Çiğdem Yıldırım Güçlü

Does Type of Pharyngeal Packing during Sinonasal Surgery Have an Effect on PONV and Throat Pain

Objective Postoperative nausea and vomiting (PONV) is a common problem that affects up to 30% of all surgical patients after general anaesthesia, which increases in sinonasal surgery due the very potent emetic effect of ingested blood that is swallowed during the procedures. Therefore, a hypo/oropharyngeal packing is commonly placed in an effort to prevent blood ingestion. The primary aim of this study was to compare the efficacy of 3 packing types in preventing PONV and to compare the results with patients who received no packing. The secondary aim was to compare the postoperative throat pain in all 4 groups. Study Design A prospective double-blind randomized controlled study. Setting A university hospital. Subjects and Methods After Institutional Review Board approval and informed consent, 201 adult patients scheduled for sinonasal surgery were randomized to 4 groups to have dry packing (n = 52), packing soaked with water (n = 48), packing soaked with chlorhexidine gluconate and benzydamine hydrochloride (n = 51), or no packing (n = 50). Postoperative PONV and throat pain were assessed. Results Demographic data, procedural characteristics, and PONV risk scores were similar among groups. The PONV incidences, throat pain scores, and analgesic use were comparable in all 4 groups. Conclusion Despite commonly used practices, usage of different types of pharyngeal packing did not affect incidence of PONV and throat pain, nor did usage of no packing.

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.

Anesthetic management of Schimke syndrome

To the Editor: Schimke syndrome is a rare autosomal recessive inherited disorder that is characterized by disproportionately short stature, spondyloepiphyseal dysplasia, hyperlordosis, facial dimorphism resembling mucopolysacchariduria, progressive nephropathy, and defective cellular immunity [1, 2]. We report the anesthetic management of a 10-yearold girl with Schimke syndrome undergoing renal transplantation. It is important to perform a detailed preoperative evaluation in patients with Schimke syndrome. Special attention should be given to airway assessment because of syndrome characteristics such as short neck, microcephaly, lordosis, and facial appearance (ESM Fig. 1). As the patient had a short neck, large tongue, and dimorphic face, we prepared all equipment (different-sized laryngeal mask airways, different-sized laryngoscopes and tracheostomy sets) to be available for the management of a difficult pediatric airway. Although we inserted an appropriate oropharyngeal airway, mask ventilation of the patient was difficult even with two hands, probably because of her large tongue and short neck. After injection of a muscle relaxant, we could perform mask ventilation and tracheal intubation. We believe that we were able to use the muscle relaxant safely because we had sugammadex for rescue events. Neurological symptoms in patients with Schimke dysplasia have been described previously as transient ischemic attacks, probably related to vascular stenosis, and ulceration resulting from atherosclerosis and thrombus formation: such stroke episodes can lead to death [3]. Extra care was taken to maintain stable blood pressure during surgery. In conclusion, difficult airway management and special attention to thrombotic events and epileptic seizures are the important issues involved in anesthetic management of this syndrome.

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.

Maintenance of balance between airway pressure and intracranial pressure in a patient with tracheal stenosis undergoing craniotomy: a case report

BACKGROUND AND OBJECTIVES Tracheal stenosis is a rare but a life-threatening condition and anesthesia of a patient with tracheal stenosis is challenging for anesthesiologists. Maintaining stable hemodynamics and ventilation parameters are important issues in neuroanesthesia. Any increase in airway peak pressure and ETCO2 will result in increase in intracranial pressure which must be avoided during craniotomies. Tracheal stenosis could be a reason for increased airway pressure. CASE REPORT We described a patient undergoing craniotomy with tracheal stenosis. CONCLUSION Detailed preparation for intubation, to stabilize airway dynamics and to make the right decision for the surgery were important points. To maintain of a good balance between cerebral dynamics and airway dynamics were the pearls of this case.

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.

The airway device preference may affect the overlapping of the common carotid artery by the internal jugular vein

Anatomical variation in the internal jugular vein (IJV), as well as its small size, tendency to collapse, and proximity to the common carotid artery (CCA) makes central venous cannulation via the IJV a technically challenging procedure, especially in pediatric patients.