Anesthesiology and Pain Medicine
Volume:2 Issue: 4, May 2013

Postoperative residual blockade, longer duration of action for neuromuscular blockade, and slower recovery were relatively common in elderly patients. We aimed to investigate the safety of train-of-four ratio and clinical tests in the assessment of patient recovery, and to determine the effects of the rocuronium, vecuronium, and cisatracurium on intubation, extubation and recovery times in elderly patients undergoing abdominal surgery.Patients and After obtaining institutional approval and informed consent, 60 patients over 60 years old and undergoing elective abdominal operations were included in this double-blind, randomized clinical trial. Following a standard anesthesia induction, 0.6mg kg-1 rocuronium, 0.1mg kg-1 vecuronium, and 0.1mg kg-1 cisatracurium were administered to the patients in Group R, Group V, and Group C, respectively. Train-of-four (TOF) ratios were recorded at 10-minute intervals during and after the operation. Modified Aldrete Score (MAS) and clinical tests were recorded in the recovery room at 10-minute intervals. In addition, intubation and extubation times, duration of recovery room stay, and any complications were recorded. Intubation time was found to be shorter in Group R than that in Groups V and C (P 0.001). Times to positive visual disturbances and grip strength tests were shorter in Group C than that in Group V (P = 0.016 and P = 0.011, respectively). In Group R and group C, time to TOF ≥ 0.9 was significantly longer than all positive clinical test times except grip strength (P < 0.05). We hold the opinion that cisatracurium is safer in elderly patients compared to other drugs. We also concluded that the usage of TOF ratio together with clinical tests is suitable for assessment of neuromuscular recovery in these patients.

Simultaneous administration of epidural local anesthetic agents (LA) and general anesthetics (intravenous or inhaled) is a common procedure in patients undergoing major operations. The effects of epidural anesthesia during combined general-epidural anesthesia on the alertness level (CGEA) in the awake phase and the doses of anesthetics have been reported. The present study was designed to determine the effects of epidural bupivacaine on the alertness level measured by bispectral index (BIS) in the awake phase and the maintenance doses of propofol and fentanyl during general anesthesia for vascular operation on the lower limb.Patients and A double-blinded randomized clinical trial was conducted on patients awaiting vascular surgery on lower extremities in a teaching hospital from October 2007 to October 2008. During the epidural anesthesia, the control group received 0.9% NS while 0.125% bupivacaine was injected in the case group via the epidural route. No sedative drug was utilized for epidural catheter placement. The BIS measurement was performed in both groups during the awake phase, before performing epidural anesthesia, and 10 minutes after epidural injection at 1-min intervals for 15 min. After induction of general anesthesia in both groups, anesthesia maintenance was established using the infusion of propofol with the aim of keeping the BIS level between 40 and 50 throughout the anesthesia. At the end of the study period, maintenance dose requirements of propofol and fentanyl were measured. Thirty-two patients were enrolled in the study. There was no difference in BIS levels of the two groups in the awake phase. There was a significant difference between the propofol and fentanyl requirements of the two groups. Performing CGEA using bupivacaine was reported to reduce propofol and fentanyl doses required to maintain BIS levels between 40 and 50 considerably..

The incidence of transient neurologic symptoms (TNS) after spinal anesthesia with lidocaine is reported as high as 40%. This prospective clinical trial was designed to determine the incidence of TNS in patients who underwent spinal anesthesia with two different needles, in two different surgical positions.Patients and The present randomized clinical trial was conducted on 250 patients (ASA I-II), who were candidates for surgery in supine or lithotomy positions. According to the needle type (Sprotte or Quincke) and local anesthetics (lidocaine and bupivacaine) all patients were randomly divided into four groups. After performing spinal anesthesia in sitting position, the position was changed into supine or lithotomy, according to surgical procedure. The patients were observed for complications of spinal anesthesia during the first five post-operative days. The primary end-point for this trial was to recognize the incidence of TNS among the four groups. Our secondary objective was to evaluate the effect of patient's position, needle type, and duration of surgery on the development of TNS following spinal anesthesia. TNS was most commonly observed when lidocaine was used as anesthetic drug (P = 0.003). The impact of needle type, was not significant (P = 0.7). According to multivariate analysis, the duration of surgery was significantly lower in cases suffering from TNS (P = 0.04). Also, the risk of TNS increased following surgeries performed in lithotomy position (P = 0.00). According to the results of this clinical study, spinal anesthesia with lidocaine, and the lithotomy position in surgery increased the risk of TNS.

Developing controlled hypercarbia is a known scheme of lowering the suprasellar part of the adenoma in order to assist the surgeon, which acts through raising the ICP and therefore the CSF pressure. The purpose of this study is to compare the effect of introducing a lumbar drain with that of controlled hypercapnia on the quality of transsphenoidal pituitary tumor resection and CSF leak.Patients and Fifty two patients with pituitary adenoma who underwent transsphenoidal hypophysectomy by the same surgeon were included. They were randomly divided into two groups. A lumbar drain catheter introduced into the L3-L4 subarachnoid space under local anesthesia in all patients. The same anesthesia was performed in both groups. In the study group, we used a saline injection into the subarachnoid space versus hypoventilation in the control group in order to increase the ICP according to the surgeon's request. The surgeon's satisfaction during the tumor resection and the resection time were assessed during the surgery. The CSF catheter was closed and sent with the patient for CSF drainage. If there was no CSF leak, the catheter removed 24 hours later. With evidence of a CSF leak, we used the catheter as a lumbar drain. The time taken for the leakage control was assessed. The satisfaction came from 21 (87.5%) and 2 (9.1%) for surgeon in the first and the second group respectively (P = 0.0001). CSF leakage time in the first and the second group was 1.6 ± 0.24 and 5 ± 0.50 respectively. It revealed a significant difference between the two groups (P = 0.001). The mean resection time was 13.54 ± 0.66 minutes in the study group; and 30.91 ± 0.98 minutes in the control group. In summary, the method described here for ICP manipulation is an effective procedure for a better visualization of the pituitary tumor during transphenoidal resection by surgeon and beneficial in managing the CSF leak following surgery.

The demand for regional blocks from both patients and surgeons has significantly increased in anesthesia practice during the last 30 years. Although the studies show that the complications are rare, regional blocks still have serious difficulties which can be prevented by training programs. The purpose of this study was to determine the factors affecting the educational methods, attitude and practice of the Turkish anesthesiologists in regional blocks during and following residency programs.Patients and Anesthesiologists were asked to answer a questionnaire. Educational proficiency was determined by at least 50 spinal, 50 epidural and 50 peripheral block applications during residency. Specialists were asked for the numbers of spinal, epidural and peripheral blocks (PBs) they applied in 2009. The mean and median values were calculated. One hundred and eighty-eight anesthesiologists (84.3 %) agreed to participate in the study. While all participants had made their first attempts in neuraxial blocks (NBs) when they were residents, this ratio was detected as 96.8% for PBs. All participants learned neuraxial and PBs on patients in the operating theater. Education proficiency ratios for spinal, epidural and PBs were 98.1 %, 92.5 % and 62.3 %, respectively. Age, perception of adequate training, nerve block rotation, adequate application in education, following innovations were the factors which significantly affected the number of PBs in practice according to univariate analysis. The participants who consider their applications on NBs were adequate (P = 0.029) and the ones working in state or private hospitals (P = 0.017), applied NBs significantly above the median number. Anesthesiologists had adequate education and practice of NB applications but a significant proportion of participants (51.8%) lacked both in PBs applications. We believe that NBs are more easily learned than PBs during residency training program..

Various attempts have been made to reduce the incidence of fentanyl-induced cough during anesthesia induction. We hypothesized that an appropriate dose of propofol might suppress fentanyl-induced cough. A study had been designed to observe the effects of propofol on a fentanyl-induced cough during anesthesia induction.Patients and We performed a randomized, double-blind study to evaluate the effect of the pre-emptive use of minimal dose intravenous propofol (20 mg) on the incidence of cough caused by a larger bolus of intravenous fentanyl. Group 1 patients were given fentanyl at a dosage of 4 µg/kg. Group 2 received 4µg/kg fentanyl and 20 mg propofol. The two groups were evaluated in 0, 5 and 10 second intervals following the injection of fentanyl. Mean age, weight, and, height was 35 ± 10.45, 67.99 ± 10.92, and 165.33 ± 31.84 respectively. The incidence of fentanyl induced cough was 29 (74.4%) in placebo group compared with 10 (25.6%) in the propofol group. There was a significant difference in the incidence and severity of cough between group 1 and 2 (P < 0.0001). This study also showed that propofol could decrease cough incidence in patients who smoke. Priming dose of propofol (20mg) one minute prior to fentanyl injection was effective in suppressing a fentanyl-induced cough.

In some hospitals, urinalysis is done routinely for all patients scheduled for cardiac surgery. Occasionally pyuria or bacteria is reported in the microscopic urinalysis of these patients that are clinically asymptomatic for urinary tract infections. We were seeking answer to this question: is the presence of a different number of bacteria in preoperative microscopic urinalysis of asymptomatic patients scheduled for cardiac surgery indicative of potential postoperative complications and as a result, a good reason to postpone the operation?.Patients and We conducted a retrospective cross-sectional study based on the review of the medical records of 1165 patients who underwent open-heart surgery. One hundered and fifty one patients were eligible in our established criteria. There were no significant difference between their demographic characteristics and the same number of randomly selected patients with normal urinalysis who had underwent open-heart surgery. In the bacteriuria group, two patients, and in the control group, three patients had an infection at the operation sites in the post-operative period, which was not a significant finding between two groups (P = 0.503).. We recommend that in the absence of symptoms of urinary tract infection, urinalysis is not necessary and not cost beneficial in the preoperative evaluation of patients scheduled for open-heart surgery.

Several methods for assessment of severity of pain have been proposed but all of them are subjective. This study evaluated the association concerning changes in electrical resistance (ER) between two acupuncture points and severity of postoperative pain in order to define an objective measurement of pain.Patients and In a cross-sectional study, 50 patients undergoing lower extremity orthopedic surgery with postoperative moderate to severe pain (VAS > 4,) were consecutively enrolled. In the recovery room, the patient's pain scores were assessed and in patients with VAS > 4, the electrical resistance between Li4 and Li11 acupuncture points as well as pain scores was measured prior and following analgesic administration. Following meperidine use, the mean VAS significantly decreased and the ER between the two acupoints was significantly increased. However, Pearson correlation analysis did not reveal any association between the trends of pain intensity and ER (P > 0.05). The ER change in patients operated under epidural anesthesia was significantly less than those who experienced general or spinal anesthesia. There is a coincidence of pain relief and change in the ER of acupuncture meridians without significant association. The diagnostic value of ER for pain, stress response or any other physiologic outcome needs to be investigated in clinical trials with a well-defined control group, with more accurate instruments and probably in different acupuncture meridians.

Carney’s complex is a rare autosomal dominantly inherited multiple endocrine neoplasia syndrome that involves spotty skin pigmentations, recurrent cardiac myxomas, endocrine hyperactivity, pituitary adenomas, peripheral nerve tumors, testicular tumors, and ovarian lesions. We present a case of sudden cardiac death in a 40 year old female with a history of Carney’s complex with recurrent cardiac myxomas presenting for exploratory laparotomy and enblock adnexal resection of a slowly enlarging right sided ovarian mass. This case highlights the risk for sudden death in these patients as well as the preoperative assessment that should be undertaken by the anesthesiologist as it relates to Carney’s complex.