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

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

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

Patients’ perceptions of chronic pain during the economic crisis: Lessons learned from Greece

Background: Chronic pain is well known to be influenced by various social factors; however, the impact of financial issues on pain has not been extensively studied. Objective: The aim of this study was to investigate the impact of the economic crisis on pain and quality of life in Greek patients suffering from chronic pain. Study Design: The study employed a prospective, open-label design. Setting: The study setting was the Pain Unit of Attikon University Hospital in Athens, Greece. Methods: The study surveyed 200 randomly selected outpatients with chronic pain during two different time periods (2012 and 2016). Patients completed a structured questionnaire to assess the impact of the economic crisis on multiple aspects of pain and pain management, health care, and quality of life. Personality characteristics and stress were also evaluated using the DASS-42 and the LOT-R questionnaires. Results: Most patients in both periods believed that the economic crisis led to a worsening of their symptoms (75%) and quality of life (97%). Most patients (97.5%) also believed that the intensity of their pain would have been improved if their financial status had been better. Their main concerns about the future were “the possibility of not having access to health care facilities and medication” (94.5%), “stress” (43%), and “fear of financial strain” (30.5%). Higher levels of anxiety, stress, and pessimism were associated with higher levels of pain and lower quality of life. Limitations: The study is based on a small sample size. Conclusions: This study identified impacts of the financial crisis on chronic pain and quality of life, pointing to the need for measures to solve this problem. © 2018, American Society of Interventional Pain Physicians. All rights reserved