Medicine

Autistic children are very difficult to manage in the hospital setting because they react badly to any change in routine. We describe a case of 10-year-old male patient with severe autism undergoing orchidopexy and circumcision. Following premedication, anesthesia was induced with remifentanil, propofol, atracurium, and maintained with total intravenous anesthesia (propofol and remifentanil). The Bispectral Index System was monitored for determination of the depth of anesthesia. After surgery, all infusions were discontinued. The patient was then transferred to the postanesthetic care unit. There were no adverse events observed during the anesthetic management. The patient was discharged from the hospital on the second postoperative day. Bispectral Index System-guided Total Intravenous Anesthesia can provide some advantages for patient with autism, such as hemodynamic stability, early and easy recovery, to facilitate faster discharge, to optimize the delivery of anesthetic agents, t...

Valproic acid (VPA) intoxication incidence is increasing, because of the use of VPA in psychiatric disorders. The most common finding of VPA intoxication is central nervous system depression which leads to coma and respiratory depression. Pancreatitis, hyperammonemia, metabolic, and bone marrow failure (thrombocytopenia and leukopenia) have also been described. Treatment is mainly supportive. We present the case of an 18-year-old female patient, who made an attempt to autolysis with VPA. Our patient's VPA plasma level was very high (924 μg/mL), confirming that it was a severe intoxication. Our treatment including levocarnitine (50 mg/kg per day for 3 days), and high-flux hemodialysis was performed for four hours. The patient's hemodynamic status and mental function improved in conjunction with the acute reduction in VPA concentrations. Her subsequent hospital course was complicated by transient thrombocytopenia and levocarnitine induced hypophosphatemia. By day 6, the patien...

To compare the effects of magnesium sulfate and ketamine on postoperative pain and total morphine consumption in a placebo-controlled design. One hundred and twenty women scheduled for total abdominal hysterectomy were included in this prospective, randomized, double-blind study. Postoperatively, when the Numeric Pain Rating Scale (NPRS) was four or more, IV-PCA morphine was applied to all patients. The patients were randomized into three groups: Group K ketamine, Group M magnesium, and Group C saline received as infusion. Total morphine consumption for 48h, pain scores, adverse effects, and patients' satisfaction were evaluated. Total morphine consumption was significantly lower in Group K (32.6±9.2 mg) than in Group M (58.9±6.5 mg) and in Group C (65.7±8.2 mg). The satisfaction level of patients in Group K was higher than the other two groups (p<0.05). Pruritus and nausea were observed more frequently in Group C. CONCLUSİON: The addition of ketamine to IV-PCA morphine reduc...

Objectives: In this prospective, randomized, double-blind, controlled study, we compared the effects of two different doses of fentanyl (10 μg or 25 μg) given intrathecally in addition to 0.5% levobupivacaine for cesarean section. Methods: Eight hundred, ASA I-II parturients, who were scheduled for elective cesarean section, were enrolled in the study. They were randomly allocated into three groups. Group I received 0.5% levobupivacaine; Group II received 0.5% levobupivacaine plus 15 μg fentanyl; Group III received 0.5% levobupivacaine plus 25 μg fentanyl intrathecally. Ephedrine was administered as a bolus dose (0.1 mg/kg), and then the continuous infusion was initiated. The rate of infusion was maintained with respect to baseline systolic blood pressure until umbilical cord clamping. We recorded maternal sistolic blood pressure, heart rate, total ephedrine dose, fetal Apgar scores (at 1st and 5th min), and umbilical cord blood parameters. Other side effects, such as hypotension, nausea/vomiting, bradycardia, etc. were also noted. Results: Bolus, infusion and total ephedrine doses were significantly lower in Group III when compared with the other groups (P<0.05). The incidences of hypotension in the I, II, and III groups were 17.30%, 13.38%, and 11.63%, respectively. There was no significant difference between the three groups regarding the Apgar scores at the 1st or 5th min, umbilical arterial or venous pH. There was no difference in the incidence of other side effects among the three groups. We conclude that the addition of 25 µg fentanyl to adjusting the dose of levobupivacaine to a patient's height decreases the ephedrine requirement without additional side effects and adverse neonatal outcomes when compared with the other groups. The levobupivacaine doses as determined by the length of the patients' and the use of the appropriate fluid resuscitation therapy with an infusion of ephedrine can be used effective methods.

Challenging differential diagnosis Background: Carbon monoxide (CO) poisoning is commonly seen during the winter season in Turkey due to use of charcoal stoves and water heaters, but narghile smoking is a rare cause of CO poisoning. Case Report: In this paper, we report a CO poisoning case caused by narghile smoking. The patient was admitted to the ED with nausea, dizziness, vertigo, and syncope. Conclusions: The diagnosis of CO poisoning depends on suspicious anamnesis. The major treatment of CO poisoning is oxygen supply.

We present a case of bilateral pneumothorax (PNX) and pneumo-mediastinum that developed after manual ventilation with a bag valve device during transport. A 65-year-old female patient underwent a lumbar disc stabilization surgery under general anesthesia. Manual ventilation with a bag valve device was performed during transport to imaging center. However, the patient developed bilateral pneumothorax and pneumo-mediastinum. The chest tube was inserted, and the patient made a rapid recovery. The chest tube was removed on the third postoperative day, and she was discharged uneventfully on the sixth postoperative day.

Background: Single-shot spinal analgesia with bupivacaine plus a short-acting opioid is an effective technique for pain control in labor, and it is particularly useful in the active phase. We compared the effects of adding two different doses of fentanyl (15 μg or 25 μg) to intrathecal bupivacaine, and to evaluate the impacts on duration of labor analgesia, newborn, and side effects. Method: One hundred and five multiparous healty women in advanced labor (cervical dilatation ≥ 7 cm, and pain score >5), requesting labor analgesia were included in the study. They were randomly allocated into three groups. Group I received 2.5 mg bupivacaine; Group II received 2.5 mg bupivacaine plus 15 μg fentanyl; Group III received 2.5 bupivacaine plus 25 μg fentanyl intrathecally. The patients' demo figure characteristics, hemodynamic parameters, pain scores (by using visual analogue scale-VAS), analgesic requirements, duration of analgesia (the time from intrathecal injection to the return of pain >4), fetal Apgar scores (at 1 st and 5 th min), and maternal and neonatal side effects were recorded. We used analysis of variance (ANOVA), post hoc test with Bonferroni adjustment, and chi-square test for statistical analysis; the analyses were performed using the SPSS-16 software. Given a significant level of 0.05, overall and pair-wise comparisons were made. Results: The mean VAS scores were significantly lower in Group II than in the other two groups at 5, 15, 30 min, and 1 h (P<0.001). There was no difference among Group I and Group III. The VAS scores were significantly higher in the Group III than in the other two groups at 2 (P=0.005) and 3 h (P<0.001). The incidence of adverse events was similar in all three groups. There was no difference in Apgar scores at 1 min, but Apgar score at 5 min was higher in Group 2 (P=0.02). Conclusion: In this study, we found that 2.5 mg of bupivacaine plus 15 μg fentanyl is more preferable option for SSA.

The number of elderly patients followed in intensive care units is increasing day by day. In the literature, there are a limited number of studies covering patients aged 90 and over. We aimed to investigate the epidemiologic characteristics and clinical outcomes of elderly patients aged ≥90 years admitted to intensive care unit. Materials and Methods: In this study, medical records of patients aged ≥90 years admitted to intensive care unit, between January 2015 and January 2018, were retrospectively reviewed. Demographic data, reason for admission (medical or surgical), Acute Physical and Chronic Health Evaluation II (APACHE II) score, need for and duration of mechanical ventilation, need for inotropic agents, duration of intensive care unit stay, and mortality rate were recorded. Results: A total of 107 nonagenarians were evaluated. The mean age of the patients was 92.65 ± 2.36 years, and 72 of them were women. The mean score of APHACHE II was 23.6 ± 7.2. Most patients were admitted due to medical reasons (n = 82, 76.63%). Sixty-four of the medical patients, and four of the surgical patients had died in the intensive care unit (n = 68, 63.55%). APACHE II score, need for and the duration of mechanical ventilation, need for inotropic agents, the duration of intensive care unit stay, and the mortality rate were higher in medical patients than in surgical patients. Conclusions: The mortality rates of the medical patients were high; nevertheless, we believe that surgical patients more benefit from intensive care unit follow-up.

Objective: The code blue call is used to alert the Code Blue team for patients with cardiac or respiratory arrest. The purpose of this study is to evaluate the time, the locations, and the outcomes of code blue calls. We also aimed to determine the rate of false code blue calls, and demographic data of the patients. Material and Methods: In this study, we retrospectively scanned the code blue call forms in our hospital between January 2017 and January 2018. The demographic data of the patients, the arrival time of the team, the time, the locations, and the outcomes of the calls, and the rate of false code blue calls were recorded. Results: We had 225 code blue calls in the study period. The mean arrival time of the team was 1.97±0.72 min. Most of the code blue calls were given in Palliative Care Unit (76 patients, 33.77 %), followed by Internal Medicine Services (54 patients, 24 %), and Department of Pulmonary Diseases (36 patients, 16%). The rate of false code blue calls was found to be 13.33 %. Most of the code blue calls (140 calls, 62.22 %) were during off times. A hundred patients had died (44.44 %); 88 patients had been admitted to the ICU (39.11 %); and 7 had been continued care in ward (3.11 %) by a successful intervention. Conclusion: Giving more blue code calls during off-hours and the absence of night duty doctor at the services, especially in rural hospitals like ours, emphasizes the importance of this system.

Th e present study aimed to compare anesthesia with sevofl urane-N 2 O and midazolam-remifentanil in terms of hemodynamic parameters and safety in low-birth-weight (LBW) premature infants undergoing diode laser photocoagulation (DLP) for retinopathy of prematurity (ROP). Materials and methods: A total of 91 infants undergoing DLP for ROP were enrolled in this study. All of the infants were established with LBW (<2000 g) and were preterm (gestational age of <32 weeks; age range: 0-28 days). Th e infants were intubated in the neonatal intensive care unit (NICU) and were randomly divided into 2 groups. For Group 1 (n = 47), anesthesia was induced with 45% O 2 + 55% N 2 O + 3%-5% sevofl urane to which 1 μg kg-1 fentanyl was added, and it was then maintained with 45% O 2 + 55% N 2 O + 1%-3% sevofl urane. For Group 2 (n = 44), anesthesia was induced with 0.1 mg kg-1 midazolam + 2 μg kg-1 remifentanil, and it was then maintained with a concomitant infusion of 0.1-0.2 mg kg-1 h-1 midazolam + 0.125-0.2 μg kg-1 min-1 remifentanil. Hemodynamic data, perioperative complications, and extubation time were recorded. Th e patients were transported to the NICU in the postoperative period without being extubated. Results: No signifi cant diff erences were observed between the groups in terms of demographic data, perioperative complications, and extubation time. Heart rate values were signifi cantly lower in both groups at diff erent measurement times with respect to baseline values. Mean arterial pressure values were signifi cantly higher in Group 1 only at 60 min in comparison to Group 2. Conclusion: Anesthesia with sevofl urane + O 2 + N 2 O and with remifentanil + midazolam were established to be safe anesthetic approaches for LBW premature infants.

The aim of the study was to evaluate the cardiorespiratory and clinical effects of propofol and remifentanil anesthesia compared to propofol and fentanyl anesthesia during ovariohysterectomy in dogs. Sixteen healthy dogs were randomly assigned to two groups. After premedication with atropine, anesthesia was induced with propofol and maintained with the infusion of propofol at a dose of 0.5 mg/kg/min. Once stable anesthesia was achieved, 1 µg/kg remifentanil or 2 µg/kg fentanyl was administered intravenously, and infusion was begun at a dose of 0.6 µg/kg/min and 0.5 µg/kg/min, respectively. Cardiorespiratory variables were recorded after propofol administration combined with remifentanil or fentanyl at 10-min intervals, and the quality of anesthesia, return of spontaneous ventilation, head lift and sternal position were also recorded. Apnea was observed after remifentanil and fentanyl administration in all dogs. Heart rate, systolic and mean arterial blood pressures tended to decrease rapidly after remifentanil and fentanyl administration, and during the first 20 min, in both groups. Although the difference between times was significant, the difference between groups was statistically insignificant. Recovery periods were longer in the fentanyl group than in the remifentanil group. The administration of propofol with remifentanil or fentanyl provides a stable haemodynamic state and depth of anesthesia with a constant infusion, and remifentanil could be preferred to fentanyl when aiming a rapid recovery period.

ABSTRACT
PURPOSE: To compare the effects of magnesium sulfate and ketamine on postoperative pain and total morphine consumption in a placebo-controlled design.
METHODS: One hundred and twenty women scheduled for total abdominal hysterectomy were included in this prospective, randomized, double-blind study. Postoperatively, when the Numeric Pain Rating Scale (NPRS) was four or more, IV-PCA morphine was applied to all patients. The patients were randomized into three groups: Group K ketamine, Group M magnesium, and Group C saline received as infusion. Total morphine consumption for 48h, pain scores, adverse effects, and patients’ satisfaction were evaluated. RESULTS: Total morphine consumption was significantly lower in Group K (32.6±9.2 mg) than in Group M (58.9±6.5 mg) and in Group C (65.7±8.2 mg). The satisfaction level of patients in Group K was higher than the other two groups (p<0.05). Pruritus and nausea were observed more frequently in Group C.
CONCLUSİON: The addition of ketamine to IV-PCA morphine reduces the total consumption of morphine without psychotic effects; however, magnesium did not influence morphine consumption.
Key words: Analgesia, Patient-Controlled. Morphine. Magnesium Sulfate. Ketamine.

Valproic acid (VPA) intoxication incidence is increasing, because of the use of VPA in psychiatric disorders. The most common finding of VPA intoxication is central nervous system depression which leads to coma and respiratory depression. Pancreatitis, hyperammonemia, metabolic, and bone marrow failure (thrombocytopenia and leukopenia) have also been described. Treatment is mainly supportive. We present the case of an 18-year-old female patient, who made an attempt to autolysis with VPA. Our patient’s VPA plasma level was very high (924 𝜇g/mL), confirming that it was a severe intoxication. Our treatment including levocarnitine (50 mg/kg per day for 3 days), and high-flux hemodialysis was performed for four hours. The patient’s hemodynamic status and mental function improved in conjunction with the acute reduction in VPA concentrations. Her subsequent hospital course was complicated by transient thrombocytopenia and levocarnitine induced hypophosphatemia. By day 6, the patient’s laboratory values had completely normalized, and she was transferred to an inpatient psychiatric facility for continuing therapy.

Eff ects of high water cadmium sulphate hydrate (3CdSO4 * 8H2O) (CdSO4) levels on the expression of serum proteins and tissue histopathology of the European chub (Leuciscus cephalus) was investigated. Three groups of fish (control, 1 st , and 2 nd ), each containing 10 animals, were placed in separate tanks containing no, 1 mg/L, and 2 mg/L CdSO4, respectively, for 10 days. At the end of the study period, blood samples were taken and sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) was performed. Fish tissue samples were taken then routinely processed and stained with hematoxylin and eosin to observe histopathological changes. Depending on the increasing concentration of CdSO4, a gradual decrease in protein bands was determined. Inhibition of 35.3 kilodalton (kD) and 100.5 kD proteins in the 1st group and of 44.5 kD and 47.3 kD proteins in the 2 nd group was detected. Microscopic examination revealed degeneration in the secondary lamellar epithelia, hydropic degeneration and necrosis in chloride cells of the fish gill in CdSO4 given groups. Hydropic degeneration and necrosis were also observed in light to severe levels in the liver depending on the groups. It was concluded that CdSO4 has toxic eff ects on the expression of serum proteins and causes degenerative changes on gill and liver morphology in Leuciscus cephalus.

The toxicity of lead in the liver seems to relate to the generation of reactive oxygen species (ROS). Caff eic acid phenethyl ester (CAPE), a fl avonoid like compound, is one of the major components of honeybee propolis which has been demonstrated to have antioxidant, free radical scavenger. This study was designed to investigate the protective eff ects of the CAPE against lead acetateinduced hepatotoxicities in mice. A total of 25 mice were equally divided into 5 groups which were: 1 st control, 2 nd injected with intraperitoneally (IP) %1 ethanol. 3 rd injected with IP CAPE, 4 th injected with IP lead-acetate, 5 th injected with IP CAPE + lead acetate. Experimental animals were decapitated at the end of the study. Following systemic necropsies of the animals, tissue paraffin blocks were prepared and cut into 5 μm thick sections for hematoxylen-eosin staining. The samples were later monitored under a light microscope for histopathological changes. In conclusion, livers which were treated with 1% ethanol and CAPE were similar to control group. In the group which was treated with lead some degenerations and necrosis were observed. In the group which was treated with CAPE and lead, levels of necrosis and degenerations was observed in less degree.

In this study, Capoeta capoeta was used to determine plasma total sialic acid (TSA), nitric oxide (NO) and malondialdehyde (MDA) levels in fishes applied glyphosate. The animals in group I in normal water environment, group II and group III sequentially in aquariums added 0.01 and 0.02 mg/L glyphosate were waited for 10 days. Plasma TSA levels in group II animals were higher than group I and group III. There was not significantly difference between groups in terms of plasma NO levels. MDA levels were determined to be higher in group III compared the other two groups.

Aim: Fluoride intake in high doses has toxic effects on various organs. Chronic fluorosis results in tubular degenerations, inflammation, fibrosis, parenchymatous nephritis, cloudy swellings, and dilations of convoluted tubules. In addition to these effects, fluoride causes deteriorative effects on the skeleton, teeth, and soft tissues. The goal of this study was to examine the impacts of chronic fluorosis on the liver tissues of mice.