Wojciech Gaszyński

Randomized comparison of sugammadex and neostigmine for reversal of rocuronium-induced muscle relaxation in morbidly obese undergoing general anaesthesia

BACKGROUND Complete and fast recovery of neuromuscular function is very important in morbidly obese patients because of the possible influence of postoperative residual curarization (PORC) on respiratory function in the postoperative period. Recent reports underline incidences of the residual influence of neuromuscular blocking agents. METHODS Seventy morbidly obese (BMI >40 kg m(-2)) patients requiring general anaesthesia and receiving rocuronium for muscle relaxation were randomly assigned into two groups: at the end of the anaesthetic procedure, one group received sugammadex 2 mg kg(-1) of corrected body weight (Group SUG) and the other group received neostigmine 0.05 mg kg(-1) of CBW (Group NEO). At the end of surgery and when response reached a train-of-four (TOF) score of 2, patients received the study drugs. The neuromuscular function was recorded and time to achieve 90% of TOF (safe extubation) was measured. Patients were examined directly after arrival to the post-anaesthesia care unit (PACU) by a blinded investigator for the presence of PORC. RESULTS Thirty-five patients received sugammadex and 35 neostigmine. Mean dose of rocuronium was 87.9 vs 85.6 mg (P>0.05), mean time to 90% of TOF was 2.7 vs 9.6 min (P<0.05), and TOF at the PACU was 109.8% vs 85.5% (P<0.05) in Groups SUG and NEO, respectively. CONCLUSIONS Administration of sugammadex provides fast recovery of neuromuscular function and prevents PORC in the morbidly obese, however neostigmine does not.

Post-anesthesia Recovery after Infusion of Propofol with Remifentanil or Alfentanil or Fentanyl in Morbidly Obese Patients

Background: The type of opioid used during general anesthesia in the morbidly obese influences recovery and the postoperative period. In a randomized clinical trial, the postoperative recovery profile and early period after general anesthesia with remifentanil, fentanyl and alfentanil were compared in morbidly obese patients. Material and Method: 60 morbidly obese patients with BMI >35 kg/m2 (mean 43.31) undergoing open Roux-en-y gastric bypass were randomly divided into 3 groups: remifentanil (R), fentanyl (F), and alfentanil (A). Dosage of opioids was based on ideal body weight (IBW): fentanyl 5 mcg/kg for intubation followed by infusion of 0.025-0.05 mcg/kg/min; alfentanil 15 mcg/kg initially, then 1.0-1.5 mcg kg/min; and remifentanil 1 mcg/kg followed by infusion of 0.25-1.5 mcg/kg/min. Anesthesia was induced with infusion of propofol and oxygen with N2O (1:1). After anesthesia, the duration to response to verbal command, spontaneous respiration, adequate respiration, and safe extubation were recorded.The incidence of postoperative nausea and vomiting were recorded. Using verbal scale for evaluation of postoperative pain, the early postoperative analgesia requirements were assessed. Results: Demographic profiles and duration of procedure did not differ between groups. A total dose of propofol was significantly lower in Group R compared with Groups A and F (P <0.05). Duration to spontaneous respiration, adequate respiration and safe extubation were significantly shorter in Group R compared with Group F (P <0.05). Shortly after anesthesia, significantly more patients in Group R required additional dose of analgesic than in Group F (P <0.05). Postoperative nausea and vomiting (PONV) occurred significantly more often in Group R compared with Group F (P <0.05). Recovery profile of Group A was more similar to Group R, and postoperative pain and PONV evaluation more similar to Group F. Conclusion: In morbidly obese individuals, alfentanil or fentanyl and remifentanil can be safely used, but there is a higher rate of PONV and postoperative pain in the remifentanil group.

The role of the immuno-inflammatory response in patients after cardiac arrest

Introduction The aim of the research was to assess whether concentrations of inflammatory markers in blood of patients after cardiac arrest (CA) are related to their clinical state and survival. Material and methods Forty-six patients, aged 63 ±12 years, 21 of them after out-of-hospital CA and 25 after in-hospital CA, were enrolled in the study. Twenty-five patients survived and were discharged from hospital (CA-S); 21 died during hospitalization (CA-D). The clinical state of the patients was evaluated by the Glasgow Coma Scale (GCS) and the Acute Physiology and Chronic Health Evaluation II (APACHE II). On the day immediately after CA (day 1) and on the following day (day 2) the plasma concentration of high specific C-reactive protein (hs-CRP), tumour necrosis factor (TNF)-α, interleukin-10 and interleukin-6 (Ile-6) were measured. Results In CA-D patients, compared with CA-S, a significantly higher concentration of hs-CRP (on day 1, 19 ±5 vs. 15 ±4; on day 2, 21 ±3 vs. 16 ±5 mg/l, p < 0.001) and Ile-6 (on day 1, 24.9 ±19.8 vs. 9.2 ±11.3; on day 2, 24.2 ±19.7 vs. 6.9 ±6.8 IU/ml, p < 0.001) was found. The level of TNF-α was greater in CA-D on day 1 (0.42 ±0.75 vs. 0.18 ±0.21 IU/ml, p < 0.04). Concentrations of hs-CRP and Ile-6 were correlated with the scores of GCS and APACHE II. Using logistic regression analysis and ROC curves the prognostic value of hs-CRP and Ile-6 for survival was proven. Conclusions Post-cardiac arrest immuno-inflammatory response, reflected mainly in elevated plasma concentration of hs-CRP and Ile-6, is not only correlated with patients’ clinical state but also with prediction of survival.

Results of the severe sepsis registry in intensive care units in Poland from 2003−2009

BACKGROUND Severe sepsis remains the most common cause of death in intensive care units (ICUs) according to many epidemiological studies. There are no data in Poland on the extent of severe sepsis cases treated in ICUs. The aim of the study was to analyse the course and outcome of severe sepsis patients treated in Polish ICUs. METHODS In 2003, the internet-based severe sepsis registry was created as a multicentre observational research project. An online questionnaire was made accessible to ICUs participating in the study. Questionnaires were completed after the discharge of patients and included demographic data, clinical and microbiological information about the cause, course, treatment and outcome of septic patients. All data were given voluntarily and anonymously. RESULTS During the 7-year period (2003-2009), 4999 cases of severe sepsis were registered for analysis. The mean age of septic patients was 57 years, and the majority of the patients were men (58%). The mean length of stay in the ICU was 10 days. A significant decrease in the mortality rate was observed from 54% in 2003 and 56% in 2004 to 46% in 2009 (P < 0.05). Most of the patients were admitted to the ICU for surgical reasons (56%), and intra-abdominal infections predominated (49%). Severe sepsis patients were admitted to ICUs in critical condition, and the majority of them (89%) had 3 or more organs dysfunction. The APACHE II score on admission was 26 points. Community acquired infections were the most frequent cause of severe sepsis (53%). Most of the pathogens responsible for infection were Gram-negative bacteria (58%). Gram-positive bacteria were identified in 34% of patients and fungi in 16%. A positive blood culture was detected in 41% of patients. Vasopressors were administered to most of the patients (86%). There was a marked increase in the frequency of administering noradrenaline and a decrease in administering dopamine. Renal replacement therapy was applied in 22% of the patients, and there was a marked increase in this type of therapy in the last two years of the study period. CONCLUSIONS Patients with severe sepsis involved in the 7-year registry were critically ill in half of the cases because of intra-abdominal infections, and the majority of them had multi-organ dysfunction. The mortality of registered patients was high, but it significantly decreased during the observation time. Based on the results obtained from this voluntary registry, the authors conclude that mandated sepsis registries should be established in Polish hospitals to improve the strategy of diagnosing and managing this syndrome.

The influence of pneumoperitoneum and anti-Trendellenburg position on Cardiac Output in morbidly obese: A-202

A-202 The influence of pneumoperitoneum and anti-Trendellenburg position on Cardiac Output in morbidly obese T. Gaszynski1, W. Machala1, T. Szewczyk2, W. Gaszynski1 1Department of Anaesthesiology and Intensive Therapy, Medical University of Lodz; 2Department of General and Gastrointestinal Surgery, Barlicki University Hospital, Lodz, Poland Background and Goal of Study: Pneumoperitoneum has important impact on haemodynamic function during general anaesthesia. The reports on cardiovascular effect of pneumoperitoneum in morbidly obese are scarce. The aim of the study was to estimate influence of laparoscopic procedures on Cardiac Output in morbidly obese during gastric banding surgery. Materials and Methods: After obtaining the consent of Institutional Bioethics Review Board, 21 patients were enrolled into the prospective, controlled study. Sufficient data was collected from 13 pts. Haemodynamic function was measured by transaesophageal Doppler probe using HemoSonic 100 device (Arrow, USA). Measurements were taken in three time points: T1after induction to anaesthesia, T2pneumoperitoneum in vertical position, T3anti-Trendellenburg (Fowler) position and pneumoperitoneum. All patients were anaesthetised using sevoflurane/O2/air, FNT, midazolam and atracurium. Pneumoperitoneum pressure was 15 mmHg. Results and Discussions: Demographic data (mean SD): BMI 45.979 7.7 kg/m2, weight 138.77 26.67 kg, high 173.54 8.29 cm, age 38.15 11.31 yrs; CO in time points (l/min): T16.88 1.13, T25.15 0.91, T35.55 1.12. In 11 pts (84.62%) CO in T3 increased comparing to T2, in 2 pts decreased furthermore. The difference between time points: D1 (T1-T2)1.73 0.72 (26.36 7.89% of T1), D2 (T2-T3, increase)0.4 0.88 (9.92 7.37% of T1); D2 (decrease)1.21 (17.8% of T1); p values when comparing time points: T1 vs T2: p 0.00026; T1 vs T3: p 0.00568; T2 vs T3: p 0.32531. The changes in CO were not accompanied by important changes in blood pressure and HR. No complications were observed in perioperative period. Conclusions: Although clinical significance of changes of CO were not observed the influence of pneumoperitoneum on cardiac function is important. The serious decrease in CO may not be recognised basing solely on BP and HR measurements. The Fowler position used in laparoscopic gastric banding procedures has no positive or negative effect on cardiac function. Further investigation on organ perfusion in abdomen during pneumoperitoneum in morbidly obese are needed.

Assessment of regional ventilation in acute respiratory distress syndrome by electrical impedance tomography

Mechanical ventilation in acute respiratory distress syndrome (ARDS) incurs a risk of ventilator-associated lung injury (VALI) from inhomogeneous conditions and different properties of dependent and non-dependent lung regions at risk of atelectasis and overdistension, respectively. Electrical impedance tomography (EIT) offers regional ventilation assessment to optimise treatment with mechanical ventilation. This article provides an overview of scientific literature on the application of impedance tomography in acute respiratory distress syndrome. It also presents the results of EIT studies in different clinical situations that may be of use in implementing impedance tomography for treating ARDS.

Dexmedetomidine for attenuating haemodynamic response to intubation stimuli in morbidly obese patients anaesthetised using low-opioid technique: comparison with fentanyl-based general anaesthesia.

BACKGROUND Anaesthesiologists are facing the problem of an increasing population of morbidly obese patients. In order to minimize the risk of opioid-induced postoperative respiratory failure, the intraoperative administration of opioids should be reduced or replaced with other drugs. The purpose of this study was to compare haemodynamic response elicited by intubation in morbidly obese patients between two variants of anaesthesia induction: fentanylbased or low-opioid using dexmedetomidine. METHODS Forty-two morbidly obese patients scheduled for bariatric surgery were randomly assigned to two groups: low-opioid using dexmedetomidine (DEX) or fentanyl-based (FNT) anaesthesia. Patients were premedicated with 100 μg of fentanyl i.v. In the DEX group, a 10 minute infusion of a loading dose of 200 μg of dexmedetomidine was started. In the FNT group, 2 mg of intravenous midazolam was given. Thereafter, propofol was used in both groups. In the FNT group, patients received a dose of fentanyl up to 5 μg kg⁻¹ of ideal body weight. Following administration of rocuronium, laryngoscopy and tracheal intubation were performed. Haemodynamic parameters, including systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressure, as well as heart rate (HR), were recorded before and after intubation. Patients who were not intubated at first attempt were excluded from the study. RESULTS Data from 33 patients were analysed. There were no statistically significant differences between the DEX and FNT groups regarding demographic data. Haemodynamic response to intubation was defined as mean change (d) in values of analysed parameters that occurred during intubation. The following differences were observed: dSBP FNT +11.6 mm Hg vs. DEX +0.4 mm Hg (P = 0.15); dDBP FNT +3.7 mm Hg vs. DEX +3.5 mm Hg (P = 0.98); dMAP FNT +8.6 mm Hg vs. DEX +1.4 mm Hg (P = 0.36); dHR FNT +2 beats min-1 vs. DEX -1 beat min⁻¹ (P = 0.30). None of these comparisons yielded significant differences. CONCLUSIONS The study revealed no advantage of fentanyl over low opioid dexmedetomidine-based induction of general anaesthesia in attenuating cardiovascular response to intubation in morbidly obese patients.

Assessment of Ventilation Distribution during Laparoscopic Bariatric Surgery: An Electrical Impedance Tomography Study

Introduction. The aim of the study was to assess changes of regional ventilation distribution at the level of the 3rd intercostal space in the lungs of morbidly obese patients as a result of general anaesthesia and laparoscopic surgery as well as the relation of these changes to lung mechanics. We also wanted to determine if positive end-expiratory pressure of 10 cm H2O prevents the expected atelectasis in the morbidly obese patients during general anaesthesia. Materials and Methods. 49 patients completed the examination and were randomized to 2 groups: ventilated without positive end-expiratory pressure (PEEP 0) and with PEEP of 10 cm H2O (PEEP 10) preceded by a recruitment maneuver with peak inspiratory pressure of 40 cm H2O. Impedance Ratio (IR) was utilized to examine ventilation distribution changes as a result of anaesthesia, pneumoperitoneum, and change of body position. We also analyzed intraoperative respiratory mechanics and pulse oximetry values. Results. In both groups general anaesthesia caused a ventilation shift towards the nondependent lungs which was not further intensified after pneumoperitoneum. Reverse Trendelenburg position promoted homogeneous ventilation distribution. Respiratory system compliance was reduced after insufflation and improved after exsufflation of pneumoperitoneum. There were no statistically significant differences in ventilation distribution between the examined groups. Respiratory system compliance, plateau pressure, and pulse oximetry values were higher in PEEP 10. Conclusions. Changes of ventilation distribution in the obese do occur at cranial lung regions. During pneumoperitoneum alterations of ventilation distribution may not follow the direction of the changes of lung mechanics. In the obese patients PEEP level of 10 cm H2O preceded by a recruitment maneuver improves respiratory compliance and oxygenation but does not eliminate atelectasis induced by general anaesthesia.

Degloving lower leg injury – the importance of additional treatment: negative pressure and hyperbaric oxygen therapy

Degloving injury poses a severe therapeutic challenge concerning both trauma and plastic surgery. The injury involves separation of skin and subcutaneous tissue from fascia and muscles. Treatment is often long-lasting and brings unsatisfying results due to the extent of damage, risk of infection and massive blood loss. In this article, we present the management and therapeutic outcomes of a patient admitted due to the degloving injury of the lower extremity caused by workplace accident. We described the complexity of treatment including surgical intervention as well as additional treatment, which combined brought good esthetic outcome.

The doripenem serum concentrations in intensive care patients suffering from acute kidney injury, sepsis, and multi organ dysfunction syndrome undergoing continuous renal replacement therapy slow low-efficiency dialysis.

Doripenem is a novel wide-spectrum antibiotic, and a derivate of carbapenems. It is an ideal antibiotic for treatment of serious nosocomial infections and severe sepsis for its exceptionally high efficiency and broad antibacterial spectrum of action. Doripenem is eliminated mainly by the kidneys. In cases of acute kidney injury, dosing of doripenem depends on creatinine clearance and requires adjustments. Doripenem is eliminated during hemodialysis because its molecular weight is 300–400 Da. The aim of this study was to establish the impact of continuous renal replacement therapy (CRRT) slow low-efficiency dialysis (SLED) on doripenem serum concentrations in a population of intensive-therapy patients with life-threatening infections and severe sepsis. Ten patients were enrolled in this observational study. Twelve blood samples were collected during the first administration of doripenem in a 1-hour continuous infusion while CRRT SLED was provided. Fluid chromatography was used for measurement of the concentration of doripenem in serum. In all collected samples, concentration of doripenem was above the minimum inhibition concentration of this antibiotic. Based on these results, we can draw the conclusion that doripenem concentration is above the minimum inhibition concentration throughout all of CRRT. The dosing pattern proposed by the manufacturer can be used in patients receiving CRRT SLED without necessary modifications.