Near-infrared spectroscopy for assessing microcirculation during laparoscopic gynaecological surgery under combined spinal-general anaesthesia or general anaesthesia alone: a randomised controlled trial.

While pneumoperitoneum causes negative macrohaemodynamic effects, much less is known about microcirculatory effects of different anaesthetic techniques and laparoscopy. Therefore, we aimed to explore microcirculatory effects of combined spinal-general anaesthesia and laparoscopy, as measured by near-infrared spectroscopy over forearm and calf muscles utilising a 3-min ischemic challenge. Patients (n = 102) undergoing elective laparoscopic gynaecological surgery were randomised to receive general anaesthesia alone or in combination with high-dose or low-dose spinal analgesia (levobupivacaine 7.5 mg or 3.75 mg, respectively, plus sufentanil 2.5 µg). Primary outcomes were near-infrared spectroscopy derived parameters before general anaesthesia induction, 5 min after tracheal intubation, and 15 min after pneumoperitoneum commencement. General anaesthesia resulted in impaired post-ischaemic recovery rate in the forearm (p < 0.001, within all groups), which improved during laparoscopy. For the calf, before general anaesthesia induction, high and low dose spinal analgesia significantly slowed the post-ischaemic recovery compared to control (34 ± 16% min-1 and 36 ± 13% min-1 vs. 52 ± 27% min-1, respectively; p = 0.002 and p = 0.006). General anaesthesia abolished differences between the groups (24 ± 14% min-1 and 25 ± 12% min-1 vs. 27 ± 18% min-1), while during laparoscopy high-dose spinal analgesia further reduced the post-ischaemic recovery compared to low-dose spinal and control groups (p = 0.023 and p = 0.040, respectively). During gynaecological laparoscopy patients show impaired calf but maintain forearm microcirculatory function, regardless of the anaesthetic technique. Reduction in post-ischaemic recovery with high-dose spinal analgesia is explained by its sympatholytic effects: number of perfused capillaries is increased, leading to a haemodynamically more favourable state. Blood pressure is positively correlated with the post-ischaemic recovery rate in vascular beds not affected by spinal analgesia.

The influence of the infusion of ephedrine and phenylephrine on the hemodynamic stability after subarachnoid anesthesia in senior adults - a controlled randomized trial.

BACKGROUND: We studied the influence of ephedrine or phenylephrine infusion administered immediately after spinal anesthesia (SA) on hemodynamics in elderly orthopedic patients. METHODS: A prospective, randomized, double-blind, placebo-controlled study. After a subarachnoid injection of 15 mg of levobupivacaine, the participants received an infusion of either ephedrine 20 mg (E group), phenylephrine 250 mcg (P group) or saline (C group) within 30 min. We measured blood pressure, cardiac index (CI) and heart rate (HR) from 15 min before to 30 min after SA. RESULTS: Seventy patients were included in the final analysis. At the end of measurements, mean arterial pressure (MAP) decreased significantly after SA in comparison to the baseline value in the C group but was maintained in the P and E group, with no significant differences between the groups. CI decreased after SA in the C group, was maintained in the P group, and increased significantly in the E group with significant differences between the C and E group (p = 0.049) also between the P and E (p = 0.01) group at the end of measurements. HR decreased significantly after SA in the C and P group but was maintained in the E group, with significant differences between the P and E group (p = 0.033) at the end of measurements. CONCLUSIONS: Hemodynamic changes after SA in elderly orthopedic patients can be prevented by an immediate infusion of phenylephrine or ephedrine. In addition to maintaining blood pressure, the ephedrine infusion also maintains HR and increases CI after SA. TRIAL REGISTRATION: ISRCTN registry with registration number ISRCTN44377602, retrospectively registered on 15 June 2017.

A prospective randomized controlled study of combined spinal-general anesthesia vs. general anesthesia for laparoscopic gynecological surgery: Opioid sparing properties.

STUDY OBJECTIVE: We aimed to determine the magnitude of peri-operative opioid sparing effect when general anesthesia is combined with spinal analgesia for laparoscopic gynecological surgery. DESIGN: A prospective randomized controlled study; a three-group trial with two comparisons (each intervention group to control). SETTING: Operating room and postoperative recovery area. PATIENTS: Patients aged between 18 and 65 years with American Society of Anesthesiologists physical status 1 or 2 who were scheduled for inpatient elective laparoscopic gynecological surgery with expected pneumoperitoneum duration of at least 20 min. Of 102 randomized patients, 99 completed the study. INTERVENTIONS: Patients were randomized to general anesthesia alone (control group) or combined with very-low-dose (levobupivacaine 3.75 mg; sufentanil 2.5 µg) or low-dose (levobupivacaine 7.5 mg; sufentanil 2.5 µg) spinal analgesia. MEASUREMENTS: Primary endpoints were perioperative opioid consumption and pain scores (11-point numeric rating scale) at 30 min, 1 h, 2 h, 4 h and 24 h post-surgery. Secondary endpoints were patient satisfaction with anesthetic care and participation in research, sevoflurane consumption and adverse effects. MAIN RESULTS: Intra-operative sufentanil (median [95% CI]) consumption was 16.1 (10.5-22.6) µg/h in the control group versus 4.7 (3.2-9.2) µg/h in the very-low-dose and versus 2.9 (0.0-4.0) µg/h in the low-dose spinal analgesia groups (p < 0.001, for both comparisons). Median (95% CI) piritramide consumption at 24 h post-surgery was 7.5 (3-8) mg in the control group versus 5 (0-7.5) mg in the very-low dose spinal analgesia group (p = 0.182) and versus 2 (0-2.5) mg in the low-dose spinal analgesia group (p = 0.001). Postoperative pain scores were consistently <3 only in the low dose spinal analgesia group. Patient satisfaction with anesthetic care and participation in research was very high in all groups. CONCLUSIONS: Low-dose spinal analgesia in combination with general anesthesia reduces peri-operative opioid consumption in laparoscopic gynecological surgery in immediate postoperative period.

The Effect of Diclofenac on Bleeding, Platelet Function, and Consumption of Opioids Following Cardiac Surgery.

OBJECTIVE: To establish whether the use of diclofenac reduces the administration of opioids and how it affects bleeding and platelet function after the coronary artery bypass grafting (CABG) surgery with use of cardiopulmonary bypass (CPB). METHODS: A total of 72 patients undergoing CABG surgery were included in this retrospective randomized study and divided into two groups (34 patients received diclofenac and the control group of 38 patients did not). For postoperative analgesia, both groups were prescribed opioids (piritramide). The primary endpoint was to establish the consumption of opioids. The secondary endpoint was to determine bleeding and the function of platelets 20 hours after the surgery. RESULTS: The consumption of piritramide (diclofenac group 26±8 mg vs. control group 28±8 mg), the blood loss, and the function of platelets did not significantly differ between the groups within 20 hours after surgery. C-reactive protein (CRP) was statistically significantly lower in the diclofenac group than in the control group (33±15 mg/L vs. 46±22 mg/L, respectively, P<0.05). CONCLUSION: The study concluded that patients administered with diclofenac after the heart surgery did not consume less opioid analgesics and did not exhibit less symptoms linked to the consumption of opioids. Diclofenac in clinically administered doses does not interfere with the function of platelets and does not cause increased bleeding. Lower CRP in the diclofenac group may indicate a reduced inflammatory response after CPB. Therefore, diclofenac could be safe for use in patients undergoing CABG surgery but its value in reducing opioid consumption should be questioned.

The effect of Trendelenburg position, lactated Ringer's solution and 6% hydroxyethyl starch solution on cardiac output after spinal anesthesia.

BACKGROUND: The aim of our study was to evaluate the effects of Trendelenburg position, infusion of 6% hydroxyetyl starch solution or lactated Ringer's solution on changes in cardiac output (CO) after spinal anesthesia in patients older than 50 yr. METHODS: Seventy patients scheduled for lower extremity orthopedic surgery under spinal anesthesia were allocated randomly to one of the three treatment groups. In the Trendelenburg group, the patients were placed in the Trendelenburg position immediately after the spinal block for 10 min. In the hydroxyethyl starch group and the lactated Ringer's group, the patients received an infusion of 500 mL of 6% hydroxyethyl starch solution or 1000 mL of lactated Ringer's solution over 20 min after the spinal block. CO was measured continuously from 15 min before until 30 min after spinal anesthesia using the impedance cardiography method and arterial blood pressure with an automated device. P < 0.05 was considered statistically significant. RESULTS: The differences among treatment groups in CO were not statistically significant. Differences in the CO changes from baseline over time were significant. In the Trendelenburg group, CO did not change while the patient was in the Trendelenburg position. In the hydroxyethyl starch group, CO increased significantly after the block and remained significantly increased until the end of measurements. In the lactated Ringer's group, CO increased significantly 10 and 20 min after the block but, after stopping the infusion, CO started to decrease. CONCLUSIONS: Our study demonstrated that a decrease in CO after spinal anesthesia is prevented by placing the patient in the Trendelenburg position, or infusion of either lactated Ringer's solution or 6% hydroxyetyl starch solution. Although the effects of the infusion of the lactated Ringer's solution are transient, the effects of the infusion of 6% hydroxyethyl starch solution are extended beyond the time the infusion.

The effect of diclofenac on bleeding, platelet function, and consumption of opioids following cardiac surgery

Abstract Objective: To establish whether the use of diclofenac reduces the administration of opioids and how it affects bleeding and platelet function after the coronary artery bypass grafting (CABG) surgery with use of cardiopulmonary bypass (CPB). Methods: A total of 72 patients undergoing CABG surgery were included in this retrospective randomized study and divided into two groups (34 patients received diclofenac and the control group of 38 patients did not). For postoperative analgesia, both groups were prescribed opioids (piritramide). The primary endpoint was to establish the consumption of opioids. The secondary endpoint was to determine bleeding and the function of platelets 20 hours after the surgery. Results: The consumption of piritramide (diclofenac group 26±8 mg vs. control group 28±8 mg), the blood loss, and the function of platelets did not significantly differ between the groups within 20 hours after surgery. C-reactive protein (CRP) was statistically significantly lower in the diclofenac group than in the control group (33±15 mg/L vs. 46±22 mg/L, respectively, P<0.05). Conclusion: The study concluded that patients administered with diclofenac after the heart surgery did not consume less opioid analgesics and did not exhibit less symptoms linked to the consumption of opioids. Diclofenac in clinically administered doses does not interfere with the function of platelets and does not cause increased bleeding. Lower CRP in the diclofenac group may indicate a reduced inflammatory response after CPB. Therefore, diclofenac could be safe for use in patients undergoing CABG surgery but its value in reducing opioid consumption should be questioned.

A randomised controlled trial comparing remifentanil and fentanyl for induction of anaesthesia in CABG surgery.

INTRODUCTION: In a prospective randomised trial we studied haemodynamic stability during induction of anaesthesia for CABG surgery in patients receiving remifentanil-propofol or fentanyl-propofol anaesthesia. METHODS: Fifty-four patients scheduled for elective CABG surgery were studied. Anaesthesia was induced with propofol and pancuronium. The patients were randomly assigned to two groups according to the opioid used during the induction. The remifentanil group received 0.5 microg kg(-1) min(-1) of the drug and the fentanyl group received 5 microg kg(-1). We measured blood pressure, central venous pressure and heart rate continuously for 15 min before and 30 min after orotracheal intubation. We also recorded use of rescue medication for maintaining the mean arterial pressure between 65 and 85 mmHg. RESULTS: After induction of anaesthesia the mean arterial pressure and heart rate decreased significantly in both groups (P<0.05). After orotracheal intubation the mean arterial pressure and heart rate increased significantly in the fentanyl group but not in the remifentanil group (P<0.05). The incidence of hypertonic events necessitating the use of rescue medication was significantly higher in the fentanyl group (P<0.05). CONCLUSIONS: Our results show more stable haemodynamics after induction of anaesthesia in CABG surgery in patients receiving remifentanil-propofol than in patients receiving fentanyl-propofol.

Effects of pregabalin on acute herpetic pain and postherpetic neuralgia incidence.

BACKGROUND AND OBJECTIVES: Acute zoster pain usually disappears with regression of the rash but may be of significant intensity and prolonged duration leading to postherpetic neuralgia. We evaluated the effect of pregabalin on alleviation of acute zoster pain and onset of postherpetic neuralgia. METHODS: The prospective randomized double-blind placebo-controlled study included 29 outpatients who had had acute zoster pain for a period of 7-14 days. Patients were treated for three weeks with 150-300 mg pregabalin daily or with a placebo. Pain was treated with naproxen, tramadol or oxycodone, as necessary. During the treatment we assessed pain, allodynia, hyperalgesia, severity of burning, prickling and tingling sensations, quality of sleep, physical activity, consumption of analgesics, manifestation of adverse events and postherpetic neuralgia. RESULTS: There were no statistically significant differences with respect to patients' demographic data, dermatomal distribution and severity of rash, use of antiviral therapy or duration of acute zoster pain. Standard statistical analyses found no significant differences between the two treatment groups in intensity of pain, allodynia, hyperalgesia, burning, prickling and tingling sensations, consumption of analgesics, or the quality of sleep and physical activity; there was also no significant difference in development of postherpetic neuralgia. However, there were statistically significant differences between the groups in the occurrence of dizziness and somnolence in relation to pregabalin. CONCLUSION: The study did not prove any statistically significant effect of pregabalin in pain relief in patients with acute zoster pain or in the onset of postherpetic neuralgia in comparison with the placebo. The use of pregabalin was related to a statistically significant increase in the appearance of adverse effects.

Influence of body position on hemodynamics in patients with ischemic heart disease undergoing cardiac surgery.

INTRODUCTION: The cardiovascular response to decreased or increased preload in high-risk patients with ischemic heart disease enables us to understand the physiologic response to hemorrhage and its treatment. Although numerous studies have failed to show its effectiveness, the head-down position is still widely used to treat patients with hypotension and shock. The aim of our study was to evaluate the influence of body position on hemodynamics in high-risk patients undergoing coronary artery bypass graft surgery. METHODS: In 16 patients with ischemic hearth disease and poor left ventricular function undergoing coronary artery bypass graft surgery, we measured cardiac output with thermodilution, arterial pressure, central venous pressure (CVP), pulmonary artery wedge pressure (PAWP) and heart rate in three different body positions: the horizontal position, 20 degrees head-up position, 20 degrees head-down position and back in the horizontal position. The measurements were made before and after cardiac surgery. RESULTS: Before skin incision the change from horizontal to 20 degrees head-up position led to a nonsignificant decrease in cardiac output and a significant decrease in mean arterial pressure, CVP and PAWP. The change from 20 degrees head-up to 20 degrees head-down position led to a significant increase in cardiac output, mean arterial pressure, CVP and PAWP. After skin closure the change from horizontal to 20 degrees head-up position led to a nonsignificant decrease in cardiac output and mean arterial pressure and a significant decrease CVP and PAWP. The change from 20 degrees head-up to 20 degrees head-down position led to a nonsignificant increase in cardiac output and a significant increase in mean arterial pressure, CVP and PAWP. There were no significant changes in heart rate during the changes in position before or after surgery. CONCLUSIONS: The results of our study showed a hemodynamic response similar to hemorrhage after placing the patients in a 20 degrees head-up position and improving hemodynamics in the head-down position in mechanically ventilated patients undergoing coronary artery bypass graft surgery.