Ali Alagöz

Performance evaluation of MR-proadrenomedullin and other scoring systems in severe sepsis with pneumonia

BACKGROUND In sepsis, risk assessment is as crucial as early and accurate diagnosis. In this study, we aimed to evaluate the prognostic value of mid-regional proadrenomedullin (MR-proADM) with other scoring systems in severe sepsis and septic shock patients due to community acquired pneumonia (CAP). METHODS Patients were divided into 2 groups as severe sepsis and septic shock due to CAP (group 1, n=31) and only CAP group (group 2, n=26). Serum MR-proADM, procalcitonin (PCT), C-reactive protein (CRP), and d-dimer level were analyzed. Acute Physiological and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment (SOFA) score, and Pneumonia Severity Index (PSI) were performed for all patients. RESULTS There was no difference between groups in terms of serum MR-proADM levels (P=0.780). Serum MR-proADM was not found a significant value for the prediction of death within the 4 and 8 weeks in all patients. SOFA score was the most significant to predict mortality in 4 and 8 weeks (P<0.001). The combination of SOFA score and serum MR-proADM was a strong factor to predict death in 4 weeks (specifity 86.8% and sensitivity 66.7%). The combination of MR-proADM, SOFA score, and APACHE II score was found 75.0% sensitive and 71.4% specific to predict mortality within 4 weeks in group 1. CONCLUSIONS The MR-proADM does not correlate with mortality or disease severity to predict mortality. The combination of SOFA, APACHE II scores, and MR-proADM was efficient to predict prognosis and mortality rate in severe sepsis or septic shock patients.

Absence of the Right Internal Jugular Vein During Ultrasound-Guided Cannulation

Cannulation of the internal jugular vein (IJV) may be diffucult because of anatomical variations. A 66-year-old female patient, who was in the intensive care unit, underwent ultrasound-guided cannulation of the right IJV. The right IJV could not be visualized by ultrasonography despite positional changes of the patient and Valsalva maneuvre. The left IJV was easily determined by ultrasonography and cannulated. Although the landmark technique may be sufficient for most of the central vein cannulations, the rate of anatomical variations and related complications is quite high. We point out that even if ultrasound cannot be used in real-time, the ultrasonographic confirmation during the pre-insertion period may be crucial for successful central vein cannulation.

Assessment of Perianesthesic Data in Subjects Undergoing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

BACKGROUND: Transbronchial needle aspiration using endobronchial ultrasonography (EBUS-TBNA), a new minimally invasive diagnostic procedure, has been used to evaluate intrathoracic lymph nodes. It has been reported that EBUS-TBNA can be performed safely under sedation and provides a high level of patient satisfaction. We aimed to describe perianesthetic data, and compare results regarding the agents of subjects undergoing EBUS-TBNA under deep sedation. METHODS: After ethics committee approval, perianesthetic data of 571 subjects undergoing EBUS-TBNA were analyzed retrospectively. Data were collected from anesthesia evaluation and observation forms. Four groups received anesthesia in the operating room as follows: propofol-midazolam (group PM), propofol-ketamine (group PK), propofol-ketamine-midazolam (group PKM), or propofol (group P). Dosage, number of anesthetic injection, hemodynamic variables, recovery time, complications, and patient satisfaction were also recorded. RESULTS: Propofol consumption was higher in groups P and PM compared with groups PK and PKM. Midazolam requirement was higher in group PM than in group PKM. Recovery time was shorter in group P compared with groups PK, PM, and PKM. It was also shorter in groups PK and PM compared with group PKM. All of these differences were statistically significant. Temporary desaturation (n = 41; 7%) and increased blood pressure (n = 78; 14%) were predominant complications. In groups PK and PKM, risk of developing hypertension was higher than in groups PM and P (P < .001). The percentage of subjects satisfied with the procedure was 99%. CONCLUSIONS: Independent from the sedative agent, deep sedation can be safe, and provide high patient satisfaction during EBUS-TBNA. The combination of ketamine with propofol or midazolam required lower doses of these anesthetics. However, the incidence of increased blood pressure was higher in groups administered ketamine. Recovery time was the shortest in group P, and the longest in group PKM. There was no relation between recovery time and total dose of anesthetics or presence of chronic disease.

EBUS may arise as an initial time saving procedure in patients who are suspected to have small cell lung cancer.

Small cell lung cancer (SCLC) commonly presents as hilar/mediastinal masses. In some occasions, conventional flexible bronchoscopy fails and a substantial amount of time is lost until establishing the diagnosis.

High‐Frequency jet ventilaton during resection of tracheal stenosis in a 14‐year‐old case

for elongation sinewes Achilis because of her main disease paralysis cerebralis spastica. She was also diagnosed pyruvate dehydrogenase deficiency in the year of 2, since when she had thiamine in therapy. Clinically, the child had developmental delay, facial dysmorphism (Figure 1), weakened hearing and could not stand. CT scan showed agenesis of the corpus callosum and frontal corns of the lateral chambers. Laboratory studies revealed elevated lactate and pyruvate levels with normal L ⁄ P ratio. Blood gas analyses were within referent values, there was no acidosis. After premedication with midazolam and atropine, anesthesia was induced with propofol and vecuronium. Intubation was difficult, but successful after third attempt. Anesthesia was maintained with fentanyl, vecuronium and nitrous oxide with oxygen. Intravenously she was given normal saline solution throughout the operation. The procedure lasted for 1 h in which time she received fentanyl 3 lgÆkg total, and propofol 3 mgÆkg. Monitoring included pulse oximetry, NIBP and capnography. Blood gas analysis at the end of the operation showed no changes. Serum blood lactate level was increased, but the same as preoperatively. She was extubated in the operating room and sent to ward in good condition. Pyruvate dehydrogenase complex deficiency (PDCD) is genetic disorder associated with abnormal mitochondrial metabolism. PDC catalyses conversion of pyruvate to acetyl-CoA which enters the tricarboxylic acid cycle and its deficiency results in energy deficit. In this age it is usually a milder form of disease. Anesthesia can be complicated by the PDCD. There are no many reports about children with this metabolic disorder who went to general anesthesia. According to them, the most important is to avoid stress which could aggravate energy production in already impaired carbohydrate metabolism and increase lactate level and decline the acidosis (1). It is recommended to avoid lactated solutions and to monitor acid base status during surgery (2). In both mentioned cases anesthesia was maintained with volatile anesthetic and there were no complications. Considering the previous recommendations we can only add that intravenous anesthesia with propofol and analgesia with opioid analgesic can be safe for patient with PDCD. Also it is important to estimate the difficulty of intubation preoperatively and to be prepared. Irina Milojevic* Dusica Simic† *Department of Anesthesiology University Children’s Hospital Belgrade, Serbia (email: mirina@sbb.co.yu) †ICU University Children’s Hospital Belgrade, Serbia (email: dussin@eunet.yu)

The Effects of Local Anaesthetics on QT Parameters during Thoracic Epidural Anaesthesia Combined with General Anaesthesia: Ropivacaine versus Bupivacaine

BACKGROUND Many studies focusing on the effects of local anaesthetics on QT intervals have been performed, but the articles evaluating the relationship between thoracic epidural anaesthesia combined with general anaesthesia and QT parameters are very limited. AIMS We aimed to compare the effects of bupivacaine and ropivacaine on QT interval, corrected QT, dispersion of QT, and corrected dispersion of QT in patients undergoing lung resection under thoracic epidural anaesthesia combined with general anaesthesia. STUDY DESIGN Prospective clinical study. METHODS Thirty ASA physical status 1-3 patients requiring thoracic epidural anaesthesia combined with general anaesthesia for thoracic surgery. Patients were randomly assigned to two groups, which were allocated to receive either bupivacaine (Group B) or ropivacaine (Group R) during thoracic epidural anaesthesia. Following haemodynamic monitoring, a thoracic epidural catheter was inserted. Local anaesthetic at an average dose of 1.5 mL/ segment was given through an epidural catheter. The same general anaesthesia protocol was administered in both groups. Records and measurements were performed on 10 phases that were between the thoracic epidural catheter insertion to the 5(th) min of endobronchial intubation. In all phases, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, heart rate, peripheral O2 saturation, and electrocardiogram monitoring were performed in patients. All QT parameters were recorded by 12-lead electrocardiogram and analysed manually by a cardiologist. RESULTS QT intervals were similar between two groups. In Group R, corrected QT values at the 20(th) min of local anaesthetic injection and the 5(th) min of endobronchial intubation were shorter than those in Group B (p<0.05). The basal dispersion of QT and dispersion of QT values at the 1(st) min of propofol injection were shorter than those in Group R (p<0.05). The corrected dispersion of QT value at the 1(st) min of propofol injection was shorter in Group R (p<0.05). In Group R, the decrease in mean arterial pressure at the 1st min of fentanyl injection was significant compared with Group B (p<0.05). There was no significant difference between the groups with respect to heart rate and complications. CONCLUSION The corrected QT, dispersion of QT, and corrected dispersion of QT intervals were slightly longer in the patients receiving bupivacaine compared with those receiving ropivacaine in various phases of the present study.