Effects of an intravenous lidocaine bolus before tracheal extubation on recovery after breast surgery - Lidocaine at the End (LATE) study: a randomized controlled clinical trial.

AIM: To investigate whether IV lidocaine improves emergence, early recovery, and late recovery after general anesthesia in women who undergo breast surgery. METHODS: Sixty-seven women with American Society of Anesthesiologists physical status I-II, scheduled for breast surgery were randomized to receive an IV lidocaine 1.5 mg/kg bolus (n=34) or saline placebo (n=33) before tracheal extubation. Anesthesia was induced with thiopental, vecuronium, and fentanyl, and maintained with sevoflurane~1 MAC and 50% nitrous-oxide in oxygen. No postoperative nausea and vomiting (PONV) prophylaxis was given. Time to extubation, bucking before extubation, and quality of emergence, as well as early and late recovery (coughing post-extubation, sore throat, PONV, and pain scores) within 24 hours postoperatively were evaluated. Diclofenac and meperidine were used for the treatment of pain and metoclopramide for PONV. RESULTS: The groups did not significantly differ in demographics, intraoperative data, or PONV risk scores. Extubation was~8 minutes in both groups. Patients who received IV lidocaine had significantly smoother recovery, both statistically and clinically; they had better extubation quality scores (1.5 [1-3] vs 3 [1-5], P<0.001), less bucking before extubation (38% vs 91%, P<0.001), less coughing after extubation (at 1 min 18% vs 42%, P=0.026; and at 24 hours 9% vs 27%, P=0.049), and less sore throat (6% vs 48%, P<0.001). Late PONV decreased (3% vs 24%, P=0.013). There were no differences in pain scores and treatment. CONCLUSION: In women who underwent breast surgery, IV lidocaine bolus administered just before extubation attenuated bucking, cough and sore throat, and PONV for 24 hours after general anesthesia, without prolonging the emergence.

VALIDATION OF THE QUALITY OF RECOVERY-40 QUESTIONNAIRE ADAPTED FOR CROATIAN POPULATION.

Quality of recovery after anesthesia is an important indicator of patient postoperative outcomes. Quality of Recovery-40 (QoR-40) is a validated and widely used multidimensional 40-item questionnaire that measures postoperative quality of recovery. The aim of this study was to perform translation and psychometric validation of the Croatian version of QoR-40, which included validity, reliability, responsiveness, and clinical acceptability. The QoR-40 and Short Form-36 (SF-36) questionnaires were administered to patients undergoing general anesthesia for elective surgery on the day before surgery and on postoperative day 3. The quality of recovery was also assessed with visual analog scale (VAS) 0-100. Of 192 enrolled patients, 162 completed the study protocol. Convergent validity assessed by Pearson correlation (r) between the QoR-40 and VAS scores was 0.68 (p<0.001). There were moderate correlations of QoR-40 with SF-36 Physical component scale (r=0.521; p<0.001) and with SF-36 Mental component scale (r=0.580; p<0.001). Construct validity was supported by negative correlation with the length of hospital stay (r=-0.21; p=0.007) and significant difference in total postoperative QoR-40 scores between patients with and without postoperative complications (p<0.001). Internal consistency of the global QoR-40 was high (Cronbach's α=0.93) and of the QoR-40 dimensions it was moderate to high (≥0.714). Split-half coefficient was 0.87, Cohen's effect size was 0.81, and standardized response mean was 0.762. Our translated QoR-40 is a valid, reliable and comprehensive questionnaire for measuring quality of postoperative recovery across surgery spectrum in Croatian population with psychometric properties similar to the original version.

AMBULATORY EYE SURGERY AND ANTITHROMBOTIC THERAPY - NEW APPROACHES.

One of the most common surgeries in elderly patients is eye surgery. An increasing number of patients undergoing ambulatory eye surgery are on antithrombotic therapy. These drugs may increase the risk of perioperative bleeding associated with ophthalmic needle blocks and/or eye surgery. Intraoperative bleeding and postoperative hemorrhagic complications may lead to the loss of vision or even eyes. On the other hand, stopping anticoagulants and antiplatelets before the surgery may increase the risk of thrombotic events with potentially life-threatening complications. The aim of this narrative review is to provide a systematic review of the published evidence for the perioperative antithrombotic management of patients undergoing different types of eye surgery in ambulatory settings. A comprehensive review of the English-language medical literature search utilizing PubMed, Ovid Medline® and Google Scholar from January 2015 to December 2018 was performed. The database searches included studies providing evidence relevant to ambulatory eye surgery and perioperative antiplatelet medications and anticoagulants. Updated recommendations will be given for continuation, discontinuation, and modification of antithrombotic agents in order to optimize the management of antithrombotic therapies in outpatients scheduled for eye surgery.

LOCAL ANESTHETICS AND STEROIDS: CONTRAINDICATIONS AND COMPLICATIONS - CLINICAL UPDATE.

The objective of this clinical update, based on recently published literature, was to discuss incidence and characteristics of the most relevant clinical adverse effects associated with local anesthetic and steroid use in regional anesthesia and treatment of acute or chronic pain. A comprehensive review of the English-language medical literature search utilizing PubMed, Ovid Medline® and Google Scholar from 2015 to 2018 was performed. This narrative review provides anesthesia practitioners with updated evidences on complications and contraindications of local anesthetic and steroid use with emphasis on current points of view regarding prevention, early diagnosis and treatment of adverse events.

EPIDURAL ANALGESIA IN MULTIPY INJURED PATIENTS WITH SEVERE CHEST TRAUMA: TWO CASE REPORTS AND LITERATURE REVIEW.

Multiply injured patients with severe chest trauma have different combinations of associated extra thoracic injuries making their treatment complex. Severe pain is a prominent symptom in a vast majority of severe chest injuries and causes deterioration of respiratory function. Epidural analgesia provides efficient pain relief but its use in this group of patients is burdened with complications, contraindications and technical difficulties. We present two cases in which epidural analgesia was successfully used in polytrauma patients with severe chest injuries and hypoxemic respiratory failure, and discuss advantages, possible pitfalls and complications.

THE ROLE OF PARAVERTEBRAL BLOCKS IN AMBULATORY SURGERY: REVIEW OF THE LITERATURE.

Ambulatory surgery often involves surgical procedures on the thorax, abdomen and limbs, which can be associated with substantial postoperative pain. The aim of this narrative review is to provide an analysis of the effectiveness of paravertebral block (PVB) alone or in combination with general anaesthesia, in this setting, with an emphasis on satisfactory postoperative analgesia in comparison to other modalities. We have conducted a search of current medical literature written in English through PubMed, Google Scholar and Ovid Medline®. Peer-reviewed professional articles, review articles, retrospective and prospective studies, case reports and case series were systematically searched for during the time period between November 2003 and February 2019. The literature used for the purpose of creating this review showed that utilisation of paravertebral block either alone or in combination with general anaesthesia, has a positive effect on satisfactory analgesia in ambulatory surgery. With a multimodal analgesic approach of PVB and other techniques of anaesthesia and analgesia there is a reduction in postoperative opioid consumption, fewer side effects, lower pain scores, decreased mortality, earlier mobilisation of patients and reduced hospital stay.

Nitrous oxide added at the end of isoflurane anesthesia hastens early recovery without increasing the risk for postoperative nausea and vomiting: a randomized clinical trial.

BACKGROUND: Nitrous oxide (N2O) has been reported to increase the risk of postoperative nausea and vomiting (PONV) in a dose-dependent manner. We investigated the effect of adding N2O at the end of isoflurane inhalational anesthesia on the recovery and incidence of PONV. Our hypothesis was that N2O would reduce the time to early recovery without increasing the incidence of PONV. METHODS: After obtaining ethics committee approval and written informed consent, 100 women at American Society of Anesthesiologists physical status I-III and scheduled for laparoscopic-assisted vaginal hysterectomy were randomized into two groups (G) according to the carrier gas: GO2 (air in 30% oxygen) and GN2O (the same mixture until the last 30 min of surgery, when 70% N2O in 30% oxygen was used). No PONV prophylaxis was given. Anesthesia was induced with thiopental 5 mg·kg-1, vecuronium 0.1 mg·kg-1, and fentanyl 1-2 µg·kg-1 iv and maintained with isoflurane. Indicators of early recovery (time to extubation, eye opening, following commands, orientation) were assessed by an anesthesiologist unaware of the group assignment. The incidence and severity of PONV was measured at two and 24 hr postoperatively. RESULTS: Altogether, 82 participants completed the study (42 in GO2, 40 in GN2O) and were analyzed. The mean (SD) time of N2O administration in GN2O patients was 27.1 (10.1) min. The mean (SD) time to extubation was faster in GN2O patients [5.4 (2.9) min] than in GO2 patients [7.5 (3.7) min] (mean difference, 2.0 min; 95% confidence interval [CI], 0.6 to 3.4, P = 0.009). The ability to open eyes, follow commands, and being oriented were all faster in GN2O patients than in GO2 patients (differences of 3.9 min, 95% CI, 1.6 to 6.1, P = 0.001; 3.4 min, 95% CI, 1.0 to 5.7, P = 0.006; 3.8 min, 95% CI, 0.9 to 6.7, P = 0.010, respectively). The incidence of PONV was not different between the groups, but the rescue antiemetic was required less often in the GN2O patients (mean difference in metoclopramide dose between the GN2O and GO2 groups, 5.1 mg; 95% CI, 0.8 to 9.4, P = 0.019). CONCLUSIONS: Adding N2O during the last 30 min of an isoflurane-based inhalational anesthetic reduced the time to extubation, eye opening, and orientation.

Clinical and Biochemical Influence of Prostatic Stones.

INTRODUCTION: The study aimed to explore clinical influence of prostatic stones on lower urinary tract symptoms (LUTS), seminal plasma cytokines, and serum biomarkers. MATERIALS AND METHODS: A total of 70 men aged ≤50 years with LUTS divided into 2 groups: group with stones (GSt) and group without prostatic stones (GNoSt). All subjects completed the International Prostate Symptom Score (IPSS) questionnaire and National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) scoring questionnaire. Pre- and post-prostate massage test and uroflowmetry were performed. The serum concentration of total prostate specific antigen (PSA), free PSA, and free/total PSA (f/t PSA) ratio, seminal concentration of cytokines interleukin (IL)-1ß, IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor-alpha were measured. RESULTS: GSt subjects had significantly more severe symptoms based on IPSS answers (p = 0.0289). All domains in NIH-CPSI scores were significantly higher in the GSt group: pain (p = 0.001), urinary symptoms (p = 0.023), quality of life (p = 0.008), and with overall (p = 0.003). GSt subjects also had significantly lower maximum urinary flow (Qmax; p = 0.011), lower f/t PSA ratio (p = 0.048), and higher concentration of IL-1ß (p = 0.011) and IL-8 (p = 0.001). CONCLUSIONS: Prostatic stones may influence the severity of LUTS and the symptoms of chronic prostatitis. They might reduce Qmax rate and lead to reduction of the f/t PSA ratio and produce more severe inflammation causing increased seminal concentration of IL-1ß and IL-8.

A combination of levobupivacaine and lidocaine for paravertebral block in breast cancer patients undergoing quadrantectomy causes greater hemodynamic oscillations than levobupivacaine alone.

AIM: To test for differences in hemodynamic and analgesic properties in patients with breast cancer undergoing quadrantectomy with paravertebral block (PVB) induced with a solution of either one or two local anesthetics. METHOD: A prospective, single-center, randomized, double-blinded, controlled trial was conducted from June 2014 until September 2015. A total of 85 women with breast cancer were assigned to receive PVB with either 0.5% levobupivacaine (n=42) or 0.5% levobupivacaine with 2% lidocaine (n=43). Hemodynamic variables of interest included intraoperative stroke volume variation (SVV), mean arterial pressure, heart rate, cardiac output, episodes of hypotension, use of crystalloids, and use of inotropes. Analgesic variables of interest were time to block onset, duration of analgesia, and postoperative serial pain assessment using a visual analogue scale. RESULTS: Although the use of 0.5% levobupivacaine with 2% lidocaine solution for PVB decreased the mean time-to-block onset (14 minutes; P<0.001), it also caused significantly higher SVV values over the 60 minutes of monitoring (mean difference: 4.33; P<0.001). Furthermore, the patients who received 0.5% levobupivacaine with 2% lidocaine experienced shorter mean duration of analgesia (105 minutes; P=0.006) and more episodes of hypotension (17.5%; P=0.048) and received more intraoperative crystalloids (mean volume: 550 mL; P<0.001). CONCLUSION: The use of 0.5% levobupivacaine in comparison with 0.5% levobupivacaine with 2% lidocaine solution for PVB had a longer time-to-block onset, but it also reduced hemodynamic disturbances and prolonged the analgesic effect.

Prognostic value of venoarterial carbon dioxide gradient in patients with severe sepsis and septic shock.

AIM: To investigate the changes in the venoarterial carbon-dioxide gradient (V-a Pco(2)) and its prognostic value for survival of patients with severe sepsis and septic shock. METHODS: The study was conducted in General Hospital Holy Spirit from January 2004 to December 2007 and included 71 conveniently sampled adult patients (25 women and 46 men), who fulfilled the severe sepsis and septic shock criteria and were followed for a median of 8 days (interquartile range, 12 days). The patients were divided in two groups depending on whether or not they had been mechanically ventilated. Both groups of patients underwent interventions with an aim to achieve hemodynamic stability. Mechanical ventilation was applied in respiratory failure. Venoarterial carbon dioxide gradient was calculated from the difference between the partial pressure of arterial CO(2) and the partial pressure of mixed venous CO(2), which was measured with a pulmonary arterial Swan-Ganz catheter. The data were analyzed using Kaplan-Meier survival analysis, along with a calculation of the hazard ratios. RESULTS: There was a significant difference between non-ventilated and ventilated patients, with almost 4-fold greater hazard ratio for lethal outcome in ventilated patients (3.85; 95% confidence interval, 1.64-9.03). Furthermore, the pattern of changes of many other variables was also different in these two groups (carbon dioxide-related variables, variables related to acid-base status, mean arterial pressure, systemic vascular resistance, lactate, body mass index, Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology II Score, and Sepsis-related Organ Failure Assessment score). Pco(2) values (with a cut-off of 0.8 kPa) were a significant predictor of lethal outcome in non-ventilated patients (P=0.015) but not in ventilated ones (P=0.270). CONCLUSION: V-a Pco(2) was a significant predictor of fatal outcome only in the non-ventilated group of patients. Ventilated patients are more likely to be admitted with a less favorable clinical status, and other variables seem to have a more important role in their outcome.

The potential role of micro-RNA-211 in the pathogenesis of sleep-related hypermotor epilepsy.

Sleep-related hypermotor epilepsy (SHE) is a rare epileptic syndrome characterized by epileptic seizures which occur during the non-rapid eye movement (NREM) stage of sleep. It manifests with hypermotor semiology resembling violent limb movements and an asymmetric tonic-dystonic posture. The genes which are responsible for the autosomal dominant form of SHE (ADSHE) and whose function is to code the sub-unit of the neuronal acetylcholine receptor are well known. Considering that ADSHE is a prototype of SHE, it is thought that the dysfunction of the cortico-subcortical cholinergic network, which regulates the cycle of sleep, has a key role in the epileptogenesis of this syndrome. Namely, studies to date, have shown that the hypercholinergic activity is sufficient for the development of epileptic seizures, even though the exact mechanism remains to be elucidated. NREM parasomnias are sleep disorders that are the most difficult to differentiate from SHE due to a similar clinical presentation. Considering the clinical similarities, NREM occurrence and probable genetic connection, it is considered that fundamentally, both of these conditions share a common pathophysiological mechanism i.e. cholinergic dysfunction. The main difference between SHE and NREM parasomnias are the genuine epileptic seizures that are responsible for the semiology in SHE. These genuine seizures are not present in NREM parasomnias. Why this is so, remains to be elucidated. Considering that animal studies have shown that dynamic changes and the decreased levels of microRNA-211 contribute to epileptic seizures and to changes in cholinergic pathways, our hypothesis is that epileptic seizures and the development of epileptogenesis in SHE are a consequence of cholinergic dysfunction and decreased levels of microRNA-211 as opposed to NREM parasomnias where there is a stable level of microRNA-211, preventing epileptogenesis despite the cholinergic system dysfunction.

The dose-response of nitrous oxide in postoperative nausea in patients undergoing gynecologic laparoscopic surgery: a preliminary study.

BACKGROUND: Whether nitrous oxide (N(2)O) increases the incidence of postoperative nausea and vomiting (PONV) after laparoscopic gynecologic surgery is still controversial, which may be due to the administration of different concentrations of inspired N(2)O. We investigated whether N(2)O results in a dose-response increase in PONV. METHODS: Patients undergoing gynecologic laparoscopic surgery were randomized to receive 30% oxygen with air (G0, n = 46), 50% N(2)O with oxygen (G50, n = 46), or 70% N(2)O with oxygen (G70, n = 45). A standardized general anesthetic was used with no PONV prophylaxis. Known risk factors for PONV were controlled. Metoclopramide was used as a rescue antiemetic. The incidence of nausea, vomiting, use of rescue antiemetic, and pain visual analog scale (VAS) score was measured at 2 and 24 h postoperatively. RESULTS: Patient demographics were comparable, and there were no differences among groups regarding factors that may influence PONV. The incidence of PONV at 24 h was 33% (15 of 46) in the G0 group, 46% (21 of 46) in the G50 group, and 62% (28 of 45) in the G70 group (P = 0.018). Subgroup analysis revealed a difference between G0 versus G70 groups (P = 0.018), but no significant difference between G0 versus G50 groups and G50 versus G70 groups. The incidence of nausea showed a similar difference (G0 = 26%, G50 = 35%, and G70 = 56%; P = 0.012), but the incidence of vomiting was not different among the groups although there was a trend (G0 = 28%, G50 = 35%, and G70 = 42%; P = 0.377). The severity of nausea (measured by VAS 100 mm) was significantly increased with increasing N(2)O concentration (G0 = 10.9, G50 = 12.7, and G70 = 20.5; P = 0.027). The highest VAS score during 24 h was used for the analysis. There was no difference in the use of a rescue antiemetic among groups. Pain VAS scores and opioids consumption were not different among groups (at 2 and 24 h after surgery). CONCLUSIONS: N(2)O increases the incidence of postoperative nausea after gynecologic laparoscopic surgery. This preliminary finding indicates that N(2)O may increase PONV in a dose-dependent fashion. A study with a sample size of >400 patients in each group would be necessary to demonstrate a statistically significant difference among each of these three groups. We do not recommend using a high concentration of N(2)O in this clinical setting.

Effect of clonidine on the cutaneous silent period during spinal anesthesia.

AIM: To investigate the effect of clonidine on the cutaneous silent period (CSP) during spinal anesthesia. METHODS: A total of 67 adult patients were included in this randomized, prospective, single-center, double-blind trial. They did not have neurological disorders and were scheduled for inguinal hernia repair surgery. This trial was registered on ClinicalTrials.gov (NTC03121261). The patients were randomized into two groups with regards to the intrathecally administered solution: (1) 15 mg of 0.5% levobupivacaine with 50 µg of 0.015% clonidine, or (2) 15 mg of 0.5% levobupivacaine alone. There were 34 patients in the levobupivacaine-clonidine (LC) group and 33 patients in the levobupivacaine (L) group. CSP and its latency were measured four times: prior to the subarachnoid block (SAB), after motor block regression to the 0 level of the Bromage scale, with ongoing sensory blockade, and both 6 and 24 h after SAB. RESULTS: Only data from 30 patients in each group were analyzed. There were no significant differences between the groups investigated preoperatively and after 24 h. The CSP of the L group at the time point when the Bromage scale was 0 was 44.8 ± 8.1 ms, while in the LC group it measured 40.2 ± 3.8 ms (P = 0.007). The latency in the L group at the time point when the Bromage scale was 0 was 130.3 ± 10.2 ms, and in the LC group it was 144.7 ± 8.3 ms (P < 0.001). The CSP of the L group after 6 h was 59.6 ± 9.8 ms, while in the LC group it was 44.5 ± 5.0 ms (P < 0.001). The latency in the L group after 6 h was 110.4 ± 10.6 ms, while in LC group it was 132.3 ± 9.7 ms (P < 0.001). CONCLUSION: Intrathecal addition of clonidine to levobupivacaine for SAB in comparison with levobupivacaine alone results in a diminished inhibitory tonus and shortened CSP.

Sevoflurane preserves regional cerebral oxygen saturation better than propofol: Randomized controlled trial.

STUDY OBJECTIVE: To investigate possible effects of volatile induction and maintenance anesthesia with sevoflurane (VIMA) and total intravenous anesthesia with propofol (TIVA) on regional cerebral oxygen saturation (rcSo2) during laparoscopic cholecystectomy. DESIGN: Randomized, prospective and single-blinded study. SETTING: Academic hospital. PATIENTS: ASA physical status of I and II surgical patients, scheduled for elective laparoscopic cholecystectomy from March 2013 to October 2014. MEASUREMENTS: Changes of regional cerebral oxygen saturation were measured by near-infrared spectroscopy on the left and right sides of forehead at different time points: before anesthesia induction (Tbas), immediately after induction (Tind), after applaying a pneumoperitoneum (TCo2), 10 minutes after positioning the patient into reverse Trendelenburg's position (TrtCo2), immediately after desufflation of gas (Tpost) and 30 (Trec30) and 60 (Trec60) minutes after emergence from anesthesia. MAIN RESULTS: Study population included 124 patients, 62 in each group. There was no significant difference between these groups according to demographic characteristics, surgery and anesthesia times as well as in the basal rcSo2 values. Statistically higher rSco2 values were noted in the VIMA group when compared to the TIVA group in all time points Tind, TCo2, TrtCo2, Tpost, Trec30 and Trec60 and incidence of critical rcSo2 decreases was statistically lower in VIMA group (P<.05). There were no serious perioperative complications. CONCLUSIONS: VIMA technique provides significantly (4%-11%) higher rcSO2 values during general anesthesia for laparoscopic cholecystectomy, when compared with TIVA and also provides significantly less number of critical rcSO2 decreases.

Transcranial Cerebral Oxymetric Monitoring Reduces Brain Hypoxia in Obese and Elderly Patients Undergoing General Anesthesia for Laparoscopic Cholecystectomy.

The aims of this prospective, observational study were to evaluate the changes of the regional cerebral saturation (rSO2) measured by near-infrared spectroscopy during elective laparoscopic cholecystectomy under total intravenous anesthesia and the association between patient's characteristics and critical decline of rSO2. Hemodynamics, rSO2, and oxygen saturation were recorded in different time points: before the anesthesia (Tbas), 2 minutes after the induction (supine position) (Tind), 2 minutes after CO2 insufflation (supine) (TCO2), 10 minutes after CO2 insufflation (reverse Trendelenburg) (TrevT), and 2 minutes after deflation (supine) (Tpost). Average age was 53±13 (range: 22 to 79 y). In 12 of a total of 62 patients (19.4%) the rSO2 decreased >20% (20.5% to 28.4%) in TCO2 or TrevT times. Significantly higher decrease of the rSO2 was found in patients older than 65 years and those with body mass index >30 kg/m (P<0.05). Noninvasive monitoring of cerebral oxygenation could be an important part of perioperative care in obese and older patients.

The effect of propofol and fentanyl as compared with sevoflurane on postoperative vomiting in children after adenotonsillectomy.

Postoperative vomiting (PV) after adenotonsillectomy in children is a common problem with an incidence as high as 40-80%. Only few studies in the recent literature compared the effect of different anesthetic techniques concerning PV in children. The aim of this study was to compare the incidence of PV in two groups of children who underwent two different general anesthesia techniques in order to determine what type of anesthetic technique is more related to less PV. The clinical trial included 50 children (physical status ASA I, 3-12 years old) divided into 2 groups and monitored for PV 24 hours following the surgery. Group one (G1) consisted of 25 children who underwent general anesthesia with gas mixture 60% nitrous oxide and 40% oxygen and anesthetic propofol, opioid fentanyl and muscle relaxant vecuronium intravenously and group two (G2) included 25 children to whom volatile anesthesia with sevoflurane in the same gas mixture was given. Demographic characteristics (gender, age, weight, history of motion sickness and earlier PV) as well as surgical data (length of surgery and anesthesia, intraoperative blood loss) were recorded. There were no significant differences considering demographic characteristics and surgical data between the investigated groups. The incidence of PV was relatively low 3 children (12%) in G1 group and 5 children (20%) in G2 group. Statistically there was no significant difference between the groups regarding the incidence of PV and both anesthetic techniques can be used equally safe regarded to PV.