A comparison of continuous femoral nerve block combined with sciatic nerve block and epidural analgesia for postoperative pain management after total knee replacement

BACKGROUND: Epidural analgesia (EPA) has been used for postoperative pain control in total knee replacement (TKR). However, many patients have suffered various side effects after epidural blockade. Peripheral nerve block (PNB) has been shown to provide effective pain relief after TKR. We compared the benefits of continuous femoral nerve block (FNB) combined with single-injection sciatic nerve block (SNB) with those of EPA for postoperative pain management after TKR. METHODS: Eighty participants undergoing unilateral TKR were randomized to receive either EPA (EPA group) or continuous FNB combined with SNB (PNB group). All patients received general anesthesia for TKR. Ropivacaine 2 mg/ml plus fentanyl 2 µg/ml was administered for EPA. Ropivacaine 2 mg/ml was administered through the femoral nerve catheter. The pain score, side effects (dizziness, sedation, nausea, vomiting, pruritus, hypotension and urinary retention), motor blockade, knee range of motion, and rehabilitation were measured postoperatively. The primary outcome measure was the number of patients experiencing side effects. RESULTS: The incidence of patients with side effects was 86.8% in the EPA group but only 35.1% in the PNB group (P < 0.001). There were no significant differences between the two groups in terms of pain score, motor blockade of the operative limb, knee range of motion, or rehabilitation. CONCLUSIONS: Continuous FNB combined with SNB can be an effective alternative to EPA for postoperative pain management in TKR.

Double Lumen Endobronchial Tube Malposition Due to Enlargement of Paratracheal Lymph Node / 계명의대학술지

Double lumen endobronchial tube (DLT) is used for lung separation in the surgical patients undergoing thoracic and mediastinal surgery. The use of DLT can lead to potential problems such as tube malposition and airway trauma. DLT can be placed in the inappropriate position due to abnormal and distorted anatomy of trachea or bronchus. We report a case of right main bronchial insertion of left-sided DLT by enlargement of paratracheal lymph node not detected in preoperative evaluations for 10 days.

A comparison of ProSeal laryngeal mask airway, I-gel and endotracheal tube insertion by novices in a simulated difficult airway scenario

BACKGROUND: Insertion of supraglottic airway devices (SADs) can be technically easier to perform for novices than endotracheal intubation (ETI), particularly in a situation with difficult airway management. We evaluated the efficacy and usefulness of the ProSeal laryngeal mask airway (PLMA), I-gel, and ETI when used by novices in a simulated difficult airway scenario. METHODS: A total of 109 novices participated in a brief educational session about PLMA, I-gel and ETI. The sequence of the airway devices was randomized for each participant using a computer-generated random table, and the devices were inserted in a manikin with restricted cervical spine movement. A nasogastric (NG) tube was then inserted through each SAD. In the case of ETI, the NG tube was inserted through the manikin's nostril. RESULTS: The success rate at the first insertion attempt was 93.6% for the I-gel compared with 72.5% for the PLMA and 19.3% for ETI. The I-gel also enabled a significantly shorter insertion time than the PLMA (I-gel 26.3 ± 21.9 sec and PLMA 36.0 ± 35.4 sec). The novices showed high success rates for NG tube insertion using SADs (PLMA 96.3% and I-gel 98.1%) compared with ETI (24.8%). CONCLUSIONS: We found that the I-gel provided a better first time success rate and a shorter insertion time than PLMA and ETI, which indicated that the I-gel may be preferable for difficult airway management by novices.

Attenuation of pneumoperitoneum-induced hypertension by intra-peritoneal lidocaine before pneumoperitoneum in laparoscopic cholecystectomy / 영남의대학술지

BACKGROUND: We have previously found that intra-peritoneal lidocaine instillation before pneumoperitoneum attenuates pneumoperitoneum-induced hypertension. Whether this procedure alters patient's hemodynamic status during operation should be determined for clinical application. This study elucidated the possible mechanism of the attenuation of the pneumoperitoneum-induced hypertension by intra-peritoneal lidocaine before pneumoperitoneum. METHODS: Thirty-four patients underwent laparoscopic cholecystectomy (LC) were randomly allocated into two groups. After induction of general anesthesia, 200 mL of 0.2% lidocaine (lidocaine group, n=17), or normal saline (control group, n=17) were sub-diaphragmatically instilled 10 minutes before pneumoperitoneum. The changes in systolic blood pressure, heart rate, central venous pressure, stroke volume, cardiac output, and systemic vascular resistance were compared between the groups. The number of analgesics used during post-operative 24 h was compared. RESULTS: Systolic blood pressure was elevated during pneumoperitoneum in both groups (p<0.01), but the degree of elevation was significantly reduced in the lidocaine group than in the control (p<0.01). However, stroke volume and cardiac output were decreased and systemic vascular resistance was increased after induction of pneumoperitoneum (p<0.05) without statistical difference between two groups. The number of analgesics used was significantly reduced in the lidocaine group (p<0.01). CONCLUSION: These data suggest that intra-peritoneal lidocaine before pneumoperitoneum does not alter patient's hemodynamics, and attenuation of pneumoperitoneum-induced hypertension may be the consequence of reduced intra-abdominal pain rather than the decrease of cardiac output during pneumoperitoneum. Therefore, intra-peritoneal lidocaine instillation before pneumoperitoneum is a useful method to manage an intraoperative pneumoperitoneum-induced hypertension and to control postoperative pain without severe detrimental hemodynamic effects.