Which test best predicts difficult endotracheal intubation? A prospective cohort study.

BACKGROUND: It is critical to identify patients whose intubation will be difficult to ensure that necessary precautions are taken. In this study, we aimed to show the power of almost all tests used to predict difficult endotracheal intubation (DEI), and to determine which test are more accurate for this purpose. METHODS: This observational study conducted between May 2015 and January 2016 at department of anesthesiology of a tertiary hospital in Turkey (n=501). A total of 25 parameters and 22 tests used for DEI were compared according to groups formed according to the Cormack-Lehane classification (gold standard). RESULTS: The mean age was 49.83±14.00 years, and 259 (51.70%) patients were males. We found difficult intubation frequency to be 7.58%. Mallampati classification, atlanto-occipital joint movement test (AOJMT), upper lip bite test, mandibulohyoid distance (MHD), maxillopharyngeal angle, height-to-thyromental distance ratio, and mask ventilation test were independently associated with difficult intubation. CONCLUSION: Despite comparing 22 tests, the results obtained in this study cannot definitively identify any single test that pre-dicts difficult intubation. Nonetheless, our results show that MHD (high sensitivity and negative predictive value) and AOJMT (high specificity and positive predictive value) are the most useful tests to predict difficult intubation.

Effects of perioperative magnesium sulfate with controlled hypotension on intraoperative bleeding and postoperative ecchymosis and edema in open rhinoplasty.

PURPOSE: This randomized, double-blind study was planned to evaluate the effect of perioperative magnesium sulfate with controlled hypotension on intraoperative bleeding, postoperative ecchymosis and edema, and side-effects. MATERIALS AND METHOD: Forty-nine patients undergoing open rhinoplasty were divided into two groups - magnesium sulfate and control. The magnesium sulfate group received 30-50 mg·kg-1 intravenously as a bolus before induction of anesthesia, followed by 10-20 mg·kg-1 h-1 by continuous intravenous infusion during surgery. Anesthesia was induced with propofol 3 mg·kg-1, fentanyl 15 µg·kg-1 and cisatracurium 0.6 mg·kg-1. Mean arterial pressure was maintained at 50 to 60 mmHg under controlled hypotensive anesthesia with magnesium sulfate titration. Hemodynamic variables, operational bleeding, early postoperative side-effects and postoperative first-, third- and seventh-day ecchymosis and edema were compared between the groups. Ecchymosis and edema were evaluated using a graded scale from 0 to 4. RESULTS: In the magnesium sulfate group, mean arterial pressure decreased during most of the perioperative period. Intraoperative bleeding also decreased. A distinct reduction in ecchymosis and edema was observed in both the upper and lower eyelids on the first, third and seventh days. Patients in the magnesium sulfate group also had a more peaceful postoperative course with less postoperative nausea vomiting, and shivering. CONCLUSION: Magnesium sulfate with controlled hypotension can lower ecchymosis and edema of the upper and lower eyelids in rhinoplasty surgery by reducing bleeding.

Evaluation of the perioperative effects of dexmedetomidine on tympanoplasty operations.

PURPOSE: This randomized double-blind study aimed to evaluate the effects of dexmedetomidine on hemodynamic parameters and the quality of surgery and recovery criteria in tympanoplasty operations. MATERIALS AND METHODS: A total of 75 patients 18-55 years undergoing tympanoplasty, who were graded as American Society of Anesthesiologists physical status I-II, were randomly divided into three groups. Group 1 included patients receiving remifentanil alone, Group 2 included patients receiving dexmedetomidine + remifentanil and Group 3 included patients receiving dexmedetomidine + ½ remifentanil. Anesthesia was induced with propofol and cisatracurium. For maintenance of anesthesia, a mixture of 2-2.5% sevoflurane, 40-60% oxygen/air was used. The groups were compared in terms of hemodynamic parameters, surgical area, recovery criteria, modified Aldrete, pain scores, additional analgesic requirements and adverse effects. RESULTS: Mean arterial pressure and heart rate values of Group 1 were higher at the time of intubation, incision, spontaneous breathing and extubation compared to Group 2 and Group 3. Surgical field satisfaction was higher in Group 2 and Group 3 than Group 1. Spontaneous breathing, eye opening and verbal cooperation times were shorter in Group 3 compared to Group 2. Eye opening and verbal cooperation times were longer in Group 2 compared to Group 1. The 30-minute modified Aldrete scores was higher in Group 3 compared to Group 1. There was no difference between the groups in terms of postoperative pain and adverse effects. CONCLUSION: The use of dexmedetomidine during tympanoplasty operations may provide better hemodynamic control and surgical view, may provide faster recovery and may reduce remifentanil consumption.

Transient unilateral combined paresis of the hypoglossal nerve and lingual nerve following intubation anesthesia.

Nerve damage may occur in the pharyngolaryngeal region during general anesthesia. The most frequently injured nerves are the hypoglossal, lingual and recurrent laryngeal. These injuries may arise in association with several factors, such as laryngoscopy, endotracheal intubation and tube insertion, cuff pressure, mask ventilation, the triple airway maneuver, the oropharyngeal airway, manner of intubation tube insertion, head and neck position and aspiration. Nerve injuries in this region may take the form of an isolated single nerve or of paresis of two nerves together in the form of hypoglossal and recurrent laryngeal nerve palsy (Tapia's syndrome). However, combined injury of the lingual and hypoglossal nerves following intubation anesthesia is a much rarer condition. The risk of this damage can be reduced with precautionary measures. We describe a case of combined unilateral nervus hypoglossus and nervus lingualis paresis developing after intubation anesthesia.

The effects of spinal, inhalation, and total intravenous anesthetic techniques on ischemia-reperfusion injury in arthroscopic knee surgery.

PURPOSE: To compare the effects of different anesthesia techniques on tourniquet-related ischemia-reperfusion by measuring the levels of malondialdehyde (MDA), ischemia-modified albumin (IMA) and neuromuscular side effects. METHODS: Sixty ASAI-II patients undergoing arthroscopic knee surgery were randomised to three groups. In Group S, intrathecal anesthesia was administered using levobupivacaine. Anesthesia was induced and maintained with sevoflurane in Group I and TIVA with propofol in Group T. Blood samples were obtained before the induction of anesthesia (t1), 30 min after tourniquet inflation (t2), immediately before (t3), and 5 min (t4), 15 min (t5), 30 min (t 6), 1 h (t7), 2 h (t8), and 6 h (t9) after tourniquet release. RESULTS: MDA and IMA levels increased significantly compared with baseline values in Group S at t2-t 9 and t2-t7. MDA levels in Group T and Group I were significantly lower than those in Group S at t2-t8 and t2-t9. IMA levels in Group T were significantly lower than those in Group S at t2-t7. Postoperatively, a temporary 1/5 loss of strength in dorsiflexion of the ankle was observed in 3 patients in Group S and 1 in Group I. CONCLUSIONS: TIVA with propofol can make a positive contribution in tourniquet-related ischemia-reperfusion.

Paresia transitória unilateral combinada do nervo hipoglosso e do nervo lingual após intubação para anestesia / Transient unilateral combined paresis of the hypoglossal nerve and lingual nerve following intubation anesthesia / Paresia transitoria unilateral combinada del nervio hipoglosoy del nervio lingual después de la intubación para anestesia

Lesões de nervos podem ocorrer na região faringolaríngea durante a anestesia geral. Os nervos mais comumente lesionados são o hipoglosso, lingual e laríngeo recorrente. As lesões podem surgir em decorrência de vários fatores, como, por exemplo, durante a laringoscopia, intubação endotraqueal e inserção de tubo e por pressão do balão, ventilação com máscara, manobra aérea tripla, via aérea orofaríngea, modo de inserção do tubo, posição da cabeça e do pescoço e aspiração. As lesões nervosas nessa região podem acometer um único nervo isolado ou causar a paralisia de dois nervos em conjunto, como a do nervo laríngeo recorrente e hipoglosso (síndrome de Tapia). No entanto, a lesão combinada dos nervos lingual e hipoglosso após intubação para anestesia é uma condição muito mais rara. O risco dessa lesão pode ser reduzido por meio de medidas preventivas. Descrevemos um caso de paresia unilateral combinada dos nervos hipoglosso e lingual após intubação para anestesia.

Nerve damage may occur in the pharyngolaryngeal region during general anesthesia. The most frequently injured nerves are the hypoglossal, lingual and recurrent laryngeal. These injuries may arise in association with several factors, such as laryngoscopy, endotracheal intubation and tube insertion, cuff pressure, mask ventilation, the triple airway maneuver, the oropharyngeal airway, manner of intubation tube insertion, head and neck position and aspiration. Nerve injuries in this region may take the form of an isolated single nerve or of paresis of two nerves together in the form of hypoglossal and recurrent laryngeal nerve palsy (Tapia's syndrome). However, combined injury of the lingual and hypoglossal nerves following intubation anesthesia is a much rarer condition. The risk of this damage can be reduced with precautionary measures. We describe a case of combined unilateral nervus hypoglossus and nervus lingualis paresis developing after intubation anesthesia.

Durante la anestesia general pueden lesionarse los nervios en la región faringolaríngea. Los nervios más a menudo lesionados son el hipogloso, lingual y laríngeo recurrente. Las lesiones pueden surgir como resultado de varios factores que pueden ser, durante la laringoscopia, intubación endotraqueal e inserción del tubo y por presión del balón, ventilación con mascarilla, maniobra aérea triple, vía aérea orofaríngea, modo de inserción del tubo, posición de la cabeza y del cuello, y aspiración. Las lesiones nerviosas en esa región pueden comprometer un solo nervio aislado o causar la parálisis de 2 nervios en conjunto, como la del nervio laríngeo recurrente hipogloso (síndrome de Tapia). Sin embargo, la lesión combinada de los nervios lingual e hipogloso, después de la intubación para la anestesia, es una condición mucho más rara. El riesgo de una lesión se puede reducir con medidas preventivas. A continuación describimos un caso de paresia unilateral combinada de los nervios hipogloso y lingual después de la intubación para la anestesia.

Effects of perioperative remifentanil with controlled hypotension on intraoperative bleeding and postoperative edema and ecchymosis in open rhinoplasty.

BACKGROUND: This randomized, double-blind study was designed to assess the effect of perioperative remifentanil with controlled hypotension on intraoperative bleeding, postoperative edema, and ecchymosis. METHODS: Fifty-two patients undergoing rhinoplasty were divided into 2 groups. The remifentanil group received 1 µg · kg(-1) intravenously as a bolus before induction of anesthesia, 0.5 to 1 µg · kg(-1) · h(-1) by continuous intravenous infusion during the operation. After anesthesia induction with propofol (2-3 mg · kg(-1)) and fentanyl (1-15 µg · kg(-1)), muscle relaxation was achieved with rocuronium (0.45-0.90 mg · kg(-1)). Mean arterial pressure was maintained at 50 to 60 mm Hg in controlled hypotensive anesthesia achieved using remifentanil infusion. Perioperative hemodynamics and bleeding; early postoperative pain and agitation scale; postoperative first, third, and seventh day edema; and ecchymosis were evaluated. Edema and ecchymosis were evaluated using graded scale from 0 to 4. RESULTS: Remifentanil reduced mean arterial pressure during the entire operative period and the first 30 minutes postoperatively (P < 0.05 for these comparisons). Intraoperative bleeding also decreased (P < 0.001). There was a significant decrease in edema in both upper and lower eyelid edema on the first and third days in the remifentanil group, although this difference was not detected on the seventh day (P(1upper) = 0.000, P(1lower) = 0.000, P(3upper) = 0.008, and P(3lower) = 0.002). Ecchymosis decreased significantly in both upper and lower eyelids on the first, third, and seventh days in the remifentanil group (P(1upper) = 0.000, P(3upper) = 0.000, P(3upper) = 0.002, P(3lower) = 0.002, P(7upper) = 0.049, and P(7lower) = 0.038). There were no differences in postoperative pain and agitation between 2 groups. CONCLUSIONS: Remifentanil with controlled hypotension may reduce edema and ecchymosis of the upper and lower eyelids, by reducing mean arterial pressure and amount of bleeding in rhinoplasty.

A comparison of intraarticular morphine and bupivacaine for pain control and outpatient status after an arthroscopic knee surgery under a low dose of spinal anaesthesia.

Effective pain control is important after an outpatient arthroscopic knee surgery to permit early discharge and improve outcome. The aim of this study was to compare intraarticular morphine and bupivacaine with placebo for postoperative pain control and outpatient status after a knee arthroscopic surgery under a low dose of spinal anaesthesia. After obtaining the ethic committee's approval and written informed consents from 60 adult outpatients undergoing knee arthroscopy, patients were enrolled in this prospective, randomized, double-blinded, placebo-controlled clinical study. All patients received spinal anaesthesia with 1.4 ml of hyperbaric bupivacaine 0.5%. Patients were randomly divided into three groups as morphine (group M, n =20), bupivacaine (group B, n = 20), and placebo (group C, n = 20). After the surgical procedure, patients received one of the following solutions intraarticularly in a double-blinded randomized manner: 5 mg morphine in 20 ml saline, 20 ml 0.25% bupivacaine, or 20 ml saline. Postoperative pain was assessed using a 10-cm visual analogue scale (VAS). Patient characteristics, hemodynamic values, sensory and motor blocks, VAS values, rescue analgesics, discharge time, and patient satisfaction were recorded. There were no significant differences in patient characteristics, surgery and tourniquet time, hemodynamic values, and sensory and motor blocks. The VAS values at 30, 60, and 90 min were similar among the three groups. The VAS values at rest and during move were higher in group C than in groups M and B at 120, 150, 180 min, and 24 h (P < 0.001). There was no difference in VAS values between the groups M and B. Rescue analgesics used and discharge time were significantly different in the placebo group when compared to groups M and B (P < 0.001). Side effects were similar among the groups. Patient satisfaction scores were high in the groups M and B. Administration of 5 mg morphine and 20 ml of 0.25% bupivacaine intraarticularly provides better pain relief and shorter discharge time without increasing the side effects than placebo for an outpatient arthroscopic knee surgery performed under a low dose of spinal anaesthesia.

Comparison of the effect of propofol and N-acetyl cysteine in preventing ischaemia-reperfusion injury.

BACKGROUND AND OBJECTIVE: The aim of this study was to compare the effects of propofol and N-acetyl cysteine (NAC) on tourniquet-induced ischaemia-reperfusion injury by determining malonyldialdehyde, ischaemia-modified albumin, lactate, blood gas and haemodynamic levels in arthroscopic knee surgery. METHODS: Sixty ASA I or II patients were randomized into three groups. Intrathecal anaesthesia was administered using 0.5% heavy bupivacaine in all patients. In group P, propofol was administered in a 0.2 mg kg(-1) bolus, followed by infusion at a rate of 2 mg kg(-1) h(-1); in group NAC, NAC was administered as an infusion at a rate of 5 mg kg(-1) h(-1), and, in group C (the control group), an equal volume of isotonic saline was administered to patients until 30 min after reperfusion. Blood samplings were obtained immediately before intrathecal anaesthesia (t1), 1 min before tourniquet release (t2), 5 min after tourniquet release (t3) and 30 min after tourniquet release (t4). RESULTS: Plasma malonyldialdehyde, ischaemia-modified albumin and lactate levels increased significantly in group C at t3 and t4 compared with the baseline values. Plasma concentrations of malonyldialdehyde, ischaemia-modified albumin and lactate in groups P and NAC were significantly lower than those in group C at t3 and t4. In blood gas analyses, pH, HCO3 and base excess were found to be significantly lower at t3 and t4 compared with t1 and t2 in group C. Comparisons between groups P and NAC revealed no significant differences. CONCLUSION: Small-dose infusions of both propofol and NAC appear to provide similar protection against ischaemia-reperfusion injury in arthroscopic knee surgery.

Interrupted aortic arch in a adult: diagnosis with MSCT.

Interrupted aortic arch (IAA) is a rare severe congenital heart defect defined as a complete loss of luminal and anatomic continuity between ascending and descending aorta. It is important that we made a good diagnosis and accurate evaluation of their morphologic conditions before a heart operation. We presented an 18-year-old girl of interrupted IAA diagnosed by multi-slice computed tomography angiography.

Does propofol or caffeic acid phenethyl ester prevent lung injury after hindlimb ischaemia-reperfusion in ventilated rats?

BACKGROUND: To investigate the effects of propofol and caffeic acid phenethyl ester (CAPE) on prevention of lung injury as a remote organ after performing hindlimb ischaemia-reperfusion (IR) in a rat model. METHODS: The animals were divided randomly into one of four groups: sham, no IR (n = 8), control, IR, (n = 8), CAPE group, IR with CAPE, (n = 8), propofol group, IR with P, (n = 8). After the rats were anaesthetised, the animals in the CAPE group received CAPE of 10 micromol, in the propofol group received propofol 50 mg/kg, in the control group received a similar volume of saline solution by means of intraperitoneal injection 1 h before reperfusion. After 4 h of ischaemia the tourniquet was removed and the animals were released for reperfusion for 4 h thereafter. At the end of the reperfusion period, a median sternotomy was performed. A blood sample was obtained for plasma malondialdehyde (MDA). The lung tissues were also removed for MDA assays, myeloperoxidase (MPO) activity, and histopathological examination. RESULTS: Plasma and lung MDA levels, and lung MPO activity were significantly higher in the control group compared to the other groups (p < 0.0005). In the CAPE group, these were significantly lower compared to the control group (p < 0.0005). Also, propofol caused a marked reduction in the MDA levels and MPO activity compared with control group (p < 0.0005), with no significant difference compared to that of the sham group. Histopathologically, the scores resulted in a grade zero (8/8) in the sham group, 3 (3/8) or 4 (5/8) in the control group, 1 (2/8) or 2 (6/8) in the CAPE group, and 1 (3/8) or 2 (5/8) in the propofol group. CONCLUSION: Propofol and CAPE seem to be effective in protecting against lung injury caused by increased oxidative stress and neutrophil accumulation after hindlimb IR in a rat model.