Dexmedetomidine: Current Role in Burn ICU.

Dexmedetomidine (DEX) is a relativelyrecent a2-adrenergic agonist which provides sedation, anxiolysis and analgesia with much less respiratory depression than other sedatives. These characteristics have implemented the use of the drug in the ICUs in order to achieve the target of a "arousable sedation", thanks to its significant manageability. Its sedative-analgesic properties are also particularly suitable for use in burn ICUs, both adult and pediatric, which is why the current Guidelines have recognized a central role in the management of these categories of patients. Finally, DEX has showed significant anti-inflammatory effect both in animal models and in preliminary clinical trials, reducing vasopressor requirements and main mediators levels of the systemic inflammatory response involved in sepsis and similar processes, suggesting its use for improved outcome in ICU septic patients.

Postoperative Pain Surveys in Italy from 2006 and 2012: (POPSI and POPSI-2).

OBJECTIVE: Despite established standards, effective treatments, and evidence-based guidelines, postoperative pain control in Italy and other parts of the world remains suboptimal. Pain control has been recognized as a fundamental human right. Effective treatments exist to control postsurgical pain. Inadequate postoperative analgesia may prolong the length of hospital stays and may adversely impact outcomes. MATERIALS AND METHODS: The same multiple-choice survey administered at the SIAARTI National Congress in Perugia in 2006 (n=588) was given at the SIAARTI National Congress in Naples, Italy in 2012 (n=635). The 2012 survey was analysed and compared to the 2006 results. RESULTS: Postoperative pain control in Italy was less than optimal in 2006 and showed no substantial improvements in 2012. Geographical distinctions were evident with certain parts of Italy offering better postoperative pain control than other. Fewer than half of hospitals represented had an active Acute Pain Service (APS) and only about 10% of postsurgical patients were managed according to evidence-based guidelines. For example, elastomeric pumps for continuous IV infusion are commonly used in Italy, although patient-controlled analgesia systems are recommended in the guidelines. The biggest obstacles to optimal postoperative pain control reported by respondents could be categorized as organizational, cultural, and economic. CONCLUSIONS: There is considerable room for improvement in postoperative pain control in Italy, specifically in the areas of clinical education, evidence-based treatments, better equipment, and implementation of active APS departments in more hospitals. Two surveys taken six years apart in Italy reveal, with striking similarity, that there are many unmet needs in postoperative pain control and that Italy still falls below European standards for postoperative pain control.

Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Non-invasive ventilation outside of the Intensive Care Unit: an Italian survey.

BACKGROUND: Non-invasive ventilation (NIV) is increasingly utilized for patients with acute respiratory failure (ARF). The shortage of Intensive Care Unit (ICU) beds, a growing confidence with the technique, and the opportunity to treat ARF in a more responsive phase lead to the application of NIV outside of the ICU. The Study Group on Emergency of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) promoted a national survey to collect data on NIV use outside of the ICU. METHODS: An anonymous questionnaire was developed, focusing on the location and modalities of NIV treatments, organizational and technical aspects, monitoring, estimated outcomes, the presence of protocols, and complications. The questionnaire was mailed to all members of the Scientific Society. RESULTS: Forty-six respondents were from 46 hospitals. Thirty-seven (80%) respondents applied NIV in the Emergency Department and/or General Wards. In the majority of hospitals (72%), training preceded NIV introduction. NIV could be applied in all ordinary wards in 28% of the hospitals. Patients remained in their ward in 89% of the hospitals, and a protocol was present in 70% of the hospitals. Monitoring was usually limited to continuous pulse-oxymetry and EKG; 18% of respondents did not have a monitoring standard. Reported complications and practical problems were potentially severe. Few hospitals (15%) collected data on NIV treatments. The efficacy of NIV was perceived as low, as 73% of respondents estimated that NIV avoided tracheal intubation in less than half of the treated patients. CONCLUSION: In Italy, NIV is extensively applied in non-intensive wards, and its use is not free from criticalities and contradictions. Further prospective studies and possibly guidelines are needed.

Novel missense mutations and unexpected multiple changes of RYR1 gene in 75 malignant hyperthermia families.

Malignant hyperthermia (MH) is an autosomal dominant pharmacogenetic disorder of skeletal muscle characterized by disturbance of intracellular calcium homeostasis in the sarcoplasmic reticulum. Mutations of the ryanodine receptor 1 (RYR1) gene account for most cases, with some studies claiming up to 86% of mutations in this locus. However, RYR1 gene is large and variants are common even in the normal population. We examined 54 families with MH susceptibility and 21 diagnosed with equivocal MH. Thirty-five were selected for an anesthetic reaction, whereas the remainder for hyperCKemia. In these, we studied all 106 exons of the RYR1 gene. When no mutation was found, we also screened: sodium channel voltage-gated, type IV alpha subunit (SCN4A), calcium channel voltage-dependent, L type, alpha 1S subunit (CACNA1S), and L-type voltage-gated calcium channel alpha 2/delta-subunit (CACNL2A). Twenty-nine different RYR1 mutations were discovered in 40 families. Three other MH genes were tested in negative cases. Fourteen RYR1 amino acid changes were novel, of which 12 were located outside the mutational 'hot spots'. In two families, the known mutation p.R3903Q was also observed in malignant hyperthermia-nonsusceptible (MHN) individuals. Unexpectedly, four changes were also found in the same family and two in another. Our study confirms that MH is genetically heterogeneous and that a consistent number of cases are not due to RYR1 mutations. The discordance between in vitro contracture test status and the presence of a proven causative RYR1 mutation suggests that the penetrance may vary due to as yet unknown factors.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version.

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.

Postoperative pain survey in Italy (POPSI): a snapshot of current national practices.

AIM: Over the last several years, significant efforts have been directed towards improving the quality of postoperative pain management. As data are lacking on the organization and quality of these services in Italy, we surveyed current Italian practices. METHODS: A 16-item questionnaire was randomly supplied to 650 anesthesiologists attending the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care Medicine (SIAARTI) National Congress in 2006. The survey requested information concerning their current practices in analgesic techniques, use of guidelines, educational programs, availability of an Acute Pain Service (APS), and existing barriers to optimal postoperative pain management. RESULTS: Based on 588 respondents, a sample of 163 hospitals was analyzed (24.4% of Italian public hospitals); 41.7% of the surveyed hospitals had an organized APS. University and teaching hospitals had an organized APS more frequently than did other hospitals (P<0.02). Continuous intravenous analgesia using elastomeric infusion systems was the most commonly used analgesic technique, performed in 44% of the treated patients. The frequency of both intravenous patient-controlled analgesia and epidural techniques was extremely low (5% and 13%, respectively). The main reasons given for suboptimal pain relief were inadequate training of surgeons and nurses (44.3%), poor organization (29.9%), and lack of equipment (21.5%). A total of 51.2% of the respondents would like to have a dedicated anesthesiologist assigned on a daily rotational basis to postoperative pain management. CONCLUSIONS: A comparison to international survey data showed that postoperative pain management in Italy is still below the European standards. Additional efforts to overcome these hurdles and to reach an acceptable level of quality are required.

Efficacy of treatment with percutaneous vertebroplasty and kyphoplasty for traumatic fracture of thoracolumbar junction.

AIM: The aim of this paper was to assess the efficacy of a minimally invasive treatment with percutaneous vertebroplasty and kyphoplasty for traumatic fracture of thoracolumbar junction. Treatment of stable traumatic vertebral fractures of the thoracolumbar junction without neurological deficit is still controversy. Conservative treatment, characterized by discomfort and limitation in patient mobility, was progressively replaced by minimally invasive techniques such as percutaneous vertebroplasty and kyphoplasty. METHODS: Between January 2003 and August 2005, 34 patients suffering from 42 thoracolumbar fractures were treated at Neurosurgical Department of Istituto Galeazzi (Milan). The treatment selected (vertebroplasty versus kyphoplasty), depended on age of patients, timing and type of fracture. Results were clinically assessed by Visual Analogue Score (VAS) and Oswestry Disability Index. RESULTS: Mean preoperative VAS was 8.32 (range 5-10). Percutaneous vertebroplasty was performed in 25 cases (73.5%); while 9 patients were treated by kyphoplasty (27.5%); 27 patients showed a single level and 7 multilevel of the fractures. No complications occurred (infection, neurological deficit, embolic events) after treatment. At the early follow-up 91.7% of the patients achieved a good pain control already after 24 hours. Pain relief and disability, analyzed by VAS and Oswestry Disability Index, showed a good results at late follow-up time. CONCLUSIONS: Percutaneous vertebroplasty and kyphoplasty are two safe and effective techniques for treatment of thoracolumbar traumatic fractures and allow a good pain-control and return to normal working activity and social life.

Strategies for the prevention of asthmatic, anaphylactic and anaphylactoid reactions during the administration of anesthetics and/or contrast media.

General anesthetics and contrast media can cause anaphylactic as well as anaphylactoid reactions. These events are of great concern to radiologists and anesthesiologists because of their relatively high prevalence, possible threat to life, and medical-legal consequences. Points discussed in this review are the critical evaluation of risk factors affecting prevention strategies, the need to be aware of pathogenic mechanisms relevant to prevention strategies, the use of alternative products if a culprit agent is known, the recognition of early signs of a reaction, the need to keep records of reactions on a patient's medical chart, the planning of prophylactic therapy, recommended actions after a reaction to an anesthetic or contrast medium, and the suggested establishment of allergy-anesthesiology centers to improve cooperation, and medical-legal issues. As any drug or contrast medium administered during general anesthesia or a diagnostic procedure can induce a potentially life-threatening or fatal event even in the absence of any evident risk factor in the patient's medical history or clinical status, we usually premedicate susceptible individuals at least to attenuate the severity of an unpredictable reaction, although we cannot rely on the efficacy of premedication to completely prevent a severe event. These recommendations, which are based on the literature and on the experience of our working group, aim to provide useful information for physicians and other specialists who operate in the absence of an allergy consultant.

Follow-up of patients tested for malignant hyperthermia susceptibility.

BACKGROUND AND OBJECTIVE: Malignant hyperthermia is an inherited disorder of skeletal muscle characterized by muscle contracture and hypermetabolic crisis following exposure to halogenated anaesthetics and depolarizing muscle relaxants. We planned this follow-up to get more information about the safety of non-triggering anaesthesia in susceptible patients; the safety of the use of trigger agents in non-susceptible patients and any minor sequelae following the biopsy. METHODS: A questionnaire was sent to 244 patients tested for susceptibility between 1998 and 2004 enquiring about sequelae from the biopsy, subsequent experience with anaesthesia and difficulties encountered because of the investigation. RESULTS: Replies were received from 129 patients. Thirty-four complained about sequelae from the biopsy: 10 reported headache and nausea; 16 experienced pain and a lack of strength in the biopsed leg and 8 found the scar less than satisfactory. Ten patients found it difficult to find a diagnostic centre. Eighteen reported problems and/or delay when they had needed a subsequent anaesthetic. Fourteen patients found the anaesthesiologist reluctant to anaesthetize them and four experienced a delay. Forty-three patients received anaesthesia since their biopsy. Complete medical records were available for 24 anaesthetic exposures in 23 patients. No documented perioperative complications occurred. Only three non-susceptible patients received one trigger agent. CONCLUSIONS: It is safe to use trigger-free anaesthesia in susceptible patients. The difficulties encountered by patients to be anaesthetized and the management of the majority of non-susceptible patients during general anaesthesia show the need of more accurate educational programmes and methods for promoting patient-centred care.

Monitored anesthesia care and loco-regional anesthesia. Vascular surgery use.

Association of locoregional techniques such as deep and superficial cervical block, lumbar epidural and/or peripheral blocks, and conscious sedation with hypnotic drugs (propofol 1-3 mg/kg/h or midazolam 2-4 mg/h) and/or opiates drugs (sufentanil 5-10 mcg or remifentanil 0.05-0.1 mcg/kg/min) is actually, the gold standard for vascular surgery. Our personal experience is based on 328 patients submitted to carotid endarterectomy, aneurysm repair and peripheral surgery.