Canturk, Mehmet

Minerva Anestesiologica

English

Kırşehir Ahi Evran University Institutional Repository

1032 Minerva anestesiologica september 2019 L E T T E R S  T O  T H E  E D I T O R© 2019 eDiZioni Minerva MeDicaonline version at http://www.minervamedica.itMinerva anestesiologica 2019 september;85(9):1032-3Doi: 10.23736/s0375-9393.19.13663-2lumbar erector spinae plane block for postoperative analgesia after nephrectomy followed by emergent complication surgeryradical nephrectomy is the surgical process for the re-section of malignant tumors of the kidney necessitating a subcostal flank incision. Mild to severe pain is ob-served in the postoperative period. Providing adequate analgesia is critical for early mobilization of the patient and shortening the length of stay at the hospitalerector spinae plane block (ePsB) is a new plane block introduced to clinical practice by Forero et al.1 the affectivity of esPB for the management of post-operative pain is reported in different surgical settings both in adults and pediatric patients.2, 3 We want to pres-ent our results of lumbar esPB for postoperative an-algesia in a 58-year-old male patient (162 cm, 78 kg) scheduled for left radical nephrectomy followed by emergent complication surgery. Written informed con-sent was obtained from the patient to use and publish all medical data (Figure 1).Following standard monitorization, the patient was sedated with two mg intravenous midazolam. esP block was performed in prone position before the in-duction of anesthesia with esaote Mylab5 (Florence, italy) 2-5 MHz convex probe. a 22g, 100 mm insulated needle was used (BBraun, sonoplex, Melsungen, ger-many). the probe was located three cm lateral to the midline in sagittal axis, and the needle was advanced in cranio-caudal direction with in-plane technique until the contact with the transverse process of l1 was visu-alized. Following hydrodissection with two ml saline, 10 ml of 0.25% bupivacaine and 10 ml of 1% prilo-caine was injected.With the completion of esP block, the patient was turned to supine position and general anesthesia was in-duced. the spread of sensory block was between t3-s1 at postoperative first hour. The patient was followed-up in the postanesthesia care unit for an hour, and his nu-meric rating scale (nrs) score was one.At the fifth postoperative hour, the patient com-plained about abdominal discomfort and dull pain. an abundant 500 ml hemorrhagic drainage was observed from the drains. the computed tomography revealed a three cm laceration in the inferior vena cava at the localization of radix of the left renal vein. the patient was in a preshock state, and his hematocrit decreased to 18% from 36%. He underwent emergent surgery for homeostasis. Following the second operation he was followed up for two hours in the postanesthesia care unit, and his nrs score was still one. He was mobi-lized eight hours after the second surgery free of pain. on the postoperative 24 hours, the sensory block spread was between t12-l2 dermatomes with pinprick.the use of esP block for postoperative analgesia after nephrectomy for Willm’s tumor was reported in two pediatric cases.4 to the best of our knowledge the postoperative analgesic affectivity of lumbar esP in adult nephrectomy patients has not been reported. in this case report, in agreement with the previous works reporting the decreased need for postoperative opioids, our patient did not ask for any rescue analgesics or opi-oid medication.2We think that lumbar esP block is an effective and long-lasting postoperative analgesia method following nephrectomy in adults.Mehmet cantUrK *Department of anesthesiology and reanimation, ahi evran University Hospital, Kirsehir, turkeyFigure 1.—sonoanatomy of local anesthetic spread in erec-tor spinae plane block.vol. 85 - no. 9 Minerva anestesiologica 1033 letters to tHe eDitordepartment of a german university hospital. Here, in the absence of contraindications, gp is administered routinely prior to induction of any general anesthesia except for children below the age of six years (who may react to anticholinergic drugs with postoperative hyperthermia). in early november 2018, the hospital pharmacy notified of an impending shortage of Gp due to supply difficulties of the German distributor. Despite the drug being requested from abroad via import, we ran out of gp within short time. routine administration of atropine prior to anesthesia induction increases the risk for intraoperative tachycardia and dysrhythmias and is therefore obsolete.3 thus, anesthesia was induced without anticholinergic premedication. We experienced a week of slow hearts and drooling patients. table i compares intraoperative mean heart rates and the use of atropine and akrinor™ (a 20:1-mixture of cafedrine/theodrenaline) with the preceding week, when gp was still available. We use akrinor™ to treat intraoperative hypotension and to titrate an adequate arterial blood pressure (i.e. 120 mmHg) during vitreoretinal surgery to prevent ischemia of the optic nerve and retina. With-out gp premedication, there was a striking increase in the incidence of bradycardias following anesthesia in-duction. Bradycardia in general is not uncommon dur-ing ophthalmic surgery due to vagal reflex mechanism, and it is even more frequent under general anaesthesia.4 When occurring concomitantly with (vagal) vasodila-tion or hypovolemia (e.g. in the elderly patient with chronic diuretic medication), bradycardia can cause critical arterial hypotension (decrease by >30% from baseline) and a relative loss of the efficiency of Akri-nor™.5 thus, the intraoperative use of atropine likewise sharply increased. of the 38 patients receiving general anesthesia without gp premedication, 10 were given at-ropine, compared to just one during the preceding week (P=0.003, Fischer’s exact test). one patient presenting for wound exploration after traumatic enucleation de-veloped an intraoperative asystole for several seconds, spontaneously recovering to a bradycardic sinus rhythm before the beginning of chest compressions.gp primarily acts via competitive blockade of the muscarinic cholinoceptor and thereby inhibits the para-sympathetic nervous system. clinically, it mainly af-fects the gastrointestinal tract (including the salivary glands), the liver and kidneys. gp elicits a prolonged suppression of salivary secretion compared to atropine, while the latter causes more tachycardia, dysrhythmias, and even electrocardiographic signs of myocardial ischemia, especially in the case of preexistent cardiac diseases.6, 7 gp was shown to protect against relevant bradycardia such as the oculocardiac reflex when used as premedication, without increasing the intraocular pressure.2 considering our experiences with the recent shortage of gp in our department, we conclude that gp may be administered routinely prior to induction of general anesthesia for eye surgery to improve intraop-erative cardiovascular stability.ricarda KircHertZ, tobias HilBert **corresponding author: Mehmet canturk, Department of an-esthesiology and reanimation, ahi evran University Hospital, Kervansaray Mah., 2019. Sok D:1, 40200 Merkez, Kirşehir, turkey. e-mail: drmcanturk@gmail.comReferences1. Forero M, adhikary sD, lopez H, tsui c, chin KJ. the erector spinae Plane Block: a novel analgesic tech-nique in thoracic neuropathic Pain. reg anesth Pain Med 2016;41:621–7. 2. aksu c, gürkan Y. opioid sparing effect of erector spinae Plane block for pediatric bilateral inguinal hernia surgeries. J clin anesth 2018;50:62–3. 3. Ueshima H, otake H. an erector spinae plane block for chronic pain management after tissue expander insertion. J clin anesth 2019;55:4. 4. aksu c, gürkan Y. Ultrasound guided erector spinae block for postoperative analgesia in pediatric nephrectomy surger-ies. J clin anesth 2018;45:35–6. Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.Article first published online: May 3, 2019. - Manuscript ac-cepted: april 9, 2019. - Manuscript revised: March 20, 2019. - Manuscript received: February 13, 2019.(Cite this article as: canturk M. lumbar erector spinae plane block for postoperative analgesia after nephrectomy fol-lowed by emergent complication surgery. Minerva anestesiol 2019;85:1032-3. Doi: 10.23736/s0375-9393.19.13663-2)© 2019 eDiZioni Minerva MeDicaonline version at http://www.minervamedica.itMinerva anestesiologica 2019 september;85(9):1033-4Doi: 10.23736/s0375-9393.19.13607-3a week of slow hearts: anesthesia for eye surgery and shortage of glycopyrrolateglycopyrrolate (gp) is among the most widely used an-ticholinergic drugs. common indications are the reduc-tion of salivation, the prevention of vagal reflexive bra-dycardia during intubation as well as of muscarinic side effects during the reversal of neuromuscular-blocking drugs.1 In the absence of specific contraindications (i.e. angle-closure glaucoma, which may be aggravated by gp), in ophthalmic surgery, it is commonly adminis-tered to suppress the oculocardiac reflex.2Medication shortages may seriously affect patient care and safety. We herein report on our experiences with a recent shortage of gp in the ophthalmic surgery 

Lumbar erector spinae plane block for postoperative analgesia after nephrectomy followed by emergent complication surgery

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Lumbar erector spinae plane block for postoperative analgesia after nephrectomy followed by emergent complication surgery

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