Single-cuff forearm tourniquet in intravenous regional anaesthesia results in less pain and fewer sedation requirements than upper arm tourniquet.

BACKGROUND: A limitation of Bier's block or i.v. regional anaesthesia (IVRA) is tourniquet pain. We hypothesized that tourniquet placement on the forearm vs upper arm during IVRA for distal upper extremity surgery may result in less tourniquet pain, lower the need for analgesic interventions, and decrease post-anaesthesia care unit (PACU) admission. METHODS: Patients for distal upper extremity surgery were randomized into upper or forearm single-cuff tourniquet placement. IVRA was either performed with 15 ml of 2% lidocaine and 20 mg ketorolac in the upper group or 8 ml of 2% lidocaine and 10 mg ketorolac in the forearm group. Vital signs and visual analogue scale (VAS) score were recorded. If VAS score was >4, 50 µg fentanyl was injected. If the patient had VAS scores >6 with fentanyl, deep sedation with propofol was administered. RESULTS: Twenty-eight subjects were in each group. There were no significant differences in patient characteristics, tourniquet time, or pressure between the groups. Ten patients in the forearm vs 27 in the upper arm group had a VAS score >4. The mean fentanyl use was 30 µg in the forearm group vs 104 µg in the upper arm group. One patient in the forearm group required propofol vs 22 in the upper arm group. PACU bypass to phase 2 recovery occurred 19 times in the forearm group vs zero times in the upper arm group (P<0.0001). CONCLUSIONS: Our results indicate that the placement of the tourniquet on the forearm resulted in less discomfort, fewer sedation interventions, and greater likelihood of bypassing the PACU when compared with upper arm tourniquet.

Vein visualization: patient characteristic factors and efficacy of a new infrared vein finder technology.

BACKGROUND: We investigated the patient characteristic factors that correlate with identification of i.v. cannulation sites with normal eyesight. We evaluated a new infrared vein finding (VF) technology device in identifying i.v. cannulation sites. METHODS: Each subject underwent two observations: one using the conventional method (CM) of normal, unassisted eyesight and the other with the infrared VF device, VueTek's Veinsite™ (VF). A power analysis for moderate effect size (ß=0.95) required 54 samples for within-subject differences. RESULTS: Patient characteristic profiles were obtained from 384 subjects (768 observations). Our sample population exhibited an overall average of 5.8 [95% confidence interval (CI) 5.4-6.2] veins using CM. As a whole, CM vein visualization were less effective among obese [4.5 (95% CI 3.8-5.3)], African-American [4.6 (95% CI 3.6-5.5 veins)], and Asian [5.1 (95% CI 4.1-6.0)] subjects. Next, the VF technology identified an average of 9.1 (95% CI 8.6-9.5) possible cannulation sites compared with CM [average of 5.8 (95% CI 5.4-6.2)]. Seventy-six obese subjects had an average of 4.5 (95% CI 3.8-5.3) and 8.2 (95% CI 7.4-9.1) veins viewable by CM and VF, respectively. In dark skin subjects, 9.1 (95% CI 8.3-9.9) veins were visible by VF compared with 5.4 (95% CI 4.8-6.0) with CM. CONCLUSIONS: African-American or Asian ethnicity, and obesity were associated with decreased vein visibility. The visibility of veins eligible for cannulation increased for all subgroups using a new infrared device.

A case of massive thymolipoma.

A massive anterior mediastinal tumor was discovered in a 9-year-old girl with long-standing symptoms of asthma. Preoperative computed tomography (CT) scan and magnetic resonance imaging (MRI) results suggested the presence of a thymolipoma, a rare benign tumor of the thymus. Few cases have been reported in the literature, although the histological and radiographic features have been well described. This case confirms previously reported characteristics and also illuminates new aspects of clinical presentation and perioperative management.