Retropharyngeal abscess presenting with acute respiratory distress in a case of cervical spondylodiscitis

We treated a 41-year-old man who presented with dysphagia, fever and respiratory distress. Magnetic resonance imaging (MRI) showed a large retropharyngeal abscess (RPA) extending to the C5-6 level, C5-6 spondylodiscitis and a spinal epidural abscess. The RPA was drained surgically under emergency conditions. Because the tuberculin skin test was positive, the patient underwent a triple anti-tuberculous drugs regimen. After six months of drug therapy, the epidural abscess was completely resolved. One of the most important aetiologies of RPA is thought to be tuberculous spondylodiscitis, and cervical vertebrae should be scanned thoroughly with pre-operative MRI.

Droperidol has comparable clinical efficacy against both nausea and vomiting

BACKGROUND

Droperidol is commonly noted to be more effective at preventing postoperative nausea (PON) than vomiting (POV) and it is assumed to have a short duration of action. This may be relevant for clinical decisions, especially for designing multiple-drug antiemetic regimens.

METHODS

We conducted a post hoc analysis of a large multicentre trial. Within this trial, 1734 patients underwent inhalation anaesthesia and were randomly stratified to receive several antiemetic interventions according to a factorial design, one of which was droperidol 1.25 mg vs placebo. We considered differences to be significant when: (i) point estimates of one outcome are not within the limits of the confidence interval (CI) of the other outcome; and (ii) differences in risk ratio (also known as relative risks, RR) are at least 20%.

RESULTS

Over 24 h, nausea was reduced from 42.9% in the control to 32.0% in the droperidol group, corresponding to a relative risk (RR) of 0.75 (95% CI from 0.66 to 0.84). Vomiting was reduced from 15.6% to 11.8%, and therefore associated with a similar RR of 0.76 (0.59-0.96). In the early postoperative period (0-2 h), droperidol prevented nausea and vomiting similarly, with an RR of 0.57 (0.46-0.69) for nausea and 0.56 (0.37-0.85) for vomiting. In the late postoperative period (2-24 h), the RR was again similar with 0.83 (0.72-0.96) for nausea compared with 0.89 (0.66-1.18) for vomiting but significantly less compared with the early postoperative period.

CONCLUSIONS

We conclude that droperidol prevents PON and POV equally well, yet its duration of action is short-lived.

Comparison of the Laryngeal Mask (LMA™) and Laryngeal Tube (LT®) with the Perilaryngeal Airway (CobraPLA®) in Brief Paediatric Surgical Procedures

We compared the laryngeal mask airway (LMA™) and the laryngeal tube (LT®) with the perilaryngeal airway (CobraPLA®, PLA) in anaesthetised, paralysed children having brief surgical procedures.

After obtaining informed consent, 90 paediatric ASA Status 1 and 2 patients awaiting short surgical procedures were randomised to have their airways managed with an LMA, LT or PLA. Anaesthesia was induced with sevoflurane (2.5 to 4%) and muscle paralysis with mivacurium (0.2 mg/kg intravenously). The number of insertion attempts, time taken to insert the device, haemodynamic responses to insertion (mean arterial blood pressure, heart rate, pulse oximetry and end-tidal CO 2 ), clinical performance and occurrence of postoperative sore throat were recorded.

When the airway device was removed, it was examined for visible blood. Patients and parents were asked about the occurrence of sore throat, dysphonia and dysphagia 24 hours postoperatively.

Heart rate, mean arterial blood pressure, pulse oximetry and end tidal CO 2 did not differ among the groups. Insertion times for the devices were similar (LMA: 19 ± 11 seconds, LT: 21 ± 12 seconds, PLA: 18 ± 12 seconds), as were the rates of successful insertion at first attempt (LMA 66.7%; LT 70.0%; PLA 73.3%). The number and type of airway interventions to achieve an effective airway were comparable. When the airways were removed, positive blood traces were noted on 20% of the LMAs, 20% of the PLAs and 10% of the LTs.

Haemodynamic, ventilation and oxygenation variables throughout the surgery were similar with LMA, LT and PLA and there were no significant differences in insertion time or signs or symptoms of mucosal trauma when these devices were used in paralysed children.

A comparison of the effect on gastric emptying of propofol or dexmedetomidine in critically ill patients: preliminary study

BACKGROUND

Propofol and dexmedetomidine are widely used for sedation in the intensive care unit yet there are limited data on its effects on gastric motility. In our preliminary study, we examined whether or not any effect of propofol and dexmedetomidine on gastric emptying is preserved in critically ill patients.

METHODS

Twenty-four critically ill, enterally fed adult patients each received enteral feeding via a nasogastric tube at 50 mL h-1 throughout the 5-h study period. Either propofol 2 mg kg-1 h-1 (n = 12, Group P) or dexmedetomidine 0.2 microg kg-1 h- (n = 12, Group D) was given intravenously over 5 h. Gastric motility was measured indirectly by analysis of the absorption over time of 1.5 g of paracetamol administered into the stomach at the start of the study period. At the beginning and end of the study, residual gastric volume and pH of residual gastric fluid were measured.

RESULTS

Gastric residual volume measured at the end of propofol infusion (19.33 +/- 11.33) was found to be higher when compared with the volume measured before infusion (11.33 +/- 4.84) and after dexmedetomidine infusion (9.17 +/- 4.54). But, there was no difference between groups in gastric emptying time (AUC120 894.53 +/- 499.39 vs. 1113.46 +/- 598.09 propofol and dexmedetomidine groups, respectively).

CONCLUSION

In our study, gastric residual volume measured at the end of propofol infusion was found to be higher when compared with the volume measured before infusion and after dexmedetomidine infusion. There was no difference between groups in gastric emptying time.

Gabapentin reduces cardiovascular responses to laryngoscopy and tracheal intubation

BACKGROUND AND OBJECTIVE

We have compared the effects of gabapentin on arterial pressure and heart rate at induction of anaesthesia and tracheal intubation in a randomized double-blind study.

METHODS

Ninety normotensive patients (ASA I) undergoing elective surgery were divided into three groups of 30 patients each. Patients received oral placebo (Group I), 400 mg of gabapentin (Group II) or 800 mg of gabapentin (Group III) 1 h prior to surgery in the operating theatre. After induction of anaesthesia heart rate and mean arterial pressure were recorded at baseline 1, 3, 5, 10 and 15 min after intubation.

RESULTS

Patients receiving placebo and 400 mg gabapentin showed a significant increase in blood pressure and heart rate associated with tracheal intubation compared to baseline levels and Group III. There was significant decrease in heart rate and arterial pressure in Group III after intubation 1, 3, 5 and 10 min (P < 0.001, P < 0.001, P < 0.05 and P < 0.05, respectively) compared to Groups I and II.

CONCLUSION

Given 1 h before operation gabapentin 800 mg blunted the arterial pressure and heart rate increase in first 10 min due to endotracheal intubation. Oral administration of gabapentin 800 mg before induction of anaesthesia is a simple and practical method for attenuating pressor response to laryngoscopy and tracheal intubation after standard elective induction.

Prediction of difficult tracheal intubation in Turkish patients: a multi-center methodological study

BACKGROUND AND OBJECTIVE

Preoperative evaluation is important in the detection of patients at risk for difficult airway management. It is still unclear whether true prediction is possible and which variables should be chosen for evaluation. The aim of this prospective, multi-centre study was to investigate the incidence of difficult intubation, the sensitivity and positive predictive values of clinical screening tests and whether combining two or more of these tests will improve the prediction of difficult intubation in Turkish patients.

METHODS

Seven study sites from six regions in Turkey participated in this study. One thousand six hundred and seventy-four ASA physical status I-III patients, scheduled to undergo elective surgery under general anaesthesia, were included.

RESULTS

The incidence of difficult intubation was 4.8% and increased with age (P < 0.05). The incidence of difficult intubation was significantly higher in patients who had a Mallampati III or IV score, a decreased average thyromental and sternomental distance, decreased mouth opening, or decreased protrusion of the mandible (P < 0.05). Mouth opening and Mallampati III-IV were found to be the most sensitive criteria when used alone (43% and 35%, respectively). Combination of tests did not improve these results.

CONCLUSIONS

There is still no individual test or a combination of tests that predict difficult intubations accurately. Tests with higher specificity despite low positive predictive value are needed.

A New Flap for Reconstruction of Pilonidal Sinus

BACKGROUND

"Adipofascial turnover flap" is a well-known procedure, but it is generally not used for the surgical treatment of pilonidal sinus disease. The "lumbar adipofascial turnover flap" has been used in this study for the reconstruction of uncomplicated pilonidal sinus disease.

METHODS

Ten cases (8 male and 2 female patients) were operated on by this technique. The reconstruction was performed with the lumbar adipofascial turnover flap. The flap sizes ranged from 4 x 7 cm to 5 x 9 cm (mean, 4.5 x 8 cm), and they were elevated with length-to-base ratio below 2:1. The follow-up period was 14 to 26 months.

RESULTS

Postoperative magnetic resonance imaging, computed tomography scan, and power Doppler ultrasound examinations revealed viability of the flaps in all patients. There was no distortion of anatomic landmarks in any of the cases. The esthetic results were satisfying for all patients as well. There was no recurrence in any cases.

CONCLUSIONS

The hospital stay and mean time off work were shorter compared with other methods of reconstruction and there was no recurrence. We advocate that the lumbar adipofascial turnover flap is an excellent choice for reconstruction of cases with uncomplicated pilonidal sinus disease.

Patients' willingness to pay for anti-emetic treatment

BACKGROUND

Post-operative nausea and vomiting (PONV) is a common complication of anaesthesia. This study was conducted in 100 German and 100 Turkish patients scheduled for elective surgery under general anaesthesia to assess the amount patients were willing to pay for an anti-emetic that completely prevented PONV.

METHODS

Post-operatively, using Dixon's up and down method, patients completed an interactive computer questionnaire with a random starting point to determine how much of their own money they were willing to pay for a totally effective anti-emetic treatment.

RESULTS

On average, participants were willing to pay 65 euro in Germany and 68 euro in Turkey to avoid PONV. However, patients who actually experienced PONV were willing to pay larger amounts: 96 euro in Germany and 99 euro in Turkey. The amount patients were willing to pay was related to female sex, history of motion sickness, non-smoking status and better education.

CONCLUSIONS

Despite differences in political and cultural origin, health care system and financial background, the amount patients were willing to pay for an effective anti-emetic was similar in both Germany and Turkey to that reported previously for the USA.

Uses of scapular island flap in pediatric axillary burn conractures

Pediatric axillary post-burn contractures one of the most challenging problems which follow treatment of the upper extremity burns. We preferred to use scapular flaps for surgical treatment of pediatric axillary contractures instead of skin grafting or Z-plasties. In this clinical study we present 13 pediatric cases treated with scapular island flaps. In pediatric scapular flap cases, the technique which we used was to extend the flap's pedicle dissection was continued to the level of bifurcation of subscapular artery. Bypassing the flap triangular space allowed us to cover the anterior part of the axillary contractures. We observed that the scapular flap repairs have many benefits to skin grafting including no recurrence of contracture and stable coverage of the shoulder joint. The other advantages of scapular island flap are that the donor site is closed primarily, and it provides an adequate amount of pliable skin while not compromising the function and range of motion of joints. In conclusion, the island scapular flap is a good choice for reconstruction of various axillary contractures in pediatric population.

Does the efficacy of supplemental oxygen for the prevention of postoperative nausea and vomiting depend on the measured outcome, observational period or site of surgery?

High intra-operative oxygen concentration reportedly reduces postoperative nausea and vomiting (PONV), but recent data are conflicting. Therefore, we tested whether the effectiveness of supplemental oxygen depends on the endpoint (nausea vs. vomiting), observation interval (early vs. late) or surgical field (abdominal vs. non-abdominal). We randomly assigned 560 adult patients undergoing various elective procedures with a PONV risk of at least 40% to intra-operative 80% (supplemental) or 30% oxygen (control). Potential confounding factors were similar between groups. Incidences of nausea were similar in the groups during early (12% (supplemental) vs. 10% (control), p = 0.43) and late intervals, 26%vs. 20%, p = 0.09, as were the incidences of vomiting (early: 2%vs. 3%, p = 0.40; late: 8%vs. 9%, p = 0.75). Supplemental oxygen was no more effective at reducing PONV in abdominal (40%vs. 31%, p = 0.37) than in non-abdominal surgery (25%vs. 21%, p = 0.368). Thus, supplemental oxygen was unable to reduce PONV independent of the endpoint, observational period or site of surgery.

Reconstruction of the Anterior Surface of the Ear Using a Postauricular Pull-Through Neurovascular Island Flap

The auricular conchal cavity is a shallow structure in the central part of the ear. It is not only 3-dimensional, but it is a gateway to the external ear canal. Many methods have been described for reconstruction of the defect of concha-antihelix: split- or full-thickness skin grafts, regional skin, chondrocutaneous and musculocutaneous flaps, but none of the authors have described this flap with neurovascular pedicle. We used postauricular neurovascular pedicle island flap for conchal and periconchal areas of anterior surface of the external ear because it matches to the skin color, thickness and texture; scars are well hidden, and there is no donor-site morbidity. Moreover, it has a constant and reliable neurovascular pedicle. The flap edema which was present in the early postoperative period began to resolve gradually after 3 weeks and disappeared in a few months. The esthetic results were excellent in all of the patients and very satisfying for the patients, too. The sensibility was positive by light touch, pin-prick, temperature and static 2-point discrimination in the postoperative control. The static 2-point discriminations in the transferred flap and in the other ear, which corresponds to the same area, were measured. The results were nearly the same as normal values. We advocate postauricular neurovascular pedicle island flap for conchal and periconchal areas of anterior surface of the external ear because it matches the skin color, thickness and texture; scars are well hidden, and there is no donor site morbidity. Moreover, it has a constant and reliable neurovascular pedicle.

Comparison of the laryngeal mask (LMA™) and laryngeal tube (LT®) with the new perilaryngeal airway (CobraPLA®) in short surgical procedures

BACKGROUND AND OBJECTIVE

We compared the laryngeal mask airway (LMA) and the laryngeal tube (LT) with the newly introduced perilaryngeal airway (CobraPLA, PLA) with regard to haemodynamic responses induced by airway insertion, clinical performance and occurrence of postoperative sore throat after short surgical procedures.

METHODS

After premedication, 90 ASA I-II patients awaiting short surgical procedures were randomized to receive, LMA, LT or PLA. Anaesthesia was induced with intravenous propofol (2.5 mg kg(-1)) and mivacurium (0.2 mg kg(-1)). Number of attempts, time of insertion of the device, any other unwanted effect, mean aterial pressure, heart rate, oxygen saturation and end-tidal carbon dioxide were recorded. At the end of surgery, the cuff of the device was immediately deflated and the airway device was removed. The device was examined and noted for the presence of visible blood. Patients were asked to rate their throat soreness, dysphonia and dysphagia 1 and 24 h postoperatively.

RESULTS

There were no differences in haemodynamic variables. Insertion times for the devices were similar (LMA: 20 +/- 11 s, LT: 19 +/- 14 s and PLA: 21 +/- 12 s.) The success rates at first insertion were lower in the (LMA group (57%) when compared with the PLA (97%, P < 0.05). The number and type of airway interventions for achieving an effective airway were similar. When the airways were removed 50% of the PLA devices had positive blood traces, while only 17% of the LMA and LT devices had positive blood traces (P < 0.01). Fifty percent of the patients suffered from a sore throat in the PLA group, which was significantly higher than in the LMA and LT groups (P < 0.05).

CONCLUSION

We conclude that haemodynamic, ventilation and oxygenation variables throughout the surgery were similar with, LMA, LT and PLA, but LT and PLA were easier to insert; LMA and LT caused less mucosal trauma.

Effect of oral gabapentin on postoperative epidural analgesia †

BACKGROUND

Gabapentin has been used successfully as a non-opioid analgesic adjuvant for postoperative pain management. We hypothesized that gabapentin might be a useful adjuvant for postoperative analgesia provided with patient-controlled epidural analgesia (PCEA).

METHODS

Forty patients undergoing lower extremity surgery procedures were randomly assigned to receive (i) placebo capsules (control) or (ii) gabapentin (1.2 g day(-1)) before and for 2 days after surgery. Anaesthetic technique was standardized. Postoperative assessments included verbal rating scale scoring for pain and sedation, PCEA usage, quality of recovery assessment, times of GI function recovery, and patient satisfaction scoring for pain management.

RESULTS

Pain scores at 1, 4, 8, 12, and 16 h (P<0.001), PCEA bolus requirements (n) at 24 [21 (3), 14 (2)], 48 [15 (4), 10 (3)] and 72 [8 (5), 2 (3)] (P<0.05) and paracetamol (mg) consumption [700 (523), 350 (400)]; P<0.05), were significantly lower in the gabapentin-treated patients than in the control group. Patient satisfaction with postoperative pain management at 24 h was better in gabapentin-treated patients [85.5 (7.5), 66.5 (15)]; P<0.001). Gabapentin-treated patients had less motor block when compared with control group. Times of return of bowel function, hospitalization, and resumption of dietary intake were similar in the groups. However, the incidence of dizziness was higher in the gabapentin group (35% vs 5%; P<0.05).

CONCLUSIONS

Oral gabapentin (1.2 g day(-1)) as an adjunct to epidural analgesia decreased pain and analgesic consumption. Despite an increased incidence of dizziness it also increased patient satisfaction.

Gabapentin: an alternative to the cyclooxygenase-2 inhibitors for perioperative pain management

The cyclooxygenase-2 inhibitor, rofecoxib, was a popular analgesic adjuvant for improving perioperative pain management. We designed this placebo-controlled study to test the hypothesis that gabapentin could produce similar reductions in postoperative pain and opioid analgesic usage, thereby improving the recovery process. One hundred patients undergoing abdominal hysterectomy procedures were randomly assigned to one of four treatment groups: 1) control group received placebo capsules and pills before and for 2 days after surgery, 2) rofecoxib group received 50 mg/d PO and placebo capsules before and after surgery and, 3) gabapentin group received 1.2 g/d PO and placebo pills before and after surgery, and 4) combination group received rofecoxib 50 mg/d and gabapentin 1.2 g/d PO before and after surgery. The anesthetic technique was standardized and the postoperative assessments included verbal rating scales for pain and sedation, IV morphine usage, quality of recovery assessment, recovery of bowel function, resumption of normal activities, and patient satisfaction with their pain management. Postoperative pain scores were significantly reduced in all three analgesic treatment groups (versus control group). Compared with the control group, patient-controlled analgesia morphine usage was also significantly reduced in the 3 analgesic treatment groups at 1, 8, 24, and 30 h after surgery. Total PCA morphine usage was decreased by 43%, 24%, and 50% in groups 2, 3, and 4, respectively, compared with group 1. Oral analgesic consumption was also smaller in groups 2 and 4 when compared with the control group. The opioid-sparing effects of rofecoxib and gabapentin lead to a faster recovery of bowel function. Discharge eligibility scores in groups 2 and 4 were improved at 24 h when compared with group 1, and patient satisfaction with postoperative pain management was significantly higher at 24 h in all 3 analgesic treatment groups. At the 72 h follow-up, all of the patients in group 4 were completely satisfied with their pain management compared with only 32%, 64%, and 72% in groups 1, 2, and 3, respectively. Gabapentin (1.2 g/d PO) appears to be an acceptable alternative to rofecoxib (50 mg/d PO) for short-term use as an adjuvant to opioid analgesics in patients undergoing lower abdominal surgery.

Diabetes care credit system: a model for comprehensive and optimal diabetes care

OBJECTIVE

To introduce a "credit system," which empowers patients with diabetes to share in the implementation of guidelines with the health-care provider and provides credits for achievement of health variables considered essential for optimal diabetes care.

METHODS

We describe the credit system and the points offered for achievement of variables that assess lifestyle, glycohemoglobin, blood pressure, lipid values, measurement of urinary albumin, annual physical examination, dilated eye examination, foot examination, and electrocardiogram, use of antiplatelet therapy, and use of angiotensin receptor blocker (ARB) or angiotensin-converting enzyme (ACE) inhibitor therapy. The patient's knowledge of diabetes and nutrition was also assessed. Patients with diabetes mellitus were enrolled in the credit program during their scheduled office visits. Results were compared with those in a control group.

RESULTS

The study enrolled 613 patients (303 male and 310 female patients), with a mean age of 59.91 +/- 13.57 years (range, 16 to 90). The control group consisted of 119 patients with diabetes (63 men and 56 women; mean age, 55.94 +/- 14.83 years) not participating in the credit system. One year after initiation of the program, analysis of the study group demonstrated high rates of implementation of guidelines: complete physical examination, 94%; foot examination, 89%; dilated eye examination, 77%; blood pressure less than 135/85 mm Hg, 78%; hemoglobin A1c less than 6%, 7%, and 8%, 26%, 58%, and 82%, respectively; serum triglycerides less than 200 mg/dL, 61%; low-density lipoprotein cholesterol less than 100 mg/dL, 49%; high-density lipoprotein cholesterol more than 35 mg/dL, 76%; use of antiplatelet therapy, 60%; quantitative urinary albumin screening, 74%; and use of ACE inhibitors or ARB, 44%. These rates of achievement of established variables for hemoglobin A1c, serum lipids, blood pressure, antiplatelet therapy, and measurement of urinary albumin were significantly higher than those in the control subjects.

CONCLUSION

The described credit system demonstrates an effective and practical means to implement and achieve the necessary guidelines and target variables that are intended to lead to optimal diabetes and cardiovascular outcomes.

Comparison of oral dolasetron and ondansetron in the prophylaxis of postoperative nausea and vomiting in children

BACKGROUND AND OBJECTIVE

In a randomized, placebo-controlled, double-blind trial, we compared the efficacy of oral dolasetron and ondansetron in preventing postoperative nausea and vomiting in children after various surgical operations.

METHODS

Children were assigned randomly to one of three groups (each contained 50 children) to receive dolasetron 1.8 mg kg(-1) or ondansetron 0.15 mg kg(-1) orally, or a placebo. All children received methylene blue capsules (10 mg) orally as an indicator before the induction of anaesthesia. Postoperatively, contamination of the mouth and the endotracheal tube by methylene blue was recorded, and postoperative nausea and vomiting was recorded for 0-1, 1-24 and 0-24 h. Metoclopramide (0.1 mg kg(-1)) intravenously was used as the rescue antiemetic.

RESULTS

In the 0-1 h period after operation, there were no differences between the groups. In the 1-24 h period, dolasetron was significantly better than placebo (nausea 8 versus 24%; vomiting 4 versus 20%; total nausea and vomiting scores 16 versus 48%). Over the 0-24 h period, both dolasetron and ondansetron were significantly better than placebo (nausea 16 versus 26 versus 40%), vomiting (8 versus 16 versus 30%), and total nausea and vomiting scores (32 versus 48 versus 78%). There were no significant differences between dolasetron and ondansetron. There was no important methylene blue contamination, and little use of rescue metoclopramide. There were no important adverse events.

CONCLUSIONS

Prophylactic oral dolasetron and ondansetron were effective in reducing postoperative nausea and vomiting in children.

Effect of aminophylline on bispectral index

BACKGROUND

The aim of the present study was to investigate the effects of aminophylline on BIS as well as clinical recovery in patients anesthetized with sevoflurane.

METHODS

Sixty patients with status of ASA I-II scheduled for elective surgery were enrolled in this study. Anesthesia was induced by 2 mg kg(-1) of propofol and 0.5 mg kg(-1) of atracurium, maintained with 1:1 ratio of oxygen and nitrous oxide and 2-2.5% sevoflurane, keeping BIS values at 50 +/- 5. During the last 30 min of the operation no muscle relaxant was given and anesthesia was continued without decreasing anesthetic concentration. After sevoflurane discontinuation, saline was given to Group P, and 5 mg kg(-1) of aminophylline was given to Group A. Bispectral index values, heart rate, blood pressure and oxygen saturation were determined in all the patients before and every min after injection of the test drug for 15 min. The following variables were measured in both groups: eye opening, extubation time, response to command, Aldrete scores, and performing three simple arithmetic calculations.

RESULTS

Between groups there was no statistically significant difference in mean arterial blood pressure, SpO2 and anesthesia time. Heart rate was found to be statistically higher (P < 0.001) at 2 to 6 min in Group A when compared with group P. Eye opening, verbal response, extubation and arithmetic calculation times were significantly shorter (P < 0.001) in Group A. Bispectral index scores were significantly higher in Group A at 1 to 12 min after aminophylline injection when compared with placebo (P < 0.001).

CONCLUSION

Recovery from sevoflurane anesthesia and BIS scores are improved in early period when aminophylline is given at emerging from anesthesia.

The prevention of pain from injection of rocuronium by magnesium sulphate, lignocaine, sodium bicarbonate and alfentanil

We compared the efficacy of magnesium sulphate, lignocaine, sodium bicarbonate or alfentanil in minimizing pain due to injection of rocuronium in 250 patients. After tourniquet application on the forearm, the patients were given saline, magnesium sulphate, lignocaine, sodium bicarbonate 8.4% or alfentanil, diluted into a 3 ml solution. The occlusion was released after 20 seconds, and rocuronium was injected over 10 to 15 seconds. The patients were observed and asked immediately if they had pain in the arm and the response was assessed. Reactions such as discomfort and pain, withdrawal of the hand and screaming after the administering of the rocuronium were recorded as side-effects and patients were reassessed at 24 hours postoperatively. We concluded that magnesium sulphate, lignocaine, sodium bicarbonate or alfentanil decreased the level of rocuronium injection pain. Of these drugs, magnesium sulphate, lignocaine and sodium bicarbonate were the most effective while alfentanil was the least effective.

Intravenous regional anesthesia using prilocaine and neostigmine

Neostigmine has been added to local anesthetics for central and peripheral nerve blocks resulting in prolonged, increased anesthesia and improved analgesia. We conducted this study to evaluate the effects of neostigmine when added to prilocaine for IV regional anesthesia (IVRA). Thirty patients undergoing hand surgery were randomly assigned to two groups to receive IVRA. The control group received 1 mL of saline plus 3 mg/kg of prilocaine diluted with saline to a total dose of 40 mL; the study group received 0.5 mg of neostigmine plus 3 mg/kg of prilocaine diluted with saline to a total dose of 40 mL. Sensory and motor block onset and recovery, anesthesia quality determined by an anesthesiologist, anesthesia quality determined by a surgeon, and dryness of the operative field were noted. Heart rate, mean arterial blood pressure, and oxygen saturation values were noted at 1, 5, 10, 20, and 40 min before surgery and after tourniquet release. Time to first analgesic requirement was also noted. Shortened sensory and motor block onset times, prolonged sensory and motor block recovery times, improved quality of anesthesia, and prolonged time to first analgesic requirement were found in the neostigmine group. We conclude that neostigmine as an adjunct to prilocaine improves quality of anesthesia and is beneficial in IVRA.

IMPLICATIONS

Neostigmine has been added to local anesthetics for central and peripheral nerve blocks. This study was conducted to evaluate the effects of neostigmine when added to prilocaine for IV regional anesthesia (IVRA). Neostigmine as an adjunct to prilocaine improves quality of anesthesia and is beneficial in IVRA.

Analgesic effects of rofecoxib in ear-nose-throat surgery

In this study we evaluated the analgesic efficacy and the opioid-sparing effect of rofecoxib in ear-nose-throat surgery patients. Patients undergoing nasal septal or sinus surgery were randomized to receive either oral placebo or rofecoxib 50 mg 1 h before surgery. All patients received propofol 0.8 mg/kg, fentanyl 1 microg/kg, and local anesthesia at the operative site. Sedation was maintained by a continuous infusion of propofol adjusted to maintain sedation at a 2-3 level on the Ramsey scale. Additional fentanyl 0.5-1 microg/kg was administered at the patient's request or if the verbal rating scale score was >4. Patient sedation and pain scores were obtained at 5, 15, 30 45, and 60 min during surgery and 30 min and 2, 4, 6, 12, and 24 h after completion of the procedure. During the postoperative period, diclofenac 75 mg IM was administered for analgesia at the patient's request or if the visual analog scale (VAS) rating for pain was more than 4. VAS pain scores, intraoperative fentanyl, and postoperative diclofenac requirements were significantly smaller in the rofecoxib group compared with the placebo group (P < 0.001). The times to first analgesic request were also significantly less in the rofecoxib group. We conclude that the preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the need for opioids in patients undergoing nasal septal and nasal sinus surgery.

IMPLICATIONS

The aim of this study was to evaluate the analgesic efficacy and opioid-sparing effect of rofecoxib, a new selective cyclooxygenase-2 inhibitor drug, in ear-nose-throat surgery patients. Preoperative administration of oral rofecoxib provided a significant analgesic benefit and decreased the need for opioids in patients undergoing nasal septal and nasal sinus surgery.

Effect of preoperative oral use of erythromycin and nizatidine on gastric pH and volume

This randomized controlled trial examined the effects of preoperative oral erythromycin or nizatidine on gastric pH and volume. Sixty patients, ASA 1 and 2 status scheduled for elective surgery were studied. All subjects received oral study medication with 10 ml of water 60 minutes prior to surgery. Patients in Group 1 (n=20) were given erythromycin 200 mg, in Group 2 (n=20) nizatidine 300 mg, and in Group 3 (n=20) placebo capsule. A nasogastric tube was inserted immediately after anaesthesia induction. Gastric content was aspirated, and volume and pH recorded. pH values determined in Group 1 were 5.6+/-1.87; in Group 2, 5.65+/-1.92 and in Group 3, 3.5+/-1.93. There was no statistical difference between Groups 1 and 2, but there was a statistically significant difference between Group 3 and Groups 1 and 2 (P<0.001). The volume of gastric content was 10.25+/-6.65 ml in Group 1, 10.3+/-6.29 ml in Group 2 and 20.25+/-16.72 ml in Group 3. Again, there was no statistical difference between Groups 1 and 2, but there was a statistically significant difference between Group 3 and Groups 1 and 2 (P<0.05). The proportion of patients considered "at risk" of significant lung injury should aspiration occur was 10% of Group 1, 5% of Group 2 and 20% of Group 3 (not statistically different). We conclude that oral erythromycin and nizatidine given one hour prior to surgery are effective in reducing gastric pH and volume.

Effect of aminophylline on recovery from sevoflurane anaesthesia

BACKGROUND AND OBJECTIVE

In this randomized, double-blind study, we aimed to investigate the effect of aminophylline on recovery from sevoflurane.

METHODS

One-hundred ASA I-II patients scheduled for elective surgery were randomly divided into two groups receiving either NaCl 0.9% (Group 1, n = 50) or aminophylline 5mg kg(-1) (Group 2, n = 50). All patients were premedicated with atropine 0.01 mgkg(-1) and midazolam 0.06mgkg(-1) intramuscularly. Anaesthesia was induced with propofol 2mg kg(-1) for muscle relaxation, and atracurium 0.5 mg kg(-1) was maintained with sevoflurane 2% in 50% oxygen and nitrous oxide. Further atracurium (0.1 mgkg(-1) was given when needed. Aminophylline or saline was given after sevoflurane was discontinued. Heart rate, mean arterial pressure, peripheral oxygen saturation, the duration of anaesthesia and recovery times (eye opening, verbal response, extubation and successful performance of arithmetical calculations) were recorded.

RESULTS

There were no statistically significant differences in mean arterial pressure, peripheral oxygen saturation and anaesthesia time between the two groups. Heart rate increased significantly (P < 0.05) after aminophylline and was also higher than in the placebo group. Recovery times were significantly shorter (P < 0.001) in the patients receiving aminophylline.

CONCLUSIONS

Aminophylline speeded recovery after sevoflurane anaesthesia and it may have some advantage in anaesthesia practice for patients.

The prevention of propofol injection pain by tramadol or ondansetron

BACKGROUND AND OBJECTIVE

To compare the efficacy of tramadol and ondansetron in minimizing the pain due to injection of propofol in 100 patients.

METHODS

An intravenous cannula was inserted in the dorsum of the hand. After tourniquet application to the forearm, tramadol 50 mg (Group 1, n = 50) or ondansetron 4 mg (Group 2, n = 50) was injected. The tourniquet was released after 20 s, and propofol 5 mL was administered over 5 s. The patients were observed and asked if they had pain in the arm and the response was assessed. Nausea and vomiting and degree of sedation were recorded for the first postoperative 24 h.

RESULTS

Twenty-one patients in Group 1 and 14 patients in Group 2 reported no pain. Slight pain was seen in 15 patients in Group 1 and in 18 patients in Group 2. Moderate pain was seen in 10 patients in Group 1 and 15 patients in Group 2. Severe pain was seen in four of the patients in Group 1 and three patients in Group 2. There was no significant difference of pain between Groups 1 and 2, but we found a significant reduction of nausea and vomiting in the ondansetron group compared with the tramadol group (P = 0.033).

CONCLUSIONS

Tramadol or ondansetron are equally effective in preventing pain from propofol injection. The added benefit of a reduction in nausea and vomiting after operation in the ondansetron group may be a reason to prefer this drug.

A new minimally invasive method of aortofemoral revascularization

In recent years, minimal invasive surgical applications have been used in every field of surgery and became a routine application for some kinds of operations. Mini-laparotomy has been limited to abdominal incisions between 3 and 10 cm long. Four aortobifemoral and one aortofemoral bypass cases that were performed with mini-laparotomy incision between January 1997 and February 1998 are presented. In all cases, revascularization of lower extremities was performed successfully without enlarging the incision. The average operation time was shorter and the number of transfused blood units was significantly lower in that group when compared to the conventional laparotomy group of 12 cases. In all cases, bowel sounds appeared in 2 to 8 hours and at the end of 24 hours, oral nutrition was started. The mean discharge time from the hospital was 4.7 days. With the advantages of less operation time, optimal aortic exposure, ability in safe cross-clamping, less postoperative pain, less scar tissue occurrence, early resumption of intestinal functions, early mobilization and shorter hospitalization time, the mini-laparotomy technique is a safe reliable method for use in aortobifemoral bypass operations.

Antenatal diagnosis of postductal coarctation of the aorta. A case report

Fetal echocardiography can be used to detect congenital heart disease prenatally with a high degree of accuracy, and complex heart malformations have also been clearly described in the fetus. However, it is difficult to diagnose correctly or to exclude definitely aortic coarctation by fetal echocardiography. A 23-year-old woman was referred for fetal echocardiographic examination at 21 weeks' gestation after discovery of hydrops fetalis (nonimmune) on an obstetric ultrasound examination. Aortic isthmus appeared hypoplastic with a diameter < or = 3rd percentile for gestational age. There was a narrowing within the descending aorta immediately distal to the origin of the ductus arteriosus. Color flow imaging demonstrated acceleration and turbulent flow and the peak pressure gradient was measured 83 mmHg by continuous wave Doppler in the same area. The pregnancy terminated in spontaneous abortion at 22 weeks' gestation. The fetus was stillborn. The autopsy findings confirmed the prenatal diagnosis. We conclude that together with the quantitative estimation of the aortic arch, color Doppler and continuous wave Doppler are helpful in diagnosis and estimation of the pressure gradient.

Maternal preeclampsia and jitteriness in preterm infants

AIM

To clarify the role of maternal preeclampsia in jitteriness in preterm infants.

METHODS

Sixteen premature infants of preeclamptic mothers were observed for occurrence of jitteriness and were compared with 32 premature infants born to normotensive women.

RESULTS

Jitteriness was present in a significantly higher percentage (75 vs 6%) and persisted longer (4.5 +/- 5.6 vs 1.5 +/- 0.7 days) in the preterm infants of preeclamptic mothers.

CONCLUSIONS

Maternal preeclampsia could be included among the pathological factors that cause jitteriness in preterm babies.

Perianal necrotizing fasciitis in a neonate

A two-week-old term male infant, weighing 1,600 grams was transferred to the neonatology unit of Doküz Eylul University hospital with sharply demarcated cutaneous gangrene surrounding the perianal region. He did well at birth. In his history, on the 10th postnatal day, a red, painful, warm cutaneous lesion was observed which was thought to be secondary to repeated and inappropriate rectal temperature measurements. Besides an ill-appearing child, a nontender frank cutaneous gangrene developed within several days. Klebsiella pneumoniae was cultured from the involved area. Blood cultures were negative. A frozen section of soft tissue biopsy could not be performed because of the localization of the lesion. The patient was successfully treated by surgical debridement and high doses of parenteral antibiotics.

Stability and purity profile of gonadorelin acetate: a high-purity gonadotropin-releasing hormone

Recently, several reports of adverse reactions after pulsatile GnRH (gonadorelin hydrochloride) infusion therapy have appeared in the medical literature. Although the cause of these reactions has been associated with GnRH itself, the contributions of impurities and degradation products in the administered drug have not been determined, suggesting that the use of high-purity material may be advantageous in controlling unwanted side effects. This study evaluates the purity and long-term stability of a new GnRH product, gonadorelin acetate (Lutrepulse, Ortho Pharmaceutical Corporation). Both the purity and potency of the drug substance, the lyophilized product for injection, and the reconstituted material that would be transferred to the infusion pump system were monitored using high-performance liquid chromatography. The gonadorelin acetate drug substance was found to be stable for at least 12 months when stored at 24 degrees C in 50% relative humidity, and showed no degradation even under accelerated storage conditions. Similarly, the lyophilized product also showed excellent stability for at least 18 months when stored at 24 degrees C in 50% relative humidity. Upon reconstitution, gonadorelin acetate was found to be stable for at least 45 days when stored at 24 degrees C or 37 degrees C.

The hexa- and pentapeptide extension of proalbumin. I. Chemical synthesis of serum albumin propeptides

The proalbumin hexapeptide extension was synthesized beginning from the C-terminal end by stepwise N-terminal peptide chain elongation starting from N-tert-butyloxycarbonyl-(Ng-nitro)arginyl-(Ng-nitro)arginine 4-nitrobenzyl ester; [alpha](20)365-12 degrees C (c = 1; dimethylformamide). The other amino acids were incorporated by excess mixed anhydrides of Ddz-amino acids (Ddz; 3,5-dimethoxyphenylisopropyloxycarbonyl) yielding the fully protected hexapeptide in crystalline quality. After removal of the protective groups by acid treatment and hydrogenation the peptide was purified by Dowex ion-exchange and Sephadex chromatography. The purity was confirmed by thin-layer chromatography and amino acid analysis.

The design of effective in vivo antagonists of rat uterus and milk ejection responses to oxytocin

Several new synthetic analogs of the oxytocin antagonist [1-deaminopenicillamine]oxytocin have been prepared and tested for their abilities to inhibit responses to oxytocin by the isolated rat uterus in the absence and presence of Mg++, by the rat uterus in situ, and by the rat mammary gland in situ. Substituting 2-O-methyltyrosine in [1-deaminopenicillamine]oxytocin strikingly enhances antagonism of all uterin responses, and [1-deaminopenicillamine, 2-O-methyltyrosine]oxytocin and its 4-threonine analog are also potent inhibitors of the milk ejection response. Substituting 2-phenylalanine in [1-deaminopenicillamine]oxytocin also enhances antagonistic activities in all uterine assays, but [1-deaminopenicillamine, 2-phenylalanine]oxytocin retains agonistic activity on milk ejection assays. From these studies we can conclude that changes in the 1-position (1-deaminopenicillamine substitution) and the 2-position (2-O-methyltyrosine or 2-phenylalanine substitution) can have additive effects on antagonistic activities. Substitution of an 8-ornithine also enhances inhibitory potency in vivo, and this effect may also be additive to those of the substitutions in 1- and 2-positions. These findings provide many clues that may lead to the design of even more effective antagonists; several of the analogs reported here appear to the most effective antagonists of oxytocin in vivo yet reported and may be useful agents in further studies on the physiological functions of endogenous oxytocin.