Thoracic Epidural Analgesia Use in Large Recurrent Desmoid Fibromatosis Resection: A Case Report.

We present a case report of the successful use of thoracic epidural analgesia for the surgical resection of a large recurrent desmoid tumor and forequarter amputation in an adolescent male. Spinal anesthesia has been reported for intra-operative management of desmoid tumor resection, however, there are no reported cases of thoracic epidural analgesia for this tumor. Thoracic epidural should be used with caution in this patient population due to risk of de novo tumor creation but can be useful adjuvant to multi-modal analgesia to decrease post-operative opioid requirement.

Evaluation of the B-Smart manometer and the CompuFlo computerized injection pump technology for accurate needle-tip injection pressure measurement during peripheral nerve blockade.

BACKGROUND AND OBJECTIVES: The exact mechanism of peripheral nerve blocks causing/leading to nerve injury remains controversial. Evidence from animal experiments suggests that intrafascicular injection resulting in high injection pressure has the potential to rupture nerve fascicles and may consequently cause permanent nerve injury and neurological deficits. The B-Smart (BS) in-line manometer and the CompuFlo (CF) computerized injection pump technology are two modalities used for monitoring pressure during regional anesthesia. This study sought to explore the accuracy of these two technologies in measuring needle-tip pressures in a simulated environment. METHODS: In seven simulated needle-syringe combinations, the BS and the CF devices were connected in series through a closed system and attached to a digital manometer at the tip of various needles. The pressures were evaluated in three trials per needle-syringe combination. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy (F1 Score) were determined for each needle type and overall. RESULTS: For pressures ≥15 psi and ≥20 psi, respectively, the CF device demonstrated a sensitivity of 100%, 100%; specificity of 96%, 98%; positive predictive value 93%, 93%; and negative predictive value of 100%, 100%. The BS device demonstrated a sensitivity of 60%, 100%; specificity of 99%, 95%; positive predictive value of 96%, 85%; and negative predictive value of 85%, 100%. Accuracy, as measured by the F1 Score, for detecting a pressure of ≥15 psi was 0.96 for the CF and 0.74 for the BS. CONCLUSIONS: Future research is needed to explore in-vivo performance and evaluate whether either of these devices can impact on clinical outcomes.

Accuracy and consistency of modern elastomeric pumps.

Continuous peripheral nerve blockade has become a popular method of achieving postoperative analgesia for many surgical procedures. The safety and reliability of infusion pumps are dependent on their flow rate accuracy and consistency. Knowledge of pump rate profiles can help physicians determine which infusion pump is best suited for their clinical applications and specific patient population. Several studies have investigated the accuracy of portable infusion pumps. Using methodology similar to that used by Ilfeld et al, we investigated the accuracy and consistency of several current elastomeric pumps.

A 3-dimensional ultrasound study of local anesthetic spread during lateral popliteal nerve block: what is the ideal end point for needle tip position?

BACKGROUND AND OBJECTIVES: Recent clinical trials suggest that subfascial (sometimes termed subepineural) injections result in faster block onset and success compared with conventional techniques. This prospective, randomized, observer-blinded study measured and compared the 3-dimensional spread pattern and volume of perineural local anesthetic (LA) in contact with the sciatic nerve after subfascial versus extrafascial lateral popliteal injections. METHODS: Sixty patients were randomly assigned to either the subfascial or the extrafascial injection group. All patients received a single-injection, US-guided lateral popliteal sciatic nerve block for postoperative pain. Depending on group assignment, the needle tip was placed outside or beneath the sciatic fascial sheath for a single injection of 30 mL of ropivacaine 0.5%. Using 3-dimensional ultrasound imaging, postblock scans were acquired to quantify the volume and spread pattern of perineural LA around the sciatic nerve in each group. RESULTS: The mean LA perineural volume for the extrafascial group was 1.48 (SD, 0.50) mL versus a mean of 5.57 (SD, 1.68) mL for the subfascial group, P < 0.05. The mean distance of longitudinal perineural LA spread (along the length of the nerve) for the subfascial group was 66% greater than that observed using the conventional technique (9.3 vs 5.6 cm, P < 0.01). Complete sensory block to pinprick for the extrafascial group was 63% versus 90% (P < 0.05) for the subfascial group. CONCLUSIONS: Placement of the needle tip beneath the complex fascial sheath of the sciatic nerve resulted in significantly greater perineural local anesthetic volume following a single-injection lateral popliteal approach at the nerve bifurcation and was associated with greater sensory blockade and a characteristic laminar LA spread pattern.

Pyoderma gangrenosum--rebel without a cure?

BACKGROUND: Pyoderma gangrenosum (PG) is a rare neutrophilic, ulcerating dermatosis that is frequently difficult to diagnose and often a diagnosis of exclusion. It is hypothesized that PG may be caused by an abnormal T-cell and neutrophil response, which correlates with its common link to other disorders, such as inflammatory bowel disease, rheumatoid arthritis, and malignancies. Several treatments have been used successfully for PG, but none has proven to be universally effective. METHODS: We present three cases of PG treated with adalimumab after failed courses of steroids (orally and parenterally), thalidomide, cyclosporine, and mycophenolate mofetil. RESULTS: Patients 2 and 3, who had previously responded to infliximab, albeit with recurrence, were successfully treated with adalimumab at a dose of 40 mg once a week. Patient 1 initially responded to adalimumab, but after 7.5 months failed to show wound bed improvement at a dose of 80 mg/week subcutaneously. This patient had not previously been treated with infliximab. CONCLUSION: We believe adalimumab to be a valuable alternative for the treatment of PG, with comparable efficacy to infliximab.