Feasibility of combined ultrasound guided interscalene and erector spinae plane block for regional anesthesia in modified radical mastectomy with axillary lymph node dissection: A pilot study

ABSTRACTBackground In patients at high risk, regional anesthesia (RA) is a viable substitute for general anesthesia (GA). For a modified radical mastectomy that included axillary lymph node dissection (MRM-ALND), we assumed that a combination erector spinae plane block (ESPB) and interscalene block (IBPB) could offer a sufficient anesthesia.Methods After clinical trial registration (No. NCT04239716), this pilot study included thirteen consecutive female, 40–85 years old, and scheduled for MRM-ALND. Patients received ESPB at T4 level (5 ml of 2% lidocaine, 10 ml of 0.5% bupivacaine, and 5 ml of normal saline), IBPB (5 ml each of 2% lidocaine and 0.5% bupivacaine), and sedation with dexmedetomidine. The primary aim was to assess the success rate of our technique as a sole anesthesia for MRM-ALND in high-risk patients. Secondary outcomes included intraoperative vital signs measurements. Postoperative measurements were numeric rating scale (NRS) score, analgesic duration, the consumption of morphine, patients’ satisfaction, and adverse effects.Results Our technique succeeded in 11 out of 13 patients. In whom RA were succeeded, the analgesia lasted 360–720 minutes, they received morphine 3–9 mg and had low NRS scores. The two failure cases received GA, the analgesia lasted 60–120 minutes postoperative, they received morphine 9 mg and had high NRS scores. The reduction of hemodynamic parameters intraoperative responded to reduce dexmedetomidine infusion rate. Two patients had postoperative vomiting treated with ondansetrone.Conclusions The combined ESPB and IBPB could be utilized as an alternative to GA for MRM-ALND, which reduced the potential risks of GA in high-risk patients; furthermore, it provides satisfactory postoperative analgesia with limited opioid consumption

The effect of adding cisatracurium versus hyaluronidase to levobupivacaine and lidocaine mixture in single injection peribulbar block for cataract surgery

Background: Several adjuvants can be utilized to improve the quality of peribulbar block (PBB). We compared the effects of adding cisatracurium or hyaluronidase to levobupivacaine and lidocaine mixture for PBB on the onset of globe and lid akinesia in cataract surgery. Methods: 105 adult patients scheduled for cataract surgery under PBB were randomly allocated into three groups. Control group received 4 ml 0.5% levobupivacaine plus 3 ml 2% lidocaine diluted in saline to a total volume of 8 ml. Hyaluronidase 15 IU/ml and cisatracurium 1 mg were added to local anesthetics (LAs) mixture in hyaluronidase and cisatracurium groups respectively. Onset and duration of lid and globe akinesia, time for adequate conditions to start surgery and adverse events were recorded. Distribution of LAs solution was evaluated by B-scan ultrasound at 3 min and 10 min after injection of LAs. Results: Onset of lid and globe akinesia, as well as time to adequate conditions to start surgery, were faster in cisatracurium and hyaluronidase groups compared to the control group (P < 0.05). Cisatracurium group had the fastest onset. At 3 min after injection of LAs, the ultrasound examination revealed that hyaluronidase group had the highest percentage of patients showing intraconal diffusion of LAs solution with the appearance of a characteristic T sign (P < 0.05). Conclusions: The addition of cisatracurium 1 mg or hyaluronidase 15 IU/ml to levobupivacaine and lidocaine mixture for PBB hastened the onset of lid and globe akinesia without increase the incidence of adverse effects. This effect is more obvious with cisatracurium compared to hyaluronidase

SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study

Background: Preoperative SARS-CoV-2 vaccination could support safer elective surgery. Vaccine numbers are limited so this study aimed to inform their prioritization by modelling. Methods: The primary outcome was the number needed to vaccinate (NNV) to prevent one COVID-19-related death in 1 year. NNVs were based on postoperative SARS-CoV-2 rates and mortality in an international cohort study (surgical patients), and community SARS-CoV-2 incidence and case fatality data (general population). NNV estimates were stratified by age (18-49, 50-69, 70 or more years) and type of surgery. Best- and worst-case scenarios were used to describe uncertainty. Results: NNVs were more favourable in surgical patients than the general population. The most favourable NNVs were in patients aged 70 years or more needing cancer surgery (351; best case 196, worst case 816) or non-cancer surgery (733; best case 407, worst case 1664). Both exceeded the NNV in the general population (1840; best case 1196, worst case 3066). NNVs for surgical patients remained favourable at a range of SARS-CoV-2 incidence rates in sensitivity analysis modelling. Globally, prioritizing preoperative vaccination of patients needing elective surgery ahead of the general population could prevent an additional 58 687 (best case 115 007, worst case 20 177) COVID-19-related deaths in 1 year. Conclusion: As global roll out of SARS-CoV-2 vaccination proceeds, patients needing elective surgery should be prioritized ahead of the general population

Characteristics and outcomes of COVID-19 patients admitted to hospital with and without respiratory symptoms

Background: COVID-19 is primarily known as a respiratory illness; however, many patients present to hospital without respiratory symptoms. The association between non-respiratory presentations of COVID-19 and outcomes remains unclear. We investigated risk factors and clinical outcomes in patients with no respiratory symptoms (NRS) and respiratory symptoms (RS) at hospital admission. Methods: This study describes clinical features, physiological parameters, and outcomes of hospitalised COVID-19 patients, stratified by the presence or absence of respiratory symptoms at hospital admission. RS patients had one or more of: cough, shortness of breath, sore throat, runny nose or wheezing; while NRS patients did not. Results: Of 178,640 patients in the study, 86.4&nbsp;% presented with RS, while 13.6&nbsp;% had NRS. NRS patients were older (median age: NRS: 74 vs RS: 65) and less likely to be admitted to the ICU (NRS: 36.7&nbsp;% vs RS: 37.5&nbsp;%). NRS patients had a higher crude in-hospital case-fatality ratio (NRS 41.1&nbsp;% vs. RS 32.0&nbsp;%), but a lower risk of death after adjusting for confounders (HR 0.88 [0.83-0.93]). Conclusion: Approximately one in seven COVID-19 patients presented at hospital admission without respiratory symptoms. These patients were older, had lower ICU admission rates, and had a lower risk of in-hospital mortality after adjusting for confounders