N. Bedforth

Levobupivacaine‐induced seizures and cardiovascular collapse treated with Intralipid®

Summary Lipid emulsion has been used in the successful treatment of local anaesthetic‐induced cardiovascular collapse in animals and in two cases of cardiac arrest in humans. Previous reports of levobupivacaine toxicity in humans have been characterised by neurological signs and symptoms, without serious cardiovascular events. We present a case in which presumed intravenous injection of levobupivacaine led to neurological and cardiovascular consequences. This was treated successfully by resuscitation that included intravenous Intralipid® infusion.

Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia

BACKGROUNDnProvision of preoperative information can alleviate patients anxiety. However, the ideal method of delivering this information is unknown. Video information has been shown to reduce patients anxiety, although little is known regarding the effect of preoperative multimedia information on anxiety in patients undergoing regional anaesthesia.nnnMETHODSnWe randomized 110 patients undergoing upper or lower limb surgery under regional anaesthesia into the study and control groups. The study group watched a short film (created by the authors) depicting the patients in-hospital journey including either a spinal anaesthetic or a brachial plexus block. Patients anxiety was assessed before and after the film and 1 h before and within 8 h after their operation, using the Spielberger state trait anxiety inventory and a visual analogue scale.nnnRESULTSnThere was no difference in state and trait anxiety between the two groups at enrollment. Women had higher baseline state and trait anxiety than men (P=0.02). Patients in the control group experienced an increase in state anxiety immediately before surgery (P<0.001), and patients in the film group were less anxious before operation than those in the control group (P=0.04). After operation, there was a decrease in state anxiety from baseline in both groups, but patients in the film group were less anxious than the control group (P=0.005).nnnCONCLUSIONSnPreoperative multimedia information reduces the anxiety of patients undergoing surgery under regional anaesthesia. This type of information is easily delivered and can benefit many patients.

Efficacy of transversus abdominis plane blocks in laparoscopic colorectal resections.

BackgroundThe increasing use of laparoscopic techniques for colorectal resections means that the issue of postoperative analgesia needs to be reassessed. This nonrandomized comparative study aimed to assess the efficacy of the transversus abdominis plane (TAP) block in laparoscopic colorectal resections.MethodsProspectively collected data from consecutive patients undergoing laparoscopic colorectal resections were used. Analgesia usage and outcome data for patients who had a TAP block and a postoperative morphine patient-controlled analgesia pump (PCA) were compared with those for patients who had a PCA alone.ResultsData for 74 patients were used in the final analysis (40 TAP/PCA and 34 PCA alone). There was a significant reduction in overall intravenous opiate use in the TAP/PCA group (31.3 vs. 51.8xa0mg; Pxa0=xa00.03). The TAP/PCA group showed a slight trend toward a shorter hospital stay (3 vs. 4xa0days; Pxa0=xa00.17) but no difference in postoperative complications or any other outcome measure. There was no procedure-related morbidity relating to the use of TAP blocks.ConclusionsIt appears that TAP blocks reduce postoperative analgesia use of patients undergoing laparoscopic colorectal resections within an enhanced recovery program, and this may have an impact on their postoperative hospital length of stay.

A randomised controlled trial of the efficacy of ultrasound-guided transversus abdominis plane (TAP) block in laparoscopic colorectal surgery

BackgroundOptimal analgesia following laparoscopic colorectal resection is yet to be determined; however, recent studies have questioned the role of postoperative epidural anaesthesia, suggesting other analgesic modalities may be preferable. The aim of this randomised controlled trial was to assess the effect of transversus abdominis plane (TAP) blocks on opioid requirements in patients undergoing laparoscopic colorectal resection.MethodsAfter appropriate trial registration (www.clinicaltrials.gov NCT 00830089) and local medical ethics review board approval (REC 09/H0407/10), all adult patients who were to undergo laparoscopic colorectal surgery at a single centre were randomised into the intervention group receiving bilateral TAP blocks or the control group (no TAP block). The blocks were administered prior to surgery after the induction of a standardised anaesthetic by an anaesthetist otherwise uninvolved with the case. The patient, theatre anaesthetist, surgeon, and ward staff were blinded to treatment allocation. All patients received postoperative analgesia of paracetamol and morphine as a patient-controlled analgesia (PCA). Cumulative opioid consumption and pain scores were recorded at 2, 4, 6, and 24xa0h postoperatively and compared between the groups as were clinical outcomes and length of stay.ResultsThe intervention (TAP block) group (nxa0=xa033) and the control group (nxa0=xa035) were comparable with respect to characteristics, specimen pathology, and type of procedure. The TAP block group’s median cumulative morphine usage (40xa0mg [IQRxa0=xa025–63]) was significantly less than that of the control group (60xa0mg [IQRxa0=xa039–81]). Pain scores and median length of stay (LOS) were similar between the two groups.ConclusionPreoperative TAP blocks in patients undergoing laparoscopic colorectal resection reduced opioid use in the first postoperative day in this study.

Pitfalls of ultrasound guided vascular access: the use of three/four‐dimensional ultrasound

The use of ultrasound guidance for central venous access is widespread and was recommended as the technique of choice by The National Institute of Clinical Excellence in the UK in 2002. However, complications have been reported using this technique. In this article we review the technique of two‐dimensional ultrasound needle guidance and the errors that can occur. We then discuss the development of three‐ and four‐dimensional ultrasound and describe our experiences using this imaging modality in simulated and actual needle‐guidance. We discuss the potential advantages for clinicians utilising this newer form of ultrasound imaging for central venous access.

Predicting patients' responses to changes in mechanical ventilation: a comparison between physicians and a physiological simulator.

Abstract We compared the accuracy and reliability of a validated, physiological simulator and six intensive care specialists in predicting changes in arterial oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2) and pH following adjustment of mechanical ventilation. Twenty-five data sets were collected before and after routine alterations in ventilator settings. Fractional inspired oxygen was adjusted in all patients and minute volume was adjusted in 13 patients. The simulator was more accurate and consistent than all the physicians in predicting the magnitude of PaO2 and pH change. The simulator had a larger bias in estimating the magnitude of change of PaCO2 than four of the physicians, but was more consistent than all but one of the physicians. The simulator may prove to be a useful tool in the management of mechanical ventilation. Incorporation into mechanical ventilators in a passive predictive role or an active ’closed-loop ventilation management system are potential roles for physiological simulation.

The hidden cost of neuraxial anaesthesia

professional organisations to do the same. The AAGBI called upon its members to exert influence within their own organisations to mitigate against climate change and environmental degradation, and to lead by example. Finally, the AAGBI called upon Government to lead the transition to a carbon-neutral economy as soon as possible. The AAGBI’s statement is an attempt by the organisation to set out its stall and focus our thoughts. None of these are new ideas and good business practice typically coincides with good environmental practice, so we are doing some of it already. Cutting back on travel saves train fares, air fares and time, as well as carbon, and members expect us to do that, whatever the motivation. Time is pressing, the failure of Copenhagen lies immediately behind us and we face the abyss.

New technologies in nerve location

Regional anaesthesia is undergoing a renaissance, perhaps assisted by the introduction of (and enthusiasm for) ultrasound‐guided regional anaesthesia into clinical practice. This article summarises the technology and principles of ultrasound imaging in anaesthesia and describes the development of three‐dimensional ultrasound imaging, considering whether this new technology has an application in regional anaesthesia.

Femoral nerve block Intervention in Neck of Femur fracture (FINOF): study protocol for a randomized controlled trial

BackgroundHip fractures are very painful leading to lengthy hospital stays. Conventional methods of treating pain are limited. Non-steroidal anti-inflammatories are relatively contraindicated and opioids have significant side effects.Regional anaesthesia holds promise but results from these techniques are inconsistent. Trials to date have been inconclusive with regard to which blocks to use and for how long. Interpatient variability remains a problem.Methods/DesignThis is a single centre study conducted at Queen’s Medical Centre, Nottingham; a large regional trauma centre in England. It is a pragmatic, parallel arm, randomized controlled trial. Sample size will be 150 participants (75 in each group). Randomization will be web-based, using computer generated concealed tables (service provided by Nottingham University Clinical Trials Unit). There is no blinding. Intervention will be a femoral nerve block (0.5 mls/kg 0.25% levo-bupivacaine) followed by ropivacaine (0.2% 5 ml/hr−1) infused via a femoral nerve catheter until 48 hours post-surgery. The control group will receive standard care. Participants will be aged over 70 years, cognitively intact (abbreviated mental score of seven or more), able to provide informed consent, and admitted directly through the Emergency Department from their place of residence. Primary outcomes will be cumulative ambulation score (from day 1 to 3 postoperatively) and cumulative dynamic pain scores (day 1 to 3 postoperatively). Secondary outcomes will be cumulative dynamic pain score preoperatively, cumulative side effects, cumulative calorific and protein intake, EUROQOL EQ-5D score, length of stay, and rehabilitation outcome (measured by mobility score).DiscussionMany studies have shown the effectiveness of regional blockade in neck of femur fractures, but the techniques used have varied. This study aims to identify whether early and continuous femoral nerve block can be effective in relieving pain and enhancing mobilization.Trial registration.Trial registrationThe trial is registered with the European clinical trials database Eudract ref: 2010-023871-25. (17/02/2011). ISRCTN: ISRCTN92946117. Registered 26 October 2012.

Dystonic reaction following anaesthesia

the tracheal tube anteriorly towards the lower jaw. In nasally intubated patients, it would be difficult to make this gap, because the tracheal tube runs along the posterior pharyngeal wall. One of us has stated that in this situation the laryngeal mask is not useful [4]. Nevertheless, another one of us has noticed that it might be easy to place the laryngeal mask behind a nasally inserted reinforced tube. The laryngeal mask is placed in the centre of the mouth, pressing the mask against the hard palate (as described in the instruction manual). When the tip of the mask reaches the posterior pharyngeal wall, the index finger moves to the side and places the tip of the mask behind the tracheal tube and mask is then advanced into its final position. Although the success rate of insertion of the laryngeal mask in nasally intubated patients, in particular in the presence of an ordinary non-reinforced tube, is not known, we have now successfully used this method in a number of patients for changing a nasal to an oral tube.