Local and Regional Anesthesia最新文献

Laparoscopic abdominal surgery has become a mainstay of modern surgical practice. Postoperative analgesia is an integral component of recovery following laparoscopic abdominal surgery and may be improved by regional anesthesia or intravenous lidocaine infusion. There is inconsistent evidence supporting the use of interfascial plane blocks, such as transversus abdominis plane (TAP) blocks, for patients undergoing laparoscopic abdominal surgery as evidenced by variable patterns of local anesthetic spread and conflicting results from studies comparing TAP blocks to local anesthetic infiltration of laparoscopic port sites and multimodal analgesia. Quadratus lumborum (QL) and erector spinae plane (ESP) blocks may provide greater areas of somatic analgesia as well as visceral analgesia, which may translate to more significant clinical benefits. Aside from the locations of the surgical incisions, it is unclear what other factors should be considered when choosing one regional technique over another or deciding to infuse lidocaine intravenously. We reviewed the current literature in attempt to clarify the roles of various regional anesthesia techniques for patients undergoing laparoscopic abdominal surgery and present one possible approach to evaluating postoperative pain.

Safe and accessible surgical and anesthetic care is critically limited for over half of the world's population, particularly in Sub-Saharan African and Southeast Asian countries. Increasing the use of regional anesthesia in these areas has potential benefits regarding access, safety, and cost-effectiveness. Perioperative anesthesia-related mortality is significantly higher in resource-limited countries and every effort should be made to encourage the use of anesthetic techniques in these countries that are safest under the present conditions. Studies from Sub-Saharan Africa, although limited in number, have shown a lower risk of death with regional compared to general anesthesia. Regional anesthesia has the further benefit of decreasing the risk of COVID-19 spread to healthcare providers by avoiding the aerosol-generating procedures that occur during general anesthesia. Neuraxial regional anesthesia is relatively easy to teach and perform and is considered the anesthetic of choice for surgeries below the umbilicus in resource-limited settings due to its safety, efficacy, and low cost. Although regional anesthesia has multiple potential advantages, education and training of anesthetic providers in low-and-middle-income countries (LMIC) are a significant barrier to growth. Anesthesia professionals, especially in Sub-Saharan Africa, are often poorly supported and undervalued, and recruitment and retention of adequate numbers of trained practitioners are a continuing problem. Greater use of regional anesthesia could be one way to safely increase anesthesia access and simultaneously create value and enthusiasm for the field. Deficits in anesthesia infrastructure, equipment, and drugs also limit anesthesia capacity in low-and middle-income countries. Ultrasound-guided regional anesthesia may be helpful in improving access to safe and reliable anesthesia in low-resource countries as it continues to become more user-friendly, durable, and affordable.

Ultrasound-guided peripheral nerve block (PNB) has become a popular anesthetic procedure. We report a case of an enlarged brachial plexus nerve noted on ultrasonographic images, as part of PNB, which was diagnosed postoperatively as Charcot-Marie-Tooth disease (CMTD), an inherited neurological disorder of the peripheral nerves. Although nerve enlargement is characteristic of demyelinating diseases such as CMTD, the use of ultrasonography in the diagnosis of neurological disorders is a developing area for neurologists and anesthesiologists can lack knowledge in this emerging field. Unusual nerve presentation on ultrasonographic images during PNB anesthetic procedures should be recognized as being indicative of underlying neurologic disorders. This case highlights that increased awareness of the diagnosis of underlying neurologic disorders by ultrasonography would assist the general practice of PNB in anesthetic medicine. This is especially important as underlying neurological conditions can have important consequences for patient-appropriate anesthesia and may inform best anesthetic practice. A new category, "neurological disorder on ultrasound image", should be introduced to PNB knowledge in anesthetic field.

Patients with congestive heart failure have a high risk of perioperative major adverse cardiac events and death. The major perioperative goal of management in patients with low ejection fraction is maintaining hemodynamic stability. Evidence is scarce on the safety of a certain anesthetic technique for patients with heart failure. In this report, we present a 48-year-old man with ischemic dilated cardiomyopathy and low-output congestive heart failure (estimated ejection fraction of 27%) who underwent emergent below-knee amputation under selective spinal anesthesia without any apparent complications. We believe that selective spinal anesthesia can be a useful alternative anesthetic technique in patients with low ejection fraction undergoing emergent lower limb surgery. We showed evidence-based and customized anesthetic management of a high-risk patient with the available equipment and resources. This report will hopefully show the contextual challenges of the perioperative care of critically ill patients in resource-constrained settings.

Defined in the last decade, erector spinae plane block (ESPB) is one of the more frequently used interfacial plans, and it has been the most discussed block among the recently defined techniques. Lumbar ESPB administered at lumbar levels is relatively novel and is a new horizon for regional anesthesia and pain practice. In this article, we aim to explain and introduce different approaches and explain the possible mechanism of action of lumbar ESPB. The objective of this review is to analyze the case reports, clinical and cadaveric studies about lumbar ESPB that have been published to date. We performed a search in "Pubmed" and "Google Scholar" database. After a selection of the relevant studies, 59 articles were found eligible and were included in this review. While we believe that lumbar ESPB is reliable and easy, we suggest that its efficacy and indications should be verified with anatomical and clinical studies, and its safety should be confirmed with pharmacokinetic studies. Moreover, the possibility of complications must be considered.

Purpose: Thoracic epidural analgesia (TEA) has been shown to reduce postsurgical morbidity and mortality; nevertheless, major and minor complications can occur. We report our 10-year experience with TEA and incidence of complications.

Patients and methods: Patients received continuous infusion TEA (0.2% ropivacaine and 2 µg ml^-1 fentanyl) to control postoperative pain. Every 8 hours, the acute pain service recorded the analgesia regimen and occurrence of side effects. The initial infusion rate was tapered daily in response to improvement in pain symptoms or occurrence of side effects.

Results: A total of 3126 patients received TEA. The median age was 65 years (range, 18-94) and the duration of catheter placement was 3.5 days (range, 2-8). Three major complications were identified (1:1042): two subarachnoid blocks and one epidural abscess which led to permanent sequela (1:3126). Minor complications were hypotension (4.8%), pruritus (4.4%), accidental catheter removal (3.7%), insertion site inflammation (2.5%), motor weakness (2.0%), postoperative nausea and vomiting (1.8%), catheter disconnection (1.9%), catheter occlusion (0.3%), post-dural puncture headache (0.5%), and catheter fragment retention (0.06%), which were the reasons for a 7.4% rate of early discontinuation of epidural analgesia. No occurrence of epidural hematoma, local anesthetic systemic toxicity, and cardiovascular/respiratory depression was recorded.

Conclusion: Postoperative TEA is an advanced technique that poses certain difficulties that can subvert its great potential. While serious complications were rare, minor complications occurred more often and affected the postoperative course negatively. A risk/benefit evaluation of each patient should be done before employing the technique.

Introduction: Eye tracking is the process of measuring an individual's eye movements to register their attentional behavior by using a device called an eye-tracker. Studies conducted using eye-tracking techniques have demonstrated a number of differences in eye movement parameters and patterns between experts and novices. The aim of this preliminary study was to evaluate if there are any differences in eye-tracking metrics between novice and expert anesthesiologists during the performance of an epidural block using an epidural simulator.

Methods: Seven experts and seven novices who gave their consent to this preliminary study were asked to perform an epidural technique using an epidural simulator while wearing a pair of Tobii Pro glasses. Number of fixations, fixation duration, heat maps and scan-paths were examined by Tobii Pro Lab Software. Duration of the procedure was also recorded.

Results: The observation of the attentional heat map and gaze plot showed different gaze dispersion between experts and novices. The mean total duration of fixations during needle insertion and advancement and catheter introduction was lower in experts than trainees (respectively, 0.18 vs 3.56 sec; P<0.05 and 0.73 vs 2.48 sec; P<0.05). The mean fixation count was greater in experts vs trainees (5 vs 2; P<0.05). The mean duration of the epidural procedure was 104.16 (41) (trainees) vs 65.3 (32.6) seconds (experts) (P<0.05). Expert anesthesiologists spent more time fixating a more specific target location (eg, the point of the epidural needle rather than the syringe's barrel) whilst novices split their attention between tracking their tools and the target location.

Discussion: Eye tracking may have interesting implications for the creation of assessment programs, which distinguish skill level through the use of gaze behavior, and may be a promising tool for monitoring training progress towards the development of expertise.

Background: We report a case in which effective dental anesthetic management was achieved using procaine hydrochloride for a patient who had an unknown history of allergic reactions to lidocaine.

Case presentation: Because the patient refused to undergo screening tests using any of the amide-type local anesthetics because of her extreme fear against local anesthetics that she had been administered previously, procaine hydrochloride, which is an ester-form local anesthetic, was the only agent to be tested on this patient at the department of dermatology. Consequent to a negative allergy test, we performed complete dental treatment using procaine hydrochloride after additional chairside drug challenge tests using minimum test dose under vital sign monitoring.

Conclusion: The success of dental treatment using procaine hydrochloride may have relieved the patient's fear of local anesthesia. We discuss an important aspect of treatment planning for patients with a history of complications during local anesthesia.

Pain after lumbar spine fusion surgery is often difficult to control in the immediate postoperative period. Historically, opioids have been the mainstay of treatment, but are associated with many unwanted side effects as well as increased hospital length of stay. The ultrasound-guided erector spinae plane block (ESP) is a relatively safe and simple regional option for the management of acute postoperative pain after spine surgery without the technical difficulty or complications noted with paravertebral injection (eg, pneumothorax, hematoma). To date, there have been reports of preoperative placement of ESP block prior to spine surgery with some success. We present a report of two cases that highlight the efficacy of the ESP block as an early postoperative "rescue" regional anesthetic technique in lumbar spine surgery. These cases demonstrate the potential effectiveness of a "rescue" use of the ESP block in patients having uncontrolled or poorly controlled pain in the early postoperative period with no evidence of significant side effects.

Purpose: To assess the efficacy and safety of a modified technique for ultrasound-guided pectoral II block for postoperative pain control after mastectomy.

Methods: In this randomized controlled trial, patients were randomly allocated into two groups (40 patients each). Group I patients were subjected to ultrasound-guided pectoral II block with injection of 10 mL lidocaine 1% as a dissecting solution before attempting catheter insertion, while group II patients underwent the standard procedure without a dissecting solution. Measured outcomes included catheter visibility, pain, patient satisfaction, performance time, and complications.

Results: Compared with group II, group I had significantly lower median catheter-visibility scores, shorter block performance time, and fewer insertion attempts. Group I had a nonsignificantly higher rate of complications than group II.

Conclusion: The modified technique facilitated the procedure, shortened the catheter-insertion time, and showed higher patient satisfaction. However, it was associated with lower catheter visibility on ultrasonography. Further studies are required to confirm the present findings and assess the safety of the modified technique.