ABSTRACT
Rebound pain after regional anesthesia can be defined as transient acute postoperative pain that ensues following resolution of sensory blockade, and is clinically significant, either with regard to the intensity of pain or the impact on psychological well-being, quality of recovery, and activities of daily living. Current evidence suggests that it represents an unmasking of the expected nociceptive response in the absence of adequate systemic analgesia, rather than an exaggerated hyperalgesic phenomenon induced by local anesthetic neural blockade. In the majority of patients, it does not appear to significantly impact cumulative postoperative opioid consumption, quality of recovery, or patient satisfaction, and is not associated with longer-term sequelae such as persistent post-surgical pain. Nevertheless, it must be considered whenever regional anesthesia is incorporated into perioperative management. Strategies to mitigate the impact of rebound pain include routine prescribing of a systemic multimodal analgesic regimen, as well as patient education on appropriate expectations regarding block offset and expected surgical pain, and timely initiation of analgesic medication. Prolonging the duration of action of regional anesthesia with continuous catheter techniques or local anesthetic adjuncts may also help alleviate rebound pain, although further research is required to confirm this.
ABSTRACT
BACKGROUND: Iliac crest bone graft (ICBG) harvesting is associated with significant perioperative pain and opioid consumption. This randomized controlled trial sought to determine if the transversalis fascia plane (TFP) block provides effective analgesia for anterior ICBG harvesting. METHODS: Fifty patients undergoing wrist fusion surgery with anterior ICBG harvesting were randomized to receive a TFP block with either 20 ml of 0.5% ropivacaine or 5% dextrose. Patients additionally received a brachial plexus block for primary surgical-site anesthesia and either a general or spinal anesthetic depending on patient preference. Primary outcomes of interest were perioperative opioid consumption (measured as intravenous morphine equivalents [IME]), pain intensity at the ICBG harvest site for up to 48 h postoperatively, and the incidence of persistent postoperative pain at 6 and 12 months after surgery. RESULTS: The TFP group used less opioid in the post-anesthetic care unit (PACU) (median 0 vs. 2.5 mg IME, P = 0.01) and in the first 8 h following PACU discharge (median 2.5 vs. 13.0 mg IME, P = 0.02). The patients who received a TFP block also had lower pain scores in PACU (median 0 vs. 4.0 out of 10, P < 0.001). Although opioid consumption and pain scores were lower in the TFP group at later timepoints, this difference was not statistically significant. Persistent pain at the ICBG site was reported in only 4.3% and 6.5% of all patients at 6 and 12 months, respectively. CONCLUSIONS: The TFP block provides effective early analgesia for anterior ICBG harvesting. The incidence of persistent postoperative pain was low.
Subject(s)
Humans , Analgesia , Anesthesia , Anesthesia, Local , Brachial Plexus Block , Fascia , Glucose , Incidence , Morphine , Nerve Block , Pain, Postoperative , Patient Preference , Transplants , WristABSTRACT
BACKGROUND@#Iliac crest bone graft (ICBG) harvesting is associated with significant perioperative pain and opioid consumption. This randomized controlled trial sought to determine if the transversalis fascia plane (TFP) block provides effective analgesia for anterior ICBG harvesting.@*METHODS@#Fifty patients undergoing wrist fusion surgery with anterior ICBG harvesting were randomized to receive a TFP block with either 20 ml of 0.5% ropivacaine or 5% dextrose. Patients additionally received a brachial plexus block for primary surgical-site anesthesia and either a general or spinal anesthetic depending on patient preference. Primary outcomes of interest were perioperative opioid consumption (measured as intravenous morphine equivalents [IME]), pain intensity at the ICBG harvest site for up to 48 h postoperatively, and the incidence of persistent postoperative pain at 6 and 12 months after surgery.@*RESULTS@#The TFP group used less opioid in the post-anesthetic care unit (PACU) (median 0 vs. 2.5 mg IME, P = 0.01) and in the first 8 h following PACU discharge (median 2.5 vs. 13.0 mg IME, P = 0.02). The patients who received a TFP block also had lower pain scores in PACU (median 0 vs. 4.0 out of 10, P < 0.001). Although opioid consumption and pain scores were lower in the TFP group at later timepoints, this difference was not statistically significant. Persistent pain at the ICBG site was reported in only 4.3% and 6.5% of all patients at 6 and 12 months, respectively.@*CONCLUSIONS@#The TFP block provides effective early analgesia for anterior ICBG harvesting. The incidence of persistent postoperative pain was low.
ABSTRACT
<p><b>INTRODUCTION</b>Despite well-established guidelines, multiple recent studies have demonstrated variability in the conduct of brain death certification. This is undesirable given the gravity of the diagnosis. We sought therefore to survey local clinicians involved in brain death certification to identify specific areas of variability, if any, and to elicit information on how the testing process can be improved.</p><p><b>MATERIALS AND METHODS</b>An anonymous questionnaire was sent to all clinicians on the brain death certification roster in a tertiary neurosciences referral centre. This survey covered clinician demographics, evaluation of current and proposed resources to assist clinicians in certification, knowledge of the legislation governing brain death and organ procurement, technical performance of the brain death tests, and their views on the appropriate limits of physiological and biochemical preconditions for brain death testing.</p><p><b>RESULTS</b>We found significant variability in the conduct of brain death testing, especially in performing the caloric and apnoea tests. Of the existing resources to assist clinicians, written aide-memoires were the most popular. Respondents felt that bedside availability of a more detailed written description of the brainstem tests, and a formal accreditation course would be useful. There was wide variation in the limits of serum sodium and glucose, and the minimum core temperature and systolic blood pressures that respondents felt would preclude testing but we were able to identify thresholds at which the majority would be happy to proceed. We addressed the issues identified in our study by improving our written hospital brain death protocol, and designing an instructional course for clinicians involved in brain death certification.</p><p><b>CONCLUSIONS</b>Our findings confirm that variability in the performance of brain death testing is indeed a universal phenomenon. Formal training appears desirable, but more importantly, clear and detailed protocols for testing should be made available at the bedside to assist clinicians. These protocols should be tailored to provide step-by-step instructions so as to avoid the inconsistencies in testing identified by this and other similar studies.</p>
Subject(s)
Humans , Apnea , Brain Death , Caloric Tests , Death Certificates , Health Care Surveys , Practice Guidelines as Topic , Singapore , Surveys and QuestionnairesABSTRACT
<p><b>INTRODUCTION</b>Awake craniotomy allows accurate localisation of the eloquent brain, which is crucial during brain tumour resection in order to minimise risk of neurologic injury. The role of the anaesthesiologist is to provide adequate analgesia and sedation while maintaining ventilation and haemodynamic stability in an awake patient who needs to be cooperative during neurological testing. We reviewed the anaesthetic management of patients undergoing an awake craniotomy procedure.</p><p><b>MATERIALS AND METHODS</b>The records of all the patients who had an awake craniotomy at our institution from July 2004 till June 2006 were reviewed. The anaesthesia techniques and management were examined. The perioperative complications and the outcome of the patients were noted.</p><p><b>RESULTS</b>There were 17 procedures carried out during the study period. Local anaesthesia with moderate to deep sedation was the technique used in all the patients. Respiratory complications occurred in 24% of the patients. Hypertension was observed in 24% of the patients. All the complications were transient and easily treated. During cortical stimulation, motor function was assessed in 16 patients (94%). Three patients (16%) had lesions in the temporal-parietal region and speech was assessed intraoperatively. Postoperative motor weakness was seen in 1 patient despite uneventful intraoperative testing. No patient required intensive care unit stay. The median length of stay in the high dependency unit was 1 day and the median length of hospital stay was 9 days. There was no in-hospital mortality.</p><p><b>CONCLUSION</b>Awake craniotomy for brain tumour excision can be successfully performed under good anaesthetic conditions with careful titration of sedation. Our series showed it to be a well-tolerated procedure with a low rate of complications. The benefits of maximal tumour excision can be achieved, leading to potentially better patient outcome.</p>