Low-Dose Ketamine for Acute Postoperative Pain Treatment

Treatment of acute postoperative pain is an essential part of perioperative care and if left untreated could complicate the healing period. Ketamine blocks nociceptive pain and pain arising from inflammation. Therefore, it is potentially beneficial in the postoperative period. After systematic review using “MEDLINE/PubMed (NLM)” database, we analyzed 18 studies published during 2011–2020 and found that 0.5 mg/kg/h ketamine bolus and 0.1–0.25 mg/kg/h ketamine infusion to be the most effective dose to alleviate postoperative acute pain. Ketamine, when compared with a placebo, did not have any impact on patients’ satisfaction with postoperative pain management and overall well-being. Only three studies revealed more frequent adverse reactions to ketamine after surgery suggesting that ketamine did not have any impact on patients’ postoperational rehabilitation. So, it is the option to recommend low-dose ketamine to be part of multimodal analgesia in acute severe postoperative pain treatment. It can be used in both opioid-dependent and opioid-tolerant patients. Ketamine bolus should be ≤0.35 mg/kg and infusion ≤1 mg/kg/h. One should avoid the use of ketamine in pregnant women, people with cardiovascular diseases, acute psychosis, impaired liver function, increased intracranial, and intraocular pressure. Intranasal ketamine may be considered for children during procedures outside of the operation room

Changes of the chicken chorioallantoic membrane and the behaviour of transplanted glioblastoma

Glioblastoma is the most common brain malignancy and is marked by an extremely poor prognosis, despite advances in surgical and clinical neuro-oncology. Glioblastomas are very heterogenic in their biological and morphological features and they are widely investigated. Existing in vivo glioblastoma models are based on the inoculation of glioma cells or cell lines into the rodent brain, the dog brain or the use of transgenic mice causing spontaneous tumors. These models suffer from the variable growth rate and poor penetration, and are limited by the difficulty of obtaining morphological data. In our research we suggested the model in which the native human glioblastoma was transplanted into the chicken embryo chorioallantoic membrane. The glioblastoma was transplanted into the embryo's chorioallantoic membrane on the seventh–ninth day, when it was fully developed and could ensure the nutrition of the tumor. Transplantation was successful if the glioblastoma survived at least for 24 hours together with the embryo. The chorioallantoic membrane after transplantation showed thickening. Between 48 and 120 hours after transplantation the thickness of the membrane changed from 2x to 5x. Starting from 144 hours after transplantation the thickness of the membrane diminished. The tumor transplanted into the chorioallantoic membrane ingrows in it in the zones where the epithelium of the membrane was mechanically removed. The tumor keeps its proliferative activity until 48 hours of transplantation, afterwards the proliferative activity is noticed in the chorioallantoic membrane until 120 hours of transplantation. This shows that the main processes take place in the zone where the tumor adheres to the chorioallantoic membrane. The human glioblastoma transplanted on chicken chorioallantoic membrane repeated all the essential stages of tumor growth, which are also typical of other mammal models. This model reflects the morphological and biological features of the glioblastoma, allows to evaluate the invasivity, the progress of the tumor, and to investigate new medicines

Potential of FX06 to prevent disease progression in hospitalized non-intubated COVID-19 patients — the randomized, EU-wide, placebo-controlled, phase II study design of IXION

Background: More than 2.7 million hospitalizations of COVID-19-infected patients have occurred in Europe alone since the outbreak of the coronavirus in 2020. Interventions against SARS-CoV-2 are still in high need to prevent admissions to ICUs worldwide. FX06, a naturally occurring peptide in humans and other mammals, has the potential to reduce capillary leak by improving endothelial dysfunction and thus preventing the deterioration of patients. With IXION, we want to investigate the potential of FX06 to prevent disease progression in hospitalized, non-intubated COVID-19 patients. Methods: IXION is an EU-wide, multicentre, placebo-controlled, double-blinded, parallel, randomized (2:1) phase II clinical study. Patient recruitment will start in September 2022 (to Q2/2023) in Germany, Italy, Lithuania, Spain, Romania, Portugal, and France. A total of 306 hospitalized patients (>= 18 years and < 75 years) with a positive SARS-CoV-2 PCR test and a COVID-19 severity of 4-6 according to the WHO scale will be enrolled. After randomization to FX06 or placebo, patients will be assessed until day 28 (and followed up until day 60). FX06 (2 x 200 mg per day) or placebo will be administered intravenously for 5 consecutive days. The primary endpoint is to demonstrate a difference in the proportion of patients with progressed/worsened disease state in patients receiving FX06 compared to patients receiving placebo. Secondary endpoints are lung function, oxygen saturation and breathing rate, systemic inflammation, survival, capillary refill time, duration of hospital stay, and drug accountability. Discussion: With IXION, the multidisciplinary consortium aims to deliver a new therapy in addition to standard care against SARS-CoV-2 for the clinical management of COVID-19 during mild and moderate stages. Potential limitations might refer to a lack of recruiting and drop-out due to various possible protocol violations. While we controlled for drop-outs in the same size estimation, recruitment problems may be subject to external problems difficult to control for

Hemodynamic studies for prediction of acute myocardial infarction outcomes

Prediction of outcomes after acute myocardial infarction was initiated more than 40 years ago. Improvement of the management options significantly reduced mortality of patients with acute myocardial infarction. In the 1960s, the mortality rate of inpatients was around 25–30%, whereas in 2007, according to the guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes, issued by the European Society of Cardiology, hospital mortality in patients with ST-elevation acute myocardial infarction was 7%, while in patients with non-ST-elevation acute coronary syndrome just 5%, but at 6 months, mortality rates were very similar in both conditions (12% vs. 13%, respectively). There are different criteria for prediction of acute myocardial infarction: demographic, clinical, laboratory, instrumental, and epidemiological. Data of hemodynamic studies are ones of the possible criteria for prediction of outcomes after acute myocardial infarction. Methods and findings of hemodynamic studies used for prediction of the outcomes are presented in this article

Bland–Altman analysis as an alternative approach for statistical evaluation of agreement between two methods for measuring hemodynamics during acute myocardial infarction

Background and objective. Evaluation of hemodynamics in patients with acute myocardial infarction is crucial. In clinical practice, the comparison of a new measurement technique with an established one is often needed to see whether they agree sufficiently for the new to replace the old. Such investigations are often analyzed inappropriately, notably by using correlation coefficients. Our objective is to present an alternative approach, suggested by D. G. Altman and J. M. Bland, based on graphical techniques and simple calculations, for evaluation of the agreement of two methods – intermittent thermodilution (recognized and accepted as a “gold standard” for hemodynamic monitoring) and impedance cardiography (newly introduced method). Patients and methods. A total of 34 patients (20 (58.8%) men and 14 (41.2%) women) were investigated according to the study protocol at Kaunas University of Medicine Hospital. A prospective controlled study was designed to compare two different methods – intermittent thermodilution and impedance cardiography – of cardiac output measurement simultaneously in patients with acute myocardial infarction. Statistical analysis was performed with Bland–Altman and linear regression. Results. A total of 34 paired measurements were carried out in 34 patients at the initiation of hemodynamic monitoring and 30 paired measurements in 32 patients after subsequent improvement or stabilization of clinical status. Correlation coefficient ranged from 0.37 to 0.98. Conclusions. Bland–Altman analysis is an alternative method for assessing the agreement between two methods of clinical measurement. According to our data, noninvasive technique – impedance cardiography – is a reliable method for hemodynamic monitoring in noncomplicated cases of acute myocardial infarction

Application of methods for hemodynamic monitoring in critical cardiac pathology. Experimental model for assessment of hemodynamics

Hemodynamic assessment of critically compromised patients with cardiac pathology is one of the goals of recent diagnostics and treatment strategies. Different methods for assessment of hemodynamics are applied in clinical practice. However, applied methods (invasive and noninvasive) have specific advantages and disadvantages. These are discussed in the article. First experience of experimental model for assessment of hemodynamics in laboratory conditions is analyzed in the article. In the year 2002 it was explored a possibility to use standard procedure to evaluate hemodynamics for laboratory animals in Kaunas University of Medicine. It were selected 6 laboratory animals of different weight and sex. 7 measurements of hemodynamics were performed. Standard methodics was successfully applied in the experimental model. Results, method limitations and recommendations for further studies are presented in the article

Anesteziologinė darbo zona operacinėje – infekcijų prevencijos rekomendacijos

The American Society for Epidemiology of Health Care (SHEA) together with the American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF) and American Association of Nurse Anesthetists (AANA) have published infection prevention recommendation in the operating room (OR) anaesthesia work zone. It is important to improve hand hygiene (HH) to optimize control of the gloves wearing technique during airway management was comment. Moreover, basic OR environmental disinfection requirements have been identified as laryngoscopes, anaesthesia machines, cart disinfection between cases, sterility during central vein catheterization and etc. Finally, to improve infection prevention practise it is recommended to identify clear plans for the future and give practitioners the opportunity to use the standards. infection in the OR: minimum requirements for HH and localization of antiseptic dispensers were recommended. Also, gloves wearing technique during airway management was comment. Moreover, basic OR environmental disinfection requirements have been identified as laryngoscopes, anaesthesia machines, cart disinfection between cases, sterility during central vein catheterization and etc. Finally, to improve infection prevention practise it is recommended to identify clear plans for the future and give practitioners the opportunity to use the standards.2019 m. Amerikos sveikatos priežiūros epidemiologijos draugija (SHEA) kartu su Amerikos anesteziologų draugija (ASA), Anestezijos ligonių saugos fondu (APSF) ir Amerikos slaugytojų anesteziologų asociacija (AANA) paskelbė infekcijų prevencijos operacinėje rekomendacijas anesteziologinėje darbo zonoje. Siekiant palaikyti tinkamą infekcijų kontrolę, svarbu gerinti rankų higieną: rekomenduoti minimalūs rankų higienos reikalavimai, antiseptiko dozatorių lokalizacijos, pirštinių mūvėjimas intubacijos metu. Taip pat išskirti pagrindiniai aplinkos dezinfekcijos reikalavimai, tokie kaip laringoskopų, anestezijos aparatų, vežimėlio priežiūra tarp operacijų, sterilumo priemonių laikymasis atliekant centrinės venos kateterizaciją ir kiti. Infekcijų prevencijai gerinti rekomenduojama nuolat tobulinti higienos planus bei suteikti galimybę praktikams vadovautis nustatytais standartais

The influence of dexamethasone and ketolgan on postoperative nausea and vomiting and estimation of risk factors in women undergoing gynecologic laparoscopic surgeries

The aim of this study was to determine the effect of dexamethasone and ketolgan on postoperative nausea and vomiting and to evaluate risk factors for postoperative nausea and vomiting. Material and methods. A prospective, double-blind, randomized clinical study was carried out. One hundred fi fty-three ASA I–II women undergoing laparoscopic gynecologic operations were randomized into three groups: dexamethasone group (n=51), ketolgan group (n=51), and control group (n=51). Patients in the dexamethasone group were given 4 mg of dexamethasone intravenously before the induction of general anesthesia, the ketolgan group received 30-mg ketolgan intravenously, and control group did not receive any medication. The incidence and severity of postoperative nausea and vomiting were registered 24 hours after the surgery. Results. The incidence of postoperative nausea and vomiting in the dexamethasone group was 13.8%; in the ketolgan group, 37.3%, and in the control group, 58.9% (P=0.026). Patients with a history of migraine suffered from postoperative nausea and vomiting in 70.3% of cases and migraine- free patients in 25.8% of cases (P=0.015). Opioids for postoperative analgesia increased the incidence of postoperative nausea and vomiting as compared with nonsteroidal anti-infl ammatory drugs (P=0.00002). Conclusions. Preoperative medication with dexamethasone signifi cantly reduces the incidence of postoperative nausea and vomiting. Avoidance of opioids for postoperative analgesia reduces the incidence of postoperative nausea and vomiting. Migraine and motion sickness are independent risk factors for postoperative nausea and vomiting

Acute heart failure

There are still many discussions among physicians how heart failure should be defined. Despite many suggested traditional classifications, majority of definitions circulating in clinical practice and their appropriate usage remain unclear. A new approach of acute heart failure classification suggested by European Society of Cardiology is presented in the article. Diagnostic strategy of acute heart failure as well as recommendations for prehospital and inpatient treatment of its forms (pulmonary edema and cardiogenic shock) are presented in the article. Application of new medications, recently introduced to the clinical practice for treatment of acute heart failure, is discussed