Effect of ankle versus thigh tourniquets on post-operative pain in foot and ankle surgery.

BACKGROUND: Tourniquets are commonly used in elective extremity orthopaedic surgery to reduce blood loss, improve visualization in the surgical field, and to potentially reduce surgical time. There is a lack of consensus in existing guidelines regarding the optimal tourniquet pressure, placement site, and duration of use. There is a paucity of data on the relationship between the site of a tourniquet and postoperative pain in foot and ankle surgery. AIM: To explore the relationship between tourniquet site and intensity of post-operative pain scores in patients undergoing elective foot and ankle surgery. METHODS: Retrospective analysis of prospectively collected data on 201 patients who underwent foot and ankle surgery in a single institution was undertaken. Intraoperative tourniquet duration, tourniquet pressure and site, and postoperative pain scores using Visual Analogue Score were collected in immediate recovery, at six hours and at 24 h post-op. Scatter plots were used to analyse the data and to assess for the statistical correlation between tourniquet pressure, duration, site, and pain scores using Pearson correlation coefficient. RESULTS: All patients who underwent foot and ankle surgery had tourniquet pressure of 250 mmHg for ankle tourniquet and 300 mmHg for thigh. There was no correlation between the site of the tourniquet and pain scores in recovery, at six hours and after 24 h. There was a weak correlation between tourniquet time and Visual Analogue Score immediately post-op (r = 0.14, P = 0.04) but not at six or 24 h post-operatively. CONCLUSION: This study shows that there was no statistically significant correlation between tourniquet pressure, site and post-op pain in patients undergoing foot and ankle surgery. The choice of using a tourniquet is based on the surgeon's preference, with the goal of minimizing the duration of its application at the operative site.

Effectiveness of ESPITO analgesia in enhancing recovery in patients undergoing open radical cystectomy when compared to a contemporaneous cohort receiving standard analgesia: an observational study.

OBJECTIVES: Bowel dysfunction is a major complication following open surgery for invasive cancer of the bladder that results in significant discomfort; complications and can prolong the length of stay. The incidence of postoperative ileus following open radical cystectomy has been reported as 23-40%. The median length of hospital stay after this surgery in the United Kingdom is 11 days. Standard analgesic techniques include wound infusion analgesia combined with systemic morphine or thoracic epidural analgsia. Combined erector spinae plane and intrathecal opioid analgesia is a novel technique that has been reported to be an effective method of providing perioperative analgesia thereby enhancing recovery after open radical cystectomy. METHODS: We performed a prospective study on the effectiveness of the novel analgesic technique (combined erector spinae plane and intrathecal opioid analgesia) in reducing the incidence of postoperative ileus, thereby facilitating early discharge following open radical cystectomy when compared to a contemporaneous control group receiving standard analgesia. Twenty-five patients received the novel analgesia while 31 patients received standard analgesia as a part of enhanced recovery programme. Standard analgesia arm included 14 patients who recived thoracic epidural analgesia (14/31, 45%) and 17 patients who received combined wound infusion analgesia and patient controlled analgesia with morphine (17/31, 55%). Primary outcome was the incidence of postoperative ileus. Secondary outcomes included length of hospital stay, tramadol consumption and time to bowel opening. RESULTS: Combined erector spinae plane and intrathecal opioid analgesia was associated with a reduced incidence of postoperative ileus (16 [4/25] vs. 65% [20/31], p<0.001), reduced time to first open bowel (4.4 ± 2.3 vs. 6.6 ± 2.3, p<0.001) and reduced median (IQR) length of hospital stay (7[6, 12] vs. 10[8, 15], p=0.007). There was no significant difference in rescue analgesia (intravenous tramadol) consumption. Complete avoidance of systemic morphine played a key role in improved outcomes. CONCLUSIONS: ESPITO was successful in reducing postoperative ileus and length of hospital stay after open radical cystectomy when compared to standard analgesia within an enhanced recovery programme.

Ultrasound-guided regional anaesthesia in foot and ankle surgery.

The use of regional anaesthesia in foot and ankle surgery is becoming well recognised, particularly in patients who prefer to stay awake during the procedure and for better post-operative analgesia. Its use is ideal for patients with multiple co-morbidities, in whom general anaesthesia (GA) otherwise would could be challenging. The procedures performed with landmark/anatomical guidance alone carry a relatively higher risk of complications, risk of inadvertant injection into the intarvascualr space leadinf to local anaesthetic toxicity, the majority of which complications are caused by incorrect placement of the needle. Hence, ultrasound guidance is frequently used to minimise those risks. Although various regional anaesthetic techniques for foot and ankle surgery have been described, their comprehensive review is lacking. This manuscript aims to fulfil this void. The focus will be on the peripheral methods of regional anaesthesia including the plexus and single nerve blocks. Various techniques with their benefits and potential complications will be discussed. In addition, the evidence on the efficacy of an ultrasound-guided approach as well as its cost implications will be explored. There are significant considerations in deciding whether to implement this technique in routine clinical practice and this review aims to summarise the available literature to establish the evidence base behind it.

Breathing Pattern Interpretation as an Alternative and Effective Voice Communication Solution.

Augmentative and alternative communication (AAC) systems tend to rely on the interpretation of purposeful gestures for interaction. Existing AAC methods could be cumbersome and limit the solutions in terms of versatility. The study aims to interpret breathing patterns (BPs) to converse with the outside world by means of a unidirectional microphone and researches breathing-pattern interpretation (BPI) to encode messages in an interactive manner with minimal training. We present BP processing work with (1) output synthesized machine-spoken words (SMSW) along with single-channel Weiner filtering (WF) for signal de-noising, and (2) k-nearest neighbor (k-NN) classification of BPs associated with embedded dynamic time warping (DTW). An approved protocol to collect analogue modulated BP sets belonging to 4 distinct classes with 10 training BPs per class and 5 live BPs per class was implemented with 23 healthy subjects. An 86% accuracy of k-NN classification was obtained with decreasing error rates of 17%, 14%, and 11% for the live classifications of classes 2, 3, and 4, respectively. The results express a systematic reliability of 89% with increased familiarity. The outcomes from the current AAC setup recommend a durable engineering solution directly beneficial to the sufferers.

Audit of postoperative pain management after open thoracotomy and the incidence of chronic postthoracotomy pain in more than 500 patients at a tertiary center.

STUDY OBJECTIVE: To evaluate the quality of postoperative pain relief during the first 3 days after surgery and to evaluate with the incidence of persistent pain at 6 months after surgery. DESIGN: Retrospective single-center audit. SETTING: University hospital. PATIENTS: Five hundred four patients who underwent thoracotomy. INTERVENTIONS: Review of patient records, questionnaire, and telephone review. RESULTS: Of the 364 survivors, 306 were contacted. Five or more episodes of severe pain (numerical rating scale >6/10 at rest or movement) during the first 72 hours after surgery occurred in 133 patients. Persistent postsurgical pain at 6 months was present in 82% (109/133) of these patients. Patient satisfaction with acute postoperative pain management was excellent (36%), good (43%), and fair or poor (21%).The incidence of postthoracotomy pain was 56% (mild 32%, moderate 18%, and severe 6%). CONCLUSIONS: Poorly controlled acute postoperative pain correlated with persistent postsurgical pain at 6 months. In view of such a high incidence in thoracotomy patients, preventative strategies assume great significance.

Four quadrant transversus abdominis plane block and continuous transversus abdominis plane analgesia: a 3-year prospective audit in 124 patients.

STUDY OBJECTIVE: Transversus abdominis plane (TAP) blocks have been reported to be an effective method of providing analgesia after abdominal surgery. To perform a prospective audit on the effectiveness of a novel technique of providing continuous transversus abdominis plane (TAP) analgesia in patients undergoing emergency and elective abdominal surgery. DESIGN: Prospective single center audit over a 3-year period. SETTING: University hospital. PATIENTS: One hundred twenty-four American Society of Anesthesiologists I to IV adult patients presenting for elective as well as emergency abdominal surgery in whom epidural analgesia was contraindicated or refused. INTERVENTIONS: Four quadrant TAP blocks and continuous TAP analgesia. MEASUREMENTS: Numerical rating scale pain scores at rest and on coughing, nausea scores, satisfaction scores, complications, frequency of analgesia failure, therapeutic failure with continuous TAP analgesia and opioid consumption. RESULTS: One hundred twenty-four patients who received continuous TAP analgesia were audited. This included 34 patients for elective open surgery, 36 patients for emergency laparotomy, and 54 patients who underwent elective laparoscopic colorectal surgery. Surgical incision was within the dermatomal limit of the block in 70% of the patients (88/124). Therapeutic failure with the technique was 10%. Frequency of analgesic failure over the 48-hour period was none in 39% and below 5 episodes in 57%. CONCLUSION: Four quadrant transversus abdominis plane blocks and continuous TAP analgesia is an effective technique for providing postoperative analgesia after abdominal surgery. It has the potential to be used as a sole analgesic technique when the surgical incision is within its dermatomal limit.