Angelo Chierichini

Hypobaric versus isobaric spinal levobupivacaine for total hip arthroplasty

BACKGROUND Spinal anesthesia (SA) in the lateral decubitus position is often used to perform total hip arthroplasty (THA). Hypobaric local anesthetic ensures enhanced and prolonged sensory and motor block in the involved side. The aim of this study was to compare the intraoperative anesthetic efficacy of hypobaric with isobaric levobupivacaine solutions for THA. METHODS Forty patients scheduled to elective THA were allocated into two groups: isobaric levobupivacaine group (IL group) and hypobaric levobupivacaine group (HL group). All the patients were placed with the operative side uppermost on the surgical table and spinal anesthesia was performed with 4 mL (12.5 mg) of selected solution. The evolution of sensory and block on nondependent (operative) and dependent sides were checked. RESULTS Regarding the nondependent side the onset times for maximal sensory block level in the in HL group was 17.8±1.1 minutes vs. 24.2±4.1 minutes in IL group. In HL group the onset time for motor block was 9.2±3.5 minutes vs. 15.6±5.4 minutes in IL group. The sensory regression time to L2 was significantly prolonged in HL group (192±30.3 minutes vs. 111±13.4 min). After surgery in HL group the residual motor block degree was 2.4±0.9 vs. 0.2±0.4 in IL group. CONCLUSIONS In patients undergoing THA under spinal anesthesia 12.5 mg of hypobaric levobupivacaine, compared with the same dose of isobaric levobupivacaine, allow shorter onset time for sensory block and delayed regression of sensory and motor block in the nondependent side.

Anesthesia and Perioperative Care in MISS

The work of the anesthesiologist in MISS ranges widely, from mild to deep sedation and Monitored Anesthesia Care (MAC) to general anesthesia, in some cases with single-lung ventilation and/or invasive systemic blood pressure or central venous pressure monitoring. There is also great variability in surgical techniques, ranging from percutaneous or mini-open posterior approaches to laparo- or thoracoscopic anterior procedures. The choice of the anesthetic technique, drugs, and the appropriate treatment setting is made by considering both the planned surgical procedure and the patient’s preoperative conditions [1]. Especially in the elderly, coexisting diseases are frequent and chronic therapies can often interfere with anesthetics or increase the rate of some surgical or anesthesiological complications.

Anesthesia in Shoulder Arthroscopy

Surgical procedures in shoulder arthroscopy can be performed under regional blockade, general anesthesia, or a combination of the two techniques. The anesthesiologist’s preoperative assessment is crucial to the formulation and execution of the anesthetic plan. The patients must be evaluated for coexisting medical problems, potential airway management difficulties, and considerations related to intraoperative positioning. This evaluation together with an understanding of the surgeon’s need is used to formulate the anesthetic plan. Hypertension is the prevalent medical problem observed in elderly patients undergoing shoulder surgery. Hypertensive patients will experience wider fluctuations in blood pressure intraoperatively than normotensive individuals, especially in the beach-chair position. Noxious stimuli will lead to exaggerated hypertensive responses. Conversely, since hypertensive patients tend to be intravascularly depleted, once general anesthesia is induced, hypotension may occur. In general, hypertensive patients should continue their antihypertensive therapy perioperatively.