Croatian national audit on videolaryngoscopes and alternative intubation devices in the era of COVID-19 pandemic.

INTRODUCTION: Videolaryngoscopy (VL) is the recommended strategy for airway management in COVID-19 patients and guidelines recommends that all anesthesiologists should be trained to use and have immediate access to the device. However, the availability of VL in hospitals and its use may vary, as well as the choice of the device and necessary training. Our primary aim was to investigate data on availability of VL in Croatia, its use, the choice of the device and its implementation, with special consideration of COVID-19 management. MATERIALS AND METHODS: An electronic survey was sent to all Croatian hospitals that have anesthesiology service available. The survey was designed to examine data on availability and use of VL with special consideration of COVID-19 wards. The survey was conducted between 1.03.2021 and 30.08.2021. RESULTS: Response rate was 83%. VL was available in 86% of hospitals and the best supplied areas were intensive care units, general surgery and gynecology/obstetrics. The most common VL devices were Bonfils, C-MAC and C-MAC D-blade. The choice of VL was mainly based on centralized hospital procurement and informal introduction was found to be the most frequent training method. The VL was mainly used in Croatian hospitals in cases of difficult airway or as a backup method after failed intubation. Only 16% of hospitals reported regular use in everyday practice. Even though, VL was available in 64% of COVID-19 wards, only 21% of hospitals reported routine use. CONCLUSION: Although VL is available in the majority of Croatian hospitals, its use is still mainly restricted to difficult airway scenarios. Use of VL in COVID-19 management is also low and education on the method is still mainly informal. Based upon our results better implementation in practice should be targeted, as well as formal skill trainings especially regarding COVID-19 care.

CROATIAN VERSION OF THE QUALITY OF RECOVERY QUESTIONNAIRE (QoR-40): TRANSCULTURAL ADAPTATION AND VALIDATION.

The Quality of Recovery-40 (QoR-40) questionnaire is a psychometric instrument designed to quantify postoperative recovery. It has been translated and validated in several countries but not in Croatia. The aim was to translate, cross-culturally adapt, and validate Croatian version of the QoR-40. The QoR-40 was translated from English by two independent translators, back-translated by a native speaker, and approved by an expert committee. The questionnaire was administered to 106 patients who underwent general anesthesia before elective spinal surgery, post-surgery in the operating room, and 30 days after surgery. Internal consistency was assessed using the Cronbach's alpha coefficient. Construct validity was assessed by evaluating correlation between the QoR-40 and hand grip strength. The mean preoperative global QoR-40 score was 177.6 (95% CI 174.9-180.3) and postoperative 168.9 (95% CI 165.8-171.9); the mean change was -8.8 (95% CI -11.9 to -5.6). Internal consistency was good for global QoR-40 score (Cronbach α=0.896), acceptable across all domains (8>α≥7). There was a significant correlation between grip strength and total QoR-40 score, pain, and physical independence, but not with other domains. In conclusion, the Croatian version of the QoR-40 has acceptable properties and can be used in the assessment of postoperative recovery in Croatian patients.

Effect of adjunctive lidocaine-based scalp block and laryngotracheal local anesthesia vs general anesthesia only on plasma and cerebrospinal fluid pro-inflammatory cytokine concentrations in patients with cerebral aneurysm: a randomized controlled trial.

AIM: To compare the effect of adjunctive lidocaine-based scalp block and laryngotracheal local anesthesia vs general anesthesia only on pro-inflammatory cytokine concentrations in patients with non-ruptured brain aneurysms undergoing elective open surgery. METHODS: This parallel, randomized, controlled, open-label trial was conducted at Clinical Hospital Center Zagreb between March 2019 and March 2020. At the beginning of anesthesia, lidocaine group received 40 mg of 2% lidocaine for laryngotracheal topical anesthesia and 4 mg/kg for the scalp block. Control group underwent general anesthesia only. Plasma concentrations of IL-6, TNF-α, and IL-1ß were measured before anesthesia (S0); at the incision (S1); at the end of surgery (S2); 24 hours postoperatively (S3). Cerebrospinal fluid (CSF) cytokine concentrations were measured at the incision (L1) and the end of surgery (L2). RESULTS: Forty patients (each group, 20) were randomized; 37 were left in the final analysis. IL-6 plasma concentrations increased significantly compared with baseline at S3 in lidocaine group, and at S2 and S3 in control group. In both groups, changes in TNF-α and IL-1ß were not significant. CSF cytokine concentrations in lidocaine group did not change significantly; in control group IL-6 and IL-1ß were significantly higher at L2 than at L1. CSF IL-6 in control group significantly increased at L2, but TNF-α and IL-1ß did not. No differences in clinical outcome and complication rates were observed. CONCLUSION: Adjunctive lidocaine-based scalp block and laryngotracheal local anesthesia might attenuate CSF IL-6 concentration increase in patients with brain aneurysm.

Effect of local anesthesia with lidocaine on perioperative proinflammatory cytokine levels in plasma and cerebrospinal fluid in cerebral aneurysm patients: Study protocol for a randomized clinical trial.

BACKGROUND: Cerebral aneurysm surgery has significant mortality and morbidity rate. Inflammation plays a key role in the pathogenesis of intracranial aneurysms, their rupture, subarachnoid hemorrhage and neurologic complications. Proinflammatory cytokine level in blood and cerebrospinal fluid (CSF) is an indicator of inflammatory response. Cytokines contribute to secondary brain injury and can worsen the outcome of the treatment. Lidocaine is local anesthetic that can be applied in neurosurgery as regional anesthesia of the scalp and as topical anesthesia of the throat before direct laryngoscopy and endotracheal intubation. Besides analgesic, lidocaine has systemic anti-inflammatory and neuroprotective effect.Primary aim of this trial is to determine the influence of local anesthesia with lidocaine on the perioperative levels of pro-inflammatory cytokines interleukin-1ß, interleukin-6, and tumor necrosis factor-α in plasma and CSF in cerebral aneurysm patients. METHODS: We will conduct prospective randomized clinical trial among patients undergoing craniotomy and cerebral aneurysm clipping surgery in general anesthesia. Patients included in the trial will be randomly assigned to the lidocaine group (Group L) or to the control group (Group C). Patients in Group L, following general anesthesia induction, will receive topical anesthesia of the throat before endotracheal intubation and also regional anesthesia of the scalp before Mayfield frame placement, both done with lidocaine. Patients in Group C will have general anesthesia only without any lidocaine administration. The primary outcomes are concentrations of cytokines interleukin-1ß, interleukin-6 and tumor necrosis factor-α in plasma and CSF, measured at specific timepoints perioperatively. Secondary outcome is incidence of major neurological and infectious complications, as well as treatment outcome in both groups. DISCUSSION: Results of the trial could provide insight into influence of lidocaine on local and systemic inflammatory response in cerebrovascular surgery, and might improve future anesthesia practice and treatment outcome. TRIAL IS REGISTERED AT CLINICALTRIALS.GOV:: NCT03823482.

Peripheral arterial catheter related infections in the neurosurgical intensive care unit.

Intravascular device infections could be serious complications with significant contributable morbidity and mortality. The aim of this prospective clinical study is to demonstrate the infection rate related to peripheral arterial catheters and their clinical significance in neurosurgical intensive care unit (ICU) patients. After removal, all arterial catheter tips were cultivated by semiquantitative method and clinical data were collected. During a period of two years, 186 arterial catheters were placed in 105 neurosurgical ICU patients. In 6 cases (3.2%) infection was presumably related to the arterial catheter. The rate of such probable catheter related infections was found to be 5/1000 catheter days. The isolated microorganisms were: Methicillin resistant Staphylococcus epidermidis (MRSE) in 4 cases, Corynebacterium species and Candida albicans each in one case respectively. Thirteen cases (7.0%) were interpreted as contamination and one as colonization. An association was found between the presence of infection from different sources and significant bacterial growth on the catheter. Patients with positive catheter culture had a significantly longer ICU stay, more cumulative catheter days, and a higher mortality rate than those with sterile catheters. We can conclude that the rate of probable peripheral arterial catheter related infection is low. A higher mortality rate in patients who experienced probable catheter related infection does not seem to be a consequence of the aforementioned infection. A more suitable explanation would be that patients with nosocomial infections and higher mortality risk have prolonged ICU stays. There is an increased chance of developing a catheter related infection in those patients who have more cumulative catheter days.

Age and individual sleep characteristics affect cognitive performance in anesthesiology residents after a 24-hour shift.

Previous research has shown that both shift work and sleep deprivation have an adverse influence on various aspects of human cognitive performance. The aim of this study was to explore changes in cognitive functioning and subjective sleepiness of anesthesiology residents after a 24-hour shift. Twenty-six anesthesiology residents completed a set of psychological instruments at the beginning and at the end of the shift, as well as a questionnaire regarding information about the shift, Stanford Sleepiness Scale, and Circadian Type Questionnaire. There was a significant decline in cognitive performance measured by the Auditory Verbal Learning Test after the shift. The effect was stronger in older participants and in those with high scores on rigidity of sleep scale and low scores on the ability to overcome sleepiness scale. There were no differences in the digits forward test (a measure of concentration), while digits backward test (a measure of working memory) even showed an improved performance after the shift. Although participants reported being significantly sleepier after the shift, the subjective sleepiness did not correlate with any of the objective measures of cognitive performance. In conclusion, the performance in short tasks involving concentration and working memory was not impaired, while performance in long-term and monotone tasks declined after sleep deprivation, and the magnitude of this decline depended on the specific individual characteristics of sleep and on age Surprisingly, age seemed to have an important impact on cognitive functions after shift work even in the relatively age-homogeneous population of young anesthesiology residents.

[Word recognition test after general anesthesia: the influence of previous anesthesia]. / Test prepoznavanja rijeci nakon opce anestezije: utjecaj prijasnje anestezije.

Among other higher brain functions such as consciousness and learning, general anesthesia also affects memory. A number of information retrieval tests are performed to determine the effects of drugs on explicit memory. In this study, we investigated the recognition of words before and after general anesthesia in subjects having and not having received anesthesia on one or more occasions before the present one. The study included 51 patients, ASA physical status I or II, median age 50, at least high-school graduates, without head trauma, known psychiatric or memory disorder, and taking no psychoactive medication. A standardized anesthesia technique, a single surgical procedure and a defined study-test interval were used. We designed our own test as a combination of story recall test and brief word learning test, both widely used in psychological and psychiatric examination. There was no significant difference in word recognition before and after general anesthesia in either patient group. Many studies indicate that anesthesia and surgery are associated with cognitive impairment lasting for 33 months in 10%-14% of elderly patients. We hypothesized that general anesthetics can cause prolonged cognitive alterations. Study results showed that previous anesthesia in addition to the current one had no significant influence on the word recognition test.

[Does the anesthesiologist sleep soundly?]. / Spava li anesteziolog cvrsto?

Working in night shifts influences human health, mood, and cognitive functions. Anesthesia residents and consultants work in long shifts that include the night. Changes of cognitive functions may diminish the quality of anesthesiologist's work, increase the number of errors, and endanger the patient. Changes of biological rhythms can influence health of the anesthesiologist himself. The alterations in circulation, metabolism, memory, fine motor control, mood and attention have been recorded. After night work, the possibility of car accident for an anesthesiologist is higher. Attempts have been made to reduce negative influences of night work by shortening the number of working hours during the week. The debate about this step is vivid and still present. From this viewpoint, the most interesting aspects are the quality of educational process, the number of errors in practical work, and the quality of health care. After shortening of working hours, there are no clear indicators of the positive effects in any of these fields. Shortening of the working week is part of 'the culture of safety' in anesthesiology.

[Pathophysiology of delirium]. / Patofiziologija delirija.

Today's understanding of the pathophysiological mechanisms of delirium is still limited, but there are several promising hypotheses. It is believed that biomarkers sensitive to death of neurons or glial cells indicate delirium. Several neurotransmitters are considered to be involved in the state of delirium, with greatest emphasis on acetylcholine and dopamine acting in opposite ways; acetylcholine reduces, while dopamine increases neuron excitability. Other neurotransmitters that probably play a role in the pathogenesis of delirium are GABA, glutamate and monoamines. Sepsis leading to systemic inflammatory response syndrome often presents with delirium and perhaps is the most common causal factor for delirium in intensive care unit; sedatives and analgesics are also common iatrogenic risk factors. Patients receiving benzodiazepines are more likely to have postoperative delirium than those who do not. Postoperative cognitive changes are more common in older than in younger patients, and they can be categorized as postoperative delirium, postoperative cognitive dysfunction and dementia. The mechanisms responsible for postoperative cognitive changes are not fully understood, but it is certain that they are multifactorial. Risk factors may be associated with patient characteristics, type of surgery and type of anesthesia.

Subclinical neurocognitive dysfunction after carotid endarterectomy-the impact of shunting.

BACKGROUND: Subclinical neurocognitive deficit after carotid endarterectomy (CEA) has been reported in 25% of patients. The influence of the type of anesthesia and shunting on early postoperative neurocognitive function remains unclear. Therefore, we analyzed the cognitive function after CEA using a battery of psychometric tests before surgery and on the first postoperative day. METHODS: Twenty nine patients under regional and 28 under general anesthesia were included in the study. Regional anesthesia was administered inducing a superficial cervical block, and the general anesthesia was induced using a standardized manner. Then cognitive function was tested using a battery of psychometric tests before and 24 hours after surgery. S 100 beta was determined at the same time points. RESULTS: A statistical difference was found between the results of the testing before and after CEA: decline in digit symbol test (9%), perceptual speed (6%), and spatial working memory (44%) and improvement in verbal fluency (6%) and attention (5%). The only intraoperative factor that correlated with the cognitive dysfunction was shunt insertion; patients with a shunt had a lower perceptual speed (P=0.005) and worse spatial working memory (P=0.004). No correlation was found between the type of anesthesia or S 100 beta level and any psychometric test, but these results might be influenced by the small sample size in our study. CONCLUSIONS: Shunt insertion was the only parameter correlated with cognitive decline on the first day after CEA. Regional anesthesia might offer indirect benefit because of a reduced need of shunting in wakeful patients. Larger studies are required to clarify the role of shunting and type of anesthesia in early neurocognitive deficit after CEA and its impact on the quality of life.

Plasma interleukin-8 as a potential predictor of mortality in adult patients with severe traumatic brain injury.

Because of complex pathophysiology and severe consequences, traumatic brain injuries (TBI) are an important medical problem. Pathophysiology of TBI includes local and systemic stress response, in which interleukin-8 (IL-8) is considered as a key mediator of neuroinflammation. However, prognostic relevance of IL-8 measurement in adult patients with severe TBI is not certain. Therefore, IL-8 was determined in blood samples from central venous and jugular bulb catheter and in cerebrospinal fluid of twenty patients with isolated TBI at admission to Intensive Care Unit. None of the patients had history of stroke, dementia, autoimmune diseases, acute infection or medication with anti-inflammatory drugs. Ten patients died due to traumatic brain injury, while the other ten recovered well. While there was no significant difference of IL-8 levels in cerebrospinal fluid between survivors and nonsurvivors, central venous plasma level of IL-8 was significantly lower in survivors (71.00 +/- 14.17 pg/ml), than in nonsurvivors (111.26 +/- 16.9 pg/ml). Receiver Operating Characteristic (ROC) analysis revealed significant prognostic value for IL-8 in the blood as well as for the age of patients, Glasgow Coma Scale (GCS) and Acute Physiologic and Chronic Health Evaluation (APACHE II). These findings suggest that the central venous plasma values of IL-8 at admission might be an early predictive marker in patients with severe TBI, comparative to standard clinical prognostic markers such as APACHE II and GCS.