Is neurostimulation in regional anesthesia still worth knowing?

Neurostimulation has been one of the most significant advances in the field of regional anesthesia. Knowledge of its technical details is still growing, and new clinical and research work on the subject is continually being published. The introduction of ultrasonography as an instrument for identifying peripheral nerves has been a true revolution and seems to be competing with neurostimulation. Most of the articles on the subject compare these 2 location methods; however they are compatible with and complementary of each other. There is some controversy about the advantages of combining both methods, and further trials are required to determine those advantages. Safety, however, increases when more than 1 system is involved. The financial cost is not high and could be absorbed if its benefits are proven. This article reviews the bases of neurostimulation and proposes new ways of using it, based both on the clinical practice and on the latest research published.     

Is ultrasound essential for regional anesthesia in children?

According to systematic reviews performed on adults, ultrasound provides moderate advantages in latency time reduction and block quality. Whether it really reduces the number of complications at the expense of less vascular puncturing, less diaphragm paralysis, and less pleural puncturing, together with lower doses of local anesthetic used, is a controversial question. Neither is there evidence that ultrasound achieves a higher rate of success than traditional techniques. Pediatric patients have special characteristics that differentiate them from adult patients, so the existing studies and their results should not be extrapolated. Ultrasound has a series of advantages: real-time visualization of our target or infiltration of anatomical plane; a view of the needle performing the puncture; and continuous monitoring of spreading of the local anesthetic. Few techniques satisfy so many requirements for adoption by the medical practice, but trials proving that this is an essential technique for pediatric regional anesthesia are scarce. However, ultrasound has shown to be at least as efficient and as safe as traditional techniques and should therefore be routinely used in pediatric regional anesthesia.     

Training and development of anesthesia in Nepal — 1985 to 2005

PURPOSE: To describe the self-sustaining anesthesia training and development program in Nepal from 1985 through 2005, and the Canadian contributions. METHODS: We examined the training program and outcome of the diploma in anesthesia (DA) and MD anesthesiology programs in Nepal over a 20-year period. Issues related to recruitment, funding, specialist training opportunities and professional development were examined and summarized. RESULTS: In 1985 there were seven Nepalese physician anesthesiologists in Nepal. With Canadian support of faculty members and the Canadian Anesthesiologists' Society International Education Fund, a one-year DA training program began in 1985, and a three-year MD anesthesia program began in 1996. As of 2005, 43 anesthesiologists were trained in the DA program, and 19 Nepalese completed MD anesthesia training. Thirteen (30%) of DA graduates have since left the country, compared to only two (10.5%) physicians from the MD anesthesia training program. Annual anesthesia symposia began in 1986, and the Society of Anesthesiologists of Nepal was formed in 1987. Nepalese anesthesiologists have been attending and presenting papers at international scientific meetings since 1991. CONCLUSION: The devotion of Nepalese anesthesiologists in teaching and training, strong guidance from Canadian medical faculties, and local government support have contributed to the successful development of Nepalese anesthesia training programs. Establishment of the training programs has assisted recruitment of trained anesthesiologists to different regional hospitals. Finally, the formation of a national society, with an organized annual symposium has improved professional self-esteem, and raised the profile of anesthesiology in Nepal.     

Cataract surgery: regional anesthesia or monitored anesthesia care?]

BACKGROUND: Retrospective study in patients undergoing cataract surgery by facoemulsification in order to evaluate the incidence of regional peribulbar anaesthesia compared with MAC (Monitored Anesthesia Care). METHODS: Between January 1999 and December 2000, 1902 patients were studied. Peribulbar anaesthesia was performed by using a double or single inferior-lateral injection with a mixture of Lidocaine 2% and Bupivacaine 0.5% or, as a single agent, of Ropivacaine 0.75%. Jaluronydase 10 UI/ml was added to either agents. RESULTS: Only in 8% of patients intravenous drugs were added during surgery to correct bradycardia in 3%, hypertension 3% and for sedation in 2%. CONCLUSIONS: Regional anesthesia represents the most suitable anesthesia technique in patients undergoing cataract surgery by facoemulsification. Only in 8% of patients MAC was suitable, due to excessive anxiety or cardiovascular imbalance. Compared to other anesthesia techniques, regional anaesthesia is significantly safer. The utility of preoperative tests in reducing the morbidity associated with surgery, is also discussed.     

Does regional anesthesia improve outcome after surgery?

The benefits and complications associated with regional anesthesia are assessed on the basis of a review of the recent literature. Benefits are separately considered as: (1) effects on hospital discharge; (2) effects on pulmonary function; (3) cardiac benefits; (4) effects on ambulation; (5) effects on metabolic stress responses; and (6) the preemptive effect. Complications reviewed are those of recent interest, and include epidural hematoma in association with anticoagulant therapy, and neural toxicity in association with high-dose local anesthetic.     

Clexane and regional anesthesia. Contraindication or possible combination?

Results of the efficacy and safety analysis of low-molecular weight heparine clexane (sodium enoxaparine) in patients with urological diseases were adduced. Postoperative usage of clexane along with epidural anesthesy had prevented occurrence of hypercoagulation as well as epidural and spinal hematoma.     

Gastrointestinal feeding access — From idea to application

In this Festschrift communication, the author of two novel approaches to long-term enteral access: the gastrostomy without laparotomy (Percutaneous Endoscopic Gastrostomy or PEG) and the skin-level feeding device (Gastrostomy “Button”), relates the history of these innovations, describes the initial and extended applications, and comments on the implications of these developments.     

Giant transit thrombus—From right to left

Pulmonary embolism can be associated with paradox embolism requiring immediate surgical therapy regardless of hemodynamic status. Here we present images illustrating a giant transit thrombus as a concomitant finding in a patient with pulmonary artery embolism.