Turk J Anaesthesiol Reanim: 47 (2)
Volume: 47  Issue: 2 - April 2019
Hide Abstracts | << Back
REVIEW
1.Understanding the Harms of HES: A Review of the Evidence to Date
M.Necmettin Ünal, Konrad Reinhart
doi: 10.5152/TJAR.2019.72681  Pages 81 - 91
İntravenöz (İV) sıvı resüsitasyonu, yoğun bakımda en sık yapılan girişimlerden birisidir. Son derece açık kılavuzlar mevcut olmasına karşın; İV sıvı seçimi, yüksek kaliteli etkinlik ve güvenlik kanıtı yerine büyük oranda hekimin tercihine bağlıdır. Bu özellikle hidroksietil nişasta (HES) gibi sentetik kolloidler için geçerlidir. Yoğun bakımlarda HES kullanımı artmış akut böbrek hasarı (AKI), renal replasman tedavisi (RRT) ve mortalite ile ilişkili bulunmuştur. Bu bulgulara dayanarak mevcut kılavuzlar, bilimsel ve mevzuatı düzenleyici kuruluşlar kritik hastalıklarda sıvı tedavisi için HES kullanımını önermemekte ve bir çok farklı durumda kullanımı içinde önlem almayı önermektedir. Buna rağmen HES kullanımı hala tartışılmakta ve kullanılmaya devam edilmektedir.
İV sıvıların endikasyon, kontrendikasyon, doz, fayda ve yan etkilerinin yanı sıra bilimsel ve mevzuatı düzenleyen kuruluşların önerilerinin bilinmesi, hasta güvenliğinin sağlanması için gereklidir. Türkiyenin de dahil olduğu bazı ülkelerde optimal İV sıvı tedavisi konusunda farkındalığın yetersiz olduğu ortaya çıkmıştır. Bu nedenle, sıvı tedavisi farkındalığını arttırmak için bu derlemede resusitasyon için kullanılan sıvılar gözden geçirildi; HES’lerin güvenlik verileri, artmış AKI ve mortalite gibi yan etkileri, bilimsel ve mevzuat düzenleyen kuruluşlarının konu ile alakalı en son güncellemeleri tartışıldı. Sonuç olarak, HES’in hiç bir klinik durumda belirgin bir yararı olmadığı, kristaloidler ve albumin gibi daha güvenli alternatiflerinin olduğu göz önüne alınarak HES’lerin kullanımından kaçınılmalıdır.
Intravenous (IV) fluid resuscitation is one of the most common interventions in intensive care medicine. Despite clear guidelines, the choice of IV fluid is largely dependent on physician preference instead of high-quality evidence of efficacy and safety. This is particularly the case for synthetic colloids, such as hydroxyethyl starch (HES). The use of HES in critical care has been associated with increased rates of acute kidney injury (AKI), renal replacement therapy and mortality. In light of this, current guidelines and scientific and regulatory bodies do not recommend the use of HES for fluid therapy in critical illness and caution against its use in many other settings. Despite this, HES products are still debated and used. Awareness of the indications, contraindications, doses, benefits and adverse effects for IV fluids, as well as recommendations from scientific and regulatory bodies, is essential to guarantee patients’ safety. Poor awareness of optimal IV fluid therapy has recently been revealed in some countries including Turkey. Therefore, we provide a review of fluids used for resuscitation, discuss safety data and adverse effects of HES, such as increased AKI and mortality, and discuss recent updates from scientific and regulatory bodies in order to raise awareness of fluid therapy. We conclude that given the lack of a clear benefit of HES in any clinical setting and the availability of safer alternatives, such as crystalloids and albumin, HES should be avoided.

CLINICAL RESEARCH
2.Effects of General Anaesthesia on the Middle Ear Pressure
Engin Deniz, Sevtap Hekimoğlu Şahin, Necdet Süt
doi: 10.5152/TJAR.2018.52284  Pages 92 - 97
Amaç: İnhalasyon ajanları orta kulak basıncına (MEP) değişen derecelerde etkilere sahip olabilir. Genel anestezi altında cerrahi uygulanan, herhangi bir kulak patolojisi olmayan hastalarda kullanılan sevofluran ve desfluranın MEP üzerine etkisini araştırmayı amaçladık.
Yöntemler: Çalışmamıza inguinal herni ve alt ekstremite cerrahisi geçirecek 50 erişkin hasta dahil edildi. Tüm hastalar 20-60 yaşları arasındaydı ve ASA I-III sınıfına aitti. Hastalar ameliyat için uygulanan inhalasyon ajanına göre iki gruba ayrıldı; Sevofluran, Grup S (n = 25) ve Desfluran, Grup D (N = 25). Anestetik ajanlar, intraoperatif soluk sonu karbon dioksit ve hava yolu basınçları kaydedildi. Preoperatif her iki kulak için MEP, intraoperatif 5., 10., 15. dakika ve postoperatif 10. 30. dakikalarda ölçüldü.
Bulgular: İntraoperatif 10. Dakikadaki MEP, Grup D'de Grup S'ye göre anlamlı olarak daha yüksek bulundu. Grup D'de preoperatif değerlere göre ameliyat sonrası 30. dakikada ve intraoperatif 10., 15. dakikalarda MEP anlamlı olarak artmış bulundu. Grup S 'de ise preoperatif değerlere göre postoperatif 10. dakikada MEP anlamlı olarak artmış bulundu.
Sonuç: Desofluranın intraoperatif ve postoperatif dönemde sevofluran ile kıyaslandığında MEP'yi artırdığıbulundu
Objective: Inhalation agents can have different effects on the middle ear pressure (MEP). We aimed to investigate the effect of sevoflurane and desflurane, the agents used in patients who do not have any ear pathology and who undergo surgery under general anaesthesia, on MEP.
Methods: Fifty adult patients who were scheduled to undergo inguinal hernia and lower extremity surgery were included in our study. All patients were aged between 20 and 60 years and belonged to the American Society of Anesthesiologists (ASA) I-III class. Patients were divided into two groups, according to the inhalation agent administered for the surgery: sevofluran, Group S (n=25); and desfluran, Group D (n=25). Anaesthetic agents, intraoperative end tidal carbon dioxide and airway pressures were recorded. The MEP was measured for both ears preoperatively, at the intraoperative 5th, 10th, 15th minutes, and at the postoperative 10th and 30th minutes.
Results: The MEP at the intraoperative 10th minute was significantly higher in Group D compared to Group S. In Group D, the MEP increased significantly at the intraoperative 10th and 15th minutes, and postoperative 30th minute, compared to preoperative values. In Group S, the MEP increased significantly at the postoperative 10th minute, compared to preoperative values.
Conclusion: We found that desflurane increases the MEP during the intraoperative and postoperative period, compared to sevoflurane.

3.Effect of Coagulation Status and Co-Morbidity on Flap Success and Complications in Patients with Reconstructed Free Flap
Yusufcan Ekin, İlkben Günüşen, Özlem Yakut Özdemir, Yiğit Özer Tiftikçioğlu
doi: 10.5152/TJAR.2019.07752  Pages 98 - 106
Amaç: Geniş defekti olan hastalarda serbest flep operasyonları rekonsrüktif cerrahinin temelini oluşturur. Bu hastalarda flep kaybına neden olan komplikasyonların önceden tahmin edilmesi hastanede kalış süresi ve maliyeti azaltma açısından çok önemlidir. Çalışmamızda hastaların koagülasyon durumlarının ve komorbiditelerinin flep kaybına ve komplikasyonlara olan etkilerini retrospektif olarak incelemeyi amaçladık.
Yöntemler: Ocak 2015-Haziran 2017 tarihleri arasında serbest flep uygulanan hastaların preoperatif, intraoperatif ve postoperatif dönemdeki anestezi ve cerrahi kayıtlarından demografik verileri, sigara, alkol alışkanlıkları, yandaş hastalıkları, laboratuar tetkiklerinden koagülasyon testleri ve TEG (tromboelastogram) sonuçları geriye dönük olarak tarandı.
Bulgular: Serbest flep uygulanan toplam 77 hastada flep başarı oranının %96,1; tromboz, hematom ve parsiyel nekroz gibi koagülasyonla ilişkili komplikasyon oranının ise %22,1 olduğu görüldü. Yaş, kronik obstrüktif akciğer hastalığı (KOAH) ve hiperkolesterolemi ile flep kaybı arasında anlamlı bir ilişki vardı (sırasıyla p=0,006, p=0,025 ve p=0,025). Flep komplikasyonlarının KOAH ve hipertansiyonu olan hastalarda daha sık görüldüğü belirlendi. Laboratuar tetkikleri incelendiğinde ise preoperatif ve postoperatif TEG ile flep komplikasyonları ve flep kaybı arasında istatistiksel bir ilişki saptanmadı. Ancak preoperatif INR’ nin hematom oluşumu ve flep kaybıyla, postoperatif aPTZ’nin ise sadece flep kaybı ile ilişkili olduğu görüldü.
Sonuç: Serbest flep cerrahisinde ileri yaşın, hipertansiyon ve KOAH gibi yandaş hastalıkların komplikasyonlar ve flep kaybıyla ilişkili olduğu görüldü. Ancak koagülasyonu gösteren laboratuar tetkikleriyle komplikasyonlar ve flep kaybı arasında klinik açıdan anlamlı bir ilişki saptanamadı. Bu tür cerrahilerde koagülasyon testlerinin alınma zamanlarının ve postoperatif antikoagülan uygulamalarının standardize edilmesi gerektiği ve bu nedenle operasyona hazırlık, intraoperatif yönetim ve postoperatif takipler açısından standart protokollerin oluşturulması gerektiği düşüncesindeyiz.
Objective: Free flap surgeries constitute the basis of reconstruction surgery in patients with major defects. Prediction of complications that cause flap loss in such patients is important in terms of reducing the length of hospital stay and expenses. We aimed to retrospectively investigate the effect of co-morbidities and the coagulation status on flap loss and complications in patients with reconstructed free flap.
Methods: Demographic data, smoking, alcohol habits, co-morbidities, coagulation tests and thromboelastogram results from preoperative, intraoperative and postoperative anaesthesia and surgical records of patients undergoing free flap surgeries between January 2015 and June 2017 were retrospectively screened.
Results: Flap success rate was found to be 96.1% in total 77 patients with free flap. Coagulation related complication rate, such as thrombosis, haematoma and partial necrosis, were 22.1%. There was a significant relationship between age, chronic obstructive pulmonary disease and hypercholesterolaemia and flap loss (p=0.006, p=0.025 ve p=0.025, respectively). Flap complications were more frequent in patients with chronic obstructive pulmonary disease and hypertension. Laboratory test results revealed no statistical correlation between flap complications and flap loss with preoperative and postoperative TEG.
Conclusion: Advanced age, co-morbidities such as hypertension and chronic obstructive pulmonary disease are associated with complications and flap loss in free flap surgery. However, there were no clinically significant association of complications and flap loss with laboratory tests showing coagulation. We believe that standardised protocols should be established in terms of preparation, intraoperative management and postoperative follow-ups because the time between taking the coagulation tests and postoperative anticoagulant administration should be standardised in such surgeries.

4.Influence of a Tourniquet on Opioid Consumption After Local Infiltration Analgesia for Total Knee Arthroplasty
Sietske M. K. Bakker, Nienke M. Kosse, Sakib Crnic, Gert-jan Scheffer, Rudolf Stienstra
doi: 10.5152/TJAR.2019.30906  Pages 107 - 111
Objective: Local infiltration analgesia (LIA) with ropivacaine is increasingly used to provide postoperative analgesia after total knee arthroplasty (TKA). TKA may be performed with or without the use of a tourniquet. The absence of local blood flow when infiltrating local anaesthesia below an inflated tourniquet may affect the rate of systemic absorption, and this may have an effect on the duration and intensity of analgesia as compared with LIA without the use of a tourniquet. The aim of the present study was to investigate the influence of tourniquet use during surgery on the time to first request (TTFR) of opioids and opioid consumption.
Methods: Two historical time-based cohorts (one with and one without tourniquet during surgery) of 300 patients underwent primary TKA under spinal anaesthesia and received LIA to provide postoperative analgesia. The cohorts were compared for TTFR of opioids and opioid consumption.
Results: TTFR did not significantly differ between the tourniquet and non-tourniquet groups with a median (25th-75th percentile) of 240 (102-651) and 282 (100-720) min, respectively. The median (25th-75th percentile) oxycodone use was higher in the tourniquet group with 50 (20-90) versus 40 (10-77.5) mg (p=0.01).
Conclusion: There was no difference in the time to first opioid consumption, suggesting that the presence of an inflated tourniquet during local anaesthetic injection does not alter systemic absorption sufficiently to affect the duration of analgesia. However, the use of a tourniquet was associated with a higher opioid consumption, which is most likely caused by pain resulting from the tourniquet itself.

5.Retrospective Analysis of Eighty-Nine Caesarean Section Cases with Abnormal Placental Invasion
Feride Karacaer, Ebru Biricik, Murat Ilgınel, Demet Tunay, Mete Sucu, Hakkı Ünlügenç
doi: 10.5152/TJAR.2018.31799  Pages 112 - 119
Amaç: Plasentanın miyometriyuma patolojik bir şekilde bağlanması anormal invazif plasentasyon (AİP) olarak adlandırılır. Doğum öncesi tanı koyulmamış AİP, doğum sırasında katastrofik hemorajilerle sonuçlanabilmektedir. Çalışmamızda, preoperatif dönemde AİP tanısı konmuş olgulardaki anestezi ve cerrahiye ilişkin verilerin retrospektif olarak araştırılması amaçlanmıştır.
Yöntemler: Kliniğimizde Nisan 2010 ve Şubat 2017 yılları arasında AİP nedeniyle sezaryen operasyonu geçiren 89 hastanın dosyaları ve anestezi kayıt formları retrospektif olarak incelendi.
Bulgular: AİP tanısı almış olgulardan 87’sinde (%97,8) geçirilmiş sezaryen öyküsü ve 68’inde (%76,4) plasenta previa tanısı mevcuttu. Regresyon analizinde eritrosit süspansiyonu (ES) (r=0,420, p=0,001) ve taze donmuş plazma (TDP) (r=0,476, p=0,022) tüketimindeki artış ile hastanede kalış süresi arasında zayıf pozitif korelasyon saptandı. Yoğun bakım ünitesine (YBÜ) çıkarılan hastaların ES ve TDP tüketimi, çıkarılmayanlara göre daha yüksekti (p<0,001). Ortalama sıvı tüketiminin üzerinde kristalloid (p=0,004) ve kolloid (p<0,001) kullanılan hastalarda postoperatif YBܒne gereksinim daha yüksekti. Seksen bir hasta (%91) elektif, 8 hasta (%9) acil şartlarda opere edilmişti. Acil şartlarda opere edilen hastaların ortalama ES tüketimi 7±4,3 Ü, elektif şartlarda opere edilen hastaların 3,85±3 Ü idi (p=0,034). Acil şartlarda opere edilen 4 hasta (%50), elektif şartlarda opere edilen 12 hasta (%14,8) YBܒne çıkarılmıştı (p=0,032).
Sonuç: Anormal invazif plasentasyon tanısı almış veya risk faktörü taşıyan hastaların anestezi yönetimi, masif hemoraji riski nedeniyle oldukça önemlidir. Bu hastaların yönetiminde cerrahi ekip, anestezi ekibi ve kan merkezinin multidisipliner yaklaşım içinde olması kanama miktarını, kan ve kan ürünleri transfüzyon ihtiyacını, YBÜ ve hastanede kalış süresini azaltmaktadır.
Objective: Abnormal placental invasion (API) is defined as an abnormal adherence of the placenta to the underlying uterine wall. Undiagnosed API may result in catastrophic maternal haemorrhage during delivery. In the present retrospective analysis, anaesthetic and surgical records were evaluated in patients with API who had undergone caesarean delivery (CD).
Methods: Clinical records of 89 patients with API who had undergone CD were retrospectively reviewed in our clinic between April 2010 and February 2017.
Results: Amongst the patients, 87 (97.8%) had a history of previous CD and 68 (76.4%) had placenta previa. In regression analysis, weak positive correlation was found between an increase in packed red blood cell (PRBC) (r=0.420, p=0.001) and fresh frozen plasma (FFP) (r=0.476, p=0.022) transfusions and time of hospital stay. PRBC and FFP consumptions were significantly greater in intensive care unit (ICU) patients than in non-ICU patients (p<0.001). ICU requirement were significantly greater in patients who had more than average crystalloid (p=0.004) and colloid (p<0.001) infusions. Elective CD was performed in 81 (91%) patients and emergency CD in 8 (9%). PRBC transfusions were 7±4.3 U in patients undergoing emergency CD and 3.85±3 U in patients undergoing elective CD (p=0.034). The number of patients requiring care in ICU was 4 (50%), who underwent emergency CD and 12 (14%) who underwent elective CD, (p=0.032).
Conclusion: It is crucial that the anaesthesiologist should be familiar with the risk factors and diagnosis of API because of the potential risk of massive haemorrhage. Multidisciplinary approach with surgery and blood bank decreases the amount of bleeding, blood transfusion requirement, ICU and hospital stay in patients with API.

6.Effectiveness of P6 Stimulation for Reduction of Nausea and Vomiting During Caesarean Section Under Combined Spinal-Epidural Anaesthesia: A Randomised Controlled Trial
Danielle Levin, Shaul Cohen, Scott Mellender, Ushma Shah, Paul Kang, Adil Mohiuddin, Rong Zhao, Geza Kiss, Enrique Pantin
doi: 10.5152/TJAR.2019.08830  Pages 120 - 127
Objective: Obstetric patients who receive combined spinal-epidural (CSE) anaesthesia for elective caesarean section (CS) frequently experience intraoperative nausea and vomiting (N&V). Prophylactic therapy with antiemetic agents can have multiple adverse effects to the mother and baby. We designed a randomised clinical trial to evaluate the efficacy of electrical P6 stimulation for prophylactic N&V treatment for scheduled elective CS performed under CSE anaesthesia.
Methods: Following the Institutional Review Board approval and informed consent, a total of 180 patients were randomly allocated into three groups: (1) P6 stimulation (via a peripheral nerve stimulator), (2) intravenous (IV) antiemetics (metoclopramide and ondansetron), and (3) control (no IV antiemetic medications and no P6 stimulation), with 60 parturients in each group
Results: Significantly fewer patients experienced intraoperative N&V in the P6 group (nausea 36.7% and vomiting 13.3%) and IV antiemetic group (nausea 23.3% and vomiting 16.7%) than those in the control group (nausea 73.3% and vomiting 45%; p<0.001). In addition, significantly fewer patients required rescue antiemetic medications in the P6 group (35%) and the IV antiemetic group (31.7%) than those in the control group (73.3%; p<0.001). There was no significant difference in the overall anaesthetic care satisfaction reported between the three study groups.
Conclusion: Our data suggest that P6 stimulation is as simple and as effective as our routine prophylactic IV antiemetic treatment for prevention of N&V during CS performed under CSE anaesthesia that could be of great interest to patients and obstetric anaesthesiologists who prefer treatments with fewer potential side effects

7.Detecting Major Complications and Death After Emergency Abdominal Surgery Using the Surgical Apgar Score: A Retrospective Analysis in a Caribbean Setting
Keevan Singh, Seetharaman Hariharan
doi: 10.5152/TJAR.2019.65872  Pages 128 - 133
Objective: The Surgical Apgar Score (SAS) is a simple 10-point scoring system that has been shown to be predictive of major postoperative complications and death after surgery. We evaluated the predictive ability of this score in a cohort of patients undergoing emergency abdominal surgery in a Caribbean tertiary hospital.
Methods: The SAS was calculated retrospectively from the anaesthesia records of all patients undergoing emergency abdominal surgery during a 12-month period. The postoperative surgical records of these patients were then examined for the presence of major complications and death. The association between the SAS and outcomes was tested using binary logistic regression, and the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis.
Results: Of the 220 patients studied, 72 (33%) suffered an in-hospital major complication or death. The highest complication rate occurred in the low-scoring groups, with 68% of those scoring <4 being affected. Low-scoring patients (<4) had four times the risk of major complications when compared to higher-scoring groups (relative risk [RR], 4.21; 95% confidence interval [CI], 2.5-7.3; p<0.001). The odds ratio (OR) for major complications or death per unit increase in the SAS was 0.58 (95% CI, 0.47-0.72; p<0.001). The c-statistic of the SAS for predicting major complications or death was 0.71 (95% CI, 0.68-0.73; p<0.0001).
Conclusion: The SAS is a simple 10-point score that can be used in patients undergoing emergency surgery in a Caribbean setting to help identify those that are at a higher risk of postoperative complications. Due to its ease in calculation, it can be added to other commonly used criteria to help triage the postoperative patient.

8.Effect of Mean Blood Pressure During Extracorporeal Life Support on Outcome After Out-of-Hospital Cardiac Arrest
Romain Jouffroy, Alexandra Guyard, Pascal Philippe, Pierre Carli, Benoit Vivien
doi: 10.5152/TJAR.2019.73558  Pages 134 - 141
Objective: Extracorporeal Life Support (ECLS) can help to improve the outcome of refractory cardiac arrest (CA). ECLS allows to maintain blood pressure and tissue perfusion until the cause of CA is treated. The aim of the present study was to describe the mean blood pressure (MBP) during the first 24 h of ECLS for out-of-hospital CA (OHCA).
Methods: We performed a retrospective analysis of consecutive refractory OHCA requiring ECLS admitted to the intensive care unit. MBP was examined after starting ECLS (H0) and every 6 h during the first 24 h (H6, H12, H18 and H24).
Results: Forty patients were analysed. MBP significantly differs between survivors and non-survivors since 6 h: 77 vs 44 mm Hg (p=0.002), 51 vs 87 mm Hg at H12 (p=0.008), 57 vs 75 mm Hg at H18 (p=0.015) and 79 vs 53 mm Hg at H24 (p=0.004), whereas no difference was observed at H0: 69 vs 55 mm Hg (p=0.06). An MBP lower than 65 mm Hg since 6 h is associated with a poor outcome (sensitivity and specificity of death of 87% and 66% at H6, 80% and 75% at H12, 100% and 75% at H18 and 70% and 80% at H24, respectively).
Conclusion: Despite high levels of catecholamine, the inability to maintain MBP higher than 60 mm Hg after starting ECLS for OHCA is associated with a poor outcome.

9.Cost Analysis on Intensive Care Unit Costs Based on the Length of Stay
Mehmet Kılıç, Nureddin Yüzkat, Celaleddin Soyalp, Nurçin Gülhaş
doi: 10.5152/TJAR.2019.80445  Pages 142 - 145
Amaç: Bu çalışmanın amacı YBÜ'de kalış süresine göre YBÜ'da hizmet maliyetlerini ve kar / zarar oranını belirlemekti.
Yöntemler: Retrospektif çalışmada Ağustos 2016-2017 tarihleri arasında YBÜ'ne yatan 458 hastanın tıbbi kayıtlarını gözden geçirildi. Hastalar YBÜ kalış süresine bağlı olarak 6 gruba ayrıldı: Grup (Gr) (I);1 gün, Gr (II); 2 gün, Gr (III) 3 gün, Gr (IV) 4 gün, Gr (V) 5 gün ve Gr (VI)> 5 gün. Bu gider kalemleri 6 kategoride değerlendirildi: cerrahi, laboratuvar testleri, ilaçlar, alet ve ekipmanlar, radyografik çalışma ve diğerleri.
Bulgular: Çalışmada tıbbi kayıtlarını gözden geçirilen hastaların yaş ortalaması 53.87 ± 22.6 yıl olup 273 (% 59.6) erkek ve 185 (% 40,4) kadın idi. Kâr / zarar oranı, Grup I (12.870.82 TL), II. Grup (9,384,61 TL) ve III. Grup (371.18 TL) zarar lehine; grup IV'te ise (16,505,4 TL) kâr lehine idi.Toptan hizmet maliyetleri% 38.51 ilaç maliyeti,% 24.45 araç / gereç,% 13.14 laboratuvar testi,% 10 diğer maliyetler,% 4.92 cerrahi maliyetler ve% 3.1 radyografik testlerden oluşmaktaydı.
Sonuç: YBܒdeki hastaların yatış gün sayına göre maliyet analizinde YBܒnin ilk üç gününde tanı, ameliyat, laboratuvar, radyolojik tetkikler ve tıbbi malzeme maliyetleri arttığı için zarar oranı yüksekken, dördüncü günden itibaren yatışları devam hastalarda bu giderlerin azalmasına bağlı kar/zarar oranının kar lehine değiştiğini saptadık. Ayrıca, toplam YBÜ maliyetleri% 38.51 ilaç maliyeti ve% 24.45 tıbbi araç ve gereçlerden oluşmaktadır.
Objective: The present study aimed to determine the profit/loss ratio and the service costs in intensive care unit (ICU) based on the length of ICU stay.
Methods: This retrospective study reviewed the medical records of 458 patients who were admitted to ICU between August 2016 and August 2017. Depending on the length of their ICU stay, the patients were divided into six groups: (I) 1 day, (II) 2 days, (III) 3 days, (IV) 4 days, (V) 5 days and (VI) more than 5 days. These charges were evaluated under six categories: surgery, laboratory tests, drugs, tools and equipment, radiographic workup and others.
Results: This study reviewed the medical records of patients including 273 (59.6%) men and 185 (40.4%) women. The mean age of the patients was 53.87±22.6 years. The profit/loss ratio was in favour of loss in group I (12,870.82 TL), group II (9,384.61 TL) and group III (371.18 TL). The ration was in favour of profit in group IV (16,505.4 TL). Total service costs comprised 38.51% drug costs, 24.45% tools/equipment, 13.14% laboratory tests, 10% other costs, 4.92% surgical costs and 3.1% radiographic tests.
Conclusion: The cost analysis based on the service costs in ICU with regards to the length of ICU stay revealed that due to the greater use of diagnostic, surgical and medical tools and equipment and laboratory and radiographic tests, the profit/loss ratio was in favour of loss within the first three days in ICU. This ratio turned to profit beginning from day 4 in ICU due to the decrease in the use of these equipment and tests. Moreover, total ICU costs comprised 38.51% drug costs and 24.45% medical tools and equipment.

10.Comparative Analysis of Balloon Compression and Radiofrequency Ablation in Idiopathic Trigeminal Neuralgia: A Retrospective Study with a 24-Month Follow-up
Anuj Jain
doi: 10.5152/TJAR.2019.53533  Pages 146 - 150
Objective: Trigeminal neuralgia (TN) is a common cause of facial pain, with a prevalence of 40 per million. This paper is a retrospective 24-month follow-up study of 20 patients with idiopathic drug-resistant TN who underwent balloon compression (BC) or radiofrequency ablation (RFA).

Methods: When neuralgia affected more than one divisions or it involved ophthalmic division, BC was performed. RFA was performed in neuralgia involving isolated mandibular or maxillary division.

Results: At all the time points, numerical rating score (NRS) was lower in the BC group, but the difference was not significant. The proportion of patients developing recurrence of pain was lower in the BC group, but the difference was not significant (p-value 0.63). The proportion of patients requiring a repeat procedure was lower in the BC group, but the difference was not significant. There was no significant correlation among recurrence of pain, age of the patient and number of divisions in which neuralgia was present. In BC, a pear shape of the balloon is desirable, but this shape is not always achievable. Recurrence of pain in the BC group was comparable to that in the available literature, but the recurrence rate in the RFA group was comparatively higher. The complications in BC were higher, but they were transient and improved with time.

Conclusion: BC and RFA are effective modalities of treatment for idiopathic TN with comparable results. In TN involving multiple divisions, BC may be more convenient.

11.Publication rate of abstracts orally presented at the Turkish Society of Anaesthesiology and Reanimation National Congresses
Büşra Tok Çekmecelioğlu, Betül Kozanhan, Gülay Eren
doi: 10.5152/TJAR.2019.33603  Pages 151 - 157
Amaç: Bilimsel kongrelerde sunulan araştırmaların kalitesinin değerlendirilmesinde en yaygın kabul gören parametre, o araştırmanın hakemli bir dergide yayımlanma başarısıdır. Literatür taramasında Türk Anesteziyoloji ve Reanimasyon Derneği Ulusal Kongrelerinde (TARK) sunulan sözlü bildirilerin bilimsel dergilerde yayımlanma oranlarıyla ilgili kısıtlı veri bulunmaktadır. Çalışmada, TARK’larda yer alan sözlü sunuların literatüre olan katkısını araştırmak ve yayımlanan bildirilerin ayrıntılı değerlendirmesiyle gelecek kongreler için öneriler sunmak amaçlanmıştır.
Yöntemler: Ekim 2011-Ekim 2014 yılları arasında yapılan TARK’larda yer alan 319 sözlü bildiri PubMed ve Google Akademik veri tabanlarında incelenmiştir. Bildiriler; gönderildikleri kurum, araştırmanın türü, bilimsel dergide yayımlanma durumu, hakemli derginin türü, yayımlanma yılı, atıf alma oranı, yazar sıralaması ve başlıktaki değişiklikler parametreleri açısından araştırılmıştır.
Bulgular: İncelenen bildirilerin; %73,1’i klinik araştırma, %21,9’u deneysel araştırma, %2,5 olgu sunumu ve %2,5 anket çalışmasıdır. Bildirilerin %75,2’si sözlü sunum oturumlarında sunulmak üzere kabul edilmiş, %24,8’i ise yarışma oturumlarında en iyi klinik veya deneysel araştırma olarak yer almıştır. Bildirilerin %57,7’si üniversite, %16’sı eğitim araştırma hastanesi, %26,3’ü ise karma kurum yazar kadrolarına sahiptir. Bildirilerin %42,3’ü makale olarak bir bilimsel dergide yayımlanmıştır. Yayımlanan dergilerin %65,9’u SCIE, %8,1’i SCIE dışı indekslerde yer alan uluslararası dergi, %25,9’u ulusal dergi idi. Bildirilerden, bilimsel dergide yayımlananların gönderildiği kurum ile yayın olduğu yer arasında istatistiksel olarak fark bulunamamıştır (p=0,068). Bildirilerin ortalama yayımlanma süresi 15,01±12,26 aydır.
Sonuç: Ekim 2011-Ekim 2014 yıllarındaki TARK’lardaki sözlü bildirilerin %42,3’lük bir yayımlanma oranı uluslararası verilerle uyumluluk göstermekte olup; bu sonuç, kongrelerdeki bildirilerin hakemlerce uluslararası seçim kriterlerine uygun şekilde ve titizlikle puanlanarak değerlendirildiğinin göstergesidir. Bildirilerin yayımlandıkları dergilerin çoğunluğunun SCIE türü dergiler olması alanımızda üretilen araştırmaların bilimsel kalitesinin kantitatif bir verisidir.
Objective: The most widely accepted parameter in evaluating the quality of research presented at scientific congresses is the success of publishing that research in a peer-reviewed journal. There are limited data in the literature about the publishing rates of abstracts orally presented at national congresses of the Turkish Society of Anaesthesiology and Reanimation (TARD) in scientific journals. The aim of the present study was to investigate the literary contribution of oral presentations at the TARD Congresses (TARK) and to present proposals for future congresses with detailed evaluation of the literature.
Methods: Overall, 319 orally presented abstracts at the TARK between October 2011 and October 2014 have been reviewed in the PubMed and Google Scholar databases. Abstracts were evaluated with respect to the institution of the principal author, type of research, publication status in scientific journal, type of publication, year of publication, rate of citation, order of authors and changes in title.
Results: The distributions of investigated papers were as follows: 73.1% clinical research, 21.9% experimental research, 2.5% case presentations and 2.5% survey studies. Moreover, 57.7% of the abstracts had authors from universities, 16% from research-training hospitals and 26.3% from mixed institutions. Further, 42.3% of the abstracts were published as articles in a scientific journal, 65.9% of the manuscripts were published in the Science Citation Index Expanded (SCIE) indexed, 8.1% in non-SCIE indexed international journals and 25.9% in national journals. There was no statistically significant difference between institution from which publications were sent and the index status of the journal (p=0.068). The average publication time of the abstracts was 15.01±12.26 months.
Conclusion: The publication rate of abstracts orally presented at the TARK between October 2011 and October 2014 is 42.3%, which is in accordance with other international studies. This indicates that the reports in the congresses were assessed by the jury according to international selection criteria and meticulously scored. The majority of the abstracts were published in journals that are listed in SCIE, indicating a quantitative data regarding the scientific quality of research in anaesthesiology.

CASE REPORT
12.Use of the Ultrasound-Guided Erector Spinae Plane Block in Segmental Mastectomy
Onur Selvi, Serkan Tulgar
doi: 10.5152/TJAR.2019.50024  Pages 158 - 160
Erektör spina plan bloğu (ESP) yeni tanımlanmış bir rejyonal anestezi/analjezi tekniğidir. Mekanizması hakkında ortak bir fikir birliği bulunmamasına rağmen, yayınlanan olgu serilerinde kronik ve akut ağrı için kullanılabilecek yeni bir blok olabileceğini vadetmektedir. Bu olgu sunumunda bilateral segmental mastektomi planlanan 47 yaşında kadın hastada ESP bloğunun kullanımı sunulmuştur. ESP bloğunun kullanımı daha önce kot kırığı, bariatrik cerrahi, açık batın cerrahisi ve meme implantı yerleştirilmesi operasyonunda rapor edilmiştir. Literatürde aksiller diseksiyon içeren meme kanseri cerrahisinde ESP blok kullanımına dair daha önce yayınlanmış bir yayına rastlanmamıştır.
Erector spinae plane (ESP) block is a recently described regional anaesthesia/analgesia technique. Although there is stil no consensus on its mechanism, the published case series seem to promise a new block for both chronic and acute pain. In this case report, the use of ESP block in 47-year-old female patient scheduled for bilateral segmental mastectomy surgery is presented. ESP was formerly reported for rib fracture, bariatric surgery, open abdominal surgery and breast implant surgery. To the best of our knowledge, no article has been published for ESP block in breast cancer surgery including axillary dissection.

13.Breast Implants and Bilateral Tension Pneumothorax Following Blunt Chest Trauma
Mathieu Martin, David Lobo, Jennifer Jaubert, Paul Henri Jost, Fabrice Cook
doi: 10.5152/TJAR.2019.73669  Pages 161 - 163
A 38-year-old woman was admitted to our trauma centre with a complete left pneumothorax. The chest tube implementation procedure was aborted quickly because of a very difficult dissection (subcutaneous emphysema over two voluminous breast implants). The patient was transferred to the imaging room without chest tube insertion due to respiratory and haemodynamic stability. During transfer, the patient presented with cardiac arrest due to tension pneumothorax. The time benefit with the use of immediate total body computed tomography has been reported. A simple and rapid initial imaging assessment including chest and pelvic X-rays and four‐chamber view and ‘swing technique’ ultrasound protocol enables the appropriate emergency decisions. While this diagnostic approach is time consuming, it nevertheless allows a reduction in the time needed to initiate life-saving interventions for the most severe patients. This case reminds us that even if patients are stable, drainage of a complete pneumothorax under mechanical ventilation should not be delayed, especially in case of technical difficulties.

LETTER TO THE EDITOR
14.Timing May Influence the Pharmacodynamics of Atropine as Pre-Medication
Aybike Onur Gönen, Eren Fatma Akçıl
doi: 10.5152/TJAR.2019.28445  Page 164
Abstract | Full Text PDF