Anesthesia and analgesia in breast surgery: the benefits of peripheral nerve block.

Breast surgery is frequently associated with postoperative pain, nausea and vomiting, that result in increased patient's suffering, prolongation of hospital stays and related costs. Thoracic paravertebral nerve block (TPVB) is a viable option to the classic multimodal analgesia in breast surgery as it enhances surgical anesthesia and postoperative analgesia. In this review, we report the results of a number of studies on the role of TPVB in breast surgery. This technique is associated with a superior control of the pain, a reduction in opioids consumption after surgery, a decrease in postoperative nausea and vomiting, and an overall decrease in length of hospital stay. In particular, TPVB seems to provide the most benefits in patients undergoing an unilateral or bilateral mastectomy followed by immediate reconstruction. Some studies also suggest that the use of regional anesthesia-analgesia could attenuate perioperative immunosuppression and minimize metastases in breast cancer patients. TPVB can be also coupled with other regional anesthetic techniques such as pectoral nerve block (PNB), thus increasing the reduction in postsurgical pain, opioids consumption and length of hospital stays.

[Pulmonary re-expansion edema. Description of two cases and observations about its management]. / L'edema polmonare da riespansione. Descrizione di due casi e considerazioni sulla sua gestione.

Two cases of Reexpansion pulmonary edema (RPE), an uncommon complication of the treatment of chronic lung collapse secondary to pneumothorax or pleural effusion, are described. RPE is generally unilateral and occurs when the lung is rapidly reexpanded by active evacuation of large amounts of air or fluid. Nevertheless, both cases observed confirm that RPE can be seen when the pulmonary collapse is of short duration and the lung is reexpanded without suction. The pathogenesis of RPE is still unclear and is probably multifactorial. Implicated in the etiological process of RPE are chronicity of collapse, technique of reexpansion, increased pulmonary vascular permeability, airway obstruction, loss of surfactant, and pulmonary artery pressure changes. In the observed cases RPE appeared unexpectedly and dramatically, which is typical of the condition. The edema progressed for 24-48 hours, although it may persist for 4-5 days. Therapy was supportive and proportional to the severity of the clinical picture. Both needed mechanical ventilation, while only in case 1 was a hemodynamic support applied. Since the outcome is still fatal in 20% of cases, physicians treating chronic lung collapse must be aware of the possible causes and try to prevent the occurrence of this complication.

[The effect of anesthesiologic technique on the mental state of elderly patients submitted for orthopedic surgery of the lower limbs]. / Influenza della condotta anestesiologica sullo stato mentale di soggetti anziani sottoposti a chirurgia ortopedica dell'arto inferiore.

UNLABELLED: Influence of anesthetic technique on mental status in elderly patients submitted to major orthopedic procedures of lower limbs. Mental impairment is a common occurrence in elderly patients after major orthopedic surgery. Few studies have been published so far on this topic in spite of its relevant clinical and economic implications. OBJECTIVE: 1) To verify whether anesthesia has a causative role in postoperative mental confusion in elderly patients; 2) to compare the effects of General Anesthesia (GA) and Spinal Anesthesia (SA) on mental status. DESIGN: Controlled, comparative study. PATIENTS: Sixty patients aged > or = 70, ASA I-II, submitted to femoral neck repair. SETTING: Anesthesia Dept. and Orthopedic Dept. of a District Hospital in Italy. METHOD: The day before surgery the mental status of elected patients was evaluated employing a modified Organic Brain Syndrome (OBS) scale (Gustafsson). The better the mental status, the lesser the OBS score. It was possible therefore to distinguish "oriented" from "confuse" patients (38 vs 22) if they scored < or = 6 or > 6 respectively. Patients from each group were than randomly assigned to receive either GA or selective SA. Neither group was premedicated. GA was induced with propofol 1 mg/kg and maintained with O2/N2O 40/60% and isoflurane; atracurium was employed to facilitate mioresolution. Spinal anesthesia was performed with hyperbaric 1% bupivacaine. All patients were monitored in the Recovery Room (RR) for at least one hour. Occurrence of hypotension and/or hypoxia in the Operating Room (OR) or the RR was immediately treated. Mental status was reassessed on the 1st and 2nd postoperative day and results were compared with the corresponding preoperative OBS scores both in GA patients and in SA patients. RESULTS: No statistically significant differences were found between pre- and postoperative OBS scores in both GA and SA group, whether "oriented" or "confuse". CONCLUSIONS: Mental status of elderly patients submitted to femoral neck repair doesn't seem to be influenced by the anesthetic technique chosen, independent of preoperative psychic conditions.