Alparslan Kus

The LMA-Supreme versus the I-gel in simulated difficult airway in children: a randomised study.

BACKGROUND Supraglottic airway devices such as the LMA-Supreme (LMA-S) and I-gel, which have an additional lumen for the insertion of a gastric tube, can be useful in the management of the difficult airway. OBJECTIVE To test the performance of these two devices in the difficult paediatric airway. DESIGN Randomised double-blind study. SETTING Anaesthesia department, university hospital. PATIENTS Sixty American Society of Anesthesiologists (ASA) I-II children undergoing elective surgery. INTERVENTION After obtaining ethical approval and written informed consent from the parents, we compared the size 2 LMA-S with the I-gel in a simulated airway scenario made more difficult by using a cervical collar to limit mouth opening and neck movement. MAIN OUTCOME MEASURES The primary aim was to compare the oropharyngeal leak pressure of the LMA-S and the I-gel. The secondary aims were to compare success rate, insertion time, time to pass a gastric tube and fibreoptic view of the larynx. RESULTS Oropharyngeal leak pressure (mean ± SD) for the LMA-S was significantly higher than with the I-gel (20.9 ± 3.2 versus 18.9 ± 3.2 cmH2O, P = 0.019). First attempt success rate for the LMA-S was 100 and 90% for the I-gel (P > 0.05). Insertion time of the LMA-S was shorter than I-gel (11.2 ± 1.8 versus 13.5 ± 2.4 s, P = 0.001). Gastric tube placement was possible in all patients. The mean insertion time of the gastric tube was shorter with the LMA-S than with the I-gel (10.3 ± 3.6 versus 12.7 ± 3.2 s, P = 0.009). Fibreoptic laryngeal views were similar in both groups. CONCLUSION In the simulated difficult airway in children, both airway devices provided effective ventilation. Paediatric size 2 LMA-S sustained a higher airway pressure before leaking and was quicker to insert than the I-gel equivalent. These differences may not be clinically significant.

Pleural Puncture and Intrathoracic Catheter Placement During Ultrasound Guided Paravertebral Block

percutaneous puncture could cause catheter fracture owing to compression of the catheter between the clavicle and the first rib (catheter pinch off syndrome). Other causes include catheter material faults and alterations of the material’s mechanical properties, probably due to the administered sub stances; however, there are no data to support the effect of administered substances. Migration of these broken fragments can lead to very serious complication like myocardial and valvular perforation, arrhyth mia, thrombotic pulmonary embolism and cardiac arrest. Infec tious complications include endocarditis, secondary infection of thrombus, mycotic aneurysm, and pulmonary abscesses. The difficulty in injection or swelling over the intraport are the most common clinical presentation in the different studies. Regular follow up chest X ray is necessary because most of the patients developed catheter fracture in the first year. Ruptured catheters are best removed by interventional radiologic technique. In rare cases surgical intervention may be needed. This complication could be prevented by avoiding inserting the puncture needle directly underneath the clavicle. It should be inserted at some distance away from the lower edge of the clavicle. The catheter may be designed more ‘‘flexible’’ to reduce the obvious gap of ‘‘firm soft’’.

The Gorham-Stout syndrome: one lung ventilation with a bronchial blocker. A case of Gorham's disease with chylothorax.

the use of a glidecope can be valuable in attaining a superior view of the anterior palatoglossal arch to block the glossopharyngeal nerve (Figure 1) and can be especially useful in infants when direct visualization may be difficult. The advantage of using the glidescope is the ability to displace the tongue downward and laterally with a magnified and illuminated view of the anatomic structures when compared to the traditional technique of direct visualization with a tongue depressor. A limitation for both the glidescope and tongue depressor is the potential for gagging when topical anesthesia of the tongue is inadequate. This is of particular concern in neonates and small infants in whom small volumes can result in toxic doses of local anesthetic solution. We are currently in the process of collecting data on a series of patients with known airway difficulty in which the glossopharyngeal nerves were blocked resulting in better tolerance of LMA insertion in awake infants. Narasimhan Jagannathan* Lisa E. Sohn† Santhanam Suresh *Assistant Professor of Anesthesiology, Northwestern University Feinberg School of Medicine, Children’s Memorial Hospital, Chicago, IL, USA †Instructor in Anesthesiology, Northwestern University Feinberg School of Medicine, Children’s Memorial Hospital, Chicago, IL, USA Professor of Anesthesiology and Pediatrics, Northwestern University Feinberg School of Medicine, Children’s Memorial Hospital, Chicago, IL, USA (email: simjag2000@yahoo.com) References

A Comparison of the EZ-Blocker With a Cohen Flex-Tip Blocker for One-Lung Ventilation

OBJECTIVES The EZ-Blocker (IQ Medical Ventures BV, Rotterdam, Netherlands) is a newly designed device for one-lung ventilation. The aim of this study was to compare the effectiveness of the Cohen Flex-Tip bronchial blocker (Cook, Bloomington, IN) and the EZ-Blocker for one-lung ventilation during thoracic surgery. DESIGN Randomized and prospective. SETTING A university hospital. PARTICIPANTS This study included 40 patients undergoing thoracic surgical procedures. INTERVENTIONS Patients were assigned to 2 study groups: Patients who received the Cohen Flex-Tip blocker were assigned to the Cohen group, and patients who received the EZ-Blocker were assigned to the EZ group. In both groups, fiberoptic guidance was used during placement of the bronchial blockers. Comparisons between the groups included the time to correct placement, the incidence of malpositioning, and the satisfaction level of the surgeon (good, fair, poor). MEASUREMENTS AND MAIN RESULTS One-lung ventilation was achieved successfully for all patients. The time to correct placement (mean±SD) was significantly shorter in the EZ group (146±56 seconds) compared with the Cohen group (241±51 seconds; p=0.01). The incidence of malpositioning was significantly lower in the EZ group compared with the Cohen group (p=0.018). Surgeon satisfaction was similar in both groups. CONCLUSIONS In this study, both bronchial blockers provided similar surgical exposure during thoracic procedures. The EZ-Blocker had a shorter time to correct positioning and less frequent intraoperative malpositioning.

Survey on Postoperative Hypothermia Incidence In Operating Theatres of Kocaeli University

OBJECTIVE Hypothermia is a common problem in anaesthetized patients and an important risk factor for mortality and morbidity. Our aim was to identify the incidence of hypothermia in our operating theatres. We also aimed to find the circumstances to which hypothermia could be related. METHODS After obtaining the ethics committee approval and informed patient consent, patients with operation times longer than 30 minutes were included into the study for a one month period. Demographical data of the patients, type and duration of surgeries, temperatures measured pre and postoperatively from the tympanic membrane with an infrared thermometer were recorded. Temperatures below 35°C were accepted as hypothermia. RESULTS A total number of 564 patients were enrolled to the study (305 women and 259 men). The ages of patients varied from 1 month to 84 years (mean 38.5±20.7). Hypothermia incidence was calculated as 45.7%. When the factors related to hypothermia were considered, age, type and duration of surgery and amount of fluids administered were found to be significant contributors to the development of hypothermia (p<0.05). CONCLUSION Postoperative hypothermia is a common problem in our clinic. Therefore, we suggest that temperature monitoring and patient warming should be a routine procedure during anaesthesia management.

Comparison of Supreme Laryngeal Mask Airway and ProSeal Laryngeal Mask Airway during Cholecystectomy.

OBJECTIVE This study compared the safety and efficacy of the Supreme Laryngeal Mask Airway (S-LMA) with that of the ProSeal-LMA (P-LMA) in laparoscopic cholecystectomy. MATERIAL AND METHODS Sixty adults were randomly allocated. Following anaesthesia induction, experienced LMA users inserted the airway devices. RESULTS Oropharyngeal leak pressure was similar in groups (S-LMA, 27.8±2.9 cmH2O; P-LMA, 27.0±4.7 cmH2O; p=0.42) and did not change during the induction of and throughout pneumoperitoneum. The first attempt success rates were 93% with both S-LMA and P-LMA. Mean airway device insertion time was significantly shorter with S-LMA than with P-LMA (12.5±4.1 seconds versus 15.6±6.0 seconds; p=0.02). The first attempt success rates for the drainage tube insertion were similar (P-LMA, 93%; S-LMA 100%); however, drainage tubes were inserted more quickly with S-LMA than with P-LMA (9.0±3.2 seconds versus 14.7±6.6 seconds; p=0.001). In the PACU, vomiting was observed in five patients (three females and two males) in the S-LMA group and in one female patient in the P-LMA group (p=0.10). CONCLUSION Both airway devices can be used safely in laparoscopic cholecystectomies with suitable patients and experienced users. However, further studies are required not only for comparing both airway devices in terms of postoperative nausea and vomiting but also for yielding definitive results.

Comparison of forced-air warming systems in prevention of intraoperative hypothermia

In this study, we aimed to compare the effects of forced-air warming upper body blankets and forced-air warming underbody blankets on intraoperative hypothermia in patients who were planned to undergo open abdominal surgical operations in which extensive heat loss occurs. This prospective and randomized study included 92 patients who would undergo lower abdominal surgery under general anesthesia. Patients were randomized by closed envelope method and divided into two groups. Group I (n:46) included the patients who would receive warming with forced-air warming upper body blanket, and Group II (n:46) consisted of the patients who received warming with forced-air warming underbody blanket. Central body temperature was recorded by measuring with a temperature probe placed in distal esophagus. Demographic data, amount of fentanyl, crystalloid and blood products used, duration of operation, type of operation, hemodynamic parameters, shivering and thermal damage information were recorded. There was not any statistically significant difference among the patients in terms of demographic data, amount of fentanyl, crystalloid and blood products used, duration and type of operation and hemodynamic parameters. No difference was found between the groups in terms of body temperatures (Group I:36.1 °C, Group II:36.3 °C, respectively) (P > 0.05). Forced air warming underbody blanket can be as effective as forced-air warming upper body blankets in preventing intraoperative hypothermia. They can be alternative in cases where use of forced-air warming upper body blankets is not feasible.

Ultrasound guided erector spinae plane block reduces postoperative opioid consumption following breast surgery: A randomized controlled study

STUDY OBJECTIVE To evaluate the analgesic effect of ultrasound-guided erector spinae plane (ESP) block in breast cancer surgery. DESIGN Randomized controlled, single-blinded trial. SETTING Operating room. PATIENTS Fifty ASA I-II patients aged 25-65 and scheduled for elective breast cancer surgery were included in the study. INTERVENTIONS Patients were randomized into two groups, ESP and control. Single-shot ultrasound (US)-guided ESP block with 20 ml 0.25% bupivacaine at the T4 vertebral level was performed preoperatively to all patients in the ESP group. The control group received no intervention. Patients in both groups were provided with intravenous patient-controlled analgesia device containing morphine for postoperative analgesia. MEASUREMENTS Morphine consumption and numeric rating scale (NRS) pain scores were recorded at 1, 6, 12 and 24 h postoperatively. MAIN RESULTS Morphine consumption at postoperative hours 1, 6, 12 and 24 decreased significantly in the ESP group (p < 0.05 for each time interval). Total morphine consumption decreased by 65% at 24 h compared to the control group (5.76 ± 3.8 mg vs 16.6 ± 6.92 mg). There was no statistically significant difference between the groups in terms of NRS scores. CONCLUSIONS Our study findings show that US-guided ESP block exhibits a significant analgesic effect in patients undergoing breast cancer surgery. Further studies comparing different regional anesthesia techniques are needed to identify the optimal analgesia technique for this group of patients.

The Role of Preoperative Evaluation for Congenital Methemoglobinemia.

Preoperative care includes a clinical examination before invasive or non-invasive interventions for anaesthesia/analgesia and is the responsibility of the anaesthesiologists. Methemoglobinemia should be considered, as well as cardiac, pulmonary, and peripheral circulatory disorders in patients with central cyanosis and low oxygen saturation despite treatment with sufficient oxygen during anaesthesia. Methemoglobinemia is a serious clinical condition, associated with increased blood methemoglobin levels characterized by clinical signs, such as cyanosis and hypoxia due to lack of oxygen-carrying capacity. Here, we present our anaesthesia management in a patient with unnoticed congenital methemoglobinemia during preoperative evaluation, in whom clinical signs of methemoglobinemia developed after local anaesthesia administration before the surgery.

Fascial Plane Blocks in Regional Anaesthesia and New Approaches

We read the article on pectoral block and pain in breast surgery, which was published in the April 2017 issue of Turkish Journal of Anaesthesiology and Reanimation, with great interest (1). Despite different mechanisms of action, the application of opioids, non-steroid anti-inflammatory agents and, if appropriate, regional methods in postoperative pain treatment is very important in terms of efficient postoperative analgesia, effective suppression of surgical stress and decreasing the incidence of chronic pain (2).