Hafize Öksüz

Re-Protective Effects of Pre- and Post-Laparoscopy Conditioning, Zinc, Pentoxifylline, and N-acetylcysteine in an Animal Model of Laparoscopy-Induced Ischemia/Reperfusion Injury of the Kidney

Background. Pneumoperitoneum (P) created to facilitate laparoscopy (L) is associated with splanchnic hypoperfusion, ischemia/reperfusion (I/R) injury, and oxidative stress. Aim. This study investigated the effects of pre- and post-laparoscopic conditioning, zinc, pentoxifylline (PTX), and N-acetylcysteine (NAC) on markers of I/R injury in an animal model. Methods. Sprague-Dawley male rats (n = 56, weight range 300–350 g) were randomly placed in one of seven treatment groups. Except for group C (control group who underwent a sham operation without pneumoperitoneum), pneumoperitoneum was created in all using CO2 insufflation under a pressure of 15 mmHg. Group L (laparoscopy) was subjected to 60 min of pneumoperitoneum. Group Lpre (laparoscopic preconditioning plus laparoscopy) was subjected to 5 min of insufflation and 5 min of desufflation followed by 60 min of pneumoperitoneum. Group Lpost (laparoscopy plus laparoscopic post-conditioning) was subjected to 60 min of pneumoperitoneum and 60 min of desufflation followed by 5 min of insufflation and 5 min of desufflation. The laparoscopy plus zinc (LZ), PTX (LP), and NAC (LNAC) groups received a single intraperitoneal injection of zinc (50 mg/kg), pentoxifylline (50 mg/kg), or N-acetylcysteine (150 mg/kg) 5 min before the desufflation period. Animals were sacrificed at the end of the experiments, and kidney samples were tested for malondialdehyde (MDA), catalase (CAT), glutathione peroxidase (GPX), and superoxide dismutase (SOD). Results. MDA levels, as an indicator of oxidative stress in kidney tissue samples, were significantly higher in all pneumoperitoneum groups compared to Group C, except for Group Lpre. The pattern of change in tissue levels of SOD, GPX, and catalase was variable in the different treatment groups. Conclusions. In this animal model of renal ischemia/reperfusion injury, laparoscopy caused renal ischemia as evidenced by elevated markers of tissue ischemia-reperfusion injury. This effect was significantly attenuated by post-laparoscopy conditioning, zinc, pentoxifylline, and N-acetylcysteine, but not by pre-laparoscopy conditioning.

Community-acquired pneumonia in patients with chronic obstructive pulmonary disease requiring admission to the intensive care unit: risk factors for mortality.

PURPOSE The aims of this study are to identify factors predicting mortality in patients with chronic obstructive pulmonary disease (COPD) and community-acquired pneumonia (CAP) requiring intensive care unit (ICU) admission and to examine whether noninvasive ventilation treatment reduces mortality. MATERIALS AND METHODS An analysis was performed on data from patients with CAP hospitalized in the ICUs of 19 different hospitals in Turkey between October 2008 and January 2011. Predictors of mortality were assessed by both univariate and multivariate statistical analyses. RESULTS Two hundred eleven patients with COPD and CAP were included. The overall ICU mortality was 23.9%. Noninvasive ventilation treatment (odds ratio [OR], 0.12; 95% confidence interval [CI], 0.03-0.49; P = .003), hypertension (OR, 0.13; 95% CI, 0.02-0.93; P = .042), bilateral infiltration (OR, 13.92; 95% CI, 2.94-65.84; P = .001), systemic corticosteroid treatment (OR, 0.19; 95% CI, 0.35-0.96; P = .045), length of ICU stay (OR, 0.65; 95% CI, 0.47-0.89; P = .007), and duration of invasive mechanical ventilation (OR, 1.11; 95% CI, 1.01-1.22; P = .032) were independent factors related to mortality. CONCLUSION Noninvasive ventilation, hypertension, systemic corticosteroid treatment, and shorter ICU stay are associated with reduced mortality, whereas bilateral infiltration and longer duration of invasive mechanical ventilation are associated with increased risk of mortality in patients with COPD and CAP requiring ICU admission.

Protective effects of zinc, pentoxifylline, and N-acetylcysteine in an animal model of laparoscopy-induced ischemia/reperfusion injury of the small intestine.

BACKGROUND Pneumoperitoneum induced to facilitate laparoscopy is associated with splanchnic hypoperfusion, ischemia/reperfusion (I/R) injury, and oxidative stress. AIM This study investigated the effects of pre- and postlaparoscopic conditioning, zinc, pentoxifylline, and N-acetylcysteine on markers of I/R injury of the small intestine in an animal model. METHODS Male Sprague-Dawley rats (n=56) were randomized to 1 of 7 treatment groups. Except for group 7 (control group that underwent sham surgery without pneumoperitoneum), pneumoperitoneum was induced in all by use of carbondioxide insufflation under a pressure of 15 mmHg. Group 1 (laparoscopic I/R) was subjected to 60 minutes of pneumoperitoneum. Group 2 (laparoscopic preconditioning plus laparoscopy) was subjected to 5 minutes of insufflation and 5 minutes of desufflation followed by 60 minutes of pneumoperitoneum. Group 3 (laparoscopy plus laparoscopic postconditioning) was subjected to 60 minutes of pneumoperitoneum and 60 minutes of desufflation followed by 5 minutes of insufflation and 5 minutes of desufflation. Group 4 (zinc), group 5 (pentoxifylline), and group 6 (N-acetylcysteine) received a single intraperitoneal injection of zinc (50 mg/kg), pentoxifylline (50 mg/kg), or N-acetylcysteine (150 mg/kg), respectively, 5 minutes before the desufflation period. Animals were killed at the end of the experiments, and small intestine samples were tested for malondialdehyde (MDA), catalase (CAT), glutathione peroxidase (GPX), and superoxide dismutase (SOD). RESULTS There was no significant difference for MDA levels between each other in the groups 1, 2, and 3. But MDA levels were higher significantly in groups 1, 2, and 3 than those of groups 4, 5, 6, and 7. SOD and GPX levels of group 3 were significantly higher than those of groups 1, 2, 4 through 7. According to the SOD levels, there was no significant difference between each other in those of groups 1, 2, 4 through 7. GPX levels of group 3 were significantly higher than those of groups 1, 2, 4 through 7. GPX levels of group 1 were significantly lower than those of groups 5 and 7. The mean CAT level of groups 1 and 2 was significantly lower than that of groups 3, 6, and 7. The mean CAT level of group 3 was significantly higher than that of groups 1, 2, 4 through 7. CONCLUSIONS In this animal model of small intestine I/R injury, laparoscopy caused small intestine ischemia as evidenced by elevated markers of tissue I/R injury. This effect was significantly attenuated by zinc, pentoxifylline, and N-acetylcysteine, but not by prelaparoscopy conditioning and postlaparoscopy conditioning.

Quadratus Lumborum Block Versus Transversus Abdominis Plane Block in Children Undergoing Low Abdominal Surgery: A Randomized Controlled Trial

Background and Objectives Truncal blocks have a place within multimodal analgesia techniques in abdominal surgery. The quadratus lumborum block is a new abdominal truncal block used for somatic analgesia of both the upper and lower abdomen. In this prospective, double-blind, randomized study, we aimed to compare quadratus lumborum block and transversus abdominis plane block in pediatric patients undergoing lower abdominal surgery. Methods Fifty-three children undergoing unilateral inguinal hernia repair or orchiopexy surgery were randomized into 2 groups: transversus abdominis plane block and quadratus lumborum block. All blocks were performed under general anesthesia before surgery. Pain levels were assessed using an FLACC (Face, Legs, Activity, Cry, Consolability) scale. Results The study included 50 patients, after excluding 3 patients who were not eligible. The number of patients who required analgesia in the first 24 hours postoperatively was significantly lower in the quadratus lumborum block group (P < 0.05). In the quadratus lumborum block group, the postoperative 30-minute and 1-, 2-, 4-, 6-, 12-, and 24-hour FLACC scores were lower compared with those of the transversus abdominis plane block group (P < 0.05). Parent satisfaction scores were higher in the quadratus lumborum block group (P < 0.05). Conclusions The results of this study showed that in pediatric patients undergoing unilateral inguinal hernia repair or orchiopexy the quadratus lumborum block provided longer and more effective postoperative analgesia compared with the transversus abdominis plane block. Clinical Trials Registration: The trial was registered prospectively at clinicaltrials.gov (NCT02715999).

Mortality indicators in community-acquired pneumonia requiring intensive care in Turkey

BACKGROUND Severe community-acquired pneumonia (SCAP) is a fatal disease. This study was conducted to describe an outcome analysis of the intensive care units (ICUs) of Turkey. METHODS This study evaluated SCAP cases hospitalized in the ICUs of 19 different hospitals between October 2008 and January 2011. The cases of 413 patients admitted to the ICUs were retrospectively analyzed. RESULTS Overall 413 patients were included in the study and 129 (31.2%) died. It was found that bilateral pulmonary involvement (odds ratio (OR) 2.5, 95% confidence interval (CI) 1.1-5.7) and CAP PIRO score (OR 2, 95% CI 1.3-2.9) were independent risk factors for a higher in-ICU mortality, while arterial hypertension (OR 0.3, 95% CI 0.1-0.9) and the application of non-invasive ventilation (OR 0.2, 95% CI 0.1-0.5) decreased mortality. No culture of any kind was obtained for 90 (22%) patients during the entire course of the hospitalization. Blood, bronchoalveolar lavage, and non-bronchoscopic lavage cultures yielded enteric Gram-negatives (n=12), followed by Staphylococcus aureus (n=10), pneumococci (n=6), and Pseudomonas aeruginosa (n=6). For 22% of the patients, none of the culture methods were applied. CONCLUSIONS SCAP requiring ICU admission is associated with considerable mortality for ICU patients. Increased awareness appears essential for the microbiological diagnosis of this disease.

Effects of Epidural-and-General Anesthesia Combined Versus General Anesthesia Alone on Femoral Venous Flow During Laparoscopic Cholecystectomy

BACKGROUND AND OBJECTIVE The pneumoperitoneum has been shown to decrease femoral blood flow, resulting in venous stasis. We analyzed the effects of the pneumoperitoneum and epidural analgesia on femoral vein diameter and the peak flow rate of femoral vein during laparoscopic cholecystectomy. PATIENTS AND METHODS Forty patients were randomly allocated to receive either combined epidural analgesia (EA) and general anesthesia (GA) (group EA/GA) or GA alone (group GA). Laparoscopic cholecystectomy was the standard operation for the selected patients. Then, 10 mL of 1% lidocaine in group EA/GA or physiologic serum in group GA was injected via epidural catheter. Peak flow rates (PFRs) of femoral vein cross-sectional areas (CSAs) were measured from the right femoral vein at three different times: after induction of anesthesia, during the pneumoperitoneum, and after abdominal deflation, but prior to reversal of anesthesia. RESULTS The two groups were similar in age, sex, body mass index, and duration of operation. The CSA slightly increased after the induction of anesthesia, compared with the previous measurements, although there was no statistical significance between them for both groups (P > 0.05). The PFR decreased, whereas the CSA increased during the pneumoperitoneum in each group. The PFR values after basal measurements were significantly higher in the EA/GA than in the GA group (P < 0.05). Group EA/GA had significantly lower heart-rate and blood-pressure levels during surgery than those in group GA (P < 0.05). CONCLUSIONS Abdominal insufflation during laparoscopic cholecystectomy results in dilation and decreased flow in the common femoral vein. Epidural analgesia added to the GA partially compensated for the reduction in femoral PFR.

Incidental pheochromocytoma presenting with sublaboratory findings in asymptomatic surrenal masses: a case report

IntroductionAdrenal incidentaloma can be described as adrenal lesions that are incidentally diagnosed during abdominal laparotomy or any abdominal screening without prior suspicion of adrenal disease. It is important to diagnose adrenal lesions to learn if they are hormonally active or malignant. The most common clinical sign of pheochromocytoma is sustained or paroxysmal hypertension, and the most common symptoms are headache, excessive truncal sweating, and palpitation. In some cases, the clinical symptoms are not clear. Roughly 70% of adrenal incidentalomas are non-functional. A small group of 5–7% of the functional ones (30%) may exist as pheochromocytoma. Ten percent of pheochromocytoma cases are diagnosed incidentally during computed tomography (CT) or magnetic resonance imaging (MRI) screenings for other reasons. The most frequent symptom of the pheochromocytoma is hypertension, and 90–100% of cases exhibit it. The literature indicates that incidental pheochromocytoma cases that are smaller than 1 cm have no clinical symptoms. Rarely, some large pheochromocytoma cases do not show any clinical symptoms, and it is difficult to diagnose very small ones.Case presentationA 45-year-old male patient experienced an epigastric ache and distended stomach for 7 years. The serum cortisol level was 19.2 ng/dL (normal range: 5–20 ng/dL), and urinary free cortisol excretion was 25.00 μg/24 h (normal range:10.00–100.00 μg/24 h). The serum basal level of adrenocorticotropic hormone (ACTH) was 21 pg/mL (normal range: 9 to 52 pg/mL). Plasma cortisol was under 1.00 μg/dL after low dose (1 mg) overnight dexamethasone suppression test. 24 hours urinary catecholamines level were vanil mandilic acid (VMA) 8.90 mg/day (normal range, 3 to 90 mg/day), metanefrin 330 μg/day (normal range, 52 to 341 μg/day), epinefrin 13 μg/day (normal range, 2 to 24 μg/day), norepinefrin 41 μg/day (normal range; 15 to 100 μg/day). During abdominal ultrasonography (USG), a tumor was diagnosed in the right perirenal space. A regular-shaped mass (dimension 36 × 35 × 35 mm) with a homogeneous and solid structure was diagnosed in CT. The density of the mass was 80 Hounsfield units (HU) in postcontrast CT. The patient was given a diagnosis of a non-functional adrenal incidental lesion, underwent a right adrenalectomy. Histopathological data correlated with pheochromocytoma as wellConclusionPheochromocytoma can be diagnosed by establishing an increase in catecholamines and metabolites in the plasma and urine. The level of catecholamines and metabolites in the plasma and urine provide 95% of the evidence of the disease. Because the dimensions of the lesion were large and the HU was very clear, the patient was underwent surrenalectomy. During laboratory investigation, there was no evidence of abnormality; we, therefore, think that these cases can be named sublaboratory pheochromocytoma.

The interrelations of radiologic findings and mechanical ventilation in community acquired pneumonia patients admitted to the intensive care unit: a multicentre retrospective study

BackgroundWe evaluated patients admitted to the intensive care units with the diagnosis of community acquired pneumonia (CAP) regarding initial radiographic findings.MethodsA multicenter retrospective study was held. Chest x ray (CXR) and computerized tomography (CT) findings and also their associations with the need of ventilator support were evaluated.ResultsA total of 388 patients were enrolled. Consolidation was the main finding on CXR (89%) and CT (80%) examinations. Of all, 45% had multi-lobar involvement. Bilateral involvement was found in 40% and 44% on CXR and CT respectively. Abscesses and cavitations were rarely found. The highest correlation between CT and CXR findings was observed for interstitial involvement. More than 80% of patients needed ventilator support. Noninvasive mechanical ventilation (NIV) requirement was seen to be more common in those with multi-lobar involvement on CXR as 2.4-fold and consolidation on CT as 47-fold compared with those who do not have these findings. Invasive mechanical ventilation (IMV) need increased 8-fold in patients with multi-lobar involvement on CT.ConclusionCXR and CT findings correlate up to a limit in terms of interstitial involvement but not in high percentages in other findings. CAP patients who are admitted to the ICU are severe cases frequently requiring ventilator support. Initial CT and CXR findings may indicate the need for ventilator support, but the assumed ongoing real practice is important and the value of radiologic evaluation beyond clinical findings to predict the mechanical ventilation need is subject for further evaluation with large patient series.

Comparison of Enflurane and Propofol in Electroconvulsive Therapy, a Randomized Crossover Open Preliminary Study on Seizure Duration and Anaesthetic Recovery

BACKGROUND AND OBJECTIVES Electroconvulsive therapy (ECT) is commonly used for treatment of depression, mania and affective disorders. Anaesthetics for general anaesthesia during ECT should have rapid onset, rapid emerge, not interfere with seizure activity and not shorten seizure duration. The aim of this study is to compare effects of enflurane, a pro-convulsive anaesthetic agent, and propofol on seizure durations, postictal suppression index and recovery times during electroconvulsive therapy. METHODS Unpremedicated subjects were divided into two groups according to induction of anaesthesia. Patients were induced for ECT with 5% enflurane in group E and 1.2mg.kg(-1) propofol in group P until loss of consciousness. The durations of electroencephalogram (EEG) and motor seizures, postictal suppression index, time to spontaneous breathing, duration of eye opening, and obeying commands were recorded. RESULTS There was no statistically significant difference between the groups regarding motor and EEG seizure times and postictal suppression index on the EEG records. Recovery times (times of starting spontaneous breathing, eye opening, and obeying command) were significantly shorter in group E compared to group P. No nausea or vomiting were observed and no ECG abnormality was noted except transient sinus bradycardia and sinus tachycardia. CONCLUSIONS Although sufficient seizure for the treatment was provided during enflurane anaesthesia, any additional benefit was not revealed regarding seizure times or postictal suppression index when compared to propofol anaesthesia. On the other hand, recovery times after enflurane anaesthesia were shorter than propofol anaesthesia. However, there is still a need for further study in different ETCO(2) levels.

Anaesthetic Management of a Neonate with Giant Cystic Hygroma.

Cystic hygroma, which originates from embryonic lymphoid tissue, is a benign tumour without any potential for malignancy. It is commonly located in the neck area. Anaesthetic management of a large neck mass may be challenging due to difficulty in intubation and the severe haemodynamic effects of surgical removal of a giant tumour. Serious consequences such as sudden airway occlusion resulting in hypoventilation and hypoxemia may arise. We present the anaesthetic management of a 15-day-old infant who underwent surgical removal of a cystic hygroma located on the left side of the neck. Anaesthesia was induced by mask ventilation with sevoflurane in 100% oxygen and intubation was carried out while maintaining spontaneous ventilation. The endotracheal tube was sutured to the tip of the right lip to avoid movement or extubation. In addition to arterial cannulation for invasive blood pressure monitoring, central venous catheterization for perioperative fluid management was put in place. After 6 hours of surgery, the infant was transported to the neonatal intensive care unit and was extubated without difficulty the next day. Facial nerve injury was observed to be temporary.