Half-Dose Sugammadex After Neostigmine Versus Neostigmine as a Routine Reversal Agent: A Pilot Randomized Trial.

PURPOSE: The use of sugammadex at a lower dose after a routine reversal dose of neostigmine may prevent residual neuromuscular blockade (rNMB). Our goal was to investigate the effects of the use of half-dose sugammadex for reversing rNMB after administration of neostigmine, and compare these effects to a routine full-dose of neostigmine. DESIGN: Prospective, single-blinded, randomized trial. METHODS: Ninety-eight patients having lower abdominal tumor resection surgery under general anesthesia were randomized into two groups. Group N (Neostigmine) (n = 48) patients received standard reversal dose of intravenous neostigmine 0.05 mg/kg and atropine 0.02 mg/kg before extubationl Group N + S (Neostigmine + Sugammadex) (n = 50) patients received 1 mg/kg of intravenous sugammadex three minutes after a standard neostigmine reversal dose. The primary end-point was the incidence of a train-of-four (TOF) ratio less than 0.9 at tracheal extubation. Secondary end-points were periods between the start of administration of reversal agents and extubation or operating room discharge in minutes to achieve recovery of TOF ratio < 0.9 to 0.7 and TOF ratio ≥ 0.9. FINDINGS: The demographic data were not different between the two groups (P > .005). The incidence of rNMB presented as TOF ratio < 0.9 to 0.7 was present in 52% of Group N patients compared to 8% in Group N + S patients (P < .0001). The time to recovery between administering reversal and extubation as well as operating room discharge in Group N were; 18.52 ± 6.34 minutes and 23.27 ± 6.95 minutes, respectively, whereas; in Group N + S, they were; 12.86 ± 5.05 and 17.82 ± 4.99 minutes, respectively. (P < .0001, P < .0001, respectively). Adverse events were similar between groups (P > .05). CONCLUSIONS: A half-dose sugammadex (1 mg/kg) after full-dose reversal of neostigmine provides a lower incidence of rNMB and shorter recovery times as compared to full-dose neostigmine reversal agent. This practice is safe and effective in case of rNMB.

The use of oxygen reserve index in one-lung ventilation and its impact on peripheral oxygen saturation, perfusion index and, pleth variability index.

BACKGROUND: Our goal is to investigate the use of the oxygen reserve index (ORi) to detect hypoxemia and its relation with parameters such as; peripheral oxygen saturation, perfusion index (PI), and pleth variability index (PVI) during one-lung ventilation (OLV). METHODS: Fifty patients undergoing general anesthesia and OLV for elective thoracic surgeries were enrolled in an observational cohort study in a tertiary care teaching hospital. All patients required OLV after a left-sided double-lumen tube insertion during intubation. The definition of hypoxemia during OLV is a peripheral oxygen saturation (SpO2) value of less than 95%, while the inspired oxygen fraction (FiO2) is higher than 50% on a pulse oximetry device. ORi, pulse oximetry, PI, and PVI values were measured continuously. Sensitivity, specificity, positive and negative predictive values, likelihood ratios, and accuracy were calculated for ORi values equal to zero in different time points during surgery to predict hypoxemia. At Clinicaltrials.gov registry, the Registration ID is NCT05050552. RESULTS: Hypoxemia was observed in 19 patients (38%). The accuracy for predicting hypoxemia during anesthesia induction at ORi value equals zero at 5 min after intubation in the supine position (DS5) showed a sensitivity of 92.3% (95% CI 84.9-99.6), specificity of 81.1% (95% CI 70.2-91.9), and an accuracy of 84.0% (95% CI 73.8-94.2). For predicting hypoxemia, ORi equals zero show good sensitivity, specificity, and statistical accuracy values for time points of DS5 until OLV30 where the sensitivity of 43.8%, specificity of 64%, and an accuracy of 56.1% were recorded. ORi and SpO2 correlation was found at DS5, 5 min after lateral position with two-lung ventilation (DL5) and at 10 min after OLV (OLV10) (p = 0.044, p = 0.039, p = 0.011, respectively). Time-dependent correlations also showed that; at a time point of DS5, ORi has a significant negative correlation with PI whereas, no correlations with PVI were noted. CONCLUSIONS: During the use of OLV for thoracic surgeries, from 5 min after intubation (DS5) up to 30 min after the start of OLV, ORi provides valuable information in predicting hypoxemia defined as SpO2 less than 95% on pulse oximeter at FiO2 higher than 50%.

The Comparison of Two Different Techniques of Remifentanil Administration During Implantable Vascular Access Device Procedures.

PURPOSE: The aim was to compare analgesic efficacy and adverse effects of two different techniques of intravenous remifentanil administration in patients undergoing vascular; access device procedures with monitored anesthesia care. DESIGN: A randomized, single-blinded controlled study. METHODS: The patients (N = 92) were 30-80 years old and of American Society of Anesthesiologists Physical Status I-III. The first group was the continuous infusion group (group CI). Intravenous continuous remifentanil was infused after starting at a dosage of 0.1 mcg/kg/min, and the dose was raised incrementally up to 1 mcg/kg/min if required. The second group was intravenous bolus patient-controlled sedation analgesia (PCSA) with remifentanil infusion at a dose of 0.05 mcg/kg per minute and bolus of 0.1 mcg/kg with lock-out time of 3 minutes. In both groups, a bolus dose of 0.1 mcg/kg remifentanil was administered. The data evaluated include level of pain and sedation, total amount of remifentanil consumption, bolus doses of remifentanil, patient and surgeon satisfaction, hemodynamic data, and adverse events. FINDINGS: In comparison between techniques, pain and sedation scores during procedure, duration of procedure, patient and surgeon satisfaction, additional rescue medication, and bolus doses were not statistically different (P > .05). The total amount of remifentanil administered was significantly lower in the infusion group than that in the bolus group (P = .031). CONCLUSIONS: For central venous access device procedures under monitored anesthesia care, remifentanil use in both infusion and bolus techniques could provide sufficient sedation and analgesia without serious adverse effects. Total remifentanil consumption amount in infusion group is lower than that in the bolus group.

Levosimendan improves renal outcome in cardiac surgery: a randomized trial.

OBJECTIVE: The effect of levosimendan on renal function in patients with low ejection fraction undergoing mitral valve surgery was investigated. DESIGN: A prospective, double-blinded, randomized clinical trial. SETTING: Tertiary teaching and research hospital. PARTICIPANTS: Of a total of 147 patients, 128 patients completed the study. In the levosimendan group (n = 64), levosimendan was administered in addition to standard inotropic support; whereas, in the control group (n = 64), only standard inotropic support was given. INTERVENTIONS: In the levosimendan group, a loading dose of levosimendan (6 µg/kg) was administered after removal of the aortic cross-clamp, followed by an infusion (0.1 µg/kg/min) in addition to standard inotropic therapy for 24 hours. In the control group, only standard inotropic therapy was administered. Preoperative characteristics, serum creatinine (sCr) levels, and estimated glomerular filtration rate (eGFR) were determined preoperatively, on postoperative days 1, 3, and 10. Independent risk factors for renal replacement therapy (RRT) requirement were investigated with stepwise multivariate logistic regression analysis. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the effect of levosimendan on postoperative renal clearance (sCr and eGFR). The secondary endpoint was the effect of levosimendan on clinical outcomes (length of intensive care unit and hospital stays, need for RRT). Preoperative characteristics and eGFR were similar between the groups (p>0.05). On postoperative days 1 and 3, sCr values were lower and eGFR values were higher in the levosimendan group in comparison with the control group (p = 0.0001, p = 0.009, respectively). Six patients (9.4%) in the levosimendan group and 10 patients (15.6%) in the control group required RRT therapy (p = 0.284). Independent risk factors for need of RRT include preoperative sCr value between 1.2 to 2.09 mg/dL and≥2.1 mg/dL (p< 0.05). CONCLUSIONS: Perioperative treatment with levosimendan in addition to standard inotropic therapy in patients with a low ejection fraction undergoing mitral valve surgery improved immediate postoperative renal function and reduced need for RRT.

A comparison of thoracic or lumbar patient-controlled epidural analgesia methods after thoracic surgery.

BACKGROUND: We aimed to compare patient-controlled thoracic or lumbar epidural analgesia methods after thoracotomy operations. METHODS: One hundred and twenty patients were prospectively randomized to receive either thoracic epidural analgesia (TEA group) or lumbar epidural analgesia (LEA group). In both groups, epidural catheters were administered. Hemodynamic measurements, visual analog scale scores at rest (VAS-R) and after coughing (VAS-C), analgesic consumption, and side effects were compared at 0, 2, 4, 8, 16, and 24 hours postoperatively. RESULTS: The VAS-R and VAS-C values were lower in the TEA group in comparison to the LEA group at 2, 4, 8, and 16 hours after surgery (for VAS-R, P = 0.001, P = 0.01, P = 0.008, and P = 0.029, respectively; and for VAS-C, P = 0.035, P = 0.023, P = 0.002, and P = 0.037, respectively). Total 24-hour analgesic consumption was different between groups (175 +/- 20 mL versus 185 +/- 31 mL; P = 0.034). The comparison of postoperative complications revealed that the incidence of hypotension (21/57, 36.8% versus 8/63, 12.7%; P = 0.002), bradycardia (9/57, 15.8% versus 2/63, 3.2%; P = 0.017), atelectasis (1/57, 1.8% versus 7/63, 11.1%; P = 0.04), and the need for intensive care unit (ICU) treatment (0/57, 0% versus 5/63, 7.9%; P = 0.03) were lower in the TEA group in comparison to the LEA group. CONCLUSIONS: TEA has beneficial hemostatic effects in comparison to LEA after thoracotomies along with more satisfactory pain relief profile.

The use of basic parameters for monitoring the haemodynamic effects of midazolam and ketamine as opposed to propofol during cardiac catheterization.

OBJECTIVE: Our aim is to compare the haemodynamic and adverse effects of propofol versus the mixture of midazolam and ketamine as used in sedation for cardiac catheterization in children. METHODS: In a prospective randomized trial, we divided patients needing sedation into 72 receiving a mixture of midazolam and ketamine and 42 receiving propofol. Their ages ranged from 6 months to 12 years, and 1 year to 16 years, respectively. We collected data relative to heart rate, mean arterial pressure, respiratory rate, peripheral saturations of oxygen, and adverse effects. We assessed cyanotic patients to establish any relationship between the haemodynamic data and peripheral arterial saturations of oxygen. RESULTS: Demographic data, including age, gender, and weight, was not statistically different between the groups. In those receiving midazolam and ketamine, mean systemic arterial pressures before, and 30 minutes after, sedation were 64.3, with standard deviation of 9.8, and 62.5, with standard deviation of 10.2, millimetre of mercury (p equals to 0.237). Heart rates were 131.3, with standard deviation of 13.5, and 109.2, with standard deviation of 17.3 beats per minute, (p less than 0.001) whereas in those given propofol the comparable values were 71.2, with standard deviation of 14.4, and 53.6 with standard deviation of 9.7 millimetres of mercury (p less than 0.001), and 115.2, with standard deviation of 13.6, and 100.5 with standard deviation of 20.1 beats per minute (p less than 0.01), respectively. Mean systemic arterial pressures in the subgroups of cyanotic patients before and 30 minutes after sedation were 74.8, with standard deviation of 14.6, and 72.7, with standard deviation of 12.4 millimetres of mercury for those receiving midazolam and ketamine (p equals to 0.544), and heart rates were 119.3, with standard deviation of 12.2, and 104.6 with standard deviation of 16.1 beats per minute (p equals to 0.001). In those given propofol, the comparable values were 71.1 with deviation of 15.5 and 53.9 with deviation of 9.2 millimetres of mercury (p equals to 0.001), and 126.7 with deviation of 20.8 and 107.2 with deviation of 13.5 beats per minute (p equals to 0.001), respectively. CONCLUSIONS: In cyanotic children, propofol used as a sedative agent during cardiac catheterization causes a decrease in mean arterial pressure and arterial desaturation. Ketamine produces more stable haemodynamic data in children with congenitally malformed hearts.

Antibacterial and antioxidant activity of essential oil terpenes against pathogenic and spoilage-forming bacteria and cell structure-activity relationships evaluated by SEM microscopy.

The antibacterial activity and antioxidant effect of the compounds α-terpineol, linalool, eucalyptol and α-pinene obtained from essential oils (EOs), against pathogenic and spoilage forming bacteria were determined. The antibacterial activities of these compounds were observed in vitro on four Gram-negative and three Gram-positive strains. S. putrefaciens was the most resistant bacteria to all tested components, with MIC values of 2% or higher, whereas E. coli O157:H7 was the most sensitive strain among the tested bacteria. Eucalyptol extended the lag phase of S. Typhimurium, E. coli O157:H7 and S. aureus at the concentrations of 0.7%, 0.6% and 1%, respectively. In vitro cell growth experiments showed the tested compounds had toxic effects on all bacterial species with different level of potency. Synergistic and additive effects were observed at least one dose pair of combination against S. Typhimurium, E. coli O157:H7 and S. aureus, however antagonistic effects were not found in these combinations. The results of this first study are encouraging for further investigations on mechanisms of antimicrobial activity of these EO components.

The use of posterior pericardiotomy technique to prevent postoperative pericardial effusion in cardiac surgery.

AIM: The goal was to determine the effectiveness of the posterior pericardiotomy technique in preventing the development of early and late pericardial effusions (PEs) and to determine the role of anxiety level for the detection of late pericardial tamponade (PT). MATERIALS AND METHODS: We divided 100 patients randomly into 2 groups, the posterior pericardiotomy group (n = 50) and the control group (n = 50). All patients undergoing coronary artery bypass grafting surgery (CABG), valvular heart surgery, or combined valvular and CABG surgeries were included. The posterior pericardiotomy technique was performed in the first group of 50 patients. Evaluations completed preoperatively, postoperatively on day 1, before discharge, and on postoperative days 5 and 30 included electrocardiographic study, chest radiography, echocardiographic study, and evaluation of the patient's anxiety level. Postoperative causes of morbidity and durations of intensive care unit and hospital stays were recorded. RESULTS: The 2 groups were not significantly different with respect to demographic and operative data (P > .05). Echocardiography evaluations revealed no significant differences between the groups preoperatively; however, before discharge the control group had a significantly higher number of patients with moderate, large, and very large PEs compared with the pericardiotomy group (P < .01). There were 6 cases of late PT in the control group, whereas there were none in the pericardiotomy group (P < .05). Before discharge and on postoperative day 15, the patients in the pericardiotomy group showed significant improvement in anxiety levels (P = .03 and .004, respectively). No differences in postoperative complications were observed between the 2 groups. CONCLUSION: Pericardiotomy is a simple, safe, and effective method for reducing the incidence of PE and late PT after cardiac surgery. It also has the potential to provide a better quality of life.

The effects of reactive hyperemia on stimulation of endothelium-derived nitric oxide in on-pump and off-pump coronary artery bypass surgeries.

The purpose of this study is to compare the effects of cardiopulmonary bypass (CPB) on the endothelium-derived nitric oxide (NO) levels in on-pump and off-pump coronary artery bypass surgeries. Forty consecutive patients were divided randomly into two groups depending on use of CPB in coronary artery bypass graft surgery (group 1: n = 20, off-pump, and group 2: n = 20, on-pump). The plasma endothelium-derived NO levels were determined at baseline and after reactive hyperemia before and after surgery. Reactive hyperemia was induced by inflating a blood pressure cuff placed on the upper forearm, for 5 min at 250 mm Hg followed by a rapid deflation. Blood was collected at 1 min after cuff deflation from the radial artery on the same side. Preoperative use of all medications was recorded. The baseline plasma NO levels before operation were 17.10 ± 7.58 in group 1 and 15.49 ± 5.26 nmol/L in group 2. Before operation after reactive hyperemia, the plasma NO levels were 26.97 ± 11.49 in group 1 and 26.57 ± 12.87 nmol/L in group 2. Two hours after surgery, the plasma NO levels at baseline and after reactive hyperemia were not significantly different from each other (group 1: 18.03 ± 6.37 and group 2: 19.89 ± 9.83 nmol/L; group 1: 27.89 ± 18.36 and group 2: 39.13 ± 23.60 nmol/L, respectively; P > 0.05). A positive correlation was shown between preoperative nitroglycerine use and the postoperative plasma NO levels after reactive hyperemia (r = 0.51, P = 0.001). Linear regression analysis was performed (F = 4.10, R = 0.56, R(2) = 0.32, P = 0.008) and the only independent parameter that had an effect on postoperative plasma NO levels after reactive hyperemia was found to be preoperative nitroglycerine use (t = 3.68, P = 0.001). Coronary artery bypass surgery with CPB does not have significant effect on plasma endothelial derived NO levels. The postoperative plasma NO levels after reactive hyperemia significantly correlated with preoperative nitroglycerine use.

The effect of cardiopulmonary bypass in coronary artery bypass surgeries (on-pump versus off-pump) on erectile function and endothelium-derived nitric oxide levels.

PURPOSE: To investigate the effects of on-pump and off-pump coronary artery bypass grafting (CABG) on the erectile function and endothelium-derived nitric oxide (eNO) levels. MATERIALS AND METHODS: Twenty-eight consecutive patients were randomized into two groups depending on use of cardiopulmonary bypass in CABG surgery. The erectile function was evaluated by using the IIEF-5 questionnaire. The plasma eNO levels were determined at baseline and after reactive hyperemia before and after surgery. Blood was collected in one minute after cuff deflation from the radial artery on the same side. RESULTS: After CABG surgery the mean IIEF-5 score increased insignificantly over baseline from 14.8 to 15.8 (p = 0.29) and 12.4 to 14.3 (p = 0.11) after on-pump and off-pump CABG surgeries, respectively. The baseline plasma NO levels before surgery were 18.16 ± 7.63 nmol/L in on-pump and 21.76 ± 11.08 nmol/L in off-pump CABG. After reactive hyperemia the plasma NO levels were 22.14 ± 10.52 nmol/L in on-pump and 21.49 ± 9.13 nmol/L in off-pump CABG before the surgery. The difference in the plasma NO levels before surgery was not significant (p = 0.51). Two hours after surgery, the difference of the plasma NO levels at baseline (24.44 ± 12.31 on -pump and 20.58 ± 6.74 nmol/L off-pump CABG) and after reactive hyperemia (35.55 ± 23.54 nmol/L on-pump and 23.00 ± 15.40 nmol/L off-pump CABG) were not significantly different from each other (p = 0.11). CONCLUSIONS: Patients who had on-pump or off-pump CABG surgeries had higher IIEF-5 scores. Nevertheless, the improvement was insignificant in both groups. Meanwhile, on-pump or off-pump CABG surgeries did not have significant effect on plasma eNO levels.

Investigation of Risk Factors Related to the Development of Hepatic Dysfunction in Patients with a Low and Moderate Cardiac Risk During Open-Heart Surgeries.

OBJECTIVE: To determine the possible risk factors associated with hepatic dysfunction during open-heart surgeries. METHODS: After excluding 71 patients, 307 patients with possible low and moderate cardiac risk who underwent either coronary artery bypass graft surgery (CABG) (n=176) or valve repair surgery (mitral valve, mitral and aortic valves and/or tricuspid valve) (n=131) were investigated prospectively during a 6-month period. Hyperbilirubinemia is defined as an occurrence of a plasma total bilirubin concentration >34 µmol/L (2 mg/dL) in any measurement during the postoperative period; the patients were divided into groups with or without postoperative hyperbilirubinemia. The collected parameters were: alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), total bilirubin (TBil), gamma-glutamyl transpeptidase (GGT) and albumin. The parameters were collected preoperatively and postoperatively on days 1, 3 and 7. Preoperative, intraoperative, and postoperative risk factors were investigated. Logistic regression analysis was performed to identify the risk factors for postoperative hyperbilirubinemia. RESULTS: Postoperative hyperbilirubinemia was observed in 7 of 176 patients (4%) who underwent CABG, and in 11 of 131 patients (8.4%) who underwent valve replacement surgeries. Independent risk factors for early postoperative hyperbilirubinemia were found as: ejection fraction (EF), aortic cross-clamp (ACC) time, intensive care unit stay and extubation time (P<0.001). In comparison to CABG procedures, postoperative hyperbilirubinemia was observed more frequently in patients undergoing valve surgeries (P=0.027). CONCLUSION: Low EF and prolonged ACC time are significant independent risk factors for early postoperative hyperbilirubinemia during open-heart surgeries with cardiopulmonary bypass. Valve surgeries show a higher incidence of hyperbilirubinemia in comparison to CABG.

Inactivation kinetics of Alicyclobacillus acidoterrestris spores in orange juice by ohmic heating: effects of voltage gradient and temperature on inactivation.

The effectiveness of ohmic and conventional heating for reducing spores of Alicyclobacillus acidoterrestris was investigated in commercial pasteurized orange juice. The kinetic parameters (D- and z-values) were determined during ohmic and conventional heating. The effects of temperature (70, 80, and 90 degrees C) and heating time (0, 10, 15, 20, and 30 min) on inactivation of A. acidoterrestris spores during ohmic heating in orange juice were significant (P < 0.05). For 70 degrees C, the voltage gradient also had an effect on inactivation kinetics. At 30 V/cm, D-values at 70, 80, and 90 degrees C were 58.48, 12.24, and 5.97 min, respectively. D-values at corresponding temperatures for conventionally heated spores were 83.33, 15.11, and 7.84 min, respectively. Results showed significantly higher lethality for spores treated with ohmic heating than for spores treated with conventional heating. Conventional heating was ineffective for pasteurizing orange juice, whereas the maximum ohmic heating treatment applied at 30 V/cm was sufficient to inactivate 5 log units of A. acidoterrestris spores.

The effect of statin therapy on stimulation of endothelium-derived nitric oxide before and after coronary artery bypass surgery.

BACKGROUND: The purpose of this study was to determine the effects of statins on endothelium-derived nitric oxide (NO) levels during coronary artery bypass grafting (CABG) surgery. METHODS: In a prospective study, 130 patients with coronary artery disease were randomized according to preoperative atorvastatin treatment. The patients in group 1 took 40 mg atorvastatin daily for at least 1 month preoperatively, and those in group 2 took no atorvastatin preoperatively. Plasma nitrite and nitrate were measured at baseline and after inducing reactive hyperemia, both before and after surgery. Reactive hyperemia was induced by placing a blood pressure cuff on the upper forearm, inflating it for 5 minutes at 250 mm Hg, and then rapidly deflating the cuff. Blood was collected from the radial artery on the same side 2 minutes after cuff deflation. Plasma levels of total cholesterol, triglycerides, and high- and low-density lipoproteins were measured and analyzed for correlations with NO. RESULTS: The mean (+/-SD) baseline plasma NO levels before operation were as follows: group 1, 33.97 +/- 18.27 nmol/L; group 2, 24.24 +/- 8.53 nmol/L (P < .001). A significant difference between the 2 groups in plasma NO levels was observed after preoperative reactive hyperemia induction: group 1, 56.43 +/- 15.03 nmol/L; group 2, 43.12 +/- 10.67 nmol/L (P < .001). Two hours after cardiopulmonary bypass (CPB), we observed no significant differences in plasma NO levels, either at baseline (group 1, 11 +/- 3.41 nmol/L; group 2, 9 +/- 5.51 nmol/L) or after reactive hyperemia (group 1, 17.98 +/- 6.77 nmol/L; group 2, 18.00 +/- 6.47 nmol/L). A correlation with preoperative nitroglycerine use was observed (P = .007; r = 0.23). Linear regression analysis (F = 1.463; R = 0.314; R2 = 0.099; P = .16) indicated that the only significant correlation was with preoperative nitroglycerine use (P = .007; t = 2.746). CONCLUSIONS: Preoperative atorvastatin treatment in patients with coronary artery disease increases plasma NO levels before and after reactive hyperemia prior to surgery. CABG surgery with CPB significantly impairs endothelial-derived NO levels, with or without preoperative atorvastatin treatment. Preoperative nitroglycerine use is correlated with higher NO levels after CABG.

Results of mitral valve repair in rheumatic mitral lesions.

BACKGROUND: We compared results for repairs of rheumatic pure mitral regurgitation (MR) and mixed mitral stenosis (MS) and MR during early and midterm time intervals. METHODS: We retrospectively analyzed 173 patients (mean age 47.6 +/- 15.1 years; 64 males) who underwent surgery for rheumatic heart disease during the period from January 1998 to June 2008. According to transvalvular mitral gradient, 91 patients had pure MR (group MR) and 82 (47%) had mixed MS-MR (group MS/MR). Preoperative and operative characteristics, postoperative MR severity, operative mortality, and early and midterm survival were examined for each surgical group. RESULTS: Preoperativley 153 patients (90.7%) were in New York Heart Association class III or IV. The most frequent pathology was leaflet prolapse (147 patients, 85.0%) and the most commonly performed procedure was annuloplasty (162 patients, 93.6%). Early mortality was similar for both groups (3.2% versus 1.2%; P = .621). The average duration of follow-up was 4.0 +/- 2.4 years (a total of 679.1 patient years). Logistic regression analysis results indicated that subvalvular repairs were related to mortality. There were no significant differences in early mortality rate, valve-related morbidity, or reoperations. CONCLUSION: Group MS/MR had more postoperative MR severity, and higher New York Heart Association class, but both groups had similar mortality and morbidity at the midterm survival point. Our results suggest that combined MS and MR repair can be performed as safely as pure MR.

[The effects of thyroid hormones and interleukin-8 levels on prognosis after congenital heart surgery]. / Dogustan kalp cerrahisinde tiroit fonksiyonlari ve interlökin-8 degerlerinin prognoz üzerine etkisi.

OBJECTIVES: We evaluated the effects of thyroid hormone levels and interleukin-8 levels on prognosis in patients undergoing congenital heart surgery under cardiopulmonary bypass (CPB). STUDY DESIGN: The study included 41 consecutive children (19 boys, 22 girls; mean age 3.4 ± 3.1 years; range 0.3 to 12 years). The patients were divided into two groups based on the presence or absence of postoperative low cardiac output state (LCOS). The definition of LCOS included oliguria, tachycardia, metabolic acidosis, and increased plasma lactate level. Plasma total (tT4) and free (fT4) thyroxine, total (tT3) and free (fT3) triiodothyronine, thyroid stimulating hormone (TSH), and interleukin-8 (IL-8) levels were measured preoperatively and at 48 hours postoperatively. RESULTS: Postoperatively, nine patients (22%) developed LCOS. While the two groups were similar with respect to preoperative levels of thyroid hormones, lactate, and IL-8, postoperative tT3 and fT3 levels were significantly lower, and lactate and IL-8 levels were significantly higher in the LCOS group (p<0.05). In correlation analysis, postoperative IL-8 level showed significant correlations with CPB time (r=0.66), duration of mechanical ventilation (r=0.68), and inotropic requirement (r=0.59) (for all p<0.001). On the other hand, LCOS was significantly correlated with the following: preoperative tT4 (r=-0.32, p=0.043) and postoperative fT3 (r=-0.44, p=0.004) levels, duration of mechanical ventilation (r=0.56, p<0.001), intensive care unit stay (r=0.45, p=0.003), and cross-clamp time (r=0.43, p=0.005). Regression analysis showed preoperative level of tT4 as the independent predictor of LCOS (t=-2.092, p=0.045). Mortality occurred in four patients (9.8%) in the early postoperative period, all of whom were in the LCOS group. CONCLUSION: Our findings suggest that the development of LCOS after congenital heart surgery is associated with decreased total and free T3, and increased IL-8 levels at 48 hours, and preoperative tT4 level is an independent predictor of LCOS.

Continuous intravenous versus intermittent bolus midazolam with remifentanil during arteriovenous fistula placement with monitored anesthesia care in chronic renal failure patients: a randomized controlled trial.

BACKGROUND: There is limited data on the use of intravenous continuous infusion (CI) versus intravenous intermittent bolus (IB) doses of midazolam for conscious sedation in patients with chronic renal failure. Unexpected adverse events can occur in chronic renal failure patients undergoing short procedures. OBJECTIVE: Investigate and compare the sedoanalgesic and adverse effects of intravenous continuous infusion (CI) use of midazolam with intravenous intermittent bolus (IB) doses of midazolam while using intravenous remifentanil as a rescue medication, and assess patient and surgeon satisfaction. DESIGN: Prospective, randomized, single-blind controlled study. SETTINGS: Two tertiary care hospitals. PATIENTS AND METHODS: Study included patients aged 43-81 years with a diagnosis of chronic renal failure who were referred for an arteriovenous fistula procedure with modified anesthesia care between August 2012 and April 2016. The patients were randomized to intravenous CI or IB doses of midazolam. IB doses of remifentanil were used as a rescue medication. MAIN OUTCOME MEASURES: Primary outcomes were amounts of midazolam and remifentanil medications during the operation, the amount of remifentanil as a rescue medication, and the satisfaction of patient and surgeon. SAMPLE SIZE: 116 assessed for eligibility; 99 randomized to CI (n=50) or IB doses (n=49 of midazolam). RESULTS: The total dose of midazolam by CI was greater than with midazolam by IB (P=.002). The total dose of remifentanil was higher with IB doses of midazolam in comparison to CI of midazolam (P=.001). The groups were similar in sedation and pain control, duration of procedure, recovery time, patient satisfaction and adverse events; surgeon satisfaction was greater with CI versus IB (P=.035). CONCLUSION: Intravenous CI midazolam during MAC provides better surgeon satisfaction then IB midazolam and can be used safely for arteriovenous fistula procedures. LIMITATIONS: Two different surgeon groups. CONFLICT OF INTEREST: None.

Inadvertent Perioperative Hypothermia and Important Risk Factors during Major Abdominal Surgeries.

OBJECTIVE: A relation between inadvertent perioperative hypothermia and possible important risk factors during major abdominal surgeries was investigated. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: Trakya University Hospital, Edirne, Turkey during 2016-2018. METHODOLOGY: Five hundred and twenty-nine patients undergoing major abdominal surgey were divided into two groups depending on postoperative body core temperature (CTM) by the use of tympanic membrane measurement. Patients with a temperature of less than 36oC indicated hypothermia group; whereas, patients with a temperature between 36 and 37.5oC indicated normothermia group. The parameters that were considered as risk factors for hypothermia include; baseline characteristics, American Society of Anesthesiologists (ASA) status, comorbidities, operative type, duration of surgery, patient and operative room temperatures, intraoperative hemodynamic parameters, transfusion of fluids and packed red blood cells (PRBCs), labaratory data, and adverse events. Correlation between these parameters and inadvertent hypothermia was sought. A p-value of less than 0.05 was considered statistically significant. RESULTS: The risk factors that showed a correlation with hypothermia include: male gender, advanced age, high ASA scores, smoking, prolonged duration of operation, transfusion of fluids and PRBCs (p<0.05). In hypothermia group, duration of operation time was longer, need for transfusion was greater, hematocrit and hemoglobin values were lower than Normothermia Group of patients (p<0.05). Hypothermia was detected in 335 (63.3%) of patients. CONCLUSION: In this study, important risk factors for inadvertent hypothermia were found as; male gender, advanced age, high ASA scores, smoking, prolonged duration of operation, transfusion of fluids and/or PRBCs.

The effect of the keyhole technique on diabetic patients undergoing autologous brachiobasilic transposition of an arteriovenous fistula.

PURPOSE: Our aim was to investigate the efficiency of the keyhole transposed brachiobasilic technique in patients with diabetes mellitus and compare the effect of different arteriovenous fistula techniques on the development of complications. MATERIALS AND METHODS: Thirty-eight diabetic, chronic renal failure patients (group 1) had transposed brachiobasilic arteriovenous fistula creations, and 49 diabetic patients (group 2) had other types of fistula creations and histories of multiple fistula attempts. The 2 groups were compared for age, sex, weight, the presence of hypertension and/or diabetes mellitus, other risk factors, arteriovenous fistula patency, and possible complications. RESULTS: The 2 groups were not different statistically regarding the demographic data including age, sex, weight, the presence of hypertension and/or diabetes mellitus, other risk factors, and mean operation time. The median follow-up after surgery in both groups was 8 months. The primary patency in group 1 was 97.4% in the early period (6 weeks after surgery) and 94.7% in the late period (mean duration of 8 months after surgery). In the second group, these rates were 73% and 62%, respectively (P < .05). The secondary patency rates were 84.2% in group 1 and 53% in group 2 (P < .05). In group 2, the primary and secondary patencies of brachiocephalic and radiocephalic fistulas were significantly lower than the patencies of group 1. The incidence of complications was significantly less in group 1 than in group 2 (P < .05). CONCLUSION: Although the groups were small in size, the success rate with the keyhole transposed brachiobasilic technique in patients with diabetes was extremely gratifying, and this report can be considered to document the first attempt of a hemodialysis-access procedure.

Modeling growth of Alicyclobacillus acidoterrestris DSM 3922 type strain vegetative cells in the apple juice with nisin and lysozyme.

In the present study, the effect of storage temperature on A. acidoterrestris DSM 3922 cells (105 CFU/mL) was examined during growth in reconstituted apple juice (pH 3.8, °Brix 11.3) containing nisin (0-100 IU/mL) and lysozyme (0-100 mg/L). The growth curves were obtained at three temperatures of 27, 35 and 43 °C using absorbance data (OD600 nm). Based on the results, the minimal inhibitory concentrations (MICs) of nisin were found as 10 IU/mL at all tested temperatures. On the other hand, increasing the temperature decreased the amount of lysozyme for growth inhibition. The MICs of lysozyme were found as 10, 2.5 and 1.25 mg/L at 27, 35 and 43 °C, respectively. At selected non-inhibitory doses, nisin (1.25-5 IU/mL) and lysozyme (0.3-2.5 mg/L) prolonged the lag time compared to the controls at the corresponding temperatures. In addition, there was a strong linear relationship between the lag time and lysozyme concentrations at 27 and 35 °C (R2 > 0.98). The results of this study demonstrated that both nisin and lysozyme could be used to inhibit the growth of A. acidoterrestris cells in the apple juice. The results also indicated that the growth parameters were variable depending on the storage temperature and the type of the antimicrobial agent used in the apple juice.