Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Deliberate practice using validated metrics improves skill acquisition in performance of ultrasound-guided peripheral nerve block in a simulated setting.

STUDY OBJECTIVES: The aim of this study was to compare the effects of deliberate vs. self-guided practices (both using validated metrics) on the acquisition of needling skills by novice learners. DESIGN: Randomized Controlled Study. SETTING: Simulation lab, Department of Anesthesia, St.Vincent's Hospital, Dublin. SUBJECTS: Eighteen medical students. INTERVENTIONS: Students were assigned to either (i) deliberate practice (n = 10) or (ii) self-guided practice (n = 8) groups. After completion of a 'learning phase', subjects attempted to perform a predefined task, which entailed advancing a needle towards a target on a phantom gel under ultrasound guidance. Subsequently, all subjects practiced this task using predefined metrics. Only subjects in the deliberate practice group had an expert anesthesiologist during practice. Immediately after completing 'practice phase', all subjects attempted to perform the same task, and, on the following day, made two further attempts in succession. Two trained consultant anesthesiologists assessed a video of each performance independently using the pre-defined metrics. MEASUREMENTS: Number of procedural steps completed and number of errors made. MAIN RESULTS: Compared with novices who self-guided their practice using metrics, those who undertook expert-supervised deliberate practice using metrics completed more steps (performance metrics) immediately after practice (median [range], 14.5 [12-15] vs. 3 [1-10], p < 0.0001) and 24 h later (15 [12-15] vs. 4.5 [1-11], p < 0.0001 and 15 [11-15] vs. 4 [2-14], p < 0.0001). They also made fewer errors immediately after practice (median [range], 0 [0-0] vs. 5 [3-8], p < 0.0001) and 24 h later, (0 [0-3] vs. 6.5 [3-8], p < 0.0001 and 0 [0-3] vs. 4 [2-7], p < 0.0001). CONCLUSION: Combining deliberate practice with metrics improved acquisition of needling skills.

Dexmedetomidine infusion for sedation during fiberoptic intubation: a report of three cases.

We report three patients undergoing cervical spine surgery who required awake fiberoptic intubation, and in whom sedation was provided using a dexmedetomidine infusion. Dexmedetomidine was used to provide a moderate level of sedation without causing respiratory distress or hemodynamic instability during fiberoptic intubation. Conditions for intubation were acceptable in all three patients after co-administration of topical anesthesia. Dexmedetomidine may serve as a useful adjunct for this procedure. The anesthetic management and anesthetic implications of using dexmedetomidine infusions for awake fiberoptic intubation are discussed.

Pharmacodynamic interactions between cisatracurium and rocuronium.

UNLABELLED: The onset and duration of maintenance doses of neuromuscular blocking drugs may be influenced by the original neuromuscular blocking drug used. We assessed the effect of the interaction between steroidal and benzo-isoquinolinium compounds on the clinical duration of maintenance doses of cisatracurium. Sixty adult patients undergoing anesthesia with isoflurane, nitrous oxide, and oxygen were randomized to receive the following: Group I = rocuronium 0.6 mg/kg followed by cisatracurium 0.03 mg/kg when the first twitch in the train-of-four (TOF) recovered to 25%, Group II = cisatracurium 0.15 mg/kg followed by cisatracurium 0.03 mg/kg, and Group III = rocuronium 0.6 mg/kg followed by rocuronium 0.15 mg/kg. Neuromuscular blockade was monitored using acceleromyography (TOF-Guard, Boxtel, The Netherlands). The clinical duration (mean +/- SD) of the first 2 maintenance doses was 41 +/- 10, 31 +/- 7++, and 25 +/- 8++ min, and 39 +/- 11, 30 +/- 6+, 29 +/- 9* min in Groups I-III, respectively (*P < 0.05, +P < 0.01, ++P < 0.001; Group I versus II and III). Thus, the clinical duration of the first two maintenance doses of cisatracurium was prolonged when administered after rocuronium. IMPLICATIONS: We assessed the clinical effect of administering cisatracurium after an intubating dose of rocuronium in 60 patients undergoing isoflurane/nitrous oxide and oxygen anesthesia. The clinical duration of the first two maintenance doses of cisatracurium administered after rocuronium was significantly prolonged. This supports the contention that combinations of structurally dissimilar neuromuscular blocking drugs result in a synergistic effect.

Unusual presentation and complication of the prone position for spinal surgery.

Patient positioning for operative procedures has long been associated with perioperative complications. We present a case report of shoulder dislocation, which occurred following positioning in the prone position, and was detected by axillary artery occlusion resulting in the loss of the radial artery blood pressure line waveform. We discuss the diagnosis and consequences of this complication.

Severe phantom leg pain in an amputee after lumbar plexus block.

OBJECTIVES: To describe the onset of phantom leg pain in an amputee with the performance of a lumbar plexus block and the subsequent alleviation after the performance of a sciatic nerve block. CASE REPORT: A 72-year-old American Society of Anesthesiologists physical status III woman presented for left total hip arthroplasty. Her history was significant for a left below the knee amputation. Since the amputation she had suffered from intermittent phantom leg pain. A lumbar plexus block was performed for postoperative pain management. After the lumbar plexus block, the patient experienced severe pain radiating to the left phantom foot. Because of the severity of the phantom pain, a sciatic nerve block was performed. The phantom leg pain resolved within 5 minutes. The intraoperative care under general anesthesia was uneventful. After surgery the patient had continued blockade in both nerve distributions with excellent analgesia. Full recovery of the lumbar plexus and sciatic nerve function was present on the first postoperative day. CONCLUSION: The temporal relationship between the onset of the phantom leg pain and the lumbar plexus block suggests a causal relationship. In this case, it appears that ongoing peripheral input from the lumbar plexus may have been sufficient for the tonic inhibition of phantom pain in the sciatic distribution. The immediate reactivation of the phantom pain and its subsequent relief suggests dynamic processing of peripheral inputs by central neurons, which apparently is rapid and reversible in some cases of phantom pain.

A study of anesthetic drug utilization in different age groups.

STUDY OBJECTIVE: To determine anesthetic drug utilization in different age groups. DESIGN: Retrospective, automated, intraoperative database study. SETTING: Tertiary care medical center. MEASUREMENTS: 30,842 noncardiac general anesthesia case records between January 1991 and July 1997 were studied. We investigated the effect of age on anesthetic requirements for fentanyl (F), midazolam (M), thiopental sodium (T), propofol (P), isoflurane (I), and nitrous oxide (N). Because drugs are not given in isolation we looked at the most common drug combinations, IFNTM, IFNPM, INFT, and PFNM. Regression analyses on log-transformed drug dosages were used to test the significance of age on individual requirements. RESULTS: In each of the above anesthetic drug combinations, reduced doses of fentanyl, propofol, midazolam, thiopental, and isoflurane were used with increasing age. Fentanyl, propofol, thiopental, and isoflurane showed a 10%, 8%, 6%, and 4% reduction in dose per decade of age, respectively, from age of maximum dose to age 80 years. CONCLUSIONS: In clinical practice, increasing age results in decreased anesthetic drug administration. The mechanism of this observation needs to be determined.

Central nervous system toxicity following the administration of levobupivacaine for lumbar plexus block: A report of two cases.

BACKGROUND AND OBJECTIVES: Central nervous system and cardiac toxicity following the administration of local anesthetics is a recognized complication of regional anesthesia. Levobupivacaine, the pure S(-) enantiomer of bupivacaine, was developed to improve the cardiac safety profile of bupivacaine. We describe 2 cases of grand mal seizures following accidental intravascular injection of levobupivacaine. CASE REPORT: Two patients presenting for elective orthopedic surgery of the lower limb underwent blockade of the lumbar plexus via the posterior approach. Immediately after the administration of levobupivacaine 0.5% with epinephrine 2.5 microgram/mL, the patients developed grand mal seizures, despite negative aspiration for blood and no clinical signs of intravenous epinephrine administration. The seizures were successfully treated with sodium thiopental in addition to succinylcholine in 1 patient. Neither patient developed signs of cardiovascular toxicity. Both patients were treated preoperatively with beta-adrenergic antagonist medications, which may have masked the cardiovascular signs of the unintentional intravascular administration of levobupivacaine with epinephrine. CONCLUSIONS: Although levobupivacaine may have a safer cardiac toxicity profile than racemic bupivacaine, if adequate amounts of levobupivacaine reach the circulation, it will result in convulsions. Plasma concentrations sufficient to result in central nervous system toxicity did not produce manifestations of cardiac toxicity in these 2 patients.

A new teaching model for resident training in regional anesthesia.

UNLABELLED: The adequacy of resident education in regional anesthesia is of national concern. A teaching model to improve resident training in regional anesthesia was instituted in the Anesthesiology Residency in 1996 at Duke University Health System. The key feature of the model was the use of a CA-3 resident in the preoperative area to perform regional anesthesia techniques. We assessed the success of the new model by comparing the data supplied by the Anesthesiology Residency to the Residency Review Committee for Anesthesiology for the training period July 1992-June 1995 (pre-model) and the training period July 1998-June 2001 (post-model). During the 3-yr training period, the pre-model CA-3 residents (n = 12) performed a cumulative total of 80 (58-105) peripheral nerve blocks (PNBs), 66 (59-74) spinal anesthetics, and 133 (127-142) epidural anesthetics. The CA-3 post-model residents (n = 10) performed 350 (237-408) PNBs, 107 (92-123) spinal anesthetics, and 233 (221-241) epidural anesthetics (P < 0.0001). All results are reported as median (interquartile range). We conclude that our new teaching model using our CA-3 residents as block residents in the preoperative area has increased their clinical exposure to PNBs. IMPLICATIONS: Inadequate exposure to peripheral nerve blocks has been a national problem. A teaching model instituted at Duke University Health System has resulted in a fourfold increase in exposure to peripheral nerve blocks compared with the national averages.