Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) as unique technique for airway management during operative hysteroscopy under general anesthesia: a registered feasibility pilot cohort study.

OBJECTIVE: The term THRIVE refers to the delivery of 100% heated and humidified oxygen via a nasal cannula to maintain viable gas exchange during prolonged apnea. There are no reports of its application for Operative Hysteroscopy (OH) under general anesthesia (GA). The aim of the study is to investigate the success rate of THRIVE as unique airway management technique in this setting. The results will support the development of a randomized controlled trial (RCT) to demonstrate the non-inferiority of THRIVE compared to traditional techniques. PATIENTS AND METHODS: Twenty consecutive ASA I-II women presenting for OH were enrolled. Standard anesthesia, as well as transcutaneous carbon dioxide (tcCO2) monitoring, was performed. After preoxygenation with 30 L∙min-1, GA was induced with propofol and fentanyl, then oxygen flow was increased to 70 L∙min-1 and anesthesia maintained with propofol infusion. The primary outcome was success rate of THRIVE defined as SpO2 > 94%, tcCO2 < 60 mmHg and no need for rescue airway intervention. RESULTS: Mean age was 47 ± 12 years. Mean duration of the procedure was 25 ± 9 minutes, and the success rate of the technique was 100%. Median SpO2 during the procedure was 100 (IQR 99-100) %. Mean maximum tcCO2 level was 51 ± 7 mmHg while mean tcCO2 level during the procedure was 45 ± 7 mmHg. At the end of the procedure, mean tcCO2 was 44 ± 5 mmHg. CONCLUSIONS: THRIVE allowed adequate gas exchange during OH under GA, without additional rescue airway interventions. The application of THRIVE in this setting may allow minimal airway manipulation and optimal comfort for the patient with low failure rate. We calculated the sample size for the planned non-inferiority RCT investigating the effectiveness of THRIVE versus laryngeal mask ventilation in OH: 82 is the minimal number of patients per group to test a non-inferiority limit of 10%.

Erector spinae plane block for postoperative analgesia after total laparoscopic hysterectomy: case series and review of the literature.

OBJECTIVE: Total laparoscopic hysterectomy (TLH) is associated with significant postoperative pain that worsens outcomes and prolongs hospital stay. Ultrasound guided erector spinae plane block (ESPB) is a new technique for thoracic analgesia. Few cases have been described for postoperative analgesia in laparoscopy. We describe the use of preoperatory bilateral ESPB at level T10 to provide postoperative analgesia following THL. PATIENTS AND METHODS: We enrolled 10 ASA 1-2 patients scheduled for TLH. After written informed consent we performed bilateral ESPB at T10 level in sitting position, with a linear probe and in plane cranio-caudal approach and ropivacaine 0.5% 20 for each side. The sensitive block was tested by pinprick. Standard general anesthesia was administered. Patient controlled analgesia (PCA) with morphine 1 mg/ml was delivered. We measured postoperative pain by visual analogue scale (VAS). RESULTS: Five patients (50%) underwent simple TLH, 5 women (50%) had TLH plus salpingo-oophorectomy. VAS scores was <4 in all cases but one, and PCA morphine consumption was 4.1 ± 3.5 mg (mean ± SD). Pinprick was positive bilaterally in 3 patients (30%). CONCLUSIONS: ESPB was an effective and safe procedure for postoperative pain control after TLH. Future research should compare ESPB to other techniques to assess its role on perioperative management of THL.

Hemodynamic changes associated with spinal and general anesthesia for hip fracture surgery in severe ASA III elderly population: a pilot trial.

BACKGROUND: Patients affected by hip fracture (HF) have high risk of perioperative complications. Despite regional anesthesia is widely used, hypotension is common and increases the risk of myocardial ischemia. The aim of this work was to study hemodynamic changes following spinal (SA) and general (GA) anesthesia in this selected population of patients. METHODS: Twenty patients over 70 years, ASA III, scheduled for HF repair were randomized to receive SA or general anesthesia GA. Hemodynamic responses to SA and GA were analyzed trough LiDCO™plus monitor (LiDCO Ltd., Cambridge, UK). RESULTS: SA provided a more stable hemodynamic profile. SA group received less interventions to keep mean arterial pressure (MAP) within limits. GA group had intraoperative cardiac index (CI), stroke volume index (SVI) and MAP significantly lower than baseline. Despite both groups experienced hypotension after the induction, MAP reduction in SA group was primarily due to systemic vascular resistance index (SVRI) decline, whereas hypotension in GA group was primarily due to a reduction in SVI and CI. The coefficient of variation (CV) was significantly higher in GA group for CI, SVI, MAP and heart rate (HR) within one hour analysis comparing to SA group. SA group had an higher CV for SVRI. CONCLUSION: SA in the elderly population with hip fracture provides a more stable hemodynamic profile requiring less intervention to keep MAP close to baseline value. Hypotension was common in SA and GA after induction and within intraoperative period. A larger randomized clinical study should be performed to confirm these preliminary data.

Bladder function after spinal anesthesia for cesarean section: an urodynamic evaluation.

BACKGROUND: This study evaluates the effects of spinal anesthesia with hyperbaric bupivacaine plus sufentanil on bladder function in women undergoing cesarean section. SUBJECTS AND METHODS: Thirty caucasian healthy pregnants scheduled for elective Cesarean section under spinal anesthesia performed with hyperbaric bupivacaine plus sufentanil were enrolled. Filling cystometry, proprioceptive bladder sensation during cystometry, rate of spontaneous voiding, post void residual volume, anocutaneous and bulbocavernosus reflex were analyzed at 4, 6 and 8 hours after spinal anesthesia. RESULTS: The proportion of women experiencing first sensation, first desire and strong desire at 4 hours was significantly different from that reported at 6 and 8 hours (p < 0.05 for first sensation and p < 0.01 for first and strong desire). Significant differences were also observed between volumes at which first sensation arose at first measurement (4 hours) and at second and third measurements (p < 0.01). There was a significant difference in rate of spontaneous micturition, with 80% of patients at 8 hours able to spontaneously void versus 40% at 6 hours, (p < 0.01). Moreover, a lower percentage of women had absent and/or light reflexes at 4 hour than at 6 and 8 hours (p < 0.01). CONCLUSIONS: Spinal anesthesia with bupivacaine plus sufentanil causes a clinically significant disturbance on bladder function in women undergoing cesarean section. Even thought recovery of proprioceptive bladder sensation is fast, a full recovery of spontaneous voiding requires a much longer time. A close monitoring of urinary function and of bladder distension is, therefore, advisable.

General anesthesia for caesarean delivery in a pregnant woman affected by acute myocardial infarction.

Acute myocardial infarction rarely occurs in women during childbearing age (1:20,000), but maternal mortality rate is high (11%). Management of pregnant woman affected by myocardial infarction could be a challenge for obstetricians, cardiologists and anesthetists. In this report, we present the management of a 36 years-old nulliparous woman affected from hypertension and dyslipidemia, who experienced acute myocardial infarction at 25th gestational week and was scheduled for caesarean delivery at 35th week. General anesthesia for cesarean section was conducted using sevoflurane and remifentanil target controlled infusion (TCI); the patient was monitored with ECG, pulse oximetry, invasive blood pressure, haemodynamic measurement by lithium dilution cardiac output (LiDCO plus) and bispectral index. The titrated use of remifentanil and the close control of hemodynamic parameters by LiDCO plus monitoring may contribute to improve maternal outcome and newborn well-being in the management of general anesthesia for caesarean section.

Occult spinal dysraphism in obstetrics: a case report of caesarean section with subarachnoid anaesthesia after remifentanil intravenous analgesia for labour.

Neuraxial techniques of anaesthesia and analgesia are the current choice in obstetrics for efficacy and general low risk of major complications. Concern exists about neuraxial anaesthesia in patients with occult neural tube defects, regarding both labour analgesia and anaesthesia for Caesarean section. Recently, remifentanil infusion has been proposed as an analgesic technique alternative to lumbar epidural, especially when epidural analgesia appears to be contraindicated. Here, we discuss the case of a pregnant woman attending at our institution with occult, symptomatic spinal dysraphism who requested labour analgesia. She was selected for remifentanil intravenous infusion for labour pain and then underwent urgent operative delivery with spinal anaesthesia with no complications.

Pregnancy-induced analgesia: a combined psychophysical and neurophysiological study.

BACKGROUND: To investigate changes in heat pain threshold and modifications in heat pain processing during pregnancy and labour, seventy-six nulliparous pregnant women were enrolled in two studies. METHODS: In the first study (psychophysical), 60 pregnant women underwent a quantitative sensory testing (QST) investigating heat perception in two body areas (right forearm and T10 dermatome) according to these groups: 32-33 gestational weeks (GW), 39-40 GW, early stage of active labour and 24 h after the delivery. In the other study (neurophysiological), contact heat-evoked potentials (CHEPs) were recorded in other 16 women at the 32nd GW and in 11 of these also at the 40th GW. RESULTS: The psychophysical study showed that heat pain threshold was significantly increased at the forearm at 32-33 GW (median ± IQR: 39.6 ± 0.7 °C), at 39-40 GW (40.6 ± 1.1 °C) and at early stage of active labour (40.8 ± 1.5 °C) as compared to 20 non-pregnant controls (p < 0.001). Heat pain threshold tested at T10 level was significantly increased at 32-33 GW (41.0 ± 1.6 °C), at 39-40 GW (42.1 ± 1.8 °C), and at early stage of active labour (42.3 ± 1.3 °C) as compared to the non-pregnant women (p < 0.001). The N2-P2 CHEP amplitude (main negative N2 and positive P2 components of the vertex biphasic potential) recorded from the pregnant women was significantly lower at the 40th than at the 32nd GW, after stimulation of both the forearm (p < 0.001) and the abdomen (p < 0.001). CONCLUSIONS: In pregnant women, there is a progressive increase of heat pain threshold and a reduction of the CHEP amplitude, suggesting that a general inhibitory mechanism may be involved.

A study of low-dose S-ketamine infusion as "preventive" pain treatment for cesarean section with spinal anesthesia: benefits and side effects.

BACKGROUND: Attenuation of central sensitization with NMDA-active drugs such as S-Ketamine may play a role in postoperative analgesia and prevention of neuropathic pain. However, during cesarean section with neuraxial block, S-Ketamine might have adverse effects on the interaction between mothers and infants, including breastfeeding. METHODS: Women undergoing elective repeat cesarean section with subarachnoid anesthesia (0.5% hyperbaric bupivacaine 8-10 mg and sufentanil 5 µg) were enrolled in a double-blind, randomized study. Patients in the S-Ketamine group (N.=28) received i.v. midazolam 0.02 mg/kg and S-Ketamine 0.5 mg/kg i.m. bolus 10 minutes after birth followed by a 2 µg/kg/min i.v. continuous infusion for 12 h. The control group (N.=28) received placebo. Paracetamol and patient controlled analgesia with intravenous morphine were given postoperatively. Von Frey filaments were used to assess pain threshold on the inner forearm and T10-T11 dermatomes (supposed hyperalgesic area). RESULTS: S-Ketamine reduced morphine consumption at 4-8, 8-12, and 12-24 hours after surgery (total 31%), even after its effect has ceased, suggesting an anti-hyperalgesic action. Mild side effects were observed in the S-Ketamine group one hour after delivery. All side effects were rated as light and there were no serious adverse events. Pain threshold was not significantly different between groups. S-Ketamine patients showed a trend towards reduced pain sensitivity at the T10 dermatome, which is involved by surgical damage. After three years, patients reported no differences in residual pain, dysesthetic symptoms, or duration of breast-feeding. CONCLUSION: Preventive administration of S-Ketamine via 12-hour infusion was safe and may have anti-hyperalgesic action after cesarean section.

ITalian Observational Study of the management of mild-to-moderate Post-Operative Pain (ITOSPOP).

BACKGROUND: The multicenter observational ITalian Observational Study on the management of mild-to-moderate PostOperative Pain (ITOSPOP) was carried out in 24 hospitals to describe current postoperative pain management in Italy and the intensity of pain experienced by patients during the first 48 hours after surgery. METHODS: Adult patients, after surgery expected to result in mild-moderate postoperative pain, underwent six evaluations. The primary endpoint was the level of organization and standardization of postoperative pain management. Secondary objectives included the intensity of postoperative pain, and an assessment of incident pain, postoperative analgesic and concomitant treatment administration. RESULTS: Only 16.7% hospitals had an acute pain service and 41.7% hospitals applied a standardized protocol for postoperative pain management. The majority (>60%) of the 1952 patients monitored underwent all six assessments, >70% of which were performed by a physician. The proportion of patients with moderate pain decreased during the study period, but almost 10% of patients still experienced moderate pain at study end. Mild pain was reported by 50% of the patients for the entire study duration. At the final assessment, 5% of patients still presented with incident pain frequently interfering with daily activities. Most patients were treated with analgesics, but 20% of patients did not receive any pain medications despite experiencing pain. CONCLUSION: The level of organization and standardization of postoperative pain management in Italian hospitals remains low. Postoperative analgesic treatment remained suboptimal and almost two-thirds of patients continued to experience pain.

Successful application of helmet non-invasive ventilation in a parturient with acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is an important cause of morbidity and mortality during pregnancy. The case of a twin pregnant woman in her 28th week who developed infection-related ARDS, undergoing a cesarean section for premature membrane rupture is described. It was performed epidural anaesthesia and helmet non-invasive ventilation (NIV) during the postoperative period. The combination of epidural anesthesia with NIV helped to restore physiological gas-exchange and to prevent common complications associated with a more invasive approach.

[PATHOS study on postoperative pain management in Europe: French data]. / Enquête européenne sur la prise en charge de la douleur et de l'analgésie postopératoires (PATHOS) : les résultats français.

INTRODUCTION: Relief of postoperative pain is a major topic of public health and has been repeatedly shown to be inadequate. STUDY DESIGN: A questionnaire survey performed in seven European countries (postoperative analgesic therapy observational survey) in 746 health structures--which perform more than 80% of the total number of surgical procedures of each country--has demonstrated significant improvement when compared with previous surveys, particularly regarding increased use of multimodal analgesia and regular administration of analgesic drugs. The present study describes specific results for the 178 French health care institutions surveyed and 345 questionnaires collected. Preoperative patient information is given on a regular basis for 84% of respondents. RESULTS: Multimodal analgesia is used after major surgery in 87% of cases and prescribed on a regular basis for 84% of respondents. Written protocols are available in 36% of responding institutions. Pain scores are measured several times a day in 65% of institutions. An acute pain service (or any other structure with a similar aim) is found in 52% of institutions. Regular on-site training courses on pain control are delivered to 30% of anaesthesiologists, to 6% of surgeons, to 57% of recovery-room nurses and to 63% of ward nurses. Overall, the study suggests an improvement of current practices but also highlights remaining insufficiencies. CONCLUSION: Important efforts remain to be done, particularly in the field of initial and continuous education of all healthcare categories as this is believed to be the only real way to obtain long-term results.

Remifentanil for cesarean section under general anesthesia: effects on maternal stress hormone secretion and neonatal well-being: a randomized trial.

BACKGROUND: Remifentanil may attenuate maternal hemodynamic response during cesarean section under general anesthesia, but could cause transient but significant neonatal depression. We investigated the effect of low-dose remifentanil on maternal neuroendocrine response and fetal wellbeing. METHODS: Forty-two ASA I-II parturients undergoing cesarean section at term under general anesthesia were randomized to receive either fentanyl after delivery (n=21, group C) or remifentanil bolus 0.5 microg/kg before induction followed by a continuous infusion at 0.15 microg x kg(-1)min(-1) until peritoneal incision, then restarted after delivery (n=21, group R). Maternal heart rate and blood pressure, and epinephrine, norepinephrine, adrenocorticotropic hormone (ACTH), and growth hormone levels were measured at baseline, uterine incision, and the end of surgery. Remifentanil was measured in maternal and umbilical arterial and venous blood. One- and 5-minute Apgar scores and umbilical arterial and venous pH were recorded. RESULTS: ACTH was significantly higher in group C at uterine incision (P<0.01). No significant differences were observed in hemodynamics, catecholamines or growth hormone. Apgar scores at 1 (P<0.05) and 5 min (P<0.01) were significantly higher in group C. Mean umbilical pH values were within normal range but significantly higher in group C. Three neonates in group R required intubation but recovered at 5 min without naloxone. Mean+/-SD maternal remifentanil concentration was 1.67+/-1.04 ng/mL. CONCLUSIONS: Remifentanil administration before peritoneal incision partially reduced the hormonal stress response. Maternal benefits must be weighed against transitory but significant neonatal respiratory depression. Neonatal resuscitation facilities are mandatory when remifentanil is used.

Anaphylactic reactions during cesarean section.

Sensitization to latex seems to occur more frequently in women than in men. Obstetric and gynecological surgical procedures have recently been shown to be a common setting for latex anaphylaxis. We analyzed all the cases of anaphylactic reactions during 1240 cesarean sections in 2004; the patients were questioned for risk factors and underwent allergy testing for drugs and latex. Four patients had anaphylaxis under spinal anesthesia and in all cases it was due to latex allergy. Reported symptoms included facial edema, profuse sweating, itching, generalized erythematous rash and hypotension. Only one patient manifested a severe reaction which included bronchospasm, dyspnea, tachypnea and anaphylactic shock, requiring orotracheal intubation and epinephrine. Our data showed a high incidence (1:310) of intraoperative latex anaphylactic reactions in the one-year study period. This may be related to the very specific population (all women) in a very specific setting (obstetrics). To prevent anaphylactic reactions during obstetric surgery it is important to identify potential risk factors to include, for example atopy, adverse reactions to foods and latex items. If latex allergy is confirmed or strongly suspected, patients should be managed in a latex-safe environment. Premedication with antihistamines and steroids might be useful to further reduce the risk. After the delivery, specific desensitization may represent a good therapeutic option.

[Postpartum hemorrhage]. / L'emorragia del postpartum.

Postpartum hemorrhage, frequently due to uterine atony, is an important cause of maternal death and morbidity. The knowledge of causes, of antenatal and intrapartum risk factors and of physiopathological changes in hemodynamics and coagulation during pregnancy are essential for the management of the condition. At the present time, many efforts are made to organize a multidisciplinary approach to this complication of delivery involving clinical and laboratory staffs, since the rapid correction of hypovolemia, the diagnosis and treatment of defective coagulation, the surgical and pharmacological control of bleeding are mandatory. Several medical options have been developed and the surgical management includes traditional and newer conservative procedures with variable success rates. The developments in the treatment of postpartum hemorrhage may reduce hysterectomy that is to be considered the last resort to resolve the hemorrhage in some cases. In the modern management of postpartum hemorrhage protocols and guidelines should be available in every delivery room.

Rectal cancer in pregnancy: a new management based on blended anesthesia and monitoring of fetal well being.

Colorectal carcinoma presenting during pregnancy is an extremely rare condition associated with a poor prognosis. In this report we studied a patient referred to our hospital at 26 weeks of gestation with the diagnosis of rectal adenocarcinoma. Tumor resection with a colostomy was planned in the attempt to preserve pregnancy until fetal viability could be reached. Blended anesthesia (general and epidural) was chosen to avoid surgical and anesthesiological risks; in fact this technique allows either an optimal block of neurohormonal response or a good control of surgical stress to be obtained. In order to monitor fetal well being during surgery, Doppler evaluations of fetal heart rate and umbilical artery flow velocity waveforms were performed. The patient was dismissed in good health and then rehospitalized at 32 weeks of gestation in order to perform an elective cesarean section. In conclusion we suggest that, with the choice of a good anesthesiological technique and monitoring of fetal well being, surgical treatment in case of rectal cancer could be performed without affecting the course of pregnancy.

Fos-like immunoreactivity increases in the lumbar spinal cord following a chronic constriction injury to the sciatic nerve of rat.

A chronic constriction injury (CCI), transection injury, or sham injury to the sciatic nerve was induced in 30 rats. Rats were then sacrificed at 1, 3, 5, 10, and 20 days following injury, and the number of cells immunohistochemically labeled for Fos-like immunoreactivity (Fos-LI) was determined in random sections from the lumbar 4 and 5 (L4 and L5) spinal segments. Non-parametric statistics (Wilcoxon) were used to compare the number of labeled cells ipsilateral to the injury to the number of labeled cells on the contralateral side. At 1 and 5 days following injury, in all treatment groups, significantly more labeled cells (P < 0.05) were observed ipsilaterally. In addition, at 3 and 10 days following injury, the CCI groups exhibited significantly more labeled cells ipsilaterally. The significant increases for the CCI groups ranged from 161% to 360%. Generally, increases were greater for the CCI groups. These results indicate that Fos-LI increases to a greater extent and for a longer duration following the CCI than following either a transection or sham injury.

Transient changes in Fos and GFAP immunoreactivity precede neuronal loss in the rat hippocampus following neonatal anoxia.

Early and delayed neuronal and glial changes in the hippocampus were studied in Wistar rats following neonatal anoxia induced by 100% N2 exposure for 25 min at approximately 30 h postnatally. Sham-treatment induced a transient increase in the number of fos immunoreactive neurons in the CA1, CA2, and CA3 regions, with a peak at 120 min following handling. In contrast, a significant decrease in the number of fos-stained cells was seen in the CA1 and CA2 regions at 120 min after the exposure to anoxia, compared to sham-treatment. At 150 and 240 min increased fos immunoreactivity was detected in the CA2 region of anoxic rats. Enhanced glial fibrillary acidic protein staining was seen at Postnatal Day 7 (P7) in the hippocampus of the rats exposed to neonatal anoxia, while no differences between anoxic and sham-treated animals were observed at later time-points. No alteration in nerve cell density was found at P7, while at P15 and later stages a significant reduction in neuronal density was seen in the CA1 region of anoxic rats. Thus, the rapid induction in hippocampal neuronal activity that followed sham-treatment was blocked by the neonatal anoxia, as revealed by changes in immediate early gene expression. A transient reactive astrocytosis developed in the days after the anoxic insult, followed by a loss of neurons in the CA1 region. The findings indicate that a sequence of specific neuronal and glial alterations takes place in the hippocampus after neonatal anoxia, which finally leads to a detectable, regionally restricted, neuronal loss. Moreover, inhibition in fos protein expression may be an early marker for the anoxic damage in CA1 neurons.