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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.

Sağır, Özlem (Balikesir Author), Introduction More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. Methods and analysis EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. Ethics and dissemination EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369. ©

INTRODUCTION: Hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRC) are effective multimodal treatment options in patients with peritoneal carcinomatosis. Procedures are long-lasting operations with excessive blood and fluid loss. Intraoperative fluid management is very important because of major hemodynamic, respiratory and metabolic changes. This study aims to investigate the effect of intraoperative restrictive fluid therapy on postoperative outcome in patients undergoing HIPEC and SRS. METHODS: Patients who underwent HIPEC and SRS in our clinic between 2014-2018 were included in the study. The demographic, intraoperative and postoperative data of all patients were retrospectively analyzed. The patients who underwent restrictive fluid replacement were named Group R, and the group with liberal fluid replacement was named Group L. RESULTS: It was observed that the mean age was 54.6 ± 11.4 years, the female gender was 60.5% and the malignancy originating from the gastrointestinal system was 76.3%. There was no effect of liberal and restrictive fluid treatments on postoperative minor and major complications, length of stay in hospital and intensive care, and mortality. DISCUSSION AND CONCLUSION: We concluded that intraoperative restrictive fluid therapy did not affect postoperative complications and mortality in HIPEC and SRS surgeries.

Objective The present study aims to describe a widely held misconception in the literature concerning preoperative hypertension diagnosis. The blood pressure elevation occurring in the operative room is seen commonly even in subjects considered hitherto fully normotensive. As these patients have a condition which - similar to White Coat Hypertension (WCH) - indicates the presence of hypertension, and thus necessitates more frequent intraoperative checks. Methods We have named a condition 'Diagnosed in Operating Room (DIOR) with Hypertension', following the preoperative stage at which it is detected. Result Our observational study evaluated 718 elective noncardiac surgery adult patients, finding 28% of them (n = 204) to be 'DIOR-tensive' and thus at risk for suboptimal intraoperative care. Conclusion In addition to recommending a modification to the domain's best practices, we provide a preliminary description of DIOR hypertension patient identifying characteristics (older, higher body weight and BMI, and higher rates of chronic obstructive pulmonary disease, hypothyroidism and obesity), so that DIOR hypertension patients may be more readily identified, and that future research may build on the findings, and that the operating team may remain generally aware that this problem can occur and be dealt with regardless of the patient's medical history.

The aim of this study was to present our anesthetic management and early hemodynamic recovery after transapical off-pump neochords implantation. Observational prospective study. The perioperative records of 13 patients who underwent mitral valve repair using the Neochord DS1000 system were analyzed. Hemodynamic measurements recorded with the Vigileo Flotrac invasive arterial cardiac output system were evaluated. Thirteen patients were included in the study. Transfusions of a total of 2 U of erythrocytes and 11 U of plasma were performed. After Neochord implantation, the mean cardiac output increased at a statistically significant level according to the values measured after induction p = 0.003. Increased cardiac output measurement after placement of the neochordaes and elimination of insufficiency have emerged as indications of early hemodynamic recovery

IntroductionIn this study, we evaluated patient response and haemodynamic parameters in patients with low ejection fraction undergoing coronary bypass surgery with either fentanil or remifentanil in conjunction with etomidate.Material and methodsWe evaluated 30 cases of coronary artery surgery, which were divided into two treatment groups (n = 15 each). In group F (fentanil group), the following regimen was employed for anaesthesia induction: 1 mg/kg lidocaine, 0.3 mg/kg etomidate, and, following a 1 µg/kg 60 s bolus dose of fentanil, a 0.1 µg/kg/min fentanil infusion was initiated, after which 0.6 mg/kg rocuronium was administered. In group R (remifentanil group), the following regimen was employed for anaesthesia induction: 1 mg/kg lidocaine, 0.3 mg/kg etomidate and, following a 1 µg/kg 60 s bolus dose of remifentanil, a 0.1 µg/kg/min remifentanil infusion was initiated, after which 0.6 mg/kg rocuronium was administered. Systolic artery pressure, diastolic artery pressure, mean arterial pressure, heart rate, SPO2 (saturation), cardiac output, stroke volume variance, central venous pressure, and systemic vascular resistance values were recorded for all study patients at five minutes before anaesthetic induction (T1), immediately following induction (T2), and immediately following intubation (T3).ResultsThe demographic values obtained for both groups were similar. We found that remifentanil use was associated with decreased cardiac output and increased fluctuations in both heart rate and mean values of arterial pressure.ConclusionsAlthough many studies have demonstrated remifentanil to be as safe as fentanil when titrated to an appropriate dose, our study suggests that fentanil may be a more appropriate choice during the induction of anaesthesia in patients with a low ejection fraction.

Risk factors for staple line bleeding (SLB) during and after sleeve gastrectomy (SG) are various, including patient related factors, perioperative medications, and surgical technique, although there is little clarification in the literature of the role played by blood pressure during the stapling phase. The aim of the present retrospective cohort study was to identify possible risk factors liable to cause SLB.Data collected prospectively from 120 consecutive patients who underwent SG were analyzed retrospectively according to age, gender, body mass index (BMI), international normalized ratio (INR) value, intraoperative systolic blood pressure (SBP), and mean arterial blood pressure (MABP).In univariate analysis, age, stapling phase SBP and MABP, and the duration of surgery were all significantly higher in patients with SLB than those without (P .05). In distinguishing patients with SLB from those without, the cutoff threshold for SBP during the stapling phase was 120 mmHg with a 78.9% sensitivity, 97.6% specificity, 93.8% positive predictive value, 90.9% negative predictive value, and 91.7% accuracy (AUC = 0.908, 95% CI: 0.839-0.976, and P .001). In multivariate logistic regression analysis, independent of age and operation time, SBP120 mmHg significantly maintained its predictive power on SLB (95% CI: 32.410-1457.896, P .001).A SBP120 mmHg during the division of the stomach is an independent risk factor for SLB. Maintaining intraoperative SBP ≤120 mmHg during the stapling phase does not only decrease the risk of SLB but also the need for homeostatic agents such as clips and sutures, which in turn prolong the operative time and increase cost.

In this manuscript, we describe a significant advantage of the intraoperative near infrared spectroscopic techniques (NIRS) using in a malignant hypertensive patient during kidney transplantation. This patient underwent operation becasue of the presence of a suitable cadaveric kidney. Moreover, although the patient’s hypertension was intensively treated by cardiology for a long time, it could not be controlled. Thus, despite severe hypertension, the patient was anaesthetized. Mean arterial pressures of about 70–90 mmHg, which are considered to be normal for most people, could cause cerebral hypoperfusion in such a patient. It is a significant advantage that the lower limit of cerebral autoregulation is quickly assessed by NIRS in the case of a kidney transplant performed under general anaesthesia.

WOS: 000384014400004, PubMed ID: 27366575, Objective: To evaluate the factors that affects the postperfusion syndrome in cadaveric liver transplantations and the effect of the postperfusion syndrome on discharge from the hospital. Methods: Patients who underwent cadaveric liver transplantations between 2007 and 2013 were scanned retrospectively. Intraoperative anaesthesia records, intensive care unit follow-up forms and discharge reports were examined from patient files. Overall, 43 patients having complete data were included in the study. The postperfusion syndrome is defined as asystoli or a decrease in mean arterial pressure of more than 30%, which occurred in the first 5 min of reperfusion and continued for 1 min. Patients were divided into two Zgroups: those who had the postperfusion syndrome and those who did not. Results: The number of patients who had the postperfusion syndrome was 25 of 43 (58.1%). The MELD score of patients without the postperfusion syndrome was calculated as 16.9+/-3.2 and that of patients with the postperfusion syndrome was 19.7+/-3.6. A statistically significant relationship was detected between the postperfusion syndrome occurrence and a high MELD score (p=0.013). The diastolic blood pressure just before reperfusion was statistically lower in the group with the postperfusion syndrome than in the other group (p=0.023, 50+/-8 vs. 58+/-11). According to the logistic regression analysis, the MELD score and the decrease in diastolic blood pressure before reperfusion were defined as independent predictive factors. Conclusion: According to the study, the ratio for having the postperfusion syndrome was found to be 58.1%. The independent predictor factors affecting the postperfusion syndrome were detected as the MELD score and the decrease in diastolic blood pressure before reperfusion. The postperfusion syndrome during orthotropic liver transplantation is an important issue for anaesthesiologists. The awareness of the related factors with the postperfusion syndrome may help in the development of various preventive strategies

OBJECTIVE: Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas 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.

Objective In this study, our aim was to investigate the efficacy and sufficiency of bispectral indeks (BIS) guided remifentanil-desflurane anaesthesia on intraoperative haemodynamic stability in both normotensive and hypertensive patients undergoing off-pump coronary artery bypass surgery. Methods Thirty adult, ASA I-III patients undergoing elective off-pump coronary surgery were included in the study. According to the presence of essential hypertension preoperatively, patients were divided into two groups. Haemodynamic parameters were recorded at 11 time points during the operation. Results There were no differences in the demographic data, heart rate and intraoperative and postoperative parameters between the groups. Arterial blood pressure and additional requirement of remifentanil were found to be significantly higher in the hypertensive group intraoperatively. Conclusion In patients undergoing off-pump coronary revascularisation surgery, intraoperative haemodynamic stabilisation with remifentanil-desflurane anaesthesia under BIS guidance was safely provided, but higher remifentanil doses were required in hypertensive patients.

Transient neurologic dysfunction is common after aortic surgery. Major causes of postoperative complications followed by cardiac surgery are due to hypoperfusion states such as selective cerebral perfusion, embolic debris during cardiopulmonary bypass and ulcerated plaque emboli originated from carotid arteries. Neurologic complications prolong periods of intensive care unit and hospital stay, worsens quality of life and unfortunately they are an important cause of morbidity. Anaesthesia during a carotid and aortic surgery constitutes of providing adequate brain perfusion pressure, attenuating cerebral metabolism by anaesthetic agents and monitoring the cerebral metabolic supply and demand relationship during the intraoperative period. We present a monitoring approach with an intraoperative 16-channel electroencephalography and bilateral near infrared spectroscopy during redo aneurysm of the sinus of Valsalva surgery.

Background Since the first liver transplantation, pretransplantation or post-transplantation renal problems are still among the main causes of mortality and morbidity. The aim of this study was to evaluate the effects of fluid replacement solutions used intraoperatively on renal functions in elective living-donor liver transplantation. Methods After Ethics Committee approval, informed consents were obtained from patients. Patients with normal renal functions and scheduled for elective living-donor-liver transplantation were included in the study. Patients were randomly allocated to infusion with 6% hydroxyehylstarch 130/40 (HES group) and 4% Gelofusine (GEL group). Blood samples were obtained before the induction of anesthesia (baseline), at the end of the operation, and postoperative days 1 and 4. Different estimated glomerular filtration rate (eGFR) formulas using creatinine (modification of renal disease, chronic kidney disease-epidemiology collaboration and Cockraud Gault) were used to calculate the eGFR. Results Thirty-six patients were included in the study (GEL group = 18; HES group = 18). Patient characteristics, modified end stage liver disease-Child Pugh score, American Society of anaesthesiologist scores, and intraoperative data were similar between groups. Postoperative measurements showed that creatinine was significantly higher in the GEL group compared with the baseline, which was not the case for the HES group. Similarly, postoperative eGFR levels, as measured using MDRD and CKD-EPI, were found to be significantly lower in the GEL group. Postoperative urine albumin:creatinine ratios were significantly higher in the GEL group compared with baseline. Total crystalloid amount used, colloid, blood, fresh frozen plasma values, extubation, and intensive care unit (ICU) and hospital stay were similar in both groups. Postreperfusion syndrome developed in 6 patients in each group. Conclusion In conclusion, Gelofusine seem to cause more impairment in renal functions in elective living-donor liver transplantation.

In the present study, changes in hemodynamic parameters and cerebral oxygen saturation (rSO2) associated with 10 cm H2O PEEP application were investigated, which is assumed beneficial for the respiratory functions and oxygenation during laparoscopic cholecystectomy (LC) applied at 30° head-up left side position. Data gathered via two devices, namely INVOS and FORESIGHT, were compared. After both the ethics committee approval from the hospital and patients’ written consents were obtained, patients undergoing elective laparoscopic surgery (only ASA I–II) were randomly divided into two groups (Clinical trials protocol NCT02071550). Sensors of INVOS and FORESIGHT devices were placed on the right side at the forehead region. In total, 11 evaluation periods were formed, namely pre-induction (1st period), post-induction (2nd period), abdominal insufflation outset (3rd period), post-insufflation at 5-min intervals (4th, 5th, 6th, 7th, and 8th period), at the end of insufflation (9th period), at the end of operation (10th period), and at the end of anesthesia (11th period). While one of the groups did not receive PEEP (ZEEP group), the other group received 10 cm H2O along with abdominal insufflation (PEEP group). Demographic data, hemodynamic values, and rSO2 values were recorded for both groups at all 11 periods. A total of 44 patients in two groups, each group containing 22 individuals, were included in the study. Systolic, diastolic, and mean arterial pressures, etCO2 and SO2 values, and demographic data were found to be similar in both groups. Heart rate was observed to be higher in the PEEP group starting with the PEEP administration. INVOS rSO2 values were found similar in both groups. However, FORESIGHT rSO2 values were found to be higher in the PEEP group compared to the ZEEP group. No patient had cerebral desaturation in both groups throughout the study. Application of PEEP with 10 cm H2O during abdominal insufflation could increase the rSO2 value and heart rate in patients undergoing laparoscopic cholecystectomy. However, all changes observed were within normal limits. FORESIGHT device yielded more compatible results with hemodynamic data compared to INVOS.

We have investigated the effects of ketamine-based and remifentanil-based anesthetic protocol on perioperative serum cystatin-C levels, and creatinine and/or cystatin-C-based eGFR equations in terms of acute kidney injury in coronary artery bypass graft (CABG) surgery. Using a simple randomization method (coin tossing), patients were divided into the two groups and not-blinded to the anesthetist. Remifentanil-midazolam-propofol or ketamine-midazolam-propofol-based anesthetic regimen was chosen. Different eGFR formulas using creatinine (MDRD, CKD-EPI, Cockrauft Gault); cystatin-C (eGFR1, eGFR2) or a combination of creatinine and cystatin-C (eGFR 3) were used to calculate estimated glomerular filtration rates (eGFRs). High-sensitive troponin T was used to determine if ketamine use in coronary surgery contributed to myocardial cell damage. Thirty-seven patients were included in the study (remifentanil group = 19, ketamine Group = 18). Urea, creatinine, cystatin-C levels were comparable between the groups in all the measurement times and also postoperative day 2 samples showed statistically higher results compared to baseline (p < 0.001). Effects of ketamine and remifentanil on renal functions were found similar. Creatinine and cystatin-C-based eGFR equations resulted similar in our study. Reversible stage 1 acute kidney injury (AKI) was observed on postoperative day 2 in seven patients from the remifentanil group and six patients from the ketamine group. Hs-troponin T was found to be higher in postoperative day 1 samples; there were no significant difference between the groups. Our results indicated that patients who have normal renal functions undergoing on-pump coronary bypass surgery, effects of ketamine and remifentanil on renal functions in terms of AKI were found to be similar.

Background. Our study aimed to compare HTEA and intravenous patient-controlled analgesia (PCA) in patients undergoing coronary bypass graft surgery (CABG), based on haemodynamic parameters and myocardial functions.Materials and Methods. The study included 34 patients that were scheduled for elective CABG, who were randomly divided into 2 groups. Anesthesia was induced and maintained with total intravenous anesthesia in both groups while intravenous PCA with morphine was administered in Group 1 and infusion of levobupivacaine was administered from the beginning of the anesthesia in Group 2 by thoracic epidural catheter. Blood samples were obtained presurgically, at 6 and 24 hours after surgery for troponin I, creatinine kinase-MB (CK-MB), total antioxidant capacity, and malondialdehyde. Postoperative pain was evaluated every 4 hours until 24 hours via VAS.Results. There were significant differences in troponin I or CK-MB values between the groups at postsurgery 6 h and 24 h. Heart rate and mean arterial pressure in Group 1 were significantly higher than in Group 2 at all measurements. Cardiac index in Group 2 was significantly higher than in Group 1 at all measurements.Conclusion. Patients that underwent CABG and received HTEA had better myocardial function and perioperative haemodynamic parameters than those who did not receive HTEA.

Amac: Pediyatrik kalp kateterizasyonunda giderek artan sedoanaljezi-genel anestezi uygulamalari nedeniyle karsilasilabilecek hemodinamik sorunlar monitorizasyon yontemlerinin onemini vurgular. Kateterizasyonda yasanan herhangi bir sorunun serebral kan akimini dusurmesi veya uygulanan sant kapatma prosedurlerinin beyin kan akimini etkilemesi soz konusu olabilir. NIRS noninvaziv olarak beyin doku oksijenasyonunu gosteren bir tekniktir. Bu calismada kalp kateterizasyonunda konjenital kalp defekti kapatma islemi yapilacak pediyatrik olgularda islem sirasinda NIRS cihazi ile rSO takibi yapilarak serebral oksijenasyon farkliliklarinin ortaya konmasi amaclandi.Gerec ve Yontem: Yedi hasta bu prospektif calismaya dâhil edildi. Olgulara ASD, VSD ve PDA kapatma islemi planlandi. Hasta kateter laboratuvarina alindiginda bazal, islem oncesi ve islem sonrasi olmak uzere 3 donemde bilateral NIRS degerleri, hemodinamik veriler, kan gazi parametreleri ve periferik oksijen saturasyonu kaydedildi. Bulgular: Serebral oksijenasyon parametreleri acisindan donemler arasinda sag ve sol rSO degerleri arasinda fark saptanmadi. Yine hastalarin sag ve sol rSO degerleri acisindan istatistiksel anlamli fark bulunmadi. Calismaya alinan tum hastalarda basarili sekilde kapatma islemi uygulandi. Sonuc: Beyin oksijen saturasyonu pek cok faktorden etkilenmesine ragmen, pediyatrik kalp kateterizasyonunda kapatma islemi yapilan hastalari inceledigimiz calismamizda bazal, islem oncesi ve islem sonrasi donemlerde bilateral rSO degerleri arasinda farklilik saptanmadi. Kan basinci ve Hct degerlerinde dususten ve kapatma isleminden rSO degerlerinin etkilenmedigi goruldu.

SUMMARY Objective: The effectiveness of remifentanil infusion and fentanyl bolus provided by patient-controlled analgesia on postoperative pain and recovery of patients undergoing pre-planned fast-track cardiac surgery was studied. Material and Methods: Anaesthesic combination of sevofloran and remifentanil were applied to 42, ASA II group patients undergoing fast-track coronary artery bypass graft surgery. Patients were divided into two groups. In Group 1 (remifentanil group), 0.1 µg kg -1 min -1 remifentanil infusion was given postoperatively by patient-controlled analgesia device. In Group 2, fentanyl was administered at 10 µg kg -1 loading dose 5 minutes before the end of surgery. After fentanyl administration, fentanyl bolus protocol was started to be applied at 0.1 µg kg -1 bolus dose with 8 minutes lockout time. Pain scores, sedation levels and additional analgesic requirements were recorded for the first 4 hours at every 15 minutes and then at 12., and 24. hours postoperatively. Results: There was no difference between groups as for analgesic effectiveness. The sedation levels were lower postoperatively during the first two hours in Group 1. After two hours, sedation levels were similar between the two groups. Conclusion: Remifentanil can be used at analgesic doses during the recovery period of patients undergoing fast-track cardiac surgery.

Long QT syndrome is a congenital disorder that is characterized by a prolongation of the QT interval on electrocardiograms and a propensity to ventricular tachyarrhythmias, which may lead to syncope, cardiac arrest or sudden death. Cardiomyopathy and pulmonary hypertension diseases have additional risks in anaesthesia management. In this study, we emphasize on one lung ventilation, pacemaker-implantable cardioverter-defibrillator and the anaesthesia management process in a patient with long QT syndrome, cardiomyopathy and pulmonary hypertension who underwent thoracic sympathectomy.

Amaç: Kadavradan karaciğer nakil ameliyatlarında postreperfüzyon sendromu gelişimini etkileyen faktörlerin belirlenmesi ve PRS'nin taburculuğa etkisinin araştırılmasıdır. Yöntemler: 2007-2013 yılları arasında kadavradan ortotopik karaciğer nakli yapılmış hastalar retrospektif tarandı. Hastaların dosyalarından intraoperatif anestezi bilgileri, yoğun bakım izlem formları, hastane çıkış epikrizleri incelendi. Bilgilerine tam ulaşılan 43 hasta çalışmaya dahil edildi. Reperfüzyon sonrası ilk 5 dakika içinde gelişen ve 1 dakika süre ile devam eden ortalama arter basıncındaki %30'dan fazla olan azalma ya da asistol gelişimi postreperfüzyon sendromu (PRS) olarak kabul edildi. Hastalar PRS gelişen ve geliş- meyen olarak 2 gruba ayrıldı. Bulgular: Kırk üç hastanın 25'inde (%58,1) PRS meydana geldiği görüldü. PRS gelişmeyen hastaların MELD skor ortalaması 16,9±3,2, PRS gelişenlerin MELD skor ortalaması 19,7±3,6 olarak hesaplandı. PRS gelişimi ile MELD skor yüksekliği arasında istatistiksel anlamlı ilişki saptandı (p=0,013). Reperfüzyon döneminin hemen öncesindeki dönemde ölçülen diyastolik kan basıncı PRS gelişen grupta PRS gelişmeyen gruba göre istatistiksel olarak anlamlı düşük seyretti (p=0,023, 50±8'e karşı 58±11) Logistik regresyon analizinde MELD skoru ve reperfüzyon öncesi diyastolik kan basıncı düşüklüğü bağımsız ön gördürücü faktör olarak belirlendi. Sonuç: Çalışmamızda PRS oranını %58,1 olarak saptadık. PRS gelişimini etkileyen faktör olarak MELD skor yüksekliğini ve reperfüzyon öncesi diyastolik basınç düşüklüğü bağımsız etken olarak belirledik. Ortotopik karaciğer transplantasyonu sırasında PRS gelişimi anestezistler için oldukça önemlidir. PRS ile ilişkili önemli klinik faktörlerin bilinmesi bu sendromun önlenmeye çalışılması için stratejilerin karar verilmesine yardımcı olabilir., Objective: To evaluate the factors that affects the postperfusion syndrome in cadaveric liver transplantations and the effect of the postperfusion syndrome on discharge from the hospital. Methods: Patients who underwent cadaveric liver transplantations between 2007 and 2013 were scanned retrospectively. Intraoperative anaesthesia records, intensive care unit follow-up forms and discharge reports were examined from patient files. Overall, 43 patients having complete data were included in the study. The postperfusion syndrome is defined as asystoli or a decrease in mean arterial pressure of more than 30%, which occurred in the first 5 min of reperfusion and continued for 1 min. Patients were divided into two groups: those who had the postperfusion syndrome and those who did not. Results: The number of patients who had the postperfusion syndrome was 25 of 43 (58.1%). The MELD score of patients without the postperfusion syndrome was calculated as 16.9±3.2 and that of patients with the postperfusion syndrome was 19.7±3.6. A statistically significant relationship was detected between the postperfusion syndrome occurrence and a high MELD score (p=0.013). The diastolic blood pressure just before reperfusion was statistically lower in the group with the postperfusion syndrome than in the other group (p=0.023, 50±8 vs. 58±11). According to the logistic regression analysis, the MELD score and the decrease in diastolic blood pressure before reperfusion were defined as independent predictive factors. Conclusion: According to the study, the ratio for having the postperfusion syndrome was found to be 58.1%. The independent predictor factors affecting the postperfusion syndrome were detected as the MELD score and the decrease in diastolic blood pressure before reperfusion. The postperfusion syndrome during orthotropic liver transplantation is an important issue for anaesthesiologists. The awareness of the related factors with the postperfusion syndrome may help in the development of various preventive strategies

This study aimed to assess the effect of intraoperative positive end–expiratory pressure (PEEP) intervention on the healing of colonic anastomoses in rabbits. A total of 32 New Zealand type male rabbits were divided into 2 groups of 16 animals each. Following ventilation with tracheostomy, colonic resection and anastomosis were performed in both groups. Although 10 cm of H2O PEEP level was applied in group 1 (PEEP), group 2 [zero end-expiratory pressure (ZEEP)] was ventilated without PEEP throughout the surgery. Half of both the PEEP and ZEEP group animals were killed on the third postoperative day, whereas the remaining half were killed on the seventh. Anastomotic bursting pressures, the tissue concentrations in hydroxyproline, and histologic assessments were performed. Intraoperative oxygen saturation and postoperative arterial blood gas parameters were also compared. On the first postoperative day, both arterial oxygen tension (PO2) and oxygen saturation (SO2) in the PEEP group were significantly higher than in the ZEEP group. On the seventh postoperative day, the bursting pressures of the anastomoses were significantly higher in the PEEP group; however, the hydroxyproline content was significantly lower in the PEEP group than in the ZEEP group. At day 7, the PEEP group was significantly associated with increased neoangiogenesis compared with the ZEEP group. The anastomotic healing process is positively influenced by the intraoperative PEEP application.

Comparison of neurological parameters in patients undergoing prosthetic heart valve replacement with two operating techniques-either cardioplegic arrest of the heart under hypothermic cardiopulmonary bypass (CPB) or the heart beating on normothermic bypass, with or without cross-clamping the aorta, without cardioplegic arrest. methods: Fifty valvular surgery patients were randomly assigned into three groups. Sixteen patients underwent beating heart valve replacement with normothermic bypass without cross-clamping the aorta, 17 patients underwent the same procedure with cross-clamping the aorta and retrograde coronary sinus perfusion, and the remaining 17 patients had conventional surgery with hypothermic bypass and cardioplegic arrest.Two-channel electroencephalography (EEG) was recorded to assess changes in cerebral cortical synaptic activity and 95% spectral edge frequency values were recorded continuously. Bispectral monitoring was used to measure the depth of anesthesia. Blood flow rates in middle cerebral artery (MCA) were measured by transcranial Doppler (TCD). Reduction in spectral edge frequency (50%) or bispectral index (BIS) (20) or transcranial Doppler flow velocity (50%) was detected in four patients in Group 1, five patients in Group 2, and three patients in Group 3. BIS or EEG values never reached zero, which indicates isoelectric silence during surgery. Gross neurological examinations were normal in all patients postoperatively.There is no difference regarding neurological monitoring results between on-pump beating heart and hypothermic arrested heart valve replacement surgery. Also no significant difference was encountered among the groups regarding the clinical outcomes.

To evaluate the factors that affects the postperfusion syndrome in cadaveric liver transplantations and the effect of the postperfusion syndrome on discharge from the hospital.Patients who underwent cadaveric liver transplantations between 2007 and 2013 were scanned retrospectively. Intraoperative anaesthesia records, intensive care unit follow-up forms and discharge reports were examined from patient files. Overall, 43 patients having complete data were included in the study. The postperfusion syndrome is defined as asystoli or a decrease in mean arterial pressure of more than 30%, which occurred in the first 5 min of reperfusion and continued for 1 min. Patients were divided into two groups: those who had the postperfusion syndrome and those who did not.The number of patients who had the postperfusion syndrome was 25 of 43 (58.1%). The MELD score of patients without the postperfusion syndrome was calculated as 16.9±3.2 and that of patients with the postperfusion syndrome was 19.7±3.6. A statistically significant relationship was detected between the postperfusion syndrome occurrence and a high MELD score (p=0.013). The diastolic blood pressure just before reperfusion was statistically lower in the group with the postperfusion syndrome than in the other group (p=0.023, 50±8 vs. 58±11). According to the logistic regression analysis, the MELD score and the decrease in diastolic blood pressure before reperfusion were defined as independent predictive factors.According to the study, the ratio for having the postperfusion syndrome was found to be 58.1%. The independent predictor factors affecting the postperfusion syndrome were detected as the MELD score and the decrease in diastolic blood pressure before reperfusion. The postperfusion syndrome during orthotropic liver transplantation is an important issue for anaesthesiologists. The awareness of the related factors with the postperfusion syndrome may help in the development of various preventive strategies.

before mediastinoscopy demonstrated a normal left ventricular size and function, with an ejection fraction of 65% and no posttransplant complications like tricuspid regurgitation. He was undergoing regular myocardial biopsies and had no documented evidence of graft rejection. He also had a stable sinus rhythm. On the day of surgery, the patient was given his morning doses of medications. Preoperative vital signs included a heart rate (HR) of 95 beats/min and blood pressure (BP) of 156/80 mmHg. The plan was to proceed with general anesthesia. The patient was given hydrocortisone (100 mg IV) and was premedicated with midazolam (2 mg IV). On the patient’s arrival in the operating room, all standard monitors were applied, including a pulse oximeter, electrocardiogram (ECG) monitoring with leads II and V5, noninvasive BP monitoring, and capnography. The patient underwent preoxygenation for 5 minutes and received fentanyl (1 mg/kg). Propofol (2-3 mg/kg) was titrated, and rocuronium (0.6 mg/kg) was administered. After the patient underwent atraumatic intubation, the radial artery was cannulated for beatto-beat BP, blood gas, and blood glucose monitoring. Anesthesia was maintained with 1.5% to 2.0% sevoflurane and a nitrous oxide and oxygen mixture (60:40). The surgery was uneventful, and the patient’s condition was hemodynamically stable throughout the procedure. At the end of surgery, the muscle relaxant was reversed with sugammadex (2 mg/kg) and the patient’s airway was extubated after return of airway reflexes. The injection of sugammadex did not cause significant changes in HR, ECG, or BP values. He was admitted to the postanesthesia care unit and had an uneventful postoperative recovery. No anesthesia complications were noted, and he was discharged 2 days after the surgery. DISCUSSION The preoperative assesment of a heart transplant recipient undergoing noncardiac surgery should focus on cardiac function; risks of rejection; infection; drug interactions; and function of other organs, particularly the kidney and liver, which may be compromised as a result of either immunosuppressive therapy or dysfunction of the transplanted heart. The patient in this report was assessed for graft rejection; his last myocardial biopsy demonstrated no evidence of graft rejection, and transthoracic echocardiogram showed a wellfunctioning graft. Blood count, coagulation profile, and all biochemical parameters were found to be normal. Hypertension is one of the common side effects of immunosuppressive therapy, and the patient in this case had a history of hypertension that was treated with amlodipine. On the day of surgery, he was given his morning doses of his medications and was normotensive throughout the procedure.

A ventricular assist device (VAD) is a mechanical pump used to support heart function and blood flow in patients with poor heart functions. For selected patients who are too ill to wait for a heart transplant or are not eligible for a heart transplant because of age or other medical problems, ventricular assist devices offer life-saving therapy. This device has also become a life-saving approach for patients with acute viral myocarditis. Following the acute illness phase, when heart function has improved, the VAD is carefully removed. It is very important to continuously monitor myocardial functions during this period. In this paper, we present a patient who underwent cardiac output and transesophageal echocardiography monitoring during VAD removal.

Two days before surgery in a 70-year-old man with renal cell carcinoma, transthoracic echocardiography showed a dense mass in the inferior vena cava, lying proximally, but no mass was observed in the right atrium. Intraoperative transesophageal echocardiography revealed unexpected tumor thrombi in the right atrium, and the surgical plan was changed. This case highlights the importance of intraoperative transesophageal echocardiography in patients with renal cell carcinoma.

We describe a 45-yr-old woman with an intermediate type atrioventricular septal defect associated with a double-orifice left atrioventricular valve (DOLAV). We diagnosed this exceptional anomaly by intraoperative transesophageal echocardiography (TEE) during surgery that was scheduled for only a primum type atrial septal defect (ASD) repair. Preoperative transthoracic echocardiography and angiography revealed the ASD but could not demonstrate the DOLAV. We were able to repair this rare and challenging abnormality successfully under the guidance of TEE imaging during the operation. TEE provides valuable information about both anatomy and functional aspect of the valvular structures. Besides its proven role in cardiac surgery, intraoperative use of TEE also serves as a useful tool for diagnosis of such unexpected and potentially missed abnormalities.

Endotrakeal entubasyon veya trakeostomi yogun bakim hastalarinda mekanik ventilasyon destegi icin kullanilabilir ve bu nedenlerle yogun bakimda uzun sure izlenen hastalarda cesitli psikiyatrik sorunlar da gorulebilir. Gerek entubasyon veya trakeostomi sonrasi olusabilen hava yolu hasari, gerek psikiyatrik sorunlar ciddi solunum sikintisi nedeni olabilirler. Gecirdigi Whipple ameliyati sonrasi uzun sure yogun bakim ve mekanik ventilasyon tedavisi alan ve perkutan trakeostomi acilan hasta genel durumunun duzelmesi sonrasinda dekanule edildi ve gelisen akut solunum sikintisi nedeniyle yine kanule edilerek mekanik ventilasyon destegi almaya devam etti. Yogun bakim tedavisinin basindan beri anksiyete bozuklugu nedeniyle psikiyatrik tedavi de alan hastaya trakeostomi kanulunden girilerek fleksibl bronkoskopi yapildi ve herhangi bir patoloji saptanmadi.Hasta yine dekanule edilerek izlendi ve solunum sikintisinin ayni sekilde yinelemesi uzerine cekilen boyun tomografisinde kanulun superior komsulugunda trakeal stenoz izlendi ve bu bolgeye trakeal dilatasyon uygulanmasinin ardindan hasta basarili bir sekilde dekanule edilerek taburcu edildi.

To the Editor; Laryngeal mask airway (LMA), which consists of a silicone tube connected to a miniature silicone mask appropriate for the shape of hypopharynx and covers the larynx as a gasket, was developed in 1980s in the United Kingdom. It is frequently used both to avoid negative effects of endotracheal intubation by establishing direct connection with the airway of patient and to easily provide a more reliable airway as compared to the facial mask. It has particular importance in difficult airway management and cardiopulmonary resuscitation since it can be successfully placed even by inexperienced users. Gel is applied to the posterior surface of the mask and it is placed blindly into the airway by pushing towards hypopharynx while the head of the patient is in extension position. Herein, we present a case, in which LMA could not be placed despite several attempts and a mass tissue was detected in the hypopharynx during laryngoscopy performed subsequently. An 81-year-old, 70 kg male patient was scheduled for cystoscopy in the urology clinic. Preanaesthetic evaluation revealed no pathology or concomitant disease except for advanced age. He had previously undergone prostate surgery under spinal anaesthesia. His Mallampati score was 3 and he had a large tongue (Figure 1). As the procedure was anticipated to take a short time and the patient, who had a high Mallampati score, did not want to be awake during the procedure, LMA was preferred for airway management. Figure 1 Examination image for Mallampati score Induction of anaesthesia was made with propofol, fentanyl and rocuronium, the patient was easily ventilated with a face mask, and an attempt was made to place a size 5 standard LMA; but as the mask, which was pushed forward, came back, it was thought that the mask was large for the patient and the attempt was repeated using a size 4 mask. However, as this attempt was also unsuccessful, it was thought that silicone tip of the balloon was folded; thus, I-Gel (size 4), which is a supraglottic airway device without a cuff and stands more stable, was tried to be placed. However as size 4 I-Gel LMA was pushed forward and ventilation was initiated, a significant air leakage occurred, and considering that size 4 was small, we again tried using size 5. However, observing substantial amount of air leak at the end of all these attempts, LMA was planned to be placed under laryngoscopic guidance. Airway examination, which was performed by a Macintosh laryngoscope, revealed a 2×2 cm mass located at the base of the hypopharynx, covered by normal mucosa, and appeared to be neither cystic nor ulcerated (Figure 2). It was thought that the mass, which was located at the same place where LMA device was placed, caused the tip of standard LMAs to be folded or remain between the mass and pharyngeal tissue, and hindered I-Gel LMA to closely fit after being placed and caused leakage from the back of the device, and consequently the attempts were unsuccessful. The patient, of whom Cormack-Lehane score was 2, was then intubated by size 8 endotracheal tube. We encountered no problem during intraoperative period and the patient was extubated without problem at the end of the procedure that lasted for 45 minutes; he was recommended to refer to the ENT outpatient clinic. Meanwhile, consent of the patient was obtained for presenting his case as a case report. Figure 2 The appearance of the mass through the laryngoscope Unforeseen dangers might have been in question because of blindly placed LMA, in this patient who had a deeply localized asymptomatic lesion that could not be detected by routine airway examination. If this mass located in the hypopharynx, had been cystic, it would have been perforated during the attempts to place the LMA and would have led to serious consequences by the spread of cyst content into the lungs. Again, if it had been a vascular mass like a haemangioma, it would have been difficult to control the unexpected bleeding. Lingual tonsil hyperplasia, which is more common in paediatric cases, may lead to similar problems (1, 2). Although blind placement of LMA without using a laryngoscope is an advantage, it may turn into a disadvantage in complicated cases and may lead to various problems. In case of recurrent failure while placing a supraglottic device, an airway disorder, as well as common problems such as incompatibility between device and patient anatomy and folded balloon, should be considered and attempts should aim at performing non-traumatic interventions as much as possible without insisting on blind replacement.

The aim of this prospective, randomized, and double-blinded study was to compare the effects of desflurane, sevoflurane, propofol on both atrial and ventricular wall function by measurement of QT dispersion (QTd), corrected QT dispersion (QTcd), and P dispersion (Pd) on electrocardiogram (ECG). Forty-six patients from the American Society of Anesthesiologists class I-II undergoing noncardiac surgery, were enrolled in this study. Patients were randomly allocated to receive desflurane, sevoflurane or propofol anesthesia. ECG recordings were taken before and after 5 minutes of drug administration. Induction with desflurane significantly increased the QTd compared to baseline (38 ± 2 ms vs. 62 ± 6 ms, P < 0.05). Sevoflurane and propofol anesthesia was not associated with any changes in QTd. QTcd was increased with desflurane induction and decreased with sevoflurane and propofol induction, but this decrease was only significant in the propofol group (67 ± 5 ms vs. 45 ± 3 ms, P < 0.05). Pd was significantly increased after induction with desflurane (34 ± 3 vs. 63 ± 6 ms, P < 0.05). There was a signiflcant increase in QTd and Pd in desflurane group, but this increment did not cause any dangerous arrhythmias. QTcd signiflcantly decreased in propofol group. We believe that further investigations are required for using desflurane as safe as sevoflurane and propofol in noncardiac surgery patients who have high cardiac arrhythmia and ischemia risk., Kazanci, D.Yaşamkent Mah. 3222/1 Sokak, Ankara, Turkey; email: dilekkazanci@gmail.com

The aim of this study was to evaluate the effects of propofol, isoflurane, and sevoflurane on middle cerebral arterial blood flow velocity during open heart surgery, and the relationship between these effects and hemodynamic parameters. Fifty-two patients undergoing coronary artery bypass on cardiopulmonary bypass were divided randomly into 3 groups: the first group received 100 μg·kg−1·min−1propofol, the other groups received one minimum alveolar concentration of sevoflurane or isoflurane for anesthesia maintenance. Middle cerebral arterial blood flow velocities were measured by transcranial Doppler, and hemodynamics were measured by the thermodilution technique. Middle cerebral arterial blood flow velocities decreased significantly after administration of isoflurane and propofol, but there was no significant difference between the groups. After weaning from cardiopulmonary bypass, cerebral blood flow increased and came close to the value after induction in all groups. The pulsatility index and resistivity index increased significantly only after the propofol infusion, but there was no significant difference between the groups.