Tülün Öztürk

Evaluation of hemostatic changes using n thromboelastography after crystalloid or colloid fluid administration during major orthopedic surgery

The effects of Ringer lactate, 6% hydroxyethyl starch (130/0.4) or 4% succinylated gelatin solutions on perioperative coagulability were measured by thromboelastography (TEG). Seventy-five patients (ASA I-III) who were to undergo major orthopedic procedures performed under epidural anesthesia were included in the study. Patients were randomly divided into three groups of 25 each for the administration of maintenance fluids: group RL (Ringer lactate), group HES (6% hydroxyethyl starch 130/0.4), and group JEL (4% gelofusine solution). Blood samples were obtained during the perioperative period before epidural anesthesia (t1, baseline), at the end of the surgery (t2), and 24 h after the operation (t3). TEG data, reaction time (R), coagulation time (K), angle value (α), and maximum amplitude (MA) were recorded. TEG parameters changed from normal values in all patients. In group RL, R and K times decreased compared to perioperative values while the α angle and MA increased (P < 0.05). In group HES, R and K times increased, however, the α angle and MA decreased (P < 0.05). In group JEL, R time increased (P < 0.05), but K time, α angle and MA did not change significantly. In the present study, RL, 6% HES (130/0.4) and 4% JEL solutions caused changes in the coagulation system of all patients as measured by TEG, but these changes remained within normal limits.

Levosimendan Attenuates Reperfusion Injury in an Isolated Perfused Rat Heart Model

OBJECTIVES The aim of this study was to investigate the effect of levosimendan on apoptosis and infarct size when administered before ischemia in an isolated rat heart model. DESIGN An in vitro experimental study. SETTING Animal laboratory. PARTICIPANTS Isolated perfused rat heart preparation (n = 22). INTERVENTIONS Perfusion with Krebs-Henseleit solution was performed for 30 minutes and then 0.1 micromol/L of levosimendan was added to the perfusion fluid for 10 minutes before global ischemia; the control hearts received no levosimendan. Hearts underwent global ischemia for 30 minutes and then were reperfused for 30 minutes before specimens were obtained for testing. MEASUREMENTS AND MAIN RESULTS Infarct sizes were measured at the end of the reperfusion period and expressed as a percentage of the area at risk. Myocardial apoptosis was detected by using the terminal deoxynucleotidyl transferase-mediated dUTP nick end-labelling (TUNEL) method. Bcl-2 expression was determined to detect antiapoptotic activity. Infarct size was significantly less in the levosimendan group (26% +/- 3% v 40% +/- 4%, respectively; p = 0.009). Levosimendan significantly reduced the proportion of TUNEL-positive cardiomyocytes (3 +/- 1 v 20 +/- 4, respectively; p < 0.001) and increased Bcl-2 expression compared with control hearts (44% +/- 3% v 31% +/- 3%, respectively; p = 0.01). Recovery of left ventricular-developed pressure 30 minutes after reperfusion in ischemic hearts pretreated with levosimendan was significantly better than that of placebo-treated hearts (53% +/- 3% v 38% +/- 3% of baseline, respectively; p = 0.004). CONCLUSIONS Levosimendan has a cardioprotective effect when administered before ischemia in ischemia-reperfusion injury. This effect may be useful in elective cardiac surgery for protecting myocytes from ischemia-reperfusion-induced apoptosis.

Immune and inflammatory role of hydroxyethyl starch 130/0.4 and fluid gelatin in patients undergoing coronary surgery

OBJECTIVES Compare the effects on inflammatory (TNF-α, IL-6, IL-8 and IL-10) and immunologic (CD3(+), CD4(+), CD8(+), CD11b(+), CD16(+)/56(+) T cells and total lymphocyte concentration) variables of hydroxyethyl starch 130/0.4, 4% modified fluid gelatin, or crystalloid when used as volume replacement fluids for acute normovolemic hemodilution (a blood conservation technique) in coronary artery bypass graft patients. METHODS Thirty patients undergoing coronary artery bypass graft surgery were randomized to receive Isolyte S® (Group ISO), 6% hydroxyethyl starch 130/0.4 (Group HES) or 4% modified gelatin solution (Group GEL) for acute normovolemic hemodilution. Blood samples were taken immediately after induction of anaesthesia (T0), and 2 h (T1), 12 h (T2), 24 h (T3), and 48 h (T4) after separation from cardiopulmonary bypass. TNF-α, IL-6, IL-8 and IL-10 levels were determined with commercially available ELISA kits. CD3(+) (mature T cells), CD4(+) (T helper cells), CD8(+) (suppressor cytotoxic T cells), CD16(+)/56(+) (natural killer lymphocytes), and CD11b(+) (Mac-1, adhesion receptor) levels were measured using flow-cytometry reagents. The CD4(+):CD8(+) ratio was calculated. RESULTS Between-group comparisons showed significantly higher levels of TNF-α at T1 (2 h after weaning from cardiopulmonary bypass) in Group HES compared to Group ISO (p=0.003). IL-8 was significantly lower in Group HES than Group GEL at T1 (p=0.0005). IL-10 was significantly higher in Group HES than in Group GEL at T1 (p=0.0001). The CD4(+):CD8(+) ratio in Group ISO was significantly lower than that in Group HES at T2 (p=0.003). CD11b(+) levels in Group HES were also higher than those in Group GEL and group ISO at T2, but not significantly. CD16/56(+) levels in Group HES were higher than those in Group GEL at T2 (p<0.003). No excessive hemorrhage occurred in any patient. Mediastinal drainage during the first 24 h after surgery in Group HES (347±207 mL) was not significantly different from that of Group GEL (272±177 mL) or Group ISO (247±109) (p>0.05). CONCLUSION Hydroxyethyl starch 130/0.4 reduced pro-inflammatory responses and increased anti-inflammatory responses to a greater degree than gelatin solution and isolyte S®. The use of hydroxyethyl starch, compared to gelatin solution and isolyte S®, resulted in less decrease in the CD4(+):CD8(+) ratio, suggesting less immunosuppression.

The effect of epidural and general anesthesia on newborn rectal temperature at elective cesarean section

Both epidural and general anesthesia can impair thermoregulatory mechanisms during surgery. However, there is lack of information about the effects of different methods of anesthesia on newborn temperature. The purpose of this study was to determine whether there are differences in newborn rectal temperature related to type of anesthesia. Sixty-three pregnant women were randomly assigned to receive general or epidural anesthesia. Maternal core temperature was measured three times with a rectal probe just before anesthesia, at the beginning of surgery and at delivery. In addition, umbilical vein blood was sampled for pH. The rectal temperatures of the babies were recorded immediately after delivery, and Apgar scores were determined 1, 5, and 10 min after birth. The duration of anesthesia and the volume of intravenous fluid given during the procedure (833 +/- 144 vs 420 +/- 215 mL) were significantly higher in the epidural group than in the general anesthesia group (P < 0.0001). Maternal rectal temperatures were not different in both groups at all measurements. In contrast, newborn rectal temperatures were lower in the epidural anesthesia group than in the general anesthesia group (37.4 +/- 0.3 vs 37.6 +/- 0.3 degrees C; P < 0.05) immediately after birth. Furthermore, the umbilical vein pH value (7.31 +/- 0.05 vs 7.33 +/- 0.01; P < 0.05) and Apgar scores at the 1st-min measurement (8.0 +/- 0.9 vs 8.5 +/- 0.7; P < 0.05) were lower in the epidural anesthesia group than in the general anesthesia group. Since epidural anesthesia requires more iv fluid infusion and a longer time for cesarean section, it involves a risk of a mild temperature reduction for the baby which, however, did not reach the limits of hypothermia.

Management of a patient with giant aneurysms in the popliteal and coronary arteries

Coexistence of multiple peripheric arterial and coronary artery aneurysms of different sizes is extremely rare in young adults. We present a case of rare giant coronary aneurysm and concurrent giant left popliteal aneurysm treated with classical open repair.

Comparison of Patient Satisfaction Between General and Spinal Anaesthesia in Emergency Caesarean Deliveries

OBJECTIVE Obstetric anaesthesia aims to deliver a healthy baby as well as render a comfortable operation for the mother. This study compared general and spinal anaesthesia in terms of the quality of recovery and patient satisfaction in women undergoing emergency caesarean deliveries. METHODS In total, 100 patients were enrolled in this prospective, single-blind, cross-sectional clinical study. Patients were divided into spinal (n=50) and general (n=50) anaesthesia groups. The recovery score, pain and satisfaction were evaluated by Quality of Recovery Score (QoR-40), Visual Analogue Scale (VAS) and Numeric Rating Scale (NRS) at 24 hours postoperatively. RESULTS The total QoR-40 scores were significantly higher and the total operation time was longer in the spinal anaesthesia group (median score: 194.5 vs. 179.0, p<0.001 and mean±SD: 69.0±13.3 vs. 62.7±13.4 minutes, p=0.02, respectively). There was no significant difference in VAS and NRS scores between the groups. CONCLUSION Both spinal anaesthesia and general anaesthesia have advantages and disadvantages in terms of emergency caesarean deliveries. Spinal anaesthesia speeds up the recovery time and enables the mother to return to normal life earlier, while general anaesthesia has a short initiation time and does not affect patient satisfaction.

The Efficacy of Femoral Block and Unilateral Spinal Anaesthesia on Analgesia, Haemodynamics and Mobilization in Patients undergoing Endovenous Ablation in the Lower Extremity.

OBJECTIVE This study aimed to investigate the efficacy of femoral block and unilateral spinal anaesthesia on analgesia, haemodynamics and mobilization during endovenous ablation in patients with lower extremity venous insufficiency. METHODS Forty patients of ASA physical status I and II, with ages ranging between 30 and 45 years, and who were scheduled for endovenous laser ablation for varicose veins were prospectively enrolled in this study. Patients were randomized into a unilateral spinal anaesthesia group (group HS, n=20) or a femoral block group (group F, n=20). Group HS received 7.5-10 mg of heavy bupivacaine for unilateral spinal anaesthesia, while group F received 100 mg prilocaine for femoral block with ultrasound guidance. The level of motor blockage (Bromage score), visual pain score, mean heart rate and mean arterial pressures were recorded at postoperative 0, 1, 2, 3d and 6 h, respectively. RESULTS Perioperative visual pain score values in both groups were <4. None of the groups required an additional analgesic agent. Bromage scores were significantly lower in group F than in group HS during the postoperative period (p<0.01). Motor function returned to normal in all patients at 3 h in group F and at 6 h in group HS. Postoperative mean heart rate and arterial pressure did not differ between the groups (p>0.05). CONCLUSION In patients with lower extremity venous insufficiency who were undergoing endovenous laser ablation, an ultrasound-guided femoral block provided similar analgesia with that of unilateral spinal anaesthesia. In group F, the duration of anaesthesia and mobilization time was shorter.

Effects of low-dose propofol vs ketamine on emergence cough in children undergoing flexible bronchoscopy with sevoflurane-remifentanil anesthesia: a randomized, double-blind, placebo-controlled trial

STUDY OBJECTIVE To determine the effects of low-dose ketamine and propofol on cough during emergence and the recovery period when administered at emergence in children undergoing fiberoptic bronchoscopy for bronchoalveolar lavage (FOBL) with sevoflurane-remifentanil anesthesia. DESIGN Randomized, double-blind, placebo-controlled trial. SETTING Operating room, postoperative recovery area. PATIENTS Sixty-eight children aged 1 to 8 years old undergoing elective diagnostic FOBL. INTERVENTIONS After discontinuation of anesthetics at the end of FOBL, patients were randomly divided into 3 groups: in group K, children were administered 0.5 mg/kg of ketamine; in group P, 0.5 mg/kg of propofol; and in group C, 0.1 mL/kg of normal saline. MEASUREMENTS Anesthesia time, procedure time, emergence time, and recovery time were recorded. Coughing and delirium scores were recorded as the patient fully emerged from anesthesia (time 0) and 5, 10, 15, and 20 minutes later. MAIN RESULTS The percentage of children with moderate or severe cough during emergence was similar in all groups. Mean delirium scores at emergence (T0) were significantly lower in group K than those in group P and in group C (P = .0001 and P = .02). Mean delirium score at 5 minutes in group K (6 [5-10]) was significantly lower than that of group C (P = .02) and similar to that of group P. The recovery time of group K was significantly longer than that of group C and group P (P = .01 and P = .03, respectively). CONCLUSIONS Ketamine or propofol given at the end of sevoflurane-remifentanil general anesthesia in children undergoing FOBL did not decrease cough more than normal saline during the emergence period. Ketamine and propofol, compared to normal saline, had a beneficial effect on decreasing the incidence of emergence delirium. Ketamine lengthened recovery time.

Acute and Chronic Pretreatment With Atenolol Attenuates Intestinal Ischemia and Reperfusion Injury in Hypercholesterolemic Rats

OBJECTIVE To evaluate the protective effects of preinjury atenolol (acute v chronic) on apoptosis, contractility, oxidative stress, and inflammatory markers in hypercholesterolemic rats undergoing intestinal ischemia-reperfusion (I/R) injury. DESIGN Prospective, experimental animal study. SETTING University laboratory. PARTICIPANTS Male Wistar rats (n = 32). INTERVENTIONS Rats were divided into the following 4 groups: 1 group was fed a normal diet (ND) (group ND+NoAT [no atenolol]), and the other 3 groups were fed a high-cholesterol diet (HCD)-group HCD+NoAT, group HCD+ChAT (chronic atenolol, 3 mg/kg/day for 8 weeks), and group HCD+AcAT (acute atenolol, 1.5 mg/kg, given 5 minutes before intestinal clamping). All rats underwent I/R injury. The superior mesenteric artery was clamped for 60 minutes, then opened for 120 minutes (reperfusion). Apoptotic cells and stimulated contractions of ileal segments were examined. Tissue markers of intestinal I/R injury were examined. Intestinal malondialdehyde, superoxide dismutase, and nitrate/nitrite levels were measured. MEASUREMENTS AND MAIN RESULTS The chronic atenolol group had fewer apoptotic cells and higher superoxide dismutase activity compared with the other groups. Intestinal contraction was higher in both atenolol pretreatment groups compared with the NoAT groups. Chronic and acute atenolol resulted in lower ileal levels of malondialdehyde and immunolabeling-positive cells (intestinal inducible nitric oxide synthase, endothelial nitric oxide synthase, interleukin-1, and interleukin-8) after I/R injury compared with the no atenolol groups. CONCLUSIONS Both chronic and acute pre-I/R injury treatment with atenolol attenuated I/R injury in this hypercholesterolemic rat model. These findings should encourage future studies of atenolol in hypercholesterolemic patients undergoing procedures with a high risk of intestinal ischemia.

Combined system usage for large neck anatomy in a high risk abdominal aortic aneurysm patient

Nowadays, endovascular aneurysm repair (EVAR) is the first line approach in abdominal aortic aneurysm (AAA) repair. A sufficient infrarenal aortic neck is one of the key points for successful outcome after EVAR. Proximal neck characteristics remain a challenge in endovascular treatments. In these case report, we present you a 75-year-old, male patient with a large neck AAA. He was unsuitable to standard EVAR therapy and open surgery because of his comorbidities. Funnel technique in which a thoracic stent-graft is placed through the main body of a bifurcated or uni-iliac endograft could be a feasible and succesfull treatment in such cases.