BACKGROUND:The need of a neurostimulator for a successful nerve block was questioned in different block types after ultrasound had become standard. AIM:To determine the effect of neurostimulator use on block success in the costoclavicular block (CCB). METHODS:Sixty patients undergoing upper limb surgery were enrolled in the study. Patients using ultrasound and injection pressure manometer were divided as Group USP, and those using ultrasound, injection pressure manometer, and neurostimulator were divided as Group USPN. After block was applied, sensory and motor block levels were measured on a numeric scale. The block was considered successful when the desired score was reached or general anesthesia was not required intraoperatively. The number of successful and unsuccessful blocks for each group was summed up. The successful block rate was compared as the primary objective. Block application time, time to readiness for surgery, the number of needle passes, diaphragm paralysis rate, and complication rate were compared as secondary goals. RESULTS:Block success rate was 90% (27/30) in Group USP and 96.7% (29/30) in Group USPN. There was no statistical difference in terms of block success rate. Block application time was significantly shorter in Group USP (207.2 ± 32.7 s) when compared to Group USPN (280.9 ± 70.1 s). Other secondary outcomes were similar. CONCLUSION:Neurostimulator use did not affect block success in the CCB. Neurostimulator utilization prolonged block application time explicitly and did not change the complication rate. Ultrasound and injection pressure manometer are sufficient for a safe and successful CCB.

Analgesic requirement for the patients undergoing posterior stabilization and instrumentation surgery is important during preoperative and postoperative periods. Erector spinae plane (ESP) block has come into question in recent years for opioid-free anesthesia and also for postoperative analgesia. In this paper, we present a bilateral bi-level ESP blocks practice for a 15-year-old phenylketonuric and cognitively disabled scoliosis adolescent boy, which is the first study in the open literature to the best of our knowledge. We planned a bilateral bi-level ESP block practice for the adolescent patient scheduled to undergo the posterior instrumentation surgery involving 12 vertebral level (T3-L2). Bilateral single-injection ESP block was performed at two levels (T5 and T7) prior to incision. Intraoperatively, patient received intravenous propofol and remifentanyl infusions which were administered as total intravenous anesthetic (TIVA) agents. FLACC (face, legs, activity, cry, consolability) scale was used to follow analgesic requirement postoperatively. The analgesic need was extremely low during postoperative 24-h follow-up, and a safe postoperative analgesia was provided for the opioid side effect-free patient. Bilateral bi-level ESP block is an easily applicable and a safe technique which could be chosen for cognitively disabled scoliosis adolescent patients as a part of multimodal analgesic regimen to avoid side effects of opioids and other invasive techniques.

Background and Aims Ultrasound (US) has become standardized during peripheral nerve block (PNB). Peripheral nerve stimulator (PNS) is combined with US to avoid intraneural injection (1). Monitoring opening injection pressure with a sensor could also show intraneural injection (2). Adding PNS to US guidance did not change block success rates for different types of PNBs (3,4). There is no study in the literature that evaluate effectiveness of adding PNS to US for a successful costaclavicular brachial plexus block (CCBPB). In this randomized prospective clinical study US and injection pressure monitor (IPM) guided CCBPB is compared with US, IPM and PNS guided CCBPB. Methods 60 patients scheduled for orthopedic surgery below the elbow were enrolled in the study. Ultrasound and IPM guided group called USP and US, IPM and PNS guided group called USPN. In both groups 30 ml bupivacaine-lidocaine mixture was injected when injection pressure is less than 15 psi. In Group USPN, local anesthetic was injected after visualizing the disappearance of motor movement under 0.3 mA on PNS. Motor and sensorial block levels of the radial, ulnar, median and musculocutaneous nerves were measured. Block success rate, block performance time, number of needle passes and complication rates were compared. Results Block success rate, number of needle passes and complications were similar (table 1). Block performance time was longer in group USPN (figure 1). Conclusions Peripheral nerve stimulator is not necessary for a successful CCBPB. Using PNS increased block performance time significantly. Ultrasound and IPM are enough for a successful block with shorter procedure time in CCBPB.

Background and Aims Multiple Sclerosis (MS) is an autoimmune disease of the Central Nervous System (CNS) In our case, we present our anesthesia management applied on a MS patient. Our patient was 47 years old, 167 cm tall, 75 kg female and has been diagnosed with MS for 20 years. She had a left ankle fracture and had lower extremity surgery. Methods After visualizing the sciatic nerve in sub-gluteal region with a linear US probe in lateral decubid position, the neurostimulator was started at 2 Hz frequency at stimulation level of 0.8 mA with 0.1 ms intervals. When motor response was seen, the stimulation level was reduced to 0.4 mA. When motor response disappeared, 20 ml of 0.5% Bupivacaine hydrochloride (100 mg) was administered around the sciatic nerve with an 80 mm block needle. Afterwards, the patient was put in supine position.15 ml of 0.5% Bupivacaine (75 mg) was administered around the femoral nerve. Motor and sensory tests were applied 30 minutes after the procedure. Her vitals remained stable throughout the surgical operation. She was discharged to the orthopedic service. Results When a nondepolarizing muscle relaxant is used, resistance or sensitivity has been observed as a result of proliferation of extra-connective cholinergic receptors due to upper motor neuron plaques (3). Most of the limited studies, support US-guided peripheral nerve blocks in MS and report that this method should not be considered as a contraindication (4). Conclusions PSB can be safely applied without increasing morbidity and avoiding possible complications that may arise from the results of other anesthesia approaches.

SARS-CoV-2 is an RNA virus that can cause pneumonia leading to acute respiratory distress syndrome and pulmonary fibrosis (PF). Lung damage caused by COVID-19 can cause severe permanent respiratory failure. Ozone therapy (OT) is used as a complementary treatment during the COVID-19 pandemic. PF, which is one of the interstitial lung diseases, is also radiologically identified in COVID-19 patients. In this case report, regression and healing on thorax CT findings are presented for a severe COVID-19 pneumonia-related intensive care unit patient who was diagnosed with PF on the post-COVID ward and treated with OT on the ward and even after discharge from hospital.

In patients with acute renal failure (ARF), the differential diagnosis may be more difficult than expected. Especially in young adults without additional diseases, it may not be considered in the diagnosis that an ARF can develop on the basis of chronic renal failure (CRF). In this case, ARF developed on the basis of CRF was presented in the light of literature in a young male patient who presented to the emergency department with ARF and who used chronic wild tobacco in his anamnesis.

Background: Using a relaxant agent before an endoscopic retrograde cholangiopancreatography (ERCP) might reduce complications. Study Aims: We aimed to investigate the relaxant effects of proton pump inhibitors (PPIs) on sheep sphincter of Oddi (SO) and the mechanisms that might take part in this relaxant effect. Patients and Methods: The sheep SO was mounted in an organ bath filled with Krebs-Ringer bicarbonate solution under 1.5 g tension and the relaxant effects of PPIs were evaluated in the tissues precontracted by carbachol (10(-6) mol/l). The relaxant responses to the PPIs were tested in the presence of various blockers to enlighten the underlying mechanism by the PPIs. Results: The PPIs exerted relaxant responses in a concentration-dependent manner in the sheep SO (P < 0.05). Esomeprazole produced the strongest relaxation. The administration of atropine, indomethacin, L-NAME, methylene blue, clotrimazole, glibenclamide, and 4-aminopyridine into the organ baths did not change the relaxations induced by PPIs in vitro (P> 0.05). On the other hand, Ca+2-activated potassium channel blocker tetraethylammonium (TEA) reduced the relaxation responses created by PPIs (P < 0.05). Conclusions: The present study suggests that PPIs create relaxation on SO partially via Ca+2-activated potassium channels. PPIs, especially esomeprazole, may be beneficial during the ERCP procedure. Further clinical studies are needed to confirm our results.

Metformin is a biguanide group drug commonly used in the treatment of Type 2 DM. Even though Metformin- Associated Lactic Acidosis (MALA) is not seen very frequently, MALA has a high mortality rate. This case is presented to draw attention to efficiency of hemodialysis and CVVHDF tin the treatment of MALA. A 25-year-old female patient was brought to the emergency service with abdominal pain and confusion. In her detailed history, it was learned that she took 100 tablets of metformin (1000 mg per tablet). Hemodialysis initiated because of severe metabolic acidosis, elevation of blood urea and hyperkalemia were seen in laboratory results. After that, patient was intubated because of low Glasgow Coma Scale (GCS:3) and vasopressor agent were started due to hypotension. In the intensive care unit, blood glucose was seen 44 mg dl-1 and treated with 10% dextrose solution. CVVHDF treatment was started because of anuria and metabolic acidosis. Patient who underwent CVVHDF treatment for 12-days transferred to nephrology service on the 23rd day of the ICU admission with full consciousness and stabilized vitals. In conclusion, hemodialysis and CVVHDF should be the first treatment methods to be considered in patients with metformin-associated lactic acidosis. Renal replacement therapies, initiated rapidly and maintained for an adequate time period are promising in this high mortality rate cases.

PURPOSE:There is a common doubt regarding the application of polypropylene mesh to treat incarcerated and strangulated hernias due to the possibility of surgical site infection. We aimed to investigate the results of mesh repair of incarcerated and strangulated hernias, and to evaluate the incidence of wound infection and recurrence.METHODS:One hundred and fifty-three consecutive patients with incarcerated and strangulated hernias underwent surgery with mesh repair. The patients were divided into two groups: a resection group and a nonresection group. Fisher's exact test, the Chi-square test and independent samples t test were used to determine the statistical significance level (p < 0.05).RESULTS:While 53 patients required organ resection, the remaining 100 patients did not. The most frequently incarcerated organs were the omentum (86), small bowel (74) and colon (15). Most of the resections were performed in the omentum (36), small bowel (23) and colon (2). While five of the 53 patients (9.4%) in the resection group developed wound infections, no infections were observed in the nonresection group (p = 0.004). The infection rate in all patients was 3.3% (five of 153 patients). None of the infected patients required mesh removal. There were no mortalities or recurrence in either group.CONCLUSIONS:The findings revealed effective and safe usage of mesh along with antibiotic therapy in patients undergoing incarcerated and strangulated hernia repair.

Background/Aims: Common bile duct ligation (CBDL) in the guinea pig is a well-defined model of acalculous cholecystitis. Nitric oxide (NO) mediates smooth muscle relaxation by stimulating the activity of soluble guanylate cyclase. The aim of this study was to determine whether the NO/cyclic guanosine monophosphate pathway plays a role in gallbladder relaxant response after CBDL. Methods: Relaxant response of gallbladder muscle strips from CBDL and sham-operated guinea pigs was studied in vitro. Animals were treated with saline, aminoguanidine or an aminoguanidine + L-arginine combination in vivo. Concentration-response curves of papaverine, diethylamine/NO, YC-1, sildenafil and amrinone were obtained and relaxations in each group were calculated as the percent of the contractions induced by carbachol (10–6 M). Results: There was a significant decrease in the gallbladder muscle relaxant responses to these substances in CBDL and aminoguanidine groups compared with sham surgical controls. The decreased relaxant response was reversed by aminoguanidine + L-arginine but not by aminoguanidine alone. Conclusion: Decreased relaxant responses might be due to the reduced guanylate cyclase enzyme activity, but further studies are required.