Visual Evaluation of Plethysmographic Waveforms: Introducing the Simple Systolic Ratio as an Indicator of Fluid Responsiveness.

Objective: For patient safety, maintaining hemodynamic stability during surgical procedures is critical. Dynamic indices [such as systolic pressure variation (SPV) and pulse pressure variation (PPV)], have recently seen an increase in use. Given the risks associated with such invasive techniques, there is growing interest in non-invasive monitoring methods-and plethysmographic waveform analysis. However, many such non-invasive methods involve intricate calculations or brand-specific monitors. This study introduces the simple systolic ratio (SSR), derived from pulse oximetry tracings, as a non-invasive method to assess fluid responsiveness. Methods: This prospective observational study included 25 adult patients whose SPV, PPV, and SSR values were collected at 30-min intervals during open abdominal surgery. The SSR was defined as the ratio of the tallest waveform to the shortest waveform within pulse tracings. The correlations among SSR, SPV, and PPV were analyzed. Additionally, anaesthesia specialists visually assessed pulse oximetry tracings to determine fluid responsiveness using the SSR method. Results: Strong correlations were observed between SSR and both SPV (r = 0.715, P < 0.001) and PPV (r = 0.702, P < 0.001). Receiver operator curve analysis identified optimal SSR thresholds for predicting fluid responsiveness at 1.47 for SPV and 1.50 for PPV. A survey of anaesthesia specialists using the SSR method to visually assess fluid responsiveness produced an accuracy rate of 83%. Conclusion: Based on the strong correlations it exhibits with traditional markers, SSR has great potential as a clinical tool, especially in resource-limited settings. However, further research is needed to establish its role, especially as it pertains to its universal applicability across monitoring devices.

Evaluation of brachial plexus stiffness in different arm and head positions by sonoelastography.

Intraoperative positioning-related nerve injuries, particularly those affecting the brachial plexus, are concerning complications believed to arise from stretching and/or compression of peripheral nerves. Although sonoelastography, a new ultrasound technology, is emerging as a valuable tool in the musculoskeletal system, its utility in evaluating peripheral nerves remains unclear. This study aimed to utilize sonoelastography to assess the brachial plexus during surgery, specifically investigating changes in its stiffness values in relation to different head and arm positions. In this prospective cohort study, bilateral brachial plexuses of 8 volunteers in 3 different positions were enrolled. Using a high-frequency linear probe, the stiffness of the brachial plexus was quantitatively measured in kilopascals (kPa) under 3 different positions: neutral, head rotated, and head rotated with arm hyperabducted. Intra-class agreement was evaluated. The stiffness of the brachial plexus was 7.39 kPa in the neutral position (NP), 10.28 kPa with head rotation, and 17.24 kPa when the head was turned, and the ipsilateral arm was hyperabducted. Significant increases were observed in stiffness values when the head was turned, whether ipsilaterally or contralaterally, and during hyperabduction of the arm while the head was turned (for all P < .001). Strong intra-class correlations were found for the measurements of stiffness values (ICC = 0.988-0.989; P < .001; Cronbach Alpha = 0.987-0.989). Sonoelastography revealed significant increases in the stiffness of the brachial plexus with various head rotations and arm positions compared to the neutral state. These findings suggest that sonoelastography could potentially serve as a valuable tool for assessing the risk of brachial plexus injury during surgery and for guiding optimal patient positioning. Further research with larger sample sizes is needed to establish definitive clinical applications.

The effect of erector spinae plane block on arterial grafts in coronary artery bypass grafting.

Background: This study aims to evaluate the sympathectomy effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and of the radial arteries. Methods: This prospective study included a total of 25 patients (14 males, 11 females; median age: 67 years; range, 23 to 75 years) who underwent erector spinae plane block categorized as the American Society of Anesthesiologists Class III and underwent off-pump coronary artery bypass grafting between June 01, 2020 and March 01, 2021. The effects of erector spinae plane block on the diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries were assessed using ultrasonography images taken both before and 45 min after the procedure, from the third, fourth, and fifth intercostal spaces for the left and right internal mammary arteries and from 3 cm proximal to the wrist for the radial arteries. Results: The diameters and cross-sectional areas of the left and right internal mammary arteries and radial arteries significantly increased compared to baseline values after the erector spinae plane block (p<0.05). There was no significant difference in the pre- and post-procedural heart rate and mean arterial pressure values (p>0.05). Conclusion: The bilateral erector spinae plane block, which was performed at the T5 level, provided vasodilatation of the left and right internal mammary arteries and radial arteries without causing any significant difference in the heart rate and mean arterial pressure. These findings indicate that the sympathetic block produced by the erector spinae plane block may facilitate better surgical conditions by preventing arterial spasms. Thus, bilateral erector spinae plane block may be a promising technique to achieve regional anesthesia for off-pump coronary artery bypass grafting.

[Infraclavicular block for elbow surgery in a patient with pneumonectomy: Case report]. / Pnömonektomili bir hastada dirsek cerrahisi için infraklavikular blok uygulamasi: Olgu sunumu.

Diaphragmatic paralysis is one of the most important complications of upper extremity blocks and therefore limits the use of these blocks in patients with impaired respiratory functions. The appropriate block type should be selected by evaluating the location of the surgery and the risks of diaphragmatic paralysis of various blocks. In this case report, we aimed to evaluate the peripheral nerve blocks associated with diaphragmatic paralysis by presenting the anesthesia management of a patient with pneumonectomy planned for elbow arthroplasty due to elbow luxation.

As a Rare Reason of Alveolar Consolidation, Negative Pressure Pulmonary Edema: Case Report.

In this paper we describe two cases with negative pressure pulmonary edema (NPPE). Excessive negative airway pressures against an obstructed airway has been reported to cause fluid filtration into alveoli and lung edema. The patients are generally young adults without any medical problems. The condition involves central interstitial area of both lungs and is treated by nonnvasive mechanical ventilation and corticosteroids.

A Randomized, Placebo-Controlled, Double-Blind Study that Evaluates Efficacy of Intravenous Ibuprofen and Acetaminophen for Postoperative Pain Treatment Following Laparoscopic Cholecystectomy Surgery.

BACKGROUND: Ibuprofen is a NSAID that has anti-inflammatory, antipyretic, and analgesic effects. The oral form of the drug has been used safely for a long time and is one of the most preferred NSAIDs. It has been shown that ibuprofen is effective in the treatment of postoperative pain; however, there have not been sufficient studies on ibuprofen. We evaluated and compared the influence of IV forms of ibuprofen and acetaminophen on pain management and opioid consumption on patients undergoing laparoscopic cholecystectomy surgery. METHODS: Patients were stratified into three groups. Group I (group ibuprofen, n = 30) was administered 800 mg of IV ibuprofen; group A (group acetaminophen, n = 30) was administered 1000 mg of IV acetaminophen; and group C (control group, n = 30) was given 100 ml of saline solution. We evaluated opioid consumption and VAS scores postoperatively. RESULTS: Pain scores in group I and group A at all time periods were lower than those in group C (p < 0.05). Group I had significantly lower VAS scores than those in group A at all time periods postoperatively (p < 0.05). Those in group C had significantly higher opioid consumption than the other groups (p < 0.05). Opioid consumption in group I at all time periods postoperatively was significantly lower than those in group A (p < 0.05). Group I had statistically lower rescue medication than the other groups at all time periods. CONCLUSION: Our study suggested that IV ibuprofen resulted in lower pain scores and reduced opioid use compared with acetaminophen postoperatively in the first 24 h in patients undergoing laparoscopic cholecystectomy surgery.

The Efficacy of Different Volumes on Ultrasound-Guided Type-I Pectoral Nerve Block for Postoperative Analgesia After Subpectoral Breast Augmentation: A Prospective, Randomized, Controlled Study.

BACKGROUND: PECS type-1 block, a US-guided superficial interfacial block, provides effective analgesia after breast surgery. Aesthetic breast augmentation is one of the most common surgical procedures in plastic surgery. Subpectoral prostheses cause severe pain. The aim of this study was to investigate the effect of different volumes of the solution on the efficacy of PECS type-I block for postoperative analgesia after breast augmentation surgery. METHODS: Ninety ASA status I-II female patients aged between 18 and 65 years who scheduled breast augmentation surgery under general anesthesia were included in this study. The patients were randomly divided into three groups of 30 patients each (Group 20 = 20 ml of anaesthetic solution, Group 30 = 30 ml anaesthetic solution, and Group K = Control group). Postoperative assessment was performed using the VAS score. The VAS scores were recorded postoperatively at 1, 2, 4, 8, 16 and 24 h. RESULTS: Fentanyl consumption was statistically significantly lower in Group 20 and Group 30 compared to the Control group (p < 0.05). There was no statistically significant difference in fentanyl consumption between Group 20 and Group 30. The right and left VAS scores were statistically significantly lower in Groups 20 and 30 than in the Control group (p < 0.05). There was no statistical difference in terms of VAS scores between Group 20 and Group 30. The use of rescue analgesia was statistically lower in Groups 20 and 30. CONCLUSIONS: PECS type-1 block using 20 ml of 0.25% bupivacaine can provide effective analgesia after breast augmentation surgery. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluation of pain scoring and free cortisol levels of postoperative analgesic methods in cardiac surgery: A new perspective.

BACKGROUND: This study aims to evaluate the most appropriate analgesic method of minimizing postoperative pain to prevent complications in patients scheduled for cardiac surgery. METHODS: Between January 2016 and June 2016, a total of 60 patients with the American Society of Anesthesiologists Physical Status Class III (27 males, 33 females; mean age 63 years; range, 49 to 77 years) with an ejection fraction of above 50% who underwent elective coronary artery bypass grafting were included. The patients were divided into two groups following admission to the intensive care unit. Group 1 (n=30) was administered intravenous fentanyl citrate with patient-controlled analgesia protocol, while Group 2 (n=30) was administered 0.1% bupivacaine hydrochloride analgesia protocol with catheter placed between the sternum and subcutaneous tissue. RESULTS: In Group 1, pain intensity scores at two h and visual analog scale scores except at 24, 36, and 48 h were higher than Group 2 (p<0.05). The length of intensive care unit stay and urine cortisol levels were higher in Group 1 than Group 2 (78±12 h and 631±505 ?g at 24 h vs. 66±13 h and 401±297 ?g at 24 h, respectively p<0.05). Partial pressure of oxygen levels at 10 and 16 h during the postoperative intensive care unit stay were lower, while partial pressure of carbon dioxide levels at 24 h was higher in Group 1 than Group 2 (p<0.05). CONCLUSION: The bupivacaine protocol is a relatively more useful analgesic method which produces improved results in blood gas analysis by reducing the effects of pain and shortens the length of intensive care unit stay. Low levels of free cortisol also confirm this finding.

Comparison of Intravenous Ibuprofen and Paracetamol for Postoperative Pain Management after Laparoscopic Sleeve Gastrectomy. A Randomized Controlled Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is defined as the first-step bariatric surgery for the treatment of obesity. Opioid analgesics are often preferred for pain management because of their strong analgesic potentials. However, opioids have undesirable adverse effects. OBJECTIVES: The objective of this study is to evaluate and compare the influence of IV forms of ibuprofen and paracetamol on pain management and opioid consumption on patients undergoing LSG surgery. SETTING: This study was conducted at Istanbul Medipol University Hospital. METHODS: Patients were stratified into three groups. Group I (group ibuprofen, n = 30) was administered 800 mg of IV ibuprofen, group P (group paracetamol, n = 30) was administered 1000 mg of IV paracetamol, and group C (control group, n = 30) was given 100 ml of saline solution. We evaluated opioid consumption and VAS scores postoperatively. RESULTS: This study included 90 patients who underwent LSG. The use of rescue medication in group I was statistically lower than the other groups. VAS scores in group I and group P at recovery and at 2, 4, 8, 12, and 24 h were lower than those in group C. In particular, the VAS scores in group I at the first 2 h postoperatively were significantly lower than those in group P (p < 0.05). Opioid consumption in group C was significantly higher than the other groups (p < 0.05). CONCLUSION: Our study suggested that IV ibuprofen resulted in lower pain scores compared to paracetamol by reducing postoperative opioid use in the first 24 h in patients undergoing LSG surgery.

Comparison of the Trendelenburg position versus upper-limb tourniquet on internal jugular vein diameter.

BACKGROUND: Central venous cannulation is a necessary invasive procedure for fluid management, haemodynamic monitoring and vasoactive drug therapy. The right internal jugular vein (RIJV) is the preferred site. Enlargement of the jugular vein area facilitates catheterization and reduces complication rates. Common methods to enlarge the RIJV cross-sectional area are the Trendelenburg position and the Valsalva maneuver. OBJECTIVE: Compare the Trendelenburg position with upper-extremity venous return blockage using the tourniquet technique. DESIGN: Prospective clinical study. SETTING: University hospital. SUBJECTS AND METHODS: Healthy adult volunteers (American Society of Anesthesiologists class I) aged 18-45 years were included in the study. The first measurement was made when the volunteers were in the supine position. The RIJV diameter and cross-sectional area were measured from the apex of the triangle formed by the clavicle and the two ends of the sternocleidomastoid muscle, which is used for the conventional approach. The second measurement was performed in a 20° Trendelenburg position. After the drainage of the veins using an Esbach bandage both arms were cuffed. The third measurement was made when tourniquets were inflated. MAIN OUTCOME MEASURE(S): Hemodynamic measurements and RIJV dimensions. RESULTS: In 65 volunteers the diameter and cross-sectional area of the RIJV were significantly widened in both Trendelenburg and tourniquet measurements compared with the supine position (P < .001 for both measures). Measurements using the upper extremity tourniquet were significantly larger than Trendelenburg measurements (P=.002 and < .001 for cross-sectional area and diameter, respectively). CONCLUSION: Channelling of the upper-extremity venous return to the jugular vein was significantly superior when compared with the Trendelenburg position and the supine position. LIMITATIONS: No catheterization and study limited to healthy volunteers.

Pheniramine Maleate is more effective than Lidocaine on Fentanyl Induced Cough.

OBJECTIVE: Fentanyl is frequently used during anesthesia induction. The use of fentanyl can cause cough through different mechanisms. Here, we aimed to investigate effects of pheniramine maleate (PM), an antihistaminic agent, and compare it with lidocaine on fentanyl induced cough. METHODS: This is a randomized double-blind prospective clinical study of ASA I-II, 120 patients scheduled for elective abdominal surgery. Patients were administered drugs intravenously and randomly allocated into three groups: Group C (2 ml 0.9 % normal saline), Group L (1mg/kg lidocaine), and Group F (PM 45.5 mg). 90 seconds after administration, 2µ/kg fentanyl was applied in three seconds to all patients. Severity of cough (mild: 1-2, moderate: 3-5, severe> 5), time of the cough and vital parameters were recorded 90 seconds after fentanyl injection. RESULTS: Eight patients (25%) in Group C had fentanyl induced cough whereas three patients (7.5%) in Group L and one patient (2.5%) in Group F experienced this phenomenon. There was statistically significant difference between Group F and Group C (p<0.05); however, differences between Group L and Group C or Group F and Group L were not statistically significant (p>0.05). CONCLUSIONS: Pheniramine Maleate 45.5 mg is better that placebo and as effective as lidocaine to prevent fentanyl induced cough.

Tetanus is still a deadly disease: a report of six tetanus cases and reminder of our knowledge.

We analysed the data in the medical records of six patients admitted for tetanus in the intensive care unit (ICU) of the anaesthesia department in the Medical Faculty of Ataturk University from 1 January 2010 to 31 December 2012. All patients received the generalized form of treatment for tetanus in the ICU. The average age of the patients was 65.33 ± 13.45 years. Treatment modalities were administered to the patients in accordance with the literature. Four patients died despite all therapeutic interventions and two patients were discharged uneventfully. All those who died had chronic disease and infected wounds on their head, but only one patient had an infected wound on his leg. The surviving patients had no chronic illnesses but did have injuries on their legs. The presence of chronic disease increases tetanus-related mortality. More information about the disease must be made available in order to make it preventable with regular vaccinations.