Emergency Caesarean Sections in Tartu University Hospital 2013-2015: Indications, Anaesthetic

Emergency caesarean sections in Tartu University Hospital 2013-2015: indications, anaesthetic methods, maternal and fetal outcomes Padar M, Palta K, Kivisikk K, Karjagin J. Tartu University Hospital, Tartu, Estonia Appelberg O, Mihnovitš V. University of Tartu, Tartu, Estonia AIM: To provide an overview on anaesthetic methods used in and risk factors, maternal and fetal outcomes associated with emergency caesarean sections (CS) performed in Tartu University Hospital in years 2013-2015. METHODS: Relevant data about parturients and neonates were retrieved from electronic and paper health records. Decision time, indications and urgency of CS according to National Institute for Health and Care Excellence 2011 guidelines were determined retrospectively by a senior resident in obstetrics and gynaecology. RESULTS: With ongoing data collection, analysis of 392 cases is provided in this abstract. The average parturient was 29 years old and in good health (94% ASA 1-2). The prevalence of gestational hypertension, diabetes and anaemia was 5, 6 and 35% respectively. The prevalence of urgency category (UC) I, II and III CSs was 39, 32 and 29%, while general anaesthesia (GA) was used in 72, 44 and 23% of cases respectively (total 49%). The decision-to-delivery interval was 24, 34 and 31 minutes for UCs I, II and III respectively, based on 21% of cases where decision time was available. Conversion from regional anaesthesia (RA) to GA was needed in 4% of cases. Anaesthesia-related complications were rare; no maternal deaths occurred. Maternal blood loss was greater when GA was used (mean 460 RA vs 605 mL GA, P=0,0001) and a significant difference persisted in both UCs I and III. 1-minute Apgar scores were significantly lower in UCs I and II when GA was used, while 5- minute scores did not differ regarding the use of GA or RA in any category. No effect of anaesthesia method was noted in any UC on umbilical arterial pH, the need for both cardiac and respiratory resuscitation immediately after birth and admission to neonatology or neonatal ICU departments. Neonatal hospital mortality was 1,5% CONCLUSION: GA is frequently used for CS in the study unit. The use of GA was associated with greater maternal blood loss and lower neonatal 1-minute Apgar scores. Postanesthesia emergence delirium incidence in preschool children after different premedication techniques in day case surgery. Veģeris, I., Skotelis, V., Bārzdiņa, A., Zundāne, A., Rozenfelds, H., Krutskih, V., Pudāne, V., Casno, G., Ramane, G. Children's Clinical University Hospital, Riga, Latvia. Psycho-emotional agitation before operation provokes postoperative complications: emergence delirium (ED), maladaptive behaviour and expressed postoperative pain syndrome. There are 3 main techniques to reduce preoperative fear: behavioural preparation, parental presence and premedication with sedatives. Aim: To assess and compare different premedication and behavioural preparation impact on preoperative agitation and postanaesthesia ED development in 1–7 years old children after day surgery Methods: Study included 72 patients (1-7 years), ASA I–II, that underwent general anaesthesia for day surgeries. Patients were randomized and selected in 4 groups. Group A patients (n=27) were premedicated with Dexmedetomidine. Group B (n=14) received Behavioural Preparation. Group C (n=16) were premedicated with Midazolam. Group D (n=15) were premedicated with Clonidine. Presence of agitation and reaction to face mask induction were observed. Postanaesthesia emergence delirium was estimated by PAED score at awakening and 30 min later. To evaluate pain and discomfort in the evening after operation, 24 and 48 hr later, a parent questionnaire (POPS score) was used. Results: All groups showed similar agitation incidence before induction and on mask imposition, no statistically significant difference. PAED score evaluation at awakening showed statistically significant difference between Behavioural Preparation and Midazolam groups (average score: group B-3,00, group C-5,13; p=0,02), but minimal difference between Dexmedetomidine and Behavioural Preparation groups (average score: group A-3,59,group B–3,00). PAED score evaluation 30 min after awakening and POPS score evaluation didn’t show statistically significant difference between groups. Conclusion: All patientsreacted similarly to the face mask induction. Postansaesthesia ED incidence was similar in Behavioural Preparation and Dexmedetomidine groups. Incidence of postanaesthesia ED was higher in Clonidine and Midazolam groups. Intraoperative haemodynamic management directed by auto calibrated arterial pressure waveform analysis: effect on postoperative complication rates Jakobson-Forbes, T, University of Tartu, Tartu, Estonia Juri Karjagin, University of Tartu, Tartu, Estonia Joel Starkopf, University of Tartu, Tartu, Estonia The aim of the study was to assess the impact of intraoperative haemodynamic management directed by autocalibrated arterial pressure waveform analysis on postoperative complications in high risk patients undergoing major abdominal surgery. Patients and methods. The prospective, randomized, controlled, single centre, open-label study took place between 01.06.2012 and 01.03.2016. We included adult patients undergoing major gastrointestinal surgery, including also hepatobiliary and pancreatic one. Patient should be at least ASA class III and have 3 points on revised cardiac risk index. In the study group, auto calibrated arterial pressure waveform analysis (Pulsioflex™, Pulsion) was used to evaluate cardiac output index and intraoperative fluid and vasoactive therapy was adjusted according to cardiac output index and stroke volume using a predefined cardiovascular treatment protocol. In the control group, infusion therapy with cristalloids and colloids was conducted according to everyday practice. Results. A total of 80 patients were recruited and analysed. Forty-one patients received the study intervention, and 39 were in the control group. Control group patients were older, otherwise no differences between groups. Study group patients received less infusion 1011 vs 1700 ml during operation (p<0.0001), more dobutamine and/or norepinephrine 14/41 vs 1/39 (p<0.0001) and less urine output 920 vs 1200 (p=0.05). Number of patients with any complication was similar between groups. But the rate of kidney injury was higher in study group and rate of wound infection was also higher in study group. LOS in ICU, LOS hospital and in-hospital mortality were also similar, but 30- day mortality was higher in study group 4 vs 0 patients (p=0.04) Conclusion. The protocol and cardiac output based patient management did not perform better, than standard therapy, moreover protocol based management resulted in higher rate of oliguria, higher rate of wound infection and also higher mortality Assessment of correlation between ultrasonographic measurement of inferior vena cava and central venous pressure for patients with severe sepsis. Snucina E, Suba O, Liguts V. Riga East Clinical University Hospital, Riga, Latvia The purpose of study was to determine the correlation between ultrasonographic measurement of inferior vena cava (IVC) diameter and central venous pressure (CVP) for patients with severe sepsis. A prospective and observational study was conducted in Toxicology and Sepsis Clinic of Riga East Clinical University Hospital during 12 month period. Thirty–four adult patients with severe sepsis who had been placed central venous catheter were enrolled. IVC minimal (IVCmin) and maximal (IVCmax) diameter during respiratory cycle was measured with bedside ultrasonography using a subxiphoid approach. The IVC respiratory variation indices (IVC-RV) were calculated. IVCmin, IVCmax, IVC-RV and CVP were evaluated at baseline and after 8-12 hour treatment period. Twenty-five patients with mean age of 60 (±14) were included in the final analysis. Fluid balance between 8-12 hour treatment period was 260 ± 454ml (-600 - +1100ml). There was strong correlation between IVC-min diameter and CVP (R=0,78, p<0,000). Correlation was moderate between change in fluid balance and IVC-min diameter change (R=0,581, p=0,002). Correlation was moderate between IVC-max diameter and CVP (R=0,56, P=0,001). There was strong negative correlation between IVC- RV and CVP (R= -0,754, p<0,000). IVC-RV > 26,3% predicted CVP <8 mmHg (sensitivity 93,1% and specificity 61,5%(AUC 0,883, p<0,000). IVC-RV <19,6% predicted CVP >12 mmHg (sensitivity 91,3% and specificity 89,9% (AUC 0,957, p<0,000). The present study indicates that ultrasonographic measurement of the IVC diameter has a good correlation with CVP. The IVC diameter’s measurement can be used for noninvasive estimation of CVP for patients with severe sepsis. Burnout Among Anesthesiology and Intensive Care Residents MIKALAUSKAS, A. Lithuanian University of Health Sciences Department of Cardiothoracic and Vascular Surgeary, Kaunas, Lithuania. Širvinskas, E. Lithuanian University of Health Sciences Department of Cardiothoracic and Vascular Surgeary, Kaunas, Lithuania. Macas, A. Lithuanian University of Health Sciences Department of Anesthesiology, Kaunas, Lithuania. Padaiga, Ž. Lithuanian University of Health Sciences Department of Preventive Medicine, Kaunas, Lithuania. Objective. The aim of this study was to determine the prevalence of burnout among anesthesiology and intensive care residents, and associations between burnout and the personal and professional characteristics of residents. Material and Methods. All of 52 anesthesiology and intensive care residents employed in hospital of Lithuanian University of Health Sciences, internet based questionnaire was sent to their personal email accounts. 39 of them filled the questionnaire correctly. Data on personal characteristics (age, gender, marital status, number of children, sleeping hours, and addictions), professional characteristics (residency semester, years in residency, work in other hospitals and workload). Burnout was measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS). Results. One-fifth (20,5%) of residents reported of being burned out. As much as 79,5% of residents reported high emotional exhaustion, 79,5% had high depersonalization, and 20,5% demonstrated low personal accomplishment at work. Only female residents were burned out. 75% of burned out residents studied intensive care residency semester, rest 25% studied anesthesiology semester. Respondents living in marriage have heavily increased high emotional exhaustion (93,1%) and high depersonalisation (93,1%) scores. Conclusions. Burnout was found to be prevalent among anesthesiology and intensive care residents. Some personal and professional characteristics were significantly related to burnout. Burnout relief measures should be developed in order to prevent a further increase of burnout among anesthesiology and intensive care residents. Propofol vs dexmedetomidine for EEG controlled sedation during elective colonoscopy Mickevica E., Riga Stradins University, Faculty of Medicine, Riga, Latvia - presenting author Margaliks M., Riga Stradins University, Faculty of Medicine, Riga, Latvia Jarocka-Jemeljanova N., Riga Eastern Clinical University Hospital Gailezers, Riga, Latvia Stepanovs J., Riga Eastern Clinical University Hospital Gailezers, Riga, Latvia Mamaja B., Riga Stradins University, Department of Anaesthesiology and Reanimatology, Riga Eastern Clinical University Hospital Gailezers, Riga, Latvia Aim:To evaluate efficiency and side effects of dexmedetomidine versus propofol for sedation during elective colonoscopy. Material and methods: 72 patients ASA I-III undergoing elective colonoscopy, included in a prospective study, were randomly assigned to 2 groups of 36.Dexmetomidine (D) group received 1μg/kg D over 10 min followed by an infusion of 0,2-0.6 µg/kg/h.Propofol (P) group-Target Controlled Infusion, using Schnider Effect Site pharmacokinetic model 2-6 µg/ml. The depth of the sedation was controlled by Narcotrend index. Results: In D group mean age of patients was 57.2±16.8 years, in P group–63.0±15.0 years. In D group after 10 min heart rate (HR) decreased from 74.8±12.0 to 59.8±9.1 x/min (P<0.01), systolic blood pressure (SBP) decreased from 143.1±23.3 to 121.7±20.7 mmHg (P<0.01), diastolic blood pressure (DBP) decreased from 71.1±12.1 to 64.3±12.0 mmHg (P<0.01), 8/36 patients developed bradycardia, atropine was given, 6/36 had hypotension treated with i/v fluid. In P group after 10 min HR decreased from 80.2±13.6 to 68.7±12.1/min (P<0.01), SBP decreased from 142.2±30.4 to 110.7±23.7 mmHg (P<0.01), DBP decreased from 70.6±13.0 to 60.1±12.4 mmHg (P<0.01). 1/36 patients developed bradycardia, atropine was given, 3/36 had hypotension treated with i/v fluid. All patients had adequate spontaneous breathing, no patient required bag-mask ventilation. In D group 7/36 patients required O2 vs 25/36 in P group. Jaw thrust was required only in P group in 10/36 cases In D group 2/36 patients required propofol bolus to proceed the procedure and 36/36 received rescue analgesics vs only 1/36 in P group Conclusions: To provide adequate sedation with dexmedetomidine in elective colonoscopy all patients required analgesics vs 1/36 in propofol sedation. Dexmedetomidine sedation supplemented with analgesics associates with less respiratory depression than propofol as a sole agent. Sedation with dexmedetomidine caused longer recovery time than sedation with propofol. A comparison of dexmedetomidine and propofol TCI sedation controlled by Narcotrend EEG in patients undergoing hand surgery under brachial plexus block Margaliks, M., Riga Stradins University, Faculty of Medicine, Latvia Mickevica, E., Riga Stradins University, Faculty of Medicine, Latvia Jaunmuktane, A., University of Latvia, Residenture Development Programme, Latvia Stepanovs, J., Riga Eastern Clinical University Hospital Gailezers, Latvia Mamaja, B., Riga Stradins University, Department of Anaesthesiology and Reanimatology, Latvia

Aim. To compare sedations with dexmedetomidine vs propofol controlled by Narcotrend EEG in patients undergoing hand surgery under brachial plexus block. Material and methods. In a prospective study 50 patients ASA I-II undergoing brachial plexus block for hand surgery were randomised in 2 groups of 25. Sedation with dexmedetomidine: a loading dose 1μg/kg over 10 min, followed by infusion 0,1-0.6 µg/kg/h. Sedation with propofol: Target Controlled Infusion, using Schnider Effect Site pharmacokinetic model, initial dose: 2,5 μg/ml. Sedation depth was controlled with electroencephalogram index. Results: After 10 min of sedation with dexmedetomidine patients’ heart rate (HR) decreased from 74.9±10.0 to 62.8±7.9 x/min (P<0.01), systolic blood pressure (SBP) decreased from 136.7±22.2 to 122.5±17.7 mmHg (P<0.01), diastolic blood pressure (DBP) decreased from 82.7±14.3 to 72.5±11.1 mmHg (P<0.01). After 10 min of sedation with propofol patients’ HR decreased from 74.1±13.1 to 71.2±10.6 x/min (P=0.15), SBP decreased from 139.2±19.4 to 128.6±19.5 mmHg (P<0.01), DBP decreased from 84.1±14.6 to 76.0±14.5 mmHg (P<0.01). Mean haemodynamic values during surgery in dexmedetomidine group: HR 61.7±7.5, SBP 120.7±38.3, DBP 70.3±10.4 and in propofol group: HR 69.4±11.5, SBP 121.6±19.6, DBP 71.8±14.7. All patients in both groups had spontaneous breathing, no patient required bag-mask ventilation. To maintain SpO2 >95% in dexmedetomidine group 48% patients required O2, no patient required oral airway insertion or jaw thrust; in propofol group 56% required O2, no patient required oral airway insertion but 20% required jaw thrust. Conclusions: Sedation with dexmedetomidine decreased patients’ heart rate more than sedation with propofol (P<0.01) but did not require treatment. There was no difference between blood pressure values between both groups. Patients sedated with dexmedetomidine required achievement of correct airway less frequently than patients sedated with propofol, (p=0.02). Metformin threats in patients with compromised renal function Kreice I., Senkans A., Strautmane A., Shapiro I. Riga East University hospital Latvia Introduction. Metformin, key drug in T2DM treatment, inhibits gluconeogenesis in liver, reduces intestinal glucose absorption, increases peripheral glucose utilization and insulin sensitivity of tissues. But combined with β-blockers, NSAIDs and potentially nephrotoxic agents it can cause hypoglycemia. Risk factors: advanced age, malnutrition, starvation, alcohol. Metformin withdrawal 48 hours prior major surgery is recomended. Purpose/Methods. Demonstrate 2 clinical cases of postop metformin induced persistent hypoglycemia. Patient L.,74, T2DM, metformin monotherapy, admitted for rectum surgery. Preop GFR 57ml/min/1.73m2. Metformin withdrawn 26 hrs prior surgery. Uneventful resection. Next morning GFR was 27ml/min/1.73m2. Despite tight glycemia control 30 hrs postop blood sugar 2.4mmol/l observed. Frequent episodes of hypoglycemia lasted for 5 days until GFR reached 52ml/min/1.73m2. Patient discharged on day 26. Patient B.,77, T2DM, metformin monotherapy, admitted for colon surgery. Preop GFR 80ml/min/1.73m2. Day 4 postop - as B. resumed normal diet internist restarted metformin. Day 9 postop - patient coughing, febrile. X-ray: right-sided pneumonia. Treatment: ACC, gentamicin 240mg q.d. Antibiotics continued till day 14 postop, when B. suddenly unconscious, blood glucose level 1,1mmol/l. Blood test revealed GFR 7ml/min/1.73m2. Hemodialysis for 10 consecutive days was complicated by frequent episodes of hypoglycemia (1.2-2,1mmol/l). After discharge patient continued outpatient hemodialysis and switched to insulin. Discussion/Results. Metformin is excreted by kidneys in unchanged form. Renal failure causes metformin accumulation in body. Case1: relatively late metformin cessation prior surgery played a negative role in postop period. Case 2: regular monitoring of daily urine output and GFR is required in diabetic patients receiving nephrotoxic drugs. Conclusions. Patients with renal failure receiving metformin are at risk of sudden hypoglycemia in postop period. Discriminating abilty of postoperative fluid balance to predict acute kidney injury in children after open heart surgery Krastins J.1, Birznieks M.2, Amerika D.3, Gravele D.3 Petersons A.4, Petersons A.5 , Erts R.6 1Clinic of Anesthesiology and Intensive Care, University Children's Hospital, 2Department of Mediciine University of Latvia ,3Clinical and Biochemical Laboratory, University Children's Hospital, 4Department of Pediatric Surgery Riga Stradin's University, 5Centre of Nephrology, Department of Internal Diseases Riga Stradin's University, 6Department of Physics, Riga Stradin's University. Purpose of the study, To evaluate postoperative fluid balance (FB) as a marker of kidney injury and to compare it to traditional markers of kidney functional and structural damage. Materials and methods During 2012-2015 years we conducted prospective uncontrolled cohort study, 93 children with various congenital heart lesions undergoing CPB were enrolled. 55,9% of patients were less than 1 year old. Serum creatinine (SCr) level was determined by Jaffé's method (Cobas 6000 analyzer, Roche), serum Cistatin C (CysC) was determined by particle-enhanced nephelometric immunoassay, urine NGAL was determined by ARCHITECT system (Abbott Diagnostics, Illinois, USA). Daily fluid balance data was extracted from the intensive care clinical information system (Intelly View, Philips) flowsheets. Results. AKI developed in 42 patients (45,6%) by meeting at least KDIGO stage I criteria (with SCr rise by more than 50% from the baseline). One patient having severity stage II and two patients having severity stage III of AKI required initiation of RRT, using peritoneal dialysis. Two patients from the RRT group survived, one died. Median CPB time was 163 min., median aortic cross-clamping time was 97,9 min., cooling during CPB to 29,5°C. The diagnosis of AKI using SCr was delayed by 48 hours after CPB. Mean fluid balance (FB) on the post operative day-1 (POD-1) in patients with normal kidney function was 3,78 ±4,56 ml/kg vs. 54,14±7,75 ml/kg in patients having AKI (p<0,0011). ROC analysis revealed sensitivity of 73%, specificity of 71%, AUC=84%. Conclusions. This study highlights the importance of monitoring FB in the pediatric cardiac surgical population and suggests that daily FB, noninvasive marker of renal function, may be a sensitive and specific predictor of AKI. FB in the POD-1 has statistically significant difference between patients with intact kidney function and those having postoperative AKI. The effect of different local anaesthetics and their doses, used for labour epidural analgesia, on foetus: a randomized double blind controlled trial Baliuliene, V., Zavackiene, A., Macas, A., Istigecev, S., Korsakova, T., Rimaitis, K. Hospital of Lithuanian University of Health Sciences Kauno klinikos, Kaunas, Lithuania Goal: to evalute the effect of different local anaesthetics (LA) and their doses, used for labour epidural analgesia, on foetus. Methods: a randomized trial of healthy primiparas, when labour pain was relieved with patient- controlled epidural analgesia, using LA and opioid fentanyl. The patients were divided into 6 groups according to used LA and concentrations: 1 Bupivacaine (B) 0.0625%, 2 B 0.1%, 3 B 0.125%, 4 Levobupivacaine (L) 0.0625%, 5 L 0.1%, 6 L 0.125%. Umbilical cord gas was collected after delivery. Results: 200 patients were included, 6 patients were excluded, because of insufficient labour pain relief. Groups were similar according to ASA class, age, gestational age, BMI, duration of delivery stages, birth weight and Apgar score in 1 and 5 minutes. Mode of delivery: vaginal 84.6% patients, instrumental 1.5%, caesarean 13.9%. Difference between six groups was insignificant (p=0.16). Total doses of LA: 1st group 49.77±22.46 mg, 2nd 74±30.92 mg, 3 – 95.56±38.06 mg, 4 – 52.92±21.06 mg, 5 – 77.6±31.1 mg, 6 – 90.43±35.96 mg. The total doses significantly differs between groups 1 and 2, 1 – 5, 1 – 6, 1 – 3, 4 – 5, 4 – 6, 4 – 3 (p=0.03, p=0.01, p=0.001, p=0.001, p=0.039, p=0.001, p=0.001 respectively). Foetal bradycardia occurred in 17% of cases, meconium in amniotic fluid was for 17% and the oxygen request was for 6.2% of new-borns. All groups don’t differ according to these parameters (χ2=3.44, p=0.63; χ2=1.89, p=0.87; χ2=8.51, p=0.13 respectively). Cord lactate ≥3.4 mmol/l was identified for 42.8% of patients, pH≤7.18 for 8.2%. The difference between groups was insignificant (χ2=4.32, p=0.504; χ2=4.38, p=0.496 respectively). The effect of total dose of LA on acidosis (pH): OR 0.999; 95%CI 0.976 - 1.022; total dose and acidosis (lactate): OR 1.01; 95%CI 0.992 – 1.027, was insignificant. Conclusion: different low doses of LAs determines significantly different total dose of LA infused, but the effect on mode of delivery and foetus between groups is similar. Cognitive performance in memory tasks decreases during the early postoperative period in patients undergoing general anaesthesia for thyroid surgery KK uK zK mK iK nK sK kK aK iK tKeK V. (1,2), Kolevinskaite S. (3), Skurkaite A. (3), Kontrimaviciute E. (1,2) (1) Vilnius University Hospital Santariskiu Clinics, Centre of Anaesthesiology, Intensive Care and Pain management, Vilnius, Lithuania (2) Vilnius University, Faculty of Medicine, Clinic of Anaesthesiology and Intensive Care, Vilnius, Lithuania (3) Vilnius University, Faculty of Medicine, Vilnius, Lithuania Postoperative cognitive dysfunction (POCD) has been defined as new cognitive deficits appearing after the surgery. POCD may improve with time, although some data show that it can last years after the surgery. The aim of our study was to evaluate early changes in cognitive functioning in patients undergoing general anaesthesia for thyroid surgery and detect the impact of patient and anaesthesia factors on these changes. We prospectively investigated 49 patients undergoing general anaesthesia for thyroid surgery in a tertiary referral university hospital. 38 patients with no documented preoperative cognitive dysfunction were included into final analysis. Anaesthesia was maintained using sevoflurane and fentanyl. Cognitive functions were evaluated a day before the surgery and repeated 24 hours postoperatively. Evaluation of cognitive functions consisted of verbal and visual memory, attention, reaction and logical thinking tasks. Total performance score and scores on individual tasks were calculated and compared before and after the surgery. Out of 38 patients, 34 were female (89,5%). Mean age of patients was 54,1 years (SD = 12,1). Mean duration of anaesthesia was 152 minutes (SD = 40,7). Total performance score was lower after the surgery (30,8 vs. 28,9, p = 0,001). Decreased performance was noticed in logical reasoning (3,0 vs. 2,5, p = 0,005), long-term verbal memory (2,5 vs. 1,9, p = 0,001) and total memory scores (10,2 vs. 8,9, p = 0,003). No difference was found when evaluating attention, reaction and visual memory. No correlation was found between the duration of anaesthesia and total performance score (r = 0,744, p = 0,426) and between age and total performance (r = -0,031, p=0,852). Cognitive performance worsens in patients after thyroid surgery and is not associated with age or duration of surgery. However, these changes are relatively small and further studies are needed to find out whether this translates into long-term cognitive decline.