Ultrasound-guided selective trunk block: Evaluation of ipsilateral sensorimotor block dynamics, hemidiaphragmatic function and efficacy for upper extremity surgery. A single-centre cohort study.

BACKGROUND: Selectively locating and blocking the individual trunks of the brachial plexus with small volumes of local anaesthetic, a selective trunk block (SeTB), may produce anaesthesia of the entire upper extremity except for the T2 dermatome. OBJECTIVE: This study aimed to evaluate the effects of an ultrasound-guided (USG) SeTB on ipsilateral sensorimotor block dynamics, hemidiaphragmatic function, and efficacy as an all-purpose regional anaesthetic technique for upper extremity surgery. DESIGN: Prospective cohort study. SETTING: Single-centre, university hospital in Hong Kong, China from February 2021 to July 2021. PATIENTS: Thirty patients (aged 53.2 ±â€Š14.8 years and BMI 23.8 ±â€Š3.6 kg m - 2 ), ASA physical status I to III, scheduled for upper extremity surgery under a brachial plexus block. INTERVENTIONS: USG SeTB with 25 ml (7, 8 and 10 ml to the superior, middle and inferior trunks, respectively) of a 1 : 1 mixture of 2% lidocaine with 1 : 200 000 epinephrine and 0.5% levobupivacaine. MAIN OUTCOME MEASURES: Ipsilateral sensorimotor blockade of the suprascapular (only motor), axillary, radial, ulnar, median and musculocutaneous nerves were assessed at regular intervals for 45 min. Ipsilateral hemidiaphragmatic excursion was also measured, at 30 min after the SeTB, using M-mode ultrasound. The SeTB was considered a success if it was possible to complete surgery without any rescue analgesia or conversion to general anaesthesia. RESULTS: Complete motor blockade of the suprascapular nerve was achieved in median [range] 5 [5 to 15] min. Complete sensory and motor blockade were achieved in all the other 5 nerves in 17.5 [10 to 30] and 15 [10 to 30] min respectively. The SeTB was successful in 93% and ipsilateral hemidiaphragmatic paresis (HDP) was present in 82%, of patients. CONCLUSION: SeTB produces sensorimotor blockade of the entire upper extremity, causes ipsilateral HDP, and is effective as the sole anaesthetic for surgery from the proximal humerus to the hand. TRIAL REGISTRION: ClinicalTrials.gov, Trial Registration No: NCT04752410, Date submitted for Registration: 09 February 2021, Date first posted: 12 February 2021, Dates of patient enrolment: 19 February 2021 to 27 July 2021 ( https://clinicaltrials.gov/ct2/show/NCT04752410 ).

Dry spinal tap during real-time ultrasound-guided paramedian spinal injection with patient in the lateral decubitus position: A single-centre retrospective study.

BACKGROUND: Real-time ultrasound-guided (USG) spinal injection is generally performed via the paramedian sagittal oblique (PMSO) ultrasound window. OBJECTIVE: The aim of this retrospective study was to draw attention to the occurrence of 'dry tap' during real-time USG spinal injection. DESIGN: Single-centre retrospective study. SETTING: University teaching hospital, Hong Kong, China. PATIENTS: Data from 113 patients (aged 69.2 ±â€Š18.0 years and BMI 22.3 ±â€Š3.6 kg m-2) of American Society of Anesthesiologists physical status 1 to 3 scheduled for surgery under neuraxial blockade between 2007 to 2017 were reviewed. INTERVENTIONS: Real-time USG spinal injections or combined spinal-epidural (CSE) using the PMSO ultrasound window with the patient in the lateral decubitus position and the spinal needle inserted from the nondependent side were studied. MAIN OUTCOME MEASURES: 'Dry tap' was defined as a failure of cerebrospinal fluid (CSF) to efflux from the hub of the needle, within 3 min, with the spinal needle visualised sonographically within the thecal sac. 'Slow CSF efflux' was defined as efflux of CSF within 1 to 3 min. Irrespective of whether it was a 'dry tap' or 'slow CSF efflux', the planned dose of local anaesthetic was injected through the spinal needle. RESULTS: The combined incidence of 'dry tap' and 'slow CSF efflux' was 23.8% (27/113) with an individual incidence for each event of 9.7% (11/113) and 14.2% (16/113), respectively. Under the conditions of this study, successful spinal anaesthesia developed in all patients. CONCLUSION: 'Dry tap' occurs in 9.7% of cases during real-time USG spinal injection using the PMSO ultrasound window, with the patient in the lateral decubitus position and the spinal needle inserted from the nondependent side. TRIAL REGISTRATION: ChiCTR-IOR-1800019011, Chinese Clinical Trials Registry (www.chictr.org.cn).

Minimum effective volume of 0.5% ropivacaine for ultrasound-guided costoclavicular brachial plexus block: A dose finding study.

BACKGROUND: Costoclavicular brachial plexus block (CC-BPB) is a relatively new regional anaesthetic technique and there are no data on the minimum effective volume 90 (MEV90) of 0.5% ropivacaine required for an ultrasound-guided CC-BPB. OBJECTIVE: To determine the MEV90 of 0.5% ropivacaine required to produce surgical anaesthesia with an ultrasound-guided CC-BPB. DESIGN: Prospective up-down sequential allocation study design. SETTING: University teaching hospital in Hong Kong from March 2016 to December 2017. PATIENTS: Forty-eight, ASA physical status I to III patients, aged 70 years or less and scheduled for elective forearm or hand surgery under an ultrasound-guided CC-BPB, were recruited. INTERVENTION: Ultrasound-guided CC-BPB was performed with the assigned volume of 0.5% ropivacaine. The Dixon 'up-and-down' sequential allocation method using the biased coin design was used to determine the MEV90 of 0.5% ropivacaine. The assigned volume of ropivacaine was based on the outcome of the previous patient. After a block failure the next patient received a volume increase of 2 ml. If the block was a success, the next patient was allocated, with a probability of b = 0.11, to receive 2 ml less, or, with a probability of 1 - b = 0.89, the same volume. MAIN OUTCOME MEASURES: A successful block was defined as a minimum score of 14 of 16 points, using a composite sensory and motor block score at 45 min after the injection. The study was stopped when 45 successful blocks were achieved. MEV90 with 95% confidence interval was calculated using the centred isotonic regression for point and interval dose response studies. RESULTS: The MEV90 of 0.5% ropivacaine for ultrasound-guided CC-BPB was 20.9 (95% confidence interval, 20.7 to 21.8) ml. The mean ±â€ŠSD time to readiness for surgery was 31.4 ±â€Š12.60 min. CONCLUSION: The MEV90 of 0.5% ropivacaine required to produce surgical anaesthesia with an ultrasound-guided CC-BPB is 20.9 ml. CLINICAL TRIAL REGISTRATION: The trial was registered with the Chinese Clinical Trials Registry (www.chictr.org.cn, ChiCTR-IOR-15007515, principal investigator: Manoj Kumar Karmakar, date of registration: 4 December 2015). CLINICAL TRIAL NUMBER AND REGISTRY URL: ChiCTR-IOR-15007515, Chinese Clinical Trials Registry (www.chictr.org.cn).

The Effect of a Freely Available Flipped Classroom Course on Health Care Worker Patient Safety Culture: A Prospective Controlled Study.

BACKGROUND: Patient safety culture is an integral aspect of good standard of care. A good patient safety culture is believed to be a prerequisite for safe medical care. However, there is little evidence on whether general education can enhance patient safety culture. OBJECTIVE: Our aim was to assess the impact of a standardized patient safety course on health care worker patient safety culture. METHODS: Health care workers from Intensive Care Units (ICU) at two hospitals (A and B) in Hong Kong were recruited to compare the changes in safety culture before and after a patient safety course. The BASIC Patient Safety course was administered only to staff from Hospital A ICU. Safety culture was assessed in both units at two time points, one before and one after the course, by using the Hospital Survey on Patient Safety Culture questionnaire. Responses were coded according to the Survey User's Guide, and positive response percentages for each patient safety domain were compared to the 2012 Agency for Healthcare Research and Quality ICU sample of 36,120 respondents. RESULTS: We distributed 127 questionnaires across the two hospitals with an overall response rate of 74.8% (95 respondents). After the safety course, ICU A significantly improved on teamwork within hospital units (P=.008) and hospital management support for patient safety (P<.001), but decreased in the frequency of reporting mistakes compared to the initial survey (P=.006). Overall, ICU A staff showed significantly greater enhancement in positive responses in five domains than staff from ICU B. Pooled data indicated that patient safety culture was poorer in the two ICUs than the average ICU in the Agency for Healthcare Research and Quality database, both overall and in every individual domain except hospital management support for patient safety and hospital handoffs and transitions. CONCLUSIONS: Our study demonstrates that a structured, reproducible short course on patient safety may be associated with an enhancement in several domains in ICU patient safety culture.

Determinants of Serum 25-Hydroxyvitamin D Concentrations and a Screening Test for Moderate-to-Severe Hypovitaminosis D in Chinese Patients Undergoing Total Joint Arthroplasty.

BACKGROUND: Hypovitaminosis D is associated with adverse surgical outcomes. We quantified the environmental, demographic, and modifiable determinants of serum 25-hydroxyvitamin D (25-OHD) concentration and assessed the potential impact of a preoperative screening questionnaire for moderate-to-severe hypovitaminosis D (25-OHD <30 nmol/L). METHODS: In a retrospective cohort study of 227 Chinese patients (69 males and 158 females) undergoing 261 joint arthroplasty, we collected information on recent sun exposure, dietary vitamin D intake, vitamin D supplementation, and Western Ontario and McMaster Universities osteoarthritis index using a questionnaire and measured a fasting 25-OHD concentration using a liquid chromatography-tandem mass spectrometry before surgery. RESULTS: The multiple regression model on the determinants of 25-OHD concentration described 14% of the total variance, with the greatest relative contribution from ambient ultraviolet radiation (42%). A 4-item screening test for moderate-to-severe hypovitaminosis D had acceptable discrimination (area under receiver operating characteristic curve = 0.76, 95% CI, 0.65-0.87), good calibration (Hosmer-Lemeshow goodness-of-fit; P = .93). Decision curve analysis showed that the screening test can potentially reduce unnecessary 25-OHD testing by 390 per 1000 patients at a threshold probability of 10%. CONCLUSION: The screening test appears moderately useful in avoiding a substantial number of unnecessary 25-OHD testing in a setting where the prevalence of moderate-to-severe hypovitaminosis D is less than 10%.

Risk of perioperative respiratory complications and postoperative morbidity in a cohort of adults exposed to passive smoking.

OBJECTIVE: To evaluate the risks of perioperative respiratory complications and postoperative morbidity associated with active and passive cigarette smoking. BACKGROUND: Environmental tobacco smoke is associated with perioperative respiratory events in children, but its effect in adults is unknown. METHODS: We conducted a cohort study of 736 adult patients receiving general anesthesia for major elective surgery. Patients were classified according to their self-reported smoking history and urinary cotinine concentration within 48 hours before surgery. The main outcomes were composite measures of perioperative respiratory complications and postoperative morbidity on the third day after surgery. RESULTS: There were 313 (42.5%) never-smokers (reference group), 92 (12.5%) passive nonsmokers, 157 (21.3%) ex-smokers without environmental tobacco smoke exposure, 53 (7.2%) passive ex-smokers, and 121 (16.4%) smokers. The incidence of perioperative respiratory complications and postoperative morbidity was 9.5% [95% confidence interval (CI), 7.5-11.8] and 29.2% (95% CI, 26.0-32.6), respectively. Smoking was significantly associated with an increased risk of perioperative respiratory complications [relative risk (RR), 4.40; 95% CI, 2.20-8.80] and postoperative morbidity (RR, 1.86; 95% CI, 1.22-2.83). Although passive smoking was not associated with the risk of perioperative respiratory complications, the risk of postoperative morbidity was increased in passive nonsmokers (RR, 1.51; 95% CI, 1.04-2.21) and passive ex-smokers (RR, 2.21; 95% CI, 1.39-3.50). CONCLUSIONS: One in 5 adults was exposed to environmental tobacco smoke before surgery. Passive cigarette smoking showed very little, if any, increased risk of perioperative respiratory complications. Both active exposure and passive exposure to cigarette smoke increased the risk of postoperative morbidity.

The accuracy of urinary cotinine immunoassay test strip as an add-on test to self-reported smoking before major elective surgery.

INTRODUCTION: Smoking is a preventable cause of perioperative complications. An accurate and rapid classification of smoking status is essential as up to 35% of smokers deny smoking before surgery. We compared the diagnostic performance of a preoperative urinary cotinine immunoassay test strip (NicAlert®) as an add-on test to patient's self-reported smoking status. METHODS: Four hundred and sixty-five patients undergoing major elective surgery self-reported their smoking history and provided a sample for measuring urinary cotinine concentration by liquid chromatography tandem mass spectrometry (reference standard) and NicAlert®. Using the "either test positive" rule, the gain in diagnostic performance for NicAlert® add-on test was assessed using relative positive and negative likelihood ratios (LRs) and area under the receiver operating characteristic curve (AUROC) with 95% CIs. RESULTS: Of the 60 patients with a positive reference standard (adjusted cotinine ≥ 50 ng/ml), 10 (16.7%) denied current cigarette smoking. The NicAlert® add-on test had better test performance measures (sensitivity = 95.0%, specificity = 94.8%) than self-reported smoking history alone (sensitivity = 83.3%, specificity = 95.0%). The relative positive and negative LRs were 1.09 (95% CI = 0.95-1.24) and 0.30 (95% CI = 0.12-0.78), respectively. The AUROC for the NicAlert® add-on test (0.90; 95% CI = 0.84-0.96) was significantly higher than for the self-reported smoking history alone (0.78; 95% CI = 0.69-0.88) (p = .006). CONCLUSION: The NicAlert® add-on test strategy had excellent diagnostic test performance for identifying current smokers who are expected to have a high risk of perioperative complications.

The Effect of ISBT-Bowen Therapy in the Treatment of Myofascial Neck Pain-a Randomized, Single-Blinded Clinical Trial.

Background: Myofascial pain syndrome (MPS) is the most common diagnosis in patient presenting with chronic non-specific neck pain. It affects people's work performance, productivity, and quality of life. To date, there is little research evaluating the effectiveness of non-invasive techniques, such as ISBT-Bowen Therapy in managing neck MPS. Objectives: To investigate the effectiveness of Bowen therapy in managing myofascial pain syndrome with symptoms lasting for more than six weeks. The study will also examine the long-term effect of ISBT-Bowen Therapy on functional enhancement, quality of life, and physical and mental well-being. Methods: This is a prospective, single-blinded randomized controlled trial (RCT). A total of 90 myofascial neck pain patients were recruited and randomized to receive 8 sessions of ISBT-Bowen Therapy over a 12-week period (n = 45) or to continue their usual conventional treatment (n = 45). Pressure pain threshold (PPT), cervical range of motion (CROM), numerical rating pain scores, Neck Disability Index (NDI), SF-12 Health Survey (SF-12) Version 2, Generalized Anxiety Disorder 7-item (GAD7), and Patient Health Questionnaire (PHQ9) were measured at baseline, 12 weeks, and 24 weeks after baseline. Results: When compared with the control group, PPT significantly increased after ISBT-Bowen Therapy at 12 and 24 weeks. CROM on flexion, lateral flexion, and rotation were greatly improved at 12 weeks after Bowen therapy, and maintained at 24 weeks, except left lateral flexion. NDI, GAD7, and PHQ9 were all reduced after Bowen Therapy at both 12 and 24 weeks. Both Physical and Mental Component Summary scores of SF-12 were improved after Bowen therapy at 12 and 24 weeks. Conclusions: This study confirmed the efficacy of ISBT-Bowen Therapy for patients with MPS. It alleviates pain, improves functional outcomes, enhances quality of life, and relieves mood symptoms.

Real-Time Ultrasound-Guided Spinal Injection Using a Transverse In-Plane Dependent Technique: A Case Series.

Ultrasound-guided (USG) spinal injection is generally performed using a paramedian sagittal oblique scan, with the patient in the lateral decubitus position, and the spinal needle inserted in-plane from the nondependent side. This report evaluated the feasibility of performing USG spinal injection, using an alternative transverse interspinous scan with in-plane needle insertion, a transverse in-plane dependent (TIPD) technique, in 30 adult patients undergoing elective surgery under spinal anesthesia. Dural puncture was successfully achieved in 29 of 30 (96.6%) patients with 2 (1-3) attempts in 5 (4-8) minutes using the TIPD technique. Multiple interspinous osteophytes accounted for technical failure in 1 patient.

Corrigendum to "Comparing cost and effectiveness of IVPCA morphine with perioperative multimodal analgesia of oral etoricoxib and oxycontin: A retrospective study" [J Orthop 16 (2019) 585-589].

[This corrects the article DOI: 10.1016/j.jor.2019.06.012.].

Ultrasound-Guided Multilevel Thoracic Paravertebral Block and Its Efficacy for Surgical Anesthesia During Primary Breast Cancer Surgery.

PURPOSE: Thoracic paravertebral block (TPVB), in conjunction with intravenous sedation, is reported to provide surgical anesthesia for primary breast cancer surgery (PBCS). Although ultrasound-guided (USG) TPVB has been described, there are no reports of USG multilevel TPVB for surgical anesthesia during PBCS. The aim of this prospective observational study was to determine the feasibility of performing USG multilevel TPVB, at the T1-T6 vertebral levels (6m-TPVB), and to evaluate its efficacy in providing surgical anesthesia for PBCS. PATIENTS AND METHODS: Twenty-five female patients undergoing PBCS received an USG 6m-TPVB for surgical anesthesia. Four milliliters of ropivacaine 0.5% (with epinephrine 1:200,000) was injected at each vertebral level. Dexmedetomidine infusion (0.1-0.5 µg.kg-1.h-1) was used for conscious sedation. Success of the block, for surgical anesthesia, was defined as being able to complete the PBCS without having to resort to rescue analgesia or convert to GA. RESULTS: The USG 6m-TPVB was successfully performed on all 25 patients but it was effective as the sole anesthetic in only 20% (5/25) of patients. The remaining 80% (20/25) reported pain during separation of the breast from the pectoralis major muscle and its fascia. Surgery was successfully completed using small doses of intravenous ketamine (mean total dose, 38.0±20.5 mg) as supplementary analgesia. CONCLUSION: USG 6m-TPVB is technically feasible but does not consistently provide complete surgical anesthesia for PBCS that involves surgical dissection on the pectoralis major muscle and its fascia. Our data suggest that the pectoral nerves, which are not affected by a 6m-TPVB, are involved with afferent nociception.

Comparing cost and effectiveness of IVPCA morphine with perioperative multimodal analgesia of oral etoricoxib and oxycontin: A retrospective study.

INTRODUCTION: Good pain control modality for post total knee replacement promotes patient's comfort and facilitates functional recovery, which may prevent post-operative complications; and shorten hospital stay. Therefore, manage pain efficiently and effectively have financial implications to the hospital. This retrospective study analyzed the clinical outcomes and costs of the intravenous (IV) patient-controlled analgesia (PCA) with a new perioperative multimodal analgesia (PMA) of using etoricoxib and oxycontin. METHODS: This retrospective study analyzed a total of 102 inpatients, 53 received both IVPCA and regular oral analgesics from September 2016 to February 2017, while 49 received preemptive oral etoricoxib before surgery and duly together with oxycontin and paracetamol after surgery from September 2017 to February 2018. Pain scores as the primary outcome were measured by Numeric Rating Scale (0-10) at rest (NRS-R) and on movement (NRS-M). They were analyzed by one-way analysis of covariance (ANCOVA). Other outcomes included side effects from analgesics, range of motion (ROMo), patient satisfaction, length of hospital stay and costs of medications. RESULTS: Patients in PMA group achieved better outcomes than PCA group. NRS-M of PMA group shown lower mean pain score and (standard error) than PCA group (2.96 [0.31] vs 4.26 [0.29]; p = 0.003), side effects from analgesics (18% vs 45%), ROM≥ 90° (55.1% vs 30.2%), patient satisfaction (8.97 vs 7.5 out of 10; p = 0.005), and length of hospital stay (6 days vs 8 days; p < 0.001). Moreover, the medication cost of PMA was 59.9% lower than PCA regimen. CONCLUSIONS: This PMA approach achieved better outcomes and saved hospital costs.

Ultrasound-Guided Infraclavicular Brachial Plexus Block: Prospective Randomized Comparison of the Lateral Sagittal and Costoclavicular Approach.

BACKGROUND AND OBJECTIVES: It has recently been proposed that an infraclavicular brachial plexus block (BPB) at the costoclavicular (CC) space may overcome some of the limitations of the lateral sagittal (LS) approach. In this study, we hypothesized that the CC approach will produce faster onset of sensory blockade of the 4 major terminal nerves of the brachial plexus than the LS approach. METHODS: Forty patients undergoing elective upper extremity surgery under a BPB were randomized to receive either the LS (Gp-LS, n = 20) or CC approach (Gp-CC, n = 20) for infraclavicular BPB. Twenty-five milliliters of 0.5% ropivacaine was used for the BPB in both study groups. Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves was assessed by a blinded observer at regular intervals for 45 minutes after the block. Sensory block was assessed using a verbal rating scale (0-100) and motor block using a 3-point qualitative scale (0-2). Onset of sensory (primary outcome variable) and motor blockade was defined as the time it took to achieve a sensory verbal rating scale of 30 or less and motor grade of 1 or less, respectively. Time to readiness for surgery was defined as the time it took to achieve a sensory score of 30 or less and motor grade of 1 or less in all the 4 nerves tested. RESULTS: The overall sensory onset time (median [interquartile range]) was significantly faster (P = 0.004) in Gp-CC (10 [10-26.25] minutes) than in Gp-LS (20 [15-30] minutes). The overall sensory score was significantly lower in Gp-CC than in Gp-LS at 5 (P < 0.001), 10 (P = 001), 15 (P = 0.001), and 20 (P = 0.04) minutes after the BPB. The overall motor score was significantly lower (P = 0.009) in Gp-CC than in Gp-LS at 10 minutes after the BPB. There were more (P = 0.04) patients with complete sensory-motor blockade at 20 minutes after the BPB in Gp-CC (25%) than in Gp-LS (0%). Time to readiness for surgery was also significantly faster (P = 0.002) in Gp-CC (10 [10-26.5] minutes) than in Gp-LS (20 [15-30] minutes). CONCLUSIONS: The CC approach for infraclavicular BPB produces faster onset of sensory blockade and earlier readiness for surgery than the LS approach. CLINICAL TRIAL REGISTRATION: This study was registered at the Centre for Clinical Trials of The Chinese University of Hong Kong, identifier CUHK_CCT00389.

Hemostatic parameters after hepatectomy for cancer.

BACKGROUND/AIMS: Epidural analgesia improves postoperative outcome, and should benefit patients undergoing hepatectomy for cancer. However, the combination of underlying disease, surgery, and blood loss after hepatectomy may lead to hemostatic changes that, theoretically, increase the risk of epidural hematoma. To quantify these changes, we retrospectively reviewed the records of 229 patients at the Prince of Wales Hospital, Hong Kong. METHODOLOGY: We analyzed the hemostatic parameters of those in whom there were complete data (n=143) up to postoperative day 3. RESULTS: We found considerable derangements in the international normalized ratio (INR), prothrombin time, activated partial thromboplastin time (aPTT), and platelet counts, with peak derangements occurring around postoperative day 2. The amount of liver resected and the preoperative Model for End-Stage Liver Disease score were predictors of peak INR > or = 1.5 in the postoperative period. CONCLUSIONS: We conclude that commonly measured hemostatic parameters are deranged after hepatectomy for cancer. Because of the complex cancer- and surgery-related hemostatic changes, whether these changes indeed indicate increased risk of neuraxial hematoma associated with neuraxial blocks is unclear. We also found that most Chinese patients were managed adequately with patient-controlled intravenous morphine. Clinicians contemplating neuraxial block on patients undergoing hepatectomy for cancer must weigh the potential risks and benefits.

Ultrasound-Guided Costoclavicular Brachial Plexus Block: Sonoanatomy, Technique, and Block Dynamics.

BACKGROUND AND OBJECTIVES: This study aimed to describe in detail the relevant sonoanatomy, technique, and block dynamics of an ultrasound-guided costoclavicular brachial plexus block (BPB). METHODS: Thirty patients scheduled for hand or forearm surgery under a BPB underwent transverse ultrasound imaging of the medial infraclavicular fossa to identify the cords of the brachial plexus at the costoclavicular space (CCS). An ultrasound-guided BPB was then performed at the CCS with 20 mL of 0.5% ropivacaine. Sensory-motor blockade of the ipsilateral median, radial, ulnar, and musculocutaneous nerves were assessed at regular intervals for 30 minutes after the injection. Successful block was defined as being able to complete surgery under the BPB. RESULTS: The CCS was visualized as a well-defined intermuscular space lying deep and posterior to the mid-point of the clavicle. The cords of the brachial plexus were clustered together lateral to the axillary artery within the CCS. The costoclavicular BPB was successfully performed in all patients, and the median onset time for sensory and motor blockade of all the 4 nerves was 5 [5-15] and 5 [5-10] minutes, respectively. Complete sensory blockade of all the 4 nerves was achieved in 30 [20-30] minutes, and the BPB was successful in 29 (97%) of 30 patients. There were no complications directly related to the technique or the local anesthetic injection. CONCLUSIONS: This report describes a novel technique of infraclavicular BPB at the costoclavicular space that produces rapid onset of BPB. Future research should compare the safety and efficacy of this new technique with the traditional lateral sagittal infraclavicular BPB.

Survival Analysis of Patients with Breast Cancer Undergoing a Modified Radical Mastectomy With or Without a Thoracic Paravertebral Block: a 5-Year Follow-up of a Randomized Controlled Trial.

AIM: This 5-year prospective follow-up of women randomized to general anesthesia (GA) with or without a thoracic paravertebral block (TPVB) examined the risk of local recurrence, metastasis and mortality after breast cancer surgery. PATIENTS AND METHODS: A total of 180 patients undergoing modified radical mastectomy were randomized to one of three study groups: standardized GA only; GA with a single-injection TPVB (s-TPVB) and placebo paravertebral infusion after surgery for 72-h; and GA plus with continuous TPVB (c-TPVB) for 72-h postoperatively. Cox proportional models were used to assess the effect of TPVB on long-term outcomes. Equivalence testing was used to help interpret the results. RESULTS: The incidence [95% confidence interval (CI)] of cancer recurrence, metastatic spread and all-cause mortality was 2.3% (0.7-5.4%), 7.9% (4.6-12.6%) and 6.8% (3.6-11.2%), respectively. Four women had cancer recurrence and had metastatic spread. Compared to the GA-only group, the risk of metastatic spread was not different from that of GA with s-TPVB [hazard ratio (HR)=1.11, 95% CI=0.32-3.83) nor from that with GA plus c-TPVB (HR=0.79, 95% CI=0.21-2.96) (p=0.88). Compared to the GA-only group, the risk of mortality was similarly not different from that of the two other groups (HR=2.57, 95% CI=0.66-9.92; and HR=0.66, 95% CI=0.11-3.97, respectively, p=0.15). CONCLUSION: Although the original study was underpowered to properly address long-term outcomes, the results of this analysis suggest that TPVB, administered whether as a single-injection or continuous infusion during the perioperative period, had little to no appreciable effect on local recurrence, metastasis or mortality after breast cancer surgery.

Effect of Hypovitaminosis D on Postoperative Pain Outcomes and Short-Term Health-Related Quality of Life After Knee Arthroplasty: A Cohort Study.

Vitamin D may have an important role in pain perception. Inadequate vitamin D levels are associated with suboptimal recovery after surgery. However, the effects of hypovitaminosis D on postoperative pain-related outcomes and its impact on health-related quality of life after surgery are not well understood. The objective of this study was to determine the effects of hypovitaminosis D on postoperative pain-related outcomes and health-related quality of life at 3 months after knee arthroplasty.This was a longitudinal cohort study of 191 consecutive Hong Kong Chinese patients who were given patient-controlled morphine analgesia for up to 72 hours after 214 knee arthroplasties. Serum total 25-hydroxyvitamin D (25-OHD) concentration was assessed by liquid chromatography-tandem mass spectrometry. The primary outcomes were postoperative pain intensity at rest scores (0-72 h), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index (pain, stiffness and function), and moderate-to-severe persistent pain (transformed WOMAC pain score of 0-75 at 3 months after knee arthroplasty; 0, extreme pain; 100, no pain). Group differences were analyzed using generalized estimating equation models and a logistic regression model.The prevalence of preoperative hypovitaminosis D (25-OHD <50 nmol/L) was 44% (95% confidence interval [CI]: 37%-51%). There were transient higher pain intensity scores in the moderate-to-severe hypovitaminosis D (25-OHD <30 nmol/L) group compared with the sufficient vitamin D group. Vitamin D status had no effect on total WOMAC index (P = 0.22). The incidence of moderate-to-severe persistent pain was 9% (95% CI: 6%-14%). Hypovitaminosis D increased the risk of moderate-to-severe persistent pain (adjusted odds ratio 2.64, 95% CI: 1.03-6.77).Preoperative hypovitaminosis D had subtle effects on pain intensity scores in the early postoperative period and is a risk factor for moderate-to-severe persistent pain after knee arthroplasty. Hypovitaminosis D was not associated with worse health-related quality of life at 3 months after knee arthroplasty.

Thoracic paravertebral block and its effects on chronic pain and health-related quality of life after modified radical mastectomy.

BACKGROUND AND OBJECTIVES: Patients undergoing breast cancer surgery frequently experience chronic postoperative pain. The primary objective of this randomized study was to determine if thoracic paravertebral block (TPVB) reduced the incidence of chronic pain after a modified radical mastectomy (MRM) when compared with general anesthesia (GA). METHODS: One hundred eighty women undergoing MRM were randomized to 1 of 3 study groups: group 1: standardized GA, group 2: GA with a single-injection TPVB and placebo paravertebral infusion, and group 3: GA with a continuous TPVB. Outcomes assessed postoperatively included acute postoperative pain and analgesic consumption and, at 3 and 6 months, the incidence and severity of chronic pain and physical and mental health-related quality of life (HRQOL). RESULTS: There was no significant difference in the incidence of chronic pain at 3 months (P = 0.13) and 6 months (P = 0.79) after the MRM between the study groups. The relative risk of developing chronic pain (P = 0.25) was also similar between the groups. There was no difference in acute pain (P = 0.22) or postoperative analgesic consumption (P = 0.67) between the groups. Nevertheless, differences were observed in chronic pain-related secondary outcome variables. The TPVB groups reported lower chronic pain scores (P < 0.05), exhibited fewer symptoms and signs of chronic pain (P ≤ 0.01), and also experienced better physical and mental HRQOL than did the GA group. Chronic pain scores also decreased with time in all study groups (P < 0.05). CONCLUSIONS: There is no significant difference in the incidence or relative risk of chronic pain at 3 and 6 months after an MRM when TPVB is used in conjunction with GA. Nevertheless, patients who receive a TPVB report less severe chronic pain, exhibit fewer symptoms and signs of chronic pain, and also experience better physical and mental HRQOL.