Can Preoperative Parameters of Inflammation be Used to Predict Acute Kidney Injury in Pediatric Liver Transplant Recipients? A Single-Center Retrospective Study - Istanbul Medical Journal

Background: Unexpected difficult laryngoscopy remains one of the leading causes of life-threatening complications in anesthetic practice. Conventional airway assessment tests (e.g., Mallampati classification, thyromental distance) are inherently subjective and demonstrate limited diagnostic accuracy. We aimed to develop a hybrid artificial intelligence model that extracts three-dimensional geometric ratios from standardized facial photographs using deep learning and graph-based modeling to predict difficult laryngoscopy. Methods: In this prospective observational study, consecutive patients scheduled for elective surgery were enrolled. Preoperatively, standardized facial photographs were obtained from eight projection angles. Instead of raw pixel-based image analysis, the images were transformed into three-dimensional anatomical graph structures following local illumination normalization using Contrast Limited Adaptive Histogram Equalization (CLAHE), combined with MediaPipe Face Mesh (468 landmark points) and Pose Estimation (33 skeletal key points). Clinically relevant anatomical indices, including Retrognathia, Overjet, Neck Bulk, and Airway Visibility, were mathematically derived from these coordinates and combined with routinely collected clinical and anthropometric variables as structured model inputs. Cormack–Lehane (CL) grading was used as the reference standard (Grades I–II: non-difficult laryngoscopy; Grades III–IV: difficult laryngoscopy). The structured dataset was used to train XGBoost, Random Forest, and Tabular Transformer models incorporating multi-head attention. To prevent data leakage, Synthetic Minority Over-sampling Technique (SMOTE) augmentation and scaling were applied exclusively to the training set. Results: Preoperative images and anatomical ratios of 198 patients were analyzed. Among the derived indices, the Mouth Opening Ratio and Oropharyngeal Visibility Index showed the highest landmark acquisition success, with extraction in 193 of 198 patients (97.5%). The proposed hybrid artificial intelligence (AI) model achieved a test-set accuracy of 80.0%, sensitivity (recall) of 85.7%, and an area under the curve (AUC) of 0.808 for difficult laryngoscopy prediction. Conclusions: Unlike conventional convolutional neural networks (CNNs) relying on raw pixel processing, the proposed model combines standardized pixel-space measurements and normalized geometric ratios. This landmark-based representation may reduce sensitivity to some acquisition-related variability under standardized imaging conditions. These findings support the feasibility of a landmark-based, geometry-driven approach for objective preoperative airway risk assessment. However, external validation and direct comparison with standardized bedside airway assessment are required before routine clinical implementation.

Aim: Emergence delirium (ED) is a common behavioral disturbance during recovery from general anesthesia in pediatric patients. This retrospective observational study aimed to evaluate the effect of intraoperative bispectral index (BIS) monitoring on the incidence and severity of ED in children undergoing elective surgery. Material and Methods: Medical records of 160 pediatric patients aged 2-7 years who underwent elective surgery under general anesthesia were retrospectively reviewed. Patients were divided into two groups according to anesthetic depth monitoring: BIS-guided (n=80) and control (n=80). ED was assessed using the pediatric anesthesia emergence delirium (PAED) scale, and postoperative pain was evaluated using the face, legs, activity, cry, consolability (FLACC) scale. Results: The rate of ED was significantly lower in the BIS group compared with the control group (4 patients [5.0%] vs. 54 patients [67.5%], p=0.001). PAED (4.00±2.1 vs. 7.17±2.9) and FLACC (2.11±1.5 vs. 3.00±1.7) scores were also significantly reduced in the BIS-monitored group (p=0.001 for both). Recovery time (8.52±2.9 vs. 10.04±3.2 minutes, p=0.001) and PACU stay duration (44.68±11.2 vs. 59.76±14.5 minutes, p=0.001) were significantly shorter in the BIS group. In multivariate logistic regression analysis, BIS monitoring remained an independent protective factor against ED (OR=0.020, 95% CI: 0.010-0.080, p=0.001). Conclusion: Intraoperative BIS monitoring significantly reduces ED and improves recovery quality in pediatric patients. Objective monitoring of anesthetic depth may improve postoperative behavioral stability.

Background/Objectives: Bariatric surgery is the most effective treatment for sustained weight loss; however, early postoperative complications remain a significant concern. Routine biochemical markers obtained in the immediate postoperative period may enable early risk stratification, yet their prognostic value remains incompletely defined. This study aimed to evaluate the association between early postoperative biochemical alterations and composite adverse outcomes after bariatric surgery. Methods: In this retrospective observational study, 260 adult patients undergoing elective bariatric surgery were included. Preoperative and postoperative day 1 (POD1) laboratory parameters were retrieved from electronic medical records. The primary endpoint was a composite adverse outcome comprising postoperative intensive care unit admission, infection, anastomotic leak, or 30-day readmission. Univariable and multivariable logistic regression analyses were performed to evaluate independent associations, and receiver operating characteristic (ROC) curve analysis was used to assess discriminative performance. Results: Composite adverse outcomes occurred in 51 patients (19.6%). In multivariable analysis, longer operative duration (OR 1.17 per 10 min, 95% CI 1.04–1.31; p = 0.009), POD1 AST (OR 1.15 per 10 U/L, 95% CI 1.07–1.24; p < 0.001), and POD1 lactate-to-albumin ratio (LAR ×100) (OR 1.20, 95% CI 1.04–1.38; p = 0.014) were independently associated with adverse outcomes. POD1 AST demonstrated the highest discriminative ability (AUC 0.733), followed by glucose (AUC 0.688) and ALT (AUC 0.680), whereas LAR showed limited stand-alone performance (AUC 0.594). Conclusions: Longer operative duration and higher POD1 AST and LAR levels were independently associated with the composite adverse perioperative outcome. AST showed the highest, although moderate, individual discrimination, whereas LAR demonstrated limited stand-alone performance. Because immediate postoperative ICU transfer preceded POD1 biomarker sampling and dominated the composite outcome, these findings should be interpreted as associations rather than prospective prediction.

Rokuronyum, anestezi pratiğinde sık kullanılan, aminosteroid yapıda, hızlı başlangıçlı ve orta etkili nondepolarizan nöromüsküler blokördür. İntravenöz kullanım için geliştirilmiş bu ajanın yanlışlıkla intramüsküler (İM) uygulanması, öngörülemeyen farmakokinetik özellikler nedeniyle ölümcül komplikasyonlara yol açabilmektedir. Bu yazıda, evde yanlışlıkla İM rokuronyum ve solunum arresti sonrası kardiyopulmoner resüsitasyon uygulanan, yoğun bakım takibiyle sağlığına kavuşan 21 yaşındaki kadın olgu sunulmaktadır. Literatürdeki benzer olgular eşliğinde kas gevşetici ajanlar grubundaki rokuronyumun ve ilaç güvenliği önlemlerinin önemi tartışılmıştır.