Manajemen Low Flow Anesthesia pada Pasien Kraniosinostosis dengan Hipertelorisme yang menjalani Four Box Wall Osteotomy, dan Eksisi Redundant Skin Fronto Nasal

Craniosynostosis is a case that diagnosed in the first year of life and can need surgical in young age. Craniosynostosis is a part of hypertelorism with incidence rate around 20%. Boy, 13 years old with hypertelorism had undergone multiple surgery for correction of hypertelorism before. Patient was planned to advance surgical correction of four box wall osteotomy which consist frontal part correction and part of it is release craniosynostosis in coronal suture. Risk of massive bleeding because patient already in teen age and length of surgery can be prolonged. Difficult airway management due to fascial deformity, use of low flow anesthesia to preserve temperature and reduce inhalation anesthesia usage, intraoperative fluid management in consideration maintenance and replacement blood loss and post operative pain management has become another consideration. Covid-19 as part of problems post operatively being known before extubation made the process is delayed. Massive bleeding needs massive transfusion protocol to speed up blood availability. Blood product such as PRC, FFP and TC should be available because coagulation factor is part of consideration. Anesthesia management in hypertelorism with four box wall osteotomy need good communication between anesthesiologist, neurosurgeon, plastic surgeon and pediatric intensivist to reduce perioperative risk including covid-19 in pandemic era.

The Effect of Sevoflurane Low Flow Anesthesia on Preserving Patient Core Temperature

Background: Low flow anesthesia reduces the fresh gas flow (FGF) entering the anesthesia circuit and saves on the volatile agent used. In this study, the effect of low-flow anesthesia with sevoflurane on core temperature and the incidence of perioperative hypothermia were investigated.Methods: Records of patients who underwent general anesthesia with sevoflurane were analyzed retrospectively. According to the fresh gas flow applied, the patients were divided into three groups: Low flow anesthesia (LFA = 1 l / min), medium flow anesthesia (MFA = 2 l / min), and high flow anesthesia (HFA = 4 l / min). Patients’ demographic data and the initial (T1) and final (T2) temperatures during the operation were compared.Results: A total of 160 patients were included in the study. There was no significant difference in T1 temperature values between the groups. The T2 value of the HFA group was significantly lower than the LFA group (p = 0.028). Different flow values were found to have a significant effect on temperature change (F = 21.630, p <0.001, partial eta squared = 0.216). There was a significant difference between the mean temperatures measured at two different times (F = 301.064, p <0.001, partial eta squared = 0.657). The overall incidence of hypothermia was 32.5%, with 52 patients. Hypothermia (T2<36 degrees) incidences were not different between the LFA group and the MFA and HFA groups (p = 0.682); However, perioperative core temperature loss was significantly lower in the LFA group (p = 0.001).Conclusions: Low flow anesthesia using sevoflurane was not sufficient alone to reduce the incidence of hypothermia. However, the LFA technique preserved the patient’s core temperature better than the MFA and HFA techniques. Therefore, in addition to low-flow anesthesia being a cost-oriented technique, we have demonstrated that it may also have a beneficial effect on reducing perioperative temperature loss.Trial Registration: Researchregistary.com/6840Ethics committee: Yozgat Bozok University 2017-KAEK-25122019.1

Change of inspired oxygen concentration in low flow anesthesia

Background: There are several advantages of low flow anesthesia including safety, economics, and eco-friendliness. However, oxygen concentration of fresh gas flow and inspired gas are large different in low flow anesthesia. This is a hurdle to access to low flow anesthesia. In this study, we aimed to investigate the change in inhaled oxygen concentration in low flow anesthesia using oxygen and medical air.Methods: A total of 60 patients scheduled for elective surgery with an American Society of Anesthesiologist physical status I or II were enrolled and randomly allocated into two groups. Group H: Fresh gas flow rate (FGF) 4 L/min (FiO₂ 0.5). Group L: FGF 1 L/min (FiO₂ 0.5). FGF was applied 4 L/min in initial phase (10 min) after intubation. After initial phase FGF was adjusted according to groups. FGF continued at the end of surgery. Oxygen and inhalation anesthetic gas concentration were recorded for 180 min at 15 min interval.Results: The inspired oxygen concentration decreased by 5.5% during the first 15 min in the group L. Inspired oxygen decreased by 1.5% during next 15 min. Inspired oxygen decreased by 1.4% for 30 to 60 min. The inspired oxygen of group L is 35.4 ± 4.0% in 180 min. The group H had little difference in inspired oxygen concentration over time and decreased by 1.8% for 180 min.Conclusions: The inspired oxygen concentration is maintained at 30% or more for 180 min in patients under 90 kg. Despite some technical difficulties, low flow anesthesia may be considered.