Romanian authors in The European Congress of Anaesthesiology “Euroanaesthesia 2007”

6-12 June 2007, München, Germany

Ambulatory anaesthesia

VIMA with sevoflurane versus balanced anesthesia in pediatrics outpatient’s surgery.
Is premedication really worth?

I.G. Cucereanu Badica, A.A. Bradis, I.M.Grintescu
Department of Anesthesia and Intesive Care, Emergency Clinical Hospital, Bucharest, Romania

Background and Goal of Study: “The simplest the best” seems to work in the operating theater where children that receive only sevoflurane spend less time in hospital than those premedicated or those that received balanced anesthesia. The aim of the study is to evaluate the perioperative evolution, incidence of side effects and time spent in hospital for those children.

Materials and Methods: After Hospital Ethics Committee approval 128 children 2-10 years of age scheduled for tonsillectomy, adenoidectomy and circumcision were randomly assigned in 3 groups: the first group (B-41 pts) was premedicated with 0,5 mg/kgc Midazolam given per os in 5 mL Ibuprofen suspension and received propofol, opioids and muscle relaxants (balanced anesthesia technique with intravenous induction), the second group (P-42 pts) received just premedication and Sevoflurane and the third group (S-45 pts) just Sevoflurane. All the children had an intravenous line and received 5 mg/kgc hemisuccinate hydrocortisone preoperative and 15 mg/kgc iv. Paracetamol. We assess the time to spontaneous breathing, extubation, Aldrete score = 9, the incidence of PONV and agitation and the hospitalization time. Statistics used ANOVA, Mann-Whitney U-test and x2 test (* p < 0,05).

Results and Discussions: The incidence of PONV was significantly statistic lower in Groups II and III (VIMA groups), recovery was faster in III group compared with group I. Agitation was practically present in all patients.

Conclusion(s): The incidence of PONV was lower and recovery was faster for VIMA with Sevoflurane than for balanced anesthesia. Premedication had no advantages but it was time consuming. Children have a strong fear of needles and they prefer an anesthetic technique without needles. As long as we can satisfy this preference and this have only advantages we see no reason not to do it.

Unilateral spinal anesthesia versus conventional spinal anesthesia in ambulatory lower abdominal surgery

I. Cindea, A. Balcan, V. Gherghina, G. Nicolae
Anesthesiology, Intensive Care, Emergency Clinical Hospital of Constanţa, Constanţa, Romania

Background and Goal of Study: Unilateral spinal anesthesia offers analgesia and operating conditions as good as standard spinal technique in outpatient scheduled for lower abdominal surgery (1).
The objective of the prospective randomized current study is to evaluate the two spinal anesthesia techniques with respect to recovery times, level of patient postoperative comfort and anesthetic-related costs.

Material and Methods: One hundred ASA I-II, premedicated subjects scheduled for hernioplasty were randomly allocated into two groups to receive convetional (n = 50) and unilateral (n = 50) spinal anesthesia with 10 mg hyperbaric bupivacaine. In unilateral spinal anesthesia group a lateral decubitus position with the operative side down was maintained for 20 min, after spinal injection. For both groups recovery times, postoperative effects profile during a 5 days follow-up period, as well as costs were registered. 5 days after the procedure, the patients were interviewed by telephone about analgesia medication requirements after discharge, as well as occurrence of headache or backache.

Results and Discussions: Compared to bilateral spinal anesthesia, the subjects receiving unilateral spinal technique had shorter recovery times (120 ± 56 min vs 240 ± 70 min, p < 0.001) and lower pain scores at discharge (14 ± 13 mm vs 32 ± 30 mm, p < 0.001). These patients had less requirements for analgesic medication at home (22/50 vs 40/50, p < 0.001). Frequency of headache (2/50 vs 9/50, p < 0.05) and backache (1/50 vs 6/50, p < 0.05) registered lower values in unilateral spinal anesthesia group, too. The anesthetic-related costs were also less for unilateral spinal technique (102.14 ± 30.82$ vs 134.93 ± 31.03$).

Conclusion(s): The unilateral spinal anesthesia technique is more cost-effective than traditional spinal anesthesia for lower abdominal surgical procedures in ambulatory setting, as it is associated with an earlier recovery, high postoperative patient satisfaction and decreased costs.

Reference: 1 Song D. Anesth Analg 2000; 91: 876-881.

Transfusion and haemostasis

Impact of leukocyte-depleted red blood cells transfusion on postoperative infections in chronic alcoholics with major abdominal surgery

I. Cîndea, A. Balcan, G. Nicolae, V. Gherghina
Anesthesiology, Intensive Care, Emergency Clinical Hospital of Constanţa, Constanţa, Romania

Background and Goal of Study: Major abdominal surgery involves important intra- and postoperative blood losses (1). On the other hand, chronic alcoholic candidates for such procedures recognize an increased risk for bleeding complications. The simultaneity of these two independent factors requires adequate hemoglobin correction by transfusions that are well known for their risk of postoperative infections due to immunosuppressive effect of leukocytes (2).

The goal of this retrospective observational study is to evaluate the impact of leukocyte-depleted red blood cells transfusions on incidence of postoperative infections in chronic alcoholics with elective major abdominal procedures.

Materials and Methods: We have analyzed 134 patients with documented chronic alcohol misuse that underwent major abdominal procedures during a period of one year.
These subjects were allocated into two groups: group A (n = 65) with leukocyte-depleted red blood cells transfusion therapy, respectivelly group B (n = 69) that has received non-leukocyte-depleted red cells products.
We have retrospectivelly investigated the incidence of postoperative infections and length of hospital stay in both groups in order to comparatively analyse these finding.
‘Student t’ test was used for statistical analysis.

Results and Discussions: Demographic and surgical variables were not different between groups. The level of perioperative coagulation parameters and transfusion requirements were similar, too.
No significant difference was recorded neither in postoperative infections incidence (12 meaning 18.5% vs 13 meaning 18.8%, p = 0.9), nor in hospital stay length (17.3 ± 0.9 versus 19.1 ± 0.6 days, p = 0.9) between groups.
Conclusion(s): These data did not conclusively demonstrate any possible advantage of leukocyte-depleted red blood cells products concerning the rate of postoperative infectious complications, as well as the hospitalization duration for alcoholics undergoing elective abdominal major surgery.

References:
1 Mynster T. Br J Surg 2000; 87: 1553-1562
2 Jensen LS. Br J Surg 1996; 83; 973-977.

Local and regional anaesthesia

The role of ropivacaine and fentanyl epidural analgesia on reducing perioperative myocardial ischaemia in hip fracture

C. Berteanu, D. Cernea, D. Ionescu, C. Roiu, M. Berteanu
Department of Anesthesiology and Intensive Care, Emergency University Hospital, Bucharest, Romania

Background and Goal of Study: Perioperative myocardial ischaemia is an important risk factor for cardiac morbidity and mortality after noncardiac surgery. The aim of the study was to evaluate the influence of combined fentanyl/ropivacaine epidural analgesia on reducing the incidence and severity of cardiac ischaemia in patients undergoing surgical treatment for traumatic hip fracture.

Materials and Methods: After Ethics Committee approval and written consent, 79 ASA II-IV patients were randomly assigned to convetional analgesic regimen (tramadol, CON group) or continuous epidural infusion of ropivacaine/fentanyl (EPI group). These regimens were started preoperatively an continued three days postoperatively, after spinal anesthesia. ECG was continuously recorded. ST segment depression of >0.1 mV or elevation of >0.2 mV, lasting > 1 min were considered as ischaemic episodes. Nocturnal arterial oxygen saturation (SaO2) was recorded perioperatively and subjective pain was assessed using visual analogue scale (VAS).

Results and Discussions: 13 patients (43%) in the CON and 12 patients in the EPI group had ischaemic episodes. However, significantly more patients in the CON group had ischaemia during surgery (8 vs 0 in the EPI group, p = 0.005). The median (quartal deviation) total ischaemic burden (i.e. integral of ST-change vs time) in patients with ischaemic episodes was ten times larger in the CON group (340 mm/min) (p = 0.002). There were no significant differences between the groups in the average heart rates (HR) at the start of ischaemic episodes or in the maximal HR during the attacks. Average nocturnal SaO2 was similar in the two groups and there were no differences in subjective pain but postoperative and average perioperative VAS scores were almost 40% lower in the EPI group (p = 0.006). Perioperative myocardial infarctions were not detected.

Conclusions: Continuous epidural ropivacaine/fentanyl analgesic regimen, started preoperatively, reduces the amount of myocardial ischaemia in elderly patients with hip fracture.

Pharmacology

Multimodal analgesia after laparoscopic cholecystectomy

I. Grecu, A.E. Nicolau, V. Merlan, M. Nicolau, I. Grintescu
Anesthesiology and ICU, Clinical Emergency Hospital of Bucharest, Bucharest, Romania

Background and Goal of Study: Multimodal analgesia is an important prerequisite for accelerated recovery after elective surgery. Our study goal was to investigate the effects of locally injected 0.25% ropivacaine (R) on postoperative pain after elective laparoscopic cholecystectomy.

Materials and Methods: After Hospital Ethics Committee approval, 60 adult patients scheduled for lapascopic cholecystectomies performed by the same surgeon were enrolled in a prospective, double-blind, placebo-controlled study over a period of 6 months (Jan-June 2006).
All patients received the same general anesthesia protocol and 1 g iv paracetamol was infused after induc-tion of anesthesia for postoperative analgesia, repeated each 6 hs postoperatively, up to 4 g/24 hs. Tramadol 50 mg iv bolus was used as rescue analgesic. After anesthesia induction, patients were randomized in 4 groups (n = 15 pts, each): group A (20 ml preincisional saline infiltration at the abdominal wall and 20 ml R 0.25% intraperitoneal instillation), group B (20 ml R 0.25% preincisional infiltration and 20 ml saline intraperitoneal instillation), group C (A + B) and group P (placebo, both sites saline infiltration). Primary endpoints were VAS at movement at 0, 2, 6, 12 and 24 postoperative hs (1-10 cm), rescue analgesic requirements, PONV and length of hospital stay.

Statistics: chi-square, one-way ANOVA (SPSS 13.0).
Results and Discussions: We found no difference in demographics, length of surgery and of hospital stay (total: 3.38 ± 0.22 days). VAS was significantly lower at all intervals in group C versus P and at 0, 6 and 12 hs in group C versus both groups A and B (p < 0.05). Tramadol boluses required were significantly fewer in group C vs P (0.73 ± 1.10 vs 1.93 ± 1.03, p = 0.017) and also the incidence of PONV (1 pt in group C vs 7 pts in group P, p = 0.01).

Conclusion(s): Ropivacaine 0.25% shows significant favorable effects on postoperative pain after laparoscopic cholecystectomy only when using combined preincisional local infiltration and intraperitoneal instillation.

Reference:
1 Louizos A A et al. Surg Endosc 2005; 19; 1503-1506.

Intensive care medicine

Weaning from mechanical ventilation: protocol vs physician decision

A. Ogica, G. Droc, D. Tomescu, H. Popescu, D. Tulbure
Anesthesiology and Intensive Care, Fundeni Clincal Institute, Bucharest, Romania

Background and Goal of Study: Due to the increased risk of complications associated with prolonged mechanical ventilation (MV), early liberation from the ventilator is important and protocol directed weaning seems to be the answer (1). We decided to evaluate a ventilator weaning protocol in our intensive care unit (ICU) in terms of length of MV, ICU stay and reintubation rate.

Materials and Methods: After Ethical Committee approval, 103 patients starting MV (EVITA IV Drager) were included over a 6 months period, being randomly distributed in two groups: group A – undergoing clas-sical ventilator disconnection and group B – assigned to the weaning protocol. Patients already on ventilatory support as well as pediatric subpopulation (< 18 years) were excluded. Severity of illness was assessed using the APACHE II and SOFA scores. Demographic data, duration of MV and superficial breathing index were analyzed. Secondary analysis focused on reintubation rate and possible correlation with mortality. Means and standard deviations were used. Comparisons between groups were made with the t-test (p < 0.05).

Resuslts and Discussions: The 103 patients represented 78% of the total number of hospitalized patients in the ICU during the study period. Group A had 52 patients, 37 survivors and group B had 51 patients, 33 survivors. By applying the weaning algorithm, the average duration of the MV decreased with 1.24 days.

The patients having survived were ventilated 5.83 ± 5.15 days, while the length of ventilation in non-survivors was 12.79 ± 13.71 days (p = 0.002). Regarding reintubation analysis, group A had a 24.32% ventilator reconnection, compared to 15.15% in the group B. No influence on mortality rate was noticed.

Conclusion(s): Using a weanig protocol led to a decrease in the number of MV days and to a lower reintubation rate.

Reference:
1. Ely WE. Weaning from mechanical ventilation (part 1): evidence supports the use of protocols. In: J.L. Vincent, Yearbook of Intensive Care and Emergency Medicine Springer; 2001: 481-495.

Central venous catheter colonization and catheter-related bloodstream infection in intensive care unit: comparing standard with silver intergrated catheter

N. Hagău, D. Studnicska, M Flonta, A. Slavcovici, S. Cocu
Aneesthesia and Intensive Care County Emergency Hospital Cluj, University of Medicine and Pharmacy “Iuliu Haţieganu”, Cluj-Napoca, Romania

Background and Goal of Study: We compared the rates of positive quantitative culture (PQC) and catheter-related bloodstream infection of standard polyurethane central venous catheters (s-CVC) with rates for silver integrated catheters (SI-CVC) (1).

Materials and Methods: A prospective, descriptive study. Data was colected over 12 months from 20 surgical-medical ICU beds. Double and triple lumen standard Vygon catheters and silver integrated MultiCath expert Vygon catheters were used. After their removal the tips of the catheters were cultured by the roll-plate method and the quantative culture technique. Pripheral blood cultures were obtained at the time of catheter removal. Continuous demographic and clinical data were analysed. The CVC colonization was expressed in terms of cumulative incidence and incidence density. The Kaplan-Meier test was used to compare the risk of PQC over time between s-CVC and SI-CVC.

Results and Discussions: A total of 175 CVC, 75 SI-CVC, 714 catheters days and 100 s-CVC, 846 catheter days, in 147 patients, were studied. There was no significant difference in CVC indwelling times between s-CVC and SI-CVC (p = 0.19). The mean duration of s-CVC was 8.46 days and of SI-CVC was 9.52 days. There was no significant difference in the colonization rate between s-CVC and SI-CVC. The cumulative incidence of catheter infection was 2.67% for SI-CVC and 8% for s-CVC (p = 0.24). The incidence density of catheter infection was 2.8 for SI-CVC and 9.5 for s-CVC (p = 0.19). The cumulative incidence of catheter colonization was 24% for SI-CVC and 25% for s-CVC (p = 0.88) and the incidence density was 25 for SI-CVC and 29 for s-CVC (p = 0.60). Using the Kaplan Meier test there was a significant difference in the incidence of infection and colonization over time between SI-CVC and s-CVC (p = 0.04).
Conclusion(s): SI-CVC could not prevent catheter colonization in critical care patients, but it is a significant difference in the incidence of colonization over time between s-CVC and SI-CVC.
Reference:
1 Marin W. Anesth Analg 2005; 101: 1778-1784.

Acute and chronic pain management

Opioids or NSAID in postoperative analgesia after total hip arthroplasty?
Comparison of adverse events

I.G. Cucereanu Badica, L. Badica, I. Grecu, A.A. Bradis, I.M. Grintescu
Anesthesia and Intensive Care, Emergency Clinical Hospital of Bucharest, Bucharest, Romania

Background and Goal of Study: NSAID and opioid analgetics have both their own spectrum of adverse events. Paracetamol has the safest profile but is not enough for pain relieving after hip arthroplasty. This study tries to assess the best analgesic regimen for those patients.

Materials and Methods: After Hospital Ethics Committee approval 90 patients who underwent hip arthroplasty under spinal anesthesia were randomized in two groups: Group O (n = 45) received Tramadol and Group NSAID (n = 45) received Diclofenac or Ketorolac as supplementary analgesia (all pts. received Paracetamol iv 4 g/day for at least 5 days, gastric protection therapy and DVT prophylaxis with Enoxaparine). We assessed the quantity of transfused blood, the incidence of vomiting, the increase in creatinine serum lever and the quality of sleep during the first five postoperative days and the incidence of digestive hemorrhage during the first 42 days after surgery. Statistics used t-test, x2 test and Mann­Whitney U­test (p < 0,05).

Results and Methods: The groups did not differ regarding the demographic data, blood loss during surgery and postoperative sedation and analgesia (VRS - none or mild for > 90% of time). The NSAID group received more blood during the first 5 postoperative days (p < 0,05), have a lower incidence of vomiting episodes (p < 0,01) and an increased in creatinine levels not statistically significant. The quality of sleep was better in the group O (p < 0,01). In group O no digestive hemorrhage was recorded; in group NSAID 2 patients were readmitted with digestive hemorrhage and 2 patients experienced this during the first 10 days after surgery.

Conclusions: We consider it is advisable to avoid NSAID in these patients because of demonstrated increase in postoperative blood loss and the increased risk of gastrointestinal bleeding. A regimen of iv. Paracetamol and a weak opioid as Tramadol provide good pain relief with just one inconvenient side effect: nausea and vomiting.

Reference
1. M. Hyllested et al., B J of Anaesth, 2002, 88: 199-214.

Autori români la al 81-lea Congres al Societăţii Internaţionale de Cercetare în Anesteziologie (IARS)

23-27 martie 2007, Orlando, SUA

Regional anaesthesia

Adding meperidine to ropivacaine for intravenous regional anesthesia

R.Pop, I Acalovschi, A. Pausan, S.Radu
Dept of Anaesthesiology, University of Medicine, Cluj-Napoca, Romania

Introduction: In a study of volunteers, ropivacaine 0.2% compared favourably with lidocaine 0.5% for IV regional anesthesia (IVRA) (1). However, ropivacaine did not prolong tourniquet tolerance compared with lidocaine. Addition of 100 mg meperidine for IVRA with prilocaine improved the quality of the sensory and motor block (2). The objective of this investigation was to determine whether the addition of meperidine may improve the quality of IVRA with ropivacaine, especially tourniquet tolerance.

Method: The study was prospective, randomized and double blind. A number of 20 patients submitted for elective hand surgery in IVRA were divided in two equal groups to receive 10 ml of 0.2% ropivacaine (80 mg) and either 1 ml of isotonic saline (group R) or 1 ml of meperidine (25 mg) (group RM). A tourniquet was kept inflated until patients complained of pain, leading to release of the tourniquet cuff. The onset and duration of sensory and motor blockade, as the incidence of side effects and duration of postoperative analgesia were also recorded.

Results: The tolerance for the tourniquet was significantly longer in the ropivacaine-meperidine group (mean 40 vs 29 min, p = 0.047). There were not significant differences in onset of sensory and motor block. Anesthesia quality was better in RM group in comparison with R group (4 patients needed supplementation of analgesia). Duration of postoperative analgesia was similar in both groups, and no side effects were registrated during the study.

Discussion: Ropivacaine in a dose of 80 mg was safe and efficient for IVRA for hand surgery. The addition of 25 mg of meperidine improved the quality of anesthesia and assured a better tolerance for tourniquet pain.

References: 1) Anesth Analg 1999; 88:1327-1330. 2) Anaesthesia 1993; 48:382-386