Postoperative pain treatment SIAARTI Recommendations 2010. Short version.

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

An alternative inexpensive treatment for deep sternal wound infections after sternotomy.

We present three cases of deep sternal wound infections after sternotomy, with partial dehiscence and instability of sternum, successfully treated with combined therapy based on hyperbaric oxygen (HBO), parenteral and intranasal antibiotics, daily debridements and medications. After a short hospitalization (10 days) to detect involved bacteria, depth of the wounds and choice of right antibiotic therapy, all patients continued the treatment as outpatients, undergoing daily medications and antibiotic therapy before every HBO session. After 3 months the sternal wounds were completely epithelialized. This conservative therapy for deep sternal wound infections can be an alternative and inexpensive approach to surgical treatment. The aggressive surgical approach could be limited for those deep sternal wounds associated with broad dehiscence and instability of sternum, complicated by paradoxical breathing and/or mediastinitis and alteration of respiratory system mechanics.

Successful treatment of a complicated case of neuroleptic malignant syndrome.

Neuroleptic malignant syndrome (NMS) is a life-threatening reaction often related to neuroleptic drugs, characterized by rigidity, hyperthermia, altered consciousness, and fluctuating blood pressure. We present a case of NMS that followed a doubled oral dose of a drug compound: tranylcypromine sulfate, a monoamine oxidase inhibitor, and trifluoperazine (neuroleptic). The case was complicated by rhabdomyolisis and disseminated intravascular coagulation. It was treated successfully with dantrolene sodium and generous fluid therapy without using neuromuscular blocking agents or dopamine agonists.

Non-invasive pressure support ventilation in patients with acute respiratory failure after bilateral lung transplantation.

OBJECTIVE: To evaluate non-invasive ventilation (NIV) prospectively in a group of patients developing acute respiratory failure (ARF) after bilateral lung transplantation (BLT). SETTING: General intensive care unit (ICU) of Rome "La Sapienza" University. PATIENTS: Twenty-one patients (18 with cystic fibrosis) undergoing BLT. RESULTS: All consecutive patients developing ARF (according to predefined criteria) and requiring ventilatory support, received non-invasive pressure support ventilation through a face-mask (PEEP 5 cmH2O, PSV 14+/-2 cmH2O) for a mean period of 5+/-4 days. Eighteen out of 21 patients avoided intubation and were discharged from the ICU; 3 patients required intubation: 1 of them survived while 2 developed septic shock and died. CONCLUSIONS: NIV administration was well tolerated and avoided intubation in the large majority of patients (86%); in NIV responders the rate of complications was low and ICU mortality nil. NIV should be considered as an interesting alternative to conventional ventilation in patients who require ventilatory support after BLT.

Lipid peroxidation, circulating cytokine and endothelin 1 levels in healthy volunteers undergoing hyperbaric oxygenation.

BACKGROUND: The aim of the present study was to evaluate the effects of hyperbaric oxygenation on lipid peroxidation, on the release of circulating cytokines (TNFa, IL6, IL1b) and endothelin-1 (ET1). EXPERIMENTAL DESIGN: single arm, prospective study. SETTING: ICU hyperbaric division of a University Hospital. PATIENTS: fifteen healthy volunteers (10 male and 5 female, mean age 32+/-7 years) studied during hyperbaric oxygenation divided at random into two groups: group A (7 subjects) and group B (8 subjects). INTERVENTIONS: Both groups were consecutively pressurized at 2 atmospheres (2 atm abs) and 2.8 atm abs, with a constant descending rate of 1 m/min; in accordance with the experimental design, group A breathed pure oxygen continuously through facial masks and group B breathed chamber air during pressurization. MEASURES: Twenty millilitres of blood were drawn from all individuals at the following times: 1) basal, before HBO; 2) after 10 min at 2 atm abs; 3) after 10 min at 2.8 atm abs; 4) 30 min after the end of HBO. In all collected samples thiobarbituric reacting substances were evaluated, using the spectrophotometric technique, IL1 TNF and IL6 serum levels by ELISA and endothelin 1 plasma levels by radioimmunoassay. RESULTS: In both groups, TBARS levels showed a twofold increase (p<0.05) in relation to the baseline, during and after hyperbaric oxygenation. Serum IL6 and IL1b values did not significantly change over the study in any of the volunteers. TNFa amounts significantly increased (p<0.05) during HBO, at 2 atm abs and 2.8 atm abs in both groups, with almost twofold increments. ET1 plasma values increased (p<0.05) in all volunteers during and after HBO: at 2 atm abs (range 7 to 24 pg/ml), 2.8 atm abs (range 7 to 19 pg/ml) and 30 min after (range 8 to 17 pg/ml) in relation to baseline (range 4 to 12 pg/ml). All the studied compounds had a similar trend in the two groups. CONCLUSIONS: Hyperbaric oxygenation in healthy volunteers can induce not only lipid peroxidation, but also liberation of compounds such as TNFa and endothelins, no matter whether pure oxygen is breathed or not. These results suggest that the phenomenon behind this release might be leukocyte activation as induced by HBO. The possible role of ET1 in determining vasoconstriction occurring during HBO is also suggested.

Epidural corticosteroid blockade in cervicogenic headache.

Cervicogenic headache (CGH) is a relatively common form of headache stemming from the neck structures which presents some pathophysiological condition probably linked together with various pain-producing factors. This report presents a series of 9 patients suffering from cervicogenic headache and the results achieved by means of epidural steroid (methylprednisolone 40 mg) injection into the epidural cervical space (C6-C7 or C7-T1) level. The effectiveness of this diagnostic blockade was compared with the results obtained using the same procedure in 6 chronic tension headache (CTH) patients. A sharp decrease in the Numeric Intensity Scale (NIS) and in the Drug Consumption Index (DCI) values were observed after the diagnostic procedure in CGH patients. The short-term (12 hours) and medium-term (4 weeks) marked clinical improvement obtained in CGH patients may increase the number of available diagnostic tools which can be used to identify these underestimated patients population. The long-term effectiveness of this approach in cervicogenic patients is being evaluated over time.

[Assessment of lipid peroxidation in hyperbaric oxygen therapy: protective role of N-acetylcysteine]. / Valutazione della perossidazione lipidica in corso di ossigenoterapia iperbarica: ruolo protettivo della N-acetilcisteina.

OBJECTIVE: To verify and quantify lipidic peroxidation by means of tiobarbituric-acid reactive substance (TBARS) dosage in patients treated daily with HBO. To verify if a potentiated glutathione enzymatic system, with N-acetylcisteine (NAC) treatment, may determine higher HBO tolerance and reduced lipidic peroxidation. DESIGN: Randomised study on patients treated with 20 HBO 2.2 ATA (90' oxygen) sessions. SETTING: Hyperbaric Medical Centre. PATIENTS: Seventeen patients divided, at random, into two groups; group A: 10 patients treated with only HBO; group B: 7 patients treated with NAC antioxidant therapy (Fluimucil, Zambon Group, Italy) 1800 mg/day in addition to HBO. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: TBARS on blood sample at T0 (basal) T1 (at the end of the 1st HBO session) T2 (at the beginning of the 20th HBO session) T3 (at the end of the 20th). The group A TBARS analysis at the different study time has shown significant data (p < 0.01) as the difference between TBARS values of the two groups at T2 (p < 0.01). CONCLUSIONS: HBO induces a lipidic peroxidation even if the therapeutical protocol cannot determine lung or cerebral oxygen toxicity symptoms. The NAC administration, during HBO treatment, determines a protection against the HBO radicalic stress.