Zehra Hatipoğlu

The Effect of Intravenous Dexamethasone on Sugammadex Reversal Time in Children Undergoing Adenotonsillectomy

BACKGROUND:Dexamethasone has been shown to cause inhibition of sugammadex reversal in functionally innervated human muscle cells. In this prospective, double-blind, randomized, controlled study, we evaluated the effect of dexamethasone on the reversal time of sugammadex in children undergoing tonsillectomy and/or adenoidectomy. METHODS:We recruited 60 patients with ASA physical status I to II, between the ages of 3 and 8 years, scheduled for elective tonsillectomy and/or adenoidectomy. After the induction of anesthesia, patients in group D received IV dexamethasone at a dose of 0.5 mg/kg within a total volume of 5 mL saline, whereas patients in group S received only 5 mL IV saline as the control group. At the end of surgery, all patients were given a single bolus dose (2 mg/kg) of sugammadex at reappearance of T2. Demographic data, hemodynamic variables, time to recovery (a train-of-four ratio of 0.9), time to tracheal extubation, and adverse effects were recorded. RESULTS:There was no statistical significance between 2 groups in time to recovery and time to extubation. Time to recovery was 97.7 ± 23.9 seconds in group D and 91.1 ± 39.5 seconds in group S (P = 0.436; 95% confidence interval, −10.3 to 23.5). Time to extubation was 127.9 ± 23.2 seconds and 123.8 ± 38.7 seconds in group D and in group S, respectively (P = 0.612; 95% confidence interval, −11.9 to 20.05). CONCLUSIONS:IV dexamethasone, given after induction of anesthesia, at a dose of 0.5 mg/kg, does not substantively affect the reversal time of sugammadex in pediatric patients undergoing adenoidectomy and/or tonsillectomy.

Sugammadex in a Patient with Brugada Syndrome

Brugada Syndrome was first described in 1992 by Pedro Brugada as a genetic syndrome that is characterized by ventricular arrhythmias that may result in sudden cardiac arrest. In particular, a right bundle branch block and ST segment elevation in the right precordial leads are observed. Many perioperative pharmalogical and physiological factors can trigger malignant arrhythmias. Although it is a rare condition, the anaesthestic management of Brugada syndrome is important because of the potentially fatal complications. Many anaesthetics have been administered during the operation of patients with Brugada Syndrome. The use of sugammadex instead of the anaesthetic management of patients with Brugada syndrome is discussed in this study.

The anesthesia of trachea and bronchus surgery.

The trachea and bronchus surgery is generally performed due to stenosis, traumatic injury, foreign body and tumors. Preoperative evaluation and anesthesia management are very important issues because of higher mortality and morbidity rates. Patients may be asymptomatic, but airway difficulties, hypoxia, stridor, cough, hemoptysis are common conditions in these patient population. The collaboration between the surgeon and the anesthesiologist is very substantial and necessary. Anesthetic techniques include various applications such as one lung ventilation, fiberoptic intubation, jet ventilation, and apneic oxygenation, general anesthesia with or without neuromuscular blockade. In this review, anesthesia management of the trachea and bronchus surgery is evaluated in the light of new knowledge.

Can high flow nasal cannula be used in a pediatric patient with tracheomalacia

Dear Editor, We read with interest the article “Home high-flow nasal cannula as a treatment for severe tracheomalacia: A pediatric case report” by Vézina et al The authors have successfully implemented high-flow nasal cannula (HFNC) oxygen therapy in children with tracheomalacia. However, we want to draw attention to some points about HFNC during clinical practice. Firstly HFNC in children is considered to be a generally safe choice among respiratory support modalities. However, the optimal gas flow during HFNC is unclear in children. The flow rate is generally used at 2-8 L/min. Chang et al reported that there is a linear relationship between pressure and flow, and the HFNC pressures are higher compared to continuous positive airway pressure (CPAP). As a result of increased pressure with the airway, the risk of serious adverse effect including pneumothorax and pneumomediastinum is likely increased during HFNC. Vézina et al stated that HFNC at a flow of 10 L/min was successfully used on a child with severe tracheomalacia. In this context, we would like to underline that patients must be closely monitored while on HFNC treatment at high flow rates to avoid complications. Secondly the authors said that the child used a nasojejunal pathway because of severe gastroesophageal reflux. In an in vitro study it was reported that for safe and effective use of HFNC, an appropriate nasal prong to nares ratio is required. In our opinion, the use of nasojejunal pathway for nutrition may impair suitable nasal prong to nares ratio, and consequently, the effectiveness of HFNC may decrease during treatment. Lastly the diagnosis of the child was tracheomalacia plus bronchomalacia. Thus, respiratory impairment likely results from a combination of the dynamic properties of the extrathoracic and the intrathoracic airway. Hypoxemia as well as hypercapnia may be seen in these patients. In a recently published study by Testa et al, HFNC did not effectively reduce increased carbon dioxide levels. Therefore, patients with tracheomalacia should be assessed both for hypoxemia and hypercapnia during HFNC treatment. CONFLICT OF INTEREST

Psychological Aspects of Critically Ill Cancer

To be diagnosed as a critically ill cancer patient is likely to cause some challenges, for both the patients and their caregivers. The primary purpose of this chapter is to identify the main psychological issues related to critically ill cancer patients and what they are likely to do after the diagnosis of their medical condition. Cancer diagnosis may result in distress, depression and anxiety resulting in extended periods of their illness. Age, gender and primary cancer site play a crucial role in anxiety and depression level. After diagnosis, patients are more likely to have emotional distress experience and also taking control stage including seeking further information and finding appropriate help. Psychological and emotional vulnerability are affected by the timing of when their medical condition is diagnosed, medication endpoints and recurrence episodes. Should a patient receive an improved cancer pain management, it can help the patient not just for biomedical reasons but also manage their psychosocial and spiritual distress levels. As for possible protective factors against distress of critically ill cancer patients, optimism and social support are suggested to increase their quality of life. Coping styles after surgery have links to psychosocial adjustment of patients. In addition to this, higher resilience amongst cancer patients, in particular, leads them to having lower psychological distress and being more physically active. It is also thought that this may also lead to them being more resilient and also potentially a more effective psychological symptom management.

Postoperative Pulmonary Management After Esophagectomy for Cancer

The incidence of esophageal cancer has been increasing in recent years, and the main treatment of it is surgical resection. Esophagectomy for cancer is a major surgery because of possible postoperative pulmonary complications such as chylothorax, atelectasis, pleural effusion, pneumonia, and acute respiratory distress syndrome. Such complications may lead to the need for mechanical ventilation support and intensive care for these patients. Respiratory muscle weakness, surgically induced pulmonary changes, and deficiency in pain management are formative mechanisms of postoperative pulmonary complications. Furthermore, these complications are closely associated with prolonged mechanic ventilation and hospitalization and increased morbidity and mortality. In postoperative pulmonary management, preoperative and intraoperative approaches contribute to improve the respiratory system. Postoperative pulmonary management includes noninvasive positive pressure ventilation, pain management, gastric decompression, and treatment of complications related to surgical. In this context, pulmonary management will be discussed in this section.

Effects of auditory and audiovisual presentations on anxiety and behavioral changes in children undergoing elective surgery

Background: Preoperative anxiety is a critical issue in children, and associated with postoperative behavioral changes. Aims: The purpose of the current study is to evaluate how audiovisual and auditory presentations about the perioperative period impact preoperative anxiety and postoperative behavioral disturbances of children undergoing elective ambulatory surgery. Materials and Methods: A total of 99 patients between the ages of 5–12, scheduled to undergo outpatient surgery, participated in this study. Participants were randomly assigned to one of three groups; audiovisual group (Group V, n = 33), auditory group (Group A, n = 33), and control group (Group C, n = 33). During the evaluation, the Modified Yale Preoperative Anxiety Scale (M-YPAS) and the posthospitalization behavioral questionnaire (PHBQ) were used. Results: There were no significant differences in demographic characteristics between the groups. M-YPAS scores were significantly lower in Group V than in Groups C and A (P < 0.001 and P < 0.001, respectively). PHBQ scores in Group C were statistically higher than in Groups A and V, but, no statistical difference was found between Groups A and V. Conclusion: Compared to auditory presentations, audiovisual presentations, in terms of being memorable and interesting, may be more effective in reducing childrens anxiety. In addition, we can suggest that both methods can be equally effective for postoperative behavioral changes.

High flow nasal cannula reduces carbon dioxide washout time: What can we pay attention to?

We readwith interest the article titled “Carbon dioxidewashout during high flow nasal cannula versus nasal CPAP support: an in vitro study” by Sivieri et al. The present study was actually well designed and planned; however, there are some key practical aspects for accurate clinical implications. Firstly, the studies related to high flow nasal cannula (HFNC) postulated that a principal mechanism of HFNCmay be flushing of the nasopharyngeal ‘dead space’, and thus the dead space is reduced. As a result, it contributes to improve respiratory efforts by increasing alveolar ventilation and reducing carbon dioxide (CO2) retention. 2,3 Lung clearance index (LCI) is defined as a measure of lung physiology derived from multiple breath washout tests (MBW), and which is helpful in detecting earlier airways disease of children. In a study conducted on 150 infants by Schmalisch et al, it was expressed that VT, FRC and dead space (VD), and their ratios, body weight and body length of the infant are important factors affecting LCI measurement. In this context, lung model created in the study of Sivieri et al. may be inadequate for CO2 washout. We know that in their study, experimental model is setup on carbon dioxide washout, and functional residual capacity (FRC), tidal volume (VT) and inspiratory rate were kept constant. However, we underline that dead space is an important component of the mechanism of HFNC in their experimental setup and actual practice. Because it is known that reduction in dead space volume would be effective in improving alveolar ventilation. For actual practice, the effects of the development of infants on lung volumes must be taken into account. Sivieri et al. reported that HFNC washout times decreased as set flow increased from3 to8 L/min in themouth-closedmodel.However, an important relationship between increasing HFNC flow and EndExpiratoryEsophagealPressures (EEEP) inpremature infantswasshown in the observational study. In contrast to this information, recently published review stated that in the randomized controlled trials, airway leak syndromes are similar toCPAP despite uncontrolled pressureswith the higher flow rates (2 to 8 L/min) in HFNC. In the literature, there are limited number of studies with the higher flow rates (>8 L/min). Therefore, we would like to mention that especially, infants using flow rates higher than 8 L/min should be closely monitored in terms of adverse effects of HFNC during clinical practice, and further controlled studies are needed to evaluate these effects.

Çocuklarda ultrasonografi eşliğinde yapılan rektus kılıf bloğunda lokal anestezik volümünün anestezik ve analjezik ajan tüketimi üzerine etkisi

Amac: Bu calismada, cocuklarda yapilacak major abdominal cerrahilerde, ultrasonografi esliginde iki farkli volumle uygulanan rektus kilif blogunun peroperatif sevofluran ve postoperatif morfin tuketimi uzerine etkilerinin arastirilmasi amaclanmistir. Gerec ve Yontem: Amerikan Anestezistler Dernegi (ASA) I-II grubu, 1-16 yas arasi, major batin cerrahisi yapilacak 40 olgu calismaya dahil edildi. Genel anestezi uygulandiktan sonra rastgele iki gruba ayrilan olgulardan Grup I’e (n=20) 0.1 ml/kg % 0.25 levobupivakain (toplam volum 0.1 ml/kg olacak sekilde serum fizyolojik ile seyreltilerek) ile Grup II’ye (n=20) 0.1 ml/kg % 0.25 levobupivakain (toplam volum 0.4 ml/kg olacak sekilde serum fizyolojik ile seyreltilerek) ile ultrasonografi esliginde rektus kilif blogu uygulandi. Operasyon boyunca hemodinamik veriler ve sevofluran tuketimi, operasyon sonunda agri duzeyleri, ek analjezik ihtiyaci ve sedasyon duzeyleri kaydedildi. Bulgular: Intraoperatif donemde inspire edilen ve tuketilen sevofluran miktarlari her iki grupta da benzer olup, toplam sevofluran tuketimi Grup I’de 106.85±28.6 ml, Grup II’de 91.50±36.6 ml olarak bulundu (p>0.05). Olgularin postoperatif agri ve sedasyon skorlari ve ek analjezik ihtiyaclari arasinda fark saptanmadi. Sonuc: Major abdominal cerrahi uygulanacak cocuklarda ultrasonografi esliginde yapilan rektus kilif blogunun etkin ve guvenilir bir analjezi sagladigi, uygulanan lokal anestezik volumunu arttirmanin intraoperatif sevofluran tuketimini ve postoperatif ek analjezik ihtiyacini azaltmadigi kanisina varildi.

Comparing the Laryngeal Mask Airway, Cobra Perilaryngeal Airway and Face Mask in Children Airway Management

OBJECTIVE We compared the effects of the laryngeal mask airway (LMA), face mask and Cobra perilaryngeal airway (PLA) in the airway management of spontaneously breathing paediatric patients undergoing elective inguinal surgery. METHODS In this study, 90 cases of 1-14-year-old children undergoing elective inguinal surgery were scheduled. The patients were randomly divided into three groups. Anaesthesia was provided with sevoflurane and 50%-50% nitrous oxide and oxygen. After providing an adequate depth of anaesthesia, supraglottic airway devices were inserted in the group I and II patients. The duration and number of insertion, haemodynamic parameters, plateau and peak inspiratory pressure and positive end-expiratory pressure of the patients were recorded preoperatively, after induction and at 5, 10, 15 and 30 min peroperatively. RESULTS There were no statistical differences between the groups in terms of haemodynamic parameters (p>0.05). In group II, instrumentation success was higher and instrumentation time was shorter than group II. The positive end-expiratory pressure and plateau and peak inspiratory pressure values were statistically lower in group II (p<0.05). CONCLUSION We concluded that for airway safety and to avoid possible complications, LMA and Cobra PLA could be alternatives to face mask and that the Cobra PLA provided lower airway pressure and had a faster and more easy placement than LMA.