Non-invasive Ventilation and High-Flow Nasal Cannula in Head/Brain Injury with Risk of Pneumocephalus: Is There a Potential Application?

Non-invasive ventilation application in neurocritical care with risk of pneumocephalus is controversial. Non-invasive ventilation-related increased intrathoracic pressure increases intracranial pressure via direct transmission of intrathoracic pressure to the intracranial cavity. In addition, increased thoracic pressure decreases venous return to the heart and increases vena jugularis interna pressure, thereby increasing cerebral blood volume. Pneumocephalus is one of the major concerns after non-invasive ventilation application in head/brain trauma patients. Non-invasive mechanical ventilation may be performed in limited conditions in head trauma/brain surgery with appropriate and close monitoring. High-flow nasal cannula oxygen therapy can provide higher FiO2 as manifested by a larger increase in PaO2/FiO2 ratio and provide the theoretical basis in pneumocephalus because augmenting the PaO2 more effectively would accelerate nitrogen (N2) washout. As a result, non-invasive mechanical ventilation may be performed in limited manner in head trauma/ brain surgery with appropriate and close monitoring.

Hyperoxic oxidative stress during abdominal surgery: a randomized trial.

PURPOSE: The hypothesis of our study is that during anesthesia, administration of 80 % oxygen concentration increases oxidative stress more than 40 % oxygen. METHODS: Forty ASA I-II patients were included in a randomized, single-blind study. Expiratory tidal volumes (ETV) were measured before induction and after extubation. After ventilation with 0.8 FiO2 and intubation, mini-bronchoalveolar lavage (mini-BAL), arterial blood gas (ABG), and blood samples were taken. Patients were randomly assigned to receive 0.8 (group I) or 0.4 (group II) FiO2 during management. Before extubation, mini-BAL, ABG, blood samples were taken. PaO2/FiO2, lactate, malondialdehyde (MDA), protein carbonyl (PCO), superoxide dismutase (SOD), total sulfhydryl (T-SH), non-protein sulfhydryl (NPSH), and protein sulfhydryl (PSH) were measured. In both groups, mean arterial pressure and heart rate values were recorded with 30-min intervals. RESULTS: ETV values were higher in group II after extubation. PaO2/FiO2 values were higher in group II after extubation compared to group I. In both groups, plasma PCO, SOD, and T-SH levels increased significantly before extubation, whereas the increase in MDA was not significant between groups. Plasma PCO, T-SH, and lactate levels were higher in group I, and plasma SOD, and PSH were higher in group I before extubation. In both groups, MDA, SOD, T-SH, and NPSH levels in mini-BAL increased significantly before extubation. Between-group comparisons, PCO, T-SH, PSH, and NPSH were significantly higher in the BAL samples of group II, and MDA levels were higher in group I. CONCLUSIONS: We found that 80 % FiO2 decreased ETV and PaO2/FiO2 and increased lactate levels and oxidative stress more, inhibiting antioxidant response compared to 40 % FiO2.

Comparison of Transversus Abdominis Plane Block and IV Patient-Controlled Analgesia after Lower Abdominal Surgery.

OBJECTIVE: We aimed to compare the first 24-hour postoperative analgesic efficiency of ultrasound (USG)-assisted transversus abdominis plane (TAP) block to IV morphine patient-controlled analgesia (PCA) in patients undergoing lower abdominal surgery. METHODS: Fifty ASA I-III patients were included into this randomised, prospective clinical study. At end of surgery, Group 1 received 1 mg kg(-1) 0.5% bupivacaine and 1 mg kg(-1) 1% lidocaine in a 30-mL volume during TAP-block. Group 2 received 1 mg kg(-1) tramadol IV 10 minutes before extubation, and PCA was started with 1 mL morphine IV at a concentration of 1 mg kg(-1) and a 10-min lock time. Visual analogue scale (VAS), heart rate (HR), respiratory rate, peripheral oxygen saturation (SpO2), additional analgesic need and nausea-vomiting at the postoperative 30(th) minute and 1, 2, 3, 6, 12, and 24 hours were evaluated. In both groups, when VAS values were >4, patients were given 1 mg kg(-1) tramadol IV in first evaluation at the 30(th) minute or 15 mg kg(-1) paracetamol at other evaluations. RESULTS: No difference was observed between groups in terms of VAS values. No difference was observed in terms of HR in the within-group comparison, but Group 1 HR values were lower compared to Group 2 (p<0.01). No difference was observed in additional analgesic need at any times. Nausea-vomiting score was higher in Group 2 in the between-group comparison at the 30(th) minute (p<0.04), but no difference was observed after the 1(st) hour. CONCLUSION: Transversus abdominis plane block is effective as IV morphine-PCA in postoperative pain therapy in lower abdominal surgery, when given in a 30-mL volume. It may be preferable to IV-PCA, as the analgesic effect starts earlier and decreases the systemic effect of the morphine used in PCA.

Anaesthesia Management and Use of Sugammadex in a Patient with Ullrich's Disease.

Here, we report anaesthesia management and the successful use of total intravenous anaesthesia and sugammadex in a patient with Ullrich's disease. Propofol and remifentanyl infusion was used for anaesthesia. After the end of the surgery, when the train-of-four value was 0%, 4 mg kg(-1) sugammadex was administered, and the patient was successfully extubated after 36 s. No adverse effects or safety concerns were observed. In conclusion, we suggest that the use of propofol infusion to avoid the use of inhalation anaesthetics and the use of sugammadex for the reversal of the effects of rocuronium is safe in patients with Ullrich's disease.

Effects of different modes of ventilation and head position on the size of the vena jugularis interna.

PURPOSE: Right internal jugular vein (RIJV) catheterisation is a common procedure in patients undergoing surgery. We aimed to compare diameters and the cross-sectional area (CSA) of the RIJV when the head is in a neutral or 30-degree rotated position during mechanical ventilation in various modes and spontaneous ventilation. METHODS: Thirty patients undergoing surgery were included in the study. In each patient, still ultrasound images of the vena jugularis interna were taken with the head in a neutral position and with the neck rotated 30 degrees to the left, first under spontaneous ventilation (group S), then after the induction of anaesthesia under volume-controlled ventilation (group V) and under pressure-controlled ventilation (group P). The six still images were evaluated in terms of transverse and anteroposterior diameters and CSA. RESULTS: Diameters in the neutral and lateral positions in group S were significantly smaller than in group P and group V (neutral transverse p = 0.01, anteroposterior p = 0.041, rotated transverse p = 0.01, anteroposterior p = 0.03). The CSAs of the RIJV in the neutral and lateral positions were significantly larger in group P and group V than Group S (lateral CSA p = 0.001, neutral CSA p = 0.002). CSA increased significantly only in group P when the head was rotated 30 degrees laterally (p = 0.002). CONCLUSION: We conclude that both pressure-controlled and volume-controlled mechanical ventilation have similar effects on the CSA and diameters of the RIJV. Positioning of the head with a 30-degree rotation laterally has different effects on CSA depending on the ventilation mode used. A neutral position should be preferred with spontaneous ventilation whereas 30 degree rotation should be preferred in patients under pressure-controlled and volume-controlled ventilation.