Paracetamol and dipyrone have well tolerability profile and effective analgesic properties when administered IV-PCA for postoperative analgesia in children after tonsillectomy.

It is highly expected that COVID-19 infection will have devastating consequences in sickle cell disease (SCD) patients due to endothelial activation and decreased tissue and organ reserve as a result of microvascular ischemia and continuous inflammation. In this study, we aimed to compare the clinical course of COVID-19 in adult SCD patients under the organ injury mitigation and clinical care improvement program (BASCARE) with healthcare professionals without significant comorbid conditions. The study was planned as a retrospective, multicenter and cross-sectional study. Thirty-nine SCD patients, ages 18 to 64 years, and 121 healthcare professionals, ages 21 to 53, were included in the study. The data were collected from the Electronic Health Recording System of PRANA, where SCD patients under the BASCARE program had been registered. The data of other patients were collected from the Electronic Hospital Data Recording System and patient files. In the SCD group, the crude incidence of COVID-19 was 9%, while in healthcare professionals at the same period was 23%. Among the symptoms, besides fever, loss of smell and taste were more prominent in the SCD group than in healthcare professionals. There was a significant difference between the two groups in terms of development of pneumonia, hospitalization, and need for intubation (43 vs 5%, P < 0.00001; 26 vs 7%, P = 0.002; and 10 vs 1%, P = 0.002, respectively). Prophylactic low molecular weight heparin and salicylate were used more in the SCD group than in healthcare professionals group (41 vs 9% and 28 vs 1%; P < 0.0001 for both). The 3-month mortality rate was demonstrated as 5% in the SCD group, while 0 in the healthcare professionals group. One patient in the SCD group became continously dependent on respiratory support. The cause of death was acute chest syndrome in the first case, hepatic necrosis and multi-organ failure in the second case. In conclusion, these observations supported the expectation that the course of COVID-19 in SCD patients will get worse. The BASCARE program applied in SCD patients could not change the poor outcome.

We read Dr. Gitkind's report with great interest [1]. Since epidural steroid injection (ESI) is a rational treatment approach for radicular pain due to herniated nucleus pulposus and lumbar stenosis [2], its popularity is rising. It is reported to decrease surgical rates and self-reported pain and disability [3]. Corticosteroids contribute to pain treatment with their ability to decrease inflammation by inhibiting production of prostaglandins and excitation of c-fibers, which is mainly responsible for pain generation. However, ESI is not an option free of side effect due to intervention itself and the drugs used [4]. Here, we describe two patients with abnormal uterine bleeding following ESI.A 48-year-old premenopausal woman with low back pain due to L4-L5 lumbar stenosis was referred to a pain clinic. Her pain was assessed as 8 according to the numeric rating scale (NRS) for pain, where 0 represented "no pain" and 10 represented "the most severe pain." She received interlaminar epidural injection with lidocaine 1% and methylprednisolone 80 mg in a 10-mL solution at the L4-L5 level. Pain level was 5 after the injection. The patient complained of uterine bleeding lasting for 2 days beginning on the second day of injection.A 42-year-old premenopausal woman with low back pain due to L5-S1 stenosis presented to a pain clinic. Her pain was assessed as 7 by the NRS. She received caudal epidural injection with lidocaine 1% and methylprednisolone 80 mg in a 20-mL solution. Pain level was 2 after the injection. The patient complained of uterine bleeding starting on the fifth day after the injection and lasting for 3 days.The two patients did not have any other known endocrinologic disorder. However, both patients consulted with the gynecologist to exclude any other condition that may present with uterine bleeding or mimic this condition, and they were confirmed to have none of the related acute pathologies. They did not experience the symptoms again because we did not repeat the injections.The systemic side effects of epidurally administered corticosteroids include increase in blood glucose, some fluid retention, Cushingoid syndrome, and temporary adrenal suppression with an incidence of 2.2% [1]. Neuroaxial corticosteroids may also initiate a negative feedback loop both in hypothalamic-pituitary and hypothalamic-ovarian axes, resulting in decreased luteinizing and follicular stimulating hormones and lack of progesterone spike. These may contribute to uterine bleeding as a side effect of ESI. There is only one report about this side effect that describes similar symptoms in a premenopausal patient and relates the symptoms to the systemic effect of corticosteroids when administered epidurally [1]. Our patients were also premenopausal, and they reported this side effect presuming that it was associated with ESI. However, some premenopausal patients with uterine bleeding following ESI may remain unreported because they experience the bleeding during their normal menstrual cycle. Besides, in clinical practice, the patients ar...

The aim of this study was to investigate the hormonal and hemodynamic changes during percutaneous nephrolithotomy (PCNL) procedure. Twenty-one patients between 15-65 years of age were included in the study. Invasive blood pressure and heart rate were monitored during PCNL. Serum sodium, potassium, BUN and creatinine levels were measured before and after the operation. Sodium and potassium levels were also measured during the operation. Arterial blood gases, renin, aldosterone and adrenocorticotrophic hormone (ACTH) levels were measured before and during irrigation. The mean systolic and diastolic blood pressure levels were significantly higher (p < 0.05) during PCNL compared to post-procedure levels while heart rate remained constant. Serum sodium, potassium bicarbonate and base-excess levels were decreased during the operation compared to the baseline levels (p < 0.001). BUN and creatinine levels remained unchanged during the study (p > 0.05). In conclusion, a tendency to hyponatremia and metabolic acidosis developed in addition to significant increases in renin, aldosterone and ACTH levels during PCNL procedures. These changes may be due to the invasive nature of the intervention to the kidney and the continuous irrigation of this vital organ. This should be taken into consideration during PCNL. More detailed studies with larger groups are needed for more precise comments on this topic.

Summary Objectives: The aim of this study was to evaluate the characteristics of spinal anesthesia, including its efficacy, adverse effects and complications, in order to determine if it can be applied safely in pediatric patients ÖzetAmaç: Çalışmamızda kliniğimizde umbilikus altı cerrahi için spinal anestezi uyguladığımız pediyatrik hastaları değerlendirerek, intraoperatif karşılaştığımız problemleri, yan etki ve komplikasyonları geriye dönük olarak belirlemeyi, genel anestezi uygulaması yönünden yüksek riskli olup, hastalarda tekniği güvenilir şekilde uygulayabilmek amacıyla, komplikasyonlarımız ve olumlu sonuçlarımızı vurgulamayı amaçladık. Gereç ve Yöntem: Kliniğimizde 2007-2008 tarihleri arasında spinal anestezi uygulanan 86 pediyatrik hastanın perioperatif bireysel özellikleri, operasyon türleri, anestezi uygulaması, cerrahi süre, motor blok ve sensoryal bloğun iki dermatom gerileme süresi, postoperatif analjezik gereksinimi ve komplikasyonlar hasta dosyaları ve anestezi kayıtlarından incelenerek kaydedildi. Bulgular: Ortalama operasyon süresi 49.8±24.1 dk, sensoryal bloğun 2 dermatom gerileme süresi 73.0±21.9 dk olarak bulundu. Cerrahi bitiminde hastaların 69'unda motor bloğun devam ettiği, 17 hastada ortadan kalktığı, bu hastalarda motor bloğun ortadan kalkış süresinin 67.3±16.2 dk olduğu görüldü. İntraoperatif hipotansiyon görülen 2 hasta ve bradikardi görülen 1 hasta dışında, hemodinamik parametrelerde giriş değerinin %20' sinden fazla değişiklik saptanmadı. Üç hastada etkisiz spinal anestezi sonucunda genel anesteziye geçildiği saptandı. Postoperatif 46 hastada ek analjezik gereksinimi olduğu ve ilk analjezik gereksinim süresinin 2.3±1.2 saat olduğu görüldü. Hastaların hiçbirinde perioperatif dönemde desatürasyon ve apne gelişmezken, postoperatif dönemde 2 hastada bulantı ve kusma, 1 hastada baş ağrısı olduğu saptandı. Hemodinamik ve solunumsal komplikasyona rastlanmadı. Sonuç: Spinal anestezi, özellikle günübirlik pediyatrik cerrahi olgularında genel anesteziye alternatif olarak kullanımı giderek artan bir teknik halini almıştır. Bununla beraber pediyatrik hastalarda spinal anestezinin güvenli ve etkin şekilde uygulanabilmesi için, bu konuda deneyim kazanılması, yan etki, komplikasyonlar ve olumlu sonuçların vurgulanması gerektiğini düşünüyoruz.