Turk J Anaesthesiol Reanim: 47 (6)
Volume: 47  Issue: 6 - December 2019
Hide Abstracts | << Back
REVIEW
1.Atelectasis in Bariatric Surgery: Review Analysis and Key Practical Recommendations
Sibel Ocak Serin, Aysun Işıklar, Gülşah Karaören, Mohamed Fawzy El-Khatib, Vania Caldeira, Antonio Esquinas
doi: 10.5152/TJAR.2019.66564  Pages 431 - 438
Obezite, çoklu organ sistemlerini, özellikle de kardiyovasküler ve solunum sistemini etkileyen bir hastalıktır. Son yıllarda, bariatrik cerrahinin morbid obezite tedavisinde altın standart olduğu bildirilmiştir. Sadece vücut kitle indeksi (VKİ) anestezi ve cerrahi ile ilgili riskleri öngörmede yetersizdir. Obezite postoperatif atelektazi oluşumuna katkıda bulunur ve fonksiyonel rezidüel kapasitenin azalmasıyla postoperatif bağımsız risk faktörü olarak kabul edilir. Bariatrik cerrahi geçiren obez hastalarda gelişen atelektazinin tedavisi ve reversibilitesi zordur. Bu nedenle, ameliyat öncesi pulmoner fonksiyonların optimizasyonu, perioperatif dönemde akciğer koruyucu ventilasyonu, cerrahi sonrası komplikasyonların bilinmesi ve önleyici tedbirler hakkında bilgi ve terapötik yaklaşımlar bariatrik cerrahide giderek daha fazla önem kazanmaktadır. Bu derleme, bariatrik cerrahi geçiren hastalarda perioperatif ve postoperatif dönemde atelektazi yönetiminde klinisyenlere yardımcı olmayı amaçlamıştır.
Obesity is a condition that affects multiple organ systems, particularly the cardiovascular and respiratory system. In recent years, bariatric surgery has been reported to be the gold standard in the treatment of morbid obesity. Body mass index alone is insufficient to predict risks related to anaesthesia and surgery. Obesity contributes to significant postoperative atelectasis and is considered an independent risk factor for postoperative atelectasis owing to decreased functional residual capacity. The treatment and reversibility of atelectasis developed in obese patients undergoing bariatric surgery are challenging. Therefore, an optimisation of pulmonary functions before surgery, lung-sparing ventilation during the perioperative period, awareness of potential postoperative complications and knowledge about preventive measures and therapeutic approaches have become increasingly important in bariatric surgery. The aim of this review was to aid clinicians in the management of atelectasis in patients undergoing bariatric surgery during the perioperative and postoperative period.

CLINICAL RESEARCH
2.Current Perspectives on Postoperative Cognitive Dysfunction in the Ageing Population
Ivan Urits, Vwaire Orhurhu, Mark Jones, Dylan Hoyt, Allison Seats, Omar Viswanath
doi: 10.5152/TJAR.2019.75299  Pages 439 - 447
Postoperative cognitive dysfunction (POCD) is defined as a prolonged cognitive function impairment that occurs within weeks to months of a surgical procedure. It is especially prevalent in the elderly population, leading to increased morbidity and mortality. As anaesthetic and surgical care continues to improve and become increasingly safer, a significantly greater number of older patients have elective surgical procedures today, yet this comes with an increased POCD risk as they go through the perioperative phases. Although the pathophysiology behind the development of POCD is still under investigation, current causative mechanisms include the mode of anaesthesia administered, anaesthetic used, cerebral hypoperfusion, hyperventilation and neuroinflammation. These findings lend an insight into the importance of being cognisant of the higher likelihood of POCD in at-risk patients, including the elderly, and taking precautions to include preoperative and postoperative cognitive testing, careful monitoring during anaesthesia, blood pressure control and early treatment of postoperative complications as they arise. In this review, we provide an update on the current understanding of the pathophysiology leading to POCD, identifying risk factors, prevention and treatment strategies, with a specific focus on the elderly population.

3.Effects of Inadvertent Perioperative Hypothermia on Metabolic and Inflammatory Mediators
Halide Aydın, Tuncer Şimşek, Yavuz Demiraran
doi: 10.5152/TJAR.2019.94715  Pages 448 - 455
Amaç: Perioperatif istenmeyen hipoterminin, vital bulgular, inflamatuar (Interlökin 8, 10, 18, 23 ve Pentraksin-3) ve metabolik yanıtlar (kortizol ve insülin) ile derlenme üzerine olan etkilerinin araştırılması amaçlanmıştır.
Yöntemler: Lomber stabilizasyon operasyonu yapılan 18-65 yaş arası toplam 60 hasta çalışmaya dahil edildi. Prospektif, randomize kontrollü bu çalışmada; operasyon öncesi ve sırasında ısıtılma yapılan (grup N) ve yapılmayan (grup K) hastalar olarak iki çalışma grubu oluşturuldu. IL-8, IL-10, IL-18, IL-23, PTX-3, kortizol, insülin değerleri ile birlikte diürez, kanama miktarları, vücut ısıları, derlenme skorları ve yan etkiler kaydedildi.
Bulgular: Perioperatif diürez değerleri grup K’da anlamlı olarak daha yüksek seyretmiştir. Grup N’de postoperatif süreçte daha yüksek Aldrate skoru, daha az titreme ve kusma görülmüştür. Postoperatif 1.saat de IL-10, PTX-3 ve kortizol seviyeleri grup K’da anlamlı daha yüksek saptandı. Postoperatif 24.saat de PTX-3 ve Kortizol grup K’da anlamlı yüksek bulundu. İnsülin grup N’de anlamlı daha yüksek saptandı. 72.saat de grup N’de IL-8 ve grup K’da Kortizol anlamlı daha yüksek saptandı.
Sonuç: Çalışmamızda, perioperatif dönemde hastaların ısıtılmasının kanama, diürez ve derlenme üzerine olumlu etkileri olduğu gözlenmiştir. Ayrıca normoterminin sağlanmasının inflamatuar ve metabolik yanıtı gösteren biyobelirteçleri değiştirebildiği görülmüştür.
Objective: The aim of the present study was to investigate the effects of perioperative undesirable hypothermia on inflammatory (interleukin (IL)-8, IL-10, IL-18, IL-23 and pentraxin (PTX)-3) and metabolic responses (cortisol and insulin) and recovery time.
Methods: A total of 60 patients between the ages of 18 and 65 years who were in the lumbar stabilisation operation were included in the study. In this prospective, randomised controlled study, two groups were constituted as with warmed (Group N) and not warmed (Group C) patients before and during the operation. Diuresis, blood loss, body temperature and side effects were recorded with IL-8, IL-10, IL-18, IL-23, PTX-3, cortisol and insulin levels.
Results: Perioperative diuresis was significantly higher in Group C. Aldrete score was significantly higher in Group N with less shivering and vomiting in the postoperative period. IL-10, PTX-3 and cortisol levels were found to be significantly higher in Group C in the first postoperative hour. PTX-3 and cortisol were found to be significantly higher in Group C after 24 h of the operation. Insulin was significantly higher in Group N. In 72 h, IL-8 in Group N and cortisol level in Group C were significantly higher.
Conclusion: Positive effects of heating the patients in the perioperative period on haemorrhage, diuresis, complications and recovery time were observed in our study. In addition, maintenance of normothermia appeared to modulate the biomarkers that indicate the inflammatory and metabolic responses.

4.Clinical Implications of Vocal Cord-Carina Distance and Tracheal Length in the Indian Population
Shashi Kumari, Smita Prakash, Parul Mullick, Sushil Guria, Kiran Kumar Girdhar
doi: 10.5152/TJAR.2019.20856  Pages 456 - 463
Objective: Securing the tracheal tube (TT) at a fixed recommended depth of 21/23 cm in female and male patients, respectively, may result in inappropriate placement of the TT in some patients. The aim of the present study was to determine the vocal cord-carina distance (VCD) and tracheal length (TL) to ascertain the optimal depth of TT placement during orotracheal intubation in the adult Indian population.
Methods: A total of 92 adults undergoing elective surgery under general anaesthesia with orotracheal intubation were studied. Surface anatomy airway measurements were noted. A cuffed TT (female size 7 mm ID and male size 8 mm ID) was inserted with the intubation guide mark at level with the vocal cords (VCs). Fiberoptic bronchoscopy-guided measurements were obtained for VCD, TL, TT tip-carina distance, VC-cricoid distance and lip-carina (L-C) distance.
Results: The mean±SD VCD was 12.82±2.05 and 12.02±1.44 cm, and TL was 10.14±2.04 and 9.37±1.28 cm in male and female patients, respectively. Statistically significant differences were observed between male and female patients in VCD (p=0.033), TL (p=0.032), L-C distance (p<0.001) and lip-TT tip distance (p<0.001); lip-TT tip distance was 19.50±1.39 cm in male patients and 18.17±1.28 cm in female patients. The L-C distance correlated with patient height, weight and neck length. L-C distance=7.214+0.049×Height+0.320×Neck length+0.033×Weight.
Conclusion: We recommend placing the TT with its proximal guide mark at the level of VCs in the Indian population. The 21/23 cm rule for tube placement depth in female and male patients, respectively, cannot be routinely followed in the Indian population.

5.Use of a Combined Laryngo-Bronchoscopy Approach in Difficult Airways Management: A Pilot Simulation Study
Filippo Sanfilippo, Francesco Sgalambro, Giuseppe Chiaramonte, Cristina Santonocito, Gaetano Burgio, Antonio Arcadipane
doi: 10.5152/TJAR.2019.99234  Pages 464 - 470
Objective: There are several airway devices available for difficult tracheal intubation (DTI) management, but the failure rate remains high. The use of laryngoscopy to facilitate the fibreoptic-bronchoscope intubation (CLBI) has been increasingly reported in DTI situations, but it has not been formally studied yet.
Methods: We designed a single-centre simulation study on DTI (neck rigidity and tongue oedema) comparing three techniques: direct laryngoscopy (DL), video-laryngoscopy (VLS) and CLBI. Eighteen anaesthesiologists naïve to VLS/CLBI approaches, participated in the study. The primary outcome was the intubation rate at the first attempt. Secondary outcomes were an overall time-to-intubate (TTI) and time-to-ventilate (TTV), success at the second and third attempt and ease of intubation as evaluated by a subjective 5-point Likert scale.
Results: The CLBI technique had a higher success rate at the first attempt than DL (66% vs 22%, p=0.007), while VLS did not (44%, p=0.16). A trend towards higher success at the third attempt was found for both VLS and CLBI vs DL (p=0.07 and p=0.06, respectively). The VLS had a shorter overall TTV than DL (88±60 vs 121±59 sec, respectively, p=0.04) and a trend towards a shorter TTI (81±61 vs 116±64 sec, respectively, p=0.06). The CLBI approach showed a non-significantly lower TTI/TTV as compared to DL (p=0.10 and p=0.16, respectively). Anaesthesiologists judged that the intubation with VLS (3.7±1.0) and CLBI (3.8±1.0) was easier than with DL (1.7±0.8, both p<0.001).
Conclusion: In a simulated DTI scenario, CLBI had a higher success rate at the first attempt than DL, while VLS did not. By the third attempt, both rescue techniques had a trend towards a higher success rate than DL. The CLBI technique seems a promising alternative for the management of DTI.

6.Randomised Control Trial Comparing Plain Levobupivacaine and Ropivacaine with Hyperbaric Bupivacaine in Caesarean Deliveries
Divya Sethi
doi: 10.5152/TJAR.2019.50465  Pages 471 - 479
Objective: The study compared spinal block characteristics of equipotent doses of plain 0.5% levobupivacaine, plain 0.75% ropivacaine and hyperbaric 0.5% bupivacaine for elective caesarean (CS) delivery.
Methods: A total of 100 parturient women undergoing elective CS under spinal anaesthesia were enrolled for the study. The parturients were randomly assigned to receive one of the following in a subarachnoid block: hyperbaric 0.5% bupivacaine 10 mg (group B), plain 0.5% levobupivacaine 10 mg (group L), or plain 0.5% ropivacaine 15 mg (group R).
Results: Motor block duration [groups B, LB, R: 143.78 (30.43) minutes, 139.31 (33.38) minutes, 137.32 (27.39) minutes, respectively; P=0.80], sensory block duration [groups B, LB, R: 122.87 (34.93) minutes, 113.03 (39.24) minutes, 125.58 (24.93) minutes, respectively; p=0.30] and first analgesic request time [groups B, LB, R: 136.87 (28.70) minutes, 133.59 (27.30) minutes, 144.19 (32.09) minutes, respectively; p=0.35] were statistically comparable. The groups were statistically comparable for sensory block onset time [T6 block; groups B, LB, R: 4.62 (2.80) minutes, 4.93 (2.63) minutes, 5.73 (3.00) minutes, respectively; p=0.29] but motor block onset time was statistically prolonged for group R as compared to group B [Bromage 3 block; group B, LB, R: 5.93 (3.41) minutes, 9.00 (4.00) minutes, 10.16 (5.66) minutes, respectively; p=0.001]. No statistically significant differences were seen in sensory and motor block recovery times, haemodynamic parameters or side-effects.
Conclusion: The anaesthesia from a spinal block with 10 mg plain levobupivacaine or 15 mg plain ropivacaine is comparable to the anaesthetic effect of 10 mg hyperbaric bupivacaine in elective caesarean deliveries.

7.Impact of Pre-Emptive Intravenous Ibuprofen on Perioperative Analgesia in Patients Undergoing Third Molar Extraction: A Randomised Controlled Study
İlke Küpeli, Yakup Gülnahar
doi: 10.5152/TJAR.2019.09623  Pages 480 - 484
Amaç: Preemptif intravenöz (IV) ibuprofenin, mandibular üçüncü molar cerrahi sırasında ve sonrasında oluşan ağrı üzerine analjezik etkinliğini değerlendirmek amaçlandı.
Yöntemler: Altmış hasta dahil edildi ve ibuprofen 800 mg IV + deksketoprofen 50 mg (grup 1), tek başına ibuprofen 800 mg IV (grup 2) ve plasebo (grup 3) olmak üzere gruplara ayrıldı. Tüm hastalara lokal anestezik infiltrasyon uygulandı.Tüm hastalarda preoperatif dönemde hemodinamik değerler (ortalama arter basıncı [OAB] ve kalp atım hızı [KAH]) kaydedildi, sonrasında infüzyonlar başladı. Anksiyete durumlarını değerlendirmek için Sürekli Kaygı Envanteri (STAI) ölçeği kullanılmıştır. İnfüzyon başlangıcından 15 dk sonra ameliyat başladı. Hemodinamik değerler ve görsel analog skala (VAS) ile ağrı skorları kaydedildi. Ağrı skorları, istirahatte (VASİ) ve yutma sırasında (VASY) postoperatif olarak kaydedildi.
Bulgular: Preoperatif STAI değerlerinde gruplar arasında anlamlı fark yoktu (p> 0.05). KAH, OAB ve VAS ağrı skorları grup 3'te grup 1 ve 2'den anlamlı olarak daha yüksekti (p <0.05). VASİ ve VASY skorları grup 3'te grup 1'e göre postoperatif ilk 4 saatte anlamlı olarak yüksekti (p <0.05). VASY skorları grup 3'te grup 2'e göre postoperatif 1-4 saatte anlamlı olarak daha yüksekti (p <0.05) ancak VASİ ve VASY skorlarında ameliyattan 48 saat sonra fark yoktu.
Sonuç: İbuprofen, tek başına veya deksketoprofen ile birlikte preemptif olarak uygulandığında perioperatif dönemde benzer analjezi sağlamıştır.
Objective: The aim of the present study was to evaluate the analgesic efficacy of pre-emptive intravenous (iv) ibuprofen on pain during and after the mandibular third molar surgery.
Methods: A total of 60 patients were included in the study. They were allocated as ibuprofen 800 mg iv+dexketoprofen 50 mg (group 1), ibuprofen 800 mg iv alone (group 2) or placebo (group 3). A local anaesthetic infiltration was administered to all patients. In all patients, haemodynamic values (mean arterial pressure (MAP) and heart rate (HR)) were recorded preoperatively, and infusions were started. State-Trait Anxiety Inventory (STAI) scale was used to assess anxiety states. Surgery started 15 min after the infusion. Haemodynamic values and pain scores with visual analogue scale (VAS) were recorded. Pain scores were recorded postoperatively at rest (VASR) and swallowing (VASS).
Results: There was no significant difference in the preoperative STAI values between the groups (p>0.05). HR, MAP and VAS pain scores were significantly higher in group 3 than in groups 1 and 2 (p<0.05). VASR and VASS scores were significantly higher in group 3 than in group 1 in the first 4 h postoperatively (p<0.05). VASS scores were significantly higher in group 3 than in group 2 at 1-4 h postoperatively (p<0.05), but there was no difference in VASR and VASS scores at 48 h after surgery.
Conclusion: Ibuprofen alone or in combination with dexketoprofen provided similar analgesia in the perioperative period when administered pre-emptively.

8.How Effective are Intensive Care Unit Beds Used in Our Region?
Esma Meltem Şimşek, Seval İzdeş, Ümit Murat Parpucu, Fatma Ulus, Mustafa Özgür Cırık, Suheyla Ünver
doi: 10.5152/TJAR.2019.65289  Pages 485 - 491
Amaç: Tüm Dünya’da olduğu gibi ülkemizde de yoğun bakım yatak ihtiyacı giderek artmaktadır. Çalışmamızda bölgemizdeki erişkin yoğun bakım ünitelerinde (YBÜ) yatak sayısı planlaması yapabilmek içi uygunsuz yatış oranlarını ve nedenlerini incelemeyi amaçladık..
Yöntemler: Etik Kurul izni alınarak Haziran 2014-Ocak 2015 tarihlerinde bölgemizdeki 12 hastanenin (6’si eğitim araştırma, 6’sı devlet hastanesi) 1., 2. ve 3. basamak erişkin YBܒ lerindeki toplam 290 hasta uzman ekip tarafından, habersiz olarak bir kez ziyaret edildi ve doldurulan formları retrospektif olarak Shapiro-Wilks ve Pearson ki kare testi kullanılarak değerlendirildi
Bulgular: Uygunsuz yatış oranı % 55.9 ‘du ve bunun nedeni en fazla alt basamak YBÜ olmamasıydı. Yatan hastaların %35. 5’inin bakım hastası olduğu, bunun da %68’unun bakımının evde devam etmesi gerektiği belirlendi. Açık YBܒ lerinde kapalı YBܒ lerine göre % 16.7 daha fazla uygunsuz yatış tespit edildi. Açık YBܒ lerinde daha çok 3. ve 4 derece öncelikli hastaların alındığını ve açık YBܒ lerinde kapalı YBܒ lerine göre daha çok servis hastası yattığı belirlendi.

Sonuç: Sonuç olarak Bölgemizde yaptığımız bu çalışmanın tüm Türkiye’yi yansıttığı düşünülürse, giderek artacak YB ihtiyacını karşılamak için, 2.-3. Basamak YB yatak sayısını artırmaktansa, aynı hastane bünyesinde 1. basamak YB yatak sayısını ya da postanestezik bakım üniteleri gibi üniteleri yaygınlaştırmak gerektiği ortaya çıkmaktadır. Ayrıca tüm YBܒ lerinin kapalı YB şekline getirilmesi ve YB’ lar arasında koordinasyon sağlanmasıyla mevcut yatakların daha etkin kullanılabileceği düşüncesindeyiz.


Objective: The demand for critical care facilities is also growing in our country. The aim of the present study was to investigate the incidence and causes of inappropriate admissions to adult intensive care units (ICUs) in our region to facilitate the planning of bed numbers.
Methods: A team of specialists made an unannounced visit to level 1, 2 and 3 adult ICUs in 12 hospitals in our region between June 2014 and January 2015. A total of 290 ICU patients were evaluated.
Results: The rate of inappropriate ICU admission was 55.9%, and the most common reason was the lack of a lower level ICU. Palliative patients comprised 35.5% of the ICU patients, 68% of whom should have been in home care. The rate of inappropriate admission was 16.7% higher in open ICUs than in closed ICUs.
Conclusion: Our results indicate that instead of increasing the number of beds in level 2 and 3 ICUs, hospitals should increase the number of level 1 ICU beds. In addition, we believe that the existing beds could be utilised more effectively if all ICUs implemented a closed management style and if there was better coordination between ICUs.

9.Contribution of Capillary Refilling Time and Skin Mottling Score to Predict ICU Admission of Patients with Septic or haemorrhagic Shock Admitted to the Emergency Department: A TRCMARBSAU Study
Romain Jouffroy, Emmanuel Bloch-laine, Maxime Maignan, Pierrick Le Borgne, Nicolas Marjanovic, Thomas Lafon, Scarlett Dehdar, Lea Thomas, Pierre Michelet, Benoit Vivien
doi: 10.5152/TJAR.2019.28459  Pages 492 - 495
Objective: In the emergency department (ED), the severity assessment of shock is a fundamental step prior to the admission in the intensive care unit (ICU). As biomarkers are time consuming to evaluate the severity of micro- and macro-circulation alteration, capillary refill time and skin mottling score are two simple, available clinical criteria validated to predict mortality in the ICU. The aim of the present study is to provide clinical evidence that capillary refill time and skin mottling score assessed in the ED also predict ICU admission of patients with septic or haemorrhagic shock.

Methods: This trial is an observational, non-randomised controlled study. A total of 1500 patients admitted to the ED for septic or haemorrhagic shock will be enrolled into the study. The primary outcome is the admission to the ICU.

Results: The study will not impact the treatments provided to each patient. Capillary refill time and skin mottling score will not be taken into account to decide patient’s treatments and/or ICU admission. Patients will be followed up during their hospital stay to determine their precise destination after the ED (home, ICU or ward) and the 28- and 90-day mortality after hospital admission.

Conclusion: The results from the present study will provide clinical evidence on the correlation between the ICU admission and the capillary refill time and the skin mottling score in septic or haemorrhagic shock admitted to the ED. The aim of the present study is to provide two simple, reliable and non-invasive tools for the triage and early orientation of these patients.

10.Anaesthesiology and Reanimation Education in Turkey: Residents’ Views
Levent Onat, Volkan Hancı, Şule Özbilgin, Nilay Boztaş, Aydın Taşdöğen, Serhan Yurtlu, Bahar Kuvaki, Atalay Arkan
doi: 10.5152/TJAR.2018.34437  Pages 496 - 502
Amaç: Bu çalışmada ülkemizdeki Anestezi ve Reanimasyon uzmanlık eğitimi alan Tıpta Uzmanlık Öğrencilerinin (TUÖ) bakış açısı ile, eğitim gördükleri kurumlarda mevcut bulunan donanım, uzmanlık eğitimi programı, uygulamaları, çalışma koşulları ve nöbet sistemlerinin değerlendirilmesi amaçlanmıştır.
Yöntemler: Çalışmamız Türkiye’deki Eğitim ve Araştırma Hastaneleri ve Üniversite Hastanelerinde, Anesteziyoloji ve Reanimasyon Uzmanlık Öğrencilerine web bazlı anketin; bilgisayar ortamında e-mail ile gönderilmesi ile gerçekleştirildi. Anket formu; demografik özellikler, kişisel memnuniyet, kurumdan ve eğitimden memnuniyet, uzmanlıkla ilgili temel bilgi, gelecek ile ilgili kaygı ve motivasyonu sorgulayan 73 sorudan oluşmaktaydı.
Bulgular: Bu çalışmaya toplam 270 kişi katıldı. Katılımcıların %82.2'i alanını isteyerek seçtiğini bildirdi. Katılımcılar, Tıpta uzmanlaşmanın %66.7 oranında birinci basamak ve pratisyen hekimliğin doğru uygulanmadığı için gerekli olduğu belirtti. TUÖ'nin haftalık çalışma saatleri ortalama 91.69±36.69 bulundu. Ayda ortalama nöbet sayısı 7.49±1.99 idi. Katılımcıların %61.9 Tıpta Uzmanlık eğitimi için öngörülen beş yıllık süreyi uzun bulduğunu belirtti. Yoğun bakım eğitim süresi %71.1 oranında, Algoloji eğitim süresi ise %26.3 oranında yeterli olarak ifade edildi.
Sonuç: Bu çalışma sonuçlarına göre, asistanlarının sayısının yetersiz olduğu saptanırken; iş yükünün ağır olduğu, çalışma sürelerinin uzun olduğu, nöbet sayılarının yüksek olmasına karşın nöbet sonrası izin kullanılamadığı tespit edildi. Olumsuzluklar ve asistanların memnuniyetsizliği yüksek olmasına rağmen katılımcıların çoğunun bölümlerini isteyerek seçtikleri ve bir şans daha verilse yine branşlarını tercih edecekleri belirlendi. Katılımcıların çalıştıkları kurumlarda; eğitim ve araştırmanın ön planda tutulması yerine hizmete öncelik verildiğini ve eğiticilerin de artan hizmet yükü sebebiyle asistanlar açısından daha az ulaşılır konuma geldiğini düşündükleri öğrenildi.
Objective: This study aimed to determine opinions of medical residents undergoing anaesthesia and reanimation training about equipment, programmes, applications, study conditions and shift systems at training institutions in Turkey.
Methods: A web-based survey was sent by e-mail to residents in anaesthesiology and reanimation training programmes. The survey comprised 73 questions about demographic characteristics, satisfaction, basic specialisation knowledge, anxiety and motivation.
Results: The study included 270 individuals. Of the residents, 82.2% willingly chose their field, whereas 66.7% stated that specialisation was necessary because of incorrect application of first-stage and GP medical services. The mean of the weekly working hours was 91.69±36.69 hours; the mean number of monthly on-call shifts was 7.49±1.99. Of the participants, 61.9% found the predicted five-year training duration long. The intensive care training duration was sufficient for 71.1% and only 26.3% found the pain management training duration sufficient.
Conclusion: According to the results, the number of residents is insufficient, workload is heavy, working hours are long and large numbers of shifts are worked without leave afterwards. In spite of negatives and high dissatisfaction, most residents willingly chose their departments and would choose the same branches again. Participants stated that their institutions emphasised service rather than education and research, and educators were less accessible to residents due to increasing service loads.

CASE REPORT
11.Anaesthesia Management in Idiopathic Pulmonary Artery Aneurysm Surgery
Eda Balcı, Aslı Demir, Ayşegül Özgök, Ümit Karadeniz
doi: 10.5152/TJAR.2019.21447  Pages 503 - 506
Pulmoner arter anevrizması oldukça nadir görülen bir hastalıktır. Semptomatik hastalarda cerrahi tedavinin yeri önemlidir. Anatomik durumu nedeni ile, bu tür anevrizmaların rüptürü ani sağ ventrikül yetmezliği veya ani ölüme sebep olabilir. Bu sunumun amacı, pulmoner arter anevrizma onarımı cerrahisi yapılan hastada dengeli genel anestezi yönetimini sunmaktır. Göğüs, sırt ağrısı ve hemoptizi şikayetleri olan 55 yaşında erkek hastada cerrahi onarım planlanmıştır. Dengeli anestezi yönetimi ile ani kan basıncı yükselişlerinden kaçınılarak anevrizma duvarında stres önlenilmeye çalışılmıştır. Uygun ventilasyon yöntemleri ile pulmoner vasküler rezistans artışından, dolayısıyla anevrizma üzerindeki baskı ve sağ ventrikül ardyükündeki artıştan kaçınılmaya çalışılmıştır. Uygun anestezi ve ventilasyon teknikleri ile, pulmoner arter anevrizması onarımında komplikasyonsuz, başarılı bir anestezi yönetimi uygulanmıştır.
Pulmonary artery (PA) aneurysm is a very rare disease. Surgical treatment is important in symptomatic patients. Due to its anatomical condition, the rupture of such aneurysms may lead to sudden right ventricular failure or sudden death. The aim of this report is to present the use of balanced general anaesthesia management in a patient who underwent PA aneurysm repair surgery. Surgical repair was planned in a 55-year-old man with chest and back pain as well as haemoptysis. With the help of balanced anaesthesia, stress on the aneurysm wall was prevented by avoiding sudden blood pressure increases. With appropriate ventilation methods, we attempted to avoid an increase in pulmonary vascular resistance, and therefore, the pressure on the aneurysm, as well as an increase in the postoperative right ventricle. With the help of appropriate anaesthesia and ventilation techniques, uncomplicated and successful anaesthetic management was effected in the repair of a PA aneurysm.

12.Loss of Haemodynamic Coherence, Diagnosed Using a Continuous Monitoring of Oesophageal Photoplethysmography
Charles-hervé Vacheron, Bernard Allaouchiche
doi: 10.5152/TJAR.2019.19794  Pages 507 - 510
We report the case of a 75-year-old man with appendicular peritonitis in whom we observed oesophageal tissue perfusion, using a new photoplethysmographic probe. As the patient suffered from lactic acidosis, we chose to increase the mean arterial pressure (MAP) using norepinephrine. Thanks to an oesophageal photoplethysmographic signal, we could observe a loss of haemodynamic coherence and a severe alteration of tissue perfusion triggered by the MAP increase. Considering new information regarding the tissue perfusion status, we were able to adjust our MAP targets accordingly and restore the initial perfusion index values. This case illustrates the loss of haemodynamic coherence and highlights the clinical relevance of continuous tissue perfusion monitoring to highlight potential adverse norepinephrine effects.

13.Septic Pulmonary Embolism Associated with Klebsiella spp. Infection in a Patient with Previous ASD Operation
Meltem Genez
doi: 10.5152/TJAR.2019.39924  Pages 511 - 514
Septik pulmoner emboli mikroorganizma ilişkili trombüsün neden olduğu sık rastlanmayan ancak iyi bilinen bir tanıdır. Trombüs pulmoner vasküler dolaşımda mekanik obstrüksiyona ve inflamatuvar reaksiyona neden olur. Sağ kalp endokarditi ile birlikte tonsil, juguler, dental ya da pelvik bölgeden kaynaklanan tromboflebitin varlığı ile tanı konur. Hastaların çoğunda septik pulmoner emboli tanısı primer enfeksiyon kaynağı ile birlikteliği olan tipik BT bulguları ile konur. Klinik bulguları; orta derecede solunum yetmezliği ve septik şok bulgularıdır. Bulguların non-spesifik olmasından dolayı ayırıcı tanısı önemlidir. Bununla birlikte yoğun bakım gereksinimi olan septik pulmoner emboli tanılı hastalar titizlikle değerlendirilmeli ayırıcı tanıda pulmoner emboli varlığı akla getirilmelidir. Bu nedenle bu çalışmada septik pulmoner emboli tanılı hastaların olası patojen sebeplerini, klinik durumlarını ve radyolojik görüntülemeleri açıklığa kavuşturmayı amaçladık. Bu çalışmada servis izleminde subileus öntanısı ile takip edilen ve ani başlangıçlı solunum sıkıntısı geliştiği için yoğun bakım ünitesine sepsis ön tanısı ile alındıktan sonra yapılan ileri tetkikler sonucunda hastaya septik pulmoner emboli tanısının konulması ve tedavisi sunulmuştur.
Septic pulmonary embolism (SPE) is an uncommon disease caused by thromboembolism associated with microorganisms. A 57-year old woman patient who was monitored for a prediagnosis of subileus suffered from sudden respiration problems in the hospital ward. The patient’s history included atrial fibrillation and atrioseptal defect (ASD) operation. The patient was admitted to the intensive care unit (ICU) in order to apply non-invasive mechanical ventilation and keep her under observation because of low saturation and loss of consciousness. In the ICU, the patient’s temperature was 38.8°C, which led to the diagnosis of sepsis. The chest X-ray showed bilateral and multiple patchy infiltrates. The thorax CT showed right lower pulmonary consolidation and left pulmonary pleuroparenchymal density with nodular shapes. The electrocardiogram showed mild pulmonary hypertension and third-degree tricuspid failure. These features indicated SPE because of the ASD operation in the past. The blood culture showed the presence of Klebsiella spp., which is uncommon. A characteristic CT sign is very important for the early diagnosis and treatment of SPE.

LETTER TO THE EDITOR
14.Smoked for Years but Stopped a Few Months Back: Dilemma Regarding the American Society of Anesthesiologists Physical Status
Habib Md Reazaul Karim
doi: 10.5152/TJAR.2019.28863  Pages 515 - 516
Abstract | Full Text PDF