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Vergari A, Cortegiani A, Rispoli M, Coluzzi F, Deni F, Leykin Y, Luca Lorini F, Martorano PP, Paolicchi A, Polati E, Scardino M, Corcione A, Giarratano A, Rossi M. Sufentanil Sublingual Tablet System: from rationale of use to clinical practice. Eur Rev Med Pharmacol Sci 2020; 24:11891-11899. [PMID: 33275260 DOI: 10.26355/eurrev_202011_23847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The control of post-operative pain in Italy and other western countries is still suboptimal. In recent years, the Sufentanil Sublingual Tablet System (SSTS; Zalviso; AcelRx Pharmaceuticals, Redwood City, CA, USA), which is designed for patient-controlled analgesia (PCA), has entered clinical practice. SSTS enables patients to manage moderate-to-severe acute pain during the first 72 postoperative hours directly in the hospital setting. However, the role of SSTS within the current framework of options for the management of post-operative pain needs to be better established. This paper presents the position on the use of SSTS of a multidisciplinary group of Italian Experts and provides protocols for the use of this device.
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Affiliation(s)
- A Vergari
- Department of Anesthesiology, Intensive Care Medicine and Toxicology, A. Gemelli University Hospital Foundation, Catholic University of the Sacred Heart, Rome, Italy.
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Leykin Y, Laudani A, Busetto N, Chersini G, Lorini LF, Bugada D. Sublingual sufentanil tablet system for postoperative analgesia after gynecological surgery. Minerva Med 2019; 110:209-215. [DOI: 10.23736/s0026-4806.19.05992-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
A small priming dose of rocuronium can shorten the onset time of neuromuscular blockade. Induction agents with less cardiovascular depression also reduce the onset time. We hypothesized that ketamine, compared to thiopentone, would reduce onset time and improve intubating conditions following priming. Sixty patients ASA I to II, randomized by computer-generated sequence to four groups were investigated in a double-blind controlled trial. In the two groups with priming, 0.04 mg/kg of rocuronium was followed by three minutes of priming interval. Induction was followed by an intubation dose of 0.4 mg/kg of rocuronium. After 30 seconds, intubation was attempted within a further 20 seconds. In the two control groups, the same sequence was repeated except sham priming (saline) was given. For induction, S-ketamine (1 mg/kg) or thiopentone (4 mg/kg) were administered. Intubating conditions were graded as excellent, good, poor, or not possible. Neuromuscular transmission was monitored by acceleromyography of the thumb. There were no measured differences in onset time of neuromuscular block or in haemodynamics between the groups. The proportion of good to excellent intubating conditions was higher when ketamine was preceded by priming compared to ketamine without priming (87% vs 20%; P<0.05). In both priming and control groups intubating conditions were improved when using ketamine compared to thiopentone (P<0.05). The mechanism of this effect was not clear from this study.
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Affiliation(s)
- Y Leykin
- Department of Anaesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy
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De Robertis E, Caprino Miceli A, Colombo GL, Corcione A, Leykin Y, Scudeller L, Vizza E, Scollo P. Effects of Deep Versus Moderate Neuromuscular Blockade in Laparoscopic Gynecologic Surgery on Postoperative Pain and Surgical Conditions: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e131. [PMID: 29986847 PMCID: PMC6056743 DOI: 10.2196/resprot.9277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/28/2018] [Accepted: 02/28/2018] [Indexed: 11/24/2022] Open
Abstract
Background Postoperative pain, especially shoulder pain, is commonly reported after laparoscopic gynecologic procedures. Some studies suggest that a lower insufflation pressure may reduce the risk of postoperative pain; however, there is no agreement on the optimal pneumoperitoneum pressure during gynecologic laparoscopic surgery or whether lower pressure would lead to clinically significant improvements without increasing operative complications. Questions remain regarding the clinical significance of improvements, safety, and cost-effectiveness of deep neuromuscular blockade with low-pressure pneumoperitoneum. Objective The primary objective of this study was to assess the superiority of anesthesia with deep neuromuscular blockade with pneumoperitoneum 8 mm Hg over moderate blockade with pneumoperitoneum 12 mm Hg in terms of overall pain 24 hours after surgery in adult women undergoing pelvic surgery for hysterectomy or benign adnexal diseases. Effects on the intensity and timing of postoperative pain in specific locations, surgeon satisfaction, respiratory and hemodynamic stability, operating times, and direct and indirect costs will be assessed. Methods In this multicenter, randomized controlled trial with a superiority design, 300 patients will be randomly allocated in the ratio 1:1 to moderate neuromuscular blockade with a target insufflation pressure of 12 mm Hg or deep neuromuscular blockade with a target insufflation pressure of 8 mm Hg, with stratification by type of surgery and clinical center. The patient, the statistician, and the nurse who will assess the primary endpoint will be blinded to the allocation. Results Recruitment to this trial is expected to open in June 2018 and is expected to close in June 2019. Conclusions This study is designed to confirm the reported benefits of postoperative pain and provide additional data needed to address questions regarding the effects of this intervention on operating theater management and direct and indirect costs. Strengths of this protocol include the large sample size distributed among diverse institutions across the Italian territory and the collection and analysis of data on numerous secondary objectives. Limitations include the possible introduction of bias because the surgeon and anesthesiologist are not blinded to the intervention. Registered Report Identifier RR1-10.2196/9277
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Affiliation(s)
- Edoardo De Robertis
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, Section of Anaesthesia and Intensive Care Medicine, University Federico II, Naples, Italy
| | | | - Giorgio L Colombo
- Department of Drug Sciences, School of Pharmacy, University of Pavia, Italy, Milan, Italy.,Studi Analisi Valutazioni Economiche, Milan, Italy
| | - Antonio Corcione
- Thoracic Surgery, AORN dei Colli Vincenzo Monaldi Hospital, Napoli, Italy
| | - Yigal Leykin
- Anesthesia and Intensive Care, Azienda per l'Assistenza Sanitaria n. 5 - Friuli Occidentale, Pordenone, Italy
| | - Luigia Scudeller
- Scientific Direction, Clinical Epidemiology Unit, IRCCS San Matteo Foundation, Pavia, Italy
| | - Enrico Vizza
- Gynecologic Oncology, Regina Elena Hospital, Rome, Italy
| | - Paolo Scollo
- Maternity and Early Childhood Department, Gynecology and Obstetrics, Cannizzaro Hospital, Catania, Italy
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Muñoz R, Leykin Y, Barrera A, Brown C, Bunge E. The impact of phone calls on follow-up rates in an online depression prevention study. Internet Interv 2017; 8:10-14. [PMID: 30135824 PMCID: PMC6096302 DOI: 10.1016/j.invent.2017.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 02/08/2017] [Accepted: 02/14/2017] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Automated Internet intervention studies have generally had large dropout rates for follow-up assessments. Live phone follow-ups have been often used to increase follow-up completion rates. OBJECTIVE To compare, via a randomized study, whether receiving phone calls improves follow-up rates beyond email reminders and financial incentives in a depression prevention study. METHOD A sample of 95 participants (63 English-speakers and 32 Spanish-speakers) was recruited online to participate in a "Healthy Mood" study. Consented participants were randomized to either a Call or a No Call condition. All participants were sent up to three email reminders in one week at 1, 3, and 6 months after consent, and all participants received monetary incentives to complete the surveys. Those in the Call condition received up to ten follow-up phone calls if they did not complete the surveys in response to email reminders. RESULTS The follow-up rates for Call vs. No Call conditions at 1, 3, and 6 months, respectively, were as follows: English speakers, 58.6% vs. 52.9%, 62.1% vs. 52.9%, and 68.9% vs. 47.1%; Spanish speakers, 50.0% vs. 35.7%, 33.3% vs. 21.4%, and 33.3% vs. 7.1%. The number of participants who completed follow-up assessments only after being called at 1-, 3- and 6 months was 2 (14.3%), 0 (0%), and 3 (25.0%) for English speakers, and 2 (18.9%), 0 (0%), and 1 (7.7%) for Spanish speakers. The number of phone calls made to achieve one completed follow-up was 58.8 in the English sample and 57.7 and Spanish-speaking sample. CONCLUSIONS Adding phone call contacts to email reminders and monetary incentives did increase follow-up rates. However, the rate of response to follow-up was low and the number of phone calls required to achieve one completed follow-up raises concerns about the utility of adding phone calls. We also discuss difficulties with using financial incentives and their implications.
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Affiliation(s)
- R.F. Muñoz
- Palo Alto University, Palo Alto, CA, United States
- i4health, Palo Alto, CA, United States
- Corresponding author at: Institute for International Internet Interventions for Health (i4Health), Palo Alto University, 1791 Arastradero Rd., Palo Alto, CA 94304, United States.
| | - Y. Leykin
- Palo Alto University, Palo Alto, CA, United States
- i4health, Palo Alto, CA, United States
| | - A.Z. Barrera
- Palo Alto University, Palo Alto, CA, United States
- i4health, Palo Alto, CA, United States
| | - C.H. Brown
- Department of Psychiatry and Behavioral Sciences, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine Chicago, United States
| | - E.L. Bunge
- Palo Alto University, Palo Alto, CA, United States
- i4health, Palo Alto, CA, United States
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Laudani A, Leykin Y. Failed spinal anesthesia with hyperbaric bupivacaine. Minerva Anestesiol 2016; 82:1360. [PMID: 27442802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Alessandro Laudani
- Anesthesia and Intensive Care, Department of General Surgery and Perioperative Medicine, Azienda per l'Assistenza Sanitaria n. 5, Friuli Occidentale, Pordenone, Italy -
| | - Yigal Leykin
- Anesthesia and Intensive Care, Department of General Surgery and Perioperative Medicine, Azienda per l'Assistenza Sanitaria n. 5, Friuli Occidentale, Pordenone, Italy
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Leykin Y, Laudani A. Use of the Sufentanil Sublingual Tablet System for postoperative pain relief in a patient with chronic liver disease. Minerva Anestesiol 2016; 83:530-531. [PMID: 27879957 DOI: 10.23736/s0375-9393.16.11722-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Yigal Leykin
- Anesthesia and Intensive Care Unit, A.A.S. n. 5 Friuli Occidentale, Pordenone, Italy
| | - Alessandro Laudani
- Anesthesia and Intensive Care Unit, A.A.S. n. 5 Friuli Occidentale, Pordenone, Italy -
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Wong EC, Kaplan CP, Shumay DM, Leykin Y, Etzel KA, Stover Fiscalini A, van't Veer LJ, Esserman LJ, Melisko ME. Abstract P1-10-22: Evaluating the incidence of supportive care referrals generated using patient reported data from the Athena health questionnaire system. Cancer Res 2016. [DOI: 10.1158/1538-7445.sabcs15-p1-10-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background
Patients at risk for or diagnosed with breast cancer have many symptoms and need for supportive care services. As part of the Athena Breast Health Network (a University of California-wide collaboration), the UCSF Breast Care Center (BCC) has incorporated an electronic health questionnaire system (HQS) prior to new patient and follow-up clinic visits, allowing patients to provide information on their personal health and family history, physical and psychological symptoms, and lifestyle. Based on these patient-reported outcomes (PRO), automated referrals for services including genetic counseling, psycho-oncology, social work, fertility preservation, and smoking cessation are generated. Algorithms defining thresholds to trigger these referrals were developed by clinicians and supportive care providers to proactively meet patients' needs.
Objectives
To evaluate the incidence and outcomes of supportive care referrals based on existing algorithms, and identify reasons for non-utilization of the services offered. The ultimate goal for this evaluation is to modify the existing algorithms to better meet patients' needs.
Methods
Patients initiating care at the UCSF BCC are invited by email to complete an HQS that provides information relevant to their clinical care. Patients sign an electronic consent, agreeing to have their PRO stored and accessed for research purposes. Family history, health behaviors, desired services, and responses to National Cancer Institute Patient Reported Outcomes Measurement Information System (PROMIS) items are processed through algorithms, generating referrals based on defined thresholds. A clinician summary report is generated and scanned into the electronic medical record (EMR), identifying services for which the patient has met thresholds. Referrals are sent to the clinician as pended orders through the EMR. Once signed by the care provider (physician or nurse practitioner), the order is routed through the EMR to the appropriate service and the patient is offered a visit or phone consultation when appropriate.
Results
Between 1/1/14 and 12/31/14, 1297 patients initiating care at the UCSF BCC completed an HQS prior to their clinic visit. 1108 patients (85.4%) agreed to have their data used for research. 623 patients (56.2%) were referred to at least one supportive care service. The table below summarizes the percentage of patients who met the defined referral thresholds:
Referrals Made, 2014Referral TypeNumber of ReferralsPercent of Patients Referred (n=1108)Genetic Counseling Services44340.0%Psychological Services25723.2%Social Work13712.4%Smoking Cessation343.1%Fertility Preservation292.6%
Ongoing analyses are underway to determine the percentage of patients who received services, explore barriers to accessing these services, and evaluate patients' preferences regarding provision of services in alternate formats, including webinars, online content, and group sessions.
Conclusions
Effective use of PRO identifies a high percentage of patients in need of supportive care services. Through analysis of utilization of services based on our existing thresholds, we hope to optimize our algorithms to better serve our patients' needs throughout the continuum of cancer care.
Citation Format: Wong EC, Kaplan CP, Shumay DM, Leykin Y, Etzel KA, Stover Fiscalini A, van't Veer LJ, Esserman LJ, Melisko ME. Evaluating the incidence of supportive care referrals generated using patient reported data from the Athena health questionnaire system. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-22.
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Affiliation(s)
- EC Wong
- University of California, San Francisco, San Francisco, CA
| | - CP Kaplan
- University of California, San Francisco, San Francisco, CA
| | - DM Shumay
- University of California, San Francisco, San Francisco, CA
| | - Y Leykin
- University of California, San Francisco, San Francisco, CA
| | - KA Etzel
- University of California, San Francisco, San Francisco, CA
| | | | - LJ van't Veer
- University of California, San Francisco, San Francisco, CA
| | - LJ Esserman
- University of California, San Francisco, San Francisco, CA
| | - ME Melisko
- University of California, San Francisco, San Francisco, CA
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Fanelli A, Ruggeri M, Basile M, Cicchetti A, Coluzzi F, Della Rocca G, Di Marco P, Esposito C, Fanelli G, Grossi P, Leykin Y, Lorini FL, Paolicchi A, Scardino M, Corcione A. Activity-based costing analysis of the analgesic treatments used in postoperative pain management in Italy. Minerva Med 2016; 107:1-13. [PMID: 26999384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND The aim of this analysis is to evaluate the costs of 72-hour postoperative pain treatment in patients undergoing major abdominal, orthopedic and thoracic procedures in nine different Italian hospitals, defined as the cumulative cost of drugs, consumable materials and time required for anesthesiologists, surgeons and nurses to administer each analgesic technique. METHODS Nine Italian hospitals have been involved in this study through the administration of a questionnaire aimed to acquire information about the Italian clinical practice in terms of analgesia. This study uses activity-based costing (ABC) analysis to identify, measure and give value to the resources required to provide the therapeutic treatment used in Italy to manage the postoperative pain patients face after surgery. A deterministic sensitivity analysis (DSA) has been performed to identify the cost determinants mainly affecting the final cost of each treatment analyzed. Costs have been reclassified according to three surgical macro-areas (abdominal, orthopedic and thoracic) with the aim to recognize the cost associated not only to the analgesic technique adopted but also to the type of surgery the patient faced before undergoing the analgesic pathway. RESULTS Fifteen different analgesic techniques have been identified for the treatment of moderate to severe pain in patients who underwent a major abdominal, orthopedic or thoracic surgery. The cheapest treatment actually employed is the oral administration "around the clock" (€ 8.23), whilst the most expensive is continuous peripheral nerve block (€ 223.46). The intravenous patient-controlled analgesia costs € 277.63. In terms of resources absorbed, the non-continuous administration via bolus is the gold standard in terms of cost-related to the drugs used (€ 1.28), and when administered pro re nata it also absorbs the lowest amount of consumables (€0.58€) compared to all other therapies requiring a delivery device. The oral analgesic administration pro re nata is associated to the lowest cost in terms of health professionals involved (€ 6.25), whilst intravenous PCA is the most expensive one (€ 245.66), requiring a massive monitoring on the part of physicians and nurses. CONCLUSIONS The analysis successfully collected information about costs of 72-hour postoperative pain treatment in patients undergoing major abdominal, orthopedic and thoracic procedures in all the nine different Italian hospitals. The interview showed high heterogeneity in the treatment of moderate to severe pain after major abdominal, orthopedic and thoracic surgeries among responding anesthesiologists, with 15 different analgesic modalities reported. The majority of the analgesic techniques considered in the analysis is not recommended by any guideline and their application in real life can be one of the reasons for the high incidence of uncontrolled pain, which is still reported in the postoperative period. Health care costs have become more and more important, although the choice of the best analgesic treatment should be a compromise between efficacy and economic considerations.
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Affiliation(s)
- Andrea Fanelli
- Department of Medical and Surgical Sciences, Anesthesia and Pain Therapy, S. Orsola-Malpighi Polyclinic, Bologna, Italy -
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Varutti R, Setti T, Ezri T, Nicolosi G, Rellini G, Cassin M, Leykin Y. Postoperative Takotsubo cardiomyopathy triggered by intraoperative fluid overload and acute hypertensive crisis. Rom J Anaesth Intensive Care 2015; 22:47-50. [PMID: 28913455 PMCID: PMC5505332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023] Open
Abstract
The Takotsubo cardiomyopathy is a rare haemodynamic dysfunction, only recently reported perioperatively. While the diagnostic criteria have been established and the outcome is known as favorable, the pathophysiological mechanisms are not entirely understood. Here we present the case of a patient scheduled for laparoscopic hysterectomy and adnexectomy, who early postoperatively developed a Takotsubo cardiomyopathy supposedly triggered by an acute hypertensive crisis due to intraoperative fluid overload.
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Affiliation(s)
- Rosanna Varutti
- Department of Anesthesia and Intensive Care, Hospital of Santa Maria degli Angeli, Pordenone, Italy
| | - Tommaso Setti
- Department of Anesthesia and Intensive Care, Hospital of Santa Maria degli Angeli, Pordenone, Italy
| | - Tiberiu Ezri
- Department of Anesthesia and Intensive Care, Hospital of Santa Maria degli Angeli, Pordenone, Italy
- Outcomes research Consortium, Cleveland, OH, USA
| | - Gianluigi Nicolosi
- Department of Cardiology, Hospital of Santa Maria degli Angeli, Pordenone, Italy
| | - Gianluigi Rellini
- Department of Cardiology, Hospital of Santa Maria degli Angeli, Pordenone, Italy
| | - Matteo Cassin
- Department of Cardiology, Hospital of Santa Maria degli Angeli, Pordenone, Italy
| | - Yigal Leykin
- Department of Anesthesia and Intensive Care, Hospital of Santa Maria degli Angeli, Pordenone, Italy
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11
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Zaslansky R, Rothaug J, Chapman RC, Backström R, Brill S, Engel C, Fletcher D, Fodor L, Funk P, Gordon D, Komann M, Konrad C, Kopf A, Leykin Y, Pogatzki-Zahn E, Puig M, Rawal N, Schwenkglenks M, Taylor RS, Ullrich K, Volk T, Yahiaoui-Doktor M, Meissner W. PAIN OUT: an international acute pain registry supporting clinicians in decision making and in quality improvement activities. J Eval Clin Pract 2014; 20:1090-8. [PMID: 24986116 DOI: 10.1111/jep.12205] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2014] [Indexed: 01/12/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES Management of post-operative pain is unsatisfactory worldwide. An estimated 240 million patients undergo surgery each year. Forty to 60% of these patients report clinically significant pain. Discrepancy exists between availability of evidence-based medicine (EBM)-derived knowledge about management of perioperative pain and increased implementation of related practices versus lack of improvement in patient-reported outcomes (PROs). We aimed to assist health care providers to optimize perioperative pain management by developing and validating a medical registry that measures variability in care, identifies best pain management practices and assists clinicians in decision making. METHODS PAIN OUT was established from 2009 to 2012 with funding from the European Commission. It now continues as a self-sustaining, not-for-profit project, targeting health care professionals caring for patients undergoing surgery. RESULTS The growing registry includes data from 40 898 patients, 60 hospitals and 17 countries. Collaborators upload data (demographics, clinical, PROs) from patients undergoing surgery in their hospital/ward into an Internet-based portal. Two modules make use of the data: (1) online, immediate feedback and benchmarking compares PROs across sites while offline analysis permits in-depth analysis; and (2) the case-based clinical decision support system offers practice-based treatment recommendations for individual patients; it is available now as a prototype. The Electronic Knowledge Library provides succinct summaries on perioperative pain management, supporting knowledge transfer and application of EBM. CONCLUSION PAIN OUT, a large, growing international registry, allows use of 'real-life' data related to management of perioperative pain. Ultimately, comparative analysis through audit, feedback and benchmarking will improve quality of care.
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Affiliation(s)
- Ruth Zaslansky
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller University Hospital, Jena, Germany
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12
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Zaslansky R, Rothaug J, Chapman C, Bäckström R, Brill S, Fletcher D, Fodor L, Gordon D, Komann M, Konrad C, Leykin Y, Pogatski-Zahn E, Puig M, Rawal N, Ullrich K, Volk T, Meissner W. PAIN OUT: The making of an international acute pain registry. Eur J Pain 2014; 19:490-502. [DOI: 10.1002/ejp.571] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2014] [Indexed: 11/10/2022]
Affiliation(s)
- R. Zaslansky
- Department of Anesthesiology & Intensive Care; Friedrich-Schiller University Hospital; Jena Germany
| | - J. Rothaug
- Department of Anesthesiology & Intensive Care; Friedrich-Schiller University Hospital; Jena Germany
| | - C.R. Chapman
- Pain Research Center; Department of Anesthesiology; University of Utah; Salt Lake City USA
| | - R. Bäckström
- Department of Anesthesiology & Intensive Care; University Hospital Örebro; Sweden
| | - S. Brill
- Department of Anesthesiology & Intensive Care; Sourasky Medical Center; Tel-Aviv Israel
| | - D. Fletcher
- Department of Anesthesiology & Intensive Care; Raymond Poincaré Hospital; Garches France
| | - L. Fodor
- Plastic and Reconstructive Surgery; Cluj University Hospital; Romania
| | - D.B. Gordon
- Department of Anesthesiology & Intensive Care; University of Washington Harborview Medical Center; Seattle USA
| | - M. Komann
- Department of Anesthesiology & Intensive Care; Friedrich-Schiller University Hospital; Jena Germany
| | - C. Konrad
- Department of Anesthesiology & Intensive Care; Kantonsspital; Lucerne Switzerland
| | - Y. Leykin
- Department of Anesthesiology & Intensive Care; Santa Maria Degli Angeli; University of Trieste and Udine; Italy
| | - E. Pogatski-Zahn
- Department of Anesthesiology & Intensive Care; University Hospital Muenster; Germany
| | - M.M. Puig
- Department of Anesthesiology & Intensive Care; IMIM-Hospital del Mar-Universitat Autònoma de Barcelona; Spain
| | - N. Rawal
- Department of Anesthesiology & Intensive Care; University Hospital Örebro; Sweden
| | - K. Ullrich
- Department of Anesthesiology & Intensive Care; Queen Mary and Westfield College; University of London; UK
| | - T. Volk
- Department of Anesthesiology & Intensive Care; Saarland University Hospital; Homburg Germany
| | - W. Meissner
- Department of Anesthesiology & Intensive Care; Friedrich-Schiller University Hospital; Jena Germany
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14
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Abstract
The aim of this article is to provide an overview on neuromuscular blocking agents and a rational selection of the most appropriate agents, along with pharmacological and pharmacoeconomic considerations on neuromuscular blockers and their antagonists. Neuromuscular blocking agents are used during anesthesia to facilitate endotracheal intubation and provide surgically required paralysis. There is continuing development in the field of neuromuscular blocking agents, with new products appearing at regular intervals. All new agents come at increased costs. The proportion of anesthesia-related drug costs on a per-patient basis are small and vary from country to country, but account for no more than 12% of hospital drug budgets. However, given the large number of anesthetics performed over time, the total cost is significant. Moreover, such costs should be put into the perspective of the operating theater and patient admission costs. Appropriate selection of neuromuscular blocking agents can help not only to reduce biological costs secondary to complications, but also to make operating lists proceed smoothly and without incident. The paucity of outcome studies in relation to anesthetic drugs is not surprising given that anesthesia is used to facilitate the provision of therapy rather than being therapeutic in its own right. Accordingly, the assessment of anesthetic drugs has a different priority to therapeutic drugs. As anesthetic drugs are nontherapeutic, it is also difficult to determine the best choice of agent. However, new neuromuscular blocking agents are marketed on the basis of improvements in the frequency of side effects, safety, reliability, duration, reversibility and undesirable hemodynamic effects.
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Affiliation(s)
- Yigal Leykin
- Santa Maria degli Angeli Hospital, Department of Anesthesia and Intensive Care, Via Montereale 24, 33170 Pordenone, Italy.
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Abstract
Acute pain is a symptom that originates from actual ongoing or impending tissue damage. Pain is an individual subjective experience and varies markedly among individuals. For this reason, patient involvement is essential, with the most reliable indicator of severity being patient self-report. The main objective of postoperative pain management is the achievement of fast rehabilitation, recovery of all normal functions and reduction of postoperative morbidity. Sufficient evidence supports the hypothesis that effective analgesia modifies many of the adverse sequelae that accompany acute pain and assists in recovery. Nevertheless, despite the availability of drugs and techniques for its effective management, postoperative pain remains undertreated. It is now accepted that the solution to the problem of inadequate pain relief lies not only in the development of new analgesic drugs or technologies but also in the development of an appropriate organization to utilize existing expertise. Methods used to control postoperative pain are numerous; this review focuses on pharmacological and anesthetic methods.
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Affiliation(s)
- Yigal Leykin
- Santa Maria degli Angeli Hospital, Department of Anesthesia and Intensive Care, Pordenone, Italy.
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Rothaug J, Zaslansky R, Schwenkglenks M, Komann M, Allvin R, Backström R, Brill S, Buchholz I, Engel C, Fletcher D, Fodor L, Funk P, Gerbershagen HJ, Gordon DB, Konrad C, Kopf A, Leykin Y, Pogatzki-Zahn E, Puig M, Rawal N, Taylor RS, Ullrich K, Volk T, Yahiaoui-Doktor M, Meissner W. Patients' perception of postoperative pain management: validation of the International Pain Outcomes (IPO) questionnaire. J Pain 2013; 14:1361-70. [PMID: 24021577 DOI: 10.1016/j.jpain.2013.05.016] [Citation(s) in RCA: 110] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 05/28/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
UNLABELLED PAIN OUT is a European Commission-funded project aiming at improving postoperative pain management. It combines a registry that can be useful for quality improvement and research using treatment and patient-reported outcome measures. The core of the project is a patient questionnaire-the International Pain Outcomes questionnaire-that comprises key patient-level outcomes of postoperative pain management, including pain intensity, physical and emotional functional interference, side effects, and perceptions of care. Its psychometric quality after translation and adaptation to European patients is the subject of this validation study. The questionnaire was administered to 9,727 patients in 10 languages in 8 European countries and Israel. Construct validity was assessed using factor analysis. Discriminant validity assessment used Mann-Whitney U tests to detect mean group differences between 2 surgical disciplines. Internal consistency reliability was calculated as Cronbach's alpha. Factor analysis resulted in a 3-factor structure explaining 53.6% of variance. Cronbach's alpha at overall scale level was high (.86), and for the 3 subscales was low, moderate, or high (range, .53-.89). Significant mean group differences between general and orthopedic surgery patients confirmed discriminant validity. The psychometric quality of the International Pain Outcomes questionnaire can be regarded as satisfactory. PERSPECTIVE The International Pain Outcomes questionnaire provides an instrument for postoperative pain assessment and improvement of quality of care, which demonstrated good psychometric quality when translated into a variety of languages in a large European and Israeli patient population. This measure provides the basis for the first comprehensive postoperative pain registry in Europe and other countries.
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Affiliation(s)
- Judith Rothaug
- Department of Anesthesiology and Intensive Care, Friedrich-Schiller University Hospital, Jena, Germany.
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Abstract
OBJECTIVE Although numerous methods are available for postoperative pain (POP) management, new approaches are constantly being investigated. This feasibility study assessed the buprenorphine transdermal therapeutic system (Bup-TTS) for the treatment of POP after gynecological open surgery. RESEARCH DESIGN AND METHODS Forty-five patients were prospectively randomized to different Bup-TTS dosages (17.5, 35, or 52.5 μg/h). Patients were blinded with regard to patch dose. MAIN OUTCOME MEASURES Efficacy was evaluated in terms of rescue boluses (intravenous morphine 2 mg in the first six postoperative hours, intravenous ketorolac 30 mg thereafter) required to achieve a static and dynamic Numerical Rating Scale (sNRS and dNRS) score ≤4. Side effects were evaluated from patch application (12 hours before surgery) until the 72nd postoperative hour. Patient satisfaction regarding POP management was assessed via anonymous questionnaire. RESULTS All Bup-TTS groups required additional postoperative analgesia, particularly in the first postoperative hour. No between-group differences in sNRS/dNRS values were recorded at emergence from anesthesia. A significant inverse correlation occurred between Bup-TTS dosage and use of morphine (p = 0.04), ketorolac (p = 0.04) or both rescues (p = 0.02). Postoperative nausea/vomiting occurred in 3.1% of assessments, with no between-group differences and a significant correlation with morphine amount (p = 0.01). No serious side effects occurred. Despite no between-group difference, patient satisfaction was inversely correlated with the number of rescue doses (p < 0.001). Study limitations include the small sample size, the absence of a control group treated with a more conventional technique for POP relief, the focus on selected patients at low perioperative risk and the presence of slightly different types of open surgery (hysterectomy vs myomectomy only). CONCLUSION Bup-TTS efficacy was directly proportional to its dosage, although additional analgesia was required, particularly in the first postoperative hour. Moreover, the consumption of morphine and ketorolac was inversely correlated to the Bup-TTS dosage. Increasing Bup-TTS doses were not associated with an increased incidence of side effects. Bup-TTS appears a safe and feasible approach for moderate POP management; further larger studies are warranted.
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Affiliation(s)
- Tommaso Setti
- Department of Anesthesia and Intensive Care, Hospital Santa Maria degli Angeli, Pordenone, Italy.
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Zaslansky R, Chapman C, Rothaug J, Bäckström R, Brill S, Davidson E, Elessi K, Fletcher D, Fodor L, Karanja E, Konrad C, Kopf A, Leykin Y, Lipman A, Puig M, Rawal N, Schug S, Ullrich K, Volk T, Meissner W. Feasibility of international data collection and feedback on post-operative pain data: Proof of concept. Eur J Pain 2011; 16:430-8. [DOI: 10.1002/j.1532-2149.2011.00024.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2011] [Indexed: 11/05/2022]
Affiliation(s)
- R. Zaslansky
- Department of Anesthesiology and Intensive Care; Friedrich-Schiller University Hospital; Jena; Germany
| | - C.R. Chapman
- Pain Research Center; Department of Anesthesiology; University of Utah; Salt Lake City; UT; USA
| | - J. Rothaug
- Department of Anesthesiology and Intensive Care; Friedrich-Schiller University Hospital; Jena; Germany
| | - R. Bäckström
- Department of Anesthesiology and Intensive Care; University Hospital Örebro; Örebro; Sweden
| | - S. Brill
- Department of Anesthesiology and Intensive Care; Sourasky Medical Center; Tel-Aviv; Israel
| | - E. Davidson
- Department of Anesthesiology and Intensive Care; Hadassah Medical Center; Jerusalem; Israel
| | - K. Elessi
- El-Wafa Medical Rehabilitation Hospital; Gaza Strip
| | - D. Fletcher
- Department of Anesthesiology and Intensive Care; Raymond Poincaré Hospital; Garches; France
| | - L. Fodor
- Plastic and Reconstructive Surgery; Cluj University Hospital; Cluj; Romania
| | - E. Karanja
- Doctor's Service; Avenue Hospital; Nairobi; Kenya
| | - C. Konrad
- Department of Anesthesiology and Intensive Care; Kantonsspital; Lucerne; Switzerland
| | - A. Kopf
- Department of Anesthesiology and Intensive Care; Charite Medical Center; Berlin; Germany
| | - Y. Leykin
- Department of Anesthesiology and Intensive Care; Santa Maria Degli Angeli; University of Trieste and Udine; Udine; Italy
| | - A. Lipman
- Department of Pharmacotherapy; College of Pharmacy; University of Utah; Salt Lake City; UT; USA
| | - M. Puig
- Department of Anesthesiology and Intensive Care; IMIM-Hospital del Mar-UAB; Barcelona; Spain
| | - N. Rawal
- Department of Anesthesiology and Intensive Care; University Hospital Örebro; Örebro; Sweden
| | - S. Schug
- Department of Anesthesiology and Intensive Care; University of Western Australia and Royal Perth Hospital; Perth; Australia
| | - K. Ullrich
- Department of Anesthesiology and Intensive Care; Queen Mary and Westfield College; University of London; London; UK
| | - T. Volk
- Department of Anesthesiology and Intensive Care; Saarland University Hospital; Homburg; Germany
| | - W. Meissner
- Department of Anesthesiology and Intensive Care; Friedrich-Schiller University Hospital; Jena; Germany
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Leykin Y, Dalsasso M, Setti T, Pellis T. The effects of low-dose ephedrine on intubating conditions following low-dose priming with cisatracurium. J Clin Anesth 2011; 22:425-31. [PMID: 20868963 DOI: 10.1016/j.jclinane.2009.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2008] [Revised: 10/18/2009] [Accepted: 10/29/2009] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE To determine whether low-dose ephedrine plus priming with low-dose cisatracurium improves intubating conditions. DESIGN Prospective, randomized, double-blinded study. SETTING Operating room. PATIENTS 124 ASA physical status I and II patients scheduled for elective surgery. INTERVENTIONS Patients were randomly assigned to 4 groups (n = 31): Group PE (priming + ephedrine), Group P (priming), Group E (ephedrine), and Group NPE (no priming, no ephedrine). All patients were induced with propofol two mg/kg and sulfentanil 0.15 μg/kg. In the priming groups, 0.005 mg/kg (10% ED(95)) cisatracurium was given, followed three minutes later by 0.145 mg/kg of cisatracurium. In Groups E and NPE, a single dose of 0.15 mg/kg cisatracurium was given. Intravenous ephedrine 70 μg/kg was given in Groups PE and E. Tracheal intubation was attempted 60 seconds after the intubating dose of cisatracurium and was considered successful only if performed within 20 seconds. MEASUREMENTS Intubating conditions were graded. Heart rate and non-invasive blood pressure, at one-minute intervals, were recorded during and 5 minutes after induction. MAIN RESULTS The tracheas of all patients in Group PE were successfully intubated within 20 seconds versus 74% in Group P, 77% in Group E, and 64% in Group NPE (P < 0.001 vs. Group PE). Intubating conditions were graded good to excellent in all PE patients, but in only 52% of Groups P and E, and 48% of NPE patients (P < 0.001). Hemodynamic variables were comparable among groups (P = ns). CONCLUSIONS Low-dose ephedrine plus priming with low-dose cisatracurium before an intubating dose, significantly improved clinical intubating conditions at 60 seconds.
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Affiliation(s)
- Yigal Leykin
- Department of Anaesthesia and Intensive Care, Santa Maria degli Angeli Hospital, 33170 Pordenone, Italy; University of Trieste, Trieste 34127, Italy.
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Leykin Y, Nespolo R, Foltran F, Burato L, Noal N, Baciarello M, Fanelli G. Anesthesia and postoperative analgesia after intra-articular injection of warmed versus room-temperature levobupivacaine: a double-blind randomized trial. Arthroscopy 2009; 25:1019-24. [PMID: 19732641 DOI: 10.1016/j.arthro.2009.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 01/05/2009] [Accepted: 03/21/2009] [Indexed: 02/02/2023]
Abstract
PURPOSE This prospective, randomized, blinded study was designed to compare the effects of warmed versus room-temperature levobupivacaine in patients undergoing knee arthroscopy and partial meniscectomy. METHODS Patients were randomly allocated into 2 groups of 16 patients each. In all patients the 2 portal sites were infiltrated with 10 mL of room-temperature mepivacaine (20 mg/mL). In the first group, patients underwent intra-articular injection of 20 mL of levobupivacaine (5 mg/mL) and 0.005-mg/mL epinephrine (1:200,000) at a temperature of 40 degrees C +/- 0.2 degrees C, whereas in the second group the levobupivacaine and epinephrine were at room temperature (25 degrees C +/- 0.5 degrees C). Pain was graded and recorded intraoperatively and postoperatively by use of a visual analog scale (VAS). Analgesia was supplemented if the VAS score was 4 cm or greater with morphine intraoperatively or ketorolac postoperatively. RESULTS There were no significant differences between groups in intraoperative and postoperative VAS values. There was no need for morphine as a rescue dose in any patient during surgery. Eight patients treated with warmed levobupivacaine and seven patients treated with room-temperature levobupivacaine requested a single rescue dose of ketorolac (30 mg) postoperatively. CONCLUSIONS No compelling evidence exists to suggest that intra-articular injection of warmed levobupivacaine is more effective than room-temperature levobupivacaine for intraoperative anesthesia and postoperative analgesia in patients undergoing partial meniscectomy during knee arthroscopy. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Affiliation(s)
- Yigal Leykin
- Department of Anaesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy.
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Brusasco C, Corradi F, Zattoni PL, Launo C, Leykin Y, Palermo S. Ultrasound-Guided Central Venous Cannulation in Bariatric Patients. Obes Surg 2009; 19:1365-70. [DOI: 10.1007/s11695-009-9902-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 06/02/2009] [Indexed: 11/24/2022]
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Leykin Y, Casati A, Rapotec A, Dal Sasso M, Barzan L, Fanelli G, Pellis T. A prospective, randomized, double-blind comparison between parecoxib and ketorolac for early postoperative analgesia following nasal surgery. Minerva Anestesiol 2008; 74:475-479. [PMID: 18414367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND The aim of this prospective, randomized, double-blind study was to compare the efficacy of parecoxibfor postoperative analgesia after endoscopic turbinate and sinus surgery, with the non-selective non-steroid anti-inflammatory drug (NSAID), ketorolac. METHODS A total of 50 patients with an ASA physical status I-II, receiving functional endoscopic sinus surgery (FESS) and endoscopic turbinectomy after local infiltration with 1% mepivacaine, were randomly assigned to receive intravenous administration of either 40 mg parecoxib (N.=25) or 30 mg ketorolac (N.=25), 15 min before the discontinuation of anaesthesia and then every 8 h postoperatively. A blinded observer recorded the incidence and severity of pain upon admission to the postanesthesia care unit (PACU), as well as 10, 20, and 30 min after PACU admission. Thereafter, observations continued every 1 h for the first 6 h, and then 12 h and 24 h after surgery. RESULTS The area under the curve of the visual analogue scale (AUCVAS) calculated during the study period was 635 (26-1 413) in the Parecoxib group and 669 (28-1 901) in the Ketorolac group (P=0.54). Rescue morphine analgesia was required by 12 patients (48%) in the Parecoxib group and 11 patients (44%) in the Ketorolac group (P<0.05); while mean morphine consumption was 5 +/- 2.5 mg and 5 +/- 2.0 mg in Ketorolac and Parecoxib groups, respectively (P<0.05). No differences in the incidence of side effects were recorded between the two groups. Patient satisfaction was similarly high in both groups, and all patients were discharged uneventfully 24 h after surgery. CONCLUSION In patients undergoing endoscopic nasal surgery and local infiltration with 1% mepivacaine, parecoxib administered before discontinuing general anesthesia is as effective in treating early postoperative pain as ketorolac.
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Affiliation(s)
- Y Leykin
- Department of Anesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy.
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23
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Abstract
PURPOSE The aim of the study was to compare the efficacy of parecoxib for postoperative analgesia after endoscopic turbinate and sinus surgery with the prodrug of acetaminophen, proparacetamol. MATERIALS AND METHODS Fifty American Society of Anesthesiology (ASA) physical status I-II patients, receiving functional endoscopic sinus surgery (FESS) and endoscopic turbinectomy, were investigated in a prospective, randomized, double-blind manner. After local infiltration with 1% mepivacaine, patients were randomly allocated to receive intravenous (i.v.) administration of either 40 mg of parecoxib (n=25) or 2 g of proparacetamol (n=25) 15 min before discontinuation of total i.v. anaesthesia with propofol and remifentanil. A blinded observer recorded the incidence and severity of pain at admission to the post anaesthesia care unit (PACU) at 10, 20, and 30 min after PACU admission, and every 1 h thereafter for the first 6 postoperative h. RESULTS The area under the curve of VAS (AUC(VAS)) calculated during the study period was 669 (28-1901) cm x min in the proparacetamol group and 635 (26-1413) cm x min in the parecoxib group (p=0.34). Rescue morphine analgesia was required by 14 patients (56%) in the proparacetamol group and 12 patients (48%) in the parecoxib (p >or= 0.05), while mean morphine consumption was 5-3.5mg and 5-2.0 mg in the proparacetamol groups and parecoxib, respectively (p >or= 0.05). No differences in the incidence of side effects were recorded between the 2 groups. Patient satisfaction was similarly high in both groups, and all patients were uneventfully discharged 24 h after surgery. CONCLUSION In patients undergoing endoscopic nasal surgery, prior infiltration with local anaesthetics, parecoxib administered before discontinuing general anaesthetic, is not superior to proparacetamol in treating early postoperative pain.
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Affiliation(s)
- Yigal Leykin
- Department of Anaesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Via Montereale 24 33170 Pordenone, Italy.
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Leykin Y, Pellis T, Ambrosio C, Zanette G, Malisano A, Rapotec A, Casati A. A recovery room-based acute pain service. Minerva Anestesiol 2007; 73:201-6. [PMID: 17242652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
AIM Despite routine postoperative pain management improves recovery and reduces postoperative morbidity and overall costs, and the availability of a large armamentarium of analgesic techniques and drugs, a significant portion of patients do not receive adequate postoperative pain control. We describe a recovery room (RR) based acute pain service model. METHODS Guidelines on postoperative pain and therapeutic protocols were instituted in January 1999. The analgesic endpoint was a visual analogic scale (VAS) below 4 for all surgical patients for the first 48-72 h. The RR, run by one anesthesiologist and 2 nurses and one assistant, acted as a coordination centre. Discharge from the RR was subject to achieving effective analgesia. Nurses of each ward monitored VAS along with vital signs, administered rescue doses if necessary, and reported to the RR nurse when needed. RR nurses monitored the patient at least twice daily and reported to the anesthesiologist. We have distributed an anonymous questionnaire, within surgical wards, to both surgeons and nurses to evaluate their perception of pain management and of this acute pain service (APS) model. RESULTS VAS was maintained significantly <4. Analgesic drug consumption increased between 1997, 2000 (first year of APS) and 2004. The auditing process confirmed the desire of all professional figures to be informed and involved in acute pain management as part of a coordinated and systematic approach to the surgical patient. CONCLUSION A RR-based APS can effectively act as coordinating centre for acute pain treatment without adjunctive personnel.
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Affiliation(s)
- Y Leykin
- Department of Anaesthesia and Intensive Care, Santa Maria degli Angeli University Affiliated Hospital, Pordenone, Italy. Yigal
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Leykin Y, Pellis T, Del Mestro E, Marzano B, Fanti G, Brodsky JB. Anesthetic management of morbidly obese and super-morbidly obese patients undergoing bariatric operations: hospital course and outcomes. Obes Surg 2007; 16:1563-9. [PMID: 17217630 DOI: 10.1381/096089206779319491] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Although the implications for the anesthetic and perioperative care of severely obese patients undergoing weight loss operations are considerable, current anesthetic management of super-obese (SO) patients (BMI > or =50 kg/m(2)), including super-super-obese (BMI > or =60) derives from experience with morbidly obese (MO) patients (BMI 40-49.9 kg/m(2)). We compared anesthetic and perioperative data of SO patients and MO patients undergoing weight loss operations to evaluate if anesthetic management influenced outcome. METHODS A retrospective analysis was performed on data from 150 consecutive patients (119 MO, 31 SO) undergoing bariatric surgery between May 2000 and March 2005. Data analyzed included preoperative anesthetic assessment, anesthetic management, postoperative care, and intra- or postoperative complications. RESULTS There were no differences in anesthetic management or in postoperative course or outcome between MO and SO patients. Intraoperative surgical complications occurred in 26% (n=8) in the SO group and 14% (n=15) in the MO group (P<0.01). CONCLUSIONS No differences in outcome occurred between MO and SO patients undergoing bariatric operations under similar anesthetic management. Anesthesia for weight loss surgery can be safely performed on SO patients with the understanding that these patients are not at risk per se due to their higher BMI. The degree of obesity influenced only the incidence of intraoperative surgical complications.
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Affiliation(s)
- Yigal Leykin
- Department of Anesthesia, Pain, Perioperative Medicine and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy.
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Leykin Y, Pellis T, Zannier G. Thiopental--ketamine association and low dose priming with rocuronium for rapid sequence in duction of anaesthesia for elective cesareum section. Minerva Anestesiol 2006; 72:683-8. [PMID: 16770309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Obstetric patients undergoing caesarean section under general anaesthesia require rapid induction due to high risk of aspiration. Rocuronium provides the shortest onset of action of nondepolarizing blocking agents. Onset time can be shortened by the priming principle. Ketamine has been shown to improve intubating conditions when used in association with rocuronium. Even if ketamine crosses the placenta rapidly, it does not produce neonatal depression unless used in doses above 1-1.5 mg x kg(-1). We present a case of elective caesarean section due to pelvic disproportion managed in general anaesthesia. Following 5 min of preoxygenation, a priming dose of 0.04 mg x kg(-1) of rocuronium was administered. The patient was maintained on spontaneous breathing with 100% oxygen by face mask for 3 min and then induced in rapid sequence with thiopental 2 mg x kg(-1), ketamine 1 mg x kg(-1) and 0.4 mg x kg(-1) or rocuronium. Intubation was performed 30 s after induction (twitch tension 17%) with an excellent clinical intubating score. No adverse events such as muscle weakness or patient discomfort were observed or reported by the patient. Time from injection of the intubating does of rocuronium to recovery of 25% of single twitch was 26 min. Recovery index (T25-75) was, instead, of 3 min and 25 s. The combination of the induction agents thiopental and ketamine, associated with low dose priming with rocuronium, have guaranteed excellent intubating conditions in this clinical context.
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Affiliation(s)
- Y Leykin
- Department of Anaesthesia and Intensive Care, Santa Maria defli Angeli Hospital, Pordenone, Italy.
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Abstract
BACKGROUND Onset of action of muscle relaxants is influenced by cardiac output and muscle blood flow. Ephedrine reduces the onset time of rocuronium. Onset is also shortened by priming. Accordingly, we hypothesized that priming combined with ephedrine is superior to either technique used separately. METHODS Four groups of randomly allocated patients (n = 31), ASA I - II, were induced with propofol 2.5 mg kg(-1). In groups I and II, 0.04 mg kg(-1) of rocuronium was followed by a 3-min priming interval. Induction was followed by an intubation dose of 0.04 mg kg(-1). Then a 30-s intubation was attempted. In groups III and IV the same sequence was repeated except for sham priming and an intubation dose of 0.44 mg kg(-1). In groups I and II, ephedrine (210 microg kg(-1)) was injected before propofol. In groups II and V, an equivalent volume of normal saline was injected. Jaw relaxation, vocal cord position, and diaphragmatic response were used to assess intubating conditions. RESULTS All patients of group I were intubated 30 s after the intubating dose and within a 20-s interval compared with 74% of patients in groups II and III, and 84% of patients in group IV. Intubating conditions were graded good to excellent in all patients in group I compared with 42% of those in group II, 35% in group III and 52% in group IV (P < 0.01 vs. group I). During the priming interval, no adverse effects were observed or reported. CONCLUSIONS Ephedrine in combination with propofol significantly improved clinical intubating conditions at 30 s following priming with rocuronium compared with priming with ephedrine without priming.
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Affiliation(s)
- Y Leykin
- Department of Anaesthesia, Pain, Perioperative Medicine and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy.
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Abstract
Anesthetic management of super-obese patients is inferred from evidence which has been based on obese or morbidly obese patients. We present the perioperative management and monitoring of a 44-year-old 232-kg patient (BMI 70) admitted for laparoscopic gastric bypass surgery. Awake fiberoptic endotracheal intubation preceded induction with propofol and rocuronium. Anesthesia was maintained with desflurane and remifentanil. Desflurane was titrated on BIS values, whereas remifentanil was based on hemodynamic monitoring (invasive arterial pressure and HemoSonic). Rocuronium was administered based on ideal body weight and recovery of twitch tension. Safe and rapid extubation in the operating theatre was made possible by the use of short-acting agents coupled with continuous intraoperative monitoring. Recovery in the post-anesthesia care unit was uneventful, pain was managed with meperidine, and after 5 hours the patient was discharged to the surgical ward. Oxygen therapy and SpO2 monitoring were continued overnight. No desaturation episodes were recorded. Pain was managed with I.V. drip of ketorolac and tramadole.
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Affiliation(s)
- Tommaso Pellis
- Department of Anesthesia, Pain, Perioperative Medicine and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy
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Abstract
There is conflicting evidence on the duration of action of atracurium in obese patients. Cisatracurium is one of the stereoisomers of atracurium. We investigated the neuromuscular effects of cisatracurium in morbidly obese patients. Twenty obese female patients (body mass index >40) were randomized in two groups. Group I (n = 10) received 0.2 mg/kg of cisatracurium on the basis of real body weight (RBW), whereas in Group II (n = 10) the dose was calculated on ideal body weight (IBW). In a control group of 10 normal weight female patients (body mass index 20-24), the dose of cisatracurium was based on RBW. Neuromuscular transmission was monitored using acceleromyography of the adductor pollicis, and anesthesia was induced and maintained with remifentanil and propofol. Onset time was comparable between Group I and the control group (132 s versus 135 s; P = ns). The duration 25% was longer in Group I than in the control group (74.6 min versus 59.1 min; P = 0.01) and in the control group compared with Group II (45.0 min; P = 0.016). In conclusion, the duration of action of cisatracurium was prolonged in morbidly obese patients when dosed according to RBW compared with a control group of normal weight patients. Duration was also prolonged in the control group patients compared with morbidly obese patients to whom the drug was administered on the basis of IBW.
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Affiliation(s)
- Yigal Leykin
- *Departments of Anesthesia, Pain, Perioperative Medicine and Intensive Care, and †Surgery, Santa Maria degli Angeli Hospital, Pordenone, Italy; and the ‡Department of Perioperative Medicine, Intensive Care and Emergency, Trieste University Medical School, Trieste, Italy
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Leykin Y, Pellis T, Lucca M, Lomangino G, Marzano B, Gullo A. The Pharmacodynamic Effects of Rocuronium When Dosed According to Real Body Weight or Ideal Body Weight in Morbidly Obese Patients. Anesth Analg 2004; 99:1086-1089. [PMID: 15385355 DOI: 10.1213/01.ane.0000120081.99080.c2] [Citation(s) in RCA: 120] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We investigated the pharmacodynamic effects of rocuronium on morbidly obese patients. Twelve morbidly obese female patients (body mass index >40 kg/m(2)) admitted for laparoscopic gastric banding were randomized into two groups. Group 1 (n = 6) received 0.6 mg/kg of rocuronium based on real body weight, whereas Group 2 (n = 6) received 0.6 mg/kg of rocuronium based on ideal body weight. In a control group of six normal-weight female patients admitted for laparoscopic surgery, rocuronium was dosed on the basis of their real body weight. Neuromuscular transmission was monitored by using acceleromyography of the adductor pollicis; anesthesia was induced and maintained with remifentanil and propofol. The onset time tended to be shorter in Group 1 and the control group compared with Group 2, but this did not achieve statistical significance. Duration of action to 25% of twitch tension was more than double in Group 1 (55 min) compared with the other two groups (22 and 25 min; P < 0.001). Duration of action was similar between Group 2 and control. Recovery index tended to be longer in Group 1, but without a significant difference. In conclusion, in morbidly obese patients, the duration of action of rocuronium is significantly prolonged when it is dosed according to real body weight. Therefore, the dosage should be assessed on the basis of ideal rather than on real body weight in clinical practice.
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Affiliation(s)
- Yigal Leykin
- *Department of Anesthesia, Pain, Perioperative Medicine and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy; †Department of Perioperative Medicine, Intensive Care and Emergency, Trieste University Medical School, Trieste, Italy; and ‡Department of Surgery, Santa Maria degli Angeli Hospital, Pordenone, Italy
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Leykin Y, Rubulotta FM, Mancinelli P, Tosolini G, Gullo A. Epidural anaesthesia for endovascular stent graft repair of a ruptured thoracic aneurysm. Anaesth Intensive Care 2003; 31:455-60. [PMID: 12973971 DOI: 10.1177/0310057x0303100416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We present a case report of the anaesthetic management of a 77-year-old man requiring endovascular thoracic stent graft repair. The patient had a history of poorly controlled type II diabetes mellitus and chronic renal failure. Chest X-ray and CT scan showed a right pleural effusion, generalized emphysema and an enlarged thyroid extending into the upper mediastinum, compromising the tracheal lumen. Endovascular stent graft repair was successfully performed under epidural anaesthesia and intravenous sedation.
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Affiliation(s)
- Y Leykin
- Santa Maria degli Angeli Hospital, Department of Anaesthesiology and Intensive Care Medicine, Montereale 24 Street, 33170 Pordenone, Italy
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Leykin Y, Rubulotta F. Prophylactic continuous intravenous ephedrine infusion for elective Caesarean section under spinal anaesthesia. Eur J Anaesthesiol 2003; 20:257-8. [PMID: 12650500 DOI: 10.1017/s0265021503240424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Leykin Y, Lucca M. [Complications related to epidural catheter in caesarean delivery]. Minerva Anestesiol 2001; 67:175-80. [PMID: 11778114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
A review of complications related to epidural catheters in caesarean delivery is presented. Catheters for prolongation of nerve blocks were first used in 1940s. Thereafter, there has been steady development in the design and plastic material technology of the different catheters. In the last decade the regional anaesthesia for caesarean section became very popular, as well as continuous increase in the use of epidural catheters. The anatomical changes of pregnancy like marked distension of the epidural veins resulted in increased risk of the complications due to the epidural catheter placement. It is likely that permanent neurologic sequelae due to regional anaesthesia in obstetrics almost never occur, while minor self-limiting complications do occur. The possible complications of epidural catheter techniques are: trauma, malposition and migration of the catheter, knotting and breaking, radiculopathy, dural puncture, subdural injection, abscess and infection, haematoma and wrong solution injection. Most of the malpositions of the epidural catheter can be avoided by a careful technique, advancing the catheter with no forceful movement and not more than 3 to 4 cm into epidural space. Broken parts of the catheters should be left as a rule within the spinal space. Test dose should be always done for continuous epidural anaesthesia. Early diagnosis and prompt appropriate treatment will usually lead to complete resolution of the neurological deficit even in cases of epidural haematoma or abscess.
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Affiliation(s)
- Y Leykin
- II Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Santa Maria degli Angeli, Pordenone, Italy
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Leykin Y, Costa N, Gullo A. [Recovery Room. Organization and clinical aspects]. Minerva Anestesiol 2001; 67:539-54. [PMID: 11602873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Correct administration in the early postoperative phase is decisive in the final outcome of surgery and the presence of the Recovery Room (RR) contributes significantly to a reduction in the post-operative risk rate. The objectives of the RR are: removal of the pharmacological effect of general anaesthesia; stabilization of vital parameters (circulation and ventilation); stabilization of body temperature; control of the hydro-electrolytic balance; intensive intervention in the case of an acute complication; prescribing a suitable postoperative analgesia; recovering movement in the case of loco-regional anesthesia. Organization of RR must take into consideration: 1) aspect of environment and location; 2) transport of the patient from the operating room to the RR; 3) definition of the equipment necessary for the RR; 4) definition of the role and qualification of the medical and nursing staff; 5) definition of regulations of assistance and the clinical file; 6) definition of criteria for discharge and transfer; 7) definition of means of adjournment, improvement and comparison with other similar structures. RR is administered by an Anesthetist with clinical, therapeutic and decision-making responsibility for the discharge of patients, while the supervision and assistance patients is entrusted to specialised professional nurses. From a clinical point of view the following data are monitored and recorded: the vital signs (passage of air-ways, cardiac and respiratory frequency, arterial pressure, saturation of O2, EtCO2 (in patient with air-way support), body temperature and the state of consciousness, instrumental monitoring of the patient (at pre-established time intervals), control of the skin, the peripheral circulation, surgical wounds, drainage and catheters. The percentage of incidence of complications in RR varies from 6-7 to 30% depending on various studies, probably in relation to the diversity of criteria in defining the complication. The principal complications which can be found in RR, reported in several studies are: respiratory (obstruction of the air-way, hypoxemia, hypoventilation, inhalation), cardio-circulatory (hypotension, hypertension, arrhythmia, myocardial ischemia), postoperative nausea and vomiting, hypothermia and hyperthermia, delayed re-awakening, disorientation and hyper-excitability, postoperative shivering. As long as the patient can be discharged from the RR the following requisites must be satisfied: return of a state of consciousness, stable cardio-circulatory parameters, absence of respiratory depression, absence of bleeding, absence of nausea and vomiting, good analgesia and recovery of movement in the case of loco-regional anesthesia (on this last point not all authors agree). What has been said until now shows the function, usefulness and importance of RRs which must not replace the Intensive Therapy Units. In fact, they are places where the cure must be concluded, in which the Anesthetist is responsible for the whole process. This cure must begin in the preoperative period, continue in the intraoperative period and it is compulsory to proceed in the immediate postoperative period until such a time that, because of the anesthesia administered, the clinical situation of the patient ceases to be considered a potential medical-surgical urgency-emergency .
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Affiliation(s)
- Y Leykin
- II Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Santa Maria degli Angeli, Pordenone, Italy
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Leykin Y, Costa N, Furlan S, Nadalin G, Gullo A. [Recovery Room. One-year experience]. Minerva Anestesiol 2001; 67:555-62. [PMID: 11602874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
BACKGROUND The objective of our study is to present the analysis of the organizational and clinical work carried out in the first year of activity of the Recovery Room (RR) at the Azienda Ospedaliera Santa Maria degli Angeli of Pordenone and to compare personal experience with what is stated in the literature. METHODS The RR is located at the center of the operating block (composed of 10 operating rooms), the number of bed is 6, 3 of which are equipped with ventilators. There is a central nursing station where it is possible to concentrate all data deriving from the single monitors on one single screen. The RR operates from Monday to Friday from 8.00 to 20.00. An Anesthetist is on duty for the 12 hours and has the clinical, therapeutic and decision-making responsibility regarding the discharge of patients, while nursing assistance is provided by 2 qualified professional nurses for shift, assisted by an auxiliary. In the first year of activity of the RR, a total of 11,626 surgical operations were carried out; of these 1,047 patients, equal to 9%, were assisted in the RR. The age of 51% of the patients was between 61 and 80 years; 53.3% belonged to the ASA 2 group and only 0.48% to the ASA 4 group. The operations were sub-divided as follows: 56.8% general, thoracic and vascular surgery, 15.3% urological, 10% orthopedic, 7.7% obstetrical and gynecological, 6.1% ENS, 3% stomatological, 1% others. 56.8% off the patients underwent general anesthesia, 30.5% combined anesthesia and 12.6% local-regional anesthesia. The time spent by the patients in RR was between 1 hour 30 minutes and 10 hours 45 minutes, with an average time of 3 hours 49 minutes. RESULTS Of the 1,047 patients studied no case of cardio-respiratory arrest or death was recorded, while the complications encountered were: 13.15% cardio-circulatory, 3.62% respiratory, 3.62% PONV, 2.1% oliguria, 1.24% hypothermia, 0.48% disoriented patients, 0.38% hyperthermia and 0.38% shivering. In the area of cardio-circulatory complications encountered, the most important was arterial hypertension (5.6%), followed by cardiac arrhythmia, such as bradycardia (2.5%) and tachycardia (2.6%). CONCLUSIONS The conclusion is drawn that correct administration in the early postoperative period is decisive for the final outcome of surgery and that the presence of RR contributes significantly to a reduction in the postoperative morbidity rate. Our case-series leads us, however, to reflect on an excellent organization of the opening hours of RR.
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Affiliation(s)
- Y Leykin
- II Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Santa Maria degli Angeli, Pordenone, Italy
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Leykin Y, Lucca M, Malisano AM, Covezzi E, Bruschelli F. [Severe and prolonged EEG depression after induction of general anesthesia for carotid endarterectomy. Report of a clinical case]. Minerva Anestesiol 2001; 67:583-9. [PMID: 11602878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
A large number of methods are available for intraoperative neurologic monitoring during endarterectomy, although no single method is infallible. Debate over choice of regional or general anesthesia for this surgery persists because of differing conclusions of various studies of risks and benefits. The case of patient undergoing left carotid endarterectomy under general anesthesia is described, in whom after the induction of anesthesia with: midazolam 2 mg, fentanyl 50 g, propofol (fractionate dose of 180 mg) and cisatracurium 12 mg, a total EEG depression occurred persisting for over 10 minutes and was followed by slow recovery, during the awakening of the patient. No significant hemodynamic changes were noted during the induction. No neurologic deficit was observed in the patient after arousal. It is suggested that the probable reason for the EEG response is the particular sensitivity of the patient to some of the induction drugs or to their association. Two weeks later surgery was successfully performed using cervical plexus block, without any anesthetic support. Regional anesthesia allows continuous neurologic assessment of the awaken patient, it is the most sensitive method for detecting inadequate cerebral perfusion and function.
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Affiliation(s)
- Y Leykin
- II Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Santa Maria degli Angeli, Pordenone, Italy
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Leykin Y, Costa N, Gullo A. [Analysis and comparison of the guidelines regarding recovery-room management]. Minerva Anestesiol 2001; 67:563-71. [PMID: 11602875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The purpose of this study was to analyse and compare the guidelines regarding Recovery-Room (RR) management at international level, pointing out the main differences and common aspects. The guidelines on the RR management in various countries have been compared in particular the Italian, French, German, Australian, Canadian and American guidelines. In addition, the management of postoperative patients in some of these countries where guidelines on the subject have not yet been published have been analysed. In some countries, France for instance, the guidelines have been published as a ministerial decree (Décret n degrees 94-1050 du Décembre 1994) and are therefore a law with proper articles, in others (Italy for instance), they are mere recommendations, which do not have immediate effect and are regarded as a target to be achieved. SIAARTI considers that this is due to the dishomogeneity of the Italian hospital situation as far as medical and nursing staff as well as buildings and applied technology are concerned. The comparison between guidelines of different countries has shown that RR is a reality which has now existed for many years at international level and it has demonstrated that all guidelines agree on the fact that postoperative patients must be observed in a protected and safe environment. The following rules are common to all guidelines: the anaesthetist is responsible for the RR and for discharging the patient; there must be a clinical record and a written report which are considered to be essential (not in Italy); RR must be next to the surgical rooms; the patient must be escorted to RR by the anesthetist; monitoring must be guaranteed during transfer; monitoring continuity in RR (at regular and a appropriate intervals) is essential. The following rules are not common to all guidelines: numbers of beds in RR; the proportion between the number of nurses and the number of patients; regulation for day-surgery; specific regulations for obstetrical patients. Guidelines are subject, as any regulation, to continuous revision, and this is a very important requirement which helps keeping them always update and in line with scientific research.
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Affiliation(s)
- Y Leykin
- II Servizio di Anestesia e Rianimazione, Azienda Ospedaliera Santa Maria degli Angeli, Pordenone, Italy
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Bonoli P, Grillone G, Fossa S, Franceschelli N, Lari S, Leykin Y, Nastasi M, Zanoni A. [Complications of pediatric anesthesia. Survey carried out by the Study Group SIAARTI for anesthesia and intensive therapy in children]. Minerva Anestesiol 1995; 61:115-25. [PMID: 7675269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This study was designed to asses in a prospective survey the intra and post-operative adverse outcome of paediatric patients in Italy. The data was carried out in representative samples of anaesthetics performed in different Italian Institutions, which were chosen by the National Study Group for Paediatric Anaesthesia, and included: paediatric, general, specialistic hospitals and departments. A total of 9289 anaesthetics were collected and studied. The mean age of the patients was 62.5 months. In the 320 cases (3.4%) 299 minor (3.2%) and 21 major (0.2%) complications occurred during or within 24 hours of surgery and anaesthesia. Seven of the major complications resulted in the exitus of the patients (0.07%). Fifty percent of the accidents regarded respiratory and twenty percent cardiovascular systems. The major incidence (risk factors) of the minor complications was present in patients less than 6 months, ASA group 2-3-4, emergency surgery, patients with associated pathology, long duration of anaesthesia and high risk operations. The incidence of the major complications appears closely related to: patients age and clinical assessment, weight, ASA group, kind of the operation, indications and durations of the surgery, while in the exitus group the major risk factor is the preoperative pathology, surgical procedures, and then: age, weight, ASA and finally surgery.
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Affiliation(s)
- P Bonoli
- Servizio di Anestesia e Rianimazione, Istituti Ortopedici Rizzoli, Bologna
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Leykin Y, Halpern P, Silbiger A, Sorkin P, Niv D, Rudick V, Geller E. Acute poisoning treated in the intensive care unit: a case series. Isr J Med Sci 1989; 25:98-102. [PMID: 2539343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
A retrospective study on patients with acute poisoning admitted to the Intensive Care Unit (ICU) of the Ichilov Hospital over a 3-year period (1982-84) is presented. Of 419 patients seen in the Emergency Room for intoxication during these years, 71 (17%) required intensive care upon admission. Suicide attempts accounted for 90% of the ICU admissions, with drugs of the benzodiazepine (BDZ) group being the most commonly used (51%). Mixed-drug overdose was seen in 55% of the patients. There was a poor correlation between the drugs suspected on admission and those actually detected in the blood. Although the total number of admissions due to poisoning increased in 1984 (21 in 1982 vs. 37 in 1984), mechanical ventilation was required by fewer patients (92% in 1982 vs. 51% in 1984) and for a shorter period of time (3.1 days in 1982 vs. 2.1 days in 1984), which resulted in a shorter ICU stay (4.8 days in 1982 vs. 3.1 days in 1984). The introduction of the new BDZ antagonist flumazenil may have partially accounted for this positive trend.
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Affiliation(s)
- Y Leykin
- Department of Anesthesiology and Intensive Care, Ichilov Hospital, Tel Aviv Medical Center, Israel
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Niv D, Ber A, Rudick V, Leykin Y, David MP, Geller E. Mode of vaginal delivery and epidural analgesia. Isr J Med Sci 1988; 24:80-3. [PMID: 3356537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A study was carried out on the mode of vaginal delivery in two large groups of parturients: one group comprised 11,264, of whom 0.1% were given epidural analgesia (1977-78) and the other, 10,650, of whom 50% delivered under epidural blockade (1982-83). When the incidence and reasons for instrumental intervention in these two groups were analyzed, it was found that the rate of instrumental delivery was only 1.3% higher (P less than 0.001) in the latter group, which was mainly due to factors not attributable to the epidural blockade. It may be concluded from this survey that epidural analgesia for labor and delivery does not cause an increase in the rate of instrumental delivery.
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Affiliation(s)
- D Niv
- Department of Anesthesia, Serlin Maternity Hospital, Tel Aviv Medical Center, Israel
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Geller E, Niv D, Nevo Y, Leykin Y, Sorkin P, Rudick V. Early clinical experience in reversing benzodiazepine sedation with flumazenil after short procedures. Resuscitation 1988; 16 Suppl:S49-56. [PMID: 2904685 DOI: 10.1016/0300-9572(88)90005-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Flumazenil (Flu) (Ro 15-1788, Anexate) is a newly synthetized specific benzodiazepine (BZD) antagonist which was recently introduced for clinical study. The drug was intravenously injected, in titrated doses, to patients undergoing diagnostic or therapeutic procedures in order to reverse the sedative effects of BZDs. A total of 63 patients undergoing hand surgery under i.v. regional block, lower abdominal surgery under epidural anesthesia, cardiac catheterization, intracardiac catheter ablation, cardioversion, gastroscopy and bronchoscopy were studied. Flu in a dose ranging from 0.1 to 0.42 mg effectively reversed BZD-induced sedation in all patients 1-2 min following i.v. injection. Patients were fully awake and oriented yet calm and in good mood. Flu was well tolerated even in the high risk cardiac patients, with no significant changes in vital signs nor any sign of local irritation at the site of Flu injection. No significant resedation was observed. Thus Flu was very useful in reversing BZD-induced sedation or unconsciousness in a variety of clinical situations.
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Affiliation(s)
- E Geller
- Department of Anesthesia and Intensive Care, Tel Aviv Medical Center, Ichilov Hospital, Israel
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Halpern P, Sorkine P, Leykin Y, Geller E. Rupture of the stomach in a diving accident with attempted resuscitation. A case report. Br J Anaesth 1986; 58:1059-61. [PMID: 3756053 DOI: 10.1093/bja/58.9.1059] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
A compressed air diver suffered pulmonary barotrauma with arterial air embolization; resuscitation was unsuccessful. Attempts at resuscitation included mouth-to-mouth ventilation and cardiac massage. A chest radiograph taken during resuscitation revealed free intraperitoneal air. Postmortem examination showed rupture of the stomach. The two possible aetiological factors--barotrauma of ascent and cardiopulmonary resuscitation--are discussed.
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Abstract
Naloxone hydrochloride (N) 0.4-1.2 mg i.v. was administered during 10 episodes of shock (8 septic and 2 cardiogenic) in 9 adult patients. Shock was defined as systolic blood pressure (SBP) less than or equal to 90 mmHg and urine output less than 0.5 ml/h and signs and symptoms of hypoperfusion lasting for greater than or equal to 30 min, despite fluid loading to a CVP 5 cmH2O above baseline. N was given as early as 30 min after onset of shock and resulted in an increase of SBP from a mean of 75 +/- 10 to a mean of 130 +/- 25 mmHg maximum (P less than 0.01). Within 10-60 min urine output increased from 16 +/- 12 to 122 +/- 56 ml/h, heart rate, CVP and arterial blood gas tensions remained unchanged. No side effects were observed. Naloxone, even in small doses, may improve hemodynamic parameters in human shock, provided it is administered very early.
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Leykin Y, Rudik V, Niv D, Geller E. Delayed respiratory depression following extradural injection of morphine. Isr J Med Sci 1985; 21:855-7. [PMID: 4077478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Rudick V, Galon A, Niv D, Leykin Y, Baram A, Geller E, Peyser MR. Anesthetic management of 646 consecutive cesarean section cases. Isr J Med Sci 1985; 21:18-21. [PMID: 3972553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
A retrospective analysis of 646 consecutive cesarean deliveries during a 1-year period was performed. The indications for cesarean section, techniques of anesthesia, fetal and maternal outcome, and complications were evaluated. Of 646 cesarean deliveries, 153 (23.7%) were elective and 493 (76.3%) nonelective. Regional block was the main anesthetic technique used for the elective (88.3%) and the nonelective (79.3%) operations. Maternal complications were few and reversible. In 96% of the newborns the Apgar score was greater than or equal to 7 at 5 min. These results suggest that regional block is the preferred anesthetic technique for cesarean section.
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Rudick V, Kogosowski A, Niv D, Leykin Y, Geller E. [The anesthetist and the gynecological day-case surgery unit]. Harefuah 1984; 107:182-3. [PMID: 6519567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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