5 research outputs found
Successful use of a 20% lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest.
THE infusion of a lipid emulsion has been shown to increase the survival rates of both rats and dogs that have been resuscitated after an overdose of bupivacaine. [1][2][3] We report the first successful use of a 20% lipid infusion to resuscitate a patient from a prolonged cardiac arrest that immediately followed the placement of an interscalene block with bupivacaine and mepivacaine. Case Report The patient was a 58-yr-old, 82-kg, 170-cm male who presented for arthroscopic repair of a torn rotator cuff in the right shoulder. His medical history was significant for coronary artery bypass graft surgery at age 43 yr. He gave a history of angina upon exertion and occasionally at rest. He declined further preoperative cardiac workup but was considered by his cardiologist to be stable on medical therapy. This included nitroglycerine as needed, lisinopril, atenolol isosorbide mononitrate, and clopidogrel and enteric-coated aspirin, both of which had been discontinued 1 week previously. His preoperative electrocardiogram revealed a right bundle-branch block, a left anterior hemiblock, and evidence of an old anterior wall myocardial infarction. The patient arrived at the operating room holding area, where standard monitors were applied. Blood pressure was 120/80 mmHg, room air oxygen saturation measured by pulse oximetry was 98%, and heart rate was 60 beats/min. Supplemental oxygen was delivered at 3 l/min via a nasal cannula. A 20-gauge intravenous catheter was placed in the dorsum of his left hand, through which 2 mg midazolam and 50 g fentanyl were administered. A 50-mm, 22-gauge Stimuplex ® insulated needle was connected to a Stimuplex ® -DIG nerve stimulator (both B. Braun, Inc., Bethlehem, PA), and the interscalene groove was identified at the level of C6. The brachial plexus was identified by eliciting biceps stimulation (0.1-ms duration, 2 Hz) at 0.34 mA, following which 40 ml local anesthetic solution (20 ml bupivacaine, 0.5%, and 20 ml mepivacaine, 1.5%) were injected slowly (over approximately 2.5 min) in 5-ml increments with gentle aspiration between doses. The patient was awake and conversant during the performance of the block. At no time was any blood aspirated, nor did he report pain or paresthesias. Approximately 30 s after removal of the block needle, the patient became incoherent and then developed a tonic-clonic seizure. Oxygen was delivered by a facemask attached to a self-inflating resuscitation bag while 50 mg propofol was injected intravenously. The seizure stopped, and spontaneous respirations resumed. Approximately 90 s later, the patient began to seize again; this time, 100 mg intravenous propofol was administered. The electrocardiogram showed asystole, and no pulse, by carotid or femoral palpation, or blood pressure was detectable. Advanced cardiac life support was immediately started. The trachea was intubated, and end-tidal carbon dioxide was detected with an EasyCap ® II (Nellcor Inc., Hayward, CA). Tube position was confirmed by auscultation, after which chest compressions were immediately resumed. During the first 20 min of advanced cardiac life support, a total of 3 mg epinephrine, given in divided doses, 2 mg atropine, 300 mg amiodarone, and 40 U arginine vasopressin were administered. In addition, monophasic defibrillation was used at escalating energy levels-200, 300, 360, and 360 J, according to the advanced cardiac life support protocol. Cardiac rhythms included ventricular tachycardia with a pulse, pulseless ventricular tachycardia that momentarily became ventricular fibrillation, and eventually asystole. The arrhythmias observed during most of the resuscitation period were pulseless ventricular tachycardia and asystole. After 20 min, at which time plans were being made to institute cardiopulmonary bypass, the administration of a lipid emulsion was suggested, and 100 ml of 20% Intralipid (for Baxter Pharmaceuticals by Fresenius Kabi, Uppsala, Sweden) was given through the peripheral intravenous catheter. Cardiac compressions continued, and a defibrillation shock at 360 J was given. Within seconds, a single sinus beat appeared on the electrocardiogram, and 1 mg atropine and 1 mg epinephrine were administered. Within 15 s, while external chest compressions were continued, the cardiac rhythm returned to sinus at a rate of 90 beats/min. The blood pressure and pulse became detectable. An infusion of lipid emulsion was started and continued at 0.5 ml · kg Ϫ1 · min Ϫ1 over the following 2 h and then discontinued. The patient remained in sinus rhythm. He was weaned from mechanical ventilation, and his trachea was extubated, approximately 2.5 h later. He was awake and responsive, and had right upper extremity weakness consistent with a brachial plexus block. No neurologic sequelae were sustained, and he was subsequently transferred to a monitored setting for overnight observation. There was no evidence of complications secondary to the administration of intralipid (i.e., pancreatitis) during the following 2 weeks. Because the patient had a cardiac arrest after which he had increased levels of cardiac enzymes, he agreed to undergo cardiac catheterization. This revealed total occlusion of the right coronary artery and a left ventricular ejection fraction of 32%. As a consequence, an automatic implantable cardiac defibrillator was inserted without any complications, and the patient was discharged home
The practice of regional anesthesia during the COVID-19 pandemic: an international survey of members of three regional anesthesia societies = Pratique de l’anesthésie régionale pendant la pandémie de COVID-19 : un sondage international auprès des membres de trois sociétés d’anesthésie régionale
Purpose
To determine: the preferences and attitudes of members of regional anesthesia societies during the COVID-19 pandemic.
Methods:
We distributed an electronic survey to members of the American Society of Regional Anesthesia and Pain Medicine, Regional Anaesthesia-UK, and the European Society of Regional Anaesthesia & Pain Therapy. A questionnaire consisting of 19 questions was developed by a panel of experienced regional anesthesiologists and distributed by email to the participants. The survey covered the following domains: participant information, practice settings, preference for the type of anesthetic technique, the use of personal protective equipment, and oxygen therapy.
Results:
The survey was completed by 729 participants from 73 different countries, with a response rate of 20.1% (729/3,630) for the number of emails opened and 8.5% (729/8,572) for the number of emails sent. Most respondents (87.7%) identified as anesthesia staff (faculty or consultant) and practiced obstetric and non-obstetric anesthesia (55.3%). The practice of regional anesthesia either expanded or remained the same, with only 2% of respondents decreasing their use compared with the pre-pandemic period. The top reasons for an increase in the use of regional anesthesia was to reduce the need for an aerosol-generating medical procedure and to reduce the risk of possible complications to patients. The most common reason for decreased use of regional anesthesia was the risk of urgent conversion to general anesthesia. Approximately 70% of the responders used airborne precautions when providing care to a patient under regional anesthesia. The most common oxygen delivery method was nasal prongs (cannula) with a surgical mask layered over it (61%).
Conclusions:
Given the perceived benefits of regional over general anesthesia, approximately half of the members of three regional anesthesia societies seem to have expanded their use of regional anesthesia techniques during the initial surge of the COVID-19 pandemic
Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery
Abstract Background Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting. Methods Providers from five academic medical centers within a single US city were surveyed from May–September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar’s tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher’s exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians. Results A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p  15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002). Conclusions While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians
Assistive artificial intelligence for ultrasound image interpretation in regional anaesthesia:an external validation study
Intelligent Ultrasound Limited (Cardiff, UK) via a grant to JSB administered by the University of Oxford (R70327/CN002).BACKGROUND: Ultrasonound is used to identify anatomical structures during regional anaesthesia and to guide needle insertion and injection of local anaesthetic. ScanNav Anatomy Peripheral Nerve Block (Intelligent Ultrasound, Cardiff, UK) is an artificial intelligence-based device that produces a colour overlay on real-time B-mode ultrasound to highlight anatomical structures of interest. We evaluated the accuracy of the artificial-intelligence colour overlay and its perceived influence on risk of adverse events or block failure. METHODS: Ultrasound-guided regional anaesthesia experts acquired 720 videos from 40 volunteers (across nine anatomical regions) without using the device. The artificial-intelligence colour overlay was subsequently applied. Three more experts independently reviewed each video (with the original unmodified video) to assess accuracy of the colour overlay in relation to key anatomical structures (true positive/negative and false positive/negative) and the potential for highlighting to modify perceived risk of adverse events (needle trauma to nerves, arteries, pleura, and peritoneum) or block failure. RESULTS: The artificial-intelligence models identified the structure of interest in 93.5% of cases (1519/1624), with a false-negative rate of 3.0% (48/1624) and a false-positive rate of 3.5% (57/1624). Highlighting was judged to reduce the risk of unwanted needle trauma to nerves, arteries, pleura, and peritoneum in 62.9-86.4% of cases (302/480 to 345/400), and to increase the risk in 0.0-1.7% (0/160 to 8/480). Risk of block failure was reported to be reduced in 81.3% of scans (585/720) and to be increased in 1.8% (13/720). CONCLUSIONS: Artificial intelligence-based devices can potentially aid image acquisition and interpretation in ultrasound-guided regional anaesthesia. Further studies are necessary to demonstrate their effectiveness in supporting training and clinical practice. CLINICAL TRIAL REGISTRATION: NCT04906018.Publisher PDFPeer reviewe