Prospective, Randomized Double-Blind Study: Does Decreasing Interscalene Nerve Block Volume for Surgical Anesthesia in Ambulatory Shoulder Surgery Offer Same-Day Patient Recovery Advantages?

BACKGROUND AND OBJECTIVES: In this randomized double-blind prospective study in patients undergoing shoulder arthroscopy, we compared the effects of ultrasound-guided interscalene nerve block using 20 mL (intervention group) and 40 mL (control group) of a mepivacaine 1.5% and bupivacaine 0.5% mixture (1:1 volume) on ipsilateral handgrip strength and other postoperative end points. METHODS: One hundred fifty-four patients scheduled for ambulatory shoulder arthroscopy were randomly assigned to receive a single-injection interscalene block under ultrasound guidance with either 40 mL (control) or 20 mL (intervention) and intravenous sedation. The primary outcome was the change in ipsilateral handgrip strength in the postanesthesia care unit (PACU) measured with a dynamometer. Secondary end points were recorded, including negative inspiratory force, incidences of hoarseness and Horner syndrome, time to readiness for discharge from PACU, time to discharge from PACU, patient satisfaction, time to block resolution, and pain scores. RESULTS: Postoperative handgrip strength was greater in the 20-mL group compared with the 40-mL group (difference in means, 2.3 kg [95% confidence interval, 0.6-4.0 kg]; P = 0.009). A smaller proportion of patients in the intervention group experienced hoarseness postoperatively compared with the control group (odds ratio, 0.26 [95% confidence interval, 0.08-0.82]; P = 0.015). Patient satisfaction and duration of analgesia were similar in both groups. CONCLUSIONS: When used for surgical anesthesia for shoulder arthroscopies in the ambulatory setting, a 20-mL volume in an ultrasound-guided interscalene block preserves greater handgrip strength on the ipsilateral side in the PACU compared with 40 mL without significant decrease in block success, duration of analgesia, and patient satisfaction.

Severe anaphylactoid reaction to thymoglobulin in a pediatric renal transplant recipient.

Intraoperative administration of thymoglobulin is an integral part of the anti-rejection regimen during organ transplantation. However, its administration may be associated with complications. An anaphylactoid reaction that occurred in a pediatric recipient of a living-related renal transplant, on initiating an intravenous infusion of thymoglobulin, is presented.

Neuroimaging for the anesthesiologist.

This article provides an overview of neuroimaging modalities of particular interest to the anesthesiologist caring for neurosurgical patients. Imaging characteristics of neuropathologies and considerations for anesthetic management of diagnostic procedures are discussed.

Anesthesia for pediatric deep brain stimulation.

In patients refractory to medical therapy, deep brain stimulations (DBSs) have emerged as the treatment of movement disorders particularly Parkinson's disease. Their use has also been extended in pediatric and adult patients to treat epileptogenic foci. We here performed a retrospective chart review of anesthesia records from 28 pediatric cases of patients who underwent DBS implantation for dystonia using combinations of dexmedetomidine and propofol-based anesthesia. Complications with anesthetic techniques including airway and cardiovascular difficulties were analyzed.

"Scalp block" during craniotomy: a classic technique revisited.

Local anesthesia of the nerves of the scalp is referred to as "scalp block." This technique was originally introduced more than a century ago, but has undergone a modern rebirth in intraoperative and postoperative anesthetic management. Here, we review the use of "scalp block" during craniotomy with its anatomic basis, historical evolution, current technique, potential advantages, and pitfalls. We also address its current and potential future applications.

Requirement for protein synthesis at developing synapses.

Activity and protein synthesis act cooperatively to generate persistent changes in synaptic responses. This forms the basis for enduring memory in adults. Activity also shapes neural circuits developmentally, but whether protein synthesis plays a congruent function in this process is poorly understood. Here, we show that brief periods of global or local protein synthesis inhibition decrease the synaptic vesicles available for fusion and increase synapse elimination. Ca(2+)/calmodulin-dependent protein kinase II (CaMKII) is a critical target; its levels are controlled by rapid turnover, and blocking its activity or knocking it down recapitulates the effects of protein synthesis inhibition. Mature presynaptic terminals show decreased sensitivity to protein synthesis inhibition, and resistance coincides with a developmental switch in regulation from CaMKII to PKA (protein kinase A). These findings demonstrate a novel mechanism regulating presynaptic activity and synapse elimination during development, and suggest that protein translation acts coordinately with activity to selectively stabilize appropriate synaptic interactions.

Occurrence of alpha-synuclein pathology in the cerebellum of Guamanian patients with parkinsonism-dementia complex.

Amyotrophic lateral sclerosis/parkinsonism-dementia complex (ALS/PDC) is a progressive neurodegenerative disease affecting the indigenous Chamorro population of Guam. Neuropathologically, PDC is characterized by neuronal loss in the substantia nigra pars compacta with severe widespread neurofibrillary tangles (NFTs) similar to those observed in Alzheimer's disease (AD), and is thus considered a tauopathy. Following reports of alpha-synuclein pathology in PDC patients of Guam, PDC has also been neuropathologically classified as a synucleinopathy. Recently, the presence of alpha-synuclein-positive bodies has been reported in the cerebellum of some patients with Parkinson's disease (PD), diffuse Lewy body disease (DLBD), or multiple system atrophy (MSA). Using immunohistochemical techniques, we investigated the deposition of alpha-synuclein in the cerebellum of Guamanian PDC patients. Numerous alpha-synuclein-immunoreactive spherical structures were found in the molecular layer of the cerebellum of 63.6% of PDC patients. These structures were only seen in patients showing alpha-synuclein pathology in the amygdala. The average density of alpha-synuclein-immunoreactive structures in the cerebellum of Guamanian PDC patients was almost an order of magnitude higher than in non-Guamanian PD patients, and this alpha-synuclein pathology was much more pronounced in the hemisphere than in the vermis. In addition, double immunohistochemistry revealed that cerebellar alpha-synuclein is co-localized with the neuronal marker calbindin and with glial-fibrillary acidic protein, suggesting the involvement of Purkinje cells and Bergmann glia. These findings demonstrate that the alpha-synuclein pathology in PDC of Guam affects not only the amygdala, but also the cerebellum, where it appears to involve both Purkinje cells and specialized astrocytes.