Answers to questions on reports (section of anesthesiologists-resuscitators)

Dear participants! During the reports of the section of anesthesiologists-resuscitators, many questions have been received, for which we are very grateful! Please see answers below.

Yu.Yu. Kobeliatskyi's answers

1. Ihor Hryzun: "I had an anecdotal case: when using B-block, a patient with cardiac disease (stable BP and severe tachycardia) had a sharp decrease in BP rather than a decrease in HR. What might it be related to?"

This may be due to the presence of latent hypovolemia. It is very important that B-block is titrated considering its clinical effect.

2. Oleksandr: "How long can B-blcok be administered intraoperatively?"

B-block can be administered throughout the entire surgery as a component of general anesthesia with hemodynamic parameter monitoring.

3. Anastasiia: "When should B-block infusion be initiated? Before the intubation? Or when hypertension or tachycardia developed during surgery?"

Yes, it should be initiated before intubation, because based on our experience, B-block well prevents the pressor reaction to this manipulation. If you did not initially administer B-block, and during the surgery, the patient developed severe hypertension, you can use it as an urgent drug to stabilize hemodynamics.

4. Anastasiia: "Should patients at risk be administered with Esmololum during the entire surgery?"

Right. It is in patients at high risk that the benefits of B-block are more pronounced. In general, beta blockers are significantly more effective in patients at high cardiac risk.

5. Oleksandr Ivanovych Tsyfrynets: "Does paracetamol contribute to the occurrence of postoperative hypothermia as an antipyretic drug?"

Intravenous paracetamol does not contribute to the occurrence of postoperative hypothermia. Intermittent intra- and postoperative hypothermia is the result of excessive heat loss during surgery, which is not always considered. Today, paracetamol allows not only to better control pain, increase the effectiveness of anesthesia care but also to optimize the course of the postoperative period, namely to control the inflammatory response manifestations.

6. Serhii Viktorovych Orlov: "Do you suggest premedication with NSAIDs before each surgical intervention, or only for the most traumatic surgeries?"

In my opinion, it is advisable to administer NSAIDs before all interventions, as it allows to reduce the risk of intense pain, control the inflammatory response, activate patients earlier, and create prerequisites for accelerated rehabilitation. This is also important for extensive surgeries, but it may not be sufficient.

7. Unknown: "How can one distinguish between hemorrhagic and ischemic stroke without CT?"

An ischemic stroke can be distinguished from a hemorrhagic one by medical history and clinical and neurological pattern. Note that 85% of all strokes are ischemic.

A.N. Nesterenko

1. Oliana Panchenko: "Levofloxacin is a reserve drug in the treatment of tuberculosis. Is there a risk of MDR-TB increase? Do you exclude tuberculosis before making a prescription?"

I understand your concern, which is formulated in your first question regarding the use of Levofloxacin  – a reserve drug in patients with multidrug-resistant tuberculosis. It is widely known that tuberculosis is one of the most relevant global problems today due to its high prevalence, despite intensive prevention and treatment measures. However, today the whole world is facing a global pandemic of the new coronavirus infection. According to leading specialized international organizations, it is patients suffering from tuberculosis who are one of the most vulnerable groups of the population for COVID-19. Both tuberculosis and the new coronavirus disease COVID-19 affects the lungs, and its symptoms – cough and fever – may resemble tuberculosis.

I am replying to your concern about the risk of multidrug-resistant tuberculosis increasing due to the common use of Levofloxacin. We use Levofloxacin exclusively as an initial empirical antimicrobial therapy drug, usually for 5 days at a dose of 750 mg perday. Further, after receiving the results of sputum and blood tests for pathogenic flora, we switch to targeted antibacterial therapy.

2. Oliana Panchenko: "Do you make any tests to exclude tuberculosis before prescribing Levofloxacin?"

Ms. Oliana, it is the second question you asked me about us making any tests to exclude the presence of tuberculosis in patients with a clinical pattern of viral-bacterial pneumonia before prescribing Levofloxacin.

My answer is: No, usually, routinely, in the context of the COVID-19 epidemic, during the initial empirical antimicrobial therapy of patients with suspected viral-bacterial pneumonia, we do not purposefully make any special laboratory tests for the presence of pulmonary tuberculosis, although we do not exclude the presence of tuberculosis even if this fact is denied by the patient themselves when acquiring the traditional epidemiological history. We will definitely conduct X-ray examinations as soon as possible. Ideally – spiral computed tomography of the chest. This is what our conclusions regarding the localization and nature of pneumonia are based on.

A.E. Domoratskyi

1. Umarkhon Vosidov: "Is it necessary to reduce BP 200sys and higher in patients with acute cerebrovascular events (ACVE)? As there are disputes about magnesia therapy in ICU?"

In the case of ischemic ACVE, aggressive reduction of BP is not recommended if it is within 200sys; in the case of thrombolysis, the maximum permissible BP is 180sys. We try to allow maximum BP of 180sys, with thrombolysis – 160sys. From my point of view, magnesia therapy is good, because magnesium is an antagonist of NMDA receptors; 30–40ml of 25% magnesia per day is used.

2. Umarkhon Vosidov: "Why is there no recommendation for administration of NLA by using IM Fentanyl-Droperidol in preoperative preparation?"

In Ukraine, Droperidol and, consequently, NLA have not been used for a very long time. This is due to the false feeling of calm after Droperidol, possible induction of arrhythmias, prolongation of opioids action (we remember that this used to be considered a good effect).

3. Oleksii: "Why is B-block better than Ebrantil?"

B-block and Ebrantil are drugs of different groups and different application points; therefore, we believe, it is not quite correct to compare them. B-block is attracting the authors with the rate of response and manageability in comparison with any drug, including Urapidil.

4. Olena: "What are the peculiarities of providing assistance to a patient suffering from the hypertensive crisis with renal insufficiency. Thank you".

HC patients with renal failure are treated with sodium Nitroprusside, Urapidil, Labetalol, Furosemide. Any beta blockers, including Esmololum, are contraindicated. There are recommendations for the level of BP depending on the level of creatinine for patients suffering from CRF (in short, within the creatinine range of 0.2 to 0.8, BP is allowed to reach 180–190sys; at higher creatinine values, any BP reduction is dangerous). We believe the range of 0.2 to 0.8 is too high; therefore, such patients should be kept within BP 160sys.

5. Natalia: "What dose is effective for high BP during surgery?"

According to the instructions, the effective dose of B-block during surgery is 1 mg/kg bolus, but not more than 80 mg. Then infusion at 150–300 µg/kg/min initially, followed by titration depending on the effect. Remember that correction of intraoperative hypertension with Esmololum is only performed if insufficient or surface anesthesia is excluded.

M.N. Pylypenko/ O.Y. Khomenko

1. Rostyslav: "What is your opinion on the use of Pregabalin? Thank you".

It is crucial in pain medicine and is gaining its niche in multimodal anesthesia. As a component of analgosedation and adaptation to mechanical ventilation in ICU, it requires further investigations to draw any conclusions.

2. Oleksandr Larionovych Marchenkov: "What criteria should be guided by when weaning a patient from a ventilator?"

First of all, 1) recovery from the underlying disease that was complicated by RD and required mechanical ventilation; 2) the ability of the pulmonary parenchyma to provide acceptable gas exchange (there are no generally recognized criteria, but PaO2/FiO2> 200 is often mentioned); 3) the ability of the respiratory muscles to overcome the elastic resistance of the lung-chest system and the resistance of the respiratory tract.

3. Oleksii Boduliev: "Does dexmedetomidine reduce respiratory drive?"

Yes, it does both due to sedative and analgesic components, but to a lesser extent than Propofol, Thiopental, and narcotic analgesics.

4. Serhii Sadoma: "MLP mode during mechanical ventilation? What are the advantages and disadvantages?"

Dear Serhii, would you explain what MLP means? Neither we nor Google knows this. In general, I would like to emphasize once again that it is ventilation parameters that can be achieved that matters rather than the choice of mode.