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BACKGROUND: Hip fracture is a major cause of hospitalization among the elderly population. The standard surgical treatment involves early repair to reduce mortality and morbidity. One type of treatment in the case of intertrochanteric and subtrochanteric fractures is intramedullary nailing, as it decreases soft tissue damage and permits early weight bearing. The most common anesthesia technique combines spinal anesthesia with a peripheral block. In cases where spinal anesthesia is contraindicated, general anesthesia is preferred. However, both techniques can lead to significant complications, especially in patients with multiple comorbidities. Pain management after hip surgery, particularly in elderly and frail individuals, poses a challenge. The pericapsular nerve group block (PENG) targets the innervation of the anterior portion of the hip joint and is increasingly used for pain management related to hip surgery. CASE SERIES: This paper presents a case series of three elderly patients who underwent pericapsular nerve group block (PENG) block combined with dexmedetomidine sedation for intramedullary femoral fixation. CONCLUSIONS: The PENG block can be effectively used as the sole anesthetic technique for managing elderly patients undergoing intramedullary femoral fixation while on antiplatelet drugs. This procedure effectively controlled pain during both the surgical and postoperative periods. The addition of dexmedetomidine for sedation enables comfortable and safe procedures, minimizing the risk of perioperative neurocognitive dysfunctions and without adverse effects on cardiorespiratory function. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The term THRIVE refers to the delivery of 100% heated and humidified oxygen via a nasal cannula to maintain viable gas exchange during prolonged apnea. There are no reports of its application for Operative Hysteroscopy (OH) under general anesthesia (GA). The aim of the study is to investigate the success rate of THRIVE as unique airway management technique in this setting. The results will support the development of a randomized controlled trial (RCT) to demonstrate the non-inferiority of THRIVE compared to traditional techniques. PATIENTS AND METHODS: Twenty consecutive ASA I-II women presenting for OH were enrolled. Standard anesthesia, as well as transcutaneous carbon dioxide (tcCO2) monitoring, was performed. After preoxygenation with 30 L∙min-1, GA was induced with propofol and fentanyl, then oxygen flow was increased to 70 L∙min-1 and anesthesia maintained with propofol infusion. The primary outcome was success rate of THRIVE defined as SpO2 > 94%, tcCO2 < 60 mmHg and no need for rescue airway intervention. RESULTS: Mean age was 47 ± 12 years. Mean duration of the procedure was 25 ± 9 minutes, and the success rate of the technique was 100%. Median SpO2 during the procedure was 100 (IQR 99-100) %. Mean maximum tcCO2 level was 51 ± 7 mmHg while mean tcCO2 level during the procedure was 45 ± 7 mmHg. At the end of the procedure, mean tcCO2 was 44 ± 5 mmHg. CONCLUSIONS: THRIVE allowed adequate gas exchange during OH under GA, without additional rescue airway interventions. The application of THRIVE in this setting may allow minimal airway manipulation and optimal comfort for the patient with low failure rate. We calculated the sample size for the planned non-inferiority RCT investigating the effectiveness of THRIVE versus laryngeal mask ventilation in OH: 82 is the minimal number of patients per group to test a non-inferiority limit of 10%. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Total laparoscopic hysterectomy (TLH) is associated with significant postoperative pain that worsens outcomes and prolongs hospital stay. Ultrasound guided erector spinae plane block (ESPB) is a new technique for thoracic analgesia. Few cases have been described for postoperative analgesia in laparoscopy. We describe the use of preoperatory bilateral ESPB at level T10 to provide postoperative analgesia following THL. PATIENTS AND METHODS: We enrolled 10 ASA 1-2 patients scheduled for TLH. After written informed consent we performed bilateral ESPB at T10 level in sitting position, with a linear probe and in plane cranio-caudal approach and ropivacaine 0.5% 20 for each side. The sensitive block was tested by pinprick. Standard general anesthesia was administered. Patient controlled analgesia (PCA) with morphine 1 mg/ml was delivered. We measured postoperative pain by visual analogue scale (VAS). RESULTS: Five patients (50%) underwent simple TLH, 5 women (50%) had TLH plus salpingo-oophorectomy. VAS scores was <4 in all cases but one, and PCA morphine consumption was 4.1 ± 3.5 mg (mean ± SD). Pinprick was positive bilaterally in 3 patients (30%). CONCLUSIONS: ESPB was an effective and safe procedure for postoperative pain control after TLH. Future research should compare ESPB to other techniques to assess its role on perioperative management of THL. [ABSTRACT FROM AUTHOR]

Acute myocardial infarction rarely occurs in women during childbearing age (1:20,000), but maternal mortality rate is high (11%). Management of pregnant woman affected by myocardial infarction could be a challenge for obstetricians, cardiologists and anesthetists. In this report, we present the management of a 36 years-old nulliparous woman affected from hypertension and dyslipidemia, who experienced acute myocardial infarction at 25th gestational week and was scheduled for caesarean delivery at 35th week. General anesthesia for cesarean section was conducted using sevoflurane and remifentanil target controlled infusion (TCI); the patient was monitored with ECG, pulse oximetry, invasive blood pressure, haemodynamic measurement by lithium dilution cardiac output (LiDCO plus) and bispectral index. The titrated use of remifentanil and the close control of hemodynamic parameters by LiDCO plus monitoring may contribute to improve maternal outcome and newborn well-being in the management of general anesthesia for caesarean section. [ABSTRACT FROM AUTHOR]

Background and Objectives: Total knee arthroplasty often results in marked postoperative pain. A recent meta-analysis supports the use of femoral nerve block or alternatively spinal injection of morphine plus local anaesthetic for post-operative analgesia. On the other hand, the use of intrathecal morphine may be associated with a large number of distressing side effects (itching, urinary retention, nausea and vomiting, delayed respiratory depression). The aim of this study was to compare the effectiveness of femoral nerve block and low dose intrathecal morphine in post-operative analgesia after primary unilateral total knee arthroplasty. Material and Methods: Fifty-two consecutive patients scheduled for primary unilateral total knee arthroplasty were allocated to the intrathecal morphine group (ITM group) or to the femoral nerve block group (FNB group). In ITM group a subarachnoid puncture was performed at the L3-L4 inter-vertebral space with hyperbaric bupivacaine 15 mg plus 100 mcg of preservative-free morphine. Patients allocated to the FNB group received a single-injection ultrasound-assisted femoral nerve block with ropivacaine 0.75% 25 ml before the spinal injection of hyperbaric bupivacaine 15 mg. All patients received postoperative patient-controlled- analgesia (PCA) morphine, using a 1- mg bolus and a 5-minute lockout period. Data were analyzed using Student t test or two-way analysis of variance (ANOVA) for repeated measures with time and treatment as the 2 factors. Post hoc comparisons were performed by Bonferroni test. Statistical significance for all test was a p value <0.05. Results: Patient characteristics were similar between the 2 groups. We found a statistically significant differences in postoperative pain between the two groups: ITM group had the lower visual analogic pain score (VAS) values. Morphine consumption was lower in the ITM group: average consumption within the first 6 hours was 0.9 mg in IT group compared to 3.1 mg in FNB group; at 12 h 4.2 mg vs 6.3 mg; at 24 h 6.9 mg vs 10.3 mg; at 48 h 9.7 mg vs 13.6 mg. However, the difference in the opiate consumption was not statistically different (p value =0.06). Thirteen patients in ITM group experienced itching, only 5 in FNB group. We did not find any difference in the two treatment groups in the use of antiemetic and antipruritic medication. No cases of respiratory depression was recorded. Conclusions: Our results show that low dose of intrathecal morphine may be safe and more efficient than single-shot femoral nerve block for post-operative analgesia after total knee arthroplasty. [ABSTRACT FROM AUTHOR]

Total knee arthroplasty (TKA) often results in marked postoperative pain. We compared in a randomized controlled study tramadol consumption, postoperative pain and patient satisfaction after primary TKA in patients who received a single injection lumbar plexus and sciatic nerve blocks or a continuous lumbar plexus and sciatic nerve blocks. Forty-four patients scheduled for unilateral total knee arthroplasty were allocated to the single shot group (group A) or to the catheter group (group B). All patients (in both groups) reported being satisfied with their anaesthetic management. Although pain scores and tramadol consumption appeared lower in the active infusion group, the differences did not reach statistical significance. This study confirms that either single injection or continuous infusion of Ropivacaine in lumbar plexus provides reliable and long-acting anaesthesia and analgesia. [ABSTRACT FROM AUTHOR]

Purpose: Intrathecal morphine and psoas compartment block represent two accepted techniques to provide postoperative analgesia after hip arthroplasty. We designed a prospective, randomized, single-blinded study to compare these two techniques. Methods: Forty patients scheduled for primary hip arthroplasty under general anesthesia were randomized to receive either an intrathecal administration of 0.1 mg morphine, 0.015 mg fentanyl and 15 mg hyperbaric bupivacaine (Group I, n = 20) or a psoas compartment block with ropivacaine 0.475% 25 mL (Group II, n = 20). Pain scores, morphine consumption, associated side-effects were assessed for 48 hr postoperatively. In addition, patient's satisfaction and acceptance of the postoperative analgesic technique were also recorded. Results: During the first 24 hr, pain scores (12 ± 27 vs 24 ± 25 at H+12, 12 ± 46 vs 20 ± 26 mm at H+24, 16 ± 19 vs 20 ± 29 mm at H+36) and tramadol consumption (30 ± 70 vs 210 ± 400 mg at H+12, 180 ± 120 vs 320 ± 100 mg at H+24) were slightly lower in Group I than in Group II, but there were no statistically significant differences. Itching was the most frequent side-effect occurring in 45% of cases in Group I vs 10% in Group II (P < 0.05). No major complication occurred. There was no difference in satisfaction scores between the two groups. Conclusion: Intrathecal administration of a combination of morphine, fentanyl and bupivacaine and single-shot psoas compartment block both provide very good postoperative analgesia after primary hip arthroplasty. [ABSTRACT FROM AUTHOR]

Background : Variability in obstetric outcomes in terms of the number and type of deliveries related to the day-night cycle has been described in previous studies. This 11-year retrospective analysis explores the effects of nighttime versus daytime delivery with labor epidural on obstetric outcomes. Methods : Data on deliveries performed between 1 October 2008 and 1 October 2019 were collected and differentiated into daytime, occurring from 8:00 a.m. to 7:59 p.m., and nighttime deliveries, occurring from 8:00 p.m. to 7:59 a.m. of the following day. The data collected included the patient history and maternal and neonatal outcomes. Results : A total of 29831 patients were included in the analysis. A positive and statistically significant correlation between the number of cesarean sections (Odds Ratio 1.35; 95% confidence interval = 1.26-1.44; p < 0.001) and the number of vaginal operative deliveries (Odds Ratio 1.21; 95% confidence interval = 1.01-1.44; p < 0.05) in patients who did not receive an epidural at nighttime was reported. Regarding the labor epidurals, a significantly greater incidence of accidental dural punctures with needles (0,4%; p < 0.05) in the nighttime versus daytime was reported. Conclusions : The absence of labor epidurals was associated with a significant increase in the number of cesarean sections and vaginal operative deliveries occurring at nighttime, without significant differences in labor duration. The incidence of anesthesiologic complications was greater in deliveries performed at nighttime.

Introduction/aims: Nusinersen intrathecal administration can be challenging in spinal muscular atrophy (SMA) adults. We aimed to determine if the ultrasound (US)-assistance reduces the number of needle attempts and needle redirections needed for intrathecal drug administration and its impact on the procedure time, the incidence of adverse events (AEs), and patient satisfaction in these patients., Methods: Fifty-eight patients aged 18 years and older scheduled for intrathecal nusinersen injection were enrolled and randomized (1:1 ratio) into Group 1 (nusinersen infusion with US-assisted technique) or Group 2 (nusinersen infusion with landmark-based technique). The number of attempts, number of redirections, periprocedural time, AEs and patient satisfaction were reported. Continuous variables were compared with the Student t-test or Wilcoxon rank sum test. Categorical variables were evaluated with the Chi-square test or Fisher's exact test in case of expected frequencies <5. The p-values <.05 were considered statistically significant., Results: There were no statistical differences in the number of attempts, AEs, or patient satisfaction between the two groups. The number of needle redirections was significantly lower in the ultrasound group versus landmark-based group (p < .05) in both the overall group of patients and in the subgroup with difficult spines. The periprocedural time was about 40 seconds longer in US-group versus landmark-based group (p < .05)., Discussion: In SMA adults, US assistance reduces the number of needle redirections needed for intrathecal drug administration. These results suggest that the US assistance may be advantageous for nusinersen therapy to reduce the therapeutic burden of intrathecal infusion., (© 2024 Wiley Periodicals LLC.)

Background: Randomized data on patients with FIGO stage III ovarian cancer receiving ≤ 3 cycles of neoadjuvant chemotherapy (NACT) showed that hyperthermic intraperitoneal chemotherapy (HIPEC) after interval debulking surgery (IDS) improved patient's survival. We assessed the perioperative outcomes and PFS of FIGO stage IV and/or patients receiving up to 6 cycles of NACT undergoing IDS+HIPEC., Methods: Prospectively collected cases from January 1, 2019 to July 31, 2022 were included. Patients underwent HIPEC if: age ≥ 18 years but < 75 years, body mass index ≤ 35 kg/m 2 , ASA score ≤ 2, FIGO stage III/IV epithelial disease treated with up to 6 cycles of NACT, and residual disease < 2.5 mm., Results: A total of 205 patients were included. No difference was found in baseline characteristics between FIGO Stage III and IV patients, whereas rate of stable disease after NACT (p = 0.004), mean surgical complexity score at IDS (p = 0.001), and bowel resection rate (p = 0.046) were higher in patients undergoing delayed IDS. A lower rate of patients with at least one G3-G5 postoperative complications was observed in FIGO stage IV versus FIGO stage III disease (5.3% vs. 14.0%; p = 0.052). This difference was confirmed at multivariable analysis (odds ratio [OR] 0.24; 95% confidence interval [CI] 0.07-0.80; p = 0.02), whereas age, SCS, bowel resection, and number of cycles did not affect postoperative complications. No difference in PFS was identified neither between FIGO stage III and IV patients (p = 0.44), nor between 3 and 4 versus > 4 cycles of NACT (p = 0.85)., Conclusions: Because of the absence of additional complications and positive survival outcomes, HIPEC administration can be considered in selected FIGO stage IV and patients receiving > 4 cycles of NACT., (© 2024. The Author(s).)

Background: Intraoperative hypotension is associated with increased perioperative complications, hospital length of stay (LOS) and healthcare expenditure in gynecologic surgery. We tested the hypothesis that the adoption of a machine learning-based warning algorithm (hypotension prediction index-HPI) might yield an economic advantage, with a reduction in adverse outcomes that outweighs the costs for its implementation as a medical device., Methods: A retrospective-matched cohort cost-benefit Italian study in gynecologic surgery was conducted. Sixty-six female patients treated with standard goal-directed therapy (GDT) were matched in a 2:1 ratio with thirty-three patients treated with HPI based on ASA status, diagnosis, procedure, surgical duration and age., Results: The most relevant contributor to medical costs was operating room occupation (46%), followed by hospital stay (30%) and medical devices (15%). Patients in the HPI group had EURO 300 greater outlay for medical devices without major differences in total costs (GDT 5425 (3505, 8127), HPI 5227 (4201, 7023) p = 0.697). A pre-specified subgroup analysis of 50% of patients undergoing laparotomic surgery showed similar medical device costs and total costs, with a non-significant saving of EUR 1000 in the HPI group (GDT 8005 (5961, 9679), HPI 7023 (5227, 11,438), p = 0.945). The hospital LOS and intensive care unit stay were similar in the cohorts and subgroups., Conclusions: Implementation of HPI is associated with a scenario of cost neutrality, with possible economic advantage in high-risk settings.

Background: Noninvasive respiratory support (NRS), including high-flow nasal oxygen therapy (HFNOT), noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP), are routinely used in the perioperative period. Objectives : This narrative review provides an overview on the perioperative use of NRS. Preoperative, intraoperative, and postoperative respiratory support is discussed, along with potential future areas of research. Results : During induction of anesthesia, in selected patients at high risk of difficult intubation, NIV is associated with improved gas exchange and reduced risk of postoperative respiratory complications. HFNOT demonstrated an improvement in oxygenation. Evidence on the intraoperative use of NRS is limited. Compared with conventional oxygenation, HFNOT is associated with a reduced risk of hypoxemia during procedural sedation, and recent data indicate a possible role for HFNOT for intraoperative apneic oxygenation in specific surgical contexts. After extubation, "preemptive" NIV and HFNOT in unselected cohorts do not affect clinical outcome. Postoperative "curative" NIV in high-risk patients and among those exhibiting signs of respiratory failure can reduce reintubation rate, especially after abdominal surgery. Data on postoperative "curative" HFNOT are limited. Conclusions : There is increasing evidence on the perioperative use of NRS. Use of NRS should be tailored based on the patient's specific characteristics and type of surgery, aimed at a personalized cost-effective approach.

ESP block (ESPB) and posterior Quadratus Lumborum Block (pQLB) have been proposed as opioid-sparing techniques for the management of pain after abdominal surgery. Between December 2021 and October 2022, we conducted a retrospective comparative study at the delivery suite of Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy, to compare the efficacy of ESPB and pQLB in preventing postoperative pain after an elective caesarean section (CS). The primary outcome was total morphine consumption in the first 24 h. Secondary outcomes were time to first opioid request; Numerical Pain Rating Scale (NPRS) at 0, 2, 6, 12 and 24 h; vital signs; adverse events. Fifty-two women were included. The total cumulative dose of morphine was not significantly different between the two groups of patients ( p = 0.897). Time to first dose of morphine, NPRS values and haemodynamic parameters were not statistically different between the two groups. NPRS values significantly increased ( p < 0.001) at the different time intervals considered. The need for rescue doses of morphine was lower in the ESPB group compared to the pQLB group (hazard ratio of 0.51, 95% CI (0.27 to 0.95), p = 0.030). No adverse event was reported. ESPB seems to be as effective as pQLB in providing analgesia after CS.

Background: Pulse pressure and stroke volume variation (PPV and SVV) have been widely used in surgical patients as predictors of fluid challenge (FC) response. Several factors may affect the reliability of these indices in predicting fluid responsiveness, such as the position of the patient, the use of laparoscopy and the opening of the abdomen or the chest, combined FC characteristics, the tidal volume (Vt) and the type of anesthesia., Methods: Systematic review and metanalysis of PPV and SVV use in surgical adult patients. The QUADAS-2 scale was used to assess the risk of bias of included studies. We adopted a metanalysis pooling of aggregate data from 5 subgroups of studies with random effects models using the common-effect inverse variance model. The area under the curve (AUC) of pooled receiving operating characteristics (ROC) curves was reported. A metaregression was performed using FC type, volume, and rate as independent variables., Results: We selected 59 studies enrolling 2,947 patients, with a median of fluid responders of 55% (46-63). The pooled AUC for the PPV was 0.77 (0.73-0.80), with a mean threshold of 10.8 (10.6-11.0). The pooled AUC for the SVV was 0.76 (0.72-0.80), with a mean threshold of 12.1 (11.6-12.7); 19 studies (32.2%) reported the grey zone of PPV or SVV, with a median of 56% (40-62) and 57% (46-83) of patients included, respectively. In the different subgroups, the AUC and the best thresholds ranged from 0.69 and 0.81 and from 6.9 to 11.5% for the PPV, and from 0.73 to 0.79 and 9.9 to 10.8% for the SVV. A high Vt and the choice of colloids positively impacted on PPV performance, especially among patients with closed chest and abdomen, or in prone position., Conclusion: The overall performance of PPV and SVV in operating room in predicting fluid responsiveness is moderate, ranging close to an AUC of 0.80 only some subgroups of surgical patients. The grey zone of these dynamic indices is wide and should be carefully considered during the assessment of fluid responsiveness. A high Vt and the choice of colloids for the FC are factors potentially influencing PPV reliability., Trial Registration: PROSPERO (CRD42022379120), December 2022. https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=379120., (© 2023. The Author(s).)

Background: We aimed at determining whether a 2-h session of high-flow nasal oxygen (HFNO) immediately after extubation improves oxygen exchange after major gynaecological surgery in the Trendelenburg position in adult female patients., Methods: In this single-centre, open-label, randomised trial, patients who underwent major gynaecological surgery were randomised to HFNO or conventional oxygen treatment with a Venturi mask. The primary outcome was the Pao 2 /FiO 2 ratio after 2 h of treatment. Secondary outcomes included lung ultrasound score, diaphragm thickening fraction, dyspnoea, ventilatory frequency, Paco 2 , the percentage of patients with impaired gas exchange (Pao 2 /FiO 2 ≤40 kPa) after 2 h of treatment, and postoperative pulmonary complications at 30 days., Results: A total of 83 patients were included (42 in the HFNO group and 41 in the conventional treatment group). After 2 h of treatment, median (inter-quartile range) Pao 2 /FiO 2 was 52.9 (47.9-65.2) kPa in the HFNO group and 45.7 (36.4 -55.9) kPa in the conventional treatment group (mean difference 8.7 kPa [95% CI: 3.4 to 13.9], P=0.003). The lung ultrasound score was lower in the HFNO group than in the conventional treatment group (9 [6-10] vs 12 [10-14], P<0.001), mostly because of the difference of the score in dorsal areas (7 [6-8] vs 10 [9-10], P<0.001). The percentage of patients with impaired gas exchange was lower in the HFNO group than in the conventional treatment group (5% vs 37%, P<0.001). All other secondary outcomes were not different between groups., Conclusions: In patients who underwent major gynaecological surgery, a pre-emptive 2-h session of HFNO after extubation improved postoperative oxygen exchange and reduced atelectasis compared with a conventional oxygen treatment strategy., Clinical Trial Registration: NCT04566419., (Copyright © 2023 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Intraoperative hypotension (IOH) is associated with increased morbidity and mortality. Hypotension Prediction Index (HPI) is a machine learning derived algorithm that predicts IOH shortly before it occurs. We tested the hypothesis that the application of the HPI in combination with a pre-defined Goal Directed Therapy (GDT) hemodynamic protocol reduces IOH during major gynaecologic oncologic surgery. We enrolled women scheduled for major gynaecologic oncologic surgery under general anesthesia with invasive arterial pressure monitoring. Patients were randomized to a GDT protocol aimed at optimizing stroke volume index (SVI) or hemodynamic management based on HPI guidance in addition to GDT. The primary outcome was the amount of IOH, defined as the timeweighted average (TWA) mean arterial pressure (MAP) < 65 mmHg. Secondary outcome was the TWA-MAP < 65 mmHg during the first 20 min after induction of GA. After exclusion of 10 patients the final analysis included 60 patients (30 in each group). The median (25-75th IQR) TWA-MAP < 65 mmHg was 0.14 (0.04-0.66) mmHg in HPI group versus 0.77 (0.36-1.30) mmHg in Control group, P < 0.001. During the first 20 min after induction of GA, the median TWA-MAP < 65 mmHg was 0.53 (0.06-1.8) mmHg in the HPI group and 2.15 (0.65-4.2) mmHg in the Control group, P = 0.001. Compared to a GDT protocol aimed to SVI optimization, a machine learning-derived algorithm for prediction of IOH combined with a GDT hemodynamic protocol, reduced IOH and hypotension after induction of general anesthesia in patients undergoing major gynaecologic oncologic surgery.Trial registration number: NCT04547491. Date of registration: 10/09/2020., (© 2023. The Author(s).)

Background: Adequate pain management for abdominal hysterectomy is a key factor to decrease postoperative morbidity, hospital length of stay and chronic pain. General anesthesia is still the most widely used technique for abdominal hysterectomy. The aim of this study was to assess the efficacy and safety of blended anesthesia (spinal and general anesthesia) compared to balanced general anesthesia in patients undergoing hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis., Methods: We retrospectively collected data from adult ASA 1 to 3 patients scheduled for laparoscopic or mini-laparotomic hysterectomy with or without lymphadenectomy for ovarian, endometrial or cervical cancer or for fibromatosis. Exclusion criteria were age below 18 years, ASA > 3, previous chronic use of analgesics, psychiatric disorders, laparotomic surgery with an incision above the belly button and surgery extended to the upper abdomen for the presence of cancer localizations (e.g., liver, spleen or diaphragm surgery). The cohort of patients was retrospectively divided into three groups according to the anesthetic management: general anesthesia and spinal with morphine and local anesthetic (Group 1), general anesthesia and spinal with morphine (Group 2) and general anesthesia without spinal (Group 3)., Results: NRS was lower in the spinal anesthesia groups (Groups 1 and 2) than in the general anesthesia group (Group 3) for every time point but at 48 h. The addition of local anesthetics conferred a small but significant NRS decrease ( p = 0.009). A higher percentage of patients in Group 3 received intraoperative sufentanil (52.2 ± 18 mcg in Group 3 vs. Group 1 31.8 ± 16.2 mcg, Group 2 44.1 ± 15.6, p < 0.001) and additional techniques for postoperative pain control (11.4% in Group 3 vs. 2.1% in Group 1 and 0.8% in Group 2, p < 0.001). Intraoperative hypotension (MAP < 65 mmHg) lasting more than 5 min was more frequent in patients receiving spinal anesthesia, especially with local anesthetics (Group 1 25.8%, Group 2 14.6%, Group 3 11.6%, p < 0.001), with the resulting increased need for vasopressors. Recovery-room discharge criteria were met earlier in the spinal anesthesia groups than in the general anesthesia group (Group 1 102 ± 44 min, Group 2 91.9 ± 46.5 min, Group 3 126 ± 90.7 min, p < 0.05). No differences were noted in postoperative mobilization or duration of ileus., Conclusions: Intrathecal administration of morphine with or without local anesthetic as a component of blended anesthesia is effective in improving postoperative pain control following laparoscopic or mini-laparotomic hysterectomy, in reducing intraoperative opioid consumption, in decreasing postoperative rescue analgesics consumption and the need for any additional analgesic technique. We recommend managing postoperative pain with a strategy tailored to the patient's physical status and the type of surgery, preventing and treating side effects of pain treatments.

Malignant hyperthermia is a rare but life-threatening pharmacogenetic disorder triggered by exposure to specific anesthetic agents. Although this occurrence could affect virtually any patient during the perioperative time, the pediatric population is particularly vulnerable, and it has a five-fold higher incidence in children compared to adults. In the last few decades, synergistic efforts among leading anesthesiology, pediatrics, and neurology associations have produced new evidence concerning the diagnostic pathway, avoiding unnecessary testing and limiting false diagnoses. However, a personalized approach and an effective prevention policy focused on clearly recognizing the high-risk population, defining perioperative trigger-free hospitalization, and rapid activation of supportive therapy should be improved. Based on epidemiological data, many national scientific societies have produced consistent guidelines, but many misconceptions are common among physicians and healthcare workers. This review shall consider all these aspects and summarize the most recent updates.