An observational trial comparing a novel continuous glucose monitor (GlySure) with standard intermittent point-of-care testing

Balciunas, M.*1, Klein, AA.2, Vuylsteke, A.2, Blaskovics, I.3, Cole, O.3, Salaunkey, K.2.

1 Locum Consultant in Cardiothoracic Anaesthesia and Intensive Care, Papworth NHS Foundation Trust, UK.2 Consultant in Cardiothoracic Anaesthesia and Intensive Care, Papworth NHS Foundation Trust, UK.3 Fellow in Cardiothoracic Anaesthesia and Intensive Care, Papworth NHS Foundation Trust, UK.

Purpose: Continuous glucose monitoring is designed to facilitate glycaemic control and to reduce frequency of episodes of hypo- and hyper-glycaemia that have been associated with increased morbidity and mortality. The aim of our observational study was to evaluate the diagnostic accuracy of a novel continuous intravascular glucose monitoring system – GlySure.

Methods: Non-randomised, non-treatment prospective study was performed in a single tertiary 28 bedded cardiothoracic critical care unit at Papworth Hospital. We compared patients’ glucose levels obtained from the Glysure (GlySure Limited, UK) with the reference value given by RAPIDLab1200 (Siemens Healthcare GmbH, Germany) blood gas analyser. Mean absolute relative deviation and consensus error grid analysis was used to compare the accuracy of the novel system with the reference method.

Results: Nine post cardiac surgery patients were monitored for a total of 149 hours (16.5±3.1 per patient) and 103 paired blood glucose samples were obtained (11.4±2.4 per patient). The measured glucose level did not differ significantly between control and novel devices (8.4±1.7mmol/L vs 8.6±1.5mmol/L, p=0.38, respectively). We found strong positive correlation between the novel device and reference (r=0.75; p < 0.001). The mean absolute relative deviation of the continuous glucose measurements was 9.6%. Consensus error grid analysis of the data showed that 85.5% of paired data points were in zone A and 14.5% -in zone B.

Conclusions: We found a good correlation between the novel continuous intravascular glucose measurement system “Glysure”; and the reference method. Implementation of continuous intravascular glucose monitoring may provide accurate continuous glucose measurement with lower medical staff workload.

1

Nutritional immunomodulation and short-term postoperative outcomes in malnourished patients undergoing cardiac surgery

Svetikiene M1, Isajevas V1, Vicka V2, Rackauskaite S2, Ringaitiene D1, Sipylaite J1

1Clinic of Anaesthesiology and Intensive Care, Vilnius University, Faculty of Medicine, Vilnius, Lithuania2Vilnius University, Faculty of Medicine, Vilnius, Lithuania

Rationale. The research in cardiac surgery field underlines the importance of malnutrition (MN) and appropriate nutritional therapy. The aim of this study is to determine whether nutritional immunomodulation (IM) has an effect on short-term outcomes in patients undergoing cardiac surgery.

Methods. This was a randomised control study. Patients scheduled for elective cardiac surgery were enrolled using selection criteria designed to form a low operative risk homogenous MN cohort. The patients were randomised into IM and control groups. The IM group was supplemented with immune nutrients for 5 postoperative days. The short-term postoperative outcomes were defined using Society of Thoracic Surgeons (STS) definitions. The differences between the groups were evaluated by Fishers exact and Mann-Whitney tests. The regression analysis was conducted to determine the effect of IM on STS outcomes.

Results. 36 patients were enrolled into study, 50% of them were men (n=18). 47.2% (n=17) were assigned to the IM group and 52.8% (n=19) to the control group. There were no differences in the operative risk measured by STS as well as there were no differences in demographic, operative and immune markers amongst the groups (p>0.05). The analysis of STS outcomes distribution among the IM and control groups revealed the higher rates of prolonged stay in hospital in the control group (57.9% (n=11) vs 17.6% (n=3) p=0.019). Furthermore, the median postoperative stay was higher in the control group (16 [14-19] vs 13.0 [10.5-14.0] p=0.004). Logistic regression analysis determined 6.42 times lesser risk of the prolonged hospitalisation for the IM group (95% CI: 1.37-30.05 p=0.018). However, there were no relationships with IM and other STS outcomes.

Conclusions. The postoperative nutritional IM shortens the postoperative stay in hospital after cardiac surgery. These findings ground the need of further studies designed to establish the link between the IM and overall morbidity of the patients.

2

Nutritional immunomodulation in malnourished patients undergoing cardiac surgery

Svetikiene M1, Ringaitiene D1, Isajevas V1, Vicka V2, Rackauskaite S2, Malickaite R3, Jurgauskiene L3, Ringaitiene D1, Serpytis M1, , Sipylaite J1

1Clinic of Anaesthesiology and Intensive Care, Vilnius University, Faculty of Medicine, Vilnius, Lithuania2Vilnius University, Faculty of Medicine, Vilnius, Lithuania3Clinic of Cardiovascular Diseases, Vilnius University, Faculty of Medicine, Vilnius, Lithuania

Rationale. The research in cardiac surgery field underlines the relationship of malnutrition (MN) and immune function. The aim of this study is to determine whether nutritional immunomodulation is effective in patients undergoing cardiac surgery.

Methods. This was a randomised control study. The patients scheduled for elective cardiac surgery were enrolled using selection criteria designed to form a low operative risk homogenous MN cohort. The patients were randomised into immunomodulation (IM) and control groups. The IM group was supplemented with immune nutrients for five postoperative days. The immune function was tested on the surgery and on the 6th postoperative day by sampling blood for CD4 count, CD8 count and CD4/CD8 ratio. The differences between and within the groups were evaluated with Independent Samples t-test and regression analysis.

Results. 36 patients were enrolled into the study, 47.2% (n=17) of them in IM group and 52.8% (n=19) in control group. 50% of them were men (n=18) with a whole groups mean age of 70.36±4.79 and operative risk of 1.58±0.53 as measured by Euroscore II. There were no differences in demographic, operative and immune markers amongst the IM and control groups on the surgery day (p>0.05). On the 6th postoperative day there was an increase in CD4/CD8 ratio in the IM group (2.31±0.92 vs 3.02±1.34 p=0.001), mainly as a result of decrease in the CD8 count (26.26±8.57 vs 21.14±7.11 p=0.003). There were no changes of these markers in the control group, as well as there were no changes in the CD4 count. The linear regression analysis of the CD4/CD8 ratios within the groups revealed the strong correlation in the IM group (R=0.884 p<0.001) and only weak correlation in the control group (R=0.535 p=0.018).

Conclusions. The postoperative nutritional immunomodulation is beneficial for cardiac surgery patients. These patients tend to have higher CD4/CD8 ratios, which grounds the presumption of better immune function and clinical outcome.

3

Perioperative pulmonary aspiration in Tartu University Hospital during 2011-2014

Ehrlich HE, Karjagin J

Department of Anaesthesiology, Tartu University Hospital, Tartu, Estonia

Aspiration pneumonitis is a rare anaesthesia-related complication which is caused by perioperative regurgitation and aspiration of gastric contents. The objective of our study was to retrospectively determine the incidence, management and risk factors of perioperative aspiration pneumonitis cases in Tartu University Hospital during 2011-2014. Similar studies have been done in other centres but there is a lack of data about perioperative aspiration pneumonitis in Estonia.

We performed a retrospective cross-sectional study. Our study group included 80133 anaesthesia cases in Tartu University Hospital during 2011-2014 (both adults and children) from which 17387 (21.7 %) were emergency cases. We found 44 patients with confirmed regurgitation of gastric contents using our anaesthetic incidence reporting database and electronic health records. Perioperative aspiration was discriminated from passive regurgitation by presence of gastric contents in tracheobronhial tree and/or radiographic evidence. Cases were studied individually by one researcher to determine the diagnosis, risk factors and management of these patients.

44 patients in study group had regurgitation of gastric contents and 20 cases had confirmed perioperative pulmonary aspiration. 33 patients had risk factors for regurgitation and 24 patients had multiple risk factors; the most frequent risk factors were emergency surgery and gastro-enteral pathology. Anaesthetic management did not affect the frequency of aspiration nor outcome. Patients who aspirated regurgitated gastric contents were more likely to develop respiratory symptoms. 4 patients with confirmed pulmonary aspiration died due to pulmonary complications. Incidence of perioperative regurgitation of gastric contents was 1:1821, incidence of aspiration pneumonitis 1:4007 and mortality 1:20033.

4

Factors influencing microvascular anastomotic thrombosis risk in free flap surgery: review of the literature

Stepanovs, J., Riga Eastern Clinical University Hospital, Riga, LATVIADrizlionoka-Gorovenko, K., Riga Eastern Clinical University Hospital, Riga, LatviaOzolina, A., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, LatviaRovite, V., Latvian Biomedical Research and Study Center, Riga, LATVIAMamaja, B., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, LatviaVanags, I., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia

Background & Aim of study. Microvascular free flap surgery during the last decades has become an important part of reconstructive surgery allowing closure of various tissue defects and restoration of organs function. Despite surgical progress resulting in high rates of transferred tissue survival, risk of pedicle vessels thrombosis remains a significant problem with highly negative consequences. This review of the literature was performed in order to assess an influence of two groups of factors on development of postoperative free flap thrombosis: the preoperatively detectable patient dependent risk factors and perioperative management strategies.

Materials & Methods. A total of 108 articles from Pubmed and Science Direct databases published in 2005-2015 were analysed.

Results. In regard to the patient dependent factors sufficient evidence was identified for hypercoagulation, advanced age and certain comorbidities. Nowadays, rotational thromboelastometry (RTE) allows early hypercoagulability detection, significantly changing further patient management. Identification of flap thrombosis promoting surgery-related aspects is also essential in preoperative settings. Concerning perioperative anaesthesiological management, review demonstrated an importance of following aspects providing conditions for optimal free flap circulation: choice of anaesthesia and postoperative analgesia methods, administration of different types and amounts of fluids, proper use of blood products and vasoactive agents, temperature control.

Conclusions. More attention should be focused on timely preoperative evaluation of patient dependent risk factors, which can influence anaesthesiological and surgical tactics during and after microvascular free flap surgery. Perioperative anaesthesiological management strategy continues to be controversial therefore it should be performed based on thrombotic risk assessment and patient individual needs thus improving flap survival rates and surgical outcome.

5

Predictive value of preoperative hypercoagulation for free flap thrombosis in microvascular surgery patients

Stepanovs, J., Riga Eastern Clinical University Hospital, Riga, LATVIADrizlionoka-Gorovenko, K., Riga Eastern Clinical University Hospital, Riga, LatviaOzolina, A., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, LatviaRovite, V., Latvian Biomedical Research and Study Center, Riga, LATVIAMamaja, B., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, LatviaVanags, I., Rīga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia

Background & Objectives. Limited information is available about prognostic value of hypercoagulation detected by rotational thromboelastometry (RTE) for transferred tissue thrombosis. The aim was to evaluate the predictive capacity of hypercoagulative RTE data.

Materials & Methods. In the prospective observational study were enrolled 51 microvascular surgery patients. Preoperatively, external thrombogenic factors and RTE data were registered. Two groups of patients: with or without hypercoagulation detected by fibrinogen/platelet ratio (FPR) ≥ 42 were compared. Association between external thrombogenic factors, hypercoagulability in RTE and surgical outcome (free flap thrombosis) was analyzed.

Results. 51 patients with mean age 39 ± 13 years were enrolled. External thrombogenic factors were identified for 25 patients: recent trauma 15/51 (29.4%), ischemic heart disease and atherosclerosis 6/51(12%), tetra-, para paresis or neurofibromatosis 3/51 (6%), obesity + recent trauma 1/51 (2%). Hypercoagulation in RTE was detected in 15 patients ((FPR) ≥ 42), mostly in those with external thrombogenic factors -13 (52%) out of 25. The main reason (67%) was recent trauma. Patients with hypercoagulation had significantly higher values of MCFEXTEM (p <0,001), MCFINTEM (p < 0,001), MCF FIBTEM (p < 0,001). Incidence of free flap thrombosis was significantly higher in RTE hypercoagulability group, 5/15 (33%) vs. 4/36 (11%), p = 0.047. Thrombosis more often developed in patients with external thrombogenic factors, 8 vs. 1 and 8 vs. 2, p = 0.008 and p = 0.03. The AUC for hypercoagulative RTE to predict free flap failure was 0.7 (p = 0.05). The highest correlation with free flap thrombosis was found for MCFINTEM, r = 0.3; p = 0.04.

Conclusion. Rotational thromboelastometry is a suitable method to detect hypercoagulability with definite predictive capacity for postoperative free flap thrombosis and can early identify patients in higher risk for transferred tissue failure.

6

Noninvasive cerebral oxygen saturation monitoring during neurosurgical spine surgery in prone position

Murniece S.1,2,Skudre A.1,Stepanovs J.1,2,Vjugins J.1,Mamaja B.1,2

1 Riga Eastern University hospital,Latvia2 Riga Stradins University,Latvia

Introduction. Cerebral oxygenation maintenance using Near infrared spectroscopy during surgery prevents complications like cognitive dysfunction and organ failure improving postoperative outcome.

Aim. To perform a systematic literature review to determine whether spinal surgery in prone position impact cerebral oxygenation(rScO2).

Materials and Methods. Relevant publications were found using PubMed with MeSH terms: (Spectroscopy,Near - Infrared),(Monitoring, Intraoperative), (Spine/surgery), (Prone position). 15 patients underwent spinal surgery. rScO2 was monitored intraoperatively using INVOS 4100. NIBP, heart rate, end tidal carbon dioxide tension, peripheral oxygen saturation, rate of postoperative complications, days spent in ICU were monitored.

Results. 309 articles were found. Only 3 articles met all the criteria. Fuchs et al(2000) had 48 patients for lumbar discectomy. There were no changes in rScO2 during supine, prone, sitting position. Deiner et al(2014) had 63 patients undergoing surgery in prone position,142-lying supine(all> 68y): desaturation was 2.3 times more often for patients in prone position. Andersen et al(2014) had 52 patients undergoing surgery in prone position hypothesing that head rotation >45o affects rScO2, the neutral head position is recommended. Our results showed medium rScO2 lying supine L 75.25%, R 74.10%, in prone position L 75.05%, R 74.49%, returning on spine L 74.42%, R 74.04%. Two patients showed rScO2 decrease >8% from baseline after turning supine. There were no incidence of postoperative complications, no patients were admitted to ICU.

Conclusion. Regional cerebral oxygen saturation is a valuable intraoperative measurement in patients undergoing neurosurgical spine procedures in prone position to manage perioperative period. Based on literature patients in prone position experience decrease in cerebral oxygen saturation more often than patients lying supine.

7

The role of inherited trombophilia in patients undergone free flap surgery: a systemic review of the literature.

Drizlionoka- Gorovenko, K.a , Stepanovs, J.a,b, Ozoliņa, A.b,d , Ņikitina-Zaķe, Lc, Mamaja, Ba,b

a Riga Eastern Clinical University Hospital, Riga, Latviab Riga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latviac Latvian Biomedical Research and Study Center, Riga, Latviad Pauls Stradins Clinical University Hospital, Riga, Latvia

Background/Objective: The role of microvascular surgery as a part of reconstructive surgery is enhancing over the past three decades and has been technically improved such as failure rates declined to under 10 percent in most centers, nevertheless mishap due to thrombosis still occure and is detrimental for both patient and surgeon. Hereditary trombophilia is well known factor possessing icreased risk for vascular events however still beyond the scope of microvascular surgery. Detailed understanding of gene polymorphism associated with thrombosis in free flap surgery is the key to prevent intraoperative and postoperative adverse events thus facilitating patient amends and saving costs. To elucidate whether inherited trombophilia has association with free flap thrombosis a systemic review of the literature was performed.

Methods: An electronic databases, including PubMed, Cochrane library for articles published between 1995-2016 were analysed.

Results: A total of 148 articles, 14 case reports and 1 retrospective cohort were analyzed. Activated protein C resistance (APCR) due to heterozigosity of Factor VLaiden R506Q polymorphism, MTHFR C677T/A1298C polymorphism leading to hyperhomocysteinemia, protein S, protein C deficiency and elevated factor VIII activity have been reported as potential contributing factor to anastamotic thrombosis in microvascular free flap surgery.

Conclusion: Interaction of gene mutation, acquired hypercoagulable states and patient factors allude to free flap thrombosis in reconstructive surgery, and, of critical importance is meticulous surgical technique. Early recognition of hereditary thrombophilia as a part of preoperative patient counseling is advocated to ensure the best milieu for successful surgery.

Keywords: free flap failure, microvascular thrombosis, inherited thrombophilia, gene mutation, VLeiden/ Prothrombin G20210A, MTHFR polimorphism/mutation, Protein C/S deficiency, antithrombin deficiency, hyperhomocysteinemia.

8

Improvement in auditing clinical practice using electronic patient records

Dr. Agarwal R., Jurong Health, SingaporeDr. Kale S.S. Jurong Health, Singapore

Background: Opening of the new Ng Teng Fong hospital in Singapore offered a platform for experimenting with fully paperless format. This study presents advantages of capturing data to help audits and computation of hospital wide harm rates Methods Prospective audits Key target areas such as preoperative assessment, post surgical recovery Department performance is judged by achieving targets set for the key performance indices. Continuous data collection to aid reflecting this information started since one year. Details and conclusions are periodically presented to hospital administration as well as to the Ministry of Health Examples of Key target areas Capturing adverse events in the immediate perioperative setting Capturing adverse events following regional or general anesthesia Computation of hospital wide harm rates Auditing changes in clinical practice and their impact Results With the implementation of electronic healthcare records, case notes are available round the clock over the hospital intranet. Password protection limits access and helps identify the reviewer. Results have started getting easily collected and compiled.

9

Nasal fibreoptic guided oral tracheal intubation : a novel technique

Dr. S. Awhad, Dept of Anaesthesia, Jurong Health, SingaporeDr. S.S. Kale, Dept of Anaesthesia, Jurong Health, Singapore

We wish to share a novel technique of orotracheal intubation. A 46 year male patient presented with trauma following car accident. MRI showed fracture of the body of 6th cervical vertebra as well as fractured right maxilla. Right zygomatic arch and orbital floor needed emergency surgical repair as a result. The patient was wearing cervical collar, had swelling over the right cheek and had trismus. The mouth opening was restricted to 15 mm. After discussing with the maxillofacial surgeons a decision was taken to perform oral endotracheal tube placement. In order to avoid displacing the vertebral body fracture, direct laryngoscopy through oral cavity was not preferred. Instead, a fibreoptic laryngoscope was inserted through the left nostril upto laryngopharynx to provide a view of the vocal cords. Tongue was retracted and an armoured endotracheal tube was successfully placed under the vision provided by the nasally inserted fibreoptic laryngoscope. The fibreoptic laryngoscope was later inserted through the endotracheal tube to confirm correct positioning. Thus we were able to intubate the trachea using the maximum diameter of endotracheal tube inserted orally but avoiding conventional laryngoscopy with the risk of movement of cervical vertebral column and possible spinal cord compression. In similar situations where cervical spine mobility is restricted and nasal intubation is best avoided while mouth opening is also compromised this technique can offer another solution.

10

Successful treatment of right heart thrombi and acute massive pulmonary embolism by repeated thrombolysis (case report)

Svetikienė, M.1, Janušauskas, V.2, Griciūtė, J.1, Katkus, R.2, Ringaitienė, D.1, Šipylaitė, J.1, Ručinskas, K.2, Šerpytis, P.2, 3

1. Center of Anesthesiology and Intensive Care, Vilnius University Hospital, Santariškių Clinics.2. Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University.3. Center Emergency Medicine, Faculty of Medicine, Vilnius University.

We present the case of a 19 year old female who underwent a massive pulmonary embolism with thrombus in right ventricle (RV) and acute RV failure. Thrombolytic treatment had failed and repeated thrombolysis was given after 24 hours. Treatment was successful and on the eleventh day of hospitalization the patient was discharged. The current guidelines do not give clear directions for the management of patients with acute massive pulmonary embolism who do not respond to fibrinolytic therapy. A repeated thrombolysis could be an alternative treatment over surgical embolectomy for these patients.

11

Pediatric trauma at the emergency department of the Tartu University Hospital.

Vendt, N.*, Nõmm, K. Talving, P.

Anestesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, EstoniaTartu University, Tartu, Estonia

Injury-related mortality is exceedingly high in Estonia compared to other EU countries (51 vs 30, respectively) per 100 000 inhabitants (Eurostat 2016). According to the Statistics Estonia, the number of deaths due to injuries in pediatric population was 36 cases in 2015.

We set out to investigate the incidence, causes and outcomes of pediatric trauma in the Southern Estonia.

Methods: This is a retrospective study of all pediatric trauma evaluations at the Emergency Department (ED) of the Tartu University Hospital in 2015. Children aged 0-19 years were enrolled. The primary outcome was the incidence of severe trauma and secondary outcomes hospitalization, number of surgical interventions and mortality.

A total of 6327 children were admitted to ED with age 0-7 yrs in 1817 and 8-19 yrs in 4510, cases. In total, 2.6% (n=164) of patients were admitted to hospital and 71% (116) were subjected to surgery. Intracranial and/or cervical spine injuries were noted in 1.7% patients (109), injuries to multiple body regions occurred in 0.6% children. Extremity fractures were diagnosed in 39% patients (2477). Burn injuries occurred in 1.6% patients (99), 62% of them were under 3 y old. Transport accidents occurred in 5.5% and 10% of them were admitted. The majority of trauma mechanisms were ground level falls, sports or play equipment accidents 69.4%. A total of 5 patients were admitted to ICU, 3 of them has sustained a severe injury burden (ISS>15) following motor vehicle accidents (n=2) and one fall from a playground. All three had intracranial injuries and were subjected to surgery.

Pediatric ED evaluates a significant number of children annually, majority sustaining their injuries during sports or play. The predominant trauma mechanisms were falls, sports and leisure activity-related injuries. Severe injuries, including severe head injuries occurred in a total of 5 (0.08%) patients in 2015.

12

Outcomes of patients with functionally univentricular hearts in Latvia

Rutka, K., Pauls Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia. (presenting author)Lubaua, I., Children’s Clinical University Hospital, Riga Stradins University, Riga, Latvia.Ozolins, V., Children’s Clinical University Hospital, Riga, Latvia.Ligere, E., Children’s Clinical University Hospital, Riga, Latvia.Smildzere, A., Children’s Clinical University Hospital, Riga, Latvia.Balmaks, R., Children’s Clinical University Hospital, Riga Stradins University, Riga, Latvia.

Introduction: Functionally univentricular heart is a rare, complex pathology posing many challenges for cardiothoracic surgeons, cardiologists and intensive care specialists. The purpose of this study was to review the outcomes of patients with functionally univentricular heart treated at the only paediatric cardiothoracic centre in Latvia.

Methods: We performed a retrospective audit of medical records of all children with functionally univentricular heart born in Latvia from 2007 until 2015 and treated at Children’s Clinical University Hospital in Riga. Cardiac anatomy and interventions were categorised in accordance with the International Paediatric and Congenital Cardiac Code (IPCCC, v3.0). Cumulative survival was calculated by using the Kaplan Meier method in SPSS Statistics (v24.0) software.

Results: During the study period, a total of 49 patients with functionally univentricular heart were admitted with the average incidence of 0.25 cases per 1000 live births per year. 26 patients had hypoplastic left ventricle and 22 patients had hypoplastic right ventricle, while 1 patient had an undifferentiated ventricle. 29 (59%) patients had died by the end of data collection. The majority of deaths (21 of 29) occurred before or during the stage I surgical palliation peri-operative period. The cumulative neonatal and five-year survival of patients with hypoplastic right ventricle was 82% and 64%, respectively; for patients with hypoplastic left ventricle these estimates were 46% and 23%, respectively.

Conclusions: This is the first long-term outcome study of patients with functionally univentricular hearts in Latvia. The high mortality reflects challenges of a small-volume developing congenital cardiac surgery centre, particularly during the first few years after the introduction of a univentricular heart treatment program in 2008. Better survival of patients with the left ventricle as the single functioning ventricle has previously been described in other centres.

13

Congenital anaemia associated severe respiratory distress (SRD): is inhaled nitric oxide always safe? A case report with review of the literature.

Väli, M., Kikas, R., Padari, H., Rõivassepp, K.

Tartu University Hospital, Tartu, Estonia

Background and aim. Congenital anaemia is a rare cause of SRD and hypoxia in neonates. Different mechanisms leading to the development of SRD are not fully understood. We present a case of congenital dyserythropetic anaemia in a newborn with the aim of analysing the management of pulmonary hypertension (PH).

Methods. Review of the medical history and literature.

Results. The case report. A boy was born vaginally at week 39 of gestation with birthweight of 4210 grams and Apgar scores 7/2/6. After its first cry the baby turned pale and started to breathe irregularly. Assisted ventilation with maximum PiP of 30 cmH2O was started, FiO2 rose up to 1.0. Laboratory tests revealed mixed acidosis with a haemoglobin of 56 g/L. The child was given 40 ml of NaCl 0.9% as a bolus injection and then intubated. Due to hypoglycaemia (2.9 mmol/L) infusion with 10% glucose was started. The patient was transferred to the NICU and a suspension of group 0/Rh negative erythrocytes was given. Total transfusion was 140 ml, additionally this baby received 20 ml of 25% albumin. The baby’s hemodynamics was supported with dobutamine (17.8 µg/kg/min). PH with a gradient of 78 mmHg was seen in the echocardiography (ECHO). As the PH worsened, treatment with inhaled nitric oxide (iNO) (20ppm) was started. The effect of iNO was excellent. The baby was weaned off over the next 3 days and extubated on the 6th day of life. Currently blood transfusions are still required and according to the bone marrow analysis congenital dyserythropoetic anaemia type I is suspected. Literature review: mild to severe congenital anaemias can be associated with SRD. PH development is rather associated with the type of anaemia. With increased pulmonary blood flow iNO could worsen PH.

Conclusion. Before initiating iNO treatment in patients with congenital anaemia associated RDS and PH the establishment of aetiology of PH is warranted by ECHO. The diagnostic work-up for the type of anaemia is of substantial importance.

14

Labor epidural analgesia with fentanyl and low back pain after delivery

Jaunberga Z., Vasilevskis E., Ozolina A., Baksa-Zveja E., Liepina E., Voita I., Logina I., Vanags I.

Riga Stradin’s University, Riga, Latvia

Background:Opioids are widely used in obstetric epidural analgesia to prolong and potentiate analgesia. Epidural fentanyl can cause opioid induced hypersensitivity- what is defined as increased sensitivity to painful stimuli consecutive to opioid use. In a previous multicentre study (Jaunberga Z. et al. The association of postpartum lower back pain and epidural analgesia. Proceedings Baltic Society of Regional Anaesthesia 2nd conference, 2016) we found a difference in the incidence of postpartum low back pain at the1st postpartum day (41.9 % vs 17.0 % , p=0.00003), at 6-8 weeks (50.7 % vs 29.8 %, p=0.02) and after 3 months (38.6 % vs 24.1%, p=0.02) between patients who benefited from an epidural analgesia during labor and those who did not. We hypothetised that epidural fentanyl might have contributed to the increased incidence of acute and chronic postpartum low back pain.

Aim:To assess the impact of epidural fentanyl on the incidence of acute and chronic postpartum low back pain.

Material and methods:The study has been approved by local Ethical Committee. We performed an additional analysis of data from non – randomised, prospective, multicentre study done previously. Nulliparous singleton parturients of legal age after full term labour, who received epidural analgesia with fentanyl, were included. Exclusion criteria:history of prolonged lower back pain and any risk factors which can provoke them postpartum.

Results: Average dose of epidural fentanyl used during labour course was 4.27±6.84 µg/hour. There was no significant correlation between fentanyl use and pain incidence at 1st postpartum day (p=0,39), after 6-8 weeks (p=0,74) and 3 months (p=0,21). Further, fentanyl use did not affect pain intensity at 1st day(p=0,14), after 6-8weeks (p=0,25) and 3 months postpartum (p=0,09).

Conclusions: Epidural fentanyl does not increase the incidence of acute and chronic postpartum low back pain.

15

Mannitol therapy after shoulder arthroscopy

Setlers, K.1, Ozolina, A.1,2, Berzins, M.1, Dukate, J.1, Sarkele, M.1,2, Gersmane, A.1, Finogejevs, A.1, Vilums, J.1, Peredistijs, A.1

1Orto clinic, Riga, Latvia2Riga Stradiņš University, Department of Anaesthesiology and Reanimatology, Riga, Latvia

Background. Successful pain management after arthroscopic shoulder surgery provides earlier patient activation, rehabilitation and shortens hospital stay. General anesthesia (GA) and interscalene brachial plexus block provides analgesia during surgery and reduces pain after operation. We hypothesized that 15% mannitol solution reduces the consumption of narcotic analgesics after arthroscopic shoulder surgery.

Methods. 31 patients underwent arthroscopic shoulder surgery. All patients had GA in combination with interscalene brachial plexus block with Ropivacain. Randomly selected 15 patients received 15% mannitol solution 500 ml within 4 hours after surgery. All patients received standard analgesia and PCA with morphine was initiated 4 hours after plexus block. Pain was evaluated immediately after surgery, 2, 4, 6 and 12 hours after surgery with Visual Analogue Scale (VAS). If VAS≥4 points extra analgesia with Tramadol or Promedol was applied. Morphine infusion was discontinued when VAS<2 was more than 6 hours.

Results. 31 patient were included. The avg. age was 52.2±12.2 years. The avg. duration of surgery was 77.8±2 min. Morphine infusion time was 18.7±3.7 h in non-mannitol group (N=16) and in mannitol group - 16.6±5.2 h; p=0.2. Total amount of morphine infused was 23.7±7 mg in non-mannitol and 20.1±10 mg in mannitol group; p=0.2. Patients receiving mannitol did not required extra analgesia vs. in non-mannitol group it was received in 5 cases (31.3%); p=0.04, respectively. VAS≥4 to non-mannitol vs. mannitol group was detected in 2 (12%) vs. 0 patients 4 h after surgery; p=0.2, 3 (18%) vs. 1 (7%) patients; p=0.3. after 6 h and 4 (24%) vs. 0 patients 12 h after surgery; p=0.03.

Conclusions. Mannitol therapy used after shoulder arthroscopic surgery could reduce morphine consumption and infusion time. Mannitol therapy may enhance postoperative analgesia, especially 12 h after surgery. Moreover, it could help to avoid requirements of extra analgesia.

16

Emergency ultrasound-guided thoracic paravertebral block in pancreatitis and isolated chest trauma

Nasonov I.Y.1, Vashukov S.A.1, Brovina T.A.1, Ilyina Y.Y.2, Uvarov D.N.2

1. Pain Management Service , City Hospital #1, Arkhangelsk, Russia2. Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk

Introduction. Thoracic paravertebral block (TPV) produces segmental, ipsilateral, somatic and sympathetic blockade in nearby thoracic dermatomes. Recent studies have demonstrated that selective segmental sympathectomy induced by TPV, may improve microcirculation and pancreatic perfusion. Due to increasing popularity of ultrasound among anesthetists and intensivists for regional anesthesia and vascular access, this tool is also used for thoracic paravertebral block. Ultrasound-guided technique has the potential to reduce complications by providing direct visualization of needle and paravertebral space.

Aims and objectives. Aims of our study are to analyze the overall statistics of ultrasound guided paravertebral blocks performed in our center.

Material and methods. Our pain management service was established in 2014. In this study, we retrospectively analyzed the patient’s data, where emergency paravertebral block with local anesthetic was performed in our hospital since February 2014 to 2015.

Results. Fifty-two patients received TPV with mean age 60.8±13.8 years. Twenty eight (53.8%) of them are female and 24 (46.2%) male. The TVP level varied and depended on diagnosis. Thirty-three (63.5%) of all patients received TPV due to isolated chest trauma at different level (Th4–Th10), 26 of them were unilateral and 7 were bilateral. 19 (36.5%) patients received TPV due to pancreatitis at the level (Th7–Th12), 10 of them unilateral and 9 bilateral. No direct complications due to TPV were observed.

Conclusions. Although thoracic paravertebral block can be safely performed for emergency pain management of chest trauma and pancreatitis, further prospective clinical trials should be conducted to evaluate efficacy and safety of ultrasound guided TPV in these situations.

17

Perioperative fluid management for patients with abdominal sepsis

Sasnauskaitė M., Bukauskas T., Macas A.

Lithuanian University of Health Sciences, Kaunas, Lithuania

Key words: sepsis, urgent surgery, volemia, liberal fluid therapy.

Aim: The goal of our study was to evaluate perioperative fluid management in our university hospital for patients with abdominal sepsis during urgent surgery and a day after it.

Methodology: A prospective study of patients who underwent emergency surgery for abdominal sepsis was carried out in Lithuanian University of Health Sciences from 2016 April to August. Patients‘ demographic data, weight, category of ASA classes, the amount and sort of intraoperative fluid given, duration of the surgery performed, the amount of fluid given at the first day after the operation and mortality rates during hospitalization were collected from patients‘case histories. Nonparametric tests were used for statistical analysis at P ≤ 0.05.

Results: 88 patients were involved into the study. There were 50 (56.8%) men and 38 (43.2%) women. The average age was 62.8 ± 16.57 years. Patients were given only crystalloids during surgery with the average of 17.62 ± 14.16 mL/Kg/h. There was statistically significant correlation found between the amount of intraoperative fluid and patients‘ weight (ρ(72) = -0.(3), P = 0.004), but no correlation found between the amount of intraoperative fluid given and patients‘ age (ρ(88) = 0.147, P = 0.218) or the fluid given next day (ρ(83) = 0.144, P = 0.238). The average of fluid given a day after surgery was 2802.18 ± 1777.37 mL. 36 (40.9%, n = 88) patients were evaluated as having III and 36 (40.9%) as having IV ASA category. ASA category was also not related to the intraoperative fluid (P > 0.05). Mortality rates were not related to the amount of fluid given during surgery (P > 0.05) but were related to ASA category (χ2 = 25.22, df = 4, P = 0.001).

Conclusions: Fluid management were performed in liberal manner. Fluid management was not individualized for each patient. Mortality rates were not related to the amount of fluid given during surgery but was related to ASA category.

18

Local infiltration analgesia as postoperative analgesia for total shoulder replacement.

Authors: Klibus,M.1, Vīksne, R.2,Scientific research supervisors: Ph.D.M.D Miščuks, A.2,3, Ph.D.M.D Golubovska, I. 1,2,3, M.D. Vugulis,A.3, M.D. Radziņš, M. 3, M.D. Zadorožnijs, S. 31Riga Stradiņš University, 2University of Latvia, 3Hospital of traumatology and orthopaedics, Latvia

Introduction: Total shoulder replacement surgery is associated with mild to severe post-operative pain. Local infiltration analgesia (LIA) technique is one of the analgesic methods. LIA technique involves long-acting anaesthetic (e.g. ropivacaine), mostly together with adjuvant (e.g. epinephrine) infiltration to the wound during surgery.

Aim: Evaluate local infiltration analgesia as a component of multimodal post-operative analgesia after total shoulder replacement

Materials and methods: 32 patients were randomized into one of the 3 groups. Patients of the first group received general anaesthesia and plexus brachialis block (Ropivacaine 0.2% 40ml). Second group received general anaesthesia and LIA (Ropivacaine 0,2% 112-187 ml combined with epinephrine). The third group received general anaesthesia only. Post-operative pain intensity was measured with VAS (visual analogue scale) After surgery all groups received acetaminophe, naproxen and morphine if VAS scale scored > 4.

Results: In IBPB group mean rank of VAS scale 4 hours after surgery was 1 +/- 1.48, LIA group – 1.75 +/- 1.14 and control group 1.89 +/- 1.62, 8 hours after surgery mean rank of VAS scale in IBPB was 1.82 +/- 1.17, LIA group 1.42 +/- 0.79, and control group 2 +/- 1. Mean bolus consumption of the rescue analgesic 2 hours after surgery shows significantly difference between groups (P – 0.033). In LIA group mean bolus consumption 2 hours after surgery was 0.41 +/- 0.66, IBPB – 0.3 +/- 0.48, control group – 1.37 +/- 1.

Conclusion: Local infiltration analgesia (LIA) showed an effective postoperative analgesia. VAS values at each time interval and needs for rescue analgesic boluses did not show any significant differences between local infiltration analgesia group and interscalene plexus brachialis block group. Due to small amount of patients further research is needed

19

Recommendations for perioperative management in patients with haemophilia

Levchenko O.K., Galstian G.M., Savchenko V.G.

National Research Center for hematology, Moscow, Russian Federation

Aim: to elaborate the recommendations for perioperative period in patients with hemophilia (PWH).

METHODS: In retrospective study the features of the perioperative period in patients with severe haemophilia A and B were evaluated. More than 300 patients have undergone orthopaedic surgery (total hip replacement or total knee replacement, total elbow replacement) or abdominal or proctology or dental surgery from 2013 to 2016.

Results: In PWH, regional and local anesthesias were avoided because of the risk of hemorrhagic complications. General anesthesia was method of choice. PWH should be provided with factor VIII (FVIII) or factor IX (FIX) concentrates before tracheal intubation and airway manipulation, because of risk of epiglottis hematoma, damage to the upper respiratory tract. Haemophilia inhibitor patients should be provided with rFVIIa or Anti-Inhibitor Coagulant Complex (FEIBA) before intubation. Coagulation profile including activated Partial Thromboplastin Time (aPTT), Prothrombin time, Fibrinogen, FVIII activity and FIX activity, Factor VIII inhibitor should be measured. Thromboelastography or thromboelastometry may be used for evaluate efficacy of hemostatic therapy, especially in PWH with inhibitor. Elderly PWH, who were treated by cryoprecipitate, often have hepatitis C. The large requirement for blood products is possible during surgery. Tranexamic acid is useful as adjunctive therapy in PWH. The use of narcotic analgesics by PWH due to their existing chronic pain syndrome greatly complicates postoperative analgesia. Own data showed that an administration of paracetamol and trimeperidin after high traumatic surgeries in PWH is very effective and safe. NSAIDs also should be avoided because of risk of hemorrhagic complications. Ambulatory anaesthesia isn't applicable at PWH because of the high risk of bleeding.

Conclusion: Knowledge of the feathers of the perioperative period at PWH allows avoiding complications.

20

Monitoring of pain in hematological patients

Levchenko O.K., Spirin M.V., Galstian G.M., Savchenko V.G.

National Research Center for Hematology, Moscow, Russian Federation

Purpose: to evaluate the methods of pain monitoring during anesthesia and resuscitation in hematological patients.

Materials and methods: In a prospective, descriptive single center study various methods of pain assessment were evaluated in hematological patients with impaired consciousness, after general anesthesia and after spinal anesthesia. Index of nociception and analgesia (ANI, MetroDoloris), vegetative index (VI), heart rate (HR), mean arterial blood pressure (MAP), modern scale pain scores (Numeric Rating Scale (NRS) and Nociception Coma Scale, (NCS)) were evaluated.

Results: In comatose patients and patients after general anesthesia, the reactions to nociception stimulus were saved and revealed with ANI monitor. During bronchoscopy and gastroscopy, ANI decreased from baseline of 90 to 20-30, during pinprick for blood taking ANI decreased to 40, during central catheter insertion ANI decreased to 30. The ranges of the changes of HR, MAP and VI corresponded to ANI, but these changes were insignificant and not available to evaluate the pain in comatose patients. In patients after spinal anesthesia, ANI data, except that correspond to the restoration of sensory-motor block, were sensitive to pain. ANI decreased from 52 to 38 an hour before spinal block recourse. These data were used to start the postoperative analgesia. At the same time changes of HR, MAP and VI weren't informative.

Conclusions: Visualization and objectification pain seems possible only by means of a comprehensive assessment of various parameters: ANI, VI, hemodynamic parameters, modern pain assessment scales. The use of ANI is represented to the most informative; however these data demand further studying.

Keywords: pain, ANI, V.I., Bromage scale, the NRS scale, the NCS scale, hematology.

21

Comparison of energy requirements measured by indirect calorimetry and predicted by validated equations in patients with acute severe pancreatitis

Erika Šalčiūtė, Julita Liučvaikytė, Andrius Klimašauskas, Vilnius University Hospital Santariškių clinics, Vilnius, Lithuania

Objective: To compare the energy requirements of patients with acute severe pancreatitis measured by indirect calorimetry and calculated by validated equations.

Methods: Mechanically ventilated patients with severe acute pancreatitis were included in to the study. Measurements of indirect calorimetry were obtained three times a week alongside caloric intake of the patient by the means of enteral and/or parenteral nutrition. The data necessary for equations was collected. Indirect calorimetry measurements were compared to 11 validated equations: 1) Harris-Benedict; 2) Penn State; 3) Faisy; 4) Swinnamer; 5) Ireton – Jones; 6) Mifflin – St. Joer; 7) Mifflin × 1.25; 8) Harris Benedict × 1.25; 9) Harris Benedict adj. for obesity; 10) ASPEN recommendation of 25 kcal/kg; 11) ASPEN recommendation of 30 kcal/kg.

Results: Total number of measurements was 173. The highest discrepancy of energy requirements was observed between indirect calorimetry and Mifflin – St. Joer equation, 2442±428 and 1887±155 kcal, respectively (p < 0.01) (mean±SD). Comparison with the other equations yielded similar result. The calculation which was the closest to the measured energy requirement was found to be American Society for Parenteral and Enteral Nutrition (ASPEN) recommendation of 25 kcal/kg resulting in 2500±263 kcal. The difference between indirect calorimetry and ASPEN calculation did not achieve statistical significance (p = 0.116).

Conclusions: A simple ASPEN recommendation of 25 kcal/kg yielded the closest result to the indirect calorimetry measurements of critically ill patients with severe acute pancreatitis.

22

Neutrophil gelatinase-associated lipocalin in prediction of acute kidney injury after cardiac surgery

Linntam, P1, Zemtsovskaja, G2, Loit, R1, Toome, V1, Kütt, M2, Karu, I1

1 Anaesthesiology Clinic, North Estonia Medical Centre, Tallinn, Estonia2 Laboratory, North Estonia Medical Centre, Tallinn, Estonia

Backround. Acute kidney injury is a common complication after cardiac surgery having a major impact on morbidity and mortality. Neutrophil gelatinase-associated lipocalin (NGAL) is a protein released by renal tubular cells after acute kidney injury (AKI). The diagnostic performance of NGAL has varied widely among different studies being influenced by the protocols and NGAL assays used. The purpose of this study was to evaluate clinical use of NGAL as a predictive marker of AKI in patients following cardiac surgery.

Methods. In a prospective observational study 14 adult patients had off-pump coronary artery bypass grafting (OPCAB) and 14 had conventional CABG with cardiopulmonary bypass (CPB) with or without concomitant aortic valve replacement (CABG+AVR, n=7; CABG n=7). Plasma NGAL was measured before induction of anaesthesia (T0), 4 h (T1) and 18 h (T2) after surgery and creatinine in the morning of 1st and 2nd postoperative days. Patients with previous renal impairment (GFR <60 ml/min/1.73 m2), ongoing inflammatory processes and malignancies were excluded since these might affect plasma levels of NGAL.

Results. Postoperative AKI developed in 7 (25%) patients (2 in OPCAB and 5 in CPB group). All of these were KDIGO stage I by the 2nd postoperative day and no renal replacement therapy was needed. Perioperative NGAL at any timepoint did not predict development of AKI (r=0.5, p>0.05). All patients with AKI in CPB group had received concomitant AVR and their NGAL at T1 had been significantly higher than in isolated CABG patients (n=7) (208.1±100.87 vs 83.6 ± 60.6 ng/mL, p=0.02).

Conclusion. Plasma NGAL did not predict development of AKI in cardiac surgical patients. The combined CABG and AVR operation seems to have higher risk of postoperative AKI development as compared to isolated CABG or OPCAB.

23

Mortality predicting factors for patients with abdominal sepsis

Bukauskas T., Sasnauskaite M., Macas A.

Lithuanian University of Health Sciences, Kaunas, Lithuania

Key words: abdominal sepsis, mortality predicting factors, preoperative blood testing.

Aim: The goal of the study was to evaluate mortality predicting factors from the blood tests which were performed before the surgery for patients presenting with abdominal sepsis.

Methodology: We carried out a prospective pilot study in Lithuanian University of Health Sciences for patients presenting with abdominal sepsis who had been operated urgently from 2016 April to August. The data collected from patients case histories included: patients demographics, hemoglobin (HGB), hematocrit (HCT), red cell distribution depth (RDW), white blood cells (WBC), platelets (PLT), C-reactive protein (CRP), creatinine (CREA), potassium (K+), sodium (Na+), glucose (GLU), lactate level (LAC). All of the laboratory tests were performed before the surgery. Mortality rates were registered during hospitalization. Nonparametric tests were used for statistical analysis at P ≤ 0.05.

Results: There were 86 patients in our study: 49 (57%) male and 37 (43%) female with the average of 63 ± 17 years. 21 (24.4%) patients were hospitalized due to perforated gastric ulcers. The overall mortality rate was 37.8% (31 patients). Significant differences were found between the groups of survivals and non-survivals while comparing the averages of: age (P = 0.001), HGB (P = 0.02), HCT (P = 0.008), RDW (P = 0.033), CREA (P = 0.003), K+ (P = 0.009), CRP (P = 0.001). However, the ROC curve analysis showed that CREA (AUC = 0.791, P = 0.001) and CRP (AUC = 0.76, P = 0.001) were fair predictors and other variables had even lower meanings. A logistic regression determined that increasing CRP values were associated with the increased likelihood of mortality (P = 0.034).

Conclusions: Even though CRP was a fair predictor of mortality, increasing preoperative CRP values were associated with the higher risk of mortality. No other preoperatively performed blood test’s variables had predictable meaning.

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Good neurological outcome after long hypotensive periods perioperatively in traumatic aortic dissection operation. A case report of TAAD syndrome.

Vijar, K., Tartu University Hospital, Tartu, EstoniaKõrgvee, L., Tartu University Hospital, Tartu, EstoniaRuusalepp, A., Tartu University Hospital, Tartu, Estonia

28-year-old male diagnosed with Type A aortic dissection at the emergency department (ED) following car accident.

Patient felt sudden severe pain in chest, back and feet, and numbness in the left leg while pushing the car out from the side of the road. At the arrival of ambulance he was conscious, GCS 15, blood pressure 220/130mmHg, heart rate 110 x/min. Hospitalized to the ED of Tartu University Hospital. Based on imaging studies the patient was diagnosed with type A aortic dissection extending until the iliac arteries.

In the OR hybrid aortic prosthesis replacement was performed with Thoraflex 28/30 prosthesis under deep hypothermic circulatory arrest with antegrade cerebral perfusion for 91 minutes. Extracorporeal circulation altogether 5h 48min. Following CPB hypotension (sBP ~35 mmHg) lasted 45 min.

Massive transfusion (altogether 19L), to control and replace blood loss (estimated 12.5L) due to surgical site bleeding during the operation, involved 3L of RBC, 4.5L of plasma, 2.1L of platelets, 3L of whole blood and 1.1L of cryoprecipitate. To control coagulopathy Cyclocapron 4000 mg, CaCl 10% 10gr and Octaplex 2000 IU were administered. With such combinations haemostasis was achieved and supported metabolic homeostasis was assured.

After operation in ICU the patient remained hypotonic (sBP approximately 49-58 mmHg) and 6h after the initial operation showed symptoms of cardiac tamponade. Rethoracotomia was performed and supported hemodynamic stability was achieved.

Due to anuria continuous dialysis was performed during 15 initial days. Imaging revealed areas of infarctions in kidneys, however, spontaneous diuresis recovered finally.

Based on genetic studies the Familial Thoracic Aortic Aneurysm and Dissection (TAAD) syndrome was diagnosed.

Despite massive blood loss and long hypotensive periods perioperatively the patient was discharged from the hospital on Day 42 after admission with fully recovered central nervous system and renal functions.

25

Aa.iliaca interna embolization with balloon in complicated cases of placenta percreta with placenta praevia

Gasiūnaitė D.1, Kontrimavičiūtė E.1, Šipylaitė J.1, Bračkutė L.2, Olendraitė U.2

1Vilnius University , Dept.of Anaesthesiology and Reanimatology, Centre of Anaesthesiology, Intensive Therapy and Pain Management, Vilnius, Lithuania,2Vilnius University, Faculty of Medicine, Vilnius, Lithuania

Background: Anesthesia management of placenta previa(PPr) or percreta(PP) involves preparation for major blood loss. Combination of PPr and PP is a rare and complicated condition which causes high morbidity and mortality. Valuable method for blood loss control is aa.iliaca interna occlusion with balloon catheters(IABO).

Case report: Gravida with a history of 2 previous CS was referred to ER at 23 week of gestation(gw) due to sudden onset of severe lower abdominal pain. Diagnosed PPr and PP with hypervascularisation of large branch of a.iliaca int sin on scar zone. CS under GA scheduled at 32 gw. Performed subtotal hysterectomy without adnexes and both IABO after delivered alive male (Apgar6/8), safely but with massive blood lost (4 L). Norepinephrine maintained throughout surgery with obvious decrease in dose after inflation IABO.3 hours after deflation IABO haemorrhage was observed, relaparotomy, left a.iliaca int ligation was performed. 2-nd gravida with a history of 2 previous CS with obstetrical haemorrhage first time was admitted to ER in 12 gw. Diagnosed PP with penetration to urinary bladder and PPr. CS under GA made on 35 gw. Delivered alive female (Apgar8/9), IABO deflated after hysterectomy and urinary bladder resection. No additional surgery performed due to bleeding. Blood loss and transfusion requirements in second case were 4 times lower. Discussion: One of the most successful treatment is hysterectomy and embolization of iliac arteries as to prevent patient from massive haemorrhage, but complications possible due embolization. Multidisciplinary teamwork is necessary in successful management in complicated cases of PPr and PP.

Learning point: Perioperative management of a parturient in such cases is extremely challenging and is possible to be successfully managed only by multidisciplinary team. There still exists a higher risk of bleeding in case of a.a iliaca int.baloon deflation after surgery. We recommend balloon deflation just after hysterectomy.

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Implementation of an enteral feeding protocol in an intensive care unit: a before-and-after study

Padar M, Uusvel G. Tartu University Hospital, Tartu, EstoniaStarkopf L. University of Copenhagen, Copenhagen, DenmarkStarkopf J, Reintam Blaser A. University of Tartu, Tartu, Estonia

Aim: To determine the effects of implementing an enteral nutrition (EN) protocol on nutritional delivery and outcomes of critically ill patients.

Methods: An uncontrolled, observational before-and-after study was performed in a tertiary mixed ICU. In 2013, a nurse-driven EN protocol was developed and implemented. Nutrition and outcome-related data of patients treated in 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local database, the Population Registry and the hospital’s Infection Control Service. Only adult patients, readmissions excluded, treated for at least 7 days in the study unit were included.

Results: In total, 231 patients were enrolled in the Before and 249 in the After group. The groups were comparable regarding demographics, patient profile and severity of illness. Fewer patients were mechanically ventilated on admission in the After group (86.7% vs. 93.1% in the Before group, P = 0.021). The prevalence of hospital-acquired infections, length of ICU stay and ICU, 30- and 60-day mortality did not differ. Patients in the After group had a lower 90-day (P = 0.026) and 120-day (P = 0.033) mortality. In the After group, EN was prescribed more frequently on all days from day 3. Implementation of the protocol resulted in a higher cumulative amount of enterally (P = 0.049) and a lower amount of parenterally (P < 0.001) provided calories by day 7, with a net reduction in caloric provision (P < 0.001). The prevalence of gastrointestinal (GI) symptoms was comparable, as was the frequency of prokinetic use. Underfeeding (<80% of caloric needs, independent of route) occurred on 59.4% of study days Before vs 76.9% After (P < 0.001). Inclusion in the Before group, previous abdominal surgery, intra-abdominal hypertension (IAH) and the sum of GI symptoms were found to be independent predictors of insufficient EN.

Conclusion: Use of a protocol improves delivery of EN in ICU patients without concomitant increases in GI symptoms or IAH.

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Diabetic ketoacidosis resolution time in pediatric population

Daukste I., Barzdina A., Jegers I.

Pediatric Intensive Care Unit, Children's Clinical University Hospital, Riga, Latvia

Introduction. Diabetic ketoacidosis (DKA) (high anion gap acidosis) is frequent and lifetrathing complication of 1st type of diabetes. Treating is based on guidelines, but still there is unknown optimal volume of fluid administration in pediatric diabetic ketoacidosis.

Aim Our aim was to determine whether the administred volume of fluid before start insulin in children with DKA influences the rate of metabolic normalization.

Materials and Methods. We performed retrospective study including children with DKA who were hospitalized in PICU from September 2011 until April 2016. First part of study is description of population. In second part we analyzed anion gap normalization, pH normalization, blood glucose level normalization, insulin dose, complications. 100 children with type 1 diabetes mellitus and DKA between 1 and 17 years of age were included. Patients were randomized in groups. One group children who recieved more than 10-20 ml/kg fluid bolus and other group children who recieved more than 10-20 ml/kg intravenous fluid bolus before starting insulin infusion.

Results. 54% had newly diagnosed type 1 diabetes mellitus. In group of known type 1 diabetes mellitus causes of DKA were poor diabetes control and infection. 49% patients had severe DKA. 24% had fluid bolus 10 ml/kg. 26% had fluid bolus more than 20 ml/kg. In 10-20 ml/kg vs more than 10-20 ml/kg fluid bolus group anion gap normalization time were 9 vs 12 hours, pH normalization time 17.5 vs 18 hours, glucose normalization time 12 vs 14 hours. Insulin dose varies between 0.05-0.1 unit/ kg/h. In larger bolus group insulin doses were lower. The most common complications were hypoglycemia and hypokalemia.

Conclusion. Fluid bolus volume more than 20 ml/kg infusion in the treatment of pediatric DKA patients did not shortened metabolic normalization time, but stabilazed circulation faster. Higher fluid volume infusion corellate with with lower doses of insulin infusion.

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Real-time ultrasound-guided percutaneous dilatational tracheostomy: a feasibility study

Simonova,A., Aron,M., Liguts, V., Rožkalne,D.

Riga East Clinical University Hospital, Riga, Latvia

Introduction. Patients in ICU frequently require tracheostomy for long-term ventilator support, and the percutaneous dilatational tracheostomy (PDT) is the method of choice.

Aim was to demonstrate that PDT performed under real-time US guidance is feasible.

Methods. Mechanically ventilated patients, without cervical spine lesions, poor anatomy, obesity and previous tracheostomy, underwent US guided PDT (US-PDT). Local anesthesia and Propofol 1% infusion titrated to deep sedation was used for all patients during the procedure. Initial neck anatomy was examined using palpation as well as US. Endotracheal tube cuff was visualized by inflating it with saline solution. Then the tube was withdrawn until the cuff was positioned immediately inferior to the vocal cords. The trachea was punctured under real-time US guidance using the acoustic shadows of the tracheal rings to identify the level of puncture. A 2 cm horizontal incision and blunt dissection was carried out after puncture. The point of tracheal puncture was: the space between the second and third rings or the third and fourth tracheal rings, as close as possible to the midline and no vascular structure in the path of the needle. Advancement of the needle was halted, when the aspiration of air into a saline-filled syringe and a palpable change in resistance was noted. Then guidewire was passed following dilatation and tube placement.

Results. A total of 10 patients underwent US-PDT. They were aged between 33 and 66 years (median 48 years, IQR 36-60). Diagnoses were: aneurysmal subarachnoid hemorrhage (n = 4), severe traumatic brain injury (n = 4), intracerebral hemorrhage (n = 2). We successfully performed US-PDT in all 10 patients. Following patients for up to 1 week (median 5 days, IQR 4-6) revealed no new complications.

Conclusion. US-PDT may become an alternative method to bronchoscopy assisted tracheostomy if several conditions will fulfill: available bed-side US, optimal patient neck anatomy.

29

Rare complication after lumbar puncture – acute subdural hematoma: case report

Maddison, L.; Kõrgvee, S.; Reinhard, V.

Tartu University Hospital, Tartu, Estonia

Background. Common complication of lumbar puncture (LP) is headache. Rare complications are low back pain, radicular injuries, abscesses, meningitis. SDH after LP is very rare. Predisposing factors for SDH can be: pregnancy, multiple punctures, use of anticoagulants, intracranial vascular abnormalities, and brain atrophy. The neurological symptoms of post-spinal headache and SDH are similar and difficult to differentiate. The correct diagnosis often delays.

Case report. 41 y previously healthy female came to ED with complaints to headache locating mainly in the forehead and nape, chills, febrile fever, nausea and vomiting, photophobia. Symptoms started 4 days ago. She had had delivery 5 months ago, breastfeeding at present. Patient was alert, temperature was 38,2 C. Lab exams showed elevated CRP and procalcitonin, thrombocytopenia, no leucocytosis.

Brain CT ruled out vascular pathology. Suspected diagnosis was meningitis, LP with 22G Quincke needle was performed and 10 ml CSF was taken for tests, which ruled out neuroinfection. Urine test was normal and thoracic X-ray suspected pneumonia on the right. ED doctor ordinated Cefuroxim and patient was discharged home in good condition.

2 days after the visit to the ED the headache got more severe and nature of the pain changed: pain started when she stood up, stayed for 5 minutes and then eased slightly. Photophobia and nausea stayed. Patient also had diarrhoea and fever up to 39 C. She returned to ED, was conscious. Kernig’s sign was slightly positive and she had stiff neck. Repeated CT showed minimal acute SDH on the right.

Patient was hospitalized for treatment. She got painkillers and caffeine, no surgical intervention was needed. 8 days later she was discharged without neurological deficit, but still having some headache.

Conclusion. SDH should not be excluded from the differential diagnosis of headache following LP, especially when there is a loss of CSF.

30

Super-refractory status epilepticus: a report of two cases

Hade, J ¹; Ilmoja, M-L¹

Tallinn Children`s Hospital, Tallinn, Estonia

Super-refractory status epilepticus (SRSE) is defined as seizure status that continues or recurs 24 hours or more after the onset of anesthetic therapy, including those cases where status epilepticus recurs on the reduction or withdrawal of general anesthesia.

Two male patients, 6 and 10 years old boy, were admitted to Tallinn Children`s Hospital intensive care unit with seizures unresponsive to first-line therapy. As the seizures continued after second-line therapy, general anesthesia was started with intention of EEG burst-supression pattern. Combination of oral antiepileptic therapy was started and both patients recieved pulse corticosteroid therapy, continued by immunotherapy.

MRT demonstrated a hyperintense hippocampus on FLAIR sequence and DWI showed diffusion restriction due to cytotoxic edema. Later continued temporomesial signal changes were detected accompanied with atrophy in sub- and supratentorial structures and expansion of ventricle.

As the seizures still continued on 67th day of barbiturate anesthesia, electroconvulsive therapy (ECT) was started for the 6-year old boy. The patient showed reduction in epileptic activity after the first 3 ECT sessions. 12 sessions of ECT were performed. Barbiturate anesthesia was discontiunued after 98 days. He was discharged after 134 days in the hospital. 3 months Glascow Outcome Score (GOS) was 3.

The second patient was discharged from the hospidal after 82 days with GOS of 2, after 44 days of barbiturate anesthesia.

Prolonged refractory epileptic status leads to high morbidity and mortality with about 80% of patients having a poor outcome at one-year follow up. SRSE is heterogeneous and its ultimate prognosis depends on factors other than treatment such as age and aetiology, which complicates assessment of individual therapies. Therefor our current therapies are based on limited amount of evidence.

31

Splenic rupture – a rare complication of haemolytic disease of the newborn.

Eelmäe, I. Anaesthesiology and Intensive Care Clinic of Tartu University Hospital, Tartu, EstoniaEhrlich, H.E. Anaesthesiology and Intensive Care Clinic of Tartu University Hospital, Tartu, EstoniaKikas, R. Anaesthesiology and Intensive Care Clinic of Tartu University Hospital, Tartu, EstoniaVärimäe, E. A. Surgery Clinic of Tartu University Hospital, Tartu, EstoniaLintrop, M. Radiology Clinic of Tartu University Hospital, Tartu, EstoniaSalumäe, L Pathology Department of Tartu University Hospital, Tartu, EstoniaMetsvaht, T. Anaesthesiology and Intensive Care Clinic of Tartu University Hospital, Tartu, Estonia

Introduction. Splenic rupture in neonates is extremely rare; major causes include haemolytic disease of the newborn (HDN), coagulopathy, traumatic rupture of liver or spleen and vascular pathologies. Of the few published cases of splenic rupture in HDN, the majority have not survived.

Case. A boy was born at term from 4th pregnancy, 3rd vaginal delivery; birth weight 3092 g. Apgar scores were 8/8 at 1/5 minutes. HDN was diagnosed based on maternal anti-D antibodies (titre 1:256), baby`s blood group (B Rhesus-D positive), positive direct Coombs test and anaemia (Hgb 71 g/L, Hct 24%, reticulocytes 9.99%, 362.6×109/L, erythroblastosis, platelets 82×109/L), without hyperbilirubinemia (bilirubin 54.3 µmol/L). The baby was treated with f packed RBC, IVIG and empiric antibiotic therapy. On day 2 of life (DOL 2) he deteriorated, looked pale, with delayed capillary refill, tachypnea, lethargy, anuria and abdominal distension. Worsening anaemia (Hgb 123 - 104 -76 g/L) despite moderate signs of haemolysis and thrombocytopenia required massive RBC, FFP and thrombocyte transfusions. Abdominal ultrasound detected ascites, suspecting haemoperitoneum. Emergency laparotomy revealed massive haemorrhage from ruptured spleen requiring splenectomy. Estimated blood loss was 230 ml; total volume of transfusion 148 mL/kg. Histology confirmed enlarged spleen (38 g; 7×5.5×1.5 cm) with rupture in the hilus; otherwise normal morphology.

His postoperative course was uneventful. From DOL 5 antibiotic treatment was switched to oral prophylaxis with phenoxymethyl penicillin for post splenectomy risk of bacterial infections. Adequate vaccination plan is to be compiled.

Conclusion. In haemolytic disease of newborn severe recurring anaemia without markers of ongoing haemolysis differential diagnosis should include other reasons of anaemia. The rare association with splenic rupture due to erythroblastosis should be considered, as prompt intervention may be life-saving.

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Sedation for colonoscopy increases patients' acceptance of repeated procedures

Kučinskaitė R., Karbonskienė A.

Clinic of Anaesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania

Aim: The aim of the study was to assess how the use of sedation during colonoscopy influences duration of the procedure, procedural pain intensity, patients’ anxiety, satisfaction, and acceptance of repeat examinations.

Methods: Patients who underwent colonoscopies over a 5 month period (September-December, 2015) were invited to participate. They were offered sedation with standard intravenous sedatives, or an unsedated colonoscopy was attempted. Demographic details were recorded. Duration of procedure, patient anxiety level prior to the procedure, patient pain assessments, satisfaction after the examination and the patient's willingness to return for the same procedure in the future were recorded.

Results: The study included 150 patients (average age 62±15,4 years; 52,7 % men). Of these, 50 patients were sedated for the procedure (sedation group) and 100 were not (awake group). Average duration of colonoscopy in sedation group was 16 ±5 min. and 20±3 min. in the awake group (p=0,021). No complications of sedation or colonoscopy procedures were observed. Preprocedural anxiety level was comparable in both groups (p=0,068). Pain intensity experienced by patients of awake group was significantly higher than by patients of sedation group (8 vs. 1 according to VAS scale, p=0,001). Patient satisfaction with the procedure was higher in sedation group (9 vs. 7 satisfaction score, p=0,015). 52 patients of awake group would not repeat procedure without sedation.

Conclusion: Sedation reduces pain experience during colonoscopy, improves both patient satisfaction and the acceptability of future procedures.

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Admission to intensive care unit after elective surgery: an audit in a tertiary hospital

Vilkevičiūtė J., Karbonskienė A.

Clinic of Anaesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania

Unplanned admission to intensive care unit (ICU) after elective surgery increases workload of this department and reflects processes which may negatively affect postoperative outcomes.

Aim of this study was to determine the features of unplanned hospitalization to ICU after elective surgeries in Lithuanian University of Health Sciences Kauno Klinikos and to determine the factors associated with patient outcomes after these surgeries.

Methods: A retrospective analysis of medical records of patients, who were hospitalized to ICU after elective surgery in Lithuanian University of Health Sciences Kauno Klinikos from 2014 to 2015. Procedures with routine postoperative admission to ICU were excluded.

Results: 120 patients entered the ICU after elective surgery. During the study period 72 (60%) patients were transferred to ICU due to respiratory failure, 6 (5.0%) due to blood loss, 5 (4.2%) due to respiratory failure and blood loss, 1 (0.8%) due to cholinesterase deficiency, 3 (2.5%) due to multiple organ dysfunction syndrome, 30 (25.0%) for postanesthesia care, 1 (0.8 %) due to myocardial infarction during surgery, 1 (0.8%) due to bradycardia, 1 (0.8%) due to anaphylactic reactions. Mean duration of ICU stay was 45.61±93.62 hours. The rate of in-hospital deaths was 7 (5.8%). Length of stay in ICU time depended on the reason of ICU admission (χ2(8)=16.962, p=0.031). In-hospital mortality depended on the following factors: blood product transfusion during surgery (χ2(1)=4.014, p=0.045), vasoactive agents during surgery (χ2(1)=3.959, p=0.047), ASA score (χ2(3)=18.352, p=0.000) and area of surgery (χ2(2)=9.228, p=0.010.

Conclusion: The most common reason of ICU admission was respiratory failure. We found that in-hospital mortality depended on blood product transfusion, vasoactive agents during surgery, ASA score and area of surgery. Further prospective studies are needed to determine the cause of these risk factors.

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Audit: Adherence to the Enhanced Recovery After Surgery (ERAS) protocol and outcomes after colorectal cancer surgery in North Estonia Medical Centre

Härma, E; Seire, I; Laas, A; Kütner, S

North Estonia Medical Centre, Tallinn, Estonia

Introduction: The purpose of this audit was to measure the impact of different adherence levels to the enhanced recovery after surgery (ERAS) protocol and the effect of various ERAS elements on outcomes following major colorectal surgery.

Methods: This audit was performed among fifty three patients with colorectal cancer from the period of October 2015- July 2016 in North Estonia Medical Centre (NEMC), Tallinn, Estonia after implementation of ERAS protocol. The baseline chracteristics included age, sex, ASA score, type of cancer and type of surgery. Completing of specific ERAS elements such as using preoperative carbohydrate drinks, selective bowel preparation, limited premedication, restricted perioperative fluid therapy, postoperative nausea and vomiting, multimodal pain management, early mobilisation and early oral nutrition was measured. The association of improved adherence to ERAS protocol and the incidence of postoperative complications (e.g. wound infection, postoperative ileus, pulmonary complications etc.), readmissions and length of hospital stay following major colorectal surgery was analysed.

Results: The proportion of adverse postoperative outcomes such as postoperative complications, readmissions and length of hospital stay was reduced in the groups with higher adherence to ERAS protocol (>70% and >90% respectively) comparing to the group of patients who had low adherence to ERAS protocol (<50%).

Conclusions: The patients who underwent major colorectal surgery and were treated with higher adherence to ERAS protocol had significantly lower rate of postoperative complications and readmissions as well as reduced length of hospital stay.

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Pressure pain threshold relation to pain, emotional status characteristics and cold pressor test in patients with chronic musculosceletal pain

Vaitkus A. (1), Januleviciene R. (2), Junevic J. (2), Sipylaite J. (3)

(1) Anesthesiology, Intensive Care and Pain Management Centre, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania(2) Faculty of Medicine, Vilnius University, Vilnius, Lithuania(3) Clinic of Anesthesiology and Intensive Care, Faculty of Medicine, Vilnius University, Vilnius, Lithuania

Objectives. To evaluate pressure pain threshold (PPT) relation to pain, emotional status characteristics and measure PPT change after cold pressor test (CPT) in chronic pain patients.

Methods. A prospective experimental study was performed at the Vilnius University Hospital Santariskiu Klinikos with chronic musculosceletal pain patients attending Pain treatment day care department. Patients with comorbidity or factors affecting somatosensory function were excluded. After collecting demographic data, pain characteristics, completing Hospital anxiety and depression scale (HADS), PPT was measured at 4 points (supraspinatus muscle on both sides and palmar thenar eminence on both sides) using algometer (FDN200, Wagner Instruments, Greenwich, USA). PPT was repeatedly measured after performing CPT (non-dominant hand was submerged in the cold water of 3-5 C° bath for 60 seconds).

Results. 20 patients (6 (30%) man, 14 (70%) women) with mean age of 49.45±14.88 were evaluated. Duration of chronic pain was 53.60±60.61 months, pain intensity at evaluation moment was 4.1±1.94 (on numeric pain scale 0 to 10), average 2 week pain 5.4±1.85, maximal 2 week pain 8.2±1.51. PPTs measured after CPT were higher that before CPT at all points: right supraspinatus muscle before 58.97±22.58 vs. after 63.49±28.92, left supraspinatus muscle 61.74±22.99 vs. 66.58±25.58, right palmar thenar eminence 66.95±17.28 vs. 71.61±18.82 (p=0.05), left palmar thenar eminence 71.04±15.06 vs. 72.78±13.62. Patients with higher anxiety score on HADS, had lower PPTs at all points before and after CPT (p<0.05). No correlations of PPTs with pain duration, intensity and depression score on HADS were detected before and after CPT.

Conclusions. CPT has an effect to increase PPTs in patients with chronic musculosceletal pain. Higher anxiety score on HADS correlated with lower PPT independently to CPT. PPTs at all points correlates between each other.

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Pre-incisional single dose ketamine does not have an effect on postoperative analgesic requirements after intraoperative remifentanil infusions

Kasputytė G., Karbonskienė A.

Clinic of Anaesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania

Remifentanil infusions provide excellent intraoperative analgesia with rapid emergence in different patient groups. But postoperative analgesia is still a challenge after this type of anaesthesia. Low-dose intravenous ketamine seems promising in reducing postoperative opioid requirements and opioid induced hyperalgesia.

Aim: to evaluate an effect of pre-incisional single injection of low-dose ketamine on postoperative analgesic requirements and patient satisfaction with postoperative analgesia in laparoscopic bariatric surgery.Methods: 22 consecutive bariatric patients were randomly assigned to receive single pre-incisional injection of ketamine (0,15 mg/kg) (K group) or saline (S group) in a double-blind manner. Standardized protocol of anaesthesia based on remifentanil infusion (0,2-0,5 mcg/mg/kg) and sevoflurane was followed. Postoperative analgesia was provided with bupivacaine infiltration of operative ports and standardized doses of acetaminophen, ketoprofen and intravenous morphine to reach acceptable pain level. Patients’ satisfaction with analgesia was recorded.

Results: both groups did not differ in demographic values, BMI, operative time, intraoperative remifentanil consumption. Postoperative pain scores were similar. Morphine consumption was 9,3±2,5 in K group and 7,4±3,2 in S group (p=0.126). Both groups demonstrated equally high satisfaction with postoperative analgesia.

Conclusion: pre-incisional single dose ketamine does not allow to escape postoperative opioids after remifentanil infusions. High patient satisfaction is achieved if multimodal analgesia protocol is followed

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Predictive value of complex haemodynamic monitoring in premature neonates during the first day of life

Hallik, M., Lepik, K., Tasa, T., Metsvaht, T.

Tallinn Children`s Hospital, Tallinn, EstoniaAnaesthesiology and Intensive Care Clinic of Tartu University Hospital, Tartu, Estonia

The aim of the retrospective study is to search for patterns/ characteristics in detailed recordings of haemodynamic parameters, to predict unfavourable clinical outcome.

Methods: The study included preterm (≤ 29 GA) neonates born between June 2014 and February 2016 with recorded monitor data for at least 6 hours during the first day of life. The database consisted of recorded values at 2.5-second intervals from patient monitors (heart rate, arterial blood pressure, peripheral oxygen saturation, cerebral regional oxygen saturation), central blood flow parameters measured by echocardiography (RVO, LVO, superior vena cava flow, PDA and PFO), administered medications and fluid infusions, acid-base balance, blood gases and lactate. Unfavourable outcome was defined by death in the first 72 hours of life, death in the first 7 days of life, grade III-IV intraventricular haemorrage or haemodynamically significant PDA.

Results: 28 neonates were included. A complex mathematical approach was developed to include the utmost available data in clinical prediction. The recorded parameters were aggregated into a set of characteristics that describe the level and variability of these parameters of each of the patient over the first day of life. These characteristics were then tested for association with outcomes using logistic regression models. To reduce the dimensionality of the data, we looked for linear combinations of the most important characteristics that describe most of the variability in the data and perform best in terms of predicting outcome. Primary principal component analysis of 72 h survival revealed clustering of favourable outcome; high variability was associated with increased risk of death.

Conclusion: Physiological data from multiple monitoring methods may hold potential to define the highest risk situations early enough to allow therapeutic interventions in neonates.

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Failure to execute pain management guideline in major urology surgery patients- old habits die hard

Herodes, V; Rebo, Maria; Valk, Helen

North Estonia Medical Centre, Tallinn, Estonia

Introduction: The aim of any guideline is standardised evidence based management of patients or clinical situation. In 2015 multidisciplinary guideline for management of major urology surgery – cystectomy, patients was launched in North Estonia Medical Centre. It consisted of perioperative nutrition and fluid management; antibiotic and thrombus prophylaxis; early mobilisation and physiotherapy. Acute pain team was involved in recommending the best pain management plan for these patients.

The purpose of this audit is the pain management pre and after the introduction of guideline.

Methods: We retrospectively collected data of 39 patients – 26 adult patients before and 13 after the guideline was implemented. We assessed pain scoring (Numeric Rating Scale- NRS 0-10), analgesics prescriptions by anaesthesiologists, the efficacy and length of epidural infusion, timing and dosing of regular and as required pain medication, recorded possible side effects and complications.

Results: Our pre-guideline data showed that all patients had epidural analgesia- median length of infusion was 116 and maximum 144 hours. There was no departmentally agreed pain management plan; the usage of IM injections was in common place. Patient’s pain was wrongly recorded as patients often found to be in pain with NRS 0-1. Post-guideline data: Epidural infusion times- median 96 and maximum 300 hours. All patients had regular and as required analgesics prescribed as per guideline. But still IM opiates administered. Pain scoring still poorly recorded. Side effects and complications are not common and minor in nature -nausea and vomiting.

Conclusion: Since the guideline was introduced, we saw only some improvements in pain management- departmentally agreed pain prescription. Either due to ward habits or lack of training there was many diversions from the guideline. Our pain team task now is to re-teach and train the nursing stuff and surgical colleagues. Re-audit within 12 months.

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In vitro stability of imipenem/cilastatin for prolonged infusion in ICU setting.

Tkatš, M., Fedulov, A., Post, A.-M., Sillaots, P., Meos, A., Moldau, M., Orav, L., Rätsep, I.Institute of Pharmacy University of Tartu, North Estonia Medical Centre Tallinn, Estonia

Prolonged infusion of β-lactam antibiotics, including imipenem/cilastatin (IC) is increasingly used in ICUs to optimize antibiotic exposure. Aim of study was to investigate stability of IC 10mg/ml (imipenem/Cilastatin Actavis 500/500 mg in 0.9% NaCl solution) at room temperature to clarify possibility of implementing prolonged infusion in ICU setting. According to manufacturer´s labelling infusion of IC 5mg/ml should not exceed 2h.

Methods. Content of vial containing imipenem monohydrate and cilastatin sodium 500/500mg was dissolved in 50ml of saline in 60 ml syringe. 1.0 ml of resulting solution was diluted 10-fold by purified water and transferred into autosampler vial. Content of IC was assayed using modified HPLC method presented in imipenem monograph of European Pharmacopoeia.

Results. Relative concentration of IC (10mg/ml) recorded at timepoints 0-8h were 0h 100%; 1h 98%; 2h 97%; 3h 96% ; 4h 95%; 5h 94% ; 6h 92%; 7h 92% ; 8h 90% (SD 1-3%) for imipenem and 0h 100%; 1h 100%; 2h 99%; 3h 99%; 4h 99%; 5h 98%; 6h 97%; 7h 98%; 8h 97% (SD 1-3%) for cilastatin. To outline, imipenem retained 95% of its activity during 4h infusion at room temperature 22-28°C. Cilastatin concentration did not change significantly during 4h (99%).

Conclusion. IC in concentration 10mg/ml is stable for at least 4h and can be used for prolonged infusion. Lack of ICU-specific information in manufacturer´s labelling is unrare problem for many drugs.

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