Comfort and satisfaction during axillary brachial plexus block in trauma patients: comparison of techniques.

STUDY OBJECTIVE: To investigate the comfort and satisfaction of patients with trauma of the upper limb during two different techniques of axillary brachial plexus block, electrical nerve stimulation and fascial pop. DESIGN: Randomized-prospective, observational study. SETTING: University surgical center. PATIENTS: 100 ASA physical status I and II patients undergoing surgery for trauma of the hand and forearm. INTERVENTIONS: Patients received axillary brachial plexus block with a mixture of 0.5% bupivacaine and 2% lidocaine. They were then allocated to one of two groups to receive either electrical nerve stimulation (Group 1, n = 50), or fascial pop technique (Group 2, n = 50) for nerve location. MEASUREMENTS: Data were collected on patient demographics, surgery, frequency of complications, and sedation required during the block. Discomfort during the block and surgical comfort were quantified by visual analog scale (0-10). Satisfaction was determined by the following scale: very satisfied, satisfied, dissatisfied, and very dissatisfied. Patients also indicated if in the future they would like to receive the same method of anesthesia. MAIN RESULTS: No differences in demographic or surgical data were found. No serious complications were observed. Eighteen Group 1 patients (36%) and none in Group 2 needed sedation during the blocks. Discomfort during the procedures was greater in Group 1 than Group 2 (4.5 +/- 1.2 vs 1.5 +/- 1, P < 0.05), while patients reported good surgical comfort with both techniques (2.4 +/- 2.9 vs 2.2 +/- 2.1, NS). Eighteen patients in Group 1 and 48 patients in Group 2 would accept the same block for future surgery. CONCLUSIONS: In trauma patients, the fascial pop technique is effective, reduces sedation during axillary brachial plexus block, and has a higher patient acceptance rate than the electrical nerve stimulation technique.

Development of human striatal anlagen after transplantation in a patient with Huntington's disease.

Replacement of damaged neuronal population by fetal tissue transplantation represents a potential treatment for neurodegenerative diseases. Consistent success has been achieved with fetal striatal transplantation in Huntington's disease animal models and patients. We report the neo-generation of metabolically active tissue with striatum-like imaging features after transplantation of striatal primordia in a patient with Huntington's disease. This study represents the first "in vivo" demonstration that a human striatal anlagen, transplanted into the adult human brain, is able to progress in its development and to generate a new anatomical structure in the host, without evidence of neoplasia or teratoma.

A new technique for regional anesthesia for arthroscopic shoulder surgery based on a suprascapular nerve block and an axillary nerve block: an evaluation of the first results.

PURPOSE: We propose a new technique of regional anesthesia that combines suprascapular nerve block (SSNB) and axillary nerve block (ANB) in arthroscopic shoulder surgery. METHODS: Twenty consecutive patients undergoing arthroscopic procedures for shoulder cuff diseases were included in the trial. SSNB was performed by introducing the stimulating needle approximately 2 cm medial to the medial border of the acromion and about 2 cm cranial to the superior margin of the scapular spine until supraspinatus or infraspinatus muscle contractions were elicited. Following negative aspiration, 15 mL of a mixture of 2% lidocaine (5 mL) and 0.5% levobupivacaine (10 mL) was injected. ANB was performed; a line was drawn between the lateral-posterior angle of the acromion and the olecranon tip of the elbow. The location was about 2 cm cranial to the convergence of this line with the perpendicular line from the axillary fold. The needle was introduced approximately 2 cm cranial to this crossing point to elicit deltoid muscle contractions, and another 15 mL of the same anesthetic mixture was injected. Five mL of the same mixture was injected into each portal of the arthroscopic area. During surgery, patients were sedated with the use of midazolam. General anesthesia was not performed. Acceptance of the technique was assessed through a postsurgical survey of those treated. RESULTS: No serious complications occurred. None of the patients required opiates, analgesics, or general anesthesia during the surgical procedure. Postoperative pain control, which was assessed using a visual analog scale, was effective during the observation time. The total demand for nonopiate analgesics during the first 24 postoperative hours was negligible. Patient satisfaction and comfort were satisfactory. CONCLUSIONS: Combining SSNB and ANB is an effective and safe technique for intraoperative anesthesia and postoperative analgesia for certain procedures of shoulder arthroscopic surgery.

Inhaled nitric oxide combined with prostacyclin and adrenomedullin in acute respiratory failure with pulmonary hypertension in piglets.

Our aim was to evaluate if the combined inhalation of both nitric oxide (iNO) and aerosolized prostacyclin or iNO and adrenomedullin (ADM) is more effective in lowering pulmonary arterial pressure (PAP) and improving oxygenation than nitric oxide alone in an animal model with pulmonary hypertension (PH). Moreover, we studied the effect on pulmonary mechanics, surfactant activity, and pulmonary oxidative stress of the different treatments. Twenty-eight piglets with acute lung injury induced by lung lavages with saline were randomized to receive nitric oxide, nitric oxide plus prostacyclin, nitric oxide plus ADM or saline, after. Dynamic compliance, tidal volume, and airway resistance were measured. Lung tissue oxidation was evaluated by measuring total hydroperoxide and advanced oxidation protein products in bronchial aspirate samples. Surface surfactant activity was studied using Capillary Surfactometer. Inhaled nitric oxide combined with prostacyclin or ADM was more effective than nitric oxide alone in lowering PAP and improving oxygenation. Nitric oxide alone or combined increased lung compliance and tidal volume, and decreased airway resistance. No effects on surfactant surface activity and lung tissue oxidation were observed. The treatment with nitric oxide alone or combined with prostacyclin or ADM were effective in decreasing mean PAP and improving oxygenation in a piglet model of PH. However, nitric oxide plus prostacyclin and nitric oxide plus ADM were more effective than nitric oxide alone. The combination of aerosolized prostacyclin and ADM with nitric oxide might have a role in the treatment of infants with PH refractory to nitric oxide alone.

Factors predictive of patient satisfaction with anesthesia.

BACKGROUND: In this multicenter prospective study, we identified factors associated with satisfaction with anesthesia in patients staying in hospital at least 24 h after surgery. METHODS: The study was performed in six centers. Inpatients aged more than 18 yr, who underwent a wide range of common surgical procedures, were asked to answer a 10-item instrument to measure patient satisfaction with anesthesia (mean score range, 0-10) and some specific questions, and to rate their perceived health (score, 0-10). Anesthesia staff members were invited to self-compile a Maslach Burnout Inventory. RESULTS: The satisfaction evaluation questionnaire was returned by 1290 patients (mean age, 61 +/- 16 yr; males, 54.4%). The mean global satisfaction score was 8.7 (95% CI: 8.7-8.8), being <9 in 632 (49%) and > or =9 in 658 (51%) patients. The Maslach Burnout Inventory was returned by 55 anesthesiologists and 68 nurses. Multivariate regression identified five variables as significant predictors of a mean global satisfaction of >/=9: 1) having been treated in a service with perioperative nurses specifically dedicated only to anesthesia; 2) having been treated where anesthesia information leaflets were provided preoperatively; 3) having received more than two anesthesiologist visits after surgery; 4) having a perceived health score >8.5; and 5) being older that 70 yr. No relationship was found between staff burnout and patient satisfaction. CONCLUSIONS: Inpatient satisfaction can be improved by an organization in which surgical suite nurses are dedicated only to anesthesia, a written anesthesia information leaflet is given during the preoperative visit and postoperative visits are enhanced.

A comparison of proximal and distal radial nerve motor responses in axillary block using triple stimulation.

BACKGROUND AND OBJECTIVES: Stimulation of the radial nerve at the axilla may cause either a proximal movement (forearm extension) or distal movements (supination, wrist or finger extension). In the most recent studies on axillary block, only a distal twitch was accepted as valid. However, this approach was based only on clinical experience. The aim of this study was to verify if a proximal motor response can be considered a satisfactory endpoint. METHODS: This was a prospective, randomized, double-blinded study. One hundred fifty patients received a triple-injection axillary brachial plexus block in which the radial nerve was located by a proximal (group PROX) or a distal motor response (group DIST). Patients were assessed for sensory and motor block of the branches of the radial nerve by a blinded investigator at 5-minute intervals over 30 minutes. RESULTS: An 81% success rate for anesthetizing the sensory distal branches of the radial nerve was seen in group PROX; a significantly higher success rate was recorded in group DIST (95%). The onset time of sensory block for the distal branches of the radial nerve was significantly shorter in group DIST (9.9 +/- 6 v 15.4 +/- 7 minutes). The time to perform the block was slightly shorter and the localization of the nerve simpler in group PROX. The overall block success rate was not significantly different in the 2 groups. CONCLUSIONS: Local anesthetic injection at the proximal radial twitch significantly reduces the efficacy and prolongs the onset time of the radial nerve block. Searching for distal response is significantly more difficult and time consuming than searching for proximal response. However, it does not significantly increase patient discomfort or adverse effects.

Respiratory function after aortic aneurysm repair: a comparison between retroperitoneal and transperitoneal approaches.

OBJECTIVE: Elective abdominal aneurysm repair can be performed by using the transperitoneal or the retroperitoneal approach. The latter has been described as having a better outcome, reducing the impairment of respiratory function or the incidence of lung complications. Hence, the retroperitoneal approach has been proposed for treatment of medically high-risk patients. However, the superiority of one technique or the other in preserving pulmonary function has not been conclusively demonstrated. The aim of this study was to ascertain whether the retroperitoneal and the transperitoneal approaches affect respiratory function differently. DESIGN: A prospective randomized study. SETTING: Two four-bed surgical-medical ICUs of a University hospital. PATIENTS: Twenty-three consecutive patients undergoing abdominal aortic aneurysm repair were randomized to the retroperitoneal (12 patients) and transperitoneal approach (11 patients). They were studied: a). within 30 min the end of surgery; b). 8 h after the end of surgery; and c). during a T-piece tube-weaning trial. MEASUREMENTS: The comparison between the two groups was based on respiratory mechanics, partitioned between lung and chest wall components, basic spirometry, tension-time index of the inspiratory muscle, weaning indexes, and length of stay both in ICU and hospital. RESULTS: The two surgical techniques do not differ in their impact on either respiratory mechanics or inspiratory muscle function or weaning indexes. However, there was a tendency for retroperitoneal patients to stay for less time both in ICU and in the hospital. CONCLUSIONS: During the first 24 h after surgery, the postoperative impairment of respiratory function is independent of the surgical approach.