Evaluation the efficacy and side effects of postoperative analgesia in patients after orthopedic surgery

1Konkayev A., 1Yeltayeva A., 2Sainov M.
1Astana Medical University, 2Institution of Traumatology and Orthopedia
Astana, Kazakhstan

Background and Goal of Study: Orthopedic surgery in adults needs an optimal postoperative pain management. In case of inadequate pain relief in 20% of patients after surgery may develop chronic pain (1). The aim of study was to evaluate the efficacy and side effects of postoperative analgesia in patients after orthopedic surgery.
Materials and methods: After obtaining written informed consent and local ethic committee approval 228 adults (aging 43.5±16.5, ASA I-II) scheduled for orthopedic surgery. Numeric rating scale (NRS), efficacy and side effects score (Kongsberg satisfaction score - KSS) and mobility degree will be registered every hour during the first 8 hours postoperatively (1). Postoperative pain was treated with doses of 100 mg tramadol i.m. on demand. Data were processed unpaired t-test with Statistica 6.0 (StatSoft Inc., Tulsa, OK, USA); p<0.05 significant. Data are means ±SD.
Results and Discussion: Mean KSS was 18±2 in the first hour after surgery. During the next 7 hours, it remained between 19 and 24 corresponding to good satisfaction. A slowly increasing degree of mobilization was revealed during the first 8 postoperative hours. By analyzing different types of anaesthesia for knee replacement, we found a higher KSS during the first 4 hours postoperatively (p < 0.05) after spinal anaesthesia as compared with total intravenous anaesthesia. NRS in second hour after spinal anesthesia (3.1±0.4) was lower than in patients after intravenous anaesthesia (5.9±0.9, p<0.05). Total analgetic consumption (tramadol) was higher in patients after general anaesthesia (50.1±5.8 mg vs 14.3±3.1; p < 0.02) on the first day after operation. 
Conclusion(s): Using KSS may be a useful for monitoring the status, efficacy and safety of postoperative pain control of orthopedic patients. 
References: (1) Kuklin V., Skraastad E., Ernst G. et al. Kongsberg satisfaction score: a novel system for monitoring the status, efficacy and safety of the postoperative pain treatment. International Anaesthesia Research Society Annual Meeting, San Diego, California, USA, May 4-7, 2013.

Evaluation the efficacy and side effects of postoperative analgesia in patients after orthopedic surgery

Background and Goal of Study: Postoperative cognitive dysfunction could occur following obstetric interventions such as caesarean section or vaginal delivery and have consequences on the mother and the child.1 Cognitive failure in consequence of caesarean section (CS) can be grounded on anesthetic agents.2 The aim of our study was to determine the effect of sevoflurane on cognitive function (CF) of women delivered by CS. 
Materials and Methods: Having agreed with the local Ethics Committee and obtained the informed consents, 64 women (at 37-42 weeks gestation, who delivered by the caesarian section) were examined. After general anaesthesia (GA) was induced with propofol (2 mg/kg) the women were randomized into 2 groups: 1st (n=30) GA was maintained with sevoflurane 1.3vol% in 50% oxygen (IA), and 2d (n=34) GA was maintained with propofol 0.1 mg/kg/min. Both groups were similar in relation to age, education, physical status (ASA I-II), intraoperative blood loss, surgery duration and CF baseline. CF were assessed by Montreal Cognitive Assessment scale (MoCA) and Cognitive Failure Assessment (CFQ) test, Memory by Luria test, Control functions by ‘Alternating Trail Making’ test (ATM), praxis by ‘Clock Drawing Test’ (CDT). Checkpoints are before delivery (baseline), at day 1st, 3d, 7th, 28th and 46th after CS. Data are presented as mean±SD or % mothers with parameters lower the norm. Mann-Whitney U test was used for statistical analysis, *p<0.05 was considered as statistically significant for comparison between groups IA vs TIVA.
Results and Discussion: Results are presented in table1. All pregnant women before delivery had initially reduced CF. There were normalization of CF in general (MoCA) and control functions (ATM) till 3d postoperative day after anesthesia with sevoflurane. These functions were not recovered to normal even till 7th day after CS in TIVA group. Memory (test Luria) and praxis (CDT) recovered till 3d day after the surgery regardless of the type of anesthetic agent. CF in IA group were completely recovered (CFQ) by 46 day after CS. At the same time, 35.5±3.3% of women had persisted violations of CF after TIVA.
Conclusion(s): Anesthesia with sevoflurane provides rapid recovery of the initial decreased cognitive functions in women after caesarean section.

Does Sevoflurane influence cognitive function recovery after caesarean section?

An enormous giant paravertebral synovial sarcoma extending to thoracic cavity obscuring mediastinum

Relation between labour pain relief methods, postpartum depression, satisfaction with labour and labour analgesia for primiparous parturients

EFICACY AND SAFETY OF BILATERAL SEQUENTIAL ANTEBRACHIAL INTRAVENOUS REGIONAL ANAESTHESIA WITH LOW DOSE LIDOCAINE FOR THE TREATMENT OF PALMAR HIPERHIDROSIS WITH BOTULINUM TOXIN

Background and Goal of Study: Palmar hyperhidrosis is a pathology that impedes patient’s daily life, theirs interpersonal relations and work. Injection of botulinum toxin in the palms significantly reduces the perspiration for months. The procedure is very painful due to the sensibility of the zone. We used a bilateral sequential intravenous regional anaesthesia with low dose lidocaine and with antebrachial ischemia with the aim to evaluate the efficiency and safety of the technique.

Material and Methods: 55 bilateral procedures were included. We cannulated a vein in at the dorsum of each hand, ischemia was accomplished with a simple cuff 3-4 cm proximal to the wrist (250-300mm Hg) and we administrated a total dose of 15ml (women) to 20ml (men) of 0,5% lidocaine per hand was administered. Cuff was deflated after 20 minutes and then we proceeded with the other hand. 

Results: The average of pain with the infiltration of toxin was of 2,12 +/-1,97 according to a VAS scale. We did 110 procedures. In 8 (7,25 %) occasions it was necessary to reinforce the dose of lidocaine administered. Once administered the reinforcement, only 2 patients needed sedation because of inadequate analgesia. The average of pain related to pressure of the cuff was 2,04 +/-2,16 and pain associated to injection of lidocaine of 3,24 +/-2,09. Complications: 2 patients referred tinnitus and in one case dizziness. No intervention needed as they resolved spontaneously in less than two minutes. 

Conclusion(s): Bilateral sequential intravenous regional anaesthesia with low dose lidocaine and with single cuff antebrachial ischemia is effective and safe for the treatment of palmar hyperhidrosis with botulinum toxin.

Eficacy and safety of bilateral sequential antebrachial intravenous regional anaesthesia with low dose lidocaine for the treatment of palmar hiperhidrosis with botulinum toxin

Objective: Parecoxib, an injectable COX-2–selective inhibitor, is approved in over 80 countries for the short-term management of post-operative pain and, in some countries, for the treatment of acute pain or renal colic. Parecoxib first received regulatory approval in 2001 and there is a wealth of post-authorization data available regarding its use in real-world settings. The current study reviews this data to examine the occurrence of pre-defined safety events associated with COX-2 inhibitors and/or traditional NSAIDs. Methods: Data were derived from a Pfizer database which captures and stores reported adverse event (AEs) information from across the globe. AEs were coded to a specific Medical Dictionary for Regulatory Activities (MedDRA) term upon entry into the database. The database was searched for specific MedDRA terms or standard queries corresponding to the pre-defined safety events. The number of medically-confirmed cases, along with outcome, through March 31st 2014 was presented for each event. Results: The occurrence of pre-defined safety events was relatively low considering that 69,567,300 units of parecoxib were sold from the first quarter of 2002 through the first quarter of 2014. The total number of reports/number of reports classified as serious for each event over this period was as follows: cardiovascular embolic and thrombotic events (66/64), renal failure and impairment (77/68), gastrointestinal ulceration-related events (35/35), hypersensitivity reactions (190/98) including severe hypotension (32/25) and severe cutaneous adverse events (17/17), and masking signs of inflammation (18/18). Among reports with known outcomes, a majority of patients recovered or were recovering from these events. A total of 46 fatalities, which cannot be confirmed as treatment-related, were reported as outcomes: cardiovascular embolic and thrombotic events (20), renal failure and impairment (6), gastrointestinal ulceration-related events (4), hypersensitivity reactions (7) including severe hypotension (3) and severe cutaneous adverse events (2), and masking signs of inflammation (4). Conclusion: The occurrence of pre-defined safety events was relatively low with parecoxib considering nearly 70 million units were sold over a 12 year evaluation period, which is consistent with data from the clinical trial program. When administered according to the approved label, the overall benefit/risk assessment is considered favorable for parecoxib. Sponsored by Pfizer.

The safety profile of parecoxib for the treatment of post-operative pain: an examination of over 10 years of post-authorization safety data

Objective: Early mobilization is a key element of early recovery after surgery protocols and contributes to improved outcomes following surgery. Parecoxib, an injectable cyclooxygenase-2 (COX-2) inhibitor, is approved in over 80 countries for the management of postoperative pain but few studies have specifically examined its effects on movement-induced pain. Methods: Data were pooled from two clinical trials to examine parecoxib’s effects on movement-related pain following major gynecological surgery. Results were compared between treatment groups receiving a single IV dose of placebo (n=87), morphine 4 mg (n=82), ketorolac 30 mg (n=83), parecoxib 20 mg (n=79), or parecoxib 40 mg (n=79) on the first day following surgery. Results: Mean pain intensity scores were significantly lower for all treatments compared with placebo at 0.5–1.5 hours post dose of medication (all p<0.05) with the exception of parecoxib 20 mg at 0.5 hours. Mean pain relief scores were also significantly better for all treatments compared with placebo at 0.25–1.5 hours post dose of medication (all p<0.05) with the exception of parecoxib 20 mg at 0.25 hours. However, in contrast to morphine, the ketorolac and parecoxib groups continued to exhibit significantly better pain intensity and pain relief scores relative to placebo at 2.0–24 hours (all p<0.05). The median time to achieve a ≥50% decrease in baseline pain intensity was significantly quicker (≤26 minutes) for all treatments compared with placebo (45 min) (all p<0.05). Finally, patient evaluation of study medication scores at 24 hours were significantly better for all treatments compared with placebo (all p<0.05) but the ketorolac and parecoxib groups exhibited significantly better scores compared to the morphine (all p<0.05). Conclusions: Though all treatments significantly reduced movement-induced pain in the first 2 hours following major gynecologic surgery, the parecoxib 20 mg, parecoxib 40 mg, and ketorolac 30mg groups produced significantly greater pain relief compared to morphine 4 mg over the full 24 hour evaluation period. Generally, there was little difference in efficacy between parecoxib 40 mg and ketorolac 30 mg over the course of the study. Sponsored by Pfizer Inc.

The effects of parecoxib on movement-related pain following major gynecological surgery

Background and Goal of Study: 
Surgical Pleth Index (SPI) is a measurement of intraoperative nociception (1). The evidence of its usability in children is limited. Since the development of neural system is strong during the first years of life, conclusions on the feasibility of Surgical Pleth Index on small children cannot be drawn from studies done in older age groups.
Materials and methods: 
Thirty children aged less than two years, planned for elective open inguinal hernia repair or open correction of undescended testicle, were recruited. They were randomized into one of two groups; receiving ilioinguinal/iliohypogastric nerve block (BG) or saline injection (SG) preoperatively ultrasound guided and in opposite order after surgery. The SPI was recorded blinded and analysed at the time points of intubation, incision and when fentanyl was administered based on clinical decision.
Results and discussion:
[Patient characteristics]
There was a significant increase in the SPI after intubation (p=0.019) and after incision in the Saline Group (p=0.048), but not at surgical incision in the Block Group (p=0.177). An increase in the SPI was also seen at the times when fentanyl was needed (p=0.008).

Table[Characteristics of SPI]

Figure 1 The median value of the SPI at incision in BG (A), SG (B), intubation (C) and at times when fentanyl was given (D) . Grey lines represent each individual and the black line shows the median of all measurements. The time point of interest is located at the middle of the x-axis (0). The total time line is 240 sec (A-C) and 600 sec (D).

Figure: [Characteristics of SPI] 

Conclusion(s): The SPI is reactive on small children after the intubation and after surgical stimulus. The reactivity of the SPI is rather small and there is marked interindividual variability in reactions. The reactivity is blunted with the use of neuraxial blockade.
Reference: 1. Huiku M et al. BJA 2007;98:447-55.

Surgical Pleth Index in children below 24 months of age: a randomized double-blinded trial

Reduction of chronic post-surgical pain with ketamine (ROCKet) pilot trial

Meta-analysis of the effectiveness of perioperative ketamine to reduce persistent postsurgical pain

Background:
Transthoracic echocardiography (TTE) cannot reliably exclude left atrial (LA) thrombi prior cardiac surgery. LA trombi have been shown to be associated with an increased stroke rate. TEE has a sensitive and specificity of 100% in detection of LA and left atrial appendage (LAA) thrombi in contrast to TTE which has limitations when assessing the presence of masses or thrombi in the left atrium.

Case report:
We report the case of a 60-year-old woman scheduled for aortic and mitral replacement. Her history includes atrial fibrillation and ischemic stroke. Chronic anticoagulation was suspended five days before surgery and low molecular weight heparin began. The intraoperative TEE revealed a new 20x30 mm diameter pedunculated mass in LAA protruding to LA. Preoperative TTE had been performed 2 months before, showing any mass inside. This made the surgeon was very cautious in the left atrial opening because the possibility of thrombus embolization.

Discussion:
According to the latest guidelines, TEE should be used in all open heart procedures in order to: (1) confirm and refine the preoperative diagnosis, (2) detect new or unsuspected pathology, (3) adjust the anesthetic and surgical plan accordingly, and (4) assess the results of surgical intervention. 
Our case confirms the importance of detection of new findings prior the operation which changes the surgical procedure and planning.
Thrombi appear as echogenic mass protruding into the main cavity, and are generally broad and pedunculated base, they mostly are stationary. It should make us suspect its presence whenever there are stasis phenomena such as atrial fibrillation and mitral stenosis. Thrombogenic risk increases with decreasing LAA velocities: <20 cm/s (29%) 20-40 cm/s (10%) and >40 cm/s (1%). The flow velocities in LAA as may incur indication surgery ligation.
The withdrawal of the anticoagulation, can cause thrombosis in this area and therefore its substitution for HLMW is necessary although not always prevent from a new thrombus.

Conclusions:
TEE should be used in all open heart procedures.
Intraoperative TEE gives the possibility to detect new pathologies that changes the surgical procedure.

Finding of left atrial appendage (LAA) thrombus despite a normal preoperative transthoracic echocardiography (TTE). Importance of intraoperative TEE. A case report

Background and Goal of Study: It is difficult to evaluate the deepness and wideness of sympathetic block, provided by regional anaesthesia, compared to motor and sensory components. Changes in skin temperature may be useful in this content.

Materials and methods: The skin temperature in different regions of lower extremity was measured with infrared thermometer before and after epidural block in 16 patients. The epidural anesthesia was performed in L3-L4 with 18 ml 0.5% bupivacaine. The skin regions were taken in accordance with innervation: nervus ischiadicus - heel and big toe, nervus femoralis - anterior surface of knee, nervus obturatorius - medial surface of thigh, nervus cutaneus femoris lateralis - lateral surface of thigh. All results are given as Mean ± standard deviation. 
Results and discussion: The skin temperature on the plantar surface of heel increased from 24.2±3.1ᴼC to 28.4±4.6ᴼC (P=0.0071). On the big toe temperature increased from 21.2±2.3ᴼC to 27.5±5.8ᴼC (P=0.0076). On the anterior surface of knee the temperature was not changed (32.8±1.21ᴼC before and 32.8±1.42ᴼC after epidural anaesthesia; P=0.39). On the medial surface of thigh the temperature increased insignificantly (31.7±0.8ᴼC before and 32.2±1.43ᴼC after epidural anaesthesia; P=0.29). On the lateral surface of thigh the temperature slightly decreased (30.3±2.3ᴼC before and 30.0±2.7ᴼC after epidural anaesthesia; P=0.28).

Conclusion(s): Under epidural anaesthesia the skin temperature of legs significantly increases in distal regions.

The skin temperature under epidural anaesthesia

Background and Goal of Study: Intravenous lidocaine can cause visceral analgesia and reduce opioid requirements during and after abdominal surgery.
Materials and methods: Twenty-one 3 to 7 year old children with acute appendicitis were randomized into 2 groups (lidocain “L”, n=11 and control C"”, n=10) before open appendectomy. Intravenous induction and maintenance of anaesthesia with propofol (3 mg/kg and 6 mg/kg*hour, respectively), single-shot right side thoraco-lumbar paravertebral block (PVB) at T12-L1 level (bupivacaine 0.25%, 0.3 ml/kg) under local anaesthesia and neurostimulation guidance were performed in all children. In all children of “L” group intravenous lidocaine 30 minutes before surgery was administered (1.5 mg/kg bolus followed with 1.5 mg/kg*hour infusion until surgery was over). If there was motor or hemodynamic response to surgical stimulation, fentanyl boluses 1 mcg/kg were used in both groups until movements or tachycardia/hypertension disappeared.
Results and discussion: Postoperative opioid dose, NSAIDs dose and pain scores (FLACC scale or Wong-Baker scale) did not differ between groups. Intraoperative fentanyl dose was significantly lower in “L” group compared to “C” group (0.4±0.009 mcg/kg vs 1.8±0.011 mcg/kg respectively, P=0.012). Number of postoperative respiratory depression episodes did not differ between groups (0 vs 1 respectively, P=0.48). Postoperative sedation was deeper in “C” group compared to “L” group. Ramsay sedation scores postoperativly were in “L” group: in 0 min - 3.9±0.9**; in10 min - 2.7±0.7**; in 20 min - 1.7±0.5*; in 30 min - 1±0.3; in 60 min -1±0.1; and in "C" group: 5.1±0.8; 4.1±0.4; 3.3±0.6; 1.6±0.2; 1±0.08, respectively.
(** - P< 0.01; * - P< 0.05 compared to “C” group). Children of “L” group were discharged from recovery room earlier compared to children of “C” group, but the difference did not reach statistical significance (19.5±7.9 vs 28.7±9.8 minutes respectively, P=0.067). Incidence of postoperative nausea/vomiting (PONV) was lower in “L” group compared to “C” group (0 vs 4 respectively, P=0.035).
Conclusion(s): Intraoperative intravenous lidocaine infusion in addition to thoraco-lumbar PVB for appendectomy in children leads to significant intraoperative fentanyl dose reduction and reduces the incidence of opioid-related adverse events, such as excessive postoperative sedation, delayed recovery room discharge and PONV.

Intravenous lidocaine as an adjunct to thoraco-lumbar paravertebral block for open appendectomy in children

Maintenance of the parturient in the left lateral position after spinal anesthesia with plain levobupivacaine for cesarean section reduces hypotension: a randomized study

Comparison of propofol/ketamine and propofol/alfentanil combinations on sedation for upper gastrointestinal system endoscopy in morbidly obese patients

Comparing three different doses of caudal morphine for analgesia after Salter innominate osteotomy

Background and aim:
Psoas compartment block, useful in hip surgery, in combination with sciatic nerve block needs rather large volume of local anesthetic. Our aim was to compare the spread of 20 ml vs 40 ml of aqueous solution injected into psoas compartment.
Methods:
In 12 fresh adult cadavers, 0.01% methylene blue aqueous solution was injected after Capdevila et al [1] into psoas compartment, 20 ml at one side and 40 ml at the opposite side. Then the dye distribution along the vertebral bodies was analysed.
Results:
The distance between the injection point and the caudal limit of the dye spread (M ± SD) was 9.3 ± 1.5 cm after 20 ml and 10.9 ± 2.1 cm after 40 ml, the difference being statistically significant (unpaired one-tailed t-test, p = 0.021), but clinically irrelevant. The upper (L1 vertebral body) and the lower (S1) limits of the dye spread were identical with both volumes, although these limits were reached in one cadaver (8%) only. L3 and L4 levels were stained densely with both volumes in all cadavers, L5 in nine (75%) with 20 ml and in ten (83%) with 40 ml, L2 in two (17%) and three (25%), respectively (non-significant difference, Fisher exact p = 0.5). 
Conclusions:
With both 40 ml and 20 ml injected into psoas compartment, the solution always spreads along L3 and L4, frequently along L5, and rarely along L1, L2, and S1 levels.

Reference:
1. Capdevila X., Macaire P., Dadure C., et al. Continuous psoas compartment block for postoperative analgesia after total hip arthroplasty: new landmarks, technical guidelines, and clinical evaluation. Anesth Analg 2002; 94: 1606-1613.

The spread of 20 ml vs 40 ml of dye injected into psoas compartment in cadavers

Background and Goal of study: Ischaemic Preconditioning (IPC) and Remote Ischaemic Preconditioning (RIPC) reduce ischaemia/reperfusion injury in experimental animal studies [1]. In contrast, clinical data are contradictive. This might be caused by interactions of drugs used in daily clinical routine. The antifibrinolytic Aprotinin, a precursor of the currently used tranexamic acid (TXA), was shown to abolish cardioprotection by preconditioning [2]. The aim of this study was to investigate, whether TXA has an impact on cardioprotection induced by IPC and/or RIPC.
Material and Methods:  Animals were treated in compliance with institutional and national guidelines. Anaesthetized Wistar rats were thoracotomized and, after pericardiotomy, a snare occluder was passed around a major left coronary artery. After surgical preparation, animals recovered for 20 minutes before starting the preconditioning protocol. Subsequently, rats were exposed to 25 minutes regional myocardial ischemia followed by 120 minutes reperfusion. At the end of reperfusion, hearts were excised for infarct size measurement by TTC staining.
Animals were randomized into six groups. Control animals (Con, n=10) were not further treated. IPC was induced by 3 cycles of 5 minutes of ischaemia and reperfusion (IPC, n=8); RIPC was induced by 4 cycles of 5 minutes of ischaemia and reperfusion of the hind legs (RIPC, n=9). In additional groups tranexamic acid (bolus 10 mg/kg BW, continuously 2 mg/kg BW) was administered i.v. with (TXA+IPC, TXA+RIPC; each group n=8) and without preconditioning (TXA, n=8).
Statistical analysis: One-way ANOVA with Tukey post hoc test. Data are expressed as mean±SD.
Results and Discussion: In the control group infarct size was 56±11% of area at risk. IPC and RIPC reduced infarct size to 30±6% and 40±8%, respectively (each P<0.05 vs. Con). Tranexamic acid alone had no influence on infarct size (TXA: 54±15%; ns vs. Con). Furthermore, tranexamic acid did not affect cardioprotection by IPC or RIPC (TXA+IPC: 25±8%, TXA+RIPC: 41±10%; each P<0.05 vs. Con).
Conclusion: Administration of tranexamic acid had no effect on myocardial infarction or the cardioprotective effects of ischaemic preconditioning or remote ischaemic preconditioning.
Literature: [1] Pharmacol Rev. 2014 Oct;66(4):1142-74, [2] Anesthesiology 2010 Dec;113(6):1289–98.

Tranexamic acid has no influence on cardioprotection induced by ischaemic preconditioning or remote ischaemic preconditioning

Takotsubo cardiomyopathy and hip fracture - delay the case or proceed to surgery?

takotsubo cardiomyopathy and hip fracture - delay the case or proceed to surgery?

Sevoflurane decreases systemic inflammatory response in lung resection surgery and one lung ventilation in an animal experimental model

Inadvertent ultrasound-guided insertion of a central venous catheter into a carotid artery: the value of pressure transduction and blood gas analysis as additional tests to check position

Background and Goal of study: In recent years has increased the interest in use of magnesium sulphate as an adjuvant drug in anaesthesia for its effects on autonomic response, cardiac arrhythmia, bronchospasm, neuroprotection, among others.The aim of the present study was determine how brazilian anaesthetists use magnesium sulphate in anaesthesia. Material and methods: Prospective transversal survey. After ethical approval, questionnaire was sent to 9869 anaesthetists members of the Brazilian Society of Anesthesiology. Anaesthetists were invited to participate for 3 consecutive occasions with an interval of 15 days between them, through e-mail sent directly by the Brazilian Society of Anesthesiology. Data were submitted to descriptive statistics. Results and Discussion: 954 (9.7%) anaesthetists answered to the questionnaire. 337 (35.3%) used magnesium sulphate in anaesthesia. Main indications were: postoperative analgesia, reducing the consumption of anesthetics and neuromuscular blockers, eclampsia, cardiac arrhythmias, prevenction of chronic pain after surgery and prevention hyperalgesia after remifentanila, among others. 334 (99.1%) used intravenous route. Complications listed: arterial hypotension 187 (55.5%), residual neuromuscular blockade 133 (39.5%) and 40 (11.9%) reported no complications. In terms of severity of complications the anaesthetist classified like: minor 227 (65.9%), moderate 77 (22.8%), severe 10 (2,9%), death 1 (0.3%) and 22 (6.5%) did not answer. Intravenous dose most commonly used for induction of general anaesthesia is 30-40 mg.kg-1 and during maintenance of general anaesthesia < 30mg.kg-1. The intravenous dose for sedation was < 30mg.kg-1. Conclusion: Thirty five per cent of brazilian anaesthetists that answered the survey used magnesium sulphate during anaesthesia on different clinical indications. The results demonstrated potential importance of adjuvant drugs as anaesthesia component, particularly magnesium sulphate.

Survey of use of magnesium sulphate in anaesthesia in Brazil

Background and Goal of study: Hemipelvectomy (external or internal) is a major orthopedic surgical procedure. Primary bone and soft tissue pelvic sarcoma are main indications. Anesthesia and perioperative care may be considered as challenging because of the extensive tissue trauma, significant blood and fluid loss, bleeding disorders and intense postoperative pain. The goal of study was determine the survival rate and demonstrate the anaesthetic and perioperative management. Material and methods: After ethical approval, we conducted a retrospective study of 35 consecutive cases collecting data from medical records and from the Department of Pathology database of all patients submitted to hemipelvectomy in the National Cancer Institute, Brazil, in the period between 2000 and 2013. Results and Discussion: Survival mean time after surgery was 22.1 months. In bivariated analysis, only advanced disease stage was significant as an independent factor for death (p=0,001, HR= 6,0, 95% CI for HR = 2,03 – 17,6). In multivariated analysis at 5% level, only advanced disease stage (levels 3 or 4) was an independent risk factor to reduce survival rate. External hemipelvectomy was performed in 23 (65.7%) patients. Preoperative data: age 44 years (median); weight 69.1 Kg (median); male 68.5%. General anaesthesia plus regional (epidural with opioids mainly) was done in 32 (91.4%) patients. In perioperative period, 23 (65.7%) patients presented hemodynamic instability. All received fluid resuscitation. Vasopressors were required in 12 (34.2%) patients. Six (17.1%) presented bleeding disorders. Median cristalloid infusion was 3500 ml and colloid administration was 500-1500 ml. Twenty (57.1%) patients received red blood cell concentrate and 4 (11.4%) required other blood products in the operating room (OR). Third tree (94.2%) patients had the trachea extubated in the OR. Severe acute pain was present in 31,4% of the cases and even a larger percentage developed chronic pain (40%). Seventeen (48.5%) patients were transfused postoperatively. One (2.8%) patient developed acute renal failure, 2 (5.7%) presented neurological disorders, 1 presented arrhythmias and 9 (25.7%) developed surgical wound complications. Median hospital stay after surgery was 6 days. Conclusion: Despite advances in anaesthesia and surgical management the survival rate after hemipelvectomy remain low and hemodynamic instability, transfusion rate, acute and chronic pain and poor outcomes remain high.