Semra Karaman

The effects of sufentanil or morphine added to hyperbaric bupivacaine in spinal anaesthesia for Caesarean section

Background and objective: The quality of spinal anaesthesia, often used for Caesarean section, can be improved by adding an opioid to the local anaesthetic. This study compared the quality of anaesthesia, postoperative analgesia, and adverse effects on mother and neonate when either sufentanil 5 μg or morphine 0.2 mg was added to intrathecal hyperbaric bupivacaine for Caesarean section. Methods: This prospective, randomized and double‐blind study encompassed 54 females undergoing Caesarean section. Spinal anaesthesia was obtained with 2 mL of 0.5% bupivacaine supplemented with either 0.2 mg morphine or 5 μg sufentanil. Characteristics of spinal block, intraoperative analgesia, maternal and neonatal side‐effects and the time to first request for analgesics were assessed. Results: There were no differences in the onset time of sensory block, time to sensory block to T10, time to highest sensory block, highest sensory block level, time to regression of sensory block to T10 level and time to resolution of motor blockade. Perioperative haemodynamic parameters, neonatal Apgar scores, neurological and adaptive capacity scores, umbilical blood gas values, sedation scores, nausea–vomiting and pruritus incidences were similar in both groups. The time to the first request for an analgesic was significantly longer (19.5 ± 4.7 h vs. 6.3 ± 5.2 h) in patients given morphine (P < 0.05). Conclusions: The addition of 5 μg sufentanil or 0.2 mg morphine to hyperbaric bupivacaine for Caesarean section both provided safe and effective anaesthesia. Morphine increased the duration of postoperative analgesia compared with sufentanil without increasing maternal or neonatal side‐effects.

Intrathecal morphine : Effects on perioperative hemodynamics, postoperative analgesia, and stress response for total abdominal hysterectomy

Intrathecal opioids provide postoperative analgesia and hemodynamic stability by depressing the neuroendocrine response during the perioperative period. The effects of preoperative intrathecal morphine on perioperative hemodynamics, stress response, and postoperative analgesia were evaluated in patients undergoing abdominal hysterectomy with general anesthesia. A total of 24 patients were randomly assigned to the morphine group (n=12) or the control group (n=12). Patients in the morphine group were given intrathecal 5 μg/kg−1 morphine before surgery. In all patients, general anesthesia was induced with 1 g/kg−1 remifentanil, 2 mg/kg−1 propofol, and 0.1 mg/kg−1 vecuronium and was maintained with 1% to 2% sevoflurane—35% oxygen in N2O and remifentanil infusion. All patients received intravenous morphine patient-controlled analgesia after surgery. Postoperative pain was evaluated by means of a visual analogue scale. Blood samples were taken at 4 time points before and up to 4 hours after the start of surgery for assessment of plasma epinephrine, norepinephrine, and glucose. Mean arterial pressure (MAP), heart rate (HR), and adverse effects were recorded. Intraoperative hemodynamics was similar in both groups, but postoperative HR and MAP values at 4 h, 8 h, 12 h, and 20 h were significantly lower in the morphine group (P < .05). Postoperative VAS scores, total morphine consumption, and plasma epinephrine, norepinephrine, and glucose levels were significantly lower in the morphine group than in the control group (P < .05). Preoperative intrathecal morphine enhanced the quality of postoperative analgesia, decreased morphine consumption, and depressed the systemic stress response in patients undergoing total abdominal hysterectomy with general anesthesia.

The Effect of Pre-operative Lornoxicam and Ketoprofen Application on the Morphine Consumption of Post-operative Patient-controlled Analgesia

We compared the efficacy of preoperative intramuscular lornoxicam and ketoprofen for post-operative analgesia in patients undergoing abdominal hysterectomy. This randomized, double-blind, placebo-controlled, parallel-group study investigated 60 patients who received lornoxicam (group L, 8 mg), ketoprofen (group K, 100 mg) or saline (group C) 60 min before standard anaesthesia. All patients received patient-controlled analgesia (intravenous morphine) during the post-operative period. Visual analogue scale (VAS) scores recorded 2, 4, 6 and 12 h after surgery in groups L and K patients were significantly lower than in group C patients, and VAS scores at 2, 4 and 6 h in group L patients were significantly lower than those in group K patients. Morphine consumption in groups L and K was significantly lower than in group C. Pre-emptive administration of lornoxicam and ketoprofen effectively reduced post-operative pain and morphine consumption, and lornoxicam was more effective than ketoprofen in the early post-operative period.

The effects of dexmedetomidine on spontaneous contractions of isolated gravid rat myometrium.

The direct effects of dexmedetomidine on isolated gravid rat myometrium were investigated in this in vitro study; such effects may have clinical repercussions in the administration of anesthesia to obstetric patients. Samples of myometrium were taken from 12 gravid rats. Myometrial strips were dissected microscopically and mounted on the myograph at a resting tension of 1 gin bath that contained Krebs solution. After spontaneous contractions of the myometrium had been steadily established, increasing concentrations of dexmedetomidine were added to baths via micropipette, and the effects of these additions were recorded via myograph. Dexmedetomidine in vitro caused a significant increase in the amplitude, frequency, and area under the curve of myometrial contractions in a dose-dependent manner. Results of this study demonstrate that dexmedetomidine increases spontaneous contractions in rat myometrium; however, further investigation is needed to clarify the usefulness of dexmedetomidine in the administration of obstetric anesthesia.

The maternal and neonatal effects of the volatile anaesthetic agents desflurane and sevoflurane in caesarean section: a prospective, randomized clinical study.

This study compared maternal and neonatal outcomes in women undergoing elective caesarean section under general anaesthesia with desflurane or sevoflurane; the neonatal effects were also compared with those in women undergoing epidural anaesthesia. Fifty women requesting general anaesthesia were randomly assigned to receive either 3% desflurane or 1% sevoflurane. Twenty-five women requesting regional anaesthesia received epidural anaesthesia with ropivacaine. Comparing desflurane and sevoflurane with respect to their maternal haemodynamic effects, maternal blood pressure levels were higher and tachycardia was more frequent in the desflurane group. Comparing general and epidural anaesthesia, no significant differences were detected in terms of neonatal Apgar scores or neurological adaptive capacity scores. In conclusion, 3% desflurane or 1% sevoflurane for general anaesthesia and ropivacaine for epidural anaesthesia for elective caesarean section had similar effects on neonatal outcomes. In women who received desflurane, blood pressure and heart rate elevation were significantly higher than in the sevoflurane group, though this difference did not have any clinical importance.

Anesthetic management for cesarean delivery in a pregnant woman with polymyositis: A case report and review of literature

IntroductionPolymyositis which is a rare disease both in general population and in pregnancy is systemic connective tissue disorder characterized by inflammation and degeneration of muscles. There is only a little information relating to the anesthetic management of a pregnant woman with polymyositis.Case presentationIn this article, we present anesthetic management of urgent cesarean delivery of a 28-year-old parturient with polymyositis under epidural anesthesia who was diagnosed with polymyositis five years ago and has been treated regularly with different doses prednisolone since then.ConclusionIn a parturient with polymyositis, it should not be suggested general anesthesia due to risks including delayed recovery from muscle relaxation, aspiration pneumonitis, arrhythmias, cardiac failure, we consider that epidural anesthesia for cesarean section can be safely applied.

Anesthetic approach to a patient with multiple pterygium (Escobar) syndrome.

SIR—We read with interest the article by Lee et al. (1) on optimum time for intravenous cannulation after induction with sevoflurane. We feel that their recommendation of 3.5 mins of sevoflurane induction after loss of eyelash reflex for problem-free intravenous cannulation may not be appropriate in all patients. This is because all patients may not be ready for cannulation at 3.5 mins as it may occasionally be prolonged depending on variables such as depth of spontaneous breathing and occasional periods of breath holding. We have been placing supraglottic device and performing intravenous cannulation in pediatric patients depending on the eye signs. We begin with gradually increasing concentrations of sevoflurane induction. While this is in progress, we watch for the eyeball movement. During initial period of induction, the eyeballs are roving from the midline and are often pulled up/down or are divergent. As anesthesia deepens, eye balls become gradually central. This generally takes 4–5 mins. It is at this stage of eye sign, which is most suited for intravenous cannulation or placement of supraglottic device without any unwanted reaction from the patient. This technique is independent of patient breathing variables and provides a clear end point for safe intervention which is tailored to the specific patient.

Peripheral nerve block in a patient with amyotrophic lateral sclerosis

To the Editor: We have used lumbar plexus and sciatic nerve blocks in an ALS patient with a collum femoris fracture. The patient was 55-year-old female who had been followed-up for the past 1.5 years for ALS with bulbar onset and upper and lower motor neuron involvement. On physical examination, jaw opening was limited, the patient was dysphonic, and, because of dysphagia, a nasogastric tube was inserted. Preoperative ALS severity score was 17 (speech, 5: frequent repeating required; swallowing, 4: supplemental tube feeding; lower extremity and walking, 4: able to support weight; upper extremity dressing and hygiene, 4: attendant assists patient) [1]. Her ALSSS score the first month postoperatively was 13. The anatomical reference points were marked for lumbar plexus and sciatic nerve blocks by the posterior approach (Winnie’s technique). An 8-cm, 17-gauge Touhy needle (Arrow, USA) was inserted and attached to a nerve stimulator (Stimuplex HNS 11, BBraun). When twitch of the quadriceps muscle and patella at 0.5 mA current was observed, a 60-cm stimulating peripheral nerve catheter (Stimucath, Arrow, International PA, USA) was placed by the lumbar plexus. A mixture of local anesthetics comprising 15 ml 0.25% levobupivacaine (Chirocaine 0.5%, Abbott, Turkey) ? 10 ml 1% prilocaine (Citanest 2%, Astra Zeneca, Turkey) was administered to the lumbar plexus via the catheter, monitoring the nerve motor response. Then, a 21-gauge, 100 mm long Stimuplex needle (Stimuplex A, BBraun, Germany) was inserted to the sciatic nerve sheet. A 0.5 mA current was given by nerve stimulator (Stimuplex HNS 11, BBraun) until plantar flexion was observed then a mixture of 10 ml 0.25% levobupivacaine and 10 ml 1% prilocaine was injected. At 20 min of the procedure, motor block score using the bromage scale was 3, and at 25 min the sensory level (T10) was determined by pin-prick and cold tests. At the fourth hour postoperatively the motor block resolved. Follow-up control visit at 3 months showed no neurological progression in terms of ALS. In neurological diseases such as ALS, regional techniques are relatively contraindicated because of mechanical trauma induced by needle or catheter, nerve ischemia as a result of supplementation of vasoconstrictor agents, and toxic effects of local anesthetics. However, more recently, researchers argue that regional techniques may be used in patients with neurological disease on the basis of risk– benefit analysis [2]. In ALS, peripheral nerve blocks have advantages over other anesthesia techniques in terms of prevention of respiratory failure due to weakness of the respiratory muscles, protection of the laryngeal reflexes, and maintaining of the hemodynamic stability [3]. Lumbar plexus and sciatic nerve blocks have disadvantages attributable to being technically challenging, late onset of anesthesia compared with neuraxial anesthesia, insufficient anesthesia, and toxicity due to use of more local anesthetic than for neuraxial anesthesia. In conclusion, we suggest that peripheral nerve blocks can be chosen as an alternative technique to neuraxial blocks and general anesthesia in ALS patients undergoing surgery on their extremities. Although we performed peripheral nerve block with a stimulating nerve catheter, ultrasound-guided nerve block with nerve stimulation could be best for regional anesthesia in ALS patients. N. Sertoz (&) S. Karaman Department of Anesthesiology and Reanimation, Ege University, School of Medicine, Izmir 35100, Turkey e-mail: nezihsertoz@mynet.com

The relationship between the Trendelenburg position and cerebral hypoxia inpatients who have undergone robot-assisted hysterectomy and prostatectomy

Background/aim: This study aimed to evaluate the relationship between the Trendelenburg position and cerebral hypoxia in robot-assisted hysterectomy and prostatectomy.Materials and methods: A standardized mini-mental state examination was administered to 50 patients enrolled in the study 1 h before and after surgery. Near infrared spectroscopy (NIRS) values and hemodynamic and respiratory parameters were recorded after induction of anesthesia (baseline) and once every 20 min in the Trendelenburg position and supine positions. The relationship between the development of cerebral desaturation and the patients position was examined. Results: For all patients, the baseline mean cerebral oxygen saturation (RSO2) on the right and left were 70.5 ± 7.3% and 70.6 ± 6.7%, respectively. Right RSO2 values at 20 min and 60 min in the Trendelenburg position decreased significantly, but they increased at 120 min. A significant positive correlation was found between right RSO2 and EtCO2 in the supine period following surgery, and between left RSO2 and EtCO2 at 60 min in the Trendelenburg and supine positions. The relationship between NIRS values and cognitive dysfunction was not significant.Conclusion: We found that cerebral saturation decreases as age increases, and cerebral desaturation may occur owing to the Trendelenburg position. There was no correlation between patients? cognitive function and NIRS values.

The Evaluation of Applied Anaesthetic Techniques for Caesarean in Parturients with Cardiac Diseases: Retrospective Analysis.

OBJECTIVE In this study, the effects of anaesthetic technique on mother and newborn were investigated in a retrospective analysis of parturients with cardiac diseases undergoing Caesarean section between 2006-2012. METHODS Our hospitals medical information system records were analyzed, and we found 107 parturients with cardiac disease and were undergoing Caesarean section, and their demographic data and obstetric, anaesthetic, and neonatal record forms were inspected. RESULTS Fifty-three (49.5%) pregnant women received general anaesthesia, and 54 (50.5%) received regional anaesthesia (34 spinal, 19 epidural and 1 CSE) (p=0.05). Week of pregnancy was lower for the group of general anaesthesia (p=0.007). Among cardiac parturients, valvular lesion rates were higher (75.7%). The relationship between existing cardiac disease and anaesthetic management was not significant (p=0.28). However, we determined that parturients with higher NYHA (New York Heart Association) classifications had higher general anaesthesia rates. (p=0.001). A rate of 39% of 74 NYHA I patients were undergoing general anaesthesia; this rate was 64% for NYHA II and 100% for NYHA III. The patients with cardiac surgery or medical treatment history had higher general anaesthesia rates (p=0.009). Although the general anaesthesia group newborn weights were lower (p=0.03), there was no difference between groups for APGAR scores. With regard to postoperative complications and hospital stay, the groups were similar. CONCLUSION We determined that general and epidural rates in parturients with cardiac diseases were similar, general anaesthesia was preferred for parturients who had higher NYHA classifications and surgical or medical treatment history. We considered that general anaesthesia criteria should reduce the anaesthesia management of parturients with cardiac disease; epidural or CSE anaesthesia applications should increase according to the patients physical state, haemodynamic parameters, and obstetric indications.