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.

Preoperative autonomic nervous system analysis may stratify the risk of hypotension after spinal anesthesia.

BACKGROUND: Studies on pregnant women undergoing cesarean delivery or elderly men scheduled for prostate brachytherapy have demonstrated the predictive value of heart rate variability (HRV) analysis for hypotension during spinal anesthesia. We conducted a prospective observational study to investigate if preoperative HRV analysis may have a role in identifying the risk of hypotension following spinal anesthesia in otherwise healthy patients. METHODS: The study investigated 47 ASA physical status I-II patients aged between 18-50 years that underwent subarachnoid anesthesia for lower abdominal or orthopedic scheduled surgery. ECG was recorded from all subjects before the subarachnoid block. We analysed the autonomic nervous system modulation, measured by HRV analysis. The variables that were be considered were preoperative HRV total power, low frequency (LF) and high frequency (HF) heart beat oscillations and LF/HF ratio. The LF/HF ratio was dichotomized according to the median for sensitivity analysis. The lowest arterial pressure value between spinal anesthesia and the end of surgery was recorded. RESULTS: The median LF/HF before anesthesia was 2.3. We considered two groups of 23 (LF/HF<2.3, group LOW) and 24 (LF/HF>2.3, group HIGH) patients respectively. Both groups had similar baseline demographic and hemodynamic variables. A high preoperative sympathetic outflow and loss of vagal modulation, as stated by LF/HF>2.3, was correlated with a relative risk of 7.7 (95%CI 1.04 to 56.6, p=0.023) of post-spinal hypotension. CONCLUSIONS: Preoperative analysis of autonomic nervous system modulation might be useful to stratify the risk of post-spinal hypotension and it might indicate the need for careful monitoring or prophylactic fluids.

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.

Ultrasound-guided posterior approach to brachial plexus for the treatment of upper phantom limb syndrome.

The purpose of the case is to report the clinical value of the ultrasound-guided posterior approach to the brachial plexus in the treatment of phantom limb syndrome after an upper extremity amputation. The author experienced ultrasound guidance as sole technique to localize the brachial plexus for the purpose of placing a catheter for continuous infusion of a local anesthetic in a patient where standard landmark-based nerve stimulation for placement of a continuous perineural block was not possible.

The nerve stimulation technique versus the loss of resistance technique for the posterior approach to lumbar plexus block: a randomized, prospective, observer-blinded, pilot study.

BACKGROUND: This prospective, randomized, observer-blinded, pilot study compares the effects of the nerve stimulation guidance technique (NS) with the loss of resistance technique (LOR) on readiness for surgery during the posterior approach to lumbar plexus block. METHODS: Thirty ASA status I-III patients who were 18-85 years old and who were undergoing hip fracture repair were enrolled. After parasacral sciatic nerve block, patients were randomly allocated to receive a continuous posterior lumbar plexus block using nerve stimulation (n=15) or a continuous psoas compartment block using the loss of resistance technique (n=15) with 20 ml of 1.5% mepivacaine. A blinded observer monitored for sensory and motor block onsets every 5 minutes. We defined readiness for surgery as complete numbness to the pinprick test and complete motor block on the surgical side. If incomplete, the lumbar plexus block was supplemented with 10 mL of 1.5% mepivacaine through the catheter before surgery. Intraoperative fentanyl or general anesthesia requirements, pain scores, local anesthetic consumption, morphine requirements for breakthrough pain and side effects were monitored. RESULTS: The mean time to readiness for surgery was 12±6 min Group NS and 22±6 min in Group LOR (P=0.03). Three patients in Group NS and 9 patients in Group LOR required additional boluses of local anesthetic through the lumbar plexus catheter before surgery (P=0.113). CONCLUSION: Nerve stimulation allowed faster readiness for surgery than loss of resistance. Nevertheless, the two techniques seem to be comparable in terms of local anesthetic consumption, morphine requirements and pain scores.

Blood-saving techniques.

Major surgery is associated with intraoperative and postoperative bleeding, generally treated with homologous blood transfusions, which carry the risk of infection, allergic reactions, or incompatibility as well as a number of organizational and economic problems. Transfusion strategies and steps to minimize perioperative bleeding are needed. Another resource is drugs; human recombinant erythropoietin, aprotinin, and some analogues of lysine have been used to reduce the rate of allogenic transfusions in the perioperative period. The safest method is autologous blood transfusions through predeposits and hemodilution; however, it can only be used for elective surgery. Autologous transfusion techniques include blood collection, both intraoperatively, as described by Orr, and postoperatively, as introduced by Borghi in 1984, which enables the continuous monitoring of postoperative bleeding. Blood collection can also be performed during emergency surgery, reducing the rate and costs of homologous transfusions.

One-day surgery for acquired forefoot deformity: sciatic nerve blockade with mepivacaine vs mepivacaine+ropivacaine: a prospective, randomized study.

AIM: The aim of the study was to determine the doses of ropivacaine combined with mepivacaine for sciatic nerve blockade to enable the extension of analgesia without prolonged motor blockade, for the management of very painful operations in one-day surgery. METHODS: After obtaining approval by the ethics committee and written informed consent, we recruited 30 ASA I-III patients undergoing corrective orthopedic surgery of the forefoot in one-day surgery with sciatic nerve blockade. The patients were randomly divided into 3 groups: one control group, treated by 1.5% mepivacaine (300 mg), and two groups differentiated by the dose of 0.5% ropivacaine (25 and 40 mg) used in combination with 1.5% mepivacaine (225 mg). The offset data of the blockade were obtained by a self-assessment form filled in by the patients, and a direct check on discharge by a blinded observer. RESULTS: There was no significant difference in the duration of the blockade among the 3 groups; the extension of analgesia was significant (P<0.003) in the group treated by mepivacaine+ropivacaine 40 mg (mean 477+/-255 min). CONCLUSION: Adequate doses of ropivacaine added to mepivacaine for peripheral blockade produce and increase the duration of analgesia without influencing the criteria for discharge after Day Surgery.

Pain relief and motor function during continuous interscalene analgesia after open shoulder surgery: a prospective, randomized, double-blind comparison between levobupivacaine 0.25%, and ropivacaine 0.25% or 0.4%.

BACKGROUND AND OBJECTIVES: To compare pain relief and motor impairment of 0.25% levobupivacaine with either an equivalent (0.25%) or equipotent (0.4%) concentration of ropivacaine for continuous interscalene block after open shoulder surgery. METHODS: Seventy-two adult patients scheduled for elective major shoulder surgery received an interscalene injection of mepivacaine 1.5% 30 mL followed by 24 h patient-controlled interscalene analgesia (basal infusion rate: 5 mL h-1; incremental bolus: 2 mL; lockout period: 10 min; maximum boluses per hour: 4) with either 0.25% levobupivacaine (n = 24), 0.25% ropivacaine (n = 24) or 0.4% ropivacaine (n = 24). A blinded observer recorded the evolution of pain relief and recovery of motor block during the first 24 h. Motor function was assessed as the maximum pressure developed while squeezing a sphygmomanometer cuff with the blocked hand. The reduction from preoperative values was considered as an index of motor impairment. RESULTS: No differences were reported among the three groups in the quality of postoperative analgesia. The number of incremental patient-controlled interscalene analgesia doses, total volume of local anaesthetic infused during the 24-h patient-controlled interscalene analgesia, and number of rescue ketoprofen analgesia were higher in the ropivacaine 0.25% group than in the other two groups (P = 0.0005). The hand strength recovered to >or=90% of baseline values within the first 24 h of infusion in all groups, without differences among the three groups. CONCLUSION: When providing patient-controlled interscalene analgesia after open shoulder surgery 0.25% levobupivacaine and 0.4% ropivacaine performed equally in terms of pain relief, motor block and number of patient-controlled boluses required, while patients receiving 0.25% ropivacaine needed significantly more boluses and rescue analgesia to control their pain.

[Epidural vs general anaesthesia]. / Anestesia epidurale vs generale.

BACKGROUND: Aim of this study is to determine if and how the anaesthesia technique can significantly influence the outcome in patients after major orthopaedic surgery in terms of: patrimony of red blood cells (blood loss and erythropoiesis), incidence of intra and postoperative complications, postoperative pain control and hospital stay. METHODS: 210 patients, ASA physical status I-III, undergoing elective primary total hip replacement were randomly allocated in three groups of 70 patients to receive either epidural anaesthesia (Group EA), general anaesthesia (GA), or epidural anaesthesia integrated with mild general anaesthesia (IA). RESULTS: Data show a significant difference between the amount of pain measured by VRS immediately after surgery: prevalently absent in groups IA (84.3%) and EA (85.7%) and prevalently severe and moderate in group AG (34.3%). The measurement of the basic circulating erythrocyte mass in the first, third and fifth postoperative day, calculated by the Mercuriali formula, which considers blood loss, autologous and homologous transfusions and erythropoiesis, showed that general anaesthesia leads to a significant delay in the resumption of haemopoiesis. This result was attenuated by its combination with epidural anaesthesia. CONCLUSIONS: On the basis of the literature and the results of our study, epidural anaesthesia seems to be the most appropriate technique for patients scheduled for total hip replacement: due to its simpler analgesic cover, its tendency to be associated with a lower incidence of complications in the first 24 hours after surgery. The incidence of relevant hypotension is minor compared to integrated anaesthesia. General anaesthesia produced a significant decrease in postoperative erythropoiesis.

Thromboembolic complications after total hip replacement.

We conducted a retrospective analysis of 1,640 consecutive patients undergoing total hip replacement between 1990 and 1997 under general anesthesia and receiving three different prophylactic regimens. The thromboembolic prophylaxis consisted of low-dose unfractioned heparin (UFH), low-molecular-weight heparin (LMWH), or indobufen (INDO). Postoperatively, occurrence of symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE) was recorded during the first 30 days after surgery and at a routine follow-up visit. Symptomatic DVT was diagnosed in 16 patients (0.9%), while PE occurred in eight patients (0.5%). Patients receiving UFH showed a higher incidence of symptomatic DVT (3.6%) than those patients receiving either LMWH (1.3%) or INDO (0.3%), with an odds ratio for developing symptomatic DVT when receiving UFH versus other treatments of 6.05 (95% confidence intervals [CI95%]: 3.63-10.07) (P=0.001). On the other hand, the diagnosis of PE was more frequently seen in patients receiving cemented hip arthroplasty (2.4%) than in patients receiving uncemented hip arthroplasty (0.34%), with an odds ratio of 3.185 (CI95%: 2.01-5.02)(P=0.05).

Molecular linkage map of Einkorn wheat: mapping of storage-protein and soft-glume genes and bread-making quality QTLs.

Two molecular maps of Triticum monococcum L were produced and integrated. The integrated map includes a total of 477 markers, 32 RFLPs, 438 AFLPs, one morphological (soft glume (Sog)) and six storage-protein markers, and covers 856 cM. The trait Sog with the recessive allele sog maps to linkage group 2S. Probably, this is the T. monococcum homologue of Tg and Tg2 in hexaploid and tetraploid wheats, respectively. Loci coding for seed storage proteins were allocated to chromosomes 1L (HMW GLU1,2 and Glu1), 1S (LMW GLU6,7, LMW GLU1-4, omega GLI1-4, gamma GLI5 and Gli-1) and 6L (alpha/beta GLI7-14). Parameters related to bread-making quality (SDS sedimentation volume, specific sedimentation volume (SSV) and total protein content) were studied in one of the two populations. A QTL that is consistently present across environments was detected for SDS sedimentation volume and for SSV. The position of the QTL on chromosome 1S was in close agreement with the map positions of storage-protein loci. A second QTL was mapped on chromosome 5. For protein content, two significant QTLs were mapped to linkage groups 1 and 5.

Pulsed venous flow pattern with hemodilution.

Venous flow pattern changes and venous flow were assessed in relation to the degree of hemodilution. Femoral vein flow was measured with a duplex scanner in two groups of 11 patients 20 days and 5 days preoperatively, and 1 day postoperatively. In group I, hemodilution was used and patients gave three autologous blood predonations between day 20 and day 5. Perioperative blood loss was reintegrated by electrolyte solution. In group II, hemodilution was not used and autologous blood predonations were not carried out. These patients received a perioperative homologous blood transfusion of 800 mL. Hemoglobin was lower on day 5 (11.3 +/-1.4 vs 13.1 +/-1 g/dL, p<0.05) and on postoperative day 1 (8.9 +/-1.6 vs 10.6 +/-1, p<0.05) in group I. The decrease in hemoglobin was associated with an increase in blood flow and a pulsed venous flow pattern in 14 of 22 veins after autologous blood predonation and in 21 of 22 veins on postoperative day 1 (p<0.05). Increased venous flow in hemodilution is associated with a pulsed venous flow pattern.

A new posterior approach to the sciatic nerve block: a prospective, randomized comparison with the classic posterior approach.

UNLABELLED: To evaluate the efficacy and acceptance of a new posterior subgluteus approach to the sciatic nerve, as compared with the classic posterior approach, 128 patients undergoing foot orthopedic procedures were randomly allocated to receive either the classic posterior sciatic nerve block (Group Labat, n = 64) or a modified subgluteus posterior approach (Group subgluteus, n = 64). All blocks were performed with the use of a nerve stimulator (stimulation frequency, 2 Hz; intensity, 1-0.5 mA). In Group subgluteus, a line was drawn from the greater trochanter to the ischial tuberosity; then, from the midpoint of this line, a second line was drawn perpendicularly and extended caudally for 4 cm. The end of this line represented the needle entry. In both groups, a proper sciatic stimulation was elicited at 0.5 mA; then 20 mL of 0.75% ropivacaine was injected. The time from needle insertion to successful sciatic nerve stimulation was 60 s (range, 10-180 s) with the Labat's approach and 32 s (range, 5-120 s) with the new subgluteus approach (P = 0.0005). The depth of appropriate sciatic stimulation was 45 +/- 13 mm (mean +/- SD) after 2 (range, 1-7) needle redirections in Group subgluteus and 67 +/- 12 mm after 4 (range, 1-10) needle redirections in Group Labat (P = 0.0001 and P = 0.00001, respectively). The failure rate was similar in both groups. Severe discomfort during the procedure was less frequent and acceptance better in Group subgluteus (5 patients [8%] and 60 patients [94%], respectively) than in Group Labat (20 patients [31%] and 49 patients [77%], respectively) (P = 0.0005 and P = 0.005, respectively). We conclude that this new subgluteus posterior approach to the sciatic nerve is an easy and reliable technique and can be considered an effective alternative to the more traditional Labat's approach. IMPLICATIONS: Evaluating the efficacy and acceptance of a new approach to the sciatic nerve block, this prospective, randomized study demonstrated that the new subgluteus posterior approach is an easy and reliable technique and can be considered an useful alternative to the more traditional Labat's approach in patients undergoing foot surgery, facilitating the performance of the sciatic nerve blocks.

Coenzyme Q blocks biochemical but not receptor-mediated apoptosis by increasing mitochondrial antioxidant protection.

Generation of free radicals is often associated with the induction and progression of apoptosis. Therefore, antioxidants can prove anti-apoptotic, and can help to elucidate specific apoptotic pathways. Here we studied whether coenzyme Q, present in membranes in reduced (ubiquinol) or oxidised (ubiquinone) forms, can affect apoptosis induced by various stimuli. Exposure of Jurkat cells to alpha-tocopheryl succinate (alpha-TOS), hydrogen peroxide, anti-Fas IgM or TRAIL led to induction of apoptosis. Cell death due to the chemical agents was suppressed in cells enriched with the reduced form of coenzyme Q. However, coenzyme Q did not block cell death induced by the immunological agents. Ubiquinol-10 inhibited reactive oxygen species (ROS) generation in cells exposed to alpha-TOS, and a mitochondrially targeted coenzyme Q analogue also blocked apoptosis triggered by alpha-TOS or hydrogen peroxide. Therefore, it is plausible that ubiquinol-10 protects cells from chemically-induced apoptosis by acting as an antioxidant in mitochondria. Our results also indicate that generation of free radicals may not be a critical step in induction of apoptosis by immunological agents.

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.

[S(-) bupivacaine (levobupivacaine) in peripheral blocks: preliminary results]. / S(-) bupivacaina (levobupivacaina) nei blocchi periferici: risultati prelminari.

We have compared the onset time, anesthetic potency and adverse effects of three local anaesthetics (ropivacaine, levobupivacaine and bupivacaine) in two type of peripheral blocks (brachial plexus block for upper limb and femoral nerve block for lower limb) in adult patients in a double blind, randomized, prospective study. A total of 66 patients undergoing orthopaedic surgery were randomly allocated to receive brachial plexus block or femoral nerve blockade with 0,5% ropivacaine (group R, n=22), 0,5% levobupivacaine (group L, n=22) or 0,5% bupivacaine (group B, n=22), each groups has been divided into two subgroups (LBP n=11, RBP n=11, BPB n=11, LBF n=11, RBF n=11, BBF n=11) dipending on the type of block. The onset of sensory nerve block was similar for the three groups; the onset of motor block and onset time ready to surgery were faster in group R (-30%) if compared with group L and B. The duration of motor block and sensory block was respectively longer in group L and in group B. Study results have not been influenced by the blocks, except for plexus nerve block where we observed the same results for group B and group R in relation to onset time ready to surgery. VRS scores were higher in group R as showed by the number of analgesic request in postoperative period. We did not observe any adverse effect. We conclude that ropivacaine acts faster with less interpatient variability, while levobupivacaine and bupivacaine offer a prolonged postoperative analgesia. For this reason, with the exception of bupivacaine due to major cardio and neuro toxicity, we can indifferently use levobupivacaine or ropivacaine depending on the requested characteristics of the anesthetic.

[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.

[Continuous brachial plexus blockade for shoulder surgery]. / Il blocco continuo del plesso brachiale per la chirurgia della spalla.

Continuous brachial plexus block is the technique of choice for postoperative shoulder pain treatment. The localization of the plexus is usually obtained drawing landmarks on the skin and using the electrical nerve stimulator; these and other different modalities are applied in order to reach safely and precisely nerve roots to be blocked with an anaesthetic solution. The Author presents a new anatomical perspective to guide the localization of the brachial plexus. It is shown how it is possible to detect the pathway of the brachial plexus from the cutaneous surface, linking between each other various landmarks: a) the apex of the scalene triangle, at the cross of a line leaving from the cricoid process and directed posterior to the posterior border of the sternocleidomastoid muscle, b) the midline of the clavicle c)the deltoid-pectoral sulcus d) the midpoint between the coracoid process and the chest profile e) the pulsation of the artery in the axylla. Following the guide of the so formed anesthetic line, is possible to place the needle, with a direction from distal to proximal, in a tangential route towards the interscalenic groove, thus allowing to perform a block of the plexus in a simple and efficacious way.

[Peripheral blocks for the lower limb: lumbar plexus]. / Blocchi periferici per l'arto inferiore: il plesso lombare.

BACKGROUND: The techniques of continuous peripheral blockades have shown to be efficient in postoperative pain control, in the various orthopaedic procedures of the limbs. The aim of this study is to evaluate the existing data about the use of a continuous blockade of the lumbar plexus or femoral nerve, together with the indications for technique and therapy. METHODS: We considered the principal results of prospective, randomised studies described in literature about the assessment of a continuous peripheral blockade of the lumbar plexus or the femoral nerve in limb surgery. Furthermore we described the principal techniques for positioning the perinerval catheters in the considered sites, and the advised dosage regimen. RESULTS: The various studies report an adequate costs/benefits relation concerning the used techniques. The analysed studies not only report an adequate efficacy of the postoperative pain control, but often show an important benefit in terms of functional recovery of the operated limbs and on final outcome of the patient. CONCLUSIONS: The use of continuous blockades of the lumbar plexus or femoral nerve shows to be an important and effective instrument not only in terms of positive effects on postoperative pain control, but also in terms of relevant advantages concerning final outcome after surgery. Nevertheless these techniques should not be considered as the only approach to postoperative pain in the orthopaedic patient, but have to be included in a global, multidisciplinary and multimodal approach.

Continuous peripheral block in foot surgery.

Peripheral neural blockade techniques are commonly used procedures to provide perioperative anesthesia and analgesia. Several continuous infusion catheter techniques have been described to extend the use of peripheral neural blockade into the postoperative period as an effective method of providing pain management. The analgesic benefit of continuous local anesthetic peripheral block in the management of postoperative pain is primarily related to the properties of providing intense analgesia thereby reducing perioperative opioid requirements and opioid-related side effects and promoting early recovery of postoperative activity. Continuous peripheral nerve blockade seems to be effective in allowing major foot and ankle surgery to be done particularly on an outpatient basis with greater pain relief. The sciatic nerve is the largest nerve in the body and it lies deep in the posterior thigh. According to its anatomy, the sciatic nerve can then be reached at different levels from the parasacral space to the popliteal fossa, ideally identifying a sciatic line running from the inferior border of the gluteus maximus muscle between the greater throcanter and the ischiatic tuberosity to the popliteal fossa. A variety of continuous peripheral blocks have been described in this paper including continuous sciatic block at several levels (para-sacral nerve block, subgluteal sciatic nerve block) and popliteal nerve block.