Preprocedural ultrasound estimates of epidural depth: Transverse median plane is comparable to paramedian sagittal oblique plane in non-pregnant patients

Objective: The aim of this study was to assess the accuracy and precision of the actual epidural depth (ND) and ultrasound (US) estimates of the distance from the skin to the epidural space in the transverse median plane (ED/TM) and paramedian sagittal oblique plane (ED/ PSO) in patients who were not pregnant and who were undergoing unilateral inguinal hernia repair surgery under combined spinal epidural anaesthesia. Methods: A total of 100 patients with the American Society of Anaesthesiology status I–III of either gender were recruited. All epidurals were inserted at the L3–4 intervertebral space, and the epidural needle was marked with a sterile marker. The ND was measured between the marker and the tip of the needle. The ED/TM and ED/PSO were assessed with a 2–5 MHz curved array probe at the L3–4 intervertebral space. The Pearson correlation coefficient and Lin’s concordance correlation coefficient were used to assess the precision and the Bland–Altman test was used to assess the 95% limit of agreement. Results: The ND was 48.98±6.91 mm, the ED/PSO was 48.92±6.91 mm and the ED/TM was 48.90±6.91 mm. The Pearson correlation coefficient between ND and ED/PSO was 0.995 (p<0.001) and 0.994 (p<0.001) with ED/TM. Lin’s concordance correlation coefficient for ND and ED/PSO was 0.995 (95%CI [confidence interval]: 0.992–0.997), and 0.993 for ND and ED/TM (95% CI: 0.990–0.996). The 95% limit of agreement between ND and ED/PSO was 0.70–1.37, and for ND and ED/TM, it was 0.79–1.54. Conclusion: Preprocedural ultrasound (US) scanning in both planes provides reliable estimates for actual epidural depth in non-pregnant patient population. © 2020 by Turkish Society of Anaesthesiology and Reanimation

Correlation of the epidural space measured intraoperatively and estimated by MRI or US: an observational study

Background and objectives: To assess the agreement between the epidural depth measured from the surgical site with the epidural depths estimated with magnetic resonance imaging (MRI) and ultrasound scanning. Methods: Fifty patients of either sex, scheduled for L4-5 lumbar disc surgery under general anesthesia were enrolled in this prospective observational study, and the results of 49 patients were analyzed. The actual epidural depth was measured from the surgical site with a sterile surgical scale. The MRI-derived epidural depth was measured from the MRI scan. The ultrasound estimated epidural depth was measured from the ultrasound image obtained just before surgery. Results: The mean epidural depth measured from the surgical site was 53.80 ± 7.67 mm, the mean MRI-derived epidural depth was 54.06 ± 7.36 mm, and the ultrasound-estimated epidural depth was 53.77 ± 7.94 mm. The correlation between the epidural depth measured from the surgical site and MRI-derived epidural depth was 0.989 (r2 = 0.979, p < 0.001), and the corresponding correlation with the ultrasound-estimated epidural depth was 0.990 (r2 = 0.980, p < 0.001). Conclusions: Both ultrasound-estimated epidural depth and MRI-derived epidural depth have a strong correlation with the epidural depth measured from the surgical site. Preprocedural MRI-derived estimates of epidural depth are slightly deeper than the epidural depth measured from the surgical site, and the ultrasound estimated epidural depths are somewhat shallower. Although both radiologic imaging techniques provided reliable preprocedural estimates of the actual epidural depth, the loss of resistance technique cannot be discarded while inserting epidural needles. © 2020 Sociedade Brasileira de Anestesiologi

Effects of intraarticular ketamine combined with periarticular bupivacaine on postoperative pain after arthroscopic meniscectomy

Objectives: This study aims to evaluate the effects of two different doses of intraarticular ketamine on visual analog scale (VAS) scores at rest and movement, time to first analgesic requirement, and 24-h morphine consumption in patients undergoing arthroscopic meniscectomy as well as to assess the frequency of postoperative nausea&vomiting, respiratory depression, pruritus, urinary retention, and constipation and to compare the time to discharge. Patients and methods: This prospective randomized doubleblind study was performed between August 2013 and August 2014 on 75 patients (32 males, 43 females; mean age 46.7±13 years; range, 18 to 75 years) with American Society of Anesthesiologists scores of I-II scheduled for unilateral meniscectomy. Patients were randomized to receive 0.5 mg.kg-1 ketamine (group K1), 1 mg.kg-1 ketamine (group K2) or saline (group S) to a total volume of 20 mL intraarticularly at the end of the surgery. All patients were performed periarticular 10 mL 0.5% bupivacaine infiltration. Visual analog scale at rest and during passive knee movement was used to evaluate pain both preoperatively and at postoperative 0, 30 min, and 1, 2, 4, 6, 12, and 24 h. Time to first analgesic requirement and morphine consumption were recorded. Results: Visual analog scale scores at rest and during movement at postoperative 0 were significantly reduced in group K2 compared with group S (p<0.05). The first analgesic requirement time was significantly longer in group K1 (76.9±25.2 min) and group K2 (93.4±26.1 min) than group S (29.3±7.1 min). Morphine consumption was lower in group K2 compared to group K1 and group S at postoperative 30 min, and 1 and 2 h. However, 24-h morphine consumption was similar in all groups. Conclusion: Intraarticular injection of 0.5 mg.kg-1 and 1 mg.kg-1 ketamine for postoperative pain management provided similar analgesic efficacy. However, high dose ketamine more noticeably decreased opioid requirement in the early postoperative period. © 2020 Turkish Joint Diseases Foundation

Plasenta previa-akreta tanılı sezaryenlerde anestezi yönetimi/

Bu retrospektif çalışmada, elektif veya acil olarak operasyona alınan, plasental yerleşim ve yapışma anomalisi olan (previa totalis, marjinalis, akreata, inkreata, perkreata) olgularda uygulanan anestezi yönetimini ve bunların klinik sonuçlarını araştırmayı; elde edilen verilere göre bu tip hastalarda, morbidite ve mortalite üzerine etkili prognostik faktörlerin saptanması amaçlanmıştır. 2004-2009 yılları arasında elektif veya acil olarak uygulanan sezaryenlerde plasenta previa totalis veya marjinalis ön tanısı ile operasyona alınan ve patolojik tetkikler sonucu akreta, inkreta ya da perkreta tespit edilen 65 hasta çalışmamıza dahil edildi. Hasta dosyaları retrospektif olarak tarandı; toplam sezaryen doğum ve normal doğum sayıları ile, demografik özellikler (yaş, kilo boy), operasyon süreleri, yandaş hastalıklar, gestasyonel yaş, parite, uygulanan anestezi yöntemi, invaziv monitörizasyon uygulamaları, preoperatif, intraoperatif ve postoperatif en düşük ve en yüksek hemoglobin ve hematokrit değerleri, transfüzyon uygulamaları (tam kan, eritrosit süspansiyonu, taze donmuş plazma, trombosit süspansiyonu) yoğun bakım süresi, intraoperatif ve postoperatif dönemde gelişen komplikasyonlar ve hastanede kalış süresi kaydedildi. Çalışmamızda, plasenta previa totalis tanılı gebelerde uygulanan anestezi yöntemleri ile kan ve kan ürünlerinin transfüzyon miktarları ve maternal mortalitemorbidite oranları arasında istatistiksel olarak anlamlı bir fark saptanmadı. Prospektif randomize çalışmaların yeterli sayıda olmaması nedeniyle, plasenta previada genel veya rejyonal anestezi kullanımı ile ilgili temel tartışma kanıta dayalı bulgulara bağlı olarak yapılamamaktadır. Obstetrik hemoraji yönetimi multidisipliner bir yaklaşım gerektirmektedir

Altered Mental Status and General Condition Disorder in Young Case: Bonsai

Yoğun bakım ünitelerinde takip ve tedavi edilen olguların bir kısmını bilinç durum değişiklikleri oluşturmaktadır. Bilinç durum değişikliği; alkol intoksikasyonu, endokrin bozukluklar, travma, serebrovasküler sorunlar, zehirlenmeler vb. gibi birçok nedene bağlı olabilir. Sentetik kannabinoid reseptör agonistlerinin elde edilmesi oldukça kolay ve ucuz olması nedeniyle son yıllarda genç yaş gurubu insan popülasyonunda kullanımı oldukça yaygınlaşmaktadır. Bu ajanlar esrar benzeri psikoaktif etkiler oluşturmaktadır. Kullanım sonrası değişken semptomlarla sağlık kuruluşlarına başvurulabilirler. Biz de bonzai kullanımı sonrası bilinç durum değişikliği nedeniyle yoğun bakım ünitesinde takip ve tedavi ettiğimiz olguyu paylaştık.Alterations in consciousness of some of the patients treated, and followed up in intensive care units are observed. Altered mental status may emerge due to several causes such as alcohol intoxication, endocrine disorders, trauma, cerebrovascular problems, and poisoning. The use of synthetic cannabinoid receptor agonists among young population has become prevalent in recent years due to their easy availability and low price. These agents cause psychoactive effects similar to marihuana. Users experiencing various symptoms can consult to health institutions. We presented the case we treated and followed in our intensive care unit who was diagnosed with altered mental status as a consequence of bonsai use

The effects of crystalloid warming on maternal body temperature and fetal outcomes: a randomized controlled trial

Background and objectives: Hypothermia occurs in about 60% of patients under anesthesia and is generally not managed properly during short lasting surgical procedures. Hypothermia is associated with adverse clinical outcomes. The current study is designed to assess the effects of crystalloid warming on maternal and fetal outcomes in patients undergoing elective cesarean section with spinal anesthesia. Methods: In this prospective randomized controlled trial, sixty parturients scheduled for elective cesarean section with spinal anesthesia were randomly allocated to receive crystalloid at room temperature or warmed at 37 °C. Spinal anesthesia was performed at L3–L4 interspace with 10 mg of hyperbaric bupivacaine without adding opioids. Core temperature, shivering, and hemodynamic parameters were measured every minute until 10th minute and 5-min intervals until the end of operation. The primary outcome was maternal core temperature at the end of cesarean section. Results: There was no difference for baseline tympanic temperature measurements but the difference was significant at the end of the operation (p = 0.004). Core temperature was 36.8 ± 0.5 °C at baseline and decreased to 36.3 ± 0.5 °C for isothermic warmed crystalloid group and baseline tympanic core temperature was 36.9 ± 0.4 °C and decreased to 35.8 ± 0.7 °C for room temperature group at the end of the operation. Shivering was observed in 43.3% in the control group. Hemodynamic parameter changes and demographic data were not significant between groups. Conclusions: Isothermic warming crystalloid prevents the decrease in core temperature during cesarean section with spinal anesthesia in full-term parturients. Fetal Apgar scores at first and fifth minute are higher with isothermic warming. Resumo: Justificativa e objetivos: A hipotermia ocorre em cerca de 60% dos pacientes sob anestesia e geralmente não é tratada adequadamente durante procedimentos cirúrgicos de curta duração. A hipotermia está associada a desfechos clínicos adversos. O presente estudo teve como objetivo avaliar os efeitos do aquecimento de cristaloides nas condições maternas e fetais em pacientes submetidas à cesariana eletiva com raquianestesia. Métodos: Neste estudo prospectivo, randômico e controlado, 60 parturientes agendadas para cesárea eletiva com raquianestesia foram distribuídas aleatoriamente para receber cristaloides à temperatura ambiente ou aquecidos a 37 °C. A raquianestesia foi realizada no interespaço L3–L4 com 10 mg de bupivacaína hiperbárica sem adição de opioides. Temperatura central, tremores e parâmetros hemodinâmicos foram medidos a cada minuto até o décimo minuto e em intervalos de 5 min até o final da operação. O desfecho primário foi a temperatura central materna ao final da cesárea. Resultados: Não houve diferença nas mensurações basais da temperatura timpânica, mas a diferença foi significativa no final da operação (p = 0,004). A temperatura central foi de 36,8 ± 0,5 °C na fase basal e diminuiu para 36,3 ± 0,5 °C no grupo com aquecimento isotérmico de cristaloides e a temperatura basal timpânica foi de 36,9 ± 0,4 °C e diminuiu para 35,8 ± 0,7 °C no grupo sem aquecimento das soluções no final da operação. Tremores foram observados em 43,3% no grupo controle. Alterações nos parâmetros hemodinâmicos e dados demográficos não foram significantes entre os grupos. Conclusões: O aquecimento isotérmico de cristaloides previne a redução da temperatura central durante a cesariana com raquianestesia em parturientes a termo. Os escores de Apgar para os fetos no primeiro e quinto minutos são maiores com o aquecimento isotérmico. Keywords: Spinal anesthesia, Warming, Crystalloids, Core temperature, Shivering, Cesarean section, Apgar score, Palavras-chave: Raquianestesia, Aquecimento, Cristaloides, Temperatura central, Tremor, Cesariana, Escore de Apga