Lung isolation is widely used in many areas, mainly in thoracic surgical operations. Double-lumen tubes and bronchial blockers are utilized for this purpose.
The first tube used for lung isolation is Carlens and many double-lumen tubes have been developed so far. The first example of a bronchial blocker in the modern sense is the Univent tube and independent bronchial blockers (Arndt, Cohen, Uniblocker, EZ, Coopdech, etc.) have been developed in the more recent years. Double-lumen tubes require less time to place and have a lower tendency to malpositioning as compared to bronchial blockers. Aspiration is more effective with double-lumen tubes, using which a single lung or both lungs may be ventilated as required. While double-lumen tubes have these advantages, bronchial blockers are recommended as the first option in patients with a challenging airway; in obese patients; in patients in whom mechanical ventilation is predicted during the postoperative period; in patients who require lung isolation during any intraoperative period; and in children.
This review discusses the development of equipment used for lung isolation, their advantages and disadvantages over each other, and their priority of use as the thoracic anesthesiologist should be knowledgeable and experienced enough to be able to use both types of lung isolation equipment as required.

OBJECTIVE: In this study, three different anesthetic agent’s effect on postoperative neurocognitive functions and changes on brain oxygen saturation determined with NIRS follow up in open heart surgery was presented
METHODS: ASA II group 62 patients aged between 30-65 who would underwent coronary artery bypass surgery were included into the study. 2 patients were excluded from the study because of inotropic support was started. All patients were evaluated preoperatively, ASEM and MMST was applied. Anesthesia induction was performed with 0,1 mg/kg midazolam, 10 µgr / kg fentanyl, 0,3 mg/kg rocuronium. Patients were divided into three groups randomly. For anesthesia maintenance
Grup I (Propofol Group, n: 20): 50-150 μgr/kg/dk propofol infusion during the operation.
Grup II (Sevofluran Group, n: 20): sevoflurane about 1 MAC during the operation (also during cardiopulmonary bypass).
Grup III(Midazolam Group, n: 20): 0,2-0,4mgr/kg/dk midazolam infusion during the operation.
During 11 measurement point named as basal, after the entubation, before the cannulation, after the cannulation, entering bypass, at 34°C, 31°C(last temperature point), 32°C, 34°C,36°C, after pump and skin closure NIRS values, desaturation over than 25% and arterial blood gases data were recorded.
Extubation time, ICU stay and hospitalization time were recorded for each entubated patient who had been sent to ICU unit postoperatively.
ASEM ad MMST were applied to all cases 24 hour preoperatively, and at 1st,2nd, 3rd, 4th, 5 th day postoperatively.

RESULTS: There were no differece between three groups demographic values and, blood gases. MMST and ASEM evaluations showed no difference between groups at any measurement period. MMST value was decreased at 1st postoperative day significantly.(p < 0.01). There was no intragroup difference at any measurement period in ASEM test.
SR02 –left, SR02- right, rO2-left, r02-right values were not different from each other between groups at any measurement period. These four parameters when compared in groups, there were decrease in measurements especially during cooling time but this decrease was not statistically significant between groups. There was not statistically significant difference between the group that has more than %25 decrease in right and left rO2 and the group that has no decrease in the way of Post operative MMST and ASEM levels.

CONCLUSION: In this study,we concluded that there was no difference between three different agents in the way of postoperative neurocognitive functions when follow up of the oxygen saturation in brain with NIRS during cardiopulmonary bypass. But there is need for futher studies since it is possible to reach extent results with more sensible tests to measure neurocognitive functions

OBJECTIVE: In this study we aimed to investigate in the light of the literature.the efficacy of the fresh frozen plasma (FFP) given before the initial heparinization on achievement of adequate heparinization against heparin resistance (HR) during cardiopulmonary bypass (CPB).
METHODS: After obtaining the consent of the patients and the consent the institutional ethics committee, total of 50 patients older than 18 years old who had undergone cardiopulmonary bypass were enrolled to this study. Patients were randomly divided into two groups of 25 patients. The patients with liver and kidney failure were excluded from the study. The body weights, ages and the ACT values of the patients before heparinization were recorded. The group of patients given 2 units “Fresh Frozen Plasma” 15-30 minutes before heparinization was called the ‘Group W’ (Study Group), a group of patients who hasn’t given FFP was called ‘Group C’ (Control Group). Four minutes after application of the first dose of heparin (Nevparin® 5000 Ý.Ü./ mL heparin sodium), the control ACTs were measured (Actalyke Mini II ACT Analyzer Helena Lab.). The ACTs were repeated every half an hour and recorded. The patients with the value of ACT under 420 seconds were given additional doses of heparin according to their “Heparin dose-response curve”.
RESULTS: The differences between the ages, body weights and the initial ACT values of the two groups were not statistically significant. The differences of the ACT values measured about 4 minutes after the first dose of heparinization between the two groups were statistically significant. This value was 650.74±244.81 seconds in the study group while in the control group it was found 505.92±159.78 seconds respectively (p = 0.018). The differences of the ACT values measured about 4 minutes after implementing the first dose of heparin were statistically significant between the two groups. Additional dose of heparin was required at about 4% of the patients in the study group and at about 24% of patients in the control group (p=0.042). Statistically no difference was observed between the two groups as for the additional need of heparin dose in the first half an hour.
CONCLUSION: Since the diagnosis and treatment process is time-consuming and has a higher risk of death, especially in cases those who had to enter pump urgently and, in cases where ACT can not be measured frequently or the calibration of the measuring device of ACT in terms of reliability is suspicious, it was concluded that it is appropriate to give 2 units of FFP before full dose of heparinization in order to prevent heparin resistance or to make it more easily controllable.

OBJECTIVE: : In our study we aimed to determine most effective analgesic and sedative medhod in the early postoperative period; by comparasion of dexmedetomidine,midazolam /fentanyl and midazolam/dexketoprofen trometamol with their effects on postoperative pain, sedation, extubation time and hemodynamic parameters.

METHODS: 75 patients who had cardiac surgery included in our study. Patients were grouped as Group I: midazolam/dexketoprofen trometamol (n: 25) Group II: midazolam /fentanyl (n: 25) and Group III: dexmedetomidine(n: 25)

Ýnfusions of midazolam 0.03mcg/kg/h and dexketoprofen 25-50 mg for group I, midazolam 0.03mcg/kg/h and fentanyl 2 mcg/kg/h for groupII and dexmedetomidine 0.3-0.5 mcg/kg/h for groupIII were applied.Heart rate, mean arterial blood pressure, arterial blood gas values were recorded evaluation of postoperative pain was obtained by visual analog scale(VAS) and evaluatin of postoperative sedation was obtained by Ramsay sedation scale(RSS). In addition periods of extubation, postoperative intensive care unit and hospitalization were recorded..

RESULTS: There was no significant difference between groups by their periods of extubation, postoperative intensive care unit, hospitalization(p>0,05).Also there was no significant difference of VAS scores between 30 minutes(T4) and 4 hours (T5)after extubation (p>0,05).There was signicantly different RSSscores between groups by their initial intensive care unit periods (T0) (p<0,01).We also found that Group I and Group II T2 and T3 RSS scores were significantly higher than Group III series (p: 0,001, p: 0,001respectively)
CONCLUSION: After cardiac surgery; with its significantly different RSS scores,sedative and analgesic effect without postoperative respiratory depression; dexmedetomidine is more appropriate agent than midazolam/ fentanyl and midazolam/dexketoprofen trometamol for postoperative sedation and analgesia.

OBJECTIVE: Central venous catheterization is an interventional procedure which holds an important place in daily practices of many clinicians. Although many routes can be used for this procedure, the most preferred one is internal jugular vein. Many positions and manoeuvres have been tried in order to make this procedure easier and with less complications, and in our study, we evaluated the combination of these positions, manoeuvres and their effects on the cross-sectional area of right internal jugular vein.
METHODS: 30 healthy volunteers were included in the study. By combining Supine, 20˚ trendelenburg, manual hepatic compression, simulated valsalva manoeuvre, and 0˚, 15˚, 30˚, 45˚ and maximum head rotations, the cross-sectional area of right internal jugular vein and the overlapping of internal jugular vein on carotid artery were evaluated.
RESULTS: Although any significant increases in internal jugular vein cross-sectional area on 30˚ and more degrees head rotations were not detected in any of the groups, the overlapping percentage of internal jugular vein on carotid artery increased significantly for 30˚ and greater head rotation. While simulated valsalva manoeuvre and widest internal jugular vein cross-sectional area was obtained in comparing the manoeuvres, a wider internal jugular vein cross-sectional area was detected in 20˚ trendelenburg position compared to the measurements for supin position.
CONCLUSION: We observed that a wider internal jugular vein crosssectional area can be obtained more safely with <30˚ head rotation, valsalva manoeuvre and 20˚ tilted trendelenburg position.

OBJECTIVE: The aim of our study was to evaluate the effect of preoperative patient characteristics, concomitant comorbidities and extubation time on postoperative mortality and morbidity; and the corelation with EuroSCORE.
METHODS: After Local Scientific Comnittee approval, 668 patients, ages between 17- 82 who were scheduled for open cardiac surgery were included in this prospective study in 2012-1013 years in Siyami Ersek Thoracic and Cardiovasculary Center Hospital. Patient characteristic, concomitant comorbidities, type of surgery, cross-clemp and cardiopulmonary bypass times, the use of inotropic agents and insertion of intraaortic baloon pump, the number of coronary anastomosis, extubation time, time of intensive care and hospital stay and the EuroSCORE scores were recorded and compared.
RESULTS: There were observed to difference significantly between actual mortality rates (% 3,1) and predicted mortality by EuroSCORE (1,73±1,26) (p<0,01).The predicted mortality rates by EuroSCORE were significantly elevated(3,71±3,01) in patients who died. In patients with preoperative scores over 1.75, the sensitivity of EuroSCORE in predicted mortality was %80.95; positive cut-off value was % 8.54 and negative cut-off value was % 99.15. The measured area under the Receiver Operating Characteristic(ROC) curve was % 78.8 and standart deviation was % 4.7.
CONCLUSION: A throughout analysis of risc factors and possible complications of surgery may help to reduce postoperative mortality and morbidity. We observed the factors related to mortality and morbidity in our patient population are similar to the literature the EuroSCORE risc scoring system can be applied. Also the management of intraoperative anesthesia and postoperative intensive care are important factors in this issue.

The incidence of complications after pneumonectomies remains high despite the advances in surgical and anesthetic techniques. This incidence has been given as 11% to 50% in studies. Most of these complications are not fatal and can be prevented beforehand. Intraoperative complications such as massive bleeding, cardiac herniation, mediastinal shift, pneumothorax, and malign arrhythmia can be rapidly identified and treated. In this case report, we present the case of an iatrogenic mediastinal shift and subsequent cardiovascular collapse occurring after removal of a thoracic drain in a patient undergoing pneumonectomy.

Lung pump is a result of immune system activation due to cardiopulmonary bypass. It is frequently seen during post-operative follow-up of the patients in the intensive care units and services. It is rare during or immediately after extracorporeal circulation. In this presentation, we discussed sudden, unexpected and massive pulmonary edema developed during coronary artery bypass surgery. We have successfully treated pulmonary edema developed after cardiopulmonary bypass surgery with appropriate medical treatment and mechanical ventilation.

Cardiac and pulmonary injuries are among the complications to be encountered during bar removal, placed by Nuss procedure. In this case report the assessment of massive hemorrhage and possible cardiac injury, occurred during the removal of a bar previously placed by Nuss procedure, by transesophageal echocardiography (TEE) is discussed and the report aimes to point out the importance of TEE monitorization in noncardiac surgeries. TEE is an efficacious imaging technique for assessing the etiology of intraoperative acute hemodynamic instability. It is especially beneficial to reevaluate with TEE in cardiac injury suspected cases, after adequate volume replacement. TEE evaluation must be done attentively if comorbidities, which can result in cardiac morphology change exist and clinical findings must definitely be evaluated for diagnosis.

Achalasia is a motility disorder characterized by absence of peristalsis in the body of esophagus and insufficient relaxation in the lower esophageal sphincter during the action of swallowing. We aimed to report a rare case of achalasia complicating with acute onset of stridor and respiratory insufficiency which might have been mortal in the clinical course. A 59-year-old male patient was brought to the emergency service with acute onset of stridor, respiratory distress and retrosternal pain which started following his dinner. Elective cervico-thoracic computerized tomography revealed an increase in the esophageal diameter, mediastinal enlargement and food residue inside the esophagus. Dilated esophagus compressed both the trachea and the main bronchi and partially narrowed their lumens. After the patient was diagnosed with achalasia depending on these findings and treated for his respiratory insufficiency in the intensive care unit; he was discharged by planning the elective surgical treatment of the achalasia.

Introduction: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative curative therapy in patients with severe calcific aortic stenosis in aging population, in which there is high operative rate with surgery due to significant co-morbidities. However, problems during and after procedure can seriously complicate the success of TAVI. We present the anesthetic management of a patient with infective endocarditis, undergoing aortic valve replacement surgery following TAVI.
Case Report: A 75-year-old woman who had undergone TAVI five months before was readmitted to hospital with complaints of palpitation, breathlessness and fever. The blood culture was positive for Enterococcus faecalis, so antimicrobial therapy was started with a diagnosis of infective endocarditis. She was intubated due to acute lung edema and acidosis; and also needed dialysis. Transesophagial echocardiography (TEE) showed vegetation on right coronary cusp of the implanted aortic valve. The patient underwent cardiac surgery for removal and replacement of the infected and malfunctioning TAVI valve. At the end of the surgical procedure, she was transferred to the intensive care unit (ICU) on inotropic support. However, in ICU, hemodynamic instability, including rhythm disturbances, persisted and intra-aortic balloon pump was inserted. Postoperative course was complicated with low cardiac output syndrome and organ failure. Unfortunately, the patient died at 10th postoperative hour in spite of all supportive management.
Conclusion: The reported incidence of prosthetic valve endocarditis after TAVI patients is less than 0.5%. However, the mortality rate varies from 30% to 50% and urgent open heart surgery with meticulous anesthesiological planning is required.