Advances in Anesthesia and Pain Medicine
Advances in Anesthesia and Pain Medicine (AAPM) is the Official Journal of ESRA ITALIA (European Society of Regional Anaesthesia & Pain Therapy). The journal is established as a platform dedicated to fostering multidisciplinary dialogue within the fields of anesthesia, pain management, and the broader domains of perioperative and critical care medicine. The journal is grounded in the conviction that the most effective approach to 21st-century healthcare lies in cross-disciplinary collaboration. We believe that optimal patient care results from the continuous integration of diverse medical expertise within cohesive, interdisciplinary teams. AAPM encompasses a wide spectrum of topics related to emergency medicine, surgery, anesthesia, and intensive care. The journal welcomes contributions ranging from experimental and laboratory research, clinical trials, and observational studies, to the development and analysis of organizational models and clinical outcomes assessment. As an open-access journal, AAPM is committed to promoting the broadest possible dissemination of scientific knowledge. The editorial process is designed to be both rigorous and efficient, ensuring timely peer review and publication. Authors receive comprehensive support from the editorial board throughout the submission and publication workflow. We seek contributions of high scientific quality, including original clinical research, experimental investigations, epidemiological analyses, and conceptual papers that propose innovative models of care. The journal accepts a variety of manuscript types: original research articles, clinical trials, short communications, case reports of particular significance, brief reports, systematic reviews, narrative reviews, perspectives, commentaries, and editorials. This diversity of formats aims to encourage the exchange of ideas and experiences—ranging from individual clinical cases to large-scale data analyses, and from structured evidence to thought-provoking hypotheses. In addition, AAPM is attentive to ethical issues and the organizational and managerial aspects of healthcare delivery. Our readership and contributor base is global, comprising professionals across the aforementioned fields, including physicians, nurses, allied healthcare providers, biomedical technicians, and healthcare managers.
Cryoneuromodulation of the sphenopalatine ganglion via transnasal approach in Sluder’s syndrome: a case report
Sluder’s neuralgia is a rare form of facial pain associated with autonomic symptoms and often refractory to conventional therapies. Cryoneuromodulation provides a minimally invasive approach capable of temporarily interrupting nociceptive transmission without permanent neural damage. We describe the case of a 41-year-old male with a 15-year history of left-sided migraine-like facial pain radiating to the nasal ala and supraorbital, frontal, and occipital regions. Symptoms included lacrimation, rhinorrhea, photophobia, and tactile hyperalgesia. A diagnostic transnasal sphenopalatine ganglion (SPG) block using 2% lidocaine resulted in complete pain remission. Due to partial recurrence, fluoroscopy-guided transnasal cryoneuromodulation at −78°C was performed for 4 minutes. Immediate and sustained relief (Numerical Rating Scale [NRS] 0) was achieved and maintained at 120-day follow-up. Fluoroscopy-guided transnasal cryoneuromodulation is a safe, effective, and well-tolerated therapeutic option for Sluder’s neuralgia, offering sustained relief without neural injury. It may represent a less invasive alternative to infrazygomatic radiofrequency (RF) or stimulation approaches, with potentially improved tolerability in selected patients.
Copyright (c) 2026 Chiara Maggiani, Pierfrancesco Fusco, Fabrizio Fattorini, Walter Ciaschi https://creativecommons.org/licenses/by-nc/4.0
Peripheral nerve blocks as an alternative for total hip endoprosthesis surgery in elderly patients with femoral fracture
Proximal femoral fractures represent a significant anesthetic challenge in the geriatric population. Advanced age, frailty, and multiple comorbidities are associated with increased perioperative risk, particularly in the context of general anesthesia, while neuraxial techniques may be limited by the frequent use of anticoagulant therapy. Ultrasound-guided peripheral nerve blocks (PNBs) combined with light sedation may offer a potential alternative approach in selected high-risk patients. We report two elderly female patients (aged 91 and 99 years) with proximal femoral fractures who underwent total hip endoprosthesis surgery. Anesthetic management consisted of a lumbar erector spinae plane (L-ESP) block combined with a fascia iliaca compartment block (FICB). Sedation was administered via target-controlled infusion (TCI) of propofol, and depth of sedation was continuously monitored using the Conox system (Fresenius Kabi, Bad Homburg, Germany). Both procedures were completed without conversion to general or neuraxial anesthesia. Intraoperative hemodynamic parameters remained within acceptable ranges, and postoperative analgesia was adequate. No episodes of postoperative delirium or major perioperative complications were observed. These cases suggest that the combined use of L-ESP and FICBs, supplemented with light TCI-guided sedation, may represent a feasible anesthetic alternative in carefully selected elderly patients undergoing total hip endoprosthesis surgery for femoral fracture. Further investigation in larger cohorts is warranted to better define its role in this setting.
Ultrasound lumbar erector spinae plane block
Copyright (c) 2026 Thierry Claude Bagaphou, Laviniarita Parisi, Nicole Sasso, Valentina Carsena, Domenico Pietro Santonastaso https://creativecommons.org/licenses/by-nc/4.0
Combined pericapsular nerve group and lumbosacral erector spinae plane blocks for hip hemiarthroplasty in a high-risk elderly patient
Elderly patients with hip fractures frequently present with severe comorbidities that substantially increase the risks associated with general or neuraxial anesthesia. In particular, severe cardiovascular disease and ongoing anticoagulation may limit anesthetic options. We report the successful use of a multimodal regional anesthesia strategy combining pericapsular nerve group (PENG) block and lumbosacral erector spinae plane (LS-ESP) block to provide surgical anesthesia and analgesia for hip hemiarthroplasty in a highly complex, frail patient. An 87-year-old woman with chronic atrial fibrillation and double mechanical heart valves underwent hip surgery under spontaneous breathing. Effective intraoperative analgesia was achieved with minimal sedation, without respiratory or hemodynamic instability. At the end of surgery, the patient reported complete pain control and remained clinically stable. This case supports the feasibility of combining extended fascial plane blocks as an alternative strategy in selected high-risk patients undergoing major orthopedic surgery.
Copyright (c) 2026 Fabrizio Fattorini, Benedetto Alfonsi, Raffaele Formica, Andrea Pecora, Francesco Marrone https://creativecommons.org/licenses/by-nc/4.0
Cyanoacrylate glue fixation of continuous infusion catheters: a simple and effective alternative to adhesive dressings
Dear Editor, The Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI), in its recommendations on acute postoperative pain management, advises the use of continuous infusion of local anesthetic when moderate-to-severe pain is expected to last more than 24 hours. The growing need to optimize surgical recovery and minimize opioid use has made regional analgesia techniques essential in many surgical specialties. [...]
Copyright (c) 2026 Maurizio Ferrara, Federica Monaco, Luca Arcopinto, Francesco Paolo D'Alessio https://creativecommons.org/licenses/by-nc/4.0
Anatomical variation of the brachial plexus roots identified during pre-procedural ultrasound for an interscalene block
Dear Editor, In shoulder surgery, the interscalene brachial plexus block (ISB) remains the most frequently employed technique. At this level, the brachial plexus roots are known to display several anatomical variations. In this letter, we report an anatomical variant of the brachial plexus roots observed during an ultrasound scan prior to performing an ISB. We illustrate the observed sono-anatomy features of the variant seen, offer an explanation as to why targeting this variant may clinically result in a failed block, and describe a rescue strategy. [...]
Copyright (c) 2026 Federico Tamburi, Giorgio Ranieri, Aneurin Moorthy https://creativecommons.org/licenses/by-nc/4.0
Oral Ialoral® Forte versus ultrasound-guided intra-articular cortisone infiltration: results of a retrospective single-center study
Osteoarthritis (OA) is a common cause of pain and functional limitation. We compared the analgesic and functional outcomes of Ialoral® Forte, a nutraceutical formulation, with those of ultrasound-guided intra-articular triamcinolone in patients with hip or knee OA and baseline Numeric Rating Scale (NRS) ≤5. This retrospective single-center study included 60 patients (NRS≤5, Kellgren-Lawrence grade I-II) treated between June 2022 and January 2023. Group A received oral Ialoral® Forte (two tablets daily for 40 days); group B underwent two ultrasound-guided intraarticular corticosteroid injections 20 days apart. Pain intensity (NRS) and joint function (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were evaluated at baseline and at 20, 40, 60, and 90 days. Both treatments significantly reduced pain and improved joint function over time. No statistically significant differences were observed between groups (p>0.05). Oral Ialoral® Forte achieved comparable analgesic and functional outcomes to intra-articular corticosteroids, without injection-related risks or contraindications. Oral Ialoral® Forte represents a safe, effective, and non-invasive alternative to intra-articular corticosteroid injections for the management of mild to moderate osteoarthritis, providing similar short-term pain relief and functional recovery with excellent tolerability.
Copyright (c) 2025 Walter Ciaschi, Fabrizio Fattorini, Pierfrancesco Fusco, Chiara Maggiani https://creativecommons.org/licenses/by-nc/4.0
Labor analgesia is more than a technique: a call for holistic and respectful care
Neuraxial labor analgesia has improved pain control and childbirth outcomes. Yet, pain is a multidimensional experience requiring more than technical skill. This article calls for a holistic, woman-centered model in which the anesthesiologist plays a key role. The purpose is to promote a cultural shift: making labor analgesia not only effective, but also respectful and meaningful.
Copyright (c) 2025 Dario Cirillo, Antonio Coviello, Giorgio Ranieri, Domenico Pietro Santonastaso, Maria Grazia Frigo https://creativecommons.org/licenses/by-nc/4.0
GekoTM system to predict peripheral nerve stimulation: reality or fantasy? A prospective pilot study
Peripheral nerve stimulation (PNS) is an established therapy for chronic pain refractory to conventional treatments. Wearable devices such as the gekoTM system, originally developed to enhance lower limb circulation, may have potential as non-invasive screening tools to predict PNS candidacy. The present prospective, uncontrolled pilot study aimed to evaluate the feasibility of using the gekoTM device for predicting responsiveness to implanted PNS in patients with refractory chronic pain. Twenty patients with refractory chronic pain were treated with low-frequency common peroneal nerve stimulation (1 Hz, 6 hours/day) for 10 consecutive days using the gekoTM device. Outcomes included Numeric Rating Scale (NRS) pain scores, quality of life (QoL), oxygen saturation index (SpO2), and patient satisfaction. The primary endpoint was defined as the proportion of patients achieving a reduction of ≥50% in NRS scores. Statistical significance was evaluated using paired t-tests (p<0.05). Treatment led to significant improvements in pain, SpO2, and QoL. Half of the patients achieved the primary endpoint, and no serious adverse events were reported. The satisfaction rate among completed cases was 100%. The gekoTM device shows promise as a non-invasive screening tool for PNS candidacy. These results should be interpreted cautiously, given the small sample size, lack of a control group, and exploratory design. Larger, controlled trials are warranted.
Copyright (c) 2025 Massimiliano Raggi, Giovanni Pedrotti https://creativecommons.org/licenses/by-nc/4.0
The integration of artificial intelligence in regional anesthesia: perspectives, challenges, and opportunities
Artificial intelligence (AI) presents new opportunities in medicine for enhancing clinical outcomes, professional training, and healthcare organizations. We emphasize the importance of thoroughly understanding new technologies and defining their potential and limitations, promoting the construction of multidisciplinary collaborations to provide modern, comprehensive anesthesiological training.
Copyright (c) 2025 the Author(s) https://creativecommons.org/licenses/by-nc/4.0
Comparative effectiveness of continuous subcostal transversus abdominis plane block versus thoracic epidural analgesia in postoperative pain management following major open abdominal surgery: a prospective observational study
This observational study compared the effectiveness of continuous subcostal transversus abdominis plane (TAP) block with bilaterally placed catheters versus continuous thoracic epidural analgesia (TEA) in managing postoperative pain following major open abdominal surgery. Thirty-one patients were enrolled between July 2019 and September 2020 at the Policlinico Paolo Giaccone in Palermo and divided into two groups. Postoperative pain, opioid consumption, incidence of postoperative nausea and vomiting (PONV), hemodynamic stability, and patient satisfaction were evaluated. No significant differences were observed in the number rating scale (NRS) values at 0, 6, 12, and 24 hours between groups. Only 3 patients in the TAP group required opioids in the first 24 hours; however, no differences were observed in median opioid consumption between groups (TEA 0.00 [0.00-0.00]; TAP 0.00 [0.00-0.00], p=0.08). Hemodynamic stability was evaluated using mean arterial pressure and heart rate values, with no significant differences found for either parameter over time. The incidence of PONV was similar in both groups (p=0.47). The continuous TAP block represents an effective, less invasive alternative to TEA, particularly in patients with contraindications to neuraxial analgesia, aligning with Enhanced Recovery After Surgery (ERAS) protocols and the procedure-specific postoperative pain management (PROSPECT) methodology.
Regional anesthesia for urgent upper limb surgery in a pregnant woman with HIV: a case-based insight into multidisciplinary and drug-sparing management
Anesthetic management in pregnant women requiring urgent non-obstetric surgery is particularly challenging in the presence of comorbidities such as HIV and obesity. This report outlines the perioperative approach adopted for a 26-year-old woman at 23 weeks of gestation with AIDS and an elevated body mass index (BMI) undergoing orthopedic surgery following elbow trauma. A supraclavicular brachial plexus block was successfully used for intraoperative anesthesia and postoperative analgesia, thus avoiding systemic medications and minimizing fetal exposure. This case exemplifies how regional anesthesia, combined with coordinated multidisciplinary care, can offer safe and effective management in high-risk pregnancies. Findings support the growing literature favoring individualized, minimally invasive anesthetic strategies, especially in immunocompromised patients.
Hip arthroplasty under pericapsular nerve group blocks combined with local anesthesia
Hip arthroplasty and endoprosthesis surgery typically utilize general or spinal anesthesia, but regional techniques like the PENG block offer potential analgesic benefits. This report presents three cases in which a modified ultrasound-guided pericapsular infiltration technique is used as the only technique for hip surgery. Three patients undergoing hip arthroplasty/endoprosthesis surgery with different approaches (direct anterior, lateral, and posterolateral) received ultrasound-guided anterior and posterior pericapsular injections (A-PENG and PONG) and additional local anesthetic infiltration tailored to the surgical approach. All patients experienced successful intraoperative anesthesia and adequate postoperative analgesia within 24 hours, with no motor block. The technique was adaptable to different approaches and patient characteristics. This case series suggests the feasibility and potential benefits of the pericapsular nerve blocks as a regional anesthesia option for hip surgery. Further research is needed to compare its efficacy, safety, and cost-effectiveness with other techniques in larger, controlled studies.
Comparative efficacy of pericapsular nerve group block versus fascia iliaca block in postoperative analgesia for total hip arthroplasty: a retrospective observational study
Effective postoperative pain management is essential to optimize outcomes in total hip arthroplasty (THA). While the fascia iliaca (FI) block has been commonly used, the pericapsular nerve group (PENG) block has emerged as a potentially more targeted alternative. This study aimed to compare the analgesic efficacy and safety of the PENG block versus the FI block in patients undergoing elective THA. In this retrospective observational study, 30 patients scheduled for primary elective THA were divided into two groups: one receiving an FI block (40 mL of 0.25% ropivacaine + 4 mg dexamethasone) and the other a PENG block (20 mL of 0.25% ropivacaine + 4 mg dexamethasone), both performed under ultrasound guidance. Pain scores were assessed using the Numeric Rating Scale (NRS) at 0, 6, 12, 18, and 24 hours postoperatively. Additional outcomes included opioid consumption, time to ambulation, and adverse events. The PENG group reported significantly lower NRS scores at all time points (p<0.05), with the most pronounced difference observed immediately postoperatively and at 24 hours. Time to ambulation was significantly shorter in the PENG group (9.2±2.1 hours vs. 11.6±2.8 hours; p=0.01). Opioid consumption and incidence of adverse events were similar between groups. The PENG block provided superior early postoperative analgesia and facilitated earlier mobilization compared to the FI block in patients undergoing elective THA, without increasing opioid use or complications. These findings support its integration into multimodal analgesic protocols for hip surgery.
Loxosceles rufescens: single-institutional epidemiology, diagnosis and treatment
Loxosceles rufescens, also known as “violin spider” due to its characteristic appearance, is a medium-sized spider species that can potentially pose a threat to humans. For this study, patients who presented to our hospital’s Poison Control Center between January 1, 2022, and December 31, 2022, and met the following inclusion criteria were included: Suspicion of a violin spider bite, as evaluated by our center. Our protocol involves an initial local treatment, which includes local washing with copious water and disinfection, along with the application of chlorotetracycline hydrochloride. Systemic therapy utilizes Amoxicillin and Clavulanic Acid as the first-line medication. The primary endpoints of this study are the timing and effectiveness of the treatment for cutaneous lesions. Demographic and anamnestic information regarding age, gender, and timelines was summarized using descriptive methods. Our study’s results indicate that erythema and pain are the most frequent symptoms. Loxoscelism is highly concentrated in the Western hemisphere and is considered the only proven arachnological cause of dermo-necrosis. In recent years, there has been an increase in diagnoses.
Copyright (c) 2024 the Author(s) http://creativecommons.org/licenses/by-nc/4.0
COVID-19 in pregnant women: description of a possible case of COVID-19-linked HELLP-like syndrome
New evidence suggests that Sars-CoV2 infection during pregnancy may result in complications such as hypertension, nephropathy, thrombocytopenia, and liver damage. A pre-eclampsia-like syndrome has also been proposed in pregnant women with severe SARS-CoV-2 infection, which meets the pre-eclampsia criteria but resolves without delivery, with improvement in respiratory symptoms. 31-year-old, second pregnancy, in Emergency Room for PROM (premature rupture of membranes), has Sars-CoV2 infection and has not been vaccinated. Normal examinations and mild hypertension were present upon admission, but no treatment was administered. Vaginal Leukocytic Delivery 12 hours after admission, newborn Apgar score 9/10, weight 3.250 kg. At 20 hours after delivery, epigastric pain VAS 8-9 for 20 minutes, systolic/diastolic hypertension peak, increase in transaminases, LDH, ALP, Bilirubin, Dimer, platelet and fibrinogen drop. Neurological and respiratory objectivity were negative, and renal indices were within normal limits, so nifedipine 30mgx2/day + methyldopa 500 mgx2/day was started. Abdominal ultrasound revealed a thin perihepatic fluid stratum. A prophilaxis of dexamethasone 12mg twice a day and magnesium sulfate was introduced. At 32 hours after delivery, the laboratory detected an increase in transaminases, LDH, and worsening of thrombocytopenia. The patient is always eupnoic, and the diuresis is adequate. Blood tests improved gradually after 56 hours postpartum. Methyldopa and steroids are escalating. On day 7, discharge with normalized platelet and bilirubin counts and a decreasing trend in transaminases, LDH, and PAL. At the one-week follow-up, liver enzymes and coagulation were completely normal, and blood pressure was well controlled with methyldopa. We conclude that the simultaneous presence of the two diseases could have had a synergistic or opportunistic effect, resulting in severe clinical manifestations via interaction with the Renin-Angiotensin-Aldosterone system.
Dealing with specialist pathology: an unusual case of ovarian hyperstimulation syndrome managed in the emergency department with point of care ultrasound
Ovarian hyperstimulation syndrome (OHSS) is a well-known complication of assisted reproduction. The hyperstimulated ovaries release vasoactive substances that can increase capillary permeability, resulting in volume shift to the extravascular space and leading to hypovolemia, ascites and, in complicated cases, pleural and pericardial effusions, kidney and liver failure, shock. Point Of Care UltraSound (POCUS) can help the emergency physician to detect many of these complications, as well as guide their treatment. In this case report we present a patient at low risk for OHSS who recently underwent a successful in vitro fertilization, coming to the emergency department with an unusual complication of OHSS (an isolated pleural effusion), that has been safely and promptly diagnosed and treated in the emergency room with the help of POCUS, without any unnecessary exposition to ionizing radiations.
Copyright (c) 2023 the Author(s) http://creativecommons.org/licenses/by-nc/4.0
Awake intubation in a patient with morbid obesity in the emergency department: our experience
Awake intubation is considered the standard of care for the management of the anticipated difficult airway. For its pharmacological properties, remifentanil is ideal for managing difficult endotracheal insertions. This process is augmented by the use of transtracheal injection of lidocaine as it disperses evenly around the area and facilitates the action of remifentanil further. A 48-year-old male patient, weight 200 kg, 184 cm tall (BMI>40) came into the emergency room for severe hypercapnic hypoxic respiratory failure. Awake fiberoptic intubation was the option to secure the airway. Successful airway management is critical to the practice of emergency medicine. All anesthesiologists should be familiar with the airway management of obese patients.
Levosimendan off-label successfully used in two patients with exacerbated COPD and severe bronchospasm: a case series focusing on an explorative review of the current literature
Levosimendan was used off label to treat two patients with similar clinical and medical history (severe COPD, bronchospasm, cigarette smoking, difficult weaning). Starting from these two favorable cases, an explorative review of the current literature was conducted relating to this use of Levosimendan and its rationale.
Vincenzo Tiberio, interspecies competition and infection control strategies
The following paper sums up the history of Dr. Vincenzo Tiberio, a military physician from Italy, who lived around the second half of the past century. His life was dedicated to clinical research, particularly in the context of microorganism competition and mechanisms of transmission of infections. His scientific work, though significant and innovative, was adequately appreciated just many years after his death; a great loss for the scientific world since his discovery could have laid the groundwork for the development of antimicrobial drugs that can be used nowadays in the infection control strategies.
Current need for guidelines in emergency surgery in peritoneal carcinomatosis
Malignant bowel obstruction caused by peritoneal carcinomatosis is a common complication that affects a large proportion of gastrointestinal and ovarian oncology patients and predicts poor longterm survival. The management strategy for these patients includes a variety of medical therapies and surgical options; however, how to choose the best treatment strategy remains a mystery. The purpose of this narrative review was to summarize the most recent evidence on multimodal malignant bowel obstruction treatment and determine whether or not progress had been made. We should work to establish consensus guidelines, where possible, to ensure that this unique patient group receives the appropriate treatment or compassionate care during this often terminal event.
Clinical data transmission in intensive care unit: what have we learned from COVID-19?
The COVID-19 pandemic, besides stimulating new integrated assistance systems 1, has altered the clinical approach in I.C.U., the management of medical information, and the methods of communication between doctors and family members. The transmission of news between the hospital and the family was ensured via a multimedia network, replacing the understanding between doctor and family established with de visu meetings. The pandemic emergency has forced healthcare professionals to adopt this new method of communication, exposing the doctor to a series of critical issues related to the transmission of sensitive data. A review of the scientific literature underlines that not many articles deal with regulations and issues related to the processing of health data in the COVID period; however, there are many challenges such as security risks, privacy, ethical and process standardization issues. We believe that this topic should be the subject of an urgent debate, deepening the matter with a specific medico-legal background.
Wearable defibrillator use in patients with high risk of sudden cardiac death: a brief report from a single center
Devices such as implantable cardioverter defibrillators (ICDs) and wearable cardioverter defibrillators (WCDs) have opened up new paths in the treatment of Sudden Cardiac Death. Guidelines advocate ICD placement for primary prevention after at least three months of optimal medical therapy following the first diagnosis of heart failure with reduced FE from any cause, and at least 40 days after an acute myocardial infarction with FE 35% notwithstanding medication. In these and other cases documented in the guidelines, the use of a wearable defibrillator (WCD), a noninvasive device that guards against malignant arrhythmias while waiting for arrhythmic risk to be defined and medication therapy to be optimized, may be considered. In our Cardiology/Utic Department, we treated 26 patients with a preliminary indication for ICD implantation: the use of the WCD allowed us to swiftly put them in clinical safety, avoiding potentially fatal arrhythmias while waiting for pharmacological therapy to be optimized. At the end of the periodic follow-up, FE had normalized in ten patients, allowing them to avoid ICD. Only 10 of the 26 participants with WCD had a proven indication for final implantation. There were no fatalities or problems in any of the patients.
Distal perfusion cannula on VA-ECMO: do not blindly trust! A case report
Distal perfusion cannulas (DPCs) are increasingly used to prevent limb ischemia, frequent and potentially serious complication on peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support. We report the case of a patient treated with femoro-femoral V-A ECMO who developed a sudden, significant asymmetric decrease in cannulated limb regional oxygen saturation, rSO2, signal, despite the presence of a DPC. This finding, noticed within 6 hours after the implementation of extracorporeal cardiopulmonary resuscitation (ECPR) in a patient experiencing refractory intra-hospital cardiac arrest (IHCA), suggested ongoing limb ischemia. After careful monitoring, a clot was detected in the line supplying DPC, which appeared completely kinked at dressing removal. Line patency and reperfusion were promptly re-established. No additional ischemic episodes occurred, and the patient was successfully weaned from extracorporeal support, and experienced full functional recovery, with no sensory or motor deficit. This case highlights the strict need for a careful, continuous monitoring of limb perfusion during V-A ECMO, even if limb perfusion through DPC is implemented, in order to prevent severe limb complications, negatively impacting on outcome.
Serratus plane block and erector spinae plane block in the management of pain associated with rib fractures in chest trauma: a brief report from a single-center
Pain harms the clinical course of individuals with rib fractures. Patients with more than three fractured ribs are more likely to have lung problems because pain can impede lung ventilation and secretion clearance due to difficulty coughing, resulting in atelectasis and hypoxia. Systemic analgesia to invasive regional anesthesia procedures such as thoracic epidural, paravertebral catheters, intercostal nerve blocks, and fascial plane blocks are all alternatives for analgesia in chest trauma. The study’s goal is to evaluate the analgesic efficacy of erector spinae plane (ESP) and serratus anterior plane (SAP) blocks in chest injuries, as well as their effect on improving respiratory metrics. For this objective, fifteen cases of isolated thoracic trauma resulting in rib fractures were reviewed retrospectively. All patients were at least 18 years old, spontaneously breathing, and had received a chest wall fascial plane block for pain relief. All patients reported practically instantaneous pain alleviation, with the onset occurring around 10 minutes after the block operation. One patient required oxygen therapy, but the rest were quickly weaned due to improved respiratory mechanics. Our findings suggest that chest wall anesthetic blocks are a safe and effective therapy for pain caused by rib fractures. At admission, the median NRS was 7 (RF 6:26.7%; 7:26.7%; 8:26.7%; 9:13.3%; 10:6.7%), with a minimum of 6 and a maximum of 10 (IQR: 1.5, CV: 0.2). All patients reported immediate pain relief that began around 10 minutes after the block was done; the average decrease in NRS was 6.8 points. They have also been shown to be effective and beneficial in improving respiratory parameters and lowering oxygen support.
Efficacy of ultrasound-guided erector spinae plane block versus transversus abdominis plane block for intraoperative and postoperative pain control in total laparoscopic hysterectomy: results of the ARTEMIDE randomised controlled trial
Laparoscopic hysterectomy (LH), one of the most common surgeries among women, results in moderate-to-severe postoperative pain. The use of the transversus abdominis plane (TAP) block for pain management in LH has been evaluated but with conflicting results. The erector spinae plane (ESP) block has emerged as an effective and safe technique for relieving visceral pain. This study aimed to compare the analgesic efficacy of posterior TAP block versus ESP block following LH. We conducted a prospective, randomised, multicentre study. Seventy-six patients (American Society of Anesthesiologists I–III) scheduled for elective LH were included in the final analysis. The interventions performed were posterior TAP block (TAP group) and ESP block at T8 (ESP group). We adopted numerical rating scale (NRS) scores for pain at different time points, intraoperative remifentanil need, rescue analgesic requirements, incidence of postoperative nausea and vomiting in the first 36 postoperative hours, and days of hospitalisation as criteria of evaluetion. At nearly all time points, NRS scores did not significantly differ between the TAP and ESP groups. The TAP group had higher NRS scores for pain in the immediate postoperative period (p=0.008). The need for intraoperative remifentanil was higher in the TAP group (p=0.0018). When needed, remifentanil was infused at slower maximum infusion rates in the ESP group than in the TAP group (mean±SD: 0.02±0.04 vs. 0.04±0.05, respectively; p=0.006). The total rescue analgesic requirements in the first 36 postoperative hours did not significantly differ between the two groups. We conclude that following LH, the posterior TAP and ESP blocks can achieve similar levels of pain management.
Acinetobacter cavitations in COVID-19 interstitial pneumonia: a case report and review of the literature
Acinetobacter baumannii is commonly known to cause infection in immunocompromised patients. During COVID-19 pandemic, outbreaks of multidrug-resistant organisms, including Acinetobacter, have been well documented in acute care hospitals, particularly among critically ill patients. In the case reported, a woman was admitted to our ICU because of a severe COVID-19 pneumonia. During her stay, she worsened due to Acinetobacterrelated lung cavitations and only after proper antibiotic treatment she eventually recovered. To our knowledge, very few cases have been reported pointing to Acinetobacter as a causal agent for the acute development of lung cavities, especially in COVID-19 patients.
Efficacy of repeated pronations in patients affected by COVID-19-related acute respiratory distress syndrome: think it twice!
Prone position is widely used to ameliorate gas exchange in severe COVID-19-related ARDS (CARDS), through its beneficial effects on shunt and dead space. However, the effectiveness of repeated pronation has never been explored in this category of patients. We then retrospectively analyzed the changes of the alveolar-arterial oxygen gradient (A-aO2grad), as shunt index, and the ratio EtCO2/paCO2 ratio, as dead space index, during repeated pronation cycles in 7 patients with CARDS admitted to our Intensive Care Unit. The A-aO2grad decreased significantly more during the first pronation than the second (-43.6% vs. -12.2% - p0.008) and, similarly, the improvement was maintained only after the first supination (-26.2% vs. +9% - p0.04). The EtCO2/paCO2 ratio showed similar behavior but did not achieve statistical significance. Considering our findings, with the inherent limitations of the study, since pronation entails risks for the patient, as well as requiring a lot of effort from the nursing staff, further caution appears to be necessary in indicating pronation.
Esophageal manometry: a valuable tool for the comprehensive management of COVID-19-related hypoxic respiratory failure
The optimal management of respiratory failure related to SARS-CoV-2 infection is a subject of heated debates in the scientific community. The lack of solid scientific evidence, combined with the unclear pathophysiology of COVID-19 pneumonia, means that the modalities and duration of ventilator assistance often rely on subjective assessments of the doctor on call. In establishing a suitable respiratory support, it is essential to evaluate the degree of activation of the respiratory muscles as objectively as possible. Among the various methods of evaluating the inspiratory effort, measurement of the phasic variations of esophageal pressure (intended as a surrogate of pleural pressure) represents the gold standard. Esophageal pressure measurement can be implemented in a minimally invasive way in every patient category, does not require sophisticated devices, and provides objective data about respiratory muscle activity. In patients with ongoing COVID-19-related respiratory failure, esophageal pressure monitoring allows i) optimizing the type and settings of noninvasive ventilation, ii) providing objective support in the delicate choice of establishing invasive ventilation in cases in which such an indication is unclear, and iii) monitoring the clinical evolution of COVID-19 pneumonia to allow early interception of cases with progressive worsening of lung function. Esophageal manometry provides a complete and objective assessment of respiratory muscle activity. Its clinical use in patients with respiratory failure in the course of COVID-19 would allow clarifying some pathophysiological aspects of the disease and customizing ventilatory support according to the needs of specific patients.
Stroke in Mycoplasma pneumoniae pneumonia: a clinical case
Mycoplasma pneumoniae (MP) cause more than 40% of community- acquired pneumonia. Sometimes extrapulmonary manifestations may occur: in particular, central nervous system (CNS) symptoms occur in 10% of hospitalizations for MP. A young woman was being admitted to our intensive care unit (ICU) for respiratory failure and suspected stroke, ten days after flu-like syndrome. The patient was already intubated, sedated, in controlled mechanical ventilation. At admission brain computed tomography (CT) was negative, chest CT showed bilateral pneumonia with interstitial thickening. After 36 hours, brain CT showed an extensive hypodense cortico-subcortical area with frontal-parietal-temporal left seat. The positivity of IgM for MP and PCR in nasopharynx led to the diagnosis of MP pneumonia complicated by stroke: 15 days after admission, a post-ischemic status was manifested by aphasia, dysphagia, right brachio-crural hemiplegia. In our paper we evaluated possible major neurological complications, up to stroke, in MP respiratory infection. We concluded that, although they are actually rare, neurological symptoms up to cerebral ischemia in young people with MP pneumonia, are to be considered.
Thoracic paravertebral block vs. mid-point transverse process to pleura block in thoracic surgery. Preliminary evaluation of effectiveness and safety
Mid-point transverse process to pleura block (MTPB) is an alternative approach to paravertebral block. We retrospectively assessed hemodynamic stability, inadvertent pleural puncture and antalgic effectiveness of this approach compared with traditional paravertebral block. Moreover, being used to add methylene bleu to local anesthetic solution as a tracer, we compared the diffusion pattern in paravertebral space of the two techniques. We reported retrospectively 40 patients underwent lung lobectomy from July to October 2021 in Monaldi Hospital (Naples, Italy) receiving thoracic paravertebral block (n=20) or mid-point transverse process to pleura block (n=20). The primary outcomes were a 20% mean arterial pressure variation from the base line, chest wall or pleural hematoma and technique failure. Analgesic effectiveness was assessed comparing remifentanil consumption to keep nociception index level <25 and patient’s visual analog scale (VAS) in post anesthesia care unit or daycare surgical unit at 60’. Also the methylene blue spread was assessed by a surgeon, blinded to patient’s name, reviewing surgery videorecord of every cases. MAP decrease >20% was greater in the thoracic paravertebral block (TPVB). No significative differences were reported for pleural punctures, chest wall hematomas or failure of the technique in the two groups. Methylene blue was evident in all patients of the TPVB, while it was not visible in any of the patients of the MTPB group. Remifentanil consumption, nociception index level and postoperative 60’ VAS were greater in the MTPB. Antalgic power and local anesthetic spread of TPVB seems to be superior to the MTPB, even if the safety profile of the latter seems to be better. Due to the retrospective nature of the study and the small number of cases in the sample, further studies are needed.
mid-point transverse process to pleura block