Serratus Plane Block: A Cadaveric Study to Evaluate Optimal Injectate Spread

Background and Objectives Although serratus plane block reportedly provides satisfactory analgesia for breast and thoracic surgeries, the optimal technique for consistent success has not been studied. The goal of this anatomical study was to evaluate the impact of volume, level, and site of injection on the extent of injectate spread that can influence anesthetic coverage. Methods Ultrasound-guided dye injection and subsequent dissection were performed in 39 cadaveric hemithoraces. Methylene blue was injected according to 1 of 4 injection protocols as follows: one 20-mL bolus, either superficial or deep to the serratus anterior muscle (SAM), at the fifth rib level (groups SUP-20 and DEEP-20, respectively), or two 20-mL boluses, either superior or deep to the SAM, one at the third rib and one at the fifth rib level (group SUP-40 and group DEEP-40, respectively). Following injection, dissection and 3-dimensional digitization were performed to map the area of dye spread. Results We found that the extent of dye spread was mostly influenced by the volume of injection rather than the plane of injection (superficial vs deep to SAM). Increasing the volume from 20 to 40 mL doubled the area of injectate spread and promoted dye spread preferentially to the anterior chest wall, with some impact on cephalad-to-caudad spread and no impact on posterior spread. Dye was found most consistently in the axilla when a separate injection was performed at the third rib level. Conclusions Our data showed that a high-volume double-injection technique provides extensive and consistent dye spread in the anterior chest wall and axilla, regardless of the plane of injection relative to the SAM. This technique likely provides more reliable analgesic coverage for breast procedures especially those that involve the axilla, pending confirmation in future clinical studies. Accepted for publication April 22, 2018. Address correspondence to: Vincent Chan, MD, FRCPC, FRCA, Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst St, MCL 2-405, Toronto, Ontario M5T 2S8, Canada (e-mail: vincent.chan@uhn.ca). V.C. has received honorarium from SonoSite, BBraun, and Aspen Pharma. He also sat on the Medical Advisory Board of Smiths Medical. A.P. has a research grant from Fisher and Pykel for an unrelated study. She is associate editor of Regional Anesthesia and Pain Medicine. A.A. is an anatomy faculty at Allergan Academy of Excellence. The other authors declare no conflict of interest. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Pericapsular Nerve Group (PENG) Block for Hip Fracture

Fascia iliaca block or femoral nerve block is used frequently in hip fracture patients because of their opioid-sparing effects and reduction in opioid-related adverse effects. A recent anatomical study on hip innervation led to the identification of relevant landmarks to target the hip articular branches of femoral nerve and accessory obturator nerve. Using this information, we developed a novel ultrasound-guided approach for blockade of these articular branches to the hip, the PENG (PEricapsular Nerve Group) block. In this report, we describe the technique and its application in 5 consecutive patients. Accepted for publication April 14, 2018. Address correspondence to: Philip W.H. Peng, MBBS, FRCPC, Founder (Pain Med), Department of Anesthesia, McL 2-405, TWH, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8 (e-mail: philip.peng@uhn.ca). A.P. has a research grant from Fisher and Pykel. P.W.H.P. has equipment support from Fujifilm/Sonosite Canada. The other authors declare no conflict of interest. The authors have no sources of funding to declare for this article. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Comparison of the ED50 and ED95 of Intrathecal Bupivacaine in Parturients Undergoing Cesarean Delivery With or Without Prophylactic Phenylephrine Infusion: A Prospective, Double-Blind Study

Background and Objectives While prophylactic phenylephrine infusions during cesarean delivery are often used to counteract the sympathectomy associated with spinal anesthesia, their use has been associated with decreased rostral spread of local anesthetic. The purpose of this study was to determine the median effective dose (ED50) and 95% effective dose (ED95) of intrathecal hyperbaric bupivacaine for cesarean delivery in the presence and absence of prophylactic phenylephrine infusion. Methods One hundred healthy parturients undergoing elective cesarean delivery under combined spinal-epidural anesthesia were enrolled in this randomized, double-blind, dose-finding study to determine ED50 and ED95. Subjects were randomly assigned to receive prophylactic phenylephrine or control (saline) infusion with injection of 6, 7.5, 9, 10.5, or 12 mg intrathecal hyperbaric bupivacaine. An effective dose was defined as achieving a T5 sensory level within 10 minutes of intrathecal drug administration without the need for epidural supplementation. Results The ED50 of intrathecal hyperbaric bupivacaine was 10.0 mg (95% confidence interval [CI], 5.9–11.4 mg) with prophylactic phenylephrine infusion and 7.9 mg (95% CI, 2.3–9.4 mg) in the control group. The ED95 of intrathecal hyperbaric bupivacaine was 14.1 mg (95% CI, 12.3–37.6 mg) with prophylactic phenylephrine infusion and 11.7 mg (95% CI, 9.9–22.8 mg) in the control group. Conclusions The administration of prophylactic phenylephrine infusion results in higher intrathecal hyperbaric bupivacaine dosing requirements in parturients undergoing cesarean delivery. Clinical Trial Registration This study was registered at the Chinese Clinical Trial Registry, identifier ChiCTR-TRC-16008938. Accepted for publication April 14, 2018. Address correspondence to: Xinzhong Chen, MD, Department of Anesthesia, Women's Hospital, School of Medicine, Zhejiang University, No. 1, Xueshi Road, 310006 Hangzhou, China (e-mail: chenxinz@zju.edu.cn). The authors declare no conflict of interest. This study was supported by the funds from National Natural Science Foundation of China (no. 81271237 and no. 81471126). Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine.

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Topical Sphenopalatine Ganglion Block Compared With Epidural Blood Patch for Postdural Puncture Headache Management in Postpartum Patients: A Retrospective Review

Background and Objectives Postdural puncture headache (PDPH) is a severe and debilitating complication of unintentional dural puncture. The criterion-standard treatment for PDPH has been epidural blood patch (EBP), but it is an invasive intervention with the potential for severe complications, such as meningitis and paralysis. We believe this is the first ever 17-year retrospective chart review in which we compare the effectiveness of sphenopalatine ganglion block (SPGB) to EBP for PDPH treatment in postpartum patients. Methods We conducted a chart review of the first authors' obstetric patients who experienced PDPH from an unintentional dural puncture from a 17-gauge Tuohy needle for labor epidural from January 1997 to July 2014. Demographic characteristics, headache severity, and associated symptoms were collected prior to treatment. Forty-two patients who received SPGB and 39 patients who received EBP were identified. Residual headache, recovery from associated symptoms, and new treatment complications were compared between the 2 groups at 30 minutes, 1 hour, 24 hours, 48 hours, and 1 week posttreatment. Results A greater number of patients showed significant relief in their PDPH and associated symptoms at 30 and 60 minutes after treatment with SPGB than after treatment with EBP (P

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Shared decision-making for postoperative analgesia: A semistructured qualitative study

BACKGROUND Shared decision-making (SDM) and decision-support tools have attracted broad support in healthcare as they improve medical decision-making. Experts disagree on how these can help patients evaluate their present situation and possible outcomes of therapy, and how they might reduce decisional conflict. Little is known about their implementation, especially in anaesthesiology. OBJECTIVE To obtain a more fundamental understanding of pre-operative SDM and evaluate the use of a decision-support tool for postoperative analgesia after major thoracic and abdominal surgery. DESIGN A qualitative study with semistructured, in-depth interviews of patients and professionals. SETTING Patient recruitment took place at the Radboud University Medical Centre in Nijmegen and the Canisius Wilhelmina Hospital in Nijmegen, a nonacademic teaching centre. Professionals of the Radboud University Medical Centre were invited to participate in the interviews. PARTICIPANTS Interviews were performed with 10 individual patients and two focus groups both consisting of eight different professionals. MAIN OUTCOME MEASURES To gain insight into the provision of pre-operative information, decision-making processes and the clarity and usability of a prototype decision-support tool. RESULTS Professionals seemed to provide their patients with information directed towards the application of epidural analgesia, providing little attention to its negative effects. For many patients, the information was not tailored to their needs. Patients' involvement in decision-making was minimal, but they did not feel a need for more involvement. They were positive about the decision-support tool, although they indicated that it would not have influenced their treatment decision. Professionals expressed their doubt about the capacity of their patients to fully understand the decisions involved and about the clinical usability of the decision-support tool, because patients might misinterpret the information provided. CONCLUSION The results of this study suggest that both patients and professionals did not adhere to some 'self-evident' principles of SDM when postoperative analgesia after major thoracic and abdominal surgery was discussed. Correspondence to Dr Martin J.L. Bucx, MD, PhD, Consultant, Anaesthesiologist and Clinical Epidemiologist, Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Internal Postal Code 717, PO Box 9101, 6500 HB Nijmegen, The Netherlands Tel: +31 24 361 45 53; fax: +31 24 354 04 62; e-mail: Martin.Bucx@Radboudumc.nl Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (https://ift.tt/2ylyqmW). © 2018 European Society of Anaesthesiology

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Informed consent for regional anesthesia

Purpose of review This narrative review describes the current framework for informed consent discussions for regional anesthesia practice from an ethical and medicolegal stand point as the cornerstone of the patient–physician relationship and the respect for patient autonomy. Recent guidelines and position statements from anesthesia societies have emphasized the importance of these discussions and their appropriate documentation. Recent findings Recent studies have shown that patients want to know more about both common and benign, as well as rare but serious adverse events, as it relates to their anesthetic care. Several strategies have been recently recommended as a means to facilitate a meaningful consent discussion and proper documentation in the perioperative environment. Summary Defining the material risks of ultrasound-guided regional anesthetic procedures remains challenging, due in part to the difficulty in quantifying incidence rates of relatively rare events. However, well informed discussions are of great importance to support patient autonomy and lay a strong foundation for the patient–anesthesiologist relationship. Correspondence to Anahi Perlas, MD, FRCPC, Staff Anesthesiologist, Toronto Western Hospital, University Health Network, Professor, Department of Anesthesia, University of Toronto, 399 Bathurst St, Toronto, ON M5T 2S8, USA. Tel: +1 416 603 5118; fax: +1 416 603 6494; e-mail: Anahi.perlas@uhn.ca Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Brucellosis in renal transplant recipients: a comparative review of 5 cases

Although brucellosis in renal transplant recipients is rare, we studied the clinical characteristics of this infection in this patient population due to the significantly increased number of renal transplantations performed over the past few decades. We report one case from our experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of 5 cases of brucellosis in renal transplant recipients were found to date. The mean time from transplantation to diagnosis of brucellosis was 4.7 years (range, 4 months to 13 years). Blood culture and detection of anti-Brucella antibodies were frequently used diagnostic investigations. Treatment with appropriate antibiotic regimen led to a clinical cure and marked improvement in Brucella titre in all the patients. This review illustrates that clinicians should remain vigilant for this infectious aetiology following renal transplantation. Further studies are required to delineate the magnitude and scope of this association.

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From carcinoma through lymphoma to myeloma: a gastric mass diagnostic rollercoaster ride

We describe a dramatic clinical presentation of extramedullary multiple myeloma (MM) in an elderly patient with known monoclonal gammopathy of unknown significance (MGUS). Gastrointestinal symptoms and a gastric mass on imaging studies suggested an advanced solid gastric malignancy. Pathological workup of gastric biopsies first suspected a lymphoma, a second opinion finally confirmed an extramedullary MM. Treatment with bortezomib, cyclophosphamide and dexamethasone induced rapid relief of symptoms and normalisation of renal function as well as serum MM markers. Our case highlights the diagnostic difficulties when MM presents with signs and symptoms of respective end-organ involvement rather than typical 'CRAB' criteria. It underlines the importance of actively considering MM in a patient with MGUS, regardless of the clinical presentation of a specific medical problem. Our report also impressively illustrates the rapid response of MM and its gastric extramedullary manifestation to guideline-adherent chemotherapy.

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Mycobacterium bovis BCG spinal osteomyelitis in a patient with bladder cancer without a history of BCG instillation

BCG has been used as intravesical immunotherapy for the treatment of bladder carcinoma. However, this treatment is not harmless and may lead to complications, with a reported incidence of systemic BCG infection ranging from 3% to 7%. We report a case of culture-proven Mycobacterium bovis (BCG) vertebral osteomyelitis in a 72-year-old patient with bladder carcinoma who was treated with intravesical mitomycin C but did not receive BCG. Cultures from biopsy recovered isolate resembling Mycobacterium tuberculosis biochemically, but resistant to pyrazinamide (PZA). The patient was originally started on a four-drug antituberculous regimen of isoniazid, rifampin, ethambutol and PZA. After genotypic analysis identified the organism as M. bovis (BCG), the regimen was changed to isoniazid and rifampin for 12 months. The patient responded well to this treatment. This case is unique as the patient received only intravesical mitomycin and did not receive BCG, implying the possibility of transmission from contaminated equipment.

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Primary malignant melanoma of urethra mimicking as urethral caruncle

Description 

A 50-year-old woman presented with dysuria and intermittent vaginal bleeding for last 6 months. On local examination, a 1x1 cm mass was seen protruding from anterior wall of urethral meatus. The mass was lobulated, firm, painless and tan coloured (figure 1). The local pelvic examination and general physical examination was normal. Cystourethroscopy revealed no abnormality in the urethra and urinary bladder. The mass was provisionally diagnosed as urethral caruncle and was excised under local anaesthesia. The histopathology came as a surprise to us as it revealed diffuse infilteration of large pleomorphic, epitheloid and spindle-shaped tumour cells with high nucleocytoplasmic ratio, vesicular chromatin, prominent nucleoli and scant amount of cytoplasm (figure 2). Melanin pigment was also seen within the cells. Further analysis with immunohistochemistry revealed positive immunostaining with HMB-45 and confirmed it to be primary malignant melanoma of urethra (figure 3). Further workup...

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Spontaneous pneumomediastinum in limited cutaneous systemic sclerosis and myositis overlap

A 58-year-old man with limited cutaneous systemic sclerosis and myositis overlap complicated by interstitial lung disease presented with several months of progressive dyspnoea and weakness. CT chest revealed extensive pneumomediastinum that was not present on imaging 6 months before this study and appeared to be spontaneous, with no preceding trauma, infection or invasive procedures.

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Acute kidney injury associated with hypercalcaemic crisis in a patient with primary hyperparathyroidism

Parathyroid or hypercalcaemic crisis is a rare presenting manifestation of primary hyperparathyroidism and usually seen in relation to parathyroid carcinoma and multiple myeloma. We present a middle-aged woman with extreme hypercalcaemia due to parathyroid adenoma presenting as acute kidney injury. This case highlights the need to consider primary hyperparathyroidism in differentials of a patient presenting with severe hypercalcaemia and renal dysfunction. Also this is the second reported case in literature of a patient surviving such extreme hypercalcaemia due to parathyroid adenoma.

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Solitary juvenile polyp as a cause of elevated faecal calprotectin in an adult

Faecal calprotectin (FCP) levels are commonly measured in both primary and secondary care as an adjunct to the diagnosis of inflammatory bowel disease (IBD). Juvenile polyps are a rare form of colonic polyp found in both adults and children. We present a case of an adult patient who presented with a very high FCP level, which subsequently normalised following removal of a solitary colonic juvenile polyp. There was no evidence of IBD. Elevation of FCP levels due to this type of colonic pathology have not previously been described in the literature.

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Multiorgan system structural malformations associated with Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS) type 2: avoiding pitfalls in diagnosis, counseling and treatment

An 18-year-old virginal woman was referred to the reproductive endocrinology clinic with primary amenorrhoea and secondary sexual development in the absence of pelvic pain. Additionally, she had significant congenital sensorineural hearing loss, autism, bipolar disorder and class III obesity. On physical examination, secondary sexual development was confirmed (Tanner 5 breasts and Tanner 4 pubic hair). She refused further pelvic examination following prior attempts by the referring physicians. Serum leutinizing hormone (LH), follicle sitmulating hormone (FSH). prolactin, estradiol and total testosterone values were within normal limits. Karyotype was 46,XX. MRI demonstrated complete uterine agenesis, short vagina, sacral dysgenesis with complete absence of the coccyx and a horseshoe kidney. Diagnosis of Mayer-Rokitansky-Küster-Hauser Syndrome type 2 was established based on clinical, laboratory and MRI findings. The patient and family were counselled regarding the disease process, techniques for vaginal elongation, sexual activity and future reproductive options.

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Unusual presentation of acute pulmonary embolus presenting with inferior ST elevation

Description  

A 67-year-old woman presented with a 6-hour history of dull, inspiratory chest pain and shortness of breath  that had subsided on arrival to hospital. She denied any history of coronary artery disease and had no veno-thromboembolic risk factors. Her semirecumbent blood pressure was 94/50 mm Hg, and oxygen saturations were 98% on room air. Chest X-ray was unremarkable. The initial ECG demonstrated sinus tachycardia only. She later developed further chest pain with dynamic 1 mm ST segment elevation in lead III (figure 1A). In addition, there was ECG evidence of S1Q3T3 pattern, and troponin was 3444 ng/mL. An urgent bedside transthoracic echocardiogram supported a diagnosis of acute pulmonary embolus (APE) as opposed to acute ST elevation myocardial infarction (figure 1B–D). It showed a D-shaped left ventricle in both phases of the cardiac cycle reflecting right ventricular volume and pressure overload and a dilated inferior vena cava. The patient was...

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Rehabilitation of simultaneous bilateral epiphysial fracture of proximal tibia in adolescent

Simultaneous and bilateral epiphysial fracture of the proximal tibia is an extremely rare injury, with only 23 cases reported in the literature. In this paper, we present a 15-year-old adolescent with a simultaneous and bilateral epiphysial fracture of the proximal tibia in sport context (trampoline jump). He underwentsurgical repair with bilateral closed reduction and internal fixation, followed by outpatient rehabilitation programme during 4 months. There was a good functional outcome, without limitation in activities of daily living and with resumption of amateur sports activity. Since there are no guidelines described for this pathology, the authors suggest a rehabilitation protocol for bilateral epiphysial fractures of the proximal tibia that underwent surgical treatment previously and in which there were no complications in the acute phase.

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