Defining success in regional anaesthesia.

Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.

Dominant hand operating probe vs needle: a comparison study of ultrasound-guided needle placement in phantom models.

We conducted a replicated crossover design study to assess if using one's dominant hand for operating a probe vs directing a needle would affect the time taken, the number of needle passes and the accuracy of an ultrasound-guided procedure in phantom models. Twenty ultrasound-novice participants completed the task 10 times for each hand arrangement (alternating between attempts). The time taken and number of needle passes required for both dominant hand-probe and hand-needle decreased over time (p = 0.001). Dominant hand-needle had a lower mean time used (p = 0.001) and fewer needle passes (p = 0.02) compared with hand-probe. Sixty-five per cent of participants preferred using their dominant hand to direct the needle. When learning ultrasound-guided needle procedures on phantom models, use of the dominant hand to operate the needle is associated with a shorter procedure time and fewer needle passes.

Triple regional anaesthesia technique in resection of left pleuropulmonary sarcoma and left subclavian artery bypass.

A 28-year-old woman presented for excision of a left-sided pleuropulmonary sarcoma which was adherent to her left subclavian artery and mediastinum. A left upper lobe wedge resection was performed via a median sternotomy and a left carotid artery-to-left subclavian artery bypass was performed through a left supraclavicular incision. We report on a triple regional anaesthesia technique to provide postoperative analgesia. We inserted bilateral transverse thoracic plane catheters for continuous local anaesthetic infusion and performed bilateral subcostal transversus abdominus plane blocks for drain site analgesia. A left superficial cervical plexus block was performed to cover pain from the supraclavicular incision. Anteromedial chest wall blocks are an emerging analgesic technique for sternotomy and were successfully used as part of a combined regional anaesthetic for a patient undergoing complex thoracic surgery.

Peripheral nerve blocks with sedation using propofol and alfentanil target-controlled infusion for hip fracture surgery: a review of 6 years in use.

BACKGROUND AND OBJECTIVES: Over the last 6 years, our center has introduced a novel technique combining peripheral nerve blocks (femoral and lateral femoral cutaneous nerves) with sedation using propofol with alfentanil target-controlled infusion for hip fracture surgery. The purpose of this review was to identify if adverse outcomes (of mortality and length of stay) were associated with its introduction compared to spinal or general anesthesia. METHODS: Retrospective data collection from hospital fracture database. Data were analyzed using Cox regression (adjusted for age, sex, and American Society of Anesthesiologists grade) to compare survival and length of stay data across the different anesthetic techniques used for hip fracture surgery. RESULTS: This technique was used in 472 (20%) of 2360 hip fractures. There was no significant difference between peripheral nerve blocks with propofol/alfentanil sedation/analgesia for mortality up to 120days (hazard ratio, 0.76; 95% confidence interval, 0.54-1.06; P=.11) and length of stay (hazard ratio, 1.03; 95% confidence interval, 0.91-1.17; P=.63) when compared to the other anesthetic techniques of spinal and general anesthesia. CONCLUSION: This novel technique does not appear to be associated with adverse mortality or length of stay after hip fracture surgery.

Locally advanced rectal cancer: histopathological correlation and predictive accuracy of serial MRI after neoadjuvant chemotherapy.

The accuracy of MRI after long-course chemoradiotherapy (CRT) in locally advanced rectal cancer (LARC) has been questioned. We have evaluated our experience of sequential MRI to assess pre-operative downstaging with histopathology correlation. 17 patients with LARC had three MRI scans: MRI 1, before treatment; MRI 2, 6 weeks post-CRT; and MRI 3, pre-operatively. MRI T and N staging were reported, with T3 subdivided into T3a (<5 mm through wall), T3b (1-5 mm), T3c (5-15 mm) and T3d (>15 mm). The maximal wall measurements and a prediction of vascular involvement were also correlated with histopathology. Histopathological agreement with MRI 3 was high: T 82%; N 88% and vascular 73%. Statistically significant (p<0.01) T downstaging was shown in MRI 2 and MRI 3 groups. In the 6 weeks post-CRT scan, T downstaging occurred in 6% of patients, with a further 29.4% showing T3c to T3b downsizing. 41% showed N stage improvement. In the third MRI group pre-surgery, 41.2% showed an MRI T stage improvement, with a further T3 downsizing in 17.6% of patients. 50% of these responders had shown no T stage improvement on their second scan. The sequential scans also showed significant reduction in wall thickness (p<0.01). In conclusion, the pre-operative MRI showed ongoing response to CRT up to 12 weeks post-CRT, which has important clinical implications regarding the most appropriate time to operate. Improved agreement between MRI 3 and histopathology compared with previous studies including only one post-treatment MRI was also demonstrated.

A new modification of the Rinne test.

A modification of Rinne's test is described. The result of the test is dependent on many factors and in particular the force with which the tuning fork is applied to the mastoid process is important. Most authorities state that firm pressure should be used but the precise force required is inadequately defined. A modification of a standard tuning fork was therefore designed which allows measurement of the actual force used. 100 ears with confirmed conductive hearing losses were examined. Rinne's test was performed on each ear comparing three different forces. The forces used were 400 g (3.9 N) corresponding to light pressure, 2400 g (23.5 N) corresponding to firm pressure, and an intermediate and indeterminate force corresponding to normal clinical performance of the test. The optimum force in this study is 2400 g (23.5 N) force. This gives increased sensitivity, specificity and accuracy compared to lesser forces. More accurate measurement of the force used allows better reproducibility and more meaningful comparison of the results thus obtained.

The laryngeal mask airway in paediatric anaesthesia.

Forty-eight children, aged between 2 and 10 years, admitted as day cases for otological surgery were allocated at random into two groups. The first group was anaesthetised using a standard facemask, and the second with a laryngeal mask airway. The laryngeal airway produced a satisfactory airway in all children, and was inserted on the first attempt in 67% of patients. Hypoxia was significantly less frequent in the laryngeal airway group (p less than 0.05), and there were significantly fewer interruptions to surgery than in the facemask group (p less than 0.001). Patient safety, operating and anaesthetic conditions were all considered superior in the laryngeal airway group.