Daniela Ghisi

Spinal anesthesia with lidocaine or preservative-free 2-chlorprocaine for outpatient knee arthroscopy : A prospective, randomized, double-blind comparison

BACKGROUND:In this prospective, randomized, double-blind study we tested the hypothesis that 50 mg of 1% preservative-free 2-chloroprocaine would provide a faster resolution of spinal block than the same dose of 1% plain lidocaine. METHODS:After IV midazolam premedication (0.03 mg/kg), 30 ASA physical status I–II outpatients undergoing knee arthroscopy were randomly allocated to receive 50 mg of either 1% plain lidocaine (n = 15) or 1% preservative-free plain chloroprocaine (n = 15). A blinded observer recorded the evolution of sensory (loss of pinprick sensation) and motor (modified Bromage scale) block until complete regression, as well as times to unassisted ambulation and voiding. A telephone call follow-up was performed 24 h and 7 days after surgery. RESULTS:Two chloroprocaine patients (13%) and one lidocaine patient (7%) required fentanyl supplementation (100 &mgr;g IV) (P = 0.99) intraoperatively, but no patient required general anesthesia to complete surgery. Median (range) times for recovery of sensory and motor function, and unassisted ambulation were faster with 2-chloroprocaine [95 (68–170) min; 60 (45–120) min; and 103 (70–191) min] than lidocaine [120 (80–175) min; 100 (60–140) min; and 152 (100–185) min] (P = 0.019, P = 0.0005, and P = 0.003, respectively). No differences in first voiding were reported between chloroprocaine [180 (100–354) min] and lidocaine patients [190 (148–340) min] (P = 0.191). Transient neurological symptoms were reported in five lidocaine patients (33%) but no chloroprocaine patients (0%) (P = 0.042). CONCLUSION:Intrathecal injection of 50 mg of preservative-free 2-chloroprocaine 1% resulted in quicker recovery of sensory/motor function, and unassisted ambulation, and fewer incidences of transient neurologic symptoms than the same dose of 1% lidocaine.

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.

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.

Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine.

Background and objectives: Levobupivacaine in combination with sufentanil may be used for labour or postoperative regional analgesia. The risk of bacterial growth within these contained solutions for several hours at room temperature is unknown. We investigated the in vitro antimicrobial effect of levobupivacaine and sufentanil against common micro‐organisms encountered during regional anaesthesia. Methods: Standardized suspensions of Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli were incubated for 1, 3, 6 and 24 h at 25°C, with saline (as control), sufentanil 0.5 or 0.75 &mgr;g mL−1, levobupivacaine hydrochloride 5.6 mg mL−1 and concentrations of 1.4, 2.8 and 5 mg mL−1 of levobupivacaine hydrochloride with sufentanil 0.5 &mgr;g mL−1. Colony counts were compared after 24 h incubation at 37°C. Results: No bacterial growth was observed on any bacterial strain for any solution tested throughout the experiment. Conclusions: Our results suggest that solutions of levobupivacaine combined with sufentanil may be used for 24 h at room temperature during regional anaesthesia with no risk of bacterial growth.BACKGROUND The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the efficacy of phrenic nerve infiltration with ropivacaine 0.2% on the incidence and severity of ipsilateral shoulder pain after thoracotomy in patients receiving continuous thoracic epidural analgesia. METHODS Fifty ASA physical status II-III patients, receiving thoracic epidural analgesia for post-thoracotomy pain, were randomly allocated to receive infiltration of the ipsilateral phrenic nerve with either ropivacaine 0.2% 10 mL (ropivacaine, n = 25), or saline 0.9% (control, n = 25) just before lung expansion and chest closure. A blinded observer recorded the incidence and severity of ipsilateral shoulder pain 6, 12, 24, 36 and 48 h after surgery. Postoperative respiratory function was also evaluated with blood gas analyses. RESULTS The cumulative incidences of ipsilateral shoulder pain during the first 24 h after surgery were 8/25 in the ropivacaine and 16/25 in the control groups (P = 0.047), with median (range) onset times for shoulder pain of 2 (2-24) h with ropivacaine and 0.5 (0.5-24) h in controls (P = 0.005). No differences were reported on the second postoperative day. The areas under the curves of the amount of pain over time were 0 (0-2760) mm h for the ropivacaine and 350 (0-1900) mm h for the control groups (P = 0.06). Postoperatively, similar reductions in indices of oxygenation were observed in both groups. CONCLUSIONS Phrenic nerve infiltration with ropivacaine 0.2% 10 mL reduced the incidence and delayed the onset of ipsilateral shoulder pain during the first 24 h after open lung resection, with no clinically relevant effects on respiratory function.

Stimulating or conventional perineural catheters after hallux valgus repair: a double‐blind, pharmaco‐economic evaluation

Background:  We prospectively evaluated direct analgesia‐related costs of continuous sciatic nerve block using either a stimulating or conventional catheter after hallux valgus repair.

Intrathecal 1% 2-chloroprocaine vs. 0.5% bupivacaine in ambulatory surgery: a prospective, observer-blinded, randomised, controlled trial.

This prospective, observer‐blinded, randomised, multicentre study aimed at determining the non‐inferiority of 50 mg of plain 1% 2‐chloroprocaine vs. 10 mg of 0.5% plain bupivacaine in terms of sensory block onset time at T10 after spinal injection. The study hypothesis was that the difference in onset times of sensory block to T10 between the two drugs is ≤ 4 min.

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.