Banu Ayhan

The Effect of HES (130/0.4) Usage as the Priming Solution on Renal Function in Children Undergoing Cardiac Surgery

Background: Experience with hydroxyethyl starch (HES) in children is limited. This study was conducted to observe the effects of HES or Ringer’s lactate (RL) usage as the priming solution on renal functions in children undergoing cardiac surgery. Methods: After ethical committee approval and parent informed consent, 24 patients were included in this prospective, randomized study. During cardiopulmonary bypass (CPB), Group I received RL and Group II received HES (130/0.4) as priming solution. Serum creatinine, blood urea nitrogen (BUN), β2-microglobulin, cystatin C, and urinary albumin and creatinine, serum, and urine electrolytes were analyzed after the induction (T1), before CPB (T2), during CPB (T3), after CPB (T4), at the end of the operation (T5), on 24th hour (T6), and on 48th hour postoperatively (T7). Fractional sodium excretion (FENa), urinary albumin/creatinine ratio, and creatinine clearance were calculated. Drainage, urine output, inotropes, diuretics, and blood requirements were recorded. Results: In both the groups, β2-microglobulin was decreased during CPB and cystatin C was decreased at T3,T4, and T5 periods (p < 0.05) and the levels remained within the normal range. Creatinine clearance did not differ in the HES group, but increased in the RL group (p < 0.05). Urine albumin/creatinine ratio was increased (p < 0.05) after CPB in the HES group, and it increased at T3, T4, and T5 in the RL group (p < 0.05). There were no differences in cystatin C, β2-microglobulin, FENa, urine albumin/creatinine ratio, creatinine clearance, total fluid amount, urine output, drainage, and inotropic and diuretic requirements between the groups. Conclusion: We conclude that usage of HES (130/0.4) did not have negative effects on renal function, and it can be used as a priming solution in pediatric patients undergoing cardiac surgery.

Comparison of the Effects of Sevoflurane, Isoflurane, and Desflurane on Microcirculation in Coronary Artery Bypass Graft Surgery

OBJECTIVE This investigation was performed to compare the effects of inhalation agents on microcirculation in coronary artery bypass grafting (CABG) using orthogonal polarization spectral imaging. DESIGN This prospective and randomized study was performed in patients scheduled for CABG surgery from March through September 2010. SETTING Tertiary care university hospital. PARTICIPANTS Thirty patients undergoing elective CABG. INTERVENTIONS Patients were assigned to sevoflurane, desflurane, or isoflurane. MEASUREMENTS AND MAIN RESULTS Orthogonal polarization spectral imaging was used to evaluate the sublingual microcirculation. Hemodynamic variables (heart rate, mean arterial pressure, central venous pressure, cardiac output, and pulmonary capillary wedge pressure), laboratory parameters (hematocrit, lactate, and potassium), and microcirculatory variables (total vascular density [TVD] [mm/mm(2)], microvascular flow index [MFI] [arbitrary units], perfused vessel density [PVD] [mm/mm(2)], and proportion of perfused vessels [PPV] [percentage] were obtained before induction, after induction, during cardiopulmonary bypass, at the end of surgery, and 24 hours after surgery. The greatest alterations in microcirculation parameters were found during cardiopulmonary bypass. In the sevoflurane group, TVD (14.7%), PVD (22%), PPV (5.97%, p < 0.05), and MFI (7.69%, p > 0.05) were decreased. In the isoflurane group, TVD (14.7%) and PVD (20.3%) were decreased, whereas PPV (1.69%) and MFI (17.99%) were increased (p < 0.05). In the desflurane group, there were no changes in TVD and PVD, but MFI (8.99%, p > 0.05) and PPV (1.48%, p < 0.05) were increased in the small vessels. These changes returned to their initial values 24 hours postoperatively. CONCLUSIONS Sevoflurane had a negative effect on the microcirculation. Isoflurane decreased vascular density and increased flow. Desflurane produced stable effects on the microcirculation. These inhalation agents induced transient alterations in microvascular perfusion.

The postoperative analgesic efficacy of intraperitoneal tramadol compared to normal saline or intravenous tramadol in laparoscopic cholecystectomy

Background and objective The aim of this study was to compare the postoperative analgesic efficacy of intraperitoneal tramadol with intravenous tramadol or normal saline in patients undergoing laparoscopic cholecystectomy. Methods Sixty‐one patients undergoing laparoscopic cholecystectomy were randomized to one of three groups in a double‐blind manner via coded syringes. All patients received an intravenous and an intraperitoneal injection after installation of the pneumoperitoneum and again before removal of the trocars. In the control group, all injections were with normal saline. In the intravenous tramadol group, patients received intravenous tramadol 100 mg and intraperitoneal saline. In the intraperitoneal tramadol group, patients received intravenous saline and intraperitoneal tramadol 100 mg. All patients had a standard anaesthetic. Postoperative analgesia was with morphine. Postoperatively, numeric pain scores for parietal and visceral pain, 1 h and 24 h morphine consumption, and adverse effects were recorded. Results Parietal and visceral pain scores were lowest in the intravenous tramadol group during the first postoperative hour (P < 0.016 compared with control). The delay until the first analgesic administration was longest in the intravenous tramadol group (median 23 min, range 1–45), when compared with the intraperitoneal tramadol group (10, 1–120 min, P = 0.263) or with the control group (1, 1–30 min, P = 0.015). One‐hour morphine consumption was significantly lower in the intravenous tramadol group (mean ± SD; 3.4 mg ± 2.5) and in the intraperitoneal tramadol group (4.4 ± 4.3 mg) compared with the control group (6 ± 2 mg) (P = 0.044). There was no difference between the three groups regarding pain scores, morphine consumption and incidence of shoulder pain or adverse effects at 24 h. Conclusion Intravenous tramadol provides superior postoperative analgesia in the early postoperative period after laparoscopic cholecystectomy compared with an equivalent dose of tramadol administered intraperitoneally and with normal saline in patients undergoing laparoscopic cholecystectomy.

A Comparison of Low and High Flow Desflurane Anaesthesia in Children

Yöntemler: ASA I-II, 5-15 yaş, 2-4 saat sürecek alt ve üst ekstremite cerrahisi geçirecek 40 çocuk çalışmaya dahil edildi. Düşük akım grubuna (DAG, n=20); anestezi başlangıcında; 2 L dk-1 N2O, 2 L dk -1 O2 ve %4-6 dezfluran verildi. Sonrasında, %50 O2+%50 N2O+%4-6 dezfluran, 1 MAK olacak şekilde taze gaz akımı 1 L dk-1 şeklinde ayarlanarak verildi. Yüksek akım grubuna (YAG, n=20); başlangıçla birlikte 2L dk-1 N2O, 2L dk -1 O2 ve %4-6 dezfluran, girişim boyunca aynı konsantrasyonda verildi. İnspirasyon ve ekspirasyon gaz karışımındaki dezfluran, N2O, O2 ve CO2 konsantrasyon ölçümleri, vital bulgu takibi, BIS ve MAK ölçümleri yapıldı. Anestezi süresince, ekstübasyon döneminde ve postoperatif 24. saatte arter kan gazı değerlendirildi.

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.

Effectiveness of preemptive intra-articular levobupivacaine on pain relief after arthroscopic knee surgery

Background and Aim: Severe pain and comfortlessness may be seen in patients after arthroscopic knee surgery despite various commonly administered analgesic methods, particularly based on local anesthetics. The aim of this study was to determine the effect of intraarticular levobupivacaine injected preoperatively on pain relief and time to first analgesic request during the postoperative period. Material and Methods: 40 adult-patients, ASA I and II, undergoing elective arthroscopic surgery were included in the study. Patients in the levobupivacaine group received intra-articular levobupivacaine at 5mg/ml dosages and 20 ml total volume 30 min before the procedure. Patients in the control group received 20 ml of normal saline. Visual analogue scale (VAS) scores were assessed at the 1st, 2nd, 4th, 8th, 12th and 24th hour postoperatively. Time to first analgesic request and total analgesics used over the course of 24 hours after the surgery were recorded. All patients received continuous morphine infusion via patient controlled analgesia (PCA) devices postoperatively. Additionally, patients’ pain satisfaction scores were recorded. Results: Lower VAS scores at the 1st, 2nd, 4th and 8th hours postoperatively - both at rest and during motion - were found in the levobupivacaine group compared to the normal saline group (p

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.

Akciğer, Karaciğer, Böbrek ve Beyin Dokularında Sevofluran Eliminasyonu ve Histopatolojik Değişiklikler

ÖZET Amaç: Ça lış ma mız da; se vof lu ran anes te zi si uy gu la nan tav şan lar da; ak ci ğer, ka ra ci ğer, böb rek ve be yin do ku la rın da flo rür dü ze yi nin öl çül me si, or gan lar da göz le nen his to pa to lo jik de ği şik lik le rin araş tı rıl ma sı ve bu de ği şik lik le rin flo rid bi ri ki mi ile iliş ki si nin in ce len me si amaç lan mış tır. Ge reç ve Yön tem ler: Ça lış ma da 2500-3000 gr ağır lı ğın da, 24 adet Ye ni Ze lan da tü rü di şi tav şan kul la nıl dı. De nek ler im 35 mg/kg ke ta min ve 5 mg/kg ksi la zin ile uyu tul duk tan son ra, EKG, ok si jen sa tu ras yo nu, oro fa rin ge al ısı mo ni to ri zas yo nu ya pıl dı ve ku lak ven le ri ka te te ri ze edil di. De nek ler dört gru ba ay rıl dı; Grup I: Kon trol Gru bu (n= 6) (anes te zi ida me si; İV 10 mg/kg ke ta min, 3 mg/kg ksi la zin ve %100 ok si jen ile kon trol lu me ka nik ven ti las yon ya pı la rak sağ lan dı), Grup II: Se vof lu ran 1 (n=6),Grup II I: Se vof lu ran 24 (n= 6) ve Grup IV: Se vof lu ran 48 (n=6) (anes te zi ida me si %100 ok si jen ve %2 kon san tras yon da se vof lu ran ile sağ lan dı). Üç sa at anes te zi uy gu lan dık tan son ra de nek ler eks tü be edil di ler.Anes te zi son ra sı; Grup I ve II’ de ki de nek ler 1.sa at te, Grup II I’ de ki ler 24.sa at te ve Grup IV’ de ki ler 48. sa at te yük sek doz in tra kar di yak ke ta min/ksi la zin ile sak ri fi ye edil di ler. Do ku inor ga nik flor dü ze yi (DİF) öl çü mü için böb rek, ka ra ci ğer, be yin ve ak ci ğer do ku su alın dı. Böb rek, ka ra ci ğer ve ak ci ğer do ku sun da his to pa to lo jik in ce le me ya pıl dı. Bul gu lar: Grup II’ de DİF en yük sek böb rek do ku sun da, en dü şük ka ra ci ğer do ku sun da iz len miş tir. Flo rür dü ze yi 24 ve 48 sa at son ra sın da böb rek do ku sun da aza lır ken, ak ci ğer ler de faz la mik tar da bi rik mek te, bu bi ri kim ak ci ğer de ha sar oluş tur ma mak ta dır. DİF ka ra ci ğer do ku sun da 24 sa at te en yük sek dü zey de bu lun muş tur (p< 0.05). Ka ra ci ğer ve böb rek do ku sun da 24. sa at te his to pa to lo jik de ği şik lik ler oluş tu ğu ve 48. sa at te de de vam et ti ği göz len miş tir. So nuç: Ça lış ma mız da se vof lu ran me ta bo liz ma sı so nu cu açı ğa çı kan flo rü rün er ken dö nem de böb rek ler de bi rik ti ği, 24 sa at son ra ise böb rek do ku sun dan atı la rak, ak ci ğer ler de ve ka ra ci ğer de bi rik ti ği, ka ra ci ğer ve böb rek te olu şan pa to lo jik de ği şik lik le rin flo rür bi rik me si ile iliş ki li ol ma dı ğı ka nı sı na va rıl mış tır.