Combined Intermediate Cervical Plexus and Costoclavicular Block for Arthroscopic Shoulder Surgery: A Prospective Feasibility Study.

A combined cervical plexus and costoclavicular block provides effective shoulder analgesia without the risk of hemidiaphragmatic paralysis. However, whether this technique can also provide effective anesthesia for shoulder surgery remains unknown. Therefore, this study aimed to assess the feasibility and adverse effects of combined blocks in arthroscopic shoulder surgery. Fifty patients scheduled for arthroscopic shoulder surgery were prospectively enrolled. Intermediate cervical plexus (5 mL of 0.5% ropivacaine) and costoclavicular (20 mL of 0.5% ropivacaine) blocks were administered under ultrasound guidance. The block procedure time, needle pass, patient discomfort, anesthesia quality, onset time, postoperative analgesia quality, adverse events, and patient satisfaction were assessed. Surgical and block success were achieved in 45 (90%; 95% confidence interval [CI], 78-97%) and 44 (88%; 95% CI, 76-95%) patients, respectively. Three patients required local anesthetic supplementation, and two required general anesthesia. The incidence of hemidiaphragmatic paralysis was 12.0% (95% CI, 4.5-24.3%). Postoperative pain control was effective for the first 24 h postoperative. Neurological deficits were not observed. The patients reported a high level of satisfaction. This study revealed that a combined cervical plexus and costoclavicular block provided effective surgical anesthesia for arthroscopic shoulder surgery with a 12% incidence of hemidiaphragmatic paralysis. Further randomized studies comparing this technique with interscalene block are required.

Comparison of the Effects of Lumbar Spine Flexion on the Acoustic Windows Between Young and Elderly Patients.

BACKGROUND: The effects of lumbar flexion on posterior longitudinal ligament (PLL) length as an acoustic window for neuraxial block in older patients have not been fully elucidated. OBJECTIVE: This study aimed to compare changes in PLL length during lumbar spine flexion in young and old patients. STUDY DESIGN: Observational cohort study. SETTING: Tertiary University Hospital. METHODS: Forty young and older adult patients were placed in the lateral decubitus position. To flex the lumbar spine, patients were asked to flex their hips and knees and then their neck and shoulder toward their knees as much as they could (fetal position). An assistant pushed the patients' abdomen to the back and held their neck and legs to help them maintain position. To obtain an optimal ultrasound view, lumbar spinal ultrasonography was performed from L5/S1 to L2/L3 using a paramedian oblique sagittal plane. PLL lengths were measured on the ultrasound image before fetal position, after unassisted fetal position, and after assisted fetal position. RESULTS: PLL lengths increased after lumbar spine flexion in both young and older adult  patients, except at the L3-L4 level in old patients. The change in PLL length during lumbar spine flexion was significantly lower in old patients than in young patients at the L5-S1 and L3-L4 levels (P = 0.0028 and P = 0.0134, respectively). After lumbar spine flexion, the PLL length was significantly different between the spinal levels in older patients (P = 0.0392). LIMITATIONS: First, we measured the PLL length as an acoustic window for neuraxial block using lumbar spinal ultrasonography. Second, the researcher who obtained the spinal ultrasound view was not blinded to the patient's group and position. However, the researcher who measured the PLL lengths on ultrasonography was blinded. Third, all participants had no history of surgery, trauma, or congenital abnormalities of the spine, regardless of age. CONCLUSION: Lumbar spine flexion can increase PLL length in young and old patients. However, lumbar spine flexion is less effective in increasing the PLL length in old patients than in young patients.

Effects of Local Anesthetic Volume (Standard Versus Low) on Incidence of Hemidiaphragmatic Paralysis and Analgesic Quality for Ultrasound-Guided Superior Trunk Block After Arthroscopic Shoulder Surgery.

BACKGROUND: Relative to interscalene block, superior trunk block (STB) provides comparable analgesia and a reduced risk of hemidiaphragmatic paralysis. However, the incidence of hemidiaphragmatic paralysis remains high when a standard volume (15 mL) of local anesthetic is used. This study aimed to evaluate the effects of local anesthetic volume of STB on the incidence of phrenic nerve palsy, as well as its analgesic efficacy following arthroscopic shoulder surgery. METHODS: Patients scheduled for elective arthroscopic shoulder surgery were randomized to receive ultrasound-guided STB using either 5- or 15-mL 0.5% ropivacaine before general anesthesia. The primary outcome was the incidence of hemidiaphragmatic paralysis at 30 minutes after block. The secondary outcomes were pulmonary function, grade of sensory and motor blockade, pain score, opioid consumption, adverse effects, and satisfaction. RESULTS: Relative to standard-volume STB, low-volume STB was associated with a lower incidence of hemidiaphragmatic paralysis after block (14.3 [4.8%-30.3%] vs 65.7 [46.8%-80.9%]; difference 51.4% [95% confidence intervals {CIs}, 29.0%-67.1%]; P < .0001) and at the postanesthesia care unit (9.4% vs 50.0%; difference 40.6 [95% CI, 18.9%-57.7%]; P = .0004). Pulmonary function was also better preserved in the low-volume group than in the standard-volume group. The extent of the sensory and motor blocks was significantly different between the groups. Pain-related outcomes, satisfaction, and any adverse events were not significantly different between the groups. CONCLUSIONS: Low-volume STB provided a lower incidence of hemidiaphragmatic paralysis with no significant difference in analgesic efficacy relative to standard-volume STB for arthroscopic shoulder surgery.

Endotracheal intubation using i-gel® and lightwand in a patient with difficult airway: a case report.

This case report involves tracheal intubation using i-gel® in combination with a lightwand in a patient with a difficult airway, classified as Cormack-Lehane grade 3. I-gel® was used during anesthesia induction to properly maintain ventilation. The authors have previously reported successful tracheal intubation on a patient with a difficult airway through the use of i-gel® and a fiberoptic bronchoscope. However, if the use of a fiberoptic bronchoscope is not immediately available in a patient with a difficult airway, tracheal intubation may be performed by using i-gel® and a lightwand in a patient with difficult airway, allowing the safe induction of anesthesia.

Comparison of dexmedetomidine and epinephrine as an adjuvant to 1% mepivacaine in brachial plexus block.

BACKGROUND: Dexmedetomidine extends the duration of nerve block when administered perineurally together with local anesthetics by central and/or peripheral action. In this study, we compared the duration of nerve block between dexmedetomidine and epinephrine as an adjuvant to 1% mepivacaine in infraclavicular brachial plexus block. METHODS: Thirty patients, scheduled for upper limb surgery were assigned randomly to 3 groups of 10 patients each. We performed brachial plexus block using a nerve stimulator. In the control group (group C), patients received 40 ml of 1% mepivacaine. In group E, patients received 40 ml of 1% mepivacaine containing 200 µg of epinephrine as an adjuvant. In group D, patients received 40 ml of 1% mepivacaine containing 1 µg/kg of dexmedetomidine as an adjuvant. Sensory block duration, motor block duration, time to sense pain, and onset time were assessed. We also monitored blood pressure, heart rate, oxygen saturation and bispectral index. RESULTS: In group D and group E, sensory block duration, motor block duration and time to sense first pain were prolonged significantly compared to group C. However, there was no significant difference between group D and group E. CONCLUSIONS: Perineural 1 µg/kg of dexmedetomidine similarly prolonged nerve block duration compared to 200 µg of epinephrine, but slowed heart rate. Thus, dexmedetomidine is expected to be a good alternative as an adjuvant to local anesthesia in patients who are cautioned against epinephrine.

The optimal effect-site concentration of remifentanil for lightwand tracheal intubation during propofol induction without muscle relaxation.

STUDY OBJECTIVE: To determine the most suitable effect-site concentration of remifentanil during lightwand intubation when administered with a target-controlled infusion (TCI) of propofol at 4.0 µg/mL without neuromuscular blockade. DESIGN: Prospective study using a modified Dixon's up-and-down method. SETTING: Operating room of an academic hospital. PATIENTS: 28 ASA physical status 1 and 2 patients, aged 18-65 years, scheduled for minor elective surgery. INTERVENTIONS: Anesthesia was induced by TCI propofol effect-site concentration to 4.0 µg/mL, and the dose of remifentanil given to each patient was determined by the response of the previously tested patient using 0.2 ng/mL as a step size. The first patient was tested at a target effect-site concentration of 4.0 ng/mL of remifentanil. If intubation was successful, the remifentanil dose was decreased by 0.2 ng/mL; if it failed, the remifentanil dose was increased by 0.2 ng/mL. Successful intubation was defined as excellent or good intubating conditions. MEASUREMENTS AND MAIN RESULTS: The remifentanil effect-site concentration was measured. The optimal effect-site concentration of remifentanil for lightwand tracheal intubation during propofol induction using 2% propofol target effect-site concentration to 4 µg/mL was 2.16 ± 0.19 ng/mL. From probit analysis, the effect-site concentration of remifentanil required for successful lightwand intubation in 50% (EC50) and 95% (EC95) of adults was 2.11 ng/mL (95% CI 1.16-2.37 ng/mL) and 2.44 ng/mL (95% CI 2.20-3.79 ng/mL), respectively. CONCLUSION: A remifentanil effect-site concentration of 2.16 ± 0.19 ng/mL given before a propofol effect-site concentration of 4 µg/mL allowed lightwand intubation without muscle relaxant.

Persistent detrusor overactivity in rats after relief of partial urethral obstruction.

Detrusor overactivity (DO) persists after prostatectomy in 20% to 25% of patients with benign disease. Assuming that nonvoiding contractions (NVCs) can be used as a surrogate for DO in humans, the rat model of obstruction/deobstruction may allow us to study the pathophysiology of persistent DO after deobstruction. We investigated bladder function, with a special focus on NVCs, in rats by use of a new, modified method of obstruction and deobstruction and compared these results with those obtained by use of the conventional method. Seventy female Sprague-Dawley rats underwent 1) sham operation (n = 10), 2) obstruction by a modified method (Modif-Obs; n = 12), 3) obstruction/deobstruction by the conventional method (Conv-Obs/Deobs; n = 13), or 4) obstruction/deobstruction by the modified method (Modif-Obs/Deobs; n = 35). The Modif-Obs/Deobs animals were divided into subgroups with (DO+) and without (DO-) NVCs. Two weeks after partial urethral obstruction, the animals were deobstructed, and 1 wk later cystometry was performed with recording of intravesical and intra-abdominal pressures. NVCs were shown in all groups: Modif-Obs (80%), Conv-Obs/Deobs (100%), and Modif-Obs/Deobs (40%). In the Modif-Obs/Deobs group, bladder weight and the muscle-to-collagen ratio were higher in DO+ than in DO- rats. The Modif-Obs/Deobs group showed no mortality compared with 25% mortality in the Conv-Obs/Deobs group. The modified method may be more adequate for studying persistent DO after deobstruction, because it resulted in pressure/volume- and DO-related parameters similar to those found in the clinical situation. The persistence of DO after deobstruction may partly be due to irreversible changes in the bladder caused during the period of obstruction.

Cerebellar hemorrhage after spine fixation misdiagnosed as a complication of narcotics use -A case report-.

Cerebellar hemorrhage occurs mainly due to hypertension. Postoperative cerebellar hemorrhage is known to be associated frequently with frontotemporal craniotomy, but quite rare with spine operation. A 56-year-old female received spinal fixation due to continuous leg tingling sensation for since two years ago. Twenty-one hours after operation, she was disoriented and unresponsive to voice. Performed computed tomography showed both cerebellar hemorrhage. An emergency decompressive craniotomy was carried out to remove the hematoma. On the basis of this case, we reported this complications and reviewed related literature.

Intravesical PGE2 Administration in Conscious Rats as an Experimental Model of Detrusor Overactivity Observed by Simultaneous Registrations of Intravesical and Intraabdominal Pressures.

PURPOSE: The urodynamic effects of intravesical PGE2 instillation on bladder function and detrusor overactivity (DO) during the filling phase were investigated in rats by measuring intraabdominal and intravesical pressures simultaneously. MATERIALS AND METHODS: Continuous cystometry was performed inconscious, female and male Sprague- Dawley rats. We investigated pressure-, volume-, and DO-related parameters. RESULTS: Intravesical instillation of PGE2 increased all pressure-related parameters and decreased volume-related ones, compared to the control cystometric ones. However, among the total number of intravesical pressure rises (IVPRs) above 2 cmH(2)O during the filling phase, only 33% in female rats and 38% in male rats after PGE2 instillation were identified as true DO during the filling phase. CONCLUSIONS: Our findings suggest that the rat model with intravesical PGE2 is inappropriate for observing the effects of some drugs or mechanisms on DO, because only approximately 30% of IVPRs were confirmed as true DO. However, this model of intravesical PGE2 instillation has some advantages for the observation of changes in pressure and volume parameters rather than in DO-related ones.

Right hydrothorax misconceived as atelectasis after left internal jugular vein catheterization -A case report-.

Central vein catheterization is a common procedure for monitoring the central venous pressure, securing vascular access, administrating vasoactive drugs and removing air embolisms. However, many complications can occur, such as vessel injury, pneumothorax, hydrothorax, nerve injury, arrhythmia and infection at the insertion site. We encountered an unusual complication of a localized right hydrothorax that was initially misinterpreted as an atelectasis after left internal jugular vein catheterization and right lateral positioning for a left lower lobectomy.

Transient quadriplegia after fluoroscopic-guided selective cervical nerve root block in a patient who received cervical interbody fusion -A case report-.

Selective cervical nerve root block is executed for patients who have symptoms of cervical radiculopathy for diagnostic and therapeutic purposes. However several catastrophic complications caused by this procedure have been reported including neurological complications. A 43-year-old male received a C5 selective cervical nerve root block procedure due to continuous radiating pain even after cervical discectomy and interbody fusion was performed. At the time of the procedure, the contrast outline revealed reflux of the nerve root and epidural space. But after the procedure was performed, the patient experienced decreased sensation in the upper and low extremities as well as motor paralysis of both extremities. Our sspecting diagnosis was anterior spinal artery syndrome but both sensory and motor functions were subsequently recovered within a few hours after the procedure was completed. Due to the difficult nature of this case, we reported these complications and reviewed current literature related to this study.

Comparison of vertical infraclavicular brachial plexus block with 0.5% levobupivacaine and 0.5% ropivacaine for upper limb surgery.

BACKGROUND: We performed a prospective, double blind study to compare the clinical effect of vertical infraclavicular brachial plexus block produced by 0.5% levobupivacaine and 0.5% ropivacaine for upper limb surgery. METHODS: We included 60 patients receiving upper limb surgery under infraclavicular brachial plexus block. The infraclavicular brachial plexus block was performed via the vertical technique with 30 ml of 0.5% levobupivacaine or 0.5% ropivacaine. We observed which nerve type was stimulated and scored the sensory and motor block. The quality of block was assessed intraoperatively. The duration of sensory and motor block and complications were assessed. RESULTS: There were no significant differences in frequencies of stimulated nerve type, evolution of sensory and motor block quality, or success of block. There were no significant difference in duration of sensory block, but duration of motor block was prolonged after 0.5% levobupivacaine. There were no complications. CONCLUSIONS: Both 0.5% levobupivacaine and 0.5% ropivacaine had similar effects in the vertical infraclavicular brachial plexus block.

Phrenic nerve palsy following coracoid infraclavicular brachial plexus block.

Various methods of infraclavicular brachial plexus block have been introduced in the past, of which Wilson's coracoid infraclavicular brachial plexus block, a more lateral approach, consequently thought to be easier and safer. While only a few cases of transient ipsilateral phrenic nerve palsy after infraclavicular brachial plexus block have been reported, we describe a rare case of phrenic nerve palsy after Wilson's coracoid infraclavicular brachial plexus block.

Rhabdomyolysis following posterior lumbar interbody fusion in prone position: report 2 cases: Two cases report.

The spine surgery performed in the prone position could cause severe complications such as visual acuity impairment, spinal infarct and rhabdomyolysis. When treating rhabdomyolysis, it is important to prevent acute renal failure from accompanying rhabdomyolysis due to the poor prognosis. We have experienced two cases of rhabdomyolysis after spine surgery where dark urine was present during spine surgery under general anesthesia. Anesthesiologists should pay attention for early diagnosis and treatment of the rhabdomyolysis developing during the spine surgery.

Correcting congenital concealed penis: new pediatric surgical technique.

INTRODUCTION: Correction of the congenital concealed penis is a difficult surgical challenge. Many techniques have been described for its treatment that differ according to the incision lines and covering techniques, but the results have generally been disappointing. We report a novel surgical technique for unfurling the inner prepuce and outer penile skin and thus obtaining sufficient penile skin coverage. TECHNICAL CONSIDERATIONS: Surgical techniques for correcting the concealed penis are aimed at freeing the penis from any tethering or webbing, providing adequate penile skin coverage and fixing the proximal penile skin to the underlying fascia to prevent the body of the penis from retracting and detaching from its overlying skin. The unfurling method we describe here consists of dividing the outer penile skin to the penile base bilaterally, with ventral and dorsal incisions of the inner prepuce in the midline, perpendicular to the incision of the outer skin. CONCLUSIONS: This method is simple and provides a good blood supply to the flap. It appears to show good subjective and objective results, and no serious complications have developed.