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    A new technique at insertion of laryngeal mask airway
    (2013-06-04) Esen A.; Bakan M.; Topuz U.; Ertaş Dursun Z.; Karaaslan K.; ESEN, ASIM; KARAASLAN, KAZıM
    A new technique at insertion of laryngeal mask airway Esen A., Bakan M., Topuz U., Ertas Z., Karaaslan K. (Bezmialem Vakif University, Dept of Anaesthesiology & Intensive Care, Istanbul, Turkey) Background and Goal of Study: Laryngeal mask airway (LMA) have been frequently used for airway management. The satisfaction of the insertion and trauma at insertion are problems. We present a new in insertion technique for LMA with partially inflated cuff. Materials and Methods: Consecutive 157 patients undergoing general anesthesia with LMA were randomized to two groups by coin toss. Induction and maintenance of anesthesia were standart in two groups. There were 85 patients in study group (group S) and 72 patients in control group (group C). LMA insertions were made by same physician. LMA was inserted with standart technique -which was described by Brain- at group C. Laryngeal mask airway was inserted with new techinque at group S. In new technique the head was positioned with extension by nondominant hand, mouth was opened with dominant hand, LMA was held with dominant hand from the tube part and inserted until the tip touches to the oropharynx. The index finger of nondominant hand was inserted to mouth to pass by the LMA and reach the tip of it and the tip of LMA was directed to caudal by index finger. Then LMA was inserted by the guidance of the index finger towards it reaches to the trianguler base of the orophariynx. Results and Discussion: There were no difference between the groups for the demographic details, ASA scores, insertion success and duration of anesthesia. The mean age was 47 ,4 for group S and 51,7 for group C. Count of attempt was better in study group. Mean count number was 1,11 at group S and 1,28 at group C (p=0.02). Also blood on LMA were seen more common at group C (p=0.04). There were no statistical difference at sore throat but it was less seen at group S. Also airway satisfaction was not statistical different between groups but while all airways were succesfull in group S we can not inserted LMA by standart method at 1 patient and inserted it at first attempt by new technique. Conclusion: New technique is less traumatic and easy to use at daily practice. References: 1. Brain AIJ : The laryngeal mask. A new consept in airway management. Br J Anaesth 55:801,1983. 2. Asai T, Morris S : The laryngeal mask airway: its’ features, effects and role. Can J Anaesth 41:930-60, 1994. 3. Wakeling HG, Butler PJ, Baxter PJ : The laryngeal mask airway: a comparison between two insertion techniques. Anesth Analg 85:687-90,1997.
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    Genel anestezi altında diş tedavisi planlanan mukopolisakkaridoz tip II’li hastada havayolu yönetimi
    (2022-01-29) Esen A.; ESEN, ASIM
    GENEL ANESTEZİ ALTINDA DİŞ TEDAVİSİ PLANLANAN MUKOPOLİSAKKARİDOZ TİP II’Lİ HASTADA HAVAYOLU YÖNETİMİAIRWAY MANAGEMENT IN PATIENT WITH MUCOPOLYSACHARIDOSIS TYPE II, WHO IS PLANNING DENTAL TREATMENT WİTH GENERAL ANESTHESIAAsım ESENDr. Öğr. Üyesi, Bezmialem Vakıf Üniversitesi Tıp Fakültesi Anesteziyoloji ve Reanimasyon AD, esen1122@hotmail.com, ORCİD No: 0000-0001-7222-7499GirişMukopolisakkaridoz tip II (MPS II ya da Hunter sendromu) lizozomal iduronat 2 sulfataz enzim eksikliğine bağlı ortaya çıkan, hemen tüm dokularda mukopolisakkarit (MPS) ve glikozaminoglikan (GAG) birikimine neden olan X resesif geçişli bir hastalıktır. Sıklığının 100 000- 170 000 doğumda bir olduğu bildirilmektedir. Hastaların büyük kısmı erkektir ve bu kişilerde hastalığın başlama yaşı, klinik bulguları, şiddeti ve seyri açısından önemli farklılıklar görülür. MPS ve GAG\"ın dokularda birikmesine bağlı olarak hastalarda önemli fiziksel değişiklikler meydana gelir. Bu değişiklikler havayolu anatomisini de etkiler. Biz burada MPS II hastalığı olan ve genel anestezi altında diş tedavisi planlanan bir hastanın havayolu ve anestezi yönetimini sunacağız.OlguHastamız 9 yaşında, 120 cm boyunda ve 35 kg ağırlığında erkek hasta. Preoperatif muayenede kısa boy, eklemlerde hareket kısıtlılığı, dirsek-kalça ve diz eklemlerinde hafif kontraktür, kaba yüz hatları, küçük çene, büyük dil, kısa boyun, azalmış ağız açıklığı, kısıtlı servikal ekstansiyon, hafif aort yetmezliği, hafif mitral stenoz ve kardiyak iletimde hafif uzama tespit edildi. Preoperatif endokardit profilaksisi yapıldıktan sonra hasta ameliyat odasına alındı ve rutin monitörizasyon (EKG, NİBP, Pulseoksimetre) uygulandı. Zor entübasyon hazırlığının yanında acil trakeostomi ihtimali düşünülerek, indüksiyon aşamasında bir KBB uzmanı da odada hazır bulundu. Ağız içinde çalışılacağı için derin sedasyon altında fiberoptik bronkoskop (FOB) ile nasotrakeal entübasyon planlandı. Bu amaçla 0,5mg midazolam, 35mcg fentanil, 0,3mg atropin ve 20mg ketamin uygulandı. İki dakika sonra FOB ile nazal geçiş rahatça sağlandı ancak epiglot çevresi dokular hipertrofikti, pasaj oldukça dardı ve FOB ile vokal kordların görülmesi mümkün olmadı. Laringoskop ile dil kökü yapılarının ekartasyonu planlandı. Blade’lerin daha kavisli olmasının dil kökü yapılarını ekarte etmede daha fazla katkı sunacağı düşünüldüğünden videolaringoskop tercih edildi. Laringoskopi planlandığından hastaya 10 mg ketamin ve 15 mg propofol daha verildi ve yaklaşık 2 dk sonra laringoskopi uygulandı. Bu şekilde, FOB ile vokal kordların alt kısmı ancak görülebildi ve alana lokal anestezik uygulandı. Yine yaklaşık iki dakika beklendikten sonra FOB ile trakeaya girildi ve ETE tüpü FOB üzerinden trakeaya yerleştirildi. Ameliyat yaklaşık 3.5 saat sürdü. Ameliyat süreci, ekstübasyon aşaması sorunsuzdu. Yaklaşık 1 saat derlenme odasında izlenen hasta sorunsuz bir şekilde servise verildi.Tartışma ve sonuçMPS II hastaları yaş ilerledikçe artan bir havayolu yönetimi zorluğu gösterirler. Preoperatif dönemde hasta yakınları ile detaylı bir şekilde planları konuşmak, en az iyi bir preoperatif hazırlık, planlama, personel ve ekipman açısından hazır olmak kadar önemlidir. Ayrıca ilgili bölümlerle konsülte edilmeli ve postoperatif süreç için yoğun bakım ihtiyacı olabileceği unutulmamalıdır. Anahtar kelimeler: Mukopolisakkaridoz tip II, Hunter Sendromu, Genel anestezi, Havayolu yönetimiABSTRACTİntroductionMucopolysaccharidosis type II (MPS II or Hunter syndrome) is an X-Linked recessive disease that occurs due to lysosomal iduronate 2 sulfatase enzyme deficiency and causes accumulation of mucopolysaccharide (MPS) and glycosaminoglycan (GAG) in almost all tissues. Its incidence is reported to be one in 100 000-170 000 births. The majority of the patients are male and there are significant differences in the age of onset, clinical findings, severity and course of the disease. Significant physical changes occur in patients due to the accumulation of MPS and GAG in the tissues. These changes also affect airway anatomy. Hereby, we will present the airway and anesthesia management of a patient with MPS II disease who is scheduled for dental treatment under general anesthesia.CaseThe patient is a 9-year-old male, 120 cm tall and 35 kg in weight. In the preoperative examination, short stature, limited range of motion in the joints, mild contractures in the elbow-hip and knee joints, coarse facial features, small jaw, large tongue, short neck, decreased mouth opening, limited cervical extension, mild aortic regurgitation, mild mitral stenosis, and mild cardiac conduction elongation detected. After preoperative endocarditis prophylaxis, the patient was taken to the operating room and routine monitoring (ECG, NIBP, pulse oximetry) was performed. In addition to the difficult intubation preparation, an ENT specialist was present in the room during the induction phase, considering the possibility of emergency tracheostomy. Nasotracheal intubation was planned with a fiberoptic bronchoscope (FOB) under deep sedation since it will be studied in the mouth. For this purpose, 0.5mg midazolam, 35mcg fentanyl, 0.3mg atropine and 20mg ketamine were administered. Two minutes later, nasal passage was easily achieved with FOB, but the tissues around the epiglottis were hypertrophied, the passage was quite narrow, and it was not possible to see the vocal cords with FOB. Retraction of the tongue and tongue root structures was planned with the laryngoscope. Since it is thought that the more curved blades will contribute more to retraction of tissues, the videolaryngoscope was preferred. Since laryngoscopy was planned, the patient was given another 10 mg of ketamine and 15 mg of propofol. After about 2 minutes, laryngoscopy was performed. Only the lower part of the vocal cords could be seen with FOB and local anesthesia was applied to the area. minutes, the trachea was entered with the FOB and the ETE tube was inserted into the trachea with seldinger technique over the FOB. The surgery took about 3.5 hours. The surgical process and the extubation phase were uneventful. The patient, who was followed up in the recovery room for approximately 1 hour, was transferred to the ward without any problem.Discussion and ConclusionMPS II patients present an increasing difficulty in airway management as they age. Discussing the plans in detail with the relatives of the patients in the preoperative period is as important as being ready with good preoperative preparation, planning, personnel and equipment. In addition, the relevant departments should be consulted and it should not be forgotten that there may be a need for intensive care for the postoperative period. Key words: Mucopolysaccharidosis type II, Hunter syndrome, General anesthesia, Airway management
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    MUKOPOLİSAKKARİDOZ TİP 3 TANISI OLAN HASTADA ANESTEZİ DENEYİMİMİZ: OLGU SUNUMU
    (2022-02-20) Sümer İ.; Esen A.; Uysal H.; SÜMER, İSMAİL; ESEN, ASIM; UYSAL, HARUN
    MUKOPOLİSAKKARİDOZ TİP 3 TANISI OLAN HASTADA ANESTEZİ DENEYİMİMİZ: OLGU SUNUMUDr. Öğr. Üyesi. İsmail SÜMERBezmialem Vakıf Üniversitesi, Tıp FakültesiORCID ID: https://orcid.org/0000-0002-0133-0218drismailsumer@gmail.com, 0533 2201576Dr. Öğr. Üyesi. Asım ESENBezmialem Vakıf Üniversitesi, Tıp FakültesiORCID ID: https://orcid.org/0000-0001-7222-7499esen1122@hotmail.com, 0533 5219455Dr. Öğr. Üyesi. Harun UYSALBezmialem Vakıf Üniversitesi, Tıp FakültesiORCID ID: https://orcid.org/0000-0003-0426-8525drharunuysal@hotmail.com, 0506 3433494ÖzetMukopolisakkaridozlar (MPS), lizozomal enzim eksikliğine bağlı olarak glikozaminoglikan vucutta birikimi ile giden, multisistem tutulum gösteren, kalıtsal, kronik ve ilerleyici bir metabolik depo hastalığıdır. Enzim eksikliğine bağlı olarak biriken maddeler hücrelerin normal işlevlerini bozarlar  ADDIN EN.CITE <EndNote><Cite><Author>Danos</Author><Year>1995</Year><RecNum>7</RecNum><DisplayText>(1)</DisplayText><record><rec-number>7</rec-number><foreign-keys><key app="EN" db-id="aawxpsrpzwsf9aewp9gv0xw2frwwvr9afwrx" timestamp="1643717026">7</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Danos, O.</author><author>Heard, J. M.</author></authors></contributors><auth-address>Laboratoire Rétrovirus et Transfert Génétique, Institut Pasteur, Paris, France.</auth-address><titles><title>Mucopolysaccharidosis</title><secondary-title>Mol Cell Biol Hum Dis Ser</secondary-title></titles><periodical><full-title>Mol Cell Biol Hum Dis Ser</full-title></periodical><pages>350-67</pages><volume>5</volume><edition>1995/01/01</edition><keywords><keyword>Animals</keyword><keyword>Bone Marrow Transplantation</keyword><keyword>Central Nervous System/metabolism</keyword><keyword>Clinical Trials as Topic</keyword><keyword>Disease Models, Animal</keyword><keyword>Genetic Therapy</keyword><keyword>Humans</keyword><keyword>Mucopolysaccharidoses/genetics/physiopathology/*therapy</keyword></keywords><dates><year>1995</year></dates><isbn>1470-0573 (Print)&#xD;1470-0573</isbn><accession-num>9532574</accession-num><urls></urls><electronic-resource-num>10.1007/978-94-011-0547-7_17</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(1). Mukopolisakkaritler bağ doku komponenti oldukları için biriktikleri dokularda farklı etkilere sebep olabilirler. Deri, solunum yolları, santral sinir sistemi kalp, karaciğer, dalak, kemik ve ligamanlarda depolanır ve bu dokular etkilenebilir. Tipik klinik belirtiler; kaba yüz görünümü, kulak burun boğaz problemleri, iskelet displazileri, büyüme gelişme geriliği, servikal instabilite, servikal kord kompresyonu, organomegali, görme ve işitme bozuklukları, eklem kontraktürleri, herniler ve kardiyopulmoner problemler olarak sıralanabilir  ADDIN EN.CITE <EndNote><Cite><Author>Kliegman</Author><Year>2011</Year><RecNum>8</RecNum><DisplayText>(2)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="aawxpsrpzwsf9aewp9gv0xw2frwwvr9afwrx" timestamp="1643717817">8</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Kliegman, R., </author><author>Stanton, B., </author><author>St. Geme, J. W.,</author><author>Schor, N. F.,</author><author>Behrman, R. E. </author><author> </author></authors></contributors><titles><title><style face="normal" font="default" charset="238" size="100%">Nelson Textbook of Pediatrics</style></title></titles><pages><style face="normal" font="default" charset="238" size="100%">480-510</style></pages><volume><style face="normal" font="default" charset="238" size="100%">19th edition</style></volume><dates><year><style face="normal" font="default" charset="238" size="100%">2011</style></year></dates><pub-location>Phialdelphia</pub-location><publisher>Elsevier</publisher><urls></urls></record></Cite></EndNote>(2).MPS tip III olan hastalarda, heparan sülfat yıkımında yetersizlik mevcuttur. Ortak özellikleri hafif somatik bulgularla birlikte yavaş ilerleyen ağır SSS tutulumudur. Bu hastalar genelde MSS tutulumuna bağlı ilerleyici psikomotor gerilik gösterir. Erken dönemde yüzde kabalaşma görülür, nörolojik belirtiler genellikle 2-4 yaş arasında belirlenir  ADDIN EN.CITE <EndNote><Cite><Author>Kliegman</Author><Year>2011</Year><RecNum>8</RecNum><DisplayText>(2)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app="EN" db-id="aawxpsrpzwsf9aewp9gv0xw2frwwvr9afwrx" timestamp="1643717817">8</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Kliegman, R., </author><author>Stanton, B., </author><author>St. Geme, J. W.,</author><author>Schor, N. F.,</author><author>Behrman, R. E. </author><author> </author></authors></contributors><titles><title><style face="normal" font="default" charset="238" size="100%">Nelson Textbook of Pediatrics</style></title></titles><pages><style face="normal" font="default" charset="238" size="100%">480-510</style></pages><volume><style face="normal" font="default" charset="238" size="100%">19th edition</style></volume><dates><year><style face="normal" font="default" charset="238" size="100%">2011</style></year></dates><pub-location>Phialdelphia</pub-location><publisher>Elsevier</publisher><urls></urls></record></Cite></EndNote>(2).Organ patolojileri nedeniyle sık operasyon gerektiren bu hastaların anestezisi sistemik sorunlar nedeniyle özellik gösterir. Özellikle yüz deformitesi, nazofaringeal mukopolisakkarid birikimi ve eklem-kemik deformitelerine bağlı hava yolu sağlanmasındaki güçlük bu hastalarda sık karşılaşılan bir sorundur  ADDIN EN.CITE <EndNote><Cite><Author>Kamin</Author><Year>2008</Year><RecNum>9</RecNum><DisplayText>(3)</DisplayText><record><rec-number>9</rec-number><foreign-keys><key app="EN" db-id="aawxpsrpzwsf9aewp9gv0xw2frwwvr9afwrx" timestamp="1643718047">9</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kamin, W.</author></authors></contributors><auth-address>Pediatric Pneumology, Allergy, Endoscopy and Cystic Fibrosis Center, Children&apos;s Hospital, University of Mainz, Mainz, Germany. kamin@kinder.klinik.uni-mainz.de</auth-address><titles><title>Diagnosis and management of respiratory involvement in Hunter syndrome</title><secondary-title>Acta Paediatr</secondary-title></titles><periodical><full-title>Acta Paediatr</full-title></periodical><pages>57-60</pages><volume>97</volume><number>457</number><edition>2008/05/28</edition><keywords><keyword>Airway Obstruction/etiology</keyword><keyword>Anesthesia, General</keyword><keyword>Continuous Positive Airway Pressure</keyword><keyword>Forced Expiratory Volume</keyword><keyword>Humans</keyword><keyword>Magnetic Resonance Imaging</keyword><keyword>Mucopolysaccharidosis II/*complications/diagnosis/physiopathology/therapy</keyword><keyword>Respiration Disorders/diagnosis/etiology/*therapy</keyword><keyword>Sleep Apnea, Obstructive/etiology/therapy</keyword><keyword>Spirometry</keyword><keyword>Vital Capacity</keyword></keywords><dates><year>2008</year><pub-dates><date>Apr</date></pub-dates></dates><isbn>0803-5253</isbn><accession-num>18339190</accession-num><urls></urls><electronic-resource-num>10.1111/j.1651-2227.2008.00650.x</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(3). Bu hastaların tipik anestezik problemleri; indüksiyon veya ekstübasyon sonrası görülen havayolu obstrüksiyonları, entübasyon zorlukları ve/ veya başarısızlıkları, acil trakeostomi ihtiyaçları, kardiyovasküler ve servikal vertebra sorunlarını içerir ADDIN EN.CITE  ADDIN EN.CITE.DATA 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Bu olgu sunumunda, MPS tip 3 tanılı diş cerrahisi geçirecek olan hastanın anestezi yönetiminden bahsedilmiştir.Olgu:Olgumuzda diş tedavisi amacıyla anestezi uygulanan MPS Tip 3 hastası 10 yaşında, 35 kg ağırlığında erkek çocuğu sunulmaktadır. Hastanın fizik muayenesinde büyük kafa ve dil, boyunda hareket kısıtlılığı ve mental retardasyon mevcuttu.(Resim 1) Labaratuvar tetkiklerinde bir sorun yoktu. Anestezi öncesinde çocuk nöroloji, çocuk metabolizma hastalıkları ve çocuk kardiyoloji konsültasyonları istendi. Konvulziyon riski nedeniyle antiepileptiklere devam etmesi, anlantoaksiyal subluksasyon riski nedeniyle entübasyonda dikkatli olunması gerektiği belirtildi. Ayrıca çocuk kardiyoloji tarafından yapılan ekokardiyografide MPS’ye bağlı hafif-orta mitral yetmezlik ve hafif aort yetmezliği tespit edildi. İşlem öncesinde endokardit proflaksisi önerildi.Hastaya işlemden 30 dk önce ampisilin 50 mg/kg uygulandı, başka herhangi bir premedikasyon uygulanmadı, operasyona alınan hasta için zor entübasyon şartları hazırlandı. Rutin monitorizasyonu takiben sol el dorsalinden 24G intraket ile damar yolu açıldı. İndüksiyon 1 mg midozolam, 3 mg/kg propofol ve 1mcg/kg fentanil ile yapıldı. Preoperatif ventilasyon sırasında airway yerleştirildi ve ventilasyonda zorluk yaşanmadı, rocuronyum 0,6 mg/kg uygulandı. Sol burun deliğinden yerleştirilen 5 numara spiralli tüp, video laringoskop ve Magill pensi yardımıyla ilerletilerek hasta nazal olarak entübe edildi.(Resim 2) Genel anestezi idamesi %50-%50 oksijen-medikal hava ve %2 sevofluran ve 0.15-0.3 mg/kg/dk remifentanil infuzyonu ile sağlandı. Postoperatif analjezi için 500 mg IV parasetamol uygulandı. Operasyon sonunda 100 mg sugammadex uygulandı ve ventilasyon problemi olmayan hasta ekstübe edildi. Gözlem amaçlı postoperatif bakım ünitesine alındı. Operasyondan sonra 1 gün yoğun bakımda takip edilen hasta problemsiz bir şekilde taburcu edildi. Tartışma:MPS’li hastaların anestezi açısından preoperatif, perioperatif ve postoperatif dönemde zorlukları ve riskleri vardır. MPS hastalarında preoperatif dönemde iyi bir değerlendirme yapılması gereklidir. Anestezi öncesi değerlendirmede zor entübasyon, zor ventilasyon, kardiyak ve servikal spinal gibi sorunlar değerlendirilir ve gerekli hazırlıkları yapılırsa anestezik riskler oldukça düşer. Hastanın servikal ve trakeolaringeal anatomisi ile altta yatan respiratuar ve kardiyak patofizyolojisi hakkında dikkatli olunmalıdır. Preoperatif olarak başta çocuk nörolojisi ve çocuk kardiyolojisi olmak üzere gerekli bölümlerce konsülte edilmelidir  ADDIN EN.CITE  ADDIN EN.CITE.DATA 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Biz hastamızı preoperatif gerekli bölülerle konsulte ederek gerekli hazırlıkları yaptık ve konsültasyon sonucunda verilen tavsiyelere uyduk. Ayrıca göğüs hastalıkları konsültasyonu istenebilir. MPS hastalarında sıklıkla OSAS görülmektedir ve şiddetli OSAS hikayesi olan hastaların anestezi sırasında havayolu acili yaşama ihtimali yüksektir  ADDIN EN.CITE <EndNote><Cite><Author>John</Author><Year>2011</Year><RecNum>11</RecNum><DisplayText>(5)</DisplayText><record><rec-number>11</rec-number><foreign-keys><key app="EN" db-id="aawxpsrpzwsf9aewp9gv0xw2frwwvr9afwrx" timestamp="1643718173">11</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>John, A.</author><author>Fagondes, S.</author><author>Schwartz, I.</author><author>Azevedo, A. C.</author><author>Barrios, P.</author><author>Dalcin, P.</author><author>Menna-Barreto, S.</author><author>Giugliani, R.</author></authors></contributors><auth-address>Sleep Disorders Center, Pulmonary Service, Hospital de Clínicas de Porto Alegre, Brazil. angelajohn@terra.com.br</auth-address><titles><title>Sleep abnormalities in untreated patients with mucopolysaccharidosis type VI</title><secondary-title>Am J Med Genet A</secondary-title></titles><periodical><full-title>Am J Med Genet A</full-title></periodical><pages>1546-51</pages><volume>155a</volume><number>7</number><edition>2011/06/04</edition><keywords><keyword>Adolescent</keyword><keyword>Child</keyword><keyword>Child, Preschool</keyword><keyword>Cross-Sectional Studies</keyword><keyword>Echocardiography, Doppler</keyword><keyword>Female</keyword><keyword>Humans</keyword><keyword>Hypertension, Pulmonary/etiology</keyword><keyword>Male</keyword><keyword>Mucopolysaccharidosis VI/*complications</keyword><keyword>Polysomnography</keyword><keyword>Prevalence</keyword><keyword>Respiratory Tract Diseases/pathology</keyword><keyword>Sleep Apnea, Obstructive/diagnosis/epidemiology/*etiology</keyword></keywords><dates><year>2011</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>1552-4825</isbn><accession-num>21638759</accession-num><urls></urls><electronic-resource-num>10.1002/ajmg.a.33902</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(5).MPS’de görülen spinal ve kraniofasiyal anomaliler nedeniyle zor maske ventilasyonu ve entübasyon beklenebilir. Bizim hastamızda bulunan büyük kafa ve dil, boyunda hareket kısıtlılığı nedeniyle işlem öncesi zor entübasyon şartları hazırlandı. Entübasyon sırasında video laringoskop kullanıldı. Ayrıca her türlü ihtimale karşılık laringeal maske airway ve fleksible laringoskop kullanılmaya hazır bir şekilde bekletildi.Hastalar cerrahi bitiminden sonraki en erken dönemde ekstübe olmalıdır. Bu durum entübasyondan kaynaklanan havayolunda oluşabilecek ödemi azaltmaya ve erken nörolojik değerlendirmeye izin verir ADDIN EN.CITE  ADDIN EN.CITE.DATA 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.Ekstübasyon tam olarak uyanmadan, yeterli solumadan, güçlü bir şekilde öksürmeden ve bilinçli hareket etmeden gerçekleştirilmemelidir  ADDIN EN.CITE <EndNote><Cite><Author>Walker</Author><Year>2003</Year><RecNum>12</RecNum><DisplayText>(6)</DisplayText><record><rec-number>12</rec-number><foreign-keys><key app="EN" db-id="aawxpsrpzwsf9aewp9gv0xw2frwwvr9afwrx" timestamp="1643718223">12</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Walker, R. W.</author><author>Colovic, V.</author><author>Robinson, D. N.</author><author>Dearlove, O. R.</author></authors></contributors><auth-address>Department of Anaesthetisia, Royal Manchester Children&apos;s Hospital, Pendlebury, Manchester, UK.</auth-address><titles><title>Postobstructive pulmonary oedema during anaesthesia in children with mucopolysaccharidoses</title><secondary-title>Paediatr Anaesth</secondary-title></titles><periodical><full-title>Paediatr Anaesth</full-title></periodical><pages>441-7</pages><volume>13</volume><number>5</number><edition>2003/06/07</edition><keywords><keyword>Adolescent</keyword><keyword>Airway Obstruction/*complications/diagnostic imaging</keyword><keyword>Anesthesia/*adverse effects</keyword><keyword>Bronchoscopy</keyword><keyword>Child</keyword><keyword>Decompression, Surgical</keyword><keyword>Humans</keyword><keyword>Male</keyword><keyword>Mucopolysaccharidoses/*complications/diagnostic imaging</keyword><keyword>Mucopolysaccharidosis I/complications</keyword><keyword>Mucopolysaccharidosis II/complications</keyword><keyword>Mucopolysaccharidosis VI/complications</keyword><keyword>Pulmonary Edema/diagnostic imaging/*etiology</keyword><keyword>Radiography</keyword><keyword>Spinal Fusion</keyword></keywords><dates><year>2003</year><pub-dates><date>Jun</date></pub-dates></dates><isbn>1155-5645 (Print)&#xD;1155-5645</isbn><accession-num>12791120</accession-num><urls></urls><electronic-resource-num>10.1046/j.1460-9592.2003.00969.x</electronic-resource-num><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>(6) Hastamızı mümkün olduğu kadar erken ekstübe etmek amacıyla kas gevşeticinin geri çevirilmesi için sugammadex kullanıldı. Hastamız sorunsuz şekilde ekstübe edildi.Postoperatif apne riski nedeniyle postoperatif bakım ünitesinde dikkatli takip gerekmektedir. Postoperatif dönemde, hastada oluşabilecek komplikasyonlar ve solunum problemleri olabileceği için hastanın yoğun bakıma transferi düşünülmelidir. MPSli hastalarda multisistem tutulumu olması nedeniyle farklı sistemler etkilenebilir. Hem havayolu problemleri hem de sistemik diğer problemler nedeniyle tüm riskler göz önünde bulundurulmalı ve yaşanabilecek tüm bu zorluklar için dikkatli hazırlık yapılmalıdır.Anahtar Kelimeler: Mukopolisakkaridoz, MPS, MPS tip 3 anestezi yönetimi, pediatrik anestezi ADDIN EN.REFLIST 1. Danos O, Heard JM. Mucopolysaccharidosis. Mol Cell Biol Hum Dis Ser. 1995;5:350-67.2. Kliegman R, Stanton B, St. Geme JW, Schor NF, Behrman RE, . Nelson Textbook of Pediatrics. Phialdelphia: Elsevier; 2011. 480-510 p.3. Kamin W. Diagnosis and management of respiratory involvement in Hunter syndrome. Acta Paediatr. 2008;97(457):57-60.4. Walker R, Belani KG, Braunlin EA, Bruce IA, Hack H, Harmatz PR, et al. Anaesthesia and airway management in mucopolysaccharidosis. J Inherit Metab Dis. 2013;36(2):211-9.5. John A, Fagondes S, Schwartz I, Azevedo AC, Barrios P, Dalcin P, et al. Sleep abnormalities in untreated patients with mucopolysaccharidosis type VI. Am J Med Genet A. 2011;155a(7):1546-51.6. Walker RW, Colovic V, Robinson DN, Dearlove OR. Postobstructive pulmonary oedema during anaesthesia in children with mucopolysaccharidoses. Paediatr Anaesth. 2003;13(5):441-7.
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    Pediyatrik Nazotrakeal Entübasyonda Nazofarenks Geçişi için Kılavuz Tel Kullanımı: Prospekif Randomize Çalışma
    (2023-11-05) Esen A.; Kangarlı N.; ESEN, ASIM; KANGARLI, NIGAR
    Pediyatrik Nazotrakeal Entübasyonda Nazofarenks Geçişi için Kılavuz Tel Kullanımı: Prospektif Randomize ÇalışmaGiriş: Genel anestezi altında yapılan pedodontik uygulamalarda nazotrakeal entübasyon (NTE) sıklıkla kullanılır. Konvansiyonel yolla yapılan NTE’de nazofarengeal travma ve kanama sık görülmektedir (1,2). Bu çalışmada, endotrakeal tüp (ETT) içine kılavuz tel konularak tüpün ucuna açı-kavis verilmesinin, nazofarengeal travma ve kanama üzerine etkisini araştırmayı amaçladık. Materyal/Metod: Çalışmaya 2-12 yaş arası 90 pedodonti hastası alındı ve iki gruba ayrıldı. Kontrol grubunda (GrupK) NTE konvansiyonel yolla yapıldı. Çalışma grubunda (GrupÇ) ise ETT içine bir kılavuz tel yerleştirildi ve tüpün distal ucuna (2,5-3 cm proksimalden) 100-120 derece açı verildi (hokey sopası şekli). ETT, ucu yüze dik olacak şekilde buruna sokuldu. Tüpün açılı kısmı burun deliklerinin girişini geçtikten sonra tüpün ucuna verilen kavise uygun şekilde ilerletildi. Bu esnada, ETT içine yerleştirilen kılavuz tel sayesinde ETT bir bütün olarak hastanın baş tarafına doğru \"yatırıldı\" ve eş zamanlı olarak ilerletildi. Bu sayede ETT ucunun nazofarenks arka duvarına temas etmeden kaudale yönlenmesi hedeflendi. Tüp ucu orofarenkse ulaşınca kılavuz tel çıkartıldı ve entübasyonun geri kalan kısmı konvansiyonel yöntemde olduğu gibi tamamlandı.Sonuçlar: Gruplar istatistiki olarak benzerdi (Tablo 1-2). Kanama kontrolü entübasyonun 1. ve 5. dakikalarında, hastanın grubunu bilmeyen bir anestezist tarafından yapıldı. Kanama; Yok, hafif kanama (tüpe bulaşma tarzında) ve şiddetli kanama (orofarenksteki tüpün etrafında kan birikintisi) olarak üç kategoride değerlendirildi. Tüm gruplarda grupÇ grupK’ya göre daha iyiydi (Tablo 3-4) (1. dk: kanama yok Ç: %84,4, K: %46,7; hafif kanama Ç:%15,6, K: 31,1; şiddetli kanama Ç: %0,0, K: %22,2. 5. dk. Kanama yok Ç: %82,2, K: %28,9, hafif kanama Ç:15,6, K: 40,0, şiddetli kanama Ç: 2,2, K: 31,1. 1. dk ve 5. dk p< 0.001)Tartışma: Sonuçlarımıza göre;1- Kılavuz tel kullanılarak yapılan NTE, konvansiyonel yönteme göre belirgin şekilde daha az nazofarengeal kanamaya neden olmuştur. 2- Test edilen yöntemin burun iç duvarlarındaki travmaya engel olması beklenmez. Bu nedenle, çalışmamıza göre konvansiyonel NTE esnasındaki kanamanın çoğunlukla nazofarenks arka duvar travmasına bağlı olduğu da düşünülebilir.
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    A new maneuver for classical laryngeal mask airway insertion: Prospective randomized study
    (2022-08-01) Esen A.; Bakan M.; Topuz U.; Ertaş Dursun Z.; Karaaslan K.; ESEN, ASIM; KARAASLAN, KAZıM
    Background/Aim: Laryngeal mask airway (LMA) has been frequently used for airway management. But the satisfaction of the insertion and trauma at insertion remain problems. We present a new insertion maneuver for classical LMA (cLMA) with a partially inflated cuff and examine its success and complication rate.Methods: In 4 months, 158 patients who were classified as ASA I–III and older than 18 years old and were planned for LMA were included in this study consecutively (according to the study design, one patient was excluded during the study). Emergency cases, patients with any contraindications with LMA, patients who were expected to undergo surgery for more than 2 h, patients with preoperative respiratory tract infection or sore throat, patients undergoing oral or nasal surgery, and patients with aspirated oropharyngeal secretions after removal of LMA was excluded from the study. Age, gender, height, weight, ASA scores, comorbidities, and the duration of anesthesia and surgery of the patients were recorded. One-hundred-fifty-seven consecutive patients were randomized into two groups by a coin toss [control group (group C) and study group (group S)]. The groups were compared in terms of LMA insertion success, the number of insertion attempts, the presence of blood on the LMA or in secretions, and postoperative sore throat. Classical Laryngeal Mask Airway was inserted with Brain’s standard technique in group C and with the new technique in group S. In the new technique, the head and neck of the patient were supported in a straight position, the mouth was opened, cLMA was held with a dominant hand from the tube part and inserted until the tip touches to the oropharynx. The index finger of the non-dominant hand was inserted into the mouth to pass by the cLMA and reach the tip of the cLMA. The tip of cLMA was directed to the caudal by the index finger. Then, cLMA was inserted by the guidance of the index finger until it reached the triangular base of the oropharynx.Results: There was no statistically significant difference in terms of demographic data and placement success; placement success was better in the study group (100% versus 98.6% and P = 0.45). Similarly, the count of attempts was better in the study group. The mean attempt number was 1.11 in group S and 1.28 in group C (P = 0.02). Also, blood on LMA was seen to be more common in group C (P = 0.04). There were no statistical differences in sore throat, but it was less seen in group S.Conclusion: The new maneuver was better than the standard technique and easy to use in daily practice.Keywords: Airway management, Laryngeal mask airway, Complications
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    Anjiotensin Dönüştürücü Enzim İnhibitörü Kullanımına Bağlı Gelişen Postoperatif Lingual Ödem
    (2023-11-05) Kök T.; Esen A.; Karaaslan K.; KÖK, TUĞBA; ESEN, ASIM; KARAASLAN, KAZıM
    Anjiotensin Dönüştürücü Enzim İnhibitörü Kullanımına Bağlı Gelişen Postoperatif Lingual ÖdemTuğba Kök , Asım Esen , Kazım Karaaslan (Bezmialem Vakıf Üniversitesi Hastanesi)Giriş / Amaç: Lingual ödem; nadir görülen, hayatı tehdit etme potansiyeline sahip bir komplikasyondur(1). Pozisyon, anjioödem, alerjik reaksiyonlar, anafilaksi ve ilaçlar sorumlu tutulmuştur(2,3). ACE inhibitörlerinden lisinopril ve perindoprile bağlı gelişen vakalar da bildirilmiştir(4,6). Bu olguda laparoskopik kolesistektomi sonrasında gelişen lingual ödem vakası sunuldu.Olgu: Laparoskopik kolesistektomi planlanan 70yaş, 61kg ve 150cm kadın hasta; DM, HT ve hipotiroidisi için levotiroksin, metformin ve triplixam (perindopril+indapamid+amlodipin) kullanmaktaydı. Preoperatif değerlendirmede zor entübasyon bulgusuna rastlanılmadı ve ASA II olarak değerlendirildi. İndüksiyon midazolam 2mg, fentanil 100µg, propofol 200mg ve roküronyum 35mg ile sağlandı ve ilk seferde 7,5 numara düz tüple entübe edildi. İdame %50 O2+hava ve sevofluran ile sağlandı. Hastanın 25 dakika ters trendelenburg pozisyonunda kaldığı ameliyat 75 dakika sürdü. Postoperatif analjezi amaçlı parasetamol 1gr ve tramadol 100mg ver(len hasta 200mg sugammadeks ile uyandırıldı. Derlenme ünitesinde 30 dakika izlenip sorunsuz olarak servise gönderilen hasta 1 saat sonra dilde şişlik sebebiyle bölümümüze konsülte edildi (Res(m-1). Muayenesinde hasta oryante-koopere ve stabildi. Solunumu etkilemeyen dildeki şişlik dışında herhangi bir olumsuz bulgu ve şikâyet yoktu. Hastaya hızlıca feniramin 45,5mg, prednizolon 40mg iv ve soğuk nebül uygulandı. Acil entübasyon ve trakeostomi hazırlıkları yapıldı. Kulak burun boğaz kliniğine de konsülte edildi. Hastanın postoperatif 2, 4, 6, 8, 10 ve 12.saat ziyaretlerinde tedrici olarak lingual ödeminin azaldığı, 24.saatte de tamamen gerilediği görüldü(Res(m-2) Tartışma / Sonuç: Ağız tabanında veya dilde oluşan postoperatif ödem hayatı tehdit etme potansiyeline sahiptir. Literatürde posterior fossa veya spinal cerrahilerde uygulanan özel pozisyonlar, dil tabanında sıkışmaya sebep olan endotrakeal tüp tespitinde boyun bağı kullanımı veya tüp etrafına ilave gazlı bez konulması da gerekçe olarak bildirilmiştir(2,3). Laringoskopi ve entübasyonun sorunsuz olduğu, pozisyon ile ilgili bir risk faktörünün de bulunmadığı olgumuzun koagülasyon profili normaldi ve antikoagülan ilaç kullanım öyküsü de yoktu. Başka bir risk faktörü tespit edilemeyen vakamızda postoperatif lingual ödemin ACE inhibitörlerinden perindoprile bağlı olabileceği ve perindopril kullanan hastalarda postoperatif dudak-dil ödemi açısından dikkat edilmesi gerektiği düşünüldü.
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    Genel anestezi altında diş tedavisi planlanan akçaağaç şurubu idrar hastalığı olan hastada anestezik yaklaşım
    (2022-02-13) Esen A.; Uysal H.; Sümer İ.; ESEN, ASIM; UYSAL, HARUN; SÜMER, İSMAİL
    Genel anestezi altında diş tedavisi planlanan akçaağaç şurubu idrar hastalığı olan hastada anestezik yaklaşımDr. Öğr. Üyesi Asım ESENBezmialem Vakıf Üniversitesi Tıp Fakültesi Anesteziyoloji ve Reanimasyon AD, esen1122@hotmail.com, ORCİD No: 0000-0001-7222-7499, GSM: +90 533 521 94 55Dr. Öğr. Üyesi Harun UYSALBezmialem Vakıf Üniversitesi Tıp Fakültesi Anesteziyoloji ve Reanimasyon AD, drharunuysal@hotmail.com, ORCİD No: 0000-0003-0426-8525, GSM: +90 506 343 34 94Dr. Öğr. Üyesi İsmail SümerBezmialem Vakıf Üniversitesi Tıp Fakültesi Anesteziyoloji ve Reanimasyon AD, isosumer@gmail.com, ORCİD No: 0000-0002-0133-0218 GSM: +90 533 220 15 76GirişAkçaağaç şurubu idrar hastalığı (MSUD) otozomal resesif, doğumsal ve sıklığı yaklaşık 1/185000 olan bir metabolik hastalıktır. Hastalığın sebebi dokularda yaygın olarak bulunan ve dallı zincirli aminoasitlerin oksidatif dekarboksilasyonundan sorumlu bir enzimin eksikliğidir. Bu eksiklik, dallı zincirli aminoasitler olan valin, lösin ve izolösinin kanda ve idrarda birikmesine neden olur. Hastalığın beş ayrı klinik fenotipi vardır. Klinik gidiş, fenotipe ve tedaviye başlanma zamanına bağlı olarak değişir.OlguHastamız 5 yaşında, 22 kg, 96 cm ve anne-babası akraba olan erkek çocuktu. Genel anestezi altında diş tedavisi planlanan hastamızda hafif bir motor-mental ve büyüme-gelişme geriliği mevcuttu. Tedavisine erken dönemde (postpartum onbeşinci gün) başlanan hasta valin-lösin replasman tedavisi, profilaktik antiepileptik ve multivitamin ilaçları almaktaydı. Preoperatif testlerinde önemli bir anormallik yoktu. Çocuk metabolizması ünitesine danışılan hastanın preoperatif açlık döneminde alması için total parenteral nutrisyon (TPN) hazırlandı. 0,5 mg/kg midazolam ile premedike edilen hasta ameliyathaneye alındı ve intravenöz anestezi indüksiyonu sonrası nazotrakeal entübasyon uygulandı. İnhalasyon anestezisi ile idame sağlandı. Ameliyat ve anestezi süreci olaysızdı. Ameliyat esnasında ve derlenme ünitesi sürecinde aralıklı kan şekeri takibi yapıldı. Derlenme ünitesinde yaklaşık yarım saat takip edildi ve her hangi bir problem yaşanmadı. Postoperatif dönemde oral beslenme başlanana kadar TPN nin devam edilmesi önerisiyle hasta servise verildi.Tartışma ve SonuçMSUD hastalarının preoperatif dönemde detaylı olarak değerlendirilmesi gerekir. İyi kontrol edilmiş bir süreçle ameliyata hazırlanan hastaların peroperatif dönemi genellikle sıkıntısız seyretme eğilimindedir. Ancak kontrol altında bir hasta değilse, nörokognitif gelişme geriliği, kasılma epizodları, epileptik nöbetler, hipoglisemi atakları, asidoz, dehidratasyon, beyin ödemi ve kafa içi basınç artışı gibi morbidite ve mortalite ihtimali yüksek problemler görülebilir. Bu nedenle peroperatif dönem için özellikle ilaçların düzenli alınıyor olması, sıvı replasmanı, beslenmeye dikkat ve yakın kan şekeri takibi önemlidir.Anahtar kelimelerAkçaağaç şurubu idrar hastalığı, genel anestezi, havayolu yönetimiAnesthetic approach to the patient with maple syrup urine disease which is planned for dental treatment under general anesthesiaBackroundMaple syrup urine disease (MSUD) is an autosomal recessive congenital metabolic disease. The frequency of disease is approximately 1/185000. The cause of the disease is the deficiency of an enzyme located in the inner membrane of the mitochondria, which is responsible for the oxidative decarboxylation of branched-chain amino acids. This enzyme is found in many tissues such as skeletal muscles, liver, brain and kidney. Deficiency of this enzyme causes the branched-chain amino acids valine, leucine and isoleucine to accumulate in the blood and urine. The disease has five different clinical phenotypes. The clinical course varies depending on the phenotype and the time of initiation of treatment.CaseOur patient is a 5-year-old boy, 22 kg, 96 cm, and whose parents are related. Our patient, who was scheduled for dental treatment under general anesthesia, had mild motor-mental and growth retardation. The patient, whose treatment was started in the early period (postpartum fifteenth day), was taking valine-leucine replacement therapy, some prophylactic antiepileptic drugs and multivitamin drugs. There was no significant abnormality in the preoperative laboratory tests. Total parenteral nutrition (TPN) solution was prepared for the patient to take during the preoperative fasting period, who was consulted with the pediatric metabolism unit. The patient, who was premedicated with 0.5 mg/kg midazolam, was taken into the operating room. After induction of intravenous anesthesia, nasotracheal intubation was performed. Maintenance of anesthesia was provided with inhalation anesthesia. Surgery and anesthesia were uneventful. Intermittent blood glucose monitoring was performed during the surgery and during the recovery unit. He was followed in the recovery unit for about half an hour and no problems were encountered. In the postoperative period, the patient was transferred to the ward with the recommendation to continue TPN until oral feeding was started.Discussion and ConclusionMSUD patients should be evaluated in detail in the preoperative period. The perioperative period of patients who are prepared for surgery with a well-controlled process generally tends to be uneventful. However, if the patient is not under control, problems such as neurocognitive disorders, convulsive episodes, epileptic seizures, hypoglycemia attacks, acidosis, dehydration, brain edema and increased intracranial pressure may be seen with a high probability of morbidity and mortality. For this reason, it is important to take medications regularly, fluid replacement, attention to nutrition and close blood sugar monitoring for the peroperative period.Keywords Maple syrup urine disease, general anesthesia, airway management