Ultrasound guidance improves the success rate of a perivascular axillary plexus block

BACKGROUND: Traditional approaches to performing brachial plexus blocks via the axillary approach have varying success rates. The main objective of this study was to evaluate if a specific technique of ultrasound guidance could improve the success of axillary blocks in comparison to a two injection transarterial technique. METHODS: Fifty-six ASA physical status I-III patients presenting for elective hand surgery were prospectively randomized to receive an axillary block performed by either a transarterial technique (Group TA) or an ultrasound-guided perivascular approach (Group US). Both groups received a total of 30 ml of 1.5% lidocaine (225 mg) with 5 microg/ml epinephrine. Patients were then evaluated for block onset in specific nerve distributions and whether or not the block acted as a surgical anesthetic. RESULTS: Group TA sustained more failures defined as conversion to general anesthesia or the inability to localize the artery [Group TA eight patients (29%) vs. Group US in which 0 patients required conversion to general anesthesia (0%) P < 0.01]. Group US demonstrated a reduction in performance times vs. Group TA (7.9 +/- 3.9 min vs. 11.1 +/- 5.7 min, P < 0.05). By 30 min post-injection, there were no significant differences between groups TA and US in terms of the proportion of patients demonstrating a complete motor or sensory loss. CONCLUSION: Ultrasonographic guidance improves the overall success rate of axillary blocks in comparison to a transarterial technique.     

Is nerve stimulation needed during an ultrasound‐guided lateral sagittal infraclavicular block?

Background: The objective of the study was to evaluate the influence of ultrasound (US) guidance alone vs. neurostimulation (NS) and US (NSUS) guidance techniques on block performance time and block success rate for the lateral sagittal infraclavicular block (LSIB). Methods: In a randomized and prospective manner, 110 adult patients scheduled for distal upper limb surgery were allocated to the US or the NSUS groups. In the US group, a local anesthetic (LA) was administered only with US guidance to produce a ‘U’‐shaped distribution around the axillary artery. In the NSUS group, LA was administered under US guidance only after electrolocation of one of the median, ulnar or radial nerve‐type responses. A total of 30 ml of LA (10 ml of levobupivacaine 5 mg/ml and 20 ml of lidocaine 20 mg/ml) was administered in both groups. Sensory block was tested at 10 min intervals for 30 min. Successful block was defined as analgesia or anesthesia of all five nerves distal to the elbow. Results: Block success rate was 94.5% in both groups. Block performance time was significantly shorter in the US than the NSUS group (157 ± 50 vs. 230 ± 104 s) (P=0.000). Block onset time was similar in both groups (12.5 ± 4.8 in the US vs. 12.8 ± 5.4 min in the NSUS groups). There were two arterial punctures in the NSUS group. Conclusions: During LSIB performance US guidance alone produces block success rate identical to both US and NS guidance yet with a shorter block performance time.     

Multiple-injection axillary brachial plexus block: A comparison of two methods of nerve localization-nerve stimulation versus paresthesia

We conducted this prospective study to compare the onset time and the success rate of a multiple-injection axillary brachial plexus block performed by using two methods of nerve localization: paresthesia elicitation or nerve stimulation. Each of the major nerves of the plexus was located by elicitation of a paresthesia (Group PAR; n = 50) or by nerve stimulation (Group PNS; n = 50) and injected with 10 mL of local anesthetic solution. Time to perform the block, onset time of the primary block, time to achieve readiness for surgery, and total anesthetic time were significantly shorter in Group PNS than in Group PAR. The incidence of complete block was larger in Group PNS than in Group PAR (91% vs 76%; P: < 0. 05), and this was related to a larger success rate for anesthetizing the radial and the musculocutaneous nerves (P: < 0.05). The frequency of venous puncture was larger in Group PAR (P: < 0.05). For multiple-injection axillary brachial plexus block, we conclude that nerve stimulation resulted in a greater success rate and a faster onset than paresthesia elicitation, and it should be considered when the radial and musculocutaneous nerve distributions are involved in the surgical area. IMPLICATIONS: Two methods of nerve localization were compared when performing an axillary brachial plexus block by the multiple-injection technique. Nerve stimulation provided a faster onset and a greater incidence of complete block, related to a better success rate for anesthetizing the radial and the musculocutaneous nerves, than paresthesia elicitation.     

Are peripheral and neuraxial blocks with ultrasound guidance more effective and safe in children?

Background and aims:  The efficacy and safety of ultrasound guided (USG) pediatric peripheral nerve and neuraxial blocks in children have not been evaluated. In this review, we have looked at the success rate, efficacy and complications with USG peripheral nerve blocks and compared with nerve stimulation or anatomical landmark based techniques in children.
Methods:  All suitable studies in MEDLINE, EMBASE Drugs and Cochrane Evidence Based Medicine Reviews: Cochrane Database of Systemic Reviews databases were identified. In addition, citation review and hand search of recent pediatric anesthesia and surgical journals were done. All three authors read all selected articles independently and a consensus was achieved. All randomized controlled trials (RCTs) comparing USG peripheral and neuraxial blocks with other techniques in children were included.
Results:  Ultrasound guidance has been demonstrated to improve block characteristics in children including shorter block performance time, higher success rates, shorter onset time, longer block duration, less volume of local anesthetic agents and visibility of neuraxial structures.
Conclusion:  Clinical studies in children suggest that US guidance has some advantages over more traditional nerve stimulation–based techniques for regional block. However, the advantage of US guidance on safety over traditional has not been adequately demonstrated in children except ilio-inguinal blocks.     

Lateral popliteal sciatic nerve block: a single injection targeting the tibial branch of the sciatic nerve is as effective as a double-injection technique

BACKGROUND: Evidence indicating that single- and double-injection techniques for inducing a sciatic nerve block via a posterior subgluteal approach yield a similar success rate prompted us to investigate whether the two anesthetic techniques yield a similar success rate via a lateral approach. We also hypothesized that, owing to the peculiar anatomic features of the sciatic nerve at the popliteal level, a single injection via the lateral approach might induce effective anesthesia by targeting the tibial nerve only. METHODS: Ninety-six patients undergoing popliteal sciatic nerve block via a lateral popliteal approach for foot surgery were randomized to receive a single 30-ml injection of ropivacaine 7.5 mg/ml to block the tibial nerve (TN group, n= 32) or the common peroneal nerve (CPN group, n= 32), or two separate 15-ml injections (TN + CPN group, n= 32), after stimulation to evoke motor responses from the target nerves. RESULTS: The mean time to obtain a complete sensory blockade (surgical anesthesia) was shorter in the TN group than in the CPN and TN + CPN groups (14 +/- 7 min vs. 23 +/- 17 and 21 +/- 14 min, respectively; P < 0.05). The success rate was similar in the TN and TN + CPN groups (94%) and, 25 min after the initial injection, was already better in these groups than in the CPN group (94% vs. 75%; P < 0.05). CONCLUSIONS: A lateral popliteal sciatic nerve block obtained with a single 30-ml injection of ropivacaine 7.5 mg/ml after electrostimulation to locate the tibial nerve is as effective as multiple TN + CPN stimulation and injection, and local anesthesia has a significantly shorter onset time.     

A prospective, randomized comparison between ultrasound and nerve stimulation guidance for multiple injection axillary brachial plexus block

BACKGROUND: This prospective, randomized, blinded study tested the hypothesis that ultrasound guidance can shorten the onset time of axillary brachial plexus block as compared with nerve stimulation guidance when using a multiple injection technique. METHODS: Sixty American Society of Anesthesiology physical status I-III patients receiving axillary brachial plexus block with 20 ml ropivacaine, 0.75%, using a multiple injection technique, were randomly allocated to receive either nerve stimulation (group NS, n = 30), or ultrasound guidance (group US, n = 30) for nerve location. A blinded observer recorded the onset of sensory and motor blocks, the need for general anesthesia (failed block) or greater than 100 microg fentanyl (insufficient block) to complete surgery, procedure-related pain, success rate, and patient satisfaction. RESULTS: The median (range) number of needle passes was 4 (3-8) in group US and 8 (5-13) in group NS (P = 0.002). The onset of sensory block was shorter in group US (14 +/- 6 min) than in group NS (18 +/- 6 min) (P = 0.01), whereas no differences were observed in onset of motor block (24 +/- 8 min in group US and 25 +/- 8 min in group NS; P = 0.33) and readiness to surgery (26 +/- 8 min in group US and 28 +/- 9 min in group NS; P = 0.48). No failed block was reported in either group. Insufficient block was observed in 1 patient (3%) of group US and 2 patients (6%) of group NS (P = 0.61). Procedure-related pain was reported in 6 patients (20%) of group US and 14 patients (48%) of group NS (P = 0.028); patient acceptance was similarly good in the two groups. CONCLUSION: Multiple injection axillary block with ultrasound guidance provided similar success rates and comparable incidence of complication as compared with nerve stimulation guidance.     

Comparison of the costs and recovery profiles of three anesthetic techniques for ambulatory anorectal surgery

BACKGROUND: Given the current practice environment, it is important to determine the anesthetic technique with the highest patient acceptance and lowest associated costs. The authors compared three commonly used anesthetic techniques for anorectal procedures in the ambulatory setting. METHODS: Ninety-three consenting adult outpatients undergoing anorectal surgery were randomly assigned to one of three anesthetic treatment groups: group 1 received local infiltration with a 30-ml mixture containing 15 ml lidocaine, 2%, and 15 ml bupivacaine, 0.5%, with epinephrine (1:200,000) in combination with intravenous sedation using a propofol infusion, 25-100 microg. kg-1. min-1; group 2 received a spinal subarachnoid block with a combination of 30 mg lidocaine and 20 microg fentanyl with midazolam, 1-2-mg intravenous bolus doses; and group 3 received general anesthesia with 2.5 mg/kg propofol administered intravenously and 0.5-2% sevoflurane in combination with 65% nitrous oxide. In groups 2 and 3, the surgeon also administered 10 ml of the previously described local anesthetic mixture at the surgical site before the skin incision. RESULTS: The mean costs were significantly decreased in group 1 ($69 +/- 20 compared with $104 +/- 18 and $145 +/- 25 in groups 2 and 3, respectively) because both intraoperative and recovery costs were lowest (P < 0.05). Although the surgical time did not differ among the three groups, the anesthesia time and times to oral intake and home-readiness were significantly shorter in group 1 (vs. groups 2 and 3). There was no significant difference among the three groups with respect to the postoperative side effects or unanticipated hospitalizations. However, the need for pain medication was less in groups 1 and 2 (19% and 19% vs. 45% for group 3; P < 0.05). Patients in group 1 had no complaints of nausea (vs. 3% and 26% in groups 2 and 3, respectively). More patients in group 1 (68%) were highly satisfied with the care they received than in groups 2 (58%) and 3 (39%). CONCLUSIONS: The use of local anesthesia with sedation is the most cost-effective technique for anorectal surgery in the ambulatory setting.     

Ultrasound guidance for lateral midfemoral sciatic nerve block: a prospective, comparative, randomized study

Block of the sciatic nerve at the midfemoral level is usually performed using nerve stimulation techniques. We investigated the efficacy of ultrasound, combined with nerve stimulation, to locate and block the sciatic nerve at the lateral midfemoral level compared to nerve stimulation alone. Sixty-one patients scheduled for foot and ankle surgery were enrolled in this prospective, randomized study. Thirty patients underwent a lateral block of the sciatic nerve at the midfemoral level guided by ultrasound (group US) and 31 patients received the block without ultrasound (group ES). Once an adequate motor response was obtained using nerve stimulation, 35 mL of ropivacaine 0.5% was administered. The main end-points of the study were: number of attempts to obtain an adequate motor response, success rate of nerve location at the first attempt, quality and duration of both sensory and motor blocks, and anesthetic distribution. The success of sciatic nerve location at the first attempt was significantly more frequent in the US group than in the ES group (76.6% versus 41.9%; P < 0.001). The quality of the sensory block and the tolerance to the pneumatic tourniquet were also significantly better in the US group (P < 0.01). We conclude that ultrasound combined with nerve stimulation improved the quality of the sensory block and the tolerance to the pneumatic tourniquet, reducing the number of attempts to perform sciatic nerve block at the midfemoral level.     

Edrophonium effectively antagonizes neuromuscular block at the laryngeal adductors induced by rapacuronium, rocuronium and cisatracurium, but not mivacurium

PURPOSE: To examine the efficacy of antagonism of rapacuronium-, mivacurium-, rocuronium- and cisatracurium-induced neuromuscular block at the laryngeal adductors (LA). METHODS: One hundred four patients were randomly assigned to one of eight study groups. They either received rapacuronium 1.5 mg x kg(-1), mivacurium 0.25 mg x kg(-1), rocuronium 0.9 mg x kg(-1) or cisatracurium 0.15 mg x kg(-1). Patients in each treatment group either received edrophonium (0.5 mg x kg(-1)) at 10% recovery of the first twitch (T1) of train-of-four (TOF) at the LA or were allowed to recover spontaneously from neuromuscular block. The effect of antagonism on speed of recovery of neuromuscular function at the LA was evaluated. RESULTS: The time to recovery to a TOF ratio of 0.9 at the LA, when compared to the spontaneous recovery group, was significantly shortened by the administration of edrophonium in patients receiving rapacuronium [19.2 +/- 7.8 vs 26.2 +/- 4.9 (mean +/- SD) min], rocuronium (24.7 +/- 14.3 vs 44.4 +/- 13.0 min) and cisatracurium (24.2 +/- 5.7 vs 35.1 +/- 7.6 min). Edrophonium administration did not shorten complete recovery from mivacurium-induced block (15.7 +/- 8.0 vs 17.6 +/- 6.1 min). CONCLUSION: Recovery from rapacuronium-, rocuronium- or cisatracurium- induced neuromuscular block to a TOF ratio of 0.9 as measured at the LA was shortened by the administration of edrophonium, when compared to spontaneous recovery.     

Comparison of the Costs and Recovery Profiles of Three Anesthetic Techniques for Ambulatory Anorectal Surgery

Background: Given the current practice environment, it is important to determine the anesthetic technique with the highest patient acceptance and lowest associated costs. The authors compared three commonly used anesthetic techniques for anorectal procedures in the ambulatory setting.

Methods: Ninety-three consenting adult outpatients undergoing anorectal surgery were randomly assigned to one of three anesthetic treatment groups: group 1 received local infiltration with a 30-ml mixture containing 15 ml lidocaine, 2%, and 15 ml bupivacaine, 0.5%, with epinephrine (1:200,000) in combination with intravenous sedation using a propofol infusion, 25-100 [mu]g [middle dot] kg-1 [middle dot] min-1; group 2 received a spinal subarachnoid block with a combination of 30 mg lidocaine and 20 [mu]g fentanyl with midazolam, 1-2-mg intravenous bolus doses; and group 3 received general anesthesia with 2.5 mg/kg propofol administered intravenously and 0.5-2% sevoflurane in combination with 65% nitrous oxide. In groups 2 and 3, the surgeon also administered 10 ml of the previously described local anesthetic mixture at the surgical site before the skin incision.

Results: The mean costs were significantly decreased in group 1 ($69 +/- 20 compared with $104 +/- 18 and $145 +/- 25 in groups 2 and 3, respectively) because both intraoperative and recovery costs were lowest (P < 0.05). Although the surgical time did not differ among the three groups, the anesthesia time and times to oral intake and home-readiness were significantly shorter in group 1 (vs. groups 2 and 3). There was no significant difference among the three groups with respect to the postoperative side effects or unanticipated hospitalizations. However, the need for pain medication was less in groups 1 and 2 (19% and 19%vs. 45% for group 3;P < 0.05). Patients in group 1 had no complaints of nausea (vs. 3% and 26% in groups 2 and 3, respectively). More patients in group 1 (68%) were highly satisfied with the care they received than in groups 2 (58%) and 3 (39%).     

A Prospective, Randomized Comparison between Ultrasound and Nerve Stimulation Guidance for Multiple Injection Axillary Brachial Plexus Block

Background: This prospective, randomized, blinded study tested the hypothesis that ultrasound guidance can shorten the onset time of axillary brachial plexus block as compared with nerve stimulation guidance when using a multiple injection technique.

Methods: Sixty American Society of Anesthesiology physical status I-III patients receiving axillary brachial plexus block with 20 ml ropivacaine, 0.75%, using a multiple injection technique, were randomly allocated to receive either nerve stimulation (group NS, n = 30), or ultrasound guidance (group US, n = 30) for nerve location. A blinded observer recorded the onset of sensory and motor blocks, the need for general anesthesia (failed block) or greater than 100 [mu]g fentanyl (insufficient block) to complete surgery, procedure-related pain, success rate, and patient satisfaction.

Results: The median (range) number of needle passes was 4 (3-8) in group US and 8 (5-13) in group NS (P = 0.002). The onset of sensory block was shorter in group US (14 +/- 6 min) than in group NS (18 +/- 6 min) (P = 0.01), whereas no differences were observed in onset of motor block (24 +/- 8 min in group US and 25 +/- 8 min in group NS; P = 0.33) and readiness to surgery (26 +/- 8 min in group US and 28 +/- 9 min in group NS; P = 0.48). No failed block was reported in either group. Insufficient block was observed in 1 patient (3%) of group US and 2 patients (6%) of group NS (P = 0.61). Procedure-related pain was reported in 6 patients (20%) of group US and 14 patients (48%) of group NS (P = 0.028); patient acceptance was similarly good in the two groups.     

Tranexamic acid reduces blood loss in total hip replacement surgery

Intraoperatively administered, tranexamic acid (TA) does not reduce bleeding in total hip replacement (THR). Therefore, its prophylactic use was attempted in the present study because this has been shown to be more effective in cardiac surgery. We investigated 40 patients undergoing THR in a prospective, randomized, double-blinded study. Twenty patients received TA given in two bolus doses of 10 mg/kg each, the first just before surgical incision and the second 3 h later. In addition, a continuous infusion of TA, 1.0 mg. kg(-1). h(-1) for 10 h, was given after the first bolus dose. The remaining 20 patients formed a control group. Both groups used preoperative autologous blood donation and intraoperative autotransfusion. Intraoperative bleeding was significantly less (P: = 0.001) in the TA group compared with the control group (630 +/- 220 mL vs 850 +/- 260 mL). Postoperative drainage bleeding was correspondingly less (P: = 0.001) (520 +/- 280 vs 920 +/- 410 mL). Up to 10 h postoperatively, plasma D-dimer concentration was halved in the TA group compared with the control group. One patient in each group had an ultrasound-verified late deep vein thrombosis. In conclusion, we found TA, administrated before surgical incision, to be efficient in reducing bleeding during THR. Implications: In a prospective, double-blinded study of 40 patients undergoing total hip replacement, the preoperative administration of tranexamic acid reduced bleeding by 35%, probably by decreasing induced fibrinolysis. Whether tranexamic acid therapy can replace predonation of autologous blood or intraoperative autotransfusion requires further study.     

Usefulness of tranexamic acid in cranial remodeling surgery

OBJECTIVES: To assess the usefulness of tranexamic acid (TA) in pediatric cranial remodeling surgery, by analyzing its effects on bleeding and transfusion requirements, number of days of cranial drainage required, and time spent in the postoperative recovery unit. MATERIAL AND METHOD: A single-blind, controlled study was designed with 20 patients (10 cases and 10 controls) randomly assigned to receive or not receive 15 mg/kg of intravenous TA upon anesthetic induction, every 4 hours during surgery, and every 8 hours throughout the 48 hours after surgery. Variables analyzed were results of blood tests, blood loss, volume transfused, time in the recovery unit, and complications related to TA infusion. RESULTS: The group treated with TA experienced less bleeding during surgery than did the controls (199 +/- 60 vs 290 +/- 43 mL) and had less need of intraoperative (176 +/- 104 vs 206 +/- 70 mL) and postoperative transfusion (9 +/- 28 vs 52 +/- 72 mL) 24 hours after surgery. TA group patients also spent less time in the recovery unit (60 +/- 14 vs 72 +/- 11 hours). Blood test variables in TA-treated children were also better 24 hours after surgery with regard to hemoglobin (12.1 +/- 2 vs 11.6 +/- 1.3 mg/dL) and platelet (261 +/- 68.5 vs 181.6 +/- 58.1 platelets/mm3) concentrations, and cephalin time (33 +/- 12 vs 49 +/- 16 seconds). No complications related to TA treatment were observed. CONCLUSIONS: TA can reduce perioperative bleeding in the context of pediatric cranial remodeling surgery. TA-treated patients have less need of transfusion and this may reduce the rate of related complications as well a make care more efficient.     

Posterior labat vs. lateral popliteal sciatic block: posterior sciatic block has quicker onset and shorter duration of anaesthesia

BACKGROUND: During foot and ankle surgery, a combination of a sciatic and femoral nerve block is a well-recognized technique for providing anaesthesia and post-operative analgesia. Our hypothesis is that the posterior gluteal sciatic block (PSB) is more efficient than the lateral popliteal sciatic block (LPSB), and this study compared the anaesthetic characteristics between these two techniques performed for elective ankle and foot surgery. METHODS: This retrospective database analysis reviewed the onset, duration of action, success rate and complications among 287 patients who were operated upon using sciatic block. PSB was performed in 149 patients and LPSB in 138 patients, all with the use of 30 ml of 5 mg/ml ropivacaine (150 mg). Results: In the PSB group, the time to perform the block was shorter than in the LPSB group (2.5 +/- 1 vs. 4.5 +/- 4 min, P < 0.001), as was the time to complete sensory block (13 +/- 13 vs. 23 +/- 26 min, respectively; P < 0.001). However, the duration of sensory block was longer in the LPSB group (1130 +/- 470 vs. 960 +/- 310 min, respectively; P < 0.006). CONCLUSION: PSB is easier to perform, and has a quicker onset of sensory blockade whereas LPSB has a longer duration of analgesia.     

Peripheral Foot Blockade Versus Popliteal Fossa Nerve Block: A Prospective Randomized Trial in 51 Patients

The majority of foot and ankle operations are performed on an outpatient basis and often under some form of regional anesthesia. In this prospective, randomized study of 51 patients undergoing elective unilateral forefoot procedures, we compared 2 different anesthetic techniques: the peripheral foot blockade and the popliteal sciatic nerve block. Variables assessed included the quality of surgical anesthesia, postoperative analgesia, and the incidence of postoperative complications. The anesthesia was classified as effective if it was the sole anesthetic technique for the forefoot surgery. We found successful results in both groups: 92% in the foot block group and 96% in the popliteal block group. Analysis of time required to perform the anesthetic procedure showed a significant difference between the 2 groups, with foot block being considerably faster (14.3 minutes vs 19.2 minutes for popliteal block) (P = .0078). Foot block patients demonstrated 10.96 hours of analgesia, whereas popliteal block patients exhibited 14.32 hours (P = .132). With a mean follow-up of 5.7 months, we did not find anesthesia-related complications in any of the patients. Both techniques showed a high level of safety and efficacy, with no significant difference detected between them. Our patients showed a high rate of satisfaction with both procedures (96% for foot block patients and 96.1% for popliteal block patients) and reported a good discharge disposition. These data show that both procedures are safe and effective anesthetic techniques and well suited to forefoot ambulatory surgery.     

Intentional lateral epidural catheter placement for anterior cruciate ligament reconstruction

BACKGROUND: Unilateral epidural block might constitute a clinical option in lower limb orthopedic surgery. METHODS: Seventy-five patients undergoing anterior cruciate ligament reconstruction (ACLR) were randomized to either a laterally directed epidural catheter (IUEC, n = 40) or a classic midline catheter (CMEC, n = 35). Paresthesia encountered during catheter insertion was registered. The start dose of the anesthetic mixture clonidine 60 microg (0.4 ml), sufentanil 15 microg (0.3 ml) and ropivacaine 10 mg ml(-1)(10.3 ml) in 11 ml of total volume) was set at 5 ml and was increased by 2 ml if anesthesia was inadequate after assessment for sensory blockade to cold and pin-prick. Data were registered intra- and postoperatively regarding pain scores as well as motor block, hemodynamic parameters, adverse effects and need for supplemental analgesia other than a continuous postoperative epidural infusion. RESULTS: In the IUEC group 80% of patients reported a light paresthesia of the affected side during catheter insertion, whereas 71% of patients in the CMEC group reported no paresthesia at all. The amount of anesthetic used to establish surgical anesthesia was lower in the IUEC group (6.2 +/- 0.8 vs. 8 +/- 1.9 ml, P < 0.001). Motor block (Bromage score) of the unaffected side was significantly lower in the IUEC group (P < 0.001). Pain intensity scores, hemodynamic parameters, and supplemental analgesia given were similar between the two groups except for VAS scores at 12 h postoperatively, which were higher in the CMEC group (P < 0.01). Urinary retention was significantly more frequent in the CMEC group (19/35 vs. 5/40, P < 0.001). CONCLUSION: These results suggest that the IUEC technique is a feasible and efficient method for providing anesthesia and analgesia for ACLR and is associated with a lower consume of anesthetics, less motor block and a reduced incidence of urinary retention.     

An acute care surgery model improves outcomes in patients with appendicitis

OBJECTIVE: To compare outcomes of appendectomy in an Acute Care Surgery (ACS) model to that of a traditional home-call attending surgeon model. SUMMARY BACKGROUND DATA: Acute care surgery (ACS, a combination of trauma surgery, emergency surgery, and surgical critical care) has been proposed as a practice model for the future of general surgery. To date, there are few data regarding outcomes of surgical emergencies in the ACS model. METHODS: Between September 1999 and August 2002, surgical emergencies were staffed at the faculty level by either an in-house trauma/emergency surgeon (ACS model) or a non-trauma general surgeon taking home call (traditional [TRAD] model). Coverage alternated monthly. Other aspects of hospital care, including resident complement, remained unchanged. We retrospectively reviewed key time intervals (emergency department [ED] presentation to surgical consultation; surgical consultation to operation [OR]; and ED presentation to OR) and outcomes (rupture rate, negative appendectomy rate, complication rate, and hospital length of stay [LOS]) for patients treated in the ACS and TRAD models. Questions of interest were examined using chi tests for discrete variables and independent sample t test for comparison of means. RESULTS: During the study period, 294 appendectomies were performed. In-house ACS surgeons performed 167 procedures, and the home-call TRAD surgeons performed 127 procedures. No difference was found in the time from ED presentation to surgical consultation; however, the time interval from consultation to OR was significantly decreased in the ACS model (TRAD 7.6 hours vs. ACS 3.5 hours, P < 0.05). As a result, the total time from ED presentation to OR was significantly shorter in the ACS model (TRAD 14.0 hours vs. ACS 10.1 hour, P < 0.05). Rupture rates were decreased in the ACS model (TRAD 23.3% vs. ACS 12.3%, P < 0.05); negative appendectomy rates were similar. The complication rate in the ACS model was decreased (TRAD 17.4% vs. ACS 7.7%, P < 0.05), as was the hospital LOS (TRAD 3.5 days vs. ACS 2.3 days, P < 0.001). CONCLUSIONS: In patients with acute appendicitis, the presence of an in-house acute care surgeon significantly decreased the time to operation, rupture rate, complication rate, and hospital length of stay. The ACS model appears to improve outcomes of acute appendicitis compared with a TRAD home-call model. This study supports the efficacy and efficiency of the ACS model in the management of surgical emergencies.     

Feasibility of laparoscopic adrenalectomy for large adrenal masses

Laparoscopic adrenalectomy (LA) is a preferred method for the removal of small adrenal masses. However, the role of LA for surgical treatment of large adrenal masses is less established. We evaluated the outcomes of LA for large (>/=5 cm) adrenal masses. We retrospectively reviewed 24 consecutive patients who underwent LA for large adrenal masses at a tertiary care university hospital. The average age of the 24 patients was 49 years, and each underwent laparoscopic resection of a large adrenal mass. All LAs were performed via a lateral transperitoneal approach. The average (+/- standard deviation) size of the masses was 6.8 +/- 1.5 cm (range, 5-11). Pathologic diagnoses included adrenal cortical adenoma (10 cases), pheochromocytoma ( 7), cyst/pseudocyst ( 3), myolipoma ( 2), and adrenal cortical hyperplasia ( 2). Statistical analysis was performed with a two-sample t test. The average operating time was 178 +/- 55 minutes (range, 120-300), and average blood loss was 87 +/- 69 mL (range, 20-300); the averages were nonsignificantly greater in the right LA group than in the left LA group (203 vs. 166 minutes, P = 0.89; 124 vs. 77 mL, P = 0.14). The average duration of nothing-by-mouth (NPO) status was 0.7 days (range, 0-4), and the average time until return to a regular diet was 1.74 +/- 0.9 days (range, 1-5). The average length of stay was 2.5 +/- 1.9 days (range, 1-10). One patient had a transient episode of pseudomembranous colitis. There were no conversions to open adrenalectomy and no major morbidities or mortalities. LA is safe and effective for surgical treatment of large adrenal masses. Both right and left large adrenal masses can be approached laparoscopically with equal success. The role of minimally invasive approaches to adrenal malignancies necessitates further investigation.     

Clinical and economic outcomes in thrombolytic treatment of peripheral arterial occlusive disease and deep venous thrombosis

PURPOSE: Over the past 2 decades the use of thrombolytic therapy in the management of peripheral occlusive diseases, most notably peripheral arterial occlusion (PAO) and deep venous thrombosis (DVT), has become an accepted and potentially preferable alternative to surgery. We examined the period when urokinase was in short supply and subsequently unavailable, to explore potential differences in clinical outcome and economic effect between urokinase and recombinant tissue plasminogen activator (rt-PA). MATERIAL AND METHODS: Data were obtained from the Premier Perspective Database, a broad clinical database that contains information on inpatient medical practices and resource use. The study population included all patients hospitalized in 1999 and 2000 with a primary or secondary diagnosis of PAO or DVT. Incidence was calculated for common adverse events, including bleeding complications, intracranial hemorrhage, amputation, and death. Cost data were also abstracted from the database, and are expressed as mean +/- SD. RESULTS: Demographic variables were similar in the urokinase and rt-PA groups. The rate of bleeding complications was similar in the urokinase and rt-PA groups. There were no intracranial hemorrhages in the urokinase group, compared with a rate of 1.5% in the rt-PA PAO group (P = .087) and 1.9% in the rt-PA DVT group (P = .175). The in-hospital mortality rate was lower in the urokinase-treated PAO subgroup (3.6% vs 8.5%; P = .026), but a similar finding in the DVT subgroup did not achieve statistical significance (4% vs 9.8%; P = .069). While pharmacy costs were greater in the urokinase-treated group (US 5472 dollars +/- US 5579 dollars vs US 3644 dollars +/- US 6009 dollars, P < .001; PAO subgroup, US 11,070 dollars +/- US 15,409 dollars vs US 6150 dollars +/- US 12,398 dollars, P = .003), overall hospital costs did not differ significantly between the 2 groups. This finding appears to be explained by a shorter hospital stay and reduced room and board costs in the urokinase-treated group. CONCLUSION: There were significant differences in outcome in patients with PAO and DVT who received treatment with urokinase and rt-PA. While pharmacy costs were significantly greater when urokinase was used, reduction in length of stay accounted for similar total hospital costs compared with rt-PA. These findings must be considered in the context of the retrospective nature of the analysis and the potential to use dosing regimens that differ from those in this study.     

A novel approach to restore atrial function after the maze procedure in patients with an enlarged left atrium.

OBJECTIVE: Left atrial (LA) volume reduction surgery concomitant with the maze procedure has been reported to facilitate sinus rhythm recovery even in patients with refractory atrial fibrillation (AF) with an enlarged LA. However, it is unknown whether the procedures can also restore effective atrial function of the enlarged LA with over-stretched myocardium. METHODS: The maze procedures in association with mitral valve surgery were performed to 57 AF patients with an enlarged LA (LA diameter >or=60mm). Among them, 32 patients had concomitant LA volume reduction surgery (VR group). Another 25 patients did not have the volume reduction (control group). RESULTS: Three months postoperatively LA end-diastolic volume (LAEDV, ml) assessed by magnetic resonance (MR) imaging was larger in the VR group than that in the control group (291+/-117 vs 223+/-81 ml, p<0.05). Postoperatively, sinus rhythm recovery rate was better (84 vs 68%, p<0.05) and LAEDV was drastically smaller (118+/-48 vs 203+/-76 ml, p<0.001) in the VR group than those in the control group. Among the patients with sinus rhythm recovery in both groups, LA contraction ejection fraction (%) improved in the VR group but not in the control group (22.3+/-7.8 vs 10.3+/-4.7%, p<0.001). CONCLUSIONS: The LA volume reduction surgery concomitant with the maze procedure restored contraction of the enlarged LA; however, the maze procedure alone did not restore LA contraction in spite of successful sinus rhythm recovery. LA volume reduction surgery may be desirable to the patients with refractory AF with over-stretched LA.