Akut böbrek yetmezliði (ABY) kardiyovasküler cerrahiden sonra geliþen majör komplikasyonlardan biridir, sýklýkla yüksek morbidite ve mortalite riski taþýr. Komplikasyonlarý tayin eden kriterlere baðlý olarak, kardiyovasküler cerrahiden sonra geliþen ABY riski % 5-31 oranlarýnda deðiþmektedir; ayrýca bunlar arasýnda diyaliz gerektiren ABY yaklaþýk % 1 oranýnda görülmektedir (8). ABY son zamanlarda “Akut Böbrek Hasarý” olarak da adlandýrýlmaktadýr.

ABY, RIFLE sýnýflandýrmasý, akut böbrek yetmezliðinin nedenleri, belirtileri, teþhis yöntemleri ve erken yetmezlik belirteçleri, konularý genel olarak ele alýnacaktýr. Ayrýca özellikle kardiyovasküler cerrahiden sonra geliþen ABY’nin nedenleri, risk deðerlendirmesi, tedavi yöntemleri, belirteçlerin nasýl kullanýldýklarý ve ABY’yi engellemek amacýyla kullanýlan farmakolojik yaklaþýmlar literatürde yapýlan çalýþmalar örnek verilerek ele alýnacaktýr.

Acuterenalfailure is one of themajorcomplicationsseenaftercardiovascularsurgeryandfrequently has a highmorbidityandmortalityrisks. Depending on thecriteriadeterminingthecomplications, risk of acuterenalfailureaftercardiovasculersurgery is changingbetween 5-31 %, besidestheincidence of acuterenalfailurerequiringdialysis is 1 %. Recentlyacuterenalfailure is referredtoacuterenalinjury. Inthisreviewthesubjectssuch as acuterenalfailure, RIFLE classification, causes, diagnosticmethodsandearlystagemarkersforacuterenalfailurewill be discussedgenerally. Especiallycauses of acuterenalfailureseenaftercardiovasculersurgery, risk evaluation, treatmentmethods, usage of markersandpharmacologicalapproachestopreventthedevelopment of acuterenalfailurewillalso be discussedbygivingreferencestothestudies on thesesubjects in theliterature.

AMAÇ: Bu çalýþmada torakotomi sonrasý aðrý tedavisinde tramadole adjuvan olarak deksmedetomidin eklenmesinin solunum fonksiyonlarýna, analjezi ve sedasyon üzerine etkisinin araþtýrýlmasý amaçlandý.
YÖNTEMLER: Torakotomi yapýlan 30 hasta randomize olarak iki gruba ayrýldý. Postoperatif hastalarýn ortalama kan basýncý (OAB), kalp hýzý (KAH), solunum sayýsý (SS) ve SpO2 deðerleri kaydedildi. Grup T’deki hastalara hasta kontrollü analjezi (HKA) ile 100 mL normal salin içinde 4 mg mL tramadol solüsyonu iv olarak HKA ayarlarý, 0,3 mg kg-1 sa-1 infüzyon, 10 mg ara bolus doz ve 20 dk kilitleme süresi olacak þekilde infüze edilmeye baþlandý. Grup D’deye ise ayný doz tramadol ile HKA iþlemine ek olarak deksmedetomidin 1,0 µg kg-1 dan 20 dk yükleme, 0,4 µg kg-1 sa-1 idame olacak þekilde 24 saat boyunca iv uygulandý. Analjezik etkinliði Visual analog skala (VAS) ile, sedasyon düzeyleri Ramsay sedasyon skalasý ile deðerlendirildi. Postoperatif dönemde arterial kan gazý (AKG), total tramadol tüketimi ve yan etkiler, zorlu vital kapasite (FVC), 1. saniye zorlu ekspiratuar volüm (FEV1), FEV1/FVC oraný ve vital kapasite (VC) deðerleri bakýldý ve gruplar karþýlaþtýrýldý.
BULGULAR: Gruplar dermografik olarak birbirine benzerdi Her iki gruptada etkin analjezi saðlandý. KAH, OAB, VAS, Ramsay sedasyon skalasý ve tramadol tüketimi Grup D de Grup T ye göre daha düþük bulundu FEV1, FVC, VC deðerlerinde her iki grup arasýnda istatistiksel olarak anlamlý fark bulunmadý.
SONUÇ: Torakotomi sonrasýnda postoperatif analjezi saðlamak amacýyla HKA yöntemi ile uygulanan tramadole deksmedetomidin ilavesinin hastalarda solunumu baskýlamadan, etkin sedasyon ve analjezi saðladýðý, tramadol tüketimini anlamlý düzeyde azalttýðý kanýsýna varýldý.

OBJECTIVE: In this study, we aimed to investigate the effects of dexmedetomidine which was used as an adjuvant to tramadol, on respiratory functions, analgesia and sedation in the treatment of the pain after thoracotomy.
METHODS: 30 patients with thoracotomy were divided randomly into two groups. The postoperative vital values were recorded including mean blood pressure(MAP), heart rate(HR), respiratory rate(RR) and SpO2. Group T received patient-controlled analgesia (PCA) with 4 mg mL-1 tramadol iv in 100 ml normal saline solution. PCA settings were 0.3 mg kg-1 h-1 infusion, a bolus dose of 10 mg and 20 minute lockout interval. Group D received tramodol similar to group T, and dexmedetomidine 1.0 µg kg-1 20 minute as loading dose than 0.4 µg kg-1 h-1 iv. for maintanence over 24 hours. Analgesic efficacy was measured with Visual analog scale (VAS), sedation levels were assessed with Ramsay sedation scale. In the postoperative period, arterial blood gas, the total consumption of tramadol and its side effects, forced vital capacity (FVC),1 second forced expiratory volume (FEV1), FEV1/FVC, and forced vital capacity (VC) values were recorded, than groups were compared.
RESULTS: Patients were similar in both groups. In all groups, effective analgesia was achieved. HR, MAP, VAS, Ramsay sedation scale, and tramadol consumption was lower in Group D. In FEV1, FVC, VC values, there were not statistically significant differences between both groups.
CONCLUSION: It was concluded that using PCA in order to provide postoperative analgesia after thoracotomy, with the addition of dexmedetomidine to tramadol provides effective sedation and analgesia without respiration depression.

Daha önce 2 kez torasik aort anevrizmasý nedeniyle opere edilmiþ yüksek riskli hastada, arkus aorta anevrizma ameliyatýnda serebral korumaya yönelik üçlü monitörizasyonun önemini ve uygulamalarýmýzý sunduk.

Daha önce Tip 1 aort disseksiyonu (1999 yýlýnda) ve asendan aort anevrizmasý (2006 yýlýnda) nedeniyle ameliyat edilen Marfan Sendromlu erkek hasta, arkus aort anevrizmasý nedeni ile 3. kez ameliyata alýndý. Rutin monitorizasyonun yanýnda, serebralkortikalsinaptik aktivite deðiþiklikleri elektroensefalografi ve % 95 spektral “edge” frekans deðerleri ile, serebral oksijen satürasyonu “near-infraredspectroscopy” ile, orta serebral arter kan akým hýzlarý trans kranialdoppler ultrasonografi ile ölçüldü. 18°C derin hipotermiksirkülatuvararrest sýrasýnda 700 mL dak-1antegradselektifserebralperfüzyonla beyin kan akýmý saðlandý. Selektifperfüzyon sýrasýnda sað ve sol spektral “edge” frekans deðerleri 0-2, sað ve sol serebral oksijen satürasyon deðerleri % 72 - % 80 aralýðýnda, sol temporal percereden ölçülen orta serebral arter ortalama kan akým hýzlarý 10-23 cm sn-1 aralýðýnda devam etti. Hasta postoperatif 22. saatte ekstübe edildi ve 3. günde sorunsuz olarak servise çýkarýldý.

Yüksek risk taþýyan, uzun selektifserebralperfüzyon süresi öngörülen hastamýzda düþük akým sýrasýnda serebraloksijenasyonun ve perfüzyonun yeterliliðini 3’lü serebralmonitorizasyon ile takip ederek maksimum hasta güvenliði saðladýðýmýzý düþünüyoruz.

In this case we present the importance of triple cerebral monitorization and our experiences in a highly-riskypatient’saorticarc surgery.

A male patient with a Marfansyndrome had been operated for type 1 aortic dissection in 1999 and again for a orticaneurysm in 2006. Aorticarcus surgery was planned in elective conditions. Besides routine monitorization, cerebral cortical synapticactivity changes were monitored by electroencephalography and 95 % spectraledge frequency values, cerebral oxygen saturation were measured with near-infrared spectroscopy and flow velocity of middle cerebral artery was measured by transcranial Doppler ultrasound system. During deep hypothermiccirculatory arrest (18˚C), antegrade selective cerebral perfusion was performed at 700 mL min-1. During selective cerebral perfusion, right and left spectral edge frequency values were 0 to 2, right and left cerebral oxygen saturations were between 72 to 80 %, and middle cerebral arterial blood flow velocities werebetween 10 to 23 cm sec-1. The patient was extubated at postoperative 22. hour and discharged from intensive care unit at postoperative third day.

We think that we provided the maximum patient safety for our highly risky patient who was predicted to endureprolonged selective cerebral perfusion during lower cerebral oxygenation by ensuring a dequate cerebral oxygenation and perfusion by using triple cerebral monitorization during selective cerebral perfusion.

Mediyastinoskopi mediasten patolojilerinin deðerlendirmesinde ve akciðer kanserlerinin evrelemesinde deðerli bir taný yöntemidir. Yazýmýzda anteriyor mediyastinoskopi sýrasýnda geliþen sað pulmoner arter kanamasýný ve anestezi yönetimini literatürler eþliðinde sunmayý amaçladýk.

Mediastinoscopy is an important surgical method for assesment of the mediastinal pathologies and grading of the lung cancers. In this case report we aim to present right pulmonary artery hemorage during anterior servical mediastinoscopy and anesthetic management in the light of the literatures.