Ultrasound-guided rectus sheath block for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery: A case report.

BACKGROUND: Anterior cutaneous nerve entrapment syndrome is defined as abdominal pain due to entrapped intercostal nerves. This is the first report of a patient successfully treated for anterior cutaneous nerve entrapment syndrome after laparoscopic surgery with an ultrasound-guided rectus sheath block. The rectus sheath block physically lysed adhesions and relieved pain from anterior cutaneous nerve entrapment syndrome. CASE SUMMARY: The patient is a 44-year-old man who presented with severe left upper abdominal pain at an operative scar one month after laparoscopic ulcer repair. Diagnosis and treatment were performed using an ultrasound-guided rectus sheath block with 0.1% lidocaine 20 mL. The pain was relieved after the block. The diagnosis was anterior cutaneous nerve entrapment syndrome. Rectus sheath block may be effective for patients with anterior cutaneous nerve entrapment syndrome. CONCLUSION: Ultrasound-guided rectus sheath block is a promising treatment modality for patients with postoperative anterior cutaneous nerve entrapment syndrome due to adhesions.

A Case Report of Femoral Hematoma following Obturator Nerve Block.

BACKGROUND: When an obturator nerve block (ONB) is performed, the conventional landmark method or ultrasound-guided method is used. The major complications of this block are hematoma, but there are very few reports of its complications. We encountered massive bleeding and a huge hematoma after ONB. Case Presentation. A 95-year-old female underwent transurethral resection of the bladder tumor. Induction of anesthesia was accomplished via spinal anesthesia and right ONB using the landmark method. Postoperatively, subcutaneous bleeding was detected in the lower right interior thigh. Concentrated red cell transfusion was conducted to address the anemia. There was no subsequent expansion of the hematoma. It resolved on postoperative day (POD) 53. The hematoma was deemed to be inadvertently introduced due to an obturator artery puncture during the obturator nerve block. CONCLUSIONS: Close attention is necessary to avoid advancing the needle too deep into the obturator during obturator nerve block.

Photoacoustic needle improves needle tip visibility during deep peripheral nerve block.

We developed a novel technology using the photoacoustic effect that improve needle tip visibility. We evaluated whether this technology improves needle tip visibility when performing a deep peripheral nerve block in a cadaver model. A photoacoustic needle was developed using a conventional echogenic needle with an intraluminal optical fiber. A pulsed laser sends light from a source through the fiber, which is converted to ultrasound at the needle tip using the photoacoustic effect. A nerve block expert performed deep nerve blocks using the photoacoustic needle and the ultrasound views recorded, with or without photoacoustic ultrasound at the needle tip. Needle tip visibility was evaluated by questionnaire (Likert scale 1: very poor, 5: very good) completed by anesthesiologists evaluating recorded images. The score was presented as median [first quartile, third quartile]. Statistical analysis was performed using the Wilcoxon matched-pairs signed rank test. The scores of needle tip visibility with photoacoustic ultrasound from the needle tip (4.3 [4.0, 4.5]) was significantly higher than that without photoacoustic ultrasound (3.5 [3.2, 3.8]) (p < 0.01). Ultrasound emitted at the needle tip using the photoacoustic effect improves needle tip visibility during deep peripheral nerve blocks.Clinical trial number University Hospital Medical Information Network Center Clinical Trials Registration System (UMIN000036974).

Shallow-angle needle guide for ultrasound-guided internal jugular venous catheterization: A randomized controlled crossover simulation study (CONSORT).

BACKGROUND: Needle guides for ultrasound-guided internal jugular venous catheterization facilitate successful cannulation. The ability of a needle guide to prevent a posterior vein wall injury which may secondarily induce lethal complications, is unknown. Previous studies showed that a shallow angle of approach may reduce the incidence of posterior wall injuries. We developed a novel needle guide with a shallow angle of approach for ultrasound-guided venous catheterization and examined whether this needle guide reduces the incidence of posterior wall injuries compared to a conventional needle guide and free-hand placement in a simulated vein. METHODS: This study was a randomized crossover-controlled trial. The primary outcome was the rate of posterior vein wall injuries. Participants had a didactic lecture about three ultrasound-guided techniques using the short-axis out-of-plane approach, including free-hand (P-free), a commercial needle guide (P-com), and a novel needle guide (P-sha). The view inside a simulated vein was recorded during venipuncture. RESULTS: Thirty-five residents participated in this study. Posterior vein wall injuries occurred in 66% using P-free, 60% using P-com, and 0% using P-sha (p< 0.01). There was no significant difference in the incidence of posterior vein wall injuries between P-free and P-com. CONCLUSIONS: Use of a shallow angle of approach needle guide resulted in a lower rate of posterior vein injuries during venipuncture of a simulated vein compared with other techniques using a steeper angle techniques.

Cricothyroidotomy needle length is associated with posterior tracheal wall injury: A randomized crossover simulation study (CONSORT).

BACKGROUND: Cricothyroidotomy is the final strategy in the "cannot intubate, cannot oxygenate" scenario, but half of needle cricothyroidotomy attempts result in failure. The most frequent complication in needle cricothyroidotomy is posterior tracheal wall injury. We hypothesized that needle length is related to posterior wall injury and compared needle cricothyroidotomy with a commercial kit to a modified shorter needle to evaluate success and posterior wall injury rates. METHODS: The commercial kit has a needle stopper to prevent posterior wall injury, with a penetrating length of 25 mm. We made long stopper to shorten the length by 5 mm (net 20 mm penetrating length). Residents were recruited, received a lecture about cricothyroidotomy and practiced needle cricothyroidotomy using the commercial kit on a simulator. They then performed cricothyroidotomy using the commercial kit or the shorter needle on an ex-vivo porcine larynx covered with artificial skin. An intra-tracheal endoscope recorded the procedure. The video was evaluated for success/failure or posterior wall injury by independent evaluators. Larynxes with a distance from the outer surface to the inner lumen exceeding 13 mm were excluded. The distance in each larynx was measured by dissection after the study. Success and posterior wall injury rates were analyzed using Fisher exact test (P < .05 was statistically significant). RESULTS: Forty-seven residents participated in the study. Data for two residents were excluded. There was no statistically significant difference in success rate between the commercial kit (100%, 45/45) and the shorter needle (91%, 41/45, P = .12). Failure was defined if the needle tip did not reach the lumen in four trials. Cannulated but complicated by posterior wall injury occurred in 33% (15/45) with the commercial kit and 5% (2/43) with the shorter needle (P < .01). CONCLUSION: During needle cricothyroidotomy, force is needed for the needle to penetrate the cricothyroid ligament. The advancing needle sometimes cannot be stopped after penetrating the cricothyroid ligament. These data suggest that needle length is associated with posterior wall injury.

Ultrasound-Guided Hydrodissection of an Entrapped Saphenous Nerve After Lower Extremity Varicose Vein Stripping: A Case Report.

A 78-year-old woman complained of numbness, tingling, and pain in the left leg 6 months after greater saphenous vein stripping. Ultrasonography identified a mass adjacent to the saphenous nerve at the scar. Ultrasound-guided hydrodissection separated the mass from the nerve. The pain disappeared after hydrodissection, and the patient remained pain free for 3 days. The visual analog pain scale decreased from 80 (before treatment) to 60 three days later. The hydrodissection was repeated weekly for a total of 8 times, and the pain completely resolved 4 months later. Ultrasound-guided hydrodissection is effective to treat nerve entrapment after lower extremity varicose vein stripping.

Ultrasonographic identification of the cricothyroid membrane in a patient with a difficult airway as a result of cervical hematoma caused by hemophilia: a case report.

BACKGROUND: Surgical cricothyroidotomy is a last resort in patients with an anticipated difficult airway, but without any guarantee of success. Identification of the cricothyroid membrane may be the key to successful cricothyrotomy. Ultrasonographic identification of the cricothyroid membrane has been reported to be more useful than the conventional palpation technique. However, ultrasonographic identification techniques are not yet fully characterized. CASE PRESENTATION: A 28-year-old man with hemophilia and poor adherence to medication. He was brought to the emergency department with a large cervical hematoma and respiratory difficulty. An otolaryngologist decided to insert a tracheal tube to maintain his airway. However, emergent laryngoscopy indicated an anticipated difficult airway. A backup plan that included awake intubation by the anesthesiologists and surgical cricothyroidotomy by an otolaryngologist was devised. The cricothyroid membrane could not be identified by palpation but was detected by ultrasonographic identification with a longitudinal approach. Awake fiberoptic intubation was successfully performed. CONCLUSIONS: In this case, the cricothyroid membrane could be identified using the longitudinal approach but not the transverse approach. It may be ideal to know which ultrasound technique can be applied for each patient.

A high-fidelity simulator for needle cricothyroidotomy training is not associated with increased proficiency compared with conventional simulators: A randomized controlled study.

BACKGROUND: A high-fidelity task simulator for cricothyroidotomy was created using data from a 3-dimensional (3D) computed tomography scan using a 3D printer. We hypothesized that this high-fidelity cricothyroidotomy simulator results in increased proficiency for needle cricothyroidotomy compared with conventional simulators. METHODS: Cricothyroidotomy-naive residents were recruited and randomly assigned to 2 groups, including simulation training with a conventional simulator (Group C) and with a high-fidelity simulator (Group 3D). After simulation training, participants performed cricothyroidotomy using an ex vivo porcine larynx fitted with an endoscope to record the procedure. The primary outcomes were success rate and procedure time. The secondary outcome was a subjective measure of the similarity of the simulator to the porcine larynx. RESULTS: Fifty-two residents participated in the study (Group C: n = 27, Group 3D: n = 25). There was no significant difference in the success rate or procedure time between the 2 groups (success rate: P = .24, procedure time: P = .34). There was no significant difference in the similarity of the simulators to the porcine larynx (P = .81). CONCLUSION: We developed a high-fidelity simulator for cricothyroidotomy from 3D computed tomography data using a 3D printer. This anatomically high-fidelity simulator did not have any advantages compared with conventional dry simulators.

A Shallow Angle Short-Axis Out-of-Plane Approach Reduces the Rate of Posterior Wall Injuries in Central Venous Catheterization: A Simulation Study.

The short-axis out-of-plane approach (SAX-OOP) is commonly used in ultrasound-guided internal jugular vein catheterization. However, this approach has a risk of posterior vein wall injuries. The authors hypothesized that a shallow angle of approach may reduce the rate of posterior wall injuries compared with the conventional steep angle approach. The present study aimed to evaluate whether a difference in the angle of approach of the needle affects the rate of posterior wall injuries. The present study was a randomized crossover-controlled trial involving 40 medical residents, conducted in the clinical training center at a hospital with a residency program. The primary outcome measure was the rate of posterior vessel wall injuries. Subjects received a didactic lecture during which the instructors taught three SAX-OOP techniques including the conventional free-hand method (procedure C), a needle navigation system (procedure N), and a shallow puncture angle using a guidance system (procedure S). Participants were trained in these approaches under supervision and each technique tested in a simulation environment. Thirty-four of 40 residents had no previous experience with central venous catheterization and were included in the final analysis. The rate of posterior vessel wall injuries in procedure S (9%) was significantly lower than using the other approaches (procedure C, 53%; procedure N, 41%). In conclusion, a shallow angle of approach using the SAX-OOP technique resulted in significantly fewer posterior vein wall injuries in central venous catheterization compared with steep angle techniques.

Ultrasound-guided identification of the cricothyroid membrane in a patient with a difficult airway: a case report.

BACKGROUND: Surgical cricothyroidotomy is considered to be the last resort for management of the difficult airway. A major point for a successful surgical cricothyroidotomy is to identify the location of the cricothyroid membrane. CASE PRESENTATION: We encountered a patient with progressive respiratory distress who was anticipated to have a difficult airway due to a large neck abscess. We prepared for both awake intubation and surgical cricothyroidotomy. The cricothyroid membrane could not be identified by palpation, but was readily identified using ultrasound. CONCLUSION: Ultrasound-guided identification of the cricothyroid membrane may be useful in a patient with a difficult airway due to neck swelling.

Postoperative analgesia comparing levobupivacaine and ropivacaine for brachial plexus block: A randomized prospective trial.

BACKGROUND: On a pharmacologic basis, levobupivacaine is expected to last longer than ropivacaine. However, most reports of these anesthetics for brachial plexus block do not suggest a difference in analgesic effect. The aim of this study is to compare the postoperative analgesic effects of levobupivacaine and ropivacaine when used for treating ultrasound-guided brachial plexus block. METHODS: A total of 62 patients undergoing orthopedic surgery procedures were prospectively enrolled and randomized to receive levobupivacaine (group L, N = 31) or ropivacaine (group R, N = 31). The duration of analgesia, offset time of motor block, need for rescue analgesics, and sleep disturbance on the night of surgery were recorded. Pain score was recorded on the day of surgery, and on postoperative days 1 and 2. RESULTS: There was no difference in the time interval until the first request for pain medication comparing the two groups (group L: 15.6 [11.4, 16.8] hours; group R: 12.5 [9.4, 16.0] hours, P = 0.32). There was no difference in the duration of motor block (group L: 12.2 [7.6, 14.4] hours; group R: 9.4 [7.9, 13.2] hours, P = 0.44), pain score (P = 0.92), need for rescue analgesics (group L: 55%; group R: 65%, P = 0.6), or rate of sleep disturbance (group L: 61%, group R: 58%, P = 1.0) on comparing the two groups. CONCLUSIONS: There was no difference in postoperative analgesia comparing levobupivacaine and ropivacaine when used for brachial plexus block.

Iatrogenic carpal tunnel syndrome induced by wrist extension for placement of an indwelling radial artery catheter: a case report.

A 38-year-old man with pancreatic cancer was scheduled to undergo pancreaticoduodenectomy. He had an unremarkable past medical history. After inducing general anesthesia, a left radial arterial catheter was successfully placed at first attempt. A wrist splint was used to obtain good arterial pulse waveforms. After the operation, he was transferred to the intensive care unit. The radial artery catheter was removed on the fourth postoperative day. He experienced numbness and a tingling sensation in the left thumb, the second and third fingers, and the lateral half of the fourth finger. He was diagnosed with carpal tunnel syndrome. Diagnostic imaging revealed a swollen median nerve, but no hematoma or injury. Some studies have suggested that excessive extension of the wrist may cause neuropathy. We recommend that patients' wrists not be over-extended, even if good arterial waveforms cannot be obtained.

Particulate-steroid betamethasone added to ropivacaine in interscalene brachial plexus block for arthroscopic rotator cuff repair improves postoperative analgesia.

BACKGROUND: Dexamethasone added to local anesthetic for brachial plexus block improves postoperative pain after arthroscopic rotator cuff repair, as compared with the use of local anesthetic alone. Dexamethasone is present in non-particulate form in local anesthetic solution, while betamethasone is partially present in particulate form. The particulate betamethasone gradually decays and is expected to cause its longer-lasting effect. This study investigated the postoperative analgesic effect of betamethasone added to ropivacaine for brachial plexus block in patients who underwent arthroscopic rotator cuff repair. METHODS: This was a prospective, randomized, triple-blind study of 44 patients undergoing arthroscopic rotator cuff repair surgery. Ultrasound-guided interscalene brachial plexus block, involving 20 mL of 0.375 % ropivacaine (group R) or 19 mL of 0.375 % ropivacaine with 4 mg (1 mL) of betamethasone (group BR), was administered and surgery was performed under general anesthesia. After surgery, the pain score was recorded at 12 h after surgery, and on the first, second, and seventh postoperative day. Analgesia duration, offset time of motor block, frequency of rescue analgesic administration, postoperative nausea/vomiting, and sleep disturbance during the night after surgery were recorded. The numerical values were expressed as median [interquartile range]. P values < 0.05 were considered statistically significant. RESULTS: The duration of analgesia was significantly prolonged in group BR (group BR: 19.1 h [16.6, 20.9 h], group R: 13.3 h [11.6, 16.5 h], p < 0.001). The pain scores at 12 h after surgery and on the first and seventh day after surgery were significantly lower in group BR than in group R. The duration of motor block was significantly prolonged in group BR. The frequency of rescue analgesic administration and the sleep disturbance rate were significantly lower in group BR. There was no difference in postoperative nausea/vomiting between the two groups. CONCLUSIONS: Betamethasone added to local anesthetic in interscalene brachial plexus block improved postoperative pain after arthroscopic rotator cuff repair, and betamethasone prolonged the duration of analgesia by almost 6 h. TRIAL REGISTRATION: University Hospital Medical Information Network Center Clinical Trials Registration System ( UMIN000012899 ).

Quadratus lumborum block for femoral-femoral bypass graft placement: A case report.

INTRODUCTION: Atherosclerosis has a complex etiology that leads to arterial obstruction and often results in inadequate perfusion of the distal limbs. Patients with atherosclerosis can have severe complications of this condition, with widespread systemic manifestations, and the operations undertaken are often challenging for anesthesiologists. CASE REPORT: A 79-year-old woman with chronic heart failure and respiratory dysfunction presented with bilateral gangrene of the distal lower extremities with obstruction of the left common iliac artery due to atherosclerosis. Femoral-femoral bypass graft and bilateral foot amputations were planned. Spinal anesthesia failed due to severe scoliosis and deformed vertebrae. General anesthesia was induced after performing multiple nerve blocks including quadratus lumborum, sciatic nerve, femoral nerve, lateral femoral cutaneous nerve, and obturator nerve blocks. However, general anesthesia was abandoned because of deterioration in systemic perfusion. The surgery was completed; the patient remained comfortable and awake without the need for further analgesics. CONCLUSION: Quadratus lumborum block may be a useful anesthetic technique to perform femoral-femoral bypass.

Difficult Airway Due to an Undiagnosed Subglottic Tumor: A Case Report.

The "cannot ventilate, cannot intubate" scenario during anesthesia induction can be lethal. We present a patient with an undiagnosed subglottic tumor who developed the "cannot ventilate, cannot intubate" situation after induction of general anesthesia, due to the presence of an undiagnosed subglottic tumor. A 93-year-old woman was brought to the operating room for repair of a femoral neck fracture. Both ventilation and intubation could not be accomplished, and the patient was awakened without complications after trials of maintaining the airway. In order to reverse muscle relaxation, sugammadex was useful to allow resumption of spontaneous breathing. A difficult airway can be caused by an undiagnosed subglottic tumor. Subglottic tumors can be misdiagnosed as asthma, because the clinical presentation can be very similar. If cricothyrotomy had been performed based on airway management algorithms, the airway may not have been controlled with a possibly fatal outcome. Ultrasound examination of the trachea may be useful to diagnose obstructive lesions in the airway.