Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges... more Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task...
In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the ... more In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniqu...
Enhanced recovery after surgery (ERAS) is an interprofessional program that can lead to hastened ... more Enhanced recovery after surgery (ERAS) is an interprofessional program that can lead to hastened patient recovery and reduced time in hospital. Nursing staff play a key role in the implementation of enhanced recovery protocols. This issue focalizes the role of nurses in ERAS program for patients submitted to Thoracic Surgery, in particular for cases of major lung resection performed by a minimally invasive surgical approach (VATS, video assisted thoracic surgery).
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, May 8, 2017
Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved p... more Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved postoperative respiratory function, reduced hospital length of stay and a higher level of tolerability for the patients. Acute postoperative pain is of considerable significance, and the late development of neuropathic pain syndrome is also an issue. As anaesthesiologists, we have investigated the available evidence to optimize postoperative pain management. An opioid-sparing multimodal approach is highly recommended. Loco-regional techniques such as the thoracic epidural and peripheral blocks can be performed. Several adjuvants have been employed with varying degrees of success both intravenously and in combination with local anesthetics. Opioids with different pharmacodynamic and pharmacokinetic profiles can be used, either through continuous infusion or on demand. Non-opioid analgesics are also beneficial. Finally, perioperative gabapentinoids may be implemented to prevent the onset of...
Journal of Anesthesia, Analgesia and Critical Care
Background Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting... more Background Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection. Results We performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain sco...
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges... more Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task...
Erector spinae plane block (ESPb) is a recently developed ultrasound-guided fascial block that co... more Erector spinae plane block (ESPb) is a recently developed ultrasound-guided fascial block that could be promising as locoregional analgesic technique in thoracic surgery. A single injection, deep to the erector spinae muscle at T5-level, can guarantee analgesia from T1-T3 to T8-T10 from the posterolateral side of the hemithorax to the midclavicular line
Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a
faste... more Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy, tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also, adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain must take into account opioid agents too, if necessary. All above is useful for careful planning and execution of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most recent evidences from literature and authors’ experiences on perioperative multimodal analgesia principles for implementing an ERAS program after VATS lobectomy.
In thoracic surgery, big changes have taken place in the past three decades. Video-assisted thora... more In thoracic surgery, big changes have taken place in the past three decades. Video-assisted thoracic surgery (VATS) was introduced only 25 years ago but has since rapidly evolved, going from three–four ports to two and finally just one: wide, disfiguring incisions have turned into minimal accesses, and the old concept of thoracoscopy has been recast from a diagnostic tool limited to pleural diseases to a full-operative surgical procedure capable of eradicating extensive pulmonary masses (1).
Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved p... more Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved postoperative respiratory function, reduced hospital length of stay and a higher level of tolerability for the patients. Acute postoperative pain is of considerable significance, and the late development of neuropathic pain syndrome is also an issue. As anaesthesiologists, we have investigated the available evidence to optimize postoperative pain management. An opioid-sparing multimodal approach is highly recommended. Loco-regional techniques such as the thoracic epidural and peripheral blocks can be performed. Several adjuvants have been employed with varying degrees of success both intravenously and in combination with local anesthetics. Opioids with different pharmacodynamic and pharmacokinetic profiles can be used, either through continuous infusion or on demand. Non-opioid analgesics are also beneficial. Finally, perioperative gabapenti-noids may be implemented to prevent the onset of chronic neuropathic pain.
The perioperative administration of systemic intravenous lidocaine has been shown to be an effect... more The perioperative administration of systemic intravenous lidocaine has been shown to be an effective method in postoperative pain management with a favorable effect on pain scores, opioid consumption and recovery after surgery without any clear evidence of harm
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges... more Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task...
In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the ... more In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniqu...
Enhanced recovery after surgery (ERAS) is an interprofessional program that can lead to hastened ... more Enhanced recovery after surgery (ERAS) is an interprofessional program that can lead to hastened patient recovery and reduced time in hospital. Nursing staff play a key role in the implementation of enhanced recovery protocols. This issue focalizes the role of nurses in ERAS program for patients submitted to Thoracic Surgery, in particular for cases of major lung resection performed by a minimally invasive surgical approach (VATS, video assisted thoracic surgery).
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, May 8, 2017
Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved p... more Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved postoperative respiratory function, reduced hospital length of stay and a higher level of tolerability for the patients. Acute postoperative pain is of considerable significance, and the late development of neuropathic pain syndrome is also an issue. As anaesthesiologists, we have investigated the available evidence to optimize postoperative pain management. An opioid-sparing multimodal approach is highly recommended. Loco-regional techniques such as the thoracic epidural and peripheral blocks can be performed. Several adjuvants have been employed with varying degrees of success both intravenously and in combination with local anesthetics. Opioids with different pharmacodynamic and pharmacokinetic profiles can be used, either through continuous infusion or on demand. Non-opioid analgesics are also beneficial. Finally, perioperative gabapentinoids may be implemented to prevent the onset of...
Journal of Anesthesia, Analgesia and Critical Care
Background Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting... more Background Dexamethasone is commonly used for the prevention of postoperative nausea and vomiting (PONV), and recent reviews suggest a role for dexamethasone in postoperative analgesia. The aim of this study is to evaluate the efficacy of dexamethasone as an analgesic adjuvant in minimally invasive thoracic surgery. Primary outcome was morphine consumption 24 h after surgery; secondary outcomes were pain control, measured as numeric rating scale (NRS), glycemic changes, PONV, and surgical wound infection. Results We performed a retrospective cohort study considering 70 patients who underwent elective lobectomy, segmentectomy, or wedge resection surgery with a mini-thoracotomy approach or video-assisted thoracoscopic surgery (VATS). All patients received the same locoregional techniques and short-acting opioids during surgery; 46 patients received dexamethasone at induction. There were no significant differences in morphine consumption at 24 h (p = 0.09) and in postoperative pain sco...
Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges... more Introduction Anesthetic care in patients undergoing thoracic surgery presents specific challenges that necessitate standardized, multidisciplionary, and continuously updated guidelines for perioperative care. Methods A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, comprising 24 members from 19 Italian centers, was established to develop recommendations for anesthesia practice in patients undergoing thoracic surgery (specifically lung resection for cancer). The project focused on preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and PubMed and Embase literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventative Services Task...
Erector spinae plane block (ESPb) is a recently developed ultrasound-guided fascial block that co... more Erector spinae plane block (ESPb) is a recently developed ultrasound-guided fascial block that could be promising as locoregional analgesic technique in thoracic surgery. A single injection, deep to the erector spinae muscle at T5-level, can guarantee analgesia from T1-T3 to T8-T10 from the posterolateral side of the hemithorax to the midclavicular line
Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a
faste... more Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy, tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also, adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain must take into account opioid agents too, if necessary. All above is useful for careful planning and execution of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most recent evidences from literature and authors’ experiences on perioperative multimodal analgesia principles for implementing an ERAS program after VATS lobectomy.
In thoracic surgery, big changes have taken place in the past three decades. Video-assisted thora... more In thoracic surgery, big changes have taken place in the past three decades. Video-assisted thoracic surgery (VATS) was introduced only 25 years ago but has since rapidly evolved, going from three–four ports to two and finally just one: wide, disfiguring incisions have turned into minimal accesses, and the old concept of thoracoscopy has been recast from a diagnostic tool limited to pleural diseases to a full-operative surgical procedure capable of eradicating extensive pulmonary masses (1).
Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved p... more Video-assisted thoracoscopic surgery is a widespread technique that has been linked to improved postoperative respiratory function, reduced hospital length of stay and a higher level of tolerability for the patients. Acute postoperative pain is of considerable significance, and the late development of neuropathic pain syndrome is also an issue. As anaesthesiologists, we have investigated the available evidence to optimize postoperative pain management. An opioid-sparing multimodal approach is highly recommended. Loco-regional techniques such as the thoracic epidural and peripheral blocks can be performed. Several adjuvants have been employed with varying degrees of success both intravenously and in combination with local anesthetics. Opioids with different pharmacodynamic and pharmacokinetic profiles can be used, either through continuous infusion or on demand. Non-opioid analgesics are also beneficial. Finally, perioperative gabapenti-noids may be implemented to prevent the onset of chronic neuropathic pain.
The perioperative administration of systemic intravenous lidocaine has been shown to be an effect... more The perioperative administration of systemic intravenous lidocaine has been shown to be an effective method in postoperative pain management with a favorable effect on pain scores, opioid consumption and recovery after surgery without any clear evidence of harm
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Papers by Marzia Umari
faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem
reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this
context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy,
tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour
opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique
for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal
anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also,
adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain
must take into account opioid agents too, if necessary. All above is useful for careful planning and execution
of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most
recent evidences from literature and authors’ experiences on perioperative multimodal analgesia principles
for implementing an ERAS program after VATS lobectomy.
faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem
reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this
context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy,
tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour
opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique
for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal
anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also,
adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain
must take into account opioid agents too, if necessary. All above is useful for careful planning and execution
of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most
recent evidences from literature and authors’ experiences on perioperative multimodal analgesia principles
for implementing an ERAS program after VATS lobectomy.