Albumin effect on hemorheological parameters in patients with liver transplant

BACKGROUND

Liver transplantation is a life-saving treatment in end-stage liver failure. Hemorheological features as blood fluidity and red blood cell aggregation may alter effective tissue perfusion, graft function and hemodynamic variables.

OBJECTIVE

The aim of the study is to investigate effect of albumin infusion on red blood cell deformability and aggregation, blood viscosity and hemodynamics in liver transplant patients.

METHODS

Seventeen live or cadaveric donors were included in this prospective study. Hemorheological and hemodynamic measurements were performed in order to evaluate the effects of albumin infusion in perioperative period.

RESULTS

Erythrocyte aggregation was significantly reduced 90 minutes after albumin infusion (p < 0.01). Mean blood viscosity revealed significant decrease at 20 rpm and 50 rpm after 90 minutes of albumin infusion (p < 0.05). Plasma viscosity decreased significantly compared to the value before albumin infusion at 20 rpm (p < 0.05). Albumin replacement improved hemodynamic variables in patients with low blood pressure and cardiac index measurements (p > 0.05).

CONCLUSIONS

Human albumin infusion led to decrease in whole blood and plasma viscosities, red blood cell aggregation and induced blood pressure and cardiac index elevation in perioperative liver transplant patients. Determination of hemodynamic and hemorheological effects of human albumin replacement in various patient populations may serve beneficial clinical data.

Serum Levels of S100β, Neuron-Specific Enolase, Glial Fibrillary Acidic Protein in Kidney Transplant Recipients and Donors: A Prospective Cohort Study

BACKGROUND

The aim of this study was to evaluate changes in serum levels of S100β, neuron-specific enolase, glial fibrillary acidic protein in living donors and recipients after kidney transplantation.

METHODS

We enrolled 56 patients into the study. Of these, 27 underwent donor nephrectomy (group D), and the remaining 29 underwent kidney transplantation (recipient, group R). Neuromarkers were measured in samples obtained before the procedure, on postoperative day 7, and at 1 month postoperatively.

RESULTS

Postoperative kidney functions were impaired in patients who underwent living donor nephrectomy compared with their preoperative levels (P < .001), although no significant difference was observed in their neuromarkers. The postoperative delirium rating scale was also impaired after living donor nephrectomy compared with preoperative levels (P < .05). Postoperative kidney functions were improved (P < .001), and a progressive decrease in neuromarker levels (P < .05) was observed in kidney transplant recipients compared with their preoperative levels. Linear regression analysis showed a significant correlation between neuron-specific enolase, glial fibrillary acidic protein levels and kidney functions in recipients.

CONCLUSION

The present study demonstrated that neuron-specific enolase and glial fibrillary acidic protein levels decrease in kidney transplant recipients and do not change in donors. This result indicated that there is no evidence of neurotoxicity in either recipients and donors in kidney transplantation.

Effect of post-perfusion hyperoxemia on early graft function in renal transplant recipients: a retrospective observational cohort study

BACKGROUND

The effects of hyperoxemia on the transplanted grafts arouse interest nowadays, particularly intraoperative hyperoxemia, on transplant kidney function and survival in the 1-year post-operative period.

AIMS

We aimed to investigate the effect of post-perfusion (5 min after perfusion) hyperoxemia on early graft function and survival in renal transplant recipients.

METHODS

Two hundred forty-seven living donor kidney transplant recipients were included in the study. Patients were divided into the three groups according to their partial arterial oxygen pressure in post-perfusion blood gas samples: group 1: normoxia (n = 52, PaO2 pressure: < 120 mmHg, 103 ± 13); group 2: moderate hyperoxemia (n = 121, PaO2: 120-200 mmHg, 169 ± 21); group 3: severe hyperoxemia (n = 74, PaO2: > 200 mmHg, 233 ± 25). Graft functions (serum creatinine levels, estimated-glomerular filtration rate values, spot urine protein/creatinine ratio), survival rates, and groups' clinical outcomes were compared in the first year after transplantation.

RESULTS

Graft survival rates were similar in the groups and the rate of BK virus viremia was the lowest in the group 3 (groups 1, 2, and 3: 15.4% (n = 8), 6.6% (n = 8), 1.4% (n = 1), respectively, P: 0.009). Serum creatinine and proteinuria levels were lower, and estimated-glomerular filtration rate values were higher in group 3. A negative correlation between partial arterial oxygen pressure and serum creatinine levels and a positive correlation with estimated-glomerular filtration rate value were noted. These results were confirmed by univariate and multivariate analyses.

CONCLUSIONS

We demonstrated that the kidney transplant recipients with post-perfusion hyperoxemia have better early graft functions and lower BK virus viremia rates.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04420897.

The relevance between graft preservation solutions and QTc interval during living donor kidney transplantation and rat cardiomyocytes sampling

BACKGROUND

The purpose of the retrospective study was to identify the impacts of different solutions on the electrocardiogram and cardiovascular changes. Moreover, the differences between these solutions were analyzed by examining their impacts on rat ventricular cardiomyocytes.

METHODS

Eighty renal transplant patients were evaluated retrospectively. The patients were divided into two groups: Group UW (n =40) used the University of Wisconsin solution, and Group HTK (n =40) used the Histidine-Tryptophan-Ketoglutarate solution. Electrocardiograms of the subjects were obtained three times at different periods; during the pre-perfusion, intraoperative kidney reperfusion, and postperfusion phase at the end of the surgery. Any Electrocardiogram or cardiovascular alterations were noted and analyzed. Adult male Wistar rats were used for in vitro experiments. Myocyte contractility, action potentials, and membrane current were recorded in enzymatically isolated ventricular myocytes.

RESULTS

Sinus bradycardia was detected in 19 patients of Group UW, while there was short-term asystole in eight patients. However, no cardiac changes were observed in Group HTK patients. In both Groups, reperfusion and postperfusion corrected QT (QTc) intervals were different from pre-perfusion QTc intervals. Group UW patients' reperfusion and postperfusion QTc's values were higher than those of the Group HTK patients. In rat myocytes, prominent asystole episodes were observed at specific concentrations of the UW solution compared to the HTK solution. The UW solution depolarized the resting membrane potential significantly and decreased the peak value of action potential, whereas the HTK solution did not elicit a significant change in those parameters. Accordingly, the UW solution elicited a significant inward current at -70 mV, while the HTK solution activated only a modest current, which may not change the membrane potential.

CONCLUSION

Prolongation of QTc intervals was detected with reperfusion in both groups according to electrocardiography analysis. However, the QTc interval was observed to be longer in cases using the UW solution and required intervention intraoperatively. HIPPOKRATIA 2021, 25 (1):22-30.

Homocysteine levels after nitrous oxide anesthesia for living-related donor renal transplantation: a randomized, controlled, double-blind study

BACKGROUND

Nitrous oxide anesthesia increases postoperative homocysteine concentrations. Renal transplantation candidates present with higher homocysteine levels than patients with no renal disease. We designed this study to investigate if homocysteine levels are higher in subjects receiving nitrous oxide for renal transplantation compared with subjects undergoing nitrous oxide free anesthesia.

METHODS

Data from 59 patients scheduled for living-related donor renal transplantation surgery were analyzed in this randomized, controlled, blinded, parallel-group, longitudinal trial. Patients were assigned to receive general anesthesia with (flowmeter was set at 2 L/min nitrous oxide and 1 L/min oxygen) or without nitrous oxide (2 L/min air and 1 L/min oxygen). We evaluated levels of total homocysteine and known determinants, including creatinine, folate, vitamin B12, albumin, and lipids. We evaluated factor V and von Willebrand factor (vWF) to determine endothelial dysfunction and creatinine kinase myocardial band (CKMB)-mass, troponin T to show myocardial ischemia preoperatively in the holding area (T1), after discontinuation of anesthetic gases (T2), and 24 hours after induction (T3).

RESULTS

Compared with baseline, homocysteine concentrations significantly decreased both in the nitrous oxide (22.3 ± 16.3 vs 11.8 ± 9.9; P < .00001) and nitrous oxide-free groups (21.5 ± 15.3 vs 8.0 ± 5.7; P < .0001) at postoperative hour 24. The nitrous oxide group had significantly higher mean plasma homocysteine concentrations than the nitrous oxide-free group (P = .021). The actual homocysteine difference between groups was 3.8 μmol/L.

CONCLUSION

This study shows that homocysteine levels markedly decrease within 24 hours after living-related donor kidney transplantation. Patients receiving nitrous oxide have a lesser reduction, but this finding is unlikely to have a clinical relevance.

Concurrent unilateral or bilateral native nephrectomy in kidney transplant recipients

BACKGROUND

The aim of this study is to present results of patients who have undergone renal transplantation concurrent with bilateral or unilateral native nephrectomy, with a special focus on polycystic kidney disease (PKD).

MATERIAL AND METHODS

We presented the outcome of renal transplantation patients who have undergone native nephrectomy unilaterally (n=38) and bilaterally (n=125) and compared the results of patients with PKD and other nephrectomy indications.

RESULTS

Overall graft survival in the 1st, 3rd, and 5th years were 93%, 90%, and 89%, respectively, in transplantation with concomitant nephrectomy patients. Overall patient survival in the 1st, 3rd, and 5th years were 97%, 94%, and 94%, respectively. Overall surgical complications rate was 17.7% and medical complication rate was 19%. Patients with PKD had more frequent complications.

CONCLUSIONS

Despite additional surgery, the long-term results of patients with complications were not affected negatively by early diagnosis and treatment. We believe that native nephrectomy concurrent with transplantation can be successfully performed when indicated in selected patients at experienced centers.

Uterus transplantation from a deceased donor

OBJECTIVE

To demonstrate the technique for uterus retrieval and transplantation from a multiorgan donor.

DESIGN

Video presentation of our case report. The video uses animation to demonstrate the technique. Institutional Review Board (IRB) approval was obtained.

SETTING

University hospital.

PATIENT(S)

A 21-year-old woman with complete müllerian agenesis.

INTERVENTION(S)

Uterus allotransplantation has been performed from a deceased donor.

MAIN OUTCOME MEASURE(S)

Acquirement of cyclic menstrual function.

RESULT(S)

This video demonstrates the technique for uterus retrieval, perfusion, and transplantation. The recipient patient has been monitored regularly for vascular flow, immunosuppression, and infection control since the operation.

CONCLUSION(S)

Uterus transplantation requires extensive evaluation of the recipient and donor by an experienced multidisciplinary transplantation team both pre- and postoperatively. It has major risks related to surgery, immunosuppression, and pregnancy. Uterus transplantation might be considered promising only after the birth of a near-term healthy baby.

Preliminary results of the first human uterus transplantation from a multiorgan donor

OBJECTIVE

To describe the first-year results of the first human uterus transplantation case from a multiorgan donor.

DESIGN

Case study.

SETTING

University hospital.

PATIENT(S)

A 21-year-old woman with complete müllerian agenesis who had been previously operated on for vaginal reconstruction.

INTERVENTION(S)

Uterus transplantation procedure consisting of orthotopic replacement and fixation of the retrieved uterus, revascularization, end to site anastomoses of bilateral hypogastric arteries and veins to bilateral external iliac arteries and veins was performed.

MAIN OUTCOME MEASURE(S)

Resumption of menstrual cycles.

RESULT(S)

The patient had menarche 20 days after transplant surgery. She has had 12 menstrual cycles since the operation.

CONCLUSION(S)

We have described the longest-lived transplanted human uterus to date with acquirement of menstrual cycles.

Neurological Complications after Liver Transplantation

This was a single-centre, prospective study to assess the frequency of neurological complications and their impact on prolonged hospitalization in 137 liver transplant patients presenting between September 1997 and June 2010. Neurological complications were seen in 22 (16%) patients during their postoperative stay in the intensive care unit. Complications included new-onset, recurrent headache (five patients), generalized seizures (four patients), dysarthria (two patients), delirium with agitation (three patients), persistent flapping tremor (two patients), alteration in level of consciousness (three patients), central pontine myelinolysis (one patient), myopathy (one patient) and visual hallucinations (one patient). Seizures were associated with immunosuppressive drug toxicity (tacrolimus). Myopathy presenting as quadriplegia was diagnosed by muscle biopsy. The patient with central pontine myelinolysis lived in a persistent vegetative state for 2 years and died of pneumonia. In conclusion, neurological complications are frequently encountered after liver transplantation, and are an important cause of severe morbidity and prolonged intensive care unit and hospital stay.

The assessment of PFA-100 test for the estimation of blood loss in renal transplantation operation

BACKGROUND

Platelet dysfunction is well known factor that may play a role in bleeding diathesis in uremia. In recent years, Platelet Function Assay 100 (PFA-100) was introduced to measure platelet function. The purpose of this study was to determine whether an abnormal PFA-100 is an accurate predictor of bleeding in dialysis patients undergoing renal transplantation (RTx).

MATERIAL/METHODS

We included 98 dialysis patients undergoing RTx operation. PFA-100 test measuring collagen/epinephrine (Col/EPI) and collagen/adenosine 5'-diphosphate (Col/ADP) closure was performed in each patients after induction of anesthesia. We compared intraoperative blood loss measured by gravimetric method during RTx operation method between patients with normal Col/EPI and Col/ADP closure times (group 1, n= 51) and with prolonged Col/EPI and Col/ADP closure times (group 2, n=47).

RESULTS

Intraoperative blood loss calculated by gravimetric method was 273+/-50 ml in the group 1 and 303+/-109 ml in the group 2 (p>0.05). Blood loss in gross formula was 356+/-87 ml in the group 1 and 450+/-99 ml in group 2 (p>0.05).

CONCLUSIONS

Assessment of platelet function with preoperative measurement of PFA-100 in RTx patients is not an effective method for estimating the risk of blood loss in the intraoperative and postoperative periods.

The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation

BACKGROUND

This study aimed to quantify changes in acid-base balance, potassium and lactate levels as a function of administration of different crystalloid solutions during kidney transplantation, and to determine the ideal fluid for such patients.

METHODS

In this double-blind study, patients were randomized to three groups (n = 30 each) to receive either normal saline, lactated Ringer's, or Plasmalyte, all at 20-30 mL x kg(-1) x h(-1). Arterial blood analyses were performed before induction of anesthesia, and at 30-min intervals during surgery, and total IV fluids recorded. Urine volume, serum creatinine and BUN, and creatinine clearance were recorded on postoperative days 1, 2, 3, and 7.

RESULTS

There was a statistically significant decrease in pH (7.44 +/- 0.50 vs 7.36 +/- 0.05), base excess (0.4 +/- 3.1 vs -4.3 +/- 2.1), and a significant increase in serum chloride (104 +/- 2 vs 125 +/- 3 mM/L) in patients receiving saline during surgery. Lactate levels increased significantly in patients who received Ringer's lactate (0.48 +/- 0.29 vs 1.95 +/- 0.48). No significant changes in acid-base measures or lactate levels occurred in patients who received Plasmalyte. Potassium levels were not significantly changed in any group.

CONCLUSIONS

All three crystalloid solutions can be safely used during uncomplicated, short-duration renal transplants; however, the best metabolic profile is maintained in patients who receive Plasmalyte.

Correlation of peripheral venous pressure and central venous pressure in kidney recipients

BACKGROUND AND OBJECTIVE

Previous studies in adults have demonstrated a clinically useful correlation between central venous pressure (CVP) and peripheral venous pressure (PVP). The current study prospectively compared CVP measurements from a central versus a peripheral catheter in kidney recipients during renal transplantation.

METHODS

With ethics committee approval and informed consent, 30 consecutive kidney recipients were included in the study. We excluded patients who had significant valvular disease or clinically apparent left ventricular failure. For each of 30 patients, CVP and PVP were measured on five different occasions. The pressure tubing of the transducer system was connected to the distal lumen of the central or to the peripheral venous catheter for measurements following induction of anesthesia, after induction, 1 hour after induction, reperfusion of the kidney, and the end of the operation, yielding 150 hemodynamic data points. Each hemodynamic measurement included heart rate, mean arterial pressure, mean CVP, and mean PVP determined at end-expiration.

RESULTS

The mean PVP was 13.5 +/- 1.8 mm Hg and the mean CVP was 11.0 +/- 1.5 mm Hg during surgery. The mean difference was 2.5 +/- 0.5 (P < .01). Repeated-measures analysis of variance indicated a highly significant relationship between PVP and CVP (P < .01) with a Pearson correlation coefficient of 0.97.

CONCLUSION

Under the conditions of this study, PVP showed a consistently high agreement with CVP in the perioperative period among patients without significant cardiac dysfunction.

Spinal analgesia for the postoperative period in renal donors

BACKGROUND

To provide postoperative analgesia by spinal anesthesia, we compared the quality of analgesia and side effects of two doses of morphine added to ropivacaine in kidney donors.

MATERIALS AND METHODS

Thirty renal donors underwent nephrectomy under standard general anesthesia. After the operation, the patients were randomly allocated into two groups of intrathecal doses for spinal anesthesia: the 0.5 group (n = 15) received a total volume of 4 mL including 0.5 mg morphine, 10 mg ropivacaine, and 0.9% NaCl, and the 0.3 group (n = 15), a total volume of 4 mL including 0.3 mg morphine, 10 mg ropivacaine, and 0.9% NaCl. After extubation, an intravenous (IV) morphine protocol was initiated by a patient-controlled analgesia pump to provide sufficient spinal analgesia.

RESULTS

In the 0.3 group, the IV morphine consumption was significantly higher, namely, 14.60 +/- 7.57 times versus 4.60 +/- 10.14 times for the 0.5 group (P = .005). The total amount of morphine was 7.80 +/- 5.40 mg in the 0.5 group and 13.53 +/- 5.30 mg in the 0.3 group (P < .05). Postoperative side effects of nausea and vomiting were higher among the 0.3 group (P < .05).

CONCLUSIONS

In the 0.5 group, the quality of analgesia was better than in the 0.3 group. The need for IV morphine was less in the 0.5 group. Also, side effects like nausea and vomiting were less, so better analgesia in the postoperative period was obtained with the 0.5 mg morphine solution.

Does dexamethasone improve the quality of intravenous regional anesthesia and analgesia? A randomized, controlled clinical study

We investigated the anesthetic and analgesic effectiveness of adding dexamethasone to lidocaine for IV regional anesthesia (IVRA). Seventy-five patients undergoing ambulatory hand surgery were randomly assigned to one of three groups: group L received 3 mg/kg lidocaine, group LD received 3 mg/kg lidocaine + 8 mg dexamethasone, and group LDc received 3 mg/kg lidocaine for IVRA and 8 mg dexamethasone IV to the nonsurgical arm. IVRA was established using 40 mL of a solution. Visual analog scale and verbal pain scores were recorded intraoperatively and for 2 h postoperatively. Postoperative pain was treated with oral acetaminophen 500 mg every 4 h when visual analog scale score was more than 3. Time to request for the first analgesic and the total dose in the first 24 h were noted. Times to onset of complete sensory and motor block were similar in the 3 groups. The times to recovery of motor block (L = 8 [5.91-10.08] min, LD = 13 [6.76-20.19] min, LDc = 6 [4.44-8.43] min) and sensory block (L = 7 [5.21-10.30] min, LD = 12 [6.11-19.40] min and LDc = 6 [4.2-8.11] min) were longer in group LD (P < 0.05). Patients in group LD reported significantly lower pain scores and required less acetaminophen in the first 24 h after surgery. In conclusion, the addition of 8 mg dexamethasone to lidocaine for IVRA in patients undergoing hand surgery improves postoperative analgesia during the first postoperative day.

The comparative effect of single dose mivacurium during sevoflurane or propofol anesthesia in children

BACKGROUND

We aimed to randomly compare intubating conditions, recovery characteristics and neuromuscular effects of single dose of mivacurium (0.2 mg.kg(-1)) during sevoflurane vs. propofol anesthesia in 60 healthy children, undergoing inguinal surgery.

METHODS

All children were randomly allocated to receive 2 mg.kg(-1) propofol iv or sevoflurane 8% inspired concentration for induction of anesthesia. Anaesthesia was maintained with 66% nitrous oxide in oxygen and 100-120 microg.kg(-1) propofol or sevoflurane approximately 2-3% inspired concentration with controlled ventilation. The ulnar nerve was stimulated at the wrist by a train-of four (TOF) stimulus every 20 s and neuromuscular function was measured at the adductor pollicis. When the response to TOF was stable, 0.2 mg.kg(-1) mivacurium was given. The trachea was intubated successfully at the first attempt in all patients.

RESULTS

Onset time following a single dose of mivacurium was shorter in the sevoflurane group (2.99 min), than in the propofol group (4.42 min). The times to 25, 50, 75, and 90% recovery were significantly longer in the sevoflurane group (13.1, 15.7, 18.6, and 21.2 min, respectively) than in the propofol group (11.4, 13.2, 14.4, and 17.2 min respectively). TOF ratios of 50, 70, and 90% were significantly occurred later in sevoflurane group than propofol group.

CONCLUSIONS

Our results indicate that when compared with propofol group, the sevoflurane group had an accelerated onset and a delayed recovery of neuromuscular block induced by mivacurium in children.

Comparison of two different techniques for brachial plexus block: infraclavicular versus axillary technique

BACKGROUND

Brachial plexus block via the axillary approach is problematic in patients with limited arm mobility. In such cases, the infraclavicular approach may be a valuable alternative. The purpose of our study was to compare axillary and infraclavicular techniques for brachial plexus block in patients undergoing arm or forearm surgery.

METHODS

After institutional approval and informed consent were obtained, 30 patients (ASA physical status I or II) scheduled for forearm and hand surgery under brachial plexus anesthesia were included in the study. Patients were randomly allocated into two groups. Brachial plexus block was performed via the axillary approach in the Group A patients and via the infraclavicular approach in the Group I patients using a peripheral nerve stimulator. All blocks were performed with a total dose of 40 ml 0.375% bupivacaine.

RESULTS

In each nerve territory (radial, ulnar, median, and musculocutaneous), the mean values of the degree and the duration of the sensory block and motor block were not significantly different between the two groups (P > 0.05). Inadvertent vessel puncture was significantly more frequent in the axillary approach (P < 0.05).

CONCLUSION

Brachial plexus block performed via the infraclavicular approach is as safe and effective as the axillary approach. Infraclavicular approach may be preferred to the axillary approach when the upper arm mobility is impaired or not desired.

A Randomized Study Comparing Combined Spinal Epidural or General Anesthesia for Renal Transplant Surgery

INTRODUCTION

The appropriate anesthesia for renal transplantation requires minimal toxicity for patients and for the transplanted organ, as well as sufficient pain relief and maintenance of vital functions. The aim of this study was to determine how the anesthetic technique influences the outcome in patients after renal transplantation in terms of preoperative and intraoperative hemodynamic changes and blood gas changes.

METHODS

Fifty adult patients undergoing renal transplantation were randomly divided into two groups receiving standardized general anesthesia or combined spinal and epidural anesthesia.

RESULTS

Demographically both groups were similar. Total anesthesia time (202 +/- 53 vs 186 +/- 37 minutes) and surgical time (191 +/- 52 vs 162 +/- 31 minutes) did not differ between the groups. The heart rate and systolic blood pressure values of the groups as measured before induction and 5, 15, 20, 30, as well as 60 minutes thereafter did not differ between the groups. Neither the frequency of bradycardia (four vs two) nor of hypotension (six vs four) during anesthesia differed between regional versus general anesthesia groups.

CONCLUSION

Regional is an important alternative to general anesthesia during renal transplantation surgery in adult patients.

Intrathecal fentanyl added to hyperbaric ropivacaine for transurethral resection of the prostate

BACKGROUND

Our purpose was to evaluate the effect of intrathecal fentanyl 25 microg added to 18 mg of 6 mg ml(-1) hyperbaric ropivacaine on the characteristics of subarachnoid block and postoperative pain relief in patients undergoing TURP surgery.

METHODS

The patients were randomly assigned into two groups: Group S (saline group, n=16) received 3 ml of 18 mg hyperbaric ropivacaine + 0.5 ml saline--in total, a 3.5-ml volume intrathecally; and Group F (fentanyl group, n=15) received 3 ml of 18 mg hyperbaric ropivacaine + 0.5 ml of 25 microg fentanyl--in total, a 3.5-ml volume intrathecally. In both groups the onset and recovery times of the sensory block, degree and recovery times of the motor block and side-effects were recorded and statistically compared.

RESULTS

There was no significant difference between the groups in achieving the highest level of sensory block, and in the times taken to reach the peak level. Regression to L1 was significantly prolonged in the fentanyl group compared with the saline group (P=0.004). Times to the first feeling of pain and the first analgesic requirement were significantly prolonged in the fentanyl group compared with the saline group (P=0.011 and P=0.016, respectively). The frequency of pruritus was significantly higher in the fentanyl group compared with the saline group (P=0.022).

CONCLUSION

Addition of fentanyl 25 microg to hyperbaric ropivacaine 18 mg for spinal anesthesia in patients undergoing TURP may significantly improve the quality and prolong the duration of analgesia, without causing a substantial increase in the frequency of major side-effects.

Systemic organophosphate poisoning following the percutaneous injection of insecticide. Case report

Organophosphates are the most common group of chemicals in the southern part of Turkey. Although organophosphate poisoning (OPP) may occur due to skin exposure or inhalation, severe poisoning is usually the result of ingestion to attempt suicide. Despite the fact that there have been a lot of experimental studies using intravenous or percutaneous injection of organophosphates, reports of human poisoning due to percutaneous injection are rare. The systemic signs of OPP have not been described in these reported patients. We report 2 cases having systemic signs of OPP due to percutaneous injection. In our first case, we noticed a 17-day muscle weakness and a 12-day muscarinic syndrome, which required prolonged atropinization. In the second patient, atropine infusion had to be continued for 2 days. Both cases also had severe swelling of the affected limb and wound infection. In conclusion, in cases of percutaneous injection of organophosphates systemic toxicity may develop in addition to local findings such as necrosis and abscesses. Close observation for evidence of systemic involvement is required, and the patient should be carefully monitored for secondary abscess formation and any delayed impairment of neurologic function.