Ultrasound Guided Transversus Thoracic Plane block, Parasternal block and fascial planes hydrodissection for internal mammary post thoracotomy pain syndrome.

INTRODUCTION: Pectoral Nerves Block (PECS) and Serratus Plane Block (SPB) have been used to treat persistent post-surgical pain after breast and thoracic surgery; however, they cannot block the internal mammary region, so a residual pain may occur in that region. Parasternal block (PSB) and Thoracic Transversus Plane Block (TTP) anaesthetize the anterior branches of T2-6 intercostal nerves thus they can provide analgesia to the internal mammary region. METHODS: We describe a 60-year-old man suffering from right post-thoracotomy pain syndrome with residual pain located in the internal mammary region after a successful treatment with PECS and SPB. We performed a PSB and TTP and hydrodissection of fascial planes with triamcinolone and Ropivacaine. RESULTS: Pain disappeared and the result was maintained 3 months later. DISCUSSION: This report suggests that PSB and TTP with local anaesthetic and corticosteroid with hydrodissection of fascial planes might be useful to treat a post thoracotomy pain syndrome located in the internal mammary region. SIGNIFICANCE: The use of Transversus Thoracic Plane and Parasternal Blocks and fascial planes hydrodissection as a novel therapeutic approach to treat a residual post thoracotomy pain syndrome even when already treated with Pectoral Nerves Block and Serratus Plane Block.

Spinal anesthesia plus ketamine-midazolam sedation for pediatric orthopedic surgery in a developing country.

INTRODUCTION: Spinal anesthesia produces a profound and uniformly distributed sensory block with rapid onset and muscle relaxation, and results in complete control of cardiovascular and stress responses. Ketamine is an anesthetic agent that is widely used for pediatric sedations in settings where safety and efficacy of the agents are mandatory because of limited healthcare resources. The authors report on their experience in a refugee hospital located in Bol-la (Saharawi, Algeria). METHODS: Spinal anesthesia was performed for orthopedic surgery procedures in children. Before the spinal puncture, the patients were sedated with intramuscular ketamine followed by intravenous ketamine and midazolam. Boluses of midazolam were also administered throughout the surgery to keep the patients sedated; spinal anesthesia was performed with levobupivacaine 0.25 mg/kg. RESULTS: There were no intraoperative adverse events; vital signs were within the normal pediatric ranges during the procedures and there was no need to switch to general anesthesia. In the postoperative period, no symptoms of dural puncture headache or postoperative delirium or nightmares were reported. CONCLUSION: Based on the authors' experience, the combination of spinal anesthesia and sedation with midazolam and ketamine was found to be a safe approach for children undergoing orthopedic surgery in a low resources setting.

Analgesia for thoracic surgery: the role of paravertebral block.

An appropriate post operative analgesia after thoracotomies is mandatory to improve the patient's outcome, reduce complications rate, morbidity, hospital cost and length of stay. In this paper we review the evidences regarding the use of paravertebral block for thoracic surgery. In particular we examine the effect of paravertebral block compared to the other technique in four major issues: analgesia, complications rate, postoperative pulmonary function and transition from acute to chronic pain. We conclude that paravertebral block is superior to intravenous analgesia in providing pain control and preserving postoperative pulmonary function while it is equal to thoracic epidural analgesia regarding this two issues. Paravertebral block has a better safety profile when compared to intravenous and thoracic epidural analgesia. Its effect on chronic pain incidence still needs further studies.

Left diaphragmatic hernia after pneumonectomy.

Patients undergoing pneumonectomy can suffer by cardiovascular and respiratory postoperative complications that can affect patient's outcome by increasing morbidity and mortality. We describe a diaphragmatic hernia occurring after pneumonectomy. with late presentation and with epidural analgesia confusing the scenario suggesting that anesthesiologists should remain aware on this complication even in the late post operative period.

The use of methylene blue in abdominal aortic surgery: a case report.

The open abdominal aortic surgery includes a well-known phase in which arterial blood flow is stopped by occluding clamps, resulting in peculiar physiologic changes usually superimposed on advanced pathologic conditions. An anesthetic plan should aim at providing hemodynamic stability and preserving organ function. Clamp removal leads to an acute fall in blood pressure following a decrease in systemic vascular resistance, caused by reactive hyperemia due to opening of the previously minimally perfused vascular beds. Several different mediators, including the nitrous oxide (NO) pathway, have been thought to be responsible for this hemodynamic effect. The massive production of NO by the inducible isoform of NO synthase could be partially responsible for the profound vasodilatation and myocardial dysfunction. The dye methylene blue (MB) has been used as to prevent vasodilatation in other clinical situations like sepsis, cardiopulmonary bypass and liver transplantation. We describe its use in a patient with poor hemodynamic status, who was submitted to aortic aneurism repair with infrarenal cross clamp. The intervention was also associated with a severe bleeding. In this case MB allowed us to control hypotension with relatively low doses of vasopressors.

Intraoperative coagulation evaluation of ischemia-reperfusion injury in small bowel transplantation: a way to explore.

BACKGROUND AND AIM OF STUDY: The success of intestinal transplantation is affected by the extreme susceptibility of the small bowel to ischemia-reperfusion (I/R) injury. Platelet aggregation decreases after reperfusion in small intestinal ischemia and liver transplantation. Thromboelastography (TEG) is a coagulation test performed whole on blood. The aims of this study were to assess coagulation derangements during bowel transplantation to define appropriate modalities of intraoperative coagulation monitoring. A secondary endpoint was to determine whether measurements of coagulation derangements were useful to estimate small intestinal I/R injury. MATERIALS AND METHODS: We recruited 19 patients who had undergone elective small bowel transplantation for primary short-gut syndrome. We divided our patients into two groups depending on their reperfusion injury as evaluated with a biopsy after reperfusion: group A composed of eight patients who had a reperfusion injury: group B composed of 11 patients who did not experience this problem. We measured five thromboelastogram indicators (r, k, angle, MA, CL30) at defined intervals: dissection phase (T1), vascular anastomoses phase (T2) as well as 30 minutes (T3) and 120 minutes (T4) after reperfusion during the intestinal reconstruction phase. RESULTS: We did not observe any significant difference between intraoperative blood loss, core temperature, or volume of fluid fresh frozen plasma, or platelet administration. Angle and MA were decreased significantly among patients with reperfusion injury. DISCUSSION: Patients showed a hypocoagulation pattern during all the manipulations. This derangement did not depend on the ischemia time. In patients with I/R injury the angle and MA did not change during ischemia, but did change significantly upon reperfusion. Several mechanisms may cause coagulation derangements. During the ischemic period, there may be damage to the vascular bed of the ischemic organ. When arterial blood passes through the damaged vascular bed after reperfusion, platelet activation occurs to varying degrees, resulting in reduced platelet function. CONCLUSION: Further studies are needed to confirm this preliminary work, which was limited by the low number of patients, in order to elucidate relevant mechanisms and develop predictive algorithms.

Right ventricular end-diastolic volume index as a predictor of preload status in patients with low right ventricular ejection fraction during orthotopic liver transplantation.

OBJECTIVE: The objective of this study was to compare the accuracy of 2 variables: pulmonary artery occlusion pressure (PAOP) and right ventricular end diastolic volume index (RVEDVI) as predictors of the hemodynamic response to fluid challenge as well as definition of the overall correlation between RVEDVI and change in PAOP, right ventricular ejection fraction (RVEF), central venous pressure (CVP), and determination of the right ventricular function during orthotopic liver transplantation. MATERIALS AND METHODS: A modified pulmonary artery catheter equipped with a fast response thermistor was used to determine RVEF, allowing calculation of RVEF end-diastolic volume index (EDVI, as the ratio of stroke index [SI] to EF). The above-mentioned hemodynamic measures were taken in 4 phases: T0, after induction of anesthesia; T1, during anhepatic phase; T2, 30' after graft reperfusion; and T3, at the end of surgery. RESULTS: The variation of the REF value was 36 +/- 4% and 39 +/- 6%. Linear regression analysis showed a significant correlation between RVEDVI (range, 133 +/- 33-145 +/- 40 mL/m(2)) and stroke volume index (SVI) in each phase (r(2) = 0.49, P < .01; r(2) = 0.57, P < .01) at T0 and T1, respectively, and at T2 and T3 (r(2) = 0.51, P < .01; r(2) = 0.44, P < .01), respectively. No significant variations in the linear regression analysis between RVEDVI, PAOP, CVP, and RVEF were observed. No relationship was found between PAOP (range, 10 +/- 2-6 +/- 2 mm Hg) and SVI. CONCLUSION: RVEDVI may be the best clinical estimate of right ventricular preload. In fact, minor changes of RVEF have been recorded, confirming that RV function was not altered during uncomplicated orthotopic liver transplantation.