<abstract><title style='display:none'>Abstract</title> Postoperative shivering is a common complication of anaesthesia. Shivering is believed to increase oxygen consumption, increase the risk of hypoxemia, induce lactic acidosis, and catecholamine release. Therefore, it might increase the postoperative complications especially in high-risk patients. Moreover, shivering is one of the leading causes of discomfort for postsurgical patients. Shivering is usually triggered by hypothermia. However, it occurs even in normothermic patients during the perioperative period. The aetiology of shivering has been understood insufficiently. Another potential mechanism is pain and acute opioid withdrawal (especially with the use of short-acting narcotics). Besides that shivering is poorly understood, the gold standard for the treatment and prevention has not been defined yet. Perioperative hypothermia prevention is the first method to avoid shivering. Many therapeutic strategies for treating shivering exist and most are empiric. Unfortunately, the overall quality of the antishivering guidelines is low. Two main strategies are available: pharmacological and non-pharmacological antishivering methods. The combination of forced-air warming devices and intravenous meperidine is the most validated method. We also analysed different medications but final conclusion about the optimal antishivering medication is difficult to be drawn due to the lack of high-quality evidence. Nevertheless, control of PS is possible and clinically effective with simple pharmacological interventions combined with non pharmacological methods. However, to be consistent with the most up-to-date, evidence-based practice, future antishivering treatment protocols should optimize methodological rigor and transparency.</abstract>

Postanaesthetic shivering – from pathophysiology to prevention

<abstract><title style='display:none'>Abstract</title> Background. Pupillary response by pupillary dilatation reflex (PDR) is a robust reflex, even measurable during general anaesthesia. However, the ability of infrared pupillometry to detect PDR differences obtained by intraoperative opioid administration in anaesthesized patients remains largely unknown. We analyzed the performance of automated infrared pupillometry in detecting differences in pupillary dilatation reflex response by a inbuilt standardized nociceptive stimulation program in patients under general anesthesia with a standardized propofol/fentanyl scheme. Methods. In this single center, interventional cohort study 38 patients (24-74 years) were enrolled. Patients were anesthetized with propofol until loss of consciousness. Two dynamic pupil measurements were performed in each patient (before opioid administration and after opioid steady state). Automated infrared pupillometry was used to determine PDR during nociceptive stimulations (10-60 mA) applied by a inbuilt pupillary pain index protocol (PPI) to the skin area innervated by the median nerve. Increasing stimulations by protocol are device specific and automatically performed until pupil dilation of &gt; 13%. Pupil characteristics, blood pressure, heart rate values were collected. Results. After opioid administration, patients needed a higher stimulation intensity (45.26 mA vs 30.79 mA, p = 0.00001). PPI score showed a reduction after analgesic treatment (5.21 vs 7.68, p = 0.000001), resulting in a 32.16% score reduction. Conclusions. PDR via automated increased tetanic stimulation may reflect opioid effect under general anaesthesia. Further research is required to detect possible confounding factors such as medication interaction and optimization of individualized opioid dosage.</abstract>

Pupillary dilation reflex and pupillary pain index evaluation during general anaesthesia: a pilot study

<abstract><title style='display:none'>Abstract</title>We anticipated that bilateral Erector spinae plane (ESP) block, which was applied in 10 patients starting from lower thoracic levels (T9) might provide effective postoperative analgesia in open abdominal hysterectomies. In addition, we aimed to obtain anatomic observation of the local anaesthetic (LA) spread in the ESP block by injecting methylene blue on 4 cadavers. All the patients had excellent pain relief. There was an extensive spread to the erector spinae muscle (ESM) involving several segmental levels on cadavers. We observed the spread of dye on the ventral and dorsal rami in the paravertebral space and as an additional finding, the dye had extended to the canal vertebralis. There was a spread of dye on the dura mater. ESP block can be used with new indications and it is an effective technique for major abdominal surgery when is applied to the lower vertebral levels. Randomized controlled trials are required to explore the clinical implications of our findings.</abstract>

Bilateral postoperative ultrasound-guided erector spinae plane block in open abdominal hysterectomy: a case series and cadaveric investigation

<abstract><title style='display:none'>Abstract</title>Early allograft dysfunction (EAD) represents one of the most common and serious complications after liver transplantation (LT). Methods. One hundred sixty-four patients who underwent LT were prospectively included in the present study. Patient demographics, intraoperative blood loss and transfusion were recorded at the time of LT. Lactate levels were recorded during surgery and daily for the first 3 postoperative days. Standard and derived rotational thromboelastometry (ROTEM) parameters were recorded 24 hours after LT. EAD was diagnosed according to Nanashima criteria and post anaesthesia care unit length of stay was recorded. Results. Forty-seven patients (28.6%) developed EAD. Intraoperative blood loss (p = 0.01), packed red blood cells (p = 0.04) and fresh frozen plasma (p = 0.01) transfusion represented intraoperative risk factors for EAD. Lactate levels were significantly higher in patients with EAD at all time points. Patients with EAD demonstrated an increased clot formation time and decreased maximum clot firmness in both intrinsically (p &lt; 0.01) and extrinsically (p &lt; 0.01) activated assay, a decreased thrombin potential index (p &lt; 0.01), area under the curve (p &lt; 0.01) and clot elasticity (p &lt; 0.01) on ROTEM assay. Conclusion. Our results show that both standard and derived ROTEM parameters may indicate early signs of graft failure and can aid in the diagnosis of EAD.</abstract>

Rotational thromboelastometry (ROTEM) 24 hours post liver transplantation predicts early allograft dysfunction

<abstract><title style='display:none'>Abstract</title><sec><title style='display:none'>Background</title>Wolff–Parkinson–White (WPW) syndrome is a rare disease that can cause various patterns of tachyarrhythmias. The main goal of anaesthesiologists for the perioperative anaesthetic management of WPW patients must be to avoid sympathetic stimulation and prevent tachyarrhythmias.</sec><sec><title style='display:none'>Case</title>A 9-year-old male patient with a diagnosis of WPW syndrome, who underwent emergency surgery for supracondylar humerus fracture, is presented. General anaesthesia in combination with infraclavicular brachial plexus (ICBP) block was performed successfully without any complications. For the reversal of neuromuscular block, sugammadex was uneventfully used. Intraoperative sympathetic discharge due to surgical intervention was prevented with ICBP block. The ICBP block has also provided good postoperative analgesia.</sec><sec><title style='display:none'>Conclusions</title>Sugammadex is a good alternative for the reversal of neuromuscular blocks to avoid the undesirable effects of cholinergic drugs. Peripheral regional blocks that require relatively large doses of local anaesthetics can be safely performed with utmost attention in paediatric WPW patients.</sec></abstract>

Infraclavicular Brachial Plexus Block and Sugammadex Use in a Paediatric Patient with Wolff–Parkinson–-White Syndrome

<abstract><title style='display:none'>Abstract</title><sec id="j_rjaic-2020-0017_s_007_w2aab3b7c14b1b6b1aab1c15b1Aa"><title style='display:none'>Clinical background</title>Volatile anaesthetics (VAs) have been shown to protect cardiomyocytes against ischaemia and reperfusion injury in cardiac surgery.</sec><sec id="j_rjaic-2020-0017_s_008_w2aab3b7c14b1b6b1aab1c15b2Aa"><title style='display:none'>Clinical problems</title>VAs have been shown in multiple trials and meta-analyses to be associated with better outcomes when compared to intravenous anaesthesia in cardiac surgery. However, recent data from a large randomised controlled trial do not confirm the superiority of VA as compared to total intravenous anaesthesia in this population.</sec><sec id="j_rjaic-2020-0017_s_009_w2aab3b7c14b1b6b1aab1c15b3Aa"><title style='display:none'>Review objectives</title>This mini review presents the VA cardioprotective effects, their clinical use in cardiac surgery and the most recent evidence that compares VA to intravenous anaesthesia for reducing perioperative morbidity. At present, there is no clear superiority of VA over intravenous anaesthesia in improving the outcome after cardiac surgery.</sec></abstract>

Role of anaesthetic choice in improving outcome after cardiac surgery

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Background</title>
A large number of spinal deformities with severe pain are treated with complex and traumatic spinal surgeries. The objectives of our study were to test the hypotheses that bilateral erector spinae plane block (BESPB) as a component of combined anaesthesia for spinal surgeries decreases the quantity of opioid analgesic used and reduces hyperalgesia in comparison with general anaesthesia. We additionally proposed the use of serum testosterone, cortisol, C-reactive protein (CRP), and glucose levels as laboratory markers for hyperalgesia.
</sec>
<sec>
<title style='display:none'>Methods</title>
Fifty-two patients who underwent posterior transpedicular fixation of the spine were randomly assigned to either general anaesthesia – control group (CG) – or combined anaesthesia with BESPB – study group (SG). The main outcomes sought were quantity of opioid analgesic perioperatively; hyperalgesia measured with mechanical pain thresholds; and testosterone, cortisol, CRP, and glucose serum levels before and after surgery.
</sec>
<sec>
<title style='display:none'>Results</title>
The quantity of fentanyl and morphine was lower in SG in comparison with CG. There was no difference in mechanical pain thresholds in the SG cohort as opposed to CG, where mechanical pain thresholds were lower on the fifth day after surgery. No difference was found before and after surgery in testosterone, cortisol, CRP, and glucose levels in SG. In the CG, the level of testosterone was significantly lower than baseline; the levels of cortisol, CRP, and glucose were significantly higher than baseline on the fifth day after surgery.
</sec>
<sec>
<title style='display:none'>Conclusion</title>
Bilateral erector spinae plane block as a component of combined anaesthesia for spinal surgeries reduces the quantity of opioid analgesic used and hyperalgesia. Also, we can propose to use the serum testosterone, cortisol, CRP, and glucose levels as the laboratory markers of hyperalgesia.
</sec>
</abstract>

The Impact of Anaesthesia on Hyperalgesia, Testosterone, Cortisol, C-Reactive Protein, and Glucose Levels After Spine Surgery: Prospective Randomised Controlled Trial

<abstract>
<title style='display:none'>Abstract</title>
In critical patients, generally, microorganisms originating from nasal cause Ventilator-Associated Pneumonia (VAP). This systematic review was aimed to identify the toothbrush U shape model usage, in potentially decrease the prevalence of ventilator-associated pneumonia among patients in intensive care units. Search strategy identified 15 potentially eligible articles, were 7 RCTs, 4 Meta-analysis, and 4 Observational studies. A total of 15 studies demonstrated the use of toothbrushing and chlorhexidine in mechanically ventilator patients in preventing VAP. Ten studies found positive association between toothbrushing and the use of chlorhexidine in preventing VAP. However, there were 5 studies that did not reveal an additional decrease of VAP incidence either of CHX and only toothbrushing or combination thereof. We cautiously assumed that toothbrushing and chlorhexidine might reduce VAP but the implementation of brushing should be taken into reconsideration in the terms of maintaining it.
</abstract>

Prevention of Pneumonia due to Ventilator in Critical Patients with U Shape Oral Hygiene Model: A Systematic Review

<abstract>
<title style='display:none'>Abstract</title>
Fluid management in the perioperative period is a grey zone in clinical practice of late. Looking back on previous practices, static parameters were the only options. Now, dynamic parameters indicating fluid responsiveness have become a significant part of goal-directed fluid therapy (GDFT). However, the efficacy of this approach has yet to be established in neurosurgery cases where patients are already on lot of diuretics, thus making fluid management more challenging. The present study aims to determine the efficacy of the Pleth Variability Index (PVI) with pulse pressure variation (PPV) in guiding GDFT in patients undergoing neurosurgery for supra-tentorial intracranial space occupying lesions (ICSOLs), in the form of a randomised controlled trial.
After randomisation, the patients were categorised into either PVI or PPV groups. Both received a baseline 2 ml/kg/h Lactated Ringer’s (RL) infusion. Additional fluid boluses consisted of 250 ml of colloid infused over a 10 min period if PVI was &gt; 15% or PPV was &gt; 13% for at least five minutes. The primary outcome was to determine the serum lactate difference between preoperative and postoperative values, which could fairly predict fluid deficit leading to inadequate perfusion.
A total of 74 patients were analysed. Both PVI- and PPV-guided GDFT strategies showed no significant difference in the postoperative lactate values, with a P-value of 0.18. Similarly, the mean total fluid administered, mean blood loss, length of CCU stay, and emetic and hypotension episodes also showed no significant differences among the groups with P-values of 0.41, 0.78, 0.25, 0.30, and 0.67, respectively.
For patients undergoing neurosurgery (supratentorial ICSOLs), PVI seems to guide GDFT comparably to PPV regarding tissue perfusion and postoperative complications. However, both the parameters had low sensitivity and specificity, with an area of curve of 0.577 for PPV and 0.423 for PVI, as far as GDFT was concerned.
</abstract>

A Randomised Controlled Study Comparing Pulse Pressure Variation (PPV) and Pleth Variability Index (PVI) for Goal-Directed Fluid Therapy Intraoperatively in Patients Undergoing Intracranial (Supratentorial ICSOLs) Surgeries

<abstract>
<title style='display:none'>Abstract</title>
<sec>
<title style='display:none'>Background and aims</title>
With the development of ultrasound-guided and laparoscopic techniques of rectus sheath block (RSB), regional analgesia promises to be efficient and safe. However, studies show controversial results. Our systematic review with meta-analysis aims to evaluate the effect of rectus sheath block in abdominal surgery.
</sec>
<sec>
<title style='display:none'>Method</title>
We searched PubMed, Google Scholar, and the Cochrane Library from inception to October 2021 for randomised controlled trials written in English. We included studies on adult populations undergoing abdominal surgery. The primary outcomes of our meta-analysis were postoperative pain intensity and postoperative opioid consumption. Data analysis was conducted using the Review Manager software (RevMan, v. 5.4). Statistical heterogeneity was estimated by the I2 statistic. The methodological quality of the included studies was assessed using the Oxford quality scoring system (Jadad Scale).
</sec>
<sec>
<title style='display:none'>Results</title>
Eight randomised controlled trials (RCTs) in English with a total of 386 patients were included in this meta-analysis. Patients in the RSB group did not consume fewer anaesthetics and opioids after abdominal surgery when compared with patients in the control group. In addition, postoperative pain intensity (out of 10) was not lower in the RSB group when compared with the control group. Finally, RSB did not improve the time to the first opioid/analgesic (min) compared with the non-RSB option.
</sec>
<sec>
<title style='display:none'>Conclusion</title>
There is no statistically significant evidence in favour of RSB over non-RSB in reducing anaesthetics and opioid consumption, postoperative pain intensity, and increasing time to first opioid/analgesic.
</sec>
</abstract>

Rectus Sheath Block in Abdominal Surgery: A Systematic Review with Meta-Analysis

<abstract>
<title style='display:none'>Abstract</title>
Pyroglutamic acidosis (PGA) is an underrecognized entity characterised by raised anion gap metabolic acidosis (RAGMA) and urinary hyper-excretion of pyroglutamic acid. It is frequently associated with chronic acetaminophen (APAP) ingestion. We report the case of a 73-year-old man with invasive pulmonary aspergillosis treated with voriconazole and APAP for analgesia with a cumulative dose of 160 g over 40 days. PGA was suspected as he developed severe RAGMA and common causes were excluded. Diagnosis was confirmed via urinary organic acid analysis which showed significant hyper-excretion of pyroglutamic acid. APAP was discontinued, and N-acetylcysteine (NAC) was administered. His RAGMA rapidly resolved following treatment.
</abstract>

Pyroglutamic Acidosis – An Underrecognised Entity Associated with Acetaminophen Use

<abstract>
<title style='display:none'>Abstract</title>
<sec><title style='display:none'>Background and Aims</title>
Securing the airway without morbidity is of prime importance. The difficult airway cart should have some advanced airway aids if not all. In this study we evaluated Airtraq laryngoscope and Intubating Laryngeal Mask Airway (ILMA) as intubating devices in novice users who were well accomplished in intubation using direct laryngoscope with Macintosh blade. Both the devices were used because of relatively lesser cost, portability and all in one compact design not requiring any setup. Methods: 60 consenting American Society of Anaesthesiology (ASA) Grade I and II patients, weighing 50 to 70 were randomly assigned to be intubated by Airtraq or ILMA. Primary Aim was to compare success rate and intubation time. Comparison of ease of intubation and postoperative pharyngeal morbidity were the secondary end points.
</sec>
<sec><title style='display:none'>Results</title>
Success rate of intubation was higher in ILMA group (100%) than Airtraq (80%) [P = 0.0237]. However, in successful intubations the time for intubation was significantly less with Airtraq (Group A = 45.37 ± 27.55, Group I = 77.6 ± 31.85; P = 0.0003). No significant difference was noted in ease of intubation, number of optimizing manoeuvres to facilitate intubation and postoperative pharyngeal morbidity.
</sec>
<sec><title style='display:none'>Conclusion</title>
In Clinicians who are well versed with laryngoscopy using Macintosh blade but new to Airtraq and ILMA, success rate of intubation is higher with ILMA. Prolonged intubation time in ILMA should not deter its use in difficult airway scenarios because of the ability to ventilate through it.
</sec>
</abstract>

Comparison of Intubation Success Rate using Airtraq Laryngoscope and Intubating Laryngeal Mask Airway in Novice Users with Prior Airway Management Experience: A Prospective Randomised Study

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Romanian Journal of Anaesthesia and Intensive Care

 The Romanian Journal of Anaesthesia and Intensive Care (Jurnalul Român de Anestezie Terapie Intensivă) is a biannual, in English, with abstracts in English and Romanian, ranked...

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 The Romanian Journal of Anaesthesia and Intensive Care (Jurnalul Român de Anestezie Terapie Intensivă) is a biannual, in English, with...