Andrea Fanelli

The effects of ultrasound guidance and neurostimulation on the minimum effective anesthetic volume of mepivacaine 1.5% required to block the sciatic nerve using the subgluteal approach.

BACKGROUND: We tested the hypothesis that ultrasound (US) guidance may reduce the minimum effective anesthetic volume (MEAV50) of 1.5% mepivacaine required to block the sciatic nerve with a subgluteal approach compared with neurostimulation (NS). METHODS: After premedication and single-injection femoral nerve block, 60 patients undergoing knee arthroscopy were randomly allocated to receive a sciatic nerve block with either NS (n = 30) or US (n = 30). In the US group, the sciatic nerve was localized between the ischial tuberosity and the greater trochanter. In the NS group, the appropriate muscular response (foot plantar flexion or inversion) was elicited (1.5 mA, 2 Hz, 0.1 ms) and maintained to ≤0.5 mA. The volume of the injected local anesthetic was varied for consecutive patients based on an up-and-down method, according to the response of the previous patient. The initial volume was 12 mL. An independent observer evaluated the occurrence of complete loss of pinprick sensation and motor block: positive or negative responses within 20 min after the injection determined a 2-mL decrease or increase for the next patient, respectively. RESULTS: The mean MEAV50 for sciatic nerve block was 12 mL (95% confidence interval [CI], 10–23 mL) in Group US and 19 mL (95% CI, 15–23 mL) in Group NS (P < 0.001). The effective dose in 95% of cases was 14 mL (95% CI, 12–17 mL) in Group US and 29 mL (95% CI, 25–40 mL) in Group NS (P = 0.008). CONCLUSIONS: US provided a 37% reduction in the MEAV50 of 1.5% mepivacaine required to block the sciatic nerve compared with NS.

The Efficacy of a Resistive Heating Under-Patient Blanket Versus a Forced-Air Warming System: A Randomized Controlled Trial

BACKGROUND: We compared temperature changes in patients undergoing hip replacement during warming with a resistive heating blanket or air-forced system. METHODS: Fifty-six patients were enrolled. Patients were randomly allocated to the “forced-air group” (forced-air system) or to the “heating-blanket group” (resistive heating under-patient blanket). RESULTS: Baseline tympanic temperatures were 36.0 ± 0.6°C in the forced-air group and 36.1 ± 0.4°C in the heating-blanket group (P > 0.05). At the end of surgery tympanic temperatures were 35.3 ± 0.5°C in the forced-air group and 35.1 ± 0.6°C in the heating-pad group (P > 0.05). CONCLUSIONS: We demonstrated that, using either a resistive heating-blanket or forced-air warming systems, patients ended surgery in mild hypothermia after elective total hip replacement, but without significant differences between these two warming devices.

Intrathecal 2-chloroprocaine for lower limb outpatient surgery: a prospective, randomized, double-blind, clinical evaluation.

We evaluated the dose-response relationship of 2-chloroprocaine for lower limb outpatient procedure in 45 ASA physical status I-II outpatients undergoing elective lower limb surgery under spinal anesthesia, with 30 mg (group Chlor-30, n = 15), 40 mg (group Chlor-40, n = 15), or 50 mg (group Chlor-50, n = 15) of 1% preservative free 2-chloroprocaine. Onset time was similar in the three groups. General anesthesia was never required to complete surgery. Intraoperative analgesic supplementation as a result of insufficient duration of spinal block was required in 5 patients of group Chlor-30 (35%) and 2 patients of group Chlor-40 (13%) (P = 0.014), with a median (range) time for supplementation request of 40 (30–60) min. Spinal block resolution and recovery of ambulation were faster in group Chlor-30 (60 [41–98] min and 85 [45–123] min) than in groups Chlor-40 (85 [46–141] min and 180 [72–281] min) and Chlor-50 (97 [60–169] min and 185 [90–355] min) (P = 0.001 and P = 0.003, respectively), with no differences in home discharge time (182 [120–267] min in group Chlor-30, 198 [123–271] min in group Chlor-40, and 203 [102–394] min in group Chlor-50; P = 0.155). No transient neurologic symptoms were reported at 24-h and 7-day follow-up. We conclude that although 40 and 50 mg of 2-chloroprocaine provide adequate spinal anesthesia for outpatient procedures lasting 45–60 min, 30 mg produces a spinal block of insufficient duration.

Does continuous sciatic nerve block improve postoperative analgesia and early rehabilitation after total knee arthroplasty?: A prospective, randomized, double-blinded study

Introduction: The aim of this prospective, randomized, double-blind study was to evaluate whether continuous sciatic nerve block can improve postoperative pain relief and early rehabilitation compared with single-injection sciatic nerve block in patients undergoing total knee arthroplasty (TKA) and lumbar plexus block. Methods: After ethical committee approval and written informed consent, 38 patients with ASA physical status I to II were enrolled. The first group received continuous sciatic and continuous lumbar plexus blocks (group regional or R, n = 19), whereas the second group received a single sciatic nerve block followed by saline infusion through the sciatic catheter and continuous lumbar plexus block (group control or C, n = 19). We assessed morphine consumption, scores for visual analog scale for pain at rest (VASr), and during continuous passive motion (VASi during CPM) for 48 hours postoperatively. Effectiveness of early ambulation was also evaluated. Results: Scores for VASr and VASi during CPM, as well as morphine consumption, were significantly higher in group C than in group R (P < 0.01). Moreover, patients in group R showed earlier rehabilitation with more effective ambulation (P < 0.05). Conclusions: Continuous sciatic nerve block improves analgesia, decreases morphine request, and improves early rehabilitation compared with single-injection sciatic nerve block in patients undergoing TKA and lumbar plexus block.

A Prospective, Double-blinded, Randomized, Clinical Trial Comparing the Efficacy of 40 Mg and 60 Mg Hyperbaric 2% Prilocaine Versus 60 Mg Plain 2% Prilocaine for Intrathecal Anesthesia in Ambulatory Surgery

BACKGROUND: In this prospective, double-blind, randomized trial we compared 60 mg and 40 mg of 2% hyperbaric prilocaine with 60 mg of 2% plain prilocaine for spinal anesthesia in terms of sensory block onset in outpatients undergoing elective short-duration (<60 minutes) surgery under spinal anesthesia. METHODS: Ninety patients were enrolled and randomly allocated to receive 1 of the 3 treatments. Times to sensory and motor block onsets, time to the maximum sensory block level, readiness for surgery, time to first urinary voiding, time to Bromages score 0, and side effects were registered blindly. A blinded observer also questioned patients about transient neurological symptoms 24 hours and 7 days after spinal anesthesia. RESULTS: Mean times to achieve a T10 level of sensory block were comparable in the 3 groups. However, 20% of patients receiving plain prilocaine did not achieve a T10 level. The 2 hyperbaric dosages (60 mg and 40 mg) showed significantly faster times to motor block onset (P = 0.0091, P = 0.0097), to the maximum sensory block level (P = 0.0297, P = 0.0183), to motor block offset (P = 0.0004, P < 0.0001), and to first urinary voiding (P = 0.0013, P = 0.0002, respectively) than did plain prilocaine. No major adverse reactions or transient neurological symptoms were observed in the study. CONCLUSIONS: Spinal anesthesia with 60 mg or 40 mg of 2% hyperbaric prilocaine is comparable to 60 mg of 2% plain prilocaine in terms of onset of sensory block at T10. The hyperbaric solution showed faster times to motor block onset and shorter duration of surgical block, suggesting its superiority for the ambulatory setting.

Cardiovascular and cerebrovascular risk with nonsteroidal anti-inflammatory drugs and cyclooxygenase 2 inhibitors: latest evidence and clinical implications:

Observational studies and meta-analyses have shown that the administration of nonsteroidal anti-inflammatory drugs (NSAIDs), especially when prescribed at high doses for long periods of time, can potentially increase the risk of cardiovascular diseases. The increased thrombotic risk related to the use of NSAIDs is mainly due to their cyclooxygenase 2 selectivity. The dosage use, the formulation selected and the duration of the therapy are other factors that can significantly impact on the cardiovascular risk. In order to minimize the risk, prescription of the right drug based on the patient’s features and the different safety profiles of several NSAIDs that are available on the market is key for their appropriate administration. Despite the baseline cardiovascular and gastrointestinal risk of each patient, monitoring of patients is suggested for increases in blood pressure, development of edema, deterioration of renal function, or gastrointestinal bleeding during long-term treatment with NSAIDs.

Transversus Abdominis Plane Block for Postoperative Analgesia in Patients Undergoing Total Laparoscopic Hysterectomy: A Randomized, Controlled, Observer-Blinded Trial.

BACKGROUND:In this randomized, controlled, observer-blinded study, we evaluated analgesia provided by transversus abdominis plane (TAP) block after elective total laparoscopic hysterectomy in terms of reduced postoperative morphine consumption as the primary end point. METHODS:Fifty-two patients were randomly divided into 2 groups: patients in group T (TAP, n = 26) received an ultrasound-guided bilateral TAP block with 40 mL of 0.375% levobupivacaine and morphine patient-controlled analgesia, whereas patients in group C (control, n = 26) received morphine patient-controlled analgesia. Secondary outcomes included pain measurements (Numeric Rating Scale from 0 to 10) during the first 24 hours postoperatively, times to postanesthesia care unit discharge, times to surgical ward discharge, incidence of postoperative nausea and vomiting, functional capacity measurements in terms of 2-minute walking test, and first oral solid intake. RESULTS:Demographic and anthropometric variables were similar in the 2 groups. The total dose of morphine consumed by patients during postanesthesia care unit stay was 6 (0–8) mg in group T vs 8 (5.5–8.5) mg in group C (P = 0.154). Postoperative morphine consumption during the first 24 hours was 10.55 ± 10.24 mg in group C vs 10.73 ± 13.45 mg in group T (P = 0.950). The 95% confidence interval of the difference between means of 24-hour morphine consumption was −7.45 to +7.09. The 2 groups were comparable. There were no significant differences in secondary outcome variables between groups. CONCLUSIONS:TAP block did not reduce morphine consumption during the first postoperative 24 hours after elective total laparoscopic hysterectomy.

Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach

ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of “multimodal” and “multidisciplinary” approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of “outcome” may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards “protective” techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.

Periprocedural management of rivaroxaban-treated patients

Introduction: The increasing and widespread use of direct oral anticoagulants (DOACs) demands guidelines and experts’ consensus for their rational and safe use, especially in certain situations for which there is no evidence-based consensus, such as the periprocedural setting. Rivaroxaban is an oral factor Xa inhibitor approved for stroke prevention in atrial fibrillation (AF) and for treatment and prevention of venous thromboembolism (VTE) in major orthopedic surgery. This article is addressed to all the clinicians involved in the periprocedural approach of patients treated with rivaroxaban, with the aim to give practical recommendations to improve patients’ management during and after surgery. Areas covered: This article is based on a consensus of specialists involved in anticoagulant treatment and in periprocedural setting, including experts in thrombosis, cardiologists, internists, clinical pathologists and anesthesiologists. The authors performed a review of the literature and expressed statements based on the results of the review as well as on personal experience. Expert opinion: Rivaroxaban is a safe and effective drug that simplifies management of anticoagulation also in patients undergoing invasive procedures. However, periprocedural management could be challenging and physicians must carefully balance the risk of bleeding and the risk of thrombosis.

Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

BACKGROUND Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA). OBJECTIVES Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA. DESIGN A web-based prospective observational registry. SETTING Five Italian Private and University Hospitals from 2012 to 2015. PATIENTS Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery. INTERVENTION(S) Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability. MAIN OUTCOME MEASURES Experience of PPSP according to the type of peri-operative analgesia. RESULTS Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months. CONCLUSION Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02147730