Kardiyak kateterizasyon laboratuarlarýndaki elektrofizyolojik iþlemler son yýllarda belirgin þekilde sayýca artmaktadýr. Çoðunlukla karmaþýk yandaþ hastalýklarý olan hastalar elektrofizyoloji çalýþmalarýna alýnmaktadýr. Bu iþlemlerde anestezi yöntemi ve özellikle anestezik seçimi iþleme uygun olmalýdýr. Elektrofizyoloji çalýþmalarýnýn amaçlarýnýn etkilemeyecek bir ilaç veya ilaçlarýn kombinasyonunu seçmek daha iyi olacaktýr. Bu yazýda deðiþen hasta profiliyle birlikte kardiyak elektrofizyoloji ve anestezi alanýndaki geliþmeler, bu uygulamalardaki pratiðimizin gözden geçirilmesi amaçlanmýþtýr.

Summary
Electrophysiologic procedures in cardiac laboratoires have increased in frequency significantly since past decades. A large number of patients with complex co-existing disease are involving for procedures in the electrophysiology laboratory (EPL). The choice of anesthesia and particular anesthetics should be tailored to the procedure in those studies. It is better to choose a drug or a combination of drugs that do not interfere with the goals EP procedure. The aim of this article is revising our practice along with changing patient profile and developments in the field of cardiac electrophysiology and anesthesia.

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AMAÇ: Bu çalýþmanýn amacý, koroner arter baypas cerrahisi sýrasýnda akut normovolemik hemodilüsyon için kullanýlan hidroksietil starch ve gelofusin sývýlarýnýn koagulasyon üzerine etkilerini araþtýrmaktýr.
YÖNTEMLER: Elektif koroner arter baypas greft cerrahisi geçiren yetmiþ iki hasta, randomize olarak, hemodilüsyonsuz (kontrol) veya kardiyopulmoner baypas öncesi akut normovolemik hemodilüsyon için; 6% HES 200/0.5 (n=24) veya 4% jelatin solüsyonu (n=24) sývýlarýný aldýlar. Thromboelastografi parametreleri, akut normovolemik hemodilüsyon öncesi (T0) ve sonrasý (T1), ve kardiyopulmoner baypasdan ayrýldýktan sonra bir (T2) ve dördüncü (T3) saatlerde ölçüldü.
BULGULAR: HES grubunda R (reaksiyon) zamaný T(2) de, kontrol grubundakinden anlamlý olarak daha uzun idi (p=0.03). HES ve GEL grubunda K (koagulasyon) deðeri T(2) ve T(3) de, kontrollerdekinden anlamlý olarak daha uzun idi (sýrasý ile, p=0.02 ve 0.03). Pýhtý oluþum hýzý (alfa açýsý), HES ve GEL grubunda, kontrollerdekinden anlamlý olarak daha küçük idi(sýrasý ile, p=0.01 ve p=0.02). HES ve GEL grubunda maximum amplitude T(2)de, kontrollerdekinden olarak farklý deðildi (sýrasý ile, p=0.3 and 0.9). GEL grubunda 3 hasta (HES de hiç biri) T(2) de, 30. dakikada pýhtý lizisi gösterdi (p=0.1). GEL ve HES, kontrolle karþýlaþtýrýldýðýnda daha az ünite eritrosit aldý (p<0.001). Mediastinal kan kayýplarý, HES grubunda kontrollerdekinden daha fazla idi (p<0.05).
SONUÇ: HES ve GEL ile akut normovolemik hemodilüsyon uygulamasý, tromboelastogram ile koagulasyonda anlamlý deðiþikliklere neden oldu, eritrosit gereksinimini azalttý. Mediastinal göðüs direnajýný artýrmasý ile HES 200/0.5 in koroner cerrahisi geçiren hastalarda, güvenli olmayabileceði sonucuna vardýk.

OBJECTIVE: The aim of this study to examine the effects of hydroxyethyl starch and gelatin solutions used for acute normovolemic hemodilution on coagulation during coronary artery bypass surgery.
METHODS: Seventy-two patients undergoing elective coronary artery bypass graft surgery randomly received no hemodilution (control), or 6% HES 200/0.5 (n=24) or 4% gelatin solution (n=24) for acute normovolemic hemodilution before cardiopulmonary bypass. Thromboelastography parameters were measured before (T0) and after(T1) acute normovolemic hemodilution, and one(T2) and four(T3) hours after separation from CPB.
RESULTS: The R (reaction) time in HES was significantly longer than in controls at T(2)(p=0.03). The K (coagulation) values in group HES and GEL were significantly longer than in controls at T(2) and T(3) (p=0.02 and 0.03,respectively). Rapidity of clot formation (alpha angle) was significantly smaller in HES and GEL compared to controls (p=0.01 and p=0.02, respectively). Maximum amplitudes in HES and GEL were not significantly different than controls at T(2)(p=0.3 and 0.9, respectively). At T2, three patients in GEL (but none in HES) showed clotlysis at 30 min (p=0.1). GEL and HES received fewer units of erythrocyts compared to controls(p<0.001); however, use of fresh frozen plasma was not significantly different than in controls. Mediastinal blood loss was greater in group HES than in controls(p<0.05).
CONCLUSION: Performing acute normovolemic hemodilution with HES and GEL solutions caused significant change in coagulation state by thromboelastography, reduced the need for errytrocyt. Regarding the increase in mediastinal chest drainage, we concluded that HES may not be safety in patients undergoing coronary surgery.

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AMAÇ: Toraks cerrahisinde tek akciðer ventilasyonunu saðlamak amacýyla yerleþtirilen çift lümenli endotrakeal tüpün pozisyonu çeþitli yöntemlerle doðrulanabilmektedir. Biz bu çalýþmamýzda toraks cerrahisi yapýlacak olan hastalara yerleþtirilen çift lümenli endotrakeal tüpün yerinin doðrulanmasýnda altýn standart olan fiberoptik bronkoskop ile kablosuz video endoskopun; görüntüleme baþarýsý ve hýzý ile hastanýn cerrahiye verilme süreleri açýsýndan karþýlaþtýrmayý amaçladýk.
YÖNTEMLER: Etik kurul onayý sonrasý çalýþmaya elektif koþullarda çift lümenli endotrakeal tüp yerleþtirme endikasyonu olan, toraks cerrahisi uygulanacak 40 hasta alýndý. Entübasyon sonrasý tüplerin yeri konvansiyonel yöntemlerle deðerlendirildi ve doðru pozisyon verildi. Hastalar randomize olarak iki gruba ayrýldý, çift lümenli endotrakeal tüplerin pozisyonlarý kablosuz video endoskop (Grup I, n=20) ve fiber optik (Grup II, n=20) ile tekrar deðerlendirilip, görüntüleme süreleri ile hastalarýn cerrahiye verilme süreleri kaydedildi.
BULGULAR: Yerleþim yerinin tespiti açýsýndan gruplar arasýnda anlamlý fark yoktu. Grup I’de 3 (%15) hastada, Grup II’de 7 (%35) hastada yanlýþ yerleþim tespit edilerek düzeltildi. Görüntüleme süreleri Grup I’de 18 sn, Grup II’de 131 sn (p< 0.05); hastalarýn cerrahiye verilme süreleri ise Grup I’de 468 sn, Grup II’de 690 sn olarak bulundu (p< 0.05).
SONUÇ: Sonuç olarak çalýþmamýzda toraks cerrahisinde çift lümenli endotrakeal tüp yerinin doðrulanmasýnda her iki yöntemin de etkin olduðu görülmüþtür. Bununla birlikte tüp yerinin doðrulanmasý iþleminin ve cerrahinin baþlatýlmasýnýn kablosuz video endoskop ile daha kýsa sürede yapýlabileceði kanaatine vardýk.

OBJECTIVE: In thoracic surgery, the position of double–lumen endotraceal tube placed in order to provide one-lung ventilation can be confirmed by various methods. In this study, we aimed to compare the groups undergoing thoracic surgery with fiberoptic bronchoscope or wireless video endoscope in confirmation of the position of double–lumen endotraceal tube with regard to success and duration of visualisation and the time until the begining of surgery.
METHODS: After ethical committe approval, forthy voluntary patients undergoing thoracic surgery with double–lumen endotraceal tube were included in to the study. After intubation, the location of the double–lumen endotraceal tubes were evaluated by conventional methods and were given the correct position. The patients were randomly divided in two groups as video endoscope (Group I, n=20) and fiberoptic bronchoscope (Group II, n=20) groups. Afterwards, duration of visualisation and the time until the begining of surgery were recorded in both groups.
RESULTS: There wasn’t statistically significant difference between two groups in confirmation of double–lumen endotraceal tube’s position. Malposition of double–lumen endotraceal tube was detected and fixed in three patients (15%) of group I and in seven (35%) of group II. Visualisation times were 18 sec in group I and 131 sec in group II (p< 0.05); and the times until the begining of surgery were 468 sec in group I and 690 sec in group II (p< 0.05).
CONCLUSION: As a result, it’seen that both methods were effective in the confirmation of double–lumen endotraceal tube’s position in thoracic surgery. Apart from that, in confirmation of double–lumen endotraceal tube’s position and earlier administiration to surgery, we concluded that wireless video endoscope may have shorter evaluation time.

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AMAÇ: Miyastenia Gravis (MG), nöromusküler kavþaðýn otoimmün bir hastalýðýdýr. Çalýþmamýzda Eylül 1994 - Ocak 2013 tarihleri arasýnda timektomi uygulanan MG’li olgularýn peroperatif anestezi yönetimlerini retrospektif olarak irdelemeyi amaçladýk.
YÖNTEMLER: Etik kurul onayý sonrasý, ASA I-III sýnýfý, 18-59 yaþ arasý ve verilerinin tamamýna ulaþýlabilen 33 olgu çalýþmaya alýndý.
Olgularýn demografik verileri ve hastalýða özgü özellikleri, peroperatif anestezi ve analjezi yönetimi ve komplikasyonlar kaydedildi.

BULGULAR: Osserman sýnýflamasýna göre %87.9’u sýnýf 1 ve 2, %12.1’i ise sýnýf 3 olarak belirlendi. 3 olgunun Leventhal skoru ≥10 olarak hesaplandý. Olgularýn %9.1’inde dengeli anestezi, %78.8’inde dengeli anestezi ve torakal epidural analjezi, %12.1’inde ise total intravenöz anestezi ve torakal epidural analjezi uygulanmýþtý. Atrakuryum %15.2 oraný ile indüksiyonda en çok tercih edilen nöromüsküler bloker idi. 20 olguda fentanil (%60.6), 12 olguda ise alfentanil (%39.4) tercih edildi. Sadece 2 olgunun idamesinde nöromüsküler bloker kullanýldý ve sugammadeks uygulanmýþtý.
Olgularýn tümü ameliyathane odasýnda ekstübe edilmiþti. 14’ü 1. gün postoperatif yoðun bakým ünitesinde izlenmiþ, reentübasyon veya ventilasyon desteði gerekmemiþti.
SONUÇ: Sonuç olarak, MG’li olgularýn anestezi yönetiminde standart bir protokol bulunmamakla birlikte; hasta ve ilaç etkileþimi göz önüne alýnmalý ve nöromüsküler monitörizasyonun ve etkin bir analjezinin önemi de unutulmamalýdýr.

OBJECTIVE: Myasthenia Gravis (MG) is an autoimmune disease in the neuromuscular junction. In our study, we intend to analyze retrospectively, the perioperative anaesthetic management of MG patients, who underwent thymectomy between September 1994 and January 2013.
METHODS: After the approval of ethics committee, 33 cases of ASA I-III class, between 18-59 ages, diagnosed with MG, underwent thymectomy and with complete data were included in the study.
The demographic data and disease-specific features of the cases, perioperative anesthesia and analgesia management and complications were recorded.

RESULTS: According to Osserman classification 87.9% are determined class 1 and 2, and 12.1% as class 3. Leventhal score of 3 cases were calculated as ≥10. Balanced anesthesia was applied to 9.1% of the cases, whereas balanced anesthesia and thoracic epidural analgesia to 78.8%, total intravenous anesthesia and thoracic epidural analgesia to 12.1%. Atracurium was the most preferable neuromuscular blocker in the induction with 15.2%. Fentanyl was preferred (60.6%) in 20 cases and alfentanil (39.4%) in 12 cases. In 2 cases neuromuscular blocker was used for maintenance and sugammadex was administered at the end of the surgery.
All patients were extubated in the operating room. 14 of them were observed in the postoperative intensive care unit in the 1st day. Reintubation or ventilation support was not required.

CONCLUSION: In conclusion, although there is not a standard protocol for the anesthetic management of MG cases, patient and drug interaction must be taken into consideration and the importance of effective analgesia and neuromuscular monitoring must be noted.

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Son yýllarda yaþam koþullarý ve týptaki geliþmelerle 65 yaþ üzeri nüfus ve bu populasyonda yapýlan kalp cerrahisi operasyonlarý giderek artmaktadýr. Yaþlanma, organ fonksiyonlarýnýn deðiþmesine ve kronik hastalýklara yol açmaktadýr. Yaþlý hastalarda morbidite ve mortalite oranlarý genç hastalara göre daha fazladýr. Kalp cerrahisi geçirecek yaþlý hastalarda preoperatif risk skorlarýn belirlenmesi, elektif þartlarda uygun anestezi ve cerrahi tekniklerinin uygulanmasý ve dikkatli yoðun bakým takibi baþarýyý arttýracaktýr.

In recent years, progress in living conditions and medicine has increased the number of people over 65 years of age. Thus, geriatric population is increasing among the patients undergoing cardiac surgery. The aging process leads to change in organ functions and chronic diseases. The elderly patients have more the ratio of morbidity and mortality than young patients. In elderly patients undergoing cardiac surgery, the success rations will increase when they are evaluated with the risk scores preoperatively and performed convenient anesthesia, surgery technics and carefully intensive care in elective operations,

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Parkinson hastalýðý, yaþlýlarda yaygýn görülen nörodejeneratif bir bozukluktur. Parkinson hastalarý sýk ameliyat olmasýna raðmen bu hastalarýnýn optimal anestezi yönetimini saðlayacak olgu sunumu sayýsý azdýr. Ameliyat öncesi kullanýlan anti-parkinson ilaçlara ara verilmesi sonucu ve kullanýlan anestezik ajanlarýn etkilerine baðlý olarak çoðu zaman hastalýk þiddeti, morbidite ve mortalite artmaktadýr. Bu yazýmýzda, 10 yýldýr Parkinson tedavisi gören 79 yaþýndaki hastamýza mitral kapak replasmaný ameliyatýnda uyguladýðýmýz anestezi yönetimimizi sunmayý amaçladýk. Perioperatif süre boyunca anti-parkinson ilaçlar enteral yolla verildi. Mevcut literatürler gözden geçirilerek uygun anestezi yönetimi saðlandý, postoperatif yedinci gün hasta sorunsuz þekilde taburcu edildi.

Parkinson disease is a neurodegenerative disorder common in the elderly. Although these patients have been operated several times, few case reports are available regarding optimal anesthetic management of patients with Parkinson's disease. Discontinuation of anti-parkinsonian drugs used before surgery and effects of using anesthetic agents often increase severity of disease, morbidity and mortality. We aimed to present the anesthetic management of mitral valve replacement surgery for 79-year-old patient with Parkinson disease who has been medicated for 10 years. Anti-parkinson drugs were given enterally during the perioperative period. The current literatures were reviewed and appropriate anesthesia management was achieved, the patient was discharged on the seventh postoperative day without any problem.

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Vena Kava Süperior Sendromu (VKSS), mediyastinal kitlenin çevresindeki yapýlara yaptýðý basý sonucu, kalbe dönen kan akýmýnýn azalarak üst ekstremite ve boyunda ödem görülmesiyle sonuçlanan klinik bir tablodur. Zor hava yolu yönetimi ve kardiyovasküler kollaps gibi hayatý tehdit eden komplikasyonlarý nedeniyle VKSS olan hastanýn anestezi yönetiminde dikkatli olunmalýdýr. Bu sunumda, mediyastinal biyopsi planlanan VKSS’lu hastada anestezi yönetimini sunmayý amaçladýk.

Superior Vena Cava Syndrome (SVCS) is a clinical condition that causing edema the upper extremities and neck by decreased blood flow returning to the heart, due to compression which created mediastinal mass the surrounding structures. The anesthetic management of patients with Vkss must be careful due to life-threatening complications such as difficult airway management and cardiovascular collapse. In this case report, we aimed to present the anesthetic management of SVCS in patient scheduled for biopsy of mediastinal.

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Total olarak implante edilebilir vasküler kateterler uzun süreli ilaç uygulamalarý, parenteral beslenme ve transfüzyon ihtiyacý olan hastalarda güvenli ve kolay ulaþýlabilir vasküler giriþim imkaný saðladýklarý için yaygýn olarak kullanýlmaktadýr. Pinch-off sendromu (POS) subklavyen santral venöz kataterin çevre doku ile birinci kosta ve klavikula arasýndaki kompresyonuna baðlý kopmasý olarak tanýmlanmaktadýr. Kopan kateter parçasýnýn ventrikül içerisine embolizasyonu ciddi aritmilere sebep olabilir. Günümüzde giriþimsel radyoloji ve kardiyoloji alanýnda kullanýlan geliþmiþ kateterler yardýmý ile emboliye sebep olmuþ kýrýk katater parçasý perkütan yolla baþarýlý bir þekilde çýkarýlmakta ve ek bir cerrahi iþleme gerek duyulmamaktadýr. Bu olgumuzda, kopan kateter parçasýnýn kalp içerisine ilerlemesi ile ciddi aritmilerin olduðu POS olgusu ve uygulanan perkütan tedavi yaklaþýmýný sunmayý amaçladýk.

Totally implantable vascular catheters are used widely in patients who need long-term drug administration, parenteral nutrition and transfusion, because they allow safe and easily available vascular access. Pinch-off syndrome (POS) is described as breaking off the subclavian central venous catheter because of the compression by the surrounding tissues, first costa and clavicle. Embolization of deteached catheter part into ventricular space can cause serious arrhythmias. Today, with the help of advanced catheters used in the field of interventional radiology and cardiology, deteached catheter part which caused embolism is successfully removed percutaneously, and no additional surgical procedure is required. In this case report, we present a case of POS included serious arrhythmias because of fragmented catheter part moving into the heart and percutaneous treatment approach.

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Allerjen ile temasý takiben, ürtikerden anaflaksiye kadar deðiþen alerjik reaksiyonlar görülebilir. Anafilaktik reaksiyonlarýn sýklýðý genel popülasyonda alerjik rinit ve astýmý olanlarda daha yüksek oranda görülebilmektedir. Perianestezik anafilaksi önemlidir. Eðer erken tanýyýp tedavi edilmez ise potansiyel ciddi sonuçlara neden olabilir. Literatürde kolloid solüsyonlar, ranitidin, antibiyotikler ve lateks gibi sýk kullanýlan maddelere karþý anafilaksi bildirilmiþtir. Oksitosin kullanýmýna baðlý anaflaktik þok geliþmesi nadir bir yan etki olarak görülebilir.
Biz, bu olgu ile allerji hikayesi olmayan gebede sezaryen operasyonu esnasýnda oksitosin infüzyonundan hemen sonra geliþen anaflaktik þoktaki anestezi yönetimini sunmayý amaçladýk.

Following contact with the allergen, allergic reactions ranging from the urticaria to anaphylaxis can be seen. The incidence of anaphylactic reactions in patients with asthma and allergic rhinitis are in higher rates in general population. Perianaesthetic anaphylaxis are important. It may be severe and potentially associated with adverse outcomes unless urgently recognized and treated. Anaphylaxis has been reported at the literature, with commonly used substances like latex, antibiotics, ranitidine, colloid solutions. Development of anaphylactic shock due to use of oxytocin is a rare side effect.
We aimed to precented with this case the anesthetic management of anaphylactic shock in a pregnant women, without a history of allergic reaction, developed immediately after infusion of the oxytocin during cesarean section.

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Akut respiratuar yetmezlik, etiyolojisinde çok sayýda faktörün yer aldýðý, her yaþ grubunda mortalitesi yüksek ciddi bir tablodur. Ekstrakorporeal membranöz oksijenatörlerin geliþmesiyle, oksijenasyonun bir membran aracýlýðý ile saðlanmasý, ve akciðer koruyucu ventilasyon uygulanmasý þeklinde tedavi yaygýnlaþmaktadýr.
Yüksekten düþmeye baðlý aðýr torakal hasar nedeniyle opere edilen bir hastamýzda geliþen akut respiratuar yetmezlik tablosunun tedavisini sunduk. Hipoksi nedeniyle dokuz gün boyunca veno-venöz EKMO uygulanan hastanýn oksijenasyonu düzeldi. Bir aylýk iyileþme sürecini takiben trakeotomize halde servise taburcu edildi.

Acute respiratory distress syndrome is a multifactorial and serious disorder with a high mortality in all age groups. With the advances in extracorporeal membraneous oxygenators, tretament involving oxygenation through a membrane and lung protective mechanical ventilation is becoming widespread.
We present management of acute respiratory distress syndrome due to serious thoracic injury following fall from height. The patient received ECMO treatment due to persistent hypoxia for nine days, and hypoxia resolved. Following a period of healing for one month, the tracheotomized patient was externed to the surgical ward.

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