Optimizing post anesthesia care unit admission after elective craniotomy for brain tumors: a cohort study.

BACKGROUND: Postoperative admission to intensive care unit (ICU) after craniotomy for brain tumor was the routine in the past years. However, there is little evidence supporting this dogma and doubts have been casted by many authors in the last years. Our aim was to identify risk factors for ICU admission after elective brain tumor surgery in order to propose an individualized admission to ICU tailored on patient needs. METHODS: We conducted a retrospective cohort study including all patients undergoing elective surgery for brain tumor in a neurosurgical post anesthesia care unit of a university hospital over a period of 6 years. In order to identify and validate risk factors for ICU admission, we split the final cohort of patients in a training cohort (two/third of the cohort) and the validation cohort (one/third of the cohort) using a random sequence. Using univariate and multivariate logistic regression, we created a scoring system in the training cohort and tested it with the validation cohort. Moreover, we perform a sensitivity analysis on the overall population. RESULTS: A total of 420 patients were eligible for this study. ASA-PS, tumor volume, and surgery length entered the scoring system. Sensitivity analysis on the overall population for the scoring system had an AUC of 0.774 (95% CI 0.668-0.880, the best threshold at 12.5) CONCLUSIONS: We created a tool based on ASA-PS, length of surgery, and tumor volume to evaluate the risk for ICU admission after supratentorial tumor resection. Prospective studies are deemed necessary to validate our tool.

Neuraxial and Perineural Bleeding after Neuraxial Techniques: An Overview of the Last Year.

Spinal hematoma following neuraxial or perineural techniques is a rare but severe complication that can potentially lead to catastrophic consequences. The aim of this review is to analyze all reported cases of neuraxial or perineural bleeding after performance of a locoregional technique since the last guidelines update in 2018. We included articles indexed by MEDLINE, Scopus, and Google Scholar. We analyzed the patient's age, surgical procedure, pre-operative anticoagulant and antiplatelet therapy, type of anesthetic procedure, vertebra level of the procedure, diameter and point type of the needle, hematoma type (spinal, subdural, epidural), signs and symptoms, time to imaging, and time to treatment and outcome. During our bibliographic research, we identified 5637 unique articles that were eligible according to our protocol criteria, identifying 18 separate cases of neuraxial bleeding. Although clinicians are usually aware of antiplatelet and anticoagulant perioperative management, a careful post-procedural observation and a detailed patient education are also imperative for the early detection of the symptoms of spinal cord ischemia.

Spinal anesthesia is a viable option for emergent laparoscopic procedure in high-risk patients.

General anesthesia is the gold-standard for laparoscopic procedures. Spinal anesthesia is usually not used and hypotension and impairment of spontaneous breathing are the most feared complications. A 86-year-old patient with a history of stage four chronic obstructive pulmonary disease (FEV1 28%) underwent emergent surgery for acute abdominal pain. A combined spinal-epidural anesthesia was successfully performed, surgery lasted ninety minutes without any surgical difficulties. Patient was discharged from the hospital on the third postoperative day. Our case depicts well how spinal anesthesia may be a viable option for high risk patients undergoing emergent laparoscopic surgery.

PECS II block is associated with lower incidence of chronic pain after breast surgery.

Background: Breast cancer is complicated by a high incidence of chronic postoperative pain (25%-60%). Regional anesthesia might play an important role in lowering the incidence of chronic pain; however it is not known if the pectoral nerve block (PECS block), which is commonly used for breast surgery, is able to prevent this complication. Our main objective was therefore to detect any association between the PECS block and chronic pain at 3, 6, 9, and 12 months in patients undergoing breast surgery. Methods: We conducted a prospective, monocentric, observational study. We enrolled 140 consecutive patients undergoing breast surgery and divided them in patients receiving a PECS block and general anesthesia (PECS group) and patients receiving only general anesthesia (GA group). Then we considered both intraoperative variables (intravenous opioids administration), postoperative data (pain suffered by the patients during the first 24 postoperative hours and the need for additional analgesic administration) and development and persistence of chronic pain (at 3, 6, 9, and 12 mo). Results: The PECS group had a lower incidence of chronic pain at 3 months (14.9% vs. 31.8%, P = 0.039), needed less intraoperative opioids (fentanyl 1.61 µg/kg/hr vs. 3.3 µg/kg/hr, P < 0.001) and had less postoperative pain (3 vs. 4, P = 0.017). Conclusions: The PECS block might play an important role in lowering incidence of chronic pain, but further studies are needed.

Quality of Erector Spinae Plane Block Educational Videos on a Popular Video-sharing Platform.

Introduction The Erector Spinae Plane (ESP) block is a novel inter-fascial block developed in 2016, which has several clinical indications. YouTube (www.youtube.com; YT) is a popular American video-sharing platform. YT permits every user to view, share, and comment the videos uploaded by other users. The aim of the study was to evaluate the educational value and the technical video quality of didactic videos for the ESP block on a popular video-sharing platform, to evaluate the difference in quality between academic and nonacademic videos, and to evaluate the correlation between the views and quality of the videos, the length, and the time since upload. Methods We performed a search on YT trying to detect all relevant educational videos for the ESP block. Both the educational value and the technical video quality were assessed independently by three assessors. Assessors were asked to watch the videos and to fill in two questionnaires, the first one regarding the technical and educational aspects of ESP block, the second one regarding the video-editing quality. The video length, academic origin, views, and time from upload were also registered. Results We identified 62 videos and 21 videos entered the final analysis. The educational material for the ESP block had an overall low quality. Academic videos have a higher quality than non-academic ones. The video views are correlated with time since upload but not with the video quality. Conclusions The educational material for the ESP block on YT has a limited technical and video quality. For this reason, we recommend physicians to be very cautious in using video-sharing platforms as a unique source of medical knowledge.

Erector spinae plane block: a systematic qualitative review.

INTRODUCTION: The erector spinae plane (ESP) block is an interfascial block proposed to provide analgesia for chronic thoracic pain. It consists in an injection of local anesthetic in a plane between the transverse process and the erector spinae muscles group. EVIDENCE ACQUISITION: We performed a systematic review of literature following the PRISMA Statement Guidelines. The bibliographic search was conducted on September 2018. We included articles indexed in MEDLINE, EMBASE, Cochrane Library and Google Scholar. Search terms included the following: "erector spinae plane block" OR "ESP block" OR "erector spinae block." We identified 367 studies and after removal of 206 duplicates and exclusion of 18 records we manually searched 140 studies. EVIDENCE SYNTHESIS: We identified four randomized controlled trials, but the endpoints were heterogeneous preventing a statistical analysis; we performed then a qualitative review of the literature. Studies showed lower use of opioids and a longer time to first analgesic requirement in the ESP group. In one study, ESP block was found to be as effective as epidural analgesia. ESP block has a wide range of clinical indications. Its mechanism of action is still not thoroughly understood. Only two reports presented complications caused by the block. CONCLUSIONS: Although data suggests that ESP block is an easy and safe technique, more studies are needed to assess safety, complications rates and efficacy of this technique. In particular, we need well designed RCTs comparing ESP block to gold standard regional anesthesia technique. Nevertheless, ESP block is already a viable option for anesthesiologists all over the world.