Postoperative prolonged epidural analgesia using disposable elastomeric pumps in elderly patients after spinal neurosurgery

BACKGROUND: Postoperative pain is a significant problem in patients that causes various complications. AIM: To evaluate the efficacy and safety of prolonged epidural analgesia using disposable elastomeric pumps in elderly patients undergoing spinal neurosurgery and its comparison with the traditional method of postoperative analgesia in 80 patients. MATERIALS AND METHODS: Hemodynamic parameters were recorded and the efficiency of pain relief and nature of postoperative complications were assessed in comparable groups. The concentration of interleukin-6 (IL-6) and IL-2 were determined. RESULTS: In the group with prolonged epidural analgesia with 0.2% ropivacaine solution, an adequate level of analgesia was achieved in 92% of the patients. The revealed changes in the blood serum levels of cytokines IL-6 and IL-2 may indicate a balanced response of the immune system in the group with prolonged epidural analgesia. CONCLUSIONS: Prolonged epidural analgesia using disposable elastomeric pumps provides complete pain relief for patients and correction of individual links of the surgical stress response.

Single-centre, double-blind, randomised, parallel-group, superiority study to evaluate the effectiveness of general anaesthesia and ultrasound-guided transversus thoracis muscle plane block combination in adult cardiac surgery for reducing the surgical stress response: clinical trial protocol

IntroductionAdult open-heart surgery is a major surgery that causes surgical stress response and activation of the immune system, contributing further to postoperative complications. Transversus thoracis muscle plane block (TTPB) may potentially benefit in reducing the surgical stress response. This study aims to know the effectiveness of preoperative TTPB in adult open-heart surgery for reducing the surgical stress response.Methods and analysisThis study is a prospective, double-blind, randomised control trial comparing the combination of general anaesthesia and TTPB versus general anaesthesia only in adult open-heart surgery. Forty-two eligible subjects will be randomly assigned to the TTPB group or control group. The primary outcomes are the difference between the two groups in the means of postoperative cortisol and interleukin-6 plasma levels at 24 hours and 48 hours after cardiac intensive care unit admission. The secondary outcomes are the difference between the two groups in the means of total 24-hour postoperative morphine consumption and time of first postoperative patient-controlled analgesia (PCA) dose.Ethics and disseminationThe study protocol and informed consent forms have been reviewed and approved by the Ethics Committee of Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo Hospital. The result will be released to the medical community through presentation and publication in peer-reviewed journals.Trial registration numberNCT04544254.

THE INFLUENCE OF COMPLEX IMPLEMENTATION OF THE ERAS PROGRAM ON THE SURGICAL STRESS RESPONSE FACTORS IN PEDIATRIC PATIENTS UNDERGOING ELECTIVE LIMB SURGERY

Surgical stress response, fluid and nutritional balance, and pain management are among the key factors influencing on the postoperative period. These areas are reflected in the Enhanced Recovery After Surgery (ERAS) concept, which is based on a set of measures aimed at minimizing the surgical stress response. The lack of ERAS recommendations for the pediatric population of surgical patients prompts to search for a solution of adaptation and implementation of the ERAS programs in children. The aim of the study. To determine the effectiveness of the complex application of the enhanced recovery after surgery by studying its influence on the factors of the surgical stress response in pediatric patients undergoing limp surgery. Materials and methods. The prospective randomized study included 47 patients aged 1 to 17 years. In the study group (n = 22), the ERAS program was used, which consisted of 14 components of preoperative, intraoperative and postoperative measures. In the control group (n = 25), the complex of all ERAS components was not purposefully applied. We compared glycaemic stress index (GSI) and length of hospital stay after surgery (LOS) as a primary outcome; secondary outcomes were fasting time after drinking fluids before induction of anesthesia, estimated fluid deficiency just before induction of anesthesia, hemodynamic parameters, the need for opioids during and after surgery, blood glucose and beta-hydroxybutyrate in the beginning and in the end of the surgery and next day morning after surgery, postoperative nausea and vomiting. Results. GSI was significantly less in the study group (1,62 ± 0,78 vs 2,12 ± 0,93, р=0,046). LOS in the study group was 37.5% less than in the control group (p = 0.002). The period of preoperative fasting and fluid deficit in the patients of the study group were shorter. The needs of fentanyl intraoperatively in the study group was 47% less (p<0.001). At the beginning of surgery, the study group had a higher blood glucose concentration and a higher systolic blood pressure. At the end of surgery, blood glucose and beta-hydroxybutyrate in the study group was lower than in the control group. In the postoperative period, 9% of patients in the study group and 36% of patients in the control group complained of nausea (p = 0.041). Linear regression analysis showed a linear relationship between the LOS after surgery and the GSI (R=0,515, R2=0,266, B=2,156, 95% CI 1,04 – 3,27, p<0,001). Results. The implementation of the ERAS program to children 1-17 years old undergoing elective limp surgery may reduce the effect of the surgical stress reaction by reducing the period of preoperative fasting, fluid deficiency, the needs of opioids and postoperative nausea. Minimizing the surgical stress response may facilitate the achievement of hospital discharge criteria and shorten the length of hospital stay in the postoperative period.

COMPARISON OF C-REACTIVE PROTEIN, CORTISOL AND INTERLEUKIN-6 DYNAMICS AFTER BREAST SURGERY UNDER GENERAL ANESTHESIA, OR GENERAL ANESTHESIA IN COMBINATION WITH PECTORAL BLOCK, OR GENERAL ANESTHESIA IN COMBINATION WITH THORACIC PARAVERTEBRAL BLOCK

Modern anesthesiologic coverage and support has its one of the main goals to decrease a surgical stress response of the patient after surgery. It is very important especially in cancer patients. Breast cancer is the most frequently diagnosed malignancy among women in Ukraine. The thoracic paravertebral block is widely used for analgesia of breast surgery by decades. In recent years, novel miofascial blocks, such of them ultrasound-guided pectoral nerve block type II, have become a very popular anesthesiologic technique in addition to general anesthesia for breast surgeries. A precise impact of these new methods of analgesia on the surgical stress response remains to be discovered. The goal of the research: to investigate surgical stress-response of the breast cancer surgical patient after Pectoral nerve block, Paravertebral block, or general anesthesia. Materials and methods. This is single center, prospective study. Ninety-one women after an elective mastectomy or quadrantectomy with axillary nodes dissection were included. Depending on the method of anesthesia, patients were randomly divided into three groups. The General Anesthesia group (GA) — only general anesthesia, PB group — general anesthesia plus pectoral nerve block type II with ropivacaine 0.375% 30 ml and PVB group — general anesthesia plus thoracic paravertebral block with ropivacaine 0.5% 20 ml. All blocks were performed under ultrasound control. The plasma levels of CRP, IL-6 were measured before and 24 hours after surgery. The plasma level of Cortisol was measured before surgery, 0 and 24 hours after. Postoperative pain was evaluated using the Numerical rating scale (NRS) at 0, 1, 2, 6, 12, 18 and 24 hours after surgery. Results. The initial (preoperative) levels of biomarkers were equal in three investigation groups. Immediate after surgery Cortisol level decreased in PB and PVB groups to 267 (182- 416) nmol/l and 311 (196-378) nmol/l respectively and increased in GA group to 355 (246-483) nmol/l, but without statistically significance (р=0.132). The day after surgery Cortisol’s level was: 340 (253-381) nmol/l; 314 (231-416) nmol/l and 339 (228-398) nmol/l respectively (р=0.678). The day after surgery C-reactive protein was statistically significant lower in blocks groups. It was achieved in GA group 83.0 (51.3-94.0) mg/l, PB group – 51.9 (36.1-79.5) mg/l, PVB group – 61.7 (25.6-73.9) mg/l (р=0.062). In a day after surgery the highest level of IL-6 was observed in the GA group, then in the PB and PVB groups: 29.5 (16.9-33.1) pg/ml, 22.2 (11.5-31.6) pg/ml and 16.8 (14.0-19.5) pg/ml respectively (р=0.002). Statistically significantly lower NRS pain scores were observed in the PB and PVB groups compared with the GA group in 1, 2, 6 and 24 hours after surgery. Conclusion. Analgesia with both pectoral nerve block or thoracic paravertebral block compared to general anesthesia alone for breast cancer surgery is associated with lower postoperative levels of CRP and IL-6, which suggest about decreasing stress-response to the surgery.

INFLUENCE OF INTRAOPERATIVE FLUID THERAPY ON STRESS RESPONSE IN PAEDIATRIC ORTHOPAEDIC SURGERY

Introduction. Optimization of the intraoperative fluid therapy is one of the elements of the ERAS program. The strategy of avoiding fluid overload has shown positive results in adults, but still remains unexplored in children. Fluid requirements in children are higher than in adults and they vary with age. It’s still not clear whether it is possible or not to extrapolate the data of studies obtained in adults to children and to use similar recommendations. The aim of this study is to compare intraoperative fluid approaches from the point of view of surgical stress response in children undergoing orthopaedic surgery. Material and Methods: The study included 60 pediatric patients over 1 year of age who had undergone orthopaedic surgery. Рatients were stratified into two groups depending on the volume of intraoperative base crystalloid infusion. First group of patients received <7 ml/kg/h crystalloids, and the second group of patients received > 7 ml/kg/h. We evaluated intraoperatively changes of blood pressure, heart rate, urine output, Hb, Ht, blood glucose, acidbase status. After surgery we estimated lactate, insulin, insulin resistance index HOMA-IR (homeostatic model assessment) and insulin sensitivity index QUICKI. Mean data was compared with Mann-Whitney U-test. Results of the study: After stratification two groups were identified. The first group of patients (n=30) received 10.7 ± 3.03 ml/kg/h and the second one 2 (n=30) – 5.07 ± 1.15 ml/kg/h of intraoperative crystalloid fluids as a basic fluid therapy. We did not find significant changes in blood pressure, heart rate, Hb, Ht, acid-base status in both groups. But the urine output was decreased in the group 2 (0.43 ± 0.59 ml/kg/h) in comparison with the group 1 (1.16 ± 0.89, p=0.009). The concentration of blood glucose was insignificantly increased in both groups, but the level of insulin and HOMA-IR was significantly higher in group 2 (insulin 5.39 ± 3.93 vs 8.94 ± 6.15 mU/L, p=0.006; HOMAIR 1.30 ± 1.05 vs 2.39 ± 2.14, p=0.004), and index QUICKI was lower (0.39 ± 0.05 vs 0.35 ± 0.04, p=0.004). We also found the tendency to lactation increase in group 2 (1.46 ± 0.62 vs 1.90 ± 0.69, p=0.07), even though that was not significant. Conclusion: This study revealed the tendency to insulin resistance of tissues as one of the signs of a surgical stress response in children who were limited in intraoperative fluid therapy during orthopaedic surgery. Results of the study suggest that the limitation of intraoperative fluids is not applicable for children, and the volume of base crystalloids must be more than at least 7 ml/kg/h during paediatric orthopaedic surgery. Further research is necessary to determine what minimum volume is acceptable in other types of paediatric surgeries.

STRESS-LIMITING ANESTHESIA IN OPHTHALMOSURGERY

Despite the significant advances made by modern anesthesiology in the perioperative management of patients, surgical interventions are still accompanied by a high proportion of complications and even deaths. At the same time, it is known that in 50% of cases mortality and serious postoperative complications could be prevented. After performing a thorough study of the factors affecting the increase in hospitalization and postoperative recovery (Kehlet H., 1997; Kehlet H., Wilmore D., 2002), it was determined that the surgical stress response is the most significant inducer of dysfunction of various organs. and systems. To date, it has been established that general anesthesia in its classical sense does not allow achieving complete protection of the patient from surgical trauma. More complete protection can be achieved by combining general anesthesia with regional blockages and adjuvant drugs with stress-protective properties. In the present study, we compared the severity of the surgical stress response and pain syndrome in patients operated on under conditions of multicomponent balanced general anesthesia (group K) with patients who received a stress-limiting anesthesia regimen (group DB). In both groups, multicomponent anesthesia was performed, in group K, sibazone was used for sedation, in group DB, dexmedetomidine was used. Also, patients of the DB group underwent regional blockade (blockade of the pterygo-palatine fossa) before surgery. The main criteria for evaluating the results were: hemodynamic stability, blood glucose, the level of venous blood leukocytes and the severity of pain according to the VAS in the postoperative period. Both schemes made it possible to avoid pronounced fluctuations in hemodynamic and gas exchange parameters at all stages of the study. When analyzing blood glucose and leukocyte counts, it was found that patients in the control group had a more significant deviation of both indicators from the preoperative level than in the stress-limiting anesthesia group. In the study of pain syndrome, it was determined that in the control group the level of pain according to the VAS was higher at all stages of the study compared to patients in the group of stress-limiting anesthesia.

Preoperative regional scalp block versus intraoperative intravenous fentanyl for attenuating intraoperative surgical stress response to supratentorial craniotomy in adult patients under general anaesthesia

During brain tumour resection a lot of noxious stimuli are released resulting in a significant hemodynamic and stress response, its control is challenging during anaesthesia, and can be evaluated by monitoring blood pressure (BP), heart rate (HR) Attenuating autonomic cardiovascular responses to pain resulting from skull pinning, skin incision, and craniotomy are considered significant benefits of Regional Scalp Block (RSB) in addition to reducing postoperative analgesic requirements. This study aims to evaluate the effect of preoperative regional scalp block (RSB) versus intraoperative intravenous fentanyl for attenuating intraoperative surgical stress response to supratentorial craniotomy in adult patients under general anaesthesia. The study included 30 patients randomly distributed into two equal groups with 15 patients in each, Group A: Preoperative RSB was done after induction of general anaesthesia and before skull pinning, Group C: Control group: patients were given conventional intraoperative analgesia in the form of intravenous fentanyl with no block. This study included patients with Supratentorial brain tumours were admitted to Zagazig University Hospitals. Patients have been gathered over two years duration from march 2018 to march 2020. The results showed that there were highly significant differences between RSB group and control group. Preoperative RSB showed advantages over Standard analgesia in terms of better attenuation of stress response to pain in the form of heart rate and blood pressure intraoperatively, decrease opioid consumption, lower Visual Analogue Score (VAS), Preoperative RSB can be performed easily in a short time with very high success rate allowing better intraoperative control of haemodynamics, less postoperative pain. We recommend using preoperative RSB in supratentorial craniotomy as a gold standard in our hospital to get the advantages mentioned above.

Effects of psychological interventions on anxiety and pain in patients undergoing major elective abdominal surgery: a systematic review

A maladaptive response to surgical stress might lead to postoperative complications. A multidisciplinary approach aimed at controlling the surgical stress response may reduce procedural complications and improve patients’ quality of life in the short and long term. Several studies suggest that psychological interventions may interact with the pathophysiology of surgical stress response, potentially influencing wound repair, innate and adaptive immunity, inflammation, perception of pain, and patients’ mood. The aim of this systematic review is to summarise the effects of perioperative psychological interventions on surgical pain and/or anxiety in adult patients scheduled for elective general abdominal and/or urologic surgery.We conducted a systematic review of controlled clinical trials and observational studies involving psychological interventions for adult patients scheduled for elective general abdominal and/or urologic surgery. Only studies reporting pain and/or anxiety among outcome measures were included in the systematic review. The following psychological interventions were considered: (1) relaxation techniques, (2) cognitive-behavioural therapies, (3) mindfulness, (4) narrative medicine, (5) hypnosis and (6) coping strategies.We examined 2174 papers. Among these, 9 studies were considered eligible for inclusion in this systematic review (1126 patients cumulatively): 8 are randomised controlled trials and 1 is an observational prospective pre/post study.Psychological characteristics widely influence the pathophysiological mechanisms underlying the neuroendocrine and inflammatory response to surgical stress, potentially interfering with surgical outcomes. Psychological interventions are technically feasible and realistically applicable perioperatively during abdominal and/or urologic surgery; they influence the pathophysiological mechanisms underlying maladaptive surgical stress response and might have positive effects on patients’ surgical outcomes, such as pain and anxiety.