Ocular motility alterations in orbital fractures: pre-post evaluation in maxillofacial surgical treatment.

PURPOSE: The study aims to investigate the ability of maxillofacial surgery to reduce strabismus and improve ocular clinical symptomatology in patients with fracture of the medial or lateral floor of the orbit, or both, and to evaluate such abilities relative to the temporal distance between trauma and surgery. PATIENTS AND METHODS: 25 patients with traumatic diplopia were evaluated by CT, Goldman manual field of view, Hess-Lancaster test, eye examination and orthoptic examination, before and after surgery. RESULTS: We observed: a statistically significant reduction of the deviation angle, both from close and long distance (P = 0.0054 and P = 0.0051 respectively) with a 38% reduction of the deviation from short distance and 54% from afar; a regression of diplopia in 20% of the surgically treated cases (CL from 0 to 39%), significant at the Mc Nemar test; a negative correlation with the time elapsed between the onset of the fracture and maxillofacial surgery (R = -0.26), even if the analysis did not show a statistical significance of the data (P = 0.2). However, it is evident that the maximum improvement is observed only in cases operated within 5 months of the trauma, while the failures (worsening or persistence of diplopia) were observed only in the cases operated later. CONCLUSION: We can state that the intervention reduces strabismus and improves ocular symptomatology, as it statistically significantly reduces cases of diplopia; furthermore, it would seem preferable to intervene early, especially when damage to a muscular structure is suspected, even if the data do not allow definitive conclusions in this regard.

Peribulbar anesthesia in sclero-retinal surgery: two quadrants vs single injection.

PURPOSE: To evaluate the advantage of peribulbar anesthesia in two quadrants (infero-temporal and upper nasal) vs single injection technique (infero-temporal) for scleral rhegmatogenous retinal detachment surgery (RRD). PATIENTS AND METHODS: 57 patients, aged between 33 and 75 years (57.01 ± 8.68), waiting for retinal detachment surgery, were randomized in two groups: a group S (29 patients), with single quadrant injection technique and a group C (28 patients) with two quadrants injection. Patients in Group S were injected in two quadrants with a 10 ml mixture containing Mepivacaine 2% 5 ml and Ropivacaine 0.75% 5 ml, with hyaluronidase 10 IU/ ml. Patients in group C were injected with the same anesthetic mixture in one quadrant. Number of additional injection, during surgery, in two groups, were reported. Pain was tested with VAS (Verbal Analogue Scale 0-10) after regional block, when muscles were insulated, during scleral buckling positioning, when conjunctive was closed and 6, 12, 24 hours after surgery. RESULTS: The need for a second peribulbar injection of anesthetic occurred in 9 patients of group C (32.14%); further injection was necessary in 1 patient (3.57%) of group S during scleral buckling (VAS = 7), statistically significant (p <0.05). Postoperative VAS 6 - 12 - 24 hours after surgery was not significant. CONCLUSIONS: The peribulbar anesthesia may be proposed in scleral surgery of retinal detachment; the injection in two quadrants secured solid and satisfactory anesthesia, increasing the outcome of retinal surgery in loco-regional anesthesia.

Infections in hospital departments. What is Hospital Responsibility?

Infections in hospitals still have a high incidence and many of them could be avoided through better welfare standards. To try to overcome them, a strategy based on prevention is needed, but cleaning, disinfection and sterilization procedures are also a key tool. It is important to provide for all healthcare professionals a constant update and the creation of protocols that take into account the technical, scientific and economic aspects, but also specific operational needs, so that the proposed solutions can be applied in daily routines. The authors outline the mandatory duties to the doctors and hospital and underline the need to document in the clinical record the treatments performed. In case of infections occurred in hospital environment, the patient must demonstrate the guilty nature of the hospital's conduct, the existence of a harm and the causal connection. The hospital must demonstrate that asepsis measures were adopted according to the actual scientific knowledge and they must cover not only the treatment but also the diagnosis, all the activities prior to surgery and the postoperative phase. The sentences examined show that hospitals can avoid being accused of negligence and imprudence only if they can prove that they have implemented all prophylaxis measures contained in the guidelines and protocols. They must demonstrate that the infection was caused by an unforeseeable event. While some initiatives to improve the quality of hospital care have already allowed a decrease in the incidence and cost of these infections, much remains to be done.

Fast glycorrhachia and cerebrospinal fluid protein as predictors of sensory block in anesthesia with subarachnoid Ropivacaine.

BACKGROUND: Identify if glycorrhachia and cerebrospinal fluid protein could influence the time of sensory block to T10, the duration and the metameric block's level, after a standard dose of Ropivacaine. METHODS: 80 patients, ASA I - III undergoing to transurethral prostate resection with spinal anesthesia in a prospected open study were recruited. A 0.2 ml liquor's sample was taken; glycorrhachia, by glycemic stix and CSF protein, by urinary stix, were got, before Ropivacaine 0.5% 15 mg injection (0.10 - 0.15 mlsec). After anti-trendelemburg, with 30 ° tilting for 15 min, the onset of sensory block to T10, the maximum metameric level to 15' and the time of sensory block were reported. The data collection were analyzed using the software language R. RESULTS: A significant correlation liquor specific weigh preoperative glycemia (0.749), liquoral specific weigh glycorrhachia (rho = 0.751; R2 = 0.564; P 0.05) and specific weigh CSF protein (rho = 0.684; R2 = 0.468; P 0.05) were reported. Inverse relation CSF weightsensory block level (rho -0.789, P 0.05, R2 0.621) was evidenced. Inverse relation onset time to T10 glycorrhachia (84%) and cephalic block glycorrhachia (76%) were found. Inverse correlation onset time to T 10 CSF protein and cephalic block proteinorrachia was respectively 84% and 67%. A rho of 0.712 with R2 of 51% BMI onset to T10 and rho of 0.681 with R2 of 51% BMI maximum cephalic block with P 0.05 were reported. CONCLUSIONS: The predictability of a iso-hypobaric local anesthetic could reduce the risk of procedure failure and adverse events by further cephalic spread.

Clinical manifestations due to pharmacological interactions in pediatric ophthalmic surgery: topical drugs and general anaesthesia.

INTRODUCTION: The authors consider the type and the incidence of the adverse effects due to the interaction between ophthalmic drugs and general anaesthesia in pediatric ophthalmic surgery. PATIENTS AND METHODS: The experience included 176 general anaesthesia in 100 children aged between 9,2 months and 11,4 years (mean age 4,9 years). RESULTS: In the 100 patients we reported: 4 cases (2.7% general anaesthesias) of sinus tachycardia with heart rhythm varying between 170 and 180 beats per minute (3.6%); 5 cases of sinus bradycardia, varying between 60 and 70 beats per minute (3.3%); 3 cases of bronchospasm (2%); 2 cases of psychomotor agitation/disturbances in pre-convulsive state after anaesthesia (1.3%); 3 cases of arterial hypotension (60-70 mmHg) (2%); 7 cases of skin rush around neck and chest (4.6%); 1 case of prolonged apnoea (0.6%). CONCLUSIONS: The clinical manifestations, principally on the cardio-circulatory and nervous system are subjected to critical revision, to foresee the pharmacological interferences and therefore to prepare the necessary measure of medical treatment.

Levobupivacaine vs. racemic bupivacaine in peribulbar anaesthesia: a randomized double blind study in ophthalmic surgery.

AIMS: The Authors examine the employement of a new anaesthetic agent, levobupivacaine 0.50% (S - enantiomer of racemic mixture of bupivacaine), for peribulbar anaesthesia in a randomized double blind study vs. racemic bupivacaine 0.50% alone or in association with hyaluronidase 10 IU x ml(-1). MATERIALS AND METHODS: 120 patients were divided into four groups of 30 each: group L (levobupivacaine 0.50%), group B (racemic bupivacaine 0.50%), group LH (levobupivacaine-hyaluronidase 10 IU x ml(-1)), group BH (racemic bupivacaine-hyaluronidase 10 IU x ml(-1)). RESULTS: The onset-time (14 +/- 3.2 min vs. 13 +/- 4.8 min) and the duration of anaesthesia (195 +/- 34.2 vs. 204 +/- 37.6) were similar. The ocular akinesia was evaluated with an 8 point system: it was considered sufficient for surgery with values of less than 5 points. The association with hyaluronidase increased the spread of local anaesthetics (76.6% of group LH, 73.3% of group BH) with local anaesthetics alone (60% of group L, 56.6% of group B). Moderate hypotension (<30% baseline) was reported in 3 patients (10%) of group L, 2 (6.6%) of group B, 1 (3.3%) of group LH and 2 (6.6%) of group BH. Statistical analysis (Student-Newman-Keuls test) was significant between group L vs. BH, B vs. BH and LH vs. BH as regards onset-time of anaesthesia; between group B vs. LH, B vs. BH and L vs. LH for the duration of anaesthesia. Chi square test for the general akinesia score showed significant results in group L vs. LH (p=0.043) and B vs. LH 8P =0.018); as regards the score 0, test reported significant values between groups B vs. LH (p=0.004) and B vs. BH (p=0.017). CONCLUSIONS: In conclusion levobupivacaine, a longlasting local anaesthetic with limited cardio and neurotoxicity, might be useful for vitreoretinal surgery in elderly patients, compared with general anaesthesia.

Effects of remifentanil-based general anaesthesia with propofol or sevoflurane on muscle microcirculation as assessed by near-infrared spectroscopy.

BACKGROUND: Although anaesthetics are known to alter microcirculation no study has, to our knowledge, documented changes in human skeletal microcirculatory function during general anaesthesia. METHODS: Forty-four patients undergoing maxillofacial surgery at a university hospital were prospectively randomized to receive general anaesthesia with remifentanil combined with propofol or sevoflurane. Muscle microcirculation was investigated with near-infrared spectroscopy (NIRS) before general anaesthesia was induced and 30 min later. An NIRS device (NIMO, Nirox) was used to quantify calf deoxyhaemoglobin [HHb], oxyhaemoglobin [HbO2], and total haemoglobin [HbT] concentrations, coupled to a series of venous and arterial occlusions to measure calf blood flow, muscle oxygen consumption, calf vascular resistance, microvascular compliance, and haemoglobin resaturation rate (RR). RESULTS: In both the groups, general anaesthesia induced marked changes in muscle microcirculation: the tissue blood volume increased (+33% in remifentanil-sevoflurane and +45% with remifentanil-propofol groups), microvascular resistance decreased (-31% and -38%, respectively), and the post-ischaemic haemoglobin RR decreased (-48% and -36%, respectively). In the remifentanil-propofol group, the muscle blood flow increased (P<0.001), whereas in the remifentanil-sevoflurane group microvascular compliance and muscle oxygen consumption decreased (P<0.01). CONCLUSIONS: Remifentanil-based general anaesthesia with propofol or sevoflurane altered the muscle microcirculation in different ways. Quantitative NIRS, a technique that takes into account the optical tissue properties of the individual subject, can effectively measure these changes non-invasively.

Neurosedation in dentistry of the disabled patient: the use of midazolam, propofol, and remifentanil.

AIM: This prospective randomized study, deals with neurosedation in dental treatment of 200 disabled patients and unable to cooperate, subdivided in 4 groups of 50 male only patients, with age ranging from 28 to 59 (39+/-11), ASA I-III. METHODS: The pharmaceuticals used were Midazolam (group MID) Propofol (group Prop) and Remifentanil. Midazolam and Propofol were used following a bolus-infusion sequence, both separately and in combination among themselves (MID\PROP group), or with an opioid, Remifentanil (MID\PROP\REMI group). ECG, heart rate , non invasive blood pressure (NIBP), SaO(2), EtCO(2) during the procedure were monitored. Induction time, duration of the sedation, recovery time and discharge were reported. RESULTS: The statistical analysis demonstrated the superiority of the PROP group for induction time in minute (3.1+/-0.5) in comparison with the MID group (10.6+/-2.1), the MID\PROP group (4.3+/-1.3) and MID\PROP\REMI (3.7+/-1.2). The recovery and discharge times have confirmed the superiority of the MID\PROP\REMI group in comparison with the other 3 groups. CONCLUSION: This combination proved best at leveraging the synergistic characteristics of each single pharmaceutical and minimizing the collateral effects of each individually.

[Propofol for the induction and maintenance of anesthesia in ophthalmic surgery]. / Il propofol come ipnoinduttore e agente di mantenimento nell'anestesia per l'oftalmochirurgia.

After brief mention of the chemical and pharmacodynamic properties of diisopropylphenol, personal experience on the administration of propofol for induction and maintenance of anaesthesia for ophthalmic surgery is reported. The results have shown that induction of anaesthesia by propofol injection is associated with a significant and useful reduction of IOP more than TPS induction. Continuous infusion of Diprivan provides satisfactory conditions for intraocular surgery and could be a real choice to thiopentone combined with enflurane.