H. Misiolek

Sensory blockade after thoracic paravertebral injection of ropivacaine or bupivacaine.

Background and objective: No clinical trials comparing the characteristics of sensory blockade caused by various local anaesthetics in thoracic paravertebral blockade have been published. The aim of this prospective study was a clinical assessment of sensory blockade after paravertebral injection of ropivacaine or bupivacaine in patients undergoing modified radical mastectomy. Methods: Seventy ASA I–II patients were randomized to receive a single injection of ropivacaine 0.5% (n = 35) or bupivacaine 0.5% (n = 35) at the T4 level. General anaesthesia with propofol and fentanyl was provided during the procedure and patients were not intubated. The following parameters were analysed: duration and dynamics of the sensory blockade and the patients and surgeons assessment. Results: Both ropivacaine and bupivacaine provided a similar level of analgesia. Ropivacaine was characterized by more rapid onset – after only 5 min 53% of patients in this group had the extent of sensory blockade wide enough to perform modified radical mastectomy in comparison to only 20% after bupivacaine (P < 0.01). The initial spread of sensory blockade (>9 segments blocked) was noted more often in the ropivacaine group (88% vs. 65%, P < 0.05), lasted longer and appeared to be wider than sensory blockade produced by bupivacaine. Regression of sensory blockade was initially similar, but after 24 h sensory blockade in the ropivacaine group still had a potential to provide analgesia for modified radical mastectomy in 81% of patients in comparison to only 50% of such patients in the bupivacaine group (P < 0.05). Degree of postoperative pain, performance of the cardiovascular system, consumption of medications and complications were all similar between the study groups. Conclusions: Both agents provide satisfactory conditions for mastectomy, but ropivacaine seems to be superior to bupivacaine for thoracic paravertebral blockade during breast cancer surgery.

Comparison of double-lung jet ventilation and one-lung ventilation for thoracotomy.

Background and objective: Thoracic surgery requires immobilization of the operating area. Usually, this is achieved with one‐lung ventilation (OLV), however this may still lead to some movement. High‐frequency jet ventilation (HFJV) may be an alternative way of ventilation in thoracic surgery. The purpose of this study was to determine the effectiveness of HFJV as an alternative option to OLV for thoracic procedures. Methods: Sixty patients were randomized to receive either HFJV (n = 29) or OLV (n = 31) during the operation. During the course of the study 10 patients were excluded (4 patients in HFJV group and 6 patients in OLV group). The following haemodynamic and ventilatory parameters were recorded: heart rate, systolic and mean blood pressure, ventricular stroke volume, cardiac index, systemic vascular resistance, peak inspiratory pressure, oxygen saturation, PaO2 and PaCO2. Overall parameters were documented before the initiation of the chosen mode of ventilation every 15 min during the operation. Results: Patients in both groups showed comparable cardiovascular function. Mean values of peak inspiratory pressure were significantly higher in the OLV group. Oxygen saturation values were statistically higher in the HFJV group. PaCO2 values were similar in both during surgery, but were higher in the OLV group after awakening. Mean values of shunt fraction were lower in the HFJV group. Lower values of peak inspiratory pressure were therefore associated with higher partial pressure of carbon dioxide levels in the HFJV group. In the OLV group, 44% of patients experienced a postoperative sore throat. Operating conditions were comparable. Conclusion: HFJV is safe option, comparable to OLV and offers some advantages for open‐chest thoracic procedures.

Epidural and opioid analgesia following the Nuss procedure

Summary Background Parents have the right to decide on behalf of their children and deny consent to regional anaesthesia. The investigators decided to investigate quality of postoperative analgesia in adolescents undergoing epidural and opioid analgesia following the Nuss procedure. Material/Methods The study subjects were 61 adolescents aged 11–18 years who underwent pectus excavatum repair with the Nuss procedure. Patients were divided into epidural (n=41) and opioid (n=20) groups, depending on their parents’ consent to epidural catheter insertion. Intraoperatively, 0.5% epidural ropivacaine with fentanyl or intermittent intravenous injections of fentanyl were used. Postoperative analgesia was achieved with either epidural infusion of 0.1% ropivacaine with fentanyl, or subcutaneous morphine via an intraoperatively inserted “butterfly” cannula. Additionally, both groups received metamizol and paracetamol. Primary outcome variables were postoperative pain scores (Numeric Rating Scale and Prince Henry Hospital Pain Score). Secondary outcome variables included hemodynamic parameters, additional analgesia and side effects. Results Heart rate and blood pressure values in the postoperative period were significantly higher in the opioid group. Pain scores requiring intervention were noted almost exclusively in the opioid group. Conclusions Denial of parental consent to epidural analgesia following the Nuss procedure results in significantly worse control of postoperative pain. Our data may be useful when discussing with parents the available anaesthetic techniques for exceptionally painful procedures.

A comparison of selective and conventional spinal anaesthesia for ambulatory surgery

BACKGROUNDnSelective spinal anaesthesia is the practice of employing minimal doses of intrathecal agents so that only the nerve roots supplying a specific area and only the modalities that require to be anaesthetised are affected. The study is based on the hypothesis that small dose lidocaine spinal anaesthesia may be adequate for elective surgical procedures, providing limited motor and sensory block, and thus enabling earlier patients discharge. The aim of this study was the comparison of the low and the conventional dose of lidocaine spinal anaesthesia discharge time.nnnMETHODSnThe study was a prospective, randomized controlled single-blind trial, with 84 patients enrolled. Patients in study group (SS-L, Selective Spinal Lidocaine) were administered 3 mL of a 0.8% lidocaine solution containing 24 mg of lidocaine and 15 μg of fentanyl for spinal anaesthesia. Patients in the control group (CD-L, Conventional Dose Lidocaine) received 5 mL of a 1% lidocaine solution containing 50 mg of lidocaine and 25 μg of fentanyl for spinal anaesthesia. Discharge time was evaluated.nnnRESULTSnIn the SS-L group time to discharge were shorter (P < 0.01) compared to the CD-L group.nnnCONCLUSIONnSelective spinal anaesthesia with low dose of lidocaine decreases the time of patient discharge compared with conventional lidocaine dose spinal anaesthesia.

Choosing the optimal method of anesthesia in anterior resection of the rectum procedures – the assessment of the stress reaction based on selected hormonal parameters

INTRODUCTIONnThe aim of this study was to compare hormonal stress responses (changes in adrenaline, noradrenaline, and cortisol concentrations) to surgical injury during total intravenous propofol anaesthesia and volatile anaesthesia with sevoflurane in patients subjected to anterior resection of the rectum.nnnMATERIAL AND METHODSnThe prospective randomised study included 61 patients qualified for anterior resection of the rectum. The subjects were randomised into two groups, based on the type of anaesthesia: 1) Group I (TIVA, n = 31), administered total intravenous propofol anaesthesia, and 2) Group II (VIMA, n = 30), administered volatile induction and maintenance sevoflurane anaesthesia. Serum concentra-tions of adrenaline, noradrenaline, and cortisol were determined prior to surgery, during assessment of abdominal cavity, after resection of the rectum, and 30 min and one day post-surgery.nnnRESULTSnThe two groups did not differ significantly in terms of their haemodynamic parameters: heart rate and arterial blood pressure. Compared to individuals subjected to TIVA, patients from the VIMA group presented with significantly higher concentrations of adrenaline during evaluation of the abdominal organs. No significant intergroup differences were found in terms of intra- and postoperative serum concentrations of noradrenaline and cortisol.nnnCONCLUSIONSnTIVA and VIMA induce similar hormonal stress responses during anterior resection of the rectum. The increase in serum adrenaline concentration during evaluation of the abdominal organs in the VIMA group implies that the dose of sevoflurane should be escalated at this time point.

Assessment of changes of regional ventilation distribution in the lung tissue depending on the driving pressure applied during high frequency jet ventilation

BackgroundElectrical impedance tomography (EIT) is a tool to monitor regional ventilation distribution in patient’s lungs under general anesthesia. The objective of this study was to assess the regional ventilation distribution using different driving pressures (DP) during high frequency jet ventilation (HFJV).MethodsProspective, observational, cross-over study. Patients undergoing rigid bronchoscopy were ventilated HFJV with DP 1.5 and 2.5xa0atm. Hemodynamic and ventilation parameters, as well as ventilation in different regions of the lungs in percentage of total ventilation, assessed by EIT, were recorded.ResultsThirty-six patients scheduled for elective rigid bronchoscopy. The final analysis included thirty patients. There was no significant difference in systolic, diastolic and mean arterial blood pressure, heart rate, and peripheral saturation between the two groups. Peak inspiratory pressure, mean inspiratory pressure, tidal volume, and minute volume significantly increased in the second, compared to the first intervention group. Furthermore, there were no statistically significant differences between each time profiles in all ROI regions in EIT.ConclusionsIn our study intraoperative EIT was an effective method of functional monitoring of the lungs during HFJV for rigid bronchoscopy procedure. Lower driving pressure was as effective in providing sufficient ventilation distribution through the lungs as the higher driving pressure but characterized by lower airway pressure.Trial registrationThe study was registered on ClinicalTrials.gov under no. NCT02997072.

Improvement of quality of life after therapeutic plasma exchange in patients with myasthenic crisis.

INTRODUCTIONnWe sought to evaluate quality of life patients with myasthenic crisis before and after therapeutic plasma exchange.nnnMATERIALS AND METHODSnIn our study we conducted an assessment of the quality of life with the use of the questionnaire SF-36, when executed eleven therapeutic plasma exchange. The assessment was made on baseline and after 4 weeks. We also did neurological clinical evaluation before and after TPE.nnnRESULTSnPatients in the study showed significant improvement in quality of life after performed therapeutic plasma exchange. The changes were observed in physical functioning, which confirmed the results of the statistical significance of p<0.05. In the analysis, the assessment of mental functioning not obtained the results of statistical significance, but the results also showed improvement in self-assessment. We observed high correlation between general health and physical mental functioning, between the role limitations due to physical health problems and role limitations due to emotional problems, and general health perception and bodily pain.nnnCONCLUSIONSnTherapeutic plasma exchange significantly improves the quality of life of patients with myasthenia gravis during the crisis.

Cochlear Function Monitoring after Spinal Anesthesia.

Background The aim of the study was to examine the effect of spinal anesthesia on the function of cochlear outer hair cells (OHCs), determined by means of objective distortion product otoacoustic emissions (DPOAE) testing. To the best of our knowledge, our study was the second OAE-based analysis of cochlear function during spinal anesthesia, and the only experiment including such a large group of patients. Material/Methods The study included 20 patients (18 men and 2 women) subjected to a scheduled uretherorenoscopic lithotripsy with routine spinal anesthesia with 10 mg (2 ml) of 0.5% hyperbaric bupivacaine and 50 μg (1 ml) of fentanyl. The levels of DPOAEs and background noise at 1000–6000 Hz were recorded prior to and immediately after the anesthesia, and on the postoperative day 2. Results We did not find significant differences between DPOAEs values recorded prior to and immediately after the anesthesia. The only exception pertained to 5652 Hz, at which a significantly higher level of DPOAEs was observed immediately after the anesthesia. The levels of DPOAEs at 2002 Hz and 2380 Hz collected on the postoperative day 2 were significantly higher than the respective baseline values. Irrespective of the frequency and time of testing, we did not find any significant differences between the recorded levels of background noise. Conclusions Our findings point to the lack of a detrimental effect of spinal anesthesia on objectively evaluated cochlear function, and thus suggest that this method is safe, even for OHCs, which are extremely susceptible to exogenous and endogenous injuries.

Possibilities of surgical correction of vocal cord palsy after thyroid gland operations

INTRODUCTIONnSurgery of the thyroid gland remains the main cause of bilateral vocal cord palsy (VCP). Ventilation problem is the main problem in such situations. There are a couple of corrective surgical procedures in the case of VCP. The aim of our study was to show the possibility of widening of the glottis, and to evaluate the techniques and effects of surgical treatments due to bilateral VCP resulting from thyroid gland surgery.nnnMATERIAL AND METHODSnFive methods of surgical treatment were used: laser-assisted posterior cordectomy, according to Denis and Kashima; laser-assisted bilateral medial arytenoidectomy, as proposed by Crumley; laser-assisted posterior ventriculocordectomy, as described by Pia; laser-assisted total arytenoidectomy with posterior cordectomy, as presented by Ossoff; and laterofixation, according to Lichtenberger. The postoperative patients subjective improvement was assessed using visual analogue scale.nnnRESULTSnBetween 1998 and 2014 we operated on 270 patients with bilateral VCP. Paresis occurred as the result of the iatrogenic effect of thyroid gland surgery in 255 patients (94.4%) vs. 15 (7.6%) from other causes. The majority of our patients (77.6%) had undergone laser arytenoidectomy with posterior partial cordectomy, and in 13.7% of them Lichtenberger laterofixation had been performed. Ossoff s surgery gives good ventilation results: successful decannulation (62.9% after first surgery; 97.6% final rate) and significant subjective ventilation improvement in 96% of patients.nnnCONCLUSIONSnOssoff s laser arytenoidectomy with posterior cordectomy is a safe procedure that gives acceptable ventilation improvement. Patients report satisfactory quality of life and the possibility of returning to active professional life. Laterofixation should be considered as an alternative for tracheotomy rather than permanent procedure.

Haemodynamics, gas exchange and surgical conditions during bilateral high frequency jet ventilation in lung surgery: A-285

Haemodynamics, gas exchange and surgical conditions during bilateral high frequency jet ventilation in lung surgery H. Misiolek1, P. Knapik1, H. Kucia1, J. Karpe1, M. Campbell2 1Department of Clinical Anaesthesia, Silesian University of Medicine; 2Students Research Team of Silesian University of Medicine, Zabrze, Poland Background and Goal: Bilateral high frequency jet ventilation (HFJV) applied to conventional endotracheal tube may be an attractive alternative to the usage of double lumen endotracheal tube and one lung ventilation (OLV) for major thoracic procedure. The aim of present study was to compare haemodynamics, oxygenation and surgical conditions during bilateral HFJV and OLV during anaesthesia for lung surgery. Material and Method: 56 patients were randomly allocated to receive either HFJV (n 28) or OLV (n 28) during major thoracic procedures. All patients were anaesthetized with TCI propofol. Muscle relaxation was achieved with rocuronium and analgesia was provided with continuous epidural infusion of 0.5% ropivacaine with fentanyl. Transoesophageal probe for non-invasive cardiac output measurements was inserted after induction of anaesthesia. Arterial and central venous blood samples for gas analysis were taken before induction of anaesthesia (0), prior to the start of the studied mode of ventilation (I), and then every 30 min during HFJV or OLV. Haemodynamic parameters were recorded at baseline (I) and every 15 min during HFJV or OLV. Measurements were taken for 120 minutes. ANOVA or Mann-Whitney tests were used when appropriate and p 0.05 was considered significant. Results: Patients in study groups were comparable. Arterial oxygen saturation and systemic vascular resistance values were significantly higher in HFJV group. Peak inspiratory pressures and shunt fraction were significantly higher in OLV group. No differences in blood pressure, heart rate, stroke volume, cardiac index and PaCO2 values were recorded. Surgeons have found comparable and satisfactory operational conditions in both groups. Conclusions: Bilateral HFJV is superior to OLV regarding both gas exchange and ventilation-perfusion ratio. This mode of ventilation may be an attractive alternative to OLV for major thoracic procedures. Reference: 1 Ihra G, et al. Eur J Anaesthesiol 2000; 17: 418–430.