Adequacy of Anaesthesia for Nociception Detection during Vitreoretinal Surgery.

Vitreoretinal surgery (VRS) is one of the most widely performed precise procedures in ophthalmic surgery; the majority of cases are carried out under regional anaesthesia (RA) only. However, in specific situations (such as when the patient fails to cooperate with the operator for various reasons), general anaesthesia (GA), alone or in combination with GA (combined general-regional anaesthesia, CGR), is the only safe way to perform VRS. While monitoring the efficacy of an intraoperative rescue opioid analgesia (IROA) during surgery (assessing the adequacy of anaesthesia (AoA)) may be challenging, the surgical pleth index (SPI) is a useful tool for detecting the reaction to noxious stimuli and allows for the rational titration of opioid analgesics (AO) during surgery. The current study investigated the influence of the SPI-based titration of fentanyl (FNT) in combination with various pre-emptive analgesia (PA) techniques on intraoperative pain perception during various stages of VRS performed under AoA. A total of 176 patients undergoing VRS under GA were enrolled in the study. They were randomly assigned to one of the five following study arms: Group GA (control group)-patients who received general anaesthesia alone; Group PBB-GA with preprocedural peribulbar block (with 0.5% bupivacaine and 2% lidocaine); Group T-GA with preventive, topical 2% proparacaine; Group M-GA with a preprocedural intravenous infusion of 1.0 g of metamizole; and Group P-GA with a preprocedural intravenous infusion of 1.0 g of paracetamol. The whole procedure was divided in four stages: Stage 1 and 2-preoperative assessment, PA administration, and the induction of GA; Stage 3-intraoperative observation; Stage 4-postoperative observation. the SPI values were monitored during all stages. The occurrence of nociception (expressed as ∆SPI >15) during various manipulations in the surgical field was observed, as were cumulative doses of rescue analgesia, depending on the PA administered. During the course of VRS, rescue FNT doses varied depending on the stage of surgery and the group investigated. The majority of patients, regardless of their group allocation, needed complementary analgesia during trocar insertion, with Group GA patients requiring the highest doses. Likewise, the highest cumulative doses of IROA were noted during endophotocoagulation in Group GA. Preventive PBB and topical anaesthesia were proven to be most efficient in blunting the response to speculum installation, while topical anaesthesia and paracetamol infusion were shown to be more efficient analgesics during endophotocoagulation than other types used PA. In the performed study, none of the PA techniques used were superior to GA with FNT dosing under the SPI with respect to providing efficient analgesia throughout the whole surgery; there was a necessity to administer a rescue OA dose in both the control and investigated groups.

Polyspikes and Rhythmic Polyspikes During Volatile Induction of General Anesthesia With Sevoflurane Result in Bispectral Index Variations.

BACKGROUND: Although electroencephalography (EEG)-based indices may show artifactual values, raw EEG signal is seldom used to monitor the depth of volatile induction of general anesthesia (VIGA). The current analysis aimed to identify whether bispectral index (BIS) variations reliably reflect the actual depth of general anesthesia during presence of different types of epileptiform patterns (EPs) in EEGs during induction of general anesthesia. METHODS: Sixty patients receiving either VIGA with sevoflurane using increasing concentrations (group VIMA) or vital capacity (group VCRII) technique or intravenous single dose of propofol (group PROP) were included. Monitoring included facial electromyography (fEMG), fraction of inspired sevoflurane (FiAA), fraction of expired sevoflurane (FeAA), minimal alveolar concentration (MAC) of sevoflurane, BIS, standard EEG, and hemodynamic parameters. RESULTS: In the PROP group no EPs were observed. During different stages of VIGA with sevoflurane in the VIMA and VCRII groups, presence of polyspikes and rhythmic polyspikes in patients' EEGs resulted in artifactual BIS values indicating a false awareness/wakefulness from anesthesia, despite no concomitant change of FiAA, FeAA, and MAC of sevoflurane. Periodic epileptiform discharges did not result in aberrant BIS values. CONCLUSION: Our results suggest that raw EEG correlate it with values of BIS, FiAA, FeAA, and MAC of sevoflurane during VIGA. It seems that because artifactual BIS values indicating false awareness/wakefulness as a result of presence of polyspikes and rhythmic polyspikes in patients' EEGs may be misleading to an anesthesiologist, leading to unintentional administration of toxic concentration of sevoflurane in ventilation gas.

Personalised Approach to Diagnosing and Managing Ischemic Stroke with a Plasma-Soluble Urokinase-Type Plasminogen Activator Receptor.

BACKGROUND: The increasing incidence of ischemic stroke has led to the search for a novel biomarker to predict the course of disease and the risk of mortality. Recently, the role of the soluble urokinase plasminogen activator receptor (suPAR) as a biomarker and indicator of immune system activation has been widely examined. Therefore, the aim of the current study was to assess the dynamics of changes in serum levels of suPAR in ischemic stroke and to evaluate the prognostic value of suPAR in determining mortality risk. METHODS: Eighty patients from the Department of Neurology, diagnosed with ischemic stroke, were enrolled in the study. Residual blood was obtained from all the patients on the first, third and seventh days after their ischemic stroke and the concentrations of suPAR and C-reactive protein (CRP), as well as the number of leukocytes and National Institute of Health's Stroke Scale (NIHSS) scores, were evaluated. RESULTS: On the first day of ischemic stroke, the average suPAR concentration was 6.55 ng/mL; on the third day, it was 8.29 ng/mL; on the seventh day, it was 9.16 ng/mL. The average CRP concentration on the first day of ischemic stroke was 4.96 mg/L; on the third day, it was 11.76 mg/L; on the seventh day, it was 17.17 mg/L. The number of leukocytes on the first day of ischemic stroke was 7.32 × 103/mm3; on the third day, it was 9.27 × 103/mm3; on the seventh day, it was 10.41 × 103/mm3. Neurological condition, which was assessed via the NIHSS, on the first day of ischemic stroke, was scored at 10.71 points; on the third day, it was scored at 12.34 points; on the seventh day, it was scored at 13.75 points. An increase in the values of all the evaluated parameters on the first, third and seventh days of hospitalisation was observed. The patients with hypertension, ischemic heart disease and type 2 diabetes showed higher suPAR and CRP concentrations at the baseline as well as on subsequent days of hospitalisation. The greatest sensitivity and specificity were characterised by suPAR-3, where a value above 10.5 ng/mL resulted in a significant increase in mortality risk. Moreover, an NIHSS-1 score above 12 points and a CRP-3 concentration above 15.6 mg/L significantly increased the risk of death in the course of the disease. CONCLUSIONS: The plasma suPAR concentration after ischemic stroke is strongly related to the patient's clinical status, with a higher concentration on the first and third days of stroke resulting in a poorer prognosis at a later stage of treatment. Therefore, assessing the concentration of this parameter has important prognostic value.

Adverse Events during Vitreoretinal Surgery under Adequacy of Anesthesia Guidance-Risk Factor Analysis.

Vitreoretinal surgeries require the administration of general anesthesia (GA) in selected groups of patients. The administration of intraoperative rescue narcotic analgesia (IRNA) during GA poses the risk of postoperative nausea and vomiting (PONV). The surgical pleth index (SPI), a crucial component of the adequacy of anesthesia (AoA) guidance of GA, optimizes the intraoperative titration of IRNA. The current analysis evaluated the risk factors for the occurrence of PONV and the oculo-cardiac reflex (OCR) in patients undergoing pars plana vitrectomy (PPV) under AoA guidance. In total, 175 patients undergoing PPV were randomly allocated to receive either GA with SPI-guided IRNA administration using fentanyl alone or in addition to different preoperative analgesia techniques. Any incidence of PONV or OCR was recorded. Obesity, overweight, smoking status, motion sickness, postoperative intolerable pain perception, female gender, fluid challenge and arterial hypertension did not correlate with an increased incidence of PONV or OCR under AoA guidance. Diabetes mellitus, regardless of insulin dependence, was found to correlate with the increased incidence of PONV. The AoA regimen including SPI guidance of IRNA presumably created similar conditions for individual subjects, so no risk factors of the occurrence of PONV or OCR were found, except for diabetes mellitus. We recommend using AoA guidance for GA administration to reduce OCR and PONV rates.

Adequacy of Anesthesia and Pupillometry for Endoscopic Sinus Surgery.

Inadequate intraoperative analgesia causes the deterioration of the condition of the surgical field (CSF) as a result of hemodynamic instability. Analgesia monitors are used to guide remifentanil) infusion to optimize intraoperative analgesia. The main aim of the current randomized controlled trial was to investigate the potential advantages of intraoperative analgesia monitoring using surgical Pleth index (SPI)- or pupillometry (PRD)-guided remifentanil administration for managing the volume of total intraoperative blood loss (TEIBL), CSF, and length of operation (LOP) in comparison with the standard practice in patients undergoing endoscopic sinus surgery (ESS). The 89 patients in our study were grouped as follows: 30 patients were assigned to the general analgesia (GA) group, 31 patients were assigned to the SPI group, and 28 patients were assigned to the PRD group. The speed of remifentanil infusion was accelerated by 50% when SPI, PRD, or BSS were increased by >15 points, >5%, or >2, respectively, in adjacent groups until their normalization. The SPI group showed significantly lower TEIBL in comparison to the GA group (165.2 ± 100.2 vs. 283.3 ± 193.5 mL; p < 0.05) and a higher mean arterial pressure (MAP; 73.9 ± 8 vs. 69.2 ± 6.8 mmHg; p < 0.05). In the PRD group, a shorter LOP compared with the GA group was observed (63.1 ± 26.7 min vs. 82.6 ± 33.1 min; p < 0.05). It was noted that the PRD group had a lower total remifentanil consumption than the SPI group (1.3 ± 1.4 vs. 1.8 ± 0.9 mg; p < 0.05). In ASA I-III patients undergoing ESS, intraoperative monitoring based on state entropy and SPI values can optimize the CSF and reduce TEIBL, whereas monitoring based on state entropy and PRD measurements can optimize the cost effectiveness of anesthetic drugs and the use of the operation room.

Adverse Events during Vitrectomy under Adequacy of Anesthesia-An Additional Report.

The intraprocedural immobilization of selected subsets of patients undergoing pars plana vitrectomy (PPV) requires the performance of general anesthesia (GA), which entails the intraoperative use of hypnotics and titration of opioids. The Adequacy of Anesthesia (AoA) concept of GA guidance optimizes the intraoperative dosage of hypnotics and opioids. Pre-emptive analgesia (PA) is added to GA to minimize intraoperative opioid (IO) usage. The current additional analysis evaluated the advantages of PA using either COX-3 inhibitors or regional techniques when added to AoA-guided GA on the rate of presence of postoperative nausea and vomiting (PONV), oculo-emetic (OER), and oculo-cardiac reflex (OCR) in patients undergoing PPV. A total of 176 patients undergoing PPV were randomly allocated into 5 groups: (1) Group GA, including patients who received general anesthesia alone; (2) Group T, including patients who received preventive topical analgesia by triple instillation of 2% proparacaine 15 min before induction of GA; (3) Group PBB, including patients who received PBB; (4) Group M, including patients who received PA using a single dose of 1 g of metamizole; (5) Group P, including patients who received PA using a single dose of 1 g of acetaminophen. The incidence rates of PONV, OCR, and OER were studied as a secondary outcome. Despite the group allocation, intraoperative AoA-guided GA resulted in an overall incidence of PONV in 9%, OCR in 12%, and OER in none of the patients. No statistically significant differences were found between groups regarding the incidence of OCR. PA using COX-3 inhibitors, as compared to that of the T group, resulted in less overall PONV (p < 0.05). Conclusions: PA using regional techniques in patients undergoing PPV proved to have no advantage when AoA-guided GA was utilised. We recommend using intraoperative AoA-guided GA to reduce the presence of OCR, and the addition of PA using COX-3 inhibitors to reduce the rate of PONV.

Adequacy of Anesthesia Guidance for Colonoscopy Procedures.

In patients undergoing colonoscopy procedures (CPs), inadequate dosing of hypnotic drugs (HD) and opioid analgesics (OA) during intravenous sedoanalgesia (ISA) may lead to intraprocedural awareness with recall (IAwR), intraprocedural (IPP) and postprocedural pain (PPP), as well as postoperative nausea and vomiting (PONV). The aim of this study was to evaluate whether the titration of HD and OA based on the observance of changing values of state entropy (SE) and surgical pleth index (SPI) (adequacy of anesthesia-AoA), state entropy alone, or standard practice may reduce the number of adverse events. One hundred and fifty-eight patients were included in the final analysis. The rate of IAwR and IPP was statistically more frequent in patients from the C group in comparison with the AoA and SE groups (p < 0.01 and p < 0.05, respectively). In turn, the rate of PPP, PONV, and patients' and operators' satisfaction with ISA between groups was not statistically significant (p > 0.05). Changes in hemodynamic parameters, demand for HD, and OA were statistically significant, but of no clinical value. In patients undergoing CPs under ISA using propofol and FNT, as compared to standard practice, intraprocedural SE monitoring reduced the rate of IAwR and IPP, with no influence on the rate of PPP, PONV, or patients' and endoscopists' satisfaction. AoA guidance on propofol and FNT titration, as compared to SE monitoring only, did not reduce the occurrence of the aforementioned studied parameters, imposing an unnecessary extra cost.

Preventive Analgesia, Hemodynamic Stability, and Pain in Vitreoretinal Surgery.

Background and Objectives: Although vitreoretinal surgery (VRS) is most commonly performed under regional anaesthesia (RA), in patients who might be unable to cooperate during prolonged procedures, general anaesthesia (GA) with intraprocedural use of opioid analgesics (OA) might be worth considering. It seems that the surgical pleth index (SPI) can be used to optimise the intraprocedural titration of OA, which improves haemodynamic stability. Preventive analgesia (PA) is combined with GA to minimise intraprocedural OA administration. Materials and Methods: We evaluated the benefit of PA combined with GA using SPI-guided fentanyl (FNT) administration on the incidences of PIPP (postprocedural intolerable pain perception) and haemodynamic instability in patients undergoing VRS (p < 0.05). We randomly assigned 176 patients undergoing VRS to receive GA with SPI-guided FNT administration alone (GA group) or with preventive topical 2% proparacaine (topical anaesthesia (TA) group), a preprocedural peribulbar block (PBB) using 0.5% bupivacaine with 2% lidocaine (PBB group), or a preprocedural intravenous infusion of 1.0 g of metamizole (M group) or 1.0 g of paracetamol (P group). Results: Preventive PBB reduced the intraprocedural FNT requirement without influencing periprocedural outcomes (p < 0.05). Intraprocedural SPI-guided FNT administration during GA resulted in PIPP in 13.5% of patients undergoing VRS and blunted the periprocedural effects of preventive intravenous and regional analgesia with respect to PIPP and haemodynamic instability. Conclusions: SPI-guided FNT administration during GA eliminated the benefits of preventive analgesia in the PBB, TA, M, and P groups following VRS.

Variations in Values of State, Response Entropy and Haemodynamic Parameters Associated with Development of Different Epileptiform Patterns during Volatile Induction of General Anaesthesia with Two Different Anaesthetic Regimens Using Sevoflurane in Comparison with Intravenous Induct: A Comparative Study.

BACKGROUND AND OBJECTIVES: Raw electroencephalographic (EEG) signals are rarely used to monitor the depth of volatile induction of general anaesthesia (VIGA) with sevoflurane, even though EEG-based indices may show aberrant values. We aimed to identify whether response (RE) and state entropy (SE) variations reliably reflect the actual depth of general anaesthesia in the presence of different types of epileptiform patterns (EPs) in EEGs during induction of general anaesthesia. MATERIALS AND METHODS: A randomized, prospective clinical study was performed with 60 patients receiving VIGA using sevoflurane with the increasing concentrations (group VIMA) or the vital capacity (group VCRII) technique or an intravenous single dose of propofol (group PROP). Facial electromyography (fEMG), fraction of inspired sevoflurane (FiAA), fraction of expired sevoflurane (FeAA), minimal alveolar concentration (MAC) of sevoflurane, RE and SE, and standard electroencephalographic evaluations were performed in these patients. RESULTS: In contrast to periodic epileptiform discharges, erroneous SE and RE values in the patients' EEGs were associated with the presence of polyspikes (PS) and rhythmic polyspikes (PSR), which were more likely to indicate toxic depth rather than false emergence from anaesthesia with no changes in the FiAA, FeAA, and MAC of sevoflurane. CONCLUSION: Calculated RE and SE values may be misleading during VIGA when EPs are present in patients' EEGs. During VIGA with sevoflurane, we recommend monitoring raw EEG data in scientific studies to correlate it with potentially erroneous RE and SE values and the end-tidal concentration of sevoflurane in everyday clinical practice, when monitoring raw EEG is not available, because they can mislead anaesthesiologists to reduce sevoflurane levels in the ventilation gas and result in unintentional true emergence from anaesthesia. Further studies are required to investigate the behaviour of EEG-based indices during rapid changes in sevoflurane concentrations at different stages of VIGA and the influence of polyspikes and rhythmic polyspikes on the transformation of EEG signals into a digital form.

Epileptiform EEG patterns during different techniques of induction of general anaesthesia with sevoflurane and propofol: a randomised trial.

BACKGROUND: The aim of the study was to assess the influence of volatile induction of general anaesthesia with sevoflurane using two different techniques and intravenous anaesthesia with propofol on the possible presence of epileptiform electroencephalograph patterns during the induction of general anaesthesia. METHODS: Sixty patients (age 18-70 years) were recruited. Exclusion criteria included history of epilepsy, neurological or neurosurgical diseases, pre-existing EPs in initial EEG recordings, medication interfering with EEG patterns. Patients were randomly allocated into three different groups: A (sevoflurane, increasing concentrations technique); B (sevoflurane, vital capacity technique); C (intravenous propofol). The clinical and instrumental monitoring included arterial blood pressure, heart rate, standard electrocardiography II, arterial oxygen saturation, facial electromyography, fraction of inspired sevoflurane, fraction of expired sevoflurane, minimal alveolar concentration of sevoflurane, and BIS. RESULTS: Neurophysiological analysis of EEGs showed different EPs: polyspikes (PS), rhythmic polyspikes (PSR), and periodic epileptiform discharges (PED). EPs (p < 0.05) were observed in Group A (56%) and Group B (37%), but not in Group C. One patient in group B presented with clinical seizures. No significant differences in the vital parameters and anaesthesia parameters between groups was observed, regardless of the presence of EPs, which were associated with both low and more likely high (falsely indicating awakening from anaesthesia) BIS scores. CONCLUSION: Our study shows that the BIS score variations do not detect epileptiform activity, which was associated with both low and high scores. The sevoflurane concentration reached either sedative or toxic concentrations.

Risk factors for occurrence of failed interscalene brachial plexus blocks for shoulder arthroscopy using 20 mL 0.5% ropivacaine: a randomised trial.

BACKGROUND: Adequate pain management after arthroscopic procedures improves patients' satisfaction with the performed procedure, as well as facilitating early rehabilitation. The aim of the current randomised, prospective clinical study was to assess the influence of anthropometric parameters and the interscalene brachial plexus block (IBPB) technique on the quality of post-operational analgesia. METHODS: 109 randomly selected patients of ASA I-III status were scheduled for elective shoulder arthroscopy. Reasons for non-inclusion were as follows: neurological deficit in the upper arm; allergies to amide Las; coagulopathy; and pregnancy. The patients received 20 mL of 0.5% ropivacaine for an ultrasound (US)-guided IBPB (group U), peripheral nerve stimulation (PNS)-confirmation IBPB (group N), or US-guided, PNS-confirmed IBPB (dual guidance; group NU). RESULTS: We observed that the studied groups did not differ in mean time of sensory and motor block terminations and, surprisingly, in each group in individual cases the sensory block lasted up to 890-990 minutes providing satisfactory long-lasting post-operational analgesia in patients receiving IBPB. We observed a negative correlation between BMI and termination of the motor block and a positive correlation between age and termination of the sensory block in patients receiving US-guided IBPB (group U) in comparison with the two other groups. We found a positive correlation between the male gender and termination of the motor block in patients receiving PNS-guided IBPB (group N) in comparison with two other groups. CONCLUSION: In our study, patients received satisfactory analgesia in the post-operational period no matter what technique was used regardless of their age, gender or potentially uncommon anthropometry.

Risk factors for the development of Horner's syndrome following interscalene brachial plexus block using ropivacaine for shoulder arthroscopy: a randomised trial.

BACKGROUND: Horner's syndrome is comprised of a set of symptoms caused by a permanent or transient ipsilateral sympathetic trunk lesion or paralysis. It may occur after numerous pathologies in the cervical region, epidural, spinal anaesthesia, and interscalene, transscalene, supraclavicular, or infraclavicular brachial plexus block. The aim of this randomised, prospective clinical study was to evaluate the effect of the interscalene brachial plexus block (IBPB) technique on the occurrence rate of Horner's syndrome and identify contributing risk factors. METHODS: 108 randomly selected patients of ASA I-III status were scheduled for elective shoulder arthroscopy. The patients received 20 mL of 0.5% ropivacaine either with ultrasound (US)-guided IBPB (U), peripheral nerve stimulation (PNS)-confirmation IBPB (N), or US-guided, PNS-confirmed IBPB (dual guidance; NU). RESULTS: We observed that Horner's syndrome developed in 12% of the N group, 6% of the NU group, and 9% of the U group. The differences in the rates were not statistically significant (P = 0.616). Regardless of the technique used to induce IBPB, our study did not demonstrate any particular anthropometric parameter that predisposed the patients to the development of Horner's syndrome. Interestingly, our results showed that NU patients with Horner's syndrome were significantly younger than NU patients without Horner's syndrome. CONCLUSION: The precision of IBPB by use of the dual guidance technique may reduce the rate of Horner's syndrome. The higher water concentration in the prevertebral spaces of younger patients may create better conditions for the diffusion of ropivacaine, which may result in a statistically significant higher HS rate.

Randomised controlled trial of analgesic effectiveness of three different techniques of single-shot interscalene brachial plexus block using 20 mL of 0.5% ropivacaine for shoulder arthroscopy.

BACKGROUND: Shoulder arthroscopic procedures impose a challenge to anaesthesiologists in terms of postoperative analgesia. Proper pain management after arthroscopic procedures improves patient satisfaction and facilitates early rehabilitation. METHODS: We performed a randomized, prospective clinical study to assess the influence of anthropometric parameters and IBPB technique on the quality of postoperative analgesia. A total of 106 randomly selected patients of ASA I-III status scheduled for elective shoulder arthroscopy. Reasons for exclusion were neurological deficit in the upper arm, allergies to amide-type local anesthetics, coagulopathy, and pregnancy.The patients received 20 mL of 0.5% ropivacaine for an ultrasound-guided interscalene brachial plexus block (IBPB) (group U), peripheral nerve stimulation (PNS)-confirmed IBPB (group N), or ultrasound-guided, PNS-confirmed IBPB (dual guidance; group NU). RESULTS: We observed that the three groups did not differ in mean time of sensory and motor block terminations. In individual cases in each group, sensory block lasted up to 890-990 minutes, providing satisfactory long lasting postoperative analgesia in patients receiving IBPB. We observed a negative correlation between body mass index and termination of motor block (P = 0.037, Pearson's correlation coefficient) and a positive correlation between age and termination of sensory block (P = 0.0314, Pearson's correlation coefficient) in group U compared to the other two groups. We found a positive correlation between male gender and termination of motor block (P = 0.0487, Pearson's correlation coefficient) in group N compared to the other two groups. CONCLUSION: In our study, patients received satisfactory analgesia in the postoperative period regardless of technique used, age, gender, or potentially uncommon anthropometry.

Randomized, comparative study of the effectiveness of three different techniques of interscalene brachial plexus block using 0.5% ropivacaine for shoulder arthroscopy.

BACKGROUND: Interscalene brachial plexus block is an effective regional anesthesia technique for shoulder surgeries. The superiority of the popular ultrasound-guided blocks over peripheral nerve stimulator-confirmed blocks remains unclear. In this study the efficacy of these different block techniques was compared. METHODS: This prospective, randomized, clinical study included 109 patients (ASA grades I-III) who receive 20 mL 0.5% ropivacaine with ultrasound-guided blocks (U group), peripheral nerve stimulator-confirmed blocks (N group), or ultrasound-guided and peripheral nerve stimulator-confirmed blocks (dual guidance; NU group) for elective shoulder arthroscopy. Block onset time, duration, and effectiveness on the Lovett rating scale were assessed. RESULTS: There was no statistically significant intergroup difference in duration of block performance, irrespective of the technique (P = 0.232). Onset time of complete warmth sensation loss (P < 0.001) and muscle strength abolition (P < 0.001) was significantly longer and mean Lovett rating scale score distribution was significantly higher in the N group than in the other groups (P < 0.001). These findings show a statistically significant correlation between the performance of the used block technique and the necessity of conversion to general anesthesia because of insufficient block in the N group (58.54%) than in the U (24.44%) and NU (19.57%) groups. CONCLUSIONS: Peripheral nerve stimulator-confirmed needle placement is not necessary to ensure effectiveness of ultrasound-guided blocks, which is expressed as a lack of necessity of conversion to general anesthesia. Nevertheless, the dual guidance technique is recommended to reduce the risk of complications and might be considered the regional anesthesia of choice for shoulder surgery.

Utility of serum concentration of protein S100 at admission to the medical intensive care unit in prediction of permanent neurological injury.

INTRODUCTION: Admission to the intensive care unit (ICU) may be preceded by dramatic events leading to permanent neurological injury. Plasma S100 protein levels are proved to be clinically useful in predicting neurological outcome following cardiac arrest. It is unclear, however, whether this may be extrapolated to a broader population of ICU patients. AIM: To assess the utility of plasma S100 protein in predicting death, permanent neurological damage, or unfavourable outcome at admission to the intensive care unit. MATERIAL AND METHODS: The concentration of plasma S100 protein was established in 102 patients on admission to the ICU, regardless of their neurological status and the reason for admission. The majority of patients were admitted with various cardiac diseases, excluding trauma patients. The patients were classified into three groups with the following binary outcomes: permanent neurological deficit or restoration of consciousness; unfavourable outcome (death or survival with permanent neurological deficit) or favourable outcome; and death or survival. RESULTS: Plasma S100 protein levels at admission facilitated the identification of patients who later developed a permanent neurological deficit or regained consciousness (p < 0.0001). All patients with plasma S100 protein over 0.532 µg/l at ICU admission either developed a permanent neurological deficit or had an unfavourable outcome (death or survival with permanent neurological deficit). However, sensitivity for this cut-off value was only 48% and 40%, respectively. CONCLUSIONS: Plasma S100 protein levels over 0.532 µg/l are specific but not sensitive for both permanent neurological deficit and unfavourable outcome when assessed in a heterogeneous population at admission to the ICU.

Penetrating brain injury: a case report.

BACKGROUND: Gunshot wounds as a result of attempted suicide, criminality or warfare comprise a significant group among penetrating injuries of the brain. A prognosis in such cases is based mainly on an initial score on the Glasgow Coma Scale (GCS). According to the literature, the mortality rate among patients with initial GCS ranging from 3 to 5 points is very high, up to 98.5%. Although there are also many other prognostic factors for high mortality, such as damage to the ventricular system or the involvement of two or more lobes, GCS score seems to be the most important determinant. The treatment in an ICU which is focused on decreasing the risk of secondary brain damage can significantly improve the prognosis and final outcome. CASE REPORT: The authors present the case of a 27-year-old man who suffered a gunshot wound to the right temporal region, self-inflicted from an air-gun. On admission to the intensive care unit he received a score of 3 points on the GCS. There were also other negative prognostic factors - the pellet penetrated two lobes and damaged the third ventricle. Despite the serious prognosis, the appropriate multiprofile treatment and rehabilitation resulted in unexpectedly good recovery. Two years after the trauma the patient was conscious, maintained logical verbal contact, and was able to walk using a walking-aid. CONCLUSION: Rapid transport to a major trauma center is essential for patients with penetrating brain injury. Among all interventions it seems essential to provide the prevention of posttraumatic nervous tissue damage and associated neurological dysfunction.

Evaluation of usefulness of hs-CRP and ferritin assays in patients with nasal polyps.

BACKGROUND: Chronic nature of the nasal polyps, tendency to recurrence, and lack of satisfying treatment need the diagnostic's parameters which show early inflammatory state as ferritin and hs-CRP. The Aim of Study. Assessment of hs-CRP and ferritin blood levels in nasal polyps patients in evaluation of treatment efficacy. METHODS: All 38 patients were divided into 2 groups. Group I included 19 patients with anti-inflammatory therapy 2 weeks after surgery. Group II included 19 patients without anti-inflammatory therapy 2 weeks after surgery. The levels of hs-CRP and ferritin have been assessed before and 2 and 6 weeks after surgical treatment. RESULTS: Research showed statistically significant difference of ferritin's concentration between examined groups 6 weeks after surgery (P < 0.05) and statistically significant difference of hs-CRP concentration 2 and 6 weeks after surgery (P < 0.05). CONCLUSION: (1) The analysis of serum ferritin and hs-CRP concentrations can be useful in early postoperative detection of inflammatory state in patients with nasal polyps and for the effectiveness of therapy. (2) Lack of correlation between mean ferritin and hs-CRP serum levels, at each diagnostic and monitoring stage, shows that they are independent and cannot be determined interchangeably.

VEGF and metalloproteinase 2 (MMP 2) expression in gastric cancer tissue.

BACKGROUND: Neoplasms are the second leading cause of death in Poland after vessel diseases, despite the huge progress in medical sciences in the last 20 years. Recently, gastric cancer morbidity has decreased, but mortality is still at a high level. MATERIAL/METHODS: Tissues from 24 patients with a histopathologically diagnosed mucosal and adenomucosal gastric cancer were tested. Patients were divided into 2 equal groups: patients without metastases (G1) and patients with metastases in the liver (G2). In all tested tissues of G1 and G2, the expression of VEGF (vascular endothelial growth factor) and metalloproteinase 2, respectively, were estimated. RESULTS: Results revealed a statistically significant increase in the VEGF expression for G1 and G2 in relation to the margin (p1<0.001; p2<0.001). The increase of gene expression for VEGF did not significantly differ statistically in G1 and G2. The obtained results revealed a statistically significant difference in the increase of gene expression for MMP-2 in G1 in relation to the margin (p<0.05) and a very high one in G2 in relation to the average margin value (p<0.001). A highly statistically significant correlation was obtained for VEGF and MMP-2 in the tissue of patients with metastases (p<0.001; r=0.714). The highly elevated expression of MMP-2 in the tissue of gastric cancer in patients with metastases confirms its participation in the invasiveness of the neoplasmatic process. CONCLUSIONS: The highly significant correlation between VEGF and MMP-2 suggests a connection between both mechanisms in the progression of gastric cancer.

Automatic detection and analysis of the EEG sharp wave-slow wave patterns evoked by fluorinated inhalation anesthetics.

OBJECTIVE: The aim of this study was to develop a method for the automatic detection of sharp wave-slow wave (SWSW) patterns evoked in EEG by volatile anesthetics and to identify the patterns' characteristics. METHODS: The proposed method consisted in the k-NN classification with a reference set obtained using expert knowledge, the morphology of the EEG patterns and the condition for their synchronization. The decision rules were constructed and evaluated using 24h EEG records in ten patients. RESULTS: The sensitivity, specificity and selectivity of the method were 0.88 ± 0.10, 0.81 ± 0.13 and 0.42 ± 0.16, respectively. SWSW patterns' recruitment was strictly dependent on anesthetic concentration. SWSW patterns evoked by different types of anesthetics expressed different characteristics. CONCLUSIONS: Synchronization criterion and adequately selected morphological features of "slow wave" were sufficient to achieve the high sensitivity and specificity of the method. SIGNIFICANCE: The monitoring of SWSW patterns is important in view of possible side effects of volatile anesthetics. The analysis of SWSW patterns' recruitment and morphology could be helpful in the diagnosis of the anesthesia effects on the CNS.

Usefulness of ultrasound guidance for central venous catheterisation in patients with end-stage renal disease.

BACKGROUND: Renal replacement therapy often requires the insertion of a central venous catheter. The procedure is invasive and can lead to a number of complications. To minimise the risk of such complications, ultrasonography is used. The aim of the present study was to assess the usefulness of ultrasound-assisted vs. traditional method of location of anatomical orientation points for the placement of central venous catheters. METHODS: . The prospective and randomised study was carried out, which included 135 patients requiring central venous catheterisation. Patients were allocated into two groups: group I (without ultrasound) - 70 patients and group II (ultrasound guidance) - 65 patients. In the latter, the procedure was performed in 38 cases due to technical problems. The following parameters were compared: age, patient's condition, results of blood clotting tests, and selected renal function parameters. Moreover, the mode of procedure (emergent, scheduled), factors directly affecting the efficacy of catheter insertion and complications (use of anticoagulants, anatomical variants, sites of access, number of cannulation attempts) were analysed. RESULTS. Ultrasound was significantly more commonly used during emergent cannulation procedures (P = 0.002), in the elderly (P = 0.001) and unconscious patients (P = 0.001). Moreover, it was more frequently applied in patients undergoing anticoagulation (P = 0.01) and during the insertion of access through the subclavian and femoral vein (P = 0.013). The percentage of successful first attempt cannulation was higher in ultrasound-guided cases (P = 0.013). There were no significant intergroup differences in the incidence of early complications (P = 0.269). CONCLUSIONS: The study findings did not demonstrate significant differences in the incidence of early complications during cannulation with and without ultrasound guidance. The first attempt success rate was found to be significantly higher in cases of ultrasound-assisted central venous catheterisation.