Abstract Background Erector spinae plane block (ESPB) can provide effective analgesia in pediatric abdominal surgery . Additionally, when used as an analgesic method in abdominal surgery, ESPB may increase regional intra-abdominal tissue oxygen saturation (rSO 2 ) throughout the operation. However, the number of related studies conducted on pediatric patients is insufficient. Results Fifty-two patients undergoing lower abdominal surgery were allocated into two groups, the ESPB (E) and the control (C). Group E received general anesthesia plus unilateral ultrasound-guided ESPB, and group C received general anesthesia alone. Intraoperative fentanyl consumption, Face, Legs, Activity, Cry, Consolability (FLACC) score, time to first rescue analgesia and adverse events were recorded over the first 24 h postoperatively. The rSO 2 level was evaluated in both groups throughout the operation. The FLACC score was significantly lower in group E than in group C ( p <0.05). Four patients in group E required intraoperative fentanyl compared to 12 patients in group C ( p <0.05). The first rescue analgesic administration time was significantly longer in group E than in group C ( p <0.05). No significant difference in rSO 2 values was detected between the groups ( p >0.05). However, in group E, rSO 2 values were significantly increased after the block compared to the postinduction values. Conclusions ESPB provides effective perioperative analgesia in children undergoing low abdominal surgery. Although there was no significant difference in rSO 2 values between the groups, ESPB administration consistently increases rSO 2 over time. Trial registration The trial was registered at ClinicalTrials.gov before patient enrolment ( NCT03808129 -13.12.2018).
Status epileptikus, jeneralize, konvulzif nobetlerin surekli olarak 5 dakika veya daha uzun surmesi ya da bilincte duzelme olmaksizin 2 veya daha fazla sayida nobet gecirilmesi seklinde tanimlanmaktadir. Morbidite ve mortalitesi yuksek acil tibbi durumlardan biridir. Direncli status epileptikus ise konvansiyonel antiepileptik ilac tedavisine ragmen, iki saatten fazla suren nobetlerin olmasi veya saatte iki veya daha fazla nobetin oldugu ve nobet aralarinda bilincin bazal degerlere donmedigi tablo olarak tanimlanmaktadir. Bu makalede propofol infuzyonu ile kontrol altina alinabilen direncli bir status epileptikus olgusu sunulmus ve literatur esliginde tartisilmistir
This Correspondence is accompanied by the following Invited Commentary: Veyckemans F. Case reports: keep a critical eye! Eur J Anaesthesiol 2012; 29:559–560. Editor, Pena-Shokeir syndrome is a rare, autosomal recessive disorder first identified by Pena and Shokeir1 in 1974. It is characterised by foetal akinesia/hypokinesia, intrauterine growth restriction, arthrogryposis (contractures of the joints), various cranio-facial anomalies (micrognathia, microphthalmia, cataracts or microcephaly), camptodactyly and pulmonary hypoplasia. These manifestations vary in severity, but are usually severe and death generally occurs during the neonatal period or soon thereafter as a result of respiratory or neurological complications. Some of these patients require anaesthesia for tracheotomy and for the corrections of the deformities if they are able to survive. We describe the anaesthetic and airway management of a child with Pena-Shokeir syndrome after we obtained consent from the patient's parents to publish this report. A 23-month-old girl, 10 kg in weight was scheduled for the correction of cleft palate deformity. She was born by caesarean section at term (39 weeks, 2600 g). She had respiratory insufficiency and difficulty in feeding and was treated in a neonatal ICU for 9 days (without ventilatory support). She was diagnosed as Pena-Shokeir syndrome with an atypical facial appearance: small eyes, a depressed nasal bridge, small mouth and retrognathia (Fig. 1); also, she had cleft palate deformity, arthrogryposis and pes equinovarus.Fig. 1: No captions available.On preoperative examination she had respiratory crackles on auscultation of the lungs, but her respiratory condition was determined by the paediatricians to be optimal. Her intelligence was not impaired and laboratory examinations were normal. In addition to the cranio-facial anomalies, she also had a short and rigid neck. She had two general anaesthesia attempts terminated because of failure of tracheal intubation in two different institutes when she was 9 and 17 months old. After premedication with oral midazolam 5 mg, she was taken to the operating theatre and standard monitors were placed. The smallest tracheal tube that can be loaded onto the flexible fibreoptic bronchoscope available in our clinic has a 5.5 mm internal diameter that may have been traumatic to the child. So, as the first option, fibreoptic-assisted laryngoscopy was planned. Anaesthesia was induced by facemask with sevoflurane and oxygen and there was no difficulty with mask ventilation. After insertion of an intravenous catheter, fentanyl 20 μg was administered and sevoflurane discontinued. Propofol infusion 10 mg kg−1 h−1 was started and the infusion rate was adjusted according to respiratory rate. While maintaining spontaneous ventilation, an anaesthetist performed laryngoscopy, and another performed endoscopy via the oral route using the fibreoptic endoscope. After the endoscopist identified the oesophagus and trachea, the patient was intubated with a 4 mm (internal diameter) armoured tracheal tube with cuff. Laryngoscopy was graded as Cormack & Lehane grade III. After intubation, anaesthesia was maintained with propofol 6–10 mg kg−1 h−1 and remifentanil 0.15–0.3 μg kg−1 min−1. Rocuronium 4 mg was administered prior to insertion of a mouth gag and no further neuromuscular blocking agent was used after this. The duration of surgery was 150 min. After cessation of remifentanil, intravenous fentanyl 20 μg and rectal paracetamol 240 mg were administered for postoperative analgesia. The patient also received intravenous methylprednisolone 20 mg. The anaesthesia and recovery were uneventful. This child was a rare presentation of this syndrome, as her intelligence was not impaired and respiratory condition was relatively good. Although there are limited anaesthetic reports, difficult tracheal intubation, reactive airway and perioperative respiratory complications related to hypoplasia of the lungs must be considered during anaesthesia management of Pena-Shokeir syndrome.2,3 In one case report, two episodes of malignant hyperthermia were mentioned in the medical history of a patient with Pena-Shokeir syndrome, but the condition was not well documented.3 The risk for malignant hyperthermia in patients with arthrogryposis is controversial. In such patients, a malignant hyperthermia-like condition with increase in body temperature was commented as a hypermetabolic response to anaesthesia and surgery.4,5 In a review of 32 years’ experience, no malignant hyperthermia was reported in 67 patients with arthrogryposis who underwent nearly 400 anaesthesia episodes with triggering agents.6 Our patient had two brief anaesthesia exposures with sevoflurane in her medical history without any sign of malignant hyperthermia. However, the triggering of malignant hyperthermia by drugs was suggested as a dose-dependent phenomenon.7 We did not persist with inhalation anaesthesia after we had ensured mask ventilation and had intravenous access. Total intravenous anaesthesia with propofol and remifentanil and low-dose rocuronium was successfully used without incident for cleft palate repair. Although, there is no strong evidence, we think that the possibility of malignant hyperthermia should be considered in Pena-Shokeir syndrome as in any child with musculoskeletal abnormality. Succinylcholine should be avoided due to the risk of hyperkalemia, as well as inhalational agents. Furthermore, difficult airway management should be anticipated in Pena-Shokeir syndrome. Acknowledgement Assistance with the study: none declared. Financial support and sponsorship: none declared. Conflicts of interest: none declared.
Providing sufficient and convenient analgesia is crucial during the postoperative period after totalknee replacement (TKR) to enhance patient mobility and reduce stress response to surgery. The scope of this study is to compare the effects of levobupivacaine and levobupivacaine plus fentanyl on stress response and analgesic efficiency after TKR.In this study, 40 ASA I - II patients scheduled to undergo TKR were subjected to combined spinal epidural anesthesia (CSEA) injecting of 15 mg levobupivacaine and randomly assigned to receive either levobupivacaine 0.125% (Group L) or levobupivacaine 0.125% plus fentanyl 4 μg ml-1 (Group F) during postoperative period via the epidural route. Patient controlled epidural analgesia (PCEA) was offered for 24 hours. Venous blood samples were assayed for adrenocorticotropic hormone (ACTH), cortisol and prolactin levels before surgery and after analgesia administration. Analgesia was assessed using a visual analogue scale (VAS) at rest (VASR) and during movement (VASM).There was no statistically significant difference between the groups in terms of total doses, bolus requests, bolus delivered and side effects (p > 0.05). The ACTH, cortisol and prolactin levels increased following the surgery and decreased during PCA infusion in both groups where the decline in Group F was significant (p < 0.05) at 24 hours after the analgesic treatment and 48 hours after the surgery.We have demonstrated that infusion of levobupivacaine (0.125%) in combination with fentanyl (4 μg ml-1) using PCEA suppressed stress response to surgery significantly and provided better pain relief than levobupivacaine (0.125%) alone after TKR.
Tukuruk bezi duktal karsinomu yaygin servikal lenf nodu tutulumu ve uzak metastaz ile karakterize oldukca agresif bir tumordur. Hastalarin buyuk cogunlugunu 50 yas veya uzeri erkek olgular olusturur. Genellikle fasiyal paralizinin eslik ettigi, hizli buyuyen, agrili sert bir kitle olarak ortaya cikan duktal karsinomun tedavisi cerrahidir. Total parotidektomi, boyun diseksiyonu ve postoperatif radyoterapi bu tumorun lokal ve bolgesel kontrolunde uygun bir tedavi secenegi olarak gorulmektedir. Agresif tedaviye ragmen prognoz cok kotudur. Uzak metastaz orani % 46 ile % 66, olum orani ise % 60 ile % 75 arasinda degismektedir. Bu yazida 67 yasinda erkek hastada parotis bezi duktal karsinomu olgusu sunulmustur. Hastaligin hem ayirici tanisi hem de cerrahi tedavi secenekleri sunulmus ve literatur gozden gecirilmistir.
