Salvatore Meola - Academia.edu (original) (raw)

Papers by Salvatore Meola

Regional Anesthesia and Pain Medicine, Sep 1, 2008

Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in childre... more Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in children and not widely available during regional neuraxial anesthesia (1). We have examined this issue using an echo-Doppler device which provides a continuous measure of aortic blood flow (ABF). With our study we want to determine if there are significant hemodynamic changes using levobupivacaine2.5 mg/kg via the caudal route.

European Journal of Anaesthesiology, Jun 1, 2011

PubMed, Feb 1, 2010

A 22-year-old male who was affected by epidermolysis bullosa (EB) and xeroderma pigmentosa (with ... more A 22-year-old male who was affected by epidermolysis bullosa (EB) and xeroderma pigmentosa (with structural and pathological changes that preclude orotracheal intubation) underwent right upper extremity amputation and ipsilateral axillary lymphadenectomy. The patient was operated without intubation, thereby assuring an optimal state of acute postoperative pain control by regional anesthesia. Intravenous administration of ketamine and remifentanil plus low-dose sevoflurane resulted in anesthesia with spontaneous breathing by the patient. Moreover, the intraoperative brachial plexus nerve block before amputation followed by positioning of an epidural catheter to deliver continuous infusion of local anesthetics close to the cut nerves during surgery obtained a very good level of acute postoperative pain control.

Pediatric Anesthesia, Jun 1, 2008

Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major... more Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major complications, including pulmonary hypertensive crisis and cardiac arrest. Several mechanisms of hemodynamic deterioration, including acute increases in pulmonary vascular resistance (PVR), alterations of ventricular contractility and function and coronary hypoperfusion can contribute to morbidity. Anesthetic drugs exert a variety of effects on PVR, some of which are beneficial and some undesirable. The goals of balanced and cautious anesthetic management are to provide adequate anesthesia and analgesia for the surgical procedure while minimizing increases in PVR and depression of myocardial function. The development of specific pulmonary vasodilators has led to significant advances in medical therapy of PAH that can be incorporated in anesthetic management. It is important that anesthesiologists caring for children with PAH be aware of the increased risk, understand the pathophysiology of PAH, form an appropriate anesthetic management plan and be prepared to treat a pulmonary hypertensive crisis.

European Journal of Anaesthesiology, Jun 1, 2011

Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve ... more Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve block for the sensory nerves in the triangle of Petit before they exit transversus abdominis neuro-fascial plane. This technique of fers a potential advantage over the rectus sheath and ilioinguinal/iliohypogastric nerve blocks thanks to a complete anterior abdominal wall block. In adults it has been shown to reliably decrease postoperative pain scores and opioid requirement in patients undergoing large bowel resection via midline abdominal incision and in women af ter cesarean delivery performed through a Pfannenstiel incision. In our study we demonstrated that ultrasound TAP block (1) was safe and ef ficacious in pediatric population for unilateral inguinal hernia and hydrocele repair together with a reduction in postoperative pain and analgesics requirements. Methods: 46 children (26 males, 20 females) ASA 1-2, 1-10 years old, 9-53 kg, sheduled for unilateral inguinal hernia and hydrocele repair were enrolled in this study af ter informed consent of parents and IRB approval. Under general anesthesia induced with propofol or sevoflurane and maintained with laryngeal mask airway in a mix ture of air/O2/sevoflurane all the patients received echoguided TAP Block before surgery. TAP block was performed under realtime ultrasonographic guidance with 0.30 cc/kg of levobupivacaine 0.25%. Muscle rela xants and opioids were not administered. Results: All blocks were successfull and no patient required any analgesics as rescue in postoperative period. Surgeons found that muscular rela xation was similar to that observed af ter the use of neuromuscular blocking agents. The mean duration of postoperative parietal analgesia (time for first analges rescue), evaluted by CHIPPS scale, was 15±2 h. Children had excellent postoperative comfort (moving, coughing, playing and laughing). No complication associated with this ultrasound technique was recorded. Conclusions: Ultrasonography-guided TAP block in pediatric patients are easy to perform, provides consistent post-operative/intraoperative pain relief and may represent an alternative for epidural/caudal anesthesia. References: 1. Suresh S, Chan V W. Ultrasound guided trans versus abdominis plane block in infants, children and adolescents: a simple procedural guidance for their performance.

Regional Anesthesia and Pain Medicine, Sep 1, 2008

Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in childre... more Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in children and not widely available during regional neuraxial anesthesia (1). We have examined this issue using an echo-Doppler device which provides a continuous measure of aortic blood flow (ABF). With our study we want to determine if there are significant hemodynamic changes using levobupivacaine2.5 mg/kg via the caudal route.

Pediatric Reports, 2012

This case report demonstrates the utility and safety of ultrasound transversus abdominis plane (T... more This case report demonstrates the utility and safety of ultrasound transversus abdominis plane (TAP) block in a paediatric patient suffering from Menkes disease. Anaesthetists, and particularly paediatric and neonatal anaesthetists, have to make a careful assessment of these patients, who are subjected to frequent surgeries, despite their tender years. These operations are often necessary in order to improve the patient's quality of life as much as possible. The choice of anaesthetic technique must take the particular nature of the disease and the patient's medical history into consideration, while careful preparation and preoperative evaluations make it possible to administer the general or local anaesthetic safely. Official literature on the subject does not provide sufficient information about the use of local anaesthetic techniques. Moreover, the use of ultrasound TAP block in patients affected by Menkes disease has never been published in literature. In our experience, ultrasound TAP block has provided positive results, although the rarity of this childhood disease makes a detailed study difficult.

Regional Anesthesia and Pain Medicine, 2008

Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in childre... more Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in children and not widely available during regional neuraxial anesthesia (1). We have examined this issue using an echo-Doppler device which provides a continuous measure of aortic blood flow (ABF). With our study we want to determine if there are significant hemodynamic changes using levobupivacaine2.5 mg/kg via the caudal route.

Plastic and Reconstructive Surgery, 2007

The combination of sedative and analgesic drugs is increasingly being used during minimally invas... more The combination of sedative and analgesic drugs is increasingly being used during minimally invasive surgery. The authors compared the clinical efficacy of two different fentanyl regimens, in combination with midazolam, for sedation analgesia in patients undergoing office-based plastic surgery procedures under local anesthesia. One-hundred patients were randomized into two groups of 50 subjects each. Group F1 received a fentanyl bolus of 0.7 microg/kg before infiltration with local anaesthetics; group F2 received the same bolus plus 0.6 microg/kg fentanyl every 45 minutes. All patients received a midazolam bolus of 0.05 mg/kg plus continuous infusion 0.08 mg/kg per hour. High-quality analgesia was obtained in every group, without significant differences between the two fentanyl regimens. Group F2 was associated with lower intraoperative mean blood pressure and SpO2 values compared with group F1. No differences were detected between the two groups in perioperative side effects or postoperative pain. Higher doses of opioid did not improve the quality of perioperative patient comfort but acted synergistically with the sedative drugs, amplifying the hemodynamic and respiratory side effects.

European Journal of Anaesthesiology, 2011

Acta Anaesthesiologica Scandinavica, 2009

Pediatric Anesthesia, Sep 17, 2010

pediatric anesthesiologists should possess. We believe that the data from our study speak for the... more pediatric anesthesiologists should possess. We believe that the data from our study speak for themselves, i.e., that removing an LMA during deep desflurane anesthesia in children is associated with a greater frequency of adverse airway events compared with isoflurane. J E R R O L D L E R M A N* G R E G H A M M E R† *Women and Children’s Hospital of Buffalo, SUNY at Buffalo, NY, USA and †Stanford University School of Medicine, Stanford, CA, USA

Pediatric Anesthesia, 2009

SIR—We read with interest the article of Caruselli et al. (1) about the case of a 7-year-old chil... more SIR—We read with interest the article of Caruselli et al. (1) about the case of a 7-year-old child that suffered from a pinch-off syndrome (POS): a 6-Fr port catheter was introduced through the subclavian vein of a child, suffering from Cooley’s syndrome, that needed frequent blood transfusion. The catheter was implanted without problems under deep sedation using absolutely a blind technique. After 22 months the child began to have pain during infusion; repeated chest X-rays during movement of the homolateral shoulder demonstrated that venous catheter was damaged by repeated mechanical compression between the clavicle and the homolateral first rib. Recent international literature have demonstrated that central venous access devices placed through a percutaneous subclavian approach may be compressed by neighboring bony structures, leading to biomaterial fatigue subsequent to repeated mechanical compression, catheter fracture at the compression site, and possible embolization of distal fragment into the central veins (2). This problem can be avoided using some alternative techniques: • the percutaneous supraclavicular technique, • the percutaneous internal jugular vein technique, • the ultrasound incannulation of the axillary vein. The percutaneous supraclavicular puncture prevents mechanical compression between the clavicle and the homolateral first rib but not pneumothorax formation (3). The percutaneous internal jugular vein technique may prevent POS rather than the percutaneous supraclavicular technique but the evidence-based medicine shows that Ultrasound incannulation vein is the golden goal (4). In USA, the Association for Vascular Access has identified that use of landmark technique for placement of central venous devices is associated with preventable, potentially serious patient complications. Each year more than 5 million central venous access devices are placed in USA utilizing landmark techniques; complications frequently associated with these procedures are pneumothorax, hemothorax, hydrothorax, arterial puncture, nerve damage, malposition, located infection, and catheterrelated bloodstream infection. These complications have been demonstrated in the literature to exceed 15% (5). Since 2001, multiple professional organizations have recommended a change from landmark technique to ultrasound guidance for placement of central venous accesses devices (6,7). The Agency for Healthcare Research and Quality (AHRQ) and US Centers for Disease Control and Prevention (CDC) both support the use of ultrasound guidance for elective CVAD placement procedures, asserting that realtime ultrasound guidance improves catheter insertion success rates, reduces the number of venipuncture attempts prior to successful placement, and reduces the number of complications associated with catheter insertion. In England, use of ultrasonography is recommended by National Institute For Clinical Excellence (NICE, 2002). Echography is able to visualize veins and adjacent structures, anatomopathological alterations, and venous thrombosis. Vein cannulation is easier and safe and a minor number of attempts are reported necessary. Using ultrasound guidance, we directly can observe axillary vein that is anterior to clavicle. We can do ultrasound venipuncture with precision and safety; in this way we can reduce the number of venipuncture attempts and avoid the POS.

Regional Anesthesia and Pain Medicine, 2008

ABSTRACT

Pediatric Anesthesia, 2008

1 Herod J, Denyer J, Goldman A et al. Epidermolysis bullosa in children: pathophysiology, anaesth... more 1 Herod J, Denyer J, Goldman A et al. Epidermolysis bullosa in children: pathophysiology, anaesthesia and pain management. Paediatr Anaesth 2002; 12: 388–397. 2 Wolff K, Goldsmith LA, Katz SI et al. Fitzpatrick’s Dermatology in General Medicine, 7th edn. New York, NY: The McGraw-Hill Companies, Inc, 2008. 3 Hutchisson B, Baird MG, Wagner S. Electrosurgical safety. AORN J 1998; 68: 830–837; quiz 8. 4 Drury NE, Petley GW, Clewlow F et al. Evidence-based guidelines for the use of defibrillation pads. Resuscitation 2001; 51: 283–286.

Pediatric Anesthesia, 2008

Pediatric Anesthesia, 2008

Background: The aim of this study is to determine if there are significant differences in hemodyn... more Background: The aim of this study is to determine if there are significant differences in hemodynamic effects between combined general-regional anesthesia using levobupivacaine 0.25% 2 mlAEkg)1 via the caudal route in comparison with balanced general anesthesia using continuous infusion of remifentanil in young children undergoing genitourinary surgery. Patients and methods: 62 ASA I-II pediatric patients (12 female, 50 male) aged 6 months to 7 years undergoing genitourinary surgery were included in the study. Patients were randomly allocated into one of two groups of 31 patients each. Group Caud received caudal blockade with levobupivacaine 0.25% 2 mgAEkg)1 in combined generalregional anesthesia and Group Gen received balanced general anesthesia with remifentanil. The noninvasive hemodynamic parameters were measured in each group 5 min after induction of general anesthesia or caudal block (Tcaud), after further 5 min coincident with skin incision (Tsi), 10 min after skin incision (T10i), at the end of surgical procedure (Tend). The time between Tcaud and Tsi was 10 min and the measurements during the interval time T10i-Tend were performed every 15 min according to the duration of surgical procedures. Results: There was a decrease in all measured hemodynamic parameters at skin incision. The decreases occurred in both groups with those in the caudal group occurring at skin incision and those in the balanced anesthesia group occurring at 10 min after skin incision. These variations showed no significant differences for any of the stated outcomes; neither between the groups at each time point nor in the caudal in comparison with baseline measurements. Conclusions: Using transesophageal Doppler no differences in hemodynamic parameters could be detected between balanced general anesthesia with either caudal levobupivacaine or remifentanil

Pediatric Anesthesia, 2010

pediatric anesthesiologists should possess. We believe that the data from our study speak for the... more pediatric anesthesiologists should possess. We believe that the data from our study speak for themselves, i.e., that removing an LMA during deep desflurane anesthesia in children is associated with a greater frequency of adverse airway events compared with isoflurane. J E R R O L D L E R M A N* G R E G H A M M E R† *Women and Children’s Hospital of Buffalo, SUNY at Buffalo, NY, USA and †Stanford University School of Medicine, Stanford, CA, USA

European Journal of Anaesthesiology, 2011

Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve ... more Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve block for the sensory nerves in the triangle of Petit before they exit transversus abdominis neuro-fascial plane. This technique of fers a potential advantage over the rectus sheath and ilioinguinal/iliohypogastric nerve blocks thanks to a complete anterior abdominal wall block. In adults it has been shown to reliably decrease postoperative pain scores and opioid requirement in patients undergoing large bowel resection via midline abdominal incision and in women af ter cesarean delivery performed through a Pfannenstiel incision. In our study we demonstrated that ultrasound TAP block (1) was safe and ef ficacious in pediatric population for unilateral inguinal hernia and hydrocele repair together with a reduction in postoperative pain and analgesics requirements. Methods: 46 children (26 males, 20 females) ASA 1 2, 1-10 years old, 9-53 kg, sheduled for unilateral inguinal hernia and hydrocele repair were enrolled in this study af ter informed consent of parents and IRB approval. Under general anesthesia induced with propofol or sevoflurane and maintained with laryngeal mask airway in a mixture of air/O2/sevoflurane all the patients received echoguided TAP Block before surgery. TAP block was performed under realtime ultrasonographic guidance with 0.30 cc/kg of levobupivacaine 0.25%. Muscle relaxants and opioids were not administered. Results: All blocks were successfull and no patient required any analgesics as rescue in postoperative period. Surgeons found that muscular relaxation was similar to that observed af ter the use of neuromuscular blocking agents. The mean duration of postoperative parietal analgesia (time for first analges rescue), evaluted by CHIPPS scale, was 15±2 h. Children had excellent postoperative comfort (moving, coughing, playing and laughing). No complication associated with this ultrasound technique was recorded. Conclusions: Ultrasonography-guided TAP block in pediatric patients are easy to perform, provides consistent post-operative/intraoperative pain relief and may represent an alternative for epidural/caudal anesthesia. References: 1. Suresh S, Chan VW. Ultrasound guided trans versus abdominis plane block in infants, children and adolescents: a simple procedural guidance for their performance. Paediatr Anaesth 2009; 19:296-9

Regional Anesthesia and Pain Medicine, Sep 1, 2008

Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in childre... more Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in children and not widely available during regional neuraxial anesthesia (1). We have examined this issue using an echo-Doppler device which provides a continuous measure of aortic blood flow (ABF). With our study we want to determine if there are significant hemodynamic changes using levobupivacaine2.5 mg/kg via the caudal route.

European Journal of Anaesthesiology, Jun 1, 2011

PubMed, Feb 1, 2010

A 22-year-old male who was affected by epidermolysis bullosa (EB) and xeroderma pigmentosa (with ... more A 22-year-old male who was affected by epidermolysis bullosa (EB) and xeroderma pigmentosa (with structural and pathological changes that preclude orotracheal intubation) underwent right upper extremity amputation and ipsilateral axillary lymphadenectomy. The patient was operated without intubation, thereby assuring an optimal state of acute postoperative pain control by regional anesthesia. Intravenous administration of ketamine and remifentanil plus low-dose sevoflurane resulted in anesthesia with spontaneous breathing by the patient. Moreover, the intraoperative brachial plexus nerve block before amputation followed by positioning of an epidural catheter to deliver continuous infusion of local anesthetics close to the cut nerves during surgery obtained a very good level of acute postoperative pain control.

Pediatric Anesthesia, Jun 1, 2008

Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major... more Pulmonary arterial hypertension (PAH) is associated with significant perioperative risk for major complications, including pulmonary hypertensive crisis and cardiac arrest. Several mechanisms of hemodynamic deterioration, including acute increases in pulmonary vascular resistance (PVR), alterations of ventricular contractility and function and coronary hypoperfusion can contribute to morbidity. Anesthetic drugs exert a variety of effects on PVR, some of which are beneficial and some undesirable. The goals of balanced and cautious anesthetic management are to provide adequate anesthesia and analgesia for the surgical procedure while minimizing increases in PVR and depression of myocardial function. The development of specific pulmonary vasodilators has led to significant advances in medical therapy of PAH that can be incorporated in anesthetic management. It is important that anesthesiologists caring for children with PAH be aware of the increased risk, understand the pathophysiology of PAH, form an appropriate anesthetic management plan and be prepared to treat a pulmonary hypertensive crisis.

European Journal of Anaesthesiology, Jun 1, 2011

Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve ... more Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve block for the sensory nerves in the triangle of Petit before they exit transversus abdominis neuro-fascial plane. This technique of fers a potential advantage over the rectus sheath and ilioinguinal/iliohypogastric nerve blocks thanks to a complete anterior abdominal wall block. In adults it has been shown to reliably decrease postoperative pain scores and opioid requirement in patients undergoing large bowel resection via midline abdominal incision and in women af ter cesarean delivery performed through a Pfannenstiel incision. In our study we demonstrated that ultrasound TAP block (1) was safe and ef ficacious in pediatric population for unilateral inguinal hernia and hydrocele repair together with a reduction in postoperative pain and analgesics requirements. Methods: 46 children (26 males, 20 females) ASA 1-2, 1-10 years old, 9-53 kg, sheduled for unilateral inguinal hernia and hydrocele repair were enrolled in this study af ter informed consent of parents and IRB approval. Under general anesthesia induced with propofol or sevoflurane and maintained with laryngeal mask airway in a mix ture of air/O2/sevoflurane all the patients received echoguided TAP Block before surgery. TAP block was performed under realtime ultrasonographic guidance with 0.30 cc/kg of levobupivacaine 0.25%. Muscle rela xants and opioids were not administered. Results: All blocks were successfull and no patient required any analgesics as rescue in postoperative period. Surgeons found that muscular rela xation was similar to that observed af ter the use of neuromuscular blocking agents. The mean duration of postoperative parietal analgesia (time for first analges rescue), evaluted by CHIPPS scale, was 15±2 h. Children had excellent postoperative comfort (moving, coughing, playing and laughing). No complication associated with this ultrasound technique was recorded. Conclusions: Ultrasonography-guided TAP block in pediatric patients are easy to perform, provides consistent post-operative/intraoperative pain relief and may represent an alternative for epidural/caudal anesthesia. References: 1. Suresh S, Chan V W. Ultrasound guided trans versus abdominis plane block in infants, children and adolescents: a simple procedural guidance for their performance.

Regional Anesthesia and Pain Medicine, Sep 1, 2008

Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in childre... more Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in children and not widely available during regional neuraxial anesthesia (1). We have examined this issue using an echo-Doppler device which provides a continuous measure of aortic blood flow (ABF). With our study we want to determine if there are significant hemodynamic changes using levobupivacaine2.5 mg/kg via the caudal route.

Pediatric Reports, 2012

This case report demonstrates the utility and safety of ultrasound transversus abdominis plane (T... more This case report demonstrates the utility and safety of ultrasound transversus abdominis plane (TAP) block in a paediatric patient suffering from Menkes disease. Anaesthetists, and particularly paediatric and neonatal anaesthetists, have to make a careful assessment of these patients, who are subjected to frequent surgeries, despite their tender years. These operations are often necessary in order to improve the patient's quality of life as much as possible. The choice of anaesthetic technique must take the particular nature of the disease and the patient's medical history into consideration, while careful preparation and preoperative evaluations make it possible to administer the general or local anaesthetic safely. Official literature on the subject does not provide sufficient information about the use of local anaesthetic techniques. Moreover, the use of ultrasound TAP block in patients affected by Menkes disease has never been published in literature. In our experience, ultrasound TAP block has provided positive results, although the rarity of this childhood disease makes a detailed study difficult.

Regional Anesthesia and Pain Medicine, 2008

Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in childre... more Introduction: Experience with intraoperative transoesophageal Doppler (TED) is limited in children and not widely available during regional neuraxial anesthesia (1). We have examined this issue using an echo-Doppler device which provides a continuous measure of aortic blood flow (ABF). With our study we want to determine if there are significant hemodynamic changes using levobupivacaine2.5 mg/kg via the caudal route.

Plastic and Reconstructive Surgery, 2007

The combination of sedative and analgesic drugs is increasingly being used during minimally invas... more The combination of sedative and analgesic drugs is increasingly being used during minimally invasive surgery. The authors compared the clinical efficacy of two different fentanyl regimens, in combination with midazolam, for sedation analgesia in patients undergoing office-based plastic surgery procedures under local anesthesia. One-hundred patients were randomized into two groups of 50 subjects each. Group F1 received a fentanyl bolus of 0.7 microg/kg before infiltration with local anaesthetics; group F2 received the same bolus plus 0.6 microg/kg fentanyl every 45 minutes. All patients received a midazolam bolus of 0.05 mg/kg plus continuous infusion 0.08 mg/kg per hour. High-quality analgesia was obtained in every group, without significant differences between the two fentanyl regimens. Group F2 was associated with lower intraoperative mean blood pressure and SpO2 values compared with group F1. No differences were detected between the two groups in perioperative side effects or postoperative pain. Higher doses of opioid did not improve the quality of perioperative patient comfort but acted synergistically with the sedative drugs, amplifying the hemodynamic and respiratory side effects.

European Journal of Anaesthesiology, 2011

Acta Anaesthesiologica Scandinavica, 2009

Pediatric Anesthesia, Sep 17, 2010

pediatric anesthesiologists should possess. We believe that the data from our study speak for the... more pediatric anesthesiologists should possess. We believe that the data from our study speak for themselves, i.e., that removing an LMA during deep desflurane anesthesia in children is associated with a greater frequency of adverse airway events compared with isoflurane. J E R R O L D L E R M A N* G R E G H A M M E R† *Women and Children’s Hospital of Buffalo, SUNY at Buffalo, NY, USA and †Stanford University School of Medicine, Stanford, CA, USA

Pediatric Anesthesia, 2009

SIR—We read with interest the article of Caruselli et al. (1) about the case of a 7-year-old chil... more SIR—We read with interest the article of Caruselli et al. (1) about the case of a 7-year-old child that suffered from a pinch-off syndrome (POS): a 6-Fr port catheter was introduced through the subclavian vein of a child, suffering from Cooley’s syndrome, that needed frequent blood transfusion. The catheter was implanted without problems under deep sedation using absolutely a blind technique. After 22 months the child began to have pain during infusion; repeated chest X-rays during movement of the homolateral shoulder demonstrated that venous catheter was damaged by repeated mechanical compression between the clavicle and the homolateral first rib. Recent international literature have demonstrated that central venous access devices placed through a percutaneous subclavian approach may be compressed by neighboring bony structures, leading to biomaterial fatigue subsequent to repeated mechanical compression, catheter fracture at the compression site, and possible embolization of distal fragment into the central veins (2). This problem can be avoided using some alternative techniques: • the percutaneous supraclavicular technique, • the percutaneous internal jugular vein technique, • the ultrasound incannulation of the axillary vein. The percutaneous supraclavicular puncture prevents mechanical compression between the clavicle and the homolateral first rib but not pneumothorax formation (3). The percutaneous internal jugular vein technique may prevent POS rather than the percutaneous supraclavicular technique but the evidence-based medicine shows that Ultrasound incannulation vein is the golden goal (4). In USA, the Association for Vascular Access has identified that use of landmark technique for placement of central venous devices is associated with preventable, potentially serious patient complications. Each year more than 5 million central venous access devices are placed in USA utilizing landmark techniques; complications frequently associated with these procedures are pneumothorax, hemothorax, hydrothorax, arterial puncture, nerve damage, malposition, located infection, and catheterrelated bloodstream infection. These complications have been demonstrated in the literature to exceed 15% (5). Since 2001, multiple professional organizations have recommended a change from landmark technique to ultrasound guidance for placement of central venous accesses devices (6,7). The Agency for Healthcare Research and Quality (AHRQ) and US Centers for Disease Control and Prevention (CDC) both support the use of ultrasound guidance for elective CVAD placement procedures, asserting that realtime ultrasound guidance improves catheter insertion success rates, reduces the number of venipuncture attempts prior to successful placement, and reduces the number of complications associated with catheter insertion. In England, use of ultrasonography is recommended by National Institute For Clinical Excellence (NICE, 2002). Echography is able to visualize veins and adjacent structures, anatomopathological alterations, and venous thrombosis. Vein cannulation is easier and safe and a minor number of attempts are reported necessary. Using ultrasound guidance, we directly can observe axillary vein that is anterior to clavicle. We can do ultrasound venipuncture with precision and safety; in this way we can reduce the number of venipuncture attempts and avoid the POS.

Regional Anesthesia and Pain Medicine, 2008

ABSTRACT

Pediatric Anesthesia, 2008

1 Herod J, Denyer J, Goldman A et al. Epidermolysis bullosa in children: pathophysiology, anaesth... more 1 Herod J, Denyer J, Goldman A et al. Epidermolysis bullosa in children: pathophysiology, anaesthesia and pain management. Paediatr Anaesth 2002; 12: 388–397. 2 Wolff K, Goldsmith LA, Katz SI et al. Fitzpatrick’s Dermatology in General Medicine, 7th edn. New York, NY: The McGraw-Hill Companies, Inc, 2008. 3 Hutchisson B, Baird MG, Wagner S. Electrosurgical safety. AORN J 1998; 68: 830–837; quiz 8. 4 Drury NE, Petley GW, Clewlow F et al. Evidence-based guidelines for the use of defibrillation pads. Resuscitation 2001; 51: 283–286.

Pediatric Anesthesia, 2008

Pediatric Anesthesia, 2008

Background: The aim of this study is to determine if there are significant differences in hemodyn... more Background: The aim of this study is to determine if there are significant differences in hemodynamic effects between combined general-regional anesthesia using levobupivacaine 0.25% 2 mlAEkg)1 via the caudal route in comparison with balanced general anesthesia using continuous infusion of remifentanil in young children undergoing genitourinary surgery. Patients and methods: 62 ASA I-II pediatric patients (12 female, 50 male) aged 6 months to 7 years undergoing genitourinary surgery were included in the study. Patients were randomly allocated into one of two groups of 31 patients each. Group Caud received caudal blockade with levobupivacaine 0.25% 2 mgAEkg)1 in combined generalregional anesthesia and Group Gen received balanced general anesthesia with remifentanil. The noninvasive hemodynamic parameters were measured in each group 5 min after induction of general anesthesia or caudal block (Tcaud), after further 5 min coincident with skin incision (Tsi), 10 min after skin incision (T10i), at the end of surgical procedure (Tend). The time between Tcaud and Tsi was 10 min and the measurements during the interval time T10i-Tend were performed every 15 min according to the duration of surgical procedures. Results: There was a decrease in all measured hemodynamic parameters at skin incision. The decreases occurred in both groups with those in the caudal group occurring at skin incision and those in the balanced anesthesia group occurring at 10 min after skin incision. These variations showed no significant differences for any of the stated outcomes; neither between the groups at each time point nor in the caudal in comparison with baseline measurements. Conclusions: Using transesophageal Doppler no differences in hemodynamic parameters could be detected between balanced general anesthesia with either caudal levobupivacaine or remifentanil

Pediatric Anesthesia, 2010

pediatric anesthesiologists should possess. We believe that the data from our study speak for the... more pediatric anesthesiologists should possess. We believe that the data from our study speak for themselves, i.e., that removing an LMA during deep desflurane anesthesia in children is associated with a greater frequency of adverse airway events compared with isoflurane. J E R R O L D L E R M A N* G R E G H A M M E R† *Women and Children’s Hospital of Buffalo, SUNY at Buffalo, NY, USA and †Stanford University School of Medicine, Stanford, CA, USA

European Journal of Anaesthesiology, 2011

Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve ... more Background: The transversus abdominis plane block (TAP) is a recently described peripheral nerve block for the sensory nerves in the triangle of Petit before they exit transversus abdominis neuro-fascial plane. This technique of fers a potential advantage over the rectus sheath and ilioinguinal/iliohypogastric nerve blocks thanks to a complete anterior abdominal wall block. In adults it has been shown to reliably decrease postoperative pain scores and opioid requirement in patients undergoing large bowel resection via midline abdominal incision and in women af ter cesarean delivery performed through a Pfannenstiel incision. In our study we demonstrated that ultrasound TAP block (1) was safe and ef ficacious in pediatric population for unilateral inguinal hernia and hydrocele repair together with a reduction in postoperative pain and analgesics requirements. Methods: 46 children (26 males, 20 females) ASA 1 2, 1-10 years old, 9-53 kg, sheduled for unilateral inguinal hernia and hydrocele repair were enrolled in this study af ter informed consent of parents and IRB approval. Under general anesthesia induced with propofol or sevoflurane and maintained with laryngeal mask airway in a mixture of air/O2/sevoflurane all the patients received echoguided TAP Block before surgery. TAP block was performed under realtime ultrasonographic guidance with 0.30 cc/kg of levobupivacaine 0.25%. Muscle relaxants and opioids were not administered. Results: All blocks were successfull and no patient required any analgesics as rescue in postoperative period. Surgeons found that muscular relaxation was similar to that observed af ter the use of neuromuscular blocking agents. The mean duration of postoperative parietal analgesia (time for first analges rescue), evaluted by CHIPPS scale, was 15±2 h. Children had excellent postoperative comfort (moving, coughing, playing and laughing). No complication associated with this ultrasound technique was recorded. Conclusions: Ultrasonography-guided TAP block in pediatric patients are easy to perform, provides consistent post-operative/intraoperative pain relief and may represent an alternative for epidural/caudal anesthesia. References: 1. Suresh S, Chan VW. Ultrasound guided trans versus abdominis plane block in infants, children and adolescents: a simple procedural guidance for their performance. Paediatr Anaesth 2009; 19:296-9