Turk J Anaesthesiol Reanim: 47 (4)
Volume: 47  Issue: 4 - August 2019
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REVIEW
1.Current Use of Neuromuscular Blocking Agents in Intensive Care Units
Büşra Tezcan, Sema Turan, Ayşegül Özgök
doi: 10.5152/TJAR.2019.33269  Pages 273 - 281
Nöromüsküler bloker ilaçlar, yoğun bakım ünitelerinde; mekanik ventilatör desteği alan hastalarda, hasta ventilatör uyumsuzluğunu ortadan kaldırmak, intraabdominal basıncı azaltıp, göğüs duvarı kompliyansını arttırarak gaz değişimini kolaylaştırmak, akciğerlerde barotravma riskini azaltmak, titremeyi önleyerek kasların oksijen tüketimine katkısını azaltmak, havayolu uyarısına bağlı intrakraniyal basınç artışını sınırlamak gibi amaçlarla kullanılabilir. Akut Respiratuar Distress Sendromu (ARDS), Status Astmatikus, artmış intrakraniyal basınç, ventriküler fibrilasyona bağlı kardiyak arrest sonrası teropatik hipotermi uygulamaları, bu amaçlarla nöromusküler bloker infüzyonunun kullanılabileceği bazı klinik alanlardır. Yoğun bakımda edinilmiş güçsüzlük, epileptik nöbetlerin maskelenmesi, yoğun bakım ve hastanede kalış sürelerinin uzayabilmesi gibi yan etkiler göz önünde bulundurulduğunda; uygun endikasyon ve kullanım pratiği önem kazanmaktadır. Bu yazının temel amacı; yetişkin yoğun bakım ünitelerindeki nöromüsküler bloker kullanım pratiğini özetlemenin yanında, bu ilaçların kardiyopulmoner resüsitasyon sonrası terapötik hipotermide titremenin önlenmesi ve erken ARDS döneminde oksijenasyonun iyileştirilmesi gibi yoğun bakımdaki güncel kullanım alanları konusundaki bilgilerin derlenmesidir.
Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation–associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report.

CLINICAL RESEARCH
2.Preoperative Fasting Times for Patients Undergoing Caesarean Delivery: Before and After a Patient Educational Initiative
Mary Yurashevich, Adrian Chow, John J. Kowalczyk, Andrea J. Traynor, Brendan Carvalho
doi: 10.5152/TJAR.2019.95770  Pages 282 - 286
Objective: Prolonged preoperative fasting may lead to dehydration, hypoglycaemia, ketoacidosis and delayed recovery. We hypothesised that a patient educational initiative would decrease our preoperative fasting periods for elective caesarean delivery.
Methods: This was an observational quality improvement impact study. Elective caesarean patients who delivered during our study period were included in the study, 40 patients in the pre-intervention and 40 patients in the post-intervention groups. Only English-speaking patients were included. We developed a patient educational pamphlet outlining preoperative fasting and analgesic expectations for caesarean delivery that was given to every patient at her preoperative anaesthesia consultation. The pamphlet included the American Society of Anesthesiologists’ preoperative fasting and enhanced recovery carbohydrate drink recommendations. The primary outcome measure was intended fasting duration for liquids (defined as time from last reported liquid consumption to scheduled caesarean delivery) before and after the patient educational initiative. Secondary outcomes included solid fasting time, types of liquids and solids consumed.
Results: The intended median (interquartile range) fasting time for liquids decreased from 10 (8.9-12) h to 3.5 (2.5-10) h (p<0.001). The fasting period for solids was not significantly different: 12.5 (10.5-14) h pre- versus 12.4 (10.6-14) h post-pamphlet introduction (p=0.384). Despite the recommendation, only 22.5% consumed a carbohydrate-containing drink with a modest decrease in water consumption (87.5% before and 67.5% after; p=0.009).
Conclusion: A patient educational pamphlet significantly reduced fasting time for clear liquids. Future studies are needed to determine what barriers limited adherence to the recommended carbohydrate-containing drink consumption.

3.Comparison of the Effects of Epidural Levobupivacaine with Tramadol or Morphine Addition on Postoperative Analgesia following Major Abdominal Surgery
Zeynep Türkoğlu, Feride Karacaer, Ebru Biricik, Murat Ilgınel, Hakkı Ünlügenç
doi: 10.5152/TJAR.2019.00936  Pages 287 - 294
Amaç: Erişkin hastalardaki majör abdominal cerrahide, epidural yolla uygulanan levobupivakaine, tramadol veya morfin eklenmesinin postoperatif analjezideki etkinliği araştırılmıştır.
Yöntemler: Çalışmaya majör abdominal cerrahi uygulanacak 18-65 yaş arasında, ASA I-II grubu 60 hasta alındı. Tüm hastalara oturur pozisyonda epidural kateter yerleştirildi. Hastalar Levobupivakain (Grup L), Levobupivakain +Morfin (Grup LM), Levobupivakain+Tramadol (Grup LT) şeklinde 3 gruba ayrıldı. Genel anestezi uygulanan hastalara operasyon bitiminden 30 dakika önce epidural kateterden yükleme dozu olarak; Grup L’de 25 mgr %0,5 Levobupivakain + 15 mL salin, Grup LM’de 25 mg %0,5 Levobupivakain + 14,5 mL salin + 100 mikrogram morfin, Grup LT’de 25 mgr %0,5 Levobupivakain + 13 mL salin + tramadol 100 mg uygulandı. Postoperatif dönemde analjezi, epidural yoldan hasta kontrollü analjezi cihazı ile sağlandı. Bolus dozu, Grup L’de levobupivakain 12 mg, Grup LM’ de levobupivakain 12 mg+morfin 1,2 mg, Grup LT’de levobupivakain 12 mg+tramadol 12 mg ve 3 grupta kilitli kalma süreleri 15 dk olacak şekilde düzenlendi. Postoperatif dönemde hastalar vizüel analog skala, hasta kontrollü analjezi’den talep edilen ve bolus verilen levobupivakain, morfin, tramadol’ün doz ve sayıları yönünden postoperatif 30. dk, 1., 2., 6., 12., 24., saatlerde izlenerek kaydedildi.
Bulgular: Vizüel analog skala skorlarının Grup L’de Grup LM ve Grup LT’ye göre yüksek olduğu, Grup L’de Grup LM ve LT’ye göre daha az bulantı kusma görüldüğü saptandı.
Sonuç: Majör abdominal cerrahide uygulanan postoperatif analjezide morfin veya tramadol ile kombine edilmiş levobupivakainin sürekli epidural analjezi şeklinde uygulanması etkin ve güvenilir bir yöntemdir.
Objective: The study was designed to compare the postoperative analgesic efficacy of epidural tramadol or epidural morphine as adjuvant to levobupivacaine in major abdominal surgery.
Methods: Patients in ASA I-II group aged between 18 and 65 years were included in study. Epidural catheter was introduced. Patients were randomised into three groups to receive levobupivacaine (Group L), levobupivacaine+morphine (Group LM) and levobupivacaine+tramadol (Group LT). General anaesthesia was administered to all patients. The solution intended for Group L contained 25 mg 0.5% levobupivacaine+15 mL saline, that for Group LM contained 25 mg 0.5% levobupivacaine+14.5 mL salin+100 μg morphine and that for Group LT contained 25 mg 0.5% levobupivacaine+13 mL salin+100 mg tramadol, which was administered via epidural catheter as loading dose 30 min before the end of the operation. Patient-controlled analgesia device was connected to the epidural catheter to provide postoperative analgesia. Bolus dose was adjusted to 12 mg levobupivacaine in Group L, 12 mg levobupivacaine +1.2 mg morphine in Group LM and 12 mg levobupivacaine+12 mg tramadol in Group LT. Lock-out period was adjusted to 15 min in three groups. Quality of analgesia was evaluated using Visual Analogue Scale; administered and demand doses of levobupivacaine, morphine and tramadol were compared at 30 min, 1, 2, 6, 12 and 24 h postoperatively.
Results: Visual Analogue Scale scores were significantly higher in Group L than Groups LM and LT. Nausea and vomiting observed in Group L were lesser than those in Groups LM and LT.
Conclusion: Continuous epidural analgesia using levobupivacaine combined with morphine or tramadol is an effective method for managing postoperative analgesia in major abdominal surgery.

4.Effects of Ultrasound-Guided Thoracic Paravertebral Block on Postoperative Pain in Children Undergoing Percutaneous Nephrolithotomy
Gülşah Akıncı, Zehra Hatipoğlu, Ersel Güleç, Dilek Özcengiz
doi: 10.5152/TJAR.2019.81205  Pages 295 - 300
Amaç: Perkütan nefrolitotomi (PNL) uygulanan pediatrik hastalarda ultrason eşliğinde yapılan torasik paravertebral blok (PVB) ve intravenöz parasetamolün postoperatif ağrı kontrolüne etkisini karşılaştırmak.
Yöntemler: ASA I - II ve 1-5 yaş arası, PNL için planlanan 40 hasta prospektif randomize kontrollü çalışmaya dahil edildi. Ameliyathaneye alındıktan sonra tüm hastalara standart genel anestezi uygulandı. Grup PVB'deki hastalara T11, T12 ve L1 vertebral seviyelerinde 0.5 mL kg-1 toplam hacimde% 0.5 bupivakain kullanılarak ultrason eşliğinde PVB uygulandı. Grup P'deki hastalara ameliyat başlamadan önce parasetamol (15 mg kg-1) intravenöz olarak uygulandı. Her iki gruptaki hastalara ek analjezi için tramadol (1 mg kg-1) verildi. Hasta demografik özellikleri, hemodinamik parametreler, periferik oksijen satürasyonu ve sevofluran konsantrasyonu kaydedildi. Postoperatif dönemde FLACC (Yüz, Bacaklar, Aktivite, Cry ve Consolability) ağrı skorları, ebeveynlerin memnuniyeti, ek analjezi gerektiren hasta sayısı ve komplikasyonlar değerlendirildi.
Bulgular: Ağrı skorları grup PVB'de grup P'ye göre anlamlı olarak düşüktü (p = 0.001). PVB grubunda analjezik gereksinimi olmadı; ancak, grup P'deki tüm hastaların ek analjezik uygulandı. Ebeveyn memnuniyeti grup PVB'de grup P'ye göre daha yüksekti.
Sonuç: Bu çalışma, PNL uygulanan çocuklarda ultrason eşliğinde - PVB'nin IV parasetamol ile karşılaştırıldığında yan etki olmaksızın daha etkili postoperatif analjezi sağladığını göstermiştir.
Objective: To compare the effects of ultrasound-guided thoracic paravertebral block (PVB) and intravenous paracetamol on postoperative pain control in paediatric patients undergoing percutaneous nephrolithotomy (PNL).
Methods: Forty patients aged 1-5 years, with an American Society of Anesthesiologists physical status I-II, scheduled for PNL were enrolled into this prospective randomised controlled trial. After arrival in the operating room, all patients were administered standardised general anaesthesia. Patients in Group PVB received ultrasound-guided PVB using bupivacaine 0.5% at a total volume of 0.5 mL kg-1 at the vertebral levels T11, T12 and L1. Patients in Group P were administered paracetamol intravenously (15 mg kg-1) before the beginning of surgery. Patients in both groups were given tramadol (1 mg kg-1) for supplemental analgesia. Patient demographics, haemodynamic parameters, peripheral oxygen saturation and sevoflurane concentration were recorded. The Face, Legs, Activity, Cry and Consolability pain scores; satisfaction of parents; the number of patients requiring supplemental analgesia; and complications were evaluated during the postoperative period.
Results: Pain scores were significantly lower in Group PVB compared with Group P (p=0.001). There were no analgesic requirements in Group PVB; however, all patients needed a supplemental analgesic in Group P. Parental satisfaction was higher in Group PVB than in Group P.
Conclusion: This study demonstrated that ultrasound-guided PVB provides more effective postoperative analgesia with no side effects compared to intravenous paracetamol in children undergoing PNL.

5.The Effects of Locally Administered Morphine Over the Dura on Postoperative Morphine Consumption and Pain After Lumbar Disc Surgery: A Prospective, Randomised, Double-Blind and Placebo-Controlled Study
Oğuzhan Kayhan, Eren Fatma Akçıl, Özlem Korkmaz Dilmen, Yusuf Tunalı
doi: 10.5152/TJAR.2019.77854  Pages 301 - 306
Amaç: Perioperatif dönemde yan etkilerden kaçınarak etkin bir ağrı tedavisi yönetimi hasta için önemlidir. Lomber disk cerrahisinde orta-ciddi derecede postoperatif ağrı gelişmekte ve opioidler sıklıkla kullanılmaktadır. Bu çalışmanın birincil amacı dura üzerine yerleştirilen 1 mg ve 2 mg morfin emdirilmiş emilebilir hemostatik materyalin postoperatif 24 saatte morfin tüketimi üzerine etkisini, ikincil amaçları ise ağrı skorları ve opoid ilişkili yan etkiler üzerine etkilerini karşılaştırmaktı.
Yöntemler: Bu çalışma 44 hastada (ASA I, II) yapıldı. Diskektomiden sonra kapamadan önce A Grubunda (n=15) 1mg morfin emdirilmiş emilebilir hemostatik materyal dura üzerine yerleştirildi. B Grubunda (n=14) aynı teknikle 2 mg morfin, C Grubunda (n=15) (kontrol) normal salin kullanıldı. Tüm hastalar lomber disk cerrahisi sonrası 24 saatte iv morfin hasta kontrollü analjezi pompası kullandılar. Postoperatif 10. dakika, birinci, ikinci, altıncı, on ikinci ve yirmi dördüncü saatlerde morfin tüketimi, ağrı skorları ve opioid yan etkileri kaydedildi.
Bulgular: Gruplararası morfin tüketimi, ağrı skorları ve opioid yan etkileri benzerdi.
Sonuç: Tek seviye lomber diskektomi sonrası dura üzerine yerleştirilen 1 mg ve 2 mg morfin emdirilmiş emilebilir hemostatik materyal, postoperatif 24 saatte morfin tüketimi, ağrı skorları ve opioid yan etkilerini azaltmamaktadır.
Objective: Effective pain management by avoiding side effects in the perioperative period is essential for patient outcome. Lumbar disc surgery is associated with moderate to severe postoperative pain, and opioids are widely used. The primary aim of the present study was to compare the effects of 1 mg and 2 mg morphine-impregnated absorbable cellulose haemostat material placed over the dura on morphine consumption, and the secondary aims were to compare pain scores and opioid-related side effects during postoperative 24 h.
Methods: The study included 44 patients (American Society of Anesthesiologists I and II). After the discectomy procedure and before the closure, in Group A (n=15), 1 mg morphine-impregnated absorbable cellulose haemostat material placed over the dura was used. In Group B (n=14), 2 mg morphine was used for the same technique, and in Group C (n=15) (control), normal saline was used. All patients used intravenous morphine patient-controlled analgesia pumps for 24 h following lumbar disc surgery. Morphine consumption, pain scores and opioid-related side effects were recorded at 10 min, 1, 2, 6, 12 and 24 h postoperatively.
Results: Morphine consumption, pain scores and opioid-related side effects were similar among the groups.
Conclusion: Morphine-impregnated absorbable cellulose haemostat material placement over the dura after single level lumbar discectomy did not reduce postoperative morphine consumption, pain scores and incidence of opioid-related side effects.

6.Diagnostic Performance of 6-Point Lung Ultrasound in ICU Patients: A Comparison with Chest X-Ray and CT Thorax
Mohammad Danish, Aarti Agarwal, Puneet Goyal, Devendra Gupta, Hira Lal, Raghunandan Prasad, Sanjay Dhiraaj, Anil Agarwal, Prabhaker Mishra
doi: 10.5152/TJAR.2019.73603  Pages 307 - 319
Amaç: To evaluate the diagnostic performance of a rapid bedside 6-point lung ultrasonography (LUS) performed by ICU physician for detection of 4 common pathological conditions of lung; alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax in critically ill patients and its comparison with bedside chest X-ray (CXR) and high resolution computerized tomographic scan (CT) of thorax. Volume of pleural effusion measured by LUS and CT thorax was also compared.
Yöntemler: It was a cross-sectional, observational study of 90 adult patients with acute lung injury score of ≥1 admitted to medical-surgical ICU. They were examined by CXR and 6 point LUS as per BLUE protocol at bedside, followed by CT thorax in radiology department.
Bulgular: Sensitivity of 6-point LUS for detecting alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax was 76%, 88%, 83% and 89% respectively, which was remarkably higher than CXR. Specificity of LUS was 100% for all pathologies which was again notably higher than CXR except for interstitial syndrome for which it was 88.5%. Measurement of volume of pleural effusion by LUS was comparable and had strong absolute agreement with CT thorax.
Sonuç: 6-point LUS can be a useful diagnostic tool, better than CXR in diagnosing respiratory pathologies in critically ill patients. Because of comparable diagnostic performance of LUS and CT scan and with increasing evidence in favour of LUS, requirement of CT thorax can be reduced. Radiation hazards associated with CXR and CT as well as potentially risky transfer of patients to CT room can also be minimised.
Objective: To evaluate the diagnostic performance of a rapid bedside 6-point lung ultrasonography (LUS) performed by an intensive care unit (ICU) physician for detection of four common pathological conditions of the lung, such as alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax, in critically ill patients and its comparison with bedside chest X-ray (CXR) and high-resolution computed tomography (CT) scan of the thorax. Volume of pleural effusion measured by LUS and CT thorax was also compared.
Methods: This was a cross-sectional, observational study of 90 adult patients with an acute lung injury score of ≥1 admitted to the medical-surgical ICU. They were examined by CXR and 6-point LUS as per BLUE protocol at bedside, followed by CT thorax in the radiology department.
Results: The sensitivity of 6-point LUS for detecting alveolar consolidation, pleural effusion, interstitial syndrome and pneumothorax was 76%, 88%, 83% and 89%, respectively, which was remarkably higher than that of CXR. The specificity of LUS was 100% for all pathologies, which was again notably higher than that of CXR except for interstitial syndrome for which it was 88.5%. Measurement of volume of pleural effusion by LUS was comparable and had a strong absolute agreement with CT thorax.
Conclusion: 6-Point LUS can be a useful diagnostic tool and is better than CXR in diagnosing respiratory pathologies in critically ill patients. Owing to the comparable diagnostic performance of LUS and CT scan and with increasing evidence in favour of LUS, the requirement of CT thorax can be reduced. Radiation hazards associated with CXR and CT, as well as potentially risky transfer of patients to CT room, can also be minimised.

7.Effectiveness of Soluble Recombinant Human Thrombomodulin in Patients with Severe Acute Pancreatitis Complicated by Disseminated Intravascular Coagulation
Takeshi Yano, Masahiko Taniguchi, Tetsuro Shirasaka, Isao Tsuneyoshi
doi: 10.5152/TJAR.2019.42709  Pages 320 - 326
Objective: We aimed to evaluate retrospectively the effect of soluble recombinant human thrombomodulin (rTM) on prognosis in patients with severe acute pancreatitis complicated by disseminated intravascular coagulation (DIC).
Methods: Based on Japanese diagnostic criteria of acute pancreatitis and DIC, patients who entered our intensive care unit (ICU) were selected. Comparisons were made between patients treated with rTM (rTM group) and without rTM (control group).
Results: A total of 38 patients were selected, and rTM was administered to 13 patients. Mortality on the 60th day after entering the ICU was significantly lower in the rTM group (15%) as compared with the control group (56%) (p=0.036). Although the platelet count was significantly lower in the rTM group at the start of treatment, the reversal rate from DIC was significantly higher than in the control group (rTM 62%, control 24%, p=0.035). According to logistic regression analysis of therapeutics, only rTM contributed to survival on the 60th day (odds ratio, 12.5; 95% confidence interval, 1.80-160; p=0.009).
Conclusion: In patients with severe acute pancreatitis complicated by DIC, it was suggested that rTM might improve the prognosis of survival, even if the platelet count was markedly reduced.

8.Effect of Nutritional Support Containing Arginine, Glutamine and β-hydroxy-β-methylbutyrate on the Protein Balance in Patients with Major Burns
Deniz Erdem, İsa Sözen, Müge Çakırca, Dilşen Örnek, Dilek Kanyılmaz, Belgin Akan, Ahmet Çınar Yastı
doi: 10.5152/TJAR.2019.40327  Pages 327 - 333
Amaç: Majör yanıklı hastalarda, arjinin, glutamin ve β-hidroksi-β-metilbutirat (HMB) içeren nutrisyonel destek ürününün nutrisyon parametreleri üzerine etkilerini değerlendirmek.
Yöntemler: Yanık ünitesinde tedavi edilen 40 major yanıklı hastanın, 20’sine standart nutrisyonel destek verilirken 20’sine de standart nutrisyonel desteğe ek olarak çalışma ürünü eklendi. Tedavinin ilk, 14 ve 28. günlerinde biyokimyasal labaratuar testlerinin sonuçları ve yanık ciddiyeti kaydedildi. Kırk hastanın kaydedilen bu sonuçları çalışma ve kontrol grubu olarak karşılaştırıldı.
Bulgular: Çalışma ürününün verildiği grupta albumin, prealbumin ve total protein değerleri, kontrol gurubu ile karşılaştırıldığında anlamlı şekilde yüksek bulunmuştur. (sırasıyla p=0.021, p=0.02, p<0.001). Yanık travması geçiren hastalarda beklendiği dibi hemoglobin ve CRP düzeyleri düşmüştür.
Sonuç: Bu çalışmada bulunan sonuçlar göstermektedir ki, yanık hastalarında nutrisyonel desteğe glutamin ve β-hidroksi-β-metilbutirat eklenmesi, protein dengesi üzerinde olumlu etkiler oluşturmuştur.
Objective: To evaluate the effect of a supplementary nutritional product containing arginine, glutamine and β-hydroxy-β-methylbutyrate (HMB) on the nutritional parameters of patients with major burns.
Methods: In a total of 40 patients with major burns treated in the Burns Unit, standard nutritional support was administered to 20 patients, and the study product was added to the standard nutritional support of the remaining 20 patients. The biochemical laboratory test results and burn severity were recorded on the first day of treatment and on Days 14 and 28. The 40 patients were divided as the study and the control group, and their results were compared.
Results: An increase in the albumin, prealbumin and total protein values in the group administered with the study product was found to be statistically significant compared to the control group (p=0.021, p=0.02, p<0.001, respectively). The decreases in haemoglobin and C-reactive protein (CRP) were at the levels expected in burn trauma.
Conclusion: The results obtained in this study demonstrated that the addition of arginine, glutamine and HMB to the nutrition of patients with burns had a positive effect on the protein balance.

9.Impact of Prehospital Mobile Intensive Care Unit Intervention on Mortality of Patients with Sepsis
Romain Jouffroy, Anastasia Saade, Pascal Philippe, Pierre Carli, Benoit Vivien
doi: 10.5152/TJAR.2019.26576  Pages 334 - 341
Objective: The outcome of sepsis relies on the early diagnosis and implementation of appropriate treatments. For management of out-of-hospital patients with sepsis, prehospital emergency services, named Service d’Aide Médicale d’Urgence (SAMU) in France, dispatch to the scene an emergency mobile team (EMT) or a mobile intensive care unit (MICU) based on the patient’s severity. Therefore, patients are admitted to the emergency department (ED) or to the intensive care unit (ICU). The impact of MICU intervention on patient’s prognosis remains unclear. The aim of the present study was to describe the impact of MICU intervention on mortality on day 28 (D28) of patients with sepsis.
Methods: We performed a retrospective study on patients with sepsis managed by prehospital teams, MICU or EMT, before admission to the ED or ICU. The primary outcome was mortality on D28.
Results: The SAMU received 30,642 calls during the study period with 140 patients with suspected sepsis. The suspected origin of sepsis was mainly pulmonary for 78 (55%) patients. Thirteen (9%) patients died on D28, 12 in the ED and 1 in the ICU. Two patients were admitted to the hospital by a MICU. After adjusting for confounding factors, the relative risk of mortality on D28 for patients admitted to the hospital by a MICU was 0.40.
Conclusion: We describe an association between MICU intervention and mortality on D28. MICU intervention for out-of-hospital patients with sepsis is associated with 60% reduced mortality on D28. Larger studies are needed to confirm the impact of the intervention of MICU on mortality of patients with sepsis.

CASE REPORT
10.Chlorhexidine Allergy: Mild Allergic Reactions Can Precede Anaphylaxis in the Healthcare Setting
Morten Schjørring Opstrup, Lene Heise Garvey
doi: 10.5152/TJAR.2019.22058  Pages 342 - 344
Chlorhexidine can cause severe immediate-type allergic reactions such as urticaria, anaphylactic shock or, even, cardiac arrest. We report the case of a patient who developed perioperative anaphylactic shock caused by chlorhexidine 1 year after a postoperative urticarial reaction, which was assumed not to be significant at the time. This case highlights the importance of identifying mild allergy symptoms after exposure to chlorhexidine at the pre-anaesthetic assessment to prevent more severe allergic reactions in future.

11.Analgesia and Anaesthesia Management of Labour and Caesarean Delivery for a Parturient with Paramyotonia Congenita
Nazuha Mohd Najid, Thohiroh Abdul Razak, Dudu Berrin Günaydın
doi: 10.5152/TJAR.2019.69094  Pages 345 - 347
Anaesthetic management in paramyotonia congenita (PC) or ‘paradoxical myotonia’ poses perioperative challenges to the anaesthesiologists both in obstetric and non-obstetric surgical patients. There are only a few case reports on the anaesthesia management particularly in the obstetric population. Therefore, we aimed to present the management of analgesia of labour and emergency caesarean delivery for a 26-year-old parturient with PC.

12.Acute Encephalitis and Myocarditis Associated with Respiratory Syncytial Virus Infections
Seher Erdoğan, Kahraman Yakut, Sevinç Kalın
doi: 10.5152/TJAR.2019.52028  Pages 348 - 351
Respiratuvar sinsityal virüs(RSV), çocuklarda akut solunum yolu enfeksiyonlarının en sık nedenlerinden biridir. RSV enfeksiyonlarının %1-2'si hastaneye yatışı gerektirir. Solunum sistemine ek olarak, dolaşım sistemi ve nörolojik sistemi de etkileyebilir.
Olgu sunumu: Daha önce sağlıklı olan 7 yaşında kız hasta solunum sıkıntısı nedeniyle çocuk yoğun bakım ünitesine yatırıldı. Hasta solunum yetmezliği nedeniyle entübe edilerek mekanik ventilatöre bağlandı. Trakeal aspiratında viral multipleks PCR çalışıldı ve RSV pozitif bulundu. Ekokardiyografik incelemesinde sol ventrikül disfonksiyonu saptandı.Sıvı kısıtlaması yapıldı, intravenöz furosemid ve inotrop desteği verildi. Kranial manyetik rezonans incelemesinde akut hemorajik ensefalit bulguları vardı. Hastaya taze donmuş plazma ile 5 seans terapotik plazma değişimi uygulandı. Yatışının 18.gününde ekstübe edildi ve yüksek akışlı nazal kanül ile oksijen tedavisi verildi. 23.günde klinik bulguları stabil seyreden hasta pediatri servisine transfer edildi.
Sonuç: Akut miyokardit ve nekrotizan ensefalit olgularının ayırıcı tanısında RSV enfeksiyonu da hatırlanmalıdır.
Respiratory syncytial virus (RSV) is one of the most common causes of acute respiratory tract infections among children. 1%-2% of RSV infections require hospitalization. In addition to the respiratory system, cardiovascular system may be also affected by the RSV infection. A 7-year-old, previously healthy, female patient presenting with respiratory difficulties was admitted to the paediatric intensive care unit. The patient was intubated and connected to a mechanical ventilator because of acute respiratory failure. Her tracheal aspirate was studied for viral multiplex polymerase chain reaction (PCR), and RSV positivity was detected. Her echocardiogram revealed left ventricular dysfunction. She was put on fluid restriction, intravenous furosemide, and inotropic support. Her cranial magnetic resonance examination showed the signs of acute haemorrhagic encephalopathy. She underwent five sessions of therapeutic plasma exchange with fresh frozen plasma. She was extubated on the 18th day of admission and provided with respiratory support with high-flow oxygen therapy thereafter. On the 23rd day, when her clinical status remained stable, she was transferred to the paediatrics ward. An RSV infection should be considered in cases with acute necrotising encephalitis and myocarditis.

13.Anaesthesia Management of Premature Conjoined Twins with Anal Atresia
Zehra Hatipoğlu, Önder Özden, Mahir Bahçeci, Dilek Özcengiz
doi: 10.5152/TJAR.2019.12316  Pages 352 - 354
Yapışık ikizlerin anestezi yönetimi hem anestezi uzmanları hem de ikizler için bazı zorluklara sahiptir. Havayolu yönetimi, çapraz dolaşım mevcudiyeti, hipotermi ve pozisyon anestezi sırasında önemli noktalardır. Bu raporda anal atrezili omphalopaguslu ikizlerde kolostomi açılması ve ultrason eşliğinde santral venöz kateterizasyonu sırasında anestezi yönetimleri sunulmaktadır.
Anaesthesia management of the conjoined twins poses some difficulties both for the anaesthesiologist and the twins. The airway management, presence of cross circulation, hypothermia and positioning are significant points during anaesthesia. We report the anaesthetic management during the colostomy opening of omphalopagus twins with anal atresia, and ultrasound-guided central venous catheterisation.

LETTER TO THE EDITOR
14.Use of Thromboelastography for Solving Neuraxial Blockade Dilemma
Nupur Karan, Sumitra G. Bakshi, Vijaya Patil, Atikh Sayed
doi: 10.5152/TJAR.2019.05695  Pages 355 - 356
Abstract | Full Text PDF

15.A Pain Medicine Physician’s Perspective on Iatrogenic Polypharmacy
Omar Viswanath
doi: 10.5152/TJAR.2019.77674  Pages 357 - 358
Abstract | Full Text PDF