Inci Kara

The Relationship between Bioimpedance Analysis, Haemodynamic Parameters of Haemodialysis, Biochemical Parameters and Dry Weight

Adequate fluid management plays an important role in the treatment of haemodialysis patients and the assessment of dry weight is important for efficient therapy. Fluid volume parameters were assessed in adults undergoing haemodialysis for end-stage renal disease, using whole-body multifrequency bioimpedance analysis (BIA), and their relationship to haemodynamic and biochemical parameters of haemodialysis was evaluated. Ultrafiltration volume was correlated with age, sodium, haemoglobin, extracellular water (ECW)/total body water (TBW) ratio and ECW/intracellular water (ICW) ratio. The ECW/TBW ratio was correlated with age, body mass index, dry weight, predialysis systolic and diastolic blood pressure, and ECW/total body weight ratio. The ECW/ICW ratio correlated with age, dry weight, TBW, albumin, adequacy of dialysis and urea removal ratio. The study demonstrated a close relationship between bioimpedance-derived fluid volume parameters and the haemodynamic and biochemical parameters of haemodialysis. It is concluded that multifrequency whole-body BIA may have clinical value in the estimation of dry weight and other haemodynamic parameters of haemodialysis and so may protect patients from the risks associated with under- or over-hydration.

Is a neutral head position as effective as head rotation during landmark-guided internal jugular vein cannulation? Results of a randomized controlled clinical trial.

OBJECTIVE Central venous access remains a cornerstone procedure for a variety of clinical conditions. Ultrasound studies suggest that rotation of the head increases the magnitude of the overlap of the internal jugular vein with the carotid artery. The authors assessed whether a neutral position of the head during anatomic landmark-guided cannulation of the internal jugular vein (IJV) was an attractive alternative to rotating the neck to a >45° head turn. DESIGN A prospective, randomized, controlled study. SETTING An education and research hospital and a university-affiliated hospital. PARTICIPANTS Eighty patients requiring central venous catheterization in the right IJV. INTERVENTIONS Under general anesthesia, patients were positioned in the Trendelenburg position with extension of the neck. In the rotated group, the head was rotated to the left at >45°. In the neutral group, the head was placed in the neutral position. Right IJV cannulation was performed using the central approach with the needle angled toward the ipsilateral nipple. The primary outcome variable was the cumulative success rate, which was defined as IJV puncture achieved in the first 3 attempts using a finder needle. A p value of <0.05 was considered statistically significant. MEASUREMENTS AND MAIN RESULTS Groups were similar in terms of demographic data. The success rates of finder needle passes into the IJV on the first attempt were 87.5% and 37.5% (p < 0.05), and the cumulative success rates on the first 3 attempts were 97.5% and 57.5% in the rotated and neutral groups, respectively (p < 0.05). Carotid artery puncture only occurred in 2 patients in the rotated group. CONCLUSIONS Because of the lower success rate, the neutral head position is not an attractive alternative for IJV catheterization when compared with the rotated head position in a central landmark IJV approach.

Optimal angle of needle entry for internal jugular vein catheterization with a neutral head position: a CT study.

Purpose: The aim of this study is to determine the optimal angle of needle entry in the sagittal plane for internal jugular vein (IJV) catheterization with the central approach while the head is in the neutral position. Methods: The contrast–enhanced carotid artery computed tomography angiographies of 123 consecutive patients were retrospectively reviewed. The point of merger between the sternal and clavicular heads of the sternocleidomastoid muscle was assumed as a clinical entry (CE) point. The angle between CE point and the center of the IJV, the depth, diameter of the vessels and the degree of overlap between the IJV and carotid artery (CA) were measured. Results: The angles between the CE point and the center of the IJVs were similar, 7° ± 13° medial and 8° ± 12° medial on the right and the left side, respectively. The center of IJVs from the CE point was between 0° and 16° toward the medial in 79.8% on the right side and 89.9% on the left side of patients. The diameters of the right IJVs were greater than the left IJVs (p = 0.001). The depth from the skin and overlap between IJV and CA did not vary between the two sides. Conclusions: When a central approach is used for right internal jugular vein (RIJV) cannulation with a neutral head position, the orientation of the angle of needle entry (i.e., 16°) medially in the sagittal plane may quadruple the success rate of RIJV catheterization compared to the success rate of a laterally oriented angle of entry as recommended by the classic method.

Relationship between the Right Internal Jugular Vein and Carotid Artery at Ipsilateral Head Rotation

Ultrasound-guided right internal jugular vein catheterization (RIJV) should be the first choice to decrease the catheter-related complications in high-risk hemodialysis patients. For this procedure, clinicians should identify the optimum positions of the RIJV, including its lower overlap with the carotid artery (CA) and high cross-sectional area of the vein. The aim of this prospective randomized study to evaluate the effects of mild ipsilateral head rotation combined with Trendelenburg position on RIJV cross-sectional area and its relation to the CA in adult patients. Forty ASA I–II patients who were undergoing elective surgery were enrolled for this study. The subjects were asked to remain supine in the 15–20° Trendelenburg position. Two-dimensional ultrasound was then used to measure the degree of overlap between the RIJV and CA, the cross-sectional area of the RIJV. These measurements were compared between head rotation to the >30° left, <30° left, neutral, and <30° right positions. When the head was in the >30° left position, overlap was seen in 38 of 40 patients (95%). As the head was rotated from >30° left to <30° right, the CA-RIJV overlap (from 95% to 57.5%), and the cross-sectional area (from 14.2 mm to 8.7 mm) significantly decreased. In conclusion, when the head was turned to <30° right, the CA-RIJV overlap significantly decreased, and the cross-sectional area also decreased. When clinicians determine the optimal head position before RIJV cannulation, it is important to consider the advantages and disadvantages of the different head positions from >30° left to <30° right.

The Effects of Intrathecal Morphine on Patient-Controlled Analgesia, Morphine Consumption, Postoperative Pain and Satisfaction Scores in Patients Undergoing Gynaecological Oncological Surgery

OBJECTIVE: Gynaecological oncological surgery (GOS) includes a wide variety of surgical procedures and postoperative pain is a major concern. This study compared the impact of intrathecal morphine (ITM) plus patient-controlled analgesia (PCA) with PCA alone on morphine consumption, pain relief and patient satisfaction after GOS. METHODS: Sixty women undergoing GOS under general anaesthesia were randomized to receive either 0.3 mg ITM or placebo. On arrival at the postanaesthesia care unit each patient received a morphine PCA pump. The three primary outcome measures were pain, patient satisfaction scores evaluated using a 100-mm visual analogue scale and cumulative PCA morphine consumption. RESULTS: No significant differences were observed in the demographic data. Cumulative PCA morphine consumption was significantly lower in the ITM group compared with the control group. Fatigue scores were lower in the ITM group compared with the control group but did not reach statistical significance. Pain, sedation and patient satisfaction scores, and the rate of side-effects were similar for the two groups. CONCLUSIONS: Administering ITM in GOS could improve postoperative analgesia and reduce morphine consumption without serious side-effects.

A comparison of the effects of intraoperative tramadol and ketamine usage for postoperative pain relief in patients undergoing tonsillectomy

OBJECTIVES We aimed to compare the effects of ketamine and tramadol administered intraoperatively on postoperative pain and analgesic demand in children undergoing tonsillectomy operations. METHODS Ninety children undergoing tonsillectomy, aging 5-15 years old, with ASA I - II , were included in this study. Cases were arranged in three groups and given standardized general anesthesia. After coagulation, ketamine (0.5 mg.kg-1) was administered intravenously (iv) in the ketamine group, and tramadol iv (2 mg.kg-1) was given in the tramadol group and the control group received a physiologic iv. The duration of anesthesia, duration of operation, and length of stay in the PACU were recorded. NRS and CHEOPS scales were used to assess postoperative pain. Paracetamol (15 mg.kg-1) was given rectally in the first 6 hours (hrs) and orally over the subsequent 6 hrs, if NRS greater than 3 and CHEOPS greater than 8 were observed. All data were recorded concerning the initial and total dosage of analgesic and the presence of complications within 24 hrs. RESULTS Demographic data, duration of anesthesia, duration of operation, and duration of stay in the PACU were similar between groups (p>0.05). The number of patients requiring additive analgesic was higher in the control group. No differences were found between the tramadol and ketamine groups (p>0.05). Additional analgesic was given earlier in the control group (p<0.05), but the need for additional analgesic was similar in tramadol and ketamine groups (p>0.05). Paracetamol dosage was significantly higher in the control group (p<0.05), but similar between the tramadol and ketamine groups (p>0.05). The frequency of nausea and vomiting was found to be significantly higher in tramadol and ketamine groups compared to the control group (p<0.05). CONCLUSION Postoperative pain was effectively managed using 2 mg.kg-1 tramadol and 0.5 mg.kg-1 ketamine in pediatric tonsillectomies.

Management of postdural puncture headache with epidural saline patch in a 10-year-old child after inguinal hernia repair: A case report

Spinal anesthesia (SA) is becoming increasingly popular among pediatric anesthetists. Postdural puncture headache (PDPH) has been reported in children. PDPH generally spontaneously resolves within a few days with bed rest and nonopioid analgesics, but it may last for several days. If the symptoms persist, an epidural blood patch is considered as an effective treatment. We describe the successful use of an epidural saline patch in a 10 year-old child with PDPH who did not respond to conservative treatment.

Repair of duodenal atresia under spinal anesthesia in a low-birth-weight preterm neonate: case report

Duodenal atresia is a well-recognized cause of neonatal bowel obstruction. General anesthesia with tracheal intubation is the traditional anesthetic technique for surgical correction of this condition. Metabolic abnormalities and fluid deficits coupled with residual anesthetics are known to increase the risk of postoperative apnea, prolonging the operating room time and delaying extubation. Spinal anesthesia (SA) is an accepted alternative to general anesthesia in formerly preterm infants. In the current literature, there are reports of successful use of SA for simple infraumbilical surgery and, occasionally, for upper abdominal surgery, but there is no information on the use of SA in neonates for duodenal atresia repair. We present a case of duodenal atresia in a preterm infant at a gestational age of 30 weeks with coexisting bronchopulmonary dysplasia successfully repaired under SA. Further studies that compare the adverse effects with the potential advantages of SA are warranted before future recommendations are made for neonates who are undergoing upper abdominal surgery.

Left femoral vein is a better choice for cannulation in children: a computed tomography study.

Central venous catheters are often required in emergency rooms and intensive care and/or those undergoing major surgical procedures. In this study, we aimed to gain a better understanding of the anatomy of the femoral vessel in relation to central venous cannulation.

Seeing is believing: ultrasound-guided internal jugular vein cannulation.

• Volume 115 • Number 6 www.anesthesia-analgesia.org 1471 REFERENCES 1. Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST. Guidelines for performing ultrasound guided vascular cannulation: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. Anesth Analg 2012;114:46–72 2. Troianos CA, Kuwik RJ, Pasqual JR, Lim AJ, Odasso DP. Internal jugular vein and carotid artery anatomic relation as determined by ultrasonography. Anesthesiology 1996;83:43–8 3. Lamperti M, Subert M, Cortellazzi P, Vailati D, Borrelli P, Montomoli C, D’Onofrio G, Caldiroli D. Is a neutral head position safer than 45-degree neck rotation during ultrasoundguided internal jugular vein cannulation? Results of a randomized controlled clinical trial. Anesth Analg 2012;114:777–84 4. FellerKopman D. Ultrasoundguided internal jugular access: a proposed standardized approach and implications for training and practice. Chest 2007;132:302–9