Combined spinal-epidural technique: single-space vs double distant space technique.

BACKGROUND/AIM: Several combined spinal-epidural (CSE) anesthesia techniques have been described. This study was designed to compare the single space ("needle-through-needle") technique (SST) and the double distant space technique (DDS) with regards to the time needed for the procedure, patient discomfort during the procedure and patient's preference technique. METHODS: This prospective, randomized single-blind study included 156 patients undergoing colorectal surgery under general anesthesia and CSE. All neuraxial blocks were performed before general anesthesia induction. DDS group of patients had thoracic epidural catheter placed at T6-7 or T7-8, followed by subarachnoid injection at the L2-3 interspace. The SST group of patients had a single injection using the needle-through-needle technique (Espocan needle) at L2-3. The epidural catheter was used for postoperative analgesia for 72 hours. Body habitus, spinal anatomy and spinal landmarks were assessed preoperatively. The number of epidural and spinal punctures, the feeling that the dura is perforated (dural perforation click) and the time needed to perform CSE were also recorded. Complications during epidural catheter placement and perioperative and postoperative epidural catheter function and patient preference for the anesthetic procedure were recorded. RESULTS: Epidural and subarachnoid spaces were successfully identified in all the patients. Duration of CSE procedure, the number of spinal punctures, dural click feeling and the effects of test dose did not differ between the groups. The patients in both groups (90% of DDS and 87% of SST) would choose CSE as preferred method in the future. The CSE procedure was painful for 16% of DDS vs 20% of SST patients. A significant correlation between time needed for CSE technique performance and body habitus (r = 0.338, p < 0.01), spinal landmarks (r = 0.452, p < 0.001) and anatomy (r = 0.265, p < 0.05) was found in the SST group. There was no correlation between the number of epidural/spinal punctures and epidural bacteriological findings. There was no correlation between the patients' choice of the CSE technique and the number of spinal punctures, duration of CSE procedure and epidural catheter stay. CONCLUSION: The two CSE techniques did not differ with regards to the procedure time and patient's preference. Procedure time correlated with body habitus, spinal landmarks and the anatomy in the SST group.

Comparison of analgesic effect of intrathecal morphine alone or in combination with bupivacaine and fentanyl in patients undergoing total gastrectomy: a prospective randomized, double blind clinical trial.

BACKGROUND/AIM: Combined spinal-epidural-general anesthesia has several advantages over general anesthesia alone. This study was designed to compare the efficacy of intrathecal (IT) morphine alone, or in combination with bupivacaine and fentanyl, as part of a combined spinal-epidural (CSE) analgesia, in patients undergoing elective total gastrectomy. METHODS: This prospective, randomized double-blind study included 60 patients undergoing total gastrectomy under general anesthesia and CSE. We compared the analgesic effect of lumbar IT morphine 300 microg (the group M, n = 20) vs morphine 300 .g + bupivacaine 2 mg (the group MB, n = 20) vs morphine 300 microg + bupivacaine 2 mg + fentanyl 25 pg (the group MBF, n = 20) given after thoracic epidural catheter placement (T6-7) but before general anesthesia induction. Pain visual analogue scale (VAS) at rest (R), with movement (M) and with cough (C), and the number of analgesia requests were assessed for 72 h and after epidural catheter removal. RESULTS: Compared to other groups, the MBF group required significantly fewer additional intra-operative epidural bupivacaine doses (p < 0.001), whereas the M group required significantly more supplemental intraoperative intravenous fentanyl, compared with the MBF (p = 0.022) and MB groups (p = 0.005). Postoperative pain relief was satisfactory in all the groups at all the time. VAS-R and VAS-M did not differ significantly among the groups. Compared to the M group, VAS-C scores 30 min postoperatively were significantly lower in the MBF (p = 0.029) and MB groups (p = 0.002). Duration of analgesia was longer in the MBF and MB groups, but the difference reached no significance. The number of supplemental analgesia requests was similar in all the groups in the first 12 h and during 72 h. Additional analgesia requests after epidural catheter removal were similar in all the groups, and side effects were infrequent. CONCLUSION: Compared to IT morphine alone, triple IT combination administered as part of CSE provided better intraoperative analgesia, but conferred no benefit with regards to postoperative analgesia.

Blood transfusion in cardiac surgery--does the choice of anesthesia or type of surgery matter?

BACKGROUND/AIM: In spite of the evidence suggesting a significant morbidity associated with blood transfusions, the use of blood and blood products remain high in cardiac surgery. To successfully minimize the need for blood transfusion, a systematic approach is needed. The aim of this study was to investigate the influence of different anesthetic techniques, general vs combine epidural and general anesthesia, as well as different surgery strategies, on-pump vs off-pump, on postoperative bleeding complications and the need for blood transfusions during perioperative period. METHODS: Eighty-two consecutive patients scheduled for coronary artery bypass surgery were randomized according to surgical and anesthetic techniques into 4 different groups: group 1 (patients operated on off-pump, under general anesthesia); group 2 (patients operated on off-pump, with combined general and high thoracic epidural anesthesia); group 3 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, under general anesthesia), and group 4 (patients operated on using standard revascularization technique, with the use of extracorporeal circulation, with combined general and high thoracic epidural anesthesia). Indications for transfusion were based on clinical judgment, but a restrictive policy was encouraged. Bleeding was considered significant if it required transfusion of blood or blood products, or reopening of the chest. The quantity of transfused blood or blood products was specifically noted. RESULTS: None of the patients was transfused blood or blood products during the surgery, and as many as 70/81 (86.4%) patients were not transfused at all during hospital stay. No difference in postoperative bleeding or blood transfusion was noted in relation to the type of surgery and anesthetic technique applied. If red blood cells were transfused, postoperative bleeding was the most influential parameter for making clinical decision. CONCLUSION: No influence of off-pump surgery or epidural anesthesia on blood transfusion requirements during a perioperative period was confirmed by this study. It seems, however, that encouraging lower hemoglobin triggers in clinical decision-making could result in less transfusions during surgery or hospital stay.

High thoracic epidural anesthesia in patients with synchronous carotid endarterectomy and off-pump coronary artery revascularization.

BACKGROUND/AIM: In order to reduce the risk of cerebrovascular insults (CVI), the latest recommendations suggest that carotid endarterectomy (CEA) is strongly indicated in patients scheduled for coronary surgery when significant carotid artery stenosis is symptomatic and/or bilateral. The best results are obtained in small studies with CEA performed immediately prior to off-pump coronary bypass (OPCAB). We present 16 consecutive patients who underwent synchronous CEA and OPCAB under general anesthesia combined with high thoracic epidural anesthesia (TEA) in order to evaluate the safety and potential benefits of such anesthetic management. METHODS: A total of 16 consecutive patients scheduled for simultaneous CEA and OPCAB with no contraindication for TEA were enrolled in the study. All the patients were anesthetized with TEA combined with general anesthesia. Early extubation was planed in all the patients for early assessment of neurological outcome. Demographics, comorbidity, quality of postoperative recovery, duration of mechanical ventilation, successful early extubation, outcome, length of Intensive Care Unit (ICU) and hospital stay were recorded. RESULTS: Only two patients did not fulfill the criteria for early extubation. The average duration of mechanical ventilation for patients who fulfilled criteria for early extubation was 87.9 +/- 85.0 (0-255) min. Five (31.25%) patients were extubated in the operating theater at the end of surgery. There were no deaths, nor neurological complications of TEA. Seven (43.7%) patients had at least one of the postoperative complications considered significant. None of them had CVI. None of the early extubated patients was reintubated or had postoperative respiratory failure. CONCLUSION: Our study revealed that a combination of general anesthesia with TEA appears to be good choice in synchronous CEA and OPCAB due to advantages of early extubation and early neurological assessment. Larger studies are necessary to determine real benefits on both short and long-term outcomes of such anesthetic management in synchronous CEA and OPCAB.

[Impact of hyaluronidase on anesthetic distribution in retrobulbar region following sub-Tenon anesthesia].

BACKGROUND/AIM: Sub-Tenon's block is nowadays commonly used in ophthalmic surgery because of its safety and efficacy. The aim of this study was to investigate the distribution of the anaesthetic solution with different amounts of hyaluronidase in the retrobulbar space, following an injection into the Sub-Tenon's space. METHODS: In this experimental study, 40 pig cadaver heads were used (80 eyeballs). The material was divided into four groups (of 20 eyeballs each). Each group was administered 4.5 ml of a mixture of 2% lignocaine, 0.5% bupivacaine, and 0.5 ml of Indian ink, with different amounts of hyaluronidase--15 IU/ml, 75 IU/ml, 150 IU/ml, except the control one. Samples of retrobulbar tissue were analysed using the standard histopathological procedure. After that, they were also analysed using the Adobe Photoshop program (Windows, USA). The retrobulbar space was divided into eight zones by four perpendicular lines, which crossed in the centre of the optic nerve. The presence of ink in fat and muscle tissues and in the sheath of the optic nerve was observed. RESULTS: The presence of the local anaesthetic solution was significantly higher in inferonasal and superonasal quadrants of the fat and muscle tissues (p < 0.01). The distribution in optic nerve sheath is similar in each quadrant. Distribution of local anesthetic in each zone of the muscle tissue (I-VIII) was strongly influenced by the amount of hyaluronidase added. In the fat tissue, the distribution of local anesthetic under the influence of hyaluronidase was significantly higher (p < 0.05) in the areas which were distant from the place of injection (I-IV). The distribution in the optic nerve sheath is significantly higher (p < 0.01) in the group with 150 IU/ml of hyaluronidase. CONCLUSIONS: Following a sub-Tenon block local anaesthetic was present in the retrobulbar space in a high percentage of the cases. The presence of local anaesthetic solution in retrobulbar space depends on the amount of hyaluronidase previously added to the local anaesthetic.

Sacrospinous ligament fixation for neovaginal prolapse prevention in male-to-female surgery.

OBJECTIVES: To report our experiences of vaginal sacrospinous ligament fixation after vaginoplasty in male transsexual patients with the aim of preventing its postoperative prolapse. METHODS: From August 1997 through November 2005, a total of 62 male transsexual patients (mean age 26 years, range 18 to 58) underwent sacrospinous ligament fixation for neovaginal prolapse during male-to-female sex reassignment surgery. The neovagina was created from a penile skin tube flap combined with a urethral flap. A deep and wide perineal cavity between the urethra, bladder, and rectum was created by dissection of the tendineous center and rectourethral muscle. The right pararectal space was opened by penetrating the right pararectal fascia (rectal pillar) and right ischial spine was palpated. Using the ischial spine as a prominent landmark, the sacrospinous ligament was palpated. Long-handled Deschamps ligature was used to pierce the ligament medially to the ischial spine. Vaginopexy to the sacrospinous ligament was performed, and the neovagina was placed deep in the perineal cavity. RESULTS: The median follow-up was 32 months (range 7 to 102). Sacrospinous ligament fixation was successfully performed in all patients. The mean vaginal length was 10.7 cm (range 9.5 to 16). Of the 62 patients, 42 (76%) were able to have normal sexual intercourse. The appearance of the neovagina was aesthetically acceptable in 52 patients. In 3 cases, a minor bulge of the anterior vaginal wall was easily resolved by simple excision. CONCLUSIONS: Vaginal sacrospinous fixation is feasible in male transsexuals for neovaginal prolapse prevention. However, extensive experience with male pelvic surgery is required to avoid possible complications.

[Influence of perioperative administration of amino acids on thermoregulation response in patients underwent colorectal surgical procedures].

BACKGROUND: Hypothermia in the surgical patients can be the consequence of long duration of surgical intervention, general anesthesia and low temperature in operating room. Postoperative hypothermia contributes to a number of postoperative complications such as arrythmia, myocardial ischemia, hypertension, bleeding, wound infection, coagulopathy, prolonged effect of muscle relaxants. External heating procedures are used to prevent this condition, but some investigations reported that infusion of aminoacids during surgery can induce thermogenesis and prevent postoperative hypothermia. CASE REPORT: We reported two males who underwent major colorectal surgery for rectal carcinoma. One patient recived Aminosol 15% solution, 125 ml/h, while the other did not. The esophageal temperatures in both cases were measured every 30 minutes during the operation and 60 minutes after in Intensive Care Unit. We were monitoring blood pressure, heart rate, ECG, and shivering. Patient who received aminoacids showed ameliorated postoperative hypothermia without hypertension, arrythmia, or shivering, while the other showed all symptoms mentioned above. CONCLUSION: According to literature data, as well as our findings, we can conclude that intraoperative intravenous treatment with amino acid solution ameliorates postoperative hypothermia along with its complications.

Immune cytokine response in combat casualties: blast or explosive trauma with or without secondary sepsis.

The aim of this study was to assess the prognostic value of tumor necrosis factor (TNF) alpha, interleukin (IL)-8, IL-4, and IL-10 in combat casualties. Fifty-six casualties with severe trauma (blast and explosive) who developed sepsis and 20 casualties with the same severity of trauma without sepsis were enrolled in this study. Fifty-five casualties developed multiple organ dysfunction syndrome; 36 died. Blood was drawn on the first day of trauma. Concentrations of IL-8, TNF-alpha, IL-4, and IL-10 were determined in plasma using enzyme-linked immunosorbent assays. Mean values of IL-8 were 230-fold, IL-10 were 42-fold, and TNF-alpha were 17-fold higher in trauma and sepsis group (p < 0.01). Mean values of IL-8 were 60-fold, TNF-alpha were 43.5-fold, and IL-10 were 70-fold higher in the multiple organ dysfunction syndrome group (p < 0.01). Mean values of IL-8 were 2.3-fold and IL-10 were 1.4-fold higher in nonsurvivors and TNF-alpha were 2.2-fold higher in survivors (p < 0.01). IL-4 had no significance as a predictor of severity and outcome.

Longitudinal dorsal dartos flap for prevention of fistula after a Snodgrass hypospadias procedure.

OBJECTIVES: The Snodgrass technique presents the procedure of choice for distal hypospadias. Fistula formation is the most common complication with various rates. We evaluated the importance of a urethral covering using vascularized dorsal subcutaneous tissue for fistula prevention. METHODS: Our study included 126 patients, aged 10 months to 16 years, who underwent hypospadias repair from April 1998 through June 2005. Of the patients, 89 had distal, 30 had midshaft and 7 had penoscrotal hypospadias. All patients underwent standard tubularized incised plate urethroplasty, which was followed by reconstruction of new surrounding urethral tissue. A longitudinal dorsal dartos flap was harvested and transposed to the ventral side by the buttonhole manoeuvre. The flap was sutured to the glans and the corpora cavernosa to completely cover the neourethra with well-vascularized subcutaneous tissue. RESULTS: Mean follow-up was 32 (6-87) months. A successful result without fistula was achieved in all 126 patients. In six patients, temporary stenosis of the glandular urethra occurred and was solved by dilation. CONCLUSIONS: A urethral covering should be performed as part of the Snodgrass procedure. A dorsal well-vascularized dartos flap that is buttonholed ventrally represents a good choice for fistula prevention. Redundancy of the flap and its excellent vascularization depend on the harvesting technique.

[Endophthalmitis in war and peace penetrating eye injuries].

BACKGROUND/AIM: Nowadays, eye injuries are a leading cause of one-eye disease or blindness worldwide. The aim of this study was to comparatively analyze the frequency of endophthalmitis following war and peace eye injuries. METHODS: All the patients went throught the detailed ophthalmologic examinations, prophylactic antibiotic treatment, and pars plana vitrectomies (VPP), or other required surgical interventions. RESULTS: Inside the period from 1991 to 1998, 647 patients with eye injuries were hospitalized, out of which 500 with penetrating eye injuries. In the period 1999-2004, 611 patients with eye injuries, were treated, out of which 297 had penetrating eye injuries. Out of 500 patients with war penetrating eye injuries, in 286 of the cases intrabulbar foreign bodies (IFB) were detected. The signs of endophthalmitis were observed in 26 eyes (5.2%) at admission. Out of totally 297 peace penetrating eye injuries, 196 (66%) were IBF. In 25 eyes (8.4%) endophthalmitis was observed. CONCLUSION: In our study, the frequency of posttraumatic endophthalmitis following penetrating war eye injuries was relatively low, even lower than the frequency of endophthalmitis following peace eye injuries.