Vol 16, No 4 (2022)

BACKGROUND: Effective anesthesia is one of the most important factors in rapid and successful rehabilitation after surgery. Inadequately selected analgesia and consequent pain significantly slow down the recovery process and are associated with several complications that cover almost all organs and systems and reduce the patient’s quality of life in the long term.

OBJECTIVE: This study aimed to analyze 6 years of clinical experience with perioperative epidural anesthesia in the Research Institute of Pediatric Oncology, considering the effectiveness, safety, and satisfaction of patients and their legal representatives with this medical aid.

MATERIALS AND METHODS: A prospective single-center continuous cohort study was conducted on patients who received epidural analgesia as part of perioperative anesthesia in the period from 2016 to 2021. Data from 702 (48.5%) boys and 745 (51.5%) girls were analyzed. Children were divided into three main groups according to age: from 1 month to 1 year (14.3%), from 1 year to 7 years (37.8%), and from 8 years to 18 years (47.8%). The area of surgical intervention was also considered: abdominal surgery (65.2%), thoracic (8.5%), and orthopedic (26.4%). The choice of the local anesthesia level has also influenced the results. The main study outcomes were the intensity of postoperative pain syndrome in pediatric oncosurgery and additional consumption of narcotic analgesics after the administration of a mixture of topical drugs with or without adjuvants into the epidural space.

RESULTS: The effectiveness of epidural anesthesia in the intraoperative period was quite high, which is confirmed by the stability of hemodynamic parameters. Intraoperatively, additional administration of systemic narcotic analgesics was noted in 5% of the total sample. In all observed patients, epidural adjuvants (morphine and promedol) ensured the optimal duration of action and analgesic efficacy of caudal blockade in the postoperative period; therefore, additional painkillers were not needed. Satisfaction with the intervention was generally high, with 98% providing a rating of “very good” or “good”.

CONCLUSION: Anesthesia methods (epidural blockade), optimal pain control, and active postoperative recovery (including early oral nutrition and mobilization) in fast-track surgery reduce stress reactions and organ dysfunction, significantly reducing the time required for a full recovery.

BACKGROUND: No consensus has been established on the role of epidural anesthesia in relation to the prevention of chronic post-thoracotomic pain during minimally invasive coronary bypass surgery.

OBJECTIVE: This study aimed to evaluate the effect of epidural anesthesia on the incidence of chronic post-thoracotomic pain syndrome after minimally invasive direct coronary artery bypass (MIDCAB) surgery.

MATERIALS AND METHODS: The study included 87 patients who underwent MIDCAB surgery. In group 1, epidural anesthesia was performed before the induction of general anesthesia; in group 2, the operation was performed only under general anesthesia.

RESULTS: The use of fentanyl for anesthesia varied: 0.5 (0.5; 0.6) mg in group 1 versus 3.5 (3.3; 3.6) mg in group 2 (p <0.01). The incidence of chronic post-thoracotomic pain in patients 3 months after surgery was higher in group 2 than in group 1 (39.1% vs 17.2%, p=0.005). The severity of pain at rest was 3 points (2; 3) in group 1 and 3 points (3; 3.5) in group 2 (p=0.018); however, during a deep breath, these differences became insignificant: 4 points (4; 4) in group 1 and 4 (4; 5) points in group 2 (p=0.453). At 6 months after surgery, chronic post-thoracotomic pain was present in 15.6% of the patients in group 1 and 34.8% in group 2 (p=0.011). After 6 months, the severity of pain at rest was 2.5 (2; 3) in group 1 and 3 (3; 3.75) in group 2 (p=0.01). No differences in cough were found: 4 (3.75; 4) points in group 1 and 4 (4; 4.5) points in group 2 (p >0.05).

CONCLUSION: The use of epidural anesthesia led to a decrease in the incidence of chronic post-thoracotomic pain in patients undergoing MIDCAB surgery.

BACKGROUND: Gestational diabetes mellitus (GDM) increases the incidence of cesarean section (CS) to 57.4%. Chronic high blood glucose levels can affect opioid receptors and neurotransmitter metabolism. Pregnant women with GDM require more analgesics and consumed more opioids in the immediate postoperative period after CS than patients without GDM. Thus, in parturients with GDM, the features of the spinal anesthesia (SA) course during CD surgery and the postoperative course remain not fully understood.

OBJECTIVE: To assess SA during CS in parturients with GDM.

METHODS AND METHODS: A prospective controlled study was conducted. The study group included patients with compensated GDM, excluding the criteria for “manifest” diabetes. The control group included patients without carbohydrate metabolism impairment. The inclusion criteria were as follows: SA, full-term and singleton pregnancy, elective CS, age 15–25 years, normal venous blood glucose levels in the morning before surgery, parity of pregnancy, and childbirth. The exclusion criteria were as follows: patients with American Society of Anesthesiologists class ≥IV, inadequate SA requiring the administration of drugs for general anesthesia, severe extragenital pathology, preeclampsia and eclampsia, insulin therapy, and use of oral hypoglycemic agents. After SA induction, Bromage motor block and sensory block were assessed.

RESULTS: Sensory block was achieved in 53% after 3 min, 84% after 4 min, and 100% of the patients in the control group after 5 min. In the GDM group, the threshold of 50% was reached after 7 min, and in all patients, sensory block was noted after 10 min. In the assessment of motor block by Bromage, all patients in the control group achieved motor block after 5 min, whereas in the GDM group, only 77.5% achieved motor block.

CONCLUSION: Our results suggest that with SA during CS in patients with GDM, compared with parturients without carbohydrate metabolism alteration, the rates of sensory and motor block development decreased. Differences in pain intensity were noted after the early postoperative period, and significant pain sensations in the GDM group are manifested on average 60 min earlier than that in the non-GDM group.

BACKGROUND: Bleeding at the puncture site during neuraxial blocks is a potentially dangerous complication, and its risk is significantly increased in patients receiving antithrombotic therapy.

CLINICAL CASE DESCRIPTION: Patient S. (aged 60 years) was admitted to the department of vascular surgery (Vladivostok). He was diagnosed with Leriche’s syndrome, for which he took 100 mg of aspirin and 75 mg of clopidogrel. On January 12, 2022, combined spinal-epidural anesthesia was performed, and the epidural space was punctured on the fourth attempt. However, massive bleeding was observed from the puncture site. Intraoperatively, before the great vessels were clamped, 100 units/kg of heparin (8000 units) was administered. After the operation, the epidural puncture site was revised: the sticker was soaked with hemorrhagic discharge and removed, and a new sticker was applied. On January 12, 2022, nadroparin calcium 9500 IU anti-Xa/ml 0.3 mL was given two times a day in the ICU. On the same day, intensive bleeding was noted in the area where the epidural catheter was located. This was treated locally with cold and two doses of fresh frozen plasma. On January 13, 2022, magnetic resonance imaging of the lumbar spine showed the spinal cord without displacement and compression, the puncture area had no signs of bleeding, the epidural catheter was removed, and the patient was discharged for outpatient treatment on day 7.

CONCLUSION: To reduce bleeding risk in neuraxial blockade, the recommendations for preparing for surgery patients receiving anticoagulant and antiplatelet therapy must be followed, and the pharmacokinetics of antithrombotic drugs must be taken into account. If puncture and catheterization of the epidural space are technically difficult, manipulation should be abandoned.