Doris Tong

Suprascapular Nerve Block for Postoperative Pain Relief in Arthroscopic Shoulder Surgery: A New Modality?

Arthroscopic shoulder surgery has a 45% incidence of severe postoperative pain.Opiates and interscalene nerve blocks have a high incidence of side effects, and intraarticular local anesthetic has been shown to be ineffective when used for postoperative pain relief. The suprascapular nerve supplies 70% of the sensory nerve supply to the shoulder joint, and local anesthetic block of this nerve is effective in certain shoulder pain disorders. To determine the efficacy of a suprascapular nerve block, subcutaneous saline was compared with a suprascapular nerve block using 10mL of 0.5% bupivacaine with 1:200,000 epinephrine before general anesthesia was induced. In the immediate postoperative period, a 51% reduction in demand and a 31% reduction in consumption of morphine delivered by a patient-controlled analgesic system was demonstrated. There was more than fivefold reduction in the incidence of nausea, as well as reduced visual analog and verbal pain scores for patients who received a suprascapular nerve block. The duration of hospital stay was reduced by 24% in the suprascapular nerve block group. A 24-h phone call interview revealed a 40% reduction in analgesic consumption and a reduction in verbal pain scores at rest and on abduction. There were no complications from the suprascapular nerve block. This study demonstrates that a suprascapular nerve block for pain relief in arthroscopic shoulder surgery is an effective and safe modality of postoperative pain relief. (Anesth Analg 1997;84:1306-12)

POSTOPERATIVE PAIN CONTROL IN AMBULATORY SURGERY

Optimizing postoperative pain control is the key to further advancement in the field of ambulatory anesthesia. The current situation in postoperative pain management indicates room for improvement, especially in the area of patient education and the development of individualized discharge analgesic packages. Multimodal analgesia provides superior analgesia with a lower side-effect profile. Preoperative administration of analgesia would decrease the intraoperative analgesic requirement, which may lead to a smooth and rapid recovery. Finally, new, portable analgesic delivery systems are under investigation and may prove to be the method of choice for future postoperative pain, management in ambulatory anesthesia.

Development of the Functional Recovery Index for Ambulatory Surgery and Anesthesia

Background:It is increasingly important to evaluate patients’ recovery after ambulatory surgery. The authors developed the Functional Recovery Index (FRI) to assess postdischarge functional recovery for ambulatory surgical patients. Methods:The scale development involved four phases: item generation, item selection, reliability, and validity testing. A draft questionnaire was tested and revised. Items were selected through testing endorsement frequency, factor analysis, and testing internal consistency. The interrater reliability was calculated. Construct validity was tested by multiple hypotheses on convergent validity, extreme groups, and discriminant validity. Responsiveness was assessed by measuring the FRI postoperatively and comparing minor versus more extensive surgery. The rate of response and the time for completion of the questionnaire were recorded. Results:The final questionnaire had 14 items grouped under 3 factors. Each item was scored from 0 to 10, with 0 = no difficulty and 10 = extreme difficulty with the activity. The 3 factors were summated for a total score. Internal consistency for the 3 factors (pain and social activity, lower limb activity, and general physical activity) was as follows: Cronbach &agr; = 0.90, 0.89, and 0.86, respectively. Interrater reliability was 0.99. Convergent validity for FRI versus verbal rating scale pain score was 0.76. Discriminant validity testing showed that the type of surgery was significant and that intermediate (&bgr; = 0.138) and major surgery (&bgr; = 0.337) were associated with higher FRI scores than minor surgery. The time to complete the questionnaires ranged between 4 min 10 s and 4 min 35 s. Conclusions:The FRI had excellent reliability, good validity, responsiveness, and acceptability, indicating that this questionnaire will be a good instrument for assessing functional recovery of ambulatory surgical patients.

Pharyngolaryngeal morbidity with the laryngeal mask airway in spontaneously breathing patients: does size matter?

Background Currently, the manufacturer of the laryngeal mask airway (LMA™; Laryngeal Mask Company, Ltd., Northfield End, Henley on Thames, Oxon, United Kingdom) recommends using as large a mask size as possible. The aim of this study was to compare the incidence of pharyngolaryngeal morbidity after the use of a large (size 5 in males and size 4 in females) or small (size 4 in males and size 3 in females) LMA in spontaneously breathing patients. Methods A total of 258 male and female patients were randomly assigned to insertion of a large or small LMA while breathing spontaneously during general anesthesia. After insertion of the LMA, a “just-seal” cuff pressure was obtained, and intracuff pressure was measured at 10-min intervals until just before removal of the LMA. The 2- and 24-h incidence of postoperative sore throat, pain, hoarseness, dysphagia, and nausea and vomiting was assessed. Complications after LMA removal, including body movement, coughing, retching, regurgitation, vomiting, biting on the LMA, bronchospasm, laryngospasm, or the presence of blood on the LMA, were recorded. Results The use of a large LMA was associated with a higher incidence of sore throat in both sexes (20%vs. 7% in men, 21%vs. 5% in women;P < 0.05) and a higher incidence of hoarseness in male patients at 2 h postoperatively (21%vs. 9%, P < 0.05). There was a higher incidence of sore throat in male patients at 24 h postoperatively with the use of a large LMA (26%vs. 12%, P < 0.05). There was no difference in the incidence of complications of LMA removal or other pharyngolaryngeal morbidity, such as difficulty swallowing, drinking, and eating, or nausea and vomiting, between male or female groups at any time period with the use of a large LMA. Conclusions Selection of a small laryngeal mask airway (size 4) in spontaneously breathing male patients may be more appropriate to limit the occurrence of sore throat on the first postoperative day. All patients had a fourfold increased risk of developing sore throat when a large LMA was used.

Prospective study on Incidence and Functional Impact of Transient Neurologic Symptoms Associated with 1% Versus 5% Hyperbaric Lidocaine in Short Urologic Procedures

Background The objectives of this study were to compare the incidence, onset, duration and pain scores of transient neurologic symptoms (TNS) with 1%versus 5% hyperbaric lidocaine in spinal anesthesia for short urological procedures in a large prospective study. This study would also evaluate patient satisfaction, and impact of TNS on functional recovery to assess the clinical significance of TNS. Methods This was a multicenter, double-blind, randomized controlled trial. Four hundred fifty-three patients undergoing short transurethral procedures were randomized to receive 1% or 5% hyperbaric lidocaine. Eighty milligrams of 1% or 5% hyperbaric lidocaine was administered. During the first 3 days after surgery, the presence of TNS, its intensity and duration, and patient functional level were recorded. An intention-to-treat analysis was used. Results There was no difference in the incidence of TNS (21%vs. 18%) between 1%versus 5% lidocaine. Patients with TNS had significantly higher pain scores (5.3 ± 3 vs. 2.3 ± 3) than patients without TNS during the first 24 h. This difference in pain scores persisted until 72 h postoperatively. There was a significant difference in the daily activities functional scores (2.2 ± 1 vs. 1.4 ± 0.8) of TNS versus non-TNS patients during the first 24 h postoperatively. Conclusions There was no difference in the incidence of TNS between the 1%versus 5% spinal lidocaine groups. Pain scores were higher in patients with TNS than those who did not have TNS. During the first 48 h postop, a small proportion of patients who had TNS experienced functional impairment of walking, sitting, and sleeping.

Recall after total intravenous anaesthesia due to an equipment misuse

PurposeTo present a case of recall after total intravenous anaesthesia (TIVA) with propofol-alfentanil infusions to point out an uncommon misuse of the Bard InfusOR syringe driver.Clinical featuresA healthy patient underwent diagnostic dilatation and curettage and laparoscopy for lysis of peritoneal adhesions. After induction, anaesthesia was maintained with propofol-alfentanil infusions using the Bard InfusOR syringe drivers. Ten minutes into maintenance, the patient was moving. The flashing green light confirmed the delivery of the medication and the alarms were not activated. However, the latch of the movable lever in the propofol syringe driver was found to be improperly positioned at the top of the plunger and only a small amount of propofol had been delivered. Postoperatively, the patient could recall the abdomen being touched during laparoscopy. An explanation was given and the patient was satisfied.ConclusionThe Bard InfusOR syringe driver is not designed to detect a malposition of the lever on the synnge plunger. The anaesthetist must ensure proper placement of the lever and visual confirmation of medication delivery in order to prevent awareness due to this particular problem.RésuméObjectifRapporter un incident de rappel consécutif à une anesthésie exclusivement intraveineuse (AEIV) réalisée avec une perfusion de propofol-fentanyl dans le but d’attirer l’attention sur l’emploi incorrect d’un poussesenngue Bard InfusOR.Éléments cliniquesUne patiente en bon état subissait une dilatation avec curetage pour fin diagnostique et une laparoscopie pour lyse d’adhérences péritonéales. Après l’induction, l’anesthésie était maintenue à l’aide d’un pousse-seringue Bard InfusOR. Dix minutes plus tard, la patiente bougeait. Le clignotant vert lumineux confirmait l’administration de la médication et aucune alarme n’était activée. Cependant, on constatait que le loquet du levier mobile du pousse-seringue était mal placé sur la tête du piston et que seulement une petite quantité de propofol avait été reçue. En postopératoire, la patiente se rappelait qu’on lui avait touché l’abdomen. Après explications, la patiente s’est déclarée satisfaite.ConclusionLe pousse-seringue Bard InfusOR n’est pas conçu pour détecter le placement incorrect du levier sur le piston de la senngue. L’anesthésiste doit s’assurer que le levier est en bonne position et que la médication est reçue dans le but de prévenir un rappel causé par ce type de problème.