Perifascial plane versus perineural approaches for ultrasound-guided axillary block: go to the simplest?

BACKGROUND: Ultrasound-guided axillary block is widely used in daily practice for upper limb orthopedic surgery. A simple, safe, efficacious and time-saving technique is mandatory to optimize surgical turnover and costs. In this perspective, we compared, in a randomized, single-blinded study, a standardized perifascial technique and the selective perineural technique. METHODS: Forty-two patients scheduled for elective hand surgery were randomly assigned to receive 20 mL of 10 mg/mL mepivacaine, either selectively around each of the radial, median, ulnar and musculocutaneous nerves (perineural group) or along the latissimus dorsi and superficial axillary fascia (perifascial group). The primary outcome was the procedure performance time in both groups. Secondary goals were the number of needle passes, a per-procedure evaluation of the performance on a visual analogue scale ranging from 0 to 10, the success rate and the incidence of adverse events. RESULTS: Performance time was significantly reduced in the perifascial group (3.6 vs. 6.5 min, P<0.001), with fewer needle passes (3 vs. 6, P<0.001) and a simpler procedure performance (8.5 vs. 7.6, P=0.02). No vascular punctures or neurologic deficits were reported. Surgical anesthesia (95% in both groups) and complete anesthetic success (perifascial 81% vs. perineural 95%) were similar. CONCLUSIONS: We reported that the ultrasound-guided axillary perifascial block is easier to perform and saves procedural time compared to the classic perineural technique. Considering the same anesthetic success rate in both groups, the perifascial plane technique should be considered a daily practice technique and the first level of learning procedure for axillary block.

Mechanical ventilation as an indicator of somatic severity of self-poisoning: implications for psychiatric care and long-term outcomes.

BACKGROUND: Somatic severity of a self-poisoning episode varies widely between patients. AIMS: To determine the correlates (psychiatric profiles, long-term outcome) of mechanical ventilation used as a proxy to define somatic severity during a self-poisoning. METHOD: All patients who required mechanical ventilation were pair-matched with ones who did not for age, gender and presence of psychiatric history. One year after the self-poisoning episode, patients were interviewed using the Hospital Anxiety and Depression Scale (HADS) and a quality-of-life assessment questionnaire (Short-Form 12 Health Survey). RESULTS: The ventilation group (n = 99) more frequently had mood disorders and less frequently had adjustment disorders (P = 0.007), with a higher depression score on the HADS (P = 0.01) than those in the non-ventilation group (n = 97). Survival curves showed lower survival in the ventilation group (P = 0.03). CONCLUSIONS: Requirement for mechanical ventilation following self-poisoning is associated with a high prevalence of mood disorders and poor long-term outcome.