Erector spinae plane block and rhomboid intercostal block for the treatment of post-mastectomy pain syndrome.

Post-mastectomy pain syndrome (PMPS) can have multiple pain generators, including neuropathic pain and myofascial pain syndrome (MPS). Erector spinae plane (ESP) block and rhomboid intercostal block (RIB) have been used to provide anesthesia of the thorax and also for some chronic pain conditions. We describe a 43-year-old man suffering from right PMPS after right mastectomy, full axillary, and mammary lymph node dissection. We treated her with ESP blocks and RIB to reduce neuralgia and MPS: Neuropathic pain disappeared and the patient experienced only slight residual pain. The result was maintained 3 months later. This report suggests that ESP block and RIB with local anesthetic and corticosteroids with might be useful to treat a PMPS.

The analgesic efficacy of continuous elastomeric pump ropivacaine wound instillation after appendectomy.

STUDY OBJECTIVE: To evaluate the analgesic efficacy and safety of ropivacaine 0.2% when administered continuously via elastomeric pump after appendectomy. DESIGN: Prospective, randomized, double-blinded study. SETTING: Surgical ward of a university hospital. PATIENTS: 96 ASA physical status I and II patients of at least 14 years of age, undergoing appendectomy through a McBurney incision. INTERVENTIONS: Patients were randomly assigned into two groups: 500 mg of ropivacaine in 48 hours (10 mL of 0.2% ropivacaine 20 mg, starter dose plus 5 mL/h continuous wound infusion via elastomeric pump device; n = 48) in the experimental group and 250 mL of normal saline, as placebo, in the control group. MEASUREMENTS: Postappendectomy pain, measured either with a simple verbal scale or with a visual analog scale, parenteral analgesic consumption, and global satisfaction were all measured. MAIN RESULTS: A reduction in postoperative pain was observed in the ropivacaine group. Degree of pain, with a simple verbal scale measurement of severe and unbearable, was significantly lower in the ropivacaine group than in the normal saline group from time 0 to 24 hours at rest and from time 0 to 36 hours on coughing. A significant lower pain intensity (visual analog scale) was found in the ropivacaine group both at rest and on coughing, beginning at three hours and continuing to 36 hours postoperatively. The mean number of rescue analgesic doses was significantly lower in the ropivacaine group. There were no statistically significant differences in the frequency of adverse events between the two groups. CONCLUSIONS: Wound instillation with ropivacaine 0.2% is a useful, practical, and safe method for management of postoperative pain after appendectomy.

Minimally invasive coronary artery bypass grafting using the inferior J-shaped ministernotomy in high-risk patients.

In the last years the population of patients referred for coronary surgery has changed toward a high-risk profile. In selected cases minimally invasive approach could be a good option to reduce mortality and morbidity. Between September 2005 and September 2007, twenty-one consecutive patients underwent minimally invasive bypass surgery using the J-shaped inferior mini-sternotomy approach. All patients had a EuroSCORE higher than 6. The operative mortality was 0%. Conversion to on-pump surgery was not necessary. The mean operation time was 89+/-18 min, the mean ventilation time was 2.4+/-2.2 h, the mean intensive care unit stay was 47.2+/-36.5 h. In four patients a hybrid approach to achieve a complete revascularization was used. After six months from the operation the graft patency was evaluated with the 64-slice computed tomography. In high-risk coronary patients the use of the minimally invasive technique appeared a good option to achieve low morbidity and mortality. Through a mini-sternotomy approach, single- or double-vessel revascularization can be performed safely off-pump even in high-risk patients without compromising the accuracy of the anastomosis. Nevertheless, a further investigation is required to evaluate the long-term results in a larger cohort of patients.