Ozlem Ozmete

Anesthesia management and sugammadex experience in a neonate for Galen vein aneurysm

Galen vein aneurysm (GVA) is a symptomatic cerebrovascular malformation in neonates, and interventional aneurysm treatment is gaining popularity in this patient group.We aimed to present our anesthesia management and experience with sugammadex in a neonate who underwent endovascular intervention for GVA. An 11-day-old term newborn was referred to the anesthesia clinic for GVA (Fig. 1). Echocardiography showed right ventricular and pulmonary arterial dilatation, pulmonary hypertension, 3° to 4°TY, and ejection fraction of 55% with normal laboratory values. Anesthesia induction was achieved by the inhalation of sevoflurane, 0.6 mg/kg rocuronium, and 1 μg/kg fentanyl, and maintenance was achieved by 1.5% sevoflurane with 50%/50% oxygen-air. Jugular vein catheter and arterial line were applied. Dexamethasone 0.5 mg/kg, mannitol 0.5 mg/kg, furosemide 1 mg/kg, and ranitidine 1 mg/kg were administered preoperatively. Sugammadex 2 mg/kg was administered initially, and 1 mg/kg additional dose was used to achieve proficiency in respiratory effort. Then the patient was extubated without any complication and transferred to the neonatal intensive care unit. Patients with GVA have an increased risk of cerebral ischemia and infarction during anesthesia. For this reason, agents should be carefully selected. Medications protecting hemodynamics and reducing cerebral metabolic rate and oxygen consumption should be given preference. According to studies, we preferred sevoflurane due to its pharmacokinetic properties for induction and maintenance of anesthesia [1]. We also avoid using nitrogen to reduce the risk of small air embolism. Anesthesiamanagement should also aim to provide andmaintain cardiovascular stability and prevent sudden volume shifts in circulation. Another issue to consider during anesthesia management of these cases is hypothermia. These patients are administered great amounts of fluids as required by endovascular procedures. Care should be taken to administer these fluids after heating to an adequate temperature, to warm up patients. The nextmain stage of anesthesia is the extubation phase in aneurysm procedures. A smooth extubation plan to reduce complication such as hypertension and obtain a full recovery to assess the neurologic status at the operating table should be themain aim of the anesthesiologist. During interventional aneurysmprocedures,

Sugammadex given for rocuronium-induced neuromuscular blockade in infants: a retrospectıve study

STUDY OBJECTIVE To evaluate the efficacy and safety of sugammadex in reversing profound neuromuscular block induced by rocuronium in infant patients. DESIGN Retrospective observational study. SETTING University teaching hospital. PATIENTS Twenty-six infants (2-12 months of age; 3-11 kg) with an American Society of Anesthesiologists classification I, II, or III who were scheduled to undergo neurosurgical procedures were included in the study. INTERVENTIONS Anesthesia was induced with 5 mg/kg thiopental, 1 μg/kg fentanyl and 0.6 mg/kg rocuronium. Sevoflurane was administered to all patients after intubation. METHODS The neuromuscular block was monitored with acceleromyography using train-of-four (TOF) stimuli. Patients received additional doses of rocuronium to maintain a deep block during surgery. If profound neuromuscular block (TOF, 0) persisted at the end of the surgery, 3mg/kg sugammadex was administered. MEASUREMENTS The demographic data, surgeries, and anesthetic agents were recorded. The time from sugammadex administration to recovery of neuromuscular function (TOF ratio, >0.9) and complications during and after extubation were also recorded. MAIN RESULTS Twenty-six infants who had a deep neuromuscular block (TOF, 0) at the end of surgery received 3 mg/kg sugammadex. The mean recovery time of the T4/T1 ratio of 0.9 was 112 seconds. No clinical evidence of recurarization or residual curarization was observed. CONCLUSIONS The efficacy and safety of sugammadex were confirmed in infant surgical patients for reversal of deep neuromuscular block induced by rocuronium.

Safety and efficacy of ventriculostomy procedures under dual antiplatelet therapy in patients treated with stent assisted coiling in subarachnoid hemorrhage

AIM Stent assisted coilling (SAC) is an alternative in the treatment of ruptured aneurysms. Stenting requires the use of dual antiplatelet agents. Hydrocephaly is a complication of subarachnoid hemorrhage (SAH) requiring ventriculostomy. Antiplatelet treatment reveal a risk of hemorrhage in ventriculostomy. Anti-aggregant effect starts at least four hours after the initial doses of treatment. However, in many studies, ventriculostomy was performed before antiplatelet treatment and the hemorrhagic complications were related to the procedure. The aim of this study was to determine the risk of ventriculostomy related hemorrhage in patients with impaired thrombocyte function and to contribute to the literature. MATERIAL AND METHODS Between 2011 and 2016, 53 patients treated with SAC due to SAH in our clinic were retrospectively evaluated. Hemorrhagic complication risks due to antiplatelet therapy related to ventriculostomy were retrospectively evaluated Results: All of the ventricular catheter procedures were performed at least 1 day after the dual therapy (in average 4,3 days after SAC). On 5 patients 1 ventriculostomy was performed, on 2 patients 2, and on 1 patient 6 ventriculostomies were performed. Although radiological hemorrhage was present on the catheter tract in 4 patients, no temporary or permanent neruologic deficit was observed. CONCLUSION Impaired thrombocyte functions pose a risk in ventriculostomy. Also, evaluating the risk of hemorrhage before the antiplatelet treatment reaches its full effect may lead to false results. Studies with small patient groups with antiagregant therapy and impaired thrombocyte functions also contribute to the literature. Larger studies regarding this subject are needed.

Congenital insensitivity to pain: how should anesthesia be managed?

Özmete Ö, Şener M, Bali Ç, Çalışkan E, Arıboğan A. Congenital insensitivity to pain: How should anesthesia be managed? Turk J Pediatr 2017; 59: 87-89. Congenital insensitivity to pain syndrome is a rare, sensorial and autonomic neuropathy characterized by unexplained fever, insensitivity to pain and anhidrosis. Patients may require anesthesia even for minor surgical procedures due to mental retardation and trauma arising from self- mutilating behavior. A child diagnosed with congenital insensitivity to pain syndrome was scheduled for gastric endoscopy under sedation due to suspected ingestion of a household cleaning disinfectant. Deep sedation was achieved, and spontaneous respiration was maintained. We did not encounter any complications. There is limited data regarding the safe anesthesia management in these patients because of the rarity of the disease. Therefore, we think that more clinical experience, case reports and studies are needed to establish the appropriate anesthesia management.

The use of flexible laryngeal mask airway for Adenoidectomies: An experience of 814 Paediatric patients

Objective: To assess flexible laryngeal mask airway (F-LMA) use during pediatric adenoidectomies in terms of patient safety, comfort, complication rates and surgeon satisfaction levels. Methods: Patients who had undergone an elective adenoidectomy after receiving general anesthesia using F-LMA from June 2012 to November 2015 were included. Patients’ demographics and the incidence of perioperative complications were investigated. The surgeon’s satisfaction level was also evaluated by questionnaire. Results: Eight hundred fourteen patient were included in the study. Conversion from F-LMA to an endotracheal tube was carried out in two patients (0.2%). Airway complications were identified in two patients. The mean duration of stay in the postoperative anesthesia care unit was 17 minutes. All patients were discharged the same day. According to the otolaryngologists F-LMA applications provide a significant reduction in the processing time (100%), postoperative patient comfort is better than when using endotracheal intubation (83.3%) and the consensus was that there should be a complete continuation of the use of the F-LMA (100%) in subsequent adenoidectomies. Conclusion: Our data show that the use of F-LMA for pediatric adenoidectomies has well tolerability profile and resulted in a lower incidence of complications. We think that the use of F-LMA for pediatric adenoidectomy is safer, simpler and speeder method.

A patient with Churg-Strauss syndrome complicated with pulmonary hemoptysis

Churg-Strauss Syndrome (CSS) is an extremely rare necrotizing vasculitis characterized by allergic rhinitis, asthma, and eosinophilia [1]. Skin, lung, and kidney involvement is usually more pronounced, but cardiovascular, gastrointestinal, and central nervous systems may also be involved [1]. Overall survival in this syndrome has been improved dramatically by the early use of corticosteroids and immunosuppressive drugs [2]. Anesthesia management of the patients with CSS is important owing to airway hypersensitivity and possible multiple-organ dysfunctions. Unfortunately, there are a few reports related to anesthesia management of CSS in the literature. A 25-year-old male patient weighing 67 kg was evaluated under urgent conditions for bronchial arteriography and embolization for massive hemoptysis. He had a history of asthma and allergic rhinitis since childhood and had CSS diagnosis for 2 years. He had also undergone mitral valve repair for mitral valvular insufficiency approximately 3 months ago. After the diagnosis, he was treated with methyl prednisolone for a year and discontinued it; he had been using budesonide-formoterol inhaler, metoprolol 50 mg, and ramipril 5 mg since then. On physical examination, he had bilateral diffuse rhonchi and rales, and otherwise, systemic examination was normal. Airway evaluation demonstrated a Mallampati score of I. Laboratory tests were all normal except for eosinophilia in complete blood count. Echocardiogram showed left ventricular hypertrophy and global hypokinesis, with a left ventricular ejection fraction of 54%. Anesthesia induction was performed by midazolam 2 mg, propofol 100 mg, sevoflurane 3%-4%, fentanyl 100 μg, and rocuronium 35 mg, and he was then intubated slightly. Anesthesia maintenance was achieved by sevoflurane (1%-2%) in the mixture of 50%/ 50% oxygen-nitrogen. Bronchial angiography indicated irregularities and active bleeding from both right and left bronchial arteries (Figure). Embolization procedure was performed successfully to stop bleeding. The procedure lasted for 1 hour, and a total of 45 mg rocuronium was

Protective Effect of Curcumin on Carbapenem-Resistant Escherichia coli–Induced Lung Injury in Rats

Curcumin has remarkable anti-inflammatory and antioxidant properties. The aim of this study was to investigate the protective effects of curcumin on a rat model of carbapenem-resistant Escherichia coli–induced acute lung injury (ALI). Thirty-two rats were randomly allocated to 4 groups to induce an ALI: negative control group (rats not infected with E coli with no antibiotic treatment), positive control group (rats infected with E coli with no antibiotic treatment), imipenem group (rats infected with E coli that received intraperitoneal injection of imipenem), and the imipenem+curcumin group (rats infected with E coli that received intraperitoneal injection of imipenem and were fed on curcumin).The rats were killed, and lung tissues samples were harvested for biochemical analyses and histopathologic examination. Total antioxidant status (TAS), total oxidant status (TOS), tumor necrosis factor α (TNFα), and interleukin-6 (IL6) were measured. TOS increased in the positive control group (P < 0.001) and decre...

Anesthesia management of a patient with Jervell and Lange-Nielsen syndrome

The success of sedation forMRIwasmeasured by 2 factors: (a) the safety without any adverse events and (b) the effectiveness of the procedure completion. The main difficulties were keeping a profound sedation with hemodynamic and respiratory stability and the limiting access to the patient during the exam. Therefore, the appropriate drugs needed to be selected and titrated to achieve these objectives. Dex was a potent, highly selective α2-adrenoreceptor agonist, declared by the American Society of Anesthesiologists to be a sedative [2], and provided profound levels of sedationwithout affecting cardiovascular and respiratory stability, in contrast to other hypnotics such as propofol [3]. InMRI, Dex was used only for pediatric patients [4]. Candiotti et al [4] showed that the use of Dex for procedures requiring monitored anesthesia care was safe and superior to the combination of midazolam and fentanyl. Arain and Ebert [5] showed that Dex provided a better sedation profile than propofol. To Mahmoud et al [6], Dex might be the preferred drug for anesthesia during MRI in children with a history of severe OSA and offered benefits to children with sleep disordered breathing. The problem was particularly worse in patients with OSA because they were sensitive to the respiratory depressant effects of sedative and hypnotic drugs and were especially vulnerable to the development of pharyngeal hypotonia with upper airway obstruction during sedation [7,8]. In contrast to other sedative drugs, Dex provided a natural sleep and pledged an effective sedation, without significant central and cardiorespiratory depressant activity [6,7]. These advantages made Dex an attractive drug for sedating patients with OSA for MRI [6]. As some authors reported that Dex did not affect RR, SpO2, and EtCO2 [9], however, some respiratory complications such as irregular respiration, apnea, slight hypoxemia, and hypercapnia were reported with large and rapid initial loading doses (over 2 minutes) [10]. Despite the safety profile of Dex, any sedative agent could result in deleterious cardiorespiratory effects, so appropriate monitoring, equipment and easy access to medications were recommended. In summary, Dex could be a favorable sedative drug for MRI scanning in claustrophobic patients with OSA. Further research and experience were required for procedural sedation during radiological imaging.