Effect of the Gupta Score on Pre-operative Cardiology Consultation Requests in Noncardiac Nonvascular Surgery.

Objective: Cardiologists are the most frequently consulted specialists during pre-operative evaluations. However, unnecessary cardiology consultations (CC) can increase cardiologists' workload without impacting anaesthesia practice, resulting in delayed surgeries and additional financial burdens. We hypothesize that using Gupta during the preoperative period can reduce these adverse effects. Methods: This prospective study included patients scheduled for elective noncardiac, nonvascular surgeries who underwent pre-operative assessment. Patients who had no specific risk index used for preoperative cardiac risk evaluation were classified as Group I, and those evaluated using the Gupta scale were classified as Group II. The study compared preoperative CC, diagnostic tests, surgical delays, major adverse cardiac event (MACE), length of hospital stay and intensive care unit (ICU) stay, mortality, and costs. Results: A total of 898 patients were included in the study, with 487 in Group I and 411 in Group II. The Gupta group reduced the demand for preoperative CC (P<0.001) and preoperative non-invasive diagnostic testing (n = 107, 21.9% vs. n = 36, 8.75%). The time from the anaesthesiology outpatient clinic to surgery was 15 days in Group I and 14 days in Group II (P=0.132). The length of ICU stay was higher in Group I (P=0.019). MACE was 15 patients (3.08%) in Group I and 9 patients (2.19%) in Group II (P=0.076). The cost of patients in Group I was higher than that in Group II (P=0.019). Conclusion: Using Gupta in preoperative evaluation may reduce unnecessary preoperative resource usage, surgical delays, ICU hospitalization rates, additional costs, and mortality.

Comparison of Two Different Methods for ProSealTM Laryngeal Mask Fixation.

Objective: This prospective randomized study compared 2 different methods for ProsealTM Laryngeal Mask Airway (PLMA) fixation. Methods: Patients scheduled for ureterorenoscopic lithotripsy surgery in the lithotomy position were included in the study. General anaesthesia with PLMA was administered to the patients. To achieve PLMA fixation, patients were randomly assigned to either adjustable elastic band (Group I) or adhesive tape fixation (Group II). Fiberoptic bronchoscope (FOB) evaluation and glottic image grading (grade 1-4) and lip margin distances of PLMA (M1 and M2) were evaluated before and after the surgical procedure. Results: We enrolled 116 patients. Surgery of 7 patients was postponed. PLMA dislocated in 2 patients in group II during positioning. For another patient who used adhesive tape in Group II, it was removed because it could not adhere to properly, and a new sticking plaster was used. The study was completed with 106 patients. In FOB evaluation, the number of patients with optimal FOB grade (FOB grade 1) after PLMA was inserted and fixed was more in Group I than in Group II (P = 0.01). FOB evaluation was repeated at the end of the operation, and the number of patients with the worst FOB grade (FOB grade 4) was 0 (0%) and 11 (10.5%) in Groups I and II, respectively. PLMA displaced more than 1 cm in 10 (18.9%) patients in Group I and in 30 patients (56.6%) in Group II. Conclusion: The adjustable elastic band method is simple, easy, and convenient and can be used in any surgical procedure for PLMA fixation.

A prospective study for an alternative probe site for pulse oximetry measurement in male patients with severe burn trauma: penile shaf.

BACKGROUND: Authors widely use pulse oximetry in clinical monitoring of heart rate (HR) and peripheral oxygen saturation (SpO2) by attachment to the fingers; however, there can be a need for an alternative attachment site, especially for burned patients. We investigate the availability of a pulse oximeter probe attached to the penile shaft as an alternative site in pediatric male patients if all extremities became unavailable for pulse oximetry measurement due to severe burn and/or trauma. METHODS: We designed a prospective comparative study in a training and research hospital. After local ethical committee approval, pediatric male cases eligible for penile and extremity pulse measurements were evaluated during general anesthesia for medical dressing and/or grafting due to severe burns. One probe was attached to the fingers of the unburned extremity, and the other was to the penile shaft. Furthermore, we recorded SpO2and HR values at 5-min intervals; 0th (baseline), 5th, 10th and 15th minutes. We compared HR and SpO2values measured by the finger probe with those measured by the penile probe. RESULTS: Data of 51 patients (median age, 2.9 years (interquartile range, 2.0-5.0 years)) in whom the duration of dressing was at least 15min were analyzed. There was no significant difference either in comparisons of hemodynamic measurements (HR and SpO2 ) obtainedby finger probe and by a penile probe for each measurement time. The Bland-Altman plot analysis reveals agreement for penile and finger probes with a mean bias value between 0.20 and 0.37 on HR and between 0.43 and -0.20 on SpO2. DISCUSSION: This clinical trial demonstrated that pulse oximetry measurement under nonhypoxic conditions we could perform confidently using penile probes in pediatric male patients whose extremities are unavailable for measurement.

Estimation of COVID-19 patient numbers using artificial neural networks based on air pollutant concentration levels.

The dilemma between health concerns and the economy is apparent in the context of strategic decision making during the pandemic. In particular, estimating the patient numbers and achieving an informed management of the dilemma are crucial in terms of the strategic decisions to be taken. The Covid-19 pandemic presents an important case in this context. Sustaining the efforts to cope with and to put an end to this pandemic requires investigation of the spread and infection mechanisms of the disease, and the factors which facilitate its spread. Covid-19 symptoms culminating in respiratory failure are known to cause death. Since air quality is one of the most significant factors in the progression of lung and respiratory diseases, it is aimed to estimate the number of Covid-19 patients corresponding to the pollutant parameters (PM10, PM2.5, SO2, NOX, NO2, CO, O3) after determining the relationship between air pollutant parameters and Covid-19 patient numbers in Turkey. For this purpose, artificial neural network was used to estimate the number of Covid-19 patients corresponding to air pollutant parameters in Turkey. To obtain highest accuracy levels in terms of network architecture structure, various network structures were tested. The optimal performance level was developed with 15 neurons combined with one hidden layer, which achieved a network performance level as high as 0.97342. It was concluded that Covid-19 disease is affected from air pollutant parameters and the number of patients can be estimated depending on these parameters by this study. Since it is known that the struggle against the pandemic should be handled in all aspects, the result of the study will contribute to the establishment of environmental decisions and precautions.

Analysis of risk factors of mortality for pediatric burned patients with inhalation injury and comparison of different treatment protocols.

BACKGROUND: We present our approach of pediatric burned patients with the suspicion of inhalation injury. METHODS: This retrospective study was conducted on children with the suspicion of inhalation injury admitted to our burn center from December 2009 to December 2019. We collected data on patient demographics, total burn surface area (TBSA), presence of inhalation injury, level of carboxyhemoglobin, grade of inhalation injury, duration of mechanical ventilation, reintubation rate, total length of hospital stay, and the mortality rate. We also reviewed the required treatment of patients with inhalation injury. RESULTS: A total of sixty pediatric burn patients were suspected inhalation injury were included in this retrospective study. 40 pa-tients included in the study were male. Age average of the patients was 87.7 months. Total burned surface area average was 32%. 46 of these patients had inhalation injury. Patients with larger cutaneous burn and needed early intubation have a higher risk of inhalation injury. There was no significant relation between inhalation injury grades and mortality and treatment protocols. Higher levels of car-boxyhemoglobin and larger TBSA are the risk factors for mortality at univariate analysis. Pediatric patient with inhalation injury whose TBSA is higher than 47.5% has a 5 times higher risk of mortality at multivariate analysis. CONCLUSION: This study demonstrated that TBSA is the risk factor that independently affects the mortality in pediatric patients with inhalation injury. Among the patients with higher than 47.5% burn surface area, the mortality rate rises 5 times.

Impact of interprofessional in situ simulations on acute pediatric burn management: Combining technical and non-technical burn team skills.

OBJECTIVE: This study aimed to evaluate the impact of interprofessional in situ simulations on the technical and non-technical skills of pediatric burn teams in acute burn management. METHODS: This quasi-experimental study consisted of a one-group pre- and post-test design conducted in a pediatric burn center in Turkey. The sample consisted of nine interprofessional burn team members. Data collection tools consisted of the following: descriptive data form, burn technical skills checklists, simulation evaluation form, and Anesthesiologists' non-technical skills in Denmark rating form. RESULTS: We found no statistically significant difference between the pre- and post-test scores for technical (p = 0.285) and non-technical skill (p = 0.180) scores. Burn team members evaluated the highest score in almost all criteria for in situ simulations. CONCLUSION: The interprofessional in situ simulations did not improve the burn teams' acute burn management; however, according to a self-report, burn team members were satisfied with the interprofessional in situ simulation experiences and achieved their own gains.

Evaluation of the difficulty of peripheral venous cannulation during anesthesia induction in children: Is DIVA score sufficient?

BACKGROUND: The primary objective of the present study was to determine the rate and the independent predictors of the difficult peripheral intravascular access (PIVA) in the operating room (OR). The secondary objective was to validate the ability of the difficult intravenous access (DIVA) scoring system in the detection of difficult PIVA in the operating room. METHODS: In this prospective observational study, patients between 0 and 18 years old who were operated in the pediatric hospital were evaluated. Peripheral intravenous cannulation performed during inhalation induction in 1008 patients were recorded. The following data were collected: demographic characteristics, the presence of a chronic disease, the DIVA score, operating room temperature, the area of PIVA application, the duration of PIVA and the number of PIVA attempts. The independent determinants of the difficult PIVA were determined with multivariate logistic regression. RESULTS: A total of 1008 patients (82% boys) with a median age of 4 (range 0.04-17 years) were included in the study. The median number of PIVA attempts was 1 whereas the median duration for successful PIVA was 15 s (range 4-2100). PIVA was successful at the first attempt in 75.3% of patients. Among patients who required more than two PIVA attempts, the most common adjunctive method was to seek help from another operator (80.8%). In the multivariable logistic regression model, only the presence of chronic disease, being underweight, and DIVA score ⩾4 (OR 6.355, CI 4.57-9.486) remained to be the significant determinants of difficult PIVA. CONCLUSION: The success rate of anesthesiologist-performed PIVA at the first attempt in the OR was 75.3%. Having a chronic disease, a DIVA score ⩾4 and being underweight appeared as the independent predictors for difficult PIVA.

Management of a Pediatric Burn Center During the Covid-19 Pandemic.

The aim of this study was to evaluate the results of an algorithm that was created to prevent coronavirus disease-2019 (COVID-19) transmission during the management of children with burns in a tertiary pediatric burn center. Children admitted to the burn center between May 2020 and November 2020 were prospectively evaluated for cause, burn depth, TBSA, length of stay, symptoms suggesting COVID-19, suspicious contact history, history of travel abroad, and COVID-19 polymerase chain reaction (PCR) test results. Patients were divided into two groups: unsuspected (group 1) and suspected (group 2), depending on any history of suspicious contact, travel abroad, and/or presence of symptoms. A total of 101 patients were enrolled in the study, which included 59 boys (58.4%) and 42 girls (41.6%). Group 1 included 79 (78.2%) patients, and group 2 consisted of 22 (21.8%) patients. The most common cause of the burns was scald injuries (74.2%). The mean age, TBSA, and length of stay were 4.5 years, 12.0%, and 13.2 days, respectively. Four patients (3.9%) had a positive PCR test (two patients in each group). Comparing groups, males were more commonly found in group 2 (P = .042), but no differences were found for the other variables. No patients or burn center staff members developed COVID-19 during the course of hospitalization. In conclusion, every child should be tested for COVID-19 upon admission to a burn unit, and a modified algorithm should be constructed for the handling and management of pediatric burn patients.

Effects of 5 µg/kg intrathecal morphine for postoperative analgesia in pediatric patients undergoing major surgery.

BACKGROUND: The effects and analgesic adequacy of intrathecal morphine (ITM) administration have been studied less frequently than other regional analgesia techniques in pediatric surgical procedures. OBJECTIVE: To evaluate the efficacy and adverse event rate of 5 µg/kg ITM administration for postoperative analgesia according to age group. METHODS: We retrospectively evaluated the medical records of patients who underwent major pediatric surgery and were administered ITM for postoperative analgesia. Patients were divided into three age groups: ≤ 5 years (group I), 5.1-13 years (group II) and > 13 years (group III). All patients received ITM 5 µg/kg (max 300 µg) through the L4-5 or L5-S1 interspace. Postoperative pain (modified pediatric objective pain score > 4), need for rescue analgesics, sleep interruption due to pain, sedation (Ramsay sedation scale score > 3), opioid-related postoperative adverse events (at 0, 4, 8, 12, and 24 h after intervention), hemodynamic data and nurse satisfaction with the analgesic method were compared between groups. RESULTS: The analysis included 100 children (47 girls, 9 ± 5.4 years). Groups were similar regarding postoperative rescue analgesia consumption and sleep interruption (p = 0.238, p = 0.958), 96% of the children did not require rescue analgesia, and sleep interruption was not observed in 97%. Postoperative adverse events were pruritus in 14 and nausea/vomiting in 9 patients (p = 0.052). Overall, nurses were satisfied or very satisfied in 99% of the cases. CONCLUSION: Administration of 5 µg/kg ITM can be used for postoperative analgesia in pediatric surgery in all age groups, with no severe adverse events and high nurse satisfaction with analgesic management.

Acupuncture as an Antiemetic in Children who Underwent Adenoidectomy and/or Tonsillectomy.

OBJECTIVE: Postoperative vomiting (POV) is one of the most common problems following general anaesthesia, and many factors, either solely or in combination, may play a role in aetiology. Acupuncture is a technique that the World Health Organization has accepted as a complementary treatment. This study presents our experience with acupuncture for POV treatment in a study of paediatric tonsillectomy cases. METHODS: The study included ASA I-II patients (n=70) aged 2-14 years who underwent tonsillectomy and/or adenoidectomy under general anaesthesia. The patients were randomly divided into the following two groups: control and study group. In the study group, an acupuncture needle was intraoperatively applied to the P6 acupuncture point for 20 min. Antiemetics were not administered to either group because of the standard applications in the preoperative period. The patients were postoperatively evaluated by nurses who were unaware about the techniques used in either group. RESULTS: No statistically significant difference was determined between the groups with regard to age, sex, nature of the operation, duration of anaesthesia, duration of the operation, surgical method and ASA scores. A statistically significant difference was determined between the groups with respect to vomiting rates. The acupuncture group presented with 0.28-times fewer vomiting episodes than the control group. CONCLUSION: The results of the study demonstrate that acupuncture has an apparent antiemetic efficacy in POV. Its routine use for POV may improve postoperative comfort and reduce drug use for prophylactic or therapeutic purposes.

Prevention of Withdrawal Movement Associated with the Injection of Rocuronium in Children: Comparison of Paracetamol and Lidocaine.

OBJECTIVE: Pain from rocuronium injection is observed in 50%-80 % of patients. This study aimed to compare the effectiveness of pretreatment with paracetamol and lidocaine in preventing pain-induced withdrawal caused by the intravenous injection of rocuronium during the induction of general anaesthesia in paediatric patients. METHODS: Ninety children were randomized into two groups using a simple drawing from the box method: a paracetamol group (Group P, n=45) and a lidocaine group (Group L, n=45). After anaesthesia induction, venous occlusion was applied by a paediatric cuff inflated to a pressure of 75 mmHg and by 50 mg paracetamol and 0.5 mg kg(-1) lidocaine was injected in Groups P and L, respectively. Venous occlusion was then released, followed by rocuronium injection (0.6 mg kg(-1)). Withdrawal was evaluated using a 4-point scale (1, no response; 2, movement at the wrist only; 3, movement/withdrawal involving arm only (elbow/shoulder) and 4, generalized response, movement/withdrawal in more than one extremity). RESULTS: The incidence of withdrawal movement was 42% and 26% in the Groups P and L, respectively (p=0.120). Although no significant differences were noted in the number of patients who had no withdrawal movement and mild withdrawal movement in Groups P and L, compared with Group L, the incidences of moderate withdrawal movement were significantly higher in Group P (p<0.05). No patient in either group revealed generalized movement. CONCLUSION: Using a venous occlusion technique, pretreatment with 50 mg paracetamol can prevent withdrawal movement caused by rocuronium injection in children but is not as effective as lidocaine to prevent moderate withdrawal movement.