The Effect of Sugammadex on Time of Sciatic Block by Perineural Bupivacaine in Rats.

OBJECTIVES: We aimed to investigate the effect of sugammadex on the motor, sensory and deep sensory block in the sciatic nerve created by bupivacaine in rats. MATERIALS AND METHODS: 18 Sprague-Dawley adult male rats treated with unilateral sciatic nerve block by bupivacaine (0.2 ml) were randomly divided into three groups. Control group (Group C, n = 6, 1.5 mL saline) perineural sugammadex group (Group PNS, n = 6, 16 mg/kg) and intraperitoneal sugammadex group (Group IPS, n = 6, 16 mg/kg) Motor, sensory, and deep sensory functions were evaluated every 10 minutes by a blind researcher. 6 tissue samples each belonging to the sciatic nerve, 1.5 cm in length and 0.2 cm in diameter, were taken from paraffin blocks. Sections of 3-4 micrometers were stained with Hematoxylin + Eosin, Masson Trichrome dyes and examined under a light microscope. RESULTS: There was no statistically significant difference between 3 groups in terms of the time to return to normal motor, sensory and deep sensory function. There was also no significant difference in edema, extracellular matrix, and myelin. Inflammatory cells were seen in all groups, mainly epineurium, epineurium, and perineurium. CONCLUSION: There are findings of no histological effects or effects on local block of sugammadex in rats undergoing sciatic nerve block.

The combined administration of systemic and topical tranexamic acid for total hip arthroplasty: Is it better than systemic?

OBECTIVE: The aim of this study was to evaluate the effect of combined intravenous and topical use of tranexamic acid (TXA) on total blood loss and transfusion rate in total hip arthroplasty. METHODS: This prospective randomized study included 57 patients who had undergone total hip arthroplasty between September 2016 and September 2017. The IV administration group (Group 1) consisted of 26 patients (mean age: 63.73 ± 10.29 years), while the IV and topical administiration group (Group 2) consisted of 22 patients (62.82 ± 8.31 years). Demographic data and outcomes were obtained through a review of individual medical records. Medical comorbidities, body mass index (BMI), ASA and CCI, preoperative and postoperative hemoglobin levels, postoperative transfusion records and 90-day joint-related (implant subsidence, dislocation, postoperative anemia, deep infection, hematoma and/or wound problem, postoperative periprosthetic fracture) readmission rate and complication rate were compared between the groups. RESULTS: No significant differences were observed between the 2 groups in terms of age, gender, height, weight, body mass index (BMI), the level of preoperative Hb values, and the American Society of Anesthesiologists (ASA) and Charleson Comorbidty Index (CCI) rating (p > 0.05). The mean postoperative Hgb in the group 2 was higher by a small amount compared to the group 1. No statistically significant difference was determined between the groups in respect of the Hgb values (p = 0.562). Hgb Delta in the group 2 was lower than that of the group 1. The difference between the groups in the Hgb Delta values was not statistically significant (p = 0.268). The mean total blood loss was lower in the group 2 than in the group 1 but the difference was not statistically significant (p = 0.788). There was no significant difference observed in terms of any adverse complications among the 2 groups (p > 0.05). CONCLUSION: The combined administration of IV and topical TXA compared with IV alone can decrease total blood loss and the number of blood transfusions required without increasing the risk of DVT or/and PE in total hip arthroplasty. But the statistical analysis and clinical relevance is not significant. LEVEL OF EVIDENCE: Level I Therapeutic Study.

Transaortic repair of concomitant mitral insufficiency in patients with critical aortic stenosis undergoing aortic valvular replacement.

BACKGROUND: In this study, we present operation technique and outcomes of transaortic mitral valve repair in high-risk patients undergoing aortic valve replacement due to severe aortic stenosis. METHODS: Between January 2005 and March 2016, a total of 11 patients (7 females, 4 males; mean age 71.2±4.1 years; range, 65 to 77 years) with severe aortic valve stenosis (aortic valve area <1 cm2 or aortic valve area index <0.6 cm2/m2) and concomitant moderate or severe mitral regurgitation (non-ischemic, regurgitant jet origin between A2-P2 portions) secondary to left ventricular dysfunction (EuroSCORE logistic score >5%, left ventricular ejection fraction <30%) who were operated were retrospectively analyzed. Aortic valve replacement and transaortic mitral edge-to-edge repair was applied to all patients. Operations were performed through sternotomy, cardiopulmonary bypass, and bicaval venous return. Transesophageal echocardiography was used to evaluate mitral valve before surgery and valve functions after surgery. Postoperative course of all patients was monitored, and postoperative complications were recorded. RESULTS: The mean preoperative ejection fraction was 24.5±4.1% and the mean transaortic pressure gradient was 35.8±4.8 mmHg. The mean aortic cross-clamp time was 62.09±10.1 (range, 43 to 76) min and the median cardiopulmonary bypass time was 90.1±11.9 (range, 66 to 114) min. No hospital mortality was observed. In the postoperative period, two patients experienced renal insufficiency. Hemofiltration was initiated in these patients and no dialysis was required at two weeks. One patient had postoperative atrial fibrillation and one patient had pericardial effusion leading to cardiac tamponade and this patient underwent reoperation. The patients were followed up for a mean of four years and control echocardiography didn"t detect increase in mitral regurgitation degree. CONCLUSION: Transaortic edge-to-edge mitral valve repair can be used in high-risk patients undergoing aortic valve replacement. This technique is feasible with shorter cross-clamp time and can reduce mortality and morbidity in selected high-risk patients.

Procedural sedation and analgesia for pediatric shock wave lithotripsy: a 10 year experience of single institution.

The aim of this study was to evaluate anesthesia practice for pediatric extracorporeal shock wave lithotripsy (ESWL) according to the age groups and discuss the anesthetic management of these patients. Pediatric patients treated with ESWL because of urolithiasis under anesthesia in our department between December 2007 and January 2017 were evaluated retrospectively. A total of 251 patients were divided into two groups as Group PS: preschool children (<6 years) and Group S: school children (≥6 years). Groups were compared according to ketamine and midazolam doses, extra anesthetic agent requirement, duration of procedure, procedural and postprocedural complications due to anesthesia, as well as mean number of sessions and calculus diameter. A total of 408 sessions of ESWL were applied to 251 children included in the study. Overall, mean age of the patients was 4.5 ± 3.2 years (7 months-14 years). In school children (Group S), mean ketamine and midazolam doses were significantly higher than the preschool group (p < 0.01 and p = 0.04, respectively). There was no statistically significant difference in additional anesthetic agent requirement (p = 0.35) as well as mean number of SWL sessions (p = 0.23), duration of anesthesia (p = 0.93), stone size (p = 0.20), and stone laterality (p = 0.71) in both preschool and school children. No severe complications were observed in both groups. In pediatric ESWL patients, ketamine-midazolam combination is an effective and safety choice for outpatient anesthesia. Appropriate dose adjustment in a monitorized and well-equipped setting is essential.

Can we make an early 'do not resuscitate' decision in severe burn patients?

BACKGROUND: The present study was conducted to examine topic of issuing early do-not-resuscitate (DNR) order at first diagnosis of patients with severe burn injuries in light of current law in Turkey and the medical literature. DNR requires withholding cardiopulmonary resuscitation in event of respiratory or cardiac arrest and allowing natural death to occur. It is frequently enacted for terminal cancer patients and elderly patients with irreversible neurological disorders. METHODS: Between January 2009 and December 2014, 29 patients (3.44%) with very severe burns were admitted to burn unit. Average total burn surface area (TBSA) was 94.24% (range: 85-100%), and in 10 patients, TBSA was 100%. Additional inhalation burns were present in 26 of the patients (89.65%). All of the patients died, despite every medical intervention. Mean survival was 4.75 days (range: 1-24 days). Total of 17 patients died within 72 hours. Lethal dose 50 (% TBSA at which certain group has 50% chance of survival) rate of our burn center is 62%. Baux indices were used for prognostic evaluation of the patients; mean total Baux score of the patients was 154.13 (range: 117-183). RESULTS: It is well known that numerous problems may be encountered during triage of severely burned patients in Turkey. These patients are referred to burn centers and are frequently transferred via air ambulance between cities, and even countries. They are intubated and mechanical ventilation is initiated at burn center. Many interventions are performed to treat these patients, such as escharotomy, fasciotomy, tangential or fascial excision, central venous catheterization and tracheostomy, or hemodialysis. Yet despite such interventions, these patients die, typically within 48 to 96 hours. Integrity of the body is often lost as result of aggressive intervention with no real benefit, and there are also economic costs to hospital related to use of materials, bed occupancy, and distribution of workforce. For these reasons, as well as patient comfort, early do-not-resuscitate or do-not-intubate protocol for these patients is suggested. Resources could then be directed to other patients with high expectancy of life and patients with burns that are beyond treatment can experience more comfortable end of life. CONCLUSION: At present in Turkey, it is not possible to give DNR order for patient with severe burns that are incompatible with survival due to legal interdiction. This subject should be discussed at high-level meetings with participation of doctors, legal experts, economists, and theologians.

The effect of surgical technique on hemodynamics, arterial oxygenation and pulmonary mechanics in radical prostatectomy operations.

OBJECTIVE: The effects of surgical technique on respiratory mechanics, arterial oxygenation and hemodynamics in radical prostatectomy operation were investigated. METHODS: The study was planned on ASA II-III, 40-65 years old, fourty patients scheduled for radical prostatectomy under general anesthesia. They were divided into two groups: perineal and suprapubic (Group P, n = 20; Group S, n = 20). Heart rate, mean arterial blood pressure, arterial oxygen saturation (SpO2), partial pressure of end-tidal carbon dioxide (PEtCO2), Peak inspiratory pressure (PIP), plato pressure (Pplato), partial pressure of oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2) values were evaluated at 10 minutes after induction. After the position applied for surgery in the 30.60 and 90th minutes, the Alveolar-arterial oxygen pressure gradient (P(A-a) O2), the ratio of physiologic dead space over tidal volume (VD/VT), arterial to end tidal CO2 gradient (P(a-et) CO2), static compliance (CS), dynamic compliance (CD) were assessed. RESULTS: In the assessment of groups, there were not statistical differences about mean blood pressure, heart rate, SpO2, PetCO2, PaO2, plateau pressure, and P (A-a) values (p > 0.05). Peak inspiratory pressure was higher in Group P. Peak inspiratory pressure and plateau pressure increased with CO2 insufflation in Group P. PaCO2 and P(a-et) CO2 were higher statistically significantly in Group 0. There was no difference in terms of the PetCO2 values. VD/VT ratios were statistically significantly lower in the Group P. CONCLUSIONS: Suprapubic surgery was shown to improve oxygenation and respiratory mechanics without causing any hemodynamic side effect in radical prostatectomy operation.

Coronary Arteriovenous Fistulas in Adult Patients: Surgical Management and Outcomes.

Objective: The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods: Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results: A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion: The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Coronary arteriovenous fistulas in adult patients: surgical management and outcomes

Abstract Objective: The aim of this study was to describe the demographic, clinical and anatomic characteristics of coronary arteriovenous fistulas in adult patients who underwent open cardiac surgery and to review surgical management and outcomes. Methods: Twenty-one adult patients (12 female, 9 male; mean age: 56.1±7.9 years) who underwent surgical treatment for coronary arteriovenous fistulas were retrospectively included in this study. Coronary angiography, chest X-ray, electrocardiography and transthoracic echocardiography were preoperatively performed in all patients. Demographic and clinical data were also collected. Postoperative courses of all patients were monitored and postoperative complications were noted. Results: A total of 25 coronary arteriovenous fistulas were detected in 21 patients; the fistulas originated mainly from left anterior descending artery (n=9, 42.8%). Four (19.4%) patients had bilateral fistulas originating from both left anterior descending and right coronary artery. The main drainage site of coronary arteriovenous fistulas was the pulmonary artery (n=18, 85.7%). Twelve (57.1%) patients had isolated coronary arteriovenous fistulas and 4 (19.4%), concomitant coronary artery disease. Twenty (95.3%) of all patients were symptomatic. Seventeen patients were operated on with and 4 without cardiopulmonary bypass. There was no mortality. Three patients had postoperative atrial fibrillation. One patient had pericardial effusion causing cardiac tamponade who underwent reoperation. Conclusion: The decision of surgical management should be made on the size and the anatomical location of coronary arteriovenous fistulas and concomitant cardiac comorbidities. Surgical closure with ligation of coronary arteriovenous fistulas can be performed easily with on-pump or off-pump coronary artery bypass grafting, even in asymptomatic patients to prevent fistula related complications with very low risk of mortality and morbidity.

Miller-Fisher syndrome after coronary artery bypass surgery.

Miller-Fisher syndrome (MFS) is an uncommon neurological disorder that is considered a variant of the Guillain-Barre syndrome (GBS). It is clinically defined by a triad of symptoms, namely ataxia, areflexia and ophthalmoplegia. These acute inflammatory polyradiculopathic syndromes can be triggered by viral infections, major surgery, pregnancy or vaccination. While the overall incidence of GBS is 1.2-2.3 per 100 000 per year, MFS is a relatively rare disorder. Only six cases of GBS after cardiac surgery have been reported, and to our knowledge, we describe the first case of MFS after coronary artery bypass surgery. Although cardiac surgery with cardiopulmonary bypass may increase the incidence of MFS and GBS, the pathological mechanism is unclear. Cardiac surgery may be a trigger for the immune-mediated response and may cause devastating complications. It is also important to be alert to de novo autoimmune and unexpected neurological disorders such as MFS after coronary bypass surgery.

Biventricular transient systolic dysfunction after mitral valve replacement: Pericardial decompression syndrome.

BACKGROUND: Pericardial decompression syndrome is defined as paradoxical hemodynamic instability, left ventricular or bi ventricular systolic dysfunction and pulmonary edema after pericardial fluid drainage. Pericardial Decompression Syndrome is an unexpected clinical scenario with an incidence less than 5% in all surgically or percutaneously managed pericardial tamponade patients. The aim of this manuscript was to describe a case with cardiac tamponade in whom acute biventricular heart failure and pulmonary edema developed after surgical creation of a pericardial window, and to discuss this case in light of the literature. CASE REPORT: A 43-year-old woman who underwent mitral valve replacement three weeks ago admitted to our hospital with dyspnea, tachycardia, and atrial fibrillation. Large quantity of pericardial fluid (35mm in the posterior wall, 25mm in the anterior wall) with partial compression of the right ventricle and 50% left ventricle ejection fraction (LVEF) was determined via transthoracic echocardiography (TTE). After creation of pericardio-pleural window, more than 1000ml of serosanguineous fluid were quickly removed from the pericardial space. During the following hours of the decompression, the patient's condition deteriorated and overt pulmonary edema developed. On the second day, biventricular systolic dysfunction, global diffuse hypokinesia and 15-20% LVEF was observed via TTE. High-dose inotropic support and diuretics was continued. During follow up she was progressively weaned off inotropes, LVEF were raised to 35%. Two weeks later, repeated TTE showed normal biventricular systolic function and LVEF was 50%. CONCLUSION: We recommend gradual removal of pericardial effusion under hemodynamic monitoring, especially in patient with postcardiotomy tamponade.

Secondary infections in cancer patients with febrile neutropenia.

OBJECTIVE: Patients with neutropenia due to cancer chemotherapy are prone to severe infections. Cancer patients canexperience >1 infectious episode during the same period of neutropenia. This study aimed to determine the etiologicaland clinical characteristics of secondary infectious episodes in cancer patients with febrile neutropenia and to identifythe factors associated with the risk of secondary infectious episodes. MATERIAL AND METHODS: All cancer patients that received antineoplastic chemotherapy at Ankara University, School ofMedicine, Department of Hematology between May 2004 and May 2005 and developed neutropenia were included in thestudy. Data were collected using survey forms that were completed during routine infectious diseases consultation visits.Categorical data were analyzed using the chi-square test, whereas Student's t-test was used for continuous variables.Multivariate logistic regression analysis was performed to identify independent predictors of secondary infections (SIs). RESULTS: SIs were observed during 138 (53%) of 259 febrile neutropenic episodes. Of the 138 episodes, 89 (64.5%)occurred in male patients with a mean age of 40.9 years (range: 17-76 years). In total, 80% of the SIs were clinically ormicrobiologically documented. Factors on d 4 of the initial febrile episode were analyzed via a logistic regression model. The presence of a central intravenous catheter (OR: 3.01; P<0.001), acute myeloid leukemia (AML) as the underlyingdisease (OR: 2.12; P=0.008), diarrhea (OR: 4.59; P=0.005), and invasive aspergillosis (IA) during the initial febrileepisode (OR: 3.96; P=0.009) were statistically significant risk factors for SIs. CONCLUSION: Among the cancer patients with neutropenia in the present study, AML as the underlying disease, thepresence of a central venous catheter, diarrhea, and IA during the initial febrile episode were risk factors for thedevelopment of SIs.

Outcomes of De Vega versus biodegradable ring annuloplasty in the surgical treatment of tricuspid regurgitation (mid-term results).

PURPOSE: The aim of this study was to compare De Vega semicircular annuloplasty and a new biodegradable ring annuloplasty technique in patients requiring surgical intervention for tricuspid valve disease with concomitant disease of the mitral valve. METHODS: Between January 2004 and May 2008, 129 consecutive patients underwent annuloplasty procedures to correct tricuspid valve regurgitation during a concomitant mitral valve operation requiring replacement. Additionally, 24 patients underwent aortic valve replacement (AVR), 11 underwent coronary artery bypass grafting (CABG), 5 underwent AVR plus CABG, 3 underwent mitral valve replacement plus atrial septal defect (ASD) closure, and 2 underwent ASD closure. The patients in this study were assigned to 2 groups: Kalangos ring annuloplasty was performed in 67 patients (group 1), and De Vega semicircular annuloplasty was performed in the remaining 62 patients (group 2). RESULTS: Both tricuspid valve repair techniques produced a low rate of complications; however, the number of patients who developed residual tricuspid regurgitation was significantly lower in group 1. CONCLUSION: The biodegradable ring annuloplasty technique may be used easily and safely in moderate and severe cases of tricuspid regurgitation; however, larger clinical series are necessary to confirm our promising results.