Practices of anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill in Turkey

BACKGROUND

To determine practices of Turkish anaesthesiologists with regard to withholding and withdrawal of life support from the critically ill.

METHODS

An anonymous questionnaire consisting of 18 questions was mailed to 439 members of the Turkish Society of Anaesthesiology and Reanimation.

RESULTS

Three hundred and 69 questionnaires were returned (84% response). Over 90% of the respondents indicated that they were Muslim. We found that 66% of respondents had initiated written or oral do-not-resuscitate orders, most frequently after discussion with colleagues (82%).

CONCLUSIONS

While a number of similarities were found between Turkish anaesthesiologists and those from other countries, some specific differences could be identified, particularly related to consensus decision-making and sharing information with other providers and the value of Ethics Committees in the decision-making process.

Effects of pressure- and volume-controlled inverse ratio ventilation on haemodynamic variables, intracranial pressure and cerebral perfusion pressure in rabbits: a model of subarachnoid haemorrhage under isoflurane anaesthesia

BACKGROUND AND OBJECTIVE

An inverse I : E ratio (inspiratory time > expiratory time) may have benefits in patients suffering trauma who requiring lung ventilation. However, this application may be deleterious if there is concomitant head injury. We aimed to determine the physiological effects of pressure- and volume-controlled modes of inverse ratio (I : E = 2 : 1) ventilation of the lungs, while maintaining normocapnia, in a rabbit model of raised intracranial pressure (ICP).

METHODS

New Zealand White rabbits were anaesthetized with isoflurane and a tracheostomy was performed. Subarachnoid haemorrhage was simulated in two groups by injecting blood into the cisterna magna. Groups 1 and 2 (n = 6, each), controls, were compared with Groups 3 and 4 (n = 6, each) with the simulated subarachnoid haemorrhage. Each ventilation mode was used with an I : E ratio of 2 : 1 for 30 min. Mean arterial pressure (MAP), ICP, cerebral perfusion pressure (CPP), mean airway pressure (P(AW)) and arterial blood-gas status were measured.

RESULTS

Both modes increased mean P(AW) (P < 0.02). This increase was greater with the volume-controlled mode (P < 0.02). The baseline value averaged 5.8 +/- 0.4 and 5.6 +/- 0.3 mmHg in Groups 3 and 4, respectively, and increased to 7.8 +/- 0.3 and 10.8 +/- 0.4 mmHg. Inducing subarachnoid haemorrhage increased ICP and MAP (P < 0.02). Baseline ICPs were 10.3 +/- 0.5 and 10.3 +/- 0.4 mmHg in Groups 1 and 2, respectively, whereas they were 25.4 +/- 1.2 and 25.8 +/- 0.8 mmHg in Groups 3 and 4. However, ICP, MAP and CPP did not differ significantly according to the mode.

CONCLUSIONS

An already raised ICP was altered by the application of induced mean PAW increases as a consequence of inverse ratio ventilation of the lungs with normocapnia.

Effects of normovolaemic haemodilution on middle cerebral artery blood flow velocity and oxygen delivery

BACKGROUND AND OBJECTIVE

Assessment of the effects of normovolaemic haemodilution on middle cerebral artery blood flow velocity with transcranial Doppler ultrasonography, intracranial pressure, cerebral perfusion pressure, arterial oxygen content and cerebral oxygen delivery.

METHODS

Normovolaemic haemodilution was induced in rabbits under general anaesthesia, and the haematocrit was allowed to decrease to 30% in Group 1 (n = 6) and to 20% in Group 2 (n = 6). Peak systolic and diastolic velocities, mean blood flow velocity, and pulsatility and resistance indices of the middle cerebral artery were measured by transcranial Doppler ultrasonography. Changes in intracranial pressure, cerebral perfusion pressure, arterial oxygen content and cerebral oxygen delivery were also assessed.

RESULTS

In Group 2, middle cerebral artery blood flow velocity increased from 0.4 +/- 0.01 to 0.51 +/- 0.02 m s(-1) after the induction of normovolaemic haemodilution (P = 0.04), while arterial oxygen content decreased from 16.2 +/- 0.1 to 8.5 +/- 0.1 mLdL(-1) (P = 0.002). The decrease in cerebral oxygen delivery from 6.5 +/- 0.2 to 4.3 +/- 0.2 was also significant (P = 0.02). However, no associated changes in intracranial pressure and cerebral perfusion pressure could be demonstrated.

CONCLUSIONS

Normovolaemic haemodilution resulted in an increase in the mean blood flow velocity of the middle cerebral artery. However, this increase did not compensate for the consequences of the altered oxygen delivery to the brain when the haematocrit was reduced to 20%.

Intracranial penetrating injury associated with an intraoperative epidural haematoma caused by a spring-laden pin of a multipoise headrest

Lack of an intermediary piece that should have been placed between the pin and spring resulted in skull penetration due to a rapid waste in the spring's compensatory capacity. Checking integrity of internal pieces should be performed regularly. Designing intermediary piece and spring as a single piece might increase safety.

Effects of CO2 pneumoperitoneum on the basilar artery

BACKGROUND

Laparoscopic surgery provides many benefits to the patients. The purpose of this study was to evaluate cerebral blood flow changes and the possibility of ischemia-reperfusion injury occurring during carbon dioxide (CO(2)) pneumoperitoneum.

METHODS

Forty-eight New Zealand white rabbits were divided into four experimental and two control groups. Rabbits were subjected to CO(2) pneumoperitoneum with an intraabdominal pressure of 8 and 15 mmHg for 60 or 180 min as designed for experimental groups. We then assessed the changes in physiological and transcranial Doppler ultrasonographic parameters, as well as brain malondialdehyde levels.

RESULTS

Transcranial Doppler sonography of the basilar artery revealed elevated mean velocity and decreased resistance index and pulsatility index values with the longer-duration and higher-pressure CO(2) pneumoperitoneum. However, there were no statistically significant difference in m alondialdehyde values.

CONCLUSION

Elevated intraabdominal pressure by CO(2)-pneumoperitoneum, which does not lead to ischemia-reperfusion injury of the brain tissue, results in increased cerebral blood flow and reduced cerebrovascular resistance as an autoregulatory cerebral answer for CO(2).

Posttraumatic isolated infarction in the territory of Heubner's and lenticulostriate arteries: case report

A 12 year old male had a secondarily generalized epileptic seizure and a subsequent right hemiparesis with fasciobrachial predominance after a closed head injury. His seizures responded to antiepileptic drug therapy immediately. Computerized tomographic scanning and magnetic resonance imaging showed an acute infarct of the head of the left caudate nucleus, indicating the isolated occlusion of the left recurrent artery of Heubner and lateral lenticulostriate arteries. Pathologies leading to vasculitis and embolism were also looked for, but no finding of associated systemic disease could be disclosed. We present this case since posttraumatic infarction in the territory of the deep perforators such as recurrent artery of Heubner and lateral lenticulostriate arteries are exceptionally rare conditions especially in this age group.

A case of split notochord syndrome: presence of dorsal enteric diverticulum adjacent to the dorsal enteric fistula

Like umblical enteric remnants (eg, umblical sinus and omphalomesenteric fistula), enteric remnants can be seen on the dorsal aspect of the body (dorsal enteric sinus, dorsal enteric fistula IDEF], dorsal enteric diverticulum) in conjunction with complete cleft of the vertebral column. Complete cleft of the vertebral column associated with gastrointestinal tract and central nervous system anomalies is known as "split notochord syndrome" (SNS). The authors present an unreported variant of SNS having dorsal enteric diverticulum adjacent to the DEF. The patient died 17 days after surgical repair.