Georgia Stamatiou

Laparoscopic cholecystectomy under spinal anesthesia : A pilot study

BackgroundRegional anesthesia has not been used as the sole anesthetic procedure other than in the scenario of a patient at high risk to undergo laparoscopic cholecystectomy with CO2 pneumoperitoneum under general anesthesia.MethodsFifteen ASA grade I or II patients underwent laparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum under spinal anesthesia. Intraoperative parameters, postoperative pain and recovery in general, as well as patient satisfaction at follow-up were prospectively recorded in a pilot study to assess the feasibility and safety of the procedure.ResultsAll operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score 4 h postoperatively was 1.5 (range, 0–5), at 8 h it was 1 (range, 0–6), and at 24 h it was 1 (range, 0–4). All patients were discharged after 24 h. Follow-up 2 weeks postoperatively showed all but one patient to be satisfied and strongly recommending the anesthetic procedure.ConclusionLaparoscopic cholecystectomy with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and at least an equally good recovery as with general anesthesia.

Spinal vs General Anesthesia for Laparoscopic Cholecystectomy: Interim Analysis of a Controlled Randomized Trial

OBJECTIVE To compare spinal anesthesia with the gold standard general anesthesia for elective laparoscopic cholecystectomy in healthy patients. DESIGN Controlled randomized trial. SETTING University hospital. PATIENTS One hundred patients with symptomatic gallstone disease and American Society of Anesthesiologists status I or II were randomized to have laparoscopic cholecystectomy under spinal (n = 50) or general (n = 50) anesthesia. METHODS Intraoperative parameters, postoperative pain, complications, recovery, and patient satisfaction at follow-up were compared between the 2 groups. RESULTS All the procedures were completed by the allocated method of anesthesia, as there were no conversions from spinal to general anesthesia. Pain was significantly less at 4 hours (P < .001), 8 hours (P < .001), 12 hours (P < .001), and 24 hours (P = .02) after the procedure for the spinal anesthesia group compared with those who received general anesthesia. There was no difference between the 2 groups regarding complications, hospital stay, recovery, or degree of satisfaction at follow-up. CONCLUSIONS Spinal anesthesia is adequate and safe for laparoscopic cholecystectomy in otherwise healthy patients and offers better postoperative pain control than general anesthesia without limiting recovery.

Cerebral oximetry in cardiac anesthesia

Cerebral oximetry based on near-infrared spectroscopy (NIRS) is increasingly used during the perioperative period of cardiovascular operations. It is a noninvasive technology that can monitor the regional oxygen saturation of the frontal cortex. Current literature indicates that it can stratify patients preoperatively according their risk. Intraoperatively, it provides continuous information about brain oxygenation and allows the use of brain as sentinel organ indexing overall organ perfusion and injury. This review focuses on the clinical validity and applicability of this monitor for cardiac surgical patients.

Impact of Pregabalin Treatment on Pain, Pain-Related Sleep Interference and General Well-Being in Patients with Neuropathic Pain

AbstractBackground and Objectives: Numerous controlled clinical trials have demonstrated the safety and efficacy of pregabalin in the treatment of neuropathic pain. The objectives of the present study were to assess the impact of pregabalin under real-world conditions on pain, pain-related sleep interference and general well-being, and to assess the tolerability and safety of pregabalin in patients diagnosed with neuropathic pain of central or peripheral origin. Methods: This was a non-interventional, multicentre study in which pregabalin was administered for 8 weeks, at the therapeutic dosages of 150–600 mg/day, to patients with a diagnosis of neuropathic pain. Pain intensity and pain-related sleep interference were measured using 11-point numerical rating scales, while well-being was assessed by documenting how often emotions associated with anxiety or depression were felt over the past week. Patient and Clinician Global Impression of Change (PGIC and CGIC) were assessed at the final visit. Results: In the 668 patients included in the full analysis set, there were significant (p< 0.0001) reductions in mean pain and pain-related sleep interference scores of 4.16 and 4.02, respectively. Indicators of general well-being showed improvement from baseline to final visit. The majority of patients were rated as ‘much improved’ (43.7% and 36.7%) or ‘very much improved’ (24.0% and 26.2%) on CGIC and PGIC scores, respectively. Discontinuation because of lack of efficacy occurred in 0.7% of 691 patients in the safety analysis set while discontinuation because of adverse events occurred in 5.1% of this population; 76.4% continued treatment after the study ended. Conclusion: Significant reductions in pain and pain-related sleep interference, combined with reductions in feelings of anxiety and depression, suggest that pregabalin under real-world conditions improves the overall health and well-being of patients with neuropathic pain.

Percutaneous Nephrolithotomy Under a Multimodal Analgesia Regime

OBJECTIVES To evaluate the possibility of performing percutaneous nephrolithotomy (PCNL) under a multimodal analgesia regime. PATIENTS AND METHODS During a period of 3 years, 51 patients requiring PCNL were enrolled in the study. All patients received a multimodal analgesic regime that included paracetamol, a COX(2) inhibitor, epidural morphine, and infiltration of the surgical field with local anesthetics. Percutaneous renal tract access was created with ultrasound guidance. All patients were informed about the possibility of experiencing short periods of discomfort or pain, and all patients completed a visual analog pain scale questionnaire postoperatively. RESULTS All 51 patients completed the study, and the procedure was well tolerated. Intraoperative problems or postoperative complications were attributed mainly to the procedure itself (PCNL) rather than to the analgesic regimen administered. We observed no morphine-related side effects. Patients were transferred directly back to the ward immediately after the operation. The use of analgesics postoperatively was minimal. CONCLUSIONS The use of our multimodal analgesia regime is a well-tolerated and safe alternative to general or regional anesthesia for patients undergoing PCNL.

Laparoscopic ventral hernia repair under spinal anesthesia: a feasibility study

BACKGROUND Regional anesthesia has not been used as the sole anesthetic procedure in laparoscopic ventral hernia repair due to the fear of potential adverse effects of the pneumoperitoneum. However, there are recent reports on the feasibility of performing laparoscopic procedures, such as cholecystectomy, in fit patients, under spinal anesthesia alone. The current study aimed to detect the feasibility of performing laparoscopic ventral hernia repair under spinal anesthesia. METHODS Twenty-five American Society of Anesthesiologists (ASA) I or II patients underwent laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum under spinal anesthesia. In 9 cases the hernia was umbilical/para-umbilical, in 5 cases epigastric, and in 11 cases incisional. Intraoperative incidents, complications, postoperative pain, and recovery in general, as well as patient satisfaction at follow-up examination, were prospectively recorded. RESULTS All operations were completed laparoscopically and conversion from spinal to general anesthesia was not required in any of the cases. Median pain score at 4 hours postoperatively was .5 (range 0-5), at 8 hours 1.5 (range 0-6), and at 24 hours 1.5 (range 0-4). Most patients were discharged 24 hours after the operation; the median hospital stay was 1 day (range 1-3 days). At 2-weeks follow-up, no late complications were detected and all patients reported being satisfied with the anesthetic procedure. CONCLUSION Laparoscopic ventral hernia repair with low-pressure CO2 pneumoperitoneum can be successfully and safely performed under spinal anesthesia. Furthermore, it seems that spinal anesthesia is associated with minimal postoperative pain and smooth recovery.

Deep anaesthesia reduces postoperative analgesic requirements after major urological procedures.

Background and objective There is evidence from previous studies that deeper anaesthetic levels reduce postoperative pain along with analgesic requirements. The aim of this study was to confirm this observation during major urological procedures under sevoflurane anaesthesia. Methods Seventy ASA I or II patients undergoing radical prostatectomy or nephrectomy were randomly allocated into two groups: the L-BIS group with BIS (bispectral index scale) values kept within a range of 20–30 and the H-BIS group with values within the range of 50–60. Sevoflurane was the main anaesthetic agent used, along with inhalation of nitrous oxide and continuous remifentanil infusion. Postoperative analgesia was achieved mainly through morphine and ketamine, which was continuously infused by pump, and intravenous parecoxib. Additional analgesics (paracetamol, parecoxib and morphine) were administered in persistent (continuous, lasting longer than predicted and requiring repeated doses of analgesics) postoperative pain. The number of patients who demanded additional analgesia during the first 24 h was recorded, as well as the number of administrations performed, along with visual analogue scale (VAS) scores at 8 and 24 h. Results Sixty patients completed the study, 30 in each group. VAS scores at 8 h were significantly higher in the H-BIS group, both at rest [1 (0–4) vs. 2 (0–8), P = 0.036] and on cough [1 (0–5) vs. 2 (2–9), P = 0.021], but at 24 h were similar between the two groups. Four patients in the L-BIS group and 17 patients in the H-BIS group demanded additional analgesia (P < 0.0009), although the patients in the L-BIS group needed significantly fewer additional doses of analgesics than those in the H-BIS group [0 (0–2) vs. 1 (0–5), P < 0.0008]. Conclusion The results show that intraoperative deep anaesthetic levels during major urological procedures, achieved with high sevoflurane concentrations, lead to reduced postoperative analgesic requirements.

Dose-related shortening of ventricular tachycardia cycle length after administration of the KATP channel opener bimakalim in a 4-day-old chronic infarct anesthetized pig model.

Potassium channel openers are known to act on potassium ATP-dependent channels in cardiac tissue. Such agents may exacerbate acceleration of acute ischemia-induced ventricular repolarization and aggravate arrhythmias. To test whether activation of K ATP channels during the healing period of myocardial infarction (MI) can still influence the electrophysiologic properties and the type of inducible arrhythmias, we investigated the effects of bimakalim (BIM) on sustained ventricular tachycardia (VT) 4 days after ligation of the left anterior descending (LAD) coronary artery in pigs. Programmed stimulation was performed to elicit VT prior to and after intravenous (IV) BIM. Combination monophasic action potential (MAP)/PACING catheters were used to enable simultaneous ventricular MAP recording and pacing. Ventricular effective refractory period (ERP) and MAP duration determined at 50% and 90% repolarization were measured prior to and after BIM. After completion of baseline measurements, BIM was consecutively given at 0.5, 1, and 3 mg/kg bolus followed by 0.025, 0.05, and 0.1 mg/kg per minute maintenance infusion, respectively. From a total of 23 pigs subjected to LAD ligation, 4 animals succumbed to infarction and the remaining 19 animals were studied by programmed stimulation. Only animals that exhibited reproducible and hemodynamically stable monomorphic VTs during control stimulation were selected for evaluation (n = 14). After the first, second, and third dose of BIM, the mean VT rate was increased by 6%, 14% (P <. 01), and 47% (P < .001) compared to control values, respectively. Ventricular ERP and repolarization were significantly shortened only by the second and third dose of BIM. Of 14 pigs receiving the highest BIM dosage, 3 revealed polymorphic VTs degenerating into ventricular fibrillation (VF). Our data suggest that high BIM doses may lead to faster and more aggressive pacing-induced reentrant VTs after subacute MI. This is consistent with the drug-induced acceleration of ventricular repolarization with shortening of MAP duration and refractoriness.

Assessment of local atrial repolarization in a porcine acetylcholine model of atrial flutter and fibrillation.

Objectives — Progressive electrical alternans followed by conduction block and fibrillatory conduction have been suggested to precede disorganization of atrial flutter (Afl) to atrial fibrillation (AF). The purpose of the present study was to investigate patterns of local repolarization in the high and low right atrium to determine the site with pronounced propensity to action potential disorganization during Afl and AF. Methods — Combination pacing/recording contact monophasic action potential (MAP) catheters were utilized to evaluate repolarization from the upper and low atrial endocardium in 16 pigs.To induce sustained atrial flutter (Afl) or fibrillation (AF), programmed atrial stimulation was carried out prior to and during intravenous acetylcholine (ACh) infusion at a dosage rate of 2.7 mg/min. Atrial repolarization was measured at 30, 50, and 90% of total MAP duration. Results — Two main types of atrial MAPs were distinguished: MAPs originated from high atrial regions showing a prominent notch and longer duration and MAPs recorded from the lower atrium displaying a much slower slope of phase 1 repolarization and shorter duration. Control stimulation did not elicit any significant atrial tachyarrhythmias. After ACh all animals developed reproducibly induced sustained and non-sustained whole Afl or AF during programmed stimulation. A total of 40 sustained arrhythmia episodes were selected for evaluation: fourteen episodes of primary AF and 26 episodes of Afl.Whole Afl and AF in all animals were associated with MAPs of almost regular morphology in lower parts of atrium and disorganized activation in higher atrial regions. ACh significantly reduced (P < 0.001) both high and low atrial effective refractory periods as well as MAP duration determined at 30, 50, and 90% repolarization. Conclusions — ACh facilitated the induction of Afl more than AF in this experimental model. MAPs recorded from high atrial regions revealed discordant repolarization during Afl or AF, whereas low atrial MAPs maintained their baseline regular morphology.These findings may help expand knowledge about mechanisms underlying instability and perpetuation of these arrhythmias

‘Single Puncture’ Mini-Percutaneous Nephrolithotomy under Assisted Local Anesthesia

Objective: To evaluate the possibility of performing minipercutaneous nephrolithotomy (mini-PCNL) under assisted local anesthesia in a selected group of patients. Patients and Methods: Twenty-one patients with unilateral renal obstruction requiring mini-PCNL were enrolled in the study. Prior to surgery, all patients received: a) paracetamol 1.2 g intravenous (i.v.); b) parecoxib (COX2 inhibitor) 40 mg i.v., and c) infiltration of the surgical field with local anesthetic (20 ml of 1% lidocaine). Prior to the dilatation, all patients received midazolam 2 mg i.v. and fentanyl 100 mg i.v. Percutaneous renal tract access was created with ultrasound guidance. All patients were informed of the possibility of experiencing short periods of discomfort or pain, and all patients completed a postoperative visual analogue pain scale questionnaire. Results: All 21 patients completed the study, and the procedure was well-tolerated. Only three patients complained of mild pain and received additional fentanyl. Intraoperative problems and postoperative complications were mainly attributed to the mini-PCNL procedure itself rather than to the analgesic regimen administered. No complications related to the modality of anesthesia were encountered. The mean visual analogue pain scale score at the end of the procedure was 2.9 ± 0.9. Patients were directly transferred back to the ward immediately after the operation. Conclusions: Our study indicates that mini-PCNL can be performed safely and effectively under assisted local anesthesia in a selected group of patients.