Epidural analgesia and liver resection: postoperative coagulation disorders and epidural catheter removal.

BACKGROUND: The aim of this study was to quantify the duration and severity of postoperative coagulopathy in order to establish the optimal time for epidural catheter removal. METHODS: In a 2-year retrospective study, 140 consecutive patients underwent major liver resection. RESULTS: Epidural catheters were present in 123 patients (87.9%). Resections were: 33 (26.8%) right hepatectomy (with or without left metastasectomy), 9 (7.3%) left hemihepatectomy (with or without right metastasectomy), 37 (30.1%) trisectionectomy (extended hemihepatectomy) and 44 (35.8%) non-anatomical metastasectomy. Surgery was quantified by segments resected (4 [range: 1-7]). Vascular inflow occlusion was used in 65.6%. Ischaemic time was 26.5 min (range: 0-104 min). Platelet count fell postoperatively and was lowest on day 2 (205±72 10(9) L(-1)). There was a significant increase in prothrombin time, activated partial thromboplastin time and International Normalised Ratio (INR) postoperatively, peaking on day 2 (21.5±5.6 s, 37.9±5.8 s and 1.9±0.5, respectively). Changes persisted beyond day 6. Epidural catheters were removed on day 5 (1-11), with a protocol criterion of INR <1.2. Actual INR on day 5 was 1.49±0.36. CONCLUSION: Despite this, no epidural or spinal haematoma was recorded.

Subarachnoid morphine, bupivacaine and fentanyl as part of combined spinal-epidural analgesia for low anterior resection. A prospective, randomised, double-blind clinical trial.

This study was designed to compare the efficacy of subarachnoid morphine alone or in combination with bupivacaine and fentanyl for combined spinal-epidural analgesia in colorectal surgery. This is a prospective, randomised, double-blind clinical trial. Sixty patients undergoing low anterior resection were assigned to one of three groups: subarachnoid morphine, bupivacaine and fentanyl, subarachnoid morphine and bupivacaine or subarachnoid morphine only. Epidural catheter placement and subarachnoid injection were done via a combined spinal-epidural Epistar needle at L2-3. The epidural catheter was used for scheduled intraoperative bupivacaine and intermittent postoperative bupivacaine and morphine administration. Intraoperative epidural bupivacaine, intraoperative intravenous fentanyl use, time to first analgesia request, postoperative visual analogue scale pain scores, tramadol requirements and side-effects were recorded for 72 hours. Postoperative analgesia was comparable in all groups. Intraoperative fentanyl and bupivacaine consumption was lowest in the morphine, bupivacaine and fentanyl group. Time to first analgesia request was longer in the morphine, bupivacaine and fentanyl compared to the morphine group (P = 0.009). Tramadol use was lower in the morphine and bupivacaine group compared to morphine, bupivacaine and fentanyl (P = 0.017) on postoperative day two. There were no significant adverse effects. All patients ambulated the morning after surgery. The addition of bupivacaine and fentanyl to subarachnoid morphine did not confer any advantage on postoperative visual analogue scale scores and tramadol use, but lowered the need for additional intraoperative intravenous fentanyl and epidural bupivacaine and prolonged the time to first analgesia request.

Combined spinal-epidural analgesia vs. intermittent bolus epidural analgesia for pain relief after major abdominal surgery. A prospective, randomised, double-blind clinical trial.

BACKGROUND: The primary aim of this study was to compare the efficacy of combined spinal-epidural (CSE) analgesia vs. intermittent bolus epidural analgesia (EA) for pain relief after major abdominal surgery. The secondary aim was to assess the effects of fentanyl addition to subarachnoid morphine and bupivacaine. METHODS: This was a prospective, randomised, double-blind trial; 160 patients scheduled for major abdominal surgery enrolled. All patients had a thoracic epidural catheter for administration of intra-operative and postoperative analgesia. Patients were assigned to one of four groups: (i) subarachnoid morphine, bupivacaine and fentanyl (MBF group); (ii) morphine and bupivacaine (MB group); (iii) morphine (M group) and (iv) normal saline (EA group). Use of additional intravenous (i.v.) fentanyl and epidural bupivacaine was recorded to measure the need for supplemental intra-operative analgesia. Pain at rest, with movement, and with cough (measured with a visual analogue scale), additional analgesia requests, and side effects were recorded over 72 h postoperatively. RESULTS: Compared with the EA group, the MBF group had significantly reduced pain with cough and lower analgesia requirements during the first 24 h (p<0.001) and after EA discontinuation (p=0.041). The MBF group required less intra-operative epidural bupivacaine compared with all other groups (p<0.001), and less intra-operative i.v. fentanyl compared with group M (p<0.001). CONCLUSIONS: Combined spinal-epidural improved intra-operative analgesia and reduced pain with cough in the immediate postoperative period. The addition of fentanyl to subarachnoid morphine and bupivacaine decreased the need for additional i.v. fentanyl and epidural bupivacaine analgesia.

[Current opinion in epidural analgesia influence on incidence of complications after major abdominal surgery].

Review article summarizes current knowledge of general and epidural anaesthesia combination for major abdominal surgery and incidence of postoperative complications. Continuous epidural local anaesthetics especially through thoracic placed epidural catheter decrease opioids use and as part of "acute rehabilitation" plays important role in postoperative recovery. Most of the studies showed tion is not dependent on kind of anaesthesia and analgesia. Successfully treated postoperative pain prevents chronic postoperative pain, which is best achieved in abdominal surgery with thoracic epidural use.

Successful outcome after a technically challenging liver transplant during pregnancy.

Little is known about the implications of liver transplantation (OLT) during pregnancy. We report the case of a 26-year-old woman with cryptogenic familial biliary cirrhosis that decompensated rapidly. OLT was performed using the donor iliac vein for a retrogastric portal vein conduit to the superior mesenteric vein and the donor iliac artery for an infrarenal aortic conduit. During the latter anastomosis, a viable fetus was noticed. Both donor and recipient were cytomegalovirus positive. Postoperative ultrasound revealed a 13.5-week-old viable fetus. The patient received tacrolimus, azathioprine, and prednisolone. The pregnancy progressed normally with the vaginal delivery of a healthy male infant after 36 weeks gestation. Nineteen months later, both the mother and child were well. This case demonstrated that even technically difficult OLT during pregnancy can have a successful outcome, raising the question of whether transplant patients of childbearing age should be routinely tested for pregnancy.

[Combined spinal-epidural anaesthesia for urgent Hartmann's procedure].

A 46- year old patient without previous history of general anaesthesia was admitted for urgent Hartman's procedure. The suspected tumor of sigmoid colon caused the obstructive ileus with extreme abdominal distension and threatened colon perforation. After induction of anaesthesia and adequate muscle relaxation it appeared that endotrh ileus because of possible regurgitation and aspiration.

[Mediastinitis caused by tonsillitis ]. / Medijastinitis kao posledica tonzilitisa.

We report case of 50-year-old female with mediastinitis due to tonsillitis. Mediastinitis was diagnosed after five days according to clinical signs, radiological examination and computerized tomography scan. The patient underwent mediastinal drainage through a cervical incision and bilateral thoracic drainage because of bilateral pleural empyema. Initial broad-spectrum antibiotic therapy was replaced with imipenem, amicacin and vancomycin after the bacteriological investigation revealed susceptibility to isolated acinetobacter spp, staphylococcus spp coagulase-negative, enterococcus and staphylococcus. After 46 days of hospitalization patient went home.

[Treatment of severe anemia and gastrointestinal tract hemorrhage in a Jehovah's Witness]. / Tretman Jehovinog svedoka sa teskom anemijom i krvarenjem iz gastrointestinalnog trakta.

This case report discribes the treatment of 67-year-old Jehovah's Witness with severe anemia and gastrointestinal haemorrhage from gastric leiomyoma and peptic ulcer. Minimal invasive surgery with meticulous hemostasis, controlled hypotension, hyperoxic normovolemia and normotermia were main principles. Minimal blood samples for necessary laboratory parameters and noninvasive onitoring were ways to decrease iatrogenic blood loss. The operative and postoperative period were uneventful and well tolerated. The patient was discharged home after eighteen days and well in follow up period.

[Esophagus preserving surgery--eversion and mucosal stripping]. / Postedna hirurgija jednjaka--everzioni i mukozni stripping.

The eversional stripping and esophageal mucosal stripping methods as standard procedures in the preserving esophageal surgery are presented in this paper. These procedures have indication limit and results are excellent in selected risk dependent group of patients. This review describes technique, indications and advantages of these techniques in comparision with conventional finger esophageal dissection.

[Mediastinitis--diagnosis and therapy]. / Medijastinitis-dijagnostika i lecenje.

Mediastinitis is serious, life-threating infection. Desceding necrotizing mediastinitis is a form of mediastinitis with mortality rate of 40%. It develops as a complication of odontogenic and deep cervical infection. Early diagnosis and therapy are the most important issues. Computed tomographic scan is suggested if odontogenic infection is complicated with dyspnea. Mediastinitis is usually polymicrobial infection. Transcervical mediastinal drainage and intravenous antibiotic therapy are suggested. In some [figure: see text] cases aggressive mediastinal drainage by thoracotomy approach is performed.

[Epidural analgesia in total gastrectomy--combination of bupivacaine with ketamine or fentanyl]. / Epiduralna analgezija za totalnu gastrektomiju--kombinacija bupivakaina sa ketaminom ili fentanilom.

The effects of intraoperative epidural administration of ketamine added to bupivacaine were compared with fentanyl added to bupivacaine in patients undergoing total gastrectomy. Prospective, randomized, double blind study was designed to compare: group F: 20 patients (pts) receiving 20 ml of 0.125% bupivacaine and 50 ug of fentanyl and group K: 20 pts in whom 20 ml of 0.125% bupivacaine was combined with 50 mg of ketamine. Pts received an epidural injection through peridural catheter introduced through either T7-8 or T8-9 interspinous space. Non invasive arterial blood pressure, heart rate and ECG were recorded every 5 mins. We measured supplementary fentanyl requirement, ephedrine consumption, first postoperative complain on pain, tracheal extubation time. The groups were comparable with regard to patients characteristics, operation and anaesthesia related factors. There were no difference between groups in mean intraoperative fentanyl requirements (F vs. K = 118.5 (122.5) ug vs. 122.5(122.5)ug) (p n > 0.05), in the duration of epidural pain relief (F vs. K = 393.72 (98.75)min vs.403.63 (111.41)min, in the tracheal extubation time (F vs.K = 52.31 (50.4) vs.46.75 (48.35) min), postoperative sedation score (F vs.K = 1.26 (0.73) vs.1.11 (0.32)) (p > 0.05). Significantly higher systolic blood pressure was measured in group K comparing with group F in 20, 75, 105, 120, 150 min (p > 0.05). Statistically significant more ephedrine was applied in F group (F vs.K = 0.88(1.76)ml vs.0.05(0.23)ml) (p > 0.05). There were no statistically significant differences between groups in heart rate during the operation. None of the pts complained of bad dreams or awakeness during operation. Both fentanyl and ketamine added to bupivacaine and given as a bolus provided good intraoperative analgesia in combination with general anaesthesia, minimal sensorimotor disturbance and early tracheal extubation. In our study fentanyl added to bupivacaine caused higher incidence of hypotension than ketamine added to bupivacaine.

[Application of surveyor in designing partial denture. 4. Partial denture designing and preparation of master model for duplication in surveyor]. / Primena paralelometra u planiranju i izradi parcijalne skeletirane proteze. IV deo: planiranje skeletirane proteze i priprema modela za dubliranje u paralelometru.

The article "Partial denture designing and preparation of master model for duplication in surveyor" is the last of four articles from a series which deals with application of surveyor in designing partial denture. The aim of this article is to describe partial denture designed as "step by step method". The operation with the surveyor, which supposes obligatory analysis of stady casts in order to prepare the supporting tissues, determination of the optimal part of denture insertion and finding of 2 heights of contour, gives this concept a biological character. Such designed partial dentures meet the prophylaxis requirements and have desired retention; they are comfortable and look well. As the suggested concept of partial denture design in surveyor represents the present achievements, in the conclusion of this paper its obligatory application is suggested.

[Application of surveyor in designing partial denture. 3. Analysis of the study cast in surveyor]. / Primena paralelometra u planiranju i izradi parcijalne skeletirane proteze. III deo: Analiza modela za studije u paralelometru.

The widely accepted method in partially edentulous treatment plan is the analysis of study cast. In our practice, however, various excuses are enumerated in order to avoid this method. The aim of this paper is to describe stages of the analysis of study cast in surveyor and to emphasize advantages of this therapy. Study cast analysis enables a real view of occlusion, morphological characteristics of abutment teeth and presents information about possible metal framework design. The conclusion of this paper is that the analysis of study cast could be an obligatory stage in preparing a patient partially edentulous treatment.

[The influence of different conditions of refractory mold preparation on precision of casting of Co, Cr, Mo alloys]. / Uticaj razlicitih uslova pripreme vatrostalnog bloka na preciznost oklivka od Co, Cr, Mo legure.

The following hypothesis was made: different conditions of preparation and heat treatment of refractory mold change its physical and mechanical characteristics which is of great importance for the precision of casting of Co, Cr, Mo alloys. To prove this hypothesis measurements of setting time, setting and thermal expansion and transverse strength were performed regarding the relationship between the powder and the liquid of investment. The research was carried out on "Politerm C", "Rema Exakt" and "Widerit" investments. The obtained results proved the hypothesis that different conditions during the preparation of refractory mold had a certain influence on the quality of casting of Co, Cr, Mo alloys. The domestic investment was approximately of the same quality as the tested investments of foreign origin.

[The role of guide planes in the retention of removable partial dentures]. / Uloga vodecih povrsina u retenciji parcijalnih proteza.

Modern understanding of the retention mechanism of partial denture assumes that the path of insertion and the path of displacement of denture form a definite angle. The denture is possible to insert in a given direction only after forming guide planes which, in the same time, possible take part in retention of denture. The aim of this work was to test the hypothesis that the preparation of guide planes and bending of models in the surveyor brings, the rigid parts of framework to increase the ability of denture to be kept on supporting tissue. The research was performed on the frameworks of denture which were of same design and models with and without preparation guide planes. Total of 60 framework removings from the vertical direction were made under the different conditions of the measurement, using universal electronic machines.

[Anatomical and histological characteristics of proximal surfaces of abutment teeth]. / Anatomske i histoloske karakteristike aproksimalnih povrsina retencionih zuba.

When the guide planes are formed on the proximal surfaces of abutment teeth the part of enamel is removed. Thickness of enamel and inclination of tooth are the factors that limit the possible tooth reduction. In this report anatomical and histological characteristics of proximal surfaces of the abutment teeth are analysed. Thickness of the enamel has been measured using the optical microscope for 280 prepared teeth. Measurements were performed on four zones of tooth's proximal surfaces, on the different distances from the top of enamel edge. Undercut of 420 proximal surfaces of tooth have been determined by micro-analyser with accuracy of 0.05 mm. By comparing the mean values of enamel thickness, in occlusal thirds, and undercut of proximal surfaces, it is possible to conclude that the formed guide plane remains in the enamel even after the removing of all natural undercuts.