Comparison of Postoperative Recovery after Manual and Target-Controlled Infusion of Remifentanil in Bariatric Surgery.

Background and Objectives: Early postoperative recovery after surgery is a key point for patients' safety and comfort. Moreover, operating room turnover depends on recovery time. Our aim was to assess which method of remifentanil administration, manual (MI) or target-controlled infusion (TCI), could reduce patient time in recovery room. In this study, patients' recovery times were registered and compared among the groups. Materials and Methods: We enrolled 31 morbidly obese patients in this prospective study. All of them had undergone bariatric surgery at the Hospital of Lithuanian University of Health Sciences Kauno Klinikos in 2020. Sevoflurane/remifentanil anaesthesia was performed for all patients. The patients were randomly assigned to the manual infusion (MI) (control group) or target-controlled infusion (TCI) group for the method of the administration of remifentanil. While the patients were waking up after the surgery, we recorded spontaneous breathing and airway reflexes recovery time, time of extubation, eye opening, recovery of orientation and beginning of the following oral command. For the TCI group, we also documented remifentanil concentrations in the blood (automatic infusion pump). Results: Patients did not differ in demographic values and duration of remifentanil infusion. We found that remifentanil consumption in the TCI group was lower, p = 0.02. Despite lower remifentanil consumption in the TCI group patients, they demonstrated longer total recovery time than the control group patiens: 14 (12-20) vs. 10 (6-16), p = 0.001. Conclusions: The study showed that, upon comparing the TCI method with MI, manual infusion produced better results in postoperative patient recovery. Additionally, higher doses of remifentanil were consumed using MI. In conclusion, the dosage recommended by highly qualified anaesthesiologists is favourable for morbidly obesity patients when compared to the TCI method.

Role of Ketamine in Multimodal Analgesia Protocol for Bariatric Surgery.

Background and Objectives: Acute postoperative pain is one of the most undesirable experiences for a patient in the postoperative period. Many options are available for the treatment of postoperative pain. One of the methods of multimodal analgesia is a combination of opioids and adjuvant agents, such as ketamine. The aim of this study was to evaluate the effect of a pre-incisional single injection of low-dose ketamine on postoperative pain after remifentanil infusion in patients undergoing laparoscopic gastric bypass or gastric plication surgery. Materials and Methods: The prospective, randomized, double-blinded and placebo-controlled trial took place at the Hospital of the Lithuanian University of Health sciences KaunoKlinikos in 2015-2017. A total of 32 bariatric patients (9 men and 23 women) were randomly assigned to receive a single pre-incisional injection of ketamine (0.15 mg/kg (LBM)) (ketamine, K group) or saline (placebo, S group). Standardized protocol of anesthesia and postoperative pain management was followed for all patients. Postoperative pain intensity, postoperative morphine requirements, incidence of side effects and patients' satisfaction with postoperative analgesia were recorded. Results: Thirty-two patients undergoing bariatric surgery: 18 (56.25%; gastric bypass) and 14 (43.75%; gastric plication) were examined. Both groups did not differ in demographic values, duration of surgery and anesthesia and intraoperative drug consumption. Postoperative pain scores were similar in both groups (p = 0.105-0.941). Morphine consumption was 10.0 (7.0-12.5 mg) in group S and 9.0 (3.0-15.0 mg) in group K (p = 0.022). The incidence of side effects was similar in both groups (p = 0.412). Both groups demonstrated very high satisfaction with postoperative analgesia. Conclusions: Pre-incisional single dose ketamine reduces postoperative opioids consumption, but does not have an effect of postoperative pain intensity and side effects after remifentanil infusions. Very high patient satisfaction is achieved if standard multimodal analgesia protocol with an individual assessment of pain and dosage of medications is followed.

How the changes in the system affect trauma care provision: The assessment of and implications for Lithuanian trauma service performance in 2007-2012.

OBJECTIVE: The aim of this study was to identify and assess the effects of changes in the Lithuanian trauma service from 2007 to 2012. We postulate that the implications derived from this study will be of importance to trauma policy planners and makers in Lithuania and throughout other countries of Eastern and Central Europe. MATERIALS AND METHODS: Out of 10,390 trauma admissions to four trauma centers in 2007, 294 patients (2.8%) were randomly selected for the first arm of a representative study sample. Similarly, of 9918 trauma admissions in 2012, 250 (2.5%) were randomly chosen for comparison in the study arm. Only cases with a diagnosis falling into the ICD-10 "S" and "T" codes were included. A survey of whom regarding changes in quality of trauma care from 2007 to 2012 was carried out by emergency medical service (EMS) providers. RESULTS: The Revised Trauma Score (RTS) mean value was 7.45±1.04 for the 2007 year arm; it was 7.53±0.93 for the 2012 year arm (P=0.33). Mean time from the moment of a call from the site of the traumatic event to the patient's arrival at the trauma center did not differ between the arms of the sample: 49.95min in 2007 vs. 51.6min in 2012 (P=0.81). An application of the operational procedures such as a cervical spine protection using a hard collar, oxygen therapy, infusion of intravenous fluids, and pain relief on the trauma scene was more frequent in 2012 than in 2007. Management of trauma patients in the emergency department improved regarding the availability of 24/7 computed tomography scanner facilities and an on-site radiographer. Time to CT-scanning was reduced by 38.8%, and time to decision-making was reduced by 16.5% in 2012. CONCLUSIONS: Changes in operational procedures in the Lithuanian pre-hospital care provision and management of trauma patients in emergency departments of trauma centers improved the efficiency of trauma care delivery over the 2007-2012 period.

The impact of neurocritical patient transfer on outcomes: retrospective analysis of practice in the largest neurosurgical centre in Lithuania.

INTRODUCTION: Critical neurological conditions require urgent assessment and treatment. The quality of care and treatment provided during the transportation is important and related to the outcome of critically ill patients. We aimed to assess the quality of interhospital transportation of neurocritical patients in the largest neurosurgical cluster in Lithuania and identify possible outcome prediction variables. MATERIAL AND METHODS: A retrospective cohort study was conducted. We analysed the data from 106 neurocritical patients who were transported to the Hospital of Lithuanian University of Health Sciences Kaunas Clinics Neurosurgery Clinic in 2018. We collected the needed data from patients' medical history, referrals, and transfer sheets. In our research, we evaluated the quality of referrals and the quality of filling protocols. RESULTS: The transportation protocols showed that during the transferrals diuresis, end-tidal carbon dioxide (ETCO2), pupil size, and reaction to light were not routinely measured in any of the patients, as opposed to other vital signs. We found that less than half of referrals (42%) were informative and suitable for sending the patient to another hospital. Results showed that the first systolic arterial blood pressure (sABP) measured at Neuro-ICU is associated with patient outcomes. Higher sABP was seen in the group of patients with negative outcomes (death, continued need for care). CONCLUSIONS: This study demonstrated that monitoring of vital signs and neurological parameters as well as the quality of referrals were found to be the weakest links in the neurocritical patient transfer.

Systemic postoperative pain management following minimally invasive pectus excavatum repair in children and adolescents: a retrospective comparison of intravenous patient-controlled analgesia and continuous infusion with morphine.

PURPOSE: Optimal postoperative pain management following minimally invasive surgical repair of pectus excavatum is not established. We compared efficacy and adverse effects in patients treated with patient-controlled analgesia (PCA) with those treated with continuous infusion (CI) with morphine in addition to nonsteroidal anti-inflammatory drugs. METHODS: 33 patient records were examined retrospectively: 21 given PCA and 12 CI with morphine. Main outcome variables were used doses of morphine, pain scores every 3 h and adverse effects. RESULTS: Median (range) used morphine dose was 0.58 (0.21-1.12) and 0.52 (0.34-0.84) mg/kg on the day 1 and 0.3 (0.02-0.6) and 0.33 (0.09-0.53) mg/kg on the day 2 in PCA and CI groups, respectively (p > 0.05). Pain scores were within moderate and low levels during 42 h after surgery and did not differ between the groups. Median (range) oxygen saturation was 96.5 (93-100) and 97 (94-100) in PCA and CI groups, respectively (p > 0.05). Additional oxygen therapy was required in 14.3% in PCA group and 25% in CI group (p > 0.05). The incidence of pulmonary adverse effects was rare and did not differ between the groups. CONCLUSION: Both methods of systemic analgesia in addition to non-opioid analgesics were equally effective and resulted in a low incidence of pulmonary adverse effects.

Pulmonary edema and hemorrhage as complications of acute airway obstruction following anesthesia.

Airway obstruction is a quite common complication while its conditioned pulmonary edema--rare. Causes associated with anesthesia are various. Forced inspiratory efforts against an obstructed upper airway generate peak negative intrathoracic pressure. This may cause pulmonary edema and in some cases pulmonary hemorrhage. Last-mentioned is extremely rare. Pulmonary edema may arise soon after airway obstruction as well as later, after some hours. Damage of bronchi is found seldom during bronchoscopy in case of pulmonary hemorrhage, while more often alveolar damage is observed due to alveolar membrane damage. Hemorrhage is conditioned by hydrostatic pressure level, level of hypoxia, damage to bronchi or alveoli (disruption of alveolar membrane). Early diagnosis of negative-pressure pulmonary edema or pulmonary hemorrhage is very important, because this affects postoperative morbidity and mortality of the patients. Two cases of pulmonary edema and hemorrhage after upper airway obstruction as well as literature overview are presented in this article. Pulmonary hemorrhage developed during anesthesia with ketamine, conditioned by increment of hydrostatic pressure, hypoxia, and effects of ketamine on hemodynamics.

[A role of thoracic epidural anesthesia in pulmonary resection surgery]. / Torakalines epidurines anestezijos vaidmuo darant plauciu rezekcines operacijas.

This article presents a review of current literature on impact of thoracic epidural anesthesia on functions of organs and systems. Its role in anesthetic management of pulmonary resection is discussed. Thoracotomy is one of the most painful surgical procedures followed by intense, acute, and chronic pain associated with post-thoracotomy. Thoracic epidural anesthesia ensures adequate analgesia in postoperative period and assists in solving problem of chronic pain. Thoracic epidural anesthesia reduces systemic stress response by inducing sensory and sympathetic blockade. Pulmonary resection produces changes in respiratory function which may result in respiratory insufficiency and other pulmonary complications. During one lung ventilation, thoracic epidural anesthesia reduces pulmonary blood shunt and improves oxygenation. Postoperatively due to effective pain relief and improvement of diaphragm function, thoracic epidural anesthesia improves respiratory function, and rate of pulmonary complications is decreased. Sympathetic blockade during thoracic epidural anesthesia reduces the rate of perioperative myocardial ischemia and cardiac mortality. It also reduces the number of thromboembolic and gastrointestinal complications and has a positive effect on immune function. Due to numerous benefits, thoracic epidural anesthesia can be recommended as a standard in pulmonary resection surgery.

Endoscopic aesthetic facial surgery: technique and results.

The endoscopic approach to forehead and midface lifting has become popular method of face rejuvenation with minimal incisions. We have performed 67 endoscopic facelift procedures in the last four years. Forehead lifting technique included five small scalp incisions, wide subperiosteal elevation, endoscopic myotomy and forehead tissue fixation with srews, superficial temporal fascia (STF) suture to deep temporal fascia (DTF). Midface lifting technique included temporal 2.5 cm and 1.5 cm vertical intraoral incision, midface subperiosteal undermining and midface elevation with cable sutures Bichat's fat to DTF. Age mediana of patients who underwent endoscopic front lift was 46, patients who had endoscopic front lift and midface lift procedure age mediana was 40. Postoperative complication rate was 7.5% and included frontal branch weakness (n=2), hematoma (n=1), infraorbital nerve paresthesia (n=1) and asymmetrical smile (n=1). The main question is the quality of the results. We have reviewed 49 patients who were followed 6 months or more. Preoperative and postoperative life-size photographs were analyzed. The mean elevation mediana at medial canthus was 2.2 mm, at medial limbus 2.3 mm, at lateral limbus 2.5 mm, at lateral canthus 2.9 mm. Midface - lift effect resulted cheek elevation from 1.07 till 4.71 mm lip corner elevation 1.03 mm to 3.27 mm. We observed cheek elevation, improving nasolabial line, increasing volume of malar region, elevating lip angles in patients after endoscopic midface lift. We have found that important advantage of subperiosteal midface lift, when performed in conjunction with endoscopic brow lift, is its ability to move the cosmetic eye unit, proportionally, leading to a harmonious facial appearance. Endoscopic facelift is effective procedure for face rejuvenation especially for eyebrows and cheek elevation.

[Bupivacaine for continuous interscalene brachial plexus analgesia after shoulder surgery]. / Interskalenine peties nervinio rezginio analgezija ilgalaike bupivakaino infuzija.

OBJECTIVE: This study evaluates clinical efficacy of continuous interscalene brachial plexus block with bupivacaine 0.15% for postoperative analgesia after shoulder surgery. MATERIAL AND METHODS: Eighty patients, scheduled for elective shoulder surgery, were included in this study. All patients received an interscalene block before surgery. A perineural catheter was then introduced for continuous brachial plexus analgesia. Patients were prospectively randomized in a double-blinded fashion to receive either bupivacaine 0.15% or placebo postoperative infusion through an interscalene catheter. Pain was assessed with a visual analog scale at rest and also in motion. Duration of surgery and surgery type, satisfaction scores, supplemental analgesia, side effects, circulatory and respiratory parameters were recorded. RESULTS: The bupivacaine group showed less pain at rest and in motion than the placebo group (p<0.0001), except 4 and 6 h after the brachial plexus block; a requirement for supplemental analgesia was also lower. Side effects (except weakness in the arm, which was more frequent in bupivacaine group), circulatory and respiratory parameters were comparable in both groups. Satisfaction scores were higher in bupivacaine group. CONCLUSIONS: Continuous interscalene brachial plexus analgesia is a reliable and effective method of providing postoperative pain relief after shoulder surgery and is superior to the systemic analgesia.

Low-dose spinal hyperbaric bupivacaine for adult anorectal surgery: a double-blinded, randomized, controlled study.

BACKGROUND AND OBJECTIVE: To produce selective spinal anesthesia for adult anorectal surgery. STUDY DESIGN: Double-blinded, randomized, controlled trial. SETTING: Operating room and postoperative recovery area. PATIENTS: 152 adult, consecutive ASA physical status I, II, and III patients. INTERVENTIONS: After patients underwent dural puncture in the sitting position at L3-L4 or L4-L5, 0.5% hyperbaric bupivacaine was injected over two minutes: Group S7.5 received 1.5 mL, Group S5 received 1.0 mL, and Group S4 0.8 mL. After sitting for 10 minutes, patients were positioned for surgery. MEASUREMENTS: Rate of success, level and duration of sensory and motor block, time to voiding and ambulation, complications, and quality of anesthesia according to the patient and medical staff, were recorded. RESULTS: Spinal block had a 98% rate of success. Mean level of sensory block was 10.4 +/- 1.7, 7.4 +/- 2.2, and 7.0 +/- 1.8 dermatomes in Groups S7.5, S5, and S4 (P < 0.01 S7.5 vs S5, and S7.5 vs S4). Mean duration of sensory block was 310.5 +/- 42.6, 255.9 +/- 43.7, and 228.8 +/- 34.8 min in Groups S7.5, S5, and S4 (P < 0.01 S7.5 vs S5, S7.5 vs S4, and S5 vs S4). Motor block was Bromage score 2-3 in 70.5% of Group S7.5 patients versus Bromage score 0-1 in 97.3% of Group S5 and 92.1% of Group S4 patients (P < 0.05). CONCLUSION: A dose of 4 mg of hyperbaric bupivacaine produces a similar level of sensory and motor block as a 5 mg dose but with shorter duration and faster recovery.

[Anesthesia and obstructive pulmonary disease]. / Anestezija ir obstrukcines plauciu ligos.

The article deals with the problems of perioperative management of patient with respiratory disease. The impact of general and regional anesthesia on respiratory system is discussed. Risk factors of perioperative respiratory complications are reviewed as well as general means for reducing them. Issues of anesthetic management of patients with bronchial asthma and chronic respiratory disease are discussed, putting stress on preoperative optimization of respiratory function, choice of anesthetic technique and postoperative pulmonary rehabilitation.

[Comparison of electrocardiographic parameters during pneumoperitoneum in patients without cardiovascular diseases and in patients with ischemic heart disease]. / Elektrokardiografiniu parametru kitimu palyginimas pneumoperitoneumo metu pacientams, nesergantiems kraujotakos ligomis ir sergantiems isemine sirdies liga.

UNLABELLED: Pneumoperitoneum induces significant pathophysiological changes. Changes in performance of cardiovascular system can be severe in patients with compromised cardiac function. Groups of patients to whom these changes may be deleterious are yet to be identified. Aim of the study was to elucidate the influence of pneumoperitoneum on the electrocardiographic recording. PATIENTS AND METHODS: 35 cardiovascular healthy (ASA I-II) patients (group 1) and 34 patients with underlying moderate ischemic heart disease (ASA II-IV, Goldman's cardiac risk class II-III) (group 2), scheduled for elective laparoscopic cholecystectomy, were included in the study. Premedication included sedatives for all patients and the group 2 received their usual cardiovascular treatment one hour before operation. A standardized protocol of monitoring and anesthesia was followed in the operating room. 12 lead electrocardiograms (ECG) were obtained before and after induction of anesthesia, every 10 minutes during pneumoperitoneum, after the peritoneal desufflation and after extubation. The ECGs were recorded and analysed by the means of computerized system for ECG record and analysis "Kaunas" (UAB "Kardiosignalas", Kaunas, Lithuania). The analysis was performed postoperatively. RESULTS: During pneumoperitoneum a deviation of cardiac electrical axis to the left was observed. There were no marked changes in duration of P wave, P-Q interval, and QRS complex. Following abdominal insufflation a tendency to flattening of T wave was observed returning to the initial position after desufflation. No significant dislocation of ST segment was recorded. CONCLUSIONS: The pneumoperitoneum induced changes of cardiac electrical axis can affect the interpretation of ECG seen on a cardiac monitor during anesthesia. Pneumoperitoneum does not pose patients with moderate ischemic heart disease at additional risk of developing myocardial ischemia.