A wound infiltration as a method of postoperative analgesia

A wound infiltration is a method of postoperative analgesia efficient in the various surgical subdisciplines. This technique resulted from the observation that patients whose surgical procedures were performed under regional anaesthesia techniques have reduced postoperative analgesic consumption. Owing to the advances in the drug discovery and to the introduction of local anaesthetics with prolonged effects, this technique has less adverse reactions and considerable analgesic effects. New local anaesthetics with long duration of action and low toxicity like levobupivacaine and ropivacaine are currently available at the market. Such drugs with lower potential for systemic toxicity provided additional safety dimension to local infiltration techniques. A variety of methods were developed to achieve painless recovery period, better patient comfort and to improve patient outcome. Probably the most common technique is a field block at the end of the surgery that can be performed both during regional anaesthesia techniques and in the general anaesthesia. The use of wound infiltration techniques was facilitated by important technical improvements in the multilumen catheters and by construction of special drug delivery devices. Numerous disposable elastomeric devices and patient controlled pumps are suitable for prolonged periods of analgesia in the clinical and outpatient setting. Although it can be used alone for less painful procedures, infiltration analgesia is now important part of multimodal pain treatment. This complex approach to the postoperative pain treatment is characterized by the use of different analgesic drugs and techniques, like wound infiltration and intravenous opioid or nonsteroidal anti-inflammatory drugs. Multimodal postoperative pain treatment is acceptable after painful procedures i.e. hip and knee replacement, where it improves pain control and patient outcome

Patient satisfaction with regional anesthesia in orthopedic surgery

Background and Purpose: The patient satisfaction with perioperative care and anesthesia is important indicator of the quality of the health care system. The evaluation of the patient’s satisfaction is a necessity, and the continuous improvement of a quality is important in anesthesia nowadays. It is important to identify the reasons and the risk factors for patients dissatisfaction with anesthesiologic procedures. We conducted this study to asses determinants of regional anesthesia on patient satisfaction. Materials and methods: This was a prospective observational study which included 164 patients older than 18 years undergoing some orthopedic procedures in regional anesthesia. We noted basic characteristics of patients, important perioperative events and on the following day patients completed a specific questionnaire. Results: Most patients (152/164) were satisfied or very satisfied with the regional anesthesia. Only 11 patients were unsatisfied, and the most common reasons for dissatisfaction were urinary retention, PONV, the multiple puncture attempts and the pain on the puncture site. About 95% patients would receive regional anesthesia again and recommend this kind of anesthesia to the others. We found statistically significant percent (12%) of increasing satisfaction in previously unsatisfied patients (p < 0,001). Conclusion: Although, the satisfaction with regional anesthesia in orthopedic surgery in our institution is generally high, there are some factors which can influence on dissatisfaction rate. It is important to identify, monitor and modify them with aim of increasing the overall satisfaction rate

Utječe li anestezijska tehnika na arterijski tlak i regionalnu moždanu perfuziju tijekom artroskopije ramena u sjedećem položaju?

This study aimed to investigate the impact of posture and anesthesia techniques on blood pressure changes, heart rate and regional cerebral oxygen saturation during shoulder arthroscopy in the beach chair position (BCP). Sixty patients were included in this prospective cohort study: 30 patients mechanically ventilated and subjected to general anesthesia (GA) and 30 patients subjected to interscalene block (ISB) without mechanical ventilation. Noninvasive blood pressure, heart rate (HR), peripheral blood oxygen saturation and regional oxygen saturation of the brain were measured in twelve predefined points during perioperative period. The GA group patients had significantly lower mean arterial pressure and heart rate values compared to patients in ISB group during BCP (p<0.001). There was a significant difference in regional cerebral saturation between the groups measured only in points of induction and emergence from anesthesia in favor of GA group when receiving 100% oxygen (p<0.001). Changes in the mean arterial pressure and regional cerebral oxygen saturation for both brain hemispheres correlated only at the 10th minute after setting up BCP in GA patients (right, p=0.004 and left, p=0.003). This correlation did not exist in the ISB group patients at any of the points measured. Cerebral desaturation events recorded in both groups were not statistically significantly different. Results of this study demonstrated that GA preserved regional cerebral oxygenation in a safe range during BCP despite changes in the arterial blood pressure and heart rate in comparison to ISB.Cilj ovoga istraživanja je bio ispitati povezanost postavljanja bolesnika u sjedeći položaj (engl. beach chair position, BCP) i vrste anestezijske tehnike s posljedičnim promjenama arterijskog tlaka i srčanih otkucaja, kao i njihovog utjecaja na regionalnu moždanu perfuziju tijekom artroskopije ramena. U studiju je bilo uključeno 60 bolesnika: prvu skupinu činilo je 30 bolesnika kod kojih je operacijski zahvat izveden u općoj anesteziji (OA) koji su bili mehanički ventilirani, a drugu skupinu 30 bolesnika kod kojih je operacijski zahvat izveden uz interskalenski blok (ISB) i spontano disanje. U 12 prethodno definiranih točaka tijekom perioperacijskog razdoblja mjerio se neinvazivno arterijski tlak, srčani otkucaji, periferna zasićenost kisikom i regionalna moždana zasićenost kisikom. Bolesnici u skupini OA imali su značajno niže vrijednosti srednjeg arterijskog tlaka i srčanih otkucaja u odnosu na bolesnike u skupini ISB tijekom BCP (p<0,001). Promjene srednjeg arterijskog tlaka i regionalne moždane zasićenosti kisikom za obje moždane hemisfere korelirale su samo u 10. minuti nakon postavljanja bolesnika u BCP kod skupine OA (desna p=0,004, lijeva p=0,003). Ova korelacija nije zabilježena kod bolesnika skupine ISB ni u jednoj od mjerenih točaka. Moždani desaturacijski događaji su zabilježeni u objema skupinama, ali nisu bili statistički značajni. Rezultati ovoga istraživanja ukazuju na to da je OA očuvala regionalnu moždanu zasićenost kisikom unutar sigurnog raspona u usporedbi sa skupinom ISB tijekom BCP, unatoč značajnim promjenama arterijskog tlaka i srčanih otkucaja

Three-dimensional transoesophageal echocardiography: new intraoperative perspective in follow-up of cardiac patients

Trodimenzionalna transezofagusna ehokardiografija u stvarnom vremenu (RT 3D-TEE) temelji se na novoj matričnoj tehnologiji uz pomoć koje se može rekonstruirati 3D živa slika srca piramidnoga oblika i punoga volumena. Postala je integralni dio intraoperacijske procjene lijeve klijetke, mitralne valvule i kongenitalnih abnormalnosti srca. Prednosti su preciznost, sekcija 3D žive slike, prostorna rezolucija, tele-obrada i virtualna stvarnost. Ograničenja su slabost planarne i vremenske rezolucije, procjena endokarda desne klijetke, izostanak prikaza epikarda srca. Buduća klinička uloga RT 3D-TEE jest analiza regionalne deformacije miokarda - 3D speckle tracking, resinhronizacijska terapija, te razvoj softvera za procjenu ostalih srčanih zalistaka.Three dimensional real-time transoesophageal echocardiography (RT 3D-TEE) is founded on a new matrix technology by which we can reconstruct a live 3D pyramidal and full volume image of the heart. It has become an integral part of intraoperative left ventricle, mitral valve and congenital anomaly assessment. Its advantages are: precision, 3D live section views, spatial resolution, tele-processing and virtual reality. Limits are: poor planar and time resolution, right ventricle endocardium assessment, absence of epicardial view. Future role of RT 3D-TEE is regional myocardial deformation assessment - 3D speckle tracking, resynchronization therapy and software development for assessment of other valves

WHY MONITORING CEREBRAL DESATURATION EVENTS DURING SURGERY IN THE BEACH CHAIR POSITION?

Moždani oksimetri se koriste u novije vrijeme za nadzor nad regionalnom moždanom oksigenacijom tijekom kirurških zahvata kod kojih se očekuje hemodinamska nestabilnost bolesnika. Jedan od takvih zahvata je operacija ramena u sjedećem položaju, koji se u inozemnoj literaturi naziva “the beach chair position” (engl. BCP). Hipotenzija koja se javlja nakon pozicioniranja bolesnika u sjedeći položaj dovodi do pada perfuzijskog tlaka u mozgu što bi moglo predisponirati potencijalni cerebrovaskularni incident. Cerebralni desaturacijski događaji (engl. cerebral desaturation events, CDE’s) predstavljaju pad vrijednosti zasićenosti kisika u mozgu za 20 % u odnosu na bazalnu vrijednost mjerenu s moždanim oksimetrom INVOS (engl. In Vivo Optical Spectroscopy, INVOS 5100; Somanetics Corp., Troy, Michigan, USA). Zbog tih potencijalnih desaturacijskih događaja koji bi mogli biti štetni za neurološku funkciju istraživači i kliničari stalno nastoje pronaći odgovarajuće metode za nadzor nad moždanom perfuzijom kao i vezu između hipotenzije, smanjene perfuzije mozga, smanjene zasićenosti mozga kisikom i neuroloških incidenata kod bolesnika tijekom artroskopije ramena u sjedećem položaju.Regional cerebral oximeters are used more recently to monitor regional cerebral oxygenation during surgical procedures in which patients are expected to be hemodynamically unstable. Such procedures are cardiac surgery, abdominal surgery that requires anti-Trendelenburg’s position, thoracic surgery with one-lung ventilation, posterior fossa neurosurgery, carotid endarterectomy, and shoulder surgery, performed in the beach chair position (BCP). Patient positioning for particular surgical procedures is extremely important for surgical fi eld visualization, but implies various physiological regulation mechanisms for adaptation to new positions. During patient positioning from supine to other positions, such as BCP, gravity infl uences distribution of the circulating blood volume to the abdomen and extremities. Anesthetized patients have an altered sympathetic response to position changes, which leads to hypotension, particularly during patient positioning from supine to sitting position. Systemic hypotension that occurs after positioning the patient to BCP is followed by decline in the cerebral perfusion pressure, which can lead to potential cerebrovascular incident. There are several case reports describing visual loss and ophthalmoplegia, postoperative cerebral ischemia with persistent vegetative state or brain death following these surgical procedures in BCP. Therefore, BCP is a major challenge for the anesthesiologist and for arterial pressure regulation during the surgery due to hypotension. Some investigators found that cerebral blood fl ow was lower with hypotension (measuring blood velocity in middle cerebral artery with transcranial Doppler) in patients during BCP for shoulder arthroscopy. Monitoring cerebral perfusion in patients during shoulder arthroscopy in BCP is suggested by many authors as a measure to improve patient safety due to potentially endangered brain perfusion. The noninvasive method of the brain oxygenation monitoring is based on the theory of light absorption within the infrared spectrum and uses the near-infrared spectroscopy (NIRS) technology. This monitoring method is user friendly, therefore is gaining much popularity as a method for monitoring cerebral oxygenation. Cerebral desaturation events (CDEs) represent a 20% decline in relation to basal cerebral oxygen saturation values measured with INVOS (In Vivo Optical Spectroscopy, INVOS 5100; Somanetics Corp., Troy, Michigan, USA) cerebral oximeter and are often recorded during this position. Meex et al. carried out a prospective observational study in volunteers and patients in the lateral decubitus position and BCP to describe changes in cerebral tissue oxygen saturation due to changes in body position. They found that more than 55% of patients in BCP had CDEs as compared with volunteers without anesthesia. As these potential CDEs could be detrimental for neurologic function, the clinicians are constantly trying to fi nd appropriate methods for monitoring cerebral perfusion and the link between hypotension, decreased brain perfusion, decreased brain oxygen saturation and neurological incidents during shoulder arthroscopy in BCP. They are also trying to correlate CDEs with possible neurocognitive changes in patients after these surgical procedures, which has not been confi rmed so far. Salazar et al. found that 18% of patients included in their study had the intraoperative incidence of CDEs during BCP but did not fi nd statistically signifi cant preoperative versus postoperative neurocognitive test scores. They concluded that the transient intraoperative CDEs were not associated with postoperative cognitive dysfunction. Patient safety is strongly ssociated with technical and clinical monitoring capabilities during any surgical procedure; therefore, using all available techniques for supervision of the patient’s vital functions is necessary to minimize the occurrence of potential adverse events

The use of an ultrasound-guided popliteal block for hallux valgus surgery in a patient with myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disease which affects neuromuscular transmission, causing muscle fatigue and weakness(1).The myasthenic patients are always a challenge to the anesthesiologist, because they demonstrate various responses to the neuromuscular blocking agents. The post-operative risk of respiratory failure has always been a matter of concern (2, 3). We report a successful use of the ultrasound guided popliteal block for elective foot surgery in a 46-year old woman with MG, showing that this regional anesthesia technique, by avoiding the use of neuromuscular blocking agents, provided safe care for this patient

Integrity of Gut Mucosa during Anaesthesia in Major Abdominal Surgery

The aim of the study was to examine a perfusion and integrity of small bowel in 60 subsequent patients during the major open abdominal surgery which lasted from 2 to 7 hours. Two samples of the intestinal mucosa were removed: at the beginning, and at the end of the surgical procedure in general anaesthesia. A mucosal injury was classified into 4 grades. pH, PCO2 and lactate level were measured in the blood samples from the arterial and mesenteric vein in one hour time intervals. The changes of intestinal mucosa were found in 31 patients (51.7%): in 19 patients (31.7%) grade 1 changes were recorded, in 10 patients (16.7%) grade 2, and in 2 patients (3.3%) grade 3. Grade 4 lesions were not recorded. There was a statistically significant correlation between grades of the mucosal damage and the surgery duration (p=0.001). Analysis during the one hour intervals showed that there was no exact time point when the significant aggravation of the pathohistological changes in intestinal mucosa occurred. However, when patients were allocated into two subgroups with surgical procedures lasting less than 4 hours and more than 4 hours, there was a statistically significant difference in the grades of mucosal damage between subgroups (p<0.05). More biopsies without pathohistological changes were observed in the patients whose procedure duration was < 4 hours. A significantly higher lactate concentrations in arterial and mesenteric venous blood were observed in the patients with pathohistological changes at 6 hours time point as compared to 2 hour time point in the patients without pathohistological changes (p<0.05). During the open abdominal surgery in general anaesthesia, the length of the procedure influences the grade of the intestinal mucosa injury. Deterioration of the pathohistological findings in the intestinal mucosa correlates with high lactate blood level, suggesting that the cause of these changes may result from tissue hypoxia

Arterial pressure and heart rate changes in patients during “beach chair position” for shoulder surgery: comparison of the regional and general anesthesia techniques

Background and Purpose: Patients scheduled to shoulder surgery are placed in a sitting position called “the beach chair position” during the operation. This type of surgery can be performed with two anesthetic techniques: general anesthesia or regional anesthesia (interscalene block). This patient positioning is characterized by changes in heart rate and systemic blood pressure. The aim of this study is to show whether the type of anesthetic technique influence the changes in systemic pressure and heart rate in this particular patient position. Materials and methods: Retrospective clinical study with reviewed anesthetic charts and medical documentation of the patients scheduled for elective shoulder surgery. Point measurements of systolic and diastolic blood pressure and heart rate were: before surgery, after the positioning of the anesthetized patient, at the end of the operation (lodging of the patient) and then the lowest recorded pressure and heart rate during surgery. Results: The study included 66 patients in the sitting position for shoulder surgery. Positioning the patients in the beach chair position for shoulder surgery in a population of patients undergoing general anesthesia in relation to the population of patients treated under regional anesthesia, had a significant effect on the decline in systolic blood pressure (p<0.001) and dyastolic blood pressure (p=0.008). Conclusion: Regional anesthesia has proven again to be the superior technique over general anesthesia, including cardiovascular stability in patients subjected to shoulder surgery in the beach chair position