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Objective: To compare levobupivacaine based caudal epidural anesthesia and spinal anesthesia in terms of Intraoperative hemodynamic changes and postoperative pain and patient comfort in subjects undergoing perianal surgery in outpatient setting. Material and methods: All consecutive patients who were scheduled for perianal surgery. The difference in intraoperative hemodynamic changes, sensory and motor block level, postoperative pain and patient comfort was the primary outcome measure of this study. Results: There were no significant differences between the groups in terms of mean arterial pressure and heart rate recorded. Subjects randomized to spinal anesthesia had a significantl extensive motor and sensory block compared to those randomized to caudal epidural anesthesia. Visual analogue scale scores for surgical pain at postoperative 12 hours was significantly higher in subjects receiving spinal anesthesia compared to those receiving caudal epidural anesthesia (p< 0.05). Time to first analgesic administration was significantly lower in subjects randomized to spinal anesthesia compared to those receiving caudal epidural anesthesia (p< 0.01). Conclusion: Spinal anesthesia is associated with more extensive sensory and motor block compared to caudal epidural anesthesia in patients undergoing perianal surgery. Both techniques lead to similar hemodynamic changes. Postoperative pain control is more favorable with caudal block than the spinal anesthesia.

Objective: Work areas and clinical practices have an effect on cesarean rates, which are also high in health professionals. Anestehsia professionals and the health professionals who are far from surgical practices may have different views on delivery methods. In this study, it was aimed to investigate which delivery method between vaginal delivery and cesarean delivery was selected by the anesthesia professionals and the health professionals outside the operating room, and why they selected it. Material and methods: 137 anesthesia professionals and 151 health professionals who had never worked in the operating room were included in this study. The participants' ages, professions and methods of delivery and reasons were questioned by the survey method. Results: While 58.3% of all the participants preferred the cesarean delivery method at their first birth, 41.7% preferred vaginal delivery. The preference rates of anesthesia professionals for cesarean delivery (69.9%) were found higher than those of the professionals working outside the operating room (46.6%),(p Conclusions: Knowing, practicing and seeing the anesthesia and surgical procedures every day have given the idea that these practices are simple, comfortable and have low risks, so the cesarean delivery rate has increased in anesthesia professionals.

Objective:Intensive care units (ICU) are the units in which critical patient care and follow-up are conducted. About 3.7-40% of ICU beds are used for intoxications. In ICU, intoxications may be mortal or can be discharged only by observation without any complication. The necessity of hospitalization of all these patients to the ICU is controversial in terms of bed occupancy and cost. In our study, it was aimed to determine the necessity and cost of hospitalization of ICU patients who were admitted to ICU with diagnosis of intoxication.Materials and Methods:This study was conducted by investigating the files of 205 intoxication patients who underwent more than 24 hours of follow-up and treatment at second and third level ICU. While patients were admitted to ICU, they were divided into two groups according to Glasgow Coma score (GCS) 15 (group=15) and below 15 (group

OBJECTIVES Surgical stress and pain affect the respiratory condition of patients and can cause complications that affect morbidity and mortality in cardiac surgeries. The authors studied the effect of thoracic epidural analgesia (TEA) versus traditional intravenous analgesia on postoperative respiratory mechanics in cardiac surgery. DESIGN Retrospective, observational study. SETTING Single, university hospital. PARTICIPANTS Patients undergoing cardiac surgery. INTERVENTIONS Comparing the postoperative respiratory effects of TEA with bupivacaine or intravenous analgesia with tramadol or paracetamol or dexmedetomidine. MEASUREMENTS AND MAIN RESULTS A total of 1,369 patients were screened, and 1,280 patients were enrolled in the study. Postoperative sedation and analgesia level, extubation times, respiratory complications, lengths of intensive care and hospital stay, morbidity, and mortality were compared. Additional sedative and analgesic drug requirement in the TEA group (25.3% and 60.1% respectively) were significantly lower than the intravenous group (41.4% and 71.8%, respectively; p < 0.001 and p < 0.05, respectively). Extubation time in the TEA group also was significantly lower than the intravenous group (p < 0.01). Respiratory complication and hospital stay in the TEA group were lower than intravenous group (p < 0.05). CONCLUSIONS TEA provided better postoperative respiratory condition via better sedative analgesia in cardiac surgery.

Purpose We aimed to compare the efficacy and safety of midazolam plus ketamine versus fentanyl plus propofol combination administered to children undergoing upper gastrointestinal endoscopy (UGE) and to determine the most appropriate sedation protocol. Materials and methods This prospective, randomized, single-blind study included patients between the ages of 4 and 17 years who underwent UGE for diagnostic purposes. Patients were divided randomly into groups A (midazolam-ketamine combination, n=119) and B (fentanyl plus propofol combination, n=119). The effectiveness of the sedation and complications during the procedure and recovery period were recorded. Results The processes started without an additional dose of the drug for 118 patients (99.1%) in group A and for 101 patients (84.8%) in group B (P=0.001). The average dose of ketamine administered to the patients in group A was 1.03±0.15 mg/kg and the average dose of propofol administered to the patients in group B was 1.46±0.55 mg/kg. None of the patients stopped the endoscopic procedure in group A, but one patient (0.8%) had to discontinue the endoscopic procedure in group B. 27 patients in group A (22.7%) and 41 patients (34.5%) in group B developed complications during the procedure (P=0.044). The rate of complications during the recovery of group A (110 patients, 92.4%) was significantly higher than that in group B (48 patients, 40.3%) (P=0.001). Conclusion In children, UGE procedures can be quite comfortable when using the midazolam-ketamine combination. However, adverse effects related to ketamine were observed during recovery.

Chylothorax is a rare sequela to cardiac surgery, associated with high rates of morbidity and mortality. There are various medical and surgical options for its management. We describe 2 cases of chylothorax that developed after coronary artery bypass grafting and were managed successfully with medical therapy alone. Conservative treatment such as we describe aims to reduce chyle flow, to drain the pleural cavity in an effective manner, and to prevent chronic sequelae. Optimal conservative treatment, consisting of nothing by mouth and the administration of a pleurodetic agent, should be started immediately upon diagnosis. In most cases, it reduces the need for reoperation and long-term hospitalization. Prospective randomized controlled trials are nonetheless needed to confirm these assumptions.

The aim of this study was to compare the effects of wound infiltration with levobupivacaine and tramadol in reducing postoperative pain in children undergoing unilateral inguinal hernia and undescended testis surgery. Under general anesthesia for elective unilateral inguinal hernia and undescended testis underwent surgery, ASA I-II, 80 children between the ages of 1-6 records in the patient's file was reviewed. The patients who were given 2mg.kg-1 tramadol in saline solution as prepared 0,2 ml.kg-1 into the surgical incision area by the surgeon at the end of the operation were accepted as Group T, who were given 0.25% levobupivacaine as 0.2 ml.kg-1 were accepted as Group L. Hemodynamic parameters, CHEOPS pain scores, additional analgesic consumption, adverse effects were recorded from the files. Patients\' CHEOPS were significantly higher in Group L compared to Group T at 4 and 6 hours (p, Biz çalışmamızda inguinal herni ve inmemiş testis operasyonu geçiren çocuklarda levobupivakain ile tramadolun yara yeri infiltrasyon yöntemiyle postoperatif ağrıyı azaltmadaki etkinliklerini karşılaştırmayı amaçladık. Genel anestezi altında elektif inguinal herni ve inmemiş testis operasyonu geçiren, ASA I-II risk grubunda, 1-6 yaş arası 80 çocuk hastanın dosya kayıtları retrospektif olarak incelendi. Cerrahi bitiminde, cilt kapanmadan önce yara dudaklarına 2 mg/kg tramadol içeren solusyondan 0.2 ml/kg olacak şekilde yapılanlar T Grubu, %0.25’ lik levobupivakain solusyondan 0.2 ml/kg olacak şekilde yapılanlar L Grubu olarak kabul edildi. Hemodinamik parametreler, CHEOPS ağrı skoru, ek analjezik tüketimi ve yan etkiler dosyalardan incelenerek kaydedildi.Hastaların CHEOPS skoru L grubunda T grubu ile kıyaslandığında 4. ve 6. saatte daha yüksek saptandı (p

BACKGROUND Our aim in this study was to investigate the effect of levobupivacaine and a levobupivacaine + tramadol combination on postoperative analgesia in intraoperative nerve block under standard general anesthetic. METHODS Forty-five patients undergoing outpatient nasal surgery under general anesthesia were randomized into 3 groups. Group L: 0.25% levobupivacaine, group T: 0.25% levobupivacaine and 50 mg tramadol, group S: normal saline solution; 2 mL of each being injected into the infraorbital foramen. Intraoperative hemodynamic changes were recorded. Verbal numeric rating scale (NRS) values were checked at 30 minutes and 1, 2, 8, and 12 hours postoperatively, and the need for rescue analgesic treatment in the first 12 hours of all patients was recorded. Also antiemetic drug requirement and side effects (nausea, edema, erythema, hematoma, and sedation) were recorded. RESULTS At 30 minutes and 1 hour postoperatively, NRS pain scores were lower in group T than in group S (P < 0.0001, P = 0.01, respectively). NRS pain score was lower in group T compared with group L at 1 hour postoperatively (P = 0.01). Effective analgesia time (sec) in the control group (142.67 ± 77.31) was shorter than levobupivacaine (240 ± 96.39) and levobupivacaine added to tramadol groups (277 ± 11.60) (P < 0.05). Additional analgesic requirement in the control group was higher than the other 2 groups in early postoperative period (P < 0.05). CONCLUSIONS Bilateral infraorbital nerve block with 0.25% levobupivacaine is an effective, reliable, and simple technique in the treatment of postoperative pain in nasal surgery. In addition, the addition of tramadol as an adjuvant to local anesthetics in this technique is safe.

Purpose: This study examined the effectiveness of dexmedetomidine in preventing lung injury resulting from pneumoperitoneum in a ventilated rat model. Methods: Animals (n=18) were allocated randomly into 3 groups: control group, no pneumoperitoneum; sham group, pneumoperitoneum with intra-abdominal pressure of 12 mm Hg for 60 minutes; and dexmedetomidine group, dexmedetomidine administration 30 minutes before pneumoperitoneum. The rats were rested for 30 minutes after abdominal deflation. Then, blood samples were obtained for plasma malondialdehyde and ischemia-modified albumin (IMA) analyses. Tissue samples were taken for histopathologic examination and malondialdehyde analysis. Results: Compared with the control group, the sham group had a significantly higher level of plasma IMA. Pretreatment with dexmedetomidine significantly reduced the IMA level. Histopathologically, tissues from sham rats exhibited moderate or severe tissue damage, compared with control tissues. Dexmedetomidine-treated rats showed significantly less tissue damage than sham rats. Conclusions: Dexmedetomidine prophylaxis resulted in significantly less IMA production and significantly less neutrophil infiltration, thereby helping to protect the lungs from injury after pneumoperitoneum.

WOS: 000384952700119 PubMed: 27687454 Study objective: To investigate the effects of dexmedetomidine on oxidative injury caused by ionizing radiation. Design: Randomized controlled experimental study. Setting: Department of radiation oncology and research laboratory of an academic hospital. Interventions: Twenty-eight rats were randomized to 4 groups (n = 7 per group). Group S rats were administered physiologic serum; group SR rats were administered physiologic serum and 10 Gy external ionizing radiation. Groups D100 and D200 were administered 100 and 200 mu g/kg dexmedetomidine intraperitoneally, respectively, 45 minutes before ionizing radiation. Measurements: Liver, kidney, lung, and thyroid tissue and serum levels of antioxidant enzymes (glutathione peroxidase [GPX], superoxide dismutase, and catalase) and oxidative metabolites (advanced oxidation protein products, malondialdehyde, and nitrate/nitrite, and serum ischemia-modified albumin) were measured 6 hours postprocedure. Main results: In group SR, IR decreased antioxidant enzyme levels and increased oxidative metabolite levels (P < .05). In plasma, antioxidant enzyme levels were higher and oxidative metabolite levels were lower in groups D100 and D200 than in group SR (P < .01). In tissues, hepatic and lung GPX levels were higher in groups D100 and D200 than in group SR (P < .001). Renal and thyroid GPX levels were higher in D200 than in group SR (P < .01). Thyroid superoxide dismutase levels were higher in groups D100 and D200 than in group SR (P < .01). Renal, lung, and thyroid catalase levels were higher in group D200 than in group SR (P < .01). Hepatic, renal, and lung advanced oxidation protein products and malondialdehyde levels were lower in groups D100 and D200 than in group SR (P < .01). Hepatic, renal, and lung nitrate/nitrite levels were lower in group D200 than in group SR (P < .05). Conclusions: Dexmedetomidine preserves the antioxidant enzyme levels and reduces toxic oxidant metabolites. Therefore, it can provide protection from oxidative injury caused by ionizing radiation. (C) 2016 Elsevier Inc. All rights reserved.

The local anesthetic mixtures are performed for peripheral nerve blocks to accelerate the onset time of sensorial and motor blocks. Also adjuvant agents can be added to local anesthetics to improve the quality and duration of plexus blocks. In this study, we compared the effect of tramadol and fentanyl as adjuvant agents to local anesthetic mixtures in axillary plexus block for orthopedic upper extremity surgery. After approval of hospital ethics committee and written patient consent, sixty patients were enrolled to the study in three groups; The Control Group (Group C, 40 mL of 0.25% levobupivacaine + 40 mg lidocaine n:20), the Fentanyl Group(Group F, 40 mL of 0.25% levobupivacaine + 40 mg lidocaine + 50 mcg fentanyl n:20), the Tramadol Group (Group T, 40 mL of 0.25% levobupivacaine + 40 mg lidocaine + 100 mg tramadol n:20) for axillary plexus block. Groups were compared for partial and complete motor and sensorial block, onset time, partial and complete motor and sensorial block recover time, and postoperative first analgesic requirement time (VAS >4). In Group T partial sensorial block onset time was shorter than Group C and complete sensorial block onset time was shorter than Group C and Group F. In Group T complete sensorial block recover time was longer than Group C and Group F. The postoperative first analgesic requirement time was significantly longer in Group T and F when compared with Group C and significantly longer in Group T when compared with Group F. We conclude that the addition of tramadol or fentanyl to local anesthetic mixtures as an adjuvant agent for axillary block provide better postoperative analgesia for orthopedic upper extremity surgery. Furthermore tramadol more improves the block quality than fentanyl.

Effective pain control is important after an outpatient arthroscopic knee surgery to permit early discharge and improve outcome. The aim of this study was to compare intraarticular morphine and bupivacaine with placebo for postoperative pain control and outpatient status after a knee arthroscopic surgery under a low dose of spinal anaesthesia. After obtaining the ethic committee’s approval and written informed consents from 60 adult outpatients undergoing knee arthroscopy, patients were enroled in this prospective, randomized, double-blinded, placebo-controlled clinical study. All patients received spinal anaesthesia with 1.4 ml of hyperbaric bupivacaine 0.5%. Patients were randomly divided into three groups as morphine (group M, n = 20), bupivacaine (group B, n = 20), and placebo (group C, n = 20). After the surgical procedure, patients received one of the following solutions intraarticularly in a double-blinded randomized manner: 5 mg morphine in 20 ml saline, 20 ml 0.25% bupivacaine, or 20 ml saline. Postoperative pain was assessed using a 10-cm visual analogue scale (VAS). Patient characteristics, hemodynamic values, sensory and motor blocks, VAS values, rescue analgesics, discharge time, and patient satisfaction were recorded. There were no significant differences in patient characteristics, surgery and tourniquet time, hemodynamic values, and sensory and motor blocks. The VAS values at 30, 60, and 90 min were similar among the three groups. The VAS values at rest and during move were higher in group C than in groups M and B at 120, 150, 180 min, and 24 h (P < 0.001). There was no difference in VAS values between the groups M and B. Rescue analgesics used and discharge time were significantly different in the placebo group when compared to groups M and B (P < 0.001). Side effects were similar among the groups. Patient satisfaction scores were high in the groups M and B. Administration of 5 mg morphine and 20 ml of 0.25% bupivacaine intraarticularly provides better pain relief and shorter discharge time without increasing the side effects than placebo for an outpatient arthroscopic knee surgery performed under a low dose of spinal anaesthesia.

Objective: The aim of this study was to compare the haemodynamic and anaesthetic effects of 12 mg ropivacaine and 8 mg bupivacaine, both with 20 µg fentanyl, in spinal anaesthesia for major orthopaedic surgery in geriatric patients. Subjects and Methods: Sixty American Society of Anesthesiologists (ASA) II–III patients scheduled for hip arthroplasty were randomly assigned to receive an intrathecal injection of either 12 mg ropivacaine with 20 µg fentanyl (group R, aged 70 ± 7 years, range 67–89) or 8 mg hyperbaric bupivacaine with 20 µg fentanyl (group B, aged 69 ± 6 years, range 66–92). Motor and sensory block, haemodynamics and side effects were recorded. Results: Mean levels of sensory block were similar, but the onset time of sensory block in group B (2.52 ± 0.69 min) was shorter than that in group R (3.17–0.72 min); the difference was statistically significant (p < 0.01), and the number of patients who had motor Bromage scale 3 in group B (24) was greater than in group R (16). The difference was also statistically significant (p < 0.05). Systolic and diastolic arterial pressures (SAP, DAP) and heart rate (HR) decreased after the block in both groups. SAP (after the 60th and 120th min of block), DAP (all measurement times), and HR (after the 20th, 25th and 30th min of block) were lower in group B than in group R. Conclusions: The data showed that 12 mg of ropivacaine and 8 mg of bupivacaine with 20 µg fentanyl in spinal anaesthesia can provide sufficient motor and sensory block for major orthopaedic surgery in geriatric patients. However, ropivacaine caused less motor block and haemodynamic side effects than bupivacaine during the procedure.

The aim of this study was to compare the effects of propofol and N-acetyl cysteine (NAC) on tourniquet-induced ischaemia-reperfusion injury by determining malonyldialdehyde, ischaemia-modified albumin, lactate, blood gas and haemodynamic levels in arthroscopic knee surgery.Sixty ASA I or II patients were randomized into three groups. Intrathecal anaesthesia was administered using 0.5% heavy bupivacaine in all patients. In group P, propofol was administered in a 0.2 mg kg(-1) bolus, followed by infusion at a rate of 2 mg kg(-1) h(-1); in group NAC, NAC was administered as an infusion at a rate of 5 mg kg(-1) h(-1), and, in group C (the control group), an equal volume of isotonic saline was administered to patients until 30 min after reperfusion. Blood samplings were obtained immediately before intrathecal anaesthesia (t1), 1 min before tourniquet release (t2), 5 min after tourniquet release (t3) and 30 min after tourniquet release (t4).Plasma malonyldialdehyde, ischaemia-modified albumin and lactate levels increased significantly in group C at t3 and t4 compared with the baseline values. Plasma concentrations of malonyldialdehyde, ischaemia-modified albumin and lactate in groups P and NAC were significantly lower than those in group C at t3 and t4. In blood gas analyses, pH, HCO3 and base excess were found to be significantly lower at t3 and t4 compared with t1 and t2 in group C. Comparisons between groups P and NAC revealed no significant differences.Small-dose infusions of both propofol and NAC appear to provide similar protection against ischaemia-reperfusion injury in arthroscopic knee surgery.

A great number of anesthetic techniques (general, regional, spinal, epidural, caudal, hypotensive, total intravenous, regional intravenous, inhalation, and nerve blocks) can be used for multiple surgical procedures [1–3]. The effect of anesthetic technique on perioperative outcomes is controversial. Central neuraxial blocks including spinal, epidural, and caudal anesthesia are regional anesthesia techniques. Regional anesthesia techniques provide important advantages compared with general anesthesia in some surgical procedures [1, 3]. Regional anesthesia is not only performed for adequate anesthesia in the surgical procedures. There are other advantages for the use of regional anesthesia techniques including excellent pain control, reduced side effects, decreased blood loss, improved cardiac and pulmonary function, and shortened stay in the postanesthesia care unit [1–4]. Low doses of spinal anesthesia and intra-articularly administered analgesic provided a better pain relief, a shorter discharge time, and a higher satisfaction for outpatient arthroscopic knee surgery [2]. Epidural technique as a regional anesthesia is one of the important methods for multimodal postoperative pain control [1, 3]. Hypotensive epidural anesthesia is another technique that decreased blood loss in hip surgeries [1]. Caudal anesthesia is commonly performed in pediatric patients for surgical anesthesia and postoperative analgesia. Regional anesthesia would provide excellent pain control and improve outcomes such as decrease in side effects, improvement of pulmonary function, prevention of chronic pain, or reduction in hospital stay. Thus the regional anesthetic techniques and outcome using regional anesthesia for postoperative pain have becoming one of the important fields [4, 5]. Total intravenous anesthesia (TIVA) has been used in some surgeries and it has been compared with other anesthesia techniques. TIVA with propofol can make a positive contribution to preventing ischemia-reperfusion-associated increases in MDA and IMA in tourniquet-related ischemia reperfusion in arthroscopic knee surgery. In scoliosis surgery, the use of TIVA with propofol and remifentanil is associated with decreased neuroendocrine stress responses in the perioperative period when compared with inhalation anesthesia. Regional intravenous anesthesia (RIVA) is generally preferred for patients who will have upper extremity surgery due to advantages such as providing a blood-free surgery site, rapid onset and termination of the anesthetic effect, lack of necessity of severe sedation, and general anesthesia and easy application. In addition some analgesic drugs to local anesthetics in intravenous regional anesthesia (IVRA) have been published. The addition of 3 mg/kg paracetamol and 50 mg dexketoprofen to lidocaine as adjuvant in RIVA applied for hand and/or forearm surgery created a significant difference clinically. Nerve blocks are used for postoperative analgesia. Interscalene brachial plexus block (ISB) is used to provide both anesthesia and analgesia for shoulder surgery. In a study the authors showed that the same volume and concentration of bupivacaine and ropivacaine (30 mL of 0.5%) for interscalene brachial plexus block anesthesia produced similar surgical block. When continuing the block with a patient-controlled interscalene analgesia infusion, 0.15% bupivacaine and ropivacaine provided adequate pain relief, similar side effects, and high patient satisfaction after shoulder surgery. This special issue contains five clinical studies and a review article related to comparison of anesthetic techniques. In the review article the benefits and risks of hypotensive anesthesia during major maxillofacial surgery were compared to those of normotensive anesthesia. The authors reported that controlled hypotension during anesthesia or hypotensive anesthesia is often used in major maxillofacial operations. Reduced blood pressure is advantageous in some settings because it can contribute to a reduction in overall blood loss and improve the surgical field conditions. Since hypotensive anesthesia carries the risk of hypoperfusion to important organs and tissues, mainly the brain, heart, and kidneys, it cannot be applied safely in all patients. In a clinical study, spinal and general anesthesia were compared for the impact of the surgical environment, especially the sounds of saw and hammer in the operating room, on patient's mood and anxiety after the operation in total knee arthroplasty (TKA). It was reported that sounds of hammer and saw had no evident negative effect on patient's mood and, in operations performed with spinal anesthesia, the patients were found to be more satisfied so that, with known advantages, regional anesthesia was advisable for TKA patients and appropriate sedation can be administered during the operation if needed. Two clinical studies are related to the comparison of supraglottic airway devices. The aim of a clinical study was to compare the performance of recently released size 1 I-gel with size 1 ProSeal LMA, which is proven to be superior to the classical LMA for small infants and neonates. The study demonstrated that the size 1 I-gel provided an effective and satisfactory airway as the size 1 ProSeal LMA. It may be a good alternative supraglottic airway device for use in small infants and neonates. However, further studies are needed to determine whether it is reliable for aspiration because of the absence of a gastric drainage tube in this size. Another study compared ProSeal, Supreme, and I-gel supraglottic airway devices in terms of oropharyngeal leak pressures and airway morbidities in gynecological laparoscopic surgeries. It was reported that ProSeal, Supreme, and I-gel provided a safe airway in paralyzed and pressure-controlled ventilation administered gynecological laparoscopic surgeries. While initial oropharyngeal leak pressures obtained by I-gel were lower than ProSeal and Supreme, increased oropharyngeal leak pressures over time, ease of placement, and lower airway morbidity were favorable for I-gel. The local anesthetics used in day-case spinal anesthesia should provide short recovery times. In a clinical study hyperbaric prilocaine and bupivacaine were compared in terms of sensory block resolution and time to home readiness in day-case spinal anesthesia. In the study it was reported that day-case spinal anesthesia with prilocaine 30 mg + 20 μg fentanyl provided faster sensory block resolution and home readiness compared to 7.5 mg bupivacaine + 20 μg fentanyl and the surgical conditions were comparable for perianal surgery. Dislocation of epidural catheters (EC) may cause early termination of postoperative regional analgesia. In a clinical study the hypothesis that maximum effort in fixation by catheter tunneling and suture decreases the incidence of its dislocation was tested. It was reported that thorough tunneling and suture of thoracic epidural catheters significantly reduced incidence and extent of catheter dislocation and potentially that of bacterial contamination. The outcomes of the comparison of anesthetic techniques are multifarious. In the future more researches are needed to explain the potential mechanisms for these outcomes. Ahmet Eroglu Alparslan Apan Engin Erturk Izhar Ben-Shlomo

To investigate the effects of propofol and caffeic acid phenethyl ester (CAPE) on prevention of lung injury as a remote organ after performing hindlimb ischaemia-reperfusion (IR) in a rat model.The animals were divided randomly into one of four groups: sham, no IR (n = 8), control, IR, (n = 8), CAPE group, IR with CAPE, (n = 8), propofol group, IR with P, (n = 8). After the rats were anaesthetised, the animals in the CAPE group received CAPE of 10 micromol, in the propofol group received propofol 50 mg/kg, in the control group received a similar volume of saline solution by means of intraperitoneal injection 1 h before reperfusion. After 4 h of ischaemia the tourniquet was removed and the animals were released for reperfusion for 4 h thereafter. At the end of the reperfusion period, a median sternotomy was performed. A blood sample was obtained for plasma malondialdehyde (MDA). The lung tissues were also removed for MDA assays, myeloperoxidase (MPO) activity, and histopathological examination.Plasma and lung MDA levels, and lung MPO activity were significantly higher in the control group compared to the other groups (p0.0005). In the CAPE group, these were significantly lower compared to the control group (p0.0005). Also, propofol caused a marked reduction in the MDA levels and MPO activity compared with control group (p0.0005), with no significant difference compared to that of the sham group. Histopathologically, the scores resulted in a grade zero (8/8) in the sham group, 3 (3/8) or 4 (5/8) in the control group, 1 (2/8) or 2 (6/8) in the CAPE group, and 1 (3/8) or 2 (5/8) in the propofol group.Propofol and CAPE seem to be effective in protecting against lung injury caused by increased oxidative stress and neutrophil accumulation after hindlimb IR in a rat model.

Objective: To report a successful vaginal delivery using slow infusion of epidural analgesia in a patient with both severe aortic stenosis and insufficiency. Clinical Presentation and Intervention: A 26-year-old primigravid patient presented to our hospital for delivery. She had aortic stenosis and insufficiency due to rheumatic fever. Although the obstetrician recommended cesarean section owing to her cardiac status, she insisted upon vaginal delivery. We performed low-dose epidural analgesia with 10 ml of 0.125% ropivacaine and 20 µg fentanyl. She had spontaneous vaginal delivery without complication. Conclusion: This case showed that in spite of the cardiac pathology, vaginal delivery under low-dose slow infusion of epidural analgesia was successful and therefore may be a safe alternative to cesarean section for cardiac patients.

Pain is an outstanding problem after surgical trauma. Pain following surgery may initiate variety of mechanisms including inflammatory, visceral, or somatic in origin and may persist to be chronic pain if improperly treated. The incidence of postoperative pain has been reported to be as higher as 60%, and, despite intensive effort, it is not able to resolve completely [1]. Most of the surgeries become less invasive and are increasingly being outpatient-based in time dependent manner. Besides technical developments on surgery, this tendency is mainly dependent on effective pain control and reduction of the side effects related to the treatments. Opioids and nonsteroidal anti-inflammatory drugs are the other main components of pain therapy which have well-known side effects that may limit their use. The modern concept of pain treatment includes multimodal approach and mainly targets to decrease opioid use in combination with other drugs or techniques in order to reduce drug related side effect profile especially to prevent postoperative respiratory depression. Until recently, there is no convincing data to demonstrate the beneficial effects of regional anesthesia on postoperative mortality, cardiovascular complications, or the incidence of thromboembolism when thromboprophylaxis is concomitantly in use, but all authors indicate that it may decrease the morbidity including postoperative pulmonary complications after major abdominal surgery and may improve the patient recovery after orthopedic surgery. It is also demonstrated that regional anesthesia reduces the incidence of postoperative pain, opioid consumption, and related side effects such as nausea and vomiting [2]. Central neuraxial blocks alone or in combination with catheter techniques are performed in various surgical interventions in order to decrease surgically induced stress and inflammation, improve pulmonary functions, and reduce the period for ambulation with better pain control. In a meta-analysis, it has been stated that postoperative pain control with local anesthetic infusion with long term catheter placement demonstrated a decrease in the occurrence of chronic pain [3]. Peripheral nerve blocks are the other type of regional techniques. Improvement in ultrasound technology may increase clinical applications for peripheral nerve and truncal blocks. Real time ultrasound use while performing the block may reduce the complications, performance time, and local anesthetic requirements. It also provides reappraising the older techniques with carrying potential complications. The rate of success may increase with clinical experience. Peripheral nerve blocks seem to lack systemic side effect related to sympathetic blockade and lesser incidence of minor complications including urinary retention when compared with central neuraxial blocks or catheter applications. Peripheral nerve blocks seem to be safer than either central neuraxial blocks or general anesthesia, especially in patients with severe coexisting disease [2]. In this special issue, we focused on the clinical studies and review articles related to various aspects of regional anesthesia for postoperative pain control. Some of these studies have investigated the effects of additives combined with local anesthetic mixture on postoperative analgesia in regional intravenous anesthesia. One of these reports investigated two additives, namely, ketamine or tramadol, combined with ropivacaine. While onset and duration of motor and sensorial block were shorter, the period of analgesia was longer in the tramadol group in the paper entitled “Does the addition of tramadol and ketamine to ropivacaine prolong the axillary brachial plexus block?” On the same topic, the efficacy on nitroglycerine or lornoxicam combination with lidocaine for regional intravenous anesthesia was searched. Each of these drug combinations effectively increased the tolerance to the tourniquet and decreased pain during peri- and postoperative period, which is discussed in the paper entitled “Peri- and postanalgesic properties of lidokain, lornoxicam, and nitroglycerine combination at intravenous regional anesthesia.” Likewise, dexketoprofen or paracetamol combination with lidocaine was compared to each other for the same purpose. Addition of dexketoprofen increased the duration of motor block and decreased pain scores, and lesser analgesic consumptions were observed in groups with paracetamol or dexketoprofen when compared with the control, in the paper entitled “Comparison of the effect of lidocaine adding dexketoprofen and paracetamol in intravenous regional anesthesia.” Central neuraxial blocks including spinal and epidural anesthesia were the subjects of the other studies. The effects of intraoperative intravenous magnesium sulfate infusion on sensorial and motor block characteristics and postoperative pain scales in female patients undergoing abdominal hysterectomy under spinal anesthesia were investigated. Authors indicated that the sensorial block period of spinal anesthesia increased, and better pain scores were observed with magnesium therapy without significant complications, in the paper entitled “The effect of intravenous magnesium sulfate infusion on sensory spinal block and postoperative pain score in abdominal hysterectomy.” In the other report, the difference of spinal block characteristics with levobupivacaine 0.5% plain solution at room and body temperature (23°C and 37°C) was observed in male patients undergoing transurethral resection of prostate operation. Authors indicated that the use of 0.5% levobupivacaine spinal anesthesia heated to the body temperature accelerated the start of sensory and motor block in the paper entitled “The effects on sensorial block, motor block, and haemodynamics of levobupivacaine at different temperatures applied in the subarachnoid space.” Epidural anesthesia was the main topic for postoperative pain control in two clinical trials. The influence of preemptive local anesthetic infusion with a thoracic epidural catheter on thoracotomy was evaluated and the effects of preemptive and postoperative infusions were compared. It was shown that preemptive administration of local anesthetic solution offered superior analgesic quality and lesser analgesic consumption, which is shown in the paper entitled “The effectiveness of preemptive thoracic epidural analgesia in thoracic surgery.” In a retrospective study, the difference of analgesic efficacy of epidural anesthesia was compared with total intravenous anesthesia performed with propofol and remifentanil infusion in patients who underwent abdominal aortic aneurysm repair. It was stated that the quality of analgesia improved with epidural anesthesia, and enteral nutrition was performed earlier, in the paper entitled “Efficacy of continuous epidural analgesia versus total intravenous analgesia on postoperative pain control in endovascular abdominal aortic aneurysm repair: a retrospective case-control study.” Caudal anesthesia is commonly performed in pediatric patients for surgical anesthesia and postoperative analgesia. In a clinical report entitled “The effects of single-dose rectal midazolam application on postoperative recovery, sedation, and analgesia in children given caudal anesthesia plus bupivacaine,” the effects of rectal midazolam combined with caudal anesthesia on the quality of sedation and postoperative analgesia were investigated, but no significant contribution was demonstrated. Gabapentin, a drug that is used for treatment of neuropathic pain, has also been investigated for possible effects on postoperative analgesia. In a review entitled “Gabapentin in acute postoperative pain management,” the influence of gabapentin treatment on postoperative pain control was documented and it was found that gabapentin was an efficacious agent for postoperative analgesia in various types of surgery. Pain is a common problem in all age groups of patients. Postoperative analgesia is a developing area and regional anesthesia is an essential part of this treatment. It is worthy of noting that future studies and technical developments about regional anesthesia will contribute vital advancements to postoperative pain control. Ahmet Eroglu Engin Erturk Alparslan Apan Urs Eichenberger Ozgun Cuvas Apan

Background. The aim of this study is to compare the effects of sevoflurane and propofol on one lung ventilation (OLV) induced ischemia-reperfusion injury (IRI) by determining the blood gas, ischemia-modified albumin (IMA), and malonyldialdehyde (MDA).Material and Methods. Forty-four patients undergoing thoracic surgery with OLV were randomized in two groups (sevoflurane Group S, propofol Group P). Anesthesia was inducted with thiopental and was maintained with 1–2.5% of sevoflurane within the 40/60% of O2/N2O mixture in Group S. In Group P anesthesia was inducted with propofol and was maintained with infusion of propofol and remifentanil. Hemodynamic records and blood samples were obtained before anesthesia induction (t1), 1 min before two lung ventilation (t2), 30 min after two lung ventilation (t3), and postoperative sixth hours (t4).Results. Heart rate att2andt3in Group P was significantly lower than that in Group S. While there were no significant differences in terms of pH and pCO2, pO2att2andt3in Group S was significantly lower than that in Group P. IMA levels att4in Group S were significantly lower than those in Group P.Conclusion. Sevoflurane may offer protection against IRI after OLV in thoracic surgery.

Ischemia-reperfusion injury represents a pathological condition characterized by an initial undersupply of blood to an area or organ followed by a restoration of perfusion and concomitant reoxygenation (= reperfusion). Ischemia typically occurs in the presence of embolism or thrombosis but can also be triggered by surgery and transplantation. Anyway, the disturbance in perfusion results in a severe imbalance between metabolic supply and demand, subsequently causing tissue hypoxia [1]. Notably, these initial changes cause time-dependent molecular and structural alterations. In this context, it is also important to consider that all tissues and organs are susceptible to ischemia, but susceptibility to an ischemic insult differs between organ systems. Whereas the brain can endure ischemia only a few minutes, other tissues (e.g., muscle) are able to withstand ischemia for a long time without signs of irreversible damage. Interestingly, restoration of blood flow and reoxygenation is commonly associated with an exacerbation of tissue injury and a profound inflammatory response (“reperfusion injury”) [1, 2]. Ischemia-reperfusion injury contributes to pathology in a wide range of conditions. For example, myocardial ischemia followed by reperfusion typically manifests in microvascular dysfunction, death of myocytes, and myocardial stunning or dysfunction. Ischemia-reperfusion injury (IRI) of the lung, for example, following transplantation, is characterized by nonspecific alveolar damage, edema formation, and hypoxemia. The clinical spectrum of pulmonary IRI may range from mild hypoxemia to acute respiratory distress syndrome. In contrast to other organs, the brain is particularly susceptible to ischemia and irreversible neuronal damage already occurs after only 5 minutes of complete ischemia [3]. For brain ischemia, as occurring in the setting of stroke, reestablishing reperfusion seems to be only beneficial, if carried out within a short time period after the onset of ischemia. Reperfusion of ischemic stroke seems to be very critical, as patients may suffer from cerebral reperfusion injury manifesting in fatal cerebral edema formation and intracranial hemorrhage. IRI of the kidney may occur in the setting of transplantation and cardiac arrest and during cardiac surgery. Here it is important to note that renal injury is usually associated with a high morbidity and mortality. The cortical-medullary region is the most susceptible region to tubular injury, inflammation, and vascular alterations. Generally, IRI of a single organ causes the release of different proinflammatory mediators, which may subsequently induce inflammation in other organs, thereby potentially contributing to multiple organ dysfunction or even failure [4]. Different pathological processes contribute to tissue injury secondary to ischemia-reperfusion. During ischemia, limited oxygen availability leads to an impaired endothelial cell barrier function with a concomitant increase in vascular permeability and leakage due to decreases of intracellular cAMP levels caused by a reduced adenylate cyclase activity [1]. Furthermore, ischemia-reperfusion induces cell death due to apoptosis, necrosis, and autophagy [5]. During the ischemic period, alterations in the transcriptional control of gene expression likewise occur. Another mechanism implicated in the pathophysiology of injury during ischemia is the inhibition of oxygen-sensing prolyl hydroxylase (PHD) enzymes, because they require oxygen as a cofactor. Hypoxia-triggered inhibition of PHD enzymes induces the posttranslational activation of hypoxia and inflammatory signaling cascades, which in turn regulate the stability of the transcription factors, hypoxia-inducible factor (HIF) and nuclear factor-κB (NF-κB) [2]. Reperfusion of ischemic tissue activates a complex inflammatory response without the involvement of pathogenic triggers, a phenomenon also referred to as sterile inflammation. During the initiation of this inflammatory response, endogenous molecules act as alarmins or danger-associated molecular patterns (DAMPs) [6]. The inflammatory process is stimulated through self-antigens, which are functional components of intact cells but become stimulators of innate immunity when released from injured or dying cells [6]. In 1996, Weiser et al. discovered and described a novel mechanism for reperfusion injury that involves antibody deposition and activation of the complement system leading to an acute inflammatory response [7]. One decade later, the concept of innate autoimmunity was introduced, which is based on the discovery that circulating natural antibodies recognize self-antigens and elicit an acute inflammatory response involving the complement system [8]. Although ischemia-reperfusion is typically established in a sterile environment, activation of innate and adaptive immune responses occurs and contributes to injury, including activation of pattern-recognition receptors such as TLRs and inflammatory cell trafficking into the injured organ [9]. During this inflammatory process, the coagulation system is also activated, because the innate immune system and coagulation system are highly interconnected [10]. As ischemia-reperfusion injury is a common clinical problem and is associated with relevant complications, it is important to identify therapeutic approaches which prevent or at least mitigate ischemia-reperfusion-induced organ injury and organ dysfunction. This special issue is devoted to the modulation of ischemia-reperfusion injury by different measures and contains eight original papers addressing this clinically relevant topic. These papers are accompanied by two review articles dealing with the effects of anesthetics on ischemia-reperfusion injury. Papers from B. U. Togrul et al., D. Dohman et al., and Y. Demirci et al. are focusing on ischemia-reperfusion injury of the liver. In two of these three papers, different therapeutic interventions on hepatic ischemia-reperfusion injury are evaluated, whereas the third paper is a retrospective study in which the authors investigated the efficacy and safety of intermittent portal triad clamping with low central venous pressure during liver resection. In this context, it has been reported that remote ischemic preconditioning and therapeutic interventions can reduce liver damage after inducing ischemia-reperfusion injury. The studies by S. C. Karahan et al., B. Michele et al., S. C. Karahan et al., D. Dohman et al., and G. Altun et al. elucidate the effects of different anesthetic techniques and drugs on ischemia-reperfusion injury. These eight papers are entitled as follows: “The effects of remote ischemic preconditioning and N-acetylcysteine with remote ischemic preconditioning in rat hepatic ischemia-reperfusion injury model” by B. U. Togrul et al., “The effects of spinal, inhalation, and total intravenous anesthetic techniques on ischemia-reperfusion injury in arthroscopic knee surgery” by S. C. Karahan et al., “Efficacy and safety of hepatectomy performed with intermittent portal triad clamping with low central venous pressure" by D. Dohman et al., “Adalimumab ameliorates abdominal aorta cross clamping induced liver injury in rats” by Y. Demirci et al., “Evidence for the use of isoflurane as a replacement for chloral hydrate anesthesia in experimental stroke: an ethical issue” by B. Michele et al., “The effect of dexmedetomidine on oxidative stress during pneumoperitoneum” by S. C. Karahan et al., “The comparison of the effects of sevoflurane inhalation anesthesia and intravenous propofol anesthesia on oxidative stress in one lung ventilation” by D. Dohman et al., and “Role of ethyl pyruvate on systemic inflammatory response and lung injury in an experimental model of ruptured abdominal aortic aneurysm” by G. Altun et al. Alexander Zarbock Ahmet Eroglu Engin Erturk Can Ince Martin Westphal

Ischemia-reperfusion injury (IRI) is induced as a result of reentry of the blood and oxygen to ischemic tissue. Antioxidant and some other drugs have protective effect on IRI. In many surgeries and clinical conditions IRI is counteract inevitable. Some anesthetic agents may have a protective role in this procedure. It is known that inhalational anesthetics possess protective effects against IRI. In this review the mechanism of preventive effects of volatile anesthetics and different ischemia-reperfusion models are discussed.

Background. The aim of this study is to investigate the effectiveness of preemptive thoracic epidural analgesia (TEA) comparing conventional postoperative epidural analgesia on thoracotomy.Material and Methods. Forty-four patients were randomized in to two groups (preemptive: Group P, control: Group C). Epidural catheter was inserted in all patients preoperatively. In Group P, epidural analgesic solution was administered as a bolus before the surgical incision and was continued until the end of the surgery. Postoperative patient controlled epidural analgesia infusion pumps were prepared for all patients. Respiratory rates (RR) were recorded. Patient’s analgesia was evaluated with visual analog scale at rest (VASr) and coughing (VASc). Number of patient’s demands from the pump, pump’s delivery, and additional analgesic requirement were also recorded.Results. RR in Group C was higher than in Group P at postoperative 1st and 2nd hours. Both VASr and VASc scores in Group P were lower than in Group C at postoperative 1st, 2nd, and 4th hours. Patient’s demand and pump’s delivery count for bolus dose in Group P were lower than in Group C in all measurement times. Total analgesic requirements on postoperative 1st and 24th hours in Group P were lower than in Group C.Conclusion. We consider that preemptive TEA may offer better analgesia after thoracotomy.

Following the removal of a hydatiform mole in a 34-year-old, 14-week pregnant patient, thyrotoxicosis and respiratory insufficiency attacks were twice unexpectedly repeated. The symptoms were resolved with the administration of plasmapheresis, antithyroid and β-blocker drugs and non-invasive mechanical ventilation; however, she was again operated due to prolonged elevated β-hCG.

Background: We compared the postoperative analgesic efficacy of caudal levobupivacaine with bupivacaine in pediatric subumbilical surgery. Methods: Sixty American Society of Anesthesiologists I-II patients scheduled for elective minor surgery (1.5-7 years old) were randomly divided into three groups to receive caudal injections of study drugs at 0.5 ml/kg. All patients received 0.1 mg/kg oral midazolam 30 min before surgery. Group B received 0.125% bupivacaine, group L received 0.125% levobupivacaine, and group LF received 0.125% levobupivacaine + 0.5 ?g/kg fentanyl. Blood pressure, heart rate and sedation (using a four-scale sedation score) were monitored perioperatively. During the postoperative period, an anesthesiologist blinded to the study groups used the Children's and Infants' Postoperative Pain Scale to monitor patients' pain and degree of sedation. The time before the first rescue analgesic was recorded as well as any side effects over the next 24 h. Results: The four-scale sedation and postoperative pain scale scores in all groups were identical. Blood pressure and heart rate measured at 15 min postoperatively were lower, and time to first rescue analgesic was longer, in Group LF compared to the others. Conclusions: Caudal 0.5 ml/kg of 0.125% bupivacaine and levobupivacaine are equally effective for postoperative analgesia after subumbilical surgeries in pediatric patients. Addition of fentanyl may lower the required amount of local anesthetics. © the Korean Society of Anesthesiologists, 2014.

In the paper titled “Regional Anesthesia for Postoperative Pain Control,” the correct author list shall be “Ahmet Eroglu, Engin Erturk, Alparslan Apan, and Ozgun Cuvas Apan." The author “Urs Eichenberger” is not an author in the paper.

Hypertrophic osteoarthropathy is characterized by digital clubbing and periosteal reaction of long bones. Most cases are associated with malignancy or other conditions such as congenital heart disease, liver cirrhosis, pulmonary fibrosis, biliary atresia, and gastrointestinal polyps. We report a 19-year-old man presenting with arthritis, broadening of the fingers and clubbing of the fingers and toes for the previous 3 years. The ankles and knees were swollen. X-rays showed periosteal apposition. The search for a secondary cause remained negative. In cases of arthralgia/arthritis together with clubbed fingers, consideration must be given to hypertrophic osteoarthropathy. The primary or idiopathic form is rare and has a good prognosis.