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.

Bilateral adrenalectomy for Cushing's syndrome: a comparison between laparoscopy and open surgery.

We report our experience with bilateral adrenalectomy for treatment of Cushing's syndrome and we compare the outcome of laparoscopy with open surgery in terms of effectiveness and safety. A series of 23 patients underwent bilateral adrenalectomy for treatment of Cushing's syndrome [Cushing's disease in 16, ectopic ACTH syndrome in 2, and ACTH-independent macronodular adrenal hyperplasia (AIMAH) in 5 cases]. From 1993 to 1996, all patients were treated using an open approach (Group A), while from 1997 all patients were treated using a transperitoneal laparoscopic approach (Group B). The comparison between the 2 groups was performed considering patients characteristics, operative times, blood losses, intraoperative and post-operative complications, analgesic consumption, post-operative hospital stay and recovery. Open surgery was performed in 10 patients and laparoscopy in 13 patients. No significant difference was recorded between the two groups as to patients' characteristics and complications. Mean operative time was significantly increased in Group B, while post-operative hospital stay was significantly longer in Group A. Laparoscopic bilateral adrenalectomy can be safely and effectively employed to treat Cushing's syndrome. However, long operatives times may represent a limitation especially in high risk patients.

[Postoperative patient controlled analgesia]. / La PCA postoperatoria.

Patient controlled analgesia (PCA) helps patients to achieve a better comfort both at rest and when dynamic pain is concerned. This aim can be reached by closing the feedback loop in a shorter time. The purpose is to keep drug concentration in the narrow therapeutic range of MEAC (minimal effective analgesic concentration). Two methods of administration can be used: demand bolus; continuous infusion rate plus demand bolus. Continuous infusion method together with opioids administration increases lethal complications 0.28 to 1.08% (p<0.05), unless patient controlled epidural analgesia (PCEA) is performed. Therefore, this method can be used only in ICU environment. An effective and safe dose delivering and a correct infusion timing is now possible due to recent improvement in technology. The success in PCA depends more by parameters chosen, patient and healthcare personnel compliance, monitoring of S(p)O(2), respiratory rate, pain VAS and Sedation Score than by the drug administered. There is recent evidence that PCA improves patient's comfort, but does not reduce the amount of personnel work, postoperative morbidity, analgesic consumption and costs.

What should be the standard operation in chronic pancreatitis: Whipple or duodenum-preserving pancreatic head resection?

Surgical options in the treatment of chronic pancreatitis have undergone both development and controversial discussion in the past decades. Operations such as the classical and pylorus-preserving Whipple resections are more and more being replaced by operations such as the duodenum-preserving pancreatic head resection, which preserves extrapancreatic organs like the stomach, the duodenum and the extrapancreatic bile duct. The latter operation preserves a normal food passage and glucose metabolism after surgical intervention. In addition, the duodenum-preserving pancreatic head resection provides long-term pain relief and reduction in up to 90% of chronic pancreatitis patients, as well as a general improvement in quality of life. This article will summarize and compare the surgical options in the treatment of chronic pancreatitis and will provide arguments why the duodenum-preserving pancreatic head resection should replace the classical and the pylorus-preserving Whipple resections as the standard surgical procedure used to treat chronic pancreatitis-related complications.

Major surgery (radical cystectomy with urethrectomy) in a patient with von Willebrand's disease type I. Reliability and limits of hemocoagulative tests.

Patients with bleeding disorders frequently need medical or surgical care. The case is reported of a man with von Willebrand's disease type I undergoing radical cystectomy with urethrectomy for multicentric bladder cancer with neoplastic involvement of prostatic urethra, who developed serious bleeding complications which can not be predicted with conventional coagulation in laboratory. The use of the thromboelastograph (TEG) in the critical postoperative period was decisive. The tracing alterations allowed to assess the clotting disorder, constantly counterbalancing the baseline deficit and the blood loss.

[The use of nefopam in the prophylaxis and treatment of postoperative shivering]. / Impiego del nefopam nella profilassi e nella terapia del brivido postoperatorio.

Chlorhydrate nefopam was used in the prophylaxis and treatment of postoperative shivering in 54 patients undergoing general anesthesia for radical cystectomy with trans-intestinal anastomosis. Postoperative shivering was not observed in any of the patients treated with nefopam before coming round, whereas it occurred in 55% of patients treated with placebo. Chlorhydrate nefopam subsequently stopped shivering in all these patients. The main side effects observed took the form of delayed awakening in 11% of patients receiving prophylactic treatment and somnolence lasting 5-10 minutes in all other patients.

[The use of propofol in combination with fentanyl or buprenorphine in long-duration anesthesia]. / Impiego del propofol in associazione con fentanyl o buprenorfina in anestesie di lunga durata.

Fifty patients of both sexes, aged between 37 and 60 years old and belonging to ASA classes I, II, III and IV, underwent urological surgery lasting more than two hours under general anesthesia using a continuous infusion of propofol, N2O/O2, vecuronium bromide 0.02% infusion. Patients were divided into two groups of 25, group A and group B, according to whether they received fentanyl or buprenorphine as an analgesic. Propofol and fentanyl consumption in group A were 5.43 +/- 0.7 mg/kg/hour and 10.53 +/- 1.7 micrograms/kg respectively, whereas those of propofol and buprenorphine in group B were 5.71 +/- 1.08 mg/kg/hour and 6.05 +/- 0.06 micrograms/kg; there was a statistically non-significant difference for propofol consumption (p greater than 0.005). During the induction and maintenance phases of anesthesia, hemodynamic parameters decreased significantly (p less than 0.001) in comparison to starting values in both groups, but no statistically significant differences were observed. Buprenorphine prolonged reawakening from anesthesia by a few minutes but at the same time extended postoperative analgesia by several hours, thus improving the overall quality of the immediate postoperative period. The most frequent side effect (32% in group A and 52% in group B) was sinusal bradycardia.

[Use of vecuronium bromide and atracurium besylate in continuous intravenous infusion in urologic surgery]. / Impiego del bromuro di vecuronio e del besilato di atracurio in infusione endovenosa continua in chirurgia urologica.

The effects of continuous i.v. infusion of atracurium and vecuronium monitored by TOF supplied by an ABM monitor have been compared in 60 patients subdivided into four groups and submitted to anaesthesia with isoflurane for urological surgery interventions. Groups A and V received respectively an initial bolus of 0.5 mg/kg atracurium and of 0.08 mg/kg vecuronium followed immediately by continuous i.v. infusion of 5.5 micrograms/kg/min. Atracurium or 0.9 micrograms/kg/min of vecuronium; recovery of neuromuscular function happened spontaneously. Groups A' and V' differed by virtue of the use of 0.04 mg/kg prostigmin in the recovery phase. Average consumption of atracurium and vecuronium were respectively 5.1 +/- 1.75 micrograms/kg/min (2.6-9.03) and 0.75 +/- 0.20 micrograms/kg/min (0.5-1.2) in groups A-A' and V-V'. In groups A and V Recovery time 25-75" of T1 and TR presented a statistically significant difference (p less than 0.05) in favour of atracurium. In groups A' and V' the same parameters presented a statistically non-significant difference (p greater than 0.05). The ratio TI/TR does not vary to a statistically significant extent in the 4 groups. The number of infusion rate variations needed to maintain stable neuromuscular block was lower in the atracurium groups.

[Use of betamethasone in heart surgery]. / Impiego del betametasone in cardiochirurgia.

Clinical experience carried out on 88 high risk patients subjected to open-heart surgery with ECC is reported. The series was subdivided into two groups of patients (A and B) and to these were applied the same surgical and anaesthesiological approaches and the same extracorporeal perfusion technique. In Group B, however, a different method of myocardial protection was employed, in the form of preventive administration of pharmacological doses of betamethasone (3 mg/kg). The results point to a marked reduction in the incidence of postoperative complications in the heart, lungs and bloodstream in Group B compared with Group A.

[Drug therapy and enteral hyperalimentation in the prevention of stress ulcer in intensive therapy]. / Trattamento farmacologico ed alimentazione enterale nella prevenzione dell'ulcera da stress in terapia intensiva.

Stress ulcer is one of the risks to which patients undergoing intensive therapy are exposed. In an attempt to gain further knowledge on the ways and means of preventing this complication, a comparison was made of a selective treatment using drugs with a specific action on the gastric mucosa in a series of 20 cases. The clinical course was compared with that observed in 20 untreated patients. Drug management was associated with continuous and constant enteral alimentation to keep the activity of the digestive apparatus as physiological as possible.

[Current treatment of tetanus patients in intensive therapy]. / Trattamento attuale del tetano in terapia intensiva.

A brief survey of recent criteria for evaluation of the seriousness of toxicity and infection in tetanus is followed by the examination of a series of cases of average severity. The method employed in their therapeutic management is described, and an account is given of its advantages and the possibility of complications. The mortality rate for the years 1974-1978 is also reported.