Original/Research Article


Comparıson of I-Gel Laryngeal Mask and Endotracheal Tube Effects on Inflammatory Response in Hand Surgery

Hüseyin Arıcan, Elif Do˘ gan Bakı, Halit Bu˘ gra Koca, Necmettin Karasu, Remziye Sıvacı

Annals of Anesthesiology and Critical Care, Vol. 3 No. 2 (2018), 21 December 2020 , Page 1-5

Background: Anesthesia and surgery together can cause endocrine and metabolic changes by creating a stress response.


Objectives: This study aimed to compare the effects of two different applications of general anesthesia on the immune system by measuring serum cytokines in patients undergoing hand surgery.


Methods: The study included 40 patients undergoing hand surgery with American Society of Anesthesiologists (ASA) physiological status I to III and ages between 18 and 65. The patients were randomly divided into two groups including I-gel LMA (group 1) and endotracheal tube (group 2). Blood samples were taken from all patients before anesthesia induction (T0), five minutes after the induction (T1), one hour postoperatively (T2), and 24 hours postoperatively (T3) for IL-1_, TNF-_, IL-6, and IL-8 analysis. The attempt numbers and the placement time of airway devices were noted in both groups.We also recorded patients’ perioperative OAB, pulse, saturation, SPI, and ETCO2.


Results: There was no difference in TNF-_, IL-1_, IL-8, and IL-6 levels between the groups. When we compared trial periods, it was seen that I-gel LMA was statistically placed faster than laryngeal tube.


Conclusions: One of the ways to reduce surgical stress is to minimize invasive procedures as much as possible. Although I-gel LMA did not reduce inflammation or stress response, placing it was faster than the endotracheal tube and this may give an advantage in favor of I-gel

Mivacurium Sensitivity at the Adductor Pollicis and Hand Grip Muscles: Differences Between Males and Females

Tom Heier, Silke Leonie Bicknell, Peter MCWright, James E Caldwell, John R Feiner

Annals of Anesthesiology and Critical Care, Vol. 3 No. 2 (2018), 21 December 2020 , Page 1-7

Background: Males lose more handgrip strength (HGS) than females when adductor pollicis (AP) TOF ratio decreases. The reason is unclear.


Objectives: The primary aim of this study was to explore gender-related differences in neuromuscular sensitivity to mivacurium. As a secondary aim, clearance of mivacurium was determined.


Methods: In 10 healthy males and 10 healthy females, constant-rate infusions of mivacurium were administered to obtain three different levels of stable neuromuscular block (normalized acceleromyography AP TOF ratio 80, 60, and 40%) in each study subject. Arterial blood samples were collected to determine mivacurium plasma concentrations. The HGS was measured every five minutes. A Hill equation was fitted to data on mivacurium concentration versus normalized AP TOF ratio and HGS to determine drug concentrations associated with 50% maximum effect (C50 AP TOF ratio and C50 HGS). Differences within and between genders were tested with the parametric t-test. Clearance of mivacurium was calculated at each block level as the ratio between drug infusion  rate and concentration. Gender-related differences in relationships between AP TOF ratio and HGS, mivacurium infusion rates, and mivacurium plasma concentrations were determined with linear mixed-models.


Results: The C50 AP TOF ratio was significantly greater than C50HGSin males, yet not in females. Mivacurium infusion rates, needed to maintain stable neuromuscular blocks, were significantly greater in males, while clearance was similar between genders. Males lost significantly more HGS with decreasing AP TOF ratio than females, both in absolute (kg) and relative (percentage of baseline) terms.


Conclusions: In males, yet not in females, the AP was significantly less sensitive to the effect of mivacurium than the muscles involved in the handgrip function. Thisfindingexplainswhyhandgripstrength decreasesmorein males than females with decreasing AP TOF ratio during the mivacurium block.

Cerebral Protection During Coronary Artery Bypasses Grafting in Bilateral Total Internal Carotids Occlusion: Case Report

Afshin Froutan, Mohammad Rezvan Nobahar, Hossein Rahimian, Azita Chegini, Faranak Behnaz

Annals of Anesthesiology and Critical Care, Vol. 3 No. 2 (2018), 21 December 2020 , Page 1-4

Introduction: The best management for the patient with coronary artery disease (CAD) that requires emergent coronary bypass graft surgery (CABG) with bilateral total internal carotid artery occlusions previously reported. Here we report two successful cases of CABG with additional occlusion in the circle of Willis anterior or posterior communicating artery “incomplete cow” with onpump technique and cerebral protection considerations.


Case Presentation: Bilateral carotid artery occlusion, coronary artery disease, and emergency operation with cardiopulmonary bypass are associated with increased stroke, especially when there is one additional occlusion of the cerebral artery in the circle of Willis. Routine preoperative carotid artery sonography and selective carotid angiography revealed bilateral total carotid occlusion in both cases in addition, CT-angiography also confirmed occlusions of right posterior communicating in the first case and left posterior communicating artery in the second case. Collateral circulation feeding in the intracranial circulations originated mainly from the vertebrobasilar system (compensatory phase) preoperative physical examinations showed no neurological deficit. Operation was done successfully with moderate hypothermia and different cerebral protection considerations and postoperative courses were uneventful and patients discharged from hospital seven days post operation.


Conclusions: Anesthesia should consider hemodynamic management and avoid significant tachycardia or bradycardia and severe hypertension or hypotension.

Postoperative Pain Treatment in Day Surgery: A Quality Improvement Study Examining the Needs of Opioid and Effects of Oxycodone and Morphine

KurtWesenberg Christiansen, Tina Magaard Joergensen, Hanne Irene Jensen

Annals of Anesthesiology and Critical Care, Vol. 3 No. 2 (2018), 21 December 2020 , Page 1-8

Background: There is sparse literature providing evidence for postoperative pain treatment in day surgery and for differences between morphine and oxycodone.


Objectives: The objectives of this study were to examine the need for opioids and the effects of morphine versus oxycodone for pain relief and side effects at home after day surgery.


Methods: This study was a prospective observational study with a quasi-randomized approach. Data consisted of self-reported three-day registration of use and the effects of the opioids, their side effects, and patient satisfaction with regards to pain treatment in a Danish day surgery conducting orthopedic and abdominal surgery. The outcomes, including the use of opioids, self-reported pain relief, and related side effects (nausea, fatigue, dizziness, and skin itchiness) were measured by a numeric rating scale and patient satisfaction with regards to pain treatment.


Results: Out of the 199 included day surgery patients, 162 (81%) returned self-reported postoperative data. A total of 73% of the patients had used opioids an average of 4 times (range 1 - 16). Median levels of nausea, dizziness, and skin itching were 0 (IQR 0 - 3) whereas the median level of fatigue was 3 (IQR 0 - 6). More than 90% of the patients were satisfied or very satisfied with their postoperative pain treatment. No statistically significant differences were found between oxycodone and morphine in regard to onset time, level, duration of pain treatment, and the experienced side effects.


Conclusions: Three-quarters of the patients used opioids after day surgery with a substantially varied number of doses. Few patients experienced substantial side effects, and the patients were generally satisfied with their pain treatment. No significant difference was found between oxycodone and morphine. The need for opioids after day surgery varies substantially and further investigations on individuals and follow-up are needed.

Survival After Methemoglobinemia Associated with Massive Paracetamol Ingestion: A Case Report and Review of the Literature

Liesbeth Geelen, Koen Verbeke, Jietse Ryckeboer, Rogier Nieuwendijk, Peter Rogiers

Annals of Anesthesiology and Critical Care, Vol. 3 No. 2 (2018), 21 December 2020 , Page 1-5

Introduction: Paracetamol is a frequently used agent in intoxications and known to cause hepatic failure. However, methemoglobinemia secondary to paracetamol toxicity has only been described in a handful of case reports and may be an important determining factor for morbidity and mortality. Methemoglobinemia results in functional anemia with cellular hypoxia. Severe cases are usually fatal.


Case Presentation: We present a case of survival after severe methemoglobinemia in a 67-year-old female. She was admitted to the Intensive Care Unit after auto-ingestion of a large amount of paracetamol. Hemoglobin-oximetry showed a methemoglobin level of 24.6%, treated with intravenous methylene blue, exchange-transfusion, ascorbic acid, and riboflavin. Toxicological screening revealed a high plasma concentration of paracetamol (611.7 mg/L). Treatment with N-acetylcysteine (NAC) was initiated. The patient deteriorated and developed acute liver failure, but refused liver transplantation. Furthermore, she developed septic shock with multi-organ failure and bowel ischemia. In spite of her severe condition and her refusing transplantation, the patient survived. There was a complete resolution of acute liver failure and she fully recovered from her critical condition.


Conclusions: A case of survival after paracetamol-induced methemoglobinemia is presented. Paracetamol-induced methemoglobinemia seems to be a rare (but possibly under-diagnosed) condition. With this report, we would like to focus more attention on the possibility of methemoglobinemia associated with paracetamol intoxication and emphasize the possible impact on morbidity and mortality. Therefore, we think there should be a low threshold for screening for this rare but hazardous problem when there is clinical suspicion.

The Effect of Retrobulbar Block and Intravenous Atropine on Oculocardiac Reflex in Vitreoretinal Surgery

Hojjat Pourfathi, Amirhossein Fathi, Amir Abdi Rad, Haleh Farzin

Annals of Anesthesiology and Critical Care, Vol. 3 No. 2 (2018), 21 December 2020 , Page 1-4

Background: Cardiac parasympathetic stimulation due to manipulation or stimulation of ocular structures that leads to sinus bradycardia, atrioventricular block or even asystole is called oculocardiac reflex.


Objectives: This study aimed at comparing two anesthetic techniques (i.e., retrobulbar block and intravenous atropine for oculocardiac reflex prevention in vitreoretinal surgery).


Methods: Patients undergoing vitreousandretinal surgery wererandomlyselected as a source of sampling during six months, from September 2017 to February 2018. All the patients enrolled in the study after the inclusion and exclusion criteria were assigned and after getting informed consent. A total of 124 patients were evaluated and compared in two groups, each consisting of 62 patients (retrobulbar block and intravenous atropine).


Results: Essentially, there were no demonstrated differences between groups in regards to patient demographics or basic heart rate (HR). Among the patients, there was not any oculocardiac reflex (OCR) in the retrobulbar block group; however, in the atropine group, two patients (3.2%) hadOCR, and in contrast, 60 patients (96.8%) had no reflex. There was no statistically significant difference between two groups in OCR occurrence (P = 0.496).


Conclusions: In a general conclusion, there was no difference between the two methods (i.e., retrobulbar block anesthesia and intravenous atropine) in the prevention of OCR. However, based on the results, it is believed that the retrobulbar block is associated with more stable HR and lower frequency of OCR in vitreoretinal surgery.