Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia.

We report a catastrophic postoperative complication of a prolonged interscalene block performed under general anaesthesia. The course of the anaesthetic was uneventful and the patient remained stable during his stay in the recovery area with the operative extremity paralysed and insensate. No further local anaesthetic was administered until later that day when the patient received 10 ml bupivacaine 0.25% through the catheter. Upon completion of the top-up dose, no change in the patient's status was noticed. The patient was next assessed 6.5 h later when he was found dead in his bed. A postmortem CT scan revealed the catheter to be sited intrathecally, presumably the result of dural sleeve penetration.

Analysis of bupivacaine and ropivacaine-related cardiac arrests in regional anesthesia: A systematic review of case reports.

Regional anesthesia as a component of multimodal analgesia protocols has become more and more a part of modern perioperative pain management. The widespread adoption of ultrasound guidance in regional anesthesia has surely played an important role in that growth and it has significantly improved patient safety, decreased the incidence of block failure, cardiac arrest, and reduced complication rates. The objective of this systematic review is to extract, analyze, and synthesize clinical information about bupivacaine and ropivacaine related cardiac arrest that we might have a clearer picture of the clinical presentation. The literature search identified 268 potentially relevant publications and 22 relevant case reports were included in the review. Patients' demographics, types of regional anesthesia, hypotension, heart rhythm disorders, seizures, cardiac arrest, fatal outcome, recommendations and limitations on prevention and treatment of bupivacaine and ropivacaine related cardiac arrest are analyzed and discussed in the systematic review. Both bupivacaine and ropivacaine-induced local anesthetic toxicity can result in cardiac arrest. Lipid emulsion, telemetry, local anesthetic toxicity resuscitation training appears to be promising in improvement of survival but more research is needed. Improvement and encouragement of reporting the local anesthetic toxicity are warranted to improve the quality of information that can be analyzed in order to make more precise conclusion.

Implementation of evidence-based recommendations to reduce elective surgical case cancellations.

BACKGROUND: Cancellation of elective surgical cases leads to a waste of resources, financial burden, patient dissatisfaction, extended hospital stay, and unnecessary repetition of preoperative preparations. AIM: The objective of this study was to identify, analyze and manage the causes of cancellation of elective surgical cases in our institution. METHODS: This quality improvement study compared preoperative cardiovascular event and case cancellation rates before and after implementing the practice of perioperative cardiovascular risk management. The study included the following phases: (1) Screening and identification of the most important reason for case cancellation; (2) Developing the strategy and internal protocol based on the international recommendations to minimize perioperative cardiovascular risk; (3) Implementing the internal protocol and monitoring preoperative cardiovascular events and case cancellation rate. RESULTS: We achieved a reduction in surgical case cancellation rate: 83 (3.7%) out of 2242 in 2018 and 28 (1.1%) out of 2538 cases in 2019 were cancelled after the patient had been delivered to the operating room area. CONCLUSION: Screening and identification of gaps in perioperative care as well as implementation of evidence-based recommendations can significantly improve the quality of patient care. In our case, implementing the internal protocol of cardiovascular risk management in perioperative period resulted in a reduction of preoperative hypertensive crisis, myocardial ischemia, heart rhythm disorder rates and in subsequently reduction in case cancellation rate.

Quadratus lumborum block in management of severe pain after uterine artery embolization.

BACKGROUND AND OBJECTIVES: The quadratus lumborum (QL) block has been widely used for acute postoperative pain management after numerous surgical procedures including urological, abdominal, gynaecological and orthopaedic surgical procedures. The local anaesthetic spread in this area can provide unilateral sensory block in T6-L2 dermatomes. We performed bilateral quadratus lumborum block for the management of acute pain after the uterine artery embolization (UAE). METHODS: A 43-year-old woman was admitted to the gynaecology department of Mother and Child Hospital, University Medical Center, for uterine artery embolization. Shortly, after successful completion of the UAE procedure, the patient began to complain of severe pain in the lower abdomen rated as a 9 on a verbal analogue scale (VAS) of 0-10. Intravenous tramadol 100 mg was infused over 30 min with minimal reduction in pain. Trimeperidine 20 mg was then infused over 30 min. Pain scores, however, remained 7-8/10 on the VAS. It was therefore decided to place a bilateral single-shot ultrasound-guided quadratus lumborum block. RESULTS: The procedure was well tolerated and brought notable pain relief. VAS declined from 8/10 to 5/10 after 30 min and to 3/10 at 60 min. Over the ensuing 24 h, VAS pain intensity remained 2-3/10. No further analgesics were necessary. CONCLUSION: A randomized control clinical trial is warranted to assess the efficacy of QL blockade and to compare it with other analgesic options in uterine artery embolization. Bilateral quadratus lumborum blockade may be an excellent pain control option after uterine artery embolization. SIGNIFICANCE: Uterine artery embolization is associated with significant postprocedural pain which can prove difficult to manage with opioids. Bilateral quadratus lumborum block may be an excellent pain control option - one that might significantly reduce not only pain, but also the need for opioids and perhaps even the need for hospitalization.

A retrospective study of the incidence of neurological injury after axillary brachial plexus block.

BACKGROUND: It has been suggested that performing a nerve block under general anesthesia, as customary in pediatric population, may predispose to nerve injury. However, few clinical data exist to either support or refute this assertion. METHODS: We retrospectively reviewed data on all patients who received an axillary block for upper extremity surgery in our institution during an eight-year period. The blocks were performed under sedation or general anesthesia, without using a nerve stimulator. Perioperative records from the Hand Surgery Unit Clinic were reviewed for postoperative complaints and complications. RESULTS: In the eight-year period of the review, 336 patients had axillary block. In total, 230 received the block with sedation and 106 during general anesthesia. All the sedated patients were older than 14 years (mean age 45.2), while of the general anesthesia patients 48 were older than 14 years (mean age 13.9 years). There were six cases of postoperative nerve injury in sedated patients (2.6%) vs. eight cases (7.5%) in the general anesthesia patients. Most patients recovered fully within several weeks. One patient had permanent nerve injury. CONCLUSIONS: Definitive conclusions cannot be drawn because of disparities in patient group demographics (majority of pediatric patients were in the general anesthesia group) and the retrospective nature of this study. Nevertheless, the findings suggest that the conduct of axillary block under general anesthesia in pediatric patients holds a greater potential for nerve injury than when the block is performed under sedation in adults.

The effect of local infiltration with morphine before carpal tunnel release.

We compared the effect of infiltration with a mixture of 1 per cent lidocaine and two milligrams of morphine in twenty-five patients who were to be managed with a carpal tunnel release with the effect of infiltration with 1 per cent lidocaine only in a second group of twenty-five patients who were to have such a release. In both groups, the injection was administered after inflation of the tourniquet. During the procedure, the patients' movement and vocalization of discomfort did not differ substantially between the groups. However, in the immediate postoperative period, the patients who had received morphine indicated a significantly higher score (on a visual-analog scale) for peak intraoperative pain than did the patients who had received lidocaine only (2.44 +/- 1.73 points compared with 1.32 +/- 1.22 points; p = 0.01). The numbers of patients who had pain in the recovery room, the numbers of patients who received analgesics in the recovery room, and the scores for pain at the time of discharge were similar for the two groups. The score for pain on the first postoperative day was more than 4 points for seven patients who had received morphine, whereas no patient who had received lidocaine only had a score of more than 4 points (p = 0.01); however, the amount of analgesics taken at home was similar for the two groups. Postoperative complications, which included hypotension, fainting, weakness, and chest pain, occurred in eight patients (32 per cent) who had received morphine and in none who had received lidocaine only (p < 0.01).

Anterior spinal fusion complicated by paraplegia. A case report of a false-negative somatosensory-evoked potential.

A case of an anterior spinal artery syndrome complicating an anterior spinal fusion is reported. Besides documenting a relatively rare complication of anterior spinal surgery, the level of the lesion (T6) and the association of spinal shock are relatively unusual. Intraoperative somatosensory-evoked potentials (SEP) deteriorated only transiently and failed to reflect adequately the neurologic injury either intraoperatively or postoperatively. The shortcomings of SEP monitoring are discussed, and the recommendation is made to use the combination of SEPs with the wake-up test when possible.

Posterior spinal fusion complicated by posterior column injury. A case report of a false-negative wake-up test.

A case is reported of an isolated posterior column injury secondary to direct mechanical trauma complicating a posterior spinal fusion. This case documents a rare complication of posterior spinal surgery. Intraoperative somatosensory-evoked potential (SEP) monitoring documented the injury whereas two intraoperative wake-up tests did not. This case demonstrates the value of intraoperative spinal cord monitoring in general. It also demonstrates the value of combining means to assess both anterior and posterior cord separately, intraoperatively. It is recommended that the wake-up test be used in conjunction with SEPs intraoperatively.

Axillary block complicated by hematoma and radial nerve injury.

BACKGROUND AND OBJECTIVES: Hematoma is typically cited as one mechanism of nerve injury following axillary block. However, documented cases of this are lacking. METHODS: A healthy 38-year-old man was scheduled for surgical removal of a tumor of the hand. A transarterial axillary block was performed with a 22-gauge short-bevel needle using 40 mL of a mixture of equal volumes of 1.5% lidocaine and 0.5% bupivacaine containing 1:200,000 epinephrine. No paresthesias were reported. Postoperative, the patient developed a large axillary hematoma accompanied by paresthesias and radial nerve weakness. RESULTS: With conservative management, nerve recovery was complete in 6 months. CONCLUSIONS: Hematoma complicating axillary block may result in nerve dysfunction.

Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery.

BACKGROUND AND OBJECTIVES: The hypotension following spinal anesthesia remains commonplace in cesarean delivery. Intrathecal opioids are synergistic with local anesthetics and intensify sensory block without increasing sympathetic block. The combination makes it possible to achieve spinal anesthesia with otherwise inadequate doses of local anesthetic. We hypothesized that this phenomenon could be used to provide spinal anesthesia for cesarean delivery while incurring less frequent hypotension. METHODS: Thirty-two women scheduled for cesarean delivery were divided into 2 groups of patients who received a spinal injection of either 10 mg of isobaric (plain) bupivacaine 0.5% or 5 mg of isobaric bupivacaine with 25 microg fentanyl added. Each measurement of a systolic blood pressure less than 95 mm Hg or a decrease in systolic pressure of greater than 25% from baseline was considered as hypotension and treated with a bolus of 5 to 10 mg of intravenous ephedrine. RESULTS: Spinal block provided surgical anesthesia in all patients. Peak sensory level was higher (T3 v T4. 5) and motor block more intense in the plain bupivacaine group. The plain bupivacaine patients were more likely to require treatment for hypotension (94% v 31%) and had more persistent hypotension (4.8 v 0.6 hypotensive measurements per patient) than patients in the minidose bupivacaine-fentanyl group. Mean ephedrine requirements were 23.8 mg and 2.8 mg, respectively, for the 2 groups. Patients in the plain bupivacaine group also complained of nausea more frequently than patients in the minidose bupivacaine-fentanyl group (69% v 31%). CONCLUSIONS: Bupivacaine 5 mg + fentanyl 25 microg provided spinal anesthesia for cesarean delivery with less hypotension, vasopressor requirements, and nausea than spinal anesthesia with 10 mg bupivacaine.

Spinal cord monitoring.

This article serves as a review of the use of spinal cord monitoring in spine surgery, including both the wake-up test and the various approaches to electrophysiologic (evoked-potential) monitoring. Physiologic and technical aspects of evoked-potential monitoring are presented. The different ways of performing evoked potentials are presented, examined, and compared, with a discussion of the pros and cons of each.

A comparison of sedation techniques for outpatient rhinoplasty: midazolam versus midazolam plus ketamine.

A total of 859 patients presenting for outpatient rhinoplasty were divided into two groups that received intravenous sedation of midazolam 0.1 mg/kg either with or without ketamine 0.4 to 0.5 mg/kg immediately prior to conduct of the local anesthetic injections and surgery. Additional midazolam was given intraoperatively as needed. No patient received narcotic either as premedication or intraoperatively. Patients were evaluated by the surgeon on their response to the injections and surgery, and patients were given a questionnaire 1 week postoperatively to examine their response to and recall of the procedure. Scoring by both the surgeon and patients revealed that the great majority of patients in both groups had adequate "sedation." Patients from both groups related a high degree of satisfaction (> 90 percent) with the technique of sedation. The differences between the two study groups achieved statistical significance only on 4 of the 12 parameters investigated. Those who had received only midazolam were less likely to vocalize during the surgery or to experience the procedure as being of undue duration. Those who had also received ketamine had a lesser chance of remembering the local anesthetic injections (11.1 versus 19.8 percent) and a lesser likelihood of being dissatisfied with their surgical experience (3.3 versus 7.4 percent). In conclusion, the use of an opioid-free sedative technique of intravenous midazolam was highly successful in meeting the needs of both patients and surgeons. The addition of a single preblock dose of intravenous ketamine to intravenous midazolam sedation for rhinoplasty does not improve intraoperative conditions for the surgeon in terms of patient behavior.(ABSTRACT TRUNCATED AT 250 WORDS)

Compliance with gloving in anesthesia: an observational study of gloving practice at induction of general anesthesia.

STUDY OBJECTIVE: To gather direct observational data on anesthesiologists' compliance with universal precautions' gloving standards during induction of general anesthesia. DESIGN: Prospective, observational study. SETTING: Operating theaters of an Israeli government teaching hospital. SUBJECTS: Over a four-month period, all "first case of the day" general anesthetics were observed to determine if the anesthesiologist directly administering patient care wore gloves during the period of anesthetic induction. All anesthesia department members were observed and none was aware of the ongoing study. MEASUREMENTS AND MAIN RESULTS: Resident anesthesiologists were found to be more compliant with gloving policy than their attendings (61.8% vs. 33.7%, p < 0.0001). However, the lower compliance among the attendings was entirely attributable to the most senior staff members (over age 55 years) whose compliance rate was 11.5% versus 55.6% for attending staff below age 55 years (p < 0.0001). Departmental compliance as a whole was 49.6%. Compliance in pediatric cases averaged 10% and was equally poor among all department staff. CONCLUSIONS: Although glove use remains inconsistent, in less than one and one half years since institution of a departmental gloving policy, a substantial degree of compliance was achieved. Nevertheless, further efforts are still needed to improve compliance with universal precautions. In this study, glove use was particularly deficient in pediatric cases and among senior staff aged 55 years and older. Pinpointing specific areas of greatest deficiency may prove useful in guiding additional efforts to improve compliance with universal precautions.

Acute renal failure following laparoscopic cholecystectomy: a case report.

The carbon dioxide (CO2) pneumoperitoneum of laparoscopic surgery is a complex physiologic event associated with neuroendocrine, respiratory, cardiovascular, and renal disturbances, as well as compromised organ blood flow. A case is presented of a 67-year-old man with a history of chronic renal failure, renal tubular acidosis, and hypertension, who underwent an uneventful elective laparoscopic cholecystectomy that included 75 minutes of CO2 pneumoperitoneum of 15 mmHg pressure. Postoperatively, the patient developed acute renal failure from which he recovered within 2 weeks. In the absence of other evident precipitating factors, we suspect that the CO2 pneumoperitoneum played a causal role in the development of his acute renal failure. The potential seriousness of the physiologic insult of conventional CO2 pneumoperitoneum suggests that "minimal access" surgery is not necessarily "minimally invasive."

The influence of preemptive spinal anesthesia on postoperative pain.

STUDY OBJECTIVE: To examine the influence of spinal anesthesia on postoperative pain and postoperative opioid requirements. DESIGN: Prospective randomized study. SETTING: Bnai-Zion Medical Center, Haifa, Israel-a government hospital. MEASUREMENTS AND MAIN RESULTS: 30 ASA physical status I and II unpremedicated women undergoing elective total abdominal hysterectomy were randomly allocated into two groups of 15 patients each using a sealed envelope technique. Patients in Group 1 were given a subarachnoid injection of 12 mg hyperbaric bupivacaine and after 10 minutes general anesthesia was induced. Patients in Group 2 received only general anesthesia. Anesthesia was induced with midazolam and maintained with oxygen, N2O, isoflurane, and pancuronium. No opioids were given intraoperatively. Postoperatively patient-controlled analgesia (PCA) with morphine was initiated in both groups (1 mg x mL(-1), bolus dose 1 mg, lockout interval 10 minutes, and background infusion 1 mg x mL(-1)) at patient first request for analgesic. Pain was assessed over 24 hours by cumulative morphine dose and visual analog score (VAS). Postoperative PCA morphine consumption at 2, 6, and 24 hours following patient first request for analgesic for Groups 1 and 2 were: 3.1 +/- 1 mg versus 7.2 +/- 3 mg (p = 0.04), 13.4 +/- 2 mg versus 17.2 +/- 4 mg (p = 0.03) and 35.9 +/- 8 mg versus 47.7 +/- 8 mg in Group 2 (p = 0.04). VAS scores at 4, 6, 12, and 24 hours postoperatively were not significantly different between the two groups. CONCLUSIONS: Preoperative neural blockade may reduce postoperative analgesic requirements.