How to set up a standard regional anesthesia service?

The practice of regional anesthesia is getting more popular after the introduction of ultrasound technology in anesthesia practice. The biggest obstacle in conducting regional anesthesia is the delay in operation room time. This brief report focuses on the set up of the so called "block room"

Pain relief following thoracoscopic sympathectomy for palmar hyperhidrosis: a prospective randomised double-blind study

Acute pain management following thoracoscopic sympathectomy [TS] has been described in the literature. The combination of interpleural [IP] injection of bupivacaine and intramuscular injection. [I.M] NSAIDs has not been reported. Therefore we conducted this randomized controlled trial to compare this technique to other reported techniques described for postoperative analgesia following TS. 40 patients scheduled to have TS under general anesthesia for the treatment of hyperhidrosis were randomly allocated into 4 groups. Group 1 received 1.5 mg/kg b.w I.M pethidine at end of surgery. Group 2 received ketoprofen 100 mg I.M at end of surgery. Group 3 received 0.4 ml/kg b.w interpleural bupivacaine 0.5%. Group 4 received a combination of I.M ketoprofen [100 mg] in addition to interpleural bupivacaine [0.4 ml/kg]. Postoperative pain was assessed using the 11 point numeric rating score [NRS] at 7 different intervals. First, immediately on admission to PACU, every 2 hours for the next 8 hours then at 12 and at 24 hours. Pain was assessed at rest, during deep inspiration and while coughing. ANOVA was used for statistical analysis and Chi-square test for comparing of the data where P values <0.05 were considered significant. The NRS at rest was 3.2 [1.9], 2.4 [1.6], 3 [1.9] and 0.7 [0.9] at Groups 1, 2, 3 and 4 respectively with significant difference in Group 4 versus other Group [P<0.05] at 2 hours postoperatively and up to 24 hours postoperatively. The same trend was also found during maximal inspiration and while coughing. Opioid consumption in 24 hours was significantly reduced in Group 4 compared to other Groups. Combination of IP bupivacaine and I.M ketoprofen provided superior analgesia when compared to each modality alone and was better than intramuscular pethidine injection in terms of NRS and the consumption of rescue morphine postoperatively. Further studies are needed on large sample size to confirm our results

Hemodynamic profile during laparoscopic cholecystectomy versus laparoscopic bariatric surgery: the impact of morbid obesity

The present study investigated the hemodynamic profile using impedance cardiography [ICG] monitor during pneumoperitoneum for laparoscopic cholecystectorny versus bariatric surgery in order to determine the impact of body weight on hemodynamics. 32 adult patients [two groups, each 16 patients] were studied. Group 1 [16 patients] scheduled to undergo laparoscopic cholecystectorny [lapchole] with body mass index [BMI] 28 +/- 5 kg/m[2]. Group 2[16 patients] scheduled to undergo laparoscopic adjustable b and [LAGB] surgery for treatment of morbid obesity with BMI 45.3 +/- 8 kg/m[2]. under general anesthesia. Besides routine monitoring, impedance cardiography was used for hemodynamic monitoring. Three stages were identified for statistical analysis A, pre-insufflation, B, during vere pneumoperitoneum and C, at gas deflation. The mean values of cardiac index in group 1 at stages A, B and C were, 3.0 +/- 1.7, 2.5 +/- 0.5 and 2.7 +/- 0.5 L/min/m[2] respectively with significant low values in stage B compared to stage A [p < 0.05]. The same trend continue in group 2 where the mean values were, 2.4 +/- 0.6, 1.8 +/- 0.6 and 2.3 +/- 0.9 L/min/m[2] respectively with significant differences compared to group 1 mean values [p < 0.05]. Other hemodynamic variables showed non-significant differences [p > 0.05]. Cardiac index showed significant decreasing trend in morbid obese patients compared to nonobese, which may reflect the effect of body weight on hemodynamics. On the other h and other hemodynamic parameters was not altered by body weight. We believe that hemodynamics should be closely monitored during laparoscopic surgery with pneumoperitoneum

Anesthesia for thoracoscopic thymectomy: modified non-muscle relaxant technique: case reports

Anesthesia for thymectomy in myasthenia gravis is challenging. The anesthetic experience of that technique is quite large. It involves either muscle relaxant or non-muscle relaxant techniques. However, the literature is deficient of st and ard anesthetic technique for thoracoscopic thymectomy. Therefore we present in this report a modified non-muscle relaxant technique for thoracoscopic thymectomy [TT]. We report two cases who underwent TT under general anesthesia using sufentanil and propofol for induction and local anesthesia spray to the vocal cords to facilitate endobronchial intubation using non-muscle relaxant technique. The intubating, operating and postoperative conditions were excellent. To the best of our knowledge, this is the first report on modified non-muscle relaxant technique for TT in myasthenia gravis. Further cases have to be done to verify our technique

Anesthetic implications for video assisted thoracoscopic thymectomy in myasthenia gravis

Thymectomy is an established therapy in the management of generalized myasthenia gravis [MG]. However, the optimal surgical approach to thymectomy has remained controversial. There are advocates for transternal, transcervical approaches for "maximal" thymectomy. Video-assisted thoracoscopic thymectomy [VATT] presents new approach to thymectomy. By minimizing chest wall trauma, VATT not only causes less postoperative pain, shortens hospital stay, gives better cosmetic results but also leads to wider acceptance by patients for earlier surgery. Anesthesia for thymectomy in MG is challenging. Currently we are using non-muscle relaxant technique [NMRT] which we adopted in 1994, for maximal thymectomy. In this paper, we present our limited experience with two cases of VATT using two different NMRTs. Two cases of MG underwent VATT under general anesthesia [GA] and one lung ventilation [OLV] using double lumen tube [DLT]. In both cases NMRT was used which encompass, light GA plus thoracic epidural analgesia [TEA] in one case and without TEA in the other case. We believe that the use of NMRT provides good operative and postoperative conditions. In this report we have described two different NMRTs, one with TEA and the other without. Further studies are needed on large number of cases to establish an anesthetic protocol for VATT

Perioperative bioelectrical impedence analysis in neurosurgery

The use of bioelectrical impedence [BI] measurement to assess body composition has recently attracted the attention of anesthesiologists. Analysis of BI provides a non-invasive method to quantify fluid distribution in different body compartments. This study was designed to assess whether BI analysis reflects fluid depletion in neurosurgical patients with moderate blood loss. Six adult male patients scheduled for elective craniotomy under general anesthesia were studied. Exclusion criteria included patients with cardio-respiratory disease. BI analysis was performed at three stages, A, day before operation, B, during surgery and c, on the first postoperative day. Total body resistivity was measured by BI analysis with a four-terminal portable impedence analyzer. At each frequency, impedence was calculated as resistance [Rx][2] + reactance [Rc][2]. The mean values of total body water [TBW] at stages A, B and C were 39.8 L [range: 33.1-46.7 L], 43.2 L [range: 33.1-66.2 L] and 36.8 L [range: 22.4-36.3 L] respectively with significant differences [P<0.05]. The impdence at the three frequencies during stages A, B and C showed significant differences [P<0.05]. In conclusion, we have found that in male neurosurgical patients multiple frequency BI measurements has reflected fluid balance perioperatively. Whether this observation remains true for other surgical procedures with massive blood loss, yet to be further investigated

Interpleural catheter analgesia for chronic pain treatment

In summary, we present a case in which long - lasting relief of upper abdominal cancer pain was achieved by injections of local anesthetic through the interpleural approach. This technique may be a good alternative to coeliac plexus block in selected cases. Furthermore, if pain relief in such a case proves to be only transient, injections of dilute phenol might provide permanent relief