I.I. Lisnyy

Background. Early postoperative cognitive decline may interfere with mobilisation of a patient, and rehabilitation recommendations after orthopaedic surgery on the upper limb. The aim of the study was to assess early postoperative cognitive dynamics, pain, sleep quality, stress response, neuron-specific enolase (NSE) and haemodynamics. Materials and methods. A prospective clinical analysis included 45 adult patients who underwent elective orthopaedic surgery on the upper limb under combined anaesthesia with propofol, fentanyl and a regional component. Cognitive function was assessed before surgery and on postoperative days 1, 3 and 7 using Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination, Frontal Assessment Battery, Trail Making Test, Part B (TMT-B) and Symbol Digit Modalities Test (SDMT). Additionally, the following parameters were analysed: pain intensity, sleep quality — by the Richards-Campbell Sleep Questionnaire (RCSQ), glucose, cortisol, NSE and haemodynamic variables. Friedman test, Wilcoxon test with Holm correction, Kendall’s W and Spearman’s ρ were used. Results. On postoperative day 1, all cognitive tests showed unidirectional deterioration. The greatest changes were observed in SDMT and TMT-B: SDMT decreased by 7.38 points, and TMT-B completion time increased by 19.53 s compared with the preoperative level (p < 0.001). The largest effect sizes were found for SDMT (Kendall’s W = 0.797) and TMT-B (W = 0.625). Clinically significant deterioration for SDMT on day 1 was recorded in 77.8 % of patients and in 48.9 % for TMT-B. On day 3, cognitive performance partially recovered; by day 7, MoCA and TMT-B no longer differed statistically from baseline. Sleep quality showed the greatest decrease on day 1, with RCSQ reduced by 18.49 mm (p < 0.001). Worsening of RCSQ was associated with deterioration in TMT-B (ρ = 0.551; Holm-adjusted p = 0.0016). Intraoperative cortisol increase was also associated with TMT-B deterioration (ρ = 0.440; Holm-adjusted p = 0.043). Haemodynamics remained stable, rescue morphine requirement was low (4.4 %), and no persistent association between NSE dynamics and cognitive tests was found. Conclusions. Combined anaesthesia for orthopaedic surgery on the upper limb was accompanied by early transient cognitive decline. SDMT and TMT-B were the most sensitive tests. Cortisol increase and reduced sleep quality were associated with deterioration in TMT-B.

BACKGROUND. Bone metastases represent the most common site of progression in advanced prostate cancer and are frequently associated with severe chronic pain. Conventional pharmacological treatment often fails to achieve adequate pain control. OBJECTIVE. To evaluate the efficacy and safety of minimally invasive interventional pain management techniques in patients with prostate cancer and bone metastases. MATERIALS AND METHODS. A retrospective non-randomized clinical study included 411 patients with prostate cancer and bone metastases treated at the National Cancer Institute of Ukraine between 2010 and 2020. Patients were divided into three groups depending on the analgesic strategy: systemic therapy, regional interventional procedures, and neuroablative interventions. Pain intensity was assessed using the Visual Analogue Scale (VAS), and functional status was evaluated using the Karnofsky Performance Status scale. RESULTS. The most significant reduction in pain intensity was observed in the neuroablative treatment group. After 6 months, clinically significant pain reduction (VAS ≥50%) was achieved in 81.3% of patients in this group, compared with 66.4% in the regional intervention group and 38.5% in the systemic therapy group (p<0.001). CONCLUSIONS. Minimally invasive interventional techniques provide significantly better pain control compared with systemic analgesic therapy and represent an important component of multimodal pain management in patients with metastatic prostate cancer.

Background. Lung resection procedures performed via a conventional thoracotomy are associated with substantial surgical trauma and pronounced postoperative pain. Providing adequate perioperative analgesia for such interventions remains a significant challenge for anesthesiologists. In thoracic surgery, the use of regional analgesia techniques is considered appropriate. The erector spinae plane (ESP) block is a relatively novel regional analgesia technique, the effectiveness of which — particularly in thoracic surgery — requires further investigation. The purpose is to evaluate the effectiveness of the ESP block for analgesia in lung resection surgery performed via a conventional thoracotomy, in comparison with thoracic epidural analgesia (TEA) and analgesia without regional techniques. Materials and methods. A prospective randomized controlled study was conducted involving 131 patients undergoing lung resection. They were randomly assigned to three groups: group A — TEA, group B — ESP block, and group C — no regional analgesia (controls). Pain intensity was assessed using the visual analog scale at rest and during deep inspiration; sleep quality was evaluated using a five-point scale over the first three postoperative days. Markers of stress response (glucose and cortisol) were measured intraoperatively and postoperatively, and cumulative postoperative morphine consumption was recorded. Results. Postoperative pain intensity was significantly lower in the TEA and ESP block groups compared to the control one. Levels of stress-response markers did not differ significantly between groups. Sleep quality was superior in the TEA group on the third postoperative day. Postoperative morphine requirements were lower in the TEA and ESP block groups than in the group without regional analgesia. Conclusions. The ESP block is an effective component of perioperative analgesia for thoracic surgery and may be considered an alternative regional analgesia technique in patients with contraindications to thoracic epidural analgesia.

Background. Pain syndrome due to thoracotomy is one of the most intense in surgery. Thoracic epidural anesthesia (TEA) is considered to be the “gold standard” of regional anesthesia for thoracic operations. Technical difficulties in applying this method can be a problem for the anesthesiologist. Goal of the study was to identify and analyze the difficulties associated with the use of TEA in thoracic surgery, to determine the percentage of effective use of TEA in the postoperative period. Materials and methods. Over a 10-month period, attempts to place an epidural catheter for analgesia of various thoracic operations were registered at the National Cancer Institute (a total of 204 patients during the observation period). During the study, the technical characteristics of the manipulation (level, patient position, duration of the procedure) were noted and the success of the attempts and the effectiveness of TEA for postoperative analgesia were evaluated, as well as the dependence of these results on the experience of the anesthesiologist performing the manipulation. Results. It was determined that out of 204 attempts to place an epidural catheter, 43 (21 %) were unsuccessful. The success of manipulation depended directly on the experience of the anesthesiologist who performed it: the lowest percentage of failures (9.3 %) was in doctors who had experience in thoracic surgery of more than 10 years, and the highest (35.9 %) was in residents. The effectiveness of postoperative analgesia in thoracic patients provided with TEA was also assessed — in 28 out of 161 patients (17.4 %), the analgesia was ineffective or insufficiently effective. The effectiveness of TEA in thoracic and gastric surgery did not differ significantly. The use of TEA was not associated with a large number of complications (6.4 %) and they were not life-threatening. Conclusions. TEA is a recognized effective method of regional anesthesia for thoracic operations, which is at the same time technically difficult to perform and has a fairly high failure rate. The success of TEA largely depends on the experience of the doctor performing the manipulation. Also, even in case of successful placement of an epidural catheter, TEA is not always effective.

Background. Extended epidural analgesia is widely used for postoperative pain control in oncological surgery. However, prolonged catheterization carries a risk of microbial colonization and infectious complications. In cancer patients, these risks are exacerbated by immunosuppression and impaired skin barrier function, underscoring the need to study the microbial spectrum and clinical implications of catheter colonization. Objective: to determine the frequency of bacterial colonization of epidural catheters, the spectrum of isolated microorganisms, and the clinical significance of these findings in patients undergoing oncological surgery. Materials and methods. A prospective study was conducted involving 51 patients who underwent prolonged epidural analgesia after oncological surgery. Demographic characteristics, somatic status, catheterization duration, incidence of infectious complications, and microbial culture results from catheter tips were analyzed. Statistical methods included descriptive analysis, Pearson’s test, Mann-Whitney U test, logistic regression, and Spearman correlation. Results. Positive cultures were found in 41.18 % of patients, with Staphylococcus epidermidis being the most common isolate. Clinical signs of infection were absent in 98 % of cases. No clinical-demographic variable showed a statistically significant association with colonization (p > 0.05), although body mass index had the strongest (nonsignificant) inverse correlation ( = –0.223). Colonization rates increased after more than 72 hours of catheterization. Conclusions. Epidural catheter colonization is common among cancer patients but rarely leads to clinically significant infections. Adherence to aseptic techniques and regular monitoring allow for the safe use of prolonged analgesia. Further research is needed to determine the optimal duration of catheterization and effective prevention strategies.

Background. Workplace-based assessment (WPBA) is a new technology for evaluating medical residents that is believed to be more effective than traditional multiple-choice tests or exam-based assessment methods. The aim of the study was to investigate the WPBA efficacy in final-year medical residents: multi-source feedback (360°) assessment, direct procedure assessment (Anaesthesia-Clinical Evaluation Exercise (A-CEX)) and clinical case-based assessment, and to identify difficult competencies, which graduate residents acquire the least successfully. Materials and methods. From April 1 to June 15, 2023, 36 residents were evaluated at the workplace: the multi-source feedback 360°-evaluation form was filled out by three representatives of the medical team where the resident worked during the on-site part of the residency (1 anesthesiologist, 1 nurse and 1 other specialist); the form of direct procedure assessment was filled out by the teacher on face-to-face bases directly during the resident’s performance of the general anesthesia in low-risk patients (American Society of Anesthesiologists (ASA) I or II), preoperative examination of low-risk patients (ASA I or II) and neuraxial anesthesia in low-risk patients (ASA I or II) with the following feedback; assessment based on a clinical case was carried out by teachers during the conference of residents, where each of them presented a clinical case of anesthetic management or treatment of a critically ill patient. Results. According to the results of the multi-source feedback (360°) evaluation, most of the residents have received 7 or more points out of 10 possible. Communication with the medical team (odds ratio (OR) 1.9 [1.05–3.5], p = 0.048) and management in a critical situation (OR 2 [1.14–3.83], p = 0.024) were most difficult competencies during the multi-source feedback (360°) assessment. During direct procedure of general anesthesia, the most difficult competencies were: 1) management in a critical situation — knowledge/recognition of risks and how to avoid and treat them (OR 5.29 [1.9–14.4], p = 0.001 compared to documentation); 2) solving problems, making decisions (OR 12.6 [1.5–10,4], p = 0.007 compared to documentation); 3) interaction in the team (OR 2.7 [1.1–6.5], p = 0.049). No problematic competencies were identified during the assessment of neuraxial anesthesia competencies and preoperative examination. Conclusions. WPBA techniques such as multi-source feedback (360°) assessment, direct procedure evaluation (A-CEX) and clinical case-based assessment are effective in final year residents, improving their communication skills, readiness to work independently, help identify skill deficiencies. Communication with the medical team and management in a critical situation were difficult competencies during the multi-source feedback (360°) evaluation. Difficult competences during the direct evaluation of general anesthesia turned out to be the management in a critical situation; solving problems, making decisions; interaction in the team. No problematic competencies were identified during the assessment of neuraxial anesthesia competencies and preoperative examination.