An Obturator Nerve Block does not Alleviate Postoperative Pain after Total Hip Arthroplasty: a Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: A substantial group of patients suffer from moderate to severe pain following elective total hip arthroplasty (THA). Due to the complex innervation of the hip, peripheral nerve block techniques can be challenging and are not widely used. Since the obturator nerve innervates both the anteromedial part of the joint capsule as well as intra-articular nociceptors, we hypothesized that an obturator nerve block (ONB) would decrease the opioid consumption after THA. METHODS: Sixty-two patients were randomized to receive ONB or placebo (PCB) after primary THA in spinal anesthesia. Primary outcome measure was opioid consumption during the first 12 postoperative hours. Secondary outcome measures included postoperative pain score, nausea score and ability to ambulate. RESULTS: Sixty patients were included in the analysis. Mean (SD) opioid consumption during the first 12 postoperative hours was 39.9 (22.3) mg peroral morphine equivalents (PME) in the ONB group and 40.5 (30.5) mg PME in the PCB group (p=0.93). No difference in level of pain or nausea was found between the groups. Paralysis of the hip adductor muscles in the ONB group reduced the control of the operated lower extremity compared with the PCB group (p=0.026). This did, however, not affect the subjects' ability to ambulate. CONCLUSIONS: A significant reduction in postoperative opioid consumption was not found for active versus PCB ONB after THA. TRIAL REGISTRATION NUMBER: NCT03064165 and 2017-000068-14.

Validation of the Peripheral Ultrasound-guided Vascular Access Rating Scale.

Evidence-based standards in proficiency are needed for ultrasound-guided peripheral intravenous access. In this study, we explored the validity of the Peripheral Ultrasound-Guided Vascular Access (P-UGVA) Rating Scale.We recruited 3 groups of physicians (5 novices, 5 intermediates, and 5 experts) of increasing proficiency in peripheral ultrasound-guided intravenous access. All participants performed 3 peripheral ultrasound-guided intravenous accesses on three different patients. Performance was video-recorded by 3 cameras and the ultrasound image. Synchronized and anonymized split-screen film clips were rated using the P-UGVA rating scale by 2 assessors, which also assessed overall performance on a 1-5 Likert-scale. Evidence of validity was explored using the contemporary validity framework by Messick (content, response process, internal structure, relations to other variables, and consequences).Content and response process was ensured in the development of the rating scale and validity study. Internal consistency of the P-UGVA rating scale was excellent and sufficient high for certification purposes (Cronbach's alpha = 0.91). Proficiency groups were successfully discriminated by the UPGIVA rating scale (P = .029, one-way ANOVA), and the P-UGVA rating scale scores also correlated strongly with the overall performance evaluations (rho = 0.87, P < .001, Pearson correlation). We calculated a pass/fail score of 29, which lead to a theoretical false positive rate of 26.5% and false negative rate of 8.5%.We present validity evidence for the P-UGVA rating scale and an evidence-based standard in proficiency for ultrasound-guided peripheral intravenous access.

Analgesia of Combined Femoral Triangle and Obturator Nerve Blockade Is Superior to Local Infiltration Analgesia After Total Knee Arthroplasty With High-Dose Intravenous Dexamethasone.

BACKGROUND AND OBJECTIVES: High-dose intravenous dexamethasone reduces the postoperative opioid requirement and is often included in the multimodal analgesia strategy after total knee arthroplasty (TKA). Combined obturator nerve and femoral triangle blockade (OFB) reduces the opioid consumption and pain after TKA better than local infiltration analgesia (LIA). The question is whether preoperative high-dose intravenous dexamethasone would cancel out the superior analgesic effect of OFB compared with LIA. The aim was to evaluate the analgesic effect of OFB versus LIA after TKA when all patients received high-dose intravenous dexamethasone. METHODS: Eighty-two patients were randomly assigned either to OFB or LIA after primary unilateral TKA. All patients received 16 mg dexamethasone. Primary outcome was morphine consumption via patient-controlled analgesia during the first 20 postoperative hours. Secondary outcomes were pain, nausea, dizziness, and length of hospital stay. RESULTS: Seventy-four patients were included in the analysis. Median total intravenous morphine consumption during the first 20 postoperative hours was 6 mg (interquartile range [IQR], 2-18 mg) in the OFB group and 20 mg (IQR, 12-28 mg) in the LIA group. The 14-mg difference (95% confidence interval, 6.4-18.0 mg) was significant (P < 0.001). There was no difference in pain score at rest at 20 hours postoperatively: 2 (IQR, 1-4) in the OFB group and 3 (IQR, 2-5) in the LIA group. CONCLUSIONS: Combined OFB reduces morphine consumption better than LIA after TKA even when all patients received high-dose intravenous dexamethasone. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02374008.

Rating scale for the assessment of competence in ultrasound-guided peripheral vascular access - a Delphi Consensus Study.

INTRODUCTION: Peripheral vascular access is vital for treatment and diagnostics of hospitalized patients. Ultrasound-guided vascular access (UGVA) is superior to the landmark technique. To ensure competence-based education, an assessment tool of UGVA competence is needed. We aimed to develop a global rating scale (RS) for assessment of UGVA competence based on opinions on the content from ultrasound experts in a modified Delphi consensus study. METHODS: We included experts from anesthesiology, emergency medicine and radiology across university hospitals in Denmark. Nine elements were drafted based on existing literature and recommendations from international societies. In a multi-round survey, the experts rated the elements on a five-point Likert scale according to importance, and suggested missing elements. The final Delphi round occurred when >80% of the experts rated all elements ≥4 on the Likert scale. RESULTS: Sixteen experts consented to participate in the study, one withdrew consent prior to the first Delphi round, and 14 completed all three Delphi rounds. In the first Delphi round the experts excluded one element from the scale and changed the content of two elements. In the second Delphi round, the experts excluded one element from the scale. In the third Delphi round, consensus was obtained on the eight elements: preparation of utensils, ergonomics, preparation of the ultrasound device, identification of blood vessels, anatomy, hygiene, coordination of the needle, and completion of the procedure. CONCLUSIONS: We developed an RS for assessment of UGVA competence based on opinions of ultrasound experts through a modified Delphi consensus study.

[Gelatine phantom for training of ultrasound guided vascular access]. / Gelatinefantom til træning af ultralydvejledt vaskulær adgang.

This article describes the production of a low-cost training phantom for ultrasound guided invasive procedures of peripheral and central veins and presents a video of the process. The phantom can be adapted for use with other ultrasound techniques. It is a universal useful skill training tool for ultrasound guided invasive procedures. The phantom is easily made of concentrated gelatine. It is cheap and recyclable. The shelf life is prolonged by cold storage in a freezer. The gelatine phantom is a useful tool for practice of probe handling techniques and needle dexterity when placing peripheral and central venous catheters.

[Ultrasound guidance during placement of central venous catheter can prevent arrhythmias]. / Brug af ultralyd ved anlæggelse af centralt venekateter kan forebygge arytmier.

Central venous access under ultrasound guidance is widely supported in current medical practice. This case report describes a new method where the tip of the guide-wire is visualized in real-time, withheld from the heart and thereby avoiding the risk of guide-wire induced arrhythmias.