Diagnosis and therapy of intrathecal bleeding.

AIM: Define pathophysiology, epidemiology, diagnosis and therapy in case of spinal bleeding after central neural blockade (CNB). METHODS: Spinal epidural hematoma (SEH) following CNB may occur due to vascular trauma from needle/catheter placement and can occur in subdural and epidural spaces. Epidural artery bleeding seems the source of SEH: the damage mechanism depends on compression and neural vascular ischemia of cord, nerve roots, ganglion and toxicity from blood cell lysis products. Incidence varies (1:150.000 - 1:500.000) but SEH may be asymptomatic. CONCLUSIONS: SEH starts with acute severe low back and/or radicular pain and neurologic signs that may progress to paraparesis, sensory loss and sphincter disturbances. After CNB, the only sign of SEH may be an unusually prolonged motor and sensory block. Symptoms may start even 96 hours after CNB and/or removal of the epidural catheter. Neurological recovery is related to severity and speed of preoperative deficits development and surgical decompression. MR imaging features (diagnostic tool of choice), including degree of cord compression, are useful to establish or confirm the diagnosis of SEH but do not influence the management or predict outcome. Hematoma resolution and severity of neurologic impairment has the greatest impact on management and outcome. Preoperative MRI information and intraoperative evidence of subarachnoid hemorrhage (SAH) and CSF leakage is important: SAH worsens outcome for its negative effect on spinal cord and cauda equina. Conservative therapy may be successful in cases with minimal neurologic deficits, despite cord compression.

[Patient controlled regional analgesia (PCRA) in surgery of stiff elbow: elastomeric vs electronic pump]. / Analgesia regionale controllata dal paziente (PCRA) nella chirurgia del gomito anchilotico: elastomero vs pompa elettronica.

BACKGROUND: Aim of this study is to confront an elastomeric pump at regular infusion controlled by the patient with an electronic pump with self-administration for analgesia, by continuous infraclavicular brachial plexus block, as support for the intensive postoperative physiotherapy. METHODS: With signed informed consent 10 patients undergoing corrective surgery for stiff elbow were included. All patients received ropivacaine 30 ml 0,50% for anaesthesia by infraclavicular block with bicipite twitch, after which a catheter was left in situ. In group 1 analgesia consisted of ropivacaina 0,4% by electronic pump (continuous infusion with self-administration of bolus) at day1 and day2, and by elastomeric pump at 5 ml/h, connected to a three way tap managed by the patient (open-closed) at day3 and day4. Group 2 received at day1 and day2 the elastomeric pump and then the electronic pump. All patients continued at home with the elastomeric pump. Flexion-extension capacity of the elbow, daily consumption of ropivacaine 0,4%, and patients comfort were all evaluated. RESULTS: With the electronic pump, flexion-extension capacity is significantly better compared to elastomeric pump. During the use of the electronic pump, consumption of ropivacaina 0.4% was significantly higher in day2 compared to day1 (physiotherapy started day2); consumption in day3 and Day4 was significantly less compared to day2. All patients preferred the electronic pump for the first two days and then the elastomeric pump. CONCLUSION: PCRA quality is higher with ropivacaine 0,4% during the first phase of recovery. The elastomeric pump instead, insufficient in the first phase, is useful for analgesia at home.

Regional anaesthesia in vascular surgery: a multidisciplinary approach to accelerate recovery and postoperative discharge.

A multimodal, rehabilitative, fast discharge approach to abdominal aortic surgery is analyzed. The approach was developed in two phases during the years 1997-2000: in the first phase (1997) patients had thoracic epidural anesthesia plus TIVA and analgesia. They had improvement of the classical surrogate outcomes and analgesia: pain relief, nasogastric tube withdrawal, mobilization, ileus, hospital length of stay were significantly (p< 0,01) improved when compared to a historical, standard management group (1996: general anesthesia or lumbar epidural anesthesia plus general anesthesia with gas). In the second phase we started a more aggressive perioperative approach based on thoracic epidural anesthesia plus general anesthesia with gas and spontaneous breathing and postoperative epidural analgesia, left subcostal minilaparotomy incisions, aggressive postoperative nursing and pain relief on the ward. Preliminary results on 44 patients show no mortality, low postoperative morbility (cardiac complications 2,2%, peripheral embolization 2,2%, no pulmonary complications), no ICU stay and fast hospital discharge (median: 3,5 days, range: 2-8 days) without complications. We conclude that preliminary data support the safety and the need for further improvement of a multimodal, aggressive rehabilitative approach in abdominal vascular surgery.

[Sufentanil vs morphine combined with ropivacaine for thoracic epidural analgesia in major abdominal surgery]. / Sufentanil vs morgina in associazione alla ropivacaina per l'analgesia epidurale toracica in chirurgia addominale maggiore.

BACKGROUND: Pain, postoperative ileus, nausea, vomiting are the universal complications after major abdominal surgery. The aim of this study was to assess pain relief, side effects and recovery of gastrointestinal function during epidural analgesia with ropivacaine plus sufentanil and ropivacaine plus morphine after major abdominal surgery. METHODS: In this prospective study, sixty patients (median age 62+/-12 years) undergoing major abdominal surgery, after informed consent, were randomized into two groups, during a period of 3 months. Patients who were not considered suitable candidates for epidural anaesthesia were excluded. Epidural catheters were inserted at T8-T9 (upper abdominal surgery) or T9-T11 (lower abdominal surgery) and ropivacaine 0,5% 7-9 ml (upper abdominal surgery) or 10-12 ml (lower abdominal surgery) combined with sufentanil 30 mcg (group S, n=30) or with morphine 2 mg (group M, n=30) was injected. General anaesthesia was induced and a continuous epidural infusion of ropivacaine 0.5% 5-10 ml/h was begun. Postoperatively, continuous epidural administration of ropivacaine 0.2% plus sufentanil 0.5 mcg/ml (group S) or ropivacaine 0.2 plus morphine 0.02 mg/ml (group M) was continued. Data on the quality of analgesia, recovery of gastrointestinal function and all side effects were recorded for 48 hours. RESULTS: Incident and resting pain scores were not significantly different among group; although sufentanil provided better resting pain scores at 16th, 20th, 24th hours, and incident pain score at 24th hour. The incidence of nausea, vomiting and pruritus was more in morphine group (p<0,0001). Time to the first flatus was significantly shorter for patients in the sufentanil group (p<0,0001). The quality of pain relief assessed by the patients was rated as good in all patients. CONCLUSIONS: Continuous administration of epidural ropivacaine combined with sufentanil or with morphine resulted in good analgesia. Epidural analgesia with ropivacaine plus sufentanil provided the best balance of analgesia, side effects and recovery of gastrointestinal function.

[Mother and child sharing the same room and breast feeding]. / Internación conjunta madre-hijo y lactancia materna.

The author analyzes the existing relationship among breast feeding and socioeconomical level and degree of instruction of the mother. He also describes the causes for the interruption of breast feeding in a maternity where rooming-in existed. He stressed the importance of the motivation to the mother for breast feeding and the independence between levels of instruction and frequency of breast feeding.