Deep Learning Detection and Segmentation of Facet Joints in Ultrasound Images Based on Convolutional Neural Networks and Enhanced Data Annotation.

The facet joint injection is the most common procedure used to release lower back pain. In this paper, we proposed a deep learning method for detecting and segmenting facet joints in ultrasound images based on convolutional neural networks (CNNs) and enhanced data annotation. In the enhanced data annotation, a facet joint was considered as the first target and the ventral complex as the second target to improve the capability of CNNs in recognizing the facet joint. A total of 300 cases of patients undergoing pain treatment were included. The ultrasound images were captured and labeled by two professional anesthesiologists, and then augmented to train a deep learning model based on the Mask Region-based CNN (Mask R-CNN). The performance of the deep learning model was evaluated using the average precision (AP) on the testing sets. The data augmentation and data annotation methods were found to improve the AP. The AP50 for facet joint detection and segmentation was 90.4% and 85.0%, respectively, demonstrating the satisfying performance of the deep learning model. We presented a deep learning method for facet joint detection and segmentation in ultrasound images based on enhanced data annotation and the Mask R-CNN. The feasibility and potential of deep learning techniques in facet joint ultrasound image analysis have been demonstrated.

Unilateral interlaminar fenestration on the convex side provides a reliable access for intrathecal administration of nusinersen in spinal muscular atrophy: a retrospective study.

BACKGROUND: As the first gene therapy for spinal muscular atrophy (SMA), nusinersen is supposed to be administrated via intrathecal injection regularly for a lifetime. However, for SMA patients with severe spinal deformities, bony fusion following posterior spinal instrumentation sets great obstacles for the application of nusinersen. Therefore, efforts have been devoted to the exploration of appropriate approach for nusinersen administration. This study aims to evaluate the safety and reliability of unilateral interlaminar fenestration on the convex side during spinal fusion surgery for intrathecal nusinersen injection in SMA. RESULTS: SMA patients receiving posterior spinal fusion and interlaminar fenestration in Peking Union Medical College Hospital from January 2020 to October 2021 were retrospectively analyzed. 13 patients were included. Of the 13 patients, 10 were classified into SMA type II and 3 into SMA type III. Distal fusion to pelvis was undertaken in 11 patients; while L5 was selected as the lowest instrumented vertebra in the other 2 patients. All patients received interlaminar fenestration on the convex side only with an area of about 15 mm × 20 mm. Fenestration at L2-L3 level was performed in 6 patients; while L3-L4 level was selected for windowing in the remaining 7 patients. 9 of the 13 patients received lumbar puncture and intrathecal nusinersen administration during the 1-year follow-up, with an accumulative total of 50 times. All injections were performed successfully under ultrasound guidance, with no one transferred to radiographic assistance. No severe complications occurred after injection. CONCLUSIONS: In SMA with severe scoliosis planning to receive posterior spinal fusion, unilateral lumbar interlaminar fenestration on the convex side provides a feasible and reliable access for intrathecal nusinersen administration after surgery.

The effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy: a randomized, double-blinded, controlled study.

BACKGROUND: We aimed to investigate the effects of intermittent bolus paravertebral block on analgesia and recovery in open hepatectomy. METHODS: Eighty 18-70 years old, American Society of Anesthesiologists level I-III patients scheduled for hepatectomy with a J-shaped subcostal incision were enrolled and randomized to receive either intermittent bolus paravertebral ropivacaine (0.5% loading, 0.2% infusion) or 0.9% saline infusion at 1:1 ratio (25 ml loading before surgery, 0.125 ml/kg/h bolus for postoperative 48 h). The primary outcome was set as postoperative 48 h cumulative intravenous morphine consumption recorded by a patient-controlled analgesic pump. RESULTS: Thirty-eight patients in each group completed the study. The cumulative morphine consumptions were lower in the paravertebral block than control group at postoperative 24 (difference -10.5 mg, 95%CI -16 mg to -6 mg, P < 0.001) and 48 (difference -12 mg, 95%CI -19.5 mg to -5 mg, P = 0.001) hours. The pain numerical rating scales at rest were lower in the paravertebral block than control group at postoperative 4 h (difference -2, 95%CI -3 to -1, P < 0.001). The active pain numerical rating scales were lower in the paravertebral block than control group at postoperative 12 h (difference -1, 95%CI -2 to 0, P = 0.005). Three months postoperatively, the paravertebral block group had lower rates of hypoesthesia (OR 0.28, 95%CI 0.11 to 0.75, P = 0.009) and numbness (OR 0.26, 95%CI 0.07 to 0.88, P = 0.024) than the control group. CONCLUSIONS: Intermittent bolus paravertebral block provided an opioid-sparing effect and enhanced recovery both in hospital and after discharge in patients undergoing hepatectomy. TRIAL REGISTRATION: clinicaltrials.gov (NCT04304274), date: 11/03/2020.

Proposal of a Route Map for Cervical Spinal Ultrasonography: A Simple and Clear Learning Tool for Beginners.

Spinal ultrasonography has increasingly been used to image axial structures from the cervical to sacral region in recent years. In this work, we propose a comprehensive, systematic cervical scanning protocol that we refined as a route map, especially for beginners, to facilitate teaching, learning, diagnosis, and treatment in clinical pain practice. As a simple and clear tool to demonstrate the scanning protocol, the route map is delineated with rectangles, lines, and arrows. The rectangles represent the positions of the transducer, the arrows indicate route directions, and the lines show the routes of transducer movement. In this article, we describe cervical spinal ultrasonography to illustrate the route map interpretation, scanning protocol and target anatomical structures in detail. We believe that this comprehensive, clear, systematic, and portable route map will be beneficial for inexperienced pain clinicians and ultrasound beginners.

Developing a magnetic POCUS-guided bronchoscope for patients with suspected difficult endotracheal intubation in a general tertiary hospital: protocol for a randomised controlled study.

INTRODUCTION: Endotracheal intubation (ETI) is a crucial but risky procedure, especially among patients suspected of difficult endotracheal intubation (DTI). Bronchoscope, as an improved technique commonly used in DTI, might encounter visualisation difficulties. The magnetic point-of-care ultrasound (MGPOCUS) provides a novel visualisation from the outside and enables estimation of the relative position and trajectory of the bronchoscope. The purpose of the study was to evaluate the efficiency of MGPOCUS-guided bronchoscopy, including the time required for successful ETI, the first attempt and overall success rate, the number of attempts, complications, and satisfaction with the visualization of the procedures. METHODS AND ANALYSIS: The study is a randomised, parallel-group, single-blinded, single-centre study. Participants (n=108) will be recruited by the primary anaesthesiologist and randomised to groups of ETI with bronchoscope or MGPOCUS-guided bronchoscope. The primary outcome is the time taken to the first-attempt success ETI. Secondary outcomes include procedure time, the first-attempt and overall success, complications, and satisfaction of visualisation. Cox regression with Bonferroni correction and linear mixed regression will be used to analyse the outcomes. ETHICS AND DISSEMINATION: The trial protocol was approved by the ethics committees at the Peking Union Medical College Hospital (Institutional Review Board #ZS-3428). Findings will be disseminated through conference presentations and peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05647174.

Ultrasound-guided pulsed radiofrequency versus dry needling for pain management in chronic neck and shoulder myofascial pain syndrome patients at a tertiary hospital in China: a randomised controlled trial protocol.

INTRODUCTION: Myofascial pain syndrome (MPS), especially in the neck and shoulder region, is one of the most common chronic pain disorders worldwide. Dry needling (DN) and pulsed radiofrequency (PRF) are the two effective methods for treating MPS. We aimed to compare the effects of DN and PRF in chronic neck and shoulder MPS patients. METHODS AND ANALYSIS: This is a prospective, single-centre, randomised, controlled trial in a tertiary hospital. We plan to recruit 108 patients aged 18-70 years who are diagnosed with chronic MPS in the neck, shoulder and upper back regions and randomly allocate them to either the DN or PRF group at a 1:1 ratio. The DN group will receive ultrasound-guided intramuscular and interfascial DN 8-10 times per pain point or until local twitch responses are no longer elicited and 30 min of indwelling. The PRF group will receive ultrasound-guided intramuscular (0.9% saline 2 mL, 42℃, 2 Hz, 2 min) and interfascial (0.9% saline 5 mL, 42℃, 2 Hz, 2 min) PRF. Follow-up will be performed by the research assistant at 0, 1, 3 and 6 months postoperatively. The primary outcome is the postoperative 6-month pain visual analogue score (0-100 mm). Secondary outcomes include pressure pain threshold measured by an algometer, Neck Disability Index, depression (Patient Health Questionnaire-9), anxiety (Generalised Anxiety Disorder-7), sleep status (Likert scale) and overall quality of life (36-Item Short Form Survey). Between-group comparisons will be analysed using either a non-parametric test or a mixed effects linear model. ETHICS AND DISSEMINATION: This study was approved by the medical ethics committee of Peking Union Medical College Hospital (JS-3399). All participants will give written informed consent before participation. The results from this study will be shared at conferences and disseminated in international journals. TRIAL REGISTRATION NUMBER: NCT05637047, Pre-results.

Comparison of the Postoperative Analgesic Effects between Ultrasound-Guided Transmuscular Quadratus Lumborum Block and Thoracic Paravertebral Block in Laparoscopic Partial Nephrectomy Patients: A Randomized, Controlled, and Noninferiority Study.

Background: This prospective, randomized, double-blinded, noninferiority study aimed to compare the effects of analgesia and recovery between transmuscular quadratus lumborum block (TMQLB) and paravertebral block (PVB). Methods: Sixty-eight, American Society of Anesthesiologists level I-III patients, who underwent laparoscopic partial nephrectomy in Peking Union Medical College Hospital were randomly allocated to either TMQLB or PVB group (independent variable) in a 1 : 1 ratio. The TMQLB and PVB groups received corresponding regional anesthesia preoperatively with 0.4 ml/kg of 0.5% ropivacaine and follow-up at postoperative 4, 12, 24, and 48 hours. The participants and outcome assessors were blinded to group allocation. We hypothesized that the primary outcome, postoperative 48-hour cumulative morphine consumption, in the TMQLB group was not more than 50% of that in the PVB group. Secondary outcomes including pain numerical rating scales (NRS) and postoperative recovery data were dependent variables. Results: Thirty patients in each group completed the study. The postoperative 48-hour cumulative morphine consumption was 10.60 ± 5.28 mg in the TMQLB group and 6.40 ± 3.40 mg in the PVB group. The ratio (TMQLB versus PVB) of postoperative 48-hour morphine consumption was 1.29 (95% CI: 1.13-1.48), indicating a noninferior analgesic effect of TMQLB to PVB. The sensory block range was wider in the TMQLB group than in the PVB group (difference 2 dermatomes, 95% CI 1 to 4 dermatomes, P=0.004). The intraoperative analgesic dose was higher in the TMQLB group than in the PVB group (difference 32 µg, 95% CI: 3-62 µg, P=0.03). The postoperative pain NRS at rest and on movement, incidences of side effects, anesthesia-related satisfaction, and quality of recovery scores were similar between the two groups (all P > 0.05). Conclusions: The postoperative 48-hour analgesic effect of TMQLB was noninferior to that of PVB in laparoscopic partial nephrectomy. This trial is registered with NCT03975296.

Automatic detection of A-line in lung ultrasound images using deep learning and image processing.

BACKGROUND: Auxiliary diagnosis and monitoring of lung diseases based on lung ultrasound (LUS) images is important clinical research. A-line is one of the most common indicators of LUS that can offer support for the assessment of lung diseases. A traditional A-line detection method mainly relies on experienced clinicians, which is inefficient and cannot meet the needs of these areas with backward medical level. Therefore, how to realize the automatic detection of A-line in LUS image is important. PURPOSE: In order to solve the disadvantages of traditional A-line detection methods, realize automatic and accurate detection, and provide theoretical support for clinical application, we proposed a novel A-line detection method for LUS images with different probe types in this paper. METHODS: First, the improved Faster R-CNN model with a selection strategy of localization box was designed to accurately locate the pleural line. Then, the LUS image below the pleural line was segmented for independent analysis excluding the influence of other similar structures. Next, image-processing methods based on total variation, matched filter, and gray difference were applied to achieve the automatic A-line detection. Finally, the "depth" index was designed to verify the accuracy by judging whether the automatic measurement results belong to corresponding manual results (±5%). In experiments, 3000 convex array LUS images were used for training and validating the improved pleural line localization model by five-fold cross validation. 850 convex array LUS images and 1080 linear array LUS images were used for testing the trained pleural line localization model and the proposed image-processing-based A-line detection method. The accuracy analysis, error statistics, and Harsdorff distance were employed to evaluate the experimental results. RESULTS: After 100 epochs, the mean loss value of training and validation set of improved Faster R-CNN model reached 0.6540 and 0.7882, with the validation accuracy of 98.70%. The trained pleural line localization model was applied in the testing set of convex and linear probes and reached the accuracy of 97.88% and 97.11%, respectively, which were 3.83% and 8.70% higher than the original Faster R-CNN model. The accuracy, sensitivity, and specificity of A-line detection reached 95.41%, 0.9244%, 0.9875%, and 94.63%, 0.9230%, and 0.9766% for convex and linear probes, respectively. Compared to the experienced clinicians' results, the mean value and p value of depth error were 1.5342 ± 1.2097 and 0.9021, respectively, and the Harsdorff distance was 5.7305 ± 1.8311. In addition, the accumulated accuracy of the two-stage experiment (pleural line localization and A-line detection) was calculated as the final accuracy of the whole A-line detection system. They were 93.39% and 91.90% for convex and linear probes, respectively, which were higher than these previous methods. CONCLUSIONS: The proposed method combining image processing and deep learning can automatically and accurately detect A-line in LUS images with different probe types, which has important application value for clinical diagnosis.

Ultrasound-Guided Continuous Thoracic Paravertebral Block Improves Patient's Quality of Recovery After Open Hepatectomy: A Randomized, Double-Blind, Placebo-Controlled Trial.

Background Ultrasound-guided continuous thoracic paravertebral block can provide pain-relieving and opioid-sparing effects in patients receiving open hepatectomy. We hypothesize that these effects may improve the quality of recovery (QoR) after open hepatectomy. Methods Seventy-six patients undergoing open hepatectomy were randomized to receive a continuous thoracic paravertebral block with ropivacaine (CTPVB group) or normal saline (control group). All patients received patient-controlled intravenous analgesia with morphine postoperatively for 48 hours. The primary outcome was the global Chinese 15-item Quality of Recovery score on postoperative day 7, which was statistically analyzed using Student's t-test. Results Thirty-six patients in the CTPVB group and 37 in the control group completed the study. Compared to the control group, the CTPVB group had significantly increased global Chinese 15-item Quality of Recovery scores (133.14 ± 12.97 vs. 122.62 ± 14.89, P = 0.002) on postoperative day 7. Postoperative pain scores and cumulative morphine consumption were significantly lower for up to 8 and 48 hours (P < 0.05; P = 0.002), respectively, in the CTPVB group. Conclusion Perioperative CTPVB markably promotes patient's QoR after open hepatectomy with a profound analgesic effect in the early postoperative period.

Dyspnea induced by hemidiaphragmatic paralysis after ultrasound-guided supraclavicular brachial plexus block in a morbidly obese patient.

RATIONALE: Hemidiaphragmatic paralysis (HDP) is a frequent complication of the brachial plexus block, caused by unintentional blockade of ipsilateral phrenic nerve. HDP did not rise enough alarm and attention to most anesthesiologists, because most patients with no coexisting comorbid diseases are asymptomatic and able to tolerate it. However, it may cause severe respiratory complication for patients with preexisting compromised cardiorespiratory function. PATIENT CONCERNS: A 67-year-old woman with morbidly obesity was planned to receive opening reduction and internal fixation of right humeral shaft fracture under regional anesthesia considering less respiratory and cardiovascular system interference compared with general anesthesia. DIAGNOSES: After ultrasound guided supraclavicular brachial plexus block, the patient developed severe hypoxia and hypercapnia.Unintentional block of phrenic nerve and diaphragm paralysis was diagnosed by diaphragm ultrasound, which was considered as the main reason of severe hypoxia. INTERVENTIONS: It led to a conversion from regional anesthesia to general anesthesia with endotracheal intubation for patient's safety and smooth operation. OUTCOMES: The unintentional phrenic nerve block leads to a prolonged ventilation time, length of stay in intensive care unit and length of stay in hospital. LESSONS: This case report highlights the risk of diaphragm paralysis in morbidly obese patients. Though new diaphragm sparing brachial plexus block (BPB) methods were developed intended to reduce the risk of HDP, no approaches could absolutely spare phrenic nerve involvement. Therefore, clinicians should always consider the risk of HDP associated with BPBs. For each individual, a detailed preoperative evaluation and sufficient preparation are paramount to avoid serious complications.

Transmuscular quadratus lumborum block for postoperative pain and recovery after laparoscopic adrenalectomy: a randomized controlled trial.

BACKGROUND: To investigate the role of transmuscular quadratus lumborum block (TMQLB) for postoperative pain control, patient satisfaction and recovery in laparoscopic adrenalectomy. METHODS: Seventy-two patients aged between 18 and 70 years with an ASA I-II and scheduled for laparoscopic adrenalectomy were randomized to receive a single-shot TMQLB with 0.4 ml/kg 0.5 % ropivacaine or 0.4 ml/kg 0.9 % saline as placebo. The primary endpoint was pain on movement at 12 h after surgery evaluated by the numeric rating scale (NRS, 0-10). P-values < 0.05 was considered statistically significant. The secondary outcomes included pain at rest and pain on movement evaluated by the NRS, and postoperative recovery related parameters. RESULTS: NRS on movement at 12 h after surgery was lower in the TMQLB group compared with the control (median 2 vs. 3, p = 0.024). Intraoperative fentanyl consumption was lower in the TMQLB group (247.08 ± 63.54 vs. 285.44 ± 74.70, p = 0.022). The rate of using postoperative rescue tramadol was also lower in the TMQLB group (5.6 vs. 27.8 %, p = 0.027). Similar incidences of nausea and vomiting were observed (11.1 vs. 25 %, p = 0.220). Patient satisfaction of pain service was better in the TMQLB group (83.3 vs. 25 %, p < 0.001) with shorter time to ambulation (16.5 vs. 21 h, p = 0.004) and flatus (18.5 vs. 23.5 h, p = 0.006). CONCLUSIONS: TMQLB showed better control of postoperative pain on movement for laparoscopic adrenalectomy with improved patients' satisfaction of anesthesia, shorter time to ambulation and flatus. TRIAL REGISTRATION: This study was registered at Clinicaltrials.gov ( NCT03942237 ; registration date: 08/05/2019; enrollment date: 10/05/2019).

Ultrasound-guided nusinersen administration for spinal muscular atrophy patients with severe scoliosis: an observational study.

BACKGROUND: This observational study describes our experience delivering nusinersen through lumbar puncture with real-time ultrasound guidance in spinal muscular atrophy (SMA) patients with severe scoliosis. RESULTS: Intrathecal nusinersen via real-time ultrasound-guided lumbar puncture was given to three patients who had severe thoracic and lumbar scoliosis: a 34-year-old female with type 3a SMA, a 28-year-old male with type 2a SMA, and a 14-year-old girl with type 3a SMA. Lumbar puncture was performed without sedation under ultrasound guidance using a 22G echogenic needle in the interlaminar aspect of the L4-L5 or L5-S1 interspace and a full dose of nusinersen (12 mg/5 mL) was injected after visualizing free cerebrospinal fluid flow. Patients completed their four loading doses and one maintenance dose of nusinersen. All 15 procedures were successful and well tolerated. CONCLUSIONS: Real-time ultrasound-guided lumbar puncture is an effective and radiation-free technique to administer intrathecal nusinersen in SMA patients with severe scoliosis when done by practitioners with expertise in this procedure.

Continuous block at the proximal end of the adductor canal provides better analgesia compared to that at the middle of the canal after total knee arthroplasty: a randomized, double-blind, controlled trial.

BACKGROUND: The optimal position for continuous adductor canal block (ACB) for analgesia after total knee anthroplasty (TKA) remians controversial, mainly due to high variability in the localization of the the adductor canal (AC). Latest neuroanatomy studies show that the nerve to vastus medialis plays an important role in innervating the anteromedial aspect of the knee and dives outside of the exact AC at the proximal end of the AC. Therefore, we hypothesized that continuous ACB at the proximal end of the exact AC could provide a better analgesic effect after TKA compared with that at the middle of the AC (which appeared to only block the saphenous nerve). METHODS: Sixty-two adult patients who were scheduled for a unilateral TKA were randomized to receive continuous ACB at the proximal end or middle of the AC. All patients received patient-controlled intravenous analgesia with sufentanil postoperatively. The primary outcome measure was cumulative sufentanil consumption within 24 h after the surgery, which was analyzed using Mann-Whitney U tests. P-values < 0.05 (two-sided) were considered statistically significant. The secondary outcomes included postoperative sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. RESULTS: Sixty patients eventually completed the study (30/group). The 24-h sufentanil consumption was 0.22 µg/kg (interquartile range [IQR]: 0.15-0.40 µg/kg) and 0.39 µg/kg (IQR: 0.23-0.52 µg/kg) in the proximal end and middle groups (P = 0.026), respectively. There were no significant inter-group differences in sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. CONCLUSIONS: Continuous ACB at the proximal end of the AC has a better opioid-sparing effect without a significant influence on quadriceps motor strength compared to that at the middle of the AC after TKA. These findings indicates that a true ACB may not produce the effective analgesia, instead, the proximal end AC might be a more suitable block to alleviate pain after TKA. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov ( NCT03942133 ; registration date: May 06, 2019; enrollment date: May 11, 2019).

Transmuscular quadratus lumborum block versus thoracic paravertebral block for acute pain and quality of recovery after laparoscopic renal surgery: study protocol for a randomized controlled trial.

BACKGROUND: Quadratus lumborum block (QLB) is increasingly gaining popularity as a novel abdominal truncal block in abdominal surgery; however, the mechanism of QLB is not yet thoroughly illustrated. The focus of our study is transmuscular QLB (TMQLB), as the latest anatomical evidence shows that anesthetics spread into the thoracic paravertebral space to exert an analgesic effect. Therefore, we designed this study to compare TMQLB with thoracic paravertebral block (TPVB) in laparoscopic renal surgery in the hope of providing clinical evidence on the analgesic mechanism of TMQLB and its application in laparoscopic renal surgery. METHODS: This trial is a prospective, randomized, single-center, open-label, parallel, three-arm, non-inferiority trial. We intend to include 120 participants undergoing laparoscopic nephrectomy and before surgery they will be randomized into three groups for postoperative pain control: TMQLB experimental group 1 (0.4 ml/kg body weight 0.5% ropivacaine), TMQLB experimental group 2 (0.6 ml/kg body weight 0.5% ropivacaine) or TPVB control group (0.4 ml/kg body weight 0.5% ropivacaine at vertebra T10). Patients will be excluded if they have allergy to anesthetics, infection at the injection site, are on coagulopathy or anticoagulants, on analgesics for chronic illness, have history of substance abuse or have a barrier to communication. Morphine is given in boluses of 1.5~2 mg by intravenous patient-controlled analgesia (IPCA) in the first 48 h after surgery. The primary outcome is the difference between TMQLB group 1 and the TPVB group in the mean visual analogue scale (VAS) pain score in the first 24 h after surgery. Secondary outcomes are the difference between TMQLB group 2 and the TPVB group in the mean VAS score in the first 24 h after surgery, cumulative morphine consumption, long-term pain control, dermatomal distribution of sensory loss, nausea score, pruritus score, ambulation time, time till recovery of bowel movement, quality of recovery, postoperative length of hospital stay and patient satisfaction with anesthesia. Safety data on procedure-related complications will also be summarized. DISCUSSION: This will the first randomized controlled trial to compare TMQLB with TPVB for analgesia in laparoscopic surgery. This trial aims to provide important clinical evidence to elaborate on the analgesic mechanism of TMQLB. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03414281 . Registered on 9 January 2018.

Ultrasound-guided Selective Cervical Nerve Root Block Plus Superficial Cervical Plexus Block for Minimally Invasive Parathyroidectomy.

Objective To explore the efficacy and safety of ultrasound-guided cervical root block (CRB) in patients undergoing minimally invasive parathyroidectomy (MIP).Methods We enrolled 35 patients with hyperparathyroidism undergoing MIP in Peking Union Medical College Hospital.C4-7 nerve roots were identified in ultrasound imaging by the shape of the transverse process.A 50 mm insulated needle was gently introduced by an in-plane approach toward the posterior edge of the nerve root located at the inside of the posterior tubercle.After careful aspiration,a total of 3-4 ml of a mixture of 0.5% ropivacaine and 1% lidocaine was slowly injected.The superficial block was administered at the midpoint of the posterior border of the sternocleidomastoid by injecting 5-6 ml of the same mixture.The patients were administrated with dexmedetomidine during the surgery.All patients were assessed for sensory following the procedure and for pain after the surgery.Results Totally 35 patients successfully received MIP under ultrasound-guided CRB plus superficial block.There was no conversion to general anesthesia,no toxic reaction of local anesthetics,and no intravertebral injection.Hoarseness occurred in 6 patients (17.1%) and Horner syndrome occurred in 3 patients (8.6%).The median cold sensory visual analogue scale score was 1.2 [0,5] points at 10 minutes after the procedure.Patient's satisfaction score was 9.5 points.Conclusion Ultrasound-guided CRB plus superficial block can achieve accurate and safe anesthesia,and it provides lasting analgesic effect during and after MIP.

Low-dose Simvastatin Increases Skeletal Muscle Sensitivity to Caffeine and Halothane.

Objective To determine whether the myotoxic side effects of statin simvastatin affect skeletal muscle's sensitivity to caffeine and halothane.Methods Primary cultured neonate rat skeletal myotubes were treated with 0.01-5.0 µmol/L simvastatin for 48 hours. MTT was used to evaluate cellular viability. The gross morphology and microstructure of the myotubes were observed with a light and electron microscope, respectively. The intracellular calcium concentrations ([Ca2+]i) at rest and in response to caffeine and halothane were investigated by fluorescence calcium imaging. Data were analyzed by analysis of variance (ANOVA) test.Results Simvastatin (0.01-5.0 µmol/L) decreased myotube viability, changed their morphological features and microstructure, and increased the resting [Ca2+]i in a dose-dependent manner. Simvastatin did not change myotube's sensitivity to low doses of caffeine (0.625-2.5 mmol/L) or halothane (1.0-5.0 mmol/L). In response to high-dose caffeine (10.0 mmol/L, 20.0 mmol/L) and halothane (20.0 mmol/L, 40.0 mmol/L), myotubes treated with 0.01 µmol/L simvastatin showed a significant increase in sensitivity, but those treated with 1.0 µmol/L and 5.0 µmol/L simvastatin showed a significant decrease. The sarcoplasmic reticulum Ca2+ storage peaked in the myotubes treated with 0.01 µmol/L simvastatin, but it decreased when cells were treated with higher doses of simvastatin (0.1-5.0 µmol/L).Conclusions The myotoxic side effect of simvastatin was found to change the sensitivity of myotubes in response to high-dose caffeine and halothane. When dose was low, sensitivity increased mainly because of increased Ca2+ content in the sarcoplasmic reticulum, which might explain why some individuals with statin-induced myotoxic symptoms may show positive caffeine-halothane contracture test results. However, when the dose was high and the damage to the myotubes was severer, sensitivity was lower. It is here supposed that the damage itself might put individuals with statin-induced myotoxic symptoms at greater risks of presenting with rhabdomyolysis during surgery or while under anesthesia.

Ultrasound-guided Transversus Abdominis Plane Block Improves Postoperative Analgesia and Early Recovery in Patients Undergoing Retroperitoneoscopic Urologic Surgeries: A Randomized Controlled Double-blinded Trial.

Objective To evaluate the effects of ultrasound-guided transversus abdominis plane (TAP) block on postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries. Methods This was a randomized, controlled, double-blinded trial. Eligible patients scheduled for retroperitoneoscopic urologic surgeries were randomly assigned to two groups. Group TAP received ultrasound-guided TAP block with 0.5% ropivacaine 20 ml at 30 minutes before surgery, and Group C received TAP sham block with normal saline. All patients received retroperitoneoscopic urologic surgeries under general anesthesia. The primary outcome was the severity of pain after surgery. Secondary outcomes included opioids consumption, analgesics, postoperative nausea and vomiting, time to Foley catheter removal and to passage of flatus, length of post-anesthesia care unit stay and hospital stay. Results Eighty patients completed the study, forty cases in each group. Compared to the Group C, the Group TAP had lower visual analogue scale pain scores within two postoperative days (all P<0.05). They also had less consumption of intraoperative fentanyl (2.0±0.5 vs. 3.8±0.7 µg/kg, P<0.05), reduced incidence of postoperative rescue analgesic usage (12.5% vs. 45.0%, P<0.05), and lower incidence of postoperative nausea and vomiting within postoperative 48 hours (12.5% vs. 25.0%, P<0.05) when compared to the Group C. In addition, Group TAP had a shortened post-anesthesia care unit stay (25±8 vs. 49±12 minutes, P<0.05), and a greater proportion of patients discharged within postoperative three days (57.5% vs. 35.0%, P<0.05). Conclusion Preoperative ultrasound-guided TAP block is an effective technique to improve postoperative analgesia and early recovery in patients undergoing retroperitoneoscopic urologic surgeries.

Parental state anxiety correlates with preoperative anxiety in Chinese preschool children.

AIM: Preoperative anxiety in children is largely dependent on age and is influenced by anxiety level in parents. The current study compared the level of preoperative anxiety in preschool children versus school-aged children and its relationship with the state and trait anxiety of the parents. METHODS: This study included 54 preschool children (2-5 years of age) and 48 school-age children (6-12 years) scheduled to receive ear, nose and throat, plastic or ophthalmologic surgeries. Preoperative anxiety of children was assessed in the holding area immediately prior to the surgery using a modified Yale Preoperative Anxiety Scale (m-YPAS). Compliance with anaesthesia induction was assessed using an Induction Compliance Checklist (ICC). The state and trait anxiety of the parent who accompanied the child was assessed using a State-Trait Anxiety Inventory (STAI) questionnaire. RESULTS: Both m-YPAS and ICC scores were higher in preschool children than in school-age children with significant correlation between the two measures. The STAI-S score of parents was higher in the preschool group than in the school-age group. No significant difference was found in STAI-T score between the two age groups. Children's m-YPAS score correlated with parental STAI-T score in both groups (rho = 0.297, P = 0.029 and rho = 0.338, P = 0.019, respectively) but only with STAI-S score in the preschool group (rho = 0.400, P = 0.003). CONCLUSIONS: Both preschool children and their parents are more anxious than school-age dyads prior to surgery. The anxiety level of the children correlates with state anxiety of the parents in preschool children but not in school-age children.