Filiz Üzümcügil

Comparison of dexmedetomidine-propofol vs. fentanyl-propofol for laryngeal mask insertion.

Background and objectives There have been many studies to find the optimum anaesthetics to provide excellent conditions for laryngeal mask insertion. We compared the effects of dexmedetomidine administered before propofol, on laryngeal mask insertion with fentanyl combined with propofol. Methods In all, 52 patients, ASA I–II, scheduled to have minor urological procedures were randomized into two groups. Group F received 1 &mgr;g kg−1 fentanyl (in 10 mL normal saline) and Group D received 1 &mgr;g kg−1 dexmedetomidine (in 10 mL normal saline). We used 1.5 mg kg−1 propofol for induction and 50% N2O and 1.5% sevoflurane in oxygen for maintenance. We observed jaw mobility (1: fully relaxed; 2: mild resistance; 3: tight but opens; 4: closed), coughing or movement (1: none; 2: one or two coughs; 3: three or more coughs; 4: bucking/movement) and other events such as spontaneous ventilation, breath holding, expiratory stridor and lacrimation. In each category, scores <2 were acceptable for laryngeal mask insertion. Results More patients developed apnoea and their apnoea times were longer in Group F than Group D (P < 0.001). Respiratory rates increased in Group D (P < 0.001). Adverse events during laryngeal mask insertion were similar. The reductions in systolic and mean blood pressures were greater in Group F (systolic: P < 0.05, mean: P < 0.01). Emergence times were shorter in Group F than in Group D (P < 0.001). Conclusion Dexmedetomidine, when used before propofol induction provides successful laryngeal mask insertion comparable to fentanyl, while preserving respiratory functions more than fentanyl.

Abdominal pain related to mitochondrial neurogastrointestinal encephalomyopathy syndrome may benefit from splanchnic nerve blockade

Patients diagnosed with abdominal pain related to mitochondrial neurogastrointestinal encephalopathy (MNGIE) may benefit from splanchnic nerve blockade. MNGIE, varying in age of onset and rate of progression, is caused by loss of function mutation in thymidine phosphorylase gene. Gastrointestinal dysmotility, pseudo‐obstruction and demyelinating sensorimotor peripheral neuropathy (stocking‐glove sensory loss, absent tendon reflexes, distal limb weakness, and wasting) are the most prominent manifestations. Patients usually die in early adulthood (mean 37.6 years; range 26–58 years). We report a case of an 18‐year‐old patient with MNGIE. Our patients abdominal pain was relieved after splanchnic nerve blockade.

Anesthetic management of a 2‐year‐old male with propionic acidemia

1 Liban E, Kozenitzky IL. Metanephric hamartomas and nephroblastomatosis in siblings. Cancer 1970; 25: 885–888. 2 Perlman M, Goldberg GM, Bar–Ziv J et al. Renal hamartomas and nephroblastomatosis with fetal gigantism: a familial syndrome. J Pediatr 1973; 83: 414–418. 3 Verloes A, Massart B, Dehalleux I et al. Clinical overlap of Beckwith-Wiedemann, Perlman and Simpson-Golabi-Behmel syndromes: a diagnostic pitfall. Clin Genet 1995; 47: 257–262. 4 Coppin B, Moore I, Hatchwell E. Extending the overlap of three congenital overgrowth syndromes. Clin Genet 1997; 51: 375–378. 5 Fahmy J, Kaminsky CK, Parisi MT. Perlman syndrome: a case report emphasizing its similarity to and distinction from Beckwith-Wiedemann and prune-belly syndromes. Pediatr Radiol 1998; 28: 179–182. 6 Chitty LS, Clark T, Maxwell D. Perlman syndrome – a cause of enlarged, hyperechogenic kidneys. Prenat Diagn 1998; 18: 1163–1168. 7 van der Stege JG, van Eyck J, Arabin B. Prenatal ultrasound observations in subsequent pregnancies with Perlman syndrome. Ultrasound Obstet Gynecol 1998; 11: 149–151. 8 Henneveld HT, van Lingen RA, Hammel BCJ et al. Perlman syndrome: four additional cases and review. Am J Med Genet 1999; 86: 439–446. 9 Schilke K, Schaefer F, Waldherr R et al. A case of Perlman syndrome: fetal gigantism, renal dysplasia, and severe neurological deficits. Am J Med Genet 2000; 91: 29–33. 10 DeRoche ME, Craffey A, Greenstein R et al. Antenatal sonographic features of Perlman syndrome. J Ultrasound Med 2004; 23: 561–564.

Anesthesia in Liver Transplantation

Liver transplantation, is the replacement of unhealthy liver with a new liver allograft. This surgical procedure is now widely common all over the world in various medical centers. The major limiting factors of this surgery is the lack of available donors and decreased chance of appropriate patient selection. Anesthetic management of organ donors includes intensive management of heart beating and brain dead donors; however the augmentation of waiting list for liver and inadequate cadaveric organs resulted in elevated living donor transplantation rates especially for the critically ill patients who will not survive waiting until a brain dead donor is provided, resulting in the growing experience in anesthetic techniques for the management of living donors (Pickett et al, 1994; Lutz et al, 2003).

Lumbar sympathetic blockade in a patient with cutis marmorata telangiectatica congenita.

SIR—We present, a 3-year-old girl, with a diagnosis of cutis marmorata telangiectatica congenita (CMTC) from 7 months of age, presenting with limping, pain in all toes of her right foot and ischemic lesions on the skin of the first three toes of the same foot, whose pain, ishemic areas and vascular lesions improved with vasodilator therapy and lumbar sympathetic blockade. At 7 months of age, she was first evaluated by the Department of Pediatrics. In both thighs, capillaries were prominent and there were hypopigmented lesions coursing from thigh to calf on the medial sides of both legs. Her right foot was hypoplasic. From the superior iliac spine to the medial malleolus; her right leg was 5 cm shorter than the left. From the point 4 cm superior to the proximal pole of the patella, the circumference of the right thigh was 2.5 cm thinner than the left. There was no significant family history and there was no associated anomaly. Punch biopsy specimen revealed dilated venules in the superficial dermis. Arteriovenous colored Doppler USG showed normal main femoral artery and vein, popliteal arterial and venous branches and calf arteries and veins. Tha dorsalis pedis artery was not observed. At angiography the femoral artery could be followed towards the popliteal artery, but the peroneal and tibial arteries were not clearly observed. She was followed up with these symptoms and signs until 17 months of age without medication. At 17 months of age, the Department of Cardiovascular Surgery started low-dose indapamide (Fludex, Servier, Neuilly-sur-Seine Cedex, France) and bencyclane hydrogen fumarate (Angiodel, Organon, Oss, The Netherlands). She was followed up until 3 years of age, but the response was limited. At 3 years of age, limping, pain, and ischemic lesions increased (Figure 1). There was also a temperature difference between the feet; but not measured quantitatively. She was referred to the Departments of Cardiovascular Surgery and Anesthesiology. Indapamide and bencyclane hydrogen fumarate therapy was replaced with femoral intra-arterial ilioprost (Iliomedine, Schering, Berlin, Germany) for 7 days and she was given acetyl salicylic acid orally. Ischemic lesions regressed partially, but temperature difference, pain, and limping persisted. At the end of 7 days, knowing that the pain had become chronic (more than 6 months), we thought that lumber sympathetic blockade might provide improvement. We avoided neurolytic blockade, because of the patient’s age. We placed an epidural catheter under general anesthesia and started continuous sympathetic blockade. Unfortunately, the epidural catheter was dislodged on the second day as there had been little change in the symptoms and signs, we decided to administer lumbar sympathetic blockade instead of continuous blockade. We gave 5 ml of 0.5% bupivacaine at levels L2–L4 under general anesthesia with fluroscopic control, twice a week for each blockade. The limb temperature difference was measured at the beginning and at the end of each blockade with at least a 4–5 C increase in temperature at the lesions. Improvement was maintained with a total of 12 blockades without complication (Figure 2). Our patient was followed up at 3-month intervals for 1 year and total relief was maintained. It has been 2 years since treatment was completed without further complication. Cutis marmorata telangiectatica congenita, first described by Von Lohuizen (1), in 1922, is an uncommon and distinctive cutaneous vascular malformation composed predominantly of capillary and venous-sized vessels (2). The disorder, affecting predominantly females (3,4), presenting at birth or shortly after (3), is characterized by a fixed reticulated vascular pattern on the skin resembling physiological cutis marmorata, but unlike this, it does not resolve with warming of the skin (3,4). Prominent veins (phlebectasia), telangiectasias, cutaneous atrophy, possible ulceration of the involved skin and hyperkeratosis often accompany the reticulated pattern, usually in a localized distribution, especially affecting the lower limbs (4,5). Even with generalized involvement, it does not occur on Figure 1 Ischemic lesion on right foot. 1292 CORRESPONDENCE

Comparison of efficacy of prophylactic ketamine and dexmedetomidine on postoperative bladder catheter-related discomfort.

Objectives: To compare the effects of prophylactic ketamine and dexmedetomidine on postoperative bladder catheter-related discomfort/pain in patients undergoing cystoscopy. Methods: This prospective study was conducted on 75 American Society of Anesthesiologists (ASA) I-II patients between 18-75 years of age and undergoing cystoscopy between November 2011 and June 2012 at Hacettepe University Hospital, Ankara, Turkey. Patients were randomly assigned to one of the 3 groups to receive 1 µ/kg dexmedetomidine, 250 µ/kg intravenous ketamine, or normal saline. All patients were questioned regarding probe-related discomfort, patient satisfaction, and pain at the end of the operation 0 (t0) and 15 (t1), 60 (t2), 120 (t3), and 360 (t4) minutes postoperatively. Evaluations were performed in person at the post-anesthesia care unit, or in ambulatory surgery rooms, or by phone calls. Results: Pain incidence in the dexmedetomidine and ketamine groups (p=0.042) was significantly lower than that in the control group (p=0.044). The sedation scores recorded at t0 in the dexmedetomidine and ketamine groups (p=0.004) were significantly higher than that of the control group (p=0.017). Patient groups were similar regarding the rate of hallucinations experienced at t1, no patients experienced hallucinations at t2, t3, or t4. Significantly more patients experienced hallucinations at t0 in the ketamine group than in the dexmedetomidine group (p=0.034) and the control group (p=0.005). Conclusion: Dexmedetomidine and ketamine had similar analgesic effects in preventing catheter-related pain; however, dexmedetomidine had a more acceptable side effect profile. To identify the optimal doses of dexmedetomidine and ketamine, more large-scale interventional studies are needed.

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.

Oral mask ventilation is more effective than face mask ventilation after nasal surgery

OBJECTIVE To evaluate and compare the face mask (FM) and oral mask (OM) ventilation techniques during anesthesia emergence regarding tidal volume, leak volume, and difficult mask ventilation (DMV) incidence. DESIGN Prospective, randomized, crossover study. SETTING Operating room, training and research hospital. SUBJECTS American Society of Anesthesiologists physical status I and II adult patients scheduled for nasal surgery. INTERVENTIONS Patients in group FM-OM received FM ventilation first, followed by OM ventilation, and patients in group OM-FM received OM ventilation first, followed by FM ventilation, with spontaneous ventilation after deep extubation. The FM ventilation was applied with the 1-handed EC-clamp technique. The OM was placed only over the mouth, and the 1-handed EC-clamp technique was used again. A childs size FM was used for the OM ventilation technique, the mask was rotated, and the inferior part of the mask was placed toward the nose. MEASUREMENTS The leak volume (MVleak), mean airway pressure (Pmean), and expired tidal volume (TVe) were assessed with each mask technique for 3 consecutive breaths. A mask ventilation grade ≥3 was considered DMV. MAIN RESULTS DMV occurred more frequently during FM ventilation (75% with FM vs 8% with OM). In the FM-first sequence, the mean TVe was 249±61mL with the FM and 455±35mL with the OM (P=.0001), whereas in the OM-first sequence, it was 276±81mL with the FM and 409±37mL with the OM (P=.0001). Regardless of the order used, the OM technique significantly decreased the MVleak and increased the TVe when compared to the FM technique. CONCLUSION During anesthesia emergence after nasal surgery the OM may offer an effective ventilation method as it decreases the incidence of DMV and the gas leak around the mask and provides higher tidal volume delivery compared with FM ventilation.

Tracheal laceration as a complication of out-of-hospital emergency tracheal intubation in a patient with COPD.

Tracheobronchial injuries related to emergency endotracheal intubations are reported to be associated with an increased risk of mortality. Many mechanical risk factors may become more frequent in an emergency setting leading to such injuries. Aside from these factors that may complicate endotracheal intubation, this procedure is not recommended a priori for ventilation due to the resulting interruptions in external chest compressions, by 2010 cardiopulmonary resuscitation (CPR) and external chest compression guidelines. We present a 78-year-old woman with known chronic obstructive pulmonary disease who had a tracheal laceration after emergency endotracheal intubation during CPR. Thorax computed tomography revealed an overinflated tube cuff. The trachea was repaired surgically; however, our patient died on the fourth postoperative day due to multiple-organ failure. Prehospital providers must remain especially vigilant to priorities in airway management during CPR and aware of the dangers associated with field tracheal intubation under less than ideal conditions.