Etrusca Brogi

Transversus abdominal plane block for postoperative analgesia: a systematic review and meta-analysis of randomized-controlled trials.

PurposeThe transversus abdominal plane (TAP) block has been described as an effective pain control technique after abdominal surgery. We performed a systematic review and meta-analysis of randomized-controlled trials (RCTs) to account for the increasing number of TAP block studies appearing in the literature. The primary outcome we examined was the effect of TAP block on the postoperative pain score at six, 12, and 24 hr. The secondary outcome was 24-hr morphine consumption.SourceWe searched the United States National Library of Medicine database, the Excerpta Medica database, and the Cochrane Central Register of Controlled Clinical Studies and identified RCTs focusing on the analgesic efficacy of TAP block compared with a control group [i.e., placebo, epidural analgesia, intrathecal morphine (ITM), and ilioinguinal nerve block after abdominal surgery]. Meta-analyses were performed on postoperative pain scores at rest at six, 12, and 24 hr (visual analogue scale, 0-10) and on 24-hr opioid consumption.Principal findingsIn the 51 trials identified, compared with placebo, TAP block reduced the VAS for pain at six hours by 1.4 (95% confidence interval [CI], −1.9 to −0.8; P < 0.001), at 12 hr by 2.0 (95% CI, −2.7 to −1.4; P < 0.001), and at 24 hr by 1.2 (95% CI, −1.6 to −0.8; P < 0.001). Similarly, compared with placebo, TAP block reduced morphine consumption at 24 hr after surgery (mean difference, −14.7 mg; 95% CI, −18.4 to −11.0; P < 0.001). We observed this reduction in pain scores and morphine consumption in the TAP block group after gynecological surgery, appendectomy, inguinal surgery, bariatric surgery, and urological surgery. Nevertheless, separate analysis of the studies comparing ITM with TAP block revealed that ITM seemed to have a greater analgesic efficacy.ConclusionsThe TAP block can play an important role in the management of pain after abdominal surgery by reducing both pain scores and 24-hr morphine consumption. It may have particular utility when neuraxial techniques or opioids are contraindicated.RésuméObjectifLe bloc dans le plan du muscle transverse de l’abdomen (ou TAP bloc) a été décrit comme une technique efficace de contrôle de la douleur après une chirurgie abdominale. Nous avons réalisé une revue systématique et une méta-analyse des études randomisées contrôlées (ERC) pour faire un état des lieux du nombre croissant d’études sur le TAP bloc qui s’ajoutent à la littérature. Le critère d’évaluation principal était l’effet d’un TAP bloc sur les scores de douleur postopératoire à six, 12 et 24 h. Le critère d’évaluation secondaire était la consommation de morphine à 24 h.SourceNous avons effectué des recherches dans la base de données de la Bibliothèque nationale américaine de médecine (United States National Library of Medicine) ainsi que dans le Registre central Cochrane des études cliniques contrôlées (Cochrane Central Register of Controlled Clinical Studies). Nous avons ensuite identifié les ERC se concentrant sur l’efficacité analgésique des TAP blocs par rapport à un groupe témoin [c.-à-d. placebo, analgésie péridurale, morphine intrathécale (MIT) et bloc nerveux ilio-inguinal] après une chirurgie abdominale. Des méta-analyses ont été réalisées en examinant les scores de douleur postopératoire au repos à six, 12 et 24 h (échelle visuelle analogique [EVA], 0-10) et la consommation d’opioïdes sur une période de 24 h.Constatations principalesParmi les 51 études identifiées, par rapport à un placebo, le TAP bloc a réduit le score de douleur de 1,4 sur l’EVA après six heures (intervalle de confiance [IC] 95 %, −1,9 à −0,8; P < 0,001), de 2,0 après 12 h (IC 95 %, −2,7 à −1,4; P < 0,001) et de 1,2 après 24 h (IC 95 %, −1,6 à −0,8; P < 0,001). De la même façon, par rapport au placebo, le TAP bloc a réduit la consommation de morphine à 24 h après la chirurgie (différence moyenne, −14,7 mg; IC 95 %, −18,4 à −11,0; P < 0,001). Nous avons observé cette réduction en matière de scores de douleur et de consommation de morphine dans le groupe TAP bloc après des chirurgies gynécologiques, des appendicectomies, des chirurgies inguinales, des chirurgies bariatriques et des chirurgies urologiques. Toutefois, une analyse séparée des études comparant la MIT au TAP bloc a révélé que la MIT semblait avoir une efficacité analgésique plus prononcée.ConclusionLe TAP bloc peut jouer un rôle important dans la prise en charge de la douleur après une chirurgie abdominale en réduisant les scores de douleur et la consommation de morphine à 24 h. Il pourrait être particulièrement utile lorsque l’utilisation de techniques neuraxiales ou les opioïdes sont contre-indiqués.

Clinical Performance and Safety of Closed-Loop Systems: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Automated systems can improve the stability of controlled variables and reduce the workload in clinical practice without increasing the risks to patients. We conducted this review and meta-analysis to assess the clinical performance of closed-loop systems compared with manual control. Our primary outcome was the accuracy of closed-loop systems in comparison with manual control to maintain a given variable in a desired target range. The occurrence of overshoot and undershoot episodes was the secondary outcome. We retrieved randomized controlled trials on accuracy and safety of closed-loop systems versus manual control. Our primary outcome was the percentage of time during which the system was able to maintain a given variable (eg, bispectral index or oxygen saturation) in a desired range or the proportion of the target measurements that was within the required range. Our secondary outcome was the percentage of time or the number of episodes that the controlled variable was above or below the target range. The standardized mean difference and 95% confidence interval (CI) were calculated for continuous outcomes, whereas the odds ratio and 95% CI were estimated for dichotomous outcomes. Thirty-six trials were included. Compared with manual control, automated systems allowed better maintenance of the controlled variable in the anesthesia drug delivery setting (95% CI, 11.7%–23.1%; percentage of time, P < 0.0001, number of studies: n = 15), in patients with diabetes mellitus (95% CI, 11.5%–30.9%; percentage of time, P = 0.001, n = 8), and in patients mechanically ventilated (95% CI, 1.5%–23.1%; percentage of time, P = 0.03, n = 8). Heterogeneity among the studies was high (>75%). We observed a significant reduction of episodes of overshooting and undershooting when closed-loop systems were used. The use of automated systems can result in better control of a given target within a selected range. There was a decrease of overshooting or undershooting of a given target with closed-loop systems.

Lung Ultrasound Pattern Is Normal during the Last Gestational Weeks: An Observational Pilot Study

Background/Aims: The normal lung ultrasound (US) pattern during a regular pregnancy has not been evaluated extensively in the current literature. Pregnancy-related changes in the respiratory tract affect maternal predisposition to several respiratory complications; consequently, it is important to differentiate between a physiologic pattern during pregnancy and a pathologic lung pattern, due to respiratory failure. The goal of our study was to assess the normal US lung pattern in women without known comorbidities in the last weeks of pregnancy. Methods: We conducted a prospective cross-sectional observational pilot study. Chest wall was examined in 8 areas, 1 scan for each area with women in supine position. Results: One hundred fifty parturients were enrolled during the 36th-38th gestational weeks. None of the participants showed pleural effusion, pneumothorax or lung consolidation. None presented an interstitial syndrome US pattern. One hundred thirteen participants out of 150 (75%) showed A-lines in all the regions. The remaining 25% showed 1 or 2 B-lines in at least 3 regions. Only 2 participants showed 2 positive regions also. Conclusions: We found that, in the majority of the women examined, the lung US pattern matches the physiological pattern in non-pregnant patients. Lung US assessment is a feasible and a helpful diagnostic tool during pregnancy.

Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment

Pleural effusion (PLEFF), mostly caused by volume overload, congestive heart failure, and pleuropulmonary infection, is a common condition in critical care patients. Thoracic ultrasound (TUS) helps clinicians not only to visualize pleural effusion, but also to distinguish between the different types. Furthermore, TUS is essential during thoracentesis and chest tube drainage as it increases safety and decreases life-threatening complications. It is crucial not only during needle or tube drainage insertion, but also to monitor the volume of the drained PLEFF. Moreover, TUS can help diagnose co-existing lung diseases, often with a higher specificity and sensitivity than chest radiography and without the need for X-ray exposure. We review data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided.

Response to: Influence of Mechanical Mentilation on the Incidence of Pneumothorax during Infraclavicular Subclavian Vein Catheterization: A Prospective Randomized Noninferiority Trial

March 2017 • Volume 124 • Number 3 www.anesthesia-analgesia.org 1015 REFERENCES 1. Hattler J, Klimek M, Rossaint R, Heesen M. The effect of combined spinal-epidural versus epidural analgesia in laboring women on nonreassuring fetal heart rate tracings: systematic review and meta-analysis. Anesth Analg. 2016;123:955–964. 2. Friedlander JD, Fox HE, Cain CF, Dominguez CL, Smiley RM. Fetal bradycardia and uterine hyperactivity following subarachnoid administration of fentanyl during labor. Reg Anesth. 1997;22:378–381. 3. Abrão KC, Francisco RP, Miyadahira S, Cicarelli DD, Zugaib M. Elevation of uterine basal tone and fetal heart rate abnormalities after labor analgesia: a randomized controlled trial. Obstet Gynecol. 2009;113:41–47. 4. Cappiello E, O’Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg. 2008;107:1646–1651.

Regional Anaesthesia Techniques for Pain Control in Critically Ill Patients

The pathophysiologic origins of pain in critically ill patients can be explained by several mechanisms. Invasive procedures, surgeries, trauma, inflammation, pre-existing chronic pain condition and immobility represent possible sources of pain in this clinical setting. Pain affects all body systems through neurohormonal mechanisms, catecholamine and inflammatory mediators release and the resulting general stress response. Sympathetic activation together with inflammatory response may have negative effects on the cardiovascular and renal systems. Pain can also lead to immune system dysfunction, hypercoagulable states and disrupted sleep quality. Accordingly, pain control is essential for reducing the aforementioned complications. A satisfactory analgesia is also critical to alleviate pain associated with breathing in patients with thoracic trauma, improving patient ventilator synchrony and facilitating ventilator weaning. A multidisciplinary approach to pain management should include both pharmacological and non-pharmacological interventions. Regional anaesthesia has become valuable for the treatment of pain during and after a wide range of surgical and invasive painful procedures at the bedside. The benefits provided by the implementation of regional anaesthesia are several: anti-inflammatory and antithrombotic effects, improvement of gastrointestinal/hepatic microcirculation and enhancement in respiratory function. Furthermore, the use of regional analgesic techniques allows the maintenance of analgesia without the need of systemic agents, thus reducing opioid use and its side effects. However, regional anaesthesia encounters special challenges when performed in critically ill patients (e.g. coagulopathies, infections, sedation). Ultrasound guidance during nerve blockade has brought important changes in this field.

Regional citrate-calcium anticoagulation during polymyxin-B hemoperfusion: A case series

Introduction: So far, only heparin-based anticoagulation has been proposed during polymyxin-B hemoperfusion. However, postsurgical septic patients can be at high risk of bleeding due to either surgical complications or septic coagulation derangement. Consequently, heparin should not represent in some cases the anticoagulation regimen of choice in this type of patients. Methods and results: We present a case series of four postsurgical septic patients treated with polymyxin-B hemoperfusion using regional citrate anticoagulation. All the treatments were performed without complications. During each treatment, there were no episodes of filter clotting, no bleeding, and no metabolic complications for any of the patients. Conclusion: To our knowledge, this is the second published report on the use of citrate anticoagulation during polymyxin-B hemoperfusion. Our case series continued to show that regional citrate anticoagulation regimen is feasible and safe during polymyxin-B hemoperfusion treatment in postsurgical septic patients.

Anaphylactic Shock During Pediatric Anesthesia: An Unexpected Reaction to Sevoflurane

During general anesthesia, while muscle relaxants, latex and antibiotics are normally considered as very common causes of anaphylactic reactions, there are no documented cases of anaphylaxis due to inhalational agents. We report the case of a 6-year-old child scheduled for adenotonsillectomy who had an anaphylactic shock reaction due to Sevoflurane. Several allergic tests were performed to detect the trigger. Drugs used during operation were tested on both patient and three matched controls. While controls were negative, the patient displayed a positive reaction to Sevoflurane. To our knowledge, this is the first published report describing an allergic reaction caused by a volatile anesthetic.