Nilgün Kavrut Öztürk

Comparison of Combined (Deep and Superficial) and Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy

OBJECTIVES Carotid endarterectomy under regional anesthesia may be performed by using superficial, intermediate, deep or combined cervical plexus block. The authors compared the combined and intermediate cervical plexus block by use of ultrasound guidance in patients undergoing carotid endarterectomy. DESIGN A prospective, randomized, double-blinded trial. SETTING Education and research hospital. PARTICIPANTS Adult patients undergoing carotid artery surgery. INTERVENTIONS Forty-eight patients were randomized to receive either combined cervical plexus block (deep plus superficial) or intermediate cervical plexus block by use of ultrasound guidance for carotid endarterectomy. The primary outcome measure was the amount of supplemental 1% lidocaine used by the surgeon. Secondary outcome measures were the time for the first analgesic requirement after surgery, block-related complications, postoperative visual analog scale score, and patient and surgeon satisfaction. MEASUREMENTS AND MAIN RESULTS Intraoperative supplemental lidocaine requirements were 3.0±1.9 mL in the combined-block group and 7.8±3.8 mL in the intermediate block group. These differences were statistically significant. There were no significant differences between the 2 groups in block-related complications and the time between the block completion and the first administration of the first dose of intravenous analgesic. In the combined-block group, maximum visual analog scale score was lower at 3 hours (2.2 [1-5] v 5.3 [3-8]), and patient satisfaction score was higher than the intermediate-block group (4.3 [3-5] v 3.1 [1-4]). One regional anesthesia procedure was converted to general anesthesia in the combined-block group. CONCLUSIONS Ultrasound-guided combined cervical plexus block compared to intermediate cervical plexus block led to less additional analgesic use, lower visual analog scale score, and higher patient satisfaction.

Evaluation of low tidal volume with positive end-expiratory pressure application effects on arterial blood gases during laparoscopic surgery.

Background: Pneumoperitoneum (PNP) and patient positions required for laparoscopy can induce pathophysiological changes that complicate anesthetic management during laparoscopic procedures. This study investigated whether low tidal volume and positive end‐expiratory pressure (PEEP) application can improve ventilatory and oxygenation parameters during laparoscopic surgery. Methods: A total of 60 patients undergoing laparoscopic surgery were randomized to either the conventional group (n = 30, tidal volume = 10 mL/kg, rate = 12/minute, PEEP = 0 cm H2O) or the low tidal group with PEEP group (n = 30, tidal volume = 6 mL/kg, rate = 18/minute, PEEP = 5 cm H2O) at maintenance of anesthesia. Hemodynamic parameters, peak plateau pressure (Pplat) and arterial blood gases results were recorded before and after PNP. Results: There was a significant increase in the partial pressure of arterial carbon dioxide (PaCO2) values after PNP in the conventional group in the reverse Trendelenburg (41.28 mmHg) and Trendelenburg positions (44.80 mmHg;p = 0.001), but there was no difference in the low tidal group at any of the positions (36.46 and 38.56, respectively). We saw that PaO2 values recorded before PNP were significantly higher than the values recorded 1 hour after PNP in the two groups at all positions. No significant difference was seen in peak inspiratory pressure (Ppeak) at the reverse Trendelenburg position before and after PNP between the groups, but there was a significant increase at the Trendelenburg position in both groups (conventional; 21.67 cm H2O, p = 0.041, low tidal; 23.67 cm H2O, p = 0.004). However, Pplat values did not change before and after PNP in the two groups at all positions. Conclusion: The application of low tidal volume + PEEP + high respiratory rate during laparoscopic surgeries may be considered to improve good results of arterial blood gases.

Comparison of Transcutaneous Electrical Nerve Stimulation and Parasternal Block for Postoperative Pain Management after Cardiac Surgery

Background. Parasternal block and transcutaneous electrical nerve stimulation (TENS) have been demonstrated to produce effective analgesia and reduce postoperative opioid requirements in patients undergoing cardiac surgery. Objectives. To compare the effectiveness of TENS and parasternal block on early postoperative pain after cardiac surgery. Methods. One hundred twenty patients undergoing cardiac surgery were enrolled in the present randomized, controlled prospective study. Patients were assigned to three treatment groups: parasternal block, intermittent TENS application, or a control group. Results. Pain scores recorded 4 h, 5 h, 6 h, 7 h, and 8 h postoperatively were lower in the parasternal block group than in the TENS and control groups. Total morphine consumption was also lower in the parasternal block group than in the TENS and control groups. It was also significantly lower in the TENS group than in the control group. There were no statistical differences among the groups regarding the extubation time, rescue analgesic medication, length of intensive care unit stay, or length of hospital stay. Conclusions. Parasternal block was more effective than TENS in the management of early postoperative pain and the reduction of opioid requirements in patients who underwent cardiac surgery through median sternotomy. This trial is registered with Clinicaltrials.gov number NCT02725229.

Anesthetic Management of Transapical Off-Pump Mitral Valve Repair With NeoChord Implantation

OBJECTIVES Various minimally invasive surgical approaches have been used in mitral valve (MV) surgery. The transapical off-pump mitral valve intervention with NeoChord implantation (TOP-MINI) is a minimally invasive, alternative procedure for the treatment of degenerative mitral regurgitation. There are several special considerations for the anesthesiologist during the TOP-MINI procedure. The main purpose of this study was to present the anesthetic management of the TOP-MINI procedure. DESIGN An observational study. SETTING Training and research hospital. PARTICIPANTS Adult patients who underwent MV repair with the NeoChord DS1000 system (NeoChord Inc, St Louis Park, MN). INTERVENTIONS The study included 12 consecutive patients who underwent MV repair with the NeoChord DS1000 system at the Antalya Training and Research Hospital, Antalya, Turkey, between June 2014 and December 2015. A record was made of preoperative demographic details, comorbidities, preoperative and postoperative mitral regurgitation severity, preoperative and postoperative forced expiratory volume in 1 second values, use of blood products and vasoactive drugs, surgical times, mechanical ventilation times, intensive care unit (ICU) and hospital length of stay, visual analog scale scores, analgesic requirement in ICU and perioperative complications. MEASUREMENTS AND MAIN RESULTS TOP-MINI was performed completely off-pump in 12 patients. Intraoperative salvaged blood via cell-saver was 660±196 mL. Patients required 0.8±0.7 U of red blood cells and 2.0±0.9 U of fresh frozen plasma in the ICU. Inotropic support was used in 5 patients. There was a significant decline in mean arterial pressure from before surgery to during implantation (70.9±4.5 mmHg v 51.7±5.8 mmHg, respectively). A statistically significant increase was demonstrated in mean arterial pressure from during implantation to postimplantation (51.7±5.8 mmHg v 67.0±6.8 mmHg, respectively). There were no significant differences in preoperative and postoperative forced expiratory volume in 1 second values. Defibrillation was required in 1 patient, and temporary atrial fibrillation was observed in 1 patient during the procedure. Atelectasis occurred in the postoperative period in 1 patient. The mean visual analog scale score was 3.6±1.4, and the mean tramadol consumption was 77±39 mg in the ICU. Extubation time and the mean length of stay in the ICU and hospital were 2.6±0.5 hours, 19.8±2.7 hours, 5±1 days, respectively. CONCLUSIONS The TOP-MINI procedure requires complex anesthetic management. Transesophageal echocardiographic guidance is essential for this procedure. One-lung ventilation, fluid administration, avoidance of hypothermia, and pain management are the bases for anesthetic management.

Effects of Parasternal Block on Acute and Chronic Pain in Patients Undergoing Coronary Artery Surgery

Background. Sternotomy causes considerable postoperative pain and postoperative pain management encompasses different analgesic regimens. In this study, we aimed to investigate the effect of peroperative parasternal block with levobupivacaine on acute and chronic pain after coronary artery bypass graft surgery. Materials and Methods. A total of 81 patients undergoing coronary artery bypass graft surgery were included in this study. Patients were randomly allocated by opening an envelope to receive either parasternal block with pharmacologic analgesia (group P; before sternal wire placement: sternotomy and mediastinal tube sites were infiltrated with local anesthetics) or pharmacologic analgesia alone (group C) for postoperative pain relief. All patients received intravenous tramadol with patient-controlled analgesia at the end of the surgery. Demographic characteristics, vital signs, tramadol consumption, analgesic intake, and intensity of pain with a visual analogue scale were recorded for each patient. Six months after surgery, the patients’ type of chronic pain was evaluated using the Leeds Assessment Neuropathic Symptoms and Signs pain scale questionnaire. Results. Patients who received parasternal block experienced less pain and needed less opioid analgesic (125.75 ± 28.9 mg in group P vs 213.17 ± 61.25 mg in group C) for 24 hours postoperatively (P < .001). There was no significant difference in nociceptive and neuropathic pain between the groups. Conclusion. Parasternal block had a benefical effect on the management of postoperative acute pain and decreased opioid consumption after surgery but had no significant effect in chronic post surgical pain.

A randomised controlled trial examining the effect on the addition of the mandibular block to cervical plexus block for carotid endarterectomy

OBJECTIVES Although the cervical plexus block generally provides adequate analgesia for carotid endarterectomy, pain caused by metal retractors on the inferior surface of the mandible is not prevented by the cervical block. Different pain relief methods can be performed for patients who experience discomfort in these areas. In this study, the authors evaluated the effect of mandibular block in addition to cervical plexus block on pain scores in carotid endarterectomy. DESIGN A prospective, randomized, controlled trial. SETTING Training and research hospital. PARTICIPANTS Patients who underwent a carotid endarterectomy. INTERVENTIONS Patients scheduled for carotid endarterectomy under cervical plexus block were randomized into 2 groups: group 1 (those who did not receive a mandibular block) and group 2 (those who received a mandibular block). The main purpose of the study was to evaluate the mandibular block in addition to cervical plexus block in terms of intraoperative pain scores. MEASUREMENTS AND MAIN RESULTS Intraoperative visual analog scale scores were significantly higher in group 1 (p = 0.001). The amounts of supplemental 1% lidocaine and intraoperative intravenous analgesic used were significantly higher in group 1 (p = 0.001 and p = 0.035, respectively). Patient satisfaction scores were significantly lower in group 1 (p = 0.044). The amount of postoperative analgesic used, time to first analgesic requirement, postoperative visual analog scale scores, and surgeon satisfaction scores were similar in both groups. There was no significant difference between the groups with respect to complications. No major neurologic deficits or perioperative mortality were observed. CONCLUSIONS Mandibular block in addition to cervical plexus block provides better intraoperative pain control and greater patient satisfaction than cervical plexus block alone.

Comparação de diferentes métodos de inserção de sonda nasogástrica em pacientes anestesiados e intubados

BACKGROUND Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding. MATERIAL AND METHODS 200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted. RESULTS Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG. CONCLUSION Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients.

Determinação da massa residual em ventrículo esquerdo por ecocardiografia transesofágica intraoperatória após ressecção de mixoma gigante e flutuante em átrio esquerdo

Atrial myxoma is a benign tumor of the heart that occurs primarily in the left atrium. Floating or large left atrial myxomas frequently cause functional mitral stenosis, may also affect mitral valve structure and flow, and lead to mitral regurgitation. Systemic embolization occurs in around 30% of cases either from tumor fragmentation or complete tumor detachment hence it should be removed as soon as it is detected. Intraoperative transesophageal echocardiography has a vital importance in the surgery. After resection of myxoma, intraoperative transesophageal echocardiography must be performed to rule out residual mass. The case here reported is of a 48-year old female, who presented with giant and floating left atrial myxoma. Residue mass was detected with intraoperative transesophageal echocardiography in the left ventricle after the resection of myxoma. Subsequently, the residue mass was successfully removed. Complete resection must be required to prevent possible complications such as recurrence, embolization in atrial myxomas. Transesophageal echocardiography performed intraoperatively is vital importance to confirm that the myxoma is completely resected.

Use of McGrath MAC Videolaryngoscope to Assist Transesophageal Echocardiography Probe Insertion in Intubated Patients.

OBJECTIVES Transesophageal echocardiography (TEE) probe insertion with the conventional blind insertion technique may be difficult in anesthetized and intubated patients. The use of a videolaryngoscope may facilitate the insertion of the TEE probe. The aim of this study was to compare the conventional technique with the use of the McGrath MAC videolaryngoscope for TEE probe insertion in terms of success rate, duration of insertion, and complications in patients undergoing cardiovascular surgery. DESIGN A prospective, randomized study. SETTING Training and research hospital. PARTICIPANTS Eighty-six adult patients undergoing cardiovascular surgery were included. INTERVENTIONS Eighty-six adult patients were randomized into 2 groups: conventional group (n = 43) and McGrath videolaryngoscope group (n = 43). Success rates, duration of insertion, complications, and hemodynamic changes during insertion were recorded. MEASUREMENTS AND MAIN RESULTS The success rate of TEE probe insertion at the first attempt was higher in the McGrath videolaryngoscope group (90.5%) than in the conventional group (43.9%) (p = 0.012). The mean duration for successful insertion of the TEE probe at the first attempt was longer in the McGrath videolaryngoscope group (24 s v 11 s) (p = 0.016). The total time for successful insertion of the TEE probe was similar in both groups. Pharyngeal injuries were observed more frequently in the conventional group (17.1% v 2.4%) (p = 0.037). The rate of blood presence on the probe tip in the conventional group was higher than in the McGrath group (21.9% v 4.8%). There were no statistical differences between the 2 groups in systolic blood pressure, mean arterial pressure, diastolic blood pressure, and heart rate before and after TEE insertion. CONCLUSIONS The use of the McGrath MAC videolaryngoscope for TEE insertion in cardiovascular surgery patients increases the success rate and reduces pharyngeal injuries compared to the conventional technique. The use of the McGrath MAC videolaryngoscope for TEE insertion causes similar hemodynamic changes as in the conventional blind insertion technique.

Anesthesia Management in Rare Case: Osteogenesis Imperfecta

Osteogenesis imperfecta is a rare genetic disorder and a collagen tissue disease for which preoperative preparation and intra-operative anesthesia management must be performed with great care on patients. An operation was planned for a 5-year old female patient with Type I osteogenesis imperfecta due to a right femoral fracture. Her medical history showed that she had been operated due to a left femoral fracture 5 months ago under sevoflurane inhalation anesthesia without any complications. On her physical examination, she was observed to be a short child with growth deficiency, kyphoscoliosis, and bone and shape deformities on her extremities. Her modified Mallampati score was III and neck extension was limited. Preoperative echocardiography, complete blood cell count, coagulation profile, and biochemical values were found in normal limits. She was taken into the Case Study Karaveli et al.; BJPR, 15(5): 1-5, 2017; Article no.BJPR.31703 2 operation theatre and monitorized. Pressure points were supported by silicon peds. Vascular access could not be established at first because of her agitation, and then it was achieved after the patient’s anesthesia induction was performed with sevoflurane. Her neck was kept stable and laryngeal mask was placed in the mouth in the first intervention. Anesthesia was provided through 50% O2 + 50% air and 2% sevoflurane. At the end of the operation that took 90 min, the patient was extubated unevenBtfully, and taken to the recovery room. Main anesthetic problems in patients with osteogenesis imperfecta are the difficulties in maintaining the airway management and malign hyperthermia. We used sevoflurane both at the induction and at the maintenance of anaesthesia due to the difficult vascular access of the patient, and we did not encounter any problems. Inhalation anesthesia such as sevoflurane as well as TIVA could be used for the anesthesia for the patients with osteogenesis imperfecta. Great care must be given because of difficult airway in such patients, and necessary precautions must be taken. Laryngeal mask airway could be preferred in order to secure the airway and avoid traumatic complications.