MF Anesteziologijos klinika (04.14)

Background
Postoperative cognitive dysfunction (POCD) commonly affects elderly patients, but the impact of BIS-guided sedation during elective orthopedic surgery under spinal anesthesia remains unclear. The aim was to compare BIS-controlled versus standard clinically guided sedation on POCD in elderly patients undergoing elective knee arthroplasty.

Methods This was a prospective, patient- and outcome assessor-blinded, randomized controlled clinical study. Participants were randomized into two groups: BIS-targeted sedation (BIS group > 70) and standard clinical sedation (non-BIS group). All patients received the same anesthetic and analgesic. The primary outcome was the change in cognitive function over time. Cognitive function was assessed four times using the Addenbrooke’s Cognitive Examination–Revised (ACE-R) questionnaire. Higher scores indicate better cognitive performance. The emotional status was evaluated two times using the Hospital Anxiety and Depression Scale (HADS)

Results Ninety-two patients (46 per group) were included in the final analysis. No statistically significant differences in total ACE-R score were found between the two groups at any time point (p > 0.05). Within the BIS group, total ACE-R scores were significantly higher on postoperative day (POD) 90 than preoperatively (PO) (87 (65–96) vs. 92 (70–98), p = 0.007). In the non-BIS group, total ACE-R scores increased significantly at several time points: from PO to 30 POD (87 (48–96) vs. 90.5 (40–98), p = 0.007), from PO to 90 POD (87 (48–96) vs. (91 (40–99), p < 0.001), and from 2 to 30 POD (88 (45–98) vs. 90.5 (40–98), p = 0.005). Significant decline in the number of patients experiencing probable anxiety at 30 POD compared with PO in both groups (BIS 28.3% to 2.2%, p = 0.004; non-BIS 32.6% to 8.7%, p = 0.015).

Conclusions
This study did not demonstrate superiority of BIS-controlled sedation compared to clinically guided sedation with regard to cognitive outcomes. Further studies are needed.

Trial registration
ClinicalTrials.gov (NCT06241859, January 28, 2024)

Virtual reality (VR) is being increasingly used as an adjunctive tool to reduce procedural pain and anxiety during various interventional procedures. Forty articles published between 2020 and 2025 were reviewed. The articles reviewed discuss the use of virtual reality to reduce procedural pain and anxiety during various interventional procedures. The results of the literature analysis show that VR can effectively direct patients’ attention and reduce the subjective intensity of pain and fear during procedures across different age groups. VR has been successfully applied to interventional procedures such as vaccination, blood draws, and peripheral vein punctures in children, as well as to a wide range of interventions in obstetrics, orthopaedics, endovascular surgery, cardiology, and dentistry. The studies reviewed confirm that VR is a safe method that rarely causes adverse side effects and can be integrated into clinical practice, contributing to patient comfort, emotional well-being, and the overall satisfaction with the procedure.

Background and objectives: Cardiac surgery with cardiopulmonary bypass (CPB) is associated with endothelial glycocalyx injury and perioperative endothelial dysfunction. Syndecan-1 is commonly used as a biomarker of glycocalyx shedding, but data on its perioperative changes and their relationship with operative and patient-related factors remain limited. The aim of this study was to evaluate perioperative Syndecan-1 dynamics during coronary artery bypass grafting (CABG) with CPB and to assess associations with ischemia–reperfusion exposure and patient characteristics. Materials and methods: This prospective observational study included 147 patients undergoing elective CABG with CPB. Syndecan-1 concentrations were measured at five time points: before induction of anaesthesia, immediately after aortic cross-clamp application, immediately after aortic declamping, on arrival at the ICU and 24 h after surgery. Perioperative changes were analysed using non-parametric tests, Spearman’s rank correlation analysis and mixed-effects modelling. The study was registered at ClinicalTrials.gov (NCT03491163; registered on 29 March 2018). Results: Syndecan-1 concentrations changed significantly over time (p < 0.001), increasing from a baseline median of 49.74 ng/mL to a peak of 147.78 ng/mL at ICU admission, followed by a partial decline to 65.26 ng/mL at 24 h. Aortic cross-clamp duration was weakly but significantly associated with Syndecan-1 concentration at ICU admission (rs = 0.243, p = 0.003) and with perioperative increases from baseline to ICU admission (ΔS4-1: rs = 0.196, p = 0.017) and from aortic clamping to ICU admission (ΔS4-2: rs = 0.207, p = 0.012). No significant associations were observed between CPB duration and Syndecan-1 concentrations in univariable analyses. In the mixed-effects model, a significant non-linear temporal pattern of Syndecan-1 concentrations was observed (both linear and quadratic time terms, p < 0.001). Male sex (β = 0.247, p = 0.009) and aortic cross-clamp duration (β = 0.016, p = 0.005) were independently associated with higher Syndecan-1 concentrations, whereas smoking status, age, BMI, diabetes status, EuroSCORE II, and CPB duration were not independently associated. Conclusions: Syndecan-1 concentrations increase significantly during cardiac surgery with cardiopulmonary bypass, peaking at ICU admission and partially declining within 24 h. Aortic cross-clamping duration, but not total CPB duration, showed weak associations with glycocalyx shedding. Male sex was independently associated with higher Syndecan-1 concentrations. These findings support ischemia–reperfusion injury as an important contributor to endothelial glycocalyx shedding during cardiac surgery.

Širdies operacijas patiriantys pacientai – ypatinga tiriamųjų grupė, kuriems dėl operacijos pobūdžio ir dirbtinės kraujo apytakos taikymo bei su tuo susijusiais sisteminiais hemodinamikos svyravimais, metabolinėmis ir uždegiminėmis reakcijomis, nustatomi galvos smegenų kraujotakos autoreguliacijos sutrikimai (GSKA). Jie siejami su įvairiomis pooperacinėmis neurologinėmis komplikacijomis: uždelstu kognityvinių funkcijų atsistatymu, delyru ar išeminiu galvos smegenų insultu. Šios komplikacijos apsunkina ankstyvąjį pooperacinį periodą, didina kitų pooperacinių komplikacijų, pvz., krūtinkaulio nestabilumo, mediastinito ir kt., riziką, ilgina hospitalizacijos trukmę ir gali lemti ilgalaikę pacientų disfunkciją bei didesnį mirštamumą. Dalis pooperacinių neurologinių komplikacijų rizikos veiksnių yra sunkiai koreguojami, tačiau intraoperaciniai GSKA sutrikimai galėtų būti vienas iš potencialiai modifikuojamų rizikos veiksnių. Vis dėlto iki šiol trūksta aiškių rekomendacijų, kaip klinikinėje praktikoje taikyti įrodymais pagrįstas GSKA stebėsenos ir korekcijos metodikas, todėl būtina toliau tirti jų sąsajas su pooperacinėmis neurologinėmis komplikacijomis. Šio darbo tikslas - įvertinti galvos smegenų kraujotakos autoreguliacijos sutrikimus aortos ir vainikinių arterijų jungčių suformavimo operacijų metu ir nustatyti jų reikšmę pooperacinių neurologinių komplikacijų išsivystymui. Šiame perspektyviniame tyrime nustatyta, kad galvos smegenų kraujo-takos autoreguliacijos sutrikimai širdies operacijų metu su dirbtine kraujo apytaka pasireiškė visiems pacientams, tačiau jų trukmė ir intensyvumas (dozė) reikšmingai skyrėsi. Daugiau nei pusei tiriamųjų pooperaciniu laiko-tarpiu buvo nustatytos neurologinės komplikacijos: uždelstas kognityvinių funkcijų atsistatymas, atminties sutrikimas, delyras ir išeminis galvos sme-genų insultas. Tyrimo rezultatai parodė, kad intraoperaciniai GSKA sutrikimai yra reikšmingai susiję su pooperaciniu atminties sutrikimu ir delyru. Gauti duomenys leidžia manyti, kad svarbus ne pats GSKA sutrikimo faktas, o jo trukmė ir intensyvumas, nes būtent šie rodikliai buvo susiję su poopera-cinėmis neurologinėmis komplikacijomis. Analizuojant rizikos ir prognozinius veiksnius nustatyta, kad amžius ir išsilavinimo trukmė buvo susiję tiek su pooperacinėmis neurologinėmis komplikacijomis, tiek su GSKA sutrikimais. Tai leidžia juos laikyti svarbiais predisponuojančiais veiksniais. Be to, šiame tyrime detaliai įvertintas ir intraoperacinių arterinio kraujo dujų rodiklių poveikis minėtoms komplikacijoms. Vertinant pacientų kognityvines funkcijas, statistiškai reikšmingi skirtu-mai nustatyti analizuojant atskirus kognityvinių funkcijų domenus tam skirtais specifiškais neuropsichologiniais testais, o bendrieji vertinimo instru¬mentai („viskas viename“ tipo testai) reikšmingų skirtumų neparodė. Taip pat šiame tyrime nustatyta, kad pacientų GSKA individualios ribos skyrėsi ir dauguma atvejų neatitiko literatūroje aprašytų klasikinių teorinių ribų. Autoreguliacijos intervalas dažnai buvo siauresnis, todėl galima manyti, kad teorinių VAS ribų taikymas širdies operacijų metu gali neužtikrinti adek-vačios smegenų perfuzijos ir būti susijęs su pooperacinėmis neurologinėmis komplikacijomis. Siekiant geriau suprasti gautų rezultatų reikšmę, būtinas jų detalesnis palyginimas su ankstesniais tyrimais ir esamu teoriniu požiūriu.

Background and Objectives: Recent studies suggest that remimazolam, a novel ultra-short-acting benzodiazepine, has an excellent pharmacokinetic and safety profile, favourable for ambulatory procedures. Although remimazolam has been studied as a sole agent for anaesthesia in day case gynaecological surgery, studies assessing its use in combination with other anaesthetics remain scarce. The aim of this study was to investigate the effects of a low-dose remimazolam adjunct on the characteristics of an intravenous propofol–remifentanil anaesthesia regimen. Materials and Methods: A single-centre retrospective observational cohort study was conducted on patients who underwent brief day case gynaecological surgery under general intravenous anaesthesia using remifentanil and propofol from November 2024 to January 2025. The patients were divided into two groups depending on whether they received remimazolam as an adjunct. To account for confounding, propensity scores (PSs) were estimated from baseline characteristics and used to derive stabilised inverse probability of treatment weights (IPTWs). Weighted regression models were then applied to estimate treatment effects on postoperative recovery time measures, consumption of anaesthetics, and incidence of any adverse effects intraoperatively and postoperatively. Cost effectiveness was evaluated using the incremental cost-effectiveness ratio (ICER). Results: The clinical data of 51 patients were retrospectively examined: 32 patients were assigned to the intervention group, and 19 patients were assigned to the reference group; after IPTW and PS trimming, the sum of weights was 22 in the intervention group and 58.8 in the reference group. The use of remimazolam as an adjunct was associated with 3.5 min shorter time to eye opening (p < 0.001) and 3.6 min shorter time to full consciousness (p = 0.002); the total consumption of propofol was decreased by 3 mg/kg (p < 0.001); the median dose of remimazolam adjunct was 0.12 mg/kg, or 10 mg per case. There were no statistically significant adverse effects. ICER was 2.35 € per minute of operating room (OR) time saved. Conclusions: In the setting of day case gynaecological surgery, the addition of remimazolam to a propofol–remifentanil regimen reduced propofol requirements and shortened recovery time without an increase in adverse effects. This may represent a more efficient anaesthetic approach for ambulatory procedures with a comparable safety profile.

Background: Trauma is one of the main causes of mortality, according to World Health Organisation, 4,4 million deaths are due to unintentional or violence- related injuries [1]. Thoracic trauma is potentially fatal and requires immediate treatment. The consequences could be significant pain, hypoventilation, respiratory failure, infection [2]. This trauma is the real issue not only for surgeons, but also a huge challenge for anaesthesiologist. It is also a reason for difficult airway, which requires not only thorough anaesthesia planning, but also excellent professional skills. Avoidance of further airway disruption is crucial, therefore visualization of airway could be beneficial [3]. Case report: 29 years old female had a motorcycle accident, which manifested in polytrauma: circular laceration of right bronchus, signs of pneumomediastinum, laceration of right lung, unstable thorax, multiple rib fractures, pneumohaemothorax. The patient arrived to operating room conscious and breathing spontaneosly. During intubation, endobrochial tube was inserted into left bronchus while using videolaryngoscope, according to CT scan and fibrobronchoscopy, trachea and left bronchus were not disrupted. Intubation was successful, fibrobronchoscope was used to ensure tube’s placement, then one lung ventilation was applied. The patient was ventilated with low tidal volumes to prevent from further injury. Arterial hypotension was treated with noradrenaline via syringe pump and pain was treated with fentanyl boluses. The surgeon sutured right bronchus and inserted chest tube with drainage system. The patient was not extubated, transferred to intensive care unit. After 3 days bronchial stent was inserted into right bronchus. The condition remained severe, however, perspectives were positive due to improved lung capacity, ventilation. Discussion: Polytrauma is a complex issue for every member of the trauma team. The anaesthesiologist has to co-operate closely with surgeon, deal with difficult airway and plan an anaesthesia carefully to improve patient’s postoperative outcomes.

Šeimos gydytojo užduotis - užtikrinti veiksmingą arterinio kraujospūdžio ir dislipidemijos kontrolę, taip pat aktyviai formuoti sveikos gyvensenos įpročius, skatinti fizinį aktyvumą ir subalansuotą mitybą. Visa tai padeda mažinti širdies ir kraujagyslių sistemos ligų, tokių kaip miokardo infarktas, krūtinės angina, aortos disekcija, pasireiškimo arba pasikartojimo riziką. Aortos disekacija yra gyvybei pavojinga širdies ir kraujagyslių sistemos liga, kuriai būtina skubi medicinos pagalba. Dažniausiai ši patologija nustatoma 60-80 metų pacientams. Aortos disekacijos riziką didina keli predisponuojantys veiksniai: arterinė hipertenzija, aterosklerozė ir įvairios jungiamojo audinio ligos, šie veiksniai didina aortos sienelės įtampą arba skatina jos struktūrinį irimą. Straipsnyje pateikiamas klinikinis aortos disekacijos atvejis. Aprašomas pacientas - vyras, kuriam nustatyta šios būklės rizikos veiksnių. Gydymo eiga buvo sudėtinga, pasireiškė perioperacinės komplikacijos.

Pooperacinio pažinimo funkcijų sutrikimo (PPFS) patofiziologija siejama su sisteminiu uždegimu, hematoencefalinio barjero pažeidimu ir mikroglijos ląstelių aktyvacija, kurių visuma gali sukelti neurouždegimą. Taip pat svarbūs anestetikų neurotoksiniai poveikiai, hemodinaminiai svyravimai bei individualūs rizikos veiksniai, tokie kaip amžius ir gretutinės ligos. Šių mechanizmų supratimas padės ieškoti naujų prevencijos ir gydymo galimybių.

Introduction Postoperative delirium affects up to 60% of cardiac surgical patients. No reliable gold standard method exists for preventing delirium after cardiac surgery. An example of patient-personal monitoring is cerebral autoregulation (CA). This study aims to highlight the personal monitoring of patients' cerebral autoregulation and to determine its relationship with postoperative delirium. Additionally, it seeks to test the hypothesis that the duration of CA impairment influences the onset of postoperative delirium. Methods A prospective study was conducted in 2021-2023. After approval of the Ethics Committee and with the patient's written consent, 104 adult patients undergoing elective coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) surgery were enrolled. To diagnose possible delirium, all patients underwent a Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) test. CA monitoring using transcranial Doppler was performed. CA status index - Mx was recorded. Results Our study found that 12.5% of patients were diagnosed with delirium after on-pump CABG surgery. The total duration of cerebral autoregulation impairment (TCAI) was longer in the delirium group, 4783.0 seconds versus 4204.5 seconds (p = .047), with a cut-off at 4380 s. Longer cardiopulmonary bypass (CPB) leads to prolonged CA impairment (p < .001). The mean arterial pressure (MAP) during CPB was 69.67 mmHg in the non-delirium group and 74.91 mmHg in the delirium group (p = .001), with a cutoff at 73.669 mmHg. Conclusions CA impairment is crucial for delirium development after cardiac surgery. The duration of the TCAI event increases the risk of delirium.

Background: The bleeding in cardiac surgery remains a significant clinical problem. There is no "gold standard" method to quantify blood loss. Traditional measurement of drainage volume often underestimates or overestimates, as it does not consider the type of fluid. We hypothesized that blood loss could be more accurately calculated using the Hb/kg index in terms of haemoglobin (Hb) mass loss per kilogram of the patient's body mass. This study aimed to Objective To develop a novel approach for calculating actual blood loss using the Hb/kg index. Methods: This single-center prospective study included 195 patients who underwent cardiac surgery between October 2023 and November 2024. The Hb/kg index was calculated based on intraoperative Hb loss, Hb loss via chest tubes, packed red blood cell transfusions and patient weight. Eighty-six additional clinical predictors were analyzed using conventional statistics and machine learning algorithms. Predictors with statistically significant Spearman correlations were included for further analysis. Results: Lasso regression achieved the best overall performance in predicting Hb/kg index. It yielded the lowest mean squared error (0.08 ± 0.04), mean absolute percentage error (0.18 ± 0.10), with the highest correlation (0.92 ± 0.06) and R² score (0.82 ± 0.13). BMI showed a significant negative relationship (-0.018, p < 0.001). Postoperative Hb and haematocrit values had negative correlation (-0.69, p < 0.001 and -0.07, p < 0.015), while initial Hb was positively correlated (0.85, p < 0.001). Conclusions: This method provides a more reliable and clinically relevant tool to calculate actual blood loss and allows for a more precise assessment and treatment.