Hypertensive crisis in a patient with an undiagnosed pheocromocytoma

Pheochromocytoma is a catecholamine secreting tumor which originates in the chromaffin cells of adrenal medulla. Silent heochromocytomas can become evident with hypertensive attack during anaesthesia. Here is presented a case of heochromocytoma without high plasma or urinary levels of catecholamines, and without history of hypertension which was detected with hypertensive attack during surgical extirpation. With all the newest medications and techniques that have been developed the anesthetic management of undiagnosed pheochromocytomas are still sources of unexpected problems for the anesthetists. In this case it was a great chance that there were no complications despite the hypertensive crisis

Intraarticular levobupivacaine or bupivacaine administration decreases pain scores and provides a better recovery after total knee arthroplasty

Purpose The aim of this prospective randomized blinded controlled study was to compare the efficacy of the two local anesthetics, intraarticular bupivacaine and levobupivacaine administration, versus control for postoperative pain control and functional recovery. Length of hospital stay, opioid consumption, and the side effects of opioids were also evaluated. Methods Sixty patients of American Society of Anesthesiologists class I–III undergoing elective knee arthroplasty under spinal anesthesia were randomized into three groups. Groups B (n = 20) and L (n = 20) both received 150 ml solution intraarticularly, containing 200 mg bupivacaine or 200 mg levobupivacaine combined with 0.5 mg epinephrine, respectively, at the end of the surgery. Group C (n = 20) received 150 ml saline intraarticularly. Postoperatively, all groups received injections through the intraarticular catheters in quantities of 120 mg (levobupivacaine for group L, bupivacaine for group B) and 0.5 mg epinephrine whereas group C received a saline bolus at 10 and 22 h. Patients were given tramadol by intravenous patientcontrolled analgesia (PCA), and sodium diclofenac 75 mg intramuscularly was used for rescue analgesic medication. Visual analogue score (VAS) for pain at rest and during mobilization (which was defined as flexion exercise supported by physiotherapist in postoperative first 8 h and afterward a 3-m walk with walker), consumption of tramadol, side effects, and patient satisfaction were recorded until the 48th hour postoperatively. Results Area under the curve values for VAS were lower in groups B and L compared to the control, both at rest and during mobilization (first 48 h) (P = 0.032 and P = 0.029, respectively). Tramadol consumption was lower (P\0.05), patient satisfaction as evaluated with a five-point Likert score (completely comfortable; quite comfortable; slight discomfort; painful; very painful) was higher (P = 0.03), and length of hospital stay was shorter (P = 0.03) in groups B and L compared to group C. Conclusion Intraarticular bupivacaine and levobupivacaine provided better postoperative analgesia both at rest and during mobilization in total knee replacement surgery compared to control. Tramadol consumption and hospital stay were also decreased in the study groups

Uzun QT sendromlu bir çocukta implante edilebilir kardiyoverter-defibrilatör yerleştirilmesi sırasında Torsade de Pointes

Long QT syndrome is characterized by a prolongation of the QT interval resulting in a tendency to ventricular tachyarrhythmias, particularly Torsade de Pointes. Inhalational anesthetics are often accused of prolonged QT interval. Herein, we report a pediatric case of long QT syndrome with a persistent Torsade de Pointes episode under general anesthesia with sevoflurane during surgical implantable cardioverter-defibrillator placement. Recurrent Torsade de Pointes requiring electrical cardioversion were considered to be unrelated to the surgical management. These episodes were considered to be related to sevoflurane inhalation. After terminating sevoflurane, arrhythmias disappeared. As malignant arrhythmias may have detrimental results for patients, we conclude that inhalation anesthetics should be avoided in patients with long QT syndrome.Uzun QT sendromu, Torsade de Pointes başta olmak üzere, ventriküler taşiaritmilere yatkınlığa neden olan, QT aralığında uzama ile karakterizedir. QT aralığının uzamasından inhaler anestetikler sorumlu tutulmaktadır. Bu yazıda, implante edilebilir kardiyoverter-defibrilatör yerleştirme cerrahisi sırasında sevofluran ile genel anestezide iken inatçı Torsade de Pointes atağı geçiren uzun QT sendromlu bir pediatrik olgu sunuldu. Elektriksel kardiyoversiyon gerektiren tekrarlayan Torsade de Pointes ataklarının cerrahi tedavi ile ilişkili olmadığı düşünüldü. Bu ataklar sevofluran inhalasyonu ile ilişkilendirildi. Sevofluran sonlandırıldıktan sonra, aritmiler ortadan kayboldu. Malign aritmiler hastalar için tehlikeli sonuçlar doğurabileceği için, uzun QT sendromlu hastalarda inhaler anestetiklerin kullanılmaması gerektiği kanısındayız

Effect of rapid ventricular pacing on cerebral oxygenation in transcatheter aortic valve implantation (Tavi): Role of routine near-infrared spectroscopy monitoring

Objective: Transcatheter aortic valve implantation has become an important treatment modality in patients with high risk comorbidities for surgical aortic valve replacement. The objective of this study is to evaluate the cerebral perfusion status using near infrared spectroscopy method especially during the rapid ventricular pacing phase of the transcatheter aortic valve implantation procedure. Methods: 20 consecutive patients undergoing trans-femoral aortic valve implantation procedure between May 2015 and March 2016 in our institute were retrospectively evaluated. The periprocedural cerebral oxygenation was measured with a near infrared spectroscopy sensor (INVOSTM-5100 C, Medtronic Inc., Minneapolis, MI, USA) located on the forehead of the patients. All hemodynamic data and cerebral near infrared spectroscopy values were recorded before, during and after the procedure with constant time intervals, especially at the time of rapid ventricular pacing and device deployment. Results: The mean age was 74.4 ± 9.2 years. Male female ratio was 1.8 to 1 (13 males, 7 females). Mean procedure time was 70.2 ± 14.3 minutes. The rapid ventricular pacing included two episodes with a total time for pacing of 22.6 ± 5.1 seconds. There was a statistically significant difference with regard to the heart rate and the cerebral near infrared spectroscopy values (p=0.006 and p=0.02; respectively) in all patients during the rapid ventricular pacing period. The cerebral near infrared spectroscopy values were statistically lower than baseline levels (p<0.001). Conclusion: This observational study presents the significant decrease of cerebral near infrared spectroscopy values during the rapid ventricular pacing phase of the transcatheter aortic valve implantation procedure. Further studies may reveal cut-off values both for near infrared spectroscopy values and rapid ventricular pacing duration in order to determine a critical cut-off level

Anesthesia and surgical collaboration on an extremely low birth weight infant undergoing ligation of patent ductus arteriosus

Patent ductus arteriosus (PDA) is one of the most common congenital cardiac anomalies in infants. Spontaneous closure of ductus arteriosus takes long time in preterm infants. Early ligation is advised in very low birth weight infants but surgical risk is bigger in older infants. In this presentation we report an anesthetic management in a male preterm infant weighing 600 grams, who underwent PDA ligation. He was born at gestation age of 24 weeks at another hospital, and since his birth he has been observed to have infant respiratory distress syndrome. Hemodynamic deterioration, ventilator dependency, increase in heart murmur, deterioration of the general status and irresponsivity to indomethacine was observed in the patient and the patient was referred to our center for surgical ligation of the PDA. He was transferred to our center in an incubator and with diagnosis of PDA. Bradycardia (50 beats/min) developed during echocardiography in our center and the patient was intubated and transported to the operating room. General anesthesia was induced by fentanyl 5µg, 0.4mg rocuronium and ketamine 0.15 mg intravenously. Anesthesia was maintained with 1.5-2.5 % sevoflurane in 50 % air and oxygen at an inspired concentration titrated to stabilize the vital signs. Because of the extreme low weight of the infant, invasive arterial monitorization and positioning was difficult. The PDA was ligated with titanium clips through left thoracotomy. The postoperative course was uneventful and he was discharged on the 77 th day,1750g of weight

Transüretral mesane tümörü rezeksiyonunda addüktör spazmını önlemek için levobupivakain ile obturator blok uygulaması

Objective: Adductor spasm can occur during transurethral resection of bladder tumour (TUR-BT) due to the stimulation of obturator nerve and can cause involuntary movement of legs, incomplete resection, bladder perforation and secondary extravesical dissemination of neoplastic cells. In this study we aimed to prevent adductor spasm and associated complications by obturator block with levobupivacain in patients with spinal anesthesia during TUR-BT for lateral wall tumors of the bladder. Material and Methods: Sixty 18-80 year-old patients, graded as ASA (American Society of Anestesiologists) I-III and scheduled for transuretral resection for lateral wall tumor of the bladder, were recruited for this study. Thirty patients, randomized as group S, received only spinal anesthesia and 30 patients randomized as group SOB, received spinal anesthesia and obturator block. Using a 22 G 50 mm insulated needle, 2 Hz, 0.5 mA electrical stimulation, with a pulse duration of 0.1 ms was applied, until the adductor muscle contractions were evoked. The local anesthetic solution 5 mL 7.5% levobupivacaine (37.5 mg) plus 5 mL 0.9% NaCl (Levobupivacaine 3.75%) was injected. Surgery was allowed after the spinal sensory block reached the T10 dermatome for all patients. Any adductor spasm occurring during surgery was recorded. Occurence of adductor muscle spasm and patient and surgeon satsifaction was evaluated. Results: Surgeon satisfaction was significantly higher in Group OBS (p<0.001) compared to Group S. Adductor spasm incidence was higher in Group S [25/30 (83%)] patients than in Group OBS [2/30 (6.7%)] patients (p<0.001). Conclusion: Obturator nerve block using levobupivacaine is effective in preventing adductor spasm in transurethral resection of lateral wall bladder tumours

Progresif supranükleer palsili hastada meme cerrahisinde anestezi yönetimi

Progressive Supranuclear Palsy (PSP) is a rare adult-onset neurodegenerative disease presenting with parkinsonian disorders such as; ophtalmoplegia, pseudobulbar paralysis, bradykinesia, rigidity, and behavioral and cognitive findings. In this case report, a 61 years old female patient who has been followed up for PSP for 6 years and who had diffuse rhonchi and decrease in respiratory sounds in both lungs was presented. Chest x-ray revealed atelectasis in lower zones bilaterally. The patient was scheduled for lumpectomy due to breast cancer. By the combination of thoracic epidural anesthesia and pectoral nerves block 1 (PECS 1) sufficient perioperative anesthesia and postoperative analgesia and to prevent the risks of general anesthesia was aimed.Progresif Supranükleer Palsi (PSP) oftalmopleji, psödobulbar paralizi, bradikinezi, rijidite, davranışsal ve bilişsel bozukluklar gibi parkinsona benzer bulgularla kendini gösteren erişkin dönemi başlangıçlı nadir bir nörodejeneratif hastalıktır. Bizim olgumuzda PSP nedeniyle 6 yıldır takip edilen 61 yaşındaki kadın hastaya meme kanseri nedeniyle lumpektomi yapılmıştır. Hastamızın solunum sistem muayenesinde her iki akciğerinde yaygın ronkus sesleri saptandı ve solunum seslerinin bilateral azaldığı anlaşıldı. Alt zonlarda atelektazi akciğer grafisinde gözlenmekteydi. Olgumuzda ilaç doz ve çeşitliliğini azaltmak amacıyla genel anesteziden kaçınarak perioperatif anestezi ve postoperative analjezi amaçlı yaptığımız torasik epidural ve pektoral sinir bloğu (PECS 1) ile başarılı anestezimizi sunmayı amaçladık

Our anaesthesia experiences outside the operating room

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Perioperative anesthesia-related complications

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Comparison of the Trendelenburg position versus upper-limb tourniquet on internal jugular vein diameter

84th IEEE Vehicular Technology Conference, VTC Fall 2016 -- 18 September 2016 through 21 September 2016 -- 126901BACKGROUND: Central venous cannulation is a necessary invasive procedure for fluid management, haemodynamic monitoring and vasoactive drug therapy. The right internal jugular vein (RIJV) is the preferred site. Enlargement of the jugular vein area facilitates catheterization and reduces complication rates. Common methods to enlarge the RIJV cross-sectional area are the Trendelenburg position and the Valsalva maneuver. OBJECTIVE: Compare the Trendelenburg position with upper-extremity venous return blockage using the tourniquet technique. DESIGN: Prospective clinical study. SETTING: University hospital. SUBJECTS AND METHODS: Healthy adult volunteers (American Society of Anesthesiologists class I) aged 18-45 years were included in the study. The first measurement was made when the volunteers were in the supine position. The RIJV diameter and cross-sectional area were measured from the apex of the triangle formed by the clavicle and the two ends of the sternocleidomastoid muscle, which is used for the conventional approach. The second measurement was performed in a 20° Trendelenburg position. After the drainage of the veins using an Esbach bandage both arms were cuffed. The third measurement was made when tourniquets were inflated. MAIN OUTCOME MEASURE(S): Hemodynamic measurements and RIJV dimensions. RESULTS: In 65 volunteers the diameter and cross-sectional area of the RIJV were significantly widened in both Trendelenburg and tourniquet measurements compared with the supine position (P<.001 for both measures). Measurements using the upper extremity tourniquet were significantly larger than Trendelenburg measurements (P=.002 and <.001 for cross-sectional area and diameter, respectively). CONCLUSION: Channelling of the upper-extremity venous return to the jugular vein was significantly superior when compared with the Trendelenburg position and the supine position. LIMITATIONS: No catheterization and study limited to healthy volunteers