Summary

Background: In this prospective, randomized, double-blind, controlled study, we investigated the sensory, motor and analgesic block characteristics of S(+) ketamine, fentanyl and saline given intrathecally (IT) in addition to 0.5% plain bupivacaine (10 mg) for spinal analgesia. Methods: Ninety ASA I or II adult patients undergoing Caesarean section were randomly allocated to receive 1.0 mL of 0.9% saline in Group S (n = 30), 0.05 mg kg−1 of S(+) ketamine (1.0 mL) in Group K (n =30) or 25 μg (1.0 mL) of fentanyl in Group F (n =30) following 10 mg of plain bupivacaine 0.5% IT. We recorded onset and duration of sensory and motor block, time to reach the maximal dermatomal level of sensory block and duration of spinal analgesia. Results: The onset time of sensory and motor block was significantly shorter in Groups K and F than in Group S (P < 0.014). Their duration was significantly longer in Group F than in Groups K and S (P < 0.009). The time to reach the maximal dermatomal level of sensory block was significantly shorter in Groups K and F than in Group S (P < 0.001). The duration of spinal analgesia was significantly longer in Group F than in Groups K and S (P < 0.001). Conclusion: In patients undergoing Caesarean section with spinal analgesia, the addition of S(+) ketamine (0.05 mg kg−1) IT to 10 mg of spinal plain bupivacaine (0.5%) led to rapid onset of both sensory and motor blockade and enhanced the segmental spread of spinal block without prolonging the duration of spinal analgesia, whereas fentanyl provided prolonged analgesia.

The aim of this prospective, randomized and double-blind study was to assess the effects of a high dose of the analgesic tramadol administered at the conclusion of surgery on extubation time, sedation, and post-anaesthetic shivering. Forty adult patients, ASA physical status I or II, underwent laparoscopic surgery of about 1 h duration and received a standardized anaesthesia that was maintained with isoflurane in O2/N2O. Tramadol 3mg kg−1 (n=20) was administered intravenously at the beginning of wound closure, and was compared with saline (n=20). Post-anaesthetic shivering did not occur in any patient who received tramadol, whereas it occurred in 60% of the control group ( P<0.001). There were no adverse effects on time to extubation and sedation, and discharge-ready time was shorter in the tramadol group (P<0.05 compared with control). Pain scores in the post-an-aesthesia care unit (PACU) were statistically not different between the two groups, but significantly more supplemental medication was administered in the control group to treat shivering and/or pain. In conclusion, administration of a high dose of tramadol at the end of surgery prevents post-anaesthetic shivering without prolongation of extubation time, and shortens the PACU/discharge-ready time.

A 41-year-old multigravida presented at 32 weeks of gestation with polyhydramnios and an anencephalic fetus. Abnormal bleeding as a result of disseminated intravascular coagulation complicated an emergency Caesarean section for severe abdominal pain thought to be due to uterine rupture. Massive transfusion with blood products was necessary and the abdomen packed to control bleeding. The patient was transferred to the intensive care unit where she made a slow but complete recovery. Amniotic fluid embolism with atypical presentation of isolated coagulopathy is the likely diagnosis in this case. The case serves to demonstrate that amniotic fluid embolism may present with symptoms and signs other than the classical pattern of dyspnoea, cyanosis and hypotension.

Background and objective: To investigate the interactions of postoperative pain and endocrine stress response, three groups of 21 patients each with total knee arthroplasty were compared in a randomized, prospective design. For postoperative pain management, a three-in-one block, an epidural catheter analgesia or an intravenous patient-controlled analgesia was used.

Methods: After standardized balanced anaesthesia, the pain intensity was measured by a visual analogue scale (VAS). For detection of epinephrine, norepinephrine, antidiuretic hormone, adrenocorticotropic hormone and cortisol in the plasma, blood samples were taken at six time points before and up to 180 min after the start of pain therapy. In addition, systolic arterial pressure, heart rate, partial arterial oxygen saturation, nausea, vomiting and satisfaction of the patients were recorded.

Results: Within 15 min after the start of pain therapy, VAS in all groups was similarly reduced from >40 mm to a range <10 mm (P < 0.001). Initially, all endocrine stress variables exceeded the normal range. Epidural anaesthesia led to a significant decrease of epinephrine and norepinephrine concentrations, while an increase was observed in the group with patient-controlled analgesia, and the decrease in patients with the three-in-one block was less than in patients receiving epidural anaesthesia (P = 0.001). Differences in antidiuretic hormone, adrenocorticotropic hormone and cortisol were less pronounced. Systolic arterial pressure decreased significantly in all groups, particularly in patients with epidural anaesthesia. Partial arterial oxygen saturation and the incidence of nausea and vomiting were comparable. All patients were satisfied with the methods used.

Conclusions: All methods of pain management led to sufficient analgesia, but they were not accompanied by an adequate reduction in endocrine stress response. Thus, postoperative pain is only a secondary stressor and sufficient analgesia with subjective well-being does not prove a stress-free state. With regard to the reduction of sympathoadrenergic stress response, epidural anaesthesia is superior to the three-in-one block and patientcontrolled analgesia. Epidural anaesthesia is recommended particularly for high-risk patients with hypertension, coronary heart disease and diabetes mellitus. In these patients, the reduction of a ‘hidden’ endocrine stress response in addition to prevention of pain is of special interest.

With better survival of critically ill patients, ‘de novo’ arising neuromuscular complications like critical illness myopathy or polyneuropathy have been increasingly observed. Prolonged hospitalization not only imposes risks like pneumonia or thrombosis on patients but also represents a real budget threat to modern intensive-care medicine. Clinical symptoms like muscle weakness and weaning failure are common to critical illness myopathy and critical illness polyneuropathy and do not allow for distinction. Specific therapies are not yet available, and the quest for the pathomechanisms has proved more complicated than anticipated. Especially for critical illness myopathy, multiple sites of disturbances to the excitation–contraction coupling cascade are possible causes of muscle weakness. The present review summarizes the epidemiological, clinical and diagnostic features of critical illness myopathy and then focuses on current concepts of the presumed pathomechanisms of critical illness myopathy. Sepsis was shown to be a major cause of critical illness myopathy and special emphasis will be placed on how sepsis and inflammatory mediators influence (i) the membrane excitability at the level of voltage-gated ion channels and (ii) the intracellular protein signalling that results in selective loss of myosin protein content and muscle wasting. For (i), critical illness myopathy represents a new type of acquired channelopathy affecting the inactivation properties of Na+ channels. For (ii), both protein proteolysis and protein build up at the transcriptional level seem to be involved. Findings from different studies are put into a common context to propose a model for cytokine-mediated failure of muscle in severe sepsis. This can open a series of new possible trials to test specific therapeutic strategies in the future.

Background and objective: To determine whether prior exposure of non-steroidal anti-inflammatory drugs increases perioperative blood loss associated with major orthopaedic surgery.

Methods: Fifty patients scheduled for total hip replacement were allocated to two groups (double blind, randomized manner). All patients were pretreated for 2 weeks before surgery: Group 1 with placebo drug, Group 2 with ibuprofen. All patients were injected intrathecally with bupivacaine 20 mg plus morphine 0.1 mg, in a total volume of 4 mL, to provide surgical anaesthesia.

Results: The presence of severe adverse effects caused eight patients in the ibuprofen group and six in the placebo group to terminate their participation in the trial. The perioperative blood loss increased by 45% in the ibuprofen group compared with placebo. The total (±SD) blood loss in the ibuprofen group was 1161 (±472) mL versus 796 (±337) mL in the placebo group.

Conclusions: Pretreatment with ibuprofen before elective total hip surgery increases the perioperative blood loss significantly. Early discontinuation of non-selective non-steroidal anti-inflammatory drugs is advised.

Summary

Background and objective: Cardiopulmonary resuscitation should not be interrupted until the return of spontaneous circulation or the decision to withhold further treatment. There are no data on how consistent in-hospital cardiopulmonary resuscitation is performed. Accordingly, the aim of the present study was to identify length and type of unnecessary interruptions in simulated cardiac arrests. Methods: The study was carried out in a patient simulator. A scenario of cardiac arrest due to ventricular fibrillation was used. Resuscitation teams consisted of three nurses, a resident and a staff physician. Using videotapes recorded during simulations, the activities of the teams were coded in 5-s intervals. Unnecessary interruptions were defined as any interruptions in cardiac massage of 10 s or more that were not caused by defibrillation or endotracheal intubation. Results: Twelve teams were studied. The total time of possible cardiac massage was 414 ± 125 s. In each team at least one unnecessary interruption occurred (range 1–5). Interruptions mounted up to 65 ± 40 s (range 20–155) or 16 ± 10% (range 5–41) of the total time of possible cardiac massage. Failure to swiftly resume cardiac massage after an unsuccessful defibrillation accounted for 14 of 39 episodes and for 44 ± 40% of the time of unnecessary interruptions. The debriefings revealed that participants had generally not noticed the unnecessary interruptions during the simulation. Conclusions: The present study identified a significant amount of unnecessary interruptions in cardiac massage. These interruptions were not noticed by the health-care workers involved.

Summary

Background and objective: Levobupivacaine 0.5% and racemic bupivacaine 0.5% are equally effective in spinal anaesthesia. Fentanyl has been used as an adjunct to racemic bupivacaine in spinal anaesthesia. At the time this study was designed, there was no published study on the intrathecal use of 0.5% levobupivacaine with fentanyl. Methods: This prospective, randomized, double-blind study compared the clinical efficacy, motor block and haemodynamic effects of using 2.6 mL of 0.5% levobupivacaine alone (25 patients) and 2.3 mL of 0.5% levobupivacaine with fentanyl 15 μg in 0.3 mL (25 patients) for spinal anaesthesia in urological surgery. The study solution was injected into the subarachnoid space at the L3–L4 interspace. Results: There were no significant differences between the two groups in the haemodynamic changes, and quality of sensory and motor block. Anaesthesia was adequate and patient satisfaction was good in all cases. Side-effects were minor and infrequent with both regimes. Conclusions: We conclude that 2.3 mL of 0.5% levobupivacaine with fentanyl 15 μg is as effective as 2.6 mL of 0.5% levobupivacaine alone in spinal anaesthesia for urological surgery. Further studies may be directed to find the optimal combination of levobupivacaine and opioid with maximal haemodynamic stability and least motor block.

Summary

Background and objective: High-dose opioid anaesthesia contributes to decreasing metabolic and hormonal stress responses in patients undergoing cardiac surgery. However, the increase in context-sensitive half-life of opioids given as a high-dose regimen can affect postoperative respiratory recovery. In contrast, remifentanil can be given in high doses without prolonging context-sensitive half-life due to its rapid metabolism. Therefore, we performed a prospective, randomized trial to compare anaesthesia consisting of propofol/remifentanil or propofol/sufentanil with regard to postoperative respiratory function and outcome. Methods: Patients undergoing coronary artery bypass grafting were randomized to a propofol/remifentanil (0.5–1.0 μg kg−1 min−1) or propofol/sufentanil (30–40 ng kg−1 min−1) based anaesthetic. Carbon dioxide response, forced expiratory volume in one second, vital capacity, and functional residual capacity were measured 1 day prior to the operation, 1 h before extubation, 1, 24 and 72 h after extubation. In addition, the incidence of atelectasis, pulmonary infiltrates, intensive care unit and postoperative length of stay were compared. Patients and physicians were blinded to the treatment group. Results: Twenty-five patients in each treatment group completed the study. There was no difference between patients of the treatment groups regarding demographics, risk- or pain scores. In all patients, carbon dioxide response, forced expiratory volume in one second, vital capacity and functional residual capacity were decreased postoperatively compared to baseline. Patients randomized to remifentanil had less depression of carbon dioxide response, less atelectasis and shorter postoperative length of stay (12 d vs. 10 d) than after sufentanil (P < 0.05). Conclusions: Intraoperative use of high-dose remifentanil for coronary artery bypass grafting may be associated with improved recovery of pulmonary function and shorter postoperative hospital length of stay than sufentanil.

Summary

Background and objective: The timing of interscalene block in relation to general anaesthesia remains a controversial subject. We believe that the results of our study demonstrate that this block may be performed safely on anaesthetized patients, providing that certain conditions are met.

Methods: Five hundred and forty-eight cases of arthroscopic shoulder surgery were analysed retrospectively in order to identify the results of interscalene block performed after induction of general anaesthesia, but before the start of surgery. Patients were kept in hospital for 24 h and assessed before being discharged from the hospital and again in the period from 4 to 8 weeks after surgery. Duration of the block, quality of postoperative pain relief and neurological complications were recorded.

Results: Our study failed to reveal any permanent or long-term neurological complications attributable to interscalene block performed after induction of general anaesthesia.

Conclusion: It is our opinion that the primary factor for safe interscalene block is modification of the anaesthetic technique rather than the timing of regional block in relation to induction of general anaesthesia.

Summary

Background and objective: Comparisons between the profile of regional blocks are difficult to make because different methods of testing are used among the studies. The aims of this prospective study were to describe the profile of epidural block by using a scoring system to evaluate the density of the block as assessed by the loss to pinprick, cold and touch sensation; to evaluate the extent of differential block and to determine whether there is any relationship between these three modalities of testing. Methods: We studied 85 parturients undergoing elective Caesarean delivery with epidural anaesthesia with pH adjusted lidocaine 2% with epinephrine 1:400.000 and sufentanil 10 μg. Assessment of sensory block was done in each dermatomal level bilaterally for loss to pinprick, cold and light touch sensation and the density of the block was evaluated on an ordinal scale every 5 min for 20 min and thereafter at 30 and 40 min. Results: We observed a two dermatomes differential block between the complete loss of cold sensation being cephalad and the complete loss of both pinprick and light touch sensation being caudal. We established a significant correlation between the scores used to assess the density of the block in the three different modalities by considering the pinprick score as reference (Spearman's rank correlation is 0.94, P < 0.001 for pinprick vs. cold, 0.97, P < 0.001 for pinprick vs. light touch). Conclusions: By scoring the density of the block on an ordinal scale, knowing the level of the block to pinprick allows one to predict the level of the block to touch and vice versa.

Summary

Background and objectives: To compare pain relief and motor impairment of 0.25% levobupivacaine with either an equivalent (0.25%) or equipotent (0.4%) concentration of ropivacaine for continuous interscalene block after open shoulder surgery. Methods: Seventy-two adult patients scheduled for elective major shoulder surgery received an interscalene injection of mepivacaine 1.5% 30 mL followed by 24 h patient-controlled interscalene analgesia (basal infusion rate: 5 mL h−1; incremental bolus: 2 mL; lockout period: 10 min; maximum boluses per hour: 4) with either 0.25% levobupivacaine (n = 24), 0.25% ropivacaine (n = 24) or 0.4% ropivacaine (n = 24). A blinded observer recorded the evolution of pain relief and recovery of motor block during the first 24 h. Motor function was assessed as the maximum pressure developed while squeezing a sphygmomanometer cuff with the blocked hand. The reduction from preoperative values was considered as an index of motor impairment. Results: No differences were reported among the three groups in the quality of postoperative analgesia. The number of incremental patient-controlled interscalene analgesia doses, total volume of local anaesthetic infused during the 24-h patient-controlled interscalene analgesia, and number of rescue ketoprofen analgesia were higher in the ropivacaine 0.25% group than in the other two groups ( P = 0.0005). The hand strength recovered to ≥90% of baseline values within the first 24 h of infusion in all groups, without differences among the three groups. Conclusion: When providing patient-controlled interscalene analgesia after open shoulder surgery 0.25% levobupivacaine and 0.4% ropivacaine performed equally in terms of pain relief, motor block and number of patient-controlled boluses required, while patients receiving 0.25% ropivacaine needed significantly more boluses and rescue analgesia to control their pain.

Postoperative nausea and vomiting (PONV) is a common adverse phenomenon following breast surgery. The efficacy of ondansetron and droperidol in preventing post–operative nausea and vomiting in women undergoing breast surgery was compared in this randomized, double–blind, placebo–controlled study. Altogether 207 women were randomly assigned to receive either a single intravenous dose of droperidol (1.25 mg) (n = 69), ondansetron (8 mg) (n = 67) or saline (n = 71) immediately after induction of general anaesthesia with thiopental, fentanyl, atracurium, nitrous oxide in oxygen and isoflurane. Complaints of nausea, vomiting and requests for rescue antiemetics were recorded during a 24-h period postoperatively. During the initial 2 h in the postanaesthesia care unit, the incidence of postoperative nausea and vomiting was 15%, 6% and 12% in the placebo, droperidol and ondansetron groups, respectively (NS). The incidence of post–operative nausea and vomiting during the first 24 h was 61%, 48% and 45% in the placebo, droperidol and ondansetron treatment groups, respectively (NS). Postoperative analgesic requirements and the length of stay in the post–anaesthesia care unit were equal in all three treatment groups. It is concluded that the intravenous pretreatment with single doses of ondansetron or droperidol did not substantially prevent postoperative nausea and vomiting after breast surgery.