Regional Nerve Blocks-Best Practice Strategies for Reduction in Complications and Comprehensive Review.

PURPOSE OF REVIEW: Understanding the etiologies of the complications associated with regional anesthesia and implementing methods to reduce their occurrence provides an opportunity to foster safer practices in the delivery of regional anesthesia. RECENT FINDINGS: Neurologic injuries following peripheral nerve block (PNB) and neuraxial blocks are rare, with most being transient. However, long-lasting and devastating sequelae can occur with regional anesthesia. Risk factors for neurologic injury following PNB include type of block, injection in the presence of deep sedation or general anesthesia, presence of existing neuropathy, mechanical trauma from the needle, pressure injury, intraneural injection, neuronal ischemia, iatrogenic injury related to surgery, and local anesthetic neurotoxicity. The present investigation discusses regional blocks, complications of regional blocks, risk factors, site-specific limitations, specific complications and how to prevent them from happening, avoiding complications in regional anesthesia, and the future of regional anesthesia.

3-dimensional analysis of scaphoid fracture angle morphology.

PURPOSE: Scaphoid fractures are classified according to their 2-dimensional radiographic appearance, and transverse waist fractures are considered the most common. Our hypothesis was that most scaphoid fractures are not perpendicular to the longitudinal axis of the scaphoid (ie, not transverse). METHODS: Computerized 3-dimensional analyses were performed on 124 computed tomography scans of acute scaphoid fractures. Thirty of the fractures were displaced and virtually reduced. The angle between the scaphoid's first principal axis (longitudinal axis) and the fracture plane was analyzed for location and displacement. The distal radius articular surface was used to depict the volar-dorsal vector of the wrist. RESULTS: There were 86 fractures of the waist, 13 of the distal third, and 25 of the proximal third. The average angle between the scaphoid longitudinal axis and the fracture plane was 53° for all fractures and 56° for waist fractures, both differing significantly from a 90°, transverse fracture. The majority of fracture planes were found to have a volar distal to dorsal proximal (horizontal oblique) inclination relative to the volar-dorsal vector. CONCLUSIONS: Most waist fractures were horizontal oblique and not transverse. According to these findings, fixation of all fractures along the longitudinal axis of the scaphoid may not be the optimal mode of fixation for most. A different approach may be needed in accordance with the fracture plane. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Regional anesthesia considerations for cardiac surgery.

Pain is a significant consequence of cardiac surgery and newer techniques in cardiac anesthesia have provided an impetus for the development of multimodal techniques to manage acute pain in this setting. In this regard, regional anesthesia techniques have been increasingly used in many cardiac surgical procedures, for the purposes of reducing perioperative consumption of opioid agents and enhanced recovery after surgery. The present investigation focuses on most currently used regional techniques in cardiac surgical procedures. These regional techniques include chest wall blocks (e.g., PECS I and II, SAP, ESB, PVB), sternal blocks (e.g., TTMPB, PSINB), and neuraxial blocks (e.g., TEA, high spinal anesthesia). The present investigation also summarizes indications, technique, complications, and potential clinical benefits of these evolving regional techniques. Cardiac surgery patients may benefit from application of these regional techniques with well controlled indications and careful patient selections.

Adjunct medications for peripheral and neuraxial anesthesia.

Regional and neuraxial anesthesia can provide a safer perioperative experience, greater satisfaction, reduced opioid consumption, and reduction of pain, while minimizing side effects. Ultrasound technology has aided clinicians in depositing local anesthetic medication in precise proximity to targeted peripheral nerves. There are a plethora of adjuvants that have been utilized to prolong local anesthetic actions and enhance effects in peripheral nerve blocks. This manuscript describes the current state of the use of adjuncts, e.g., dexmedetomidine, dexamethasone, clonidine, epinephrine, etc., in regional anesthesia. Additionally, evidence behind dosing and block prolongation is summarized along with patient outcomes, adverse effects, and future directions.

Nipple-areola complex reconstruction improves psychosocial and sexual well-being in women treated for breast cancer.

INTRODUCTION: Women choose to undergo nipple-areola complex (NAC) reconstruction as part of breast reconstruction following breast cancer treatment. However, the effect of this procedure on psychosocial and sexual well-being is not well studied. The present study aimed to evaluate how NAC reconstruction affects patient satisfaction with regard to psychosocial and sexual well-being. METHODS: A retrospective chart review was performed for all patients who underwent NAC reconstruction at Magee-Women's Hospital from January 1, 2004 to July 31, 2011. A letter and questionnaire based on the BREAST-Q were mailed to patients to request their participation in the study. Patient satisfaction and health-related quality of life were measured before and after NAC reconstruction. RESULTS: In total, 107 of 328 patients (32.6%) completed the survey. The BREAST-Q scale score for satisfaction with outcome following NAC reconstruction was 85.1 ± 15.8, with higher satisfaction scores for patients with a follow-up of <1.5 years than those with a follow-up of >2.5 years (82.5 ± 21.7 vs. 69.5 ± 19.5; p < 0.01). No significant differences were found in satisfaction with the breast mound before and after NAC reconstruction. Women scored significantly higher on the psychosocial and sexual well-being scales after NAC reconstruction (p < 0.002 and 0.00004, respectively). CONCLUSIONS: This study indicates that patients are highly satisfied after undergoing NAC reconstruction. Satisfaction with the procedure, however, may decrease over time. NAC reconstruction significantly contributes to patient psychosocial and sexual well-being, and this effect did not change over time. NAC reconstruction improves patient outcomes in those who choose to undergo the procedure.

The scope of plastic surgery according to 2434 allopathic medical students in the United States.

BACKGROUND: The general public and physicians often equate plastic surgery with cosmetic surgery. The authors investigate whether this perception is present in U.S. medical students. METHODS: A national survey of first- and second-year allopathic medical students was conducted. Students were asked to determine whether 46 specific procedures are performed by plastic surgeons: 12 aesthetic and 34 reconstructive procedures, which were further separated into three subgroups (general reconstruction and breast, craniofacial, and hand and lower extremity). RESULTS: Of the questionnaires sent out, 2434 from 44 medical schools were returned completed (23 percent response rate); 90.7 percent of aesthetic, 66.0 percent of general reconstruction and breast, 51.0 percent of craniofacial, and 33.4 percent of hand and lower extremity procedures were correctly identified. There was no relationship with self-reported interest in plastic surgery (1 = not at all interested to 10 = extremely interested) and the number of correctly identified aesthetic procedures. However, there was a nonlinear relationship with correctly identified reconstructive procedures; compared to those with an interest level of 1 to 5, those who chose 10 scored on average 6.5 points higher (14.2 versus 20.7) (p < 0.01). An anticipated career in surgery was associated with more correctly identified procedures across all sections but neither year (first versus second) nor region (Northeast, South, Central, West) with any section. CONCLUSIONS: U.S. medical students are unaware of the true scope of plastic surgery. Early exposure to basic aspects of plastic surgery could serve as a means of increasing interest and knowledge in the field and help educate future generations of referring physicians.

Postoperative management of Dupuytren's disease with topical nitroglycerin.

Dupuytren's contracture remains a significant clinical challenge due to associated complications and a recurrence rate of up to 60%. Commonly, the operated skin tends to rebuild scar in the area of surgery. Assuming local ischemia as an etiological factor, two cases in which topical nitroglycerin was used following surgical treatment of Dupuytren's disease are presented. In these patients, no raised scar formation developed during healing. At least six months after surgery, disease recurrence was not noted and the patients and surgeon reported improved skin quality. In the present study, the use of topical nitroglycerin, a local vasodilator, appeared to prevent recurrent scar formation, possibly through prevention of local ischemia. Further study and follow-up is necessary.

La maladie de Dupuytren demeure un problème clinique important en raison des complications connexes et d'un taux de récurrence pouvant atteindre 60 %. La peau opérée a souvent tendance à former de nouvelles cicatrices. Les auteurs présentent deux cas pour lesquels ils ont utilisé de la nitroglycérine topique après le traitement chirurgical de la maladie de Dupuytren, selon l'hypothèse que l'ischémie locale représentait un facteur étiologique. Chez ces patients, aucune cicatrice surélevée ne s'est formée. Au moins six mois après l'opération, il n'y avait pas eu de récurrence de la maladie, et les patients et le chirurgien avaient fait état d'une meilleure qualité de la peau. Dans la présente étude, le recours à de la nitroglycérine topique, un vasodilatateur local, a semblé prévenir la formation de cicatrices récurrentes, peut-être en prévenant une ischémie locale. D'autres études et un suivi s'imposent.