Comparison of Pressure Control Ventilation and Palpation Methods to Protect the Endotracheal Tube Cuff During Tracheotomy: A Manikin Simulation Study.

Objective This study aims to evaluate and compare the suitability and safety of palpation and pressure control ventilation (PCV) methods for the accurate positioning of an endotracheal tube (ETT) cuff. Methods We conducted a pilot simulation randomized crossover study using a medical manikin. Twenty junior resident physicians who had completed anesthesiology training participated in the study. Airway management was performed using a modified manikin designed to simulate palpation and PCV methods. Participants performed both methods in a randomized order. The primary outcome was the number of successful ETT placements. The secondary outcomes were procedure duration and the perceived difficulty of each procedure. Results Five successful procedures were observed in the palpation method group (PALG), while 19 were observed in the PCV method group (PCVG). The duration of the trial was 98 s (standard deviation [SD], 41) in the PALG and 93 s (SD, 49) in the PCVG. The visual analog scale score for difficulty encountered during the trial was 30 (SD, 21) in the PALG and 69 (SD, 19) in the PCVG. Conclusions Our findings suggest that the PCV method had a higher success rate than the palpation method. Thus, the PCV method may be more suitable for inexperienced physicians to perform the procedure with greater confidence.

Perioperative Analgesia Using an Indwelling Catheter to Deliver an Inferior Alveolar Nerve Block: A Case Report.

A 74-year-old male was diagnosed with osteomyelitis of the left mandible requiring marginal mandibulectomy under general anesthesia. However, the patient's pulmonary function tests demonstrated findings consistent with severe chronic obstructive pulmonary disease, classified as stage III. The consulting pulmonologist explained the increased risk of respiratory complications associated with general anesthesia and advised against its use. Therefore, we opted to perform the surgery under moderate sedation using 0.2% ropivacaine administered via bilateral ultrasound-guided inferior alveolar nerve blocks (UGIANBs) and an indwelling catheter with a pump for continuous perioperative local anesthesia and prolonged postoperative analgesia. This approach delivered excellent local anesthetic effects without any need for rescue medications or complications. Use of UGIANBs along with an indwelling catheter and pump may provide adequate local anesthesia and postoperative analgesia in patients with contraindications for general anesthesia.

Ultrasound-Guided Local Anesthetic Nerve Blocks in a Forehead Flap Reconstructive Maxillofacial Procedure.

Head and neck reconstructive surgery involving tissue flaps is often complex requiring the development of an individualized anesthetic plan. The following case report describes the anesthetic management of an 87-year-old man considered at high risk for postoperative delirium due to advanced age and blindness undergoing general anesthesia for resection of squamous cell carcinoma of the right side of the nose and reconstructive surgery with a scalping forehead flap. Ultrasound-guided local anesthetic maxillary and supraorbital nerve blocks were successfully used perioperatively to reduce the need for alternative analgesics associated with higher risks of complications such as postoperative nausea, vomiting, and delirium.

Spread of injectate in ultrasound-guided serratus plane block: a cadaveric study.

BACKGROUND: Serratus plane block is a thoracic truncal block that has been proposed as alternatives for analgesia such as epidural anesthesia and paravertebral block for the anterolateral chest wall. Previously, we performed the clinical study about optimal volume of the local anesthetic in serratus plane block. The primary aim of this study was to assess the pattern of distribution of dye into the serratus plane of cadavers after ultrasound-guided serratus plane injection. FINDINGS: Ultrasound-guided serratus plane injection was performed at the level of the fourth rib on the mid-axillary line in nine adult Thiel-embalmed cadavers. In each cadaver, one side was injected with 20 ml of methylene blue dye and the contralateral side with 40 ml. Dissections of the thoracic walls were performed 20 min after the injection. The spread of the dye to intercostal nerves, lateral and medial pectoral nerves, long thoracic nerve, and thoracodorsal nerves was assessed. All T2-T5 intercostal nerves in the 40-ml group and all T3-T4 nerves in the 20-ml group were stained with the dye. A larger number of intercostal nerves was stained in the 40-ml group than that in the 20-ml group. Medial and lateral pectoral nerves were not frequently stained in either group. CONCLUSIONS: The range of craniocaudal spread of the injectate was wider in the 40-ml group than that in the 20-ml group after ultrasound-guided serratus plane injection in Thiel-embalmed cadavers.

Transient obturator nerve block with fascia iliaca compartment block following local infiltration for open inguinal herniorrhaphy.

BACKGROUND: Ilioinguinal nerve block is effective for analgesia after open inguinal herniorrhaphy. However, transient femoral nerve palsy can happen after the block. The ambulatory patients sometimes cannot discharge from the hospital with the motor deficiency. Here is described a case of fascia iliaca compartment block with complete obturator nerve block after surgical infiltration analgesia for open inguinal herniorrhaphy. CASE PRESENTATION: An ambulatory open inguinal herniorrhaphy was performed for a 63-year-old male under general anesthesia. The mixture of short-/long-acting local anesthetics was injected by the surgeon into the subcutaneous tissue, between the Camper's and Scarpa's fasciae, into the inguinal canal, and between the internal oblique and transversus abdominis muscles. The patient could not adduct his ipsilateral hip joint at all 1 h after emergence. The flexion of the hip joint was weakened two more hours later, and numbness of the lateral thigh emerged. The complications completely resolved 7 h after surgery. CONCLUSIONS: Surgical infiltration analgesia as well as percutaneous ilioinguinal nerve block can cause both fascia iliaca plane block and obturator nerve block. Analgesia regimen should be carefully built for ambulatory surgery.

Motor-sparing continuous median nerve block for hand surgery: A pediatric case.

Here is described a successful perioperative pain control with continuous median nerve block after flexor tendon repair surgery on 2nd finger of a child. A 9-year-old patient was admitted for reconstruction surgery. The combination of median nerve block and lateral/medial antecubital cutaneous nerve blocks were performed before the surgery to cover all the surgical incision including the 2nd finger, palm, the graft site proximal to the wrist, and Kleinert traction at the nail bed. At the end of the surgery, the infusion catheter was inserted at the distal one-third to spare the muscle strength of flexor digitorum muscles. Continuous bupivacaine infusion provided complete analgesia until the postoperative day 4 without interfering the postoperative physiotherapy. The continuous median nerve block at the distal one-third of the forearm spared finger flexion, and supported effective postoperative early mobilization after zone 2 flexor tendon repair surgery.

Injection Volume and Anesthetic Effect in Serratus Plane Block.

BACKGROUND AND OBJECTIVES: Serratus plane block is performed for analgesia of the anterior chest wall. However, there has been no study concerning the appropriate volume for this block. This prospective randomized controlled study assesses the dermatomal spread and analgesic effects of serratus plane block. METHODS: Ultrasound-guided serratus plane block was performed for breast cancer surgery. The patients were randomly assigned to receive 20 or 40 mL of 0.375% ropivacaine. The primary end point was the number of affected dermatomes as assessed by cold test and pinprick test 20 minutes after the block procedure. Secondary end points were the time until the first postoperative analgesic rescue, adverse effects, and complications. RESULTS: The number of affected dermatomes assessed by the cold test for patients receiving 40 mL of 0.375% ropivacaine was significantly larger than that for patients receiving 20 mL (P = 0.002; 6 [5-7] vs 4 [3-4] dermatomes). Similarly, with the pinprick test, the affected area was larger for the 40 mL group than for the 20 mL group (P = 0.009; 4 [2-6] vs 2 [1-3] dermatomes). There were no differences between the 2 groups in secondary end points. CONCLUSIONS: Ultrasound-guided serratus plane block spread in the craniocaudal direction is more widespread with 40 mL than with 20 mL of 0.375% ropivacaine. The time until the first postoperative analgesic rescue dose was not extended by a larger volume of injection. CLINICAL TRIALS REGISTRATION: UMIN Clinical Trials Registry (identifier UMIN000016549).

Ultrasound-guided para-umbilical block: a pediatric case.

BACKGROUND: Rectus sheath block is a common peripheral nerve block for patients undergoing umbilical hernia repair surgery. However, rectus sheath block alone can affect only anterior branches of intercostal nerves and, therefore, is incomplete for postoperative analgesia for the anterior abdomen, which is innervated by both anterior and lateral branches. We describe a successful perioperative analgesia with ultrasound-guided para-umbilical block after pediatric umbilical hernia surgery. CASE PRESENTATION: A 4-year-old child underwent hernia repair surgery. Following induction of general anesthesia, the anatomy of the umbilical region was observed under ultrasound with a 5-10-MHz linear probe. An ultrasound-guided injection between the rectus abdominis muscle and the posterior lobe of the rectus sheath and an injection into the subcutaneous space around the umbilicus were performed. The peripheral nerve block was effective during surgery, and the patient required no additional rescue analgesia during the perioperative period. There were no complications. CONCLUSION: We performed ultrasound-guided para-umbilical block with four injections. This peripheral nerve block could be an efficient technique for complete perioperative analgesia.

Retrolaminar block: analgesic efficacy and safety evaluation.

PURPOSE: Retrolaminar block (RLB) is a thoracic truncal block that can produce analgesia for the thoracic and abdominal wall. However, the characteristics of RLB are not well known. The aim of this study was to determine analgesic efficacy by measuring postoperative consume of patient-controlled analgesia (PCA), additional nonsteroidal antiinflammatory drug (NSAID) rescue, and opioid rescue. Our secondary analysis included assessment of the chronological change in arterial levobupivacaine concentrations after the block. METHODS: This prospective, randomized, double-blinded study included 30 patients scheduled for modified radical mastectomy under general anesthesia. The patients were randomized to receive either a landmark-guided RLB or paravertebral block (PVB) catheter placement on T4. Continuous infusion with 4 ml/h of 0.25 % levobupivacaine was started for 72 h, after initial injection of 20 ml 0.375 % levobupivacaine before surgery. Postoperative pain was compared using the amount of block PCA (3 ml 0.25 % levobupivacaine with 30-min lockout), NSAID, and opioid rescue. Arterial blood was sampled for 120 min after the initial injection. RESULTS: The frequency of postoperative block PCA use was significantly high after RLB in 24 h [p = 0.01; 6 (3-12) vs. 2.5 (0.3-3) times, respectively]. There was no PCA use after 24 h in either group. There was no postoperative opioid rescue use throughout the study. After RLB and PVB, there was no significant difference in T max (p = 0.14; 15 ± 8 vs. 15 ± 8 min, respectively) and C max (p = 0.2; 0.9 ± 0.2 vs. 0.9 ± 0.3 µg/ml, respectively), and all the concentrations were below the threshold of local anesthetic systemic toxicity. CONCLUSION: Continuous RLB was not inferior to PVB except for the first 24 h, and was satisfactory after mastectomy. RLB showed safe, low peak arterial levobupivacaine concentrations.

[Anesthetic Management for Non-cardiac Surgery in a Patient with Severe Pulmonary Arterial Hypertension].

Severe pulmonary arterial hypertension is a significant risk factor for anesthetic management in patients undergoing even non-cardiac surgery. A 64-year-old female patient with severe pulmonary arterial hypertension was scheduled to undergo inguinal hernioplasty. Preoperative systolic pulmonary arterial pressure was 115 mmHg. We selected monitored anesthesia care with 0.2-0.5 µg x kg(-1) x hr(-1) dexmedetomidine and ultrasound-guided iliohypogastric block. Thereafter, LiDCOrapid was used to acquire the hemodynamic responses during surgery. Continuous iliohypogastric block produced postoperative pain relief and the supplemental analgesic was not needed. The monitored anesthesia care by dexmedetomidine and ultrasound guided continuous iliohypogastric block would be a safe procedure for patients with severe pulmonary arterial hypertension undergoing non-cardiac surgery. LiDCO rapid could be low invasive and useful as a hemodaynamic monitor in such a case.