The role of intraoperative stroke volume variation on bleeding during functional endoscopic sinus surgery.

BACKGROUND: Functional endoscopic sinus surgery (FESS) is a minimally-invasive surgical technique for patients with paranasal sinus pathology. Surgical bleeding reduces operative field visibility and increases the incidence of serious complications. Epinephrine injection into the nasal mucosa and controlled hypotension are used to minimize bleeding. Hypotension carries risks and sometimes does not reduce surgical bleeding. The goal of this study is to discover which hemodynamic parameter better correlates with surgical bleeding. METHODS: We enrolled 55 patients undergoing FESS. Inclusion criteria: male or female with chronic rhinosinusitis (CRS), older than 18 years, ASA I to III and primary surgery. Exclusion criteria: ASA>III, cerebrovascular and cardiac disorders, supraventricular tachycardia, renal or hepatic diseases, non-treated arterial hypertension, beta-blocking agent therapy, platelet-inhibiting agent or anticoagulant therapy, coagulopathy, pregnancy, clotting disorders, presence of neoplastic lesions and history of cranio-facial surgery. We used standard ASA plus ClearSight to assess hemodynamic parameters. Surgical procedures were performed by one surgeon and divided in ten surgical times (from T0 to T9). Intraoperative bleeding was assessed using the Fromme-Boezaart Scale. RESULTS: Analysis between all the hemodynamic parameters registered and the Fromme-Boezaart Score showed a negative correlation between surgical bleeding and stroke volume variation (SVV) only. When dichotomizing according to Fromme-Boezaart Score (above or below 2), SVV was the only parameter which showed significant differences between groups. A cut-off of 12.5% in SVV is optimal to distinguish the group with the better surgical visibility from the group with the worst one. CONCLUSIONS: Targeting SVV larger than 12% achieves a possible reduction of the intraoperative bleeding in patients undergoing FESS.

Electrochemotherapy for basocellular and squamocellular head and neck cancer: preliminary experience in Day Surgery Unit.

BACKGROUND: The aim of this study was to evaluate feasibility, safety and efficacy in day surgery of electrochemotherapy (ECT) using bleomycin in non-melanoma head and neck skin cancer. METHODS: We performed a prospective study on fifteen patients treated at the General Surgery Department at University Hospital of Tor Vergata, Rome between April 2011 and February 2013. RESULTS: We observed 100% complete response evaluated with WHO criteria at 6 weeks after treatment. No partial response was achieved. CONCLUSIONS: ECT is a simple, highly effective and safe treatment for head and neck non melanoma skin cancer. In our experience ECT can be performed safely in Day Surgery also in patients ASA III. Side effects associated with ECT are minimal and the treatment is well tolerated also by older patients, with minimal impairment of organ function and healthy tissues and with good esthetic results. We would encourage this treatment especially for older patients with multiple comorbidities, in which conventional surgical approach is not easily practicable.

Switching to low-dose oral prolonged-release oxycodone/naloxone from WHO-Step I drugs in elderly patients with chronic pain at high risk of early opioid discontinuation.

PURPOSE: Chronic pain has a high prevalence in the aging population. Strong opioids also should be considered in older people for the treatment of moderate to severe pain or for pain that impairs functioning and the quality of life. This study aimed to assess the efficacy and safety of the direct switch to low-dose strong opioids (World Health Organization-Step III drugs) in elderly, opioid-naive patients. PATIENTS AND METHODS: This was a single-center, retrospective, observational study in opioid-naive patients aged ≥75 years, with moderate to severe chronic pain (>6-month duration) and constipation, who initiated treatment with prolonged-release oxycodone/naloxone (OXN-PR). Patients were re-evaluated after 15, 30, and 60 days (T60, final observation). Response to treatment was defined as an improvement in pain of ≥30% after 30 days of therapy without worsening of constipation. RESULTS: One-hundred and eighty-six patients (mean ± SD age 80.7±4.7 years; 64.5% women) with severe chronic pain (mean average pain intensity 7.1±1.0 on the 11-point numerical rating scale) and constipation (mean Bowel Function Index 64.1±24.4; 89.2% of patients on laxatives) were initiated treatment with OXN-PR (mean daily dose 11.3±3.5 mg). OXN-PR reduced pain intensity rapidly and was well tolerated; 63.4% of patients responded to treatment with OXN-PR. At T60 (mean daily OXN-PR dose, 21.5±9.7 mg), the pain intensity was reduced by 66.7%. In addition, bowel function improved (mean decrease of Bowel Function Index from baseline to T60, -28.2, P<0.0001) and the use of laxatives decreased. Already after 15 days and throughout treatment, ~70% of patients perceived their status as much/extremely improved. Only 1.6% of patients discontinued treatment due to adverse events. CONCLUSION: Low-dose OXN-PR in elderly patients naive to opioids proved to be an effective option for the treatment of moderate to severe chronic pain. Large-scale trials are needed to improve clinical guidance in the assessment and treatment of pain in older people.

Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular and wound infusion after anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: This prospective, randomized, clinical trial compared pain intensity and analgesic drug consumption after anterior cruciate ligament (ACL) reconstruction with patellar tendon under femoral-sciatic nerve block anesthesia in patients who received either a continuous femoral nerve block (CFNB) or continuous local anesthetic wound and intra-articular infusions. METHODS: Fifty patients were randomized to CFNB (n = 25) or an ON-Q device (I-Flow Corp, Lake Forest, Calif) (n = 25). All patients received sciatic nerve block (25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). The first group received a CFNB (2 mg/mL of ropivacaine at 7 mL/hr), and the second group received a single-shot femoral nerve block (both using 25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). At the end of the intervention, an ON-Q device was positioned on the ON-Q patients to continuously infuse the patellar tendon wound and intra-articular cavity with ropivacaine 2 mg/mL at 2 mL/hr for each catheter. Data regarding demographic, hemodynamic, pain scores, adverse effects, and need for supplemental analgesia were registered in a 36-hr follow-up period. RESULTS: The CFNB group reported lower visual analog scale values than the ON-Q group: at rest at 12 hrs (2.4 [SD, 2.2] vs 5.4 [SD, 3.1]; P < 0.001) and on movement at 12 (3.1 [SD, 2.5] vs 6.3 [SD, 2.9]; P < 0.001) and 24 hrs (2.7 [SD, 1.9] vs 4.6 [SD, 2.6]; P = 0.01) after surgery. The number of morphine and ketorolac boluses was lower in the CNFB group (morphine: 3.2 [SD, 2.2] vs 6.2 [SD, 2.5]; P < 0.001; ketorolac: 1.1 [SD, 1.0] vs 2.4 [SD, 0.9]; P < 0.001). CONCLUSION: Continuous femoral nerve block provides better analgesia than the continuous patellar tendon wound and intra-articular infusions after anterior cruciate ligament reconstruction with patellar tendon.