Pain management using a novel hybrid technique of perineural stimulation combined with regional anaesthesia through a stimulating perineural catheter for below knee amputation.

Pain after amputation can be difficult to manage due to its complex aetiology. A multimodal approach to analgesia, including regional anaesthetic techniques, is advised. However, optimal pain management cannot always be achieved, and high doses of opioid analgesics may contribute to adverse effects. We describe the management of an elderly patient with significant co-morbidities undergoing below knee amputation. Pre-operatively, a popliteal sciatic stimulating perineural catheter and a femoral non-stimulating perineural catheter were placed. When pain control was suboptimal on the first postoperative day, a combination of local anaesthetic and a brief period of peripheral nerve stimulation through the sciatic stimulating perineural catheter was used to augment pain control, thereby avoiding additional opioid use. Although nerve stimulation utilising specialised equipment, such as percutaneous stimulator electrodes, has been previously described in acute pain medicine, we demonstrate the use of a novel hybrid technique which combines nerve stimulation through a perineural catheter and local anaesthetic. Further research is warranted to explore the utility of this neuromodulation technique in clinical practice.

Continuous interscalene block: the good, the bad and the refined spread.

Continuous interscalene block is popular for shoulder surgery, but there are several challenges when performing this continuous block. The interscalene catheter is susceptible to incidental dislodgement and migration due to movement of the head and neck. Another important consideration is phrenic nerve involvement; the phrenic nerve is susceptible to being incidentally anaesthetised with local anaesthetic during interscalene block, owing to its close proximity to the interscalene groove. We present two cases: firstly, a case demonstrating an interscalene catheter insertion approach that provides an effective spread of local anaesthetic perineurally within the interscalene groove, with the additional benefit of preventing catheter dislodgement. Secondly, we present a case in which ultrasound-guided interscalene catheter insertion resulted in phrenic nerve palsy in an asthmatic patient, where dilution or 'wash-off' of local anaesthetic with normal saline and repositioning of the catheter under ultrasound guidance resulted in rapid recovery of respiratory function and adequate pain control.

An expedited stroke triage pathway: the key to shortening the door-to-needle time in delivery of thrombolysis.

OBJECTIVES: To assess time management of stroke thrombolysis triage and functional outcomes in patients receiving recombinant tissue plasminogen activator for hyperacute stroke, and identify bottlenecks in delivery of the treatment. DESIGN: Prospective study. SETTING: A university teaching hospital in Hong Kong. PATIENTS: Patients with suspected hyperacute stroke referred to the stroke thrombolysis team during October 2008 to September 2009. MAIN OUTCOME MEASURES: Time performance records including door-to-stroke team, door-to-needle, and onset-to-thrombolysis times. Functional outcomes by modified Rankin Scale score at 3 months, and thrombolysis-related complications including haemorrhagic transformations and mortality. RESULTS: During the 12-month period, 95 thrombolysis calls were received; recombinant tissue plasminogen activator was given intravenously to 17 (18%) of the patients and intra-arterially to 11 (12%). The mean (standard deviation) door-to-stroke team and the door-to-needle times for intravenous recombinant tissue plasminogen activator patients were 33 (25) and 80 (25) minutes, respectively; both were about 20 minutes longer than that recommended by the National Institute of Neurological Disorders and Stroke. The mean National Institute of Health Stroke Scale score for patients received intravenous recombinant tissue plasminogen activator was 16 (standard deviation, 7). The mean (standard deviation) onset-to-treatment time was 144 (42) minutes. Nine (53%) patients who received intravenous recombinant tissue plasminogen activator achieved favourable outcomes at 3 months, with a modified Rankin Scale score of 0 to 1. Symptomatic haemorrhage and mortality occurred in one (6%) patient. CONCLUSION: A dedicated stroke triage pathway is essential to ensure efficient and safe delivery of thrombolysis therapy. Improvements in door-to-stroke team time through integration with emergency medicine staff and neuroradiologists may improve thrombolysis eligibility.