Preprocedural Ultrasonography Versus Landmark-Guided Spinal Anesthesia in Geriatric Patients with Difficult Anatomy: A Prospective Randomized Trial.

OBJECTIVE: This study was aimed to determine whether preprocedural ultrasonography (USG) affects the technical performance of spinal anesthesia in elderly patients with difficulty in palpating landmarks, scoliosis, or previous spine surgery. MATERIALS AND METHODS: This prospective study was conducted in 156 elderly patients scheduled for elective orthopedic lower extremity surgery. The patients were randomly divided into 2 groups to receive spinal anesthesia by the preprocedural USG examination (group U) or conventional landmark palpation technique (group P). The primary finding of our study was the rate of successful access to the subarachnoid space on initial needle insertion attempt. Secondary achievements included number of needle insertion attempts, number of needle redirections, total procedure time, needle pain scores, patient satisfaction, and complications of spinal anesthesia. RESULTS: The rate of successful access to the subarachnoid space at the first needle insertion attempt was significantly higher in group U than in group P (74.4% vs 53.8%, p=0.008). Medians (interquartile range) of both needle insertion attempts (group P, 2 [1-3] vs group U, 1 [1-2]; p=0.038) and needle redirections (group P, 3 [2-5] vs group U, 2 [1-4]; p=0.028), requiring to achieve dural puncture, were significantly higher among the patients in group P than those in group U. No statistically significant difference was found between the groups regarding total procedure time, pain scores, patient satisfaction scores, and spinal anesthesia-induced complications (p>0.05). CONCLUSION: Our study findings showed that preprocedural neuroaxial USG improves technical performance of spinal anesthesia in elderly patients with difficult anatomy.

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

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

Ultrasound-guided nasogastric feeding tube placement in critical care patients.

BACKGROUND: Nasogastric feeding tube (NGT) placement is a common practice performed in intensive care units (ICUs). Complications due to the improper placement of NGT are well known. In this prospective descriptive study, the effectiveness of ultrasound (US)-guided NGT placement was investigated. MATERIALS AND METHODS: Fifty-six mechanically ventilated patients monitored in the ICU were included. A linear US probe was transversely placed just cranial to the suprasternal notch, and the concentric layers of the esophagus were attempted to be viewed on the posterolateral side of the trachea (generally left) by shifting the probe. If the esophagus can be seen, an attempt was made to insert the NGT under real-time visualization of ultrasonography. Furthermore, gastric placement of the NGT tip was confirmed with abdominal radiograph. RESULTS: A total of 56 patients were included in the study. For 52 (92.8%), the NGT image was obtained during placement within the esophagus. For 3 (5.3%), the esophagus could not be seen by US, and NGT was placed blindly. For 1 patient, we could not detect passing of the NGT into the stomach despite the successful visualization of esophagus. In this patient, NGT was radiographically detected in the trachea after the procedure. CONCLUSION: This study revealed that passing of the NGT through the esophagus could be visualized at a high rate in real-time US among ICU patients. These data suggest that ultrasonographic visualization of the upper esophagus during NGT insertion can be used as an adjuvant method for confirmation of correct placement.

Serum uric acid may predict development of progressive acute kidney injury after open heart surgery.

OBJECTIVES: Acute kidney injury (AKI) is a common complication of cardiac surgery developing in 25-35% cases. Recently, neutrophil gelatinase-associated lipocalin (NGAL) was shown to predict AKI development earlier than serum creatinine. Some studies demonstrated the predictive role of post-operative serum uric acid (SUA) as an early marker of AKI. We aimed to study the role of serum and urine NGAL as well as SUA to predict progression of AKI. DESIGN AND METHODS: This is a prospective observational study of patients undergoing cardiac surgery. Blood and urine samples for measurement of uric acid, serum and urine NGAL levels were collected prior to cardiac surgery (0 h), and in the time course at 2nd and 24th hours after surgery. Patients who developed AKI were divided into two subgroups as progressing and non-progressing AKI. RESULTS: Sixty patients (42 males, 18 females) were included. After cardiac surgery, 40 patients developed AKI, 20 of whom non-progressing AKI, and 20 progressing AKI. All of the markers significantly increased in AKI patients. A receiver operator characteristics (ROC) curve analysis showed higher predictive ability of SUA for progressing AKI compared with serum and urine NGAL. When compared markers obtained at the second hour after surgery, UA had significantly large AUC than NGAL to predict AKI developed at 24 and 48 h, particularly in patients, who require renal replacement therapy (RRT). CONCLUSION: Uric acid seems to predict the progression of AKI and RRT requirement in patients underwent cardiac surgery better than NGAL.

Eficacia do videolaringoscopio C-MAC no manejo de intubacoes malsucedidas inesperadas / Effectiveness of the C-MAC video laryngoscope in the management of unexpected failed intubations / Eficacia del videolaringoscopio C-MAC® en el manejo de intubaciones no exitosas

Justificativa e objetivos: O objetivo deste estudo foi fazer uma revisão das experiências de um departamento de anestesiologia em relação ao uso do videolaringoscópio C-MAC em tentativas malsucedidas de intubação. Métodos: Analisamos os dados de 42 pacientes, cujas tentativas de intubação com o uso delaringoscopia direta (Macintosh) tinham falhado e nos quais o videolaringoscópio C-MAC foi usado como o dispositivo de resgate primário. A taxa de sucesso do C-MAC em intubação foi avaliada e a visão da laringe em ambos os dispositivos foi comparada. Resultados: Com o laringoscópio Macintosh, o escore de Cormack e Lehane foi 3 em 41 pacientes e 4 em um paciente e com o CMAC, foi 1 em 27 pacientes, 2 em 14 pacientes e 3 em um paciente. Intubação traqueal com CMAC foi bem-sucedida em 36 pacientes (86%) na primeira tentativa e em seis pacientes (14%) na segunda tentativa. Nenhuma complicação foi observada, além de pequena lesão (sangue na lâmina) em oito pacientes (19%). Conclusão: Esses dados fornecem evidência para a eficácia clínica do videolaringoscópio C-MAC no manejo de intubações malsucedidas inesperadas em assistência rotineira de anestesia. O videolaringoscópio C-MAC é eficiente e seguro como dispositivo de resgate primário em intubações malsucedidas inesperadas. .

Background and objectives: The purpose of this study was to review the experiences of an anesthesiology department regarding the use of a C-MAC videolaryngoscope in unexpected failed intubation attempts. Methods: Data were analyzed from 42 patients whose intubation attempts using Macintosh direct laryngoscopes had failed, and on whom a C-MAC videolaryngoscope was utilized as the primary rescue device. The success rate of C-MAC in intubation was assessed, and laryngeal views from both devices were compared. Results: The Cormack and Lehane score was III in 41 patients, and IV in one patient, with the Macintosh laryngoscope, while Cormack and Lehane score was I in 27 patients, II in 14 and III in one with CMAC. Tracheal intubation with CMAC was successful on the first attempt in 36 patients (86%), and on the second attempt in 6 patients (14%). No complications were observed other than minor damage (blood on blade) in 8 patients (19%). Conclusion: These data provide evidence for the clinical effectiveness of C-MAC videolaryngoscope in managing the unexpected failed intubations in routine anesthesia care. The C-MAC videolaryngoscope is efficient and safe as a primary rescue device in unexpected failed intubations. .

Justificación y objetivos: El objetivo de este estudio fue hacer una revisión de las experiencias de un departamento de anestesiologia con relación al uso del videolaringoscopio C-MAC® en intentos de intubación que fracasaron. Métodos: Analizamos los datos de 42 pacientes, cuyos intentos de intubación con el uso de laringoscopia directa (Macintosh) habían fallado y en los cuales el videolaringoscopio C-MAC® fue usado como el dispositivo de rescate primario. Se calculó la tasa de éxito del C-MAC® en la intubación y se comprobó la visión de la laringe en los 2 dispositivos. Resultados: Con el laringoscopio Macintosh, la puntuación de Cormack y Lehane fue 3 en 41 pacientes y 4 en un paciente; y con el C-MAC®, fue 1 en 27 pacientes, 2 en 14 pacientes y 3 en un paciente. La intubación traqueal con C-MAC® fue exitosa en 36 pacientes (86%) en el primer intento y en 6 pacientes (14%) en el segundo intento. No se observaron complicaciones, a no ser una pequena lesión (sangre en la lámina) en 8 pacientes (19%). Conclusiones: Esos datos suministran evidencias para la eficacia clínica del videolaringoscopio C-MAC® en el manejo de intubaciones no exitosas inesperadas en asistencia de rutina en anestesia. El videolaringoscopio C-MAC® es eficiente y seguro como dispositivo de rescate primario en intubaciones no exitosas inesperadas. .

Combined use of ultrasound guided infraclavicular block and lateral femoral cutaneous nerve block in upper extremity reconstruction requiring large skin graft: case report.

Combined nerve blocks of the upper extremity and lower limb in same operation rarely performed due to the risk of systemic toxicity of local anesthetics. Therefore, general anesthesia is generally preferred in this operations. However, use of ultrasound allows reliable deposition of the anesthetic around the nerves, potentially lowering the local anesthetic requirement. In this case report, we present a 44-year-old, ASA physical status I, male patient who was operated for upper extremity reconstruction requiring skin graft from anterolateral thigh region under ultrasound-guided infraclavicular brachial plexus block and lateral femoral cutaneous nerve block. The block was successful and no block-related complications were noted. We think that combining an ultrasound guided infraclavicular brachial plexus block and a lateral femoral cutaneous nerve block is a clinically useful and safe technique and an alternative anesthetic method for procedures requiring skin grafts for the upper extremity.

[The effects of intravenous paracetamol on postoperative analgesia and tramadol consumption in cesarean operations]. / Sezaryen cerrahisinde intravenöz parasetamolün postoperatif analjezi ve tramadol tüketimine etkisi.

OBJECTIVES: In this study, the effects and side effects of intravenous paracetamol application, combined with patient-controlled intravenous tramadol analgesia, were investigated in elective cesarean operations for postoperative pain control and its tramadol-sparing effect. METHODS: Fifty ASA I-II patients scheduled for cesarean operation were enrolled in this study. Patients were randomly divided into two groups: group I served as a control group, with saline administration (100 ml) 15 min before the end surgery and every 6 h for 24 h, whereas group II received paracetamol (1 g/100 ml) at the stated time points. All patients received a standard anesthetic protocol. At the end of surgery, all patients received tramadol i.v. via a PCA (patient-controlled analgesia) device. Pain and sedation scores were assessed at 1, 3, 6, 12 and 24 h postoperatively. RESULTS: Tramadol consumption and adverse effects were noted in the first 24 hours following surgery. The pain scores were significantly lower in the paracetamol group when compared with the control group (p<0.05). The cumulative tramadol consumption was lower in the paracetamol group than the control group (p<0.05). No significant difference was observed in sedation scores and nausea-vomiting scores between the groups (p>0.05). CONCLUSION: We conclude that paracetamol is a safe and effective treatment option in post-cesarean pain for combination with tramadol, as it produces effective analgesia and reduces tramadol consumption.