Unilateral spinal anesthesia with low dose bupivacaine and ropivacaine: hypobaric or hyperbaric solutions with fentanyl for one-day surgery?

Background and Objectives: The purpose of this study was to compare the quality of unilateral spinal anesthesia with low dose bupivacaine and ropivacaine deluded in different baric solutions (hyperbaric / hypobaric). In our special interest was to define possibilities to use hypobaric solutions of local anesthetics if they prove to have any advantages. Methods: This prospective study was conduced over a 24-month period, enrolling eighty patients (ASA groups I, II, III) randomly divided into four groups. The study solution [5mg of o.5% bupivacaine or 5 mg 1.0% ropivacaine with 25/mikron/ g fentanyl, prepared in a different baric solution (hyperbaric / hypobaric)] were injected into the subarachnoidal interspaces at the level L2-L3/L3-L4. After the inducing spinal anesthesia, the patients in the hyperbaric groups kept the lateral decubitus position with the operated side facing down; while the patients in the hypobaric groups kept lateral decubitus position facing the operated side up. During the set time intervals we evaluated how rapid was the beginning and the regression of the unilateral block; the extension of the motor and the sensoric block, the haemodinamic changes and the home admition time. Results: All of the patients included in the study tolerated the procedure well. The median time for achieving the unilateral surgical anesthesia was the shortest in hyperbaric ropivacaine group (6.95 minutes). Themaximal degree of themotor block (Bromage 3)was the highest in the hyperbaric bupivacaine group. Themedian recovery time to be able to walk and to the first urine pass was faster achieved in the hyperbaric and hypobaric ropivacaine groups (160 minutes vs.190 minutes), comparing to the hyperbaric and hypobaric bupivacaine groups (230 minutes vs.250 minutes). Side–effects were minor and infrequent in all groups. Conclusions: According to this study the baricity of the anesthetic solution has no influence in achieving successful unilateral spinal block. Ropivacain will be chosen if we want to realize a faster readiness to surgery, and a faster recovery with few side-effects and complications; all particularly appreciable in an outpatient surgery

A critical assessment of thromboprophylaxis in surgically treated patients

Profilaksa duboke venske tromboze dio je prijeoperacijske pripreme bolesnika za kirurške zahvate. Izvori plućne embolije najčešće su tromboze dubokih vena donjih ekstremiteta, male zdjelice i donje vene kave. Frekvencija venskih ugrušaka je asimptomatična. Venski tromboembolizam je najvažnija komplikacija u ortopedskoj i drugoj velikoj kirurgiji bolesnika, s umjerenim i povišenim rizikom. Ako se ne pokuša sniziti rizik tromboembolizma, očekuje se mortalitet do 5% bolesnika. Veliki broj bolesnika zahtijeva mehanički ili farmakološki oblik profilakse. Kemijska profilaksa niskomolekulskim heparinom u obliku supkutanih injekcija, jednom dnevno, pokazala se veoma djelotvornom, bolesnici je dobro podnose i cijenom je prihvatljiva. Ipak, u nekim situacijama još ima prostora za raspravu. Da li venografski dokazana tromboza odgovara kliničkoj realnosti? Da li je opasno primijeniti regionalnu anesteziju u bolesnika na antikoagulacijskoj terapiji? Da li oralne antikoagulancije smiju biti ordinirane? Koliko dugo je potrebita poslijeoperacijska profilaksa duboke venske tromboze? Kakva je budućnost mehaničke profilakse?Deep vein thrombosis (DVT) prophylaxis is a part of the perioperative patient care. Pulmonary emboly (PA) usually originates from thrombosis in the deep veins of the lower limbs, pelvis or inferior vena cava. Frequently these venous thrombi are asymptomatic. Venous thromboembolism is an important complication of major orthopaedic and other major surgeries. If no attempt is made to reduce the risk of thromboembolism, mortality can be up to 5% of the patients. Most of the patients who undergo surgery require mechanical or pharmacological prophylaxis. Low molecular weight heparins have considerably simplified chemical prophylaxis since a signle daily subcutaneous injection is efficient, well tolerated and cost-effective. However, several points are still a matter of debate. Does venographically proven thrombosis reflect clinical reality? Is the association of loco-regional anesthesia and anticoagulants dangerous? Should oral anticoagulants still be prescribed? How long should DVT prophylaxis be contineud post-operatively? What is the future of mechanical prophylaxis

In vitro effect of subinhibitory concentrations of ceftazidime and meropenem on the serum sensitivity of Pseudomonas aeruginosa strains

The aim of this study was to determine the effect of subminimal inhibitory concentrations (subMICs) of ceftazidime, meropenem and gentamicin on the in vitro serum sensitivity of Pseudomonas aeruginosa strains isolated from a variety of isolation sites at two medical wards and an intensive care unit in a government university hospital in Croatia. A total of 20 serum-resistant P aeruginosa strains isolated from different clinical specimens were selected. Bacteria were exposed to 1/2, 1/4, 1/8, 1/16, and 1/32 x MIC of each antibiotic tested. Sensitivity of P. aeruginosa strains to bactericidal activity of normal human serum before and after bacterial exposure to subMICs was determined. Significant difference in serum sensitivity of the strains was observed after the bacteria were exposed to subMICs of ceftazidime and meropenem (p < 0.01), while the exposure to subMICs of gentamicin did not affect significantly the resistance of tested strains to the serum bactericidal activity. Comparing the number of serum-resistant strains before and after exposure to subMICs of antibiotics, statistically significant differences were determined (p < 0.01) after exposure of the strains to 1/2, 1/4, 1/8 and 1/16 x MIC of meropenem, and after exposure to 1/2, 1/4 and 1/8 x MIC of ceftazidime. SubMICs of ceftazidime and meropenem affected not only the resistance to serum bactericidal activity of bacteria, but also their morphology. The alterations in bacterial morphology caused by subMICs of ceftazidime and meropenem could be connected with consecutive bacterial serum sensitivity

Mechanical ventilation in chronic obstructive pulmonary disease patients, noninvasive vs. invasive method (randomized prospective study) [Usporedba neinvazivne i invazivne umjetne ventilacije kod bolesnika s kroničnom opstruktivnom plućnom bolesti: prospektivna randomizirana studija]

Acute respiratory failure due to chronic obstructive pulmonary disease (COPD) presents an increasing problem throughout the world. The aim of this study was to compare invasive and non-invasive mechanical ventilation (MV) for patients with COPD. A prospective, randomized trial was performed in a multidisciplinary intensive care unit for the period of 36 months and included 156 patients with COPD. MV procedure was performed using standard methods, and was applied as either invasive MV (IMV) or noninvasive MV (NIMV). Patients were randomized in two groups for application of MV using closed, nontransparent envelops. Comparison was made based on patient characteristics, objective parameters on admission and 1h, 4h, 24h, and 48h after admission and based on treatment outcome. We have confirmed that NIMV method is superior to IMV for patients with COPD. MV duration NIMV:IMV was 94:172 hours, p<0.001, time spent in Intensive Care Unit 120:223 hours, p<0.001. Ventilator associated pneumonia 5(6%):29(37%), p<0.001.The advantage of NIMV in COPD patients, especially in the early stages was confirmed

Spinalna anestezija u kirurgiji kuka – posebitosti

Spinal anesthesia is generally accepted as the first choice for hip surgery due to the deep nerve block affecting a large part of the body achieved through a relatively simple procedure of injecting a small amount of local anesthetic. By controlling the factors that influence the widening of the blocked area, the desired type of block can be achieved, the variability of which can be attributed to factors such as cerebrospinal fluid density, lumbar lordosis or volume of lumbosacral cerebrospinal fluid, namely, its dilution through the injection of isobaric anesthetic solution. However, it is important to know that in certain indications surgical anesthesia needs to be accomplished by a general endotracheal anesthesia. Spinal anesthesia of acceptable height and solidity is achieved through adequate intrathecal distribution of the local anesthetic solution, therefore the difference between the density of liquor and the injected solution of local anesthetic provides the main effect on the intrathecal spread of anesthetics. Anticipated spinal anesthesia is achieved by a hyperbaric or hypobaric solution of local anesthetic; in other words, hyperbaric solutions “sink” while the hypobaric solutions “swim” in such a way that the level of caudal or cranial spread of local anesthetic will depend on the mutual interaction of the density of the solution and the patient’s body posture.Općenito, spinalna anestezija predstavlja anesteziju izbora za operacije kuka radi dubokog nervnog bloka koji se postiže u velikim dijelovima tijela relativno jednostavnim injiciranjem male količine lokalnog anestetika. Upravljanjem čimbenicima koji utječu na širenje blokade dijela tijela može se pridonijeti željenom tipu spinalnog bloka, dok se velika varijabilnost pripisuje brojnim čimbenicima kao što su: gustoća cerebrospinalne tekućine, lumbalna lordoza ili volumen lumbosakralne cerebrospinalne tekućine, odnosno njezino razrjeđenje injiciranom otopinom izobaričnog anestetika. Stoga je vrlo važno da se, u pojedinim indikacijama, kirurška anestezija postigne općom endotrahealnom anestezijom. Spinalna anestezija dostatne visine i čvrstoće bloka postiže se dostatnom raspodjelom otopine lokalnog anestetika intratekalno, a razlika između gustoće likvora i injektirane otopine lokalnog anestetika ima glavni učinak na intratekalno širenje anestetika. Predvidljiva se spinalna anestezija postiže hiperbaričnom ili hipobaričnom otopinom lokalnog anestetika; ovdje se radi o gravitacijskom učinku, hiperbarične otopine “tonu” a hipobarične “plivaju” tako da će stupanj kaudalnog ili kranijalnog širenja, odnosno raspodjele lokalnog anestetika, zavisiti o uzajamnom djelovanju gustoće otopine i položaja tijela pacijenta

A Comparison of the Interlaminar v. the Transforaminal Approach To Steroid Injections under Fluoroscopic Control in Treating Lumbar Radicular Pain

Background and Purpose: Lateral lumbar spinal compression is a common source of lower back and leg pain. Steroids injected around the dura-sac markedly decrease inflammation commonly associated with conditions such as, disc-herniation or s. This study’s goal was to prove how epidural injections of steroids, transforaminal or interlaminar, lead to improved pain reduction. Materials and Methods: 50 patients were included in the study by random choice. They were stratified with magnetic resonance imaging and mlectromyography, according to their confirmed diagnosis of lumbar lateral spinal compression. The selected patients were divided into two groups according to reception-path of epidural steroids. In both groups 25 patients were selected by random choice to receive interlaminar or transforaminal epidural steroid injections, in both cases under fluoroscopic guidance. The patients were monitored and their pain assessed by using the visual analogue scale (0–10) during each visit, and during the visits three and six months following the first injection (using VAS scores). Results and conclusions: After the first and second injection of steroids an efficient decrease of pain was evident, although a tendency towards further decrease was not continued after the third injection of steroids and local anaesthesia. The tendency towards decreasing and maintaining the level of pain was recorded as the same both with the interlaminar and the transforaminal approach to steroid injections. The difference in assessed pain between the group with the transforaminal approach and the group with the interlaminar approach did not appear significant in our study. The results of our research have demonstrated that there is no difference in the efficacy of the epidural steroid injection regarding its approach; that is the efficacy is at the same level both with the interlaminar approach as with the transforaminal approach