Fascial plane blocks for cardiothoracic surgery: a narrative review.

In recent years, there has been a growing awareness of the limitations and risks associated with the overreliance on opioids in various surgical procedures, including cardiothoracic surgery.This shift on pain management toward reducing reliance on opioids, together with need to improve patient outcomes, alleviate suffering, gain early mobilization after surgery, reduce hospital stay, and improve patient satisfaction and functional recovery, has led to the development and widespread implementation of enhanced recovery after surgery (ERAS) protocols.In this context, fascial plane blocks are emerging as part of a multimodal analgesic in cardiac surgery and as alternatives to conventional neuraxial blocks for thoracic surgery, and there is a growing body of evidence suggesting their effectiveness and safety in providing pain relief for these procedures. In this review, we discuss the most common fascial plane block techniques used in the field of cardiothoracic surgery, offering a comprehensive overview of regional anesthesia techniques and presenting the latest evidence on the use of chest wall plane blocks specifically in this surgical setting.

Assessment of Frequency and Predictive Value of Comorbidities in Patients With Disorders of Consciousness in the Acute Setting.

Medical comorbidities are frequent in patients with disorders of consciousness (DoC) and their impact on outcomes is under investigation. The aim of this study was to investigate patients with DoC in the acute stage and the influence of comorbidities. Patients admitted to intensive care units and neurological units with a diagnosis of coma, vegetative state/unresponsive wakefulness syndrome (VS/UWS), and minimally conscious state (MCS) were investigated through the Glasgow Coma Scale (GCS), the Coma Recovery Scale - Revised (CRS-R) and the Comorbidities Coma Scale (CoCos). Forty-three patients (21 men and 22 women; mean age at admission: 60.4 ± 21.0) were included in the study. The most frequent diagnosis at admission was coma (72%) followed by VS/UWS (14%) and MCS (14%). The most frequent brain injury was subarachnoid hemorrhage (46%). At the 6-month follow-up, 19 patients had died (44%), 15 showed a full recovery of consciousness (35%), 7 were in a condition of emergence from MCS (16%), and 2 showed a persistent VS/UWS (5%). Forty-two (98%) patients showed at least one comorbidity: presence of life-support device (92.9%), anemia (76.2%), arterial hypertension (66,7%), hydrocephalus (45.3%), and respiratory infections (45.2%) were those most frequently reported. At the Multivariable Cox regression, the presence of renal disease (hazard ratio [HR] 33.37; p = 0.033) and malnutrition (HR 14.52; p = 0.001) were predictors of missed recovery of full consciousness. Although adverse outcomes are generally predicted by the severity of brain damage, the presence of medical comorbidities in an acute phase could influence outcomes and long-term prognosis.

A Modified Approach to a Parasternal Block: A Case Report.

The parasternal block is an ultrasound-guided interfascial plane block that provides anesthesia of the medial quadrants of the breast. The original approach provided injections in the fascial plane between the pectoral major and external intercostal muscles. We observed that this technique might limit an adequate diffusion of the injectate due to the anatomical convexity of the ribs, which might hinder fascial hydrodissection. We suggest a modified approach by positioning the tip of the needle on the rib dome to reduce the local anesthetic volume and obtain a more homogeneous and longitudinal spread into the target fascial compartment.

Two cases of metformin-associated lactic acidosis in post-operative period in emergency department: time to be aware-case reports.

Background: Diabetic patients on metformin therapy may be vulnerable to lactic acidosis during acute illness. This is particularly true since the comorbid conditions among patients with diabetes and the frequent use of renin-angiotensin system blockers increase the risk of renal dysfunction. Case Description: We present two cases of metformin-associated lactic acidosis (MALA) occurred after abdominal surgery. A 74-year-old woman presented to emergency department (ED) for a transient loss of consciousness. She had vomiting, diarrhea, and lack of appetite in the last 3 days and she had had an abdominal adhesiolysis surgery 12 days before. A 78-year-old man, with history of right hemicolectomy performed 15 days before admission to ED. Patient presented with diffuse abdominal pain, diarrhea, nausea, and vomiting). Arterial blood gas analysis showed acidemia (pH 7.031), elevated anion gap (AG), lactate >15.5 mmol/L. Due to the patients' critical condition, vasopressor infusion and fluid resuscitation were started and an urgent continuous veno-venous hemodialysis with citrate and calcium (CVVHD-CiCa) treatment was provided. Conclusions: A promptly differential diagnosis at ED and early treatment with vital support and CVVHD-CiCa enabled the resolution of MALA, which can often be a fatal complication in diabetic patients taking metformin. Close collaboration with the surgical and endocrinological team would be necessary for the management of the postoperative period planning the reintroduction of metformin in patients undergoing major abdominal surgery, to avoid the possibility of the onset of MALA.

Fascial Plane Blocks Combination for Breast Surgery in Obese Patients With Difficult Airway Management: Insidious or a Valid Alternative.

Obesity poses several challenges for anesthetists. The several comorbidities associated with obesity can result in very complex management, which requires a multimodal and reasoned approach. The possible difficult airways are, certainly, the obstacle that most can put the anesthetist to the test. From this point of view, regional anesthesia (RA) can be a valid alternative to general anesthesia (GA) in selected patients. The possibility of performing an anesthetic block allows the fulfilment of the surgical act. We present the case of a 56-year-old woman, with a BMI of 43. In her medical history, she has obstructive sleep apnea syndrome (OSAS) on home-oxygen therapy without continuous positive airway pressure (CPAP) therapy. The patient reported probable airway difficulties in previous breast surgery, and the preoperative evaluation highlighted and confirmed the high risk. For this reason, in agreement with the surgeons and the patient, we decided to perform RA. Forty minutes before the start of the surgery, a deep anesthetic ultrasound-guided serratus anterior plane (US-SAP; branches of the intercostal nerves in the middle axillary line [BRILMA]) was performed, followed by a right ultrasound-guided erector spinae plane (US-ESP) block. Mild sedation with propofol 1 mg/kg/h was administered and SpO2 always remained above 97% with nasal oxygen at 3 l/min. The surgery was completed in 35 minutes, the patient complained of no pain, and received opioid rescue therapy during the post-operative period. This case presents clinical evidence that RA can help in avoiding some dreadful complications that can occur during GA in obese patients. In any case, the anesthetic management choice must be carefully reasoned, considering the patient's clinical conditions, surgical needs, and, not least, the skills of the anesthetist.

Hypopharynx, oropharynx morphology and histology in severe Coronavirus 2 patients treated by noninvasive ventilation: comparison between full-face mask and helmet strategies.

BACKGROUND: Non-invasive ventilation may alter the morphology and histology of the upper airway mucosa. This study aimed to investigate the alterations of hypopharynx and oropharynx mucosa, identified during oro-tracheal intubation procedure via video-assisted laryngoscopy, in severe acute respiratory syndrome Coronavirus 2 related, treated by non-invasive ventilation via full-face mask or helmet. METHODS: Data of patients affected by Coronavirus 2 admitted to COVID Hospital of L'Aquila (Italy), presenting hypopharynx and oropharynx morphology alterations, requiring oro-tracheal intubation for invasive ventilation and initially treated with non-invasive ventilation were included in the study. The study aimed to investigate the upper airway mucosa alterations using oropharyngeal and hypopharyngeal images and biopsies taken during video-assisted-laryngoscopy. Data from the hypopharynx and oropharynx morphology and histology alterations between non-invasive ventilation via a full-face mask or helmet used during hospitalization were compared. RESULTS: From 220 data recorded, 60 patients were included in the study and classified into non-invasive ventilation full-face mask group (30/60) and via helmet group. Comparing data between groups, significant differences were found with respect to hyperemia (77% vs. 20%), laryngeal bleeding ulcerations (87% vs. 13%), and vocal cord edema with >50% narrowing of the tracheal lumen (73% vs. 7%), respectively. The histology examination revealed fibrin-necrotic exudate with extensive necrotic degenerative changes in the sample tissue of the groups. There were not any differences in the duration time of non-invasive ventilation, time from hospitalization and the start of ventilation between groups. CONCLUSIONS: The data from this research suggested that there were differences in airway mucosa damages among patients treated with a full-face mask or helmet. Further studies should be planned to understand which non-invasive ventilation support may mitigate upper airway mucosa damages when oro-tracheal intubation is requested for invasive respiratory support.

Use of Video Laryngoscope in Sedated Spontaneously Breathing Patients with Predicted Difficult Tracheal Intubation and Impossibility of Using Fibreoptic Bronchoscopy.

Intubation with a flexible fibrobronchoscope in an awake patient is frequently considered the technique of choice in patients with predicted difficult intubation. There are, however, situations in which the use of the fibrobronchoscope is not applicable, particularly due to problems attributable to the patient or to limited use of the instrument. In such situations, the video laryngoscope can be a useful alternative, as long as it is associated with adequate sedation of the patient. In fact, it ensures excellent viewing of the glottis, allowing for successful orotracheal intubation to be performed even in case of difficult airways, while keeping the patient spontaneously breathing throughout the procedure. From the data present in the literature, this technique seems to ensure a success rate and a safety profile similar to those obtained with the fibrobronchoscope, moreover, with greater ease of use by the anaesthesiologist. The main purpose of this work is to provide a valid and safe alternative to intubation with a fibrobronchoscope while awake in those patients with anticipated difficult airway management and in whom, for different reasons, fibrobronchoscope cannot be used.

Translation and Transcultural Adaptation of the Wessex Head Injury Matrix, Italian Version: A Preliminary Report.

BACKGROUND: Patients who are in a coma, a vegetative state or a minimally conscious state present a clinical challenge for neurological assessment, which is a prerequisite for establishing a prognosis and planning management. Several scales have been developed to evaluate these patients. The Wessex Head Injury Matrix is a comprehensive tool but is currently available only in the French and English languages. The aim of this study was to translate and evaluate the reliability of the Italian version of the scale. METHODS: The original scale was translated according to a standard protocol: three separate translations were made, and a selected version was back-translated to check for any errors in order to obtain the most accurate Italian translation. A final back translation of the agreed version was made as a further check. The final version was then administered blind to a consecutive series of patients with severe acquired brain injury by two examiners. Inter-rater and test-retest reliability were assessed using a weighted Cohen's kappa (Kw). Concurrent validity of the WHIM was evaluated by ρ Spearman's correlation coefficient using the Glasgow Coma Scale (GCS) and the Coma Recovery Scale Revised (CRS-R) as the available gold standard. RESULTS: Twenty-four patients (12 males and 12 females; mean age 59.9 ± 20.1; mean duration from index event 17.7 ± 20.0 days) with stroke (n = 15), traumatic brain injury (n = 7) and anoxic encephalopathy (n = 2) were included. Inter-rater [Kw 0.80 (95% CI 0.75-0.84)] and test-retest reliability [Kw 0.77 (95% CI 0.72-0.81)] showed good values. WHIM total scores correlated significantly with total scores on the GCS (ρ = 0.776; p < 0.001) and the CRS-R (ρ = 0.881; p < 0.001) demonstrating concurrent validity; Conclusion: The Italian version of the scale is now available for clinical practice and research.