Serdar Kokulu

Anti-inflammatory and Antiapoptotic Effect of Interleukine-18 Binding Protein on the Spinal Cord Ischemia-Reperfusion Injury

We investigated the anti-inflammatory and antiapoptotic effects of interleukin-18 binding protein (IL-18BP) on spinal cord ischemia/reperfusion (I/R) injury in rats. Twenty-one adult male rats were divided into three groups: sham, I/R, and I/R+IL-18BP. Proinflammatory cytokines were determined in rat blood samples by using ELISA, while apoptosis was immunohistochemically evaluated in spinal cord tissue using caspase 3. Both IL-18 and TNF-α were significantly decreased in the IL-18BP group compared to that in the sham group. The highest caspase 3 levels were observed in the I/R group, while the lowest levels were found in the sham group. The mean Tarlov score of the I/R group was significantly lower than that of the sham group. However, the mean Tarlov score of the IL-18BP group was significantly higher than that of the I/R group. The results of the current study demonstrate that IL-18BP plays both anti-inflammatory and antiapoptotic roles in spinal cord I/R injury.

The effectiveness of transdermal opioid in the management multiple rib fractures: randomized clinical trial.

BACKGROUND The most commonly observed pathology in chest traumas is rib fracture, and the most important clinical symptom is severe pain. AIMS To investigate the effectiveness of intramuscular opioid (IMO), intravenous patient-controlled analgesia (IVPCA) and the Fentanyl transdermal therapeutic system (TTS) in the management of rib fracture pain. STUDY DESIGN Prospective randomized clinical trial. METHODS In our prospective and randomised study, we included 45 patients with a diagnosis of multiple rib fractures. There were three groups and intercostal nerve blockage (ICB) in the first day and oral paracetamol for five days was administered to each group as standard. In Group IMO (n=15), 4×40 mg pethidine HCl was administered to the patients, while in Group IVPCA (n=15) this was 5 μg/mL continuous intravenous fentanyl and was 50 μg fentanyl TTS in Group TTS (n=15). The demographics, injury data and vital signs of the patients were recorded. Pain was scored using Visual Analogue Scale (VAS). The pain during lying down (VASl) and mobilisation (VASm) was detected. RESULTS There were no differences between the three groups regarding age, sex, the trauma pattern, the number and distribution of costal fracture localisations, the presence of additional pathology, complications, thoracal catheter and the duration of thoracal catheter. No significant difference between the groups regarding systolic and diastolic arterial tension, number of breaths and beats in a minute was observed (p>0.05). We observed an improvement in the mean VAS score after treatment in all three groups. The mean VASl score significantly decreased after treatment in each group (p<0.05). The mean VASl and VASm scores measured on the 1(st), 2(nd), 3(rd), 4(th) and 5(th) days were found to be higher in Group IMO than in Groups IVPCA and TTS; however, these differences were not statistically significant (p>0.05). CONCLUSION In the analgesia of patients with multiple rib fractures, TTS administration with ICB showed similar effectiveness with IVPCA administration with ICB. In the management of pain due to multiple rib fractures, TTS administration is a safe, non-invasive and effective procedure.

Effect of Transversus Abdominis Plane Block on Cost of Laparoscopic Cholecystectomy Anesthesia

Background Use of transversus abdominis plane (TAP) block for postoperative analgesia is continuously increasing. However, few studies have investigated intraoperative effects of TAP block. We aimed to study the effects of TAP block in terms of cost-effectiveness and consumption of inhalation agents. Material/Methods Forty patients undergoing laparoscopic cholecystectomy were enrolled in this study. Patients were randomly divided into 2 groups: Group 1 (n=20) patients received TAP block and Group 2 (n=20) patients did not receive TAP block. Standard anesthesia induction was used in all patients. For the maintenance of anesthesia, fractional inspired oxygen (FIO2) of 50% in air with desflurane was used with a fresh gas flow of 4 L/min. All patients were monitored with electrocardiography and for peripheral oxygen saturation (SpO2), end-tidal carbon dioxide (ET), heart rate (HR), noninvasive mean blood pressure (MBP), and bispectral index (BIS). Bilateral TAP blocks were performed under ultrasound guidance to Group 1 patients. The BIS value was maintained at between 40 and 50 during the surgery. The Dion formula was used to calculate consumption of desflurane for each patient. Results There was no difference between the groups with respect to demographic characteristics of the patients. Duration of anesthesia, surgery time, and dosage of fentanyl were similar in the 2 groups. However, the cost and consumption of desflurane was significantly lower in Group 1. Conclusions Total anesthesia consumption was lower and the cost-effectiveness of anesthesia was better in TAP block patients with general anesthesia than in non-TAP block patients undergoing laparoscopic cholecystectomy.

Interleukin-18 Binding Protein Pretreatment Attenuates Kidney Injury Induced by Hepatic Ischemia Reperfusion ☆ ☆☆ ★

Objective: Acute kidney injury (AKI) is a serious condition that can be induced by liver transplantation, major hepatic resection or prolonged portal vein occlusion. AKI can increase the frequency of postoperative complications. In the current study, we aimed to investigate whether interleukin‐18 binding protein (IL‐18BP) pretreatment has a protective effect against possible kidney injury following liver ischemia‐reperfusion (IR) achieved by Pringle maneuver in an experimental rat model. Materials and Methods: A total of 24 male Wistar albino rats were included in this study. Animals were equally and randomly separated into 3 groups as follows: I, Sham group, II, IR group (1‐hour ischemia and 4‐hour reperfusion) and III, IR + IL‐18BP group (50 &mgr;g/kg IL‐18BP was intraperitoneally administered 30 minutes before surgery). Blood, liver and kidney samples were collected for histopathological and biochemical (hepatic and renal function, nitric oxide, malondialdehyde and glutathione levels) analysis. In addition, proinflammatory cytokines including tumor necrosis factor &agr;, IL‐1&bgr; and IL‐6 levels were measured in kidney tissues. Results: IL‐18BP has improved kidney functions in acute kidney damage, restored structural changes, exhibited anti‐inflammatory effects by decreasing proinflammatory cytokines and regulated the oxidative stress parameters by antioxidant effect. Conclusions: Current study would be the first to evaluate the protective, antioxidant and anti‐inflammatory effects of IL‐18BP on renal damage induced by liver ischemia (1 hour) and reperfusion (4 hours). As a result, we have demonstrated that AKI may develop after hepatic IR with Pringle maneuver and IL‐18BP pretreatment can attenuate this damage. By this way, complications related to liver IR could be minimized and also postoperative hospitalization durations, treatment costs and healing periods could be decreased.

Evaluation of low tidal volume with positive end-expiratory pressure application effects on arterial blood gases during laparoscopic surgery.

Background: Pneumoperitoneum (PNP) and patient positions required for laparoscopy can induce pathophysiological changes that complicate anesthetic management during laparoscopic procedures. This study investigated whether low tidal volume and positive end‐expiratory pressure (PEEP) application can improve ventilatory and oxygenation parameters during laparoscopic surgery. Methods: A total of 60 patients undergoing laparoscopic surgery were randomized to either the conventional group (n = 30, tidal volume = 10 mL/kg, rate = 12/minute, PEEP = 0 cm H2O) or the low tidal group with PEEP group (n = 30, tidal volume = 6 mL/kg, rate = 18/minute, PEEP = 5 cm H2O) at maintenance of anesthesia. Hemodynamic parameters, peak plateau pressure (Pplat) and arterial blood gases results were recorded before and after PNP. Results: There was a significant increase in the partial pressure of arterial carbon dioxide (PaCO2) values after PNP in the conventional group in the reverse Trendelenburg (41.28 mmHg) and Trendelenburg positions (44.80 mmHg;p = 0.001), but there was no difference in the low tidal group at any of the positions (36.46 and 38.56, respectively). We saw that PaO2 values recorded before PNP were significantly higher than the values recorded 1 hour after PNP in the two groups at all positions. No significant difference was seen in peak inspiratory pressure (Ppeak) at the reverse Trendelenburg position before and after PNP between the groups, but there was a significant increase at the Trendelenburg position in both groups (conventional; 21.67 cm H2O, p = 0.041, low tidal; 23.67 cm H2O, p = 0.004). However, Pplat values did not change before and after PNP in the two groups at all positions. Conclusion: The application of low tidal volume + PEEP + high respiratory rate during laparoscopic surgeries may be considered to improve good results of arterial blood gases.

Interleukin 18–binding protein ameliorates liver ischemia–reperfusion injury

BACKGROUND The aim of this study was to investigate the possible protective effect of interleukin 18-binding protein (IL-18BP) on ischemia-reperfusion (I/R)-induced liver injury in experimental rat models. Liver is one of the most affected organs from I/R process. IL-18 is an important proinflammatory cytokine, which may induce some events such as production of reactive oxygen substances and release of various cytokines. IL-18BP acts as an inhibitor of IL-18. The relationship between IL-18 and IL-18BP has an important place in inflammatory process. MATERIALS AND METHODS Rats were equally divided into three groups as follows: sham: Hepatic pedicle dissection was done, but hepatic pedicle clamping was not used. I/R: Sixty minutes of ischemia and 2 h of reperfusion were applied. IR + IL-18BP: Recombinant human IL-18BP (100 μg/kg) was administered 30 min before the surgery. Hepatic pedicle was clamped during 60 min of ischemia and 2 h of reperfusion was achieved. RESULTS Liver enzyme levels were significantly lower in the IR + IL-18BP group, when compared with the I/R group. Serum and tissue levels of tumor necrosis factor-α, IL-6, and IL-18 were considerably lower in the IR + IL-18BP group, when compared with the I/R group, but hepatic interferon-γ and IL1β levels were not significant. Serum oxidative stress index level was significantly higher in the I/R group, when compared with the IR + IL-18BP group. In immunostaining, it was observed that pathologic changes were lower in IR + IL-18BP group than the I/R group. CONCLUSIONS IL-18BP exhibited anti-inflammatory, antioxidant, and protective effects in I/R-mediated hepatic injury via regulating some liver enzyme activities and cytokine levels. Additionally, these effects have been verified by histomorphologic examination and oxidative stress markers.

Exploring for the Safer Ventilation Method in Laparoscopic Urologic Patients? Conventional or Low Tidal?

BACKGROUND To study the effects of low tidal volume with positive end-expiratory pressure (PEEP) on arterial blood gases of patients undergoing laparoscopic urologic surgeries. SUBJECTS AND METHODS Eighty-six laparoscopic urologic patients were enrolled in this study. Patients were randomized into two groups according to the ventilatory settings. In the conventional group (Group C) (n=43), the tidal volume was 10 mL/kg, and the PEEP was set at 0 cm of H2O. In the low tidal volume with PEEP group (Group LP), the tidal volume was 6 mL/kg, with PEEP of 5 cm of H2O. In both groups total minute volume was 6 L/kg. Peak and plateau airway pressure (PPEAK and PPLAT, respectively) and arterial blood gases were recorded before pneumoperitoneum (PNP) (T1) and the first and third hour (T3) after PNP induction and also after extubation in the intensive care unit. Additionally, heart rate, mean arterial pressure, and peripheral O2 saturation of hemoglobin were recorded. RESULTS Heart rate, PPEAK, and PPLAT values were similar in both groups. Partial arterial O2 pressure values measured postoperatively were significantly higher in Group LP, whereas those measured before PNP induction were similar (P=.014 and P=.056, respectively). Compared with the baseline, partial arterial CO2 pressure values measured at T1 and at T3 after PNP induction were significantly higher in Group C than in Group LP (P<.001). The pH values of Group C at T1 and at T3 postoperatively were significantly lower than the values of Group LP (P<.001). Extubation times were significantly lower in Group LP. CONCLUSIONS The results of the present study suggest that low tidal volume with PEEP application may be a good alternative for preventing high CO2 levels and yielding better oxygenation and lower extubation times in patients undergoing prolonged laparoscopic urology.

Results of the open surgery after endoscopic basket impaction during ERCP procedure

AIM To report the results of open surgery for patients with basket impaction during endoscopic retrograde cholangiopancreatography (ERCP) procedure. METHODS Basket impaction of either classical Dormia basket or mechanical lithotripter basket with an entrapped stone occurred in six patients. These patients were immediately operated for removal of stone(s) and impacted basket. The postoperative course, length of hospital stay, diameter of the stone, complication and the surgical procedure of the patients were reported retrospectively. RESULTS Six patients (M/F, 0/6) were operated due to impacted basket during ERCP procedure. The mean age of the patients was 64.33 ± 14.41 years. In all cases the surgery was performed immediately after the failed ERCP procedure by making a right subcostal incision. The baskets containing the stone were removed through longitudinal choledochotomy with the stone. The choledochotomy incisions were closed by primary closure in four patients and T tube placement in two patients. All patients were also performed cholecystectomy additionally since they had cholelithiasis. In patients with T-tube placement it was removed on the 13(th) day after a normal T-tube cholangiogram. The patients remained stable at postoperative period and discharged without any complication at median 7 d. CONCLUSION Open surgical procedures can be applied in patients with basket impaction during ERCP procedure in selected cases.

Comparison of Transcutaneous Electrical Nerve Stimulation and Paravertebral Block for Postthoracotomy Pain Relief

BACKGROUND Inadequate relief of postthoracotomy pain is a major reason of increased occurrence of postoperative complications. We aimed to investigate and compare the effects of transcutaneous electrical nerve stimulation (TENS) and paravertebral block (PVB) to relieve pain after thoracotomy procedures. MATERIALS AND METHODS We studied 40 patients who underwent thoracotomy. Patients were randomly allocated to receive either PVB (group P, n = 20) or TENS (group T, n = 20) for postoperative pain. The electrodes of TENS were placed 2 cm under and 2 cm over the thoracotomy cut on both posterior and anterior sides. The surgeon inserted paravertebral catheters using direct vision at the end of the surgery. A patient-controlled analgesia (PCA) device was connected to all patients. Visual analog scales, patient demand, and consumption of tramadol were evaluated postoperatively. RESULTS Mean visual analog scale (VAS) values were significantly lower in group P for all time points. The patients in group P needed lower amounts of opioid (tramadol) and the difference was statistically significant (258.4 ± 13.52 mg vs. 314.4 ± 8.65 mg, p = 0.005). In addition, the number of demand attempts recorded from the PCA device was significantly lower in group P (14.95 ± 13.64 vs. 26.7 ± 17.34, respectively and p < 0.001). CONCLUSION TENS has beneficial effects for pain relief after thoracotomy, without any side effects; however, it cannot provide sufficient pain relief when compared with PVB.

Nossa experiência em anestesia durante terapia eletroconvulsiva em pacientes grávidas

e administration of remote location anesthesia, analsia, and sedation practices to pregnant patients has reased in recent years. Psychiatric disorders emerging or ccurring during pregnancy may cause severe problems Choosing an anesthetic agent that has no maternal or fetal toxic effects is important in remote location anesthesia for pregnant women. In terms of teratogenic risk, ECT use in pregnancy is considered relatively safe. Propofol and methohexital are commonly used anesthetic drugs for ECT. The teratogenic effects related to these drugs have not been specified.2 Propofol seems to be associated with some advantages in ECT practice, including lower rises in blood pressure and heart rate and faster postictal recovery in some measures.3 Succinylcholine is often used as a neuromuscular block during ECT.2 Succinylcholine is not transfered to any extent across the placenta, and has little effect on the fetus. The amount of succinylcholine that crosses the placental barrier depends on the concentration inclination between the maternal and fetal circulation; thus, repeated high doses both the woman and the fetus. Psychotropic drugs used the treatment of psychiatric disorders occurring during gnancy have side effects on the mothers and fetuses. e American Psychiatric Association (APA) practice guidees suggest electroconvulsive therapy (ECT) as a primary atment for major depression and bipolar disorder durpregnancy. ECT has been reported as a treatment with h efficacy and low risk for the management of these disers during all three trimesters of pregnancy as well as stpartum.1 These case studies report our experience administeranesthesia to four pregnant women with psychiatric orders who were scheduled for ECT treatment during gnancy. The women undergoing ECT treatment were diagnosed th bipolar disorder (two of them), atypical psychosis, d depression. All of the cases were evaluated by either obstetrician/gynecologist or an anesthesiologist the day fore treatment. The patients were monitored in the operng room with an electrocardiogram (ECG), a noninvasive od pressure monitor, and peripheral oxygen saturation O2). All of the patients were given oxygen by mask at 6 L/min. To prevent aspiration, all of the patients were en an H2-receptor antagonist 15--20 min before the produre and this was continued throughout the operation. ring the process, the fetal heart rates were constantly ntrolled with an ultrasound or doppler device by a senior stertics/gynecology assistant. The plasmacholinesterase els and other routine blood values of the patients were asured before the procedure. Propofol and Lystenon were d for anesthesia induction and maintenance in all cases mask ventilation with oxygen. The mean age of the tients was 28 (24--31) years, the mean gestational age was weeks (12--28), and the mean number of ECT applications s 10 (8--13). No maternal or fetal complications occurred rioperatively. All of the pregnant women gave birth at normal gestational age and the average Apgar score of newborns was between 8 and 10. No complications were served in the newborns during the one-month after birth or the presence of atypical pseudocholinesterase may lead to newborn apneas and muscle relaxation.4 In our cases, we used propofol as a hypnotic agent and succinylcholine as a neuromuscular block. All of the patients had unproblematic terminations to their pregnancies and the treatment did not have any adverse effects on the babies or the mothers.