Intrathecal opioid versus ultrasound guided fascia iliaca plane block for analgesia after primary hip arthroplasty: study protocol for a randomised, blinded, noninferiority controlled trial.

BACKGROUND: Hip replacement surgery is increasingly common due to an ageing population, and rising levels of obesity. The provision of excellent pain relief with minimal side effects is important in order to facilitate patient mobilisation and rehabilitation.Spinal opioids provide excellent analgesia but are associated with adverse effects. The fascia-iliaca block is an alternative technique which provides analgesia to the nerves innervating the hip. The success of fascia iliaca blocks has been demonstrated to be superior when using ultrasound compared to landmark techniques. However, the clinical benefit of this improvement has yet to be investigated.The aim of this study is to compare the efficacy and safety of ultrasound guided fascia iliaca block with spinal morphine for hip replacement surgery. METHODS/DESIGN: This study is a randomised, blinded, placebo-controlled, noninferiority trial. Patients scheduled to undergo unilateral primary hip arthroplasty will receive a study information sheet and consent will be obtained in keeping with the Declaration of Helsinki. Patients will be randomised to receive either; (i) Ultrasound guided fascia iliaca block using levobupivacaine, plus spinal anaesthesia with hyperbaric bupivacaine containing no morphine, or (ii) sham ultrasound guided fascia iliaca block performed with sterile saline, and spinal anaesthesia containing hyperbaric bupivacaine and 0.1 mg of spinal morphine.A total of 108 patients will be recruited. Primary outcome is post-operative morphine consumption in a 24 hour period. Secondary outcomes include; pain scores at 3, 6, 12, 24, 36 and 48 hours, episodes of respiratory depression, hypotension, nausea and vomiting, pruritus, sedation, time to first mobilisation and patient satisfaction. CONCLUSIONS: There are no studies to date comparing ultrasound guided fascia iliaca block with spinal morphine for pain control after hip arthroplasty. If the ultrasound guided fascia iliaca block provides pain relief which is not inferior to spinal morphine, then morphine could be removed from the spinal injection. This could reduce side effects and improve patient safety. TRIAL REGISTRATION: This study has been approved by the West of Scotland Research Ethics Committee 4 (reference no. 10/S0704/43) and is registered with ClinicalTrials.gov (reference no. NCT01217294).

Sedation for oocyte retrieval using target controlled infusion of propofol and incremental alfentanil delivered by non-anaesthetists.

Oocyte retrieval is a procedure where sedation is recommended. This paper presents the process of setting up a new, non-anaesthetist delivered service in our institution, the development of safety systems and the audit data we have used to assure quality, effectiveness and safety. Logbook data were collected for 4342 cases, with detailed audit data collected for 260 cases. Safety is acceptable with a respiratory adverse incident rate of 0.5/1000 (95% CI 0.1-1.6/1000 cases). Unplanned, direct anaesthetic assistance was required in 3.5/1000 cases (95% CI 1.7-5.3/1000 cases). Anaesthetic advice was required in 7.5% cases (95% CI 4.2-10.7%) at the inception of the service, but rarely once established: 0.6% (95% CI 0.2-1.0%). Nearly all patients (99%) would have the same sedation method again, no patients required admission, and patients' co-operation was judged by the operating surgeon as very good or good in 91% of cases.

Normobaric hyperoxia reduces cardiac index in patients after coronary artery bypass surgery.

OBJECTIVE: The purpose of this study was to assess the hemodynamic changes in response to normobaric hyperoxia in patients immediately after coronary artery bypass surgery. DESIGN: Observational study. SETTING: Single-center university hospital. PARTICIPANTS: Patients immediately after coronary artery bypass surgery. INTERVENTION: Change of fractional inspired oxygen concentration from baseline (< or =0.60) to 1.0 and return to baseline. MEASUREMENTS AND MAIN RESULTS: Cardiovascular changes were assessed with a lithium dilution technique. Cardiac index decreased from 2.82 to 2.52 L/min/m2 (10.6%). Heart rate decreased from 85.9 to 82.5 beats/min (4.0%), and the systemic vascular resistance index increased from 1,858 to 2,304 dyne/s/cm5/m2 (24.1%). Stroke index or mean arterial pressure did not change significantly. On reducing the FIO2 from 1.0 to the baseline FIO2 , there was significant reversal of the previous changes in heart rate and systemic vascular resistance. Heart rate increased from 82.5 to 84.0 beats/min (1.8%), and the systemic vascular index decreased from 2304 to 1932 dyne/s/cm5/m2 (16.1%). The cardiac output did not return to baseline, and the mean arterial pressure decreased from 69.6 to 64.4 mmHg (7.6%). CONCLUSIONS: Exposing patients after coronary artery surgery to hyperoxia induces significant hemodynamic changes.

QTc dispersion is prolonged in patients with early postoperative adverse cardiovascular events and those with silent myocardial ischemia.

OBJECTIVE: To determine if increased QT interval dispersion (corrected and not corrected for heart rate) is associated with perioperative silent myocardial ischemia or postoperative adverse cardiovascular events. DESIGN: Blinded retrospective observational study. SETTING: University hospital. PARTICIPANTS: One hundred eighty-one perioperative patients receiving general anesthesia for elective major vascular or orthopedic surgery. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: QT dispersion, corrected and uncorrected for heart rate, was prolonged in patients suffering significant myocardial ischemia up to 48 hours assessed by Holter ECG monitoring, for early cardiac morbidity and all early cardiac events (including mortality) up to 1 month postoperatively. There were no significant changes in patients showing early cardiovascular mortality or late cardiac morbidity or mortality between 1 and 12 months postoperatively. Morbidity and mortality were determined from clinical notes, laboratory investigations, and autopsy when available. QT dispersion performed poorly as a screening test to identify those who subsequently developed early adverse cardiovascular outcomes. CONCLUSIONS: QT dispersion is prolonged in those at risk of early adverse cardiovascular events but is a poor screening tool.

Reversible coma in children after improper baclofen pump insertion.

We report the occurrence of delayed postoperative coma in five of nine consecutive children following surgery for insertion of baclofen infusion pumps. We suspect that improper technique resulted in an inadvertent administration of an intrathecal baclofen bolus. We suggest ways to minimize this risk.