The increase in knee arthroscopy performed on an out-patient basis, along with the need for cost reduction and a safe and rapid patient discharge, has underlined the importance of adequate anaesthe...

clinical efficacy, technical problems and bupivacaine plasma concentrations. Acta Anesthesiol Scand 1989;33:84–8. 3. Ekatodramis G, Borgeat A, Huledal G, et al. Continuous interscalene analgesia with ropivacaine 2mg/mL after major shoulder surgery. Anesthesiology 2003;98:143–50. 4. Knudsen K, Beckmann Suurküla M, et al. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997;78:507–14.

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

BACKGROUND:The authors investigated the accuracy of transcutaneous capnometry (TcPCO(2)) in estimating arterial blood carbon dioxide partial pressure (PaCO(2)) during spontaneous breathing in patients admitted to our surgical intensive care unit (ICU). METHODS:Serial TcPCO(2) and PaCO(2) measurements were taken in stable patients undergoing postoperative monitoring after major abdominal, vascular, or thoracic surgery. Patients were enrolled 12 hours after extubation. Exclusion criteria were pulmonary dysfunction, hemodynamic instability, or anemia. Linear regression, mixed models, and Bland-Altman analyses were used to compare accuracy and correlation between the two variables. Data are presented as means (95% confidence intervals). RESULTS:PaCO(2) values ranged between 26 mmHg and 52 mmHg. Mean values for TcPCO(2) and PaCO(2) were 35.3 (33.8-36.8) mmHg and 39.2 (37.6-40.7) (P<0.001). Bland-Altman analysis showed a bias of -3.8 (-5.1-2.5) mmHg with upper and lower limits of agreement of 5.6 (3.4-7.9) mmHg and -13.3 (-15.6 -11.1) mmHg, respectively. Thirty-one (55.4%) measurements disagreed by 3 mmHg or more. Linear mixed model analysis with adjustment for repeated measurements showed low correlation (r=0.63; P<0.0005). There were small but significant differences between patients in the correlation coefficient (P=0.04). CONCLUSION:TcPCO(2) showed moderate bias with wide limits of agreement when compared to PaCO(2) in our patients. The regression model showed low correlation of the measurements when adjusting for repeated measurements and between-subject variances. TcPCO(2) may not provide an accurate quantitative estimation of PaCO(2) in stable, spontaneously breathing, nonintubated patients in the early postoperative period.

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.

Purpose: The aim of the study was to compare the efficacy of parecoxib for postoperative analgesia after endoscopic turbinate and sinus surgery with the prodrug of acetaminophen, proparacetamol. Materials and Methods: Fifty American Society of Anesthesiology (ASA) physical status I-II patients, receiving functional endoscopic sinus surgery (FESS) and endoscopic turbinectomy, were investigated in a prospective, randomized, double-blind manner. After local infiltration with 1% mepivacaine, patients were randomly allocated to receive intravenous (M administration of either 40 mg of parecoxib (n = 25) or 2 g of proparacetamol (n = 25) 15 min before discontinuation of total IV anaesthesia with propofol and remifentanil. A blinded observer recorded the incidence and severity of pain at admission to the post anaesthesia care unit (PACU) at 10, 20, and 30 min after PACU admission, and every I h thereafter for the first 6 postoperative h. Results: The area under the curve of VAS (AUC(VAS)) calculated during the study period was 669 (28 - 1901) cm . min in the proparacetamol group and 635 (26 - 1413) cm . min in the parecoxib group (p = 0.34). Rescue morphine analgesia was required by 14 patients (56%) in the proparacetamol group and 12 patients (48%) in the parecoxib (p >= 0.05), while mean morphine consumption was 5 - 3.5 ing and 5 - 2.0 ing in the proparacetamol groups and parecoxib, respectively (p >= 0.05). No differences in the incidence of side effects were recorded between the 2 groups. Patient satisfaction was similarly high in both groups, and all patients were uneventfully discharged 24 h after surgery. Conclusion: In patients undergoing endoscopic nasal surgery, prior infiltration with local anaesthetics, parecoxib administered before discontinuing general anaesthetic, is not superior to proparacetamol in treating early postoperative pain.

BACKGROUND:The aim of this prospective, randomized, double-blind study was to compare the efficacy of parecoxibfor postoperative analgesia after endoscopic turbinate and sinus surgery, with the non-selective non-steroid anti-inflammatory drug (NSAID), ketorolac.METHODS:A total of 50 patients with an ASA physical status I-II, receiving functional endoscopic sinus surgery (FESS) and endoscopic turbinectomy after local infiltration with 1% mepivacaine, were randomly assigned to receive intravenous administration of either 40 mg parecoxib (N.=25) or 30 mg ketorolac (N.=25), 15 min before the discontinuation of anaesthesia and then every 8 h postoperatively. A blinded observer recorded the incidence and severity of pain upon admission to the postanesthesia care unit (PACU), as well as 10, 20, and 30 min after PACU admission. Thereafter, observations continued every 1 h for the first 6 h, and then 12 h and 24 h after surgery.RESULTS:The area under the curve of the visual analogue scale (AUCVAS) calculated during the study period was 635 (26-1 413) in the Parecoxib group and 669 (28-1 901) in the Ketorolac group (P=0.54). Rescue morphine analgesia was required by 12 patients (48%) in the Parecoxib group and 11 patients (44%) in the Ketorolac group (P<0.05); while mean morphine consumption was 5 +/- 2.5 mg and 5 +/- 2.0 mg in Ketorolac and Parecoxib groups, respectively (P<0.05). No differences in the incidence of side effects were recorded between the two groups. Patient satisfaction was similarly high in both groups, and all patients were discharged uneventfully 24 h after surgery.CONCLUSION:In patients undergoing endoscopic nasal surgery and local infiltration with 1% mepivacaine, parecoxib administered before discontinuing general anesthesia is as effective in treating early postoperative pain as ketorolac.

Levobupivacaine and ropivacaine, two new long-acting local anesthetics, have been developed as an alternative to bupivacaine, after the evidence of its severe toxicity. Both of these agents are pure left-isomers and, due to their three-dimensional structure, seem to have less toxic effects on the central nervous system and on the cardiovascular system. Many clinical studies have investigated their toxicology and clinical profiles: theoretically and experimentally, some differences have been observed, but the effects of these properties on clinical practice have not been shown. By examining randomised, controlled trials that have compared these three local agents, this review supports the evidence that both levobupivacaine and ropivacaine have a clinical profile similar to that of racemic bupivacaine, and that the minimal differences reported between the three anesthetics are mainly related to the slightly different anesthetic potency, with racemic bupivacaine > levobupivacaine > ropivacaine. However, the reduced toxic potential of the two pure left-isomers suggests their use in the clinical situations in which the risk of systemic toxicity related to either overdosing or unintended intravascular injection is high, such as during epidural or peripheral nerve blocks.

Study Objective: TO evaluate the pharmacokinetic profile of 0.35 mL/kg of 0.5% levobupivacaine during superficial and combined (deep and superficial) cervical plexus block (CPB) in patients undergoing minimally invasive parathyroidectomy.Design: Prospective randomized study.Setting: Operating theater of a university hospital.Patients: 12 ASA physical status II and III patients (11 women and 1 man), scheduled for minimally invasive parathyroidectomy.Interventions: Seven and 5 patients were randomly assigned to receive either superficial or combined CPB, respectively. The superficial CPB was performed with an injection of 0.35 mL/kg of 0.5% levobupivacaine subcutaneously along the posterior border of the sternocleidomastoid muscle and deeper on its medial surface. The combined CPB was initiated by the deep block at the C3 level vertebra by injecting 0.2 mL/kg of 0.5% levobupivacaine, followed by the superficial block with an injection of the remaining 0.15 mL/kg. After completion of the block, venous blood was sampled at the intervals of 5, 10, 15, 20, 30, 45, and 60 minutes.Measurements and Main Results: Venous plasma concentrations were measured using gas chromatography-mass spectroscopy. Mean +/- SD of maximal concentrations of levobupivacaine was 0.58 +/- 0.41 mg/L in group superficial and 0.52 +/- 0.28 mg/L in group combined (P = 0.71). The median (range) time required to reach the maximal concentrations was 30 minutes (20-30 min) in group supeficial and 20 minutes (15-30 min) in group combined (P = 0.45). The areas under the drug concentration/time curve (AUC(10-60)) were also similar in both groups. No signs of central nervous system or cardiovascular toxicity or other untoward events were observed in any patient.Conclusion: With the given dose regimen, levobupivacaine plasma concentrations were within safe ranges. (C) 2008 Elsevier Inc. All rights reserved.

Spinal anesthesia is a simple technique that provides a deep and fast surgical block through the injection of small doses of local anesthetic solution into the subarachnoid space. The purpose of this review is to provide an overview on recent developments on local anesthetic drugs, side effects, and special techniques of intrathecal anesthesia. Spinal anesthesia can be considered adequately safe, and severe complications are reasonably rare. The cardiovascular effects associated with sympathetic block are more frequent, but successfully treated with volume expansion and administration of vasoactive drugs. It is clear that the total dose of local anesthetic injected into the subarachnoid space is the most important determinant of both therapeutic and unwanted effects of spinal anesthesia. Several studies have also demonstrated the efficacy and safety of using small doses of long acting agents, such as bupivacaine or ropivacaine, to produce an adequately short spinal block in outpatients. Levopivacaine, the pure S(-)-enantiomer of racemic bupivacaine showed a lower risk of cardiovascular and central nervous system (CNS) toxicity than bupivacaine. In the last years we have assisted important changes in the health care organization, with most of the surgical procedures performed on outpatients or on elderly patients with concomitant diseases. This forced us to change the indications and clinical use of intrathecal anesthesia techniques, which have been modified according to the changing needs of surgery. The development of new drugs and special techniques for spinal anesthesia will further improve the clinical use of this old but evergreen technique.

BACKGROUND AND OBJECTIVES:To evaluate if psoas compartment block requires a larger concentration of mepivacaine to block the femoral nerve than does an anterior 3-in-1 femoral nerve block. METHODS:Forty eight patients undergoing anterior cruciate ligament repair were randomly allocated to receive an anterior 3-in-1 femoral block (femoral group, n = 24) or a posterior psoas compartment block (psoas group, n = 24) with 30 mL of mepivacaine. The concentration of the injected solution was varied for consecutive patients using an up-and-down staircase method (initial concentration: 1%; up-and-down steps: 0.1%). RESULTS:The minimum effective anesthetic concentration of mepivacaine blocking the femoral nerve in 50% of cases (ED(50)) was 1.06% +/- 0.31% (95% confidence interval [CI], 0.45%-1.68%) in the femoral group and 1.03% +/- 0.21% (95% CI, 0.6%-1.45%) in the psoas group (P = .83). The lateral femoral cutaneous and obturator nerves were blocked in 4 (16%) and 5 (20%) femoral group patients as compared with 20 (83%) and 19 (80%) psoas group patients (P = .005 and P = .0005, respectively). Intraoperative analgesic supplementation was required by 15 (60%) and 5 (20%) patients in the femoral and psoas groups, respectively (P = .01). CONCLUSIONS:Using a posterior psoas compartment approach to the lumbar plexus does not increase the minimum effective anesthetic concentration of mepivacaine required to block the femoral nerve as compared with the anterior 3-in-1 approach, and provides better quality of intraoperative anesthesia due to the more reliable block of the lateral femoral cutaneous and obturator nerves.

BACKGROUND AND AIM OF THE WORK To evaluate the efficacy in terms of pain relief and degree of motor impairment of a continuous epidural infusion of 0.125% levobupivacaine in patients undergoing total knee replacement surgery. METHODS 186 patients receiving effective epidural analgesia with 0.125% levobupivacaine during the first 24 hours after surgery were randomly allocated to receive postoperative analgesia for the following 48 hours consisting in either a continued epidural infusion of 0.125% levobupivacaine (Levobupivacaine group, n = 96), or IV PCA morphine only (Morphine PCA group, n = 90). An independent observer recorded the average amount of morphine required per hour following randomisation, pain intensity, degree of motor blockade and occurrence of side effects. RESULTS Median (range) hourly morphine consumption during the study period was 0.21 (0.00-4.65) mg/hr in the Levobupivacaine group and 0.43 (0.04-4.65) mg/hr in the Morphine PCA group (P = 0.005). The quality of pain relief was adequate (VAS < 30 mm) in both groups, but patients in the Levobupivacaine group showed lower VAS values during motion than patients in the Morphine PCA group (P = 0.001). No differences in the proportion of patients with clinically relevant motor block (Bromage's score > or = 1) were reported between the two groups. CONCLUSIONS Continuing the epidural infusion of a concentration of levobupivacaine as low as 0.125% improves pain relief with a 50% reduction of hourly morphine consumption after total knee replacement even during the second and third postoperative days, and does not result in a gross impairment of motor function.

BACKGROUND:The complexity of pain from laparoscopic cholecystectomy and the need for treating incident pain provide rationale for multipharmacological analgesia. We investigated the preoperative administration of controlled-release (CR) oxycodone as transition opioid from remifentanil infusion for pain after laparoscopic cholecystectomy.METHODS:Fifty consecutive patients undergoing laparoscopic cholecystectomy were randomly, double-blindly assigned to treatment group (n=25, CR oxycodone: 1 h before surgery and 12 h after the first administration) or to the control group (n=25, placebo: administered at the same intervals). General anaesthesia was maintained with propofol and remifentanil target-controlled infusions (TCIs). All patients received ketorolac 30 mg i.v. Tramadol i.v. was administered for patient-controlled analgesia (PCA) postoperatively. Numerical rating scale for pain at rest and at movement (NRSr and NRSi), tramadol consumption, times to readiness to surgery and awakening, times to modified Aldrete's and modified Post-Anesthetic Discharge Scoring System (PADSS)>9 and side effects were evaluated.RESULTS:All NRSr and NRSi and tramadol consumption were significantly lower in the treatment group. The oxycodone group showed higher modified Aldrete's scores at each time and reached a PADSS>9 faster. Side effects and postoperative nausea and vomiting episodes were comparable.CONCLUSIONS:We demonstrated the success of a multipharmacological treatment including opioid premedication with CR oxycodone used as transition opioid for TCI remifentanil infusion; the treatment group showed lower pain scores and rescue analgesic consumption, shorter time to discharge from recovery room and from surgical ward, and the same incidence of side effects, comparably to controls.

Il dolore, insieme a sanguinamento, nausea e vomito, è una delle complicanze che maggiormente ostacola la dimissione dopo interventi eseguiti in regime di day-surgery. Il 40% di pazienti accusa dolore moderato-severo dopo intervento chirurgico e questo comporta dimissione ritardata o rientro in ambiente ospedaliero. L’intensità del dolore dipende da diversi fattori: tipo, sede e durata dell’intervento, tipo di anestesia e di farmaci utilizzati nel periodo perioperatorio, educazione e informazione del paziente. Per ridurre l’influenza che il dolore ha sui nostri pazienti è necessario mettere in pratica i moderni concetti di medicina perioperatoria che prvedono un sistema organizzativo tale da assicurare prestazioni di elevata qualità fornendo cure adeguate ad ogni tipo di paziente, minimizzando le complicanze. In tale ottica i migliori risultati si otterranno creando una struttura specifica e applicando le strategie di trattamento multifarmacologico.

This chapter will discuss peripheral nerve blocks (PNBs) of the lower extremity. There are relatively few reports about complications associated with the use of PNBs in general and also about the mechanisms of injury after nerve blockade and methods to prevent them. There is a general agreement about the benefits of PNBs, including preservation of consciousness, hemodynamic stability, postsurgery analgesia, early discharge of the patient, and limited sensory and motor blockade. Lower extremity blocks are very useful techniques to be familiar with and apply, because they provide excellent postoperative pain relief and have a very low incidence of complications, varying between 0% _5%.1 A complication is an undesired event subsequent to a medical treatment that may or may not be reversible, has different grades of severity, and is not always preventable. It differs from an adverse reaction, which may be defined as an undesired event ranging from a simple discomfort to damage limiting daily activities of the patient, but generally preventable. PNBs of the lower extremity have never been as widely taught or used as other techniques of regional anesthesia. This may be attributable to the impossibility of anesthetizing the entire lower extremity with a single injection. Furthermore, injections required to perform a block of the lower extremity are generally deeper than those required for upper extremity block.2 Over the past decade, several developments have led to a growing interest in PNBs of the lower extremity; these changes in clinical practice are mainly the result of reports of new complications associated with central neuraxial techniques, e.g., transient neurologic symptoms associated with spinal anesthesia, an increased risk of epidural hematoma with the introduction of new anti thromboembolic prophylaxis regimens, and to the positive effects on rehabilitation outcomes associated with continuous lower extremity PNBs.2 PNBs are often incorrectly blamed for nerve injuries that are more likely caused by tourniquet pressure, surgical intervention, or poor positioning of the patient.

BACKGROUND AND AIM OF THE WORK:Perioperative hypothermia is a frequent occurrence and can lead to several complications, which adversely affect the patient's outcome, expecially in high risk patient. Nonetheless, central temperature is not frequently monitored in the clinical routine. The aim of this work is to make the point on complications, monitoring techniques, prevention and treatment of mild perioperative hypothermia.METHODS:We reviewed literature on cardiovascular, haemorragic, infectious, and other clinical consequences of mild intraoperative hypothermia, epidemiology and techniques, of temperature monitoring and efficacy of different approaches for the prevention and treatment of mild hypothermia.RESULTS:Cardiovascular, haemorragic and infectious complications are significantly more frequent in hypothermic than in normothermic patients. Elderly and high risk patients are more prone to develop perioperative hypotherma, and are more liable to hypothermia-related complications. The ideal monitoring site has to be chosen considering both the patients characteristics and surgical procedure. Once identified, hypothermia has to be treated and the most effective systems are represented by active forced-air skin warming system. Active prewarming during the preoperative period has been also demonstrated to be efficient in reducing the development of intraoperative hypothermia. Humidification and warming of inspired gases, and warming of intravenous fluids are useful techniques when used in a multimodal approach with active skin warming to maintain perioperative normothermia.CONCLUSIONS:All the patient undergoing surgery for more than 30 minutes should receive an accurate temperature monitoring and a correct management for the maintenance of normothermia. Reducing the incidence and severity of perioperative hypothermia has the potential for drastically reducing complication-related costs.

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 microg 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.

BACKGROUND:Minimally invasive parathyroidectomy (MIP) can be performed under cervical plexus block (CPB). Superficial CPB has been reported to be easier to perform with similar efficacy and less anesthesia-related complications than combined deep and superficial CPB. In this study, we compared the efficacy of superficial and combined (deep and superficial) CPB in patients undergoing MIP. METHODS:Forty-two patients with primary hyperparathyroidism due to a solitary adenoma were randomized to receive either a superficial (group superficial, n = 20) or a combined deep and superficial CPB (group combined, n = 22) using 0.35 mL/kg of 0.5% levobupivacaine. The primary end-point was the amount of supplemental fentanyl required to complete surgery. RESULTS:There were no differences in onset of block, pain scores during surgery, or time to first analgesic request between groups. Fentanyl consumption was similar in both groups, i.e., 50 (0-200) microg in group superficial and 50 (0-100) microg in group combined (P = 0.60). Six patients [1 in group superficial (5%) and 5 in group combined (22.7%)] were converted to general anesthesia for surgically required bilateral neck dissection (P = 0.18). General anesthesia for block failure was reported in three superficial (15%) and two combined group patients (9%) (P = 0.99). In group combined, only one patient (4.5%) showed diaphragmatic paresis after the block (P = 0.99). CONCLUSION:Superficial CPB is an alternative to combined block for MIP.