Italian Intersociety Recommendations on pain management in the emergency setting (SIAARTI, SIMEU, SIS 118, AISD, SIARED, SICUT, IRC).

BACKGRAUND: Pain is the primary reason for admission to the Emergency Department (ED). However, the management of pain in this setting is often inadequate because of opiophagia, fear of excessive sedation, and fear of compromising an adequate clinical assessment. METHODS: An intersociety consensus conference was held in 2010 on the assessment and treatment of pain in the emergency setting. This report is the Italian Intersociety recommendations on pain management in the emergency department setting. RESULTS: The list of level A recommendations includes: 1) use of IV acetaminophen for opioid sparing properties and reduction of opioid related adverse events; 2) ketamine-midazolam combination preferred over fentanyl-midazolam fentanyl-propofol in pediatric patients; 3) boluses of ketamine IV (particularly in the population under the age of 2 years and over the age of 13) can lead to impairment of the upper airways, including the onset of laryngospasm, requiring specific expertise and skills for administration; 4) the use of ketamine increases the potential risk of psychomotor agitation, which can happen in up to 30% of adult patients (this peculiar side effect can be significantly reduced by concomitant systemic use of benzodiazepines); 5) for shoulder dislocations and fractures of the upper limbs, the performance of brachial plexus block reduces the time spent in ED compared to sedation; 6) pain relief and the use of opioids in patients with acute abdominal pain do not increase the risk of error in the diagnostic and therapeutic pathway in adults; 7) in newborns, the administration of sucrose reduces behavioural responses to blood sampling from a heel puncture; 8) in newborns, breastfeeding or formula feeding during the procedure reduces the measures of distress; 9) in pediatric patients, non-pharmacological techniques such as distraction, hypnosis and cognitive-behavioural interventions reduce procedural pain caused by the use of needles; 10) in pediatric patients, preventive application of eutectic mixtures of prilocaine and lidocaine allows arterial and venous samples to be taken in optimum conditions; 11) in pediatric patients, the combination of hypnotics (midazolam) and N2O is effective for procedural pain, but may be accompanied by loss of consciousness. CONCLUSION: The diagnostic-therapeutic pathway of pain management in emergency should be implemented, through further interdisciplinary trials, in order to improve the EBM level of specific guidelines.

Bradykinin B2 receptor antagonist off label use in short-term prophylaxis in hereditary angioedema.

Hereditary angioedema type I (HAE-C1-INH) is an inherited disorder characterized by repeated severe angioedema attacks mostly triggered by traumas, emotional stress, increased estrogen levels or surgical procedures, in particular, odontostomatological interventions. Icatibant, a bradykinin B2 receptor antagonist, has been approved for treatment of HAE attacks. In this paper we describe the “off label” administration of icatibant as short-term prophylaxis of dental extraction in a patient with HAE with the aim of preventing perioperative angioedema attacks. The drug showed an effective and safe profile. Thus, a short-term prophylaxis of angioedema attacks in patients with HAE may be arranged on a multidisciplinary basis, according to the clinical history of each single patients.

Anaesthesia management in patients with multiple chemical sensitivity syndrome.

Multiple Chemical Sensitivity (MCS) is characterised by the appearance of numerous and sometimes severe symptoms, when subjects are in contact with various chemicals and medicinal substances. Currently there are no useful guidelines for managing clinical issues and, specifically, anaesthesia for patients with MCS. This case report describes anaesthesia management in a patient affected by clinically documented MCS and a latex allergy, a candidate for a laparoscopic cholecystectomy operation.

Anxiolysis and postoperative pain in patients undergoing spinal anesthesia for abdominal hysterectomy.

AIM: The relationship between pain and psychological factors is well known. The aim of the study was to evaluate the influence of lorazepam, given before total abdominal hysterectomy, on postoperative pain control. METHODS: Sixty patients, enrolled in the study, were defined as either anxious or not anxious when the State/Trait Anxiety Inventory (STAI) score was =/>51 or =/< 50, respectively. The anxious patients were randomly assigned to receive oral lorazepam 0.035 mg/kg the night and 2 h before surgery (Group A), or placebo at the same time (Group B). The not anxious patients were assigned to receive oral lorazepam 0.035 mg/kg the night and 2 h before surgery (Group C), or placebo at the same time (Group D). Anesthesia was performed with subarachnoidal block. Ketorolac was used for postoperative pain. As rescue drug, tramadol was administered using a patient controlled analgesia (PCA) modality. Postoperative pain was assessed during the 24 h after surgery by tramadol consumption. RESULTS: Tramadol consumption was significantly greater in Group B (216.3+/-58.9 mg) than in Groups A, C and D respectively (150.9+/-28.9 mg; 153.6+/-39.9 mg; 154.4+/-39.9 mg). Group B showed a significantly higher pain score compared to the other groups during the first 8 h. No difference in patient satisfaction with perioperative treatment was noted. CONCLUSION: Preoperative lorazepam reduced perioperative anxiety. This could explain the better postoperative pain control in patients undergoing hysterectomy, a very stressful surgical procedure.

Cervical pain and headache in patients with facial asymmetries: the effect of orthognathic surgical correction.

AIM: Facial asymmetries are often associated with cervicobrachial pain and headache. The aim of the study was to evaluate the influence of surgical orthognathic correction of facial asymmetries on the intensity of cervicobrachial pain and headache in the short and long term. METHODS: Thirty-two patients affected by maxillomandibular asymmetries associated with pain referred to occipital, cervical, dorsal and scapulohumeral areas who were undergoing orthodontic surgical correction were enrolled in the study. The pain intensity at rest and on fibromyalgia trigger points was assessed using a 0-10 Visual Analogue Scale (VAS) preoperatively (T(0)) and 5 days (T(1)), 6 months (T(2)) and 12 months (T(3)) after surgery. Functional limitation was evaluated by the same method at T(0),T(2) and T(3). RESULTS: VAS scores at rest were significantly lower at T(1), T(2) and T(3) compared to T0 in every area to which pain was referred. After 12 months (T(3)), pain at rest was completely absent in 23 patients (71.8%) in the occipital region, in 23 patients (71.8%) in the cervical area, in 22 patients (68.7%) in the dorsal area, and in 28 patients (87.5%) in the scapulohumeral area. In the other patients, the pain scores in all areas were < 1 (0.77, 0.83, 0.95, 0.5 in the occipital, cervical, dorsal, and scapulohumeral areas respectively). The VAS at neck fibromyalgia points were significantly reduced at T(1), T(2), T(3) and functional limitation was improved at T(3) and T(4) (P=0.00). CONCLUSION: This study appears to demonstrate the utility of orthognathic surgery when facial asymmetry is associated with cranial-cervicobrachial pain syndrome, presumably through a new musculoskeletal rearrangement of stomatognathic apparatus. Indeed, the surgical correction has resulted in morphological, functional and symptomatic effects.

Parenteral nutrition in ventilated patients with chronic obstructive pulmonary disease: long chain vs medium chain triglycerides.

AIM: The aim of this study was to assess the usefulness of a lipid formulation containing a physical mixture of medium (MCT) and long chain triglycerides (LCT) compared with a long chain triglycerides emulsion in patients affected by chronic obstructive pulmonary disease with acute respiratory failure. METHODS: Twenty-four patients requiring mechanical ventilation were randomly selected in 2 groups and received total parenteral nutrition. Twelve patients received a MCT/LCT emulsion (50:50), the others used a 100% LCT emulsion. Nutritional status, metabolic rate, time of ventilatory support and weaning were evaluated. RESULTS: Both groups showed an improvement of all nutritional parameters evaluated; oxygen uptake, carbon dioxide output and respiratory gas exchange ratio were similar in both groups. The duration of mechanical ventilation was not significantly different; however, the time of weaning in the MCT/LCT group was significantly shorter. The longer weaning time in the LCT group patients could be related to vasoactive intermediates deriving from long chain fatty acids. The T-cell subsets, which were evaluated for both groups, showed a significant decrease of T helper-T suppressor ratio in the LCT group. CONCLUSION: MCT/LCT emulsion is an effective lipid supplementation and should be considered the therapy of choice in COPD patients; however, the relationship between lipid emulsions administered and length of weaning requires further investigations.

Hemodynamic variations during thoracic and abdominal stop-flow regional chemotherapy.

AIMS: The aim of this study was to study hemodynamic modifications during thoracic and abdominal stop-flow regional chemotherapy and to evaluate the need for routine hemodynamic monitoring during such kind of procedures. METHODS: Thirty patients, aged 17-67 years, ASA physical status II-III, scheduled for thoracic (group A, n = 15), and abdominal (group B, n = 15) stop-flow regional chemotherapy were enrolled. Heart rate (HR), electrocardiogram lead I and V(5), end tidal carbon dioxide (ETCO(2)), arterial oxygen saturation (SaO(2)), systolic, diastolic and mean arterial pressure (SBP, DBP, MAP), mean pulmonary arterial pressure (MPAP), pulmonary capillary wedge pressure (PCWP), central venous pressure (CVP), cardiac output (CO), stroke volume (SV), stroke index (SI), systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), left cardiac work (LCW), right cardiac work (RCW), left cardiac work index (LCWI), right cardiac work index (RCWI), cardiac index (CI), and body O(2) consumption (VO(2)) were recorded. RESULTS: After aortic and inferior vena cava endovascular occlusion (T(1)), a significant reduction of CO and SV, associated with an increase of CVP, MAP, PAPM and PCWP were observed. A concomitant reduction of CI and increase of SVR and PVR were registered. The VO(2) was significantly reduced compared to basal values in both groups. After deflating aortic and vena cava balloons (T(2)), CO, SV and CI increased with respect to basal value p < 0.05) whereas MAP, CVP, PAPM, PCWP and calculated parameters (SVR, PVR) showed a significant reduction compared to T(1). The oxygen consumption was significantly higher than that of basal values p < 0.05. After hemofiltration (T(3)), all hemodynamic variables were comparable with the basal values. Modifications of direct and calculated parameters, during the stop-flow period, showed a similar trend in both study groups, without any statistically significant difference. No ST modifications at ECG were noted during all perioperative period. CONCLUSIONS: The results of this study have confirmed in both groups, the safety of stop-flow regional chemotherapy procedure, despite endovascular occlusion of the aorta and inferior cava vein. The hemodynamic and oxygenation changes are reversible and did not produce any ST modifications at ECG during all perioperative period. Routine pulmonary artery catheterization is thus unnecessary, except in high cardiac risk patients.

[Diagnosis and treatment of non-palpable breast lesions: from the biopsy to the microhistology results. Our experience]. / La diagnosi ed il trattamento delle lesioni non palpabili della mammella: dalla biopsia su repere alla microistologia. Nostra esperienza.

The aim of modern senology lies in the diagnosis and treatment of non-palpable breast lesions (NPBLs). Through the diffusion of regional mammography screening the lesions being observed are continuously smaller, thus calling for more and more accurate methodology. Our experience in this area is based on the use of certain methods for retrieval and removal of NPBLs, such as Kopan's sec. philo-guide, ultrasound and advanced breast biopsy instrumentation. In our opinion methods allowing total removal of lesions in order to obtain complete histopathological characterization and enabling adequate therapeutic programs are to be preferred. In reviewing case studies a noteworthy increase of initial carcinoma (DCIS or LCIS), from 19.5% to 57.1%, has been observed in the last three years due to the extensive use of the aforementioned methods.

[Clinical use of spinal or epidural steroids]. / Uso degli steroidi per via spinale ed epidurale.

Steroids, drugs with potent antiinflammatory properties on the damaged nervous roots, have been especially used as adjuvants of local anesthetics, by spinal route, in the treatments of low-back pain. Spinal route was chosen to obtain a higher local concentration of drug, with few systemic side effects and to improve drug's action mechanism. Steroids seem to interact with GABA receptors and thus control neural excitability through a stabilising effect on membranes, modification of nervous conduction and membrane hyperpolarization, in supraspinal and spinal site. Epidural steroids are especially used in the treatment of low back pain due to irritation of nervous roots. They have been administered alone or in association with local anesthetics and/or saline solution. Slow release formulations have been generally used (methylprednisolone acetate, and triamcinolone diacetate). Other indications of epidural steroids are: postoperative hemilaminectomy pain, prevention of post herpetic neuralgia, degenerative ostheoartrithis. Intra-thecal steroids have been frequently used in the treatment of lumbar radiculopathy due to discopathy, as an alternative treatment when epidural administration is ineffective. Positive results have been obtained with methylprednisolone acetate, alone or in association with local anesthetics. Complications related to intraspinal steroids injections are due to execution of the block and side effects of drugs. Complications associated with intrathecal steroids are more frequent and severe than epidural injections and include: adhesive arachnoiditis, aseptic meningitis, cauda equina syndrome. Steroidal toxicity seems to be related to the polyethylenic glycole vehicle. Anyway, slow release formulations contain less concentrated polyethylenic glycole. The epidural administration, a correct dilution of steroid with local anesthetics solution and/or saline solution, and a limited number of injections (no more than three) allows a significant reduction of steroid neurotoxicity.

Haemodynamic effects of intravenous clonidine on propofol or thiopental induction.

The study evaluated the effects of premedication with intravenous clonidine on thiopental or propofol requirements for induction and haemodynamic changes associated with both induction and endotracheal intubation. Clonidine administered intravenously before induction of anaesthesia reduced propofol or thiopental requirements. The association of clonidine and propofol caused, after injection of the induction drug, a decrease in mean arterial pressure which was significantly greater than with thiopental. Moreover, a major haemodynamic stability was registered before and after laryngoscopy in the clonidine-thiopental group. These findings might contraindicate the clonidine-propofol combination in patients with cardiovascular disease.

[Use of remifentanil in ambulatory obstetric-gynecologic surgery. A dose-effect study]. / Uso del remifentanil in chirurgia ambulatoriale ostetrico-ginecologica. Studio dose-effetto.

BACKGROUND: Remifentanil, a recently commercialised opioid, is characterised by a predictable and non cumulative effect which vanishes rapidly without determining side effects in the long term. These characteristics make remifentanil an ideal opioid in continuous infusion for the ambulatory surgery setting. Aim of this study was to assess the ideal dose of remifentanil, administered in bolus before propofol, in patients undergoing uterine curettage and assisted by mask ventilation in 100% oxygen. METHODS: Sixty patients, ASA status I-II, scheduled for uterine curettage, were divided into three study groups according to the bolus dose of remifentanil received before the induction agent: group A (n = 20) 1 microgram/kg; group B (n = 20) 2 micrograms/kg; group C (n = 20) 2 micrograms/kg. All patients were assisted by 100% oxygen ventilation with facial mask. During surgery the following were recorded: time to spontaneous ventilation (in case of post induction apnea); incidence of somatic and autonomic responses to surgical stress (treated with remifentanil in bolus). At the end of surgery the times to response to simple verbal commands, to discharge from the recovery room (by Aldrete score every 5') and to discharge from hospital (by PADSS score every 30') were registered. RESULTS: All patients presented post-induction apnea with a significantly more rapid return to spontaneous ventilation in group A. Six patients of group A responded to surgical stress while in groups B and C there was no need for supplementary boluses (p < 0.05). Five patients of group C were treated with atropine for bradycardia, in four of group C it was necessary to administer succinylcholine for thoracic rigidity. No significant differences regarding the anesthesia recovery times were observed. All patients were discharged from the recovery room after 10' from the end of surgery. Overall, the qualification for discharge from hospital was obtained at the second PADSS score control, except for one group A patient who incurred in metrorrhagia. CONCLUSIONS: The administration in bolus of remifentanil, before the inducing agent, permits short-term surgery in ambulatory surgery settings thanks to the rapid recovery of vital functions. Compared to the other doses, the 1.5 micrograms/kg dose guaranteed a good control over surgical stress without influencing the speed of awakening and without determining uncomfortable side effects.

Intra-articular buprenorphine after knee arthroscopy. A randomised, prospective, double-blind study.

BACKGROUND: Demonstration of peripheral opioid receptors in inflamed synovia supports the concept of peripheral opioid analgesia. The aim of this study was to evaluate the analgesic effect of intra-articular administration of buprenorphine after knee arthroscopy. METHODS: In a double-blind randomised trial, 48 patients were assigned to four groups: group A patients received buprenorphine 100 micrograms i.a. and NaCl 0.9% i.m., group B patients received bupivacaine 0.25% 50 mg i.a. and NaCl 0.9% i.m., group C patients received NaCl 0.9% i.a. and buprenorphine 100 micrograms i.m., and group D patients received NaCl 0.9% i.a. and NaCl 0.9% i.m. Intensity of postoperative pain was evaluated by VAS at recovery (T0) and 1, 3, 6, 12, 24 h after operation (T1, T2, T3, T4, T5), at rest and during passive 10 degrees knee flexion. Total analgesic requirements and side effects related to study drugs were recorded. RESULTS: The VAS scores were significantly higher in groups C and D than in group A and B patients. The differences were significant at T0, T1, T2 and T3. At T1, group C and D patients had greater analgesic requirement than groups A and B. No patients developed side effects. CONCLUSION: Intra-articular buprenorphine and i.a. bupivacaine, both produced equally good postoperative pain control and allowed a significant reduction of analgesic requirement after knee arthroscopy.

[MR characterization of breast pathology using inversion recovery sequence]. / Caratterizzazione RM della patologia mammaria mediante la sequenza inversion recovery.

As yet, a valid tissue characterization of human breast diseases has not been possible with conventional MR techniques. On the basis of the experimental thesis according to which fibroadenomas and carcinomas have a slight, though significant, difference in T1 relaxation times, we employed specific inversion recovery sequences at the T null of the breast glandular and adipose tissues, to enhance the differences in the signal intensities of the various pathologies. We examined 16 (6 cystic dysplasias, 5 fibroadenomas, 3 carcinomas, and 1 phylloid fibroadenoma) selected patients with the above-mentioned sequences in addition to the routine T1- and T2-weighted spin echo sequences. The following conclusions were reached by evaluating the characteristic signal intensities: MR spin echo sequences allow solid lesions to be distinguished from cystic ones; MR inversion recovery sequences allow fibroadenomas to be distinguished from carcinomas with 88% accuracy.

[Magnetic resonance of the breast. Clinical experience with a dedicated coil]. / Risonanza magnetica della mammella. Esperienza clinica con bobina dedicata.

MR Imaging was performed on 10 healthy volunteers and 86 patients, using a 0.5 T superconducting magnet and a dedicated coil to image both breasts simultaneously. The patients were selected by the presence of nodules at clinical examination. Final diagnoses were made either at histology--in the patients who underwent surgery--or at cytology, with fine needle biopsy. The MR findings of the different breast diseases are discussed. In spite of an improved spatial resolution and of a very good natural contrast between different tissues, MR Imaging does not allow a satisfactory characterization of the lesions; its use is thus limited to the staging of cancers which need a better therapeutic planning.

[Clinical dosimetry in xeromammography using the low dose system]. / Dosimetria clinica in xeromammografia con sistema "low dose".

The results obtained by utilizing low-dose plates in xeromammography are reported. Phantom experimental examinations and dosimetric measurements were made before using these plates. The new exposition data were then compared to those obtained with the old plates. Findings prove low-dose plates to be more sensitive--thus granting very good iconographic results with reduction of skin dose (about 30%) at FFD of 110 cm. The skin dose has been compared to that obtained with the most modern mammographs.

[Xeroductogalactography. Case reports]. / Xeroduttogalattografia. Contributo casistico.

Xerogalactography represents the most important instrumental examination in the diagnosis of the secreting breast. The authors describe the radiological findings in the ductal ectasia, intraductal papillomas and papillomatosis and carcinomas in a personal experience concerning 52 patients with mammary secretion.