A&A practice最新文献

Effective pain management after arthroscopic shoulder surgery is essential for recovery. Traditional regional anesthesia techniques may lead to motor blockade. The serratus posterior superior intercostal plane (SPSIP) block is a recently described technique that aims to provide predominantly sensory analgesia. In this descriptive case series, 12 patients undergoing arthroscopic rotator cuff repair received ultrasound-guided SPSIP block. Postoperative pain was assessed using Numerical Rating Scale (NRS) scores, and tramadol consumption was recorded during the first 24 hours. Patients demonstrated low pain scores and modest tramadol use (mean 58 ± 36 mg). No formal motor assessment was performed; therefore, any potential motor-sparing effect should be interpreted cautiously and considered hypothesis-generating only.

Background: Peripheral nerve blocks are an integral part of the multimodal analgesia for total knee arthroplasty (TKA). The adductor canal block (ACB) gained popularity for its motor-sparing effect. This study evaluated ACB alone or combined with local infiltration analgesia (LIA), in comparison to LIA alone in TKA patients.

Methods: A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed. The MEDLINE and PMC using PubMed, Cochrane Library, and Scopus databases were searched for RCTs evaluating ACB alone or with LIA compared to LIA alone after TKA published up to December 18, 2024. The random-effect model was used for both the standardized mean difference (SMD) of continuous parameters, as well as for the odds ratio of binary parameters. Postoperative pain scores assessed by a visual analog scale or a numerical rating scale at 24 and 48 hours constituted the primary outcome. Secondary outcomes were opioid consumption, knee range of motion (ROM), length of hospital stay, and postoperative nausea and vomiting (PONV). The risk of bias was assessed with the risk of bias tool 2 (RoB-2).

Results: In total, 26 studies (2,400 patients) were included. Static and dynamic pain scores at 24 and 48 hours in the ACB+LIA group compared to LIA alone were lower (SMD24rest = -0.54, 95% confidence interval [CI], -0.80 to -0.28, P < .00001; SMD24activity = -0.85, 95% CI, -1.37 to -0.32, P = .001; SMD48rest= -0.26, 95% CI, -0.49 to -0.03, P = .02; SMD48activity = -0.66, 95% CI, -0.96 to -0.36, P ≤ .0001). ACB alone reduced pain during activity but not at rest compared to LIA (SMD24activity = -0.93, 95% CI, -1.88 to 0.02, P = .05; SMD48activity = -1.10, 95% CI, -2.03 to -0.17 P = .02). Reduced opioid consumption (P = .005) and greater ROM at 24 hours (P = .02) were observed with ACB+LIA. Regarding the remaining outcomes, no differences were observed in opioid consumption, ROM, and hospital stay. ACB patients experienced lower PONV rates (P = .05). The GRADE framework rated evidence certainty from moderate to very low with a moderate to high bias according to the RoB-2.

Conclusion: Adding ACB to LIA improves pain scores at 24 and 48 hours compared to LIA alone.

This report describes the use of continuous rocuronium infusion for paralysis during 2 extensive spinal surgeries in a pediatric patient with Thomsen myotonia congenita. Although paralytics are typically avoided to allow motor-evoked potential monitoring, in this case, paralysis was required to reduce myotonic episodes and related complications. Rocuronium infusion with sugammadex reversal was used successfully, with only one presumed myotonic episode and no serious sequelae. This novel approach highlights the need for anesthesiologists to balance monitoring considerations with patient safety. Our report provides practical guidance to optimize outcomes in similar cases and expand the literature on myotonia management.

Perioperative right ventricular dysfunction can be life-threatening. Anesthetic management of elderly patients with hip fractures and advanced cardiac disease poses considerable perioperative risks. The problem-based learning discussion examines the management of an 87-year-old female with severe pulmonary hypertension, right ventricular dysfunction, and recent anticoagulation scheduled for urgent hip fracture repair. A tailored management approach included peripheral nerve blocks, intraoperative transesophageal echocardiographic monitoring, goal-directed hemodynamic support, and management of acute RV decompensation with intratracheal milrinone and inhaled epoprostenol. It presents strategies for high-risk geriatric trauma patients, individualized anesthetic planning, and the role of pulmonary vasodilators.

When removing an airway foreign body using a flexible bronchoscope through a supraglottic airway device, the foreign body must be passed through the glottis. However, passing the foreign body through the glottis may be difficult because of a relatively narrow glottic opening. We report 2 cases in which a tracheal tube was used to assist bronchoscopic removal of the foreign body when passage through the glottis was difficult. Both foreign bodies were successfully removed without complications. Our method prevented the foreign bodies from being dropped or crushed and was useful as an adjunct to bronchoscopic removal with supraglottic airway devices.

The clavipectoral fascial plane block (CPB) provides regional anesthesia for clavicular procedures while minimizing complications. Although the hematoma block (HB) is well-established in distal radius fractures, its combination with CPB for clavicle fractures is not widely described. A 72-year-old man presented with a right distal clavicle fracture and elected to undergo surgical fixation. A modified CPB was performed preoperatively, with a portion of the local anesthetic injected into the fracture hematoma. The patient had excellent intraoperative and postoperative analgesia with minimal rescue opioid requirements. This case demonstrates the efficacy of combining a CPB with hematoma injection for distal clavicle fractures.

Flail chest resulting from multiple rib fractures after cardiopulmonary resuscitation (CPR) can cause pain and respiratory distress. In this case report, we describe the use of bilateral parasternal intercostal block catheters in a patient who was unable to breathe adequately and could not be extubated due to rib fractures after CPR. The patient received analgesia via the parasternal catheter for 11 days and was discharged on the 17th day. This report highlights the importance of successful pain management through continuous analgesia via a continuous parasternal intercostal block catheter, thereby reducing the time to extubation and decreasing respiratory complications.