Tracheal injury: late symptom after double-lumen tube intubation - A case report.

As a basic skill, endotracheal intubation, performed throughout the world by health care professionals is a relatively safe and effective maneuver. However, this technique is not risk free and could lead to many serious complications. We wanted to report that in a patient with double lumen tube intubation, airway trauma can cause late symptoms . We thought that such complications must be published to share experiences.

The Predictor Role of the Aqueduct Cerebrospinal Fluid Flow on Endoscopic Third Ventriculostomy: Explication on Assumption Physical Model.

AIM: To evaluate the cerebrospinal fluid (CSF) flow dynamics in the aqueductus sylvii of patients with obstructive hydrocephalus who underwent endoscopic third ventriculostomy (ETV) and to predict ventriculostomy patency via aqueduct flow measurements. MATERIAL AND METHODS: Twenty-four patients with obstructive hydrocephalus caused by primary aqueduct stenosis who underwent ETV were included in the study. All the patients underwent conventional and cine magnetic resonance imaging before and after treatment. The flow of CSF in the aqueduct of Sylvius and prepontine cistern was assessed, and the diameter of the third ventricle was also measured. Increase in the aqueduct flow velocity after a successful ETV was supported by the assumption physical model that highlights a possible mechanism that explains the clinical findings. RESULTS: The flow pattern and velocity in the prepontine cistern and aqueduct were normal in 17 out of 24 patients who responded to ETV clinically. However, seven patients who did not respond to ETV had an abnormal flow pattern in both the prepontine cistern and aqueduct. CONCLUSION: The flow pattern in the aqueduct was normalised and velocity was increased compared with those of preoperative values after a successful ETV. The flow of CSF in the prepontine cistern is routinely used for ventriculostomy patency assessment. In addition, aqueduct measurements may be useful in predicting ventriculostomy patency. The physical model provides valuable insights on a possible mechanism that affected the experimental data.

Evaluation of the neurotoxicity of intrathecal dexmedetomidine on rat spinal cord (electromicroscopic observations).

BACKGROUND: Spinal administration of dexmedetomidine has been proposed as an adjuvant in spinal anesthesia. However, there is limited information about its possible neurotoxic effect after its neuraxial administration. Potential spinal neurotoxicity should be investigated in animals before administering drugs through the spinal cord. Our aim was to investigate the neurotoxic effects of intrathecal dexmedetomidine in rats. METHODS: Two groups were performed: the dexmedetomidine (D) group (n = 10) received 10 µg (0.5 ml), whereas the control (C) group (n = 10) received 0.9% (0.5 ml) sodium chloride through indwelling intrathecal catheter. Seven days after the injection, the medulla spinalis was extracted. Samples were withdrawn from both groups for histologic, electron microscopic examination. The histologic examination was performed separately on each of the four sites. The findings were categorized as follows: 0 - normal neuron; 1 - intermediate neuron damage; and 2 - neurotoxicity. RESULTS: Intrathecal administration of dexmedetomidine sensorial block was seen in the dexmedetomidine group and significant differences in the dexmedetomidine group than control group in 15th and 30th min (P < 0.05). Histological examination did not show evidence suggestive of neuronal body or axonal lesion, gliosis, or myelin sheath damage in any group. In all animals, there were observed changes compatible with unspecific inflammation at the tip of the needle location. On the four-area scoring histologic examination, the scores of both groups were 0-1, and no statistical difference was observed between the groups. CONCLUSIONS: A single dose of intrathecal dexmedetomidine did not produce histologic evidence of neurotoxicity.

Comparison of forced-air warming systems in prevention of intraoperative hypothermia.

In this study, we aimed to compare the effects of forced-air warming upper body blankets and forced-air warming underbody blankets on intraoperative hypothermia in patients who were planned to undergo open abdominal surgical operations in which extensive heat loss occurs. This prospective and randomized study included 92 patients who would undergo lower abdominal surgery under general anesthesia. Patients were randomized by closed envelope method and divided into two groups. Group I (n:46) included the patients who would receive warming with forced-air warming upper body blanket, and Group II (n:46) consisted of the patients who received warming with forced-air warming underbody blanket. Central body temperature was recorded by measuring with a temperature probe placed in distal esophagus. Demographic data, amount of fentanyl, crystalloid and blood products used, duration of operation, type of operation, hemodynamic parameters, shivering and thermal damage information were recorded. There was not any statistically significant difference among the patients in terms of demographic data, amount of fentanyl, crystalloid and blood products used, duration and type of operation and hemodynamic parameters. No difference was found between the groups in terms of body temperatures (Group I:36.1 °C, Group II:36.3 °C, respectively) (P > 0.05). Forced air warming underbody blanket can be as effective as forced-air warming upper body blankets in preventing intraoperative hypothermia. They can be alternative in cases where use of forced-air warming upper body blankets is not feasible.

Anaesthetic considerations and perioperative features of endoscopic third ventriculostomy in infants: analysis of 57 cases.

AIM: Endoscopic third ventriculostomy (ETV) is currently considered the best alternative to shunt systems in the treatment of triventricular hydrocephalus. However, there has been very few published data about the anaesthetic management and the complications of ETV procedure in infants. In this report, we detail our experience with 57 infants, who underwent ETV as an initial treatment for obstructive triventricular hydrocephalus between 2003 and 2010. MATERIAL AND METHODS: Anesthesia chart-records were retrospectively investigated and perioperative data were classified according to the stages of the procedure. RESULTS: In this series, mean heart rate values showed a statistically significant difference in the period concerning the balloon dilatation of ventriculostomy orifice. An episode of bradycardia occurred in 2 patients during balloon dilatation. After the deflation of the balloon, bradycardia resolved immediately without administration of any medication. Video recordings of those two patients revealed that one of them had a narrow and opaque tuber cinereum, and the other had a shallow interpeduncular cistern. CONCLUSION: During ETV procedure in infants, bradycardia may be a serious complication especially when performing balloon dilatation of the ventriculostomy orifice. We believe that close communication between the surgeon and the anaesthetist is extremely essential in this stage of the procedure.

Comparison of the Laryngeal Mask Airway (CTrach(TM)) and Direct Coupled Interface-Video Laryngoscope for Endotracheal Intubation: a Prospective, Randomized, Clinical Study.

OBJECTIVE: Video laryngoscopy was developed to facilitate tracheal intubation of difficult airways. We aimed to compare the efficacy of CTrach™ (CT) and Direct Coupled Interface-Videolaryngoscope (DCI-VL) in patients with normal airways. MATERIAL AND METHODS: Sixty ASA I-II (American Society of Anesthesiologists) adult patients admitted for elective surgery were enrolled in this prospective study. The patients were randomly assigned to two groups, where intubation was performed via CT or DCI-VL. Time to obtain a good glottic view, total intubation time, success rates and the number of patients who required maneuvers for a good glottic view were recorded. RESULTS: The mean time to obtaining a good glottic view was significantly longer with CT than with DCI-VL (29.4±20.3 seconds vs. 12.8±1.9 seconds, respectively; p=0.01). Intubation was achieved on the first attempt in 28 patients in the CT group (93.3%) and in 24 in the DCI-VL group (80%) (p=0.77). The total intubation time for CT was significantly longer compared to DCI-VL (99.9±36.0 seconds vs. 39.2±21.4 seconds, respectively; p=0.01). Optimization maneuvers were required in eight and two patients in the CT and DCI-VL groups, respectively (p=0.03). CONCLUSION: Although the normal airway endotracheal intubation success rates were similar in both groups, the time to obtain a good glottic view and the total intubation time were significantly shorter with DCI-VL.

Evaluation of early visual recovery in pituitary macroadenomas after endoscopic endonasal transphenoidal surgery: Quantitative assessment with diffusion tensor imaging (DTI).

BACKGROUND: Visual field analyses reflect the degree of the compression to the optic nerve that results the structural damage of the nerve. These structural damages can be evaluated by diffusion tensor imaging (DTI), which assesses the structural integrity of white matter tracts. Thus, we evaluated the quantitative assessment of early visual recovery in patients with pituitary macroadenomas, corresponding DTI with visual field analyses. METHODS: Seventy-two patients who had pituitary macroadenomas with visual field defects were included in the study retrospectively. All patients were operated on by pure endoscopic transphenoidal approach. Visual field assessment using Humphrey field analyzer and DTI with 3T magnet were performed in the preoperative and postoperative second day and sixth month. FINDINGS: Mean symptom duration was 14.7 ± 10.5 weeks in the full recovery group patients, 50.1 ± 29.1 weeks in partial recovery patients, and 92.4 ± 15.4 weeks in the ones with no recovery. There was a significant difference at p < 0.001 among the groups. On visual field analysis, the visual lost was mostly recognized at upper temporal levels preoperatively. Visual field findings of both eyes were improved in 80% of the patients. Among these, 25% revealed full recovery, 55.6% partial recovery, and 19.4% did not demonstrate significant changes. DTI assessments of affected sides revealed preoperative fractional anisotropy (FA) values below 0.400 and mean diffusivity (MD) values over 1,400 × 10(-6) mm(2) s(-1) were related with no visual improvement in the postoperative 6 months period. The percentage increase of mean FA values of the affected areas postoperatively were found to be 21.9% in totally responded patients, 20.6% in partial responded patients, and 9.8% in patients that did not respond. CONCLUSIONS: There is a correlation between DTI-derived FA values of the optic nerves and visual parameters. DTI assessments of the affected sides with FA and MD values may help to estimate the response of visual improvement to the surgical therapy in the early postoperative period.

The LMA CTrach™ in morbidly obese and lean patients undergoing gynecological procedures: a comparative study.

PURPOSE: The tracheas of obese patients may be more difficult to intubate than those of normal-weight patients. The aim of this study was to compare the airway management quality in morbidly obese and lean patients with use of the LMA CTrach. METHODS: After Ethics Committee approval, 60 adult patients (30 morbidly obese patients with body mass index >40 kg/m² and 30 lean patients with body mass index <30 kg/m²) scheduled to undergo gynecological surgery were enrolled in this prospective study. The induction of anesthesia was standardized using propofol, fentanyl, and rocuronium. Ventilation and intubation success rates, time taken to achieve successful ventilation, and intubation through the CTrach and airway complications were recorded. RESULTS: The CTrach was successfully inserted and adequate ventilation through the CTrach was achieved in 59 patients (98%). Only 1 patient in the lean group was not able to ventilate through the CTrach. We were successful in endotracheal intubation, either under vision or blind, in 56 patients (93%). We were able to view the larynx in 51 patients (85%). Total intubation time was significantly longer in morbidly obese patients, 69 (311) s, than in lean patients, 33 (107) s [median (range)] (P < 0.001). CONCLUSIONS: We concluded that the time to intubate the trachea in obese patients was significantly longer than in lean patients when the LMA CTrach was used.

Levobupivacaine-tramadol combination for caudal block in children: a randomized, double-blinded, prospective study.

BACKGROUND: The aim of this prospective study was to compare the postoperative analgesic efficacy and duration of analgesia after caudal levobupivacaine 0.125% or caudal tramadol 1.5 mg.kg(-1) and mixture of both in children undergoing day-case surgery. METHODS: Sixty-three American Society of Anesthesiologists (ASA) I or II children between 1 and 7 years old scheduled for inguinal hernia repair under sevoflurane anesthesia were randomized to receive caudal levobupivacaine 0.125% (group L), caudal tramadol 1.5 mg.kg(-1) (group T) or mixture of both (group LT) (total volume of caudal solution was 1 ml.kg(-1)). Duration of analgesia and requirement for additional analgesics were noted. Postoperative pain was evaluated using the Children's and Infants' Postoperative Pain Scale (CHIPPS) every 15 min for the first hour, and after 2, 3, 4, 6, 12, and 24 h. Analgesia was supplemented whenever pain score was > or =4. RESULTS: No patient experienced significant intraoperative hemodynamic response to surgical incision. Duration of analgesia was significantly longer in group LT than in group L and group T (545 +/- 160 min vs 322 +/- 183 min and 248 +/- 188 min, respectively) (P < 0.01). There were no significant differences between the group L and group T for duration of analgesia (P > 0.05). There were no significant differences among the groups in the number of patients requiring analgesia after operation (P = 0.7). No signs of motor block were observed after the first postoperative hour in any of the patients. CONCLUSION: Addition of tramadol increased the duration of analgesia produced by caudal levobupivacaine in children.

Ultrasound guided lateral sagital infraclavicular block for pectoral flap release.

Ultrasound may provide effective guidance during nerve blocks in cases where nerve stimulation is not feasible for various reasons. We describe a 28-year-old, ASA physical status I, male patient who was operated for pectoral flap release under lateral sagittal infraclavicular block. Using ultrasound guidance alone, total volume of 30 ml of local anesthetic mixture (15 ml of levobupivacaine 5 mg/ml and 15 ml of lidocaine 20 mg/ml with 5 microg/ml epinephrine) was injected dorsal to the axillary artery. There was no vascular puncture or any other complication. The block was successful and the patient was ready for surgery 20 minutes after block performance. This case report is one of the examples that ultrasound guidance may be the only way to perform safe regional anesthesia; ultrasound guidance alone is an effective way of performing infraclavicular block.

[The effects of various doses of intrathecal morphine in addition with ropivacaine in combined spinal-epidural technique for labour analgesia]. / Kombine spinal epidural ile dogum analjezisinde ropivakaine eklenen farkli dozlarda intratekal morfinin etkileri.

We evaluated the duration of analgesia, side effects and neonatal effects of intrathecal ropivacaine combined with two different doses of morphine using combined spinal epidural (CSE) technique for labour analgesia. Fourty term parturients were enrolled. Group I received 0,2% ropivacaine 3 mg + morphine 50 microg and Group II received 0,2% ropivacaine 3 mg + morphine 100 microg intrathecally. When VAS for pain was equal or above 30 mm, PCEA(Patient controlling epidural analgesia) was started using 0,1% ropivacaine. There wasn't any statistical significant difference considering the duration of analgesia between two groups. The first stage of labour was significantly shorter in Group II then Group I, and the epidural local anaesthetic volume was significantly lower in Group II. The most common side effect in both groups was pruritus. There was not any side effect of local anaesthetic and opioid on the newborns. Adequate analgesia was obtained during labour with CSE technique, using ropivacaine combined with 50 and 100 microg morphine intrathecally. However cervical dilatation was faster and epidural local anaesthetic volume was lower in the group in which 100 microg morphine was used. Also considering the unchanged incidence of the side effects, 3 mg 0,2% ropivacaine + 100 microg morphine may be a useful combination for labour analgesia.

Effect of preoperative epidural morphine administration on desflurane requirements during gynecologic surgery.

BACKGROUND AND OBJECTIVES: The goal of this study is to examine the influence of epidural morphine on the end-tidal desflurane concentration titrated to maintain the bispectal index (BIS) values between 40 and 60 during gynecologic surgery. METHODS: Forty patients undergoing transabdominal hysterectomy under general anesthesia were randomly and prospectively assigned to 1 of 2 study groups: group saline (group S) and group morphine (group M). After placing an epidural catheter at L3-4 or L4-5, patients received either 10 mL of saline or 4 mg of morphine in 10 mL of saline approximately 60 minutes before anesthesia induction. Anesthesia maintenance was provided with desflurane and nitrous oxide in oxygen with a ratio of 2:1 by an anesthesiologist blinded to the group. Measurements included BIS value, end tidal desflurane concentration, heart rate, and blood pressure before surgery and every 10 minutes during surgery. RESULTS: Although there was a tendency to slightly lower end-tidal desflurane concentrations in the morphine group, this difference did not reach statistical significance at any time. In the morphine group, the heart rate was lower than in the saline group at 20, 30, 40, and 50 minutes of surgery (P < .05). BIS values were similar throughout surgery. CONCLUSIONS: Preoperative administration of epidural morphine does not reduce desflurane requirements in patients undergoing gynecologic surgery.

The learning curve in endoscopic pituitary surgery and our experience.

Experience is the important point in reduction of the complications and in the effectiveness of the surgical procedure in pituitary surgery. Endoscopic pituitary surgery differs from microscopic surgery, since it requires a steep learning curve for endoscopic skills. In this article, we evaluate our learning curve in two groups, as early and late experience. Purely endoscopic transsphenoidal operations were performed on 78 patients, which were retrospectively reviewed and grouped as early and late experience groups. We used the purely endoscopic endonasal approach to the sella that was performed via an anterior sphenoidotomy, without the use of a transsphenoidal retractor. All patients with adenomas were evaluated considering operation time, endocrinology, ophthalmology, total removal and, especially, modifications of standard technique. On the basis of the experience gained with the use of the endoscope in transphenoidal surgery over the years, modifications can be performed on the different phases of the endoscopic approach. Reviewing our cases in two groups of period due to our experience showed that the effectiveness of endoscopic surgery increases and operation time decreases. In our study, we identified a learning curve in endoscopic pituitary surgery.