0.125% 8 ml/h v.s. 0.25% 8 ml/h of levobupivacaine in continuous paravertebral block for postoperative analgesia in video-assisted thoracoscopic surgery: a randomized, controlled, double-blind study.

PURPOSE: Research has shown that a higher dose of bupivacaine administered in continuous paravertebral block (CPVB) provides a greater analgesic effect after video-assisted thoracoscopic surgery (VATS). In this randomized, controlled, double-blind study, we hypothesized that 0.25% 8 ml/h of levobupivacaine administered in CPVB after VATS provides a greater analgesic effect than 0.125% 8 ml/h. METHODS: Fifty patients who underwent unilateral VATS were randomized to receive a postoperative continuous infusion of 0.125% (low group, n = 25) or 0.25% (high group, n = 25) levobupivacaine at 8 mL/h for CPVB. The primary outcome was the visual analog scale (VAS) score during coughing on the morning of postoperative day (POD) 1. The secondary outcomes were the VAS scores at rest and during coughing on POD 2, the number of anesthetized dermatomes, the frequency of rescue analgesics, postoperative nausea and vomiting, patient satisfaction, and adverse events and complications. RESULTS: There was no significant difference in the VAS score during coughing on the morning of POD 1 between the low and high groups [median, 37.5 (interquartile range 21-50) vs. 40.0 (interquartile range 21-50), respectively; p = 0.79]. Similarly, there were no significant differences in any secondary outcomes between the two groups. CONCLUSIONS: Levobupivacaine at 0.25% 8 ml/h in CPVB did not provide better analgesia after VATS over 0.125% 8 ml/h. CLINICAL TRIAL REGISTRATION NUMBER: UMIN000037930.

Use of Ultrasound-Guided Selective Sensory Nerve Blocks to Provide Satisfactory Postoperative Analgesia Without Motor Paralysis in Bilateral Distal Radius Fracture Fixation: A Case Report.

Peripheral nerve blocks for postoperative pain management in distal radius fracture fixation with volar locking plates can cause undesirable motor paralysis. We performed bilateral ultrasound-guided selective sensory nerve blocks to the lateral cutaneous nerve of the forearm, superficial branch of the radial nerve, and anterior interosseous nerve for a patient undergoing bilateral distal radius fracture fixation with volar locking plates. This case report describes the first successful use of this ultrasound-guided selective sensory nerve block, which provided satisfactory postoperative analgesia and preserved the patient's motor function following distal radius fracture fixation with volar locking plates.

[Clipping of a Large Unruptured Basilar Artery Trunk Large Aneurysm Using Rapid Ventricular Pacing:A Case Report].

Neck clipping of basilar trunk aneurysms, particularly those of a large size, is challenging because of its location. Here, we report a case of a basilar artery aneurysm successfully treated with neck clipping using rapid ventricular pacing(RVP). A 67-year-old woman was referred to our hospital for treatment of a large basilar artery aneurysm. Although coiling was considered, we performed neck clipping of this aneurysm because of the expected radical therapeutic effect. The patient was positioned in the right park-bench position, and right suboccipital craniotomy was performed. The aneurysm was mainly approached via the right supracerebellar route. RVP softened the aneurysm for easy dissection and insertion of multiple clips. The postoperative course was uneventful, and she was discharged 1 week later without neurological deficits. RVP should be considered for the treatment of complex aneurysms as adjunctive techniques.

A novel technique for ultrasound-guided central venous catheterization under short-axis out-of-plane approach: "stepwise flashing with triangulation".

In ultrasound-guided central venous catheterization, there is no standard technique either for the needle tip visualization or for the adequate needle angle and entry to the skin with short-axis view under out-of-plane technique. In the present study, we propose a novel technique named "stepwise flashing with triangulation", and the efficacy of this technique is assessed. Before and after a didactic session in which the technique was explained, 12 novice residents were asked to position the needle tip on or into the imitation vessels and to avoid deeper penetration by using an agar tissue phantom with ultrasound guidance. "Stepwise flashing" technique was for stepwise visualization of the needle tip, and "triangulation" technique was for adequate needle angle and entry to the skin. After the session, the success rate was increased and a deeper penetration rate was decreased. This technique will help us to facilitate vascular access and to avoid complications in clinical settings.

[Ischemic Changes in the Electrocardiogram and Circulatory Collapse Accompanied by Severe Anemia Owing to the Delay of Red Blood Cell Concentrate Transfusion in Two Patients with Intraoperative Massive Bleeding].

We present two patients developing intraoperative massive bleeding and showed ischemic changes in the electrocardiogram and circulatory collapse accompanied by severe anemia owing to the delay of red blood cell concentrate transfusion. One patient underwent hepatectomy and the other pancreaticoduodenectomy. Their lowest hemoglobin concentration was around 2 g x dl(-1), and they showed ischemic changes in the electrocardiogram and severe decreases in blood pressure. The former received compatible red blood cell concentrate and the latter received uncrossmatched same blood group red blood cell concentrate immediately, and their electrocardiogram and blood pressure quickly improved. To avoid life-threatening anemia, emergency red blood cell concentrate transfusion including compatible different blood group transfusion should be applied for intraoperative massive bleeding.

[Difficult airway management during emergency tracheostomy in a patient with severe rheumatoid arthritis].

We experienced difficult airway management in a 65-year-old woman with acute dyspnea due to bilateral recurrent nerve palsy suffering from severe rheumatoid arthritis for fifty years. Her cervical spine was ankylosed and could not be extended at all. Tracheostomy was planned under local anesthesia because of difficulty of endotracheal intubation, possibility of airway obstruction and laryngeal edema. In this condition, the surgical area was narrow and difficult to approach. The surgical bleeding and blood-aspiration into the tracheostomy site occurred followed by airway obstruction. A rigid tracheal tube could not be inserted through the tracheal incision and SpO2 decreased to 81%. We inserted a percutaneous cricothyroidotomy cannula through the tracheal incision and superimposed HFJV on her spontaneous ventilation. Assisting the ventilation in this way finally, a spiral endtracheal tube was inserted and her oxygenation became stable.

Influence of patient variables and sensor location on regional cerebral oxygen saturation measured by INVOS 4100 near-infrared spectrophotometers.

Cerebral oximeter based on near-infrared spectroscopy has been used as a continuous, noninvasive monitoring of regional cerebral oxygen saturation (rSO2). Although the absolute rSO2 values have a wide range of variability, the factors affecting a variability of rSO2 values have not been extensively investigated. The authors investigated the influence of patient variables and sensor location on rSO2 measured by the cerebral oximeter INVOS 4100 in 111 patients anesthetized with sevoflurane, fentanyl, and nitrous oxide in oxygen. The sensors for rSO2 measurements were applied on the right forehead (R), 1 cm lateral to R (R1), on the left forehead (L), 1 cm lateral to L (L1), and on the center of the forehead (C). The relationship between the rSO2 values and patient variables were also analyzed. Values of rSO2 at R1 and L1 were significantly lower than those at R and L, respectively. Values of rSO2 at C were significantly higher compared with those at other sites. There were no significant correlations between the rSO2 values and values of weight, height, and head size. Values of rSO2 were similar between males and females. A significant negative correlation between the rSO2 values and age and a positive correlation between the rSO2 values and hemoglobin concentration were observed. These data indicate that patient age, hemoglobin concentration at the measurement, and sensor location can affect rSO2 values.