Continuous lumbar epidural infusion of levobupivacaine: effects of small-or large-volume regimen of infusion.

BACKGROUND: The question of whether the dose, concentration or volume of a local anesthetic solution is the relevant determinant of the spread and quality of post-operative epidural analgesia is still open. In this prospective, randomized, double-blind study, we compared the effects of a large volume-low concentration with a small-volume-high-concentration lumbar epidural infusion of levobupivacaine. METHODS: Seventy patients scheduled for total hip replacement were enrolled. After surgery, patients were randomly allocated to receive a continuous epidural infusion of levobupivacaine (10.5 mg/h) using either 0.125% levobupivacaine infused at 8.4 ml/h (low concentration group, n=35) or 0.75% levobupivacaine infused at 1.4 ml/h (high concentration group, n=35). We blindly recorded the degree of pain relief at rest and during movement every 8 h for the first two post-operative days, as well as hip flexion, motor block, rescue analgesic consumption and adverse events. RESULTS: No difference in pain relief was observed between groups as estimated with the areas under the curve of the verbal Numerical Rating Scale for pain over time, both at rest and during movement. Similarly, there was no difference between groups in hip flexion degree, motor blockade and hemodynamic stability. CONCLUSIONS: Continuous lumbar epidural infusion of 0.75% levobupivacaine was as effective as continuous lumbar epidural infusion of 0.125% levobupivacaine, when administered at the same hourly dose of 10.5 mg, in achieving adequate analgesia both at rest and during movement, without differences in the incidence of hypotension and motor blockade.

Sciatic nerve block with lateral popliteal approach for hallux vagus correction. Comparison between 0.5% bupivacaine and 0.75% ropivacaine.

AIM: In this study the authors compared the clinical profile of 2 local anesthetic drugs in the sciatic nerve block used during hallux valgus correction, a surgical procedure known to be post-operatively extremely painful. Since hallux valgus correction is painful post-operatively, many attempts have been tried to ensure a long-lasting analgesia. Block of the sciatic nerve appears to be the right choice balancing ease to performance, satisfaction of the patient and duration of action. METHODS: The authors investigated the use of 20 ml of 0.5% bupivacaine or 0.75% ropivacaine regarding the speed of onset, quality and length of duration of sciatic nerve block performed with a lateral popliteal approach. Sixty ASA I-III patients (aged 19-73 years) were enrolled in this trial. Written informed consent was asked and obtained. A 20 G 50 mm Teflon coated Crawford needle, delivering 0.5 mA at 2 Hz, was used to locate and block the sciatic nerve in the popliteal fossa with a lateral approach. RESULTS: Patients in the ropivacaine group required about 13 minutes to achieve a complete block and about 16 minutes were needed in the bupivacaine group for the anesthesia to be complete. The length of analgesia was 16 h for the ropivacaine group and 13 h for the bupivacaine group. This kind of approach to block the sciatic nerve appeared to the authors to be very easy to perform, with the patient lying in a natural position. Surgical anesthesia required less than 30 min in both groups to be ready, while the ropivacaine group had a longer length of analgesia compared to the bupivacaine group. CONCLUSIONS: Patient satisfaction was high in both groups.

The use of remifentanil for bloodless surgical field during vertebral disc resection.

BACKGROUND: A short hospital stay is nowadays desirable and affordable for a wide range of surgical pathology, respecting safety of care and home discharge. In the present study, the Authors investigated the use of TIVA with propofol/remifentanil during microsurgical vertebral disc resection to maintain a controlled vascular hypotension for bloodless surgical field aiming to reduce the operating time and consequently recovery room length of stay and morbility related to anaesthesia. METHODS: The study took place in a 300 bed Orthopaedics hospital over a period of 3 months and 50 ASA I-II patients were enrolled in this trial; further data are presented for comparison of 50 ASA I-II patients homogeneous for age and sex to the studied population, operated under a standard TIVA with propofol and boluses of fentanyl. Duration of anaesthesia and surgery, time for awakening after cessation of TIVA, incidence of postoperative nausea and vomiting (PONV), amount and quality of postoperative analgesia, length of stay in the recovery room are reported in statistical presentation. RESULTS: Time of surgery and anaesthesia were reduced in the remifentanil group compared with the fentanyl group, thanks to an easily reachable and durable state of controlled hypotension in the first group without the use of any other drug. The recovery profile was shorter in the remifentanil group the drug being rapidly metabolised by plasma cholinesterase. CONCLUSIONS: No difference occurred between the two groups regarding quality and amount of postoperative analgesia, while PONV presented more in the fentanyl group and shivering more in the remifentanil group.

0.25% levo-bupivacaine for interscalene block during shoulder surgery. A survey on 20 patients.

BACKGROUND: Interscalene brachial plexus block (ISB) is an alternative procedure to general anaesthesia for shoulder surgery, and consents the anaesthetist to easily control postoperative pain that, indeed, is known to be intense and often requires strong analgesic administration. The introduction of regional anaesthesia for this type of surgery, contributed to the relief of acute postoperative pain occurring in the recovery room since the analgesic effects of block persist for several hours after surgery depending upon the selected drug. The aim of this study was to determine the effects of 40 ml of 0.25% levo-bupivacaine, a local anaesthetic derived from the racemic mixture of bupivacaine, on the speed of onset, quality and duration of ISB. METHODS: Twenty adult ASA I-II patients, undergoing shoulder surgery for various pathologies, were enrolled in this study. All patients were examined before surgery and were given a full explanation; written informed consent was asked for and obtained. ISB was placed with the classic Winnie approach and the plexus was localised by means of a 40 mm, 22G Teflon(R) coated needle connected to an electro neural stimulator distributing 0.5 mA at 2 Hz. Once twitching was observed, 16 ml of 0.25% levo-bupivacaine were injected on shoulder lift, 12 ml on forearm abduction and 12 ml on forearm adduction. Monitoring: the time elapsing from last injection to loss of sensibility of pin-prick on the shoulder area, degree of motor block expressed on a 4 points scale, surgery time, as well as total time of analgesia were recorded for statistical analysis. STATISTICS: data were analysed at the STATISTICS Department of the University of Messina (Italy) and results are expressed as means and standard deviations. RESULTS: Eighteen patients were operated under ISB and light sedation while 2 patients were scheduled for interscalene block plus deep sedation, the position being very discomforting and surgery supposed to last more than 60 min (shoulder arthroscopy). Less than 9 min were required for the block to be complete with satisfactory muscle relaxation, optimal intraoperative anaesthetic condition and more than 13 hours of postoperative analgesia occurred. CONCLUSIONS: Levobupivacaine is a newly developed local anaesthetic derived from a bupivacaine racemic mixture from which the right isomer has been eliminated. Levo-bupivacaine, compared to racemic mixture, is acknowledged to be less cardiotoxic, faster at equal dosage, and ensures a longer analgesic interval. Zero point twenty-five percent concentration was preferred in this study in order to inject large volumes (40 ml) with a minimal anaesthetic amount (100 mg), resulting in short time for obtaining loss of sensibility, optimal intraoperative conditions and long lasting block with adequate postoperative analgesia.

A case of central nervous system vasculitis related to an episode of Guillain-Barrè syndrome.

The authors report their knowledge about an uncommon case of isolated vasculitis, restricted to the left sylvian artery during an auto-immune Guillain-Barrè syndrome (GBS), sustained by cytomegalovirus (CMV). An acute cardiopulmonary failure requiring a ventilator and vasopressor support manifested, notwithstanding plasma exchanging and immune-modulating therapy. An IgM-enriched formula administration coincided with a rapid amelioration of GBS and vasculitis to a complete recovery the next month after her discharge to a rehabilitation centre.

Use of acetylcysteine as the life-saving antidote in Amanita phalloides (death cap) poisoning. Case report on 11 patients.

alpha-Amanitin is an amatoxin known to produce deleterious effects on the liver and the kidneys, when circulating in the blood. It is produced by a particular kind of mushroom called amanita phalloides. Therapeutic options employed to treat mushroom intoxication, such as haemodiaperfusion on activated charcoal, high dosages of penicillin G, oral charcoal, etc., very often failed to act properly and liver transplantation (when a graft is available) appeared to be the only solution. In recent years, as suggest by some authors, it has been postulated that the oxidant effects of alpha-amanitin could be counteracted by the use of antioxidants such as silibinin. High dosages of N-acetyl-cysteine (CAS 616-91-1, NAC), already used as antioxidant in paracetamol poisoning, were successfully used in our Intensive Care Unit (ICU) in the treatment of Amanita phalloides poisoning. In the last two years, 11 patients (mean age of 5-72 = 38.5) were treated for Amanita phalloides poisoning of various degrees, with a protocol (haemodiaperfusion on activated charcoal, high dosages of penicillin G, etc.) further comprehending NAC (fluimucil). All the patients recovered successfully but one (bearing precedent liver disease) needed liver transplantation. Daily monitoring of liver enzymes, creatinine, coagulation, LDH, blood and urinary alpha-amanitin were used to screen the progresses of the patients.