Osman Kaçmaz

Determination of Absence of Right Internal Jugular Vein During Ultrasonographic Guided Central Venous Cannulation

Written informed consent was obtained from the patient for sharing his clinical condition in a scientific journal. The 53-year-old male patient (weight 78 kg) was going to undergo liver transplantation from a living donor because of end-stage liver failure. His history revealed that he had cirrhosis for 1 year and had thrombus in his portal vein. He was admitted into the operating room and underwent induction after standard monitoring. A cannula was inserted into the left radial artery, and invasive arterial pressure was monitored. A central catheter was planned to be inserted into the right IJV under USG guidance. The table was set in the Trendelenburg position and the patients head was slightly turned to the left side. The patient was covered in a sterile way and 9-L linear probe of USG (5.0–13.0 MHz, multi-frequency, boardband) was sterilised and placed in the right neck region, but the right IJV was not visible. While the right carotid artery could be clearly observed using colour Doppler, the right IJV was not detected (Figure 1). Although the right neck was thoroughly examined via USG, the right IJV was absent. The left IJV was evaluated through USG and it was easily viewed (Figure 2). A central venous catheter was inserted into the left IJV without any problem.

General anesthesia management in carotid endarterectomy surgery: a single center experience

Carotid endarterectomy (CEA) is an effective surgery which is applied in order to reduce the risk of stroke associated with severe stenosis of the carotid artery. Anesthesia management is important in these patients due to high incidence of cardiovascular disease and studies are in progress for ideal anesthesia management. In this study, we aimed to share our experience in carotis endarterectomy and evaluate the clinical outcomes and review retrospectively. Patients informations were obtained from the patients and anesthesia records. Age, ASA physical status, Mallampati score (MP), anesthesia and surgery duration, ICU and discharge time, blood transfusion rate, anesthetic and analgesic drugs, invasive procedures, complications, smoking, stenosis side and ratio, comorbid conditions of patients and drugs were recorded. The mean age of patients was 67.19±1.07 (33-98). It was evaluated that 44 patients (61.2%) were ASA II, 28 patients (38.8%) were ASA III. It was recorded that mean duration of anesthesia was 226.25 ± 37.99 min, duration of surgery was 195.83±38 min, ICU stay was 2.45 ± 2.52 days and hospital stay time was 5.23 ± 2.77 days. 29 of patients (40.3%) were smokers and 7 of patients (9.7%) were identified as secondary smokers. The mortality rate was 6.9% (5 patients). Clinical experience and outcome data from our study are consistent with the literature. In CEA surgery, anesthetic technique that is safe enough to guide the evidence is not there yet. Experience of the anesthesiologist and the surgeon as surgical anesthetic management of CEA is an important point to be noted that the current developments in the patients characteristics and monitoring.

Emergency Difficult Airway Management in a Patient with Severe Epidermolysis Bullosa

Epidermolysis bullosa (EB) is a rare disease characterised by vesiculobullous lesions with minimal trauma to the skin and mucous membranes. Bleeding, scar tissue, contractures, oedema and lesions that can spread throughout the body can cause a difficult airway and vascular access in patients with EB. Therefore, anaesthetic management in patients with EB is a major problem even for experienced anaesthesiologists. Herein, we report a case of difficult airway management in a patient diagnosed with severe EB who presented for emergency tracheostomy because of respiratory failure under general anaesthesia.

Successful Management of Ultrasound-Guided Combined Spinal-EpiduralAnesthesia for Cesarean Section in a Patient with Achondroplasia

Anesthetic management of the pregnant achondroplastic patient for cesarean section poses significant challenges for anesthetists when coupled with anesthetic risks encountered during the third trimester of pregnancy. We report the case of a 25-year-old, 107 cm in height, and 37-week woman with achondroplasia who underwent neuraxial anesthesia for an elective cesarean section. Due to lumbar hyperlordosis and tissue edema, spinous processes could not be palpated and ultrasound probe was used to identify the vertebral interspace and also, the distance to the ligamentum flavum was measured. Accompanied by combined spinal-epidural (CSE) set, epidural space was located and a spinal needle was placed to the subarachnoid space. After 5 mg 0.5% hyperbaric bupivacaine with 10 μg fentanyl (total volume 1.2 mL) was injected to the subarachnoid space, the epidural catheter was advanced. A bilateral T5 sensory block level to pinprick was obtained after 5 min and the operation was allowed. A baby girl weighing 2460 gr was delivered 7 min after skin incision. The patient felt pain and discomfort during the elevation of the uterus and 3 mL 2% lidocaine was injected twice at 5 min intervals via the epidural catheter. The patient had no complications related to her delivery or anesthetic and was discharged home on the second postoperative day. CSE anesthesia with low spinal dose and ability to increase the level of the block via epidural route when needed, in combination with ultrasound guidance, provided successful and safe anesthesia.

Retrospective Evaluation of Dental Treatment under General Anaesthesia

OBJECTIVE Most dental procedures can be performed with local anaesthesia, however noncompliant paediatric patients, patients with mental retardation or psychiatric disorders, severe anxiety, severe craniofacial anomalies and orofacial trauma may need general anaesthesia. In these patients accompanying central nervous system diseases and airway problems increase the risk of complications. Anaesthesia records of 467 cases of dental surgery performed under general anaesthesia between 2011-2014 is reported with information from the recent literature. METHODS In the study, 467 cases of dental procedures performed under general anaesthesia were taken from the İnönü University of Medicine, Dentistry Disabled Treatment Centre, after approval of the İnönü University Faculty of Medicine Ethics Committee. Demographic data, ASA classification, Mallampati (MP) score, duration of surgery, type of intubation and difficulties, comorbid diseases, premedication application, endocarditis prophylaxis, recovery time, analgesia and reasons for general anaesthesia were recorded as mean±standard deviation (SD) or as a number. RESULTS The mean age of the patients was 16.78±12 years and the female/male ratio was 277/190 (59.3%/40.7%). Of the 467 patients, 219 (46.9%) were classified as ASA I, 234 (50.1%) as ASA II and 14 (3%) as ASA III. Furthermore, 182 (38.9%) patients with mental retardation, 33 (7.1%) with cerebral palsy and 28 (6%) with autism were identified. The mean operative time was 114.53±35.4 min, and the average recovery time 40.4±6 was min. Of the endotracheal intubations 277 (59.3%) were oral, 82 (17.6%) were nasal, and 108 (23.1%) were nasal with the help of fibreoptics. Difficult intubation was observed in 20 (4.3%) patients. The MP score was 1 in 397 (85%) patients, 2 in 50 (10.7%) patients, 3 in 18 (3.9%) patients and 4 in 2 (0.4%) patients. General anaesthesia was applied because of cooperation difficulties in 213 (45.6%), mental retardation in 182 (38.9%), autism in 28 (5.9%), schizophrenia in 7 (1.7%) and jaw surgery in 37 (7.9%) patients. Local infiltration was used for analgesia in 141 (30.2%), morphine in 12 (2.6%), tramadol in 3 (0.6%) and paracetamol in 311 (66.6%) patients. Endocarditis prophylaxis was employed in 36 (7.7%) cases. CONCLUSION General anaesthesia in dental procedures is becoming increasingly common. Anaesthetic management is important due to the frequency of genetic syndromes and mental retardation. In the anaesthetic management of these patients, strategies for the patient should be identified, the process should be implemented in the operating room and preparations should be made with risk analyses.