Pseudoendogenous origin of prednisolone in pigs from the food chain

The debate about the origin of prednisolone in animal organisms has lasted for 5 years. Bovine species have been the most studied, but studies on humans and horses are also present in the literature. Even if prednisolone in pigs does not yet represent a problem for control agencies, interest has recently increased with regard to this species. To date, there has been just a single study in the literature about this topic, performed on 10 sows treated with prednisolone or a synthetic analogue of adrenocorticotropic hormone. We therefore initiated a study on 80 pigs, a number considered representative in relation to the expected frequency (prevalence) of prednisolone detection in urine collected at slaughter. Prednisolone was detected in urine both at the farm and at the slaughterhouse, with a concentration and frequency higher at slaughter. The presence of prednisolone was also studied in the adrenal glands, where the corticosteroids are produced in response to stress, and it was detected in 89% of the samples. These results, together with the similar behaviours of prednisolone and cortisol, i.e. a mutual rise in the two corticosteroids in urine collected at the slaughterhouse and the correlation between the concentrations of the two corticosteroids in the adrenal glands, seem to indicate an endogenous origin of prednisolone in pigs.

Investigation of the origin of prednisolone in cow urine

After a two-year period of the frequent detection of prednisolone-positive bovine urine samples in the Italian region of Lombardy, studies were initiated to investigate the source. Because the majority of positive samples were detected at the slaughterhouse, researchers hypothesised that, together with increased cortisol and cortisone, a small quantity of prednisolone could be produced by the cows in stressful situations. In the present study, three dairy cows underwent intramuscular treatments with tetracosactide hexaacetate, a synthetic analogue of adrenocorticotropic hormone, to simulate stress. The animals were slaughtered at the end of the study. The results indicated that prednisolone could be detected occasionally in the non-stressful state, but was consistently found in the urine of stressed cows (concentrations ranged from 1.01 to 4.08 ng/mL). To confirm the stress condition, urinary cortisol and cortisone were also detected at high concentrations in the urine, typically at concentrations of hundreds of nanograms per millilitre. The results of this preliminary study did not reveal the metabolic pathway responsible for prednisolone but suggested that this corticosteroid could be produced endogenously.

Cell-autonomous regulation of hematopoietic stem cell cycling activity by ATP

Extracellular nucleotides regulate many cellular functions through activation of purinergic receptors in the plasma membrane. Here, we show that in hematopoietic stem cell (HSC), ATP is stored in vesicles and released in a calcium-sensitive manner. HSC expresses ATP responsive P2X receptors and in vitro pharmacological P2X antagonism restrained hematopoietic progenitors proliferation, but not myeloid differentiation. In mice suffering from chronic inflammation, HSCs were significantly expanded and their cycling activity was sensitive to treatment with the P2X antagonist periodate-oxidized 2,3-dialdehyde ATP. Our results indicate that ATP acts as an autocrine stimulus in regulating HSCs pool size.

Postoperative pain treatment SIAARTI Recommendations 2010. Short version

The aim of these recommendations is the revision of data published in 2002 in the "SIAARTI Recommendations for acute postoperative pain treatment". In this version, the SIAARTI Study Group for acute and chronic pain decided to grade evidence based on the "modified Delphi" method with 5 levels of recommendation strength. Analgesia is a fundamental right of the patient. The appropriate management of postoperative pain (POP) is known to significantly reduce perioperative morbidity, including the incidence of postoperative complications, hospital stay and costs, especially in high-risk patients (ASA III-V), those undergoing major surgery and those hospitalized in a critical unit (Level A). Therefore, the treatment of POP represents a high-priority institutional objective, as well as an integral part of the treatment plan for "perioperative disease", which includes analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A). In order to improve an ACUTE PAIN SERVICE organization, we recommend: --a plan for pain management that includes adequate preoperative evaluation, pain measurement, organization of existing resources, identification and training of involved personnel in order to assure multimodal analgesia, early mobilization, early enteral nutrition and active physiokinesitherapy (Level A); --the implementation of an Acute Pain Service, a multidisciplinary structure which includes an anesthetist (team coordinator), surgeons, nurses, physiotherapists and eventually other specialists; --referring to high-quality indicators in establishing an APS and considering the following key points in its organization (Level C): --service adoption; --identifying a referring anesthetist who is on call 24 hours a day; --patient care during the night and weekend; --sharing, drafting and updating written therapeutic protocols; --continuous medical education; --systematic pain assessment; --data collection regarding the efficacy and safety of the implemented protocols; --at least one audit per year. --a preoperative evaluation, including all the necessary information for the management of postoperative analgesia (Level C); --to adequately inform the patient about the risks and benefits of drugs and procedures used to obtain the maximum efficacy from the administered treatments (Level D). We describe pharmacological and loco-regional techniques with special attention to day surgery and difficult populations. Risk management pathways must be the reference for early identification and treatment of adverse events and chronic pain development.

Wave-number spectrum of drift-wave turbulence

A simple model for the evolution of turbulence fluctuation spectra, which includes neighboring interactions leading to the usual dual cascade as well as disparate scale interactions corresponding to refraction by large scale structures, is derived. The model recovers the usual Kraichnan-Kolmogorov picture in the case of exclusively local interactions and midrange drive. On the other hand, when disparate scale interactions are dominant, a simple spectrum for the density fluctuations of the form |nk|2 proportional to k(-3)/(1+k2)2 is obtained. This simple prediction is then compared to, and found to be in fair agreement with, Tore Supra CO2 laser scattering data.

Turbulence in the TORE SUPRA tokamak: measurements and validation of nonlinear simulations

Turbulence measurements in TORE SUPRA tokamak plasmas have been quantitatively compared to predictions by nonlinear gyrokinetic simulations. For the first time, numerical results simultaneously match within experimental uncertainty (a) the magnitude of effective heat diffusivity, (b) rms values of density fluctuations, and (c) wave-number spectra in both the directions perpendicular to the magnetic field. Moreover, the nonlinear simulations help to revise as an instrumental effect the apparent experimental evidence of strong turbulence anisotropy at spatial scales of the order of ion-sound Larmor radius.

A prospective, randomized, double-blind comparison between parecoxib and ketorolac for early postoperative analgesia following nasal surgery

BACKGROUND

The aim of this prospective, randomized, double-blind study was to compare the efficacy of parecoxibfor postoperative analgesia after endoscopic turbinate and sinus surgery, with the non-selective non-steroid anti-inflammatory drug (NSAID), ketorolac.

METHODS

A total of 50 patients with an ASA physical status I-II, receiving functional endoscopic sinus surgery (FESS) and endoscopic turbinectomy after local infiltration with 1% mepivacaine, were randomly assigned to receive intravenous administration of either 40 mg parecoxib (N.=25) or 30 mg ketorolac (N.=25), 15 min before the discontinuation of anaesthesia and then every 8 h postoperatively. A blinded observer recorded the incidence and severity of pain upon admission to the postanesthesia care unit (PACU), as well as 10, 20, and 30 min after PACU admission. Thereafter, observations continued every 1 h for the first 6 h, and then 12 h and 24 h after surgery.

RESULTS

The area under the curve of the visual analogue scale (AUCVAS) calculated during the study period was 635 (26-1 413) in the Parecoxib group and 669 (28-1 901) in the Ketorolac group (P=0.54). Rescue morphine analgesia was required by 12 patients (48%) in the Parecoxib group and 11 patients (44%) in the Ketorolac group (P<0.05); while mean morphine consumption was 5 +/- 2.5 mg and 5 +/- 2.0 mg in Ketorolac and Parecoxib groups, respectively (P<0.05). No differences in the incidence of side effects were recorded between the two groups. Patient satisfaction was similarly high in both groups, and all patients were discharged uneventfully 24 h after surgery.

CONCLUSION

In patients undergoing endoscopic nasal surgery and local infiltration with 1% mepivacaine, parecoxib administered before discontinuing general anesthesia is as effective in treating early postoperative pain as ketorolac.

Transcutaneous carbon dioxide monitoring in spontaneously breathing, nonintubated patients in the early postoperative period

BACKGROUND

The authors investigated the accuracy of transcutaneous capnometry (TcPCO(2)) in estimating arterial blood carbon dioxide partial pressure (PaCO(2)) during spontaneous breathing in patients admitted to our surgical intensive care unit (ICU).

METHODS

Serial TcPCO(2) and PaCO(2) measurements were taken in stable patients undergoing postoperative monitoring after major abdominal, vascular, or thoracic surgery. Patients were enrolled 12 hours after extubation. Exclusion criteria were pulmonary dysfunction, hemodynamic instability, or anemia. Linear regression, mixed models, and Bland-Altman analyses were used to compare accuracy and correlation between the two variables. Data are presented as means (95% confidence intervals).

RESULTS

PaCO(2) values ranged between 26 mmHg and 52 mmHg. Mean values for TcPCO(2) and PaCO(2) were 35.3 (33.8-36.8) mmHg and 39.2 (37.6-40.7) (P<0.001). Bland-Altman analysis showed a bias of -3.8 (-5.1-2.5) mmHg with upper and lower limits of agreement of 5.6 (3.4-7.9) mmHg and -13.3 (-15.6 -11.1) mmHg, respectively. Thirty-one (55.4%) measurements disagreed by 3 mmHg or more. Linear mixed model analysis with adjustment for repeated measurements showed low correlation (r=0.63; P<0.0005). There were small but significant differences between patients in the correlation coefficient (P=0.04).

CONCLUSION

TcPCO(2) showed moderate bias with wide limits of agreement when compared to PaCO(2) in our patients. The regression model showed low correlation of the measurements when adjusting for repeated measurements and between-subject variances. TcPCO(2) may not provide an accurate quantitative estimation of PaCO(2) in stable, spontaneously breathing, nonintubated patients in the early postoperative period.

Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine

BACKGROUND

The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the efficacy of phrenic nerve infiltration with ropivacaine 0.2% on the incidence and severity of ipsilateral shoulder pain after thoracotomy in patients receiving continuous thoracic epidural analgesia.

METHODS

Fifty ASA physical status II-III patients, receiving thoracic epidural analgesia for post-thoracotomy pain, were randomly allocated to receive infiltration of the ipsilateral phrenic nerve with either ropivacaine 0.2% 10 mL (ropivacaine, n = 25), or saline 0.9% (control, n = 25) just before lung expansion and chest closure. A blinded observer recorded the incidence and severity of ipsilateral shoulder pain 6, 12, 24, 36 and 48 h after surgery. Postoperative respiratory function was also evaluated with blood gas analyses.

RESULTS

The cumulative incidences of ipsilateral shoulder pain during the first 24 h after surgery were 8/25 in the ropivacaine and 16/25 in the control groups (P = 0.047), with median (range) onset times for shoulder pain of 2 (2-24) h with ropivacaine and 0.5 (0.5-24) h in controls (P = 0.005). No differences were reported on the second postoperative day. The areas under the curves of the amount of pain over time were 0 (0-2760) mm h for the ropivacaine and 350 (0-1900) mm h for the control groups (P = 0.06). Postoperatively, similar reductions in indices of oxygenation were observed in both groups.

CONCLUSIONS

Phrenic nerve infiltration with ropivacaine 0.2% 10 mL reduced the incidence and delayed the onset of ipsilateral shoulder pain during the first 24 h after open lung resection, with no clinically relevant effects on respiratory function.

Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve

BACKGROUND

We tested the hypothesis that ultrasound guidance may reduce the minimum effective anaesthetic volume (MEAV50) of ropivacaine 0.5% required to block the femoral nerve compared with nerve stimulation guidance.

METHODS

After standard premedication and sciatic nerve block were given, 60 patients undergoing knee arthroscopy were randomly allocated to receive a femoral nerve block with ropivacaine 0.5% using either nerve stimulation (group NS, n = 30) or ultrasound (group US, n = 30) guidance. The volume of the injected solution was varied for consecutive patients based on an up-and-down staircase method according to the response of the previous patient. The initial volume was 12 ml. A double-blinded observer evaluated the occurrence of complete loss of pinprick sensation in the femoral nerve distribution, with concomitant block of the quadriceps muscle: positive or negative responses within 30 min after the injection determined a 3 ml decrease or increase for the next patient, respectively.

RESULTS

The mean (sd) MEAV50 for femoral nerve block was 15 (4) ml (95% CI, 7-23 ml) in group US and 26 (4) ml (95% CI, 19-33 ml) in group NS (P = 0.002). The effective dose in 95% of cases (ED95) calculated with probit transformation and logistic regression analysis was 22 ml (95% CI, 13-36 ml) in group US, and 41 ml (95% CI, fs 24-66 ml) in group NS.

CONCLUSIONS

Ultrasound guidance provided a 42% reduction in the MEAV of ropivacaine 0.5% required to block the femoral nerve as compared with the nerve stimulation guidance.

A recovery room-based acute pain service

AIM

Despite routine postoperative pain management improves recovery and reduces postoperative morbidity and overall costs, and the availability of a large armamentarium of analgesic techniques and drugs, a significant portion of patients do not receive adequate postoperative pain control. We describe a recovery room (RR) based acute pain service model.

METHODS

Guidelines on postoperative pain and therapeutic protocols were instituted in January 1999. The analgesic endpoint was a visual analogic scale (VAS) below 4 for all surgical patients for the first 48-72 h. The RR, run by one anesthesiologist and 2 nurses and one assistant, acted as a coordination centre. Discharge from the RR was subject to achieving effective analgesia. Nurses of each ward monitored VAS along with vital signs, administered rescue doses if necessary, and reported to the RR nurse when needed. RR nurses monitored the patient at least twice daily and reported to the anesthesiologist. We have distributed an anonymous questionnaire, within surgical wards, to both surgeons and nurses to evaluate their perception of pain management and of this acute pain service (APS) model.

RESULTS

VAS was maintained significantly <4. Analgesic drug consumption increased between 1997, 2000 (first year of APS) and 2004. The auditing process confirmed the desire of all professional figures to be informed and involved in acute pain management as part of a coordinated and systematic approach to the surgical patient.

CONCLUSION

A RR-based APS can effectively act as coordinating centre for acute pain treatment without adjunctive personnel.

Pain relief and motor function during continuous interscalene analgesia after open shoulder surgery: a prospective, randomized, double-blind comparison between levobupivacaine 0.25%, and ropivacaine 0.25% or 0.4%

BACKGROUND AND OBJECTIVES

To compare pain relief and motor impairment of 0.25% levobupivacaine with either an equivalent (0.25%) or equipotent (0.4%) concentration of ropivacaine for continuous interscalene block after open shoulder surgery.

METHODS

Seventy-two adult patients scheduled for elective major shoulder surgery received an interscalene injection of mepivacaine 1.5% 30 mL followed by 24 h patient-controlled interscalene analgesia (basal infusion rate: 5 mL h-1; incremental bolus: 2 mL; lockout period: 10 min; maximum boluses per hour: 4) with either 0.25% levobupivacaine (n = 24), 0.25% ropivacaine (n = 24) or 0.4% ropivacaine (n = 24). A blinded observer recorded the evolution of pain relief and recovery of motor block during the first 24 h. Motor function was assessed as the maximum pressure developed while squeezing a sphygmomanometer cuff with the blocked hand. The reduction from preoperative values was considered as an index of motor impairment.

RESULTS

No differences were reported among the three groups in the quality of postoperative analgesia. The number of incremental patient-controlled interscalene analgesia doses, total volume of local anaesthetic infused during the 24-h patient-controlled interscalene analgesia, and number of rescue ketoprofen analgesia were higher in the ropivacaine 0.25% group than in the other two groups (P = 0.0005). The hand strength recovered to >or=90% of baseline values within the first 24 h of infusion in all groups, without differences among the three groups.

CONCLUSION

When providing patient-controlled interscalene analgesia after open shoulder surgery 0.25% levobupivacaine and 0.4% ropivacaine performed equally in terms of pain relief, motor block and number of patient-controlled boluses required, while patients receiving 0.25% ropivacaine needed significantly more boluses and rescue analgesia to control their pain.

Does clonidine 50 μg improve cervical plexus block obtained with ropivacaine 150 mg for carotid endarterectomy? A randomized, double-blinded study

STUDY OBJECTIVE

To evaluate the effects of adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block in patients undergoing elective carotid endarterectomy (TEA).

DESIGN

Randomized, double-blind study.

SETTING

Departments of Anesthesia and Vascular Surgery of a university hospital.

PATIENTS

40 ASA physical status II and III patients undergoing elective TEA during superficial cervical plexus block.

INTERVENTIONS

Superficial cervical plexus block was placed using 20 mL of 0.75% ropivacaine alone (Ropi group, n = 20) or with the addition of 50 microg clonidine (Ropi-Clonidine group, n = 20). If required, analgesic supplementation was given with local infiltration with 1% lidocaine and intravenous fentanyl (50-microg boluses). Nerve block profile, need for intraoperative analgesic supplementation, and time to first analgesic request were recorded.

MEASUREMENTS AND MAIN RESULTS

Median (range) onset time was 10 minutes (5-25 min) in the Ropi group and 5 minutes (5-20 min) in the Ropi-Clonidine group (P < 0.05). Intraoperative consumption of both 1% lidocaine and fentanyl was higher in patients of the Ropi group (15 mL [0-25 mL] and 250 microg [50-300 microg]) than in patients of the Ropi-Clonidine group (8 mL [0-20 mL] and 0 microg [0-150 microg]; P < 0.05 and P < 0.05, respectively). First postoperative analgesic request occurred after 17 hours (10-24 hrs) in the Ropi group and 20 hours (10-24 hrs) in the Ropi-Clonidine group (P > 0.05).

CONCLUSIONS

Adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block shortened the onset time and improved the quality of surgical anesthesia in patients undergoing elective TEA.

Stimulating or conventional perineural catheters after hallux valgus repair: a double-blind, pharmaco-economic evaluation

BACKGROUND

We prospectively evaluated direct analgesia-related costs of continuous sciatic nerve block using either a stimulating or conventional catheter after hallux valgus repair.

METHODS

The perineural catheter was inserted through a stimulating introducer either blindly (group Conventional, n= 38) or while stimulating via the catheter (group Stimulating, n= 38). Nerve block was induced with 25 ml of mepivacaine 15 mg/ml, and was followed 3 h later by a patient-controlled infusion of ropivacaine 2 mg/ml (basal infusion: 3 ml/h; incremental dose: 5 ml; lock-out time: 30 min). Rescue tramadol [100 mg intravenous (i.v.)] was given if required. Local anesthetic consumption, need for rescue tramadol and post-operative nausea and vomiting (PONV) treatment, and patient's satisfaction were recorded during first 24-h infusion. Cost calculations were based on the acquisition cost of drugs and devices.

RESULTS

Both techniques were similarly effective, but local anesthetic consumption and need for rescue analgesics were lower in the Stimulating group [respectively, 120 vs. 153 ml (P= 0.004) and 21% vs. 60% (P= 0.001)]. The analgesia-related costs for 24 h were similar when 100-ml bags of ropivacaine 2 mg/ml were used (66 euro vs. 67 euro; P= 0.26). When 200-ml bags of ropivacaine were used, the analgesia-related costs were higher in the Stimulating group than the Conventional group (75 euro vs. 55 euro; P= 0.0005).

CONCLUSIONS

Direct costs of continuous sciatic nerve block ranged from 55 to 75 euro. Stimulating catheters reduced local anesthetic consumption and need for rescue analgesics. This was only cost effective when 100-ml bags of 2 mg/ml ropivacaine were used, while the cheapest combination was the use of conventional catheters and 200-ml bags of ropivacaine.

Posterior subgluteal approach to block the sciatic nerve: description of the technique and initial clinical experiences

BACKGROUND AND OBJECTIVE

A new posterior approach to the sciatic nerve in the subgluteal region was developed. We describe our clinical experiences on 135 consecutive patients.

METHODS

All blocks were performed with a nerve stimulator (stimulation frequency 2 Hz; intensity from 1 reduced to < or = 0.5 mA before application). A line was drawn from the greater trochanter to the ischial tuberosity of the femur; then, from the mid-point of this line, a second line was drawn perpendicularly and extended caudally for 4 cm: the end of this line represented the entry point of the needle. Sciatic stimulation was elicited at < or = 0.5 mA; then ropivacaine 0.75% 20 mL was injected. An independent observer recorded the time from needle insertion to successful sciatic nerve stimulation (performance time), the depth of appropriate sciatic stimulation and the number of needle redirections, as well as the quality of nerve block, the discomfort during the procedure and patient acceptance.

RESULTS

The performance time was 41 +/- 25 s (mean +/- SD) and the mean (SD) depth at which the sciatic nerve stimulation was found was 45 +/- 10 mm. The median (range) number of needle redirections required to find the proper sciatic stimulation was 2 (1-5). The tibial response was observed in 77 patients (57%), while the common peroneal response was observed in 58 patients (43%). The degree of discomfort reported was very low and only 16 patients (12%) reported severe pain during placement of the block. The onset time (mean +/- SD) of sensory and motor block was 7 +/- 4 and 17 +/- 13 min respectively, and the surgical procedure was completed with only the peripheral nerve block in 127 patients (94%). The same anaesthesia procedure was acceptable by 127 patients (94%) and only eight patients (6%) would prefer a different anaesthesia technique in the future.

CONCLUSIONS

The study demonstrated that the sciatic nerve can be easily blocked using this new posterior subgluteal approach, suggesting that it represents a safe and effective alternative to block the sciatic nerve at a proximal level, with the potential for reducing the discomfort experienced by the patient during block placement.

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study

BACKGROUND AND OBJECTIVES

The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery.

METHODS

rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h.

RESULTS

Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005).

CONCLUSIONS

In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.

A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery

BACKGROUND

The aim of this prospective, randomized, blinded study was to compare analgesic efficacy of continuous paravertebral and epidural analgesia for post-thoracotomy pain.

METHODS

Forty-two ASA physical status II-III patients undergoing lung resection surgery were randomly allocated to receive post-thoracotomy analgesia with either a thoracic epidural (group EPI, n = 21) or paravertebral (group PVB, n = 21) infusion of 0.2% ropivacaine (infusion rate: 5-10 mL h-1). The degree of pain at rest and during coughing, haemodynamic variables and blood gas analysis were recorded every 12 h for the first 48 h.

RESULTS

The area under the curve of the visual analogue pain score during coughing over time was 192 (60-444) cm h-1 in group EPI and 228 (72-456) cm h-1 in group PVB (P = 0.29). Rescue morphine analgesia was required in four patients of group EPI (19%) and five patients of group PVB (23%) (P = 0.99). The PaO2/FiO2 ratio reduced significantly from baseline values in both groups without between-group differences. The median (range) percentage reduction of systolic arterial pressure from baseline was -9 (0 to -9)% in group PVB and -17 (0 to -38)% in group EPI (P = 0.02); while clinically relevant hypotension (systolic arterial pressure decrease >30% of baseline) was observed in four patients of group EPI only (19%) (P = 0.04). Patient satisfaction with the analgesia technique was 8.5 (8-9.8) cm in group EPI and 9 (7.5-10) cm in group PVB (P = 0.65).

CONCLUSIONS

Continuous thoracic paravertebral analgesia is as effective as epidural blockade in controlling post-thoracotomy pain, but is associated with less haemodynamic effects.

New technology for noninvasive brain monitoring: continuous cerebral oximetry

Although the central nervous system is the primary endpoint of most general anesthetics, it is still the least monitored organ in clinical anesthesiology. In the last decade, technological research has expanded the application of near-infrared spectroscopy to allow continuous, non-invasive, and bedside monitoring of cerebral oxygen saturation (rSO(2)) through the scalp and skull, providing accurate information on the balance between brain oxygen supply and demand. The aim of this review is to provide an overview on relevant technological issues of cerebral oximetry, describe a systematic approach to its use, and summarize current information on its possible impact on our daily practice. We reviewed studies published on peer-reviewed journals about technological development and clinical application of rSO(2) monitoring in different fields of application to clinical practice. Due to the wide patient-to-patient variability of baseline rSO(2) values in each patient the baseline value should be determined before inducing general anesthesia, and cerebral ischemia is related more to the changes from baseline than to the absolute value: a reduction of 20% from baseline is usually accepted as clinical threshold of cerebral ischemia. If baseline rSO(2) is lower than 50% the critical threshold should be reduced to 15%. Routine use of rSO(2) monitoring in patients undergoing cardiac surgery to guide the anesthesia plan has been demonstrated to improve patient outcome and shorten hospital stay. However, rSO(2) monitoring does not seem to provide information accurate enough to indicate the placement of a Javid's shunt during carotid endarterectomy. In patients with neurological pathology or head trauma rSO(2) monitoring has been reported accurate enough in detecting early changes in cerebral blood flow that might result in cerebral ischemia. In aged patients undergoing major abdominal surgery rSO(2) monitoring to guide the anesthesia plan has been reported to reduce the exposition to cerebral ischemia with less effects on cognitive decline and shorter hospital stay. In conclusion several clinical conditions routinely encountered in our daily practice have the potential to disrupt the balance between the brain oxygen supply and demand, exposing to the risk of intraoperative cerebral ischemia. These alterations in brain oxygen balance remain totally undiagnosed if we do not specifically monitor it; while the possibility of monitoring regional cerebral oxygen saturation through a simple and totally non-invasive device has the potential for optimizing our anesthesia plan to the real needs of our main targeted organ: the brain.

Fast-track anaesthesia for laparoscopic cholecystectomy: a prospective, randomized, multicentre, blind comparison of desflurane-remifentanil or sevoflurane-remifentanil

BACKGROUND AND OBJECTIVE

To evaluate the effects of sevoflurane and desflurane in combination with intravenous remifentanil on time for discharge from the postanaesthesia care unit and need for postanaesthesia care unit management after elective laparoscopic cholecystectomy.

METHODS

231 ASA Grade I-II patients, undergoing elective laparoscopic cholecystectomy in seven University teaching hospital, were randomly allocated to receive a desflurane-remifentanil (n = 105) or sevoflurane-remifentanil (n = 126) anaesthetic. A blinded observer recorded times for emergence and postanaesthesia care unit discharge (achievement of an Aldrete score > or =9), number of patients eligible for postanaesthesia care unit discharge when exiting the operating room and occurrence of adverse events.

RESULTS

Intraoperative cardiovascular stability was similar in the two groups. Emergence, response and extubation occurred earlier after desflurane (5.4 +/- 3 min, 5.5 +/- 3 min and 7.5 +/- 4 min) than sevoflurane (6.6 +/- 3.5 min, 7.2 +/- 4 min and 9.1 +/- 4.2 min) (P = 0.0005, 0.05 and 0.003, respectively). Postanaesthesia care unit bypass was possible in 44 desflurane-remifentanil patients (41%) and 55 sevoflurane- remifenatnil patients (43%) (P = 0.69), while postanaesthesia care unit discharge occurred after 46 min (25th-75th percentiles: 18-40 min) with desflurane and 64 min (25th-75th percentiles: 20-50 min) with sevoflurane (P = 0.04). Postoperative nausea and vomiting was observed in 40 desflurane-remifentanil patients (36%) and 53 sevoflurane-remifentanil patients (42%) (P = 0.42).

CONCLUSIONS

Both the desflurane-remifentanil and sevoflurane-remifentanil combinations provide a similarly adequate intraoperative cardiovascular stability. Emergence and postanaesthesia care unit discharge were faster with desflurane-remifentanil than sevoflurane-remifentanil, but this was not associated with a larger proportion of postanaesthesia care unit bypass, confirming that no clinically relevant differences are present between the two agents.

Opioid-related side-effects after intrathecal morphine: a prospective, randomized, double-blind dose-response study

BACKGROUND AND OBJECTIVE

The aim of this prospective, randomized, double-blind investigation was to assess the dose-effect characteristics of postoperative nausea and vomiting after intrathecal administration of small doses of morphine (from 0.015 to 0.25 mg) in opioid-naïve, non-surgical patients.

METHODS

With Ethic Committee approval and written informed consent 144 opioid-naïve patients suffering from non-cancerous chronic back-pain, and receiving intrathecal morphine as diagnostic test for their chronic pain, were randomly allocated to receive intrathecal injection of 0.015 mg (Group I, n=25), 0.03 mg (Group II, n=30), 0.06 mg (Group III, n=31) or 0.25 mg (Group IV, n=33) morphine. The control group consisted in 25 further patients not included in the dose-effect study and receiving a placebo injection of normal saline in the interspinous ligament. A blinded observer recorded the occurrence of pruritus, nausea, vomiting, urinary retention and respiratory depression (respiratory rate<6 bpm) at 2, 4 and 24 h after injection.

RESULTS

Clinically significant pain relief was observed in all patients receiving intrathecal morphine but only six patients (25%) of the control group (P=0.0005). The incidence of pruritus was lower in patients of Groups III (6%) and IV (3%) than in Groups I (12%) and II (20%) (P=0.002). The incidence of nausea and vomiting was higher at 2- and 4-h observation times, and decreased 24 h after intrathecal injection. Surprisingly, nausea was more frequent in Groups I (56%) and II (50%) than in Groups III (33%) and IV (24%) (P=0.0005). Vomiting was higher in patients receiving morphine than in control group, but without differences among the four doses. No urinary retention was observed in the control group, while 2 h after intrathecal injection urinary retention was observed in 20-40% of cases, and decreased to less than 10% 24 h after spinal injection without differences among the four doses.

CONCLUSIONS

The onset and incidence of minor opioid-related side-effects after intrathecal morphine administration do not depend on its dose, occurring with even very small doses of morphine. Accordingly, they can be considered as a patient-dependent effect of the drug, suggesting the presence of a primary dose-independent excitatory component that might be related to the theory of the bimodal activation of opioid receptors. The very low incidence major respiratory depression prevents us from drawing any conclusion about the dose-effect relationship for this side-effect, and further properly powered studies should be advocated to evaluate major respiratory depression after spinal morphine.

Analysis of circulating gammadelta T cells in children affected by IgE-associated and non-IgE-associated allergic atopic eczema/dermatitis syndrome

Recent studies have suggested that not only alphabeta(+) T cells, but also the less common gammadelta(+) T cells may play a role as effectors and immunoregolatory cells in the development and perpetuation of allergic inflammation. The objective of this study was to focus on the role of gammadelta(+) T cells in atopic dermatitis (AD), a chronic relapsing inflammatory disease of the skin, often associated with allergic bronchial asthma. The present study employed flow cytometric analysis to compare numbers and phenotypic characteristics of gammadelta(+) T cells in the peripheral blood of children with atopic dermatitis and age-matched healthy controls. The percentage of circulating Vgamma 9Vdelta2(+) T lymphocytes was significantly increased in AD patients with respect to the age-matched controls, with a positive correlation with clinical score severity. The prevalent phenotype in both AD patients and controls was CD45RO(+), with no differences observed in the percentage of Vdelta2(+) CD45RO(+) between these groups. Conversely, memory CD45RO(+) CD62L(+) Vdelta2(+) lymphocytes were significantly lower in AD patients. Furthermore, naive circulating Vdelta2(+) T lymphocytes were significantly lower in AD children than in aged-matched controls. No correlation was observed between circulating Vgamma 9Vdelta2(+) expansion and IgE serum levels. It was concluded that an association exists between the levels of circulating gammadelta(+) T lymphocytes and atopic dermatitis, with a positive correlation with clinical score but no link with IgE serum levels. The pathophysiological role of gammadelta T lymphocytes in atopic dermatitis awaits further investigation.

The effect of adding nitrous oxide on MAC of sevoflurane combined with two target-controlled concentrations of remifentanil in women

BACKGROUND AND OBJECTIVE

The aim of this prospective, randomized, double-blind study was to determine the effects of adding nitrous oxide on sevoflurane requirement for blunting sympathetic responses after surgical incision combined with two different target-controlled concentrations of remifentanil (1 and 3 ng mL(-1)) in female.

METHODS

102 female patients, aged 20-50 yr, ASA I, undergoing general anaesthesia for elective abdominal surgery were enrolled and randomly allocated to receive sevoflurane anaesthesia alone (Group A, n=53), or with the addition of 60% nitrous oxide (Group N, n=49). Patients of both groups were further assigned to receive a target-controlled remifentanil infusion with an effect-site concentration of either 1 ng mL(-1) (Group N1, n=27; Group A1, n=30), or 3 ng mL(-1) (Group N3, n=22; Group A3, n=23). Sympathetic responses to surgical incision were determined after a 20-min period of stable end-tidal sevoflurane and target-controlled remifentanil concentrations. Predetermined end-tidal sevoflurane concentrations and minimum alveolar concentration (MAC) for each group were determined using an up-and-down sequential allocation technique.

RESULTS

The MAC of sevoflurane was 3.96% (95% confidence interval, CI95: 3.69-4.23%) in Group A1 and 1.2% (CI95: 0.9-1.3%) in Group N1 (P < 0.01), while in Groups A3 and N3 the MAC of sevoflurane was 0.36% (CI95: 0.24-0.47%) and 0.18% (CI95: 0.1-0.3%), respectively (P < 0.05).

CONCLUSION

Adding 60% nitrous oxide reduces the MAC of sevoflurane by 70% when using a remifentanil concentration of 1 ng mL(-1) and 50% when using a remifentanil concentration of 3 ng mL(-1).

Sciatic nerve block with 0.5% levobupivacaine, 0.75% levobupivacaine or 0.75% ropivacaine

BACKGROUND AND OBJECTIVE

This prospective, randomized, double-blind study was conducted to evaluate the onset time and duration of sciatic nerve block produced with 0.5% levobupivacaine, 0.75% levobupivacaine and 0.75% ropivacaine.

METHODS

Forty-five healthy patients undergoing hallux valgus repair were randomly allocated to receive sciatic nerve block with levobupivacaine 0.5% (n=15), levobupivacaine 0.75% (n=15) or ropivacaine 0.75% 20 mL (n=15). A femoral nerve block was also performed with mepivacaine 2% 15 mL to cover pain related to the thigh tourniquet. A blinded observer recorded the onset time and duration of sciatic nerve block.

RESULTS

The median (range) onset time was 5 (5-40) min with 0.75% levobupivacaine, 30 (5-60) min with 0.5% levobupivacaine and 20 (5-50) min with 0.75% ropivacaine (P = 0.02 and P = 0.12, respectively). Mean (25-75 percentiles) first request for pain medication occurred after 13 (11-14) h with 0.75% ropivacaine, 18 (15-19) h with 0.75% levobupivacaine and 16 (13-20) h with 0.5% levobupivacaine (P = 0.002 and P = 0.002, respectively). Rescue tramadol after surgery was required by three patients in the 0.75% levobupivacaine group, eight patients in the 0.5% levobupivacaine group and nine patients in the 0.75% ropivacaine group (P = 0.05).

CONCLUSIONS

We conclude that 0.75% levobupivacaine provides a shorter onset time than 0.5% levobupivacaine and a longer duration of postoperative analgesia than both 0.5% levobupivacaine and 0.75% ropivacaine with reduced need for rescue analgesia after surgery.

Epidural block does not worsen oxygenation during one-lung ventilation for lung resections under isoflurane/nitrous oxide anaesthesia

BACKGROUND AND OBJECTIVES

The aim of this prospective, randomized, controlled clinical study was to evaluate the effects of thoracic epidural anaesthesia combined with isoflurane/nitrous oxide anaesthesia on intraoperative oxygenation during one-lung ventilation for lung resections.

METHODS

Forty patients were randomly allocated to receive general anaesthesia maintained with isoflurane/nitrous oxide (group General, n = 20) or the same anaesthetic combined with thoracic epidural anaesthesia (group Integrated, n = 20). All patients were mechanically ventilated with the same settings (FiO2 = 0.5; VT = 9 mL kg(-1); inspiratory: expiratory time = 1:1; inspiratory pause = 10%). Effects on oxygenation were evaluated by determining the changes in PaO2/FiO2 ratio at 10, 30, 45 and 60 min of one-lung ventilation as compared to values obtained after induction of anaesthesia (supine, two-lung ventilation).

RESULTS

The PaO2/FiO2 ratio was decreased in both groups during one-lung ventilation until the end of surgery. No differences were found at any observation time between the groups. Ventilation with 100% oxygen because of SpO2 decrease <92% was required in nine patients of group General (45%) and in eight patients of group Integrated (40%) (P = 0.64). Manual re-inflation of the operated lung was required in one patient of group General only (P = 0.99). Heart rate was lower in group Integrated than in group General throughout the study. No differences between the two groups in mean arterial pressure were observed.

CONCLUSIONS

Adding a thoracic epidural block to isoflurane/nitrous oxide anaesthesia during one-lung ventilation for lung resections does not result in clinically relevant detrimental effects on intraoperative oxygenation.

0.2% ropivacaine with or without sufentanil for patient-controlled epidural analgesia after anterior cruciate ligament repair

AIM

The aim of this prospective, randomized, double-blind study was to evaluate the effects of adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia (PCEA) on the quality of postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction.

METHODS

Twenty ASA physical status I-II patients, scheduled to have elective ACL repair were studied. Combined spinal-epidural anesthesia was performed at the L3-L4 or L4-L5 interspace using a needle-through-needle technique. Spinal anesthesia was induced with 10 mg of 0.5% hyperbaric bupivacaine. Postoperative epidural analgesia was started at the end of surgery using a continuous epidural infusion of 0.2% ropivacaine alone (n=10) or 0.2% ropivacaine/0.5 mg mL(-1) sufentanil (n=10). The degree of pain was evaluated at 1, 8, 16, 24 and 48 hours after surgery; at the same observation times the degree of motor block, sedation, oxygen saturation, total consumption of PCEA solution and incremental doses given to the patient were also recorded.

RESULTS

No differences in the quality of intraoperative anesthesia was observed, and in no case general anesthesia was required to complete surgery. Patients receiving the combination of ropivacaine and sufentanil showed lower levels of VAS from 16 hours after surgery as compared with ropivacaine group (P=0.02). However, no differences in the degree of pain were observed between the 2 groups during continuous passive mobilization.

CONCLUSION

Adding 0.5 microg/ml sufentanil to 0.2% ropivacaine for patient controlled epidural analgesia improved pain control at rest but did not result in significant improvement of postoperative analgesia during continuous passive mobilization.

Prilocaine or mepivacaine for combined sciatic-femoral nerve block in patients receiving elective knee arthroscopy

AIM

The aim of this study was to evaluate the onset time of surgical block, recovery of motor function and duration of post-operative analgesia of combined sciatic-femoral nerve block performed with either mepivacaine or prilocaine.

METHODS

With Ethical Committee approval and written informed consent, 30 ASA physical status I-II patients, undergoing elective arthroscopic knee surgery, received a combined sciatic-femoral nerve block with 30 ml of either 2% mepivacaine (n=15) or 1% prilocaine (n=15). An independent observer recorded the onset time of sensory and motor blocks, the need for intraoperative analgesia supplementation, recovery of motor function, and first request of post-operative pain medication.

RESULTS

Onset time of nerve block required 15+/-5 min with prilocaine and 12+/-7 min with mepivacaine (p=0.33). No patient required general anesthesia to complete surgery; 3 patients receiving prilocaine (20%) and 2 patients receiving mepivacaine (13%) required 0.1 mg fentanyl intravenously to complete surgery (p=0.99). Recovery of motor function and first request of post-operative pain medication occurred after 238+/-36 min and 259+/-31 min with prilocaine, and 220+/-48 min and 248+/-47 min with mepivacaine (p=0.257 and p=0.43, respectively). Patient satisfaction was good in all studied patients.

CONCLUSION

Prilocaine 1% provides adequate sensory and motor block for arthroscopic knee surgery, with a clinical profile similar to that produced by 2% mepivacaine, and may be a good option for surgical procedures of intermediate duration and not associated with severe postoperative pain.

A prospective, randomized, blind comparison between saline, calcium gluconate and diphoterine for washing skin acid injuries in rats: effects on substance P and beta-endorphin release

BACKGROUND AND OBJECTIVE

A randomized, blind study to evaluate the effects on beta-endorphin and substance P release after washing acid burns with 0.9% saline, calcium gluconate or diphoterine in a model of chemical burn in rats.

METHODS

Twenty Sprague-Dawley rats (approximate weight 250 g) were anaesthetized with ketamine (30 mg kg(-1) intramuscularly) and then given an acid injury on the back skin with 0.5 mL of hydrochloric acid 52%. The rats were then randomly allocated to receive no washing (control group, n = 5), washing with normal saline (0.9% NaCl) (n = 5), 10% calcium gluconate (n = 5) or diphoterine (n = 5). Blood concentrations of substance P and beta-endorphin were measured 6 h, 48 h and 7 days after the chemical burn. An independent blinded observer evaluated wound healing at the 7th day.

RESULTS

Seven days after burn wound healing was almost complete only in rats treated with diphoterine. Plasma concentrations of substance P were lower in rats receiving skin flushing with diphoterine compared to the other groups at 6 and 48 h after acid burn (P < 0.05 and P < 0.05, respectively); this was also associated with higher concentrations of beta-endorphin at day 7 (P < 0.05).

CONCLUSIONS

Skin flushing with diphoterine reduced substance P release during the first 48 h after burn, and was associated with better wound healing and higher concentrations of beta-endorphin 7 days later when compared with normal saline or 10% calcium gluconate.

Total intravenous anesthesia, spinal anesthesia or combined sciatic-femoral nerve block for outpatient knee arthroscopy

AIM

The aim of this study was to compare efficacy, efficiency and surgeon's satisfaction of total intravenous anesthesia with propofol and remifentanil with those of spinal or peripheral nerve blocks for outpatient knee arthroscopy.

METHODS

One hundred and twenty patients undergoing elective outpatient knee arthroscopy were randomly allocated to receive total intravenous anesthesia with propofol and remifentanil (40), combined sciatic-femoral nerve block (40), or spinal anesthesia (40). Preparation times, surgeon's satisfaction, and discharge times with the 3 anesthesia techniques were measured. Anesthesia-related costs were also compared based on costs of drugs, disposable materials, and anesthesia and nurse staff.

RESULTS

Preparation time was 13 min (8-22 min) with general anesthesia, 15 min (5-30 min) with spinal anesthesia and 15 min (5-25 min) with sciatic-femoral blocks (p=0.006). Surgeon's satisfaction was similar in the 3 groups, but 17 patients receiving peripheral nerve block (42%) and 12 receiving spinal anesthesia (30%) by-passed the postanesthesia care unit after surgery as compared with only 2 general anesthesia patients (5%) (p=0.01). Discharge from the postanesthesia care unit required 5 min (5-20 min) after peripheral block as compared with 15 min (5-25 min) with spinal and 15 min (5-80 min) with general anesthesia (p=0.005); however, stay in the Day-Surgery Unit was shorter after general anesthesia [170 (100-400) min] than peripheral [265 (110-485) min] or spinal blocks [230 (95-800) min] (p=0.026). Urinary retention was reported in 3 spinal patients only (8%) (p=0.03).

CONCLUSION

Regional anesthesia techniques reduce the rate of admission and the duration of stay in the postanesthesia care unit as compared with general anesthesia. Peripheral rather than spinal nerve blocks should be preferred to minimise the risk for urinary retention.

A multicenter survey on anaesthesia practice in Italy

AIM

To achieve more information on anaesthesia practice in Italy.

METHODS

One questionnaire was completed for every anaesthetic procedure performed during the last week of June 1999 in 162 public hospitals selected in the northern, central and southern parts of Italy.

RESULTS

A total of 12 263 anaesthetic procedures were performed during the study week in participating hospitals, extrapolating to 4 905200 anaesthetic procedures performed in Italy in 1999 (95% confidence interval, (+/-245000), with an annual rate of 8.5 anaesthetic procedures per 100 population. Children represented 12%, adults 60%, and elderly patients 28% of all studied patients. Emergency procedures were performed in 14% of cases; only 14% of cases were outpatients, but 31% of patients were discharged within 48 h after surgery. General anaesthesia was used in 65% of cases (45% volatile and 20% intravenous anaesthesia), regional anaesthesia in 24%, local anaesthesia in 8.8% and monitored anaesthesia care in 2.2%. No differences in the distribution of anaesthesia techniques were observed according to the geographic region or hospital size.

CONCLUSION

Some organizational problems still remain to be implemented, including the development of proper preoperative evaluation clinics and postanaesthesia care units, especially in bigger hospitals with more than 1 000 beds.

A prospective, randomized, double-blind comparison of epidural levobupivacaine 0.5% with epidural ropivacaine 0.75% for lower limb procedures

BACKGROUND AND OBJECTIVE

This prospective, randomized, observer-blinded study compared onset time and duration of epidural anaesthesia produced by with levobupivacaine and ropivacaine for lower limb surgery.

METHODS

ASA I-III adult patients undergoing elective lower limb procedures were randomized to receive epidural levobupivacaine 0.5% 15 mL (n = 30) or epidural ropivacaine 0.75% 15 mL (n = 35). A blinded observer evaluated onset time and regression of motor and sensory block, and intraoperative needs for fentanyl supplementation (0.1 mg intravenously).

RESULTS

With levobupivacaine, onset time was 29 +/- 24 min, with ropivacaine it was 25 +/- 22 min (P = 0.41). Complete resolution of motor block required 105 +/- 63 min with levobupivacaine and 95 +/- 48 min with ropivacaine (P = 0.86). The time for regression of sensory block to T12 was 185 +/- 77 min with levobupivacaine and 201 +/- 75 min with ropivacaine (P = 0.46). Analgesic supplementation was required in one patient receiving levobupivacaine (3.5%) and in two patients receiving ropivacaine (5.7%) (P = 0.99).

CONCLUSIONS

In adults undergoing lower limb surgery, levobupivacaine 0.5% 15 mL produces an epidural block with the same clinical profile as ropivacaine 0.75% 15 mL.

Prospective, randomized, controlled evaluation of the preventive effects of positive end-expiratory pressure on patient oxygenation during one-lung ventilation

BACKGROUND AND OBJECTIVE

This prospective, randomized, controlled study evaluated the effects on oxygenation by applying a selective and patient-specific value of positive end-expiratory pressure (PEEP) to the dependent lung during one-lung ventilation.

METHODS

Fifty patients undergoing thoracic surgery under combined epidural/general anaesthesia were randomly allocated to receive zero PEEP (Group ZEEP, n = 22), or the preventive application of PEEP, optimized on the best thoracopulmonary compliance (Group PEEP, n = 28). Patients' lungs were mechanically ventilated with the same setting during two- and one-lung ventilation (FiO2 = 0.5; VT = 9mL kg(-1), inspiratory :expiratory time = 1 : 1, inspiratory pause = 10%).

RESULTS

Lung-chest wall compliance decreased in both groups during one-lung ventilation, but patients of Group PEEP had 10% higher values than patients with no end-expiratory pressure (ZEEP) applied--Group ZEEP (P < 0.05). During closed chest one-lung ventilation, the PaO2 : FiO2 ratio was lower in Group PEEP (232 +/- 88) than in Group ZEEP (339 +/- 97) (P < 0.05); but no further differences were reported throughout the study. No differences were reported between the two groups in the need for 100% oxygen ventilation (10 patients of Group ZEEP (45%) and 14 patients of Group PEEP (50%) (P = 0.78)) or re-inflation of the operated lung during surgery (two patients of Group ZEEP (9%) and three patients of Group PEEP (10%) (P = 0.78)). Postanaesthesia care unit discharge required 48 min (25th-75th percentiles: 32-58 min) in Group PEEP and 45 min (30-57 min) in Group ZEEP (P = 0.60).

CONCLUSIONS

The selective application of PEEP to the dependent, non-operated lung increases the lung-chest wall compliance during one-lung ventilation, but does not improve patient oxygenation.

Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery

BACKGROUND AND OBJECTIVE

This prospective, randomized study was conducted to compare unilateral spinal block using small doses of hyperbaric bupivacaine and single-agent anaesthesia with sevoflurane in elderly patients undergoing hip surgery.

METHODS

Thirty patients (> 65 yr) undergoing hip fracture repair were randomly allocated to receive unilateral spinal anaesthesia with hyperbaric bupivacaine 7.5 mg 0.5% (Group Spinal, n = 15) or volatile induction and maintenance anaesthesia with sevoflurane (Group SEVO, n = 15). General anaesthesia was induced by increasing the inspired concentration to 5%. A laryngeal mask airway was placed without muscle relaxants, and the end-tidal concentrations of sevoflurane were adjusted to maintain cardiovascular stability. Hypotension (decrease in systolic arterial pressure > 20% from baseline), hypertension or bradycardia (heart rate < 50 beats min(-1)) requiring treatment, and the length of stay in the postanaesthesia care unit was recorded. Cognitive functions were evaluated the previous day, and 1 and 7 days after surgery with the Mini Mental State Examination test.

RESULTS

Hypotension occurred in seven patients of Group Spinal (46%) and in 12 patients of Group SEVO (80%) (P = 0.05). Phenylephrine was required to control hypotension in three spinal patients (21%) and four SEVO patients (26%) (n.s.). SEVO patients had lower heart rates than spinal patients from 15 to 60 min after anaesthesia induction (P = 0.01). Bradycardia was observed in three SEVO patients (22%). Discharge from the postanaesthesia care unit required 15 (range 5-30) min in Group Spinal and 55 (15-80) min in Group SEVO (P = 0.0005). Eight patients in Group Spinal (53%) and nine patients in Group SEVO (60%) showed cognitive decline (Mini Mental State Examination test decreased > or = 2 points from baseline) 24 h after surgery (n.s.). Seven days after surgery, confusion was still present in one patient of Group Spinal (6%) and in three patients of Group SEVO (20%) (n.s.).

CONCLUSIONS

In elderly patients undergoing hemiarthroplasty of the hip, induction and maintenance with sevoflurane provide a rapid emergence from anaesthesia without more depression of postoperative cognitive function compared with unilateral spinal anaesthesia. This technique represents an attractive option when patient refusal, lack of adequate co-operation or concomitant anticoagulant therapy contraindicate the use of spinal anaesthesia.

A prospective, observational evaluation of a new supraglottic airway: the PAXpress

AIM

Little information is available on efficacy and safety of the new supraglottic device, PA(Xpress), in anesthetized patients. The aim of this prospective observational study was to evaluate the use of this new supraglottic device in clinical practice.

METHODS

Ninety-one patients (mean age: 45+/-11 years) undergoing extremity or minor peri-phery procedures (mean duration 53+/-18 min), with a supraglottic airway were prospectively studied in 10 hospitals, using a simple questionnaire with data concerning anthropometric variables, surgical procedure, and occurrence of untoward events during PA(Xpress) placement, anesthesia maintenance, or postoperative period.

RESULTS

First attempt placement was achieved in 74 patients (82.2%), while 9 patients (10%) required 2 attempts, and 7 patients (7.7%) required more than 2 attempts. In only 2 patients (2%) airway control was not achieved with the studied device. The mean time required to achieve successful placement was 49+/-18 s (range 4-300 s). Mechanical ventilation was effectively maintained in all studied patients, and no severe adverse events were reported during the procedure. Blood on the device was observed in 54% of cases, and this was associated with an incidence of sore throat of 26% in the recovery area and 13% after 6 hours from the end of surgery.

CONCLUSION

Although further comparative, randomized studies should be advocated to better evaluate the use of this new supraglottic device, this prospective, observational study demonstrated that PA(Xpress) provides safe and effective airway control during mechanical ventilation in up to 98% of cases.

Lidocaine versus ropivacaine for continuous interscalene brachial plexus block after open shoulder surgery

BACKGROUND

This study compared the postoperative infusion of 1% lidocaine and 0.2% ropivacaine for continuous interscalene analgesia in patients undergoing open shoulder surgery.

METHODS

Forty patients undergoing open shoulder surgery received an interscalene brachial plexus block with 30 ml of either 1.5% lidocaine (n = 20) or 0.5% ropivacaine (n = 20), followed by a continuous patient-controlled interscalene analgesia with 1% lidocaine or 0.2% ropivacaine, respectively. A blinded observer recorded the quality of analgesia and recovery of motor function during the first 24 h of infusion.

RESULTS

Onset of the block occurred after 7.5 (5-40) min with lidocaine and 30 (10-60) min with ropivacaine (P = 0.0005). Postoperative pain intensity was higher with lidocaine than ropivacaine for the first 8 h of infusion. The ratio between boluses given and demanded from the pump was 0.5 (0.13-0.7) with lidocaine and 0.7 (0.4-1.0) with ropivacaine (P = 0.005). Rescue IV tramadol was required during the first 24 h of infusion by 16 patients of the lidocaine group (84%) and eight patients of the ropivacaine group (46%) (P = 0.05). At the 16 h and 24 h observation times a larger proportion of patients receiving ropivacaine had complete regression of motor block (70% and 95%) than patients receiving lidocaine (50% and 55%) (P = 0.05 and P = 0.013, respectively).

CONCLUSIONS

Although 1% lidocaine can be effectively used for postoperative patient-controlled interscalene analgesia, 0.2% ropivacaine provides better pain relief and motor function.

Atopic dermatitis: molecular mechanisms, clinical aspects and new therapeutical approaches

Atopic dermatitis (AD) is a genetically determinated, chronic inflammatory skin disorder associated with cutaneous erythema and severe pruritus, affecting 10-15% of children with increasing incidence and socio-economical relevance. Frequently, AD is associated with development of allergic rhinitis and/or asthma later in childhood. In most of patients AD is associated with a sensitization to food and/or environmental allergens and increased serum-IgE, while only a fewer percentage missed links to the classical atopic diathesis. Currently investigated pathogenetic aspects of AD include imbalanced Th1/Th2 responses, altered prostaglandin metabolism, intrinsic defects in the keratinocyte function, delayed eosinophil apoptosis, and IgE-mediated facilitated antigen presentation by epidermal dendritic cells. An inflammatory response of the two-phase-type and the effects of staphylococcal superantigens (SAgs) are also reported. At present a standardized cure of AD and a consensus on therapeutical approach of the severe form of the disease have not been established. Current management of AD is directed to the reduction of cutaneous inflammation and infection, mainly by S. aureus, and to the elimination of exacerbating factors (irritants, allergens, emotional stresses). Since patient with AD show abnormalities in immunoregulation, therapy directed to adjustment of their immune function could represent an alternative approach, particularly in the severe form of the disease. In this review, we analyse the clinical and genetic aspects of AD, the related molecular mechanisms, and the immunobiology of the disease, focusing our attention on current treatments and future perspectives on this topic.

Radial artery pseudoaneurysm successfully treated by compression bandage

In children, surgery for radial artery pseudoaneurysm (PA) may be followed by growth retardation of the hand because of inadequate blood flow. We believe this is the first report of a child with PA of the radial artery cured by compression bandage. Conservative management is a safe and valuable initial treatment option for uncomplicated radial PA.

Spinal block or total intravenous anaesthesia with propofol and remifentanil for gynaecological outpatient procedures

BACKGROUND AND OBJECTIVE

The aim of this prospective, randomized study was to compare the preparation and discharge times, the side-effects and patient satisfaction after gynaecological outpatient procedures performed using either spinal block or total intravenous anaesthesia with propofol and remifentanil.

METHODS

With Ethics Committee approval and written informed consent, 40 healthy females scheduled for hysteroscopic ablation of endometrial neoplasm were randomly allocated to receive either a spinal block with bupivacaine 0.5% hyperbaric solution 10 mg (n = 20) or total intravenous anaesthesia with propofol and remifentanil (n = 20). Preparation and discharge times, as well as occurrence of untoward events and anaesthesia-related costs, were recorded.

RESULTS

The median (range) preparation time was 7 (7-10) min with general anaesthesia, and 11 (7-21) min with spinal block (P = 0.00005). No differences in discharge time from the postanaesthesia care unit and incidence of hypotension or bradycardia, or both, were reported between the two groups. Hospital discharge times were 156 (101-345) min after general anaesthesia and 296 (195-720) min after spinal anaesthesia (P = 0.0005). Acceptance of the anaesthesia technique was better after general (100%) than after spinal anaesthesia (75%) (P = 0.04). No differences in total costs were reported between spinal block ([symbol: see text] 155 ([symbol: see text] 117-[symbol: see text] 224)) and propofol-remifentanil general anaesthesia ([symbol: see text] 143 ([symbol: see text] 124-[symbol: see text] 203) (P = 0.125)).

CONCLUSIONS

Accurate titration of short-acting intravenous anaesthetic drugs such as propofol and remifentanil results in shorter preparation times and earlier home discharge after outpatient gynaecological procedures compared with spinal anaesthesia with hyperbaric bupivacaine 10 mg, with better patient acceptance and no increased costs.