Gaetano Draisci

Postoperative Analgesic THerapy Observational Survey (PATHOS): a practice pattern study in 7 central/southern European countries.

&NA; Surveys evaluating pain in hospitals keep on showing that postoperative pain (POP) remains undertreated. At the time when guidelines are edited and organisational changes are implemented, more recent data are necessary to check the impact of these measures on daily practice and needs for improvement. This prospective, cross‐sectional, observational, multi‐centre practice survey was performed in 2004–2005 in 7 European countries. It was conducted in surgical wards of a randomised sample of hospitals. Data on POP management practices following surgery in adult in‐patients were collected anonymously via a standardised multiple choice questionnaire. Among 1558 questionnaires received from 746 European hospitals, 59% were provided by anaesthetists and 41% by surgeons. There are no regular on‐site staff training programmes on POP management in the institution for 34% of the respondents, patients are systematically provided with POP information before surgery for 48% of respondents; balanced analgesia following major surgery and regular administration of analgesics are largely used; 25% of respondents have specific written POP management protocols for all patients in their ward; 34% of respondents say that pain is not assessed and 44% say that pain scores are documented in the patient’s chart. This largest ever performed survey confirms the extensive body of evidence that current POP management remains suboptimal and identifies needs for improvement on European surgical wards. However, the wide use of balanced analgesia and the regular administration of analgesics are indicators of ongoing change.

Remifentanil for cesarean section under general anesthesia: effects on maternal stress hormone secretion and neonatal well-being: a randomized trial

BACKGROUND Remifentanil may attenuate maternal hemodynamic response during cesarean section under general anesthesia, but could cause transient but significant neonatal depression. We investigated the effect of low-dose remifentanil on maternal neuroendocrine response and fetal wellbeing. METHODS Forty-two ASA I-II parturients undergoing cesarean section at term under general anesthesia were randomized to receive either fentanyl after delivery (n=21, group C) or remifentanil bolus 0.5 microg/kg before induction followed by a continuous infusion at 0.15 microg x kg(-1)min(-1) until peritoneal incision, then restarted after delivery (n=21, group R). Maternal heart rate and blood pressure, and epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), and growth hormone levels were measured at baseline, uterine incision, and the end of surgery. Remifentanil was measured in maternal and umbilical arterial and venous blood. One- and 5-minute Apgar scores and umbilical arterial and venous pH were recorded. RESULTS ACTH was significantly higher in group C at uterine incision (P<0.01). No significant differences were observed in hemodynamics, catecholamines or growth hormone. Apgar scores at 1 (P<0.05) and 5 min (P<0.01) were significantly higher in group C. Mean umbilical pH values were within normal range but significantly higher in group C. Three neonates in group R required intubation but recovered at 5 min without naloxone. Mean+/-SD maternal remifentanil concentration was 1.67+/-1.04 ng/mL. CONCLUSIONS Remifentanil administration before peritoneal incision partially reduced the hormonal stress response. Maternal benefits must be weighed against transitory but significant neonatal respiratory depression. Neonatal resuscitation facilities are mandatory when remifentanil is used.

Transient changes in Fos and GFAP immunoreactivity precede neuronal loss in the rat hippocampus following neonatal anoxia

Early and delayed neuronal and glial changes in the hippocampus were studied in Wistar rats following neonatal anoxia induced by 100% N2 exposure for 25 min at approximately 30 h postnatally. Sham-treatment induced a transient increase in the number of fos immunoreactive neurons in the CA1, CA2, and CA3 regions, with a peak at 120 min following handling. In contrast, a significant decrease in the number of fos-stained cells was seen in the CA1 and CA2 regions at 120 min after the exposure to anoxia, compared to sham-treatment. At 150 and 240 min increased fos immunoreactivity was detected in the CA2 region of anoxic rats. Enhanced glial fibrillary acidic protein staining was seen at Postnatal Day 7 (P7) in the hippocampus of the rats exposed to neonatal anoxia, while no differences between anoxic and sham-treated animals were observed at later time-points. No alteration in nerve cell density was found at P7, while at P15 and later stages a significant reduction in neuronal density was seen in the CA1 region of anoxic rats. Thus, the rapid induction in hippocampal neuronal activity that followed sham-treatment was blocked by the neonatal anoxia, as revealed by changes in immediate early gene expression. A transient reactive astrocytosis developed in the days after the anoxic insult, followed by a loss of neurons in the CA1 region. The findings indicate that a sequence of specific neuronal and glial alterations takes place in the hippocampus after neonatal anoxia, which finally leads to a detectable, regionally restricted, neuronal loss. Moreover, inhibition in fos protein expression may be an early marker for the anoxic damage in CA1 neurons.

Latex Sensitization: A Special Risk for the Obstetric Population?

Background:Previous studies have reported a greater frequency of sensitization to latex in the female population and a higher incidence of anaphylactic reactions to latex during cesarean section. In this study, the authors investigated the prevalence of latex sensitization in obstetric patients compared with nonpregnant subjects. Methods:Two hundred ninety-four healthy pregnant women who were at term with a singleton fetus and scheduled for caesarean section (group A) were compared with 294 healthy nulliparous women with childbirth potential undergoing gynecologic surgery (group B). Before surgery, patients completed a questionnaire, and venous blood samples were collected to measure specific immunoglobulin E serum concentrations with a fluorescent enzyme immunoassay test. Skin-prick tests were performed if adverse reactions occurred during surgery. Latex allergy was diagnosed on the basis of immunoglobulin E results and/or positive skin-prick tests. Results:The prevalence of latex sensitization was higher in group A than in group B (15/294, 5.1% vs. 5/294, 1.7%; P < 0.05). A significant difference in specific immunoglobulin E serum concentration was noted between pregnant and nonpregnant patients who had a positive fluorescent enzyme immunoassay test (median serum concentration: 1.93 kilounits/l; interquartile range = 2.28 vs. 0.78 kilounits/l; interquartile range = 1.07; P less than 0.05). Two patients in group A experienced an anaphylactic reaction to latex. Statistical analysis disclosed no association between latex sensitization and accepted risk factor for latex allergy. Conclusions:The authors report a higher prevalence of latex sensitization in the obstetric population than in nonpregnant subjects undergoing gynecologic surgery.

Quantitative determination of sufentanil in human plasma by liquid chromatography–tandem mass spectrometry

A sensitive and specific method for the quantification of sufentanil in human plasma by liquid chromatography coupled with tandem mass spectrometry has been developed. Fentanyl was used as the internal standard. Rapid sample preparation involved purification on a C(18) solid-phase extraction column. Chromatographic separation of the analytes was obtained using an RP-C(18) mu-HPLC column. LC-MS-MS detection was performed by atmospheric pressure ionisation (API) source equipped with an ionspray (IS) interface operating in the positive ion mode. For unambiguous substance confirmation, three analyte precursor-product ion combinations were monitored during multiple reaction monitoring (MRM) LC-MS-MS analysis. The methods performance characteristics were evaluated in blank and spiked control plasma samples. Overall accuracy (relative error, R.E., %), repeatability (relative standard deviations, R.S.D., %) and within-laboratory reproducibility (R.S.D., %) ranged from -9.28 to -2.71%, from 6.42 to 2.82% and from 13.52 to 6.06%, respectively, for sufentanil. The limit of quantification for sufentanil in human plasma samples was 0.3 ng ml(-1). Due to its high sensitivity and specificity, the method was successfully employed for sufentanil determination in maternal plasma samples collected immediately before epidural administration of a single sufentanil dose to women in labour, 20 min after drug administration, and at birth in arterial and venous umbilical cord plasma samples from the newborn babies. Research is in progress to adopt the method for performance of complete pharmacokinetic studies of sufentanil in human plasma.

Tracheal agenesis without esophageal fistula: genetic, resuscitative, and pathological issues

An exceptional case of tracheal agenesis with no communication with the esophagus is described. This malformation needs surgical airway approach and is hardly classifiable. We analyzed the literature and our institutional data: this resulted to be the first case of such anatomical variant. Genetic and pathological issues are reviewed: recent genetic data seem to explain this malformation. We also reviewed the available literature about prenatal presentation. Because prenatal diagnosis is difficult to achieve and current guidelines for neonatal resuscitation do not provide any recommendation, the resuscitative team may not be prepared for managing such a case. Usefulness of uncommon resuscitative maneuvers is discussed: a promptly performed surgical tracheotomy is the only mean to ventilate such a baby.

Rectal cancer in pregnancy: a new management based on blended anesthesia and monitoring of fetal well being

Colorectal carcinoma presenting during pregnancy is an extremely rare condition associated with a poor prognosis. In this report we studied a patient referred to our hospital at 26 weeks of gestation with the diagnosis of rectal adenocarcinoma. Tumor resection with a colostomy was planned in the attempt to preserve pregnancy until fetal viability could be reached. Blended anesthesia (general and epidural) was chosen to avoid surgical and anesthesiological risks; in fact this technique allows either an optimal block of neurohormonal response or a good control of surgical stress to be obtained. In order to monitor fetal well being during surgery, Doppler evaluations of fetal heart rate and umbilical artery flow velocity waveforms were performed. The patient was dismissed in good health and then rehospitalized at 32 weeks of gestation in order to perform an elective cesarean section. In conclusion we suggest that, with the choice of a good anesthesiological technique and monitoring of fetal well being, surgical treatment in case of rectal cancer could be performed without affecting the course of pregnancy.

POST-TRANSFUSIONAL VARIATION IN URINARY OXYGEN TENSION IN SURGICAL PATIENTS

1 Prior studies have suggested urinary oxygen tension (Puo2) as a putative index of renal blood flow (RBF) and tissue oxygenation. 2 In the present study, we collected intraoperative data from eight anaemic, bladder‐catheterized patients who received erythrocyte transfusions during various surgical procedures under general anaesthesia. Urinary and arterial blood gas analysis and co‐oximetry were performed before and after transfusion, during an interval in which RBF was assumed to be constant. 3 Pre‐ and post‐transfusion haematocrit levels were 23 ± 4.8 and 27 ± 6.4%, respectively, and arterial oxygen content (Cao2) was 10.5 ± 2.5 and 12.4 ± 3.1 mL/dL, respectively (P = 0.012). Pre‐ and post‐transfusion Puo2 was 90 ± 14 and 108 ± 20 mmHg, respectively (P = 0.036). 4 These results, although limited, suggest that under conditions of stable haemodynamics, systemic oxygenation and renal function, intraoperative blood transfusion may increase Puo2 in anaemic anaesthetized patients. If confirmed by subsequent clinical and laboratory studies, Puo2 measurement could become a simple, non‐invasive way to monitor renal medullary oxygenation and tissue oxygen availability and help determine whether red blood cells should be transfused.

Utility of ultrasound-guided transversus abdominis plane block for day-case inguinal hernia repair

Background The transversus abdominis plane (TAP) block is a regional anesthesia technique that effectively reduces the pain intensity and use of analgesia in abdominal surgery. The aim of this study was to determine the utility of the ultrasound-guided TAP block in improving the efficacy of the ultrasound-guided ilioinguinal/iliohypogastric nerve (IIN/IHN) block for intraoperative anesthesia and postoperative pain control in day-case inguinal hernia repair (IHR). Methods We conducted a descriptive study of patients undergoing elective primary unilateral open IHR. Fifty-nine patients were divided into two groups according to the anesthetic technique used: ultrasound-guided TAP block plus ultrasound-guided IIN/IHN block (TAP group) vs. ultrasound-guided IIN/IHN block alone (IIN/IHN group). The outcome measures were the adequacy of anesthesia during surgery and postoperative analgesia. Results Four patients (12.5%) in the TAP group and 10 patients (37.0%) in the IIN/IHN group experienced inadequate anesthesia and needed systemic sedation (P < 0.05). No significant differences in additional local anesthetic volume were found between the two groups. Patients in the TAP group reported lower pain scores at the end of surgery (0.4 ± 0.8 vs. 2.1 ± 2.5, P < 0.01), at 2 hours after surgery (0.8 ± 1.3 vs. 3.0 ± 2.2, P < 0.01), at discharge (1.4 ± 1.2 vs. 4.3 ± 2.2, P < 0.01), and at 24 hours (1.5 ± 1.1 vs. 4.5 ± 2.3, P < 0.01). Conclusions The combination of the TAP and IIN/IHN blocks is associated with better intraoperative anesthesia and lower postoperative pain scores compared with the IIN/IHN block alone.

Does Huntington's disease enhance cephalad spread during neuraxial anesthesia for cesarean section?

To the Editor: Huntingtons disease has several implications for anesthesiologists. Cognitive dysfunction and dyskinesia may complicate both general and neuraxial anesthesia. The management of two consecutive Cesarean sections performed in the same Huntingtons disease patient is presented. At the first cesarean section, the patient was 32 years old, 166 cm, with a body mass index of 23.4 kg/m2. She presented with minimal signs of involuntary movement; the diagnosis of Huntingtons disease was confirmed by family history and genetic counseling. She underwent an urgent Cesarean section for suspected placental abruption and preeclampsia. With the patient placed in sitting position, a single-shot spinal anesthesia with a 25-gauge (G) Whitacre needle was performed at the L3-L4 interspace. Hyperbaric bupivacaine 0.5% 12 mg plus sufentanil 5 μg were administered intrathecally. Sensory block reached T5 in 10 minutes and reverted to T10 after 130 minutes. Four years later, during elective Cesarean section, the patient showed clinical deterioration, mild dementia, and increased involuntary movements without modification of body habitus. Combined spinal-epidural anesthesia was performed to ensure adequate postoperative analgesia. The patient was placed in sitting position; the epidural space was entered at the L3-L4 level with an 18-G Tuohy needle (lossof-resistance technique). Needle-through-needle spinal anesthesia was performed with hyperbaric bupivacaine 0.5% 7 mg plus sufentanil 5 μg. An epidural catheter was then inserted. Unexpectedly, after 15 minutes the sensory block reached C6-C7, resulting in severe hypotension that was treated with fluids and ephedrine intravenously (IV). Delivery was completed uneventfully. After 150 minutes, the analgesic block reverted to T10 and morphine 2.5 mg was administered epidurally. A normal spread of spinal anesthetic has been reported in a few nonpregnant Huntingtons disease patients undergoing spinal anesthesia [1]. In pregnant women, anatomical changes are responsible for the cephalad spread of spinal anesthetics [2,3]. It is controversial whether the spread of