Validation of the Thai version of the obstetric quality of recovery score (obsqor-10-Thai) after elective cesarean delivery.

BACKGROUND: The Obstetric Quality of Recovery score (ObsQoR-10) is a questionnaire used to assess recovery after cesarean delivery. However, the original ObsQoR-10 is in English and was mainly validated in the Western population. We therefore evaluated the reliability, validity, and responsiveness of the ObsQoR-10-Thai in patients undergoing elective cesarean delivery. METHODS: The original ObsQoR-10 was translated into Thai, and psychometric validation was performed to evaluate the quality of post-cesarean recovery. The ObsQoR-10-Thai, activities of daily living checklist, and 100-mm visual analog scale of global health (VAS-GH) questionnaires were administered to the study participants before and 24 and 48-h postpartum. Validity, reliability, responsiveness, and feasibility of the ObsQoR-10-Thai were assessed. RESULTS: We included 110 patients undergoing elective cesarean delivery. The mean ObsQoR-10-Thai score at baseline and 24 and 48-h postpartum was 83.35 ± 11.15, 56.75 ± 11.6, and 70.96 ± 13.65, respectively. The ObsQoR-10-Thai score differed significantly between the two groups divided based on the VAS-GH (≥ 70 vs. < 70): 75.58 ± 13.81 and 52.56 ± 10.61, respectively (P < 0.001). The convergent validity between the ObsQoR-10-Thai and VAS-GH was good (r = 0.60, P < 0.001). The ObsQoR-10-Thai displayed good internal consistency (Cronbach's alpha = 0.87), split-half reliability (0.92), and test-retest reliability (0.99, 95% CI: 0.98-0.99). The median time to complete the questionnaire was 2 (IQR, 1-6) min. CONCLUSIONS: Our findings indicate that the ObsQoR-10-Thai is valid and has good reliability, with a high degree of responsiveness in terms of assessment of recovery after elective cesarean delivery. TRIAL REGISTRATION: This study was registered on the Thai Clinical Trials Registry, identifier TCTR20210204001, registered on 04/02/2021 (Prospectively registration).

Clinical Course and Outcomes among COVID-19 Patients at the Hospitel in Bangkok: A Retrospective Study.

A hospitel is a hotel that has been designated as an extension of the healthcare facilities during the COVID-19 pandemic in resource-limited settings. However, the clinical course and outcomes of patients with COVID-19 admitted to this unique type of facility have never been studied. We retrospectively reviewed the medical records of adult patients with COVID-19 who were admitted to a single hospitel in Bangkok, Thailand. Risk factors with respect to chest X-ray progression and clinical progression were analyzed using a logistic regression. A total of 514 patients were recruited, with a mean (standard deviation) age of 35.6 (13.4) years, and 58.6% were women. Patients were admitted after a median (interquartile range) of 3 (2−6) days of illness and were classified with mild (12.3%), moderate (86.6%), and severe (1.1%) conditions. Favipiravir and corticosteroids were prescribed in 26.3% and 14.9% of patients, respectively. Chest X-ray progression was found in 7.6% of patients, and hospital transfer occurred in 2.9%, with no deaths. Favipiravir use (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.4−7.5, p = 0.005), nausea/vomiting after admission (OR 32.3, 95% CI 1.5−700.8, p = 0.03), and higher oxygen saturation on admission (OR 1.99; 95% CI 1.22−3.23, p = 0.005) were factors associated with chest X-ray progression. Additionally, an oxygen requirement on admission was an independent risk factor for hospital transfer (OR 904, 95% CI 113−7242, p < 0.001). In a setting where the hospitel has been proposed as an extension facility for patients with relatively non-severe COVID-19, most patients could achieve a favorable clinical outcome. However, patients who require oxygen supplementation should be closely monitored for disease progression and promptly transferred to a hospital if necessary.

Use of Favipiravir for the Treatment of Coronavirus Disease 2019 in the Setting of Hospitel.

Objective: In a setting with a limited capacity for hospitalization, "hospitels" have been developed by using hotels as extension healthcare facilities for patients with mild illness. This study examined the clinical evidence of patients with coronavirus disease 2019 (COVID-19) who were treated with favipiravir, the main medication for treating COVID-19, in the hospitel setting in Thailand. Methods: We retrospectively collected demographic and clinical information, medication treatment, and outcome data for all patients who received favipiravir for COVID-19 during admission to a hospitel from April 27, 2021, to July 2, 2021. Risk factors for adults who could not complete treatment in a hospitel and who required hospitel transfer were analyzed. Results: In total, 421 patients were included in the study. Most patients (94.5%) received favipiravir to treat COVID-19 pneumonia. Adjunctive corticosteroids were prescribed to 42.3% of patients. Concerning the treatment outcome, 83.6% of patients completed treatment at a hospitel, and only two deaths occurred. No serious adverse drug reactions were observed. On multivariate analysis, age (odds ratio (OR) = 1.06; 95% confidence interval (CI) = 1.02-1.10, P=0.002), dyspnea (OR = 2.84; 95% CI = 1.25-6.44, P=0.013), loss of taste (OR = 107.63; 95% CI = 1.24-9337.39, P=0.040), corticosteroid use (OR = 12.56; 95% CI = 3.65-43.18, P < 0.001), and an extended duration of favipiravir use (OR = 16.91; 95% CI = 7.29-39.24, P < 0.001) were associated with a higher risk of hospitel transfer. Conclusions: Low rates of hospitel transfer and mortality were observed in mild-to-moderate COVID-19 patients treated with favipiravir at hospitel. Caution might be required in elderly patients, patients with dyspnea or a loss of taste, and patients receiving a 10-day course of favipiravir or adjunctive corticosteroids because these patients might require further management in the hospitel.

Predicting surgical factors for unplanned overnight admission in ambulatory arthroscopic surgery of the knee: a prospective cohort in one hundred and eighty four patients.

PURPOSE: Unplanned overnight admission (UOA) is an important indicator for quality of care with ambulatory knee arthroscopic surgery (AKAS). However, few studies have explored the factors related to the UOA and how to predict UOA after AKAS. This study aimed to evaluate the effectiveness of a standardized peri-operative protocol for the AKAS and identify whether a correlation exists between the peri-operative surgical factors and UOA in the patients undergoing AKAS. We hypothesized that more surgical invasiveness and prolong tourniquet time increase the risk of UOA after AKAS. METHOD: A prospective cohort study was conducted between October 2017 and March 2021. All 184 patients operated on standard AKAS protocol. The UOA is defined as overnight hospitalization of a patient undergoing AKAS. Demographic and peri-operative data were recorded, and the procedure was categorized based on the surgical invasiveness based on less invasive (intra-articular soft tissue surgery) (n = 65) and more complex surgery (involving extra-articular soft tissue surgery or ligamentous reconstruction) (n = 119). The clinical risk factors for UOA were identified and analyzed with multivariate analysis. RESULTS: The incidence of UOA in the more complex group (n = 7, 14.3%) was significantly higher than in the less invasive group (n = 3, 4.6%) (p = 0.049). The peri-operative factors significantly associated with UOA were age, more complex surgery, and longer tourniquet time (p < 0.10 all). However, the multivariate analysis revealed that longer tourniquet time was the only significant predictor for UOA (OR = 1.045, 95% CI = 1.022-1.067, p = 0.0001). The optimal cut-off points of tourniquet time for predicting UOA with the highest Youden index in the less invasive and more complex groups were 56 minutes and 107 minutes, respectively. CONCLUSION: The UOA after AKAS is more common in more complex surgery compared to less invasive surgery. This study showed that unplanned admission significantly associated with many factors-as patient factors, surgical invasiveness, and tourniquet time. However, tourniquet time is the only independent predictor for UOA. Therefore, strict perioperative management protocol must be applied in AKAS, and all patients having these risk factors should be prepared for UOA.

Decreasing leakage during continuous femoral nerve catheter fixation using 2-octyl cyanoacrylate glue (Dermabond®): a randomized controlled trial.

BACKGROUND: Continuous peripheral nerve catheters (CPNCs) have been used for postoperative pain relief. A common problem encountered with CPNCs is pericatheter leakage, which can lead to dressing adhesive failure. Frequent dressing changes increase the risk of catheter dislodgement and infections. Adhesive glue is effective in securing the peripheral nerve catheter and decreasing leakage around the catheter insertion site. This study aimed to evaluate the incidence of pericatheter leakage with fixation using 2-octyl cyanoacrylate glue (Dermabond®) as compared to sterile strips. METHODS: Thirty patients undergoing unilateral total knee arthroplasty (TKA) with continuous femoral nerve catheter for postoperative analgesia were randomized into the catheter fixation with 2-octyl cyanoacrylate glue (Dermabond®) group or the sterile strip group. The primary outcome was the incidence of pericatheter leakage. Secondary outcomes included the frequent of catheter displacement, the difficulty of catheter removal, pain score and patient satisfaction. RESULTS: The incidence of pericatheter leakage at 24 and 48 h was 0% versus 93 and 0% versus 100% in the Dermabond® and sterile strip groups, respectively (P < 0.001). The incidence of displacement at 24 and 48 h was 6.7% versus 93.3 and 6.7% versus 100% in the Dermabond® and sterile strip, respectively (P < 0.001). There was no difference in numeric rating scale, difficulty of catheter removal, or satisfaction scores between groups. CONCLUSIONS: Catheter fixation with 2-octyl cyanoacrylate glue (Dermabond®) decreased the incidence of pericatheter leakage, as well as catheter displacement, over 48 h as compared to sterile strip fixation. TRIAL REGISTRATION: This trial was registered on Thai clinical trial registry: TCTR20200228002 , registered 24 February 2020- Retrospectively registered.

Effect of Multimodal Drugs Infiltration on Postoperative Pain in Split Laminectomy of Lumbar Spine: A Randomized Controlled Trial.

STUDY DESIGN: A randomized, double-blinded controlled trial. OBJECTIVE: This study tested the effect of single-dose wound infiltration with multiple drugs for pain management after lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Patients undergoing spine surgery often experience severe pain especially in early postoperative period. We hypothesized that intraoperative wound infiltration with multiple drugs would improve outcomes in lumbar spine surgery. METHODS: Fifty-two patients who underwent one to two levels of spinous process splitting laminectomy of lumbar spine, were randomized into two groups. Infiltration group received intraoperative wound infiltration of local anesthetics, morphine sulfate, epinephrine, and nonsteroidal anti-inflammatory drugs at the end of surgery, and received patient-controlled analgesia (PCA) postoperatively. The control group received only PCA postoperatively. The primary outcome measures were amount of morphine consumption and visual analogue scale (VAS) for pain. The secondary outcome measures were Oswestry Disability Index (ODI), Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ), patient satisfaction, length of hospital stay, and side effects. RESULTS: A total of 49 patients (23 patients for local infiltration group, and 26 patients for control group) were analyzed. There were statistically significant [P < 0.001, the effect size -5.0, 95% CI (-6.1, -3.9)] less morphine consumptions in the local infiltration group than the control group during the first 12 hours, 12 to 24 hours, and 24 to 48 hours after surgery. The VAS of postoperative pain reported by patients at rest and during motion was significantly lower in the local infiltration group than the control group at all assessment times (P < 0.001). The effect size of VAS of postoperative pain at rest and during motion were -2.0, 95% CI (-2.5, -1.4) and -2.0, 95% CI (-2.6, -1.4) respectively. ODI and RMDQ at 2 week and 3 month follow-ups in both groups had significant improvement from baseline (P < 0.001). No significant differences were found between groups (P = 0.262 for ODI and P = 0.296 for RMDQ). There were no significant differences of patient satisfaction, length of stay, and side effects between both groups (P = 0.256, P = 0.262, P = 0.145 respectively). CONCLUSION: Intraoperative wound infiltration with multimodal drugs reduced postoperative morphine consumption, decreased pain score with no increased side effects. LEVEL OF EVIDENCE: 1.

Randomized comparison between epidural waveform analysis through the needle versus the catheter for thoracic epidural blocks.

BACKGROUND: Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle/catheter tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. Epidural waveform analysis can be carried out through the tip of the needle (EWA-N) or the catheter (EWA-C). In this randomized trial, we compared the two methods. We hypothesized that, compared with EWA-C, EWA-N would result in a shorter performance time. METHODS: One hundred and twenty patients undergoing thoracic epidural blocks for thoracic or abdominal surgery were randomized to EWA-N or EWA-C. In the EWA-N group, LOR was confirmed by connecting the epidural needle to a pressure transducer. After obtaining a satisfactory waveform, the epidural catheter was advanced 5 cm beyond the needle tip. In the EWA-C group, the epidural catheter was first advanced 5 cm beyond the needle tip after the occurrence of LOR. Subsequently, the catheter was connected to the pressure transducer to detect the presence of waveforms. In both study groups, the block procedure was repeated at different intervertebral levels until positive waveforms could be obtained (through the needle or catheter as per the allocation) or until a predefined maximum of three intervertebral levels had been reached. Subsequently, the operator administered a 4 mL test dose of lidocaine 2% with epinephrine 5 µg/mL through the catheter. An investigator present during the performance of the block recorded the performance time (defined as the temporal interval between skin infiltration and local anesthetic administration through the epidural catheter). Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. Success was defined as a bilateral block in at least two dermatomes. Furthermore, postoperative pain scores, local anesthetic consumption, and breakthrough analgesic consumption were recorded. RESULTS: No intergroup differences were found in terms of performance time, success rate, postoperative pain, local anesthetic requirement, and breakthrough analgesic consumption. CONCLUSION: EWA can be carried out through the needle or through the catheter with similar efficiency (performance time) and efficacy (success rate, postoperative analgesia). TRIAL REGISTRATION NUMBER: NCT03603574.

A multicenter, randomized comparison between 2, 5, and 8 mg of perineural dexamethasone for ultrasound-guided infraclavicular block.

BACKGROUND AND OBJECTIVES: This multicenter, randomized trial compared 2, 5, and 8 mg of perineural dexamethasone for ultrasound-guided infraclavicular brachial plexus block. Our research hypothesis was that all three doses of dexamethasone would result in equivalent durations of motor block (equivalence margin=3.0 hours). METHODS: Three hundred and sixty patients undergoing upper limb surgery with ultrasound-guided infraclavicular block were randomly allocated to receive 2, 5, or 8 mg of preservative-free perineural dexamethasone. The local anesthetic agent (35 mL of lidocaine 1%-bupivacaine 0.25% with epinephrine 5 µg/mL) was identical in all subjects. Patients and operators were blinded to the dose of dexamethasone. During the performance of the block, the performance time, number of needle passes, procedural pain, and complications (vascular puncture, paresthesia) were recorded. Subsequently a blinded observer assessed the success rate (defined as a minimal sensorimotor composite score of 14 out of 16 points at 30 min), onset time as well as the incidence of surgical anesthesia (defined as the ability to complete surgery without local infiltration, supplemental blocks, intravenous opioids, or general anesthesia). Postoperatively, the blinded observer contacted patients with successful blocks to inquire about the duration of motor block, sensory block, and postoperative analgesia. The main outcome variable was the duration of motor block. RESULTS: No intergroup differences were observed in terms of technical execution (performance time/number of needle passes/procedural pain complications), onset time, success rate, and surgical anesthesia. Furthermore, all three doses of dexamethasone provided similar durations of motor block (14.9-16.1 hours) and sensory block. Although 5 mg provided a longer analgesic duration than 2 mg, the difference (2.7 hours) fell within our pre-established equivalence margin (3.0 hours). CONCLUSIONS: 2, 5, and 8 mg of dexamethasone provide clinically equivalent sensorimotor and analgesic durations for ultrasound-guided infraclavicular block. Further trials are required to compare low (ie, 2 mg) and ultra-low (eg, 0.5-1 mg) doses of perineural dexamethasone for brachial plexus blocks. TRIAL REGISTRATION NUMBER: TCTR20150624001.

Malposition of Cage in Minimally Invasive Oblique Lumbar Interbody Fusion.

INTRODUCTION: Minimally invasive oblique lumbar interbody fusion is one of the novel lateral lumbar interbody fusion techniques for which the successful early results have been reported. However, new complications were increasingly reported from ongoing studies. CASE PRESENTATION: We report a case of an unusual complication of minimally invasive oblique lumbar interbody fusion associated with contralateral nerve root compression due to deep and posterior position of polyetheretherketone cage and discussion of the operating technique for repositioning polyetheretherketone cage. CONCLUSION: Malposition of polyetheretherketone cage can cause contralateral nerve root compression and neurological complication. The surgical technique to proper pull the polyetheretherketone cage back into the acceptable position should be considered and well prepared.

Ultrasound with neurostimulation compared with ultrasound guidance alone for lumbar plexus block: A randomised single blinded equivalence trial.

BACKGROUND: Ultrasound-guided lumbar plexus blocks usually require confirmatory neurostimulation. A simpler alternative is to inject local anaesthetic inside the posteromedial quadrant of the psoas muscle under ultrasound guidance. OBJECTIVE: We hypothesised that both techniques would result in similar total anaesthesia time, defined as the sum of performance and onset time. DESIGN: A randomised, observer-blinded, equivalence trial. SETTING: Ramathibodi Hospital and Maharaj Nakorn Chiang Mai Hospital (Thailand) from 12 May 2016 to 10 January 2017. PATIENTS: A total of 110 patients undergoing total hip or knee arthroplasty, who required lumbar plexus block for postoperative analgesia. INTERVENTION: In the combined ultrasonography-neurostimulation group, quadriceps-evoked motor response was sought at a current between 0.2 and 0.8 mA prior to local anaesthetic injection (30 ml of lidocaine 1% and levobupivacaine 0.25% with epinephrine 5 µg ml and 5 mg of dexamethasone). In the ultrasound guidance alone group, local anaesthetic was simply injected inside the posteromedial quadrant of the psoas muscle. MAIN OUTCOMES MEASURES: We measured the total anaesthesia time, the success rate (at 30 min), the number of needle passes, block-related pain, cumulative opioid consumption (at 24 h) and adverse events (vascular puncture, paraesthesia, local anaesthetic spread to the epidural space). The equivalence margin was 7.4 min. RESULTS: Compared with ultrasound guidance alone, combined ultrasonography-neurostimulation resulted in decreased mean (±SD) total anaesthesia time [15.3 (±6.5) vs. 20.1 (±9.0) min; mean difference, -4.8; 95% confidence interval, -8.1 to -1.9; P = 0.005] and mean (±SD) onset time [10.2 (±5.6) vs. 15.5 (±9.0) min; P = 0.004). No inter-group differences were observed in terms of success rate, performance time, number of needle passes, block-related pain, opioid consumption or adverse events. CONCLUSION: Although the ultrasonography-neurostimulation technique results in a shorter total anaesthesia time compared with ultrasound guidance alone, this difference falls within our accepted equivalence margin (±7.4 min). TRIAL REGISTRATION: www.clinicaltrials in the (Study ID: TCTR20160427003).

A Multicenter Randomized Comparison Between Intravenous and Perineural Dexamethasone for Ultrasound-Guided Infraclavicular Block.

BACKGROUND AND OBJECTIVES: This multicenter, randomized trial compared intravenous (IV) and perineural (PN) dexamethasone for ultrasound (US)-guided infraclavicular brachial plexus block. Our research hypothesis was both modalities would result in similar durations of motor block. METHODS: One hundred fifty patients undergoing upper limb surgery with US-guided infraclavicular block were randomly allocated to receive IV or PN dexamethasone (5 mg). The local anesthetic agent (35 mL of lidocaine 1%-bupivacaine 0.25% with epinephrine 5 µg/mL) was identical in all subjects. Patients and operators were blinded to the nature of IV and PN injectates. During the performance of the block, the performance time, number of needle passes, procedural pain, and complications (vascular puncture, paresthesia) were recorded.Subsequently, a blinded observer assessed the success rate (defined as a minimal sensorimotor composite score of 14 of 16 points at 30 minutes), onset time as well as the incidence of surgical anesthesia (defined as the ability to complete surgery without local infiltration, supplemental blocks, IV opioids, or general anesthesia). Postoperatively (at 24 hours), the blinded observer contacted patients with successful blocks to enquire about the duration of motor block, sensory block, and postoperative analgesia. The main outcome variable was the duration of motor block. RESULTS: No intergroup differences were observed in terms of technical execution (performance time/number of needle passes/procedural pain/complications), onset time, success rate, and surgical anesthesia. However, compared to its IV counterpart, PN dexamethasone provided 19% to 22% longer durations for motor block (15.7 ± 6.2 vs 12.9 ± 5.5 hours; P = 0.009), sensory block (16.8 ± 4.4 vs 13.9 ± 5.4 hours; P = 0.002), and postoperative analgesia (22.1 ± 8.5 vs 18.6 ± 6.7 hours; P = 0.014). CONCLUSIONS: Compared with its IV counterpart, PN dexamethasone (5 mg) provides a longer duration of motor block, sensory block, and postoperative analgesia for US-guided infraclavicular block. Future dose-finding studies are required to elucidate the optimal dose of dexamethasone.

A Randomized Comparison Between Conventional and Waveform-Confirmed Loss of Resistance for Thoracic Epidural Blocks.

BACKGROUND AND OBJECTIVES: Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for loss of resistance (LOR): when the needle tip is correctly positioned inside the epidural space, pressure measurement results in a pulsatile waveform. In this randomized trial, we compared conventional and EWA-confirmed LOR in 2 teaching centers. Our research hypothesis was that EWA-confirmed LOR would decrease the failure rate of thoracic epidural blocks. METHODS: One hundred patients undergoing thoracic epidural blocks for thoracic surgery, abdominal surgery, or rib fractures were randomized to conventional LOR or EWA-LOR. The operator was allowed as many attempts as necessary to achieve a satisfactory LOR (by feel) in the conventional group. In the EWA-LOR group, LOR was confirmed by connecting the epidural needle to a pressure transducer using a rigid extension tubing. Positive waveforms indicated that the needle tip was positioned inside the epidural space. The operator was allowed a maximum of 3 different intervertebral levels to obtain a positive waveform. If waveforms were still absent at the third level, the operator simply accepted LOR as the technical end point. However, the patient was retained in the EWA-LOR group (intent-to-treat analysis).After achieving a satisfactory tactile LOR (conventional group), positive waveforms (EWA-LOR group), or a third intervertebral level with LOR but no waveform (EWA-LOR group), the operator administered a 4-mL test dose of lidocaine 2% with epinephrine 5 µg/mL. Fifteen minutes after the test dose, a blinded investigator assessed the patient for sensory block to ice. RESULTS: Compared with LOR, EWA-LOR resulted in a lower rate of primary failure (2% vs 24%; P = 0.002). Subgroup analysis based on experience level reveals that EWA-LOR outperformed conventional LOR for novice (P = 0.001) but not expert operators. The performance time was longer in the EWA-LOR group (11.2 ± 6.2 vs 8.0 ± 4.6 minutes; P = 0.006). Both groups were comparable in terms of operator's level of expertise, depth of the epidural space, approach, and LOR medium. In the EWA-LOR group, operators obtained a pulsatile waveform with the first level attempted in 60% of patients. However, 40% of subjects required performance at a second or third level. CONCLUSIONS: Compared with its conventional counterpart, EWA-confirmed LOR results in a lower failure rate for thoracic epidural blocks (2% vs 24%) in our teaching centers. Confirmatory EWA provides significant benefits for inexperienced operators.

Reliability of Waveform Analysis as an Adjunct to Loss of Resistance for Thoracic Epidural Blocks.

BACKGROUND: The epidural space is most commonly identified with loss of resistance (LOR). Although sensitive, LOR lacks specificity, as cysts in interspinous ligaments, gaps in ligamentum flavum, paravertebral muscles, thoracic paravertebral spaces, and intermuscular planes can yield nonepidural LOR. Epidural waveform analysis (EWA) provides a simple confirmatory adjunct for LOR. When the needle is correctly positioned inside the epidural space, measurement of the pressure at its tip results in a pulsatile waveform. In this observational study, we set out to assess the sensitivity, specificity, as well as positive and negative predictive values of EWA for thoracic epidural blocks. METHODS: We enrolled a convenience sample of 160 patients undergoing thoracic epidural blocks for thoracic surgery, abdominal surgery, or rib fractures. The choice of patient position (sitting or lateral decubitus), approach (midline or paramedian), and LOR medium (air or normal saline) was left to the operator (attending anesthesiologist, fellow, or resident). After obtaining a satisfactory LOR, the operator injected 5 mL of normal saline through the epidural needle. A sterile tubing, connected to a pressure transducer, was attached to the needle to measure the pressure at the needle tip. A 4-mL bolus of lidocaine 2% with epinephrine 5 µg/mL was then administered and, after 10 minutes, the patient was assessed for sensory blockade to ice. RESULTS: The failure rate (incorrect identification of the epidural space with LOR) was 23.1%. Of these 37 failed epidural blocks, 27 provided no sensory anesthesia at 10 minutes. In 10 subjects, the operator was unable to thread the catheter through the needle. When compared with the ice test, the sensitivity, specificity, and positive and negative predictive values of EWA were 91.1%, 83.8%, 94.9%, and 73.8%, respectively. CONCLUSIONS: Epidural waveform analysis (with pressure transduction through the needle) provides a simple adjunct to LOR for thoracic epidural blocks. Although its use was devoid of complications, further confirmatory studies are required before its routine implementation in clinical practice.

A randomized trial comparing axillary block versus targeted intracluster injection supraclavicular block for upper limb surgery.

PURPOSE: This randomized trial aimed to validate a new method for brachial plexus blockade, i.e., targeted intracluster injection supraclavicular block (TII SCB), by comparing it with ultrasound-guided axillary block (AXB). We hypothesized that TII SCB would result in a shorter total anesthesia-related time. METHODS: Forty patients undergoing upper limb surgery were randomized to ultrasound-guided TII SCB (n = 20) or AXB (n = 20). In the TII SCB group, we deposited 16 mL of lidocaine 1.5% with epinephrine 5 µg·mL(-1) into the largest neural cluster (i.e., brachial plexus trunks/divisions). Subsequently, an additional 16 mL was divided into equal aliquots and injected inside each satellite cluster. In the AXB group, 5.5 mL were deposited around the musculocutaneous nerve and 23.5 mL were injected at the 6 o'clock position of the axillary artery. The main outcome for comparison between the two groups was the total anesthesia-related time (defined as the sum of block performance and onset times). We also recorded the number of needle passes, procedural pain, and complications (vascular puncture, paresthesia). RESULTS: The TII SCB method provided a quicker mean (SD) onset time compared with the AXB group [9.5 (5.8) min vs 18.9 (6.1) min; mean difference, -9.5 min; 99% CI, -14.7 to -4.2; P < 0.001] and a shorter mean (SD) total anesthesia-related time [20.1 (5.0) min vs 27.2 (6.5) min; mean difference, -7.0 min; 95% CI, -10.9 to -3.1; P = 0.001]. There were no intergroup differences in terms of success rate (95%), procedural pain, vascular puncture and paresthesia. The AXB group displayed a faster performance time [8.2 (1.6) min vs 10.6 (2.6) min; P = 0.001] with fewer median [interquartile range] needle passes (3 [2-6] vs 5 [4-8]; P < 0.001). CONCLUSION: Ultrasound-guided TII SCB provides a quicker onset and a shorter total anesthesia-related time than ultrasound-guided AXB.

Paravertebral Catheter for Three-Level Injection in Radical Mastectomy: A Randomised Controlled Study.

INTRODUCTION: Paravertebral block (PVB) is an alternative to general anaesthesia (GA) for breast surgery. However, for extensive surgery multiple punctures are needed increasing the immanent risk of the method. The purpose of this study was to evaluate PVB via catheter and injections at three different levels. Primary outcome was the quality of postoperative analgesia, in particular, the number of patients requiring additional morphine. METHODS: In a randomised single blinded clinical study patients scheduled for breast surgery including axillary approach, were randomly allocated to different anaesthetic techniques, n = 35 each. Patients received either GA with sevoflurane or PVB with catheter at level Th 4. In PVB-patients a 1:2 mixture of bupivacaine 0.5% and lidocaine 2% with adrenaline was injected sequentially 10 ml each at three different levels. RESULTS: Complication-free catheter insertion was possible in all 35 scheduled patients. The need for postoperative analgesics was higher after GA compared to PVB (22 vs.14 patients); p = 0.056. Postoperative morphine consumption was 1.55 (GA) and 0.26 mg (PVB) respectively (p < 0.001). Visual rating score (VRS) for pain at rest and at movement was higher in GA patients on post anaesthesia care unit (PACU) as well as on the ward at 1-6 h and 6-12 h. Readiness for discharge was earlier after PVB (4.96 and 6.52 hours respectively). After GA the incidence and severity of postoperative nausea and vomiting (PONV) was higher, though not significantly. Patients' satisfaction was comparable in both groups. CONCLUSIONS: Three-level injection PVB via catheter for extensive mastectomy was efficient and well accepted. Using a catheter may enhance safety by avoiding multiple paravertebral punctures when extended spread of analgesia is required. TRIAL REGISTRATION: www.ClinicalTrial.gov NCT02065947.

A Randomized Comparison Between Single- and Triple-Injection Subparaneural Popliteal Sciatic Nerve Block.

BACKGROUND AND OBJECTIVES: This prospective randomized trial compared ultrasound-guided single-injection (SI) and triple-injection (TI) subparaneural popliteal sciatic nerve block. We hypothesized that multiple injections are not required when local anesthetic (LA) is deposited under the paraneurium because the latter entraps LA molecules, ensuring circumferential spread around the nerve. Therefore, in addition to comparable success rates, we also expected similar total anesthesia-related times (sum of performance and onset times) and designed this study as an equivalency trial. METHODS: Ultrasound-guided subparaneural posterior popliteal sciatic nerve block was carried out in 100 patients. In the SI group, LA was deposited at a single location between the tibial and peroneal nerves. In the TI group, LA was injected between the tibial and peroneal divisions, medial to the tibial nerve, and lateral to the common peroneal nerve. The total LA volume (15 mL) and mixture (lidocaine 1%-bupivacaine 0.25%-epinephrine 5 µg/mL) were identical in all subjects. The performance time, number of needle passes, and adverse events (paresthesia, neural edema) were recorded by the (nonblinded) investigator supervising the block. A blinded observer evaluated the success rate (sensorimotor composite score ≥6/8 points at 30 minutes) as well as the onset time and contacted patients 7 days after the surgery to inquire about persistent numbness or motor deficit. RESULTS: Both techniques provided comparable success rates (92%) and total anesthesia-related times (17.1-19.7 minutes). Expectedly, the SI group required fewer needle passes (1 vs 3; P < 0.001) and a shorter needling time (3.0 ± 2.3 minutes vs 4.0 ± 2.3 minutes; P = 0.025). The TI group displayed a shorter onset time (12.5 ± 7.9 minutes vs 15.8 ± 7.9 minutes; P = 0.027). The performance time, procedural discomfort, and incidence of paresthesia (14%-20%) were similar between the 2 groups. Sonographic neural swelling was detected in 2 subjects in the SI group. In both cases, the needle was carefully withdrawn and the injection was completed uneventfully. Follow-up of the 100 subjects 1 week after surgery revealed no residual numbness or motor deficit. CONCLUSIONS: Ultrasound-guided SI and TI subparaneural popliteal sciatic nerve blocks result in comparable success rates and total anesthesia-related times. Expectedly, the SI technique requires fewer needle passes.