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Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.

Background and objectives: documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. Methods: following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as >= 75% agreement and weak consensus as 50%-74% agreement. Results: seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. Conclusion: by means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia., European Society of Regional Anaesthesia and Pain Therapy (ESRA); ASRA Pain Medicine

Airway management has undergone dramatic transformation since the development of videolaryngoscopy (VL). VL improves glottic views when compared to direct laryngoscopy (DL). The image obtained is from a camera at the tip of the curved blade, and the view is not direct line of sight. Placement of the endotracheal tube (ETT) may therefore require the ETT to be manipulated in multiple planes to match the curvature of the VL blade. This placement of the ETT "around the corner" may be difficult without additional airway aids. The aim of this retrospective observational study was to determine whether endotracheal placement during VL in patients with a difficult airway required the use of an additional airway aid (bougie or fiberoptic scope). Difficult airway was defined as a Cormack and Lehane (CL) grade 3 or 4 view obtained using DL prior to VL use. Data from 165 patients was included in the study. Simple ETT placement without an additional airway device was achieved in only 20.6% of cases (n = 34). The remaining 131 patients required a bougie or fiberscope to assist intubation. ETT placement was not possible with the bougie in 33 patients. These 33 patients were successfully intubated using a fiberscope-assisted VL (FAV) technique. VL improved CL grade 3 views by at least one grade in 99.1% of cases, and grade 4 view to a grade 1 or 2 in 96.3% of cases. VL improves glottic view in patients with a difficult airway; but in nearly 80% of patients, a bougie or fiberscope is required to properly place the ETT. Practitioners should be aware that improved glottic views with VL may not translate into simple ETT placement, and additional airway aids need to be readily available.

Femoral fractures represent a substantial orthopaedic injury. In the developed world, closed reduction and locked intramedullary nailing is recognized as the optimal treatment. In the less developed world, the use of skeletal traction remains limited by cost and availability of traction pins, which are obtained from orthopaedic companies in the UK or Indian subcontinent. This study aimed to establish whether traction pins may be manufactured locally in resource-limited countries from cut down stainless steel rods. The overall costs for traction pins were obtained from five UK, Indian subcontinent-based companies and metal fabrication shops in Africa. Strict design specifications were provided. The mean price for 100 Steinmann pins was$428 in the Indian subcontinent,$96 in Malawi,$105 in Kenya and$244 in Tanzania. Our results indicate that Steinmann pins may be manufactured locally in resource-limited countries at a significantly cheaper price, which may increase the access to skeletal traction.

Ambulatory surgery numbers are rising in the United States at a rapid pace. Between 1996 and 2006, procedures carried out in free-standing surgical centers rose by 300 %. Airway management is a key factor in time management, patient safety, and cost-effectiveness. For the anesthesiologist practicing in a free-standing or office-based unit, patient selection and preparation for all eventualities are essential. A combination of traditional skills and advances in technology and anesthetic research are discussed to outline what we believe is a guide to safe anesthetic practice and airway management in the ambulatory setting. Pre-assessment of the patient, the management of the uncomplicated airway, and management of the anticipated and unanticipated difficult airway are discussed in this article.

Background and Goal of the Study. Desiccated soda lime is known to produce toxic compounds when interacting with volatile anesthetic agents. Amsorb Plus does not produce these but is more expensive per unit weight. Materials and Methods. In a prospective cross-over study, we evaluated the cost of using soda lime (Spherasorb, Intersurgical, UK) and Amsorb Plus. In four operating theatres over two 4-week periods, one for each product, we measured sevoflurane consumption, amount of absorbent used (kg), and amount of waste disposal (kg). Soda lime was changed weekly, and Amsorb Plus once colour change happened. Both were changed if inspired CO2 occurred. Low fresh gas flows were encouraged with Amsorb Plus. Results and Discussion. The total costs over each four-week period were €4375.69 and €3150.94 for soda lime and Amsorb Plus respectively. Reduced cost during Amsorb Plus period (28%) was due to (1) less sevoflurane consumption, (2) fewer Amsorb Plus changes because of reliable colour change, and (3) cheaper domestic waste disposal of Amsorb Plus as it is inert. Conclusion. We demonstrated Amsorb Plus to be a cost-efficient alternative to soda lime in everyday clinical practice.

Psoas compartment block (PCB) is a peripheral regional anaesthetic technique that blocks the main components of the lumbar plexus, namely the femoral, lateral femoral cutaneous (LFC), and obturator nerves as they run within the psoas major muscle. The psoas compartment block is also known as the posterior lumbar plexus block. A posterior approach to the lumbar plexus was first described by Winnie and colleagues. They described an approach for ‘lumbosacral’ block but provided no data on the extent of neural block. The term ‘psoas compartment block’ was coined by Chayen and colleagues to describe a loss of resistance technique with injection of solution into the ‘compartment’ between the quadratus lumborum and psoas major muscles. There have been a number of other approaches described since, including an approach by Capdevila and colleagues based on modifications to Winnie’s landmarks using computed tomography.

Importance The optimum size of endotracheal tube (ETT) for general anesthesia remains unresolved. Choice of ETT size may be of particular relevance to thyroid surgery because of the increased risk of laryngeal trauma and concerns regarding postoperative vocal outcomes. Objective To test our hypothesis that intubation with a smaller ETT would lead to reduced postoperative vocal impairment and associated reduced laryngoscopic evidence of laryngeal trauma compared with intubation with a standard-size ETT. Design, Setting, and Participants This double-blind randomized clinical trial studied patients 18 years and older undergoing elective thyroidectomy at an academic teaching hospital from October 15, 2012, through June 13, 2013. Interventions Patients were randomized to group 1 (standard-size ETT, 8.0 mm for men and 7.5 mm for women; n = 24) or group 2 (small ETT, 7.0 mm for men and 6.5 mm for women; n = 25). Patients were assessed preoperatively and at 24 hours and 3 weeks postoperatively. Main Outcomes and Measures Fiberoptic videolaryngoscopy with modified scoring system, voice assessment using the GRBAS (grade, roughness, breathiness, asthenia, strain) rating scale, vocal self-assessment using the 30-item Voice Handicap Index, and subjective pain score. Results At 24 hours, no significant differences were found between patients in groups 1 and 2 in change in GRBAS scores, change in laryngoscopic score (1.71 vs 1.76, P = .90), or postoperative pain score (3.3 vs 3.2, P = .91). At 3 weeks, no significant differences were found in changes in the 30-item Voice Handicap Index score (−2.2 vs −1.3, P = .74), GRBAS scores, or laryngoscopic score (0.25 vs 0.16, P = .67). Conclusions and Relevance We did not find evidence that smaller ETT size for thyroidectomy has any significant effect on postoperative vocal outcomes, incidence of laryngeal trauma as assessed by laryngoscopy, or pain scores. However, because of the small sample size, our study may have been underpowered to detect small differences. Trial Registration clinicaltrials.gov Identifier:NCT02136459

Background and Objectives Magnetic resonance imaging (MRI) provides for excellent visualization of spread of solution after peripheral nerve block. The aim of this observational study was to utilize MRI to describe the distribution of injectate (gadopentetate dimeglumine) administered for continuous psoas compartment block (PCB) performed by use of two approaches (Capdevila and modified Winnie) and to describe the spread of injectate to the lumbar plexus. Methods Four volunteers were enrolled in a prospective crossover study. Each volunteer underwent PCB with catheter placement performed by use of Capdevila’s approach followed 1 week later by PCB, with catheter placement performed by use of a modified Winnie approach. MRI of injectate distribution was performed after each PCB. Results The catheter was unable to be inserted in 1 volunteer undergoing Winnie’s approach; therefore, 7 sets of MR images were analyzed. In 6 of 7 cases (4 Capdevila and 2 Winnie) spread was primarily within the psoas muscle. Contrast surrounded the L2-3 lumbar branch of the femoral nerve at L4 and cleaved the fascial plane within the psoas muscle and spread cephalad to reach the lumbar nerve roots. In 1 case (Winnie approach) contrast spread between the psoas and quadratus lumborum muscles. Contrast surrounded the femoral and obturator nerves where they lie outside the psoas muscle at L5. Conclusion The most common pattern of injectate spread seen on MRI with both approaches to PCB was spread within the body of the psoas muscle around the lumbar branches (L2-4), with cephalad spread to the lumbar nerve roots. One catheter resulted in injectate between the psoas and quadratus lumborum muscles.

We compared the approaches of Winnie and Capdevila for psoas compartment block (PCB) performed by a single operator in terms of contralateral spread, lumbar plexus blockade, and postoperative analgesic efficacy. Sixty patients underwent PCB (0.4 mL/kg levobupivacaine 0.5%) and subsequent spinal anesthesia for primary joint arthroplasty (hip or knee) in a prospective, double-blind study. Patients were randomly allocated to undergo PCB by using the Capdevila (group C; n = 30) or a modified Winnie (group W; n = 30) approach. Contralateral spread and lumbar plexus blockade were assessed 15, 30, and 45 min after PCB. Contralateral spread (bilateral from T4 to S5) and femoral and lateral cutaneous nerve block were evaluated by sensory testing, and obturator motor block was assessed. Bilateral anesthesia occurred in 10 patients in group C and 12 patients in group W (P = 0.8). Blockade of the femoral, lateral cutaneous, and obturator nerves was 90%, 93%, and 80%, respectively, for group C and 93%, 97%, and 90%, respectively, for group W (P > 0.05). No differences were found in PCB procedure time, pain scores, 24-h morphine consumption, or time to first morphine analgesia.

We evaluated the systemic and local effects of clonidine as an analgesic adjunct to psoas compartment block (PCB) with levobupivacaine. In a randomized, prospective, double-blind trial, 36 patients requiring hip fracture surgery received PCB and general anesthesia. Patients were randomized into three groups. Each patient received PCB with 0.4 mL/kg of levobupivacaine 0.5%. The control group (group L) received IV saline, the systemic clonidine group (group IC) received IV clonidine 1 mug/kg, and the peripheral clonidine group (group C) received IV saline and PCB with clonidine 1 microg/kg. The interval from time of completion of block injection to first supplementary analgesic administration was longer in group IC compared with group L (mean +/- sd, 13.4 +/- 6.1 versus 7.3 +/- 3.6 h; P = 0.03). There was no difference between group C and group L (10.3 +/- 5.9 versus 7.3 +/- 3.6 h; P > 0.05). The groups were similar in terms of 24 h cumulative morphine and acetaminophen consumption. There were no significant differences among groups regarding postoperative adverse effects (bradycardia, hypotension, sedation, and nausea). We conclude that IV but not perineural clonidine (1 microg/kg) prolongs analgesia after PCB without increasing the incidence of adverse effects.

Background : Medical students are often considered by anaesthetists to have a lack of knowledge of anaesthesia and the role of the anaesthetist. Aim : The aim of this study was to assess the impact of a clinical clerkship in anaesthesia on Irish medical students understanding of anaesthesia as a specialty, the role of anaesthetists and career choice through comparison of pre-clinical and clinical medical students. Methods : This was a cross sectional study of 80 Irish medical students who completed an anonymous questionnaire consisting of 16 items. Results : Only 47.5% of clinical students were aware that anaesthetists participate in running intensive care units and just 65% knew that anaesthetists were involved in the management of chronic pain. However, 100% of clinical students recognised that anaesthetists administered epidural analgesia to obstetric patients and 30% of clinical students would consider a career in this specialty. Conclusion : This research is providing medical professionals and educators with updated information which may be useful for improving students experience and understanding of anaesthesia.

To the Editor, The Glidescope (Verathon Medical (UK) Ltd., Aston Sandford, United Kingdom) is a videolaryngoscope, which improves the Cormack and Lehane (CL) grade of laryngoscopy due to its 60 viewing orientation. Notwithstanding this ability to ‘‘see around corners’’, it is impossible to intubate the trachea in 4% of patients using the Glidescope , despite a satisfactory glottic view and the use of a preformed stylet or flexible introducer. Reasons for failure include the inability to maneuver the endotracheal tube (ETT) into the glottis or the ETT abutting the anterior portion of the larynx when using the stylet. An intubating fibreoptic bronchoscope (fibrescope) can be dynamically manipulated in multiple directions potentially overcoming the aforementioned limitations. Previous reports of combining a Glidescope and fibrescope were focused either on the Glidescope as an oropharyngeal camera aiding fibreoptic intubation or on a single case performed by one operator with limited detail regarding the technique. We present our experience of fibrescopeassisted videolaryngoscopy (FAV) in both anticipated and unanticipated difficult airways, in multiple patients, and with multiple operators. The FAV technique is performed following induction of general anesthesia and involves two components. First, the Glidescope is inserted to obtain the best possible view of the glottis. Second, the fibrescope (with ETT pre-mounted) is introduced into the pharynx by an assistant until seen on the Glidescope screen. Using the Glidescope image for guidance, the anesthesiologist manipulates the fibrescope to direct it into the larynx and then the trachea (Fig. 1). The ETT is next advanced over the fibrescope, thus securing the airway. The FAV technique has been used successfully in 25 patients, including 12 anticipated and 13 unanticipated difficult airways, where intubation of the trachea was impossible with the Glidescope alone. The cases involved six independent anesthesiologists and one head and neck surgeon. The details of four cases are summarized in Table 1. Since its introduction, there have been no failures using the FAV technique. For CL grades 1 and 2 views, the fibrescope functions as a dynamic laryngeal and tracheal introducer. In patients with CL grades 3 and 4 views, the Glidescope optimizes the position of the tongue and pharyngeal structures facilitating rapid placement of the fibrescope followed by conventional fibreoptic confirmation of tracheal intubation. Fig. 1 Using the Glidescope screen image, the fibrescope tip is placed at the glottic aperture but requires manipulation caudally and posteriorly to enter the trachea

Background. Tramadol has been administered peripherally to prolong analgesia after brachial plexus and neuraxial blocks. Our aim was to evaluate the systemic and perineural effects of tramadol as an analgesic adjunct to psoas compartment block (PCB) with levobupivacaine. Methods. In a randomized, prospective, double-blinded trial, 60 patients (ASA I–III), aged 49–88 yr, undergoing primary total hip or knee arthroplasty underwent PCB and subsequent bupivacaine spinal anaesthesia. Patients were randomized into three groups. Each patient received PCB with levobupivacaine 0.5%, 0.4 ml kg−1. The control group (group L, n=21) received i.v. saline, the systemic tramadol group (group IT, n=19) received i.v. tramadol 1.5 mg kg−1 and the perineural tramadol group (group T, n=20) received i.v. saline and PCB with tramadol 1.5 mg kg−1. Postoperatively patients received regular paracetamol 6-hourly and diclofenac sodium 12-hourly. Time to first morphine analgesia, 24-hour morphine consumption, sensory block, pain and sedation scores and haemodynamic parameters were recorded. Results. Time (h) to first morphine analgesia was similar in the three groups [mean (sd)]: group L, 11.2 (6.6); group T, 14.5 (8.0); group IT, 14.6 (6.8); P=0.35. Twenty-four-hour cumulative morphine (mg) consumption was also similar in the three groups [group L, 21.9 (10.1); group T, 19.8 (6.7), group IT, 16.5 (9.5)], as were durations of sensory and motor block. There were no differences in the incidence of adverse effects except that patients in group IT were more sedated at 14 h than group L (P=0.02). Conclusion. We conclude that our data do not support a clinically important local anaesthetic or peripheral analgesic effect of tramadol as adjunct to PCB with levobupivacaine 0.5%.