF- concentrations were not different in both groups. Histopathologically, mild renal damage was found in one rabbit in each group. Conclusion: CO2-PNP did not have any additional effect on the nephrotoxicity of sevoflurane.

Right lung atelectasis during general anesthesia with laryngeal mask airway

SIR—This is a short report of anesthesia in a child with pyruvate dehydrogenase deficiency who presented for a lower extremity surgery. Pyruvate dehyrogenase deficiency is an X-linked mutation causing deficiencies of pyruvate dehydrogenase phosphatase (1). This results in elevated lactic acid which is aggravated by carbohydrates. There are three types of presentation of this disease. The first occurs in the neonatal period presents as a lethal lactic acidosis. The infantile form may also present as a lethal disease but more commonly presents with psychomotor retardation, cystic lesions in the brainstem and basal ganglia. (1) A milder form presents in later childhood and occurs predominantly in boys. This presents as ataxia associated with high carbohydrate diets. The enzyme is more active in these patients and thus they have less lactate acidosis. These children will have normal intelligence and facial dysmorphologic features. (1). Treatment for this particular disease is thiamine and a ketogenic diet. The patient was an 8-year-old male child presenting for tibial reconstruction. He had undergone an MRI under sedation but had no other surgical history. He was being treated with a ketogenic diet and thiamine. He was premedicated with midazolam. Following placement of electrocardiogram monitors, noninvasive blood pressure and pulse oximetry, and anesthesia was induced using oxygen, nitrous oxide and sevoflurane. When an adequate depth of anesthesia was achieved, 1 ml of 2% lidocaine was sprayed on his vocal cords and his trachea was intubated without difficulty. An intravenous line was started in the dorsum of his left hand and normal saline solution was infused. A blood gas at the beginning of surgery revealed a base deficit of )3.2 mmolÆl . The procedure lasted 150 min. At the end of the surgery another blood gas revealed a base deficit of )5.1 mmolÆl. When he was fully awake and responding to commands his trachea was extubated. His postoperative course was uneventful and he was discharged home under the care of his mother. There are very few reports of anesthesia in children with pyruvate dehydrongenase deficiency. A report of Dierforf and McNiece (2) was of an infant with the severe form which is usually fatal in the neonatal period. From their report it appears that treatment of the disease is now changing from the one which they described. The use of thiamine and a ketogenic diet is now the treatment of choice. Also our patient had the milder form of the disease and was well controlled with diet and thiamine. Although Dierdorf (2) suggested the avoidance of halogenated agents which could interfere with glucose metabolism as could thiopental, however, this is based on theory(3). As our experience with anesthesia in these children is limited, our recommendations may be restricted to the following: (i) avoid lactated solutions, (ii) give the least stress-producing anesthesia, and (iii) monitor the acid base status during surgery. J .F . Mayhew Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS, USA (email: rejfm@hotmail.com)

Comparison of Laryngeal Mask Airway SupremeTM Versus UniqueTM in Edentulous Geriatric Patients

OBJECTIVE It is more difficult to perform bag-mask ventilation in edentulous patients than in patients with intact dentition. The laryngeal mask airway (LMA) provides a better alternative to the standard face mask if the facial contours of the patient are not suited for the standard face mask. We aimed to compare these two different LMAs in edentulous geriatric patients. METHODS Edentulous patients aged ≥65 years of American Society of Anesthesiologists physical status I-III were included in the study. They were randomly assigned to Supreme group (n=30) and Unique group (n=30). Success of first insertion attempt, ease and time of insertion and oropharyngeal leak pressure were recorded. RESULTS The success rate of the first insertion attempt was higher in the Supreme group than in the Unique group (86.6 and 73.3%, respectively; p=0.04). Time of insertion was similar (10.04 s and 11.87 s, respectively) and insertion was easy in 90% and 100% of patients, respectively. Oropharyngeal leak pressures were measured as 20.56-cm H2O and 17.10-cm H2O for LMA Supreme™ and LMA Unique™, respectively. CONCLUSION The efficacy and safety in both groups were comparable in edentulous geriatric patients during short surgical procedures. Even the success rate of insertion with both was lower than that mentioned in the literature; the success of insertion at the first attempt was superior with the LMA Supreme™ in our edentulous study group.

Retrospective Evaluation of Anaesthetic Techniques for Caesarean.

OBJECTIVE This study aimed to evaluate the maternal, foetal and neonatal effects of anaesthetic techniques used in caesarean sections (C/S) retrospectively over 6 years at the Hospital of Medical School of Dokuz Eylül University and to compare the results with the literature from Turkey and developed countries. METHODS After obtaining approval from the ethics committee, anaesthetic and gestational data from all caesarean operations performed over a 6-year period between 2005 and 2010 was retrospectively obtained from hospital archives. RESULTS During this period, a total of 10,819 labours was conducted and C/S ratio was 55% with 5953 patients. General anaesthesia was performed in 1479 patients (24.8%) and regional anaesthesia was performed in 4474 patients (75.2%) [Spinal anaesthesia for 1203 patients (26.9%), epidural anaesthesia for 830 patients (18.5%) and combined spinal-epidural anaesthesia for 2441 patients (54.6%)]. In 2010, regional anaesthesia ratio increased to 84.6%, whereas in 2005, it was 63.8%. Regional anaesthesia was used significantly more often in both elective and urgent patients (82% elective and 65.2% emergency). Because of failed regional anaesthesia or surgical complications, anaesthesia was changed to general anaesthesia in 215 patients (4.8%). APGAR scores in 1 and 5 min were significantly higher with regional anaesthesia when compared with general anaesthesia. CONCLUSION Regional anaesthesia rate for C/S patients in the Hospital of Medical School of Dokuz Eylül University is increased and is higher than Turkeys average; but these figures are still lower than those in the developed countries.

Cardioprotective Effects of Remifentanil in a Sympathetic Hyperactivity Model in Rabbits.

OBJECTIVE In this study, the antiarrhythmic and anti-ischemic effects of a 6 μg kg(-1) min(-1) infusion dose of remifentanil are investigated in a central sympathetic hyperactivity model in rabbits. METHODS In this study, 18 New Zealand rabbits were used. The subjects were randomly divided into three groups (n=6) and received 10 μmol L(-1) glutamate intracerebroventricularly to provide the central sympathetic hyperactivity. In group 1, 10 μmol L(-1) glutamate was used; in group 2, 1 h before L-glutamate injection, 40 mg kg(-1) N (omega)-nitro-L-arginine methyl ester was intravenously (iv) administered; and in group 3, also 1 h before L-glutamate injection, 40 mg kg(-1) N (omega)-nitro-L-arginine methyl ester was iv administered. A 6 μg kg(-1) min(-1) dose of remifentanil infusion was administered 5 min before L-glutamate injection. Heart rate, systolic arterial pressure and mean arterial pressure were measured and recorded. Within 15 min of the intracerebroventricular L-glutamate injection, premature ventricular complexes, bigeminy ventricular arrhythmia, ventricular tachycardia, ST-segment shift and T-wave inversions were recorded. RESULTS When incidences of heart rate, rate pressure product, premature ventricular complexes and bigeminy ventricular arrhythmia were compared between groups, significant differences were not determined. Mean arterial pressure was more significantly increased in group 2 than in the other groups (p<0.05). Ventricular tachycardia, ST-segment shift and T-wave inversions were significantly lower in group 3 than in groups 1 and 2 (p<0.05). CONCLUSION Remifentanil (6 μg kg(-1) min(-1) for 5 min of infusion) prevented life-threatening ventricular tachycardia and electrocardiographic signs of myocardial ischemia in a model of arrhythmia resulting from the association of central sympathetic overactivity.