"Blind" interlaminar epidural steroid injections in lumbar spinal stenosis; effective and safe technique in elderly patients

Background and purpose: Blind interlaminar epidural steroid injection (BESI) is one of the treatment modalities for lumbar spinal stenosis (LSS). There are a growing number of elderly patients with LSS. The optimal timing and outcome of BESIs in this population are not well defined, which is the aim of this study. Patients and methods: Thirty patients aged 67±1.5 yrs, with diagnosis of LSS and refractory painwere recruited during year 2010 and followed up for 12months. “Blind” epidural in corresponding interspace was performed with 18G Tuohy needle, using loss of resistance. The epidural mixture (10ml) consisted of 80 mg of triamcinolone acetonide and 40mg of lidocaine. Each patient received in total 3 BESIs every 3 weeks (BESI1, BESI2, BESI3). The pain was evaluated with visual analogue scale (VAS) before first BESI (VAS0) and after each treatment (VAS1, VAS2, VAS3). Subjective quality of performing the same physical activity (PA) was evaluated with simple 3-points scale (0 = no change, 1 = slight improvement, 2 = significant improvement). Results: BESI resulted in significant reduction of VAS (VAS0 8.1±0.3, VAS1 5.8±0.2, VAS2 4.9±0.2, VAS3 4.4±0.3; F=87.57, P< 0.001) – all pair-wise comparisons were significantly different in post-hoc analysis (P<0.001), except VAS2 vs VAS3 having borderline significance (P=0.06). Subjective quality of physical activity significantly improved regarding baseline conditions (BESI1 PA score: 0=1/30,1=7/30, 2=22/30 patients; BESI2 PA score:0=1/30,1=5/30,2=24/30 patients; BESI 3 PA score: 0=4/30, 1=6/30, 2=20/30 patients; c2=3.7, p=0.45). The average duration of successful BESI treatmentwas 6.3±0.8months (range 1–12). There were no reported complications. Conclusions: Blind interlaminar epidural steroid injections (in total 3 injections every 3 weeks) resulted in significant reduction of pain and improvement of physical activity in elderly patients with LSS. It could be regarded as effective and safe procedure in this population

The pathogenesis of cognitive decline after cardiac surgery: A Narrative Review

Unatoč stalnom opadanju poslijeoperacijskih komplikacija nakon kardiokirurškog zahvata razvojem suvremene medicine, učestalost poslijeoperacijskih kognitivnih poremećaja (POKP) je nepromijenjena, postavši tako najčešćom komplikacijom. Razlog tome je u još uvijek nerazjašnjenoj patogenezi POKP-a, ali i u nepostojanju opće prihvaćene definicije POKP-a među istraživačima. POKP-i imaju značajnu reperkusiju na bolesnikovo zdravlje, ali i na širu zajednicu zbog znatnih troškova liječenja i rehabilitacije bolesnika, smanjenja radne sposobnosti bolesnika i potrebe za njegovim prijevremenim umirovljenjem. Cilj ovog narativnog preglednog rada je na temelju pretraživanja dostupne literature čitateljima dati uvid u najnovija saznanja o POKP-ima nakon kardiokirurškog zahvata, s osobitim osvrtom na patogenezu POKP-a. Stoga su autori ovog rada pretraživali baze podataka Web of Science (All Databases) i Scopus u svrhu prikupljanja najnovijih spoznaja o ovoj iznimno važnoj poslijeoperacijskoj komplikaciji. Utvrdili smo kako upalni odgovor na kardiokirurški zahvat vjerojatno ima ključnu ulogu u međusobno preklapajućim mehanizmima koji su u podlozi nastanka POKP-a, te kako metodološka nedosljednost u definiranju POKP-a među istraživačima uvelike otežava istraživanje ove komplikacije.Although the rates of postoperative complications following cardiac surgery are constantly declining because of improvements in medical techniques, the incidence of postoperative cognitive decline (POCD) is still unchanged and has become the most common postoperative complication. The pathogenesis of POCD is still poorly understood, and universally accepted POCD definition has not yet been established. POCD occurrence has a significant repercussion on patient health, but also on the community, given that POCD is associated with reduced work ability, early withdrawal from the workforce and significantly increased use of healthcare resources. The purpose of this narrative review is to summarize and evaluate the latest findings based on the search of available literature, with special attention paid to the pathogenesis of POCD. Therefore, we searched the Web of Science (All Databases) and Scopus databases for the best evidence about this significant postoperative complication. We revealed that the inflammatory response to cardiac surgery plays a key role in the mutually overlapping processes included in POCD development, and that the methodological inconsistency in defining POCD among researchers makes a significant obstacle in the investigation of this issue

Personalized medicine – parenteral ketogenic diet in pyruvate dehydrogenase deficiency in the ICU; what do we need to know about it?

Manjak kompleksa piruvat dehidrogenaze (engl. Pyruvate Dehydrogenase Complex Deficiency, PDCD) rijedak je genetski neurometabolički poremećaj. Pripada u skupinu mitohondrijskih bolesti. Kliničke manifestacije se kreću od često smrtonosne, teške, novorođenačke laktacidoze do ozbiljnih neuroloških poremećaja kasnije tijekom života. Većina bolesnika ne doživi odraslu dob i rijetko je ova problematika nazočna u jedinicama intenzivnog liječenja odraslih bolesnika. Jedan od važnijih terapijskih postupaka kod ovih bolesnika je ketogena prehrana s visokim udjelom masti kojom se proizvode ketoni kao alternativno gorivo za tijelo i mozak. Ponekad može biti potrebna parenteralna ketogena prehrana koja još uvijek nije precizno definirana u postojećim smjernicama za prehranu bolesnika u jedinicama intenzivnog liječenja. Prikazano je provođenje parenteralne ketogene prehrane, te laboratorijski i klinički nadzor u 18-godišnje bolesnice s mitohondrijskom bolesti (PCDC) i to nakon abdominalnoga zahvata povezanog s upalnim komplikacijama, kada enteralna prehrana nije bila moguća. Prehrana je zahtijevala detaljni izračun osnovnih sastojaka kako bi se osigurala adekvatna opskrba energijom, volumenom i mikronutirijentima, a da bi se pri tome proizvela ketoza. Zajedno s ostalim metodama intenzivnoga liječenja, ovakav način prehrane pomogao je rješavanju komplikacija i ishodu liječenja ove epizode. U zaključku, pravilno propisana parenteralna ketogena prehrana kod bolesnika s PCDC smanjuje laktacidozu i učestalost neuroloških komplikacija. Treba je provoditi isključivo u jedinicama intenzivnoga liječenja, poglavito zbog nužnosti trajnog laboratorijskog i kliničkog nadzora. Kad god je moguće, treba ponovo što prije prijeći na enteralnu prehranu. Poželjno bi bilo imati i točno definirane smjernice za parenteralnu ketogenu prehranu.The pyruvate dehydrogenase complex deficiency (PDCD) is a rare genetic neurometabolic disorder. It belongs to the group of mitochondrial diseases. Clinical manifestations range from often fatal, severe, neonatal lactic acidosis to serious neurological disorders later in life. Most patients do not reach adulthood and are rarely present in intensive care units for adult patients. One of the most important therapeutic procedures in these patients is a ketogenic high-fat diet that produces ketones as an alternative fuel for the body and brain. Sometimes a parenteral ketogenic diet may be required; however, it has not been yet precisely defined in existing nutrition guidelines for intensive care patients. Here we described the implementation of parenteral ketogenic diet, along with the basics of laboratory and clinical monitoring in the 18-year old patient with mitochondrial disease (PCDC) after abdominal surgery associated with inflammatory complications, while enteral intake was not possible. It required a detailed calculation of the basic ingredients of the diet to ensure an adequate supply of energy, volume and micronutrients, while producing ketosis. Together with other intensive care methods, it helped resolve the complications and treatment outcome of this episode. In conclusion, properly prescribed and implemented parenteral ketogenic diet in patients with PCDC reduces the incidence of lactic acidosis and neurological complications. It should be performed exclusively in intensive care units, mainly due to continuous laboratory and clinical monitoring. Whenever possible, enteral nutrition should be resumed as soon as possible. It would also be desirable to have well-defined guidelines for parenteral ketogenic nutrition

Combined Usage of Inhaled and Intravenous Milrinone in Pulmonary Hypertension after Heart Valve Surgery

Secondary pulmonary hypertension is a frequent condition after heart valve surgery. It may significantly complicate the perioperative management and increase patients’ morbidity and mortality. The treatment has not been yet completely defined principally because of lack of the selectivity of drugs for the pulmonary vasculature. The usage of inhaled milrinone could be the possible therapeutic option. Inodilator milrinone is commonly used intravenously for patients with pulmonary hypertension and ventricular dysfunction in cardiac surgery. The decrease in systemic vascular resistance frequently necessitates concomitant use of norepinephrine. Pulmonary vasodilators might be more effective and also devoid of potentially dangerous systemic side effects if applied by inhalation, thus acting predominantly on pulmonary circulation. There are only few reports of inhaled milrinone usage in adult post cardiac surgical patients. We reported 2 patients with severe pulmonary hypertension after valve surgery. Because of desperate clinical situation, we decided to use the combination of inhaled and intravenous milrinone. Inhaled milrinone was delivered by means of pneumatic medication nebulizer dissolved with saline in final concentration of 0.5 mg/ml. The nebulizer was attached to the inspiratory limb of the ventilator circuit, just before the Y-piece. We obtained satisfactory reduction in mean pulmonary artery pressure in both patients, and they were successfully extubated and discharged. Although it is a very small sample of patients, we conclude that the combination of inhaled and intravenous milrinone could be an effective treatment of secondary pulmonary hypertension in high-risk cardiac valve surgery patient. The exact indications for inhaled milrinone usage, optimal concentrations for this route, and the beginning and duration of treatment are yet to be determined

OBSTRUCTIVE SLEEP APNEA, ANESTHESIA AND AIRWAY – CLINICAL DILEMMAS AND REVIEW OF THE LATEST GUIDELINES

Cilj ovoga preglednog članka je objasniti anesteziološki pristup bolesnicima s opstrukcijskom apnejom tijekom spavanja (engl. Obstructive Sleep Apnea, OSA), prikazati rezultate najnovijih istraživanja i osvrnuti se na nedavno objavljene smjernice i preporuke. OSA je najčešći poremećaj disanja vezan uz spavanje. Smatra se da je OSA sustavna bolest s više raznih fenotipova i patofi zioloških mehanizama. Dokazano je da bolesnici s OSA-om imaju znakovito povećanu incidenciju perioperacijskih komplikacija, a osobito onih vezanih za održavanje dišnoga puta. Bolesnici s OSA-om osjetljivi su na konvencionalne anestetike i sedative, osobito na opioide. Stoga, u ovih bolesnika kad god je moguće treba primijeniti lokoregionalne tehnike. Među kirurškim bolesnicima izrazito je visoka prevalencija OSA-e, a veliki broj bolesnika je prijeoperacijski nedijagnosticiran. Defi nitivna dijagnoza OSA-e moguća je jedino polisomnografi jom, koja nije uvijek dostupna. Stoga se danas sve više preporuča uporaba raznih validiranih prijeoperacijskih testova i upitnika (STOP, STOP-BANG, Berlin, ASA, P-SAP) koji zadovoljavajuće koreliraju s poslijeoperacijskim ishodima i pomažu u prijeoperacijskoj stratifi kaciji rizika. Veliki napredak su i smjernice Američkog udruženja anesteziologa iz 2014. godine, te preporuke Američkog udruženja za anesteziju i medicinu spavanja iz 2016. godine. Novije smjernice doimaju se praktične, jer svrstavaju bolesnike u tri skupine: 1) bolesnici s dijagnosticiranom OSA-om, koji se pridržavaju liječenja pozitivnim tlakom (engl. Continuous Positive Airways Pressure, CPAP), 2) bolesnici s dijagnosticiranom OSA-om, koji odbijaju ili se slabo pridržavaju liječenja CPAP-om, te 3) bolesnici pod sumnjom na OSA-u. Te smjernice po prvi puta navode i defi niraju termin nekontrolirane sustavne bolesti. Nadalje, taj novi strukturirani pristup daje jasne preporuke uz već nazočne smjernice ASA iz 2014. godine.The aim of this review article is to explain the anesthetic approach to patients with obstructive sleep apnea (OSA), to show results of the most recent research, and to review the recently published guidelines and recommendations. OSA is the most common sleep-related breathing disorder. It is considered that OSA is a systemic disease with many different phenotypes and pathophysiological mechanisms. It has been shown that patients with OSA have an increased incidence of perioperative adverse events, especially those associated with maintaining the airway. Patients with OSA are sensitive to conventional anesthetics and sedatives, particularly opioids. Therefore, in these patients, local and regional techniques should be applied whenever possible. Among surgical patients, there is a high prevalence of OSA, and a large number of patients are not diagnosed preoperatively. Defi nitive OSA diagnosis is only possible with polysomnography, which is not always easily available. Therefore, the use of various validated preoperative tests and questionnaires (STOP BANG, Berlin, ASA, P-SAP) is increasingly recommended today, as these correlate satisfactorily with postoperative outcomes and help in preoperative risk stratification. In the last years, two new important documents have appeared. The practice guidelines for the perioperative management of patients with obstructive sleep apnea were published by the American Society of Anesthesiologists (ASA) in 2014, and the Recommendations of the American Association for Anesthesiology and Sleep Medicine two years later. The latter are practical because they classify patients into 3 groups: 1) surgical patients with OSA, adherent to positive airway pressure (PAP) therapy, 2) surgical patients with OSA, who decline or are poorly adherent to PAP therapy, and 3) surgical patients who have a high probability of OSA. These recommendations defi ne the term of uncontrolled systemic disease for the fi rst time. Furthermore, this new structured approach gives clear recommendations in addition to the current ASA guidelines from 2014

Intracoronary administration of levosimendan in patients with acute coronary syndromes and decreased left ventricular ejection fraction undergoing coronary artery bypass graft surgery

In cardiac surgery patients, intracoronary (IC) administration of levosimendan can provide optimal drug spread, enabling effective manifestation of favorable drug effects and avoiding potentially harmful systemic hypotension. This could be beneficial in acute coronary syndromes (ACS) with decreased left ventricular ejection fraction (LVEF). We present ten cases of IC administration of levosimendan in ACS manifested as ST segment elevation myocardial infarction, non-ST segment elevation myocardial infarction or unstable angina pectoris. All patients underwent coronary artery bypass graft (CABG) surgery, performed as an “off-pump” or “onpump”/“ off-clamp” procedure (latter one with the use of cardiopulmonary bypass on the beating heart). Levosimendan was administered as an IC bolus (125-250 μg) in each coronary artery graft (2-3 grafts). Intravenous (IV) levosimendan infusion continued (0.1-0.2 μg•kg-1•min-1) after graft placements (24-48 h), with IV infusion of norepinephrine (0.1 mg•ml-1), if needed. Cardiac function was assessed using LVEF (%) (Teicholz), thermodilution cardiac index (CI) (ml•m-2), and systemic vascular resistance (SVR) (dynes•sec•cm-5). Nonparametric Wilcoxon signed-ranks test [presented as median (MED) with interquartile range (IQR)] indicated a significant difference between preoperative vs. immediate postoperative CI, SVR, and LVEF in all cases [2.2 (1.9-2.5) vs. 3.1 (2.9- 3.4) ml•m-2, 1173.0 (1062.7-1278.2) vs. 882.5 (763.5-993.0) dynes•sec•cm-5, 44.5 (36.0-46.7) vs. 53.5 (45.7-59.2) %, respectively] (P=0.005), i.e. IC administration of levosimendan was associated with prompt improvement of intraoperative hemodynamics and cardiac contractility. IC administration of levosimendan may be a promising alternative method for improving decreased cardiac function in acute cardiac ischemia, besides necessary surgical revascularization

Intravenous anaesthesia for adenoidectomy in a 3-year-old child with Kartagener syndrome and sleep disordered breathing

Kartagener syndrome (KGS) is a rare inherited disorder characterized by situs inversus viscerum (including dextrocardia) and primary ciliary dyskinesia resulting in chronic respiratory tract infections, bronchiectasis and sinusitis. Possible anesthesiologic challenges are related to the respiratory system and increased susceptibility to infectious complications. There are several case reports of general anesthesia in these patients, but mainly in the adult population . Here, we report on a 3-year old female child with KGS, who underwent adenoidectomy because of sleep disordered breathing (SDB). Preoperative preparation consisted of intravenous antibiotics, steroids, as well as postural drainage and inhalations of bromhexine and salbutamol. Anesthesia was induced with propofol, fentanyl and vecuronium and maintained with a continuous infusion of propofol (150-200 gkg-1min-1) and supplemental doses of fentanyl. The child was ventilated with oxygen/air mixture (50%:50%) in the pressure-controlled mode of ventilation to keep end-tidal CO2 between 30 and 35 mmHg. During anesthesia the child’s hemodynamic and respiratory parameters were stable. Extubation, after thorough endotracheal and oral suction, was uneventful. After two hours in the post-anaesthesia care unit (PACU), the child was transferred to the ward. To the best of our knowledge, this is the youngest reported child with KGS and SDB that underwent intravenous general anesthesia. We also stress here the importance of comprehensive pre-anesthetic preparation, i.e. postural drainage, inhalations, bronchodilators, i.v. antibiotics and steroids. Furthermore, the condition of the respiratory system in the patient with KGS is seldom appropriate at the time of surgery, so the decision to anesthetize or not, should be made on an individual basis

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P &lt; 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P &lt; 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223