The clinical impact of pectoral nerve block in an 'enhanced recovery after surgery' program in breast surgery.

Background: Pectoral nerve block (PECS) is increasingly performed in breast surgery. Aim: The study evaluated the clinical impact of these blocks in the postoperative course. Patients & methods: In this case-control study, patients undergoing breast surgery with 'enhanced recovery after surgery' pathways were divided into group 1 (57 patients) in whom PECS was performed before general anesthesia, and group 2 (57 patients) in whom only general anesthesia was effected. Results: Postoperative opioid consumption (p < 0.002), pain at 32 h after surgery (p < 0.005) and the length of stay (p < 0.003) were significantly lower in group 1. Conclusion: Reducing opioid consumption and pain after surgery, PECS could favor a faster recovery with a reduction in length of stay, ensuring a higher turnover of patients undergoing breast surgery.

'Enhanced recovery after surgery' (ERAS) protocols have been recently applied in breast cancer patients in order to improve the postoperative course. However, the incidence of moderate to severe pain after breast surgery is frequent, and a multimodal approach is recommended. In this view, the interfascial plane blocks are advocated as a valid alternative to both paravertebral and epidural blockade. In this study, we evaluated the effects of these blocks on the postoperative course in patients undergoing breast surgery with ERAS protocols. We compared two patient groups: in the first, pectoral blocks were performed before general anesthesia, while in the second no block was carried out. We found that in the patient group receiving the blocks, postoperative opioid consumption (with essentially the same pain after surgery) and length of stay were significantly lower. Therefore, although more robust studies are needed to confirm our findings, these emerging locoregional techniques could favor a faster recovery in the context of ERAS in breast surgery. These results could have important clinical implications in terms of not only reducing healthcare costs but also ensuring a higher turnover of patients undergoing breast surgery.

The multidisciplinary audit in enhanced recovery after surgery (ERAS) colorectal surgery: experience in a single Italian center.

BACKGROUND: Current literature underlines the role of periodical feed-back to improve Enhanced Recovery After Surgery (ERAS) path adherence during implementation program. The aim of this retrospective study was to evaluate the clinical impact of an audit program in an ERAS path. METHODS: All elective patients submitted to elective colorectal surgery from November 2018 to January 2020 in our Institution were considered. The sample was divided into two study groups: group 1, including patients enrolled in the first sixth months of ERAS program until the first audit; group 2, patients enrolled in a time period of a six months after the first audit. RESULTS: The final analysis included 46 patients in group 1 and 64 in group 2. Group 2 showed a higher ASA Score (P<0.03), a higher prevalence of right hemicolectomy, and a lower prevalence of left hemicolectomy and anterior rectum resection (RAR) (P<0.016). Group 2 also had a lower prevalence of anastomotic leakage (AL) (P<0.004). Intraoperative normothermia (T>36 C°) in this group was achieved in a larger number of patients in comparison with group 1 (39% vs. 19.5%) (P<0.01). Group 2 experienced a higher average body temperature at admission in recovery room (RR) when compared to Group 1 (35.8 vs. 35.1 C°, P<0.01). CONCLUSIONS: Audit program may represent a useful tool to promote advantageous changes in clinical practice and to favor a better compliance to ERAS program.

The Role of the Recovery Room in Improving Adherence During an Enhanced Recovery After Surgery (ERAS) Implementation Program for Colorectal Surgery: A Single-Center Retrospective Analysis.

PURPOSE: The purpose of thisstudy was to evaluate the clinical impact of the Recovery Room (RR) in an Enhanced Recovery After Surgery (ERAS) pathway in colorectal surgery. DESIGN: Single-center retrospective study. METHODS: From November 2019 until September 2021, a total of 149 consecutive patients that underwent to colon-rectal surgery were enrolled. The patients were divided into two study groups: RR Group if admitted to RR after surgery, and no-Recovery Room (NRR) Group if monitored directly on the ward, bypassing the RR. The postoperative ERAS items adherence was assessed in the two study groups. FINDINGS: Final analysis included 119 patients in the RR Group and 30 patients in NRR Group. Patients that started clear liquid oral intake within two hours postoperatively were 118 in the RR group and 19 in the NRR group (99.1% vs 63.3%, P < .001). A total of 98 patients and 18 patients were mobilized on day 0 in the RR group and in NRR group, respectively (84.4% vs 15.5%, P < .05). In the RR group, postoperative adherence to the ERAS protocol components was higher in comparison with the NRR group (P < .003); adherence to the all protocol components was also higher (P < .004). CONCLUSIONS: Among patients undergoing colorectal surgery admitted to RR after surgery, the RR nurse guaranteed effective patient assistance and ensured appropriate compliance to the postoperative ERAS items.

Combined pericapsular nerve group and lateral femoral cutaneous nerve blocks for hip fracture in a polytraumatized patient-A case report.

Locoregional anesthetic techniques in hip fracture are significant in order to control pain, reduce postoperative opioid use, and perioperative adverse events. Pericapsular nerve group (PENG) block has been described and proved as an effective analgesic method for hip surgery as an alternative to other regional nerve blocks. The association of PENG and lateral femoral cutaneous nerve (LCFN) block can be performed to achieve skin and subcutaneous tissues analgesia or anesthesia. Direct anterior approach PENG block is considered a safe and effective anesthesia technique for total hip arthroplasty surgery. In this paper, we aim to describe a case report of a PENG and LFCN block successful association for anesthesia in a major trauma patient who undergone surgical percutaneous fixation of femoral neck fracture.

"In Less than No Time": Feasibility of Rotational Thromboelastometry to Detect Anticoagulant Drugs Activity and to Guide Reversal Therapy.

Anticoagulant drugs (i.e., unfractionated heparin, low-molecular-weight heparins, vitamin K antagonists, and direct oral anticoagulants) are widely employed in preventing and treating venous thromboembolism (VTE), in preventing arterial thromboembolism in nonvalvular atrial fibrillation (NVAF), and in treating acute coronary diseases early. In certain situations, such as bleeding, urgent invasive procedures, and surgical settings, the evaluation of anticoagulant levels and the monitoring of reversal therapy appear essential. Standard coagulation tests (i.e., activated partial thromboplastin time (aPTT) and prothrombin time (PT)) can be normal, and the turnaround time can be long. While the role of viscoelastic hemostatic assays (VHAs), such as rotational thromboelastometry (ROTEM), has successfully increased over the years in the management of bleeding and thrombotic complications, its usefulness in detecting anticoagulants and their reversal still appears unclear.

Questions about COVID-19 associated coagulopathy: possible answers from the viscoelastic tests.

Abnormal coagulation parameters are often observed in patients with coronavirus disease 2019 (COVID-19) and the severity of derangement has been associated with a poor prognosis. The COVID-19 associated coagulopathy (CAC) displays unique features that include a high risk of developing thromboembolic complications. Viscoelastic tests (VETs), such as thromboelastometry (ROTEM), thromboelastography (TEG) and Quantra Hemostasis Analyzer (Quantra), provide "dynamic" data on clot formation and dissolution; they are used in different critical care settings, both in hemorrhagic and in thrombotic conditions. In patients with severe COVID-19 infection VETs can supply to clinicians more information about the CAC, identifying the presence of hypercoagulable and hypofibrinolysis states. In the last year, many studies have proposed to explain the underlying characteristics of CAC; however, there remain many unanswered questions. We tried to address some of the important queries about CAC through VETs analysis.

Antiphospholipid antibodies in critically ill COVID-19 patients with thromboembolism: cause of disease or epiphenomenon?

Coronavirus 2019 disease (COVID-19) is associated with coagulation dysfunction that predisposes patients to an increased risk for both arterial (ATE) and venous thromboembolism (VTE) and consequent poor prognosis; in particular, the incidence of ATE and VTE in critically ill COVID-19 patients can reach 5% and 31%, respectively. The mechanism of thrombosis in COVID-19 patients is complex and still not completely clear. Recent literature suggests a link between the presence of antiphospholipid antibodies (aPLs) and thromboembolism in COVID-19 patients. However, it remains uncertain whether aPLs are an epiphenomenon or are involved in the pathogenesis of the disease.

Derangement of the coagulation process using subclinical markers and viscoelastic measurements in critically ill patients with coronavirus disease 2019 pneumonia and non-coronavirus disease 2019 pneumonia.

Systemic coagulation abnormalities including clotting activation and inhibition of anticoagulant factors have been observed in patients with pneumonia. In severe coronavirus disease 2019 (COVID-19) the alteration of coagulation parameters was associated with poor prognosis. We evaluated the difference in coagulopathy between critically ill patients with COVID-19 pneumonia (COVID group) and non-COVID-19 pneumonia (non-COVID group), using traditional coagulation markers and rotational thromboelastometry (ROTEM). Standard laboratory and ROTEM parameters were evaluated in 45 patients (20 COVID group patients and 25 non-COVID group patients) at time of admission to the Intensive Care Unit (ICU) (T0) and at 5 (T5) and 10 days (T10) later. In all evaluations times, platelet count was found higher in COVID group rather than in non-COVID group. At T0, COVID group revealed a fibrinogen value greater than non-COVID group. d-Dimer values were high in both groups and they were not statistically different. At T0 COVID group showed a significant reduction of clot formation time in INTEM and in EXTEM and a significant increase of maximum clot firmness in INTEM, EXTEM and FIBTEM respect to non-COVID group. Moreover, COVID group demonstrated a coagulability state with ROTEM profiles higher than non-COVID group at T5 and T10. Coagulation profiles showed that critically ill patients with COVID-19 pneumonia are characterized by a higher coagulable state than others; this greater procoagulative state persists over time.

Risk factors for non-invasive/invasive ventilatory support in patients with COVID-19 pneumonia: A retrospective study within a multidisciplinary approach.

OBJECTIVES: To investigate risk factors for non-invasive/invasive ventilatory support (NI/I-VS) in patients with coronavirus disease 2019 (COVID-19). METHODS: All consecutive patients admitted to the Infectious Diseases Unit and Intensive Care Unit (ICU) of Santa Maria Annunziata Hospital (Florence, Italy), from February 25 to April 25, 2020, with a confirmed COVID-19 diagnosis were enrolled in this retrospective cohort study. NI/I-VS was defined as the need for continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) (non-invasive ventilation) or mechanical ventilation, not including low-flow systems of oxygen therapy such as the Venturi mask or nasal cannula. RESULTS: Ninety-seven patients were enrolled; 61.9% (60/97) were male and the median patient age was 64 years. The in-hospital mortality was 9.3%. Thirty-five of the 97 patients (36%) required ICU admission and 94.8% (92/97) were prescribed oxygen therapy: 10.8% (10/92) by nasal cannula, 44.5% (41/92) by Venturi mask, 31.5% (29/92) by CPAP, 2.2% (2/92) by BPAP, and 10.8% (10/92) by mechanical ventilation following intubation. On univariate analysis, patients with a body mass index >30, type II diabetes mellitus, and those presenting with dyspnoea, asthenia, SOFA score ≥2 points, PaO2/FiO2 <300, temperature >38 °C, increased levels of lactate dehydrogenase (LDH), alanine aminotransferase, and C-reactive protein, and a d-dimer >1000 ng/mL at admission more frequently underwent NI/I-VS. Multivariate logistic regression analysis confirmed temperature >38 °C (odds ratio (OR) 21.2, 95% confidential interval (95% CI) 3.5-124.5, p = 0.001), LDH >250 U/l (OR 15.2, 95% CI 1.8-128.8, p = 0.012), and d-dimer >1000 ng/mL (OR 4.5, 95% CI 1.2-17.3, p = 0.027) as significantly associated with the requirement for NI/I-VS. A non-significant trend (p = 0.051) was described for PaO2/FiO2 <300. CONCLUSIONS: Temperature >38 °C, LDH > 250 U/l, and d-dimer >1000 ng/mL were found to be independent risk factors for NI/I-VS in COVID-19 patients. In order to quickly identify patients likely at risk of developing a critical illness, inflammatory markers should be assessed upon hospital admission.

Venous thromboembolism and bleeding in critically ill COVID-19 patients treated with higher than standard low molecular weight heparin doses and aspirin: A call to action.

BACKGROUND: Critically ill COVID-19 patients have a clear pattern of inflammation and hypercoagulable state. The main aim of the study was to evaluate the outcome of severe COVID-19 patients basing on prothrombotic risk factors (i.e. D-dimer). We also evaluated the impact of different doses of low molecular weight heparin (LMWH) on the incidence of bleedings. METHODS: The data of forty-two patients admitted to the Intensive Care Unit (ICU) were retrospectively analyzed. On ICU admission, patients with D-dimer < 3000 ng/mL (Group 1) received enoxaparin 4000 UI (6000 UI, if body mass index >35) subcutaneously b.i.d. and patients with D-dimer ≥ 3000 ng/mL (Group 2) received enoxaparin 100 UI/kg every 12 h. Aspirin was administered to all patients once a day. RESULTS: Both groups presented a high incidence of perivascular thrombosis (40.9% in Group 1 and 30% in Group 2). Patients of Group 2 suffered a higher incidence of venous thromboembolism (VTE) than Group 1 (65% vs 13.6%, p = 0.001). One patient (4.5%) of Group 1 and three patients (15%) of Group 2 suffered from minor bleeding; no patient had major bleeding. Group 2 had a longer ICU and hospital stay than Group 1 (11.5 ±â€¯5.6 vs 9.0 ±â€¯4.8 and 30 ±â€¯4.9 vs 21 ±â€¯2.3, p < 0.05, respectively) as well as increased ICU mortality (25% vs 9.1%). CONCLUSIONS: More severe critically ill COVID-19 patients have a high incidence of VTE and worse outcome, despite the use of heparin at the therapeutic dose. However, the use of heparin did not increase the incidence of bleeding complications.

Very early postoperative troponin increase and clinical outcome in patients admitted to the recovery room after noncardiac surgery with suspected cardiac events.

We assessed the prognostic meaning of very early (<6 h) troponin increase after noncardiac surgery in a population of patients admitted to the recovery room, for whom troponin measurements were taken because of a suspected cardiac event. Among a total of 296 patients, abnormal troponin was found in 24 (8.1%). Ten patients in this group (41.7%) and 27 among those with normal troponin (9.9%) experienced cardiovascular death, myocardial infarction, or decompensated heart failure at one month (p < 0.0001). Troponin was independently associated with a two-fold risk of events (p < 0.0001). In these patients, very early troponin measurement in the recovery room may help to identify patients at risk of cardiovascular events.