Assessment of changes of regional ventilation distribution in the lung tissue depending on the driving pressure applied during high frequency jet ventilation.

BACKGROUND: Electrical impedance tomography (EIT) is a tool to monitor regional ventilation distribution in patient's lungs under general anesthesia. The objective of this study was to assess the regional ventilation distribution using different driving pressures (DP) during high frequency jet ventilation (HFJV). METHODS: Prospective, observational, cross-over study. Patients undergoing rigid bronchoscopy were ventilated HFJV with DP 1.5 and 2.5 atm. Hemodynamic and ventilation parameters, as well as ventilation in different regions of the lungs in percentage of total ventilation, assessed by EIT, were recorded. RESULTS: Thirty-six patients scheduled for elective rigid bronchoscopy. The final analysis included thirty patients. There was no significant difference in systolic, diastolic and mean arterial blood pressure, heart rate, and peripheral saturation between the two groups. Peak inspiratory pressure, mean inspiratory pressure, tidal volume, and minute volume significantly increased in the second, compared to the first intervention group. Furthermore, there were no statistically significant differences between each time profiles in all ROI regions in EIT. CONCLUSIONS: In our study intraoperative EIT was an effective method of functional monitoring of the lungs during HFJV for rigid bronchoscopy procedure. Lower driving pressure was as effective in providing sufficient ventilation distribution through the lungs as the higher driving pressure but characterized by lower airway pressure. TRIAL REGISTRATION: The study was registered on ClinicalTrials.gov under no. NCT02997072 .

Thoracic paravertebral block for postoperative pain management after renal surgery: A randomised controlled trial.

BACKGROUND: Thoracic paravertebral block (ThPVB) combined with general anaesthesia is used in thoracic and general surgery. It provides effective analgesia, reduces surgical stress response and the incidence of chronic postoperative pain. OBJECTIVE: To assess the efficacy of ThPVB in reducing opioid requirements and decreasing the intensity of pain after renal surgery. DESIGN: A randomised, open label study. SETTING: A single university hospital. Study conducted from August 2013 to February 2014. PARTICIPANTS: In total, 68 patients scheduled for elective renal surgery (open nephrectomy or open nephron-sparing surgery). INTERVENTIONS: Preoperative ThPVB with 0.5% bupivacaine combined with general anaesthesia, followed by postoperative oxycodone combined with nonopioid analgesics as rescue drugs. Follow-up period: 48 h. MAIN OUTCOME MEASURES: Total dose of postoperative oxycodone required, pain intensity, occurrence of opioid related adverse events, ThPVB-related adverse events and patient satisfaction. RESULTS: A total of 68 patients were randomised into two groups and, of these, 10 were subsequently excluded from analysis. Patients in group paravertebral block (PVB; n = 27) had general anaesthesia and ThPVB, and those in group general (anaesthesia) (GEN) (n = 31) formed a control group receiving general anaesthesia only. Compared with patients in group GEN, patients who received ThPVB required 39% less i.v. oxycodone over the first 48 h and had less pain at rest (P < 0.01) throughout the first 24 h. Group PVB patients also experienced fewer opioid-related adverse events and were less sedated during the first 12 postoperative hours. Patients in the PVB group had higher satisfaction scores at 48 h compared with the control group. There were no serious adverse events. CONCLUSION: In our study, preoperative ThPVB was an effective part of a multimodal analgesia regimen for reducing opioid consumption and pain intensity. Methods and drugs used in both groups were well tolerated with no serious adverse events. Compared with the control group, patients in the ThPVB group reported increased satisfaction. TRIAL REGISTRATION: Clinical Trials NCT02840526.

Effect of high-fidelity simulation on alpha-amylase activity and concentrations of secretory immunoglobulin class A, cortisol, and testosterone among medical students.

PURPOSE: High-fidelity simulation calls heavily upon cognitive capacities and generates stress and anxiety. The objective of this prospective, observational study was to evaluate the degree of stress in medical students by measuring hormone levels during critical care classes. METHODS: Overall, 55 students (senior years of medical faculty) of both sexes were divided into 5-person teams. Demographic data and information on diagnosed diseases, stimulants used, and previous experience in the field of medical simulation were collected with a personal questionnaire. Before starting the scenario (T0), after the end of the scenario (T1), and 120 min thereafter (T2), stress level was measured. For this purpose, systolic blood pressure, diastolic blood pressure, mean blood pressure, heart rate and blood oxygen saturation were evaluated. In addition, saliva was collected to determine alpha-amylase activity and the concentrations of secretory immunoglobulin class A, cortisol, and testosterone. RESULTS: Among hemodynamic parameters, systolic and mean blood pressure and heart rate were significantly higher in T1 than in T0 and T2 time points (p < 0.05). Cortisol concentration was higher at T2 compared with T0 and T1. Alpha-amylase activity was highest at T1. Secretory immunoglobulin class A concentration was highest at T0, followed by T1 and then T2. These differences were not statistically significant. Testosterone concentration showed significantly higher values at T2 compared with T0 and T1 (p < 0.05). The analysis of team leaders vs. other members revealed significantly lower cortisol and alpha-amylase values in leaders (p < 0.05). CONCLUSIONS: High-fidelity simulation is a useful education method in medical subjects, especially in cases where a mistake could produce serious or irreversible consequences. It can increase stress hormone concentrations and thus can be assumed effective as a learning aid even in senior-year students of medical faculty.

Thyromental height test as a new method for prediction of difficult intubation with double lumen tube.

BACKGROUND: Predicting difficult intubation is of high clinical interest. METHODS: 237 patients aged ≥18 years were included in the study. Preoperative airway evaluation included: Mallampati test, thyromental distance, sternomental distance and thyromental height test. During direct laryngoscopy Cormack & Lehane classification was graded. We calculated the ROC AUC, sensitivity and specificity for thyromental height test as a primary end point of our study. RESULTS: Only thyromental height test and Cormack-Lehane scale proved significant on occurrence of difficult intubation. The optimal sensitivity and specificity values of thyromental height test were met with a cut off value of 50 mm. With 1 mm increase in thyromental height test, risk of difficult intubation decreased by 7%. CONCLUSION: Thyromental height test is a simple, easy to perform and non-invasive test to predict difficult intubation in patients scheduled for elective double lumen tube intubation during thoracic surgical procedures. With 1 mm above 50 mm increase in thyromental height test the risk of difficult intubation decreased by 7%. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02988336.

Comparison of different methods of postoperative analgesia after thoracotomy-a randomized controlled trial.

BACKGROUND: Continuous thoracic epidural analgesia (TEA) is a preferred method of postoperative analgesia in thoracic surgery. Intravenous patient-controlled analgesia (IVPCA) may be an effective alternative. One of the most commonly used opioids in PCA is morphine. It has high antinociceptive efficacy but is associated with many adverse events. Oxycodone can be an alternative. A small number of scientific reports comparing morphine and oxycodone in PCA for the treatment of acute postoperative pain after thoracotomy was the reason to conduct this study. METHODS: Prospective, randomised, observational study. In total of 99 patients scheduled for elective thoracotomy were randomized into three study groups. TEA group received continuous TEA as a method of postoperative pain management, morphine (MF) group received morphine IVPCA, and morphine (OXY) group oxycodone IVPCA. For 48 hours' hemodynamic parameters, level of pain, sedation and the need for rescue analgesia were monitored. After 48 hours' patients were asked about their satisfaction with pain treatment using Likert scale and assessment of opioid related adverse events via overall benefit of analgesia score (OBAS). RESULTS: The level of pain in visual analogic score (VAS) and Prince Henry Hospital Pain Score (PHHPS) scales was significantly lower in TEA group with no significant difference between groups MF and OXY. Using morphine in PCA was associated with a significantly higher likelihood of need of rescue analgesia. The level of sedation in Ramsay scale was significantly higher in MF compared to OXY and TEA group. There were no significant differences between groups in OBAS scale. TEA group was characterized by the highest degree of patient satisfaction. CONCLUSIONS: TEA provided superior anaesthesia compared to PCA in our study group. Use of PCA oxycodone in postoperative pain management after open thoracotomy provides similar nociception control compared to morphine but is associated with less sedation and patients using oxycodone IVPCA require smaller doses of rescue analgesia compared to systemic morphine IVPCA.

Effect of dexmedetomidine or propofol sedation on haemodynamic stability of patients after thoracic surgery.

BACKGROUND: Dexmedetomidine and propofol are commonly used sedative agents in non-invasive ventilation as they allow for easy arousal and are relatively well controllable. Moreover dexmedetomidine is associated with low risk of respiratory depression. However, both agents are associated with significant hemodynamic side effects. The primary objective of this study is to compare the influence of both drugs on hemodynamic effects in patients after thoracic surgical procedures receiving dexmedetomidine or propofol for noninvasive postoperative ventilation. METHODS: A prospective, randomised, observational study University Hospital. Interventions: Continuous sedation with dexmedetomidine or propofol for six hours of postoperative non-invasive ventilation after thoracic surgery, with concomitant use of continuous epidural analgesia. RESULTS: A total of 38 patients (20 dexmedetomidine and 18 propofol) were included in the analysis. The primary outcomes of this study is that heart rate, systolic and mean arterial blood pressure did not differ significantly between the groups, but diastolic arterial blood pressure was significantly higher in propofol group. Comparison analysis of epinephrine usage did not reveal significant differences between the groups. Cardiac output (CO) and cardiac index (CI) analysis did not show significant differences between the groups, but there is a clear tendency of lower values of CO/CI in group receiving propofol. We also observed similar tendency in stroke volume index (SVI) and stroke volume variation (SVV) values, but also those differences did not reach statistical significance. Systemic vascular resistance index (SVRI) values were higher in propofol group, exceeding reference values, but similarly, the difference between the groups was not significant. CONCLUSIONS: The main finding of this study is that dexmedetomidine and propofol provide similar advantages in haemodynamic stability during short-term sedation for non-invasive ventilation after thoracic surgical procedures in patients receiving continuous epidural analgesia.

In-hospital sudden cardiac arrest protocol analysis.

BACKGROUND: In-hospital sudden cardiac arrest (SCA) is an event that is linked to high mortality. Data analysis of SCA and the course of in-hospital cardiopulmonary resuscitation (CPR) allows for its better understanding and improvement. AIM: Analysis of cases of SCA and the procedures taken by the medical staff of University Hospital. METHODS: A retrospective analysis of 104 protocols of SCA, from May 2014 to December 2015. Actions taken by medical staff before the arrival of the resuscitation team (RT) and RT proceedings. Data are presented as median and mean ± standard deviation. RESULTS: 52.88% of cases were women, and their mean age was 70.82 ± 13.32 years. Resuscitation activities (basic life support: 48.08%, advance life support: 42.31%) were performed before the RT arrival, and no action was taken in 5.77% of cases. The cardiac arrest occurred most commonly in the afternoons hours, and the Emergency Room was the place of CPR in 41.35% of cases. The waiting time for RT was on average 4.47 ± 5.85 min. Non-defibrillation rhythms occurred in 79.80%, and the efficacy of resuscitation was 40%. CONCLUSIONS: Resuscitation protocols should be registered not only as an important part of medical records, but also as a source of information during the CPR training of staff. The lack of rescue activities before the arrival of the RT indicates the urgent need to identify the cause of the problem and eliminate these negative behaviours.

Ropivacaine has no advantage over bupivacaine in thoracic epidural analgesia for patients with pectus excavatum undergoing the Nuss procedure - a single blind randomized clinical trial comparing efficacy and safety.

INTRODUCTION: Pectus excavatum repair (Nuss procedure) is a painful procedure requiring effective postoperative analgesia. AIM: To establish whether thoracic epidural analgesia with ropivacaine is non-inferior to epidural analgesia with bupivacaine following the Nuss procedure in children. MATERIAL AND METHODS: The prospective, randomized, controlled, single blind study included 81 children. Computer-generated random numbers were used to allocate treatment. All children received general anesthesia. Intraoperative and postoperative analgesia was achieved with either 0.5% and 0.1% ropivacaine (group R) or 0.375% and 0.0625% bupivacaine (group B). The Numeric Rating Scale (NRS) and the Prince Henry Hospital Pain Score (PHHPS) were used to assess postoperative pain directly after and 1, 8, 20 and 24 hours after awakening from general anesthesia. NRS scores of more than 2 and a PHHPS score of more than 1 were considered as pain requiring intervention. Hemodynamic stability and side effects were also compared between the groups. RESULTS: The durations of the procedure and extubation times in groups R and B were similar (59 ±7 vs. 56 ±10 minutes and 9 ±5 vs. 10 ±5 minutes, respectively). Pain scores requiring intervention were below 10% and were recorded with similar frequency in both groups, except for one difference in the PHHPS score in favor of group R after 24 hours (12% vs. 40%, p < 0.05). The frequency of side effects and hemodynamic stability were similar in both groups. CONCLUSIONS: 0.1% epidural ropivacaine has no advantage over 0.0625% epidural bupivacaine for pectus excavatum repair in children.

Electrical impedance tomography for diagnosis and monitoring of pulmonary function disorders in the intensive care unit - case report and review of literature.

The aim of this paper is to describe the possibility of using Electrical Impedance Tomography (EIT) as a treatment monitoring tool in the ICU. It was based on case report and literature review. A 19-year-old female was admitted to ICU due to severe acute respiratory distress syndrome. Despite aggressive treatment there was no improvement. We decided to use EIT in the monitoring of treatment because of difficulties in transporting the patient to the radiology department in order to perform a control CT scan. After identifying the causing factor (Pneumocyctis jiroveci), EIT monitoring was maintained to assess the effectiveness of targeted microbial treatment. In the following days, we observed an improvement of regional ventilation of the upper and middle segments of the left lung that corresponded well with laboratory test results, especially arterial blood gas analysis. The use of Electrical Impedance Tomography enables non-invasive, bedside, continuous assessment of regional lung ventilation. It is possible to use it in both mechanically ventilated and spontaneously breathing patients. It allows efficient and dynamic monitoring of the course of the therapeutic process. Interpretation of the results is relatively easy to learn and does not require specialist knowledge. Moreover, it is possible to use EIT in those cases where other methods are of high risk or contraindicated.

Thoracic combined spinal-epidural anesthesia for laparoscopic cholecystectomy in an obese patient with asthma and multiple drug allergies: a case report.

Drug allergies, asthma, and obesity are more common in modern societies, and patients with these problems are often a challenge for anesthetists. Different techniques of regional anesthesia can be beneficial particularly for this group of patients. We present a patient who suffered from all of the above-mentioned conditions and successfully underwent laparoscopic cholecystectomy under thoracic combined spinal-epidural anesthesia. It is still not a popular practice, and we would like to show another indication for using it.

Ryszard Rodzinski-A Forgotten Polish Inventor and Pioneer of Combined Spinal-Epidural Anesthesia.

Dr. Ryszard Rodzinski was a Polish surgeon who, in spite of his short life, had a productive career. His most important discovery was a safer method of performing regional anesthesia for abdominal surgery. The first description of combined spinal epidural anesthesia is generally attributed to Soresi in 1937. In the early 20th century, Rodzinski invented a novel technique, "combined lumbosacral anesthesia," which combined lumbar spinal anesthesia and sacral epidural anesthesia. During the 19th Meeting of Polish Surgeons in July 1922 in Warsaw, Rodzinski presented an article entitled "On Combined Lumbosacral Anaesthesia," in which he described this technique used in surgical clinic in Lwów since October 1921. Given this presentation, Rodzinski could be considered to have made the first known presentation of the combined spinal and epidural anesthesia.

Ipsilateral shoulder pain after thoracic surgery procedures under general and regional anesthesia - a retrospective observational study.

BACKGROUND: Ipsilateral shoulder pain (ISP) is a common complication of mixed etiology after thoracic surgery (its prevalence is estimated in the literature at between 42% and 97%). It is severe and resistant to treatment (patients complain of pain despite effective epidural analgesia at the surgical site). AIM OF THE STUDY: The aim of this retrospective, observational study was to evaluate the prevalence of ISP in patients operated on in our facility and to determine the risk factors for ISP development. MATERIAL AND METHODS: 68 patients after thoracotomy or videothoracoscopy (video-assisted thoracic surgery - VATS) conducted under general and regional anesthesia were enrolled in the study and divided into two groups: group I without ISP and group II with postoperative ISP. We recorded age, sex, BMI, duration of surgery, type of surgery, type of regional anesthesia, and, in patients with epidural anesthesia, level of catheter placement. RESULTS: Statistically significant differences between the groups were obtained for BMI (24.67 and 27.68, respectively; p = 0.049), type of surgery (24% for thoracotomy and 0% for VATS, p = 0.026), and level of epidural catheter placement (4.35% for catheters placed at the level of Th5 or higher and 40.47% for catheters placed below Th5; p = 0.003). CONCLUSIONS: The prevalence of ISP in our medical center amounts to 24% of thoracotomy patients. The fact that the difference in ISP prevalence was significantly related to the level of epidural catheter placement is consistent with the theory that ISP is related to phrenic nerve innervation. Moreover, epidural catheter placement is a modifiable factor, which can be used to reduce the prevalence of post-thoracotomy ISP.