Continuous bilateral subomohyoid suprascapular nerve blocks for postoperative analgesia for bilateral rotator cuff repair: a case report.

PURPOSE: Blocking the suprascapular nerve under the inferior belly of the omohyoid muscle is a novel regional anesthesia technique that has been proposed for shoulder analgesia. We describe the use of and our experience with bilateral indwelling suprascapular catheters for pain management via continuous infusions in a patient undergoing bilateral shoulder surgery. CLINICAL FEATURES: Bilateral subomohyoid suprascapular catheters were inserted prior to surgery for postoperative analgesia in a patient undergoing bilateral rotator cuff tear repair. The catheters were placed 0.5-1 cm beyond the needle tip, and low local anesthetic infusion rates (ropivacaine 0.2% at 5 mL·hr-1 on each side) were used. CONCLUSIONS: Judicious use of preoperatively placed bilateral suprascapular catheters added to a comprehensive multimodal analgesic regimen provided excellent analgesia without respiratory compromise throughout the perioperative course.

RéSUMé: OBJECTIF: Une nouvelle technique d'anesthésie régionale proposée pour l'analgésie de l'épaule consiste à bloquer le nerf suprascapulaire sous la partie inférieure du muscle omohyoïdien. Nous décrivons l'utilisation et notre expérience avec des cathéters suprascapulaires bilatéraux pour la prise en charge de la douleur par l'intermédiaire de perfusions continues chez un patient subissant une chirurgie bilatérale des épaules. ÉLéMENTS CLINIQUES: Des cathéters suprascapulaires sous-omohyoïdiens bilatéraux ont été insérés avant la chirurgie pour l'analgésie postopératoire d'un patient subissant une réparation bilatérale de rupture de la coiffe des rotateurs. Les cathéters ont été positionnés 0,5-1 cm au-delà de l'extrémité de l'aiguille, et de faibles quantités d'anesthésique local (ropivacaine 0,2 % à 5 mL·h−1 de chaque côté) ont été utilisées. CONCLUSION: L'utilisation judicieuse de cathéters suprascapulaires bilatéraux installés en période préopératoire, ajoutée à un régime analgésique multimodal exhaustif, a procuré une excellente analgésie sans atteinte respiratoire tout au long de la période périopératoire.

The Effects of Intraoperative Sedation on Surgical Outcomes of Deep Brain Stimulation Surgery.

BACKGROUND: Intraoperative sedation is often used to facilitate deep brain stimulation (DBS) surgery; however, these sedative agents also suppress microelectrode recordings (MER). To date, there have been no studies that have examined the effects of differing sedatives on surgical outcomes and the success of DBS surgery. METHODS: We performed a retrospective study to evaluate the effect of differing sedative agents on postoperative surgical outcomes at 6 months in parkinsonian adult patients who underwent DBS surgery, from January 2004 through December 2014, at one academic center. Surgical outcomes of DBS were evaluated using a simplified Unified Parkinson Diseases Rating Score-III and levodopa dose equivalent reduction at baseline and 6 months postoperatively. RESULTS: We analyzed data from 121 of 124 consecutive parkinsonian patients. Propofol, dexmedetomidine, remifentanil, and midazolam were used individually or in combination. All sedatives were routinely discontinued 20 to 30 minutes before MER, in accordance with our institutional protocol. We found no statistically significant association between the use of individual agent or combination of sedative agents and surgical outcomes at 6 months, the success of DBS, duration of MER, duration of stage 1 procedure, and perioperative complications. CONCLUSIONS: Our study showed that the choice of sedative agent was not associated with poor surgical outcomes after DBS surgery using MER and macrostimulation techniques in parkinsonian patients.

An update on the prone position: Continuing Professional Development.

PURPOSE: The purpose of this Continuing Professional Development module is to provide information needed to prepare for and clinically manage a patient in the prone position. PRINCIPAL FINDINGS: Prone positioning is required for surgical procedures that involve the posterior aspect of a patient. We searched MEDLINE(®) and EMBASE™ from January 2000 to January 2015 for literature related to the prone position and retrieved only original articles in English. We reviewed the advantages and disadvantages of various equipment used in prone positioning, the physiological changes associated with prone positioning, and the complications that can occur. We also reviewed strategies for the safe conduct and management of position-related complications. CONCLUSION: Increased age, elevated body mass index, the presence of comorbidities, and long duration of surgery appear to be the most important risk factors for complications associated with prone positioning. We recommend a structured team approach and careful selection of equipment tailored to the patient and surgery. The systematic use of checklists is recommended to guide operating room teams and to reduce prone position-related complications. Anesthesiologists should be prepared to manage major intraoperative emergencies (e.g., accidental extubation) and anticipate postoperative complications (e.g., airway edema and visual loss).

Anaesthesia for endoscopic neurosurgical procedures.

PURPOSE OF REVIEW: Endoscopic neurosurgical procedures are becoming more frequent and popular in the treatment of intracranial disease. When endoscopy involves the intraventricular structures, irrigating solutions are required and may contribute to sudden and sharp increases in intracranial pressure. More recently, nasal endoscopic approach has been used to perform skull base surgery for aneurysms and tumours. We have analysed published articles in order to detect anaesthesia management and perioperative complications. RECENT FINDINGS: Sudden and dangerously low decreases in cerebral perfusion pressures do not provoke the 'traditional Cushing's response' usually associated with significantly high intracranial pressure. It is important to note that tachycardia (not bradycardia) and/or hypertension are the most frequent haemodynamic complications during neuroendoscopic procedures. With the transnasal approach severe intraoperative haemorrhage is the most important complication to consider followed by direct injury to surrounding neural structures. SUMMARY: Invasive arterial blood pressure and intracranial pressure should be measured continuously during neuroendoscopies to detect early intraoperative cerebral ischaemia instead of waiting for the appearance of bradycardia which may be a late sign. General anaesthesia remains the technique of choice. Intracranial haemorrhage increases the likelihood of perioperative complications. Close postoperative monitoring is required to diagnose and treat complications such as convulsions, persistent hydrocephalus, haemorrhage or electrolytic imbalance.

Endoscopic and stereotactic neurosurgery.

PURPOSE OF REVIEW: Review of the anesthetic considerations for neuroendoscopy and stereotactic procedures. RECENT FINDINGS: Minimally invasive procedures are increasingly applied in novel ways in the diagnosis and treatment of neurological pathologies. Endoscopic third ventriculostomy, endoscopic shunt revisions and drainage of intraventricular hematoma using a neuroendoscope have become routine neurosurgical procedures. Stereotaxis has expanded its scope from simple brain biopsy to functional neurosurgery and psychiatry. While these procedures are 'minimally invasive', perioperative critical events may still occur. SUMMARY: Vigilance in preoperative assessment and intraoperative monitoring is essential in minimizing perioperative morbidity and mortality in patients undergoing neuroendoscopic and stereotactic procedures.

Anaesthesia for minimally invasive neurosurgery.

Technological advances in imaging, computing and surgical instrumentation have encouraged the application of minimally invasive surgical techniques to various neurosurgical disorders. This chapter discusses the wide application of neurosurgery and the implications for anaesthesia, focusing on the specific anaesthetic considerations for neuroendoscopy, stereotactic procedures and radiosurgery.