Anaesthesia and Stress Response to Surgery

The body reaction to surgery ranges from minor to massive both locally and generally. General response is in the form of widespread endocrinal, metabolic and biochemical reactions throughout the body. Neuro-endocrinal hormone system and inflammation mediators are involved and this process is called “stress response”. The response has a compensatory mechanism and provides a maximum chance of survival because of increased cardio-vascular functions, fluid preservation and supply of increased demands for energy generating substrates. If the stress response is prolonged, it may result in exhaustion of essential components of the body, fatigue, decreased resistance, delayed ambulation and increased morbidity and mortality. Suppression of immune defense mechanisms has been demonstrated in the postoperative period. Such immune compromise can affect the postoperative infection rate, healing process, and the rate and size of tumour metastases disseminated during surgery. The mechanism of immunosuppression in the postoperative period is not fully understood. The known mediators of immune depression are neuroendocrine response as well as intravenous opioids and inhalational agents, which have shown to increase the susceptibility to infection through a significant cautions in choosing anaesthetic agents, to minimise harm to the patients. In this paper we review the data about the influence of different anaesthetic agents on neuroendocrine, immune and inflammatory response to surgical stress.publishersversionPeer reviewe

Special Devices for Regional Anaesthesia

The rapid growth of regional anaesthesia in the last 20 years has resulted in an increasing number of technical devices. Technical resources play a very considerable role in modern regional anaesthesia and they are being introduced to facilitate the quality performance of this type of anaesthesia. The task of this survey is to summarise the most important technical devices currently utilised for regional anaesthesia and to provide a review of the history of their introduction. Technical devices for performing regional anaesthesia could be divided in seven groups: 1) neurostimulation and simple needles and catheters; 2) neurostimulator with transcutaneous nerve stimulation (TENS); 3) ultrasonograph with a device to fix the probe; 4) devices for injection of local anaesthetics, such as perfusors, patient controlled analgesia systems and elastomeric infusion systems; 5) arm, leg and instruments supports; 6) regional anaesthesia injection monitor and data register devices, and 7) catheter fastenings and auxiliary materials. It is recommended that all of the apparatus applied should be classified to make it easier to acquire more immediate and understanding, and be easy to add this knowledge to the overall checklist before starting anaesthesia. The history of the introduction of technical equipment shows how much time was necessary for the development of modern regional anaesthesia methods.publishersversionPeer reviewe

Cerebral Oxygenation Changes Observed In Patients Undergoing Spinal Neurosurgery in Prone Position Using Near Infrared Spectroscopy

Near infrared spectroscopy (NIRS) devices like cerebral oximeters have lately gained their actuality in different fields of medicine. Used intraoperative they can early detect harmful event and gives a possibility to avoid from further brain damage. The goal of study was to determine whether prone position during spinal neurosurgery impacts cerebral oxygen saturation using NIRS.publishersversionPeer reviewe

Factors affecting a successful out-of-hospital cardiopulmonary resuscitation

A retrospective patient record analysis of the Emergency Medial Service's Rîga City Regional Centre was provided from January 2012 through December 2013. 1359 adult patients were CPR treated for out-of-hospital cardiac arrest according to ERC Guidelines 2010. A total of 490 patients were excluded from the study. The main outcome measure was survival to hospital admission. Of 869 CPR-treated patients, 60% (n = 521) were men. The mean age of patients was 66.68 ± 15.28 years. The survival rate to hospital admission was 12.9% (n = 112). 54 of survived patients were women. Mean patient age of successful CPR was 63.22 ± 16.21 and unsuccessful CPR 67.20 ± 15.09. At least one related illness was recorded with 63.4% (n = 551) patients. There were 61 survivors in bystander witnessed OHCA and nine survivors in unwitnessed OHCA. The rate of bystander CPR when CA (cardiac arrest) was witnessed was 24.8%. Ventricular fibrillation (VF) as initial heart rhythm was significantly associated with survival to hospital admission in 54 cases (p < 0.0001). Age and gender affected return of spontaneous circulation. Survival to hospital admission had rhythm-specific outcome. Presence of OHCA witnesses improved outcome compared to bystander CPR. The objective of this study was to report patient characteristics, the role of witnesses in out-of-hospital cardiac arrest (OHCA) and outcome of adult cardiopulmonary resuscitation.publishersversionPeer reviewe

Association of Interleukin 6 Promoter Polymorphism (-174G/C) with IL-6 Level and Outcome in Severe Sepsis

Interleukin (IL-6) is a key cytokine in the pathogenesis of severe sepsis. The importance of a regulatory polymorphism within the IL-6 promoter remains unclear in these patients. The aim of the study was to determine if IL-6 (-174 G/C) promoter polymorphism has an effect on IL-6plasma level and outcome of severe sepsis. The study was conducted in general ICU of Stradiņš Clinical University Hospital. A total of 103 critically ill patients with confirmed severe sepsis were prospectively included. Association analysis of the IL-6 (-174C) allele with serum level and clinical outcome was performed. We found no differences in genotype distribution between survivors and nonsurvivors. The serum IL-6 level was significantly higher in nonsurvivors compared with survivors. We found an association of genotype with the IL-6 level in non survivors, but not in survivors. Our findings show a functional significance of IL-6 promoter polymorphisms in nonsurviving severe sepsis patients.publishersversionPeer reviewe

Arterial stiffness measured by pulse wave velocity in patients with early sepsis

Publisher Copyright: © by Sigita Kazune 2015.Sepsis is characterised by massive inflammatory response, which can affect vascular function. This study was designed to assess the impact of early severe sepsis and septic shock on arterial stiffness and the relationship of this impact to outcome. Twelve patients with severe sepsis and 22 with septic shock were included in the study. We measured carotid to femoral and carotid to radial pulse wave velocity (PWV), an index of aortic and brachial arterial stiffness, in patients with early severe sepsis and septic shock within 24 hours of admission to intensive care unit and repeatedly after 48 hours. No difference was observed between patients with severe sepsis and septic shock regarding carotid to femoral PWV (11.7 ± 2.2 vs. 11.3 ± 3.6 m/s) and carotid to radial PWV (12.0 ± 3.8 vs. 9.5 ± 2.2 m/s). On 48 hour follow-up, PWV did not significantly differ between survivors and non-survivors. A positive, similar correlation occurred between PWV and pulse pressure in all patients (r = 0.35, p = 0.05), and there was a negative correlation between PWV and C-reactive protein levels (r = -0.43, p = 0.04). In conclusion, PWV is not affected by disease severity or prognosis.publishersversionPeer reviewe

Effects of Different Epidural Analgesic Compositions on Postoperative Pain Relief and Systemic Response to Surgery

Despite many achievements during the last decade, postoperative pain remains the dominant complaint after major surgery and has great potential to be influenced by the anaesthesiologist. Reports suggest that short-term effective anaesthesia and analgesia can have long-lasting beneficial effects on recovery from surgery. The aim of our study is to compare the effect of epidural analgesia, using different compositions, including glucocorticoids (methylprednisolone), and habitual composition of bupivacaine-morphine, in regard to analgesic and anti-inflammatory properties. A total of 129 patients participated in the study in four different treatment groups: patients from Group I received glucocorticoid methylprednisolone succinate and long-acting opioid morphine hydrochloride, Group II received local anaesthetic bupivacaine hydrochloride and morphine hydrochloride, Group III received methylprednisolone succinate and short-acting opioid fentanyl, and Group IV received glucocorticoid methylprednisolone succinate. We obtained good analgesic profiles in all groups. However, significantly better results were achieved using the combination of methylprednisolone and morphine. Epidural methylprednisolone in dose 80 mg/24 h is more effective, compared to the conventional local anaesthetics-opioid composition, when administered as a part of multimodal preventive postoperative analgesia after major joint replacement surgery. Epidural methylprednisolone has a reliable anti-inflammatory and immunomodulatory potential. It attenuates profiles of acute inflammatory response markers as Interleukin-6 and C-reactive protein and stress hormone cortisol. The novelty of this study was application of epidural glucocorticoids for acute postoperative pain relief as part of daily perioperative care. By developing studies on anti-inflammatory and immunomodulatory properties of glucocorticoids, we expect to improve patient rehabilitation in the postoperative period.publishersversionPeer reviewe

Impaired vascular reactivity in sepsis - a systematic review with meta-analysis

Introduction: Vascular dysfunction due to reduced nitric oxide bioavailability plays an important role in the pathogenesis of sepsis. This meta-analysis examines evidence from published literature to evaluate whether in the adult population the presence/severity of sepsis is associated with impaired vasoreactivity. Material and methods: We performed a search of the Medline, Scopus, and EMBASE databases to identify observational studies using measurement of reactive hyperaemia in adult patients with sepsis. After data extraction using predefined protocol, qualitative synthesis of findings was performed regarding consistency of findings between methods, evidence of association between vascular reactivity and severity of sepsis, multiple organ failure, and death. A meta-analyses of standardised mean differences in vasoreactivity between groups was performed, in which data were available for relevant outcomes. Results: Eighteen studies using four methods to measure vascular reactivity from a total of 466 were included in the analysis. The pooled standardised mean difference estimate showed that septic patients had less reactive hyperaemia than controls (-2.59, 95% CI: -3.46 to -1.72; p < 0.00001), and peak hyperaemic blood flow was lower in patients with sepsis than in the control group (SMD = -1.42, 95% CI: -2.14 to -0.70; p = 0.0001). The combined SMD between non survivors and survivors was -0.36 (95% CI: -0.67 to -0.06; p = 0.02) for reactive hyperaemia and -0.70 (95% CI: -1.13 to -0.27; p = 0.001) for peak hyperaemic blood flow. Conclusions: Septic patients have attenuated vascular reactivity when compared to healthy volunteers. There are insufficient data indicating that these changes can identify patients at risk of worsening organ failure or death.publishersversionPeer reviewe

Regional cerebral oxygen saturation monitoring during spinal surgery in order to identify patients at risk for cerebral desaturation

Publisher Copyright: © 2020 by the authors. Copyright: Copyright 2020 Elsevier B.V., All rights reserved.Background: Near infrared spectroscopy (NIRS) devices are non-invasive and monitor cerebral oxygen saturation (rScO2) continuously. NIRS interventional protocol is available in order to avoid hypoxic brain injury. Methods: We recruited patients scheduled for spinal surgery (n = 44). rScO2 was monitored throughout the surgery using INVOS 4100 cerebral oximeter. If the rScO2 values dropped more than 20% below baseline, or there was an absolute drop to below 50%, NIRS interventional protocol was followed. Results: In two patients rScO2 decreased by more than 20% from baseline values. In one patient rScO2 decreased to below 50%. NIRS protocol was initiated. As the first step, correct head position was verified-in one patient rScO2 increased above the threshold value. In the two remaining patients, mean arterial pressure was raised by injecting Ephedrin boluses as the next step. rScO2 raised above threshold. Patients with desaturation episodes had longer medium time of the operation (114 ± 35 versus 200 ± 98 min, p = 0.01). Pearson's correlation showed a negative correlation between rScO2 and duration of operation (r = 0.9, p = 0.2). Receiver operating characteristic curve analysis showed blood loss to be a strong predictor for possible cerebral desaturation (Area under the curve (AUC): 0.947, 95%CI: 0.836-1.000, p = 0.04). Conclusion: Patients with higher blood loss might experience cerebral desaturation more often than spinal surgery patients without significant blood loss.publishersversionPeer reviewe

Fibrinolytic system changes in liver surgery : A pilot observational study

Publisher Copyright: © 2018 Ozolina, Nemme, Ozolins, Bjertnæs, Vanags, Gardovskis, Viksna and Krumina.Introduction: Bleeding occurs frequently in liver surgery. Unbalance between tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) concentrations might increase bleeding. Our aim was to analyze perioperative fibrinolytic changes during liver surgery. Materials and Methods: We evaluated 15 patients for inclusion into a prospective pilot study of liver surgery. We assessed fibrinolysis by plasma PAI-1 and t-PA: before surgery (T1), before Pringle maneuver (PM;T2), at the end of surgery (T3) and 24 h postoperatively (T4), and registered demographic and laboratory data, extent and duration of surgery, hemodynamic parameters, blood loss, and transfused volumes of blood products. Data presented as mean ± SD. Significance at P < 0.05. Results: After exclusion of six patients only undergoing biopsies, we included six women and three men aged 49.1 ± 19.6 years; two patients with liver metastases of colorectal cancer and hepatocellular carcinoma, respectively, two with focal nodular hyperplasia, two with hepatic hemangioma, and one with angiomyolipoma. Six patients underwent PM. PAI-1 plasma concentration (n = 9) rose from 6.25 ± 2.25 at T1 through 17.30 ± 14.59 ng/ml at T2 and 28.74 ± 20.4 (p = 0.007) and 22.5 ± 16.0 ng/ml (p = 0.04), respectively, at T3 and T4. Correspondingly, t-PA plasma concentration (n = 9) increased from 4.76 ± 3.08 ng/ml at T1 through 8.00 ± 5.10 ng/ml (p = 0.012) at T2 and decreased to 4.25 ± 2.29 ng/ml and 3.04 ± 3.09 at T3 and T4, respectively. Plasma t-PA level at T2 was significantly different from those at T1, T3, and T4 (p < 0.004). In PM patients, t-PA levels increased from T1, peaked at T2 (p = 0.001), and subsequently decreased at T3 and T4 (p = 0.011 and p = 0.037), respectively. Mean blood loss was 1,377.7 ± 1,062.8 ml; seven patients received blood products. Patients with higher PAI-1 levels at T3 received more fresh frozen plasma (r = 0.79; p = 0.01) and red blood cells (r = 0.88; p = 0.002). Conclusions: During liver surgery, fibrinolysis increased, as evidenced by rises in plasma PAI-1and t-PA, especially after start of surgery and following PM. Transfused volumes of blood products correlated with higher plasma concentrations of PAI-1. Confirming this tendency requires a larger cohort of patients.publishersversionPeer reviewe