Ufuk Topuz

Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study

BACKGROUND AND OBJECTIVES Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting. METHODS 80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6h after surgery. The primary outcome variable was postoperative fentanyl consumption. RESULTS Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75 ± 59 μg and 120 ± 94 μg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need. CONCLUSION Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting.

Anestesia venosa total livre de opioides, com infusões de propofol, dexmedetomidina e lidocaína para colecistectomia laparoscópica: estudo prospectivo, randomizado e duplo-cego

BACKGROUND AND OBJECTIVES Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting. METHODS 80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6h after surgery. The primary outcome variable was postoperative fentanyl consumption. RESULTS Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75±59μg and 120±94μg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need. CONCLUSION Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting.

The influence of airway supporting maneuvers on glottis view in pediatric fiberoptic bronchoscopy

INTRODUCTION Flexible fiber optic bronchoscopy is a valuable intervention for evaluation and management of respiratory diseases in both infants, pediatric and adult patients. The aim of this study is to investigate the influence of the airway supporting maneuvers on glottis view during pediatric flexible fiberoptic bronchoscopy. MATERIALS AND METHODS In this randomized, controlled, crossover study; patients aged between 0 and 15 years who underwent flexible fiberoptic bronchoscopy procedure having American Society of Anesthesiologists I-II risk score were included. Patients having risk of difficult intubation, intubated or patients with tracheostomy, and patients with reduced neck mobility or having cautions for neck mobility were excluded from this study. After obtaining best glottic view at the neutral position, patients were positioned jaw trust with open mouth, jaw trust with teeth prottution, head tilt chin lift and triple airway maneuvers and best glottis scores were recorded. RESULTS Total of 121 pediatric patients, 57 girls and 64 boys, were included in this study. Both jaw trust with open mouth and jaw trust with teeth prottution maneuvers improved the glottis view compared with neutral position (p<0.05), but we did not observe any difference between jaw trust with open mouth and jaw trust with teeth prottution maneuvers (p>0.05). Head tilt chin lift and triple airway maneuvers improved glottis view when compared with both jaw trust with open mouth and jaw trust with teeth prottution maneuvers and neutral position (p<0.05); however we found no differences between head tilt chin lift and triple airway maneuvers (p>0.05). CONCLUSION All airway supporting maneuvers improved glottic view during pediatric flexible fiberoptic bronchoscopy; however head tilt chin lift and triple airway maneuvers were found to be the most effective maneuvers.

A influência das manobras de suporte das vias aéreas sobre a visibilidade da glote em fibrobroncoscopia pediátrica

INTRODUCTION Flexible fiber optic bronchoscopy is a valuable intervention for evaluation and management of respiratory diseases in both infants, pediatric and adult patients. The aim of this study is to investigate the influence of the airway supporting maneuvers on glottis view during pediatric flexible fiberoptic bronchoscopy. MATERIALS AND METHODS In this randomized, controlled, crossover study; patients aged between 0 and 15 years who underwent flexible fiberoptic bronchoscopy procedure having American Society of Anesthesiologists I-II risk score were included. Patients having risk of difficult intubation, intubated or patients with tracheostomy, and patients with reduced neck mobility or having cautions for neck mobility were excluded from this study. After obtaining best glottic view at the neutral position, patients were positioned jaw trust with open mouth, jaw trust with teeth prottution, head tilt chin lift and triple airway maneuvers and best glottis scores were recorded. RESULTS Total of 121 pediatric patients, 57 girls and 64 boys, were included in this study. Both jaw trust with open mouth and jaw trust with teeth prottution maneuvers improved the glottis view compared with neutral position (p<0.05), but we did not observe any difference between jaw trust with open mouth and jaw trust with teeth prottution maneuvers (p>0.05). Head tilt chin lift and triple airway maneuvers improved glottis view when compared with both jaw trust with open mouth and jaw trust with teeth prottution maneuvers and neutral position (p<0.05); however we found no differences between head tilt chin lift and triple airway maneuvers (p>0.05). CONCLUSION All airway supporting maneuvers improved glottic view during pediatric flexible fiberoptic bronchoscopy; however head tilt chin lift and triple airway maneuvers were found to be the most effective maneuvers.

Anesthetic Management for a Patient With Transcatheter Mitral Valve Implantation

MITRAL VALVE REDO OPERATIONS due to failing bioprostheses are known to be associated with high rates of morbidity and mortality. Transcatheter mitral valve implantation (TMVI) procedures in high-risk patients with severe mitral regurgitation have become a promising treatment option. We report a new transcatheter technique as an alternative to redo operations in patients with degenerative mitral valve bioprosthesis. There are a limited number of studies on the use of this technique. The main objective of the administration of anesthesia for TMVI application is to maintain hemodynamic stability. In this report, the authors present the anesthesia management of TMVI for a 79-year-old female patient with severe mitral valve regurgitation resulting from a degenerative mitral bioprosthetic valve. Although a standard method of anesthesia in this high-risk group of patients has not yet been established, the authors prefer general anesthesia because it provides airway safety in cases of pulmonary edema and facilitates the implementation of transesophageal echocardiography (TEE).

Transient ventricular flutter in Devic’s syndrome during hysteroscopy under anesthesia

Neuromyelitis optica, also known as Devic’s syndrome, is a rare, idiopathic relapsing demyelinating disease of the central nervous system first described by Devic in 1894 [1]. Both neuraxial and general anesthesia have been described in the literature for this condition [2, 3]. In this case, a patient with Devic’s syndrome experienced two episodes of transient ventricular flutter during hysteroscopy, while under general anesthesia. She gave written informed consent for the publication of this report. The patient, a 37-year-old woman, 162 cm tall and weighing 72 kg, was scheduled for polyp resection under hysteroscopy. For the past 9 years, she has suffered from relapsing scapular numbness, lower extremity paresthesia, and weakness. Magnetic resonance imaging of the spine revealed a hyperintense lesion from levels C7 to T2 of the spinal cord, leading to the diagnosis of transverse myelitis. Devic’s syndrome was diagnosed 4 years ago by means of a positive serology testing for Anti-aquaporin-4. She was treated with azathioprine. According to her medical history, she also had had an intracranial hematoma 3 years before the surgery. The preoperative laboratory test results were within normal ranges. During the preoperative period, the patient expressed her anxiety. After routine monitorization with electrocardiogram, peripheral oxygen saturation, and noninvasive arterial blood pressure, midazolam 2 mg and fentanyl 50 lg were administered as premedication. Her pre-induction heart rate was 70 beats/min, and blood pressure was 120/70 mmHg. Anesthesia was induced with propofol 2 mg/kg, lidocaine 1.5 mg/kg, and rocuronium 0.3 mg/kg to produce neuromuscular blockade. The laryngeal mask was inserted successfully at the first attempt. General anesthesia was maintained with total intravenous anesthesia (TIVA) composed of propofol 6 mg/kg/h and remifentanil 0.2 lg/kg/min. Just after the dilatation of the cervix uteri, the patient’s ventricle abruptly began to flutter. Surgery and TIVA were immediately stopped. The anesthesia equipment was checked, as well as the monitoring and IV line, 100 % oxygen was administered, and the defibrillator was prepared for use. After 45–60 s, the ventricular flutter spontaneously resolved. Normal sinus rhythm resumed with a heart rate of 42 beats/min, and blood pressure was 100/50 mm Hg. Atropine 0.5 mg was administered, IV fluid administration was increased, and TIVA was restarted. After 10 min, heart rate increased to 60 beats/min and blood pressure to 122/68 mmHg. Depth of anesthetic was assured by the patient’s myotic pupils and absence of hypertension or sweating while propofol 8 mg/kg/h and remifentanil 0.25 lg/kg/min were infusing. Directly after introduction of the hysteroscopy device, another ventricular flutter occurred, so the hysteroscopy device was immediately removed from the uterine cavity. The oxygen level was elevated, and TIVA was stopped. After 10 s, her heart rate returned to an absolutely normal G. Basaranoglu (&) M. Bakan T. Umutoglu U. Topuz Z. Salihoglu Faculty of Medicine, Department of Anesthesiology and Reanimation, Bezmialem Vakif University, Vatan Caddesi, Fatih, 34093 Istanbul, Turkey e-mail: gbasaranoglu@hotmail.com

The effects of different oxygen concentrations on recruitment maneuver during general anesthesia for laparoscopic surgery.

Introduction and Purpose: Recruitment maneuvers (RMs), which aim to ventilate the collaborated alveolus by temporarily increasing the transpulmonary pressure, have positive effects in relation to respiration, mainly oxygenation. Although many studies have defined the pressure values used during RM and the application period, our knowledge of the effects of different oxygen concentrations is limited. In this study, we aimed to determine the effects of different oxygen concentrations during RM on the arterial oxygenation and respiration mechanics in laparoscopic cases. Materials and Methods: Thirty-two patients undergoing laparoscopic cholecystectomy were recruited into the study. The patients were randomly divided into 2 groups. RM with a 30% oxygen concentration was performed in patients within the first group (group I, n=16), whereas patients in the second group (group II, n=16) received RM with 100% oxygen. To study respiratory mechanics, dynamic compliance (Cdyn), airway resistance (Raw), and peak inspiratory pressure were measured at 3 different times: 5 minutes after anesthesia induction, 5 minutes after the abdomen was insufflated, and 5 minutes after the abdomen was desufflated. Arterial blood gases were measured during surgery and 30 minutes after surgery (postoperative). Results: The average postoperative partial arterial oxygen pressure values of the patients in groups I and II were 121 and 98 mm Hg, respectively. The difference between the groups was statistically significant. In addition, the decrease in compliance from induction values after desufflation in group II was statistically significant. Discussion: On the basis of our results, maintaining oxygen concentrations below 100% during RM may be more beneficial in terms of respiratory mechanics and gas exchange.

Inadvertent Venous Air Embolism during Cesarean Section: Collapsible Intravenous Fluid Bags Without Self-sealing Outlet have Risks. Case Report

The anesthesiologist must be aware of the causes, diagnosis and treatment of venous air embolism and adopt the practice patterns to prevent its occurrence. Although venous air embolism is a known complication of cesarean section, we describe an unusual inattention that causes iatrogenic near fatal venous air embolism during a cesarean section under spinal anesthesia. One of the reasons for using self-collapsible intravenous (IV) infusion bags instead of conventional glass or plastic bottles is to take precaution against air embolism. We also demonstrated the risk of air embolism for two kinds of plastic collapsible intravenous fluid bags: polyvinyl chloride (PVC) and polypropylene-based. Fluid bags without self-sealing outlets pose a risk for air embolism if the closed system is broken down, while the flexibility of the bag limits the amount of air entry. PVC-based bags, which have more flexibility, have significantly less risk of air entry when IV administration set is disconnected from the outlet. Using a pressure bag for rapid infusion can be dangerous without checking and emptying all air from the IV bag.

Embolia gasosa venosa inadvertida durante cesariana: bolsas retráteis para líquidos intravenosos sem saídas autovedantes oferecem riscos. Relato de caso

The anesthesiologist must be aware of the causes, diagnosis and treatment of venous air embolism and adopt the practice patterns to prevent its occurrence. Although venous air embolism is a known complication of cesarean section, we describe an unusual inattention that causes iatrogenic near fatal venous air embolism during a cesarean section under spinal anesthesia. One of the reasons for using self-collapsible intravenous (IV) infusion bags instead of conventional glass or plastic bottles is to take precaution against air embolism. We also demonstrated the risk of air embolism for two kinds of plastic collapsible intravenous fluid bags: polyvinyl chloride (PVC) and polypropylene-based. Fluid bags without self-sealing outlets pose a risk for air embolism if the closed system is broken down, while the flexibility of the bag limits the amount of air entry. PVC-based bags, which have more flexibility, have significantly less risk of air entry when IV administration set is disconnected from the outlet. Using a pressure bag for rapid infusion can be dangerous without checking and emptying all air from the IV bag.

New technique for pediatric venous port implantation: Single incision double pocket technique -

Objective: In general intravenous access might be essential in patients with increased length of hospital stay for obtaining blood samples and for administration of intravenous fluid solutions, medications and total intravenous nutrition solutions. Extended length of use and repeated usage may worsen the peripheral intravenous access. In these conditions long term central venous catheters and implantable chest ports eases the clinicians’ duty. With single incision double pocket technique, two subcutaneous pockets were done with surgical technique just above and below the incision; catheter was placed when the reservoir is in the upper pocket and then fixed at the lower pocket. We think that this technique will decrease the complications related with implantable chest ports placement in pediatric patients. In this study sigle incision double pocket technique was evaluated. Material and Methods: Single-incision two pocket technique has been practiced since January 2011 in our clinic. A total of 32 pediatric venous port placement patient in our hospital were evaluated retrospectively. In retrospective, demographic information, notes regarding the interventional process, pathology, microbiology and laboratory results and clinical observations were recorded, and the data obtained from the notes reported as a descriptive case serie. Results: At the age of 1 month to 132 months, with an average 47.3 months, a total of 32 patients (16 female, 16 male) were included in this study. Complications associated with intervention and port dysfunction was not occurred any of our patients. Venous port related infection was observed in only one of our patients (3.1%). Conclusion: Single incision double pocket technique is feasible and facilitating the process eases the procedure. Low rate of dysfunction might be an alternative for conventional technique.