Recovery of laryngeal nerve function with sugammadex after rocuronium-induced profound neuromuscular block.

STUDY OBJECTIVE: The aim of this study was to evaluate the efficacy of sugammadex in reversing profound rocuronium-induced neuromuscular block at the laryngeal adductor muscles using motor-evoked potentials (mMEPs). DESIGN: A prospective observational study. SETTING: University surgical center. PATIENTS: Twenty patients with American Society of Anesthesiologists physical class I-II status who underwent propofol-remifentanil anesthesia for the surgery of the thyroid gland. INTERVENTIONS: Patients were enrolled for reversal of profound neuromuscular block (sugammadex 16 mg/kg, 3 minutes after rocuronium 1.2 mg/kg). To prevent laryngeal nerve injury during the surgical procedures, all patients underwent neurophysiologic monitoring using mMEPs from vocal muscles. At the same time, the registration of TOF-Watch acceleromyograph at the adductor pollicis muscle response to ulnar nerve stimulation was performed; recovery was defined as a train-of-four (TOF) ratio ≥0.9. MEASUREMENT AND MAIN RESULTS: After injection of 16 mg/kg of sugammadex, the mean time to recovery of the basal mMEPs response at the laryngeal adductor muscles was 70 ± 18.2 seconds. The mean time to recovery of the TOF ratio to 0.9 was 118 ± 80 seconds. In the postoperative period, 12 patients received follow-up evaluation of the vocal cords and no lesions caused by the surface laryngeal electrode during electrophysiological monitoring were noted. CONCLUSIONS: Recovery from profound rocuronium-induced block on the larynx is fast and complete with sugammadex. In urgent scenarios, "early" extubation can be performed, even with a TOF ratio ≤0.9. However, all procedures to prevent postoperative residual curarization should still be immediately undertaken.

The experience of setting up a resident-managed Acute Pain Service: a descriptive study.

BACKGROUND: The benefits of an Acute Pain Service (APS) for pain management have been widely reported, but its diffusion is still limited. There are two APS models: anesthesiologist-based and a nurse-based model. Here we describe the development of a different APS model managed by anesthesia residents, and we report the first year of activity in a tertiary Italian university hospital (Careggi University Hospital, Florence, IT). METHODS: Patients were included in the APS were those undergoing abdominal and urologic surgery causing moderate or severe postsurgical pain. The service was provided for patients, beginning upon their exit from the operating room, for 4, 12, 24 and 48 h for iv, and up to 72 h for epidural therapy. Vital signs, static/dynamic VAS, presence of nausea/vomiting, sedation level, and Bromage scale in case of epidural catheter, were monitored. RESULTS: From September 2013 to April 2015, a total of 1054 patients who underwent major surgery were included in the APS: 542 from abdominal surgery and 512 from urological surgery. PCA and epidural analgesia were more adopted in general surgical patients than in urology (48% vs 36% and 15% vs 2%, respectively; P < 0.0001). Patients who underwent to abdominal surgery had a significantly higher self-administration of morphine (30.3 vs 22.7 mg; P = 0.0315). Elastomeric pump was the analgesic of choice in half of the urologic patients compared to a quarter of the general surgical patients (P < .0001). Among the different surgical techniques, epidural analgesia was used more in open (16.5%) than in videolaparoscopic (1.9%) and robotic technique (1.1%), whereas PCA was predominant in videolaparoscopic (46.5%) and robotic technique (55.5%) than in open technique (31.4%). CONCLUSIONS: The creation of APS, managed by anesthesia residents, may represent an alternative between specialist-based and nurse-based models.

The influence of interscalene block technique on adverse hemodynamic events.

PURPOSE: A hemodynamic event such as hypertension after interscalene block (ISB) is a complication that is often overlooked. The irregular spread of local anesthetic would cause a blockade of carotid sinus baroreceptors leading to the adverse event. The purpose of the present study is to compare ultrasound and neurostimulation technique in preventing hypertension after ISB. METHODS: Thirty patients without hypertension history who underwent arthroscopic shoulder surgery for a rotator cuff tear were enrolled. After preoperative administration of the State Trait Anxiety Inventory questionnaire, patients were allocated to receive ultrasound-guided ISB with 20 ml levobupivacaine-HCl 0.5 % (group US) and 40 ml levobupivacaine-HCl 0.5 % with neurostimulation (group NS). The need for antihypertensive drug was recorded. Block onset sensory and motor times were assessed. Systolic and diastolic blood pressures, and heart rate and pulse oximetry (SpO2), were evaluated before the block as well as 2, 5, 10, 15, 20, and 30 min after. RESULTS: No differences in patient characteristics and anxiety were found in the two groups. Block onset times were similar. At 15 min after block placement, group NS showed significantly higher systolic and diastolic blood pressures compared to group US. No differences in heart rate and SpO2 were found between the two groups. Three patients of group NS required urapidil administration because of hypertension. CONCLUSIONS: Ultrasound-guided ISB permits the use of a low volume of local anesthetic and seems to reduce the incidence of hypertension.

Perioperative pregabalin for postoperative pain control and quality of life after major spinal surgery.

BACKGROUND: Adequate management of postoperative pain after major spine surgery is often difficult to achieve. We investigated the efficacy of an antineuropathic pain drug, pregabalin (PG), on postoperative pain control and on improvement of quality of life (QoL). METHODS: Sixty patients scheduled for elective decompressive spine surgery were enrolled. One hour before surgery patients received 300 mg of either oral PG or placebo (PL) and 150 mg of PG or PL twice a day for 48 hours postoperatively. During the first 48 postoperative hours, a continuous infusion of morphine 0.01 mg/kg/h and ketorolac tromethamine 2.5 mg/h was administered. Intravenous morphine in 2-mg aliquots up to a maximum of 10 mg was used as rescue therapy. Pain was measured at rest and during movement using a visual analog scale (VAS score), and side effects were recorded in the first hour and at 4, 8, 12, 24, and 48 hours. Three months and 1 year after discharge, patients were contacted by telephone by 1 of the authors to obtain follow-up information using the EuroQoL questionnaire. RESULTS: During the first 8 postoperative hours, VAS scores at rest were significantly lower in the PG group than in the PL group (P<0.05), whereas VAS scores on movement were significantly lower up to 12 hours after the operation in the PG group (P<0.05). The morphine consumption in the PG group was 3±2 mg, whereas in the PL group it was 9.5±2.5 mg (P<0.05). Postoperative incidence of constipation and nausea/vomiting was higher in the PL group than in the PG group. No significant differences between the 2 groups were observed with regard to other adverse effects. QoL measures revealed an improvement in outcome, especially in movement and in pain dimensions in both groups; however, at 3 months, subjective qualification of overall QoL was better in the PG group than in the PL group. There were no differences in QoL after the 1-year follow-up period. CONCLUSIONS: Perioperative PG administration reduces early postsurgical pain at rest and particularly during movement after major spine surgery with less opioid consumption, and it seems to influence the improvement of overall QoL 3 months after surgery.

Vacuum-assisted closure device enhances recovery of critically ill patients following emergency surgical procedures.

INTRODUCTION: Critically ill surgical patients frequently develop intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) with subsequent high mortality. We compared two temporary abdominal closure systems (Bogota bag and vacuum-assisted closure (VAC) device) in intra-abdominal pressure (IAP) control. METHODS: This prospective study with a historical control included 66 patients admitted to a medical and surgical intensive care unit (ICU) of a tertiary care referral center (Careggi Hospital, Florence, Italy) from January 2006 to April 2009. The control group included patients consecutively treated with the Bogota bag (Jan 2006-Oct 2007), whereas the prospective group was comprised of patients treated with a VAC. All patients underwent abdominal decompressive surgery. Groups were compared based upon their IAP, SOFA score, serial arterial lactates, the duration of having their abdomen open, the need for mechanical ventilation (MV) along with length of ICU and hospital stay and mortality. Data were collected from the time of abdominal decompression until the end of pressure monitoring. RESULTS: The Bogota and VAC groups were similar with regards to demography, admission diagnosis, severity of illness, and IAH grading. The VAC system was more effective in controlling IAP (P < 0.01) and normalizing serum lactates (P < 0.001) as compared to the Bogota bag during the first 24 hours after surgical decompression. There was no significant difference between the SOFA scores. When compared to the Bogota, the VAC group had a faster abdominal closure time (4.4 vs 6.6 days, P = 0.025), shorter duration of MV (7.1 vs 9.9 days, P = 0.039), decreased ICU length of stay (LOS) (13.3 vs 19.2 days, P = 0.024) and hospital LOS (28.5 vs 34.9 days; P = 0.019). Mortality rate did not differ significantly between the two groups. CONCLUSIONS: Patients with abdominal compartment syndrome who were treated with VAC decompression had a faster abdominal closure rate and earlier discharge from the ICU as compared to similar patients treated with the Bogota bag.