Finger ischemia in a young lady: an unusual presentation of papillary fibroelastoma with intraventricular location.

An otherwise healthy 32-year-old woman suffered from finger ischemia. An echocardiogram and computed tomography scan revealed a mobile mass in the left ventricle that was attached to the anterior papillary muscle and did not involve the valve leaflets. The tumor was resected, and histopathology confirmed it to be a papillary fibroelastoma. Our case emphasizes the significance of a comprehensive diagnostic work-up for a peripheral ischemic lesion. This resulted in the discovery of an unusual intra-ventricular origin for a commonly benign tumor.

The learning curve for laryngoscopy: Airtraq versus Macintosh laryngoscopes.

PURPOSE: Airtraq use by inexperienced personnel has been evaluated in simulator studies, but little is known about the learning process in real patients. This prospective study was designed to compare learning curves for laryngoscopy with the Airtraq or Macintosh laryngoscopes in patients under general anesthesia. METHODS: Ten medical students with no prior experience in airway management were recruited on a voluntary basis and underwent training in Macintosh and Airtraq laryngoscopy. Patients with no difficult intubation criteria were enrolled after consent. Each student performed laryngoscopy with either device on ten consecutive patients. Success was defined as Cormack-Lehane grading ≤2. We also recorded subjective difficulty scores on an 11-point numerical rating scale. Learning curves were drawn using cumulative success rates and 95% confidence intervals calculated with bootstrap procedures. RESULTS: The mean (95% CI) success rates for the procedures were 86.0% (76.7-93.3%) for the Airtraq and 64.0% (52.0-75.0%) for the Macintosh laryngoscope. Differences in success rate were significant from the fourth attempt and were 22.0% (8.2-36.5%) after the tenth. Seven students achieved success rates ≥90% using the Airtraq, versus one using the Macintosh (P = 0.022). Median (25th-75th percentile) difficulty scores were 2 (1-4) and 4 (2-6), respectively (P < 0.001). CONCLUSION: Students achieved higher success rates using the Airtraq laryngoscope during early training on live patients. The Airtraq may be a useful choice for teaching advanced airway management, especially to professionals who will not perform laryngoscopy on a regular basis.

Tramadol/paracetamol combination tablet for postoperative pain following ambulatory hand surgery: a double-blind, double-dummy, randomized, parallel-group trial.

This randomized, double-blind, double-dummy, multicenter trial compared efficacy and safety of tramadol HCL 37.5 mg/paracetamol 325 mg combination tablet with tramadol HCL 50 mg capsule in the treatment of postoperative pain following ambulatory hand surgery with iv regional anesthesia. Patients received trial medication at admission, immediately after surgery, and every 6 hours after discharge until midnight of the first postoperative day. Analgesic efficacy was assessed by patients (n = 128 in each group, full analysis set) and recorded in a diary on the evening of surgery day and of the first postoperative day. They also documented the occurrence of adverse events. By the end of the first postoperative day, the proportion of treatment responders based on treatment satisfaction (primary efficacy variable) was comparable between the groups (78.1% combination, 71.9% tramadol; P = 0.24) and mean pain intensity (rated on a numerical scale from 0 = no pain to 10 = worst imaginable pain) had been reduced to 1.7 ± 2.0 for both groups. Under both treatments, twice as many patients experienced no pain (score = 0) on the first postoperative day compared to the day of surgery (35.9% vs 16.4% for tramadol/paracetamol and 36.7% vs 18% for tramadol treatment). Rescue medication leading to withdrawal (diclofenac 50 mg) was required by 17.2% patients with tramadol/paracetamol and 13.3% with tramadol. Adverse events (mainly nausea, dizziness, somnolence, vomiting, and increased sweating) occurred less frequently in patients under combination treatment (P = 0.004). Tramadol/paracetamol combination tablets provided comparable analgesic efficacy with a better safety profile to tramadol capsules in patients experiencing postoperative pain following ambulatory hand surgery.

Kounis syndrome in a patient with ovarian cancer and allergy to iodinated contrast media: report of a case of vasospastic angina induced by chemotherapy.

We report the case of a 71-year-old woman with previous coronary angioplasty, ovarian cancer with multiple metastases and allergy to iodinated contrast media, who developed vasospastic angina after several treatments with cisplatin and cyclophosphamide, so that we considered this as a case of "allergic angina" or Kounis syndrome (type II variant). The patient underwent standard anti-ischemic therapy with nitrates, calcium blocking agents and enoxaparin so having an uneventful outcome.

The effects of ultrasound guidance and neurostimulation on the minimum effective anesthetic volume of mepivacaine 1.5% required to block the sciatic nerve using the subgluteal approach.

BACKGROUND: We tested the hypothesis that ultrasound (US) guidance may reduce the minimum effective anesthetic volume (MEAV(50)) of 1.5% mepivacaine required to block the sciatic nerve with a subgluteal approach compared with neurostimulation (NS). METHODS: After premedication and single-injection femoral nerve block, 60 patients undergoing knee arthroscopy were randomly allocated to receive a sciatic nerve block with either NS (n = 30) or US (n = 30). In the US group, the sciatic nerve was localized between the ischial tuberosity and the greater trochanter. In the NS group, the appropriate muscular response (foot plantar flexion or inversion) was elicited (1.5 mA, 2 Hz, 0.1 ms) and maintained to

Preoperative administration of controlled-release oxycodone as a transition opioid for total intravenous anaesthesia in pain control after laparoscopic cholecystectomy.

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.

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

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.

Spinal anesthesia with lidocaine or preservative-free 2-chlorprocaine for outpatient knee arthroscopy: a prospective, randomized, double-blind comparison.

BACKGROUND: In this prospective, randomized, double-blind study we tested the hypothesis that 50 mg of 1% preservative-free 2-chloroprocaine would provide a faster resolution of spinal block than the same dose of 1% plain lidocaine. METHODS: After IV midazolam premedication (0.03 mg/kg), 30 ASA physical status I-II outpatients undergoing knee arthroscopy were randomly allocated to receive 50 mg of either 1% plain lidocaine (n = 15) or 1% preservative-free plain chloroprocaine (n = 15). A blinded observer recorded the evolution of sensory (loss of pinprick sensation) and motor (modified Bromage scale) block until complete regression, as well as times to unassisted ambulation and voiding. A telephone call follow-up was performed 24 h and 7 days after surgery. RESULTS: Two chloroprocaine patients (13%) and one lidocaine patient (7%) required fentanyl supplementation (100 microg IV) (P = 0.99) intraoperatively, but no patient required general anesthesia to complete surgery. Median (range) times for recovery of sensory and motor function, and unassisted ambulation were faster with 2-chloroprocaine [95 (68-170) min; 60 (45-120) min; and 103 (70-191) min] than lidocaine [120 (80-175) min; 100 (60-140) min; and 152 (100-185) min] (P = 0.019, P = 0.0005, and P = 0.003, respectively). No differences in first voiding were reported between chloroprocaine [180 (100-354) min] and lidocaine patients [190 (148-340) min] (P = 0.191). Transient neurological symptoms were reported in five lidocaine patients (33%) but no chloroprocaine patients (0%) (P = 0.042). CONCLUSION: Intrathecal injection of 50 mg of preservative-free 2-chloroprocaine 1% resulted in quicker recovery of sensory/motor function, and unassisted ambulation, and fewer incidences of transient neurologic symptoms than the same dose of 1% lidocaine.

Clinical complications, monitoring and management of perioperative mild hypothermia: anesthesiological features.

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.

Intrathecal 2-chloroprocaine for lower limb outpatient surgery: a prospective, randomized, double-blind, clinical evaluation.

We evaluated the dose-response relationship of 2-chloroprocaine for lower limb outpatient procedure in 45 ASA physical status I-II outpatients undergoing elective lower limb surgery under spinal anesthesia, with 30 mg (group Chlor-30, n = 15), 40 mg (group Chlor-40, n = 15), or 50 mg (group Chlor-50, n = 15) of 1% preservative free 2-chloroprocaine. Onset time was similar in the three groups. General anesthesia was never required to complete surgery. Intraoperative analgesic supplementation as a result of insufficient duration of spinal block was required in 5 patients of group Chlor-30 (35%) and 2 patients of group Chlor-40 (13%) (P = 0.014), with a median (range) time for supplementation request of 40 (30-60) min. Spinal block resolution and recovery of ambulation were faster in group Chlor-30 (60 [41-98] min and 85 [45-123] min) than in groups Chlor-40 (85 [46-141] min and 180 [72-281] min) and Chlor-50 (97 [60-169] min and 185 [90-355] min) (P = 0.001 and P = 0.003, respectively), with no differences in home discharge time (182 [120-267] min in group Chlor-30, 198 [123-271] min in group Chlor-40, and 203 [102-394] min in group Chlor-50; P = 0.155). No transient neurologic symptoms were reported at 24-h and 7-day follow-up. We conclude that although 40 and 50 mg of 2-chloroprocaine provide adequate spinal anesthesia for outpatient procedures lasting 45-60 min, 30 mg produces a spinal block of insufficient duration.

Spinal ropivacaine or bupivacaine for cesarean delivery: a prospective, randomized, double-blind comparison.

BACKGROUND AND OBJECTIVES: The aim of this prospective, randomized, double-blinded study was to compare clinical efficacy and safety of ropivacaine and bupivacaine given intrathecally in combination with morphine for cesarean delivery. METHODS: With ethical committee approval and a written informed consent, 60 women scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive spinal anesthesia with either 20 mg ropivacaine plus 0.1 mg morphine (n = 30) or 15 mg bupivacaine plus 0.1 mg morphine (n = 30). Profile of spinal block (onset and recovery times), cardiovascular effects, and quality of postoperative analgesia (patient-controlled morphine) were recorded by a blinded observer. RESULTS: The onset time of motor block was shorter after bupivacaine (8 +/- 2 min) than after ropivacaine (12 +/- 5 minutes) (P <.05), whereas duration of both sensory and motor blocks was longer after bupivacaine (139 +/- 37 minutes and 254 +/- 76 minutes) than after ropivacaine (112 +/- 27 minutes and 211 +/- 48 minutes) (P <.01 and P <.05, respectively). No differences in intraoperative quality of anesthesia and clinical hypotension requiring ephedrine administration were observed between the two groups. Postoperative analgesia was similarly effective in both groups; however median consumption of patient-controlled morphine during the first 24 hours after surgery was higher in patients of group Ropivacaine (5 mg; range, 0 to 18 mg) than in patients of group Bupivacaine (2 mg; range, 0 to 7 mg) (P <.01). CONCLUSION: Spinal anesthesia produced with 20 mg ropivacaine plus 0.1 mg morphine is as effective and safe as that provided by 15 mg bupivacaine plus 0.1 mg morphine, with an earlier recovery of sensory and motor functions after surgery.

Intraoperative epidural anesthesia and postoperative analgesia with levobupivacaine for major orthopedic surgery: a double-blind, randomized comparison of racemic bupivacaine and ropivacaine.

STUDY OBJECTIVE: To compare the onset time and duration of epidural anesthesia, and the quality of postoperative analgesia produced by levobupivacaine, racemic bupivacaine, and ropivacaine. DESIGN: Prospective, randomized, double-blinded study. SETTING: Inpatient anesthesia at a University Hospital. PATIENTS: 45 ASA physical status I, II, and III patients, undergoing elective total hip replacement. INTERVENTIONS: After standard intravenous midazolam premedication and infusion of 500 mL of Ringer's acetate solution, patients were randomly allocated to receive epidural block with 0.5% levobupivacaine (n = 15), 0.5% bupivacaine (n = 15), or 0.5% ropivacaine (n = 15). Postoperatively, after pinprick sensation recovered at T(t), a patient-controlled epidural infusion was provided with 0.125% levobupivacaine, 0.125% bupivacaine, or 0.2% ropivacaine, respectively (baseline infusion rate 5 mL/hr; incremental bolus 2 mL, lockout time: 20 min). Intravenous ketoprofen was also available for rescue analgesia if required. MEASUREMENTS AND MAIN RESULTS: The onset time of sensory block was 31 +/- 16 minutes with levobupivacaine, 25 +/- 19 minutes with bupivacaine, and 30 +/- 24 minutes with ropivacaine (p = 0.98), after a median (range) volume of 15 (10-18) mL in Group Levobupivacaine, 14 (10-18) mL in Group Bupivacaine, and 15 (10-18) mL in Group Ropivacaine (p = 0.85). Six patients in the ropivacaine group (40%) showed an intraoperative Bromage score <2 as compared with only three patients of Group Levobupivacaine (20%) and no patient of Group Bupivacaine (p = 0.02). Recovery of pinprick sensation at T(t) occurred after 214 +/- 61 minutes with levobupivacaine, 213 +/- 53 minutes with bupivacaine, and 233 +/- 34 minutes with ropivacaine (p = 0.26). A similar degree of pain relief was observed in the three groups without differences in local anesthetic consumption and need for rescue analgesia. Motor blockade progressively resolved without differences among the three groups. CONCLUSIONS: Levobupivacaine 0.5% produces an epidural block of similar onset, quality, and duration as the one produced by the same volume of 0.5% bupivacaine, with a motor block deeper than that produced by 0.5% ropivacaine. When prolonging the block for the first 12 hours after surgery with a patient-controlled epidural infusion, 0.125% levobupivacaine provides adequate pain relief after major orthopedic surgery, with similar recovery of motor function as compared with 0.125% bupivacaine and 0.2% ropivacaine.

Temperature control and recovery of bowel function after laparoscopic or laparotomic colorectal surgery in patients receiving combined epidural/general anesthesia and postoperative epidural analgesia.

UNLABELLED: We compared the effects of a laparoscopic (n = 23) versus laparotomic (n = 21) technique for major abdominal surgery on temperature control in 44 patients undergoing colorectal surgery during a combined epidural/general anesthesia. A thoracic epidural block up to T4 was induced with 6-10 mL of 0.75% ropivacaine; general anesthesia was induced with thiopental, fentanyl, and atracurium IV and maintained with isoflurane. Core temperature was measured with a bladder probe and recorded every 15 min after the induction. In both groups, core temperature decreased to 35.2 degrees C (range, 34 degrees C-36 degrees C) at the end of surgery. After surgery, normothermia returned after 75 min (60-120 min) in the Laparoscopy group and 60 min (45-180 min) in the Laparotomy group (P = 0.56). No differences in postanesthesia care unit discharge time were reported between the two groups. The degree of pain during coughing was smaller after laparoscopy than laparotomy from the 24th to the 72nd observation times (P < 0.01). Morphine consumption was 22 mg (2-65 mg) in the Laparotomy group and 5 mg (0-45 mg) in the Laparoscopy group (P = 0.02). The time to first flatus was shorter after laparoscopy (24 h [16-72 h]) than laparotomy (72 h [26-96 h]) (P = 0.0005), and the first intake of clear liquid occurred after 48 h (24-72 h) in the Laparoscopy group and after 96 h (90-96 h) in the Laparotomy group (P = 0.0005). Although laparoscopic surgery provides positive effects on the degree of postoperative pain and recovery of bowel function, the reduction in heat loss produced by minimizing bowel exposure with laparoscopic surgery does not compensate for the anesthesia-related effects on temperature control, and active patient warming must also be used with laparoscopic techniques. IMPLICATIONS: This prospective, randomized, controlled study demonstrates that laparoscopic colorectal surgery results in less postoperative pain and earlier recovery of bowel function than conventional laparotomy but does not reduce the risk for perioperative hypothermia. Accordingly, active warming must be provided to patients also during laparoscopic procedures.