Objective:We aimed to compare the analgesia quality of caudal block of low volume, high concentration bupivacaine to the conventionally used volumes and concentrations of the drug in neonates undergoing circumcision with sole caudal anesthesia. Material and Methods: Fifty neonates, undergoing circumcision were randomly assigned to low volume high concentration (group LVHC, n=25) and control groups (group C, n=25). In group LVHC 0.5 ml/kg bupivacaine 0.375% (1.875 mg/kg) and group C 1 ml/kg bupivacaine 0.25% (2.5 mg/kg) was used. Hemodynamic parameters, block onset and analgesia periods were compared. Pain scores were evaluated hourly for 3 hours postoperatively with NIPS (neonatal infant pain score). Student’s t-test for continuous variables, X2 and Mann– Whitney U-tests were used for nominal and/or categorical variables. Results: Demographic, hemodynamic data, block onset time (group LVHC and C values were 4.9±1 vs 5.2±2 mins, respectively; p=0.53) was similar and postoperative median NIPS were identical among the groups (median value of (0); p=0.7, p=0.9, p=1). None of the neonates required additional analgesic postoperatively. Conclusions: Low volume high concentration caudal bupivacaine provided a similar perioperative analgesia quality, time and safety profile compared to conventional doses in awake neonates undergoing circumcision. LVHC bupivacaine may be used to reduce the risk of local anesthetic toxicity in neonates.

High arterial oxygen levels may aggravate oxidative stress associated with CPB (cardiopulmonary bypass). Most cardiac surgery patients have COPD (chronic obstructive pulmonary disease), complicating the relationship of hyperoxia and oxidative stress. In this study the effects of different oxygenation strategies on oxidative balance during CPB in patients with COPD was assessed. Forty patients with COPD underwent elective coronary bypass surgery, using CPB. In 20 patients, high arterial oxygen levels were maintained (PaO2 between 300-400 mm Hg) during CPB, whereas 20 patients underwent normoxic (PaO2 between 100- 200 mm Hg) bypass. Oxidative balance was assessed by measurement of thiobarbituric acid reactive substance, paraoxanase and uric acid levels in blood. Thiobarbituric acid reactive substance, paraoxanase and uric acid levels obtained throughout the study period were similar among the two groups. In both groups, thiobarbituric acid reactive substance, paraoxanase and uric acid levels remained unchanged after CPB, compared to baseline values. High arterial oxygen levels during CPB do not cause alterations in oxidative balance in the blood of COPD patients.

Elastofibromas are benign pseudotumoral fibroelastic lesions commonly localized in the periscapular region in elderly women. The etiology of these lesions are not known. They were first reported in 1961.These lesions are well recognized in the pathology literature and have also received some attention in the radiology literature recently. They are often confused with neoplasms on CT (Computed Tomography) or MRI (Magnetic Resonance Imaging). We present a patient with infrascapluar elastofibroma dorsi. Bilateral subscapuler FDG (Flour 18-Deoxy-Glucose) hypermetabolism in PET (Positron Emission Tomography) were detected and these images were compared to CT or PET-CT fusion images, after which we diagnosed elastofibroma dorsi. This technique may prevent patients undergo unnecessary biopsies and surgical procedures.

While the appendicitis and blunt abdominal trauma are two distinct entities, there are still rare instances where they may unite and can come as a surprise to the clinician. The authors report one such child who had abdominal pain due to trauma at presentation but went on to develop appendicitis. This reports discusses the coincidence and pitfalls of the situation for both the clinician and the surgeon.

We report a removal difficulty of a stuck epidural catheter between the lomber vertebral facets. An epidural catheter was inserted for perioperative pain management before general anesthesia to a woman undergoing laparatomy for oopherectomy. A lomber epidural catheterization was performed with 18- gauge needle using midline approach in left lateral position. Following a test dose general anesthesia was commenced. After extubation, patient has reported a severe abdominal pain which revealed an incomplete epidural analgesia. Therefore removal of the epidural catheter was decided. As all the removal attempts were failed, a CT scan evaluation which revealed catheter stuck between the left interfacet junctions of the L2-L3 vertebrae, was performed. This is an uncommon cause of catheter stuck. None of the recommended maneuvers worked in this stuck catheter case. Therefore iv midazolam and removal attempt in right lateral position with the legs flexed and vertebra flexed and rotated contralaterally, was decided. This approach was successful for the removal of the catheter.

Cholangiocarcinoma is the cancer of the bile duct epithelium and usually presents with painless jaundice and weight loss. Cutaneous metastases have rarely been reported in cholangiocarcinoma. Most of the reports of cutaneous metastases of cholangiocarcinoma are those seen around the percutaneous biliary drainage in the abdominal skin due to implantation of tumor cells during the procedure. Here we report a 41-year old male patient who was diagnosed with cholangiocarcinoma The presented case is the first case of cholangiocarcinoma with distant cutaneous metastases to the face. Distant skin metastases of cholangiocarcinoma must be in the differential diagnosis if atypical cutaneous lesions appears in patients with known cholangiocarcinoma.