Programmed intermittent epidural bolus versus continuous epidural infusion for pain relief during termination of pregnancy: a prospective, double-blind, randomized trial.

BACKGROUND: Pain is a major concern during medical abortion but no evidence-based recommendations for optimal analgesia during medical termination of pregnancy are available. We compared two methods of epidural analgesia during second trimester termination of pregnancy, with the primary aim of assessing the incidence of motor block. METHODS: Women were randomly assigned to receive continuous epidural infusion (CEI Group; n=52) or programmed intermittent epidural bolus (PIEB Group; n=52). Assessment of motor block was performed every hour. Patients with a modified Bromage score <6 were considered to have motor block. RESULTS: Motor block occurred more frequently in the CEI Group compared with the PIEB Group (46.2% vs. 5.8%, P<0.001). Pain scores were low and comparable between groups. Patients in the CEI Group experienced nausea more frequently than those in the PIEB Group (34.6% vs. 13.5%, P=0.022). The degree of satisfaction was higher in the PIEB Group compared with the CEI Group. CONCLUSIONS: During second trimester termination of pregnancy in our patient groups, a programmed intermittent epidural bolus technique was associated with less motor block and greater patient satisfaction than continuous epidural infusion. Both techniques had similar analgesic efficacy.

Reversal of rocuronium induced neuromuscular block with sugammadex or neostigmine: a large observational study.

BACKGROUND: This 'real-life' study aimed to analyze the time from the start of neostigmine or sugammadex administration to recovery to a train of four ratio (TOFr) of 0.9 in a real-life in patients receiving rocuronium. The secondary aims were to assess the proportion of patients: presenting TOFr < 0.9 after 5, 10, and 20 min from reversal agent administration, receiving opioids for intraoperative analgesia and extubated in the post-anesthesia care unit (PACU). METHODS: This was a multisite, prospective, nonrandomized, observational real-life study. Reversal agent was administered at either T2 reappearance or at a post-tetanic count of 1 or 2. Drugs dosages were free according to each investigator's usual practice. RESULTS: Three hundred fifty-nine patients were enrolled onto the study. Time from reversal administration to TOFr to 0.9 is significantly faster in the sugammadex group than in the neostigmine group (shallow block: 2.2 vs. 6.9 min, respectively; P < 0.0001; deep block: 2.7 vs. 16.2 min, respectively; P < 0.0001). The number of patients with TOFr < 0.9 at 5, 10, and 20 min post-reversal agent administration was higher in the neostigmine than in the sugammadex group. Just five patients did not receive opioids. All patients were extubated in the operative room except for a single patient in the sugammadex group who was extubated following PACU admission. CONCLUSIONS: This real-life study confirms that reversal time is faster in patients receiving sugammadex than in those receiving neostigmine. TOFr < 0.9 20 min after reversal was only present in patients treated with neostigmine.

Total intravenous anesthesia with propofol and remifentanil for elective non-cardiac surgery.

BACKGROUND: Remifentanil is a highly effective mu opioid agonist with predictable pharmacokinetics and a close concentration-effect relationship. Moreover, studies on anesthetic drugs interactions show that optimal propofol concentrations decrease more significantly with remifentanil as compared with other opioids and recovery appears to be much faster than when propofol is combined with other opioids combinations. This intervention study was designed to evaluate the efficacy of propofol combined with remifentanil in elective non cardiac inpatient surgery. METHODS: N. 405 patients undergoing intraperitoneal, head-neck, intrathoracic, major orthopaedics, breast and major vascular surgery received: remifentanil (1 microgram.kg-1 at induction; 0.50 microgram.kg-1.min-1 at laryngoscopy; 0.25 microgram.kg-1.min-1 at skin incision; 0.25-0.30 microgram.kg-1.min1 from skin incision to end of skin suture) and propofol (0.5-1 mg.kg-1 at induction; 5 mg.kg-1.h-1 at laryngoscopy; 5 mg.kg-1.h-1 at skin incision and 5 mg.kg1.h1 thereafter). Intraoperative end-points included somatic responses, tachycardia and hypertension to laryngoscopy and surgery. Incidence of intraoperative bradycardia, hypotension and muscle rigidity were also recorded. Postoperative end-points included Aldrete score > or = 9, pain immediately following emergence and PONV. RESULTS: Propofol-remifentanil combination effectively controlled responses to laryngoscopy and surgical stress. Drug related adverse events were transient bradycardia (< 50 bpm) and hypotension (SBP < or = 80 mmHg) respectively: at prelaryngoscopy 11.60-1.48% and at pre-skin incision 10.61-0.98%. N. 365 patients were discharged from PACU and the median time to first Aldrete score > or = 9 was 22.3 min. The most frequent postoperative event was shivering recorded in n. 46 patients (12%). Postoperative analgesic medication was requested by n. 16 patients (4.4%) and PONV was noted in n. 6 patients (1.6%). CONCLUSIONS: When combined with propofol, remifentanil effectively provided for profound analgesia during surgery, stable anesthetic conditions, simplicity of use and predictable recovery.

Total intravenous anaesthesia in Charcot-Marie-Tooth disease. Case report.

A Total Intravenous Anaesthesia (TIVA) protocol in a case of hereditary motor-sensory neuropathy Charcot-Marie-Tooth disease in three consecutive orthopaedic surgical procedures is described. History, physical examination and sural nerve fascicular biopsy findings are reported. Problems related to the perioperative anaesthesiological management in peripheral neuropathies are discussed. Propofol and fentanyl without muscle relaxants, proved to be a safe technique, fast at reaching the level of surgical anaesthesia required, manageable for maintenance and rapidly reversible.

[Neuroanesthesia during carotid thromboendarterectomy interventions]. / Neuroanestesia durante gli interventi di TEA carotidea.

The paper describes two techniques of anesthesia used during carotid thromboendarteriectomy surgery. The first technique utilises a mixture of O2-N2O, isofluorane and fentanyl as analgesic; the halogenate compound is not administered during carotis clamping and fentanyl is used for maintenance. The second technique is predominantly intravenous and utilises differing doses of propofol during the entire operation with fentanyl as an analgesic. The two techniques are comparable in terms of management and efficacy; the use of ECG monitoring is vital to identify possible intraoperative cerebral ischemic phenomena.

[Ventricular pre-excitation syndrome: anesthesiologic aspects]. / Sindrome da preeccitazione ventricolare: aspetti anestesiologici.

Two cases of pre-excitation syndrome are reported and the anaesthesiological management adopted is discussed. After a brief overview of the pathophysiology of the syndrome relative indications and contraindications of the main anaesthetic drugs and volatile agents are analyzed. The high incidence of perioperative atrial fibrillation, atrial flutter or supraventricular tachycardia and the importance of maintaining sinus rhythm is recalled. The task confronting the anaesthetist is to ensure an adequate level of anaesthesia during induction and maintenance while carefully selecting specific drugs associated with minor cardiovascular side effects. In the Authors' experience benzodiazepines, fentanyl, vecuronium and isoflurane have proved to be the most adequate choice for this type of patient.

Heart rate-respiration relationship: computerized method for early assessment of cardiac autonomic damage in diabetic patients.

This study compares the sensitivity of electrocardiographic R-R methods, used alone and with respiration, for diagnosis of cardiac disautonomy in diabetic patients. In 12 diabetic subjects with laboratory signs of neuropathy (45 +/- 10.4 years) (group A), 24 diabetic subjects without neuropathy (45 +/- 11.9 years) (group B) and 16 normal subjects (43 +/- 12.6 years) (group C), electrocardiogram and respiration were on-line digitized during spontaneous breathing and hyperpnea at 3-18 breaths/minute. Heart rate, R-R standard deviation (SD), R-R range (RG) and cross-correlation function (CC) were computed. Reproducibility was tested in 10 normal volunteers (age 22-28 years, mean 25.2). During spontaneous breathing, heart rate was 87.5 +/- 11.8 beats/min in group A, 77.3 +/- 10.8 in group B, and 71.6 +/- 14.9 in group C (p less than 0.05); RG was 102 +/- 51 msec in group A, 166 +/- 78 in group B and 272 +/- 168 in group C (p less than 0.005); SD was 18.2 +/- 10.1 msec in group A, 29.3 +/- 13.7 in group B and 49.2 +/- 26.5 in group C (p less than 0.001); CC was 2.38 +/- 0.66 units in group A, 3.00 +/- 0.72 in group B and 3.85 +/- 0.59 in group C (p less than 0.0001). During hyperpnea the difference between A and B increased for SD, RG (p less than 0.01) and CC (p less than 0.001). CC better discriminates between normals and diabetics without neuropathy during normal breathing; hyperpnea enhances the relationship heart rate-respiration in normal and, at a lesser degree, in diabetic subjects, thus slightly improving the method. The CC method had better reproducibility and lower intersubject variability than traditional methods of R-R variability.