Effect of the "Recruitment" Maneuver on Respiratory Mechanics in Laparoscopic Sleeve Gastrectomy Surgery.

PURPOSE: LSG surgery is used for surgical treatment of morbid obesity. Obesity, anesthesia, and pneumoperitoneum cause reduced pulmoner functions and a tendency for atelectasis. The alveolar "recruitment" maneuver (RM) keeps airway pressure high, opening alveoli, and increasing arterial oxygenation. The aim of our study is to research the effect on respiratory mechanics and arterial blood gases of performing the RM in LSG surgery. MATERIALS AND METHODS: Sixty patients undergoing LSG surgery were divided into two groups (n = 30) Patients in group R had the RM performed 5 min after desufflation with 100% oxygen, 40 cmH2O pressure for 40 s. Group C had standard mechanical ventilation. Assessments of respiratory mechanics and arterial blood gases were made in the 10th min after induction (T1), 10th min after insufflation (T2), 5th min after desufflation (T3), and 15th min after desufflation (T4). Arterial blood gases were assessed in the 30th min (T5) in the postoperative recovery unit. RESULTS: In group R, values at T5, PaO2 were significantly high, while PaCO2 were significantly low compared with group C. Compliance in both groups reduced with pneumoperitoneum. At T4, the compliance in the recruitment group was higher. In both groups, there was an increase in PIP with pneumoperitoneum and after desufflation this was identified to reduce to levels before pneumoperitoneum. CONCLUSION: Adding the RM to PEEP administration for morbidly obese patients undergoing LSG surgery is considered to be effective in improving respiratory mechanics and arterial blood gas values and can be used safely.

Comparison of EtView™ tracheoscopic ventilation tube and video-assisted fiberoptic bronchoscopy during percutaneous dilatational tracheostomy.

Fiberoptic bronchoscopy (FOB) via endotracheal tube (ETT) is the most frequent utilized technique for monitoring of percutaneous dilatational tracheostomy (PDT) procedure while maintaining mechanical ventilation. Endoscopic guidance has increased the safety of this procedure; nevertheless, the use of a bronchoscope via ETT potentially may deteriorate ventilation and lead to hypercarbia and/or hypoxia. EtView tracheoscopic ventilation tube (EtView TVT) is a standard endotracheal tube with a camera and light source embedded at the tip. The objectives of this study are to introduce EtView TVT as a monitoring tool during PDT and to compare it with video assisted FOB via ETT. We hypothesized that using EtView TVT during PDT may obtain similar visualization; also may have advantages regarding better mechanical ventilation conditions when compared with video-assisted FOB via ETT. Patients, 18-75 years of age requiring mechanical ventilation scheduled for PDT were randomly allocated into two groups for airway monitorization to guide PDT procedure either with FOB via ETT (Group FOB, n = 12) or EtView TVT (Group EtView, n = 12). After standard anesthesia protocol, alveolar recruitment maneuver was applied and all patients were mechanically ventilated at pressure-controlled ventilation mode with same pressure levels. The primary outcome variable was the reduction in arterial oxygen partial pressure (PaO2) values during the procedure. Other respiratory variables and the effectiveness (the visualization and identification of relevant airway structures) of two techniques were the secondary outcome variables. Patients in both groups were comparable with respect to demographic characteristics and initial respiratory variables. Visualization and identification of relevant airway structures in any steps of the PDT procedure were also comparable. The decrease in minute ventilation in Group FOB was higher when compared with Group EtView (51 ± 4 % vs. 12 ± 7.3 %, p < 0.05). The decrease in PaO2 from initial levels during (34 ± 21 % vs. 5 ± 7 % decrease) and after (26 ± 27 % vs. 2.8 ± 16 % decrease) the procedure was higher in Group FOB when compared with Group EtView (p < 0.05). Considering comparable features in monitorization and advantageous features over mechanical ventilation when compared with video bronchoscopy; EtView TVT would be a good alternative for airway monitorization during PDT especially for patients with poor pulmonary reserve.

Traumatic rupture of solid pseudopapillary tumors of the pancreas in children: A case report.

Solid pseudopapillary tumor (SPT) of the pancreas is a pathological entity rarely encountered in children. Despite its malignant characteristics, SPT has a favorable clinical prognosis. This tumor is more frequently observed in females and is commonly localized in the tail and body of the pancreas. This is the case report of a 9-year-old female patient who presented with severe abdominal pain of sudden onset and vomiting following blunt abdominal trauma. Upon physical examination, abdominal distension, tenderness and abdominal guarding were detected. Abdominal magnetic resonance imaging revealed a mass sized 8×9×12 cm in the pancreas, with hemorrhagic-necrotic areas, and abundant intra-abdominal fluid. Intra-abdominal exploration confirmed the presence of an abundant amount of intraperitoneal hemorrhagic fluid. A mass was identified, originating from the body and the tail of the pancreas, adherent to the mesentery of the colon and the hilum of the spleen, which had ruptured in its inferolateral side. The tumor was extirpated together with the spleen and the involved parts of the pancreas. Histopathological examination demonstrated a solid pseudopapillary tumor of pancreatic origin. The patient's postoperative course was uneventful, clinically as well as metabolically.

Effects of pressure-controlled and volume-controlled ventilation on respiratory mechanics and systemic stress response during prone position.

BACKGROUND: Prone position during general anesthesia for special surgical operations may be related with increased airway pressure, decreased pulmonary and thoracic compliance that may be explained by restriction of chest expansion and compression of abdomen. The optimum ventilation mode for anesthetized patients on prone position was not described and studies comparing volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) during prone position are limited. We hypothesized that PCV instead of VCV during prone position could achieve lower airway pressures and reduce the systemic stress response. In this study, we aimed to compare the effects of PCV and VCV modes during prone position on respiratory mechanics, oxygenation, and hemodynamics, as well as blood cortisol and insulin levels, which has not been investigated before. METHODS: Fifty-four ASA I-II patients, 18-70 years of age, who underwent percutaneous nephrolithotomy on prone position, were randomly selected to receive either the PCV (Group PC, n = 27) or VCV (Group VC, n = 27) under general anesthesia with sevoflurane and fentanyl. Blood sampling was made for baseline arterial blood gases (ABG), cortisol, insulin, and glucose levels. After anesthesia induction and endotracheal intubation, patients in Group PC were given pressure support to form 8 mL/kg tidal volume and patients in Group VC was maintained at 8 mL/kg tidal volume calculated using predicted body weight. All patients were maintained with 5 cmH2O PEEP. Respiratory parameters were recorded during supine and prone position. Assessment of ABG and sampling for cortisol, insulin and glucose levels were repeated during surgery and 60 min after extubation. RESULTS: P-peak and P-plateau levels during supine and prone positions were significantly higher and P-mean and compliance levels during prone position were significantly lower in Group VC when compared with Group PC. Postoperative PaO2 level was significantly higher in Group PC compared with Group VC. Cortisol levels were increased with surgery in both groups (p < 0.05) and decreased to baseline levels in Group PC while remained high in Group VC in the early postoperative period. Cortisol levels were significantly higher in Group VC during surgery and in the early postoperative period compared with Group PC. CONCLUSION: When compared with VCV mode, PCV mode is associated with lower P-peak and P-plateau levels during both supine and prone positions, better oxygenation postoperatively, lower blood cortisol levels during surgery in prone position and in the early postoperative period. We concluded that PCV mode might be more appropriate in prone position during anesthesia.

Effects of pressure-controlled and volume-controlled ventilation on respiratory mechanics and systemic stress response during laparoscopic cholecystectomy.

Pressure-controlled ventilation (PCV) is less frequently employed in general anesthesia. With its high and decelerating inspiratory flow, PCV has faster tidal volume delivery and different gas distribution. The same tidal volume setting, delivered by PCV versus volume-controlled ventilation (VCV), will result in a lower peak airway pressure and reduced risk of barotrauma. We hypothesized that PCV instead of VCV during laparoscopic surgery could achieve lower airway pressures and reduce the systemic stress response. Forty ASA I-II patients were randomly selected to receive either the PCV (Group PC, n = 20) or VCV (Group VC, n = 20) during laparoscopic cholecystectomy. Blood sampling was made for baseline arterial blood gases (ABG), cortisol, insulin, and glucose levels. General anesthesia with sevoflurane and fentanyl was employed to all patients. After anesthesia induction and endotracheal intubation, patients in Group PC were given pressure support to form 8 mL/kg tidal volume and patients in Group VC was maintained at 8 mL/kg tidal volume calculated using predicted body weight. All patients were maintained with 5 cmH2O positive-end expiratory pressure (PEEP). Respiratory parameters were recorded before and 30 min after pneumoperitonium. Assessment of ABG and sampling for cortisol, insulin and glucose levels were repeated 30 min after pneumoperitonium and 60 min after extubation. The P-peak levels observed before (18.9 ± 3.8 versus 15 ± 2.2 cmH2O) and during (23.3 ± 3.8 versus 20.1 ± 2.9 cmH2O) pneumoperitoneum in Group VC were significantly higher. Postoperative partial arterial oxygen pressure (PaO2) values are higher (98 ± 12 versus 86 ± 11 mmHg) in Group PC. Arterial carbon dioxide pressure (PaCO2) values (41.8 ± 5.4 versus 36.7 ± 3.5 mmHg) during pneumoperitonium and post-operative mean cortisol and insulin levels were higher in Group VC. When compared to VCV mode, PCV mode may improve compliance during pneumoperitoneum, improve oxygenation and reduce stress response postoperatively and may be more appropriate in patients having laparoscopic surgery.

The influence of airway supporting maneuvers on glottis view in pediatric fiberoptic bronchoscopy / A influência das manobras de suporte das vias aéreas sobre a visibilidade da glote em fibrobroncoscopia pediátrica

ABSTRACTINTRODUCTION:Flexible fiber optic bronchoscopy is a valuable intervention for evaluation and management of respiratory diseases in both infants, pediatric and adult patients. The aim of this study is to investigate the influence of the airway supporting maneuvers on glottis view during pediatric flexible fiberoptic bronchoscopy.MATERIALS AND METHODS:In this randomized, controlled, crossover study; patients aged between 0 and 15 years who underwent flexible fiberoptic bronchoscopy procedure having American Society of Anesthesiologists I---II risk score were included. Patients having risk of difficult intubation, intubated or patients with tracheostomy, and patients with reduced neck mobility or having cautions for neck mobility were excluded from this study. After obtaining best glottic view at the neutral position, patients were positioned jaw trust with open mouth, jaw trust with teeth prottution, head tilt chin lift and triple airway maneuvers and best glottis scores were recorded.RESULTS:Total of 121 pediatric patients, 57 girls and 64 boys, were included in this study. Both jaw trust with open mouth and jaw trust with teeth prottution maneuvers improved the glottis view compared with neutral position (p < 0.05), but we did not observe any difference between jaw trust with open mouth and jaw trust with teeth prottution maneuvers (p > 0.05). Head tilt chin lift and triple airway maneuvers improved glottis view when compared with both jaw trust with open mouth and jaw trust with teeth prottution maneuvers and neutral position (p < 0.05); however we found no differences between head tilt chin lift and triple airway maneuvers (p > 0.05).

RESUMOINTRODUÇÃO: A broncofibroscopia flexível (BF) é uma valiosa intervenção para o manejo eavaliação de doenças respiratórias em pacientes tanto pediátricos quanto adultos. O obje-tivo deste estudo foi investigar a influência das manobras de apoio das vias aéreas sobre avisibilidade da glote durante a BF pediátrica.MATERIAL E MÉTODO: Estudo cruzado, randômico e controlado, incluindo pacientes com idadesentre 0-15 anos, ASA I-II, que foram submetidos à BF. Pacientes com risco de intubação difí-cil, entubados ou com traqueostomia e aqueles com mobilidade reduzida do pescoço ou queexigissem cuidados para a mobilidade do pescoço foram excluídos do estudo. Depois de obter amelhor visibilidade da glote na posição neutra, os pacientes foram posicionados com elevaçãoda mandíbula e abertura da aberta (EMBA), com elevação da mandíbula e protrusão dos dentes(EMPD), com inclinação da cabeça elevação do queixo (ICEQ) e com a tripla manobra das viasaéreas (TMVA). Os melhores escores da glote foram registrados.RESULTADOS: No total, 121 pacientes pediátricos foram incluídos no estudo: 57 pacientes do sexofeminino e 64 do sexo masculino. Ambos as manobras EMBA e EMPD melhoraram a visibilidadeda glote em comparação com a posição neutra (p < 0,05), mas não observamos diferença entreas manobras EMBA e EMPD (p > 0,05). As manobras ICEQ e TMVA melhoraram a visibilidade daglote em comparação com as manobras EMBA e EMPD e a posição neutra (p < 0,05); porém, nãoencontramos diferenças entre a ICEQ e a TMVA (p > 0,05).CONCLUSÃO: Todas as manobras de acesso às vias aéreas melhoraram a visibilidade da glotedurante a BF pediátrica; porém, a inclinação da cabeça e elevação do queixo e a tripla manobradas vias aéreas foram consideradas as manobras mais eficazes.

The influence of airway supporting maneuvers on glottis view in pediatric fiberoptic bronchoscopy.

INTRODUCTION: Flexible fiber optic bronchoscopy is a valuable intervention for evaluation and management of respiratory diseases in both infants, pediatric and adult patients. The aim of this study is to investigate the influence of the airway supporting maneuvers on glottis view during pediatric flexible fiberoptic bronchoscopy. MATERIALS AND METHODS: In this randomized, controlled, crossover study; patients aged between 0 and 15 years who underwent flexible fiberoptic bronchoscopy procedure having American Society of Anesthesiologists I-II risk score were included. Patients having risk of difficult intubation, intubated or patients with tracheostomy, and patients with reduced neck mobility or having cautions for neck mobility were excluded from this study. After obtaining best glottic view at the neutral position, patients were positioned jaw trust with open mouth, jaw trust with teeth prottution, head tilt chin lift and triple airway maneuvers and best glottis scores were recorded. RESULTS: Total of 121 pediatric patients, 57 girls and 64 boys, were included in this study. Both jaw trust with open mouth and jaw trust with teeth prottution maneuvers improved the glottis view compared with neutral position (p<0.05), but we did not observe any difference between jaw trust with open mouth and jaw trust with teeth prottution maneuvers (p>0.05). Head tilt chin lift and triple airway maneuvers improved glottis view when compared with both jaw trust with open mouth and jaw trust with teeth prottution maneuvers and neutral position (p<0.05); however we found no differences between head tilt chin lift and triple airway maneuvers (p>0.05). CONCLUSION: All airway supporting maneuvers improved glottic view during pediatric flexible fiberoptic bronchoscopy; however head tilt chin lift and triple airway maneuvers were found to be the most effective maneuvers.

Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study / Anestesia venosa total livre de opioides, com infusões de propofol, dexmedetomidina e lidocaína para colecistectomia laparoscópica: estudo prospectivo, randomizado e duplo-cego / Anestesia venosa total libre de opiáceos, con infusiones de propofol, dexmedetomidina y lidocaína para la colecistectomía laparoscópica: estudio prospectivo, aleatorizado y doble ciego

BACKGROUND AND OBJECTIVES: Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting. METHODS: 80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6 h after surgery. The primary outcome variable was postoperative fentanyl consumption. RESULTS: Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75 ± 59 µg and 120 ± 94 µg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need. CONCLUSION: Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting. .

JUSTIFICATIVA E OBJETIVOS: O uso de opioides no período intraoperatório pode estar associado à hiperalgesia e ao aumento do consumo de analgésicos no período pós-operatório. Efeitos colaterais como náusea e vômito no período pós-operatório, por causa do uso perioperatório de opioides, podem prolongar a alta. Nossa hipótese foi que a anestesia venosa total com o uso de lidocaína e dexmedetomidina em substituição a opioides pode ser uma técnica opcional para a colecistectomia laparoscópica e estaria associada a uma menor solicitação de fentanil e incidência de náusea e vômito no período pós-operatório. MÉTODOS: Foram programados para colecistectomia laparoscópica eletiva 80 pacientes adultos, estado físico ASA I-II. Os pacientes foram randomicamente alocados em dois grupos para receber anestesia livre de opioides com infusões intravenosas (IV) de dexmedetomidina, lidocaína e propofol (Grupo DL) ou anestesia baseada em opioides com infusões de remifentanil e propofol (Grupo RF). Todos os pacientes receberam um regime padrão de analgesia multimodal. Um dispositivo de analgesia controlada pelo paciente foi ajustado para liberar fentanil IV por seis horas após a cirurgia. O desfecho primário foi o consumo de fentanil no pós-operatório. RESULTADOS: O consumo de fentanil na segunda hora de pós-operatório foi significativamente menor no grupo DL do que no Grupo RF, 75 ± 59 µg e 120 ± 94 µg, respectivamente, mas foi comparável na sexta hora de pós-operatório. Durante a anestesia, houve mais eventos hipotensivos no Grupo RF e mais eventos hipertensivos no grupo DL, ambos estatisticamente significativos. Apesar de apresentar um tempo de recuperação mais prolongado, o Grupo DL apresentou escores de dor e consumo de analgésicos de resgate e de ondansetrona significativamente mais baixos. CONCLUSÃO: A anestesia livre de opioides com infusões de dexmedetomidina, lidocaína e propofol pode ser uma técnica opcional para a colecistectomia laparoscópica, ...

JUSTIFICACIÓN Y OBJETIVOS: El uso de opiáceos en el período intraoperatorio puede estar asociado con la hiperalgesia y con el aumento del consumo de analgésicos en el período postoperatorio. Los efectos colaterales como náuseas y vómito en el período postoperatorio, debido al uso perioperatorio de opiáceos, pueden retrasar el alta. Nuestra hipótesis fue que la anestesia venosa total con el uso de lidocaína y dexmedetomidina como reemplazo de los opiáceos puede ser una técnica alternativa para la colecistectomía laparoscópica y estaría asociada con un requerimiento menor de fentanilo y con una menor incidencia de náuseas y vómito en el período postoperatorio. MÉTODOS: Ochenta pacientes adultos, estado físico ASA I-II, fueron programados para colecistectomía laparoscópica electiva. Los pacientes fueron divididos aleatoriamente en 2 grupos para recibir anestesia libre de opiáceos con infusiones de dexmedetomidina, lidocaína y propofol (grupo DL), o anestesia basada en opiáceos con infusiones de remifentanilo y propofol (grupo RF). Todos los pacientes recibieron un régimen estándar de analgesia multimodal. Un dispositivo de analgesia controlada por el paciente fue ajustado para liberar el fentanilo intravenoso durante 6 h después de la cirugía. El resultado primario fue el consumo de fentanilo en el postoperatorio. RESULTADOS: El consumo de fentanilo en la segunda hora del postoperatorio fue significativamente menor en el grupo DL que en el grupo RF, 75 ± 59 µg y 120 ± 94 µg, respectivamente, pero se pudo comparar en la sexta hora del postoperatorio. Durante la anestesia hubo más eventos hipotensivos en el grupo RF y más eventos hipertensivos en el grupo DL, ambos estadísticamente significativos. A pesar de presentar un tiempo de recuperación más prolongado, el grupo DL tuvo puntuaciones de dolor y consumo de analgésicos de rescate y de ondansetrón significativamente más bajos. CONCLUSIÓN: La anestesia libre de opiáceos con infusiones de ...

Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study.

BACKGROUND AND OBJECTIVES: Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting. METHODS: 80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6h after surgery. The primary outcome variable was postoperative fentanyl consumption. RESULTS: Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75 ± 59 µg and 120 ± 94 µg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need. CONCLUSION: Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting.

[Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study]. / Anestesia venosa total livre de opioides, com infusões de propofol, dexmedetomidina e lidocaína para colecistectomia laparoscópica: estudo prospectivo, randomizado e duplo-cego.

BACKGROUND AND OBJECTIVES: Intraoperative use of opioids may be associated with postoperative hyperalgesia and increased analgesic consumption. Side effects due to perioperative use of opioids, such as postoperative nausea and vomiting may delay discharge. We hypothesized that total intravenous anesthesia consisting of lidocaine and dexmedetomidine as an opioid substitute may be an alternative technique for laparoscopic cholecystectomy and would be associated with lower fentanyl requirements in the postoperative period and less incidence of postoperative nausea and vomiting. METHODS: 80 Anesthesiologists I-II adults were scheduled for elective laparoscopic cholecystectomy. Patients were randomly allocated into two groups to have either opioid-free anesthesia with dexmedetomidine, lidocaine, and propofol infusions (Group DL) or opioid-based anesthesia with remifentanil, and propofol infusions (Group RF). All patients received a standard multimodal analgesia regimen. A patient controlled analgesia device was set to deliver IV fentanyl for 6h after surgery. The primary outcome variable was postoperative fentanyl consumption. RESULTS: Fentanyl consumption at postoperative 2nd hour was statistically significantly less in Group DL, compared with Group RF, which were 75±59µg and 120±94µg respectively, while it was comparable at postoperative 6th hour. During anesthesia, there were more hypotensive events in Group RF, while there were more hypertensive events in Group DL, which were both statistically significant. Despite higher recovery times, Group DL had significantly lower pain scores, rescue analgesic and ondansetron need. CONCLUSION: Opioid-free anesthesia with dexmedetomidine, lidocaine and propofol infusions may be an alternative technique for laparoscopic cholecystectomy especially in patients with high risk for postoperative nausea and vomiting.

Remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy: comparison of adjuvant propofol and ketamine.

OBJECTIVE: Laryngoscopy and stimuli inside the trachea cause an intense sympatho-adrenal response. Remifentanil seems to be the optimal opioid for rigid bronchoscopy due to its potent and short-acting properties. The purpose of this study was to compare bolus propofol and ketamine as an adjuvant to remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy. MATERIALS AND METHODS: Forty children under 12 years of age who had been scheduled for a rigid bronchoscopy were included in this study. After midazolam premedication, a 1 µg/kg/min remifentanil infusion was started, and patients were randomly allocated to receive either propofol (Group P) or ketamine (Group K) as well as mivacurium for muscle relaxation. Anesthesia was maintained with a 1 µg/kg/min remifentanil infusion and bolus doses of propofol or ketamine. After the rigid bronchoscopy, 0.05 µg/kg/min of remifentanil was maintained until extubation. Hemodynamic parameters, emergence characteristics, and adverse events were evaluated. RESULTS: The demographic variables were comparable between the two groups. The decrease in mean arterial pressure from baseline values to the lowest values during rigid bronchoscopy was greater in Group P (p = 0.049), while the reduction in the other parameters and the incidence of adverse events were comparable between the two groups. The need for assisted or controlled mask ventilation after extubation was higher in Group K. CONCLUSION: Remifentanil-based total intravenous anesthesia with propofol or ketamine as an adjuvant drug along with controlled ventilation is a viable technique for pediatric rigid bronchoscopy. Ketamine does not provide a definite advantage over propofol with respect to hemodynamic stability during rigid bronchoscopy, while propofol seems more suitable during the recovery period.

Remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy: comparison of adjuvant propofol and ketamine

OBJECTIVE: Laryngoscopy and stimuli inside the trachea cause an intense sympatho-adrenal response. Remifentanil seems to be the optimal opioid for rigid bronchoscopy due to its potent and short-acting properties. The purpose of this study was to compare bolus propofol and ketamine as an adjuvant to remifentanil-based total intravenous anesthesia for pediatric rigid bronchoscopy. MATERIALS AND METHODS: Forty children under 12 years of age who had been scheduled for a rigid bronchoscopy were included in this study. After midazolam premedication, a 1 µg/kg/min remifentanil infusion was started, and patients were randomly allocated to receive either propofol (Group P) or ketamine (Group K) as well as mivacurium for muscle relaxation. Anesthesia was maintained with a 1 µg/kg/min remifentanil infusion and bolus doses of propofol or ketamine. After the rigid bronchoscopy, 0.05 µg/kg/min of remifentanil was maintained until extubation. Hemodynamic parameters, emergence characteristics, and adverse events were evaluated. RESULTS: The demographic variables were comparable between the two groups. The decrease in mean arterial pressure from baseline values to the lowest values during rigid bronchoscopy was greater in Group P (p = 0.049), while the reduction in the other parameters and the incidence of adverse events were comparable between the two groups. The need for assisted or controlled mask ventilation after extubation was higher in Group K. CONCLUSION: Remifentanil-based total intravenous anesthesia with propofol or ketamine as an adjuvant drug along with controlled ventilation is a viable technique for pediatric rigid bronchoscopy. Ketamine does not provide a definite advantage over propofol with respect to hemodynamic stability during rigid bronchoscopy, while propofol seems more suitable during the recovery period. .

The effects of different oxygen concentrations on recruitment maneuver during general anesthesia for laparoscopic surgery.

INTRODUCTION AND PURPOSE: Recruitment maneuvers (RMs), which aim to ventilate the collaborated alveolus by temporarily increasing the transpulmonary pressure, have positive effects in relation to respiration, mainly oxygenation. Although many studies have defined the pressure values used during RM and the application period, our knowledge of the effects of different oxygen concentrations is limited. In this study, we aimed to determine the effects of different oxygen concentrations during RM on the arterial oxygenation and respiration mechanics in laparoscopic cases. MATERIALS AND METHODS: Thirty-two patients undergoing laparoscopic cholecystectomy were recruited into the study. The patients were randomly divided into 2 groups. RM with a 30% oxygen concentration was performed in patients within the first group (group I, n=16), whereas patients in the second group (group II, n=16) received RM with 100% oxygen. To study respiratory mechanics, dynamic compliance (Cdyn), airway resistance (Raw), and peak inspiratory pressure were measured at 3 different times: 5 minutes after anesthesia induction, 5 minutes after the abdomen was insufflated, and 5 minutes after the abdomen was desufflated. Arterial blood gases were measured during surgery and 30 minutes after surgery (postoperative). RESULTS: The average postoperative partial arterial oxygen pressure values of the patients in groups I and II were 121 and 98 mm Hg, respectively. The difference between the groups was statistically significant. In addition, the decrease in compliance from induction values after desufflation in group II was statistically significant. DISCUSSION: On the basis of our results, maintaining oxygen concentrations below 100% during RM may be more beneficial in terms of respiratory mechanics and gas exchange.

Endobronchial lesion due to pulmonary Fusobacterium nucleatum infection in a child.

Clinically significant infections due to the members of the genus Fusobacterium are rare. The clinical manifestations of pulmonary Fusobacterium nucleatum infections range from simple aspiration pneumonia to severe diseases as necrotizing pneumonia, lung abscess, and empyema. Endobronchial lesions and obstructions are rarely seen in children and are often a misdiagnosed result in delay of definitive treatment. Here, we report a case of endobronchial lesion due to pulmonary F. nucleatum infection in an entirely healthy child before illness. This is the first case reported in the literature of endobronchial lesion due to pulmonary F. nucleatum infection.

Laparoscopic correction of right transverse colostomy prolapse.

Colostomy prolapse is a frequently seen complication of transverse colostomy. In one child with recurrent stoma prolapse, we performed a loop-to-loop fixation and peritoneal tethering laparoscopically. No prolapse had recurred at follow-up. Laparoscopic repair of transverse colostomy prolapse seems to be a less invasive method than other techniques.

Anesthetic management of the SRS™ Endoscopic Stapling System for gastro-esophageal reflux disease.

The SRS(TM) Endoscopic Stapling System (Medigus, Tel Aviv, Israel) is a new tool capable of creating a totally endoscopic fundoplication, combined with an endoscope, endoscopic ultrasound and a surgical stapler. SRS(TM) endoscopic stapling for gastro-esophageal reflux disease is a minimally invasive, outpatient procedure, which requires general anesthesia with positive-pressure ventilation. Keeping the patient on positive end-expiratory pressure (PEEP) may minimize the pressure gradient between the esophagus and the mediastinum, as well as help to prevent air from leaking around the screws and causing pneumomediastinum. In addition, in patients with hiatal hernia, higher PEEP levels may be required to increase intra-thoracic pressure and to force the stomach to slide into the abdomen for ease of endoscopy. We advise smoother emergence from anesthesia, taking precautions for retching, postoperative nausea and vomiting (PONV), while coughing and gagging during extubation and PONV may affect the success of the procedure. Total intravenous anesthesia with propofol and remifentanil seems to be a good choice for these reasons.