Influence of non-pharmacological obstetric interventions on adverse outcomes of childbirth under regional analgesia.

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012-November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28-0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22-0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36-0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01-0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Regional anaesthesia practice for arteriovenous fistula formation surgery.

We conducted a survey and semi-structured qualitative interviews to investigate current anaesthetic practice for arteriovenous fistula formation surgery in the UK. Responses were received from 39 out of 59 vascular centres where arteriovenous access surgery is performed, a response rate of 66%. Thirty-five centres reported routine use of brachial plexus blocks, but variation in anaesthetic skill-mix and practice were observed. Interviews were conducted with 19 clinicians from 10 NHS Trusts including anaesthetists, vascular access and renal nurses, surgeons and nephrologists. Thematic analysis identified five key findings: (1) current anaesthetic practice showed that centres could be classified as 'regional anaesthesia dominant' or 'local anaesthesia/mixed'; (2) decision making around mode of anaesthesia highlighted the key role of surgeons as frontline decision makers across both centre types; (3) perceived barriers and facilitators of regional block use included clinicians' beliefs and preferences, resource considerations and patients' treatment preferences; (4) anaesthetists' preference for supraclavicular blocks emerged, alongside acknowledgement of varied practice; (5) there was widespread support for a future randomised controlled trial, although clinician equipoise issues and logistical/resource-related concerns were viewed as potential challenges. The use of regional anaesthesia for arteriovenous fistula formation in the UK is varied and influenced by a multitude of factors. Despite the availability of anaesthetists capable of performing regional blocks, there are other limiting factors that influence the routine use of this technique. The study also highlighted the perceived need for a large multicentre, randomised controlled trial to provide an evidence base to inform current practice.

Epidemiology of regional anesthesia in children: Lessons learned from the European Multi-Institutional Study APRICOT.

BACKGROUND: Recently, the European prospective observational multicenter cohort study, APRICOT, reported anesthesia techniques and complications in more than 31 000 pediatric procedures. The main objective of this study was to analyze the current practice in regional anesthesia in the 33 countries that participated to APRICOT. METHODS: Data on regional anesthesia techniques were extracted from the database of APRICOT (261 centers across 33 European countries). All children, aged from birth to 16 years old, were eligible for inclusion during a 2-week period. Type of regional anesthesia, whether used awake or with sedation or general anesthesia, techniques of guidance, and the drugs administered were analyzed. RESULTS: Regional anesthesia was used in 4377 pediatric surgical procedures. The large majority was performed under general anesthesia with central blocks and truncal blocks, representing, respectively, 42.6% and 41.8% of performed techniques. Caudal blocks represented 76.9% of all central blocks. The penile and ilioinguinal/iliohypogastric blocks were the most commonly performed truncal blocks. Anesthetists used mainly anatomical landmarks; ultrasound guidance was applied in only 23.8% of cases. A wide variability of practices was observed in terms of regional anesthesia techniques and local anesthetics among the participating European countries. No serious complications were reported. CONCLUSION: These data show a large predominance of central and truncal blocks in APRICOT study. Ultrasound guidance was mainly used for peripheral nerve blocks while central blocks were performed using landmark techniques.

Open inguinal hernia repair with self-gripping Parietex ProGrip mesh: a retrospective study of 204 cases.

Chronic pain and recurrence rates are the main challenge in modern inguinal hernia surgery. Several trials have investigated the role of self-adhesive mesh repair for inguinal hernia, with special attention to the incidence of chronic postoperative inguinal pain and recurrence. The purpose of our study was to retrospectively evaluate the early and long-term results using a self-gripping mesh (Parietex Progrip® , Covidien) in our institution. A total of 204 patients, mean age 50.3 standard deviation (SD) 15.3, was included in the study. The repair was performed under local anaesthesia in 159 (78%) cases and locoregional anaesthesia in remaining 45 (22%). Mean operative time was 39 ± 20 minutes. The time for self-gripping mesh placement ranged from 5 to 9 minutes (mean 7 ± 2 minutes). There were no intraoperative complications. Clinical follow-up was performed at 1 month, 1 year and 2 years and consisted in the evaluation of complications, discomfort/pain and recurrence. One case of cutaneous infection and three cases of seroma were observed at one-month follow-up and were all treated conservatively. 8 patients were lost at one year follow-up, and another 4 were lost at 2 years. 3 patients died for other causes during follow-up. At 1 year and 2 years follow-up no cases of seroma, testicular complications or mesh infection were observed. Two cases of recurrence were recorded at 2 years follow up. No patient reported VAS score > 2 at one month, 1 year and 2 years follow-up. There were no readmissions, systemic complications or death during 2 years follow-up. Lichtenstein open repair using Parietex Progrip® mesh is a simple, rapid, effective and safe method for inguinal hernia repair. The main advantage of self-fixing mesh is the reduced operative time. A suturless fixation seems to prevent the development of postoperative chronic pain, without increasing recurrence rate in the majority of the trials.

Assessment and support during early labour for improving birth outcomes.

BACKGROUND: The progress of labour in the early or latent phase is usually slow and may include painful uterine contractions. Women may feel distressed and lose their confidence during this phase. Support and assessment interventions have been assessed in two previous Cochrane Reviews. This review updates and replaces these two reviews, which have become out of date. OBJECTIVES: To investigate the effectiveness of assessment and support interventions for women during early labour.In order to measure the effectiveness of the interventions, we compared the duration of labour, the rate of obstetrical interventions, and the rate of other maternal or neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 October 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials of any assessment or support intervention in the latent phase of labour. We planned to include cluster-randomised trials if they were eligible. We did not include quasi-randomised trials. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We resolved any disagreement by discussion or by involving a third assessor. The quality of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included five trials with a total of 10,421 pregnant women in this review update. The trials were conducted in the UK, Canada and America. The trials compared interventions in early labour versus usual care. We examined three comparisons: early labour assessment versus immediate admission to hospital; home visits by midwives versus usual care (telephone triage); and one-to-one structured midwifery care versus usual care. These trials were at moderate- risk of bias mainly because blinding women and staff to these interventions is not generally feasible. For important outcomes we assessed evidence using GRADE; we downgraded evidence for study design limitations, imprecision, and where we carried out meta-analysis, for inconsistency.One trial with 209 women compared early labour assessment with direct admission to hospital. Duration of labour from the point of hospital admission was reduced for women in the assessment group (mean difference (MD) -5.20 hours, 95% confidence interval (CI) -7.06 to -3.34; 209 women, low-quality evidence). There were no clear differences between groups for the number of women undergoing caesarean section or instrumental vaginal birth (risk ratio (RR) 0.72, 95% CI 0.30 to 1.72, very low quality evidence; and, RR 0.86, 95% CI 0.58 to 1.26, very low quality evidence, respectively). Serious maternal morbidity was not reported. Women in the early assessment group were slightly less likely to have epidural anaesthesia (RR 0.87, 95% CI 0.78 to 0.98, low-quality evidence), and considerably less likely to have oxytocin for labour augmentation (RR 0.57, 95% CI 0.37 to 0.86) and this group also had increased satisfaction with their care compared with women in the immediate admission group (MD 16.00, 95% CI 7.53 to 24.47). No babies were born before admission to hospital and only one infant had a low Apgar score at five minutes after the birth (very low quality evidence). Admission to neonatal special care was not reported.Three studies examined home assessment and midwifery support versus telephone triage. One trial reported the duration of labour; home visits did not appear to have any clear impact compared with usual care (MD 0.29 hours, 95% CI -0.14 to 0.72; 1 trial, 3474 women, low-quality evidence). There was no clear difference for the rate of caesarean section (RR 1.05, 95% CI 0.95 to 1.17; 3 trials, 5170 women; I² = 0%; moderate-quality evidence) or the rate of instrumental vaginal birth (average RR 0.95, 95% CI 0.79 to 1.15; 2 trials, 4933 women; I² = 69%; low-quality evidence). One trial reported birth before arrival at hospital or unplanned home birth; there was no clear difference between the groups (RR 1.33, 95% CI 0.30 to 5.95; 1 trial, 3474 women). No clear differences were identified for serious maternal morbidity (RR 0.93, 95% CI 0.61 to 1.42; 1 trial, 3474 women; low-quality evidence), or use of epidural (average RR 0.95, 95% CI 0.87 to 1.05; 3 trials, 5168 women; I² = 60%; low-quality evidence). There were no clear differences for neonatal admission to special care (average RR 0.84, 95% CI 0.50 to 1.42; 3 trials, 5170 infants; I² = 71%; very low quality evidence), or for Apgar score less than seven at five minutes after birth (RR 1.19, 95% CI 0.71 to 1.99; 3 trials, 5170 infants; I² = 0%; low-quality evidence).One study, with 5002 women, examined one-to-one structured care in early labour versus usual care. Length of labour was not reported. There were no clear differences between groups for the rate of caesarean section (RR 0.93, 95% CI 0.84 to 1.02; 4996 women, high-quality evidence), or for instrumental vaginal birth (RR 0.94, 95% CI 0.82 to 1.08; 4996 women, high-quality evidence). No clear differences between groups were reported for serious maternal morbidity (RR 1.13, 95% CI 0.84 to 1.52; 4996 women, moderate-quality evidence). Use of epidural was similar in the two groups (RR 1.00, 95% CI 0.99 to 1.01; 4996 women, high-quality evidence). For infant outcomes, there were no clear differences between groups (admission to neonatal intensive care unit: RR 0.98, 95% CI 0.80 to 1.21; 4989 infants, high-quality evidence; Apgar score less than seven at five minutes: RR 1.07, 95% CI 0.64 to 1.79; 4989 infants, moderate-quality evidence). AUTHORS' CONCLUSIONS: Assessment and support in early labour does not have a clear impact on rate of caesarean section or instrumental vaginal birth, or whether the baby was born before arrival at hospital or in an unplanned home birth. However, evidence suggested that interventions may have an impact on reducing the use of epidural anaesthesia, labour augmentation and on increasing maternal satisfaction with giving birth. Evidence about the effectiveness of early labour assessment versus immediate admission was very limited and more research is needed in this area.

Trends in the Use of Regional Anesthesia: Neuraxial and Peripheral Nerve Blocks.

BACKGROUND: A growing body of evidence indicates that the use of regional anesthesia offers advantages over general anesthesia, not only in terms of reducing complications but also regarding resource utilization and patient satisfaction. Because of the paucity of data on the nationwide adoption of regional anesthesia techniques, we aimed to elucidate trends in the use of neuraxial anesthesia (NA) and peripheral nerve blocks (PNBs) in orthopedic surgeries. METHODS: We extracted data from N = 959,257 (Premier Perspective database; 2006-2013) total hip and knee arthroplasties (THA, TKA) and assessed NA/PNB use by a 2-year period, stratified by demographics and hospital factors. Cochran-Armitage trend tests assessed significance of trends. RESULTS: Comparing 2006-2007 with 2012-2013, NA utilization decreased slightly from 21.7% to 19.7% for THA patients; this was 24.7% to 21.3% for TKA patients (with the main drop between 2012 and 2013). Conversely, PNB utilization increased from 6.5% to 8.7% for THA patients and 10.3% to 20.4% for TKA patients (all P < 0.001). These general trends did not change when stratified by patient demographics, whereas stratification by hospital factors did show differences: the highest NA utilization was seen in rural, nonteaching, and small hospitals, whereas the highest PNB utilization was seen in large and teaching hospitals. CONCLUSIONS: Our findings provide important insight into the dynamics of the adoption of regional anesthetic techniques. Whereas PNB utilization is significantly increasing, overall, NA and PNBs are performed in the minority of cases. With accumulating evidence in favor of regional anesthesia, promoting the use of NA and a further increase in PNB utilization could have far-reaching medical and economic implications.

Variability in anesthetic considerations for arteriovenous fistula creation.

INTRODUCTION: Anesthetic options for arteriovenous fistula (AVF) creation include regional anesthesia (RA), general anesthesia (GA) and local anesthetic for select cases. In addition to the benefits of avoiding GA in high-risk patients, recent studies suggest that RA may increase perioperative venous dilation and improve maturation. Our objective was to assess perioperative outcomes of AVF creation with respect to anesthetic modality and identify patient-level factors associated with variation in contemporary anesthetic selection. METHODS: National Surgical Quality Improvement Project (NSQIP) data (2007-2010) were accessed to identify patients undergoing AVF creation. Univariate analysis and multivariate logistic regression were performed to assess the relationships among patient characteristics, anesthesia modality and outcome. RESULTS: Of 1,540 patients undergoing new upper extremity AVF creation, 52% were male and 81% were younger than 75 years. Anesthesia distribution was GA in 85.2%, local/monitored anesthetic care (MAC) in 2.9% and RA in 11.9% of cases. By multivariate analysis, independent predictors of RA were dyspnea at rest (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.1-4.9), age >75 (HR 1.6, 95% CI 1.1-2.3) and teaching hospital status as indicated by housestaff involvement (HR 3.7, 95% CI 2.5-5.5). RA was associated with higher total operative time, duration of anesthesia, length of time in operating room and duration of anesthesia start until surgery start (p<0.01). There were no differences between perioperative complications or mortality among anesthetic modalities, although all deaths occurred in the GA group. DISCUSSIONS: Despite recent reports highlighting potential benefits of RA for AVF creation, GA was surprisingly used in the vast majority of cases in the United States. The only comorbidities associated with preferential RA use were advanced age and dyspnea at rest. Practice environment may influence anesthetic selection for these cases, as a nonteaching environment was associated with GA use. The trend seen here toward higher mortality in GA and the potential perioperative benefits of RA for the access should encourage more widespread use of RA in practice for this high-risk patient population.

Farmacopuntura con tramadol como analgesia posoperatoria preventiva en la herniorrafia inguinal / Pharmacopuncture with tramadol as preventive postoperative analgesia in inguinal herniorrhaphy

INTRODUCCIÓN: estudios demuestran que más del 40 % de los pacientes sufren dolor en el posoperatorio inmediato, y tres de cada cuatro lo experimentan los dos primeros días. OBJETIVO: evaluar la efectividad de la farmacopuntura con tramadol en la prevención del dolor posoperatorio en pacientes operados de hernia inguinal. MÉTODOS: estudio prospectivo, descriptivo, aleatorio y controlado a 60 pacientes operados de manera electiva de herniorrafia inguinal en el Hospital Militar Central "Dr. Carlos J. Finlay" en el período de septiembre de 2010 a septiembre de 2011. Se conformaron dos grupos de igual cantidad de pacientes: grupo F (estudio) en el que se aplicó farmacopuntura con tramadol 12,5 mg en los puntos del meridiano de estómago (E36, E44) y anestesia regional subaracnoidea, y el grupo C (control) en el que se empleó tramadol 100 mg por vía intramuscular e igual método anestésico. Se evaluó el dolor posoperatorio, según criterios del paciente por ubicación en la escala análoga visual. RESULTADOS: predominó el sexo masculino y el rango de más de 60 años de edad. Los pacientes que recibieron el método de anestesia-analgesia y farmacopuntura presentaron mayor grado de analgesia posoperatoria con ausencia completa de dolor en 60 %, con menor cantidad de náuseas y vómitos posoperatorios y una excelente estabilidad hemodinámica. CONCLUSIONES: la farmacopuntura con tramadol constituye un método terapéutico analgésico en la prevención del dolor posoperatorio.

INTRODUCTION: studies have shown that over 40 % of patients suffer from pain in the immediate postoperative period, and three out of every four during the first two days. OBJECTIVE: evaluate the effectiveness of pharmacopuncture with tramadol to prevent postoperative pain in patients undergoing surgery for inguinal hernia. METHODS: a prospective descriptive randomized controlled study was conducted of 60 patients electively operated on for inguinal hernia at Dr. Carlos J. Finlay Central Military Hospital from September 2010 to September 2011. Patients were divided into two equal groups: Group F (study) received pharmacopuncture with tramadol 12.5 mg at stomach meridian acupoints (E36, E44) and regional subarachnoid anaesthesia, and Group C (control) received intramuscular tramadol 100 mg and the same anaesthetic procedure. Postoperative pain was ranked on the visual analog scale based on criteria provided by patients. RESULTS: there was a predominance of the male sex and the over-60 age group. Patients receiving anaesthesia-analgesia and pharmacopuncture showed greater postoperative analgesia, with total absence of pain in 60 %, less postoperative nausea and vomiting, and excellent hemodynamic stability. CONCLUSIONS: pharmacopuncture with tramadol constitutes an analgesic therapeutic method to prevent postoperative pain.

Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective.

PURPOSE: In 1987, Duncan et al.(1) reported on a survey of the members of the American Society for the Surgery of the Hand (ASSH) about their practices in treating carpal tunnel syndrome (CTS). To better understand changes in the treatment of CTS over the past 25 years, we repeated the survey while incorporating present-day controversies. METHODS: With the approval of the ASSH, an Internet-based survey was e-mailed to all members of the Society. This included 33 primary questions focusing on 4 areas of study: surgeon demographic information, nonoperative treatment, surgical technique, and postoperative care. A total of 1,463 surveys were delivered and 707 surveys were completed and returned, for a response rate of 48%. Responses were compared with the responses from Duncan et al. published 25 years ago.(1) RESULTS: In contrast to the practice patterns identified 25 years ago, this survey identified several changes in current clinical practices including the following statistically significant findings: Preoperatively, surgeons have increased the use of splints and corticosteroid injections, treat nonoperatively longer, and have narrowed their surgical indications. Regarding surgical technique, surgeons now are using tourniquets less, infiltrate the carpal tunnel with corticosteroids less, and place deep sutures less often. Furthermore, performing concomitant procedures along with release of the transverse carpal ligament has decreased. Orthotic use and duration postoperatively also decreased. CONCLUSIONS: Although significant differences are evident between management of CTS between 1987 and 2011, no consensus has emerged.

Aspectos técnicos en la infiltración caudal guiada por tomografía computarizada / Technical aspects of CT guided caudal infiltration

Introducción. La infiltración epidural caudal constituye en la actualidad una de las técnicas de analgesia regional que se utiliza con más frecuencia para el dolor crónico lumbar. Nuestro objetivo principal a alcanzar en esta exposición es poner de relieve una nueva técnica para realizar esta intervención que resulta más sencilla y menos agresiva para el paciente que la utilizada clásicamente. Material y métodos. Esta técnica se ha realizado en 13 pacientes (2 varones y 11 mujeres), con edades comprendidas entre los 33 y los 84 años. Todos los pacientes tenían dolor lumbar crónico. Para realizarla se ha utilizado un equipo de tomografía computarizada (TC) General Electric Light Speed 16, una aguja de punción lumbar de 22G y las medidas estériles adecuadas. La TC es una herramienta que facilita enormemente la visualización del ligamento sacrocoxígeo. Una vez introducida la aguja y comprobado mediante TC que se encuentre en el interior del canal raquídeo caudal, se procede a girar el bisel en dirección craneal con el objetivo de que el fármaco administrada salga por el orificio de la aguja hacia el canal neural. Discusión. La técnica más frecuente en la práctica de la infiltración epidural caudal se realiza habitualmente con el paciente en decúbito prono, con la cabeza girada sobre un lado utilizando un arco de rayos X. Mediante la técnica que mostramos, la punción es menos agresiva, más rápida y hay menos posibilidades de complicaciones. El riesgo de perforar el saco dural es prácticamente inexistente, así como de producir hematomas o infecciones, debido a que la manipulación con la aguja es mucho menor y se ciñe únicamente a una punción directa. Discusión. En el 100% de los casos en que se ha practicado nuestra técnica, la difusión de la medicación administrada se ha realizado en dirección craneal, lo cual se ha verificado debido al contraste que se ha añadido a la mezcla farmacológica (AU)

Introduction. Caudal epidural infiltration is currently one of the most used regional analgesia techniques for control of chronic low pack pain. Our primary objective in this presentation is to highlight a new technique for performing this intervention which is simpler and less aggressive for the patient than that classically used. Material and methods. This new technique has been used on 13 patients (2 males and 11 females) between 33 and 84 years. All patients had chronic lumbar pain. A General Electric Light Speed 16 CT scanner, a 22G lumbar puncture needle and appropriate sterile measures, were used to perform the technique. The CT scanner is a tool that makes it much easier to visualise the sacrococcygeal ligament. After the needle is introduced, and checked using CT, into the caudal spinal canal, the bevel is turned in the cranial direction in order that the medication administered comes out of the needle orifice towards the neural canal. Discussion. The most common technique for performing caudal epidural infiltration is usually done in the prone position with the head turned to one side using an X-ray arch. Using this technique we show that the puncture is less aggressive, quicker and with fewer possibilities of complications. The risk of perforating the dural sac is practically non-existent. There is also less risk of producing haematomas or infections, due to there being much less manipulation of the needle and only involves a direct puncture. Discussion. In the 100% of cases on which our technique has been performed, the diffusion of the administered medication has been made in the cranial direction, which has been verified using contrast added to the pharmacological mixture (AU)

[Present state of anesthetic management for awake craniotomy in Japan].

To avoid the neurological deficits after neurosurgical procedures, awake craniotomy applying intraoperative awake functional brain mapping has been employed. Anesthesia for awake craniotomy requires particular attention to airway management, control of seizures and measures for decreasing the anxiety of the patients. We investigated the current status of anesthetic management for awake craniotomy in Japan to establish a standard procedure for safe anesthesia. A questionnaire was sent to 80 universities with departments of anesthesia in Japan and 34 (43%) responded. In 19 institutes, awake craniotomies are being practiced. The first experience of awake craniotomy was in 1996 in Japan and since then most of the institutes have experienced only three or fewer cases. Airway management, control of nausea and vomiting, stable awakening during functional mapping and control of seizures were pointed out as problems during awake craniotomy. Based on the present results, our experience and the information from previous investigations, standard anesthetic management for awake craniotomy in our country will be documented.

Anaesthetic practice for groin hernia repair--a nation-wide study in Denmark 1998-2003.

BACKGROUND: Recent scientific data suggest that local infiltration anaesthesia for inguinal hernia surgery may be preferable compared to general anaesthesia and regional anaesthesia, since it is cheaper and with less urinary morbidity. Regional anaesthesia may have specific side-effects and is without documented advantages on morbidity in this small operation. METHODS: To describe the use of the three anaesthetic techniques for elective open groin hernia surgery in Denmark from January 1st 1998 to December 31st 2003, based on the Danish Hernia Database collaboration. RESULTS: In a total of 57,505 elective open operations 63.6% were performed in general anaesthesia, 18.3% in regional anaesthesia and 18.1% in local anaesthesia. Regional anaesthesia was utilized with an increased rate in elderly and hospitalized patients. Outpatient surgery was most common with local infiltration anaesthesia. CONCLUSION: Use/choice of anaesthesia for groin hernia repair is not in accordance with recent scientific data. Use of spinal anaesthesia should be reduced and increased use of local anaesthesia is recommended to enhance recovery and reduce costs.

Visual experience during phacoemulsification under topical anaesthesia: a nationwide survey of Singapore ophthalmologists.

BACKGROUND: All patients undergoing phacoemulsification under topical anaesthesia experience a variety of visual sensations that may be frightening in a small proportion of patients. This study evaluates Singapore ophthalmologists' knowledge and practices regarding patients' visual experience during phacoemulsification under topical anaesthesia. METHODS: A nationwide survey of all ophthalmologists in Singapore who had performed at least one cataract surgery within the last year was carried out. Questions regarding patients' experience were asked. Surgeons were also asked about patients' fear during surgery, usefulness of preoperative counselling and feedback from patients postoperatively. RESULTS: Of 105 ophthalmologists 89 responded, of which 44 performed phacoemulsification under topical anaesthesia. The percentage of respondents who thought that the patients experienced the various visual sensations were: no light perception (4.6%), light perception (97.7%), one or more colours (95.5%), flashes of light (77.3%), movements (90.9%), instruments (61.4%), surgeon's hands/fingers (56.8%), surgeon (47.7%) and change in brightness of light (90.9%). Although 52.3% of surgeons believed that patients may be frightened by their visual experience and 50.0% felt that preoperative counselling would be useful in reducing such fear, only 11.4% routinely offered preoperative counselling and 18.2% counselled their patients occasionally. In total, 50.0% ophthalmologists had patients who reported to them that they could see during surgery, whereas 20.5% had been told by patients that they were frightened by the visual experience. CONCLUSION: Despite the awareness of patients' visual experience and the belief that preoperative counselling may be useful, most ophthalmologists do not counsel their patients preoperatively.

[Locoregional anesthesia]. / Anesthésie loco-régionale.

Local anaesthetics used for regional anaesthesia inhibit impulse depolarisation through blockade of sodium channels. Regional anaesthesia accounts for 20% of all anaesthetic procedures performed in France. Spinal anaesthesia is the most common technique used peroperatively, while epidural anaesthesia is used in labouring women and for postoperative pain control. Nerve stimulation allows a safer an easier approach to peripheral blocks. Regional anaesthesia is mainly indicated for limb or eye surgery, and for mildly invasive surgical procedures. Regional anaesthetic techniques are the most efficient to control postoperative pain and to facilitate patient rehabilitation. The risk related to the practice of regional anaesthesia compares with that of general anaesthesia and is thus very low. Main complications are epidural haematoma, cardiac arrest due to inadvertent intravascular injection of local anaesthestics, and peripheral nerve damage. Regional anaesthesia requires the same technical environment and careful monitoring as general anaesthesia.

Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists.

We report the results of a prospective study on the practice of pediatric regional anesthesia by the French-Language Society of Pediatric Anesthesiologists (ADARPEF) during the period from May 1, 1993 to April 30, 1994. This study was designed to provide data concerning the epidemiology of regional anesthesia and its complications in a totally anonymous way. Data from 85,412 procedures, 61,003 pure general anesthetics and 24,409 anesthetics including a regional block, were prospectively collected. Central blocks (15,013), most of which were caudals, accounted for more than 60% of all regional anesthetics. Peripheral nerve blocks and local anesthesia techniques represented only 38% of regional blocks and Bier block was used only 69 times. Central and peripheral nerve blocks were performed in all pediatric age groups with some intergroup differences. Most blocks were performed under light general anesthesia (89%), confirming the fact that regional anesthetics are used as techniques of analgesia rather than anesthesia. Complications were rate (25 incidents involving 24 patients) and minor, and did not result in any sequelae or medicolegal action. Peripheral nerve blocks and local anesthesia techniques were generally safe. The overall complication rate of regional anesthesia was 0.9 per 1000, but because all complications occurred with central blocks, the complication rate of central blocks is in fact 1.5 per 1000 with significant variations in different age groups. This prospective study, based on a large and representative series of pediatric anesthetics, establishes the safety of regional anesthesia in children of all ages. It provides new insights on the practice of regional blocks and reveals that complications are rare and minor as they occur most often in the operating room and are readily managed by experienced anesthesiologists with resuscitative equipment at hand. The extremely low incidence of complications (zero in this study) after peripheral nerve blocks should encourage pediatric anesthesiologists to use them more often when they are appropriate, in the place of a central block.

A tide of change in the management of an old fracture?

Colles' fractures are manipulated under a variety of anaesthetic techniques. An increasing awareness of cost and time within the National Health Service contributes to a marked change in the anaesthetic management of Colles' fractures. This paper presents the results of a survey of the anaesthetic techniques used in the larger accident and emergency (A&E) departments of the UK, and demonstrates the increasing popularity of the haematoma block compared with 5 years ago (7% in 1989 vs. 33% in 1994), at the expense of the general anesthetic (44% in 1989 vs 24% in 1994). The popularity of the Bier's block has remained unchanged (33% in 1989 and 1994). Local and regional anaesthetic techniques can be safely performed by A&E doctors, with appropriate monitoring, and this has beneficial resource implications for the anaesthetic department and the hospital.

Changing attitudes and practices regarding local analgesia for newborn circumcision.

STUDY OBJECTIVE: To change physician attitudes and practices regarding the routine use of local and regional anesthesia for newborn circumcision. DESIGN: Interventional study, followed by an audit of physician practice over a 1-month period, 1 year following interventions. SETTING: The newborn nurseries of the Women's Pavilion, Royal Alexandra Hospital, Edmonton. INTERVENTIONS: A broad range of awareness and educational programs were directed at physicians who perform newborn circumcisions, including posters, newsletters, presentations at grand rounds, video recordings, and practical "hands-on" demonstration of the techniques of local anesthesia to the prepuce and dorsal penile nerve block. RESULTS: Only one physician was using local analgesia for newborn circumcision prior to the introduction of the educational program. The audit, performed 12 months later, documented 46 circumcisions performed by 22 physicians, each performing between 1 and 6 circumcisions (median = 1). Sixteen of the 22 physicians (73%) used either local anesthesia to the prepuce (19 cases) or dorsal penile nerve block (13 cases) during circumcisions. Thus, local analgesia was used in 66% (32/48) of all circumcisions. Six physicians, performing 16 circumcisions, do not use any form of analgesia. CONCLUSIONS: This simple educational program has been associated with a remarkable change in attitudes and practice regarding local analgesia for neonatal circumcision. Our ideal objective, which we hope to achieve through repeated education and practical demonstrations of the techniques to interested physicians, is that all newborn circumcisions are performed under local or regional anesthesia in our institution.

[The real risks of locoregional anesthesia]. / Les vrais risques de l'anesthésie loco-régionale.

Regional anaesthesia involves its own risks of which five main categories appear to stand out: 1. Excessive indications, especially of epidural anaesthesia instead of nerve blocks or general anaesthesia. 2. Delayed use of vasopressive amines after excessive fluid infusion. 3. Toxicity of local drugs which can be largely avoided by slow injection. 4. Neurological complications of traumatic punctures, such as nerve root or dura mater injury. 5. Excessive complementary sedation.

Anaesthesia for Charcot-Marie-Tooth disease: a review of 86 cases.

Operative charts were reviewed in 86 patients with Charcot-Marie-Tooth disease, a condition characterized by chronic muscular denervation. A total of 161 surgical procedures was performed. Major complications were few, and only one operative death occurred, unrelated to anaesthesia. Succinylcholine and malignant hyperthermia triggering agents were used in 41 (48%) and 77 (90%) patients, respectively, without untoward effects. Contrary to previous reports, this survey supports the safe use of succinylcholine and MH triggering agents in this disease.