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BACKGROUND: The dural puncture epidural (DPE) technique has been associated with better sacral analgesia compared with a traditional epidural (EPL) technique in laboring parturients. The aim of this study was to investigate whether DPE with a 27-gauge pencil-point needle compared with a traditional EPL technique produces more rapid bilateral sacral blockade in nulliparous parturients. METHODS: Patients were randomized to a DPE or EPL technique. Epidural analgesia in both groups was initiated with ropivacaine 0.1% and sufentanil 0.5⯵g/mL (15â¯mL) and maintained via programmed intermittent epidural boluses. Analgesic blockade was tested bilaterally beginning 10â¯min after initiation, and then at predefined intervals until delivery. The presence of an S2 blockade at 20â¯min was the primary outcome. RESULTS: Among 108 (54 per group) patients enrolled, bilateral sacral (S2) blockade at 20â¯min was significantly more common in the DPE than in the EPL group [47 (87%) vs. 23 (43%), absolute risk reduction (ARR) 44%, 95% CI 28 to 60; Pâ¯<â¯0.001]. Time to a numeric pain rating scale score (0-10 scale)â¯≤â¯3 (20 [20,30] min in both groups, HR 1.15, 95% CI 0.77 to 1.15; Pâ¯=â¯0.50), number of rescue doses [0 (0, 1) vs 0 (0, 1); P 0.08], and presence of bilateral S2 blockade at delivery were not significantly different between groups. CONCLUSIONS: The DPE technique with a 27-gauge pencil-point spinal needle more often provides bilateral sacral blockade at 20â¯min following block initiation compared with the EPL technique. The time to adequate analgesia and need for supplemental analgesia did not appear to differ between techniques.
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OBJECTIVE: The term THRIVE refers to the delivery of 100% heated and humidified oxygen via a nasal cannula to maintain viable gas exchange during prolonged apnea. There are no reports of its application for Operative Hysteroscopy (OH) under general anesthesia (GA). The aim of the study is to investigate the success rate of THRIVE as unique airway management technique in this setting. The results will support the development of a randomized controlled trial (RCT) to demonstrate the non-inferiority of THRIVE compared to traditional techniques. PATIENTS AND METHODS: Twenty consecutive ASA I-II women presenting for OH were enrolled. Standard anesthesia, as well as transcutaneous carbon dioxide (tcCO2) monitoring, was performed. After preoxygenation with 30 Lâmin-1, GA was induced with propofol and fentanyl, then oxygen flow was increased to 70 Lâmin-1 and anesthesia maintained with propofol infusion. The primary outcome was success rate of THRIVE defined as SpO2 > 94%, tcCO2 < 60 mmHg and no need for rescue airway intervention. RESULTS: Mean age was 47 ± 12 years. Mean duration of the procedure was 25 ± 9 minutes, and the success rate of the technique was 100%. Median SpO2 during the procedure was 100 (IQR 99-100) %. Mean maximum tcCO2 level was 51 ± 7 mmHg while mean tcCO2 level during the procedure was 45 ± 7 mmHg. At the end of the procedure, mean tcCO2 was 44 ± 5 mmHg. CONCLUSIONS: THRIVE allowed adequate gas exchange during OH under GA, without additional rescue airway interventions. The application of THRIVE in this setting may allow minimal airway manipulation and optimal comfort for the patient with low failure rate. We calculated the sample size for the planned non-inferiority RCT investigating the effectiveness of THRIVE versus laryngeal mask ventilation in OH: 82 is the minimal number of patients per group to test a non-inferiority limit of 10%.
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Insuflación , Propofol , Adulto , Manejo de la Vía Aérea , Anestesia General , Dióxido de Carbono , Estudios de Cohortes , Estudios de Factibilidad , Femenino , Fentanilo , Humanos , Histeroscopía , Persona de Mediana Edad , EmbarazoRESUMEN
OBJECTIVE: Total laparoscopic hysterectomy (TLH) is associated with significant postoperative pain that worsens outcomes and prolongs hospital stay. Ultrasound guided erector spinae plane block (ESPB) is a new technique for thoracic analgesia. Few cases have been described for postoperative analgesia in laparoscopy. We describe the use of preoperatory bilateral ESPB at level T10 to provide postoperative analgesia following THL. PATIENTS AND METHODS: We enrolled 10 ASA 1-2 patients scheduled for TLH. After written informed consent we performed bilateral ESPB at T10 level in sitting position, with a linear probe and in plane cranio-caudal approach and ropivacaine 0.5% 20 for each side. The sensitive block was tested by pinprick. Standard general anesthesia was administered. Patient controlled analgesia (PCA) with morphine 1 mg/ml was delivered. We measured postoperative pain by visual analogue scale (VAS). RESULTS: Five patients (50%) underwent simple TLH, 5 women (50%) had TLH plus salpingo-oophorectomy. VAS scores was <4 in all cases but one, and PCA morphine consumption was 4.1 ± 3.5 mg (mean ± SD). Pinprick was positive bilaterally in 3 patients (30%). CONCLUSIONS: ESPB was an effective and safe procedure for postoperative pain control after TLH. Future research should compare ESPB to other techniques to assess its role on perioperative management of THL.
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Analgesia Controlada por el Paciente , Histerectomía , Laparoscopía , Bloqueo Nervioso , Adulto , Anciano , Femenino , Humanos , Persona de Mediana Edad , Manejo del Dolor , Dolor Postoperatorio , Columna Vertebral , Ultrasonografía IntervencionalAsunto(s)
Ventilación no Invasiva/métodos , Trabajo de Parto Prematuro/terapia , Insuficiencia Respiratoria/terapia , Enfermedad Aguda , Adulto , Anestesia Obstétrica , Espasmo Bronquial/complicaciones , Cesárea/métodos , Parto Obstétrico/métodos , Femenino , Hemodinámica/fisiología , Histiocitosis de Células de Langerhans/complicaciones , Humanos , Recién Nacido , Pulmón/embriología , Pulmón/crecimiento & desarrollo , Mediciones del Volumen Pulmonar , Obesidad Mórbida/complicaciones , Neumotórax/complicaciones , Embarazo , Complicaciones del Embarazo/terapiaRESUMEN
BACKGROUND: This study evaluates the effects of spinal anesthesia with hyperbaric bupivacaine plus sufentanil on bladder function in women undergoing cesarean section. SUBJECTS AND METHODS: Thirty caucasian healthy pregnants scheduled for elective Cesarean section under spinal anesthesia performed with hyperbaric bupivacaine plus sufentanil were enrolled. Filling cystometry, proprioceptive bladder sensation during cystometry, rate of spontaneous voiding, post void residual volume, anocutaneous and bulbocavernosus reflex were analyzed at 4, 6 and 8 hours after spinal anesthesia. RESULTS: The proportion of women experiencing first sensation, first desire and strong desire at 4 hours was significantly different from that reported at 6 and 8 hours (p < 0.05 for first sensation and p < 0.01 for first and strong desire). Significant differences were also observed between volumes at which first sensation arose at first measurement (4 hours) and at second and third measurements (p < 0.01). There was a significant difference in rate of spontaneous micturition, with 80% of patients at 8 hours able to spontaneously void versus 40% at 6 hours, (p < 0.01). Moreover, a lower percentage of women had absent and/or light reflexes at 4 hour than at 6 and 8 hours (p < 0.01). CONCLUSIONS: Spinal anesthesia with bupivacaine plus sufentanil causes a clinically significant disturbance on bladder function in women undergoing cesarean section. Even thought recovery of proprioceptive bladder sensation is fast, a full recovery of spontaneous voiding requires a much longer time. A close monitoring of urinary function and of bladder distension is, therefore, advisable.
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Anestesia Raquidea , Anestésicos/farmacología , Bupivacaína/farmacología , Cesárea , Sufentanilo/farmacología , Vejiga Urinaria/efectos de los fármacos , Adulto , Femenino , Humanos , Embarazo , Vejiga Urinaria/fisiopatología , Urodinámica/efectos de los fármacosRESUMEN
Acute myocardial infarction rarely occurs in women during childbearing age (1:20,000), but maternal mortality rate is high (11%). Management of pregnant woman affected by myocardial infarction could be a challenge for obstetricians, cardiologists and anesthetists. In this report, we present the management of a 36 years-old nulliparous woman affected from hypertension and dyslipidemia, who experienced acute myocardial infarction at 25th gestational week and was scheduled for caesarean delivery at 35th week. General anesthesia for cesarean section was conducted using sevoflurane and remifentanil target controlled infusion (TCI); the patient was monitored with ECG, pulse oximetry, invasive blood pressure, haemodynamic measurement by lithium dilution cardiac output (LiDCO plus) and bispectral index. The titrated use of remifentanil and the close control of hemodynamic parameters by LiDCO plus monitoring may contribute to improve maternal outcome and newborn well-being in the management of general anesthesia for caesarean section.
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Anestesia General , Anestesia Obstétrica , Cesárea , Infarto del Miocardio/fisiopatología , Complicaciones Cardiovasculares del Embarazo/fisiopatología , Adulto , Femenino , Humanos , EmbarazoRESUMEN
BACKGROUND: Attenuation of central sensitization with NMDA-active drugs such as S-Ketamine may play a role in postoperative analgesia and prevention of neuropathic pain. However, during cesarean section with neuraxial block, S-Ketamine might have adverse effects on the interaction between mothers and infants, including breastfeeding. METHODS: Women undergoing elective repeat cesarean section with subarachnoid anesthesia (0.5% hyperbaric bupivacaine 8-10 mg and sufentanil 5 µg) were enrolled in a double-blind, randomized study. Patients in the S-Ketamine group (N.=28) received i.v. midazolam 0.02 mg/kg and S-Ketamine 0.5 mg/kg i.m. bolus 10 minutes after birth followed by a 2 µg/kg/min i.v. continuous infusion for 12 h. The control group (N.=28) received placebo. Paracetamol and patient controlled analgesia with intravenous morphine were given postoperatively. Von Frey filaments were used to assess pain threshold on the inner forearm and T10-T11 dermatomes (supposed hyperalgesic area). RESULTS: S-Ketamine reduced morphine consumption at 4-8, 8-12, and 12-24 hours after surgery (total 31%), even after its effect has ceased, suggesting an anti-hyperalgesic action. Mild side effects were observed in the S-Ketamine group one hour after delivery. All side effects were rated as light and there were no serious adverse events. Pain threshold was not significantly different between groups. S-Ketamine patients showed a trend towards reduced pain sensitivity at the T10 dermatome, which is involved by surgical damage. After three years, patients reported no differences in residual pain, dysesthetic symptoms, or duration of breast-feeding. CONCLUSION: Preventive administration of S-Ketamine via 12-hour infusion was safe and may have anti-hyperalgesic action after cesarean section.
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Anestesia Raquidea , Anestésicos Disociativos , Cesárea/métodos , Ketamina , Manejo del Dolor/métodos , Dolor Postoperatorio/prevención & control , Adyuvantes Anestésicos , Adulto , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestésicos Disociativos/administración & dosificación , Anestésicos Locales , Bupivacaína , Método Doble Ciego , Femenino , Humanos , Ketamina/efectos adversos , Morfina/administración & dosificación , Morfina/uso terapéutico , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Embarazo , SufentaniloRESUMEN
BACKGROUND: To investigate changes in heat pain threshold and modifications in heat pain processing during pregnancy and labour, seventy-six nulliparous pregnant women were enrolled in two studies. METHODS: In the first study (psychophysical), 60 pregnant women underwent a quantitative sensory testing (QST) investigating heat perception in two body areas (right forearm and T10 dermatome) according to these groups: 32-33 gestational weeks (GW), 39-40 GW, early stage of active labour and 24 h after the delivery. In the other study (neurophysiological), contact heat-evoked potentials (CHEPs) were recorded in other 16 women at the 32nd GW and in 11 of these also at the 40th GW. RESULTS: The psychophysical study showed that heat pain threshold was significantly increased at the forearm at 32-33 GW (median ± IQR: 39.6 ± 0.7 °C), at 39-40 GW (40.6 ± 1.1 °C) and at early stage of active labour (40.8 ± 1.5 °C) as compared to 20 non-pregnant controls (p < 0.001). Heat pain threshold tested at T10 level was significantly increased at 32-33 GW (41.0 ± 1.6 °C), at 39-40 GW (42.1 ± 1.8 °C), and at early stage of active labour (42.3 ± 1.3 °C) as compared to the non-pregnant women (p < 0.001). The N2-P2 CHEP amplitude (main negative N2 and positive P2 components of the vertex biphasic potential) recorded from the pregnant women was significantly lower at the 40th than at the 32nd GW, after stimulation of both the forearm (p < 0.001) and the abdomen (p < 0.001). CONCLUSIONS: In pregnant women, there is a progressive increase of heat pain threshold and a reduction of the CHEP amplitude, suggesting that a general inhibitory mechanism may be involved.
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Potenciales Evocados Somatosensoriales/fisiología , Percepción del Dolor/fisiología , Umbral del Dolor/fisiología , Embarazo/fisiología , Adulto , Estudios de Casos y Controles , Femenino , Calor , Humanos , Primer Periodo del Trabajo de Parto/fisiología , Periodo Posparto/fisiología , Tercer Trimestre del Embarazo/fisiologíaRESUMEN
BACKGROUND: The multicenter observational ITalian Observational Study on the management of mild-to-moderate PostOperative Pain (ITOSPOP) was carried out in 24 hospitals to describe current postoperative pain management in Italy and the intensity of pain experienced by patients during the first 48 hours after surgery. METHODS: Adult patients, after surgery expected to result in mild-moderate postoperative pain, underwent six evaluations. The primary endpoint was the level of organization and standardization of postoperative pain management. Secondary objectives included the intensity of postoperative pain, and an assessment of incident pain, postoperative analgesic and concomitant treatment administration. RESULTS: Only 16.7% hospitals had an acute pain service and 41.7% hospitals applied a standardized protocol for postoperative pain management. The majority (>60%) of the 1952 patients monitored underwent all six assessments, >70% of which were performed by a physician. The proportion of patients with moderate pain decreased during the study period, but almost 10% of patients still experienced moderate pain at study end. Mild pain was reported by 50% of the patients for the entire study duration. At the final assessment, 5% of patients still presented with incident pain frequently interfering with daily activities. Most patients were treated with analgesics, but 20% of patients did not receive any pain medications despite experiencing pain. CONCLUSION: The level of organization and standardization of postoperative pain management in Italian hospitals remains low. Postoperative analgesic treatment remained suboptimal and almost two-thirds of patients continued to experience pain.
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Manejo del Dolor/métodos , Dolor Postoperatorio/tratamiento farmacológico , Adolescente , Adulto , Anciano , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/uso terapéutico , Niño , Preescolar , Ensayos Clínicos como Asunto , Relación Dosis-Respuesta a Droga , Femenino , Encuestas de Atención de la Salud , Humanos , Lactante , Recién Nacido , Italia , Masculino , Persona de Mediana Edad , Clínicas de Dolor , Manejo del Dolor/efectos adversos , Dimensión del Dolor/métodos , Satisfacción del Paciente , Adulto JovenRESUMEN
The authors briefly review the clinical applications of non-invasive ventilation (NIV) in patients with chronic obstructive pulmonary disease (COPD), mostly focusing on the application of NIV in the intensive care setting. After a short discussion of the main pathophysiologic aspects of NIV administration in patients with acute exacerbation of COPD, the most relevant clinical trials are shortly reviewed, particularly focussing on prospective randomised trials. NIV application is analysed both in its early administration, as a tool to prevent endotracheal intubation and its main complication, and as a technique alternative to endotracheal intubation in patients requiring mechanical ventilation. Finally, the main contraindications for NIV are reviewed and discussed.