BACKGROUND: Hip fracture is a common clinical problem which causes severe pain in geriatric patients. However, severe pain following fracture may bring on mental disorders and delirium. A neuroinflammatory response with IL-6 and IL-8 has been shown to be associated with the pathophysiology of delirium. In this study, our primary hypothesis is that preoperative femoral nerve block (FNB) intervention in geriatric patients will more effectively attenuate pain following trochanteric femur fracture than the preoperative paracetamol application. Our secondary hypothesis is that interleukin levels (IL-6, IL-8) in cerebrospinal fluid (CSF) will be lower in the femoral nerve block group than the paracetamol group. Our tertiary hypothesis is that the incidence of postoperative delirium will be lower in the femoral nerve block group. METHODS: The patients over 65 years of age with ASA status II-IV and admitted to the Emergency Service for femur fracture were included in this study. Recommendations of the "delirium prevention table" were applied to all of the patients at arrival. In the first group, 15 mg/kg paracetamol was administered intravenously every eight hours. In the second group, femoral nerve blockage was performed, and a catheter was placed. Then, 0.5 mL/kg bupivacaine 0.25% was applied every eight hours. In both groups, pain scores four hours after interventions were recorded. All patients were operated within 48 hours under spinal anesthesia. During spinal anesthesia, 2 mL of CSF samples were taken from all patients for analysis of IL-6 and IL-8 cytokines, and pain scores during positioning were recorded. RESULTS: VAS scores four hours after the first preoperative pain treatment and during the positioning for regional anesthesia were significantly lower in the femoral nerve block group. IL-8 levels are significantly lower in the femoral nerve block group but not in IL-6 levels. The incidence of delirium was less in the femoral nerve block group, but the difference was not statistically significant. CONCLUSION: The femoral nerve block was more effective in preoperative pain management of trochanteric femur fracture and preventing pain during regional anesthesia application. The mean IL-8 level was lower in the femoral nerve block group when compared to the paracetamol group. There is no difference in the postoperative delirium incidence between groups.

No abstract

A 74-year- old male, who was known to have hypertension, chronic obstructive lung disease, and benign prostate hyperplasia, was evaluated preoperatively in our clinic for a femur fracture. In addition, it was found that the patient was using 1000 mg of metformin per oral due to type 2 diabetes. At the preoperative cardiology evaluation, the ejection fraction was 60% with normal systolic ventricular function. Routine laboratory tests were normal. Metformin was held 24 hours before surgery. Spinal anesthesia was applied with 10 mg bupivacaine and 20 mcg fentanyl. Total blood loss at surgery was 150 cc. After an uneventful surgery, the patient was observed at the surgical postanesthesia care unit. Cardiac and respiratory physical examinations seemed normal but the patient had minimal acidosis and hypoxia in the arterial blood gas analysis. Twelve hours after the operation, compensated high anion gap ( 30 mEq/l) metabolic acidosis emerged, but lactate was normal. The patient's urea and creatinine levels were normal in the control blood tests, and the patient's urine output was above 0.5 ml/kg. Within this period, glucose levels were around 80-140 mg/dl. To overcome metabolic acidosis, bolus intravenous 8.4 % bicarbonate solution was administered. Bicarbonate infusion was started on the continuation of metabolic acidosis and base loss despite the bolus bicarbonate treatment. Since there was no other reason for the metabolic acidosis, metformin usage was considered to cause metabolic acidosis. During this treatment period, despite high anion gap acidosis, there was no lactate elevation. The patient had normal laboratory and hemodynamic values and was discharged from the intensive care unit at postoperative Day 3.

No abstract

Tetanus is an acute and deadly disease caused by Clostridium tetani. A 60-year-old male came to hospital after he injured his thumb with a knife. Ten days later, he returned to hospital with abdominal spasms. He was vaccinated against tetanus and referred to intensive care unit. As he had sudden difficulty in respiration, he was entubated. Midazolam, magnesium and esmolol infusion were started. Next day, muscle spasms progressed all over his body. Midazolam infusion was replaced with propofol and vecuronium. At the third day, morphine infusion was added. At the 16th day, dexmedetomidine infusion was started. At the 20 day, ultrasound guided stellate ganglion block was performed to denervate sympathetic activity. The block was performed three times in a 10 days period. At the 30 the patient recovered from very severe tetanus. The mainstay of tetanus treatment is adequate sedation. Neuroaxial blocks were proved to be effective for the control of sympathetic overactivity in recent years. Circulatory collapse remains to be the major cause of death. The mechanism is unclear but altered myocardial function is thought to be related to changeable catecholamine levels. The effect of stellate ganglion block on sympathetic and parasympathetic control of heart has been studied since the beginning of 1980s. Recently Scanlon et al. reported they treated a patient with medically refractory ventricular arrhythmias by ultrasound guided bilateral stellate ganglion block. In conclusion, stellate ganglion block can be an alternative method when the autonomic storm cannot be controlled with medical agents.