Sukran Sahin

Conscious sedation for endoscopic retrograde cholangiopancreatography: dexmedetomidine versus midazolam.

OBJECTIVE Midazolam and dexmedetomidine, which are used for sedation during endoscopic retrograde cholangiopancreatography, were compared to evaluate the differences in efficacy, hemodynamics, and side effects. MATERIALS AND METHODS Fifty patients aged between 18 and 80 were randomly assigned to two groups according to American Society of Anesthesiologists (ASA) classification: Group M received midazolam with an initial bolus infusion of 0.04 mg/kg intravenously (i.v.), followed by additional doses of 0.5 mg i.v. midazolam, titrated to achieve a Ramsay sedation scale score of 3-4. Group D received dexmedetomidine with an initial bolus infusion of 1 mcg/kg/hr i.v. over 10 minutes, followed by a continuous infusion of 0.2-0.7 mcg/kg/hr, titrated to achieve an RSS of 3-4. A Mini Mental Status Examination (MMSE) was performed prior to sedation and in the recovery room once the Modified Aldrete Score (MAS) reached 9-10. Patient heart rates, arterial pressure and pain were evaluated. RESULTS Patients in Group D had lower heart rates at 20, 25, 30, 35 and 40 minutes following the initiation of sedation (p<0.05). There was no statistical difference in arterial pressure, RSS, MMSE or respiratory rate between the two groups. Coughing, nausea and vomiting occurred in 3 patients in Group M (12%), whereas no patient in Group D experienced these symptoms. The procedure elicited a gag response in 7 patients in Group M (28%) and in 4 patients in Group D (16%), with no significant difference between groups (p>0.05). When patient and surgeon satisfaction was compared between the two groups, Group D showed higher surgeon satisfaction scores (p<0.05). CONCLUSION The use of dexmedetomidine for conscious sedation during short, invasive procedures, such as endoscopic retrograde cholangiopancreatography, could be a superior alternative to the use of midazolam.

Accidental epidural catheterization during continuous interscalene block via the posterior approach

Abstract In recent years, interscalene catheterization via the posterior approach and continuous local anesthetic infusion has been suggested for pain relief related to brachial plexus tumor infiltration. Improper catheterization could lead to complications such as epidural or spinal anesthesia or phrenic nerve paralysis.A 54 year old man was referred to our pain clinic with severe right upper extremity and shoulder pain, dysesthesia and allodynia involving the right C7-T1 dermatomes, and 3/5 strength loss of the right forearm due to inoperable apical lung tumor with brachial plexus infiltration. For pain relief, a continuous interscalene block via the posterior approach was performed in the sitting position. Four millilitres 1% lidocaine without epinephrine were administered through the catheter. Approximately 5 minutes after the injection, the patient developed respiratory distress and dizziness. Fifteen minutes after the injection, side effects regressed and the vital signs stabilized. To confirm cathe...

Lumbar epidural lysis: a cranio-caudal lateral intralaminar approach

AbstractThe standard approach for epidural lysis is reaching to the problematic area through the caudal canal. If the symptoms do not cease and no improvement is seen, a cranio-caudal approach can be tried. In a patient with back pain due to failed back surgery syndrome for six months, epidurography was performed using caudal approach under fluoroscopy in the first intervention. A catheter was progressed to fibrotic tissue for epidural lysis. But the pain regression was not satisfactory at the L4 dermatome. After 3 weeks, a second intervention was planned with the lateral cranio-caudal approach at the L3-4 level and a catheter was placed around the fibrotic tissue and lysis was applied. The patients back pain totally disappeared and neurological symptoms started to decrease at the end of the first week. We suggest that, for patients with low back pain due to failed back surgery syndrome, a cranio-caudal approach may be applied after caudal epidural lysis.

Obstetric anaesthesia practices in Turkey

Turkey is a developing country making steady improvements in obstetric-related health care as is reflected by a decrease in maternal and infant mortality. Continued efforts should be undertaken to encourage patient participation in obstetric medical services, especially in eastern Turkey. Furthermore, universities should be challenged to use regional blockade more fully for caesarean section and labour analgesia. Not only might this eventually modernise practice patterns in other hospitals throughout the country, but it will also improve the safety and enhance the childbirth experience for Turkish women.

Obturator Nerve Block in Adductor Spasticity: Comparison of Peripheral Nerve Stimulator and Ultrasonography Techniques

Results: The average number of punctures in Group PNS was 2.0 (1.0 to 6.0) and in Group USG was 3.0 (1.0 to 5.0); there was no statistically significant difference between the two groups. The average time of the block was 10.0 min in Group PNS (2.0 to 30.0) and 16 min (4.0 to 35.0) in Group USG, and no significant differences were detected. The patient and the practitioner satisfactions were not statistically different between the two groups. Conclusion: Clinical studies showed that USG-guided regional blocks were safer and more efficient than other conventional techniques. However, there are very few studies comparing USG and other techniques; therefore, more studies are needed.

867 BILATERAL OBTURATOR NEUROLYTIC NERVE BLOCK USING ULTRASOUND GUIDANCE

of pudendal neuropathy. We have developed a technique using CAT SCAN guidance to block the pudendal nerve. The sample consists of fourteen patients with perineal pain; the pain typically is induced by sitting for a short period of time and relieved by standing or sitting on a toilet. The pain is associated with perineal allodynia and hyperesthesia, dyspareunia, and dysuria. We have performed the procedure on thirteen females and one male. Technically, a scan of the pelvis is taken, subsequently 5mm CAT SCAN slices are taken across the coxo-femoral joint. The anatomical location where the ischial tuberosity appears to be most prominent is chosen to perform the block. The nerve is approached from the gluteal area. The needle tip is positioned medial to the ischial tuberosity where contrast material is deposited to precisely assess needle placement. This is followed by injecting 5ml of bupivacaine and triamcinolone. Perineal anesthesia was observed in every patient, however, only 10 experienced pain relief which was reproduced twice. The treatment options in the responders included pulsed radiofrequency, nerve decompression and neuroaugentation. We concluded that pudendal nerve block under CAT SCAN is a valuable diagnostic precision technique in the differential diagnosis of pelvic pain.

Low-dose Clonidine and Neostigmine Prolong the Duration of Intrathecal Bupivacaine-Fentanyl for Labor Analgesia

Background Intrathecal (IT) opioid and local anesthetic combinations are popular for labor analgesia because of rapid, effective pain relief, but the duration of analgesia is limited. This study was undertaken to determine whether the addition of clonidine and neostigmine to IT bupivacaine–fentanyl would increase the duration of analgesia without increasing side effects for patients in labor. Methods Forty-five healthy parturients in active labor were randomized to receive a 2-ml IT dose of one of the following dextrose-containing solutions using the combined spinal–epidural technique: (1) bupivacaine 2.5 mg and fentanyl 25 &mgr;g (BF); (2) BF plus clonidine 30 &mgr;g (BFC); or (3) BFC plus neostigmine 10 &mgr;g (BFCN). Pain, sensory levels, motor block, side effects, maternal vital signs, and fetal heart rate were systematically assessed. Results Patients administered BFCN had significantly longer analgesia (165 ± 32 min) than those who received BF (90 ± 21 min;P < 0.001) or BFC (123 ± 21 min;P < 0.001). Pain scores, block characteristics, maternal vital signs, Apgar scores, maternal satisfaction, and side effects were similar among groups except for nausea, which was significantly greater in the BFCN group (P < 0.05 as compared with BFC). Conclusions The addition of clonidine and neostigmine significantly increased the duration of analgesia from IT bupivacaine–fentanyl during labor, but neostigmine caused more nausea. Although serious side effects were not observed in this study, safety must be further addressed before the routine use of multiple IT drugs is advocated.