Hilal Sazak

A comparison of ketamine-midazolam and ketamine-propofol combinations used for sedation in the endobronchial ultrasound-guided transbronchial needle aspiration: a prospective, single-blind, randomized study

OBJECTIVE We aimed to compare the effectiveness and safety of ketamine-midazolam and ketamine-propofol combinations for procedural sedation in endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). METHODS Sixty patients who were undergoing EBUS-TBNA were included in this study. Patients were randomly divided into two groups. Group 1 was given 0.25 mg/kg intravenous (iv) ketamine, 2 min later than 0.05 mg/kg iv midazolam. Group 2 received 0.125 mg/kg ketamine-propofol mixture (ketofol), 2 min subsequent to injection of 0.25 mg/kg each. Sedation was maintained with additional doses of ketamine 0.25 mg/kg, and ketofol 0.125 mg/kg each in Group 1 and Group 2, respectively. Blood pressure, heart rate (HR), peripheral oxygen saturation, respiratory rate (RR), Ramsay Sedation Score (RSS), and severity of cough were recorded prior to and after administration of sedation agent in the beginning of fiberoptic bronchoscopy (FOB) and every 5 min of the procedure. The consumption of the agents, the satisfactions of the bronchoscopist and the patients, and the recovery time were also recorded. RESULTS HR in the 10(th) min and RSS value in the 35(th) min of induction in Group 1 were higher than the other group (P<0.05). The recovery time in Group 1 was statistically longer than Group 2 (P<0.05). There was no statistically significant difference between groups with respect to other parameters (P>0.05). CONCLUSIONS It was concluded that both ketamine-midazolam and ketamine-propofol combinations for sedation during EBUS-TBNA were similarly effective and safe without remarkable side effects.

Absence of the Right Internal Jugular Vein During Ultrasound-Guided Cannulation

Cannulation of the internal jugular vein (IJV) may be diffucult because of anatomical variations. A 66-year-old female patient, who was in the intensive care unit, underwent ultrasound-guided cannulation of the right IJV. The right IJV could not be visualized by ultrasonography despite positional changes of the patient and Valsalva maneuvre. The left IJV was easily determined by ultrasonography and cannulated. Although the landmark technique may be sufficient for most of the central vein cannulations, the rate of anatomical variations and related complications is quite high. We point out that even if ultrasound cannot be used in real-time, the ultrasonographic confirmation during the pre-insertion period may be crucial for successful central vein cannulation.

Coexistence of Obstructive Sleep Apnea and Superior Vena Cava Syndromes Due to Substernal Goitre in a Patient With Respiratory Failure: A Case Report.

Introduction: Substernal goiter may rarely cause superior vena cava syndrome (SVCS) owing to venous compression, and cause acute respiratory failure due to tracheal compression. Obstructive sleep apnea syndrome (OSAS) may rarely occur when there is a narrowing of upper airway by edema and vascular congestion resulting from SVCS. Case Presentation: We presented the clinical course and treatment of acute respiratory failure (ARF) developed in a patient with SVCS and OSAS due to substernal goiter. After treatment of ARF with invasive mechanical ventilation, weaning and total thyroidectomy were successfully performed through collar incision and median sternotomy without complications. Conclusions: Our case showed that if the respiratory failure occurred due to substernal goiter and SVCS, we would need to investigate the coexistence of OSAS and SVCS.

Assessment of Perianesthesic Data in Subjects Undergoing Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration

BACKGROUND: Transbronchial needle aspiration using endobronchial ultrasonography (EBUS-TBNA), a new minimally invasive diagnostic procedure, has been used to evaluate intrathoracic lymph nodes. It has been reported that EBUS-TBNA can be performed safely under sedation and provides a high level of patient satisfaction. We aimed to describe perianesthetic data, and compare results regarding the agents of subjects undergoing EBUS-TBNA under deep sedation. METHODS: After ethics committee approval, perianesthetic data of 571 subjects undergoing EBUS-TBNA were analyzed retrospectively. Data were collected from anesthesia evaluation and observation forms. Four groups received anesthesia in the operating room as follows: propofol-midazolam (group PM), propofol-ketamine (group PK), propofol-ketamine-midazolam (group PKM), or propofol (group P). Dosage, number of anesthetic injection, hemodynamic variables, recovery time, complications, and patient satisfaction were also recorded. RESULTS: Propofol consumption was higher in groups P and PM compared with groups PK and PKM. Midazolam requirement was higher in group PM than in group PKM. Recovery time was shorter in group P compared with groups PK, PM, and PKM. It was also shorter in groups PK and PM compared with group PKM. All of these differences were statistically significant. Temporary desaturation (n = 41; 7%) and increased blood pressure (n = 78; 14%) were predominant complications. In groups PK and PKM, risk of developing hypertension was higher than in groups PM and P (P < .001). The percentage of subjects satisfied with the procedure was 99%. CONCLUSIONS: Independent from the sedative agent, deep sedation can be safe, and provide high patient satisfaction during EBUS-TBNA. The combination of ketamine with propofol or midazolam required lower doses of these anesthetics. However, the incidence of increased blood pressure was higher in groups administered ketamine. Recovery time was the shortest in group P, and the longest in group PKM. There was no relation between recovery time and total dose of anesthetics or presence of chronic disease.

Methemoglobinemia following prilocaine administration for bilateral tube thoracostomy in a pediatric case

13.6 or 16.0 mm deep at maximum in a 45or 60degree insertion. Thus, the needle can reach the anterior wall of the vertebral artery. In cyanotic patients, it would be difficult to distinguish arterial blood from venous blood by its behavior because nonpulsatile blood appeared slowly from the thin needle. A 24-G puncture needle damages the vertebral artery little even if it was punctured mistakenly. However, the misplacement of a guidewire might lead to serious complications such as intra-aortic misplacement of a central venous catheter through the IJV (2) and vertebral artery pseudoaneurysms (3,4). In conclusion, we have to be careful to check small arteries such as vertebral arteries under or below IJVs with color Doppler flow imaging before puncture needle insertion to avoid accidental arterial puncture in securing pediatric CVCs, using real-time ultrasound guidance. Funding

An uncommon procedure for a rare ailment: massive bronchoalveolar lavage in a patient with pulmonary alveolar proteinosis.

As a rare procedure, massive bronchoalveolar lavage (MBAL) is a large-volume lavage which necessitates general anesthesia and one-lung ventilation (OLV). During MBAL isotonic saline is instilled into one lung and drained through one lumen of a double-lumen tube. MBAL is the most effective treatment for symptomatic pulmonary alveolar proteinosis (PAP). A 27-year-old male with PAP was scheduled for therapeutic MBALs. After standard preoxygenation, monitoring and anesthesia induction, a double-lumen tube was placed. Tube position was verified by a fiberoptic bronchoscope. The internal jugular vein, radial and pulmonary arteries were cannulated. A temperature probe and foley catheter were inserted. The nonventilated lung was filled with 1000 mL saline and then drained in each session. The left and right lung were lavaged with an interval of 2 weeks. A total of 20 L saline was used in each MBAL without retention. MBALs were terminated after the effluent became clear. Duration of the left and right MBALs were 325 and 275 minutes, respectively. Despite increased shunt fraction, oxygenation was within acceptable limits during OLV. The trachea was extubated in the operating room uneventfully after each MBAL. The patients clinical and laboratory findings were evidently improved. Consequently, if proper conditions are provided, MBAL is safe and beneficial despite its risks and the long duration.

High‐Frequency jet ventilaton during resection of tracheal stenosis in a 14‐year‐old case

for elongation sinewes Achilis because of her main disease paralysis cerebralis spastica. She was also diagnosed pyruvate dehydrogenase deficiency in the year of 2, since when she had thiamine in therapy. Clinically, the child had developmental delay, facial dysmorphism (Figure 1), weakened hearing and could not stand. CT scan showed agenesis of the corpus callosum and frontal corns of the lateral chambers. Laboratory studies revealed elevated lactate and pyruvate levels with normal L ⁄ P ratio. Blood gas analyses were within referent values, there was no acidosis. After premedication with midazolam and atropine, anesthesia was induced with propofol and vecuronium. Intubation was difficult, but successful after third attempt. Anesthesia was maintained with fentanyl, vecuronium and nitrous oxide with oxygen. Intravenously she was given normal saline solution throughout the operation. The procedure lasted for 1 h in which time she received fentanyl 3 lgÆkg total, and propofol 3 mgÆkg. Monitoring included pulse oximetry, NIBP and capnography. Blood gas analysis at the end of the operation showed no changes. Serum blood lactate level was increased, but the same as preoperatively. She was extubated in the operating room and sent to ward in good condition. Pyruvate dehydrogenase complex deficiency (PDCD) is genetic disorder associated with abnormal mitochondrial metabolism. PDC catalyses conversion of pyruvate to acetyl-CoA which enters the tricarboxylic acid cycle and its deficiency results in energy deficit. In this age it is usually a milder form of disease. Anesthesia can be complicated by the PDCD. There are no many reports about children with this metabolic disorder who went to general anesthesia. According to them, the most important is to avoid stress which could aggravate energy production in already impaired carbohydrate metabolism and increase lactate level and decline the acidosis (1). It is recommended to avoid lactated solutions and to monitor acid base status during surgery (2). In both mentioned cases anesthesia was maintained with volatile anesthetic and there were no complications. Considering the previous recommendations we can only add that intravenous anesthesia with propofol and analgesia with opioid analgesic can be safe for patient with PDCD. Also it is important to estimate the difficulty of intubation preoperatively and to be prepared. Irina Milojevic* Dusica Simic† *Department of Anesthesiology University Children’s Hospital Belgrade, Serbia (email: mirina@sbb.co.yu) †ICU University Children’s Hospital Belgrade, Serbia (email: dussin@eunet.yu)

Effects of epidural morphine and levobupivacaine combination before incision and after incision and in the postoperative period on thoracotomy pain and stress response

Background/aim This study aims to investigate the effects of thoracic epidural analgesia, before and after surgical incision and in the postoperative period, on thoracotomy pain and stress response. Materials and methods A total of 45 patients who were scheduled for posterolateral thoracotomy were included in this study. A combination of epidural levobupivacaine and morphine was administered as a bolus before incision (Group 1; n=15), after incision (Group 2; n=15), or at the end of surgery (Group 3; n=15). Additionally, infusion was used in Group 1 and Group 2 during operation. Postoperative patient-controlled epidural analgesia infusion pumps were connected to all patients. Visual analog scale (VAS) scores and morphine consumption were recorded during the postoperative 48 h. Glucose, insulin, cortisol, and C-reactive protein (CRP) levels were compared before surgery and at 4, 24, and 48 h after the operation. Results There were no differences in the morphine consumption and VAS scores for all measurements among the groups (P > 0.05). Both blood glucose levels at 4 h and CRP values at 48 h were higher in Group 2 than Group 1 (P < 0.05). Cortisol levels at 4, 24, and 48 h after the operation were similar to baseline values in all groups (P > 0.05). Conclusion The application of thoracic epidural analgesia before and after surgical incision and in the postoperative period did not result in a significant difference in the severity of the postthoracotomy pain and stress response in all groups. Based on our results, we suggest that epidural levobupivacaine combined with morphine provides an effective and safe analgesia and can partially suppress surgical stress response.

The Effects of Local Anaesthetics on QT Parameters during Thoracic Epidural Anaesthesia Combined with General Anaesthesia: Ropivacaine versus Bupivacaine

BACKGROUND Many studies focusing on the effects of local anaesthetics on QT intervals have been performed, but the articles evaluating the relationship between thoracic epidural anaesthesia combined with general anaesthesia and QT parameters are very limited. AIMS We aimed to compare the effects of bupivacaine and ropivacaine on QT interval, corrected QT, dispersion of QT, and corrected dispersion of QT in patients undergoing lung resection under thoracic epidural anaesthesia combined with general anaesthesia. STUDY DESIGN Prospective clinical study. METHODS Thirty ASA physical status 1-3 patients requiring thoracic epidural anaesthesia combined with general anaesthesia for thoracic surgery. Patients were randomly assigned to two groups, which were allocated to receive either bupivacaine (Group B) or ropivacaine (Group R) during thoracic epidural anaesthesia. Following haemodynamic monitoring, a thoracic epidural catheter was inserted. Local anaesthetic at an average dose of 1.5 mL/ segment was given through an epidural catheter. The same general anaesthesia protocol was administered in both groups. Records and measurements were performed on 10 phases that were between the thoracic epidural catheter insertion to the 5(th) min of endobronchial intubation. In all phases, systolic arterial pressure, diastolic arterial pressure, mean arterial pressure, heart rate, peripheral O2 saturation, and electrocardiogram monitoring were performed in patients. All QT parameters were recorded by 12-lead electrocardiogram and analysed manually by a cardiologist. RESULTS QT intervals were similar between two groups. In Group R, corrected QT values at the 20(th) min of local anaesthetic injection and the 5(th) min of endobronchial intubation were shorter than those in Group B (p<0.05). The basal dispersion of QT and dispersion of QT values at the 1(st) min of propofol injection were shorter than those in Group R (p<0.05). The corrected dispersion of QT value at the 1(st) min of propofol injection was shorter in Group R (p<0.05). In Group R, the decrease in mean arterial pressure at the 1st min of fentanyl injection was significant compared with Group B (p<0.05). There was no significant difference between the groups with respect to heart rate and complications. CONCLUSION The corrected QT, dispersion of QT, and corrected dispersion of QT intervals were slightly longer in the patients receiving bupivacaine compared with those receiving ropivacaine in various phases of the present study.