Diaphragm and Lung Ultrasonography During Weaning From Mechanical Ventilation in Critically Ill Patients.

AIM: Optimum timing is crucial to avoid negative outcomes of weaning. We aimed to investigate predictive values of diaphragmatic thickening fraction (DTF), diaphragmatic excursion (DE), and anterolateral lung ultrasound (LUS) scores in extubation success and compare with rapid shallow breathing index (RSBI) in patients extubated under traditional parameters. METHODS: Patients undergoing mechanical ventilation for >48 hours were included in the study. In patients planned for extubation, sonographic evaluations of the diaphragm and lung were performed at the T-tube stage. RSBI was achieved in the pressure support (PS) ventilation stage. Predictive values of DTF, DE, and anterolateral LUS scores were compared with RSBI in extubation success. RESULTS: Sixty-two patients were enrolled in the study. The study population consisted mostly of trauma patients (77%). A cut-off value of 64 was obtained for RSBI. The positive predictive value (PPV) was found at 97% in extubation success. Cut-off values of 27.5 for DTF, 1.3 cm for the DE, and 6.5 for LUS scores were obtained at the T-tube stage, respectively. PPVs of all sonographic parameters were found over 90%. At the first stage, weaning and extubation failures were determined as 35 and 9.6%, respectively. RSBI was found as a powerful parameter in determining extubation success (r=0.774, p≤0.001) and moderately correlated with sonographic parameters. CONCLUSION: Investigating the lung and diaphragm via ultrasound provides real-time information to increase extubation success. Cut-off values of 64 for RSBI, 27.5 for DTF, 1.3 cm for the DE, and 6.5 for LUS scores were obtained, respectively, and PPVs of all sonographic parameters were found over 90%. We consider that sonographic evaluations accompanied by an RSBI will increase extubation success in the weaning process.

The Potential Effect of Epidural Anesthesia on Mesenteric Injury after Supraceliac Aortic Clamping in a Rabbit Model.

BACKGROUND: Epidural anesthesia is known to increase blood flow by producing vasodilatation on mesenteric circulation. In this experimental study, we aim to examine the effect of epidural anesthesia on mesenteric ischemic-reperfusion (IR) injury induced by supracoeliac aortic occlusion in a rabbit model. METHODS: Twenty-eight male white New Zealand rabbits were assigned into 4 separate groups, with 7 rabbits in each group: group I, control group; group II, IR-only group; group III, IR plus epidural anesthesia group; group IV, epidural anesthesia-only group. IR model was produced by clamping supraceliac aorta with an atraumatic vascular clamp for 60 min, followed by reperfusion for 120 min. An epidural catheter was placed via Th12-L1 intervertebral space by using open technique before aortic clamping in those assigned to epidural anesthesia. IR injury was assessed using blood markers interleukin-6 and IMA and tissue markers superoxide dismutase and malondialdehyde. Also histopathological examination was performed to evaluate the degree of injury. RESULTS: All biochemical markers in group II were significantly elevated in comparison with the other 3 groups (p < 0.05). This was paralleled by a more severe histopathological injury in IR- only group (group II). The group receiving IR plus epidural anesthesia (group III) had lower biochemical marker levels as compared with the IR-only group (group II). CONCLUSIONS: Mesenteric IR injury that can occur during abdominal aorta surgery can be reduced by epidural anesthesia, which is commonly used during or after major operations for pain control. Controlled clinical studies are required to evaluate these findings.

Hemodynamic responses to endotracheal intubation performed with video and direct laryngoscopy in patients scheduled for major cardiac surgery.

This study aims to compare the hemodynamic responses to endotracheal intubation performed with direct and video laryngoscope in patients scheduled for cardiac surgery and to assess the airway and laryngoscopic characteristics. One hundred ten patients were equally allocated to either direct Macintosh laryngoscope (n = 55) or indirect Macintosh C-MAC video laryngoscope (n = 55). Systolic, diastolic, and mean arterial pressure, and heart rate were recorded prior to induction anesthesia, and immediately and two minutes after intubation. Airway characteristics (modified Mallampati, thyromental distance, sternomental distance, mouth opening, upper lip bite test, Wilson risk sum score), mask ventilation, laryngoscopic characteristics (Cormack-Lehane, percentage of glottic opening), intubation time, number of attempts, external pressure application, use of stylet and predictors of difficult intubation (modified Mallampati grade 3-4, thyromental distance < 6 cm, upper lip bite test class 3, Wilson risk sum score ≥ 2, Cormack-Lehane grade 3-4) were recorded. Hemodynamic parameters were similar between the groups at all time points of measurement. Airway characteristics and mask ventilation were no significant between the groups. The C-MAC video laryngoscope group had better laryngoscopic view as assessed by Cormack-Lehane and percentage of glottic view, and a longer intubation time. Number of attempts, external pressure, use of stylet, and difficult intubation parameters were similar. Endotracheal intubation performed with direct Macintosh laryngoscope or indirect Macintosh C-MAC video laryngoscope causes similar and stable hemodynamic responses.

Acute Pancreatitis Due to Hypertriglyceridaemia in Pregnancy.

Acute pancreatitis due to hypertriglyceridaemia during pregnancy is a rare but severe clinical condition that may cause fatal results for both the mother and the foetus. Acute pancreatitis developed in a 37-year-old pregnant woman with familial hypertriglyceridaemia and diabetes mellitus in the 31(st) week of pregnancy. As intrauterine foetal death developed, the pregnancy of the patient was terminated. Additionally, insulin, octreotide and plasmapheresis with "double membrane filtration" were applied, and triglycerides rapidly decreased. After 24 hours, the level of triglycerides decreased from 9742 mg dL(-1) to 432 mg dL(-1). The patient was discharged from the intensive care unit at the end of 5 days and was discharged from the hospital after 32 days. The current article presents the successful treatment of severe hypertriglyceridaemia in a pregnant case.

Comparison of the effect of the Trendelenburg and passive leg raising positions on internal jugular vein size in critically ill patients.

Central vein catheterization is a common procedure performed on patients under intensive care. The safe and successful placement of the central venous catheter depends on vein size. Although used for this purpose, the Trendelenburg position can be hazardous in some patients. The aim of this study was to compare the effects of the Trendelenburg and passive leg raising (PLR) positions on the size of the right internal jugular vein (IJV) in mechanically ventilated patients under intensive care. Seventy-eight mechanically ventilated patients under intensive care were included into the study. Sonographic images of the right IJV were recorded in supine (control), 10° Trendelenburg and 40° PLR positions. Anterior-posterior and transverse diameter, cross-sectional area (CSA), and depth were calculated from the recorded images. The size of the right IJV (CSA, transverse and vertical diameters) was significantly larger in the Trendelenburg and PLR positions than in supine position. An increase of 26% in the IJV CSA was obtained in the Trendelenburg position and 23% in the PLR position, compared to the supine position. There was no significant difference between the measurements obtained from the Trendelenburg and PLR positions. The study shows that the Trendelenburg and PLR positions increase the size of the IJV to a similar extent in mechanically ventilated patients under intensive care.

Determination of optimum time for intravenous cannulation after induction with sevoflurane and nitrous oxide in children premedicated with midazolam.

BACKGROUND: It has been shown that early placement of an intravenous line in children administered sevoflurane anesthesia increased the incidence of laryngospasm and movement. However, the optimal time for safe cannulation after the loss of the eyelash reflex during the administration of sevoflurane and nitrous oxide is not known. AIM: The aim of the study was to determine the optimum time for intravenous cannulation after the induction of anesthesia with sevoflurane and nitrous oxide in children premedicated with oral midazolam. METHOD: We performed a prospective, observer-blinded, up-down sequential, allocation study, and children, aged 2-6 years, ASA physical status I, scheduled for an elective procedure undergoing inhalational induction were included in the study. Anesthesia was induced with sevoflurane and nitrous oxide after premedication with oral midazolam. For the first child, 4 min after the loss of the eyelash reflex, the intravenous cannulation was attempted by an experienced anesthesiologist. The time for intravenous cannulation was considered adequate if movement, coughing, or laryngospasm did not occur. The time for cannulation was increased by 15 s if the time was inadequate in the previous patient, and conversely, the time for cannulation was decreased by 15 s if the time was adequate in the previous patient. The probit test was used in the analysis of up-down sequences. RESULTS: A total of 32 children were enrolled sequentially during the study period. The adequate time for effective intravenous cannulation after induction with sevoflurane and nitrous oxide in 50% and 95% of patients were 1.29 min (95% confidence interval, 0.96-1.54 min) and 1.86 min (95% confidence interval 1.58-4.35 min), respectively. CONCLUSION: We recommend waiting 2 min for attempting intravenous placement following the loss of the eyelash reflex in children sedated with midazolam and receiving an inhalation induction with sevoflurane and nitrous oxide.

Anaesthetic Management of a Child with Limb-Girdle Muscular Dystrophy.

Limb-girdle muscular dystrophies are a group of disorders with wide genetic and clinical heterogeneity. These disorders may lead to an increase in life-threatening complications related to surgery and anaesthesia. In this case, the anaesthetic management of a child with limb-girdle muscular dystrophy is presented.

Use of remifentanil in a patient with Eisenmenger syndrome requiring urgent cesarean section.

We describe a case of 41-yr.-old multigravida at 35 weeks gestation, with a diagnosis of Eisenmenger syndrome, requiring urgent Cesarean section. The parturient had signs and symptoms of respiratory distress due to high pulmonary artery pressure, and the pregnancy was complicated by preeclampsia. A general anesthetic consisting of ketamine and etomidate and an intravenous infusion of remifentanil were used to provide stable anesthesia and analgesia for a successful delivery. The baby was delivered with high Apgar scores. The potential benefits and safety of the use of remifentanil in parturients with high pulmonary artery pressures are discussed.

Successful mitral valve surgery in a patient with myasthenia gravis.

Myasthenia gravis (MG) is an autoimmune disease characterized by a weakness of the muscles with remissions and exacerbations due to antibodies against acetylcholine receptors. Most of the patients die because of a respiratory failure toward the end of the disease. A 49-year-old male patient with MG in whom a thymectomy operation had been performed five years ago had dyspnea, palpitation, and chest pain during his admission. After his examination, a severe mitral regurgitation was detected, and he underwent a successful mitral valve replacement. A general anesthesia management was performed using sufentanyl and propophol without any muscle relaxant agent. He was extubated seven hours after the surgery. He had difficulty in swallowing at postoperative day three, and his medication doses were increased. He was discharged from the hospital at postoperative day seven without any complication. MG is a rare disease and may cause morbid complications during the cardiac surgery, but can be successfully managed.

Surgical treatment of postinfarction pseudoaneurysms of the left ventricle.

BACKGROUND: Left ventricular pseudoaneurysm is a rare and frequently fatal complication of acute myocardial infarction. It occurs as a consequence of rupture of the ventricular free wall that gets confined by a portion of the pericardium. The purpose of this study was to present our surgical experience of postinfarction left ventricular pseudoaneurysms and to evaluate mid-term results. METHODS: The study population comprised five symptomatic patients diagnosed with left ventricular pseudoaneurysm and treated surgically in a short period of time. There were three males and two females. The mean age of the patients was 66.8 +/- 10.8 years. The diagnosis was made initially by echocardiography and subsequently confirmed by angiography. An additional cardiac magnetic resonance imaging study was performed in three patients. Surgical resection of the pseudoaneurysm was combined with an endoaneurysmorrhaphy procedure in all patients. Associated cardiac operations were performed in three patients. Definitive diagnosis of pseudoaneurysm was confirmed by histopathological evaluation of the excised wall in all patients. RESULTS: All patients survived the operation and were discharged to home care. The mean duration of hospital stay was 11.6 +/- 4.6 days. Patients were either in class I or II of New York Heart Association classification at discharge. All patients are still being followed after surgery with a mean follow-up period of 10.4 +/- 6.6 months with no further problems. CONCLUSION: Surgical repair is indicated in left ventricular pseudoaneurysm as it carries a high risk of rupture and sudden cardiac death. Surgical repair combined with an endoaneurysmorrhaphy procedure carries a low mortality risk and improves functional capacity.

A comparative study of the effect of rofecoxib (a COX 2 inhibitor) and naproxen sodium on analgesic requirements after abdominal hysterectomy.

This study evaluated the analgesic efficacy of administering preoperatively rofecoxib or naproxen sodium to patients undergoing abdominal hysterectomy. A randomized, double-blinded prospective study was conducted with 60 women undergoing elective abdominal hysterectomy under general anesthesia. Patients were randomly allocated into one of three equally sized groups. Patients in the first group received rofecoxib 50 mg 1 h before operation (group R), patient in the second group received naproxen sodium 550 mg 1 h before surgery (group N) and patients in the third group received a placebo tablet in the same time (group P). Total amount of used morphine mixture was higher in placebo group (93+/-6 ml) than in the group R (50+/-4 ml) and group N (64+/-6 ml). There were significant difference for total amount of used morphine mixture between group P and other two groups. There was significant difference in the volumes of morphine mixture used in the first 12 h in group P and other two groups. The occurrence of side effects such as, dyspepsia, epigastric discomfort, heartburn, were similar in group R and group P. However, this side effects were increased in group N. Rofecoxib receiving preoperatively was provided clinical efficacy for postoperative pain control and well tolerated for gastrointestinal side effects comparable with naproxen sodium.