Regional anaesthesia for limb surgery: a review of anaesthetists' beliefs and practice in the Oxford region.

We conducted a postal survey of 210 anaesthetists in the Oxford region to determine their views and practice regarding the timing of regional anaesthesia when combined with general anaesthesia for adults undergoing limb surgery and to compare the results with those obtained in a similar survey conducted in 2001. Of the 151 respondents (72% response rate), 102 (68%) regularly combined regional and general anaesthesia for adult limb surgery. Over 80% believed that central neuraxial blocks should be performed before general anaesthesia. This matched their current practice, marking a change from 2001. Significantly fewer anaesthetists believed it necessary to perform peripheral nerve blocks before general anaesthesia than in 2001, marking another significant change in practice. Overall, the results indicate an increased popularity of regional blocks in combination with general anaesthesia when compared with 2001 practice, which we believe is related to high quality advanced training modules now on offer to senior trainees in the Oxford region.

Use of three-dimensional animation for regional anaesthesia teaching: application to interscalene brachial plexus blockade.

BACKGROUND: Using commercial computer graphics software (TrueSpace), we constructed a virtual-reality model for teaching interscalene brachial plexus block. This tool combines the clarity of schematic drawings and the clinical relevance of video clips and live demonstrations. The aim is to accelerate learning and aid retention of relevant information. METHOD: We made a series of continuous short virtual-reality animations demonstrating the steps to perform an interscalene block. Superficial structures were made transparent to show the anatomical relevance of landmarking and needle manipulation. The clips were presented to delegates at a training course in Oxford. Delegates were surveyed to ascertain whether or not the presentation enhanced their understanding of anatomy and regional block technique. Before and after the presentation, delegates indicated surface landmarking, needle angulation, and movement on photographs of the lateral and anterolateral neck views of two volunteers. The markings were analysed by two independent assessors and rated as 'good', 'bad', or 'ungradeable'. The percentage improvement for each skill group was calculated and McNemar's test applied. RESULTS: Of 24 respondents, the majority thought that the presentation enhanced their understanding of the anatomical (87.5%) and technical principles (79.2%) of interscalene blocks. Analysis of the marked photographs showed an overall 24.1% improvement in landmarking skills after the teaching presentation (P<0.001). Changes were significant in moderately experienced skill groups (P<0.001) but not for the very experienced (P>0.5) and the inexperienced skill groups (P<0.1). There was 76.3% concordance in scoring between the two assessors. CONCLUSION: Three-dimensional animation is a promising new tool to accelerate the learning of regional anaesthetic techniques.

Regional anaesthesia for limb surgery--before or after general anaesthesia. A survey of anaesthetists in the Oxford region.

We conducted a postal survey of 221 anaesthetists in the Oxford region to determine their views and actual clinical practice regarding regional anaesthesia in adult patients undergoing limb surgery, when a combined regional and general anaesthetic was planned. Of the 162 respondents (73.3%), 142 (87.6%) regularly practised regional blocks for limb surgery in adult patients. For all the regional anaesthetic techniques in question, more anaesthetists felt it was safer to perform these blocks before induction of general anaesthesia than after induction. However, their actual practice varied markedly from their views, with more anaesthetists performing these blocks after general anaesthesia. Overall, trainees performed blocks before induction of general anaesthesia more often than consultants (p = 0.047).

Management of accidental dural puncture in labour with intrathecal catheters: an analysis of 10 years' experience.

The records of 15030 labour epidural blocks were analysed. Seventy-two accidental dural punctures (ADP) were recognised at the time of the procedure. In 34 women an epidural catheter was inserted intrathecally through the Tuohy needle and continuous spinal analgesia provided. In a further 37 women the primary management of ADP was to resite an epidural catheter. One woman who received a microspinal catheter later in labour was excluded from analysis. There were no significant differences in maternal characteristics, quality of labour analgesia and anaesthesia, or mode of delivery between the groups. Three repeat ADPs occurred during attempts to resite the epidural. Two women developed high blocks after epidural resiting, one of whom required intubation and ventilation. There was one high block in the intrathecal catheter group. The incidence of postdural puncture headache was 71% in the intrathecal catheter group compared with 81% in the non-intrathecal catheter group (P = 0.45). Epidural blood patch was performed on 50% of women managed with intrathecal catheters compared with 73% of those managed without (P = 0.08). Following ADP in labour an intrathecal catheter is a simple and effective alternative to resiting an epidural. Recognition of ADP is important as it allows appropriate management avoiding possible complications of administering epidural top-ups in the presence of a dural tear.

'Shared spinal cord' scenario: paraplegia following abdominal aortic surgery under combined general and epidural anaesthesia.

Serious neurological complications of abdominal aortic vascular surgery are rare but devastating for all involved. When epidural blockade is part of the anaesthetic technique such complications may be attributed to needles, catheters or drugs. We present a patient who developed paraplegia following an elective abdominal aortic aneurysm repair. Continuous epidural blockade was part of the anaesthetic technique and postoperative analgesia. In this case the spinal cord damage was explained by ischaemia caused by the aortic surgery. This event has made us aware of a rare complication associated with abdominal aortic surgery and highlighted safety aspects of epidural anaesthesia in such patients.