A Randomized Comparison of Plasma Levobupivacaine Concentrations Following Thoracic Epidural Analgesia and Subpleural Paravertebral Analgesia in Open Thoracic Surgery.

BACKGROUND: The aim of this study was to compare plasma levobupivacaine concentrations in thoracic epidural and subpleural paravertebral analgesia. METHODS: Forty-four patients indicated for open lung resection had an epidural catheter inserted preoperatively or a subpleural catheter surgically. A bolus of 0.25% levobupivacaine at a dosage of 0.5 mg × kg-1 was given after the thoracotomy closure. Plasma levobupivacaine level at 30 min was the primary outcome. Pharmacokinetic modeling was performed subsequently. Secondary outcomes included the quality of analgesia, complications, and patients'mobility. RESULTS: Plasma concentrations were similar 30 min after application-0.389 mg × L-1 in the epidural and 0.318 mg × L-1 in the subpleural group (p = 0.33) and lower in the subpleural group at 120 min (p = 0.03). The areas under the curve but not maximum concentrations were lower in the subpleural group. The time to reach maximum plasma level was similar in both groups-27.6 vs. 24.2 min. No clinical symptoms of local anesthetic toxicity were recorded. CONCLUSIONS: Levobupivacaine systemic concentrations were low in both groups without the symptoms of toxicity. This dosage should be safe for postoperative analgesia after thoracotomy.

[Renal cell carcinoma in the coming era of robotic technology]. / Karcinom ledviny v ére nastupujících robotických technologií.

Renal cell carcinoma is the most malignant urological tumour and the incidence in the Czech Republic is currently highest in the world. Kidney cancer is associated with seven different genes and is characterized nowadays as metabolic disease. Authors present some current facts about advances in diagnosis and new treatment methods. Different findings required individual approach. Diagnosis improved with more sophisticated ultrasonography, computed tomography, magnetic resonance imaging and positron emission tomography etc. Apart from standard surgery new alternative methods of minimally invasive procedures also assert (laparoscopy, robotic surgery, radiofrequency ablation, kryoablation) and are incorporated in current complex treatment strategies. Systemic therapy with new targeted antiangiogenics drugs is a new standard of treatment for metastatic kidney cancer Complex care with integration of local treatment (surgery, radiotherapy, selective embolization, radiosurgery, cementoplasty, vetrebroplasty etc.) and systemic medication with best supportive care is optimal for a metastatic kidney cancer. More accurate diagnostic methods and complex interdisciplinary approach with integration of systemic therapy with new targeted drugs and new minimally invasive procedures represent new possibilities for patients with kidney cancer.

Laryngotracheal stenosis in critically ill patients.

CONCLUSIONS: Prolonged artificial pulmonary ventilation by tracheostomy tube (>30 days) doubled the risk of stenosis (relative risk, RR = 2.04, p = 0.002). Critically ill patients with repeated tracheotomies were more than six times likely to experience stenosis (RR = 6.44, p< 0.001) than other critically ill patients. OBJECTIVE: In this retrospective study, we describe the occurrence of laryngotracheal stenosis (LTS) in critically ill patients after elective tracheostomy who had undergone treatment for LTS at the Na Homolce Hospital in Prague, Czech Republic. METHODS: We studied 28 patients who were diagnosed with symptomatic LTS. Basic major demographic data, duration of mechanical ventilation, onset of tracheal stenosis after decannulation, and tracheostomy type (percutaneous dilatational or surgical tracheostomy) were recorded. The number of patients requiring repeated tracheostomies was also recorded. RESULTS: Neither the demographic data nor the type of tracheostomy represented statistically significant risk factors. The risk factors for LTS were prolonged artificial pulmonary ventilation using the tracheostomy tube (p = 0.005) and repeated tracheostomy (p< 0.001). The mean onset of stenosis symptoms was 53.7 days (range 2-300 days), with a median of 58 days. Stenosis involved the trachea in 20 patients, subglottis in five cases, and glottis and subglottis in three cases. Seven patients (25%) underwent a tracheal resection and primary end-to-end reconstruction. One patient underwent laryngotracheoplasty with dilatation. The procedure was endoscopic in 18 patients (64.3%). Two patients (7.1%) received permanent tracheostomies.