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Interventional pain management bears a significant risk of hemorrhagic complications. This risk increases in patientswith coagulation disorders and those taking anticoagulant therapy. The population of the latter is growing, and manynew drugs and new treatment regimens have become widespread in recent years. The latest guidelines on the periproceduraluse of anticoagulant therapy also apply to regional anaesthesia techniques for the treatment of chronicand acute pain. However, despite the existence of guidelines and recommendations, decision-making difficultiescan still be encountered in the practice of interventional pain management. The presentation includes a summaryof existing recommendations for the prophylactic use of anticoagulants and antiaggregants in clinical practice inthe periprocedural period. Also included is a discussion of selected concerns regarding their use in the practice ofinterventional pain management.

Peripheral intravenous catheters (PIVCs) play a particularly important role in Emergency Departments (ED), during the administration of anesthesia in the operating room, in post-operative and monitored wards of various specialties, in cases when the patient requires access to the vein due to intensive and varied intravenous therapy. Using short peripheral intravenous catheters carries a high risk of complications, despite their prevalence and staff experience. Patients with DIVA require a comprehensive approach not only during elective (scheduled) intravenous therapy, but also in the aforementioned departments and during emergency interventions in case of deterioration in Non-Intensive-Care-Units. Emergency intravenous access is required for the implementation of many procedures, so it is reasonable to introduce methods that increase the safety and quality of therapy. Midline catheters (MCs) are becoming increas¬ingly popular in Poland. However, based on our experience, they are not the optimal solution in every situation. “Mini-midlines” can be clinically useful in patients with DIVA whose therapy is expected to exceed 5 days. They may be applied in patients who require a secure and rapid insertion of the cannula into the vein and greater fluid flow than via a classic MC. Regardless of the equipment used, the ultrasound-guided mini-midline implantation procedure is simple and quick. Based on available research and experience at our centres, we follow a management regimen for patients who arrive in the ED, have no intravenous access and the team is faced with the clinical dilemma of choosing which cannulation method should be used. Proper patient enrollment and subsequent cannula maintenance increases the quality of care and patient satisfaction. It is advisable to introduce local protocols for selecting appropriate intravenous access and to run prospective studies regarding the topic under discussion.

Aim: The present paper attempts to find the risk factors for hypotension suffered by patients in the postoperative period taking into account the following aspects: gender, type of anaesthesia, ASA score, type of surgery, and time after surgery when it is likely to be at its lowest. Material and methods: The main method used in the study was to analyze the medical records regarding patient data in the perioperative period. Patients had their mean arterial pressure (MAP) measured and documented in the Intensive Care Chart. Information on the type of surgery and choice of anesthesia was obtained from the Anaesthesia Records. Eighty patients participated in the study. Results: There was no clear correlation between the gender of the patients and the decrease in blood pressure. Hypotonia occurred in the 8th hour after surgery in both men and women in the study group. It was observed that in subjects under 80 years of age, hypotonia occurs mainly in the 8th hour after the procedure, while in older subjects – after 12 hours following surgery. The type of procedure affects the occurrence of hypotonia. In patients undergoing general and epidural anaesthesia, the highest decreases in mean arterial pressure values were observed 8 hours after surgery compared to other methods of anaesthesia. The ASA classification proved useful in predicting the incidence of hypotonia; in Class 4 patients, it was pronounced and persisted for 12 hours after surgery. Conclusions: It cannot be conclusively stated which factors most influence the occurrence of hypotension in patients after surgery.

The stress of surgery is characterized by an inflammatory response with immune suppression resulting from many factors, including the type of surgery and the kind of anesthesia, linked with the drugs that are used and the underlying disease of the patient. The trauma of surgery triggers a cascade of reactions involving the immune response and nociception. As strong analgesics, opioids provide the analgesic component of general anesthesia with bi-directional effect on the immune system. Opioids influence almost all aspects of the immune response in regards to leukocytes, macrophages, mast cells, lymphocytes, and NK cells. The suppressive effect of opioids on the immune system is limiting their use, especially in patients with impaired immune response, so the possibility of using multimodal anesthesia without opioids, known as opioid-free anesthesia (OFA), is gaining more and more sympathizers. The idea of OFA is to eliminate opioid analgesia in the treatment of acute pain and to replace it with drugs from other groups that are assumed to have a comparable analgesic effect without affecting the immune system. Here, we present a review on the impact of anesthesia, with and without the use of opioids, on the immune response to surgical stress.

Objective Introduction: Medical marijuana is used in many diseases. There are not many studies on society's knowledge about use of medical cannabis. This study aimed to check the level of knowledge about aspects of medical cannabis among students of medical and medical emergency degree courses. Authors emphasize the need of knowledge about law regulations, composition, properties or contraindications of medical cannabis among students of medical universities, as they are fundamental resource of information for patients and any other person who is not included in medical world. Patients and methods Material and methods: An original questionnaire containing 29 questions was created. There were 311 randomly selected students from medicine (N=52), nursing (N=117), midwifery (N=66), paramedicine (N=54) and dietetics (N=22). Results of the study were evaluated with help of statistical test ANOVA and student t-test. The Bioethical Committee at the Medical University of Warsaw took note of the information about the study and issued a statement with reference number AKBE/35/2020. Results Results: The correctness of answers among students was on the average level of 24.06%. In the survey, the highest percentage of correct answers was characteristic for medicalstudents, achieving about 35.0% effectiveness, then medical emergency students answered correctly in 26.9%, nursing - 23.7%, obstetrics - 21.5%, dietetics - 13.2%. Among all groups, the answer was "I don't know": medical students - 44.0% of all answers, emergency medical services - 53.2%, nursing - 56.2% obstetrics - 62.4%, dietetics - 73.9%. The value of correct answers was assessed as statically valid in the ANOVA test; at the significance level p = 0.05 (F-ratio: 11.32004; p = 0.0001). In the t-student test, it was proved that the ANOVA test result relates to the variance of responses between all study groups except dietetics. Conclusion Conclusions: The level of knowledge of medical students is insufficient to inform patients about possibility of using medical marijuana in their diseases. The low level of knowledge is conditioned by little time at the university devoted to medical marijuana. Education of students about medical marijuana should be increased.

Objective The aim: Women of reproductive age often think of motherhood and labor with fear of intense labor pain. The anxiety they experience can lead to their postponing pregnancy. There are not many studies in the literature that research the knowledge young women have about the analgesia of labor. The aim of the present work was to evaluate the state of awareness about the possible methods of labor analgesia among women of childbearing age. Patients and methods Material and methods: An Internet survey was conducted among 160 women. It consisted of questions on the pharmacological and non-pharmacological methods of labor analgesia. Most of the respondents were not medical university students (96.2%). Correct answers ranged between 11.3% and 97.5% of the total responses. Results Results: The greatest number of incorrect answers were given to the question regarding contraindications to labor anesthesia (only 11.3% of answers were correct). There was also a low percentage of correct answers to questions about the risk of spinal cord injury during the procedure of inducing anesthesia (18.8% of correct answers), the motor activity of a woman after analgesia (22.5%) and the reimbursement of anesthesia (29.4%). Nearly 40% of the respondents did not know the correct answer to the question about the possibility of breastfeeding after anesthesia. The problem of aalgesia during twin delivery also posed a challenge. Over half of the respondents (54.1%) incorrectly answered the question about the occurrence of complications among women who want to become pregnant again after the procedure of labor anesthesia. Moreover, 70.6% of the women surveyed considered non-pharmacological methods of labor anesthesia to be safer compared to pharmacological analgesia. The most commonly mentioned methods of non-pharmacological labor pain relief included breathing techniques and water birth. Conclusion Conclusions: The study shows that women of childbearing potential have an unsatisfactory level of knowledge about labor anesthesia. There is a need to improve the level of health education on this topic.

Demographic data clearly show the progressive aging of societies. Problems and specificity of anaesthesia in the elderly becomes a particularly important issue in this context. Spinal anesthesia is a method often used to anesthetize elderly patients, and hypotension is one of its most common early complications. Untreated or improperly treated hypotension increases the risk of perioperative complications such as myocardial infarction, ischemic stroke or acute renal failure. The prevention of hypotension consists of intravenous fluid therapy and pre-emptive use of vasoconstrictor drugs. Among vasoconstrictors, ephedrine and phenylephrine are commonly used to treat hypotension due to spinal anaesthesia. Both drugs are available in Poland. Issues related to their use in the treatment of hypotension caused by spinal anaesthesia in the elderly, including the features of both drugs, their method of administration and dosage based on the literature and own experience are the subject of this study. It should be noted, however, that most studies in the use of ephedrine and phenylephrine as a targeted treatment for hypotension concern the obstetric patient population while the elderly population is underrepresented and the results are inconclusive.

Background The aim of the study was to check if a situation of extreme and traumatizing stress, such as living kidney donation, would result in changes in the quality of the donor's life: whether a posttraumatic growth should occur, and if the donor would develop a strategy to handle strong and uncommon stress, known as resilience. Methods The study was conducted on 23 living kidney donors aged 25 to 63, who were examined 3 days before the donation and 6 months after. The study was conducted using the following tools: self-prepared questionnaires for donors before and after donations and validated questionnaires Cognitive Emotion Regulation (PRE), Posttraumatic Growth Inventory (PTGI-R), and Resilience Scale Inventory (SPP25). Results The results of the study proved that situations of extreme stress resulted in an increase of resilience. It was found that resilience was a moderator in the adaptation to extreme stress. A number of positive changes, known as posttraumatic growth, were noted. The examined patients focused on the adaptive strategies. Conclusion It may be concluded that resilience is responsible for handling situations of extreme stress. Increased ability to mobilize, stronger focus on adaptive strategies, planning, and creating perspectives are observed. An observable increase of openness for new experiences, personal competencies to handle difficulties, tolerating negative emotions, and an optimistic approach to life may be noted.

Tissue damage following injury triggers the processes of coagulation, inflammation and healing. In tissues surrounding the bone, the result of the healing process is a scar, while bone tissue has a unique ability to achieve shape, strength and pre-injury function. Bone healing is a process of regeneration rather than classic recovery. The result of this process is the formation of new, healthy bone tissue instead of a scar. Many factors can inhibit or impair the bone healing process, and their influence is critical during the stages of inflammation and angiogenesis and finally on the clinical outcome. Nonsteroidal anti-inflammatory drugs (NSAIDs) play an essential role associated with their analgesic potency and anti-inflammatory effects. NSAIDs are also the most often used drugs in patients who require pain control and inflammation reduction due to musculoskeletal diseases or injures. Although their analgesic effect is well documented, NSAIDs also interfere with bone healing; therefore, the relative benefits and disadvantages connected with their administration should be taken into consideration. Despite the negative effect, NSAIDs have beneficial properties, but their clinical benefits in relation to dose and time of use are still unclear. Therefore, in this review, we focus on bone healing with relation to the impact of NSAIDs.

In this review, we discuss the current data about the anatomy and function of bone tissue with particular regard to influence of prostaglandins. Bone tissue dynamics are characterized by a constant remodeling process that involves all bone tissue cells. The communication between bone component cells and other organs is necessary for bone remodeling equilibrium and confirms the dynamic character of bone tissue. Remodeling is also a vital element of healing processes and in adapting bone tissue to stress responses. Therefore, in our review we present the role and significance of bone cells and signaling pathways enabling maintenance of bone homeostasis and remodeling process stability. Cyclooxygenase (COX) is a crucial enzyme in the production of prostaglandins and thromboxane. We focus on the role of COX isoenzymes with highlighting their connection with bone formation, resorption and repair. Prostaglandins are known as arachidonic acid metabolites acting through specific membrane receptors and play an important role in the regulation of osteoblast and osteoclast functions. Prostaglandin PGE2 with its four defined receptors (EP1R, EP2R, EP3R and EP4R) is crucial to maintain balanced bone turnover. Their stimulatory or inhibitory effects appear to depend on different structure-activity relations and signaling pathways. We have described the role of these receptors in bone metabolism and healing. We conclude that the activity of prostaglandins in bone tissue is defined by maintaining bone remodeling balance and its reactions to humoral mediators and mechanical stress. Most data confirm that among prostaglandins, PGE2 takes part in all processes of trauma response, including homeostasis, inflammation and healing, and plays a key role in bone physiology.

The dominant cause of injuries in traffic crashes. A significant portion of them affects victims under the influence of ethyl alcohol. The goal of the studies was to assess the correlation between the state of sobriety and the severity of injuries expressed by injury severity scales in fatal pedestrian victims of traffic crashes. Research Material and Method: The data were obtained from the Warsaw Medical University's Department of Forensic Medicine. The analysis covered the data for 2009-2013 and included 200 fatal pedestrian victims hit by passenger cars. The assessment of the effect of risk factors on injury severity expressed in terms of injury severity scales such as Life Threat Indicator (LTI), International Classification based Injury Severity Score (ICISS), Injury Severity Score (ISS) and New Injury Severity Score (NISS), was made using adequately selected methods of statistical analysis.As alcohol concentration increases in women, the values of LTI, ICISS-10 and ICISS-15 decrease, which denotes more severe injuries. In the ISS and NISS, the effect of alcohol concentration on the severity of injuries turned out to be negligible. However, these injuries are significantly heavier in women than in men. According to all the scales used, the older the victims, the milder injuries cause their death.The studies show that ethyl alcohol concentration may harm injury severity, especially in the case of women. The assessment of the severity of injuries in traffic crash victims is significantly influenced by their age and gender. The more risk factors the scale takes into consideration, the more precise is the assessment.

IntroductionA substantial percentage of traffic crashes involve people under the influence of ethyl alcohol. In such circumstances, we speak of the possible effect of ethanol upon trauma outcomes. The present research aimed to assess the state of sobriety fatal pedestrian victims and the correlation between the level of sobriety and the severity of injuries.Research material and methodThe data was obtained from the Warsaw Medical University's Department of Forensic Medicine. The analysis covered the data for the period of 2009-2013; it encompassed 158 fatal pedestrian victims hit by passenger cars. The appropriate methods of statistical analysis were applied.ResultsThe majority of the fatal pedestrian victims were individuals under the influence of ethyl alcohol (72.15%). Significant correlations were observed between the concentration of ethyl alcohol and the victims' gender (pConclusionsPedestrians under the influence of ethyl alcohol are a significant group of victims of traffic crashes. Ethyl alcohol is not an independent factor affecting the severity of injuries. A higher percentage of pedestrian victims die on the scene, especially in rural areas.

The aim of this study was to determine the role of resilience and alexithymia in the post-traumatic growth as a response to extreme stress in patients after kidney transplantation and to determine whether there are differences in the level of posttraumatic growth in patients after living and cadaveric donor kidney transplantation. The relationships between these variables were also evaluated. The questionnaire survey of 91 kidney recipients took place in 2018 and 2019. The following tools were used: authorial post-transplant questionnaire for recipients and validated questionnaires, Post Traumatic Growth Inventory (PTGI-R), Resilience Coping Scale Questionnaire, and Toronto Alexithymia Scale Questionnaire (TAS20). The results obtained showed significant differences between the group of kidney recipients from living donors and recipients from cadaveric donors, in terms of overall post-traumatic growth, as well as changes in self-perception and a greater appreciation for life. Post-traumatic growth in both groups was related to the level of resilience and the level of alexithymia. Resilience is an accurate predictor of posttraumatic growth in general and for each of the groups of recipients separately.

The aim of the study was to measure the frequency of such emotional disturbances as anxiety, depression and aggression among patients treated in a pain clinic, as well as assess the factors contributing to such disorders. Research was conducted from January 2014 to April 2018 and involved patients treated in two pain clinics in the city of Warsaw, Poland. The study used the Hospital Anxiety and Depression Scale&mdash, Modified Version (HADS-M) and the Numerical Rating Scale (NSR). 1025 patients were recruited. The main reasons for their attending the pain clinic were osteoarticular pain (43.61%) and neuropathic pain (41.56%). Emotional disturbances in the form of anxiety were diagnosed in 32.39% of all the patients, depression in 17.85%, and aggression in 46.15%. The factors determining the level of anxiety in the study group were: sex, age, pain intensity and the lack of pharmacological treatment. Depression was determined by sex, pain intensity and the time of treatment in the clinic, while aggression by age and pain intensity.

Introduction. Chronic pelvic pain syndrome occurs in 4–14% of women. Pain pathomechanism in this syndrome is complex, as it is common to observe the features of nociceptive, inflammatory, neuropathic and psychogenic pain. The common findings in women with pelvic pain are endometriosis and pelvic adhesions. Objective. Aim of the study was to test the effectiveness of pharmacological treatment and regional anesthesia techniques for pain control as the next step of treatment after the lack of clinical results of surgical and pharmacological methods normally used in the management of endometriosis and pelvic adhesions. Materials and method. 18 women were treated between January 2010 – October 2013 in the Pain Clinic of the Department of Anaesthesiology and Intensive Care at the Centre for Postgraduate Education in Warsaw due to chronic pelvic pain syndrome related to either endometriosis or pelvic adhesions. During the previous step of management, both conservative and surgical treatments were completed without achieving satisfactory results. Initial constant pain severity was 3–9 points on the Numeric Rating Scale, while the reported paroxysmal pain level was 7–10. The pharmacological treatment implemented was based on oral gabapentinoids and antidepressants, aided by neurolytic block of ganglion of Walther, pudendal nerve blocks and topical treatment (5% lidocaine, 10% amitriptyline, 10% gabapentin). Results. In 17 women, a significant reduction of both constant and paroxysmal pain was achieved, of which complete and permanent cessation of pain occurred in 6 cases. One patient experienced no improvement in the severity of her symptoms. Conclusions. The combination of pain management with pharmacological treatment, pudendal nerve blocks, neurolysis of ganglion impar (Walther) and topical preparations in cases of chronic pelvic pain syndrome seems to be adequate medical conduct after failed or otherwise ineffective causative therapy.

5% lidocaine medicated plasters (5% LMP) have been appointed as a first-line treatment for post-herpetic neuralgia (PHN), while formerly used sympathetic nerve blocks (SNBs) were recently denied their clinical efficacy. The aim of this study was to compare the results of PHN management with the use of SNBs and 5% LMP as a first-line treatment.This study was designed as a retrospective, consecutive, case-series study. Data of 60 consecutive PHN patients with allodynia treated with the use of SNBs and 60 subsequent patients managed with 5% LMP were analyzed. Pain severity after 8 weeks was assessed to recognize the results of the implemented therapy, with numeric rating scale (NRS) score3 or =3 considered a success. Additionally, the number of pain-free patients (NRS=0) after 8 weeks were identified in both groups and compared.The rate of failures in SNBs and 5% LMP group was similar (18.9% vs. 27.1% of poor treatment results, respectively), with the average change in NRS of 5.88 ± 2.41 in nerve blocks and 5.01 ± 1.67 in lidocaine group (p=0.02). Significant difference was also noted in the rates of pain-free patients: 20 patients (34.4%) treated with SNBs and 8 (13.5%) using 5% LMP were pain-free after 8 weeks of treatment.It may be concluded that SNBs may still be considered useful in PHN management, as it appears that in some cases this mode of treatment may offer some advantages over 5% LMP.

Here we report on the use of neurolytic block of ganglion impar (ganglion of Walther) for the management of intractable chronic pelvic pain, which is common enough to be recognized as a problem by gynecologists, likely to be difficult to diagnose and even more challenging to manage. Following failure in controlling the symptoms with pharmacological management, nine women underwent neurolysis of the ganglion impar in our Pain Clinic from 2009 to March 2013. The indication for the procedure was chronic pelvic pain (CPP) of either malignancy-related (4) or other origin (5). The Numeric Rating Scale (NRS) and duration of pain relief were employed to assess effectiveness of the procedure. Neurolysis was efficacious in patients with both malignancy-related CPP and CPP of non-malignant origin. Reported relief time varied from 4 weeks to 3 years, while in 4 cases complete and permanent cessation of pain was achieved. No complications were noted.

BACKGROUND: The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4–L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment. METHODS: Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbar puncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The ‘counting-up’ approach starting with the L5–S1 space was applied. RESULTS: One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences found in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture. CONCLUSIONS: The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.

Biphalin is an opioid peptide analogue that currently is under clinical development as a new type of site-directed analgesic. In rats, the intrathecal (i.t.) analgesic potency of biphalin is 1000-fold greater than morphine. Such a high activity may reflect this compound's activation of three types of opioid receptors (mu, delta and kappa). NMDA receptors also play an important role in nociceptive processing. Therefore, we investigated in rats whether an NMDA antagonist may influence biphalin-induced antinociception. In the present study, ketamine was chosen because of the widespread safe use of this drug in clinical practice. I.t. application of ketamine alone had relatively little analgesic effect and its excitatory effects limited possible doses of the drug. Co-administration of ketamine with biphalin or morphine produced markedly greater antinociception than biphalin or morphine alone in acute, thermal tail flick testing. These results suggest that NMDA antagonists may be useful potentiators of biphalin analgesia. Thus, to obtain the same spinal antinociceptive effect, lower doses of biphalin or morphine are required when ketamine is co-administered.

This study was performed to present the outcomes of trigeminal neuropathy management with the application of neurolytic block of sphenopalatine ganglion. This type of procedure is used in cases where pain is not well controlled with medical treatment. Twenty patients were treated with sphenopalatine ganglion neurolysis after their response to pharmacological management was not satisfactory. Significant pain relief was experienced by all but one patient and they were able to reduce or stop their pain medication. The time of pain relief was between a few months and 9 years during the study period. Number of procedures implemented varied as some of the patients have been under the care of our Pain Clinic for as long as 18 years, satisfied with this type of management and willing to have the procedure repeated if necessary. It appears that neurolytic block of sphenopalatine ganglion is effective enough and may be an option worth further consideration in battling the pain associated with trigeminal neuropathy.

The discovery of numerous endogenous neuropeptides that participate in the formation, transmission, modulation, and perception of pain signals offers numerous strategies for the development of new analgesics. Nevertheless, the same research has not yet replaced opioids as the gold standard of pain treatment. Therefore, one possible avenue of drug development may shift interest from searching for receptor-selective opioids to creating an arsenal of drugs that target multiple opioid and non-opioid sites simultaneously. The presented short review focuses on the development of potential analgesic peptidomimetic compounds based upon opioid neuropeptides and substance P.

Background Aprotinin, a plasmin inhibitor, had been used for reduction of intraoperative bleeding caused by hyperfibrinolysis during extensive surgery. Prophylaxis with aprotinin to limit blood loss during orthotopic liver transplantation (OLT) had been widely applied until the drug was weaned off the therapeutic list for severe complications. We compared the need for blood and blood products transfusion in patients undergoing OLT with and without the use of aprotinin. Materials and Methods A retrospective analysis was performed on 150 patients, who underwent OLT between March 2004 and August 2008 and were divided into 2 groups: the APRO group (n = 111) after induction of anesthesia was given a bolus of 500 kIU of aprotinin in a 30-minutes infusion followed by 140 kIU/h till the end of the OLT in which aprotinin was not administered, and the NON-APRO group (n = 39). Results Patients from the NON-APRO group needed significantly more units of packed red blood cells (PRBC) than the APRO group (5.53 ± 4.89 vs 3.99 ± 3.58 units; P = .037). Avoidance of aprotinin administration (β = 1.408), Child-Pugh score (β = 0.519), and duration of anhepatic phase (β = 0.03) affected the volume of transfused blood according to multiple regression analysis (P Conclusions Our study confirmed the important prophylactic role aprotinin used to have during OLT in limiting the need for blood transfusions. Further research and progress in methods of blood loss minimization and monitoring of hemostasis are needed to warrant safe liver transplantation.

The anatomical landmark which is used to identify the correct level for lumbar puncture is the line connecting both iliac crests. This crosses the vertebra column at the level of the L4-L5 intervertebral space or L4 vertebra. It can be difficult to determine in a group of orthopaedic patients due to chronic orthopaedic disorders, chronic pain, overweight, or difficulties with positioning for lumbar puncture. The objective of this study was to determine if identification of intervertebral space by a physical exam differs from that of an ultrasound assessment.Adult patients scheduled for lower limb surgery under spinal block were enrolled in this study. The intervertebral space suitable for lumbar puncture was determined by physical exam by an anaesthetist in the sitting or lateral position. This was followed by a lumbar ultrasound. Primarily, a transducer was placed in paramedian sagittal view followed by transverse interlaminar view to confirm the identification of the interlaminar spaces. The 'counting-up' approach starting with the L5-1 space was applied.One hundred and twenty two patients (122) were included in this study. Lumbar intervertebral spaces were identified by ultrasound in all cases. There was concordance of intervertebral space identification (between clinical and ultrasound examination) in 78 cases (64%). Mean deviation of inacuracy was one intervertebral space with no statistical difference among cephalad and caudal direction. There were no statistically significant differences fund in terms of demographic data (sex, age, height, weight, or BMI), positioning for lumbar puncture, or intervertebral space chosen for the puncture between the concordant and the nonconcordant identification groups. The only statistically significant difference found was the difference in the years of experience of the anaesthetist performing the clinical assessment and puncture.The concordance rate between clinical examination and using assessment of intervertebral space identification for lumbar puncture is 64% among patients undergoing lower limb surgery. No special parameters were found which could make an anaesthetist aware that a patient is at greater risk of inadequate intervertebral space level assessment. Spinal ultrasound can reduce the incidence of inappropriate lumbar puncture level in orthopaedic patients.

Bleeding due to fibrinolysis is a serious intraoperative complication during orthotopic liver transplantation (OLT). For a number of years aprotinin was used to minimize risk of this complication. This drug was however banned in 2007 and substituted with other antifibrinolytics. The aim of the study was to assess the potential of intraoperative thromboelastometry to evaluate hemostasis and channelize antifibrinolytic therapy.Since ban on aprotinin, 39 patients underwent OLT in our center with no monitoring of fibrinolysis (NMF). Severe disturbances of hemostasis assessed clinically only as a need for blood and blood products transfusion and were treated with transfusion of fresh frozen plasma only. In 2008 we started to use thromboelastometry (ROTEM group, n=39), which allowed for targeted treatment of hyperfibrinolysis with tranexamic acid.The need for blood transfusion in ROTEM group was insignificantly a lower than in NMF group (4.1±4.76 vs 5.53±4.89 units, p=0.2). Patients from ROTEM group required also less plasma transfusions (10.01±7.47 vs 13.15±6.62, p=0.06). Severe fibrinolysis was found in 3 patients from ROTEM group (7.7%) and was treated with tranexamic acid.Thromboelastometry provides an immediate diagnosis of fibrinolysis, justifies implementation of targeted treatment and confirms effectiveness of the therapy. In a larger study group it can also result in significant minimization of blood products transfusion during OLT.

The opioid peptide dimmer biphalin [(Tyr-D-Ala-Gly-Phe-NH-)(2)] has high potency both in vivo and in vitro. Its antinociceptive activity depends on the route of administration: the lowest potency is after subcutaneous, and the highest after intrathecal or inracerebroventricular administration. We tested the analgesic activity of biphalin in a wide range of doses after intrathecal administration to rats. Doses as low as 0.005 nmol produced significant analgesia. Increasing the dose up to 2 nmol elevated and prolonged antinociception without any evident side effects, indicating that biphalin is an extremely potent opioid after intrathecal application with a wide therapeutic window. The highest dose tested (20 nmol) produced full analgesia and body rigidity lasting 2-3 h. After muscle tone returned to normal, antinociception lasted for several more hours. During these studies we observed a correlation between responses to biphalin and catheter placement. Postmortem verification of catheter placement revealed that in those rats in which high-dose biphalin did not produce analgesia or muscle rigidity, the catheter was positioned incorrectly or the flow of drug solution was obstructed. Therefore, a secondary conclusion is that assessment of transient rigidity after administration of a high dose of biphalin may be used as an easy method to confirm intrathecal placement of the catheter.

It is possible that peripheral analgesic targets may enhance central analgesia. We present our preliminary results of selected opioid peptides on morphine (MOR) analgesia. Coinjection of demorphin with MOR resulted in antinociceptive synergy, whereas mophiceptin coinjected wiht MOR yielded antinociceptive activity lower than MOR alone. At lower doses of MOR, DADLE strongly potentiates analgesia, but at higher doses of MOR, DADDLE inhibits the antinociceptive effect of MOR