Blocking around the transversalis fascia: behind the scene.

BACKGROUND: The transversalis fascia plane and the quadratus lomborum blocks target the branches of T12-L1 nerves and provide analgesia in patients undergoing surgery involving the corresponding dermatomes. The transversalis fascia is believed to contribute to determine the spread of local anesthetic in such blocks. Nonetheless, the anatomy of this fascia and its possible role in these blocks still have to be precisely defined. METHODS: We conducted a series of 10 dissections and full-thickness specimens were obtained from one side for the microscopic analysis. RESULTS: Macroscopic study showed failed to identify a distinguishable fascial structure between the fascia of the transversus abdominis muscle and the peritoneum. Microscopic examination showed the presence of a further fascial layer (0.1-0.2 mm), ascribable to transversalis fascia. Transversalis fascia and transversus abdominis epimysium posteriorly diverge: transversus epimysium goes posteriorly to quadratus lomborum to joint the oblique internal aponeurosis, while transversalis fascia continues in front to quadratus lomborum. So, a little fascial triangle (2-3 mm) is formed on the lateral border of quadratus lomborum, defined by transversalis fascia and transversus abdominis. Inside this triangle, T12 and L1 nerves are present. CONCLUSIONS: Considering the thinness of the transversalis fascia and the small size of the triangular space that contains the target nerves, this is most likely a virtual, ideal rather than realistic injection site. Accordingly, it is probable that the local anesthetic is injected in the much wider retroperitoneal space and reaches the nerves by spreading backwards through the thin transversalis fascia.

Ultrasonography and Italian anesthesiology: a national cross-sectional study.

PURPOSE: In recent years, ultrasound has seen a rapid development with numerous applications in anesthesia, intensive-care medicine, and pain medicine, increasing efficacy and safety of procedures. We investigated the prevalence of ultrasound use among Italian anesthetists. METHODS: A cross-sectional prevalence study was carried out on a sample of 735 anesthetists. The research was conducted during the ultrasound training in anesthesia and intensive care, in the Italian Associazione Anestesisti Rianimatori Ospedalieri - Emergenza Area Critica "SimuLearn®" training centre (Bologna, Italy). RESULTS: The overall prevalence of a dedicated ultrasound devices in the operating room was 70% [95% CI 66-73%], while 74% [95% CI 69-78%] in northern Italy, 61% [95% CI 52-68%] in southern Italy, and 70% [95% CI 63-77%] in central Italy, indicating a significant difference between the north and south of Italy. The prevalence of regular use of ultrasound was high for regional anesthesia and for central venous cannulation [82-95% CI 79-85%] and low for pain therapy procedures [7-95% CI 6-10%]. Multivariate logistic analysis showed that the presence of a dedicated ultrasound device and high expertise were factors associated with routine use of ultrasound for regional anesthesia in upper and lower limb blocks and in vascular access. CONCLUSION: The appropriate training in the use of ultrasound in anesthesia, intensive-care medicine, and pain therapy should be implemented in south of Italy to make uniform the widespread of ultrasonography in anesthesia, in all Italian regions.

Continuous wound infusion and local infiltration analgesia for postoperative pain and rehabilitation after total hip arthroplasty.

BACKGROUND: Total hip arthroplasty is one of the most common procedures in orthopedic surgery. We hypothesized that local infiltration of analgesia and continuous wound infusion of anesthetics in the first 72 hours after surgery could provide more effective postoperative analgesia with better rehabilitation. METHODS: A double-blind, randomized, controlled study was conducted with 96 patients who underwent total hip arthroplasty. The patients were randomized to receive either a local infiltration analgesia and continuous wound infusion of anesthetics or a local infiltration analgesia and continuous wound infusion of saline solution. The patients in both groups received subarachnoid anesthesia and a local infiltration analgesia. A multihole catheter was placed next to the implant and connected to an electronic pump containing a 300-mL solution of 0.2% levobupivacaine (experimental group) or saline (control group). RESULTS: A total of 96 consecutive patients were enrolled and randomized. Of these, 48 patients received local infiltration analgesia and continuous wound infusion of local anesthetics, and the remainder received local infiltration analgesia and continuous wound infusion of saline solution. The analysis showed a significant main effect of treatment on the postoperative incident of pain (Ftreat(1,93)=22.62, P=0.000) and on resting pain during the post-surgery follow-up (Ftreat(1,93)=15.62, P=0.0002). The pain scores during the rehabilitation period were significantly less in the experimental group. Analgesic consumption was less in the experimental group. CONCLUSIONS: The addition of continuous wound infusion of anesthetics to local infiltration analgesia provided an extended analgesic effect associated with good rehabilitation performance.

Unilateral paravertebral block compared with subarachnoid anesthesia for the management of postoperative pain syndrome after inguinal herniorrhaphy: a randomized controlled clinical trial.

Inguinal herniorrhaphy is a common surgical procedure. The aim of this investigation was to determine whether unilateral paravertebral block could provide better control of postoperative pain syndrome compared with unilateral subarachnoid block (SAB). A randomized controlled study was conducted using 50 patients with unilateral inguinal hernias. The patients were randomized to receive either paravertebral block (S group) or SAB (C group). Paravertebral block was performed by injecting a total of 20 mL of 0.5% levobupivacaine from T9 to T12 under ultrasound guidance, whereas SAB was performed by injecting 13 mg of 0.5% levobupivacaine at the L3 to L4 level. Data regarding anesthesia, hemodynamic changes, side effects, time spent in the postanesthesia care unit, the Karnofsky Performance Status, acute pain and neuropathic disturbances were recorded. Paravertebral block provided good anesthesia of the inguinal region without patient or surgeon discomfort, with better hemodynamic stability and safety and with a reduced time to discharge from the postanesthesia care unit compared with SAB. During the postsurgical and posthospital discharge follow-ups, rest and incident pain and neuropathic positive phenomena were better controlled in the S group than in the C group. The consumption of painkillers was higher in the C group than in the S group throughout the follow-up period. Paravertebral block can be considered a viable alternative to common anesthetic procedures performed for inguinal hernia repair surgery. Paravertebral block provided good management of acute postoperative pain and limited neuropathic postoperative disturbances.

A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations: To Whom It May Concern.

Local anesthetic systemic toxicity (LAST) occurrence may cross several medical specialties. In 2010, the American Society of Regional Anesthesia and Pain Medicine (ASRA) published the first algorithm on LAST management, introducing the use of lipid emulsion (ILE) treatment. In the present study, we retrieved the cases of LAST published between ASRA guidelines dissemination and March 2014. We analyzed the reported clinical manifestations of LAST, characteristics of affected patients, onset time of toxicity, and clinical setting. We also focused on the treatment measures that were applied in the different cases, especially on the use of ILE and adherence to ASRA recommendations. Despite the limits of a review of case reports, the present study calls attention to the insidious nature of LAST, especially its atypical manifestations, and shows that ILE may currently be underadministered in daily clinical practice, especially in nonanesthesiology practice.