Objective: Static monitors for assessing the fluid status during major surgeries and in critically ill patients have been gradually replaced by more accurate dynamic monitors in modern-day anaesthesia practice. Pulse pressure variation (PPV) and systolic pressure variation (SPV) are the two commonly used dynamic indices for assessing fluid responsiveness. Methods: In this prospective observational study, 50 patients undergoing major surgeries were monitored for PPV and SPV: after the induction of anaesthesia and after the administration of 500 mL of isotonic crystalloid bolus. Following the fluid bolus, patients with a cardiac output increase of more than 15% were classified as responders and those with an increase of less than 15% were classified as non-responders. Results: There were no significant differences in the heart rate (HR), mean arterial pressure (MAP), PPV, SVV, central venous pressure (CVP) and cardiac index (CI) between responders and non-responders. Before fluid bolus, the stroke volume was significantly lower in responders (p=0.030). After fluid bolus, MAP was significantly higher in responders but there were no significant changes in HR, CVP, CI, PPV and SVV. In both responders and non-responders, PPV strongly correlated with SVV before and after fluid bolus. Conclusion: Both PPV and SVV are useful to predict cardiac response to fluid loading. In both responders and non-responders, PPV has a greater association with fluid responsiveness than SVV. Keywords: Fluid management, pulse pressure variation, systolic pressure variation, fluid responsiveness Amaç: Günümüzde anestezi pratiğinde, büyük ameliyatlarda ve ağır hastalarda sıvı durumunun değerlendirilmesi için kullanılan statik izlem yöntemlerinin yerini, daha doğru sonuçlar veren dinamik izlemler almıştır. Nabız basıncı değişimi (PPV) ve sistolik basınç deği-şimi (SPV) sıvı yanıtını değerlendirmek amacıyla yaygın bir şekilde kullanılan dinamik indekslerdir. Yöntemler: Bu prospektif gözlemsel çalışmada, major cerrahi geçire-cek 50 hastada anestezi indüksiyonundan ve 500 mL izotonik verildikten sonra PPV ve SPV monitörize edildi. Bolus sıvı uygulamasını takiben, %15'ten fazla kardiyak debisi artışı olan hastalar yanıt verenler olarak, %15'ten daha az artışı olanlar ise yanıt vermeyenler olarak sınıflandırıldılar. Bulgular: Yanıt verenler ve vermeyenler arasında kalp atım hızı (HR), ortalama arter basıncı (MAP), PPV, SVV, santral venöz basınç (CVP) ve kardiyak indeks (CI) açısından anlamlı bir fark bulunmadı. Bolus sıvı uygulaması öncesinde, atım hacmi yanıt verenlerde anlamlı derecede daha düşüktü (p=0,030). Bolus sıvı uygulaması sonrasında, MAP yanıt verenlerde anlamlı ölçüde daha yüksek bulundu, ancak HR, CVP, CI, PPV ve SVV açısın-dan anlamlı fark gözlenmedi. Bolus sıvı uygulaması öncesinde ve sonrasında, hem yanıt veren hem de yanıt vermeyen hastalarda, PPV değeri ile SVV değeri arasında güçlü bir ilişki saptandı. Sonuç: PPV ve SVV sıvı yüklenmesine verilen kardiyak yanıtı tahmin etmede yararlıdır. Hem yanıt veren hem de vermeyen hastalarda ...

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Purpose: To describe the outcomes of descemet stripping automated endothelial keratoplasty (DSAEK) in congenital hereditary endothelial dystrophy (CHED) and to evaluate the role of microscope integrated optical coherence tomography (Mi-OCT) during the surgery. Design: Retrospective data analysis. Methods: A retrospective study from the medical records of all those patients who were diagnosed with CHED and underwent DSAEK at our centre from 2015 were evaluated. All patients underwent Mi-OCT-guided standard DSAEK procedure. Intra-operative difficulties, visual outcomes and graft survival were recorded. Results: A total of 48 eyes of 29 patients with a mean age of 9.87 ± 8.2 years and mean follow-up of 17.3 months were evaluated. Thirty-nine eyes underwent primary DSAEK and 9 eyes underwent PKP. Three eyes who underwent PKP had failed graft for which they underwent DSAEK. The mean preoperative Snellen's visual acuity was 1.71 ± 0.66 and the mean preoperative central corneal thickness was 1.10 ± 0.174 mm. Intraoperatively, all the grafts were attached which was confirmed using Mi-OCT. Graft detachment was seen in the immediate postoperative period in 10.4% (4 eyes) of primary DSAEK, out of which DM scoring was not performed in 2 eyes. Following DSAEK, cornea cleared at four-week follow-up in 89.7% eyes and in all the eyes the cornea cleared at six-week follow-up. Conclusion: Primary DSAEK could be a preferred option over PKP for CHED with early presentation and in those eyes with failed primary PKP. Mi-OCT is a very useful tool in these eyes for various intraoperative procedures, thereby improving the outcomes of the procedure.

Wilson disease is an inherited autosomal recessive disease of copper metabolism that results in copper toxicity; it has an incidence of 1 in 40,000 [1]. Wilson disease is associated with liver failure; however, evidence on its bleeding tendencies is equivocal [2]. We present a case of Wilson disease with secondary parkinsonism and liver cirrhosis complicated by intracerebral hemorrhage (ICH), which has not yet been reported in the literature. Patient consent was obtained for this report. A 35-year-old man, who had been diagnosed with Wilson disease two years earlier, presented with inability to sleep and increased tremors that had lasted for a month. He had secondary Parkinsonism along with child Pugh A liver cirrhosis that had lasted for 1 year. He also had bipolar disease and alcohol and cannabis abuse disorders, and was on regular follow-up at a psychiatric clinic. Clinically, he had extrapyramidal symptoms. Hematological investigations were essentially normal; however, biochemistry revealed a serum ceruloplasmin level < 9.5 mg/dl and 24-hour urinary copper level of 398.18 µg/day, which are consistent with Wilson disease. Ultrasonography of the abdomen revealed hepatomegaly with coarse echotexture and splenomegaly. Portal hypertension was diagnosed on the basis of color doppler flow imaging findings, and upper gastrointestinal endoscopy revealed small varices with severe portal hypertensive gastropathy and gastric antral vascular ectasia. At the time of reporting, the patient was undergoing zinc treatment for Wilson disease. He was admitted, and penicillamine treatment was initiated. His anti-parkinsonism treatment was also optimized. He was discharged after 1 week and scheduled for regular follow-up. One month after the initiation of penicillamine and while on follow-up, he developed pancytopenia with a hemoglobin (Hb) level of 12.8 g/dl total leukocyte count of 4.1 × 10 9 /L and platelet count of 70 × 10 9 /L. Given the pancytopenia, penicillamine was discontinued and the zinc tablet dosing was increased. At 1 week post-cessation of the penicillamine therapy, he had a left-sided focal seizure associated with extensor posturing of the right limbs and altered sensorium. On clinical evaluation, the patient had a pulse of 66 beats/min and blood pressure of 126/84 mmHg with a right gaze preference, extensor posturing, fixed dilated right pupil, and left pupil at 6 mm with sluggish reaction. Urgent non-contrast computed tomography of the head revealed a large left basal ganglia hemorrhage with an intraventricular extension (13-mm midline shift) and uncal herniation (Fig. 1). Anti-compression measures were initiated with mannitol. He was intubated and mechanically ventilated. Hematology revealed a Hb level of 9.4 g/dl and platelet count of 43 × 10 9 /L with an international normalized ratio of 1.65. The external ventricular drain was placed following neurosurgical consultation, and blood component transfusion was administered with 6 units of random donor platelets Letter to the Editor

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