A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series

Background - Shoulder arthroplasty is associated with significant post-operative pain. Interscalene plexus block is the gold standard for pain management in patients undergoing this surgery, however, alternatives are currently being developed. We hypothesized that a combination of anterior suprascapular nerve block and lateral sagittal infraclavicular block would provide effective post-operative analgesia. Primary aims for this study were to document numeric rating scale (NRS) pain score and use of oral morphine equivalents (OMEq) during the first 24 hours after surgery. Secondary aim was to determine the incidence of hemidiaphragmatic paralysis. Methods - Twenty patients (ASA physical status I-III) scheduled for shoulder arthroplasty were studied. Four mL ropivacaine 0.5% was administered for the suprascapular nerve block and 15 mL ropivacaine 0.75% for the infraclavicular block. Surgery was performed under general anaesthesia. Paracetamol and prolonged-release oxycodone were prescribed as post-operative analgesics. Morphine and oxycodone were prescribed as rescue pain medication. Diaphragm status was assessed by ultrasound. Results - Median NRS (0-10) at 1, 3, 6, 8 and 24 hours post-operatively were 1, 0, 0, 0 and 3, respectively. NRS at rest during the first 24 post-operative hours was 4 (2.5-4.5 [0-5]), median (IQR [range]). Maximum NRS was 6.5 (5-8 [0-10]) median (IQR [range]). Total OMEq during the first 24 post-operative hours was 52.5 mg (30-60 [26.4-121.5]) median (IQR [range]). Hemidiaphragmatic paralysis was diagnosed in one patient (5%). Conclusions - The combination of suprascapular and infraclavicular nerve block shows an encouraging post-operative analgesic profile and a low risk for hemidiaphragmatic paralysis after total shoulder arthroplasty

A randomised placebo-controlled trial examining the effect on hand supination after the addition of a suprascapular nerve block to infraclavicular brachial plexus blockade

This is the peer reviewed version of the following article: Flohr-Madsen, S., Ytrebø, L.M., Valen, K., Wilsgaard, T. & Klaastad, Ø. (2016). A randomised placebo-controlled trial examining the effect on hand supination after the addition of a suprascapular nerve block to infraclavicular brachial plexus blockade. Anaesthesia, 71, 938–947, which has been published in final form at https://doi.org/10.1111/anae.13504. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions.Some surgeons believe that infraclavicular brachial plexus blocks tends to result in supination of the hand/forearm, which may make surgical access to the dorsum of the hand more difficult. We hypothesised that this supination may be reduced by the addition of a suprascapular nerve block. In a double‐blind, randomised, placebo‐controlled study, our primary outcome measure was the amount of supination (as assessed by wrist angulation) 30 min after infraclavicular brachial plexus block, with (suprascapular group) or without (control group) a supplementary suprascapular block. All blocks were ultrasound‐guided. The secondary outcome measure was an assessment by the surgeon of the intra‐operative position of the hand. Considering only patients with successful nerve blocks, mean (SD) wrist angulation was lower (33 (27) vs. 61 (44) degrees; p = 0.018) and assessment of the hand position was better (11/11 vs. 6/11 rated as ‘good’; p = 0.04) in the suprascapular group. The addition of a suprascapular nerve block to an infraclavicular brachial plexus block can provide a better hand/forearm position for dorsal hand surgery

Continuous Infusion of Iohexol to Monitor Perioperative Glomerular Filtration Rate

Continuous monitoring of the glomerular ltration rate (GFR) in the perioperative setting could provide valuable information about acute kidney injury risk for both clinical and research purposes. ­is pilot study aimed to demonstrate that GFR measurement by a continuous 72 hrs iohexol infusion in patients undergoing colorectal cancer surgery is feasible. Four patients undergoing robot-assisted colorectal cancer surgery were recruited from elective surgery listings. GFR was determined preoperatively by the single-sample iohexol clearance method, and postoperatively at timed intervals by a continuous iohexol infusion for 72 hrs. Plasma concentrations of creatinine and cystatin C were measured concurrently. GFR was calculated as (iohexol infusion rate (mg/min))/(plasma iohexol concentration (mg/mL)). ­e association of the three di erent ltration markers and GFR with time were analysed in generalized additive mixed models. ­e continuous infusion of iohexol was established in all four patients and maintained throughout the study period without interfering with ordinary postoperative care. Postoperative GFR at 2 hours were elevated compared to the preoperative measurements for patients 1, 2, and 3, but not for patient 4. Whereas patients 1, 2, and 3 had u-shaped postoperative mGFR curves, patient 4 demonstrated a linear increase in mGFR with time. We conclude that obtaining continuous measurements of GFR in the postoperative setting is feasible and can detect variations in GFR. ­e method can be used as a tool to track perioperative changes in renal function

Spinal Anaesthesia as an Adjunct to General Anaesthesia for Laparoscopic Abdominoperineal Rectal Amputation

Background: Spinal anaesthesia as an adjunct to general anaesthesia may reduce postoperative pain and opioid consumption after laparoscopic abdominoperineal rectal amputation. We designed a randomized double blinded pilot study with two objectives: 1) to explore potential benefits of spinal anaesthesia as an adjunct to general anaesthesia and 2) to provide power and sample size estimations for potential differences between the groups. Primary outcome measures were postoperative pain and oral morphine equivalent (OMEq) consumption. Methods: Patients scheduled for elective laparoscopic abdominoperineal rectal amputation at the University Hospital of North Norway were randomised to spinal (n=5) or a sham spinal procedure (n=5). Numeric rating scale (NRS) and OMEq were monitored postoperatively for 72 h. Results: Age, sex, body mass index, and ASA were not significantly different between the groups. During surgery, patients in the spinal group received less remifentanil (p=0.06). NRS was lower in the spinal group 1 hr after admittance to the post-anaesthesia care unit (PACU) (p=0.06) and on the first postoperative day at 8 AM (p=0.03). OMEq consumption in the PACU was lower in the spinal group (p=0.008), but no differences between the groups were detected after discharge to the ward. Sample size estimations revealed that eight patients in each group would be needed to study potential NRS differences after admission to the PACU and 23 patients in each group to study potential differences in OMEq consumption on day 1. Conclusion: Spinal anaesthesia as an adjunct to general anaesthesia reduces postoperative pain and opioid consumption after laparoscopic abdominoperineal rectal amputation. Data from the current study should be followed up by a sufficiently powered randomized controlled trial

Minimum effective volume of ropivacaine 7.5mg/ml for an ultrasound-guided infraclavicular brachial plexus block

Background - Ultrasound guidance has been shown to reduce the minimum effective volume (MEV) of local anaesthetics for several peripheral nerve blocks. Although the lateral sagittal infraclavicular block (LSIB) is a well‐established anaesthesia method, MEV for this technique has not been established. Our aim with this study was to determine the MEV using ropivacaine 7.5 mg/ml for the LSIB method. Methods - Twenty‐five adult American Society of Anesthesiologists physical status I‐II patients scheduled for hand surgery received an ultrasound‐guided LSIB with ropivacaine 7.5 mg/ml. A successful block was defined as anaesthesia or analgesia for all five sensory nerves distal to the elbow, 30 min after local anaesthetic injection. The MEV for a successful block in 50% of the patients was determined by using the staircase up‐and‐down method introduced by Dixon and Massey. Logistic regression and probit transformation were applied to estimate the MEV for a successful block in 95% of the patients. Results - The patients received ropivacaine 7.5 mg/ml volumes in the range of 12.5–30 ml. The MEVs in 50% and 95% of the patients were 19 ml [95% confidence interval (CI), 14–27] and 31 ml (95% CI, 18–45), respectively. Conclusions - For surgery distal to the elbow, the MEV in 95% of patients for an ultrasound‐guided LSIB with ropivacaine 7.5 mg/ml was estimated to be 31 ml (95% CI, 18–45 ml). Further studies should determine the factors that influence the volume of local anaesthetic required for a successful infraclavicular block

Forbruk av opioider ved to kirurgiske sykehusavdelinger

BAKGRUNN - Formålet med undersøkelsen var å dokumentere forbruket av opioider ved to kirurgiske avdelinger ved Universitetssykehuset Nord-Norge Tromsø i perioden 2010–17. MATERIALE OG METODE - Forbruket av opioider ved Gastrokirurgisk avdeling og Avdeling for hjerte-, lunge- og karkirurgi ble innhentet fra Sykehusapotek Nord. Alle opioider ble omregnet til orale morfinekvivalenter. RESULTATER< - Forbruket av morfin ved Gastrokirurgisk avdeling ble redusert fra 223 835 orale morfinekvivalenter per år i perioden 2010–13 til 147 641 i perioden 2014–17. Ved Avdeling for hjerte-, lunge- og karkirurgi ble forbruket av morfin per år redusert fra 28 652 orale morfinekvivalenter i perioden 2010–13 til 22 945 i perioden 2014–17. Forbruket av oksykodon ved Gastrokirurgisk avdeling økte fra 210 643 orale morfinekvivalenter per år i perioden 2010–13 til 376 322 i perioden 2014–17. Ved Avdeling for hjerte-, lunge- og karkirurgi økte forbruket av oksykodon fra 28 922 orale morfinekvivalenter per år i perioden 2010–13 til 123 875 i perioden 2014–17. Ved Gastrokirurgisk avdeling var økningen tydeligst for oksykodon gitt intravenøst eller subkutant. Ved Avdeling for hjerte-, lunge- og karkirurgi var økningen størst for oksykodon administrert per os. FORTOLKNING - Forbruket av opioider økte ved begge studieavdelingene, og oksykodon utgjorde størstedelen av økningen

A novel combination of peripheral nerve blocks for arthroscopic shoulder surgery

Background - Interscalene brachial plexus block is currently the gold standard for intra‐ and post‐operative pain management for patients undergoing arthroscopic shoulder surgery. However, it is associated with block related complications, of which effect on the phrenic nerve have been of most interest. Side effects caused by general anesthesia, when this is required, are also a concern. We hypothesized that the combination of superficial cervical plexus block, suprascapular nerve block, and infraclavicular brachial plexus block would provide a good alternative to interscalene block and general anesthesia. Methods - Twenty adult patients scheduled for arthroscopic shoulder surgery received a combination of superficial cervical plexus block (5 ml ropivacaine 0.5%), suprascapular nerve block (4 ml ropivacaine 0.5%), and lateral sagittal infraclavicular block (31 ml ropivacaine 0.75%). The primary aim was to find the proportion of patients who could be operated under light propofol sedation, without the need for opioids or artificial airway. Secondary aims were patients' satisfaction and surgeons' judgment of the operating conditions. Results - Nineteen of twenty patients (95% CI: 85–100) underwent arthroscopic shoulder surgery with light propofol sedation, but without opioids or artificial airway. The excluded patient was not comfortable in the beach chair position and therefore received general anesthesia. All patients were satisfied with the treatment on follow‐up interviews. The surgeons rated the operating conditions as good for all patients. Conclusion - The novel combination of a superficial cervical plexus block, a suprascapular nerve block, and an infraclavicular nerve block provides an alternative anesthetic modality for arthroscopic shoulder surgery

Pulmonary vascular clearance of harmful endogenous macromolecules in a porcine model of acute liver failure

Background. Pulmonary complications are common in acute liver failure (ALF). The role of the lungs in the uptake of harmful soluble endogenous macromolecules was evaluated in a porcine model of ALF induced by hepatic devascularization (n = 8) vs. controls (n = 8). In additional experiments, pulmonary uptake was investigated in healthy pigs. Fluorochrome-labeled modified albumin (MA) was applied to investigate the cellular uptake. Results. As compared to controls, the ALF group displayed a 4-fold net increased lung uptake of hyaluronan, and 5-fold net increased uptake of both tissue plasminogen activator and lysosomal enzymes. Anatomical distribution experiments in healthy animals revealed that radiolabeled MA uptake (taken up by the same receptor as hyaluronan) was 53% by the liver, and 24% by the lungs. The lung uptake of LPS was 14% whereas 60% remained in the blood. Both fluorescence and electron microscopy revealed initial uptake of MA by pulmonary endothelial cells (PECs) with later translocation to pulmonary intravascular macrophages (PIMs). Moreover, the presence of PIMs was evident 10 min after injection. Systemic inflammatory markers such as leukopenia and increased serum TNF-α levels were evident after 20 min in the MA and LPS groups. Conclusion. Significant lung uptake of harmful soluble macromolecules compensated for the defect liver scavenger function in the ALF-group. Infusion of MA induced increased TNF-α serum levels and leukopenia, similar to the effect of the known inflammatory mediator LPS. These observations suggest a potential mechanism that may contribute to lung damage secondary to liver disease

Non-sedation versus sedation with a daily wake-up trial in critically ill patients receiving mechanical ventilation (NONSEDA Trial) : study protocol for a randomised controlled trial

BACKGROUND: Through many years, the standard care has been to use continuous sedation of critically ill patients during mechanical ventilation. However, preliminary randomised clinical trials indicate that it is beneficial to reduce the sedation level. No randomised trial has been conducted comparing sedation with no sedation, a priori powered to have all-cause mortality as primary outcome.The objective is to assess the benefits and harms of non-sedation versus sedation with a daily wake-up trial in critically ill patients. METHODS/DESIGN: The non-sedation (NONSEDA) trial is an investigator-initiated, randomised, clinical, parallel-group, multinational trial designed to include 700 patients from at least six ICUs in Denmark, Norway and Sweden.Inclusion criteria are mechanically ventilated patients with expected duration of mechanical ventilation &gt;24 hours.Exclusion criteria are non-intubated patients, patients with severe head trauma, coma at admission or status epilepticus, patients treated with therapeutic hypothermia, patients with PaO2/FiO2 &lt; 9 where sedation might be necessary to ensure sufficient oxygenation or place the patient in prone position.Experimental intervention is non-sedation supplemented with pain management during mechanical ventilation.Control intervention is sedation with a daily wake-up trial.The primary outcome will be all cause mortality at 90 days after randomization. Secondary outcomes will be: days until death throughout the total observation period; coma- and delirium-free days; highest RIFLE score; days until discharge from the intensive care unit (within 28 days); days until the participant is without mechanical ventilation (within 28 days); and proportion of patients with a major cardiovascular outcome. Explorative outcomes will be: all cause mortality at 28 days after randomisation; days until discharge from the intensive care unit; days until the participant is without mechanical ventilation; days until discharge from the hospital; organ failure.Trial size: we will include 700 participants (2 × 350) in order to detect or reject 25% relative risk reduction in mortality with a type I error risk of 5% and a type II error risk of 20% (power at 80%). DISCUSSION: The trial investigates potential benefits of non-sedation. This might have large impact on the future treatment of mechanically ventilated critically ill patients. TRIAL REGISTER: ClinicalTrials.gov NCT0196768, 09.01.2014