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    Comparison of the effects of remifentanil and alfentanil on cardiovascular response to nasotracheal intubation: A prospective, randomized, double-blind study
    (Excerpta Medica Inc, 2005) Olmez, G; Ozyilmaz, MA; Menekse, A
    Background: Nasotracheal intubation is often necessary in patients undergoing elective or emergency maxillofacial surgery. Previous studies have suggested that the increase in blood pressure after nasotracheai intubation is significantly greater than the increase after orotracheal intubation. Many drugs, including narcotic analgesics, are effective in modifying cardiovascular responses to orotracheal intubation. Objective: The effects of remifentanil and alfentanil on the cardiovascular responses to nasotracheal intubation were compared in healthy patients scheduled to undergo surgery. Methods: This prospective, randomized, double-blind study was conducted at the Department of Anesthesiology and Reanimation, Faculty of Medicine, Dicle University, Diyarbakir, Turkey. Patients aged 16 to 65 years scheduled to undergo elective maxillofacial surgery and who were American Society of Anesthesiologists status I or II were randomly assigned to receive remifentanil 1 mu g/kg in 10 mL, saline over 30 seconds followed by an infusion of 0.5 mu g/kg center dot min, or alfentanil 10 mu g/kg in 10 ml, saline over 30 seconds followed by an infusion of saline. Anesthesia was then induced with propofol, cisatracurium, and 1% isoflurane with 66% nitrous oxide in oxygen. Heart rate (HR) and systolic and diastolic arterial pressures (SAP and DAP, respectively) were measured noninvasively at 2 minutes before general anesthesia induction (baseline); 2 minutes after induction; and 1, 3, and 5 minutes after nasotracheal intubation. Patients were monitored for cardiac changes using electrocardiography. Results: Forty consecutive patients were enrolled in the study. Twenty patients (11 males, 9 females; mean [SD] age, 27.7 [12.6] years) received remifentanil, and 20 patients (12 males, 8 females; mean [SD] age, 31.5 [17.2] years) received alfentanil. Two minutes after anesthesia induction, mean (SD) arterial pressures decreased significantly from baseline in the remifentanil group (changes, 22 [8]/11 [6] mm Hg) and the alfentanil group (changes, 10 [9]/12 [8] mm Hg) (both, P < 0.05). Changes in SAP and DAP followed a similar pattern in both groups, but SAP was significantly lower in the remifentanil group compared with that in the alfentanil group throughout the study period (all, P < 0.05). After 1 minute of intubation, DAP was significantly lower in the remifentanil group compared with that in the alfentanil group (66 [9] mm Hg vs 73 [20] mm Hg; P < 0.05). Compared with baseline, HR was decreased significantly in both groups throughout the study (all, P < 0.05). Except SAP in the alfentanil group, SAP, DAP, and HR were increased I minute after intubation compared with preintubation values. However, SAP, DAP, and HR remained significantly lower compared with baseline values throughout the study period in both groups (all, P < 0.05) except DAP at I minute after intubation in the alfentanil group. Five patients in the remifentanil group and 2 patients in the alfentanil group required treatment of hypotension. None of the patients in either group required treatment of bradycardia. Conclusions: In this study in healthy surgical patients aged 16 to 65 years, remifentanil 1 mu g/kg given over 30 seconds, followed by a remifentanil infusion of 0.5 mu g/kg center dot min, was similarly effective compared with alfentanil 10 mu g/kg in attenuating the pressor response to nasotracheal intubation, but the incidence of hypotension in patients administered remifentanil was high.
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    Effects of high-dose propofol on succinylcholine-induced fasciculations and myalgia
    (Wiley, 2003) Kararmaz, A; Kaya, S; Turhanoglu, S; Ozyilmaz, MA
    Background: The purpose of this prospective study was to determine the effects of high-dose propofol on the incidence of fasciculations and myalgia, and to evaluate changes in creatine kinase levels following the administration of succinylcholine in 90 women who underwent laparoscopy. Methods: Patients were randomly assigned to one of three groups. Induction of anesthesia was performed with thiopentone 5 mg kg(-1) in Group I (n = 30), propofol 2 mg kg(-1) in Group II (n = 30), and propofol 3.5 mg kg(-1) in Group III (n = 30). Then succinylcholine 1 mg kg(-1) was administered to the patients for intubation. Results: Fasciculation was absent in 20% of Group III patients, and no vigorous fasciculation occurred in this group. Furthermore, the severity of fasciculation in Group III was significantly lower than in the other two groups (P = 0.01). Seventy per cent of patients had no myalgia in Group III, 39.2% in Group II and 37% in Group I (P = 0.007). Severity of myalgia was also significantly lower in Group III compared with the other two groups (P = 0.011). Post-operative creatine kinase levels were significantly higher than their baseline values in Groups I and II (P < 0.0001). Conclusion: Administration of propofol 3.5 mg kg(-1) is effective in reducing fasciculations and myalgia after succinylcholine.
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    Intraoperative intravenous ketamine in combination with epidural analgesia: Postoperative analgesia after renal surgery
    (Lippincott Williams & Wilkins, 2003) Kararmaz, A; Kaya, S; Karaman, H; Turhanoglu, S; Ozyilmaz, MA
    We designed this double-blinded, randomized, controlled study to evaluate the effect of small-dose ketamine IV in combination with epidural morphine and bupivacaine on postoperative pain after renal surgery. An epidural catheter was inserted, and the administration of morphine and bupivacaine was started before surgery. Forty patients were assigned to one of two groups (ketamine or control). The ketamine group was administered a ketamine bolus and infusion during surgery. The median visual analog pain scale (VAS) scores at rest were significantly lower in the ketamine group during the first 6 h (P < 0.01). VAS pain scores on coughing were also significantly lower in the ketantine group (P < 0.01). Cumulative postoperative total analgesic consumption was less in the ketamine group on Days 1 and 2 (P < 0.001). The first analgesic demand time was shorter in the control group (9.2 +/- 11.5 min) than in the ketamine group (22.3 +/- 17.1 min) (P < .0001). The incidence of nausea and pruritus was more frequent in the control group (P < 0.05). In conclusion, postoperative analgesia was more effective when spinal cord and brain sensitization were blocked by a combination of epidural morphine/ bupivacaine and IV ketamine.
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    Low-dose bupivacaine-fentanyl spinal anaesthesia for transurethral prostatectomy
    (Wiley, 2003) Kararmaz, A; Kaya, S; Turhanoglu, S; Ozyilmaz, MA
    We evaluated the effect of low-dose bupivacaine plus fentanyl administered intrathecally in elderly patients undergoing transurethral prostatectomy. Patients were randomly assigned to one of two groups. Group F received plain bupivacaine 4 mg with 25 mug of fentanyl and sterile water to a total of 1.5 ml, and Group B received only 0.5% plain bupivacaine 7.5 mg for spinal anaesthesia. Sensory block was adequate for surgery in all patients. The mean level of motor block was higher and the duration of motor block was longer in Group B (p<0.0001). Hypotension and shivering were significantly more common in Group B (p<0.05). The addition of fentanyl 25 mug to plain bupivacaine 4 mg provides adequate analgesia for transurethral prostatectomy with fewer side-effects in elderly patients when compared with the conventional dose of bupivacaine.
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    Oral ketamine premedication can prevent emergence agitation in children after desflurane anaesthesia
    (Blackwell Publishing Ltd, 2004) Kararmaz, A; Kaya, S; Turhanoglu, S; Ozyilmaz, MA
    Background: The purpose of the present study was to determine whether oral ketamine premedication affected the incidence of emergence agitation in children. Methods: Thirty minutes before induction of anaesthesia, 80 children who were undergoing adenotonsillectomy with or without bilateral myringotomy and insertion of tubes received either ketamine 6 mg(.)kg(-1) per oral in group K or sour cherry juice alone in group C. Anaesthesia was maintained with desflurane. Emergence and recovery times were recorded. Tramadol was used for postoperative analgesia. Fentanyl (1 mug(.)kg(-1)) was administered for the treatment of emergence agitation or severe pain that still continued after tramadol administration. Postoperative behaviour was evaluated using a 5-point agitation scale. Results: The incidence of emergence agitation was 56% in group C, and 18% in group K (P = 0.001). There was no significant difference with respect to emergence times except from time to eye opening that was significantly longer in group K (P < 0.0001). Conclusion: Oral ketamine premedication reduced the incidence of postanaesthesia emergence agitation in children without delaying recovery.
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    Which administration route of fentanyl better enhances the spread of spinal anaesthesia: intravenous, intrathecal or both?
    (Blackwell Munksgaard, 2003) Kararmaz, A; Kaya, S; Turhanoglu, S; Ozyilmaz, MA
    Background: To enhance the spread of spinal anaesthesia, fentanyl may be administered intrathecally (i.t.) or intravenously (i.v.). The purpose of this prospective study was to investigate the effects of fentanyl administered i.v., i.t. or concurrently by both i.v. and spinal routes on the spread of spinal anaesthesia. Methods: Sixty patients were randomly assigned to one of three groups. In Groups I and II, spinal anaesthesia was performed with plain bupivacaine 10 mg plus 20 mg fentanyl and in Group III with 10 mg of plain bupivacaine. The level of first peak sensory block was marked. In addition, fentanyl 50 mg was administered i.v. in Groups II and III or by saline in Group I after the sensory blockade reached the highest dermatomal level. Ten minutes after i.v. administration, the level of the second peak sensory block was marked. The distance between the first- and second-highest levels of sensory block was measured. Results: The distance between the first- and second-highest level of sensory block was significantly different for the three groups: Group II ( 5.8 +/- 2.6 cm)> Group III (2.9 +/- 2.1 cm) > Group I ( - 0.15 +/- 1.7 cm). The peak dermatomal level of spinal block was significantly higher in Group II [ T4 ( T3 - T7)] than in Group I [ T6 ( T4 - T9)] and Group III [ T6 ( T4-T8)]. In Groups I and II the sensory block regressed to S2 for a longer period of time than it did in Group III. Conclusion: Both the spinal and systemic administration of fentanyl enhanced the spread of spinal anaesthesia. The co-administration of spinal and i.v. fentanyl produced a greater increase in the cephalad spread of spinal block.