БЕЗОПИАТНАЯ АНЕСТЕЗИЯ ПРИ ВМЕШАТЕЛЬСТВАХ НА ЭКСТРАКРАНИАЛЬНЫХ АРТЕРИЯХ У ПАЦИЕНТОВ С МУЛЬТИФОКАЛЬНЫМ АТЕРОСКЛЕРОЗОМ

Aim. To assess safety and effectiveness of opioid-free anesthesia in patients with polyvascular disease undergoing carotid endarterectomy for early mobilization and hemodynamic stability in the perioperative period.Methods. 28 consecutive male patients with polyvascular disease and internal carotid artery stenoses were included in a single-center, randomized observational study. The control group (n = 12) received conventional intravenous anesthesia of fentanyl 0.1 mg bolus every 20 minutes with continuous sedation with propofol at a rate of 4 mg / kg / h. The study group (n = 16) received conventional anesthesia followed by introvenous nefopam 20 mg with continuous infusion of 40 mg/h. Invasive monitoring of blood pressure, sedation depth, and the analgesia nociception index were measured. The marker of brain damage, S100 protein, was measured in blood plasma. All patients underwent neuropsychological testing in the perioperative period.Results. There were no reliable hemodynamic derangements during anesthesia in both study groups. There were no cases with worsening of the initial coronary circulation according to the ECG. No alterations in the initial neurological status were registered. BIS values were maintained at 56±19 in both groups without increasing the dose of propofol. All patients in the study group versus 5 patients (41.7%) in the control group were extubated in the OR unit.Conclusion. Opioid-free anesthesia in patients with polyvascular disease undergoing CEA allows achieving adequate pain management in the perioperative period, ensuring early extubation in the OR unit and postoperative mobilization while maintaining stable hemodynamic parameters and ensuring safe cognitive status.Цель. Оценить безопасность и эффективность безопиатной анестезии при каротидной эндартерэктомии у больных с мультифокальным атеросклерозом для обеспечения ранней активизации и гемодинамической стабильности в периоперационном периоде.Материалы и методы. В одноцентровое рандомизированное наблюдательное исследование было включено 28 мужчин с мультифокальным атеросклерозом и стенозами внутренних сонных артерий. В группе сравнения (n = 12) базовая анестезия обеспечивалась сочетанием внутривенного введения фентанила 0,1 мг болюсно каждые 20 мин и пропофола 4 мг/кг/ч, в исследуемой группе (n = 16) после вводного наркоза – в/в введением 20 мг нефопама с последующей его непрерывной инфузией со скоростью 40 мг/ч. Использовали мониторинг инвазивного артериального давления, глубины седации, индекса ноцицепции и аналгезии; определяли маркер повреждения головного мозга в сыворотке крови (белок S100); нейропсихологическое тестирование проводили в периоперационном периоде.Результаты. В обеих группах в течение анестезии не отмечено достоверных расстройств гемодинамики, по данным электрокардиографии не регистрировалось ухудшения исходного коронарного кровообращения; отсутствовали отклонения по сравнению с исходным неврологическим статусом. Седация на уровне 56±19 баллов по BIS-мониторингу наблюдалась в обеих группах в течение всего вмешательства, что не требовало увеличения дозы пропофола. В исследуемой группе все пациенты экстубированы по окончании операции, в группе сравнения экстубированы в операционной 5 (41,7%) пациентов.Заключение. Безопиатная анестезия при каротидной эндартерэктомии у пациентов с мультифокальным атеросклерозом позволяет осуществлять адекватное обезболивание в течение всего периоперационного периода, обеспечивая раннюю послеоперационную активизацию и экстубацию при сохранении стабильности гемодинамических показателей и комфорта пациента

Alla ricerca di un target per la somministrazione di oppioide in anestesia generale

L'Analgesia Nociception Index (ANI) è un indice di recente sviluppo per il monitoraggio del dolore del paziente che analizza, attraverso il tracciato elettrocardiografico, la varianza dell'intervallo RR (Heart Rate Variability, HRV). Questo dato, come mostrato in vari studi, riflette l'influenza del sistema nervoso autonomo sul nodo del seno. (1, 2) Attraverso un logaritmo viene elaborato un indice numerico da 0 a 100, che sarà tanto più basso quanto maggiore è il dolore del paziente. Ogni ciclo respiratorio è associato ad un fisiologico lieve aumento della frequenza cardiaca durante l’inspirazione (con relativa riduzione dell’intervallo RR), e ad una riduzione durante l’espirazione (con aumento dell’intervallo RR). Questo pattern respiratorio è dovuto al fatto che, in un paziente senza dolore, è prevalente il tono parasimpatico. Durante l’inspirazione si ha lo stiramento dei recettori alveolari, che provocano un riflesso vagale il quale esita in una riduzione della frequenza cardiaca nella successiva fase del ciclo respiratorio, cioè quella espiratoria. Ciò si rifletterà in un basso indice ANI. Un paziente che sperimenta uno stimolo dolorifico avrà un aumento del tono simpatico. Ciò risulterà in una importante riduzione del tono parasimpatico. La potenza del fisiologico riflesso parasimpatico durante il ciclo respiratorio si attenuerà moltissimo, lasciando pressoché invariata la frequenza cardiaca e la HRV in fase inspiratoria ed espiratoria. In questo caso invece avremo un basso indice ANI. (3) I limiti di questo tipo di monitoraggio sono vari: o Il valore dell’indice ANI è ottenibile quando gli alveoli polmonari vengono dilatati e i recettori di stiramento sono sollecitati (cosa che avviene sia con ventilazione a pressione negativa che positiva), ma non durante l’apnea (ANI non registrabile durante l’intubazione, ad esempio). o L’indice ANI è registrabile solo se il riflesso parasimpatico agisce sulla frequenza cardiaca attraverso il nodo del seno. Tutte le condizioni in cui lo stimolo sia ectopico (ad es. fibrillazione atriale, presenza di pace maker) costituiscono un criterio di esclusione. o Tutti i farmaci che vanno ad alterare il tono simpatico/parasimpatico (atropina, efedrina, catecolamine) interferiscono con l’affidabilità dell’indice ANI. (4) In questo elaborato ci siamo proposti di valutare 60 pazienti sottoposti a tiroidectomia completa o lobectomia tiroidea, ASA I-II, in anestesia generale totalmente endovenosa in mantenimento con propofol 2% e remifentanyl 0,5 mcg/ml in infusione continua. 30 pazienti sono stati monitorati con ANI, con l’obiettivo di mantenere l’indice compreso tra 50 e 70 attraverso l’aggiustamento della dose di remifentanyl somministrata (espressa in mcg/kg/min). Negli altri 30 il dosaggio dell’oppioide intraoperatorio è stato effettuato solamente sulla base dei parametri clinici ed emodinamici (PA, FC). 1. PhysioDoloris: a monitoring device for analgesia / nociception balance evaluation using heart rate variability analysis. Logier R1, Jeanne M, De Jonckheere J, Dassonneville A, Delecroix M, Tavernier B.Conf Proc IEEE Eng Med Biol Soc. 2010;2010:1194-7 2. Pain/analgesia evaluation using heart rate variability analysis. Logier R1, Jeanne M, Tavernier B, De Jonckheere J. Conf Proc IEEE Eng Med Biol Soc. 2006;1:4303-6 3. Heart rate variability during total intravenous anesthesia: effects of nociception and analgesia. Auton Neurosci, Jeanne M, Logier R, De Jonckheere J, Tavernier B. 2009. 147(1-2): 91-6. 4. Validation of a graphic measurement of heart rate variability to assess analgesia/nociception balance during general anesthesia. Conf Proc IEEE Med Biol Soc, 2009.1:1840-

Management of Chronic Venous Insufficiency (CVI): Literature Review

Chronic venous insufficiency (CVI) of the lower extremities manifests itself in a variety of clinical spectrums, ranging from cosmetic issues that are asymptomatic to severe symptoms like venous ulcer. Due to a lack of understanding of the various presenting manifestations of primary and secondary venous disorders and an underestimation of the problem's magnitude and impact, CVI is a relatively common medical condition that is frequently overlooked by healthcare providers. Due to the possibility of underdiagnosis of CVI, an increase in obesity, and an aging population, it is anticipated that the prevalence of CVI will rise. Duplex ultrasound, radiofrequency ablation, and iliac vein stenting play an important role in the diagnosis, treatment, and prevention of CVI of the lower extremities

UWOMJ Volume 18, Number 3, June 1948

Schulich School of Medicine & Dentistryhttps://ir.lib.uwo.ca/uwomj/1140/thumbnail.jp

Objective assessment of microcirculatory response in venous disease to therapy

Venous stasis is associated with leucocyte & endothelial activation as well as local growth factor response in chronic venous distasease (CVD). There is no good data on the response of this increased activation to treatment. The theme of this thesis was to show changes in leucocyte/endothelial activation as well as microcirculatory stasis in response to medical, surgical and compression therapy. Thus these may act as objective measures of response to treatment. Vascular endothelial growth factor (VEGF) is being investigated extensively in various arterial scenarios I demonstrated high plasma levels of among patients with CVD for the first time. Levels in patients were about 60% higher (82pg Vs 52 pg in controls). This may represent an (reparative!) angiogenic response existing along with the leucocyte inflammatory response. I used a model of medical treatment (60 days oral flavonoid therapy) and demonstrated significant change in plasma VEGF (50% reduction i.e. 98 pg to 57 pg/dl), ICAM (32%), VCAM (29%) & lactoferrin (36%) levels in patients. Thus I showed that endothelial cell activation (ECA) as well as VEGF might be used as an objective surrogate marker in CVD. I propose that amelioration of endothelial activation may be a mechanism of action for these compounds. I studied the response of these parameters to surgical treatment of varicose veins in 20 patients. I showed that there is an increased plasma lactoferrin at 4 weeks that goes below starting base line levels at 6 months (865 Vs 870 Vs 519). VEGF levels continued to increase (65 Vs 83 Vs 134 pg/dl) in these patients and this may represent vascular remodelling. Although not all of them are easily explainable, the microcirculatory parameters were shown to have a definable response to therapy. I used a new apparatus (Laser capillary anemometer) to assess the response of the velocity of blood in the microvasculature of patients with venous, arterial or mixed disease. I demonstrated that compression increases velocity of blood in the sub-papillary plexus & lower levels of compression (20 mm Hg) are more effective in increasing velocity in patients with mixed disease. This may explain the basis for using compression therapy in these patients. Thus I have shown that various parameters of microcirculation may be used to assess the response to therapy in CVD. Future uses of these findings may include design of new and novel therapeutic approaches and to prognosticate for the development of skin changes and ulceration of the leg in CVD