The Effect of Oral Fluid Administration 1 Hour before Surgery on Preoperative Anxiety and Gastric Volume in Pediatric Patients.

INTRODUCTION: Today, preoperative fasting guidelines have changed, allowing clear liquid intake up to 1 h before surgery. However, concerns remain regarding the risk of aspiration associated with clear liquid intake. This study aimed to investigate the impact of clear fluid given 1 h before surgery on child anxiety and gastric volumes. METHODS: A prospective, randomized, controlled study included 90 patients aged 5-12 years. The patients were randomly allocated into three groups by a computer-generated randomization: group F (n = 30): standard fasting group, group W (n = 30): patients who received oral water at a dose of 5 mL/kg 1 h before surgery, group C (n = 30): patients who received oral carbohydrate fluid at a dose of 5 mL/kg 1 h before surgery. All patients were assessed using the modified Yale Preoperative Anxiety Scale (m-YPAS) before and 1 h after fluid administration. Antral cross-sectional area (CSA) was measured with ultrasonography after intubation, and gastric residual volume (GRV) was calculated. Hemodynamic data, blood sugar level, and parental satisfaction were also recorded. RESULTS: The m-YPAS scores obtained after 1 h were significantly lower in group C than in the other groups (p < 0.001). Antral CSA and GRV values were lower in group C and group W than in the fasting group (p < 0.001). Parental satisfaction was highest in group C. CONCLUSION: This study suggests that allowing a carbohydrate-rich clear liquid intake 1 h before surgery can significantly reduce preoperative anxiety in pediatric patients without increasing the risk of aspiration.

The predictive role of carotid artery flow time for anesthesia-induced hypotension in high-risk elderly patients.

Hypotension induced by general anesthesia is associated with postoperative complications, increased mortality, and morbidity, particularly elderly patients. The aim of this study was to investigate the effectiveness of corrected carotid artery flow time (FTc) for predicting hypotension following anesthesia induction in patients over 65 years old. After faculty ethical committee approval and written informed consent, 138 patients (65 years and older, ASA physical status I-III) who scheduled for elective surgery were included in this study. In the pre-operative anesthesia unit, the carotid artery FTc value was measured by ultrasound and hemodynamic values were recorded. Following anesthesia induction with propofol, hemodynamic data were recorded at 1-minute intervals for 3 min. Measurements were terminated prior to endotracheal intubation, as direct laryngoscopy and endotracheal intubation could cause sympathetic stimulation and hemodynamic changes. Hypotension occurred in 52 patients (37.7%). The preoperative FTc value of the patients who developed hypotension was statistically lower (312.5 ms) than the patients who did not (345.0 ms) (p < 0.001). The area under the ROC curve for carotid artery FTc was 0.93 (95% CI for AUC:0.89-0.97; p < 0.001) with an optimal cut-off of value for predicting post-anesthesia hypotension 333 ms, a sensitivity of 90.4% and a specificity of 84.9%. As a result of the multiple logistic regression model, carotid artery FTc emerged as the sole independent risk factor for hypotension following anesthesia induction. Preoperative carotid artery FTc measurement is a simple, bedside, noninvasive, and reliable method for predicting anesthesia-induced hypotension in elderly patients.

Thoracic Anaesthesia Practices in Turkey: A Survey Study.

OBJECTIVE: In this survey study, we aimed to investigate thoracic anaesthesia practices in Turkey. METHODS: The survey was sent to the members of the Turkish Society of Anesthesiology and Reanimation by e-mail. Participants were asked to answer 35 questions about their thoracic anaesthesia practice. RESULTS: A total of 148 questionnaires were completed. Most of the participants preferred double-lumen endobronchial tube for one-lung ventilation. 69.6% of auscultation method and 45.9% of fiberoptic bronchoscope method were used to confirm the tube position. The most frequently used additional monitoring method was invasive blood pressure. Generally, intravenous anaesthetic agents were preferred for anaesthesia induction, and a combination of inhalation and intravenous agents was used for anaesthesia maintenance. Most of the participants used intraoperative lung-protective mechanical ventilation strategies. For postoperative analgesia, 75% of participants preferred regional analgesic techniques and 89.9% of them used routine opioid agents. In general, moderate amount of fluid was applied (57.4%), crystalloids were the first choice in fluid therapy, and intraoperative hypotension was generally treated with controlled intravenous fluid and vasoactive agents. The haemoglobin threshold value for blood transfusion was stated as 8 g dL-1 by 35.8% of participants. CONCLUSIONS: Our data showed that the anaesthesia management of thoracic surgery in Turkey is generally compatible with the current international guidelines. However, the following conclusion was reached: training on blood transfusion, the use of fiberoptic bronchoscope, regional techniques, and intraoperative additional monitoring would be beneficial, and a national consensus should be reached on the thoracic anaesthesia practice.

Molecular determinants of behavioral changes induced by neonatal ketamine and dexmedetomidine application.

Ketamine (KET), an anesthetic, analgesic, and a sedative N-methyl-D-aspartate (NMDA) receptor antagonist agent, exposure during neonatal period may lead to learning impairment, behavioral abnormalities, and cognitive decline in the later years of life. In recent studies, it has been reported that sedative-acting α2 agonist dexmedetomidine (DEX), which is commonly used in clinical practice with KET, has neuroprotective effects and prevents the undesirable effects of anesthesia. To elucidate the underlying mechanisms of these actions, we investigated the interaction between NMDA receptors α2 adrenoceptor and adulthood behaviors in neonatally KET and/or DEX administrated mice. Balb/c male mice were administrated with saline, KET (75 mg/kg), DEX (10 µg/kg), or KET + DEX (75 mg/kg + 10 µg/kg) on postnatal day 7. During adulthood (8-10 weeks old) mice were subjected to elevated plus maze, open field, and Morris water maze tests. After behavioral tests, hippocampus samples were extracted for mRNA expression studies of NMDAR subunits (GluN1, GluN2A, and GluN2B) and α2 adrenoceptor subunits (α2A, α2B, and α2C) by real-time PCR. Ketamine increased horizontal and vertical locomotor activity (p < 0.01) and impaired spatial learning-memory (p < 0.05). DEX increased anxiety-like behavior (p < 0.01), but did not affect spatial learning-memory and locomotor activity. KET + DEX impaired spatial learning-memory (p < 0.01), increased horizontal locomotor activity (p < 0.01), and anxiety-like behavior (p < 0.05). Our study implies that DEX cannot prevent the adverse effects of KET, on spatial learning-memory, and locomotor activity. In addition to this, it can be thought that during brain development, there is an interaction between NMDAR and α2 adrenoceptor systems.

The Effect of Sevoflurane and Dexmedetomidine on Pulmonary Mechanics in ICU Patients.

OBJECTIVE: In intensive care unit (ICU) patients, intravenous (iv) and volatile agents are used for sedation. The aim of the present study was to investigate the effects of dexmedetomidine and sevoflurane on pulmonary mechanics in ICU patients with pulmonary disorders. METHODS: After approval of the ethical committee and informed consent between the ages of 18-65 years were obtained, 30 patients with an American Society of Anesthesiologist status I-III, who were mechanically ventilated, who had pulmonary disorders and who needed sedation were included in the study. Exclusion criteria were severe hepatic, pulmonary and renal failures; pregnancy; convulsion and/or seizure history; haemodynamic instability and no indication for sedation. Patients were divided into two groups by randomised numbers generated by a computer. For sedation, 0.5%-1% sevoflurane (4-10 mL h-1) was used by an Anaesthetic Conserving Device in Group S (n=15), and iv dexmedetomidine infusion (1 µg-1 kg-1 10 min-1 loading and 0.2-0.7 µg-1 kg-1 h-1 maintenance) was performed in Group D (n=15). Arterial blood gas analysis, airway resistance, positive end-expiratory pressure (PEEP), frequency, tidal volume (TV), peak airway pressure (Ppeak), static pulmonary compliance and end-tidal CO2 values were recorded at baseline, 1, 3, 6, 9, 12 and 24 h. RESULTS: Demographic data, airway resistance, PEEP, frequency, TV, Ppeak and static pulmonary compliance values were similar between the groups. PaCO2 and end-tidal CO2 values were higher in Group S than in Group D. Sedation and patient comfort scores were similar between the two groups. CONCLUSION: Both sevoflurane and dexmedetomidine are suitable sedative agents in ICU patients with pulmonary diseases.

Comparative study of ultrasound-guided paravertebral block versus intravenous tramadol for postoperative pain control in percutaneous nephrolithotomy.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is a minimally invasive surgical procedure for renal calculi, and nephrostomy tubes lead to postoperative pain after PCNL. Regional techniques (e.g., epidural analgesia and peripheral blocks) and opioids are applied for postoperative pain treatment. The aim of this study was to compare effectiveness of ultrasound-guided paravertebral block (PVB) and tramadol on postoperative pain in patients who underwent PCNL. METHOD: Fifty-three patients were included in this prospective randomized study. The patients were allocated into two groups: the PVB group (group P, n = 26) and the tramadol group (group T, n = 27). All patients were administered standard general anaesthesia. Ultrasound-guided PVB was performed at the T11- L1 levels using 0.5% bupivacaine for a total dose of 15 mL in group P. Patients in group T were intravenously administered a loading dose of 1 mg/kg tramadol. Patients in both groups were given patient-controlled analgesia. Haemodynamic parameters, visual analogue scale (VAS) scores, side effects, and complications, tramadol consumption and additional analgesic requirements of the patients were recorded after surgery. RESULTS: Haemodynamic parameters were statistically similar between the groups. The VAS in group P were statistically lower than in group T. In the 24-h period after surgery, total PCA tramadol consumption was statistically lower in group P than in group T. The use of supplemental analgesic in group T was higher than in group P. CONCLUSIONS: Ultrasound-guided PVB was found to be an effective analgesia compared to tramadol, and no additional complications were encountered. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02412930 , date of registration: March 27, 2015, retrospectively registered.

Comparison of the cardioprotective effects of dexmedetomidineand remifentanil in cardiac surgery

Background/aim: Myocardial protection is an important factor of open heart surgery and biological biomarkers (lactate, CKMB, cardiac troponin I, and pyruvate) are used to assess myocardial damage. This study compares the effects of dexmedetomidine and remifentanil on myocardial protection during coronary artery bypass grafting (CABG) surgery. Materials and methods: Patients scheduled for elective CABG surgery (n = 60) were included in this study. Anesthesia induction was introduced with propofol, fentanyl, and vecuronium bromide. Anesthesia was maintained with remifentanil infusion and sevoflurane in the remifentanil group (Group R) and with dexmedetomidine infusion and sevoflurane in the dexmedetomidine group (Group D). Blood samples for biochemical markers were taken from the coronary sinus catheter before cardiopulmonary bypass (T1), 20 min after aortic cross-clamping (T2), 20 min after removal of the aortic cross-clamping (T3), and 10 min after separation from cardiopulmonary bypass (T4).Results: Demographic data were similar between the groups. Lactate level at the T2 period and CKMB levels during the study period were lower in Group D than in Group R. In both groups, all values except pyruvate significantly increased over time. Conclusion: The dexmedetomidine-sevoflurane combination may improve the cardioprotective effect in comparison with remifentanil-sevoflurane in CABG surgery.

Community acquired infections among refugees leading to Intensive Care Unit admissions in Turkey.

OBJECTIVES: Data on the impact of refugees on Intensive Care Units (ICUs) are lacking in the literature, in particular for community-acquired (CA) infectious diseases, for which they are known to be at higher risk. We did a descriptive, multicenter study to analyze CA infections among refugee patients requiring ICU admission. METHODS: Inclusion criteria were adult refugee patients admitted to an ICU due to CA infections. Anonymized data were collected between January 1, 2010 and December 30, 2015 across 10 referral centers. RESULTS: 29.885 patients were admitted to the ICUs in the study period. 37 patients were included the study, the majority were from Syria (n=31, 83.8%). Mean (SD) age of the patients was 45.92±20.16years. The 5-year prevalence rate was 123.8 per 100.000 patients in the ICUs. All patients had at least one comorbid condition. Forty-nine CA infections were diagnosed. The most common CA infection was pneumonia (49%) followed by urinary-tract infections (16.3%). 21 patients (56.7%) hospitalized in the ICU had trauma history. Mortality rate was high at 22 patients (59.5%) with 5 (22.7%) deaths directly attributed to CA infections. CONCLUSIONS: Refugees presented to ICUs with CA infections similar to the host populations (pneumonia and urinary-tract infections) but had high mortality rates (59.5%). It seems that Turkish ICUs were not congested with the refugee patients' influx for CA infections. More research needs to be done to better understand how to deliver preventative and timely health care services to this group of patients.

Comparing the Laryngeal Mask Airway, Cobra Perilaryngeal Airway and Face Mask in Children Airway Management.

OBJECTIVE: We compared the effects of the laryngeal mask airway (LMA), face mask and Cobra perilaryngeal airway (PLA) in the airway management of spontaneously breathing paediatric patients undergoing elective inguinal surgery. METHODS: In this study, 90 cases of 1-14-year-old children undergoing elective inguinal surgery were scheduled. The patients were randomly divided into three groups. Anaesthesia was provided with sevoflurane and 50%-50% nitrous oxide and oxygen. After providing an adequate depth of anaesthesia, supraglottic airway devices were inserted in the group I and II patients. The duration and number of insertion, haemodynamic parameters, plateau and peak inspiratory pressure and positive end-expiratory pressure of the patients were recorded preoperatively, after induction and at 5, 10, 15 and 30 min peroperatively. RESULTS: There were no statistical differences between the groups in terms of haemodynamic parameters (p>0.05). In group II, instrumentation success was higher and instrumentation time was shorter than group II. The positive end-expiratory pressure and plateau and peak inspiratory pressure values were statistically lower in group II (p<0.05). CONCLUSION: We concluded that for airway safety and to avoid possible complications, LMA and Cobra PLA could be alternatives to face mask and that the Cobra PLA provided lower airway pressure and had a faster and more easy placement than LMA.

The Effect of Intravenous Dexamethasone on Sugammadex Reversal Time in Children Undergoing Adenotonsillectomy.

BACKGROUND: Dexamethasone has been shown to cause inhibition of sugammadex reversal in functionally innervated human muscle cells. In this prospective, double-blind, randomized, controlled study, we evaluated the effect of dexamethasone on the reversal time of sugammadex in children undergoing tonsillectomy and/or adenoidectomy. METHODS: We recruited 60 patients with ASA physical status I to II, between the ages of 3 and 8 years, scheduled for elective tonsillectomy and/or adenoidectomy. After the induction of anesthesia, patients in group D received IV dexamethasone at a dose of 0.5 mg/kg within a total volume of 5 mL saline, whereas patients in group S received only 5 mL IV saline as the control group. At the end of surgery, all patients were given a single bolus dose (2 mg/kg) of sugammadex at reappearance of T2. Demographic data, hemodynamic variables, time to recovery (a train-of-four ratio of 0.9), time to tracheal extubation, and adverse effects were recorded. RESULTS: There was no statistical significance between 2 groups in time to recovery and time to extubation. Time to recovery was 97.7 ± 23.9 seconds in group D and 91.1 ± 39.5 seconds in group S (P = 0.436; 95% confidence interval, -10.3 to 23.5). Time to extubation was 127.9 ± 23.2 seconds and 123.8 ± 38.7 seconds in group D and in group S, respectively (P = 0.612; 95% confidence interval, -11.9 to 20.05). CONCLUSIONS: IV dexamethasone, given after induction of anesthesia, at a dose of 0.5 mg/kg, does not substantively affect the reversal time of sugammadex in pediatric patients undergoing adenoidectomy and/or tonsillectomy.

The anesthesia of trachea and bronchus surgery.

The trachea and bronchus surgery is generally performed due to stenosis, traumatic injury, foreign body and tumors. Preoperative evaluation and anesthesia management are very important issues because of higher mortality and morbidity rates. Patients may be asymptomatic, but airway difficulties, hypoxia, stridor, cough, hemoptysis are common conditions in these patient population. The collaboration between the surgeon and the anesthesiologist is very substantial and necessary. Anesthetic techniques include various applications such as one lung ventilation, fiberoptic intubation, jet ventilation, and apneic oxygenation, general anesthesia with or without neuromuscular blockade. In this review, anesthesia management of the trachea and bronchus surgery is evaluated in the light of new knowledge.

Preoperative informational video reduces preoperative anxiety and postoperative negative behavioral changes in children.

BACKGROUND: Anesthesia and surgery can lead to major distress for children. Sedative premedication and preoperative preparation techniques are available to reduce preoperative anxiety in children. We aimed to assess the effect of informational video based on role-play modelling on preoperative anxiety and postoperative behavior changes in children undergoing surgery. METHODS: Forty-two children aged 5-12 years, with American Society of Anesthesiologist physical status I-II, scheduled for elective outpatient surgery, were enrolled in this study. Patients were randomly allocated to one group with or without information video presentation. In group V, patients watched the information video (N.=21). Other children were verbally informed in a standard care (group C, N.=21). We recorded patient's demographics (age, birth order, surgery time, surgery type, history of previous surgery, parent's age, parental working status, parental education level), the preoperative anxiety level using Modified Yale Preoperative Anxiety Scale (MYPAS) and at 1 week after discharge, new developing postoperative maladaptive behaviors (POMB) using the Post Hospitalization Behavioral Questionnaire by telephone interview. RESULTS: Patient's demographics were similar in both groups. Total MYPAS scores were found to be lower in group V as compared to group C P=0.0001). Difficulty getting to sleep, nocturnal enuresis, fear of dark, to object to go to bed at night and decreased appetite of new developing POMB were found to be lower in group V than group C. We also found a correlation between anxiety scores and POMB. CONCLUSIONS: The presentation of an informational video based on model making reduces preoperative anxiety at the time of placement of the facemask and postoperative negative behavioral changes in children.

Cusum analysis for learning curve of videothoracoscopic lobectomy.

BACKGROUND: Video assisted thoracoscopic (VATS) lobectomy has a demanding learning curve due to its technical complexity and risk of uncontrollable bleeding. We investigated the case number required for gaining technical proficiency by applying cumulative sum analysis on initial VATS lobectomy operations of a single surgeon. METHODS: CALGB definition was used for the definition of VATS lobectomy. The data of the initial cases evaluated and cumulative sum (CUSUM) analysis was applied to duration of the operations and length of hospital stay. RESULTS: Fifty-eight patients underwent VATS lobectomy. Of those 51 were malignant and 7 were benign. Fifty-five of the procedures were lobectomy, 2 were inferior bi-lobectomy and 1 was left upper lobectomy with chest wall resection. CUSUM analysis reached to proficiency at 27 cases for duration of the operations. CONCLUSIONS: The length of learning curve depends on previous experience of the surgeon on open lobectomy and simpler VATS operations, potential number of VATS lobectomy cases and VATS capability of the surgeon. Depending on these factors, it is possible to obtain technical proficiency with an inferior number of procedures compared with existing literature (50-200).

Comparison between minimal right vertical infra-axillary thoracotomy and standard median sternotomy for repair of atrial septal defects.

BACKGROUND: The minimal right vertical infra-axillary thoracotomy could be a safe and cosmetic alternative to standard median sternotomy. This study reviews our results and experience with a minimal right vertical infra-axillary thoracotomy technique for the repair of atrial septal defects compared with standard median sternotomy. METHODS: The study was designed as a retrospective, observational, and case-controlled study. Between May 2007 and November 2012, 26 patients underwent atrial septal defect closure with standard median sternotomy (Group 1). This group was compared with 21 patients who underwent repair of atrial septal defects using minimal right vertical infra-axillary thoracotomy (Group 2). Quantitative data were given as mean ± standard deviation, and qualitative values were expressed as percentages. In the comparison of the normal variables between the two groups, we used independent sample t test, and in the comparison of categorical variables between groups, Chi-square test was used. RESULTS: The mean length of incision was significantly shorter in Group 2 than in Group 1 (p = 0.03). The time it took to establish cardiopulmonary bypass was longer in Group 2 (p = 0.04). There were no statistically significant differences in cardiopulmonary bypass time (p = 0.11), aortic cross-clamp time (p = 0.10), and total operation time (p = 0.10) between the two groups. Group 2 had less chest tube drainage (p = 0.04), less blood transfusion (p = 0.02), and shorter postoperative mechanical ventilation time (p = 0.09) than Group 1. CONCLUSION: Minimal right vertical infra-axillary thoracotomy can be performed with favorable cosmetic and clinical results for atrial septal defects closure. Infra-axillary thoracotomy provides a good alternative to standard median sternotomy for patients with atrial septal defects.

The Effect of Intravenous Magnesium Sulphate Treatment on the Spinal Anaesthesia Produced by Bupivacaine in Pre-eclamptic Patients.

OBJECTIVE: In our study, the effect of intravenous magnesium sulphate in normal and pre-eclamptic patients on spinal anaesthesia produced by bupivacaine was investigated. METHODS: Sixty-four pregnant (32 normal and 32 pre-eclamptic) were accepted in this study. Pregnants were divided into four groups as patients given intravenous magnesium sulphate and as control. Spinal anaesthesia was induced with 12.5 mg 0.5% hyperbaric bupivacaine. Intraoperative and postoperative haemodynamic variables, sensorial block periods, onset times of sensorial and motor block, maximum sensorial block levels, the time to reach maximum block level, Bromage scores, consumptions of intraoperative analgesic and ephedrine, the quality of anaesthesia, the duration of spinal anaesthesia and magnesium levels in blood and cerebrospinal fluid were measured and recorded. RESULTS: The level of magnesium in blood and cerebrospinal fluid was significantly higher in the group given magnesium in pre-eclamptic patients (p<0.01). Onset of sensory block times were significantly longer in intravenous magnesium group than in groups 1, 2 and 3 (p<0.05). Onset of motor block times were significantly longer and the duration of anaesthesia was shorter in groups given magnesium (p<0.05). Although the quality of anaesthesia was similar, supplemental analgesic consumption was significantly higher in pre-eclamptic pregnants given magnesium sulphate than in pre-eclamptic pregnants who were not given magnesium sulphate (p<0.05). CONCLUSION: Intravenous magnesium sulphate treatment during the spinal anaesthesia produced by bupivacaine extended the onset of sensory and motor block times, shortened the duration of spinal anaesthesia and therefore led to early analgesic requirement.

Ultrasound-Guided Rectus Sheath Block in Gynaecological Surgery with Pfannenstiel Incision.

OBJECTIVE: This study aimed to evaluate the effects of ultrasound-guided rectus sheath block in gynaecological surgery with Pfannenstiel incision. METHODS: After the approval of the ethics committee and the patients' consent, 75 ASA I-II patients who were aged between 20 and 70 years and scheduled for a gynaecological surgery with Pfannenstiel incision were included in this study. After induction of general anaesthesia, patients were randomly divided into three groups. In Group UR patients (n=25), ultrasound-guided rectus sheath block with 0.25% levobupivacaine (0.2 mL kg(-1)) was performed. In Group SR patients (n=25), surgical rectus sheath block with 0.25% levobupivacaine (0.2 mL kg(-1)) was applied. In Group T (n=25) patients, tramadol (2 mg kg(-1)) was intravenously administered 30 min before the end of surgery. Patient-controlled analgesia device was established for postoperative pain relief in all groups. Haemodynamic data and inspired sevoflurane concentration were recorded during the operation. Pain scores, total tramadol consumption, supplemental analgesic requirement and side effects were postoperatively evaluated. RESULTS: Demographic characteristics, duration of surgery and haemodynamic parameters were similar between the groups. Inspired sevoflurane concentration (%) and VAS scores were significantly lower in Group UR than those in Groups SR and T. Total tramadol consumption was significantly lower in Groups UR and SR than that in Group T. There was no significant difference in the incidence of side effects. CONCLUSION: This study demonstrates that ultrasound-guided rectus sheath block helps to provide the effective analgesia without any side effects compared with surgical rectus sheath block and intravenous tramadol for gynaecological surgery with Pfannenstiel incision.