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.

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.

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.

Comparison of a novel real-time SonixGPS needle-tracking ultrasound technique with traditional ultrasound for vascular access in a phantom gel model.

OBJECTIVE: Ultrasound-guided percutaneous vascular access for endovascular procedures is well established in surgical practice. Despite this, rates of complications from venous and arterial access procedures remain a significant cause of morbidity. We hypothesized that the use of a new technique of vascular access using an ultrasound with a novel needle-guidance positioning system (GPS) would lead to improved success rates of vascular puncture for both in-plane and out-of-plane techniques compared with traditional ultrasound. METHODS: A prospective, randomized crossover study of medical students from all years of medical school was conducted using a phantom gel model. Each medical student performed three ultrasound-guided punctures with each of the four modalities (in-plane no GPS, in-plane with GPS, out-of-plane no GPS, out-of-plane with GPS) for a total of 12 attempts. The success or failure was judged by the ability to aspirate a simulated blood solution from the model. The time to successful puncture was also recorded. A poststudy validated NASA Task Load Index workload questionnaire was conducted to assess the student's perceptions of the two different techniques. RESULTS: A total of 30 students completed the study. There was no significant difference seen in the mean times of vascular access for each of the modalities. Higher success rates for vascular access using the GPS for both the in-plane (94% vs 91%) and the out-of-plane (86% vs 70%) views were observed; however, this was not statistically significant. The students perceived the mental demand (median 12.0 vs 14.00; P = .035) and effort to be lower (mean 11.25 vs 14.00; P = .044) as well as the performance to be higher (mean 15.50 vs 14.00; P = .041) for the GPS vs the traditional ultrasound-guided technique. Students also perceived their ability to access vessels increased with the aid of the GPS (7.00 vs 6.50; P = .007). The majority of students expressed a preference for GPS (26/30, 87%) as opposed to the traditional counterpart. CONCLUSIONS: Use of the novel SonixGPS needle-tracking ultrasound system (UltraSonix, Richmond, BC, Canada) was not associated with a higher success rate of vascular puncture compared with the traditional ultrasound-guided technique. Assessment of mental task load significantly favored the use of the ultrasound GPS over the traditional ultrasound technique.

Single-operator real-time ultrasound-guided spinal injection using SonixGPS™: a case series.

PURPOSE: The SonixGPS™ is a novel needle tracking system that has recently been approved in Canada for ultrasound-guided needle interventions. It allows optimization of needle-beam alignment by providing a real-time display of current and predicted needle tip position. Currently, there is limited evidence on the effectiveness of this technique for performance of real-time spinal anesthesia. This case series reports performance of the SonixGPS system for real-time ultrasound-guided spinal anesthesia in elective patients scheduled for joint arthroplasty. METHODS: In this single-centre case series, 20 American Society of Anesthesiologists' class I-II patients scheduled for lower limb joint arthroplasty were recruited to undergo real-time ultrasound-guided spinal anesthesia with the SonixGPS after written informed consent. The primary outcome for this clinical cases series was the success rate of spinal anesthesia, and the main secondary outcome was time required to perform spinal anesthesia. RESULTS: Successful spinal anesthesia for joint arthroplasty was achieved in 18/20 patients, and 17 of these required only a single skin puncture. In 7/20 (35%) patients, dural puncture was achieved on the first needle pass, and in 11/20 (55%) patients, dural puncture was achieved with two or three needle redirections. Median (range) time taken to perform the block was 8 (5-14) min. The study procedure was aborted in two cases because our clinical protocol dictated using a standard approach if spinal anesthesia was unsuccessful after three ultrasound-guided insertion attempts. These two cases were classified as failures. No complications, including paresthesia, were observed during the procedure. All patients with successful spinal anesthesia found the technique acceptable and were willing to undergo a repeat procedure if deemed necessary. CONCLUSIONS: This case series shows that real-time ultrasound-guided spinal anesthesia with the SonixGPS system is possible within an acceptable time frame. It proved effective with a low rate of failure and a low rate of complications. Our clinical experience suggests that a randomized trial is warranted to compare the SonixGPS with a standard block technique.

A method for ultrasonographic visualization and injection of the superior laryngeal nerve: volunteer study and cadaver simulation.

Superior laryngeal nerve block is a valuable technique for provision of upper airway anesthesia. In bilateral scans of 20 volunteers, we developed a technique for ultrasonographic visualization of the superior laryngeal nerve and key anatomical structures using a hockey stick-shaped 8 to 15 MHz transducer (HST15 to 8/20 linear probe, Ultrasonix, Richmond, BC, Canada). Subsequently, we simulated superior laryngeal nerve scanning and injection in bilateral injections in 2 cadavers. Ultrasound-guided in-plane advancement of a needle toward the superior laryngeal nerve and injection of 1 mL of green dye was achieved in all 4 attempts and confirmed by a postprocedural dissection performed by an anatomist. We conclude that ultrasound-guided superior laryngeal nerve block in humans may be feasible.

Role of computed tomography (CT) in identifying foreign body ingestion in an individual with autism - A case report.

Foreign body ingestions are quite common and most often will uneventfully pass in stool, however, some ingestions, can lead to complications such as obstruction. If left untreated, this can lead to perforation and fistula formation. Hence, threshold for intervention should be low and diagnostic imaging can assist with treatment decisions. We present to you a case of 17-year-old male with non-verbal autism with an unusual hollow foreign body ingestion leading to small bowel obstruction.

Development and implementation of a quick reference (QR) code linked online education tool in anaesthesiology practice.

BACKGROUND: We conducted a feasibility study of an anaesthetic online educational tool that is accessed via quick reference (QR) codes. The primary objective of the study was to assess the feasibility of an online educational tool for providing satisfactory teaching to patients presenting for surgery and assess if using QR codes are a viable method for directing patients to the information. The secondary objective was to obtain feedback from anaesthesiologists. METHODS: The educational tool was developed and hosted on a password-protected website. The educational material on the website focused on anaesthesia-related processes that the patient should expect to experience in the hospital as well as fasting information. A survey was embedded into the website to obtain patient feedback. The website was redesigned following patient and staff feedback. RESULTS: Ninety-three patients accessed the online education tool. Of the 73 responses to the survey, 81% of patients reported that the tool improved their knowledge and understanding about anaesthesia. 73% of patients expressed a preference for, or were neutral regarding using online patient education. 36% of patients were familiar with QR codes and 28% were frequent users of QR codes. Most anaesthesiologists expressed satisfaction with the tool being used by their patients following the redesign process (93.1%, 89.6% and 89.6% for general anaesthesia, neuraxial anaesthesia and regional anaesthesia, respectively). CONCLUSIONS: This feasibility study demonstrated that an online anaesthetic educational tool has utility in promoting patient education about the anaesthetic experience and was well received by both patients and anaesthesiologists. QR codes are not feasible as the sole method for linking our patient population to an online education resource.