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Open access

Iveta Golubovska and Indulis Vanags

Anaesthesia and Stress Response to Surgery

The body reaction to surgery ranges from minor to massive both locally and generally. General response is in the form of widespread endocrinal, metabolic and biochemical reactions throughout the body. Neuro-endocrinal hormone system and inflammation mediators are involved and this process is called "stress response". The response has a compensatory mechanism and provides a maximum chance of survival because of increased cardio-vascular functions, fluid preservation and supply of increased demands for energy generating substrates. If the stress response is prolonged, it may result in exhaustion of essential components of the body, fatigue, decreased resistance, delayed ambulation and increased morbidity and mortality. Suppression of immune defense mechanisms has been demonstrated in the postoperative period. Such immune compromise can affect the postoperative infection rate, healing process, and the rate and size of tumour metastases disseminated during surgery. The mechanism of immunosuppression in the postoperative period is not fully understood. The known mediators of immune depression are neuroendocrine response as well as intravenous opioids and inhalational agents, which have shown to increase the susceptibility to infection through a significant cautions in choosing anaesthetic agents, to minimise harm to the patients. In this paper we review the data about the influence of different anaesthetic agents on neuroendocrine, immune and inflammatory response to surgical stress.

Open access

Kaspars Setlers, Indulis Vanags and Anita Kalēja


A retrospective patient record analysis of the Emergency Medial Service’s Rîga City Regional Centre was provided from January 2012 through December 2013. 1359 adult patients were CPR treated for out-of-hospital cardiac arrest according to ERC Guidelines 2010. A total of 490 patients were excluded from the study. The main outcome measure was survival to hospital admission. Of 869 CPR-treated patients, 60% (n = 521) were men. The mean age of patients was 66.68 ± 15.28 years. The survival rate to hospital admission was 12.9% (n = 112). 54 of survived patients were women. Mean patient age of successful CPR was 63.22 ± 16.21 and unsuccessful CPR 67.20 ± 15.09. At least one related illness was recorded with 63.4% (n = 551) patients. There were 61 survivors in bystander witnessed OHCA and nine survivors in unwitnessed OHCA. The rate of bystander CPR when CA (cardiac arrest) was witnessed was 24.8%. Ventricular fibrillation (VF) as initial heart rhythm was significantly associated with survival to hospital admission in 54 cases (p < 0.0001). Age and gender affected return of spontaneous circulation. Survival to hospital admission had rhythm-specific outcome. Presence of OHCA witnesses improved outcome compared to bystander CPR. The objective of this study was to report patient characteristics, the role of witnesses in out-of-hospital cardiac arrest (OHCA) and outcome of adult cardiopulmonary resuscitation

Open access

Edgars Vasiļevskis, Aleksejs Miščuks and Indulis Vanags

Special Devices for Regional Anaesthesia

The rapid growth of regional anaesthesia in the last 20 years has resulted in an increasing number of technical devices. Technical resources play a very considerable role in modern regional anaesthesia and they are being introduced to facilitate the quality performance of this type of anaesthesia. The task of this survey is to summarise the most important technical devices currently utilised for regional anaesthesia and to provide a review of the history of their introduction. Technical devices for performing regional anaesthesia could be divided in seven groups: 1) neurostimulation and simple needles and catheters; 2) neurostimulator with transcutaneous nerve stimulation (TENS); 3) ultrasonograph with a device to fix the probe; 4) devices for injection of local anaesthetics, such as perfusors, patient controlled analgesia systems and elastomeric infusion systems; 5) arm, leg and instruments supports; 6) regional anaesthesia injection monitor and data register devices, and 7) catheter fastenings and auxiliary materials. It is recommended that all of the apparatus applied should be classified to make it easier to acquire more immediate and understanding, and be easy to add this knowledge to the overall checklist before starting anaesthesia. The history of the introduction of technical equipment shows how much time was necessary for the development of modern regional anaesthesia methods.

Open access

Iveta Golubovska, Peteris Studers and Indulis Vanags

Local Anaesthetics: What Can We Expect More than Pain Relief?

This problem - solving article considers positive and negative non-analgesic actions of local anaesthetics, which may play a significant role in patient morbidity and mortality. Direct impact on inflammatory and immune substances and cells leads to antibacterial, anti-inflammatory, immunomodulating and systemic functions of numerous local anaesthetics. Local anaesthetics used perioperatively locally in continuous infusions or in systemic circulation reach and maintain safe and effective rates, but myotoxic and tissue growth inhibiting effect should be taken in account.

Open access

Agnese Ozolina, Eva Strike and Indulis Vanags

The Predictive Value of Thrombelastography and Routine Coagulation Tests for Postoperative Blood Loss in Open Heart Surgery

Introduction. Hemorrhage after cardiopulmonary bypass remains a clinical problem.

Aim of the Study. Study was performed to compare efficacy of trombelastography (TEG) and routine coagulation tests in relation for postoperative bleeding after cardiac surgery in CPB.

Materials and methods. Forty-seven adult cardiac surgical patients were enrolled in prospective study at Pauls Stradins Clinical University Hospital in 2010. Blood samples for prothrombin time, international normalized ratio, activated partial thromboplastin time (APTT), fibrinogen level, platelet count were collected before surgery, at admission in intensive care unit (ICU) and 6, 12 hours after operation.

Before induction of general anesthesia blood sample was collected to perform kaolin activated TEG (kTEG) and at admission in ICU - kTEG and heparinase- modified kTEG.

Results. Correlation postoperatively was between kTEG reaction time (R) and APTT, as well as heparinase-modified kTEG maximum amplitude (MA) and platelet count. Significant correlation with postoperative bleeding showed heparinase-modified kTEG MA on admission to the ICU.

The highest predictive value preoperatively showed kTEG alpha angle (A), APTT, platelet count and postoperatively kTEG MA, APTT on admission to ICU.

Conclusions. Associated with bleeding are following TEG variables: preoperatively kTEG A, postoperatively kTEG MA and heparinase-modified kTEG MA. APTT and platelet count are also related to postoperative bleeding but to a lesser degree.

Open access

Oļegs Sabeļnikovs, Liene Ñikitina-Zaķe and Indulis Vanags

Association of Interleukin 6 Promoter Polymorphism (-174G/C) with IL-6 Level and Outcome in Severe Sepsis

Interleukin (IL-6) is a key cytokine in the pathogenesis of severe sepsis. The importance of a regulatory polymorphism within the IL-6 promoter remains unclear in these patients. The aim of the study was to determine if IL-6 (-174 G/C) promoter polymorphism has an effect on IL-6 plasma level and outcome of severe sepsis. The study was conducted in general ICU of Stradiñš Clinical University Hospital. A total of 103 critically ill patients with confirmed severe sepsis were prospectively included. Association analysis of the IL-6 (-174C) allele with serum level and clinical outcome was performed. We found no differences in genotype distribution between survivors and nonsurvivors. The serum IL-6 level was significantly higher in nonsurvivors compared with survivors. We found an association of genotype with the IL-6 level in nonsurvivors, but not in survivors. Our findings show a functional significance of IL-6 promoter polymorphisms in nonsurviving severe sepsis patients.

Open access

Irina Evansa, Edgars Vasilevskis, Michail Aron, Inara Logina and Indulis Vanags

Interventional Pain Management using Fluoroscopy and Ultrasound Imaging Techniques

Interventional injection therapies play a major role in the management of various pain conditions and are becoming an integral part of the multidisciplinary therapies required to improve and rehabilitate pain patients. Many of these procedures have historically been performed without imaging guidance. Imaging-guided techniques with fluoroscopy or ultrasound increase the precision of these procedures and help confirm needle placement. Imaging-guided techniques should lead to better results and reduced complication rates and they are now becoming more popular. These improvements are probably due in part also to better patient selection by experienced pain physicians.

Open access

Sniedze Murniece, Indulis Vanags and Biruta Mamaja


Introduction. The adverse effects of hypoxia are well known, especially regarding the brain, and can lead to postoperative cognitive disturbances. On the other hand, the brain is still one of the least monitored organs intraoperatively. Near infrared spectroscopy devices are non-invasive continuous cerebral oxygenation monitoring devices that can also be used intraoperatively.

Prone position used during spinal neurosurgery is of particular importance regarding physiological changes that can occur in the human body and can lead to reduced blood and oxygen supply of the brain.

Aim of the Study. The aim of the study was to determine whether prone position used during spinal neurosurgery impacts cerebral oxygenation and patients’ cognitive performance after the surgery.

Material and methods. 40 patients were included in the study (32 study group, 8 control group). Patients were scheduled for spinal neurosurgery in prone position. All patients received standard general anaesthesia. In the study group regional cerebral oxygen saturation (rScO2) was continuously monitored using INVOS 4100 near infrared spectroscopy device. During the surgery every 5 minutes in study and control group medium non–invasive blood pressure, heart rate, peripheral oxygen saturation, exhaled CO2 and cerebral oxygenation measurements were fixed. We also fixed intraoperative blood loss and duration of the operation. Cognitive function was assessed in both groups using Montreal - Cognitive Assessment (MoCA) scale before surgery and two days after the surgery.

Results. We didn’t observe any significant changes in our calculated medium rScO2 intraoperative values. During induction of anaesthesia when patients were lying supine rScO2 above the right cerebral hemisphere was rScO2 72±9.7%, above the left cerebral hemisphere 71± 9.7%. Cerebral oxygen saturation in prone position was rScO2 R 74±10.7% and rScO2 L 74±10.1%. At the end of the surgery when patients were lying supine again rScO2 R was 74±9.3% and rScO2 L was 74±7.9%.

We didn’t observe any differences in medium MoCA scores when comparing study and control group. MoCA score before surgery in the study group was 24.1±2.9 points and 24.6±4.1 points in the control group. MoCA performed 2 days after the surgery was 24.6 ±3.2 points in study group and 24.6±2.4 points in control group.

Conclusions. No significant changes were observed in medium MoCA scores between patients who intraoperatively received noninvasive cerebral oxygen saturation monitoring and patients who did not receive it.

Despite medium calculated MoCA scores, individually we observed postoperative cognitive function impairment for MoCA 1-2 points in 5 out of 8 patients in the control group, but in the study group only 1 patient out of 32 showed cognitive dysfunction.

Intraoperative regional cerebral oxygen saturation monitoring can help to obviate cerebral desaturation that can lead to postoperative cognitive decline.

Open access

Iveta Golubovska, Pēteris Studers, Inta Jaunalksne and Indulis Vanags

Effects of Different Epidural Analgesic Compositions on Postoperative Pain Relief and Systemic Response to Surgery

Despite many achievements during the last decade, postoperative pain remains the dominant complaint after major surgery and has great potential to be influenced by the anaesthesiologist. Reports suggest that short-term effective anaesthesia and analgesia can have long-lasting beneficial effects on recovery from surgery. The aim of our study is to compare the effect of epidural analgesia, using different compositions, including glucocorticoids (methylprednisolone), and habitual composition of bupivacaine-morphine, in regard to analgesic and anti-inflammatory properties. A total of 129 patients participated in the study in four different treatment groups: patients from Group I received glucocorticoid methylprednisolone succinate and long-acting opioid morphine hydrochloride, Group II received local anaesthetic bupivacaine hydrochloride and morphine hydrochloride, Group III received methylprednisolone succinate and short-acting opioid fentanyl, and Group IV received glucocorticoid methylprednisolone succinate. We obtained good analgesic profiles in all groups. However, significantly better results were achieved using the combination of methylprednisolone and morphine. Epidural methylprednisolone in dose 80 mg/24 h is more effective, compared to the conventional local anaesthetics-opioid composition, when administered as a part of multimodal preventive postoperative analgesia after major joint replacement surgery. Epidural methylprednisolone has a reliable anti-inflammatory and immunomodulatory potential. It attenuates profiles of acute inflammatory response markers as Interleukin-6 and C-reactive protein and stress hormone cortisol. The novelty of this study was application of epidural glucocorticoids for acute postoperative pain relief as part of daily perioperative care. By developing studies on anti-inflammatory and immunomodulatory properties of glucocorticoids, we expect to improve patient rehabilitation in the postoperative period.

Open access

Anita Kaleja, Elina Snucina and Indulis Vanags


Introduction.Survival rate among patients with cardiac arrest remains unclear. Return of spontaneous circulation (ROSC) is just the first step toward the goal of complete recovery from cardiac arrest. It depends on quality of cardiopulmonary resuscitation (CPR) during resuscitation and factors of postresuscitation care. Regular CPR analysis has not been carried out in Latvia.

Aim of the study was to evaluate survival rate among patients with out-of-hospital cardiac arrest and in-hospital cardiac arrest.

Materials and methods. The study was conducted in the State Emergency service of Latvia and Pauls Stradins Clinical University Hospital during 15 months in 2010/2011. There were 221 adult patients with in-hospital cardiac arrest and 162 adult patients with out-of-hospital cardiac arrest and performed CPR included in retrospective research. The information was analyzed by medical records. The obtained results were expressed in percents and compared, using the Pearson’s Chi-square (Pearson χ2) test.

Results. The short-term ROSC was achieved among patients with out-of-hospital cardiac arrest (OHCA) in 62 cases and among patients with in-hospital cardiac arrest (IHCA) in 186 cases. Survival to discharge was achieved in 20.3% among patients with OHCA and 15.8% among patients with IHCA. The most commonly used CPR algorithm was pulseless electrical activity/asystole (72 - 73%). Short-term ROSC was achieved most frequently by ventricular fibrillation/pulseless ventricular tachycardia (41.3-56%), but the largest number of unsuccessful CPR episodes was observed by pulseless electrical activity/ asystole.

Conclusion. Results of CPR were different among patients with OHCA and IHCA. ROSC is rhythm-specific outcome.