Serkan Tulgar

Ultrasound guided Erector Spinae Plane block at L-4 transverse process level provides effective postoperative analgesia for total hip arthroplasty

First described by Forero in 2016 for the treatment of thoracic neuropathic pain, Erector Spinae Plane (ESP) block is a regional anesthesia technique in which local anesthetic is injected between the erector spinae muscle and transverse process under ultrasound guidance, blocking the dorsal and ventral rami of the thoracic and abdominal spinal nerves [1,2]. Studies have shown that the spread of local anesthetic in the paravertebral space in the cephalic and caudal direction can lead to analgesia from C7-T2 to L2-3 [2]. It has also been reported that paravertebral block performed at L2 segment has similar postoperative analgesic effects when compared to psoas compartment block in patients undergoing total hip arthroplasty [3].Wehypothesized that ultrasound guided ESP performed at L4 transverse process level would lead to adequate postoperative analgesia in total hip arthroplasty surgeries, as the local anesthetic would spread similar to ESP performed in thoracal levels. To our knowledge, ESP performed in lumbar region has not been reported. We report a successful ultrasound guided ESP block performed at L4 transverse process level for postoperative analgesia in an 86 year old female patient with controlled hypertension, undergoing left sided total hip arthroplasty under general anesthesia. The patient received routine intravenous perioperative analgesia (paracetamol 1 g, tenoxicam 20 mg and morphine 3 mg). At completion of surgery ultrasound guided ESP was performed under general anesthesia using a linear transducer under sterile conditions. The transverse process was visualised by sliding the transducer 3.5–4 cm laterally from the midline at the T4 vertebral level in the parasagittal plane. Thirtymillilitre of local anesthetic (15 ml bupivacaine 0.5%, 5 ml lidocaine 2% and 10 ml serum physiologique)was injected between the erector spinaemuscle and the transverse process. The patient was extubated. Standard multimodal analgesia regimen was ordered (scheduled acetaminophen, tenoxicam at bedtime in addition to tramadol as required). The patients numeric rating score (NRS) was 1/10 in the postoperative recovery room immediately after extubation. Sensorial block was

Mechanical Bowel Preparation Does Not Affect Anastomosis Healing in an Experimental Rat Model.

Background Mechanical bowel preparation before colorectal surgery is commonly performed, but its benefits are controversial. The aim of this study was to compare the effects of mechanical bowel preparation on healing of colonic anastomosis and tissue strength. Material/Methods After institutional review board approval, 20 adult Wistar albino rats were randomly divided into 2 groups of 10 animals each. Mechanical bowel preparation including sodium phosphate was performed on the experimental group via a feeding tube, whereas no bowel preparation procedures were performed on the control group. Transverse colon resection and anastomosis were performed on all rats under general anaesthesia. On postoperative day 5, re-laparotomy was performed and the anastomotic areas were resected. Animals were killed, after which bursting pressure and tissue hydroxyproline concentrations were measured, histopathological examination was performed, and we evaluated and compared the results. Results There were no differences between control and experimental groups in bursting pressure, tissue hydroxyproline concentrations, or histopathological examination results (P>0.05). Conclusions Our study demonstrated no significant difference between bursting pressures, tissue hydroxyproline levels, or modified wound healing score at postoperative day 5 between rats undergoing and not undergoing mechanical bowel preparation. Mechanical bowel preparation is not essential for healing or strength of colonic anastomosis in rats.

Ultrasound guided distal adductor canal block provides effective postoperative analgesia in lower leg surgery

In order to provide adequate postoperative analgesia in patients undergoing lower extremity surgeries, blockage of both lumbar and sacral plexus originating nerves are required as part of multimodal analgesia regimens. Block of the sciatic nerve from the popliteal region is a frequently used regional anesthesia/analgesia technique in lower leg surgery. Additionally, saphenous nerve block at the adductor canal level or femoral nerve block may also be included. Runge et al. reported that local anesthetic injected at the distal of the adductor canal around the femoral artery spread both proximally to the saphenous nerve and distally to the popliteal area, around the sciatic nerve in a cadaver model [1].Morozumi et al. [2] recently described theuse of distal adductor canal block (DACB) in arthroscopic joint synovectomy, reporting their results of its use for postoperative analgesia of lower limb surgery. Sciatic nerve block at thepopliteal region and saphenousnerve block at the adductor canal region leads to effective analgesia and improved satisfaction in patients with tibia or ankle fractures [3]. This combination requires two puncture sites, positioning of the knee, removal of the patients cast and discomfort for the patient. We performed DACB as described byMorozumi et al. [2], in a patient with right trimalleolar ankle fracture. Open reduction and internal fixationwas planned in a 32 year old female patient. We described the procedure to the patient clearly and written informed consent from the patient for procedure obtained. And also; we obtained written consent from the patient to publish this case report. Under sterile conditions following premedication, slight adduction and internal rotation of the leg was performed and linear transducer was placed about 10 cm superior to themedial femoral condyle. The adductor hiatus where the femoral artery forms the popliteal artery, was located and 35 ml of local anesthetic (prepared as 40 ml–20 ml bupivacaine 0.5%, 10 ml lidocaine 2% and 10 ml serum physiologic) was administered, surrounding the femoral artery. General anesthesia was performed. Anesthesia was maintained with 0.6 MAC sevoflurane, 0.025 mcg/kg/min remifentanil infusion. Hemodynamic stability was maintained throughout surgery with no requirement for increase in remifentanil dosage. Surgery lasted 150 min. The patient received routine intravenous perioperative

Evaluation of the reliability of preoperative descriptive airway assessment tests in prediction of the Cormack-Lehane score: A prospective randomized clinical study

STUDY OBJECTIVE In this study we investigated and compared the predictive values of different airway assessments tests including thyromental height measurement test, which has been recently suggested, in difficult laryngoscopy (Cormack and Lehane [C-L] scores 3 and 4). In addition, we compared the effectiveness of methods and C-L scores, by IDS, in terms of predicting difficult intubation. DESIGN Prospective, blinded study. SETTING Maltepe University. PATIENTS Four hundred fifty-one patients selected randomly who underwent general anesthesia. INTERVENTIONS In this study we compared predictive value of thyromental height measurement test (TMH), which has been recently suggested, modified Mallampati test (MMT), upper lip bite test (ULBT), and thyromental distance measurement test (TMD) in difficult laryngoscopy. Final C-L scores were compared with intubation difficulty scale (IDS) in terms of predicting difficult intubation. MEASUREMENTS Patients American Society of Anesthesiology score, age and weight were recorded. TMH, TMD, MMT, ULBT, IDS and C-L scores were measured and determined. MAIN RESULTS The optimal cut-off point for TMH for predicting difficult laryngoscopy was 43.5 mm and for TMD was 82.06 mm. Use of TMH <43.5 with MMT has the highest sensitivity for predicting difficult intubation (78.38) with 75.36% specificity and 97.50% negative predictive value. TMH showed sensitivity of 91.89% and specificity 52.17% at 50 mm cut-off value. In the comparison of the area under the receiver operating characteristic curve values, none of the tests came forth individually or in combination with MMT test. CONCLUSIONS The present study demonstrates the practicality of TMH as a digitalized test however the clinical benefits of TMH in daily medical practice are drawn into question. The additional variable of race may have had some bearing on this and further studies, larger in patient sample size, may need to use different methodology concerning age-, sex-, and race-dependent variables in evaluating these tests.

Comparison of Effects of Separate and Combined Sugammadex and Lipid Emulsion Administration on Hemodynamic Parameters and Survival in a Rat Model of Verapamil Toxicity

Background Toxicity of calcium channel blockers leads to high patient mortality and there is no effective antidote. The benefit of using 20% lipid emulsion and sugammadex has been reported. The present study measured the effect of sugammadex and 20% lipid emulsion on hemodynamics and survival in a rat model of verapamil toxicity. Material/Methods In this single-blinded randomized control study, rats were separated into 4 groups of 7 rats each: Sugammadex (S), Sugammadex plus 20% lipid emulsion (SL), 20% lipid emulsion (L), and control (C). Heart rates and mean arterial pressures were monitored and noted each minute until death. Results Average time to death was 21.0±9.57 minutes for group C, 35.57±10.61 minutes for group S, 37.14±16.6 minutes for group L and 49.86±27.56 minutes for group SL. Time to death was significantly longer in other groups than in the control group (p<0.05). Conclusions Verapamil overdose is has a comparatively high mortality rate and there is no effective antidote. Treatment generally involves gastric decontamination and symptomatic treatment to counteract the drug’s negative effects. In animal studies sugammadex and lipid emulsion had a positive effect on survival in patients with calcium channel blocker toxicity. Sugammadex and intralipid increased survival in a rat model of verapamil toxicity. The combination of both drugs may decrease cardiotoxicity. Sugammadex alone or combined with 20% lipid emulsion reduce the need for inotropic agents. The mechanism requires clarification with larger studies.

Evaluation of ultrasound-guided erector spinae plane block for postoperative analgesia in laparoscopic cholecystectomy: A prospective, randomized, controlled clinical trial

STUDY OBJECTIVE Laparoscopic cholecystectomy (LC) is a commonly performed minimally invasive procedure that has led to a decrease in procedure-related mortality and morbidity. However, LC requires analgesia that blocks both visceral and somatic nerve fibers. In this study, we evaluated the effectiveness of Erector Spinae Plane Block (ESPB) for postoperative analgesia management in LC. DESIGN Single-blinded, prospective, randomized, efficiency study. SETTING Tertiary university hospital, postoperative recovery room & ward. PATIENTS 36 patients (ASA I-II) were recruited in two equal groups (block and control group). Following exclusion, 30 patients were included in final analysis. INTERVENTIONS Standard multimodal analgesia was performed in Group C (control) while ESPB block was also performed in Group B (block). MEASUREMENTS Pain intensity between groups were compared using Numeric Rating Scores (NRS). Also, tramadol consumption and additional rescue analgesic requirement were measured. MAIN RESULTS NRS was lower in Group B during the first 3 h. There was no difference in NRS scores at other hours. Tramadol consumption was lower in Group B during the first 12 h. Less rescue analgesia was required in Group. CONCLUSION Bilateral ultrasound guided ESPB leads to effective analgesia and a decrease in analgesia requirement in first 12 h in patients undergoing LC.

Short-lasting pediatric laparoscopic surgery: Are muscle relaxants necessary? Endotracheal intubation vs. laryngeal mask airway

PURPOSE Technical advances have led to lower insufflation pressures and shorter anesthesia times for children undergoing laparoscopic procedures. In this study we compared the use of endotracheal tube (ETT) and laryngeal mask airway (LMA) with or without muscle relaxant (MR) in children undergoing laparoscopic repair for inguinal hernia. METHODS Children undergoing laparoscopic inguinal hernia repair were randomized into four groups which underwent procedure with either ETT+MR (group 1), ETT without MR (group 2), LMA with subparalytic dose of MR (group 3) or LMA without MR (group 4). Surgical, anesthesia and recovery times, intragastric pressures and peak airway pressures during insufflation were compared. RESULTS After exclusion criteria and discontinued interventions, groups 1 and 3 contained 20, groups 2 and 4 contained 19 patients each. Surgical times were similar between groups. Anesthesia times were statistically significantly different between groups with shortest time in group 4 and longest time in group 1. Recovery time was statistically significantly longer in group 1 when compared to other groups. There was no difference between basal intragastric pressure, average intragastric pressure during insufflation, peak airway pressure, and average peak airway pressure during insufflation of groups. CONCLUSION Use of muscle relaxants in short-lasting laparoscopic procedures in children is not absolutely necessary and LMA with subparalytic dose of muscle relaxant or with no muscle relaxant is a safe alternative. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level II.

A atividade antimicrobiana de efedrina e da combinação de efedrina e propofol: um estudo in vitro

INTRODUCTION Propofol and Ephedrine are commonly used during anesthesia maintenance, the former as a hypnotic agent and the later as a vasopressor. The addition of propofol to ephedrine or administration of ephedrine before propofol injection is useful for decreasing or preventing propofol related hemodynamic changes and vascular pain. This in vitro study evaluated the antibacterial effect on common hospital-acquired infection pathogens of ephedrine alone or combined with propofol. MATERIAL AND METHOD The study was performed in two stages. In the first, the Minimum Inhibitory Concentration of propofol and ephedrine alone and combined was calculated for Escherichia coli, Enterococcus faecium, Staphylococcus aureus, Pseudomonas aeruginosa, and a clinical isolate of Acinetobacter spp. at 0, 6, 12 and 24h, using the microdilution method. In the second stage, the same drugs and combination were used to determine their effect on bacterial growth. Bacterial solutions were prepared at 0.5MacFarland in sterile 0.9% physiological saline and diluted at 1/100 concentration. Colony numbers were measured as colony forming units.mL-1 at 0, 2, 4, 6, 8, 10 and 12th hours. RESULTS Ephedrine either alone or combined with propofol did not have an antimicrobial effect on Escherichia coli, Enterococcus faecium or Pseudomonas aeruginosa and this was similar to propofol. However, ephedrine alone and combined with propofol was found to have an antimicrobial effect on Staphylococcus aureus and Acinetobacter species at 512mcg.mL-1 concentration and significantly decreased bacterial growth rate. CONCLUSION Ephedrine has an antimicrobial activity on Staphylococcus aureus and Acinetobacter species which were frequently encountered pathogens as a cause of nosocomial infections.

Local anaesthetic injection point of erector spinae plane block

Forero first described ESPB for thoracic neuropathic pain in a four-case series and cadaveric study.[2] In the first case, the authors successfully applied local anaesthesia (LA) in the interfascial plane between rhomboideus major muscle (RMM) and erector spinae muscle (ESM). This technique failed in the second patient, and subsequent ESPB was performed deep to ESM. In their discussion, the authors clearly state that ‘the cadaveric findings and our subsequent clinical experience indicate that the optimal plane for injection in the ESP block is deep to the ESM rather than superficial to it.’[2] All subsequent studies of ESPB have used this technique.[3,4]

Use of Femoral and Sciatic Nerve Block Combination in Severe Emphysematous Lung Disease for Femoral Popliteal Arterial Bypass Surgery

Regional anesthesia is a widely used anesthesia technique for high-risk patients with severe vascular or pulmonary diseases in which general anesthesia is considered harmful and should be avoided. In this case, we present the use of femoral-sciatic nerve block combination for a 65-year-old, ASA IV, male patient who had severe emphysematous lung disease and was planned for a right femoral-popliteal arterial bypass surgery. He had severe pulmonary disease, hypertension, peripheral vascular disease, and was on clopidogrel treatment. Due to his existing comorbidities, regional anesthesia was considered the right method. The combination of femoral and sciatic nerve block was successfully used for the operation, which lasted for one hour and fifty minutes under sedation, and was continuously supplied with a propofol infusion. The patient was safely discharged to the surgical ward with no pain. The femoral block and sciatic block combination is described as one of the most useful, and at the same time, the most ignored anesthetic method. This technique is considered a standard technique and is often taught early in training; however, its use seems to be underestimated as there are only a few cases documented in Turkey. The aim of this case is to serve as a reminder of its significant value in patients who are not appropriate for general anesthesia and neuraxial blocks.