Procedure-specific peripheral nerve blocks

Cork University Hospital, Ireland, Congresul II Internaţional al Societăţii Anesteziologie Reanimatologie din Republica Moldova 27-30 august 2009Peripheral nerve blockade [PNB] is an anaesthetic technique, which renders specific body parts insensate to surgical stimuli while permitting the patient to remain conscious. Peripheral nerve blockade may be used as a sole anaesthetic technique or as an additional component of general anaesthesia. Significant benefits have been associated with the use of peripheral nerve block for both patients and the healthcare institutions. Nonetheless, for a variety of reasons, nerve block techniques are under-utilised in current anaesthetic practice. The Department of Anaesthesia at Cork University Hospital Ireland has, as part of an international consortium (including Bulgarian an Greek partners), been awarded EU funding under the Leonardo da Vinci Lifelong Learning Programme. to develop an integrated web-based platform providing real time, remote interactive training in perioperative care of patients undergoing orthopaedic surgery. As part of the project, we performed needs analyses of clinicians in this area, and we are going to apply the e-learning system to training in procedures such as Peripheral Nerve Blockade. The system will be pilot tested at Cork University Hospital and other UCC affiliated hospitals. The project is of two years duration ending in November 2010 (http://onlineortho. ath.cx/). This internet-based performance support system is aimed at providing just-in-time, just enough and at the point of need support to learners in remote areas in order to deal with complex authentic tasks in the context of problem-based learning

The effect of simulation-based training on initial performance of ultrasound-guided axillary brachial plexus blockade in a clinical setting – a pilot study

BACKGROUND: In preparing novice anesthesiologists to perform their first ultrasound-guided axillary brachial plexus blockade, we hypothesized that virtual reality simulation-based training offers an additional learning benefit over standard training. We carried out pilot testing of this hypothesis using a prospective, single blind, randomized controlled trial. METHODS: We planned to recruit 20 anesthesiologists who had no experience of performing ultrasound-guided regional anesthesia. Initial standardized training, reflecting current best available practice was provided to all participating trainees. Trainees were randomized into one of two groups; (i) to undertake additional simulation-based training or (ii) no further training. On completion of their assigned training, trainees attempted their first ultrasound-guided axillary brachial plexus blockade. Two experts, blinded to the trainees’ group allocation, assessed the performance of trainees using validated tools. RESULTS: This study was discontinued following a planned interim analysis, having recruited 10 trainees. This occurred because it became clear that the functionality of the available simulator was insufficient to meet our training requirements. There were no statistically significant difference in clinical performance, as assessed using the sum of a Global Rating Score and a checklist score, between simulation-based training [mean 32.9 (standard deviation 11.1)] and control trainees [31.5 (4.2)] (p = 0.885). CONCLUSIONS: We have described a methodology for assessing the effectiveness of a simulator, during its development, by means of a randomized controlled trial. We believe that the learning acquired will be useful if performing future trials on learning efficacy associated with simulation based training in procedural skills. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01965314. Registered October 17th 2013

Microstream capnography during conscious sedation with midazolam for oral surgery: a randomised controlled trial.

Objectives/Aims: There has been no dentistry-specific published data supporting the use of monitoring with capnography for dental sedation. Our aim was to determine if adding capnography to standard monitoring during conscious sedation with midazolam would decrease the incidence of hypoxaemia. Materials and Methods: A randomised controlled trial was conducted in which all patients (ASA I and II) received standard monitoring and capnography, but were randomised to whether staff could view the capnography (intervention) or were blinded to it (control). The primary outcome was the incidence of hypoxaemia (SpO2⩽94%). Results: We enrolled 190 patients, mean age 31 years (range, 14–62 years). There were 93 patients in the capnography group and 97 in the control group. The mean cumulative dose of midazolam titrated was 6.94 mg (s.d., 2.31; range, 3–20 mg). Six (3%) patients, three in each group, required temporary supplemental oxygen. There was no statistically significant difference between the capnography and control groups for the incidence of hypoxaemia: 34.4 vs 39.2% (P=0.4962, OR=0.81, 95% CI: 0.45–1.47). Conclusions: We were unable to confirm an additive role for capnography to prevent hypoxaemia during conscious sedation with midazolam for patients not routinely administered supplemental oxygen

A cross-sectional survey of anaesthesia-related expectations amongst patients awaiting upper limb trauma surgery

Background and aims: Little is known regarding patients’ anaesthesia-related expectations when presenting for upper limb trauma surgery. Methods: We conducted a prospective cross-sectional survey exploring prior anaesthetic experience, anaesthesia-related knowledge, anaesthesia expectations, the preoperative visit and factors likely to influence anaesthesia choice. The survey was completed by 192 patients. Results: Anaesthetists were identified as doctors by 52%; 53% were unaware of their planned anaesthesia; 58% indicated likely acceptance of regional anaesthesia. Information regarding anaesthesia originated mostly from surgeons (65%); 93% had not seen an anaesthetist at the time of the survey. Most believed anaesthesia involved ‘going to sleep’ (82%) and 71% expected to receive general anaesthesia. The preoperative anaesthesia visit was rated as important by 65% of patients. 78% indicated that provision of information would increase the likelihood of accepting regional anaesthesia. Reducing postoperative pain and nausea would influence 80% in choosing a regional technique. Conclusion: A knowledge deficit exists regarding anaesthesia modalities for upper limb trauma surgery

A comparison of three techniques (local anesthetic deposited circumferential to vs. above vs. below the nerve) for ultrasound guided femoral nerve block

Background: Fractured neck of femur generally requires operative fixation and is a common cause of admission to hospital. The combination of femoral nerve block and spinal anesthesia is a common anesthetic technique used to facilitate the surgical procedure. The optimal disposition of local anesthetic (LA) relative the femoral nerve (FN) has not been defined. Our hypothesis was: that the deposition of LA relative to the FN influences the quality of analgesia for positioning of the patient for performance of spinal anesthesia. The primary outcome was verbal rating (VRS) pain scores 0–10 assessed immediately after positioning the patient to perform spinal anesthesia. Methods: With Institutional ethical approval and having obtained written informed consent from each, 52 patients were studied. The study was registered with ClinicalTrials.gov (NCT01527812). Patients were randomly allocated to undergo to one of three groups namely: intention to deposit lidocaine 2% (15 ml) i. above (Group A), ii. below (Group B), iii. circumferential (Group C) to the FN. A blinded observer assessed i. the sensory nerve block (cold) in the areas of the terminal branches of the FN and ii. VRS pain scores on passive movement from block completion at 5 minutes intervals for 30 minutes. Immediately after positioning the patient for spinal anesthesia, VRS pain scores were recorded. Results: Pain VRS scores during positioning were similar in the three groups [Above group/Below group/Circumferential group: 2(0–9)/0(0–10)/3(0–10), median(range), p:0.32]. The block was deemed to have failed in 20%, 47% and 12% in the Above group, Below group and Circumferential group respectively. The median number of needle passes was greater in the Circumferential group compared with the Above group (p:0.009). Patient satisfaction was greatest in the Circumferential group [mean satisfaction scores were 83.5(19.8)/88.1(20.5)/93.8(12.3), [mean(SD), p=0.04] in the Above, Below and Circumferential groups respectively. Conclusions: We conclude that there is no clinical advantage to attempting to deposit LA circumferential to the femoral nerve (relative to depositing LA either above or below the nerve), during femoral nerve block in this setting

Long versus Short Axis ultrasound guided approach for internal jugular vein cannulation: a prospective randomised controlled trial

Abstract Aim: The aim of this study was to compare the short and long axis approaches to ultrasound guided right internal jugular vein cannulation with respect to indicators of success. Methods: Patients undergoing cardiac surgery requiring central venous cannulation (99 patients) were randomised to undergo either long or short axis ultrasound guided cannulation of the right internal jugular vein by a skilled anaesthetist. First pass success, number of needle passes, procedural taken and complications were documented for each procedure. Results: The right internal jugular vein was successfully cannulated in all 99 patients. The first pass success rate was significantly higher in the short axis 98% group compared to the long axis group 78% [48:1 (98%) versus 39:11 (78%) p <0.006]. Procedural time was comparable in both the groups [39.6 (18.4) versus 46.9 (42.4)]. Fewer needle redirections were required in the short axis group [1.02 (0.02) versus 1.24 (0.56) p <0.004]. Carotid artery puncture only occurred in the long axis group. Conclusions: We conclude that anaesthetists with experience in ultrasound guided internal jugular vein cannulation, have higher first pass success rate and less carotid artery puncture when a short axis, rather than a long axis, approach is employed. Keywords: internal jugular vein, ultrasound, venous cannulation, scanning axis Rezumat Scopul studiului: Compararea ratei de succes a cateterizării în ax lung şi în ax scurt a venei jugulare interne prin ghidaj ecografic. Metode: Au fost randomizaţi 99 de pacienţi supuşi unor intervenţii chirugicale cardiovasculare ce necesitau montarea unui cateter central; acestora li s-a montat un cateter la nivelul venei jugulare interne drepte de către un anestezist cu experienţă, prin ghidaj ecografic, folosind abordul vascular în axul lung sau în cel scurt. Reuşita la prima tentativă, numărul de redirecţionări ale acului, timpul necesar precum şi complicaţiile survenite au fost documentate pentru fiecare dintre cele doua proceduri. Rezultate: Vena jugulară internă dreaptă a fost cateterizată cu succes la toţi cei 99 de pacienţi. Succesul de la prima tentativa a fost semnificativ mai mare la grupul cu abord in ax scurt 98%, prin comparatie cu grupul cu abord in ax lung 78% [48:1 (98%) versus 39:11 (78%) p <0.006]. Timpul procedurii a fost similar in ambele grupuri [39.6 (18.4) versus 46.9 (42.4)]. Un numar mai mic de redirectionari ale acului au fost necesare in grupul cu abord in ax scurt [1.02 (0.02) versus 1.24 (0.56) p <0.004]. Punctionarea accidentala a arterei carotide a survenit doar la grupul cu abord in ax lung. Concluzii: Anesteziştii cu experienţă în cataterizarea venei jugulare interne prin ghidaj ecografic au o rată mai mare a succesului de la prima tentativă şi un numar mai mic de puncţionari ale arterei carotide atunci când folosesc abordul în ax scurt. Cuvinte cheie: vena jugulară internă, ecografie, canulare venoasă, plan de examinar

A year in review in Minerva Anestesiologica 2014

Year in revie

Pain after upper limb surgery under peripheral nerve block is associated with gut microbiome composition and diversity

peer-reviewedGut microbiota play a role in certain pain states. Hence, these microbiota also influence somatic pain. We aimed to determine if there was an association between gut microbiota (composition and diversity) and postoperative pain. Patients (n = 20) undergoing surgical fixation of distal radius fracture under axillary brachial plexus block were studied. Gut microbiota diversity and abundance were analysed for association with: (i) a verbal pain rating scale of < 4/10 throughout the first 24 h after surgery (ii) a level of pain deemed “acceptable” by the patient during the first 24 h following surgery (iii) a maximum self-reported pain score during the first 24 h postoperatively and (iv) analgesic consumption during the first postoperative week. Analgesic consumption was inversely correlated with the Shannon index of alpha diversity. There were also significant differences, at the genus level (including Lachnospira), with respect to pain being “not acceptable” at 24 h postoperatively. Porphyromonas was more abundant in the group reporting an acceptable pain level at 24 h. An inverse correlation was noted between abundance of Collinsella and maximum self-reported pain score with movement. We have demonstrated for the first time that postoperative pain is associated with gut microbiota composition and diversity. Further work on the relationship between the gut microbiome and somatic pain may offer new therapeutic targets

Ethical procedures and patient consent differ in Europe

BACKGROUND: Research ethics approvals, procedures and requirements for institutional research ethics committees vary considerably by country and by type of organisation. OBJECTIVE: To evaluate the requirements and procedures of research ethics committees, details of patient information and informed consent based on a multicentre European trial. DESIGN: Survey of European hospitals participating in the prospective observational study on chronic postsurgical pain (euCPSP) using electronic questionnaires. SETTING: Twenty-four hospitals in 11 European countries. PARTICIPANTS: From the 24 hospitals, 23 local investigators responded; 23 answers were analysed. OUTCOME MEASURES: Comparison of research ethics procedures and committee requirements from the perspective of clinical researchers. Comparison of the institutions' procedures regarding patient information and consent. Description of further details such as costs and the duration of the approval process. RESULTS: The approval process lasted from less than 2 weeks up to more than 2 months with financial fees varying between 0 and 575 €. In 20 hospitals, a patient information sheet of variable length (half page up to two pages) was provided. Requirements for patients' informed consent differed. Written informed consent was mandatory at 12, oral at 10 and no form of consent at one hospital. Details such as enough time for consideration, possibility for withdrawal and risks/benefits of participation were provided in 25 to 30% of the institutions. CONCLUSION: There is a considerable variation in the administrative requirements for approval procedures by research ethics committees in Europe. This results in variation of the extent of information and consent procedures for the patients involved