Perioperative Anaesthetic Management of Confirmed or Suspected COVID-19 Patients.

The outbreak of coronavirus disease (COVID-19) that started in Wuhan, China, has spread to 210 countries, infecting 2,726,274 patients and causing 191,075 deaths by April 24, 2020, and has turned into a global threat. Although various measures have been taken to stop human-to-human transmission in many countries, health care workers are in the high-risk zone for transmission as they deliver patient care. It is evident that anaesthesiologists will keep encountering patients with confirmed or suspected COVID-19 infection who will undergo emergency surgeries. Anaesthesiologists carry a higher risk of being infected during aerosol-creating procedures, hence appropriate protective measures should be taken, both during preoperative evaluation and management anaesthesia. Anaesthesia management of patients with COVID-19 also is a challenge for anaesthesiologists as it is an infection that may affect not only the respiratory system but also other vital organs. The aims of this review are to provide prudent safety measures to protect anaesthesiologists and other health care workers in the operating theatre and recommendations or the safest anaesthesia management of patients with suspected or confirmed COVID-19 undergoing surgery.

A comparison of the efficacy of three different peak airway pressures on intraoperative bleeding point detection in patients undergoing thyroidectomy: a randomized, controlled, clinical trial.

BACKGROUND: Various techniques are used to detect intraoperative bleeding points in thyroid surgery. We aimed to assess the effect of increasing peak airway pressure to 30, 40 and 50 cm H2O manually in detecting intraoperative bleeding points. METHODS: One hundred and 34 patients scheduled for total thyroidectomy were included to this prospective randomised controlled clinical study. We randomly assigned patients to increase peak airway pressure to 30, 40 and 50 cm H2O manually intraoperatively just before surgical closure during hemostasis control. The primary endpoint was the rate of bleeding points detected by the surgeon during peak airway pressure increase. RESULTS: The rate of detection of the bleeding points was higher in 50 cm H2O Group than the other two groups (15.9 vs 25.5 vs 40%, P = 0.030), after pressure administration, the HR, SpO2, and P peak were similar between groups (P = 0.125, 0.196, 0.187, respectively). The median duration of the bleeding point detection after the pressure application was 21.82 s in 30 cm H2O, 25 s in 40 cm H2O, and 22.50 s in 50 cm H2O groups. Postoperative subcutaneous hematomas or hemorrhages requiring surgery were not seen in any patient. CONCLUSIONS: Manually increasing peak airway pressure to 50 cm H2O during at least 22.50 s may be used as an alternative way to detect intraoperative bleeding points in thyroid surgery. CLINICAL TRIAL REGISTRATION: NCT03547648. Registered 6 June2018.

Evaluation of the effects of subcostal transversus abdominis plane block on acute and subacute pain development following inguinal herniography: Randomized clinical study.

OBJECTIVES: The effect of subcostal transversus abdominis plane (TAP) block on postoperative pain is contradictive. The aim of this study was to evaluate the effect of subcostal TAP block on subacute pain in patients who have undergone inguinal herniography. METHODS: Patients aged between 18 and 75 years with American Society of Anesthesiologists 1-3 and who were to undergo elective unilateral inguinal herniography with mesh under general anesthesia were included. Fifty patients were under an intravenous analgesic regimen (group I) and 50 patients underwent subcostal TAP block postoperatively in addition to the intravenous analgesic regimen (group II). The primary outcome measure was pain scores 1 month postoperatively by comparing Numerical Rating Scale values with the Mann-Whitney U test between groups I and II. Secondary outcome measures were life qualification scores 1 month postoperatively and pain scores 24 h and 15 days postoperatively. RESULTS: Postoperative 15th-min; 1st-, 6th-, 12th-, and 24th-h; 15th-day (p=0.00); and 1st-month Numerical Rating Scale values were significantly lower in group II than in group I (p=0.02). No significant difference was observed between the groups in terms of LQS 15 days postoperatively (p=0.013). On group comparison, LQS was higher in the 1st month than at the 15th day postoperatively in group I (p=0.201). CONCLUSION: Subcostal TAP block provides an effective postoperative pain treatment in the acute period and in the 1st postoperative month in patients undergoing inguinal herniography.

The Assessment of Risk Factors for Difficult Intubation in Thyroid Patients.

OBJECTIVES: We aimed to assess possible risk factors related to difficult intubation in patients undergoing thyroid surgery. METHODS: We prospectively collected data of 200 patients scheduled for thyroid surgery. Clinical risk factors were defined as: Mallampati score, interincisor gap, thyromental distance, sternomental distance, range of neck motion, body mass index, neck circumference, goiter, the presence of radiological findings suggesting compression and thyroid weight. All evaluations were performed with Macintosh assessed for Cormack and Lehane (CL) classification and modified intubation difficulty scale (MIDS). RESULTS: It was observed that the proportion of patients with a thyroid weight ≥40 g, goiter, a Macintosh CL score = 3-4 and the mean neck circumference were significantly higher in the group with a MIDS score >5 (p = 0.018, p = 0.011, p < 0.001, respectively). CONCLUSION: The presence of a palpable goiter, thyroid weight ≥40 g and thyromental distance <6.5 cm were risk factors associated with difficult intubation in the multivariate regression model.

Ultrasound-assisted transversus abdominis plane block vs wound infiltration in pediatric patient with inguinal hernia: randomized controlled trial.

STUDY OBJECTIVE: To compare the analgesic efficacy of ultrasound-assisted transversus abdominis plane (TAP) block and wound infiltration during the first postoperative 24hours. DESIGN: A prospective, observer-blinded, randomized, and controlled study SETTING: Operating room of a university hospital. PATIENTS: Forty patients received a TAP block (TAP group) and 40 patients received wound infiltration (INF group) at the end of the surgery. INTERVENTIONS: Patients were randomized to receive a TAP block or wound infiltration. Postoperative analgesics were administered on request and selected based on pain severity. MEASUREMENTS: Pain scores, analgesic drug requirement, and side effects were observed for 24hours. MAIN RESULTS: Postoperative pain scores were lower in TAP group compared to INF group (P<.001). Analgesic consumption was significantly higher at the 5th minute and 1st, 6th, and 12th hours in the INF group (P<.001). The frequency of additional analgesic use in home and the total analgesic used during the postoperative 24hours were significantly higher in INF group (P<.001). Side effects were lower in the TAP group. Parent's satisfaction scores were higher in TAP group. CONCLUSION: Transversus abdominis plane block is effective method with convenient technique, drug dosage, and volume in pediatric patients undergoing inguinal hernia surgery.

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.

The effect of single dose etomidate during emergency intubation on hemodynamics and adrenal cortex.

BACKGROUND: The study aimed to evaluate and compare the effects of a single dose of etomidate and the use of a steroid injection prior to etomidate during rapid sequence intubation on hemodynamics and cortisol levels. METHODS: Sixty patients were divided into three groups (n=20). Before intubation, and at 4 and 24 hours, blood samples were taken for cortisol measurements and hemodynamic parameters (systolic-diastolic-mean arterial pressure, heart rate), and SOFA scores were recorded. Intubation was achieved with 0.3 mg/kg etomidate IV in Group I, 0.3 mg/kg etomidate following 2 mg/kg methylprednisolone IV in Group II, and 0.15 mg/kg IV midazolam in Group III. RESULTS: Mean arterial pressure values were lower in Group I at the 24th hour when compared to Groups II and III. In Group I, heart rate values were higher compared to the other Groups. Cortisol levels were lower in Group I at the 4th and at the 24th hour in Groups II and III. CONCLUSION: Administration of methylprednisolone 2-4 minutes prior to etomidate use in emergency situations can prevent adrenal insufficiency in patients undergoing rapid sequence intubation. Moreover, midazolam can be used in low induction doses as an alternative to etomidate.

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.

Comparison and Evaluation of the Effects of Administration of Postoperative Non-Invasive Mechanical Ventilation Methods (CPAP and BIPAP) on Respiratory Mechanics and Gas Exchange in Patients Undergoing Abdominal Surgery.

OBJECTIVE: The aim of our study is to investigate the effect of two different methods of continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BIPAP) and oxygen support under spontaneous ventilation on respiration mechanics, gas exchange, dry mouth and face mask lesion during an early postoperative period in patients undergoing upper abdominal surgery. METHODS: Eighty patients undergoing elective abdominal surgery with laparotomy, between the age of 25 and 75 years and American Society of Anesthesiologists Physical Status score (ASA) II-III with chronic obstructive pulmonary disease (COPD) diagnosis were included to the study. Subjects were randomly allocated in to four groups. During the first postoperative hour, the first group received BIPAP, second group received high-flow CPAP, third group received low-flow CPAP and fourth group received deep breathing exercises, respiratory physiotherapy and O2 therapy. Preoperative, postoperative before and after treatment PaO2, PaCO2, SpO2, tidal volume (TV), respiratory rate (RR) levels were recorded. Subjects with dry mouth or face mask lesion were recorded. RESULTS: In all groups, PaO2 and TV measurements were higher at the postoperative first hour than the postoperative zero hour. We found that low-flow CPAP increased PaO2 and SpO2 values more, and TV levels were higher in the postoperative period than the preoperative period. PaCO2 levels were elevated at the zero hour postoperatively and at the end of the first hour; they decreased approximately to preoperative values, except in the fourth group. CONCLUSION: Administration of prophylactic respiratory support can prevent the deterioration of pulmonary functions and hypoxia in patients with COPD undergoing upper abdominal surgery. In addition, we found that low-flow CPAP had better effects on PaO2, SpO2, TV compared to other techniques.

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.