Background: Carotid endarterectomy (CEA) is an established surgical procedure for patients with high-grade carotid artery stenosis. Cerebral hypoperfusion after clamping the carotid artery can lead to the development of new strokes or worsen existing damage. Near-infrared spectroscopy (NIRS) provides continuous and non-invasive monitoring of cerebral oxygenation, allowing for early detection of cerebral ischemia due to hypoperfusion in critical patients and a reduction in early complications. Postoperative cognitive dysfunction (POCD) refers to changes in cognitive function following surgery and anesthesia. Methods: In this prospective and observational study, our aim is to evaluate whether cerebral desaturation, as assessed by NIRS, contributes to the occurrence of POCD. Hemodynamic and NIRS assessments were recorded at various time points: baseline, post-intubation, pre-clamping, 5th and 10th minutes after carotid clamping, 5th minutes after unclamping, pre-extubation, and the end of the operation. The Mini-Mental Status Examination was administered to patients on the day before surgery and the second day after surgery. Results: Cerebral desaturation was observed in 33% of patients. Regional cerebral oxygen saturation (rSO2) showed a slight decrease in the early stages after clamping the carotid artery. During the clamping period, rSO2 values increased, and by the end of the operation, they had returned to baseline or even exceeded baseline levels. We did not identify any cases of POCD during the early postoperative periods. Conclusions: NIRS is a practical and effective method for detecting cerebral hypoperfusion. However, based on our study, we were unable to establish a correlation between NIRS values and the occurrence of POCD.
Background: This study aimed to compare the effectiveness of readily available and less expensive inhalational anesthetics in combination with local anesthetics as pre-emptive analgesia with inhalational anesthesia and intravenous opioids in maintaining favorable operating conditions, ensuring hemodynamic stability, improving surgeon satisfaction, and evaluating the correlation with postoperative analgesia. In addition, the study recorded and compared the incidence of postoperative nausea between the two anesthesia approaches. Methods: A total of twenty-four patients scheduled for external dacryocystorhinostomy were randomly assigned to two groups: Group G, which received general anesthesia with intravenous opioid and local infiltration of saline, and Group L, which received general anesthesia with intravenous saline and local infiltration of a mixture of lidocaine/bupivacaine with epinephrine. The primary outcomes assessed were intraoperative and early postoperative pain control, intraoperative anaesthetic requirements, intraoperative bleeding, extubation time, and time to reach the modified Aldrete scoring system. Secondary outcomes included evaluations of patient satisfaction and surgeon satisfaction. Results: Both groups were matched regarding age, sex, BMI and duration of surgery. There was significant difference between the studied groups regarding SBP and DBP at 10 minutes post induction, mean intra operative and post extubation, but there was no significant change when comparing blood pressure at different durations. There was significant difference between groups regarding HR at 10 minutes post induction, mean intra operative and post extubation and also there was significant change when comparing blood pressure within each group. Regarding extubation time, intra operative bleeding, ISO and first-time needed analgesia, there was a significant difference between both groups with longer extubating time, more bleeding and more ISO in the G group. Also, L group needed analgesia after longer duration (150min) than group G (24.5min). Conclusions: Combined local anaesthesia containing adrenaline with general anaesthesia in external dacryocystorhinostomy is associated with better intraoperative and early postoperative pain control when compared to general anaesthesia alone with an intravenous opioid, which decreases the intraoperative anaesthetic requirement and allows rapid recovery.
Background: Infection and sepsis constitute one of the most serious problems affecting mortality in intensive care units. Not only rapid administration of appropriate antimicrobial treatment but also timing of culture samples plays an important role. We aimed to investigate the culture samples taken from blood, urine and Mini-Bronco Alveolar Lavage (Mini-BAL) during the patient's intensive care unit admission for the frequency of growth and the type of microorganism grown. Methods: Patients admitted to the Multidisciplinary Intensive Care Unit of Izmir Private Hospital between January 01, 2018 and December 30, 2019 from the Emergency Department or inpatient services were evaluated retrospectively. Inclusion criteria were: Age older than 18 years, with a diagnosis of intensive care indication, recorded body temperature measured from the tympanic membrane, and culture samples (blood, urine, mini BAL) taken within the first 24 hours after admission. Patients <18ys, with missing data in records, and with MRSE in blood were excluded. Results: A total of 506 patients were evaluated in the study. The number of female and male patients were 222 and 284, respectively. The mean age was 69.91 +/- 15.08 years. 341 patients were admitted from the emergency department and 165 patients were admitted from inpatient wards. Growth was observed in 190(37.55%) of 506 patients. The percentage of growth in culture samples was 45.57% and 60% in patients admitted from the emergency department and inpatient services, respectively. In 11 of these 64 patients (82.81%), the body temperature was observed to be above 37.5 degrees C during culture sampling). Conclusions: The importance of targeted and early treatment of infection/sepsis in ICU patients is widely recognized. However, not all patients show a fever response to infection. Therefore, obtaining routine cultures on admission to the ICU without waiting for a fever response may be useful for early identification of the causative pathogen and to avoid delaying the initiation of effective antibiotherapy.
Background: Citrate is commonly used as an anticoagulant in renal replacement therapy. We aimed to investigate the preconditioning effect of citrate on renal ischemia reperfusion (I/R) injury in rats. Methods: Adult 24 Wistar-Albino rats were divided into 4 groups. Sham group (Group S, n= 6) underwent bilateral nephrectomy. Ischemia-reperfusion group (Group IR, n= 6) administered 40min ischemia and 60min reperfusion. Citrate group (Group C, n= 6), received 4% trisodium citrate (1mmol/kg/h) and calcium gluconate (2ml/kg/hour) through different veins for 90min. In ischemia-reperfusion and citrate group (Group IR+C, n= 6), citrate and calcium gluconate were administered at the doses determined 60min before ischemia and in the first 30min of reperfusion (total 40min ischemia and 60min reperfusion). Then blood samples were collected for biochemical analysis and bilateral kidneys were removed for histopathologic examination. Results: The histopathologic scores of Group C and Group IR+C were lower than Group IR (p<0.01). Total oxidant status level was lower in Group C compared to Group IR (p<0.05). Total antioxidant status, Thiol, Native-Thiol and Thiol/Disulfide levels of Group C and Group IR+C were higher than Group IR (p<0.05). Paraoxonase-1 levels were increased in Group C compared to Group IR (p<0.01). Ischemia modified albumin levels of Group C and Group IR+C were lower than Group IR (p<0.05, p= 0.01). Conclusions: Citrate infusion reduced oxidative damage with its preconditioning effect and had an antioxidant effect in I/R injury in the kidneys. We believe that citrate may be helpful in reducing the adverse effects of renal I/R injury.
Background: As average life expectancy rises, the rate of elderly people admitted to intensive care units (ICUs) increases steadily. Elderly patients who are hospitalized in the ICU because of severe illness face a greater risk of mortality in comparison to other patients receiving inpatient care. Identifying critically ill patients with a higher likelihood of mortality is important to determine the direction of treatment as well as for improvement in the quality of care in clinical practice. Unfortunately, there is no ideal combination of prognostic factors predicting mortality in older ICU patients. Methods: This was a prospective cohort study conducted with ninety elderly ICU patients. Patients underwent full clinical evaluation, baseline comorbidity was assessed by the Charlson comorbidity index (CCI), baseline severity of illness was assessed by the Acute Physiology and Chronic Health Evaluation 2 (APACHE 2) Score and baseline organ dysfunction was assessed by the Sequential Organ Failure Assessment (SOFA) Score. Measurement of serum albumin level and interleukin 6 (IL-6) level were done. Results: The outcome of all-cause ICU mortality was 28.9%. By univariate analysis, there is a significant relationship between all factors (IL-6, IL-6/Albumin ratio, SOFA score, and APACHE 2 score) and mortality prediction. Still by multivariate analysis, there is a relationship between APACHE 2 and mortality. Conclusions: The IL-6-to-albumin ratio offers a slight improvement in mortality prediction compared to either of its constituent individual biomarkers, and as such, it may be a potential tool to aid in the prognostication of critically ill elderly patients.
Introduction: Effective postoperative pain management after bariatric surgery is still greatly challenging. Morbidly obese patients have a high prevalence of cardiopulmonary complications. While Transversus Abdominis Plane Block, Port-Site Infiltration, and Erector Spinae Plane Block are effective for managing somatic and incisional pain, they do not adequately address visceral pain. Individualization of supplemented analgesics by patient-controlled analgesia can provide optimal pain control and minimize side effects. The objective of this trial was to study whether using morphine systemically through IV-PCA) Or epidurally through (PCEA) would be more effective in controlling postoperative pain in morbidly obese patients after laparoscopic sleeve gastrectomy (LSG). Methods: The trial was conducted from March 2021 to September 2022 at Menoufia University Hospitals, following approval from the Hospital Ethics Committee. Sixty patients with a BMI of 40-59kg/m2, aged 18-45 years, were scheduled to undergo LSG. The patients were allocated into Group M, which received IV PCA with 1mg/h morphine with a lockout interval of 8min. Group E: received PCAE with 0.125% bupivacaine and 0.05mg/ml morphine. The primary outcome was to assess postoperative pain using VAS. The secondary outcomes were to evaluate sedation score, nausea, vomiting, pruritus, urine retention, desaturation, and morphine and lornoxicam consumption. Results: The mean VAS at rest and movement was decreased in group E versus group M. There were significant decreases in morphine and rescue lornoxicam consumption, as well as fewer complications in group E. Conclusion: The analgesic effect of PCAE morphine is superior to IV-PCA morphine after LSG, with fewer complications.
Background: Caudal block is a regional anesthetic technique that is often used in children. The length of caudal block must be properly assessed in order to optimise anaesthetic management. Because these children are already under heavy sedation or general anaesthetic, these clinical signals and objective evaluations are not timely or reliable enough to offer useful feedback. Methods: This prospective observational study was performed on 54 patients undergoing caudal block aged 6-10 years over a period of 6 months. The Masimo Set monitor probe was placed on the big toe of the non-operated limb of the child. The PI, HR, SBP, DBP and MAP were monitored and recorded every 10 minutes. Results: Intraoperative perfusion index was significantly higher at 10, 20, 30, 40, 50 and 60min than baseline. Postoperative perfusion index was significantly higher at 1h than 2, 3 and 4h, while was significantly higher in 2h than 3 and 4h and in 3h than 4h. PI can significantly predict caudal block fading (AUC= 0.706, P-value= 0.004) at cut off <= 0.8, 82. Conclusions: PI can significantly predict caudal block fading (AUC= 0.706, P-value= 0.004) at cut off <= 0.8, 82.14% sensitivity, 50.00% specificity, 63.9%
Introduction: Anesthetic management in elderly is challenging due to the age-related physiological changes and comorbidities. We aimed to investigate the relationship between age and anesthesia techniques with morbidity and mortality in oldest-old patients (aged 80 years and above) operated for orthopedic surgery. Data from oldest-old patients who underwent orthopedic surgery between 2016 and 2022 in our 3rd-level hospital were reviewed retrospectively. Patients were divided into groups: Group I (patients aged 80-89) and Group II (patients aged 90 years and above) and analyzed for comorbidities, operation types, anesthetic technique, intensive care unit admission, mechanical ventilation need and mortality. Methods: The data of patients, aged 80 years and above, who underwent orthopedic surgery at Istanbul Medeniyet University Goztepe Research and Educational Hospital between January 02, 2016 and December 31, 2022, were reviewed retrospectively. Age and gender of the patients, presence and type of comorbidities, and type of applied operation were noted. The anesthetic technique (general, regional, local anesthesia) performed for surgery and notes of perioperative anesthetic management Total hospital stay, admission to ICU and total ICU stay, need for mechanical ventilation, and total MV time (hour) were obtained from ICU records. The outcomes of the patients, including deaths, were also noted. Patients were divided into two groups; Group I; those between 80 and 89 years of age, and group II those >90 years of age. Results: Data from 1356 patients (1049 patients in Group I, 307 patients in Group II) were analyzed in total. General anesthesia was applied to 879(83,8%) patients in Group I, 248(80,8%) patients in Group II, and regional anesthesia was performed to 170(16,2%) patients in Group I, and 59(19,2%) patients in Group II. Comorbidities, intensive care admission rate, and mechanical ventilation needs were higher, and hospital stay was longer in group II and in the patients who received general anesthesia. There was no difference in mortality between groups and between anesthetic techniques applied. Conclusion: A total of 1356 oldest-old orthopedic patients had been operated successfully in our hospital during a seven-year study period and tolerated anesthesia well. Mortality has not been increased with age, found to be related to anesthetic techniques, although ICU admission rate and hospital stay were correlated with age and general anesthesia.
Background: Total hip arthroplasty (THA) can be associated with significant postoperative pain. Poor pain control can adversely affect patient's recovery. Aim of the Work: This study was designed to evaluate the effect of dexmedetomidine addition to Bupivacaine in lumbar erector spinae plane block (L-ESPB) on duration of postoperative analgesia after THA. Patients and Methods: This randomized, controlled, double blind study was carried out on 60 patients undergoing THA under spinal anesthesia, their age ranged between 18 and 65 years, both sexes with ASA I-III. Postoperatively, all Patients received unilateral L-ESPB on the operated side using either 30mL 0.25% plain bupivacaine (Group B) or 30mL 0.25% bupivacaine in addition to 1 & micro;g/kg dexmedetomidine (Group BD). Results: Time of 1st rescue analgesia was delayed in group BD. Total dose of nalbuphine consumption in the first 24h was lower in group BD than group B. Pain score was lower at 8h, 12h and 16h in group BD than group B. Sedation score was similar in both groups. Heart rate and mean blood pressure readings were lower at 8h, 12h and 16h in group BD than group B. Hypotension, bradycardia and nausea and vomiting were similar in both groups. Conclusions: The addition of dexmedetomidine to bupivacaine in L-ESPB after THA prolongs analgesia, reduces opioid consumption.
Background: Fluid therapy remains the cornerstone of hemodynamic resuscitation of shocked patients. Fluid resuscitation seeks to rapidly restore the effective circulating blood volume and oxygen delivery to organs. Effective fluid resuscitation can improve the prognosis, while repeated or inappropriate fluid bolus administration is associated with increased mortality and the length of stay. The most commonly used parameter for detecting volume status is still central venous pressure (CVP); however, recently, various methods are being used for volume assessment like inferior vena cava respiratory variability index. Objective: This study aimed to evaluate the relationship between CVP and ultrasound guided Inferior Vena Cava distensibility index (IVC DI) as a tool to assess the volume status and fluid responsiveness in ventilated shocked patients as regard sensitivity and accuracy. Methods: Fifty shocked patients were prospectively included in the study. All patients were ventilated in volume control mode. IVC DI measurement was evaluated using ultrasonography and simultaneous CVP values were recorded while patient in supine position. Results: IVC DI has higher accuracy in predicting hypovolemia in ventilated shocked patients than CVP, Receiver Operating Characteristic (ROC) curve analysis showed that cutoff point 14.5 IVC DI has sensitivity 94% and specificity 100% for predicting hypovolemia while cutoff point 7 CVP has sensitivity 96% and specificity 95.4%. IVCDI has higher accuracy in predicting fluid responsiveness, ROC curve analysis showed cutoff point 13 IVC DI has sensitivity of 100% and specificity 93.3% for predicting fluid responsiveness while cutoff point 7 CVP has sensitivity 85.2% and specificity of 95.3%. Conclusions: CVP and ultrasound guided IVC-DI are reliable markers in predicting fluid responsiveness and hypovolemia among ventilated shocked patients with the superiority of IVC-DI.
Background: Tracheal resection and anastomosis in adults is usually carried out for stenosis due to various pathologies or for neoplasms obstructing the tracheal lumen. Strategies for airway management during tracheal tumor resection vary depending on the nature, growth pattern and tumor location as well as the degree of airway obstruction and also the surgical approach. Case Presentation: A 55 year old female presented with cough, expectoration and hemoptysis since 3 months. Computerized tomography of the thorax reported a small enhancing lesion measuring 7.4X5.3X7.6mm on the posterior aspect of the trachea at the level of Thoracic 3 vertebra. The surgical approach was through right posterolateral thoracotomy incision. Hence an EZ bronchial blocker was placed through an endotracheal tube for lung isolation. The distal end of the tube was placed proximal to the tumor and resection was done by providing intermittent apnea. Conclusions: Anesthesia for tracheal resection and reconstruction is technically challenging. Every tracheal resection requires specific anesthesia and airway maintenance strategy.
