Ugur Goktas

Management of a severe carbamazepine overdose with continuous venovenous hemodiafiltration.

Carbamazepine (CBZ) is a commonly used antiepileptic agent. Common toxic effects include neurological abnormalities; ataxia, seizures, coma, cardiorespiratory problems; dysrhythmias; conduction disorders; respiratory depression; and eye abnormalities, such as nystagmus and ophthalmoplegia. Carbamazepine is highly protein bound. There is no antidote for the medication. Carbamazepine is not removed effectively through conventional hemodialysis. Supportive measures and charcoal hemoperfusion have been regarded as efficient treatment methods. We herein report a 17-year old girl to whom continuous venovenous hemodiafiltration lacking the albumin-enhance after suicidal overdose of CBZ was performed. We suggest continuous venovenous hemodiafiltration lacking the albumin-enhance as an alternative emergency treatment modality for cases who had ingested CBZ in toxic levels.

Clinical outcomes of suture delay in forehead flap.

Abstract The delay phenomenon is a surgical procedure performed to raise a wider skin flap and to improve the survival of skin flaps. Surgery, chemicals, sutures, and lasers can be used for the delay procedure. In this study, delayed forehead flaps created by suturing were used for coverage of nasal skin defects in eleven patients. In 7 patients, the cross-paramedian forehead flap was used to increase the extent of flap lengthening. In the first session, suture delay was performed on both sides of the forehead flap margin. In the second session, the flap was elevated and sutured to its new position, 7 to 10 days after the initial surgery. All flaps were completely viable, and patient satisfaction was optimal in all cases. The positive effect of surgical delay on flap survival has been shown in experimental and clinical studies. However, experimentally, suture delay or chemical delay procedures have been shown to be beneficial in flap survival only. Suture delay seems to be an inexpensive, effective, easily performed, atraumatic, and safe technique, especially among patients with systemic diseases such as diabetes or cardiovascular diseases, smoking patients who may lose the flap, or patients who need very wide and long flaps.

Effects of lidocaine infiltration on cost of rhinoplasty made under general anesthesia.

AbstractThis study aimed to compare the effects of combined and noncombined lidocaine with adrenaline infiltration in general anesthesia (GA) procedures, in which the standard anesthesia depth is monitored by Bispectral Index monitoring, on minimum alveolar concentration (MAC) levels and the costs. Following approval by the local ethics committee, an American Society of Anesthesiologists physical status I–II group of 40 adult patients for whom elective rhinoplasties under GA were planned was divided into 2 double-blind randomized groups. In group 1, GA and lidocaine + adrenaline were administered, whereas in group 2, only GA and adrenaline were administered. All the patients who had been taken to the operation room underwent electrocardiography and measurements of the peripheral oxygen saturation, end-tidal carbon dioxide, heart rate, mean blood pressure, and Bispectral Index monitoring. Using the operation time and the MAC% values, the total consumed inhalation agent amounts were calculated, and the cost difference was determined. The mean blood pressure values were lower in group 1 (P < 0.05). In group 1, the MAC% was 20.83% lower than that of group 2; the consumed desflurane amount was 20.29%, and the cost was 20.29% lower than that of group 2 (P < 0.05). In rhinoplasties under GA, the lidocaine + adrenaline combination infiltration not only decreased inhaled anesthetic requirement and cost but also supported the hemodynamic stability. In addition, surgical satisfaction increased in the lidocaine + adrenaline group because of small number of agitated patients during the recovery period.

Management of outpatient anesthesia in an unusually case with glutaric aciduria type-1.

SIR—Glutaric aciduria type-1 (GA-1) is an autosomal recessive, uncommon and severe metabolic disorder with a deficiency of glutaryl-CoA dehydrogenase. This disorder mainly detects in early childhood (1). Most children with this disorder have no measurable enzyme activity, but several have had 10–15% residual enzyme activity (2). The population frequency has been estimated at 1 in 30 000 neonates in a Scandinavian study (3). Most patients have a dystonic–dyskinetic syndrome. The patient’s symptoms are psychomotor delay, dystonia, spastic quadriparesis and macrocephaly (1). In the literature only two cases with GA-1, who underwent general anesthesia, were reported (4). Our cases are two sisters with GA-1, who were aged 12 (39 kg) and 16 (51 kg) years, respectively, and presented with macrocephaly and psychomotor delay. Laboratory analysis yielded urinary glutaric acid values of 157 and 153 nmolÆmol creatinine (normal: 0–5.3), respectively. On preanesthetic clinical examination, macrocephaly was observed, with an occipitofrontal circumference of 58 cm and 62 cm (>98%). They were hypotonic, especially in both arms and her reflexes were normal. Their optics discs were pale, and a dystonic posturing of both hands was noted. Father and mother weren’t consanguineous. There required sedation for magnetic resonance imaging during routine follow up. The cases weren’t premedicated before sedation. They were continuously monitored by electrocardiogram, oxygen saturation (SpO2), body temperature, and noninvasive blood pressure. A 22 G intravenous cannula was inserted in the arm and a fluid infusion was started with dextrose in normal saline instead. Sedation was achieved by using bolus of propofol 1 mgÆkg. Sedation was maintained using a bolus of propofol 0.5 mgÆkg in case of necessity and spontaneous breathing was maintained during this time period. Oxygen was administered via facemask. Procedures time were approximately 10 mins. All the monitored parameters remained within normal ranges during the procedures. The procedures were completed uneventfully. They were being treated with a low-protein diet, riboflavin, and carnitine. The patients were discharged home 1 h after the procedure. GA-1 prevails in communities with a high rate of consanguineous marriages or in groups who are ethnically or culturally isolated. The father and mother of our cases were not relatives. The cerebral damage seen in GA-1 is caused by the direct effect of glutaric acid in the brain and Cerebrospinal fluid (4). Acute neurological crises are typically precipitated by the glutaric acid passage through the blood-brain barrier associated with an infection or some physiological stress. The most common presenting symptoms of GA-1 are macrocephaly, hypotonia or diffuse rigidity, consciousness, seizures, and dystonic limb movements (4). Our patient’s symptoms were psychomotor delay, dystonia, spastic quadriparesis and macrocephaly. Metabolic manifestations, such as hypoglycemia and metabolic acidosis, are rarely present except in the acute phases of the disease (5). Our patients didn’t have a metabolic problem. The principles of the treatment of GA1 consist of an initial diet low in lysine and tryptophan to reduce total glutaric acid production, administration of oral L-carnitine supplements as all patients present a secondary carnitine deficiency, and riboflavin, a cofactor of glutaryl-CoA dehydrogenase (4). Our patients were also being treated with a low-protein diet, riboflavin, and carnitine. An emergency protocol is established for preventing encephalopathic crises that consists of a high-calorie dextrose infusion, rapid correction of fluid deficits, ensuring brisk output of alkaline urine, high-dose intravenous carnitine, and anticonvulsants usage (5). To prevent hypoglycemia and metabolic acidosis in our patients during the sedation, we avoided using Ringer’s lactate since it contains lactic acid, and used dextrose in normal saline instead. Joaquin et al., reported that there were no reports on the superiority of one anesthetic drug over another in patients with GA-1 in the literature (4). The following should be taken into consideration in anesthesia management: the possibility of pulmonary aspiration, prolonged responses to nondepolarizing muscle relaxants, and hyperkalemic responses to succinylcholine. The patients with severe dystonia may be at a greater risk for aspiration of gastric contents during general anesthesia. Appropriate measures to avoid aspiration or its complications must be undertaken, including fasting, use of H2 blockers and rapidsequence anesthesia induction with cricoid pressure (4). Before sedation, 25 mg of ranitidine was given intravenous to patients having fasting for 8 h in order to prevent aspiration of gastric content. We used a bolus of propofol to maintain a sedation as protected spontanaous breathing. In concluded that we suggested performing sedation with propofol without any difficulty in these cases. Ugur Goktas Ismail Kati Osman Cagatay Aytekin Department of Anesthesiology, Medical Faculty, Yuzuncu Yil University, Van, Turkey (email: mdugoktas@yahoo.com)

Difficult airway management in Lymphangiomatos Macroglossia

SIR—Lymphangiomas may be congenital or acquired and related to a host of genetically, metabolically, or anatomically defined conditions or lesions. Lymphangioma of the tongue may lead to a dry ⁄ cracked tongue with ulcerating secondary infections, difficulty in swallowing and mastication, speech disturbances, exclusive nasal breathing, airway obstruction, mandibular prognathism and other possible deformities of maxillofacial structures (1,2). Anesthetic concerns include bleeding, difficulty visualizing the airway, extrinsic and intrinsic pressure on the airway causing distortion, and enlarged upper respiratory structures, including the lips, tongue, and epiglottis (3). There seems to be a little information on the anesthetic management for this age group in English literature. We pay attention that huge lymphangioma of the tongue might cause various anesthetic problems especially on airways which we should keep in mind. A 4-year-old male with a clinical presentation of macroglossia is described, which was causing difficulty in eating, speaking, and breathing. The child’s parents were aware of the enlargement since birth and reported that the tongue continued to grow larger as the child aged. The child was otherwise developmentally healthy and of normal height (97 cm) and weight (20 kg). Clinically, the tongue appeared diffusely bulky, dry, and ulcerated but exhibited texture and movement. The child had a severe anterior open bite as a result of tongue thrust, with accompanying malocclusion and short neck. The child’s laboratory values, mental and psychological status, and neurological and other systematical examination findings were normal. The main indications of surgery were to obtain good cosmetic appearance and functional upper airway, thus it was decided to reduce the tongue size. Suggesting that intubation and airway management of the case would be difficult, the necessary preparations for difficult laryngoscopy and intubation were made. His airway was not obstructive even during sleep. Mallampati class was evaluated as one. Inhalation induction of anesthesia was not performed because of preoperative indirect laryngoscopy showed adequate space around the larynx. For 3 min, preoxygenation with 100% oxygen was obtained by the help of a mask which is large enough to cover his mouth, nose, and protruding tongue (Figure 1). Without problem, anesthesia induction was achieved with propofol and fentanyl without muscular relaxant after routine anesthesia monitoring. A laryngoscope blade was used one number bigger than expected. Although the vocal cords were invisible, endotracheal intubation was succeeded at first attempt by the help of a guidewire, and then muscular relaxant was administered. After intubation, tracheostomy was opened. Maintenance of anesthesia was provided by O2 ⁄ dry air, fentanyl, and vecuronium during the operation. After the operation, residual neuromuscular block was reversed after the patient gained ability to open his eyes and to respond to simple verbal command. The postoperative course was uneventful. Upper airway obstruction is a frequent problem in spontaneously breathing children undergoing anesthesia or sedation procedures. Failure to maintain a patent airway can rapidly result in severe hypoxemia, bradycardia, or asystole, as the oxygen demand of children is high and oxygen reserve is low (4). Macroglossia may interfere with normal breathing, particularly during sleep, produce sleep apnea, and in certain instances, producing a life-threatening upper airway compromise (2). The main responsibility of the anesthetist is to keep the airway open safely and to do what is necessary to continue the adequate gas exchange. Both direct laryngoscopy and endotracheal intubation are still the technics of choice in supplying safe airway. In such circumstances, controlling the airway becomes extremely difficult. The incidence of difficult intubation in non-obstetric cases was reported as 0.05–2% (5). Further intubation technics, such as fiber-optic intubation, retrograde intubation, and blunt nasal intubation are taken into consideration in cases whose airway have not been controlled because of anatomic and technical causes. As in our case with protruding macroglossia, it is possible to do endotracheal intubation without employing the alternate method of visualization of the vocal cords by indirect laryngoscopy. Nevertheless, in the presence of macroglossia protruding outwards, preoxygenation should be *Presented in part at the 41st Annual Meeting of the Turkish Society of Anesthesiology and Reanimation, Antalya, October 2007. Figure 1 Lateral view of the huge lymphangioma. CORRESPONDENCE 1127

Effectivity of one session charcoal hemoperfusion treatment in severe carbamazepine poisoning.

A carbamazepine intoxication with suicide attempt is a relatively common clinical problem that presenting with coma, respiratory depression, arrhythmia, hemodynamic instability and even death. We report a case of severe carbamazepine poisoning that was successfully treated with one session charcoal hemoperfusion. On admission, the patient was comatose and required ventilator support. Hemoperfusion with coated activated charcoal successfully decreased the serum carbamazepine concentration from 45 µg mL−1 to 21 µg mL−1 within 2 h, with subsequent clinical improvement.

Effects of Sugammadex and Neostigmine on Renal Biomarkers

Background Neostigmine, the currently commonly used agent for reversal of neuromuscular blockade. Sugammadex is a novel and unique compound designed as an antagonist of steroidal neuromuscular blockers. In this study, we evaluated the effects of sugammadex or neostigmine on kidney functions in patients scheduled for elective surgery. Material/Methods Patients scheduled for a surgical procedure under desflurane/opioid anesthesia received an intubating dose rocuronium. Patients were divided into 2 groups receiving either sugammadex or neostigmine atropine to reverse neuromuscular blockade. Cystatin C, creatinine, urea, blood urea nitrogen, sodium, potassium, and calcium levels in the blood and α1microglobulin, β2microglobulin, and microalbumin levels in the urine were measured. Results There was no significant difference between the groups with regard to the demographic data. In the Neostigmine Group, although β2microglobulin and microalbumin were similar, a significant increase was found in the postoperative α1microglobulin and cystatin C values. In the Sugammadex Group, although β2-microglobulin and cystatin C were similar, a significant increase was found in the postoperative α1-microglobulin and microalbumin values. The only significant difference was cystatin C value variation in the Neostigmine Group compared to the Sugammadex Group. Conclusions We believe that the use of more specific and sensitive new-generation markers like cystatin C to evaluate kidney function will provide a better understanding and interpretation of our results. Sugammadex has more tolerable effects on kidney function in patients than does neostigmine. However, when compared to preoperative values, there is a negative alteration of postoperative values. Neostigmine and sugammadex do not cause renal failure but they may affect kidney function.

Reconstruction of lower lip with myomucosal advancement flap

In this article, a new surgical procedure that can be used for reconstruction of lower lip defects of any size is described.

Bilateral superficial and deep cervical plexus block for thyroidectomy in pregnancy

4. von Breunig F, Goetz AE, Heckel K. Severe muscular dystrophy and pregnancy: interdisciplinary challenge. Anaesthesist 2012;61:52–5. 5. Rojas-Suarez J, Cogollo-González M, Garcı́a-Rodrı́guez MC, Paternina-Caicedo A, Miranda-Quintero J. Non-invasive mechanical ventilation as adjuvant strategy in the management of acute respiratory failure secondary to peripartum pulmonary edema in severe preeclampsia. Med Intensiva 2011;35:518–9. 6. Perbet S, Constantin JM, Bolandard F, et al. Non-invasive ventilation for pulmonary edema associated with tocolytic agents during labor for a twin pregnancy. Can J Anaesth 2008;55:769–73.

Is the Coexistence of Intraoral Synechia and Cleft Palate Anomaly a Sequence

Intraoral synechia is a rarely seen intraoral anomaly. As a result of intraoral synechiae, fusion of the palatal shelves may be prevented because of the abnormal interposition of the tongue. Hence, cleft palate anomaly accompanies intraoral synechiae in many patients. The main problem for these patients is the inadequate oral opening for feeding. Flexible nasopharyngeal examination before intubation may help the anesthetist for simple excision of synechiae in the newborn period. In this article, a newborn who had a congenital synechia between the mandible and the maxilla has been presented, and the etiopathogenesis of intraoral synechia and the importance of flexible nasal endoscopy before endotracheal intubation are discussed.