Comparison of postoperative pain in children after maintenance anaesthesia with propofol or sevoflurane: a systematic review and meta-analysis

BACKGROUND

Propofol and sevoflurane are two of the most commonly used anaesthetics for paediatric surgery. Data from some clinical trials suggest that postoperative pain incidence is lower when propofol is used for maintenance of anaesthesia compared with sevoflurane, although this is not clear.

METHODS

This meta-analysis compared postoperative pain following maintenance of anaesthesia with propofol or sevoflurane in paediatric surgeries. PubMed Medline, Embase, Scopus, Web of Science and Cochrane Library were searched for randomised controlled trials (RCTs) that compared postoperative pain between sevoflurane and propofol anaesthesia in children. After quality assessment, a meta-analysis was carried out using bias-adjusted inverse heterogeneity methods, heterogeneity using I2 and publication bias using Doi plots.

RESULTS

In total, 13 RCTs with 1174 children were included. The overall synthesis suggested nearly two-fold higher odds of overall postoperative pain in the sevoflurane group compared with the propofol group (odds ratio [OR] 1.88, 95% confidence interval [CI] 1.12-3.15, I2=58.2%). Further, children in the sevoflurane group had higher odds of having higher pain scores (OR 3.18, 95% CI 1.83-5.53, I2=20.9%), and a 60% increase in the odds of requiring postoperative rescue analgesia compared with propofol (OR 1.60, 95% CI 0.89-2.88, I2=58.2%).

CONCLUSIONS

Children maintained on inhalational sevoflurane had higher odds of postoperative pain compared with those maintained on propofol. The results also suggest that sevoflurane is associated with higher odds of needing postoperative rescue analgesia compared with propofol.

REGISTRATION

The protocol for this systematic review and meta-analysis was registered on the International Prospective Register of Systematic Reviews (PROSPERO) with registration ID CRD42023445913.

The Reliability of Carotid Artery Doppler Ultrasonography Indices in Predicting Fluid Responsiveness during Surgery for Geriatric Patients: A Prospective, Observational Study

BACKGROUND

The reliability of determining fluid responsiveness during surgery in geriatric patients is challenging. Our primary outcome was to determine the reliability of Corrected Flow Time (FTc) in predicting fluid responsiveness.

METHODS

Elderly patients undergoing major surgery under general anesthesia were included. Measurements of common carotid artery diameter, velocity time integral, and systolic flow time (FT) were performed before and after a fluid challenge. FTc and carotid blood flow (CBF) were subsequently calculated.

RESULTS

The median change in carotid diameter was significantly higher in the fluid-responder (R) compared to the non-responder (NR) (6.51% vs. 0.65%, p = 0.049). The median change in CBF was notably higher in R compared to NR (30.04% vs. 9.72%, p = 0.024). Prior to the fluid challenge, systolic FT was significantly shorter in R than NR (285 ms vs. 315 ms, p = 0.027), but after the fluid challenge, these measurements became comparable among the groups. The change in systolic FT was higher in R (15.38% vs. 7.49%, p = 0.027). FTc and the change in FTc exhibited similarities among the groups at all study time points. Receiver operating characteristic analysis demonstrated an area under the curve of 0.682 (95% CI: 0.509-0.855, p = 0.039) for carotid diameter, 0.710 (95% CI: 0.547-0.872, p = 0.011) for CBF, 0.706 (95% CI: 0.540-0.872, p = 0.015) for systolic FT, and 0.580 (95% CI = 0.389-0.770, p = 0.413) for FTc.

CONCLUSIONS

In geriatric patients, potential endothelial changes in the carotid artery may influence the dynamic markers of fluid responsiveness. Despite the demonstrated effectiveness of FTc in predicting fluid responsiveness in the general population, this study underscores the limited reliability of carotid Doppler ultrasonography indices for prediction in a geriatric patient population.

Evaluation of the Effect of Pressure-Controlled Ventilation-Volume Guaranteed Mode vs. Volume-Controlled Ventilation Mode on Atelectasis in Patients Undergoing Laparoscopic Surgery: A Randomized Controlled Clinical Trial

Background and Objectives: Laparoscopic surgery, which results in less bleeding, less postoperative pain, and better cosmetic results, may affect the lung dynamics via the pneumoperitoneum. After laparoscopic surgery, atelectasis develops. The primary aim of the present study is to demonstrate the effects of two different ventilation modes on the development of atelectasis using lung ultrasound, and the secondary outcomes include the plateau pressure, peak inspiratory pressure, and compliance differences between the groups. Materials and Methods: In this study, 62 participants aged 18-75 years undergoing laparoscopic cholecystectomy were enrolled. The patients were randomly assigned into two groups: the volume-controlled ventilation (VCV) group (group V) or the pressure-controlled-volume guaranteed ventilation (PCV-VG) group (group PV). The lung ultrasound score (LUS) was obtained thrice: prior to induction (T1), upon the patient's initial arrival in the recovery room (T2), and just before departing the recovery unit (T3). The hemodynamic data and mechanical ventilation parameters were recorded at different times intraoperatively. Results: The LUS score was similar between the groups at all the times. The change in the LUS score of the right lower anterior chest was statistically higher in the VCV group than the PCV group. The peak inspiratory pressure (PIP) was found to be statistically higher in the V group than the PV group five minutes after induction (T5) (20.84 ± 4.32 p = 0.021). The plateau pressure was found to be higher in the V group than the PV group at all times (after induction (Tind) 17.29 ± 5.53 p = 0.004, (T5) 17.77 ± 4.89 p = 0.001, after pneumoperitoneum (TPP) 19.71 ± 4.28 p = 0.002). Compliance was found to be statistically higher in the PV group than the V group at all times ((Tind) 48.87 ± 15.37 p = 0.011, (T5) 47.94 ± 13.71 p = 0.043, (TPP) 35.65 ± 6.90 p = 0.004). Before and after the pneumoperitoneum, the compliance was determined to be lower in the V group than the PV group, respectively (40.68 ± 13.91 p = 0.043, 30.77 ± 5.73 p = 0.004). Conclusions: LUS score was similar between groups at all times. The PCV-VG mode was superior to the VCV mode in providing optimal ventilatory pressures and maintaining high dynamic compliance in patients undergoing laparoscopic abdominal surgery.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

The influence of the COVID-19 pandemic on videolaryngoscopy: a cross-sectional before-and-after survey

BACKGROUND

Guidelines and consensus statements recommend the use of videola-ryngoscopes (VLs) in airway management of patients with COVID-19. However, there is a lack of knowledge about which types of videolaryngoscopes are used, differences of use between countries, and how the COVID-19 pandemic influenced their use. The primary aim of this before-and-after cross-sectional survey study was to assess the frequency of the use of videolaryngoscopy in the operation theatres in different countries. Also, the preferred characteristics of videolaryngoscopes were assessed.

METHODS

With Ethics Committee approval, a questionnaire was distributed among anaes-thesiologists through the European Airway Management Society's network in 2019 before and in 2021 during the COVID-19 pandemic. Responses to the questions were analysed and presented as descriptive statistics.

RESULTS

We reached out to 791 anaesthesiologists; 155 (19.5%) returned the first questionnaire, and 91 (11.5%) returned the second survey. Videolaryngoscopes were used in 24.1% of cases before COVID-19 and in 43.1% after the pandemic ( P < 0.001). We revealed that the availability of videolaryngoscopes increased to 100% in all centres during the pandemic. Routine use of videolaryngoscopes in all cases increased from 12.5% to 38.9%. The type of videolaryngoscope and the blade preference did not change during this period ( P = 1.000).

CONCLUSIONS

This survey reflects that the COVID-19 pandemic significantly increased the availability and use of videolaryngoscopes in operating theatres, and that more anaesthesiologists now use them routinely in all cases. The preferred type of VL or blade did not change during the pandemic.

Continuous hemoglobin measurement during frontal advancement operations can improve patient outcomes

Massive hemorrhage in pediatric cranioplasty operations may necessitate blood transfusion, which may cause many complications. Radical-7 Pulse CO-Oximeter (Massimo Corporation, Irvine, CA) can provide continuous hemoglobin concentration (SpHb) measurements noninvasively. In this study, we aimed to evaluate the effects of SpHb measurement on perioperative transfusion management and postoperative patient outcomes. For this retrospective case-control study, we collected the data of pediatric patients undergoing fronto-orbital advancement surgery for plagiocephaly and trigonocephaly between 2018 and 2021. Perioperative SpHb monitoring was performed for patients in the SpHb Group. Other patients that were managed conventionally were considered as the control group (C Group). The data on patients' demographic and clinical characteristics, intraoperative hemodynamic and laboratory variables such as blood gases, intraoperative blood losses, the amount of the transfused blood products, the length of postoperative intensive care unit (ICU) stay, and the duration of hospital stay were collected. The data of 42 patients were collected, and 29 of these patients were males (69%). In 16 of the patients, SpHb monitoring was performed. The demographic, clinical, and perioperative hemodynamic characteristics of the patients were comparable between the groups. Compared to the C Group, the SpHb Group had significantly lower perioperative packed red blood cell (PRBC) transfusion (136.3 ± 40.1 vs. 181.5 ± 74.8 mL, P = 0.015), less postoperative drainage (125.3 ± 47.7 vs. 185.8 ± 97.6 mL, P = 0.013), and shorter ICU stay (37.1 ± 12.0 vs. 64.8 ± 24.9 h, P < 0.001). There was a positive correlation between the amount of PRBC transfusion and the length of ICU stay (r = 0.459, P = 0.003). Patients with perioperative continuous SpHb measurement have lower intraoperative PRBC transfusion, less postoperative bleeding, and shorter ICU stay. When necessary, SpHb, together with clinical judgment and laboratory confirmation, can be used in decision-making for perioperative PRBC transfusion.

Pleth Variability Index Guided Volume Optimisation in Major Gynaecologic Surgery

OBJECTIVE

To compare conventional fluid management (CFM) with pleth variability index (PVI) guided goal-directed fluid management (GDFM) during elective total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO) operations.

STUDY DESIGN

Randomised controlled trial.

PLACE AND DURATION OF STUDY

Department of Anaesthesiology and Reanimation, Faculty of Medicine, Health Sciences University, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey, from February to July 2021.

METHODOLOGY

This trial included 78 patients aged 18-65 years with ASA I-III who would undergo elective TAH-BSO under general anaesthesia. Following randomisation with the closed envelope method, standard monitoring, and 250 ml crystalloid infusion during anaesthesia induction, maintenance fluid therapy was administered at 8-10 ml/Kg/hour to the control group and 2-3 ml/Kg/hour to the PVI group. If the mean arterial pressure (MAP) was ≤65 mmHg and/or the MAP was decreased by more than 20%, and the PVI was >13%, a 250 ml colloid bolus was given. When there was no response, a vasoactive agent was administered. Vital signs, laboratory findings, and postoperative complications were evaluated.

RESULTS

Age, weight, BMI, urine output, bleeding, hospital stay, comorbidities, intraoperative use of blood products, and complication rates were not significantly different between the PVI and CFM groups (p>0.05). The PVI group had shorter operational times and used less crystalloid than the control group (p=0.033 and p<0.001, respectively). The PVI group's postoperative base excess (BE) levels changed significantly less than the control group's (p<0.001). In both pre- and postoperative haemoglobin, haematocrit, urea, creatinine, electrolytes, and lactate measurements, there were no statistically significant differences between the groups (p>0.05).

CONCLUSION

PVI-GDFM is equally safe as CFM for intraoperative fluid management during elective complete abdominal hysterectomy and bilateral salpingo-oophorectomy procedures.

KEY WORDS

Pleth variability index, Fluid management, Base excess.

Blind vs. video-laryngoscope-guided laryngeal mask insertion: A prospective randomized comparison of oropharyngeal leak pressure and fiberoptic grading

PURPOSE

Laryngeal Mask Airway (LMA) insertion may not always be smooth without complications. Controversial results of several studies evaluating ideal insertion conditions have been published. This study compared the oropharyngeal leak pressure values and fiberoptic grading scores between blind and video-laryngoscope-guided LMA insertion.

METHODS

Patients were randomly assigned into blind insertion (n = 50) and video-laryngoscope guided insertion (n = 50) groups. The oropharyngeal leak pressure, peak airway pressure, fiberoptic grading score, first attempt success rate, hemodynamic parameters, and complications were recorded.

RESULTS

All laryngeal mask airways were successfully inserted in both groups at the first attempt. The fiberoptic staging scores were: grade 1 in 8.2% of patients, grade 2 in 24.4% of patients, grade 3 in 44.8% of patients, grade 4 in 22.4% of patients in the control group. On the other hand, grade 1 in 2.2% of patients, grade 2 in 28.6% of patients, grade 3 in 51% of patients, grade 4 in 8.2% of patients in the VL group (p = 0.260). The peak airway pressure and LMA insertion time were similar between groups. However, the oropharyngeal leak pressure before extubation was significantly higher in the video-laryngoscope-guided insertion than blind insertion (36.29 ± 7.09 vs. 33.79 ± 8.84 cmH2O respectively, p = 0.04).

CONCLUSIONS

The findings of our study suggest that the video-laryngoscope-guided LMA-Classic insertion with a standard blade technique may be a helpful alternative to blind insertion.

The outcomes of using high oxygen concentration in pediatric patients

Oxygen reserve index, available as part of Masimo Rainbow SET pulse oximetry, is a noninvasive and continuous variable intended to provide insight into a patient's oxygen status in the moderate hyperoxic range (PaO₂ > 100 and ≤ 200 mm Hg), defined as a patient's oxygen "reserve". When used in conjunction with pulse oximetry, ORi extends the knowledge on a patient's oxygen status providing clinically important information helping to prevent hyperoxemia and hypoxemia. There are limited data on patients undergoing craniosynostosis surgery. Our primary goal was to evaluate the effects of different concentrations of inspiratory oxygen (FiO₂) on patient oxygenation status by monitoring ORi. Thirty patients scheduled for craniosynostosis were included in this observational cohort study. Patients were randomized into two equal groups: Group 1 received a fraction of inspired oxygen of 0.8 and group 2 received a FiO₂ of 0.6 during induction of anaesthesia. In addition to standard haemodynamic variables with ORi were recorded at baseline 1 min, 5 min, 60 min, and 120 min after intubation. Postoperative complications, length of stay in the intensive care unit and hospital were recorded. In total, 14 patients were evaluated in each group. Gender, age, BMI, ASA scores were similar between groups (p > 0.05). In Group 1, ORi values were significantly higher when compared to group 2 at baseline (0.86 ± 0.21 vs 0.45 ± 0.32, p = 0.001), one minute (0.61 ± 0.24 vs 0.27 ± 0.21, p = 0.001), and 5 min (0.34 ± 0.31 vs 0.10 ± 0.13, p = 0.033). High inspired oxygen concentration during induction of anesthesia in pediatric patients is associated with higher levels of ORi. Therefore, ORi may provide the means to safely reduce the inspired oxygen fraction during inhalational induction in paediatric patients.

COVID-19 patients in the operating room: a concise review of existing literature

A novel Coronavirus was identified in late 2019 as the cause of COVID-19 disease which is highly contagious. SARS-CoV-2 is a single-stranded RNA, enveloped virus from the beta Coronavirus family. Intraoperative management of patients with COVID-19 is a high-risk procedure. An international attention has raised to develop recommendations for the management strategies. This review article was designed to synthesize the existing evidence and experience related to intraoperative management of COVID-19. This review provides a summary of clinical guidance and addresses six domains: principles of intraoperative monitoring, airway management and related difficulties, ventilation, type of anesthesia, medications and side effects, and intraoperative fluid management.

Positive Heparin/PF4 Antibodies and High Mortality Rate: a Retrospective Case-Series Analysis

Introduction

Heparin-induced thrombocytopenia (HIT) is a potentially lethal complication of unfractionated or low-molecular weight heparin therapy. We aimed to determine the incidence and mortality rate of patients with positive heparin/platelet factor 4 (PF4) antibodies, which is a rapid detection test of HIT.

Methods

Coronary artery bypass grafting and mitral and aortic valve surgeries were evaluated. Cardiopulmonary bypass was employed in all patients. The diagnosis of HIT was based on immunological assays. Postoperative complications, mortality rates, and the causes of death were specified in patients with positive heparin/PF4 antibodies.

Results

Postoperative thrombocytopenia was detected in 257 patients. Twenty of these patients undergoing open heart surgery were included in the final analysis. Antibodies against heparin/PF4 complex were positive in 20 patients. The mean body mass index was 28.8±2.3 kg/m², mean value of left ventricular ejection fraction was 48.3±6.7%, cardiopulmonary bypass time was 113.0±35.0 min, aortic cross-clamping time was 88.0±32.7 min, mean intensive care unit length of stay was 10.9±4.9 days, mean preoperative platelet count was 307.250±88528 platelets/microliter, and mean postoperative platelet count was 243.050±89.354 platelets/microliter. The mean duration of heparin exposure was 6.9±2.9 days. The mortality rate was 45% (nine patients) and 1.2% (three patients) in heparin/PF4 complex positive and negative patients, respectively.

Conclusion

Although the incidence of HIT was low in patients undergoing open heart surgery, an increased rate of early mortality was observed in patients with positive heparin/PF4 antibodies.

The Psychological Impact of COVID-19 Disease is more Severe on Intensive Care Unit Healthcare Providers: A Cross-sectional Study

OBJECTIVE

: Fear, anxiety, depression and sleep deprivation are common mental health disorders in COVID-19 disease. We aimed to analyse the risk for healthcare providers during COVID-19 pandemic in a university hospital.

METHODS

Anesthesiologists, nurses and nurse anesthetists were invited to fill out the survey. The survey was consist of questions from ''The Fear of COVID-19 Scale'', ''Patient Health Questionnaire'' and ''Pittsburgh Sleep Quality Index'' (PSQI). Each question was worth a point.

RESULTS

The data of 208 participants were analyzed. Mean age was 29 ± 7.748 years, 72.1% were male, 67.3% were nurses, 62% were working in intensive care units, 38% were in hospital wards, 62% of all participants were living alone. Moderate depression was the most frequently detected outcome (n = 90, 43.3%). Mean The Fear of COVID-19 Scale for all participants was 18.56 ± 7.731. The mean PSQI of patients was 6.18 ± 4.356 with a 45.7% rate of poor sleep quality. PSQI was found significantly higher in nurses (7.1 ± 4.7, p = 0.000). Nurses were the group with the highest deterioration in sleep quality (53.6%, p = 0.003). The rate of moderate-to-severe depressive symptoms was significantly higher in intensive care unit nurses and physicians (p = 0.018). PSQI score was found significantly higher in intensive care unit nurses and physicians than hospital ward co-workers (7.02 ± 4.59 vs. 4.81 ± 3.57 respectively, p = 0.001). A significant positive correlation was observed between PSQI and The Fear of COVID-19 Scale total score in all patients (p < 0.005).

CONCLUSION

Depression, anxiety, fear and sleep disorders may occur in healthcare workers during COVID-19 outbreak. Intensive care unit nurses were at highest risk.

Percutaneous Spinal Cord Stimulation for Failed Back Surgery Syndrome: A Retrospective Study

AIM

To evaluate the outcomes of percutaneous spinal cord stimulation (PSCS) in patients with failed back surgery syndrome (FBSS) in an academic tertiary care center.

MATERIAL AND METHODS

The hospital records of patients with FBSS who had undergone PSCS were retrospectively reviewed. A total of 19 patients with FBSS matched the search criteria, and among them, 16 were included in the study, in whom permanent implantable pulse generators (IPGs) were implanted. Demographic, clinical and surgical outcomes were evaluated.

RESULTS

Twelve (75%) women and 4 (25%) men with a median age of 50 years (range, 35-80 years) were analysed. The average number of surgeries before PSCS was 1.6 ± 1.2 (range, 1-4). Pain was localised in the back and leg in 81.25% of the patients. The mean duration of symptoms was 6.3 ± 3.1 years (range, 2-10 years). The mean length of trial period was 16.3 ± 6.8 days (range, 7?29 days). In this study, the permanent implantation rate was 84.2% (16/19). The mean follow-up time was 18.3 ± 3.9 months (range, 14-26 months). Postoperative back/leg numerical pain rating scale (NPRS) score was significantly lower than preoperative back/ leg NPRS score (p < 0.001). The postoperative Oswestry Disability Index (ODI) score was significantly lower than the preoperative ODI score (p < 0.001).

CONCLUSION

PSCS is a safe and effective treatment method for patients with FBSS. In this study, the high rate of improvement in the outcome scores may be attributed to the small sample size and early PSCS implantation.

Long Term Outcomes of Freestyle Stentless Aortic Bioprosthesis: A Single Center Experience

Background: The study is presenting our long-term clinical results after freestyle stentless aortic root bioprosthesis replacement in patients with severe aortic insufficiency with ascending aortic aneurysm. Methods: Seventy-seven patients with ascending aortic aneurysms and aortic valve insufficiency underwent a total root replacement procedure using a stentless “Freestyle” valve (Medtronic Inc., Minneapolis, Minnesota). There were 50 (64.9%) men and 27 (35.1%) women. Mean age was 68.7 ± 11.1 years. The surgical procedure used a complete root replacement. Concomitant procedures included coronary artery bypass grafting in 15 (19.5%) patients. Results: The mean cardiopulmonary bypass time was 130.3 ± 26.4 minutes and total aortic cross clamp time was 99.5 ± 23.6 minutes. Hospital mortality was 2.6%. The median follow-up time was 11.2 years. The 5- and 10-years freedom from aortic valve reoperation were 97.4 ± 1.2% and 93.4 ± 4.9%, respectively. During 10 years follow up, there were 14 late deaths; 4 deaths were cardiac, and 10 deaths were noncardiac. Valve-related deaths were attributable to thromboembolism in 1 patient, endocarditis in 2 patients, and congestive heart failure in 1 patient. Conclusion: The freestyle stentless aortic root bioprosthesis offered good clinical outcomes, in terms of survival and structural valve deterioration. The Freestyle valve is a viable option for use in patients undergoing bioprosthetic aortic valve replacement and expected desire for long-term durability.

Pecha Kucha with Part-Task Training Improves Airway Management in Fresh Frozen Cadavers: A Case-Control Observational Study

OBJECTIVE

The objective of this study was to ascertain whether the addition of part-task training as a step in Pecha Kucha for fiberoptic tracheal intubation increases the success rate and reduces the complication rate.

SUBJECTS AND METHODS

The residents of the Department of Anesthesiology were initially included in an orientation program. We used the Pecha Kucha method for the presentation of teaching fiberoptic intubation skills. Afterwards the participants were trained in Laerdal® airway management and each participant performed tracheal intubation using the Aintree catheter. The participants were divided into two groups. Group 1 (n = 9) received part-task training and group 2 (n = 9) received whole-task training. The tracheal intubation performances of participants were evaluated on fresh frozen cadavers. The number of interventions, incidence of complications, success rate, and optimization maneuver requirements were recorded.

RESULTS

Eighteen residents aged between 27 and 33 years were included. All were junior residents with less than 2 years of experience. There was no significant difference in terms of duration of tracheal intubation, complication rates, and optimization maneuvers between the study groups. Six participants could not place the tracheal tube in the last section. The success rates for the part-task group during Aintree and tracheal tube placement were 100 and 66.7%, respectively, whereas the rates were 55.6 and 44.4%, respectively, in whole-task group (p < 0.05).

CONCLUSION

In addition to the Pecha Kucha method in fiberoptic intubation training, simulation-based part-task training appears to increase the success rate and to reduce the complication rate on fresh frozen cadavers.

Anesthesia Management for a Patient Undergoing Pulmonary Endarterctomy without Cardiopulmonary Bypass

Pulmonary endarterectomy is a curative procedure for chronic thromboembolic Pulmonary Hypertension. As usual, cardiopulmonary bypass circuit is required. However, there are several complications attributed to extracorporeal circulation. Hemodilution, systemic inflammatory response syndrome and leukocyte sequestration are circulation related complications. The severe forms include Acute Respiratory Distress Syndrome, Acute Lung Injury, myocardial stunning, dysfunction of the right ventricle, coagulopathy, postoperative stroke or renal dysfunction. In this case report, we aimed to give information about perioperative anesthesia and surgical management of pulmonary endarterectomy which was successfully managed without Cardiopulmonary Bypass.

Analysing the efficacy of the I-gel supraglottic airway device in the supine and lateral decubitus positions

BACKGROUND

The advantages of the I-gel supraglottic airway device include ease and speed of insertion, reduced trauma incidence, an integral bite block, gastric access, a non-inflatable cuff and superior seal pressure. The primary goal of this study was to compare airway leak pressures and the fibreoptic view in the supine and lateral positions. Our secondary aim was to analyse the effects of I-gel insertion on haemodynamic parameters.

METHODS

One hundred patients undergoing saturation biopsy due to prostatic hyperplasia were recruited to this prospective randomised study. An I-gel device was inserted in the supine position. Taking of measurements, patients were placed in the lateral decubitus position. Mean arterial pressure, heart rate, peripheral O₂ saturation and end-tidal CO₂ were recorded before and after insertion. We recorded the number of attempts and insertion time for the I-gel device. Oropharyngeal leak pressures and I-gel device positioning were scored in the lateral decubitus and supine positions.

RESULTS

It was possible to insert the I-gel device in 88 patients on the first attempt. The median time for insertion was 7.97 ± 2.18 sec. The mean arterial pressure and heart rate decreased 1 and 2 min after insertion. Oropharyngeal leak pressure was similar in the supine (27.45 ± 5.37 mm Hg) and lateral decubitus positions (26.04 ± 4.92 mm Hg) (P > 0.05). On fibreoptic examination through the I-gel device, the scores of patients were comparable in different positions (P = 0.542).

CONCLUSION

As there was no significant difference in oropharyngeal leak pressure and fibreoptic view, we concluded that the I-gel device may be used safely in both the supine and lateral positions.

Surgical treatment of patients with myelomeningocele-related spine deformities: study of 26 cases

INTRODUCTION

Scoliosis, kyphosis, and sacral agenesis (SA) are common spine deformities in myelomeningocele (MMC) patients. Surgery of spine deformities in MMC patients is associated with various difficulties as infection, pathological skin breakage, instrumentation failure, and neurological deterioration. The purposes of this study are to share our clinical experience and discuss different surgical techniques which are defined in the literature.

PATIENTS AND METHOD

We retrospectively evaluated our database of patients with MMC who underwent surgical procedures for spine deformities from 2014 to 2016. Demographic and clinical data, surgical parameters, surgical techniques and levels, pre- and postoperative deformity angles, level of posterior fusion defect, spinal malformations, neurological evaluation of lower extremities and complications were collated. We divided the cases into three groups according to the type of deformities. The groups were lumbar kyphosis (Group 1), congenital scoliosis (Group 2), and paralytic scoliosis (Group 3).

RESULTS

There were 26 patients in the study. Fifteen patients were male and 11 patients were female. The median age of the patients was 8.03 (range = 3-17 years) at the time of operation. There were 10 patients in Group 1, 7 patients in Group 2, and 9 patients in Group 3. In Group 1, preoperative kyphosis angle varied between 51° and 160°, with an average of 95.7°. In Group 2, preoperative Cobb angle varied between 57° and 150°, with an average of 106.6°. Kyphosis was present in 4 patients. Preoperative kyphosis angle varied between 74° and 140°, with an average of 93°. In Group 3, preoperative Cobb angle varied between 45° and 145°, with an average of 72.5°.

CONCLUSION

Spinal deformity in children with MMC has been considered to cause severe disability. Surgical treatment is a challenging procedure with a wide spectrum of complications, but can provide good correction of spinal deformity and pelvic obliquity, and improve the quality of life. Self-growing systems which are a new alternative to traditional growing rod systems, must be considered to preserve growing potential of spine.

Predictive Factors of Operative Hemodynamic Instability for Pheochromocytoma

Pheochromocytoma is an uncommon catecholamine-secreting tumor in which resection is often associated with hemodynamic instability (HI). In this study, we aim to clarify the factors affecting surgical HI in patients who underwent surgery with the diagnosis of pheochromocytoma. All patients who underwent surgery with the diagnosis of pheochromocytoma between 2008 and 2015 were analyzed retrospectively. Patients with inconsistent diagnosis or missing outcomes and follow-up data were excluded. A total of 37 patients were included in this study. Patient demographics, operative time, tumor size, period of medical treatment until surgery, catecholamine levels in urine, and HI patterns were analyzed. There were 23 (62%) male and 14 (38%) female patients. Hemodynamic instability occurred in 13 (35%) patients. Overall, HI was higher in patients with tumor size <6 cm (P < 0.02); moreover, urine catecholamine levels were detected significantly higher than a cutoff value of 2000 mg/24 hours in hemodynamically instable group. In this study, tumor diameter of <6 cm and urine catecholamine levels >2000 mg/24 hours were associated with HI. Preoperative management is essential for preventing hypertensive crisis and HI before or during surgery.

Predictive Factors of Operative Hemodynamic Instability for Pheochromocytoma

Pheochromocytoma is an uncommon catecholamine-secreting tumor in which resection is often associated with hemodynamic instability (HI). In this study, we aim to clarify the factors affecting surgical HI in patients who underwent surgery with the diagnosis of pheochromocytoma. All patients who underwent surgery with the diagnosis of pheochromocytoma between 2008 and 2015 were analyzed retrospectively. Patients with inconsistent diagnosis or missing outcomes and follow-up data were excluded. A total of 37 patients were included in this study. Patient demographics, operative time, tumor size, period of medical treatment until surgery, catecholamine levels in urine, and HI patterns were analyzed. There were 23 (62%) male and 14 (38%) female patients. Hemodynamic instability occurred in 13 (35%) patients. Overall, HI was higher in patients with tumor size <6 cm (P < 0.02); moreover, urine catecholamine levels were detected significantly higher than a cutoff value of 2000 μg/24 hours in hemodynamically instable group. In this study, tumor diameter of <6 cm and urine catecholamine levels >2000 μg/24 hours were associated with HI. Preoperative management is essential for preventing hypertensive crisis and HI before or during surgery.

VivaSight: a new era in the evolution of tracheal tubes

STUDY OBJECTIVE

To evaluate the available data describing the use of single and double lumen VivaSight tubes.

DESIGN

Systematic review.

SETTING

The use of VivaSight tubes for elective surgeries including advantages, disadvantages, and possible complications.

PATIENTS

Systematic review of randomized controlled trials from databases including Medline, Web of Knowledge, Google Scholar, and Cochrane Central Register of Controlled Trials.

INTERVENTIONS

Comparison of VivaSight single and double-lumen tubes with conventional tubes during normal airway and expected difficult airway management. The effectiveness of the devices was also evaluated during 1-lung ventilation for patients undergoing thoracic surgery.

MEASUREMENTS

Intubation time, success rate, the requirement for fiberoptic bronchoscope, and the rate of complications.

MAIN RESULTS

Following a VivaSight double-lumen tube, a flexible bronchoscope is still needed. It is difficult to agree that VivaSight tube reduces the need or use of a bronchoscope. According to the current literature, it is unclear if there is any advantage of the VivaSight compared with using flexible bronchoscopy to direct a blocker into the correct lung. The cost may be another issue. Studies comparing VivaSight tubes with standard double lumen tubes reported faster tracheal intubation rate and higher success rate at first attempt for VivaSight. However, VivaSight tubes may cause soft tissue trauma such as bleeding, hematoma, edema, and erythema. Sore throat and dysphonia are other reported complications. Due to the outer thickness, smaller-sized double-lumen tube may be necessary. It has been reported to have the disadvantages, such as melting due to the heat of light source before insertion and sudden shutdown without warning.

CONCLUSIONS

Problems such as overheating and melting on the distal end of the tube due to the light source and potential breakdowns of the cable should be solved by the manufacturer. This will probably require a redesign and necessitate further studies.

Statistical analysis of associated vertebra and costal anomalies in spina bifida patients

Objective: Spina bifida is one of the most severe birth defects and can happen as a result of disrupted primary neurulation. Congenital vertebra and costa anomalies are more frequently seen with spina bifida, and associated anomalies significantly affect the prognosis of affected children. In this study, we aimed to determine the incidence of scoliosis, costal anomalies, and vertebral deformations seen at the time of diagnosis and to statistically evaluate their concomitancies.

Methods: Gender and mean ages of the patients were determined. The spina bifida patients were examined for deformation anomalies, butterfly vertebra, hemivertebra, wedge vertebra, costal anomalies and scoliosis. The relationships between these anomalies were evaluated.

Results: 94 patients with a mean age of 11,5 months examined. The incidence of scoliosis was 21.8% among female infants and 17.9% among males. Rates of scoliosis with vertebra anomalies (hemivertebra, wedge vertebra) and costal anomalies did not differ significantly (P > 0.05). Wedge vertebra were the most frequent vertebra anomaly type with 38.2% ratio. Costal anomalies were detected in 25.5% of females and 20.5% of male infants. Hemivertebra and wedge vertebra were seen significantly more frequently in this group. Gender distribution did not differ between with and without any vertebra types.

Conclusion: Congenital vertebra and costa anomalies are more frequently seen with spina bifida. We believe that these anomalies and relationship with spina bifida may demonstrate differences among different ethnic groups or locations. More detailed multi-centered studies performed on this issue will aid in the determination of etiologies, genetics, and treatment principles of these congenital anomalies.

The use of sugammadex in a pregnant patient with Wolff-Parkinson-White syndrome

Wolff-Parkinson-White (WPW) syndrome is a rare pre-excitation syndrome which develops when atrioventricular conduction occurs through a pathologic accessory pathway known as the bundle of Kent instead of atrioventricular node, hence resulting in tachycardia. Patients with WPW syndrome may experience various symptoms arising from mild-to-moderate chest disease, palpitations, hypotension, and severe cardiopulmonary dysfunction. These patients are most often symptomatic because of cardiac arrhythmias. In this case report, we present an uneventful anesthetic management of a pregnant patient with WPW syndrome undergoing cesarean delivery. A 23-year-old American Society of Anesthesiologists class 2 pregnant patient was diagnosed with WPW syndrome. Her preoperative 12-lead electrocardiogram showed a sinus rhythm at 82 beats per minute, a delta wave, and a short PR interval. After an uneventful surgery, sugammadex 2mg/kg was administered as a reversal agent instead of neostigmine. Then she was discharged to her obstetrics service. Serious hemodynamic disorders may occur in patients with WPW syndrome due to development of fatal arrhythmias. Neostigmine used as a reversal agent in general anesthesia can trigger such fatal arrhythmias by leading changes in cardiac conduction. We believe that sugammadex, which is safely used in many areas in the scope of clinical practice, can be also used for patients diagnosed with WPW syndrome.