A randomized controlled trial investigating rectus sheath catheters following radical cystectomy.

OBJECTIVE: To evaluate whether rectus sheath catheter (RSC) insertion may be an alternative to thoracic epidural (TE). PATIENTS AND METHODS: In a non-blinded, single-centre, non-inferiority study, patients undergoing open radical cystectomy were randomized 1:1 to receive either a TE or surgically placed RSC. The primary endpoint was cumulative opiate use (median oral morphine equivalent [OME]) in the first 72 h postoperatively. Secondary outcomes included visual analogue scale pain scores, measures of postoperative recovery including mobility and time to regular diet, and complications. RESULTS: Ninety-seven patients were randomized (51 TE, 46 RSC). The median OME was 103 (77.5-132.5) mg in the TE arm and 161.75 (117.5-187.5) mg in the RSC arm. A Mann-Whitney U-test confirmed non-inferiority of RSC to TE at a threshold of 15 mg OME (P = 0.002). When comparing pain scores for the first three postoperative days, an early difference was observed that favoured the TE group during post-anaesthesia care unit stay, which was lost after postoperative day 1. Patient satisfaction with analgesia on the third postoperative day was similar in the two arms (P = 0.47). There were no statistically significant differences between arms with respect to the other secondary outcomes. CONCLUSIONS: The outcomes from this prospective randomized trial demonstrated non-inferiority of RSC insertion compared to TE with respect to 72-h opiate use. Patient satisfaction with pain control on postoperative day 3 was the same for each group.

A comparative study on position and paramedian neuraxial access on healthy volunteers using three-dimensional models registered to lumbar spine ultrasound.

PURPOSE: Optimizing patient position and needle puncture site are important factors for successful neuraxial anesthesia. Two paramedian approaches are commonly utilized and we sought to determine whether variations of the seated position would increase the chance of puncture success. METHODS: We simulated paramedian needle passes on three-dimensional lumbar spine models registered to volumetric ultrasound data acquired from ten healthy volunteers in three different positions: 1) prone; 2) seated with thoracic and lumbar flexion; and 3) seated as in position 2, but with a 10° dorsal tilt. Simulated paramedian needle passes from the right side performed on validated models were used to determine L2-3 and L3-4 neuraxial target size and success. We selected two paramedian puncture sites according to standard anesthesia textbook descriptions: 10 mm lateral and 10 mm caudal from inferior edge of the superior spinous process as described by Miller, and 10 mm lateral from the superior edge of the inferior spinous process as described by Barash. RESULTS: A significant increase in the area available for dural puncture was found in the L2-3 (61-62 mm2) and L3-4 (76-79 mm2) vertebral levels for all seated positions relative to the prone position (P < 0.001). Similarly, a significant increase in the total number of successful punctures was found in the L2-3 (77-79) and L3-4 (119-120) vertebral levels for all seated positions relative to the prone position (P < 0.001). No differences were found between seated positions. The Barash puncture site achieved a higher number of successful punctures than the Miller puncture site in both the L2-3 (19) and L3-4 (84) vertebral levels (P < 0.001). CONCLUSION: An added dorsal table tilt did not increase puncture success in the seated position. The landmarks for puncture site described by Barash resulted in significantly more successful punctures compared with those described by Miller in all positions.

RéSUMé: OBJECTIF: L'optimisation de la position du patient et celle du site de ponction de l'aiguille sont des facteurs importants pour la réussite d'une anesthésie neuraxiale. Deux approches paramédianes sont fréquemment utilisées et nous avons tenté de déterminer si des variations de la position assise augmenteraient la probabilité de réussite de la ponction. MéTHODE: Nous avons simulé les passages paramédians de l'aiguille sur des modèles tridimensionnels de la colonne lombaire adaptés à partir de données d'échographie volumétriques acquises auprès de dix volontaires sains placés dans trois positions différentes : 1) couché sur le ventre; 2) assis en flexion thoraco-lombaire; et 3) assis comme en position 2, mais avec une inclinaison dorsale de 10°. Les passages paramédians simulés de l'aiguille du côté droit réalisés sur des modèles validés ont été utilisés pour déterminer la taille des cibles neuraxiales L2­3 et L3­4 ainsi que la réussite de la ponction. Nous avons sélectionné deux sites de ponction paramédians selon les descriptions de deux manuels d'anesthésie standard, soit 10 mm en latéral et 10 mm en caudal depuis le bord inférieur de l'apophyse épineuse supérieure tel que décrit par celui de Miller, et 10 mm en latéral depuis le bord supérieur de l'apophyse épineuse inférieure, tel que décrit par celui de Barash. RéSULTATS: Une augmentation significative de la surface disponible pour la ponction durale a été observée aux niveaux vertébraux L2­3 (61­62 mm2) et L3­4 (76­79 mm2) dans les deux positions assises par rapport à la position ventrale (P < 0,001). De la même manière, nous avons observé une augmentation significative du nombre total de ponctions durales réussies aux niveaux vertébraux L2­3 (77­79) et L3­4 (119­120) dans les deux positions assises par rapport à la position ventrale (P < 0,001). Aucune différence n'a été observée entre les deux positions assises. Le site de ponction selon le manuel de Barash a permis la réalisation d'un nombre plus élevé de ponctions réussies que le site de ponction selon celui de Miller, tant au niveau vertébral L2­3 (19) qu'au niveau L3­4 (84) (P < 0,001). CONCLUSION: L'ajout d'une inclinaison du plan dorsal n'a pas augmenté le taux de réussite de la ponction en position assise. Les repères utilisés pour le site de ponction décrits par le manuel de Barash ont entraîné un nombre significativement plus élevé de ponctions réussies que ceux décrits par celui de Miller, toutes positions confondues.

Impact of leg movement on skin-adductor canal distance: a potential cause for catheter tip displacement?

PURPOSE: Catheter-based adductor canal blocks are an effective pain management strategy for total knee arthroplasty. Nevertheless, catheter-based techniques may fail if the tip migrates because of leg movement. This observational study used ultrasound to measure the distance from the skin to the adductor canal (SAC). We tested the hypothesis that leg movements mimicking those occurring during postoperative physiotherapy change the SAC distance. METHODS: Following total knee arthroplasty under spinal anesthesia, the SAC distance was measured using ultrasound in 40 patients. The leg was passively moved into five standardized positions: neutral, neutral position with manual lateral displacement of the skin, 30° external rotation, straight leg raised to 30°, and knee and hip flexed to 90°. RESULTS: The mean (standard deviation) SAC distance change from the neutral position was +1.0 (0.6) cm with manual displacement, +0.3 (0.4) cm with external rotation, +0.4 (0.4) cm with straight leg raise, and +0.6 (0.5) cm with leg flexion (P < 0.001 for all positions). SAC distance changes did not correlate with height, body mass index, or leg circumference. CONCLUSION: Passive leg movements in five standardized positions increase the SAC distance. We speculate that the altered SAC distance associated with passive leg movement may contribute to catheter tip dislodgement and adductor canal block failure. TRIAL REGISTRATION: www.clinicaltrials.gov , NCT03562559; registered 19 June, 2018.

RéSUMé: OBJECTIF: Les blocs du canal des adducteurs utilisant un cathéter constituent une stratégie efficace du contrôle de la douleur pour l'arthroplastie totale de genou. Néanmoins, les techniques reposant sur des cathéters peuvent échouer si leur extrémité migre du fait d'un mouvement de la jambe. Cette étude observationnelle a utilisé l'échographie pour mesurer la distance séparant la peau du canal des adducteurs (P-CA). Nous avons testé l'hypothèse que des mouvements de la jambe imitant ceux qui surviennent au cours de la physiothérapie postopératoire modifient la distance P-CA. MéTHODES: Après une arthroplastie totale de genou sous rachianesthésie, la distance P-CA a été mesurée par échographie chez 40 patients. La jambe a été mobilisée passivement dans cinq positions standardisées : position neutre, position neutre avec déplacement latéral manuel de la peau, rotation latérale de 30°, jambe tendue soulevée à 30° et, enfin, genou et hanche fléchis à 90°. RéSULTATS: La modification de la distance P-CA moyenne (écart-type) à partir de la position neutre a été +1,0 (0,6) cm avec le déplacement manuel, +0,3 (0,4) cm avec la rotation latérale, +0,4 (0,4) cm avec la jambe tendue soulevée et +0,6 (0,5) cm avec la jambe fléchie (P < 0,001 pour toutes les positions). Les modifications de la distance P-CA n'étaient pas corrélées à la taille, l'indice de masse corporelle ou la circonférence de la jambe du patient. CONCLUSION: Les mouvements passifs de la jambe dans cinq positions standardisées augmentent la distance P-CA. Nous pensons que la modification de la distance P-CA associée à un mouvement passif de la jambe peut contribuer au déplacement de l'extrémité du cathéter et à l'échec du bloc du canal des adducteurs. ENREGISTREMENT DE L'ESSAI CLINIQUE: www.clinicaltrials.gov, NCT 03562559; Enregistré le 19 juin 2018.

Comparison of Patient Position and Midline Lumbar Neuraxial Access Via Statistical Model Registration to Ultrasound.

Patient positioning and needle puncture site are important for lumbar neuraxial anesthesia. We sought to identify optimal patient positioning and puncture sites with a novel ultrasound registration. We registered a statistical model to volumetric ultrasound data acquired from volunteers (n = 10) in three positions: (i) prone; (ii) seated with thoracic and lumbar flexion; and (iii) seated as in position ii, with a 10° dorsal tilt. We determined injection target size and penetration success by simulating lumbar injections on validated registered models. Injection window and target area sizes in seated positions were significantly larger than those in prone positions by 65% in L2-3 and 130% in L3-4; a 10° tilt had no significant effect on target sizes between seated positions. In agreement with computed tomography studies, simulated L2-3 and L3-4 injections had the highest success at the 50% and 75% midline puncture sites, respectively, measured from superior to inferior spinous process. We conclude that our registration to ultrasound technique is a potential tool for tolerable determination of puncture site success in vivo.

Multidisciplinary in-situ simulation to evaluate a rare but high-risk process at a level 1 trauma centre: the "Mega-Sim" approach

Summary: Multidisciplinary simulation has been used to successfully teach crisis resource management in operating room and emergency department settings. This article describes a "Mega-Sim" approach using an in-situ simulation that moves among multiple hospital departments to enhance multidisciplinary training and assess institutional response to a rare but high-risk event: trauma in a pregnant patient. It appears that a Mega-Sim can be used to identify systems issues, increase medical knowledge and improve perceptions of teamwork and communication within and among hospital departments.

Effect of table tilt and spine flexion-rotation on the acoustic window of the lumbar spine in pregnant women / Efeito da inclinação da mesa e flexão da coluna sobre a janela acústica da coluna lombar em mulheres grávidas

Abstract Study objective: The purpose of this study was to assess whether application of dorsal table tilt and body rotation to a parturient seated for neuraxial anesthesia increased the size of the paramedian target area for neuraxial needle insertion. Setting: Labor and Delivery Room. Patients: Thirty term pregnant women, ASA I-II, scheduled for an elective C-section delivery. Interventions: Lumbar ultrasonography was performed in four seated positions: (F) lumbar flexion; (FR) as in position F with right shoulder rotation; (FT) as in position F with dorsal table-tilt; (FTR) as in position F with dorsal table-tilt combined with right shoulder rotation. Measurements: For each position, the size of the 'target area', defined as the visible length of the posterior longitudinal ligament was measured at the L3-L4 interspace. Main results: The mean posterior longitudinal ligament was 18.4 ± 4 mm in position F, 18.9 ± 5.5 mm in FR, 19 ± 5.3 mm in FT, and 18 ± 5.2 mm in FTR. Mean posterior longitudinal ligament length was not significantly different in the four positions. Conclusions: These data show that the positions studied did not increase the target area as defined by the length of the posterior longitudinal ligament for the purpose of neuraxial needle insertion in obstetric patients. The maneuvers studied will have limited use in improving spinal needle access in pregnant women.

Resumo Objetivo do estudo: O objetivo deste estudo foi avaliar se a inclinação lateral da mesa cirúrgica e a rotação do corpo de uma parturiente sentada para anestesia neuraxial aumentou o tamanho da área-alvo paramediana para a inserção da agulha neuraxial. Ambiente: Sala de parto. Pacientes: Trinta grávidas a termo, ASA I-II, agendadas para cesárea eletiva. Intervenções: Ultrassonografia lombar foi feita em quatro posições sentadas: (F) flexão lombar; (FR) como na posição F com rotação do ombro direito; (FT) como na posição F com inclinação lateral da mesa cirúrgica; (FTR) como na posição F com inclinação lateral da mesa cirúrgica combinada com a rotação do ombro direito. Mensurações: Para cada posição, o tamanho da "área-alvo", definido como o comprimento visível do ligamento longitudinal posterior, foi medido no interespaço de L3-L4. Principais resultados: As médias do ligamento longitudinal posterior foram: 18,4 ± 4 mm na posição F; 18,9 ± 5,5 mm na posição FR; 19 ± 5,3 mm na posição FT e 18 ± 5,2 mm na posição FTR. O comprimento médio do ligamento longitudinal posterior não foi significativamente diferente nas quatro posições. Conclusões: Esses dados mostram que as posições avaliadas não aumentaram a área-alvo, conforme definido pelo comprimento do ligamento longitudinal posterior com o objetivo de inserção da agulha neuraxial em pacientes obstétricas. As manobras avaliadas terão um uso limitado na melhoria do acesso à agulha espinhal em mulheres grávidas.

[Effect of table tilt and spine flexion-rotation on the acoustic window of the lumbar spine in pregnant women]. / Efeito da inclinação da mesa e flexão da coluna sobre a janela acústica da coluna lombar em mulheres grávidas.

STUDY OBJECTIVE: The purpose of this study was to assess whether application of dorsal table tilt and body rotation to a parturient seated for neuraxial anesthesia increased the size of the paramedian target area for neuraxial needle insertion. SETTING: Labor and Delivery Room. PATIENTS: Thirty term pregnant women, ASA I-II, scheduled for an elective C-section delivery. INTERVENTIONS: Lumbar ultrasonography was performed in four seated positions: (F) lumbar flexion; (FR) as in position F with right shoulder rotation; (FT) as in position F with dorsal table-tilt; (FTR) as in position F with dorsal table-tilt combined with right shoulder rotation. MEASUREMENTS: For each position, the size of the 'target area', defined as the visible length of the posterior longitudinal ligament was measured at the L3-L4 interspace. MAIN RESULTS: The mean posterior longitudinal ligament was 18.4±4mm in position F, 18.9±5.5mm in FR, 19±5.3mm in FT, and 18±5.2mm in FTR. Mean posterior longitudinal ligament length was not significantly different in the four positions. CONCLUSIONS: These data show that the positions studied did not increase the target area as defined by the length of the posterior longitudinal ligament for the purpose of neuraxial needle insertion in obstetric patients. The maneuvers studied will have limited use in improving spinal needle access in pregnant women.

A Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique.

BACKGROUND: Adductor canal blocks (ACBs) provide effective analgesia following total knee arthroplasty. We hypothesized that ACB single injection plus intravenous (IV) dexamethasone (Dex) shows non-inferiority to catheter, while ACB single injection does not. METHODS: One hundred eighty patients were randomized and 177 analyzed from among 1 of 3 ACB interventions: (1) 0.5% ropivacaine 20 mL; (2) 0.5% ropivacaine 20 mL plus IV Dex 8 mg; (3) 0.5% ropivacaine 20 mL followed by continuous infusion of 0.2% ropivacaine at 5 mL/h for 48 hours. The primary endpoint was cumulative opioid consumption at 24 hours in oral morphine equivalents, with a non-inferiority limit of 30 mg. Secondary endpoints included opioid consumption at 12 and 48 hours, rest pain scores, quality of recovery survey, length of stay, and anti-emetic usage. RESULTS: For 24-hour opioid consumption, single injection ACB with and without IV Dex had a mean difference of -24.2 mg (confidence interval [CI] 0.5 to -48.9, P < .001) and -21 mg (CI 3.2 to -45.1, P < .001) relative to catheter, demonstrating non-inferiority. Non-inferiority was also shown at 12 hours by Dex and single injection over catheter with mean difference of -20.4 mg (CI -6.8 to -33.9, P < .001) and -15.1 mg (CI -2.1 to -28.2, P < .001), respectively. No intergroup difference was found for 48-hour opioid consumption. No differences in other secondary outcomes were observed across the 3 groups. CONCLUSION: Single injection ACB, with and without IV Dex, is non-inferior to ACB catheters in 24-hour opioid consumption, and may be attractive options for early-discharge, fast-track total knee arthroplasty.

Epistaxis during nasotracheal intubation: a randomized trial of the Parker Flex-Tip™ nasal endotracheal tube with a posterior facing bevel versus a standard nasal RAE endotracheal tube.

PURPOSE: Nasotracheal intubation is a widely performed technique to facilitate anesthesia induction during oral, dental, and maxillofacial surgeries. The technique poses several risks not encountered with oropharyngeal intubation, most commonly epistaxis due to nasal mucosal abrasion. The purpose of this study was to test whether the use of the Parker Flex-Tip™ (PFT) nasal endotracheal tube (ETT) with a posterior facing bevel reduces epistaxis when compared with the standard nasal RAE ETT with a leftward facing bevel. METHODS: Sixty American Society of Anesthesiologists physical status I and II patients undergoing oral or maxillofacial surgery with nasotracheal intubation were recruited. Patients were randomized to either a standard nasal RAE ETT or a PFT nasal ETT. The ETT was thermosoftened and lubricated for both study groups prior to insertion, and the size of the tube was chosen at the discretion of the attending anesthesiologist. The primary outcome was the incidence of epistaxis, with a secondary outcome of epistaxis severity (scored as none, mild, moderate, or severe). An investigator measured both outcomes five minutes after intubation was completed. RESULTS: Mild or moderate epistaxis was experienced by 22 of 30 (73%) patients in the PFT group compared with 21 of 30 (70%) patients in the standard nasal RAE ETT group (absolute risk reduction, 3%; 95% confidence interval, -19 to 25; P = 0.78). There were no occurrences of severe epistaxis in either group. CONCLUSION: There was no difference in the incidence or severity of epistaxis following nasal intubation using the Parker Flex-Tip nasal ETT when compared with a standard nasal RAE ETT. This trial was registered at ClinicalTrials.gov, identifier: NCT02315677.

Real-time measurement of blood pressure with Nexfin in a patient with thalidomide-related phocomelia.

We report the novel application of photoplethysmographic technology with the Nexfin HD monitor for real-time measurement of blood pressure (BP) in a patient with tetraamelia. The patient was a 58-year-old man with tetraamelia secondary to thalidomide exposure in utero, who presented for surgical excision of a maxillary schwannoma. Because difficulty of cuff use on rudimentary limbs and failure to gain invasive arterial access due to abnormalities of limb vasculature, this population is known to pose some unique challenges for BP measurement. Nexfin may offer an alternative noninvasive method to detect BP in patients with phocomelia during the perioperative period.