Turk J Anaesthesiol Reanim: 47 (3)
Volume: 47  Issue: 3 - June 2019
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CLINICAL RESEARCH
1.Comparison of Haemodynamic Response to Inhalational Bolus with Desflurane in Normotensive and Hypertensive Patients Undergoing Laparoscopic Cholecystectomy
Kamlesh Kumari, Tanvir Samra, Vikas Saini, Sameer Sethi, Neerja Banerjee, Sujata Sharma
doi: 10.5152/TJAR.2018.93457  Pages 165 - 172
Amaç: Desfluran yüksek soluk sonu konsantrasyonlarda sempatik stimülasyona neden olabilmektedir. Bu çalışmada amaç laparoskopik kolesistektomi uygulanan normotansif ve hipertansif hastalarda bolus desfluran inhalasyonuna verilen hemodinamik yanıtı karşılaştırmaktır.
Yöntemler: Bu prospektif klinik çalışmada, yaşları 18 ile 60 arasında değişen ve laparoskopik kolesistektomi uygulanan 40 hasta normotansif (Grup N; n=20) ve hipertansif (Grup H; n=20) olarak iki gruba ayrıldılar. Başlangıçta ve indüksiyon, entübasyon, ve bolus desfluran inhalasyonu başlanması sonrasındaki 5 dakika süresince her 60 saniyede bir kalp atım hızı (KAH), ortalama arter basıncı (OAB) ve bispektral indeks (BIS) ölçüldü. Primer amaç hemodinamik yanıtı karşılaştırmak, sekonder amaç ise inhalasyon bolusu ihtiyacını değerlendirmek ve her inhalasyon bolusu sonrasında BIS değerindeki aşırı ve yetersiz düzeltmelerin sayısını karşılaştırmaktı. Gruplar arasında çalışma parametrelerini kıyaslamak için bağımsız bir t-test ve aynı grup içerisinde çalışma parametrelerinin ortalamalarındaki yüzde değişikliği kıyaslamak için ise bağımlı bir t-test kullanıldı. p<0.05 değeri istatiksel anlamlılık olarak tanımlandı.
Bulgular: Desfluran inhalasyon bolusu sonrasında iki grup arasında, KAH ve OAB açısından azalma, artış ya da hiçbir değişiklik göstermeyen hastaların yüzdelerinde istatiksel olarak anlamlı bir farklılık gözlenmedi. Grup H’de hastaların %60’ında ve Grup N’de hastaların %15’inde aşırı BIS düzeltmesi (değer <45) görüldü (p=0,003). Her iki gruptaki hiçbir hastada yetersiz düzeltme izlenmedi (BIS>55).
Sonuç: BIS rehberliğinde desfluran uygulaması ve BIS tetiklemeli bolus desfluran inhalasyonu güvenli ve uygulanabilirdir; ve normotansif ya da hipertansif hastalarda sempatik stimülasyona yol açmamaktadır.
Anahtar Sözcükler: İnhalasyon anestetikleri, desfluran, bolus, komplikasyonlar, kardiyovasküler etkiler.
Objective: Desflurane causes sympathetic stimulation at high end-tidal concentrations. We conducted this study to compare the haemodynamic response to inhalational bolus with desflurane in normotensive and hypertensive patients undergoing laparoscopic cholecystectomy.
Methods: In this prospective, clinical trial, 40 patients aged 18-60 years and undergoing laparoscopic cholecystectomy were divided into normotensives (Group N; n=20) and hypertensives (Group H; n=20). Heart rate (HR), mean arterial pressure (MAP) and bispectral index (BIS) were measured at baseline and every 60 s for 5 min after induction, intubation, initiation and inhalational bolus of desflurane. The primary objective was to compare haemodynamic response, and the secondary objective was to assess the need for inhalational boluses and to compare the number of overcorrections and undercorrections in BIS value after each inhalational bolus. An independent t-test was used to compare the means of the study parameters between the groups, and a dependent t-test was used to compare the percentage change in the means of the study parameters within the same group. Statistical significance was defined as p<0.05.
Results: No statistically significant difference in the percentage of patients responding with a decrease, increase or no change of HR or MAP were seen between the two groups after inhalational bolus of desflurane. An overcorrection of BIS (value <45) was seen in 60% of the patients in Group H and 15% of the patients in Group N (p=0.003). None of the patients in either group had an undercorrection (BIS>55).
Conclusion: BIS-guided desflurane administration and BIS-triggered inhalational boluses of desflurane is safe, feasible and does not cause sympathetic stimulation in either normotensive or hypertensive patients.

2.A Comparison of the Effects of Lung Protective Ventilation and Conventional Ventilation on Thermoregulation During Anaesthesia
Ahmet Yüksek, Elif Doğan Bakı, Tuba Berrak Sarıtaş, Remziye Sıvacı
doi: 10.5152/TJAR.2018.73659  Pages 173 - 178
Amaç: Uzun süreli cerrahi sırasında hipotermi sıklıkla gelişen ve komplikasyon oranlarını artıran istenmeyen bir durumdur. Mekanik ventilasyon sırasında pozitif ekspirasyon basıncının (PEEP) erken periferik vazokonstriksiyon sağlayarak hipotermi gelişimini azalttığı gösterilmiştir. Bu çalışmada, iki farklı ventilasyon modelinin perioperatif hipotermi gelişimi üzerine etkisi araştırılmıştır.
Yöntemler: Elektif lomber disk cerrahisi uygulanan 40 hasta, geleneksel grubuna (Grup C, n = 20, tidal hacim = 10 ml / kg, PEEP = 0 cm H2O) veya akciğer koruyucu ventilasyon grubuna (Grup P, tidal hacim = 6 ml / kg, PEEP = 5 cm H20) randomize edildi. Hastaların cinsiyet, yaş, ağırlık, boy gibi demografik verileri, preoperatif-postoperatif sıcaklıklar ve hemodinamik değerlerin kaydedildi. Önkol-parmak ucu cilt sıcaklık farkının 0°C'ye ulaştığı nokta periferik vazokonstriksiyon gelişimi olarak ayarlandı ve bu noktada hastanın iç sıcaklığı vazokonstriksiyon eşiği olarak kayıt edildi.
Bulgular: Hastaların demografik özellikleri ve hemodinamik değişkenler gruplar arasında benzerdi. Preoperatif ve postoperatif sıcaklık farkları iki grup arasında anlamlı farklılık göstermedi (p=0.827). Hastaların vazokonstriksiyon eşiği açısından da gruplar arasında anlamlı farklılık yoktu (p = 0.432 ).
Sonuç: Çalışma sonuçları, akciğer koruyucu ventilasyonun geleneksel ventilasyona kıyasla perioperatif iç sıcaklığı korumada bir avantajının olmadığını göstermiştir.


Objective: During prolonged surgery, hypothermia is an unwanted condition that frequently develops and increases complication rates. It has been shown that positive end-expiratory pressure (PEEP) during mechanical ventilation reduces hypothermia development by providing earlier peripheral vasoconstriction. In the present study, an investigation was made of the effect of two different ventilation models on perioperative hypothermia development.
Methods: A total of 40 patients undergoing elective lumbar disc surgery were randomised to either the conventional group (Group C, n=20, tidal volume=10 mL kg-1, PEEP=0 cm H2O) or the lung protective ventilation group (Group P, n=20, tidal volume=6 mL kg-1, PEEP=5 cm H2O). Demographic data on gender, age, weight, height, preoperative–postoperative temperatures and haemodynamic values were recorded. The point where the forearm to fingertip skin temperature difference reached 0°C was determined as the peripheral vasoconstriction development. At this point, the core temperature was recorded as the thermoregulatory vasoconstriction threshold.
Results: Demographic characteristics of the patients and haemodynamic variables were similar between the groups. Preoperative and postoperative temperature gradients were not significantly different between the two groups (p=0.827). There was also no significant difference between the two groups in respect of the vasoconstriction threshold of the patients (p=0.432).
Conclusion: The study results showed that lung protective ventilation has no advantage in preserving the perioperative core temperature compared to conventional ventilation.

3.Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty. POWER.2 Study: Study Protocol for a Prospective, Multicentre, Observational Cohort Study
Javier Ripollés-melchor, Ane Abad-motos, Margarita Logroño-Egea, César Aldecoa, José Antonio García-Erce, Ignacio Jiménez-López, Concepción Cassinello-Ogea, Oliver Marín-Pena, Carlos Ferrando-Ortolá, Alejandro Suárez De La Rica, Manuel A. Gómez-Rios, Rubén Sánchez-Martín, Alfredo Abad-Gurumeta, Rubén Casans-Francés, Ana Mugarra-Llopis, Marina Varela-Durán, Javier Longás-Vailén, Álvaro Ramiro-Ruiz, Ana B. Cuellar-martínez, José M. Ramírez-Rodríguez, José M. Calvo-Vecino
doi: 10.5152/TJAR.2019.87523  Pages 179 - 186
Objective: The number of indications for total hip replacement (THR) and total knee replacement (TKR) surgery is increasing. Enhanced recovery after surgery (ERAS) represents the next step in the evolution of standardised care. The primary aim of this study is to measure the in-hospital 30-day medical and surgical postoperative complications rate. The study’s secondary aims are to determine the length of stay, 30-day mortality rate, 30-day reoperation and readmission rates, the ERAS overall compliance and predefined ERAS individual items compliance.
Methods: This multicentre, prospective, observational study will include adult patients (aged >18 years) undergoing elective THR and TKR surgery. Consecutive patients undergoing surgery within the 2-month data collection period will be included. Centres that offer the THR and/or TKR surgery will be eligible to participate. The data collection will be done through an online data collection form via a secure, password-protected platform at each centre with predefined data fields.
Results: Ethical approval for this study has been obtained from the Comité de Ética de la Investigación de la Comunidad Autónoma de Aragón (C.P.-C.I. PI18/135; on 23 May 2018). It was prospectively registered on 27 June 2018, at www.clinicaltrials.gov with identification no. NCT03570944.
Conclusion: The study will be disseminated through the SPARN-RedGERM, SEDAR, GERM and through social media. Peer-reviewed publications will be published under corporate authorship, including POWER.2 Study Group and SPARN-RedGERM.

4.Can Partial Oxygen Pressure of Urine be an Indicator for Tissue Perfusion?
Melis Tosun, Halim Ulugöl, Uğur Aksu, Fevzi Toraman
doi: 10.5152/TJAR.2019.89083  Pages 187 - 191
Amaç: Rutin pratikte kullanılan ve sadece hemodinamik ve kan gazı parametrelerine odaklanan ileri monitörizasyon tekniklerinin hiçbiri, doku perfüzyonunun yeterliliği hakkında yeterli bilgi vermemektedir. Doku perfüzyonunun yeterliliğini gösterecek noninvazif ve güvenilir parametrelerin geliştirilmesi gerekmektedir. Bu çalışmada, açık kalp cerrahisi sonrası kardiyak basınç-volüm ilişkisinin azaldığı, sepsis-benzeri sendromda olan hastalarda; sistemik doku perfüzyonunun yeterliliğini göstermede idrar parsiyel oksijen basıncı (PuO2) analizi, diğer doku perfüzyon parametreleri ile karşılaştırılmıştır.
Yöntemler: Koroner baypas cerrahisi geçiren 50 hasta çalışmaya dahil edildi. Postoperatif dönemde rutin hemodinamik monitörizasyonun yanı sıra; 180’inci, 360’ıncı ve 540’ıncı dakikalarda arter parsiyel oksijen basıncı (PaO2), kalp debisi, arter laktat düzeyleri ve mesane idrarından parsiyel oksijen basıncı (PuO2) ölçümleri yapıldı.
Bulgular: Hastaların doku perfüzyon parametreleri takip süresince stabil seyretti. İdrar parsiyel oksijen basıncı (PuO2); ilk ölçümde 91±22 mmHg, ikincide 99±22 mmHg ve son ölçümde 97±13 mmHg olarak ölçüldü. Ölçülen bu değerler ile kalp debisi, arter parsiyel oksijen basıncı ve arter laktat değerleri arasında anlamlı bir korelasyon saptanamadı.
Sonuç: Bu çalışmada, idrar parsiyel oksijen basınçları (PuO2) ile arter parsiyel oksijen basıncı, laktat düzeyleri ve kalp debisi gibi rutin sistemik doku perfüzyon parametreleri arasında bir ilişki gösterilememiştir. Kanımızca, çalısmaya dahil edilen hastaların kalp debilerinin normal sınırlarda olduğu ve hiçbir hastada renal hasar gelişmemiş olduğu için, olası bir korelasyon gösterilememiş olabilir. Renal oksijen sunumunda eşik değerlerin saptanabilmesi amacıyla; geçici transrenal iskemik atak geçiren hasta gruplarında çalışmalar yapılması gerektiği görüşündeyiz.
Objective: None of the advanced monitorisation procedures, which are focusing only on the haemodynamic and blood gas parameters, are sufficient to estimate tissue perfusion adequately. The search for new parameters that are non-invasive and reliable to provide information about tissue hypoperfusion is significant. The purpose of the present study was to evaluate the relationship between urine partial pressure of oxygen (PuO2) and routine systemic tissue perfusion parameters in patients with sepsis-like syndrome and impaired cardiac pressure–volume relationship after an open cardiac surgery.
Methods: The study was designed in 50 patients who had elective coronary bypass surgery. Patients were assessed for arterial lactate levels, arterial partial oxygen pressure (PaO2), cardiac output (CO) and PuO2 in bladder urine at 180, 360 and 540 min postoperatively.
Results: Tissue perfusion parameters were found to be similar throughout the surgery in addition to no significant rise in plasma creatinine levels. PuO2 was found to be 91±22, 99±22 and 97±13 mmHg, respectively, at the time points described above. Any correlation between PuO2 and other measurements was not determined at any time points.
Conclusion: The present study suggests that urine PuO2 has no relationship with routine systemic tissue perfusion parameters, such as PaO2, lactate levels and CO. In our opinion, since the COs of the patients were within the normal limits, and none of the patients developed renal injury, the present study might have been unable to determine any correlation. Further studies focused on patients with transient renal ischaemia are needed.

5.Intraoperative Single-Dose Intravenous Acetaminophen for Postoperative Analgesia After Skin Laser Irradiation Surgery in Paediatric Patients: A Small Prospective Study
Syunsuke Kuroki, Yoshihiro Nagamine, Yoshihumi Kodama, Yoko Kadota, Satoshi Kouroki, Toyoaki Maruta, Shiho Kanemaru, Masahiro Amano, Isao Tsuneyoshi
doi: 10.5152/TJAR.2019.10476  Pages 192 - 198
Objective: Acetaminophen is an analgesic that shows efficacy in postoperative pain relief in children. Many drugs such as opioids, non-steroidal anti-inflammatory drugs, and/or acetaminophen have been used in paediatric skin laser irradiation surgery for postoperative pain relief. However, acetaminophen has some advantages over opioids, and opioids are being used less often. We aimed to demonstrate the effectiveness of intravenous (IV) acetaminophen during surgery for postoperative pain in paediatric skin laser irradiation.
Methods: The present study is a small, prospective, double-blinded, randomized controlled trial. Paediatric patients (1–12 years old with an American Society of Anesthesiologists physical Status I and II), scheduled for skin laser irradiation for a nevus or haemangioma between October 2014 and April 2016 were randomized into the acetaminophen (n=9) and placebo (saline, n=8) groups. The observational face scale (FS) and the Behavioural Observational Pain Scale (BOPS) scores were recorded on emergence from anaesthesia, and 1, 2, and 4 hr post-surgery.
Results: Patient characteristics were not significantly different except with regard to the irradiation area and surgery time. The observational FS and BOPS scores of the acetaminophen group were lower than those of the placebo group; median (minimum–maximum) at each recording time: 1 (0–2) – 0 (0–2) – 0 (0–1) – 0 (0–2) vs. 2 (0–4) – 0 (0–2) – 0 (0–2) – 0 (0–1) and 1 (0–3) – 1 (0–3) – 1 (0–2) – 0 (0–1) vs. 2 (0–4) – 3 (0-5) – 1 (0–4) – 0 (0–3), p=0.07 and p=0.003, respectively. No differences in post-surgical analgesic use or adverse events were observed.
Conclusion: In this study, we showed that the IV acetaminophen group had lower observational FS and BOPS scores in the early postoperative period; however, further studies including a large number of patients are required to confirm our findings.

6.Mannitol and the Combination of Mannitol and Gelatin Impair Whole Blood Coagulation and the Platelet Function In Vitro
Thomas Palmaers, Elke Krämer, Julia Hinsenkamp, Hendrik Eismann, Dirk Scheinichen, Paul Frank
doi: 10.5152/TJAR.2019.86300  Pages 199 - 205
Objective: Mannitol 20% and succinylated gelatin 4% are routinely used in neurosurgical procedures. The aim of this in vitro study was to explore the influence of both agents on blood coagulation and platelet function.
Methods: Blood from 21 healthy volunteers was obtained and then diluted so as to form five groups: (1) 7% dilution with mannitol; (2) 10% dilution with gelatin; (3) 17% dilution with isotonic balanced electrolyte solution; (4) 17% dilution with mannitol+gelatin; and (5) undiluted blood. The extrinsic thrombelastometry (EXTEM) and fibrin thrombelastometry (FIBTEM) tests were examined by rotational thrombelastometry via ROTEM®, and thrombocyte aggregometry with the aspirin inhibiting- (ASPI), adenosine diphosphate- (ADP), and thrombin-activating protein (TRAP) tests performed by Multiplate.
Results: In the EXTEM test clot formation time, the alpha angle, and maximum clot firmness were significantly reduced by mannitol and the combination of mannitol with gelatin. The platelet function tested in the ADP test was also significantly reduced with this combination.
Conclusion: In this in vitro study, clinically relevant dilutions of mannitol and gelatin showed a significant inhibition of whole blood coagulation and the platelet function, which could be detrimental in neurosurgical settings.

7.The Effect of Sevoflurane and Dexmedetomidine on Pulmonary Mechanics in ICU Patients
Mediha Türktan, Ersel Güleç, Zehra Hatipoğlu, Murat Türkeün Ilgınel, Dilek Özcengiz
doi: 10.5152/TJAR.2019.37108  Pages 206 - 212
Amaç: Yoğun bakım hastalarında sedasyon amacıyla intravenöz ajanların yanısıra volatil ajanlar da kullanılabilmektedir. Bu çalışmanın amacı pulmoner patolojili hastalarda sedasyon amacıyla kullanılan sevofluran ve deksmedetomidinin pulmoner etkilerini araştırmaktır.
Yöntemler: Çalışmaya etik kurul onayı ve bilgilendirilmiş hasta onamı alındıktan sonra 18-65 yaş arası, ASA I-III grubu, mekanik olarak ventile edilen, pulmoner patolojisi ve sedasyon ihtiyacı olan otuz hasta dahil edildi. Ciddi hepatik, renal ve pulmoner yetmezlik olan, konvülsiyon ve bayılma hikayesi olan, hemodinamik olarak stabil olmayan ve sedasyon ihtiyacı olmayan hastalar çalışma dışı bırakıldı. Randomizasyon yöntemi ile iki gruba ayrılan hastalara sedasyon amacıyla Grup S’de (n=15) AnaConda ile % 0.5-1 konsantrasyon sağlamak için 4-10 mL sa-1 sevofluran, Grup D’de (n=15) deksmedetomidin infüzyonu (1 µg-1 kg-1 10 dak-1 yükleme, 0.2-0.7 µg-1 kg-1 dak-1 idame) uygulandı. Arter kan gazı analizi, havayolu direnci, statik kompliyans, tepe havayolu basıncı, PEEP değerleri, sedasyon skorları ve ventilatör uyumları başlangıç, 1, 3, 6, 9, 12 ve 24. saatlerde değerlendirilerek kaydedildi.
Bulgular: Demografik veriler, havayolu direnci, statik kompliyans, tepe havayolu basıncı, PEEP, solunum frekansı ve tidal volüm değerleri her iki grup için benzerdi. Ancak arter kan gazındaki PaCO2 değerlerinin ve end-tidal CO2 değerlerinin Grup S’de Grup D’ye göre anlamlı yüksek olduğu gözlendi. Sedasyon skorları ve hasta konforu gruplar arasında benzerdi.
Sonuç: Pulmoner patolojili yoğun bakım hastalarında sevofluran ve deksmedetomidinin etkin sedasyon sağladığı ve pulmoner mekanikler yönünden birbirlerine üstünlüklerinin olmadığı kanısına varıldı.
Objective: In intensive care unit (ICU) patients, intravenous (iv) and volatile agents are used for sedation. The aim of the present study was to investigate the effects of dexmedetomidine and sevoflurane on pulmonary mechanics in ICU patients with pulmonary disorders.
Methods: After approval of the ethical committee and informed consent between the ages of 18-65 years were obtained, 30 patients with an American Society of Anesthesiologist status I-III, who were mechanically ventilated, who had pulmonary disorders and who needed sedation were included in the study. Exclusion criteria were severe hepatic, pulmonary and renal failures; pregnancy; convulsion and/or seizure history; haemodynamic instability and no indication for sedation. Patients were divided into two groups by randomised numbers generated by a computer. For sedation, 0.5%-1% sevoflurane (4-10 mL h−1) was used by an Anaesthetic Conserving Device in Group S (n=15), and iv dexmedetomidine infusion (1 µg−1 kg−1 10 min−1 loading and 0.2-0.7 µg−1 kg−1 h−1 maintenance) was performed in Group D (n=15). Arterial blood gas analysis, airway resistance, positive end-expiratory pressure (PEEP), frequency, tidal volume (TV), peak airway pressure (Ppeak), static pulmonary compliance and end-tidal CO2 values were recorded at baseline, 1, 3, 6, 9, 12 and 24 h.
Results: Demographic data, airway resistance, PEEP, frequency, TV, Ppeak and static pulmonary compliance values were similar between the groups. PaCO2 and end-tidal CO2 values were higher in Group S than in Group D. Sedation and patient comfort scores were similar between the two groups.
Conclusion: Both sevoflurane and dexmedetomidine are suitable sedative agents in ICU patients with pulmonary diseases.

8.Atrial Fibrillation in Patients with Septic Shock: A One-Year Observational Pilot Study
Irene Steinberg, Etrusca Brogi, Lorenza Pratali, Danila Trunfio, Greta Giuliano, Elena Bignami, Francesco Forfori
doi: 10.5152/TJAR.2019.44789  Pages 213 - 219
Objective: The negative effect of sepsis on the myocardium affects its electric functionality. This study aims to evaluate the incidence of atrial fibrillation (AF) in patients with septic shock, and the mortality rate of patients with AF versus patients that maintained sinus rhythm (SR).
Methods: This is a one-year observational prospective pilot study. It was conducted at the Department of Anaesthesia and Intensive Care of Pisa University. Patients with septic shock were enrolled in this study. They were divided in two groups based on the occurrence of AF while in the ICU. Data were collected at admission and after 72 hours, and the data consisted of anamnesis, vital parameters, blood results and severity score.
Results: Out of 27 patients, 9 developed AF during the first 72 hours. At admission and at 72 hours, SOFA was statistically higher in the patients with AF (p=0.012 and p=0.002, respectively). In the AF group, the overall mortality was 66.7%, whereas, it was 11.1% (p=0.006) in the patients with SR. Age, rhythm and noradrenaline dosage were univariate predictors of total mortality.
Conclusion: In patients with septic shock, AF has a high incidence, and it correlated with a worse outcome. Patients with higher SOFA score are at a greater risk of developing arrhythmia.

9.Sedation Practices and Preferences of Turkish Intensive Care Physicians: A National Survey
Seval Ürkmez, Elif Erdoğan, Tuğhan Utku, Yalım Dikmen
doi: 10.5152/TJAR.2019.49799  Pages 220 - 227
Amaç: Yoğun bakım ünitelerinde sedasyon en sık uygulamalardandır ve günümüzde sedasyon, analjezi ve delirium yönetimi bu ünitelerde bir kalite ölçüm göstergesidir. Sedasyon konusunda bazı rehberler ve sedasyon uygulamalarını araştıran pek çok anket çalışması yayınlandı, ancak Türkiye’de sedasyon uygulamaları konusunda bilgi eksikliği mevcuttur. Bu çalışmanın amacı, ülkemizdeki yoğun bakım doktorlarının sedasyon uygulamaları ve tercihleri hakkında temel bir bilgi sağlamak ve geliştirilmesi gereken bazı noktaları belirlemektir.
Yöntemler: Otuzdört sorudan oluşan bir anket formu geliştirildi ve Türk Yoğun Bakım Derneği üye veri tabanında kayıtlı doktorların e-mail adreslerine gönderildi. Anket demografik özellikler ve sedasyon, analjezi, nöromüsküler bloker ve deliryum uygulamaları hakkında soruları içerdi.
Bulgular: E-mail gönderilen 1700 doktordan 429’u (%25) anketi yanıtladı. Ankete katılanların %98’I sedasyon uygulamaktaydı ve primer sedasyon endikasyonu mekanik ventilasyondu (%94). Yoğun bakım ünitelerinde yazılı bir sedasyon protokolünün varlığı %37 idi. Sedasyon için en çok tercih edilen ilaç midazolamdı (%90). Ağrı soruları ile ilgili, en sık kullanılan ağrı değerlendirme gereci vizüel analog skala (69.0%) ve en çok tercih edilen ilaç tramadoldü. Katılımcıların neredeyse yarısı rutin olarak deliryumu değerlendirmekte ve yoğun bakım konfüzyon değerlendirme metodu kullanmaktaydı.
Sonuç: Bu anketin sonuçları geliştirilmesi gereken bazı alanlara işaret etmektedir ve sedasyon, ağrı ve delirium odaklı ulusal bir rehber hazırlanması gereklidir.
ClinicalTrials.gov ID: NCT03488069
Objective: Sedation is one of the most common practices applied in the intensive care units (ICUs), and the management of sedation, analgesia and delirium is a quality measure in the ICUs. Several guidelines on sedation had been published, and many surveys investigated the practices of sedation in the ICUs, but knowledge on the sedation practices in Turkey is lacking. The aim of the present study was to provide baseline knowledge on the sedation practices and preferences of Turkish intensive care physicians and to establish some points to be improved.
Methods: An electronic survey form consisting of 34 questions was generated and posted to email addresses. The survey included questions about demographics and practices on sedation, analgesia, neuromuscular blockage and delirium.
Results: Of 1700 email addresses, 429 (25.0%) were returned. Sedation was practised by 98.0% of the respondents, and mechanical ventilation was indicated as the primary indication (94.0%) for sedation. The presence of a written sedation protocol was 37.0%. For drug choices for sedation, midazolam was the most preferred agent (90.0%). With regard to pain questions, the most commonly used evaluation tool was Visual Analogue Scale (69.0%), and the most preferred drug was tramadol. Nearly half of the participants routinely evaluated delirium and used the confusion assessment method in the ICU.
Conclusion: The results of this survey have indicated some areas to be improved, and a national guideline should be prepared taking pain, agitation and delirium in focus. ClinicalTrials.gov ID: NCT03488069.

10.Anaesthetic Management for Face Transplantations: The Experience of Akdeniz University
Necmiye Hadımıoğlu, Melike Cengiz, Atilla Ramazanoğlu, Özlenen Özkan, Mustafa Gökhan Ertosun, Nilgun Bilal, Ömer Özkan
doi: 10.5152/TJAR.2019.04935  Pages 228 - 234
Amaç: Solid organ transplantasyonları yaşam kurtaran operasyonlar olmasına karşın kompozit doku nakillerinden biri olan yüz nakli yaşam kalitesini artıran nakillerdir. Pek çok rekonstrüktif cerrahi geçirmiş olan hastalarda zor hava yolu, ciddi kanama ve uzun cerrahi süresi gibi anestezi yönetimi zorlukları mevcuttur.
Yöntemler: Bu çalışmada merkezimizde gerçekleştirilmiş olan 4 tam bir parsiyel olmak üzere 5 yüz nakli operasyonu gözden geçirildi. Operasyon öncesi, operasyon sırasında ve sonrasında karşılaşılan güçlükler özetlendi.
Bulgular: Hastalarımızın 2 tanesi kalıcı trakeostomisi olan hastalardı (3. ve. 4. hasta). 2. ve 5. hastada lokal anestezi ve sedasyon ile trakeostomi açıldıktan sonra operasyon başlatıldı. 1. hasta herhangi bir güçlükle karşılaşılmadan genel anestezi altında oral olarak entübe edildi ve trakeostomi açıldıktan sonra operasyona devam edildi. Hastalarımızdan ikisine (2. ve 4. hastada) 13 Ü eritrosit süspansiyonu; ikisine (1. ve 4. hastada) 5 Ü eritrosit süspansiyonu verildi. Orta yüz nakli yapılan ve operasyon süresi 7.5 saat olan 5. hastada kan transfüzyonu gereksinimi olmadı. İntaoperatif ve postoperatif dönemde yaşamı tehtid eden ciddi bir komplikasyonla karşılaşılmadı.
Sonuç: Sonuç olarak yüz nakli operasyonları anestezinin zorlu girişimlerinden biridir. Zor havayolu yönetimi, ciddi kanama, uzun cerrahi süresi, postoperatif yoğun bakım izlemi gibi zorlu konularla baş edilmesi gerekir. Hastaların hemodinamik olarak monitorizasyonu ve yakın izlemle yan etkiler ve komplikasyonlar en aza indirilebilir.
Objective: Solid organ transplantation is a rescue therapy, whereas face transplantation, as well as other composite tissue allotransplantations, offers treatment options to enhance the quality of life. Difficult airway, severe haemorrhage and prolonged operative length are among the frequently encountered complications of anaesthetic management in patients with a history of multiple reconstructive surgeries.

Methods: Five face allotransplants that were performed in our institute, arising from four full and one partial face transplantations, were reviewed. The pitfalls encountered before, during and following surgery were then summarised.

Results: Two of our patients (patients 3 and 4) underwent permanent tracheostomy preoperatively. Transplantation was initiated after surgical tracheostomy under local anaesthesia and under sedation in cases 2 and 5. Patient 1 was orally intubated without difficulty under general anaesthesia and was operated following tracheal cannulation via surgical tracheostomy. Thirteen units of red blood cells were transfused each for patients 2 and 4. Two other patients (patients 1 and 4) each received 5 units of red blood cells. Patient 5, who underwent mid-face transplantation lasting for 7.5 h, was not transfused. No major life-threatening complications were observed intraoperatively or following surgery.

Conclusion: Face transplantation is a surgical procedure in which anaesthetic management may be problematic. The anaesthetist may encounter difficulties, such as difficult airway, severe bleeding, a prolonged operative time and postoperative complications. Side effects and complications may be reduced by strict follow-up and haemodynamic monitoring of patients.

CASE REPORT
11.Ultrasound-Guided Continuous Erector Spinae Plane Block in a Patient with Multiple Rib Fractures
Rakesh Kumar, Ankur Sharma, Rakhi Bansal, Manoj Kamal, Lovepriya Sharma
doi: 10.5152/TJAR.2018.46794  Pages 235 - 237
The invention of new modalities in regional anaesthesia has included a number of important fascial plane blocks. We here describe a case of a successful erector spinae plane block using a continuous catheter technique for pain relief in a patient with multiple rib fractures.

12.Combined use of Ventrain and S-Guide for Airway Management of Severe Subglottic Stenosis
Maël Zuercher, Mélanie Pythoud-brügger, Kishore Sandu, Patrick Schoettker
doi: 10.5152/TJAR.2019.75428  Pages 238 - 241
The airway management of a patient with severe tracheal stenosis depends on its severity, length, location, and type of surgery. Its management is complex and requires the collaboration of an experienced team of anaesthetist and ear, nose, and throat surgeon. We report an innovative combination of Ventrain™ and S-Guide™ for airway management of a planned endoscopic dilation of a severe subglottic stenosis in an adult patient. This new alternative may offer advantages over existing airway management techniques in similar cases.

LETTER TO THE EDITOR
13.The Negative Influence of Cigarette Smoke on Passive Smokers-Deteriorated Pulmonary Function Tests and Increased Urine Cotinine Levels
Yahya Yıldız, İbrahim Özgür Önsel, Bahadır Çiftçi, Murat Uğurlucan
doi: 10.5152/TJAR.2019.98415  Pages 242 - 243
Abstract | Full Text PDF

GUIDELINES
14.Pre-Operative Evaluation of Adults Undergoing Elective Noncardiac Surgery: Summary of the Updated Guideline From the European Society of Anaesthesiology
Berrin Günaydın, Ömer Kurtipek
doi: 10.5152/TJAR.2019.150419  Pages 244 - 272
Abstract | Full Text PDF