Relationship between disease severity and serum IL-6 levels in COVID-19 anosmia.

BACKGROUND: An association between IL-6 levels and cytokine storm syndrome in COVID-19 patients has been suggested. Cases with higher IL-6 levels have more rapid progression and a higher complication rate. On the other hand, COVID-19 cases with anosmia have a milder course of the disease. OBJECTIVE: We aimed to investigate whether there is a relationship between serum IL-6 levels and presence of anosmia in COVID-19 patients. METHODS: Patients with a confirmed diagnosis of COVID-19 based on laboratory (PCR) were stratified into two groups based on presence of olfactory dysfunction (OD). In all cases with and without anosmia; psychophysical test (Sniffin' Sticks test) and a survey on olfactory symptoms were obtained. Threshold (t) - discrimination (d) - identification (i), and total (TDI) scores reflecting olfactory function were calculated. Clinical symptoms, serum IL-6 levels, other laboratory parameters, and chest computed tomography (CT) findings were recorded. RESULTS: A total of 59 patients were included, comprising 23 patients with anosmia and 36 patients without OD based on TDI scores. Patients with anosmia (41.39 ± 15.04) were significantly younger compared to cases without anosmia (52.19 ± 18.50). There was no significant difference between the groups in terms of comorbidities, smoking history, and symptoms including nasal congestion and rhinorrhea. Although serum IL-6 levels of all patients were above normal values (7 pg/mL), patients with anosmia had significantly lower serum IL-6 levels (16.72 ± 14.28 pg/mL) compared to patients without OD (60.95 ± 89.33 pg/mL) (p = 0.026). CONCLUSION: Patients with COVID-19 related anosmia tend to have significantly lower serum levels of IL-6 compared to patients without OD, and the lower IL-6 levels is related to milder course of the disease. With the effect of low cytokine storm and IL-6 level, it may be said that anosmic cases have a milder disease in COVID-19.

Brain MRI Findings in Patients in the Intensive Care Unit with COVID-19 Infection.

Online supplemental material is available for this article.

Elevated strong ion gap: A predictor of the initiation of continuous renal replacement therapy in acute kidney injury.

BACKGROUND: There is no optimal timing for continuous renal replacement therapy (CRRT) in acute kidney injury (AKI). AKI is a reason for the increased unmeasured anions, which refers to the increased organic acids in the blood, and they can be detected by calculating strong ion gap (SIG). SIG level at the moment of the AKI diagnosis may be a predictor for the initiation of CRRT. METHODS: Patients who were diagnosed with AKI in the first week of the intensive care unit (ICU) period were included in this prospective observational study. At the moment of the AKI diagnosis, blood gas samples were recorded, and SIG was calculated. RESULTS: The median level of SIG at the moment of the AKI diagnosis of CRRT (+) patients was significantly higher than CRRT (-) patients (7.4 and 3.2 mmol L-1, respectively). In the multivariate Cox regression analysis, the likelihood of the initiation of CRRT was increased 1.16-fold (1.01-1.33) and 4.0-fold (1.9-8.7) by only 1 mmol L-1 increases in SIG and SIG ≥6 mmol L-1 at the moment of AKI diagnosis, respectively (p = 0.035 and p < 0.001). CONCLUSIONS: Increased SIG at the moment of the AKI diagnosis in patients with AKI may be a predictive marker to initiate CRRT.

The usage of immunosuppressant agents and secondary infections in patients with COVID-19 in the intensive care unit: a retrospective study.

Although COVID-19 infection is an immunosuppressant disease, many immunosuppressant agents, such as pulse methylprednisolone (PMP), dexamethasone (DXM), and tocilizumab (TCZ), were used during the pandemic. Secondary infections in patients with COVID-19 have been reported recently. This study investigated these agents' effects on secondary infections and outcomes in patients with COVID-19 in intensive care units (ICUs). This study was designed retrospectively, and all data were collected from the tertiary intensive care units of six hospitals between March 2020 and October 2021. All patients were divided into three groups: Group I [GI, PMP (-), DXM (-) and TCZ (-)], Group II [GII, PMP (+), DXM (+)], and Group III [GIII, PMP (+), DXM (+), TCZ (+)]. Demographic data, PaO/FiO2 ratio, laboratory parameters, culture results, and outcomes were recorded. To compare GI-GII and GI-GIII, propensity score matching (PSM) was used by matching 14 parameters. Four hundred twelve patients with COVID-19 in the ICU were included in the study. The number of patients with microorganisms ≥ 2 was 279 (67.7%). After PSM, in GII and GIII, the number of (+) tracheal cultures and (+) bloodstream cultures detected different microorganisms ≥ 2 during the ICU period, neuropathy, tracheotomized patients, duration of IMV, and length of ICU stay were significantly higher than GI. The mortality rate was similar in GI and GII, whereas it was significantly higher in GIII than in GI. The use of immunosuppressant agents in COVID-19 patients may lead to an increase in secondary infections. In addition, increased secondary infections may lead to prolonged ICU stay, prolonged IMV duration, and increased mortality.

CT Findings of the Massive Air Embolism in a Case with Thoracic Gunshot Wound: A Special Case Report as if a Whole Body Pneumo- Angiography was Performed.

BACKGROUND: Massive Systemic Arterial Air Embolism (SAAE) associated with penetrating trauma is a rare condition. A few cases were reported for massive arterial air embolism in the literature. Computed tomography is a fast and easily accessible modality for detecting air in the vasculature. We report CT findings of a rare case with a thoracic gunshot wound, which demonstrate air almost in all systemic vessels like ''full body pneumoangiography''. CASE PRESENTATION: A 42-year-old male patient with a thoracic gunshot wound was admitted to the Accident and Emergency (A&E) unit in a state of cardiac arrest. Postmortem Computed Tomography (CT) was performed and extensive air was revealed in several great vessels. CONCLUSION: We conclude that the underline causes of massive air embolism in our case are two main mechanisms: firstly, massive air enters the vasculature via bronchovascular fistula as there was bilateral lung contusion and directly through cardiac truncus, secondly while CPR was being conducted, massive air was pumped to the systemic circulation.

Hemodynamic outcome of different ventilation modes in laparoscopic surgery with exaggerated trendelenburg: a randomised controlled trial.

PURPOSE: To compare hemodynamic effects of two different modes of ventilation (volume-controlled and pressure-controlled volume guaranteed) in patients undergoing laparoscopic gynecology surgeries with exaggerated Trendelenburg position. METHODS: Thirty patients undergoing laparoscopic gynecology operations were ventilated using either volume-controlled (Group VC) or pressure-controlled volume guaranteed mode (Group PCVG) (n = 15 for both groups). Hemodynamic variables were measured using Pressure Recording Analytical Method by radial artery cannulation in addition to peak and mean airway pressures and expired tidal volume. RESULTS: The only remarkable finding was a more stable cardiac index in Group PCVG, where other hemodynamic parameters were similar. Expired tidal volume increased in Group VC while peak airway pressure was lower in Group PCVG. CONCLUSION: PCV-VG causes less hemodynamic perturbations as measured by Pressure Recording Analytical Method (PRAM) and allows better intraoperative hemodynamic control in exaggerated Trendelenburg position in laparoscopic surgery.

Base-excess chloride; the best approach to evaluate the effect of chloride on the acid-base status: A retrospective study.

To practically determine the effect of chloride (Cl) on the acid-base status, four approaches are currently used: accepted ranges of serum Cl values; Cl corrections; the serum Cl/Na ratio; and the serum Na-Cl difference. However, these approaches are governed by different concepts. Our aim is to investigate which approach to the evaluation of the effect of Cl is the best. In this retrospective cohort study, 2529 critically ill patients who were admitted to the tertiary care unit between 2011 and 2018 were retrospectively evaluated. The effects of Cl on the acid-base status according to each evaluative approach were validated by the standard base excess (SBE) and apparent strong ion difference (SIDa). To clearly demonstrate only the effects of Cl on the acid-base status, a subgroup that included patients with normal lactate, albumin and SIG values was created. To compare approaches, kappa and a linear regression model for all patients and Bland-Altman test for a subgroup were used. In both the entire cohort and the subgroup, correlations among BECl, SIDa and SBE were stronger than those for other approaches (r = 0.94 r = 0.98 and r = 0.96 respectively). Only BECl had acceptable limits of agreement with SBE in the subgroup (bias: 0.5 mmol L-1) In the linear regression model, only BECl in all the Cl evaluation approaches was significantly related to the SBE. For the evaluation of the effect of chloride on the acid-base status, BECl is a better approach than accepted ranges of serum Cl values, Cl corrections and the Cl/Na ratio.

Predictive value of CT imaging findings in COVID-19 pneumonia at the time of first-screen regarding the need for hospitalization or intensive care unit.

PURPOSE: In this study, we aimed to reveal the relationship between initial lung parenchymal involvement patterns and the subsequent need for hospitalization and/or intensive care unit admission in coronavirus disease 2019 (COVID-19) positive cases. METHODS: Overall, 231 patients diagnosed with COVID-19 as proven by PCR were included in this study. Based on the duration of hospitalization, patients were divided into three groups as follows: Group 1, patients receiving outpatient treatment or requiring hospitalization <7 days; Group 2, requiring hospitalization ≥7 days; Group 3, patients requiring at least 1 day of intensive care at any time. Chest CT findings at first admission were evaluated for the following features: typical/atypical involvement of the disease, infiltration patterns (ground-glass opacities, crazy-paving pattern, consolidation), distribution and the largest diameters of the lesions, total lesion numbers, number of affected lung lobes, and affected total lung parenchyma percentages. The variability of all these findings according to the groups was analyzed statistically. RESULTS: In this study, 172 patients were in Group 1, 39 patients in Group 2, and 20 patients in Group 3. The findings obtained in this study indicated that there was no statistically significant difference in ground-glass opacity rates among the groups (p = 0.344). The rates of crazy-paving and consolidation patterns were significantly higher in Groups 2 and 3 than in Group 1 (p = 0.001, p = 0.002, respectively). The rate of right upper, left upper lobe, and right middle lobe involvements as consolidation pattern was significantly higher in Group 3 than in Group 1 (p = 0.148, p = 0.935, p = 0.143, respectively). A statistically significant difference was also found between the affected lobe numbers, total lesion numbers, the diameter of the largest lesion, and the affected lung parenchyma percentages between the groups (p = 0.001). The average number of impacted lobes in Group 1 was 2; 4 in Group 2 and Group 3. The mean percentage of affected lung parenchyma percentage was 25% in Group 1 and Group 2, and 50% in Group 3. CONCLUSION: In case of infiltration dominated by right middle or upper lobe involvement with a consolidation pattern, there is a higher risk of future intensive care need. Also, the need for intensive care increases as the number of affected lobes and percentage of affected parenchymal involvement increase.

A practical approach to imaging characteristics and standardized reporting of COVID-19: a radiologic review.

Novel coronavirus (2019-nCoV), also known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a pathogen that has caused a rapidly spreading pandemic all over the world. The primary mean of transmission is inhalation with a predilection for respiratory system involvement, especially in the distal airways. The disease that arises from this novel coronavirus is named coronavirus disease 2019 (COVID-19). COVID-19 may have a rapid and devastating course in some cases leading to severe complications and death. Radiological imaging methods have an invaluable role in diagnosis, follow-up, and treatment. In this review, radiological imaging findings of COVID-19 have been systematically reviewed based on the published literature so far. Radiologic reporting templates are also emphasized from a different point of view, considering specific distinctive patterns of involvement.

Struggle Against Pandemic in A Private Hospital: What We Have Learnt from Pandemic?

Corona Virus disease 2019 (COVID-19), which is one of the biggest outbreaks in the last century and is caused by a kind of coronavirus, spread to many countries in a short time after being first seen in the Wuhan region of China in December 2019. The COVID-19 outbreak, which spread rapidly and caused many deaths, was declared as a pandemic by the World Health Organization on March 11, 2020. The first COVID-19 case in Turkey, coincidentally, was seen on the same day. In this article, the story of the pandemic struggle successfully carried out in a private hospital and the teachings of the process are provided.

The effect of scalp block and local infiltration on the haemodynamic and stress response to skull-pin placement for craniotomy.

BACKGROUND AND OBJECTIVE: The insertion of skull pins into the periosteum induces not only a haemodynamic response but also an increase in stress hormones. We compared the effects of scalp-nerve block, infiltration anaesthesia, and routine anaesthesia during skull-pin insertion on haemodynamic and stress responses to craniotomy. METHODS: Forty-five ASA I or II patients, scheduled for elective craniotomies, were enrolled in this prospective, randomized, placebo-controlled study. Anaesthesia was induced with thiopental (5 mg kg(-1)), fentanyl (2 microg kg(-1)) and vecuronium (0.1 mg kg(-1)), and was maintained with 50% N2O in oxygen and 1% isoflurane. Five minutes before head pinning, 0.5% bupivacaine was infiltrated at each pin-insertion site in group L. In group S, scalp block was performed by blocking the supraorbital, supratrochlear, auriculotemporal, occipital, and postauricular branches of the greater auricular nerves using 20 ml 0.5% bupivacaine. Opioids were used to control haemodynamic responses in group C (the control group). Heart rate and mean arterial pressure were recorded at regular intervals before and for 1 h after induction. Blood samples were collected for cortisol and adrenocorticotropic hormone analysis 5 min before induction and 5 and 60 min after pin-holder insertion. RESULTS: There were significant increases in heart rate and mean arterial pressure during head pinning in groups L and C compared with group S and also at the 1st, 2nd and 3rd minutes after pinning (P < 0.05). In group S, the reduced plasma cortisol and adrenocorticotropic hormone levels measured at the 5th and 60th minutes after pinning were significantly lower than those in groups L and C (P < 0.05). CONCLUSION: We conclude that scalp block using 0.5% bupivacaine blunts the haemodynamic and stress responses to head pinning better than routine anaesthesia or scalp infiltration with bupivacaine and should be considered in conjunction with general anaesthesia for craniotomy.

Impact of anxiety on sedative medication dosage in patients undergoing esophagogastroduodenoscopy.

INTRODUCTION: Esophagogastroduodenoscopy (EGD) is a diagnostic method used in the investigation of upper gastrointestinal system diseases. A high level of anxiety of patients who undergo EGD increases the duration of the procedure and the sedation and analgesic requirements. Sedation is used to increase patient comfort and tolerance by reducing the anxiety and pain associated with endoscopic procedures. AIM: In this study, the effect of anxiety scores on medication doses was investigated in patients who underwent EGD under sedation. MATERIAL AND METHODS: A psychiatrist, an endoscopist and an anesthesiologist conducted a prospective observational study blindly to investigate the effect of pre-procedural (before EGD) anxiety level on medication doses for sedation. Patients were divided into two groups, with and without additional medication doses. RESULTS: The study included 210 consecutive patients who underwent EGD under sedation. The average STAI-S score was 40.28 and the average STAI-T score was 40.18. There was no relationship between anxiety scores and gender (p = 0.058, p = 0.869). Statistically significant results were obtained for anxiety scores with additional sedation dosing (p < 0.05). It was observed that an additional dose of medication was affected by age, body mass index and anxiety scores (p < 0.005). Patients who were young, had a low body mass index and had high anxiety scores had significantly higher additional dose requirements. CONCLUSIONS: The medications used for sedation during EGD may be inadequate or an additional dose of medication may be needed for patients who have higher anxiety scores, younger age, and lower body mass index.

Effects of different doses of tramadol added to levobupivacaine in continuous wound infusion for postoperative pain treatment following cesarean section.

OBJECTIVE: The aim of this study was to compare the effects of two different doses of tramadol added to levobupivacaine as continuous wound infusion, on VAS scores following cesarean section. METHODS: The study was conducted in an University Hospital and was approved by the Local Ethical Committee. Sixty-five ASA I-II parturients, between 18 and 45 years were enrolled. The participants were randomized to three groups. Group T1 (n = 21) was given the study solution consisting of levobupivacaine 0.25% + tramadol 1 mg/kg. Group T2 (n = 21) was given levobupivacaine 0.25% + tramadol 2 mg/kg and Group L (n = 21) was given levobupivacaine 0.25%, subcutaneously, alone. Each patient who delivered by cesarean section was applied a triple orifice epidural catheter above rectus fascia for continious wound infiltration. VAS at rest and with 20 degrees leg lift, time to first additional analgesic, total additional analgesic consumption, side effects, and sedation scores were recorded. RESULTS: There were no statistically significant differences among groups, concerning VAS scores at rest and VAS scores at leg lift. Total amount of additional analgesics and sedation scores were also similar for three groups. CONCLUSION: Different doses of tramadol as adjunct to local anesthetics in continuous wound infiltration following cesarean section do not seem to provide superior analgesia.

Effects of alfentanil or fentanyl added to propofol for sedation in colonoscopy on cognitive functions: Randomized controlled trial.

BACKGROUND/AIMS: To assess the effect of propofol supplemented with alfentanil or fentanyl on cognitive functions for sedation during elective colonoscopy. MATERIALS AND METHODS: Patients (n=150, 18-65 years old, American Society of Anesthesiologists risk group I-III) scheduled undergo elective colonoscopy were included. They were randomized into three groups using the closed envelope methodpropofol-alfentanil (Group A), propofol-fentanyl (Group F), and propofol only (Group P).Group A patients were given an alfentanil (10 mcg/kg)-supplemented propofol bolus infusion and 5 mcg/kg alfentanil when necessary. Group F patients were given fentanyl (1 mcg/kg)-supplemented propofol and 0.5 mcg/kg fentanyl when necessary. Group P patients were given 1 mg/kg propofol and 0.5 mg/kg propofol when necessary. Vital signs, depth of sedation, recovery parameters, and patient and endoscopist satisfaction were recorded. Trieger dot test (TDT) and Digit Symbol Substitution Test (DSST) were performed post procedure. RESULTS: Demographic data were similar among all patients in the groups. Bispectral index values were lower in Group P (p<0.001). DSST scores were higher in Group A (p=0.004). TDT scores and Facial Pain Scale scores were higher in Group P (p<0.005). Apnea incidence (p=0.009) and Observer's Assessment of Alertness/Sedation Scale scores (p=0.002) were also higher in Group P. Patient satisfaction and endoscopist satisfaction were similar among all patients. CONCLUSIONS: Compared with propofol-alfentanil and propofol-fentanyl, propofol alone is associated with an increased incidence of apnea, drug consumption, and reported pain. Propofol-alfentanil has a less negative effect on cognitive functions than propofol alone or propofol-fentanyl.

Neutrophil Gelatinase-Associated Lipocalin Levels During Pneumoperitoneum.

BACKGROUND AND OBJECTIVES: A temporary deterioration in renal function during pneumoperitoneum has been reported, but the extent is not known. A new marker for the early detection of renal injury, neutrophil gelatinase-associated lipocalin (NGAL), has been shown to increase in various conditions that affect renal function. This study was conducted to explore detrimental effects of pneumoperitoneum in laparoscopic surgery on renal function by studying levels of urinary NGAL (uNGAL). METHODS: Thirty-two women scheduled to undergo laparoscopic surgery in a gynecology clinic were recruited. NGAL was measured in urine collected at the beginning (0 h) and at 2 and 24 hours after the initiation of surgery. Hemodynamic parameters were analyzed immediately after intubation and before desufflation. RESULTS: Levels of uNGAL increased from 5.45 ng/mL at 0 hours to 6.35 ng/mL at 2 hours and to 6.05 ng/mL at 24 h; however, there was no significant change in uNGAL levels at the collection time points. Intraoperative oliguria was observed in all cases, and the severity increased with the duration of surgery. uNGAL levels did not correlate with the duration of surgery or pneumoperitoneum. CONCLUSION: In patients with normal renal functions, pneumoperitoneum results in transient oliguria without any early renal damage, as indicated by nonsignificant changes in uNGAL levels.

Is there an ideal approach for rapid-sequence induction in hypertensive patients?

STUDY OBJECTIVE: To compare 4 different anesthesia induction protocols, in a simulated model of rapid-sequence induction, in controlled hypertensive patients. DESIGN: Prospective, randomized, double-blind, clinical investigation. SETTING: Large metropolitan university hospital. PATIENTS: 120 ASA II-III adult hypertensive patients. INTERVENTIONS: Patients were allocated to 4 groups at random. After preoxygenation for 3 minutes, induction and tracheal intubation was performed in a 30 degrees head-up position. Thiopental (5-7 mg/kg) was the induction agent. Study groups were as follows: group LS (n = 30), lidocaine (1.5 mg/kg) and succinylcholine (1 mg/kg); group LR (n = 30), lidocaine (1.5 mg/kg) and rocuronium (1 mg/kg); group RS (n = 30), remifentanil (1 microg/kg) and succinylcholine (1 mg/kg); group RR (n = 30), remifentanil (1 microg/kg) and rocuronium (1 mg/kg). Patients were intubated 60 seconds after administration of muscle relaxant. MEASUREMENTS: Hemodynamic data were obtained before induction (baseline), after induction, at intubation, and at 1, 3, 5, and 10 minutes after intubation. More than 20% change in blood pressure and heart rate was considered significant. MAIN RESULTS: Systolic and mean arterial blood pressures at intubation and 1 and 3 minutes after intubation were higher in group LS compared with groups RS and RR (P < 0.01). Mean arterial blood pressure decreased after induction in groups LS, LR, and RR, but increased at intubation and 1 minute after intubation in groups LS and LR (P < 0.01). Mean arterial blood pressure was similar at all measurement intervals in group RS. The median area under the systolic, mean, and diastolic blood pressure time curves was higher in groups LS and LR compared with groups RS and RR (P < 0.05 and P < 0.01). CONCLUSIONS: Remifentanil is a better adjunct for attenuation of the response to laryngoscopy and intubation compared with lidocaine, whereas remifentanil-succinylcholine combination appears to be more beneficial in terms of hemodynamic stability in hypertensive patients.

[Hemodynamic performance of mechanical aortic valves in narrow aortic annulus cases]. / Küçük aortik annuluslu olgularda mekanik aort kapaklarinin hemodinamik performansi.

OBJECTIVE: Small-sized prosthetic valves used in aortic valve position usually cause a high transvalvular gradient. This situation, especially in people with a high body surface area, causes a patient-prosthetic valve mismatch. In this study, hemodynamic performances of the two new generation bileaflet, small size mechanical valves were evaluated during rest and stress conditions. METHODS: Eighteen patients with implanted 21-mm St. Jude HP (11 cases) and Sorin Bicarbon (7 cases) prosthetic valves in aortic position were evaluated at rest and during dobutamine infusion, 16.3+/-5.5 months after the operation. Dobutamine infusion was started at a dose of 5 microg/kg/min. The infusion rate was increased every 15 minutes up to 10-20-30 microg/kg/min. Maximum gradient, mean gradient, effective valve area (EVA), effective valve area index (EVAI) and performance index (PI) were calculated during rest and maximum dobutamine infusion rate. RESULTS: When the rest and dobutamine infusion measurements were compared, the maximum and mean gradients were found to be increased moderately, but EVA, EVAI, PI values did not change with increasing heart rates. For St. Jude valve; maximum gradient increased from 30.5+/-6.5 mmHg to 74.7+/-33.6 mmHg (p=0.03) and mean gradient increased from 17.9+/-3.8 to 40.8+/-23.8 mmHg (p=0.03). For Sorin Bicarbon valve; maximum gradient increased from 31.7+/-13.3 mmHg to 52.0+/-11.2 mmHg (p=0.01), mean gradient increased from 16.1+/-6.4 mmHg to 28.8+/-1.0 mmHg (p=0.01). The difference was not significant between the two valves with respect to measured parameters during rest and maximum dobutamine infusion. CONCLUSION: According to our findings, 21-mm Sorin Bicarbon and St. Jude HP mechanical bileaflet valves have good hemodynamic performance during exercise and these types of valves seem to be appropriate for patients with small aortic annulus.

Endobronchial intubation in thoracic surgery: Which side should be preferred?

AIM: This study was undertaken to compare the clinical performance of right versus left double-lumen endotracheal tubes placed without using fiberoptic bronchoscopy in thoracic surgery operations. METHODS: This was a retrospective review of patients who were operated on in our institution between January 2013 and February 2014. We analyzed clinical performance in terms of hypoxia, hypercapnia, and adequate deflation of the lungs with both left- and right-sided double-lumen endotracheal tubes. RESULTS: There were 80 patients with a mean age of 53.74 ± 15.59 years. Right-sided double-lumen tubes were used in 33 patients, and left-sided double-lumen tubes were used in 47. Perioperative hypoxi (p < 0.05), hypercapnia (p < 0.01), and inadequate deflation of the lung (p < 0.001) were found more frequently with the use of right-sided double-lumen endotracheal tubes. Arterial blood gas analyses in the post-anesthesia care unit showed that high pCO2 (>45 mm Hg), low pH (<7.36), and high lactate levels (>4 mmol L(-1)) were more frequent with right-sided double-lumen endotracheal tubes (p < 0.001). The incidence of atelectasis was greater (p < 0.001) and the duration of hospital stay was longer (p = 0.02) with the use of right-sided double-lumen endotracheal tubes. CONCLUSION: Right-sided double-lumen endotracheal tubes resulted in poorer clinical performance. Therefore, a left-sided double-lumen endotracheal tube should be preferred in thoracic surgery operations when an appropriate size of fiberoptic bronchoscope is not available.

Echocardiographic predictors of hemodynamic response and significance of dyspnea development in patients with mitral stenosis during dobutamine stress echocardiography.

BACKGROUND AND AIM OF THE STUDY: In mitral stenosis (MS) patients, resting hemodynamic data do not always correlate with symptom severity. Stress tests may be carried out in these patients, but the mechanisms of different hemodynamic and clinical responses to stress are not clearly established. The study aim was to evaluate hemodynamic changes that correlate with dyspnea development during dobutamine infusion (DI) in patients with MS, and to assess determinants of transmitral gradient response. METHODS: Forty-five consecutive mild or moderately symptomatic patients (36 women, nine men; mean age 44 +/- 10 years; range: 26-66 years), in NYHA class II and with MS (mean mitral valve area (MVA) 1.6 +/- 0.1 cm2; range: 1.5-1.9 cm2) were evaluated with dobutamine stress echocardiography. RESULTS: During DI, dyspnea developed in 12 patients, and 33 patients remained asymptomatic. During infusion, both mean transmitral gradient (6 +/- 3 versus 11 +/- 6 mmHg, p = 0.01) and pulmonary artery systolic pressure (PASP) (13 +/- 4 versus 21 +/- 3 mmHg, p < 0.001) were significantly increased in patients who developed dyspnea compared to others. Hence, a subgroup of patients with more serious MS was identified using the hemodynamic response to dobutamine. Based on these clinical and hemodynamic results, management was changed in 12 patients (27%); five underwent percutaneous mitral balloon commissurotomy and seven received intensive medical treatment. In all patients, PASP at rest (p = 0.001), MVA (p < 0.0001) and subvalvular mitral score (p = 0.004), which is indicative of mitral valve damage, were significantly correlated with mean mitral valve gradient response. CONCLUSION: These results suggest that patients in whom dyspnea is provoked during DI show a greater increase in hemodynamic parameters than patients in whom provocation does not occur. The mean mitral valve gradient-response correlates with baseline pulmonary artery pressure, MVA and subvalvular echo score, and may be predicted by these parameters. Association between dyspnea and presence of severe mitral valve hemodynamics showed a high sensitivity and negative and positive predictive value. It is possible that dyspnea may be of value in identifying those patients with significant mitral valve obstruction.

The effect of adding dexmedetomidine to levobupivacaine for interscalene block for postoperative pain management after arthroscopic shoulder surgery.

OBJECTIVE: Arthroscopic subacromial decompression may cause substantial postoperative pain. We undertook a randomized controlled trial to examine whether adding dexmedetomidine to the local anesthetic in an interscalene brachial plexus block and subsequent patient-controlled interscalene analgesia (PCIA) regime improved postoperative pain scores, patient satisfaction, rescue analgesic requirement, and local anesthetic consumption. METHODS: A total of 48 patients aged between 18 and 65 years undergoing arthroscopic subacromial decompression were enrolled and randomized into 1 of the 2 groups. Group L (n=25) received levobupivacaine and epinephrine, whereas Group LD (n=23) received levobupivacaine, epinephrine, and dexmedetomidine through an interscalene catheter. Four hours after surgery, a PCIA regime was commenced. In Group L patients were administered levobupivacaine and in Group LD levobupivacaine and dexmedetomidine. Demographic and hemodynamic data, duration of motor and sensory blocks, pain VAS, side effects, PCIA demand and delivery values, consumption of lornoxicam as a rescue analgesic, and patient satisfaction were recorded for 24 hours after surgery. RESULTS: PCIA demand and delivery, and pain VAS values were significantly lower, and patient satisfaction was significantly higher in the dexmedetomidine group (P=0.004, 0.001, 0.004, and 0.002, respectively). The side effect profile was similar between the groups. Levobupivacaine consumption was significantly lower in Group LD (P=0.009). In the first 24 postoperative hours, Group LD consumed significantly less lornoxicam (P=0.01). DISCUSSION: Addition of dexmedetomidine to levobupivacaine for interscalene brachial plexus block decreases pain scores and increases patient satisfaction after arthroscopic subacromial decompression.