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Background: Pain management after surgery is crucial to decrease perioperative morbidity and mortality. Acute pain services (APS) are multidisciplinary teams that represent a modern strategy to address pain inside hospitals. The APS defines and applies pain treatment protocols specific for each surgery. To evaluate the performance of the APS at our institute, we performed a large retrospective cohort study focusing on complications of epidural analgesia and IV opiates., Methods: Data from the 10 years of activity of the APS were collected. Pain was assessed using the VAS at rest (VASr) and during movement (VASm) at each daily visit; the presence of side effects and complications was also assessed., Results: A total of 17,913 adult patients were followed by APS during the study period. Epidural analgesia was used in 7,776 cases (43%), while 9,239 (52%) patients used IV patient-controlled analgesia (PCA). A combination of the 2 was used in 87 patients (0.5%). A total of 456 perineural catheters (2.6%) were placed, while 442 patients(2.5%) used other analgesic techniques. We recorded 163 dural punctures during catheter placement, with no epidural hematoma, epidural abscess, or meningitis, and no permanent modification in sensitive or motor functions., Conclusions: In our large case series, APS was confirmed safe and effective in treating postoperative pain, using both epidural analgesia and IV PCA with morphine., (© 2019 World Institute of Pain.)

Study Design: Prospective, randomized, single blind., Objective: To compare the effects of sevoflurane and propofol on lumbar-paraspinal-muscles regional blood flow, as well as bleeding when controlled hypotension is used., Summary of Background Data: Controlled hypotension is the technique of choice to reduce blood loss during spine surgery, but changes in blood flow occurring to lumbar paraspinal muscles during controlled hypotension with propofol and sevoflurane, as well as the entity of bleeding, are unknown., Methods: Blood flow was assessed by means of a laser Doppler flowmeter during the prehypotensive and hypotensive (defined as a 15% reduction of baseline mean arterial pressure) period in 28 patients (aged 28-73 years, American Society of Anesthesiologists (ASA) I-II) undergoing lumbar spine surgery. Patients were randomized to receive either sevoflurane or propofol as main anesthetic agent to achieve hypotension. At the end of the surgery, blood loss was calculated and intraoperative bleeding (Visual Analogue Scale ranging from 0 to 100) was evaluated by the surgeon. RESULTS.: Peripheral Blood flow was significantly greater in the propofol group both before and during the hypotensive period (median values of 32.7 FU vs. 7.7 and 38.5 FU vs. 10.5, respectively). Despite this fact, blood loss and intraoperative bleeding were significantly reduced when propofol had been used (P < 0.05)., Conclusion: Despite the greater blood flow when it is used, propofol causes less bleeding than sevoflurane during spine surgery and could be more indicated to produce hypotension during anesthesia. Moreover, it is possible to explain our findings hypothesizing a selective vasodilation of propofol (postcapillary, venous vasodilation), different from that of sevoflurane (precapillary, arteriolar vasodilation).

We have compared interscalene brachial plexus block performed with ropivacaine or mepivacaine in 60 healthy patients undergoing elective shoulder surgery. Patients were allocated randomly to receive interscalene brachial plexus anaesthesia with 20 ml of 0.5% ropivacaine (n = 15), 0.75% ropivacaine (n = 15), 1% ropivacaine (n = 15) or 2% mepivacaine (n = 15). Readiness for surgery (loss of pinprick sensation from C4 to C7 and inability to elevate the limb from the bed) was achieved sooner with 1% ropivacaine (mean 10 (SD 5) min) than with 0.5% ropivacaine (22 (7) min) (P < 0.001) or 2% mepivacaine (18 (9) min) (P < 0.02). Postoperative analgesia was similar with the three ropivacaine concentrations (11.5 (5) h, 10.7 (2) h and 10 (2.4) h with 0.5%, 0.75% and 1% concentrations, respectively) and nearly two-fold longer compared with 2% mepivacaine (5.1 (2.7) h) (P < 0.001).

Objective: To evaluate the changes in hemodynamic variables and intraocular pressure (IOP) after tracheal intubation using either lightwand or direct-vision laryngoscopy techniques., Design: Prospective, randomized study., Setting: Inpatient anesthesia at a University Anesthesia Department., Patients: 50 normotensive, ASA physical status I and II patients, without ocular or cardiovascular diseases, and with a Mallampati score no greater than 2., Interventions: After intravenous (i.v.) midazolam premedication (0.05 mg.kg-1), general anesthesia was induced with fentanyl (1 microgram.g-1) and thiopental sodium (5 mg.g-1) followed by vecuronium bromide (0.1 mg.g-1), then patients were randomly allocated to receive either the lightwand (Trachlight, n = 25) or direct-vision laryngoscopy (Laryngoscopy, n = 25) intubating techniques. General anesthesia was maintained with 1% isoflurane and 60% nitrous oxide in oxygen mixture for 5 minutes., Measurements and Main Results: Baseline hemodynamic variables were recorded 10 minutes after i.v. premedication, and then every minute after tracheal intubation. Intraocular pressure measurements were performed by means of a computerized indentation tonometer after general anesthesia induction and then 1 and 5 minutes after tracheal intubation. In both groups, mean arterial blood pressure and heart rate increased from baseline, without differences between the two groups. One minute after intubation, IOP increased in both groups: the mean percentage increase was 32% in the Laryngoscopy group and 16% in the Trachlight group. However, this difference was not statistically significant. Five minutes after intubation, IOP decreased to baseline values in both groups., Conclusion: We conclude that in healthy patients without ocular disease, using a lightwand intubating technique does not reduce the hemodynamic responses and increase in IOP associated with tracheal intubation as compared with conventional direct-vision laryngoscopy.

Background and Objectives: The purpose of this randomized, double-blind study was to evaluate if use of an asymmetric spinal block affects the incidence of hypotension during spinal anesthesia., Methods: With Ethical Committee approval and patient consent, 120 patients undergoing lower limb surgery were placed in the lateral position with the side to be operated on dependent, and received 8 mg 0.5% hyperbaric bupivacaine through a 25-gauge Whitacre spinal needle. Patients were randomized to one of two groups: (a) local anesthetic was injected with barbotage through a cranially directed needle orifice, then patients were immediately turned to supine (conventional, n = 60); (b) local anesthetic was injected without barbotage with the needle orifice turned toward the dependent side, then the lateral position was maintained for 15 minutes (unilateral, n = 60). A blind observer recorded noninvasive hemodynamic variables, as well as loss of cold and pinprick sensation and motor block on both sides., Results: In the unilateral group, 31 patients (52%) showed a unilateral loss of cold sensation and 48 patients (80%) had no motor block on the nondependent side for the duration of the study, whereas all conventional patients had bilateral distribution of spinal block (P < .0001). The onset time and two-segment regression of sensory block on the dependent side were more rapid in the conventional group (18 +/- 7 minutes and 60 +/- 18 minutes) than in the unilateral group (22 +/- 8 minutes and 67 +/- 19 minutes) (P < .05 and P < .05, respectively). The incidence of hypotension (SAP decrease >30% from baseline) was higher in the conventional (22.4%) than unilateral group (5%) (P < .01). The maximum percentage changes from baseline values of systolic arterial blood pressure and heart rate were greater in conventional group (-28% +/- 16% and -19% +/- 10%) than in unilateral group (-8% +/- 16% and -12% +/- 18%) (P < .0001 and P < .01, respectively)., Conclusions: Achieving an asymmetric distribution of spinal block by injecting a small dose of 0.5% hyperbaric bupivacaine through a Whitacre spinal needle into patients placed in the lateral position for 15 min reduces the incidence of hypotension during spinal anesthesia.

Purpose: To determine the plasma concentrations of propofol required to achieve different levels of sedation during monitored anesthesia care., Methods: Sixty ASA I-II, 18-65 yr-old patients, received a target-controlled continuous iv infusion of propofol. The target plasma concentration of propofol (Cpt) was initially set at 0.4 microg x ml(-1). Two minutes after calculated equilibrium between plasma and effect-site concentrations, the Cpt of propofol was increased by 0.2 microg x ml(-1) steps until the patient showed no reaction to squeezing the trapezius. The level of sedation was assessed immediately before each increase in propofol Cpt using the Observer's Assessment of Alertness/Sedation (OAA/S) scale., Results: The Cpt of propofol required to induce lethargic response to name was 1.3 microg x ml(-1) (5 degrees and 95 degrees percentiles: 1.0 - 1.8 microg x ml(-1)), to obtain response after loud and repeated calling name was 1.7 microg x ml(-1) (1.2 - 2.2 microg x ml(-1)), to obtain response after prodding or shaking was 2.0 microg x ml(-1) (1.6 - 2.6 microg x ml(-1)), to obtain response after squeezing the trapezius was 2.4 microg x ml(-1) (1.8 - 3.0 microg x ml(-1)). Patients showed no response after squeezing the trapezius at 2.8 microg x ml(-1) (2.0 - 3.6 microg x ml(-1)). Correlation between Cpt propofol and sedation scores were r = 0.76, P < 0.0001., Conclusions: Target-controlled infusion of propofol provided easy and safe management of intraoperative sedation, allowing fast and predictable deepening in the level of sedation, while minimizing systemic side effects of intravenous sedation due to the minimal risk of overdosing the drug.