Turkish journal of anaesthesiology and reanimation最新文献

Neonatal severe hyperparathyroidism (NSHPT) is an extremely rare disorder with uncontrolled severe hypercalcemia and its clinical manifestations. It is caused by a mutation in the calcium-sensing receptor (CaSR) gene, which modulates the negative feedback of parathormone. We present anaesthetic management of two children with NSHPT who were posted for total parathyroidectomy as a life saving procedure. Both patients presented with lethargy, failure to thrive, and hypotonia. Intraoperative anaesthetic challenges include susceptibility to bradycardia, prolonged QT interval, precipitation of hypercalcemic crisis in the form of renal failure, hyperkalemia and electrocardiography changes, unpredictable response to neuromuscular blockade, susceptibility to recurrent laryngeal nerve injury, refractory hypocalcemia, which may start developing within six hours after surgery. Anaesthetic goals include preoperative optimisation of serum calcium with subcutaneous. Calcitonin, intravenous pamidronate and tablet cinacalcet, which are calcimimetics, maintenance of hydration and readiness to deal with intraoperative hypercalcemic crises. Anaesthetic management of NSHPT posted for total parathyroidectomy is challenging. To the best of our knowledge, there is no anaesthetic literature published to this day and only four surgical cases have been reported. Genome sequencing in both patients showed a CaSR gene mutation that is homozygous for a suspected pathogenic variant. Management requires a preoperative multidisciplinary approach for severe hypercalcemia and postoperative refractory hypocalcemia. These patients need lifelong calcium and vitamin D supplementation.

Objective: Postoperative pain control after hypospadias surgery can be challenging, and the effectiveness of caudal block (CB) for analgesia is limited. This study evaluated the analgesic efficacy of pudendal nerve block (PNB) using both ultrasound and a peripheral nerve stimulator (PNS), compared to a CB performed using landmark guidance, in paediatric patients undergoing hypospadias surgical repair.

Methods: A total of 40 patients scheduled for hypospadias surgery were included in this prospective, randomized, double-blind controlled trial, who received either a PNB or a CB. Patients in the pudendal group received an ultrasound- and PNS-guided, PNB with a combination of bupivacaine (0.25%) at a dose of 0.5 mL kg^-1 and clonidine at a dose of 1 μg kg^-1, whereas those in the caudal group received a landmark-guided CB with bupivacaine (0.25%) at a dose of 1 mL kg^-1 along with clonidine at a dose of 1 μg kg^-1. The objective pain scale (OPS) was used to assess pain intensity in each group within 24 hours post-surgery. Perioperative hemodynamic changes and analgesic requirements were also recorded.

Results: The CB provided effective analgesia, lasting an average of 6 hours. OPS scores at 6, 12, 18, and 24 hours after surgery were significantly lower in the PNB group than in the CB group. The PNB group had a significantly longer time to the need for initial analgesia, while the CB group required a significantly greater dose of paracetamol after surgery (P < 0.001).

Conclusion: Findings from this study suggest that, at these doses, PNB is more effective than CB in providing longer-lasting pain relief, significantly lower pain scores, and a reduced need for postoperative analgesics.

Objective: To evaluate the cardiopulmonary effect during prone position (PP) on right ventricular (RV) recovery in coronavirus disease-2019 related acute respiratory distress syndrome (C-ARDS) through transesophageal echocardiography (TEE).

Methods: This prospective study included 30 moderate-to-severe C-ARDS patients who were treated with PP in the first 48 h of invasive mechanical ventilation support. It was evaluated with TEE three times: before PP (T₀f), the first hour of PP (T₁), and the first hour of returning to the supine position (T₀ + 24 h) (T₂) after 23 hours of PP treatment. RV end-diastolic area/left ventricular (LV) end-diastolic area (RVEDA/LVEDA), tricuspid annular plane systolic excursion (TAPSE) and LV end-systolic eccentricity index were preferred RV evaluations as primary outcomes. Pulmonary effects of PP were evaluated as a secondary outcome, including PaO₂/FiO₂, driving pressure (dP), static compliance (Cstat), mechanical ventilation parameters, and their association with 28-day survival. Tissue DO₂ was examined as a secondary outcome, and it was calculated using the measured cardiac output through TEE.

Results: With the cardiopulmonary effect of PP, the decrease in RVEDA/LVEDA, the increase in TAPSE, PaO₂/FiO₂, and Cstat, and the decrease in dP were statistically significant (P < 0.05). The Cstat value associated with 28-day survival showed decreased mortality for each unit increase. The Cstat cut-off value, which was statistically significant for survival, was 37.

Conclusion: PP can improve RV recovery and oxygenation, but it isn't always accompanied by increased survival. An increase in the Cstat may improve survival without the development of RV dysfunction while maintaining heart-lung interaction.

Objective: Aspiration of gastric contents during induction of anaesthesia is a rare but well-recognized complication with high morbidity and mortality risk. Patients at highest risk include those with full stomachs, diabetes, hiatal hernias, gastrointestinal obstructions, severe gastroesophageal reflux, and known delayed gastric emptying. Recently, the use of glucagon-like peptide-1 (GLP-1) agonists has expanded rapidly, including their application in cosmetic weight loss. This drug class suppresses glucagon release after meals, thereby delaying gastric emptying over an undefined duration. For patients taking these medications in the perioperative period, the effect on overall aspiration risk is unknown. This survey details the current practice pattern of anaesthesiologists regarding GLP-1 agonists.

Methods: An IRB-approved 30-question, uncompensated survey was distributed to 30,096 self-reported actively practicing United States members of the American Society of Anesthesiologists (ASA). The survey collected demographic information, practice information, and included questions about the management of patients taking GLP-1 agonists. To ensure participant confidentiality, no identifiable information was collected.

Results: The survey response rate was 5.98%, with 1,801 surveys returned. Ninety-seven percent of respondents indicated familiarity with GLP-1 agonists, and eighty-one percent indicated they had not personally witnessed complications in patients taking GLP-1 agonists. Most respondents indicated perioperative aspiration as the largest concern and the most commonly reported witnessed complication. 62% reported having "some" to "a lot" of experience providing anaesthesia to patients taking these medications. Most respondents reported NPO guidelines consistent with current ASA practice guidelines.

Conclusion: The majority of anaesthesiologists report perioperative aspiration as their highest concern for patients taking this class of medications.

We present a case series using a hybrid technique of video laryngoscope-assisted flexible bronchoscopy to facilitate endotracheal intubation in children with anticipated difficult airway. This series describes the management of difficult airways in four paediatric cases using the hybrid technique: two cases of Apert syndrome scheduled for cranial remodelling with orbito-facial advancement, one case of an incomplete cleft palate and retrognathia scheduled for palatoplasty, and another case of Parry Romberg syndrome scheduled for a reconstructive procedure. This case series aims to highlight the value of the hybrid technique as a safe and effective intubation modality in paediatric difficult airways.

Objective: In the paediatric population, the selection of an appropriately sized endotracheal tube (ETT) is extremely important not only to ensure adequate ventilation but also to avoid post-extubation stridor and stenosis. Conventionally, formulas based on age, height, or weight are used to determine the most appropriate size. In this study, we compared ultrasonography (USG) and age-based formula for predicting the best microcuff ETT size in paediatric patients aged 1-5 years.

Methods: One hundred eighteen patients, aged 1 to 5 years, with American Society of Anesthesiologists, classifications of I or II, were included. After standard general anaesthesia protocols, the subglottic diameter was assessed by USG. Intubation was performed using ETT size according to age-based formula. The best clinical fit was determined after the leak test. The internal and external diameters of the ETTs were predicted by both methods and correlated with the best-fit ETT sizes used during the procedures using Pearson's correlation. Cohen's kappa was used for statistical agreement between two methods.

Results: USG had a significantly higher correlation with the best-fit model as compared to the age-based formula, with 99.2% and 77.1% agreement rates. The best-fit ETT showed a better correlation with the USG-guided estimate (r = 0.994, P < 0.001). The Cohen's Kappa value of 0.986 showed a statistically significantly higher agreement between USG-guided estimate and best-fit ETT.

Conclusion: USG-guided estimation of subglottic diameter is a better predictor for optimally sized microcuff ETT than the age-based formula in the paediatric age group of 1-5 years. 22% of tube changes could have been prevented with ultrasound-guidance as a primary approach for estimating ETT size.

Paediatric neurosurgery has seen significant increases and improvements because of advancements in technology and monitoring techniques. This type of surgery presents unique challenges to the anaesthesiology team because of the general characteristics of paediatric patients and the complexity of the procedures. Managing paediatric patients undergoing complex neurosurgery requires profound knowledge of age-related normal physiology and the principles of common paediatric neuroanaesthesia. This review focuses on updated information about various critical topics in paediatric neurophysiology, bleeding management, acute pain treatment, intraoperative neuromonitoring, the specifics of the sitting position, and the general principles of paediatric neuroanaesthesia.

Multiple endocrine neoplasia type 2A (MEN2A), is associated with pheochromocytoma and medullary carcinoma of the thyroid. A surgical procedure in these patients can be complicated if they have any congenital heart disease (CHD). Nowadays, CHD patients are increasingly presenting at advanced age for non-cardiac surgeries, posing unique challenges to anesthesiologists. We hereby present a 44-year-old male with Eisenmenger syndrome (ES) and MEN2A, scheduled for bilateral adrenal excision and thyroidectomy. Patients with ES require meticulous and goal-directed management during non-cardiac surgery, depending upon pulmonary hypertension, cyanosis, and right ventricular dysfunction.

Objective: Delirium is a common condition that can significantly worsen a patient's clinical status. Timely and accurate detection of this often-overlooked condition is essential for effective prevention and treatment. This study aims to validate the Turkish version of the 3-Minute Diagnostic Interview for Confusion Assessment-defined Delirium (3D-CAM-TR), which has been culturally adapted for surgical intensive care patients.

Methods: This study was conducted in surgical intensive care units and wards at three academic hospitals, including 133 surgical intensive care patients. The 3D-CAM was culturally adapted and translated into Turkish. The 3D-CAM-TR was administered by trained clinicians from the first to the third postoperative day. During this period, delirium diagnosis was made by experienced psychiatrists using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria as the reference standard. All assessors were blinded to each other's assessment results. The 3D-CAM delirium diagnosis was compared with the reference standard in all patients.

Results: A total of 133 adult patients were assessed over three consecutive days, findings in 399 paired assessments. Compared to the DSM- 5-based reference standard, the sensitivity and specificity of the 3D-CAM-TR assessment were found to be 95% and 97%, respectively, for rater 1, and 93% and 99%, respectively, for rater 2, with good inter-rater reliability (Kappa coefficient=0.898, confidence interval=0.84, 0.96).

Conclusion: Our resultings indicate that the 3D-CAM-TR is a dependable and precise instrument for assessing delirium in postoperative intensive care patients.