Use of an Endobronchial Blocker in a Patient with Tracheobronchial Anomaly for Minimally Invasive Cardiac Surgery: A Case Report.

Tracheal bronchi (TB) is a rare anomaly and is usually asymptomatic. Although it is generally not a problem when a single lumen tube is used, it may cause ventilation difficulties in the intraoperative period in procedures requiring one lung ventilation, such as minimally invasive cardiac surgery. Therefore, these difficulties may cause intraoperative and postoperative complications. While a double-lumen tube is recommended as the primary choice for one-lung ventilation in patients with TB, bronchial blockers can be used to avoid the need for tube exchange in patients who will remain intubated in the postoperative period.

Ultrasound-guided erector spinae plane block in coronary artery bypass surgery: the role of local anesthetic volume-a prospective, randomized study.

BACKGROUND: Erector spinae plane block has been shown to help with pain management in different regions and many areas with different indications. However, the effectiveness of this block in cardiac surgery has been shown in the literature, the optimal volume remains unclear. The aim of this study is to determine the analgesic efficacy of two different volumes of local anesthetic injection used in ultrasound-guided bilateral-thoracic erector spinae plane block in patients undergoing coronary artery bypass graft. METHODS: This study was conducted on adult patients undergoing surgery with coronary artery bypass graft, and 70 patients were analyzed in each group. Group 20 received erector spinae plane block with 20 ml of 0.25% bupivacaine, Group 30 received 30 ml of 0.25% bupivacaine bilaterally. Postoperative sternotomy and chest tube-related pain were evaluated using the numerical rating scale (NRS) at rest and during movement. RESULTS: There were significant differences between the groups regarding rescue tramadol consumption was higher in Group 20 than in Group 30 (25/35 vs. 2/35, p < 0.001). In addition, there were substantial differences between the two groups concerning the time of the first-rescue analgesic requirement. The mean time ± standard deviation was 11.26 ± 9.57 h and 24.03 ± 4.12 h in Groups 20 and 30 (p < 0.001). The median scores, both at sternotomy and chest tubes, were significantly lower in Group 30 than in Group 20 at the different time points after the surgery (p < 0.05). CONCLUSIONS: In coronary artery bypass graft surgery, erector spinae plane block performed with 30 ml instead of 20 ml on each side resulted in less pain in the sternum and chest tube region, less need for rescue analgesics, and delayed first-rescue analgesic requirement.

The Influence of Pre-operative Pain and Anxiety on Acute Postoperative Pain in Cardiac Surgery Patients Undergoing Enhanced Recovery after Surgery.

Objective: Perioperative multimodal analgesia is an important step in enhanced recovery after surgery (ERAS) care. Many factors, such as preoperative chronic pain and anxiety, may provide information about the expected postoperative pain. In this study, we evaluated preoperative pain and anxiety and investigate their effects on acute postoperative pain in patients undergoing elective cardiac surgery. Methods: After ethics committee approval, 67 consenting patients undergoing on-pump cardiac surgery under the ERAS program were included in our prospective observational study. Pre- and postoperative pain scores were obtained using a numeric rating scale (NRS) at rest and during movement. Preoperative anxiety was assessed on a 0-10 scale, and data were recorded. The relationships between pre-operative pain/anxiety and postoperative pain were evaluated using correlation analysis. Results: In preoperative pain assessment, the percentage of patients with a pain score above 4 with NRS was 1.5%, regardless of whether they were at rest or mobilize. In postoperative pain assessment, there were 20.9% and 34.3% patients with NRS >4 at rest and mobilization, respectively. 7.5% of patients had preoperative anxiety of grade 5 or higher. While preoperative pain was not correlated with postoperative pain, preoperative anxiety had a moderate positive correlation with postoperative pain (r=0.382, P=0.003). Conclusion: The prevalence of preoperative pain in patients who underwent cardiac surgery is quite low and is not associated with postoperative pain. There is also a significant relationship between the severity of preoperative anxiety and postoperative pain.

Preoperative ultrasound-guided bilateral thoracic erector spinae plane block within an enhanced recovery program is associated with decreased intraoperative lactate levels in cardiac surgery.

INTRODUCTION: In the perioperative period, regional analgesia techniques may play an increasingly important role in "Enhanced Recovery After Surgery (ERAS)" programs, as they can facilitate recovery. We hypothesized that Erector Spinae Plane (ESP) block could improve regional perfusion, thereby limiting blood lactate increase. Therefore, we aimed to evaluate the effect of ESP block on intraoperative blood lactate levels in patients scheduled for elective on-pump cardiac surgery with ERAS protocol. METHODS: A total of 68 adult patients scheduled for on-pump cardiac surgery were included. All patients were randomized to the ESP group and the non-ESP group. Blood lactate analyses were performed at intraoperative five-time points. C-Reactive protein (CRP) values were also measured. RESULTS: Blood lactate values were significantly lower in the ESP group than in the Non-ESP group, at the end of CPB [1.78 (1.23-2.78) mmol L-1 to 2.63 (1.70-3.12) mmol L-1] and during the sternal closure period [1.78 (1.27-2.42) mmol L-1 to 2.40 (2.14-2.80) mmol L-1] (p = 0.039, p = 0.009). In addition, CRP values were significantly lower in the ESP group in the postoperative period [0.048 (0.036-0.105) g L-1 to 0.090 (0.049-0.154) g L-1] (p = 0.035). CONCLUSIONS: This study showed that preoperative bilateral single-shot ESP block significantly reduces intraoperative final blood lactate and postoperative CRP values. We consider that these results are related to the attenuation of intraoperative hypoperfusion and the alleviation of surgery-related postoperative inflammation. ERAS programs aim to achieve the rapid recovery of patients, a decrease in inflammation, and high-quality analgesia with less opioid consumption. Therefore, our results also prove that it is easier to reach the primary goals of ERAS programs with the application of ESP block in cardiac surgery.

Colour Doppler Imaging of the Ophthalmic Artery During Heart Transplantation.

Colour Doppler imaging of the ophthalmic artery is a non-invasive, fast, and easy access ultrasound technique. Estimation of cerebral perfusion from colour Doppler imaging of the ophthalmic artery is a technique with great potential in this field. In the present case, we monitored blood flow of the ophthalmic artery by colour Doppler ultrasonography during heart transplantation, and we obtained information about the adequacy of the perfusion. Colour Doppler imaging of the ophthalmic artery may be a useful method that can be applied for monitoring cerebral perfusion during heart transplantation and all cardiac operations in order to detect impaired cerebral blood flow.

All in one: Multiple coronary stents, history of stent thrombosis, pancreatic carcinoma, postoperative bleeding and thrombocytosis.

Although the management of a stent patient may appear in the guidelines, some patients may be unique and out of class. In this presentation, the patient had multiple thrombotic risk factors for perioperative myocardial injury. These factors included coronary artery disease with multiple implantations of drug-eluting stent (DES), stent thrombosis history, implantation of a new stent 11months ago and hypercoagulability (due to malignancy and surgical procedure). The patient's history of DES presented a dilemma for the anesthesiology, surgery, and cardiology teams in considering the optimal method to minimize the risk of perioperative bleeding and stent re-thrombosis.

Effects of upper limb ischemia-reperfusion on regional oxidative stress during aortic surgery with moderate hypothermia.

INTRODUCTION: This study aims to evaluate the effect of acute, iatrogenic right arm ischemia and reperfusion (I/R) due to right axillary cannulation on regional oxidative stress using tissue perfusion markers such as central venous oxygen saturation, lactate, the difference between central venous and arterial CO2 pressure, near-infrared spectroscopy (NIRS) measurements, and biomarkers like sialic acid, malondialdehyde, advanced oxidative protein products in aortic surgery with moderate hypothermia. METHODS: Adult patients undergoing ascending aorta repair with antegrade cerebral perfusion via the axillary artery participated. Blood samples were collected from the internal jugular vein, right arm cubital vein, and left arm cubital vein, and analysis was performed at intraoperative time points. RESULTS: Right-arm venous oxygen saturation levels are significantly lower than left arm and central venous, as expected in iatrogenic ischemia. Right arm lactate levels are significantly higher. Somatic right arm NIRS values are significantly lower than somatic left arm. There are no significant differences for biomarkers throughout the time points. CONCLUSIONS: We have concluded that well-known markers reflect the results of ischemia-reperfusion more rapidly, and are more valuable than novel biomarkers. NIRS is a promising monitor in terms of providing information about tissue oxygenation. Oxidative stress biomarkers do not change quickly enough to give useful information in a short enough period of time; moreover, their costs are high and laboratory studies take time. Although axillary cannulation is controlled limb ischemia, the local effects of I/R did not completely normalize at the end of the surgery, and this regional I/R did not affect the global body organism.

Anesthetic Management of Left Ventricular Assist Device Exchange in a Patient with Intracranial Hemorrhage.

The gold standard treatment for end-stage heart failure is heart transplantation; however, the rate of transplantation remains inadequate because of the paucity of organ donation. The left ventricular assist device (LVAD) has been used as a bridge therapy before transplantation. The LVAD is being used increasingly because it reduces mortality despite the accompanying morbidities. Therefore, the anesthetic management of LVAD-related morbidities is important and requires experience and knowledge. Herein, we describe a 60-year-old male patient with an LVAD with complaints of right hemiparesis, dysphasia, and facial paralysis. We aim to present the anesthetic management of a patient with intracranial hemorrhage who underwent LVAD exchange due to thrombosis.

Does uncontrolled diabetes mellitus affect cerebral hemodynamics in heart surgery?

BACKGROUND: In this study, we aimed to investigate the effects of poor blood glucose control on the intraoperative cerebral system in patients undergoing coronary artery bypass grafting using various neuromonitors. METHODS: Between January 2011 and December 2011, a total of 40 adult patients (31 males, 9 females; mean age 58.8±9.2 years; range, 38 to 78 years) who were scheduled for elective coronary artery bypass grafting were included in the study. The patients were divided into four groups according to hemoglobin A1c levels as follows: Group 1 including non-diabetic controls (n=11); Group 2 including those with a hemoglobin A1c value of <7% (n=10); Group 3 including those with a hemoglobin A1c value of 7 to 10% (n=11); and Group 4 including those with a hemoglobin A1c value of ≥10% (n=8). Cerebral monitoring was performed with near-infrared spectroscopy and transcranial Doppler. Measurement periods were defined as follows: Before anesthesia induction (period 1), 10 min after anesthesia induction (period 2), during cannulation (period 3), 10 min after cardiopulmonary bypass (period 4), at 32°C temperature during cardiopulmonary bypass (period 5), at 36°C temperature during cardiopulmonary bypass (period 6), and at the end of the operation (period 7). RESULTS: There was a significant difference in the near-infrared spectroscopy values in the cannulation period for both right (p<0.001) and left (p=0.002) sides and the mean transcranial Doppler flow velocity (p=0.002) in Group 4, compared to Group 1. The heart rate was found to be significantly lower in Group 4 in the cannulation period. The near-infrared spectroscopy values and transcranial Doppler blood flow velocity decreased in Group 4 in all measurement periods. CONCLUSION: The results of our study show that, in patients with severe diabetes undergoing open heart surgery, heart rate decreases in the cannulation period due to possible autonomic neuropathy, and cerebral blood flow and oxygenation decrease. For these patients, particularly in the cannulation period, perfusion of both cerebral and other organs should be closely monitored and necessary interventions should be performed.

Anaesthesia Management in Idiopathic Pulmonary Artery Aneurysm Surgery.

Pulmonary artery (PA) aneurysm is a very rare disease. Surgical treatment is important in symptomatic patients. Due to its anatomical condition, the rupture of such aneurysms may lead to sudden right ventricular failure or sudden death. The aim of this report is to present the use of balanced general anaesthesia management in a patient who underwent PA aneurysm repair surgery. Surgical repair was planned in a 55-year-old man with chest and back pain as well as haemoptysis. With the help of balanced anaesthesia, stress on the aneurysm wall was prevented by avoiding sudden blood pressure increases. With appropriate ventilation methods, we attempted to avoid an increase in pulmonary vascular resistance, and therefore, the pressure on the aneurysm, as well as an increase in the postoperative right ventricle. With the help of appropriate anaesthesia and ventilation techniques, uncomplicated and successful anaesthetic management was effected in the repair of a PA aneurysm.

The Results of Cardiac Surgery in Terms of Patient Blood Management in Our Hospital.

OBJECTIVE: Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek Ihtisas Training and Research Hospital, beginning in 2014, the patient blood management (PBM) protocol is individualised based on patients' comorbidities, and the threshold for transfusion is 7 g dL-1 of haemoglobin for patients without comorbidities and 8-9 g dL-1 for patients with comorbidities. In this study, our aim was to compare patient outcomes, requirement for transfusion and the cost of transfusion between two different periods with and without PBM protocol. METHODS: 229 and 283 patients who underwent open-heart surgery using cardiopulmonary bypass during the first 4 months of 2012 and the first 4 months of 2017, respectively, were included in this retrospective, cross-sectional study. RESULTS: There were no differences between the groups in preoperative data. Blood and blood product usage was observed to be significantly lower at the time of the PBM protocol. The use of packed red blood cells decreased from 2 units to 0and that of fresh frozen plasma decreased from 2 units to 0. In terms of postoperative mortality, there were no differences between the groups. CONCLUSION: According to the results of this study, the transfusion of unnecessary blood and blood products was reduced and the cost decreased with PBM protocol. Blood product usage did not affect 30-day mortality. It will be possible to achieve more valuable results if more patients are assessed, PBM protocol is implemented and postoperative results are evaluated in detail.

Effect of dilutional anemia that can be treated with only one unit of red blood cell transfusion on tissue oxygenation in cardiac surgery patients

Background/aim: Cardiac surgery, especially in the presence of cardiopulmonary bypass (CPB), is associated with an inflammatory reaction that may promote microcirculatory alterations, in addition to the general impact on system hemodynamics. Anemia and transfusion make patients more susceptible to the deleterious effects of CPB. In this study, it was aimed to evaluate the effect of dilutional anemia, which is caused by CPB and can be treated with 1­2 units of red blood cell (RBC) transfusion, on global tissue oxygenation parameters in cardiac surgery patients. Materials and methods: This prospective observational study comprised 127 patients who had a relatively stable operation period without any major anesthetic or surgical complications (e.g., operation duration >5 h, bleeding or hemodilution requiring more than 1­2 units of RBCs, or unstable hemodynamics, requiring inotropic support of more than 5 µg/kg/min dopamine). Patients were observationally divided into two groups: minimally transfused (Group Tr) and nontransfused (Group NTr). Global tissue oxygenation parameters were evaluated after anesthesia induction (T1) and at the end of the operation (T3) and compared between the groups. Results: Group Tr consisted of patients who had significantly lower preoperative hemoglobin values than Group NTr patients. The dilutional anemia of all Group Tr patients could be corrected with 1 unit of RBCs. The lactate levels at T3, increment rates of lactate, and venoarterial carbon dioxide pressure difference (ΔpCO2) levels [(T3 ­ T1) : T1] in Group Tr were significantly higher than those in Group NTr. Conclusion: Dilutional anemia as a result of CPB mostly occurs in patients with borderline preoperative hemoglobin concentrations and its correction with RBC transfusion does not normalize the degree of microcirculatory and oxygenation problems, which the patients are already prone to because of the nature of CPB. Preventing dilutional anemia and transfusion, especially in patients with preoperative borderline hemoglobin levels, may therefore reduce the burden of impaired microcirculation-associated organ failure in on-pump cardiac surgery.

Current Use of Neuromuscular Blocking Agents in Intensive Care Units.

Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation-associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report.

Comparison of new generation baska mask with i-gel and classical laryngeal mask in outpatient urological interventions.

OBJECTIVES: To compare the clinical performance of the baska mask (PTY Ltd, Australia), i-gel (Intersurgical Ltd, UK) and classic laryngeal mask airway (cLMA) in adult patients undergoing outpatient urologic interventions. METHODS: One hundred fifty patients with American Society of Anesthesiologists I-III physical status were enrolled between January 2017 and September 2017 in Yuksek Ihtisas Research and Educational Hospital, Ankara, Turkey for elective urological surgery for this prospective randomized controlled trial. There were 50 patients in each of the following groups: baska mask, i-gel, and cLMA. In each group, the insertion times, ventilation times, 'first attempt' success rates, airway dynamics-complications and hemodynamic variables were evaluated. RESULTS: No statistically significant values were observed in means of demographic data, airway dynamics, complications, and hemodynamic variables. Insertion and ventilation times were different between groups (p less than 0.001 for each). In cLMA group, insertion and ventilation times were found to be shorter than others (insertion times 5.78±1.72 seconds and ventilation times 11.72±4.72 seconds). The longest insertion and ventilation times were observed in baska mask with 12.04±6.25 and 21.26±8.53 seconds. The 'first attempt' success rates were 98% for cLMA, 92% for i-gel, and 88% for baska mask. The addition maneuvering requirements in baska mask group was  20% (40/10). Conclusion: When cLMA, i-gel and baska mask are compared regarding insertion and ventilating times, first attempt success rates, and additional maneuvers, cLMA and i-gel are superior to baska mask in urological ambulatory surgical cases.

Heparin dose calculated according to lean body weight during on-pump heart surgery.

BACKGROUND: The aim of this study is to compare heparin dose regimen calculated based on the lean body weight with traditional heparin regimen in terms of ensuring adequate anticoagulation and complications associated with perioperative bleeding. METHODS: This prospective, single-blind, randomized study included a total of 100 adult patients (42 males, 58 females; mean age 52.7 years; range, 22 to 84 years) undergoing elective valve surgery with cardiopulmonary bypass between June 2016 and January 2017. Prior to cardiopulmonary bypass, heparin dose was adjusted as 4 mg/kg, according to the actual body weight (n=50) and lean body weight (n=50). The minimal activated clotting time target value was accepted as 480 sec for cardiopulmonary bypass initiation. Demographic and hemodynamic data, post-heparin activated clotting time, additional heparin and perioperative transfusion, postoperative drainage volumes, reoperations, and mortality were recorded. RESULTS: Demographic data, cross-clamp and cardiopulmonary bypass times, and intraoperative transfusion requirement were not significantly different between the groups. The initial and total doses of heparin, as well as the total dose of protamine, were significantly higher in the actual body weight group. Postoperative transfusion rates were also higher in this group. None of the patients in the lean body weight group required reoperation, while three patients in the actual body weight group underwent reoperation. CONCLUSION: Our study results showed that adequate anticoagulation was achieved with the titration of heparin dose calculated according to the lean body weight during cardiopulmonary bypass and reduced total heparin and protamine doses decreased postoperative bleeding and blood product transfusion requirement.

Animal ethics in laparoscopic urology training.

Laparoscopic urologic operating techniques are in widespread use throughout the world and because of various advantages, over the years they have virtually become a gold standard surgical intervention method. As laparoscopy is a painstaking technique to learn, the training consists of different stages. Within these stages of training, wet laboratory training where animals are used, is the most sensitive stage. The widespread use of experimental animals in medical research necessitated standardization and the establishment of certain regulations. This standardization and organization of laws and regulations started to be discussed in Europe approximately a century ago and have been established on a certain foundation. In this rewiev article, we discuss some important points and ethic rules about laparoscopic urologic training practiced on live animals.

Intraoperative left atrium inversion after implantation of HeartMate III ventricular assist device.

We report here a case of left atrium inversion after implanting HeartMate III LVAD, which is known to be the first in literature. LVAD can be functional only if there is adequate inflow to the device. Parameters and filling of left ventricle can be assessed by TEE. In our case, initial examination with TEE showed thrombus like images. HeartMate III has a reliable algorithm that automatically reduces pump speed if 'suction effect' is detected. HeartMate III demonstrates clean flow properties and good surface wash. Despite these positive features of the HeartMate III, left atrium inversion can still be seen with it, so users should be alert in this regard.

Preliminary investigation of preoperative pregabalin and total intravenous anesthesia doses: a randomized controlled trial.

STUDY OBJECTIVE: To determine the efficacy of 2 different doses (150-300mg) of preoperative pregabalin on propofol and remifentanil doses for total intravenous anesthesia in laparoscopic cholecystectomy. DESIGN: Prospective, randomized, placebo-controlled, double-blinded study. SETTING: Training and research hospital. PATIENTS: Forty-eight adult, American Society of Anesthesiologists physical status 1 and 2 patients. INTERVENTIONS: Patients were randomly assigned to 3 groups to receive orally 1hour before surgery, a placebo group (group 1), pregabalin 150mg (group 2), or pregabalin 300mg (group 3). MEASUREMENTS: In the operating room, heart rate, systolic and diastolic blood pressures, SpO2, bispectral index, and body temperature were recorded just before anesthesia induction; 1 and 5minutes after induction; and at minutes 10, 15, 20, 25, 30, 35, and 40 of the surgery. Required propofol and remifentanil doses to obtain bispectral index value less than 60 were also recorded. MAIN RESULTS: The remifentanil doses used in the pregabalin groups at minutes 10, 15, 20, 25, and 30 and propofol doses at minutes 15, 20, 25, and 30 were statistically significantly lower in comparison to the placebo group. CONCLUSION: The observations provide preliminary evidence that preoperative pregabalin may decrease anesthetic agent requirement in total intravenous anesthesia patients.