Aysun Ankay Yılbaş

Anesthesia for percutaneous transcatheter closure of atrial septal defects in adults.

The percutaneous transcatheter device closure of cardiac and extracardiac defects is a preferred method because of reduced morbidity and mortality, shorter hospital stay, superior cosmetic results, avoidance of cardiopulmonary bypass, decreased cost and less postoperative pain (1, 2). The aim of our study was to investigate the anesthetic management of percutaneous closure of atrial septal defects (ASD). A retrospective review of anesthesia management data of 106 patients who underwent transcatheter closure of ASD between the years 2004-2009 was conducted. Demographic data, systolic pulmonary artery pressure, procedure time, anesthesia time, ASD size, device size, incidence of failure to deploy the device, incidence of need for surgery, the anesthetic drugs used, complications seen during or after the procedure and hospitalization time in the cardiac intensive care unit (ICU) were recorded. The mean age of 106 patients (44 men and 62 women) was 37.4±14.04 years. The mean procedure and anesthesia time were 36.5±16.8 and 45.6±18.4 minutes. Mean size of the atrial septal defects and the septal occluder devices were 16.0±4.4 mm and 19.9±5.5 mm. Amplatzer septal occluder was used in 94.3% and Occlutech Figulla septal occluder was used in 5.7% of patients. All procedures were performed under general anesthesia. The procedure was finished without any complications in 103 patients. Two patients had severe bradycardia. Trombus formation on the device was seen in one patient. No major arrhythmias or hypotension occurred during the procedure. After the procedure, all patients were hospitalized in the cardiac intensive care unit with a median discharge time of 12 hours (6-96 hours). Ninetyfive patients (88.8%) were discharged from the hospital without any complications. The mortality rate was 0. Many anesthetic drugs have been used for diagnostic and interventional cardiac catheterizations. Tosun et al. (3) compared dexmedetomidine-ketamine and propofol-ketamine combinations in spontaneously breathing children undergoing cardiac catheterization and dexmedetomidine-ketamine combination resulted with insufficient sedation and analgesia and a longer recovery time. Koruk et al. (4) showed that both dexmedetomidine and ketamine used with propofol were well tolerated in children who required ASD closure. Kogan et al. (5) used propofolketamine mixture safely in children undergoing cardiac catheterization. Laussen et al. (6) used sedation for the closure of muscular VSDs in their series, but later they changed their anesthetic management to general anesthesia because of high urgent intubation need due to hemodynamic instability. We used propofol induction in adults with 1 μg/kg fentanyl as our routine anesthetic management. We did not see hemodynamic instability in any of the patients during induction and also we concluded that rapid recovery with propofol was an advantage for this patient group. The experience with the anesthetic management of percutaneous transcatheter closure of ASD is improving with the new technology of devices and delivery systems. We concluded that general anesthesia is a more safe and comfortable method for the anesthetic management of percutaneous ASD closure because of the risk of hemodynamic instability, the need for a immobile patient, discomfort and embarrassing feeling of transesophageal echocardiography. Acknowledgement Thanks to chief of Anesthesiology and Reanimation Department Prof. Dr. Ülkü Aypar and chief of Cardiology Department Prof. Dr. Ali Oto and Prof. Dr. Kudret Aytemir for their great support.

Evaluation of the stability and stratification of propofol and ketamine mixtures for pediatric anesthesia

The combination of propofol and ketamine is commonly used for total intravenous anesthesia. These drugs can be delivered in different syringes or in the same syringe. We hypothesized that the drugs might separate and different concentrations of each drug could be found in different parts of the syringe during the procedure period when they were mixed in 1 syringe.

Incidence of venous air embolism and blood gas changes seen in infratentorial surgeries operated in sitting position

Our aim was to find out the rate and timing of venous air embolism (VAE), other complications associated with sitting position and changes on arterial blood gas during and after VAE. We analyzed retrospectively files of 124 patients who underwent posterior fossa surgery in department of Neurosurgery of our institute between January 2004 and April 2014. The incidence of emboli was 76,3% in the first 3 hours of the surgery while it was 38.2% in the first 2 hours in total. VAE was seen in a total of 21 patients (16.9%) and it was detected by a sudden drop of minimum 2mmHg of end-tidal CO2 (EtCO2)(25.38 ± 3.28 mmHg) in all cases (100%). The pH, PaO2 and PaCO2 values of the patients with and without emboli were evaluated pre and post-operatively and no significant difference was found (p>0.05). Precordial doppler ultrasonography is the most sensitive non-invasive monitoring device for accurate detection of even small VAE which are not clinically relevant. The most sensitive technique for detection of VAE is transoesophageal echocardiography but it is expensive, invasive and can cause some serious complications. In our study, emboli were most frequently seen in the 3rd hour of the surgery which coincide with tumor resection, thus proposing anaesthesiologists to be more cautious about VAE and EtCO2 during the tumor resection period.

Body Surface Area Is Not a Reliable Predictor of Tracheal Tube Size in Children

Objectives The age-based Cole formula has been employed for the estimation of endotracheal tube (ETT) size due to its ease of use, but may not appropriately consider growth rates among children. Child growth is assessed by calculating the body surface area (BSA). The association between the outer diameter of an appropriate uncuffed-endotrachealtube (ETT-OD) and the BSA values of patients at 24–96 months of age was our primary outcome. Methods Cole formula, BSA, age, height, weight and ultrasound measurement of subglottic-transverse-diameter were evaluated for correlations with correct uncuffed ETT-OD. The Cole formula, BSA, and ultrasound measurements were analyzed for estimation rates in all patients and age subgroups. The maximum allowed error for the estimation of ETT-OD was ≤0.3 mm. Patients’ tracheas were intubated with tubes chosen by Cole formula and correct ETT-OD values were determined using leak test. ETT exchange rates were recorded. Results One-hundred twenty-seven patients were analyzed for the determination of estimation rates. Thirteen patients aged ≥72 months were intubated with cuffed ETT-OD of 8.4 mm and were accepted to need uncuffed ETT-OD >8.4 mm in order to be included in estimation rates, but excluded from correlations for size analysis. One-hundred fourteen patients were analyzed for correlations between correct ETT-OD (determined by the leak test) and outcome parameters. Cole formula, ultrasonography, and BSA had similar correct estimation rates. All three parameters had higher underestimation rates as age increased. Conclusion. The Cole formula, BSA, and ultrasonography had similar estimation rates in patients aged ≥24 to ≤96 months. BSA had a correct estimation rate of 40.2% and may not be reliable in clinical practice to predict uncuffedETT-size.

Hematoma progressivo na região anterior do pescoço após tratamento endovascular de aneurisma da artéria cerebral média

BACKGROUND Cervical hematomas can lead to airway compromise, a life threatening condition, regardless of the cause. The following case is the first presentation of cervical hematoma as a complication of endovascular treatment of middle cerebral artery aneurysm. CASE REPORT A 49 year-old woman was scheduled for stent placement under general anesthesia for middle cerebral artery aneurysm. Few days before intervention, acetyl salicylic acid and clopidogrel treatment was started. Following standard monitoring and anesthesia induction, the patients trachea was intubated with a 7.5mm endotracheal tube and the procedure was completed without any complications. Three hours later, dyspnea developed and physical examination revealed progressive swelling and stiffness in the neck. Endotracheal intubation was performed with a 6mm diameter uncuffed tube with the aid of sedation. The vocal cords were completely closed due to compression. There was no leak around the endotracheal tube. The rapidly performed computerized tomography scans showed an enormous hematoma around the neck and extravasation of contrast medium through superior thyroid artery. After coil embolization of superior thyroid artery, she was taken to the intensive care unit as intubated and sedated. Surgical exploration of the hematoma was not recommended by the surgeons, because she was on clopidogrel. After two days, the patients trachea was extubated safely ensuring that the swelling was sufficiently ceased and leak detected around the endotracheal tube. CONCLUSIONS Securing the airway rapidly by endotracheal intubation is the most crucial point in the management of cervical hematomas. Diagnostic and therapeutic procedures should be performed only afterwards.

The Effect of Different End-tidal Desflurane Concentrations on Bispectral Index Values in Normal Children and Children with Cerebral Palsy.

OBJECTIVE In this study, we aimed to compare the effects of different intraoperative end-tidal desflurane concentrations on bispectral index (BIS) values in normal children and children with cerebral palsy. METHODS Twenty normal children (Group N) and 20 children with non-communicative/nonverbal cerebral palsy (Group CP), between 2 and 15 years of age, undergoing elective orthopaedic surgery were included in the study. Following premedication with midazolam, anaesthesia was induced by infusing 1% propofol at a rate of 200 mL hr(-1) until BIS reached 50. Heart rate, blood pressure and BIS values were recorded before and after the induction of anaesthesia, at steady-state end-tidal concentrations of 4% and 6% desflurane, and after emergence from anaesthesia. A p value <0.05 was considered significant in the statistical analyses, including Kolmogorov-Smirnov, t-test, paired samples t-test and chi-square test. RESULTS The time to extubation and eye opening after discontinuation of anaesthesia was longer in Group CP. BIS values before the induction of anaesthesia, at a steady-state end-tidal desflurane concentration of 4% and after emergence from the anaesthetic were significantly lower in Group CP. At a steady-state end-tidal desflurane concentration of 6%, BIS values were slightly lower in Group CP but this difference was not statistically significant. CONCLUSION Based on the data obtained, we concluded that BIS monitoring in children with cerebral palsy can be useful in terms of decreasing adverse effects and drug interactions due to multiple drug usage by reducing the use of anaesthetic agents and improving emergence from the anaesthetic.