Perioperative Intravenous Dexamethasone Significantly Reduces Postoperative Opioid Requirement and Nausea After Unilateral Elective Hip Arthroscopy: A Randomized Double-blinded Placebo-controlled Trial.

BACKGROUND: Previous studies have shown that dexamethasone has a positive effect on postoperative pain control, opioid consumption, nausea, and vomiting and length of hospital stay after arthroplasty surgery. PURPOSE/HYPOTHESIS: The purpose of this study was to assess whether adding perioperative dexamethasone to our current pain regimen after hip arthroscopy is more effective than a placebo. It was hypothesized that dexamethasone would reduce postoperative pain, reduce opioid consumption, improve subjective pain and nausea scores, and reduce the number of vomiting events. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 50 patients requiring unilateral elective hip arthroscopy were randomized to receive intravenous dexamethasone immediately before induction of anesthesia and at 8 am on the first postoperative day (2 ×12 mg) or a placebo (sodium chloride 0.9%). The patient, the surgeons, the treating anesthesiologist, and the involved nursing and physical therapy personnel were blinded to group assignment. The primary outcome was postoperative pain, and secondary outcomes were opioid consumption and nausea scores-assessed using a translated revised version of the American Pain Society Patient Outcome Questionnaire 6 hours postoperatively and on days 1 and 2-and vomiting events. A clinical follow-up was performed 12 weeks postoperatively to assess adverse events. RESULTS: The mean age at inclusion was 29 years in both groups. Postoperative pain levels did not differ significantly in most instances. Opioid requirements during the hospitalization in the dexamethasone group were significantly lower than those in the placebo group (31.96 ± 20.56 mg vs 51.43 ± 38 mg; P = .014). Significantly fewer vomiting events were noted in the dexamethasone group (0.15 ± 0.59 vs 0.65 ± 0.91; P = .034). Descriptive data and surgical parameters did not differ significantly. CONCLUSION: Perioperative intravenous dexamethasone significantly reduced postoperative opioid consumption by 40% without compromising pain level and safety, as no corticosteroid-related side effects were observed. Dexamethasone may be a valuable adjuvant to a multimodal systemic pain regimen after hip arthroscopy. REGISTRATION: NCT04610398 (ClinicalTrials.gov identifier).

The effect of experimentally induced gluteal muscle weakness on joint kinematics, reaction forces, and dynamic balance performance during deep bilateral squats.

Squatting is a common daily activity and fundamental exercise in resistance training and closed kinetic chain programs. The aim of this study was to investigate the effects of an experimentally induced weakness of the gluteal muscles on joint kinematics, reactions forces (JRFs), and dynamic balance performance during deep bilateral squats in healthy young adults. Ten healthy adults received sequential blocks of (1) branch of the superior gluteal nerve to the tensor fasciae latae (SGNtfl) muscle, (2) superior gluteal nerve (SGN), and (3) inferior gluteal nerve (IGN) on the dominant right leg. At the control condition and following each block, the participants were instructed to perform deep bilateral squats standing on two force plates. Hip, knee, ankle, and pelvis kinematics did not differ significantly following iatrogenic weakness of gluteal muscles. The most important finding was the significant differences in JRFs following SGN and IGN block, with the affected hip, patellofemoral, and ankle joint demonstrating lower JRFs, whereas the contralateral joints demonstrated significantly higher JRFs, especially the patellofemoral joint which demonstrated an average maximum difference of 1.43 x body weight compared with the control condition. When performing a deep bilateral leg squat under SGN and IGN block, the subjects demonstrated an increased center of pressure (CoP) range and standard deviation (SD) in mediolateral compared with the control condition. These results imply that squat performance changes significantly following weakness of gluteal muscles and should be considered when assessing and training athletes or patients with these injuries.

Augmented reality in ultrasound-guided regional anaesthesia: useful tool or expensive toy?

Use of augmented reality is increasingly applied in medical education and practice. The main advantage of this technology is the display of relevant information in the visual field of multiple operators. Here we provide a critical analysis of the potential application of augmented reality in regional anaesthesia.

Detection of heart rate using smartphone gyroscope data: a scoping review.

Heart rate (HR) is closely related to heart rhythm patterns, and its irregularity can imply serious health problems. Therefore, HR is used in the diagnosis of many health conditions. Traditionally, HR has been measured through an electrocardiograph (ECG), which is subject to several practical limitations when applied in everyday settings. In recent years, the emergence of smartphones and microelectromechanical systems has allowed innovative solutions for conveniently measuring HR, such as smartphone ECG, smartphone photoplethysmography (PPG), and seismocardiography (SCG). However, these measurements generally rely on external sensor hardware or are highly susceptible to inaccuracies due to the presence of significant levels of motion artifact. Data from gyrocardiography (GCG), however, while largely overlooked for this application, has the potential to overcome the limitations of other forms of measurements. For this scoping review, we performed a literature search on HR measurement using smartphone gyroscope data. In this review, from among the 114 articles that we identified, we include seven relevant articles from the last decade (December 2012 to January 2023) for further analysis of their respective methods for data collection, signal pre-processing, and HR estimation. The seven selected articles' sample sizes varied from 11 to 435 participants. Two articles used a sample size of less than 40, and three articles used a sample size of 300 or more. We provide elaborations about the algorithms used in the studies and discuss the advantages and disadvantages of these methods. Across the articles, we noticed an inconsistency in the algorithms used and a lack of established standardization for performance evaluation for HR estimation using smartphone GCG data. Among the seven articles included, five did not perform any performance evaluation, while the other two used different reference signals (HR and PPG respectively) and metrics for accuracy evaluation. We conclude the review with a discussion of challenges and future directions for the application of GCG technology.

[Noninvasive Treatments for Acute and Chronic Back Pain]. / Nicht-invasive Therapieansätze bei akuten und chronischen Rückenschmerzen.

Noninvasive Treatments for Acute and Chronic Back Pain Abstract. The therapy of back pain - especially the medication with opioids - can be challenging for the treating physician. Specific back pain can often be diagnosed by imaging and successfully treated by surgery or medication. In contrast, nonspecific back pain can be worsened by inappropriate imaging, questionable surgical indications and uncontrolled drug use. For the therapy of nonspecific back pain, maintaining daily activity and exercise therapy is central. Opioids are effective drugs for short-term use. However, long-term use often leads to opioid-induced hyperalgesia and hormonal dysfunction with decreased quality of life and libido. Furthermore, opioids can lead to abuse and addiction. After an ineffective treatment with non-opioids, opioids may be given for a limited time period (if possible shorter than four weeks) according to international guidelines.

Inadvertent Placement of an Infraclavicular Catheter in the Interscalene Region With an Unusual Complication: A Case Report.

An infraclavicular catheter is a very efficient technique to provide excellent perioperative anesthesia/analgesia for upper limb surgery. However, complications can occur and are dependent on the technique used. We report the inadvertent placement of an infraclavicular catheter in the interscalene region when an ultrasound-guided infraclavicular catheter was threaded cranially. We proposed some strategies to avoid the occurrence of complications when performing this block.

Physician anaesthesia providers in Switzerland today and tomorrow: results of the National Anaesthesia Workforce Study (NAWOS).

AIMS OF THE STUDY: The Swiss healthcare system is highly ranked, given its unrestricted access to specialised care and short waiting lists for surgery. However, the need for anaesthetic and surgical care is escalating owing to the increasing size and ageing of the Swiss population. In addition, to address the persistent and recurrent SARS-CoV-2 pandemic crisis, the speciality of anaesthesia is under tremendous pressure to maintain an effective workforce in order to address population needs. The current number, characteristics and future evolution of the physician anaesthesia workforce in Switzerland are currently unknown. The purpose of this study was to assess the size and professional and sociodemographic characteristics of the current anaesthesia workforce in Switzerland and to forecast its development up to 2034. METHODS: We performed a cross-sectional study using a 150-item questionnaire prepared by the National Anaesthesia Workforce Study Group (NAWOS). We included all physicians (trainees and certified) practising anaesthesia in Switzerland. We collected demographic and professional information, such as the current position, hospital characteristics, workload, number of shifts and future life plans. We built a computer-based Markov model with Monte Carlo simulations to project both supply and demand for physician anaesthesia provider positions. RESULTS: Of the 2661 distributed questionnaires, 1985 (74.2%) were completed and returned. We found that the average age of anaesthesiologists practising in Switzerland was 45.2 years, with 44.3% of them being women and 76.9% holding a Swiss specialist title. Only 59.6% of respondents worked full time. The forecasting model showed a steady increase in the number of anaesthesiologists retiring by 2034, with 27% of full-time equivalent jobs being lost in the next 8 years. Even if existing full-time equivalent training positions are all filled, a gradual deficit of anaesthesiologists is to be expected after 2022, and the deficit should culminate in 2034 with a deficit ratio of 0.87. CONCLUSIONS: Due to the upcoming high retirement rate of anaesthesiologists, Switzerland is likely to face a shortage of anaesthesiologists in the near future. To compensate for the shortage, the country will likely increase its reliance on medical staff trained abroad. Southern and eastern cantons of Switzerland are particularly at risk, given that they already heavily rely on foreign anaesthesia workforce. This reliance should be considered a national priority because anaesthesiologists are heavily involved in both the treatment of patients with respiratory complications of SARS-CoV2 infection and the care of surgical patients, the number of which is expected to rise steadily in upcoming years.

[Peripheral Regional Anaesthesia for Perioperative Analgesia]. / Periphere Regionalanästhesie oder Allgemeinanästhesie ­ eine individuelle Risiko-Nutzen-Abwägung.

Peripheral Regional Anaesthesia for Perioperative Analgesia Abstract. Peripheral regional anaesthesia is the actual gold standard of opioid-sparing perioperative analgesia and is mainly used for surgery of the shoulder, arm and leg. Well-trained anaesthesiologists are the prerequisite for the correct individual risk-benefit assessment and the performance of the nerve blocks using a combination of ultrasound guidance and peripheral nerve stimulation (dual guidance). The postoperative care of the patients requires trained staff.

Deltoid muscle contribution to shoulder flexion and abduction strength: an experimental approach.

BACKGROUND: The rotator cuff (RC) and the deltoid muscle are 2 synergistic units that enable the functionally demanding movements of the shoulder. A number of biomechanical studies assume similar force contribution of the force couple (RC and deltoid) over the whole range of motion, whereas others propose position-dependent force distribution. There is a lack of in vivo data regarding the deltoid's contribution to shoulder flexion and abduction strength. This study aimed to create reliable in vivo data quantifying the deltoid's contribution to shoulder flexion and abduction strength throughout the range of motion. METHODS: Active range of motion and isometric muscle strength of shoulder abduction and flexion in 0°, 30°, 60°, 90°, and 120° of abduction/flexion as well as internal and external rotation in 0° and 90° of abduction were obtained in 12 healthy volunteers on the dominant arm before and after an ultrasound-guided isolated axillary nerve block. Needle electromyography was performed before and after the block to confirm deltoid paralysis. Radiographs of the shoulder and an ultrasonographic examination were used to exclude relevant shoulder pathologies. RESULTS: Active range of motion showed a minimal to moderate reduction to 94% and 88% of the preintervention value for abduction and flexion. Internal and external rotation amplitude was not impaired. The abduction strength was significantly reduced to 76% at 0° (P = .002) and to 25% at 120° (P < .001) of abduction. The flexion strength was significantly reduced to 64% at 30° (P < .001) and to 30% at 120° (P < .001) of flexion. The strength reduction was linear, depending on the flexion/abduction angle. The maximal external rotation strength showed a significant decrease to 53% in 90° (P < .001) of abduction, whereas in adduction no strength loss was observed (P = .09). The internal rotation strength remained unaffected in 0° and 90° of abduction (P = .28; P = .13). CONCLUSION: The deltoid shows a linear contribution to maximal shoulder strength depending on the abduction or flexion angle, ranging from 24% in 0° to 75% in 120° of abduction and from 11% in 0° to 70% in 120° of flexion, respectively. The overall contribution to abduction strength is higher than to flexion strength. The combination of deltoid muscle and teres minor contributes about 50% to external rotation strength in 90° of abduction. The internal rotation strength is not influenced by a deltoid paralysis. This study highlights the position-dependent contribution of the shoulder muscles to strength development and thereby provides an empirical approach to better understand human shoulder kinematics.

Dislocation rates of perineural catheters placed either perpendicular or parallel to the femoral nerve: A randomised controlled trial.

BACKGROUND: Ultrasound has increased the efficacy of femoral nerve catheters but their postoperative dislocation still remains a common problem. Although catheter placement parallel to the nerve seems to reduce dislocation rates in other nerves and plexuses, the possible advantage for femoral nerve catheter placement remains unclear. OBJECTIVE: To compare the dislocation rates of femoral catheters when placed perpendicular or parallel to the femoral nerve. DESIGN: Randomised controlled study. SETTING: University orthopaedic hospital. Duration of study: October 2018 to June 2019. PATIENTS: Eighty patients scheduled for major knee surgery with femoral catheter were enrolled and randomly allocated in two groups. Data from 78 patients could be analysed. INTERVENTIONS: The femoral nerve catheters was placed perpendicular to the nerve in Group 1 (n=40), whereas in Group 2 (n=38) parallel to it. For Group 1 the short-axis view of the nerve and an in-plane puncture was used. For Group 2 we used the short-axis view of the nerve and an out-of-plane puncture technique combined with rotation of the transducer to the long-axis view with the needle in-plane. MAIN OUTCOME MEASURES: Primary outcome was the catheter dislocation rate in the first 48 h. Secondary outcomes were pain scores and sensory blockade. RESULTS: There was no statistically significant difference between the two techniques regarding dislocation of the catheters at 24 or 48 h (at 48 h, Group 1: 15%, Group 2: 2.6%, P = 0.109). Also pain scores, sensory blockade and rescue doses of ropivacaine did not differ between the groups. However, in Group 2 the technique took longer. CONCLUSION: Rotating the ultrasound probe to the long-axis in-plane view enabled examination of the catheter position when it was placed parallel to the nerve. The parallel placement of the catheter required more time, but did not significantly improve dislocation rate, pain scores or sensory blockade. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT03693755.

Ultrasonography-guided anterior approach for axillary nerve blockade: An anatomical study.

Combined ultrasound (US)-guided blockade of the suprascapular and axillary nerves (ANs) has been proposed as an alternative to interscalene blockade for pain control in shoulder joint pathology or postsurgical care. This technique could help avoid respiratory complications and/or almost total upper limb palsy. Nowadays, the AN blockade is mostly performed using an in-plane caudal-to-cephalic approach from the posterior surface of the shoulder, reaching the nerve immediately after it exits the neurovascular quadrangular space (part of the spatium axillare). Despite precluding most respiratory complications, this approach has not made postsurgical pain relief any better than an interscalene blockade, probably because articular branches of the AN are not blocked.Cephalic-to-caudal methylene blue injections were placed in the first segment of the AN of six Thiel-embalmed cadavers using an US-guided anterior approach in order to compare the distribution with that produced by a posterior approach to the contralateral AN in the same cadaver. Another 21 formalin-fixed cadavers were bilaterally dissected to identify the articular branches of the AN.We found a good spread of the dye on the AN and a constant relationship of this nerve with the subscapularis muscle. The dye reached the musculocutaneous nerve, which also contributes to shoulder joint innervation. We describe the anatomical landmarks for an ultrasonography-guided anterior AN blockade and hypothesize that this anterior approach will provide better pain control than the posterior approach owing to complete blocking of the joint nerve. Clin. Anat. 33:488-499, 2020. © 2019 Wiley Periodicals, Inc.

A Swiss nationwide survey shows that dual guidance is the preferred approach for peripheral nerve blocks.

Ultrasound has significantly increased safety and effectiveness in regional anesthesia. However, little is known about its clinical use. We studied clinical approaches currently used by anesthesiologists, conducted a nationwide survey, and analyzed data collected in ordered logistic regression models. All active members of the Swiss Society for Anaesthesiology and Resuscitation (SSAR/SGAR) were asked to participate. Reported practice in nerve localization, safety, and techniques used for peripheral nerve blocks (PNB) were main outcome measures. Experience ranged from 3 to >30 years. The mean number of block techniques mastered was 11.5 ± 5.9. Standard monitoring was regularly used, whereas sterile coats were less frequently used by anesthesiologists who self-estimated a higher level of expertise in PNB (ordered logit coefficient -0.05, 95% CI -0.07 to -0.02, P < 0.001; pseudo r2 = 0.019; probability > Chi2 = 0.02). The more self-estimated expertise anesthesiologists had, the less likely they were to use nerve stimulation in combination with ultrasound (dual guidance) (ordered logit coefficient -0.31; 95% CI -0.85 to -0.03: P = 0.03; pseudo r2 = 0.007; probability > Chi2 = 0.05). The high share of reported standard monitoring meets the recommendations of the Helsinki Patient Safety Declaration. Dual guidance appears to be the preferred approach for safely localizing nerves for PNB in Switzerland.

Early Recognition of a Transient Ischemic Attack Utilizing Cerebral Oxygenation Monitoring During Shoulder Surgery in the Beach Chair Position: A Case Report.

Shoulder surgery in the beach chair position is routinely performed, and central neurological events are rare but potentially devastating. We present a patient with transient neurological deficits after a sudden blood pressure drop with a simultaneous decrease of regional cerebral saturation values registered by cerebral oximetry. We reviewed published cases and proposed possible strategies to prevent the occurrence of similar complications in this context.

Ultrasound-Guided Approach for L5 Dorsal Ramus Block and Fluoroscopic Evaluation in Unpreselected Cadavers.

BACKGROUND AND OBJECTIVES: Medial branch blocks are frequently performed to diagnose lumbar facet-joint-mediated pain. Ultrasound guidance can increase practicability and eliminate exposure to ionizing radiation when compared with fluoroscopy. However, ultrasound-guided L5 dorsal ramus block, which, together with L4 medial branch block is necessary to anesthetize the most commonly affected facet joint L5/S1, has not been described so far. The objective of this study was to develop a technique and to evaluate its accuracy with standard fluoroscopy in unpreselected cadavers. METHODS: Twenty ultrasound-guided L5 dorsal ramus block approaches were performed with a new oblique out-of-plane technique in a rotated cross-axis view bilaterally in 10 cadavers. After checking the needle position in a second perpendicular sonographic plane, the final needle position was confirmed with conventional fluoroscopy by an independent observer. RESULTS: All cadavers had significant degenerations of the lumbar spine, and 5 of them had moderate to severe spondylolisthesis. Skin-to-target distances were 42 ±7 mm. Sixteen L5 dorsal ramus block attempts were located at the exact radiological target, 1 was slightly too lateral, and 3 were slightly too caudal (3-10 mm away). The overall success rate in unpreselected cadavers reached 80% (95% confidence interval, 56%-94%) and in the subgroup of corpses without spondylolisthesis 100% (95% confidence interval, 69%-100%). CONCLUSIONS: This is the first study to show that ultrasound-guided L5 dorsal ramus block is accurate and feasible in the absence of significant spondylolisthesis when performed with an oblique out-of-plane technique.

Use of a perineural coiled catheter at the sciatic nerve in dogs after tibial plateau levelling osteotomy - preliminary observations.

The analgesic effects of peripheral nerve blocks can be prolonged with the placement of perineural catheters allowing repeated injections of local anaesthetics in humans. The objectives of this study were to evaluate the clinical suitability of a perineural coiled catheter (PCC) at the sciatic nerve and to evaluate pain during the early post-operative period in dogs after tibial plateau levelling osteotomy. Pre-operatively, a combined block of the sciatic and the femoral nerves was performed under sonographic guidance (ropivacaine 0.5%; 0.3 mL kg-1 per nerve). Thereafter, a PCC was placed near the sciatic nerve. Carprofen (4 mg kg-1 intravenously) was administered at the end of anaesthesia. After surgery, all dogs were randomly assigned to receive four injections of ropivacaine (group R; 0.25%, 0.3 mL kg-1) or NaCl 0.9% (group C; 0.3 mL kg-1) every 6 h through the PCC. Pain was assessed by use of a visual analogue scale (VAS) and a multi-dimensional pain score (4Avet) before surgery (T-1), for 390 min (T0, T30, T60, T120, T180, T240, T300, T360 and T390) as well as 1 day after surgery (Day 1). Methadone (0.1 mg kg-1) was administered each time the VAS was ≥40 mm or the 4Avet was ≥5. At T390 dogs received buprenorphine (0.02 mg kg-1). Data were compared using Mann-Whitney rank sum tests and repeated measures analysis of variance. Regardless of group allocation, 55% of dogs required methadone. VAS was significantly lower at T390 (P = 0.003), and at Day 1 (P = 0.002) and so was 4Avet at Day 1 (P = 0.012) in group R than in group C. Bleeding occurred in one dog at PCC placement and PCC dislodged six times of 47 PCCs placed. Minor complications occurred with PCC but allowed four repeated administrations of ropivacaine or saline over 24 h in 91.5% of the cases.

Computer-tomographic verification of ultrasound-guided piriformis muscle injection: a feasibility study.

BACKGROUND: Approximately 6% to 8% of lumbar pain cases, whether associated with radicular pain or not, may be attributed to the presence of piriformis muscle syndrome. Available treatments, among others, include pharmacotherapy, physical therapy, and injections of different substances into the muscle. Various methods have been used to confirm correct needle placement during these procedures, including electromyography (EMG), fluoroscopy, computed tomography (CT), or magnetic resonance imaging (MRI). Ultrasonography (US) has now become a widely used technique and therefore may be an attractive alternative for needle guidance when injecting this muscle. OBJECTIVE: The objective of this study was to assess the reliability of US in piriformis injection of patients with piriformis syndrome. STUDY DESIGN: Feasibility study; 10 patients with piriformis muscle syndrome were injected with botulinum toxin A using a US-guided procedure. Then patients were administered 2 mL iodinated contrast and were then transferred to the CT scanner, where they underwent pelvic and hip imaging to assess intramuscular distribution of the iodinated contrast. SETTING: Multidisciplinary Pain Management Department in Spain. RESULTS: Of all 10 study patients (8 women, 2 men), 9 had intramuscular or intrafascial contrast distribution. Distribution did not go deeper than the piriformis muscle in any of the patients. The absence of contrast (intravascular injection) was not observed in any case. LIMITATIONS: The main limitation of our study is the use of ionizing radiation as confirmation technique. CONCLUSION: Ultrasound-guided puncture may be a reliable and simple procedure for injection of the piriformis muscle, as long as good education and training are provided to the operator. US has a number of advantages over traditional approaches, including accessibility and especially no ionizing radiation exposure for both health care providers and patients.