Airway management in general anesthesia for endovascular treatment of cerebral arteriovenous malformation: a retrospective observational study.

BACKGROUND AND OBJECTIVE: This retrospective and observational study aimed to retrospectively evaluate the use of the endotracheal tube (ETT) and the Laryngeal Mask Airway (LMA) for the airway management with respect to airway safety, hemodynamic stability, adverse respiratory events, and recovery characteristics in patients who underwent endovascular treatment (EVT) for cerebrovascular arteriovenous malformation under general anesthesia between 2011 and 2018. METHODS: The study included data from the patient's electronic medical records and anesthesia files. The primary outcome measure was the incidence of hemodynamic disturbances and respiratory adverse events during airway management. The secondary outcome measure was the comparison of recovery characteristics. RESULTS: The airway was secured using ETT in 41 patients and LMA in 39 patients. Airway safety was established in all patients without a complication throughout the procedure. Mean arterial blood pressure and heart rate were increased to > 20% of baseline levels at intubation and extubation periods in more patients in the ETT group than the LMA group (27 vs. 3; p = 0.07, and 11 vs. 2; p = 0.021). Respiratory adverse events including straining and coughing were observed in ten patients in the ETT group but only in one patient in the LMA group (p = 0.013). Time to extubation, to neurological assessment, and to discharge from the angiography unit were similar (p > 0.05). CONCLUSION: It was concluded that LMA provided sufficient airway safety as with ETT and may be used as an alternative to ETT for EVTs under general anesthesia.

Comparison of three sitting positions for combined spinal - epidural anesthesia: a multicenter randomized controlled trial.

BACKGROUND AND OBJECTIVES: The aim of this prospective, multi-centered and multi-arm parallel randomized trial was to test the hypothesis that modified sitting positions including hamstring stretch position (HSP) and squatting position (SP) would reduce needle - bone contact events and increase the success rate of combined spinal - epidural anesthesia (CSEA) compared to traditional sitting position (TSP) in patients undergoing total knee or hip arthroplasty. PATIENTS AND METHODS: Three hundred and sixty American Society of Anesthesiologists (ASA) I-III patients, aged between 45-85 years were randomly allocated to one of three groups using computer-generated simple randomization: group TSP (n = 120), group HSP (n = 120), and group SP (n = 120). Primary outcome measures were the number of needle-bone contact and success rates. Secondary outcome measure was the ease of interspinous space identification. RESULTS: Seven patients in group SP and four of HSP could not tolerate their position and were excluded. Number of needle-bone contact, success rates, and grade of interspinous space identification were similar between groups (p = 1.000). Independent of positioning, the success rates were higher in patients whose interspinous space was graded as easy compared to difficult or impossible (p < 0.001). Success rates reduced, interspinous space identification became more challenging, and number of needle - bone contact increased as patient's body mass index (BMI) increased (p < 0.001). CONCLUSION: SP and HSP may be used as alternatives to the TSP. BMI and ease of interspinous space identification may be considered important determinants for CSEA success.

Erythrocyte Autoantibody Positivity in Serological Cross-matching.

OBJECTIVE: To investigate the erythrocyte autoantibody positivity detected in the serological cross-matching (XM), and its  possible effects on salient hemogram parameters. STUDY DESIGN: A descriptive study. PLACE AND DURATION OF STUDY: Balikesir Atatürk City Hospital's Blood Transfusion Centre, Faculty of Medicine, Department of Anesthesiology and Reanimation, Balikesir University, Turkey, from 2017 to 2018. METHODOLOGY: Erythrocyte autoantibody positivity, which was detected in the traditional serological cross-matching for a pre-transfusion laboratory test were analysed retrospectively. Later, hemogram changes in the previous (no erythrocyte autoantibodies) and following (erythrocyte autoantibodies present) transfusions were investigated using statistical methods. RESULTS: Erythrocyte autoantibody positivity rate was 10.16% (342/3,365). There was no statistically significant difference in the increase of hemoglobin, hematocrit, and red blood cell between the period when erythrocyte autoantibodies were detected or not, (p = 0.27, 0.13, and 0.09, respectively). CONCLUSION: Erythrocyte autoantibodies positivity found on routine cross-match exmination, which must be considered together with parameters such as previous transfusion history, other pre-transfusion laboratory test results, and clinical presentation and management. Key Words: Transfusion, Erythrocye autoantibody, Alloantibody, Hemogram, Cross-matching.

Retrospective evaluation of pain in patients with coccydynia who underwent impar ganglion block.

BACKGROUND: We aimed to evaluate pain scores one year after impar ganglion block in patients with coccydynia who did not benefit from conservative treatment. METHODS: The medical records of 29 patients with coccydynia were reviewed. Patients who were referred to the algology clinic and underwent impar ganglion blocks were retrospectively evaluated. Demographic data, time to the onset of pain, causes of pain, X-ray findings, administered invasive procedures, and visual analog scale (pain) scores were recorded. RESULTS: A total of 29 patients were included in the study, 10 males (34%) and 19 females (66%). The average age and body mass index were 53.45 ± 9.6 and 29.55 ± 4.21 respectively. In 21 patients, the onset of pain was associated with trauma. Nineteen patients (65.5%) had anterior coccygeal angulation. The average visual analog scale score before undergoing an impar ganglion block was 7.4 ± 1. After the procedure, the scores at < 3 months, 3-6 months and 6 months-1 year follow-up intervals were significantly lower (p < 0.05). Furthermore, visual analog scale scores at the 3-6 months and 6 months-1 year periods were significantly lower in patients who received diagnostic blocks plus pulse radiofrequency thermocoagulation than in patients who underwent a diagnostic block only. CONCLUSIONS: The impar ganglion block provides effective analgesia without complications in patients with coccydynia. Pulse radiofrequency thermocoagulation combined with a diagnostic block prolongs the analgesic effect of the procedure.

Preoperative ankle block for postoperative analgesia in foot surgery.

BACKGROUND: The use of a tourniquet and patients' preference for general anesthesia (GA) limit performing ankle blocks (AB) as a sole anesthetic technique for orthopedic foot surgery. The aim of this prospective and randomized study was to test the hypothesis that administration of an AB before GA could be effective for postoperative pain relief in patients undergoing outpatient hallux valgus surgery. Primary outcome measure was mean pain score and secondary outcome measures were time to mobilization of patients, time to hospital discharge, and complications. METHODS: A total of 110 adult patients were randomly assigned into two groups: group GA (n = 55) and group GA + AB (n = 55). Group GA + AB received an AB using 100 mg lidocaine 2% and 75 mg bupivacaine 0.5% before the induction of GA. Pain intensity was evaluated using a visual analogue scale (VAS). RESULTS: Mean VAS scores were higher and times to first rescue analgesic were shorter in group GA compared to group GA + AB (p = 0.001). More patients required rescue analgesic in group GA and pethidine consumption was higher (p = 0.001). Time to mobilization was shorter in GA + AB group (p = 0.001) but hospital discharge time was similar between groups (p = 0.269). The incidence of nausea and vomiting was higher in group GA (p = 0.002). CONCLUSION: Ankle block is an effective and simple technique for reducing postoperative pain and opioid consumption. It reduced the time to mobilization without a delay in hospital discharge. It is concluded that the routine administration of AB before GA may be an effective and simple method for pain relief after foot surgery.

Our Brain Death and Organ Donation Experience: Over 12 Years.

PURPOSE: Nowadays, as the number of patients waiting for organ transplant is increasing, it is important to diagnose brain death in intensive care units and to provide good donor care. We aimed to share our experience of donor care with the diagnosis of brain death in our clinic. MATERIAL AND METHOD: One hundred and fifty-one patients diagnosed in our clinic with brain death between June 2006 to 2018 were studied retrospectively. FINDINGS: The mean age of the 151 patients was 46.6 (1-89) years. Fifty-seven (37.7%) of the 151 patients' families accepted donation. Ten out of 57 patients could not be organ donors for medical reasons. Eighty-four kidneys, 7 hearts, and 40 livers were transplanted to the patients. When the diagnosis at admission to the intensive care unit was examined, it was found that the most common diagnosis was intracranial hemorrhage (36.8%), followed by head trauma (21.05%), drowning in water (3.5%), and firearm injury (3.5%). The apnea test was applied to all cases, but 17 patients could not complete the apnea test. In order to support the diagnosis of brain death, in 63% of patients (n = 95) radiological methods were performed. Cranial computed tomography angiography was performed as a radiological method. All cases were found to have received at least 1 inotropic support. We used dopamine in 41 patients, noradrenaline in 36 patients, dobutamine in 8 patients, and adrenaline in 3 patients. During the 12 months when the organ transplant coordinator was not on duty, there were no organ donors. It is important to maintain an organ and tissue transplant coordinator and an intensive care unit team for organ donation. CONCLUSION: In order to increase the cadaver donor pool, it is necessary to increase the number of brain death diagnoses and decrease the rate of family rejection. Therefore, patients with poor neurologic prognosis should be carefully monitored for brain death. Successful family discussions by an experienced and trained organ transplant coordinator should try to increase donation rates by emphasizing the importance of organ donation and the fact that brain death is a real death.

Laryngeal mask airway for general anesthesia in interventional neuroradiology procedures.

OBJECTIVES:   To evaluate whether using laryngeal mask airway (LMA) made a difference in terms of airway security, hemodynamic changes, complications, and recovery times compared to tracheal intubation during the procedure in patients undergoing general anesthesia for endovascular treatments  of unruptured cerebrovascular aneurysms. METHODS: The electronic medical records database, patient files, and anesthesia charts were examined between May 2008 and September 2016 to identify patients with the following inclusion criteria: 1) aged 18-70 years; 2) American Society of Anesthesiologists (ASA) classification I-III; 3) diagnosis of unruptured CVA; 4) Glasgow coma scale of 15 without neurological deficit; and 5) underwent elective EVT under general anesthesia. RESULTS:   Tracheal tube (TT) was used in 46 patients (group TT, n=46) and LMA in 42 patients (group LMA, n=42). Mean arterial pressure (MAP) levels were increased to greater than 20% of baseline in 14 patients (30.4%) after intubation and in 6 (13%) after extubation in group TT. All LMA patients remained within normal MAP limits (p less than 0.05). Six patients (13%) displayed coughing or straining at extubation in group TT whereas none in group LMA (p less than 0.05). Recovery and discharge times were similar (p greater than 0.05). Conclusion:  Laryngeal mask airway  and TT provided comparable airway security during procedure. Laryngeal mask airway attenuated stress response in hemodynamic parameters at intubation and extubation and smoother emergence compared to TT without delay in recovery.

Epidemiological evaluation of an Acinetobacter baumannii outbreak observed at an intensive care unit.

OBJECTIVES: To reveal the relationship between clinical and environmental isolates, analyzing both phenotypic and molecular aspects, in an Acinetobacter baumannii (A. baumannii) epidemic, and to use the epidemiological data to determine the source of the epidemic, to identify potential risk factors, and inform the effort to prevent and manage future epidemics. METHODS: Acinetobacter baumannii was isolated from 5 clinical samples in Sultan Abdulhamid Han Training and Research hospital, Istanbul, Turkey, for a week period. To determine potential sources of infection we established  cultures surveillance. Microbiological identification and antibiotic susceptibility testing of A. baumannii were performed using conventional methods and automated identification system. Multiplex polymerase chain reaction (PCR) and pulsed-field gel electrophoresis (PFGE) were used for carbapenemase gene screening and clonal relationship evaluation. RESULTS: Among the environmental samples, bacterial growth was observed in 3 of the sample cultures. Clinical and environmental samples collected from patients X and Y had phenotypically similar antibiotic susceptibility patterns. The clinical and environmental isolates from patients X and Y comprised the first cluster (6 isolates), the isolates from patient Z formed the second cluster (2 isolates). CONCLUSION: We detected that all outbreak-related isolates contained the same OXA-type carbapenemase genes. Phenotypic similarity, based on the analysis of antimicrobial susceptibility patterns, was correlated with genotypic similarity. These results suggest that monitoring antimicrobial resistance patterns with daily culture surveillance follow-ups, coupled with the use of amplification based methods to detect that clonal relationships are important for the early identification of outbreaks and rapid deployment of proper countermeasures to halt the spread of the causative agent.

Fast-track anesthesia in patients undergoing outpatient laparoscopic cholecystectomy: comparison of sevoflurane with total intravenous anesthesia.

BACKGROUND: The use of short-acting anesthetics has introduced a "fast-track anesthesia" concept in outpatient surgery which provides discharge of the patients from operation room directly to the phase II recovery area without entering into postanesthesia care unit. The aim of this prospective and randomized study was to compare general anesthesia using sevoflurane with propofol-remifentanil-based total intravenous anesthesia (TIVA) for fast-track eligibility in patients undergoing outpatient laparoscopic cholecystectomy. The secondary aim was to compare 2 discharge scoring systems: White's Fast-Tracking Scoring System (WFTSS) and Modified Aldrete Scoring Systems (MASS) with regard to postanesthesia care unit bypass rate and postoperative problems. METHODS: After obtaining ethical approval and written informed patient consent, 80 patients were randomly assigned into 2 groups: group sevoflurane (n=40) and group TIVA (n=40). Anesthesia was induced with propofol, fentanyl, and rocuronium in both groups and maintained with sevoflurane in group sevoflurane and with remifentanil-propofol in group TIVA. Fast-track eligibility was evaluated using both WFTSS and MASS while patients were discharged from operation room according to WFTSS. Recovery times, number of fast-track eligible patients, factors related to fast-track ineligibility, and perioperative complications were evaluated. RESULTS: The ratio of fast-track eligible patients was higher and times to fast-track eligibility were shorter in group TIVA compared with group sevoflurane (82.1% vs 57.5% and 8 minutes vs 12 minutes; P<.05). The primary factors that have inhibited fast-tracking were desaturation, hemodynamic instability, pain, and postoperative nausea and vomiting, respectively. Postoperative nausea and vomiting presented a major difference in the rate of fast-track ineligibility between groups (4 patients in group sevoflurane, whereas none in group TIVA; P<.05). The fast-track ratio was lower with the WFTSS compared with MASS in group sevoflurane (57.5% vs 77.5%, P<.05), but similar in group TIVA.

First report of macroscopic biofilm formation caused by Candida albicans on silver hydrogel-coated urinary catheters.

We report macroscopic biofilms on silver hydrogel-coated urinary catheters in 2 patients from 2 different intensive care units. The catheters were removed on observation of a white, jelly layer on the catheters, respectively, 9 and 21 days after insertion. Yeast cells and pseudohyphal structures were observed with microscopy. Both isolates were identified as Candida albicans. To our knowledge, these are the first cases demonstrating the formation of macroscopic biofilm layers on silver nitrate-coated catheters in the literature.

Do the patients read the informed consent?

BACKGROUND: Informed consent is a process which consists of informing the patient about the medical interventions planned to be applied to the patient's body and making the patient active in the decision making process. AIMS: The aim of this study was to evaluate whether the patients read the informed consent document or not and if not, to determine why they did not read it. This was achieved via a questionnaire administered at the pre-anaesthetic visit to assess the perception of patients to the informed consent process. STUDY DESIGN: Survey study. METHODS: The patients were given a questionnaire after signing the informed consent document at the pre-anaesthetic visit. We studied whether the patients read the informed consent document or not and asked for their reasons if they did not. RESULTS: A total of 522 patients were included during the two month study (mean age: 38.1 years; 63.8% male, 36.2% female). Overall, 54.8% of patients reported that they did not read the informed consent. Among them, 50.3% did not care about it because they thought they would have the operation anyway, 13.4% did not have enough time to read it, 11.9% found it difficult to understand, 5.9% could not read because they had no glasses with them, and 5.2% found it frightening and gave up reading. Inpatients, older patients and patients with co-morbidities were less likely to read the informed consent document than outpatients, and younger and healthy patients (p<0.05). Also, 57.9% of parents whose children would be operated on had read the document. CONCLUSION: This study shows that the majority of our patients did not understand the importance of the informed consent. It is therefore concluded that informed consent documents should be rearranged to be easily read and should be supported with visual elements such as illustrations or video presentations, as informed consent is a process rather than just simply signing a form.