A prospective, randomized, double-blinded comparison between multimodal thoracic paravertebral bupivacaine and levobupivacaine analgesia in patients undergoing lung surgery.

OBJECTIVES: To compare the effects of paravertebral analgesia with levobupivacaine or bupivacaine on intra- and postoperative pain for thoracic surgery. DESIGN: A prospective, randomized, and double-blinded study. SETTING: A university hospital. PARTICIPANTS: Forty patients undergoing thoracic surgery. INTERVENTIONS: Patients received paravertebral catheterization and a bolus (14-20 mL) of 0.5% bupivacaine (n = 20) or 0.5% levobupivacaine (n = 20) with morphine, 60 µg/kg, before the induction of general anesthesia that consisted of a propofol infusion. A paravertebral continuous infusion (0.05 mL/kg/h) of 0.25% bupivacaine or 0.25% levobupivacaine, 100 mL, with added morphine, 10 mg, and clonidine, 0.15 mg, was started at the end of surgery for 72 hours postoperatively. Postoperative rescue diclofenac analgesia was available if required. MEASUREMENTS AND MAIN RESULTS: The primary outcome was intraoperative fentanyl consumption. Static and dynamic pain scores measured by a visual analog scale were assessed regularly. Intraoperative fentanyl consumption was significantly lower in the levobupivacaine group compared with the bupivacaine group (p = 0.001). On all 3 postoperative days, static pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group (p < 0.05). Dynamic pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group during the 2 postoperative days (p < 0.05). A smaller proportion of patients in the levobupivacaine group used rescue analgesia (p < 0.005). CONCLUSIONS: Paravertebral analgesia with levobupivacaine resulted in less intraoperative fentanyl consumption, lower static (3 days) and dynamic (2 days) pain scores, and less rescue analgesia than analgesia with bupivacaine.

Multiple indicators model of long-term mortality in traumatic brain injury.

OBJECTIVE: To examine the prognostic ability of protein S100B, neuron-specific enolase (NSE) and glial fibrillary acid protein (GFAP) for prediction of 1-year mortality in patients with traumatic brain injury (TBI) in relation to clinical and radiological characteristics of TBI. METHODS: Brain injury was quantified in 84 patients (Glasgow Coma Scale [GCS] ≤ 12) using clinical (GCS, pupils), radiological (computed tomography [CT] classification and individual CT characteristics) and biochemical (S100B, NSE and GFAP) data at admission and in the acute post-injury period. RESULTS: Initial and peak S100B, NSE and GFAP concentrations were higher in non-survivors (n = 26) than in survivors (p-value range: <0.001-0.018). Cox regression showed that GFAP and S100B concentration and the temporal profile of S100B were more powerful independent predictors of mortality than baseline clinical and radiological characteristics or clinical and radiological indicators of neurological deterioration. The prognostic models containing admission variables and those available during the subsequent clinical course showed the same discrimination ability (area under receiver characteristic curve 0.92), but the model based on variables available in the acute post-injury period calibrated better (p = 0.428). CONCLUSION: Mortality at 1-year post-TBI is accurately predicted by the combination of GFAP and S100B concentration and clinical and radiological characteristics at admission or in the acute post-injury period.

Intracranial pressure and biochemical indicators of brain damage: follow-up study.

AIM: To investigate the relation between metabolic parameters of the brain tissue, as direct indicators of real metabolic conditions within the brain, and intracranial pressure, as the consequence of pathophysiological changes. METHODS: Twelve patients with closed head injuries were followed up for 24 hours after injury. A Codman parenchymal intracranial pressure and a Neurotrend electrode were inserted within 3 hours after injury to monitor parenchymal intracranial pressure, brain tissue partial oxygen pressure (P(br)O2), brain tissue partial carbon dioxide pressure (P(br)CO2), pH, and brain tissue temperature. Data detected at 8-hourly intervals were compared with repeated measures analysis of variance. RESULT: At the initial observation, the mean value of intracranial pressure was 22.2 +/- 3.2 mm Hg. Although it increased at the second and decreased at the third measurement, the differences between the measurements were not significant (P = 0.320). The value of P(br)CO2 was increased from the beginning (63.3 +/- 6.0 mm Hg), whereas P(br)O2 was within the normal range at the first measurement (38.9 +/- 6.9 mm Hg), but significantly decreased after 8 hours (P = 0.004), remaining low at later time points. CONCLUSION: After brain injury, changes in P(br)CO2 are visible earlier than those in P(br)O2. Improvement in intracranial pressure values did not necessary mean improvement in the brain tissue oxygenation. In addition to intracranial pressure, P(br)O2, P(br)CO2 and pH should also be monitored, as they directly reflect the real metabolic conditions within brain tissue and may be used in predictions about the outcome and possible therapeutic approaches.

Relationship between injury severity and lactate levels in severely injured patients.

OBJECTIVE: To determine the correlation of blood concentration of lactate and severity of injury and survival in severely injured patients. DESIGN AND SETTING: A prospective study of severely injured patients admitted directly from an emergency surgical unit to a surgical intensive care unit with an Injury Severity Score (ISS) of 16 points or more. The study was conducted over 30 months. PATIENTS: 98 severely injured subjects aged between 16 and 82 years with ISS range from 16 to 75 points, overall 25.5% mortality. INTERVENTIONS: Blood lactate concentrations were measured once on admission, twice daily during the first 2 days and once daily during the next 3 days. ISS, Revised Trauma Score, Shock Index, and Trauma and Injury Severity Score were calculated for each subject. MEASUREMENTS AND RESULTS: Of 98 severely injured patients 91 had elevated blood lactate concentration (over 2.0 mmol/l). Regression analyses demonstrated that injury severity, as measured by ISS, can be predicted from lactate concentration on admission, while survival, either actual or predicted by Trauma and Injury Severity Score higher than 0.5, can be predicted from lactate concentration after 12 h. We also found that patients with Shock Index higher than 0.9 had significantly higher lactate levels during the first 36 h than those with values less than 0.9. CONCLUSIONS: This study confirmed the relationship between blood lactate levels and injury severity as well as the prognostic value of blood lactate level for survival of severely injured patients.