Close correlation of cortisol with pain intensity and Aldrete score in immediate post anesthesia period

Background: Few studies have been made on postoperative pain, the patient’s stress and Aldrete scale score at the awakening period. In this study we investigated the correlation of the serum cortisol concentration between both pain scale score and Aldrete scale score at the early postoperative period. It is obvious that an Aldrete scale score less than 9, at the awakening, is possible to prolong the surgical patient’s staying in Post anesthesia care unit (PACU). Determining of this relation is important in clinical setting.Methods: Twenty five (25) - ASA physical status I, II - patients scheduled, to undergo a medium severity surgery, with gen­eral anesthesia were enrolled in this study. The patients received as pre–medication 100mg hydroxyzine (P.O) and 150 mg ranitidine (P.O). Anesthesia was induced with: ondasetron 4mg IV, fentanil 0.2mg IV, propofol 2mg.kg-1 IV, cis-atracurium 1mg.kg-1IV, midazolam 3mg IV. Anesthesia was maintained with sevoflurane, air, oxygen and remi­fentanil -as analgesic factor-. As postoperative analgesia morphine 0.1mg.kg-1IV, 30 min before the end of surgery was used. Blood samples were collected at the end of the surgery as well as after the awakening of the patients, and the concentration of serum cortisol was determined.Results: In the samples of the 25 patients, the mean (± SD) concentration of cortisol was 22.13 μg/dl (± 12.44). The patients Aldrete Scale mean score was 8.52 (± 1.15). The range of Aldrete score was 4 (6-10). Also, the mean pain score of patients was 2.88 (± 1.64), with range of pain score: 6 (0-6). Nine of the enrolled patients reached a score of 9 at the Aldrete scale and five reached a score of 10 at the Aldrete scale, at the awakening. Patients with Aldrete scale score less than 9, at the awakening, prolonged their staying in PACU from 60 to 165 minutes.Conclusion: There is clearly a positive correlation between the concentration of serum cortisol and Aldrete scale score, at the awakening stage of the surgical patient, but without any statistical significance.There is a statistically significant positive correlation between the concentration of serum cortisol and the pain scale score

Morphological and morphometric features of sacral hiatus and its clinical significance in caudal epidural anesthesia

Background: Caudal epidural block (CEB) failure or complications are not unheard even among experienced anesthesiologists and are usually due to sacral hiatus (SH) anatomy variations. The aim of the present study is to observe, record and analyze important anatomical features of SH and correlate them with potential CEB limitations. Materials and methods: The SH of 155 complete and undamaged Greek adult dry sacra of known sex were included in the study. Three non-metric (shape of SH and location of hiatal apex and base in relation to level of sacral/coccygeal vertebra) and five metric parameters (height of the SH, transverse width of the SH at the base, anteroposterior diameter of the SH at the level of its apex and the distance from the sacral apex and base to the upper border of S2 foramina) were evaluated. Results: Inverted U (34.83%) and inverted V (26.45%) were the commonest shapes. Hiatal apex and base were most commonly related to the level of S4 (78.70%) and S5 vertebra (89.03%), respectively. Mean height, depth and intercornual distance were 19.05±8.65 mm, 5.39±1.84 mm and 12.41±3.16 mm, respectively, whereas mean distance between the upper border of S2 foramen and the apex and base of the sacral hiatus were 46.34 mm and 63.48mm, respectively. Anatomical variations of sacral hiatus that might be responsible for CEB failure, such as elongated SH, absence of SH, complete dorsal wall agenesis of sacral canal and narrowing ( < 3 mm) at the apex of SH were found in 17.43% of sacra (male 10.94% and female 25.22%).  Conclusions: This study suggests a potential risk of failure of CEB in Greek patients, especially in females, which should be kept in mind while giving caudal epidural anesthesia

Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)

Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. Results: Infants (n=5609) born at mean (standard deviation [SD]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04–1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15–1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7–3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64–7.71) and mortality (RR=19.80; 95% CI, 5.87–66.7). Conclusions: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants. Clinical trial registration: NCT02350348

Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)

BACKGROUND: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. METHODS: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. RESULTS: Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04–1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15–1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7–3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64–7.71) and mortality (RR=19.80; 95% CI, 5.87–66.7). CONCLUSIONS: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

Background: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. Methods: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. Results: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1e6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2&lt;90% for 60 s) was reported in 40%. No associated risk factors could be identified among comorbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. Conclusions: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event. Clinical trial registration: NCT02350348

Difficult tracheal intubation in neonates and infants. NEonate and Children audiT of Anaesthesia pRactice IN Europe (NECTARINE): a prospective European multicentre observational study

BACKGROUND: Neonates and infants are susceptible to hypoxaemia in the perioperative period. The aim of this study was to analyse interventions related to anaesthesia tracheal intubations in this European cohort and identify their clinical consequences. METHODS: We performed a secondary analysis of tracheal intubations of the European multicentre observational trial (NEonate and Children audiT of Anaesthesia pRactice IN Europe [NECTARINE]) in neonates and small infants with difficult tracheal intubation. The primary endpoint was the incidence of difficult intubation and the related complications. The secondary endpoints were the risk factors for severe hypoxaemia attributed to difficult airway management, and 30 and 90 day outcomes. RESULTS: Tracheal intubation was planned in 4683 procedures. Difficult tracheal intubation, defined as two failed attempts of direct laryngoscopy, occurred in 266 children (271 procedures) with an incidence (95% confidence interval [CI]) of 5.8% (95% CI, 5.1–6.5). Bradycardia occurred in 8% of the cases with difficult intubation, whereas a significant decrease in oxygen saturation (SpO2<90% for 60 s) was reported in 40%. No associated risk factors could be identified among co-morbidities, surgical, or anaesthesia management. Using propensity scoring to adjust for confounders, difficult anaesthesia tracheal intubation did not lead to an increase in 30 and 90 day morbidity or mortality. CONCLUSIONS: The results of the present study demonstrate a high incidence of difficult tracheal intubation in children less than 60 weeks post-conceptual age commonly resulting in severe hypoxaemia. Reassuringly, the morbidity and mortality at 30 and 90 days was not increased by the occurrence of a difficult intubation event

Peri-operative red blood cell transfusion in neonates and infants: NEonate and Children audiT of Anaesthesia pRactice IN Europe: A prospective European multicentre observational study

BACKGROUND: Little is known about current clinical practice concerning peri-operative red blood cell transfusion in neonates and small infants. Guidelines suggest transfusions based on haemoglobin thresholds ranging from 8.5 to 12 g dl-1, distinguishing between children from birth to day 7 (week 1), from day 8 to day 14 (week 2) or from day 15 (≥week 3) onwards. OBJECTIVE: To observe peri-operative red blood cell transfusion practice according to guidelines in relation to patient outcome. DESIGN: A multicentre observational study. SETTING: The NEonate-Children sTudy of Anaesthesia pRactice IN Europe (NECTARINE) trial recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. PATIENTS: The data included 5609 patients undergoing 6542 procedures. Inclusion criteria was a peri-operative red blood cell transfusion. MAIN OUTCOME MEASURES: The primary endpoint was the haemoglobin level triggering a transfusion for neonates in week 1, week 2 and week 3. Secondary endpoints were transfusion volumes, 'delta haemoglobin' (preprocedure - transfusion-triggering) and 30-day and 90-day morbidity and mortality. RESULTS: Peri-operative red blood cell transfusions were recorded during 447 procedures (6.9%). The median haemoglobin levels triggering a transfusion were 9.6 [IQR 8.7 to 10.9] g dl-1 for neonates in week 1, 9.6 [7.7 to 10.4] g dl-1 in week 2 and 8.0 [7.3 to 9.0] g dl-1 in week 3. The median transfusion volume was 17.1 [11.1 to 26.4] ml kg-1 with a median delta haemoglobin of 1.8 [0.0 to 3.6] g dl-1. Thirty-day morbidity was 47.8% with an overall mortality of 11.3%. CONCLUSIONS: Results indicate lower transfusion-triggering haemoglobin thresholds in clinical practice than suggested by current guidelines. The high morbidity and mortality of this NECTARINE sub-cohort calls for investigative action and evidence-based guidelines addressing peri-operative red blood cell transfusions strategies. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02350348

Investigation of inflammatory reaction markers to epidural catheter during epidural anesthesia and analgesia

Background: Anaesthesia and inflammatory response have been studied in major abdominal and thoracic surgical procedures, but not in major orthopaedic reconstructive procedures such as total knee arthroplasty. Most studies have compared general anaesthesia with epidural anaesthesia, but none has compared spinal with epidural or with combined spinal and epidural.Methods: In a prospective randomized study three groups of patients scheduled for total knee arthroplasty for osteoarthritis, were evaluated regarding the inflammatory response to three types of regional anaesthesia. In 30 patients (Group A) with spinal anaesthesia followed by intravenous morphine analgesia, in 24 patients (Group B) with epidural anaesthesia followed by epidural analgesia and in 23 patients (Group C) with combined spinal and epidural anaesthesia followed by epidural analgesia, the inflammatory response was assessed through the calculation of leukocyte concentration (WBC), C- reactive protein (CRP), monocyte chemotactic protein 1 (MCP-1), interleukins ( IL-1, IL-6, IL-10, IL-18) , TNF-a, and leukocyte activation molecules CD11b and CD62L , in three blood samples (immediately before induction to anaesthesia, immediately after closure of the operative wound and at 24 hours post-operatively).Results: The MCP-1 values showed a statistically significant increase (p<0.02) in the group of patients with spinal anaesthesia. Of the leukocyte activation molecules a high statistically significant increase was noticed in the expression of CD11b on monocytes in the sample taken 24 hours post-operatively, in the patients of group A. Similarly, CD62L expression on neutrophils showed a high statistically significant reduction in the sample taken 24 hours post-operatively in the group of patients with spinal anaesthesia compared to the group of patients with epidural anaesthesia and combined spinal with epidural anaesthesia.Conclusions: Our results show that epidural anaesthesia followed by epidural analgesia produced less inflammatory response compared with spinal anesthesia followed by intravenous morphine analgesia or with combined spinal with epidural anaesthesia in patients operated with total knee arthoplasty, and that the most sensitive markers, of those investigated, were the CD11b and CD62L leukocyte activation molecules.Εισαγωγή : Η φλεγμονώδης αντίδραση του οργανισμού σε διάφορους τύπους αναισθησίας έχει μελετηθεί εκτενέστατα σε μείζονες κοιλιακές χειρουργικές επεμβάσεις καθώς και σε επεμβάσεις του θώρακα. Εν τούτοις, παρά το γεγονός ότι μείζονες ορθοπαιδικές επεμβάσεις που αφορούν την αντικατάσταση μεγάλων εκφυλισμένων αρθρώσεων όπως του ισχίου και του γόνατος είναι πολύ συχνές, ελάχιστες δημοσιεύσεις υπάρχουν στην διεθνή βιβλιογραφία που να αναφέρονται στην μελέτη της φλεγμονώδους αντίδρασης μετά από τέτοιου είδους χειρουργικές επεμβάσεις. Επιπλέον σε όλες τις βιβλιογραφικές αναφορές συγκρίνεται η επίπτωση στην φλεγμονώδη αντίδραση της γενικής αναισθησίας με αυτή της επισκληρίδιας, αλλά δεν υπάρχει σύγκριση μεταξύ ραχιαίας και επισκληρίδιας και συνδυασμένης ραχιαίας με επισκληρίδια.Υλικό-Μέθοδος : Σε αυτή την προοπτική τυχαιοποιημένη μελέτη τρείς ομάδες ασθενών, που είχαν προγραμματισθεί να υποβληθούν σε ολική αρθροπλαστική του γόνατος συνεπεία οστεοαρθρίτιδας, εκτιμήθηκαν σχετικά με την φλεγμονώδη αντίδραση σε τρείς τύπους περιοχικής αναισθησίας. Σε 30 ασθενείς με ραχιαία αναισθησία που ακολουθήθηκε από ενδοφλέβια αναλγησία με μορφίνη (Ομάδα Α), σε 24 ασθενείς με επισκληρίδια αναισθησία που ακολουθήθηκε από επισκληρίδια αναλγησία (Ομάδα Β) και σε 23 ασθενείς με συνδυασμένη ραχιαία και επισκληρίδια αναισθησία και επισκληρίδια αναλγησία (Ομάδα Γ), η φλεγμονώδης αντίδραση αξιολογήθηκε με την μέτρηση των ακόλουθων παραγόντων : αριθμό λευκοκυττάρων WBC, C-αντιδρώσα πρωτείνη, χειμοτακτική πρωτείνη μονοκυττάρων (MCP-1, monocyte chemotactic protein-1), ιντερλευκίνες IL-1,IL-6, IL-10, IL-18, TNF-a και μόρια προσκόλλησης CD11a και CD62L, σε τρία δείγματα αίματος, αμέσως πρίν την έναρξη της αναισθησίας (δείγμα 1), αμέσως μετά την σύγκλειση του χειρουργικού τραύματος (δείγμα 2) και 24 ώρες μετεγχειρητικά (δείγμα 3)Αποτελέσματα : Οι τιμές έδειξαν μία στατιστικά σημαντική αύξηση της τιμής της MCP-1 (p < 0.02) στους ασθενείς της ομάδας με ραχιαία αναισθησία (Ομάδα Α) Από τα μόρια προσκόλλησης παρατηρήθηκε μία στατιστικά πολύ σημαντική αύξηση στην έκφραση του CD11b στα μονοκύτταρα ομοίως στην ομάδα Α και στο δείγμα αίματος που ελήφθη 24 ώρες μετεγχειρητικά (Δείγμα 3). Ομοίως η έκφραση του CD62L στα ουδετερόφιλα πολυμορφοπύρηνα ελαττώθηκε στατιστικά πολύ σημαντικά στο δείγμα αίματος που ελήφθη 24 ώρες μετεγχειρητικά στην ομάδα των ασθενών με ραχιαία αναισθησία σε σύγκριση με τους ασθενείς της επισκληρίδιας αναισθησίας και της συνδυασμένης.Συμπεράσματα : Τα αποτελέσματά μας δείχνουν ότι η επισκληρίδια αναισθησία που ακολουθήθηκε από επισκληρίδια αναλγησία προκάλεσε μικρότερη φλεγμονώδη αντίδραση σε σύγκριση με την συνδυασμένη ραχιαία και επισκληρίδια αναισθησία αλλά στατιστικά πολύ σημαντικά μικρότερη σε σύγκριση με την ραχιαία αναισθησία που ακολουθήθηκε από ενδοφλέβια αναλγησία στους ασθενείς που υποβλήθηκαν σε ολική αρθροπλαστική του γόνατος. Επιπλέον από τους δείκτες φλεγμονής που μελετήθηκαν οι πιο ευαίσθητοι ήταν τα μόρια προσκόλλησης CD11b και CD62l

Preoperative Anxiety in Greek Children and Their Parents When Presenting for Routine Surgery

Background. A surgical operation in pediatric patients is a rather stressful experience for both children and their parents. The aim of this study was to assess the effect of specific demographic characteristics in parent’s and children’s preoperative anxiety. Methods. The sample was composed of 128 Greek-speaking children (1–14 years of age) who had to undergo minor surgery in a University General Hospital. Before surgical operation, the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire and a questionnaire for the social-demographic characteristics were completed by the parents. Children’s preoperative anxiety was evaluated using the Modified Yale Preoperative Anxiety Scale (m-YPAS). Results. The independent predictors of increased anxiety levels in parents are child’s age (p=0.024) and gender (girls: p=0.008), living in rural areas (parents: p<0.001; children: p=0.009), being a mother (p=0.046), high or low education level (p=0.031), a no premedicated child (p=0.007), and high baseline parental anxiety (p=0.003). Previous hospitalization (p=0.019), high situational parental anxiety (p<0.001), no premedication (p=0.014), and being the only child in the family (p=0.045) are found to be the main determinants of preoperative anxiety control in children. Conclusions. This study identifies possible risk factors of preoperative anxiety in parents and their children, which are high parental anxiety, child’s age, no premedication, being the only child in the family, living in rural areas, education level, and previous hospitalization

Validation of the Patient Neurotoxicity Questionnaire for Patients Suffering From Chemotherapy-Induced Peripheral Neuropathy in Greek

Purpose: The Patient Neurotoxicity Questionnaire (PNQ) represents a diagnostic tool concerning patients with chemotherapy-induced peripheral neuropathy (CIPN). The application of such a tool in the Greek clinical praxis requires validation. Methods: Validation consists of three stages - translation, reverse translation, and patient application. Hundred oncologic patients were assessed by comparing the PNQ to the National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE) at the chemotherapy onset and second, fourth, and sixth sessions. The diagnostic tool’s specific requirements (compliance, validity, concordance, sensitivity, specificity, reliability) were statistically evaluated. Results: Differences between translated texts and between the reverse translation and the original were considered negligible. At the second, fourth, and sixth session compliance was 98%, 95%, and 93% while Cronbach’s a was 0,57 0,69, and 0,81, respectively. Cohen’s weighted. was 0,67 and 0,58, Spearman’s. was 0,7 and 0,98, while the area under the curve (AUC) of the receiver operating characteristic (ROC) was 1 and 0,9 for the sensory and the motor part, respectively. The variance’s linear regression analysis confirmed CIPN worsening over time (P&lt;0.0001). Discussion: The Greek version remains close to the original English version. Compliance rates reflect easy PNQ applications. Cohen’s. values highlight the physicians’ tension to underestimate the patients’ condition. Spearman’s., Cronbach’s a, and AUC values reflect good validity, reliability, and specificity of the PNQ respectively. Finally, the linear analysis confirmed the PNQ sensitivity over time. Conclusions: The PNQ validation in Greek adds a crucial tool to the physicians’ armamentarium. It can now delineate the necessary information to modify the chemotherapy and analgesic treatment regimens at both preventive and acute levels