Determination of Risk Factors for Postoperative Acute Kidney Injury in Patients With Gynecologic Malignancies.

Background Postoperative acute kidney injury (AKI) is an important cause of mortality and morbidity among surgical patients. There is little information on the occurrence of AKI after operations for gynecologic malignancies. This study aimed to determine the incidence of AKI in patients who underwent surgery for gynecological malignancies and determine the risk factors in those who developed postoperative AKI. Methodology A total of 1,000 patients were enrolled retrospectively from January 2007 to March 2013. AKI was defined according to the Kidney Disease Improving Global Outcomes 2012 Clinical Practice Guideline for Acute Kidney Injury. Perioperative variables of patients were collected from medical charts. Results The incidence of postoperative AKI was 8.8%, with stage 1 occurring in 5.9%, stage 2 in 2.4%, and stage 3 in 0.5% of the patients. Patients who had AKI were significantly older, had higher body mass index (BMI) higher preoperative C-reactive protein (CRP) levels, and more frequently had a history of distant organ metastasis when compared with those who did not have AKI. When compared with patients who did not develop AKI postoperatively, longer operation times and intraoperative usage of higher amounts of erythrocyte suspension and fresh frozen plasma were seen in those who developed AKI. Conclusions Patients who had AKI were older, had higher BMI with higher preoperative CRP levels, more frequent distant organ metastasis, longer operation times, and higher amounts of blood transfused intraoperatively. Defining preoperative, intraoperative, and postoperative risk factors for postoperative AKI and taking necessary precautions are important for the early detection and intervention of AKI.

Relationship Between Postoperative Acute Kidney Injury and Early Extubation After Pediatric Liver Transplant.

OBJECTIVES: Postoperative acute kidney injury after pediatric liver transplant is a serious complication with considerable short-term and long-term consequences. We hypothesized that incidence of postoperative acute kidney injury after pediatric liver transplant is lower among patients extubated early after surgery in the operating room. MATERIALS AND METHODS: In this retrospective cohort study, we reviewed the medical records of all patients aged <18 years who underwent liver transplant from January 2012 to December 2020. Early extubation was defined as extubation in the operating room. Children were divided into 2 groups: those who were extubated in the operating room and those who were extubated in the intensive care unit. RESULTS: A total of 132 pediatric liver transplant recipients were analyzed. The mean age of transplant was 58.2 ± 60.1 months, and 54.5% were male recipients. Early immediate tracheal extubation in the operating room was performed in 86 patients (65.2%). Postoperative acute kidney injury was seen in 24 children (18.2%) of which 15 (11.4%) had stage 1 acute kidney injury, 8 (6.1%) had stage 2, and 1 (0.8%) had stage 3. There was no statistically significant difference between the 2 groups regarding development of acute kidney injury (18.6% vs 17.4%; P > .05). Compared with patients who were not extubated in the operating room, the need for an open-abdomen procedure (76.9% vs 23.1%; P = .001) was significantly higher in patients who were extubated in the operating room. Durations for length of stay in the intensive care unit and hospital were significantly shorter in patients who were extubated in the operating room (P < .001). CONCLUSIONS: Our results showed that early extubation was performed in nearly two-thirds of our cohort. There was no association between early extubation and development of acute kidney injury among pediatric liver transplant recipients.

A rare case of granulomatosis with polyangiitis with involvement of the gastrointestinal system.

We report a rare case of a 37-year-old man with granulomatosis with polyangiitis (GPA) with gastrointestinal system (GIS) involvement who needed 526 units of blood and blood product transfusions and was followed up in the intensive care unit (ICU). GIS involvement due to GPA is a rare condition that increases morbidity and mortality of patients. Patients may require ultramassive blood product transfusions. Thus, patients with GPA can be admitted to ICUs because of massive hemorrhage due to multisystem involvement, and survival is achievable with meticulous care through a multidisciplinary approach.

Incidence of and Risk Factors for Prolonged Intensive Care Unit Stay After Open Heart Surgery Among Elderly Patients.

OBJECTIVE: Open heart surgery (OHS) is frequently performed on elderly patients. We aimed to investigate the risk factors associated with prolonged intensive care unit (ICU) stay in elderly patients undergoing open heart surgery. MATERIALS AND METHODS: Medical records of all patients ≥ 75 years who underwent OHS (coronary artery bypass grafting (CABG) and/or heart valve surgery) between June 1, 2013, and December 31, 2020, were retrospectively analyzed. Those staying in the ICU longer than five days were determined as prolonged ICU stay. Patients were divided into two groups, according to ICU stay <5 days and ≥5 days. RESULTS: Out of the 198 patients included in the study, 130 (65.7%) were male. Seventy patients (35.4%) had prolonged ICU stay. The mean age was higher in patients within the prolonged ICU stay group when compared to the other group (79.9±3.5 years vs.78.1±2.7 years, p<0.001). The patients who used statins and angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARBs) in the preoperative period had a shorter ICU stay compared to those who did not (45% vs 31.4%, p=0.04; 57% vs 42.9%, p=0.03). The history of previous thoracic surgery (2.3% vs 10% p=0.03), emergency surgery (12.5% vs 24.5% p=0.04), and preoperative pacemaker usage (0.8% vs 7%, 1 p=0.01) were higher in the group of patients with prolonged ICU stay compared to the other group. Preoperative ejection fraction (EF)% (47.7±11.3 vs 51.1±8.8, p<0.001) and hemoglobin level (11.8±1.9 mg/dL vs 12.9±1.6, p<0.001) were lower in the group with prolonged ICU stay compared to the other group. Incidence of cardiac arrest (3.9% vs 15.7% p=0.006), presence of arrhythmia (16.4% vs 41.6%,p<0.001), frequency of pacemaker and intra-aortic balloon pump (IABP) usage (0 vs 10% p=0.002; 1.6% vs 8.6% p=0.02), and need for renal replacement therapy (3.1% vs 12.9%,p=0.02) were higher in the group with prolonged ICU stay compared to the other group. According to the logistic regression analysis; higher age (OR: 1.225, 95%CI 1.104-1.360, p<0.001), preoperative pacemaker usage (OR: 0.100, 95%CI 0.01-0.969, p<0.04), preoperative statin non-use (OR: 2.056, 95%CI 1.040-4.066, p<0.03) and preoperative low EF (OR: 0.947, 95%CI 0.915-0.981, p=0.002) were determined as independent risk factors for prolonged ICU stay. CONCLUSION: The incidence of prolonged ICU stay after OHS among patients ≥75 years was 35.4% in our cohort. Higher age, preoperative pacemaker usage, preoperative statin non-use, and low preoperative EF were associated with prolonged ICU stay.

Neurologic Complications in Heart Transplant Recipients Readmitted to the Intensive Care Unit.

Introduction Neurologic complications after transplantation surgery are major causes of morbidity, and the incidence of neurologic complications among heart transplant recipients varies from 7% to 81%. In our study, we aimed to determine the incidence, etiologies, and risk factors of neurologic complications among patients readmitted to the intensive care unit (ICU) after heart transplantation. Method In this retrospective cohort study, the medical records of all patients who underwent cardiac transplantation from February 2003 to July 2019 were reviewed, and those admitted to the ICU due to neurologic complications during the early and late postoperative period were evaluated. The patients were divided into two groups based on the development of neurologic complications to compare demographic and other characteristics. Results A total of 130 heart transplant recipients were analyzed. We excluded 33 patients from the study because they either had neurologic complications or died postoperatively without discharge from the intensive care unit. The mean age of the cohort was 35.4 ± 18.5 years, and 74 (76.3%) were male. Out of those 97 heart transplant recipients, 22 (22.7%) developed neurologic complications. Five patients (22.7% ) were admitted to the ICU in the first month, six patients (27.3%) were admitted to the ICU between one and six months, and 11 patients (50%) were admitted to the ICU six months after transplantation due to neurologic complications. The most common diagnosis was posterior reversible encephalopathy syndrome (PRES) (n = 6, 27.3%). The other diagnoses were calcineurin inhibitor toxicity (n = 5, 22.7%), intracranial hemorrhage (n = 3, 13.6%), seizures (n = 2, 9.2%), stroke (n = 2, 9.2%), femoral neuropathy (n = 1, 4.5%), myopathy (n = 1, 4.5%), phrenic nerve damage (n = 1, 4.5%), and cerebral abscess (n = 1, 4.5%). The rate of neurologic complications was higher in males when compared with females (p = 0.03). Both groups were similar in terms of the etiologies of cardiac failure, coexisting disease, and anticoagulant and immunosuppressive usage. The requirement for mechanical ventilation, renal replacement therapy, and the incidence of acute kidney injury were similar in both groups (p > 0.05). The incidence of sepsis was significantly higher in patients with neurologic complications (n = 8, 36.4%, versus n = 5, 6.7%; p < 0.001). The mean length of hospital stay was significantly higher in patients with neurologic complications (21.4 ± 15.8 versus 11.1 ± 13.3 days, p = 0.01). The risk of developing neurologic complications is 3.036 times higher in males, and this is statistically significant (odds ratio (OR), 3.036; 95% confidence interval (CI), 1.078-8.444; p = 0.036). Conclusion Our results suggest that neurologic complications develop in 22.7% of heart transplant recipients admitted to the ICU, and half of them are seen after six months postoperatively. PRES was the most frequent (27.3%) neurologic complication. The risk of neurologic complications is three times higher for males. The mean length of hospital stay and incidence of sepsis were significantly higher in heart transplant recipients who developed neurologic complications.

Effects of personality traits on severity of sepsis.

INTRODUCTION: The aim of this study was to reveal the effect of the individual's lifestyle and personality traits on the disease process in patients with sepsis and to have clinical predictions about these patients. MATERIALS AND METHODS: The study was planned as a multi-center, prospective, observational study after obtaining the approval of the local ethics committee. Patients were hospitalized in different intensive care units. Besides demographics and personal characteristics of patients, laboratory data, length of hospital and ICU stay, and mortality was recorded. Two hundred and fifty-nine patients were followed up in 11 different intensive care units. Mortality rates, morbidities, blood analyses, and personality traits were evaluated as primary outcomes. RESULT: Of the 259 patients followed up, mortality rates were significantly higher in men than in women (p= 0.008). No significant difference was found between the patients' daily activity, tea and coffee consumption, reading habits, smoking habits, blood groups, atopy histories and mortality rates. Examining the personal traits, it was seen that 90 people had A-type personality structure and 51 (56.7%) of them died with higher mortality rate compared to type B (p= 0.038). There was no difference between personalities, in concomitant ARDS occurrence, need for sedation and renal replacement therapies. CONCLUSIONS: Among individuals diagnosed with sepsis/septic shock, mortality increased significantly in patients with A-type personality trait compared to other personality traits. These results showed that personal traits may be useful in predicting the severity of disease and mortality in patients with sepsis/septic shock.

Continuous veno-venous hemodiafiltration in metformin-associated lactic acidosis caused by a suicide attempt: A report of two cases.

Lactic acidosis is the most important and life-threatening side effect of metformin that is widely used in the treatment of type 2 diabetes mellitus. In this case report, two cases who were treated in our intensive care unit for lactic acidosis due to high-dose metformin intake for suicidal purposes are presented. The first patient could be successfully treated with continuous venous-venous hemodiafiltration (CVVHDF) and supportive therapy. The second case required endotracheal intubation and mechanical ventilation in addition to CVVHDF and supportive therapy due to delay in treatment.

Successful Liver And Kidney Transplantations From A Donor With Left Ventricular Assist Device.

Organ transplant from donors with ventricular assist devices is not common. Here, we report organ retrieval from a donor with a left ventricular assist device who had been on the heart transplant wait list before a brain death diagnosis. The organ donor was diagnosed with dilated cardiomyopathy and underwent left ventricular assist device surgery for bridging to heart transplant in 2016. Brain death occurred 22 months after implantation of the device at the age of 39 years due to widespread intraparenchymal and subarachnoid hemorrhage. Brain death diagnosis was confirmed with brain perfusion single-photon emission computed tomography. In accordance with the donor's will, the relatives approved organ donation. The donor's organ reserve was assessed to be suitable for liver and kidney transplants, and proper donor care was given. During recovery of organs, the organ transplant team was accompanied by cardiovascular surgeons to control flow of the left ventricular assist device and to ensure optimum organ perfusion. After a successful operation, the liver was transplanted to a patient with primary sclerosing cholangitis who had been on the wait list for liver transplant for 13 years. The kidneys were transplanted to patients awaiting kidney transplant for 31 and 14 years with diagnoses of nephrolithiasis and polycystic kidney disease, respectively. No complications occurred among the liver and kidney transplant recipients. There are few reports of donors with assist devices. This is the first case of an organ donor with an assist device waiting for an organ transplant who became an actual donor in our country.

Risk Factors for Postoperative Prolonged Mechanical Ventilation After Pediatric Liver Transplantation.

OBJECTIVES: Duration of postoperative mechanical ventilation after pediatric liver transplant may influence pulmonary functions, and postoperative prolonged mechanical ventilation is associated with higher morbidity and mortality. Here, we determined its incidence and risk factors after pediatric liver transplant at our center. MATERIALS AND METHODS: We retrospectively analyzed the records of 121 children who underwent liver transplant between April 2007 and April 2017 (305 total liver transplant procedures were performed during this period). Prolonged mechanical ventilation was defined as postoperative tracheal extubation after 24 hours. RESULTS: Mean age at transplant was 6.2 ± 5.4 years and 71/121 children (58.7%) were male. Immediate tracheal extubation was achieved in 68 children (56.2%). Postoperative prolonged mechanical ventilation was needed in 12 children (9.9%), with mean extubation time of 78.0 ± 83.4 hours. Reintubation was required in 13.4%. Logistic regression analysis revealed that presence of preoperative hepatic encephalopathy (odds ratio of 0.130; 95% confidence interval, 0.027-0.615; P = .01), high aspartate amino transferase levels (odds ratio of 1.001; 95% confidence interval, 1.000-1.002; P = .02), intraoperative usage of more packed red blood cells (odds ratio of 1.001; 95% confidence interval, 1.000-1.002; P = .04), and longer surgery duration (odds ratio of 0.723; 95% confidence interval, 0.555-0.940, P = .01) were independent risk factors for postoperative prolonged mechanical venti-lation. Although mean length of intensive care unit stay was significantly longer (12.6 ± 13.6 vs 6.0 ± 0.6 days; P = .001), mortality was similar in children with and without postoperative prolonged mechanical ventilation. CONCLUSIONS: Our results indicate that postoperative prolonged mechanical ventilation was needed in 9.9% of our children. Predictors of postoperative prolonged mechanical ventilation after pediatric liver transplant at our center were preoperative presence of hepatic encephalopathy, high aspartate amino transferase levels, intraoperative usage of more packed red blood cells, and longer surgery duration.

Early Postoperative Acute Kidney Injury Among Pediatric Liver Transplant Recipients.

OBJECTIVES: Acute kidney injury after pediatric liver transplant is associated with increased morbidity and mortality. Here, we evaluated children with acute kidney injury early posttransplant using KDIGO criteria to determine incidence, risk factors, and clinical outcomes. MATERIALS AND METHODS: In this retrospective cohort study, medical records of all patients < 16 years old who underwent liver transplant from April 2007 to April 2017 were reviewed. RESULTS: Of 117 study patients, 69 (59%) were male and median age at transplant was 72 months (range, 12-120 mo). Forty children (34.2%) had postoperative acute kidney injury, with most having stage 1 disease (n = 21). Compared with children who had acute kidney injury versus those who did not, preoperative activated partial thromboplastin time (median 35.6 s [interquartile range, 32.4-42.8 s] vs 42.5 s [interquartile range, 35-49 s]; P = .007), intraoperative lactate levels at end of surgery (median 5.3 mmol/L [interquartile range, 3.3-8.6 mmol/L] vs 7.9 mmol/L [interquartile range, 4.3-11.2 mmol/L]; P = .044), and need for open abdomen (3% vs 15%; P= .024) were significantly higher. Logistic regression analysis revealed that preoperative high activated partial thromboplastin time (P= .02), intraoperative lactate levels at end of surgery (P = .02), and need for open abdomen (P = .03) were independent risk factors for acute kidney injury. Children who developed acute kidney injury had significantly longer intensive care unit stay (7.1 ± 8.5 vs 4.4 ± 5.4 days, P= .04) and mortality (12.8% vs 1.8%; P = .01). CONCLUSIONS: Early postoperative acute kidney injury occurred in 34.2% of pediatric liver transplant recipients, with patients having increased mortality risk. High preoperative activated partial throm-boplastin time, high intraoperative end of surgery lactate levels, and need for open abdomen were shown to be associated with acute kidney injury after pediatric liver transplant.

Effects of volume-controlled equal ratio ventilation with recruitment maneuver and positive end-expiratory pressure in laparoscopic sleeve gastrectomy: a prospective, randomized, controlled trial

Background/aim: We compared the effects of volume-controlled equal ratio ventilation (VC-ERV) and volume-controlled conventional ratio ventilation (VC-CRV) on oxygenation, ventilation, respiratory mechanics, and hemodynamic status during mechanical ventilation with recruitment maneuver (RM) and positive end-expiratory pressure (PEEP) in patients undergoing laparoscopic sleeve gastrectomy. Materials and methods: A total of 111 patients scheduled for laparoscopic sleeve gastrectomy were randomized to ventilation with inspiratory to expiratory ratio of 1:1 (Group VC-ERV) or 1:2 (Group VC-CRV) following tracheal intubation. RM (40 cmH2O, 15 s) and PEEP (10 cmH2O) were administered to all patients. Arterial blood gas samples were taken and peak airway pressure (Ppeak), mean airway pressure (Pmean), dynamic compliance (Cdyn), mean arterial pressure, heart rate, SpO2, and EtCO2 were recorded at 4 time points. Postoperative respiratory complications were recorded. Results: Oxygenation, ventilation, Pmean levels, and hemodynamic variables were similar in both groups. VC-ERV significantly decreased Ppeak and increased Cdyn compared to VC-CRV at all time points of the operation (P < 0.05). No pulmonary complication was observed in any patients. Conclusion: VC-ERV provides significantly lower Ppeak and higher Cdyn with similar oxygenation, ventilation, hemodynamic parameters, and Pmean levels when compared to VC-CRV during mechanical ventilation with RM and PEEP in laparoscopic sleeve gastrectomy.

Bilateral mandibular nerve injury following mask ventilation: a case report / Lesão do nervo mandibular bilateral após ventilação com máscara: um relato de caso

Abstract Background and objectives Nerve injury following mask ventilation is a rare but serious anesthetic complication. The majority of reported cases are associated with excessive pressure applied to the face mask, long duration of mask ventilation, excessive digital pressure behind the mandible to relieve airway obstruction and pressure exerted by the plastic oropharyngeal airway. Case report We present a case of bilateral mandibular nerve injury following mask ventilation with short duration, most likely due to a semi-silicone facemask with an over-inflated cushion. Conclusion An over-inflated sealing cushion of a facemask may trigger difficult mask ventilation leading to mandibular nerve injury following mask ventilation. Alternative airway management techniques such as laryngeal mask airway should be considered when airway maintenance can only be achieved with strong pressure applied to the facemask and/or mandible.

Resumo Justificativa e objetivos A lesão nervosa após ventilação com máscara é uma complicação anestésica rara, mas grave. A maioria dos casos relatados está associada à pressão excessiva aplicada à máscara facial, ao tempo prolongado de ventilação, à pressão digital excessiva atrás da mandíbula para aliviar a obstrução das vias aéreas e à pressão exercida pela cânula orofaríngea. Relato de caso Apresentamos um caso de lesão do nervo mandibular bilateral após uma ventilação de curta duração via máscara, provavelmente devido ao uso de uma máscara facial (de semissilicone) com insuflação excessiva da almofada. Conclusão A insuflação excessiva da almofada de uma máscara facial pode desencadear uma ventilação com máscara difícil, levando à lesão do nervo mandibular após a ventilação. Técnicas alternativas de manejo das vias aéreas, como o uso de máscara laríngea, devem ser consideradas quando a manutenção das vias aéreas só pode ser obtida com forte pressão aplicada à máscara facial e/ou mandíbula.

Anesthetic and Perioperative Management of Nontransplant Surgery in Patients After Liver Transplant.

OBJECTIVES: We aimed to document the anesthetic management and metabolic, hemodynamic, and clinical outcomes of liver-graft recipients who subsequently undergo nontransplant surgical procedures. MATERIALS AND METHODS: We retrospectively analyzed the data of 96 liver-graft recipients who underwent 144 nontransplant surgeries between October 1998 and April 2016 at Baskent University Hospital. RESULTS: The median patient age at the time of nontransplant surgery was 32 years, and 35% were female (n = 33). The median time between transplant and nontransplant surgery was 1231 days. The most frequent types of nontransplant surgery were abdominal (22%), orthopedic (16%), and urologic (13%). Seventy patients had an American Society of Anesthesiologists status of 2 (49%); the status was 3 in 71 patients (49%) and 4 in 3 patients (2%). Of the 144 procedures, 23 were emergent (16%) and 48% were abdominal. General anesthesia was used in 69%, regional anesthesia in 19%, and sedoanalgesia in 11%. Twenty-five patients required intraoperative blood-product transfusion (17%). Intraoperative hemodynamic instability developed in 17% of patients, and hypoxemia developed in 2%. Eleven patients remained intubated at the end of surgery (8%). Of the 144 procedures, 19 (13%) required transfer to the intensive care unit, 108 (75%) transferred to the ward, and the remaining 17 (12%) were discharged on the same day. Eight patients developed respiratory failure (6%), 7 had renal dysfunction (5%), 4 had coagulation abnormalities (3%), and 10 had infectious complications (7%) in the early postoperative period. The median hospital stay was 4 days, and 5 patients (4%) developed rejection during hospitalization. Five patients died of respiratory or infectious complications (4%). CONCLUSIONS: Most liver-graft recipients who undergo nontransplant surgery are given general anesthesia, transferred to the ward after the procedure, and discharged without major complications. We suggest that orthotopic liver transplant recipients may undergo nontransplant surgery without any postoperative graft dysfunction.

A Randomized Controlled Comparison of the Internal Jugular Vein and the Subclavian Vein as Access Sites for Central Venous Catheterization in Pediatric Cardiac Surgery.

OBJECTIVES: To compare internal jugular vein and subclavian vein access for central venous catheterization in terms of success rate and complications. DESIGN: A 1:1 randomized controlled trial. SETTING: Baskent University Medical Center. PATIENTS: Pediatric patients scheduled for cardiac surgery. INTERVENTIONS: Two hundred and eighty children undergoing central venous catheterization were randomly allocated to the internal jugular vein or subclavian vein group during a period of 18 months. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the first-attempt success rate of central venous catheterization through either approach. The secondary outcomes were the rates of infectious and mechanical complications. The central venous catheterization success rate at the first attempt was not significantly different between the subclavian vein (69%) and internal jugular vein (64%) groups (p = 0.448). However, the overall success rate was significantly higher through the subclavian vein (91%) than the internal jugular vein (82%) (p = 0.037). The overall frequency of mechanical complications was not significantly different between the internal jugular vein (25%) and subclavian vein (31%) (p = 0.456). However, the rate of arterial puncture was significantly higher with internal jugular vein (8% vs 2%; p = 0.03) and that of catheter malposition was significantly higher with subclavian vein (17% vs 1%; p < 0.001). The rates per 1,000 catheter days for both positive catheter-tip cultures (26.1% vs 3.6%; p < 0.001) and central-line bloodstream infection (6.9 vs 0; p < 0.001) were significantly higher with internal jugular vein. There were no significant differences between the groups in the length of ICU and hospital stays or in-hospital mortality rates (p > 0.05 for all). CONCLUSIONS: Central venous catheterization through the internal jugular vein and subclavian vein was not significantly different in terms of success at the first attempt. Although the types of mechanical complications were different, the overall rate was similar between internal jugular vein and subclavian vein access. The risk of infectious complications was significantly higher with internal jugular vein access.

Acute Respiratory Failure in Cardiac Transplant Recipients.

OBJECTIVES: This study sought to evaluate the incidence, risk factors, and outcomes of acute respiratory failure in cardiac transplant recipients. MATERIALS AND METHODS: Cardiac transplant recipients >15 years of age and readmitted to the intensive care unit after cardiac transplant between 2005 and 2015 were included. RESULTS: Thirty-nine patients were included in the final analyses. Patients with acute respiratory failure and without acute respiratory failure were compared. The most frequent causes of readmission were routine intensive care unit follow-up after endomyocardial biopsy, heart failure, sepsis, and pneumonia. Patients who were readmitted to the intensive care unit were further divided into 2 groups based on presence of acute respiratory failure. Patients' ages and body weights did not differ between groups. The groups were not different in terms of comorbidities. The admission sequential organ failure assessment scores were higher in patients with acute respiratory failure. Patients with acute respiratory failure were more likely to use bronchodilators and n-acetylcysteine before readmission. Mean peak inspiratory pressures were higher in patients in acute respiratory failure. Patients with acute respiratory failure developed sepsis more frequently and they were more likely to have hypotension. Patients with acute respiratory failure had higher values of serum creatinine before admission to intensive care unit and in the first day of intensive care unit. Patients with acute respiratory failure had more frequent bilateral opacities on chest radiographs and positive blood and urine cultures. Duration of intensive care unit and hospital stays were not statistically different between groups. Mortality in patients with acute respiratory failure was 76.5% compared with 0% in patients without acute respiratory failure. CONCLUSIONS: A significant number of cardiac transplant recipients were readmitted to the intensive care unit. Patients presenting with acute respiratory failure on readmission more frequently developed sepsis and hypotension, suggesting a poorer prognosis.

Percutaneous Dilational Tracheotomy in Solid-Organ Transplant Recipients.

OBJECTIVES: Solid-organ transplant recipients may require percutaneous dilational tracheotomy because of prolonged mechanical ventilation or airway issues, but data regarding its safety and effectiveness in solid-organ transplant recipients are scarce. Here, we evaluated the safety, effectiveness, and benefits in terms of lung mechanics, complications, and patient comfort of percutaneous dilational tracheotomy in solid-organ transplant recipients. MATERIALS AND METHODS: Medical records from 31 solid-organ transplant recipients (median age of 41.0 years [interquartile range, 18.0-53.0 y]) who underwent percutaneous dilational tracheotomy at our hospital between January 2010 and March 2015 were analyzed, including primary diagnosis, comorbidities, duration of orotracheal intubation and mechanical ventilation, length of intensive care unit and hospital stays, the time interval between transplant to percutaneous dilational tracheotomy, Acute Physiology and Chronic Health Evaluation II score, tracheotomy-related complications, and pulmonary compliance and ratio of partial pressure of arterial oxygen to fraction of inspired oxygen. RESULTS: The median Acute Physiology and Chronic Health Evaluation II score on admission was 24.0 (interquartile range, 18.0-29.0). The median interval from transplant to percutaneous dilational tracheotomy was 105.5 days (interquartile range, 13.0-2165.0 d). The only major complication noted was left-sided pneumothorax in 1 patient. There were no significant differences in ratio of partial pressure of arterial oxygen to fraction of inspired oxygen before and after procedure (170.0 [interquartile range, 102.2-302.0] vs 210.0 [interquartile range, 178.5-345.5]; P = .052). However, pulmonary compliance results preprocedure and postprocedure were significantly different (0.020 L/cm H2O [interquartile range, 0.015-0.030 L/cm H2O] vs 0.030 L/cm H2O [interquartile range, 0.020-0.041 L/cm H2O); P = .001]). Need for sedation significantly decreased after tracheotomy (from 17 patients [54.8%] to 8 patients [25.8%]; P = .004]). CONCLUSIONS: Percutaneous dilational tracheotomy with bronchoscopic guidance is an efficacious and safe technique for maintaining airways in solidorgan transplant recipients who require prolonged mechanical ventilation, resulting in possible improvements in ventilatory mechanics and patient comfort.

Addition of low-dose ketamine to midazolam-fentanyl-propofol-based sedation for colonoscopy: a randomized, double-blind, controlled trial.

STUDY OBJECTIVE: To evaluate the effects of low-dose ketamine on midazolam-fentanyl-propofol-based sedation for outpatient colonoscopy. DESIGN: Prospective, randomized, double-blinded, placebo-controlled trial. SETTING: Gastroenterology unit at a practice and clinical research center. SUBJECTS: Ninety-seven healthy American Society of Anesthesiology physical status 1 volunteers. INTERVENTIONS: Subjects were randomized to receive midazolam (0.02 mg/kg), fentanyl (1 µg/kg), and ketamine (0.3 mg/kg) and midazolam (0.02 mg/kg), fentanyl (1 µg/kg), and placebo (0.9% sodium chloride) in group K and group C, respectively. In both groups, incremental doses of propofol were used to maintain a Ramsay sedation score of 3 to 4. MEASUREMENTS: Values of heart rate, blood pressure, oxygen saturation, and respiratory rate were measured. Procedure times, recovery times, drug doses used, complications associated with the sedation, and physician and patient satisfaction were also recorded. MAIN RESULTS: In group K, mean amount of propofol used and mean induction time (P < .001), the need for the use of jaw thrust maneuver and mask ventilation, and the incidence of disruptive movements were significantly lower (P < .05) and gastroenterologist satisfaction at the beginning of the procedure was significantly superior (P < .05). Mean systolic blood pressures at 4, 6, 8, and 10 minutes (P < .01); diastolic blood pressures at 4, 6, and 8 minutes (P < .05); respiratory rates at 4, 6, 8, 10, 15, 20, and 25 minutes (P < .01); and oxygen saturation at 6, 8, 10, 15, and 20 minutes (P < .05) were significantly lower in group C. Patient satisfaction scores, recovery times, and discharge times were similar. No patient in either group experienced unpleasant dreams or hallucination in the postanesthesia care unit and on the first postoperative day. CONCLUSIONS: Addition of low-dose ketamine to midazolam-fentanyl-propofol-based sedation for outpatient colonoscopy resulted in more rapid and better quality of sedation, less propofol consumption, more stable hemodynamic status, and less adverse effects with similar recovery times in adult patients.

Radial mean arterial pressure reliably reflects femoral mean arterial pressure in uncomplicated pediatric cardiac surgery.

OBJECTIVE: To see if radial mean arterial pressure reliably reflects femoral mean arterial pressure in uncomplicated pediatric cardiac surgery. DESIGN: An ethics committee-approved prospective interventional study. SETTING: Operating room of a tertiary care hospital. PARTICIPANTS: Forty-five children aged 3 months to 4 years who underwent pediatric cardiac surgery with hypothermic cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Simultaneous femoral and radial arterial pressures were recorded at 10-minute intervals intraoperatively. A pressure gradient>5mmHg was considered to be clinically significant. The patients' mean age was 14±11 months and and mean weight was 8.0±3.0kg. A total of 1,816 simultaneous measurements of arterial pressure from the radial and femoral arteries were recorded during the pre-cardiopulmonary bypass, cardiopulmonary bypass, and post-cardiopulmonary bypass periods, including 520 (29%) systolic arterial pressures, 520 (29%) diastolic arterial pressures, and 776 (43%) mean arterial pressures. The paired mean arterial pressure measurements across the 3 periods were significantly and strongly correlated, and this was true for systolic arterial pressures and diastolic arterial pressures as well (r>0.93 and p<0.001 for all). Bland-Altman plots demonstrated good agreement between femoral and radial mean arterial pressures during the pre-cardiopulmonary bypass, cardiopulmonary bypass, and post-cardiopulmonary bypass periods. A significant radial-to-femoral pressure gradient was observed in 150 (8%) of the total 1,816 measurements. These gradients occurred most frequently between pairs of systolic arterial pressure measurements (n = 113, 22% of all systolic arterial pressures), followed by mean arterial pressure measurements (n = 28, 4% of all mean arterial pressures) and diastolic arterial pressures measurements (n = 9, 2% of all diastolic arterial pressures). These significant gradients were not sustained (ie, were not recorded at 2 or more successive time points). CONCLUSIONS: The results suggested that radial mean arterial pressure provided an accurate estimate of central mean arterial pressure in uncomplicated pediatric cardiac surgery. There was a significant gradient between radial and femoral mean arterial pressure measurements in only 4% of the mean arterial pressure measurements, and these significant gradients were not sustained.

Perioperative anesthetic management for recipients of orthotopic liver transplant undergoing nontransplant surgery.

OBJECTIVES: The number of organ transplant recipients who present for nontransplant surgery has increased annually. The aim of this study was to evaluate the perioperative anesthetic management of recipients of an orthotopic liver transplant who have undergone nontransplant surgery at Baskent University Hospital. PATIENTS AND METHODS: The medical records of 22 recipients of an orthotopic liver transplant who had undergone a total of 32 nontransplant elective surgeries between December 1988 and February 2006 were retrospectively reviewed. Demographic information, including the anesthetic management and the results of perioperative liver and renal function tests, was recorded. RESULTS: The mean age of the patients at the time of transplant was 20.2 +/- 17.9 years. The mean interval from liver transplant to the first surgery was 739.1 +/- 502.2 days. The most frequent type of surgery was abdominal (28.1%). The types of anesthetic techniques used were general (75%), regional (9.4%), local (9.4%), and sedoanalgesia (6.3%). General anesthesia was induced with thiopental, propofol, or ketamine, and was maintained with isoflurane and nitrous oxide. Endotracheal intubation was performed in 43.8% of the patients. Spinal anesthesia was induced in 3 patients, and peripheral neural blockage was used in 2 patients. Prothrombin time, activated partial thromboplastin time, international normalized ratio, and levels of serum alanine transaminase, aspartate transaminase, total bilirubin, blood urea nitrogen, and creatinine were similar preoperatively and on the first day after surgery (P > .05). CONCLUSIONS: In this study, neither regional nor general anesthesia was associated with a deterioration of liver function. We suggest that recipients of orthotopic liver transplant can undergo nontransplant surgery without postoperative graft dysfunction if hepatic perfusion is maintained with appropriate anesthetic management.