Post-Cardiac arrest targeted temperature management in a parturient with severe COVID-19 disease.

Background and Objective: Targeted temperature management (TTM) may improve neurological outcomes and mortality after cardiac arrest. We present a targeted mild hypothermia treatment in a postpartum patient with COVID-19 after successful cardiopulmonary resuscitation (CPR). Case presentation: A 23 year old, 26-week pregnant patient with the diagnosis of COVID-19. The patient developed respiratory arrest followed by cardiac arrest and underwent CPR for six minutes. The patient underwent an emergency cesarean section after CPR in intensive care unit. After the resuscitation, 72-hours hypothermia protocol was initiated. We extubated the patient 13 days after the hypothermia procedure. The patient was conscious and cooperative. Respiratory distress worsened in the following days; the patient was re-intubated 18 days after the TTM. The benefit of targeted hypothermia was improved neurologic outcome in our patient. However, severe infectious complications led to multi-organ failure and the patient died on the 45th ICU admission day.

A Novel Method for Ultrasound-Guided Central Catheter Placement-Supraclavicular Brachiocephalic Vein Catheterization Versus Jugular Catheterization: A Prospective Randomized Study.

OBJECTIVES: To assess the superiority of a novel ultrasound-guided central venous catheterization technique, supraclavicular brachiocephalic catheterization, compared to jugular vein catheterization. DESIGN: Prospective randomized trial. SETTING: Operating rooms and intensive care unit. PARTICIPANTS: Eighty-six patients with central catheter placement were included in the present study. INTERVENTIONS: In the brachiocephalic group, ultrasound-guided catheterization of the brachiocephalic vein was performed via the supraclavicular route using needle-in-plane and syringe-free techniques. In the jugular group, ultrasound-guided catheterization of the internal jugular vein was performed using the needle-out-of-plane technique. MEASUREMENTS AND MAIN RESULTS: Measurements included number of needle insertion attempts, ultrasonography times, and cannulation times. Additionally, ultrasound visibility of the veins, needle, guidewire, and catheter, as well as ease of the procedure, were assessed. Mean cannulation time was 27.65 ± 25.36 seconds in Group B and 28.16 ± 21.72 seconds in Group J. The overall success rate was 97.6% in Group B and 97.7% in Group J. The mean ease score of the cannulation procedure was 8.78 ± 1.13 in Group B and 8.67 ± 1.23 in Group J. No significant differences were detected between groups. The mean ultrasonography time was 11.98 ± 6.91 seconds in Group B and 2.88 ± 1.47 seconds in Group J. Ultrasound visibility of the brachiocephalic, jugular, and subclavian veins, as well as the needle and the guidewire, were good; however, visibility of the catheter was poor. CONCLUSIONS: Although not superior to the standard internal jugular approach, the novel supraclavicular approach proved to be a noninferior method for central venous cannulation.

Maternal and Neonatal Outcomes of Critically Ill Pregnant and Puerperal Patients Diagnosed with COVID-19 Disease: Retrospective Comparative Study.

BACKGROUND: We assessed maternal and neonatal outcomes of critically ill pregnant and puerperal patients in the clinical course of coronavirus disease 2019 (COVID-19). METHODS: Records of pregnant and puerperal women with polymerase chain reaction positive COVID-19 virus who were admitted to our intensive care unit (ICU) from March 2020 to August 2021 were investigated. Demographic, clinical and laboratory data, pharmacotherapy, and neonatal outcomes were analyzed. These outcomes were compared between patients that were discharged from ICU and patients who died in ICU. RESULTS: Nineteen women were included in this study. Additional oxygen was required in all cases (100%). Eight patients (42%) were intubated and mechanically ventilated. All patients that were mechanically ventilated have died. Increased levels of C-reactive protein (CRP) was seen in all patients (100%). D-dimer values increased in 15 patients (78.9%); interleukin-6 (IL-6) increased in 16 cases (84.2%). Sixteen patients used antiviral drugs. Eleven patients were discharged from the ICU and eight patients have died due to complications of COVID-19 showing an ICU mortality rate of 42.1%. Mean number of hospitalized days in ICU was significantly lower in patients that were discharged (P = 0.037). Seventeen patients underwent cesarean-section (C/S) (89.4%). Mean birth week was significantly lower in patients who died in ICU (P = 0.024). Eleven preterm (57.8%) and eight term deliveries (42.1%) occurred. CONCLUSION: High mortality rate was detected among critically ill pregnant/parturient patients followed in the ICU. Main predictors of mortality were the need of invasive mechanical ventilation and higher number of days hospitalized in ICU. Rate of C/S operations and preterm delivery were high. Pleasingly, the rate of neonatal death was low and no neonatal COVID-19 occurred.

Fahr's syndrome presenting with seizures in SARS-CoV-2 (COVID-19) pneumonia-a case report.

BACKGROUND: Fahr's syndrome (or Fahr's disease) is a rare, neurological disorder characterized by bilateral calcification in the cerebellum, thalamus, basal ganglia, and cerebral cortex as a result of calcium and phosphorus metabolism disorder. The patients may be asymptomatic and clinical symptoms represent a wide range of neurologic manifestations and nonspecific neuropsychiatric disorders. We report an unusual case of Fahr's syndrome which was asymptomatic and incidentally diagnosed by generalized tonic-clonic seizure in a patient with SARS-CoV-2 (COVID-19) pneumonia. CASE PRESENTATION: The patient was a 68-year-old female and admitted to our emergency department suffering from cough and fatigue. After thorax computed tomography (CT) and SARS-CoV-2 PCR test, she was diagnosed as COVID-19 pneumonia. In the intensive care unit, the patient had a tonic-clonic convulsion starting from the left arm and spreading to the whole body. Fahr's syndrome was diagnosed after a cranial CT scan and blood metabolic panel test. CONCLUSIONS: As a result of the clinical, radiological, and biochemical evaluations, the patient was diagnosed incidentally as Fahr's syndrome associated with hypoparathyroidism. Seizures could be induced by hydroxychloroquine that was in the COVID-19 treatment or the inflammation caused by COVID-19 pneumonia. The association between the mortality of COVID-19 pneumonia and Fahr's syndrome is unknown which needs further research.

A Comparison of Direct Laryngoscopy and Videolaryngoscopy for Endotracheal Intubation by Inexperienced Users: A Pediatric Manikin Study.

OBJECTIVE: Direct laryngoscopy (DL) is the most common technique for endotracheal intubation, whereas videolaryngoscopy provides an indirect view of the glottis without the need to align the oral, pharyngeal, and tracheal axes. The current study compares videolaryngoscopy with DL among experienced and inexperienced users for endotracheal intubation using a pediatric manikin. METHODS: Participants performed DL using Miller and Macintosh laryngoscopes and videolaryngoscopy using CMAC and GlideScope devices on a manikin (SimBaby; Laerdel, Wappingers Falls, NY). Time to endotracheal intubation, number of attempts, and successful intubation within 120 seconds were recorded. RESULTS: Among 31 experienced users, time to endotracheal intubation with the CMAC (20 ± 13 seconds) did not differ from DL with either the Miller (30 ± 28 seconds) or Macintosh (27 ± 23 seconds) laryngoscopes. However, with the GlideScope, time to endotracheal intubation (85 ± 38 seconds) was longer. The results were similar among 12 inexperienced users, as time to endotracheal intubation with the CMAC (61 ± 34 seconds) was comparable with the Miller (72 ± 45 seconds) or Macintosh (72 ± 45 seconds) laryngoscopes but was longer with the GlideScope (118 ± 6 seconds) for each comparison. CONCLUSIONS: The standard straight or curved laryngoscope blades including the CMAC were associated with shorter procedural time and higher success rate when compared with indirect videolaryngoscopy with an unconventional blade design such as the GlideScope in both experienced and inexperienced users. However, the current study demonstrates that results may be influenced by the anatomical design of the manikin.

Efficacy of Rapid Fluid Administration Using Various Setups and Devices.

OBJECTIVES: In clinical practice, there are various methods that can be used for the rapid administration of fluid in infants and children. The current study prospectively evaluates gravity, pressure-assisted, and hand-pump methods for the rapid administration of fluid using an in vitro model. METHODS: Thirty participants were asked to deliver 500 mL of fluid using 1 of 6 setups: (1) standard blood tubing with gravity administration, (2) standard blood tubing with pressure bag maintained at 300 mm Hg, (3) standard blood tubing with pressure bag inflated to 300 mm Hg and left to flow, (4) blood tubing with in-line bulb pump, (5) blood tubing with in-line bulb pump and pressure bag, and (6) standard blood tubing with 20-mL syringe attached to the stopcock for a push-and-pull technique using a 20-mL syringe. RESULTS: The blood tubing with an in-line bulb pump to allow manual acceleration of the administration of fluid along with a pressure bag on the intravenous fluid bag achieved the fastest flow rate, requiring an average of 98 seconds to deliver 500 mL of fluid. CONCLUSIONS: When considering factors that affect fluid administration, Poiseuille's law dictates that the most important variable is the radius of the intravenous cannula, whereas the length of the cannula and the viscosity of the fluid administered are of secondary importance. With these limitations in mind, other factors may be used to speed fluid administration. Our study demonstrates the advantage of using blood tubing with the in-line bulb pump combined with a pressure bag.

Videolaryngoscopy in Neonates, Infants, and Children.

Airway management is vital during anesthetic care and during resuscitative efforts in the PICU, the emergency department, and the delivery room. Given specific anatomic and physiologic differences, neonates and infants may be more prone to complications during airway management. Videolaryngoscopy may offer an alternative to or advantages over direct laryngoscopy in specific clinical scenarios. The following article reviews some of the basic types of videolaryngoscopy and discusses their potential applications in the pediatric population.

The effect of esophagogastroduodenoscopy probe insertion on the intracuff pressure of airway devices in children during general anesthesia.

Given the size of the esophagogastroduodenoscopy (EGD) probe and the compressibility of the pediatric airway, the EGD probe may increase the intracuff pressure (IP) of an airway device. The current study evaluated IP changes during EGD examination under general anesthesia in pediatric patients. Following the induction of anesthesia, a laryngeal mask airway (LMA) or endotracheal tube (ETT) was placed without neuromuscular blockade. The IP was measured at baseline, during EGD probe insertion, while the EGD probe was in place, and after probe removal. The study cohort included 101 patients (mean age 11.3 years). The airway was secured with an LMA and an ETT in 88 and 13 patients, respectively. The IP increased from 27 ± 15 cmH2O at baseline to 34 ± 17 cmH2O during probe insertion (p < 0.001), remained at 33 ± 16 cmH2O while the probe was in place, and decreased to 26 ± 14 cmH2O after probe removal. The IP of the LMA or ETT increased during EGD probe insertion and remained elevated while the probe was in place. High IP may compromise mucosal perfusion resulting in a sore throat when using an LMA or the potential for airway damage if an ETT is used. Removal of air from the cuff and titration of the IP should be considered after EGD insertion.

Pilot study comparing post-anesthesia care unit length of stay in moderately and severely obese children.

OBJECTIVE: Obesity is a risk factor for surgical complications in adults and children. Differences in postsurgical outcomes according to severity of obesity [moderate: 95-98th age-gender-specific body mass index (BMI) percentile versus severe: ≥99th percentile] in children remain unclear. This study compared post-anesthesia care unit (PACU) stay and hospital admission between severely obese children and moderately obese children undergoing surgery. METHODS: In a retrospective review over a 6-month period, obese children, 2-18 years of age undergoing surgery were identified. Multivariate mixed-effects regression was used to compare PACU length of stay (LOS) need for opioid analgesia, and hospital admission between moderately and severely obese patients. RESULTS: There were 1324 records selected for inclusion. PACU LOS did not significantly differ between moderately obese (50 ± 36 min) and severely obese patients (55 ± 38 min). There were no differences between moderately and severely obese patients in use of opioids in the PACU. Yet, severely obese patients were more likely to require inpatient admission than moderately obese patients. CONCLUSIONS: The duration of PACU stay still averaged less than 1 h in our cohort, suggesting that the majority of these patients can be cared for safely in the outpatient setting. Future studies should focus on identifying the co-morbid conditions that may prolong postoperative PACU stay or result in unplanned hospital admission in moderately and severely obese patients. Our preliminary data suggest that these factors may include a younger age and the complexity or duration of the surgical procedure.

PERIOPERATIVE CARE OF AN INFANT WITH GOMEZ-LOPEZ-HERNANDEZ SYNDROME.

Gomez-Lopez-Hernandez syndrome, also known as cerebello-trigeminal dermal dysplasia, is a rare neurocutaneous syndrome classically characterized by the triad of rhombencephalosynapsis, trigeminal anesthesia, and bilateral parietal alopecia. Associated clinical features include a characteristic facial appearance (mid-face hypoplasia, hypertelorism, and low-set, posteriorly rotated ears), brachycephaly, strabismus, ataxia, developmental delay, short stature, and corneal opacities. Given the associated congenital anomalies, anesthetic care may be required for various surgical interventions. We report a 7-month-old with Gomez-Lopez-Hernandez syndrome scheduled for laparoscopic gastrostomy with tube placement and frenulotomy under general anesthesia. The potential perioperative implications of such patients are reviewed and options for anesthetic care discussed.

A randomized controlled trial of preinsertion ultrasound guidance for spinal anaesthesia in pregnancy: outcomes among obese and lean parturients: ultrasound for spinal anesthesia in pregnancy.

PURPOSE: The present study was conducted to examine if preinsertion lumbar ultrasound scanning helps with performance of spinal puncture, as a tool for decreasing the number of puncture attempts and spinal procedure time and increasing the success rate. We hypothesized that ultrasound can facilitate neuraxial blockade, particularly in pregnant women with difficult topographic anatomy. METHODS: One hundred (50 lean, BMI <30 kg/m(2), and 50 obese, BMI ≥30 kg/m(2)) parturients scheduled for cesarean delivery were divided into ultrasound and control groups. Subarachnoid block was performed with prepuncture ultrasound examination in lean parturients (group 1, n = 25) and in obese parturients (group 2, n = 25), and subarachnoid block was performed without prepuncture ultrasound examination in lean parturients (group 3, n = 25) and in obese parturients (group 4, n = 25). The number of puncture attempts and puncture levels were recorded. RESULTS: A lower number of puncture attempts and fewer puncture levels were detected in ultrasound (US) groups (p < 0.001). First attempt success rate under US guidance was 92 % in comparison to 44 % using a conventional technique in obese parturients (p < 0.001). In 52 % of the lean patients and in 54.2 % of the obese patients, the intercristal line was at the L3-L4 and at the L2-L3 interspace, respectively. The duration of spinal procedure was shorter in US groups (22 vs. 52 s, p = 0.031). We found a high correlation between ultrasound and needle depth (r = 0.709, p < 0.001). CONCLUSIONS: We found a high level of success in the prepuncture ultrasound-determined insertion point. The ultrasound imaging technique can be a reliable guide to facilitate spinal anesthesia, especially in obese parturients.

Perioperative use of fascial plane blocks; anesthesiology and reanimation physicians' approach in Türkiye: A national survey study.

OBJECTIVES: Our aim was to assess the approach of Turkish Anesthesiology and Reanimation Specialists to the perioperative use of truncal/fascial plane blocks (FPB) in various surgeries. A survey was designed to evaluate the perioperative management of FPBs. METHODS: Anesthesiology and Reanimation specialists and residents in various hospitals in Türkiye were surveyed on a voluntary basis. We contacted them between June 1 and September 10, 2022, using email and smartphone messenger applications. They were asked to complete a questionnaire form regarding the perioperative management of FPBs. RESULTS: A total of 242 anesthesiology specialists and residents responded to the survey. Most participants (42.3%) were anesthesiology specialists in 3rd level (academic, teaching, or university) hospitals. 90% of the participants use these blocks in their clinical practice. The primarily used FPBs were the erector spinae plane (ESP) (629 responses in all categories). CONCLUSION: The anesthesia and reanimation specialists in Türkiye are reasonably familiar with FPBs and use these blocks frequently in clinical practice. The primarily preferred blocks seem to be ESP and TAP blocks. Lack of equipment is a major reason for the non-performance of FPBs. There is still a lack/need for additional education and training for these blocks.

The effect of low-dose and high-dose low-molecular-weight-heparin and aspirin thromboprophylaxis on clinical outcome and mortality in critical ill patients with COVID-19: A retrospective cohort study.

OBJECTIVES: To assess the effect of different thromboprophylaxis regimens on clinical outcomes and mortality of critical ill patients with coronavirus disease -19 (COVID-19). METHODS: We investigated the medical records of patients with positive COVID-19 (using polymerase chain reaction test) who were admitted to the intensive care unit (ICU) at Sakarya University Hospital, Sakarya, Turkey, from March 2020 to January 2021. We included patients under anticoagulant therapy in the clinical course. The patients were allocated to 3 groups: Group A - low-dose (prophylactic) low-molecular-weight-heparin (LMWH) therapy, Group B - high-dose (therapeutic) LMWH therapy, and patients that received aspirin additional to the high-dose (therapeutic) LMWH as Group C. Primary outcomes were overall mortality rates and length of stay (LOS) in ICU. Secondary outcomes were rates of major hemorrhagic and thrombotic events. RESULTS: Records of 475 patients were reviewed and 164 patients were included. No significant difference was detected in mortality rates between groups (p=0.135). Intensive care unit stay was 13 (9-24.5) days in Group A, 11 (8.75-23) days in Group B, and 13 (9-17) days in Group C without a significant difference (p=0.547). No significant difference was detected between groups in terms of thrombotic (p=0.565) and hemorrhagic events (p=0.615). CONCLUSION: A high-dose anticoagulation therapy and addition of aspirin to LMWH therapy did not decrease the mortality rates and LOS in ICU in critical ill COVID-19 patients. In addition, it did not increase the incidence of major hemorrhage and major thrombotic events.

Percutaneous Dilational Tracheostomy in a Patient With SARS-CoV-2 (COVID-19) Disease: A Case Report With Implications in Staff Safety.

Some patients may need mechanical ventilation support during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease-2019, COVID-19) infection and may eventually require tracheostomy in the following days. Tracheostomy is considered as a high-risk procedure for surgeons and operative personnel in terms of air contamination. We present a case of percutaneous dilational tracheostomy performed in a patient with COVID-19 pneumonia and the methods we used to reduce contamination risks for the healthcare staff.

Ultrasound guided erector spinae plane block provides effective opioid-sparing postoperative visceral pain relief after intussusception surgery: A pediatric case report.

Pediatric postoperative pain management may require a multimodal approach. Single injection erector spinae plane (ESP) block may provide prolonged opioid-sparing postoperative analgesiain pediatric patients. We present a pediatric case of ESP block for postoperative analgesia after intussusception surgery.Surgical reduction was planned for 9-month-old patient after a trial of hydrostatic enema reduction had failed.We performed ultrasound guided unilateral bi-level ESP block. ESP block provided effective postoperative visceral and somatic pain relief and opioid sparing analgesia in our case.

Lateral oblique approach for internal jugular vein catheterization: Randomized comparison of oblique and short-axis view of ultrasound-guided technique.

OBJECTIVE: The lateral oblique approach is a novel needle-in-plane technique for ultrasound-guided catheterization of the internal jugular vein. In this study, we aimed to compare the oblique approach with the classical short-axis technique for facilitating the procedure and reduction of mechanical complications. METHODS: This research was planned as a prospective study. Eighty-four open-heart surgery patients requiring a central venous catheter were randomly allocated into two groups: Oblique approach group (n=42) and short-axis group (n=42). Time to cannulate, the number of necessary puncture attempts, and frequency of carotid artery puncture, hematoma, puncture site bleeding, pneumothorax, and hemothorax in each group were recorded. Visualization of the vein and the needle using ultrasound were also evaluated by a subjective scale. RESULTS: The patient's characteristics were comparable between the two groups. The mean time of catheterization was 52.00±70.18 seconds in the oblique approach group and 40.76±49.30 seconds in short-axis group. The mean number of needle puncture attempts was 1.21±0.61 in oblique approach and 1.12±0.50 in short-axis group. The results did not differ significantly. There was an improved visualization of the needle in the oblique approach group, but this was not proved as statistically significant. CONCLUSION: The results of our study suggest that the lateral oblique approach is a safe and effective technique, which can be a strong alternative to the classical short-axis technique for ultrasound-guided catheterization of the internal jugular vein.

Ultrasound-guided supraclavicular brachiocephalic vein catheterization in children: Syringe-free in-plane technique with micro-convex probe.

Central venous catheterization of children is often a challenging procedure due to small anatomical structures. Ultrasound guidance has been shown to reduce complications and improve cannulation success as compared with the landmark-based technique. In-plane techniques allow for longitudinal visualization of the vessels and real-time visualization of needle track during its advancement. When in-plane and syringe-free techniques are combined, advancement of the guidewire can also be visualized. We aim to introduce our supraclavicular approach for brachiocephalic vein cannulation in pediatric patients. A syringe-free and in-plane technique is used to cannulate the patients. The subclavian, jugular, and the brachiocephalic veins were visualized by endocavity micro-convex ultrasound probe as a Y shape during the cannulation procedure. We present a case series of successful cannulation by using this technique.