John A. Dilger

Simulation education in anesthesia training: a case report of successful resuscitation of bupivacaine-induced cardiac arrest linked to recent simulation training.

Simulation training is rapidly becoming an integral element of the education curriculum of anesthesia residency programs. We report a case of successful resuscitation of bupivacaine-induced cardiac arrest treated with i.v. lipid emulsion by providers who had recently participated in simulation training involving a scenario nearly identical to this case. Upon debriefing, it was determined that the previous training influenced execution of the following steps: rapid problem recognition, prompt initiation of specific therapy in the setting of supportive advanced cardiac life support measures, and coordinated team efforts. Although the true cause of efficient resuscitation and ultimate recovery cannot be proven, the efficiency of the resuscitation process, including timely administration of lipid emulsion, is evidence that simulation may be useful for training providers to manage rare emergencies.

A Comprehensive Anesthesia Protocol That Emphasizes Peripheral Nerve Blockade for Total Knee and Total Hip Arthroplasty

R ecently, advances in radiographic imaging and surgical instrumentation have allowed experienced orthopaedic surgeons to perform total hip and total knee replacement surgery with surgical exposures that are less extensive than those associated with traditional techniques1,2. Commonly referred to as “minimally invasive total hip and total knee arthroplasty,” these techniques are now being touted as important surgical advancements. The introduction of minimally invasive total hip and total knee techniques has been accompanied by substantial concomitant changes in perioperative anesthetic techniques, rapid rehabilitation protocols, and changes in patient education and expectations. However, the specific contribution of each of these changes to observed improvements after contemporary total hip and total knee arthroplasty remains unclear. Tremendous strides in anesthesiology and perioperative pain management have been made with regard to the understanding of pain mechanisms and the importance of perioperative analgesia. The consequences of uncontrolled pain and medication-related side effects include the inability to actively participate in rehabilitation, delayed recovery, poor or suboptimal surgical outcome, prolonged hospitalization, and greater use of health-care resources3. Traditionally, the administration of intravenous opioids has been the mainstay for postoperative analgesia following total hip or total knee arthroplasty. However, parenteral opioids are commonly associated with inadequate pain relief, generalized sedation, and adverse side effects such as nausea, vomiting, gastrointestinal ileus, and pruritus. In response, some anesthesiologists have embraced the concept of “preemptive multimodal perioperative analgesia.” Preemptive analgesia involves the administration of analgesics prior to painful stimuli in order to prevent central sensitization and thus the amplification of pain4. Multimodal analgesia refers to the use of combined analgesic regimens for the treatment of postoperative pain. For example, low-dose opioids, local anesthetic infiltration, peripheral nerve blockade, nonsteroidal anti-inflammatory drugs, corticosteroids, clonidine, and cryotherapy all have been used in various combinations to manage postoperative …

Needle Echogenicity in Sonographically Guided Regional Anesthesia Blinded Comparison of 4 Enhanced Needles and Validation of Visual Criteria for Evaluation

Needle visualization is important for sonographically guided regional anesthesia procedures. Needle characteristics that improve needle visualization are therefore important to anesthesiologists. This study compared several echogenic needle designs by defining characteristics of needle echogenicity and assessing regional anesthesiologist preferences for these characteristics across various needle angles.

Role of Regional Anesthesia in the Ambulatory Environment

The use of local anesthetics in ambulatory surgery offers multiple benefits in line with the goals of modern-day outpatient surgery. A variety of regional techniques can be used for a wide spectrum of procedures; all are shown to reduce postprocedural pain; reduce the short-term need for opiate medications; reduce adverse effects, such as nausea and vomiting; and reduce the time to dismissal compared with patients who do not receive regional techniques. Growth in ambulatory procedures will likely continue to rise with future advances in surgical techniques, changes in reimbursement, and the evolution of clinical pathways that include superior, sustained postoperative analgesia. Anticipating these changes in practice, the role of, and demand for, regional anesthesia in outpatient surgery will continue to grow.

Remifentanil provides better analgesia than alfentanil during breast biopsy surgery under monitored anesthesia care

PurposeTo compare the analgesic effects of remifentanil and alfentanil during breast biopsy under monitored anesthesia care (MAC).MethodsSixty patients received sedation with propofol (50 μg· kg−1·min−1). After receiving a loading dose of opioid (either remifentanil 0.5 μg· kg−1, or alfentanil 2.5 μg· kg−1), an infusion was initiated (remifentanil 0.05 μg· kg−1· min−1 or alfentanil 0.25 μg· kg−1· min−1), and this was supplemented with local anesthetic infiltration. The pain was evaluated with aten-point visual analogue scale (VAS) during local anesthetic infiltration and deep tissue dissection. Inadequate analgesia, defined as VAS scores ≥ 5, was treated first with boluses of opioid (remifentanil group 10 μg or alfentanil group 50 μg) and if inadequate after two treatments with additional local anesthetic. Postoperative times were recorded including the times until discharge criteria were achieved and patient’s actual discharge.ResultsThe pain scores were similar between the two groups during the initial injections of local anesthetic in the breast, however, patients in the remifentanil group had lower mean pain scores during deep tissue dissection (2.3vs 4.3,P < 0.01). Patients in the remifentanil group required fewer rescue doses of opioid (1.9 vs 3.6,P < 0.03) and local anesthetic (5 vs 15,P < 0.006). The two study groups had comparable speed of recovery.ConclusionRemifentanil was a better opioid choice than alfentanil for breast biopsy under MAC at the doses studied, but it did not increase the rapidity in which patients recovered postoperatively.RésuméObjectifComparer les effets analgésiques du rémifentanil et de l’alfentanil pendant la biopsie mammaire sous surveillance anesthésique (SA).MéthodeSoixante patientes ont reçu une sédation avec du propofol (50 μg· kg−1· min−1). Après une dose de charge d’opioïde (soit le rémifentanil 0,5 )μg· kg−1 ou l’alfentanil 2,5 μg · kg−1), une perfusion a été amorcée (0,05 )μg · kg−1 · min−1 de rémifentanil ou 0,25 μg · kg−1· min−1 d’alfentanil) et complétée par une infiltration d’anesthésique local. La douleur a été évaluée avec une échelle visuelle analogique en dix points (EVA) pendant l’infiltration et la dissection des tissus profonds. L’analgésie incomplète, définie par un score ≥ 5 à l’EVA, a été traitée d’abord avec des bolus d’opioïde (10 μg de rémifentanil ou 50 μg d’alfentanil), puis avec un anesthésique local si l’analgésie était incomplète après deux doses. Après l’opération, nous avons noté le délai nécessaire à l’atteinte des critères de sortie et le temps réel avant la sortie des patientes.RésultatsLes scores de douleur ont été similaires dans les deux groupes pendant les injections initiales d’anesthésique local dans le sein, quoique les patientes qui ont reçu le rémifentanil aient présenté des scores de douleur moyens plus bas pendant la dissection tissulaire (2,3 vs 4,3, P < 0,01). Les patientes sous rémifentanil ont demandé moins d’opioïde de secours (1,9 vs 3,6, P < 0,03) et d’anesthésique local (5 vs 15, P < 0,006). Les temps de récupération ont été comparables entre les groupes.ConclusionLe choix du rémifentanil s’est révélé meilleur que celui de l’alfentanil pour la biopsie mammaire sous SA aux doses étudiées, mais n’a pas raccourci la récupération postopératoire.

Use of WuScope for Exchange of Endotracheal Tube in a Patient With Difficult Airway

Objective To describe a method for the exchange of a defective endotracheal tube using the WuScope in patients with difficult airways who cannot tolerate interrupted ventilation.