Anesthesiology and Reanimation

Case Report / Olgu Sunumu Here, we report anaesthesia management and the successful use of total intravenous anaesthesia and sugammadex in a patient with Ullrich's disease. Propofol and remifentanyl infusion was used for anaesthesia. After the end of the surgery, when the train-of-four value was 0%, 4 mg kg −1 sugammadex was administered, and the patient was successfully extubated after 36 s. No adverse effects or safety concerns were observed. In conclusion, we suggest that the use of propofol infusion to avoid the use of inhalation anaesthetics and the use of sugammadex for the reversal of the effects of rocuronium is safe in patients with Ullrich's disease.

Introduction H ypothermia is defined as the lowering of the core body temperature below 36°C. The frequency of perioperative hypothermia is 50-90% (1). Perioperative hypothermia, especially in operations exceeding half an hour and those occurring in patients in the high risk group lead to important complications. It causes prolongation of the effects of anaesthetic drugs and the duration of patient recovery, and increases the risk for complications like coagulophaty, respiratory and cardiovascular system depression, and surgical site infections. (1, 2). Risk of perioperative hypothermia is increased in patients with an ASA score higher than II, in those over 70 years of age, the newborns, and the patients with a concomitant disease (3, 4). The nature and duration of the surgical procedure, ambient temperature, the amount of intravenous fluids, blood and blood products used, the duration of mechanical ventilation and body temperature of the patient before anaesthesia induction, are the determinants of risk for perioperative hypothermia (2-5). Perioperative hypothermia, which underlie numerous complications that increase the morbidity and mortality, and that increase the duration of hospital stay and costs, is a condition that needs to be prevented, but has not been completely solved yet. When the articles published until now has been reviewed, it was observed that approximately only 10 to 13 of 800 articles published were randomized, clinical, prospective trials. There are no common guidelines for the prevention of management of perioperative hypothermia that is used worldwide. Countries such as England and Germany use their national guidelines.

Objective: In this study, we aimed to compare Bispectral Index (BIS) monitoring with the conventional anaesthesia approach based on haemodynamic changes in terms of anaesthetic agent consumption, haemodynamic recordings, recovery time and cost. Methods: This study was performed in 82 patients, aged 20 to 60 years, who were operated for supratentorial mass and were graded ASA I or II. Cases were randomly divided into two equal groups. In the standard control group haemodynamic parameters were used to determine depth of anaesthesia and in the BIS group, BIS monitoring was applied. In the BIS group the BIS values were kept between 40 and 60; in the control group haemodynamic changes within the range of +/-20% of initial values were controlled using appropriate anaesthetic practice. Haemodynamic parameters, awakening conditions and drug usage were recorded. Results: The difference between the two groups in terms of timing of eye opening and initial spontaneous breath was not statistically significant. The 'Aldrete' score at the 20 th postoperative minute for the BIS group was significantly higher than the score calculated for the control group (p<0.05). Rocuronium consumption (mg kg-1 hr-1) was significantly lower in the BIS group than the control group (p<0.05). Although a statistically significant difference (p<0.05) was found between the two groups in terms of initial heart rate and SpO 2 values, there was no clinically significant difference in other haemodynamic parameters. Conclusion: Although using BIS monitoring to evaluate depth of anaesthesia does not bring much benefit versus the use of haemodynamic parameters, it may be beneficial for selected surgeries such as awake craniotomy, for patients with a history of awareness and in haemodynamically unstable patients.

The aim of our study is to investigate the effect of two different methods of continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP) and oxygen support under spontaneous ventilation on respiration mechanics, gas exchange, dry mouth and face mask lesion during an early postoperative period in patients undergoing upper abdominal surgery. Methods: Eighty patients undergoing elective abdominal surgery with laparotomy, between the age of 25 and 75 years and American Society of Anesthesiologists Physical Status score (ASA) II-III with chronic obstructive pulmonary disease (COPD) diagnosis were included to the study. Subjects were randomly allocated in to four groups. During the first postoperative hour, the first group received BIPAP, second group received high-flow CPAP, third group received low-flow CPAP and fourth group received deep breathing exercises, respiratory physiotherapy and O 2 therapy. Preoperative, postoperative before and after treatment PaO 2 , PaCO 2 , SpO 2 , tidal volume (TV), respiratory rate (RR) levels were recorded. Subjects with dry mouth or face mask lesion were recorded. Results: In all groups, PaO 2 and TV measurements were higher at the postoperative first hour than the postoperative zero hour. We found that low-flow CPAP increased PaO 2 and SpO 2 values more, and TV levels were higher in the postoperative period than the preoperative period. PaCO 2 levels were elevated at the zero hour postoperatively and at the end of the first hour; they decreased approximately to preoperative values, except in the fourth group. Conclusion: Administration of prophylactic respiratory support can prevent the deterioration of pulmonary functions and hypoxia in patients with COPD undergoing upper abdominal surgery. In addition, we found that low-flow CPAP had better effects on PaO 2 , SpO 2 , TV compared to other techniques.

Özet Amaç: Trakeal veya bronşiyal yabancı cisim aspirasyonu genel anestezi altında bronkoskopi gerektiren çocukluk çağının önemli acillerindendir. Bu geriye dönük çalışmada yabancı cisim aspirasyonu nedeniyle uygulanan bronkoskopiler; anestezi yöntemleri, ...

PURPOSE: Right internal jugular vein (RIJV) catheterisation is a common procedure in patients undergoing surgery. We aimed to compare diameters and the cross-sectional area (CSA) of the RIJV when the head is in a neutral or 30-degree rotated position during mechanical ventilation in various modes and spontaneous ventilation. METHODS: Thirty patients undergoing surgery were included in the study. In each patient, still ultrasound images of the vena jugularis interna were taken with the head in a neutral position and with the neck rotated 30 degrees to the left, first under spontaneous ventilation (group S), then after the induction of anaesthesia under volume-controlled ventilation (group V) and under pressure-controlled ventilation (group P). The six still images were evaluated in terms of transverse and anteroposterior diameters and CSA. RESULTS: Diameters in the neutral and lateral positions in group S were significantly smaller than in group P and group V (neutral transverse p = 0.01, anteroposterior p = 0.041, rotated transverse p = 0.01, anteroposterior p = 0.03). The CSAs of the RIJV in the neutral and lateral positions were significantly larger in group P and group V than Group S (lateral CSA p = 0.001, neutral CSA p = 0.002). CSA increased significantly only in group P when the head was rotated 30 degrees laterally (p = 0.002). CONCLUSION: We conclude that both pressure-controlled and volume-controlled mechanical ventilation have similar effects on the CSA and diameters of the RIJV. Positioning of the head with a 30-degree rotation laterally has different effects on CSA depending on the ventilation mode used. A neutral position should be preferred with spontaneous ventilation whereas 30 degree rotation should be preferred in patients under pressure-controlled and volumecontrolled ventilation. Clinical trial registration number at ClinicalTrials.gov: NCT01790334

BACKGROUND: The study aimed to evaluate and compare the effects of a single dose of etomidate and the use of a steroid injection prior to etomidate during rapid sequence intubation on hemodynamics and cortisol levels. METHODS: Sixty patients were divided into three groups (n=20). Before intubation, and at 4 and 24 hours, blood samples were taken for cortisol measurements and hemodynamic parameters (systolic-diastolic-mean arterial pressure, heart rate), and SOFA scores were recorded. Intubation was achieved with 0.3 mg/kg etomidate IV in Group I, 0.3 mg/kg etomidate following 2 mg/kg methylprednisolone IV in Group II, and 0.15 mg/kg IV midazolam in Group III. RESULTS: Mean arterial pressure values were lower in Group I at the 24 th hour when compared to Groups II and III. In Group I, heart rate values were higher compared to the other Groups. Cortisol levels were lower in Group I at the 4 th and at the 24 th hour in Groups II and III. CONCLUSION: Administration of methylprednisolone 2-4 minutes prior to etomidate use in emergency situations can prevent adrenal insufficiency in patients undergoing rapid sequence intubation. Moreover, midazolam can be used in low induction doses as an alternative to etomidate.

The effect of subcostal transversus abdominis plane (TAP) block on postoperative pain is contradictive. The aim of this study was to evaluate the effect of subcostal TAP block on subacute pain in patients who have undergone inguinal herniography. Methods: Patients aged between 18 and 75 years with American Society of Anesthesiologists 1-3 and who were to undergo elective unilateral inguinal herniography with mesh under general anesthesia were included. Fifty patients were under an intravenous analgesic regimen (group I) and 50 patients underwent subcostal TAP block postoperatively in addition to the intravenous analgesic regimen (group II). The primary outcome measure was pain scores 1 month postoperatively by comparing Numerical Rating Scale values with the Mann-Whitney U test between groups I and II. Secondary outcome measures were life qualification scores 1 month postoperatively and pain scores 24 h and 15 days postoperatively. Results: Postoperative 15 th-min; 1 st-, 6 th-, 12 th-, and 24 th-h; 15 th-day (p=0.00); and 1 st-month Numerical Rating Scale values were significantly lower in group II than in group I (p=0.02). No significant difference was observed between the groups in terms of LQS 15 days postoperatively (p=0.013). On group comparison, LQS was higher in the 1 st month than at the 15 th day postoperatively in group I (p=0.201). Conclusion: Subcostal TAP block provides an effective postoperative pain treatment in the acute period and in the 1 st postoperative month in patients undergoing inguinal herniography.

Background and Objectives: Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure for removing kidney stones, but patients still suffer from moderate postoperative pain. The aim of this study is to evaluate the perioperative analgesic effect of ultrasound-guided subcostal transversus abdominis plane (TAP) block performed before PCNL procedure. Materials and Methods: Patients scheduled for elective PCNL were randomized into two groups: Group TAP and Group IV. General anesthesia was induced with propofol, fentanyl, and rocuronium and maintained with sevoflurane, fentanyl, and rocuronium. Unilateral ultrasound-guided TAP block was performed with total of 30 mL volume of local anesthetic solution (20 mL bupivacaine 0.125% plus 10 mL lidocaine 1%) after intubation but before surgery to the Group TAP patients. Paracetamol 1 g was given to the Group IV. Tramadol 100 mg and morphine IV-patient-controlled analgesia were applied to both groups. Perioperative fentanyl consumption, postoperative verbal analog scale (VAS), morphine consumption, and additional analgesic drug requirement were assessed. Chi square with Yates correction and Mann-Whitney U tests were used for statistical analysis. Results: Eighty patients were assessed for enrollment. One patient developed septicemia at the recovery room so data of 79 patients were collected for statistical analysis. Total morphine consumption at 48th hour after the surgery was lower at Group TAP (p = 0.022). Perioperative fentanyl consumption was lower at Group TAP (p < 0.001). Additional analgesic requirement and VAS were comparable between groups. Conclusions: Preemptive unilateral ultrasound-guided subcostal TAP block decreases perioperative fentanyl and postoperative total morphine consumption in PCNL patients compared to IV analgesic management.

Non-invasive ventilation has gained an increasingly pivotal role in the treatment of acute hypoxemic and/or hypercapnic respiratory failure and offers multiple advantages over invasive mechanical ventilation. Some of these advantages include the preservation of airway defense mechanisms, a reduced need for sedation, and an avoidance of complications related to endotracheal intubation. Despite its advantages, non-invasive ventilation has some contraindications that include, among them, severe encephalopathy. In this review article, the rationale, evidence, and drawbacks of the use of noninvasive ventilation in the context of hypercapnic and non-hypercapnic patients with an altered level of consciousness are analyzed.

Sum mary Aim: Tracheal or bronchial foreign body aspiration is a life-threatening emergency in children requiring immediate bronchoscopy under general anesthesia. The aim of this retrospective study was to evaluate the anesthetic management, hazards and complications of bronchoscopies performed because of suspicion of foreign body aspiration. Material and Method: We retrospectively analyzed the history, clinical and radiological findings and complications of 401 children admitted to the pediatric surgery department due to suspicion of foreign body aspiration between January 2006 and June 2011. Children requiring diagnostic bronchoscopies were excluded. All brochoscopies were performed under general anesthesia. Inhalation or IV induction and maintenance, spontaneous or controlled mechanical ventilation were selected individually according to the circumstances. Clinical findings, physical examination, radiological findings, anesthesia methods and complications of the patients were eva...

Sum mary Aim: Tracheal or bronchial foreign body aspiration is a life-threatening emergency in children requiring immediate bronchoscopy under general anesthesia. The aim of this retrospective study was to evaluate the anesthetic management, hazards and complications of bronchoscopies performed because of suspicion of foreign body aspiration. Material and Method: We retrospectively analyzed the history, clinical and radiological findings and complications of 401 children admitted to the pediatric surgery department due to suspicion of foreign body aspiration between January 2006 and June 2011. Children requiring diagnostic bronchoscopies were excluded. All brochoscopies were performed under general anesthesia. Inhalation or IV induction and maintenance, spontaneous or controlled mechanical ventilation were selected individually according to the circumstances. Clinical findings, physical examination, radiological findings, anesthesia methods and complications of the patients were eva...

Sum mary Aim: Exposure to passive smoking is associated with side effects on pulmonary function in children and also a risk factor for adverse outcomes following anesthesia and surgery. The objective of this study was to determine the effect of passive smoking on COHb, arterial oxygen pressure (PaO2) and arterial carbon dioxide pressure (PaCO2) levels and on postoperative adverse respiratory events in children undergoing general anesthesia. Material and Method: One hundred children (1-16 y) undergoing urologic or abdominal surgery with a history of passive smoking from one or both parents and 50 children with no history of exposure to smoking were analyzed for COHb, PaO2 and PaCO2 levels during the anesthesia and for postoperative respiratory events. Parents were asked to complete a questionnaire about their smoking habits before surgery. The arterial blood samples were obtained after intubation of the patients. The respiratory symptoms were evaluated during the stay in the recovery...

Sum mary Aim: Exposure to passive smoking is associated with side effects on pulmonary function in children and also a risk factor for adverse outcomes following anesthesia and surgery. The objective of this study was to determine the effect of passive smoking on COHb, arterial oxygen pressure (PaO2) and arterial carbon dioxide pressure (PaCO2) levels and on postoperative adverse respiratory events in children undergoing general anesthesia. Material and Method: One hundred children (1-16 y) undergoing urologic or abdominal surgery with a history of passive smoking from one or both parents and 50 children with no history of exposure to smoking were analyzed for COHb, PaO2 and PaCO2 levels during the anesthesia and for postoperative respiratory events. Parents were asked to complete a questionnaire about their smoking habits before surgery. The arterial blood samples were obtained after intubation of the patients. The respiratory symptoms were evaluated during the stay in the recovery...

Introduction R ocuronium is a steroidal nondepolarizing neuromuscular blocking agent, with similar block onset time as succinylcholine, which is preferred by the anaesthetists because of its rapid effect (1). One of the most frequent complications of rocuronium is injection pain. Even after anaesthesia induction when a state of complete hypnosis is achieved, this pain may lead to hand withdrawal (1-3). The mechanism of pain is not completely known. In order to prevent this side effect, premedication with various drugs before rocuronium injection and application of rocuronium together with drugs such as lidocaine, midazolam and fentanyl had been tested (3-6). Multiple studies evaluated rocuronium-associated pain and hand withdrawal (2, 3, 6). In our study, using isolated forearm technique, we aimed to evaluate the effects of three different concentrations (10 mg mL-1 , 5 mg mL-1 , 2.5 mg mL-1) of rocuronium on pain, rash, and skin eruptions and the hemodynamic changes associated with this complication. Methods After the approval of the Ethics Committee of İstanbul University Cerrahpaşa Medical School (approval date 03.05.2011 and number 28234), a randomized clinical, prospective, double-blind study was performed in the General Surgery operating theatre, on 80 ASA I-II patients who required general anaesthesia. The study was performed after obtaining the informed consent of the patients. Exclusion criteria were, known allergies to any anaesthetic agent, dementia, the presence of diseases causing tremor or involuntary movements such as Alzheimers' or Parkinsons' disease and being younger than 18 years of age. Before injection, the patients were informed that the medication used might cause burning sensation in hands. Patients were informed on the Visual Analogue Scale (VAS), and after the drug was administered, they were asked to evaluate pain intensity on VAS. VAS is a horizontal or vertical 10 cm line; anchored by "No Pain" at one end and "Unbearable Pain" at the other. At the same time with patients VAS evaluation, a numeric scale which was produced to evaluate it numerically (7-9).

Cerrahi travma ve ağrı nedeniyle metabolik, endokrin, immün sistemde oluşan değişiklikler sitokin gibi biyolojik mediatörlerin artışı ile beraberdir. Preemptif epidural analjezi, cerrahi travmanın neden olduğu ağrı ve nöromediatörlerin oluşturduğu nörohümoral cevabı etkileyebilir. Bu çalışmada preemptif epidural analjezinin postoperatif ağrı ve sitokin düzeyine etkisinin araştırılması amaçlandı. Yöntem: Ürolojik cerrahi planlanan 60 çocuk; preemptif epidural analjezi (Preempt EA, n=31) grup ve postoperatif epidural analjezi grubu olarak (Postop EA, n=29) randomize iki gruba ayrıldı. Epidural infüzyon; Preempt EA grubunda cerrahi insizyon öncesi, Postop EA grubunda periton kapanışından sonra başlandı. Kan örnekleri preoperatif dönem, cerrahiden 1 saat ve 24 saat sonrasında ELISA yöntemi ile plazma TNF-α ve IL-2 düzeylerini tespit için alındı. Postoperatif ağrı FACES ağrı skalası ile cerrahiden 1 ve 24 saat sonrasında değerlendirildi. Bulgular: Her iki grupta TNF-α değerleri 1. ve 24. saatte preoperatif değerlere oranla arttı. Postop EA grubunda değerler Preempt EA grubuna göre daha yüksek bulundu. Preempt EA grubunda, IL-2 değerleri postoperatif dönemde Postop EA grubuna göre daha yüksekti. Ağrı skorları açısından gruplar arasında istatiksel olarak fark yoktu Sonuç: Sonuçlarımız preemptif epidural analjezinin proinflamatuvar cevabı azalttığı ama ağrı şiddetine etkisi olmadığını düşündürdü.

† Transversus abdominis plane (TAP) blocks are increasingly used for analgesia after abdominal surgery. † This study assessed whether TAP blocks provide additional analgesia to spinal morphine after Caesarean section. † Pain scores and analgesia requirements were lowest in those receiving spinal morphine 100 mg. † Bilateral TAP blocks using bupivacaine 2 mg kg 21 had no extra analgesic effects. Background. Transversus abdominis plane (TAP) block is an alternative to spinal morphine for analgesia after Caesarean section but there are few data on its comparative efficacy. We compared the analgesic efficacy of the TAP block with and without spinal morphine after Caesarean section in a prospective, randomized, double-blinded placebo-controlled trial. Methods. Eighty patients were randomized to one of four groups to receive (in addition to spinal anaesthesia) either spinal morphine 100 mg (S M) or saline (S S) and a postoperative bilateral TAP block with either bupivacaine (T LA) 2 mg kg 21 or saline (T S). Results. Pain on movement and early morphine consumption were lowest in groups receiving spinal morphine and was not improved by TAP block. The rank order of median pain scores on movement at 6 h was: S M T LA (20 mm),S M T S (27.5 mm),S S T S (51.5 mm),S S T LA (52.0 mm) (P,0.05, highest vs lowest). The rank order of median morphine consumption at 6 h was: S M T S (4.0 mg),S M T LA (5.0 mg),S S T LA (8.0 mg),S S T S (12.0 mg) and at 24 h was: S M T LA (5.0 mg),S M T S (6.0 mg),S S T S (9.5 mg),S S T LA (15.0 mg) (P,0.05, highest vs lowest). Sedation scores and patient satisfaction did not differ between groups. Anti-emetic use and pruritus were highest in the S M T LA group. Conclusions. Spinal morphine-but not TAP block-improved analgesia after Caesarean section. The addition of TAP block with bupivacaine 2 mg kg 21 to spinal morphine did not further improve analgesia.