Thromboprophylaxis and peripheral nerve blocks in patients undergoing joint arthroplasty

This study was designed to assess the risk of hematoma related to the combination of peripheral nerve blocks and thromboprophylaxis. A total of 3588 patients undergoing joint arthroplasty were included. Blocks performed included continuous lumbar plexus, continuous femoral, and continuous or single sciatic. The perineural catheters were removed on postoperative days 2 or 3. A total of 6935 blocks were performed in patients receiving warfarin (50.0%), fondaparinux (12.8%), deltaparin (11.6%), enoxaparin (1.8%), and aspirin (23.8%). In this patient population, no perineural hematoma was recorded. Our data provide evidence that continuous/single peripheral nerve blocks can be safely performed before thromboprophylaxis initiation, and perineural catheters can be safely removed while the patient is receiving thromboprophylaxis and/or aspirin.     

Initial results of a structured rotation in hematology and transfusion medicine for anesthesiology residents

Study Objective

To develop and evaluate a new curriculum in transfusion medicine for anesthesiology residents.

Study Design

Quasi-experimental study.

Setting

Single center, pilot curriculum in the anesthesiology residency program at a university-affiliated medical center.

Participants

Group TM consisted of residents who participated in the one month-long transfusion medicine rotation in postgraduate year 2 (PGY2; n = 9). The comparison group (non-TM) consisted of residents who had no exposure to the transfusion medicine rotation (n = 21).

Measurements

We compared results of the 2009 American Board of Anesthesiology In-Training Exam (ABA-ITE) 2009 by residents of our program with the national performance of residents in the first clinical anesthesia year (AMG CA1 = PGY-2) and second clinical anesthesia year (AMG CA2 = PGY-3) on transfusion medicine/hematology knowledge. Performance on a pre-test and post-test of those who took part in the transfusion medicine curriculum, and overall performance on the ABA-ITE, of departmental residents who had and had not participated in the Transfusion Medicine curriculum within the target knowledge area of hematology/transfusion medicine and compared against national peer performance data, was assessed. An anonymous electronic survey (5-Point Likert scale) was used to assess the perceived educational value of the curriculum.

Main Results

Transfusion medicine-related knowledge of anesthesia residents markedly improved from the pre- to post-rotation examination and on the ABA-ITE. In the ABA-ITE 2009, the TM group performed better than their national peers (AMG CA1 and CA2) in the hematology content area. The post-rotation anonymous resident survey indicated high resident satisfaction.

Conclusions

A structured transfusion medicine curriculum improved anesthesiology resident knowledge in transfusion medicine and was associated with high learner satisfaction.     

Internet remote control of pump settings for postoperative continuous peripheral nerve blocks: A feasibility study in 59 patients

Introduction

During continuous peripheral nerve blocks, infusion adjustments are essential for postoperative analgesia without side effects. Beside, physicians and nurse visits related to pump's settings and monitoring are time consuming and costly. We hypothesized that a remote control of pump's settings, by telemedicine transmission, adjusted to patients’ feedbacks, is feasible and interesting in optimizing patient's postoperative pain management.

Methods

Fifty-nine ASA physical status I and II patients were included. Ropivacaine 0.2% was infused during 72 h in CPNB catheters. After returning to the surgical ward, the patient was allowed to answer a 10 indicators questionnaire 3 times a day (8.00 AM, 2.00 PM, 8.00 PM), or unlimited on patient's demand. This information was transmitted from the pump to a server through the Internet. If one indicator was out of the predefined thresholds, the anesthesiologist in charge was immediately informed by texto on his cell phone. The anesthesiologist connected to the website, checked the data from the patient and modified the settings of the pump by remote control according to a written protocol. The changes need a secure access with a password and a confirmation. The number of settings changes, the time to realize the procedure and the adverse events related to the technique were noted. When the catheter was removed, the pump was unassigned to the patient and the data archived.

Results

Thirty sciatic, 24 femoral and 5 interscalene catheters were inserted in 59 patients. Five catheters were accidentally removed before the end of the 72-h period. The median VAS pain values at rest and during movement were respectively at 2 and 3. Sixteen patients complained about numbness promoting 2 (0–3) changes in pump settings; 9 about motor blockade with 1 (0–2) change; 5 about difficulties for physiotherapy with 1 (0–3) change. The mean time of pump settings modification after response to questionnaire or voluntarily patient's alert was 15 ± 2.2 minutes. Early physiotherapy in the surgical ward was totally uneventful in 54 patients. The mean value of satisfaction scale of the patients was 8.4 ± 1.6. No adverse event necessitated a postoperative analgesia technique change.

Conclusion

Remote control pump's feedbacks and e-settings for postoperative analgesia using CPNB permitted a real adaptation to patients’ needs, complaints and pain VAS values without nurse and physician physical intervention.     

Diagnostic nerve blocks in chronic pain

Diagnostic blocks are used to obtain information about the source of a patient's pain. As such they differ in principle and in practice from regional anaesthetic blocks. In order to be valid, diagnostic blocks must be precise and target-specific. They must be controlled in order to exclude false-positive responses. Sympathetic blocks have traditionally been performed without pharmacological controls, but studies have shown that the features of complex regional pain syndromes can be relieved equally well when normal saline is administered as when local anaesthetic is used. This warns that sympathetic blocks must be controlled in each and every case lest false conclusions be drawn about the response. Medial branch blocks of the lumbar and of the cervical dorsal rami have been extensively investigated in order to establish their validity, diagnostic utility and therapeutic utility. They provide an example and benchmark for how diagnostic blocks can and should be validated.     

A survey of airway training among U.S. and Canadian anesthesiology residency programs

Study Objective

To determine the current trends in airway education in academic programs.

Design

Survey instrument.

Setting

American academic medical center.

Subjects

147 directors of American and Canadian anesthesiology residency programs.

Measurements

An invitation to complete an online questionnaire was sent. Non-responding institutions were contacted repeatedly by email and telephone to ensure a reasonable response rate.

Main Results

88 of the 147 (60%) programs completed the survey. Forty-three respondents (49%) reported that they had formal airway rotations, and 39 respondents said that a designated titled faculty member was responsible for airway training. Didactic lecture and manikin instruction were used by more than two thirds of the programs. Documentation of supervised airway experience was recorded in 71 (82%) programs. The majority of the programs (81%) had videolaryngoscopes. A fiberoptic bronchoscope was nearly universally available, and approximately one third (34%) of graduating residents were estimated to have performed more than 25 awake fiberoptic intubations. For most techniques, the estimates of the required number of procedures to ensure competence varied widely.

Conclusions

The number of programs with a formal airway management program continues to increase, and programs are incorporating newer intubation techniques. The criteria for competence have not been established.     

Characteristics of anesthesiology residency program directors

The roles and responsibilities of anesthesiology core program directors have evolved, in part because the Anesthesiology Residency Review Committee of the Accreditation Council for Graduate Medical Education no longer requires that the department chair also serve in this role. We reviewed several core anesthesiology program director academic and demographic characteristics including age, academic rank, gender, duration of service, board certification and re-certification status, and whether the program director also serves as department chair. Anesthesiology core residency program directors range in age from 33 to 74 years, with a median of 52 years. Thirty-seven (28%) program directors are women. The majority (67%) have senior academic rank (professor or associate professor). The median appointment duration is 3.7 years. The core residency program director currently also serves as department chair in 24 of the 131 (18.3%) programs.     

The use of peripheral nerve blocks at the elbow for carpal tunnel release

This case report illustrates that median, radial, and ulnar nerve blocks at the elbow provides anesthesia for ambulatory carpal tunnel release surgery. This report discusses 3 patients with medical conditions, including vascular access problems and morbid obesity, which made nerve blocks at the elbow advantageous compared with other anesthetic techniques. Peripheral nerve blocks at the elbow were done before surgery in a block room, so the patients spent less time in the operating room. Nerve blocks at the elbow are effective anesthesia for hand procedures with no patient requiring further local anesthetic injection and opioids for pain or expressing any discomfort during surgery. The blocks are easy to perform and set up quickly, and using long-acting local anesthetics, elbow blocks provide postoperative pain control for approximately 10 hours. The nerve blocks at the elbow facilitate the perioperative process by being done out of the operating room and providing prolonged pain control without the need for opioids, so nausea may be avoided.     

周围神经缺损修复研究进展

周围神经损伤并形成缺损临床上较常见,治疗仍然是临床面临的一个巨大挑战.由于周围神经解剖和功能上的特殊性,其损伤修复是一个复杂的过程,精细的显微外科技术可以较好地恢复神经的连续性,但神经功能的恢复仍不令人满意.近年来,国内外学者始终还在为此进行着不懈的努力,在许多方面取得成就,尤其是异体神经移植已应用于临床.     

Repair and reconstruction of peripheral nerve injuries

Axonal regeneration after transection is a complex biological process. It is not merely a process of tissue repair, but rather of cellular repair of a large number of nerve cells. Regeneration involves restoration of the original morphology of each single cell, rather than proliferation. Techniques in microneurosurgical reconstruction of peripheral nerve injuries have improved over the last two decades, with subsequent improvement in functional results. Nerve autografts are now routinely used to guide the regrowth of the proximal nerves to distal nerve segments. However, the limited source of expendable cutaneous nerves restricts the use of nerve grafting techniques and is associated with significant morbidity. With extensive injuries there is an insufficient quantity of nerve autograft material to facilitate optimal repair. In future, the use of artificial conduits or nerve allografts could provide a limitless source of material to reconstruct otherwise irreparable traumatic nerve injuries. Establishment of appropriate strategies to suppress host-immune reaction or donor antigenicity would facilitate clinical allogeneic nerve transplantation. Guest lecture presented at the 69th Annual Meeting of the Japanese Orthopaedic Association in Tokyo on April 13, 1996.     

周围神经阻滞后爆发痛的研究进展

周围神经阻滞是围术期控制疼痛和减少阿片类药物使用的重要手段。然而,以周围神经阻滞后痛觉过敏为特征的术后爆发痛可能会减少这种方式的总体获益,它会对镇痛药物总用量、患者整体满意度和术后恢复产生明显影响,也可能引起心血管和肺部并发症,对患者的预后产生负面影响。了解周围神经阻滞后爆发痛的特征、危险因素和防治策略对于有效利用周围神经阻滞起到重要作用。     

周围神经断裂减张缝合术

目的 介绍并评价３种新的修复周围神经断裂减张缝合方法。方法 治疗周围断裂８９６例,１０３条神经,其中正中神经２０条,桡神经３９条,尺神经４４条。分别采用外膜－外膜法,神经瘤外膜－外膜法,外膜－神经床法等３种方法,使神经断端在无张力下缝合。结果 手术优良率８４．４％。结论 神经减张缝合术效果确切,利于神经的再生。     

声学功能神经导管用于修复周围神经损伤

修复周围神经损伤是再生医学面临的一大难题,应运而生的新兴治疗方法中,低强度脉冲超声(LIPUS)具有无创、非侵入、高穿透及低衰减的优点,可有效刺激周围神经再生。随着组织工程学的发展,联合应用LIPUS和生物材料神经导管(NGC)可进一步提高轴突再生率,促进周围神经损伤恢复,极具临床应用前景。本文就LIPUS联合声学功能NGC修复周围神经损伤研究进展进行综述。     

Risk of catheter‐associated infection in young hematology/oncology patients receiving long‐term peripheral nerve blocks

Background: Continuous peripheral nerve blocks (CPNBs) are increasingly used to control postoperative and chronic pain. At our pediatric oncology institution, the duration of CPNBs is often prolonged. The risk of catheter‐associated infection with prolonged CPNBs has not been previously investigated. Aim: We analyzed the incidence of CPNB‐related infection and its relation to catheter duration, catheter site, intensive care stay, and antibiotic coverage. Methods: All CPNBs placed at our institution between August 1, 2005 and October 31, 2010 were studied. Primary diagnosis and the site, indication, duration, and infectious adverse effects of CPNBs were obtained from our Pain Service QI database. Patients’ age and sex, antibiotic administration, and number of days in intensive care were collected from patients’ medical records. Results: The use of 179 catheters in 116 patients was evaluated. Mean age at CPNB placement was 15.1 years (median, 14.7; range, 0.4–26.9). The most frequent indication for CPNB was surgery (89.4%), most commonly orthopedic (78.8%). Mean CPNB duration was 7.2 days (median, 5.0; range, 1–81 days). Two cases (1.12%) of CPNBs developed signs of infection, both associated with femoral catheters. The infections were mild and necessitated catheter removal at days 10 and 13, respectively. Conclusion: Nerve block catheter‐associated infections are infrequent at our institution despite prolonged CPNB use. Both patients with infection had femoral catheters and prolonged catheter (≥10 days) use.     

Ultrasound guidance characteristics and efficiency of suprazygomatic maxillary nerve blocks in infants: a descriptive prospective study

Background: Bilateral suprazygomatic maxillary nerve blocks approach improves pain relief after palate surgery. We report the feasibility and efficiency of ultrasound‐guided suprazygomatic maxillary nerve blocks in cleft palate repair in children. Methods: Twenty‐five children scheduled to undergo surgical cleft palate repair were included. Ultrasound‐guided suprazygomatic maxillary blocks were performed according to landmarks previously defined. The ultrasound probe was located optimally over the maxilla and under the zygomatic bone to visualize the pterygopalatine fossa. 0.15·ml·kg^?1 of 0.2% ropivacaine was injected bilaterally. Feasibility of block, spread of local anesthetic, pain scores and side effects were noted. Results: Fifty ultrasound‐guided suprazygomatic maxillary nerve blocks were performed in 25 children. The needle movement was seen in all cases using an out‐of‐plane approach. The spread of LA was clearly observed in 94% (47/50) of cases. A poor ultrasound imaging was found in 4% (2/50), and the spread of LA was not identified in 2% of case (1/50). The median time to perform the block was 56 s (35–120 s). The median pain scores and consumption of nalbuphine were low during the study period. 80% of patients did not require continuous opioid infusion. No complication related to maxillary blocks was reported. Conclusion: With a very low technical failure rate and a good clinical success rate, ultrasound appears to be a useful and simple tool to aid suprazygomatic maxillary nerve block in children.