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Background Since sedatives are often administered to immune-compromised and critically ill patients, our understanding of immunomodulation by sedation will be critical. Dexmedetomidine, a selective α2-adrenergic receptor agonist, is often used for sedation and analgesia especially in intensive care units. There are conflicting and little data concerning both the effect and the mechanism of dexmedetomidine on immune response. In our study, we aimed to investigate the effect of dexmedetomidine on immune system at two different doses (5 μg.kg−1 and 30 μg.kg−1) during inflammatory bowel disease by using an experimental model, which resembles both systemic and local inflammation. Methods The effect of dexmedetomidine on the course of inflammatory bowel disease was investigated by measuring macroscopic and microscopic parameters. We investigated pro-inflammatory Th1, Th2, and Th17 cytokine levels in serum samples to analyze systemic immune response. Following this, local immune response was investigated by measuring cytokine levels in the presence of dexmedetomidine in spleen cell culture. Results Dexmedetomidine administration led to amelioration of all disease associated pathological manifestations. According to our in vitro and in vivo results, dexmedetomidine shows anti-inflammatory effect by increasing IL-4 and IL-10 levels responsible from anti-inflammatory response via Th2 pathway. Moreover, we showed for the first time in the study that dexmedetomidine administration reduces IL-23, which is responsible from initiation of inflammatory response via Th17 pathway. Conclusions Dexmedetomidine can have beneficial effect on preoperative or postoperative inflammatory bowel disease patients in intensive care units by down-regulating inflammatory immune response not only in systemic circulation but also in tissue-specific manner.

It has been shown that anesthetic requirements during liver transplantation are inversely proportional to the degree of hepatic dysfunction. We investigate alterations during the three phases of requirements for intraoperative isoflurane within the target of 40 to 55 Bispectral Index (BIS) values concerning patients with end-stage liver disease who are undergoing liver transplantation. After faculty ethics committee approval, we studied 50 patients of (age range, 18 to 65 years) who were undergoing liver transplantation. After induction, we used isoflurane with air/oxygen (FiO(2) = 0.5%) for anesthetic maintenance. The isoflurane concentration was set within the range of 40 to 55 BIS values. Remifentanil (0.15 μg/kg/min) was infused for analgesia and cisatracurium was administered via continuous infusion. After anesthetic induction, we inserted arterial, pulmonary artery, and central venous catheters. The heart rate, mean arterial pressure (MAP), mean pulmonary arterial pressure (MPAP), body temperature, BIS values, end-tidal isoflurane concentration (ETiso) and end-tidal carbon dioxide concentration (ETCO(2)) were recorded at 30-minute intervals during the dissection and neohepatic phases, at 15-minute intervals during the anhepatic phase. In addition, we calculated the cardiac index during the three phases. There was no difference in heart rates among the operative phases. In contrast, there were significant changes in MAP, MPAP, BIS, ETCO(2) and body temperature values. However, all of these parameters were in physiological ranges and clinically acceptable. The ETiso values were lowest in the anhepatic phase compared to other phases, but the differences were not clinically important. The ETiso values in the dissection and neohepatic phases were compared with the anhepatic phase higher 5% and 8.6% respectively. During liver transplantation, ETiso requirement for the anhepatic phase was lower compared with the other two phases within the range of 40 to 55 BIS values.

Removal of the tonsils and adenoid tissue because of recurrent infection and/or respiratory obstruction is one of the most commonly performed operations. A rare complication during this intervention is subcutaneous surgical emphysema. The awareness of anaesthesiologists and otolaryngological surgeons will protect the patient from serious consequences. We report our experience with this complication and provide a review of the literature.

Infections in solid-organ transplant recipients are the most important causes of morbidity and mortality. A primary goal in organ transplant is the prevention or effective treatment of infection, which is the most common life-threatening complication of long-term immunosuppressive therapy. A 21-year-old woman who underwent heart transplant 3 years previous owing to dilated cardiomyopathy was referred to our hospital with symptoms of high fever and cough. The patient's history revealed that she had received a trimethoprim-sulfamethoxazole double-strength tablet each day for prophylactic purposes. On chest radiograph, pneumonia was detected, and in broncho-alveolar lavage sample, Pneumocystis jiroveci cysts were found. After diagnosing P. jiroveci pneumonia, trimethoprim-sulfamethoxazole was initiated at 20 mg/kg/d including intravenous trimethoprim in divided dosages every 6 hours. On the sixth day of therapy, she died in intensive care unit. In solid-organ transplant recipients, although antipneumocystis prophylaxis is recommended within the first 6 to 12 months after transplant, lifelong prophylaxis is also used in several settings. In addition, the physician should keep in mind that P. jiroveci pneumonia may develop in solid organ recipients, despite trimethoprim-sulfamethoxazole prophylaxis.

Cedecea spp. which are the members of Enterobacteriaceae family, are mostly isolated from sputum and their clinical importance is not yet demonstrated. This report presents a pneumonia case caused by Cedecea lapagei. A 38-years-old male patient admitted to Inonu University Faculty of Medicine Emergency department with prediagnosis of subarachnoid haemorrhage was operated and transferred to Intensive Care Unit of Reanimation where he underwent artificial ventilation. On the third day of hospitalization his temperature was 39 degrees C, white blood cell count was 27.000/ml and he was still unconscious. He had a history of chronic obstructive pulmonary disease. Chest X-ray revealed opacities in the right lower lobe and mucoid tracheal secretion ensued following tracheal entubation performed after operation. Direct microscopic examination of bronchoalveolar lavage (BAL) fluid yielded abundant number of leukocytes and gram-negative bacilli. Bacteria isolated from BAL specimen were identified as C. lapagei by Phoenix 100 (Becton Dickinson, USA) automated system and also by API 20E kit (Biomerieux, France). Upon the initiation of intravenous amikacin (1 x 1 g) and meropenem (3 x 1 g), the signs of infection decreased in intensity, however, the patient was lost due to subarachnoid hemorrhage on the 12th day of hospitalization. In this case it was estimated that C. lapagei pneumonia originated from the aspiration of upper airway secretion owing to unconsciousness of the patient. Although there were reports of Cedecea infections in the literature, this was the first documented case of C. lapagei pneumonia when the accessible related literature was concerned.

Thrombotic microangiopathy is a microvascular occlusive disorder characterized by microangiopathic hemolytic anemia, thrombocytopenia, and variable signs of organ injury due to platelet thrombosis in the microcirculation. Regarding to the severe of brain or renal lesions, two clinical entities (pathologically similar but clinically different) are described: thrombotic thrombocytopenic purpura and hemolytic uremic syndrome. Thrombotic thrombocytopenic purpura usually affect adults, and is characterized by severe neurologic involvement in most cases, and variable renal involvement. Hemolytic uremic syndrome occurs in young children, and is characterized by acute renal failure, and absent or minimal neurologic abnormalities. In this case report, the clinical features, diagnosis, pathophysiology, and treatment of an adult with acute renal failure due to the thrombotic microangiopathy with hemolytic uremic syndrome are discussed.

To determine the validity of some criteria that could guide in the decision to cancel or proceed with the second side of planned bilateral simultaneous percutaneous nephrolithotomy (bsPCNL).Patients with an indication for bilateral PCNL were enrolled in this study. The operation was stopped at the end of the initial side if operative time was180 min, the hemoglobin level was11 g/dL, the hemoglobin decrease was3 g/dL, the systolic arterial pressure was100 mm Hg, the arterial oxygen saturation was95%, the arterial blood pH was7.35, or the blood sodium was128 mg/mL. The success and complication rates were compared in patients who underwent second side PCNL (group 1) and those for whom the procedure was stopped after the initial side (group 2).Of 42 planned bsPCNLs, 12 were stopped after the initial side, with the cause being prolonged operative time in 7, hemoglobin decrease in 6, systolic arterial pressure decrease in 2, arterial oxygen saturation decrease in 2, pH decrease in 1, and sodium decrease in 1. Differences in patient characteristics, stone burdens, and overall success and complication rates were insignificant. Transfusion, postoperative urinary infection, and prolonged urine drainage rates were similar, but the total hospitalization time was significantly longer in group 2. One hydrothorax and one renal pelvic perforation occurred in group 2. The need for transfusion correlated positively with the number of nephrostomy tracts in group 2 (r = 0.895, P = .001). No such correlation was found in group 1.Despite the best of intentions, about 30% of anticipated bsPCNL cases might be limited to single-sided PCNL, depending on the intraoperative events. Our criteria seem reasonable, because similar success and complication rates were obtained with bilateral, separate-session PCNL and bsPCNL. These criteria can be considered in the decision making to omit the advantages of a single session for safety.

Aim: To investigate the effects of a single dose of tramadol administered prior to extubation on post-operative pain and morphine consumption after coronary artery bypass surgery. Methods: Patients were randomized post-operatively into two groups (group T, n= 30; group P, n= 30). The technique of anaesthesia was standardized for all patients. The patients in group T received intravenous tramadol, 1 mg/kg, and the patients in group P received 2 ml of saline 0.9%, both approximately 1 h before extubation. After extubation, all patients were allowed to use the morphine patient-controlled analgesia (PCA) device for 24 h post-operatively. Post-operative data were recorded in the cardiac intensive care unit at 30 min, 1 h, 2 h, 4 h, 12 h and 24 h after extubation by the same anaesthesiologist, who had no knowledge of the groups, and the side-effects were also evaluated. Results: In group P, the visual analogue scale (VAS) scores were found to be higher 30 min (P < 0.01), 1 h (P < 0.01), 2 h (P < 0.01) and 4 h (P < 0.05) after extubation. The patient comfort scores were higher in group T 30 min (P < 0.01), 1 h (P < 0.05), 2 h (P < 0.01) and 4 h (P < 0.01) after extubation. The total morphine consumption was higher in group P at all evaluation times (P < 0.01), and the numbers of PCA demands and boluses were also higher in group P (P < 0.01). Conclusions: The study demonstrated that a single dose of tramadol administered prior to extubation following coronary artery bypass surgery is associated with a decrease of up to 25% in morphine consumption, a decrease in the VAS scores and an improvement in patient comfort within the first 4 h post-operatively.