Romanian journal of anaesthesia and intensive care最新文献

Background: The incidence of difficult intubation (DI) in obese patients may reach a two-digit figure. No studies have assessed the effect of primary use of special intubation devices on lowering the incidence of DI. We assessed the effect of primary selection of special intubation techniques on the incidence of DI in patients with a BMI of 35 kg/m² or higher.

Patients and methods: Data from 546 patients with a BMI of 35 kg/m² or higher who underwent bariatric surgery at Wolfson Medical Center from 2010 through 2014 was retrospectively extracted and analyzed for demographics, predictors of DI and intubation techniques employed. Difficult intubation was defined as the presence of at least one of the followings: laryngoscopy grade 3 or 4, need for >1 laryngoscopy or intubation attempt, need for changing the blade size, failed direct laryngoscopy (DL), difficult or failed videolaryngoscopy (VL-Glidescope), difficult or failed awake fiberoptic intubation (AFOI) and using VL or awake AFOI as rescue airway techniques. Primary intubation techniques were direct DL, VL and AFOI. We correlated the predictors of DI with the actual incidence of DI and with the choice of intubation technique employed.

Results: The overall incidence of DI was 1.6% (1.5% with DL vs. 2.2 with VL + AFOI, p = 0.61). With logistic regression analysis, age was the only significant predictor of DI. Predictors of DI that affected the selection of VL or AFOI as primary intubation tools were Mallampati class 3 or 4, limited neck movement, age, male gender, body mass index and obstructive sleep apnea syndrome.

Conclusion: The lower incidence of DI in our study group may stem from the primary use of special intubation devices, based on the presence of predictors of DI.

Background & aims: Altered lung function and consequent decrease in oxygenation has been linked to the duration of anaesthesia. This necessitates oxygen monitoring and supplementation in the perioperative period. But, evidence is lacking regarding the parameter that guides best the oxygen supplementation in the postoperative period and the parameter that correlates best with the duration of anaesthesia.

Methods: Adult patients scheduled for head & neck surgery under general anaesthesia were recruited. Two radial arterial blood samples one at pre-induction and the other at one hour after extubation were obtained. Primary outcome measures were partial pressure of oxygen (PaO₂), saturation (SpO₂), arterial oxygen content (CaO₂) and Carrico index (PaO₂/FiO₂) and their relation with duration of anaesthesia.

Results: Data from 112 patients showed a hypoxaemia incidence of 11.6%. We observed a drop in the mean CaO₂ and haemoglobin concentration but a rise in the mean PaO₂ at recovery. The mean PaO₂/FiO₂ deteriorated by 225.65 ± 72.46 (95% CI 367.66, 83.64, p = 0.000) at recovery and there was a significant correlation (r = 0.2, p = 0.03) between duration of anaesthesia and decrease in PaO₂/FiO₂ at recovery with a regression coefficient of 0.27 (95% CI 0.02, 0.50).

Conclusions: The Carrico index was proven to be the best parameter which needs to be monitored perioperatively to detect the alteration in the gaseous exchange in patients undergoing general anaesthesia for head and neck surgery. There is a positive correlation between the decrease in the Carrico index and the duration of anaesthesia especially when it is prolonged beyond 150 minutes.

Anaesthesiology training is going through continuous transformations worldwide. Recent data from a European Survey on anaesthesiology postgraduate trainees and their concerns have been published for the first time, following an initiative by the European Society of Anaesthesiology. Among the responders of this survey, 10.8% were represented by Romanian trainees. The main needs of the Romanian anaesthesiology trainees who completed the questionnaire were, in descending order educational contents/EDAIC, technical skills, exchange programmes, residency workload, residency costs and autonomy transition. Another observation coming from the analysed data is that Romanian anaesthesiologists in training are highly concerned and interested in the field of intensive care medicine. The results also pinpoint to the high costs associated with continuous medical education, leading to a high incentive for workforce migration.

Background and aims: Effective postoperative analgesia is a key element in reducing postoperative morbidity, accelerating recovery and avoiding chronic postoperative pain. The aim of this study was to evaluate the effectiveness of ultrasound-guided Transversus Abdominis Plane (TAP) block, performed before surgical incision, in providing postoperative analgesia for patients undergoing open ventral hernia repair under general anaesthesia.

Methods: Seventy elective patients scheduled for open ventral hernia repair surgery under general anaesthesia were divided randomly into two equal groups: Group I received bilateral TAP block performed before surgical incision (n = 35); Group II received systemic postoperative analgesia with parenteral opioid (morphine) alone (n = 35). Postoperatively pain scores at rest and with movement, total morphine consumption and opioid related side effects were recorded.

Results: Postoperative pain scores at rest and mobilization/cough were significantly higher in patients without TAP block (p < 0.05). Mean intraoperative fentanyl consumption was comparable between the two groups: 0.75 ± 0.31 mg in group I (TAP) and 0.86 ± 0.29 mg in group II (MO), p = 0.1299. Patients undergoing preincisional TAP block had reduced morphine requirements during the first 24 hours after surgery, compared to patients from group II, without TAP block (p = 0.0001). There was no difference in the incidence of opioid related side effects (nausea, vomiting) in the both groups during the first 24 postoperative hours.

Conclusion: The use of preincisional ultrasound guided TAP block reduced the pain scores at rest and with movement/cough, opioid consumption and opioid-related side effects after ventral hernia repair when compared with opioid-only analgesia.

Background and aims: Our aim was to ascertain the opinions and preferences of physical therapists with regard to use of peripheral nerve blocks and their impact on the recovery of patients undergoing total joint replacement.

Methods: We conducted an anonymous 24-question survey of 20 full-time inpatient physical therapists at a single tertiary care medical center.

Results: One respondent indicated they never work with patients who have undergone total joint replacement surgery. Nineteen questionnaires were included in the final analysis. Questions omitted by respondents or with write-in answers were not included in the analysis. A majority of respondents (15 [78.9%]) agreed nerve blocks somewhat to greatly improve a patient's pain after total joint replacement surgery. Most respondents answered that nerve blocks somewhat to greatly impede a patient's ability to participate in physical therapy (14 [73.6%]) and make therapy somewhat to very difficult for them as physical therapists (16 [84.2%]). When asked about specific surgeries, (17/18 [94.4%]) and (14/18 [77.8%]) of respondents would prefer that their patients receive periarticular infiltration or no block at all after total knee arthroplasty or total hip arthroplasty, respectively. All respondents (19 [100%]) answered that they thought lower extremity nerve blocks increased a patient's risk of falling after surgery.

Conclusions: According to the physical therapists we surveyed, nerve blocks impede patient recovery and increase the risk of falls, despite their positive impact on pain control. When considering surgery for themselves, therapists indicated they would not want a nerve block.

The pudendal nerve block (PNB) is widely used for regional anesthesia during obstetric and anorectal procedures, but its role in urologic procedures has not been thoroughly studied. While transvaginal PNB is relatively straightforward, PNB in male patients often requires imaging guidance due to difficulty appreciating anatomic landmarks. We review the PNB and relevant sonoanatomy, and describe its analgesic efficacy in three male patients undergoing urethroplasty for urethral stricture. In this procedure, the patient was placed in lithotomy position, the ischial tuberosity was palpated, and the sacrotuberous ligament and pudendal artery were identified using ultrasound. Ropivacaine was injected medial to the pudendal artery and disappearance of muscle twitch was demonstrated. Two patients reported well-controlled pain at 24 hours postoperatively. One reported perineal pain requiring additional analgesia. All patients were discharged on postoperative day 1 without complications. Ultrasound-guided PNB provides safe and reasonably effective pain control to male patients undergoing urologic procedures.

Background and aims: Little is known regarding patients' anaesthesia-related expectations when presenting for upper limb trauma surgery.

Methods: We conducted a prospective cross-sectional survey exploring prior anaesthetic experience, anaesthesia-related knowledge, anaesthesia expectations, the preoperative visit and factors likely to influence anaesthesia choice. The survey was completed by 192 patients.

Results: Anaesthetists were identified as doctors by 52%; 53% were unaware of their planned anaesthesia; 58% indicated likely acceptance of regional anaesthesia. Information regarding anaesthesia originated mostly from surgeons (65%); 93% had not seen an anaesthetist at the time of the survey. Most believed anaesthesia involved 'going to sleep' (82%) and 71% expected to receive general anaesthesia. The preoperative anaesthesia visit was rated as important by 65% of patients. 78% indicated that provision of information would increase the likelihood of accepting regional anaesthesia. Reducing postoperative pain and nausea would influence 80% in choosing a regional technique.

Conclusion: A knowledge deficit exists regarding anaesthesia modalities for upper limb trauma surgery.

Background and aims: Regional oxygen saturation (rSO₂) monitoring of the brain by near-infrared spectroscopy (NIRS) has been mainly used during carotid endarterectomy. The present study was conducted in volunteers and investigates the rSO₂ values of the brain, heart and liver tissue as assessed by NIRS in the supine and the sitting position.

Methods: After obtaining written informed consent from forty-nine healthy volunteers, rSO₂ values were recorded in the heart and liver areas in the supine and the sitting position, while simultaneously the rSO₂ values of the brain.

Results: The rSO₂ brain values in the supine and the sitting position were 69 ± 6.0 and 66 ± 6.1 respectively (p = 0.0001). The rSO₂ values in the supine and the sitting position were 76 ± 10.5 and 79 ± 6.7 for the heart (p > 0.05) and 85 ± 6.8 and 82 ± 7.2 for the liver, (p = 0.007). Heart rSO₂ values were higher than the brain rSO₂ values in both the supine (76 ± 10.4 versus 69 ± 6.6; p = 0.0001) and the sitting position (79 ± 6.7 versus 66 ± 6.1; p = 0.0001). The liver rSO₂ values were also higher than the brain rSO2 values in the supine (85 ± 6.8 versus 69 ± 6.0; p = 0.0001) and in the sitting position (82 ± 7.2 versus 66 ± 5.7; p = 0.0001). Arterial blood pressure and arterial oxygen saturation (SpO₂) did not differ between the two positions but the heart rate was higher in the sitting position (p = 0.030).

Conclusions: We conclude that brain and liver (but not heart) rSO₂ values are higher in the supine than sitting position. Additionally, NIRS may be used to assess oxygenation of the heart and liver.

Abdominal surgery in obese patients may be associated with pulmonary morbidity, and mortality. Some patients may arrive in the PACU with residual paralysis. The purpose of this study was to find out if there was an association between the type of muscle relaxant reversal agent and the development of postoperative respiratory events in patients undergoing laparoscopic sleeve gastrectomy surgery.

Methods: From September 2012 to February 2013, in a prospective randomized pilot study, two different muscle relaxant reversal agents were administered at the end of surgery in 57 patients undergoing laparoscopic sleeve gastrectomy: sugammadex 2 mg/kg (32 patients) vs. neostigmine 2.5 mg (25 patients). We compared the occurrence of early and late respiratory events/complications by the type of reversal agent. Postoperative respiratory rate, oxyhemoglobin saturation (SpO₂), number of patients with SpO₂ lower than 95% in PACU, the minimum value of SpO₂ in PACU, train-of four counts (TOF) before reversal, unexpected ICU admissions, duration of hospitalization and incidence of reintubation were recorded.

Results: SpO₂ in the PACU was significantly lower in the neostigmine group - 95.80 (± 0.014)) vs. in sugammadex group - 96.72 (± 0.011) (p < 0.01), despite a lower TOF count measured in the sugammadex group before reversal, meaning a deeper level of residual relaxation in this group before the administration of the reversal agent (2.53 ± 0.98 vs. 3.48 ± 0.58 p < 0.01). Also, the minimal SpO₂ was significantly lower in the PACU in the neostigmine group: 93% vs. 94% (p = 0.01). Respiratory rates were not different. After the administration of reversal, both groups had TOF counts of 4 with no fade assessed visually. There were no postoperative respiratory events or complications.

Conclusions: The use of sugammadex (as compared to neostigmine) as a reversal agent following laparoscopic sleeve gastrectomy surgery was associated with higher postoperative SpO₂ despite the lower TOF count before the administration of reversal agent. Despite the statistical difference in SpO₂, its clinical importance seems to be minimal. The lack of difference in the other measured variables may stem from the small number of patients studied (pilot).

Patients with untreated anaemia or iron deficiency who undergo surgical procedures have an increased risk for mortality and morbidity. Patient Blood Management programmes address this issue worldwide and try to improve patient outcomes through a complex set of measures targeting anaemia correction, minimisation of bleeding and improvement of anaemia tolerance, in all phases of perioperative care. The Patient Blood Management Initiative Group is a multidisciplinary team of physicians from specialties including anaesthesiology, nephrology, surgery, orthopaedics, haematology, gastroenterology and transfusion medicine. The team has elaborated ten recommendations, divided into five categories, in order to implement a Patient Blood Management programme in Romania, using the most recent and relevant evidence. The document was discussed during three meetings which took place during October 2016 and May 2017 and the result was modified and updated via e-mail.