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)

Effect of Sugammadex versus Neostigmine/Atropine Combination on Postoperative Cognitive Dysfunction after Elective Surgery

This study aimed to assess the effects of sugammadex and neostigmine/atropine on postoperative cognitive dysfunction (POCD) in adult patients after elective surgery. A randomised, double-blind controlled trial was carried out on 160 American Society of Anesthesiologists physical status I to III patients who were >40 years of age. The Mini–Mental State Evaluation, clock-drawing test and the Isaacs Set test were used to assess cognitive function at three timepoints: 1) preoperatively, 2) one hour postoperatively, and 3) at discharge. The anaesthetic protocol was the same for all patients, except for the neuromuscular block reversal, which was administered by random allocation using either sugammadex or neostigmine/ atropine after the reappearance of T2 in the train-of-four sequence. POCD was defined as a decline ≥1 standard deviation in ≥2 cognitive tests. The incidence of POCD was similar in both groups at one hour postoperatively and at discharge (28% and 10%, in the neostigmine group, 23% and 5.4% in the sugammadex group, P=0.55 and 0.27 respectively). In relation to individual tests, a significant decline of clock-drawing test in the neostigmine group was observed at one hour postoperatively and at discharge. For the Isaacs Set test, a greater decline was found in the sugammadex group. These findings suggest that there are no clinically important differences in the incidence of POCD after neostigmine or sugammadex administration. © 2017 Australian Society of Anaesthetists

A multicenter survey on the use of neuromuscular blockade in Greece. Does the real-world clinical practice indicate the necessity of guidelines?

Background and Aims: The aim of this study was to investigate the current status of clinical practice regarding neuromuscular blocking drugs and their antagonists in Greece. Material and Methods: This is a multicenter survey, including a questionnaire based on previous studies, which was translated and modified by a Task Force of the Hellenic Society of Anaesthesiology. It was completed on a web-based database after invitation via e-mail and was left online for a period of 2 months. Results: A total of 1,100 questionnaires were sent, with a response rate of 7.9%. 13.7% stated that they do not use neuromuscular monitoring. Rocuronium was most commonly used for intubation ['often' stated by 19 (21.8%) and 'very often' by 62 (71.2%)], followed by cis-atracurium, atracurium, and succinylcholine. Neostigmine and sugammadex were both used, with reversal not always administered by 23 (26.4%). Both agents were mostly used at fixed doses and not calculated based on TOF monitoring or body weight. Sugammadex was preferred in special patient groups and in operations of short duration. Reversal was most often administered based on clinical signs of neuromuscular recovery rather than objective monitoring. A significant percentage of respondents used an inadequate TOF ratio for extubation [37 (43.2%) used a TOF ratio <90%]. The reported incidence of observed residual neuromuscular blockade (RNMB) was 44.8%. Conclusion: Great variability was observed in Greek clinical practice regarding the use of neuromuscular blockade, which indicates serious issues that must be addressed. The needs for educating anesthesia providers and developing official guidelines are obvious in order to improve patient outcomes. © 2019 Medknow Publications. All rights reserved

The impact of the first wave of the covid-19 pandemic on patients’ perceptions of chronic pain

Purpose: On 10 March 2020, Greece entered an increasingly restrictive 42-day lockdown, in order to contain the first wave of the COVID-19 pandemic. All scheduled appointments and activities of the pain clinics around the country were postponed indefinitely. The aim of this prospective study was to assess the perceived impact of the first wave of the pandemic on pain, quality of life, and access to treatment, during the first austere lockdown in Greece. Patients and Methods: In this cross-sectional study, 101 patients suffering from chronic pain completed a structured questionnaire. Levels of depression, anxiety, stress, personal wellbeing, optimism and personality traits were also evaluated, using the Depression, Anxiety and Stress Scale (DASS42), the Ten Item Personality Index (TIPI), the Life Orientation Test-Revised (GrLOT-R) and the Personal Wellbeing Index (PWI). Results: Despite the dramatic decrease in health care visitations before, during and after the imposed lockdown, most patients did not feel that access to pain physicians and medication was significantly affected. Higher levels of stress, anxiety, depression, neuroticism, openness to experience and general satisfaction with life seemed to be important determinant factors in how patients experienced their level, intensity and duration of pain, quality of life and response to medication. Conclusion: The effects of the lockdown had a more severe impact on patients than the pandemic itself. For most, the level of their pain was not affected by the pandemic and was affected only slightly by the lockdown. Quality of life, however, was affected formost participants. Both the necessity and the complications of introducing the use of telemedicine to Greek chronic pain patients became evident during the study. © 2021 Smyrnioti et al

A single dose of celecoxib 200 mg improves postoperative analgesia provided via patient-controlled epidural technique after caesarean section

Introduction: Celecoxib in a dose of 200 mg is safe for the breast feeding mother, as its milk levels are extremely low. We investigated the efficacy of celecoxib in improving postoperative pain management in parturients under patient-controlled epidural analgesia (PCEA). Material and methods: We studied 64 healthy parturients undergoing elective caesarean section under combined spinal-epidural anesthesia. Postoperative analgesia was performed via PCEA with ropivacaine 0.15% and fentanyl 2 μg/ml (4 ml bolus administration, lock-out 15 min). Patients were randomly allocated to receive either only PCEA (n = 32) or PCEA plus celecoxib 200 mg orally (n = 32). Paracetamol 500 mg was given orally as rescue analgesia. We recorded visual analogue scale (VAS) scores for pain at rest and movement, attempted and given PCEA doses, Bromage scores, level of sensory blockade, rescue doses of paracetamol, maternal side effects during the first 24 h after the PCEA instrumentation, and the overall patient satisfaction. Results: Fifty-six patients completed the entire protocol. Patient demographics, duration of surgery, side effects, attempted and given PCEA doses, and motor and sensory blockade did not differ between the groups. Significantly lower VAS scores at rest and movement, fewer paracetamol doses (p = 0.039) and increased patient satisfaction (p = 0.001) were found in the celecoxib group compared to controls. Conclusions: A single dose of 200 mg of celecoxib effectively improved pain management in parturients with PCEA, limited the need for supplemental analgesics and improved efficacy of analgesia, increasing patient satisfaction. Copyright © 2013 Termedia & Banach

Effect of exogenous catecholamines on tumor necrosis factor alpha, interleukin-6, interleukin-10 and beta-endorphin levels following severe trauma

Cytokines and endogenous opioids are mediators of the post traumatic inflammatory response. The aim of this study was to determine the effect of exogenous catecholamines on Tumor Necrosis Factor alpha (TNFa), interleukin-6 (IL-6), interleukin-10 (IL-10) and Beta(β)-endorphin levels in patients with severe trauma, during the first 24 h after injury. Forty four traumatized patients with haemorrhage class III and IV were included in the study. Patients were divided in two groups: Group 1 (adrenergic, n = 22) and Group 2 (non adrenergic, n = 22), depending on the use of exogenous catecholamines. Blood samples were collected at 0, 2, 4 and 24 h time points. Baseline values were different between the two groups, but an altered pattern of release was observed for TNFa, IL-6, IL-10 and β-endorphin levels in patients treated with catecholamines. ICU stay was longer for the adrenergic group, while survival after 1 month was significantly lower. Findings support an altered pattern of cytokine release during the early phase after trauma, probably due to catecholamine presence. © 2007 Elsevier Inc. All rights reserved

Lessons learned from first case of Cesarean delivery in a COVID-19 positive parturient in Greek region

We report the successful anesthetic management of a 24-year-old patient, with an active COVID-19 viral infection, scheduled for elective Cesarean section at 40th week of pregnancy. This was the first case in Greek region, and we report and discuss the difficulties and safety issues regarding a COVID-19 positive patient during an elective cesarean delivery. Regional anesthesia with full protective equipment for health personnel involved, along with careful planning and adherence to guidelines achieved safe completion of the operation. © 2020 Wolters Kluwer Medknow Publications. All rights reserved

Postoperative spinal infection mimicking systemic vasculitis with titanium-spinal implants

Background: Secondary systemic vasculitis after posterior spinal fusion surgery is rare. It is usually related to over-reaction of immune-system, to genetic factors, toxicity, infection or metal allergies.Case Description: A 14 year-old girl with a history of extended posterior spinal fusion due to idiopathic scoliosis presented to our department with diffuse erythema and nephritis (macroscopic hemuresis and proteinuria) 5 months post surgery. The surgical trauma had no signs of inflammation or infection. The blood markers ESR and CRP were increased. Skin tests were positive for nickel allergy, which is a content of titanium alloy. The patient received corticosteroids systematically (hydrocortisone 10 mg) for 6 months, leading to total recess of skin and systemic reaction. However, a palpable mass close to the surgical wound raised the suspicion of a late infection. The patient had a second surgery consisting of surgical debridement and one stage revision of posterior spinal instrumentation. Intraoperative cultures were positive to Staphylococcus aureus. Intravenous antibiotics were administered. The patient is now free of symptoms 24 months post revision surgery without any signs of recurrence of either vasculitis or infection.Literature Review: Systemic vasculitis after spinal surgery is exceptionally rare. Causative factors are broad and sometimes controversial. In general, it is associated with allergy to metal ions. This is usually addressed with metal on metal total hip bearings. In spinal surgery, titanium implants are considered to be inert and only few reports have presented cases with systemic vasculitides. Therefore, other etiologies of immune over-reaction should always be considered, such as drug toxicity, infection, or genetic predisposition.Purposes and Clinical Relevance: Our purpose was to highlight the difficulties during the diagnostic work-up for systemic vasculitis and management in cases of posterior spinal surgery. © 2011 Sakellariou et al; licensee BioMed Central Ltd