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Abstract

Background and Aims: In this study, we aimed to evaluate whether the age or the APACHE-II score was a better predictor of mortality in each group. The secondary objective was to investigate the factors affecting the mortality in each individual age group.

Methods: We designed this retrospective study between 2016-2017. Age groups were classified into 3 classes: Patients < 60 years were Group 1, patients between 60-70 years were Group 2, and patients > 70 years were Group 3. We recorded patients’ age, ICU indication, demographic data, APACHE-II, ASA, length of hospital stays and mortality.

Results: We analysed 150 patients and reported mortality for 58 patients (38.7%). We did not detect any association between age and mortality for all groups. ASA, length of ICU stays and predicted mortality rate, were significantly higher for exitus patients (p < 0.001). The ROC curve for the APACHE-II score, with a cut-off point of 23, demonstrated 74.14% sensitivity, 60.87% specificity, an area under the curve (AUC) of 67.3%, with 4.5% standard deviation (SD). The ODDS ratio for APACHE-II scores was 4.459 (95% CI: 2.167-9.176). For the adjusted mortality rate, ROC analysis identified a cut-off of 60.8 with 70.69% sensitivity, 52.17% specificity, AUC of 61.2% and 4.6% SD. The ODDS ratio for the adjusted mortality rate was 2.631 (95% CI: 1.309-5.287).

Conclusion: We could not demonstrate any correlation between age and mortality. We consider APACHE-II as a valuable scoring system to predict mortality. We do not consider age as a predictor of mortality. Therefore, we do not suggest its use as a sole prognostic marker in ICU patients.

Abstract

We anticipated that bilateral Erector spinae plane (ESP) block, which was applied in 10 patients starting from lower thoracic levels (T9) might provide effective postoperative analgesia in open abdominal hysterectomies. In addition, we aimed to obtain anatomic observation of the local anaesthetic (LA) spread in the ESP block by injecting methylene blue on 4 cadavers. All the patients had excellent pain relief. There was an extensive spread to the erector spinae muscle (ESM) involving several segmental levels on cadavers. We observed the spread of dye on the ventral and dorsal rami in the paravertebral space and as an additional finding, the dye had extended to the canal vertebralis. There was a spread of dye on the dura mater. ESP block can be used with new indications and it is an effective technique for major abdominal surgery when is applied to the lower vertebral levels. Randomized controlled trials are required to explore the clinical implications of our findings.

Abstract

Background and aims. This study aims to identify the extent to which Burnout syndrome is present among medical staff in the anaesthesia and intensive care units in Romania and if there are significant differences dependant on age or sex.

Methods. Maslach Burnout Inventory (MBI), structured in three dimensions: Emotional Exhaustion – 9 items (EE), Depersonalization – 6 items (D) and Reduction of personal achievement – 10 items (RPA), was used for the evaluation of Burnout Syndrome in 275 medical staff in anaesthesia and intensive care physician and nurses from departments in Romania.

Results. Burnout syndrome among medical staff with MBI had a total score of 68 and average scores for all syndrome categories. There were no statistically significant differences dependant on age and sex (p < 0.05, chi-squared test). The logistic regression has highlighted three elements that are risk factors, which belonged to the psycho-emotional sphere, communication abilities and the degree of organization and professional planning (item – I feel at the end of my rope, item – I do not communicate easily with people regardless of their social status and character, and item – I have professional disillusion). The risk factor with the most reliable range was the item “I feel at the end of my rope”.

Conclusion. The level of Burnout syndrome is medium regardless of sex or age category. Possibly, the concern of the ICU medical staff for the psycho-emotional life is not efficient, as well as for identifying/ developing communication abilities. The association between risk factors for burnout syndrome and psycho-emotional life development require further research.

Abstract

Severe chronic pain is often devastating for the affected individuals causing substantial suffering, health impairment, and a very low quality of life, including significant negative consequences for the patient and for society. Patients with complex pain disorders are seen often in relation to anaesthesia. They deserve special attention and require long time hospitalization and multiple contacts with health-care providers after discharge from hospital. A wider adoption of best perioperative and intraoperative pain management practice is required. This paper reviews current knowledge of perioperative and intraoperative pain management and anaesthetic care of the chronic pain patient. The individual topics covered include the magnitude of the problem created by chronic pain, the management of the patients taking various types of opioids, tolerance and opioid induced hyperalgesia and the multidisciplinary approach to pain management. The preventive and preemptive strategies for reducing the opioid needs and chronic pain after surgery are reviewed. The last section includes the role of acute pain services and an example of the implementation of a transitional pain service with the various benefits it offers; for example, the decrease of the opioid dose after discharge from the hospital. Patients also receive the continuity of care, with not only pain relief but also improvements in physical functioning, quality of life and emotional stress.

Abstract

Background: Cerebral oxygen desaturation can arise during various durations of cardiopulmonary bypass (CBP), thus continuous monitoring is necessary. This desaturation may account for distinct neuropsychological deficits. Near-infrared spectrophotometry (NIRS) is a non-invasive method that offers many advantages for monitoring cerebral oxygenation.

Objectives: The aim of this study was to compare the outcome of propofol and dexmedetomidine on cerebral regional oxygen saturation (rScO2) during CPB and on postoperative cognitive dysfunction.

Patients and Methods: 50 patients anticipated for open heart surgeries were encompassed in the study. Patients were divided into 2 groups, group P (receiving propofol) and group D (receiving dexmedetomidine) during CPB. Both groups were studied for variations in right and left rScO2 as well as postoperative cognitive dysfunction using the Mini Mental State Examination Score (MMSE) test.

Results: The results showed no significant difference in both groups of the study, with an increase in rScO2 on the right and left side in T1 compared to T0 and maximum increase in T3-4-5, then a decrease in T6-7. With regard to the cognitive dysfunction there was a decrease in the values at 1 h in both groups without significant difference; after 1 week MMSE values returned to baseline values.

Conclusion: Propofol and dexmedetomidine infusion used during CPB preserve the rScO2 and do not affect the neurological outcome.

Abstract

Background: Accumulating evidence indicates that objective neuromuscular monitoring and pharmacological reversal of neuromuscular block reduces the occurrence of residual muscle paralysis in the acute postoperative phase. However, objective neuromuscular monitoring is not a routine habit in anaesthesia. In order to change this situation, we wished to find out, as a first step to improvement, the current use of neuromuscular monitors and the custom of anaesthetists for reversal of neuromuscular block before tracheal extubation.

Methods A ten-point questionnaire was available via the Surveymonkey website and the link was sent to 2202 Hungarian and Romanian anaesthetists by email.

Results: Three hundred and two (13.7%) of the 2202 registered anaesthetists responded. Less than 10% of them regularly use neuromuscular monitors. They underestimated the occurrence of residual block; only 2.2% gave a correct answer. Neuromuscular monitors are available in 74% of hospitals but are scarcely used. One third of anaesthetists rarely or never use reversal; approximately 20% regularly reverse before extubation. The responders typically believe that clinical signs of residual block are reliable. Instead of monitoring, they use the “timing methods” for tracheal extubation such as time elapsed from last dose, the duration of action of relaxant, the number of top-up doses, the cumulative dose, the return of adequate respiratory tidal volume and the ability to sustain a 5 s head lift.

Conclusions: We concluded that neuromuscular monitoring in these two European countries is suboptimal as is the reversal strategy. Given the fact that monitors are available in the hospitals, the mentality should be changed towards evidence based practice.

Abstract

Background. The classic adductor canal block (ACB) is a regional technique that aims to introduce local anesthetic to the saphenous nerve as it traverses the adductor canal. It offers the benefit of preserved quadriceps strength, and is ideal for rehabilitation. Proximal ACB (PACB) allows the operator to place the block away from the surgical site, permitting preoperative placement. Our primary outcome was total opioid consumption; secondary outcomes included the highest numerical rating scale scores and total gait distance at the indicated time intervals.

Questions/purposes. We asked: 1) Does a Continuous Proximal ACB block with Periarticular knee injection (PACB) provide better analgesia than a Continuous Epidural (CSE)?; 2) Do PACB catheter patients do better with physical therapy compared to CSE patients?; 3) Are PACB patients discharged earlier than CSE patients?

Methods. With IRB approval we performed a retrospective chart review of patients who had underwent primary total knee arthroplasty between October 2015 and September 2016. The selected patients (n = 151) were divided into two groups: CSE group, 72 patients who received a continuous epidural catheter and the PACB group, 79 patients who received at PACB with Periarticular injection. The CSE group received a single-segment combined spinal epidural (CSE) in the operating room. The epidural catheter infusion was started with 0.1% ropivacaine at 8 mL/hour to 14 mL/hour during the post-operative period. The PACB group received a proximal adductor canal catheter with 20 ml of 0.5 % ropivacaine and maintained with ropivacaine 0.2% at 8 ml to 14 ml post operatively. Total opioid consumption, highest numeric rating scores and total gait distance travelled were recorded upon discharge from the PACU and completion of postoperative day (POD) 0, 1, and 2.

Results: We found that the median cumulative morphine consumption was significantly higher in the CSE group compared to the PACB group (194 (0-498) versus 126 (0-354) mg, p = 0.012), a difference that was most notable on POD 1 (84 (16-243) versus 60 (5-370) mg, p = 0.0001). Mean hospital length of stay was also shorter in the PACB group (2.6 ± 0.67 versus 3.0 ± 1.08 days, p = 0.01).

Conclusion: PACB group used significantly lower morphine consumption compared to the CSE group; they were better participants during physical therapy and achieved longer gait distances. The mean hospital length of stay was also shorter in the PACB group

Abstract

Annual implants of cardiovascular implantable devices (CIEDs) are increasing, thus increasing the risk of device exposure. This case presents CIED management issues following traumatic thermal injury. A 59-year-old female presented to intensive care with 42% total body surface area burn involving tissue over her pacemaker generator. Electrophysiologists interrogated and reprogrammed the pacer and observed the patient over 72 hours without pacing. Serratia bacteremia developed and cardiology recommended device removal. The pacemaker generator and leads were removed by cardiothoracic and burn surgery. Postoperatively, asystole required emergency transvenous pacing wire placement. During bacteremia treatment, cardiology planned to pace with an active-fixation screw-in lead with long-term plans to place a single right ventricular chamber leadless pacemaker because of the extensive burns. The patient developed fungemia and the family opted for comfort care. This case report discusses the management of a CIED exposed after a traumatic thermal burn, including device extraction.

Abstract

There has been substantial interest in the use of ketamine for perioperative analgesia. Recently published articles on ‘low dose’ ketamine mark the resurgence in interest in the use of the drug for acute pain. Continued interest in ketamine as an anti-depressant also has opened the door to applications beyond the operating room. In this article, we will review: the history of ketamine’s clinical use; basic ketamine pharmacology; evidence for the use of perioperative ketamine for analgesia; comments on patient selection for ketamine research; a discussion of the safety and side effect profile of ketamine infusions beyond the operating room; and, lastly, ketamine as a treatment option for psychiatric diseases.