Mean arterial pressure versus cardiac index for haemodynamic management and myocardial injury after hepatopancreatic surgery: A randomised controlled trial.

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) frequently complicates the peri-operative period and is associated with increased mortality. OBJECTIVES: We hypothesised that cardiac index (CI) based haemodynamic management reduces peri-operative high-sensitive troponin-T (hsTnT) elevation and MINS incidence in patients undergoing hepatic/pancreatic surgery compared to mean arterial pressure. DESIGN: A randomised controlled study. SETTING: A single-centre study conducted in a university-affiliated tertiary hospital between June 2022 and March 2023. PATIENTS: Ninety-one patients, who were ≥ 65 years old or ≥ 45 years old with a history of at least one cardiac risk factor were randomised to either mean arterial pressure (MAP) based (n = 45) or CI-based (n = 46) management groups, and completed the study. INTERVENTIONS: In group-MAP, patients received fluid boluses and/or a noradrenaline infusion to maintain MAP above the predefined threshold. In group-CI, patients received fluid boluses and/or dobutamine infusion to keep CI above the predefined threshold. When a low MAP was observed despite a normal CI, a noradrenaline infusion was started. MAIN OUTCOME MEASURES: The primary outcome was peri-operative hsTnT elevation. The secondary outcomes were MINS incidence and 90-day mortality. RESULTS: The median absolute troponin elevation was 4.3 ng l-1 (95% CI 3.4 to 6) for the CI-based group, and 9.4 ng l-1 (95% CI 7.7 to 12.7) for the MAP-based group (median difference: 5.1 ng l-1, 95% CI 3 to 7; P < 0.001). MINS occurred in 8 (17.4%) patients in the CI-based group and 17 (37.8%) patients in the MAP-based group (relative risk: 0.46, 95% CI: 0.22 to 0.96; P = 0.029). Two patients in group-MAP died from cardiovascular-related causes. One patient in group-CI and two in group-MAP died from sepsis-related complications (for all-cause mortality: χ2 = 1.98, P = 0.16). MAP-AUC and CI-AUC values of the CI- and MAP-based groups were 147 vs. 179 min × mmHg (P = 0.85) and 8.4 vs. 43.2 l m-2 min-1 × min (P < 0.001), respectively. CONCLUSIONS: CI-based haemodynamic management assures sufficient flow and consequently is associated with peri-operative hsTnT elevation and the incidence of MINS compared to MAP. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT05391087.

Paravertebral block versus erector spinae plane block for analgesia in modified radical mastectomy: a randomized, prospective, double-blind study.

BACKGROUND: Pain control after breast surgery is crucial and supported with regional techniques. Paravertebral block (TPVB) is shown to be effective in postoperative pain management. Erector spinae plane block (ESPB) is assumed to have a similar analgesic effect as an easier and safer block. Our aim was to compare TPVB and ESPB for modified radical mastectomy (MRM) in terms of analgesic efficiency and dermatomal spread. METHODS: Patients were randomized into Group E (ESPB) and Group P (TPVB). Total 83 patients completed study 42 in Group E and 41 in Group P. Blocks were performed under ultrasonography with 20 mL 0.375% bupivacaine at T4 prior to surgery. T1-10 dermatomal block was examined via pin-prick sensation on the midaxillary and midclavicular lines. Primary outcome was 24-hour morphine consumption. Dermatomal coverage, postoperative 0th minute, 30th minute, 1st, 4th, 6th, 12th and 24th hours pain scores, rescue analgesia requirement and adverse events were secondary outcomes. RESULTS: Morphine consumption was lower in Group P (19.2±2.9 vs. 21±3.1, P=0.007; mean difference 1.8 mg, 95%CI=0.48-3.1 mg). The number of dermatomes with total loss of sensation was higher in Group P. Pain scores were significantly lower in Group P at all time points. The incidence of complications and adverse events was similar in both groups. CONCLUSIONS: Thoracal paravertebral block reduced morphine consumption compared to ESPB after MRM, albeit a small difference. A through coverage of TPVB may be preferred with experienced operators in MRM due to lower pain scores.

Perioperative myocardial injury after elective neurosurgery: incidence, risk factors, and effects on mortality.

Perioperative myocardial injury is an important reason of mortality and morbidity after neurosurgery. It usually is missed due to its asymptomatic character. In the present study, we investigated myocardial injury after noncardiac surgery (MINS) incidence, the risk factor for MINS, and association of MINS with 30-day mortality in neurosurgery patients. Patients with cardiac risk who underwent elective neurosurgery were enrolled to present prospective cohort study. The patients' demographics, comorbidities, medications used, medical history, and type of operation were recorded. The high-sensitivity cardiac troponin (hs-cTn) levels of the patients were measured 12, 24, and 48 h after surgery. The patients were considered MINS-positive if at least one of their postoperative hs-cTn measurement values was ≥ 14 ng/l. All the patients were followed up for 30 days after surgery for evaluation of their outcomes, including total mortality, mortality due to cardiovascular cause, and major cardiac events. A total of 312 patients completed the study and 64 (20.5%) of them was MINS-positive. Long antiplatelet or anticoagulant drug cessation time (OR: 4.9, 95% CI: 2.1-9.4) was found the most prominent risk factor for MINS occurrence. The total mortality rate was 2.4% and 6.2% in patients MINS-negative and MINS-positive, respectively (p = 0.112). The mortality rate due to cardiovascular reasons (0.8% for without MINS, 4.7 for with MINS, and p = 0.026) and incidence of the major cardiac events (4% for without MINS, 10.9 for with MINS, and p = 0.026) were significantly higher in patients with MINS. MINS is a common problem after neurosurgery, and high postoperative hs-cTn level is associated with mortality and morbidity.

Ability of short-time low peep challenge to predict fluid responsiveness in mechanically ventilated patients in the intensive care.

Short-time low PEEP challenge (SLPC, application of additional 5 cmH2O PEEP to patients for 30 s) is a novel functional hemodynamic test presented in the literature. We hypothesized that SLPC could predict fluid responsiveness better than stroke volume variation (SVV) in mechanically ventilated intensive care patients. Heart rate, mean arterial pressure, stroke volume index (SVI) and SVV were recorded before SLPC, during SLPC and before and after 500 mL fluid loading. Patients whose SVI increased more than 15% after the fluid loading were defined as fluid responders. Reciever operating characteristics (ROC) curves were generated to evaluate the abilities of the methods to predict fluid responsiveness. Fifty-five patients completed the study. Twenty-five (46%) of them were responders. Decrease percentage in SVI during SLPC (SVIΔ%-SLPC) was 11.6 ± 5.2% and 4.3 ± 2.2% in responders and non-responders, respectively (p < 0.001). A good correlation was found between SVIΔ%-SLPC and percentage change in SVI after fluid loading (r = 0.728, P < 0.001). Areas under the ROC curves (ROC-AUC) of SVIΔ%-SLPC and SVV were 0.951 (95% CI 0.857-0.991) and 0.747 (95% CI 0.611-0.854), respectively. The ROC-AUC of SVIΔ%-SLPC was significantly higher than that of SVV (p = 0.0045). The best cut-off value of SVIΔ%-SLPC was 7.5% with 90% sensitivity and 96% specificity. The percentage change in SVI during SLPC predicts fluid responsiveness in intensive care patients who are ventilated with low tidal volumes; the sensitivity and specificity values are higher than those of SVV.

Effect of Intraoperative Computed Tomography on Ventriculoperitoneal Shunt Survival.

BACKGROUND: In patients with hydrocephalus who undergo ventriculoperitoneal shunt placement, the ventricular catheter tip position is one of the most important prognostic factors influencing shunt survival. The aim of this study was to present our findings of ventriculoperitoneal shunt placement performed with intraoperative computed tomography (CT) and to evaluate the effect of intraoperative CT-based image guidance on optimal catheter positioning and overall shunt survival. METHODS: Of the study enrolled 345 patients with hydrocephalus who underwent ventriculoperitoneal shunt placement for the first time between 2008 and 2018. Ventricular catheters were inserted freehand via the Kocher point into the lateral ventricle in all patients. In 163 patients, intraoperative CT was performed to confirm the tip position. In this group of patients, if the tip position was nonoptimal, the catheter was ejected and reinserted during the surgery. In the remaining 182 patients, the tip position was assessed with routine postoperative CT. The effect of performing intraoperative CT on catheter tip positioning and shunt failure was investigated. RESULTS: Nonoptimal tip position was significantly correlated with shunt dysfunction even when excluding nonobstructive causes (P < 0.001). In the intraoperative CT group, 11 ventricular catheters (6.7%) were intraoperatively repositioned. The repositioning significantly improved the optimal tip position rate from 54% to 58.3% (P = 0.007). Intraoperative CT usage also showed direct correlation with shunt survival (P = 0.006). CONCLUSIONS: Intraoperative CT is an effective tool for increasing the rate of optimal tip positioning and thereby overall shunt survival.

Comparison of arterial blood pressure and cardiac index-based hemodynamic management on cognitive function in elderly patients undergoing spinal surgery: a randomized clinical trial.

BACKGROUND: Postoperative delayed neurocognitive recovery (DNR) is frequent in elderly patients. Prevention of DNR is essential to achieve a better postoperative outcome. METHODS: The aim of the present study was to compare mean arterial pressure (MAP) and Cardiac Index (CI) based hemodynamic management on early cognitive function in elderly patients undergoing spinal surgery. Sixty patients aged ≥60 years were enrolled. Patients were randomized to one of two groups. In Group MAP, hemodynamic management of patients was performed according to the MAP value. In Group CI, hemodynamic management of patients was performed according to the CI value. In all patients, standard anesthesia method was used and regional cerebral oxygen saturation (rScO2) was measured. Cognitive functions of patients were assessed by Montreal cognitive assessment (MoCA) test before surgery and seven days after surgery. Change in MoCA test (ΔMoCA) was calculated. RESULTS: Postoperative MoCA score was significantly greater in Group CI (25.2±2.4) than Group MAP (23.9±2.5) (P=0.046). The ΔMoCAs were 1 (IQR, 0-3) and 3 (IQR, 2-3.5) in Group CI and MAP respectively (P<0.001). Lowest and average rScO2 values were significantly greater, and the decreased load of rScO2 below the threshold of 10% (AUCΔ10%) and 20% (AUCΔ20%) below its baseline were significantly lower in Group CI (P<0.05). CONCLUSIONS: CI-based hemodynamic management provided better postoperative cognitive function and higher intraoperative rScO2 when compared with MAP-based hemodynamic management.

Prognostic Value of Antithrombin Levels in COVID-19 Patients and Impact of Fresh Frozen Plasma Treatment: A Retrospective Study

Objective: The defective interplay between coagulation and inflammation may be the leading cause of intravascular coagulation and organ dysfunction in coronavirus disease-19 (COVID-19) patients. Abnormal coagulation profiles were reported to be associated with poor outcomes. In this study, we assessed the prognostic values of antithrombin (AT) activity levels and the impact of fresh frozen plasma (FFP) treatment on outcome. Materials and Methods: Conventional coagulation parameters as well as AT activity levels and outcomes of 104 consecutive critically ill acute respiratory distress syndrome (ARDS) patients with laboratory-confirmed COVID-19 disease were retrospectively analyzed. Patients with AT activity below 75% were treated with FFP. Maximum AT activity levels achieved in those patients were recorded. Results: AT activity levels at admission were significantly lower in nonsurvivors than survivors (73% vs. 81%). The cutoff level for admission AT activity was 79% and 58% was the lowest AT for survival. The outcome in those patients who had AT activity levels above 75% after FFP treatment was better than that of the nonresponding group. As well as AT, admission values of D-dimer, C-reactive protein, and procalcitonin were coagulation and inflammatory parameters among the mortality risk factors. Conclusion: AT activity could be used as a prognostic marker for survival and organ failure in COVID-19-associated ARDS patients. AT supplementation therapy with FFP in patients with COVID-19-induced hypercoagulopathy may improve thrombosis prophylaxis and thus have an impact on survival.

The Role of Indirect Laryngoscopy, Clinical and Ultrasonographic Assessment in Prediction of Difficult Airway.

OBJECTIVES: Pre-operative airway evaluation is essential to decrease the proportion of possible mortality and morbidity due to difficult airway (DA). The study aimed to evaluate the accuracy of pre-operative ultrasonographic airway assessment (UAA) and indirect laryngoscopy (IL) in predicting DA. STUDY DESIGN: Prospective obsevational study. METHODS: Preoperative clinical examination (body mass index [BMI], mallampati classification [MP], thyromental distance, sternomental distance, neck circumference), UAA (epiglottis-skin distance [ESD], hyoid bone-skin distance [HSD], the thickness of tongue root [ToTR], anterior commissure-skin distance [ACSD]) and IL with the rigid 70-degree laryngoscope were performed to predict DA (Cormack-Lehane grade 3 and 4). The sensitivity, specificity, positive predictive value (PP), and negative predictive values of the parameters were assessed. RESULTS: Twenty-two of 140 (15.7%) patients were diagnosed with DA. The cut-off points of ESD, HSD, ToTR, ACSD, and BMI were 2.09 cm, 0.835 cm, 4.05 cm, 0.545 cm, and 27.10, respectively. AUC values were 0.874, 0.885, 0.871, 0.658, and 0.751 in the same order. AUC values for IL and MP were 0.773 and 0.925, respectively. MP and HSD had the best sensitivity (91%), IL grading had the best specificity (100%), and PP (100%) value among all measurements. The best-balanced sensitivity (91%), specificity (97%), and PP (88%) values were obtained by combining the IL with MP and ESD or with MP and HSD. CONCLUSIONS: Ultrasonographic measurements and IL were found significantly correlated to predict DA. Combined parameters, the IL with MP and ESD or with MP and HSD, are the best parameters in predicting the DA. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E555-E560, 2021.

An investigation into the effects of hemodynamic changes on the patient's clinical condition during the treatment of patients undergoing aneurysmal subarachnoid hemorrhage.

BACKGROUND: In this study, we investigated the hemodynamic changes in patients with aneurysmal subarachnoid hemorrhage (aSAH) during the intensive care unit and the effects of PiCCO on the hemodynamic clinical course during hydration and hypertension treatment. METHODS: In our study, 15 adult aSAH patients, whose aneurysm had been treated by surgery or coiling, were examined for the signs of vasospasm in between the dates 03/01/2015 and 01/03/2016. The PICCO measurement was made at least twice in a day. Positive daily fluid balance was attempted to be at least 1000 mL and the value of the Global end-diastolic index (GEDI) was targeted to 680 to 800 mL/m2 for each patient. The values of mean arterial pressure (MAP), systolic arterial pressure (SAP), heart rate (HR), central venous pressure (CVP), and cardiac index (CI), GEDI, systemic vascular resistance index (SVRI), extravascular lung water index (ELWI) measured by PiCCO, and daily neurological outcome of patients and GCS values were recorded. RESULTS: It had been observed that CVP value was randomly changing during the volume therapy, but the GEDI value determined by thermodilution was consistent. A positive correlation was detected between the period of reaching the hospital and the first measured value of SVRI. Low GEDI value was detected as a risk factor in the perspective of vasospasm, but an ideal GEDI value could not be determined. CONCLUSION: GEDI values were correlated with daily fluid balance. While low GEDI value was found as a risk factor, we could not determine an ideal GEDI value.

Role of ultrasonography in determining the cricothyroid membrane localization in the predicted difficult airway.

BACKGROUND: The aim of this study was to investigate the success rates of ultrasound (US) and palpation methods in identifying the cricothyroid membrane (CTM), and compare the results with the gold standard method-computed tomography (CT) scan. METHODS: A total of 110 patients were included into the study. The midline was estimated by a single investigator using both the US and palpation methods from the prominence of the thyroid cartilage to the center of the sternal notch, and the distance was measured (in millimeters) between the two points: Point A (the midpoint of CTM) and Point B (the inferior process of thyroid cartilage). Furthermore, the distance between Point A and Point B was calculated using the CT images. Time taken to assess the CTM by using US and palpation methods were recorded. Moreover, difficulty in using the two methods was measured with the visual analog scale (VAS). In addition, demographic and morphometric characteristics of the patients were noted. RESULTS: The CTM was detected accurately in 50 (45.5%) patients with palpation and 82 (74.5%) with US. In the Bland-Altman analysis, a better agreement was observed with US. The time to assess CTM was shorter with US than with palpation, p<0.001. The VAS scores for the palpation and US difficulty were 5.13+-1.1 and 3.32+-0.9 (p<0.001), respectively. While an increased neck circumference and thyromental distance were found to be independent risk factors for the success rates of determining the CTM by palpation, body mass index is an independent risk factor for US. CONCLUSION: Localization of the CTM is more accurate and easier with US than palpation. Furthermore, the results gathered with US are in a closer range to CT scan.

Ability of mini-fluid challenge to predict fluid responsiveness in obese patients undergoing surgery in the prone position.

BACKGROUND: Pulse pressure variation (PPV) and stroke volume variation (SVV) can predict fluid responsiveness effectively. However, high Body Mass Index (BMI) can restrict their use due to changes in respiratory system compliance (CS), intra-abdominal pressure, and stroke volume (SV) in the prone position. Therefore, we aimed to investigate the effectiveness of mini-fluid challenge (MFC) in predicting fluid responsiveness in obese (BMI ≥30 kg/m2) patients in the prone position. METHODS: A total of 33 patients undergoing neurosurgery were included. After standardized anesthesia induction, patients' PPV, SVV, stroke volume index (SVI) and CS values were recorded in the prone position (T1), after the infusion of 100 mL of crystalloid named as MFC (T2) and after fluid loading was completed with additional 400 mL of crystalloid. Patients whose SVI increased more than 15% after the fluid loading were defined as volume responders. RESULTS: Fifteen (45%) patients were responders to 500 mL fluid loading. After the 100 mL fluid load, a higher percentage increase in SVI was observed among responders (P<0.001), with values of 6.6% (6.2-8.6%) and 3.5% (1.7-4.8%) in responders and non-responders, respectively. Areas under the receiver operating characteristic curves of MFC, PPV, and SVV were 0.967 (95% CI: 0.838-0.999), 0.683 (95% CI: 0.499-0.834), and 0.709 (95% CI: 0.526-0.853), respectively. The area under the curve of MFC was significantly higher than that of PPV (P=0.003) and SVV (P=0.005). CONCLUSIONS: The increase in SVI after a rapid infusion of 100 mL crystalloid could predict fluid responsiveness in patients with BMI ≥30 kg/m2 in the prone position.

Comparison of ability of pulse pressure variation to predict fluid responsiveness in prone and supine position: an observational study.

We aimed to compare the ability of pulse pressure variation (PPV) to predict fluid responsiveness in prone and supine positions and investigate effect of body mass index (BMI), intraabdominal pressure (IAP) and static respiratory compliance (CS) on PPV. A total of 88 patients undergoing neurosurgery were included. After standardized anesthesia induction, patients' PPV, stroke volume index (SVI), CS and IAP values were recorded in supine (T1) and prone (T2) positions and after fluid loading (T3). Also, PPV change percentage (PPVΔ%) between T2 and T1 times was calculated. Patients whose SVI increased more than 15% after the fluid loading were defined as volume responders. In 10 patients, PPVΔ% was ≤ - 20%. All of these patients had CST2 < 31 ml/cmH2O, seven had BMI > 30 kg/m2, and two had IAPT2 > 15 mmHg. In 16 patients, PPVΔ% was ≥ 20%. In these patients, 10 had CST2 < 31 ml/cmH2O, 10 had BMI > 30 kg/m2, and 12 had IAPT2 > 15 mmHg. Thirty-nine patients were volume responder. When all patients were examined for predicting fluid responsiveness, area under curves (AUC) of PPVT2 (0.790, 95%CI 0.690-0.870) was significantly lower than AUC of PPVT1 (0.937, 95%CI 0.878-0.997) with ROC analysis (p = 0.002). When patients whose CST2 was < 31 ml/cmH2O and whose BMI was > 30 kg/m2 were excluded from analysis separately, AUC of PPVT2 became similar to PPVT1. PPV in the prone can predict fluid responsiveness as good as PPV in the supine, only if BMI is < 30 kg/m2 and CS value at prone is > 31 ml/cmH2O.

Comparison of Different Cuff Pressure Use with the Supreme Laryngeal Mask Airway on Haemodynamic Response, Seal Pressure and Postoperative Adverse Events: A Prospective Randomized Study.

OBJECTIVE: The Supreme™ laryngeal mask airway (SLMA) is a supra glottic airway (SGA) device that is used as an alternative to endotracheal tubes. In the present study, we aimed to compare the use of the SLMA with normal cuff pressure and low cuff pressure, primarily for haemodynamic response. METHODS: In the present study, 120 patients diagnosed with hypertension and scheduled for varicose vein or inguinal hernia operation were enrolled and 99 patients finished. Using randomization, patients were divided into two groups according to cuff pressure as a low-pressure group (Group L, 45 cm H2O) and a normal-pressure group (Group N, 60 cm H2O). Demographics, Mallampati score and the type and duration of surgery, heart rate (HR), mean arterial pressure (MAP), percentage of tidal volume leakage, Ppeak, Pmean, etCO2, seal pressure, fibreoptic scores and postoperative adverse effects of all patients were recorded. RESULTS: MAP and HR values immediately and 2 minutes after SLMA insertion were significantly lower in Group L (p<0.001). In Group L and Group N, the seal pressures were 24.1±3.1 cm H2O and 26.2±3.9 cm H2O, respectively (p=0.003). Also, blood staining and sore throat occurred less frequently in Group L (p<0.05). The fibreoptic average score, insertion features and ventilation parameters were similar between the groups (p>0.05). CONCLUSION: SLMA use with a cuff pressure of 45 cm H2O significantly decreases haemodynamic response and post-operative side effects compared with a normal cuff pressure. Therefore, except for some specific surgeries that require higher seal pressures, we recommend the use of the SLMA with cuff pressures as low as 45 cm H2O.

Is nighttime laparoscopic general surgery under general anesthesia safe?

BACKGROUND: Fatigue and sleep deprivation can affect rational decision-making and motor skills, which can decrease medical performance and quality of patient care. The aim of the present study was to investigate the association between times of the day when laparoscopic general surgery under general anesthesia was performed and their adverse outcomes. METHODS: All laparoscopic cholecystectomies and appendectomies performed at the emergency surgery department of a tertiary university hospital from 01. 01. 2016 to 12. 31. 2016 were included. Operation times were divided into three groups: 08.01-17.00 (G1: daytime), 17.01-23.00 (G2: early after-hours), and 23.01-08.00 (G3: nighttime). The files of the included patients were evaluated for intraoperative and postoperative surgery and anesthesia-related complications. RESULTS: We used multiple regression analyses of variance with the occurrence of intraoperative complications as a dependent variable and comorbidities, age, gender, body mass index (BMI), ASA score, and operation time group as independent variables. This revealed that nighttime operation (p<0.001; OR, 6.7; CI, 2.6-16.9) and older age (p=0.004; OR, 1.04; CI, 1.01-1.08) were the risk factor for intraoperative complications. The same analysis was performed for determining a risk factor for postoperative complications, and none of the dependent variables were found to be associated with the occurrence of postoperative complications. CONCLUSION: Nighttime surgery and older patient age increased the risk of intraoperative complications without serious morbidity or mortality, but no association was observed between the independent variables and the occurrence of postoperative complications.

Comparison of 3% Hypertonic Saline and 20% Mannitol for Reducing Intracranial Pressure in Patients Undergoing Supratentorial Brain Tumor Surgery: A Randomized, Double-blind Clinical Trial.

BACKGROUND: In the present study, we hypothesized that 3% hypertonic saline (HS) is more effective than 20% mannitol to reduce intracranial pressure (ICP) and to modify brain bulk in patients undergoing an elective supratentorial craniotomy. MATERIALS AND METHODS: After institutional review board approval, patients scheduled to undergo supratentorial craniotomy were enrolled into this prospective, randomized, double-blind study. The patients were monitored for routine hemodynamic parameters, depth of anesthesia, and ICP. They received 5 mL/kg 20% mannitol (n=20) or 3% HS (n=19) as infusion for 15 minutes. The patients' ICP values were monitored during hypertonic fluid infusion and throughout 30 minutes after infusion as a primary outcome. Secondary outcomes were hemodynamic variables, serum sodium value, blood gases, and surgeon brain relaxation assessment score (1=relaxed, 2=satisfactory, 3=firm, 4=bulging). In addition, the length of intensive care unit and hospital stay were recorded. RESULTS: Demographic and tumor characteristics were similar between groups. The basal (before hypertonic infusion, ICPT0) and last (30 min after hypertonic infusion finished, ICPT45) ICP values were 13.7±3.0 and 9.5±1.9 mm Hg, respectively, for the M group, which were comparable with the corresponding levels of 14.2±2.8 and 8.7±1.1 mm Hg in the HS group (P>0.05). The median amount of ICP reduction between T0 and T45 timepoints were 4 (1 to 7) and 5 (1 to 9) mm Hg for group M and group HS, respectively (P=0.035). Baseline central venous pressure, pulse pressure variation, and serum sodium and lactate values were similar between groups, but the last measured pulse pressure variation and lactate value were lower, and sodium value was higher in group HS than in group M (P<0.05). Duration of hospital and intensive care unit stay were similar between groups. CONCLUSIONS: Our results suggest that 3% HS provided more effective ICP reduction than 20% mannitol during supratentorial brain tumor surgery.

The role of ultrasound in appropriate endotracheal tube size selection in pediatric patients.

BACKGROUND: The aim of this prospective study was to investigate the success of ultrasound in pediatric patients in determining the appropriate sized cuffed endotracheal tube and to compare the results with conventional height-based (Broselow) tape and age-based formula tube size. METHODS: One hundred and fifty-two children of 1-10 years of age, who received general anesthesia for adenotonsillectomy were enrolled to the study. In all participants, the transverse diameter of the subglottis was measured with ultrasound during apnea. An endotracheal tube was chosen with the outer diameter matched to the measured subglottic airway diameter. An age-based (Motoyama-Khine) and height-based (Broselow) endotracheal tube size was calculated. If there was resistance to passage of the tube into the trachea or an airway pressure >25 cmH2 0 was required to detect an audible leak, the endotracheal tube was replaced with internal diameter of 0.5 mm smaller. If there was an audible leak at airway pressure <10 cmH2 O, or peak pressure >25 cmH2 0 or a cuff pressure > 25 cmH2 O was required to seal, the tube was changed to the 0.5 mm larger internal diameter. Best-fit tube internal diameter was the resultant tube internal diameter that met the previously stated conditions. The need for endotracheal tube replacement and peak airway pressure were recorded. RESULTS: The internal diameter of ultrasound determined tube was the same as best-fit tube in 88% of children. Endotracheal tube was replaced in 15 patients with a one size larger, and in three patients with one size smaller tube. Using Bland-Altman analysis, a better agreement was observed with ultrasound measurement rather than height-based estimation and age-based formulas. CONCLUSION: Our findings show that subglottic diameter measured by ultrasound appears to be a reliable predictor for the assessment of the subglottic diameter of the airway in estimating appropriate size pediatric endotracheal tube.

Effect of Visible Light on Vasospasticity of Post-Subarachnoid Hemorrhage Cerebrospinal Fluid.

Background and Objective Cerebral vasospasm (CV) is a serious complication of subarachnoid hemorrhage (SAH) with high morbidity and mortality rates. The mechanism of CV has not been determined. There are many theories related to this unsolved issue, one of which supports CV as a two-stage phenomenon from a pathophysiologic perspective. The first stage consists of inhibition of neuronal nitric oxide synthase by oxyhemoglobin, which results in a decrease of nitric oxide (NO) production. The second stage consists of an increase in the levels of asymmetric dimethylarginine through bilirubin oxidation products (BOXes), which are oxidized by-products of hemoglobin metabolism. These in turn inhibit endothelial nitric oxide synthase (eNOS), which results in the blockage of the second NO production mechanism. BOXes are sensitive to visible light, as is their precursor bilirubin. The hypothesis of CV prevention using the photosensitivity of BOXes was tested in this study. Material and Methods Cerebrospinal fluid (CSF) obtained from two patients with SAH was divided in half and either exposed to a standard dose of visible light or not exposed to any light. The CSF was spectrophotometrically investigated and the concentration of BOXes was measured. A comparison between CSF samples exposed to light and not exposed to light was made. Using two groups of 16 rats each, the vasospastic effect of the CSF exposed and not exposed to light on arteries of the cortical surface was measured. The cortex was exposed using the cranial window. Results Spectrophotometric analysis revealed that the concentration of BOXes in the CSF decreased significantly after being exposed to visible light (p < 0.001). There was a significant difference of the vasospastic effect of CSF on exposed cortical arteries (p < 0.001). Conclusion The concentration of BOXes and the vasospastic effect of CSF taken from patients with SAH were significantly reduced after being exposed to visible light if compared with CSF not exposed to light.

A Comparison of the Effects of 20% Mannitol and 3% NaCl on Coagulation Parameters In Vitro using ROTEM: A Prospective Randomized Crossover Study.

OBJECTIVE: The aim of the present study is to compare the effect of 20% mannitol and 3% NaCl on blood coagulation in vitro using rotational thromboelastometry (ROTEM). METHODS: Twenty-millilitre blood samples were obtained from 15 volunteers. In each group, 2 mL blood samples were collected into both polypropylene tubes and EDTA tubes for ROTEM and hemogram analysis. After sampling, blood samples were diluted with test solutions. Group C (control): Only blood, Group M (mannitol): 7% vol 20% mannitol concentration in the blood, Group hypertonic saline (HS): 7% vol 3% hypertonic saline (NaCl) in the blood, Group M/H (mannitol and hydroxyethyl starch solutions [HES]): 6% vol 20% mannitol concentration and 8% vol HES in the blood and Group HS/H (hypertonic saline and HES): 6% vol 3% hypertonic saline concentration and 8% vol HES in the blood. The following thromboelastometric parameters were measured automatically: clotting time (CT) and clot formation time (CFT) with intrinsic activation by tissue factor (InTEM), CT, CFT and maximum clot firmness (MCF) with extrinsic activation by tissue factor (ExTEM) and MCF with FibTEM. RESULTS: The ExTEM CT value was found to be significantly longer in the M/H group than in the controls. The ExTEM CFT median and percentile values were: group C: 85 s (70-95 s), group M: 115 s (94-128 s), group HS: 102 s (84-114 s), group M/H: 128 s (110-144 s) and group HS/H: 118 s (107-132 s). In all the groups, FibTEM MCF values were significantly lower than the control and also there was a significant difference between groups M and HS according to FibTEM MCF values. CONCLUSION: Whole-blood coagulation disorder induced by these solutions is mainly dependent on fibrinogen and fibrin interaction. However, 3% HS has much less negative effect on coagulation.

Evaluation of risk factors and development of acute kidney injury in aneurysmal subarachnoid hemorrhage, head injury, and severe sepsis/septic shock patients during ICU treatment.

BACKGROUND: There are few studies examining development of acute kidney injury (AKI) in the various types of patients in intensive care units (ICUs). Presently described is evaluation of risk factors and development of AKI in different groups of ICU patients. METHODS: Present study was performed in 3 different ICUs. Development of AKI was measured using Acute Kidney Injury Network (AKIN) classification system. Total of 300 patients who were treated in trauma, neurosurgery, or general ICU departments (due to head injury, aneurysmal subarachnoid hemorrhage [aSAH], or severe sepsis/septic shock, respectively) were assessed for incidence, risk factors, and development of AKI. RESULTS: AKI did not develop in aSAH patients when evaluated based on serum creatinine level; however, it was observed in 5% of aSAH patients according to volume adjusted creatinine (VACr) level. AKI developed in 76% of sepsis group, and in 20% of head injury group, based on AKIN classification, according to both serum and VACr levels. Incidence of AKI was significantly higher in sepsis group (p<0.001). Only use of vasopressor was significantly related to AKI development in sepsis and head injury groups. Mortality rate was 8%, 22%, and 42% in aSAH, head injury, and sepsis groups, respectively. AKI development and vasopressor use were significantly related to mortality in sepsis group. CONCLUSION: Despite similar characteristics and risk factors, there were fewer instances of AKI in aSAH group. Hypertension or hydration therapy used to treat vasospasm and polyuria due to cerebral salt-wasting syndrome may prevent aSAH patients from developing AKI.

Transcortical Removal of Third Ventricular Colloid Cysts: Comparison of Conventional, Guided Microsurgical and Endoscopic Approaches and Review of the Literature.

AIM: To compare the clinical results of different transcortical approaches for the removal of third ventricular colloid cysts (CC). MATERIAL AND METHODS: Records of 41 colloid cyst patients who underwent transcortical conventional microsurgical, microsurgical with the aid of stereotactically guided cylindrical retractor (minitubular), and endoscopic removal between 1999 and 2015 were retrospectively analyzed. The clinical results of these three different transcortical surgical approaches were compared and a literature review of published series was conducted. RESULTS: Ages ranged between 16 and 66 years (mean: 36.8). There were 18 female and 23 male patients. Headache was the main presenting symptom. The mean CC diameter was 15.5 mm. Intraventricular hemorrhage was encountered in 2 patients. Three patients needed postoperative ventriculoperitoneal shunt surgery. Postoperative seizures were seen in 3, postoperative neurological deficit in 3 and residual tumor in 2 patients. The conventional approach resulted in significantly higher rates of postoperative seizure compared to the minitubular and endoscopic approaches (p=0.012). The rate of residual cyst was significantly higher in endoscopic approach compared to conventional and minitubular approaches (p=0.024). Conventional approach led to significantly higher rates of neurological deficit compared to the two other approaches (p < 0.05). CONCLUSION: With respect to complication rates, the stereotactic and endoscopic approaches are both safe and reliable compared to conventional microsurgical approach that has unacceptably high rates of seizures and neurological deficit. Concerning completeness of removal, both microsurgical approaches are by far superior to neuroendoscopy. The stereotactic microsurgical approach compares favorably in both respects with endoscopic and conventional microsurgical approaches.