Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Background: The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). Methods: Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. Results: A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. Conclusions: OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI

Anesthesia Related Toxic Effects on in Vitro Fertilization Outcome: Burden of Proof

Management of pain and anxiety during oocyte retrieval makes anesthesia an important part of the in vitro fertilization (IVF) procedures. There are many studies investigating the influence of anesthesia on IVF success. This review article provides an overview of published data regarding the potential toxic effects of different anesthetic techniques (Loco-regional, general anesthesia (GA), and monitored anesthesia care (MAC)), different anesthetic agents, and alternative medicine approach (principally acupuncture) on the IVF outcome. From our analysis, evidence of serious toxicity in humans is not well established. Trials regarding different anesthetic techniques ended up without clear conclusions. Studies about GA came up with conflicting results. A few trials relate GA with lower pregnancy rates, although some others failed to prove this conclusion. Furthermore, detectable amounts of some anesthetic agents are measurable in the follicular fluid but these findings are not strongly associated with toxicity. MAC and Loco-regional anesthesia appear as safe alternative choices and there is evidence of improved outcome. Whereas acupuncture may provide assistance increasing IVF success according to some trials, some others could not obtain these effects. Questions about the appropriate time of application and the underlying mechanism of action are not answered yet, so further investigation should be done. © 2015 Paraskevi Matsota et al

Patient-controlled epidural analgesia after caesarean section: Levobupivacaine 0.15% versus ropivacaine 0.15% alone or combined with fentanyl 2 μg/ml: a comparative study

Introduction: The aim of this study was to compare the postoperative analgesic efficacy of epidural ropivacaine 0.15%, levobupivacaine 0.15% and ropivacaine 0.15% plus fentanyl 2 μg/ml, used with a patient-controlled epidural analgesia (PCEA) device after Caesarean section. Material and methods: Sixty women undergoing elective Caesarean section under combined spinal-epidural anaesthesia were enrolled. Postoperatively, patients received PCEA with either ropivacaine or levobupivacaine 0.15% (basal rate 6 ml/h, bolus 5 ml/20 min), or ropivacaine 0.15% plus fentanyl 2 μg/ml (basal rate 6 ml/h, bolus 4 ml/20 min). Sympathetic and sensory level of analgesia, motor ability (Bromage 0-3), and pain scores at rest, movement and cough (VAS 0-10), haemodynamic parameters, oxygenation, side effects and total doses of local anaesthetic were documented every 6 h for 24 h. Patient satisfaction was assessed using a descriptive scale. Results: No significant difference was observed in pain scores at all time intervals. A significantly higher sympathetic and sensory blockade occurred with levobupivacaine and ropivacaine 0.15% compared to ropivacaine 0.15% plus fentanyl, with no significant difference in total local analgesic consumption at 24 h (p = 0.08). Rescue analgesic requirements did not differ between the groups (p = 0.8) while patients' satisfaction was significantly higher in the ropivacaine 0.15% plus fentanyl group (p = 0.02). Haemodynamics, oxygenation, nausea, pruritus and numbness did not differ between the groups. Conclusions: Dilute local anaesthetic solutions provided satisfactory postoperative analgesia after Caesarean section when used with a PCEA device. The combination of ropivacaine 0.15% with fentanyl 2 μg/ml appeared superior, since it provided higher patient satisfaction with statistically equal pain scores and local anaesthetic consumption. Copyright © 2011 Termedia & Banach

Opioid-Free Anesthesia and Postoperative Cognitive Dysfunction After Minor Urological Surgery: A Case Series Study

Background: Postoperative cognitive dysfunction (POCD) is a complication that mainly occurs in adult patients and refers to a new-onset decline in cognitive function after anesthesia and surgery. The literature lacks evidence regarding opioid-free anesthesia and its impact on mental function postoperatively. Objectives: The effect of opioid-free anesthesia on POCD following urological surgery has not been previously reported. Accord-ingly, we present a case series of 15 adult patients undergoing transurethral urological surgery under general anesthesia using an opioid-free protocol with dexmedetomidine, ketamine, and lidocaine. Methods: Patients that underwent simple transurethral elective urological procedures under general opioid-free anesthesia were included. This case series is part of a prospective clinical study regarding opioid-free anesthesia and served as a pilot sample. The mini-mental state examination (MMSE) test, performed preoperatively and 12 hours postoperatively, was applied to assess POCD. Results: Fifteen patients with a mean age of 68 years old were included in the study. The opioid-free protocol was associated with non-statistically significant changes of the MMSE test after minor urological procedures. Conclusions: In our study, an opioid-free protocol of general anesthesia, using a mixture of dexmedetomidine, ketamine, and lido-caine, did not seem to have a negative impact on postoperative cognitive function in patients undergoing transurethral urological surgery. Further studies specifically designed to identify this effect are certainly required to further prove such an effect. © 2022, Author(s)

Malfunction of SynchroMed II baclofen pump delivers a near-lethal baclofen overdose

Introduction: Intrathecal baclofen therapy using implantable pumps is an established treatment for spasticity. The pumps occasionally experience serious malfunction. Case Report: A 12-year-old girl suffering from spastic diplegia was implanted with a Medtronic SynchroMed II pump (Medtronic Inc., Minneapolis, Minn., USA). During a refill at 3 months 19 ml of baclofen were still in the pump. It was assumed that there was a lumbar catheter obstruction and a revision was performed. At 11 months she was receiving 180 μg/day. When she presented for refill, there were again 19 ml of baclofen in the reservoir. The pump was refilled, stopped and restarted at a lower dose. Ten minutes after restart the patient was complaining that she could not move her legs. Within the next 50 min she lapsed into coma, from a presumed baclofen overdose. She was intubated and ventilated. The reservoir was emptied of baclofen and the pump stopped. Seventeen hours after the baclofen overdose, the patient woke up gradually with no new neurological deficits. The pump was removed a week later. Medtronic laboratories examined the pump and reported no technical fault. Discussion: The implanted Medtronic SynchroMed II pump suffered an unusual malfunction. It is postulated that the pump had suffered a motor stall, and when it was restarted, it gave an unusually high, potentially lethal, dose to the patient. Conclusion: Physicians who implant pumps for intrathecal baclofen administration need to be aware that these devices may suffer unheralded catastrophic failure that can lead to potentially lethal overdose administration. Copyright © 2010 S. Karger AG, Basel

The role of the post-anaesthesia care unit in the management of high-risk obstetric patients

Introduction: High-risk obstetric patients in the immediate postpartum period are frequently admitted to the intensive care unit, but the necessity of this practice has recently been doubted. Herein we describe the efficiency of utilizing the post-anaesthesia care unit (PACU) as an intermediate intensive care facility for those patients. Material and methods: We retrospectively described the reasons for admission, duration of stay, the anaesthetic used, main interventions and outcome for all obstetric admissions in the PACU during a period of 4 years in a university hospital. Results: During the 4-year period 47 women were admitted to the PACU after delivery. The frequency of admission to the PACU was 15.3 per 1000 deliveries, while obstetric cases represented 4.4 per 1000 admissions to the PACU. The majority represented caesarean sections (81%). The main reasons for admission to the PACU were haemorrhage (49%), cardiovascular problems (19%) and preeclampsia/eclampsia (17%). Mean length of stay in the PACU was 14.5 ±11.6 h, being significantly less in women having received epidural anaesthesia (8.2 ±5.6 h) compared to those who delivered with general anaesthesia (19.0 ±13.6 h, p < 0.05). General anaesthesia was used in 85% of cases in which emergency delivery was indicated, but only in 27% of cases without emergency indications for delivery (p < 0.01). No death or admission to the intensive care unit occurred during the study period. Conclusions: The PACU can offer an intermediate intensive care facility for high-risk obstetric patients, thus reducing unnecessary admissions to the intensive care unit. Copyright © 2011 Termedia & Banach

Low-dose (1 μg/kg) clonidine premedication and hypotension after carotid artery surgery

We investigated the role of low-dose clonidine intravenous (IV) premedication in arterial pressure variation during and after carotid endarterectomy (CEA). A total of 84 patients, American Society of Anesthesiologists (ASA) II-III, scheduled for elective CEA under general anesthesia participated in this study. The patients were divided into 2 groups: group P (n = 42) and group C (n = 42) and received N/S 0.9% (placebo) or clonidine 1 μg/kg IV, respectively, 15 minutes before induction of anesthesia. Recovery times, number of patients needed to be treated for circulatory events (hypertension, hypotension, and bradycardia), number of circulatory events per patient, and consumption of vasoactive drugs (nitroglycerine, phenylphrine, and atropine) intraoperatively and the first 6 hours postoperatively were recorded. Significantly less hypertensive episodes were observed intraoperatively, but more hypotensive episodes were observed postoperatively in patients receiving clonidine. Intravenous premedication with low-dose clonidine (1 μg/kg) seems to be effective in preventing hypertensive episodes during CEA under general anesthesia but seems to increase the incidence of hypotension postoperatively. © SAGE Publications 2011