Peripheral Nerve Stimulation for Pudendal Neuralgia: A Technical Note.

BACKGROUND: Pudendal neuropathy is a chronic, disabling form of perineal pain that involves the pudendal nerve, a mixed somatic and autonomic nerve that originates from sacral nerve roots. Peripheral nerve stimulation of the pudendal nerve can be useful to decrease symptom burden in patients who have failed initial conservative treatment modalities. METHODS: In this manuscript, we describe an approach to the placement of a peripheral nerve stimulator for the treatment of pudendal neuralgia. We present a case of complex pelvic neuropathy and review the factors that lead to successful placement. Technical aspects of stimulator placement and ultrasound landmarks are reviewed. RESULTS: A lateral to medial approach with ultrasound guidance at the level of the ischial spine is likely to facilitate proper lead placement along the course of the pudendal nerve. Aftercare and adherence to postimplant activity restrictions-particularly avoiding use of the extremes of hip flexion and extension for four weeks-lead to the absence of lead migration. CONCLUSIONS: Pudendal nerve stimulation is an emerging technique for neuromodulation of refractory pudendal neuralgia. Ultrasound-guided pudendal nerve stimulation is a viable technique for neuromodulation of pudendal neuralgia. Optimization of patient selection, ultrasound guidance, and proper adherence to postimplant activity restrictions may be helpful for long-term therapeutic success.

The Effect of Ondansetron on Acute Opioid Tolerance in Patients Receiving Intrathecal Opioids Prior to Cesarean Delivery.

BACKGROUND: Multiple animal studies suggest that ondansetron ameliorates opioid-induced hyperalgesia and tolerance. In this study, we aimed to determine if the administration of ondansetron prior to spinal anesthesia would have an effect on intrathecal opioid-induced acute opioid tolerance, postoperative pain, and analgesic requirements in patients undergoing cesarean delivery with spinal anesthesia. METHODS: Eighty-six patients undergoing elective cesarean delivery were recruited and randomly allocated to receive either 8 mg intravenous ondansetron (n = 44) or placebo (n = 42) in a prospective, double-blind design. All patients received spinal anesthesia consisting of 15 mg bupivacaine, 20 µg of fentanyl, and 100 µg of preservative-free morphine. We used linear mixed-effects models to assess the difference in pain and opioid consumption in the first 24 hours after surgery between the 2 groups. RESULTS: No differences between the 2 groups were found in age, body mass index, American Society of Anesthesiologists physical status scores, duration of surgery, or sensory and motor block characteristics. There was no difference between the 2 groups in postoperative pain scores (P = 0.95) or opioid consumption (P = 0.68). CONCLUSIONS: In patients undergoing cesarean delivery under spinal anesthesia with intrathecal opioids, the administration of ondansetron prior to spinal anesthesia did not significantly affect postoperative pain scores or opioid consumption. Thus, the administration of ondansetron did not have an effect on acute opioid tolerance in our study.

Comparison of SEER Sonorheometry With Rotational Thromboelastometry and Laboratory Parameters in Cardiac Surgery.

BACKGROUND: The Quantra Hemostasis Analyzer is a novel diagnostic device that uses an ultrasound-based technology, sonic estimation of elasticity via resonance (SEER) sonorheometry, to characterize the dynamic changes in viscoelastic properties of a blood sample during coagulation. Cardiac surgery utilizing cardiopulmonary bypass (CPB) is associated with a significant impact on the coagulation system and can result in perioperative coagulopathy. The aim of this study was to correlate SEER sonorheometry results to corresponding rotational thromboelastometry (ROTEM) and laboratory parameters obtained before, during, and after CPB. METHODS: The Quantra uses a multiwell cartridge that performs 4 independent measurements with different combination of reagents. The output test results include Clot Time, Clot Stiffness, Fibrinogen and Platelet Contribution, Clot Time Ratio, and Heparinase Clot Time. Clot Time was compared with ROTEM INTEM clotting time and the adjusted partial thromboplastin time. Clot Stiffness was compared with ROTEM EXTEM. The Fibrinogen Contribution to the Clot Stiffness was correlated to ROTEM FIBTEM as well as fibrinogen concentration by the Clauss method. The Platelet Contribution to Clot Stiffness was compared with absolute platelet count and ROTEM-determined clot elasticity attributable to platelets. RESULTS: Fifty-five patients undergoing elective cardiac surgery were enrolled in this prospective observational study. Clot Time exhibited good correlation with ROTEM INTEM clotting time (pre-CPB r = 0.84, post-CPB r = 0.65) and adjusted partial thromboplastin time (pre-CPB r = 0.72, post-CPB r = 0.89); however, the majority of values were within a narrow normal range. Clot Stiffness exhibited significant correlation with ROTEM EXTEM A10 throughout the course of the study in all samples (r = 0.84). Fibrinogen Contribution correlated strongly with FIBTEM A10 (r = 0.85), and moderately with the fibrinogen concentration (r = 0.73) determined with the Clauss assay. The Platelet Contribution to Clot Stiffness showed moderate correlation to absolute platelet counts (r = 0.48). However, the correlation between Platelet Contribution and ROTEM-determined clot elasticity attributable to platelets was stronger (r = 0.78) than platelet number. All of the correlation coefficients were statistically significant with P < .001. CONCLUSIONS: SEER sonorheometry demonstrates significant correlation with ROTEM for determining Clot Stiffness and assessing Fibrinogen Contribution. SEER sonorheometry results can provide valuable information about the coagulation status in patients undergoing cardiac surgery using CPB.

SEER Sonorheometry Versus Rotational Thromboelastometry in Large Volume Blood Loss Spine Surgery.

BACKGROUND: Sonic estimation of elasticity via resonance (SEER) sonorheometry is a novel technology that uses acoustic deformation of the developing clot to measure its viscoelastic properties and extract functional measures of coagulation. Multilevel spine surgery is associated with significant perioperative blood loss, and coagulopathy occurs frequently. The aim of this study was to correlate SEER sonorheometry results with those of equivalent rotation thromboelastometry (ROTEM) and laboratory parameters obtained during deformity correction spine surgery. METHODS: Four independent SEER sonorheometry hemostatic indices (clot time, clot stiffness, fibrinogen, and platelet contribution) were measured. SEER sonorheometry clot time, using kaolin as an activator, was correlated with ROTEM intrinsic temogram clotting time and the activated partial thromboplastin time. For clot stiffness, thromboplastin was the primary activator, and this was correlated against ROTEM external temogram amplitude at 10 minutes (A10). The assay for the fibrinogen contribution was similar to clot stiffness, but abciximab was added to inhibit platelet function. The fibrinogen contribution assay was correlated with the ROTEM fibrinogen temogram A10. Finally, the SEER sonorheometry platelet contribution was calculated by subtracting the fibrinogen contribution from the clot stiffness. This variable was correlated with both absolute platelet counts, and ROTEM determined clot elasticity attributable to platelets. RESULTS: Fifty-one patients were enrolled in this prospective observational study. SEER sonorheometry clot stiffness, fibrinogen, and platelet contribution had a very strong correlation with ROTEM external temogram A10 (rs = .92; 99% confidence interval, .85-.96), fibrinogen temogram A10 (rs = .90; 99% confidence interval, .83-.93), and ROTEM-determined clot elasticity attributable to platelets (rs = .89; 99% confidence interval, .80-.95). SEER sonorheometry clot time exhibited moderate correlation with ROTEM intrinsic temogram clotting time (rs = .62; 99% confidence interval, .44-.77) and very weak correlation with activated partial thromboplastin time (rs = .33; 99% confidence interval, .10-.51). CONCLUSIONS: SEER sonorheometry demonstrates very strong correlation with ROTEM for determining clot stiffness and assessing fibrinogen and platelet contribution to clot strength in major spine surgery. An advantage of SEER sonorheometry is direct measurement of clot elasticity with no need to transform amplitude oscillation to elasticity.

Effects of hydroxyethyl starch 6 % (130/0.4) on blood loss during cesarean delivery: a propensity-matched analysis.

BACKGROUND: Hydroxyethyl starch is commonly used in the obstetric patient population to prevent hypotension during cesarean delivery. Evidence suggests hetastarch is associated with a dysfunction in coagulation cascade. We hypothesized that hetastarch use to prevent spinal hypotension during cesarean delivery would be associated with an increase in blood loss when compared to crystalloid use. METHODS: We performed a retrospective review of patients who underwent elective cesarean delivery under spinal anesthesia at the University of Virginia between 2011 and 2014. Data from 819 patients was used. Blood loss was the primary outcome. Propensity score-matching was used to match patients who received hetastarch (treatment group) with those who did not receive hetastarch (control group). RESULTS: Genetic matching resulted in 196 patients in the hetastarch group and 182 patients in the control group. There was no difference in estimated blood loss (p = 0.068), calculated blood loss (p = 0.720), total intraoperative fluid intake (p = 0.289), urine output (p = 0.421), Apgar 1 min (p = 0.830), Apgar 5 min (p = 0.138), phenylephrine consumption (p = 0.742), postoperative day 1 (POD1) hematocrit (p = 0.070) and POD1 platelets (p = 0.233). However, there was a statistically significant difference (but clinically irrelevant) in hematocrit difference between the day of admission and POD1 (mean difference 0.47, p = 0.024), and ephedrine consumption (mean difference 2 mg, p = 0.017) in favor of the control group. CONCLUSIONS: Our study did not find an association between increased perioperative blood loss and hetastarch use in patients presenting for elective cesarean delivery.

Does Ondansetron Modify Sympathectomy Due to Subarachnoid Anesthesia?: Meta-analysis, Meta-regression, and Trial Sequential Analysis.

BACKGROUND: Disagreement among many underpowered studies has led to an equivocal understanding of the efficacy of the 5-HT3 antagonist ondansetron in preventing the consequences of sympathectomy after subarachnoid anesthesia. The authors assessed the efficacy of ondansetron with respect to the overall quality and statistical power of the meta-analyses. METHODS: The authors used a standard and a newer method of meta-analysis, trial sequential analysis (TSA), to estimate adjusted CIs based on how much information has been accrued. They also used random-effects meta-analyses techniques, small trial bias assessment, selection models, sensitivity analyses, and the Grading of Recommendations on Assessment, Development, and Evaluation system. These results from the aforementioned techniques were compared, and importance of consideration of these factors was discussed. RESULTS: Fourteen randomized placebo-controlled trials (1,045 subjects) were identified and analyzed. By using conventional meta-analyses, the authors determined that ondansetron was associated with reduction in the incidence of hypotension (relative risk = 0.62 [95% CI, 0.46 to 0.83], P = 0.001; TSA-adjusted CI, 0.34 to 1.12; I = 60%, P = 0.002) and bradycardia (relative risk = 0.44 [95% CI, 0.26 to 0.73], P = 0.001; TSA-adjusted CI, 0.05 to 3.85; I = 0%, P = 0.84). However, the authors found indications of bias among these trials. TSAs demonstrated that the meta-analysis lacked adequate information size and did not achieve statistical significance when adjusted for sparse data and repetitive testing. The Grading of Recommendations on Assessment, Development, and Evaluation system showed that the results had low to very low quality of evidence. CONCLUSIONS: The analyses fail to confirm evidence that ondansetron reduces the incidence of hypotension and bradycardia after subarachnoid anesthesia due to the risk of bias and information sizes less than the required. As results from meta-analysis are given significant weight, it is important to carefully evaluate the quality of the evidence that is input.

A Clinical Comparison of Intravenous and Epidural Local Anesthetic for Major Abdominal Surgery.

BACKGROUND: Epidural analgesia provides good pain control after many postoperative procedures, but it can lead to complications, has some contraindications, and occasionally fails. Intravenous lidocaine infusion has been suggested as an alternative. We assessed, in our clinical practice, the effects of perioperative intravenous lidocaine infusion compared with epidural analgesia for major abdominal surgery. METHODS: We conducted a retrospective review of patients who had received intravenous lidocaine (1 mg/kg per hour) perioperatively after a major abdominal surgery. We matched them with patients who had received epidural analgesia. We tested a joint hypothesis of noninferiority of lidocaine infusion to epidural analgesia in postoperative pain scores and opioid consumption. We assigned a noninferiority margin of 1 point (on an 11-point numerical rating scale) difference in pain and a ratio [mean (lidocaine) / mean (epidural)] of 1.2 in opioid consumption, respectively. RESULTS: Two hundred sixteen patients (108 in each group) were analyzed. Intravenous lidocaine was not inferior to epidural analgesia with respect to pain scores. Lidocaine infusion was inferior to epidural analgesia with respect to opioid consumption. Patients in the lidocaine group had fewer episodes of hypotension and less postoperative nausea and vomiting, pruritus, and urinary retention. Patients receiving lidocaine also had earlier urinary catheter removal and earlier first gastrointestinal function. Daily mental status assessment was similar between the 2 groups. CONCLUSIONS: Patients who received systemic lidocaine infusions with the addition of PRN (as needed) opioids administered for breakthrough pain did not have clinically significant differences in pain scores on postoperative day 2 and beyond. Intravenous lidocaine infusion in major abdominal surgery was inferior to epidural analgesia with respect to opioid consumption. However, lidocaine was associated with improvements in several important aspects of recovery.

Flexible bronchoscopy in children: Utility and complications.

BACKGROUND AND OBJECTIVES: The flexible bronchoscope has become widely used by pediatric pulmonologists as a diagnostic and therapeutic tool. Nevertheless, there are several gaps in our knowledge to help refine its use and reduce its complications. In this study, we aimed to evaluate the utility and complications of pediatric bronchoscopy. DESIGN AND SETTING: We conducted a retrospective review of bronchoscopy cases between March 2006 and April 2015 at a tertiary care medical center (King Fahad Medical City). One-hundred forty nine patients were studied. PATIENTS AND METHODS: We evaluated how bronchoscopy contributed to the patients' diagnosis, assessed the accuracy of bronchoalveolar lavage white blood cell count (BAL WBC) to differentiate between infectious and non-infectious conditions, assessed the ability of clinical factors to predict high risk of desaturation during bronchoscopy, and finally summarized the reported procedural complications. RESULTS: We found pediatric bronchoscopy was a crucial diagnostic (confirming, ruling out, and discovering unexpected diagnosis) and therapeutic tool. The accuracy of BAL WBC counts is poor (AUC (95% CI) = 0.609 (0.497-0.712)); however, using two cutoff values (≤10 WBCs (sensitivity = 84.44% and specificity = 29.27%) to rule out, and ≥400 WBCs (sensitivity = 33.33% and specificity 81.49%) to rule in infection) helped in early differentiation between infectious and non-infectious conditions. From the factors that we test, none we found predictive of desaturation. The most common procedural complication was desaturation (pooled incidence (95% CI) = 13 (8-19)%) followed by cough, mild airway bleeding, and spasm. CONCLUSIONS: Flexible bronchoscopy is an important and relatively safe diagnostic and therapeutic tool in pediatric medicine, and utilization of this service should be encouraged after a careful consideration of which patient needs this procedure and a rigorous estimate of its pros and cons.

Efficacy of the methoxyflurane as bridging analgesia during epidural placement in laboring parturient.

BACKGROUND: Establishing an epidural in an agitated laboring woman can be challenging. The ideal pain control technique in such a situation should be effective, fast acting, and short lived. We assessed the efficacy of inhalational methoxyflurane (Penthrox™) analgesia as bridging analgesia for epidural placement. MATERIALS AND METHODS: Sixty-four laboring women who requested epidural analgesia with pain score of ≥7 enrolled in an observational study, 56 of which completed the study. The parturients were instructed to use the device prior to the onset of uterine contraction pain and to stop at the peak of uterine contraction, repeatedly until epidural has been successfully placed. After each (methoxyflurane inhalation-uterine contraction) cycle, pain, Richmond Agitation Sedation Scale (RASS), nausea and vomiting were evaluated. Maternal and fetal hemodynamics and parturient satisfaction were recorded. RESULTS: The mean baseline pain score was 8.2 ± 1.5 which was reduced to 6.2 ± 2.0 after the first inhalation with a mean difference of 2.0 ± 1.1 (95% confidence interval 1.7-2.3, P < 0.0001), and continued to decrease significantly over the study period (P < 0.0001). The RASS scores continuously improved after each cycle (P < 0.0001). Only 1 parturient from the cohort became lightly sedated (RASS = -1). Two parturients vomited, and no significant changes in maternal hemodynamics or fetal heart rate changes were identified during treatment. 67% of the parturients reported very good or excellent satisfaction with treatment. CONCLUSION: Penthrox™ provides rapid, robust, and satisfactory therapy to control pain and restlessness during epidural placement in laboring parturient.

Improving Analgesic Efficacy and Safety of Thoracic Paravertebral Block for Breast Surgery: A Mixed-Effects Meta-Analysis.

BACKGROUND: While most trials of thoracic paravertebral nerve blocks (TPVB) for breast surgery show benefit, their effect on postoperative pain intensity, opioid consumption, and prevention of chronic postsurgical pain varies substantially across studies. Variability may result from use of different drugs and techniques. OBJECTIVES: To examine the use of TPVB in breast surgery, and to determine which method(s) provide optimal efficacy and safety. STUDY DESIGN: Mixed-Effects Meta-Analysis. METHODS: We conducted a systematic review of randomized trials comparing TPVB to no intervention using random-effects models. To evaluate the contributions of various techniques, clinical approaches were included as moderators in mixed-effects models. RESULTS: A total of 24 randomized controlled trials (RCTs) with 1,822 patients were included. Use of TPVB decreased postoperative pain scores at rest and movement at the first 2, 24, 48, and 72 hours. TPVB modestly decreased intraoperative and postoperative opioid consumption, reduced nausea and vomiting, and shortened hospitalization, but to a probably clinically irrelevant degree. Blocks also appeared to reduce the incidence of chronic postsurgical pain at 6 months. Adding fentanyl to the TPVB improved pain at rest (at 24, 48, and 72 hours) and movement (at 24 and 72 hours). Multilevel blocks provided better postoperative pain control, but only during movement (at 2, 48, and 72 hours). Fewer procedural complications (especially hypotension, epidural spread, and Horner's syndrome) occurred when anatomical landmarks were supplemented with ultrasound guidance. LIMITATIONS: The number of studies available was limited in the meta-analytic model of incidence of chronic post-surgical pain. CONCLUSION: TPVB reduces postoperative pain and opioid consumption, and has a limited beneficial effect on the quality of recovery. From all the techniques that were evaluated, only the addition of fentanyl, and performing multilevel blocks were associated with improved acute analgesia. TPVB may reduce chronic postsurgical pain at 6 months.

Rotational thromboelastometry-guided blood product management in major spine surgery.

OBJECT Major spinal surgery in adult patients is often associated with significant intraoperative blood loss. Rotational thromboelastometry (ROTEM) is a functional viscoelastometric method for real-time hemostasis testing. In this study, the authors sought to characterize the coagulation abnormalities encountered in spine surgery and determine whether a ROTEM-guided, protocol-based approach to transfusion reduced blood loss and blood product use and cost. METHODS A hospital database was used to identify patients who had undergone adult deformity correction spine surgery with ROTEM-guided therapy. All patients who received ROTEM-guided therapy (ROTEM group) were matched with historical cohorts whose coagulation status had not been evaluated with ROTEM but who were treated using a conventional clinical and point-of-care laboratory approach to transfusion (Conventional group). Both groups were subdivided into 2 groups based on whether they had received intraoperative tranexamic acid (TXA), the only coagulation-modifying medication administered intraoperatively during the study period. In the ROTEM group, 26 patients received TXA (ROTEM-TXA group) and 24 did not (ROTEM-nonTXA group). Demographic, surgical, laboratory, and perioperative transfusion data were recorded. Data were analyzed by rank permutation test, adapted for the 1:2 ROTEM-to-Conventional matching structure, with p < 0.05 considered significant. RESULTS Comparison of the 2 groups in which TXA was used showed significantly less fresh-frozen plasma (FFP) use in the ROTEM-TXA group than in the Conventional-TXA group (median 0 units [range 0-4 units] vs 2.5 units [range 0-13 units], p < 0.0002) but significantly more cryoprecipitate use (median 1 unit [range 0-4 units] in the ROTEM-TXA group vs 0 units [range 0-2 units] in the Conventional-TXA group, p < 0.05), with a nonsignificant reduction in blood loss (median 2.6 L [range 0.9-5.4 L] in the ROTEM-TXA group vs 2.9 L [0.7-7.0 L] in the Conventional-TXA group, p = 0.21). In the 2 groups in which TXA was not used, the ROTEM-nonTXA group showed significantly less blood loss than the Conventional-nonTXA group (median 1 L [range 0.2-6.0 L] vs 1.5 L [range 1.0-4.5 L], p = 0.0005), with a trend toward less transfusion of packed red blood cells (pRBC) (median 0 units [range 0-4 units] vs 1 unit [range 0-9 units], p = 0.09]. Cryoprecipitate use was increased and FFP use decreased in response to ROTEM analysis identifying hypofibrinogenemia as a major contributor to ongoing coagulopathy. CONCLUSIONS In major spine surgery, ROTEM-guided transfusion allows for standardization of transfusion practices and early identification and treatment of hypofibrinogenemia. Hypofibrinogenemia is an important cause of the coagulopathy encountered during these procedures and aggressive management of this complication is associated with less intraoperative blood loss, reduced transfusion requirements, and decreased transfusion-related cost.

Ondansetron Does Not Attenuate Hemodynamic Changes in Patients Undergoing Elective Cesarean Delivery Using Subarachnoid Anesthesia: A Double-Blind, Placebo-Controlled, Randomized Trial.

INTRODUCTION: Hypotension is the most common complication after subarachnoid anesthesia for cesarean delivery. Several therapeutic and preventive measures are used to attenuate this side effect. Serotonin receptor-blocking drugs have been suggested as one such approach. We sought to determine whether prophylactically administered intravenous ondansetron could attenuate hypotension in patients undergoing elective cesarean delivery performed under subarachnoid anesthesia. METHODS: Eighty-six patients undergoing elective cesarean delivery were recruited and randomly allocated to receive either 8 mg intravenous ondansetron (group O; n = 44) or placebo (group P; n = 42) in a prospective double-blind design. Systolic blood pressure (SBP), mean arterial pressure (MAP), diastolic blood pressure (DBP), and heart rate (HR) were measured at baseline and at 3-minute intervals from the time of initiation of subarachnoid anesthesia until delivery. Ondansetron effect on hemodynamics (SBP, DBP, MAP, and HR) was quantified and analyzed using a linear mixed effect model. RESULTS: We did not find differences in SBP (P = 0.78), MAP (P = 0.89), DBP (P = 0.82), or HR (P = 0.18) between the 2 groups during the study period. Phenylephrine requirements to treat hypotension were 350 µg (175-700 µg) in group O and 450 µg (300-700 µg) in group P (P = 0.30). The incidence of pruritus was 63% (n = 28 of 44) in group O and 56% (n = 23 of 42) in group P (difference, 0.08 [95% confidence interval, -0.23 to 0.41], P = 0.59). No difference in the incidence of nausea and vomiting or sensory level was found. CONCLUSIONS: Ondansetron premedication does not attenuate hemodynamic changes after subarachnoid anesthesia nor does it reduce the amount of vasopressor use, pruritus, or nausea and vomiting.

Perioperative lidocaine infusion reduces the incidence of post-mastectomy chronic pain: a double-blind, placebo-controlled randomized trial.

BACKGROUND: Chronic post-surgical pain (CPSP) is a not uncommon complication after mastectomy, with a reported incidence between 20% and 68%. Careful dissection, the use of minimally invasive surgical techniques, and attempts to reduce the associated inflammatory and hyperalgesic responses are suggested methods to prevent CPSP. OBJECTIVE: To determine if the use of perioperative lidocaine infusion is associated with decreased incidence of CPSP after mastectomy. STUDY DESIGN: Double-blind, placebo-controlled randomized trial. METHODS: This is a secondary analysis of data from 61 out of 71 patients who underwent mastectomy for breast cancer. Patients were randomized to either placebo (Group P; n = 27) or intravenous lidocaine (Group L; n = 34, bolus 1.5 mg/kg at induction, then infusion at 2 mg/kg/hr, up to 2 hours after the end of surgery) in a prospective double-blind design. CPSP was assessed at 6 months after surgery. Stepwise logistic regression analysis was performed to assess the efficacy of lidocaine. RESULTS: Overall 12 (20%) patients developed CPSP, 8 (30%) in the placebo group and 4 (12%) in the lidocaine group. Predictive factors for CPSP that remained significant after multivariate analysis included lidocaine (associated with a 20-fold decrease in CPSP, P = 0.013), breast implant placement (associated with a 16-fold increase in CPSP, P = 0.034), and radiotherapy (associated with a 29-fold increase in CPSP, P = 0.008). LIMITATIONS: Small sample size. CONCLUSION: Perioperative lidocaine administration was associated with a decreased incidence of CPSP, while breast implant placement and radiotherapy were associated with an increased incidence. These findings suggest a protective effect of lidocaine on CPSP development in mastectomy patients.

Randomized clinical trial of continuous femoral nerve block combined with sciatic nerve block versus epidural analgesia for unilateral total knee arthroplasty.

Pain control following total knee arthroplasty (TKA) is crucial to hasten rehabilitation and decrease morbidity. We evaluated whether there is a difference between epidural infusion and continuous femoral nerve block with respect to postoperative pain control and rehabilitation course. Fifty patients completed the study. There was no statistically significant difference in the pain scores (P=0.33), morphine consumption (P=0.09) mean blood pressure or heart rate (P=0.957, and P=0.716) between groups. The postoperative daily mobilization (P=0.80), knee joint range of motion (P=0.83), and straight leg test (P=0.99) were also similar between both groups. Patients were highly satisfied with their pain management in both groups without statistically significant difference (P=0.98).

General anesthesia for the heaviest man in the world.

The prevalence of obesity has increased greatly over the last 20 years, resulting in an increase in the number of bariatric and nonbariatric surgeries in this population. We present the case of a 20-year-old male, weighing 610 kg (1345 lb), and believed to be the heaviest living man in the world. After 4 months of rigorous in-hospital weight reduction, now weighing 510 kg (1125 lb), he underwent a laparoscopic gastric sleeve procedure under general anesthesia. This report describes the management of his anesthetic and exemplifies the challenges associated with this patient population.

Effect of intravenous lidocaine on postoperative recovery of patients undergoing mastectomy: a double-blind, placebo-controlled randomized trial.

BACKGROUND: One of the modalities of treatment for breast cancer surgery pain is opioids, and opioids are associated with adverse effects such as itching and postoperative nausea and vomiting (PONV). Intravenous (IV) lidocaine has been shown to reduce opioid consumption and to improve overall postoperative outcomes in abdominal surgery. In this study, we tested the effect of intraoperative IV lidocaine infusion on the quality of postoperative recovery after breast cancer surgery. METHODS: Seventy-one patients undergoing breast cancer surgery were randomly assigned to receive either placebo (group P; n = 34) or IV lidocaine (group L; n = 37, bolus 1.5 mg/kg at induction, then infusion at 2 mg/kg/h, stopped 2 hours after the end of surgery) in a prospective double-blind design. Intraoperative and postoperative morphine consumption was calculated. Postoperative pain scores, PONV, and fatigue were assessed at 2, 24, and 48 hours after surgery. Duration of postoperative hospital stay was recorded. RESULTS: Demographics were the same between the groups. There was no statistically significant difference in intraoperative or postoperative morphine consumption (P = 0.188 and P = 0.758) between groups. Overall pain scores either at rest or activity (P = 0.348 and P = 0.810, respectively), PONV (P = 0.350), fatigue (P = 0.758), or duration of postoperative hospital stay (P = 0.218) were not statistically different. CONCLUSIONS: Our findings did not show a significant effect of IV lidocaine during breast cancer surgery on opioid consumption, pain score, PONV, or fatigue, indicating that the benefit of this approach does not generalize across all types of surgery.

Early prediction of oral calcium and vitamin D requirements in post-thyroidectomy hypocalcaemia.

OBJECTIVE: To optimize and individualize post-thyroidectomy hypocalcemia management. STUDY DESIGN: A multicenter prospective cohort study. SETTING: Two tertiary care hospitals. SUBJECTS AND METHODS: parathyroid hormone (PTH) was measured preoperatively, then at 1 and 6 hours after surgery. The required doses of calcium and vitamin D were defined as those maintaining the patients asymptomatic and their cCa ≥ 2 mmol/L. They were used as an endpoint in a generalized linear mixed effect model (GLIMMEX) aiming to identify the best predictors of these optimal required doses. Models were evaluated by goodness of fit and Receiver Operating Characteristic (ROC) curves. RESULTS: One hundred and sixty-eight patients were analyzed; 85.1% were female, 49.3% had BMI > 30, and 64% had vitamin D deficiency. Post-thyroidectomy hypocalcemia was found in 25.6%, of whom 18 (41.9%) were symptomatic and received intravenous calcium. First hour percentage of drop in PTH correlated positively with the severity of hypocalcemia (P < .0001). The GLIMMIX prediction model for oral calcium requirement was based on first-hour percentage change from preoperative PTH level, preoperative actual PTH, BMI, and thyroid function. The same predictors were identified for vitamin D, except that thyroid function was replaced with vitamin D status. These factors were used to build predictive equations for calcium and vitamin D doses. CONCLUSION: Our findings help to optimize management of post-thyroidectomy hypocalcemia by assisting in the early identification of those who are not at risk of hypocalcaemia and by guiding early effective management of those at risk. This may reduce complications and medical cost.