Sennur Uzun

Dexmedetomidine and postoperative shivering in patients undergoing elective abdominal hysterectomy.

Background Post‐anaesthetic shivering is one of the most common complications, occurring in 5–65% of patients recovering from general anaesthesia and 33% of patients receiving epidural anaesthesia. Our objective was to investigate the efficacy of intraoperative dexmedetomidine infusion on postoperative shivering. Methods Ninety female patients, ASA I‐II, 35–60 yr old, scheduled for elective total abdominal hysterectomy with or without bilateral salpingo‐oophorectomy were randomized into two groups. After endotracheal intubation one group received normal saline infusion and the other received dexmedetomidine as a loading dose of 1 &mgr;g kg−1 for 10 min followed by a maintenance infusion of 0.4 &mgr;g kg−1 h−1. In the recovery room, pain was assessed using a 100 mm visual analogue scale and those patients who had a pain score of more than 40 mm were administered 1 mg kg−1 intramuscular diclofenac sodium. Patients with shivering grades more than 2 were administered 25 mg intravenous meperidine. Patients were protected with passive insulation covers. Results Post‐anaesthetic shivering was observed in 21 patients in the saline group and in seven patients in the dexmedetomidine group (P = 0.001). Shivering occurred more often in the saline group. The Ramsay Sedation Scores were higher in the dexmedetomidine group during the first postoperative hour. Pain scores were higher in the saline group for 30 min after the operation. The need for intraoperative atropine was higher in the dexmedetomidine group. Intraoperative fentanyl use was higher in the saline group. Perioperative tympanic temperatures were not different between the groups whereas postoperative measurements were lower in the dexmedetomidine group (P < 0.05). Conclusion Intraoperative dexmedetomidine infusion may be effective in the prevention of post‐anaesthetic shivering.

Perioperative anxiety and postoperative behavioural disturbances in children : comparison between induction techniques

Background and objective: This study was designed to determine if subhypnotic propofol reduces postoperative behavioural disturbances in children undergoing sevoflurane induction compared with intravenous propofol induction for elective adenoidectomy and tonsillectomy. Methods: Following Ethics Committee approval and parental informed consent, ASA I–II, 120 children (2–10 yr) were recruited. Parents were not allowed to accompany their child. Unpremedicated children were randomly allocated to groups receiving inhalation induction with sevoflurane, 2–2.5 mg kg−1 intravenous propofol induction or inhalation induction with sevoflurane followed by subhypnotic dose of propofol (1 mg kg−1). Anaesthesia was maintained with 2–4% sevoflurane, O2 and N2O. Anxiety on arrival to operating theatre, at anaesthesia induction and 30 min after emergence was assessed. Parents completed a state–trait anxiety inventory test preoperatively and a post hospitalization behaviour questionnaire a week later to assess childrens postoperative behavioural disturbances. Kruskal–Wallis test, Wilcoxon signed rank sum test, Bonferronis test, Paired t‐test, t‐test, Pearson and Spearmans rank correlation test, χ2‐test were used for statistical analysis. Results: The anxiety level at induction was high in all groups (P < 0.05). There was no difference between groups in respect to anxiety at other measurement times. A relation between preoperative anxiety level and postoperative behavioural disturbances was determined (P < 0.05). Some behavioural disturbances as nightmare/night fear and desire of sleeping with parents were rarely seen in intravenous propofol induction group (P < 0.05). Conclusion: Addition of subhypnotic dose of propofol to sevoflurane induction did not reduce the incidence of postoperative behavioural disturbances.

A clinical comparison of etomidate-lipuro, propofol and admixture at induction.

Objective: The purpose of this study was to compare etomidate-lipuro and propofol and 50%, (1:1) admixture of these agents at induction with special reference to injection pain, hemodynamic changes, and myoclonus. Methods: Ninety patients were assigned at random to three groups in which induction was performed with either etomidate-lipuro, propofol or etomidate-lipuro–propofol admixture. After monitorization with bispectral index (BIS) all agents were given with infusion with a perfuser at a constant rate of 200 ml/min till the BIS values decreased to 40. Blood pressure and heart rate were measured every 30 s at this period. Patients were asked for pain at the injection site and observed visually for myoclonus. The time BIS values decreased to 40 (BIS 40 time) and total amounts of induction doses were measured. Results: BIS 40 time measurements were P > E > PE (199.4 ± 40.9, 176.9 ± 31.6, 163.5 ± 20.6 s). The hemodynamic (systolic, diastolic and mean blood pressures, heart rate) changes were minimal in group PE than other two groups (P = 0.017). The intensity of myoclonus was graded as mild in 9, moderate in 12, and severe in 5 patients in the group E (76.3%). Myoclonus was not observed in group PE and group P. There were no injection pain in group PE as the incidence were (83.8%) in group P and in (63.2%) group E. Conclusion: Incidence of hemodynamic changes, myoclonus, and injection pain is significantly lower in group PE. BIS 40 times is least in group PE. We concluded that 1:1 admixture of etomidate-lipuro and propofol is a valuable agent for induction.

The effect of intravenous paracetamol for the prevention of rocuronium injection pain

Rocuronium is a nondepolarizing neuromuscular blocking agent used in anesthesia induction and is associated with considerable discomfort and burning pain during injection, which is reported to occur in 50–80% of patients. This study was carried out to investigate the effectiveness of intravenous paracetamol pretreatment compared with lidocaine and normal saline to prevent rocuronium injection pain. The study included 150 ASA I–II patients undergoing elective orthopedic, gastrointestinal, and gynecological procedures under general anesthesia. They were allocated into three groups according to pretreatment drugs: lidocaine (40 mg) (n = 50), paracetamol (n = 50), and normal saline group (n = 50). Before anesthesia induction with propofol, all patients were pretreated with rocuronium. The pain caused by the injection was evaluated. Local signs were assessed on the arm at the end of the injection, as well as 24 hours after recovery from anesthesia. There were no patients with blurred speech or vision and there was no respiratory depression in any group after pretreatment with the study drug. The level of pain on injection was statistically lower in those who had received paracetamol compared to normal saline (p = 0.009). There were more patients in the saline group with severe pain (p < 0.001). Paracetamol relieved the rocuronium injection pain better than normal saline but lidocaine was the best of the three drugs (p < 0.001).

Asymptomatic vallecular cyst: case report.

A 56-year-old man presented himself for an intracranial glioblastoma multiforme excision. After being routinely monitored, he was preoxygenated. We induced anesthesia and paralysis with 200mg propofol, 50 μg fentanyl and 9 mg vecuronium. Direct laryngoscopy with a Macintosh 3 blade revealed a 2 x 2 cm cyst, pedunculated, arising from the right side of the vallecula preventing the endotracheal intubation. While the patient remained anesthetized, we urgently consulted an otolaryngologist and aspirated the cyst with a 22-gauge needle and syringe under direct laryngoscopy. We aspirated 10 cc of liquid content. This was followed by an uneventful tracheal intubation with a 9.0 enforced spiral cuffed tube. An alternative to fiberoptic intubation may be careful cyst aspiration to facilitate the intubation.

Incidence of venous air embolism and blood gas changes seen in infratentorial surgeries operated in sitting position

Our aim was to find out the rate and timing of venous air embolism (VAE), other complications associated with sitting position and changes on arterial blood gas during and after VAE. We analyzed retrospectively files of 124 patients who underwent posterior fossa surgery in department of Neurosurgery of our institute between January 2004 and April 2014. The incidence of emboli was 76,3% in the first 3 hours of the surgery while it was 38.2% in the first 2 hours in total. VAE was seen in a total of 21 patients (16.9%) and it was detected by a sudden drop of minimum 2mmHg of end-tidal CO2 (EtCO2)(25.38 ± 3.28 mmHg) in all cases (100%). The pH, PaO2 and PaCO2 values of the patients with and without emboli were evaluated pre and post-operatively and no significant difference was found (p>0.05). Precordial doppler ultrasonography is the most sensitive non-invasive monitoring device for accurate detection of even small VAE which are not clinically relevant. The most sensitive technique for detection of VAE is transoesophageal echocardiography but it is expensive, invasive and can cause some serious complications. In our study, emboli were most frequently seen in the 3rd hour of the surgery which coincide with tumor resection, thus proposing anaesthesiologists to be more cautious about VAE and EtCO2 during the tumor resection period.