Assessment of fetal antioxidant and oxidant status during different anesthesia techniques for elective cesarean sections

Background:

We aimed to investigate the effects of general, spinal and epidural anesthesia on fetal total antioxidant status (TAS) and total oxidant status (TOS), and oxidative stress index (OSI) during elective cesarean section in this study.

Materials and Methods:

Forty-seven parturients scheduled for elective cesarean section were randomly allocated into three groups: Group spinal (n = 15), group epidural (n = 17), and group general (n = 15), This prospective randomized study was performed in Faculty of Medicine, Turgut Ozal University, Turkey. After the baby was delivered; TAS, TOS levels, and arterial blood gases parameters were analyzed in an umbilical arterial blood sample. OSI values are calculated by a ratio of TOS to the TAS.

Results:

The levels of TAS and TOS in umbilical arterial blood sample were not statistically different among three. However, OSI values were significantly different among the three groups (P = 0.042). Median OSI values is 24 (interquartile range [IQR], 2-37) in group spinal, 19 (IQR, 4-44) in group epidural, and 8 (IQR, 4-36) in group general. There was no significant difference in OSI values in the comparison of group spinal with group general and group epidural, but it was significantly lower in group general when compared with group epidural with Bonferroni correction (P = 0.017). Umbilical cord arterial blood gas values (pH, PaCO₂, PaO₂, SaO₂, HCO₃, and CtO₂), glucose, lactate, and hemoglobin levels were similar in three groups.

Conclusion:

General anesthesia may be more favorable than epidural in those undergoing cesarean section when fetal oxidative status gains importance.

Comparison of Epidrum, Epi-Jet, and Loss of Resistance syringe techniques for identifying the epidural space in obstetric patients

BACKGROUND

Identifying the epidural space is essential during epidural anesthesia (EA). Pressure of the epidural space in pregnancy is higher than that in nonpregnant woman. Loss of resistance (LOR) method is the most commonly preferred method for identifying the epidural space. Epidrum and Epi-Jet are recently innovated supporting devices that facilitate identifying process for epidural space. In this study we aimed to compare Epidrum, Epi-Jet, and LOR methods in identifying the epidural space, feasibility of technique.

METHODS

Two hundred and forty pregnant women who were scheduled for caesarian section surgery under lumbar EA or combined spinal epidural anesthesia (CSEA) were randomized into three groups (Group I Epidrum, n = 80), Group II (Epi-Jet, n = 80), and Group III (LOR, n = 80). We recorded the time required to identify the epidural space and deflation of Epidrum balloon and Epi-Jet syringe, number of attempts, additional methods used to identify epidural space, usefulness of methods, accuracy of identification of epidural space, and outcomes of epidural catheterization.

RESULTS

There were no significant differences between the groups with respect to demographic data, duration of deflation of Epidrum balloon and Epi-Jet syringe and distance between skin and epidural space. The mean time required to enter epidural space in Group I was shorter than that in Group II (P = 0.031). Feasibility of Epi-Jet was easier than that of Epidrum (P = 0.015). Number of uncertainties of epidural space identification was higher in Group I than that in Group II (P = 0.009). Also, the requirement for LOR to confirm epidural space and failure rates was higher in Group I than Group II (P < 0.001).

CONCLUSION

We suggest that Epi-Jet is superior to Epidrum in pregnant patients in terms of clarity of epidural space identification, usefulness, and success rates of EA or CSEA.

Evaluation of the effects of esmolol and remifentanil for controlled hypotension application on hemodynamics and oxidative stress parameters

Introduction: Anesthesia induced during a surgical intervention, the duration of the surgical intervention, and the surgical intervention itself tend to affect immune functions, resulting in the formation of free radicals in the metabolism. Free radicals can cause postoperative disorders by targeting biomolecules in the cell, such as lipids, carbohydrates, proteins, and DNA. In the present study, we used remifentanil or esmolol to induce a controlled hypotension in patients who were undergoing septorhinoplasty under general anesthesia, and we planned to compare the effect of these agents on hemodynamics and oxidative stress relative to the control group. Methodology: A total of 75 patients aged between 18 and 65 y, ASA I-II, planned to undergo elective septorhinoplasty, were included in this study. Patients were randomly divided into the following three groups: Group R (remifentanil group, n = 25); Group E (esmolol group, n = 25); and Group C (control, n = 25). Anesthesia was induced with 2 mg/kg propofol 2 mg/kg, fentanyl 1 µg/kg, and rocuronium 0.6 mg/kg. Immediately after induction, Group R was started loading dose of remifentanil 1 µg/kg/min, followed by infusion at 0.25–0.50 µg/kg/min. In Group E, a loading dose of esmolol 500 µg/kg was given for 1 min, then infusion was continued @ 150–300 µg/kg. A targeted mean arterial pressure (MAP) of 55–65 mmHg was aimed. In Group C, remifentanil was infused at 0.1–0.2 µg/kg/min until a MAP of 70–100 mmHg was reached. During operation; systolic (SAP), diastolic (DAP) and mean arterial pressure (MAP), heart rate (HR), peripheral oxygen saturation (SpO2), EtCO2 (end tidal CO2) were recorded before induction, after induction, after intubation, at 5-min intervals during the first 30 min, and then at 10-min intervals during the intervention. The amounts of remifentanil and esmolol consumed by the patients during the operation were calculated and recorded. Blood samples that were taken twice, preoperatively and postoperatively, for malondialdehyde (MDA), superoxide dismutase (SOD), total oxidant level (TOL), total antioxidant level (TAL), and oxidative stress index (OSI). Results: MAP showed a greater decrease starting from the 25th min and 40th min after intubation in remifentanil group and esmolol group respectively, compared to the control group. In the remifentanil and control groups, there was a statistically significant decrease in the postoperative OSI levels compared to the preoperative levels. One the other hand, in the esmolol group, there was no statistically significant difference between the preoperative and postoperative median OSI levels. There was a significant increase in the postoperative TAL of the remifentanil group compared to the preoperative level. Conclusion: It was observed that during a hypotensive anesthesia induced by remifentanil or esmolol, remifentanil ensured more stable operating conditions in terms of hemodynamics compared with esmolol, and that remifentanil was also superior to esmolol in reducing oxidative stress.   Abbreviations: TOL: Total oxidant level; TAL: Total antioxidant level; SOD: Superoxide dismutase; MDA: Malondialdehyde; OSI: Oxidative stress index Citation: Kaşıkara H, Demircioğlu RI, Gözdemir M, Karabayırlı S, Erdamar H, Namuslu M, Yazıcı U, Yüksel A. Evaluation of the effects of esmolol and remifentanil for controlled hypotension application on hemodynamics and oxidative stress parameters. Anaesth pain & intensiv care 2019;23(2):__ DOI: https://doi.org/10.35975/apic.v24i1. Received : 18 January 2019 Reviewed : 3 February 2019 Revised : 1 May 2019 Accepted : 9 May 2019 

The effects of positive end-expiratory pressure (PEEP) application on optic nerve sheath diameter in patients undergoing laparoscopic cholecystectomy: a randomized trial

BACKGROUND

Positive end-expiratory pressure (PEEP) can overcome respiratory changes that occur during pneumoperitoneum application in laparoscopic procedures, but it can also increase intracranial pressure. We investigated PEEP vs. no PEEP application on ultrasound measurement of optic nerve sheath diameter (indirect measure of increased intracranial pressure) in laparoscopic cholecystectomy.

METHODS

Eighty ASA I-II patients aged between 18 and 60 years scheduled for elective laparoscopic cholecystectomy were included. The study was registered in the Australian New Zealand Clinical Trials (ACTRN12618000771257). Patients were randomly divided into either Group C (control, PEEP not applied), or Group P (PEEP applied at 10 cmH20). Optic nerve sheath diameter, hemodynamic, and respiratory parameters were recorded at six different time points. Ocular ultrasonography was used to measure optic nerve sheath diameter.

RESULTS

Peak pressure (PPeak) values were significantly higher in Group P after application of PEEP (p = 0.012). Mean respiratory rate was higher in Group C at all time points after application of pneumoperitoneum (p < 0.05). The mean values of optic nerve sheath diameters measured at all time points were similar between the groups (p > 0.05). The pulmonary dynamic compliance value was significantly higher in group P as long as PEEP was applied (p = 0.001).

CONCLUSIONS

During laparoscopic cholecystectomy, application of 10 cmH2O PEEP did not induce a significant change in optic nerve sheath diameter (indirect indicator of intracranial pressure) compared to no PEEP application. It would appear that PEEP can be used safely to correct respiratory mechanics in cases of laparoscopic cholecystectomy, with no significant effect on optic nerve sheath diameter.

The effect of positive end-expiratory pressure on inflammatory cytokines during laparoscopic cholecystectomy

Objectives:

To investigate effects of the positive end-expiratory pressure (PEEP) application of 10 cm H₂O on the plasma levels of cytokines during laparoscopic cholecystectomy.

Methods:

A prospective study was conducted on 40 patients who presented to the Department of General Surgery, Medical Faculty, Turgut Özal University, Ankara, Turkey scheduled for laparoscopic cholecystectomy operation during a 10 month period from September 2012 to June 2013. Forty patients scheduled for laparoscopic cholecystectomy operation were randomly divided into 2 groups; ventilation through zero end-expiratory pressure (ZEEP) (0 cm H₂O PEEP) (n=20), and PEEP (10 cm H₂O PEEP) (n=20). All patients were ventilated with 8 ml/kg TV. Levels of interleukin (IL)-6, tumor necrosis factor (TNF)-α, IL 10, and transforming growth factor (TGF)-β1 were measured in the pre- and post-operatively collected samples.

Results:

Blood samples of 30 patients’ were analyzed for plasma cytokine levels, and 10 were excluded from the study due to hemolysis. Post-operative plasma IL-6 levels were observed to be significantly higher than the pre-operative patients (p=0.035). Post-operative plasma TGF-β1 levels in the PEEP group was found significantly higher compared with the pre-operative group levels (p=0.033). However, there were no significant differences in the pre- and post-operative plasma cytokine levels between the 2 groups.

Conclusion:

The application of PEEP of 10 cm H₂O, which has known beneficial effect on respiratory mechanics, does not have any effect on systemic inflammatory response undergoing pneumoperitoneum during laparoscopic cholecystectomy surgery.