Association of intraoperative lactate elevation and postoperative mortality and morbidity in patients undergoing craniotomy: retrospective analysis

BACKGROUND: Intraoperative lactate levels increase in patients undergoing craniotomy, but the reason is not yet fully known. High levels of intraoperative lactate are associated with mortality and morbidity in patients with septic shock and abdominal and cardiac surgery. OBJECTIVES: Investigate whether intraoperative lactate elevation is associated with postoperative systemic and neurological complications and mortality in craniotomy. DESIGN: Retrospective study SETTING: University hospital in Turkey. PATIENTS AND METHODS: In this study, we included patients who underwent elective intracranial tumor surgery in our hospital between 1 January 2018, and 31 December 2018. According to the level of intraoperative lactate, patients were divided into two groups: high (≥2.1 mmol/L) and normal (<2.1 mmol/L). The groups were compared by the presence of postoperative new neurological deficits, postoperative surgical and medical complications, mechanical ventilation duration, 30-day mortality, in-hospital mortality, and hospital stay length. Cox regression analysis was performed for the 30-day mortality outcome. MAIN OUTCOME MEASURES: Association between intraoperative lactate levels and postoperative 30-day mortality. SAMPLE SIZE: 163 patients with lactate data. RESULTS: While no significant difference was found between the groups regarding age, gender, ASA score, tumor location, operation time and pathology results, preoperative neurologic deficits were higher in the high intraoperative lactate group (P=.017). No statically significant difference was found between the groups for postoperative neurological deficit, need for prolonged mechanical ventilation, and hospital stay length. The postoperative 30-day mortality rate was higher in the group with high intraoperative lactate (P=.028). High lactate and medical complications were significant in the Cox analysis. CONCLUSION: Intraoperative lactate elevation was associated with postoperative 30-day mortality in patients undergoing craniotomy. The intraoperative level of lactate is an important mortality predictor in patients undergoing craniotomy. LIMITATIONS: Retrospective design and single-centered, missing most data for several variables. CONFLICT OF INTEREST: None

Drug Interaction Between Valproic Acid and Meropenem: A Case Report

To report a probable interaction between meropenem and antiepileptic drugs that resulted in poor control of epileptic seizures. A previously healthy 21 years old woman admitted to emergency department with fever and stiff neck. Her Glasgow Coma Scale score was E3M5V4. Physical examination revealed conscious to tend to fall asleep, closed eyes and normal-sized and reactive pupils. Meropenem and vancomycin were initiated for the suspicion of menengitis. On the 3rd day of the antibiotic therapy generalized tonic clonic seizures were observed. Phenytoin and intravenous (IV) thiopental were initiated. The patient was intubated and mechanically ventilated. EEG revealed generalized epileptiform activity. In the following days, seizure activity continued. Levetirasetam, carbamazepine and VPA were added for treatment respectively, but seizures were continued. On the 20th day of meropenem therapy, interaction of carbapenems and anti-epileptic agents was suspected. Antibiotherapy was discontinued. Serum concentrations of VPA increased over the next days and achieved therapeutic levels. On day 21 she was extubated, no seizures occurred over the following 48 hours. She was discharged from the ICU, with blood anti epileptic concentrations within the therapeutic range. Carbapenems have a potential effect of inducing seizures and may also lower serum levels of antiepileptic drugs. Clinicians should be aware of this potential interaction that may be associated with serious adverse effects. Status epilepticus is one of the most important neurologic emergencies, and therapeutic control becomes more difficult as its duration becomes longer. Patients receiving antiepileptics and carbapenem group antibiotics concominantly should be closely monitored due to possible drug interaction between these agents

Original Article Radiological Evaluation of the Line Between the Crista Iliaca (Tuffier&apos;s line) in Elderly Patients

Objective: Tuffier&apos;s line is defined as the line connecting the highest points of both iliac crests, which generally passes through either the body of the fourth lumbar vertebra or the intervertebral space between fourth and fifth vertebrae. In this study, we assessed the radiological correlation of the level of Tuffier&apos;s line with changes in age and sex. Methods: In this study, antero-posterior pelvic X-rays of 590 patients aged 18 and older were retrospectively analyzed. It is revealed that Tuffier&apos;s line crosses the vertebral column at one of three levels, which are the L4 vertebral body, L4-L5 vertebral interspace and L5 vertebral body. Patients&apos; sex, age and vertebral level of the Tuffier&apos;s line were recorded. Data was analyzed using the chi-square test. Results: The assessment of the X-rays of 317 female patients showed that Tuffier&apos;s Line passes through the L4 vertebral body in 115 (37.8%), through the L4-L5 intervertebral space in 126 (40%) and through the L5 vertebral body in 76 (22.2%) patients. A Tuffier&apos;s line passing through the level of the L5 vertebral body was found to be statistically significant in female patients (p=0.00). No significant relevance was found between male gender and the level of Tuffier&apos;s line in 273 male patients. It is found that the height of the vertebral levels that Tuffier&apos;s line crosses does not correlate with mean age of the groups (p=0.939). Conclusion: It should be considered that Tuffier&apos;s line can cross at vertebral levels other than anticipated. The level of Tuffier&apos;s line should be precisely determined with supplementary radiological methods, such as AP pelvic X-ray in addition to physical examination, to reduce the complications in association with regional anaeshesia and to achieve sensorial block levels sufficient to sustain a comfortable surgery, particularly in female patients who carry higher cardiac and respiratory risks