[Fascia iliaca Block with General Anaesthesia vs. Subarachnoid Morphine Block in Total Hip Arthroplasty]. / Blokáda fascia iliaca s celkovou anestezií vs. subarachnoidální blokáda s morfinem u totální náhrady kycelního kloubu.

PURPOSE OF THE STUDY Many physicians believe that loco-regional anaesthesia and analgesia improve the postoperative course of patients indicated for total hip arthroplasty compared to general anaesthesia. However, there are many patients who refuse subarachnoid or epidural anaesthesia, or have contraindications or conditions making the use of such techniques impossible. An alternative option is the combination of general anaesthesia and a peripheral nerve blockade. The aim of this prospective randomized open-label clinical trial was to compare the efficacy and quality of postoperative analgesia between fascia iliaca block combined with general anaesthesia (GA) and subarachnoid anaesthesia with morphine and bupivacaine (SAB). MATERIAL AND METHODS After having obtained the ethics committee approval and the patients consent, a prospective, open-label, randomized trial was conducted in patients referred for total hip arthroplasty (THR). The GA group was administered ultrasound-guided fascia iliaca block with 40 ml of 0.25% bupivacaine solution after the induction of general anaesthesia. In the SAB group, subarachnoid blockade was performed with a mixture of 3 ml of 0.5% bupivacaine with 0.150 mg morphine prepared in the hospital pharmacy. Right after surgery the patients were taken to the ICU for 24 hours, after which they were transferred to a general ward. In addition to vital signs monitoring, pain intensity using a 0-10 numeric rating scale (NRS), first morphine administration at NRS >4, total morphine consumption and potential adverse effects were observed over the period of 72 hours. RESULTS There was no statistical difference between the GA (14 persons) and the SAB (14 persons) group in demographic parameters, time to first morphine administration (10 hrs vs. 19 hrs, p=0.10), number of persons with no need for morphine after surgery (5 vs. 7), tingling sensation (1 vs. 0) or numbness of the limb (0 vs. 1). There was no difference in cardiorespiratory parameters or side effects of therapy. In neither case was there respiratory depression or delayed rehabilitation. No patient developed delirium after surgery, and no patient reported dissatisfaction with pain management. DISCUSSION The fascia iliaca block and subarachnoid anaesthesia using local anaesthetic with opioid addition have been repeatedly published for patients after total hip arthroplasty, but this study is unique by comparing the two methods. The study added a new piece of knowledge to the findings of several recent meta-analyses on the comparable outcomes of general and subarachnoid anaesthesia for hip replacement in the perioperative period. CONCLUSIONS If subarachnoid anaesthesia cannot be used in hip arthroplasty, general anaesthesia with fascia iliaca block provides comparable analgesia and quality of postoperative course. Key words: total hip arthroplasty, general anaesthesia, fascia iliaca block, subarachnoid anaesthesia, postoperative analgesia, postoperative course.

Can changes in skin impedance be used to monitor sedation after midazolam and during recovery from anesthesia?

It has been suggested that sympathetic activity, measured as changes in electrical skin impedance (SI), can be used to assess the adequacy of general anesthesia. Our prospective study investigated if measurements of skin impedance can determine levels of sedation induced by midazolam. Twenty-seven patients scheduled for arthroscopy requiring general anesthesia were served as their own control. These were blinded to the order of injections by telling them that they will be randomly administered a placebo (saline) orsedative agent. A DM 3900 multimeter was used for SI measurements. The degree of sedation was measured using the modified Observer's Assessment of Alertness and Sedation (mOAAS) scale. Resting SI values were noted, and all participants were then administered the placebo followed 5 min later by midazolam 2 mg i.v. Five min after that, patients were administered standard general anesthesia with propofol, oxygen, nitrous oxide 60 %, and isoflurane 1 MAC via a laryngeal mask, and sufentanil 5 - 10 µg. SI significantly increased after administration of midazolam and induction of anesthesia. There were no significant differences between pre-administration (baseline) and placebo and end of surgery and end of anesthesia with closed eyes. There were highly significant differences (p<0.001) between pre-administration vs. midazolam, placebo vs. midazolam, pre-administration vs. induction of anesthesia. We found slight correlation between mOAAS and SI. There were no significant changes between the end of surgery and the end of anesthesia with closed eyes, but SI significantly decreased (p<0.01) after eyes opened.

Non-traditional administration of remifentanil in an experimental setting.

Remifentanil is ultrashort-acting opioid with a unique pharmacokinetic profile. It is used exclusively intravenously. While considering its rapid onset of action and other pharmacokinetic properties, we decided to assess its effects following administration via non-traditional routes. Rabbits (n=10 per each group) were randomized into six groups: remifentanil 1 microg/kg and 3 microg/kg IM, 5.0 and 10.0 microg/kg conjunctivally, and 10 microg/kg and 25.0 microg/kg intranasally. Sedating effects were assessed via a loss of the righting reflex. Secondary, mean arterial blood pressure, arterial oxygen saturation of hemoglobin, and pulse rate was monitored in all rabbits. Non-traditional routes of administration were shown to provide a rapid onset of action as well as fast recovery. Importantly, the administration of remifentanil did not result in any deterioration of cardiovascular functions.

Sedative effects of intranasal oxytocin in rabbits and rhesus monkeys.

Oxytocin is a hormone therapeutically used mainly for its peripheral effects during pregnancy in the uterus and breasts. However, additional central effects, i.e. anxiolytic effect, decreased level of social stress and increased empathy have been also observed. Hence, the aim of our study was to evaluate if nasal oxytocin can be used as anxiolytic substance in rhesus monkeys (n=20) and rabbits (n=20). Simultaneously, mean arterial blood pressure, arterial oxygen saturation of hemoglobin and pulse rate were monitored in all the evaluated animals. While rabbits lost righting reflex, monkeys developed a dose-dependent loss of aggressiveness and/or anxiety as evaluated by behavioral methods (aggressive behavior was classified as non-sedated - sedated - strongly sedated).

Ephedrine accelerates psychomotor recovery from anesthesia in macaque monkeys.

BACKGROUND: Ephedrine is used in treatment of hypotension during anesthesia. We investigated its effects on the psychomotor recovery and its potential adverse reactions on cardiorespiratory functions in rhesus monkeys. METHODS: The monkeys received 50 µg/kg medetomidine, 2.0 mg/kg S-ketamine with 150 IU hyaluronidase i.m. Pulse rate, blood pressure and saturation of haemoglobin were monitored for 20 minutes. Thereafter, 1 mg/kg of ephedrine or a placebo was administered i.m. and behavioural changes, pulse rate, blood pressure and saturation of haemoglobin were monitored every 5 minutes. RESULTS: Ephedrine shortened recovery from anaesthesia from 80.4 ± 25.8 to 14.83 ± 13.70 minutes. Ephedrine also increased oxygen saturation of haemoglobin and systolic blood pressure and caused significant decrease in pulse rate 5 minutes after its administration. CONCLUSIONS: Ephedrine can be successfully used to accelerate psychomotor recovery after the use of common anesthetic protocols combining dissociative anesthetic agent and alpha 2-adrenoceptor agonist in primates.

[A combination of dexmedetomidine with ketamine and opioids results in significant inhibition of hemodynamic changes associated with laparoscopic cholecystectomy and in prolongation of postoperative analgesia]. / Kombinace dexmedetomidinu s ketaminem a opioidy významne potlacuje hemodynamické zmeny zpusobené laparoskopickou cholecystektomií a prodluzuje trváiní pooperacní analgezie.

THE AIM OF THE STUDY: Recently, alpha2 sympathoadrenergic drugs are used in premedication to improve the perioperative course. The aim of our study was to compare a premedication with a new alpha2 sympathoadrenergic drug and standard premedication. METHODS: After ethic committee approval and written patient consent, in a randomised, double-blinded study, combination of dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + fentanyl 1.0 microg x kg(-1) + atropine 0.5 mg (group FNT), dexmedetomidine 1.0 microg x kg(-1) + ketamine 0.5 mg x kg(-1) + alfentanil 5.0 microg x kg(-1) + atropine 0.5 mg (group ALFNT), or pethidine 1.0 mg x kg(-1) + atropine 0.5 mg (group Dolsin) was administered to a deltoid muscle 15 min. before anaesthesia (GA) in patients elicited for laparoscopic cholecystectomy (LCHE). GA was performed in a standard way, ECG, NIBP, respiration rate, SpO2, onset of effect, Observers Assessment of Alertness Sedation Score (OAASS) before GA, circulatory reaction to intubation and capnoperitoneum, fentanyl consumption during GA, time to the first request for post-operative analgesia and postoperative nausea and vomiting were measured. The data were processed by Kruskal-Wallis and Fisher tests. P-value < 0.05 was considered significant. RESULTS: There were 16 patients in FNT and Dolsin and 15 patients in ALFNT with no differences in demography except for younger age in ALFNT. The main differences were in hypertension during capnoperitoneum: 0/16 FNT and 1/15 ALFNT vs. 11/16 Dolsin, both p < 0.001, per-operative fentanyl consumption: FNT 31.5 microg vs. Dolsin 165.0 microg, p < 0.001 and ALFNT 50.0 microg, p < 0.05 (ALFNT vs. Dolsin, p < 0.01) and request to the first analgesic post surgery: FNT 1.3 h. vs. Dolsin 0.45 h., p < 0.05 vs. ALFNT 0.8 h., p < 0.01. There were no differences in side effects except for bradycardia in ALFNT (p < 0.05). CONCLUSIONS: Dexmedetomidine-ketamine-fentanyl-atropine combination is superior to pethidine-atropine combination in suppressing of adverse hemodynamic effects of capnoperitoneum, decreased need for analgesia during GA and prolonged postoperative analgesia.

[Knowledge level of cardiopulmonary resuscitation in secondary school students of non-medical specialisation in the Czech Republic]. / Uroveni znalostí studentu stredních nezdravotnických skol o neodkladné resuscitaci v Ceské republice.

BACKGROUND: Knowledge of cardiopulmonary resuscitation (CPR) is essential part of the first aid skill. Constant attention is given to education in CPR mainly among adolescents. The aim of our epidemiological study was to asses the actual level of theoretical knowledge in CPR. METHODS AND RESULTS: We have developed a simple questionnaire including 17 items with 4 possible answers, just one correct. The questionnaire was distributed to students of middle schools excluding those with medical specialisation. Total 796 students from 26 classrooms participated, 784 (98.5%) of questionnaires could be used for evaluation. Excluding the knowledge in the purpose of resuscitation mask and telephone number of Emergency service, the number of correct answers was below 30%, even in items, which did not change for many years (position of the victim's body during resuscitation, frequency of artificial ventilation). CONCLUSIONS: Our results demonstrate that in spite of the effort to increase the level of knowledge in CPR in laymen, the actual level of knowledge is low and more frequent repetition of courses should be considered. In the future, we shall evaluate the effectiveness of new educational film.

[Chronic post-mastectomy pain]. / Chronická bolest po operaci prsu.

BACKGROUND: Surgery results in chronic pain in 7-80 percent. One of the most studied is chronic post-mastectomy pain. The prevalence was 40-50 percent in studies performed abroad. As this problem has not yet been studied in the Czech Republic, a retrospective prevalence study was performed to asses the extent of the problem and risk factors for development of chronic post-mastectomy pain. METHODS AND RESULTS: After ethic committee approval an anonymous questionnaire was developed and distributed in various oncology department and patients'organisations. Response rate was 100 percent, 330 questionnaires were processed. Chronic post-mastectomy pain (lasting longer than 3 months after surgery) was described by 69 (20.9 per cent) women. The pain was permanent in 17 and transient in 46 cases, not specified in 6 cases. The pain intensity was predominantly mild or moderate. Risk factors were younger age (below 55-60 years, p=0.0098), less extensive surgery (tumourectomy vs. mastectomy, p=0.0017), intensive post operative pain (p=0.0002) and radiotherapy (p=0.0174). Trend in chemotherapy (p=0.0778) was observed. CONCLUSIONS: The prevalence of chronic post-mastectomy pain was lower in our study comparing to studies in other countries. The reason remains obscure in spite of detailed analysis.

[Patients' perioperative worries and experiences]. / Obavy a prozitky pacientu v perioperacním období.

AIM: The aim of this study was to detect the main causes of patients' preoperative distress and their subjective experiences. METHODS: After institutional ethic committee approval and patients consent an anonymous questionnaire was randomly distributed on the first and second postoperative day. Its content were basic demography, preoperative anxiety level using five point verbal scale, main cause; of anxiety, the worst postoperative experience, postoperative pain intensity (11 point scale) and its treatment incidence of postoperative nausea and vomiting (PONV) and other side effects of the surgery and the anesthesia. Correlations with specific patients' characteristics were searched for to determine the risk groups. RESULTS: Two hundred filled in questionnaires out of the 244 distributed could be used for further evaluation. Sixty-two per cent of patients suffered from preoperative anxiety, more women (p < 0.01) and more frequently after intra-abdominal (intra-thoracic) surgeries (p < 0.05). Forty-three per cent of patients had no subjective problems following surgery, others suffered more frequently from the postoperative pain (18.5 percent), PONV (11.5 percent) and postoperative procedures, e.g. changing of dressing, drains and from the postoperative regime. There was a correlation between PONV and both the intensity of postoperative pain and anamnesis of PONV during previous surgery (p < 0.01).

[Progress in surgical treatment may improve the quality of life in patients with breast surgery for malignant tumors]. / Pokroky v chirurgické lécbe mohou zlepsovat kvalitu zivota pacientek po operaci prsu pro zhoubný nádor.

Breast cancer surgery (BCS) is a common procedure performed in women. Chronic postmastectomy pain (PMP) has been reported in as many as 22-72 percent of patients. There are no published reports in Czech Republic. This study was performed to evaluate the prevalence and risk factors of PMP. An anonymous questionnaire was given to women after attending oncology departments in various hospitals during 3-month period. All 176 questionnaires have returned. The average age was 63.6 (SD 11.2) years, BMI 26.3 (SD 4.0). There was 23.6% of PMP prevalence in our group. The risk factors were younger age (below 60, p < 0.001, below 65, p < 0.01 resp.) and type of surgery (total mastectomy vs. tumour removal, p < 0.01). The prevalence of PMP in our study was significantly lower than in other studies. The age of our group was higher, than in other studies, but it does not explain the difference. We can hypothesise the reason is improved surgical technique.

[Infiltration of local anesthetics into the thyroid gland capsule for surgery and the postoperative period]. / Prínos infiltrace pouzdra stítné zlázy lokálním anestetikem pro operacní a bezprostrední pooperacní prubeh.

In a prospective randomized study the hypothesis was tested whether infiltration of the thyroid capsule by a local anaesthetic will reduce the haemodynamic response to surgical trauma, consumption of anaesthetics and opioids during surgery and will shorten the time of arousal. A total of 64 patients indicated for planned goitre surgery were divided at random into a control group (C, n = 32) and experimental group (LA, n = 32). The preoperative medication and anesthesia did not differ in the two groups. In group C into the thyroid capsule a maximum of 40 ml saline was administered, in LA the same volume of 0.5% trimecain. A highly significant difference was found (p < 0.001) in the incidence of hypertension during surgery (21 C vs. 5 LA) and the need of further pharmacological interventions (21 vs. 8). In the control group was a higher consumption (p < 0.95) of the opioid phentanyl (167.5 +/- 111 micrograms vs. 125 +/- 93.5 micrograms), a trend of longer arousal and the need to antagonize the effect of opioid (p < 0.1). The substitution of saline by a local anaesthetic for infiltration of the thyroid capsule is a safe and simple method leading to a reduction of cardiovascular complications during surgery.

[Adverse hemodynamic changes during laparoscopic cholecystectomy and their possible suppression with clonidine premedication. Comparison with intravenous and intramuscular premedication]. / Nezádoucí hemodynamické zmeny behem laparoskopických cholecystektomií a moznost jejich potlacení clonidinem v premedikaci. Srovnání intravenózní a intramuskulární premedikace.

Laparoscopic cholecystectomies have adverse haemodynamic effects which limit their use in risk patients with heart disease. This applies in particular to significant hypertension. The etiology is analysed in detail in a review of the literature. The authors confirmed in their work involving 21 patients the incidence of these effects and tried to suppress them by premedication with clonidine (CATAPRESAN, Boehringer). 21 patients were given 0.15 mg clonidine in an infusion 15 minutes before operation and 21 patients 0.15 mg clonidine by the i.m. route 60-90 min. before operation. Standard anaesthesia was administered. A highly significant drop in the incidence of hypertension was recorded during operation for systolic pressure (p < 0.001) after both ways of administration, as well as of diastolic pressure (p < 0.01 for intravenous and p < 0.05 for intramuscular premedication). Premedication with intravenous clonidine can be recommended as a routine procedure before laparoscopic cholecystectomies.