The Impact of Perioperative Viscoelastic Test Application on Blood Product Usage and Outcome in Cardiac Surgery; Regional Cardiac Surgery Center Experience

Objective: Thromboelastography (TEG) is a diagnostic modality that gives information about coagulation. Despite all blood-preserving precautions in open heart surgery there are blood losses and the use of blood and blood products becomes inevitable. TEG is mostly not available in every center and habits, trends and clinical experience in blood use create the possibility of causing unnecessary use of blood and blood products. In this study, it was aimed to determine the effect of the use of thromboelastography on the use of blood and blood products in cardiac surgery. Methods: Two hundred patients between 18-70 years old who underwent open heart surgery were included in the study. After the cardiopulmonary bypass (CPB), the cases were confirmed to have an Activated Clotting Time (ACT) value in the range of 120-150 sec after protamine administration. In 100 patients in the TEG group, the coagulation status was evaluated with TEG and it was decided how to apply blood and blood product use. Blood and blood product use was applied to 100 patients in the control group based on clinical experience and foresight. The total amount of blood and blood product used, fluid balance, need for inotropics, mechanical ventilator time, complications, duration of intensive care and discharge times were recorded. Results: Use of Fresh Frozen Plasma (FFP) at the after CPB in the TEG group was statistically significantly lower than that of the control group FFP (p<0.05). Postoperative FFP and postoperative platelet use in the study group were statistically significantly lower than in the postoperative FFP and postoperative platelet values of the control group (p <0.05). Conclusion: The use of thromboelastography is a very useful monitoring in terms of reducing FFP use after CPB and reducing FFP and platelet usage in the postoperative period. In this way, the unnecessary use of blood and blood products can be prevented.

Anesthesia Management in Endovascular Aortic Repair

Objective: Our study aimed to examine retrospectively the anesthesia techniques and their results applied to patients who underwent endovascular aortic repair due to aortic pathology. Methods: This retrospective and observational study included patients who underwent EVAR or TEVAR for abdominal and/or thoracic aortic aneurysm between 2015-2021. Patients’ demographic data, type of surgery and anesthesia, duration of surgery and anesthesia, amount of blood transfusion, lengths of stay in ICU and of hospital were recorded. Results: The data of 206 patients who underwent EVAR and TEVAR for abdominal and/or thoracic aortic aneurysm were obtained. TEVAR was applied to 63 patients and EVAR was applied to 143 patients. The procedure was performed under general anesthesia (GA) in all 63 patients who underwent TEVAR, while 15 patients who underwent EVAR were operated under GA and 128 patients under regional anesthesia (RA). The mean anesthesia and surgery times were found 136.1±72.0 min. and 112.2±71.3 min. in GA patients and it was 112.2±71.3 min. and 96.5±32.1 min. in RA patients. The mean length of ICU and hospital stays were determined as 1.6±2.1 days and 3.1±2.7 days in GA patients, and 1.2±0.6 days and 3.1±2.5 days in RA patients. Conclusion: GA or RA methods are preferred as anesthesia techniques in patients undergoing EVAR due to aortic aneurysm. Although RA has advantages compared to GA, such as shorting the lenght of hospital and ICU stays, reducing the blood product requirements, shorting both anesthesia and surgery times, patient characteristics should also be considered in the selection of anesthesia techniques.

Measurement of the Endotracheal Tube Diameter Using Computed Tomography Images for Pediatric Patients: Comparison with Classic Formulas

Objective: In this retrospective study, we aimed to evaluate the compatibility of endotracheal tube (ETT) size used during surgery with tracheal diameter measured by computed tomography(CT) and classic formulas in children who underwent CT imaging preoperatively due to surgical indications. Methods: The study included preoperatively CT scanned, 0-3 year-old patients who were operated due to congenital heart diseases between June 1-October 1, 2018.Using the CT scans, transverse and anteroposterior tracheal diameters were measured from the subglottic level. As these diameters reflect the external diameter of the ETT, the inner diameter-which corresponds the ETT size-was calculated using a correction formula. Besides, Cole’s formula was used to calculate the ETT size for each child, and the tube sizes used during surgeries were obtained from anesthesia charts.ETT sizes were compared. Results: 43 patients (22 girls [51.2%],21 boys [48.8%]) were included.The mean age was 10.5±9.6 months. 18 patients (41.9%) had cyanotic, 25 patients (58.1%) had acyanotic heart disease.Mean corrected transverse and anteroposterior tracheal diameters at CT images were 4.35±0.69mm and 4.30±0.71 mm, respectively. The mean diameter calculated by Cole’s formula was 4.22±0.20 mm. The mean tube size used during surgeries was 4.37±0.60 mm. There was no statistically significant difference between the tube sizes used during the surgeries and the corrected transverse tracheal diameters from CT measurements (p>0.05). But the tube sizes used during the surgeries found significantly larger than the diameters obtained by Cole’s formula (p<0.05). Conclusion: In 0-3 years of age pediatric patients who undergo a congenital heart surgery,corrected tracheal transverse diameter measured by CT is more effective,reliable and less invasive than classic formulas for determining appropriate ETT size

Management of Anesthesia and Complications in Pulmonary Endarterectomy Operations

Objective: Chronic thromboembolic pulmonary hypertension is a chronic progressive disease developing obstruction ocurring in pulmonary vascular bed. Pulmonary endarterectomy is the surgical procedure described in the management of chronic pulmonary hypertension which excises, and removes the obstructing thromboembolic material from the affected vascular structures. Our aim is to share our approaches to the management of anesthesia and complications in pulomanry endarterectomy operations performed in our center. Methods: The data of 200 PEA cases conducted in June 2017-2020 were retrospectively analyzed. The demographic data of the patients, preoperative pulmonary function tests, cardiac catheterization findings, peroperative cardiac output measurement values, aortic cross clamp, extubation, intensive care unit, and hospital stay times and complications were recorded. Results: Average age of the patients’ ages was 50.8 years, and female/male ratio was 108/92. In the thermodilution measurements of the patients after induction, mean values of CO, PVR and mPAP were determined as 4.4 l/min, 594 dyn/s/cm-5, 40 mmHg, respectively. The corresponding measurements made after the sternal closure were stated as 6 l/min, 241 dyn/s/cm-5 and 28 mmHg, respectively. The patients were hospitalized in the intensive care unit for 4 days. In our patient group residual pulmonary hypertension occurred in 21%, reperfusion pulmonary edema in 10% and pulmonary bleeding in 4% of the cases. Conclusion: Only a very few centers in the world are experienced in PEA surgery. Anesthesia management and treatment of the complications of PEA surgery are quite difficult. Therefore, PEA surgery shl be performed in experienced centers.

Comparison of Mid-, and Late- Term Morbidity and Mortality Results of Surgical Endarterectomy Versus Endovascular Stent Implantation in Carotid Artery Stenosis

Objective: Carotid artery stenosis is an important etiological cause of cerebrovascular events and stent implantation is widely used as an alternative treatment to endarterectomy. In this study, we compared the mid and late-term results of carotid artery stenosis patients who underwent endarterectomy and stent implantation. Methods: Patients who underwent endarterectomy (Group A, n: 27) and endovascular stent implantation (Group B, n: 22) due to carotid artery stenosis between 2008 and 2014 were included in the study. All examination, laboratory data and radiological images were collected from the hospital database. Morbidity and mortality developed in the mid (1-12 months) and late term (>12 months) periods were evaluated retrospectively. Results: While there were no neurological complications and restenosis in the midterm in Group A, 2 patients (9.09%) had stroke and 2 patients (9.09%) had restenosis in Group B. In the late-term, while there were no neurological complications in Group A, stroke in 3 patients (13.63%) (p=0.048) in Group B, restenosis was observed in 1 patient in Group A and 5 patients in Group B (3.7% vs 22.72%, p=0.043). Conclusion: We recommend endarterectomy as the primary approach for carotid artery revascularization and percutaneous approach especially in high-risk patients with recurrent ICA stenosis and distal carotid artery lesions.

Neuromuscular Block Management in Tracheal Stenosis Surgery; Retrospective Evaluation

Objective: In the surgical treatment of tracheal stenosis, whether in long procedures such as tracheal resection-anastomosis or in short procedures such as rigid bronchoscopy and dilatation, performing a deep neuromuscular block to provide patient comfort and facilitate the surgery. In this study, neuromuscular block antagonism using sugammadex during the surgical treatment of tracheal stenosis was investigated. The aim of our study was to evaluate the antagonism of the neuromuscular block with sugammadex in cases of postintubation tracheal stenosis and posttracheostomy tracheal stenosis in terms of postoperative residual block, complications and its effect on postoperative respiratory pattern. Method: In order to evaluate the effectiveness of the anesthesia methods and neuromuscular block management procedures applied during the surgical treatment of tracheal stenosis, patient files, anesthesia record forms, early postoperative follow-up and discharge process were retrospectively reviewed. Since most of the 34 patients diagnosed with tracheal stenosis underwent more than one surgical procedure at different times, a total of 140 interventional procedures and anesthesia applications were examined. Patients who underwent tracheal stenosis surgery and used sugammadex for neuromuscular block antagonism were included in the study. Results: 34 patients were evaluated as postintubation- posttracheostomy tracheal stenosis. While rigid bronchoscopy (n = 78), balloon dilatation (n = 35) and stent (n = 5) were applied to the patients as short surgical procedures, 22 patients underwent tracheal resection-anastomosis surgery. After the use of sugammadex in short and long surgical procedures, the time to start spontaneous breathing was found to be similar. No complications related to sugammadex were identified. Conclusion: We argue that the use of sugammadex under the monitoring of anesthesia depth and muscle strength in tracheal stenosis surgery is an effective and reliable choice for neuromuscular block antagonism.

Comparison of the Intraoperative Hemodynamic Effects of Remifentanil and Fentanyl in Pediatric Cardiac Surgery Anesthesia

Objective: The aim of this prospective observational study was to compare the hemodynamic effects of remifentanil and fentanyl, which are used as intraoperative analgesics in pediatric cardiac surgery. Methods: Patients were divided into two groups as those who received continuous intravenous remifentanil infusion (Group R) or intermittent intravenous fentanyl for intraoperative analgesia (Group F). These groups were compared in terms of hemodynamic characteristics and intraoperative complications. Results: The most common congenital cardiac pathology observed in the patients included in the study was ventricular septal defects (32%). Intraoperative complications occurred in 21 (40%) patients, and ventricular fibrillation was the most common complication (n=6; 11.5%). When the patients in both groups were compared in terms of intraoperative hemodynamic indicators, the mean arterial pressure values of the patients in Group R after sternotomy were significantly lower than those of the patients in Group F (p=0.034). No statistically significant difference was found between the two groups in terms of other hemodynamic indicators. When the two groups were compared in terms of intraoperative complications, the difference was not statistically significant although the number of patients with complications was higher in Group F (p=0.1). Conclusion: As a result of this study, it was found that remifentanil was as effective as fentanyl in maintaining intraoperative hemodynamic stability in patients undergoing pediatric cardiac surgery.