A randomised controlled comparison between stimulating and standard catheters for lumbar plexus block.

The aim of this randomised, prospective, blinded study was to evaluate if stimulating catheters can decrease the minimum effective anaesthetic volume in 50% of patients during lumbar plexus block using mepivacaine 1.5% compared with standard catheters. Fifty-eight patients of ASA physical status 1-3 were randomly allocated to receive a lumbar plexus block via a stimulating or standard catheter, with 29 in each group. The first dose was 30 ml and subsequent doses were determined using the up-and-down staircase method. The minimum effective anaesthetic volume50 was 12.2 ml (95% CI 7.3-17.1 ml) using the stimulating catheter and 24.8 ml (95% CI 23.2-27.5 ml) with the standard catheter (p < 0.0001). Complete lumbar plexus block was achieved with the initial dose of mepivacaine in 29 (100%) patients in the stimulating catheter group and 20 (69%) patients in the standard catheter group (p = 0.002). This study showed that use of a stimulating catheter halves the minimum effective anaesthetic volume50 of mepivacaine 1.5% while increasing the success rate in patients receiving continuous lumbar plexus block.

Periferic intravenous infusion of fenoldopam through an elastomeric pump.

INTRODUCTION: Fenoldopam has been used to protect renal function in critically ill patients and in those undergoing major surgery, where a possible damage of kidney is expected. Numerous randomized studies and meta-analysis demonstrated the efficacy of fenoldopam in this setting. We performed this study to demonstrate the feasibility of administering fenoldopam, trough an elastomeric pump connected to a peripheral vein, to patients undergoing nephron sparing surgery. MATERIALS AND METHODS: Twenty consecutive patients, ASA physical status class I-III, undergoing laparoscopic or laparotomic renal tumorectomy were enrolled. Fenoldopam was infused trough an elastomeric pump at a fixed dosage of 0.1 mcg/kg/min, obtained after diluting the drug with saline solution according to the weight of the patient. We injected the drug trough a peripheral vein from the induction of anaesthesia for 48 hours after the end of surgery. RESULTS: The infusion of fenoldopam did not modify the haemodynamic parameters. We did not find episodes of hypotension and only in three patients we registered episodes of tachycardia, not requiring the suspension of the infusion. No other side-effect was noted. CONCLUSIONS: The administration of fenoldopam, trough an elastomeric pump, in patients undergoing renal tumorectomy is feasible through a peripheral vein access.

Laparoscopic bilateral adrenalectomy for persistent Cushing's disease after transsphenoidal surgery.

BACKGROUND: We performed bilateral laparoscopic adrenalectomies on four patients (three women and one man) with Cushing's disease (pituitary-dependent Cushing's syndrome) showing persistent hypercortisolism after transsphenoidal surgery. METHODS: The technique for bilateral transperitoneal laparoscopic adrenalectomy was derived from the one previously adopted by our group for unilateral adrenalectomy and previously described. Eight trocars were used, of which two were used for both left and right adrenalectomy. RESULTS: Bilateral laparoscopic adrenalectomy was performed in a one-stage procedure in the three women and, because of the abundant abdominal fat of the patient, in a two-stage procedure (after a 1-week interval) in the man. Operating times for the three women were 255 minutes, 230 minutes, and 220 minutes, and for the man 170 minutes for right adrenalectomy and 140 minutes for left adrenalectomy. No surgical or anesthesiologic complications were encountered. All patients were discharged from the hospital within 5 days after operation. At present, after follow-up periods of 23, 8, 6, and 18 months, all patients show remission of Cushing's disease and undetectable cortisol levels. CONCLUSIONS: Our experience suggests that bilateral laparoscopic adrenalectomy is a safe and effective procedure and a valid therapeutic option in patients with Cushing's disease showing persistent hypercortisolism after transsphenoidal surgery. However, the decision to remove both adrenal glands in such patients needs to be weighed against the risk of their having Nelson's syndrome or other long-term complications.

Effectiveness and safety of laparoscopic adrenalectomy.

A laparoscopic approach was used to remove the adrenal gland in 7 patients with aldosterone-producing adenoma (Conn's disease), 2 with corticosteroid-producing adenoma (pituitary-independent Cushing's syndrome) and 2 with pheochromocytoma. The affected gland was on the right side in 3 patients and on the left side in 8. Mean operative time was 3 hours 10 minutes (range 140 to 370 minutes). The operation was uneventful in all patients and blood transfusions were never required. Mean postoperative hospitalization was 2.9 +/- 0.8 days (standard error). Only minimal doses of analgesics were used postoperatively. All patients returned to work within 10 days postoperatively (mean 8.4 +/- 1.2 days). Two months postoperatively no patient had clinical, biochemical or hormonal evidence of recurrent or persistent disease. We conclude that laparoscopic adrenalectomy is a safe and effective, minimally invasive approach for patients with benign adrenal neoplasms.

[Comparative clinical evaluation of 4 heat and moisture exchangers (HME) in general anesthesia]. / Valutazione clinica comparativa di quattro scambiatori di calore e umidità (HME) in corso di anestesia generale.

OBJECTIVE: To determine the efficiency, during general anaesthesia, of four commercially available HMEs, with particular attention to the change of performances due to the new modifications introduced by the manufacturers. DESIGN: Comparisons of the performances of each HMEs with psychometric method in terms of T degree C, RH (%), AH (mgH2O/1) of inhaled and expired gases. PATIENTS: A sample of 28 patients under general anesthesia longer than 150 minutes, undergone elective urological surgery. Patients with cardiological, respiratory and metabolic impairments have been excluded. MEASUREMENTS AND RESULTS: The measurements of T degree C, RH and AH have been performed with thermometric probes every minute. The collected data have been analyzed by Student's "t"-test for unpaired data. CONCLUSIONS: The obtained data show that a good conditioning of the inhaled gases is possible, although only few HMEs satisfy the requirements indicated in the ISO and BSI standards.

[Sciatic and femoral nerve block with electro-neural stimulator (ENS) in surgery of the knee in day-care surgery]. / Blocco dei nervi sciatico e femorale con elettroneurostimolatore (ENS) nella chirurgia del ginocchio in regime di day hospital.

This study was designed to evaluate locoregional anesthesia (double block of sciatic and femoral nerves with ENS) for ambulatory knee arthroscopic surgery. A statistical evaluation was performed in 50 adult outpatients (41 males, 9 females, ASA class 1 or 2) undergoing ambulatory knee arthroscopic procedures. Basal and intraoperative BP, HR SaO2 were recorded and the intensity of analgesia was also assessed according to the patient's subjective evaluation. Extra sedative or analgesic requirements were also recorded. There were no statistical changes in hemodynamic parameters during the perioperative period. The effectiveness of the anaesthetic block was classified as very good in 84% of patients, good in 2%, sufficient in 6% and inadequate in 8%. All patients were discharged in four hours after surgery. Our study shows that in ambulatory arthroscopic surgery, sciatic and femoral block with ENS is a valuable alternative to general anaesthesia.

[Laparoscopic adrenalectomy: a case report]. / Surrenalectomia laparoscopica: case report.

The authors report the first case of laparoscopic adrenalectomy for Conn's disease. The operative technique and clinical results are thoroughly discussed.