Diaphragm and Lung Ultrasonography During Weaning From Mechanical Ventilation in Critically Ill Patients.

AIM: Optimum timing is crucial to avoid negative outcomes of weaning. We aimed to investigate predictive values of diaphragmatic thickening fraction (DTF), diaphragmatic excursion (DE), and anterolateral lung ultrasound (LUS) scores in extubation success and compare with rapid shallow breathing index (RSBI) in patients extubated under traditional parameters. METHODS: Patients undergoing mechanical ventilation for >48 hours were included in the study. In patients planned for extubation, sonographic evaluations of the diaphragm and lung were performed at the T-tube stage. RSBI was achieved in the pressure support (PS) ventilation stage. Predictive values of DTF, DE, and anterolateral LUS scores were compared with RSBI in extubation success. RESULTS: Sixty-two patients were enrolled in the study. The study population consisted mostly of trauma patients (77%). A cut-off value of 64 was obtained for RSBI. The positive predictive value (PPV) was found at 97% in extubation success. Cut-off values of 27.5 for DTF, 1.3 cm for the DE, and 6.5 for LUS scores were obtained at the T-tube stage, respectively. PPVs of all sonographic parameters were found over 90%. At the first stage, weaning and extubation failures were determined as 35 and 9.6%, respectively. RSBI was found as a powerful parameter in determining extubation success (r=0.774, p≤0.001) and moderately correlated with sonographic parameters. CONCLUSION: Investigating the lung and diaphragm via ultrasound provides real-time information to increase extubation success. Cut-off values of 64 for RSBI, 27.5 for DTF, 1.3 cm for the DE, and 6.5 for LUS scores were obtained, respectively, and PPVs of all sonographic parameters were found over 90%. We consider that sonographic evaluations accompanied by an RSBI will increase extubation success in the weaning process.

Preprocedural Ultrasonography Versus Landmark-Guided Spinal Anesthesia in Geriatric Patients with Difficult Anatomy: A Prospective Randomized Trial.

OBJECTIVE: This study was aimed to determine whether preprocedural ultrasonography (USG) affects the technical performance of spinal anesthesia in elderly patients with difficulty in palpating landmarks, scoliosis, or previous spine surgery. MATERIALS AND METHODS: This prospective study was conducted in 156 elderly patients scheduled for elective orthopedic lower extremity surgery. The patients were randomly divided into 2 groups to receive spinal anesthesia by the preprocedural USG examination (group U) or conventional landmark palpation technique (group P). The primary finding of our study was the rate of successful access to the subarachnoid space on initial needle insertion attempt. Secondary achievements included number of needle insertion attempts, number of needle redirections, total procedure time, needle pain scores, patient satisfaction, and complications of spinal anesthesia. RESULTS: The rate of successful access to the subarachnoid space at the first needle insertion attempt was significantly higher in group U than in group P (74.4% vs 53.8%, p=0.008). Medians (interquartile range) of both needle insertion attempts (group P, 2 [1-3] vs group U, 1 [1-2]; p=0.038) and needle redirections (group P, 3 [2-5] vs group U, 2 [1-4]; p=0.028), requiring to achieve dural puncture, were significantly higher among the patients in group P than those in group U. No statistically significant difference was found between the groups regarding total procedure time, pain scores, patient satisfaction scores, and spinal anesthesia-induced complications (p>0.05). CONCLUSION: Our study findings showed that preprocedural neuroaxial USG improves technical performance of spinal anesthesia in elderly patients with difficult anatomy.

Hemodynamic responses to endotracheal intubation performed with video and direct laryngoscopy in patients scheduled for major cardiac surgery.

This study aims to compare the hemodynamic responses to endotracheal intubation performed with direct and video laryngoscope in patients scheduled for cardiac surgery and to assess the airway and laryngoscopic characteristics. One hundred ten patients were equally allocated to either direct Macintosh laryngoscope (n = 55) or indirect Macintosh C-MAC video laryngoscope (n = 55). Systolic, diastolic, and mean arterial pressure, and heart rate were recorded prior to induction anesthesia, and immediately and two minutes after intubation. Airway characteristics (modified Mallampati, thyromental distance, sternomental distance, mouth opening, upper lip bite test, Wilson risk sum score), mask ventilation, laryngoscopic characteristics (Cormack-Lehane, percentage of glottic opening), intubation time, number of attempts, external pressure application, use of stylet and predictors of difficult intubation (modified Mallampati grade 3-4, thyromental distance < 6 cm, upper lip bite test class 3, Wilson risk sum score ≥ 2, Cormack-Lehane grade 3-4) were recorded. Hemodynamic parameters were similar between the groups at all time points of measurement. Airway characteristics and mask ventilation were no significant between the groups. The C-MAC video laryngoscope group had better laryngoscopic view as assessed by Cormack-Lehane and percentage of glottic view, and a longer intubation time. Number of attempts, external pressure, use of stylet, and difficult intubation parameters were similar. Endotracheal intubation performed with direct Macintosh laryngoscope or indirect Macintosh C-MAC video laryngoscope causes similar and stable hemodynamic responses.

Morphometric Analysis of the Sacral Canal and Hiatus Using Multidetector Computed Tomography for Interventional Procedures.

AIM: The sacral canal has been frequently used as "a passage" for minimally invasive diagnostic and therapeutic procedures for spinal diseases. The aim of the present study was to investigate morphometric analyses of the sacral canal, hiatus, and surrounding structures according to different age groups and gender by using the "multidetector computed tomography" method. MATERIAL AND METHODS: Multiplanar-reconstructed images from 300 adult (150 females and 150 males, between 20 and 80 years old) were divided into three groups according to age and retrospectively examined. Various anatomic measurements of the sacral hiatus, surrounding structures, and sacral canal were performed. Sacral curvature angle and lumbosacral lordotic angle were noted. RESULTS: Bony anatomic abnormalities such as absent hiatus (0.3%), complete agenesis (1%), and bony septum (2.6%) were detected in some cases. The anteroposterior (AP) diameter of the hiatus was less than 2 mm in 5% of cases. In all groups, the mean values of the hiatus AP diameter and area, and the shortest distance of the sacral canal AP diameter were shorter in the 60-80 years age group when compared with those in 20-39 years age group (p=0.01). The shortest sacral canal AP diameter was commonly located at the S2 and S3 levels in 59.2% and 33.9% of cases, respectively. The levels of maximum curvature were at S3 and S2 in 63.3% and 26.7% of cases, respectively. Median sacral curvature angles and lumbosacral lordotic angles were measured as 164° and 134°, respectively. CONCLUSION: Sacral structures have morphometric variations. Understanding of the detailed anatomy may improve the reliability of interventional procedures.

The Effects of Sugammadex on Progesterone Levels in Pregnant Rats.

BACKGROUND: Sugammadex has been shown to decrease the efficiency of progesterone-containing oral contraceptive drugs which possess a steroid structure. AIMS: The aim of the present study was to evaluate the effects of sugammadex on progesterone levels in pregnant rats as well as on the physiological course of the pregnancy. STUDY DESIGN: Animal experiment. METHODS: This study was approved by the Selçuk University Ethical Committee for Experimental Animal Research. Pregnant Winster Albino rats (n=26) were divided into three groups and administered with various intravenous injections on the 7(th) day of pregnancy. The control group (Group K, n=6) received 1.5 mL serum physiologic, the sugammadex group (Group S, n=10) received 30 mg/kg sugammadex and the sugammadex + rocuronium group (Group SR, n=10) received 30 mg/kg sugammadex and 3.5 mg/kg rocuronium. Progesterone levels were measured and the offspring were monitored for morphologic status. RESULTS: Mean progesterone levels were 94.16±15.54 ng/mL in Group K, 87.86±12.48 ng/mL in Group S, and 94.53±16.10 ng/mL in Group SR (p>0.05). No stillbirth or miscarriage was observed in the rats. The mean number of offspring was 6.8±1.47 in Group K, 6.5±1.35 in Group S, and 6.4±1.17 in Group SR. The offspring appeared macroscopically normal. CONCLUSION: Sugammadex does not appear to affect the progesterone levels in pregnant rats in the first trimester and the clinical course. Successful completion of pregnancy and the absence of stillbirth or miscarriage will guide future studies about the use of sugammadex, particularly in the first trimester of the pregnancy.

Ultrasound-guided nasogastric feeding tube placement in critical care patients.

BACKGROUND: Nasogastric feeding tube (NGT) placement is a common practice performed in intensive care units (ICUs). Complications due to the improper placement of NGT are well known. In this prospective descriptive study, the effectiveness of ultrasound (US)-guided NGT placement was investigated. MATERIALS AND METHODS: Fifty-six mechanically ventilated patients monitored in the ICU were included. A linear US probe was transversely placed just cranial to the suprasternal notch, and the concentric layers of the esophagus were attempted to be viewed on the posterolateral side of the trachea (generally left) by shifting the probe. If the esophagus can be seen, an attempt was made to insert the NGT under real-time visualization of ultrasonography. Furthermore, gastric placement of the NGT tip was confirmed with abdominal radiograph. RESULTS: A total of 56 patients were included in the study. For 52 (92.8%), the NGT image was obtained during placement within the esophagus. For 3 (5.3%), the esophagus could not be seen by US, and NGT was placed blindly. For 1 patient, we could not detect passing of the NGT into the stomach despite the successful visualization of esophagus. In this patient, NGT was radiographically detected in the trachea after the procedure. CONCLUSION: This study revealed that passing of the NGT through the esophagus could be visualized at a high rate in real-time US among ICU patients. These data suggest that ultrasonographic visualization of the upper esophagus during NGT insertion can be used as an adjuvant method for confirmation of correct placement.