Introduction. The hemodynamic parameters during the Nuss procedure for repair of pectus excavatum are under the influence of surgical procedures and anesthetic components especially regional blocks. The aim of the study: analysing the hemodynamic parameters during the Nuss procedure for repair of pectus excavatum under the combination of general anesthesia with different regional analgesia techniques. Materials and methods. The observative prospective study inclueded 60 adolescents (boys/girls=47/13) undergone the Nuss procedure for repair of pectus excavatum under the combination of general anesthesia with different types of regional blocks. The patients were randomized into three groups (n=20 in each) according to the regional analgesia technique: standart epidural anaesthesia in the dermatome of maximal deformity (SEA), high epidural anaesthesia in Th2-Th3 level (HEA) and bilateral paravertebral anaesthesia (PVA). The deformity severity by Haller index in all patients was 3.9 [3.6–4.1]. The blood pressure (BP) and heart rate (HR) were analyzed at different stages of anesthesia and surgery. Results. SEA resulted to significant derease in BP up to 30% compared to initial level before anesthesia. In the HEA group the decrease in BP was moderate and in PVA group the BP did not decrease at all. The sternal elevation and applying capnothorax increased BP without increasing HR. The bar rotation provided a little hemodynamic change in spite of being the most traumatic moment of such surgery. Under PVA HR was moderately increased but BP was almost unchanged, and the intraoperative infusion volume was the smallest in PVA group. HEA provided more stable hemodynamics in comparison to SEA. At the end of surgery hemodynamic parameters almost the same as initial before surgery. Conclusions. During the Nuss procedure for pectus excavatum repair the blood pressure decreased significantly under the standart epidural anaesthesia in the dermatome of maximal deformity, moderately – under the high epidural anaesthesia in Th2-Th3 level and was stable under the bilateral paravertebral anaesthesia. HR decreased under epidural blocks but not under PVA. The sternal elevation and applying capnothorax increased BP. The initial hemodynamic parameters before surgery did not correlate with the severity of deformity according to the Haller index. The study was conducted in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the institution. Informed consent of parents and children was obtained for the study. The author declares no conflict of interest. Key words: hemodynamics, pectus excavatum, Nuss procedure, epidural anaesthesia, paravertebral anaesthesia.

Introduction. The anesthesiologic management of bar removal after the Nuss procedure for repair of pectus excavatum is not clearly discussed in literature. The aim of the study: analysing the anesthetic technique of bar removal after the Nuss procedure for repair of pectus excavatum. Materials and methods. The prospective randomized study included 24 adolescents undergone the bar removal after the Nuss procedure for repair of pectus excavatum under general anesthesia with tracheal intubation and artificial lung ventilation. The patients were randomized into two groups according to the analgesia technique: in group PVA (n=14) bilateral paravertebral anaesthesia was used and in group G (n=10) fentanyl was used intraoperatively and ketoprophen – postoperatively. Intravenous induction: propofol 2–3 mg/kg, fentanyl 3–4 mcg/kg, atracurium 0.6 mg/kg. The maintenance of anesthesia: propofol 6–10 mg/kg/h, fentanyl 2 mcg/kg as needed. The following parameters were analyzed: blood pressure systolic (BPs), diastolic (BPd), mean (BPm), pulse rate (PR) and pain intensity using visual analogue scale (VAS). Results: The changes in hemodynamic parameters during surgery and anesthesia were statistically significant (p<0.05), but the hemodynamics was clinically stable. BP and PR were more decreased during anesthesia in group PVA than in group G. Anesthesia was adequate in both groups. There was no need in additional fentanyl bolus after the induction dose in PVA group. Patients in G group needed additional 200 mcg fentanyl during surgery. After surgery the pain intensity was significantly higher in group G than in group PVA: at recovery from anesthesia and extubation of trachea in group PVA – 0 (0–1), in group G – 3 (2–4) (U=1.5; р=0.000002); in the evening of the day of surgery in group PVA – 1 (0–1); in group G – 3 (2–3) (U=6.0; р=0.000031); in the next morning after surgery in group PVA – 0 (0-0); in group G – 1.5 (1–2) (U=12.0; р=0.00027) cm according to VAS. There was no patient with pain intensity higher than 3 cm, so all patients had adequate analgesia. Conclusion. Bilateral paravertebral anesthesia provides more adequate analgesia than systemic administration of analgesics perioperatively for bar removal after the Nuss procedure for pectus excavatum correction. The study was conducted in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the institution. Informed consent of parents and children was obtained for the study. The author declares no conflict of interest. Key words: anesthesia, paravertebral block, pectus excavatum, Nuss procedure, bar removal.

The ventilation parameters during the Nuss procedure for repair of pectus excavatum depend on surgical procedures and airway protection technique. The aim of the study: analyzing the ventilation parameters during the Nuss procedure for repair of pectus excavatum according to the airway protection technique. Material and Methods. The observational prospective study included 60 adolescents (boys/girls=47/13) who had undergone the Nuss procedure for repair of pectus excavatum under a combination of general anesthesia with different types of regional blocks. The patients were randomized into two groups (n=20 in each) according to the airway protection technique: Group S (n=32) where the patients were intubated with a standard single-lumen tube, and capnothorax with 4-6 mmHg intrapleural pressure was applied; Group D (n=28) where the patients were intubated with a double-lumen tube, and open pneumothorax was applied without additional pressure in the thoracic cavity. All patients were ventilated using PCV with changing of the parameters in relevance with EtCO2. The following parameters were analyzed: peripheral blood saturation (SpO2), inspiratory fractional oxygen concentration (FiO2), end-tidal carbon dioxide partial pressure (EtCO2), tidal volume (Tv), peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP), the number of repeated intubation attempts, and the quality of operation field visualization checked by surgeon with a 5-point scale. Results and Discussion. During capno/pneumothorax and bar rotation, in both groups SpO2 decreased up to 95%, which required increasing FiO2 up to 70% in Group D, and up to 63% in Group S (р=0.04). Applying capno/pneumothorax lead to reduced Tv, which was 52 ml less in Group D than in Group S (р=0.0001). The levels of EtCO2, PIP, and PEEP were comparable in both groups at all stages of the surgery. The number of repeated intubation attempts was- 1 case (3,1%) in group S, and 2 cases (7,1%) in group D: c2 = 0,51; p=0.48, the adjusted c22 = 3.84 for p <0.05. The quality of operation field visualization evaluated by the surgeons with the 5-point scale was better in Group D (4.5 points), than in Group S - 3 points (р<0.000001) at all stages. Conclusions. The one-lung ventilation using double-lumen left-side tube provides better operating field visualization than ventilation throw single-lumen tube with capnothorax. Both techniques supply adequate ventilation and oxygenation parameters. Key words: tracheal intubation, ventilation, pectus excavatum, Nuss procedure

The aim of the study was to analyze cardiac function during Nuss procedure under the combination of general anesthesia with different variants of the regional block. Materials and methods: The observative prospective study included 60 adolescents (boys/girls=47/13) undergone Nuss procedure for pectus excavatum correction under the combination of general anaesthesia and regional blocks. The patients were randomized into three groups (n=20 in each) according to the perioperative regional analgesia technique: standart epidural anaesthesia (SEA), high epidural anaesthesia (HEA) and bilateral paravertebral anaesthesia (PVA). The following parameters of cardiac function were analyzed: heart rate, estimated cardiac output (esCCO), cardiac index (esCCI), stroke volume (esSV) and stroke volume index (esSVI) using non-invasive monitoring. Results: Induction of anesthesia and regional blocks led to a significant decrease in esCCO (-9.4%) and esCCI (-9.8%), while esSV and esSVI remained almost unchanged in all groups (H=4.9; p=0.09). At this stage, the decrease in cardiac output was mainly due to decreased heart rate. At the stage of sternal elevation we found an increase in esSV, which was more pronounced in the groups of epidural blocks (+23.1% in HEA and +18.5% in SEA). After awakening from anesthesia and tracheal extubation esSV was by 11% higher than before surgery without ingergroup difference. Conclusions: The Nuss procedure for pectus excavatum correction lead to improved cardiac function. increase in stroke volume and its index were more informative than cardiac output and cardiac index which are dependent on heart rate that is under the influence of anaesthesia technique.

The perioperative stress-response is a dynamic process under the influence of patient-specific, surgical and anaesthesiologic factors. Purpose – to evaluate stress response during the correction of pectus excavatum by Nuss under the combination of general anesthesia with different variants of the regional block. Materials and methods. The observative prospective study included 60 adolescents (boys/girls=47/13) undergone Nuss procedure under the combination of general anesthesia and regional blocks. The patients were randomized into three groups (n=20 in each) according to the perioperative regional analgesia technique: standard epidural anesthesia (SEA) in Th5–Th8, high epidural anesthesia (HEA) in Th2–Th3, and bilateral paravertebral anesthesia (PVA) in Th5–Th8. The serum cortisol and glycemia were analyzed at three stages: 1 – baseline before surgery, 2 – during bar rotation, and 3 – after surgery finished. Results. The average serum cortisol level among all patients before surgery was 342.4 [282.1–415.0] nmol/L. At stage 2 the plasma cortisol decreased up to 223.1 [174.9–282.3] nmol/L (p<0.000001). After the surgery and anesthesia finished the average plasma cortisol was 279.6 [216.7–312.6] nmol/L (p<0.000001 vs baseline). During surgery serum cortisol decreased in group SEA by 41%, in group HEA – by 30%, and in group PVA – by 31% compared with baseline levels. After surgery, the serum cortisol was lower than baseline measurements in group SEA by 28%, in group HEA – by 20%, and in group PVA – by 26%. The average baseline glycemia among all patients before surgery was 4.62 [4.01–5.05] mmol/L. At stage 2 glycemia decreased significantly up to 4.05 [3.86–4.62] mmol/L (p=0.00018). After the surgery finished the average serum glucose among all patients was 4.24 [4.09–4.99] mmol/L (p=0.7). At stage 2 serum glucose decreased in group SEA by 11%, in groups HEA and PVA – by 5% compared with the baseline level. The dynamics of serum cortisol and glycemia were similar in all groups with statistically insignificant intergroup differences at all three stages. Conclusions. Serum cortisol and glycemia during the Nuss procedure under the combination of general anesthesia with regional blocks decreased significantly. After surgery finished glycemia returned to baseline level, but serum cortisol was lower than baseline measurement. The changes in serum cortisol and glycemia were more pronounced in patients under standard epidural analgesia in Th5–Th8 compared with the high epidural in Th2–Th3 and paravertebral blocks. The study was conducted in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the institution. Informed consent of parents and children was obtained for the study. The author declares no conflict of interest. Key words: cortisol, glycaemia, pectus excavatum, Nuss procedure, regional anaesthesia.