Expanding the Use of HIPEC in Ovarian Cancer at Time of Interval Debulking Surgery to FIGO Stage IV and After 6 Cycles of Neoadjuvant Chemotherapy: A Prospective Analysis on Perioperative and Oncologic Outcomes.

BACKGROUND: Randomized data on patients with FIGO stage III ovarian cancer receiving ≤ 3 cycles of neoadjuvant chemotherapy (NACT) showed that hyperthermic intraperitoneal chemotherapy (HIPEC) after interval debulking surgery (IDS) improved patient's survival. We assessed the perioperative outcomes and PFS of FIGO stage IV and/or patients receiving up to 6 cycles of NACT undergoing IDS+HIPEC. METHODS: Prospectively collected cases from January 1, 2019 to July 31, 2022 were included. Patients underwent HIPEC if: age ≥ 18 years but < 75 years, body mass index ≤ 35 kg/m2, ASA score ≤ 2, FIGO stage III/IV epithelial disease treated with up to 6 cycles of NACT, and residual disease < 2.5 mm. RESULTS: A total of 205 patients were included. No difference was found in baseline characteristics between FIGO Stage III and IV patients, whereas rate of stable disease after NACT (p = 0.004), mean surgical complexity score at IDS (p = 0.001), and bowel resection rate (p = 0.046) were higher in patients undergoing delayed IDS. A lower rate of patients with at least one G3-G5 postoperative complications was observed in FIGO stage IV versus FIGO stage III disease (5.3% vs. 14.0%; p = 0.052). This difference was confirmed at multivariable analysis (odds ratio [OR] 0.24; 95% confidence interval [CI] 0.07-0.80; p = 0.02), whereas age, SCS, bowel resection, and number of cycles did not affect postoperative complications. No difference in PFS was identified neither between FIGO stage III and IV patients (p = 0.44), nor between 3 and 4 versus > 4 cycles of NACT (p = 0.85). CONCLUSIONS: Because of the absence of additional complications and positive survival outcomes, HIPEC administration can be considered in selected FIGO stage IV and patients receiving > 4 cycles of NACT.

Ultrasound-Guided Bilateral Erector Spinae Plane Block vs. Ultrasound-Guided Bilateral Posterior Quadratus Lumborum Block for Postoperative Analgesia after Caesarean Section: An Observational Closed Mixed Cohort Study.

ESP block (ESPB) and posterior Quadratus Lumborum Block (pQLB) have been proposed as opioid-sparing techniques for the management of pain after abdominal surgery. Between December 2021 and October 2022, we conducted a retrospective comparative study at the delivery suite of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, to compare the efficacy of ESPB and pQLB in preventing postoperative pain after an elective caesarean section (CS). The primary outcome was total morphine consumption in the first 24 h. Secondary outcomes were time to first opioid request; Numerical Pain Rating Scale (NPRS) at 0, 2, 6, 12 and 24 h; vital signs; adverse events. Fifty-two women were included. The total cumulative dose of morphine was not significantly different between the two groups of patients (p = 0.897). Time to first dose of morphine, NPRS values and haemodynamic parameters were not statistically different between the two groups. NPRS values significantly increased (p < 0.001) at the different time intervals considered. The need for rescue doses of morphine was lower in the ESPB group compared to the pQLB group (hazard ratio of 0.51, 95% CI (0.27 to 0.95), p = 0.030). No adverse event was reported. ESPB seems to be as effective as pQLB in providing analgesia after CS.

Reliability of pulse pressure and stroke volume variation in assessing fluid responsiveness in the operating room: a metanalysis and a metaregression.

BACKGROUND: Pulse pressure and stroke volume variation (PPV and SVV) have been widely used in surgical patients as predictors of fluid challenge (FC) response. Several factors may affect the reliability of these indices in predicting fluid responsiveness, such as the position of the patient, the use of laparoscopy and the opening of the abdomen or the chest, combined FC characteristics, the tidal volume (Vt) and the type of anesthesia. METHODS: Systematic review and metanalysis of PPV and SVV use in surgical adult patients. The QUADAS-2 scale was used to assess the risk of bias of included studies. We adopted a metanalysis pooling of aggregate data from 5 subgroups of studies with random effects models using the common-effect inverse variance model. The area under the curve (AUC) of pooled receiving operating characteristics (ROC) curves was reported. A metaregression was performed using FC type, volume, and rate as independent variables. RESULTS: We selected 59 studies enrolling 2,947 patients, with a median of fluid responders of 55% (46-63). The pooled AUC for the PPV was 0.77 (0.73-0.80), with a mean threshold of 10.8 (10.6-11.0). The pooled AUC for the SVV was 0.76 (0.72-0.80), with a mean threshold of 12.1 (11.6-12.7); 19 studies (32.2%) reported the grey zone of PPV or SVV, with a median of 56% (40-62) and 57% (46-83) of patients included, respectively. In the different subgroups, the AUC and the best thresholds ranged from 0.69 and 0.81 and from 6.9 to 11.5% for the PPV, and from 0.73 to 0.79 and 9.9 to 10.8% for the SVV. A high Vt and the choice of colloids positively impacted on PPV performance, especially among patients with closed chest and abdomen, or in prone position. CONCLUSION: The overall performance of PPV and SVV in operating room in predicting fluid responsiveness is moderate, ranging close to an AUC of 0.80 only some subgroups of surgical patients. The grey zone of these dynamic indices is wide and should be carefully considered during the assessment of fluid responsiveness. A high Vt and the choice of colloids for the FC are factors potentially influencing PPV reliability. TRIAL REGISTRATION: PROSPERO (CRD42022379120), December 2022. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=379120.

Effect of a pre-emptive 2-hour session of high-flow nasal oxygen on postoperative oxygenation after major gynaecologic surgery: a randomised clinical trial.

BACKGROUND: We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients. METHODS: In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the Pao2/FiO2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, Paco2, the percentage of patients with impaired gas exchange (Pao2/FiO2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days. RESULTS: A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) Pao2/FiO2 was 52.9 (47.9-65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P=0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6-10] vs 12 [10-14], P<0.001), mostly because of the difference of the score in dorsal areas (7 [6-8] vs 10 [9-10], P<0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P<0.001). All other secondary outcomes were not different between groups. CONCLUSIONS: In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy. CLINICAL TRIAL REGISTRATION: NCT04566419.

Intraoperative hypotension when using hypotension prediction index software during major noncardiac surgery: a European multicentre prospective observational registry (EU HYPROTECT).

Background: Intraoperative hypotension is associated with organ injury. Current intraoperative arterial pressure management is mainly reactive. Predictive haemodynamic monitoring may help clinicians reduce intraoperative hypotension. The Acumen™ Hypotension Prediction Index software (HPI-software) (Edwards Lifesciences, Irvine, CA, USA) was developed to predict hypotension. We built up the European multicentre, prospective, observational EU HYPROTECT Registry to describe the incidence, duration, and severity of intraoperative hypotension when using HPI-software monitoring in patients having noncardiac surgery. Methods: We enrolled 749 patients having elective major noncardiac surgery in 12 medical centres in five European countries. Patients were monitored using the HPI-software. We quantified hypotension using the time-weighted average MAP <65 mm Hg (primary endpoint), the proportion of patients with at least one ≥1 min episode of a MAP <65 mm Hg, the number of ≥1 min episodes of a MAP <65 mm Hg, and duration patients spent below a MAP of 65 mm Hg. Results: We included 702 patients in the final analysis. The median time-weighted average MAP <65 mm Hg was 0.03 (0.00-0.20) mm Hg. In addition, 285 patients (41%) had no ≥1 min episode of a MAP <65 mm Hg; 417 patients (59%) had at least one. The median number of ≥1 min episodes of a MAP <65 mm Hg was 1 (0-3). Patients spent a median of 2 (0-9) min below a MAP of 65 mm Hg. Conclusions: The median time-weighted average MAP <65 mm Hg was very low in patients in this registry. This suggests that using HPI-software monitoring may help reduce the duration and severity of intraoperative hypotension in patients having noncardiac surgery.

Blended (Combined Spinal and General) vs. General Anesthesia for Abdominal Hysterectomy: A Retrospective Study.

BACKGROUND: Adequate pain management for abdominal hysterectomy is a key factor to decrease postoperative morbidity, hospital length of stay and chronic pain. General anesthesia is still the most widely used technique for abdominal hysterectomy. The aim of this study was to assess the efficacy and safety of blended anesthesia (spinal and general anesthesia) compared to balanced general anesthesia in patients undergoing hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. METHODS: We retrospectively collected data from adult ASA 1 to 3 patients scheduled for laparoscopic or mini-laparotomic hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. Exclusion criteria were age below 18 years, ASA > 3, previous chronic use of analgesics, psychiatric disorders, laparotomic surgery with an incision above the belly button and surgery extended to the upper abdomen for the presence of cancer localizations (e.g., liver, spleen or diaphragm surgery). The cohort of patients was retrospectively divided into three groups according to the anesthetic management: general anesthesia and spinal with morphine and local anesthetic (Group 1), general anesthesia and spinal with morphine (Group 2) and general anesthesia without spinal (Group 3). RESULTS: NRS was lower in the spinal anesthesia groups (Groups 1 and 2) than in the general anesthesia group (Group 3) for every time point but at 48 h. The addition of local anesthetics conferred a small but significant NRS decrease (p = 0.009). A higher percentage of patients in Group 3 received intraoperative sufentanil (52.2 ± 18 mcg in Group 3 vs. Group 1 31.8 ± 16.2 mcg, Group 2 44.1 ± 15.6, p < 0.001) and additional techniques for postoperative pain control (11.4% in Group 3 vs. 2.1% in Group 1 and 0.8% in Group 2, p < 0.001). Intraoperative hypotension (MAP < 65 mmHg) lasting more than 5 min was more frequent in patients receiving spinal anesthesia, especially with local anesthetics (Group 1 25.8%, Group 2 14.6%, Group 3 11.6%, p < 0.001), with the resulting increased need for vasopressors. Recovery-room discharge criteria were met earlier in the spinal anesthesia groups than in the general anesthesia group (Group 1 102 ± 44 min, Group 2 91.9 ± 46.5 min, Group 3 126 ± 90.7 min, p < 0.05). No differences were noted in postoperative mobilization or duration of ileus. CONCLUSIONS: Intrathecal administration of morphine with or without local anesthetic as a component of blended anesthesia is effective in improving postoperative pain control following laparoscopic or mini-laparotomic hysterectomy, in reducing intraoperative opioid consumption, in decreasing postoperative rescue analgesics consumption and the need for any additional analgesic technique. We recommend managing postoperative pain with a strategy tailored to the patient's physical status and the type of surgery, preventing and treating side effects of pain treatments.

Real Evidence and Misconceptions about Malignant Hyperthermia in Children: A Narrative Review.

Malignant hyperthermia is a rare but life-threatening pharmacogenetic disorder triggered by exposure to specific anesthetic agents. Although this occurrence could affect virtually any patient during the perioperative time, the pediatric population is particularly vulnerable, and it has a five-fold higher incidence in children compared to adults. In the last few decades, synergistic efforts among leading anesthesiology, pediatrics, and neurology associations have produced new evidence concerning the diagnostic pathway, avoiding unnecessary testing and limiting false diagnoses. However, a personalized approach and an effective prevention policy focused on clearly recognizing the high-risk population, defining perioperative trigger-free hospitalization, and rapid activation of supportive therapy should be improved. Based on epidemiological data, many national scientific societies have produced consistent guidelines, but many misconceptions are common among physicians and healthcare workers. This review shall consider all these aspects and summarize the most recent updates.

Hypotension Prediction Index guided Goal Directed therapy and the amount of Hypotension during Major Gynaecologic Oncologic Surgery: a Randomized Controlled clinical Trial.

Intraoperative hypotension (IOH) is associated with increased morbidity and mortality. Hypotension Prediction Index (HPI) is a machine learning derived algorithm that predicts IOH shortly before it occurs. We tested the hypothesis that the application of the HPI in combination with a pre-defined Goal Directed Therapy (GDT) hemodynamic protocol reduces IOH during major gynaecologic oncologic surgery. We enrolled women scheduled for major gynaecologic oncologic surgery under general anesthesia with invasive arterial pressure monitoring. Patients were randomized to a GDT protocol aimed at optimizing stroke volume index (SVI) or hemodynamic management based on HPI guidance in addition to GDT. The primary outcome was the amount of IOH, defined as the timeweighted average (TWA) mean arterial pressure (MAP) < 65 mmHg. Secondary outcome was the TWA-MAP < 65 mmHg during the first 20 min after induction of GA. After exclusion of 10 patients the final analysis included 60 patients (30 in each group). The median (25-75th IQR) TWA-MAP < 65 mmHg was 0.14 (0.04-0.66) mmHg in HPI group versus 0.77 (0.36-1.30) mmHg in Control group, P < 0.001. During the first 20 min after induction of GA, the median TWA-MAP < 65 mmHg was 0.53 (0.06-1.8) mmHg in the HPI group and 2.15 (0.65-4.2) mmHg in the Control group, P = 0.001. Compared to a GDT protocol aimed to SVI optimization, a machine learning-derived algorithm for prediction of IOH combined with a GDT hemodynamic protocol, reduced IOH and hypotension after induction of general anesthesia in patients undergoing major gynaecologic oncologic surgery.Trial registration number: NCT04547491. Date of registration: 10/09/2020.

A case report of an atypical haemolytic uremic syndrome in pregnancy: something wicked this way comes.

BACKGROUND: Atypical Haemolytic Uremic Syndrome is an acute life-threatening condition, characterized by the clinical triad of microangiopathic hemolytic anaemia, thrombocytopenia, kidney injury. Management of pregnants affected by Atypical Haemolytic Uremic Syndrome can be a serious concern for obstetric anesthesiologist in the delivery room and in the intensive care unit. CASE PRESENTATION: A 35-year-old primigravida with a monochorionic diamniotic twin pregnancy, presented with an acute haemorrhage due to retained placenta after elective caesarean section and underwent surgical exploration. In the postoperative period, the patient progressively developed hypoxemic respiratory failure and, later on, anaemia, severe thrombocytopenia, and acute kidney injury. A timely diagnosis of Atypical Haemolytic Uremic Syndrome was made. Non-invasive ventilation and high-flow nasal cannula oxygen therapy sessions were initially required. Hypertensive crisis and fluid overload were aggressively treated with a combination of beta and alpha adrenergic blockers (labetalol 0,3 mg/kg/h by continuous intravenous infusion for the first 24 hours, bisoprolol 2,5 mg twice daily for the first 48 hours, doxazosin 2 mg twice daily), central sympatholytics (methyldopa 250 mg twice daily for the first 72 hours, transdermal clonidine 5 mg by the third day), diuretics (furosemide 20 mg three times daily), calcium antagonists (amlodipine 5 mg twice daily). Eculizumab 900 mg was administered via intravenous infusion once per week, attaining hematological and renal remissions. The patient also received several blood transfusion units and anti- meningococcal B, anti-pneumococcal, anti-haemophilus influenzae type B vaccination. Her clinical condition progressively improved, and she was finally discharged from intensive care unit 5 days after admission. CONCLUSIONS: The clinical course of this report underlines how crucial it is for the obstetric anaesthesiologist to promptly identify Atypical Haemolytic Uremic Syndrome, since early initiation of eculizumab, together with supportive therapy, has a direct effect on patient outcome.

Personalized Noninvasive Respiratory Support in the Perioperative Setting: State of the Art and Future Perspectives.

Background: Noninvasive respiratory support (NRS), including high-flow nasal oxygen therapy (HFNOT), noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP), are routinely used in the perioperative period. Objectives: This narrative review provides an overview on the perioperative use of NRS. Preoperative, intraoperative, and postoperative respiratory support is discussed, along with potential future areas of research. Results: During induction of anesthesia, in selected patients at high risk of difficult intubation, NIV is associated with improved gas exchange and reduced risk of postoperative respiratory complications. HFNOT demonstrated an improvement in oxygenation. Evidence on the intraoperative use of NRS is limited. Compared with conventional oxygenation, HFNOT is associated with a reduced risk of hypoxemia during procedural sedation, and recent data indicate a possible role for HFNOT for intraoperative apneic oxygenation in specific surgical contexts. After extubation, "preemptive" NIV and HFNOT in unselected cohorts do not affect clinical outcome. Postoperative "curative" NIV in high-risk patients and among those exhibiting signs of respiratory failure can reduce reintubation rate, especially after abdominal surgery. Data on postoperative "curative" HFNOT are limited. Conclusions: There is increasing evidence on the perioperative use of NRS. Use of NRS should be tailored based on the patient's specific characteristics and type of surgery, aimed at a personalized cost-effective approach.

Personalized Predictive Hemodynamic Management for Gynecologic Oncologic Surgery: Feasibility of Cost-Benefit Derivatives of Digital Medical Devices.

BACKGROUND: Intraoperative hypotension is associated with increased perioperative complications, hospital length of stay (LOS) and healthcare expenditure in gynecologic surgery. We tested the hypothesis that the adoption of a machine learning-based warning algorithm (hypotension prediction index-HPI) might yield an economic advantage, with a reduction in adverse outcomes that outweighs the costs for its implementation as a medical device. METHODS: A retrospective-matched cohort cost-benefit Italian study in gynecologic surgery was conducted. Sixty-six female patients treated with standard goal-directed therapy (GDT) were matched in a 2:1 ratio with thirty-three patients treated with HPI based on ASA status, diagnosis, procedure, surgical duration and age. RESULTS: The most relevant contributor to medical costs was operating room occupation (46%), followed by hospital stay (30%) and medical devices (15%). Patients in the HPI group had EURO 300 greater outlay for medical devices without major differences in total costs (GDT 5425 (3505, 8127), HPI 5227 (4201, 7023) p = 0.697). A pre-specified subgroup analysis of 50% of patients undergoing laparotomic surgery showed similar medical device costs and total costs, with a non-significant saving of EUR 1000 in the HPI group (GDT 8005 (5961, 9679), HPI 7023 (5227, 11,438), p = 0.945). The hospital LOS and intensive care unit stay were similar in the cohorts and subgroups. CONCLUSIONS: Implementation of HPI is associated with a scenario of cost neutrality, with possible economic advantage in high-risk settings.

A Case of Multidisciplinary Approach to Post-Radiotherapy Dilative Cardiomyopathy Undergoing Elective Cesarean Delivery: Anesthetic and Intensive Care Management.

Background: Cardiovascular diseases are the most common non-obstetric cause of maternal death. These cases became more common thanks to the improvement in cardiovascular therapies. A multidisciplinary team is necessary to manage these pregnancies. Case Report: A 32 years old women at the 25th week of gestation for acute heart failure in pre-existing left ventricular dysfunction induced by radio-chemotherapy admitted to the Coronary Unit of IRCCS Policlinico Universitario Agostino Gemelli for worsening of dyspneic symptoms and anuria not responding to diuretic therapy. At the echocardiogram: ejection fraction 30%, enlarged left atrium, systolic pulmonary arterial pressure 38 mmHg, bilateral pleural effusion, bilateral diffused pulmonary B lines. A multidisciplinary team composed by cardiologists, gynecologists, anesthesiologists, cardiac surgeons, neonatologists and bioethicists decided for an elective cesarean delivery at the 27th week of gestation in the hybrid cardio-thoracic operating theater. Anesthesia was provided by combined spinal-epidural technique under invasive continuous hemodynamic monitoring with the Edwards Lifesciences HemoSphere with Hypotension Prediction Index (HPI) and ForeSight technology (Edwards Lifesciences, Irvine, USA) through catheterization of the left radial artery. The femoral arteries were left available for extracorporeal circulation. Continuous norepinephrine infusion was started once liquor was collected in the spinal needle at a 0.1 mcg/kg/minute through a central line and was continued until the end of surgery. Fluid management consisted of a total of 200 ml of crystalloids. HPI values never reached alarm values (maximum value =10). The patient was discharged home on the 5th day after delivery with good hemodynamic compensation. The baby was intubated at birth and then gradually weaned from mechanical ventilation, then discharged.

The Effect of Epidural Analgesia on Labour and Neonatal and Maternal Outcomes in 1, 2a, 3, and 4a Robson's Classes: A Propensity Score-Matched Analysis.

Background: Lumbar epidural analgesia (EA) is the most commonly used method for reducing labour pain, but its impact on the duration of the second stage of labour and on neonatal and maternal outcomes remains a matter of debate. Our aim was to examine whether EA affected the course and the outcomes of labour among patients divided according to the Robson-10 group classification system. Methods: Patients of Robson's classes 1, 2a, 3, and 4a were divided into either the EA group or the non-epidural analgesia (NEA) group. A propensity score-matching analysis was performed to balance the intergroup differences. The primary goal was to analyse the duration of the second stage of labour. The secondary goals were to evaluate neonatal and maternal outcomes. Results: In total, 21,808 cases were analysed. The second stage of labour for all groups was prolonged using EA (p < 0.05) without statistically significant differences in neonatal outcomes. EA resulted in a lower rate of episiotomies in nulliparous patients, with a higher rate of operative vaginal deliveries (OVD) (p < 0.05) and Caesarean sections (CS) (p < 0.05) in some classes. Conclusions: EA prolonged the duration of labour without affecting neonatal outcomes and reduced the rate of episiotomies, but also increased the rate of OVDs.

Impact of maternal lateral tilt on cardiac output during caesarean section under spinal anaesthesia: a prospective observational study.

BACKGROUND: Left uterine displacement (LUD) has been questioned as an effective strategy to prevent aortocaval compression after spinal anesthesia (SA) for cesarean delivery (CD). We tested if LUD has a significant impact on cardiac output (CO) in patients undergoing CD under SA during continuous non-invasive hemodynamic monitoring with Clearsight. METHODS: Forty-six patients were included in the final analysis. We considered 4 timepoints of 5 min each: T1 = baseline with LUD; T2 = baseline without LUD; T3 = after SA with LUD; T4 = after SA without LUD. LUD was then repositioned for CD. The primary outcome was to assess if CO decreased from T3 to T4 of at least 1.0 L/min. We also compared CO between T1 and T2 and other hemodynamic variables: mean, systolic and diastolic blood pressure (respectively MAP, SAP and DAP), heart rate (HR), stroke volume (SV), stroke volume variation (SVV), pulse pressure variation (PPV), contractility (dP/dt), dynamic arterial elastance (Eadyn) at the different timepoints. Data on fetal Apgar scores and umbilical arterial and venous pH were collected. RESULTS: CO did not vary from T3 to T4 (CO mean difference -0.02 L/min [95% CI -0.88 to 0.82; P = 1). No significant variation was registered for any variable at any timepoint. CONCLUSIONS: LUD did not show a significant impact on CO during continuous hemodynamic monitoring after SA for CD. TRIAL REGISTRATION: (retrospectively registered on 03/12/2021) NCT05143684 .

Bilateral lumbar ultrasound-guided erector spinae plane block versus local anesthetic infiltration for perioperative analgesia in lumbar spine surgery: a randomized controlled trial.

BACKGROUND: Lumbar spinal surgery is associated with severe postoperative pain. We examined the analgesic efficacy of bilateral lumbar ultrasound-guided erector spinae plane block (ESPB) with ropivacaine compared with local infiltration. METHODS: Patients undergoing elective lumbar arthrodesis were randomly divided into two groups. Control group received 0.375% ropivacaine 40 mL through the wound, and ESPB group received preoperative bilateral ESPB with 0.375% ropivacaine 40 mL. Primary outcome was postoperative pain intensity at rest using a Numeric Rating Scale (NRS). Secondary outcomes included difference in pain intensity between preintervention and defined timepoints, total amount of opioid analgesic requested by the patients at the same timepoints, the incidence of any adverse event, and the length of hospital stay (LOS) after surgery. RESULTS: Sixty patients were enrolled in the study. After surgery we detected a NRS value of 1.9±1.5 in ESPB group and 5.9±1.6 in control group (P<0.001). About the opioid consumption we found a total sufentanil tablets consumption of 17±6 and 10±3 at 48 hours for control group and ESPB group, respectively (P<0.001). Concerning LOS, 30 (100%) patients in the control group and 22 (73.3%) in ESPB group were discharged after 72 hours (P=0.005). CONCLUSIONS: Bilateral ultrasound-guided ESPB offers improved postoperative analgesia compared with local infiltration in patients undergoing lumbar spinal surgery.