Zeynep Kayhan

Which is responsible for the haemodynamic response due to laryngoscopy and endotracheal intubation? Catecholamines, vasopressin or angiotensin?

Background and objective: We have investigated the concentrations of epinephrine, norepinephrine, vasopressin and angiotensin converting enzyme activity to explore the role of these mediators in the neuroendocrine response to laryngoscopy and tracheal intubation. Methods: One hundred (50 male, 50 female) ASA I patients aged 20‐50 yr (mean ± SEM; 35.59 ± 0.99) were included in the study. They were undergoing elective surgery under standard anaesthesia induction and maintenance using tracheal intubation. Plasma concentrations of epinephrine, norepinephrine and vasopressin as well as plasma angiotensin converting enzyme activity were determined at four time points, before (T1) and after (T2) induction, and 2 (T3) and 5 min (T4) after intubation. Blood pressure and heart rate were recorded at corresponding times to reveal if any correlation existed between haemodynamic parameters and neuroendocrine response. Results: Heart rate increased after induction and intubation (P < 0.05) and decreased significantly at T4 (P < 0.05). Systolic blood pressure decreased significantly (P < 0.05) after induction and increased slightly after intubation decreasing to below baseline value (P < 0.05) at T4. Diastolic blood pressure increased slightly after intubation and decreased significantly (P < 0.05) at T4. Plasma epinephrine and norepinephrine concentrations decreased after induction and increased at T3 and T4 without reaching significance. Vasopressin concentrations increased slightly at T2 and T3 and decreased significantly at T4 (P < 0.05). Angiotensin converting enzyme activity was unaffected when compared with baseline values. Conclusions: Blood pressure, heart rate, plasma epinephrine, norepinephrine and vasopressin concentrations increased slightly in response to laryngoscopy and intubation, all returning to or below baseline 5 min later with no change in angiotensin converting enzyme activity in normotensive patients.

Epidural anesthesia for renal transplantation : A preliminary report

PATIENTS receiving renal transplants present many problems to the anesthesists. Use of continuous epidural anesthesia in chronic renal failure patients is still controversial but promising. Since 1985 more than 900 transplantations have been carried out at our institution under general anesthesia. For the last 6 months we have routinely administered continuous epidural anesthesia for these procedures. In this study, we review recipient demographics, intraoperative anesthesia, postoperative analgesia strategies, and length of hospital stay and report on associated complications.

Syringe pumps take too long to give occlusion alarm.

Background:  The aim of this study was to assess the time needed to trigger an occlusion alarm, and the influence of the type of infusion pump, type and size of the syringe, and the set infusion rate.

Propofol inhibits potassium chloride induced contractions of isolated human umbilical vessels

Background and objective: We have evaluated the effects of propofol and its relationship with K+ channels on human isolated umbilical vessels. Methods: Umbilical vessel rings were suspended in isolated organ baths containing Krebs–Ringer solution. In the first series of experiments the effect of propofol (10−9–10−4M) was examined in a concentration‐dependent manner on umbilical vessels precontracted with KCl (60 mmol). In the second series, these effects were studied in the presence of tetraethylammonium. Results: A mild contraction was produced by low dose propofol in both precontracted umbilical artery and umbilical vein segments. 10−4M propofol caused significant relaxation in both umbilical artery and umbilical vein. The relaxation response was significantly reduced by the addition of 10−1 M tetraethylammonium. Conclusion: These results suggested that the responses of propofol on KCl‐induced contractions of both umbilical artery and vein were dose dependent, and this effect involved Ca2+ activated K+ channels.

Patient-controlled epidural analgesia with morphine in renal transplant patients

WITH THE INCREASING use of epidural anesthesia for renal transplantation surgery, epidural analgesia might become an alternative choice for postoperative pain management in transplant patients. The aim of this study was to evaluate the use of patient-controlled epidural analgesia with morphine and to compare two dose regimens in the early postoperative period. Twenty-seven patients with chronic renal failure undergoing transplantation received epidural anesthesia. Postoperatively, a patient-controlled analgesia (PCA) pump was connected to the patient and programmed to give either morphine boluses of 0.3 mg only with a 20-minute lockout time (group 1) or an additional infusion of morphine at a rate 0.3 mg/h (group 2), both using a 0.1-mg/mL concentration. Pain assessment was done using the NRS (numerical rating scale) and patients were compared with respect to bolus and total doses of morphine, demand:delivery ratio, side effects (nausea and vomiting, pruritis, hypotension), and the hemodynamic status (mean blood pressure, heart rate). Patients’ characteristics in the groups were similar. In both groups, demand and delivery doses were comparable, but the total dose of morphine was significantly higher in the second group (P 5 .0005, P , .05). Eight of the patients in group 1 and five in group 2 developed pruritis; seven and four, respectively, had nausea and vomiting, but there was no significant difference between the groups with regard to frequency of side effects (P . .05). None of the patients became hypotensive and hemodynamic status was similar in both groups (P . .05). In conclusion, epidural PCA with morphine as a bolus dose of 0.3 mg without basal infusion is sufficient for pain management following renal transplantation. Continuous epidural anesthesia for renal transplantation has been used for the last decade. Postoperative epidural analgesia has also been used in these patients during this same period of time, but only rarely. Hence, the search for appropriate agents and doses will continue to be the subject of future studies. We compared the effects of postoperative patient-controlled epidural analgesia (PCEA) with two morphine dosing regimens following renal transplantation. PATIENTS AND METHODS

Dealing with a hemophilia-A patient undergoing cerebral aneurysm surgery.

In this article anesthesiologic and hematologic aspects of a patient with Hemophilia-A, who underwent craniotomy for a right middle cerebral artery aneurysm, are discussed.

Anesthetic Management of Renal and Liver Transplantation Recipients During Cesarean Section

Introduction The aim of this study is to present our experience in renal transplantation recipients (RTR) and liver transplantation recipients (LTR) during cesarean section. Materials and Methods Retrospective data regarding renal transplantation recipients and liver transplantation recipients who underwent cesarean section at Baskent University Hospital in Ankara between January 1997 and January 2017 have been collected from hospital records. Results and Discussion Fourteen live births occurred from five LTRs and nine RTRs, all of them from C/S. The mean maternal age (28.4±4.1 years vs 29.2±4.1 years, p=.38), body weight before conception (57.4±8.8 kg vs 64.5±8.2 kg, p=.48) and the time from transplantation to conception (99.0±50.7 months vs 101.0±57.5 months, p=.46) were similar respectively for LTRs and RTRs. All recipients were maintained on cyclosporine, azathioprine, tacrolimus and corticosteroids before and during pregnancy for immunosuppression. Four C/Ss were performed under general anesthesia (1 LTR vs 3 RTRs, p>.05) whereas spinal anesthesia was used in 10 patients. Liver and renal function tests were stable in all of the patients and we did not observe any acute or subacute rejection. Only one mother with renal transplantation died in one year after delivery. The mean birth weight was similar (2502 ± 311 gr vs 2161±658 gr, p=.3). There were 3 premature vs 6 premature and low birth weight (<2500 gr) 2 vs 4 among 14 newborns. Infants small for gestational age were diagnosed in 9/14 (3 LTRs vs 6 RTRs, p=1). None of the neonates died. Conclusion General and regional anesthesia can be safely used during cesarean delivery of the LTRs and RTRs without increased risk of graft loses. Prematurity and low birth weight was mainly due to the cytotoxic drugs for immunosuppression. There are no differences in LTRs and RTRs for maternal and fetal complications due to in our data.

PiCCO Monitoring During Liver Transplantation for Pediatric Patients

Introduction Anesthetic management of pediatric liver transplant recipients (PLTR) is based on fluid management, adhering to hemodynamic goals and managing associated comorbidities. The PiCCO (pulse contour cardiac output) system gives validated intermittent cardiac output measurements by transpulmonary thermodilution and is less invasive than pulmonary artery catheterization. Monitoring the cardiopulmonary system of PLTR during surgery using PiCCO system is reflective of ongoing hemodynamic response to intraoperative maneuvers. We compare the intraoperative and postoperative parameters with hemodynamic volumetric parameters monitored by PiCCO system in PLTR during surgery. Materials and Methods In a retrospective analysis of PLTR from Sept 2014 to Oct 2017, demographic, laboratory and perioperative data were collected. Transpulmonary thermodilutions were performed at different times of surgery: beginning of surgery (To); before hepatectomy and after selective vascular exclusion (Tanhepatic); new hepatic phase (Tend). Hemodynamic volumetric parameters monitored by the PiCCO system were mean arterial pressure (MAP), cardiac index (CI), intrathoracic blood volume index (ITBVI), extravascular lung water index (EVLWI), systemic vascular resistance index (SVRI) and stroke volume variability (SVV). Results 41 PLTR (aged 4 mo to 17 y) underwent hemodynamic monitoring with PiCCO during LT. Measurements including CI, CVP and MAP were significantly lower during Tanhepatic phase when compared to To and Tend phases (p<.05 for all, Table). Patients whose mean Tend EVLWI measurements were >7 mL/kg; greater amounts of intraoperative blood transfused (p=.027), higher graft recipient body weight ratio (GRWR) (p=.016) and longer anesthesia times (p=.046) were seen. The mean Tend SVV measurements were >10 in patients who had a higher GRWR (p=.033). More blood transfusion was needed and higher GRWR was observed in patients with GEDV <650ml/m2 (p=.000). Patients with a mean Tend CI measurement <3L/min/m2 received more colloid transfusion and had longer anesthesia time during LT. Conclusion PiCCO monitoring enables flow and dynamic parameters which predict fluid responsiveness and help to make critical decisions to restore hemodynamic stability during pediatric LT. Table. No title available.

Tourniquet pressure settings based on limb occlusion pressure determination or arterial occlusion pressure estimation in total knee arthroplasty? A prospective, randomized, double blind trial

Objective The aim of this study was to compare the limb occlusion pressure (LOP) determination and arterial occlusion pressure (AOP) estimation methods for tourniquet pressure setting in adult patients undergoing knee arthroplasty under combined spinal-epidural anesthesia. Methods Ninety-three patients were randomized into two groups. Pneumatic tourniquet inflation pressures were adjusted based either on LOP determination or AOP estimation in Group 1 (46 patients, 38 female and 8 male; mean age: 67.71 ± 9.17) and Group 2 (47 patients, 40 female and 7 male; mean age: 70.31 ± 8.27), respectively. Initial and maximal systolic blood pressures, LOP/AOP levels, required time to estimate AOP/determinate LOP and set the cuff pressure, initial and maximal tourniquet pressures and tourniquet time were recorded. The effectiveness of the tourniquet was assessed by the orthopedic surgeons using a Likert scale. Results Initial and maximal systolic blood pressures, determined LOP, estimated AOP, duration of tourniquet and the performance of the tourniquet were not different between groups. However, the initial (182.44 ± 14.59 mm Hg vs. 200.69 ± 15.55 mm Hg) and maximal tourniquet pressures (186.91 ± 12.91 mm Hg vs. 200.69 ± 15.55 mm Hg) were significantly lower, the time required to estimate AOP and set the tourniquet cuff pressure was significantly less (23.91 ± 4.77 s vs. 178.81 ± 25.46 s) in Group II (p = 0.000). No complications that could be related to the tourniquet were observed during or after surgery. Conclusion Tourniquet inflation pressure setting based on AOP estimation method provides a bloodless surgical field that is comparable to that of LOP determination method with lower pneumatic inflation pressure and less required time for cuff pressure adjustment in adult patients undergoing total knee arthroplasty under combined spinal epidural anesthesia.

Anaesthesia Management of a Patient with Factor XI Deficiency

Factor XI deficiency is an extremely rare disease presenting no clinical symptoms, unless there is an inducing reason such as trauma or surgery. Normally, factor levels are in the range of 70-150 U dL-1 in healthy subjects. Although no clinical symptoms are seen, only high levels of aPTT can be found. Once a prolongation is detected in aPTT, factor XI deficiency should be suspected and factor levels should be analysed. With careful preoperative preparations in factor-deficient people, preoperative and postoperative complications can be decreased. In this case report, management of anaesthesia during total hip arthroplasty of a patient with factor XI deficiency is presented.