IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H 2 O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H 2 O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with SpO 2 Յ92% for >1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, −2.3% [95% CI, −5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, −8.6% [95% CI, −11.1% to 6.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.

Storz Miller laryngoscope was found to have advantages over the other laryngoscopes in regard to glottic view, duration of successful intubation, number of attempts, dental trauma severity, need for additional maneuvers, and ease of use.

ÖZET Nuss ameliyatı ile intratorasik yerleştirilen barın çekil- GİrİşPektus ekskavatum göğüs duvarının en sık rastlanan anomalisi olup sternum ve kıkırdak kostaların değişik derecelerde depresyonu ile karakterizedir. Tedavisinde Nuss ameliyatı ile metal bar göğüs kemiğini itecek şekilde yerleştirilir. 2-4 yılın sonunda bar çıkartılır. Genel anestezi altında yapılan ameliyatta pnömoto-raks, kanama, kardiyak ve pulmoner yaralanma gibi komplikasyonlar görülebilmektedir [1] . Kontrol edilemeyen kanamalarda sternotomi gerekebilir. Bu olgu sunumunda Nuss ameliyatı sonrası bar çekilmesi sırasında abondan kanaması ve kardiyak yaralanma şüphesi olan bir hastada transözofageal ekokardiyografi (TÖE) ile kardiyak yaralanmanın nasıl değerlen-dirildiğinin irdelenmesi ve nonkardiyak cerrahide TÖE monitorizasyonunun öneminin vurgulanması amaçlandı. OlGU sUnUmUPektus ekskavatum tanısıyla 2011 yılında takılan barın çıkarılması planlanan 25 yaşında 89 kg erkek hasta ameliyathaneye alınarak monitorize edilip sol kol antekübital venden 20 G branül ile damar yolu Alındığı tarih: 25.02.2014

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