Ultrasound-Guided Bilateral Erector Spinae Plane Block vs. Ultrasound-Guided Bilateral Posterior Quadratus Lumborum Block for Postoperative Analgesia after Caesarean Section: An Observational Closed Mixed Cohort Study.

ESP block (ESPB) and posterior Quadratus Lumborum Block (pQLB) have been proposed as opioid-sparing techniques for the management of pain after abdominal surgery. Between December 2021 and October 2022, we conducted a retrospective comparative study at the delivery suite of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, to compare the efficacy of ESPB and pQLB in preventing postoperative pain after an elective caesarean section (CS). The primary outcome was total morphine consumption in the first 24 h. Secondary outcomes were time to first opioid request; Numerical Pain Rating Scale (NPRS) at 0, 2, 6, 12 and 24 h; vital signs; adverse events. Fifty-two women were included. The total cumulative dose of morphine was not significantly different between the two groups of patients (p = 0.897). Time to first dose of morphine, NPRS values and haemodynamic parameters were not statistically different between the two groups. NPRS values significantly increased (p < 0.001) at the different time intervals considered. The need for rescue doses of morphine was lower in the ESPB group compared to the pQLB group (hazard ratio of 0.51, 95% CI (0.27 to 0.95), p = 0.030). No adverse event was reported. ESPB seems to be as effective as pQLB in providing analgesia after CS.

Effect of a pre-emptive 2-hour session of high-flow nasal oxygen on postoperative oxygenation after major gynaecologic surgery: a randomised clinical trial.

BACKGROUND: We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients. METHODS: In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the Pao2/FiO2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, Paco2, the percentage of patients with impaired gas exchange (Pao2/FiO2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days. RESULTS: A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) Pao2/FiO2 was 52.9 (47.9-65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P=0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6-10] vs 12 [10-14], P<0.001), mostly because of the difference of the score in dorsal areas (7 [6-8] vs 10 [9-10], P<0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P<0.001). All other secondary outcomes were not different between groups. CONCLUSIONS: In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy. CLINICAL TRIAL REGISTRATION: NCT04566419.

Blended (Combined Spinal and General) vs. General Anesthesia for Abdominal Hysterectomy: A Retrospective Study.

BACKGROUND: Adequate pain management for abdominal hysterectomy is a key factor to decrease postoperative morbidity, hospital length of stay and chronic pain. General anesthesia is still the most widely used technique for abdominal hysterectomy. The aim of this study was to assess the efficacy and safety of blended anesthesia (spinal and general anesthesia) compared to balanced general anesthesia in patients undergoing hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. METHODS: We retrospectively collected data from adult ASA 1 to 3 patients scheduled for laparoscopic or mini-laparotomic hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. Exclusion criteria were age below 18 years, ASA > 3, previous chronic use of analgesics, psychiatric disorders, laparotomic surgery with an incision above the belly button and surgery extended to the upper abdomen for the presence of cancer localizations (e.g., liver, spleen or diaphragm surgery). The cohort of patients was retrospectively divided into three groups according to the anesthetic management: general anesthesia and spinal with morphine and local anesthetic (Group 1), general anesthesia and spinal with morphine (Group 2) and general anesthesia without spinal (Group 3). RESULTS: NRS was lower in the spinal anesthesia groups (Groups 1 and 2) than in the general anesthesia group (Group 3) for every time point but at 48 h. The addition of local anesthetics conferred a small but significant NRS decrease (p = 0.009). A higher percentage of patients in Group 3 received intraoperative sufentanil (52.2 ± 18 mcg in Group 3 vs. Group 1 31.8 ± 16.2 mcg, Group 2 44.1 ± 15.6, p < 0.001) and additional techniques for postoperative pain control (11.4% in Group 3 vs. 2.1% in Group 1 and 0.8% in Group 2, p < 0.001). Intraoperative hypotension (MAP < 65 mmHg) lasting more than 5 min was more frequent in patients receiving spinal anesthesia, especially with local anesthetics (Group 1 25.8%, Group 2 14.6%, Group 3 11.6%, p < 0.001), with the resulting increased need for vasopressors. Recovery-room discharge criteria were met earlier in the spinal anesthesia groups than in the general anesthesia group (Group 1 102 ± 44 min, Group 2 91.9 ± 46.5 min, Group 3 126 ± 90.7 min, p < 0.05). No differences were noted in postoperative mobilization or duration of ileus. CONCLUSIONS: Intrathecal administration of morphine with or without local anesthetic as a component of blended anesthesia is effective in improving postoperative pain control following laparoscopic or mini-laparotomic hysterectomy, in reducing intraoperative opioid consumption, in decreasing postoperative rescue analgesics consumption and the need for any additional analgesic technique. We recommend managing postoperative pain with a strategy tailored to the patient's physical status and the type of surgery, preventing and treating side effects of pain treatments.

Real Evidence and Misconceptions about Malignant Hyperthermia in Children: A Narrative Review.

Malignant hyperthermia is a rare but life-threatening pharmacogenetic disorder triggered by exposure to specific anesthetic agents. Although this occurrence could affect virtually any patient during the perioperative time, the pediatric population is particularly vulnerable, and it has a five-fold higher incidence in children compared to adults. In the last few decades, synergistic efforts among leading anesthesiology, pediatrics, and neurology associations have produced new evidence concerning the diagnostic pathway, avoiding unnecessary testing and limiting false diagnoses. However, a personalized approach and an effective prevention policy focused on clearly recognizing the high-risk population, defining perioperative trigger-free hospitalization, and rapid activation of supportive therapy should be improved. Based on epidemiological data, many national scientific societies have produced consistent guidelines, but many misconceptions are common among physicians and healthcare workers. This review shall consider all these aspects and summarize the most recent updates.

Risk factors associated with severe perineal lacerations during vaginal delivery: a 10-year propensity score-matched observational study.

BACKGROUND: Severe perineal lacerations are rare obstetrical complications in high-income countries. However, the prevention of obstetric anal sphincter injuries is crucial because of their long-term consequences on a woman's digestive function, sexual-mental health, and well-being. The probability of obstetric anal sphincter injuries can be predicted by assessing antenatal and intrapartum risk factors. OBJECTIVE: This study aimed to assess the incidence of obstetric anal sphincter injuries at a single institution for 10 years and to identify women more at risk by evaluating the relationship between antenatal and intrapartum risk factors and severe perineal tears. The main outcome measured in this study was the occurrence of obstetric anal sphincter injuries during vaginal delivery. STUDY DESIGN: This was an observational retrospective cohort study conducted at a University Teaching Hospital in Italy. The study was conducted from 2009 to 2019 using a prospectively maintained database. The study cohort included all women with singleton pregnancy at term who delivered via vaginal delivery in cephalic presentation. Of note, data analysis was performed in 2 stages: a propensity score matching to balance possible differences between patients with obstetric anal sphincter injuries and those without and a stepwise univariate and multivariate logistic regression. A secondary analysis was performed to further evaluate the effect of parity, epidural anesthesia, and duration of the second stage of labor by adjusting for potential confounders. RESULTS: Of 41,440 patients screened for eligibility, 22,156 met the inclusion criteria, and 15,992 were balanced after propensity score matching. Obstetric anal sphincter injuries occurred in 81 cases (0.4%), 67 (0.3%) after spontaneous delivery and 14 (0.8%) after vacuum delivery(P=.002). There was an increased odds of severe lacerations of nearly 2-fold for nulliparous women delivering by vacuum delivery (adjusted odds ratio, 2.85; 95% confidence interval, 1.19-6.81; P=.019), with a reciprocal reduction in women with spontaneous vaginal delivery (adjusted odds ratio, 0.35; 95% confidence interval, 0.15-0.84; P=.019) and at least 1 previous delivery (adjusted odds ratio, 0.51; 95% confidence interval, 0.31-0.85; P=.005). Epidural anesthesia was associated with a lower incidence of obstetric anal sphincter injuries (adjusted odds ratio, 0.54; 95% confidence interval, 0.33-0.86; P=.011). The risk of severe lacerations was independent of the duration of the second stage of labor (adjusted odds ratio, 1.00; 95% confidence interval, 0.99-1.00; P=.3), whereas the risk was reduced when mediolateral episiotomy was performed (adjusted odds ratio, 0.20; 95% confidence interval, 0.11-0.36; P<.001). Neonatal risk factors include head circumference (odds ratio, 1.50; 95% confidence interval, 1.18-1.90; P=.001) and vertex malpresentation (adjusted odds ratio, 2.71; 95% confidence interval, 1.08-6.78; P=.033). Induction of labor (adjusted odds ratio, 1.13; 95% confidence interval, 0.72-1.92; P=.6), frequent obstetrical examinations (adjusted odds ratio, 1.17; 95% confidence interval, 0.72-1.90), and women's supine position at birth (adjusted odds ratio, 1.25; 95% confidence interval, 0.61-2.55; P=.5) were further evaluated. Among severe obstetrical complications, shoulder dystocia increased the risk of obstetric anal sphincter injuries by nearly 4 times (adjusted odds ratio, 3.92; 95% confidence interval, 0.50-30.74; P=.2), whereas postpartum hemorrhage occurred 3 times more often in cases of delivery complicated by severe lacerations (adjusted odds ratio, 3.35; 95% confidence interval, 1.76-6.40; P<.001). The relationship among obstetric anal sphincter injuries, parity, and the use of epidural anesthesia was further confirmed in a secondary analysis. We found that primiparas who delivered without epidural anesthesia had the highest risk of obstetric anal sphincter injuries (adjusted odds ratio, 2.53; 95% confidence interval, 1.46-4.39; P=.001). CONCLUSION: Severe perineal lacerations were found to be a rare complication of vaginal delivery. By using a robust statistical model, such as propensity score matching, we were able to investigate a broad range of antenatal and intrapartum risk factors, including use of epidural anesthesia, number of obstetrics examinations, and patient position at birth, which are usually underreported. Moreover, we found that women who delivered for the first time without epidural anesthesia had the highest risk of obstetric anal sphincter injuries.

Hypotension Prediction Index guided Goal Directed therapy and the amount of Hypotension during Major Gynaecologic Oncologic Surgery: a Randomized Controlled clinical Trial.

Intraoperative hypotension (IOH) is associated with increased morbidity and mortality. Hypotension Prediction Index (HPI) is a machine learning derived algorithm that predicts IOH shortly before it occurs. We tested the hypothesis that the application of the HPI in combination with a pre-defined Goal Directed Therapy (GDT) hemodynamic protocol reduces IOH during major gynaecologic oncologic surgery. We enrolled women scheduled for major gynaecologic oncologic surgery under general anesthesia with invasive arterial pressure monitoring. Patients were randomized to a GDT protocol aimed at optimizing stroke volume index (SVI) or hemodynamic management based on HPI guidance in addition to GDT. The primary outcome was the amount of IOH, defined as the timeweighted average (TWA) mean arterial pressure (MAP) < 65 mmHg. Secondary outcome was the TWA-MAP < 65 mmHg during the first 20 min after induction of GA. After exclusion of 10 patients the final analysis included 60 patients (30 in each group). The median (25-75th IQR) TWA-MAP < 65 mmHg was 0.14 (0.04-0.66) mmHg in HPI group versus 0.77 (0.36-1.30) mmHg in Control group, P < 0.001. During the first 20 min after induction of GA, the median TWA-MAP < 65 mmHg was 0.53 (0.06-1.8) mmHg in the HPI group and 2.15 (0.65-4.2) mmHg in the Control group, P = 0.001. Compared to a GDT protocol aimed to SVI optimization, a machine learning-derived algorithm for prediction of IOH combined with a GDT hemodynamic protocol, reduced IOH and hypotension after induction of general anesthesia in patients undergoing major gynaecologic oncologic surgery.Trial registration number: NCT04547491. Date of registration: 10/09/2020.

A case report of an atypical haemolytic uremic syndrome in pregnancy: something wicked this way comes.

BACKGROUND: Atypical Haemolytic Uremic Syndrome is an acute life-threatening condition, characterized by the clinical triad of microangiopathic hemolytic anaemia, thrombocytopenia, kidney injury. Management of pregnants affected by Atypical Haemolytic Uremic Syndrome can be a serious concern for obstetric anesthesiologist in the delivery room and in the intensive care unit. CASE PRESENTATION: A 35-year-old primigravida with a monochorionic diamniotic twin pregnancy, presented with an acute haemorrhage due to retained placenta after elective caesarean section and underwent surgical exploration. In the postoperative period, the patient progressively developed hypoxemic respiratory failure and, later on, anaemia, severe thrombocytopenia, and acute kidney injury. A timely diagnosis of Atypical Haemolytic Uremic Syndrome was made. Non-invasive ventilation and high-flow nasal cannula oxygen therapy sessions were initially required. Hypertensive crisis and fluid overload were aggressively treated with a combination of beta and alpha adrenergic blockers (labetalol 0,3 mg/kg/h by continuous intravenous infusion for the first 24 hours, bisoprolol 2,5 mg twice daily for the first 48 hours, doxazosin 2 mg twice daily), central sympatholytics (methyldopa 250 mg twice daily for the first 72 hours, transdermal clonidine 5 mg by the third day), diuretics (furosemide 20 mg three times daily), calcium antagonists (amlodipine 5 mg twice daily). Eculizumab 900 mg was administered via intravenous infusion once per week, attaining hematological and renal remissions. The patient also received several blood transfusion units and anti- meningococcal B, anti-pneumococcal, anti-haemophilus influenzae type B vaccination. Her clinical condition progressively improved, and she was finally discharged from intensive care unit 5 days after admission. CONCLUSIONS: The clinical course of this report underlines how crucial it is for the obstetric anaesthesiologist to promptly identify Atypical Haemolytic Uremic Syndrome, since early initiation of eculizumab, together with supportive therapy, has a direct effect on patient outcome.

Personalized Predictive Hemodynamic Management for Gynecologic Oncologic Surgery: Feasibility of Cost-Benefit Derivatives of Digital Medical Devices.

BACKGROUND: Intraoperative hypotension is associated with increased perioperative complications, hospital length of stay (LOS) and healthcare expenditure in gynecologic surgery. We tested the hypothesis that the adoption of a machine learning-based warning algorithm (hypotension prediction index-HPI) might yield an economic advantage, with a reduction in adverse outcomes that outweighs the costs for its implementation as a medical device. METHODS: A retrospective-matched cohort cost-benefit Italian study in gynecologic surgery was conducted. Sixty-six female patients treated with standard goal-directed therapy (GDT) were matched in a 2:1 ratio with thirty-three patients treated with HPI based on ASA status, diagnosis, procedure, surgical duration and age. RESULTS: The most relevant contributor to medical costs was operating room occupation (46%), followed by hospital stay (30%) and medical devices (15%). Patients in the HPI group had EURO 300 greater outlay for medical devices without major differences in total costs (GDT 5425 (3505, 8127), HPI 5227 (4201, 7023) p = 0.697). A pre-specified subgroup analysis of 50% of patients undergoing laparotomic surgery showed similar medical device costs and total costs, with a non-significant saving of EUR 1000 in the HPI group (GDT 8005 (5961, 9679), HPI 7023 (5227, 11,438), p = 0.945). The hospital LOS and intensive care unit stay were similar in the cohorts and subgroups. CONCLUSIONS: Implementation of HPI is associated with a scenario of cost neutrality, with possible economic advantage in high-risk settings.

A Case of Multidisciplinary Approach to Post-Radiotherapy Dilative Cardiomyopathy Undergoing Elective Cesarean Delivery: Anesthetic and Intensive Care Management.

Background: Cardiovascular diseases are the most common non-obstetric cause of maternal death. These cases became more common thanks to the improvement in cardiovascular therapies. A multidisciplinary team is necessary to manage these pregnancies. Case Report: A 32 years old women at the 25th week of gestation for acute heart failure in pre-existing left ventricular dysfunction induced by radio-chemotherapy admitted to the Coronary Unit of IRCCS Policlinico Universitario Agostino Gemelli for worsening of dyspneic symptoms and anuria not responding to diuretic therapy. At the echocardiogram: ejection fraction 30%, enlarged left atrium, systolic pulmonary arterial pressure 38 mmHg, bilateral pleural effusion, bilateral diffused pulmonary B lines. A multidisciplinary team composed by cardiologists, gynecologists, anesthesiologists, cardiac surgeons, neonatologists and bioethicists decided for an elective cesarean delivery at the 27th week of gestation in the hybrid cardio-thoracic operating theater. Anesthesia was provided by combined spinal-epidural technique under invasive continuous hemodynamic monitoring with the Edwards Lifesciences HemoSphere with Hypotension Prediction Index (HPI) and ForeSight technology (Edwards Lifesciences, Irvine, USA) through catheterization of the left radial artery. The femoral arteries were left available for extracorporeal circulation. Continuous norepinephrine infusion was started once liquor was collected in the spinal needle at a 0.1 mcg/kg/minute through a central line and was continued until the end of surgery. Fluid management consisted of a total of 200 ml of crystalloids. HPI values never reached alarm values (maximum value =10). The patient was discharged home on the 5th day after delivery with good hemodynamic compensation. The baby was intubated at birth and then gradually weaned from mechanical ventilation, then discharged.

The Effect of Epidural Analgesia on Labour and Neonatal and Maternal Outcomes in 1, 2a, 3, and 4a Robson's Classes: A Propensity Score-Matched Analysis.

Background: Lumbar epidural analgesia (EA) is the most commonly used method for reducing labour pain, but its impact on the duration of the second stage of labour and on neonatal and maternal outcomes remains a matter of debate. Our aim was to examine whether EA affected the course and the outcomes of labour among patients divided according to the Robson-10 group classification system. Methods: Patients of Robson's classes 1, 2a, 3, and 4a were divided into either the EA group or the non-epidural analgesia (NEA) group. A propensity score-matching analysis was performed to balance the intergroup differences. The primary goal was to analyse the duration of the second stage of labour. The secondary goals were to evaluate neonatal and maternal outcomes. Results: In total, 21,808 cases were analysed. The second stage of labour for all groups was prolonged using EA (p < 0.05) without statistically significant differences in neonatal outcomes. EA resulted in a lower rate of episiotomies in nulliparous patients, with a higher rate of operative vaginal deliveries (OVD) (p < 0.05) and Caesarean sections (CS) (p < 0.05) in some classes. Conclusions: EA prolonged the duration of labour without affecting neonatal outcomes and reduced the rate of episiotomies, but also increased the rate of OVDs.

Impact of maternal lateral tilt on cardiac output during caesarean section under spinal anaesthesia: a prospective observational study.

BACKGROUND: Left uterine displacement (LUD) has been questioned as an effective strategy to prevent aortocaval compression after spinal anesthesia (SA) for cesarean delivery (CD). We tested if LUD has a significant impact on cardiac output (CO) in patients undergoing CD under SA during continuous non-invasive hemodynamic monitoring with Clearsight. METHODS: Forty-six patients were included in the final analysis. We considered 4 timepoints of 5 min each: T1 = baseline with LUD; T2 = baseline without LUD; T3 = after SA with LUD; T4 = after SA without LUD. LUD was then repositioned for CD. The primary outcome was to assess if CO decreased from T3 to T4 of at least 1.0 L/min. We also compared CO between T1 and T2 and other hemodynamic variables: mean, systolic and diastolic blood pressure (respectively MAP, SAP and DAP), heart rate (HR), stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), contractility (dP/dt), dynamic arterial elastance (Eadyn) at the different timepoints. Data on fetal Apgar scores and umbilical arterial and venous pH were collected. RESULTS: CO did not vary from T3 to T4 (CO mean difference -0.02 L/min [95% CI -0.88 to 0.82; P = 1). No significant variation was registered for any variable at any timepoint. CONCLUSIONS: LUD did not show a significant impact on CO during continuous hemodynamic monitoring after SA for CD. TRIAL REGISTRATION: (retrospectively registered on 03/12/2021) NCT05143684 .

Hypotension Prediction Index with non-invasive continuous arterial pressure waveforms (ClearSight): clinical performance in Gynaecologic Oncologic Surgery.

Intraoperative hypotension (IOH) is common during major surgery and is associated with a poor postoperative outcome. Hypotension Prediction Index (HPI) is an algorithm derived from machine learning that uses the arterial waveform to predict IOH. The aim of this study was to assess the diagnostic ability of HPI working with non-invasive ClearSight system in predicting impending hypotension in patients undergoing major gynaecologic oncologic surgery (GOS). In this retrospective analysis hemodynamic data were downloaded from an Edwards Lifesciences HemoSphere platform and analysed. Receiver operating characteristic curves were constructed to evaluate the performance of HPI working on the ClearSight pressure waveform in predicting hypotensive events, defined as mean arterial pressure < 65 mmHg for > 1 min. Sensitivity, specificity, positive predictive value and negative predictive value were computed at a cutpoint (the value which minimizes the difference between sensitivity and specificity). Thirty-one patients undergoing GOS were included in the analysis, 28 of which had complete data set. The HPI predicted hypotensive events with a sensitivity of 0.85 [95% confidence interval (CI) 0.73-0.94] and specificity of 0.85 (95% CI 0.74-0.95) 15 min before the event [area under the curve (AUC) 0.95 (95% CI 0.89-0.99)]; with a sensitivity of 0.82 (95% CI 0.71-0.92) and specificity of 0.83 (95% CI 0.71-0.93) 10 min before the event [AUC 0.9 (95% CI 0.83-0.97)]; and with a sensitivity of 0.86 (95% CI 0.78-0.93) and specificity 0.86 (95% CI 0.77-0.94) 5 min before the event [AUC 0.93 (95% CI 0.89-0.97)]. HPI provides accurate and continuous prediction of impending IOH before its occurrence in patients undergoing GOS in general anesthesia.

Performance of the Hypotension Prediction Index With Noninvasive Arterial Pressure Waveforms in Awake Cesarean Delivery Patients Under Spinal Anesthesia.

BACKGROUND: Arterial hypotension is common after spinal anesthesia (SA) for cesarean delivery (CD), and to date, there is no definitive method to predict it. The hypotension prediction index (HPI) is an algorithm that uses the arterial waveform to predict early phases of intraoperative hypotension. The aims of this study were to assess the diagnostic ability of HPI working with arterial waveforms detected by ClearSight system in predicting impending hypotension in awake patients, and the agreement of pressure values recorded by ClearSight with conventional noninvasive blood pressure (NIBP) monitoring in patients undergoing CD under SA. METHODS: In this retrospective analysis of pregnant patients scheduled for elective CD under SA, continuous hemodynamic data measured with the ClearSight monitor until delivery were downloaded from an Edwards Lifesciences HemoSphere platform and analyzed. Receiver operating characteristic (ROC) curves were constructed to evaluate the performance of HPI algorithm working on the ClearSight pressure waveform in predicting hypotensive events, defined as mean arterial pressure (MAP) <65 mm Hg for >1 minute. The sensitivity, specificity, positive predictive value, and negative predictive value were computed at the optimal cutpoint, selected as the value that minimizes the difference between sensitivity and specificity. ClearSight MAP values were compared to NIBP MAP values by linear regression and Bland-Altman analysis corrected for repeated measurements. RESULTS: Fifty patients undergoing CD were included in the analysis. Hypotension occurred in 23 patients (48%). Among patients experiencing hypotension, the HPI disclosed 71 alerts. The HPI predicted hypotensive events with a sensitivity of 83% (95% confidence interval [CI], 69-97) and specificity of 83% (95% CI, 70-95) at 3 minutes before the event (area under the curve [AUC] 0.913 [95% CI, 0.837-0.99]); with a sensitivity of 97% (95% CI, 92-100) and specificity of 97% (95% CI, 92-100) at 2 minutes before the event (AUC 0.995 [95% CI, 0.979-1.0]); and with a sensitivity of 100% (95% CI, 100-100) and specificity 100% (95% CI, 100-100) 1 minute before the event (AUC 1.0 [95% CI, 1.0-1.0]). A total of 2280 paired NIBP MAP and ClearSight MAP values were assessed. The mean of the differences between the ClearSight and NIBP assessed using Bland-Altman analysis (±standard deviation [SD]; 95% limits of agreement with respective 95% CI) was -0.97 mm Hg (±4.8; -10.5 [-10.8 to -10.1] to 8.5 [8.1-8.8]). CONCLUSIONS: HPI provides an accurate real time and continuous prediction of impending intraoperative hypotension before its occurrence in awake patients under SA. We found acceptable agreement between ClearSight MAP and NIBP MAP.

Ultrasound assisted lumbar intrathecal administration of nusinersen in adult patients with spinal muscular atrophy: A case series.

INTRODUCTION/AIMS: Intrathecal nusinersen administration can be challenging in certain adult spinal muscular atrophy (SMA) patients with difficult spinal anatomy who require imaging techniques (fluoroscopy or computed tomography scans) or invasive approaches (catheter placement, laminotomy) to identify the intrathecal space. We used ultrasound (US) assistance to access the lumbar intrathecal space in patients with SMA who experienced previous difficulties or failures with intrathecal dosing. METHODS: Eighteen adult patients with difficult spines were enrolled. We used US assistance, and we recorded the successful administrations, number of attempts, procedure times, and "patient satisfaction." RESULTS: There were 57 consecutive successful nusinersen spinal administrations in all patients enrolled. In 50% of patients, two or fewer attempts were needed to obtain a successful administration, with four or fewer attempts in 83.3%; only three patients reported more than four attempts because of both severe scoliosis and severe spine rotation (two patients) and obesity (one patient). The mean procedure time was 11.8 min (range, 1.7-28.9). Patient satisfaction was 4.97/5 (range, 4-5; median, 5) on Likert scale at 5 min and at 72 h. No major adverse events were reported, and two post dural puncture headaches were managed with medical therapy and with complete resolution within 72 h. DISCUSSION: US assistance seems to be a valid option among treatment choices for intrathecal nusinersen administration in patients with difficult spine. The absence of radiation exposure and the lack of need for intravenous sedation or general anesthesia are additional potential advantages to US assisted administration.

Comparison of ropivacaine plasma concentration after posterior Quadratus Lumborum Block in Cesarean Section with ropivacaine with epinephrine vs. plane.

BACKGROUND: The posterior quadratus lumborum block (pQLB) has been used in postoperative pain management after cesarean section (CS). However, clinicians have no data about pQLB safety in pregnants, at increased risk of local anesthetic systemic toxicity (LAST). The purpose of the present study was to explore the efficacy and the safety of adding epinephrine to ropivacaine for bilateral pQLB vs. bilateral pQLB performed with ropivacaine alone in CS. METHODS: In this prospective trial 52 pregnants, ASA 2 physiological status, were consecutively allocated to one of two groups, e-pQLB and pQLB; e-pQLB group received 0.375% ropivacaine+100 mcg epinephrine, 20 mL each side; pQLB received 0.375% ropivacaine alone, 20 mL each side. The primary and secondary outcomes were to evaluate if the adjunct of epinephrine to ropivacaine increases efficacy and safety of pQLB, respectively. RESULTS: Authors found in e-pQLB group vs. p-QLB group: a total mean morphine consumption statistically lower during the first 24 postoperative hours (5.08±3.12, vs. 9.11±4.67 SD mg, P=0.0002); NRS values statistically lower at six hours from block, both at rest (1.73±1.88 SD vs. 2.88±2.53, P=0.03) and with movement (3.03±1.98 SD vs. 4.23±2.87, P=0.04); a longer time between block and the first opioid request (5.92±2.48 vs. 3.78±2.68 SD hrs, P<0.003); venous ropivacaine concentrations significantly lower at any time of samples but at 120 minutes. CONCLUSIONS: Adding epinephrine to ropivacaine increases efficacy and duration of pQLB. Moreover it increases block safety, reducing peak and mean venous ropivacaine concentration.

Lung ultrasound to monitor the development of pulmonary atelectasis in gynecologic oncologic surgery.

BACKGROUND: Atelectasis formation is considered the major cause of hypoxemia during general anesthesia (GA). Gynecologic oncologic surgery (GOS) often requires pneumoperitoneum and steep bed angulation that further reduce lung compliance by shifting bowels and diaphragm. The aim of our study was to assess the impact of intraoperative variables on lung aeration using lung ultrasound (LUS) score and their correlation with postoperative oxygenation in women undergoing GOS. METHODS: In this prospective observational study 80 patients scheduled for GOS were enrolled. After three minutes pre-oxygenation, propofol-sufentanil-sevoflurane GA and standard mechanical ventilation (MV) were administered (tidal volume of 8 mL/kg of predicted body weight, FiO2 40%, I:E ratio of 1:2 and PEEP 5 cm H2O). A 0-36 LUS score was calculated considering 12 pulmonary areas, and arterial blood gas analysis were performed before GA (T1) and in recovery room (T2). RESULTS: LUS score increased significantly between T1 (1.79±2.39) and T2 (11.08±4.40, ΔLUS=9.29±4.10, P<0.05), mostly in basal and posterior areas. Changes in LUS score correlated significantly with time of MV (r=0.246, P<0.05), cumulative time in TR position (r=0.321, P<0.05) and worsening in oxygenation (ΔPaO2/FiO2, r=-0.260, P<0.05). ΔLUS score significantly correlated with colloid infusion. The linear regression analysis showed that TR time can predict ΔLUS score (F1,78=8.97, P=0.004). No correlation was found with pneumoperitoneum, apnea time at induction and TR angle. CONCLUSIONS: Aeration loss after GOS detected using LUS correlates with TR time, MV time, colloid infusion and worsening in oxygenation.

"Please mind the gap": successful use of ultrasound-assisted spinal anesthesia for urgent cesarean section in a patient with implanted spinal cord stimulation system for giant chest wall arteriovenous malformation - a case report.

BACKGROUND: The use of Spinal Cord Stimulation (SCS) system to treat medically refractory neuropathic pain is increasing. Severe neuropathic pain can be found in giant chest wall arteriovenous malformations (AVMs), exceedingly rare and debilitating abnormalities, rarely reported during pregnancy. CASE PRESENTATION: We present a report of a pregnant patient with implanted Spinal Cord Stimulation (SCS) system because of painful thoracic AVM scheduled for an urgent cesarean section in which we used lumbar ultrasound (US) to rule out the possibility to damage SCS electrodes and to find a safe site to perform spinal anesthesia. CONCLUSIONS: The use of lumbar US to find a safe site for a lumbar puncture in presence of SCS system in a patient affected by painful thoracic AVM makes this case a particularly unique operative challenge and offers a new possible use of ultrasound to detect a safe space in patients with SCS implant.