Sule Akin

Percutaneous nephrolithotomy under general versus combined spinal-epidural anesthesia.

PURPOSE We analyzed the results of patients who underwent percutaneous nephrolithotomy (PCNL) for management of kidney stone disease under combined spinal-epidural anesthesia and compared surgical parameters and outcomes with a matched control group who underwent PCNL under general anesthesia. PATIENTS AND METHODS A total of 82 patients were studied in two groups. Group 1 (n = 45) consisted of the patients who underwent general anesthesia, and group 2 (n = 37) comprised those who received combined spinal-epidural anesthesia. RESULTS The mean ages of patients in groups 1 and 2 were 45 +/- 15 and 44 +/- 15 years, respectively. The mean areas of the stones in groups 1 and 2 were 734 +/- 386 mm(2) and 731 +/- 394 mm(2), respectively. There were no significant differences between groups 1 and 2 among surgical parameters, including age, stone area, operative time, irrigation fluids, fluoroscopy time, delta hemoglobin, and hospitalization time (P = 0.439). At the end of the surgery, stone-free rates were 76% in group 1 and 81% in group 2; clinically insignificant residue fragments rates were 24% in group 1 and 19% in group 2. The difference was statistically insignificant between the groups (P = 0.543). CONCLUSIONS We consider that combined spinal-regional anesthesia is a feasible technique in PCNL operations because the efficacy and safety were not affected. Further investigations with larger series are needed.

Patient-controlled intravenous analgesia with remifentanil in nulliparous subjects in labor

Objective: in this study we controlled the efficiency and safety of using remifentanil combined with two different supplementary background infusions for labor analgesia in nulliparous patients. Research design and methods: 60 subjects were allocated to two groups. After programming the patient-controlled analgesia device to deliver a fixed load and demand doses of intravenous remifentanil for all subjects, group r (n = 30) received a background infusion of remifentanil 0.1 μg/kg/min and group R (n = 30) received a supplementary infusion of remifentanil 0.15 μg/kg/min. Visual analogue scale for analgesia, hemodynamic parameters, sedation scales and fetal heart rates were recorded at the 5th, 10th, 20th and 30th min of the study and measurements continued every 15 min during 90 min of labor and delivery. Side effects, Apgar and satisfaction scores were obtained for every subject. Results: visual analogue scale scores of group R were significantly lower than those of group r throughout labor and delivery (p < 0.05). Hemodynamic parameters and fetal heart rates of the two groups were not different (p > 0.05). Most subjects were awake and only nausea was obtained (p > 0.05). The increase in the Apgar and satisfaction scores was not statistically significant (p > 0.05). Conclusion: it was determined that remifentanil with a 15-μg demand dose and 0.15 μg/kg/min supplementary continuous infusion is an effective choice for patient-controlled analgesia during labor in nulliparous subjects.

Dexmedetomidine as an adjunct to epidural analgesia after abdominal surgery in elderly intensive care patients: A prospective, double-blind, clinical trial.

BACKGROUND The ideal postoperative analgesia management of elderly surgical patients in intensive care units (ICUs) is continually being investigated. OBJECTIVE The purpose of this study was to assess the effectiveness and tolerability of IV administration of dexmedetomidine as an adjunct to a low-dose epidural bupivacaine infusion for postoperative analgesia after abdominal surgery in elderly patients in the ICU. METHODS ICU patients aged >70 years undergoing abdominal surgery were eligible for the study. A lumbar epidural catheter was inserted at the beginning of the surgery with no medication. On arrival at the ICU, the catheter was loaded with 0.25% bupivacaine 25 mg at the T8 to T10 sensory level, and a continuous infusion of 0.125% bupivacaine was started at 4 to 6 mL/h in combination with patient-controlled epidural analgesia (PCEA) of fentanyl (4 μg/bolus) for pain treatment. Patients in the treatment group received dexmedetomidine as an IV loading dose of 0.6 pg/kg for 30 minutes followed by continuous infusion at 0.2 μg/kg · h(-1). Patients in the control group were not administered dexmedetomidine. The effectiveness of the pain relief was determined using a visual analog scale (VAS) (0 = no pain to 10 = worst pain imaginable) at rest. VAS score, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure, and arterial blood gases were monitored periodically for 24 hours after surgery. If required, tenoxicam (20-mg IV bolus) was used to ensure a VAS score of ≤3. The number of times PCEA and tenoxicam were administered and the occurrence of adverse events (AEs) were also recorded. RESULTS Sixty patients (34 men, 26 women; mean [SD] age, 75.96 [4.25] years; mean [SD] weight, 74.13 [10.62] kg) were included in the study. VAS scores were significantly lower in the dexmedetomidine group compared with the control group at hours 1, 2, and 12 (VAS [hour 1]: 2.8 [0.4], P < 0.001; VAS [hour 2]: 2.7 [0.5], P < 0.001; and VAS [hour 12]: 0.9 [0.7], P 0.044). The mean number of administrations of fentanyl via PCEA was significantly greater in the control group compared with the dexmedetomidine group (2.20 vs 6.63 times; P < 0.001). The mean number of administrations of tenoxicam was significantly lower in the treatment group than the control group (0.27 vs 1.07 times; P < 0.001). In the control group, the decreases in sedation at 0, 8, 12, 16, and 20 hours were significant compared with baseline (P = 0.024, P = 0.001, P = 0.020, P < 0.001, and P = 0.005, respectively). Mean HR, SBR and AEs (eg, bradycardia [HR <60 beats/min], respiratory depression [respiratory rate <8 breaths/min], hypotension \SBP <90 mm Hg], oversedation, hypoxia, and hypercapnia) decreased significantly in the dexmedetomidine group (all, P < 0.05). Significantly more patients in the dexmedetomidine group rated their satisfaction with postoperative pain control as excellent compared with the control group (12 vs 6 patients; P = 0.014). CONCLUSION Intravenous dexmedetomidine was effective and generally well tolerated as an analgesic adjunct to epidural low-dose bupivacaine infusion for pain treatment, with lower need for opioids after abdominal surgery in these elderly intensive care patients than in the control group.

Transsacral S2-S4 Nerve Block For Vaginal Pain Due To Pudendal Neuralgia

Pudendal neuralgia is a type of neuropathic pain experienced predominantly while sitting, and causes a substantial decrease in quality of life in affected patients. Pudendal nerve block is a diagnostic and therapeutic option for pudendal neuralgia. Transsacral block at S2 through S4 results in pudendal nerve block, which is an option for successful relief of pain due to pudendal nerve injury. Herein is reported blockade of S2 through S4 using lidocaine and methylprednisolone for successful treatment of pudendal neuralgia in 2 patients with severe chronic vaginal pain. The patients, aged 44 and 58 years, respectively, were referred from the Gynecology Department to the pain clinic because of burning, stabbing, electric shock-like, unilateral pain localized to the left portion of the vagina and extending to the perineum. Their initial pain scores were 9 and 10, respectively, on a numeric rating scale. Both patients refused pudendal nerve block using classical techniques. Therefore, diagnostic transsacral S2-S4 nerve block was performed using lidocaine 1%, and was repeated using lidocaine 1% and methylprednisolone 80 mg after confirming block efficiency as demonstrated by an immediate decrease in pain scores. After 1 month, pain scores were 1 and 0, respectively, and both patients were free of pain at 6-month follow up. It is suggested that blockade of S2 through S4 using lidocaine and methylprednisolone is an effective treatment option in patients with chronic pudendal neuralgia when traditional pudendal nerve block is not applicable.

Ergotamine-induced lower extremity arterial vasospasm presenting as acute limb ischemia.

Ergotamine-induced limb ischemia is rare and usually results from an accidental overdose. Several agents, including erythromycin and tetracycline, raise serum ergotamine levels and augment its effect. We present a case of acute lower limb ischemia with characteristic angiography findings of diffuse arterial spasm resulting from use of ergotamine and an erythromycin derivative, clarithromycin. The history of the patient and classic features seen on angiography helped us establish the diagnosis. The patient was successfully treated with low molecular heparin and epidural infusion of bupivacain. Since ergot vasospasm is a self limited and medically treatable condition, interventional radiologists must be aware of ergotamine-induced acute limb ischemia to avoid any unnecessary interventional procedures, unless necrosis and gangrene are imminent.

Lumbar Plexus Blockade with Ropivacaine for Postoperative Pain Management in Elderly Patients Undergoing Urologic Surgeries

Background/Aims: We evaluated the effectiveness and safety of lumbar plexus blockade with ropivacaine for postoperative pain relief in elderly patients undergoing flank incision for urological surgery. Methods: 60 urological patients (>65 years old) were chosen randomly for paravertebral lumbar blockade. Postoperatively ropivacaine was used in group I (n = 30) and bupivacaine was administered in group II (n = 30) for lumbar plexus blockade. Heart rates, systolic and diastolic blood pressures, peripheral oxygen saturations, analgesia levels with visual analogue scales (VAS) were measured postoperatively at 5 and 30 min and 1, 3, 6, 8,and 12 h. Patient satisfaction scores and complications were recorded. Results: The hemodynamic parameters of the groups were in the normal ranges (p > 0.05). VAS were significantly decreased at 60 min in both groups (p < 0.05) and no important increase was observed during the first 8 h (p > 0.05). After the 8-hour measurement, analgesic was given to 7 patients in group I and 6 patients in group II (p < 0.05). There were no complications (p > 0.05). Patient satisfaction scores were found to be higher for all patients (p > 0.05). Conclusion: In elderly patients, lumbar plexus blockade with ropivacaine can be a simple, safe and effective analgesic technique especially in the early postoperative period after urologic surgeries with flank incision.

Patient-Controlled Epidural Analgesia after Major Urologic Surgeries

The efficiency and safety of patient-controlled epidural analgesia by using tramadol alone and combined with bupivacaine were investigated for postoperative pain treatment after major urological surgeries. For PCEA: in group I (n = 17) a loading dose of 20 mg tramadol with a continuous infusion of 1 mg/ml tramadol at a rate of 8 ml/h was given. In group II (n = 17), patients received an initial loading dose of 20 ml bupivacaine 0.125% and a supplemental continuous infusion of 8 ml/h. In group III (n = 17), a loading dose of 20 mg tramadol with 20 ml bupivacaine 0.125% were given and a supplemental infusion of 1 mg/ml tramadol in 20 ml bupivacaine 0.125% combination was begun with a rate of 8 ml/h. A demand epidural bolus dose of 5 ml with a lockout time of 30 min was also used in all patients. VAS for pain intensity, vital signs, sedation scale and side effects was monitored at 0, 15, 30 min and 1, 2, 3, 4, 8, 12, and 24 h of the postoperative period. Statistical significance was determined using Kruskal-Wallis, Fisher’s exact, analysis of variance for repeated measurements and Tukey tests. The hemodynamic values and sedation scales were insignificantly different (p > 0.05). The adequate analgesia was provided in all patients. However VAS values were significantly lower in group III than in groups I and II at every measurement (p < 0.05). The incidence of side effects in all three groups was low (p > 0.05). In conclusion, we suggested that a combination of tramadol with bupivacaine can provide the most effective and safe postoperative analgesia with minimal risk for side effects.

Effect of Intraoperative Paracetamol on Catheter-Related Bladder Discomfort: A Prospective, Randomized, Double-Blind Study

BACKGROUND The insertion of urinary catheters during urinary surgical interventions may lead to catheter-related bladder discomfort (CRBD) in the postoperative period. OBJECTIVE We aimed to evaluate the effect of single-dose intravenous paracetamol on CRBD. METHODS In this randomized, controlled, double-blind study, 64 patients (age >18 years, American Society of Anesthesiologists Physical Status I-II) requiring urinary bladder catheterization for percutaneous nephrolithotomy were assigned to groups that received either intravenous paracetamol (15 mg/kg) (group P) or NaCl 0.9% solution (control group [group C]) 30 minutes before the end of surgery. Patients received patient-controlled analgesia (10-mg bolus of meperidine, without infusion, 20-minute lock out) postoperatively. CRBD and pain status were assessed at 30 minutes and 1, 2, 4, 6, and 12 hours postoperatively. Postoperative meperidine requirement and patient and surgeon satisfaction were assessed. RESULTS Group P had significantly lower CRBD scores at all time points except at 12 hours postoperatively compared with group C (P < 0.05). Total meperidine consumption was significantly higher in group C (P < 0.05). Patient and surgeon satisfaction scores were significantly higher in group P (P < 0.05). CONCLUSIONS Intraoperative single-dose paracetamol was found to be effective in reducing the severity of CRBD and pain in urologic surgery. We suggest that it may be an efficient, reliable, easy-to-apply drug for CRBD. ClinicalTrials.gov identifier: NCT01652183.

Thoracic Epidural Anesthesia and Analgesia During the Perioperative Period of Thoracic Surgery: Levobupivacaine Versus Bupivacaine

OBJECTIVES To compare the effects of thoracic epidural anesthesia with levobupivacaine or bupivacaine on block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery. DESIGN A prospective, randomized, and double-blind study. SETTING A university hospital. PARTICIPANTS Fifty patients undergoing thoracic surgery. INTERVENTIONS Patients received thoracic epidural catheterization either with levobupivacaine or bupivacaine. A bolus of 0.1 mL/kg of 0.25% levobupivacaine or 0.25% bupivacaine was administered, and infusion of the same drug with 0.25% concentration was started at 0.1 mL/kg/h. General anesthesia was induced after assessing the sensory block and maintained with 0.3% to 0.8% isoflurane and 50% O(2) in air. Epidural patient-controlled analgesia with the same agent was started at the end of the operation for 48 hours postoperatively. MEASUREMENTS AND MAIN RESULTS Sensory block features such as onset time and spread were assessed for the next 20 minutes after the bolus dose. Heart rate and systolic, diastolic, and mean arterial blood pressures were recorded intraoperatively and postoperatively. Pain at rest and activity was evaluated by the visual analog scale (VAS) for 48 hours after the operation. All patients were comparable with respect to the demographic data. Onset time of the block and the number of blocked dermatomes and hemodynamic parameters were similar in both groups. All VAS assessments were comparable between groups except VAS at the 36th hour postoperative, which was higher in the levobupivacaine group (p = 0.039). CONCLUSIONS Thoracic epidural anesthesia with either levobupivacaine or bupivacaine provided comparable sensory block features, intraoperative hemodynamics, and postoperative analgesia for thoracic surgery.

Single-stage endovascular treatment of multiple intracranial aneurysms with combined endovascular techniques: is it safe to treat all at once?

Background and purpose Multiple aneurysms have a high reported incidence, but the optimal treatment strategy is not clear. The aim of this study was to evaluate the safety and effectiveness of single-stage endovascular treatment of multiple aneurysms with a combination of various endovascular techniques. Materials and methods Fifty-three consecutive patients with multiple intracranial aneurysms who underwent single-stage endovascular treatment for ≥2 aneurysms from June 2011 to May 2016 were included in the study. Patient and aneurysm characteristics, treatment technique, complications, clinical and angiographic outcomes were retrospectively evaluated. Results 125 of 128 aneurysms (97.6%) were treated by the following endovascular techniques: simple coiling in 19, balloon-assisted coiling in 27, stent-assisted coiling in 33, flow diverters in 43, intrasaccular flow modifiers in 2, and a neck-bridging device in 1. Overall mortality and mortality directly related to the single-stage treatment was 15% (8/53) and 3.7% (2/53), respectively. Clinical and angiographic follow-up was available in 44 (83%) patients for 104 (83.2%) aneurysms for a mean duration of 16.2 months (range 3–51 months). According to the last angiographic follow-up, overall occlusion rates were complete in 85 (81.7%), near complete in 8 (7.6%), and incomplete in 11 (10.5%) aneurysms. Conclusions Single-stage endovascular treatment of multiple aneurysms with combined endovascular techniques is technically feasible and increases the treatment possibility of all detected aneurysms. However, the safety of the procedure is controversial due to relatively high complication rates. In particular, in patients with bilateral internal carotid artery aneurysms, staged therapy may be used instead of simultaneous treatment with flow diverters to avoid thromboembolic events.