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Abstract Introduction Controlled hypotension is a reversible procedure in which the patient's baseline mean arterial blood pressure is reduced by 30% and sustained at 60-70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures. Objectives The purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency. Methods The research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon's satisfaction. Results Between May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15-51), 43.0 mL (21-105) and 40.0 mL (26-97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon's satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001). Conclusion Less volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients' characteristics and advantages/disadvantages of the drugs.

Resumo Introdução Hipotensão controlada é um procedimento reversível no qual a pressão arterial média basal do paciente é reduzida em 30% e mantida em 60-70 mmHg durante o procedimento. Isso diminui a perda de sangue e propicia um campo cirúrgico limpo durante os procedimentos. Objetivo Comparar agentes usados para hipotensão controlada: esmolol, remifentanil e nitroglicerina em cirurgia sinusal endoscópica funcional, em termos de alterações hemodinâmicas e impactos na eficácia cirúrgica. Método O estudo foi feito como de coorte. Pacientes submetidos à cirurgia sinusal endoscópica funcional foram randomizados em 3 grupos. A hipotensão controlada foi feita com remifentanil (Grupo R), esmolol (Grupo E) e nitroglicerina (Grupo R). A eficácia dos medicamentos foi testada com a comparação do período de tempo com a pressão arterial média desejada, a quantidade de anestésicos usados, o escore de sangramento no campo cirúrgico e a satisfação do cirurgião. Resultados Entre maio e dezembro de 2015, 60 pacientes foram incluídos e randomizados igualmente nos três grupos de estudo. A mediana do período com a pressão arterial desejada foi menor no Grupo R quando comparado ao Grupo E (p = 0,01) e Grupo N (p = 0,14). A quantidade de anestésicos voláteis usados foi de 25,0 mL (15 ± 51), 43,0 mL (21 ± 105) e 40,0 mL (26 ± 97) nos Grupos R, E e N, respectivamente (p < 0,001). Houve mais sangramento com nitroglicerina e escores de sangramento no campo cirúrgico foram menores no Grupo R quando comparados com esmolol (p = 0,001) e nitroglicerina (p < 0,001). A análise dos escores da satisfação do cirurgião concluiu que os cirurgiões estavam mais satisfeitos com o grupo R (100%) quando comparados ao grupo E (60%) e o grupo N (30%) (p < 0,001). Conclusão Agente menos volátil, pouco tempo para obter a hipotensão controlada, pressão arterial estável, menor escore de sangramento no campo cirúrgico e período de pressão arterial desejada curto foram considerados como vantagens do remifentanil. Menor custo, eficácia de obtenção da pressão arterial média desejada e menos complicações pós-operatórias foram as vantagens da nitroglicerina. Nos procedimentos de cirurgia sinusal endoscópica funcional, os agentes apropriados para obtenção de hipotensão controlada devem ser selecionados de acordo com as características dos pacientes e as vantagens/desvantagens dos fármacos.

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INTRODUCTION: Controlled hypotension is a reversible procedure in which the patient's baseline mean arterial blood pressure is reduced by 30% and sustained at 60-70 mmHg during the procedure. It decreases blood loss and provides clear surgical field during the procedures. OBJECTIVES: The purpose of this study was to compare the efficacy of controlled hypotension agents esmolol, remifentanil, and nitroglycerin in functional endoscopic sinus surgery, in terms of hemodynamic changes and impact on the surgical efficiency. METHODS: The research was carried out as a cohort study. Patients who underwent functional endoscopic sinus surgery were randomized into 3 groups. Controlled hypotension was achieved with remifentanil (Group R), esmolol (Group E) and nitroglycerin (Group N). The efficacy of the drugs was tested by comparing the length of time with the targeted mean arterial pressure, the amount of anesthetics used, surgical field bleeding score and surgeon's satisfaction. RESULTS: Between May to December 2015, 60 patients were included and randomized equally into 3 different study groups. The median of the length of time with the targeted mean arterial pressure was shorter in the Group R when compared with Group E (p = 0.01) and Group N (p = 0.14). The amount of volatile anesthetics used was 25.0 mL (15-51), 43.0 mL (21-105) and 40.0 mL (26-97) in Groups R, E and N, respectively (p < 0.001). While there was more bleeding with nitroglycerin, surgical field bleeding scores were lower in Group R when compared with esmolol (p = 0.001) and nitroglycerin (p < 0.001). The analysis of surgeon's satisfaction scores concluded that surgeons were more satisfied with the group R (100%), when compared with group E (60%) and group N (30%) (p < 0.001). CONCLUSION: Less volatile agent, short time to achieve controlled hypotension, stable blood pressure, lower surgical field bleeding scores and larger length of time with the targeted mean arterial pressure were found as the advantages of Remifentanil. Less costly, efficiency of achieving the targeted median arterial pressure and less postoperative complications were the advantages of nitroglycerin. In functional endoscopic sinus surgery procedures, appropriate controlled hypotensive agents should be selected according to the patients' characteristics and advantages/disadvantages of the drugs.

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Abstract The mechanism of the antidepressant effect of bupropion is not fully understood. Besides, using it in the treatment of depression, it is found to be effective in reducing withdrawal symptoms due to smoking cessation. A 28-year-old female patient with a history of depression was admitted to emergency department an hour after ingestion of bupropion, quetiapine, and levothyroxine in high doses to commit suicide. While accepting her into the Intensive Care Unit, she was awake, alert, disoriented and agitated. After 2 h, the patient had a generalized tonic-clonic seizure. The necessary treatment was given and 9 h later with hemodynamic improvement, the patients’ mental status improved. Bupropion may cause unusual behaviors such as delusions, paranoia, hallucinations, or confusion. The risk of seizure is strongly dose-dependent. We want to emphasize the importance of early gastric lavage and administration of activated charcoal.

Resumo O mecanismo do efeito antidepressivo de bupropiona ainda não está bem esclarecido. Contudo, seu uso no tratamento de depressão revelou ser eficaz para reduzir os sintomas de abstinência relacionados à cessação do tabagismo. Uma paciente do sexo feminino, 28 anos, com história de depressão, deu entrada no setor de emergência uma hora após a ingestão de bupropiona, quetiapina e levotiroxina em doses elevadas para cometer suicídio. Ao ser internada em unidade de terapia intensiva, estava acordada, alerta, desorientada e agitada. Após duas horas, apresentou uma crise tônico-clônica generalizada. O tratamento necessário foi administrado e nove horas mais tarde, com a estabilização hemodinâmica, o estado mental da paciente melhorou. Bupropiona pode causar comportamentos incomuns, incluindo delírios, paranoia, alucinações ou confusão mental. O risco de convulsão é altamente dependente da dose. Queremos enfatizar a importância da lavagem gástrica precoce e da administração de carvão ativado.

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The mechanism of the antidepressant effect of bupropion is not fully understood. Besides, using it in the treatment of depression, it is found to be effective in reducing withdrawal symptoms due to smoking cessation. A 28-year-old female patient with a history of depression was admitted to emergency department an hour after ingestion of bupropion, quetiapine, and levothyroxine in high doses to commit suicide. While accepting her into the Intensive Care Unit, she was awake, alert, disoriented and agitated. After 2h, the patient had a generalized tonic-clonic seizure. The necessary treatment was given and 9h later with hemodynamic improvement, the patients' mental status improved. Bupropion may cause unusual behaviors such as delusions, paranoia, hallucinations, or confusion. The risk of seizure is strongly dose-dependent. We want to emphasize the importance of early gastric lavage and administration of activated charcoal.

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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. CONCLUSION: The addition of ketamine to IV-PCA morphine reduces the total consumption of morphine without psychotic effects; however, magnesium did not influence morphine consumption.

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BACKGROUND: The aim of this study was to investigate the effects of spinal anesthesia using two different doses of fentanyl combined with low-dose levobupivacaine in anorectal surgery. METHODS: In this prospective, double-blind study, 52 American Society of Anaesthesiologists I-II patients scheduled for elective anorectal surgery were randomized into two groups. The patients in group I received intrathecal 2.5mg hyperbaric levobupivacaine plus 12.5µg fentanyl and in group II received intrathecal 2.5mg hyperbaric levobupivacaine plus 25µg fentanyl. All the patients remained in the seated position for 5min after completion of the spinal anesthesia. Sensory block was evaluated with pin-prick test and motor block was evaluated with a modified Bromage scale. RESULTS: Motor block was not observed in both of the groups. The sensory block was limited to the S2 level in group I, and S1 level in group II. None of the patients required additional analgesics during the operation. Time to two-segment regression was shorter in group I compared with group II (p<0.01). One patient in group I and 5 patients in group II had pruritus. Hemodynamic parameters were stable during the operation in both of the groups. CONCLUSION: Spinal saddle block using hyperbaric levobupivacaine with both 12.5µg and 25µg fentanyl provided good quality of anesthesia without motor block for anorectal surgery in the prone position.

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BACKGROUND: the aim of this study was to investigate the effects of spinal anesthesia using two different doses of fentanyl combined with low-dose levobupivacaine in anorectal surgery. METHODS: in this prospective, double-blind study, 52 American Society of Anaesthesiologists I-II patients scheduled for elective anorectal surgery were randomized into two groups. The patients in group I received intrathecal 2.5 mg hyperbaric levobupivacaine plus 12.5 µg fentanyl and in group II received intrathecal 2.5 mg hyperbaric levobupivacaine plus 25 µg fentanyl. All the patients remained in the seated position for 5 min after completion of the spinal anesthesia. Sensory block was evaluated with pin-prick test and motor block was evaluated with a modified Bromage scale. RESULTS: motor block was not observed in both of the groups. The sensory block was limited to the S2 level in group I, and S1 level in group II. None of the patients required additional analgesics during the operation. Time to two-segment regression was shorter in group I compared with group II (p < 0.01). One patient in group I and 5 patients in group II had pruritus. Hemodynamic parameters were stable during the operation in both of the groups. CONCLUSION: spinal saddle block using hyperbaric levobupivacaine with both 12.5 µg and 25 µg fentanyl provided good quality of anesthesia without motor block for anorectal surgery in the prone position.

JUSTIFICATIVA: O objetivo deste estudo foi investigar os efeitos da raquianestesia com o uso de duas doses diferentes de fentanil em combinação com dose baixa de levobupivacaína em cirurgia anorretal. MÉTODOS: Neste estudo prospectivo e duplo-cego, 52 pacientes com estado físico ASA I-II, programados para cirurgia eletiva anorretal, foram randomicamente alocados em dois grupos. Os pacientes do Grupo I receberam 2,5 mg de levobupivacaína hiperbárica mais 12,5 µg de fentanil por via intratecal e os do Grupo II receberam 2,5 mg de levobupivacaína hiperbárica mais 25 µg de fentanil por via intratecal. Todos permaneceram em posição sentada por cinco minutos após o término da raquianestesia. O bloqueio sensorial foi avaliado com o teste da picada de agulha e o bloqueio motor com a escala modificada de Bromage. RESULTADOS: O bloqueio motor não foi observado em ambos os grupos. O bloqueio sensorial limitou-se ao nível S2 no Grupo I e S1 no Grupo II. Nenhum dos pacientes precisou de analgésico suplementar durante a operação. O tempo de regressão de dois seguimentos foi menor no Grupo I em comparação com o Grupo II (p < 0,01). Um paciente do Grupo I e cinco do Grupo II apresentaram prurido. Os parâmetros hemodinâmicos permaneceram estáveis durante a cirurgia em ambos os grupos. CONCLUSÃO: O bloqueio espinhal em sela com o uso de levobupivacaína hiperbárica, tanto com 12,5 µg quanto com 25 µg de fentanil, proporciona boa qualidade de anestesia sem bloqueio motor para cirurgia anorretal em decúbito ventral.

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BACKGROUND: the aim of this study was to investigate the effects of spinal anesthesia using two different doses of fentanyl combined with low-dose levobupivacaine in anorectal surgery. METHODS: in this prospective, double-blind study, 52 American Society of Anaesthesiologists I-II patients scheduled for elective anorectal surgery were randomized into two groups. The patients in group I received intrathecal 2.5mg hyperbaric levobupivacaine plus 12.5 µg fentanyl and in group II received intrathecal 2.5mg hyperbaric levobupivacaine plus 25 µg fentanyl. All the patients remained in the seated position for 5 min after completion of the spinal anesthesia. Sensory block was evaluated with pin-prick test and motor block was evaluated with a modified Bromage scale. RESULTS: motor block was not observed in both of the groups. The sensory block was limited to the S2 level in group I, and S1 level in group II. None of the patients required additional analgesics during the operation. Time to two-segment regression was shorter in group I compared with group II (p<0.01). One patient in group I and 5 patients in group II had pruritus. Hemodynamic parameters were stable during the operation in both of the groups. CONCLUSION: spinal saddle block using hyperbaric levobupivacaine with both 12.5 µg and 25 µg fentanyl provided good quality of anesthesia without motor block for anorectal surgery in the prone position.

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PURPOSE: Postoperative pain and nausea/vomitting (PNV) are common in laparoscopic cholecystectomy patients. Sympatholytic agents might decrease requirements for intravenous or inhalation anesthetics and opioids. In this study we aimed to analyze effects of esmolol on intraoperative anesthetic-postoperative analgesic requirements, postoperative pain and PNV. METHODS: Sixty patients have been included. Propofol, remifentanil and vecuronium were used for induction. Study groups were as follows; I - Esmolol infusion was added to maintenance anesthetics (propofol and remifentanil), II - Only propofol and remifentanil was used during maintenance, III - Esmolol infusion was added to maintenance anesthetics (desflurane and remifentanil), IV - Only desflurane and remifentanil was used during maintenance. They have been followed up for 24 h for PNV and analgesic requirements. Visual analog scale (VAS) scores for pain was also been evaluated. RESULTS: VAS scores were significantly lowest in group I (p = 0.001-0.028). PNV incidence was significantly lowest in group I (p = 0.026). PNV incidence was also lower in group III compared to group IV (p = 0.032). Analgesic requirements were significantly lower in group I and was lower in group III compared to group IV (p = 0.005). Heart rates were significantly lower in esmolol groups (group I and III) compared to their controls (p = 0.001) however blood pressures were similar in all groups (p = 0.594). Comparison of esmolol groups with controls revealed that there is a significant decrease in anesthetic and opioid requirements (p = 0.024-0.03). CONCLUSION: Using esmolol during anesthetic maintenance significantly decreases anesthetic-analgesic requirements, postoperative pain and PNV. .

OBJETIVO: A dor e a incidência de náusea e vômito no período pós-operatório (NVP) são comuns em pacientes submetidos à colecistectomia laparoscópica. Os agentes simpatolíticos podem diminuir a necessidade de opiáceos ou anestésicos inalatórios ou intravenosos. Neste estudo, nosso objetivo foi analisar os efeitos de esmolol sobre a necessidade de anestésico no período intraoperatório e de analgésico no pós-operatório e a incidência de dor e NVP. MÉTODOS: Sessenta pacientes foram incluídos. Propofol, remifentanil e vecurônio foram usados para a indução. Os grupos de estudo foram os seguintes: grupo I, a infusão de esmolol foi adicionada aos anestésicos (propofol e remifentanil) para manutenção; grupo II, apenas propofol e remifentanil foram usados durante a manutenção; grupo III, a infusão de esmolol foi adicionada aos anestésicos (desflurano e remifentanil) para manutenção; grupo IV, apenas desflurano e remifentanil foram usados durante a manutenção. O período de acompanhamento foi de 24 horas para avaliar a incidência de NVP e a necessidade de analgésicos. Os escores de dor também foram avaliados por meio da escala visual analógica (EVA). RESULTADOS: Os escores EVA foram significativamente menores no grupo I (p = 0,001-0,028). A incidência de NVP foi significativamente menor no grupo I (p = 0,026). NVP também foi menor no grupo III em relação ao grupo IV (p = 0,032). A necessidade de analgésicos foi significativamente menor no grupo I e menor no grupo III em relação ao grupo IV (p = 0,005). A frequência cardíaca foi significativamente menor nos grupos esmolol (grupos I e III) comparados com os controles (p = 0,001), mas a pressão arterial foi semelhante em todos os grupos (p = 0,594). A comparação entre os grupos esmolol e controles revelou que houve uma diminuição. CONCLUSÃO: O uso de esmolol durante a manutenção da anestesia reduz significativamente a necessidade de anestésico-analgésico, dor e incidência de NVP. .

OBJETIVO: El dolor y la incidencia de náuseas y vómito en el período postoperatorio (NVPO) son comunes en pacientes sometidos a colecistectomía laparoscópica. Los agentes simpaticolíticos pueden disminuir la necesidad de opiáceos o anestésicos inhalatorios o intravenosos. En este estudio, nuestro objetivo fue analizar los efectos del esmolol sobre la necesidad de anestésico en el período intraoperatorio y de analgésico en el postoperatorio y la incidencia de dolor y NVPO. MÉTODOS: Sesenta pacientes fueron incluidos. Para la inducción fueron usados el propofol, el remifentanilo y el vecuronio. Los grupos de estudio fueron los siguientes: grupo I, la infusión de esmolol fue añadida a los anestésicos (propofol y remifentanilo) para el mantenimiento; grupo II, durante el mantenimiento solamente fueron usados el propofol y el remifentanilo; grupo III, la infusión de esmolol fue añadida a los anestésicos (desflurano y remifentanilo) para mantenimiento; grupo IV, solamente fueron usados durante el mantenimiento el desflurano y el remifentanilo. El período de acompañamiento fue de 24 h para calcular la incidencia de NVPO y la necesidad de analgésicos. Las puntuaciones de dolor también fueron evaluadas mediante la escala visual analógica. RESULTADOS: Las puntuaciones de la escala visual analógica fueron significativamente menores en el grupo I (p = 0,001-0,028). La incidencia de NVPO fue significativamente menor en el grupo I (p = 0,026). NVPO también fue menor en el grupo III con relación al grupo IV (p = 0,032). La necesidad de analgésicos fue significativamente menor en el grupo I y menor en el grupo III con relación al grupo IV (p = 0,005). La frecuencia cardíaca fue significativamente menor en los grupos esmolol (grupos I y III) comparados con el control (p = 0,001), pero la presión arterial fue similar en todos los grupos (p = 0,594). La comparación entre los grupos esmolol y control reveló que hubo una disminución significativa de la necesidad ...

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PURPOSE: Postoperative pain and nausea/vomitting (PNV) are common in laparoscopic cholecystectomy patients. Sympatholytic agents might decrease requirements for intravenous or inhalation anesthetics and opioids. In this study we aimed to analyze effects of esmolol on intraoperative anesthetic-postoperative analgesic requirements, postoperative pain and PNV. METHODS: Sixty patients have been included. Propofol, remifentanil and vecuronium were used for induction. Study groups were as follows; I - Esmolol infusion was added to maintenance anesthetics (propofol and remifentanil), II - Only propofol and remifentanil was used during maintenance, III - Esmolol infusion was added to maintenance anesthetics (desflurane and remifentanil), IV - Only desflurane and remifentanil was used during maintenance. They have been followed up for 24h for PNV and analgesic requirements. Visual analog scale (VAS) scores for pain was also been evaluated. RESULTS: VAS scores were significantly lowest in group I (p=0.001-0.028). PNV incidence was significantly lowest in group I (p=0.026). PNV incidence was also lower in group III compared to group IV (p=0.032). Analgesic requirements were significantly lower in group I and was lower in group III compared to group IV (p=0.005). Heart rates were significantly lower in esmolol groups (group I and III) compared to their controls (p=0.001) however blood pressures were similar in all groups (p=0.594). Comparison of esmolol groups with controls revealed that there is a significant decrease in anesthetic and opioid requirements (p=0.024-0.03). CONCLUSION: Using esmolol during anesthetic maintenance significantly decreases anesthetic-analgesic requirements, postoperative pain and PNV.