Ultrasound-guided suprainguinal fascia iliaca compartment block and early postoperative analgesia after total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Hip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy. METHODS: Consenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness. RESULTS: There were no significant differences in 24-h opioid consumption (block vs sham block, mean difference -3.2 mg oral morphine equivalent, 95% confidence interval -15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes. CONCLUSIONS: In patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov (NCT03069183).

Comparison of the Analgesic Duration of 0.5% Bupivacaine With 1:200,000 Epinephrine Versus 0.5% Ropivacaine Versus 1% Ropivacaine for Low-Volume Ultrasound-Guided Interscalene Brachial Plexus Block: A Randomized Controlled Trial.

BACKGROUND: Bupivacaine and ropivacaine are the preferred long-acting local anesthetics for peripheral nerve blocks as they provide prolonged analgesia in the postoperative period. No studies have directly compared the analgesic duration of these commonly used local anesthetics in the setting of low-volume ultrasound-guided interscalene block (US-ISB). This study was designed to determine which local anesthetic and concentration provides superior analgesia (duration and quality) for low-volume US-ISB. METHODS: Sixty eligible patients scheduled for arthroscopic shoulder surgery were randomized (1:1:1) to receive US-ISB (5 mL) with 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine. All individuals were blinded including study participants, anesthesiologists, surgeons, research personnel, and statistician. All participants received a standardized general anesthetic and multimodal analgesia. The primary outcome was duration of analgesia defined as the time from the end of injection to the time that the patients reported a significant increase in pain (>3 numeric rating scale [NRS]) at the surgical site. RESULTS: The mean duration of analgesia for 0.5% bupivacaine with 1:200,000 epinephrine, 0.5% ropivacaine, or 1% ropivacaine was 14.1 ± 7.4, 13.8 ± 4.5, and 15.8 ± 6.3 hours, respectively (analysis of variance [ANOVA], P = .51). There were no observed differences in analgesic duration or other secondary outcomes between the 3 groups with the exception of a difference in cumulative opioid consumption up to 20h00 on the day of surgery in favor of ropivacaine 0.5% over bupivacaine of minimal clinical significance. CONCLUSIONS: In the context of single-injection low-volume US-ISB, we have demonstrated a similar efficacy between equal concentrations of ropivacaine and bupivacaine. In addition, increasing the concentration of ropivacaine from 0.5% to 1% did not prolong the duration of US-ISB.

Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial.

BACKGROUND: Efforts to prolong interscalene block (ISB) analgesia include the use of local anaesthetic adjuvants such as dexamethasone. Previous work showing prolonged block duration suggests that both perineural and intravenous (i.v.) routes can both prolong analgesia. The superiority of either route is controversial given the design of previous studies. As perineural dexamethasone is an off-label use, anaesthesiologists should be fully informed of the clinical differences, if any, on block duration. This study was designed to test whether perineural vs i.v. dexamethasone administration are equivalent. METHODS: We randomised 182 eligible patients scheduled for arthroscopic shoulder surgery to receive low-dose ISB (0.5% ropivacaine 5 ml) with perineural or i.v. dexamethasone 4 mg. Subjects, anaesthesiologists, and research personnel were blinded. All subjects also received a standardised general anaesthetic and multimodal analgesia. The primary outcome was duration of analgesia analysed as an equivalence outcome (2 h equivalency margin) using the two one-sided test (TOST) method. RESULTS: For the primary outcome, duration of analgesia, and perineural and i.v. administration of dexamethasone were not equivalent. The upper and lower bounds of the 90% confidence interval were 1 h (P=0.12) and -2.5 h (P=0.01), respectively. The observed difference in mean block duration was not clinically relevant (0.75 h longer for i.v. dexamethasone). There were no other clinically significant differences between groups. CONCLUSION: In the context of low-volume ISB with ropivacaine, perineural and i.v. dexamethasone were not equivalent in terms of their effects on block duration. However, there were no clinically significant differences in outcomes, and there is no advantage of perineural over intravenous dexamethasone. WWW.CLINICALTRIALS. GOV REGISTRATION: NCT02322242.

Medial Open Transversus Abdominis Plane (MOTAP) Catheters Reduce Opioid Requirements and Improve Pain Control Following Open Liver Resection: A Multicenter, Blinded, Randomized Controlled Trial.

OBJECTIVE: Conventional management of pain following open liver resection involves intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. The objective of this trial was to assess the efficacy of a regional technique called Medial Open Transversus Abdominis Plane (MOTAP) catheter analgesia compared with IV PCA. METHODS: This was a blinded, randomized, controlled parallel-arm trial conducted at 2 high-volume centers. Patients undergoing liver resection through a subcostal incision were enrolled. Using a standardized technique, 2 catheters were placed after resection: one in the plane between internal oblique and transversus abdominis and the other in the posterior rectus sheath. Patients were randomized to receive ropivacaine 0.2% (ROP) or saline (NS) through both catheters for 72 hours. All patients received IV PCA with hydromorphone as part of a multimodality analgesia program. Primary outcome was opioid use over the first 48 hours. RESULTS: One hundred fifty-three patients were included in the analysis (71 ROP, 82 NS). Patients receiving ROP used significantly less opioid than patients with NS at 48 hours (median 39.6 mg morphine-equivalent vs 49.2 mg, P = 0.033) and at 72 hours (median 50.0 vs 66.4 mg, P = 0.046). Pain scores at rest and with coughing were significantly lower at all time points in patients who received ROP (P = 0.002). Median length of hospital stay was 5 days in patients receiving ROP and 6 days in patients who received NS (P = 0.035). There was no difference between groups in complications [ROP 20 (28.2%) vs NS 26 (31.7%), P = 0.63]. CONCLUSION: MOTAP catheter analgesia reduces opioid requirements, pain, and length of hospital stay compared with IV PCA following open liver resection with subcostal incisions.

Analysis of Inpatient Falls After Total Knee Arthroplasty in Patients With Continuous Femoral Nerve Block.

Continuous femoral nerve block (cFNB) is thought to increase the risk of falls after total knee arthroplasty (TKA). Previous studies have failed to consider the timing of cFNB removal in relation to inpatient falls. We investigated all inpatient falls after TKA over a 3-year period using our institutional safety report database. Ninety-five falls were reported from a total of 3745 patients. The frequency of falls after TKA persisted at a similar rate despite removal of cFNB and likely regression of femoral nerve block. Other modifiable risk factors may play a more prominent role in falls risk after TKA.

Randomized control trial of a holographic needle guidance technique for thoracic epidural placement.

INTRODUCTION: The Microsoft HoloLens is a head-mounted mixed reality device, which allows for overlaying hologram-like computer-generated elements onto the real world. This technology can be combined with preprocedural ultrasound during thoracic epidural placement to create a visual of the ideal needle angulation and trajectory in the users' field of view. This could result in a technically easier and potentially safer alternative to traditional blind landmark techniques. METHODS: Patients were randomly assigned to one of two groups: (1) HoloLens-assisted thoracic epidural technique (intervention-group H) or (2) traditional thoracic epidural technique (control-group C). The primary outcome was needling time (defined as skin puncture to insertion of epidural catheter) during the procedure. The secondary outcomes were number of needle punctures, number of needle movements, number of bone contacts, and epidural failure. Procedural pain and recovery room pain levels were also evaluated. RESULTS: Eighty-three patients were included in this study. The primary outcome of procedure time was reduced in the HoloLens group compared with control (4.5 min vs 7.3 min, p=0.02, 95% CI), as was the number of needle movements required (7.2 vs 14.4, p=0.01), respectively. There was no difference in intraprocedure or postprocedure pain, bone contacts, or total number of needle punctures. Three patients in the control group experienced epidural failure versus one patient in the HoloLens group. CONCLUSIONS: This study shows that thoracic epidural placement may be facilitated by using a guidance hologram and may be more technically efficient. TRIAL REGISTRATION NUMBER: NCT04028284.

Genicular nerve and fracture site chemical neurolysis for distal femoral fracture: a case report.

BACKGROUND: Distal femur fractures account for approximately 3%-6% of all femoral fractures. Non-operative management may be an attractive option for the elderly with significant perioperative mortality risk. Adequate pain control is a major barrier to non-operative fracture management. Chemical neurolysis has been described for analgesic management of proximal hip fractures, however no description of interventional management of distal femur fracture exists in literature. We describe a case of phenol chemical neurolysis of genicular nerves in addition to injection at the site of fracture to provide effective analgesia for distal femur fracture. CASE PRESENTATION: A patient in their 90s with a witnessed mechanical fall sustained an intra-articular displaced fracture of the distal right femur shaft with extension into the distal femoral condyle. The patient elected to undergo non-surgical management given the high perioperative mortality risk. Acute pain service was involved and multimodal oral analgesics including opioids were insufficient in managing the patient's pain. The addition of femoral nerve catheter local anesthetic infusion did not sufficiently improve analgesia. Phenol chemical neurolysis of the superolateral, superomedial, inferomedial genicular nerves and of the fracture site was offered and performed. Resting pain decreased from Numerical Rating Scale 5/10 to 0/10 on postprocedure day 1. This was sustained at the 2-month timepoint. CONCLUSIONS: We report the successful use of phenol neurolysis of genicular nerves and the fracture site in an elderly patient with a conservatively managed distal femur fracture. These interventions resulted in improved analgesia and achieved prolonged duration of effect.

Novel use of continuous pericapsular nerve group (PENG) block technique for traumatic superior and inferior pubic rami fractures: a case report.

BACKGROUND: Pubic rami fractures are painful injuries more commonly seen in the elderly with osteoporosis after high velocity trauma. In the most cases, management is conservative and non-operative with the goal to provide optimal pain relief to facilitate early mobilization and hospital discharge. Unfortunately, opioids remain the mainstay analgesic option and regional anesthesia techniques are limited but may include lumbar epidural anesthesia. CASE PRESENTATION: A female patient in her 80s presented to the emergency department of a level 1 trauma center following a high-speed motor vehicle collision. The patient suffered multiple non-life-threatening injuries. Notably, the patient was experiencing severe right groin and leg pain secondary to superior and inferior pubic rami fractures. Due to the severity of this pain, the patient was unable to mobilize or participate with physiotherapy. A lumbar epidural anesthesia technique was not deemed suitable and instead, we inserted a continuous pericapsular nerve group (PENG) block with a programmed intermittent bolus regimen. Immediate relief of pain was achieved and 48 hours later, the patient still reported satisfactory pain control and started to independently mobilize. CONCLUSION: Analgesia options are limited in pubic rami fractures. We present the first published case of a novel use of the PENG block with a continuous catheter technique for the analgesic management of a traumatic superior and inferior pubic rami fracture. The clinical utility of this technique in pubic ramus fractures warrants further clinical investigation.

Development of a Head-Mounted Holographic Needle Guidance System for Enhanced Ultrasound-Guided Neuraxial Anesthesia: System Development and Observational Evaluation.

BACKGROUND: Neuraxial anesthesia is conventionally performed using a landmark-based technique. Preprocedural ultrasound is often used in challenging clinical scenarios to identify an ideal needle path. The procedure is then carried out by the operator recreating the ultrasound needle path from memory. We suggest that a needle guidance system using the Microsoft HoloLens mixed reality headset, which projects a hologram of the ideal needle path, can assist operators in replicating the correct needle angulation and result in fewer needle passes. OBJECTIVE: The objective of the study was to develop software for the mixed reality HoloLens headset, which could be used to augment the performance of neuraxial anesthesia, and establish its face validity in lumbar spine phantom models. METHODS: We developed an ultrasound transducer marker and software for the HoloLens, which registers the position and angulation of the ultrasound transducer during preprocedural scans. Once an image of a clear path from skin to the intrathecal space is acquired, a hologram of the ideal needle path is projected onto the user's visual field. The ultrasound probe is removed while the hologram remains in the correct spatial position to visualize the needle trajectory during the procedure as if conducting real-time ultrasound. User testing was performed using a lumbar spine phantom. RESULTS: Preliminary work demonstrates that novice (2 anesthesia residents) and experienced operators (5 attending anesthesiologists) can rapidly learn to use mixed reality holograms to perform neuraxial anesthesia on lumbar spine phantoms. CONCLUSIONS: Our study shows promising results for performing neuraxial anesthesia in phantoms using the HoloLens. Although this may have wide-ranging implications for image-guided therapies, further study is required to quantify the accuracy and safety benefit of using holographic guidance. TRIAL REGISTRATION: ClinicalTrials.gov NCT04028284; https://clinicaltrials.gov/ct2/show/NCT04028284.

Pulsed radiofrequency under ultrasound guidance for persistent stump-neuroma pain.

Limb amputation is a leading cause of pain and disability. Limb amputation can be associated with a myriad of symptoms, including phantom limb sensation, phantom limb pain, and stump pain. Treatment of phantom limb pain and stump pain, remains difficult, therefore optimal management must include a multidisciplinary approach. This case report describes the use of ultrasound for diagnosis and successful management, of persistent stump-neuroma pain, using pulsed radiofrequency ablation.

Posterior interscalene block: an ultrasound-guided case series and overview of history, anatomy and techniques.

BACKGROUND: The posterior interscalene block has been described as an alternative to the lateral interscalene block. However, this technique has not gained popularity because of the close proximity of the approach to vascular and central neural structures. OBJECTIVE: To describe the posterior interscalene block technique using ultrasound imaging, and to review the history of its evolution. METHODS: The use of ultrasound imaging to facilitate the insertion of interscalene catheters using the posterior approach in 11 patients undergoing total shoulder arthroplasty is described. RESULTS: All 11 patients had satisfactory analgesia in the first 24 h of the postoperative period. None of the patients complained of neck pain, as had been found in earlier techniques using the posterior approach. CONCLUSIONS: This modification of the posterior approach is a safe and effective method for the insertion of interscalene brachial plexus catheters. These catheters are also comfortable for patients and, in the present study, none of the catheters inadvertently fell out.

Ultrasound detection of iatrogenic injury during peribulbar eye block: a cadaveric study.

BACKGROUND: Ophthalmic eye blocks, such as retrobulbar, peribulbar and sub-Tenon's, are traditionally conducted "blind". Complications are rare but potentially devastating. Life-threatening complications include brain stem anesthesia and local anesthetic toxicity, whereas sight-threatening complications include globe perforation, optic nerve damage and ocular muscle damage. Ultrasound permits a view of orbital structures and can be used to guide needle placement. The ultrasound appearances of unintended local anesthetic injection into vital orbital structures have not been documented. This study aimed to record the ultrasound appearances of unintended injection locations. METHODS: The spherical shape of the eyeballs of three soft-fix Thiel embalmed human cadavers were restored using glycerol. Iatrogenic injury in peribulbar block was then simulated through injection of printers' ink mixed with Thiel embalming fluid. Ultrasound was used to guide the needles and the tips were redirected to lie within the globe, lateral rectus and optic nerve. Ultrasound images were recorded during injection. The orbital cavities were then dissected via a superior approach to record the location and extent of injectate spread. RESULTS: Real-time globe rupture, ocular muscle injection and optic nerve injection were visible using ultrasound. Characteristic appearances were identified in each case. Dissection confirmed needle and injection placement. CONCLUSIONS: The ultrasound appearance of block complications is important to document and should be an integral part of regional anesthesia training. This study is the first to provide such images for ophthalmic nerve blocks. It offers ophthalmic anesthetists and ophthalmologists the potential to diagnose severe complications rapidly and accurately with a potential impact on patient safety.

In-hospital opioid consumption, but not pain intensity scores, predicts 6-month levels of pain catastrophizing following hepatic resection: A trajectory analysis.

BACKGROUND: The study aims were to model acute pain intensity and opioid consumption trajectories up to 72 hr after open hepatic resection, identify predictors of trajectory membership and examine the association between trajectory memberships and 6-month pain and psychological outcomes. This is a long-term analysis of a published randomized controlled trial on the impact of medial open transversus abdominis plane catheters on post-operative outcomes. METHODS: A total of 152 patients (89 males; mean age 63.0 [range: 54-72]) completed questionnaires on pain and related characteristics pre-operatively and 6 months post-operatively. Total opioid use was recorded several times over a 72-hr period while self-reported pain intensity scores were collected multiple times until hospital discharge. Analyses were carried out using growth mixture modelling, logistic regression and general linear models. RESULTS: Both pain intensity and opioid consumption showed that a four-trajectory model best fits the data. Patients in the lowest opioid consumption trajectory were more likely to be classified in the constant mild pain intensity trajectory. Age and baseline levels of anxiety significantly predicted opioid trajectory membership while baseline depressive symptoms significantly predicted pain intensity trajectory membership. Patients in the two highest opioid consumption trajectories reported significantly higher levels of pain catastrophizing at 6 months compared to patients in the other 3 trajectories (all p < 0.05). CONCLUSION: High consumption of opioids after surgery is associated with higher levels of pain catastrophizing 6 months later. Identification of patients within these trajectories may lead to the development of early interventions targeted to high risk individuals. SIGNIFICANCE: Differences in initial levels of opioid consumption and rates of change in opioid consumption shortly after surgery can help predict long-term psychological responses to pain. Identifying key characteristics associated with initial opioid consumption can lead to the development of cost-effective early interventions targeted to high risk individuals.

Thoracic Epidural Catheter Placement in a Preoperative Block Area Improves Operating Room Efficiency and Decreases Epidural Failure Rate.

BACKGROUND AND OBJECTIVES: The primary aim of this study was to review the impact of inserting thoracic epidural catheters in a preoperative block room setting on operating room efficiency. METHODS: We conducted a retrospective preintervention/postintervention review of thoracic epidurals inserted over a 12-month period. The review included 6 months of data prior to implementation of the regional anesthesia block room and 6 months of data following implementation. The primary outcome measure was anesthesia-controlled operating room time, defined as time from patient arrival to the operating room to time of surgical site sterile preparation. Secondary measures included operating room waiting time for the patient arrival, thoracic epidural failure rate, and number of epidural insertion attempts. RESULTS: Data from thoracic epidurals for 112 patients of preblock room and 142 patients of postblock room implementation were collected. Anesthesia-controlled operating room time was reduced by an average of 22.9 minutes per patient (95% confidence interval, 19.3-26.3 minutes; P < 0.01). Average operating room waiting time for patient arrival increased by 3.8 minutes (95% confidence interval, 1.0-6.5 minutes; P < 0.01), resulting in net operating room time savings of 19.1 minutes per epidural. The epidural failure rate decreased from 16.0% to 5.6% (P < 0.01). There was no difference in the number of epidural insertion attempts made per patient. CONCLUSIONS: Insertion of thoracic epidural analgesia in a preoperative block room setting can significantly reduce anesthesia-controlled operating room time and epidural failure rates.

The minimal effective volume (MEAV 95) for interscalene brachial plexus block for surgical anesthesia under sedation: A prospective observational dose finding study.

Background: Interscalene brachial plexus (ISB) block is routinely used to provide anesthesia and analgesia for shoulder surgery. Traditional local anesthetic volumes for ISB result in near universal ipsilateral phrenic nerve paresis potentially including oxygenation and ventilation. Aims: The purpose of this study was to determine the lowest minimal effective anesthetic volume in 95% of patients (MEAV 95) of ropivacaine 0.75% for ISB that provides surgical anesthesia for arthroscopic shoulder surgery. Methods: Prospective observational cohort study in patients undergoing arthroscopic shoulder surgery under ISB (C6 level) with sedation. The dose finding protocol used the Narayana rule for up/down sequential allocation to estimate the MEAV 95 of ropivacaine 0.75%. Successful ISB was defined as complete absence of pinprick sensation in the C5 and C6 dermatomes 30 min postblock. Secondary outcomes assessed included ability to complete surgery with propofol sedation, change in slow vital capacity, room air oxygen saturation postblock, block duration, ISB complications, and numeric rating scale for pain immediately after surgery. Results: The study was stopped early due to futility. Among 225 participants approached, 54 consented to participate. The MEAV 95 for ultrasound-guided ISB of ropivacaine 0.75% for shoulder surgery was unable to be accurately estimated. Local anesthetic volumes between 5 and 20 ml did not influence any of the predefined secondary outcomes. Conclusions: The MEAV 95 (at 30 min) of ropivacaine 0.75% for ultrasound-guided ISB exceeds the local anesthetic volumes that consistently produces hemidiaphragmatic impairment. ISB cannot be guaranteed to provide surgical anesthesia at 30 min without the potential for concomitant phrenic nerve block.

Contexte: Le bloc du plexus brachial par approche interscalénique (BIS) est régulièrement utilisé pour l'anesthésie et l'analgésie lors de chirurgies de l'épaule. Les volumes d'anesthésique local traditionnellement utilisés pour le BIS entraînent couramment une parésie ipsilatérale du nerf phrénique compromettant l'oxygénation et la ventilation.Objectifs: Le but de cette étude était de déterminer le plus petit volume minimal effectif chez 95% des patients (VME 95) de la ropivacaïne 0,75 % lorsqu'utilisé pour un BIS lors d'une chirurgie arthroscopique de l'épaule.Méthodes: Étude de cohorte prospective observationnelle auprès de patients subissant une chirurgie arthroscopique de l'épaule sous BIS (niveau C6) avec sédation. Le protocole d'identification du VME 95 de la ropivacaïne 0,75% a été effectué selon la règle de Narayana pour augmenter ou diminuer l'allocation séquentielle des doses. Un BIS réussi était défini comme l'absence totale de sensation de picotement dans les dermatomes aux niveaux C5 et C6 30 minutes après le bloc. Les critères d'évaluation secondaires comprenaient la capacité de compléter la chirurgie avec une sédation à base de propofol, les changements dans la capacité vitale lente, la saturation de l'oxygène de l'air ambiant après le bloc, la durée du bloc, les complications rencontrées avec le BIS et l'intensité de la douleur immédiatement après la chirurgie mesurée à l'aide d'une échelle numérique.Résultats: L'étude a été arrêtée avant terme en raison de son insuccès. Parmi les 225 patients approchés, 54 ont accepté d'y participer. Le VME 95 de la ropivacaïne 0,75 % pour un BIS écho-guidé lors d'une chirurgie de l'épaule n'a pu être estimé avec précision. Les volumes d'anesthésique local entre 5 et 20 ml n'ont influencé aucun des critères d'évaluation secondaires prédéfinis.Conclusions: Le VME 95 de la ropivacaïne 0,75 % (à 30 minutes) pour un BIS écho-guidé excède les volumes d'anesthésique local qui entraînent systématiquement une déficience au niveau du l'hémidiaphragme. Le BIS ne peut fournir une anesthésie de 30 minutes pour une chirurgie arthroscopique de l'épaule sans risque concomitant de bloquer le nerf phrénique.

Ultrasound guidance for lumbar puncture.

PURPOSE OF REVIEW: To review the literature and describe techniques to use ultrasound to guide performance of lumbar puncture (LP). RECENT FINDINGS: Ultrasound evaluation of the lumbar spine has been shown in randomized trials to improve LP success rates while reducing the number of attempts and the number of traumatic taps. SUMMARY: Ultrasound mapping of the lumbar spine reveals anatomical information that is not obtainable by physical examination, including depth of the ligamentum flavum, width of the interspinous spaces, and spinal bone abnormalities, including scoliosis. Using static ultrasound, the lumbar spine anatomy is visualized in transverse and longitudinal planes and the needle insertion site is marked. Using real-time ultrasound guidance, the needle tip is tracked in a paramedian plane as it traverses toward the ligamentum flavum. Future research should focus on efficient methods to train providers, cost-effectiveness of ultrasound-guided LP, and the role of new needle-tracking technologies to facilitate the procedure.

Impact of fluid resuscitation on major adverse events following pancreaticoduodenectomy.

BACKGROUND: Pancreaticoduodenectomy remains a major undertaking with substantial perioperative morbidity and mortality. Previous studies in the colorectal population have noted a correlation between excessive postoperative fluid resuscitation and anastomotic complications. This study sought to assess the relationship between perioperative fluid management and clinical outcomes in patients undergoing pancreaticoduodenectomy. METHODS: Data from a single institution, prospective database over a 10-year period (2002 to 2012) were reviewed. Patients were compared for perioperative fluid balance and postoperative outcomes. Multivariable analysis was performed to assess the relationship between perioperative fluid administration and incidence of major adverse events. RESULTS: Higher positive fluid balance on postoperative day 0, postoperative day 1, and postoperative day 2 was associated with increased incidence of major adverse events, increased postoperative intensive care unit admission, and longer hospital stay. Higher positive fluid balance on postoperative day 0 was most strongly associated with postoperative morbidity (odds ratio 1.39, confidence interval 1.16 to 1.66, P = .0003). Fluid balance on postoperative day 3 was not associated with adverse events. CONCLUSIONS: Increased early perioperative fluid resuscitation is associated with major adverse events in patients undergoing pancreaticoduodenectomy. More restrictive fluid administration may improve postoperative outcomes; further prospective clinical trials focused on fluid resuscitation and goal-directed therapy are needed.

Medial open transversus abdominis plane (MOTAP) catheters for analgesia following open liver resection: study protocol for a randomized controlled trial.

BACKGROUND: The current standard for pain control following liver surgery is intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. We have developed a modification of a regional technique called medial open transversus abdominis plane (MOTAP) catheter analgesia. The MOTAP technique involves surgically placed catheters through the open surgical site into a plane between the internal oblique muscle and the transverse abdominis muscle superiorly. The objective of this trial is to assess the efficacy of this technique. METHODS/DESIGN: This protocol describes a multicentre, prospective, blinded, randomized controlled trial. One hundred and twenty patients scheduled for open liver resection through a subcostal incision will be enrolled. All patients will have two MOTAP catheters placed at the conclusion of surgery. Patients will be randomized to one of two parallel groups: experimental (local anaesthetic through MOTAP catheters) or placebo (normal saline through MOTAP catheters). Both groups will also receive IV PCA. The primary endpoint is mean cumulative postoperative opioid consumption over the first 2 postoperative days (48 hours). Secondary outcomes include pain intensity, patient functional outcomes, and the incidence of complications. DISCUSSION: This trial has been approved by the ethics boards at participating centres and is currently enrolling patients. Data collection will be completed by the end of 2014 with analysis mid-2015 and publication by the end of 2015. TRIAL REGISTRATION: The study is registered with http://clinicaltrials.gov ( NCT01960049; 23 September 2013).