Antonio Coviello

Background and Aim: Neuraxial anesthesia is commonly used for intertrochanteric fracture surgery but may be contraindicated in frail elderly patients, particularly in the presence of anticoagulation or urgent surgical settings. The Lumbar Erector Spinae Plane Block (L-ESPB) has been proposed as a para-neuraxial technique potentially suitable as a main anesthetic strategy. This study aimed to evaluate whether L-ESPB could represent a viable alternative to Spinal Anesthesia (SA) combined with a Pericapsular Nerve Group (PENG) block in patients undergoing urgent intramedullary nailing for intertrochanteric fractures. Methods: This multicenter comparative pilot study included ≥ 65 years undergoing surgery within 48 hours of hospital admission, between May and November 2025. Fifty patients were analyzed: 24 received L-ESPB as the sole anesthetic technique, and 26 received SA combined with a PENG block. The comparison focused on anesthesiologic plane adequacy, intraoperative hemodynamic stability, and postoperative recovery outcomes. Results: An adequate anesthesiologic plane was achieved in all patients. Sensory and motor block onset was faster and more intense in the PENG + SA group. Intraoperatively, hemodynamic stability was more frequently preserved in the L-ESPB group (58.3% vs 19.2%, p = 0.02), despite similar surgical duration. Intraoperative ketamine rescue was required in a small proportion of patients in the L-ESPB group. Postoperatively, time to mobilization was shorter in the PENG + SA group, whereas pain scores remained low in both groups, with minimal need for rescue analgesia and no relevant anesthesia-related adverse events. Conclusion: L-ESPB provided effective surgical anesthesia and was associated with greater intraoperative hemodynamic stability compared with SA combined with PENG block. These preliminary findings suggest that L-ESPB may represent a feasible alternative in elderly patients with contraindications to neuraxial anesthesia, warranting confirmation in larger prospective studies.

Effective perioperative pain control is essential in Total Knee Arthroplasty (TKA) to support early mobilization and enhance recovery, particularly within Enhanced Recovery After Surgery (ERAS) protocols. The use of a thigh tourniquet, although common, is increasingly questioned due to its association with postoperative pain and thromboembolic risk, especially in patients with a history of Deep Vein Thrombosis (DVT). Periarticular Vasoconstrictor Infiltration (PVI) is a recently described technique aimed at achieving localized hemostasis through epinephrine-based infiltration. This case report illustrates the clinical utility of ultrasound-guided PVI as part of a multimodal, tourniquet-free strategy in high-risk patient. A 66-year-old female with severe right knee osteoarthritis and a history of right lower limb DVT underwent primary TKA under spinal anesthesia. Due to the patient’s elevated thrombotic risk—defined by a high Caprini score—a tailored regional anesthesia protocol was adopted, combining multi-target PVI with a proximal adductor canal block and spinal anesthesia. The PVI solution included ropivacaine, dexmedetomidine, and epinephrine. No tourniquet was inflated during the procedure. The surgical field remained bloodless throughout the 72-minute procedure. Intraoperative blood loss was less than 200 mL, and no transfusion was required. Postoperative analgesia was effective, opioid use was minimized, and the patient mobilized the same evening without complications. No clinical or ultrasound signs of early postoperative thrombotic events were observed. This case demonstrates the feasibility and clinical benefit of integrating ultrasound-guided PVI into a multimodal, tourniquet-free anesthetic strategy for TKA in high-thrombotic-risk patients. The approach provided effective analgesia and hemostasis, aligned with ERAS principles, and may represent a valuable alternative for personalized perioperative care in orthopedic surgery.

Background: Peripherally inserted central catheters (PICCs) are widely used for medium- and long-term intravenous therapies but remain associated with mechanical and thrombotic complications, particularly during venipuncture and guidewire insertion. The growing use of Non-Operating Room Anesthesia (NORA) environments, where anesthesiologists frequently perform ultrasound-guided vascular access under conditions of limited resources and support, underscores the need for simple, reproducible, and inherently safe techniques. The objective of this technical note is to describe a modified ultrasound-guided venipuncture technique for non-tunneled PICC insertion, specifically developed for NORA settings, aimed at reducing procedure-related complications and preserving patient safety in routine clinical practice. Methods: The proposed technique consists of controlled intraluminal advancement of the needle tip (approximately 0.3–0.5 cm) under continuous ultrasound visualization, combined with progressive reduction in the insertion angle to achieve stable central intraluminal alignment before guidewire insertion. The technique has been applied in routine clinical practice across multiple Italian centers over the last two years, within a large multicenter real-world experience exceeding 5000 non-tunneled PICC procedures. Results: Based on real-world clinical observations, the systematic application of the technique was associated with a low incidence of early mechanical complications, including failed guidewire advancement, multiple venipuncture attempts, local pain, and hematoma formation. During standardized post-procedural ultrasound follow-up of the catheterized upper-extremity veins, no cases of catheter-related deep vein thrombosis were detected. Conclusions: This modified ultrasound-guided venipuncture technique represents a feasible and reproducible procedural refinement for non-tunneled PICC insertion in NORA environments. By enhancing intraluminal needle stability during guidewire advancement, it may contribute to improving procedural reliability and supporting patient safety in routine clinical practice. Further prospective and comparative studies are warranted to confirm these findings and define the generalizability of this approach.

Proximal Femur Fractures (PFF) are common among the elderly and can lead to significant disability. Anesthesiological management typically involves Spinal

Background and Aim: Interscalene Brachial Plexus Block (ISBPB) is commonly used for shoulder surgery anesthesia to reduce opioid use and general anesthesia complications. However, it may cause diaphragmatic paresis due to phrenic nerve involvement. This study compares the incidence of hemidiaphragmatic paralysis and the frequency of side effects—including hemodynamic changes and postoperative complications—between the Extrafascial (ExF) and Intrafascial (InF) approaches for ISBPB using reduced anesthetic volume. The aim is to assess whether the ExF approach may be preferable in patients with reduced cardiopulmonary reserve (eg, COPD or heart failure). Methods: A retrospective study was conducted at Federico II University in Naples, Italy, including 61 patients undergoing shoulder surgery from January 2024 to October 2024. About 33 patients received ExF while 28 received InF ISBPB, all with Ropivacaine 0.5% (10 mL), Mepivacaine 2% (5 mL), and Dexamethasone (4 mg). The primary outcome was the incidence of hemidiaphragmatic paralysis, evaluated via ultrasound pre and 30 minutes after the block by assessing diaphragm excursion, thickness, and thickening fraction. Secondary outcomes included intraoperative hemodynamic changes and postoperative complications: pain (NRS), analgesic/antiemetic requests, PONV, pruritus, shivering, anxiety, and discomfort. Results: The TF significantly decreased after the block in both groups (p < 0.001), with no intergroup. Diaphragm paralysis occurred in 28 patients in each group (p = 0.093), without clinical respiratory effects. The InF group had more hypotension episodes (100% vs 30.3%, p = 0.002), and significantly lower mean and systolic blood pressure values at 1 and 2 hours after-block. No cases of anxiety, pruritus, shivering, or discomfort were observed. NRS was higher in the InF group at 6 hours but lower at 12 and 24 hours. Analgesic/antiemetic needs were similar; PONV was more frequent in the ExF. Conclusion: Both approaches resulted in similar rates of hemidiaphragmatic paralysis. However, ExF was associated with fewer hemodynamic effects, suggesting potential benefit in high-risk cardiopulmonary patients.

Labor analgesia is increasingly widespread throughout the world with a rate ranging from 10 to 60%. The benefits regarding clinical and non-clinical maternal–fetal outcomes are currently discussed in international scientific literature. Even stage of labor needs a different and appropriate approach to control the pain; however, different techniques are reported in literature. The following study intends to give a brief overview of the characteristics of the different neuraxial and non-neuraxial techniques currently available and the non-technical skills necessary for effective assistance to pregnant women, providing insights on the topic to understand critical issues at the same time. After bibliographic research since 2018 to 2023, many randomized controlled trials, literature reviews, systematic reviews, and metanalysis were evaluated to create this brief overview. The following pharmacological and non-pharmacological approaches were assessed: spinal techniques, such as epidural analgesia (EA), combined spinal-epidural (CSE), dural puncture epidural (DPE), and continuous spinal anesthesia (CSA); pharmacological administration of nitrous oxide (N₂O) and systemic opioids (morphine, fentanyl, and pethidine); as the third one transcutaneous electric nerve stimulation (TENS), acupressure/acupuncture, aromatherapy, and breathing exercises. All the assessed approaches are relatively safe and effective, but the association of technical and non-technical skills is needed to improve the maternal and fetus outcome. More studies are needed to clarify what is the best approach to labor analgesia.