Romanian journal of anaesthesia and intensive care最新文献

Background: The classic adductor canal block (ACB) is a regional technique that aims to introduce local anesthetic to the saphenous nerve as it traverses the adductor canal. It offers the benefit of preserved quadriceps strength, and is ideal for rehabilitation. Proximal ACB (PACB) allows the operator to place the block away from the surgical site, permitting preoperative placement. Our primary outcome was total opioid consumption; secondary outcomes included the highest numerical rating scale scores and total gait distance at the indicated time intervals.

Questions/purposes: We asked: 1) Does a Continuous Proximal ACB block with Periarticular knee injection (PACB) provide better analgesia than a Continuous Epidural (CSE)?; 2) Do PACB catheter patients do better with physical therapy compared to CSE patients?; 3) Are PACB patients discharged earlier than CSE patients?

Methods: With IRB approval we performed a retrospective chart review of patients who had underwent primary total knee arthroplasty between October 2015 and September 2016. The selected patients (n = 151) were divided into two groups: CSE group, 72 patients who received a continuous epidural catheter and the PACB group, 79 patients who received at PACB with Periarticular injection. The CSE group received a single-segment combined spinal epidural (CSE) in the operating room. The epidural catheter infusion was started with 0.1% ropivacaine at 8 mL/hour to 14 mL/hour during the post-operative period. The PACB group received a proximal adductor canal catheter with 20 ml of 0.5 % ropivacaine and maintained with ropivacaine 0.2% at 8 ml to 14 ml post operatively. Total opioid consumption, highest numeric rating scores and total gait distance travelled were recorded upon discharge from the PACU and completion of postoperative day (POD) 0, 1, and 2.

Results: We found that the median cumulative morphine consumption was significantly higher in the CSE group compared to the PACB group (194 (0-498) versus 126 (0-354) mg, p = 0.012), a difference that was most notable on POD 1 (84 (16-243) versus 60 (5-370) mg, p = 0.0001). Mean hospital length of stay was also shorter in the PACB group (2.6 ± 0.67 versus 3.0 ± 1.08 days, p = 0.01).

Conclusion: PACB group used significantly lower morphine consumption compared to the CSE group; they were better participants during physical therapy and achieved longer gait distances. The mean hospital length of stay was also shorter in the PACB group.

Background: Two methods of local anaesthetic administration into the epidural space in natural delivery pain management are compared in the article. Methods compared are programmed intermittent epidural bolus (PIEB) and continuous epidural infusion (CEI). Patient-controlled epidural analgesia was provided simultaneously in all cases.

Methods: 84 primipara with average age 30.7 (27.5-34) years, and gestational age 39.1 (38.5-40) weeks planned to natural delivery were examined. PIEB and patient controlled epidural analgesia was used in the first group. Patient controlled epidural analgesia and continuous epidural infusion (CEI) of local anaesthetic was used in the second group. Ropivacaine hydrochloride 0.08% without any adjuvants was utilized as local anaesthetic. Pain assessment was conducted using VAS while motor block was assessed using the Bromage scale.

Results: Labor progression dynamics and condition of newborns were equally independent to the method of analgesia. However, analgesic endpoint was better and more long-lasting while using PIEB with patient controlled epidural analgesia. Moreover, a lesser amount of local anaesthetic was consumed. In the group with programmed bolus, the total volume of local anaesthetic was 59.9 (45-66) ml in comparison with 69.5 (44-92) ml in the continuous infusion group (p = 0.033). The time to first bolus requested by the puerpera was significantly longer in the programmed bolus group - 89.2 (57-108) min compared to 43.2 (35-65) minutes in the continuous infusion group (p = 0.021).

Conclusion: Administration of low-concentrated ropivacaine solution 0.08% with no opioids using PIEB provides better and more prolonged analgesia with less local anaesthetic consumption and without any additional maternal and newborn side effects in comparison with continuous infusion.

Background and aim: Intra/post-operative shivering is frequently observed in parturients posted for elective cesarean delivery (C/D) under spinal anaesthesia. Several studies have advocated the anti-shivering effect of 5-HT₃ antagonists, although none has revealed convincing results. The study aims to evaluate the prophylactic effect of a single intravenous dose of ramosetron (0.3 mg), compared with a placebo (N - normal saline), for the prevention of post-spinal shivering (PSS) during elective C/D.

Method: The study comprised 80 parturients of the American Society of Anaesthesiologists (ASA) physical status I/II, posted for elective C/D under spinal anaesthesia who were randomly divided into 2 equal groups; Group N: 0.9% normal saline (4 ml) immediately before induction of spinal anaesthesia and Group R: ramosetron (0.3 mg) intravenously diluted to 4 ml volume. Shivering at any time on a (0-4) scale and total dose of tramadol required for its treatment was recorded. The study also includes the recording of haemodynamic parameters and the incidence of early onset nausea and vomiting.

Results: Statistically significant data was obtained while comparing incidence of shivering and maximum shivering at any time (P = 0.001). A lower incidence of early onset nausea and decreased total dose of tramadol was also observed in the ramosetron group.

Conclusion: Ramosetron (0.3 mg) is advocated to be an effective drug in preventing post-spinal shivering among parturients posted for elective C/D. Moreover, its role in preventing maternal nausea together with better haemodynamic parameters further supported the advantageous role of ramosetron in our group of patients.

Objective: Continuous quadratus lumborum (QL) analgesia is a new option for proximal femur surgery considered safe and effective. The purpose of this report was to show that we may not be aware of all the possible complications of this technique, and urinary retention may occur even when the block is performed unilaterally.

Case report: To an obese, intubated, mechanically ventilated, female patient, operated in prone position for removal of a femur tumour, we performed a trans-muscular quadratus lumborum block (TQL). We mounted a catheter and administered continuous infusion of local anaesthetic in the postoperative period. The patient experienced urinary retention. A urinary catheter was placed and it was maintained for the entire period of local anaesthetic infusion. When the catheter was removed, 72 hours after the surgery, the patient resumed normal bladder functions.

Conclusion: Urinary retention is a possible complication when continuous quadratus lumborum analgesia is used, even when performed unilaterally.

We anticipated that bilateral Erector spinae plane (ESP) block, which was applied in 10 patients starting from lower thoracic levels (T9) might provide effective postoperative analgesia in open abdominal hysterectomies. In addition, we aimed to obtain anatomic observation of the local anaesthetic (LA) spread in the ESP block by injecting methylene blue on 4 cadavers. All the patients had excellent pain relief. There was an extensive spread to the erector spinae muscle (ESM) involving several segmental levels on cadavers. We observed the spread of dye on the ventral and dorsal rami in the paravertebral space and as an additional finding, the dye had extended to the canal vertebralis. There was a spread of dye on the dura mater. ESP block can be used with new indications and it is an effective technique for major abdominal surgery when is applied to the lower vertebral levels. Randomized controlled trials are required to explore the clinical implications of our findings.

Background: Accumulating evidence indicates that objective neuromuscular monitoring and pharmacological reversal of neuromuscular block reduces the occurrence of residual muscle paralysis in the acute postoperative phase. However, objective neuromuscular monitoring is not a routine habit in anaesthesia. In order to change this situation, we wished to find out, as a first step to improvement, the current use of neuromuscular monitors and the custom of anaesthetists for reversal of neuromuscular block before tracheal extubation.

Methods: A ten-point questionnaire was available via the Surveymonkey website and the link was sent to 2202 Hungarian and Romanian anaesthetists by email.

Results: Three hundred and two (13.7%) of the 2202 registered anaesthetists responded. Less than 10% of them regularly use neuromuscular monitors. They underestimated the occurrence of residual block; only 2.2% gave a correct answer. Neuromuscular monitors are available in 74% of hospitals but are scarcely used. One third of anaesthetists rarely or never use reversal; approximately 20% regularly reverse before extubation. The responders typically believe that clinical signs of residual block are reliable. Instead of monitoring, they use the "timing methods" for tracheal extubation such as time elapsed from last dose, the duration of action of relaxant, the number of top-up doses, the cumulative dose, the return of adequate respiratory tidal volume and the ability to sustain a 5 s head lift.

Conclusions: We concluded that neuromuscular monitoring in these two European countries is suboptimal as is the reversal strategy. Given the fact that monitors are available in the hospitals, the mentality should be changed towards evidence based practice.

Background and aims: In this study, we aimed to evaluate whether the age or the APACHE-II score was a better predictor of mortality in each group. The secondary objective was to investigate the factors affecting the mortality in each individual age group.

Methods: We designed this retrospective study between 2016-2017. Age groups were classified into 3 classes: Patients < 60 years were Group 1, patients between 60-70 years were Group 2, and patients > 70 years were Group 3. We recorded patients' age, ICU indication, demographic data, APACHE-II, ASA, length of hospital stays and mortality.

Results: We analysed 150 patients and reported mortality for 58 patients (38.7%). We did not detect any association between age and mortality for all groups. ASA, length of ICU stays and predicted mortality rate, were significantly higher for exitus patients (p < 0.001). The ROC curve for the APACHE-II score, with a cut-off point of 23, demonstrated 74.14% sensitivity, 60.87% specificity, an area under the curve (AUC) of 67.3%, with 4.5% standard deviation (SD). The ODDS ratio for APACHE-II scores was 4.459 (95% CI: 2.167-9.176). For the adjusted mortality rate, ROC analysis identified a cut-off of 60.8 with 70.69% sensitivity, 52.17% specificity, AUC of 61.2% and 4.6% SD. The ODDS ratio for the adjusted mortality rate was 2.631 (95% CI: 1.309-5.287).

Conclusion: We could not demonstrate any correlation between age and mortality. We consider APACHE-II as a valuable scoring system to predict mortality. We do not consider age as a predictor of mortality. Therefore, we do not suggest its use as a sole prognostic marker in ICU patients.

There has been substantial interest in the use of ketamine for perioperative analgesia. Recently published articles on 'low dose' ketamine mark the resurgence in interest in the use of the drug for acute pain. Continued interest in ketamine as an anti-depressant also has opened the door to applications beyond the operating room. In this article, we will review: the history of ketamine's clinical use; basic ketamine pharmacology; evidence for the use of perioperative ketamine for analgesia; comments on patient selection for ketamine research; a discussion of the safety and side effect profile of ketamine infusions beyond the operating room; and, lastly, ketamine as a treatment option for psychiatric diseases.

Severe chronic pain is often devastating for the affected individuals causing substantial suffering, health impairment, and a very low quality of life, including significant negative consequences for the patient and for society. Patients with complex pain disorders are seen often in relation to anaesthesia. They deserve special attention and require long time hospitalization and multiple contacts with health-care providers after discharge from hospital. A wider adoption of best perioperative and intraoperative pain management practice is required. This paper reviews current knowledge of perioperative and intraoperative pain management and anaesthetic care of the chronic pain patient. The individual topics covered include the magnitude of the problem created by chronic pain, the management of the patients taking various types of opioids, tolerance and opioid induced hyperalgesia and the multidisciplinary approach to pain management. The preventive and preemptive strategies for reducing the opioid needs and chronic pain after surgery are reviewed. The last section includes the role of acute pain services and an example of the implementation of a transitional pain service with the various benefits it offers; for example, the decrease of the opioid dose after discharge from the hospital. Patients also receive the continuity of care, with not only pain relief but also improvements in physical functioning, quality of life and emotional stress.