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Anesthetic considerations for robotic cystectomy: a prospective study.

BACKGROUND AND OBJECTIVES Robotic cystectomy is rapidly becoming a part of the standard surgical repertoire for the treatment of prostate cancer. Our aim was to describe respiratory and hemodynamic challenges and the complications observed in robotic cystectomy patients. PATIENTS Sixteen patients who underwent robotic surgery between December 2009 and January 2011 were prospectively enrolled. Main outcome measures were non-invasive monitoring, invasive monitoring and blood gas analysis performed at supine (T0), Trendelenburg (T1), Trendelenburg+pneumoperitoneum (T2), Trendelenburg-before desufflation (T3), Trendelenburg (after desufflation) (T4), and supine (T5) positions. RESULTS There were significant differences between T0-T1 and T0-T2 with lower heart rates. The mean arterial pressure value at T1 was significantly lower than T0. The central venous pressure value was significantly higher at T1, T2, T3, and T4 than at T0. There was no significant difference in the PET-CO2 value at any time point compared with T0. There were no significant differences in respiratory rate at any time point compared with T0. The mean f values at T3, T4, and T5 were significantly higher than T0. The mean minute ventilation at T4 and T5 were significantly higher than at T0. The mean plateau pressures and peak pressures at T1, T2, T3, T4, and T5 were significantly higher than the mean value at T0. CONCLUSIONS Although the majority of patients generally tolerate robotic cystectomy well and appreciate the benefits, anesthesiologists must consider the changes in the cardiopulmonary system that occur when patients are placed in Trendelenburg position, and when pneumoperitoneum is created.

Transversus abdominis plane block as a component of multimodal analgesia for laparoscopic cholecystectomy

OBJECTIVE To evaluate and compare intercostal-iliac transversus abdominis plane (TAP) and oblique subcostal TAP (OSTAP) blocks for multimodal analgesia in patients receiving laparoscopic cholecystectomy. DESIGN A prospective, randomized, double-blinded clinical study. SETTING Operating room, postoperative recovery area, and ward. PATIENTS In total, 60 laparoscopic cholecystectomy patients (43 women, 17 men, American Society of Anesthesiologists grades I-II) were enrolled from the general surgery department of our tertiary care center. INTERVENTION The patients were assigned to 1 of the 3 groups. Group 1 received TAP blocks (n=20), group 2 received OSTAP blocks (n=20), and group 3 patients were used as controls and received patient-controlled analgesia (PCA) only (n=20). After the induction of anesthesia, blocks were performed bilaterally in study groups 1 and 2, using 20mL of lidocaine (5mg/mL). PCA with intravenous tramadol was routinely provided for all patients during the first 24hours. MEASUREMENTS The intraoperative use of remifentanil, postoperative visual analog scale (VAS) scores, demand for PCA, and total analgesic consumption were recorded. MAIN RESULTS The patients in the control group had greater analgesic demands and analgesic consumption than did those in groups 1 and 2. However, patients in the OSTAP group had lower VAS scores than did those in groups 1 and 3. RESULTS The demand for analgesia was greater in the control group than in groups 1 and 2. Moreover, lower VAS scores were recorded in the OSTAP group than in groups 1 and 3 and were positively correlated with total PCA consumption among all patients. However, postoperative VAS scores were negatively correlated with the total intraoperative consumption of remifentanil at 24hours. CONCLUSIONS TAP and OSTAP blocks improved postoperative analgesia in patients receiving laparoscopic cholecystectomy, which resulted in lower VAS scores and reduction in total analgesic consumption.

The effect of ondansetron on analgesic efficacy of acetaminophen after hysterectomy: A randomized double blinded placebo controlled trial

OBJECTIVES To determine that perioperative ondansetron reduces the analgesic efficacy of acetaminophen. DESIGN Randomized, double-blinded study. PATIENTS 120 patients ASA I-II who underwent abdominal hysterectomy. INTERVENTIONS All the patients were given 1g acetaminophen at skin closure. Patients were divided into two groups; ondansetron HCl (8mg, 2ml IV) (Group I, N=60) and saline (2ml IV) (Group II, N=60) at the skin closure. MEASUREMENT Postoperative pain scores (VAS) while resting in bed and sitting, total opioid consumption were noted. MAIN RESULTS Patients randomized to ondansetron had significantly worse pain scores upon arrival to the recovery unit [by 1.7 (99.7% CI: 0.75, 2.59) cm] and at 1h [by 1.3 (0.5, 2.1) cm] while resting in bed. Pain scores while sitting were also significantly greater in ondansetron group at arrival in PACU by 0.6 (99.7% CI: 0.1, 1.0) cm. Thereafter, pain scores did not differ significantly. Median total opioid (tramadol) consumption was 441 [Q1, Q3: 280, 578] mg in the ondansetron group and 412 [309, 574] mg in the placebo group, P=0.95. CONCLUSIONS Ondansetron significantly decreased the analgesic effect of acetaminophen during the initial postoperative period. Our results thus confirm that acetaminophen analgesia is partially mediated by serotonin receptors. However, the reduction was of marginal clinical importance and short-lived.

Authors's reply to "Preventing atelectasia at robotic surgery"

e letter by Yetim et al. discussed mechanical ventiion modes and parameters to prevent hypoxemia and prove lung function during robotic surgery, using Recruitnt Maneuvers (RMs), positive pressure ventilation mode, d Positive End-Expiratory Pressure (PEEP).1 We agree that pressure control ventilation is an option d PEEP and RMs may be needed during robotic surgery. wever, some studies have reported that PEEP and RMs may prove gas exchange during laparoscopic surgery, whereas ers have shown no changes.2 In both our robotic cystomy and prostatectomy series, patients in the deep ndelenburg position and with intra-abdominal pressure e to pneumoperitoneum tended to generate auto-PEEP as ll as high inspiratory peak and plateau pressures. Hower, adjusting the ventilator settings to a higher breathing quency with respect to auto-PEEP values and to a lower al volume using a volume-controlled ventilator mode was ry helpful in obtaining normal values for peak and plateau ssures and in avoiding the generation of auto-PEEP. hough PEEP can improve gas exchange in these patients, was not needed because of the very few instances auto-PEEP. Additionally, no signs of low hemoglobin ygen saturation and/or hypoxemia were observed on artel blood gas analysis, and atelectasis was not diagnosed in y patient. However, it is possible that PEEP and RMs may be needed even in dual-controlled ventilation modes, and they can be considered in hemodynamically stable cases.

Ultrasonography Guided Spinal Anesthesia In A Case With Severe Kyphoscoliosis

ABSTRACT Patients with spinal abnormalities present unusual challenges for the administration of sedation and anesthesia during surgical and technical procedures. Airway management and respiratory problems are the commonest. In this case with severe kyphoscoliosis, we aimed to evaluate the advantages of spinal anesthesia technique performed under the guidance of ultrasonography. A 80-year-old female patient presented to our hospital with total uterine prolapsus. Medical history of the patient revealed severe congenital kyphoscoliosis, and restrictive lung disease. Lumbar vertebras and intervertebral spaces of the patient were scanned with an 8MHz head piece of the ultrasound. For spinal access, L4-L5 intervertebral space through which dura can be observed was selected. At the end of the operation, pin prick test detected sensory block at T12 dermatome. This case demonstrates that spinal anesthesia performed under the guidance of ultrasonography can be successful even in cases of severe kyphoscoliosis. Key words: Anesthesia, Spinal, Neuroaxial blockade, Kyphoscoliosis, Ultrasonography

Sedation Monitoring and Management during Percutaneous Endoscopic Lumbar Discectomy

Percutaneous endoscopic laser discectomy (PELD) is a painful intervention that requires deep sedation and analgesia. However, sedation should be light at some point because cooperation by the patient during the procedure is required for successful surgical treatment. Light sedation poses a problem for endotracheal intubation, while patients placed in the prone position during percutaneous endoscopic discectomy pose a problem for airway management. Therefore, under these conditions, sedation should be not deeper than required. Here we report the sedation management of three cases that underwent PELD, with a focus on deep and safe sedation that was monitored using bispectral index score and observers assessment of alertness/sedation score.

Is It Possible to Maintain Consciousness and Spontaneous Ventilation with Chest Compression in the Early Phase of Cardiac Arrest

Chest compression is important in cardiopulmonary resuscitation. However, life support algorithms do not specify when chest compression should be initiated in patients with persistent spontaneous normal breathing in the early phase after cardiac arrest. Here we describe the case of a 69-year-old man who underwent femoral bypass surgery and was extubated at the end of the procedure. After extubation, the patients breathing pattern and respiratory rate were normal. The patient subsequently developed ventricular fibrillation, evident on two monitors. Because defibrillation was ineffective, chest compression was initiated even though the patient had spontaneous normal breathing and defensive motor reflexes, which were continued throughout resuscitation. He regained consciousness and underwent tracheal extubation without neurological sequelae on postoperative day 1. This case highlights the necessity of chest compression in the early phase of cardiac arrest.

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