Bloqueos del plano fascial ecoguiados,como única técnica anestésica para mastectomía total en la era de la COVID-19: caso clínico

IntroductionRegional anesthesia techniques were recently introduced to provide analgesia for breast surgery. These techniques are rarely used as the primary anesthesia due to the complexity of breast innervation, with numerous structures that can potentially be disrupted during breast surgery.Case reportA female patient in her sixties diagnosed with invasive ductal carcinoma on her left breast was scheduled for a simple mastectomy. After anesthetic evaluation, identification of high risk perioperative cardiovascular complications, it was proposed to perform the surgery only with regional anesthesia. A combination of pectoral nerve block (Pecs II), pecto-intercostal fascial block (PIFB) and supraclavicular nerve block ultrasound-guided were successfully performed.ConclusionThis is the first case reporting a novel approach in a patient with severe cardiopulmonary disease who underwent breast surgery in a COVID-19 era.     

Múltiplos bloqueios de nervos periféricos guiados por ultrassom,uma saída para anestesia em pacientes com obesidade mórbida para aspiração de medula óssea

Morbid obesity is associated with various pathophysiological changes which affect the outcome of anesthesia and surgery. So it's challenging to give anesthesia to such patients. We present a 59‐year‐old adult morbidly obese, hypertensive, diabetic female with hypothyroidism operated for proximal humerus fracture and now presented with non‐union of fracture, requiring percutaneous injection of bone marrow aspirate from the iliac crest to the site of non‐union. The patient was extremely anxious and refused to undergo the procedure under local anesthesia or sedation and demanded anesthesia. Given her comorbidities general anesthesia (GA) was avoided and the procedure was accomplished using Ultrasound (USG) guided Transversus abdominis plane (TAP) block and Lateral Femoral Cutaneous Nerve (LFCN) block for the bone marrow aspirate from the iliac crest and Intercostobrachial nerve block (T2) was given to prevent pain while injecting the aspirate into the non‐union site. Dexmedetomidine and ketamine were given for deep level sedation and analgesia. TAP block and LFCN block is generally used for post‐op analgesia but can be also used for surgical anesthesia instead of General anesthesia in specific scenarios. Its perioperative application and its potential use instead of GA have been discussed.     

Safety of regional anesthesia in Eisenmenger's syndrome

BACKGROUND AND OBJECTIVES: Eisenmenger's syndrome is characterized by right-to-left or bidirectional shunting and pulmonary hypertension. Perioperative risk is high for noncardiac surgery, and many clinicians avoid regional anesthesia because of the potential deleterious hemodynamic effects. We determined perioperative mortality based on published reports describing anesthetic management in patients with Eisenmenger's syndrome. METHODS: A literature search identified 57 articles describing 103 anesthetics in patients with Eisenmenger's syndrome. An additional 21 anesthetics were identified in patients receiving regional anesthesia for labor. RESULTS: Overall perioperative mortality was 14%; patients receiving regional anesthesia had a mortality of 5%, whereas those receiving general anesthesia had a mortality of 18%. This trend favored the use of regional anesthesia but was not statistically significant. A better predictor of outcome was the nature of the surgery (and presumably the surgical disease). Patients requiring major surgery had mortality of 24%, whereas those requiring minor surgery had mortality of 5% (P <.05). Patients in labor receiving regional anesthesia had a mortality rate of 24%, and most of these occurred several hours after delivery. CONCLUSIONS: This review of anesthesia and surgery in patients with Eisenmenger's syndrome reveals that most deaths probably occurred as a result of the surgical procedure and disease and not anesthesia. Although perioperative and peripartum mortalities are high, many anesthetic agents and techniques have been used with success.     

区域麻醉或镇痛联合全麻的临床应用与争议

背景近年全麻手术中加入区域阻滞的应用日益增多。尽管有证据支持区域阻滞比全麻具有更好的镇痛作用,但其对总体术后转归的改善仍未完全清楚。目的评价区域阻滞对患者中长期术后转归的影响以及实施区域阻滞的风险和争议。内容硬膜外阻滞减少血管大手术或高危患者的心血管并发症;尽管区域阻滞对早期术后康复有一定改善,但对长期术后康复的影响不...     

区域阻滞麻醉与老年患者术后神经系统功能、病死率关系的研究进展

背景 区域阻滞麻醉应用于老年患者手术日益增多,其对老年患者术后神经系统功能、病死率的影响有待总结. 目的 通过文献综述,分析区域阻滞麻醉对老年患者术后神经系统、病死率的影响. 内容 讨论区域阻滞麻醉与老年患者术后神经系统功能,包括术后谵妄、认知功能障碍、脑卒中以及与病死率之间的关系. 趋向 区域阻滞麻醉可以减少老年患者术后肺部并发症,减少术后早期认知功能障碍,与全身麻醉相比,具有一定优势.区域阻滞麻醉是否能降低老年患者术后病死率、心血管并发症发生率、谵妄发生率、围手术期脑卒中发生率尚有待于进一步研究.     

髋关节囊周神经阻滞的研究进展

髋关节囊周神经（PENG）阻滞是一种新型的神经阻滞区域麻醉方法。它最早在髋关节手术麻醉和围术期镇痛方面应用,现在已逐渐应用于下肢截肢手术、大隐静脉曲张结扎剥离术以及大腿内侧肿物切除术等下肢手术。由于PENG阻滞能操作简单且几乎完善地将闭孔神经阻滞,产生良好的围术期镇痛,减少阿片类药物需求和相关不良反应,且不影响下肢肌力,使得近几年国内外不少专家对其研究热度日益高涨。该文针对PENG阻滞的解剖基础、B超引导下麻醉技术分析及其应用于下肢手术中的效果临床研究进展予以综述。     

Anesthetic management of a parturient with VACTERL association undergoing Cesarean delivery

Purpose

We present the anesthetic management of a parturient with VACTERL association undergoing combined regional and general anesthesia for Cesarean delivery. Defined as a syndrome, VACTERL association comprises at least three of the following abnormalities: vertebral, anal atresia, cardiac, tracheoesophageal, renal, and limb.

Clinical features

The patient’s anatomic abnormalities and comorbidities comprised severe cervicothoracic scoliosis, kyphoscoliosis, congenitally fused ribs, and severe restrictive lung disease. She had a Mallampati class 3 airway, a right laterally flexed neck, and reduced mandibular protrusion. We performed a lumbar spine ultrasound for epidural placement which was used to provide peri- and postoperative analgesia. Due to the anticipated difficult tracheal intubation, the patient underwent an awake fibreoptic intubation and subsequently received general anesthesia. The patient’s trachea was extubated on the first postoperative day, and she received adequate post-Cesarean epidural analgesia.

Conclusion

This case highlights the challenges that anesthesiologists face when managing parturients at extremely high risk for perioperative anesthetic morbidity due to the presence of severe pre-existing disease, anticipated difficult airway, and major spinal abnormalities complicating neuraxial anesthesia. We used a combined general and epidural anesthetic approach to control ventilation, provide effective postoperative analgesia, and reduce the risk of anesthetic-related perioperative morbidity. An individualized approach should be considered for the anesthetic management of high-risk pregnant patients with complex and multiple medical and surgical morbidities undergoing labour and delivery.     

Implantación subcutánea de DCI-S mediante bloqueos del plano del músculo serrato y del músculo torácico transverso. Caso clínico

IntroductionThe development of a subcutaneous implantable cardioverter-defibrillator (S-ICD) combined with the typical patient comorbidities creates new challenges for anesthesia.Clinical caseA young male, ASA II, was proposed for S-ICD placement, after recovery from a sudden CRP episode. We performed regional anesthesia with a serratus plane block and transversus thoracic muscle plane block with administration of mepivacaine and ropivacaine. S-ICD placement was achieved under regional anesthesia. In the perioperative period, the patient remained hemodynamically stable, without any complications or pain.DiscussionThe implantation of the ICD occurs in fragile patients, with high anesthetic risk. In this case, the association of serratus plane block and transversus thoracic muscle plane block was an effective anesthetic/analgesic approach, has advantages when compared with other techniques and has potential use in other procedures.     

Dexmedetomidine: clinical application as an adjunct for intravenous regional anesthesia

The selective α-2 adrenoceptor agonist, dexmedetomidine, has been shown to be a useful, safe adjunct in perioperative medicine. Intravenous regional anesthesia is one of the simplest forms of regional anesthesia and has a high degree of success. However, intravenous regional anesthesia is limited by the development of tourniquet pain and its inability to provide postoperative analgesia. To improve block quality, prolong postdeflation analgesia, and decrease tourniquet pain, various chemical additives have been combined with local anesthetics, although with limited success. The antinociceptive effects of α-2 adrenoceptor agonists have been shown in animals and in humans. However, less is known about the clinical effects of dexmedetomidine when coadministered with local anesthetics in patients undergoing intravenous regional anesthesia. This review examines what is currently known to improve our understanding of the properties and application of dexmedetomidine when used as an adjunct in intravenous regional anesthesia.     

Regionalanästhesie in der Orthopädie

Regional anesthesia has its place in the perioperative pain management of orthopedic patients. A reduction in postoperative mortality and morbidity with regional anesthesia is acknowledged for subsets of patient populations. Single shot and continuous applications are techniques for providing regional analgesia. Continuous infusion of local anesthetics with catheter techniques provides for uninterrupted postoperative analgesia. The combination of regional and general anesthesia reduces the consumption of systemic anesthetics. The side effects of opioid therapy are thereby reduced. The inhibition of intraoperative stress reaction, especially with epidural anesthesia, helps to prevent or lower unwanted metabolic changes. Patient contentment with analgesic quality differs with the technique with which the regional anesthesia is applied (PDA, PCEA, IVRA, peripheral block, i.a. injection), and the medication (LA, opioid) used.     

A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials

Both regional anesthesia and general anesthesia have been proposed to provide optimal ambulatory anesthesia. We searched MEDLINE and other databases for randomized controlled trials comparing regional anesthesia and general anesthesia in ambulatory surgery patients for meta-analysis. Only major conduction blocks were considered to be regional anesthesia. Regional anesthesia was further separated into central neuraxial block and peripheral nerve block. Fifteen (1003 patients) and 7 (359 patients) trials for central neuraxial block and peripheral nerve block were included in the meta-analysis. Both central neuraxial block and peripheral nerve block were associated with increased induction time, reduced pain scores, and decreased need for postanesthesia care unit analgesics. However, central neuraxial block was not associated with decreased postanesthesia care unit bypass or time or reduced nausea despite reduced analgesics, and it was associated with a 35-min increase in total ambulatory surgery unit time. In contrast, peripheral nerve block was associated with decreased postanesthesia care unit need and decreased nausea but, again, not with decreased ambulatory surgery unit time. This meta-analysis indicates potential advantages for regional anesthesia, such as decreased postanesthesia care unit use, nausea, and postoperative pain. Although these factors have been proposed to reduce ambulatory surgery unit stay, neither central neuraxial block nor peripheral nerve block were associated with reduced ambulatory surgery unit time. Other factors, such as unsuitable discharge criteria and limitations of meta-analysis, may explain this discrepancy.     

Insertion of vagal nerve stimulator using local and regional anesthesia

BACKGROUND: Vagal nerve stimulation (VNS) is a valuable therapy for patients with intractable epilepsy. Placement of a vagal nerve stimulator typically requires general anesthesia, which frequently interrupts anticonvulsant therapy. Insertion of the stimulator using regional/local anesthesia may offer the advantages of continuity of anticonvulsant therapy and implantation in the outpatient setting. METHODS: We retrospectively compared the first 10 consecutive patients undergoing VNS implantation under general anesthesia with the first 12 consecutive patients undergoing VNS implantation under regional/local anesthesia. Patients for the regional/local anesthesia were selected on the basis of their ability to cooperate and follow commands. Regional anesthesia for implantation of the VNS leads was achieved by performing superficial and deep cervical plexus blocks. A local anesthetic field block of a small area of the posterior chest provided anesthesia for insertion of the generator. RESULTS: All of the patients undergoing regional/local anesthesia completed the procedure without difficulty and on an outpatient basis. None complained of discomfort, sedation, nausea, or vomiting and none had seizures in the perioperative period. These results contrasted with the group that underwent general anesthesia (n = 10), who had an 80% incidence of nausea and vomiting and a 30% incidence of postoperative seizures. CONCLUSION: VNS implantation under regional/local anesthesia is proficiently performed as an outpatient procedure with minimal postoperative side effects.     

Multiple sclerosis: basic knowledge and new insights in perioperative management

Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system affecting young adults that may lead to significant disability. The clinical course varies among the types of the disease as well as among individuals. Herein we provide a brief review of the recent data concerning the clinical presentation, diagnosis, causes, and pathogenesis of MS as well as medication used, followed by the anesthetic considerations of patients diagnosed with the disease. To accomplish this, we conducted a systematic PubMed literature search for articles, using the terms multiple sclerosis, anesthesia, general, regional, perioperative, and preoperative, and we then manually reviewed the references from each pertinent article. Because randomized controlled trials on the field are rare, most information is derived by case reports and case series. We concluded that the disease itself as well as the treatment modalities may have several implications in the conduct of anesthesia and perioperative management of MS patients. General and regional anesthetic techniques have been successfully used. With thorough preoperative evaluation and in depth knowledge of the disease and its complications, the MS patients can be managed safely.     

胸椎旁神经阻滞在患儿围术期镇痛中的应用进展

胸椎旁神经阻滞（TPVB）是一种将局麻药注入胸椎旁间隙，从而节段性地阻滞单侧躯体感觉神经、运动神经及交感神经的区域阻滞技术。近年来，TPVB技术用于患儿胸部及上腹部手术麻醉与镇痛的研究不断增加，表现出良好的围术期镇痛效果。本文从TPVB用药方案、扩散途径、操作方法、临床应用及并发症等方面对TPVB技术用于患儿围术期镇痛的应用现状及研究进展进行综述。     

The influence of anesthetic technique on perioperative complications after carotid endarterectomy

Purpose: This study evaluated the influence of anesthetic techniques on perioperative complications after carotid endarterectomy.Methods: Perioperative complications, the use of a carotid artery shunt, the duration of the operative procedure and postoperative hospital course were retrospectively compared in 584 consecutive patients undergoing 679 carotid endarterectomies with use of either general anesthesia (n = 361) or cervical block regional anesthesia (n = 318). There was no significant difference in the preoperative medical characteristics between the two anesthetic groups. Symptomatic carotid artery disease was the indication for surgery in 247 (68.4%) patients receiving general anesthetics, whereas 180 (56.6%) patients treated with a cervical block anesthetic had a symptomatic carotid artery stenosis (p = 0.02).Results: The perioperative stroke rate and stroke-death rate for the entire series was 2.4% and 3.2%, respectively, and was not significantly different between the anesthetic groups or between patients with symptomatic or asymptomatic disease. A carotid artery shunt was used in 61 (19.2%) patients receiving a cervical block anesthetic and 152 (42.1%) patients treated with a general anesthetic (p < 0.0001). Use of cervical block anesthesia was associated with a significantly shorter operative time, fewer perioperative cardiopulmonary complications, and a shorter postoperative hospitalization when compared with general anesthesia. Multivariate risk factor analysis indicated that age greater than 75 years, operative time greater than 3 hours, and the use of a carotid artery shunt were all independent risk factors for perioperative cardiopulmonary complications. When a carotid artery shunt was not analyzed as a multivariate risk factor, then general anesthesia became a significant risk factor for perioperative cardiopulmonary complications (risk ratio 2.08; p = 0.04).Conclusions: We conclude that cervical block anesthesia is safer and results in a more efficient use of hospital resources than general anesthesia in the treatment of patients undergoing carotid endarterectomy. (J VASC SURG 1994;19:834-43.)     

Perioperative outcome of carotid endarterectomy with regional anesthesia: two decades of experience from the Caribbean

Study ObjectiveTo evaluate the perioperative outcome of carotid endarterectomy (CEA) with regional anesthesia.DesignRetrospective chart review of consecutive patients who underwent CEA with regional anesthesia in a 23-year period.SettingOperating rooms of a general hospital in a developing country.MeasurementsDemographic data, perioperative clinical data, postoperative morbidity and unplanned admissions were recorded.Main ResultsA total of 183 CEA procedures were performed. In 172 cases, CEA was done exclusively with deep cervical plexus block and local infiltration, while in 11 (6%) cases, there was a need for conversion to general anesthesia intraoperatively. Clamping of the internal carotid artery (ICA) for a three-minute period was the method used to monitor any development of neurological impairment. Perioperative complications included intraoperative seizures in one patient, intraoperative transient hemiparesis in three patients, postoperative transient hemiparesis in two patients, and intraoperative hemiplegia in one patient. One hundred fifty-three patients (83.6%) were discharged home within 24 hours, and 29 (15.8%) were discharged home in 48 hours. The hemiplegic patient had a hospital stay of 12 days. There was no perioperative mortality.ConclusionsRegional anesthesia is a safe method for CEA in a limited-resources setting, as it facilitates intraoperative clinical assessment of the effects of ICA clamping.     

Successful perioperative management of factor X deficiency associated with primary amyloidosis

Acquired bleeding abnormalities are common in patients with primary amyloid light-chain amyloidosis. Factor X deficiency is the most common coagulopathy associated with life-threatening hemorrhagic complications when surgery is indicated. Fresh-frozen plasma (FFP) or prothrombin complex concentrates (PCCs) are the most frequently used blood products in this disease; however, FFP is often ineffective in controlling bleeding and PCCs have a significant risk of thrombosis when used intraoperatively. This report describes a patient with primary amyloidosis and factor X deficiency who underwent hemicolectomy with preoperative and intraoperative administration of recombinant human factor VIIa and postoperative administration of Bebulin (a PCC that contains the highest concentration of factor X). The management was successful with no signs of bleeding postoperatively. To our knowledge, few reports of successful perioperative management of factor X deficiency have been published to date. This is the first case report using recombinant human factor VIIa and Bebulin in the perioperative management of factor X deficiency associated with primary amyloidosis. Recombinant human factor VIIa and Bebulin may allow for successful perioperative management of bleeding disorders in patients with primary amyloidosis.     

The definition of block "success" in the contemporary literature: are we speaking the same language?

ABSTRACT: A successful nerve block is the common goal that shapes modern regional anesthesia practice and research, yet the meaning of block "success" can be open to interpretation. For this Special Article, we reviewed all applicable randomized controlled trials published over the last decade to determine the most commonly used definitions of block success. We also sought to uncover which relevant indicators of block success are routinely reported in the contemporary literature. Twenty-two trials that explicitly designated the term block "success" as their primary outcome measure were identified. The most common definition of block success was the achievement of a surgical block within a designated period, used in half of the trials. Block success was inconsistently defined in the remaining 11 trials. Patient-related indicators of block success including postoperative pain and patient satisfaction were measured in only 4 trials, whereas anesthesiologist-related indicators such as block onset time and complications were reported most frequently. Surgeon- and hospital administrator-related indicators were not collected in any trial. We found that the definition of block success is highly variable in the contemporary regional anesthesia literature. Our findings underscore the clear and present need for a comprehensive definition of block success, whereas future research should endeavor to capture the indicators of block success that are important to all key perioperative stakeholders.     

Caudal block complication in a patient with trisomy 13

In this report we describe a complication of a caudal block in a 4-year-old child with trisomy 13. The patient's history was remarkable for microcephaly, developmental delay, seizures, apnea, and prolonged emergence times. Induction of anesthesia and tracheal intubation were uneventful. A caudal block was aborted after positive aspiration of cerebrospinal fluid. A radiogram suggestive of spinal dysraphism, found on subsequent review, was confirmed by a magnetic resonance imaging scan consistent with tethered cord and dural ectasia. Congenital abnormalities associated with trisomy 13 and cutaneous signs suggestive of spinal abnormalities are reviewed. Avoidance of neuraxial regional anesthesia in these patients is recommended.     

局部麻醉下外套式剥脱导管联合点状剥脱术治疗原发性大隐静脉曲张的效果分析

目的 探讨局部麻醉下外套式剥脱导管联合点状剥脱术治疗原发性大隐静脉曲张的效果.方法 选取2019年1月至2021年1月山东大学第二医院收治的482例原发性大隐静脉曲张患者,按照随机数字表法将其随机分为观察组(n=220)和对照组(n=262),观察组患者采用局部麻醉下外套式剥脱导管联合点状剥脱术,对照组患者采用神经阻滞...