Anaesthesia reports最新文献

Continuous wound infusion with local anaesthetics after open abdominal surgery may provide opioid-sparing analgesia, but evidence on very low-concentration regimens is limited. We conducted a prospective observational study including 50 patients receiving continuous infusion of levobupivacaine 0.0625% via pre-peritoneal or subfascial catheters at a flow rate of 12 ml.h⁻¹ per catheter. Six patients (12%) required intravenous morphine rescue in the first 48 h, with a median dose of 3 mg. Median pain scores remained consistently low and 14 patients (28%) received additional local anaesthetic boluses with effective relief. No major catheter-related complications or systemic local anaesthetic toxicity were observed. Continuous wound infusion with levobupivacaine 0.0625% after open abdominal surgery was feasible and associated with minimal opioid use. These findings provide preliminary evidence supporting the feasibility of an ultralow concentration regimen.

The recto-intercostal fascial plane block is a novel regional anaesthetic technique proposed for cardiac and upper abdominal surgery, with limited evidence for its use in laparoscopic cholecystectomy. We report a series of seven patients undergoing elective laparoscopic cholecystectomy under general anaesthesia, one of whom required a xipho-umbilical incision for common bile duct exploration. All patients received a recto-intercostal fascial plane block prior to surgical incision. Postoperative analgesia included paracetamol 1000 mg for all patients, with one patient additionally receiving diclofenac 75 mg. At 1, 3, 6, 12 and 24 h postoperatively, pain scores remained low (numerical rating scale 0–2 at rest and 2–3 on movement), no rescue opioids were required and all patients had an uncomplicated recovery with early discharge. These cases illustrate the feasibility of incorporating recto-intercostal fascial plane block into multimodal analgesia after laparoscopic cholecystectomy.

Poor sleep is known to have a negative impact on pain perception, and obstructive sleep apnoea is the most prevalent sleep disorder in adults. Current evidence is conflicting with respect to the benefits of positive airway pressure treatment on pain in patients with obstructive sleep apnoea, which leaves the question of obstructive sleep apnoea as a modifiable factor in pain syndromes unanswered. We conducted a retrospective cohort study of United States of America veterans with obstructive sleep apnoea who underwent total knee or hip arthroplasty to compare positive airway pressure treatment adherence to postoperative opioid use. We reviewed the records for patients with a diagnosis of obstructive sleep apnoea who underwent elective total knee or hip arthroplasty at a single Veterans Affairs hospital. For patients who reported nocturnal positive airway pressure use, we reviewed data downloaded from positive airway pressure devices to determine adherence to therapy based on Medicare criteria. Patient characteristics, peri-operative opioid prescriptions and postoperative outcomes were collected from the electronic medical record. The cohort consisted of 401 patients between April 2014 and May 2019: 104 patients were adherent to positive airway pressure therapy at the time of surgery and 297 were non-adherent. Patients adherent to positive airway pressure therapy were significantly less likely to be prescribed an opioid prior to surgery compared to untreated patients (22% vs 39%, respectively, p = 0.010). Positive airway pressure adherence was not an independent predictor of postoperative opioid requirements in the first three postoperative days. Independent predictors of postoperative opioid requirements included pre-operative opioid prescription, age, history of cocaine abuse and congestive heart failure. In patients with obstructive sleep apnoea who undergo lower limb arthroplasty, adherence to positive airway pressure therapy was not associated with opioid consumption in the immediate postoperative period.

Regional anaesthesia to facilitate awake mastectomy is increasingly recognised as a viable alternative for patients in whom general anaesthesia presents significant risk. This case report describes a successful total mastectomy in a patient with secondary angiosarcoma and multiple complex comorbidities. The planned regional anaesthetic technique included multilevel transverse paravertebral blocks, pecto-intercostal fascial plane blocks and a supraclavicular brachial plexus block. The intricate sensory innervation of the breast, anterior chest wall and axilla present considerable challenges to achieving adequate anaesthesia; these are explored in detail, with emphasis on the necessity of an individualised approach which accounts for both patient-specific and surgical factors. Sedation is commonly employed to enhance patient comfort during awake procedures; however, pharmacological selection and administration may be complicated in patients with pulmonary hypertension, as illustrated in this case. The patient experienced optimal conditions for surgical resection and reported a positive peri-operative journey, from pre-assessment to hospital discharge. A reflective account of the patient's experience is included. This case, in conjunction with existing literature, supports the broader implementation of awake mastectomy as a feasible and patient-centred option in appropriately selected individuals.

We describe the anaesthetic management of the first caesarean birth following uterus transplantation in the United Kingdom. This remains a novel procedure globally, and there are important considerations for the anaesthetist. A 36-year-old female with a background of Mayer–Rokitansky–Küster–Hauser syndrome presented for caesarean birth at 34⁺² weeks' gestation following uterus transplantation and in vitro fertilisation. The principal challenges for the anaesthetist are the ongoing requirement for immunosuppression, a different surgical technique compared with that required for caesarean birth in the native uterus and increased risk of haemorrhage requiring careful management of uterotonics and blood products. We used a combined spinal–epidural technique to provide anaesthesia in preparation for a potentially prolonged procedure. We prepared for the possibility of major haemorrhage, including the use of cell salvage. A multidisciplinary team involving transplant physicians and surgeons, obstetric physicians, obstetricians, midwives and anaesthetists guided the care of the patient throughout. We expect that this procedure will become increasingly common in the United Kingdom as uterus transplantation becomes more established as a treatment for uterine factor infertility.

Acute pain remains a significant issue for inpatients, for example, 20–40% of surgical inpatients report severe pain in the first 24 postoperative hours. Simple pain rating scales are widely used but have limitations. National guidelines recommend incorporating functional assessment to guide individualised pain management, though how best to do this remains unclear. This quality improvement project aimed to enhance the assessment of acute pain in adult inpatients at Leeds Teaching Hospitals by introducing functional assessment alongside standard pain scoring. Applying the Model for Improvement and Plan–Do–Study–Act cycles, we prototyped a Leeds Functional Activity Score and evaluated its usability across three cycles. Once the methodology of assessing functional pain was prototyped (cycle one), 79 adult inpatients' pain was assessed using both Leeds Functional Activity Score and the Numeric Rating Scale (cycle two). We found pain intensity patterns did not always predict functional impact. Functional assessment enabled conversations with patients about the need to manage function rather than targeting a pain score. Cycle three involved evaluation by 37 ward staff, with 73% rating it as ‘easy’ or ‘very easy’ to use. This cycle helped us to identify training needs. This report demonstrates that implementing functional assessment alongside traditional pain scoring is feasible, well received by staff and provides clinically meaningful context to guide analgesia. The Leeds Functional Activity Score has now been integrated into the hospital's electronic systems, alongside supporting training videos and communications.

We describe the anaesthetic management of a parturient with catecholaminergic polymorphic ventricular tachycardia and an implantable cardioverter-defibrillator during induction of labour and subsequent emergency caesarean birth. Catecholaminergic polymorphic ventricular tachycardia is characterised by genetic mutations leading to increased sympathetic activity, potentially causing ventricular arrhythmias and cardiac arrest. There are limited data discussing the anaesthetic management of parturients with catecholaminergic polymorphic ventricular tachycardia. We describe our approach to anaesthetic management, focusing on minimising sympathetic stimulation through early combined spinal-epidural placement, the use of epidural adjuvants, such as α2-agonists, and the avoidance of catecholaminergic medications.

We present the case of a 47-year-old man undergoing an elective laparoscopic inguinal hernia repair complicated by intra-operative asystole following pneumoperitoneum and a subsequent delayed intra-abdominal haemorrhage. Notably, he exhibited profound paradoxical bradycardia and hypotension in the context of significant haemorrhage, diverging from the expected tachycardic response. Management required prompt resuscitation, urgent re-exploration and intensive care support. Paradoxical bradycardia presents a diagnostic challenge, as limited awareness among clinicians may confer false reassurance of haemorrhagic resolution, thereby contributing to delayed intervention. This case report seeks to underscore this uncommon deviation from the classical physiological response, with the intention of mitigating diagnostic oversight in the management of peri-operative haemorrhagic shock and offers alternative clinical considerations to support early recognition.

The rising popularity of facial cosmetic procedures presents new challenges for peri-operative anaesthetic care. We report a case of failed facemask ventilation in a woman with recent dermal filler injections to her cheeks and chin and without any well-described predictors of a difficult airway. After pre-oxygenation and induction of anaesthesia, attempts at facemask ventilation failed to achieve an effective seal as the augmented areas were unusually firm and unyielding, preventing proper mask fit. Despite head optimisation and chin lift, insertion of an oropharyngeal airway and the use of a two-person technique effective ventilation could not be achieved. Early insertion of a second-generation supraglottic airway device restored ventilation and allowed surgery to proceed safely. This case illustrates how dermal fillers can alter facial compliance, obscure anatomical predictors of difficulty, and even be mistaken for allergic swelling. Anaesthetists are encouraged to ask specifically about cosmetic procedures, use inclusive language to promote disclosure and adapt airway plans accordingly.

This case report discusses the anaesthetic management of a patient reliant on a left ventricular assist device who presented with a contained ruptured aortic aneurysm. The placement and removal of the aortic clamp, as well as the blood loss and replacement, constituted a challenge for maintaining cardiac output, optimal pump flow, left ventricular off-loading and avoiding right ventricular failure. Continuous monitoring with transoesophageal echocardiography was a cornerstone for managing the different stages of surgery and for adapting pump revolutions to preload and afterload fluctuations and right ventricular function. Inodilators and vasoconstrictors were used to stabilise sudden fluctuations in haemodynamic parameters. It is important to develop clinical protocols and guidelines for the use of ventricular assist devices to address the complex haemodynamic changes resulting from their use.