[Plan A blocks]

With the increase in ultrasound use, regional anesthesia practices have gained popularity and many novel techniques are being described. However, the rapidly increasing number of new block techniques also led to confusion. Therefore, seven basic regional anesthesia techniques that are effective in most of the surgeries have been listed as 'Plan A Blocks.' The purpose of this review is to introduce the basic sono-anatomy and indications of Plan A blocks.

The modified pectoral nerve block versus bi-level erector spinae plane block for postoperative analgesia after radical mastectomy surgery: A prospective, randomized, controlled trial

Background

Regional anesthesia techniques constitute an important part of successful analgesia strategies, and in the perioperative care of breast surgery patients. The advent of ultrasound-guided regional anesthesia led to the development of fascial plane blocks. The abundance of blocks available for postoperative analgesia in breast surgery has increased the accessibility of regional anesthesia but has also created the dilemma of choice. This study compared the analgesic efficacy of ultrasound-guided modified pectoral nerve (PECS) block and erector spinae plane block (ESPB) in patients undergoing modified radical mastectomy (MRM).

Method

Seventy women were enrolled for the study. After exclusion, 67 female patients undergoing MRM were finally analyzed. Ultrasound-guided PECS block and ESPB were performed with 30 ml 0.25% bupivacaine in this prospective, double-blind, randomized control trial. Postoperative morphine and pain scores were compared between the groups.

Results

Postoperative total morphine consumption in the first 24 h was significantly higher in the PECS group (P = 0.000). The ESPB group exhibited significantly reduced morphine consumptions at all postoperative time points. Numeric rating scale scores were lower in the ESPB group at postoperative 6, 12, and 24 h at rest and when coughing.

Conclusions

Ultrasound guided bi-level ESPB provided better postoperative analgesia compared to PECS block after radical mastectomy surgery.

Erector spinae block for postoperative pain management in lumbar disc hernia repair

PURPOSE

Lumbar disc herniation is the most common spinal disorder and various less invasive techniques such as microdiscectomy have been described. However, postoperative pain management in patients undergoing discectomy is still commonly inadequate. Erector spinae plane (ESP) block is a relatively easier technique with lower risks of complications, and can be performed to provide postoperative analgesia for various procedures. The current study aimed to determine the effect of ESP block on postoperative analgesia in patients who underwent elective lumbar disc herniation repair surgeries.

METHODS

Fifty-four ASA I-II patients aged 18-65 years scheduled for elective discectomy surgery were included in the study. Patients were randomized either to the ESP or control group. Ultrasound-guided ESP block with 20 mL of 0.25% bupivacaine was performed preoperatively in the ESP group patients and a sham block was performed with 20 mL normal saline in the control group patients. All the patients were provided with intravenous patient-controlled analgesia devices containing morphine. Morphine consumption and numeric rating scale (NRS) scores for pain were recorded 1, 6, 12, and 24 h after surgery.

RESULTS

A significantly lower morphine consumption was observed at 6, 12, and 24 h timepoints in the ESP group (p < 0.05 for each timepoint). Total morphine consumption at 24 h after surgery decreased by 57% compared to that of the control group (11.3 ± 9.5 mg in the ESP group and 27 ± 16.7 mg in the control group). NRS scores were similar between the two groups.

CONCLUSION

This study showed that ESP block provided effective analgesia in patients who underwent lumbar disc herniation surgery.

CLINICAL TRIALS REGISTRY

NCT03744689.

General Anesthesia Practices During the COVID-19 Pandemic in Turkey: A Cohort Study With a National Survey

Introduction This study aimed to examine the anesthesia practices applied to the cases during the pandemic, to analyze the rate of the precautions taken in emergency/elective operations in non-COVID patients, what precautions were taken, what resources the clinics had, and the patient management in the perioperative period by organizing a survey among anesthesiologist in Turkey. Methods After obtaining approval from the Turkish Ministry of Health (2020-05-04T09_30_03) and the local ethics committee (GOKAEK-2020/10.09), a survey consisting of 21 questions was formed over the online survey inquiry (surveymonkey.com). The survey was conducted in Turkish. Results The survey aimed at reaching the anesthesiologists, who were Turkish Anesthesiology and Reanimation Society (TARD) members, by e-mail, and it was seen that 120 people out of approximately 2700 members who had received our e-mail participated in the survey. After the first case was reported in our country, it was understood that 62.1% of the participants stopped accepting elective cases in their institutions. The anesthesia method preferred in this period was general anesthesia by 47.6%, regional anesthesia by 52.1%, and sedation by 0.3%. The arrival time of coronavirus disease COVID-19 tests (PCR and/or rapid diagnostic kits showing antibodies) to the hospital was questioned; seven people (5.83%) stated that tests were not performed at their hospitals. It was observed that tests arrived and were applied at the hospitals of the remaining participants in an average of 2.7 ± 1.6 weeks. It was determined that 59.32% of the participants avoided positive pressure ventilation after induction, 5.98% of the intubation on the patients were performed by anesthesia technicians, 66.67% by anesthesiologists, 25.64% by senior resident doctors with at least two years of experience, and 1.71% by junior anesthesia assistants with less than two years of experience. The use of personal protective equipment (PPE) is applied by 95% of the participants. 22.69% of the participants stated that they preferred to use supraglottic airway (SGA) devices during this period. While 45.06% of the participants stated that they provided oxygen support to the patient with the mask belonging to the circuit after extubation, 14.8% preferred the nasal cannula, and 33.1% used an oxygen mask. Our results showed that 90% of additional precautions were taken in our country's clinics, and 95% of PPE was used. Also, the use of video laryngoscope (VL) was 75% in this period. Finally, it was found that 50.85% of the patients were taken to the recovery unit after being extubated, and 49.15% were sent directly to the service. Conclusion We can reveal that each clinic made arrangements according to its own conditions. We think that plans should be made to standardize clinical facilities and algorithms throughout the country. Apart from technological and financial facilities, we believe that the continuity of the training organized by national and international associations should be ensured so that anesthesiologists' knowledge, skills, and experience who manage this process can remain at the highest level.

Regional Anesthesia Practices in Turkey During the COVID-19 Pandemic

Introduction

The aim of the survey was to investigate the changes, methods, and preferences in regional anesthesia (RA) applications during the COVID-19 pandemic in Turkey.

Methods

The questionnaire prepared on surveymonkey.com was sent to anesthesiology and reanimation specialists by e-mail.

Results

A total of 126 physicians participated in the study. Forty-two point sixty-two percent (42.62%) of the participants reported an increase in RA practices in their clinical anesthesia applications, whereas 57.38% did not state any change. Neuraxial anesthesia was determined to be the most preferred RA application, with a rate of 74%. The distribution of peripheral nerve blocks (PNBs) showed that upper extremity blocks were used at a rate of 64.9%, lower extremity blocks at 30.38%, and trunk blocks at 15%. Investigation of neurostimulator (NS) and/or ultrasound (US) use with PNB showed that 44% of the participants used only US while 50% used both US and NS.

Conclusion

Neuraxial blocks play an important role in RA applications. PNB comprise one-quarter of RA applications during the pandemic. The importance of ultrasound has gradually increased in RA applications worldwide, as well as in Turkey, during the pandemic.

[Surgical anesthesia using ultrasound-guided penile nerve block for adult hemophilia patient]

Ultrasound-Guided Dorsal Penile Nerve (DPNB) Block was performed to provide surgical anesthesia for a 22 years old ASA II patient who had hemophilia A and was undergoing circumcision surgery. 20 ml of 0.25% bupivacaine was used for the DPNB. Surgery was completed under block without complication. Twenty-four hours of the analgesia was provided following surgery.

[The effect of thoracic paravertebral block on seroma reduction in breast surgery - a randomized controlled trial]

BACKGROUND

Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.

OBJECTIVE

With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.

METHODS

Forty ASA I-II female patients aged 18-65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24^th hour postoperatively.

RESULTS AND CONCLUSIONS

Mean seroma formation at postoperative 24^th hour was 112.5±53.3 mL in the control group and 74.5±47.4 mL in the TPVB group (p=0.022). NRS scores were similar between two groups (p=0.367) at postoperative 24^th hour but mean morphine consumption at postoperative 24^th hour was 5.6±4 mg in the TPBV group, and 16.6±6.9 mg in the control group (p <0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.

The effect of thoracic paravertebral block on seroma reduction in breast surgery – a randomized controlled trial

Background

Increasing number of patients are being operated because of breast cancer. Seroma is the most common problem that occurs after surgery that increases morbidity. For postoperative pain management, Thoracic Paravertebral Block (TPVB) has long been considered the gold standard technique. With performing TPVB, sympathetic nerves are also blocked.

Objective

With this study, we aimed to search the effect of TPVB on seroma reduction in patients who undergo mastectomy and axillary node dissection surgery.

Methods

Forty ASA I–II female patients aged 18–65, who were scheduled to go under elective unilateral mastectomy and axillary lymph node resection were included to the study. Patients were randomized into two groups as TPVB and Control group. Ultrasound guided TPVB with 20 mL 0.25% bupivacaine was performed at T1 level preoperatively to the TPVB group patients. All patients were provided with i.v. patient-controlled analgesia device. Seroma formation amounts, morphine consumptions and Numeric Rating Scale (NRS) scores for pain were recorded 24th hour postoperatively.

Results and conclusions

Mean seroma formation at postoperative 24th hour was 112.5 ± 53.3 mL in the control group and 74.5 ± 47.4 mL in the TPVB group (p = 0.022). NRS scores were similar between two groups (p = 0.367) at postoperative 24th hour but mean morphine consumption at postoperative 24th hour was 5.6 ± 4 mg in the TPBV group, and 16.6 ± 6.9 mg in the control group (p < 0.001). TPVB reduces the amount of seroma formation while providing effective analgesia in patients who undergo mastectomy and axillary lymph node removal surgery.

[Quadratus lumborum block for both cholecystectomy and right-sided nephrectomy]

The quadratus lumborum block (QLB) is a unilateral facial plane block, which extends from T4 to L1 at the paravertebral space. Injecting local anesthetic between the facial plane of the quadratus lumborum muscle and the psoas major muscle provides the block of the referred dermatomes. However, the number of published studies for QLB used in various surgical procedures is limited. In this case report, we share the results of a 46-years-old ASA I female patient, who underwent open surgery for cholecystectomy and right-sided nephrectomy in the same session. After general anesthesia was induced, QLB was performed in the left lateral decubitus position. A convex probe was placed in transversely between the iliac crest and the costal margin at the midclavicular line. 20cc of 0.25% bupivacaine was injected to the facial plane between the quadratus lumborum and psoas major muscles. The surgery lasted 4 hours and completed uneventfully. In the postoperative period, the patient was provided with morphine PCA. After 24 hours, the VAS score was 0, and the total demanded morphine dose was 13 mg. This case report recommends that QLB may be an adequate choice in the postoperative pain management for patients undergoing cholecystectomy and nephrectomy.

The Effect of Ibuprofen on Postoperative Opioid Consumption Following Total Hip Replacement Surgery

Objective

Postoperative pain following hip surgery can be severe. Non-steroidal anti-inflammatory drugs are used in the treatment of postoperative pain to reduce opioid consumption. Our aim was to investigate the effect of ibuprofen on postoperative opioid consumption following total hip replacement surgery.

Methods

Patients undergoing elective total hip replacement under general anaesthesia were included into this randomised, prospective and double-blind study. Forty patients classified according to the American Society of Anesthesiologists as Class I and II were randomised to receive 800 mg ibuprofen intravenously (IV) every 6 hours, or placebo. At the end of surgery, all patients were also administered tramadol 100 mg IV and paracetamol 1 gm IV. In the postoperative period, all patients were provided with a morphine PCA device. The PCA device was set to deliver 1 mg bolus dose and had 8 minutes of lockout period and 6 mg 1-hour limit. VAS scores were recorded at 1, 6, 12 and 24 h postoperatively. The incidence of nausea and vomiting, total morphine consumption during the 24 h postoperative period was recorded. The Mann-Whitney U and chi-squared tests were used for statistical analysis.

Results

The VAS score at postoperative 24 h was lower in the ibuprofen group (p=0.006). Morphine consumption at 24 hours was significantly lower at the ibuprofen group compared to the control group (p=0.026) (the mean doses were 16 mg and 24 mg, respectively). Five patients in the control group and 3 patients in the ibuprofen group reported vomiting. No other side effects or complications were observed.

Conclusion

Following total hip replacement surgery, the administration of ibuprofen IV significantly reduced morphine consumption.

Comparison of conventional fluid management with PVI-based goal-directed fluid management in elective colorectal surgery

Intraoperative fluid management is quite important in terms of postoperative organ perfusion and complications. Different fluid management protocols are in use for this purpose. Our primary goal was to compare the effects of conventional fluid management (CFM) with the Pleth Variability Index (PVI) guided goal-directed fluid management (GDFM) protocols on the amount of crystalloids administered, blood lactate, and serum creatinine levels during the intraoperative period. The length of hospital stay was our secondary goal. Seventy ASA I–II elective colorectal surgery patients were randomly assigned to CFM or GDFM for fluid management. The hemodynamic data and the data obtained from ABG were recorded at the end of induction and during the follow-up period at 1 h intervals. In the preoperative period and at 24 h postoperatively, blood samples were taken for the measurement of hemoglobin, Na, K, Cl, serum creatinine, albumin and blood lactate. In the first 24 h after surgery, oliguria and the time of first bowel movement were recorded. Length of hospital stay was also recorded. Intraoperative crystalloid administration and urine output were statistically significantly higher in CFM group (p < 0.001, p: 0.018). The end-surgery fluid balance was significantly lower in Group GDFM. Preoperative and postoperative Na, K, Cl, serum albumin, serum creatinine, lactate and hemoglobin values were similar between the groups. The time to passage of stool was significantly short in Group-GDFM compared to Group-CFM (p = 0.016). The length of hospital stay was found to be similar in both group. PVI-guided GDFM might be an alternative to CFM in ASA I–II patients undergoing elective colorectal surgery. However, further studies need to be carried out to search the efficiency and safety of PVI.

[Ultrasound-guided penile nerve block for pediatric hypospadias surgery]

An ultrasound-guided dorsal penile nerve (DPN) block was performed for postoperative analgesia in a 6-year-old, 19 kg, American Society of Anesthesiologists class II patient undergoing hypospadias surgery. The block was applied following the induction of general anesthesia. Anesthesia maintenance was provided with sevoflurane 2% in a 1:2 ratio of oxygen and nitrous oxide. The DPN block was performed using 0.2 mL/kg of 0.25% bupivacaine. Almost 24 hours of analgesia was provided following surgery.

Comparison of tidal volume and deep breath preoxygenation techniquesundergoing coronary artery bypass graft surgery: effects of hemodynamicresponse and arterial oxygenation

Background/aim: Different techniques exist for the preoxygenation of patients that will be operated on under general anesthesia. Preoxygenation with the deep breath (DB) method may affect cardiovascular stability, which is crucial for coronary artery bypass graft (CABG) patients. In this study, we aimed to compare the effects of the 3 min TVB preoxygenation technique and 1 min 8DBs technique on hemodynamic response and arterial oxygenation in patients with normal ejection fraction that were scheduled for elective CABG surgery. Materials and methods: Forty patients classified as ASA II?III and scheduled for elective CABG surgery were randomly assigned to TVB/3 min or 8DBs/1 min for preoxygenation. Cardiovascular variables, i.e. heart rate, mean arterial pressure, central venous pressure, cardiac index, systemic vascular resistance index, and stroke volume index, and arterial blood gas samples were analyzed before and after preoxygenation and at the end of the apneic period before intubation. Results: The preoxygenation methods affected the hemodynamic response similarly. PaO2 increased significantly with 8DBs compared to the TVB at the end of preoxygenation but was similar between the groups at the end of the apneic period (respectively, P: 0.03; P: 0.15). PaCO2 changes were similar between the groups. Conclusion: In patients with normal ejection fraction scheduled for CABG, 8DBs can be an alternative to TVB preoxygenation. Our results should be compared with those of other studies.

Awake hand surgery under ultrasound-guided infraclavicular block is possible for cooperative children

In recent years, brachial plexus anesthesia techniques for upper limb surgery have been used more and more commonly on children; however, the patient is typically under deep sedation or general anesthesia. For eligible, cooperative children, surgery can also be performed using regional blocks while the patient is awake. We present 5 cases in which Ultrasound (US)-guided infraclavicular brachial plexus blocks (ICB) were used on children for hand or forearm surgery. Surgical anesthesia was achieved in all patients and surgery was completed uneventfully using brachial plexus anesthesia, without need for deep sedation.

[Our ultrasound-guided paravertebral block experiences in thoracic surgery]

OBJECTIVES

Ultrasound-guided thoracic paravertebral block (TPVB) may be employed for postoperative analgesia in thoracic surgery. In application of TPVB, single injections, multiple injections or catheter techniques may be used. In this paper we present our experiences with ultrasound-guided TPVB in thoracic surgery patients for postoperative analgesia.

METHODS

Patients undergoing thoracic surgery and on whom ultrasound-guided TPVB was performed for postoperative analgesia from January 2012 to March 2013 in our clinic were analyzed retrospectively. Demographic data, block technique, complications and 1st, 6th, 12th and 24th hour VAS scores were recorded.

RESULTS

A total of 18 patients had TPVB. Single injection was administered to 9 patients, multiple injections to 5, and catheters to 4. While statistically insignificant, 1st hour VAS scores were found to be greater than 3 in the single injection and catheter groups.

CONCLUSION

Similarly to multiple injection and continuous TPVB administration, ultrasound-guided single injection TPVB provides effective 24-hour postoperative analgesia.

[Ultrasound-guided obturator block experience from past year at Kocaeli University Hospital]

OBJECTIVES

Obturator nerve block is recommended to prevent obturator nerve reflex during transurethral resection. However, alternate techniques have been developed. The aim of the present study was to examine outcomes of interadductor approach.

METHODS

After obtaining approval from the ethics committee, files of patients who underwent transurethral resection surgery between October 2013 and October 2014 were reviewed.

RESULTS

A total of 137 transurethral resection patients were identified, in 69 (2 women, 67 men) of whom a combination of spinal anesthesia and obturator nerve block was used. Obturator nerve blocks were ultrasound-guided with interadductor approach. Nerve block was unsuccessful in 2 cases due to obturator nerve reflex. Surgeries were performed without complication.

CONCLUSION

Obturator nerve block is an effective method of preventing obturator nerve reflex. Combination of obturator nerve block and spinal anesthesia seems to be a safe method of anesthesia in transurethral surgery. Ultrasound guidance improves success rates and provides additional advantages for patient safety.

[Changing trends and regional anesthesia practices in Turkey]

OBJECTIVES

Introduction of ultrasound into regional anesthesia (RA) practice has resulted in important changes and developments in RA. These developments have had a major influence on the way of practice and choice of blocks. The purpose of this study was to present the most recent instruments used in RA and clinical applications in our country.

METHODS

A questionnaire consisting of 10 questions were distributed to the participants of the National RA Congress in 2011. Besides demographic data, RA techniques used and the method of nerve location was questioned. Participants were asked whether they were satisfied with their training in RA and if they participated in a RA course.

RESULTS

A total of 95 participants filled out the forms. Spinal anesthesia was the most commonly performed technique. Peripheral nerve blocks constitute only 12% of RA practice. Axillary block was the most commonly performed peripheral nerve block technique. The most commonly used nerve localization methods were nerve stimulation and ultrasound. The majority of the participants (58%) were not satisfied with their RA training and half (50%) participated in a course for continuing medical education.

CONCLUSION

Nerve stimulation is the most performed method, whereas US is increasingly becoming popular. The most commonly performed blocks are central neuroaxial blocks. All in all, there is still room for improvement in RA training.

Anaesthetic Management of a Patient with Pseudo-TORCH Syndrome

BACKGROUND

Pseudo-TORCH syndrome is a rare, chronic disorder that is characterised by dimorphic features such as microcephaly, intracranial calcification, seizures, mental retardation, hepatosplenomegaly and coagulation disorders.

CASE REPORT

We present the anaesthetic management of a forty day-old boy with Pseudo-TORCH syndrome during magnetic resonance imaging. Microcephaly, growth failure, high palate and bilateral rales in the lungs were detected in pre-anaesthetic physical examination. The peripheral oxygen saturation was 88-89% in room-air and was 95% in a hood with 5 L/min oxygen. We planned general anaesthesia to ensure immobility during magnetic resonance imaging. After standard monitoring, general anaesthesia was induced with 8% sevoflurane in 100% O2. After an adequate depth of anaesthesia was reached, we inserted a supraglottic airway device to avoid intubation without the use of a muscle relaxant.

CONCLUSION

In patients with Pseudo-TORCH syndrome, the perioperative anaesthetic risk was increased. We believe that using a supraglottic airway device to secure the airway is less invasive than intubation, and can be performed without the need of muscle relaxants.

Management of Difficult Airway in a Failed Intubation with Videolaryngoscopy in an Infant Patient

The videolaryngoscope is a useful alternative airway device for anaesthesia management of difficult airways. However videolaryngoscope intubation may fail due to lack of experience, incorrect application, inappropriate stylet, prior traumatic attempts, restricted cervical movement and limited oropharyngeal airspace. Using a stylet and correctly shaped endotracheal tube is important to facilitate tracheal intubation with the videolaryngoscope, especially in paediatric patients. However, anatomical difficulty in the placement of the laryngoscope blade, association with facial deformities such as micrognathia, having a short neck, cleft palate and being younger than 1 year increase the likelihood of a difficult airway. In this report, we present our approach to difficult airway management in a failed intubation with a videolaryngoscope in an infant undergoing cleft palate surgery.

The Role of Preoperative Evaluation for Congenital Methemoglobinemia

Preoperative care includes a clinical examination before invasive or non-invasive interventions for anaesthesia/analgesia and is the responsibility of the anaesthesiologists. Methemoglobinemia should be considered, as well as cardiac, pulmonary, and peripheral circulatory disorders in patients with central cyanosis and low oxygen saturation despite treatment with sufficient oxygen during anaesthesia. Methemoglobinemia is a serious clinical condition, associated with increased blood methemoglobin levels characterized by clinical signs, such as cyanosis and hypoxia due to lack of oxygen-carrying capacity. Here, we present our anaesthesia management in a patient with unnoticed congenital methemoglobinemia during preoperative evaluation, in whom clinical signs of methemoglobinemia developed after local anaesthesia administration before the surgery.

Survey on Postoperative Hypothermia Incidence In Operating Theatres of Kocaeli University

OBJECTIVE

Hypothermia is a common problem in anaesthetized patients and an important risk factor for mortality and morbidity. Our aim was to identify the incidence of hypothermia in our operating theatres. We also aimed to find the circumstances to which hypothermia could be related.

METHODS

After obtaining the ethics committee approval and informed patient consent, patients with operation times longer than 30 minutes were included into the study for a one month period. Demographical data of the patients, type and duration of surgeries, temperatures measured pre and postoperatively from the tympanic membrane with an infrared thermometer were recorded. Temperatures below 35°C were accepted as hypothermia.

RESULTS

A total number of 564 patients were enrolled to the study (305 women and 259 men). The ages of patients varied from 1 month to 84 years (mean 38.5±20.7). Hypothermia incidence was calculated as 45.7%. When the factors related to hypothermia were considered, age, type and duration of surgery and amount of fluids administered were found to be significant contributors to the development of hypothermia (p<0.05).

CONCLUSION

Postoperative hypothermia is a common problem in our clinic. Therefore, we suggest that temperature monitoring and patient warming should be a routine procedure during anaesthesia management.

Monoplegia after combined spinal epidural anesthesia

Serious neurological complications after neuraxial block, including permanent neurological injury, are rare in contemporary anesthetic practice. We report a case of a 36 year old female undergoing a venous stripping operation under combined spinal epidural anesthesia (CSE). The CSE procedure was completed after a second attempt at the L4-L5 level and the surgery was completed uneventfully. After full recovery of motor block in the recovery room, the patient was discharged to the surgical ward. Epidural patient controlled analgesia with levobupivacine 0.125% and fentanyl 2 µg/ml was initiated. 10 hours after surgery, right lower limb sensory loss and monoplegia occurred. The epidural catheter was removed and normal MRI findings were noted. After one month of physical therapy treatment and two months follow up the patient was able to walk with the aid of a walking stick. We discuss factors that might have contributed to radiculopathy and neurotoxicity as a cause of neurologic deficit.

Comparison of Supreme Laryngeal Mask Airway and ProSeal Laryngeal Mask Airway during Cholecystectomy

OBJECTIVE

This study compared the safety and efficacy of the Supreme Laryngeal Mask Airway (S-LMA) with that of the ProSeal-LMA (P-LMA) in laparoscopic cholecystectomy.

MATERIAL AND METHODS

Sixty adults were randomly allocated. Following anaesthesia induction, experienced LMA users inserted the airway devices.

RESULTS

Oropharyngeal leak pressure was similar in groups (S-LMA, 27.8±2.9 cmH2O; P-LMA, 27.0±4.7 cmH2O; p=0.42) and did not change during the induction of and throughout pneumoperitoneum. The first attempt success rates were 93% with both S-LMA and P-LMA. Mean airway device insertion time was significantly shorter with S-LMA than with P-LMA (12.5±4.1 seconds versus 15.6±6.0 seconds; p=0.02). The first attempt success rates for the drainage tube insertion were similar (P-LMA, 93%; S-LMA 100%); however, drainage tubes were inserted more quickly with S-LMA than with P-LMA (9.0±3.2 seconds versus 14.7±6.6 seconds; p=0.001). In the PACU, vomiting was observed in five patients (three females and two males) in the S-LMA group and in one female patient in the P-LMA group (p=0.10).

CONCLUSION

Both airway devices can be used safely in laparoscopic cholecystectomies with suitable patients and experienced users. However, further studies are required not only for comparing both airway devices in terms of postoperative nausea and vomiting but also for yielding definitive results.

[Infraclavicular block with ultrasound at amputated upper extremity]

When ultrasound (US) is used in peripheric nerve blocks, successful nerve blocks can be performed even if nerve stimulation is not possible. In this case report, we present a 37-year-old male patient, ASA physical status I, undergoing debridement and grafting for incomplete arm whose upper extremity (forearm) was amputated due to electric shock; motor response to nerve stimulation was not possible. With the help of US, lateral sagittal infraclavicular block was performed with 20 ml local anesthetic mixture (10 ml of 0.5% levobupivacaine and 10 ml 2% lidocaine with 5 mcg/ml epinephrine). After 20 minutes, the patient was ready for surgery and the operation was performed successfully.

[Lateral sagittal infraclavicular block: a case report of three patients]

Magnetic resonance imaging (MRI) analysis performed on healthy volunteers assessed the effectiveness of brachial plexus block via the lateral sagittal infraclavicular approach to be easy-performed and relatively safe. In this case report, we presented three cases to whom we performed infraclavicular block via the lateral sagittal approach. One of our cases was a high risk patient with osteomyelitis of the elbow joint and the other was a patient who had required surgery for Dupuytren's contracture. The third one was a patient admitted to emergency room who had got open metacarps fractures. Lateral sagittal infraclavicular block was planned in all of the patients. Twenty minutes after local anesthetic (LA) injection, sufficient surgical anesthesia was achieved. Non of the patients developed vascular puncture, LA toxicity and pneumothorax. In conclusion, LSIB appears to be an easy, a safe and a more acceptable approach for the patient, therefore a good alternative.