Evaluation of the Effect of Morphological Structure on Dilatational Tracheostomy Interference Location and Complications with Ultrasonography and Fiberoptic Bronchoscopy

Background: Percutaneous dilatational tracheostomy (PDT) is the most commonly performed minimally invasive intensive care unit procedure worldwide. Methods: This study evaluated the percentage of consistency between the entry site observed with fiberoptic bronchoscopy (FOB) and the prediction for the PDT level based on pre-procedural ultrasonography (USG) in PDT procedures performed using the forceps dilatation method. The effect of morphological features on intervention sites was also investigated. Complications that occurred during and after the procedure, as well as the duration, site, and quantity of the procedures, were recorded. Results: Data obtained from a total of 91 patients were analyzed. In 57 patients (62.6%), the USG-estimated tracheal puncture level was consistent with the intercartilaginous space observed by FOB, while in 34 patients (37.4%), there was a discrepancy between these two methods. According to Bland Altman, the agreement between the tracheal spaces determined by USG and FOB was close. Regression formulas for PDT procedures defining the intercartilaginous puncture level based on morphologic measurements of the patients were created. The most common complication related to PDT was cartilage fracture (17.6%), which was proven to be predicted with maximum relevance by punctured tracheal level, neck extension limitation, and procedure duration. Conclusions: In PDT procedures using the forceps dilatation method, the prediction of the PDT intervention level based on pre-procedural USG was considerably in accordance with the entry site observed by FOB. The intercartilaginous puncture level could be estimated based on morphological measurements.

Ultrasound-Guided External Oblique Intercostal Plane Block for Postoperative Analgesia in Laparoscopic Sleeve Gastrectomy: A Prospective, Randomized, Controlled, Patient and Observer-Blinded Study

PURPOSE

The external oblique intercostal plane (EOI) block is a novel block technique for anterolateral upper abdominal wall analgesia. The superficial nature of the external oblique intercostal plane allows it to be easily identified even in patients with obesity. The aim of this study was to test the hypothesis that EOI block would reduce IV morphine consumption within 24 h after laparoscopic sleeve gastrectomy.

MATERIALS AND METHODS

Patients were randomly assigned to one of two groups: EOI block group and control group. The patients in the EOI block group received ultrasound-guided bilateral EOI block with a total of 40 ml 0.25% bupivacaine after anesthesia induction. The patients in the control group received no intervention. Postoperatively, all the patients were connected to an intravenous patient controlled analgesia (PCA) device containing morphine. The primary outcome of the study was IV morphine consumption in the first postoperative 24 h.

RESULTS

The median [interquartile range] morphine consumption at 24 h postoperatively was significantly lower in the EOI block group than in the control group (7.5 [3.5 to 8.5] mg vs 14 [12 to 20] mg, p = 0.0001, respectively). Numerical rating scale (NRS) scores at rest and during movement were lower in the EOI block group than in the control group at 2, 6, and 12 h but were similar at 24 h. No block-related complications were observed in any patients.

CONCLUSION

The results of the current study demonstrated that bilateral EOI block reduced postoperative opioid consumption and postoperative pain in patients with obesity undergoing laparoscopic sleeve gastrectomy.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05663658.

Comparison of the Effects of Anaesthesia Methods Used in Caesarean Delivery on Neonatal Cerebral and Renal Oxygenation: A Randomised Controlled Trial

Background: During a newborn's adaptation to extrauterine life, many changes take place that are influenced by various factors. The type of delivery and anaesthesia strategy utilised during labour can modify these adaptive modifications. In this regard, this study was designed to compare the effects of general and spinal anaesthesia on cerebral and renal oxygenation after elective caesarean deliveries. Methods: This randomised controlled study comprised sixty parturient women who were over 18 years old and had a gestational age between 37 and 41 weeks. All participants had an ASA (American Society of Anesthesiologists) classification of II. Neonatal cerebral (CrSO2) and renal (RrSO2) regional oxygen saturations were assessed using near-infrared spectroscopy. Additionally, the 1st-5th min Apgar scores, preductal and postductal peripheral oxygen saturation (SpO2), and perfusion index were recorded in both the general anaesthesia and spinal anaesthesia groups. Results: There was no statistically significant difference between the two groups in terms of CrSO2 or RrSO2 values. The values of CrSO2 and RrSO2 in both groups showed a significant rise from the 10th to the 15th min, respectively. Conclusions: General and spinal anaesthesia techniques used for cesarean delivery have similar effects on neonatal cerebral and renal oxygenation.

PECS II block for cardiac implantable electronic device insertion: A pilot study

AIM

Some truncal blocks could provide adequate surgical anesthesia and postoperative analgesia in cardiac implantable electronic devices (CIED) insertion. The aim of this study was to evaluate the feasibility of the pectoral nerves (PECS) II block for CIED insertion.

METHODS

PECS II blocks were performed on the left side using the ultrasound-guided single injection technique in all patients. The primary outcome for feasibility was the percentage of the cases completed without intraoperative additional local anesthesia. Secondary outcomes were the amount of intraoperative additional local anesthetic, intraoperative opioid requirement, postoperative pain scores, first requirement for postoperative analgesia, postoperative analgesic consumption, patient satisfaction, and block-related complications.

RESULTS

Of the total 30 patients, 19 (63.3%) required intraoperative additional local anesthetic. The median (IQR [range]) volume of the additional local anesthetic used was 7 (4-10 [2.5-12]) mL. Two patients needed additional IV analgesics in the first 24 h postoperatively. No statistically significant differences were determined between the patients requiring and not requiring intraoperative additional local anesthetic in respect of age, gender, duration of surgery, block performance time, and hospital stay. A total of 26 (86.6%) patients reported a high level of satisfaction with the procedure.

CONCLUSIONS

PECS II block for cardiac electronic implantable device insertion provides effective postoperative analgesia for at least 24 h. Although PECS II block alone could not provide complete surgical anesthesia in the majority of the patients, when combined with supplementary local anesthetic, contributes to a smooth intraoperative course for patients.

Immediate Extubation in the Operating Room Following Pediatric Liver Transplantation: A Retrospective Cohort Study

BACKGROUND

Although immediate extubation in the operating room following pediatric liver transplantation can be safe and beneficial for select patients, many surgeons and anesthesiologists are still cautious. The study aimed to evaluate the safety and efficiency of immediate extubation in the operating room following pediatric liver transplantation.

METHODS

Sixty-four pediatric liver transplant recipients were included in this retrospective study. Patients were divided into 2 groups: immediate extubation (IE) (those who were extubated in the operating room) and delayed extubation (DE) (those who were extubated in the intensive care unit). Preoperative, intraoperative, and postoperative variables were recorded.

RESULTS

Although a total of 19 (29.7%) patients were extubated in the pediatric intensive care unit (group DE), 45 (70.3%) were extubated in the operating room at the end of surgery (group IE). The use of fresh frozen plasma and platelets was statistically higher in group DE (P = .017 and P = .002, respectively). Duration of anesthesia and length of stay in the pediatric intensive care unit was statistically longer in group DE (P = .020 and P = .0001, respectively). Three (15.8%) patients required reintubation in group DE and 2 (4.4%) in group IE. Hospital stay was statistically longer in group DE (P = .012).

CONCLUSIONS

The current study demonstrated that immediate extubation in the operating room after surgery for pediatric patients who have undergone liver transplantation was safe. The duration of anesthesia and the intraoperative use of blood products such as platelet and fresh frozen plasma can effectively decide immediate extubation.

Comparison of plasma neutrophil gelatinase-associated lipocalin (NGAL) levels after robot-assisted laparoscopic and retropubic radical prostatectomy: an observational study

Background and objectives

Patients undergoing radical prostatectomy are at increased risk of Acute Kidney Injury (AKI) because of intraoperative bleeding, obstructive uropathy, and older age. Neutrophil Gelatinase-Associated Lipocalin (NGAL) may become important for diagnosis of postoperative AKI after urogenital oncosurgery. The objective of this study was to evaluate and compare the efficacy of NGAL as a predictor of AKI diagnosis in patients who underwent Retropubic Radical Prostatectomy (RRP) and Robot-Assisted Laparoscopic Prostatectomy (RALP) for prostate cancer.

Methods

We included 66 patients who underwent RRP (n = 32) or RALP (n = 34) in this prospective, comparative, nonrandomized study. Patients’ demographic data, duration of surgery and anesthesia, amount of blood products, vasopressor therapy, intraoperative blood loss, fluid administration, length of hospital stay, creatinine, and plasma NGAL levels were recorded.

Results

Intraoperative blood loss, crystalloid fluid administration, and length of hospital stay were significantly shorter in RALP. There was no statistically significant difference between the groups in terms of intraoperative blood transfusion. Postoperative creatinine and plasma NGAL levels were increased in both groups. The 6-h NGAL levels were higher in RRP (p = 0.026). The incidence of AKI was 28.12% in RRP and 26.05% in RALP, respectively. The NGAL level at 6 hours was more sensitive in the early diagnosis of AKI in RALP.

Conclusion

Although postoperative serum NGAL levels were increased in both RRP and RALP, the 6-h NGAL levels were higher in RRP. RALP was associated with fewer intraoperative blood loss and fluid administration, and shorter length of hospital stay.

Regional anesthesia in two consecutive surgeries in a patient with mitochondrial neurogastrointestinal encephalomyopathy: a case report

Mitochondrial Neurogastrointestinal Encephalomyopathy (MNGIE) is a rare autosomal-recessive disorder which is due to mutations in TYMP. The case reported here is of an 18-year-old male with MNGIE syndrome who presented for two different operations on two different occasions under regional anesthesia. The patient presented with urinary incontinence and abdominal pain. A cystoscopy under spinal anesthesia was scheduled. At 3 months after discharge, gastric perforation was diagnosed and combined spinal-epidural anesthesia, surgical repair was planned. Surgical and perioperative periods were uneventful. Based on this experience, we believe that regional anesthesia can be considered safe for use in patients with MNGIE disease.

[Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial]

BACKGROUND

It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity.

OBJECTIVES

To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery.

METHODS

Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5 minutes after induction, 30 minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O₂ pressure/fractional O₂ ratio, and alveolar-arterial oxygen gradient pressure were calculated.

RESULTS

Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses.

CONCLUSIONS

Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.

Comparison of volume-controlled and pressure-controlled ventilation on respiratory mechanics in laparoscopic bariatric surgery: randomized clinical trial

Background

It is not clear which mechanical ventilation mode should be used in bariatric surgery, one of the treatment options for patients with obesity.

Objectives

To compare volume-controlled ventilation and pressure-controlled ventilation in terms of respiratory mechanics and arterial blood gas values in patients undergoing laparoscopic bariatric surgery.

Methods

Sixty-two patients with morbid obesity scheduled for gastric bypass were included in this study. Their ideal body weights were calculated during preoperative visits, and patients were divided into two groups, volume-controlled ventilation and pressure-controlled ventilation. The patients were ventilated in accordance with a previously determined algorithm. Mechanical ventilation parameters and arterial blood gas analysis were recorded 5minutes after induction, 30minutes after pneumoperitoneum, and at the end of surgery. Also, the dynamic compliance, inspired O₂ pressure/fractional O₂ ratio, and alveolar-arterial oxygen gradient pressure were calculated.

Results

Peak airway pressures were lower in patients ventilated in pressure-controlled ventilation mode at the end of surgery (p = 0.011). Otherwise, there was no difference between groups in terms of intraoperative respiratory parameters and arterial blood gas analyses.

Conclusions

Pressure-controlled ventilation mode is not superior to volume-controlled ventilation mode in patients with laparoscopic bariatric surgery.

Minimum effective volume of bupivacaine 0.5% for ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block

Background and objectives

The current study aimed to determine the minimum effective volume (MEV) of bupivacaine 0.5% in 50% of patients for an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block.

Methods

A total of 25 adult patients who were scheduled for upper limb surgery received an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block with bupivacaine 0.5%. The needle insertion point was posterior to the clavicle and the needle was advanced from cephalad to caudal. Block success was defined as a composite score of 14 at 30 min after local anesthetic (LA) injection. The minimum effective volume in 50% of patients was determined using the Dixon-Massey up-and-down staircase method. Minimum effective volume for a successful block in 95% of the patients was also calculated using logistic regression and probit transformation.

Results

The minimum effective volume of bupivacaine 0.5% resulting in successful block in 50% of patients (MEV50) according to the up-and-down staircase method was found to be 9.6 mL (95% confidence interval (CI), 5.7–13.4). The calculated minimum effective volume required for a successful block in 95% of patients (MEV95) using the probit transformation and logistic regression analysis was 23.2 mL (95% CI, 18.8–36.7).

Conclusions

The MEV50 of bupivacaine 0.5% for US-guided retroclavicular approach to infraclavicular brachial plexus block was 9.6 mL and the calculated MEV95 was 23.2 mL. Future studies are required for infraclavicular brachial plexus block with different approaches, other LA agents and different concentrations of bupivacaine.

[Minimum effective volume of bupivacaine 0.5% for ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block]

BACKGROUND AND OBJECTIVES

The current study aimed to determine the minimum effective volume (MEV) of bupivacaine 0.5% in 50% of patients for an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block.

METHODS

A total of 25 adult patients who were scheduled for upper limb surgery received an ultrasound-guided retroclavicular approach to infraclavicular brachial plexus block with bupivacaine 0.5%. The needle insertion point was posterior to the clavicle and the needle was advanced from cephalad to caudal. Block success was defined as a composite score of 14 at 30min after local anesthetic (LA) injection. The minimum effective volume in 50% of patients was determined using the Dixon-Massey up-and-down staircase method. Minimum effective volume for a successful block in 95% of the patients was also calculated using logistic regression and probit transformation.

RESULTS

The minimum effective volume of bupivacaine 0.5% resulting in successful block in 50% of patients (MEV50) according to the up-and-down staircase method was found to be 9.6mL (95% confidence interval (CI), 5.7-13.4). The calculated minimum effective volume required for a successful block in 95% of patients (MEV95) using the probit transformation and logistic regression analysis was 23.2mL (95% CI, 18.8-36.7).

CONCLUSIONS

The MEV50 of bupivacaine 0.5% for US-guided retroclavicular approach to infraclavicular brachial plexus block was 9.6mL and the calculated MEV95 was 23.2mL. Future studies are required for infraclavicular brachial plexus block with different approaches, other LA agents and different concentrations of bupivacaine.

[Determination of residual mass in left ventricle by intraoperative transesophageal echocardiography after a giant and floating left atrial myxoma resection]

Atrial myxoma is a benign tumor of the heart that occurs primarily in the left atrium. Floating or large left atrial myxomas frequently cause functional mitral stenosis, may also affect mitral valve structure and flow, and lead to mitral regurgitation. Systemic embolization occurs in around 30% of cases either from tumor fragmentation or complete tumor detachment hence it should be removed as soon as it is detected. Intraoperative transesophageal echocardiography has a vital importance in the surgery. After resection of myxoma, intraoperative transesophageal echocardiography must be performed to rule out residual mass. The case here reported is of a 48-year old female, who presented with giant and floating left atrial myxoma. Residue mass was detected with intraoperative transesophageal echocardiography in the left ventricle after the resection of myxoma. Subsequently, the residue mass was successfully removed. Complete resection must be required to prevent possible complications such as recurrence, embolization in atrial myxomas. Transesophageal echocardiography performed intraoperatively is vital importance to confirm that the myxoma is completely resected.

A Randomized Controlled Trial Examining the Effect of the Addition of the Mandibular Block to Cervical Plexus Block for Carotid Endarterectomy

OBJECTIVES

Although the cervical plexus block generally provides adequate analgesia for carotid endarterectomy, pain caused by metal retractors on the inferior surface of the mandible is not prevented by the cervical block. Different pain relief methods can be performed for patients who experience discomfort in these areas. In this study, the authors evaluated the effect of mandibular block in addition to cervical plexus block on pain scores in carotid endarterectomy.

DESIGN

A prospective, randomized, controlled trial.

SETTING

Training and research hospital.

PARTICIPANTS

Patients who underwent a carotid endarterectomy.

INTERVENTIONS

Patients scheduled for carotid endarterectomy under cervical plexus block were randomized into 2 groups: group 1 (those who did not receive a mandibular block) and group 2 (those who received a mandibular block). The main purpose of the study was to evaluate the mandibular block in addition to cervical plexus block in terms of intraoperative pain scores.

MEASUREMENTS AND MAIN RESULTS

Intraoperative visual analog scale scores were significantly higher in group 1 (p = 0.001). The amounts of supplemental 1% lidocaine and intraoperative intravenous analgesic used were significantly higher in group 1 (p = 0.001 and p = 0.035, respectively). Patient satisfaction scores were significantly lower in group 1 (p = 0.044). The amount of postoperative analgesic used, time to first analgesic requirement, postoperative visual analog scale scores, and surgeon satisfaction scores were similar in both groups. There was no significant difference between the groups with respect to complications. No major neurologic deficits or perioperative mortality were observed.

CONCLUSIONS

Mandibular block in addition to cervical plexus block provides better intraoperative pain control and greater patient satisfaction than cervical plexus block alone.

[Comparison of different methods of nasogastric tube insertion in anesthetized and intubated patients]

BACKGROUND

Nasogastric tube insertion may be difficult in anesthetized and intubated patients with head in the neutral position. Several techniques are available for the successful insertion of nasogastric tube. The primary aim of this study was to investigate the difference in the first attempt success rate of different techniques for insertion of nasogastric tube. Secondary aim was to investigate the difference of the duration of insertion using the selected technique, complications during insertion such as kinking and mucosal bleeding.

MATERIAL AND METHODS

200 adult patients, who received general anesthesia for elective abdominal surgeries that required nasogastric tube insertion, were randomized into four groups: Conventional group (Group C), head in the lateral position group (Group L), endotracheal tube assisted group (Group ET) and McGrath video laryngoscope group (Group MG). Success rates, duration of insertion and complications were noted.

RESULTS

Success rates of nasogastric tube insertion in first attempt and overall were lower in Group C than Group ET and Group MG. Mean duration and total time for successful insertion of NG tube in first attempt were significantly longer in Group ET. Kinking was higher in Group C. Mucosal bleeding was statistically lower in Group MG.

CONCLUSION

Use of video laryngoscope and endotracheal tube assistance during NG tube insertion compared with conventional technique increase the success rate and reduce the kinking in anesthetized and intubated adult patients. Use of video laryngoscope during nasogastric tube insertion compared to other techniques reduces the mucosal bleeding in anesthetized and intubated adult patients.

Use of McGrath MAC Videolaryngoscope to Assist Transesophageal Echocardiography Probe Insertion in Intubated Patients

OBJECTIVES

Transesophageal echocardiography (TEE) probe insertion with the conventional blind insertion technique may be difficult in anesthetized and intubated patients. The use of a videolaryngoscope may facilitate the insertion of the TEE probe. The aim of this study was to compare the conventional technique with the use of the McGrath MAC videolaryngoscope for TEE probe insertion in terms of success rate, duration of insertion, and complications in patients undergoing cardiovascular surgery.

DESIGN

A prospective, randomized study.

SETTING

Training and research hospital.

PARTICIPANTS

Eighty-six adult patients undergoing cardiovascular surgery were included.

INTERVENTIONS

Eighty-six adult patients were randomized into 2 groups: conventional group (n = 43) and McGrath videolaryngoscope group (n = 43). Success rates, duration of insertion, complications, and hemodynamic changes during insertion were recorded.

MEASUREMENTS AND MAIN RESULTS

The success rate of TEE probe insertion at the first attempt was higher in the McGrath videolaryngoscope group (90.5%) than in the conventional group (43.9%) (p = 0.012). The mean duration for successful insertion of the TEE probe at the first attempt was longer in the McGrath videolaryngoscope group (24 s v 11 s) (p = 0.016). The total time for successful insertion of the TEE probe was similar in both groups. Pharyngeal injuries were observed more frequently in the conventional group (17.1% v 2.4%) (p = 0.037). The rate of blood presence on the probe tip in the conventional group was higher than in the McGrath group (21.9% v 4.8%). There were no statistical differences between the 2 groups in systolic blood pressure, mean arterial pressure, diastolic blood pressure, and heart rate before and after TEE insertion.

CONCLUSIONS

The use of the McGrath MAC videolaryngoscope for TEE insertion in cardiovascular surgery patients increases the success rate and reduces pharyngeal injuries compared to the conventional technique. The use of the McGrath MAC videolaryngoscope for TEE insertion causes similar hemodynamic changes as in the conventional blind insertion technique.