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.

Anaesthetic Management of Renal and Liver Transplantation Recipients During Caesarean Section.

OBJECTIVE: The aim of this study was to present our experience in liver transplantation recipients and renal transplantation recipients during caesarean section. METHODS: Retrospective data regarding liver transplantation recipients and renal transplantation recipients who underwent caesarean section between January 1997 and January 2017 have been collected from the hospital records. RESULTS: Fourteen live births occurred from 5 liver transplantation recipients and 9 renal transplantation recipients, all of them from caesarean section. The mean maternal age (28.4 ± 4.0 years vs. 29.2 ± 4.1 years, P = .38), body weight before conception (57.4 ± 8.8 kg vs. 64.5 ± 8.2 kg, P = .48), and the time from transplantation to conception (99.0 ± 50.7 months vs. 101.0 ± 57.5 months, P = .46) were similar for 5 liver transplantation recipients and 9 renal transplantation recipients, respectively. Four caesarean sections were performed under general anaesthesia, whereas spinal anaesthesia was used in 10 patients. The mean birth weight was similar (2502 ± 311g vs. 2161 ± 658 g, P = .3). There were 3 premature deliveries in liver transplantation recipients versus 6 premature deliveries in renal transplantation recipients and 2 low-birth-weight infants (<2500 g) in liver transplantation recipients versus 4 in renal transplantation recipients among 14 newborns. Infants small for gestational age were diagnosed in 9/14 (3 liver transplantation recipients versus 6 renal transplantation recipients, P = 1). CONCLUSION: General and regional anaesthesia can be safely used during caesarean delivery of liver transplantation recipients and renal transplantation recipients without increased risk of graft losses. Prematurity and low birth weight were mainly due to the cytotoxic drugs for immunosuppression. There are no differences in liver transplantation recipients and renal transplantation recipients for maternal and foetal complications according to our data.

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.

Effects of Minimal Flow Sevoflurane or Desflurane Anaesthesia on Hemodynamic Parameters, Body Temperature and Anaesthetic Consumption.

OBJECTIVE: We aimed to compare minimal flow sevoflurane and desflurane anaesthesia in terms of hemodynamic parameters, body temperature, anaesthetic gas consumption and cost. METHODS: 120 patients with ASA I-II (>18yo) who underwent elective surgery for longer than 60 min after general anaesthesia were randomized into two groups. The Dräger Perseus® A500 workstation was used. Pre-oxygenation was performed for 3 min with 6 L min-1 to 100% oxygen. Fractional inspirium oxygen concentration (FiO2) was reduced to 40%, fresh gas flow was 4 L min-1 after intubation. Sevoflurane or desflurane was started at 1.5 minimal alveolar concentration (MAC). When the MAC value reached 0.9, fresh gas flow was reduced to 0.5 L min-1, FiO2 was increased to 68%. At the end of the surgery, the vaporizer was switched off, the fresh gas flow was increased (4 L min-1, FiO2 100%). When the train-of-four (TOF) ratio was 100%, extubation was carried out. RESULTS: There were no differences in patient characteristics and initial hemodynamic parameters of the groups. There were statistically significant differences between the times to reach 0.9 MAC, extubation and eye opening; anaesthetic, O2 and air consumption in both groups. CONCLUSION: With minimal flow, the time to reach target MAC, time to extubation and eye opening were significantly faster for desflurane and anaesthetic, oxygen and air consumption in desflurane anaesthesia were less than sevoflurane. Thus, we can say that desflurane has faster anaesthetic induction and recovery time with lower anaesthetic consumption than sevoflurane.

Retrospective Evaluation of Patients who Underwent Laparoscopic Bariatric Surgery.

OBJECTIVE: In the present study, we aimed to retrospectively evaluate the preoperative characteristics, intraoperative and postoperative results of patients who underwent laparoscopic obesity surgeries. METHODS: After obtaining the approval of the Ethics Committee, records of patients who underwent laparoscopic obesity surgery from January 2013 to December 2016 were reviewed. Demographic characteristics, medications used in anaesthesia and analgesia, the duration of recovery unit/hospital stay, intensive care unit/mechanical ventilation requirements and complications were recorded. RESULTS: A total of 329 ASA II-III patients over a 3-year period were operated. Thiopental and propofol were administered at induction, sevoflurane, isoflurane and desflurane were administered for the maintenance, and vecuronium and rocuronium were administered to aid in neuromuscular blockage. The mean durations of recovery unit and hospital stays were 30.80±6.01 minutes and 4.27±1.68 days, respectively. The hypnotic agent, muscle relaxant or inhalation anaesthetics used did not have a significant effect on the duration of recovery unit and hospital stay. Mask ventilation and intubation were noted to be difficult in 5.5% and 8.5% of the cases, respectively. The presence of obstructive sleep apnoea syndrome and high body mass index and Mallampati scores significantly increased difficult mask ventilation and difficult intubation rates. Four patients were transferred to intensive care unit for close monitoring. Two patients were re-operated on, two patients had rhabdomyolysis, one patient had Wernicke's encephalopathy and two patients had peripheral neuropathy. Perioperative mortality did not occur in any patient. CONCLUSION: We believe that appropriate patient selection, the use of well-designed anaesthesia and surgical protocols play important roles in increasing the success rate of patient outcomes and early and late complications in laparoscopic obesity surgery.

Tourniquet pressure settings based on limb occlusion pressure determination or arterial occlusion pressure estimation in total knee arthroplasty? A prospective, randomized, double blind trial.

OBJECTIVE: The aim of this study was to compare the limb occlusion pressure (LOP) determination and arterial occlusion pressure (AOP) estimation methods for tourniquet pressure setting in adult patients undergoing knee arthroplasty under combined spinal-epidural anesthesia. METHODS: Ninety-three patients were randomized into two groups. Pneumatic tourniquet inflation pressures were adjusted based either on LOP determination or AOP estimation in Group 1 (46 patients, 38 female and 8 male; mean age: 67.71 ± 9.17) and Group 2 (47 patients, 40 female and 7 male; mean age: 70.31 ± 8.27), respectively. Initial and maximal systolic blood pressures, LOP/AOP levels, required time to estimate AOP/determinate LOP and set the cuff pressure, initial and maximal tourniquet pressures and tourniquet time were recorded. The effectiveness of the tourniquet was assessed by the orthopedic surgeons using a Likert scale. RESULTS: Initial and maximal systolic blood pressures, determined LOP, estimated AOP, duration of tourniquet and the performance of the tourniquet were not different between groups. However, the initial (182.44 ± 14.59 mm Hg vs. 200.69 ± 15.55 mm Hg) and maximal tourniquet pressures (186.91 ± 12.91 mm Hg vs. 200.69 ± 15.55 mm Hg) were significantly lower, the time required to estimate AOP and set the tourniquet cuff pressure was significantly less (23.91 ± 4.77 s vs. 178.81 ± 25.46 s) in Group II (p = 0.000). No complications that could be related to the tourniquet were observed during or after surgery. CONCLUSION: Tourniquet inflation pressure setting based on AOP estimation method provides a bloodless surgical field that is comparable to that of LOP determination method with lower pneumatic inflation pressure and less required time for cuff pressure adjustment in adult patients undergoing total knee arthroplasty under combined spinal epidural anesthesia.

Obese patients require higher, but not high pneumatic tourniquet inflation pressures using a novel technique during total knee arthroplasty.

OBJECTIVES: This study aims to investigate the effect of obesity on pneumatic tourniquet inflation pressures determined with a novel formula during total knee arthroplasty (TKA). PATIENTS AND METHODS: Data of 208 patients (19 males, 199 females; mean age 69.8 years; range, 53 to 84 years) who were performed TKA between January 2013 and December 2016 were evaluated prospectively. Patients were divided into two groups as non-obese (body mass index [BMI] ≤30.0 kg/m2) and obese (BMI >30.0 kg/m2) according to BMI. Tourniquet inflation pressures were set using arterial occlusion pressure (AOP) estimation method and adding 20 mmHg of safety margin to AOP value. All patients were assessed intra- and postoperatively with outcome measures such as systolic blood pressure, AOP, tourniquet pressure and its effectiveness. The quality of the surgical field and complications were assessed by the surgical team in a blinded fashion. RESULTS: The study included 118 and 90 lower extremity operations in obese and non-obese groups, respectively. Compared to non-obese group; extremity circumference, initial and maximal systolic blood pressures, AOP values, initial and maximal tourniquet pressures were higher in obese group. The performance of the tourniquet was assessed as "excellent" and "good" at almost all stages of the surgical procedure in all patients in both groups. No complication occurred intra- or postoperatively. CONCLUSION: Compared to non-obese patients, higher tourniquet inflation pressure is required in obese patients during TKA due to their wider extremity circumference and higher systolic blood pressure profile.

Case reports: Should we do away with them?

STUDY OBJECTIVE: There has been a gradual decline in the number of case reports published in leading medical journals in recent years. Since case reports are not highly cited they have an adverse effect on the journal impact factor. On the other hand sharing new experiences, challenges, or discoveries with colleagues is essential for medical community. Should case reports be eliminated from the journals or published only in journals devoted to case reports? DESIGN: Observational study. SETTING: Web of Science database was searched, between 2005 and 2009, with terms: "anesthesia", "anesthesiology" and "case report" yielding 25 969, 9532, and 661 publications, respectively. Since some reports contained large number of cases, only those involving up to three cases (n = 425) were evaluated by the authors with respect to their type, contribution to knowledge and/or practice (Likert scale) and times they were cited. MAIN RESULTS: Distribution of answers to the statement "Case has added to my knowledge and/or improved my practice" was; 3% (strongly disagree), 10.5% (disagree), 33.2% (neither agree nor disagree), 39.3% (agree) and 13.7% (strongly agree). Average citations per item was 4.43 (1883/425), 7.32 (4838/661), and 7.82 (74 529/9532). As to the types of the reports; 50% unexpected event in the course of anesthesia, 31% unusual and instructive cases, 9.6% novel/unique anesthetic techniques, 6% novel use of equipment, 1.6% new information on diseases of importance to anesthesiology and 1% scientific observations. CONCLUSION: Case reports have been an important source of clinical guidance and scientific insight, and play an important role in medical education. They can be published quickly, providing publication opportunity for juniors and for clinicians who may not have the time or finance to conduct large-scale research. On the other hand some argue, that case reports are irrelevant in current medical practice and education, being at the bottom of the hierarchical ladder of medical evidence. We conclude that case reports should not be done away with but be published in websites and journals like the venue to be launched in 2013 by the International Anesthesia Research Society, devoted entirely to them to meet the need for the publication of interesting cases.

Effects of music on sedation depth and sedative use during pediatric dental procedures.

STUDY OBJECTIVE: The study aimed to investigate the effects of listening to music or providing sound isolation on the depth of sedation and need for sedatives in pediatric dental patients. DESIGN: Prospective, randomized, and controlled study. SETTING: Tertiary, university hospital. PATIENTS: In total, 180 pediatric patients, American Society of Anesthesiologists physical status I and II, who were scheduled for dental procedures of tooth extraction, filling, amputation, and root treatment. INTERVENTIONS: Patients were categorized into 3 groups: music, isolation, and control. During the procedures, the patients in the music group listened to Vivaldi's The Four Seasons violin concertos by sound-isolating headphones, whereas the patients in the isolation group wore the headphones but did not listen to music. All patients were sedated by 0.1 mg/kg midazolam and 1 mg/kg propofol. During the procedure, an additional 0.5 mg/kg propofol was administered as required. MEASUREMENTS AND MAIN RESULTS: Bispectral index was used for quantifying the depth of sedation, and total dosage of the propofol was used for sedative requirements. The patients' heart rates, oxygen saturations, and Observer's Assessment of Alertness and Sedation Scale and bispectral index scores, which were monitored during the operation, were similar among the groups. In terms of the amount of propofol used, the groups were similar. Prolonged postoperative recovery cases were found to be significantly frequent in the control group, according to the recovery duration measurements (P = .004). CONCLUSIONS: Listening to music or providing sound isolation during pediatric dental interventions did not alter the sedation level, amount of medication, and hemodynamic variables significantly. This result might be due to the deep sedation levels reached during the procedures. However, listening to music and providing sound isolation might have contributed in shortening the postoperative recovery duration of the patients.

Anaesthesia Management of a Patient with Factor XI Deficiency.

Factor XI deficiency is an extremely rare disease presenting no clinical symptoms, unless there is an inducing reason such as trauma or surgery. Normally, factor levels are in the range of 70-150 U dL-1 in healthy subjects. Although no clinical symptoms are seen, only high levels of aPTT can be found. Once a prolongation is detected in aPTT, factor XI deficiency should be suspected and factor levels should be analysed. With careful preoperative preparations in factor-deficient people, preoperative and postoperative complications can be decreased. In this case report, management of anaesthesia during total hip arthroplasty of a patient with factor XI deficiency is presented.

EVALUATION AND MANAGEMENT OF DIFFICULT AIRWAY IN OBESITY A SINGLE CENTER RETROSPECTIVE STUDY.

The primary aim of this single center retrospective study was to evaluate difficult mask ventilation (DMV) and difficult laryngoscopy (DL) in a unique group of obese patients. A total of 427 adult patients with body mass index (BMI) ≥ 25 and surgically treated for endometrial cancer from 2011 to 2014 were assessed. Additional increase in BMI, comorbidities, bedside screening tests for risk factors, and the tools used to manage the patients were noted and their effects on DMV and/or DL investigated. Every escalation in the number of risk factors increased the probability of DMV 2.2-fold, DL 1.8-fold and DMV+DL 3.0-fold. Among bedside tests, limited neck movement (LNM), short neck (SN) and absence of teeth were significant for DMV (p < 0.05), LNM, SN and obstructive sleep apnea for DL (p < 0.05), and LNM and SN for DMV+DL (p < 0.05). However, a 10-point increase of BMI was not an independent risk factor when patients with BMI > 25% were considered. In conclusion, LNM and SN are independent risk factors for developing DMV and/or DL in obese endometrial cancer patients, while BMI increase over 30 was not additionally affecting difficult airway.

Clinical utilization of arterial occlusion pressure estimation method in lower limb surgery: effectiveness of tourniquet pressures.

OBJECTIVE: The effectiveness of the arterial occlusion pressure (AOP) estimation method to set tourniquet inflation pressures was assessed in patients undergoing lower limb surgery. METHODS: One hundred ninety-eight operations were performed in 224 lower extremities of 193 patients. Tourniquet inflation pressures were set using the AOP estimation formula and adding 20 mmHg of safety margin to AOP value. Primary outcome measures were the amount of tourniquet pressure and its effectiveness. The quality of the surgical field and complications were assessed by the surgical team in a blinded fashion. Secondary measures included the time required to set the tourniquet pressure and complications. RESULTS: The initial and maximal tourniquet pressures used were 168.4±14.5 and 173.3±15.6 mmHg, respectively. The performance of the tourniquets was assessed as "excellent" and "good" in all stages of the procedure in 97.76% of cases. The time required to measure AOP and set the tourniquet cuff pressure was 19.0±2.6 sec. No complications occurred during or after surgery until discharge. CONCLUSION: Clinical utilization of the AOP estimation formula is a practical and effective way of setting tourniquet pressures for lower limb surgery. Its usage allows achievement of a bloodless field with inflation pressures lower than those previously recommended in the literature for lower limb tourniquets.

Teaching Our Students, Our Residents and Ourselves.

Even though postgraduate medical education has been the focus of interest in anaesthesiology education, in a broader sense the entire medical community can be considered appropriate learners of anaesthesiology. Anaesthesiologists are equipped to teach physiology, pharmacology, resuscitation, pain management, perioperative assessment, and medical technology. For residency training, an approach based on competencies, skills and professionalism should be used instead of the traditional "apprenticeship" model. When teaching ourselves as qualified anaesthesiologists, areas of continuing professional development, academic career training and continuing medical education should be taken into account. Whereas the responsibility for undergraduate medical education rests with university medical schools, postgraduate medical education is carried out by universities and/or the national health authorities/services. Establishment of partnerships between health-care services and universities should be central to the provision of postgraduate education so as not to dissociate various stages of education. When determining educational strategies, institutional preferences, target populations and their learning styles should be taken into account. To this end, especially for high risk situations simulation-based approaches, scenarios, standardized patients, research, mentoring, journal clubs, seminars, lectures, case discussions, bed-side discussions, courses, games and portfolios have been and are being used widely. Departments of anaesthesiology should establish and maintain a strong presence in undergraduate medical education. Besides being good clinicians, anaesthesiologists should understand all aspects of education and educational outcome in order to better teach students, residents and themselves. Quality of education and the teaching environment should continually be evaluated within the context of quality assurance.

Impaired coronary microvascular function in familial Mediterranean fever.

BACKGROUND: Patients with inflammatory rheumatic diseases have an increased risk of developing atherosclerosis. However, the question of whether patients with familial Mediterranean fever (FMF) are at risk of atherosclerosis and related diseases remains controversial. OBJECTIVE: We aimed to use transthoracic Doppler echocardiography to investigate coronary flow reserve (CFR) and left ventricular (LV) diastolic function in patients with FMF. METHODS: CFR and LV diastolic function were studied in 33 patients with FMF (16 men, 17 women; mean age, 36.7+/-12.0 years) and 35 healthy volunteers (20 men, 15 women; mean age, 36.8+/-5.2 years). Coronary diastolic peak flow velocities (DPFV) were measured at baseline and after dipyridamole infusion. LV diastolic function was assessed by standard and tissue Doppler imaging. RESULTS: CFR was significantly lower in the FMF group than in the control group (2.27+/-0.38 versus 3.02+/-0.50, P<0.0001). Significant between-group differences were found regarding LV diastolic function mitral E/A ratio, mitral E-wave deceleration time, and lateral A(m). Serum high sensitivity C-reactive protein (hsCRP) levels were significantly higher in the patients with FMF, and hsCRP values independently correlated with CFR. CONCLUSIONS: Coronary microvascular function and LV diastolic function are impaired in patients with FMF. The severity of these impairments is correlated with hsCRP. Impaired CFR may be an early manifestation of cardiac involvement in patients with FMF.

Difficult intubation in pediatric cardiac anesthesia.

OBJECTIVE: The aim of this study was to investigate cases of difficult intubation in pediatric cardiac surgical patients and to evaluate the importance of associated congenital abnormalities. DESIGN: Retrospective analysis. SETTING: Departments of Anesthesiology and Pediatric Cardiovascular Surgery of a tertiary university hospital. PARTICIPANTS: All children undergoing congenital heart surgery. INTERVENTIONS: Patients who had difficult intubations according to their anesthetic charts were further evaluated from hospital files for demographic characteristics, associated congenital abnormalities, and perioperative airway and/or respiratory complications. MEASUREMENTS AND MAIN RESULTS: A total of 1,278 pediatric patients with congenital heart disease were operated on from January 1999 to July 2002. Difficult intubation was encountered in 16 cases (1.25%). Two of these were newborns, 11 were infants, and 3 were in the pediatric age group. Anterior larynx was the most common reason for difficult intubation (7 cases, 43.7%). There were associated syndromes and/or other congenital abnormalities in 8 children (50%). CONCLUSION: The likelihood of difficult intubation during pediatric cardiac surgery, especially in cases with other congenital pathologies should be kept in mind, and the anesthetic approach must be planned accordingly.

Knowledge of basic life support: a pilot study of the Turkish population by Baskent University in Ankara.

A total of 494 participants who were scheduled to take Baskent University's basic life support (BLS) training programme in 2001-02 were asked to complete a 25-item questionnaire prior to the course. The questionnaire investigated the demographic characteristics of the subjects, their knowledge of the theoretical and practical aspects of BLS, and personal experience and attitudes related to BLS. The 'non-medical group' included 179 laypersons, and the 'medical group' was composed of medical students (n=220), residents (n=69) and clinical nurses (n=26). One-hundred and twenty-six (25.5%) of the participants had an encounter with some form of medical emergency event in their past and 207 (41.9%) had taken a BLS course previously. The most commonly cited anxiety about performing BLS was the fear of further harming the victim (56.9%). Nine of the participants said they would not perform mouth-to-mouth ventilation (1.8%). Compared to the other participants, individuals with previous emergency experience, and those who had previous BLS training answered significantly more of the theoretical questions correctly. However, neither of these groups performed significantly better than the other participants in the practical questions (P>0.05 for both comparisons). Based on our findings, we recommend that BLS training for medical undergraduates, other medical personnel and laypersons be improved and standardized throughout Turkey.

Anesthetic risks for donors in living-related liver transplantation: analysis of 30 cases.

Liver transplantation involving living-related donors has been adopted in many centers as a way of relieving organ shortage. This study reviewed the anesthetic considerations for donor operations at our institution in relation to intraoperative blood transfusion, complications, and postoperative liver function test results. From January 1990 to May 2001, 30 living-related liver transplantations were performed at Baskent University Hospital, Ankara. The donor data used for analysis were retrospectively obtained through chart review, anesthesia records, and the computerized hospital database. Left lobectomy was performed in 19 cases, and left lateral segmentectomy in 11 cases. Intraoperatively, the average volume of intravenous fluids used was 6431+/-468 ml, and the average amount of blood transfused was 2.1+/-0.4 units. The mean postoperative hospital stay was 11.5+/-1.3 days. The only intraoperative complication observed in these 30 donors was severe bleeding during retrohepatic vena cava dissection in one of the cases. The postoperative complications related to anesthesia were one case each of shoulder pain, neuropraxia, and compartment syndrome. The levels of total and direct bilirubin, aspartate aminotransferase, and alanine aminotransferase peaked within the first 2 postoperative days (2.19+/-0.36 mg/dl, 1.02+/-0.18 mg/dl, 245.7+/-26.6 U/l, 313.5+/-51.9 U/l, respectively). In all 30 donors, these levels had normalized by 1 month after surgery. Maximal efforts must be applied in the anesthetic approach to minimize donor complications in living-related liver transplantation; however, this will not completely eliminate some risks to the donor.