The effects of preoperative anxiety on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy / Efeitos da ansiedade pré-operatória na recuperação anestésica e na dor pós-operatória em pacientes submetidos a nefrectomia para doação

Abstract Background and objectives: It is suggested that 38-45% of patients experience preoperative anxiety. We observe that patients undergoing living donor nephrectomy suffer from anxiety. Preoperative anxiety may complicate a patient's recovery from anesthesia and postoperative pain control. This study investigates the preoperative anxiety rate and its effect on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy. Methods: Forty-eight individuals undergoing living-related renal donor nephrectomy were included in this analytic prospective observational cohort study. Their preoperative anxiety was measured with the STAI-I and STAI-II inventories. The relationships between anxiety scores with data regarding demographics, recovery from anesthesia, and postoperative pain scores were investigated. Results: The findings were remarkable in that the anxiety scores of living renal donors were significantly correlated with their recovery variables, which are spontaneous respiration time, sufficient respiration time, extubation time, and PACU discharge time (p < 0.01). Anxiety scores were significantly positively correlated with the pain scores of the 30th minute, 1st, 2nd, 4th, 8th, 12th, 24th hours, and the total amounts of analgesic administered in 24 hours (p < 0.05). A significantly negative correlation was also determined between anxiety scores and patients' satisfaction. Conclusion: Our study showed that patients undergoing living-related donor nephrectomy with high anxiety levels had late recovery times and high postoperative pain scores. Thus, determining those patients with high preoperative anxiety level is crucial to providing patients with satisfactory emerging from anesthesia and the control of their postoperative pain during donor nephrectomy.

Resumo Justificativa e objetivos: Estima-se que 38-45% dos pacientes apresentem ansiedade pré-operatória. Observamos que doadores vivos submetidos à nefrectomia para doação apresentam ansiedade. A ansiedade pré-operatória pode complicar a recuperação anestésica e controle pós-operatório de dor do paciente. O presente estudo mediu as taxas de ansiedade no pré-operatório e seus efeitos na recuperação anestésica e dor pós-operatória em pacientes doadores submetidos a nefrectomia. Método: Quarenta e oito doadores vivos submetidos a nefrectomia para doação de rim foram incluídos neste estudo de coorte prospectivo observacional. A ansiedade pré-operatória foi medida usando os inventários IDATE-I e IDATE-II. As relações entre os escores de ansiedade e dados relacionados a demografia, recuperação da anestesia e escores de dor no pós-operatório foram estudadas. Resultados: Os achados foram notáveis porque os escores de ansiedade de doadores renais vivos se correlacionaram de maneira significante com as variáveis de recuperação, a saber, tempo para respiração espontânea, tempo para respiração adequada, tempo para extubação e tempo para alta da RPA (p < 0,01). Os escores de ansiedade apresentaram correlação significantemente positiva com os escores de dor do 30o minuto e horas 1, 2, 4, 8, 12 e 24, e a quantidade total de analgésicos administrada nas 24 horas (p < 0,05). Foi observada também correlação significantemente negativa entre os escores de ansiedade e satisfação dos pacientes. Conclusão: Nosso estudo mostrou que doadores vivos submetidos a nefrectomia para doação com altos níveis de ansiedade apresentaram tempos de recuperação tardios e altos escores de dor no pós-operatório. Assim, a identificação dos pacientes com alto nível de ansiedade no pré-operatório é crucial para propiciar recuperação da anestesia e controle da dor no pós-operatório satisfatórios durante a nefrectomia para doação de órgão.

The relationship between the Trendelenburg position and cerebral hypoxia inpatients who have undergone robot-assisted hysterectomy and prostatectomy

Background/aim: This study aimed to evaluate the relationship between the Trendelenburg position and cerebral hypoxia in robot-assisted hysterectomy and prostatectomy.Materials and methods: A standardized mini-mental state examination was administered to 50 patients enrolled in the study 1 h before and after surgery. Near infrared spectroscopy (NIRS) values and hemodynamic and respiratory parameters were recorded after induction of anesthesia (baseline) and once every 20 min in the Trendelenburg position and supine positions. The relationship between the development of cerebral desaturation and the patient's position was examined. Results: For all patients, the baseline mean cerebral oxygen saturation (RSO2) on the right and left were 70.5 ± 7.3% and 70.6 ± 6.7%, respectively. Right RSO2 values at 20 min and 60 min in the Trendelenburg position decreased significantly, but they increased at 120 min. A significant positive correlation was found between right RSO2 and EtCO2 in the supine period following surgery, and between left RSO2 and EtCO2 at 60 min in the Trendelenburg and supine positions. The relationship between NIRS values and cognitive dysfunction was not significant.Conclusion: We found that cerebral saturation decreases as age increases, and cerebral desaturation may occur owing to the Trendelenburg position. There was no correlation between patients? cognitive function and NIRS values.

Comparison of Acute and Chronic Pain after Open Nephrectomy versus Laparoscopic Nephrectomy: A Prospective Clinical Trial.

We evaluated postoperative pain intensity and the incidence of chronic pain in patients with renal cell carcinoma undergoing laparoscopic or open radical nephrectomy. In this prospective study, 27 laparoscopic nephrectomy (Group LN) and 25 open nephrectomy (Group ON) patients were included. All patients received paracetamol infusion and intramuscular morphine 30 minutes before the end of the operation and intravenous patient controlled analgesia with morphine postoperatively. Data including patients' demographics, visual analog scale (VAS) pain scores at postoperative 0.5, 1, 2, 4, 6, 12, and 24 hours, postoperative morphine consumption, analgesic demand, analgesic delivery, number of patients requiring rescue analgesics, side effects because of analgesic medications, and overall patient satisfaction were recorded and compared between the two groups. Two and 6 months after the operation, patients were evaluated for chronic postsurgical pain (CPSP). Postoperative average VAS pain scores were not different between the two groups. However, only at 2 hours postoperatively, pain score was significantly higher in Group ON than in Group LN. In both groups, the highest pain scores were recorded at 30 minutes and 1 hour after surgery. Ninety-six percent of group ON patients and 88% of group LN patients required additional analgesia in the early postoperative period (P = 0.33). Postoperative morphine consumption and analgesic demand were found to be similar between the two groups. CPSP at 2 months after surgery was observed in 4 out of 25 patients (16%) in the ON group and 3 out of 27 patients (11.1%) in the LN group (P = 0.6). Chronic pain at 6 months after surgery was observed in 1 ON patient (4%) and 1 LN patient (3.7%, P = 0.9). This study demonstrated that postoperative acute pain scores were not different after laparoscopic or open nephrectomy and patients undergoing laparoscopic or open nephrectomy were at equal risk of developing CPSP. Pain control should be carefully planned in order to reduce early postoperative pain and also potentially prevent CPSP.

Laparoscopic cholecystectomy pain: effects of the combination of incisional and intraperitoneal levobupivacaine before or after surgery.

OBJECTIVES: We aimed to investigate whether the timing of administration, using a combination of incisional and intraperitoneal levobupivacaine (0.25%), has an effect on the postoperative pain after laparoscopic cholecystectomy in a prospective, randomized, and controlled study. METHODS: Sixty six patients were allocated to one of the three groups. Group BS received levobupivacaine before trocar site incision and intraperitoneal levobupivacaine immediately after pneumoperitoneum. Group AS received intraperitoneal levobupivacaine before trocars were withdrawn and incisional levobupivacaine administered at the end of surgery. Group C received no treatment. Data of intraoperative variables, postoperative pain relief, rescue analgesic consumption, and patient satisfaction were compared. RESULTS: The intraoperative fentanyl consumption was found lower in Group BS, compared to Groups AS and C (p<0.05). VAS scores were lower in both Groups BS and AS, compared to Group C immediately after the operation (p<0.05). VAS scores were significantly decreased during the first two hours in Group AS, compared to Group C. The mean doses and number of patients needing rescue meperidine were lower in Group AS, compared to the Groups BS and C (p<0.05). CONCLUSION: The combination of incisional and intraperitoneal levobupivacaine administered before or after surgery can reduce postoperative pain and analgesic and antiemetic consumption together with improved patient satisfaction. However, administering levobupivacaine before surgery might be advantageous for less intraoperative fentanyl consumption, while levobupivacaine after surgery is advantageous for less postoperative rescue analgesic requirement.

Effects of sociodemographic factors and maternal anxiety on preoperative anxiety in children.

OBJECTIVE: To investigate the effects of sociodemographic factors and maternal anxiety levels on behaviour in children undergoing surgery. METHODS: This study included children aged 3-12 years who were scheduled for surgery, and their respective mothers. Each mother completed a questionnaire concerning sociodemographic and economic characteristics. Maternal anxiety was assessed using the State-Trait Anxiety Inventory (STAI) form Tx-1, following transfer of the child to the operating room. An anaesthesiologist rated preoperative anxiety in each child using the Frankl Behaviour Rating Scale (FBRS) and Venham Picture Test (VPT). RESULTS: One hundred children (mean ± SD age 7 ± 2.7 years) who received dental (47%), plastic (39%) or urological (14%) surgery, and 100 mothers (mean ± SD age 34 ± 6.6 years) were included. A statistically significant difference between maternal STAI Tx-1 scores and children's VPT scores was revealed. There was no significant difference between maternal STAI Tx-1 scores and children's FBRS scores. Maternal education level and socioeconomic status had no effect on FBRS, VPT and STAI Tx-1 scores. CONCLUSION: Maternal knowledge and experience of anaesthesia, and high levels of maternal anxiety, may be related to increased anxiety in children undergoing surgery.

Anesthetic management in pediatric liver transplantation: a comparison of deceased or live donor liver transplantations.

PURPOSE: Pediatric liver transplantations (LT) are becoming increasingly more common in the treatment of a child with end-stage liver disease. The aim of this study was to evaluate the perioperative anesthetic experience of pediatric patients undergoing deceased and live donor liver transplantations. METHODS: We performed a chart review of 164 patients between December 1997 and February 2009 in a retrospective cohort study design. Patient characteristics, operational variables, hemodynamic course, blood and fluid requirements, and extubation rates were evaluated in both deceased [deceased donor liver transplantation (DDLT, n = 56)] and live donor liver transplantation (LDLT, n = 101) patients. RESULTS: The LDLT patients had a lower mean age and body weight than the DDLT patients (p < 0.05). The mean operation time was significantly longer and the mean anhepatic time was shorter for LDLT patients than for DDLT patients. The mean red blood cell (RBC) count and crystalloid and colloid requirements were significantly higher in LDLT patients. Relative to DDLT patients, significantly more patients in the LDLT group did not require fresh frozen plasma. The overall success rates of immediate extubation at the end of surgery were 74% in LDLT patients and 49% in DDLT patients (p = 0.086). The immediate extubation rate by year, including both groups, increased from 0% in 1997 to 95.6% in 2008. CONCLUSION: The results of this study show that among pediatric patients LDLT continues to become an 'obligatory' option that is associated with longer operation times and higher RBC and fluid requirements than DDLT. As a marker of successful LT, higher extubation rates immediately following surgery is achievable for both pediatric LDLT and DDLT patients.

Soluble cytokeratin 18 biomarkers may provide information on the type of cell death during early ischemia and reperfusion periods of liver transplantation.

Hepatocellular damage takes place as a result of ischemia and reperfusion during liver transplantation (LT). To discriminate the type of cell death and quantitate its severity may provide new insights into the mechanisms of hepatocellular damage. Therefore, we investigated the type of cell death by ELISA-based assays in patient sera. Apoptosis was specifically assessed by measuring a novel soluble biomarker, the caspase-cleaved cytokeratin 18, while total cell death (apoptosis and necrosis) by cytokeratin 18 released from dead (necrotic and apoptotic) cells. Twenty-seven live (LDLT) and 14 deceased (DDLT) donor liver transplantations were analyzed before the operation, at the anhepatic stage, first, sixth and 24th hour after the reperfusion. Both apoptosis and total cell death have successfully been demonstrated although they have not been confirmed by the liver biopsy that is impossible to perform in this setting. Apoptosis was not induced in LDLT. Total cell death (primarily necrosis) only transiently appeared the first hour after the reperfusion in LDLT, while it sharply increased the first hour after the reperfusion and maintained its level in DDLT. Soluble cytokeratin 18 biomarkers seem to be useful to discriminate and quantitate the type of cell death during early ischemia and reperfusion periods of LT.

Effects of intraperitoneal levobupivacaine on pain after laparoscopic cholecystectomy: a prospective, randomized, double-blinded study.

OBJECTIVES: We aimed to determine the effects of intraperitoneal administration of levobupivacaine on pain after laparoscopic cholecystectomy in a prospective, randomized, double-blinded, placebo-controlled trial. METHODS: In all patients, infiltration of levobupivacaine 0.25% (15 mL) was used prior to skin incisions for trocar insertion. After pneumoperitoneum was achieved, patients were allocated randomly to receive intraperitoneally either 40 mL of 0.25% levobupivacaine (LB group, n=20) or normal saline (NS group, n=20) under direct vision into the hepatodiaphragmatic lodge and above the gallbladder. Data of intraoperative variables, postoperative pain relief, rescue analgesic consumption, side effects, and patient satisfaction were followed in both groups. RESULTS: The postoperative pain scores were significantly lower in the first half-hour period in the LB group than in the NS group (p<0.05). However, the incidence of right shoulder pain was not significantly different between the LB group (10%) and NS group (15%). The mean dose of meperidine consumption and the number of patients needing rescue meperidine were significantly lower in the LB group than in the NS group (p<0.05). Significantly lower vomiting incidence and increased patient satisfaction were determined in the LB group compared to the NS group (p<0.05). CONCLUSION: Intraperitoneal administration of 40 mL levobupivacaine 0.25% given immediately after pneumoperitoneum into the hepatodiaphragmatic lodge and above the gallbladder demonstrated useful effects on postoperative pain relief after laparoscopic cholecystectomy, especially in the early postoperative period, and reduced postoperative rescue analgesic requirement, with excellent patient satisfaction. There were no LB-related complications or side effects.

Management of resistant cardiac depression after hepatic trauma controlled with a packing procedure.

In addition to hemorrhage, which is one of the most well-known factors, there are many other causative factors for serious hypotension after hepatic trauma. In this report, we present patients with persistent cardiac depression after perihepatic packing due to high grade liver injury and report on treatment modalities, including the early second-look procedure. Three patients with isolated hepatic trauma were included. Two of the patients who underwent perihepatic packing were transferred from outside hospitals, and one patient required repacking due to severe hemorrhage. All patients had grade IV injuries due to blunt (n=2) or penetrating injury (n=1). In the intensive care unit, central venous pressure (8, 12, 13 mmHg) and hematocrit (26, 27, 29%) were in the normal range, but blood pressure (40/60, 50/70, 45/75mmHg) was abnormal despite the use of inotropic support. The three patients underwent an unpacking procedure 8, 10, and 14 hours later, respectively. Inotropic support was not required after postoperative hours 3, 5, and 6, respectively. The management of post reperfusion syndrome due to hepatic trauma can be achieved, but close collaboration between the surgeon and anesthesiologist is absolutely necessary. In the case of resistance cardiac depression in patients with packing, second-look procedures should be performed as early as possible.

Reabsorption of ascites and the factors that affect this process in cirrhosis.

Ascites is one of the main features of liver decompensation in cirrhosis, and it is considered to be a dynamic process. In this study, we aimed to (1) measure the reabsorption rate of ascites; (2) evaluate whether these findings were related to features of ascites, hemodynamics, and serum measurements; and (3) examine morphologic changes in the diaphragm of cirrhotic patients. In all, 42 cirrhotic patients with ascites were enrolled in the study to comprise our study group. Using the dextran 70 test, patient ascites volumes and reabsorption rates were measured. Biopsies from the peritoneal side of the diaphragm were also processed for scanning electron microscopy and lymphatic immunohistochemical studies from the cirrhotic patients and control cadavers. The mean ascites reabsorption rate was 4.5 +/- 4.5 (0.18-14.6) mL/min, which correlated significantly with the calculated ascites volume (r = 0.75, P < 0.001). The mean ascites viscosity was 1.07 +/- 0.07 (0.99-1.17) centipoise, which demonstrated a high degree of negative correlation with the ascites reabsorption rate (r = -0.77, P < 0.001). Patients with a history of spontaneous bacterial peritonitis had significantly lesser ascites reabsorption rates than patients without this particular history. The size of lymphatic stomata in scanning electron microscopy depictions was increased, and lymphatic lacunae were dilated in immunohistochemical studies in the cirrhotic patients with ascites. However, these findings were not uniform in every cirrhotic patient with ascites. The volume and viscosity of ascites seem to influence its reabsorption rate. Additionally, previous episodes of spontaneous bacterial peritonitis may be responsible for the decreased ascites reabsorption rates observed in certain patient populations.

Propofol - not thiopental or etomidate - with remifentanil provides adequate intubating conditions in the absence of neuromuscular blockade.

PURPOSE: Administration of remifentanil followed by propofol provides adequate conditions for tracheal intubation without muscle relaxants. Other hypnotic drugs have not been thoroughly investigated in this regard. Intubating conditions with remifentanil followed by propofol, thiopentone or etomidate are compared in this study. METHODS: In a randomized, double-blind study 45 healthy males were assigned to one of three groups (n = 15). After iv atropine, remifentanil 3 microg x kg(-1) were injected over 90 sec followed by propofol 2 mg x kg(-1) (Group I), thiopentone 6 mg x kg(-1) (Group II) or etomidate 0.3 mg x kg(-1) (Group III). Ninety seconds after the administration of the hypnotic agent, laryngoscopy and intubation were attempted. Intubating conditions were assessed as excellent, good or poor on the basis of ease of ventilation, jaw relaxation, position of the vocal cords, and patient response to intubation and slow inflation of the endotracheal tube cuff. RESULTS: One patient in Group I, three patients in Group II and five patients in Group III could not be intubated on the first attempt. Clinically acceptable intubating conditions were observed in 93.3%, 66.7%, 40.0% of patients in Groups I, II and III, respectively. Overall conditions at intubation were significantly (P < 0.05) better, and the frequency of excellent conditions was significantly (P < 0.05) higher in the propofol group compared with the thiopentone and etomidate groups. No patient was treated for hypotension or bradycardia. CONCLUSION: Propofol 2 mg x kg(-1) was superior to thiopentone 6 mg x kg(-1) and etomidate 0.3 mg x kg(-1) for tracheal intubation when combined with remifentanil 3 microg x kg(-1) and no muscle relaxant.