The hip fracture surgery in elderly patients (HIPELD) study to evaluate xenon anaesthesia for the prevention of postoperative delirium: a multicentre, randomized clinical trial.

BACKGROUND: Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery. METHODS: This was a phase II, multicentre, randomized, double-blind, parallel-group, controlled clinical trial conducted in hospitals in six European countries (September 2010 to October 2014). Elderly (≥75yr-old) and mentally functional hip fracture patients were randomly assigned 1:1 to receive either xenon- or sevoflurane-based general anaesthesia during surgery. The primary outcome was postoperative delirium diagnosed through postoperative day 4. Secondary outcomes were delirium diagnosed anytime after surgery, postoperative sequential organ failure assessment (SOFA) scores, and adverse events (AEs). RESULTS: Of 256 enrolled patients, 124 were treated with xenon and 132 with sevoflurane. The incidence of delirium with xenon (9.7% [95% CI: 4.5 -14.9]) or with sevoflurane (13.6% [95% CI: 7.8 -19.5]) were not significantly different (P=0.33). Overall SOFA scores were significantly lower with xenon (least-squares mean difference: -0.33 [95% CI: -0.60 to -0.06]; P=0.017). For xenon and sevoflurane, the incidence of serious AEs and fatal AEs was 8.0% vs 15.9% (P=0.05) and 0% vs 3.8% (P=0.06), respectively. CONCLUSIONS: Xenon anaesthesia did not significantly reduce the incidence of postoperative delirium after hip fracture surgery. Nevertheless, exploratory observations concerning postoperative SOFA-scores, serious AEs, and deaths warrant further study of the potential benefits of xenon anaesthesia in elderly hip fracture surgery patients. CLINICAL TRIAL REGISTRATION: EudraCT 2009-017153-35; ClinicalTrials.gov NCT01199276.

Soft tissue depression at the iliac crest prominence: a new landmark for identifying the L4-L5 interspace.

BACKGROUND: One of the most common approaches to identifying the L4-L5 interspace is using the iliac crest as a landmark. We propose a new landmark to identify the L4-L5 interspace based on the soft tissue depression palpable at the iliac crest prominence. The aim of this study was to assess the reliability and time saving when using this new landmark compared to using the iliac crest to perform a lumbar plexus block. METHODS: Fifty-four patients scheduled for lower limb surgery were randomly allocated to have a lumbar plexus block performed using the iliac crest (Chayen's approach) or the soft tissue depression (Borghi's approach). The landmarks for both approaches were drawn on each patient prior to randomization (N.=27 per group). All the blocks were performed by an anesthesiologist familiar with both techniques using a nerve stimulator and 30 mL of 0.5% levobupivacaine. The time to achieve successful needle placement and the number of needle re-directions, as well as the onset time for the sensory and motor blockade, were recorded. RESULTS: All the blocks using Borghi's approach were performed successfully. With the Chayen's approach, there were 5 needle placement failures. The mean times to onset of a successful block after injection of the local anesthetic did not differ between the two groups: 17.8±3.9 min for the Chayen vs. 15.9±2.4 min for the Borghi's approach (P=0.14). However, the mean time to achieve correct needle placement was 7.6±3.2 min with the Chayen's approach compared to 5.1 (±2.6 SD) min with the Borghi's approach (P<0.01). The Chayen's approach also required a significantly higher median number of needle redirections (2 [inter-quartile range (IQR): 0-4] vs. 0 [IQR: 0-4], P<0.01). In obese patients (BMI ≥30 kg/m(2)), the mean placement time was 10.5±1.7 min vs. 4.8±2.1 min (P<0.01), and median number of needle re-directions was 2.5 (IQR: 2-3) vs. 0.5 (IQR: 0-3) (P=0.04), with the Chayen and Borghi's approach, respectively. CONCLUSION: Use of the palpable soft tissue depression at the iliac crest prominence for performing a lumbar plexus block offered several potential advantages over the standard inter-iliac crest approach.

Levobupivacaine.

Bupivacaine has been the most widely used local anaesthetic for years. Recent studies point out levobupivacaine, an S(-) isomer of the racemic bupivacaine. This review shows the properties of levobupivacaine describing the animal and human volunteers studies on toxicity and the first clinical studies in obstetrics, general surgery and paediatrics. In vitro animal studies show that, injected intravenously, levobupivacaine has less cardiotoxic effects and less toxic effects on the CNS in comparison with both R(+) bupivacaine and bupivacaine itself, caused by a minor affinity for brain tissue resulting in less CNS depressant effects as well as for myocardial tissue, which leads to a higher dose necessary before being lethal in comparison to bupivacaine. Studies in human volunteers confirm these results, adding a minor arrhythmogenic, and less negative inotropic effect. Clinical studies show no significant differences in onset, duration and sensory block, but complete regression of sensory block takes longer. Potency is equal for levo- and bupivacaine according to MLAC in labour analgesia. Studies in paediatrics confirm effective analgesia but show less intensity of motor block. The reduced toxicity of levobupivacaine gives wider safety margin in the daily clinical practice both for single shot and for continuous infusion, intraoperatively during various surgical procedures and for the postoperative pain control and analgesia in labour.

[Loco-regional anaesthesia of the lower limbs]. / Anestesia loco-regionale dell'arto inferiore.

Lumbar plexus and sacral plexus are responsible for sensory and motor innervation of the whole inferior limb and their blockade can be used as a single technique or integrated with general anaesthesia for hip-, femur-, knee-, lower leg-, ankle- and foot surgery. For the performance of the blocks, knowledge of peripheral and central percourse of the nerves and their anatomical relationships to bone-, muscle-, vessel and skin structures is important. In case of the sciatic nerve, a cutaneous projection of the percourse of the nerve is possible (the so-called sciatic line) formed by a virtual line from the midpoint of the line between great trochanter and ischial tuberosity to the apex of the popliteal fossa. Peripheral blocks used for the above mentioned types of surgery are: lumbar plexus block, sacral plexus block, femoral nerve block, obturator nerve block, lateral cutaneous femoral nerve block and sciatic nerve block. Regarding the last one, the following approaches are possible, depending on the anatomical site of performance: classic proximal posterior block, parasacral proximal block, lithotomic posterior proximal block, subgluteal posterior proximal block, anterior proximal block, lateral medio femoral popliteal proximal block, block distal from the poplitea, subcalcaneal block. The terms distal and proximal are in relation to the small trochanter. All blocks have to be performed using a nerve stimulator, teflon insulated needles of various measures depending on the kind of block, variable stimulation from 1,5 mA (when evoking muscle contraction) to 0,5-0,3 mA (injection of local anaesthetic) with frequencies of 2 Hz/0,1 ms.

[Patient controlled regional analgesia (PCRA) in surgery of stiff elbow: elastomeric vs electronic pump]. / Analgesia regionale controllata dal paziente (PCRA) nella chirurgia del gomito anchilotico: elastomero vs pompa elettronica.

BACKGROUND: Aim of this study is to confront an elastomeric pump at regular infusion controlled by the patient with an electronic pump with self-administration for analgesia, by continuous infraclavicular brachial plexus block, as support for the intensive postoperative physiotherapy. METHODS: With signed informed consent 10 patients undergoing corrective surgery for stiff elbow were included. All patients received ropivacaine 30 ml 0,50% for anaesthesia by infraclavicular block with bicipite twitch, after which a catheter was left in situ. In group 1 analgesia consisted of ropivacaina 0,4% by electronic pump (continuous infusion with self-administration of bolus) at day1 and day2, and by elastomeric pump at 5 ml/h, connected to a three way tap managed by the patient (open-closed) at day3 and day4. Group 2 received at day1 and day2 the elastomeric pump and then the electronic pump. All patients continued at home with the elastomeric pump. Flexion-extension capacity of the elbow, daily consumption of ropivacaine 0,4%, and patients comfort were all evaluated. RESULTS: With the electronic pump, flexion-extension capacity is significantly better compared to elastomeric pump. During the use of the electronic pump, consumption of ropivacaina 0.4% was significantly higher in day2 compared to day1 (physiotherapy started day2); consumption in day3 and Day4 was significantly less compared to day2. All patients preferred the electronic pump for the first two days and then the elastomeric pump. CONCLUSION: PCRA quality is higher with ropivacaine 0,4% during the first phase of recovery. The elastomeric pump instead, insufficient in the first phase, is useful for analgesia at home.

[Quality of the postoperative course and patients' satisfaction produced by a system of postoperative pain control: postoperative clinical evidence that influences the quality of the postoperative course]. / Qualità del decorso postoperatorio e soddisfazione del paziente prodotta da un sistema di controllo del dolore postoperatorio. Evidenze cliniche postoperatorie che influenzano la qualità del decorso postoperatorio.

UNLABELLED: Acute pain treatment after surgery or trauma, when inadequate, contributes to increased morbidity and prolonged in hospital stay. Acute postoperative pain management can be realised by application of treatment protocols and the regular assessment of the patients clinical conditions. The aim of the ACUTE PAIN SERVICE (APS) is to plan postoperative treatment. According to our experience, besides providing assistance, the APS elaborates results and intervenes through regular audits to improve quality. This system is further enriched through collection of information obtained through an anonymous questionnaire compiled by the patients about forty eight hours after surgery. The questions are expressed such to outline a judgement about patients' satisfaction towards the services supplied by the agency. OBJECTIVE: Evaluation of effectiveness of pain treatment and level of postoperative wellbeing through continuous observation of the patient. METHODS: a retrospective study on about 4400 consecutive patients arriving at the APS in the last 2 years of activity, who have been evaluated at fixed moments using various indicators (VAS at rest/activity, PONV and other discomforts). RESULTS: Follow-up of the patients showed that: - pain relief, when reached, does not conform well-being; - for certain symptoms of discomfort, specific protocols are necessary; - there are correlations between type of surgery, type of anaesthesia and discomfort, which may be reducible through the right attitude in behaviour and therapy; - antalgic therapy itself can cause several side-effects. The solution of the discomfort problem gets close to the concept of perioperative medicine in which APS action goes beyond pain, towards a more complete pain management.

[Orthopaedic one day surgery: anaesthesiologic techniques used and intra- and postoperative complications]. / One day surgery otropedico: tecniche anestesiologiche utilizzate e complicanze intra- e postoperatorie.

OBJECTIVE: Optimize patient management in one day surgery (ODS) by an observative study regarding one day orthopaedic surgery, assessing kind and quantity of intra- and postoperative complications, need for prolonged postoperative assistance postponing discharge, recovery in other hospitals, patients satisfaction index. METHODS: From september 1999 until december 2000 we distributed a questionnaire 1286 consecutive patients. The patients were ASA I (80,7%), ASA II (17%) and ASA III (2,3%). We evaluated intra- and postoperative complications considering type of surgery and anaesthesiologic technique; need and reason for medical consulting; if consulting took place in other institutes. Patients judgement regarding medical and nursing assistance during in hospital stay was assessed. RESULTS: Main surgical procedures: arthroscopy (44,6%), internal fixation removal (21,3%), neurolysis (9,5%), cysts/tumours/nodules removal (7,5%), foot surgery (8,0%). Used anaesthesiologic techniques: neural block (65,6%), plexus block (15,1%), general (12,5%), spinal (4,8%) and local anaesthesia (1,9%). An intraoperative complication (convulsion) was reported twice. Postoperative complications: pain (3,6%) most frequent in foot surgery (5,2%), nausea (0,2%), fever (0,7%), haematoma (0,5%). 5 delayed discharges (beyond 24h) were reported, for surgical reasons. In 5 cases another institute was visited. There were no deads. CONCLUSIONS: The percentage of not planned recoveries (0,1%) is an indication of frequency of major complications. Satisfaction index of patients was high (96%). Kind of surgical procedure and anaesthesiologic technique, considering the minimal intra- and postoperative complications, are adjusted to the ODS regime. Reinforcing analgesic protocols in foot surgery though are necessary. According to our opinion the peripheral block is preferable in orthopaedic ODS.