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SIAARTI guidelines for safety in locoregional anaesthesia

Pain is still a major public health problem, with a high prevalence of both acute and chronic conditions. The inclusion of genomic (and other omics) technologies represents a new approach in pain research. However, new research and diagnostic tools in the field of health care always require a detailed study of ethical aspects and implications. In particular, pain research represents an area with many challenges when it comes to ethical aspects. Using placebo treatment, an agent biologically inert in respect to pain condition but potentially helpful for the patient, represents a classic paradigmatic type of ethical concerns in this area (1,2). Placebo treatment is based on the concept of deception. It undermines honest relationship and trust between doctor and patient, which is extremely important for a successful treatment (1). Still, application of placebo in terms of analgesia will cause a positive response in 35% of patients (3). It is important to highlight that response to placebo does not mean that the patient is faking the pain and, therefore, it would be unethical to withhold the specific treatment. Functional magnetic resonance imaging of the brain showed that placebo analgesia produces activation of relevant brain areas (4). On the other hand, intentionally giving placebo treatment for a condition that can be adequately treated would be against the right of patients to receive the best possible care. Another controversial subject are patients unable to “correctly” express pain or to give consent. In animal research, important improvements are made in order to avoid suffering and pain of the involved animals (5). But what happens when the main issue of research is pain? Animal research is intended to be limited to those studies where the animal model is the only possibility. A controversial editorial comment in Nature Neuroscience, with the provocative title “Italian biomedical research under fire,” pointed out the risks of excessive restrictions in animal research (6). Although there is an overall agreement to avoid “avoidable” pain, the question remains what is “avoidable.” A particular issue is fetal, neonatal, and infant pain. In 1985, the infant Jeffrey Lawson underwent open heart surgery awake and conscious throughout the entire procedure. The opinion of the anesthesiologist was that it had never been demonstrated that premature babies felt pain (7). In contrast, recently a study protocol including the use of placebo control to study neonatal pain in an intensive care unit has not been approved by the institutional review board (8). However, fetal surgeries continue to be performed with little (or no) regard about pain. Practical problems such as correct monitoring and physiological issues (immaturity of the central nervous system) can be difficult to address even in a standard approach. Pain research in cognitively impaired people is of particular interest because the prevalence of both conditions increases with age. There has been considerable evidence on inadequate assessment and treatment of pain in this vulnerable population. It seems that unfortunately research that supports best practices for assessing and treating pain in cognitively impaired patients is limited by methodological obstacles (9). In the current practice of clinical research, this population is excluded from studies. The development of new monitoring tools for animal and human pain could be an innovative path to resolve these problems. The desired result would be to maintain the minimum intensity of pain required to achieve the goals of the study and to hold this level of intensity during its entire course. Another important point in pain research is the lack of knowledge about pain treatment by the general population, and in particular by health care personnel (10). Physicians and nurses involved in pain treatment showed lack of preparation regarding pain (11) and patients had misconceptions about pain treatment. Famous examples are that the use of opioids always produces addiction and that “pain is part of the cure.” Some countries, like Italy, modified the law to include mandatory pain monitoring in the clinical records (12). At the moment, several medical associations are studying the inclusion of pain assessment and treatment skills in the resident study programs. Inclusion of genomic (and other omics) technologies in pain research represents a delicate topic and it raises several questions and concerns. Genomic (and other omics) technologies in the last two decades have produced not only a deep change in biomedical research, but also generated a change in the agenda of institutional review boards and research ethics. The potential to discover large amounts of possibly important incidental information during the genomic analysis has been identified as one of the greatest challenges to genomic medicine (13). Debates should be focused on the physicians’ obligations arising from this type of the research, protection of the included individuals, and communication of such research to patients and the community (14). Omics analyses in humans raise complex ethical issues, which often significantly impact the pace of research programs. By working collaboratively, researchers intend to answer questions never addressed before, but at the same time different team members may have varied ethical perceptions due to differences in disciplines as well as legal traditions and cultures. Furthermore, recent studies have demonstrated how “easy” it is to deduce individual identity from diverse public data sets (Genomes Project Consortium Nature 2012) (15). The authors were able to establish the identity of close to 50 of the Center for Study of Human Polymorphisms participants (both women and men). It is important to note that the authors did not reveal the names of the participants (or violated any known policies), but merely demonstrated their ability to identify them through the analysis of publicly available information. These findings alert us about how easy information is available in the era of information networks. Particular attention should be paid to preserve the privacy right in this new global village (16). In conclusion, innovative tools in pain research could introduce new answers to old questions. However, there are numerous ethical issues to consider. Ethical pain research should not only guarantee the right of patients to the correct treatment, but also it should assure the inclusion of excluded categories of patients (fetal, pediatric, and cognitively impaired patients) with particular solutions for specific queries. The use of innovative models and monitoring would be useful in this setting. Omics research adds an additional variable to the equation. It provides important benefits to research, but increases the vulnerability of those affected when patients’ privacy is concerned.

We prospectively tested the hypothesis that the use of a stimulating catheter improves the efficacy of continuous posterior popliteal sciatic nerve block in 100 randomized patients scheduled for elective orthopedic foot surgery. After eliciting a sciatic mediated muscular twitch ator = 0.5 mA nerve stimulation output, the perineural catheter was advanced 2-4 cm beyond the tip of the introducer either blindly (Group C; n = 50) or stimulating via the catheter (Group S; n = 50). A bolus dose of 25 mL of 1.5% mepivacaine was followed by a postoperative patient-controlled infusion of 0.2% ropivacaine (basal infusion: 3 mL/h; incremental dose: 5 mL; lockout time: 30 min). Propacetamol 2 g IV was administered every 8 h, and opioid rescue analgesia was available if required. Catheter placement required 7 +/- 2 min in Group S and 5 +/- 2 min in Group C (P = 0.056). A significantly shorter onset time of both sensory and motor blocks was noted in Group S. No difference in quality of pain relief at rest and during motion was reported between the groups. Median (range) local anesthetic consumption during the first 48 h after surgery was 239 mL (175-519 mL) and 322 mL (184-508 mL) in Groups S and C, respectively (P = 0.002). Rescue opioid analgesia was required by 12 (25%) and 28 (58%) patients in Groups S and C, respectively (P = 0.002). We conclude that the use of a stimulating catheter results in shorter onset time of posterior popliteal sciatic nerve block, similar pain relief with reduced postoperative consumption of local anesthetic solution, and less rescue opioid consumption.This prospective, randomized, blind investigation demonstrated that the use of a stimulating catheter for continuous posterior popliteal sciatic nerve block resulted in shorter onset time of sensory and motor blocks and less local anesthetic consumption and need for rescue pain medication after elective orthopedic foot surgery compared with blind catheter advancement.

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.

We evaluated the effects of adding clonidine for continuous peripheral nerve infusions. Sixty patients undergoing total knee arthroplasty under combined single-injection sciatic block and continuous femoral infusion were randomly allocated to three groups: block induction with 0.75% ropivacaine followed by 0.2% ropivacaine (group control; n = 20); block induction with 0.75% ropivacaine and 1 microg/kg clonidine followed by 0.2% ropivacaine (group cloni-bolus; n = 20), and block induction with 0.75% ropivacaine and 1 microg/kg clonidine followed by 0.2% ropivacaine with 1 microg/mL clonidine (group cloni-infusion; n = 20). After surgery, continuous femoral infusion was provided with a patient-controlled infusion pump (basal infusion rate, 6 mL/h; incremental dose, 2 mL; lockout time, 15 min). The median (range) onset time of surgical block was 15 min (5-30 min) in group control, 10 min (5-35 min) in group cloni-bolus, and 10 min (5-30 min) in group cloni-infusion (P = 0.07). No differences were reported among groups in the degree of pain measured with the visual analog scale. The total consumption of local anesthetic solution after a 24-h infusion was 170 mL (144-220 mL) in group control, 169 mL (144-260 mL) in group cloni-bolus, and 164 mL (144-248 mL) in group cloni-infusion (P = 0.51); after the second day of infusion, total consumption was 168 mL (144-200 mL) in group control, 156 mL (144-288 mL) in group cloni-bolus, and 150 mL (144-210 mL) in group cloni-infusion (P = 0.48). Hemodynamic profiles and sedation were similar in the three groups. Motor function impairment after 48 h of infusion was observed in 27% of cloni-infusion patients but in only 6% of both the control and cloni-bolus groups (P = 0.05). We conclude that adding clonidine 1 microg/mL to local anesthetic for continuous femoral nerve block does not improve the quality of pain relief but has the potential for delaying recovery of motor function.

The aim of this prospective, randomized, double-blinded study was to compare clinical efficacy and safety of ropivacaine and bupivacaine given intrathecally in combination with morphine for cesarean delivery.With ethical committee approval and a written informed consent, 60 women scheduled for elective cesarean delivery under spinal anesthesia were randomly allocated to receive spinal anesthesia with either 20 mg ropivacaine plus 0.1 mg morphine (n = 30) or 15 mg bupivacaine plus 0.1 mg morphine (n = 30). Profile of spinal block (onset and recovery times), cardiovascular effects, and quality of postoperative analgesia (patient-controlled morphine) were recorded by a blinded observer.The onset time of motor block was shorter after bupivacaine (8 +/- 2 min) than after ropivacaine (12 +/- 5 minutes) (P.05), whereas duration of both sensory and motor blocks was longer after bupivacaine (139 +/- 37 minutes and 254 +/- 76 minutes) than after ropivacaine (112 +/- 27 minutes and 211 +/- 48 minutes) (P.01 and P.05, respectively). No differences in intraoperative quality of anesthesia and clinical hypotension requiring ephedrine administration were observed between the two groups. Postoperative analgesia was similarly effective in both groups; however median consumption of patient-controlled morphine during the first 24 hours after surgery was higher in patients of group Ropivacaine (5 mg; range, 0 to 18 mg) than in patients of group Bupivacaine (2 mg; range, 0 to 7 mg) (P.01).Spinal anesthesia produced with 20 mg ropivacaine plus 0.1 mg morphine is as effective and safe as that provided by 15 mg bupivacaine plus 0.1 mg morphine, with an earlier recovery of sensory and motor functions after surgery.

Study Objective: To compare the onset time and duration of epidural anesthesia, and the quality of postoperative analgesia produced by levobupivacaine, racemic bupivacaine, and ropivacaine. Design: Prospective, randomized, double-blinded study. Setting: Inpatient anesthesia at a University Hospital. Patients: 45 ASA physical status I, II, and III patients, undergoing elective total hip replacement. Interventions: After standard intravenous midazolam premedication and infusion of 500 mL of Ringer's acetate solution, patients were randomly allocated to receive epidural block with 0.5% levobupivacaine (n = 15), 0.5% bupivacaine (n = 15), or 0.5% ropivacaine (n = 15). Postoperatively, after pinprick sensation recovered at T t , a patient-controlled epidural infusion was provided with 0.125% levobupivacaine, 0.125% bupivacaine, or 0.2% ropivacaine, respectively (baseline infusion rate 5 mL/hr; incremental bolus 2 mL, lockout time: 20 min). Intravenous ketoprofen was also available for rescue analgesia if required. Measurements and Main Results: The onset time of sensory block was 31 ± 16 minutes with levobupivacaine, 25 ± 19 minutes with bupivacaine, and 30 ± 24 minutes with ropivacaine (p = 0.98), after a median (range) volume of 15 (10-18) mL in Group Levobupivacaine, 14 (10-18) mL in Group Bupivacaine, and 15 (10-18) mL in Group Ropivacaine ( p = 0.85). Six patients in the ropivacaine group (40%) showed an intraoperative Bromage score p = 0.02). Recovery of pinprick sensation at T t occurred after 214 ± 61 minutes with levobupivacaine, 213 ± 53 minutes with bupivacaine, and 233 ± 34 minutes with ropivacaine ( p = 0.26). A similar degree of pain relief was observed in the three groups without differences in local anesthetic consumption and need for rescue analgesia. Motor blockade progressively resolved without differences among the three groups. Conclusions: Levobupivacaine 0.5% produces an epidural block of similar onset, quality, and duration as the one produced by the same volume of 0.5% bupivacaine, with a motor block deeper than that produced by 0.5% ropivacaine. When prolonging the block for the first 12 hours after surgery with a patient-controlled epidural infusion, 0.125% levobupivacaine provides adequate pain relief after major orthopedic surgery, with similar recovery of motor function as compared with 0.125% bupivacaine and 0.2% ropivacaine.

To evaluate the frequency of hypotension and bradycardia during integrated epidural-general anesthesia as compared with general anesthesia or epidural anesthesia alone.Prospective, randomized, open, multicenter study.Inpatient anesthesia at 7 University or Hospital Departments of anesthesia.210 ASA physical status I, II, and III patients undergoing elective total hip replacement.Using a balanced randomization method, each hospital enrolled 30 consecutive patients who received integrated epidural-general anesthesia, epidural anesthesia, or general anesthesia.Occurrence of clinically relevant hypotension (systolic arterial blood pressure (BP) decrease30% from baseline), or bradycardia (heart rate (HR)45 bpm) requiring pharmacologic treatment were recorded, as well as routine cardiovascular parameters. Clinically relevant hypotension during induction of nerve block was reported in 13 patients receiving epidural block (18%) and 16 patients receiving epidural-general anesthesia (22%) (p = 0.67). Subsequently, 22 of the remaining 54 patients in the epidural-general anesthesia group (41%) developed hypotension after the induction of general anesthesia, as compared with 16 patients of the general anesthesia group (23%) (p = 0.049). No differences in HR or in frequency of bradycardia were observed in the three groups.The induction of general anesthesia in patients with an epidural block up to T10 increased the odds of developing clinically relevant hypotension as compared with those patients who received no epidural block, and was associated with a twofold increase of the odds of hypotension as compared with the use of epidural anesthesia alone.

Coastal fish assemblages were studied to assess two sorts of human impacts in southwestern Apulia (SE Italy, Mediterranean Sea). Fish assemblages were evaluated by visual census along two rocky locations impacted by a sewage outfall discharging nearshore (S) and by date-mussel (Lithophaga lithophaga) fisheries (F), respectively, and at two control locations (Cs). Multivariate analyses showed that fish assemblage structures at S and F differed from those at Cs. Asymmetric ANOVAs indicated that species richness were significantly lower both at S (approximately 27%) and at F (approximately 35%) compared with Cs. Total fish abundance was 5- to 7-fold higher at S than at Cs, while the values recorded at F were comparable to those of Cs. At S, average abundances of planktivorous fish and POM feeders were higher, and those of labrids and sparids of the genus Diplodus were lower, respectively, than at Cs. Labrids of the genus Symphodus and small serranids were significantly less abundant at F than Cs. Data suggested that coastal fish respond to the impact caused by the sewage discharge and provided a framework to assess potential benefits of its future displacement to deeper waters. For the first time, moreover, this study provided suggestive evidence that the habitat destruction caused by the illegal date-mussel fisheries may affect fish assemblages.

UNLABELLED We compared the effects of using a single- or multiple-injection technique on the volume of 0.5% ropivacaine required to block the femoral nerve, in a prospective, randomized, blinded fashion in which 50 premedicated patients received a femoral nerve block with 0.5% ropivacaine by use of a nerve stimulator and either a single- (n = 25) or multiple- (n = 25) injection technique. Muscular twitches were elicited at < or =0.5 mA before anesthetic injection. The designated volume of local anesthetic was equally divided among contraction of the vastus medialis, vastus intermedius, and vastus lateralis for the multiple injections, or it was injected at the contraction of the vastus intermedius with motion of the patella for the single injection. The local anesthetic volumes were varied for consecutive patients by using an up-and-down staircase method; a blinded observer determined the adequacy of nerve blockade (loss of pinprick sensation in the medial, patellar, and lateral portions of the knee, with concomitant block of the quadriceps muscle) 20 min after injection. The mean (95% confidence interval) volume required for blocking the femoral nerve with the multiple-injection technique (14 [12-16] mL) was significantly smaller than that observed with the single injection (23 [20-26] mL) (P = 0.001). According to logistic regression analyses, the 95% effective volumes of ropivacaine required to block the femoral nerve within 20 min after injection were 29 and 21 mL with a single or multiple injection, respectively. We conclude that searching for multiple muscular twitches reduces the volume of 0.5% ropivacaine required to produce blockade of the femoral nerve. IMPLICATIONS We evaluated the effects of using a single- or multiple-injection technique on the volume of 0.5% ropivacaine required to block the femoral nerve. The 95%effective concentration values for producing the same degree of sensory and motor blockade of the femoral nerve within 20 min after injection were 29 mL after elicitation of a patella twitch and 21 mL when the three main branches of the femoral nerve were identified, potentially leading to an important benefit for patients receiving peripheral nerve blocks.

We compared the recovery profile and postoperative SpO(2) after the administration of general anesthesia with either sevoflurane-remifentanil or sevoflurane-sufentanil in 30 healthy patients undergoing upper abdominal surgery. They were randomly allocated to receive general anesthesia with sevoflurane and small doses of either remifentanil (n = 15) or sufentanil (n = 15), followed by postoperative epidural analgesia. The median sevoflurane minimum alveolar anesthetic concentration-hour was 2.3 (1.2-6.3) in group Remifentanil and 2.6 (1.4-5.2) in group Sufentanil (P: = 0.39), while the median consumption of remifentanil was 1.3 mg (0.7-3.4 mg) and sufentanil 0.09 mg (0.05-0.6 mg). Tracheal extubation required 10 min (6-18 min) with remifentanil and 14 min (8-24 min) with sufentanil (P: = 0.05); however, no differences in time to discharge from the recovery area were reported (24 min [12-75 min] with remifentanil and 30 min [12-135 min] with sufentanil; P: = 0. 35). From the first to seventh hour after surgery, SpO(2) was decreased more in the sufentanil than in the remifentanil group (P: = 0.001), and seven patients in the sufentanil group showed at least one episode with SpO(2)or = 90% for more than 1 min (P: = 0.006) (median: 1 episode; range: 0-17 episodes; P: = 0.003). When added to sevoflurane, remifentanil is as effective as sufentanil during the intraoperative period, but provides shorter time to tracheal extubation and fewer effects on postoperative SpO(2) in the first 7 h after surgery.In this double-blinded study, we evaluated the effects of adding small infusions of either remifentanil or sufentanil to sevoflurane in combination with postoperative epidural analgesia for upper abdominal surgery. We demonstrated that remifentanil is as effective as sufentanil during the intraoperative period, but that it provides shorter time to extubation and fewer effects on postoperative SpO(2) in the first 7 h after surgery.

UNLABELLED To evaluate the effects of adding small-dose clonidine to 0.75% ropivacaine during peripheral nerve blocks, 30 ASA physical status I and II patients undergoing hallux valgus repair under combined sciatic-femoral nerve block were randomly allocated in a double-blinded fashion to receive block placement with 30 mL of either 0.75% ropivacaine alone (group Ropivacaine, n = 15) or 0.75% ropivacaine plus 1 microg/kg clonidine (group Ropivacaine-Clonidine, n = 15). Hemodynamic variables, oxygen saturation, and levels of sedation, as well as the time required to achieve surgical block and time to first analgesic request, were recorded by a blinded observer. Time to surgical blockade required 10 min in both groups. Patients in the Ropivacaine-Clonidine group were more sedated than patients in the Ropivacaine group only 10 min after block placement. No differences in oxygen saturation and hemodynamic variables, degree of pain measured at first analgesic request, and consumption of postoperative analgesics were observed between the two groups. The mean time from block placement to first request for pain medication was shorter in group Ropivacaine (13.7 h; 25th-75th percentiles: 11. 8-14.5 h) than in group Ropivacaine-Clonidine (16.8 h; 25th-75th percentiles: 13.5-17.8 h) (P = 0.038). We conclude that adding 1 microg/kg clonidine to 0.75% ropivacaine provided a 3-h delay in first request for pain medication after hallux valgus repair, with no clinically relevant side effects. IMPLICATIONS This prospective, randomized, double-blinded study demonstrated that, when providing combined sciatic-femoral nerve block for hallux valgus repair, the addition of 1 microg/kg clonidine to 0.75% ropivacaine prolongs the duration of postoperative analgesia by 3 h, with only a slight and short-lived increase in the degree of sedation and no hemodynamic adverse effects.

UNLABELLED We evaluated the effect of the injection technique on the onset time and efficacy of femoral nerve block performed with 0.75% ropivacaine. A total of 30 patients undergoing arthroscopic knee surgery were randomly allocated to receive femoral nerve blockade with 0.75% ropivacaine by using either a single injection (Single group, n = 15) or multiple injection (Multiple group, n = 15). Nerve blocks were placed by using a short-beveled, Teflon-coated, stimulating needle. The stimulation frequency was set at 2 Hz, and the intensity of stimulating current, initially set at 1 mA, was gradually decreased to

To evaluate the time required to achieve surgical block and fulfill standardized discharge criteria in outpatients receiving knee arthroscopy with either unilateral spinal anesthesia or combined sciatic-femoral nerve block.After a standard midazolam/ketoprofen premedication and baseline measurement of cardiovascular parameters, 50 ASA physical status I-II patients scheduled for elective outpatient knee arthroscopy were randomized to receive unilateral spinal anesthesia with 8 mg of 0.5% hyperbaric bupivacaine injected without barbotage through a 25-gauge Whitacre spinal needle (group USA, n = 25), or combined sciatic-femoral nerve block with 25 ml of 2% mepivacaine (15 ml for femoral nerve block and 10 ml for sciatic nerve block) (group SFNB, n = 25). Times from local anesthetic injection to achievement of surgical block defined as the presence of adequate motor (complete motor blockade of the operated limb in the USA group and inability to move the ankle and the knee of the operated limb in the SFNB group) and sensory (loss of pinprick sensation at T12 on the operated side in the USA group, or in the femoral and sciatic nerves distribution in the SFNB group) blocks was recorded. Times to block resolution, urination, unassisted ambulation, and readiness to home discharge were also recorded by a blind observer, as well as occurrence of untoward events during surgery.Surgical block was achieved in 15 +/- 6 min in group USA and 16 +/- 6 min in group SFNB (p = NS). No differences in hemodynamic undesired effects and success rate were observed. Even though USA patients showed a faster time to ambulation (166 +/- 44 min versus 217 +/- 49 min, p = 0.002) and later urination (240 +/- 90 min versus 145 +/- 36 min, p = 0.0001) than SFNB group, no differences in home discharging were reported (246 +/- 98 min versus 211 +/- 77 min, respectively). Bladder catheterization was required in 2 patients of USA group only; however, no patient was admitted to the hospital because of urinary retention.In outpatient knee arthroscopy, a combined sciatic-femoral nerve block with 2% mepivacaine provides similarly successful anesthesia with onset times and home discharge similar to those provided by unilateral spinal anesthesia.

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) (P0.001) or 2% mepivacaine (18 (9) min) (P0.02). 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) (P0.001).

To evaluate arterial (PaCO2), end-tidal (PETCO2) and carbon dioxide tension difference during mechanical ventilation with extratracheal airways, 60 patients ASA physical status I-II, receiving general anaesthesia for minor extra-abdominal procedures were randomly allocated to receive either a cuffed oropharyngeal airway (group COPA, n = 30) or a laryngeal mask (group LMA, n = 30). The lungs were mechanically ventilated by IPPV using a 60% nitrous oxide and 1-1.5% isoflurane in oxygen mixture (VT = 8 mL kg-1; RR = 12 b min-1; l/E = 1/2). After PETCO2 had been stable for at least 10 min after airway placement, haemodynamic variables and PETCO2 were recorded and an arterial blood sample was obtained for measurement of PaCO2. No differences in anthropometric parameters, smoking habit, haemodynamic variables and incidence of untoward events were observed between the two groups. Airway manipulation, to maintain adequate ventilation, was required in only nine patients in the cuffed oropharyngeal airway group (30%) (P < 0.0005); however, in no case was it necessary to remove the designated extratracheal airway due to unsuccessful mechanical ventilation. The mean difference between arterial and end-tidal carbon dioxide partial pressure was 0.4 +/- 0.3 KPa in the laryngeal mask group (95% confidence intervals: 0.3-0.5 KPa) and 0.3 +/- 0.26 KPa in the cuffed oropharyngeal airway group (95% confidence intervals: 0.24-0.4 KPa) (P = NS). We conclude that in healthy adults who are mechanically ventilated via the cuffed oropharyngeal airway, the end-tidal carbon dioxide determination is as accurate an indicator of PaCO2 as that measured via the laryngeal mask, allowing capnometry to be reliably used to evaluate the adequacy of ventilation.

UNLABELLED No study has evaluated the efficacy of ropivacaine in peribulbar block for ophthalmic surgery. The purpose of this prospective, randomized, double-blinded study was to compare ropivacaine and a lidocaine-bupivacaine mixture in peribulbar anesthesia. Sixty ASA physical status I or II patients scheduled for elective vitreoretinal surgery were randomized to receive a peribulbar block with 8 mL of either 0.75% ropivacaine (ropivacaine group, n = 30) or a 1:1 mixture of 2% plain lidocaine and 0.5% plain bupivacaine (lido-bupivacaine group, n = 30). Time required for onset of surgical anesthesia, quality of postoperative analgesia, incidence of side effects, and analgesic consumption were recorded. Surgical block was achieved after 8 +/- 5 min in the lido-bupivacaine group and after 10 +/- 5 min in the ropivacaine group (P = 0.23). A 3-mL supplemental injection 15 min after block placement was required in 6 patients in the lido-bupivacaine group (20%) and in 10 patients in the ropivacaine group (33%) due to inadequate motor block (P = 0.38). On Postoperative Day 1, 26 patients in the ropivacaine group (87%) reported no pain at the verbal rating score, compared with 18 patients in the lido-bupivacaine group (60%) (P = 0.005). We conclude that 0.75% ropivacaine may be a suitable choice when performing peribulbar anesthesia for vitreoretinal surgery. IMPLICATIONS Quick onset of block with prolonged postoperative analgesia is an important goal in regional anesthesia for ophthalmic surgery. Evaluating clinical properties of 0.75% ropivacaine and a 1:1 mixture of 2% lidocaine and 0.5% bupivacaine for peribulbar anesthesia, we demonstrated that ropivacaine has an onset similar to that of the lidocaine-bupivacaine mixture and provides a better quality of postoperative analgesia.

Through a prospective study, we evaluated the efficacy of an integrated autotransfusion regimen comprised of predeposit-hemodiluition and intra and post-operative blood salvage in major orthopaedic surgery.We examined the records of 2303 consecutive patients (1524 females and 779 males, mean age 62.7, standard deviation 11 years (range 16-90 yrs), pre-operative haemoglobin (Hb) concentration 13.5 (SD 1.4) (range 6.7-19.3) g/dl undergong total hip arthroplasty (THA 1582 patients), THA after the removal of internal fixation devices (RFD+THA, 25 patients), total knee arthroplasty (TKA, 347 patients), revision surgery of the hip (HR, cup+stem revision, 248 patients; cup revision 64 patients; stem revision 23 patients) and total knee revision (TKR 14 patients). We estimated that the number of predonations (MSBOS - maximum surgery blood order schedule) was 2 units for THA, TKA and TKR, and 3 units for partial or total hip revision and for total hip arthroplasty with fixation removal.It was possible to obtain the MSBOS in 2070 patients (89.8%). Homologous red blood cell (HRBC) transfusion were carried out in 184 patients (8%). We found that the need to use HRBC was significantly associated with failure to meet the number of MSBOS, female sex, lower pre-operative Hb concentration, use of calcium heparin for antithrombosis prophylaxis, more extensive surgery, a higher ASA rating and co-existing diseases such as coronary artery disease.Cooperation among anaesthesis, transfusionists and surgeons in the application of an integrated autotransfusion regimen enabled us to treat 92% of our patients with only autotransfusion.

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 (IV) midazolam premedication (0.05 mg · kg −1 ), general anesthesia was induced with fentanyl (1 μg · 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 IV 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.

To evaluate the effects of hyperbaric bupivacaine concentration in producing unilateral spinal anaesthesia.With Ethical Committee approval and written consent, 60 patients undergoing lower limb surgery were placed in the lateral position with the side to be operated on dependent. After dural puncture (25-gauge Whitacre spinal needle), the needle hole was turned toward the dependent side and patients were randomly assigned to receive 8 mg of either 0.5% (Group0.5%, n = 30) or 1% (Group1%, n = 30) hyperbaric bupivacaine. The lateral position was maintained for 15 min, while a blinded observer recorded loss of pinprick sensation and degree of motor block on both sides until two segment regression of sensory level on the dependent side.At the end of the 15 min lateral position spinal anaesthesia was more frequently unilateral in Group0.5% (80%) than in Group1% (53%)(P0.05). However, 30 min after patients were turned supine, unilateral spinal anaesthesia decreased to 60% of cases in Group0.5% and 40% of cases in Group1% (P = NS). The maximum sensory level on the dependent side [T10(L1-T2) in Group0.5% and T8 (T12-T3) in Group1%], time to reach it [20 (5-30) min in Group0.5% and 25 (10-35) min in Group1%], and time to two segment regression of sensory level [80 (30-135) min in Group0.5% and 75 (20-135) min in Group1%] were similar in both groups.Highly concentrated solutions of hyperbaric bupivacaine are not advantageous in obtaining a unilateral spinal anaesthesia, when a small anaesthetic dose is injected slowly through a Whitacre spinal needle.

A low dose of hyperbaric local anaesthetic solution, pencil point needle and slow speed of intrathecal injection have been reported to obtain a unilateral distribution of spinal anaesthesia. This should also minimize cardiovascular effects of spinal block. The aim of this prospective, randomized, parallel group study was to evaluate cardiac performance during unilateral subarachnoid block and to compare it with that produced by standard bilateral spinal anaesthesia.With Ethic Committee approval and patients' consent we studied 30 ASA I-II patients scheduled for one leg surgery. Dural puncture was performed by 25-G Whitacre needle with patients lying in the lateral position and the side to be operated on dependent. Patients then randomly received 8 mg of 0.5% hyperbaric bupivacaine injected over 80 sec with needle hole orientated towards the dependent side (Unilateral, n = 15), or 15 mg of the same solution injected over 6 sec with needle bevel cranially directed (Control, n = 15). Only patients of the Unilateral group remained in the lateral position for 15 min. Noninvasive Arterial blood pressure, heart rate, stroke volume index and cardiac index were measured before spinal block (baseline) and then at 5, 15, 30 and 45 min; while sensory and motor blocks were evaluated at 15, 30 and 45 min on both sides.Unilateral spinal anaesthesia was observed in 11 patients of the Unilateral group (73%). Three patients of the Control group (20%) required colloids for intraoperative hypotension. Mean arterial blood pressure and heart rate decreased from baseline only in the Control group (p = 0.001 and p = 0.0003 respectively), while heart rate was decreased in Control even when compared to Unilateral group (p = 0.01). The stroke volume index was unchanged in the two groups (p = 0.22), while the cardiac index showed a 15-20% decrease from baseline in Control group (p = 0.001), with a significant decrease at 30 and 45 min when compared to Unilateral (p = 0.01).The use of 8 mg of 0.5% hyperbaric bupivacaine slowly injected through a directional needle provided a spinal block relatively restricted to the operative side with minimal effects on cardiovascular homeostasis.

Combined epidural/general anaesthesia might theoretically emphasise the cardiovascular effects of epidural block alone. The goal of the present investigation was to evaluate the incidence of both hypotension and bradycardia during integrated epidural/general anaesthesia in a multicentric, observational study.The incidence of clinical hypotension (systolic arterial blood pressure decrease by 30% or more from baseline), and bradycardia (heart rate50 beats/min) and other side effects have been evaluated in 1200 consecutive patients receiving integrated epidural/general anaesthesia. The time from induction of epidural anaesthesia to induction of general anaesthesia was considered as preoperative; while the time after general anaesthesia induction was considered as intraoperative.Preoperatively hypotension developed in 85 patients (2.8%), and bradycardia in 54 patients (4.5%). Intraoperatively, hypotension was observed in 380 patients (31.6%), and bradycardia in 153 patients (12.7%). Hypotension and bradycardia were not influenced by the type of surgical procedure, the type of maintenance of general anaesthesia (inhalational versus total intravenous general anaesthesia) and the level of epidural block (lumbar versus thoracic); but they were more frequent in patients with ASA physical status II and III-IV compared to patients with ASA physical status I (p0.05). Prophylactic volume preload decreased the incidence of hypotension from 41.5% to 22.4% (p0.0001), while prophylactic atropine before epidural block did not affect the incidence of bradycardia. Patients receiving epidural clonidine showed an increased incidence of intraoperative bradycardia compared to those who did not receive it (p0.0001).Randomized, controlled studies should be advocated in order to compare the incidence of hypotension and bradycardia during integrated anaesthesia and during epidural block alone. Our results demonstrated that the use of integrated epidural/general anaesthesia produces an incidence of perioperative hypotension and bradycardia similar to that reported when central blocks are used alone.

Axillary brachial plexus block using 20 mL of 0.75% ropivacaine or 2% mepivacaine was compared in a prospective, randomized, double-blind study of two groups of 15 patients. The times to onset of sensory and motor block and to resolution of motor block, as well as the time to onset and degree of post-operative pain were recorded by an observer blinded to the identity of drug. Times to onset of sensory block were similar in the two groups (ropivacaine 10 min, mepivacaine 8 min). Resolution of motor block in the operated hand and the time to first requirement of post-operative analgesia occurred later with ropivacaine (9 h 50 min and 10 h) than with mepivacaine (3 h 50 min and 6 h), P < 0.01 for both measurements. Nine patients who received ropivacaine and two patients who received mepivacaine did not require further post-operative analgesia (P < 0.05). Ropivacaine is less toxic than other long-acting local anaesthetics, and 0.75% ropivacaine may be better for brachial plexus block when fast onset is required and prolonged pain relief is useful.

Study Objective: To compare passive heat retention by low-flow anesthesia, alone and with additional thermal insulation by reflective blankets, with forced-air warming preventing intraoperative hypothermia during combined epidural-general anesthesia. Design: Randomized, controlled study. Setting: Inpatient anesthesia at a university department of orthopedic surgery. Patients: 30 ASA physical status I and II patients, who were scheduled for elective hip or knee arthroplasty and were free from systemic disease. Interventions: Patients received epidural block up to T 10 by alkalinized lidocaine 2 %, and then were administered standard general anesthesia by means of low-flow rebreathing system (fresh gas flow=1 L/min). All procedures started between 8 and 10 am, and operating room (OR) temperature was maintained between 21 ° and 23 °C, with relative humidity ranging between 40% and 45%. For heat retention or warming therapy, patients received either low-flow anesthesia only (control, n=10), low-flow anesthesia with additional reflective blankets (blanket, n=10), or low-flow anesthesia with active forced-air warming (forced-air, n=10). Tympanic temperature was measured at OR arrival (baseline); immediately following general anesthesia induction; 30, 60, 90, and 120 minutes from general anesthesia induction; and at the end of surgery. Measurements and Main Results: Duration of anesthesia, invasiveness of surgery, and baseline core temperature were similar in the three groups. Core temperature decreased in all the three groups 30 minutes after general anesthesia induction compared with baseline ( p p = 0.004), with a reduction from baseline values measured at the end of surgery of 2.0 °C and 1.6 °C, respectively. In the forced-air group, after the initial significant decrease ( p = 0.01 vs. baseline), core temperature progressively increased to 35.8 ± 0.6 °C, which was similar to preoperative values and significantly higher than either the control or blankets groups ( p = 0.004). Conclusions: During combined epidural-general anesthesia for elective hip and knee arthroplasty, passive heat retention by means of low-flow anesthesia alone and in combination with reflective blankets is ineffective in maintaining intraoperative normothermia and definitely inferior to active forced-air warming.

Anaesthesia, surgical procedures and operating room temperature can deeply alter the human thermoregulatory system. Unexpected and sometimes serious perioperative complications can occur. Many studies have been carried out in order to describe and evaluate the detrimental effects produced by different anaesthesia procedures (whether by general, regional or integrated anaesthesia) on thermic homeostasis. More recently it has also been reported that perioperative hypothermia significantly affects patients' outcome, increasing intraoperative blood losses, incidence of postoperative wound infection, and hospital stay. Italian anaesthetists have still a poor consideration about intraoperative body temperature monitoring and patients' warming as basic important skills for a better anaesthesiologic patients management. According with the literature, we do believe that this is not a right opinion. The purpose of the present paper would be to point out the most important knowledges concerning thermic homeostasis management, in order to increase anaesthesiologist's awareness in this essential field of patients perioperative care.

The large use of double block of sciatic and femoral nerves (bibloc) with high mepivacaine 2% doses (10 mg/kg) has pointed out some cases of toxicity. We found a relationship between shiver and mepivacaine arterious plasma levels higher than 6 micrograms/ml. These symptoms were self-limited and statistically not significant.

A new technique for regional anaesthesia for arthroscopy of the knee is presented. The method includes sciatic nerve block according to the technique proposed by Labat, through a posterior approach and the block of the femoral and lateral cutaneous nerves using a single anterior approach. Results obtained in 30 patients are presented: they include good stability of the cardiovascular and respiratory parameters, high efficiency and duration of anaesthesia resulting in a satisfactory surgical procedure.

Background Intra- and postoperative clinical properties of sciatic-femoral nerve block performed with either ropivacaine at different concentrations or mepivacaine have been evaluated in a multicenter, randomized, blinded study. Methods Adult patients scheduled for foot and ankle surgery were randomized to receive combined sciatic-femoral nerve block with 225 mg of either 0.5% (n = 83), 0.75% (n = 87), or 1% (n = 86) ropivacaine, or with 500 mg of 2% mepivacaine (n = 84). A thigh tourniquet was used in all patients. Onset time, adequacy of surgical anesthesia, time to offset of nerve block, and time until first postoperative requirement for pain medication were evaluated by a blinded observer. Results The adequacy of nerve block was similar in the four treatment groups (the ratios between adequate:inadequate: failed blocks were 74:9:0 with 0.5% ropivacaine, 74:13:0 with 0.75% ropivacaine, 78:8:0 with 1% ropivacaine, and 72:12:0 with 2% mepivacaine). The onset of the block was slower with 0.5% ropivacaine than with other anesthetic solutions (P < 0.001). Regardless of the concentration, ropivacaine produced a longer motor blockade (10.5+/-3.8 h, 10.3+/-4.3 h, and 10.2+/-5.1 h with 0.5%, 0.75%, and 1% ropivacaine, respectively) than with mepivacaine (4.3+/-2.6 h; P < 0.001). The duration of postoperative analgesia was shorter after mepivacaine (5.1+/-2.7 h) than after ropivacaine (12.2+/-4.1 h, 14.3+/-5 h, and 14.5+/-3.4 h, with 0.5%, 0.75%, or 1% ropivacaine, respectively; P < 0.001). Pain relief after 0.5% ropivacaine was 14% shorter than 0.75% or 1% ropivacaine (P < 0.05). During the first 24 h after surgery, 30-37% of patients receiving ropivacaine required no analgesics compared with 10% of those receiving mepivacaine (P < 0.001). Conclusions This study suggests that 0.75% ropivacaine is the most suitable choice of local anesthetic for combined sciatic-femoral nerve block, providing an onset similar to mepivacaine and prolonged postoperative analgesia.

In order to compare interscalene brachial plexus block performed with ropivacaine or bupivacaine, 45 healthy, unpremedicated patients, undergoing elective shoulder surgery, were randomly allocated to receive interscalene brachial plexus anaesthesia with 20 mL of either ropivacaine 0.75% (n = 15), ropivacaine 1% (n = 15), or bupivacaine 0.5% (n = 15). Readiness for surgery (loss of pinprick sensation from C4 to C7 and inability to elevate the limb from the bed) was achieved later with bupivacaine 0.5% (28 +/- 15 min) than with ropivacaine 1% (10 +/- 5 min) (P = 0.005) and ropivacaine 0.75% (15 +/- 8 min) (P = 0.0005). No differences in success rate were observed between the three groups; however, seven patients receiving bupivacaine 0.5% required intra-operative analgesic supplementation (fentanyl 0.1 mg intravenous) compared with one patient receiving ropivacaine 0.75%, and two patients treated with ropivacaine 1% (P = 0.02). The time from the block placement to first request for pain medication was similar in the three groups (10.7 +/- 2 h, 11 +/- 2.4 h, and 10.9 +/- 3.9 h after 0.75% and 1% ropivacaine or 0.5% bupivacaine, respectively). We conclude that interscalene brachial plexus block performed with 20 mL of either 0.75% or 1% ropivacaine allows for a prolonged post-operative pain relief, similar to that provided by bupivacaine 0.5%, with short onset time of surgical anaesthesia.