Volume Of Anesthetic Research Articles

Anterior Quadratus Lumborum block area comparison in the three different volumes of Ropivacaine: a double-blind, randomized controlled trial in healthy volunteers

BackgroundIn abdominal surgery, ultrasound-guided anterior quadratus lumborum blocks (QLB) are performed to induce analgesia. However, no study reported suitable volumes of the anterior QLB for the different postoperative analgesia regions. Therefore, this prospective randomized controlled study assessed the dermatomal spread and analgesic effects of the three different volumes of a local anesthetic for anterior QLB.MethodsUltrasound-guided anterior QLB was performed at the L2 level on 30 healthy volunteers. The volunteers were randomized to receive 20 ml (n = 10), 30 ml (n = 10), and 40 mL (n = 10) of 0.375% ropivacaine. The cutaneous sensory blocked area (CSBA), the number of block dermatomes, and the block duration time were measured by determining the extent of the cold sensation.ResultsThe CSBA was significantly larger in the 40 ml group than in the 30 (P = 0.001; 1350.6 ± 234.4 vs. 1009.5 ± 151.6 cm2) and 20 ml groups (P < 0.001; 1350.6 ± 234.4 vs. 808.1 ± 120.5 cm2). Similarly, the number of blocked dermatomes was significantly higher in the 40 ml group than in the 30- and 20-ml groups. However, no significant difference was observed in block duration among the groups.ConclusionsNo difference was observed in block duration with the various volumes of 0.375% ropivacaine. However, the larger volume for anterior QLB contributed to a larger area of cutaneous sensory blockade. Appropriate volumes in anterior QLB can create suitable postoperative analgesia levels for the different operative sites.Trial registrationThe study was registered in the Chinese Clinical Trial Registration Center on www.chictr.org.cn on 27th April 2018 (registration number: ChiCTR-IOR-17010853).

The Minimum Effective Analgesic Volume of 0.5% Bupivacaine for Ultrasound-Guided Anterior Suprascapular Nerve Block.

Objective The interscalene brachial plexus block (ISBB) constitutes the gold standard for analgesia after shoulder procedures. Ipsilateral phrenic nerve block remains the most common adverse effect after ISBB. Alternative nerve blocks are performed in shoulder surgery in order to prevent hemi-diaphragmatic paralysis (HDP). The purpose of the present study was to investigate the minimum effective local anesthetic volume of 0.5% bupivacaine for postoperative analgesia with an anterior suprascapular nerve block (ASSB). The secondary aim was to investigate diaphragm functions with the local anesthetic doses used while conducting effective volume research. Method This prospective observational study was conducted at the American Hospital of Istanbul, Turkey, from March to July 2022. The initial injected volume of 0.5% bupivacaine was 10 ml. Our clinical experience indicates that this yields a complete sensory block of the anterior suprascapular nerve. In accordance with the up-and-down method, the volume of 0.5% bupivacaine used for a particular patient was determined by the outcome of the preceding block, which represented block success. In case of effective ASSB being achieved, the volume of 0.5% bupivacaine to be administered to the next patient was lowered by 1 ml. In case of block failure, however, the volume of 0.5% bupivacaine to be applied in the subsequent case was increased by 1 ml. Ipsilateral hemi-diaphragmatic movement measurements were taken before (baseline) and 30 minutes after the block. General anesthesia was induced 60 minutes after the completion of the block performance by means of a standardized protocol. Results Sixty-seven patients were included in the study. The ED50 and ED95 calculated for anterior suprascapular nerve block using probit transformation and logistic regression analysis were 2.646 (95% CI, 0.877-2.890) and 3.043 ml (95% CI, 2.771-4.065), respectively. When complete paralysis was defined as 75% or above, partial paralysis as 25-50%, and no paralysis as 25% or less, volumes of 6 ml or lower appeared to cause no paralysis for the anterior suprascapular nerve block. Conclusion We, therefore, recommend using a volume of 6 ml or less in order to achieve diaphragm-sparing features for anterior suprascapular nerve blocks.

Simultaneous Repair of Bilateral Inguinal Hernia under Local Anaesthesia

Open repair of inguinal hernias is a recognised standard approach to groin hernia repairs. Furthermore, this approach is uniquely suited to repair under local anaesthesia (LA). LA repair of unilateral Inguinal hernia (IH) is widely reported in the literature as a safe, well tolerated, and effective operation. However, there is minimal evidence in literature on simultaneous repair of bilateral inguinal hernias under local anaesthesia. This approach is a useful tool in patients with bilateral IH who are unfit for or choose to avoid general anaesthesia (GA). We report our experience with simultaneous repair of bilateral inguinal hernias under local anaesthetic.&#x0D; Methods: We reviewed prospectively collected data of patients with bilateral inguinal hernias for whom simultaneous repair under LA was performed between 2009 – 2019. Data was collected for patient demographics, post-operative visual analogue pain score (VAS), operating time, volume of local anaesthetic used, patient satisfaction and complication rates. All patients had a Lichtenstein's hernioplasty using a buffered local anaesthetic mixture made up of 30ml 0.5% Bupivacaine with adrenaline, 20 ml 2% Lignocaine with adrenaline, 50 ml of 0.9% Saline and 6 ml of 8.6% Sodium Bicarbonate. In each patient, both procedures were performed sequentially as a day case operations.&#x0D; Results: In total, 24 patients were included in the study with male preponderance (92%) and only two were females. Their ages ranged 35 - 81 years. Their BMI varied from 18 – 30 , with a mean of 24.The average operating time was 66.8 minutes (ranging 38 - 120 minutes, median 60 min). The mean pain score was 24, on a VAS 0-100 scale (range 4 - 50, median 25) with patient satisfaction scores (0-100 scale) varying from 50-100 (Median 90, Mean 88.1).&#x0D; Conclusion: We conclude that successful simultaneous repair of bilateral inguinal hernia under local anaesthetic can be performed safely in a timely fashion, with minimal patient discomfort and high satisfaction rate. This approach should be considered as a viable alternative in the tailored approach to repairing IHs0 and offered to patients not deemed suitable for elective general anaesthesia with the advantage of addressing both groin hernias during the same operating session.

Analgesia and spread of erector spinae plane block in breast cancer surgeries: a randomized controlled trial

BackgroundTo evaluate the analgesic efficacy and spread of variable volumes of local anesthetics (LA) in Erector spinae plane block (ESPB).MethodsSixty patients aged between 18 and 50 years with an ASA I-II and scheduled for breast cancer surgery were randomized to receive either ESPB with 20 ml 0.25% bupivacaine (Standard volume ESPB), or with 40 ml 0.125% bupivacaine (High volume ESPB), or no ESPB (GA only group). The primary outcome was pain intensity evaluated by the visual analogue scale (VAS), 12 hours after surgery. P-values < 0.05 were considered the cutoff point for statistical significance. The secondary outcomes were pain at rest and pain on movement evaluated by the VAS, craniocaudal injectate spread, to paravertebral (PV) and epidural spaces assessed by CT, clinical dermatomal spread, level of sedation or agitation, and patient satisfaction with anesthesia and analgesia.ResultsVAS at rest 12 h after surgery was less in both intervention groups compared to the control (1.75 ± 0.79 vs. 1.6 ± 0.88 vs. 3.4 ± 1.96, p = 0.001). The LA had extended further in the high volume group than the standard volume group (11.20 ± 3.07 vs. 9.15 ± 2.54 vertebral levels, p = 0.027). No difference of the spread to PV or epidural spaces between the 2 intervention groups. More dermatomes were covered in the high volume group (7.20 ± 2.12 vs. 5.75 ± 1.37 dermatomes, p = 0.014). Agitation was higher in the GA only group than both ESPB groups in the first 8 postoperative hours. Patients were more satisfied in both ESPB groups than the GA only group.ConclusionsPreoperative ESPB is an excellent analgesic modality and it can also attenuate both postoperative agitation and sedation. Doubling the injectate volume enhances the craniocaudal spreading and may be useful for surgeries requiring multiple dermatomes. However, larger volume has no effect on analgesic efficacy or patient satisfaction as there is no further spread to the PV, epidural spaces or spinal nerve rami.Trial registrationNCT04796363 (12/3/2021).

Ultrasound-guided versus conventional peribulbar anaesthesia in cataract surgery: A randomised controlled study.

Blind ophthalmic anaesthetic techniques may have serious complications. To assess the safety of ultrasound as a guide in ophthalmic blocks. Fifty adult patients undergoing cataract surgery under peribulbar block anaesthesia were randomly assigned to ultrasound-guided and conventional block groups. In the ultrasound-guided block group, a large amount of the standard ultrasound gel was applied to the closed eyelids. The globes were scanned in both sagittal and transverse planes. The patients were asked to look straight ahead with closed eyes without clenching the eyelids. The depth and gain were adjusted before performing the block. The primary outcome was the rate of complications. Secondary outcomes included the volume of injected anaesthetics and surgeon and patients' satisfaction. The local anaesthetic volume used was not significantly different between the two groups (7.08 ± 1.66 and 6.72 ± 1.97ml). The block onset, time and quality were comparable in both groups. No complications were reported, and there were no significant differences regarding surgeons' or patients' satisfaction with either procedure. The ultrasound-guided local ophthalmic block is as safe as the conventional method. Although its use was not superior to the conventional procedure, direct visualisation with ultrasound may be important to avoid vulnerable structures such as staphylomas.

Trends in Cardiac Anesthesiologist Compensation, Work Patterns, and Training From 2010 to 2020: A Longitudinal Analysis of the Society of Cardiovascular Anesthesiologists Salary Survey.

Increasing cardiac procedural volume, a shortage of practicing cardiac anesthesiologists, and growth in specialist physician compensation would be expected to increase cardiac anesthesiologist compensation and work load. Additionally, more cardiac anesthesiologists are graduating from accredited fellowships and completing echocardiography certification. The Society of Cardiovascular Anesthesiologists (SCA) biannual salary survey longitudinally measures these data; we analyzed these data from 2010 to 2020 and hypothesized survey respondent inflation-adjusted total compensation, work load, and training would increase. For the primary outcome, we adjusted the median reported annual gross taxable income for inflation using the Consumer Price Index and then used linear regression to assess changes in inflation-adjusted median compensation. For the secondary outcomes, we analyzed the number of cardiac anesthetics managed annually and the most common care delivery staffing ratios. For the tertiary outcomes, we assessed changes in the proportion of respondents reporting transesophageal echocardiography (TEE) certification and completion of a 12-month cardiac anesthesia fellowship. We performed sensitivity analyses adjusting for yearly proportions of academic and private practice respondents. Annual survey response rates ranged from 8% to 17%. From 2010 to 2020, respondents reported a continuously compounded inflation-adjusted compensation decrease of 1.1% (95% confidence interval [CI], -1.6% to -0.6%; P = .003), equivalent to a total inflation-adjusted salary reduction of 10%. In sensitivity analysis, private practice respondents reported a continuously compounded compensation loss of -0.8% (95% CI, -1.4% to -0.2%; P = .022), while academic respondents reported no significant change (continuously compounded change, 0.4%; 95% CI, -0.4% to 1.1%; P = .23). The percentage of respondents managing more than 150 cardiac anesthetics per year increased from 26% in 2010 to 43% in 2020 (adjusted odds ratio [aOR], 1.03 per year; 95% CI, 1.03-1.04; P < .001). The proportion of respondents reporting high-ratio care models increased from 31% to 41% (aOR, 1.01 per year; 95% CI, 1.01-1.02; P < .001). Reported TEE certification increased from 69% to 90% (aOR, 1.10 per year; 95% CI, 1.10-1.11; P < .001); reported fellowship training increased from 63% to 82% (aOR, 1.15 per year; 95% CI, 1.14-1.16; P < .001). After adjusting for the proportion of academic or private practice survey respondents, SCA salary survey respondents reported decreasing inflation-adjusted compensation, rising volumes of cardiac anesthetics, and increasing levels of formal training in the 2010 to 2020 period. Future surveys measuring burnout and job satisfaction are needed to assess the association of increasing work and lower compensation with attrition in cardiac anesthesiologists.

424 High Volume vs. Low Volume Transversus Abdominis Plane (TAP) Blocks and Post-Operative Pain in Elective Colorectal Surgery- the More the Merrier?

Abstract Introduction Transversus abdominis plane (TAP) regional anaesthetic blocks are often performed by surgeons and provide effective anaglesia in the immediate postoperative period. It is not known whether the volume and concentration of local anaesthetic used for TAP blocks influences the quality of analgesia when the total drug dose is similar. Aim This pilot aimed to compare low volume versus high-volume TAP block and post-operative pain in patients undergoing elective colorectal surgery, using analgesic consumption as a proxy for pain. Method Single centre cohort study. Data were collected for patients undergoing elective colorectal resections from April – December 2021. Patients were cohorted into those receiving low-volume, high-concentration TAP block (40–50ml 0.25% levobupivacaine) and those receiving high-volume, low-concentration TAP block (100ml 0.125% levobupivacaine). Data including PCA (patient-controlled analgesia) type (morphine/ oxycodone) and post-operative consumption were collected. Results 107 patients undergoing elective colorectal resections were identified. Data regarding TAP block usage was available for 55 patients. 23 (41.8%) patients were given high volume TAP blocks. 78.3% (p=0.56) of patients in the high-volume group were prescribed a PCA postoperatively, compared to 84.3% in the low-volume group. Median morphine PCA consumption was 11mg in the high-volume cohort, compared to 18mg in the low volume cohort (p=0.23). Conclusions High volume TAP block was associated with reduced requirement for a post-operative PCA and a reduced consumption of morphine PCA. Although not statistically significant in our small sample size, our results may be of interest to surgeons and suggest that the use of high-volume TAP blocks warrants further study.

Ultrasound-guided bilateral erector spinae plane block in dogs undergoing sternotomies anaesthetised with propofol-dexmedetomidine continuous infusion

To describe the use of a bilateral thoracic (T5 - T9) ultrasound-guided erector spinae plane block (UG-ESPB) in dogs undergoing sternotomy anaesthetised with propofol and dexmedetomidine continuous infusions. Demographic information, perioperative anaesthetic and analgesic drugs, the prevalence of hypotension and nociceptive events, and their treatment, were recorded and analysed. Local anaesthetic injection point, volume and concentration were reported for each dog. In attempt to differentiate somatic nociception from visceral nociception, the surgery was divided into three timeframes: from the skin incision to the thoracic cavity opening; from the latter to the beginning of its closure; from thoracic cavity closure to the end of surgery. Overall, 10 dogs were included and four experienced nociception: somatic nociception was recorded in one dog, whereas visceral nociception was recorded in four dogs. The overall fentanyl consumption to control nociception was 0.3µg/kg/h. No adverse events associated with the UG-ESPB were reported. The bilateral UG-ESPB could be used as a part of a multimodal analgesic technique in dogs undergoing sternotomies. However, more clinical studies are warranted to assess its safety and effects.

Piglets' acute responses to procaine-based local anesthetic injection and surgical castration: Effects of two volumes of anesthetic.

Surgical castration of piglets is painful, but practiced routinely in commercial pig production. Procaine-based local anesthetics are used to mitigate piglet pain during castration in some countries. Yet, effects of the volume of anesthetic injected remain under-studied. The volume of drug administered may modulate the pain mitigating effect via variation in intra-testicular pressure at injection, potentially leading to pain or discomfort, as well as variation in the dose of active ingredient administered. The present study investigated the effects of injection with two volumes of a procaine-based local anesthetic, 0.3 vs. 0.5 mL per testis, on acute responses of 3–4 day old piglets. A total of 290 piglets were divided into 5 treatment groups: castration without anesthesia, castration after intra-testicular injection of 0.5 or 0.3 mL of drug per testis, and sham handling with one or two stays in a castration bench. Acute responses to drug injection, castration and sham handling were evaluated based on quantification of intra-procedural vocalizations and foreleg movements, as well as saliva cortisol concentrations before and after castration. Regardless of the volume, injection of anesthetic as well as castration led to significantly stronger responses than sham handling. Responses to the two drug volumes did not differ significantly, and responses to castration following injection of 0.3 mL did not differ from piglets castrated without anesthesia. All treatments, including sham handling, led to a significant increase in saliva cortisol, and no difference was found between anesthesia treatments and sham handling. Overall, the results suggested that injection of 0.5 mL led to better pain mitigation at castration compared to injection of 0.3 mL, but even when the local anesthetic was used, the combined procedures of injection and castration led to intra-procedural signs of pain and stress.

Estimation of minimum effective local anaesthetic volume to block the lower trunk during selective truncal injection brachial plexus block.

Estimation of minimum effective local anaesthetic volume to block the lower trunk during selective truncal injection brachial plexus block.

Estimation of the minimum effective volume of 0.5% bupivacaine for ultrasound-guided popliteal sciatic nerve block in diabetic patients with neuropathy.

Background and Aims:The safety of conventional regional nerve block techniques in patients with established neuropathies, such as diabetic peripheral neuropathy (DPN), is still unclear. We designed this prospective dose finding study to identify the minimum effective local anaesthetic volume of 0.5% bupivacaine for ultrasound-guided subparaneural popliteal sciatic nerve block in 90% of DPN patients undergoing below-knee surgery (MELAV90).Methods:Fifty-three patients with diabetic peripheral neuropathy and scheduled for below knee surgical procedure received popliteal sciatic nerve block under ultrasound guidance. The initial local anaesthetic volume used was 10 ml of 0.5% bupivacaine. The subsequent local anaesthetic volume allocation was based on biased-coin-design. Accordingly, the local anaesthetic volume given to each subject was based on the block outcome of the previous patient. The study included patients prospectively until 45 successful blocks were obtained. The primary measurement was the minimum effective local anaesthetic volume resulting in a successful subparaneural popliteal sciatic nerve block in 90% of DPN patients. The MELAV90 was calculated using isotonic regression and a 95% confidence interval bootstrapping method.Results:The study included 53 patients to obtain 45 successful blocks. The MELAV90 of 0.5% bupivacaine was obtained at 5.85 ml (95% confidence interval, 5.72 to 6.22 ml). Eight patients needed supplemental anaesthesia to complete the surgery. No other complications were noted.Conclusion:For patients with diabetic peripheral neuropathy undergoing below-knee surgery, the MELAV90 of 0.5% bupivacaine for subparaneural popliteal sciatic nerve to achieve surgical anaesthesia was 5.85 ml.

"Combination of Thoracic Epidural Anesthesia, Supraclavicular Brachial Plexus Block and Supraclavicular Nerve Block as Surgical Anesthesia for Modified Radical Mastectomy-A Case Series".

Sensory innervation of the breast is complex, thereby making it difficult to perform any surgical procedure with a single regional anesthesia technique. Because of the involvement of pectoral muscles and extension of the incision into the axilla, a modified radical mastectomy makes it further challenging and requires multiple techniques. We have used a new combination of regional techniques in this case series and found that it provided complete surgical anesthesia with a smaller volume of local anesthetic.

Comparison of mean duration of two-segment regression time in patients undergoing lower limb surgery treated with combined spinal-epidural anaesthesia vs. Combined spinal-epidural anaesthesia plus epidural volume extension with saline

Background: Combined spinal-epidural (CSE) anesthesia is a novel technique that decreases the amount of anesthetic required yet with greater anesthetic effect compared to spinal or epidural anesthesia alone. Recent studies showed that epidural volume extension (EVE) with saline further increased the anesthetic effect of this combined approach resulting in longer two-segment regression time. However, literature was scarce in the local context that provides the basis of the present study. Aim: The study focuses on the comparison between the mean duration of two-segment regression time in patients who underwent lower limb surgery treated with CSE and CSE plus EVE with saline. Methods: It was a randomized controlled trial and included 60 patients of both genders who range between 20-60 years. They belong to ASA class I and II and underwent lower limb trauma surgery with CSE anesthesia which were further randomly divided into two treatments groups. The patients of Group-A received EVE in addition to standard CSE while Group-B received standard CSE alone. The outcome variable was the mean two-segment regression time which was compared in these two groups. Results: Mean age of selected patients was 35.75±10.60 years. Study included 35 (58.3%) male and 25 (41.7%) female patients. The mean duration of surgery was 79.65±12.92 minutes while the mean BMI was 27.78±3.25 Kg/m2. Nineteen (31.7%) patients were from ASA Class-I and 41 (68.3%) patients associated with ASA Class-II. The mean two-segment regression time was substantially longer in the CSE plus EVE group as compared to the group receiving CSE alone (83.77±7.56 vs. 59.97±6.22 minutes; p-value&lt;0.001). In these two groups, a statistically important difference was also noted across subgroups based on the age of the patient, gender, BMI, duration of surgery, history of diabetes and ASA status. Conclusion: CSE anesthesia with EVE proved its superiority over the conventional practice of CSE alone in terms of longer mean two-segment regression time in patients with lower limb trauma surgery. Keywords: Combined Spinal-Epidural Anesthesia, Epidural Volume Extension, Two-segment Regression Time

MP04-01 IMPACT OF 5-ALPHA REDUCTASE INHIBITORS ON FUNCTIONAL OUTCOMES OF GREENLIGHT PHOTOVAPORIZATION OF THE PROSTATE (PVP): AN ANALYSIS OF 3500 MEN IN THE GLOBAL GREENLIGHT GROUP (GGG) DATABASE

MP04-01 IMPACT OF 5-ALPHA REDUCTASE INHIBITORS ON FUNCTIONAL OUTCOMES OF GREENLIGHT PHOTOVAPORIZATION OF THE PROSTATE (PVP): AN ANALYSIS OF 3500 MEN IN THE GLOBAL GREENLIGHT GROUP (GGG) DATABASE

Ultrasound‐ and nerve stimulation‐guided sciatic and saphenous nerve blocks in a pet rabbit (Oryctolagus cuniculus) undergoing calcaneal fracture repair

AbstractThe beneficial effects of performing regional anaesthesia techniques as part of a pre‐emptive analgesic strategy are to improve perioperative analgesia and reduce opioid and general anaesthetic drug requirements. In prey species, an early recovery of voluntary motor function, especially after a regional anaesthesia, is essential for the animal's health and welfare. To reduce motor paralysis, a low volume and concentration of local anaesthetic should be administered close to the targeted nerve. This is the first report of an ultrasound (14 MHz linear probe)‐ and nerve stimulation (0.2 mA; 0.3 second; 2 Hz)‐guided saphenous and sciatic nerve blocks using bupivacaine (0.125%; 0.2 mL/kg per nerve) in a rabbit. Drug consumption, physiological response to surgery and postoperative pain scoring were used to determine block success. The ultrasound‐ and nerve stimulation‐guided sciatic and saphenous nerve blocks could be recommended as part of multimodal pain management in rabbits undergoing appropriate pelvic limb orthopaedic surgeries.

Limited dilute lidocaine anesthesia: A useful technique with many practical applications.

BackgroundLimited dilute lidocaine infiltration facilitates a comfortable procedure and a rapid recovery process following a novel intervention for reduction of cellulite. Infiltration of dilute lidocaine has many other practical applications in dermatologic surgery.ObjectivesThis article describes a safe, effective technique for local infiltration of limited volume dilute lidocaine anesthesia in a cellulite reduction procedure.MethodsThe limited dilute lidocaine technique was utilized in studies of a novel device designed to reduce the appearance of cellulite by focal release of fibrous septa in a minimally invasive procedure. No sedation was used. A small (27‐ to 30‐gauge) needle was used to deliver anesthesia to the entry sites. Then, a 20‐gauge spinal needle was tunneled under the skin in the superficial plane to manually deliver anesthetic along the advancement pathway of the device and marked cellulite targets.ResultsDuring the initial studies, the mean delivered anesthesia volume was 357.2 ml (range, 250–525 ml) or 18.7 mg/kg (range, 11.1–28.4 mg/kg). The mean anesthesia time was 16 min (range, 8–32 min). The mean number of cellulite depressions treated was 19.8 (range, 11–34). Adverse events were closely monitored, and there were no signs of toxicity in any study patients. There were very low levels of discomfort; all patients reported the procedure was tolerable. This technique facilitates a time‐efficient procedure and minimizes weeping of excess fluid during recovery.ConclusionsWhen administered with care and skill, the limited dilute anesthesia technique is a safe, effective approach for local anesthesia with many practical applications in dermatologic surgery.

Anatomical and Technical Considerations of the Hi-PAC (Hi-Volume Proximal Adductor Canal) Block: A Novel Motor-Sparing Regional Analgesia Technique for Below-Knee Surgeries.

Below-knee surgeries are among the most commonly performed orthopedic or plastic and reconstructive procedures. They are associated with significant postoperative pain despite the use of systemic analgesics. The regional analgesia (RA) technique has been proven beneficial for better patient outcomes when used as an adjunct to multimodal analgesia in the early postoperative period. However, apprehension of an acute compartment syndrome (ACS) can limit the administration of appropriate RA techniques in such surgeries, leading to more opioid consumption to meet the increasing analgesic demands. Many modifications in the RA related to techniques and the local anesthetic type, concentration, and volume have been described to tackle such situations. The ideal RA technique should provide procedure-specific analgesia below the knee joint without affecting motor power and/or causing any delay in diagnosing or treating ACS.The high-volume proximal adductor canal (Hi-PAC) block is a novel RA technique described as motor-sparing and procedure-specific for the below-knee surgeries. The Hi-PAC block, a single-injection technique, is administered in the proximal adductor canal targeting the saphenous nerve and depositing local anesthetics (LA) adjacent to the femoral artery below the vasoadductor membrane (VAM). By directly blocking the saphenous nerve and indirectly the sciatic nerve, it covers the entire innervation of the pain-generating components involved in the below-knee surgeries.This article describes the anatomical and technical considerations of the Hi-PAC block and provides background knowledge of the relevant anatomy and sonoanatomy for a better understanding of its intricacies.

Sympathetic Blocks for Raynaud's Phenomena in Pediatric Rheumatological Disorders.

Sympathetic blocks are invaluable to prevent morbidity from Raynaud's phenomenon (RP). RP may occur in children with rheumatological disorders and causes severe pain, discoloration of digits, gangrene, and auto-amputation. We describe the planning and execution of sympathectomy blocks in children with rheumatological disorders presenting with RP. With upper-limb involvement, ultrasound-guided stellate ganglion block (USGB) was given with ropivacaine and clonidine. When all four limbs were involved, intrathecal block with bupivacaine and clonidine was also given. A total of 68 sympathectomy blocks were performed: 28 bilateral USGBs, two unilateral USGBs, and 10 intrathecal injections. Multiple interventions in a single day were frequently required. For safety, all USGBs were performed with an ultrasound with strict adherence to local anaesthetic volume was maintained, with periprocedure monitoring of 2-3 hours. All blocks were performed by an experienced specialist. All children reported immediate pain relief with prevention of major amputation. With meticulous planning, monitoring, and precautions, sympathectomy of limbs in pediatric rheumatological disorders with RP can be safely undertaken. Bilateral stellate ganglion block with ultrasound is safe in children, and clonidine is a useful adjunct for vasodilation and prolongation of the effect of sympathectomies in children.

Regional anesthesia for shoulder surgery.

Regional anesthesia should be the preferred technique for analgesia in shoulder surgery, which is a frequent procedure in the daily practice of anesthesiologists. The use of ultrasound guidance enables the visualization of the relevant nerve structures and the adjacent anatomical details. Low volumes of local anesthetics reduce the incidence of inadvertent blockade of the phrenic nerve with subsequent respiratory impairment. The additional administration of dexmedetomidine to local anesthetics prolonges the duration of analgesia with a minimal increased incidence of haemodynamic side effects. An optimal workflow is associated with economical advantages due to an improved use of operation rooms. Attention have to be paid regarding intraoperative hypotension, cerebral hypoperfusion and complications due to positioning.

Comparison of oral mucosal biopsies done using scalpel and diode lasers: A vivo study

Background:As dental lasers are becoming more popular in the branch of oral medicine for its various advantages and applications, this study was carried out to evaluate better mode of obtaining oral biopsies which is a common and inevitable procedure for providing final diagnosis in majority of conditions.Methodology:In this study, a total of 60 patients who required biopsy for final diagnosis of oral mucosal lesions as part of diagnosis in department of Oral Medicine were selected, out of which 30 were subjected to scalpel biopsies and 30 patients were subjected to diode laser biopsies. A 980 nm Zolar plus diode laser was used for the study. Out of 30 patients who were subjected to laser biopsies, 3W continuous mode settings were used for 15 patients and 3W pulsed mode was used for 15 patients. The specimens were sent to Department of Oral Pathology for histopathological evaluation to provide the final diagnosis. The time taken for each patient, volume of local anesthesia, during operative, postoperative pain scale, and co-relation of provisional and final diagnosis was noted for comparison purpose and the pathologist comments, peripheral tissue damage and artifact's for each slide were noted.Results:The study results showed the postoperative pain was comparatively less in diodlaser than scalpel, the lasers were patient friendly as the heammorage was negligible when compared to scalpel and suturing was not required. The pulsed mode in diode laser was advantageous over continuous mode when amount of thermal damage and postoperative pain score was compared.Conclusion:The results showed that oral biopsies can be made better using diode lasers, by having thorough knowledge on the device.