Combined psoas compartment and sciatic block for lower extremity surgery in two high-risk patients

87 ve 89 yaşlarında yüksek riskli iki kadın hastanın alt ekstremite cerrahisinde psoas kompartman ve siyatik sinir bloğunu birlikte uyguladık. İlk olguda yineliyen kalça çıkığına açık redüksiyon, ikinci olguda ise popliteal arter embolisi nedeniyle embolektomi ve trombektomi ameliyatı uygulandı. İlk ameliyat 75, ikincisi ise 100 dakika sürdü. Olgularda operasyon boyunca ağrı olmadı ve hemodinamik değişiklikler çok azdı. Operasyonlar başarılı bir şekilde sonuçlandırıldı. Postoperatif dönemde ilk hastada beşbuçuk, ikinci hastada ise 7 saat boyunca ağrı kesici gerekmedi. Psoas kompartman ve siyatik sinir bloğu ikilisi, yaşlı ve yüksek riskli olguların alt ekstremite cerrahisinde genel anestezi veya diğer bölgesel santral bloklara karşı seçenek olarak düşünülmelidir.We applied combined psoas compartment and sciatic nerve block in two high-risk women, who are 87 and 89 years old. First operation was an open reduction of recurrent luxation of the hip, while the second was an embolectomy- thombectomy following femoropopliteal bypass. There was no pain during operations. Hemodynamic changes were minimal. The operation were succesfully concluded. There was no postoperative analgesic requirement within first five and half hours in the first case, and 7 hours in the second one. Combined blocks such as psoas compartment and sciatic nerve is a good choice for lower extremity operations in elderly and high risk patients

Kalça cerrahisi geçiren yüksek risk grubu yaşlı hastalarda psoas kompartman - siyatik sinir bloğu kombinasyonu ile anestezi deneyimlerimiz

Amaç. Kalça kırığı cerrahisi geçiren yüksek risk grubu yaşlı hastalarda psoas kompartman bloğu ve siyatik sinir blok kombinasyonunun hemodinamik parametrelere etkisi araştırıldı. Yöntem. Bu çalışmada kalça cerrahisi anestezisi için psoas kompartman bloğu ve siyatik sinir bloğu ikilisi yapılan yüksek risk grubu, yaşlı hastalar retrospektif olarak değerlendirildi. Lokal anestezik olarak levobupivakain ve lidokain kombinasyonu verilen 14 yaşlı hasta Grup 1 olarak, levobupivakain ve prilokain kombinasyonu verilen 10 yaşlı hasta Grup 2 olarak adlandırıldı. Çalışmamızda hastaların tümünde, gruplar arasında ve 85 yaşın üstünde olanlarla altında olanların kalp atım hızı, ortalama kan basıncı değerleri ve sedasyon ihtiyacı incelendi. Bulgular. Gruplar arasında ve yaş grupları arasında ortalama kan basıncı değerleri ve kalp atım hızları karşılaştırıldığında istatiksel olarak anlamlı bir fark saptanmadı (p?0,05). Grup 1’de ortalama kan basıncında %6,18 düşüş olurken Grup 2’de %16,52 düşüş oldu. Tüm hastalar değerlendirildiğinde ortalama kan basıncında %10,06 oranında düşüş gözlendi. Sonuç. Kalça cerrahisi uygulanan yaşlı ve yüksek risk grubu hastalarda anestezik yöntem olarak psoas ve siyatik blok kombinasyonunun uygun bir seçenek olabileceğini düşünüyoruz.Aim. The effect of psoas compartment and sciatic nerve block combination on hemodynamic parameters in high risk geriatric patients with hip fracture surgeries was evaluated. Methods. In this study, high risk old patients who underwent psoas compartment block and sciatic nerve block for hip surgery anesthesia were evaluated retrospectively. In Group 1 there were 14 patients with levobupivacaine and lidocaine combination and in Group 2 there were 10 patients with levobupivacaine and prilocaine combination. In our study we evaluated the heart rate, systolic blood pressure, diastolic blood pressure, mean arterial blood pressure levels and sedation need between groups, between age over and below 85 years and in all patients. Results. There were no statistically significant difference in heart rate and mean arterial blood pressure levels between groups and age groups (p˃0.05). There were a 6.18% and 16.52% decrease in mean arterial blood pressure in Group 1 and 2 respectively. When we evaluated the whole patients there was a 10.06% decrease in mean arterial blood pressure. Conclusion. We consider that the combination of psoas and sciatic block as an anesthetic method may be a proper option especially in the elderly and high-risk patients who were underwent the hip surgery

Negatıve pressure pulmonary edema

Negatif basınçlı pulmoner ödem (NBPÖ) üst havayolu tıkanıklığına bağlı olarak gelişen nonkardiyojenik bir pulmoner ödemdir. Görülme sıklığı % 0.094’dür. Genç, sağlıklı, yüksek negatif intraplevral basınç oluşturabilecek kas kütlesi fazla, erkek hastalar risk grubundadır. En sık nedeni laringospazm olan negatif basınçlı pulmoner ödem; krup, epiglottit, üst solunum yolu tümörleri, yabancı cisim aspirasyonları, boğulma, trakeal sekresyonlar, hıçkırık, guatr, zor entübasyon, hematom, orofaringeal cerrahi, obezite, obstrüktif uyku apnesi, endotrakeal tüpü ısırma ve reaksiyon verme gibi nedenlere bağlı olarak da gelişebilir. Bu olguda obeziteli kadın hasta akut batın ön tanısı ile acil koşullarda operasyona alındı. Ekstübasyon sonrası dakikalar içinde hastada şiddetli laringospazma bağlı olarak negatif basınçlı pulmoner ödem gelişti. Hastanın oksijenizasyonunu sağlamak için tekrar entübe edilerek PEEP uygulamalı pozitif basınçlı mekanik ventilasyon başlandı. Olgunun takibinde pulmoner ödemin çözülmesi ve arteriyel oksijen saturasyonunun düzelmesi ile postoperatif 3. saatte ekstübe edildi. Yoğun bakım ünitesinde yakın takip edilen hastanın solunumunun düzelmesi üzerine postoperatif 12. saatte genel cerrahi servisine devredildi. Bu sunumda üst havayolu tıkanıklığının sonrasında gelişen, ciddi ve potansiyel olarak hayatı tehdit edici bir komplikasyon olan NBPÖ’yü tartışmayı amaçladık.Development of upper airway obstruction due to negative pressure pulmonary edema is not related to the heart. It,'s incidence is 0.0 94 %. Muscular young healthy men who can produce high negative intrapleural pressure are at risk. Laryngospasm is the most common cause of negative pressure pulmonary edema. The other causes negative pressure pulmonary edema are epiglottitis, croup, upper airway tumors, foreign body aspiration, drowning, tracheal secretions, hiccups, goitre, difficult intubation, hematoma, oropharyngeal surgery, obesity, obstructive sleep apnea, endotracheal tube bite and react. In this case obese female patient who was diagnosed as acute abdomen was taken to operating room under emergency conditions. Negative pressure pulmonary edema had developed after extubation period, depending on severe laryngospasm. To improve the patient’s oxygenisation she was re- intubated and PEEP was started as positive pressure mechanical ventilation. In follow up patient was extubated after pulmonary edema was resolved and arterial oxygen saturation at the post operative third hour. The patient were followed closely in the intensive care unit till recovery of respiration on the 12th postoperative hours and were transferred to the general surgery ward. In this presentation, we aimed to discuss the negative pressure pulmonary edema which is a serious and life threatening complication of the upper airway obstruction

A simple method to be used to predict the severity of pain in transrectal ultrasound- guided prostate biopsy: Digital rectal examination staging

Amaç: Transrektal ultrason rehberliğinde biopsi (TRUS-bx) sırasında ağrı seviyeleri değişik olan hastalardaki farkları inceleyip, ağrıyı tahmin etmede parmakla rektal muayene (PRM) evrelemesinin etkinliğini araştırmaktır. Yöntem: Nisan 2012 - 2013 arasında PRM evrelemesi ve prostat kanser şüphesiyle TRUS-bx yapılan 77 hasta retrospektif olarak tarandı. PRM evresi üç evre olarak sınıflandırıldı. Hastalar vizuel analog skalası (VAS)’na göre iki gruba ayrıldı (median=4) (Grup 1: <4; group 2: ?4). Gruplar ile ilişkisi olabilecek parametreler (yaş, vucut kitle indeksi (BMİ), prostat volümü, PRM evresi, PSA, serbest/total PSA oranı, biopsi patalojisi) karşılaştırıldı ve korelasyon analizleri yapıldı. Bulgular: Yaş ortalaması 65.74±7.5 (47-84) olan 77 erkek TRUS-bx hastası çalışmaya alındı. Grup 1’de 31 hasta, Grup 2’de 46 hasta değerlendirildi. VAS skroru ile prostat boyutu ve PRM evresi arasında korelasyon bulundu (sırasıyla, p=0.019, p=0.002), VAS grupları karşılaştırıldığında sadece PRM evresinde anlamlı bir fark bulundu (p=0.038). PRM evrelemesine göre Grup 2’de evre I’e %58.3, evre II’ye %62 ve evre III’e %88.9 hastada saptandı. Sonuç: VAS PRM evresi ile ilişkilidir. TRUS-bx esnasında, prostat boyutundan bağımsız olarak, PRM evresi artan hastalar daha fazla ağrı duyabilirler.Aim: To examine the differences in patients with different levels of pain during transrectal ultrasound guided biopsy (TRUS-bx) of prostate, and to evaluate the effectiveness of digital rectal examination (DRE) staging. Methods: Between April 2012 and 2013, patients who underwent DRE staging and TRUS-bx due to suspicion of prostate cancer were retrospectively evaluated. All patients were categorized into two groups according to visual analog scale (VAS) (median = 4) (Group 1: &lt; 4; Group 2: &amp;#8805;4). Parameters regarding the relationship between groups were compared and investigated for the correlations. Results: The mean age of 65.74 &plusmn; 7.5 (47-84) total 77 TRUS-bx patients were studied. 31 and 46 patients were included in Group 1 and 2, respectively. A correlation was found between VAS and prostate volume and DRE staging (p=0.019, p=0.002, respectively), but when the VAS groups were compared, there was only significant difference in DRE staging (p=0.038). Accoding to DRE staging, in group 2, patients were 58.3%, 62% and 88.9% in stage I, stage II and in stage III, respectively. Conclusion: There was a relation between VAS and DRE staging. Independent of the size of the prostate, patients with increased DRE stage may experience more pain during TRUS-bx

A severe case of TUR-P syndrome

Günümüzde benign prostat hipertrofisinde (BPH), lazer kullanımı gibi alternatif cerrahi tedaviler geliştirilmesine rağmen klasik transüretral prostat rezeksiyonu (TUR-P) yöntemi hala altın standart olarak görülmektedir. Ancak bu yöntemin uygulandığı olguların %1,1’inde TUR-P sendromu gelişebilmektedir. Spinal anestezi altında 66 yaşında, 82 kg ağırlığındaki olgumuzda intraoperatif dönemde hemodinami stabil seyrederken baş ağrısı ve bulantı şikayetinin ardından görme bozukluğu, solunum sıkıntısı, hipotansiyon ve konvülzyon gelişti. Her iki akciğerde dinlemeyle bilateral krepitan ralleri olan hastanın çekilen akciğer grafisinde bilateral interstisyel infiltrasyonlar tespit edildi. Yapılan tetkiklerde hiponatremi ve trombositopeni tespit edilen hastaya TUR-P sendromu tanısı konularak tedavisi düzenlendi. Sonuç olarak rejyonal anestezi hastanın mental durumunun değerlendirilmesini sağlayarak TUR-P sendromunun erken tanı ve tedavisine olanak sağlar. Ancak anestezi doktorunun bu sendromu tanımada deneyimli ve dikkatli olması gerektiğini düşünüyoruz.At the present time despite the development of new treatment modalities like laser usage; traditional transurethral prostate resection is the gold standard in benign prostatic hypertrophy. However, TUR-P syndrome may develop in 1.1% of these cases. In our patient who was 66years old and 82 kg weight, although the hemodynamics was normal intraoperatively under spinal anesthesia, respiratory difficulty, hypotension and convulsion were developed after headache and nausea. In auscultation there were crepitant rales and there were bilateral interstitial infiltrations on chest radiography. In laboratory tests hyponatremia and thrombocytopenia were detected, the patient was diagnosed as TUR-P and the treatment was commenced. In conclusion, regional anesthesia allows the evaluation of mental status of the patients and provides early diagnosis and treatment of TUR-P syndrome. However, we suggest that the anesthesia doctor should have experience and attention in recognizing this syndrome

Efficacy of resuscitation with Intralipid in a levobupivacaine-induced cardiac arrest model

Aim: Cardiac toxicity due to the administration of local anesthetics may be fatal. In this study, we evaluated the efficacy of a 20% lipid solution combined with epinephrine in a levobupivacaine-induced cardiac arrest model. Materials and methods: A total of 14 New Zealand rabbits were sedated and mechanically ventilated. Asystole was induced with intravenous levobupivacaine injection. The rabbits were randomized into groups receiving the same volume of either 0.9% saline (CR group) or a 20% lipid solution (LE group) along with a 100 &micro;g/kg epinephrine bolus, which were administered immediately upon asystole. Standard advanced cardiac life support protocols were performed. Results: Four subjects in the LE group as well as 3 subjects in the CR group had a spontaneous recovery (P = 0.592). In the 20th minute after arrest, 3 subjects in the LE group had maintained spontaneous circulation, while there was only 1 subject from the CR group with the same outcome. Conclusion: We found that adding a lipid solution to epinephrine for the resuscitation of rabbits that underwent levobupivacaineinduced cardiac arrest increased recovery rates of circulation and therefore the likelihood of survival. Further studies are needed to develop clinical therapies for the systemic toxicity of local anesthetics.Aim: Cardiac toxicity due to the administration of local anesthetics may be fatal. In this study, we evaluated the efficacy of a 20% lipid solution combined with epinephrine in a levobupivacaine-induced cardiac arrest model. Materials and methods: A total of 14 New Zealand rabbits were sedated and mechanically ventilated. Asystole was induced with intravenous levobupivacaine injection. The rabbits were randomized into groups receiving the same volume of either 0.9% saline (CR group) or a 20% lipid solution (LE group) along with a 100 &micro;g/kg epinephrine bolus, which were administered immediately upon asystole. Standard advanced cardiac life support protocols were performed. Results: Four subjects in the LE group as well as 3 subjects in the CR group had a spontaneous recovery (P = 0.592). In the 20th minute after arrest, 3 subjects in the LE group had maintained spontaneous circulation, while there was only 1 subject from the CR group with the same outcome. Conclusion: We found that adding a lipid solution to epinephrine for the resuscitation of rabbits that underwent levobupivacaineinduced cardiac arrest increased recovery rates of circulation and therefore the likelihood of survival. Further studies are needed to develop clinical therapies for the systemic toxicity of local anesthetics

DELAYED EMERGENCE FROM ANESTHESIA ASSOCIATED WITH UNDIAGNOSED CENTRAL SLEEP APNEA SYNDROME

Delayed awakening from anesthesia is often multifactorial including residual anesthetic drugs, excessive reaction to narcotics and sedatives, residual neuromuscular blockade and duration of surgery. Hypercapnic central sleep apnea syndrome is often encountered at central hypoventilation syndromes which may be secondary to other diseases that cause respiratory centre dysfunction. In this case, 36 years, which had operated from pontine cavernomas awakening complications following general anesthesia after pilonidal sinus surgery was reported. This disorder may be due to central sleep apnea syndrome in a patient without previous diagnosis. He was referred to the sleep laboratory in aspect of the differential diagnosis. The patient was diagnosed as central sleep apnea syndrome and home device for CPAP was recommended. The patient who had a history of brainstem surgery should be taken into consideration for the candidate of central sleep apnea syndrome, and a meticulous evaluation should be done before surger

MYASTENİA GRAVİSLİ BİR HASTADA SPİNAL ANESTEZİ YAKLAŞIMIMIZ

Myastenia Gravis is an autoimmune neuromuscular transmission disorder. The main symptoms of the illness muscle weakness, progressive muscle tiredness, ptosis, disorders. In these patients group, the main problems are determination of appropiate anesthesia medicine doses and shortness of breath in the postoperative period. There were a few reports of spinal anesthesia prefered for the patients with myastenia gravis in the literature. In this article, we present a case of spinal anesthesia was applied for inguinal hernia operatio

Intraoperative ephedrine allergy in a patient who received chemotherapy and perioperative hypersensitivity reactions

Kemoterapi almış hastada intraoperatif efedrin alerjisi ve perioperatif hipersensitivite reaksiyonları anestezi, farmakolojik açıdan özgül bir durumu temsil eder ve bu süre boyunca çok sayıda yabancı maddelere maruz kalan hastalarda erken aşırı duyarlılık reaksiyonları veya anafilaksi gelişebilir. Otuz yedi yaşındaki, total abdominal histerektomi planlanan hastada intraoperatif hipotansiyon gelişmesi nedeniyle (5 mg) efedrin iv uygulandı. Uygulama sonrası aynı ekstremitenin iv kanülün yerleştirildiği ven trasesi hattında kızarıklık görüldü. Yaklaşık 15 dakika sonra her iki ekstremitede, batında yaygın ürtiker plakları gözlendi. İntravenöz kristalloid infüzyon hızı arttırılarak, metilprednisolon (100 mg+100 mg), Feniraminmaleat (45,5 mg) verildi. Postoperatif sorunsuz ekstübe edilerek postoperatif bakım ünitesinde gözleme alındı. Lezyonları postoperatif 60. dakikada tamamen ortadan kalkmasının ardından yaşamsal bulgularının da istikrarlı olması nedeniyle servise alındı. Cerrahi takibinde herhangi bir komplikasyon gelişmeyen hasta yatışının ikinci gününde taburcu edildi.Anaesthesia represents a specific set-up in respect to pharmacology, and during this time, early hypersensitivity reactions or anaphylaxis may occur in patients who are exposed to a great number of foreign substances. Intravenous ephedrine (5 mg) was applied to a 37-year-old patient due to the development of intraoperative hypotension in a total abdominal hysterectomy operation. After application, hyperaemia was seen in the track of the intravenous catheter of that extremity. Approximately 15 minutes later, urticarial plaques were observed extensively in the abdomen and in both extremities. Methylprednisolone (100 mg+100 mg) and pheniramine (45.5 mg) were given with an increasing infusion rate of intravenous crystalloid. The patient was extubated without any problem and removed to the recovery unit for observation. After the total disappearance of lesions at postoperative 60 minutes and because of the stability of vital signs, the patient was removed to the service. In the follow-up of surgery, no complication developed, and the patient was discharged on postoperative day 2

Successful management of aluminium phosphide poisoning resulting in cardiac arrest

Alüminyum fosfid alındığı zaman yüksek toksisiteye sahiptir ve nemle temas etmesi halinde fosfin gazı ortaya çıkar. Alüminyum fosfid zehirlenmesi metabolik asidoz, aritmi, akut respiratuar distres sendromu ve şoka sebep olur ve spesifik antidotu yoktur. On yedi yaşında erkek hasta 1500 mg alüminyum fosfid tabletin alımı sonucu intahar girişimi tanısı ile hastanemize sevk edildi. Bilinci açık uykuya meyilliydi. Yaşamsal parametreleri; TA: 85/56 mmHg, KTA: 88/dk, SpO2: %94, ateş: 36,4°C olarak ölçüldü. Hipotansiyon nedeniyle dopamin ve steradin infüzyonu başlandı. Solunum sıkıntısı gelişmesi ve bilincinin kapanması nedeniyle en- tübe edilip mekanik ventilatöre bağlandı. Arter kan gazı değerinde şiddetli metabolik asidoz tespit edildi ve hastaya sodyum bikar- bonat tedavisi uygulanarak metabolik asidozu düzeltildi. Zehir- lenmenin destekleyici tedavisine ek olarak hemodiyaliz uygulandı. Yoğun bakım ünitesindeki takibinde kardiyak arrest gelişti ve 10 dakika kardiyopulmoner resüsitasyon uygulandıktan sonra sinüs ritmi sağlandı. Toplam üç seans hemodiyaliz uygulanan hasta yatı- şının dokuzuncu gününde şifa ile taburcu edildi. Sonuç olarak bu olgu sunumunda hemodiyaliz aluminyum fosfid zehirlenmesinin semptomatik tedavisine katkı sağlamıştırAluminum phosphide has high toxicity when it is ingested, and in case of contact with moisture, phosphine gas is released. Alumi- num phosphide poisoning causes metabolic acidosis, arrhythmia, acute respiratory distress syndrome and shock, and there is no specific antidote. A 17-year-old male patient was referred to our hospital because of aluminum phosphide poisoning with 1500 mg of aluminum phosphide tablets. The patient's consciousness was clear but he was somnolent. Vital parameters were as follows: blood pressure: 85/56 mmHg, pulse: 88 beats/min, SpO2: 94%, temperature: 36.4&deg;C. Because of hypotension, noradrenaline and dopamine infusions were started. The patient was intubated be- cause of respiratory distress and loss of consciousness. Severe met- abolic acidosis was determined in the arterial blood gas, and met- abolic acidosis was corrected by sodium bicarbonate treatment. In addition to supportive therapy of the poisoning, hemodialysis was performed. Cardiac arrest occurred during follow-ups in the intensive care unit, and sinus rhythm was achieved after 10 min of cardiopulmonary resuscitation. The patient was discharged after three sessions of haemodialysis on the ninth day. As a result, hae- modialysis contributed to symptomatic treatment of aluminum phosphide poisoning in this case report