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Uvod: O kronični pooperativni bolečini govorimo, kadar ne najdemo drugega vzroka za njen nastanek in ko traja dlje kot 2 meseca po operaciji. Pojavi se pri 10-50 % bolnikov po velikih abdominalnih operacijah. Podskupina kronične bolečine, ki jo je najtežje zdraviti, je kronična nevropatska bolečina. Medoperativna epiduralna analgezija in infuzija deksmedetomidina lahko vplivata na incidenco kronične pooperativne bolečine in na incidenco nevropatske bolečine. Metode: V prospektivno raziskavo smo vključili odrasle kirurške bolnike, sprejete na KO za abdominalno kirurgijo, pri katerih je bila načrtovana operacija želodca, operacija trebušne slinavke ali operacija črevesja. Vsi bolniki so imeli epiduralno analgezijo in medoperativno infuzijo deksmedetomidina. Tri mesece po operaciji smo bolnikom poslali vprašalnike. Ocenjevali smo jakost in vrsto bolečine. Za oceno smo uporabili DN4 (Douleur Neuropathique 4) in vprašalnik painDetect. Rezultati: Prejeli smo 42 (50 %) pravilno izpolnjenih vprašalnikov DN4 in 45 (53 %) vprašalnikov painDetect. V naši raziskavi je bila incidenca kronične bolečine 25 %, nevropatske bolečine 7,1 % (3 bolniki so izpolnjevali merila za nevropatsko bolečino po vprašalniku DN4). Zaključek: Rezultati naše prospektivne raziskave nakazujejo, da bi lahko medoperativna uporaba epiduralne analgezije in infuzije deksmedetomidina zmanjšala pojav pooperativne kronične bolečine.

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (V(T)). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients. OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference. DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries. MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as V(T) of 8 ml kg(−1) or less predicted bodyweight (PBW). A V(T) was deemed ‘default’ if the set V(T) was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation. RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default V(T) was often set, both in women and men; mode V(T) was 500 ml. Median [IQR] V(T) was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg(−1) PBW, P*** < 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P*** < 0.001]. In the mediation analysis, patients’ height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default V(T). CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher V(T) than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Background: Combined monitoring of blood flow with assessment of fluid status and cerebral tissue oxygenation improve perioperative management and outcome of high-risk surgical patients. The study tests if intraoperative multimodal monitoring reduces postoperative morbidity and duration of hospitalisation in patients undergoing major abdominal surgery managed by same anaesthetic protocols with epidural analgesia.Methods: Prospective study was conducted in 2 parallel groups. High risk surgical patients undergoing major abdominal surgery were randomised in control group (CG), where standard monitoring was applied and protocol group (PG), where cerebral oxygenation and haemodynamic monitoring were used with protocol for intraoperative interventions.Results: There was no difference in median length of hospital stay, CG 9 days (IQR 8 days), PG 9 (5.5), p= 0.851. There was no difference in postoperative renal of cardiac impairment. Procalcitonin was significantly higher (highest postoperative value in first 3 days) in CG, 0.75 mcg/L (IQR 3.19mcg/L), than in PG 0.3 mcg/L (0.88 mcg/L), p= 0.001. Patents in PG received larger intraoperative amount of fluids; median intraoperative fluid balance +1300 ml (IQR 1063ml) than CG; +375 ml (IQR 438ml), pConclusions: There was no difference in postoperative morbidity or hospital stay. Median postoperative value of procalcitonin was significantly higher in CG and was above laboratory reference range. There were significant differences in intraoperative fluid management.Trial registration: ClinicalTrials.gov, NCT02293473, Registered June 10, 2014, https://clinicaltrials.gov/

Objective The consumption of opioid analgesics could be reduced by the use of analgesics with different mechanisms of action. We investigated whether additional treatment with dexmedetomidine or lidocaine could reduce opioid consumption. Methods We randomized 59 study participants into three groups and examined: (i) fentanyl consumption, (ii) consumption of piritramide, and (iii) cognitive function and neuropathic pain. The control group received continuous propofol infusion and fentanyl boluses. Continuous intravenous infusion of dexmedetomidine (0.5 µg/kg/h) was administered to the dexmedetomidine group and lidocaine (1.5 mg/kg/h) was administered to the lidocaine group. Results No reduction in fentanyl consumption was observed among the groups. However, we noted a significantly lower consumption of piritramide on the first and second postoperative day in the lidocaine group. Total consumption of piritramide was significantly lower in the lidocaine group compared with the control group. Conclusions Lidocaine and dexmedetomidine reduced intraoperative propofol consumption, while lidocaine reduced postoperative piritramide consumption. Clinical trial registration: NCT02616523

© 2017 European Society of Anaesthesiology. All rights reserved., Procedural sedation and analgesia (PSA) has become a widespread practice given the increasing demand to relieve anxiety, discomfort and pain during invasive diagnostic and therapeutic procedures. The role of, and credentialing required by, anaesthesiologists and practitioners performing PSA has been debated for years in different guidelines. For this reason, the European Society of Anaesthesiology (ESA) and the European Board of Anaesthesiology have created a taskforce of experts that has been assigned to create an evidence-based guideline and, whenever the evidence was weak, a consensus amongst experts on: the evaluation of adult patients undergoing PSA, the role and competences required for the clinicians to safely perform PSA, the commonly used drugs for PSA, the adverse events that PSA can lead to, the minimum monitoring requirements and post-procedure discharge criteria. A search of the literature from 2003 to 2016 was performed by a professional librarian and the retrieved articles were analysed to allow a critical appraisal according to the Grading of Recommendations Assessment, Development and Evaluation method. The Taskforce selected 2248 articles. Where there was insufficiently clear and concordant evidence on a topic, the Rand Appropriateness Method with three rounds of Delphi voting was used to obtain the highest level of consensus among the taskforce experts.These guidelines contain recommendations on PSA in the adult population. It does not address sedation performed in the ICU or in children and it does not aim to provide a legal statement on how PSA should be performed and by whom. The National Societies of Anaesthesiology and Ministries of Health should use this evidence-based document to help decision-making on how PSA should be performed in their countries. The final draft of the document was available to ESA members via the website for 4 weeks with the facility for them to upload their comments. Comments and suggestions of individual members and national Societies were considered and the guidelines were amended accordingly. The ESA guidelines Committee and ESA board finally approved and ratified it before publication.

The anesthesiologic technique, where substances are injected intravenously, is known as total intravenous anesthesia (TIVA). The anesthesiologist’s task is to carefully assess the depth of anesthesia (DoA) and adjusts the injection of intravenous anesthetic agents accordingly. In the paper, we present a framework for studying DoA dynamics within the Matlab-Simulink environment. DoA can be indirectly measured by bispectral index (BIS index), which is calculated from appropriate electroencephalographic (EEG) signals, and is assumed to be influenced primarily by inflow of propofol. The 3-compartmental model is presented and the 4th (virtual) compartment dealing with the effect-site model is introduced. Next, the pharmacodynamic model structure is presented and the BIS-index effect output is formulated. The relevant parameters based on patient’s age, weight, height and gender are established. The model is verified by comparing the simulation results to the data obtained during an actual target-controlled anesthetic application of intravenously administered propofol (total duration approx. 70 minutes). The data were recorded by an Orchestra Base Primea infusion workstation and a Lidco monitor. The data parser and the model developed in the Matlab-Simulink environment provide a basis for further refining the dynamic model and for development and validation of closed-loop control approaches for DoA. The presented model allows conducting simulations and tests of various scenarios of propofol administration within the Matlab-Simulink environment with the goal of a deeper insight into the mechanisms of DoA dynamics. This will lead to better administration methods that will benefit the patient, relieve the workload and allow the anesthesiologist to focus on the critical aspects of the procedure.

Animal studies suggest that dynamic predictors remain useful in patients with pneumoperitoneum, but human data is conflicting. Our aim was to determine predictive values of pulse pressure variation (PPV) and stroke volume variation (SVV) in patients with pneumoperitoneum using LiDCORapid™ haemodynamic monitor. Standardised fluid challenges of colloid were administered to patients undergoing laparoscopic procedures, one fluid challenge per patient. Intra-abdominal pressure was automatically held at 12 mmHg. Fluid responsiveness was defined as an increase in nominal stroke index (nSI) ≥ 10%. Linear regression was used to assess the ability of PPV and SVV to track the changes of nSI and logistic regression and area under the receiver operating curve (AUROC) to assess the predictive value of PPV and SVV for fluid responsiveness. Threshold values for PPV and SVV were obtained using the “gray zone” approach. A p

Importance Morbidity is still high in pancreatic surgery, driven mainly by gastrointestinal complications such as pancreatic fistula. Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are frequently used for pain control after pancreatic surgery. Evidence from a post hoc analysis suggests that PCIA is associated with fewer gastrointestinal complications. Objective To determine whether postoperative PCIA decreases the occurrence of gastrointestinal complications after pancreatic surgery compared with EDA. Design, Setting, and Participants In this adaptive, pragmatic, international, multicenter, superiority randomized clinical trial conducted from June 30, 2015, to October 1, 2017, 371 patients at 9 European pancreatic surgery centers who were scheduled for elective pancreatoduodenectomy were randomized to receive PCIA (n = 185) or EDA (n = 186); 248 patients (124 in each group) were analyzed. Data were analyzed from February 22 to April 25, 2019, using modified intention to treat and per protocol. Interventions Patients in the PCIA group received general anesthesia and postoperative PCIA with intravenous opioids with the help of a patient-controlled analgesia device. In the EDA group, patients received general anesthesia and intraoperative and postoperative EDA. Main Outcomes and Measures The primary end point was a composite of pancreatic fistula, bile leakage, delayed gastric emptying, gastrointestinal bleeding, or postoperative ileus within 30 days after surgery. Secondary end points included 30-day mortality, other complications, postoperative pain levels, intraoperative or postoperative use of vasopressor therapy, and fluid substitution. Results Among the 248 patients analyzed (147 men; mean [SD] age, 64.9 [10.7] years), the primary composite end point did not differ between the PCIA group (61 [49.2%]) and EDA group (57 [46.0%]) (odds ratio, 1.17; 95% CI, 0.71-1.95P = .54). Neither individual components of the primary end point nor 30-day mortality, postoperative pain levels, or intraoperative and postoperative substitution of fluids differed significantly between groups. Patients receiving EDA gained more weight by postoperative day 4 than patients receiving PCIA (mean [SD], 4.6 [3.8] vs 3.4 [3.6] kg;P = .03) and received more vasopressors (46 [37.1%] vs 31 [25.0%];P = .04). Failure of EDA occurred in 23 patients (18.5%). Conclusions and Relevance This study found that the choice between PCIA and EDA for pain control after pancreatic surgery should not be based on concerns regarding gastrointestinal complications because the 2 procedures are comparable with regard to effectiveness and safety. However, EDA was associated with several shortcomings. Trial Registration German Clinical Trials Register:DRKS00007784

Background: Perioperative thoracic epidural analgesia (EDA) and patient-controlled intravenous analgesia (PCIA) are frequently used for pain control after pancreatic surgery. However, there is substantial uncertainty regarding the postoperative morbidity associated with these two strategies. Evidence from a post-hoc analysis suggests that PCIA is associated with fewer gastrointestinal complications. Therefore, we designed the multicentre PAKMAN trial to compare the occurrence of gastrointestinal complications after pancreatic surgery with PCIA versus EDA. Methods: We conducted an adaptive, pragmatic, randomised, controlled, international, multicentre, superiority trial in nine European pancreatic surgery centres. Adult patients scheduled for elective pancreatic surgery were randomised to general anaesthesia with postoperative PCIA or general anaesthesia with intra- and postoperative EDA. The primary endpoint was a composite of pancreatic fistula, bile leakage, delayed gastric emptying, gastrointestinal bleeding, or postoperative ileus within 30 days after surgery. The trial was prospectively registered (DRKS00007784). Findings: Between 30 June 2015 and 1 October 2017, 371 patients were randomly assigned to PCIA (n=185) or EDA (n=186); 248 patients (124 in each group) were analysed. The primary composite endpoint did not differ between the two groups (OR 1⋅174, 95% CI 0⋅707-1⋅949; p=0⋅536). Neither individual components of the primary endpoint nor 30-day mortality, postoperative pain levels, or intra- and postoperative substitution of fluids differed significantly. Patients with EDA gained more weight by postoperative day 4 and received more vasopressors. The failure rate of EDA was 18⋅5%. Interpretation: The choice between PCIA and EDA for pain control after pancreatic surgery should not be based on concerns regarding gastrointestinal complications. The two procedures are comparable with regard to effectiveness and safety. However, EDA was associated with several shortcomings. Trial Registration: The PAKMAN trial was registered with the German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS; number DRKS00007784) on 23 March 2015. Funding Statement: Dietmar Hopp Stiftung gGmbH, Raiffeisenstr. 51, 68789 St. Leon-Rot, Germany (project number 23011217). Declaration of Interests: All authors declare that they have no conflicts of interest in relation to this trial. None of the authors has had any financial and personal relationships with funding bodies or any other people or organisations that could inappropriately influence their work within this project. Ethics Approval Statement: The PAKMAN trial protocol and other relevant documents were approved by the ethics committee of the Medical Faculty of Heidelberg University and the individual ethics committees of all other participating institutions before the first patient was enrolled. The trial was conducted in accordance with the ethical principles of the Declaration of Helsinki and the principles of Good Clinical Practice (ICH-GCP E6). Reporting of the trial complied with the recommendations of the CONSORT statement.

The manuscripts is this issue were presented at the joint 7th Croatian congress of regional anaesthesia and analgesia with international participation held on June 14.-15, 2019, School of Medicine University of Zagreb, Croatia. Content of Supplement are: Holistic Approach to the Immunobiology of Aging (view on the turn of millenium), Dexamethasone - Intrathecal Minimiser of Simple Haemathologic Stress Biomarkers in Hip Fracture, Comparison of Plexus Brachial Blockade Effect by Supraclavicular and Axillary Approach - our Experience, Influence of Local Infiltration Analgesia on Postoperative Pain in Abdominoplasty Patients, The Anatomy of Orofacial Innervation, The Role of Paravertebral Blocks in Ambulatory Surgery: Review of the Literature, Regional Anaesthesia for Neurosurgery, Local Anesthetics and Steroids: Contraindications and Complications. (Over) view of the clinical problems, Impact of Local Infiltration Anesthesia on Postopertive Pain Management after Rhinoplasty in Day Care Surgery, Comparison of Different Surgical Procedures with Local Infiltration Analgesia in Day Surgery, Ultrasound Skills in Lower Extremity Traumatology and Orthopedics – Regional Anesthesia and Beyond, Spinal Anaesthesia-induced Hypotension in Obstetrics: Prevention and Therapy, Regional Anaesthesia in Thoracic and Abdominal surgery, Regional Analgesia Modalities in Abdominal and Lower Limb Surgery - Comparison of Efficacy, Applications and Critical Evaluation of Fascia Iliaca Compartment Block and Quadratus Lumborum Block for Orthopaedic Procedures, Medico - Legal Responsibility in Management of Acute and Chronic Pain in Obstetric.Epidural Analgesia in Multipy Injured Patients with Severe Chest Trauma: -Two Case Reports and Literature Review

Surgical procedure causes tissue damage which activates systemic inflammatory response and leads to changes in endocrine and metabolic system. Anaesthesia and pain can further disrupt immune performance. Regional anaesthesia causes afferent nerve blockade and in this way mediates immune protection. Thoracic epidural analgesia is the cornerstone of pain relief in thoracic and abdominal surgery. Alternatively thoracic paravertebral block can be used with less side effects and good analgesic properties. Drugs that interfere with blood coagulation obstruct the use of central regional blocks. Surgery has also changed recently from open to minimally invasive. Also pain treatment for this procedures has changed to less aggressive, systemic or locoregional techniques. It was shown that transversus abdominis plane block and epidural analgesia have the same effect on postoperative pain, but transversus abdominis plane block was better regarding hemodynamic stability and hospital stay. Multimodal approach combining regional and systemic analgesia is currently the most appropriate perioperative pain management strategy. More studies should be done to give recommendations., Kirurški zahvat uzrokuje tkivno oštećenje koje aktivira sistemski upalni odgovor i dovodi do promijena u endokrinom i metaboličkom sustavu pacijenta. Anestezija i bolovi mogu još dodatno utjecati na imunološki sustav. Regionalna anestezija uzrokuje aferentnu blokadu živaca i time dovodi do zaštite imunološkoga sustava. Torakalna epiduralna analgezija je zlatni standard za liječenje bolova u torakoabdominalnoj kirurgiji. Alternativna tehnika je torakalni paravertebralni blok koji ima manje nuspojava i dobar analgetski učinak. Antikoagulantni lijekovi ograničavaju upotrebu centralnih živčanih blokova. Kirurške se tehnike mijenjaju u smjeru minimalno invazivnih kirurških tehnika. Isto tako tehnike liječenja bolova se mijenjaju prema upotrebi manje agresivnih sistemskih i lokoregionalnih tehnika. Studije su pokazale da su “transversus abdominis block” (TAP) i epiduralna analgezija jednako učinkoviti u liječenju postoperativnih bolova, s tim da se kod TAP blokova puno rjeđe pojavljuje pad krvnoga tlaka i da je vrijeme hospitalizacije kraće. Multimodalni pristup s kombinacijom regionalne i sistemske analgezije je trenutno najbolja tehnika za liječenje perioperativnih bolova. Potrebna su dodatna istraživanja da bi se izradile smjernice.

We present our position statement for the use of sugammadex, a specific binder for aminosteroid muscle relaxants, in the most common clinical circumstances (in the case of an emergency intubation, when the patient cannot be ventilated or intubated; in patients with neuro-muscular disease, in patients with liver failure, in patients with renal failure, in patients with allergic reaction to sugammadex or to rocuronium, in cases of residual muscle relaxation and when we have to use a muscle relaxant short time after sugammadex application). Sugammadex is the drug of choice in cases of cardiac arhythmia, COPD, asthma, neuro-muscular diseases, pathological obesity, intraoperative use of continuous infusion of aminoglycoside muscle relaxants. It is therefore necessary to control the neuro-muscular block during surgery due to different response of patients to the muscle relaxant. Clinical tests alone are not an adequate substitute for objective control of muscular strength recovery.

To compare the effects of paravertebral analgesia with levobupivacaine or bupivacaine on intra- and postoperative pain for thoracic surgery.A prospective, randomized, and double-blinded study.A university hospital.Forty patients undergoing thoracic surgery.Patients received paravertebral catheterization and a bolus (14-20 mL) of 0.5% bupivacaine (n = 20) or 0.5% levobupivacaine (n = 20) with morphine, 60 μg/kg, before the induction of general anesthesia that consisted of a propofol infusion. A paravertebral continuous infusion (0.05 mL/kg/h) of 0.25% bupivacaine or 0.25% levobupivacaine, 100 mL, with added morphine, 10 mg, and clonidine, 0.15 mg, was started at the end of surgery for 72 hours postoperatively. Postoperative rescue diclofenac analgesia was available if required.The primary outcome was intraoperative fentanyl consumption. Static and dynamic pain scores measured by a visual analog scale were assessed regularly. Intraoperative fentanyl consumption was significantly lower in the levobupivacaine group compared with the bupivacaine group (p = 0.001). On all 3 postoperative days, static pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group (p0.05). Dynamic pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group during the 2 postoperative days (p0.05). A smaller proportion of patients in the levobupivacaine group used rescue analgesia (p0.005).Paravertebral analgesia with levobupivacaine resulted in less intraoperative fentanyl consumption, lower static (3 days) and dynamic (2 days) pain scores, and less rescue analgesia than analgesia with bupivacaine.

Acute injuries of the tracheobronchial system are rare and life-threatening situations. Tracheal rupture most commonly occurs after blunt trauma to the chest. It is a rare but most concerning immediate complication of intubation. One-lung ventilation is required in lung surgery. Video assisted thoracoscopic procedures are an absolute indication for one-lung intubation. The double-lumen tube is the mainstay of one lung ventilation. Due to their larger size and rigidity, double lumen tubes are more difficult to insert, and complications are more common than with single lumen tubes. Opinions about the need for checking routinely the position of a double lumen tube by fiber optic bronchoscopy directly after intubation are divided. A 69-year-old woman with epidermoid lung carcinoma was scheduled for video assisted thoracoscopic left upper pulmonary lobectomy under general anaesthesia. The patient was prepared for the operation and itubated with the Carlens double lumen tube as usual. On introducing the camera into the thoracic cavity, the surgeon noted that the lungs were not completely collapsed. During blind adjustment the position of the tube the trachea was ruptured. The right-sided thoracotomy was performed and closed the greater part of the tracheal laceration. Only its upper 1.5-cm segment was surgically inaccessible because of the anatomical situation and thus remained unsutured. The patient received antibiotics, continuous airway humidification, analgesia with piritramide, and chest physiotherapy. She had no complications. In the literature, opinions about checking routinely the position of a double lumen tube by fiber optic bronchoscopy are divided.. Possibly, the very serious complication encountered in our patient could have been avoided, had the tube position been checked by bronchoscopy. The treatment strategy for post-intubation tracheal rupture depends on the size and location of the rupture, its clinical presentation, and the overall condition of the patient). Early surgical repair is the treatment of choice for most patients when a transmural tear with a length exceeding 2 cm. In our the combination of surgical and conservative treatment was performed. The uppermost part of the tear could not be sutured because of the anatomical situation, and so about 1.5 cm of the trachea remained open. The case is interesting from many perspectives. It shows that intubation with a Carlens tube is a potentially hazardous procedure, which should be performed only by experienced anaesthesiologists. Furthermore, our case report underscores the importance of checking routinely the position of a double lumen tube by fiber optic bronchoscopy. It provides evidence that minor tracheal lacerations can be successfully managed by conservative measures.

Background: To avoid large dose opioids, the authors investigated an alternative method for postoperative pain relief after Port Access cardiac surgery. Methods: Out of 104 patients who underwent Port Access heart surgery, 78 patients who were extubated in the operating room were enrolled in the retrospective study. The standardized fast track cardiac anesthesia was used for all patients, and the catheter was placed in the surgical wound at the end of the operation. Analgesia was started with a bolus of bupivacaine (B group) or ropivacaine (R group) through the catheter and followed by continuous infusion of local anesthetic. The variables recorded were visual analogue scale (VAS) at extubation and during the first 24 hours, additional requirements of local anesthetic (LA), and opioid analgetic. Possible complications that could be connected with the catheter in the wound or with the administration of LA were recorded as well. Results: There was no statistical difference between the R and B groups in mean pain score at extubation and in the first 24 hours. The groups were also comparable concerning the need for bolus application of the LA and opioid analgetic. The microbiological analysis of 9 randomly chosen catheter tips from both groups was sterile. Conclusion: Both local anesthetics, ropivacaine and bupivacaine, are equally effective for pain relief after Port Access cardiac surgery. The catheter in surgical incision and application of LA through it does not increase the risk for wound infection and does not interfere with wound healing.

The purpose of this randomised, single-centre study was to prospectively investigate the impact of anaesthetic techniques for craniotomy on the release of cytokines IL-6, IL-8, IL-10, and to determine whether intravenous anaesthesia compared to inhalational anaesthesia attenuates the inflammatory response. The study enroled 40 patients undergoing craniotomy, allocated into two equal groups to receive either sevoflurane (n = 20) or propofol (n = 20) in conjunction with remifentanil and rocuronium. The lungs were ventilated mechanically to maintain normocapnia. Remifentanil infusion was adjusted according to the degree of surgical manipulation and increased when mean arterial pressure and the heart rate increased by more than 30 % from baseline. The depth of anaesthesia was adjusted to maintain a bispectral index (BIS) of 40–60. Invasive haemodynamic monitoring was used. Serum levels of IL-6, IL-8 and IL-10 were measured before surgery and anaesthesia, during tumour removal, at the end of surgery, and at 24 and 48 h after surgery. Postoperative complications (pain, vomiting, changes in blood pressure, infection and pulmonary, cardiovascular and neurological events) were monitored during the first 15 days after surgery. Compared with patients anaesthetised with sevoflurane, patients who received propofol had higher levels of IL-10 (p = 0.0001) and lower IL-6/IL-10 concentration ratio during and at the end of surgery (p = 0.0001). Both groups showed only a minor response of IL- 8 during and at the end of the surgery (p = 0.57). Patients who received propofol had higher levels of IL-10 during surgery. Neither sevoflurane nor propofol had any significant impact on the occurrence of postoperative complications. Our findings should incite future studies to prove a potential medically important anti-inflammatory role of propofol in neuroanaesthesia. Identified as NCT02229201 at www.clinicaltrials.gov

Background The use of cardiac output monitoring may improve patient outcomes after major surgery. However, little is known about the use of this technology across nations. Methods This is a secondary analysis of a previously published observational study. Patients aged 16 years and over undergoing major non-cardiac surgery in a 7-day period in April 2011 were included into this analysis. The objective is to describe prevalence and type of cardiac output monitoring used in major surgery in Europe. Results Included in the analysis were 12,170 patients from the surgical services of 426 hospitals in 28 European nations. One thousand four hundred and sixteen patients (11.6 %) were exposed to cardiac output monitoring, and 2343 patients (19.3 %) received a central venous catheter. Patients with higher American Society of Anesthesiologists (ASA) scores were more frequently exposed to cardiac output monitoring (ASA I and II, 643 patients [8.6 %]; ASA III–V, 768 patients [16.2 %]; p

Introduction.The maintainaning of optimal perioperative fluid and electrolyte balance in the perioparative period (before, during and after an operation) is a crucial for anaesthesia and intensive therapy. Fluid treatment interferes with the metabolism and functioning of all organ systems, therefore it is important that the patient gets the right type and quantity of fluid at the right time. Perioperative fluid therapy should be guided by the patient’s condition and type of the operation procedure. In fluid therapy, one should take into consideration the need for fluid maintenance (basal metabolism needs), preoperative fluid loss correction (e.c. duration of preoperative starving, especially in children), and aim for good tissue perfusion with an adequate fluid load. The final goal of fluid replacement is to maintain fluid and electrolyte balance, intravascular volume and consequently cardiovascular stability (adequate cardiac output), organ perfusion and tissue oxygenation. Before, during and after surgery balanced fluids should be used, in order to minimise disturbances to the electrolyte balance. In our article, literature of perioperative fluid replacement is reviewed. The results of the latest research have provoked a lot of criticism and disagreement about colloids. Only guidelines about crystalloid application are presented.Conclusions. The latest guidelines for perioperative fluid therapy emphasise the application of balanced intravenous fluids that minimise electrolyte and acid base balance disturbances. It is important to individualise the amount of the intravenous fluid to avoid hyper- or hypovolemia. The correct choice of the type of solution is equally important as any other medication that influences the patient’s outcome.

Launois-Bensaude syndrome, otherwise known as Madelung's disease, is a rare disorder characterized by fatty accumulations of the upper trunk, neck and head, causing serious cosmetic deformity and neck immobility. We report a case of a patient with Launois-Bensaude syndrome who required 4 different airway management strategies during his hospitalization for postoperative complications after an elective surgical excision of a severe neck lipomatosis. Anesthesiologists who treat patients with Madelung's disease should be aware of 2 major problems: difficult airway and increased frequency of postoperative bleeding. A proper choice of airway management technique is therefore necessary, including a safe intubation and extubation plan to reduce the consequences of airway complications.

Major spinal surgery is associated with severe postoperative pain and stress response, bowel dysfunction, and a potential for chronic pain development. Epidural analgesia has been shown to be advantageous compared to intravenous analgesia alone. The aim of the study was to investigate whether postoperative addition of epidural levobupivacaine to intravenous opioid analgesia offers advantage over intravenous opioid analgesia alone. Eighty-one patients scheduled for spinal fusion were enrolled in the study and randomized into two groups. Postoperatively, group A received 0.125% epidural levobupivacaine and group B received saline. Both groups also received intravenous piritramide as a rescue analgesic. Pain intensity, rescue analgesic consumption, blood glucose, cholesterol and cortisol levels, postoperative blood loss, paresthesia, time to first postoperative defecation, and length of hospital stay were recorded. Sixty-eight patients completed the study. The visual analog scale score (mean 2 vs. 4, p = 0.01), consumption ofpiritramide (25 mg vs. 51.5 mg, p = 0.01) and metamizole (1400 vs. 1875 mg, p0.01), incidence of nausea (6% vs. 28% p = 0.02) and blood loss (450 mL vs. 650 mL, p0.05) were significantly lower in group A. Bowel recovery and first postoperative defecation also occurred earlier in group A (6% vs. 45%, p0.01). Blood cortisol, glucose and cholesterol levels and the incidence of paresthesia did not differ between the groups. In conclusion, after spinal fusion, postoperative epidural administration of levobupivacaine provides better analgesia and fewer side effects with no impact on stress response.

Background. For some surgical proce-dures a higher sensory block is needed. However, it is complicated by a higher in-cidence of hypotension, more bradycardia and nausea and a higher use of vasoactive drugs. In elderly and obstetric population complications have been attributed to the decrease in cardiac output and systemic vascular resistance, especially in a high block (above Th6). The aim of our study was to find the incidence of hypotension and bradycardia after a spinal anaesthesia in young, healthy patients. As young pa-tients compensate more, we aimed to find the difference in haemodynamic variables between the group with a high and the group with a low spinal block and the un-derlying mechanisms of hypotension. Methods. In a prospective, randomized study 44 American Society of Anaesthe-siologists (ASA) 1 patients scheduled for knee arthroscopy under spinal anaesthe-sia were randomly distributed to a high (group H) and a low (group L) spinal block group. In a group H patients were placed into horizontal, whereas in a group L in 15-degree anti-Trendelenburg posi-tion immediately after the spinal block. Haemodynamic parameters were meas-ured continuously noninvasively from 10 min before to 25 min after the spinal block using the CNAPTM device with the LiD-CORapid monitor.Results. The differences in haemodynamic parameters between the groups were not statistically significant at all measured times despite a significant difference in the spinal block level (18.5 vs 13.3 dermato-mes above S5, p

Management of difficult airway is one of the most challenging tasks for anesthesiologists, and failure of securing it could have fatal consequences. We must be prepared to deal with problems in management of difficult airway at any time. Difficult intubation can either be anticipated or unanticipated. An anesthesiologist must be aware of the possibility of both situations to arise and preparations must be taken to deal with such cases and improve the safety of our patients. Practice guidelines are systematically developed recommendations that help anesthesiologists in the management of difficult airway.

The number of indications for lung collapse during different procedures is rising. Difficult upper airway is more often encountered with the need for single lung ventilation. In patients with difficult airway, the safest approach is by placing a single-lumen endotracheal tube with the aid of a flexible fiberoptic bronchoscope. Lung isolation in these patients is then achieved by means of a bronchial blocker. An alternative technique is exchanging the single-lumen for a double-lumen tube using an airway exchange catheter. When there is a tracheostomy in place, an independent bronchial blocker is recommended.

Background: Epidural analgesia can result in perioperative hypotension in patients having thoracotomy. This randomized prospective study assessed the effects of epidural and paravertebral analgesia on hemodynamics during thoracotomy. Methods: Thirty-two patients were randomized to receive either epidural analgesia (n = 16, 0.25% levobupivacaine and 30 μg/kg morphine) or paravertebral block (n = 16; 0.5% levobupivacaine and 30 μg/kg morphine). Oxygen delivery, stroke volume and systemic vascular resistance indices, heart rate, and mean arterial pressure measurements were performed before administration of local anesthetic, after induction of general anesthesia, institution of 1-lung ventilation, first skin incision, retractor placement, lung-inflation maneuver, and at last skin suture. The primary end point was the volume of the colloid infusion necessary to maintain oxygen delivery index of 500 mL/min per squared meter or higher. Postoperative analgesia was provided immediately after surgery by an infusion of 0.125% levobupivacaine and 20 μg/mL morphine in epidural/paravertebral infusion. Pain, rescue-analgesia consumption, arterial pressure, and heart rate were recorded at 6, 24, and 48 hrs after surgery. Administration of anesthesia and data collection were done by research staff blinded to the regional analgesia technique. Results: The groups did not differ significantly in heart rate, mean arterial blood pressure, or systemic vascular resistance indices. However, to maintain the targeted oxygen delivery index, a greater volume of colloid infusion and phenylephrine were required, respectively, in the epidural than in the paravertebral group (554 ± 50 vs 196 ± 75 mL, P = 0.04; and 40 ± 10 vs 17 ± 4 μg, P = 0.04). Pain intensity before and after respiratory physiotherapy as well as 24 hr rescue piritramide consumption was similar in the epidural (4.1 ± 3.1 mg) and the paravertebral (2.5 ± 1.5 mg) groups (P = 0.14). Systolic blood pressure after 24 and 48 hrs was lower in the epidural group. Conclusions: Under the conditions of our study, continuous paravertebral block resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients having thoracotomy. Paravertebral block also required smaller volume of colloids and vasopressors to maintain the target oxygen delivery index (DO2I).

Inhalation induction with sevoflurane would appear to offer several objective advantages compared to induction with propofol. In our study, the hemodynamic results of sevoflurane vs. propofol induction in patients undergoing thoracotomy were studied. In a prospective, randomized, blinded study 24 patients were randomly allocated to one of 2 groups: sevoflurane (S) and propofol (P) (n=12 each). For hemodynamic monitoring the LIDCO plus system was used. Patients in group S were induced into anaesthesia with sevofluran, remifentanil and vecuronium, whereas patients in group P with propofol, remifentanil and vecuronium. The anaesthesia was maintained with the same agents. Hemodynamic stability was guided using a special algo-rithm. The goal was oxygen delivery index (DO2I) > 500 mL min-1 m-2. According to the algorithm, patients received colloids or vasoactive drugs. Hemodynamic parameters were recorded before induction, 3 minutes after induction and 3 minutes after intubation and commencement of one lung ventilation. The consumption of vasoactive drugs and colloids and the time from the beginning of induction to intubation were documented. No statistically significant differences in measured hemodyna-mic parameters, remifentanil and colloid consumption between the S and P group were found. In group P, statistically more ephedrine was used (S: 4.2, P:20.8, p

Objective: In this retrospective study, we evaluated the "fast-track" recovery protocol for endoscopic Port Access™ (PA) (Edwards Lifesciences) heart procedures. We also determined which factors and variables are important for the success of immediate extubation at the end of the operation while the patient is still in the operating room (OR).Methods: In the study, we included 104 patients scheduled for PA heart surgery under cardioplegic arrest. All patients were marked before surgery for the fast-track recovery protocol. If the patients fulfilled the extubation criteria within 10 to 15 minutes after the end of operation, they were extubated in the OR (OR group); the others were transferred to the intensive care unit (ICU) (ICU group) and extubated later. The 2 groups were compared with respect to preoperative and intraoperative variables that could influence early extubation, postoperative complications, duration of ICU stay, and hospital stay.Results: Seventy-eight patients (75%) were extubated in the OR. The patients from the OR group had significantly lower EuroSCOREs than the patients from the ICU group (P = .025). The variables of vital capacity (P = .001) and forced expiratory volume in the first second (FEV1) (P < .001) were significantly higher preoperatively in the OR group than in the ICU group. There were no significant differences between the groups with respect to intraoperative characteristics. Postoperative complications were fewer in the OR group. The mean duration of ICU stay was significantly shorter in the OR group than in the ICU group (P < .001).Conclusions: Immediate extubation in the OR after endoscopic cardiac procedures is safe and possible for the majority of patients. The preoperative patient characteristics of Euro-SCORE, vital capacity, and FEV1 influence the success of ontable extubation.

Acute bacterial transverse myelitis, secondary to an epidural catheter, developed in a 49-year-old man who underwent surgery for carcinoma of the left lung. Left pneumonectomy was performed under combined general and epidural (Th6-7) anesthesia. The operative procedure, anaesthesia and early postoperative course were uneventful. On the fifth postoperative day, the patient developed neurological deficits consistent with high-level paraplegia. Elevated inflammatory parameters along with the results of cerebrospinal fluid analysis and magnetic resonance imaging were suggestive of acute transverse bacterial myelitis of the dorsal part of the spinal cord secondary to epidural analgesia. Despite prompt antibiotic therapy, anti-oedema treatment and rehabilitation, the neurological deficit failed to resolve.

Background Minimally invasive parathyroidectomy (MIP) can be performed under cervical plexus block (CPB). Superficial CPB has been reported to be easier to perform with similar efficacy and less anesthesia-related complications than combined deep and superficial CPB. In this study, we compared the efficacy of superficial and combined (deep and superficial) CPB in patients undergoing MIP. Methods Forty-two patients with primary hyperparathyroidism due to a solitary adenoma were randomized to receive either a superficial (group superficial, n = 20) or a combined deep and superficial CPB (group combined, n = 22) using 0.35 mL/kg of 0.5% levobupivacaine. The primary end-point was the amount of supplemental fentanyl required to complete surgery. Results There were no differences in onset of block, pain scores during surgery, or time to first analgesic request between groups. Fentanyl consumption was similar in both groups, i.e., 50 (0-200) microg in group superficial and 50 (0-100) microg in group combined (P = 0.60). Six patients [1 in group superficial (5%) and 5 in group combined (22.7%)] were converted to general anesthesia for surgically required bilateral neck dissection (P = 0.18). General anesthesia for block failure was reported in three superficial (15%) and two combined group patients (9%) (P = 0.99). In group combined, only one patient (4.5%) showed diaphragmatic paresis after the block (P = 0.99). Conclusion Superficial CPB is an alternative to combined block for MIP.

Study Objective To evaluate the pharmacokinetic profile of 0.35 mL/kg of 0.5% levobupivacaine during superficial and combined (deep and superficial) cervical plexus block (CPB) in patients undergoing minimally invasive parathyroidectomy. Design Prospective randomized study. Setting Operating theater of a university hospital. Patients 12 ASA physical status II and III patients (11 women and 1 man), scheduled for minimally invasive parathyroidectomy. Interventions Seven and 5 patients were randomly assigned to receive either superficial or combined CPB, respectively. The superficial CPB was performed with an injection of 0.35 mL/kg of 0.5% levobupivacaine subcutaneously along the posterior border of the sternocleidomastoid muscle and deeper on its medial surface. The combined CPB was initiated by the deep block at the C3 level vertebra by injecting 0.2 mL/kg of 0.5% levobupivacaine, followed by the superficial block with an injection of the remaining 0.15 mL/kg. After completion of the block, venous blood was sampled at the intervals of 5, 10, 15, 20, 30, 45, and 60 minutes. Measurements and Main Results Venous plasma concentrations were measured using gas chromatography-mass spectroscopy. Mean ± SD of maximal concentrations of levobupivacaine was 0.58 ± 0.41 mg/L in group superficial and 0.52 ± 0.28 mg/L in group combined ( P = 0.71). The median (range) time required to reach the maximal concentrations was 30 minutes (20-30 min) in group superficial and 20 minutes (15-30 min) in group combined ( P = 0.45). The areas under the drug concentration/time curve (AUC 10-60 ) were also similar in both groups. No signs of central nervous system or cardiovascular toxicity or other untoward events were observed in any patient. Conclusion With the given dose regimen, levobupivacaine plasma concentrations were within safe ranges.