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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Ischemic Heart Disease and Ongoing Surgery

The prevalence of ischemic heart disease in surgery patients is increasing. Up to 34 % of patients require surgery within one year of percutaneous coronary intervention (PCI) with stenting. Dual antiplatelet therapy (DAPT) should be introduced for at least 12 months to prevent late stent thrombosis, especially in drug-eluting stents (DES), where endothelisation of stented segment is slower. Risk of stent thrombosis is greater with recent myocardial infarction, bifurcation lesions, suboptimal stent deployment, first generation DES, while second generation DES and bare metal stents have lower risk of stent thrombosis. Although some randomized studies showed that it might be safe do discontinue DAPT 3-6 months after second generation DES implantation, stent thrombosis is still feared and grave complication in first year after PCI. The preoperative management of patients after PCI requires consideration of bleeding risk on DAPT and risk of stent thrombosis. There are no randomized data about optimal timing of surgery. Guidelines recommend postponing surgery for at least 6 months after percutaneous coronary intervention with drug-eluting stent implantation (DES-PCI) and 12 months if PCI was done following myocardial infarction. The 2016 American College of Cardiology/American Heart Association guidelines update strongly advises against elective noncardiac surgery <3 months after DES implantation, but surgery may be considered 3 to 6 months after DES-PCI, with discontinuation of DAPT if the delayed surgery risk is greater than the stent thrombosis risk. A big recent Danish study showed that surgery in first 12 months after DES-PCI was associated with an increased risk of myocardial infarction and cardiac death but not all-cause mortality compared to patients without ischemic heart disease. However, the increased risk was only present within first month after DES-PCI. According to PARIS registry it may be safe to interrupt DAPT for <14 days under physician guidance. Knowing both, surgery might be undertaken earlier than currently recommended. There is a consensus that excluding emergency, surgery can be done between 1 and 3 months after DES-PCI if there is uncontrolled bleeding or the outcome is strongly influenced by surgical delay. On the other hand, surgery should be delayed at least 3 to 6 months in acute coronary syndrome, diabetes mellitus, low left ventricular ejection fraction, history of stent thrombosis, PCI of left main, small stents and long stented segments.

Keywords: percutaneous coronary intervention, surgery, antiplatelet therapy.

Efficacy and Safety of an Acute Pain Service among 10,760 Postoperative Patients


Introduction. Post-operative pain control improves surgical outcome and many hospitals created multidisciplinary teams, called “Acute Pain Services” (APS). We collected APS data on 10,760 adult patients over a five year period, including complications, side effects and patient satisfaction.

Methods. Data on patients managed by APS in a high surgical-volume university hospital over a 5-year period were collected and analyzed. Data included demographic characteristics, primary analgesic modality, adjuvant analgesic treatment, type of surgical procedure, Visual Analogue Scale, and analgesia-related side-effects and complications.

Results. Patient controlled analgesia with morphine was used in 4,992 surgical patients while epidural analgesia was used in 3,687 surgical patients and 1,670 pregnant women for delivery analgesia. A total of 411 patients received other forms of analgesia. No epidural haematoma was observed. A single case of respiratory depression occurred in an elderly patient using the patient controlled analgesia system. Acetaminophen was the most frequently adjuvant drug prescribed. Postoperative nausea and vomiting was the most frequent analgesia-related side effect. Visual Analogue Scale at rest and on movement was low on day one (0.84±1.15 and 2.05±1.67) and decreased thereafter with epidural analgesia associated with better pain control following hip and liver surgery, and with less postoperative nausea and vomiting (5.0%) when compared to morphine patient controlled analgesia (7.2%).

Conclusions. An APS, with daily postoperative visits, permits adequate post-operative pain control without serious adverse events. Epidural analgesia was associated with less postoperative nausea and vomiting and had at least similar pain control than morphine patient controlled analgesia.

Key words: acute pain service, epidural analgesia, patient controlled analgesia, anesthesia, surgery

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Anesthesia for carotid endarterectomy: where do we stand at present?


Carotid endarterectomy (CEA) is a surgical procedure performed to reduce the incidence of embolic and thrombotic stroke. Although only a preventive procedure, CEA carries the risk of perioperative complications. There is constant searching for an optimal anesthetic technique. There are pros and cons for both anesthetic techniques used: regional (RA) and general anesthesia (GA). A large number of studies have compared RA and GA techniques in CEA surgery patients. The primary outcome was the proportion of patients with stroke, myocardial infarction, or death. However, neither the GALA trial nor the pooled analysis was adequately powered to reliably detect an effect of type of anesthesia on mortality. It may therefore be appropriate to consider other additional parameters (stress response, incidence of postoperative delirium and cognitive impairment, functional recovery, total surgery time, intensive care unit requirement, hospital stay, hospital costs and patients satisfaction) when comparing the outcomes of the two techniques.

Although, the debate continues as to whether regional anesthesia or general anesthesia is safer, the choice of anesthetic technique is a complex decision and surgical teams should be able to offer both RA and GA. The individual approach is the ideal choice and should be determined at the discretion of the surgeon, anesthetist and patient depending on the clinical situation and own preferences.

Key words: surgery, carotid endarterectomy, anesthesia, general, regional, outcome

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A rare cause of intestinal obstruction due to an exophytic gastrointestinal stromal tumor of the small bowel


Introduction: Gastrointestinal stromal tumors constitute a distinct group of rare gastrointestinal tract tumors that originate from the interstitial cells of Cajal. These jejunoileal lesions are a rare cause of obstruction but can be associated with substantial morbidity.

Case: A 59-year-old woman presented to the emergency department with abdominal pain and distention. Physical examination revealed tenderness and rebound in right lower quadrant. Computed tomography revealed a mass in lower right quadrant. A 9x9x4 cm exophytic ileal mass was observed at exploration. Preoperative diagnose was a small bowel tumor and then segmental resection and primary anastomosis were performed. Histopathological investigation revealed spindle cells that stained strongly for C-117, consistent with a diagnosis of a malign gastrointestinal stromal tumor.

Conclusion: We conclude that exophytic small bowel gastrointestinal stromal tumors are rare lesions, which should be kept in mind by physicians among the diagnosis of small bowel obstructions in order to reduce substantial morbidity and mortality.

Key words: intestinal obstruction, gastrointestinal stromal tumor, small bowel, surgery


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Early complications of percutaneous tracheostomy using the Griggs method


This article presents our observations and experiences with the Griggs method of percutaneous dilation tracheostomy (PTD). We performed 200 tracheostomies on neurosurgical and surgical patients who needed temporary ventilatory support and protection. Early complications were defined and registered. Frequency of early complications was 22,5 %. The majority of complications were minor and improved quickly. Therefore, PTD was shown to be a safe and appropriate technique for patients treated in the intensive care unit (ICU). Unfortunately, lack of standardization and defined criteria deprive the opportunity for good comparisons between the Griggs method and other PTD methods.

Key words: percutaneous trache-ostomy, Griggs method, early compli-cations, surgery, neurosurgery

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