Triple injection peri-sartorius (TIPS) block for postoperative analgesia after total knee arthroplasty: Randomised controlled study.

Background and Aims: Motor-sparing analgesia after total knee arthroplasty (TKA) is crucial. The primary endpoint was the postoperative visual analogue scale (VAS) score after triple injection peri-sartorius (TIPS) block after TKA. Secondary endpoints were postoperative morphine consumption, 24-h postoperative ambulation distances and the degrees of active knee extension. Methods: After general anaesthesia or spinal anaesthesia administration and before surgical incision, 80 patients undergoing TKA were randomised into group TIPS (received ultrasound-guided TIPS block where 40 ml 0.25% bupivacaine and 4 mg dexamethasone were injected: 10 ml at the distal femoral triangle, 10 ml above the sartorius and 20 ml at the distal adductor canal) and group FNB (femoral nerve block; received ultrasound-guided FNB with 20 ml 0.25% bupivacaine mixed with 4 mg dexamethasone). Postoperative pain score was noted and compared. Results: Dynamic VAS scores were lower in the TIPS group than in FNB, while the resting VAS scores were not significantly different. Mean (standard deviation [SD]) postoperative morphine consumption was 5.82 (2.47) mg in the TIPS group (95% confidence interval [CI] 5.03,6.61) versus 9.87 (2.99) mg in the FNB group (95% CI 8.91,10.83). Ambulation distances and active postoperative knee extension in the TIPS group showed greater significance than in the FNB group (TIPS: 18.0 [7.37] m, 95% CI 15.64,20.35] vs. FNB: 8.95 [5.93] m, 95% CI 7.05,10.84) and (TIPS: 52.12 [16.39], 95% CI 46.88,57.33 vs. FNB: 26.05 [11.10], 95% CI 22.501,29.59). Nausea was more evident in FNB patients. Conclusion: TIPS block provides superior analgesia than FNB with motor sparing of the quadriceps after TKA.

Single puncture combined lumbar erector spinae plane and quadratus lumborum block (SEQ block) in acetabular fracture surgeries: randomized clinical trial.

BACKGROUND: Acetabular fracture surgery can cause severe postoperative pain. A combined lumbar erector spinae plane block and paraspinous sagittal shift quadratus lumborum block may augment analgesia. METHODS: Fifty two patients undergoing posterior column acetabular surgery were divided into: Group Single puncture combined lumbar Erector spinae and Quadratus lumborum block (SEQ), patients who received SEQ block before anesthesia; and Group morphine (MOR), those who received general anesthesia (GA) and morphine. RESULTS: Demographic characteristics were comparable. The heart rate and mean arterial blood pressure were significantly lower in the SEQ group than in the MOR group between 60 and 180 min intraoperatively (P < 0.001). Postoperative resting and dynamic visual analogue scale scores in the SEQ group were significantly lower than those in the MOR group at all studied periods (P = 0.022-0.001), except at 20 and 24 h postoperatively. Fentanyl was required in all MOR group patients at a mean dose of 110.0 ± 28.42 µg while 18 patients required fentanyl in SEQ group at a mean dose of 60.55 ± 25.54 µg. Postoperative morphine consumption was significantly less in SEQ group (6.33 ± 2.37 mg) than MOR group (17.0 ± 2.55 mg). Postoperative nausea and vomiting were recorded in eight and four patients in MOR and SEQ group, respectively. No complications associated with the block technique were observed. CONCLUSIONS: The SEQ block reduces the postoperative opioid consumption and provides stable intra and postoperative hemodynamics without observed complications in posterior column acetabular surgery.

Randomized comparative study between two different techniques of intercostobrachial nerve block together with brachial plexus block during superficialization of arteriovenous fistula.

BACKGROUND: This study compared proximal and distal approaches of intercostobrachial nerve block (ICBNB) combined with infraclavicular brachial plexus block (ICBPB) during superficialization of arteriovenous fistula. METHODS: Seventy adult patients were randomized to receive ICBPB and 6 ml 0.25% bupivacaine at the level of the 3rd rib in the anterior axillary line between pectoralis minor and serratus anterior muscles (group P) or subcutaneously along the medial side of the upper arm (group D). The primary outcome was the achievement of complete sensory block. Secondary outcomes were onset of analgesia, volume of local anesthetic (LA) supplementation, fentanyl administration, success rate, and conversion to general anesthesia (GA). RESULTS: Complete sensory block in the medial side of the upper arm was achieved in 91% of patients in group P and 51% in group D. Failure rate of ICBNB was higher in group D (49%) than group P (14%). Conversion to GA was determined by the attending anesthesiologist in 26% of patients in group D and 0% in group P. LA supplementation was required in 5 patients in group P and 11 patients in group D, and the mean volume of LA was statistically higher in group D than group P (9.5 ± 1.5, 7.5 ± 2 ml, respectively). Onset of sensory block was faster in group P than group D (8.75 ± 1.67 and 10 ± 2.14 min, respectively). No differences were observed regarding fentanyl administration. CONCLUSION: ICBNB proximal approach provides a high success rate with less amount of rescue analgesia compared to the distal approach.

Feeding obturator as an airway adjunct during complete unilateral cleft palate repair.

BACKGROUND AND AIMS: The palatal defect and abnormal dentition in cleft palate make mask ventilation and laryngoscopy difficult. This study aimed to assess the effect of feeding obturator on laryngeal view in unilateral complete cleft palate. METHODS: Ninety non-syndromic infants scheduled for the first stage correction of complete unilateral cleft palate were randomised to Group A (no feeding obturator) or Group B (obturator used for induction and intubation). The primary objective was to assess effect of the feeding obturator on the Cormack-Lehane grade on laryngoscopy. Effects on face mask ventilation, easiness of laryngoscopy and intubation and the side effects were also measured. RESULTS: Ninety patients completed the study. There was no statistically significant difference between the two groups regarding the CL grade (P < 0.1). However duration for intubation was significantly longer in Group A than Group B (31.4 ± 12.8 vs. 23.4 ± 40.7 sec, P < 0.001). The degree of difficulty of face mask ventilation was significantly greater in Group A than Group B (P < 0.008). Attempts for successful intubation and manoeuvres for successful intubation were significantly more in Group A than B (P < 0.05). Trauma occurred in ten patients in Group A relative to no patients in Group B. CONCLUSION: Use of a pre-sized obturator in infants with complete unilateral cleft palate does not improve the laryngoscopic view. However, it results in better face mask ventilation and easier and faster laryngoscopy and intubation.

Endotracheal intubation: ultrasound-guided versus fiberscope in patients with cervical spine immobilization.

BACKGROUND: Ultrasound has growing applications in airway management during anesthesia. The aim of the present study was to evaluate the feasibility of real-time ultrasound-guided tracheal intubation in patients with cervical spine immobilization relative to fiberscope-guided tracheal intubation. PATIENTS AND METHODS: This randomized controlled study was carried out on 266 adult patients who have a rigid neck collar in place for cervical spine immobilization and were randomly allocated into two equal groups. All patients were subjected to the same anesthetic protocol. After full neuromuscular blockade, neck collar was removed and tracheal intubation was done in the neutral position. In group A, the trachea was intubated guided by a 5-12-MHz linear ultrasound probe attached to a Sonoscape A5 ultrasound machine. In group B, the trachea was intubated by an endotracheal tube mounted over a fiberscope (Karl Storz, working length 65 cm, distal tip diameter 5.6 mm). Hemodynamic measurements and oxygen saturation were recorded. Tracheal intubation criteria for both groups including duration of the intubation procedure, number of intubation attempts, success rate at each attempt, and the lowest oxygen saturation recorded during tracheal intubation were recorded. RESULTS: Ultrasound and fiberscope achieved comparable time for tracheal intubation (57 ± 12 vs. 55 ± 10 s), respectively. Success rate of tracheal intubation at the first attempt was higher in the fiberscope group than the ultrasound group, with a P value of 0.032. The overall success rate was not significantly different between the two groups. CONCLUSIONS: Ultrasound-guided tracheal intubation showed a lower first attempt success rate in patients with cervical spine immobilization compared to fiberscope-guided tracheal intubation but the overall success rates were comparable. Ultrasound can be an alternative technique for guiding tracheal intubation in patients with cervical spine immobilization. REGISTRY NUMBER: PACTR201602001476292.

Nasotracheal Intubation with Parker Flex-Tip Versus Preformed Nasal Endotracheal Tubes for Children Undergoing Adenotonsillectomy.

Abstract: The design of the endotracheal tube might be an important factor in the incidence of injurious complications during nasotracheal intubation. Aim of the work: Primary aim: to compare the parker flex tip (PFT) and the preformed nasal (PNT) tubes regarding the ease of insertion during nasotracheal intubation in children undergoing adenotonsillectomy. Secondary aim: to verify the incidence of traumatic complications of both types of tubes during nasotracheal intubation in children undergoing adenotonsillectomy. Patients and methods: 100 patients aged between 4 and 10 years ASA physical status I-II scheduled for adenotonsillectomy were divided into two groups; Group PFT: Patients were nasally intubated using the parker flex-tip endotracheal tube, Group PNT: Patients were nasally intubated using the preformed nasal tube. Ease of insertion of the ETT, degree of trauma and the time of intubation was measured. Results: ETT was easily inserted without any resistance in 24% of patients of the PFT group versus 12% of patients in the PNT group. ETT could not be passed through the right or left nostrils in 20% of patients of the PNT group relative to only 4% of patients of the PFT group. Incidence of trauma to the nasal mucosa was significantly higher in patients of the PNT group than patients of the PFT group. Duration of intubation was statistically significantly longer among patients of the PNT group than patients of the PFT group. Conclusions: It seems that the flexible tapered tip of the PFT tube has led to easier insertion through the nasal passages as well as less trauma to the nasal mucosa in children having nasopharyngeal pathology in the form of adenoids. At the same time, the duration of intubation was less in the PFT group relative to the control group in spite of the more familiarity of the investigator with the standard portex tube.

Fiberoptic assessment of the Laryngeal Mask Airway (Laryseal) position after one hour of positive pressure ventilation: an observational study.

STUDY OBJECTIVES: To determine, by fiberoptic endoscope, malpositioning of the Laryngeal Mask Airway (LMA) and other extraglottic devices. DESIGN: Prospective study. SETTING: University-affiliated medical center. PATIENTS: 60 adult, ASA physical status 1 and 2 patients, aged 20 - 60 years, scheduled to undergo ophthalmic procedures with general anesthesia during controlled ventilation via LMA (Laryseal). MEASUREMENTS: Adequacy of ventilation was determined by the absence of audible leak and appropriate capnograph trace. Fiberoptic assessment and imaging of LMA position were done after proper insertion of the LMA and after one hour of positive pressure ventilation (PPV). Assessment included position of the epiglottis, glottis, and cuff. MAIN RESULTS: The epiglottis was visible in 50 patients (83.3%). Vocal cords were visible in 58 patients at the time of insertion, and in 52 patients after one hour of PPV (P = 0.047). The arytenoids were herniating through the mask aperture after one hour of PPV (P = 0.0132). The cuff position was less optimal after one hour of controlled ventilation (P = 0.032). CONCLUSION: LMA position may change spontaneously with time during PPV, especially when the LMA position is not optimum at the time of insertion. The LMA should be adequately inserted with all possible measures in cases with general anesthesia and PPV. Fiberoptic assessment of LMA position intraoperatively may be advantageous.