Axial rotation and pain are associated with facet joint osteoarthritis in adolescent idiopathic scoliosis.

OBJECTIVE: Facet joints are crucial for spinal stability but develop premature osteoarthritis in patients with adolescent idiopathic scoliosis (AIS). Here, we evaluated the association between facet joint cartilage and subchondral bone homeostasis, perceived back pain and 3-dimensional spinal deformity to better understand the role of facet joint degeneration in AIS progression and pain. METHOD: The osteoarthritic state of cartilage and bone of AIS facet joint surgical samples were characterized using histological OARSI scoring, visual morphological grading and µCT analysis, respectively. Back pain was self-reported using a numerical rating scale and expressed relative to the location on the patient's back. The scoliotic curves from our patient cohort were digitally reconstructed using biplanar radiographs and the eOS system (EOS imaging). The deformity was then reduced to three intervertebral angles (coronal, sagittal and axial) for each pair of bilateral facet joints. Statistical associations between the intervertebral angles, osteoarthritis parameters and pain intensity were performed using the Spearman method and Friedman test. RESULTS: Facet joint cartilage degeneration was associated with decreased subchondral bone volume and quality. Most importantly, asymmetrical, and overall degeneration of facet joints was strongly correlated to intervertebral axial rotation. Additionally, kyphotic intervertebral segments in the sagittal plane were good predictors of increased facet joint degeneration and back pain. CONCLUSION: Facet joint degeneration is associated with axial deformity, kyphotic intervertebral angle and back pain intensity in AIS. These results suggest that facet joints are important features to consider for rotational instability in AIS spines and related disease progression and perceived back pain.

Anesthetic Management for Left Ventricular Assist Device Implantation Through Left Thoracotomy: Evaluation of On-Pump Versus Off-Pump.

BACKGROUND: Ventricular assist devices (VADs) are alternative approaches to medical treatment in patients with acute or chronic heart failure. The goal of this study was to compare an anesthetic approach in patients undergoing implantation of a VAD with (on-pump) or without (off-pump) cardiopulmonary bypass (CPB) through left thoracotomy. METHODS: A total of 32 patients were divided into 2 groups: on-pump (group 1) and off-pump (group 2). A standard anesthesia protocol was used in all patients. Baseline characteristics of the patients, intraoperative hemodynamic and respiratory variables, anesthetic agents and vasoactive drugs administered, the amount of blood products, extubation, length of hospital stay and intensive care unit stay, and postoperative complications were recorded. RESULTS: Patients' mean age was 54.7 ± 13.3 years (range, 18-74 years). Eighteen patients underwent surgery with CPB. Demographic data of the patients, preoperative characteristics, intraoperative use of blood products, intraoperative complications, and anesthetic drugs used were similar between groups (P > .05). The duration of surgery (219 ± 23 vs 273 ± 56 minutes) and anesthesia (274 ± 38 vs 323 ± 57 minutes) were shorter in group 2; there was no difference between the 2 groups in terms of mechanical ventilation time, length of stay in the intensive care unit, and length of hospital stay. There was no decrease in postoperative oxygen parameters and an increase in patient lactate levels with the use of CPB. The use of fresh frozen plasma and platelet suspension in the postoperative period was significantly higher in group 1 (P < .05). The rate of complications and mortality rate were comparable between the 2 groups (P > .05). CONCLUSIONS: Our study results show that the use of CPB during VAD implantation via left thoracotomy increases operation time and use of blood products, while causing no change in the rate of complications.

Postoperative Outcomes of the Largest HeartMate-II Experience in Turkey.

INTRODUCTION: HeartMate II (HMII; Thoratec Corporation, Pleasanton, Calif, United States) is a continuous-flow pump approved by the Food and Drug Administration (FDA) for bridge-to-transplantation (BTT) since 2008 and for destination therapy (DT) since 2010. Herein, we present the postoperative outcomes of HMII implantation due to end-stage heart failure in our center. METHODS: Twenty-eight patients (mean age, 51.2 ± 8.7 years; 1 female) were implanted with the HMII between August 2012 and August 2014. Indications were dilated (n = 18) and ischemic (n = 10) cardiomyopathy. The intended treatment was BTT in 24 and DT in 4 patients. Preoperative clinical status was International Registry for Mechanical Circulatory Support (INTERMACS) 2, 3, and 4 in 6, 14, and 8 patients, respectively. The procedure was performed via conventional sternotomy under cardiopulmonary bypass. Heparin, acetylsalicylic acid, and warfarin were used for postoperative anticoagulation. RESULTS: Mean duration of support was 326 days (median, 272). Three patients underwent heart transplantation and 22 remain on pump support. One patient died before discharge due to respiratory failure and 2 others died following a cerebral bleeding 248 and 265 days postoperatively, respectively. The survival rates at 6 and 12 months were 96% and 90%, respectively. Temporary right ventricular failure was observed in 2 patients. Two patients had pump thrombosis treated with anticoagulation management or pump exchange, whereas another patient who had aortic root thrombosis underwent reoperation for removal of the thrombus. DISCUSSION: Mechanical circulatory support with HMII axial flow pump seems to be effective and may provide good survival rates compared with optimum medical management and old-generation devices. Patient selection and timing of implantation are crucial for success.

Anesthetic Management for Left Ventricular Assist Device Implantation Without Using Cardiopulmonary Bypass: Case Series.

PURPOSE: Ventricular assist devices are an alternative to medical treatment in patients with hemodynamic disturbances related to acute or chronic congestive heart failure. In this case series, we present our anesthesia management for implantation of left ventricular assist device (LVAD) with thoracotomy. METHOD: Sixteen patients with end-stage heart failure undergoing LVAD implantation via thoracotomy between November 2012 and August 2014 were analyzed prospectively. Preoperative characteristics, intraoperative hemodynamic and respiratory parameters, use of anesthetic and blood products, and durations of mechanical ventilation, hospital, and intensive care stays were recorded. RESULTS: Sixteen patients (mean age, 54.6 ± 13 years) were investigated. Single-lung ventilation was applied to 2 patients. Cardiopulmonary bypass (CPB) was required in 5 patients. Intraoperative ketamine, midazolam, fentanyl, and rocuronium requirements were 112 ± 63 mg, 5.5 ± 3.5 mg, 438 ± 187 µg, and 179 ± 49 mg, respectively. Requirements of fresh donor blood, fresh frozen plasma, and thrombocyte and erythrocyte suspension were 1.19 ± 1, 1 ± 0.8, 0.44 ± 0.5, and 0.25 ± 0.7 U, respectively. Durations of mechanical ventilation, intensive care unit, and hospital stay were 46 ± 53 hours, 8.2 ± 6.6 days, and 20.5 ± 11.6 days, respectively. Twelve patients were discharged from hospital with full recovery and 2 patients died; 2 patients are still receiving treatment in the hospital. CONCLUSION: A left thoracotomy approach can be used without CPB, because it reduces the incidences of pump complications and blood transfusion. In addition, this case series showed that the implantation of LVAD by thoracotomy can be implemented securely with single-lumen endotracheal tube without single-lung ventilation.

Anesthesia for cardiac transplantation: experience from a single center.

BACKGROUND: Cardiac transplantation has become the established therapeutic modality in patients with end-stage heart failure. This article presents our institution's clinical experience in the anesthetic management of patients who underwent cardiac transplantation between February 1998 and August 2012. METHODS: In our institution, 175 patients (136 males and 39 females) diagnosed as having end-stage heart failure have undergone cardiac transplantation between February 1998 and August 2012. A retrospective review performed on this series of patients sought to analyze elements of perioperative anesthetic care, including preoperative characteristics, general anesthia, and blood product usage. RESULTS: The patients were diagnosed as having either nonischemic cardiomyopathy (n = 128; 73%) or ischemic cardiomyopathy (n = 47; 27%). Seventy-three of them had undergone previous cardiac surgery. Invasive arterial, central venous, and pulmonary arterial pressures were monitored as well as intraoperative transesophageal echocardiography. Etomidate was used as the induction agent in 158/175 patients (average dose, 18.67 ± 1.91 mg). The average intraoperative fentanyl dose was 898.85 ± 211.65 µg. Anesthesia was maintained with either end-tidal 2%-4% sevoflurane (n = 132) or 4%-6% desflurane (n = 43). Dopamine, dobutamine, and epinephrine were used after weaning from cardiopulmonary bypass and continued upon exiting the operating room in 168, 159, and 143 patients, respectively. Inhaled nitric oxide (20-40 ppm) was used in 37 patients (21%). The total amount of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were 2.95 ± 2.05 (range, 1-15), 1.29 ± 0.97 (range, 0-6), and 1.23 ± 2.29 (range; 0-12) units, respectively. On average, patients were extubated 16 hours after arrival in the intensive care unit where they remained to day 6. A total of 67 patients (38%) died during the follow-up; infection and right ventricular failure were the most common causes. CONCLUSION: Anesthesia for cardiac transplantation requires an appreciation of heart failure pathophysiology, invasive monitoring, and skillful anesthetic and postoperative care.

Anesthesia for ventricular assist device placement: experience from a single center.

BACKGROUND: Circulatory support with ventricular assist systems has become a treatment alternative for patients with end-stage heart failure owing to the donor shortage. In this report, we have presented our institution's clinical experience in the anesthetic management of ventricular assist device (VAD) implantation. METHODS: Between April 2007 and August 2012, VAD implantation was performed in 84 adult patients with end-stage heart failure. The group included 75 male and 9 female patients of overall mean age, 47.6 ± 13.4 years. Our retrospective review analyzed elements of perioperative anesthetic care, including preoperative characteristics, general anesthetic care, and blood product usage. RESULTS: The indications for VAD implantation were dilated (n = 59; 70%) or ischemic cardiomyopathy (n = 25; 30%). An intra-aortic balloon pump had been placed in 16 patients. We monitored invasive arterial and central venous pressures as well as intraoperative transesophageal echocardiography. Etomidate was used as the induction agent in 79 of 84 patients (average dose, 18.75 ± 1.40 mg). Intraoperative fentanyl dose was 939.69 ± 212.44 µg. Anesthesia was maintained with sevoflurane (n = 55) or desflurane (n = 29). Dopamine, dobutamine, epinephrine, norepinephrine, and levosimendan were used in 74, 79, 60, 14, and 32 patients, respectively. Inhaled nitric oxide was administered to 38 subjects (45%). The amounts of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were 3.96 ± 2.78, 1.91 ± 1.21, 1.80 ± 2.48 u, respectively. On average, patients were extubated 13 hours after arrival in the intensive care unit and discharged therefrom on day 8. Thirty-one patients were successfully bridged to heart transplantation. While 27 patients (32%) died during the follow-up period, 26 are still living on VAD support. CONCLUSION: Among patients undergoing VAD implantation, the anesthesiologist should become familiar with the device and consider the severity of cardiac and other end-organ dysfunction.

Anesthesia for ventricular assist device placement in pediatric patients: experience from a single center.

BACKGROUND: The use of a ventricular assist device (VAD) as a bridge to heart transplantation in the pediatric population has evolved over the past decades This article presents our institution's clinical experience in the anesthetic management of pediatric patients with end-stage heart failure who underwent implantation of a VAD between June 2009 and August 2012. METHODS: Between February 2011 and August 2012, implantation of a VAD was performed in 10 children of mean age 8.6 years. This retrospective review analyzed their perioperative anesthetic care. RESULTS: All patients had end-stage heart failure due to dilated cardiomyopathy. We used invasive arterial and central venous pressure monitoring and intraoperative transesophageal echocardiography in conjunction with intravenous administration of either ketamine (1 mg/kg) and midazolam (n = 3) or thiopental (3-5 mg/kg; n = 7). The mean intraoperative fentanyl dose was 434 ± 264.27 µg. Anesthesia was maintained with sevoflurane. Dopamine, dobutamine, and epinephrine were infused in 8, 10, and 5 patients, respectively. Inhaled nitric oxide was administered to all patients. The amounts of perioperative blood, fresh frozen plasma, and thrombocyte suspension transfusions were be 2.3 ± 0.82 (range, 1-4), 1.6 ± 0.69 (range, 1-3), and 2.4 ± 1.42 (range, 0-4) units, respectively. On average, patients were extubated 23 hours after arrival in the intensive care unit and exited there on day 6. Six patients were successfully bridged to heart transplantation, 2 died during the follow-up, and 2 patients remain on VAD support. CONCLUSION: VAD is increasingly being used as a bridge to heart transplantation in the pediatric population. Anesthesiologists must be vigilant about the pathophysiology of heart failure, the operative procedure, and the implanted device.

The neuromuscular effects of 0.6 mg kg(-1) rocuronium in elderly and young adults with or without renal failure.

BACKGROUND AND OBJECTIVES: The elderly represent a wide and increasing patient population and significant numbers of elderly patients have chronic renal disease. This study aimed to investigate the neuromuscular effects of 0.6 mg kg(-1) rocuronium under propofol anaesthesia in young adults and elderly patients with or without renal failure. METHODS: The neuromuscular effects of rocuronium 0.6 mg kg(-1) under propofol anaesthesia were investigated in 40 patients with renal failure undergoing arteriovenous shunt surgery, of whom 20 were young adults (18-50 yr) and 20 were elderly (>65 yr) and in 40 patients with normal renal function undergoing peripheral venous surgery, of whom 20 were young adults and 20 were elderly. Neuromuscular transmission was monitored using acceleromyography. The times to recovery of the twitch (T1) to 25%, 50%, 75% and 90% and of the train-of-four ratio to 70%, and the recovery index were recorded. RESULTS: The times to recovery of the first twitch to 25%, 50%, 75% and 90% and train-of-four to 70% and recovery index were found to be prolonged in both young and elderly patients with renal failure compared to those with normal renal function (e.g. T1 25%: 58.4 +/- 20.2 and 80.1 +/- 23.7 min vs. 32.8 +/- 5.6 and 46.3 +/- 9.0 min, respectively) (P < 0.05). These parameters were also prolonged in the elderly when compared with young adults in both the renal failure and the non-renal failure groups. CONCLUSIONS: The neuromuscular effects of 0.6 mg kg(-1) rocuronium under propofol anaesthesia were markedly prolonged in young and elderly renal failure patients compared to patients with normal renal function, and also in elderly patients with normal renal function compared with young adults.

Infiltration of the sternotomy wound and the mediastinal tube sites with 0.25% levobupivacaine as adjunctive treatment for postoperative pain after cardiac surgery.

BACKGROUND AND OBJECTIVE: This study aimed to investigate the effect of 0.25% levobupivacaine infiltration of the sternotomy wound and the mediastinal tube sites on postoperative pain, morphine consumption and side-effects in patients undergoing cardiac surgery. METHODS: After obtaining Ethics Committee approval and informed consent,50 patients aged 18-65 yr, undergoing coronary artery bypass grafting, were included in this study. Anaesthesia was induced with 5 microg kg (-1) fentanyl, 0.3 mg kg (-1) etomidate, 1 mg kg (-1) lidocaine, 0.1 mg kg (-1) vecuronium and maintained with 1-2% sevoflurane, 50% oxygen in air and fentanyl. Patients were randomized into two groups before sternal wire placement: sternotomy and mediastinal tube sites were infiltrated with either 60 mL 0.25% levobupivacaine (infiltration group, n = 25) or 60 mL saline placebo (control group, n = 25). All patients received intravenous morphine patient-controlled analgesia (bolus dose: 2 mg, lock-out time: 15 min, 4 h limit: 20 mg) after extubation. Postoperative pain at rest and on coughing was assessed by a visual analogue scale (0-10). Pain scores,sedation scores (Ramsay scale), haemodynamic and respiratory parameters, arterial blood gases and morphine consumption were recorded. RESULTS: The times to extubation and visual analogue scale scores were similar between groups. Morphine consumption at 24 h was significantly lower in the infiltration group compared with the control group (29.5 +/- 5.1 vs. 42.8 +/- 4.7 mg, respectively, P < 0.05). The sedation scores were found to be significantly higher in the control group when compared with the infiltration group at 1, 2 and 4 h after extubation (P < 0.05), whereas sedation scores after 4 h were similar between groups. CONCLUSION: Infiltration of the median sternotomy incision and the mediastinal tube insertion sites with 0.25% levobupivacaine in addition to morphine patient-controlled analgesia was found to be effective in reducing postoperative morphine consumption when compared with morphine patient-controlled analgesia alone during the initial 24 h after cardiac surgery.

The efficacy of intrathecal morphine in post-thoracotomy pain management.

This study compared the analgesic efficacy of intrathecal (IT) morphine plus IV patient-controlled analgesia (PCA) morphine with IV PCA morphine alone in 33 patients undergoing thoracotomy randomized to two groups: the IT morphine group (n=17) received 10 microg/kg morphine 1 h before the end of surgery, while the control group (n=16) did not. All patients had access to an IV PCA pump post-operatively that delivered 2 mg morphine boluses. Post-operative pain and sedation scores, respiratory and haemodynamic parameters, and morphine demand and delivery were assessed up to 48 h. Post-operative pain scores and morphine consumption were significantly reduced, while peak expiratory flow rates were significantly increased in the IT morphine group compared with controls. We concluded that IT morphine in addition to IV PCA established superior analgesia and maintained better respiratory function compared with IV PCA alone in post-thoracotomy patients.

The effects of sufentanil or morphine added to hyperbaric bupivacaine in spinal anaesthesia for caesarean section.

BACKGROUND AND OBJECTIVE: The quality of spinal anaesthesia, often used for Caesarean section, can be improved by adding an opioid to the local anaesthetic. This study compared the quality of anaesthesia, postoperative analgesia, and adverse effects on mother and neonate when either sufentanil 5 microg or morphine 0.2 mg was added to intrathecal hyperbaric bupivacaine for Caesarean section. METHODS: This prospective, randomized and double-blind study encompassed 54 females undergoing Caesarean section. Spinal anaesthesia was obtained with 2 mL of 0.5% bupivacaine supplemented with either 0.2 mg morphine or 5 microg sufentanil. Characteristics of spinal block, intraoperative analgesia, maternal and neonatal side-effects and the time to first request for analgesics were assessed. RESULTS: There were no differences in the onset time of sensory block, time to sensory block to T10, time to highest sensory block, highest sensory block level, time to regression of sensory block to T10 level and time to resolution of motor blockade. Perioperative haemodynamic parameters, neonatal Apgar scores, neurological and adaptive capacity scores, umbilical blood gas values, sedation scores, nausea-vomiting and pruritus incidences were similar in both groups. The time to the first request for an analgesic was significantly longer (19.5 +/- 4.7 h vs. 6.3 +/- 5.2 h) in patients given morphine (P < 0.05). CONCLUSIONS: The addition of 5 microg sufentanil or 0.2 mg morphine to hyperbaric bupivacaine for Caesarean section both provided safe and effective anaesthesia. Morphine increased the duration of postoperative analgesia compared with sufentanil without increasing maternal or neonatal side-effects.

Ondansetron does not block tramadol-induced analgesia in mice.

Tramadol is a weak opioid agonist and an inhibitor of the reuptake of noradrenaline and serotonin. This study was undertaken to assess a possible pharmacological interaction of ondansetron, a serotonin-3 (5-hydroxytryptamine-3, 5-HT3) antagonist, and tramadol in an animal model for acute pain. Sixty-three male albino mice were randomly given saline, tramadol (10, 20, and 40 mg kg(-1)), ondansetron (1, 2, and 4 mg kg(-1)), or ondansetron (1, 2, and 4 mg kg(-1)) and tramadol (20 mg kg(-1), given 10 min after ondansetron injection) intraperitoneally. Each mouse was assessed twice for tail-flick latency before saline or drug administration and 15, 30, 60, 90, and 120 min thereafter. Tramadol (10 mg kg(-1)) had no effect on pain threshold levels of mice, but tramadol doses of 20 or 40 mg kg(-1) increased pain threshold levels in a dose-dependent manner (p < 0.01 for 20 mg kg(-1) and p < 0.001 for 40 mg kg(-1)). Ondansetron doses of 1, 2, or 4 mg kg(-1) alone had no effect on pain threshold levels of mice. Tramadol (20 mg kg(-1)) and ondansetron (1, 2, and 4 mg kg(-1)) increased pain threshold levels at all doses (p < 0.001 for 1 and 2 mg kg(-1) ondansetron and p < 0.01 for 4 mg kg(-1) ondansetron). The pain threshold levels of mice given tramadol (20 mg kg(-1)) alone or tramadol and ondansetron (p > 0.05 for 1, 2, and 4 mg kg(-1)) were similar. Our results indicate that ondansetron-a 5-HT3 selective antagonist-does not decrease the analgesic effectiveness of tramadol in mice, which may be the result of different mechanisms involving 5-HT3 receptors.

The use of tramadol and morphine for pain relief after abdominal hysterectomy.

OBJECTIVE: The aim of this study was to determine whether the addition of a tramadol infusion to morphine patient-controlled analgesia (PCA) results in improved analgesic efficacy compared with morphine PCA alone after abdominal hysterectomy. METHODS: Sixty patients undergoing abdominal hysterectomy were randomized into two groups, each receiving IV morphine PCA after surgery. The tramadol group received a loading dose of tramadol (1 mg/kg) at skin closure and a postoperative infusion of tramadol at 0.2 mg/kg/h. The control group received an equivalent volume of saline at skin closure and a postoperative saline infusion. RESULTS: The addition of a tramadol infusion to morphine PCA was associated with lower pain scores, a reduction in PCA morphine requirements (27 +/- 4.6 mg vs 40.5 +/- 5.4 mg over 24 h) and improved patient satisfaction with pain relief (p < 0.05). No intergroup differences were found with regard to sedation, nausea and antiemetic use (p > 0.05). CONCLUSION: The addition of a tramadol infusion to morphine PCA resulted in improved analgesic efficacy and reduced morphine requirements compared with morphine PCA alone after abdominal hysterectomy.

The evaluation of diagnostic accordance between plain radiography and bone scintigraphy for the assessment of sternum and rib fractures in the early period of blunt trauma.

OBJECTIVE: To evaluate the diagnostic accordance between scintigraphy and radiography in the early period following blunt thoracic trauma. DESIGN: Double-blind, prospective clinical study. METHODS: Thirty-four adult patients with blunt thoracic trauma were examined by plain radiography and scintigraphy within 24 hours of trauma. RESULTS: Radiography displayed pathologies in 25 (73.5%), while scintigraphy suggested pathologies in 24 (70.5%) patients. Rib fractures were identified radiographically in 16 (47%) and scintigraphically in 17 (50%) patients. Lateral radiograph of the sternum showed fracture in 10 (52.6%), while scintigraphy suggested fracture in 14 (73.6%) patients with suspected sternal trauma. CONCLUSION: Scintigraphy gave better results in the evaluation of sternal fractures during the early period of thorax trauma. Conventional plain radiography is thought to be the initial imaging modality, because it saves time and shows hemothorax or pneumothorax besides the osseous abnormality.