Anaesthesiology and Reanimation Education in Turkey: Residents' Views

Objective

This study aimed to determine opinions of medical residents undergoing anaesthesia and reanimation training about equipment, programmes, applications, study conditions and shift systems at training institutions in Turkey.

Methods

A web-based survey was sent by e-mail to residents in anaesthesiology and reanimation training programmes. The survey comprised 73 questions about demographic characteristics, satisfaction, basic specialisation knowledge, anxiety and motivation.

Results

The study included 270 individuals. Of the residents, 82.2% willingly chose their field, whereas 66.7% stated that specialisation was necessary because of incorrect application of first-stage and GP medical services. The mean of the weekly working hours was 91.69±36.69 hours; the mean number of monthly on-call shifts was 7.49±1.99. Of the participants, 61.9% found the predicted five-year training duration long. The intensive care training duration was sufficient for 71.1% and only 26.3% found the pain management training duration sufficient.

Conclusion

According to the results, the number of residents is insufficient, workload is heavy, working hours are long and large numbers of shifts are worked without leave afterwards. In spite of negatives and high dissatisfaction, most residents willingly chose their departments and would choose the same branches again. Participants stated that their institutions emphasised service rather than education and research, and educators were less accessible to residents due to increasing service loads.

Morbidity and mortality predictivity of nutritional assessment tools in the postoperative care unit

The aim was to evaluate the nutritional situation of patients admitted to the Postoperative Acute Care Unit using classic methods of objective anthropometry, systemic evaluation methods, and Nutrition Risk in Critically Ill (NUTRIC) score, and to compare them as a predictor of morbidity and mortality.At admission to the postoperative care unit, patients undergoing various surgeries were assessed for the following items: Subjective Global Assessment (SGA), Nutritional Risk Index (NRI), Nutritional Risk Screening (NRS)-2002, Mini Nutritional Assessment (MNA), Charlson comorbidity index (CCI), and NUTRIC score, anthropometric measurements, serum total protein, serum albumin, and lymphocyte count. Patients were monitored for postoperative complications until death or discharge. Correlation of complications with these parameters was also analyzed.A total of 152 patients were included in the study. In this study a positive correlation was determined between mortality and NRS-2002, SGA, CCI, Acute Physiology and Chronic Health Evaluation , Sepsis-related Organ Failure Assessment, and NUTRIC score, whereas a negative correlation was determined between mortality and NRI. There was a correlation between NUTRIC score and pneumonia, development of atrial fibrillation, delirium, renal failure, inotrope use, and duration of mechanical ventilation. In our study group of postoperative patients, MNA had no predictive properties for any complication, whereas SGA had no predictive properties for any complications other than duration of hospital stay and mortality.The NUTRIC score is an important indicator of mortality and morbidity in postoperative surgical patients. NRI correlated with many postoperative complications, and though SGA and NRS were correlated with mortality, they were not correlated with the majority of complications. MNA was determined not to have any correlation with any complication, mortality, and duration of hospital stay in our patient group.

[Effects of various anesthesia maintenance on serum levels of selenium, copper, zinc, iron and antioxidant capacity]

BACKGROUND AND OBJECTIVES

In this study, we aimed to investigate the effects of sevoflurane, desflurane and propofol maintenances on serum levels of selenium, copper, zinc, iron, malondialdehyde, and glutathion peroxidase measurements, and antioxidant capacity.

METHODS

60 patients scheduled for unilateral lower extremity surgery which would be performed with tourniquet under general anesthesia were divided into three groups. Blood samples were collected to determine the baseline serum levels of selenium, copper, zinc, iron, malondialdehyde and glutathion peroxidase. Anesthesia was induced using 2-2.5mgkg(-1) propofol, 1mgkg(-1) lidocaine and 0.6mgkg(-1) rocuronium. In the maintenance of anesthesia, under carrier gas of 50:50% O2:N2O 4Lmin(-1), 1 MAC sevoflorane was administered to Group S and 1 MAC desflurane to Group D; and under carrier gas of 50:50% O2:air 4Lmin(-1) 6mgkgh(-1) propofol and 1μgkgh(-1) fentanyl infusion were administered to Group P. At postoperative blood specimens were collected again.

RESULTS

It was observed that only in Group S and P, levels of MDA decreased at postoperative 48th hour; levels of glutathion peroxidase increased in comparison to the baseline values. Selenium levels decreased in Group S and Group P, zinc levels decreased in Group P, and iron levels decreased in all three groups, and copper levels did not change in any groups in the postoperative period.

CONCLUSION

According to the markers of malondialdehyde and glutathion peroxidase, it was concluded that maintenance of general anesthesia using propofol and sevoflurane activated the antioxidant system against oxidative stress and using desflurane had no effects on oxidative stress and antioxidant system.

Efficiency of levobupivacaine and bupivacaine for supraclavicular block: a randomized double-blind comparative study

BACKGROUND AND OBJECTIVES

Success rate of catheter applications is low in supraclavicular block. Thus, bupivacaine and levobupivacaine become important with their long effect time in single injection practices. In this study, we aimed to compare the effectiveness, side effects and complications of bupivacaine and levobupivacaine in supraclavicular block.

METHODS

Sixty patients aged between 20 and 65, with body weight between 50 and 100 kg, in the ASA I-II-III group who were scheduled for hand, forearm and arm surgery using supraclavicular block were randomized into two groups of 30. The patients received 30 ml 0.5% bupivacaine (Group B) or 30 ml 0.5% levobupivacaine (Group L). Motor and sensory blocks were evaluated. Motor and sensory block onset times, total block durations, postoperative pain, amount of postoperative analgesic used and patient satisfaction were recorded.

RESULTS

Demographic data, distribution of surgical area and hemodynamic data were similar between the two groups. Surgery, motor and sensory block durations of Group B and L patients did not vary statistically significantly. However, motor and sensory block onset times in Group B were significantly shorter than Group L (p<0.05). The mean time for first postoperative analgesic demand were 16.6 ± 8.0 h in Group B and 14.4 ± 7.3h in Group L (p>0.05).

CONCLUSION

30 ml 0.5% bupivacaine and levobupivacaine provide similar block characteristics for supraclavicular block. Bupivacaine leads to faster motor and sensory block onset compared to levobupivacaine however similar duration of postoperative analgesia.

Comparison of propofol-dexmedetomidine, tiopental-dexmedetomidine and etomidate-dexmedetomidine combinations' effects on the tracheal intubation conditions without using muscle relaxants

BACKGROUND

In our study, we aimed to compare the endotracheal intubation conditions without muscle relaxants during induction with the combinations of dexmedotimidine-propofol, dexmedotimidine-thiopenthal and dexmedetomidine-etomidate.

METHOD

Seventy-six patients, in ASA risk group I-II, between ages 20-60 years, with Mallampati Class 1 were included in the study. All patients were premedicated with midazolam. The patients were randomly divided into three groups as Group P (n=30, dexmedetomidine-propofol), Group T (n=30, dexmedetomidine-thiopenthal), Group E (n=16, dexmedetomidine-etomidate). All patients received dexmedetomidine 1 μg.kg-1 in 10 min. Then, the patients were administered 2.5 mg.kg-1 propofol for Group P, 5 mg.kg-1 thiopental for Group T and 0.3 mg.kg-1 etomidate for Group E during induction. Hemodynamic data of the patients were recorded before induction, after dexmedetomidine administration, immediately after intubation and 3, 5 and 10 minutes after intubation.

RESULTS

There was no difference between the groups according to hemodynamic data. Sixteen patients in Group P and 10 patients in Group T had acceptable intubation conditions. Muscle relaxant was needed in 14, 20 and 16 patients in Groups P, T and E, respectively (p<0.05).

CONCLUSION

In conclusion, we determined that best intubation conditions without muscle relaxants were achieved with propofol-dexmedetomidine combination. None of the patients receiving etomidate -dexmedetomidine combination could be intubated without muscle relaxants (Tab. 6, Ref. 29).

The effect of levobupivacaine and bupivacaine on QT, corrected QT (Qtc), and P wave dispersions in cesarean section

BACKGROUND AND OBJECTIVES

In our study we aimed to investigate the effect of bupivacaine and levobupivacaine on QT, corrected QT (QTc), and P wave dispersion durations during spinal anesthesia in cesarean section.

METHODS

Sixty parturients scheduled for elective cesarean section in ASA I-II risk groups were included in the study. Baseline electrocardiographic (ECG) records of the patients were obtained in the operation room. Heart rate (HR), non-invasive blood pressure (NIBP), peripheral oxygen saturation (SpO2) and respiration rates (RR) were recorded. Venous cannulation was performed with 18G cannula and fluid preload made with 10 mL.kg(-1). Lactated Ringer solution. After fluid preload, second ECG recordings were taken and the patients were randomly separated into two groups. Group B (n = 30) received 10mg of bupivacaine and Group L (n = 30) received 10mg of levobupivacaine for spinal anesthesia. ECG recordings were repeated at 1, 5 and 10 minutes after spinal block. HR, NIBP, SpO2, RR and sensory block levels were also recorded at the same time intervals. At predetermined time intervals of spinal anesthesia, P wave dispersion (Pwd), QT dispersion (QTd), and QTc dispersion (QTcd) durations were measured from ECG records. QT and QTc durations are calculated with Bazzett formula.

RESULTS

There was no difference between two groups according to block levels, hemodynamic parameters, Pwd, QTd, QTc and QTcd durations.

CONCLUSION

Bupivacaine and levobupivacaine may be preferred in spinal anesthesia in pregnant patients who have extended Pwd and QTcd preoperatively.

The effects of nitrous oxide on vitamin B12 and homocysteine levels in methyltetrahydrofolate reductase gene mutation

BACKGROUND

We aimed to investigate the effects of nitrous oxide on plasma total homocysteine and vitamin B12 levels in patients with or without methyltetrahydrofolate reductase (MTHRF) gene mutation.

METHODS

After obtaining the ethics committee approval and written informed consents of patients, 93 patients between 18-70 years of age scheduled for surgery anticipated to last 1-4 hours were enrolled in the study. Patients with contraindications for nitrous oxide use were excluded. Preoperatively, blood samples were obtained from all patients for the determination of MTHFR gene mutation. Anesthesia induction was achieved with 3 mg.kg-1 of propofol and 1 µg.kg-1 of fentanyl. Anesthesia maintenance was performed with sevoflurane and with a carrier gas composed of 40 % O2 and 60 % N2O. Venous blood samples were obtained after venous canulation, and 24 hours after extubation for the analysis of plasma total homocysteine, vitamin B12 levels.

RESULTS

Eighty-one patients were included in the study. Postoperative vitamin B12 levels were found to be significantly lower when compared with their preoperative levels (p<0.05). It was found that MTHRF gene polymorphism had no significant effect on postoperative plasma total homocysteine and serum vitamin B12 levels (p>0.05). Postoperative plasma total homocysteine levels were found to be significantly different between patients with operation times under and over 3 hours (p=0.028).

CONCLUSIONS

We conclude that MTHRF gene polymorphism had no significant effects on postoperative plasma total homocysteine levels. However, we found that homocysteine levels might rise in patients who received general anesthesia with nitrous oxide for longer than 3 hours (Tab. 7, Ref. 26).

Effect of ghrelin on inflammatory response in lung contusion

The purpose of this study was to investigate the effects of ghrelin on inflammatory response and tissue damage following trauma-induced acute lung injury. Thirty male wistar albino rats (300-400 g) were randomly assigned into three groups: control group (n = 6), lung contusion plus saline (saline-treated, n = 12), and lung contusion plus ghrelin (ghrelin-treated, n = 12). Saline- or ghrelin-treated traumatic rats were sacrificed at two time points (24 and 72 hours) after lung contusion. Blood was collected for the analysis of serum adenosine deaminase (ADA). Tissue transforming growth factor-beta 1 (TGF-β1) and matrix metalloproteinase-2 (MMP-2) levels were measured by enzyme-linked immunosorbent assay and histopathological examination was performed on the lung tissue samples. Our results indicated that ghrelin significantly reduced morphologic damages. Serum ADA activities were significantly decreased after lung contusion and this decline started early with ghrelin treatment. TGF-β1 and MMP-2 levels in lung tissue were elevated at 72 hours after lung contusion and treatment with ghrelin significantly increased TGF-β1 level and reduced MMP-2 level. In conclusion, our study demonstrates that acute lung injury initiated proinflammatory responses and ghrelin administration showed an anti-inflammatory effect in lung contusion.

Dexmedetomidine did not reduce the effects of tourniquet-induced ischemia-reperfusion injury during general anesthesia

Ischemia reperfusion injury causes the release of free oxygen radicals. Free oxygen radicals initiate the production of toxic metabolites, such as malondialdehyde (MDA), through the lipid peroxidation of cellular membranes. Following lipid peroxidation, the antioxidant enzyme system is activated against reactive oxygen species (ROS) and attempts to protect cells from oxidative damage. There is a balance between the scavenging capacity of antioxidant enzymes and ROS. Because of this balance, the total antioxidant capacity (TAC) measurement is a sensitive indicator of the overall protective effects of the antioxidants. Alpha(2) receptor agonists are effective in preventing hemodynamic reactions during extremity surgeries by preventing the release of catecholamines secondary to tourniquet application. They have also been shown to possess preventive effects in various ischemia-reperfusion injury models. In our study, we examined the effects of dexmedetomidine on tourniquet-induced ischemia-reperfusion injury in lower extremity surgeries performed under general anesthesia. The effects of dexmedetomidine were measured with serum MDA and TAC levels. We studied 60 adult American Society of Anesthesiologists (ASA) physical status I or II patients undergoing one-sided lower extremity surgery with tourniquet. The patients were randomly divided into two groups. Group D was administered a dexmedetomidine infusion at a rate of 0.1μg/kg/minute(-1) for 10 minutes prior to induction and then at 0.7μg/kg/hour(-1) until 10 minutes before the end of the operation. The control group (Group C) received a saline infusion of the same amount and for the same period of time. General anesthesia was induced with thiopental, fentanyl, and rocuronium and maintained with nitrous oxide and sevoflurane in both groups. Venous blood samples were obtained before the administration of the study drugs (basal) at 1 minute before tourniquet release and at 5 and 20 minutes after tourniquet release (ATR). In both groups, MDA levels decreased at 5 and 20 minutes ATR when compared with the basal values (p<0.05). TAC levels decreased at 1 and 5 minutes ATR and then returned to basal values at 20 minutes ATR (p<0.05). In reference to the prevention of lipid peroxidation in tourniquet-induced ischemia-reperfusion injury, the results from the two groups in our study showed that dexmedetomidine did not have an additional protective role during routine general anesthesia.

The Analgesic Effect of Dexketoprofen When Added to Lidocaine for Intravenous Regional Anaesthesia: A Prospective, Randomized, Placebo-Controlled Study

This prospective, randomized, placebo-controlled study evaluated the effects of dexketoprofen as an adjunct to lidocaine in intravenous regional anaesthesia (IVRA) or as a supplemental intravenous (i.v.) analgesic. Patients scheduled for elective hand or forearm soft-tissue surgery were randomly divided into three groups. All 45 patients received 0.5% lidocaine as IVRA. Dexketoprofen was given either i.v. or added into the IVRA solution and the control group received an equal volume of saline both i.v. and as part of the IVRA. The times of sensory and motor block onset, recovery time and postoperative analgesic consumption were recorded. Compared with controls, the addition of dexketoprofen to the IVRA solution resulted in more rapid onset of sensory and motor block, longer recovery time, decreased intra- and postoperative pain scores and decreased paracetamol use. It is concluded that coadministration of dexketoprofen with lidocaine in IVRA improves anaesthetic block and decreases postoperative analgesic requirements.

Preoperative abnormal P and QTc dispersion intervals in patients with metabolic syndrome

We evaluated P wave dispersion (Pwd), QT, corrected QT (QTc), QT dispersion, and corrected QT dispersion (QTcd) intervals in patients with metabolic syndrome (MetS). Patients scheduled to undergo elective noncardiac surgery were included in the study. The main diagnoses, anthropometric measurements, waist circumferences, body mass index, electrocardiograms, serum levels of electrolytes, glucose, and lipids were recorded for all patients. QTc, QTcd intervals were determined with the Bazett formula. MetS (group M, n = 36) was diagnosed using the Adult Treatment Panel III. Controls (group C, n = 40) were chosen on the basis of patients with no MetS and matched for age and gender. There were no differences between groups in terms of age, sex, or serum electrolyte levels (P > 0.05). Waist circumferences, body mass index, serum glucose, and triglyceride values in group M were significantly higher than those in group C (P < 0.001). In group M, Pwd, QTc, QT dispersion and QTcd intervals were significantly longer than those in group C (P < 0.001). This finding and our retrospective analysis suggest that these patients may be at greater risk of perioperative arrhythmias.

Brief report: the effects of the menstrual cycle on the hemodynamic response to laryngoscopy and tracheal intubation

We designed this study to determine the effect of the menstrual cycle on the hemodynamic response to tracheal intubation (TI). Sixty-two ASA I women who were either in the follicular phase (group F, n = 31) or luteal phase (group L, n = 31) of their menstrual cycle were included in the study. Patients received propofol and rocuronium for intubation. Hemodynamic variables were recorded before administration of the IV anesthetic, as well as after TI. Rate pressure products were calculated. Groups were similar in terms of demographic data. Rate pressure products values at the first minute after TI were significantly increased in group L than were those in group F (P < 0.001). We conclude that the phase of the menstrual cycle is an important factor in the hemodynamic response to TI.

Effects of dexmedetomidine pretreatment on bupivacaine cardiotoxicity in rats

BACKGROUND AND OBJECTIVE

We evaluated the effects of dexmedetomidine pretreatment on bupivacaine cardiotoxicity in anesthetized rats.

METHODS

Sixteen Wistar-Albino male rats (300-400 g) were anesthetized with ketamine. Electrocardiographic and invasive blood pressure monitoring were performed, and the results were continuously recorded. The rats were randomized into 2 groups. In group D, rats were pretreated with intravenous dexmedetomidine at a dose of 10 Kg/kg (n = 8), whereas in group S, rats were pretreated with intravenous saline (n = 8). Fifteen minutes later, bupivacaine was infused at a rate of 3 mg/kg per minute until cardiac asystole occurred. The timing of specific cardiotoxic events (a 25%, 50%, and 75% reductions of mean arterial pressure and heart rate as well as occurrence of the first arrhythmia and asystole) was recorded.

RESULTS

Dexmedetomidine pretreatment reduced the heart rates and mean arterial pressures of the rats who received it (P G 0.05). Dexmedetomidine pretreatment before bupivacaine administration also significantly increased the time to the 25%, 50%, and 75% reductions in mean arterial pressure and the time to the 25% and 50% reductions in heart rate (P G 0.05). In addition, dexmedetomidine significantly increased the time to first arrhythmia and time to asystole (P G 0.05) in the rats who received it before receiving bupivacaine.

CONCLUSIONS

Dexmedetomidine pretreatment delays the effects of bupivacaine cardiotoxicity.

An Evaluation of P Wave Dispersion, QT, Corrected QT and Corrected QT Dispersion Intervals on the Electrocardiograms of Malnourished Adults

The aim of our study was to investigate P wave dispersion (Pwd), QT, corrected QT (QTc), QT dispersion (QTd) and corrected QT dispersion (QTcd) intervals in subjects with malnutrition diagnosed in the pre-anaesthetic assessment, compared to those without malnutrition.

A total of 76 adult patients were included. Main diagnoses, anthropometric measurement, body mass index, electrocardiogram and serum sodium, potassium, chloride, magnesium and calcium levels were recorded for all patients. Pwd, QT and QTd intervals were measured on all electrocardiogram records and QTc and QTcd intervals determined with the Bazett formula. Protein-energy malnutrition was diagnosed with the nutritional risk index.

No statistically significant difference was found between the age, gender and malignant cancer diagnosis rates between patients with malnutrition (group M) and those not suffering from malnutrition (group N) (P >0.05). Serum albumin, total protein, potassium, calcium, magnesium and chloride values of group M were found to be significantly lower than group N (P <0.05). In group M, Pwd, QT, QTc, QTd and QTcd intervals were significantly longer than in group N (P <0.001).

Patients diagnosed with malnutrition during pre-anaesthetic assessment had significantly longer Pwd, QTc and QTcd interval durations than the control group. We attribute such extended Pwd, QTc and QTcd durations in these patients to malnutrition and malnutrition-related electrolyte imbalance.

Effect of Dexmedetomidine on Testicular Torsion/Detorsion Damage in Rats

<i>Background and Objective:</i> We assessed the antioxidant activity of dexmedetomidine (DEX) during an ischemic period in a rat model of testicular torsion/detorsion (T/DT) by using biochemical and histopathological methods. <i>Methods:</i> Wistar Albino male rats weighing 250–300 g were divided into three groups: sham (group S, n = 7); torsion/detorsion (group T/DT, n = 7), and DEX treatment (group DEX, n = 7). In the T/DT group, right testes were rotated 720° for 1 h. Group S served for normal basal values. Rats in group T/DT were operated to make T/DT, this group served as a control group. Group DEX received intraperitoneal DEX 10 µg · kg^–1 after the 30-min torsion period. For measurement of total antioxidant enzyme activities and malondialdehyde (MDA) levels, testes of 7 animals in each group were excised after 4 h of reperfusion. Germ cell apoptosis was evaluated using the apoptosis protease-activating factor 1 (APAF-1) antibody in all groups and also on the expressions of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) were assessed within the bilateral testes. <i>Results:</i> Mean MDA levels in group T/DT were significantly higher than in groups S and DEX (p < 0.05). There were also significant decreases in mean total antioxidant activities in group T/DT when compared to groups S and DEX (p < 0.05). These values were significantly higher in group DEX than group T/DT. Germ cell apoptosis, eNOS and iNOS levels were significantly higher in group T/DT when compared to groups S and DEX (p < 0.05). <i>Conclusions:</i> DEX treatment has potential biochemical and histopathological benefits by preventing ischemia/reperfusion-related cellular damage in an experimental testicular torsion model. Preference of DEX for anesthesia during the detorsion procedure may attenuate ischemia-reperfusion injury.

The effects of intravenous fentanyl and lidocaine infiltration on the hemodynamic response to skull pin placement

The aim of this study was to evaluate the effects of intravenous fentanyl and local lidocaine infiltration on the hemodynamic response to Mayfield skull pin head holder (MH) placement. Forty-five patients scheduled for elective craniotomy were studied. They were randomly divided into three groups. Group F received fentanyl 2 microg/kg IV 5 min before placement of the MH, group L was administered plain lidocaine 3 ml 1% by infiltration at each pin site 1 minute before placement, and both methods were applied together in group FL. Mean blood pressure (MAP) and heart rate (HR) were recorded at 5 preset times. In group F during and after MH placement, MAP and HR were significantly higher than in the L and FL groups. In the L group, there was significantly higher MAP and HR during the placement of MH than in the FL group. In the FL group, there was no significant increase in MAP or HR at any time of the recordings. We conclude that intravenous fentanyl with local infiltration of lidocaine into the periosteum is effective in reducing the hemodynamic response to MH placement in patients undergoing craniotomy.

The effects of intravenous fentanyl and lidocane infitration on the haemodynamic response to skull placement

The aim of this study is to evaluate the effects of intravenous fentanyl and local lidocaine infiltration on the haemodynamic response to Mayfield skull pin head holder (MH) placement. Forty-five patients scheduled for elective craniotomy were studied. They were randomly divided into three groups. Group F received 2 microg/kg(-1) fentanyl i.v. 5 min before placement of the MH, group L was administered 3 ml 1% plain lidocaine by infiltration at each pin site 1 minute later and before placement of the MH, and both methods were applied together in group FL. Mean arterial blood pressure (MAP) and heart rate (HR) were recorded at 5 preset times. Both were significantly increased during and after MH placement in group F compared to groups L and FL. In group L, there was a significant increase in MAP and HR during the placement of MH compared to group FL. In group FL, there was no significant increase in MAP or HR at any time of the recordings. We conclude that intravenous fentanyl with local infiltration of lidocaine into the periosteum is effective in reducing the haemodynamic response to MH placement in patients undergoing craniotomy.