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Meme koruyucu cerrahi (MKC) erken evre meme kanserlerinde sıklıkla uygulanır. Torakal paravertebral blok (TPVB) meme cerrahileri ağrı yönetiminde etkinliği kabul edilmiş bir yöntemdir. Son yıllarda yeni tanımlanan Erektör Spina Plan Bloğu (ESPB) güvenli, kolay ve benzer analjezik etkileri olan yöntem olarak gündeme gelmiştir. Çalışmamız MKC’lerde TPVB ve ESPB’nin opioid tüketimi ve analjezi etkinliğini karşılaştırmaktadır. Gözlemsel, prospektif olarak Grup P(TPVB)’de 43 ve Grup E(ESPB)’de 42 olmak üzere toplam 85 hasta ile tamamlandı. Bloklar ameliyat öncesinde ultrasonografi altında 20 ml %0.375 bupivakain ile T4 vertebra seviyesinden yapıldı. Birincil sonuç postoperatif 24 saat morfin tüketimi, ikincil sonuçlar postoperatif 0. ve 30. dk, 1., 4., 6., 12. ve 24. saat ağrı skorları, kurtarma analjezi gereksinimi, blok uygulama süreleri ve bulantı kusma yan etkileriydi. Morfin tüketimi Grup P’de (17,582,29 mg) Grup E’den (18,962,67 mg) daha düşüktü. (p=0.012) Tüm zamanlarda istirahat ve hareket ağrı skorları benzerdi. Grup P’de iki hastada, Grup E’de beş hastada kurtarma analjezisi yapıldı. (p>0.05) Blok uygulama süresi Grup P’de (78,6210,93 sn), Grup E’ye göre (57,177,84 sn) daha uzundu. (p0.05) MKC’lerde TPVB ve ESPB benzer analjezik etkinlik sağlamıştır. Ancak ESPB daha kolay uygulanabilir olmasıyla iyi bir alternatiftir., Breast conserving surgery (BCS) is frequently performed in early stage breast cancers. Thoracic paravertebral block (TPVB) is an accepted method in the pain management of breast surgery. In recent years, newly defined ESPB has come to the fore as a safe, easy method with similar analgesic effects. Our study is to compare opioid consumption and analgesia effectiveness of TPVB and ESPB in BCS. The observational prospective study was completed with a total of 85 patients, 43 in Group P(TPVB) and 42 in Group E(ESPB). Blocks were applied at the T4 level with 20 ml of 0.375% bupivacaine under ultrasonography preoperatively. The primary outcome was morphine consumption at postoperative 24 hours, secondary outcomes were postoperative pain scores at 0 and 30 minutes, 1, 4, 6, 12 and 24 hours, need for rescue analgesia, block application times, and nausea-vomiting side effects.Morphine consumption was lower in Group P (17.582.29 mg) than in Group E (18.962.67 mg). (p=0.012) Pain scores at rest and at movement were similar at all times. Rescue analgesia was performed in two patients in Group P and in five patients in Group E. (p>0.05) Block application time was longer in Group P (78.6210.93 seconds) than Group E (57.177.84 seconds). (p0.05) TPVB and ESPB provided similar analgesic efficacy in BCS. However, ESPB is a good alternative as it is easier to implement.

Pain control after breast surgery is crucial and supported with regional techniques. Paravertebral block (TPVB) is shown to be effective in postoperative pain management. Erector spinae plane block (ESPB) is assumed to have a similar analgesic effect as an easier and safer block. Our aim was to compare TPVB and ESPB for modified radical mastectomy (MRM) in terms of analgesic efficiency and dermatomal spread.Patients were randomized into Group E (ESPB) and Group P (TPVB). Total 83 patients completed study 42 in Group E and 41 in Group P. Blocks were performed under ultrasonography with 20 mL 0.375% bupivacaine at T4 prior to surgery. T1-10 dermatomal block was examined via pin-prick sensation on the midaxillary and midclavicular lines. Primary outcome was 24-hour morphine consumption. Dermatomal coverage, postoperative 0Morphine consumption was lower in Group P (19.2±2.9 vs. 21±3.1, P=0.007; mean difference 1.8 mg, 95%CI=0.48-3.1 mg). The number of dermatomes with total loss of sensation was higher in Group P. Pain scores were significantly lower in Group P at all time points. The incidence of complications and adverse events was similar in both groups.Thoracal paravertebral block reduced morphine consumption compared to ESPB after MRM, albeit a small difference. A through coverage of TPVB may be preferred with experienced operators in MRM due to lower pain scores.

Anesthesia management of pheochromocytoma excision surgery is associated with severe hemodynamic fluctuations. The objective of this study is to compare the number of hypertensive crisis requiring sodium nitroprusside (SNP) administration between the groups treated with magnesium (Mg)-dexmedetomidine (Dex) and conventional group in pheochromocytoma.This retrospective cohort study included patients who underwent pheochromocytoma surgery between 2011 and 2020. Patients were examined into two groups: 1-Conventional group (GC) included patients who were operated between 2011 and 2015 under standard anesthesia care and who did not receive perioperative additional medication. 2- Mg-Dex therapy group (GMD) comprised the patients who were operated between 2015 and 2020 and who had received 300 mg Mg per oral daily 1 week before the surgery and Mg-Dex infusion intraoperatively. Blood pressure, heart rate (HR), and SNP requirement were recorded throughout surgery as well as demographics and operative data. Hypertensive crisis was defined as systolic blood pressure (SBP)180 mmHg, and tachycardia was defined as HR110 bpm.A total of 78 patients' data were analyzed from 108 patients' documentary. (38 in GC, 40 in GMD) SNP requirement was significantly higher in GC (39.5%) comparing GMD (7.5%) (p=0.001). SBPs during tumor manipulation period were statistically higher in GC than in GMD at 10th, 15th, 20th, 25th, 30th, and 35th min. HR values were significantly higher in GC compared to GMD at 10th and 15th min of tumor manipulation period (p0.05).Combination of Mg-Dex seems to be an alternative therapy for reducing vasodilator requirement in perioperative management of pheochromocytoma.

Bir kadının yabancı bir kişiden gördüğü şiddet ve istismarın dinamikleri, bununla baş etme stratejisi, tanıdığı, yakın ilişki içinde bulunduğu bir kişiden gördüğü istismardan ve bununla baş etmek için geliştirdiği yöntemlerden farklıdır. Dolayısıyla kadına yönelik şiddetle ilgili araştırmaların bu farklılıkları göz önünde bulundurması önemlidir. Bu kabulden yola çıkarak, söz konusu çalışma ile toplumsal cinsiyet algısı ve içkin ataerkil bakış açısı bağlamında Eskişehir’deki üniversitelerde okuyan öğrencilerin flört şiddeti davranışlarına yönelik tutum ve algılarını tespit edip ikisi arasındaki ilişki ortaya konmaktadır. Betimleyici tipte olan bu araştırma Mayıs 2020-Nisan 2021 tarihleri arasında Eskişehir’deki üniversitelerde örgün öğrenim gören öğrencilerle gerçekleştirilmiştir. Covid 19 Pandemi koşullarında çevrimiçi olarak uygulanan araştırma 430 katılımcıyla tamamlanmıştır. Sonuç olarak araştırma bulguları üniversite öğrencilerinin kamusal alanı erkekle özel alanı kadınla ilişkilendiren geleneksel cinsiyetçi rolleri içeren ifadelere büyük oranda katılmadıklarını göstermektedir. Toplumsal cinsiyetçi tutum ve flört şiddeti tutum arasında anlamlı bir ilişki bulunmaktadır. Dolayısıyla gençlerin flört döneminde maruz kaldıkları ve uyguladıkları şiddet davranışlarının azalmasına yönelik çalışmalar kapsamında toplumsal cinsiyet eşitliğine yönelik duyarlılığın arttırılmasının da önemli olduğu görülmektedir.

Coronavirus disease 2019 (COVID-19) is an infection caused by the severe acute respiratory syndrome coronavirus 2. It began at the end of 2019 in the Hubei province of China and quickly expanded worldwide. The World Health Organisation announced the determination of the Public Health Emergency of International Concern on 31 January, 2020, and later proclaimed a global pandemic on 10 March, 2020. The first case in Turkey was officially declared on 11 March, 2020. On 17 March, 2020, the Turkish Ministry of Health published a circular number 14500235-403.99, which regulated precautions to minimise the workload of healthcare systems as well as that of caregivers. This involves the cancellation of elective surgeries to ensure rational and effective use of healthcare resources during the pandemic to reduce viral transmission between patients and healthcare staff and to manage rationally critical care utilisation. In contrast, maintenance of non–COVID-19 healthcare and resumption of critical procedures are serious issues after 60 days of the pandemic. Oncological surgery, procedures to rescue affected limbs, operations to improve function or quality of life and alleviation of pain should be revised in this context and should be scheduled. Per the Turkish Association of Anaesthesia and Reanimation, we aimed to compile our suggestions about the elective surgery schedule, share them with public authority and guide our colleagues in decision making. Local factors with institutional features and opportunities should be considered with local authority coordination for these recommendations. Essential factors to consider while planning elective surgery are the regional incidence of the disease and patient population of the relevant institution before the pandemic. Evaluation of logistic conditions and institutional status within the pandemic would allow a reliable planning. Clearly redefining elective surgery would be advantageous in terms of a common language between departments and would improve collaboration. This guideline based on actual data involves recommendations for the management of anaesthesia and reanimation. Newer data or evidence will possibly weaken these suggestions. As a part of professional responsibility, one should follow current knowledge and regulations by communication channels of the Ministry of Health. Evaluation before planning elective surgery It is recommended to manage the transition period with an institutional scientific board committee. Collaboration with the head nursery is rational in this time course. Before resuming scheduled surgery, institutional opportunities should be assessed and coordination with local health authorities should be established. Moreover, local conditions of COVID-19 infection should be evaluated with a period of fall in the past 14 days (1). a) Assessment of patients with COVID-19 It is recommended to determine the prevalence for the relevant institution as well as the local rate, availability of ward beds and intensive care units (ICUs), discharge status and mortality rate before resuming. It is recommended to have a local policy for retest and follow-up for patients who are positive. Because COVID-19 is associated with high perioperative morbidity and mortality, surgery is conceivable only in life-threatening conditions for patients who are positive for COVID-19. b) Coronavirus disease 2019 diagnostic opportunities Diagnostic opportunities should be reviewed and updated before resuming scheduled surgery. Local policy for COVID-19 diagnosis would be rather established considering local factors with incidence of asymptomatic ratio. Despite the high incidence of false negatives (30%), reverse transcriptase-polymerase chain reaction (RT-PCR) testing is actually a standard tool. Resuming elective surgery can be planned when adequate diagnostic facilities for patients and staff are all available. c) Healthcare workers Considering fatigue and stress during the pandemic, it is recommended to carefully plan for working hours. Staff assigned in high-risk areas would benefit from a flexible programme. The availability of diagnostic tests for healthcare workers is crucial, and it would affect the development of local policy. High-sensitive antibody tests, whenever obtained, would be primarily suitable for caregivers working in high-risk areas. Administration of an immune chart would be appropriate, especially for this group. The safety of healthcare workers should be accepted as the first and most critical step of organisation. Prevalence in this special group should be closely monitored with vigilant follow-up. Before resuming elective surgery, a task distribution close to that of the pre-pandemic period would be suitable. Staff working out of their own places would rather return. Apart from operating rooms (ORs), adequate staff should be reserved for outpatient clinics or post-anaesthesia care units for perioperative period. d) Institutional facilities Normalisation should be established for ICU beds (ORs, paediatric ICUs used for patients with COVID-19 and so on) with an approximate capacity to that of the pre-pandemic period. COVID-19–dedicated building, OR, ICU or any department for diagnostic or therapeutic procedures should be revisited. Similar organisations should be ensured for patients without COVID-19. If these groups are to be treated in the same building, isolation standards, transport conditions between sections and disinfection or sterilisation protocols should be planned in detail (1). Staff should receive training in personal protective equipment (PPE), disinfection or sterilisation topics. Surgical timetables for elective procedures should be organised considering emergent cases, such as trauma. Other facilities for surgical patients, such as laboratory, radiological suits and postoperative care units, should be included in the preliminary plan. Any change in construction or acclimatisation would be planned with the technical department. e) Personal protective equipment It is mandatory to have an appropriate number of PPEs as described in guidelines (N95/FFP2 masks, face shield, gloves, gown, cap, shoe cover and antiseptic solutions) to ensure staff safety. PPE supply chain should be reliably assumed in collaboration with the local authority. A stock of at least 30 days for PPE is recommended in a hospital before the start of elective surgery. Elective surgery schedule a) Planning patients’ preparation (Figure 1) Open in a separate window Figure 1 Preoperative preparation diagram for resuming elective surgery

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (V(T)). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as V(T) of 8 ml kg(−1) or less predicted bodyweight (PBW). A V(T) was deemed ‘default’ if the set V(T) was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation. RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default V(T) was often set, both in women and men; mode V(T) was 500 ml. Median [IQR] V(T) was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg(−1) PBW, P*** < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P*** < 0.001]. In the mediation analysis, patients’ height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default V(T). CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher V(T) than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Objectives: This study aims to investigate the possible relationship between low ankle-brachial index (ABI) and shunt requirement during carotid endarterectomy (CEA) operations. Patients and methods: Medical records of a total of 56 patients (40 males, 16 females; mean age: 65.6±8.4 years; range, 48 to 82 years) who underwent CEA between January 2013 and December 2016 were retrospectively reviewed. The ABI was measured in all patients at the time of hospital admission. Peripheral arterial disease was defined as having an ABI of ≤0.90 in either leg. Selective carotid artery shunt strategy was applied to all patients who underwent CEA under regional anesthesia. Results: Forty-eight (85.8%) patients were symptomatic. Peripheral arterial disease was diagnosed in 25 (44.6%) patients with ABI measurements. Eleven (19.6%) patients required shunt placement due to neurological deterioration during the carotid clamping test. The mean ABI of 11 (19.6%) patients was 0.8±0.15, while the ABI was less than 0.90 in 10 (17.8%) patients. There was a statistically significant correlation between perioperative shunt usage and peripheral arterial disease (odds ratio [OR]: 19.68, 95% confidence interval [CI]: 2.3-164.4; p=0.001). Conclusion: Low ABI appears to be related to a higher rate of shunt requirement in patients undergoing CEA under regional anesthesia with a selective shunt strategy in our modest cohort.

The objective of this study was to compare analgesic efficacy of erector spinae plane block (ESPB), thoracic paravertebral block (TPVB), and intercostal nerve block (ICNB) after video-assisted thoracoscopic surgery (VATS).Prospective, randomized, single-blind study.University hospital, single institution.Adult patients undergoing VATS.Ultrasonography-guided ESPB, ultrasonography-guided TPVB, or ICNB.Patients were enrolled into the following three groups according to analgesia technique as ESPB, TPVB, or ICNB, respectively, group erector spinae plane block (GESP) (n = 35), group thoracic paravertebral block (GTPV) (n = 35), and group intercostal nerve block (GICN) (n = 36). Multimodal analgesia was achieved with paracetamol, tenoxicam, and intravenous morphine (via patient-controlled analgesia) for all study groups. Pain scores were assessed by visual analog scale, and morphine consumption, rescue analgesic requirement, and side effects were recorded postoperatively. Dynamic visual analog scale at the first hour as primary outcome was determined five (two-seven), four (one-six) and (two-six) in GESP, GTPV, and GICN, respectively. Dynamic pain scores were significantly lower in GTPV compared with GESP and GICN at 24 hours (p0.017). Dynamic pain scores in GICN were significantly lower at 12 hours compared with GESP (p0.017). Morphine consumption for the first 24 hours was similar in GICN and GTPV, and it was significantly lower in GICN and GTPV in comparison to GESP (p0.017). Rescue analgesic requirement and side effects were similar among groups.All three blocks can obtain sufficient analgesia after VATS; however, TPVB appeared to be the preferable method compared with ESPB and ICNB, with a more successful analgesia and less morphine consumption.

Resumo Justificativa e objetivos A disfuncao cognitiva no pos‐operatorio e comum apos cirurgia cardiaca. A perfusao cerebral adequada e essencial e a espectroscopia no infravermelho proximo (NIRS) pode medir a oxigenacao cerebral. O objetivo deste estudo foi comparar a incidencia de disfuncao cognitiva no pos‐operatorio, precoce e tardio, em pacientes idosos tratados com monitoracao convencional ou espectroscopia no infravermelho proximo. Metodos Os pacientes submetidos a cirurgia coronariana, acima de 60 anos, foram incluidos e randomicamente alocados em dois grupos: grupo controle e grupo NIRS. O manejo dos pacientes no periodo perioperatorio foi feito com NIRS no grupo NH e com abordagem convencional no grupo controle A bateria de testes foi feita antes da cirurgia, na primeira semana e no terceiro mes de pos‐operatorio. A bateria incluiu o desenho do relogio, a memoria, a geracao de uma lista de palavras, a sequencia de digitos e subtestes que exigem habilidades visuoespaciais.Disfuncao cognitiva no pos‐operatorio foi definida como queda de um DP (desvio‐padrao) da fase basal em dois ou mais testes. O teste U de Mann Whitney foi usado para comparacao de medidas quantitativa e o teste exato do qui‐quadrado para comparar dados quantitativos. Resultados Vinte e um pacientes do grupo controle e 19 do grupo NIRS concluiram o estudo. Os dados demograficos e operacionais foram semelhantes. Na primeira semana, nove pacientes (45%) do GC e sete pacientes (41%) do grupo NIRS apresentaram disfuncao cognitiva no pos‐operatorio. No terceiro mes, 10 pacientes (50%) foram avaliados como disfuncao cognitiva no pos‐operatorio; a incidencia foi de quatro (24%) no grupo NIRS (p = 0,055). O grupo que apresentou disfuncao cognitiva no pos‐operatorio precoce e tardio teve uma permanencia significativamente maior na UTI (1,74 + 0,56 vs. 2,94 + 0,95; p Conclusao Neste estudo piloto, a monitoracao convencional e a espectroscopia no infravermelho proximo resultaram em taxas semelhantes de disfuncao cognitiva no pos‐operatorio precoce. A disfuncao cognitiva tardia tende a melhorar com espectroscopia no infravermelho proximo. Os declinios cognitivos precoces e tardios foram associados a internacoes prolongadas tanto em UTI quanto hospitalares.

Resumo Introducao A disfuncao cognitiva pos‐operatoria (DCPO) e um resultado adverso cirurgico que e mais comum apos cirurgias cardiacas abertas. O objetivo deste estudo foi investigar o papel dos niveis de glicose no sangue rigorosamente controlados durante a cirurgia coronariana no declinio cognitivo precoce e tardio. Metodos Foram randomizados em dois grupos 40 pacientes acima de 50 anos e submetidos a cirurgia coronariana eletiva. No grupo “controle rigoroso” (GI), a glicemia foi mantida entre 80‐120 mg.dL −1 ; enquanto no grupo “liberal” (GII), variou entre 80‐180 mg.dL −1 . A bateria de testes neuropsicologicos foi feita tres vezes: fase basal, antes da cirurgia e na primeira e 12a semana de acompanhamento no pos‐operatorio. DCPO foi definida como uma queda de um desvio padrao da fase basal em dois ou mais testes. Resultados Na primeira semana de pos‐operatorio, os testes neurocognitivos mostraram que 10 pacientes no GI e 11 pacientes no GII apresentaram DCPO. A incidencia de DCPO precoce foi semelhante entre os grupos. No entanto, a avaliacao tardia revelou que a disfuncao cognitiva persistiu em cinco pacientes no GII, enquanto nenhum paciente foi classificado como cognitivamente prejudicado no GI ( p = 0,047). Conclusao Sugerimos que o controle glicemico rigoroso no perioperatorio de cirurgia coronariana pode desempenhar um papel na prevencao da deterioracao cognitiva persistente.

To the Editor We were very interested to read the remarkable work in the January issue of Regional Anesthesia & Pain Medicine entitled ‘Influence of postoperative analgesia on systemic inflammatory response and postoperative cognitive dysfunction after femoral fractures surgery’.[1][1] The

BACKGROUND Cognitive dysfunction in the early postoperative course is common for the elderly population. Anesthetic management may affect postoperative cognitive decline. Effective analgesia, early recovery and modulation of the stress response are advantages of neuraxial blocks. This study aims to compare the effects of general anesthesia and the combination of general anesthesia with epidural analgesia for postoperative cognitive dysfunction (POCD). We hypothesized that neuraxial block combined with general anesthesia (GA) would have a favorable influence on POCD prevention. METHODS Patients above 60 years undergoing non-cardiac surgery were included in this randomized, prospective study and randomized into two groups. Patients in the first group (GI) were treated under GA, whereas in the second group (GII), epidural analgesia was combined with GA. Patients' cognitive function was assessed before and one week after surgery using a neuropsychological test battery. POCD was defined as a drop of one standard deviation from baseline on two or more tests. RESULTS A total of 116 patients were allocated for the final analysis. Demographic and operative data were similar between groups, except maximum pain scores, which were significantly higher in GI than GII (4.9±2.8 vs. 1.7±1.7; p

Severe hypophosphatemia is a rare electrolyte disturbance among surgical patients associated with severe fatigue, impaired cardiac and respiratory functions. Although mild hypophosphatemia is common after parenteral administration of intravenous iron replacement, severe hypophosphatemia is not usual in perioperative period. We present a case of 76-year-old female who underwent surgery for a left paramediastinal mass. Laboratory examination showed hypochromic microcytic anemia. A total dose of parenteral 1000 mg ferric carboxymaltose was administered two days prior to the operation with the aim of achieving a rapid increase in hemoglobin. We performed a wedge resection for the mass originating from the left upper lobe. The patient developed dyspnea and fatigue with severe hypophosphatemia on postoperative third day. The clinical status of the patient could be only improved with parenteral administration of high dose of sodium phosphate. We tried to emphasize this unexpected complication of intravenous iron replacement and the features of its management.

Objective: Vena cava thrombectomy together with radical tumor excision in the case of cavoatrial tumor thrombosis is vitally important. In this document, we present the infrarenal inferior vena cava cannulation technique which overcomes the need of total circulatory arrest during the treatment of renal tumors extending into the right atrium. Methods: Between June 2013 and December 2017, 5 patients with renal tumors extending into the right atrium, were diagnosed. The mean age of the patients was 43.2 years. One pediatric and 1 adult patient were male, the other 3 were adult females. The three-venous cannulation system containing vena cava superior, infrarenal vena cava inferior and two-stage venous cannulae was used. The tumor thrombus was removed following vena cava superior and infrarenal vena cava inferior cannulations. A two-stage venous cannula was placed in the right atrium while closing atriotomy. The procedure was continued. Results: There was no mortality in the peroperative and postroperative period. The mean operation time was 465 minutes, the duration of cardiopulmonary bypass was 48 minutes and myocardial ischemia time was 27 minutes. The mean hepatic and renal ischemia time was 15.4 minutes. The mean intensive care unit and hospital stay were 28.4 hours and 9.3 days, respectively. The total follow-up period was 12 months. There was no mortality in long term follow-up. Conclusion: Complete tumor resection without any remnant is the main predictor of mortality in this particular patient population. This technique allows tumor resection in moderate hypothermia without needing hypothermic circulation and provides a safe procedure for complete resection., Amaç: Vena kava trombektomisi ile birlikte yapılan radikal tümör eksizyonu, kavoatrial tümör trombozlarının tedavisinde son derece önemlidir. Bu yazıda sağ atriuma uzanım gösteren renal tümörlerde uyguladığımız hipotermik dolaşım durdurulmasını engelleyen infrarenal vena kava inferior kanülasyon tekniğini anlatmaktayız. Yöntemler: Haziran 2013-Aralık 2017 tarihleri arasında intrakardiak uzanım gösteren böbrek kaynaklı tümör saptanan 5 hasta tarafımıza konsülte edilmiştir. Hastaların yaş ortalaması 43,2 yıl idi. Pediatrik ve 1 yetişkin hasta erkek, diğer 3 yetişkin hasta kadındı. Operasyonlarda vena kava superior, infrarenal vena kava inferior ve two-stage venöz kanüller takılı olan üçlü venöz kanülasyon sistemi kullanıldı. Vena kava süperior ve infrarenal vena kava inferior kanülasyonlarını takiben tümör trombüsü çıkarıldı. Atriotomi kapatılırken two-stage venöz kanül sağ atriuma yerleştirildi. Prosedüre usulünce devam edildi. Bulgular: Operasyon sırasında ya da sonrasında mortalite gözlenmedi. Ortalama operasyon süresi 465 dk, kardiyopulmoner bypass süresi 48 dk ve myokardial iskemi süresi 27 dk idi. Hepatik ve renal iskemi süreleri ortalama 15,4 dk oldu. Ortalama yoğun bakım ve hastanede kalış süreleri sırasıyla 28,4 saat ve 9,3 gün hesaplandı.Toplam takip süresi 12 ay idi. Hiç bir hastada uzun dönem takiplerde mortalite ile karşılaşılmadı. Sonuç: Tümörün tamamen çıkarılması ve rezidü trombüs bırakılmaması bu hasta grubunun mortalitesini belirleyen en önemli etkenlerdendir. Uyguladığımız teknikle birlikte hastalarda hipotermik dolaşıma gereksinim duyulmadan orta hipotermide tam bir tümör eksizyonu sağlanmış ve trombüs dokusu bırakılmadığından emin olunmuştur.

Aim:Standard surgical treatment of the interrupted aortic arch with the use of cardiopulmonary bypass is risky especially in critically ill babies. In this manuscript, we present the results of off-pump pericardial roll bypass for the treatment of aortic interruption.Material and methods:The technique was applied in nine critically ill infants between July 2011 and December 2019. Data were reviewed retrospectively. There were four girls and five boys. The types of the interruption were type B in six cases and type A in three babies. Additional cardiovascular anomalies were ventricular septal defect in all, atrial septal defect or patent foramen ovale in all, single-ventricle pathologies in two and bicuspid aortic valve in three cases. All the patients were in critical situations such as intubated, having symptoms of infection, congestive heart failure or ischaemia and malperfusion leading visceral organ dysfunction.Results:All patients underwent off-pump ascending aorta or aortic arch to descending aorta bypass with a pericardial roll. Post-operative early mortality occurred in one patient with severe mitral regurgitation due to cardio-septic shock. One patient who had single-ventricle pathology underwent bidirectional Glenn and was lost on the post-operative 26th day due to sepsis 2 years after operation. Two patients presented with dilatation of the pericardial tube 18 and 24 months after the operations and one underwent reconstruction of the neo-arch. The remaining patients are asymptomatic, active and within normal limits of body and mental growth.Conclusion:Treatment of interrupted aortic arch with a bypass with an autologous pericardial roll treated with gluteraldehyde without cardiopulmonary bypass seems a safe and reliable technique especially for the treatment of critically ill infants.

Trials 20(1), 213 (2019). doi:10.1186/s13063-019-3208-8

BACKGROUNDPostoperative pneumonia is associated with increased morbidity, mortality and costs. Prediction models of pneumonia that are currently available are based on retrospectively collected data and administrative coding systems.OBJECTIVETo identify independent variables associated with the occurrence of postoperative pneumonia.DESIGNA prospective observational study of a multicentre cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe database).SETTINGSixty-three hospitals in Europe.PATIENTSPatients undergoing surgery under general and/or regional anaesthesia during a 7-day recruitment period.MAIN OUTCOME MEASUREThe primary outcome was postoperative pneumonia. Definition: the need for treatment with antibiotics for a respiratory infection and at least one of the following criteria: new or changed sputum; new or changed lung opacities on a clinically indicated chest radiograph; temperature more than 38.3 °C; leucocyte count more than 12 000 μl-1.RESULTSPostoperative pneumonia occurred in 120 out of 5094 patients (2.4%). Eighty-two of the 120 (68.3%) patients with pneumonia required ICU admission, compared with 399 of the 4974 (8.0%) without pneumonia (P < 0.001). We identified five variables independently associated with postoperative pneumonia: functional status [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.58 to 3.12], pre-operative SpO2 values while breathing room air (OR 0.83, 95% CI 0.78 to 0.84), intra-operative colloid administration (OR 2.97, 95% CI 1.94 to 3.99), intra-operative blood transfusion (OR 2.19, 95% CI 1.41 to 4.71) and surgical site (open upper abdominal surgery OR 3.98, 95% CI 2.19 to 7.59). The model had good discrimination (c-statistic 0.89) and calibration (Hosmer-Lemeshow P = 0.572).CONCLUSIONWe identified five variables independently associated with postoperative pneumonia. The model performed well and after external validation may be used for risk stratification and management of patients at risk of postoperative pneumonia.TRIAL REGISTRATIONNCT 01346709 (ClinicalTrials.gov).

Background: The effect of intravenously administered dexmedetomidine on oxygenation during one-lung ventilation has not been studied. The hypothesis of this prospective, randomized study was that dexmedetomidine would be associated with an improvement in oxygenation during one-lung ventilation. The secondary outcome was the change in the intrapulmonary shunt. Materials and Methods: Thirty patients undergoing one-lung ventilation were included. Patients in Group D (n = 15) received a bolus dose of 1 μg·kg-1 dexmedetomidine at 10 min after induction of anaesthesia followed by an infusion of 0.4 μg·kg-1·hr-1 that was stopped at the end of the surgery, and those in the control group(Group C, n = 15) were given saline at the same dosage. Vital signs, PaO2, and pulmonary shunting (Qs/Qt) were compared. Results: During one-lung ventilation, the PaO2 in Group D increased significantly and Qs/Qt significantly decreased compared to Group C (PaO2, 203.7 ± 42.3 mmHg vs. 173 ± 37.6 mmHg [P = 0.04] and Qs/Qt 19.8% ± 4.5% vs. 31% ± 2.4% [P < 0.0001], Group D and Group C, respectively). Conclusion: Intravenous administration of dexmedetomidine achieved an improvement in oxygenation during one-lung ventilation. This was associated with a decrease in pulmonary shunt. Use of intraoperative dexmedetomidine during thoracic surgery can be suggested.

Methylene tetrahydrofolate reductase (MTHFR) deficiency is an autosomal recessive disorder that results in increased homocysteine levels in the body. Hyperhomocysteinemia causes a predisposition to venous and arterial thrombosis and ischaemic insults. The incidence of the deficiency is around 40% in some countries. In this study, we aimed to evaluate the effects of anaesthetic agents in children with MTHFR deficiency.Twelve paediatric patients with an MTHFR enzyme deficiency who underwent surgery in a ten-month period in a single centre were retrospectively evaluated. Demographic data, homocysteine levels before and after surgery, anaesthesia management and postoperative complications were recorded.In four patients, propofol was used both for anaesthesia induction and total intravenous anaesthesia (TIVA). Eight patients received sevoflurane for both induction and maintenance of anaesthesia. Nitrous oxide (NSevoflurane and propofol have no deleterious effects on homocysteine levels in patients with MTHFR deficiency. Avoidance of N

Introduction Video assisted thoracoscopic surgeries (VATS) as well as thoracotomies require multimodal analgesia. Erector spinae plane block (ESPB) is newly introduced and showed adequate analgesia after VATS (1). In this report, we aimed to investigate the analgesic efficacy of the ESPB in thoracoscopic surgeries. Methods Written informed consent was obtained from all patients (for use of images and information) in this report. Patients (ASA I to III) above 18 years undergoing VATS were enrolled. Prior to anesthesia induction, we performed unilateral, single-injection ESPB at the level of T5 with USG guidance (figure 1). We used 20mL of 0.5% bupivakain. Multimodal analgesia comprised morphine via patient controlled analgesia, NSAID and paracetamol. Postoperative pain was questioned at 1st, 4th, 12th, 24th, 36th, and 48th hours (at rest and cough) using visual analog scale (VAS). Morphine consumption, additional analgesic (tramadol 0.5 mg/kg) requirement were enrolled as well as complications, mobilization and feeding times. Results This case series consisted of 3 female and 10 male patients with a mean age of 57±7. Four of them underwent lobectomy and resting 9 segmentectomy. VAS values (at rest and cough) are summarized in table 1. Mean morphine consumption for 12th and 24th hours were respectively 27.7±5.5mg and 48.2±13.6mg. Eleven of study patients needed once additional analgesic at 5±2.4 hours. Mobilization time was postoperatively at 4.7±0.98 hours and feeding at 5.11±0.92 hours. There was no complication among patients. Discussion ESPB is a simple and safe block with USG and systemic complications are rare. We think that ESPB is a suitable and reliable option at rest; meanwhile multimodal analgesia is still essential to ensure adequate analgesia for dynamic pain control after VATS.

Fluid management during thoracic anesthesia remains as a challenge for the anesthesiologists. The "safe zone" between volume overload (risk of pulmonary edema) and hypovolemia (potential risk of renal failure) is hard to determine and narrow. Relationship between perioperative fluid administration and postoperative lung injury has been clearly demonstrated but lung injury can even occur after the most restrictive management. Multiple hit hypothesis and endothelial glycocalyx in addition to revised Starling equation can help us understand this dilemma. Although a "liberal" fluid strategy is out of question for thoracic surgery, evidence on "restrictive" and "goal-directed" fluid strategies are missing. New monitors with dynamic parameters can help to evaluate if the patient will respond to a fluid challenge. However, "volume responsiveness" should not be equated with volume deficiency, especially in a patient with thoracic epidural catheter. Fluid type (crystalloids or colloids) is also another unclear point, although balanced solutions should be preferred for crystalloids. Minimal discontinuation of oral hydration, early feeding and mobilization should be encouraged. This review summarizes current evidence on the topic and highlights unanswered questions.

Myasthenia gravis (MG), an autoimmune disease of neuromuscular junction, is associated with an interaction with the muscle relaxants (MR). Thymectomy is often the method of choice for its treatment; anesthetic and also postoperative management require meticulous preoperative evaluation, careful monitoring, and adequate dose titration. The frequency of video-assisted thoracoscopic extended thymectomy (VATET) is also increasing, thus making the use of MR obligatory. Introduction of sugammadex into modern practice has provided a safe choice to the avoidance of prolonged action of MR also in patients with MG. Still, postoperative management of MG can be challenging, including the risks of prolonged mechanical ventilation, both cholinergic and myasthenic crisis, and drug interactions. This chapter aims to give information about some approaches to obtain a safe postoperative period in patients with MG. The general approach to MG and also other operations of myasthenic patients are not included within the range of this chapter.

The aims of this study are to present the results of videothoracoscopic thymectomy in patients with myasthenia gravis (MG) and to predict the factors affecting the next morning discharge (NMD). This is a retrospective analysis of the prospectively recorded data of 181 consecutive myasthenic patients who underwent videothoracoscopic thymectomy from June 2002 to September 2009. Sixty-one patients (33.7%) were discharged on the next morning. Univariate and multivariate analyses were evaluated to determine the predictors for NMD. Mean calculated variables were: age (29.8 years), duration of symptoms (22.5 months), duration of surgery (51.3 min), postoperative stay (2.1) days, and visual analogue scale (2.1). No mortality occurred. Four patients were required to stay in intensive care unit (ICU) with a mean of 18.6 h. With logistic regression analysis, duration of operation (DoO) was calculated to be the only predictive factor for NMD (P=0.006). Video-assisted thoracoscopic thymectomy (VAT thymectomy) is a safe surgery procedure with a smooth postoperative period for MG. Although a detailed analysis was performed, only DoO was found to be a predictive factor for NMD in MG patients.

PurposeThe aim of this study is to determine Turkish managers' conflict styles in different sectors, namely durable consumer goods, aviation, automotive and banking.Design/methodology/approachA total of 130 managers' conflict management styles were assessed by applying the Rahim's 1983 Organizational Conflict Inventory‐II.FindingsFirst, integrating and, second, compromising are found to be the most preferred conflict styles of Turkish managers. The other important finding is that preferring obliging styles of conflict management changes according to the status of managers. Obliging is mostly used when the conflict partner has an upper level status.Research limitations/implicationsAdditional data from cross‐cultural studies are needed to form a comprehensive understanding of conflict management styles. Also, the number of respondents in the study is not enough to generalize the findings; additional data from different sectors could make the findings more valid.Practical implicationsThere seems to be a need for seminars or practice‐oriented workshops on evaluating and understanding the nature of conflict and learning to manage conflict as a beneficial and creative process for the betterment of both individuals in organizations and organizations themselves.Originality/valueThe study provides a revised base for cross‐cultural conflict management studies and also highlights the national dynamics of Turkish managers' relationships, especially for international investors.

BACKGROUND The approach to acute and chronic type B aortic dissection has changed significantly over the past years. In this aspect, we have reviewed our single-center experience in surgery for type B dissections and compared the current data presented by other centers. METHODS Twenty-nine patients operated at our center for type B aortic dissection (14 acute, 15 chronic) were reviewed over the years between 1996 and 2004. All patient data in addition to immediate and late outcome following surgery were noted. RESULTS The mean age in acute and chronic groups was 53 +/- 16 versus 62 +/- 12 years, respectively (p = 0.1). Hospital mortality was 4 patients. The mean period in the intensive care unit was 4.2 +/- 3.1 days. Follow-up time was 36 +/- 11 months. Median interval between the initial symptoms and surgery was 3.8 days for acute cases. No patients underwent reoperation in acute patients; whereas 3 underwent reoperation in the chronic group. False lumen patency rates in acute and chronic dissections were 16.7% versus 46% after 24 months (p< 0.05). Distal anastomoses included both true and false lumens in 83% of the chronic cases with false lumen patency. The mean reoperation-free survival was 79.35 months with standard error of 5.57 months (95% CI, 68.42 to 90.27) in all patients. CONCLUSIONS Open surgery in acute type B dissections yielded excellent immediate and long-term durability in our series with no false lumen patency or aortic expansion. However, incorporation of both false and true lumina into distal anastomosis in patients with chronic dissection resulted in false lumen patency with aortic expansion.

Purpose of review Myasthenia gravis, a chronic disease of the neuromuscular junction, is associated with an interaction with neuromuscular blocking agents (NMBAs). As thymectomy is often the method of choice for its treatment, anaesthetic management requires meticulous preoperative evaluation, careful monitoring, and adequate dose titration. The frequency of video-assisted thoracoscopic extended thymectomy (VATET) is also increasing, making the use of NMBA obligatory. The number of cases of the juvenile form has also increased over years; airway management in juvenile one-lung ventilation is another challenge. Recent findings Sugammadex appears to be a safe choice to avoid prolonged action of NMBA also in patients with myasthenia gravis, although this information has to be confirmed in further series. The number of VATETs is increasing so that the experience with sugammadex will also increase in time. In non-VATET operations, use of NMBA should and can be avoided as much as possible. New scoring systems are defined to predict a postoperative myasthenic crisis. For VATET in juvenile cases, blockers can be a good option for the airway management. Summary Anaesthetic management of thymectomy in myasthenia gravis requires experience concerning different approaches. Sugammadex should be considered as a possible further step toward postoperative safety.

To investigate the relationship between end-tidal carbon dioxide levels and augmentation of pulmonary blood flow achieved by insertion of systemic-pulmonary shunts.Prospective clinical study.University hospital.Nineteen cyanotic children with tetralogy of Fallot.Modified Blalock-Taussig shunt operations were performed on the left side in 14 patients and on the right side in 5 patients.End-tidal carbon dioxide tension was recorded, and an arterial blood gas sample was obtained simultaneously after thoracotomy (T0) and after completion of systemic-pulmonary shunt (T1). End-tidal carbon dioxide tension was significantly higher ( p0.01), and arterial to end-tidal carbon dioxide tension difference was significantly lower (p0.01) at T1 when compared with T0. The increase in end-tidal carbon dioxide showed a statistically significant correlation with the response of arterial oxygen saturation (r = 0.61, p0.01). The fall in arterial to end-tidal carbon dioxide tension difference correlated inversely with the change of oxygen saturation (r = -0.81, p0.0001).It is concluded that end-tidal carbon dioxide tension alterations offer an alternative intraoperative tool to monitor pulmonary blood flow during modified Blalock-Taussig shunt procedures.

Objective: To compare the effects of thiopental and propofol during defibrillation threshold testing (DFT) on hemodynamics and recovery profile in patients requiring automatic internal cardioverter-defibrilator placement. Design: Prospective clinical investigation. Setting: University hospital. Participants: Thirty-four adult patients. Interventions: After administration of midazolam, 0.025 mg/kg, and fentanyl, 0.5 to 1 μg/kg, surgery was performed under topical infiltration with 1% lidocaine. In group I (GI) (n = 17), patients received thiopental by slow injection and patients in group II (GII) (n = 17) received propofol before induction of ventricular fibrillation (VF). Measurements and main results: Patients received 4.1 ± 1.4 mg of midazolam, 114 ± 34 μg of fentanyl, and 280 ± 78 mg of thiopental in GI; and 4.6 ± 1.7 mg of midazolam, 119 ± 62 μg of fentanyl, and 147 ± 40 mg of propofol in GII (p > 0.05). Hemodynamics did not show significant differences between the groups at any recording time. Average time needed to regain the pretest sedation level was 16.4 ± 8.8 minutes in GI and 10.9 ± 5.5 minutes in GII (p = 0.03). Time required to achieve a score of 10 using a modified Aldrete score was 26.4 ± 9.3 minutes in GI and 17.4 ± 4.9 in GII (p = 0.001). Seven patients in GII (41%) and 1 patient in GI (6%) became hypotensive after DFT (p = 0.04). Conclusions: Deepening the sedation level by slow injection of thiopental or propofol before DFT provided satisfactory conditions during brief episodes of VF. Delay in recovery of arterial pressure after DFT with propofol and delay in arousal and discharge of patients with thiopental are major disadvantages of the regimens.

Experience in video-assisted thoracoscopic (VATS) thymectomy is limited in paediatric patients with non-thymomatous myasthenia gravis (MG). The aim of this study is to evaluate the medical status and surgical results of paediatric patients who underwent a VATS thymectomy.Of the 367 VATS thymectomies performed for MG patients in our Department of Thoracic Surgery between June 2002 and April 2013, 40 patients were in the paediatric age group. The data were evaluated retrospectively. Age, sex, duration of disease, body mass index, prescribed medication, duration of the operation, complications, chest tube duration, length of postoperative hospital stay and pain score using a visual analogue scale were analysed.The average age was 14.8 ± 2.2 years (range, 8-18 years), and 27 (68%) patients were female. The electromyography and acetylcholine receptor antibody tests were positive in 30 (75%) and 27 (67%) patients, respectively. The mean quantitative MG score was 11.5 ± 5.3. The mean prescribed preoperative pyridostigmine bromide dosage was 209 ± 112 mg. Eleven (27.5%) patients were on corticosteroid treatment and 22 (55%) received intravenous immunoglobulin treatment preoperatively. There were no open conversions or mortalities. The average duration of the operation was 48.9 ± 31.3 min. All patients were extubated on the table and only one (2.5%) required mechanic ventilation for 18 h postoperatively. Three (7.5%) patients experienced complications. The average duration of chest drainage and postoperative stay were 20.5 ± 12.1 h and 1.8 ± 1.0 days, respectively. The average pain score using a visual analogue scale was 2.3 ± 1.2.A right-sided VATS thymectomy is a safe procedure in paediatric patients with MG.