Laurie LAYBOURN-LANGTON, Richard SMITH
Laurie LAYBOURN-LANGTON, Richard SMITH
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More than 50 years have passed since Starzl et al. did the first liver transplant. Since then the transplant speciality has witnessed enormous
growth and at present more than 1 000 000 liver transplants have been performed to date in over 100 liver transplant centers around the
world. In Europe and North America, the predominant mode is deceased donor liver transplantation, while in Turkey and most of the Asian
countries, the living donor liver transplant or split liver transplantation is the most widely available method for liver transplantation. The
etiology of end-stage liver disease is also different in developed and developing countries.
Liver recipients usually have multiple comorbidities and in addition, derangements in liver functions also indirectly affect other systems. The
anaesthesiologist plays a very crucial role as a perioperative physician concerning liver transplantation. He is the lead person involved, from
preoperative workup to intraoperative management and postoperative care in critical care units. Anaesthesiologists are also actively involved
in developing organ transplant pathways and protocols for perioperative assessments.
Although there are local protocols and pathways for assessing liver transplant recipients, there is a lack of standardization in the literature for
such assessments. This article highlights essential aspects in assessing liver transplant recipients and the role of some specific assessment tools
and establishes a standardized protocol for selecting and optimizing suitable patients, thereby reducing the mortality and morbidity associated
with this major surgery.
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Objective: In this study, we aimed to investigate the effect of 2 different dosages of tenoxicam in the prevention of propofol injection pain.
Methods: A total of 120 patients between the ages of 20-50 years who were scheduled for elective surgery were included in this prospective.
Patients were randomly divided into 3 groups. Group 1 received 5 mL saline, group 2 received 10 mg tenoxicam in 5 mL saline, and group
3 received 20 mg tenoxicam in 5 mL saline intravenously as a pretreatment. Venous occlusion was applied for 60 seconds with a rubber
tourniquet after the injection was completed. After injecting propofol, the pain at the injection site of the patient was questioned according
to the Verbal Rating Scale.
Results: The overall pain incidence during propofol injection was 85% in group 1, 75% in group 2, and 60% in group 3 (P = .039). While
there was no significant difference between groups 1 and 2 (P = .264), there was a significant difference between groups 1 and 3 (P = .012).
Moreover, there was a significant decrease in the level of severe pain in group 3 compared to group 1 (P = .008). There was no significant
difference between the groups in terms of mild and moderate pain levels (P > .05).
Conclusions: We found that 20 mg of tenoxicam pretreatment was effective in reducing the incidence and severity of propofol injection
pain compared to the control saline group, but the 10 mg dose did not significantly reduce the injection pain.
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Objective: This study aims to evaluate the approach of anaesthesiologist in Turkey and their applications toward postoperative pain treatment
and in addition to raise awareness in this regard.
Methods: The target audience of this descriptive survey study was physician members of the Turkish Society of Anaesthesiology and
Reanimation, who were volunteering/accepting to participate in the study. The doctors were contacted via their e-mail addresses. Data were collected
online, between October 10, 2016, and November 30, 2016, using a web-based (SurveyMonkey®, https://tr.surveymonkey.com/) questionnaire
form, and the data were analyzed by the Statistical Package for the Social Sciences (SPSS) version 20 software (IBM Corp.; Armonk,
NY, USA). Descriptive data were presented with frequency, percentage, mean, standard deviation, median, minimum, and maximum values.
Results: A total of 315 people were included in the study. Around 34.9% anaesthesiologists had 5-10 years of professional experience and
61.9% of the anaesthesiologists stated that they routinely check the patients’ pain level in the postoperative period. Multimodal analgesia is
mostly preferred (25.3%) after major surgical intervention. Around 71.9% of the participants stated that they cannot find the required time
for postoperative analgesia in their institution, and they associated this matter with excessive workload and lack of staff time.
Conclusion: In this study, we found that anaesthesiologists in Turkey are doing the follow-up of patients during the postoperative period
pain-wise and that they use specific pain scales. Anaesthesiologists think that postoperative pain treatment is not done effectively and time
required for the pain treatment is not enough. They also stated that a separate team should be formed for postoperative pain management
in the hospital. We believe that this study will raise awareness on this issue and will contribute to the creation of algorithms for postoperative
pain treatment, the establishment of pain teams, and the provision of more effective and safer health services.
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Objective: Perioperative shivering is a very common complication. Despite the vast array of knowledge regarding perioperative shivering
and its after-effects, its prophylaxis is often overlooked. The study aims to compare the efficacy and safety of low-dose ketamine, ondansetron,
and pethidine in the prevention of perioperative shivering in patients undergoing total knee replacement surgery under the subarachnoid
block.
Methods: In this randomized controlled study, 203 patients aged 18-75 were included and allocated to one of the 4 groups; normal saline
(group S), ondansetron 4 mg (group O), ketamine 0.25 mg kg−1 (group K), and pethidine 0.25 mg kg−1 (group P). Side effects, namely hypotension,
nausea and vomiting, sedation, hallucinations, and respiratory depression were recorded.
Results: Perioperative shivering was present in 22 (44%), 8 (16%), 4 (7.84%), and 4 (7.69%) patients respectively in group S, O, K, and P,
which was statistically significant when compared to group S with group K and P (P < .01). No difference in the incidence of hypothermia
was observed across the groups (P < .17). A significantly lower incidence of hypotension was observed in group K. In group K, 5.9% of the
patients were scored as being under severe sedation, according to the modified Wilson sedation scale. There was no incidence of hallucination
or respiratory depression observed in any of the groups.
Conclusions: Patients undergoing total knee replacement surgeries are highly predisposed to the development of hypothermia. Temperature
monitoring is thus imperative for all patients. Prophylactic administration of low-dose ketamine or ondansetron or low-dose pethidine produces
a significant anti-shivering effect without any significant side effects. However, low-dose ketamine has the advantages of a lower incidence
of hypotension, nausea, and vomiting than pethidine.
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West syndrome is a rare syndrome that consists of a triad of infantile spasms, hypsarrhythmia pattern on electroencephalogram and mental
retardation. Tuberous sclerosis complex (TSC) is one of the disorders that can cause it. Radiology suites are considered as remote locations for
anaesthesiologists, and the delivery of anaesthesia becomes challenging if a patient with such a rare disease having multiple anaesthetic implications
arrives. We present anaesthetic management for the radiological procedure of the MRI brain of a year old paediatric patient with the West
syndrome having suspected TSC based on presenting signs and symptoms. Anaesthetic consideration and management of this rare syndrome
are discussed. Detailed preoperative assessment, pre-emptive preparation for possible difficult intubation and difficult intravenous access, careful
positioning and prevention of seizures should be the goal. Thorough knowledge of the disease process, its manifestation and its management is
the key to the successful management of such cases.
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We report a healthy 29-year-old primigravida at 38 weeks gestation who underwent elective cesarean section and suffered from Horner’s
syndrome and trigeminal palsy following epidural anaesthesia. The prompt recognition of this complication associated with lumbar epidural
anaesthesia requiring close monitoring of the patient in order to prevent autonomic complications has been addressed.
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Hemoglobin A1c (A1C) or glycated hemoglobin reflects the levels of blood glucose during the previous 8–12 weeks duration. It also helps
us to diagnose diabetes in some cases, during the preoperative screening, who were initially missed out. Although the number of patients
with diabetes undergoing various surgeries has increased many times, the role of A1C as a predictor for the complications during the
perioperative phase remains intriguing. This could be due to various factors such as lack of best shreds of evidence, various cut-off levels
of target A1C, variations of the patient population, presence of other comorbid conditions, and so on. This narrative review article
presents the role of A1C as a reflector of perioperative adverse events in various surgeries and discusses the controversies surrounding it.
We searched “PubMed Central” database with search criteria of “hemoglobin A1c, glycated hemoglobin, and perioperative complications”
with publication date from January 01, 2010, to January 31, 2020, and found a total of 214 articles. We included only the relevant
articles to our topic and added a few more articles that we found as “secondary references” from those articles to suit the structured
headings of our narrative review and made it a total of fifty. To our knowledge, the majority of the studies published on this topic are of
the “Retrospective analysis” type of study, besides no narrative review article available to date in the literature. We suggest that assessment
of A1C levels preoperatively can be used as a routine practice for major procedures in patients with diabetes and for patients who
have persistent high glucose values during preoperative screening regardless of whether a diagnosis of diabetes is established or not.
We found that a cut-off of 8% is acceptable for the majority of the surgical procedures. However, it is better to have a cut-off of 7% or
lower for procedures such as spine and joint replacement surgeries, cardiac surgeries, and so on. Further prospective studies involving a
large population preferably with a multicenter design would provide us more clarity on this topic.
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Objective: Arterial pulse-derived cardiac output monitors are routinely employed to guide hemodynamic management during liver transplant
surgery. In this study, we sought to assess the reliability by evaluating the agreement of the cardiac output measured by the FloTrac
Vigileo versus pulmonary artery catheter (continuous cardiac output) at specified times during liver transplant.
Methods: Liver transplant database with cardiac output values measured by FloTrac Vigileo and continuous cardiac output was analyzed
retrospectively at a tertiary care hospital. Data were compared at T0: baseline, T1: 1 hour in dissection phase, T2: anhepatic phase, T3:
portosystemic shunt, T4: reperfusion, T5: 1 hour after reperfusion, and T6: skin closure. Statistical analysis was done using Bland–Altman
analysis and percentage error (<30%) to assess the agreement between cardiac output measured by 2 techniques, Lin’s concordance correlation
coefficient for quantifying the agreement and 4-quadrant plots to compare the trends of cardiac output.
Results: Bland–Altman analysis showed mean cardiac output ± standard deviation L min-1 (95% CI) at T0: 0.2 ± 2.09 (−3.9 to 4.3), T1:
0.53 ± 3.0 (−5.4 to 6.4), T2: 0.47 ± 2.1(−3.7 to 4.6), T3: 0.31 ± 1.9 (−3.4 to 4.0), T4: 0.44 ± 2.15 (−3.8 to 4.7), T 5:0.69 ± 1.9. (−2.9 to 4.3),
and at T6: 0.43 ± 2.25 (−4.0 to 4.8). Percentage error was 44%-72% and concordance correlation coefficient was poor (<0.65) at all points.
Conclusions: There is poor agreement between the cardiac output measured by FloTrac and pulmonary artery catheter among liver transplant
recipients. The need for superior hemodynamic monitoring is mandated in liver transplant.
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The surgical procedure of lipomas is performed under local, regional, or general anaesthesia depending on the location, number, and size of
the lipoma. Anaesthesia can be achieved with a superficial cervical plexus block in the short-term surgery of soft tissue lesions in the dermatome
areas of the lesser occipital nerve and great auricular nerve. In this article, we presented a high-risk patient with comorbid diseases and difficult
airway who underwent superficial cervical plexus block for retro-auricular lipoma excision.
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