Radomir Sindjelic

Emergence Delirium in Children: Many Questions, Few Answers

The introduction of a new generation of inhaled anesthetics into pediatric clinical practice has been associated with a greater incidence of ED, a short-lived, but troublesome clinical phenomenon of uncertain etiology. A variety of anesthesia-, surgery-, patient-, and adjunct medication-related factors have been suggested to play a potential role in the development of such an event. Restless behavior upon emergence causes not only discomfort to the child, but also makes the caregivers and parents feel unhappy with the quality of recovery from anesthesia. Although the severity of agitation varies, it often requires additional nursing care, as well as treatment with analgesics or sedatives, which may delay discharge from hospital. To reduce the incidence of this adverse event, it is advisable to identify children at risk and take preventive measures, such as reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. More clinical trials are needed to elucidate the cause as well as provide effective treatment.

Diagnosis and treatment of carotid body paraganglioma: 21 years of experience at a clinical center of Serbia

BackgroundThe carotid body paraganglioma (chemodectoma) is a relatively rare neoplasm of obscure origin. These are usually benign and commonly present as asymptomatic cervical mass.Patients and methodsRecords of 12 patients (9 female and 3 male) with carotid body tumors treated between 1982 and 2003, treated at our center were retrospectively reviewed. Data on classification, clinical presentation, and surgical treatment were extracted from the case records. Surgical complications and treatment outcome were noted and survival was calculated by actuarial method. The literature on carotid body paraganglioma was reviewed.ResultsThe average age of the patients was 52 years (range 30–78 years). Eight of these cases presented as a large asymptomatic non-tender neck mass, and two each presented with dysphagia, and hoarseness of voice. As per Shamblin classification seven of tumors were type II and 5 were types III. In 7 cases subadventitial tumor excision was performed, while in 5 associated resection of both external and internal carotid arteries was carried out. The artery was repaired by end-to-end anastomosis in one case, with Dacron graft in one case, and with saphenous vein graft in 3 cases. There was no operative mortality. After a mean follow-up of 6.2 years (range 6 months to 20 years), there were no signs of tumor recurrence in any of the cases.ConclusionsSurgical excision is the treatment of choice for carotid body paragangliomas although radiation therapy is an option for patients who are not ideal candidates for surgery. For the tumors that are in intimate contact with carotid arteries, the treatment by vascular surgeon is recommended.

Ruptured abdominal aortic aneurysm. Predictors of survival in 229 consecutive surgical patients.

Background and Purpose:A ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality. The aim of the present study was to define relevant prognostic predictors for the outcome of surgical treatment.Patients and Methods:This study included 229 subsequent patients (83% males, 17% females, age 67.0 ± 7.5 years) with a ruptured abdominal aortic aneurysm. Before surgery, all patients underwent clinical examination, ultrasonography was performed in 78.6% (mean aneurysm diameter 73 mm, range 40–100 mm), computed tomography (CT) scan in 16.2%, magnetic resonance imaging (MRI) in 0.9%, and angiography in 12.6% of patients. The aneurysm was infrarenal in 74%, juxtarenal in 12.3%, suprarenal in 6.8%, and thoracoabdominal in 6.8% of patients. Types of rupture were retroperitoneal (65%), intraperitoneal (26.8%), chronic (3.8%), rupture into vena cava inferior (3.2%), and into duodenum (0.6%). Reconstruction included interposition of Dacron graft (53%), aortobiiliac bypass (32.8%), and aortobifemoral bypass (14.2%).Results:Findings on admission that significantly correlated with both intraoperative (13.5%) and total intrahospital mortality (53.7%) were: systolic blood pressure < 95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes > 14 × 109/l, hematocrit < 0.29%, hemoglobin < 100 g/l, urea > 11 mmol/l, and creatinine > 180 µmol/l. Intraoperative determinants of increased mortality were: aortic cross-clamping time > 47 min, duration of surgery > 200 min, intraoperative blood loss > 3,500 ml, diuresis < 400 ml, arterial systolic pressure < 97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were associated with a lethal outcome in the postoperative period.Conclusion:Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 46.3% of patients. Hypotension, low diuresis, high urea and creatinine levels, signs of blood loss, unconsciousness, cardiac arrest, and the need for aortobifemoral reconstruction predicted poor outcome. Short aortic cross-clamping and total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival.Hintergrund und Ziel:Ein rupturiertes Bauchaortenaneurysma gehört zu den Operationsindikationen mit höchster Dringlichkeit, da es unbehandelt eine hohe Mortalität aufweist. Das Ziel dieser Untersuchung war es, prognostische Faktoren zu identifizieren, die das intra- und postoperative Überleben der Patienten bestimmen.Patienten und Methodik:Zwischen 1991 und 2001 wurden 229 konsekutive Patienten (83% Männer, 17% Frauen, mittleres Alter 67,0 ± 7,5 Jahre) mit der Diagnose eines rupturierten Bauchaortenaneurysmas operiert. Vor der Operation wurden alle Patienten klinisch untersucht und Laborwerte erhoben, bei 78,6% der Patienten wurde eine Ultraschalluntersuchung, bei 16,2% eine Computertomographie (CT), bei 0,9% eine Magnetresonanztomographie (MRT) und bei 12,6% eine Angiographie durchgeführt. Nach den Ultraschallbefunden betrug der mittlere Durchmesser der Aneurysmata 73 mm, der kleinste Durchmesser lag bei 40 mm, der größte bei 100 mm. Bei 74% der Patienten waren die Aneurysmata infrarenal, bei 12,3% juxtarenal, bei 6,8% suprarenal und bei 6,8% thorakoabdominal lokalisiert. Folgende Rupturtypen wurden bei den Patienten nachgewiesen: retroperitoneal (65%), intraperitoneal (26,8%), chronisch (3,8%), in die Vena cava (3,2%) und das Duodenum (0,6%). Das operative Management erforderte folgende Gefäßrekonstruktionen: das Einbringen einer Dacron-Prothese (53%), einen aortobiiliakalen Bypass (32,8%) oder einen aortobifemoralen Bypass (14,2%).Ergebnisse:Die intraoperative Mortalität bei allen Patienten betrug 13,5%, und die Mortalität während des gesamten Krankenhausaufenthalts lag bei 53,7%. Faktoren bei Aufnahme der Patienten, die die Mortalität signifikant erhöhten, waren Bewusstlosigkeit, ein systolischer Blutdruck < 95 mmHg, Herzstillstand, eingeschränkte Diurese, ein Hämatokrit < 0,29%, ein Hämoglobinwert < 100g/l, Kreatinin > 180 µmol/l, Leukozyten > 14 × 109/l und Harnstoff > 11 mmol/l. Intraoperative Faktoren, die die Mortalität erhöhten, beinhalteten eine Aortenischämiezeit > 47 min, eine Operationsdauer > 200 min, einen intraoperativen Blutverlust > 3 500 ml, Nierenversagen mit einer Diurese < 400 ml sowie einen arteriellen systolischen Blutdruck < 97,5 mmHg und die Notwendigkeit einer aortobifemoralen Gefäßrekonstruktion. Beatmungsassoziierte Komplikationen und ein Multiorganversagen waren häufig mit einer hohen postoperativen Letalität verbunden.Schlussfolgerung:Zusammenfassend lässt sich feststellen, dass perioperative Faktoren definiert werden können, die die Prognose der Patienten mit rupturiertem Bauchaortenaneurysma signifikant beeinflussen. Diese intra- und perioperativen Parameter sollten möglichst optimiert werden, um langfristig ein besseres Überleben der Patienten zu erreichen.

The addition of fentanyl to local anesthetics affects the quality and duration of cervical plexus block: a randomized, controlled trial.

BACKGROUND: Cervical plexus block is frequently associated with unsatisfactory sensory blockade. In this randomized, double-blind, placebo-controlled trial, we examined whether the addition of fentanyl to local anesthetics improves the quality of cervical plexus block in patients undergoing carotid endarterectomy (CEA). METHODS: Seventy-seven consecutive adult patients scheduled for elective CEA were randomized to receive either fentanyl 1 mL (50 &mgr;g) or saline placebo 1 mL in a mixture of 10 mL bupivacaine 0.5% and 4 mL lidocaine 2% for deep cervical plexus block. Superficial cervical plexus block was performed using a mixture of 10 mL bupivacaine 0.5% and 5 mL lidocaine 2%. Pain was assessed using the verbal rating scale (0–10; 0 = no pain, 10 = worst pain imaginable), and propofol in 20-mg IV bolus doses was given to patients reporting verbal rating scale >3 during the procedure. Rescue medication consumption during surgery and analgesia requirements over the next 24 hours, as well as onset of sensory blockade, were recorded. A P value <0.05 was regarded as statistically significant. RESULTS: Fewer patients in the fentanyl group (4 of 38, 10.5%) required propofol compared with the placebo group (26 of 39, 66.7%; P < 0.001). In comparison with the placebo group, the fentanyl group consumed less propofol (median 0 [0–60] vs 60 [0–160] mg, respectively; P < 0.001), required postoperative analgesia less frequently (22 of 38 patients, 57.9% vs 35 of 39 patients, 89.7%, respectively; P = 0.002), and requested the first analgesic after surgery later (median 5.8 [1.9–15.6] vs 3.1 [1.0–11.7] hours, respectively; P < 0.001), whereas the onset time of sensory blockade was similar in both groups (median 12 [9–18] vs 15 [9–18] minutes, respectively; P = 0.18). CONCLUSIONS: The addition of fentanyl to local anesthetics improved the quality and prolonged the duration of cervical plexus block in patients undergoing CEA.

Ruptured Abdominal Aortic Aneurysm

Background and Purpose:A ruptured abdominal aortic aneurysm is one of the most urgent surgical conditions with high mortality. The aim of the present study was to define relevant prognostic predictors for the outcome of surgical treatment.Patients and Methods:This study included 229 subsequent patients (83% males, 17% females, age 67.0 ± 7.5 years) with a ruptured abdominal aortic aneurysm. Before surgery, all patients underwent clinical examination, ultrasonography was performed in 78.6% (mean aneurysm diameter 73 mm, range 40–100 mm), computed tomography (CT) scan in 16.2%, magnetic resonance imaging (MRI) in 0.9%, and angiography in 12.6% of patients. The aneurysm was infrarenal in 74%, juxtarenal in 12.3%, suprarenal in 6.8%, and thoracoabdominal in 6.8% of patients. Types of rupture were retroperitoneal (65%), intraperitoneal (26.8%), chronic (3.8%), rupture into vena cava inferior (3.2%), and into duodenum (0.6%). Reconstruction included interposition of Dacron graft (53%), aortobiiliac bypass (32.8%), and aortobifemoral bypass (14.2%).Results:Findings on admission that significantly correlated with both intraoperative (13.5%) and total intrahospital mortality (53.7%) were: systolic blood pressure < 95 mmHg, low diuresis, unconsciousness, cardiac arrest, leukocytes > 14 × 109/l, hematocrit < 0.29%, hemoglobin < 100 g/l, urea > 11 mmol/l, and creatinine > 180 µmol/l. Intraoperative determinants of increased mortality were: aortic cross-clamping time > 47 min, duration of surgery > 200 min, intraoperative blood loss > 3,500 ml, diuresis < 400 ml, arterial systolic pressure < 97.5 mmHg, and the need for aortobifemoral bypass. Respiratory complications and multisystem organ failure were associated with a lethal outcome in the postoperative period.Conclusion:Surgical treatment of ruptured abdominal aortic aneurysm was life-saving in 46.3% of patients. Hypotension, low diuresis, high urea and creatinine levels, signs of blood loss, unconsciousness, cardiac arrest, and the need for aortobifemoral reconstruction predicted poor outcome. Short aortic cross-clamping and total operation time, low intraoperative blood loss, and well-controlled diuresis and arterial pressure during surgery have improved survival.Hintergrund und Ziel:Ein rupturiertes Bauchaortenaneurysma gehört zu den Operationsindikationen mit höchster Dringlichkeit, da es unbehandelt eine hohe Mortalität aufweist. Das Ziel dieser Untersuchung war es, prognostische Faktoren zu identifizieren, die das intra- und postoperative Überleben der Patienten bestimmen.Patienten und Methodik:Zwischen 1991 und 2001 wurden 229 konsekutive Patienten (83% Männer, 17% Frauen, mittleres Alter 67,0 ± 7,5 Jahre) mit der Diagnose eines rupturierten Bauchaortenaneurysmas operiert. Vor der Operation wurden alle Patienten klinisch untersucht und Laborwerte erhoben, bei 78,6% der Patienten wurde eine Ultraschalluntersuchung, bei 16,2% eine Computertomographie (CT), bei 0,9% eine Magnetresonanztomographie (MRT) und bei 12,6% eine Angiographie durchgeführt. Nach den Ultraschallbefunden betrug der mittlere Durchmesser der Aneurysmata 73 mm, der kleinste Durchmesser lag bei 40 mm, der größte bei 100 mm. Bei 74% der Patienten waren die Aneurysmata infrarenal, bei 12,3% juxtarenal, bei 6,8% suprarenal und bei 6,8% thorakoabdominal lokalisiert. Folgende Rupturtypen wurden bei den Patienten nachgewiesen: retroperitoneal (65%), intraperitoneal (26,8%), chronisch (3,8%), in die Vena cava (3,2%) und das Duodenum (0,6%). Das operative Management erforderte folgende Gefäßrekonstruktionen: das Einbringen einer Dacron-Prothese (53%), einen aortobiiliakalen Bypass (32,8%) oder einen aortobifemoralen Bypass (14,2%).Ergebnisse:Die intraoperative Mortalität bei allen Patienten betrug 13,5%, und die Mortalität während des gesamten Krankenhausaufenthalts lag bei 53,7%. Faktoren bei Aufnahme der Patienten, die die Mortalität signifikant erhöhten, waren Bewusstlosigkeit, ein systolischer Blutdruck < 95 mmHg, Herzstillstand, eingeschränkte Diurese, ein Hämatokrit < 0,29%, ein Hämoglobinwert < 100g/l, Kreatinin > 180 µmol/l, Leukozyten > 14 × 109/l und Harnstoff > 11 mmol/l. Intraoperative Faktoren, die die Mortalität erhöhten, beinhalteten eine Aortenischämiezeit > 47 min, eine Operationsdauer > 200 min, einen intraoperativen Blutverlust > 3 500 ml, Nierenversagen mit einer Diurese < 400 ml sowie einen arteriellen systolischen Blutdruck < 97,5 mmHg und die Notwendigkeit einer aortobifemoralen Gefäßrekonstruktion. Beatmungsassoziierte Komplikationen und ein Multiorganversagen waren häufig mit einer hohen postoperativen Letalität verbunden.Schlussfolgerung:Zusammenfassend lässt sich feststellen, dass perioperative Faktoren definiert werden können, die die Prognose der Patienten mit rupturiertem Bauchaortenaneurysma signifikant beeinflussen. Diese intra- und perioperativen Parameter sollten möglichst optimiert werden, um langfristig ein besseres Überleben der Patienten zu erreichen.

Intraoperative Cell Salvage versus Allogeneic Transfusion during Abdominal Aortic Surgery: Clinical and Financial Outcomes

The objective of this study was to assess the clinical and financial outcomes of intraoperative cell salvage (ICS) during abdominal aortic surgery. In this study, 90 patients were operated on with the use of ICS (group 1, prospective) and 90 patients without ICS (group 2, historical control). According to the type of operation, the patients were subdivided into three consecutive 30-patient subgroups (1, aortoiliac occlusive disease [AOD]; 2, elective abdominal aortic aneurysm [AAA]; or 3, ruptured abdominal aortic aneurysm [RAAA]). Transfusion requirements and postoperative complications were recorded. The total amounts of perioperatively transfused allogeneic blood were higher in all patient subgroups that underwent surgery without ICS (p = .0032). In the ICS group, 50% of AOD patients and 60% of elective AAA patients received no allogeneic transfusions. There were no significant differences in the incidence of postoperative complications in any group examined. ICS significantly reduced the necessity for allogeneic transfusions during abdominal aortic surgery. ICS use was most valuable in urgent situations with high blood losses, such as RAAA, for which only small amounts of allogeneic blood were initially available. In patients with more than 3 units of autologous blood reinfused, this method was cost effective.

Cervical plexus block versus general anesthesia in carotid surgery: single center experience.

Introduction Carotid endarterectomy may be performed under general (GA) or regional anesthesia (RA). The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing carotid surgery. Material and methods This prospective study included 1098 consecutive patients operated on between 2003 and 2009 (773 underwent cervical plexus block and 325 underwent general anesthesia). Results There were 6 deaths, 3 (0.9%) after GA and 3 (0.4%) after RA (p = 0.272). Neurological complication rates were not significantly different (GA 2.1% vs. RA 1.1%, p = 0.212). Incidence of myocardial infarction was similar (GA 0.31% vs. LA 0.39%, p = 0.840). Shunt placement rate was the same in both groups, 11.1%. Total operating time and carotid clamping time were significantly shorter in RA patients (RA: 92 min vs. GA: 106 min; p < 0.001 and RA: 18 min vs. GA: 19 min; p = 0.040). There was no significant difference in number of reinterventions (RA: 1.0% vs. GA: 0.6%; p = 0.504). Pulmonary complications were common in the GA group (RA: 0 vs. GA 0.9%; p = 0.007). Time to first postoperative analgesic was significantly shorter in the GA group (RA: 226 min vs. GA: 139 min; p < 0.001). Conclusions Type of anesthesia does not affect the outcome of surgical treatment of carotid disease. However, it should be stressed that fewer respiratory complications, later requirement for first postoperative analgesic, and an awake patient who can continue oral therapy early after surgery, give priority to regional techniques of anesthesia.

Pain Associated with Carotid Artery Surgery Performed under Carotid Plexus Block: Preemptive Analgesic Effect of Ketorolac

Carotid artery surgery (CAS) performed under cervical plexus block is frequently associated with significant intra- and postoperative pain. To evaluate whether preoperative administration of ketorolac may improve analgesia in this type of surgery, 80 patients scheduled for CAS under cervical plexus block were randomly allocated to receive intravenously either 30 mg of ketorolac or placebo 30 minutes before surgery. Verbal rating scale pain scores during surgery and 3 and 6 hours after surgery, the number of patients requiring additional analgesia, and the total analgesic consumption both during and within 6 hours after surgery were significantly lower, whereas the time to first postoperative analgesia was significantly shorter in the ketorolac group than in the control group. The results of this prospective, randomized, double-blind study show that a single 30 mg dose of ketorolac administered intravenously 30 minutes before surgery reduces intraoperative pain and preempts postoperative pain in patients undergoing CAS under carotid plexus block.

Some technical considerations of open thoracoabdominal aortic aneurysm repair in a transition country

A variety of operative approaches and protective adjuncts have been used in thoracoabdominal aneurysm (TAA) repair to minimize the major complications of perioperative death and spinal cord ischemia. There is no consensus with respect to the optimal approach. We present 118 surgically treated patients over a 10-year period. The present study reviews our experience as a transition country (Serbia) in the treatment and problems we have encountered during open operative treatment of TAAs. Between 1999 and 2009, the authors reviewed 118 consecutive patients who underwent thoracoabdominal aortic resection using a variety of spinal cord protection. Clinical data collected prospectively were analyzed retrospectively. The purpose of the current study was to review the results of a large series of TAA repairs and to present some technical considerations and complications of open TAA repair. There were seven operative deaths (5.9%): two in the setting of ruptured TAAs, three myocardial infarctions and two due to hemorrhage. All 30 (25.4%) postoperative deaths occurred during the initial hospitalization. Postoperative complications included paraplegia in 11 patients (9.3%); renal failure in eight patients (6.8%), with four patients (3.4%) requiring hemodialysis; pulmonary complications in 75 patients (63.5%); bleeding requiring reoperation in two patients (1.7%) and coagulopathic hemorrhage in five patients (4.2%); cardiac complications in six patients (5.1%); stroke in five patients (4.2%); wound dehiscence in six patients (5.1%); and subdural hemorrhage in one patient (0.87%). Open TAA repair intrinsically has substantial complications, of which spinal cord ischemia and renal failure are the most devastating, despite major progress in our understanding of the pathophysiology and operative strategy. Our current review of data clearly proves that the surgical repair of TAAs remains a challenge even in the 21st century, especially in a country in transition.

Use of Propofol in Combination with Remifentanil for Plastic and Reconstructive Surgery.

We have read the recent study by Sanatkar et al. with great interest [1]. The authors evaluated the effects of a mixture of propofol and two different concentrations of ketamine on sedation in adult patients undergoing plastic and reconstructive surgery. In addition to ketamine, midazolam and fentanyl were administered for premedication, and 2 % lidocaine with epinephrine 1/200,000 was used for local anesthesia. The results of the study demonstrated satisfactory levels of hemodynamic and respiratory stability as well as adequate sedation and analgesia. Low doses of ketamine can be useful for analgesia and sedation [1, 2] but may also be associated with a variety of adverse effects including increased oral secretion, nausea and vomiting, hemodynamic instability, and postoperative hallucinations [3]. This may limit the use of ketamine, particularly in patients with cardiovascular, respiratory, neurological, psychological, and other diseases, which was shown in the study [1]. Considering that an increasing number of elderly patients with some of the aforementioned comorbidities are seeking aesthetic surgery, the routine use of ketamine for procedural sedation may not be appropriate in clinical settings. We propose administration of a mixture of propofol and remifentanil for similar or longer surgical procedures (e.g., facial plastic surgery), which is an anesthetic technique widely used at our institution. In most cases, satisfactory levels of sedation and analgesia are produced by application of target-controlled infusion (TCI) to achieve effectsite concentration of propofol (0.4–0.8 mcg/ml) and remifentanil (0.5–1 ng/ml) [4]. Local anesthesia is provided by a mixture of 1 % lidocaine and 0.25 % levobupivacaine with epinephrine (1/200,000). The patients are encouraged to take oral anxiolytics as well as antiemetic medication prior to admission. Before surgery, premedication is administered using midazolam (2 mg) and atropine (0.5 mg) i.v. In addition to adequate sedation and analgesia levels, this anesthetic technique enhances patient comfort without compromising hemodynamic stability or respiratory function during surgery. However, close monitoring of vital signs is required during and after the procedure to avoid potentially serious adverse cardiovascular and respiratory events.