Aslı Demir

Unilateral Antegrade Cerebral Perfusion and Moderate Hypothermia: Assessing Safety With Novel Biomarkers

BACKGROUND Antegrade cerebral perfusion in aortic surgery is a well-established brain protection method. Open distal anastomosis during aortic surgery has some well-known advantages. Antegrade cerebral perfusion allows repair to some extent of the aortic arch, even in isolated ascending aortic aneurysm. The present study aims to investigate the adequacy of contralateral perfusion with novel oxidative stress parameters during unilateral antegrade cerebral perfusion. METHOD The study included 30 consecutive patients undergoing thoracic aortic surgery with unilateral antegrade cerebral perfusion (uACP) under moderate hypothermia (28° C). Blood samples from right and left jugular vein were obtained at four time intervals during surgery (after the anaesthetic induction - Phase 1, at the beginning of cardiopulmonary bypass - Phase 2, 15th minute of uACP - Phase 3 and after weaning from cardiopulmonary bypass - Phase 4). Novel oxidative stress parameters (advanced oxidation protein products, sialic acid, thiol reagents and ischaemia-modified serum albumin), blood gas analysis, and serum glucose and lactate levels were measured. In addition, intraoperative and early postoperative follow-up parameters were recorded. RESULTS Mean unilateral antegrade cerebral perfusion time was observed to be 16.4±5.9min (9 - 46min). No significant differences between right and left hemispheres were observed in novel oxidative parameters or biochemical values. There was only one temporary neurological deficit (3.3%) in the patient group. CONCLUSIONS The present study demonstrated that open distal anastomosis for hemiarch repair can be performed safely with unilateral antegrade cerebral perfusion under moderate hypothermia with both clinical outcome and novel biomarkers.

Hematological predictors and clinical outcomes in cardiac surgery

PurposeThe present study was to investigate if five values that are part of the hemogram analysis routinely checked before heart surgeries can be used as a high-quality, quick, low-cost, and easy-to-use outcome predictor.MethodsThis investigation was a retrospective, observational, cross-sectional study. Univariate and multivariate logistic regression was used to identify independent predictors for combined adverse events. We enrolled 1500 consecutive patients who underwent elective, on-pump, open-heart surgery from 2011 to 2014. Preoperative hemogram evaluation, red cell distribution width (RDW), mean platelet volume (MPV), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR) were recorded. We classified combined adverse events (CAE) as (1) myocardial infarction, (2) cardiac reoperation, (3) prolonged mechanical ventilation, (4) prolonged hospital stay, (5) rehospitalization, or (6) mortality.ResultsIt was found that several parameters obtained as part of the hemogram, namely RDW, MPV, PLR, and NLR, can predict, individually or in combinations, the outcomes in open-heart surgery patients. It was found that the prediction success of NLR (4.8 fold) was higher compared to RDW (1.8 fold) and MPV (1.5 fold). When the prediction success of the combined parameters was investigated, the NLR–RDW (4.7 fold) pair was found higher in the prediction of CAE occurrence. The predictive success of the triple combination of NLR–MPV–RDW (5.5 fold) was higher than other combinations.ConclusionsThe triple combination of parameters obtained as part of the hemogram, NLR–RDW–MPV, indicated a much more predictive power than two parameters coupled. This combination of three parameters, NLR–RDW–MPV, is to be considered as a sensitive, high-quality, low-cost outcome prediction marker for cardiac surgery patients that is less time consuming and easy to use.

A comparison of the effects of ketamine and remifentanil on renal functions in coronary artery bypass graft surgery

Abstract We have investigated the effects of ketamine-based and remifentanil-based anesthetic protocol on perioperative serum cystatin-C levels, and creatinine and/or cystatin-C-based eGFR equations in terms of acute kidney injury in coronary artery bypass graft (CABG) surgery. Using a simple randomization method (coin tossing), patients were divided into the two groups and not-blinded to the anesthetist. Remifentanil–midazolam–propofol or ketamine–midazolam–propofol-based anesthetic regimen was chosen. Different eGFR formulas using creatinine (MDRD, CKD-EPI, Cockrauft Gault); cystatin-C (eGFR1, eGFR2) or a combination of creatinine and cystatin-C (eGFR 3) were used to calculate estimated glomerular filtration rates (eGFRs). High-sensitive troponin T was used to determine if ketamine use in coronary surgery contributed to myocardial cell damage. Thirty-seven patients were included in the study (remifentanil group = 19, ketamine Group = 18). Urea, creatinine, cystatin-C levels were comparable between the groups in all the measurement times and also postoperative day 2 samples showed statistically higher results compared to baseline (p < 0.001). Effects of ketamine and remifentanil on renal functions were found similar. Creatinine and cystatin-C-based eGFR equations resulted similar in our study. Reversible stage 1 acute kidney injury (AKI) was observed on postoperative day 2 in seven patients from the remifentanil group and six patients from the ketamine group. Hs-troponin T was found to be higher in postoperative day 1 samples; there were no significant difference between the groups. Our results indicated that patients who have normal renal functions undergoing on-pump coronary bypass surgery, effects of ketamine and remifentanil on renal functions in terms of AKI were found to be similar.

Thrombi migration to atrium diagnosed by transesophageal echocardiography

Two days before surgery in a 70-year-old man with renal cell carcinoma, transthoracic echocardiography showed a dense mass in the inferior vena cava, lying proximally, but no mass was observed in the right atrium. Intraoperative transesophageal echocardiography revealed unexpected tumor thrombi in the right atrium, and the surgical plan was changed. This case highlights the importance of intraoperative transesophageal echocardiography in patients with renal cell carcinoma.

Visceral oxidative stress during antegrade cerebral perfusion and lower body circulatory arrest

Abstract Background: Antegrade cerebral perfusion (ACP) is the standard neuroprotection method in aortic surgery. Visceral ischemia during this modality brings out some controversies. We aimed to investigate the level of oxidative stress at the lower part of body during ACP. Methods: Thirty consecutive patients underwent elective ascending aorta and hemiarch repair with ACP (without distal perfusion) were enrolled to study. The patients were enrolled into two groups which were based on 50th percentile of ACP duration (15 patients in each group). Blood samples from inferior vena cava at the end of ACP were collected to assess oxidative stress with biochemical parameters such as lactate, advanced oxidative protein products (AOPP) and thiol levels. Clinical follow-up parameters regarding to visceral and spinal cord ischemia were recorded. There were no clinical complications at both groups. Results: Mean ACP duration for the study group was found to be 15 min (10–28 min). Lactate, AOPP, and thiol levels were found to be similar between two groups. Furthermore, correlation analysis revealed only low level of correlation between ACP duration and lactate levels. Renal and liver function tests were found to be similar between groups. Conclusions: Immediate parameters (such as lactate, AOPP, and thiol) that show alterations in response to oxidative stress were not affected by the duration of ACP. Therefore, ACP without distal perfusion may not be harmful when conducted for short duration.

Postperfusion Syndrome in Cadaveric Liver Transplantations: A Retrospective Study.

OBJECTIVE To evaluate the factors that affects the postperfusion syndrome in cadaveric liver transplantations and the effect of the postperfusion syndrome on discharge from the hospital. METHODS Patients who underwent cadaveric liver transplantations between 2007 and 2013 were scanned retrospectively. Intraoperative anaesthesia records, intensive care unit follow-up forms and discharge reports were examined from patient files. Overall, 43 patients having complete data were included in the study. The postperfusion syndrome is defined as asystoli or a decrease in mean arterial pressure of more than 30%, which occurred in the first 5 min of reperfusion and continued for 1 min. Patients were divided into two groups: those who had the postperfusion syndrome and those who did not. RESULTS The number of patients who had the postperfusion syndrome was 25 of 43 (58.1%). The MELD score of patients without the postperfusion syndrome was calculated as 16.9±3.2 and that of patients with the postperfusion syndrome was 19.7±3.6. A statistically significant relationship was detected between the postperfusion syndrome occurrence and a high MELD score (p=0.013). The diastolic blood pressure just before reperfusion was statistically lower in the group with the postperfusion syndrome than in the other group (p=0.023, 50±8 vs. 58±11). According to the logistic regression analysis, the MELD score and the decrease in diastolic blood pressure before reperfusion were defined as independent predictive factors. CONCLUSION According to the study, the ratio for having the postperfusion syndrome was found to be 58.1%. The independent predictor factors affecting the postperfusion syndrome were detected as the MELD score and the decrease in diastolic blood pressure before reperfusion. The postperfusion syndrome during orthotropic liver transplantation is an important issue for anaesthesiologists. The awareness of the related factors with the postperfusion syndrome may help in the development of various preventive strategies.

Anaesthesia Application for Cardiac Denervation in a Patient with Long QT Syndrome and Cardiomyopathy.

Long QT syndrome is a congenital disorder that is characterized by a prolongation of the QT interval on electrocardiograms and a propensity to ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest or sudden death. Cardiomyopathy and pulmonary hypertension diseases have additional risks in anaesthesia management. In this study, we emphasize on one lung ventilation, pacemaker-implantable cardioverter-defibrillator and the anaesthesia management process in a patient with long QT syndrome, cardiomyopathy and pulmonary hypertension who underwent thoracic sympathectomy.

Intraoperative 16-Channel Electroencephalography and Bilateral Near Infrared Spectroscopy Monitorization in Aortic Surgery

Transient neurologic dysfunction is common after aortic surgery. Major causes of postoperative complications followed by cardiac surgery are due to hypoperfusion states such as selective cerebral perfusion, embolic debris during cardiopulmonary bypass and ulcerated plaque emboli originated from carotid arteries. Neurologic complications prolong periods of intensive care unit and hospital stay, worsens quality of life and unfortunately they are an important cause of morbidity. Anaesthesia during a carotid and aortic surgery constitutes of providing adequate brain perfusion pressure, attenuating cerebral metabolism by anaesthetic agents and monitoring the cerebral metabolic supply and demand relationship during the intraoperative period. We present a monitoring approach with an intraoperative 16-channel electroencephalography and bilateral near infrared spectroscopy during redo aneurysm of the sinus of Valsalva surgery.

Difficult Laryngeal Mask Airway Placement.

To the Editor; Laryngeal mask airway (LMA), which consists of a silicone tube connected to a miniature silicone mask appropriate for the shape of hypopharynx and covers the larynx as a gasket, was developed in 1980s in the United Kingdom. It is frequently used both to avoid negative effects of endotracheal intubation by establishing direct connection with the airway of patient and to easily provide a more reliable airway as compared to the facial mask. It has particular importance in difficult airway management and cardiopulmonary resuscitation since it can be successfully placed even by inexperienced users. Gel is applied to the posterior surface of the mask and it is placed blindly into the airway by pushing towards hypopharynx while the head of the patient is in extension position. Herein, we present a case, in which LMA could not be placed despite several attempts and a mass tissue was detected in the hypopharynx during laryngoscopy performed subsequently. An 81-year-old, 70 kg male patient was scheduled for cystoscopy in the urology clinic. Preanaesthetic evaluation revealed no pathology or concomitant disease except for advanced age. He had previously undergone prostate surgery under spinal anaesthesia. His Mallampati score was 3 and he had a large tongue (Figure 1). As the procedure was anticipated to take a short time and the patient, who had a high Mallampati score, did not want to be awake during the procedure, LMA was preferred for airway management. Figure 1 Examination image for Mallampati score Induction of anaesthesia was made with propofol, fentanyl and rocuronium, the patient was easily ventilated with a face mask, and an attempt was made to place a size 5 standard LMA; but as the mask, which was pushed forward, came back, it was thought that the mask was large for the patient and the attempt was repeated using a size 4 mask. However, as this attempt was also unsuccessful, it was thought that silicone tip of the balloon was folded; thus, I-Gel (size 4), which is a supraglottic airway device without a cuff and stands more stable, was tried to be placed. However as size 4 I-Gel LMA was pushed forward and ventilation was initiated, a significant air leakage occurred, and considering that size 4 was small, we again tried using size 5. However, observing substantial amount of air leak at the end of all these attempts, LMA was planned to be placed under laryngoscopic guidance. Airway examination, which was performed by a Macintosh laryngoscope, revealed a 2×2 cm mass located at the base of the hypopharynx, covered by normal mucosa, and appeared to be neither cystic nor ulcerated (Figure 2). It was thought that the mass, which was located at the same place where LMA device was placed, caused the tip of standard LMAs to be folded or remain between the mass and pharyngeal tissue, and hindered I-Gel LMA to closely fit after being placed and caused leakage from the back of the device, and consequently the attempts were unsuccessful. The patient, of whom Cormack-Lehane score was 2, was then intubated by size 8 endotracheal tube. We encountered no problem during intraoperative period and the patient was extubated without problem at the end of the procedure that lasted for 45 minutes; he was recommended to refer to the ENT outpatient clinic. Meanwhile, consent of the patient was obtained for presenting his case as a case report. Figure 2 The appearance of the mass through the laryngoscope Unforeseen dangers might have been in question because of blindly placed LMA, in this patient who had a deeply localized asymptomatic lesion that could not be detected by routine airway examination. If this mass located in the hypopharynx, had been cystic, it would have been perforated during the attempts to place the LMA and would have led to serious consequences by the spread of cyst content into the lungs. Again, if it had been a vascular mass like a haemangioma, it would have been difficult to control the unexpected bleeding. Lingual tonsil hyperplasia, which is more common in paediatric cases, may lead to similar problems (1, 2). Although blind placement of LMA without using a laryngoscope is an advantage, it may turn into a disadvantage in complicated cases and may lead to various problems. In case of recurrent failure while placing a supraglottic device, an airway disorder, as well as common problems such as incompatibility between device and patient anatomy and folded balloon, should be considered and attempts should aim at performing non-traumatic interventions as much as possible without insisting on blind replacement.

Anksiyete Bozukluğu Olan Yoğun Bakım Hastasında Gecikmiş Trakeal Stenoz Tanısı

Endotrakeal entubasyon veya trakeostomi yogun bakim hastalarinda mekanik ventilasyon destegi icin kullanilabilir ve bu nedenlerle yogun bakimda uzun sure izlenen hastalarda cesitli psikiyatrik sorunlar da gorulebilir. Gerek entubasyon veya trakeostomi sonrasi olusabilen hava yolu hasari, gerek psikiyatrik sorunlar ciddi solunum sikintisi nedeni olabilirler. Gecirdigi Whipple ameliyati sonrasi uzun sure yogun bakim ve mekanik ventilasyon tedavisi alan ve perkutan trakeostomi acilan hasta genel durumunun duzelmesi sonrasinda dekanule edildi ve gelisen akut solunum sikintisi nedeniyle yine kanule edilerek mekanik ventilasyon destegi almaya devam etti. Yogun bakim tedavisinin basindan beri anksiyete bozuklugu nedeniyle psikiyatrik tedavi de alan hastaya trakeostomi kanulunden girilerek fleksibl bronkoskopi yapildi ve herhangi bir patoloji saptanmadi.Hasta yine dekanule edilerek izlendi ve solunum sikintisinin ayni sekilde yinelemesi uzerine cekilen boyun tomografisinde kanulun superior komsulugunda trakeal stenoz izlendi ve bu bolgeye trakeal dilatasyon uygulanmasinin ardindan hasta basarili bir sekilde dekanule edilerek taburcu edildi.