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Introduction: The aims of this randomized prospective mannequin study were to determine the amount of attempts required for successful intubation using different fiberscopes (Bonfils and SensaScope) by inexperienced anesthesiologists in a difficult airway scenario and to build the associated learning curves., Methods: Difficult airway simulation was achieved with tongue edema in mannequin. After approval of volunteers, we asked 15 anesthesiology residents without any experience with fiberscopes to intubate with each device in a random order. Intubation success (endotracheal intubation within 120 seconds), the degree of difficulty of intubation, and reality of simulation using a 10-point scale were recorded. Learning curves were generated with cumulative sum method., Results: With Bonfils, 13 volunteers were able to pass lower decision boundary with a median number of 26 [95% confidence interval (CI) = 21.4-25.9] attempts, whereas in SensaScope, the same outcome was observed in 10 residents with a median number of attempts of 26 (95% CI = 23.5-32.5). Total success rate was found significantly higher with Bonfils compared with SensaScope (550/600 vs 512/600, respectively, P < 0.001). Intubation with Bonfils was considered as less difficult compared with SensaScope [median = 4 (95% CI = 3.32-4.42) and 6 (95% CI = 4.96-6.64), P = 0.01, respectively]. The reality of the simulation was rated as a median of 5 (95% CI = 4.37-5.8)., Conclusions: Although a similar number of attempts were required to reach predetermined competency for both fiberscopes, only 10 of residents were able to obtain the targeted success using SensaScope as compared with 13 with Bonfils. Inexperienced residents found intubation via Bonfils less difficult than SensaScope. High individual variability in obtaining competency observed in this study with cumulative sum analysis underlines the importance of defining success a priori to simulation, the need for follow-up of individual progress, and the need to offer adequate trials to achieve competency. Therefore, learning opportunities should be adapted accordingly.

Objectives: We performed this prospective clinical study to compare the postoperative recovery profile of our patients after transperitoneal (Group T) and retroperitoneal (Group R) laparoscopic nephrectomy approaches. Our primary hypothesis was that epidural analgesic consumption in Group R would be higher at the end of the first postoperative day., Methods: Forty-four patients scheduled for elective transperitoneal or retroperitoneal laparoscopic nephrectomies were enrolled. All patients in both groups received epidural catheter and general anesthesia induction. At the end of the operation, patients were given 10 ml 0.25% bupivacaine through epidural catheters and extubated. Postoperatively, patients started to receive a continuous infusion of 0.1% bupivacaine and 1μg/ml fentanyl 5ml/h with patient-controlled boluses of an additional 4ml through a patient controlled epidural analgesia (PCEA) device. They were prescribed IV tramadol 1mg/kg as a rescue analgesic VAS≥4). Total analgesic consumption from PCEA devices and VAS scores during the first 24 postoperative hours were recorded as well as number of patients who required analgesic rescue., Results: Forty patients completed the study, 20 in each group. Total epidural analgesic consumption during the first 12 hours were significantly higher in Group R (p<0.05). Basal, postoperative 30 min, 2, 6 hours VASrest, VASmobilization and 12 h VASmobilization scores, and number of patients who required rescue analgesic at 0, 30 min in Group R were significantly higher than Group T (p<0.05)., Conclusion: Retroperitoneal laparoscopic nephrectomy was found to be more painful and patients in this group required more epidural and analgesic rescue during the first 12 postoperative hours. ClinicalStudys.gov: (NCT02622893).

Introduction: The performance of laryngoscopes that have been developed for difficult airways can vary widely. The aim of the study was to compare Macintosh, McCoy, McGrath MAC, and C-MAC laryngoscopes in cervical immobilization and tongue edema scenarios in a mannequin, primarily to evaluate the time to intubation., Methods: In this randomized crossover study, 41 anesthesiology residents used 4 laryngoscopes in a mannequin (SimMan 3G) in 2 different scenarios. Intubation time (insertion of the blade between the teeth, to placement of the endotracheal tube into the trachea) longer than 120 seconds or inability to successfully place the endotracheal tube into the trachea after 5 or more attempts was defined as intubation failure. Besides intubation time, laryngoscopic view, number of intubation attempts, presence of esophageal intubation, need for stylet, difficulty of intubation, and success rate were recorded as secondary outcomes., Results: Intubation time was observed from longest to shortest as McGrath > McCoy > C-MAC > Macintosh in both scenarios. Laryngeal view was better with C-MAC laryngoscope. McGrath laryngoscope performed poorly specifically in tongue edema scenarios, which resulted in higher number of intubation attempts, esophageal intubation, need for intubation stylets, and overall intubation failure., Conclusions: The short intubation time observed with the Macintosh underlines the necessity of familiarity in success. Tongue edema is a more challenging scenario for simulated difficult airway and the McGrath may not be a good choice for such a scenario.

Background: Increased intra-abdominal pressure in pregnancy is thought to affect intrathecal drug spread. However this assumption remains largely untested. The aim of this prospective study was to evaluate the association between intra-abdominal pressure and maximum sensory block level in parturients receiving spinal anesthesia for cesarean section., Methods: Parturients having elective cesarean section with single-shot spinal anesthesia using hyperbaric bupivacaine 12.5mg were included. Intra-abdominal pressure was measured via a bladder catheter after establishing a T4 sensory block and at the end of surgery in the supine position with 10° left lateral tilt. We recorded demographic data, descriptive characteristics of pregnancy, self-reported weight gain and weight of the newborn. As secondary outcomes, we evaluated onset of sensory block, maximum sensory block, motor block, number of hypotensive episodes, fluid and ephedrine requirements, time to first analgesic request, time to one-point recovery of motor block and side effects., Results: The median value of the maximum sensory block level was T2 in 117 parturients. Median [interquartile range] pre-incision and postoperative intra-abdominal pressure were 13 [11-16] and 9 [6-10]mmHg respectively. No association was observed between maximum sensory block level and pre-incision intra-abdominal pressure (P=0.83). Weight was associated with pre-incision intra-abdominal pressure with an estimated odds ratio of 1.04 per kg (99.4% CI: 1.00-1.08). There was a moderate correlation between pre-incision and postoperative intra-abdominal pressure with a Spearman correlation coefficient of 0.67 (99.5% CI: 0.5-0.79). There was no association between pre-incision intra-abdominal pressure and secondary outcomes., Conclusions: In parturients, intra-abdominal pressure was not associated with spinal block spread, block onset time, recovery or side effects., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Local analgesia through wound catheters is used as a part of multimodal analgesia. The efficacy of continuous subfascial wound infusion compared to epidural analgesia is unknown for abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO) via Pfannenstiel incision. The aim of this study was to compare the aforementioned two methods in this type of surgery for postoperative morphine consumption, acute and persistent postsurgical pain., Methods: Fifty patients enrolled in the study were randomly allocated to receive continuous 10 mL/h levobupivacaine either via subfascial (Group S) or epidural (Group E) catheter for 48 h postoperatively. In Group S 0.25% levobupivacaine was used for the first six hours and 0.125% thereafter, whereas Group E received 0.125% levobupivacaine throughout the study period. Cumulative morphine consumption, static and dynamic pain, gastrointestinal recovery, ambulation, patient satisfaction, hospital stay, as well as pain at 2nd and 6th months were evaluated., Results: Group S was superior to Group E regarding cumulative morphine consumption (16.8±7.2 mg and 28.7±10.3 mg respectively, P<0.001; mean difference -11.9 with 95% CI of the difference -17.1 to -6.7) and pain relief. Patient satisfaction was higher in Group S compared to Group E (P=0.006). Less postoperative vomiting was observed in Group S. No difference was detected in length of hospital stay and persistent postsurgical pain incidence., Conclusion: Wound analgesia via subfascial catheter with continuous levobupivacaine infusion decreases postoperative morphine consumption and increases patient satisfaction compared to epidural analgesia with no difference in persistent postsurgical pain following TAH-BSO via Pfannenstiel incision.

Background: In this randomized, double-blind study, the effects of thoracic and lumbar epidural anaesthesia on the induction doses (IDs) and maintenance doses (MDs) of propofol during bispectral index (BIS) guided total i.v. anaesthesia were compared., Methods: Fifty-four patients (three groups, n=18 each) undergoing urological surgery in lumbotomy position were studied in Groups T (Th7-8) and L (L3-4), epidural anaesthesia was performed with initial doses obtaining sensorial block at Th4 (sd 1) followed by 7 ml h(-1) infusion; Group C received no epidural anaesthesia intraoperatively. The ID (BIS <45) and MD (BIS: 40-50) of propofol and recovery (BIS >80) and extubation times were recorded., Results: The volume to obtain a block was significantly lower in Group T than in Group L [10.7 (1.5) vs 14.7 (1.0) ml; P<0.001]. ID was significantly higher in Group C compared with that in Groups T and L [2.16 (0.15) vs 1.33 (0.19) vs 1.46 (0.14) mg kg(-1), respectively; P<0.001] with no significant difference between Groups T and L. For MD, there were significant differences between all groups [3.82 (0.9) vs 5.8 (1.32) vs 9.21 (0.55) mg kg(-1) h(-1) in Groups T, L, and C, respectively; P<0.001]. For recovery and extubation times, Group T

Background: In this prospective, clinical study we tested the hypothesis whether two different doses of spinal administered bupivacaine and accordingly, two different levels of spinal anaesthesia can affect the dose requirement of propofol during BIS guided sedation., Methods: Fifty women undergoing vaginal hysterectomy (high spinal group, HS) or transvaginal tape (TVT) procedure for urinary incontinence (low spinal group, LS) under spinal anaesthesia were enrolled to the study. In group HS, 17.5 mg and in group LS, 7.5 mg of hyperbaric bupivacaine were given intrathecally. After 15 min to obtain the appropriate level of spinal anaesthesia, propofol infusion was started at a rate of 100 microg kg(-1) min(-1) to reach a BIS level of less than 75 (onset time), and titrated to maintain the BIS value between 65 and 75. Propofol infusion was stopped 45 min after placing the spinal to measure the time to reach a BIS level of 90 (recovery time)., Results: Median anaesthetic level was T3 (T1-4) in the HS group and T10 (T9-11) in the LS group. In both the HS and the LS groups, onset time was 226 (47) vs 273 (48) s (P=0.001), recovery time was 234 (47) vs 202 (56) s (P=0.03), total dose of propofol was 2.17 (0.43) vs 3.14 (0.56) mg kg(-1) (P<0.001), respectively., Conclusion: A high spinal block obtained with hyperbaric bupivacaine 17.5 mg was associated with a faster onset, delayed recovery and lower doses of propofol sedation compared with a low spinal block with 7.5 mg of the same drug.

The use of opioids for spinal anesthesia increases the anesthetic quality, reduces side effects and also has advantages for the postoperative analgesia. The aim of this study was to evaluate the effects of subarachnoid %0.5 hyperbaric bupivacaine (B) alone or combined with 10 or 20 mg fentanyl (F) on the anesthetic properties for cesarean section and newborn. 45 patients were randomized to three groups to receive 1.8 ml anesthetic drug for spinal anesthesia. GI (n=15) received B, GII (n=15) 10 mg F+B, GIII (n=15) 20 mg F+B. The onset of sensory blok at T4 level, maximum anesthetic level and the onset time, the level of the motor block, duration of effective analgesia, use of total i.v. fluids and ephedrine, relaxation at the operative area, side effects, umblical cord blood gases, Apgar and neurological and adaptive capacity scores of the newborn were compared among the groups. We conclude that compared to control group, the addition of fentanyl to hyperbaric bupivacaine leads to a decrease in local anesthetic doses and so to a decrease in the incidence of side effects and postoperative analgesic consumption. 7 mg B+20 mg F seems to be the preferable combination for that reasons.