Romanian journal of anaesthesia and intensive care最新文献

Introduction: Caudal epidural block is a reliable technique in paediatric patients but associated with various complications especially with higher concentration of drugs. We proposed a comparative study between levobupivacaine and ropivacaine at low concentration (0.125%) with clonidine at low dose (1 mcg/kg) taken as adjuvant. We aimed to see duration of post-operative analgesia, degree of motor blockade and other associated complications.

Materials and methods: Eighty paediatric patients (1-6 years), American society of anaesthesiologists grade I and II, undergoing infra-umbilical surgery under general anaesthesia were randomly allocated into two groups of 40 each. Group A patients were given caudal levobupivacaine (0.125%) and Group B patients were given caudal ropivacaine (0.125%). Clonidine (1 mcg/kg) was taken as adjuvant in both the groups. Post-operative pain, sedation and motor blockade were assessed at 30 minutes, 1 hour, 2 hours, 4 hours, 6 hours, 12 hours, 18 hours and 24 hours using Observational Pain Scale, modified Bromage Scale and four-point sedation score, respectively. Any other complications were also noted.

Results: Motor blockade was not associated with any of the patients. Duration of post-operative sedation was similar in both the groups. Duration of post-operative analgesia was significantly higher in Group A (p < 0.0001). Adverse effects and complications were negligible in both the groups.

Conclusion: Both levobupivacaine and ropivacaine can be used safely at low concentration (0.125%) taking clonidine at low dose (1 mcg/kg) as adjuvant in paediatric caudal epidural block without significant motor blockade and other complications, duration of post-operative analgesia being significantly higher in the levobupivacaine group.

Objective: Spinal anaesthesia interferes with physiological thermoregulatory responses, potentially leading to peri-operative hypothermia. Spinal morphine can further compound this by a paradoxical clinical presentation leading to poor patient outcome.

Case report: Following an uneventful caesarean delivery (CD) under spinal anaesthesia with intrathecal morphine for post-operative analgesia, a parturient presented in the recovery room with increasing somnolence, excessive sweating and a sensation of feeling hot. She was haemodynamically stable, but her temperature was 34.5°C. Active warming measures were implemented, and normothermia was achieved in 3 hours.

Conclusion: Spinal morphine can alter the clinical presentation of hypothermia by manifesting as excessive sweating and subjective sensation of warmth. Teams involved in the perioperative care of parturients should be aware of (a) the possibility of spinal anaesthesia causing perioperative hypothermia, (b) intrathecal morphine masking the clinical presentation of hypothermia and (c) the importance of monitoring temperature of patients who have received spinal anaesthesia with added morphine.

Background and aims: Patient-controlled analgesia (PCA) with morphine is commonly used to provide analgesia following major surgery, but is not sufficient as a monotherapy strategy. This study aimed to compare the adjunctive analgesic effect of ketamine versus tramadol on postoperative analgesia provided via PCA-morphine in patients undergoing major upper abdominal surgeries.

Methods: Forty-two patients undergoing elective major upper abdominal surgery under general anesthesia were allocated to receive either ketamine (load dose of 0.5 mg kg^-1 followed by a continuous infusion of 0.12 mg kg^-1 h^-1 up to 48 postoperative hours; ketamine group, n = 21) or tramadol (load dose of 1 mg kg^-1 followed by a continuous infusion of 0.2 mg kg^-1 h^-1 up to 48 postoperative hours; tramadol group, n = 21) in addition to their standard postoperative analgesia with PCA-morphine. Postoperative data included morphine consumption, visual analog scale (VAS) scores, and side effects during the first 48 postoperative hours after PCA-morphine initiation.

Results: There were no significant differences in patient demographic and intraoperative data between the two groups. Tramadol group had significantly less total morphine consumption during the first 48 postoperative hours (28.905 [16.504] vs 54.524 [20.846] mg [p < 0.001]) and presented significantly lower VAS scores at rest and mobilization (p < 0.05) than the ketamine group. No statistical difference was recorded between the two groups (p > 0.05) regarding postoperative cough, sedation, hallucinations, pruritus, urine retention, and postoperative nausea and vomiting. However, patients in the ketamine group reported dry mouth more frequently than patients in the tramadol group (p = 0.032).

Conclusions: Postoperative administration of tramadol was superior to ketamine due to significantly reduced opioid consumption and better pain scores in patients receiving PCA-morphine after major upper abdominal surgery.

Objective: Maternal heart disease is one of the major causes for mortality among parturients. In our study, we surveyed 220 patients with different valvular disorders who gave birth in our medical center in the years 2012-2018. The aim of this study was to characterize various valvular pathologies and compare the results of different anesthetic approaches.

Methods: In this retrospective study, the computerized system and file archive were searched for maternal valvular pathologies according to the International Classification of Diseases, Ninth Revision (ICD-9). The women included in the study were defined as American Society of Anesthesiology (ASA)-II or more, who suffer from valvular heart disease.

Results: The most common pathology was mitral valve regurgitation (57.73% of all cardiac patients). Most women were defined as having mild insufficiency, and 82.68% had normal vaginal delivery. In 17.3% of patients who had cesarean section, the main type of anesthesia was neuraxial anesthesia (95.45%). The second most common pathology was tricuspid valve regurgitation (22.73%). Most patients (78%) had normal vaginal delivery, and epidural analgesia was used in 64.1%. A minority of cardiac patients in our study were patients with stenotic heart diseases, such as aortic stenosis, mitral stenosis and pulmonic stenosis (8.18%, 4.55%, and 1.36%, respectively). No complications were observed in the peripartum period.

Conclusion: The use of regional anesthesia is recommended for all valvular pathologies without exception, as we observed no cases in which the severity of cardiac condition had not allowed the use of various types of regional anesthesia, for surgery or vaginal delivery.

Background: Wolff-Parkinson-White (WPW) syndrome is a rare disease that can cause various patterns of tachyarrhythmias. The main goal of anaesthesiologists for the perioperative anaesthetic management of WPW patients must be to avoid sympathetic stimulation and prevent tachyarrhythmias.

Case: A 9-year-old male patient with a diagnosis of WPW syndrome, who underwent emergency surgery for supracondylar humerus fracture, is presented. General anaesthesia in combination with infraclavicular brachial plexus (ICBP) block was performed successfully without any complications. For the reversal of neuromuscular block, sugammadex was uneventfully used. Intraoperative sympathetic discharge due to surgical intervention was prevented with ICBP block. The ICBP block has also provided good postoperative analgesia.

Conclusions: Sugammadex is a good alternative for the reversal of neuromuscular blocks to avoid the undesirable effects of cholinergic drugs. Peripheral regional blocks that require relatively large doses of local anaesthetics can be safely performed with utmost attention in paediatric WPW patients.

Background and aim: Epidural administration of opioids with local anaesthetics is a popular choice for perioperative pain relief. But opioid induced side effects limit their use for postoperative analgesia. Hence, this study was designed to evaluate the effectiveness of epidural naloxone, an opioid receptor antagonist, in reducing PONV in patients receiving epidural fentanyl.

Methods: After obtaining the Institutional Ethics Committee approval and written informed consent, 46 patients, between 18-80 years, of either sex, with ASA physical status 1-3, undergoing lower limb orthopaedic surgeries were enlisted for this prospective, randomized, double blind comparative study. Subjects were allocated to one of the two groups and received epidurally, either fentanyl with bupivacaine (Group C, n = 23) or fentanyl with bupivacaine and naloxone 2 mcg (Group N, n = 25), for reducing postoperative pain. PONV score and Wong Bakers Scale (WBS) for pain score were recorded at 6, 12 and 18hrs, postoperatively.

Results: All patients were comparable with respect to age, gender, ASA PS, height, body weight as well as duration of surgery. A statistically significant decrease in PONV score was observed in Group N at 6 and 12 hours, postoperatively. The patients who required rescue antiemetic were also significantly lower in Group N at 6 and 12 hours. The mean WBS score for pain also showed significant reduction in Group N at 6 hours, postoperatively.

Conclusion: Concomitant use of low dose epidural naloxone and fentanyl is effective in attenuating PONV, besides enhancing analgesia in the earlypostoperative period.

Pediatric laryngotracheal injuries from blunt force trauma are rare but can lead to significant morbidity and mortality. In pediatric patients with severe laryngotracheal disruption, extracorporeal membrane oxygenation has been used to improve oxygenation and ventilation until definitive repair can be performed. We describe the case of a 3-year-old girl with blunt neck trauma secondary to an all-terrain vehicle accident in which her neck was clotheslined against a fence, leading to a complete tracheal transection at the C7-T1 level. Emergent extracorporeal membrane oxygenation cannulation was initiated. We discuss the evaluation and management of tracheal injuries and the requisite multidisciplinary team approach. Pediatric patients with laryngotracheal trauma require definitive airway management, which should be performed by skilled personnel.

Purpose: During pneumoperitoneum (PP) for robot-assisted prostatectomy, a deep neuromuscular block (NMB) is necessary. New relaxometry equipment permits maintenance of profound NMB in order to improve patient safety and surgical conditions.

Methods: Twenty adult patients undergoing robot-assisted prostatectomy were included. Under automated quantitative relaxometry with the TOFcuffTM device, rocuronium dosing was adapted with the aim to keep NMB at deep levels. The time fractions with intense block (PTC 0), adequately deep block (PTC 1 to 3) and a not sufficiently deep block (PTC > 3) were quantified.

Results: An optimally deep block (PTC 1-3) was achieved during 110 ± 38 min (50 ± 15%). Intense block was found during 60 ± 45 min (27 ± 18%) of total PP time. Values of PTC > 3 lasted 60 ± 45 min (23 ± 17%). Median PTC always remained between 1 and 3. Inadvertent movements during PP were never encountered, and operation conditions as reported by the surgeons were excellent.

Conclusion: Our technique of controlled profound NMB by repetitive bolus doses achieved its goal in 77% of PP time. Under automated quantitative relaxometry, an optimized rocuronium dosing strategy should be applied to maintain a high level of safety and adequate operation conditions without risking an unnecessary prolongation of NMB into the post-pneumoperitoneum period.

Annual implants of cardiovascular implantable devices (CIEDs) are increasing, thus increasing the risk of device exposure. This case presents CIED management issues following traumatic thermal injury. A 59-year-old female presented to intensive care with 42% total body surface area burn involving tissue over her pacemaker generator. Electrophysiologists interrogated and reprogrammed the pacer and observed the patient over 72 hours without pacing. Serratia bacteremia developed and cardiology recommended device removal. The pacemaker generator and leads were removed by cardiothoracic and burn surgery. Postoperatively, asystole required emergency transvenous pacing wire placement. During bacteremia treatment, cardiology planned to pace with an active-fixation screw-in lead with long-term plans to place a single right ventricular chamber leadless pacemaker because of the extensive burns. The patient developed fungemia and the family opted for comfort care. This case report discusses the management of a CIED exposed after a traumatic thermal burn, including device extraction.