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Peripheral nerve blocks (PNBs) are widely used for postoperative analgesia, but rebound pain following block resolution poses a significant clinical challenge. Dexamethasone, administered either intravenously (IV) or perineurally, has shown promise in reducing rebound pain incidence, but the optimal route remains unclear. This network meta-analysis (NMA) aims to compare the effectiveness of different routes of dexamethasone administration, including IV, perineural, and control, in reducing the incidence of rebound pain following PNBs. Network meta-analysis. Operating room, postoperative recovery area and ward. Seven randomized controlled trials involving 561 patients undergoing peripheral nerve block for postoperative pain management. Intravenous and perineural dexamethasone compared to control for preventing rebound pain. The primary outcome was the incidence of rebound pain. Secondary outcomes included median time to first analgesic request, rebound pain resolution time, difference in pain scores before and after PNB resolution, and nausea/vomiting. Both IV and perineural dexamethasone significantly reduced the incidence of rebound pain following peripheral nerve blocks compared to the control group. IV dexamethasone ranked first based on P-score (OR, 0.13; 95 % CI, 0.07–0.23; P-score, 0.92). Secondary outcomes, including time to the first analgesic request, pain score difference, and nausea/vomiting, also favored both IV and perineural dexamethasone over the control group. Both IV and perineural dexamethasone are preferred over no dexamethasone for preventing rebound pain after PNBs, with IV dexamethasone being the more effective route. Despite limitations, these findings provide valuable insights for clinical decision-making in postoperative pain management. Systematic review registration: PROSPERO CRD42024530943. • Both IV and perineural dexamethasone are preferred over no dexamethasone for preventing rebound pain after PNBs. • IV dexamethasone appears to be more effective than perineural dexamethasone in preventing rebound pain. • Perineural dexamethasone remains off-label, making IV administration a safer choice. • Systemic effects of dexamethasone likely drive rebound pain reduction. [ABSTRACT FROM AUTHOR]

Newer regional anesthesia techniques and minimally invasive surgeries have yielded decreased postoperative pain scores, potentially leading to decreased need for perioperative epidural analgesia. Limited literature is available on trends in usage rates of epidurals. The objective of this study was to identify trends in perioperative epidural analgesia rates among multiple fields of surgery. All patients undergoing general, thoracic, urologic, plastic, vascular, orthopedic, or gynecological surgery in 2014–2020 were included from the National Surgical Quality Improvement Program database of over 700 hospitals in the U.S. and 11 different countries. Annual trends in epidural analgesia for all surgeries and each surgical specialty were assessed by mixed effects multivariable logistic regression. The odds ratios (OR) and 99 % confidence intervals (CI) were reported. There were 3,111,435 patients from 2014 to 2020 that were included in the final analysis, in which 107,209 (3.4 %) received perioperative epidural analgesia. Among all surgeries combined, epidural use throughout the study period decreased (OR 0.98 per year, 99 % CI 0.97–0.98, P < 0.001). When only analyzing the surgeries with the top 5 most frequent epidural use per specialty, there was no statistically significant trend in epidural utilization (OR 0.99 per year, 99 % CI 0.99–1.00, P = 0.09). However, there was an increasing trend in epidural utilization in general surgery (OR 1.05 per year, 99 % CI 1.03–1.07, P < 0.001) and vascular surgery (OR 1.08 per year, 99 % CI 1.05–1.10, P < 0.001). Rates of perioperative epidural analgesia use has decreased in recent years overall, however, among surgeries within the general surgery and vascular surgery specialty, utilization has increased for procedures that have the highest rates of usage. • Based on data mainly from the U.S., perioperative epidural usage has decreased from 2014 to 2020. • Epidural usage has increased in open vascular and general surgeries from 2014 to 2020. • General surgery procedures had the highest rate of epidural utilization [ABSTRACT FROM AUTHOR]

Describe dosing of local anesthetic when both a periarticular injection (PAI) and peripheral nerve block (PNB) are utilized for knee arthroplasty analgesia, and compare the dosing of local to suggested maximum dosing, and look for evidence of local anesthetic systemic toxicity (LAST). A single center retrospective cohort study between May 2018 and November 2022. A major academic hospital. Patients who had both a PAI and PNB while undergoing primary, revision, total, partial, unilateral, or bilateral knee arthroplasty. None. Calculate the dose of local anesthetic given via PAI, PNB, and both routes combined as based on lean body weight and compare that to the suggested maximum dosing. Look for medications, clinical interventions, and critical event notes suggestive of a LAST event. There were 4527 knee arthroplasties where both a PAI and PNB were performed during the study period. When combining PAI and PNB doses, >75% of patients received more than the suggested maximum dose of 3 mg/kg lean body weight. The median local anesthetic dosing over the study period, 4.4 mg/kg (IQR 3.5,5.9), was 147% of the suggested maximum dose (IQR 117,197). There was no conclusive evidence of LAST among any of the patients in the study. Over the course of our study, we had 4527 knee arthroplasties with a median PAI and PNB local anesthetic dose that was 147% of the suggested maximum without any clear clinical evidence of a LAST event. [Display omitted] • Total combined dose of local anesthetic given via PAI and PNB often exceeds suggested maximum lean body weight-based amount. • No definitive local anesthetic toxicity events were observed in this retrospective single-center study. • Maximum recommended doses of bupivacaine and ropivacaine could be reevaluated in knee arthroplasty. [ABSTRACT FROM AUTHOR]

To compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy. A prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial. A single tertiary academic medical center. 126 adults aged 18–65 years undergoing elective laparoscopic cholecystectomy. Patients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion. The primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of −6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events. 124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117–127) for lidocaine, 124 (119–126) for ESPB, and 112 (108–117) for placebo. Lidocaine was non-inferior to ESPB (median difference –1, 97.5% CI: −4 to ∞). Both lidocaine (median difference 9, 95% CI: 6–12, P < 0.001) and ESPB (median difference 10, 95% CI: 7–13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred. For patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways. [Display omitted] • Intravenous lidocaine was non-inferior to ESPB for improving quality of recovery post laparoscopic cholecystectomy. • Intravenous lidocaine and ESPB offered similar postoperative analgesic benefits in laparoscopic cholecystectomy patients. • No significant differences in adverse events between intravenous lidocaine and ESPB groups were noted. [ABSTRACT FROM AUTHOR]

To determine if single-injection bilateral posterior quadratus lumborum block (QLB) with ropivacaine would improve postoperative analgesia in the first 24 h after laparoscopic hepatectomy, compared with 0.9% saline. Prospective, double blinded, randomized controlled trial. A single tertiary care center from November 2021 and January 2023. A total of 94 patients scheduled to undergo laparoscopic hepatectomy due to hepatocellular carcinoma. Ninety-four patients were randomized into a QLB group (receiving 20 mL of 0.375% ropivacaine on each side, 150 mg in total) or a control group (receiving 20 mL of 0.9% saline on each side). The primary outcome was the cumulative opioid consumption during the initial 24-h post-surgery. Secondary outcomes included pain scores and intraoperative and recovery parameters. The mean cumulative opioid consumption during the initial 24-h post-surgery was 30.8 ± 22.4 mg in the QLB group (n = 46) and 34.0 ± 19.4 mg in the control group (n = 46, mean differences: −3.3 mg, 95% confidence interval, −11.9 to 5.4, p = 0.457). The mean resting pain score at 1 h post-surgery was significantly lower in the QLB group than in the control group (5 [4–6.25] vs. 7 [4.75–8], p = 0.035). No significant intergroup differences were observed in the resting or coughing pain scores at other time points or in other secondary outcomes. Preoperative bilateral posterior QLB did not reduce cumulative opioid consumption during the first 24 h after laparoscopic hepatectomy. • Posterior QLB didn't reduce postoperative opioid dose in laparoscopic hepatectomy. • Posterior QLB and control groups showed comparable recovery outcomes. • Need for further studies focusing on optimizing the timing and dosage of QLB. [ABSTRACT FROM AUTHOR]

The suitability of ambulatory surgery for patients with obstructive sleep apnea (OSA) remains controversial. This systematic review and meta-analysis aimed to evaluate the odds of perioperative adverse events in patients with OSA undergoing ambulatory surgery, compared to patients without OSA. Four electronic databases were searched for studies published between January 1, 2011 and July 11, 2023. The inclusion criteria were: adult patients with diagnosed or high-risk of OSA undergoing ambulatory surgery; perioperative adverse events; control group included; general and/or regional anesthesia; and publication on/after February 1, 2011. We calculated effect sizes as odds ratios using a random effects model, and additional sensitivity analyses were conducted. Seventeen studies (375,389 patients) were included. OSA was associated with an increased odds of same-day admission amongst all surgery types (OR 1.94, 95% CI 1.46–2.59, I2:79%, P < 0.00001, 11 studies, n = 347,342), as well as when only orthopedic surgery was considered (OR 2.68, 95% CI 2.05–3.48, I2:41%, P < 0.00001, 6 studies, n = 132,473). Three studies reported that OSA was strongly associated with prolonged post anesthesia care unit (PACU) length of stay (LOS), while one study reported that the association was not statistically significant. In addition, four studies reported that OSA was associated with postoperative respiratory depression/hypoxia, with one large study on shoulder arthroscopy reporting an almost 5-fold increased odds of pulmonary compromise, 5-fold of myocardial infarction, 3-fold of acute renal failure, and 5-fold of intensive care unit (ICU) admission. Ambulatory surgical patients with OSA had almost two-fold higher odds of same-day admission compared to non-OSA patients. Multiple large studies also reported an association of OSA with prolonged PACU LOS, respiratory complications, and/or ICU admission. Clinicians should screen preoperatively for OSA, optimize comorbidities, adhere to clinical algorithm-based management perioperatively, and maintain a high degree of vigilance in the postoperative period. ∙ This is the first review to provide a quantitative synthesis of same-day admission data for ambulatory OSA patients vs non-OSA outpatients. ∙ Ambulatory surgical patients with OSA had two-fold higher odds of same-day admission compared to non-OSA patients. ∙ For orthopedic surgery, the odds were 2.7-fold higher. ∙ Clinicians should screen for OSA, optimize comorbidities, adhere to algorithm-based management, and maintain a high degree of vigilance postoperatively. [ABSTRACT FROM AUTHOR]

Regional analgesia following visceral cancer surgery might provide an advantage but evidence for best treatment options related to risk-benefit is unclear. Systematic review of randomized controlled trials (RCT) with meta-analysis and GRADE assessment. Postoperative pain treatment. Adult patients undergoing visceral cancer surgery. Any kind of peripheral (PRA) or epidural analgesia (EA) with/without systemic analgesia (SA) was compared to SA with or without placebo treatment or any other regional anaesthetic techniques. Primary outcome measures were postoperative acute pain intensity at rest and during activity 24 h after surgery, the number of patients with block-related adverse events and postoperative paralytic ileus. 59 RCTs (4345 participants) were included. EA may reduce pain intensity at rest (mean difference (MD) -1.05; 95% confidence interval (CI): −1.35 to −0.75, low certainty evidence) and during activity 24 h after surgery (MD -1.83; 95% CI: −2.34 to −1.33, very low certainty evidence). PRA likely results in little difference in pain intensity at rest (MD -0.75; 95% CI: −1.20 to −0.31, moderate certainty evidence) and pain during activity (MD -0.93; 95% CI: −1.34 to −0.53, moderate certainty evidence) 24 h after surgery compared to SA. There may be no difference in block-related adverse events (very low certainty evidence) and development of paralytic ileus (very low certainty of evidence) between EA, respectively PRA and SA. Following visceral cancer surgery EA may reduce pain intensity. In contrast, PRA had only limited effects on pain intensity at rest and during activity. However, we are uncertain regarding the effect of both techniques on block-related adverse events and paralytic ileus. Further research is required focusing on regional analgesia techniques especially following laparoscopic visceral cancer surgery. • When employed in the context of visceral cancer surgery epidural analgesia may reduce pain intensity at rest and during activity 24 h after surgery to a clinical relevant extent, but the certainty of evidence is limited. • Mostly single-shot peripheral regional anesthesia likely results in little difference in pain intensity at rest and pain during activity 24 h after surgery. • Epidural analgesia compared to peripheral regional anesthesia may reduce pain intensity during activity after surgery with limited certainty of evidence. [ABSTRACT FROM AUTHOR]

To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia. A Systematic review and meta-analysis of randomized controlled trials. The major dates were obtained in the operating room and the postoperative recovery ward. A total of 1011 patients at ASA physical status I and II were included in the analysis. Procedure performed including cesarean section, orthopedic, radical mastectomy, urological or lower abdominal surgery and intracavitary brachytherapy implants insertion. After an extensive search of the electronic database, patients received regional anesthesia combined or not combined general anesthesia and with or without adding ketamine to LA were included in the analysis. The regional anesthesia includes spinal anesthesia, brachial plexus block, pectoral nerve block, transversus abdominis plane block and femoral and sciatic nerve block. The primary outcome was the duration of analgesia. Secondary outcomes were the duration and onset time of motor and sensory block as well as the ketamine-related adverse effect. Data are expressed in mean differences in continuous data and odds ratios (OR) for dichotomous data with 95% confidence intervals. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials. The quality of evidence for each outcome was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group system. Twenty randomized controlled trials were included in the analysis. When ketamine was used as an adjuvant to LA, the duration of analgesia could be prolonged(172.21 min, 95% CI, 118.20 to 226.22; P<0.00001, I2 = 98%), especially in the peripheral nerve block(366.96 min, 95% CI, 154.19 to 579.74; P = 0.0007, I2 = 98%). Secondary outcomes showed ketamine could prolong the duration of sensory block(29.12 min, 95% CI, 10.22 to 48.01; P = 0.003, I2 = 96%) but no effect on the motor block(6.94 min, 95% CI,-2.65 to 16.53; P = 0.16, I2 = 84%), the onset time of motor and sensory block (motor onset time, −1.17 min, 95% CI, −2.67 to 0.34; P = 0.13, I2 = 100%; sensory onset time, −0.33 min, 95% CI,-0.87 to 0.20; P = 0.23, I2 = 96%) as well as the ketamine-related adverse effect(OR, 1.97, 95% CI,0.93 to 4.17; P = 0.08, I2 = 57%). This study indicates that ketamine could be an ideal adjuvant to local anesthetics regardless of the types of anesthesia. Overall, the quality of the evidence is low. • Ketamine as an adjuvant to regional anesthesia whether combined general anesthesia or not, could prolong the duration of analgesia without ketamine-related adverse effect. • Ketamine as an adjuvant to regional anesthesia prolongs the duration of analgesia about 3 h while in peripheral nerve block about 6 h. • Ketamine could be an idea adjuvant to local anesthetics regardless of types of anesthesia. [ABSTRACT FROM AUTHOR]

Racial and ethnic disparities exist in the delivery of regional anesthesia in the United States. Anesthesiologists have ethical and economic obligations to address existing disparities in regional anesthesia care. Current evidence of racial and ethnic disparities in regional anesthesia utilization in adult patients in the United States is presented. Potential contributors and solutions to racial disparities are also discussed. Literature search was performed for studies examining racial and ethnic disparities in utilization of regional anesthesia, including neuraxial anesthesia and/or peripheral nerve blocks. While minoritized patients are generally less likely to receive regional anesthesia than white patients, the pattern of disparities for different racial/ethnic groups and for types of regional anesthetics can be complex and varied. Contributors to racial/ethnic disparities in regional anesthesia span hospital, provider, and patient-level factors. Potential solutions include standardization of regional anesthetic practices via Enhanced Recovery After Surgery (ERAS) pathways, increasing patient education, health literacy, language translation services, and improving diversity and cultural competency in the anesthesiology workforce. Racial and ethnic disparities in regional anesthesia exist. Contributors and solutions to these disparities are multifaceted. Much work remains within the subspecialty of regional anesthesia to identify and address such disparities. • Racial and ethnic disparities exist in the provision of regional anesthesia. • As physicians, moral obligation and economic incentives exist in understanding and addressing these disparities. • Minoritized patients in general are less likely to receive regional anesthesia compared to white patients. • Specific contributors and potential solutions to racial and ethnic disparities in regional anesthesia are multifactorial. [ABSTRACT FROM AUTHOR]

Study Objective: Cesarean Delivery (CD) is a commonly performed obstetric procedure. Adding a regional anesthesia technique to multimodal analgesia in CD, may improve the quality of postoperative analgesia. In this study we evaluated the efficacy of Transversalis Fascia Plane Block (TFPB) for postoperative analgesia management in CD.Design: Blinded, prospective, randomized study.Setting: Postoperative recovery room & ward, tertiary university hospital, Istanbul, Turkey, PATIENTS: Seventy-five patients (ASA II-III) scheduled to undergo Cesarean delivery were recruited. Following exclusion, 70 patients were randomized into two equal groups (block and control group).Interventions: Standard multimodal analgesia (routine paracetamol and tramadol PCA in addition to diclophenac sodium as rescue analgesia) was performed in Group C while TFPB block was also performed in the intervention (TFPB) group.Measurements: The primary outcome was tramadol consumption within the first 24 h. The secondary outcome was Numeric Rating Scale (NRS) scores during rest and movement/coughing.Main Results: Tramadol consumption in the first 24 h was 175 ± 72.32 mg in the control and 101.42 ± 51.45 mg in the TFPB group (p < 0.05). NRS was lower in Group TFPB during the first 3 h and at the 12th hour. There was no difference in NRS scores at other hours.Conclusion: Bilateral ultrasound guided TFPB leads to effective analgesia and a decrease in analgesia requirement in first 24 h in patients undergoing CD. [ABSTRACT FROM AUTHOR]

Study Objective: Arthroscopic knee procedures are increasingly being performed in an outpatient setting. Appropriate intraoperative anesthesia is vital to prevent complications such as unanticipated hospital admission. We examined differences in complications between general (GA) vs neuraxial anesthesia (NA) as the primary anesthetic for patients undergoing arthroscopic knee procedures.Design: This was a retrospective cohort study. We queried the National Surgical Quality Improvement Program for arthroscopic knee procedures performed between 2007 and 2016. We compared postoperative complication rates between propensity-matched cohorts (NA vs GA). The anesthesia groups were matched based on age, race, BMI, gender, diabetes, smoking history, COPD, CHF, functional status, HTN, ASA class, steroid use, bleeding disorder history, and readmission status. Univariable and multivariable logistic regression were used to compare factors associated with inpatient admission - defined as hospital length of stay >1 day.Patients: A total of 57,494 patients were included - 55,257 GA and 2237 NA patients.Main Results: Among the matched cohorts, NA patients were significantly more likely to be admitted to the hospital postoperatively (p < 0.001). Neuraxial anesthesia (OR 5.93, 95% CI 4.90-7.21) use was also significant in the final multivariable regression model for inpatient admission. Additional significant predictors for inpatient admission included history of bleeding disorder (OR 5.44, 95% CI 2.14-12.76), Asian race (OR 6.47, 95% CI 4.90-8.56), COPD (OR 3.10, 95% CI 1.94-4.82), diabetes (OR 1.90, 95% CI 1.43-2.49), and increased operation time (OR 3.01, 95% CI 2.69-3.37).Conclusions: NA was significantly associated with inpatient admission following knee arthroscopy. Further research should focus on examining the reason for this association and methods to reduce inpatient admission for patients undergoing arthroscopic knee procedures using neuraxial anesthesia. [ABSTRACT FROM AUTHOR]

Background: Regional anesthesia may mitigate the risk of persistent postoperative pain (PPP). This Cochrane review, published originally in 2012, was updated in 2017.Methods: We updated our search of Cochrane CENTRAL, PubMed, EMBASE and CINAHL to December 2017. Only RCTs investigating local anesthetics (by any route) or regional anesthesia versus any combination of systemic (opioid or non-opioid) analgesia in adults or children, reporting any pain outcomes beyond three months were included. Data were extracted independently by at least two authors, who also appraised methodological quality with Cochrane 'Risk of bias' assessment and pooled data in surgical subgroups. We pooled studies across different follow-up intervals. As summary statistic, we reported the odds ratio (OR) with 95% confidence intervals and calculated the number needed to benefit (NNTB). We considered classical, Bayesian alternatives to our evidence synthesis. We explored heterogeneity and methodological bias.Results: 40 new and seven ongoing studies, identified in this update, brought the total included RCTs to 63. We were only able to synthesize data from 39 studies enrolling 3027 participants in a balanced design. Evidence synthesis favored regional anesthesia for thoracotomy (OR 0.52 [0.32 to 0.84], moderate-quality evidence), breast cancer surgery (OR 0.43 [0.28 to 0.68], low-quality evidence), and cesarean section (OR 0.46, [0.28 to 0.78], moderate-quality evidence). Evidence synthesis favored continuous infusion of local anesthetic after breast cancer surgery (OR 0.24 [0.08 to 0.69], moderate-quality evidence), but was inconclusive after iliac crest bone graft harvesting (OR 0.20, [0.04 to 1.09], low-quality evidence).Conclusions: Regional anesthesia reduces the risk of PPP. Small study size, performance, null, and attrition bias considerably weakened our conclusions. We cannot extrapolate to other interventions or to children. [ABSTRACT FROM AUTHOR]

Background: While the incidence of postoperative delirium is high in aged hospitalized patients undergoing major surgery, little is known concerning patients undergoing ambulatory surgery.Objective: To determine the incidence of postoperative delirium in aged patients after hospital discharge from an ambulatory surgery unit.Design: Prospective observational study.Patients: Elderly patients (≥75 years) scheduled for a surgical procedure on an ambulatory basis.Interventions: Filling of the Family Confusion Assessment Method (FAM-CAM) questionnaire (11 items) during a phone interview of family caregivers on two separate occasions: five to three days before surgery, and three to five days after surgery.Main Outcome Measures: The detection of acute onset and fluctuating course inattention, disorganized thinking, altered level of consciousness, disorientation, perceptual disturbances, and psychomotor agitation from the observations of family caregivers.Results: Signs of delirium appeared de novo in 2 of 141 patients (incidence 1.4%) in the postoperative period: a 80-years old man who was disoriented and had incoherent and illogical speech on postoperative day 1 of resection of a cephalic cutaneous melanoma under local anesthesia and sedation (midazolam, sufentanil, and propofol), and a 83-years old woman with a pre-existing mental confusion, who experienced visual and hearing hallucinations and had inappropriate behaviour on postoperative day 2 of cataract surgery performed under episcleral block. Both patients returned to their preoperative states within a few days.Conclusions: Using the FAM-CAM instrument for the detection of postoperative delirium in ambulatory patients, the study showed that the incidence of cognitive changes in the ambulatory setting is very low. Among several putative factors, the lightness of the surgical procedure, the wide use of regional anesthesia, and the short hospital stay may be contributing factors to this result. The findings of this study need to be confirmed in a larger sample of patients. [ABSTRACT FROM AUTHOR]

• New insights on how to advance acute pain service. • Newest publications in postoperative pain combined to provide a new pain management plan. • Solid advice to researchers and clinicians alike on how to organize institutional pain services. [ABSTRACT FROM AUTHOR]

Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF. • Urgent need for literature on perioperative care of surgical rib fracture patients. • Many recent advancements in locoregional analgesia including fascial plane blocks. • Opportunities to apply novel thoracic anesthesia techniques to rib fixation surgery • Few high-quality studies directly compare approaches in this population. [ABSTRACT FROM AUTHOR]

Study Objective: To review research highlights of manuscripts published in 2016 that pertain to all aspects of the clinical practice of anesthesiology.Design: Narrative review.Setting: N/A.Materials: The major themes address broad categories of general anesthesia including airway management, abdominal surgery, and obstetrical and gynaecological anesthesia. In addition, recent advancements in specialties of anesthesiology including regional anesthesia are reviewed.Interventions: N/A.Main Results: N/A.Conclusions: This recent body of evidence will both help inform anesthesiologists of the developing trends in anesthesiology and will also pose new challenges for further studies. [ABSTRACT FROM AUTHOR]

Study Objective: Beach chair position is considered a potential risk factor for central neurological events particularly if combined with low blood pressure. The aim of this study was to assess the impact of regional anesthesia on cerebral blood flow and neurobehavioral outcome.Design: This is a prospective, assessor-blinded observational study evaluating patients in the beach chair position undergoing shoulder surgery under regional anesthesia.Setting: University hospital operating room.Patients: Forty patients with American Society of Anesthesiologists classes I-II physical status scheduled for elective shoulder surgery.Interventions: Cerebral saturation and blood flow of the middle cerebral artery were measured prior to anesthesia and continued after beach chair positioning until discharge to the postanesthesia care unit. The anesthesiologist was blinded for these values. Controlled hypotension with systolic blood pressure≤100mm Hg was maintained during surgery.Measurements: Neurobehavioral tests and values of regional cerebral saturation, bispectral index, the mean maximal blood flow of the middle cerebral artery, and invasive blood pressure were measured prior to regional anesthesia, and measurements were repeated after placement of the patient on the beach chair position and every 20 minutes thereafter until discharge to postanesthesia care unit. The neurobehavioral tests were repeated the day after surgery.Main Results: The incidence of cerebral desaturation events was 5%. All patients had a significant blood pressure drop 5 minutes after beach chair positioning, measured at the heart as well as the acoustic meatus levels, when compared with baseline values (P<.05). There was no decrease in either the regional cerebral saturation (P=.136) or the maximal blood flow of the middle cerebral artery (P=.212) at the same time points. Some neurocognitive tests showed an impairment 24 hours after surgery (P<.001 for 2 of 3 tests).Conclusions: Beach chair position in patients undergoing regional anesthesia for shoulder surgery had no major impact on cerebral blood flow and cerebral oxygenation. However, some impact on neurobehavioral outcome 24 hours after surgery was observed. [ABSTRACT FROM AUTHOR]

Study Objective: We endeavor to assess the impact of introduction of guidelines for preoperative investigations (PIs) on anesthetic practices and costs and compare their efficacy to current practices.Design: A prospective study.Setting: Queen Elizabeth Hospital, Barbados.Patients: Participants comprised all patients undergoing general, epidural, spinal, and regional anesthesia, with the exception of emergency cases or instances where an anesthesiologist was not required.Intervention: Introduction of formal guidelines for preoperative investigations.Measurements: The patterns of preoperative testing were assessed by audit, and this assessment was repeated postintervention. PI guidelines developed were presented to all surgical departments.Main Results: For younger patients (<60 years), the mean number of tests decreased from 3.42±1.8 in the preguideline group to 2.89±1.98 in the postguideline group (P=.042). The total number of chest x-rays decreased by 14.8% (P=.012) and full blood counts by 7.6% (P=.036). The implementation of PI guidelines led to overall savings of US $7589 per 1000 patients, which is equivalent to (US $40,745.50 per annum). The most notable savings were due to decreased number of chest x-rays. PIs were performed routinely even in the absence of clinical indications.Conclusion: Our findings indicate that introduction of guidelines has reduced the level of preanesthetic investigations to some extent; nevertheless, further change is desirable. In addition, costs to the institution were decreased with no compromise to patient safety. [ABSTRACT FROM AUTHOR]

Study Objective: To quantify the impact of preoperative medication adherence on recovery length of stays and complication rates.Design: Cross-sectional analytical study.Setting: Postanesthetic care unit (PACU) of a single-center tertiary hospital.Patients: Surgical patients admitted for surgery at our institution over a 4-month period.Intervention: A data collection tool was used to collect demographic data, length of stay in recovery, prespecified conditions likely to impact on PACU recovery (chronic pain, insulin-dependent diabetes, epilepsy, hypertension, on a methadone program, and Parkinson disease), medication compliance, and complications in PACU.Measurements: Differences among categorical variables were assessed for significance using the χ2 test; continuous parametric data were compared using a time to survival analysis via Kaplan-Meier estimates and Cox proportional hazard regressions to account for possible confounders.Main Results: Preoperative medication compliance for the prespecified conditions was 65.1%. Patients with a preoperative condition spent more time in the PACU compared to patients without a preoperative condition. Time in PACU was not significantly longer for patients who took their medications compared to those who failed to take their medications. Patients with multiple prespecified conditions were more likely to incur a postoperative complication compared to patients without a prespecified condition. Patients with preoperative hypertension and insulin-dependent diabetes incurred higher complication rates in PACU for medication nonadherence compared to medication adherence.Conclusion: This study taken together with accruing evidence suggests that preoperative medication omission remains an ongoing issue that can influence complication rates in the PACU. Patients with preoperative conditions stay longer in PACU, and medication omission was associated with higher rates of certain postoperative complications in PACU. This identifies patients likely to require more interventions and greater recovery resources. Further research into the impact of medication omission on recovery parameters after discharge from the PACU is warranted. [ABSTRACT FROM AUTHOR]

Study Objective: Neuraxial anesthesia has been widely used in China. Recently, Chinese anesthesiologists have applied nerve stimulator and ultrasound guidance for peripheral nerve blocks. Nationwide surveys about regional anesthesia practices in China are lacking. We surveyed Chinese anesthesiologists about regional anesthesia techniques, preference, drug selections, complications, and treatments.Design: A survey was sent to all anesthesiologist members by WeChat. The respondents can choose mobile device or desktop to complete the survey. Each IP address is allowed to complete the survey once.Main Results: A total of 6589 members read invitations. A total of 2654 responses were received with fully completed questionnaires, which represented an overall response rate of 40%. Forty-one percent of the respondents reported that more than 50% of surgeries in their hospitals were done under regional anesthesia. Most of the participants used test dose after epidural catheter insertion. The most common drug for test dose was 3-mL 1.5% lidocaine; 2.6% of the participants reported that they had treated a patient with epidural hematoma after neuraxial anesthesia. Most anesthesiologists (68.2%) performed peripheral nerve blocks as blind procedures based on the knowledge of anatomical landmarks. A majority of hospitals (80%) did not stock Intralipid; 61% of the respondents did not receive peripheral nerve block training.Conclusions: The current survey can serve as a benchmark for future comparisons and evaluation of regional anesthesia practices in China. This survey revealed potential regional anesthesia safety issues in China. [ABSTRACT FROM AUTHOR]

Study Objective: Regional anesthesia and analgesia for shoulder surgery is most commonly performed via interscalene nerve block. We developed an ultrasound-guided technique that specifically targets the C5 nerve root proximal to the traditional interscalene block and assessed its efficacy for shoulder analgesia.Design: Prospective case series.Setting: Vanderbilt Bone and Joint Surgery Center.Patients: Patients undergoing shoulder arthroscopy at an ambulatory surgery center.Interventions: Thirty-five outpatient shoulder arthroscopy patients underwent an analgesic nerve block using a new technique where ultrasound visualization of the C5 nerve root served as the primary target at a level proximal to the traditional interscalene approach. The block was performed with 15mL of 0.5% plain ropivicaine.Measurements: Post anesthesia care unit pain scores, opioid consumption, hand strength, and duration of block were recorded. Cadaver dissection after injection with methylene blue confirmed that the primary target under ultrasound visualization was the C5 nerve root.Main Results: Pain scores revealed 97% patients had 0/10 pain at arrival to PACU, with 91% having a pain score of 3/10 or less at discharge from PACU. Medical Research Council (MRC) hand strength mean (SD) score was 4.17 (0.92) on a scale of 1-5. The mean (SD) duration of the block was 13.9 (3.5) hours.Conclusions: A new technique for ultrasound-guided blockade at the level of the C5 nerve root proximal to the level of the traditional interscalene block is efficacious for shoulder post-operative pain control. [ABSTRACT FROM AUTHOR]

In the axillary fossa, the musculocutaneous nerve (MC) is generally distant from the axillary artery and from the other brachial plexus nerves. In that way, MC requires a specific block. We observed that the location of MC is influenced by the position of the patient's arm and shoulder. Abduction of the shoulder significantly reduced the distance between the MC and the axillary artery. This change in the location of the MC is probably due to the moving of the nerve because of muscle rearrangements and the ability to achieve better proximity of the probe in the axillary fossae. [ABSTRACT FROM AUTHOR]

Objective: Left lateral table tilt of 15° to 30° is recommended for cesarean section, although little is known about the practical problems of its implementation. This study examines these issues from the perspective of anesthesiologists, obstetricians, theater nurses, and patients. Initially, the tilt was set by visual estimation in 100 women and checked by inclinometer afterwards.Study Design: Observational survey.Patients: One hundred women undergoing primary cesarean section.Intervention: The anesthesiologist's initial estimated tilt setting was documented, then patient comfort and obstetrician's needs were assessed at 15°, and the tilt was adjusted accordingly. Problems were identified, and possible solutions were introduced. The effects of our solutions were reevaluated after 12months.Results: Despite appropriate training, too little tilt was achieved in most cases. Even with objective inclinometry, complaints by patients, obstetricians, and theater nurses made physicians reluctant to press for 15° tilt. Better compliance was achieved by the introduction of a 2-step tilt procedure, side bar mounting, and inclinometry. After 12months, 96% of anesthesiologists were using the inclinometer to set at least 10°. Most observed an improvement in patient care.Conclusion: Implementation of 10° to 15° tilt requires objective inclinometry. It allows tilt adjustment to be made by interdisciplinary staff in greater confidence that patient comfort and surgical conditions will not be impaired. Strategies to reduce discomfort are presented in this article. [ABSTRACT FROM AUTHOR]

Acute compartment syndrome is a condition that may result in sensorimotor deficits and loss of function of the affected limb as a result of ischemic injury. It is considered a surgical emergency and prompt diagnosis and treatment results in more favorable outcomes. The use of regional anesthesia is controversial in patients at risk for compartment syndrome due to concern of its potential to mask symptoms of the condition. A 44-year-old African American male presented to surgery for open reduction and internal fixation of a comminuted distal radius fracture. As part of an off-label, investigator-initiated, and institutional review board-approved study, he received a perineural injection of liposomal bupivacaine (Exparel) around the median, ulnar, and radial nerves at the level of the proximal forearm. The following morning, his initial complaints of numbness and incisional pain progressively evolved into worsening numbness, diffuse discomfort, and pain with passive movement. A diagnosis of compartment syndrome was made and he underwent an emergency fasciotomy. The diagnosis of compartment syndrome requires a high index of suspicion and prompt treatment. This patient's changing pattern of symptoms-rather than his pain complaints alone-resulted in the diagnosis of compartment syndrome treated with emergent fasciotomy in spite of finger numbness that was initially attributed to the liposomal bupivacaine. While the use of liposomal bupivacaine did not preclude the diagnosis of compartment syndrome in our patient, it should be used with caution in patients at risk for compartment syndrome until additional data, particularly regarding block characteristics, are available. [ABSTRACT FROM AUTHOR]

Study Objective: To determine the incidence of major complications in patients undergoing regional anesthesia (RA) in China.Design: Multicenter prospective survey.Setting: Eleven teaching hospitals in China.Patients and Interventions: A total of 106,569 patients undergoing RA from April 1, 2009, to April 30, 2011, were involved.Measurement: Information on patients, types of surgery, and RA techniques was collected with a standardized chart. After RA, the patients were followed up by an investigator in each center for 1 to 3 weeks according to the patient's condition. Data were integrated and analyzed with a structured query language server system.Main Results: Among the patients undergoing RA, 37 developed major complications, including Horner syndrome (n = 9; 0.84/10,000), recurrent laryngeal nerve blockade (n = 6; 0.56/10,000), cardiac arrest (n = 1; 0.09/10,000), hematoma (n = 2; 0.19/10,000), seizures (n = 5; 0.46/10,000), catheter break (n = 1; 0.09/10,000), paraplegia (n = 1; 0.09/10,000), cauda equina syndrome (n = 2; 0.19/10,000), and extensive neuraxial block (n = 10; 0.94/10,000). The incidence of major RA complications varied from 0.8/10,000 to 18.8/10,000 among centers and was highest in cervical plexum block. Plastic surgery had the highest incidence of complications (19.0/10,000), most of which were recurrent extensive neuraxial block. The total incidence of major RA complications was 3.47/10,000.Conclusion: This large, multicenter, prospective survey revealed the incidence of major complications after RA in China's hospitals. Although severe complication like cardiac arrest is rare, it is distressing and challenging. Hence, there is still a room to improve on daily basis to further reduce complications related to RA. [ABSTRACT FROM AUTHOR]

Ehlers-Danlos syndrome is an inherited disorder of collagen production that results in multiorgan dysfunction. Patients with hypermobility type display skin hyperextensibility and joint laxity, which can result in chronic joint instability, dislocation, peripheral neuropathy, and severe musculoskeletal pain. A bleeding diathesis can be found in all subtypes of varying severity despite a normal coagulation profile. There have also been reports of resistance to local anesthetics in these patients. Several sources advise against the use of regional anesthesia in these patients citing the 2 previous features. There have been reports of successful neuraxial anesthesia, but few concerning peripheral nerve blocks, none of which describe nerves of the lower extremity. This report describes 2 cases of successful peripheral regional anesthesia in the lower extremity. In case 1, a 16-year-old adolescent girl with hypermobility type presented for osteochondral grafting of tibiotalar joint lesions. She underwent a popliteal sciatic (with continuous catheter) and femoral nerve block under ultrasound guidance. She proceeded to surgery and tolerated the procedure under regional block and intravenous sedation. She did not require any analgesics for the following 15 hours. In case 2, an 18-year-old woman with hypermobility type presented for medial patellofemoral ligament reconstruction for chronic patella instability. She underwent a saphenous nerve block above the knee with analgesia in the distribution of the saphenous nerve lasting for approximately 18 hours. There were no complications in either case. Prohibitions against peripheral nerve blocks in patients with Ehlers-Danlos syndrome, hypermobility type, appear unwarranted. [ABSTRACT FROM AUTHOR]

Lower limb orthopedic operations are frequently performed under regional anesthesia, which allows avoidance of potential side effects and complications of general anesthesia and sedation. Often though, patients feel anxious about being awake during operations. To decrease intraoperative anxiety, we use multimedia equipment consisting of a tablet device, noise-canceling headphones, and a makeshift frame, where patients can listen to music, watch movies, or occupy themselves in numerous ways. These techniques have been extensively studies in minimally invasive, short, or minor procedures but not in prolonged orthoplastic operations. We report 2 cases where audiovisual distraction was successfully applied to 9.5-hour procedures, proved to be a very useful adjunct to epidural anesthesia + sedation, and made an important contribution to positive patients' outcomes and overall patients' experience with regional anesthesia for complex limb reconstructive surgery. In the era when not only patients' safety and clinical outcomes but also patients' positive experiences are of paramount importance, audiovisual distraction may provide a simple tool to help improve experience of appropriately informed patients undergoing suitable procedures under regional anesthesia. The anesthetic technique received a very positive appraisal by both patients and encouraged us to study further the impact of modern audiovisual technology on anxiolysis for major surgery under regional anesthesia. The duration of surgery per se is not a contraindication to the use of audiovisual distraction. The absolute proviso of successful application of this technique to major surgery is effective regional anesthesia and good teamwork between the clinicians and the patients. [ABSTRACT FROM AUTHOR]

Objectives: To determine the psychometric outcomes of patients participating in an extensive patient-centered verification process before receiving sedation for regional anesthesia. Design: Survey. Setting: Perioperative areas of university-affiliated hospital. Patients: Two hundred eligible patients scheduled for elective orthopedic surgery undergoing peripheral nerve blockade. Interventions: Postoperative survey evaluating patient perception, experience, and satisfaction with the anesthetic timeout before regional anesthesia. Measurements: Measures using numeric rating scales were obtained on patient perceptions of safety, confidence in anesthesia provider, anxiety, and positive sentiments during participation in block timeout. These variableswere analyzed using logistic regression models to correlate with reported pain and satisfaction perioperatively. Main Results: One hundred seventy-five patients (93% enrollment) completed the study. More than 90% of patients reported agreeing strongly to feeling safe, confident, relaxed, and positive about their participation in the block timeout. These sentiments are associatedwith less reported perioperative pain and higher overall satisfaction. Conclusions: Patient perceptions of confidence and safety in regional anesthesia providers were enhanced by a preprocedural timeout process. These positive attitudes are associated with a superior perioperative experience and patient satisfaction. [ABSTRACT FROM AUTHOR]

Study Objective: To determine the effectiveness of a short educational video and simulation on improvement of ultrasound (US) image acquisition and interpretation skills. Design: Prospective, randomized study. Setting: University medical center. Subjects: 28 anesthesia residents and community anesthesiologists with varied ultrasound experience were randomized to teaching video with interactive simulation or sham video groups. Subjects: Participants were assessed preintervention and postintervention on their ability to identify the sciatic nerve and other anatomic structures on static US images, as well as their ability to locate the sciatic nerve with US on live models. Main Results: Pretest written test scores correlated with reported US block experience (Kendall tau rank r = 0.47) and with live US scanning scores (r = 0.64). The teaching video and simulation significantly improved scores on the written examination (P < 0.001); however, they did not significantly improve live US scanning skills. Conclusions: A short educational video with interactive simulation significantly improved knowledge of US anatomy, but failed to improve hands-on performance of US scanning to localize the nerve. [ABSTRACT FROM AUTHOR]

Study Objectives: To develop evidence-based recommendations for prevention and management of infections, bleeding, and local anesthetic toxicity in children undergoing regional anesthesia.Design: A joint committee of the European Society of Regional Anesthesia and Pain Therapy (ESRA) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) studied electronic literature databases of pediatric regional anesthesia to construct evidence-based recommendations.Main Results: For epidural anesthesia lumbar or thoracic placement is preferred. Skin preparation prior to block placement with chlorhexidine is preferred to povidone iodine. A tunneled catheter technique is suggested when using the caudal route or if the epidural catheter placement is kept in situ for more than 3 days. Inspection of the epidural catheter insertion site should be performed at least once a day as part of the postoperative management. When medical and physical examination is normal, coagulation tests are usually unnecessary but if coagulation tests are abnormal, neuraxial and deep peripheral nerve blocks are contraindicated. For patients receiving Low Molecular Weight Heparin thromboprophylaxis, a safety interval of two half-lives plus the time required for heparin to reach maximal levels is considered an adequate compromise between bleeding risk and thrombosis risk when removing epidural catheters. Ultrasound-guided peripheral nerve blocks reduce the risk of vascular puncture and thus the risk of local anesthetic toxicity is reduced.Conclusions: In children undergoing regional anesthesia the incidence of infection, hematoma, and local anesthetic toxicity is low. The ASRA/ESRA joint committee proposes a practice advisory to prevent and treat these complications. [ABSTRACT FROM AUTHOR]

• Median hospital length of stay in the regional anesthesia cohort was 0 days in comparison to 1 day in the other cohort. • The use of regional anesthesia was associated with decreased time to hospital discharge. • There was no difference in 30 day readmissions • There is value in implementing and maintaining regional anesthesia pathways [ABSTRACT FROM AUTHOR]

• The benefits of regional anesthesia (RA) on cancer recurrence rate in cancer surgery remain unclear • Ten retrospective observational studies were included for qualitative and quantitative meta-analysis • RA was not significantly associated with a lower cancer recurrence rate in cancer resection surgery • No significant difference in survival rate, time to cancer recurrence, or cancer-related mortality • This review neither supports nor opposes the advantages of RA related to the incidence of cancer recurrence [ABSTRACT FROM AUTHOR]

Study Objective: To compare the efficacy of ultrasound-guided tansversus abdominis plane (TAP) block with placebo for postoperative analgesia after retropubic radical prostatectomy (RRP). Design: Prospective, randomized, double-blinded study. Setting: Tertiary-care Veterans Affairs (VA) hospital. Patients: ASA physical status 1, 2, and 3 patients scheduled for RRP. Interventions: Patients were randomized to two groups: the TAP group and the control group. All patients underwent an ultrasound-guided TAP block procedure after induction of general anesthesia and received either local anesthetic (TAP group) or normal saline (control group). Measurements: Opioid use and verbal analog pain scores at 1, 6, 12, and 24 hours after surgery were recorded, as was the frequency of side effects. Times to ambulation and first oral intake also were recorded. [ABSTRACT FROM AUTHOR]

Study Objective: To monitor the pulmonary hemodynamics of patients undergoing bilateral total knee arthroplasty (BTKA) intraoperatively and up to 24 hours following surgery. Design: Prospective observational study. Setting: University-affiliated teaching hospital. Patients: 30 ASA physical status 2 and 3 patients scheduled for single-stage, cemented BTKA during epidural anesthesia. Interventions: Pulmonary artery catheters were in all patients. Measurements: Systemic vascular resistance (SVR), pulmonary vascular resistance (PVR), the ratio of PVR to SVR at baseline, at the beginning of surgery, and after each knee implantation were recorded and compared with measurements taken one day postoperatively (POD 1). Main Results: On POD 1, PVR/SVR was increased by 30% compared with baseline (P < 0.0001) and by 20% versus the end of surgery (P < 0.0001). Systemic vascular resistance decreased during surgery and was significantly lower than baseline at 24 hours after surgery (P < 0.0001). No significant change in PVR was noted during surgery. Conclusion: The PVR/SVR ratio on the day following BTKA was increased. This change may represent the different effects of inflammatory perioperative stresses on the pulmonary and systemic vasculature. Published by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: To assess the interest in and barriers to pursuing global health outreach (GHO) experiences for anesthesiology residents in the United States. Design: Survey instrument. Setting: Academic department of anesthesiology. Subjects: Anesthesiology residents who were members of the American Society of Anesthesiologists (ASA). Measurements: An online survey was administered to residents in anesthesiology via the ASA membership database. Descriptive statistics, including means, frequencies, and percentages were calculated. Main Results: 91% of participants indicated an interest in GHO, of whom fewer than half (44%) had done a GHO medical mission. Seventy-nine percent reported that GHO affected their current practice or education; 33% commented they were now less wasteful with supplies and resources. Permission from work or obtaining work coverage were the primary barriers for both those with and without previous GHO participation. Of all respondents, 78% agreed that the availability of a GHO residency track would influence their ranking of that program for training, and 71% would pursue a GHO fellowship if available. Conclusions: Anesthesiology residents have an interest in residency and fellowship GHO programs. Formalization of GHO programs during training may reduce work-related barriers associated with GHO participation and broaden academic program recruitment. [Copyright &y& Elsevier]

Abstract: Study Objective: To compare the effect of central neuraxial (spinal or epidural) anesthesia with general anesthesia on postoperative natural killer (NK) T lymphocyte function. Design: Meta-analysis. Setting: University-affiliated hospital. Measurements: A systematic search of the medical literature from 1966 to 2009 yielded 5 eligible studies with a total of 184 patients who received neuraxial blockade. Natural killer T lymphocyte function was studied. Main Results: There was significant heterogeneity between the studies [I2 = 94.4% (95% CI= 90.3-96.2%)]. Overall fixed-effect odds ratio was 0.86 (0.66-1.14, P = 0.25). The random-effect odds ratio was 1.13 (0.26-4.92, P = 0.79). Conclusion: Anesthetic technique does not appear to significantly affect postoperative NK T lymphocyte function. Given the heterogeneity observed, further clinical studies in cancer patients of the effect of anesthetic technique on immune function in general, and NK T lymphocyte function in particular, are needed. [Copyright &y& Elsevier]

Abstract: Study Objective: To test the hypothesis that, if the femoral nerve is correctly localized using ultrasound (US) guidance, the type of perineural catheter used has no effect on catheter success. Design: Randomized controlled trial. Setting: Post-anesthesia care unit of an academic teaching hospital. Patients: 40 ASA physical status 1, 2, and 3 patients, ages 55-85 years, undergoing elective total knee arthroplasty. Interventions: All patients received postoperative continuous femoral nerve blocks and a single injection sciatic nerve block. Nerve localization was accomplished using US guidance and electrical nerve stimulation so that the needle tip was visualized deep to the femoral nerve. Patients were randomized to receive either stimulating (Group SC) or nonstimulating catheters (Group NSC) in the usual manner for each device. Catheters were bolused with ropivacaine and an infusion commenced. Measurements: The primary outcome was quality of analgesia (as measured by a numerical rating scale). Other outcomes included sensory block success rate, number of attempts and time required to localize the needle tip correctly, number of attempts and time required to place the perineural catheter, amount of local anesthetic and opioid use postoperatively, and degree of completion of preset postoperative rehabilitation goals. Main Results: Quality of analgesia was similar at all time intervals. Rates of successful femoral block (95% vs 80%; P = 0.34) were similar between groups. Time required to position the catheter was greater in Group SC than Group NSC (3.45 ± 2.05 min vs 1.72 ± 0.88 min; P < 0.01). Conclusions: Ultrasound guidance for needle localization prior to catheter insertion for femoral nerve block results in similar block characteristics between stimulating and nonstimulating catheters. The use of nonstimulating catheters avoids the technical challenges of stimulating catheters and does not require additional helpers. [Copyright &y& Elsevier]

Abstract: Study Objective: To test the feasibility and efficacy of a new approach to paravertebral catheter placement in patients undergoing major surgery of the breast. Design: Single-group, single-center observational study. Setting: Operating room, postoperative recovery area, and normal ward of a university hospital. Patients: 25 ASA physical status 1, 2, 3, and 4 patients undergoing major unilateral surgery of the breast. Interventions: Paravertebral catheters for intraoperative and postoperative anesthesia and analgesia were applied using the recently described lamina technique. This technique is performed at a more medial puncture site, avoiding the pleura. Measurements: Additional opioid requirements were recorded to assess effectiveness of regional anesthesia. At the time of catheter withdrawal, patients, staff nurses, and anesthesiologists who provided postoperative pain management were asked to rate their satisfaction with paravertebral catheter effectiveness. Main Results: All patients successfully received a paravertebral catheter using the lamina technique. During the surgical procedure, 84% of patients received no additional opioids after intubation. No patient required opioids as rescue medication postoperatively (visual analog scale rating > 30mm) or during the rest of the hospital stay. Postoperative analgesia provided with paravertebral catheters was rated very high by patients, staff nurses, and anesthesiologists involved in postoperative care. Conclusions: The lamina technique for placement of a paravertebral catheter is a feasible and effective technique for intraoperative and postoperative analgesia in patients scheduled for major breast surgery with or without axillary lymph node resection. [Copyright &y& Elsevier]

Abstract: The case of a patient who suffered a seizure following a nerve stimulator-guided coracoid infraclavicular brachial plexus block, is reported. Following the seizure, an ultrasound machine was used to image the patient''s infraclavicular region, which showed an anatomical variation in the position of the axillary vein relative to the axillary artery. The use of ultrasound in regional anesthesia provides additional safety information beyond nerve stimulation, which may help decrease the likelihood of such complications. [Copyright &y& Elsevier]

Abstract: Study Objective: To evaluate the perioperative outcome of carotid endarterectomy (CEA) with regional anesthesia. Design: Retrospective chart review of consecutive patients who underwent CEA with regional anesthesia in a 23-year period. Setting: Operating rooms of a general hospital in a developing country. Measurements: Demographic data, perioperative clinical data, postoperative morbidity and unplanned admissions were recorded. Main Results: A total of 183 CEA procedures were performed. In 172 cases, CEA was done exclusively with deep cervical plexus block and local infiltration, while in 11 (6%) cases, there was a need for conversion to general anesthesia intraoperatively. Clamping of the internal carotid artery (ICA) for a three-minute period was the method used to monitor any development of neurological impairment. Perioperative complications included intraoperative seizures in one patient, intraoperative transient hemiparesis in three patients, postoperative transient hemiparesis in two patients, and intraoperative hemiplegia in one patient. One hundred fifty-three patients (83.6%) were discharged home within 24 hours, and 29 (15.8%) were discharged home in 48 hours. The hemiplegic patient had a hospital stay of 12 days. There was no perioperative mortality. Conclusions: Regional anesthesia is a safe method for CEA in a limited-resources setting, as it facilitates intraoperative clinical assessment of the effects of ICA clamping. [Copyright &y& Elsevier]

Abstract: Study Objective: To determine whether warmed (body temperature) ropivacaine increases the speed of onset of sensory block of epidural anesthesia. Study Design: Prospective, randomized, double-blind study. Setting: University hospital. Patients: 180 ASA physical status I and II patients, aged 18 to 64 years, undergoing elective anal surgery. Interventions: Patients were randomly divided into 6 groups defined by ropivacaine temperature [room temperature (RT) or body temperature (BT)] and concentration (0.5%, 0.75%, or 1.0%). Measurements: Sensory block was evaluated by pinprick at the T10, T12, L3, and the perianal region (S4, S5) dermatomes. pH values and adverse events were also recorded. Main Results: There were no differences in baseline demographics, pH, or upper sensory level between groups. Mean onset time of T12 and L3 sensory block was significantly faster for each BT than RT ropivacaine concentration. Anal region (S4, S5) sensory block was significantly faster after BT 0.75% versus RT 0.75% ropivacaine. Conclusions: Warmed ropivacaine shortens the onset of sensory block of epidural anesthesia. [Copyright &y& Elsevier]

Abstract: Study Objective: To evaluate the incidence of perioperative minor adverse events and to analyze patient satisfaction based on potential explanatory variables. Design: Structured, face-to-face interview of 25% of all patients undergoing surgery during the period from January 2003 through June 2006. Setting: Academic university medical center. Patients: 12,276 patients (5,793 men and 6,483 women) from all surgical disciplines: 7,440 patients had general anesthesia, 4,236 patients had regional anesthesia, and 600 patients had a combined general-regional anesthetic technique. Measurements: Occurrence of perioperative minor adverse events was assessed during the interview. Patient satisfaction was measured with a 4-point Likert scale. Main Results: 3,652 (30%) patients reported at least one perioperative complaint and 737 (6%) patients reported multiple minor adverse events. Overall, a total of 4,475 minor adverse events were reported. Leading adverse events included postoperative nausea and vomiting (1,705 complaints), sore throat (1,228 complaints), and hoarseness (802 complaints). Patient satisfaction with anesthetic care was generally high (97% satisfied or highly satisfied). Patients were significantly more satisfied following regional than general anesthesia (P < 0.001). Patient dissatisfaction was also associated with the occurrence of at least one minor adverse event (P < 0.001) or with increasing ASA physical status (P < 0.001). Conclusion: Minor events occur with a surprisingly high incidence and are significantly associated with patient dissatisfaction. Regional anesthesia is associated with fewer patient complaints and significantly higher postoperative patient satisfaction. [Copyright &y& Elsevier]

Abstract: Study Objective: To investigate the comfort and satisfaction of patients with trauma of the upper limb during two different techniques of axillary brachial plexus block, electrical nerve stimulation and fascial pop. Design: Randomized-prospective, observational study. Setting: University surgical center. Patients: 100 ASA physical status I and II patients undergoing surgery for trauma of the hand and forearm. Interventions: Patients received axillary brachial plexus block with a mixture of 0.5% bupivacaine and 2% lidocaine. They were then allocated to one of two groups to receive either electrical nerve stimulation (Group 1, n = 50), or fascial pop technique (Group 2, n = 50) for nerve location. Measurements: Data were collected on patient demographics, surgery, frequency of complications, and sedation required during the block. Discomfort during the block and surgical comfort were quantified by visual analog scale (0-10). Satisfaction was determined by the following scale: very satisfied, satisfied, dissatisfied, and very dissatisfied. Patients also indicated if in the future they would like to receive the same method of anesthesia. Main Results: No differences in demographic or surgical data were found. No serious complications were observed. Eighteen Group 1 patients (36%) and none in Group 2 needed sedation during the blocks. Discomfort during the procedures was greater in Group 1 than Group 2 (4.5 ± 1.2 vs 1.5 ± 1, P < 0.05), while patients reported good surgical comfort with both techniques (2.4 ± 2.9 vs 2.2 ± 2.1, NS). Eighteen patients in Group 1 and 48 patients in Group 2 would accept the same block for future surgery. Conclusions: In trauma patients, the fascial pop technique is effective, reduces sedation during axillary brachial plexus block, and has a higher patient acceptance rate than the electrical nerve stimulation technique. [Copyright &y& Elsevier]

Abstract: Study Objective: To characterize the complications reported with intravenous regional anesthesia (IVRA). Design: Literature search. Setting: University-affiliated hospital. Measurements: A search was done in the American National Library of Medicine''s PUBMED, EMBASE (1980-2007, wk 11), and Medline (from 1950) in March 2007. All complications associated with IVRA were reviewed. Main Results: The lowest dose of local anesthetic associated with a seizure was 1.4 mg/kg for lidocaine; 4 mg/kg for prilocaine, and 1.3 mg/kg for bupivacaine. Cardiac arrests and deaths were reported with lidocaine and bupivacaine only. The lowest dose associated with a cardiac arrest was 2.5 mg/kg for lidocaine and 1.6 mg/kg for bupivacaine. Local anesthetic toxicity occurring during tourniquet inflation has been reported, with tourniquet pressure exceeding initial systolic arterial blood pressure by 150 mmHg. Seizures occurring after tourniquet deflation have been reported with a tourniquet time as long as 60 minutes. Ten cases of compartment syndrome are reported. Conclusion: Seizures have been reported with lidocaine at its lowest effective dose (1.5 mg/kg). [Copyright &y& Elsevier]