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.
After the demonstration of its life-saving effect in severe hyperkalemia and the recovery of skeletal muscle after injury, pentadecapeptide BPC 157 has been shown to attenuate the local paralytic ...effect induced by succinylcholine, in addition to systemic muscle disability (and consequent muscle damage). Hyperkalemia, arrhythmias and a rise in serum enzyme values, were counteracted in rats. Assessments were made at 3 and 30min and 1, 3, 5, and 7 days after succinylcholine administration (1.0mg/kg into the right anterior tibial muscle). BPC 157 (10µg/kg, 10ng/kg) (given intraperitoneally 30min before or immediately after succinylcholine or per-orally in drinking water through 24h until succinylcholine administration) mitigated both local and systemic disturbances. BPC 157 completely eliminated hyperkalemia and arrhythmias, markedly attenuated or erradicated behavioral agitation, muscle twitches, motionless resting and completely eliminated post-succinylcholine hyperalgesia. BPC 157 immediately eliminated leg contractures and counteracted both edema and the decrease in muscle fibers in the diaphragm and injected/non-injected anterior tibial muscles. Therefore, the depolarizing neuromuscular blocker effects of succinylcholine were successfully antagonized.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
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.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Here we present two cases of gastrostomy insertion via laparotomy in patients with malignant esophageal disease. Patients were ASA (American Society of Anesthesiologists) physical status III and IV. ...The patients presented as very high risk for general anesthesia, so we decided to use unilateral left sided paravertebral block (PVB) on four thoracic levels along with contralateral local infiltration at the gastrostomy insertion site. We present two cases, one of them a 57-year-old male ASA III patient scheduled for a gastrostomy procedure due to esophageal cancer with infiltration of the trachea. We also present a case of a 59-year-old male patient, ASA IV status, scheduled for the same procedure due to advanced esophageal cancer with a fistula between the left main bronchus and the esophagus and metastases in the left lung. The paravertebral space was identified with the use of an 8 Hertz (Hz) linear ultrasound probe and a nerve stimulator. Paravertebral block was successfully used for insertion of a gastrostomy, thereby enabling adequate anesthesia and perioperative analgesia without hemodynamic or respiratory complications.
To analyze the short and long-term outcome of patients aged 65 years and over, after cardiac surgery. Over a 12-year period we analyzed 1750 patients with a mean age of 70.09 3.94 years. They were ...classified into three age groups: between 65 and 69 (n = 709), between 70 and 74 (n = 695) and 75 years and above (n = 346). Follow-up information was obtained by telephone conversation after a 6-month and 3-year period of discharge from the hospital. Included in the follow-up were 1235 patients and an interview was conducted with 501 (40.6%) patients or their next of kin.
Even though the in-hospital morbidity was highest in the oldest age group, there were no significant differences between groups (p = 0.051). There was no significant difference between groups in the length of hospital stay. The greatest in-hospital mortality was noted in the oldest age group (p = 0.046) compared to patients in the age groups between 65 and 69 and between 70 and 74 years old (p = 0.023 and p = 0.036). In the follow-up study, there was a significantly smaller telephone feedback response in the oldest age group compared to the youngest group (p = 0.003). There were no differences between the groups with respect to mortality and cardiac death after the 6-month and 3-year periods of discharge from hospital.
Our data showed that despite a poor short – and long-term outcome in patients aged 75 and over, all patients had an acceptable operative risk.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
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.
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.
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).
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.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
To investigate the effect of clonidine on the cutaneous silent period (CSP) during spinal anesthesia.
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.
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 (
= 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 (
< 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 (
< 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 (
< 0.001).
Intrathecal addition of clonidine to levobupivacaine for SAB in comparison with levobupivacaine alone results in a diminished inhibitory tonus and shortened CSP.
Physicians have always strived to uphold all the ethical postulates of the medical profession in all aspects of the practice, however with the vast advances in science and technology, numerous ...ethical dilemmas regarding all aspects of life and ultimately death have emerged. Medical decisions however, are no longer in the sole jurisdiction of traditional Hippocratic medicine but are now deliberated and delivered by the patient and they are comprised of a number of additional determining aspects such as psychological, social, legal, religious, esthetic, administrative etc., which all together represent the complete best interest of the patient. This is the basic goal of the "Informed Consent". The widening of legal boundaries regarding professional liability may consequentially lead to a "defensive medicine" and a deterioration in the quality of healthcare. In the Republic of Croatia there a four types of liability and the hyperproduction of laws which regulate healthcare geometrically increase the hazards to which physicians are exposed to on a daily basis. When evaluating the Croatian informed consent for anesthesia, we can come to the conclusion that it is completely impractical and as such entirely unnecessary. Anesthesiologists should concentrate on an informed consent which would in brief explain all the necessary information a "reasonable" anesthesiologist would disclose to a "reasonable" patient so that a patient could undertake a diagnostic or therapeutic procedure unburdened and with complete confidence in the physicians who are involved in the treatment of the respective patient.
Subtotal esophagectomy with retrosternal transposition of the gastric tube to the neck was performed in a 62-year-old patient with squamous cell carcinoma of the proximal third of the esophagus. He ...developed a salivatory fistula in the early postoperative period that healed spontaneously. Five months later, the patient developed partial stenosis of the esophagogastric anastomosis which required recervicotomy and excision, after numerous failed dilatation attempts. Eighteen months later, the patient presented to the hospital for severe pain in the upper abdomen. Clinical work-up revealed pericardial perforation by the gastric tube ulcer necessitating emergent surgery and gastric tube removal. We present a patient who developed both early and late complications of subtotal esophagectomy with gastric tube transposition as well as a review of the literature.
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