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BACKGROUND: Brachial plexus block is useful for upper extremity surgery, and many techniques are available. The aim of our study was to compare the efficacy of axillary brachial plexus block using an ultrasound technique to the peripheral nerve stimulation technique. METHODS: 60 patients scheduled for surgery of the forearm or hand were randomly allocated into two groups (n = 30 per group). For Group 1; US, and for Group 2 PNS was applied. The quality and the onset of the sensorial and motor blockade were assessed. The sensorial blockade, motor blockade time and quality of blockade were compared among the cases. RESULTS: The time needed to perform the axillary brachial plexus block averaged is similar in both groups (p > 0.05). Although not significant statistically, it was observed that the sensory block had formed earlier in Group 1 (p > 0.05). But the degree of motor blockade was intenser in Group 1 than in Group 2 (p < 0.05). CONCLUSIONS: Ultrasound offers a new possibility for identifiying the nerves of the brachial plexus for regional anesthesia. The ultrasound-guided axillary brachial plexus block is a safe method with faster onset time and better quality of motor blockade compared to peripheral nerve stimulation technique.

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A 47-year-old Turkish male was scheduled for laparoscopic cholecystectomy under general anesthesia. The patient had 2 operations 28 and 19 years ago under general anesthesia. It was learned that the patient was administered succinylcholine during both of these previous operations and that he did not have a history of prolonged recovery or postoperative apnea. The patient had been using sertraline for 3 years before the operation. Pseudocholinesterase is a drug-metabolizing enzyme responsible for hydrolysis of the muscle-relaxant drugs mivacurium and succinylcholine. Deficiency of this enzyme from any cause can lead to prolonged apnea and paralysis following administration of mivacurium and succinylcholine. The diagnosis of pseudocholinesterase enzyme deficiency can be made after careful clinic supervision and peripheral nerve stimulator monitoring. A decrease in the activity of pseudocholinesterase enzyme and a decline in the block effect over time will help verify the diagnosis. Our patient's plasma cholinesterase was found to have low activity. Instead of pharmacological interventions that may further complicate the situation in such cases, the preferred course of action should be to wait until the block effect declines with the help of sedation and mechanical ventilation. In our case, the prolonged block deteriorated in the course of time before any complications developed.

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INTRODUCTION: Marfan syndrome is an autosomal dominant connective tissue disorder characterized by a combination of clinical manifestations in different organ systems. Patients with Marfan syndrome (MFS) whose lifetimes are extended may be encountered as acute abdomen (appendicitis) cases apart from the obligatory reasons and emergencies arising naturally out of their disease, as in the case reported. CASE PRESENTATION: In a 28-year-old Turkish male, arachnodactyly, pectus excavatum, kyphoscoliosis and, according to pulmonary roentgenogram, a density increase in the left apical field were detected. In addition, according to the echocardiographic examination, Ebstein's anomaly, mitral valve prolapse, pulmonary hypertension, and inferior deficiency of mitral, aorta, and tricuspid valves were present. The patient was planned to be operated on with the prediagnosis of acute abdomen. CONCLUSION: Taking into consideration the pathologies that may accompany MFS and the probable future complications, the patients must be closely monitored during anesthesia applications and required measures should be taken beforehand.

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BACKGROUND: Chronic renal failure is strongly associated with poor pregnancy outcome. Women dependent on hemodialysis before conception rarely achieve a successful live birth. CASE PRESENTATION: A 31-year-old multiparous Turkish woman was scheduled for cesarean section under spinal anesthesia at 37 weeks and five days' gestation because of hemorrhage due to secondary placenta previa. Spinal anesthesia with 8 mg of hyperbaric bupivacaine was successfully performed. Invasive blood pressure, central venous pressure, and heart rate were stable during the surgery. The mother returned to regular hemodialysis on the first postoperative day. CONCLUSION: Pregnancy is uncommon in women with chronic renal failure requiring chronic dialysis. Rates of maternal hypertension, pre-eclampsia, anemia, and infection in the pregnant chronic dialysis patient are high. However, our findings suggest that with careful, close, and effective monitoring preoperatively and intraoperatively, spinal anesthesia can be safely performed for cesarean section in patients undergoing hemodialysis.

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BACKGROUND: Neurofibromatosis is a syndrome caused by the abnormal deposition of neural tissues of the nervous system, endocrine system, visceral structures, and skin. On the other hand, pectus carinatum and temporomandibular joint dysfunction are illnesses that adversly affect the respiratory system and cause additional problems in airway management. CASE PRESENTATION: Fifty-eight-year-old Turkish male patient had neurofibromatosis, pectus carinatum and temporomandibular joint dysfunction. The case was due to be operated on with the diagnosis of incarcerated umbilical hernia. Spinal anesthesia was successfully performed and the duration of the surgery was 1 hour. No postoperative complications were observed and he was discharged from the hospital on the 3rd post-operative day. CONCLUSION: The anesthetic management of patients with neurofibromatosis requires attention to all possible abnormalities and associated disturbances. Furthermore, the presence of pectus carinatum and temporomandibular joint dysfunction also increase the potential risks. The operation was successfully completed with spinal anesthesia that was carefully applied upon taking the required measures and considering all pathologies that may accompany the case and complications that may occur.

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BACKGROUND: Even if carried out under optimal conditions, postdural puncture headache is still a frustrating and unpleasant complication in spinal anesthesia. This syndrome has an estimated incidence from less than 1% to about 5% of patients undergoing spinal anesthesia, even in the highest risk subset, the young, female, and pregnant population. CASE PRESENTATION: In our two female cases, headaches started following spinal anesthesia on the 11th and 14th hours, respectively. No response was obtained from patients diagnosed with postdural puncture headache with classical treatments such as bed rest, hydration, oral analgesic, and caffeine combination as well as intravenous theophylline application. The treatment of oral pregablin, commonly used for cases that rejected epidural blood patch, caused a significant decrease in headache severity. Later, the two cases whose headaches were completely resolved were discharged from the hospital on the post-operative 7th day. CONCLUSION: Postdural puncture headache is one of the most common complications of spinal anesthesia. Cerebral spinal fluid leakage into the epidural space has been proposed as the main mechanism responsible for this syndrome. Multiple methods of treatment have been applied with wide-ranging results. We detected that oral pregabalin application caused a significant decrease in the difficult and severe postdural puncture headaches of both our cases who did not respond to conventional treatments.

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Migraine is defined as a disorder characterized by intermittent headache episodes, accompanied with nausea, photophobia and/or phonophobia. Pharmacological therapy is in accordance with the severity of pain and may include acute, prophylactic and most commonly both approaches. The aim of the acute therapy is stopping or alleviating the attack or progression of the pain and, in case of a migraine attack that has started, lessening the pain. Preventive therapy aims to reduce attack frequency and severity. This study was designed to evaluate the effect of dietary factors in the management and prophylaxis of migraine in cases diagnosed as having migraine disorder according to the 2003-IHS criteria. Fifty consecutive Turkish patients (13 men, 37 women) with diagnosis of migraine were randomly divided into two groups for treatment protocols with the written approval of the ethics committee. The cases in the first group (K) were treated with metoprolol, vitamin B(2) (riboflavin), and naproxen sodium just at the aura or at the beginning of the attacks. The cases in the second group (D) were also supplied with a comprehensive dietary list arranged by our algology clinic in addition to the same medication protocol. There were no demographic differences between the cases (P > 0.05). VAS scores were lower in group D than group K (P < 0.01), and also the migraine attack frequencies and monthly amounts of analgesic consumed amounts were also statistically significantly less. It was concluded that beta-blocker and riboflavin therapy supplemented with a convenient diet with appropriate alternatives in patients with migraine disorder was associated with statistically significant decreases in headache frequency, intensity, duration and medication intake.

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OBJECTIVE: Failed back surgery syndrome is characterized by the presence of intractable pain and varying degrees of functional incapacity after lumbar spine surgery. Because the mechanisms that cause pain are variable, treatment of this syndrome is quite difficult, and one of the most common methods that is used for treatment nowadays is epidural injection. This research evaluates the analgesic efficacy of addition of oral gabapentin treatment to epidural corticosteroid application in patients with failed back surgery syndromes. METHODS: Forty-two patients, including 23 females and 19 males, with failed back surgery syndrome who had been previously operated on at least twice due to lumbar disc herniation were randomly divided into two groups. Following epidural application of a single dose of methylprednisolone in the first group of patients (Group K), an oral medical treatment containing naproxen sodium, tizanidine, and vitamin B and C complex, was devised to be applied for one month. For the second group, oral gabapentin was added to the same treatment regime (Group G). Pain levels were evaluated by a visual analog scale for straight leg raise before, during, and after treatment, as well as in the first and third months. RESULTS: There was no demographically significant difference between the patients (P > 0.05). After the beginning of treatment, it was observed that the pain level in Group G patients regressed earlier and that it progressed at a significantly lower level (both in the first and third month controls). CONCLUSION: It was concluded that addition of oral gabapentin to epidural corticosteroid application in patients with failed back surgery syndromes was effective in ameliorating pain at an early stage without significant side effects.

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OBJECTIVE: To assess the levels and clinical significance of high sensitive(hs)-CRP (C-reactive protein), IL-6(interleukin-6), TNF-alpha(tumor necrosis factor-alpha), homocysteine, folic acid and vitamin B12 in normotensive healthy pregnant women, mild and severe preeclamptic patients, and to evaluate the correlations between these markers and the severity of preeclampsia and fetal birth weight. STUDY DESIGN: Using a cross-sectional study design, hs-CRP, IL-6, TNF-alpha, homocysteine and vitamin B12 were measured in the third trimester of pregnancy from normotensive healthy women with uncomplicated pregnancies (n = 62), mild (n = 61) and severe (n = 60) preeclamptic patients. RESULTS: There were statistically significant differences between three groups for hs-CRP (p = 0.012), TNF- alpha (p = 0.046), IL-6 (p = 0.015), homocysteine (p < 0.001) and fetal birth weight (p < 0.001). Fetal birth weights in mild (2477 +/- 746) and severe (2435 +/- 768) preeclamptic patients were significantly lower than controls (3485 +/- 365) (p < 0.001). No significant difference was found between the three groups for folic acid (p = 0.066) and vitamin B12 (p = 0.286). Bonferroni adjusted multiple comparison test showed that the statistical differences with respect to TNF-alpha, IL-6 and homocysteine were mainly created by control and severe preeclampsia groups. Hs-CRP levels still remained higher in severe preeclampsia patients than mild preeclampsia and normotensive patients except for overweight patients in the previous two groups after Bonferroni post hoc adjustment test. CONCLUSION: Elevated maternal serum levels of hs-CRP, TNF- alpha, IL-6 and homocysteine in preeclamptic women correlate with fetal birth weight in the early third trimester.

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INTRODUCTION: Pseudocholinesterase (butyrylcholinesterase) is a drug metabolizing enzyme responsible for hydrolysis of the muscle relaxant drugs succinylcholine and mivacurium. Deficiency from any cause can lead to prolonged apnoea and paralysis following administration of succinylcholine and mivacurium. CASE PRESENTATION: Within the last two years we have had four patients who have had prolonged apnea following the administration of mivacurium. It was understood that one was congenital and the other three due to various reasons had enzyme-deficiencies. In all four of the patients, the prolonged blocks deteriorated. CONCLUSION: Prolonged blocks may be encountered due to mivacurium use. The diagnosis of pseudocholinesterase enzyme deficiency can be given after a careful clinic supervision and peripheral nerve stimulator monitoring. A decrease in the activity of pseudocholinesterase enzyme and improvement in neuromuscular function will help verifying our diagnosis. Instead of pharmacological applications that may further complicate the situation, what should be done in such patients is to wait until the block-effect goes down by the help of sedation and mechanical ventilation.

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INTRODUCTION: Psoas abscess, a collection of pus in the iliopsoas compartment that has traditionally been classified as primary and secondary according to its origin. CASE PRESENTATION: 48-year-old Turkish female presented to the department with fever, weakness and pain in the bilateral pelvic region. In contrast abdominal magnetic resonance, a collection compatible with the hyperintense abscess was observed in the right and left ilipsoas muscles. It was decided to simultaneously drain both abscesses of the case who had been using oral and intravenous broad-spectrum antibiotics for two months. No factors were detected in the microbiological reviews made on the abscess fluid of the operated case. The case was also examined in terms of tuberculosis and Crohn's disease and no findings were encountered to rise suspicions of such diseases. CONCLUSION: An abscess of the psoas muscle was a rare entity. However, with the increased use of computed tomography scans to evaluate patients with unknown foci of sepsis, psoas abscesses now are diagnosed and reported more frequently. What should be done after diagnosis are, if possible, defining the infection factor, selecting the appropriate antibiotics and draining the abscess openly or percutaneously.

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BACKGROUND AND GOALS: A relatively high incidence of postoperative nausea and vomiting (PONV) occurs in patients undergoing a laparoscopic cholecystectomy. Prophylaxis of PONV is usually achieved with a single-dose antiemetic drug administered during the surgical procedure. The aim of the current study was to compare the antiemetic activity of different 5-hydroxytryptamine-3 receptor antagonists with that of metoclopramide. MATERIALS AND METHODS: In a randomised, double-blind study, 75 patients received the following: Group M, 10 mg metoclopramide; Group K, 40 mcg . kg(-1) granisetron; and Group Z, 15 mcg . kg(-1) ondansetron intravenously (IV) diluted in 20 cc 0.9% NaCl (n = 25 of each) i.v. immediately before the induction of anesthesia. The standard general anesthetic technique, which consisted of sevoflurane in air-oxygen and a fentanyl perfusion, was used. Nausea, vomiting, and safety assessments were performed continuously during the first 24 hours after anesthesia. RESULTS: There were no statistically significant differences for demographic data, American Society of Anesthesiology (ASA), operation duration, or anesthesia time among the three groups (P > 0.05). Evaluated nausea and vomiting scores in the first 3-hour period revealed that each of the drugs had a similar antiemetic effect (P > 0.05). Nausea and vomiting scores, evaluated between the 4-24 hours, also revealed that the group M scores were obviously higher than groups K and Z (P < 0.001). A comparison of incidences of dose administrations were statistically not significant among the groups (P > 0.05). CONCLUSIONS: Granisetron, when given prophylactically, resulted in a significantly lower incidence of PONV than metoclopramide and ondansetron, whereas metoclopramide was ineffective. Garnisetron may be an effective treatment in the proflaxy of PONV.

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In this paper, we report a case of vertebral hemangioma during pregnancy in a 21-year-old woman presenting with paraparesis of rapid onset. An emergency MRI scan of the dorsal spine showed a lesion of the ninth thoracic vertebra with extradural extension and marked spinal cord compression. A cesarean section was done, and this was followed by emergent laminectomy. Her symptoms and neurologic deficits quickly improved. The etiopathogenesis, clinical, radiological features, and treatment modalities are discussed in the light of the literature.

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