Perioperative intravenous adenosine infusion to extend postoperative analgesia in brachial plexus block

BACKGROUND AND OBJECTIVE: Adenosine infusions have been shown to reduce requirements of anaesthetics, to decrease the need for postoperative analgesics and to attenuate hyperaesthesia related to neuropathic pain. We decided to investigate the effects, beneficial or otherwise, of an adenosine infusion administered during surgery. A brachial plexus block was used to produce anaesthesia for the surgery. METHODS: Sixty adults undergoing upper extremity surgery were included in the study. Brachial plexus block was performed via an axillary approach with lidocaine 1.25% and epinephrine 1/200 000 (40 mL). Patients were randomly assigned to two groups. During surgery, saline (control) or adenosine 80 microg kg min was infused intravenously in a double-blind fashion for 1 h. Visual analogue scores every 4 h, analgesic consumption, time to first spontaneous pain sensation, time to first rescue analgesic and adverse effects were noted during the first 24 h. RESULTS: Vital signs were stable in both groups throughout surgery. During the adenosine infusion, one patient fainted while another complained of palpitations and tightness of the chest; both patients were excluded from further analyses. The time to first sensation of pain was significantly longer in the adenosine group compared to the control group (438 +/- 387 vs. 290 +/- 227 min, P = 0.02). The time to first rescue analgesic, the visual analogue scale scores and analgesic consumption in the postoperative period were similar. CONCLUSIONS: In patients undergoing surgery with an axillary plexus block, a perioperative adenosine infusion prolongs the duration of postoperative analgesia to some extent. However, the time to first rescue analgesic, total analgesic requirements and pain scores were unchanged; the risk of potentially serious adverse effects is high. This therapy cannot be recommended.     

A comparison of four intravenous sedation techniques and Bispectral Index monitoring in sinonasal surgery

This study was performed to investigate the quality of different intravenous sedation techniques, and the correlation between the Bispectral Index (BIS) values and the Observer's Assessment of Alertness/Sedation (OAA/S) scores. Eighty patients undergoing sinonasal surgery were randomly assigned to one of four groups. Group MF received midazolam and fentanyl, group PF received propofol and fentanyl, group MR received midazolam and remifentanil, and group PR received propofol and remifentanil. Heart rate and mean arterial pressure values were not different among the groups. SpO2 decreased only after intravenous medication in groups MF and MR (P < 0.017). Emesis was less common with propofol. A positive relationship existed between the BIS values and OAA/S scores during the operation in all groups and the strongest correlation was observed in group PR (r = 0.565 and P < 0.001). In conclusion, these four intravenous sedation techniques did not change mean arterial pressure, heart rate or SpO2 clinically and produced a similar level of light sedation. The BIS was useful for monitoring of sedation during sinonasal surgery under local anaesthesia with intravenous sedation.     

A double-orifice atrioventricular valve case: intraoperative transesophageal echocardiography in diagnosis and treatment

We describe a 45-yr-old woman with an intermediate type atrioventricular septal defect associated with a double-orifice left atrioventricular valve (DOLAV). We diagnosed this exceptional anomaly by intraoperative transesophageal echocardiography (TEE) during surgery that was scheduled for only a primum type atrial septal defect (ASD) repair. Preoperative transthoracic echocardiography and angiography revealed the ASD but could not demonstrate the DOLAV. We were able to repair this rare and challenging abnormality successfully under the guidance of TEE imaging during the operation. TEE provides valuable information about both anatomy and functional aspect of the valvular structures. Besides its proven role in cardiac surgery, intraoperative use of TEE also serves as a useful tool for diagnosis of such unexpected and potentially missed abnormalities.     

Remifentanil with thiopental for tracheal intubation without muscle relaxants

Tracheal intubation may be accomplished with remifentanil and a non-opioid IV anesthetic without a muscle relaxant. In this study, we evaluated in double-blinded, prospective, randomized manner the dose requirements for remifentanil with thiopental without muscle relaxant administration to obtain clinically acceptable intubation conditions and cardiovascular responses. After premedication with midazolam 0.03 mg/kg IV, 105 patients were randomized equally to one of three study groups, each receiving the following: remifentanil 2 micro g/kg (Group I), 3 micro g/kg (Group II), and 4 micro g/kg (Group III). Remifentanil was administered over 30 s, and anesthesia was induced with thiopental 5 mg/kg. Tracheal intubation conditions were assessed by the anesthesiologist performing the intubation as: (a) excellent, (b) satisfactory, (c) fair, and (d) unsatisfactory. There were no statistically significant differences among groups regarding to demographic data. Blood pressure and heart rate did not increase in any group after accomplishing intubation. There was a significant improvement in intubation conditions between Groups I and II, I and III, and II and III (P < 0.001). We conclude that remifentanil 4 micro g/kg administered before thiopental 5 mg/kg provided excellent or satisfactory intubation conditions in 94% of patients and prevented cardiovascular responses to intubation. IMPLICATIONS: We evaluated in a double-blinded manner the dose requirements for remifentanil with thiopental without muscle relaxants for obtaining acceptable intubation condition. Our results show that remifentanil 4 micro g/kg administered before thiopental provided excellent or satisfactory intubation condition in 94% of patients.     

Effect of sumach (Rhus coriaria L.) extracts on the oxidative stability of peanut oil

The antioxidant activities of sumach (Rhus coriaria L.) extracts and butylated hydroxyanisole (BHA) at various concentrations were tested in natural peanut oil stored at 65 degrees C for 35 days. The concentrations (weight/volume) of extracts added into oil were 1.0%, 3.0%, and 5.0%, and those of BHA were 0.1%, 0.3%, and 0.5%. Antioxidant effect was determined by the measurement of peroxide value. After 7 days of storage, BHA and extracts of sumach were active in varying degrees against autoxidation of peanut oil, compared with the control test (P <.01). The sumach extracts generally inhibited the formation of hydroperoxide, as did BHA. After 28 days of storage, antioxidant effects of extracts were significantly decreased when compared with BHA. The decrease in the antioxidant activity of extracts might have resulted from the decrease of polyphenolic constituents. The results showed that high concentrations can enhance the potency of the antioxidant effect of sumach extract.     

Lipoma arborescens (diffuse articular lipomatosis)

Lipoma arborescens (LA) (diffuse articular lipomatosis, synovial lipomatosis, Hoffa disease) is a rare intra-articular lesion of unknown etiology. This article presents three patients who had LA, which was diagnosed in the knee in two patients and in the wrist of the third patient. Details of the clinical and histomorphological examination and treatment, in addition to a review of the literature, are discussed. The article concludes that in patients with a slow increase in painless swelling of the joints, unresolving articular pain with or without limited motion, or intermittent effusions following a minor trauma, LA should be considered in the differential diagnosis. It should be remembered that LA occurs in joints other than the knee, such as the elbow, shoulder, and wrist. Although recommended surgery involves arthrotomy and synovectomy, arthroscopic synovectomy may be a useful treatment modality, particularly in the larger joints as the recurrence rate is low.     

Etiology of deafness at the Yeditepe School for the deaf in Istanbul

OBJECTIVE: The etiology of deafness can be classified as genetic, acquired and unknown. An unknown etiology was a high incidence in previous reports. The aim of this study is to explore the etiology of deafness and to reduce the cases in the unknown group. METHODS: This study was conducted on 162 students at the Yeditepe School for the deaf. Otologic, physical and psychological examinations were performed by a team of doctors including four otologists, a geneticist, a dentist, an ophthalmologist and an audiologist. RESULTS: A genetic cause was identified in 41.35%, acquired 37.65% and unknown 20.98%. Genetic etiologies were stratified as familial and syndromic subgroups. A familial cause was found in 60 of 162 children and in 22 of those 60 cases, the parents had a consanguineous marriage. There was 11 cases associated with a syndrome. Ninety four minor abnormalities have been established in some deaf children. Febrile convulsion (36%) was identified as the most common etiology in acquired cases. CONCLUSION: In contrast with other studies the consanguineous marriage was present in 36.6% of the familial cases and 38.8% in total of the school. An unknown etiology was reported in high rates in previous reports. These unknown cases could be described as a part of a syndrome by a crowded team of consultants. Evaluation of early diagnostic criterias and minor abnormalities can help us to provide early rehabilitation of deafness in childhood.     

Preoperative and postoperative cardiac and clinical findings of patients with adenotonsillar hypertrophy

OBJECTIVE: Our aim was to determine if there was any detectable clinical and cardiac changes in hypertrophied adenotonsillary disease with obstructive sleep apnea syndrome and to demonstrate the curative effect of adenotonsillectomy on these patients. METHODS: Thirty-three children with adenotonsillary hypertrophy and sleep related breathing disorders were included in this study group. There were 16 female and 17 male patients and the mean age was 6.9+/-2 years. Age and sex matched control group consisted of 33 children (16 female, 17 male) with a mean age of 6.3+/-2. Complete clinical and laboratory examinations were done for each patient. The results were analysed with the SPSS (statistical package for social sciences) computer program. The significance of changes was performed by means of the independent samples of one-tailed t-test. For categorical variables, chi-square analysis was performed. RESULTS: According to our snoring scale, snoring was mild in six patients (18.2%), moderate in 19 patients (57.5%) and severe in eight patients (24.3%). Severe apnea was not observed in any patients, moderate apnea in ten patients (30.3%) and mild apnea was observed in 23 patients (69.7%) preoperatively. Nine patients had Grade IV tonsils, 14 patients Grade III, seven patients Grade II, three patients Grade I. Twelve patients had 3+ (obstructive) adenoids, 21 patients had 2+ adenoids. Chest X-rays showed cardiomegaly in two patients with moderate degree of apnea. Electrocardiogram results were abnormal in four patients. When we compared echocardiographic results of study and control groups, we found several significant differences (RV: 1.6+/-0.3 vs 1.4+/-0.2; P<0.05, LVEDD: 3.6+/-0.5 cm vs 3.3+/-0.4; P<0.05, IVS: 6.8+/-1.4 mm vs 6.1+/-1.1 mm; P<0.05). Also a decreased left ventricular compliance measured by prolongation of deceleration time was found in patient group (DT: 173+/-44 vs. 126+/-22 ms; P<0.001). The echocardiographic results in postoperative group were similar to control group. CONCLUSION: This study illustrated that adenotonsillary disease with obstructive sleep apnea symptoms leaded to right and/or left ventricular enlargement, hypertrophy when compared with control subjects, which were recovered postoperatively.