Incidence of and indications for conversion of cervical plexus block to general anesthesia in patients undergoing carotid surgery: a single center experience.

AIM: He aim of this paper was to investigate the incidence of and the indications for conversion to general anesthesia (GA) in a large single-center series of patients undergoing carotid surgery under cervical plexus block (CPB). METHODS: With IRB approval we retrospectively analyzed the medical records of all patients who underwent carotid surgery under CPB from November 2007 to October 2010. Cervical plexus was blocked at both the superficial and deep levels. An intraluminal shunt was inserted in patients who demonstrated signs of inadequate cerebral perfusion upon carotid clamping (CC). Propofol was given to patients reporting pain or discomfort throughout the procedure. The primary outcomes were the number and percentage of conversions to GA as well as the indications for this intervention. The secondary outcome was the incidence of partial cervical block failure, defined as the need for supplemental propofol administration for pain relief during surgery. RESULTS: In total, 1464 carotid surgical procedures were performed under CPB in 1305 consecutive patients during the investigated period. Conversion to GA was required in 17 (1.2%) patients. The most common reason for conversion to GA was persisting neurological deterioration upon CC and intraluminal shunt insertion, which was recorded in 8/17 (47.1%) procedures. Other indications to convert were systemic toxicity of local anesthetics, pain, general discomfort and restlessness during surgery, and acute myocardial infarction. CONCLUSION: Cervical plexus block for carotid surgery is associated with a low rate of conversions to GA. Neurological deterioration upon carotid clamping and local anesthetic toxicity are identified as the most common indications for such intervention.

[A look into the larynx--two centuries along the path of laryngoscopy].

Both the design and purpose of the laryngoscope have been changed significantly since Alfred Kirstein invented his own "laryngeal mirror"--the autoscope. An initially straight, rigid oesophageal tube has been reshaped into a number of laryngeal blade modifications, suitable for use in various patient subpopulations. A tool initially intended to help otorhynolaryngologists diagnose and treat laryngeal diseases has been transformed into an instrument intended to help anesthesiologists intubate the trachea for the purpose of either anesthesia administration or airway maintenance. As direct laryngoscopy depends greatly upon individual manual skills, there has been almost no beginner who feels no proud of his first successful intubation. Thus, we should never forget the pioneers of laryngoscopy whose curiosity, creativity, and enthusiasm enabled us to give a clear and safe look into the larynx.

[Perspective of mechanical ventilation of lungs].

Mechanical ventilation of lungs during the long history has gone through different phases, which have been associated with technological and scientific development of its time. This is the most complex process and in spite of many progress it does not solve all problems, maintained of respiratory homeostasis, especially in patients with difficult lungs damage. Therefore, there is an existing need for further development of mechanical ventilation of lungs. Over the past time, a number of innovative approaches or adjuncts to mechanical ventilation have been actively researched. Many of these have shown some promise in improving our ability to provide ventilatory support. Which of these innovations will outlast the future? Based on actual development at innovations of mechanical ventilation, it can be assumed that it will be: protective lung ventilation, special form of gas exchange, weaning from mechanical ventilation, noninvasive and home use ventilators, development in fallowing patient's condition and pharmacotherapy development.

Ketorolac as a pre-emptive analgesic in retinal detachment surgery: a prospective, randomized clinical trial.

OBJECTIVE: Retinal detachment surgery is associated with a high incidence of post-operative pain, nausea and vomiting. Previous studies demonstrated a beneficial role of pre-emptive analgesia using regional anesthetic blocks for this type of surgery. The aim of the present study was to evaluate the pre-emptive analgesic effect of ketorolac in patients undergoing retinal detachment surgery under general anesthesia. METHODS: With the approval of the Institutional Ethics Committee and written informed consent, 60 adult patients were randomized prospectively, in a double-masked manner, to receive intravenously either ketorolac 30 mg or saline placebo 30 min before operation. Pain scores at 2, 6, 12, 18 and 24 h after surgery, the number of patients requiring post-operative analgesia, total consumption of analgesics, the incidence of oculocardiac reflex as well as the incidence and severity of post-operative nausea and vomiting were recorded. RESULTS: The ketorolac group required post-operative analgesia less frequently than the placebo group (p < 0.0001). The ketorolac group had significantly lower pain scores at all measurement time points (p < 0.001) and lower intra- and post-operative total consumption of analgesics (p < 0.01). The incidence and severity of nausea and vomiting were lower in patients given ketorolac when compared with placebo-treated patients (p < 0.05). The incidence of oculocardiac reflex was not significantly different between groups (p = 0.14). CONCLUSIONS: The use of ketorolac for pre-emptive analgesia is effective in patients undergoing retinal detachment surgery under general anesthesia.

Ex vivo repair of renal artery aneurysm associated with repairing of abdominal aortic aneurysm. Case report.

A case of right renal artery distal aneurysm associated with juxtarenal abdominal aortic aneurysm in a 75-year-old male, who presented with abdominal and back pain and chronic renal failure, is reported. The abdominal aortic aneurysm was repaired with a bifurcated Dacron graft. The right kidney was simultaneously explanted, ex vivo reconstruction of the renal artery with PTFE graft was performed, followed by autotransplantation of the kidney into the right iliac fossa. In the postoperative course the renal function returned to normal.

[Early results in the surgical treatment of Crawford type IV thoracoabdominal aneurysms].

OBJECTIVE: The aim of the study was to present the outcome of surgical treatment of patients with thoracoabdominal aortic aneurysm Crawford type IV, operated on between January 2001 and April 2004. METHODS: This study included 42 subsequent patients (40 males, 2 females, age 41-76 years). All patients underwent ultrasonography, angiography, computed tomography or magnetic resonance imaging (MRI). Surgical treatment was performed under combined anaesthesia (continuous thoracic epidural analgesia and general endotracheal anaesthesia). In two patients thoracophrenolumbotomy was performed at the level of X rib, while others were operated through left lumbotomy after the extra pleural resection of XI rib. We did not perform any spinal cord protection procedures in this type of aneurysm. Reconstruction included interposition of Dacron graft in 20 patients, aortobiiliac bypass in 18, and aortobifemoral bypass in 4 patients with different varieties of visceral branches reimplantation. RESULTS: Thirty-days mortality was 31% (13 patients, two of them intraoperatively). Causes of death were: pulmonary embolism--in 1 patient; haemorrhage--in 2; myocardial infarction--in 4 (two intraoperative); acute renal failure--in 2; multisystem organ failure (MSOF)--in 4 patients. Respiratory failure dominated in all cases of MSOF. One patient with acute renal failure had paraplegia also, and that was the only case of neurological complication in whole group. All female patients (2), all patients with ruptured aneurysm (4), acute myocardial infarction (4) and acute renal failure (2) have died. Advanced age (over 70 years) and the need for extensive operative procedure with bifurcated graft use significantly influenced their mortality (p < 0.01 and p < 0.05 respectively). CONCLUSIONS: Surgical treatment of thoracoabdominal aortic aneurysm Crawford IV type was successful in 69% of our patients. There was no need for spinal cord protection measures, and extra peritoneal approach with XI rib resection under the combined anaesthesia was preferred.

Takayasu's aortoarteritis.

Surgical treatment of two female patients aged 32 and 41 years, with neurological problems causes by type I Takayasu's aortoarteritis, are presented here. Both of them were treated with by pass from ascending aorta to left common carotid and left subclavian arteries, using transsternal approach. During the follow up period (3.5 years for the first, and 2 years for the second patient) both patients were free of neurologic symptoms. Corticosteroid therapy was given to the first patient for controlling of active diseases, immediatelly after the operation and during the first three postoperative months. By this reason an infection af the proximal part of sternal wound was developed. MRI showed involvement of the vascular graft. Due to high risk of reoperation, medical treatment was performed. Takayasu's aortoarteritis is very unsommon in our country, as well as in other countries which don't belong to Far East. In cases with hemodinamic important arterial lesions produced disabling symptoms, a standard PTA and reconstructive vascular procedures are indicated. Takayasu's aortoarteritis is a complex disease. It requires combined dignostic and therapeutic approaches which produce satisffied long-term results.

[Role of nitric oxide in treatment of acute lung injury after surgery with extracorporeal circulation]. / Uloga azotnog oksida u lecenju akutnih plucnih ostecenja posle operacija izvedenih u uslovima vantelesnog krvotoka.

Postoperative acute lung injury (ALI) compromises oxygen transfer across alveolar-capillary membrane with consecutive hypoxia, one of its indicators being reduction of oxygenation index PaO2/FiO2 below 40 kPa (300 mm Hg). Management of ALI includes different procedures like mechanical lung ventilation (MLV), drugs and others. One of the new possibilities for treatment of ALI is nitric oxide (NO) inhalation. The aim of this prospective study was to examine the role of NO inhalation in treatment of ALI. 14 patients with ALI developed immediately after operation with extracorporeal circulation (ECC) were included in the study. Group A (n = 8) inhaled NO and group B (n = 6) did not inhale NO during treatment of ALI. All other therapeutic measures were the same in both groups. The groups were similar in relation to demographic data, type of surgery and duration of ECC. PaO2/FiO2 was calculated before operation (T1), immediately after surgery (T2) and after lung recovery, when the need for MLV stopped (T3). The duration of MLV was also registered. PaO2/FiO2 (kPa) in referent times was in group A 54.9 +/- 1.6, 33.8 +/- 1.2 and 46.2 +/- 0.8 and in group B 52.2 +/- 1.1, 33.5 +/- 1.5 and 47.3 +/- 0.9, respectively. There was a statistically significant decrease of PaO2/FiO2 in T2 and T3 vs T1 in both groups (p < 0.05), while the difference between the groups was not statistically significant. The duration of MLV (h) in group B (28.5 +/- 1.6) was statistically significantly shorter than in group A (63.1 +/- 8.7) (p < 0.01). According to the results of this study we conclude that NO inhalation during ALI after surgery with ECC significantly reduces the duration of MVL and improves pulmonary recovery.

[Perioperative oxygenation and pulmonary shunt during myocardial revascularization in function of duration of extracorporeal circulation]. / Odnos perioperacione oksigenacije krvi tokom revaskularizacije miokarda i trajanja primene vantelesnog krvotoka.

Perioperative oxygenation is of great importance for the result of operative treatment, especially in patients undergoing open-heart surgery. We studied effect of the duration of extracorporeal circulation on value of pulmonary shunt in 27 patients undergoing coronary artery bypass grafting surgery. The patients were divided into one of two groups according to the duration of extracorporeal circulation: A1 group--extracorporeal circulation less than 90 minutes (9), and A2 group extracorporeal circulation over 90 minutes (18). Measurements of pulmonary shunt were performed at the following times: before (I) and after induction of anaesthesia (II), 5 minutes (III), 2 hours (IV) and 6 hours (V) after extracorporeal circulation, 30 minutes after extubation (VI), 24 hours after extracorporeal circulation (VII), on the second (VIII), third (IX), fifth (X), eighth (XI) and thirteenth (XII) postoperative day. Pulmonary shunt was calculated according to the standard shunt equation (Berggren 1942) in control times I-VII, and formula of estimated shunt in control times VIII-XII. The length of extracorporeal circulation had influence on pulmonary shunt and oxygenation in patients undergoing myocardial revascularization. Extracorporeal circulation lasting over 90 minutes significantly increased pulmonary shunt in the first 24 hours after extracorporeal circulation, excluding the period of artificial ventilation following operation. The recovery of pulmonary function occurred between the eighth and the thirteenth postoperative day, regardless of the duration of extracorporeal circulation.

Intraarterial perfusion of prostaglandin E1 after lumbar sympathectomy or reconstruction on femoropopliteal segment.

Out of 100 patients treated by intraarterial perfusion of prostaglandin E1 we selected 36 cases who have been treated after a lumbar sympathectomy or reconstruction on the femoro-popliteal segment. The patients were in the III and IV stage of occlusive diseases by Fontain. All patients were divided into four groups: (a) prostaglandin E1 after a lumbar sympathectomy (20); (b) prostaglandin E1 after failed femoro-popliteal bypass (8); (c) prostaglandin E1 with patent femoro-popliteal bypass and distal progression of the occlusive disease (3); (d) prostaglandin E1 with previously femoro-popliteal reconstruction and poor run off (5). After intraoperative introduction of a catheter into the superficial femoral artery, profunda femoral artery (a, b), a patent graft (c) or just implanted graft (d), a continuous intraarterial perfusion of prostaglandin E1 was applied, in doses 10 nanograms/kg body weight/minute, in total doses 3000 nanograms. The perfusion time was 48-72 h. The patients were controlled immediately after treatment as well as 1, 3, 6 and 12 months after. Our early and late results of the intraarterial perfusion of prostaglandin E1 proved as a very successful limb salvage procedure.

Clinical and functional evaluation of the Carbomedics Prosthetic Heart Valve in the mitral position. Preliminary results.

The Carbomedics Prosthetic Heart Valve is a new bileaflet pyrolite carbon prosthesis. This paper reports the preliminary results in 40 patients who underwent mitral valve replacement (MVR) using the Carbomedics Valve in 1988. The operative mortality rate was 5% and the early results have been encouraging, with no valve related complications observed in the first post-operative year.

[Femoro-axillary bypass in the treatment of subclavian steal syndrome]. / Femoro-aksilarni bajpas u lecenju supklavija-stil-sindroma.

Extra-anatomic bypass is a nonanatomic procedure of vascular graft from the donor to the recipient artery. The subclavian or axillary artery is very often used for the revascularization of the lower limbs (axillary-femoral bypass). The usage of the femoral artery for the arm or cerebral revascularization is seldom. The authors describe 74-year old woman with femoral-axillary bypass. The bypass was due to subclavian steel syndrome (cerebral and arm vascular insufficiency). Desobstruction and patch angioplasty of the subclavian artery or aorto-subclavian bypass after, transthoracic approach were a contraindication because of the patients advanced age and subcompensated cardiomyopathy. The authors made no typical extraanatomyc bypasses between branches of the aortic arch (carotidosubclavian, or subclavian-subclavian bypass) because of changes on these arteries (occlusion of the left common carotid artery and stenosis of the innominate artery). This is the reason why the femoroaxillary reconstruction was the only possibility of the cerebral and arm revascularization. The Doppler sonographic and angiographic control examination gave good early, and late results. This case is the confirmation of the good use of this unusual method in surgery of subclavian steel syndrome.