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

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

Circadian effects on neural blockade of levobupivacaine and fentanyl intrathecal administration for caesarian section

Introduction: Circadian variations in biological rhythms affect the pharmacological properties of many anaesthetic agents, suggesting circadian patterns of local anaesthetics’ activity in labour pain analgesia, with important differences among diurnal and nocturnal phases. Aim: We examined whether a rhythmic variation of the effect of intrathecal mixture of levobupivacaine and fentanyl exists throughout the day period regarding caesarean sections. Materials and methods: Eighty parturients presented for caesarean section, both urgent and/or elective, were assigned to five equal groups (A, B, C, D, and E) according to the time-point of the intrathecal drug administration. The same levobupivacaine and fentanyl dose was given to all patients. Pinprick or cold test, the four-point modified Bromage scale (0-3), and the numerical scale (NRS 0-10) were used respectively for the assessment of sensory and motor blockade, and post-anaesthetic pain. The duration of sensory and motor blockade, analgesia duration and pain score at first analgesic request were recorded. Results: Statistically significant differences were found among the studied groups in the duration of motor and sensory blockade and pain score at first postoperative analgesic request. Prolonged duration of motor blockade in groups A, B and C (p<0.001) and prolonged duration of sensory blockade and analgesia in groups A, B (p<0.001) were observed. Higher pain scores at first postoperative analgesic request were recorded in group Ε (p<0.001). Conclusions: The present study highlights the significant effects of circadian rhythm on the efficacy of a mixture of local anaesthetics, levobupivacaine and fentanyl, during caesarean delivery

The Effectiveness of Ultrasound-Guided, Continuous, Bilateral Erector Spinae Plane Block in Perioperative Pain Management of Patients Undergoing Colorectal Surgery: A Randomized, Controlled, Double Blind, Prospective Trial

Open and laparoscopic colorectal surgeries, while essential in the management of various colorectal pathologies, are associated with significant postoperative pain. Effective perioperative pain management strategies remain an anesthesiologic challenge. The erector spinae plane block (ESPB), a novel peripheral nerve block, has gained attention for its potential in providing analgesia for a wide variety of surgeries. This study aimed to evaluate the effectiveness of continuous, bilateral ultrasound-guided ESPB in perioperative pain management of patients undergoing colectomy. This prospective, randomized, controlled, double-blind trial included 40 adult patients scheduled for elective open or laparoscopic colectomy. Patients undergoing open colectomy as well as patients undergoing laparoscopic colectomy were randomly allocated into two groups: the ESPB group (n = 20) and the control group (n = 20). All patients received preoperatively ultrasound-guided, bilateral ESPB with placement of catheters for continuous infusion. Patients in the ESPB group received 0.375% ropivacaine, while patients in the control group received sham blocks. All patients received standardized general anesthesia and multimodal postoperative analgesia. Pain scores, perioperative opioid consumption, and perioperative outcomes were assessed. Patients in the ESPB group required significantly less intraoperative (p p = 0.002 for laparoscopic colectomies) and postoperative opioids (p p = 0.002 for laparoscopic colectomies) and had higher quality of recovery scores on the third postoperative day (p = 0.002 for open and laparoscopic colectomies). Patients in the ESPB group did not exhibit lower postoperative pain scores compared to those in the control group (p > 0.05 at various time points), while patients in both groups reported comparable satisfaction scores with their perioperative pain management (p = 0.061 for open colectomies, and p = 0.078 in laparoscopic colectomies). No complications were reported. ESPB is a novel and effective strategy in reducing perioperative opioid consumption in patients undergoing colectomy. This technique, as part of a multimodal analgesic plan and enhanced recovery after surgery protocols, can be proven valuable in improving the comfort and satisfaction of patients undergoing colorectal surgery

Physical Improvement and Biological Maturity of Young Athletes (11-12 Years) with Systematic Training

AIM: The aim of this study was to investigate the infl uence of systematic training in physical growth and biological maturity in prepubertal males and estimate how this affects the physical growth and skeletal maturity. MATERIALS AND METHODS: 177 primary school students of the fifth and sixth grade, from schools in Alexandroupolis, participated voluntarily in our study. Questionnaires were used in order to measure physical activity levels. The subjects were subdivided into two groups; control group (prepubertal, whose physical activity was the physical education of their school and which had never participated in systematic training, n = 95) and experimental group (prepubertal, whose weekly physical activity included physical education in their schools and additionally 3-4 training units organized training in various sports clubs in the city, n = 82). The following parameters were recorded: biological age measured by determination of skeletal age; bone density measured by ultrasound methods; anthropometric and morphological features such as height, body composition, selected diameters, circumferences and skinfolds; motor ability features. RESULTS: The experimental group exhibited older biological age (p = 0.033), higher bone density (p < 0.001), lower BMI and body fat (p < 0.001), better anthropometric features and higher performance throughout all motor ability tests (p < 0.05), compared to the control group. CONCLUSION: The present study demonstrates that systematic physical activity has a positive effect on both the physical and biological maturity of pre-pubertal children. This effect is mainly expressed in bone strengthening as a result of the increased bone density and in improvement of the kinetic skills of pupils who participated in organized extracurricular sport-activities

The Effect of Strontium Ranelate on Fracture Healing: An Animal Study

Background. Strontium ranelate (StR) is an antiosteoporotic agent previously utilized for the enhancement of fracture union. We investigated the effects of StR on fracture healing using a rabbit model. Methods. Forty adult female rabbits were included in the study and were divided in 2 equal groups, according to StR treatment or untreated controls. All animals were subjected to osteotomy of the ulna, while the contralateral ulna remained intact and served as a control for the biomechanical assessment of fracture healing. Animals in the study group received 600 mg/kg/day of StR orally. All animals received ordinary food. At 2 and 4 weeks, all animals were euthanatized and the osteotomy sites were evaluated for healing through radiological, biomechanical, and histopathological studies. Results. The treatment group presented statistically significant higher callus diameter, total callus area, percentage of fibrous tissue (p<0.001), vessels/mm2, number of total vessels, and lower osteoclast number/mm2 (p<0.05) than the control group at 2 weeks. Additionally, the treatment group presented significantly higher percentages of new trabecular bone, vessels/mm2, osteoclast number/mm2, and lower values for callus diameter, as well as total callus area (p<0.05), than the control group at 4 weeks. At 4 weeks, in the treatment group, force applied (p=0.003), energy at failure (p=0.004), and load at failure (p=0.003) were all significantly higher in the forearm specimens with the osteotomized ulnae compared to those without. Radiological bone union was demonstrated for animals receiving StR at 4 weeks compared with controls (p=0.045). Conclusion. StR appears to enhance fracture healing but further studies are warranted in order to better elucidate the mechanisms and benefits of StR treatment

The Effect of Strontium Ranelate on Fracture Healing: An Animal Study

Background. Strontium ranelate (StR) is an antiosteoporotic agent previously utilized for the enhancement of fracture union. We investigated the effects of StR on fracture healing using a rabbit model. Methods. Forty adult female rabbits were included in the study and were divided in 2 equal groups, according to StR treatment or untreated controls. All animals were subjected to osteotomy of the ulna, while the contralateral ulna remained intact and served as a control for the biomechanical assessment of fracture healing. Animals in the study group received 600 mg/kg/day of StR orally. All animals received ordinary food. At 2 and 4 weeks, all animals were euthanatized and the osteotomy sites were evaluated for healing through radiological, biomechanical, and histopathological studies. Results. The treatment group presented statistically significant higher callus diameter, total callus area, percentage of fibrous tissue (p&lt;0.001), vessels/mm(2), number of total vessels, and lower osteoclast number/mm(2) (p&lt;0.05) than the control group at 2 weeks. Additionally, the treatment group presented significantly higher percentages of new trabecular bone, vessels/mm(2), osteoclast number/mm(2), and lower values for callus diameter, as well as total callus area (p&lt;0.05), than the control group at 4 weeks. At 4 weeks, in the treatment group, force applied (p=0.003), energy at failure (p=0.004), and load at failure (p=0.003) were all significantly higher in the forearm specimens with the osteotomized ulnae compared to those without. Radiological bone union was demonstrated for animals receiving StR at 4 weeks compared with controls (p=0.045). Conclusion. StR appears to enhance fracture healing but further studies are warranted in order to better elucidate the mechanisms and benefits of StR treatment