Local Regional Anesthesia Research Articles

Local-regional anesthesia in the management of stingray stings: Experience of the Bouffard medical-surgical hospital in Djibouti.

Stingray injuries are very painful. Systemic analgesics are ineffective, and the use of local-regional anesthesia has been reported. This retrospective descriptive study reviewed all cases of stingray injuries seen at the emergency department of the Bouffard Hospital (Djbouti, Africa) between 2011 and 2014. The study included 35 patients. Most of the injuries (n= 31, 89%) concerned the lower limbs. Median pain intensity was 6 [5-8] on a visual analog scale of 0 (no pain) to 10. The following systemic medications were administered: acetaminophen to 13 (27%) patients, morphine to 8 (23%), and tramadol to 6 (17%). In all, 25 (71%) patients received local-regional anesthesia, 15 (60%) by injections at the ankle. All procedures were successful, and no adverse event was reported. This study reports clinical data about stingray injuries in the Red Sea area and highlights the interest of local-regional anesthesia in their management. Most of the procedures were distal and could be performed by trained emergency physicians.

Symptoms During or Shortly After Isolated Carpal Tunnel Release and Problems Within 24hours After Surgery.

This study used the National Survey of Ambulatory Surgery (NSAS) database to measure the incidence of and risk factors for symptoms in the ambulatory surgery center and problems within 24h after isolated carpal tunnel release (CTR). The NSAS contained records on 400,000 adult patients with carpal tunnel syndrome who were treated with CTR in 2006, based on ICD-9 codes. The type of anesthesia used and factors associated with symptoms and problems were sought in bivariate and multivariable statistical analyses. The mean duration of the procedure was 16 ± 8.8min. Only 5% were performed under local anesthesia without sedation, 45% with IV sedation, 28% regional anesthesia, and 19% general anesthesia. Symptoms in the ambulatory surgery center or a problem within 24h after discharge were recorded in 10% of patients, all of them minor and transient, including difficulties with pain and its treatment. The strongest risk factors were male sex, age of 45years and older, and participation of an anesthesiologist. Local anesthesia and regional anesthesia were associated with more perioperative symptoms and postoperative problems. Most CTR are performed with some sedation in the United States. CTR is a safe procedure: one in 10 patients will experience a minor issue in the perioperative or immediate postoperative period.

Comparison of the Efficacy of Local Infiltration and Mandibular Block Anesthesia With Articaine for Harvesting Ramus Grafts

We compared the efficacy of local infiltrative anesthesia and regional mandibular block anesthesia using articaine to harvest ramus grafts and the postoperative sequelae. A total of 20 patients with alveolar bone deficiency participated in the present comparative, prospective, randomized study. The first group received regional anesthesia with the mandibular block technique (group A; n= 10), and those in the second group received local infiltration anesthesia (group B; n= 10). Intraoperative pain and bleeding were evaluated as the primary outcome variables. The visual analog scale (VAS) scores were compared at 0.5, 1, 2, and 4hours postoperatively. The maximal interincisal mouth opening (MIO) (on days 3 and 7) and VAS scores (at 6, 12, 24, and 48hours and on days 3 and 7) were compared as secondary outcome variables. The correlation between pain (VASscores) and trismus (MIO) were also compared. A painless procedure was performed in both groups. The VAS score, MIO, and intraoperative bleeding were not significantly different between the 2 groups. Paresthesia was not observed in either group postoperatively. No statistically significant correlations were found between the VAS scores andMIO. Local infiltrative anesthesia preserves almost the same depth of anesthesia as mandibular block anesthesia. No differences were found between these techniques in terms of efficacy and postoperative sequelae during and after ramus graft harvest. Thus, using articaine with a local infiltration technique is an alternative to mandibular block anesthesia during ramus graft harvesting and results in a reduced risk of inferior alveolar nerve damage.

Imaging photoplethysmography for clinical assessment of cutaneous microcirculation at two different depths.

The feasibility of bispectral imaging photoplethysmography (iPPG) system for clinical assessment of cutaneous microcirculation at two different depths is proposed. The iPPG system has been developed and evaluated for in vivo conditions during various tests: (1) topical application of vasodilatory liniment on the skin, (2) skin local heating, (3) arterial occlusion, and (4) regional anesthesia. The device has been validated by the measurements of a laser Doppler imager (LDI) as a reference. The hardware comprises four bispectral light sources (530 and 810 nm) for uniform illumination of skin, video camera, and the control unit for triggering of the system. The PPG signals were calculated and the changes of perfusion index (PI) were obtained during the tests. The results showed convincing correlations for PI obtained by iPPG530 nm and LDI at (1) topical liniment (r = 0.98) and (2) heating (r = 0.98) tests. The topical liniment and local heating tests revealed good selectivity of the system for superficial microcirculation monitoring. It is confirmed that the iPPG system could be used for assessment of cutaneous perfusion at two different depths, morphologically and functionally different vascular networks, and thus utilized in clinics as a cost-effective alternative to the LDI.

Dorsal capsule tears of the wrist

Introduction Large dorsal capsule tears of the wrist are misdiagnosed because this lesion is unknown. Wrist arthroscopy allowed the diagnosis and the treatment. This study reports the results of the procedure. Materials and methods This retrospective study reported the patients with dorsal capsule tears between October 2011 and September 2014. The procedure was performed on outpatient under local regional anesthesia. The diagnosis is done arthroscopically. We always found a large rupture of the dorsal capsule with direct vision of the extensor tendons from the radiocarpal joint. The reparation is performed by a dorsal capsuloligamentous repair after enlarging the 3–4 portal. Results Sixteen procedures were performed on 15 patients, which represent 2% of the wrist arthroscopy. One was excluded because the follow-up was done abroad. There were 7 men and 7 women, mean age 27,9 years old (14–43). The surgery was performed on average 21 months after the accident (2–96). The clinical examination was not specific, neither the imaging. The diagnosis was performed arthroscopically. The scapholunate ligament was intact from the radiocarpal joint in 46,6%. In the midcarpal joint, we reported 4 stage 1 with EWAS classification, 2 stage 2B, 1 stage 3A, 4 stage 3B, 1 stage 3 C and 1 stage 4. A peripheral lesion of the TFCC was reported in 6 cases. A splint was worn on average 47.8 days. The average follow-up was 7.75 months (1.5–32.5). The range of motion and strength improved in all cases. The pain decreased from 6.3 u (4–8) to 0.9 (0–2) and the dash from 44.5 (20,45–95,45) to 6.25 (0–27,27). All radiographs were normal at the longest follow-up. We reported two Sudeck syndromes. Discussion Diagnosis of chronic wrist pain is difficult. More often, they are due to posttraumatic lesions - fracture or ligamentous tears, which lead both to arthrosis. A large dorsal capsule tear is one of the etiology, and its diagnosis was made possible thanks to arthroscopy, others paraclinic exams being poor. Conclusion Large dorsal capsule rupture could explain some non-diagnosed wrist pain. The diagnosis is arthroscopic. Arthroscopic suture avoids stiffness related to open surgery. These encouraging preliminary results require a larger serie with longer follow-up.

Femoral Hernia Invading the Right Thigh

Clinical Image: This is a 72 years old woman, who consults for a mass of the right thigh. In her medical history, we find the concept of femoral hernia 30 years ago and a second surgery to recurrence three years ago. Clinical examination revealed a mass that takes the anterior and lateral thigh ending a few inches from the knee. The examination of CT scan of the right leg was found at the thigh femoral hernia with heterogeneous densities inside the images representing the small bowel. The patient was operated under local regional anesthesia; recovery of the incision opening of the inguinal hernia, after omentum and small bowel, resection of the omentum and reduction of the small bowel. The parietal repair was carried out by the establishment of two prostheses sandwiched in musculo aponevrotic interstices of the femoral repair and the root of the thigh. A drain of the large cavity left by the hernia has been done. Good postoperative evolution, drainage was removed and was replaced with a pressure bandage to prevent seroma or hematoma.

Staple aneurysmorrhaphy to salvage autogenous arteriovenous fistulas with aneurysm-related complications

Aneurysm-related complications could lead to loss of a functioning arteriovenous fistula (AVF). We report our midterm and long-term results with the staple aneurysmorrhaphy technique to repair and preserve aneurysmal AVFs. We retrospectively reviewed our surgical treatment of patients with aneurysmal autogenous AVF complicated by skin erosion, bleeding, infection, pain, and difficulty with needle access from 2007 through 2014. We identified 52 patients, 40 (77%) of whom underwent repair with the staple aneurysmorrhaphy technique. The operation involved mobilizing the entire aneurysmal segments. A TA (Covidien, Norwalk, Conn) or Endo GIA (Covidien, Mansfield, Mass) stapler was used to resect the redundant aneurysm wall to create a 6- to 8-mm-diameter conduit. A subcutaneous skin flap was created after excising compromised skin. The remodeled vein was repositioned underneath the subcutaneous flap, with the staple line rotated laterally to avoid needle puncture. We attempted staple aneurysmorrhaphy in 40 patients with complicated AVF aneurysms, of which 38 repairs (95%) were successful. Median patient age was 66 years (range, 29-88 years). Median AVF age was 63 months (range, 12-136 months). Median follow-up was 20 months (range, 5-81 months). At 1 year, primary patency was 67%, assisted primary patency was 88%, and secondary patency was 91%. At 2 years, primary patency was 59%, assisted primary patency was 84%, and secondary patency was 91%. At 3 years, primary patency was 46%, assisted primary patency was 69%, and secondary patency was 85%. Surgery was performed under local-regional anesthesia in 28 patients (70%) and under general anesthesia in the remaining 12 (30%). Proximal venous outflow stenoses were detected in 19 of 40 AVFs (48%) preoperatively and in 11 of 38 AVFs (29%) postoperatively. Aneurysm recurrence occurred in two repaired AVFs. Our experience with staple aneurysmorrhaphy shows that it is an effective, safe, and durable procedure to preserve a functioning autogenous AVF with complicated aneurysmal degeneration. Key principles are to reduce the vein to normal adjacent diameter and to provide healthy skin coverage. The remodeled AVF has a low aneurysm recurrence rate and maintains the beneficial properties of superior patency and low infection. It is important to aggressively monitor for and treat proximal outflow venous stenoses to prevent aneurysm recurrence. The surgery can be done safely under local anesthesia in selected patients.

Optimizing perioperative analgesia for the complex pain patient: medical and interventional strategies

The purpose of this article is to review the literature and to highlight current practice regarding the management of the chronic pain patient presenting for surgery. It can be difficult to achieve adequate postoperative analgesia in patients who present for surgery with preexisting chronic pain. Such complex pain patients require a care plan that involves preoperative, intraoperative, and postoperative considerations. Preoperatively, it is important to identify these patients' specific concerns, to address anxiety, to review expectations of care, and to consider premedication. Intraoperatively, it is important to consider local anesthetic regional anesthesia techniques and to supplement as necessary with pharmaceutical agents, e.g., ketamine, dexamethasone, ketorolac, and opioids. Postoperatively, it is important to continue multimodal analgesia techniques. It is vital to maintain a healthy therapeutic alliance with the patient and withallied health professionals. Nonspecific treatment effects can bolster efforts to achieve adequate analgesia. Successful management of the complex pain patient requires knowledge of the art and science of perioperative medicine.

Does anesthesia type influence breast cancer outcomes?

66 Background: Surgery maintains a central role in the local treatment of Stage 0-III breast cancer. Recent studies suggest patient immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective case review has concluded that breast cancer patients receiving regional anesthesia with paravertebral block (PVB) anesthesia had better cancer outcomes compared to patients receiving GA, but these conclusions have not been validated. We hypothesized that local regional anesthesia (LRA) would be associated with better cancer outcomes compared to GA. Methods: We performed a retrospective review of Stage 0-III breast cancer patients undergoing surgery in a single center during a nine year period ending 1/1/2010. Patients undergoing neoadjuvant therapy or major flap reconstruction were excluded. Data regarding patient, tumor and treatment factors known to influence cancer outcomes were collected. Overall survival (OS), disease free survival (DFS), local regional recurrence (LRR), and ipsilateral breast tumor recurrence (IBTR) were calculated by Kaplan-Meier method with Log-Rank comparison. Results: We analyzed 1,107 patients. Median age was 64 years (range 24-97). Median and longest follow-up were 5.5 and 12.5 years. GA was utilized for 461 (42%) patients, and 646 (58%) received LRA. Initial operation was breast conserving in 796 (72%) and mastectomy in 311 (28%). Forty two patients died from breast cancer (crude mortality 3.8%). LRR occurred in 34 patients (3%). LRA was used more than GA in patients with lower grade and stage, smaller tumors, positive hormone receptor status, and negative nodal status (p<0.001). We identified no differences in OS, DFS, LRR or IBTR in comparison of GA to LRA. Conclusions: Type of anesthesia for breast cancer surgery did not affect cancer outcomes in our institution. This result differs from the only prior published clinical report on this topic.

Sedation in elderly patient undergoing surgery with spinal anesthesia: propofol vs. midazolam

Abstract It is widely known the need for a high quality sedation associated with local regional anesthesia in elderly patients’ surgery. The aim of this study was to compare two sedation regimes: propofol and midazolam, associated to spinal anesthesia with isobaric 0.5% bupivacaine in lower abdominal surgery in elderly patients. After obtaining the informed consent, 60 patients aged between 65 and 82 years old (ASA I-III), scheduled for unilateral hernioplasty , under spinal anesthesia with isobaric bupivacaine 1,5 ml (0.5%), were randomized into two groups of 30 patients each: P group - patients received propofol 3mg/kg/body/hour in the first 10 minutes and then continuous infusion by injection of 1,8 mg/kg/body/hour, and group M-patients who have received midazolam 0,2mg/kg/body/hour in the first 10 minutes and then continuous infusion by injection of 0,15 mg/kg/body/hour. In order to achieve a similar level of sedation we used 0,1% midazolam infusion and 1% propofol. Intraoperative, the following have been monitored: heart rate and breath, mean arterial pressure, hemoglobin oxygen saturation. We have also recorded the sedation score (modified Wilson sedation scale), awakening times, patient satisfaction at 24 hours (satisfaction score according to Iowa University). The average score of sedation for group P was of 3,24 ± 0,23, compared to 2,64 ±0,42 in group M (p = 0.001). Both drugs reduce blood pressure, but not more than 20% of the initial value. There are no significant differences in the satisfaction score of the patient (p = 0,18). There was just one case of respiratory depression in group M with the decrease of SpO2 at 86%.Sedation with propofol associated with local regional anesthesia techniques in elderly patients seems to provide better conditions in terms of sedation score and lack of respiratory depression compared with the administration of midazolam. Recovery was significantly faster after sedation with propofol. The satisfaction score of the patient was similar in the two groups

Free Flap Scalp Reconstruction in a 91-Year-Old Patient under Local-Regional Anesthesia: Case Report and Review of the Literature

In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.

Anesthesia and Perioperative Management of Patients Who Undergo Transfemoral Transcatheter Aortic Valve Implantation: An Observational Study of General Versus Local/Regional Anesthesia in 125 Consecutive Patients

To describe differences in intra- and postoperative care between general (GA) and local/regional anesthesia (LRA) in consecutive high-risk patients with aortic stenosis who underwent transfemoral transcatheter aortic valve implantation (TAVI). A retrospective review of data collected in an institutional registry. An academic hospital. One hundred twenty-five consecutive patients with severe aortic stenosis who underwent transfemoral TAVI. GA versus LRA followed by postoperative care. Complications were defined by pre-established criteria. Consecutive patients referred for transfemoral TAVI between October 2006 and October 2010 initially underwent GA (n = 91) followed by LRA after March 2010 (n= 34). Results are presented as mean ± standard deviation or median (25-75 percentiles) as appropriate. GA and LRA TAVI patients had similar preoperative characteristics. LRA was associated with a significantly shorter procedure duration (LRA: 80 [67-102]; GA: 120 [90-140 minutes]; p < 0.001), hospital stay (LRA: 8.5 [7-14.5]; GA: 15.5 [10-24] days; p < 0.001), intraoperative requirements of catecholamines (LRA 23%; GA: 90% of patients; p < 0.001), and volume expansion (LRA: 11 [8-16]; GA: 22 [15-36] mL/kg; p < 0.001). There were significant differences in delta creatinine (day 1, preoperative creatinine values; LRA: 0 [-12 to 9]; GA: -15 (-25 to 2.9) μmol, p < 0.004). The frequency of any postoperative complications was 38% (LRA) and 77% (GA) (p = 0.11). Thirty-day mortality was 7% (GA) and 9% (LRA) (p = 0.9). This observational study suggests that LRA was associated with less intraoperative hemodynamic instability and significant shortening of the procedure and hospital stay. Changes in the anesthetic technique adapted to changes in TAVI interventional techniques and did not increase the rate of postoperative complications.

Local and Paravertebral Block Anesthesia for Outpatient Elective Breast Cancer Surgery

Most breast cancer operations in the United States are performed with the patient given general anesthesia. We retrospectively reviewed our prospective breast cancer database to determine the percentage of patients who underwent breast cancer operations with either local or paravertebral block regional anesthesia from January 1 through June 30, 2008. Fifty-two of 70 patients (74%) were able to undergo breast cancer surgery with local or paravertebral block regional anesthesia. Operations included mastectomy, full axillary dissections, and expander or implant reconstruction. There were no conversions to general anesthesia and no unplanned overnight admissions. Only 5 of 52 patients (10%) undergoing surgery with local or paravertebral block regional anesthesia developed postoperative nausea or vomiting. We conclude that most elective outpatient breast cancer surgery operations can be performed with the patients given local or regional anesthesia.

Aplicaciones de la ventilación mecánica no invasiva en Anestesiología y Reanimación

Noninvasive ventilation (NIV) can be useful to anesthesiologists working in critical care units, postanesthesia recovery units, operating theaters, or other settings. NIV can help in situations of acute respiratory failure or serve as a preventive measure in patients undergoing interventions under local-regional anesthesia or diagnostic or therapeutic procedures requiring sedation. Successful NIV depends on adequately trained health personnel and the proper choice of material (interfaces, respirators, etc.) for each setting where this modality is used.

Pain Management and Regional Anesthesia for the Dental Patient

Current standards of care in veterinary medicine dictate an adequate level of pain control for our patients. Effective pain control uses a proactive, multimode approach that starts with preoperative medications, includes the anesthetic protocol selected, and continues into the postoperative period. A basic understanding of the physiology of pain assists in selecting those agents and modalities best suited for individual patients. Analgesic drug selection and local anesthesia are both integral parts of pain control when performing surgery in the oral cavity. Local (regional) anesthesia plays an important part in the pain control of oral surgical patients. Regional anesthetic techniques are used for many common oral procedures, including extractions, periodontal flap surgery, treatment of traumatic injuries of the oral cavity, tumor removal, palatal surgery, periodontal therapy, and root canal therapy. This presentation will cover strategies for analgesia and the techniques and materials used in local/regional anesthesia in the oral cavity. Anatomic landmarks and guidelines for effective regional blocks will be covered.

Pediatric regional anesthesia – update

New topics in pediatric regional anesthesia are discussed. Continuous peripheral nerve blocks, new local anesthetics and the performance of regional blocks with ultrasonography guidance are summarized. Prolonged analgesia with continuous peripheral nerve blocks in the treatment of pediatric postoperative limb pain, sometimes with patient-controlled regional analgesia, should be preferred instead of continuous epidural analgesia. Levobupivacaine and ropivacaine display the same pharmacokinetic profile as racemic bupivacaine with less cardiac toxicity. Conversely, continuous infusion of these new local anesthetics offers the safest therapeutic index, especially in infants. Many adjuvants have been used, but clonidine offers clear advantages. Ultrasonography guidance blocks will probably become the reference technique for local anesthetics injection and regional anesthesia catheter placement; new training in this field should be available.

Avaliação do tratamento da hérnia inguinal sob anestesia local e sedação em 1560 pacientes

OBJETIVO: Analisar a aplicabilidade da anestesia local da região inguinal no tratamento da hérnia inguinal. MÉTODO: Foram estudados os dados de 1560 pacientes submetidos ao tratamento operatório para cura de hérnia inguinal, entre maio de 1996 e dezembro de 2003, pela técnica de Lichtenstein, sob anestesia local da região inguinal associada à sedação. Foram analisados so seguintes dados: idade,sexo,índice de massa corporal, número de recidivas, as intercorrências pré e pós-operatórias, tempo de permanência hospitalar. Os tipos de hérnia foram classificados segundo Nyhus. RESULTADOS: Todas as operações foram concluídas sob a anestesia local e sedação não sendo necessário nenhuma complementação. As complicações pós-operatórias ocorreram em 7,16 % dos pacientes, nenhum deles necessitou de reinternação. CONCLUSÕES: A anestesia loco-regional da região inguinal na totalidade dos casos produziu conforto para os pacientes e boas condições de operabilidade para os cirurgiões.

Tiroidectomía en régimen de cirugía mayor ambulatoria. Estudio prospectivo

The recent reintroduction of local/regional anesthesia (LRA) for thyroidectomy has enabled this intervention to be performed in the outpatient setting. The aim of this study was to compare the results of thyroidectomy using two anesthesia methods. One hundred twenty-five patients requiring thyroidectomy and who met the criteria for outpatient surgery were prospectively selected. The patients were offered LRA plus sedation; patients who did not accept this option were offered LRA combined with orotracheal intubation (CLRA). LRA was accepted by 58 patients and CLRA by 67. Age, sex, anesthesia risk, body mass index, and thyroid function were similar in both groups. Postoperative vomiting, pain at discharge, need for admission, postoperative morbidity, and complaints occurring at home were evaluated. Sixty-one bilateral and 64 unilateral thyroidectomies were performed, with no statistically significant difference between the two groups. There were no differences in surgical time, conversion to general anesthesia, intraoperative events, pathological diagnosis, or size and weight of the surgical specimen. The only difference between the two groups was the hour of discharge (LRA: 6.5 +/- 1.2 hours; CLRA: 7.76 +/- 2.07 hours; p = 0.0003). The admission rate was higher in the CLRA group (22.4%) than in the LRA group (8.62%); this difference was not statistically significant (p = 0.06) and the main cause was personal preference in patients in the CLRA group. Rates of postoperative morbidity, vomiting (7.2%) and nausea (6.4%), postoperative pain (2.47 +/- 1.85 on a visual analog scale), and analgesic requirements showed no differences between the two groups. One patient in the LRA group developed a noncompressive asymptomatic neck hematoma 36 hours after discharge. The patient was admitted for observation but did not require reoperation. Complaints occurring at home were minor. Satisfaction with the procedure was high or very high in 95% of the patients, with no differences between the two groups. In selected patients, outpatient thyroidectomy is safe and produces good patient satisfaction. Both anesthesia methods were valid, but postoperative recovery was faster with LRA than with CLRA.

Essential Surgical Skills, 2nd ed.

Essential Surgical Skills is an excellent source of fundamental surgical knowledge. As a resident, I enjoyed reviewing the text and learned a fair amount from it. The table of contents is rather intimidating, but the book goes on to provide an extremely clear and concise overview of a very broad topic, that of surgical skills. I have always thought that surgical skills are best learned by “see one, do one, teach one,” but this book truly does lay the groundwork from which students and residents can build on. The strong points of the book are as follows. First, the text is quite easy to read. I found the flow and transition between sections to be smooth. Second, the figures are very helpful for readers to fully comprehend the surgical skill at hand. Third, the text and images are fairly large, and there is not an overwhelming amount of material on each page. Fourth, the topics are not only unique, but all-inclusive. Until now, I have never seen a surgical text that explains surgical skills and techniques in such a clear and concise way. One example is Figure G-29 regarding cutting sutures. I remember learning how to cut sutures through trial and error in the operating room. Another great example is page 60 and how to read the suture package. These are all very valuable pieces of information that are never taught to the surgical student and resident. Recommendations I have are as follows. First, I might interpose “Scrubbing,” “Surgical Instruments,” and “Sutures, Needles and Knots” after the “Operating Room” section in the table of contents. Second, expand the section on anesthesia to include all types of anesthesia and how one chooses. This would discuss local anesthesia, intravenous sedation, regional anesthesia, spinal anesthesia, and general anesthesia. Last, it might be worthwhile to have a PDA version of the textbook and software available. Essential Surgical Skills is best suited for senior medical students with surgical interest. More specifically, the fourth-year medical student preparing for surgical residency would benefit the most. I believe the price is quite reasonable and should be highly recommended to all subinterns in surgery.

CHAPTER 1: THE MANAGEMENT OF ERECTILE DYSFUNCTION: AN AUA UPDATE

approach to develop a guideline for the ED treatment modalities that had become available in the United States after publication of the 1996 Report. Guideline statements from the 1996 Report on previously available therapeutic modalities were either revised or brought forward unchanged depending on the existing evidence. All guideline statements were graded according to the degree of flexibility in clinical application: standard, recommendation, or option, with standard being the least flexible and option being the most flexible (Table 1). Grading is based on two characteristics: knowledge of the health outcomes of the alternative intervention and preference for the intervention. The Panel believed that the patient, with physician guidance, must make his own decision in selecting treatment. Outcome estimates derived from review and meta-analysis of evidence provide physicians and patients with scientifically based information to assist them in making appropriate treatment decisions. Thus, a second Panel objective was to determine whether or not there was sufficient evidence for outcomes (both benefits and risks) to be estimated.