Regional analgesia for lower leg trauma and the risk of acute compartment syndrome: Guideline from the Association of Anaesthetists.

Pain resulting from lower leg injuries and consequent surgery can be severe. There is a range of opinion on the use of regional analgesia and its capacity to obscure the symptoms and signs of acute compartment syndrome. We offer a multi-professional, consensus opinion based on an objective review of case reports and case series. The available literature suggested that the use of neuraxial or peripheral regional techniques that result in dense blocks of long duration that significantly exceed the duration of surgery should be avoided. The literature review also suggested that single-shot or continuous peripheral nerve blocks using lower concentrations of local anaesthetic drugs without adjuncts are not associated with delays in diagnosis provided post-injury and postoperative surveillance is appropriate and effective. Post-injury and postoperative ward observations and surveillance should be able to identify the signs and symptoms of acute compartment syndrome. These observations should be made at set frequencies by healthcare staff trained in the pathology and recognition of acute compartment syndrome. The use of objective scoring charts is recommended by the Working Party. Where possible, patients at risk of acute compartment syndrome should be given a full explanation of the choice of analgesic techniques and should provide verbal consent to their chosen technique, which should be documented. Although the patient has the right to refuse any form of treatment, such as the analgesic technique offered or the surgical procedure proposed, neither the surgeon nor the anaesthetist has the right to veto a treatment recommended by the other.

Intraoperative asystole associated with fibroid uterus.

The authors present the case of a patient with a large retroperitoneal fibroid whose laparotomy was abandoned due to intraoperative asystole. Perioperative management and possible etiological factors are discussed in this paper.

Irish patients knowledge and perception of anaesthesia.

Patients are often unaware of the extensive duties of an anaesthetist and their significant contributions to patient management. This study aimed to evaluate current knowledge and perceptions of anaesthesia among an Irish patient population. 100 surgical patients completed multiple choice questionnaires which assessed patients knowledge of anaesthesia, the role of an anaesthetist and satisfaction with the consent process. 62 (62%) patients attributed their knowledge of anaesthesia to a previous operation and 78 (78%) patients knew that anaesthetists were qualified doctors. 30 (30%) patients were unaware that anaesthetists are involved in activities outside of the operation theatre. 44 (44%) patients wanted to be informed pre-operatively of all possible risks that can occur with anaesthesia and 82 (82%) would find an anaesthetics information leaflet helpful. 48 (48%) patients reported feeling anxious/fearful about undergoing anaesthesia. This data confirms existing research in other countries which indicates a need to further educate Irish patients about the roles of the anaesthetist and how anaesthesia is conducted.

How and why to use ultrasound for regional blockade.

The practice of regional anaesthesia will be probably forever changed by the introduction of ultrasonography into everyday clinical practice. The ability to now visualise directly the spread of local anaesthetic solution and its relationship with the nerve allows for immediate adjustments to needle position and/or local anaesthetic volume and spread resulting theoratically in improved block performance through faster onset, reduced local anaesthetic volumes and higher success rates. However, whether US guided blocks will ever replace neurostimulation techniques is debatable especially when regional anaesthesia is performed by specialists in the field.

Club foot treatment in Malawi - a public health approach.

UNLABELLED: PURPOSE. Malawi is a very poor country with a current population of 12 million people and very few orthopaedic surgeons or physiotherapists. An estimated 1125 babies are born per year with club foot. If these feet are not corrected early, then severe deformity can develop, requiring complex surgery. A task force was established to address this problem using locally available resources. METHODS: A nationwide early manipulation programme was set up using the Ponseti technique, and a club foot clinic established in each of Malawi's 25 health districts. One year later the clinics were reviewed. RESULTS: Twenty out of the 25 clinics originally established were still active, and over one year had seen a total of 342 patients. Adequate records existed for 307 patients, of whom 193 were male and 114 female (ratio 1.7:1). A total of 175 patients had bilateral club foot and 132 were unilateral (ratio 1.3:1) giving a total of 482 club feet; 327 of the 482 feet were corrected to a plantigrade position. Most clinics had problems with supply of materials. Many patients failed to attend the full course of treatment. CONCLUSIONS: Overall the establishment of a nationwide club foot treatment programme was of benefit to a large number of children with club feet and their families. In a poor country with many demands on health funding many challenges remain. The supply of plaster of Paris and splints was inadequate, clinic staff felt isolated, and patient compliance was limited by many factors which need further research.

Dermatitis artefacta revisited.

Self-induced factitial dermatitis, or dermatitis artefacta, is a rare and difficult condition to treat. We present an unusual case of factitious dermatitis with its subsequent severe complications. The clinical features, radiographic findings, histopathologic features, and treatment options are reviewed.

The benefits of hypopharyngeal packing in nasal surgery: a pilot study.

BACKGROUND: Hypopharyngeal packs are used in nasal surgery to reduce the risk of aspiration and postoperative nausea and vomiting. Side effects associated with their use range from throat pain to retained packs postoperatively. AIM: To evaluate, as a pilot study, postoperative nausea/vomiting and throat pain scores for patients undergoing nasal surgery in whom a wet or dry hypopharyngeal pack was placed compared with patients who received no packing. METHODS: A randomized, double-blind prospective trial in a general ENT unit. RESULTS: The study failed to show a statistically significant difference between the three groups in terms of their postoperative nausea/vomiting and throat pain scores at 2 and 6 h postoperatively. This is the first study in which dry packs have been compared with wet and absent packs. CONCLUSION: Based on our findings, the authors recommend against placing hypopharyngeal packs for the purpose of preventing postoperative nausea and vomiting.

Tramadol as adjunct to psoas compartment block with levobupivacaine 0.5%: a randomized double-blinded study.

BACKGROUND: Tramadol has been administered peripherally to prolong analgesia after brachial plexus and neuraxial blocks. Our aim was to evaluate the systemic and perineural effects of tramadol as an analgesic adjunct to psoas compartment block (PCB) with levobupivacaine. METHODS: In a randomized, prospective, double-blinded trial, 60 patients (ASA I-III), aged 49-88 yr, undergoing primary total hip or knee arthroplasty underwent PCB and subsequent bupivacaine spinal anaesthesia. Patients were randomized into three groups. Each patient received PCB with levobupivacaine 0.5%, 0.4 ml kg(-1). The control group (group L, n=21) received i.v. saline, the systemic tramadol group (group IT, n=19) received i.v. tramadol 1.5 mg kg(-1) and the perineural tramadol group (group T, n=20) received i.v. saline and PCB with tramadol 1.5 mg kg(-1). Postoperatively patients received regular paracetamol 6-hourly and diclofenac sodium 12-hourly. Time to first morphine analgesia, 24-hour morphine consumption, sensory block, pain and sedation scores and haemodynamic parameters were recorded. RESULTS: Time (h) to first morphine analgesia was similar in the three groups [mean (SD)]: group L, 11.2 (6.6); group T, 14.5 (8.0); group IT, 14.6 (6.8); P=0.35. Twenty-four-hour cumulative morphine (mg) consumption was also similar in the three groups [group L, 21.9 (10.1); group T, 19.8 (6.7), group IT, 16.5 (9.5)], as were durations of sensory and motor block. There were no differences in the incidence of adverse effects except that patients in group IT were more sedated at 14 h than group L (P=0.02). CONCLUSION: We conclude that our data do not support a clinically important local anaesthetic or peripheral analgesic effect of tramadol as adjunct to PCB with levobupivacaine 0.5%.

Haemoglobin SC disease presenting with a compartment syndrome secondary to a deep vein thrombosis.

A patient presented with a deep vein thrombosis (DVT), which resulted in a compartment syndrome of both the thigh and the calf. Subsequently, the patient was found to have haemoglobin SC disease. Prompt fasciotomies were performed; however, some muscle and nerve damage was later clinically apparent. This case highlights the value of prompt diagnosis of compartment syndrome and the need for urgent formal fasciotomies. The case also demonstrates the value of seeking an underlying cause for a DVT when none is apparent.

10-year experience of injuries sustained during clearance of anti-personnel mines.

Clearance of anti-personnel mines and unexploded ordnance in countries recovering from war usually continues long after conflict has ceased. We prospectively recorded 92 traumatic injuries sustained by 73 mineclearers working in seven countries over a period of 10 years. 15% of injuries were fatal, with an incidence of 116 injuries per 100000 workers per year. Limb injury occurred in 59% of cases, with an overall amputation rate of 30%. 44% of injuries were sustained by workers handling a mine, resulting in severe upper limb and facial injuries. The incidence of facial injuries fell after the introduction of visors.

The London nail bombings: the St. Thomas' Hospital experience.

At 18:00 h on 17 April 1999 a nail bomb exploded outside a supermarket in Brixton, London. This was the first of a series of three identical nail bombs. The injuries were due to penetrating nails, most were relatively minor, with only three patients requiring general anaesthesia for removal of nails and debridement. One 6-year-old child subsequently underwent onward referral for neurosurgical treatment. At 18:40 h on 30 April 1999, the third bomb exploded (there were no casualties at our hospital from the second bomb, that in Brick Lane on 24 April 1999) in the confined environment of the Admiral Duncan public house in Soho. The injuries were much more severe than those seen from the Brixton bomb. Two persons died on the scene and 81 were injured; 27 were transferred to our hospital. Three primary lower limb amputations were performed. Within the first 24h, four patients required ITU care and two onward referral to the regional burns unit. Injuries such as those seen in these two bombings are common in war situations. In peacetime it is rare to see this spectrum of injury and hence surgeons can be unaware of optimal management protocols. Our approach in these patients, based on thorough initial debridement and delayed closure/split skin grafting is similar to that advocated by the International Committee of the Red Cross based on their war surgery experience. We emphasise debridement without any initial reconstructive procedures. We also discuss some logistic problems of major incidents.

Injury rates in Shotokan karate.

OBJECTIVE: To document the injury rate in three British Shotokan karate championships in consecutive years. In these tournaments strict rules governed contact, with only "light" or "touch" contact allowed. Protective padding for the head, hands, or feet was prohibited. METHODS: Prospective recording of injuries resulting from 1770 bouts in three national competitions of 1996, 1997, and 1998. Details of ages and years of karate experience were also obtained. RESULTS: 160 injuries were sustained in 1770 bouts. The overall rate of injury was 0.09 per bout and 0.13 per competitor. 91 (57%) injuries were to the head. The average age of those injured was 22 years, with an average of nine years of experience in karate. CONCLUSIONS: The absence of protective padding does not result in higher injury rates than in most other series of Shotokan karate injuries. Strict refereeing is essential, however, to maintain control and minimise contact.