The effectiveness of ambulatory continuous popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia in patients undergoing foot or ankle surgery (CAREFREE trial); a randomized, open label, non-inferiority trial.

STUDY OBJECTIVE: Management of pain after foot and ankle surgery remains a concern for patients and healthcare professionals. This study determined the effectiveness of ambulatory continuous popliteal sciatic nerve blockade, compared to standard of care, on overall benefit of analgesia score (OBAS) in patients undergoing foot or ankle surgery. We hypothesized that usage of ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care. DESIGN: Single center, randomized, non-inferiority trial. SETTING: Tertiary hospital in the Netherlands. PATIENTS: Patients were enrolled if ≥18 years and scheduled for elective inpatient foot or ankle surgery. INTERVENTION: Patients were randomized to ambulatory continuous popliteal sciatic nerve blockade or standard of care. MEASUREMENTS: The primary outcome was the difference in OBAS, which includes pain, side effects of analgesics, and patient satisfaction, measured daily from the first to the third day after surgery. A non-inferiority margin of 2 was set as the upper limit for the 90% confidence interval of the difference in OBAS score. Mixed-effects modeling was employed to analyze differences in OBAS scores over time. Secondary outcome was the difference in opioid consumption. MAIN RESULTS: Patients were randomized to standard of care (n = 22), or ambulatory continuous popliteal sciatic nerve blockade (n = 22). Analyzing the first three postoperative days, the OBAS was significantly lower over time in the ambulatory continuous popliteal sciatic nerve blockade group compared to standard of care, demonstrating non-inferiority (-1.9 points, 90% CI -3.1 to -0.7). During the first five postoperative days, patients with ambulatory continuous popliteal sciatic nerve blockade consumed significantly fewer opioids over time compared to standard of care (-8.7 oral morphine milligram equivalents; 95% CI -16.1 to -1.4). CONCLUSIONS: Ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care with single shot popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia.

Regional Anesthesia for Arthroscopic Knee Repair in a Patient With Hypertrophic Obstructive Cardiomyopathy (HOCM) Under Monitored Anesthesia Care With Dexmedetomidine Infusion.

Patients with hypertrophic obstructive cardiomyopathy (HOCM) who are scheduled for elective, noncardiac surgery present a distinctive challenge for perioperative healthcare providers. The use of general anesthesia and neuraxial anesthesia carries the risk of unpredictable hemodynamic changes and potential complications. Regional anesthesia (RA) emerges as a prudent and effective option for HOCM patients. RA provides advantages such as minimizing hemodynamic fluctuations, avoiding intubation, reducing pharmacologic side effects, facilitating enhanced recovery after surgery, and contributing to greater patient satisfaction. We share the case of a 15-year-old individual diagnosed with HOCM and exercise intolerance, undergoing arthroscopic repair for right patellar instability. In this instance, the patient received preoperative peripheral nerve blocks for surgical anesthesia and underwent repair utilizing monitored anesthesia care (MAC) with a dexmedetomidine (DEX) infusion.

Periarticular Injection Versus Peripheral Nerve Blockade in Bilateral Total Hip Arthroplasty.

Pain control after total hip arthroplasty is associated with patient satisfaction, early discharge, and improved surgical outcomes. Two commonly utilized opioid-reducing analgesic modalities are periarticular injection (PAI) by surgeons and motor-sparing peripheral nerve block (PNB) by anesthesiologists. We present a case contrasting PAI and PNB in a single patient undergoing bilateral total hip arthroplasty. For the left hip, the patient received preoperative transmuscular quadratus lumborum, femoral nerve, and lateral femoral cutaneous nerve blocks using a combination of low-concentration local anesthetic and glucocorticoids. For the right hip, the patient received an intraoperative PAI with liposomal bupivacaine. The patient's pain scores and recovery were evaluated for three months postoperatively. The patient's pain scores on postoperative day (POD) zero to five were consistently lower in the left hip than in the right hip. For this patient undergoing bilateral hip replacement, preoperative PNBs were superior to PAI for postoperative pain control.

Vasovagal Syncope and Transient Asystole During Peripheral Nerve Blockade.

Vasovagal syncope has been associated with chronic pain procedures, phlebotomy, and musculoskeletal injections. While vasovagal syncope is commonly associated with interventional pain procedures, its occurrence during peripheral nerve block procedures has not been reported. We report a case of vasovagal syncope leading to transient asystole in a patient undergoing a lower extremity peripheral nerve block procedure. The episode resolved after halting the procedure and administering ephedrine, atropine, and intravenous fluids.

Closing the gap: artificial intelligence applied to ultrasound-guided regional anaesthesia.

The role of artificial intelligence in ultrasound-guided regional anaesthesia is explored in a recent study by Bowness and colleagues, published in the British Journal of Anaesthesia. The investigators showed that non-expert ability to identify key sono-anatomical structures was improved with the assistance of proprietary artificial intelligence software. Whether such software could increase learning efficiency, and thereby patient access, to regional anaesthesia, will require further study.

A Practical Guide to Lower Extremity Nerve Blocks for the Sports Medicine Surgeon.

BACKGROUND: Peripheral nerve blocks (PNBs) are vital in the administration of surgical analgesia and have grown in popularity for use in lower extremity arthroscopic procedures because of their capacity to safely and effectively control pain. The number and specificity of PNBs, however, have made choosing the best option for a procedure nebulous for orthopaedic surgeons. PURPOSE: To present a narrative literature review of the PNBs available for arthroscopic hip and knee procedures that is adapted to an audience of orthopaedic surgeons. STUDY DESIGN: Narrative literature review. METHODS: A combination of the names of various lower extremity PNBs AND "hip arthroscopy" OR "knee arthroscopy" was used to search the English medical literature including PubMed, Cochrane Library, ScienceDirect, Embase, and Scopus. Placement technique, specificity of blockade, efficacy, and complications were assessed. Searches were performed through May 2, 2021. RESULTS: A total of 157 studies were included in this review of lower extremity PNBs. Femoral nerve, lumbar plexus, sciatic nerve, and fascia iliaca compartment blocks were most commonly used in arthroscopic hip surgery, while femoral nerve, 3-in-1, and adductor canal blocks were preferred for arthroscopic knee surgery. Each block demonstrated a significant benefit (P > .05) in ≥1 of the following outcomes: intraoperative morphine, pain scores, nausea, and/or opioid consumption. Combination blocks including the lateral femoral cutaneous nerve block, obturator nerve block, quadratus lumborum block, and L1 and L2 paravertebral block have also been described. Complication rates ranged from 0% to 4.8% in those administered with ultrasound guidance. The most commonly reported complications included muscular weakness, postoperative falls, neuropathy, intravascular and intraneural injections, and hematomas. CONCLUSION: When administered properly, PNBs were a safe and effective adjuvant method of pain control with a significant potential to limit postoperative narcotic use. While blockade choice varies by surgeon preference and procedure, all PNBs should be administered with ultrasound guidance, and vigilant protocols for the risk of postoperative falls should be exercised in patients who receive them.

The Use of a New Device-Assisted Needle Guidance versus Conventional Approach to Perform Ultrasound Guided Brachial Plexus Blockade: A Randomized Controlled Study.

Purpose: Ultrasound guidance during nerve blockade poses the challenge of maintaining in-plane alignment of the needle tip. The needle guidance device maintains needle alignment and assists with in-plane needle visualization. The purpose of this study is to evaluate the utility of this device by comparing procedure performance during brachial plexus blockade with the conventional approach. Methods: After the Institutional Review Board approval and obtaining informed consent, 70 patients receiving either interscalene or supraclavicular nerve blocks were randomly assigned into 2 groups, a conventional approach versus utilizing the needle guidance device. An independent observer recorded: total procedure time; needle insertion time; number of unplanned redirections; and number of reinsertions. Additionally, physician satisfaction and ease of needle visualization were assessed. Results: Data from seventy patients were analyzed. The median [25th percentile-75th percentile] time to complete the block by the device assisted needle guidance group was 3 (2-3.75) minutes and 4 (3-6) minutes in the conventional approach group (p < 0.001). Additionally, subgroup analyses were performed in the supraclavicular block and interscalene block. Supraclavicular blockade, needle insertion time (median [25th percentile-75th percentile] in seconds) (106 [92-162] vs 197 [140-278]), total procedure time (3 [2-3] vs 4.5 [4-6] in minutes) and unplanned needle redirections (2 [1-5] vs 5.5 [3-9]) were significantly lower in needle guidance group (p < 0.001). With interscalene blockade, needle insertion time (86 [76-146] vs 126 [94-295]) and unplanned needle redirections (2 [1-3] vs 4 [2-8.5]) were significantly lower with needle guidance (p < 0.001), but total procedure time was similar. All the physicians reported that they would use the needle guidance again, and 90% would prefer it for in-plane blocks. Conclusion: Performing regional blocks using the needle guidance device reduces needle insertion time and unplanned needle redirections in brachial plexus blockade. Moreover, physician satisfaction also improved compared to the use of the conventional technique.

Femoral and sciatic nerve blockade of the pelvic limb with and without obturator nerve block for tibial plateau levelling osteotomy surgery in dogs.

OBJECTIVE: To determine the effect of blocking the obturator nerve in addition to performing femoral nerve and sciatic nerve blocks on intraoperative nociception in dogs undergoing unilateral tibial plateau levelling osteotomy (TPLO) surgery. STUDY DESIGN: Prospective, blinded, randomized, placebo-controlled, clinical comparison. ANIMALS: A total of 88 client-owned dogs undergoing unilateral TPLO surgery (100 procedures). METHODS: Dogs were randomly assigned to either group FSO (femoral, sciatic and obturator nerve blocks) [n = 50; ropivacaine 0.75% (0.75 mg kg-1)] or group FSP (femoral, sciatic and placebo) [n = 50; ropivacaine 0.75% (0.75 mg kg-1) femoral and sciatic nerve blocks plus saline solution 0.9% (0.1 mL kg-1) as a placebo injection around the obturator nerve]. The anaesthetic protocol was standardized. Data collection included intraoperative cardiopulmonary variables and opioid consumption. Rescue analgesia consisted of an intravenous bolus of fentanyl (2 µg kg-1) and was administered when a change in cardiopulmonary variables (20% increase in mean arterial pressure or heart rate) was attributed to a sympathetic stimulus. Data were analysed using generalized linear mixed models, cross tables and multivariable binary logistic regression. Results were expressed as adjusted odds ratios with 95% confidence intervals and Wald p values (α = 0.05). RESULTS: There were no clinically relevant differences between groups in intraoperative cardiopulmonary variables and need for rescue analgesia. The requirement for rescue analgesia was significantly higher in dogs with a body weight >34 kg. CONCLUSIONS AND CLINICAL RELEVANCE: Anaesthesia of the obturator nerve in addition to the femoral and sciatic nerves was not associated with clinically significant differences in cardiopulmonary variables or a reduced need for rescue analgesia. Therefore, the clinical benefit of an additional obturator nerve block for intraoperative antinociception in dogs undergoing unilateral TPLO surgery using the described anaesthetic regimen is low.

Swedish Web Version of the Quality of Recovery Scale Adapted for Patients Undergoing Local Anesthesia and Peripheral Nerve Blockade (SwQoR-LA): Prospective Psychometric Evaluation Study.

BACKGROUND: The frequency and timing of assessing patient symptoms and discomfort during postoperative recovery are goals. Therefore, real-time recovery evaluation has been suggested to identify specific deficits in patient recovery. OBJECTIVE: This study aimed to psychometrically evaluate the Swedish Web Version of the Quality of Recovery (SwQoR) Scale adapted for patients undergoing local and peripheral nerve block (SwQoR-LA). METHODS: This was a secondary analysis of a psychometric evaluation of 107 patients aged ≥18 years undergoing day surgery under local or peripheral nerve block anesthesia at 4 different day surgery departments in Sweden. The SwQoR-LA, available through a mobile app called Recovery Assessment by Phone Points (RAPP), was completed daily on postoperative days 1-7. RESULTS: Some evidence of construct validity was supported, and discriminant validity was found in 7 of 8 items related to general anesthesia. The internal consistency was acceptable (.87-.89), and the split-half reliability was 0.80-0.86. Cohen d effect size was 0.98, and the percentage of change from baseline was 43.4%. No floor nor ceiling effects were found. CONCLUSIONS: The SwQoR-LA is valid, reliable, responsive, and clinically feasible for digital real-time recovery assessment of patient recovery to identify specific deficits in patient recovery and detect those patients who might benefit from a timely intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT02492191; https://clinicaltrials.gov/ct2/show/NCT02492191. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2015-009901.

New composite scale for evaluating peripheral nerve block quality in upper limb orthopaedics surgery.

INTRODUCTION: Developments in ultrasound guided (UG) peripheral nerve block (PNB) techniques have significant advantages for patients undergoing trauma surgery. Brachial plexus blockade (BPB) for upper extremity surgery provide superior analgesia, improve recovery and patient satisfaction. To the best of our knowledge there is no tool for evaluation of the quality of UG PNB which concerns the quality of PNB, the tolerance of the patient towards the anaesthetic approach, and postoperative analgesia as well. PATIENTS AND METHODS: Standardized UG BPB anaesthesia - was performed; interscalene-supraclavicular (ISC-SC) and axillary-supraclavicular (AX-SC) approach for upper limb surgery. A GCS like tool was developed with which the Sensory, Motor, Coping of patient and Postoperative (SMCP) pain qualities were measured. The quality of PNBs were evaluated by a quality of anaesthesia graded by anaesthesiologist (QAGA) and the SMCP scale as well, the means of midazolam and opioid consumption during surgery, vital parameters, postoperative pain intensity (VNRS) were compared between the two groups. RESULTS: Ninety three unpremedicated adult patients with ASA I-III were scheduled for unilateral upper limb surgery. Nearly the same mean volumes of local anaesthetic solution were used in the AX-SC and ISC-SC groups (28.3-31.0 ml). There were no significant difference in the quality of PNB measured by QAGA or SMCP scale between the AX-SC and the ISC-SC groups, however 75 patients were assessed as Excellent with the SMCP scale vs. 39 with the QAGA. 97.8% of the patients were in the Excellent and Good category evaluated with SMPC vs. 86% with QAGA (p < 0.001). There was no surgery abandoned due to failed PNB and no tourniquet pain was detected. There was no evidence of side effects or complications of PNB during the follow-up period. DISCUSSION: This composite tool is designed for evaluating the loss of sensory and motor function; the coping of the patient and the postoperative pain as well. Our novel SMCP evaluation tool focuses on the overall condition of the patient during surgery and in the postoperative period. This more precise outcome evaluating scale is significantly superior to the formerly used QAGA in representing the high success rate of UG PNB.

Short-term Outcomes in Pediatric Patients Managed with Peripheral Nerve Blockade for Arthroscopic Anterior Cruciate Ligament Reconstruction and/or Meniscus Surgeries.

Introduction Peripheral nerve blockade (PNB) can be a useful component of a multimodal analgesia approach in managing pain after knee arthroscopy. However, the impact of PNB and short-term recovery in pediatric patients, particularly adolescents, who underwent knee arthroscopy for anterior cruciate ligament (ACL) reconstruction and/or meniscus surgery (repair or resection) has not been well characterized. This prospective study presents observational data on short-term patient outcomes and side effects for 72 hours following discharging home of pediatric patients who underwent arthroscopic ACL and/or meniscus procedures with PNB. Methods This is a single-center, single-surgeon prospective observational study conducted over a three-year period. We characterized 72-hour postoperative outcomes including pain scores, return of sensation to the affected limb, analgesic use [nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids], readmission rate, and activities of daily living (ADL) via telephone survey. In addition, retrospective chart review was conducted to obtain perioperative and anesthesia details. Results for surgery groups were analyzed using descriptive and Pearson correlations using the SPSS version 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Mac, Version 24.0. Armonk, NY, USA). Results We collected data on 47 patients undergoing ACL reconstruction with or without meniscus surgery (18/47, 38.3%) or meniscus surgery only (29/47, 61.7%). At 72 hours postsurgery, there were no readmissions or complications related to pain. Median-reported pain scores were 2.5 and 5.0 for the ACL and meniscus groups, respectively. A majority of patients continued to require opioids (45/47, 95.7%) and NSAIDs (46/47, 97.9%) at 72 hours postsurgery, but the number of daily opioid doses taken decreased with each day postoperatively. Over 93% of the patients could ambulate and shower at 72 hours postsurgery. Conclusions Regional nerve block appears to be an effective and safe analgesic strategy for pediatric arthroscopic ACL and meniscus procedures, with no short-term complications or readmissions related to pain in our cohort. Future prospective investigation is needed to characterize long-term pain outcomes in this surgical population.

Massive Lymphedema Necessitating Disarticulation of Shoulder Joint Following Treatment for Carcinoma Breast.

We report a case of massive upper-limb edema necessitating disarticulation, in a cancer survivor who tended to ignore instructions regarding preventive exercises since 2002 after completion of her treatment for breast cancer. However, she was in a family situation where she was constrained to physically involve in daily chores. Consequently, she presented 14 years later with a lymphedematous arm which weighed over 31 kg, necessitating disarticulation. We highlight the role of preventive exercises in postmastectomy patients and also the efficacy of continuous nerve block techniques in preventing the development of phantom limb pain in cases of disarticulation and amputation. The role of family support for a working female cancer survivor in a country like India needs to be addressed. We salute her commitment to her family as also her grit and determination. Shoulder disarticulation was the last choice for this woman. We also want to highlight the role of the community in monitoring and preventing such disasters.

Pediatric Ambulatory Continuous Peripheral Nerve Blocks.

Despite the widespread use of ambulatory continuous peripheral nerve blocks in adults, its use in children has been sporadic. Indications for the use of ambulatory continuous peripheral nerve block in children involve orthopedic procedure, where significant pain is anticipated beyond 24 hours. Techniques to place the perineural catheters in children are similar to that used in adults. The incidence of serious side effects in pediatric ambulatory continuous peripheral nerve block is extremely rare. When this is combined with the potential to increase patient and family satisfaction and decrease opioid-related side effects, ambulatory continuous peripheral nerve block become a compelling choice.

A comparative analysis of femoral nerve block with adductor canal block following total knee arthroplasty: A systematic literature review.

BACKGROUND: Patients undergoing total knee arthroplasty suffer from moderate-to-severe postoperative pain resulting in immobility-related complications and prolonged hospitalization. Femoral nerve block is associated with reduction in the quadriceps strength and increasing incidence of falls. Adductor canal block has been shown to be as effective as femoral nerve block without causing quadriceps weakness. OBJECTIVES: To compare outcomes of studies comparing adductor canal block and femoral nerve block in patients undergoing primary total knee arthroplasty. DATA SOURCES: Original articles, published between July 2013 and April 2017, comparing the above interventions. STUDY ELIGIBILITY CRITERIA PARTICIPANTS AND INTERVENTIONS: Comparison of outcome measures of all original articles shortlisted by the PUBMED and Google Scholar databases search using key words, "adductor canal block; femoral nerve block; total knee arthroplasty; total knee replacement." STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome measures reviewed were: pain scores; interventional failure; post-operative opioid consumption; patient fall or near fall during postoperative rehabilitation; and length of stay. RESULTS: The opioid consumption was found to be comparable with both the interventions on the first and second postoperative day. Patients administered adductor canal block had better quadriceps power, longer ambulation distance, and shorter length of hospital stay. LIMITATIONS: Of the studies reviewed five were retrospective and thus data quality amongst the studies may have been compromised. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS: Mobilization and ambulation, which are both important for recovery after total knee arthroplasty are both inhibited less by adductor canal block.

The effect of metrics-based feedback on acquisition of sonographic skills relevant to performance of ultrasound-guided axillary brachial plexus block.

The objective of this study was to examine the effect of metrics-based vs. non-metrics-based feedback on novices learning predefined competencies for acquisition and interpretation of sonographic images relevant to performance of ultrasound-guided axillary brachial plexus block. Twelve anaesthetic trainees were randomly assigned to either metrics-based-feedback or non-metrics-based feedback groups. After a common learning phase, all participants attempted to perform a predefined task that involved scanning the left axilla of a single volunteer. Following completion of the task, all participants in each group received feedback from a different expert in regional blocks (consultant anaesthetist) and were allowed to practise the predefined task for up to 1 h. Those in the metrics-based feedback group received feedback based on previously validated metrics, and they practised each metric item until it was performed satisfactorily, as assessed by the supervising consultant. Subsequently, each participant attempted to perform ultrasonography of the left axilla on the same volunteer. Two trained consultant anaesthetists independently scored the video recording pre- and post-feedback scans using the validated metrics list. Both groups showed improvement from pre-feedback to post-feedback scores. Compared with participants in the non-metrics-based feedback group, those in the metrics-based feedback group completed more steps: median (IQR [range]) 18.8 (1.5 [17-20]) vs. 14.3 (4.5 [11-18.5]), p = 0.009, and made fewer errors 0.5 (1 [0-1.5]) vs. 1.5 (2 [1-6]), p = 0.041 postfeedback. In this study, novices' sonographic skills showed greater improvement when feedback was combined with validated metrics.

Surgical site infection related to use of elastomeric pumps in pectus excavatum repair. Lessons learned from root cause analysis.

BACKGROUND: Pectus excavatum repair (PEX) is among the most painful thoracic procedures performed. Continuous peripheral nerve blockade (CPNB) is known to be efficacious in optimizing pain control while limiting narcotic use in adult thoracic procedures. It was introduced in May 2015 as a bridge to oral pain control in children undergoing PEX. Consequently, the surgical site infection (SSI) rate increased from 2.7% to 27.7%. METHODS: SSI surveillance followed national guidelines. The abrupt increase prompted root cause analysis and cessation of CPNB use. A dynamic systems model of SSI in PEX was developed. Statistical analysis compared SSI outcomes with and without CPNB. RESULTS: From May 2015 to June 2015, 21 PEX were performed; 11 with CPNB. 6 SSIs were observed. Use of CPNB significantly (p=0.008) increased SSI incidence. Haller index, number of bars, usage of Fiberwire®, methicillin resistant S. aureus colonization and length of stay did not differ. Root cause analysis revealed the proximity of CPNB catheters to the wound, the use of CPNB with implanted hardware and a delayed utilization of CPNB catheters to be of concern. CONCLUSION: Introduction of CPNB coincided with a significant increase in SSI. Further study is needed to assess the safety of CPNB in pediatric PEX. LEVEL OF EVIDENCE: Level III treatment study.

Dexmedetomidine Added to Local Anesthetic Mixture of Lidocaine and Ropivacaine Enhances Onset and Prolongs Duration of a Popliteal Approach to Sciatic Nerve Blockade.

PURPOSE: A literature review of multiple clinical studies on mixing additives to improve pharmacologic limitation of local anesthetics during peripheral nerve blockade revealed inconsistency in success rates and various adverse effects. Animal research on dexmedetomidine as an adjuvant on the other hand has promising results, with evidence of minimum unwanted results. This randomized, double-blinded, contrastable observational study examined the efficacy of adding dexmedetomidine to a mixture of lidocaine plus ropivacaine during popliteal sciatic nerve blockade (PSNB). METHODS: Sixty patients undergoing varicose saphenous vein resection using ultrasonography-guided PSNB along with femoral and obturator nerve blocks as surgical anesthesia were enrolled. All received standardized femoral and obturator nerve blocks, and the PSNB group was randomized to receive either 0.5 mL (50 µg) of dexmedetomidine (DL group) or 0.5 mL of saline (SL group) together with 2% lidocaine (9.5 mL) plus 0.75% ropovacaine (10 mL). Sensory onset and duration of lateral sural cutaneous nerve, sural nerve, superficial peroneal nerve, deep peroneal nerve, lateral plantar nerve, and medial plantar nerve were recorded. Motor onset and duration of tibial nerve and common peroneal nerve were also examined. FINDINGS: Sensory onset of sural nerve, superficial peroneal nerve, lateral plantar nerve, and medial plantar nerve was significantly quicker in the DL group than in the SL group (P < 0.05). Sensory onset of lateral sural cutaneous nerve and deep peroneal nerve was not statistically different between the groups (P > 0.05). Motor onset of tibial nerve and common peroneal nerve was faster in the DL group than in in the SL group (P < 0.05). Duration of both sensory and motor blockade was significantly longer in the DL group than in the SL group (P < 0.05). IMPLICATIONS: Perineural dexmedetomidine added to lidocaine and ropivacaine enhanced efficacy of popliteal approach to sciatic nerve blockade with faster onset and longer duration.

Femoral and sciatic nerve blockades and incision site infiltration in rabbits undergoing stifle joint arthrotomy.

This study was designed to determine whether perineural injections of local anaesthetics decreases intraoperative nociception and improves postoperative analgesia in New Zealand White rabbits undergoing experimental stifle arthrotomy. All animals were anaesthetized using isoflurane and received morphine intramuscularly. The sciatic and femoral nerves of the leg to be operated on were located using a nerve stimulator (1 Hz, 0.5 mA). Rabbits were assigned to a treatment group (LB; n = 12) or a placebo group (P; n = 12) in a randomized blinded fashion. Group LB received lidocaine 2% (1 mg/kg) combined with bupivacaine 0.5% (0.25 mg/kg) injections around the sciatic and femoral nerves (0.1 mL/kg total volume per site) and subcutaneous infiltration of the incision site with lidocaine 1% (1.25 mg/kg). Group P received the same volume of 0.9% NaCl. Rabbits in group P required higher doses of intraoperative fentanyl and propofol to reduce heart rate and suppress increase in systolic blood pressure, and maintain an adequate anaesthetic plane. Interventional analgesia (buprenorphine and carprofen) was required significantly earlier in rabbits in group P (2 and 6 h after the first nerve blockade, respectively) based on assessment of their pain-related behaviour and range of motion. Using a visual analogue scale (0 mm= no pain to 100 mm= maximal possible pain), rabbits in group LB were judged to show significantly less pain compared with rabbits in group P (14 ± 10 mm and 37 ± 25 mm, respectively) 2 h after nerve blockade. In conclusion, this technique of perineural analgesia combined with incision site infiltration reduced intraoperative fentanyl requirements and improved postoperative analgesia in rabbits.

An electronic surgical order, undertaking patient education, and obtaining informed consent for regional analgesia before the day of surgery reduce block-related delays.

BACKGROUND: Obtaining patient informed consent for a regional analgesia block on the day of surgery can result in surgical case delays. We hypothesized that implementing a preoperative electronic surgical order, undertaking patient education, and obtaining informed consent for a regional block in our preoperative assessment clinic prior to the day of surgery would reduce surgical case delays attributed to our regional anesthesia pain service and increase the percentage of patients for whom our regional anesthesia pain service was requested to provide a block. METHODS: A prospective two-group time-series design, with a nonrandomized, pre- and post-intervention data collection strategy, was applied. Based upon the surgeons' newly implemented preoperative electronic outpatient orders, patients were identified by our preoperative assessment clinic staff to receive educational materials. The attending anesthesiologist in the preoperative assessment clinic then obtained written informed consent. Block-related delay and utilization data were analyzed with conventional inferential statistics. RESULTS: We observed a 14.8% (95% CI: 9.4%, 20.1%; P<0.001) decrease in surgical case delays, attributed to the regional nerve block, in the post- vs pre-intervention group. In addition, there was a 9.9% (95% CI: 4.7%, 15.1%); P<0.001) increase in the proportion of patients for whom a regional nerve block was ordered by our three high-volume orthopedic surgeons in the post- vs pre-intervention time periods. CONCLUSION: When performed before the day of surgery, a surgeon's electronic order, patient education, and informed consent for regional postoperative analgesia can improve patient throughput, thereby reducing block-related operating room delays. The preoperative assessment clinic can serve as a venue to achieve this goal, thereby adding value by decreasing downstream delays on the day of surgery.

Local Infiltration Analgesia Versus Continuous Femoral Nerve Block in Pain Relief After Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Although both local infiltration analgesia (LIA) and continuous femoral nerve block (FNB) are common analgesic modalities for pain relief after total knee arthroplasty (TKA), we are aware of no parallel-group, randomized controlled trial that has solely compared the efficacy of LIA and continuous FNB. METHODS: We conducted a prospective, 2-arm, parallel-group, randomized controlled trial involving patients scheduled for TKA. A total of 45 patients were randomly assigned to either the LIA or the continuous FNB group. Except for the analgesic modality, perioperative managements were identical in both groups. The primary outcome was postoperative pain score at rest 1 day after surgery, measured using a 100-mm visual analog scale. RESULTS: Patients in the LIA group had a significantly lower visual analog scale score at rest 1 day after surgery than those in the continuous FNB group (34 ± 10 vs 42 ± 13 mm; P = .028). The opioid consumption during the initial 24 hours was significantly lower in the LIA group (12 ± 4 vs 16 ± 7 mg; P = .031). There were no differences in the rate of complications between the groups. CONCLUSION: LIA was associated with better pain relief with a comparable complications rate for patients undergoing TKA than FNB. We recommend LIA for pain relief after TKA.