Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial.

The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.

Sufentanil sublingual tablet system (Zalviso®) as an effective analgesic option after thoracic surgery: An observational study.

INTRODUCTION: Sufentanil sublingual tablet system (SSTS) (Zalviso®) is a sublingual system for patient controlled analgesia, demonstrated to be an effective strategy for pain control after major abdominal and orthopedic surgery. We present a prospective observational study on the use of SSTS for the management of postoperative pain after thoracic surgery. The aim of this study was to assess the efficacy of Zalviso® in reducing pain scores and increasing respiratory ability during postoperative period. MATERIALS AND METHODS: There were about 40 patients underwent video assisted thoracoscopy were included in the study. All the enrolled patients signed the informed consent were educated to the use of the device. Pain numeric rating scale values (NRS) were recorded at awakening from anesthesia (T0) and during the next hours, both at rest and with cough. We evaluate the time to obtain a mean NRS value ≤3 and difference in pain scores between first and subsequent measurements as the primary outcomes. The ability to use incentive spirometer and eventual drug adverse effect were evaluated as secondary outcomes. RESULTS: All patients in recovery room experienced moderate to severe pain. Pain score at rest and coughing decreased to a mean NRS value ≤3 (mild pain) respectively after 2 and 6 hours and the pain score difference continued to increase significantly after repeated measurements. 67.5% of patients resumed the original spirometric ability in pod 1; 9.5% in pod 2; 12% in pod 3. Only three patients out of forty (7,5%) experienced nausea; one patient (2,5%) had a vomiting episode. CONCLUSION: Our study showed SSTS as an effective option for postoperative pain management in thoracic surgery, improving pain scores and respiratory ability.

Failed back surgery syndrome: a new strategy by the epidural injection of MESNA.

PURPOSE: Evaluate the efficacy and safety of MESNA (sodium 2-mercaptoethanesulfonate) injection into the epidural space in the FBSS. METHODS: We designed a prospective phase II longitudinal study. Six consecutive patients were enrolled. Patients underwent one peridural injection per week for 3 weeks. NRS and ODI were investigated before and 48 h after injections, and at 1 week, 1 month and 2 months after the last procedures. Opioids intake is investigated before procedures and 1 week, 1 month and 3 months after the last procedures. Lumbosacral MRI is performed before the first procedure, at the end and 3 months after the last procedures. RESULTS: From baseline, at 3 months, NRS in standing, sitting and lying position improved, respectively, of 34.29, 30.56 and 26.47%; ODI improved of 20.3%; the average decrease in morphine intake was 20.54%. No difference in MR images was found. Conclusions Our preliminary results suggest that MESNA might be an efficacy alternative to common practice.

Use of GlideScope® in adults: an overview.

This paper is an overview of the literature concerning the "know how" of the GlideScope® use in adults. We summarized the main evidences of the last 10 years with particular attention to experts' suggestions about clinical practice of the GlideScope®, noticing matters still debated on GlideScope® use. We used PubMed to search publications from January 2003 to June 2013 using the search terms "GlideScope", "video laryngoscope" and "videolaryngoscopy". These publications were searched manually or references to further publication not identified using PubMed. All works that made a point worth including were cited in the discussion. Our research confirms the value of GlideScope® use in airway management and highlights the debate about the use of videolaryngoscopes in routine cases and the operators who may use them in clinical practice.

Force and pressure distribution using Macintosh and GlideScope laryngoscopes in normal and difficult airways: a manikin study.

BACKGROUND: The forces applied to the soft tissues of the upper airway may have a deleterious effect. This study was designed to evaluate the performance of the GlideScope compared with the Macintosh laryngoscope. METHODS: Twenty anaesthetists and 20 trainees attempted tracheal intubation of a Laerdal SimMan manikin. Forces and pressure distribution applied by both laryngoscope blades onto the soft upper airway tissues were measured using film pressure transducers. The minimal force needed to achieve a successful intubation, in the same simulated scenario, was measured; additionally, we considered the visualization score achieved by using the Cormack-Lehane grades. RESULTS: All participants applied, on average, lower force with the GlideScope than with the Macintosh in each simulated scenario. Forces [mean (sd)] applied in the normal airway scenario [anaesthetists: Macintosh 39 (22) N and GlideScope 27 (15) N; trainees: Macintosh 45 (24) N and GlideScope 21 (15) N] were lower than forces applied in the difficult airway scenario [anaesthetists: Macintosh 95 (22) N and GlideScope 66 (20) N; trainees: Macintosh 100 (38) N and GlideScope 48 (16) N]. All the intubations using the GlideScope were successful, regardless of the scenario and previous intubation experience. The average pressure on the blades was 0.13 MPa for the Macintosh and 0.07 MPa for the GlideScope, showing a higher uniformity for the latter. CONCLUSIONS: The GlideScope allowed the participants to obtain a successful intubation applying a lower force. A flatter and more uniform pressure distribution, a higher successful rate, and a better glottic view were observed with the GlideScope.

Static forces variation and pressure distribution in laryngoscopy performed by straight and curved blades.

A theoretical analysis of the forces acting on the laryngoscope during the lifting of the epiglottis is carried out by applying the basic principles of statics. The static model of a laryngoscope equipped with a straight and a curved blade and the forces variation, as a function of the introduction angle and of tissue reaction application point, are described. The pharyngeal tissues and epiglottis pressure distribution on the blade is obtained, with a 1mm(2) resolution, by measurements performed in-vitro on a simulation mannequin, using straight and curved blades. The straight blade requires more effort than the curved one to obtain the same visualization of vocal cords, however forces exerted by using a laryngoscope with a curved blade do not vary linearly with the application point of tissue reaction. Average intensity of the tissue reaction has been found in the order of 32+/-11 N. Pressure distribution is maximally concentrated on the tip of curved blades (0.5 MPa on 5mm axial length), whereas it is more dispersed on straight blades (0.2 MPa on 10mm axial length). The inclination of the handle also influences the effort of the operator: for both blades, from 0 rad to 1.57 rad, the lifting force shows a total variation of about 13% of the top value, the transversal forces vary less than 6% of the top value.

New devices and techniques for airway management.

Innovation over the past 25 years in the field of the airway management has led to the proliferation of new and improved techniques and devices. It is important to emphasize that the definition of a failed airway must include the inability to maintain acceptable oxygenation and not only the evidence of unsuccessful laryngoscopy and impossible intubation. We must ask ourselves: is it always necessary to intubate? Is it necessary in all patients? Our answer is absolutely ''no." Patients' oxygenation is the absolute priority, where the choice of whether or not to intubate represents only a technical problem. The existing literature primarily supports the use of the classic laryngeal mask airway (LMA) for providing effective ventilation and oxygenation; it suggests the use of the intubating LMA as an important rescue device and the use of the Combitube as a well-established emergency airway. The role in managing complex airway problems of many new extraglottic devices has not yet been completely investigated and will likely be better defined in the coming years. The videolaryngoscopes seem to be an interesting and promising option in the field of airway management. Furthermore, the applicability of associated techniques could represent an efficacious strategy to overcome the limitations of the single device by strengthening their capabilities and chances of successful airway management. To date there is no technique found to be effective in every case or that can solve all airway problems. It is not the latest device or the latest technique that can solve an airway management problem, but the operator's experience and skill with the device and technique that he knows best and uses daily.

Postoperative myocardial infarction: pathophysiology, new diagnostic criteria, prevention.

With the introduction of biomarkers like troponin I (cTnI), our ability to identify and quantify myocardial infarction in the postoperative period has been greatly enhanced. Even small elevations of cTnI should be considered as a myocardial infarction. Small increases in cTnI postoperatively have indeed been found to be associated with worse short and long-term outcomes, the higher the cTnI level the worse the outcome. Studies undertaken in the 1980s when postoperative myocardial infarction (PMI) was detected by means of electrocardiogram recordings every 12 hours following operation suggested that this complication occurred on the second or third postoperative day. More recent studies where postoperative myocardial necrosis has been detected by repeated troponin dosages have revealed that, in fact, postoperative myocardial infarction appears much earlier between 12 and 32 hour after the end of surgery. Two types of PMI were identified based on intense troponin surveillance. They stem from two different major pathophysiological mechanisms. One seems to be related to plaque-vulnerability, while the other may be due to the effects of prolonged ischemia. The postoperative period should be regarded as a vulnerable period' that acts synergistically with both plaque and patient vulnerabilities in the development of PMI. Monitoring troponin levels in the postoperative period following surgery enables the identification of patients with myocardial damage and the institution of early aggressive intervention (e.g., intensive beta blockers therapy, adequate analgesia, correction of anemia) in order to prevent the evolution of PMI during this golden period' that lasts about two days. In patients that are prone to develop PMI, and especially in those who are prone to develop PMI related to plaque rupture, prevention can be achieved by better preoperative identification of the vulnerable plaque, and by a better plaque stabilization, either metabolically (e.g., statins) or by actual coronary stenting. Further understanding of the mechanisms underlying PMI, as well as their early identification, may contribute to the reduction of the incidence of PMI and its associated morality in the future.

[Evaluation of the withdrawal of ACE inhibitors in coronary artery surgery]. / Valutazione della sospensione degli ACE-inibitori in chirurgia cardiaca coronarica.

During cardiac surgery, as a result of surgical aggression, myocardial ischaemia and cardiopulmonary bypass, the renin-angiotensin-aldosterone mechanism is intensely activated. Our aim is to document whether, in the case of patients undergoing chronic treatment with lisinopril, the non-withdrawal of this inhibitor's administration before cardiac surgery and the administering of a last dose on the day of the operation are associated with coronary haemodynamic alterations. A study was made of 18 patients submitted to myocardial revascularization under extracorporeal circulation and distributed in two groups: group A) without ACE inhibitorsplacebo, group B) with ACE inhibitors (Lisinopril). Coronary blood flow (CBF) was determined by inverted thermodilution via Baim's catheter. Coronary and metabolic haemodynamic values were calculated. Lisinopril had no significant influence on the CBF or on the other above-mentioned values. Therefore, it is not necessary to withdraw ACE inhibitors in cardiac surgery interventions.