EPIdemiology of Surgery-Associated Acute Kidney Injury (EPIS-AKI) : Study protocol for a multicentre, observational trial

More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369

The role of sugammadex in a patient with respiratory failure followed by postoperative anaphylactoid reaction [Postoperatif anaflaktoid reaksiyon sonrasi gelişen solunum yetmezügi olgusunda sugammadeksin rolü]

In this case report; reversal of anaphylactoid reaction-related postoperative residual neuromuscular paralysis and oxygen desaturation with sugammadeks has been presented in a 64- year- old woman with recurrence endometrial cancer undergoing abdominal laparotomy and staging surgery. Patient was extubated and transferred to the recovery unit following the end of surgery. On arrival recovery unit, erythema and urticaria was observed, firstly, in head-neck region and then in the whole body, followed by angioedema. In respiratory variables, oxygen desaturation was observed and oxygen saturation was dropped quickly first to 89 % and then 79 % and continued to drop down. On developing asphyxia, shortness of breath, cough, laryngospasm, hypoxemia and cyanosis, to increase oxygenation, positive pressure ventilation was launched. Patient was administered rapid fluid infusion, im 0.3 mg adrenaline, iv 4 mg kg' metilprednisolone and 40 mg antistine. Urticarial and hemodynamic symptoms were resolved quickly, however respiratory functions were partially improved and oxygen saturation values remained lower than safety values (<90%).It was supposed that postoperative residual neuromuscular paralysis, which causes impossible to reach safe oxygenation levels, was worsened by anaphylactoid reaction and 2 mg kg' of sugammadex was administered intravenously. Within 3-4 minutes, respiration was better and oxygen saturation values reached to safer levels and she did not need the positive pressure ventilation support.It is important to keep in mind that beside antiallergic and antiedema therapy, the use of sugammadex significantly improves respiratory functions in a woman that developed postoperative anaphylactoid reaction leading to résiduel neuromuscular paralysis and oxygen desaturation

The effects of morphine and remifentanil in isolated rat pherenic nerve-hemidiaphragma muscle [·Izole siçan frenik s?n?r-hemidiyafragma kas preparatlarinda re?ifentan?l ve morf?n?n etk?ler?]

In our study, we aimed to investigate the effect of remifentanil and morphine on neuromuscular junction in isolated rat pherenic nerve-hemidiaphragma muscle preparation. Following approvel the protocol by animal ethic commite of Çukurova University, fourty Wistar rats (220-260 gr.) were killed by decapitation and pherenic nerve-hemidiaphragma muscle (70-80 mg weight) were isolated carefully according to the method described by Kelsen ve Nochomovitz. After the thermoregulation and equilibration period for 60 minutes, the voltage of supramaximal stimulation and optimal muscle strenght were determined by both direct and indirect stimulations. Specimens were divided randomly into two groups before the contraction responses were recorded. After control contraction responses were recorded, morphine (0.1, 1, 10 and 100 µM) in group I (n=20) and remifentanil (0.001, 0.01, 0.1 ve 1 µM) in group II (n=20) were added to the bath solution cumulatively and contraction responses (contraction power: KK), contraction time: KS) and 1/2-relaxation time (YGS) were recorded again. In isolated pherenic nerve-hemidiaphragma muscle, control contraction responses contraction power (KK), contraction time (KS) and elaxation time (YGS) determined by direct and indirect supramaximal stimulations were found similar in morphine and remifentanil group. Contraction responses did not change and were found similar with the cumulative addition of opioids (morphine and remifentanil). It is concluded that remifentanil and morphine did not effect neither presinaptic (indirect) nor postsinaptic (direct) depolarization in isolated pherenic nerve-hemidiaphragma muscle produced any relaxation in neuromuscular junction

Management of acute craniotomy pain: The analgesic effect of diclofenac sodium-tramadol or paracetamol-tramadol

BACKGROUND AND OBJECTIVE: There is currently no consensus on pain management after craniotomy in neurosurgical centers in the world. We have investigated either the addition of diclofenac sodium or paracetamol to tramadol for analgesia after craniotomy. METHODS: Fifty patients were allocated randomly to receive an intravenous tramadol with diclofenac sodium (DT) or tramadol plus paracetamol (PT), in a double-blind, randomized study. Then, all patients received bolus doses of tramadol (1.5 mg/kg) every 6 hours during the first 24 hours. Discomfort, sedation, pain scores, and side effects were recorded for up to 24 hours. RESULTS: Although there was no difference in visual analog scale scores between groups 15 and 30 minutes after extubation, and after 1 (t3), 8 (t5), 12 (t6), and 16 hours, the diclofenac-tramadol group had significantly lower scores 4 and 24 hours postoperatively (P<0.05). The number of patients requiring supplementary meperidine was significantly higher in the PT group than in the DT group. Four patients in the DT group (16%) and 10 patients in the PT group (40%) complained of pain during the first 24 hours, despite the tramadol therapy and they were treated with intravenous meperidine (25 mg). CONCLUSIONS: Addition of either diclofenac sodium or paracetamol to tramadol provided effective postoperative analgesia and patient comfort, without causing any sedation or respiratory depression after major intracranial surgery. In addition, diclofenac sodium-tramadol combination provided better postoperative pain relief and less supplementary analgesics than paracetamol-tramadol combination. © 2011 by Lippincott Williams & Wilkins

Postoperative pain management with intravenous patient-controlled morphine: Comparison of the effect of adding magnesium or ketamine

PubMedID: 12790216Background and objective: This double-blind randomized study tested whether the addition of magnesium or ketamine to morphine for intravenous patient-controlled analgesia resulted in improved analgesic efficacy and lower pain scores compared with morphine patient-controlled analgesia alone after major abdominal surgery. Methods: Ninety patients (3 × 30) were randomly allocated to receive either morphine 0.4 mg mL-1 (Group M) by patient-controlled analgesia, morphine 0.4 mg mL-1 + MgSO4 30 mg mL-1 (Group MM) or morphine 0.4 mg mL-1 + ketamine 1 mg mL-1 (Group MK). Postoperative analgesia was started when the verbal rating scale was ?2. Patients were first given a standardized loading dose (0.05 mg kg-1) of the study solution. They were then allowed to use bolus doses of this solution (0.0125 mgkg-1 every 20 min without time limit). Discomfort, sedation, pain scores, cumulative morphine consumption and adverse effects were recorded up to 24 h after the start of the patient-controlled analgesia. Results: The level of discomfort, level of sedation and verbal rating scores decreased significantly with time in all groups (P &lt; 0.05). Both verbal rating and discomfort scores were significantly lower in Groups MM and MK at 15, 30 and 60 min compared with Group M (P &lt; 0.001). Cumulative morphine consumption after 12 and 24 h was significantly higher in Group M alone (median 26 and 49 mg, respectively) compared with Group MM (24.2 and 45.7 mg) and Group MK (24.4 and 46.5 mg). Conclusions: In the immediate postoperative period, the addition of magnesium or ketamine to morphine for intravenous patient-controlled analgesia led to a significantly lower consumption of morphine. However, these differences are unlikely to be of any clinical relevance

Radiofrequency thermocoagulation for the treatment of lower extremity ischemic pain: Comparison of monopolar and bipolar modes

PubMedID: 28895981Objectives: Radiofrequency thermocoagulation (RFT) has been reported to be used safely to treat ischemic lower extremity pain. The objective of the present study was to evaluate eficiency of RFT for treatment of lower extremity ischemic pain and to compare effectiveness of monopolar RFT and bipolar RFT modes. Methods: Following ethics committee approval, 30 American Society of Anesthesiologists classification I-III patients with ischemic lower extremity pain aged between 18 and 65 years were recruited. Patients were randomly allocated into 2 groups: MRT group (n=15) received monopolar RFT (80°C) for 2 minutes at L2-3 level, and BRT group (n=15) received bipolar RFT (80°C) for 2 minutes at L2-3 level. Systolic and diastolic blood pressure, heart rate, pain score, and supplemental analgesic requirements were recorded at 24 hours after application and at 7, 30, and 90 days. Results: Numerical rating scale values in both groups decreased significantly over time and it was found to be significantly lower in BRT group after first and third months (p>0.05). Supplemental analgesic requirements were similar with no significant difference between the 2 groups at any point of study period (p>0.05). No adverse event or complication related to procedure or treatment was reported. Conclusion: In patients with ischemic lower extremity pain, both monopolar and bipolar RFT treatment modalities were found to significantly decrease pain levels. However, bipolar mode led to lower pain scores at 30 and 90 days, and longer duration of analgesia than monopolar mode. © 2017 Turkish Society of Algology

The comparison of remifentanil, alfentanil and fentanyl in the management of pain in burned patients [Yanikli hastalarin agri tedavisinde remifentanil, alfentanil ve fentanil karşilaştirmasi]

Objective of this study was to compare sixty adult burned patients intermittent bolus administration of remifentanil (2 µg/kg), alfentanil (40 µg/kg) and fentanyl (2 µg/kg) for pain management in burned patients undergoing dressing changes and debridement procedures. Following 0.15 mg/kg IV midazolam, IV remifentanil 2 µg/kg in group I, alfentanil 40 µg/kg in group II and fentanyl 2 µg/kg were applied at 30-60 s. The level of sedation was assessed with a score of 0 = awake, alert to 3 = asleep, unarousable. Discomfort and pain were assessed using visual analog scale (VAS). Side effects were not observed. VAS values were statistically significant lower (p=0.018), in group III than in group I at 5. minutes, whereas no statistically significant difference observed among the groups at 1. and 15. minutes. The level of sedation was statistically significant higher(p=0.002, p=0.036), in group III than in group I and II at 15. min., whereas no statistically significant difference was observed among the groups at 1. and 5. min. Apnea and respiratory depression were not seen in group III whereas 3 patients in group I and 1 patient in group II showed apnea episodes. In conclusion we observed that IV bolus administration of remifentanil (2 µg/kg), alfentanil (40 µg/kg) and fentanyl (2 µg/kg) provided effective analgesia for pain control in burn patients. As it is required frequent dose application and caused apnea, intermittent bolus doses of remifentanil is not thought to be suitable whereas alfentanil and fentanyl can used safely for long-term therapeutic procedures in burn patients

The effect of dexmedetomidine on bispectral index monitoring in children

PubMedID: 23327035The primary aim of this study was to test whether dexmedetomidine administration based on the bispectral index (BIS) monitoring caused a reduction in consumption of sevoflurane. following institutional ethic committee approval and written informed consent from all parents, fifty-four children undergoing sevoflurane anaesthesia randomly allocated to receive either dexmedetomidine (Group D) or saline (Group S). The anaesthesia was induced with 8% sevoflurane in nitrous oxide/oxygen in all children. following anaesthesia induction, group D (n=27) children received a loading dose of dexmedetomidine 1 µgkg-1 iV over ten minutes, followed by a continuous infusion at a rate of 0.5 µgkg-1 hr-1 throughout the surgery. group s (n=27) children received same volume of saline infusion due to obtained blindness. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (hr), body temperature and peripheral oxygen saturation (spO2), end-tidal concentrations of oxygen, carbon dioxide (eTcO2), and sevoflurane (ETsevo) were monitorized. Bispectral index numbers and eTsevo concentrations were recorded at 2 min before incision, 2 min after incision, at the end of surgery and before the termination of anaesthesia, and finally immediately after wake-up from anaesthesia (Final BIS number). BIS number was found significantly lower in group D at before incision, after incision and at the end of surgery than in group S (p=0.000, 0.001, 0.007). End tidal sevoflurane concentrations were significantly higher in group S at before incision, after incision and at the end of surgery than in group D (p &lt;0.000 to p &lt;0.001). Final BIS number and sevoflurane concentrations were similar and there were no significant difference between the groups. it was concluded that intravenous (iV) dexmedetomidine infusion at a rate of 0.5 µgkg-1 hr-1 during sevoflurane anaesthesia significantly reduces end-tidal sevoflurane concentration and BIS number in children undergoing minor surgical interventions

Comparison of different doses of remifentanil in brief surgical procedures [Sedonanaljezide farkli dozda remifentanil uygulamasi]

This study was designed to compare the safety and analgesic effectiveness of remifentanil when administred as intermittent bolus injections or a single bolus injection followed by two different dosages of continuous infusion during brief painful procedures. Sixty adult patients undergoing breast or lymph node biopsy were premedicated with intravenous 0.15 mg kg-1 midazolam following haemodynamic and respiratory monitoring Patients were randomly assigned to one of the three modes of remifentanil administration. Group I received 1 kg-1 bolus of remifentanil at 30-60 seconds followed by intermittent 0.5 µg kg-1 bolus of remifentanil as needed. Group II received 1 µg kg-1 bolus of remifentanil followed by a continuous infusion of remifentanil at a rate 0.1 µg kg-1 min-1 Group III received 1 µg kg-1 bolus of remifentanil followed by a continuous infusion of remifentanil at a rate 0.2 µg kg-1 min-1 Discomfort, pain, sedation scores, haemodynamic variables and complications were recorded at pretreatment and 1, 5 and 15 minutes after administration. In all groups, respiratory rate was significantly lower than preoperative control values at 1 and 5 min (p&lt;0.05), whereas heart rate was only lower at 1 min (p&lt;0.05) There were no differences in oxygen saturation and blood pressure (systolic-diastolic) among the groups. Patient comfort and VAS were superior in the 0.2 µg kg-1 min-1 remifentanil group (p&lt;0.05) whereas sedation scores and incidence of O2 desaturation were higher than group I and II during the procedures (p&lt;0.05). Both bolus injections and continuous infusions of remifentanil provided effective analgesia for pain control during brief surgical procedures without using local anaesthetic but was complicated by a high incidence of O2 desaturation at higher doses of 0.2 µg kg-1 min-1

Comparison of the effects of epidural levobupivacaine with tramadol or morphine addition on postoperative analgesia following major abdominal surgery [Majör abdominal cerrahilerde postoperatif analjezi İçin epidural levobupivakaine İlave edilen tramadol İle morfin’in etkilerinin Karşılaştırılması]

Objective: The study was designed to compare the postoperative analgesic efficacy of epidural tramadol or epidural morphine as adjuvant to levobupivacaine in major abdominal surgery. Methods: Patients in ASA I-II group aged between 18 and 65 years were included in study. Epidural catheter was introduced. Patients were randomised into three groups to receive levobupivacaine (Group L), levobupivacaine+morphine (Group LM) and levobupivacaine+tramadol (Group LT). General anaesthesia was administered to all patients. The solution intended for Group L contained 25 mg 0.5% levobupivacaine+15 mL saline, that for Group LM contained 25 mg 0.5% levobupivacaine+14.5 mL salin+100 µg morphine and that for Group LT contained 25 mg 0.5% levobupivacaine+13 mL salin+100 mg tramadol, which was administered via epidural catheter as loading dose 30 min before the end of the operation. Patient-controlled analgesia device was connected to the epidural catheter for evaluating postoperative analgesia. Bolus dose was adjusted to 12 mg levobupivacaine in Group L, 12 mg levobupivacaine +1.2 mg morphine in Group LM and 12 mg levobupivacaine+12 mg tramadol in Group LT. Lock-out period was adjusted to 15 min in three groups. Quality of analgesia was evaluated using Visual Analogue Scale; administered and demand doses of levobupivacaine, morphine and tramadol were compared at 30 min, 1, 2, 6, 12 and 24 h postoperatively. Results: Visual Analogue Scale scores were significantly higher in Group L than Groups LM and LT. Nausea and vomiting observed in Group L were lesser than those in Groups LM and LT. Conclusion: Continuous epidural analgesia using levobupivacaine combined with morphine or tramadol is an effective method for managing postoperative analgesia in major abdominal surgery. © 2019 by Turkish Anaesthesiology and Intensive Care Society