Anaesthetic challenging in microsurgical flap reconstruction: a systematic review

Background: Anaesthetic management for microvascular reconstructive surgery is challenging and clearly affects the risk of major complications such as flap hypo-perfusion. In this systematic review we explore recent (last 7 years) clinical evidences related to perioperative management and anaesthetic controversy of patients undergoing microvascular reconstructive surgery, especially focused on head and neck surgery with free flaps (FF) and breast reconstructive surgery with deep inferior epigastric perforator flap (DIEP-flap). Methods: A literature search of published clinical studies between 2011 and 2018 was conducted, yielding a total of 4307 papers. Only 150 were eligible, according inclusion and exclusion criteria. Results: 62 studies were selected for this review and categorized in 3 groups: preoperative-intraoperative- postoperative anaesthetic management and areas of controversy for patients undergoing head and neck surgery with FF and breast reconstructive surgery with DIEP-flap. Discussion: Anaesthetic management for flap reconstructive surgery remains an open field of interest with limited evidences regarding a standard care. Main components of research currently are: the need to join standard multidisciplinary enhanced recovery pathways, as well as the necessity to develop a standard intraoperative management. In theatre, the recent hemodynamic parameter “Hypotension Probability Indicator” (HPI) is promising: the advantage to predict a drop in the mean arterial pressure can be more effective than a fluid therapy titrated to maintain SVV less than 13%. Prospective studies are necessary to clarify

The challenge of perioperative pain management in opioid-tolerant patients

The increasing number of opioid users among chronic pain patients, and opioid abusers among the general population, makes perioperative pain management challenging for health care professionals. Anesthesiologists, surgeons, and nurses should be familiar with some pharmacological phenomena which are typical of opioid users and abusers, such as tolerance, physical dependence, hyperalgesia, and addiction. Inadequate pain management is very common in these patients, due to common prejudices and fears. The target of preoperative evaluation is to identify comorbidities and risk factors and recognize signs and symptoms of opioid abuse and opioid withdrawal. Clinicians are encouraged to plan perioperative pain medications and to refer these patients to psychiatrists and addiction specialists for their evaluation. The aim of this review was to give practical suggestions for perioperative management of surgical opioid-tolerant patients, together with schemes of opioid conversion for chronic pain patients assuming oral or transdermal opioids, and patients under maintenance programs with methadone, buprenorphine, or naltrexone

La via peridurale: confronto tra metodiche di somministrazione.

Nel periodo peri-operatorio il controllo del dolore permette di migliorare la qualit\ue0 di vita dei pazienti, riduce le complicanze e permette un pi\uf9 veloce recupero post-operatorio. Un elemento imprescindibile per l\u2019impostazione e il mantenimento di un adeguato trattamento antalgico \ue8 la corretta somministrazione degli analgesici. Il presente lavoro confronta la somministrazione continua e quella intermittente a boli di soluzioni analgesiche per via peridurale. Dai nostri dati emerge che entrambe le modalit\ue0 considerate sono effi caci nel controllo del dolore peri-operatorio nei pazienti affetti da Arteriopatia Ostruttiva Cronica Periferica. Ciononostante, dato che lo schema di somministrazione a boli richiede un impegno organizzativo notevole, si raccomanda l\u2019introduzione dell\u2019analgesia peridurale controllata dal paziente (PCEA, Patient Controlled Epidural Analgesi

Il dolore e la formazione universitaria.

La prevalenza del dolore, sia nell\u2019ambito ospedaliero che in quello extra-ospedaliero, \ue8 ingiustificatamente elevata. Il dolore e la sofferenza sono trascurati, sottostimati e/o maltrattati dalla classe medica nonostante quest\u2019ultima possegga gli strumenti adeguati per lenire il dolore in 90% dei pazienti. (Zech DHJ 1995). Questa condizione \ue8 ascrivibile, in primis, alle manchevolezze degli operatori sanitari e della classe medica in particolare. \uc8 noto che negli ospedali il dolore viene considerato inevitabile e che il suo controllo non costituisca una priorit\ue0. Spesso prevale negli operatori, un atteggiamento fatalistico verso il dolore. Secondo molti, il dolore fa parte integrante della malattia e come tale rientra nel quotidiano e perde di visibilit\ue0. Molti professionisti, carenti di una conoscenza adeguata nel riconoscere e quantificare il dolore, sono riluttanti verso l\u2019uso di analgesici di qualit\ue0 e di dosaggio idonei. Inoltre, dato l\u2019errato presupposto che la medicina deve guarire le malattie e non i sintomi, il sollievo dal dolore e dalla sofferenza sono considerati di priorit\ue0 secondaria. Tale atteggiamento da parte degli operatori condiziona anche i pazienti che si astengono dal riferire la propria sofferenza. L\u2019inadeguato controllo del dolore, oltre ad essere un fenomeno trasversale che interessa tutte le branche mediche, ha una portata mondiale. Infatti, nel 1992 fu avviato un progetto canadese, finalizzato a modificare attitudini e comportamenti sia degli operatori sanitari che dei malati ricoverati nei nosocomi. Tale progetto, denominato \u201dverso un ospedale senza dolore\u201d ed appoggiato dall\u2019Organizzazione Mondiale della Sanit\ue0, \ue8 stato adottato da vari paesi. Anche il Ministero Italiano della Sanit\ue0 ha istituito nel Settembre 2000 una Commissione di Studio \u201cOspedale senza dolore\u201d le cui linee-guida sono state approvate dalla Conferenza Stato-Regioni il 24 Maggio 2001 e pubblicate sulla G.U. il 29 Giugno 2001. Le proposte di modelli di principio e di linee guida per\uf2, non possono esimere le singole strutture sanitarie, e soprattutto quelle universitarie, dall\u2019analisi delle proprie condizioni di partenza in tema del dolore. Infatti, gli interventi mirati, atti a contrastare l\u2019inadeguato trattamento del dolore, non possono prescindere da un\u2019iniziale quantificazione, caratterizzazione ed esame delle cause del fenomeno. A tal proposito \ue8 stato disegnato, presso il Dipartimento di Scienze Chirurgiche ed Anestesiologiche della facolt\ue0 di Medicina e Chirurgia dell\u2019Universit\ue0 di Bologna, un progetto di ricerca dal titolo: \u201cIl trattamento del dolore nella pratica medica ospedaliera, male curabile. Quantificazione, analisi delle cause e proposte di risoluzione del fenomeno\u201d. Il primo obiettivo del progetto, la quantificazione della prevalenza del dolore in ospedale, \ue8 stato implementato attraverso un\u2019indagine trasversale presso l\u2019ospedale universitario \u201cAzienda Universitario-Ospedaliera di Bologna\u201d. L\u2019indagine ha coinvolto oltre 1000 pazienti (da 6 a 99 anni d\u2019et\ue0) ricoverati, da almeno 24 ore, in 57 reparti ospedalieri. Nella giornata indice, i pazienti hanno riferito l\u2019intensit\ue0 del dolore da loro percepito al momento dell\u2019intervista e quella del peggior dolore percepito nelle 24 ore precedenti. Parallelamente sono state raccolte informazioni sulla durata del dolore e del ricovero, il trattamento antalgico applicato, l\u2019et\ue0, il sesso e lo stato civile dei pazienti. I risultati di questa indagine sono stati recentemente pubblicati in una rivista specialistica internazionale (Melotti et al. 2005). Tra i principali risultati figura la conferma che la prevalenza del dolore in un nosocomio universitario \ue8 un fenomeno reale. Infatti, il 38% dei pazienti arruolati nello studio accusava dolore e il 25% dei pazienti lamentava dolore da moderato a severo. La prevalenza di alti livelli di dolore era particolarmente elevata (~60%) nei reparti di radioterapia, ostetricia e chirurgia. Le donne, i giovani adulti ed i pazienti ..

Scoring system for breakthrough-pain likelihood in cancer patients

Scoring system for breakthrough-pain likelihood in cancer patients Submission No: 2044 Submission Type: Poster Abstract Submission Aim of Investigation: Breakthrough pain (BTP) shows variable prevalence in different clinical contexts of cancer patients. BTP diagnostic tools with demonstrated reliability, validation and prognostic capability are lacking. We report the preliminary results of an ongoing impact study following the development of a diagnostic/prognostic tool, the IQ-BTP, for BTP recognition and its likelihood among cancer patients. Methods: A sample of 120 chronic pain patients was used as a learning set. An univariate analysis was conducted in order to select the variables associated with the variable of interest (likelihood level of BTP); these have been employed in the planning of a Naive Bayes classifier; a set of scores for each predictor was computed, by extending the approach usually used for binary classification to the case of three likelihood classes of BTP (High, Low, None). The developed BTP-likelihood scoring system, under the form of a questionnaire (IQ-BTP), recently validated, is now used in a multicenter impact study. The study was authorized by the hospital Ethics Committee, and conducted according to the Helsinki declaration and IASP's guidelines for pain research in animals and humans. Results: The scoring system analysis showed that two thirds of the patients may be correctly classified as potentially having (or not having) BTP; proportions of correct classification for BTP likelihood classes "High" and "No BTP" was greater than 80%: most of the patients satisfying the criteria for having BTP were correctly recognized. Conclusions: The IQ-BTP with its peculiar scoring system and with adequate feasibility may enable, in cancer patients, the detection of potential-BTP and its likelihood. The latter may have significant relevance to BTP epidemiology and management

Determinants of clinical priority and of actual waiting times for surgical interventions

To explore determinants of clinical priority and of actual waiting times for elective surgical interventions. DESIGN, SETTING PARTECIPANTS: 405 patients cared for at two general surgery wards, receiving an explicit judgement of clinical priority and whose actual waiting times to surgery were assessed. Clinicalpriority was assessed through 0 (no priority) to 10 (maximum priority). MAIN OUTCOME MEASURE: Identification through multivariate regression techniques of the clinical characteristics associated with high clinical priority (score 28) and with shorter actual waiting times. RESULTS: Patients with cancer, severe pain, relevant impairment in functional status and relevant expert improvement on quality and duration of survival were more frequently attributed a high clinical priority. As for waiting times, presence of cancer was the only factor associated with shorter waitings. Only for cancer patients high priority judgement was associated with shorter waiting times (median 21 vs. 69 days; p < 0.008). CONCLUSIONS: These findings suggest that actual waiting times are not influenced by the same clinical characteristics that clinicians value when assigning clinical priority. That may have some relevant implications on how waiting lists are managed, if consideration of relevant aspects of patients' needs are missed