Marco Baciarello

A prospective, randomized comparison between ultrasound and nerve stimulation guidance for multiple injection axillary brachial plexus block.

Background:This prospective, randomized, blinded study tested the hypothesis that ultrasound guidance can shorten the onset time of axillary brachial plexus block as compared with nerve stimulation guidance when using a multiple injection technique. Methods:Sixty American Society of Anesthesiology physical status I–III patients receiving axillary brachial plexus block with 20 ml ropivacaine, 0.75%, using a multiple injection technique, were randomly allocated to receive either nerve stimulation (group NS, n = 30), or ultrasound guidance (group US, n = 30) for nerve location. A blinded observer recorded the onset of sensory and motor blocks, the need for general anesthesia (failed block) or greater than 100 &mgr;g fentanyl (insufficient block) to complete surgery, procedure-related pain, success rate, and patient satisfaction. Results:The median (range) number of needle passes was 4 (3–8) in group US and 8 (5–13) in group NS (P = 0.002). The onset of sensory block was shorter in group US (14 ± 6 min) than in group NS (18 ± 6 min) (P = 0.01), whereas no differences were observed in onset of motor block (24 ± 8 min in group US and 25 ± 8 min in group NS; P = 0.33) and readiness to surgery (26 ± 8 min in group US and 28 ± 9 min in group NS; P = 0.48). No failed block was reported in either group. Insufficient block was observed in 1 patient (3%) of group US and 2 patients (6%) of group NS (P = 0.61). Procedure-related pain was reported in 6 patients (20%) of group US and 14 patients (48%) of group NS (P = 0.028); patient acceptance was similarly good in the two groups. Conclusion:Multiple injection axillary block with ultrasound guidance provided similar success rates and comparable incidence of complication as compared with nerve stimulation guidance.

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.

Changes in total plasma and serum N-glycome composition and patient-controlled analgesia after major abdominal surgery

Systemic inflammation participates to the complex healing process occurring after major surgery, thus directly affecting the surgical outcome and patient recovery. Total plasma N-glycome might be an indicator of inflammation after major surgery, as well as an anti-inflammatory therapy response marker, since protein glycosylation plays an essential role in the inflammatory cascade. Therefore, we assessed the effects of surgery on the total plasma N-glycome and the association with self-administration of postoperative morphine in two cohorts of patients that underwent major abdominal surgery. We found that plasma N-glycome undergoes significant changes one day after surgery and intensifies one day later, thus indicating a systemic physiological response. In particular, we observed the increase of bisialylated biantennary glycan, A2G2S[3,6]2, 12 hours after surgery, which progressively increased until 48 postoperative hours. Most changes occurred 24 hours after surgery with the decrease of most core-fucosylated biantennary structures, as well as the increase in sialylated tetraantennary and FA3G3S[3,3,3]3 structures. Moreover, we observed a progressive increase of sialylated triantennary and tetraantennary structures two days after surgery, with a concomitant decrease of the structures containing bisecting N-acetylglucosamine along with bi- and trisialylated triantennary glycans. We did not find any statistically significant association between morphine consumption and plasma N-glycome.

Intrathecal ropivacaine 5 mg/ml for outpatient knee arthroscopy: a comparison with lidocaine 10 mg/ml

Purpose: The aim of this prospective, randomised, blind study was to compare the evolution of spinal block produced with 50 mg lidocaine 10 mg/ml and 10 mg ropivacaine 5 mg/ml for outpatient knee arthroscopy.

Systemic hemodynamic effects of sequential pneumatic compression of the lower limbs: a prospective study in healthy volunteers

STUDY OBJECTIVE To evaluate the effects on systemic hemodynamics of sequential pneumatic compression of the lower limbs in healthy volunteers. DESIGN Prospective, self-controlled, volunteer study. SETTING University teaching hospital. PATIENTS 11 healthy volunteers, aged 25 +/- 1.3 years. INTERVENTIONS AND MEASUREMENTS After volunteers underwent a 6-hour period of fasting and 15 minutes of rest in the supine position, baseline systemic hemodynamics were assessed using transthoracic electrical bioimpedance. Peripheral venous pressure was measured using a 16-gauge intravenous cannula inserted in the forearm and connected to a pressure monitor. Then sequential pneumatic compression of the lower limbs was activated for a 30-minute period, and systemic hemodynamic measurements were repeated. In each volunteer, measurements were repeated twice in two consecutive days, and average values were calculated for each volunteer. MAIN RESULTS After activation of sequential pneumatic compression of the lower limbs, mean arterial blood pressure increased from 90 mmHg (79-107 mmHg) to 95 mmHg (79-129 mmHg) (P = 0.02), whereas heart rate decreased from 79 bpm (51-94 bpm) to 75 bpm (53-90 bpm) (P = 0.02). This was associated with a significant increase in peripheral vascular resistance index (from 545 [440-1066] to 613 [369-1280] dynes s cm(-5) m(-2) [P = 0.013]) and reduction in cardiac index (from 3.4 [2.7- 4.5] to 3.2 [2.5-4.0] L/min per m2 [P = 0.034]). CONCLUSIONS The application of sequential pneumatic compression to the lower limbs is associated with minor increases in mean arterial blood pressure, with moderate reduction of cardiac output and heart rate.

Effects of baricity of 0.5% or 0.75% levobupivacaine on the onset time of spinal anesthesia: a randomized trial.

Purpose: Levobupivacaine has been extensively evaluated for spinal anesthesia. Its pharmacologic properties are similar to those of bupivacaine, but differences in density between two commercially-available preparations of plain levobupivacaine might lead to different block profiles. We examined the characteristics of spinal anesthesia using the same dose of 0.5% and 0.75% plain levobupivacaine.Methods: In this randomized, controlled, double-blind clinical trial, 60 ASA I-III patients, scheduled for hip fracture surgery, were randomly allocated to receive spinal anesthesia with 15 mg of either 0.5% (group Levo-0.5), or 0.75% (group Levo-0.75) plain levobupivacaine.Onset time (primary outcome), sensory block height level by pinprick, motor block using a modified Bromage scale, and hemodynamic variables were recorded.Results: In group Levo-0.5 (n=29), surgical anesthesia was obtained within 15 (10–20) min, compared to 12 (7–21) min in group Levo-0.75 (n=31) (p=0.409). The highest sensory block level was T11 (T6–T12) in group Levo-0.5, and T10 (T8–T12) in group Levo-0.75 (p=0.759). Mean duration of anesthesia was 285 (224–303) min in group Levo-0.5, and 318 (243–375) min in group Levo-0.75 (p=0.117). The groups were similar in regards to the number of failed blocks requiring general anesthesia, and the number of patients requiring vasopressors.Conclusions: In this population of elderly patients, spinal anesthesia with 15 mg of either 0.5% or 0.75% plain levobupivacaine resulted in similar onset of pharmacological actions, and outcomes. Potential differences in baricity did not appear to be clinically relevant in this setting.RésuméObjectif: La lévobupivacaïne en rachianesthésie a fait l’objet de nombreuses évaluations. Ses propriétés pharmacologiques sont semblables à celles de la bupivacaïne, mais les densités différentes de deux préparations de lévobupivacaïne simple disponibles sur le marché pourraient avoir pour conséquences des profils de blocs différents. Nous avons examiné les caractéristiques d’une rachianesthésie réalisée à l’aide d’une même dose de lévobupivacaïne simple à 0,5 % ou à 0,75 %.Méthode: Dans cette étude clinique randomisée, contrôlée et en double aveugle, 60 patients ASA I-III devant subir une chirurgie pour une fracture de la hanche ont été randomisés à recevoir une rachianesthésie avec 15 mg de lévobupivacaïne simple, soit à 0,5 % (groupe Levo-0.5), soit à 0,75 % (groupe Levo-0.75). Le délai d’installation (résultat principal), le niveau du bloc sensitif mesuré à la piqûre, le bloc moteur mesuré par une échelle de Bromage modifiée et les variables hémodynamiques ont été enregistrés.Résultats: Dans le groupe Levo-0.5 (n=29), l’anesthésie chirurgicale a été réalisée en 15 (10–20) min, par rapport à 12 (7–21) min dans le groupe Levo-0.75 (n=31) (P=0,409). Le niveau de bloc sensitif le plus élevé était T11 (T6–T12) dans le groupe Levo-0.5, et T10 (T8–T12) dans le groupe Levo-0.75 (P=0,759). La durée moyenne de l’anesthésie était de 285 (224–303) min dans le groupe Levo-0.5, et de 318 (243–375) min dans le groupe Levo-0.75 (P=0,117). Le nombre de blocs non réussis ayant nécessité une anesthésie générale et le nombre de patients nécessitant des vasopresseurs étaient semblables dans les deux groupes.Conclusion: La rachianesthésie réalisée avec 15 mg de lévobupivacaïne simple à 0,5 % ou 0,75 % chez une population de patients âgés provoque des réactions pharmacologiques semblables et donne des résultats similaires. Les différences possibles de baricité ne semblent pas avoir été pertinentes dans ce contexte.

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.

Effect of postoperative analgesia on acute and persistent postherniotomy pain: a randomized study

STUDY OBJECTIVE The study objective is to identify differences in postoperative pain management according to different analgesic treatments, targeting 2 main pathways involved in pain perception. DESIGN The design is a randomized, parallel groups, open-label study. SETTING The setting is in an operating room, postoperative recovery area, and surgical ward. PATIENTS There are 200 patients undergoing open inguinal hernia repair (IHR) with tension-free technique (mesh repair). INTERVENTIONS The intervention is a randomization to receive ketorolac (group K) or tramadol (group T) for 3 days after surgery. MEASUREMENTS The measurements are differences in analgesic efficacy (numeric rating scale [NRS]) in the postoperative (up to 5 days) period, chronic pain incidence (1 and 3 months), side effects, and complications. MAIN RESULTS We found no differences in analgesic efficacy (NRS value ≥4 in the first 96 hours: 26% in group K vs 32% in group T, P = .43); the proportion of patients with NRS ≥4 was similar in both groups, and the time trajectories were not significantly different (P for interaction = .24). Side effects were higher (12% vs 6%) in the tramadol group, although not significantly (P = .14), with a case of bleeding in the ketorolac group and higher incidence of constipation in tramadol group. One patient in each group developed chronic pain. CONCLUSIONS Ketorolac or weak opioids are equally effective on acute pain and on persistent postsurgical pain development after IHR, and drug choice should be based on their potential side effects and patients comorbidities. Further studies are needed to standardize the most rational approach to prevent persistent postsurgical pain after IHR.

Anesthesia and Postoperative Analgesia After Intra-articular Injection of Warmed Versus Room-Temperature Levobupivacaine: A Double-Blind Randomized Trial

PURPOSE This prospective, randomized, blinded study was designed to compare the effects of warmed versus room-temperature levobupivacaine in patients undergoing knee arthroscopy and partial meniscectomy. METHODS Patients were randomly allocated into 2 groups of 16 patients each. In all patients the 2 portal sites were infiltrated with 10 mL of room-temperature mepivacaine (20 mg/mL). In the first group, patients underwent intra-articular injection of 20 mL of levobupivacaine (5 mg/mL) and 0.005-mg/mL epinephrine (1:200,000) at a temperature of 40 degrees C +/- 0.2 degrees C, whereas in the second group the levobupivacaine and epinephrine were at room temperature (25 degrees C +/- 0.5 degrees C). Pain was graded and recorded intraoperatively and postoperatively by use of a visual analog scale (VAS). Analgesia was supplemented if the VAS score was 4 cm or greater with morphine intraoperatively or ketorolac postoperatively. RESULTS There were no significant differences between groups in intraoperative and postoperative VAS values. There was no need for morphine as a rescue dose in any patient during surgery. Eight patients treated with warmed levobupivacaine and seven patients treated with room-temperature levobupivacaine requested a single rescue dose of ketorolac (30 mg) postoperatively. CONCLUSIONS No compelling evidence exists to suggest that intra-articular injection of warmed levobupivacaine is more effective than room-temperature levobupivacaine for intraoperative anesthesia and postoperative analgesia in patients undergoing partial meniscectomy during knee arthroscopy. LEVEL OF EVIDENCE Level I, randomized controlled trial.

Continuous wound infusion of local anesthetic and steroid after major abdominal surgery: study protocol for a randomized controlled trial

BackgroundInflammatory response is one of the key components of pain perception. Continuous infusion (CWI) of local anesthetics has been shown to be effective in controlling pain and reducing postoperative morphine consumption, but the effect of adding a potent anti-inflammatory drug (such as a steroid) has never been addressed. In our study, we want to investigate the effect of CWI with local anesthetic + methylprednisolone on acute and persistent pain, correlating clinical data with biomarkers of inflammation and genetic background.Methods/DesignAfter approval by their institutional review board, three hospitals will enroll 120 patients undergoing major abdominal surgery in a randomized, double-blind, phase III study. After a 24-h CWI of ropivacaine 0.2 % + methylprednisolone 1 mg/kg, patients will be randomly assigned to receive either ropivacaine + steroid or placebo for the next 24 h. Then, patient-controlled CWI with only ropivacaine 0.2 % or placebo (according to the group of randomization) is planned after 48 h up to 7 days (bolus 10 ml, lock-out 1 h, maximum dose of 40 ml in 4 h). Morphine equivalent consumption up to 7 days will be analyzed, together with any catheter- or drug-related side effect. Persistent post-surgical pain (PPSP) incidence will also be investigated. Our primary endpoint is analgesic consumption in the first 7 days after surgery; we will evaluate, as secondary endpoints, any catheter- or drug-related side effect, genotype/phenotype correlations between some polymorphisms and postoperative outcome in terms of morphine consumption, development of the inflammatory response, and incidence of PPSP. Finally, we will collect, in a subgroup of patients, wound exudate samples by micro-dialysis, blood samples, and urine samples up to 72 h to investigate local and systemic inflammation and oxidative stress.DiscussionThis is a phase III trial to evaluate the safety and efficacy of wound infusion with steroid and local anesthetic. The study is aimed also to evaluate how long this infusion has to be maintained in order to maximize effectiveness. Our data are intended to quantify the amount of ropivacaine and methylprednisolone needed by patients undergoing major abdominal surgery, to be stored in a new nanotechnology device for sustained pain treatment after surgery. We also aim to clarify the roles of inflammatory response, oxidative stress, and genetic background on postoperative and persistent pain after major abdominal surgery.Trial registrationThe trial was registered on ClinicalTrials.gov (NCT02002663) on 24 Oct. 2013.