Ivana Budic

The effects of different anesthesia techniques on free radical production after tourniquet-induced ischemia-reperfusion injury at children's age.

BACKGROUND/AIM Reperfusion of previously ischemic tissue leads to injuries mediated by reactive oxygen species. The aim of the study was to investigate the effects of different anesthesia techniques on oxidative stress caused by tourniquet-induced ischemia-reperfusion (IR) injury during extremity operations at childrens age. METHODS The study included 45 patients American Society of Anesthesiologists (ASA) classification I or II, 8 to 17 years of age, undergoing orthopedic procedures that required bloodless limb surgery. The children were randomized into three groups of 15 patients each: general inhalational anesthesia with sevoflurane (group S), total intravenous anesthesia with propofol (group T) and regional anesthesia (group R). Venous blood samples were obtained at four time points: before peripheral nerve block and induction of general anesthesia (baseline), 1 min before tourniquet release (BTR), 5 and 20 min after tourniquet release (ATR). Postischemic reperfusion injury was estimated by measurement of concentration of malondialdehyde (MDA) in plasma and erythrocytes as well as catalase (CAT) activity. RESULTS Plasma MDA concentration in the group S was significantly higher at 20 min ATR in comparison with the groups T and R (6.78 +/- 0.33 micromolL-1(-1) vs. 4.07 +/- 1.53 and 3.22 +/- 0.9. micromolL-1(-1), respectively). There was a significant difference in MDA concentration in erytrocythes between the groups S and T after 5 min of reperfusion (5.88 +/- 0.88 vs. 4.27 +/- 1.04 nmol/mlEr, p < 0.05). Although not statistically significant, CAT activity was slightly increased as compared to baseline in both groups S and R. In the group T, CAT activity decreased at all time points when compared with baseline, but the observed decrease was only statistically significant at BTR (34.70 +/- 9.27 vs. 39.69 +/- 12.91 UL-1, p < 0.05). CONCLUSION Continuous propofol infusion and regional anesthesia techniques attenuate lipid peroxidation and IR injury connected with tourniquet application in pediatric extremity surgery.

Intraoperative use of hydroxyethyl starch 130/0.4 in neonates

ation of DMD and true MH is available and describe alternative pathophysiological mechanisms for these ‘MHlike’ reactions during anaesthesia in DMD patients. They group these reactions into three categories based on clinical presentation. We like to comment on two of them. In the first group they reviewed reports between 1970 and 2005 of 13 patients with Duchenne or Becker muscular dystrophy who had sudden hyperkalemic cardiac arrest without hypermetabolism during or after anesthesia using volatile agents without succinylcholine. We realize how difficult it is to analyse the information (presented or unavailable) from these sometimes anecdotal case reports, and we would also like to emphasize that the lack of specific clinical signs or symptoms is the main reason for the limited use of the MH Clinical Grading Scale (3). It is well-known, as the authors state, that patients with Duchenne or Becker muscular dystrophy are susceptible to perioperative respiratory and cardiac complications. with or without ‘triggering’ anesthetics. However, it is not clear from the review whether these children had preexisting cardiomyopathy, nor what concentrations of volatile anesthetics were used. Furthermore, two case reports describe intraoperative cardiac arrest In DMD children during spinal surgery under propofol-sufentanyl anesthesia without succinylcholine or volatile anesthetics (4,5). The third group comprises six patients with postoperative rhabdomyolysis without cardiac signs or symptoms. Most patients with DMD have already greatly increased creatine kinase levels preoperatively possibly as the hallmark symptom of ongoing rhabdomyolysis. These levels may increase during surgery proportionally with the duration of surgery and other factors (positioning, obesity etc.). So, in our view it is not reasonable to blame only volatile anesthetics for the rhabdomyolysis. Fortunately, the authors recommend the use of volatile anesthetics for short periods when a total intravenous technique is not an option e.g. for difficult airway management. However, the authors fail to mention a specific agent for such a TIVA technique. Propofol has been regularly proposed as an alternative anesthetic for patients with DMD and other myopathies although this drug is well known to trigger rhabdomyolysis and MH-like reactions in susceptible patients (6). Shouldn’t the conclusion of the review better be that DMD patients are prone to develop serious problems during surgery and anesthesia irrespective of the type of anesthetic agents used? We belief this topic deserves special attention in an international working group. Jacques Driessen* Marc Snoeck† *Department of Anesthesiology, Radboud University, Nijmegen, the Netherlands †MH investigation unit, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands (email: JJ.Driessen@anes.umcn.nl) References

A Comparison of Three Different Volumes of Levobupivacaine for Caudal Block in Children Undergoing Orchidopexy and Inguinal Hernia Repair

Objective: The aim of this study was to compare the efficacy of 3 different volumes of 0.25% levobupivacaine caudally administered on the effect of intra- and postoperative analgesia in children undergoing orchidopexy and inguinal hernia repair. Subjects and Methods: Forty children, aged 1-7 years, American Society of Anesthesiologists (ASA) physical status I and II, were randomized into 3 different groups according to the applied volumes of 0.25% levobupivacaine: group 1 (n = 13): 0.6 mL∙kg-1; group 2 (n = 10): 0.8 mL∙kg-1; and group 3 (n = 17): 1.0 mL∙kg-1. The age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were compared among the groups. The time to first use of the analgesic and the number of patients who required analgesic 24 h after surgery in the time intervals within 6 h, between 6 and 12 h, and between 12 and 24 h postoperatively were evaluated among the groups. Statistical analyses were performed with a Dunnett t test, ANOVA, or Kruskal-Wallis test and χ2 test. Logistic regression analysis was used in order to examine predictive factors on duration of postoperative analgesia. Results: Age, weight, duration of anesthesia, onset time of intraoperative analgesic, dosage, and addition of intraoperative fentanyl were similar among the groups. The time to first analgesic use did not differ among the groups, and logistic regression modelling showed that using the 3 different volumes of levobupivacaine had no predictive influence on duration of postoperative analgesia. The numbers of patients who required analgesics within 6 h (3/2/3), between 6 and 12 h (3/1/3), and between 12 and 24 h (1/0/2) after surgery were similar among the groups. Conclusion: The 3 different volumes of 0.25% levobupivacaine provided the same quality of intra- and postoperative pain relief in pediatric patients undergoing orchidopexy and inguinal hernia repair.

INITIAL EXPERIENCES IN TREATMENT OF GASTROINTESTINAL FOREIGN BODIES IN CHILDREN

We performed a retrospective analysis of all records of children with ingested foreign bodies presented to Clinical Center of Nis Pediatric Clinic and Pediatric Surgery and Orthopedics Clinic in the period from January 2014 to June 2017. The most commonly detected foreign bodies were: metal coins (7) followed by hairclips (2), metal key (1), trichobezoar (1) magnets (1) button battery (1) and zipper puller (1). Regarding anatomical location, foreign bodies were most frequently found in stomach (in 11 patients) followed by esophagus (in 2 patients) and jejunum (in 1 patient). In the majority of our patients (7) foreign bodies passed out of gastrointestinal tract spontaneously. Endoscopic foreign body removal was performed in 5 cases while surgery as a sole therapeutic action was done in 1 patient. In one child multiple magnets were removed from the stomach performing both endoscopic and surgical interventions. Teamwork of a gastroenterologist and a surgeon is crucial for optimizing therapeutic options for each individual patient. Public awareness of this problem and education of parents should be increased to a higher level in order to prevent cases of foreign bodies ingestion in children.

MEDICAL SIMULATION: MORAL AND ETHICAL ISSUES

Medical simulation is now widespread as an integral part of medical education. Simulation begins with an important moral claim: we must do the best we can to keep patients safe while training the next generation of clinicians and retraining current clinicians so that they are kept up-to-date. As a powerful teaching tool, simulation allows practicing communication, decision-making, practical skills and leadership as well as evaluation which can be standardized and poses no risk to patients associated with experiential learning conducted in the actual clinical setting. It is also the fact that simulation raises ethical questions of its own. That training is not simply technical. It is also a way to learn and practice dealing with the emotional challenges of real-life ethical situations. Simulation also provides a safe zone for students to make practical skills and communication mistakes and to develop moral imagination. Despite the growing acceptance of clinical simulation to enhance quality and safety in medical education, the question of whether students actually acquire and transfer the ethical principles that takes place in a simulation setting is unknown. Acta Medica Medianae 2018;57(1):64-69.

Management of Anesthesia in a Child with a Large Neck Rhabdoid Tumor.

Objective: The aim of this paper was to report the management of anesthesia of a child with a large neck rhabdoid tumor. Clinical Presentation and Intervention: A 9-month- old female patient underwent urgent neck tumor excision due to intratumoral bleeding from a large tumor that compressed and dislocated the trachea; therefore, intubation was expected to be difficult. Sevoflurane inhalation induction was utilized to maintain spontaneous respiration. Oral laryngoscopy revealed Cormack-Lehane grade 3 laryngeal view. The trachea was intubated using a reinforced tube on the third attempt. Fiberoptic bronchoscope-assisted intubation was planned as an alternative in case of conventional intubation failure. Anticipation of massive blood loss necessitated central venous catheterization. Conclusion: Establishing a safe airway, intubation during spontaneous breathing and invasive hemodynamic monitoring are crucial factors in the anesthetic management of pediatric patients with a large neck tumor.