Patient In Lateral Decubitus Position Research Articles

Posterior Malleolus Fracture Fixation In Lateral Decubitus Position: Surgical Technique and Results in 60 Patients

The present study shows how posterior malleolus fractures (PMFs) and distal fibular fractures were fixed using the posterolateral approach with the patient in lateral decubitus position, not previously described in the literature. This technique has been used in 60 consecutive patients (42 women and 18 men; mean age 54.7; range 21-92 years), 33 of which presented as fracture dislocations from March, 2021 to December, 2023. After PMFs fixation in lateral decubitus position, release of the sacral support allowed patients to be placed supine (without de-sterilizing the operative field), in order to proceed with medial malleolus or posteromedial fragment fixation. Fractures were classified according to the Lauge Hansen classification as SER4 (n = 50), PER4 (n = 7), SAD (n = 1), and PAB (n = 2). Fractures were classified according to Rammelt & Bartonicek, as type B (n = 40), C (n = 13), and D (n = 7). During the same period of time 14 fractures involving the PM, classified as type A, were treated with indirect fixation, whilst 6 geriatric and/or poor mobility patients with fracture dislocations were treated with retrograde hindfoot nail fixation. Follow-up period ranged from 4-36 months (mean = 14.4; SD = 8.8). Complications occurred in 5 patients (8.3%; 3 had delayed (medial) wound healing, one developed CRPS and one required implants removal and arthroscopy because of metal irritation and stiffness). No deep infections, thromboembolic events, fracture malreductions or malunions were recorded and all patients returned to the preinjury mobilization status. In conclusion, PM fracture fixation was feasible and safely performed with patients in lateral decubitus position.

Mid-term results of cemented hip arthroplasties through the direct anterior approach in the lateral decubitus position: a retrospective cohort study

BackgroundReports show a high complication rate when starting with the Direct Anterior Approach (DAA) in a supine position for hip arthroplasty. The DAA with the patient in lateral decubitus position may avoid this problem because it supposedly provides better visibility, especially on the femoral side. However, this approach did show a rather high complication rate during the adoption of the approach at 1 year follow up in our previous report. We were interested what the overall 7 year survival estimate would be and whether improvement could be seen with growing experience.MethodsA cohort of patients undergoing total hip arthroplasty right from the start of applying the DAA in lateral decubitus position was analysed.ResultsIn total 175 hip prostheses (162 patients) were evaluated. The 7-year survival estimate was 95.1%, 95 CI: 91.8–98.4%. In 6 of 8 revisions there was aseptic loosening of the stem. By dividing the cohort into 3 consecutive groups in time we did not see a significantly improving revision rate.ConclusionsIn our experience, the adoption of the direct anterior approach in lateral decubitus position caused a relatively low 7-year survival estimate without an apparent decrease with growing experience, however given the low number of cases further research is needed to investigate the long-term risk of adopting a new approach.

Masquelet Technique: Visualization of Cement Spacer Utilizing Methylene Blue

Masquelet Technique: Visualization of Cement Spacer Utilizing Methylene Blue

Treatment of Chronic Femoral Neck Fracture With Cemented Bipolar Hemiarthroplasty and Management of Intraoperative Fracture With Cerclage Cabling.

We cover the operative treatment of a neglected chronic femoral neck fracture nonunion treated at 6 months. We begin with a description of the case and concomitant injuries. The operative portion includes the direct lateral approach with the patient in lateral decubitus position, exposure of the fracture site, osteotomy of the neck, debridement of the nonunion site, broaching, trialing, recognition and treatment of an intraoperative proximal femur fracture using cerclage cabling above and below the lesser trochanter, cementation of final components, and reduction. We conclude with the patient's radiographs at 2 weeks and clinical outcome at 6-week follow-up.

Reducing Complication Rates of Fat Grafting in Gluteal Augmentation

INTRODUCTION: Gluteal augmentation via autologous fat grafting is an increasingly popular procedure used in body contouring. However, concerns remain about the patient safety of the procedure due to reported high complication rates in numerous countries around the world. METHODS: The author reports on a retrospective analysis of a 181 patient database who all had intramusular and deep subcutaneous gluteal augmentation via autologous fat grafting following liposuction. Average age, body mass index, tumescent fluid volumes, aspirate, fat volumes grafted, and operating room times are analyzed along with complication rates in the 181 patient cohort. Triple antibiotic solution was added to the grafted fat after four of the first 31 patients developed an infection. Patient positioning after fat grafting in the prone position was changed to the right lateral decubitus position for extubation after three of the first 51 patients developed clinically significant fat embolism in supine position. Statistical analysis using Fisher exact test is performed to determine if these changes in protocol result in better patient safety. RESULTS: Data from 181 patients reveal an average age of 38.6 years, average BMI of 28.4, average tumescent fluid injected 4078 cm3, average aspirate 4962 cm3, average right buttock injected 790 cm3, and average left buttock injection is 790 cm3. Mean operative time was 4 hours and 8 minutes. Fisher exact test was used to analyze two changes in buttock augmentation protocol consisting of adding a triple antibiotic solution to the harvested fat and extubating the patient in a lateral decubitus position on the recovery room bed. Four of the first 31 patients developed an infection but after adding triple antibiotic solution of gentamycin, ancef, and bacitracin to the aspirate, no infections were seen in the next 150 patients. The P value is 0.0008 for infection, which is statistically significant. Three of the first 51 patients experienced a clinically significant fat embolism, which required supplemental postoperative oxygen and hospital admission. The extubation protocol after general anesthesia was changed to position the patient in the right lateral decubitus position on the recovery room bed for extubation and no patient out of the next 130 experienced a fat embolism despite intramuscular injections. The P value is 0.0229 for this change in protocol. Other complications include abdominal seromas requiring serial aspirations, cubital tunnel syndrome from lying prone for 2–3 weeks postoperatively, and one patient with a pulmonary embolism and death. CONCLUSIONS: Fat embolization in gluteal augmentation can be greatly reduced by positioning the patient in the lateral decubitus position for extubation after injecting the fat in a prone position. Infection rates can be reduced by mixing a triple antibiotic solution with the aspirate prior to grafting. Since the popularity of gluteal augmentation is increasing, we must develop protocols in performing the procedure that maximize patient safety and minimize risks of complications. The buttock augmentation patient is at a higher risk of DVT/PE because they do not ambulate normally; so prophylactic lovenox may be of benefit. Further studies are required.

Comparative study of psoas compartment block and sciatic nerve block with that of spinal block anesthesia for lower extremity surgeries

Aim and Objectives: Aim of the present study was to compare the efficacy of the block, hemodynamic effects, postoperative analgesia and side effects of combined psoas compartment sciatic nerve block with continuous spinal anaesthesia in adult patients undergoing lower extremity surgeries. Materials and Methods: Sixty patients of either sex, ASA grade I, II and III, age between 18-70 years, were randomly allocated into two groups. In group A, psoas compartment block was performed by posterior approach using 30cc of 0.25% bupivacaine and sciatic nerve block by classical posterior approach using the 20cc of 0.25% bupivacaine. In group B, continuous spinal anaesthesia was performed in the L3-L4 interspaced with the patient in lateral decubitus position using 3cc (15 mg) of 0.5% heavy bupivacaine. We studied various parameters of block, hemodynamic effects, duration of postoperative analgesia and any complications. Results: Group B had earlier onset of sensory and motor block as compare to group A. The mean duration of sensory and motor block was significantly prolonged in group A than in group B. The efficacy of sensory blockade was comparable in both the groups while in group A 90% patients and in group B 97% of patients had complete motor blockade. The incidence of hypotension was more with group B as compared to group A. The duration of post-operative analgesia was longer in group A than in group B. No major complications were observed in both the groups. Conclusions: It was concluded that combined psoas compartment block and sciatic nerve block is a beneficial alternative to existing anaesthesia techniques for lower extremities surgeries. Keywords: Bupivacaine, Combined psoas compartment-sciatic nerve block, Continuous spinal anaesthesia, Lower extremity surgeries, Post-operative analgesia, Sensory and motor blockade.

Statistical Shape Modeling to Determine the Anterior Pelvic Plane for Total Hip Arthroplasty.

The anterior pelvic plane (APP) defined by both iliac spines and the pubic symphysis, is essential in total hip arthroplasty (THA) for the orientation of the prosthetic cup. However, the APP is nowadays still difficult to determine in computer assisted orthopedic surgery (CAOS). We propose to use a statistical shape model (SSM) of the pelvis to estimate the APP from ipsilateral anatomical landmarks, more easily accessible during surgery in computer assisted THA with the patient in lateral decubitus position. A SSM of the pelvis has been built from 40 male pelvises. Various ipsilateral anatomical landmarks have been extracted from these data and used to deform the SSM. Fitting the SSM to several combinations of these landmarks, we were able to reconstruct the pelvis with an accuracy between 2.8mm and 4.4mm, and estimate the APP inclination with an angular error between 1.3° and 2.8°, depending on the landmarks fitted. Results are promising and show that the APP could be acquired during the intervention from ipsilateral landmarks only.

Trans-lateral decubitus radiograph of the hip: A new view to measure the anteversion of the femoral stem

BackgroundMalposition of the femoral stem is a risk factor for dislocation after total hip arthroplasty (THA). Currently, two radiological methods are available for the measurement of stem anteversion. However, one method is not applicable in patients with a stiff hip, and the other one cannot differentiate the anteversion and retroversion of the stem. Therefore, we developed a method to measure the stem anteversion and assessed its reliability as well as validity. MethodsTrans-lateral decubitus view of the proximal femur was taken with the patient in lateral decubitus position, the hip in extension and the knee in 90° flexion. Hip anteroposterior (AP) view, trans-lateral decubitus view and CT scan of the hip were taken in 36 patients, who underwent THA. Their mean age was 59.8 (27–84) years and the mean body mass index was 25.2 (18.8–30.9) kg/m2. The stem neck-femoral shaft angle was measured on hip AP view and the trans-lateral decubitus view. Then, the stem anteversion was calculated using the Ogata-Goldsand formula. We assessed the intra- and inter-observer reliabilities and evaluated the validity by comparing with the measurements on CT scan. ResultsThe intra- and inter-observer reliabilities were 0.934 and 0.935, respectively. The calculated stem anteversion (23.72°±8.17°) correlated well with the stem anteversion on CT scan (23.91°±10.25°), especially when the radiological anteversion was <30° (correlation coefficient = 0.729, p = 0.001). ConclusionWe developed a reliable and valid method to measure stem anteversion using hip AP view and trans-lateral decubitus view of the femur. This method can replace conventional radiological methods.

Femoral malalignment after gamma nail insertion in the lateral decubitus position.

Introduction: Insertion of gamma nail with the patient in lateral decubitus position have the advantages of easier access to the entry point, easier fracture reduction and easier implant positioning. Our study described the incidence of femoral angular and rotational deformity following gamma nail insertion in lateral decubitus position.Methods: In a prospective clinical case series, 31 patients (26 males and 5 females; the average age of 42.6 years) with 31 proximal femoral shaft fractures that were treated with gamma IMN were included in our study. Postoperatively, computerized tomography scans of the pelvis and both knees (injured and uninjured sides) were examined to measure anteversion angles on both sides. A scout film of the pelvis and upper both femurs was taken to compare the neck shaft angles on both sides.Results: No angular malalignment was detected in our series; the mean angular malalignment angle was 1.6 ± 1.5°. There was a high incidence of true rotational malalignment of ≥10° in 16 out of 31 patients (51.6%); most of them were external rotational malalignment. Younger age group (≤40 years) had significantly more incidence of rotational malalignment (≥10°) than older age group (>40 years) (P-value 0.019).Discussion: Gamma nail fixation in lateral decubitus position without the fracture table gives an accurate and easier access to the entry point, good implant positioning with no or minimal angular malalignment (varus −valgus) but poses high incidence of true rotational malalignment. Great care and awareness of rotation should be exercised during fixing proximal femoral fractures in lateral decubitus position.

Surgical Dislocation of the Hip in the Treatment of Complex Osteochondral Injury to the Femoral Head.

The optimal treatment for osteochondral fracture of the femoral head associated with posterior dislocation remains unclear. A case can be made to treat small fragments and those that concentrically reduce nonoperatively. On the other end of the spectrum are those where significant size and residual displacement warrant consideration of operative fixation. This video demonstrates the treatment of a large complex multifragmentary osteochondral femoral head fracture with surgical dislocation. With the patient in lateral decubitus position, the trochanter is approached through lateral incision. The trochanter is cut and capsulotomy performed taking care to preserve the critical medial femoral circumflex artery. Fixation with headless screws is performed from the small comminuted fragments into the dominant section of intact femoral head. Experience suggests that anatomic fixation through surgical dislocation can be carried out with low incidence of subsequent avascular necrosis and degenerative articular change. Given the degree of local osseous and muscular trauma, consideration should be given to prophylaxis of heterotopic bone. Although small osteochondral fragments restricted to the acetabular fossa can be treated nonoperatively, the size and displacement of the presented fragment mandated operative reduction. Given the predicted complexity of repair, the surgical dislocation approach was chosen to provide maximum exposure optimizing the chances for successful fixation.

Deep versus moderate neuromuscular block during one-lung ventilation in lung resection surgery

Background and objectivesNeuromuscular relaxants are essential during general anesthesia for several procedures. Classical anesthesiology literature indicates that the use of neuromuscular blockade in thoracic surgery may be deleterious in patients in lateral decubitus position in one-lung ventilation. The primary objective of our study was to compare respiratory function according to the degree of patient neuromuscular relaxation. Secondary, we wanted to check that neuromuscular blockade during one-lung ventilation is not deleterious. MethodsA prospective, longitudinal observational study was made in which each patient served as both treated subject and control. 76 consecutive patients programmed for lung resection surgery in Gregorio Marañon Hospital along 2013 who required one-lung ventilation in lateral decubitus were included. Ventilator data, hemodynamic parameters were registered in different moments according to train-of-four response (intense, deep and moderate blockade) during one-lung ventilation. ResultsPeak, plateau and mean pressures were significantly lower during the intense and deep blockade. Besides compliance and peripheral oxygen saturation were significantly higher in that moments. Heart rate was significantly higher during deep blockade. No mechanical ventilation parameters were modified during measurements. ConclusionsDeep neuromuscular blockade attenuates the poor lung mechanics observed during one-lung ventilation.

Closed Cephalomedullary Nailing with Patient in Lateral Decubitus Position for Repair of Peritrochanteric Femoral Fracture.

Closed repair of peritrochanteric fractures with cephalomedullary nail fixation with the patient in the lateral decubitus position on a flat table with manual traction may allow improved fracture reduction and fixation in comparison with what is possible in a supine setup. Perform sterile preparation, have the patient brought to the operating room, induce anesthesia, and place the patient in the lateral decubitus position before sterile draping. Reduce the fracture using manual traction and slight internal or external rotation; confirm anatomic reduction radiographically. Determine the appropriate nail length, identify the nail entry point, open the femoral canal, insert a ball-tipped guide into the canal, insert the nail, and attach the aiming arm to the nail. Attach the aiming arm to the insertion handle, pass a guidewire, drill over the guidewire to open the lateral cortex, and insert the cannulated screw with soft hammer blows. Confirm fracture reduction on anteroposterior and lateral views, drill through the lateral cortex of the femur for the distal interlocking screw, measure the screw length, insert the screw, and remove the aiming arm if one was used. Obtain anteroposterior and lateral views to confirm maintenance of fracture reduction and appropriate placement and length of the nail and cephalic and distal locking screws. Irrigate and close the wounds, and apply operative dressings. Intramedullary device technology has been altered to address the complication of periprosthetic fracture at the distal tip that made earlier intramedullary fixation less appealing compared with extramedullary fixation for stable fracture patterns.

Endoscopic Thoracodorsal Neurectomy for Correction of Animation Deformity following Latissimus Dorsi-Based Breast Reconstruction.

Sir: Painful muscular contractions, involuntary twitching, tightness, and/or dynamic displacement of the breast affect a high percentage of patients (41 percent) undergoing innervated latissimus dorsi–based breast reconstruction.1 These sequelae can limit physical activity, jeopardize satisfaction, and diminish quality of life for individuals who have otherwise achieved a favorable aesthetic result. Studies evaluating the impact of surgical denervation of the latissimus dorsi muscle demonstrate significantly reduced pain and animation; comparable preservation of volume, shape, and symmetry; and improved satisfaction following thoracodorsal neurectomy.2,3 It is therefore our preference to perform primary nerve resection during immediate or delayed breast reconstruction, which is readily accomplished through an open axillary or dorsal approach and eliminates the need for a second-stage procedure. Nevertheless, plastic surgeons must also be familiar with treatment strategies for patients who present with secondary contractile deformities. In such cases, chemical denervation with botulinum toxin type A offers a temporary solution; however, results with this approach are unpredictable, and the need for repeated injections over time increases the risk of implant leakage and/or rupture.4 Alternatively, delayed proximal resection of the thoracodorsal nerve may offer the best available option for symptomatic relief. Although high success rates have been reported using an axillary approach (90 percent), sectioning of the latissimus dorsi muscle to access the thoracodorsal nerve is excessively destructive and may alter muscle tropism and contour without guaranteeing successful denervation.1 Furthermore, scarring and/or fibrosis, which are often encountered during secondary revisions, increase the risk and complexity of dissection and the need for more extensive incisions.4 In this communication, we propose a minimally invasive, endoscopic approach to thoracodorsal neurectomy that minimizes incisions, bypasses axillary scarring, and eliminates dynamic abnormalities through selective denervation of the latissimus dorsi muscle. With the patient in lateral decubitus position, endoscopic visualization of the thoracodorsal neurovascular hilus is achieved using carbon dioxide insufflation (10 mmHg) through a 3-mm trocar inserted along the posterior axillary line. Two additional trocars placed distal to the dorsocaudal border of the latissimus dorsi permit unobstructed dissection through the nonirradiated, dorsal submuscular plane. Once identified on the undersurface of the muscle, the thoracodorsal nerve is isolated proximal to the point of divergence from the vascular pedicle and clipped (Fig. 1). Proximal resection of at least 4 cm of extramuscular nerve is then performed under endoscopic guidance, following confirmation of latissimus dorsi contraction on nerve stimulation (Fig. 2).Fig. 1: Endoscopic view of the thoracodorsal neurovascular bundle in situ. The nerve (arrow) is traced proximal to the point of divergence from the vascular pedicle, isolated, and clipped to prevent nerve sprouting and/or aberrant regeneration from adjacent nerve fibers following segmental resection.Fig. 2: A minimum of 4 cm of extramuscular nerve is routinely excised, proximal to the neurovascular hilus, to minimize the risk of latissimus dorsi reinnervation along the vascular pedicle.It is important to note that both muscular reinnervation and incomplete/distal nerve transection may contribute to compromised results and/or persistent animation.4 Technical error can be prevented through segmental resection of the main thoracodorsal nerve trunk—proximal to the neurovascular hilus—using a dorsal approach to avoid injuring the latissimus dorsi muscle and any structures embedded within the scarred axillae. As recommend by Schroegendorfer et al., at least 4 cm of thoracodorsal nerve is resected to achieve permanent sufficient denervation.5 We routinely clip the proximal/distal ends to prevent nerve sprouting and/or aberrant regeneration from adjacent nerve fibers. As with other minimally invasive techniques, improved scarring, reduced pain, and earlier postoperative recovery can be expected following endoscopic thoracodorsal neurectomy for correction of latissimus dorsi–based contractile deformities. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Michael V. DeFazio, M.D. Troy A. Pittman, M.D. Department of Plastic Surgery Medstar Georgetown University Hospital Washington, D.C.

First experiences with the direct anterior approach in lateral decubitus position: learning curve and 1 year complication rate.

The direct anterior approach (DAA) in supine position for hip arthroplasty has been reported to suffer from high complication rates initially. The DAA with the patient in lateral decubitus position is believed to provide better visibility and especially femoral accessibility with potential fewer complications.The first cohort of total hip prostheses, which were implanted by a single surgeon using DAA in lateral decubitus position more than 1 year ago, was analysed retrospectively.In total 182 hip prostheses (172 patients) were analysed. Three consecutive time periods based on equal number of surgical procedures were compared. The technical complication rate and operating time improved significantly between the 3 consecutive groups. The 1 year infection rate was 0.5% and survival rate of 98.9%.This is the first series of patients that were subjected to a hip replacement based on the direct anterior approach in a lateral decubitus position in which decreasing complication rates suggest the presence of a learning curve in surgeons conducting this type of surgery. Initial complication rate was high but decreased significantly in time and was acceptable certainly in the third group of our cohort. An unacceptable complication rate with the straight uncemented stem forced us to discontinue this configuration after only 7 surgical procedures. Complication, infection and revision rates were acceptable for the all cemented hip replacements using a curved anatomical stem.

Posterior Füzyon Cerrahisi Sonrası Preemptif Segmental Epidural Levobupivakain Uygulaması ve Yara Yeri İnfiltrasyonu: Vaka Serisi

Objective: The current study aimed to provide intraoperative smooth wake-up test and postoperative effective analgesia by segmental epidural analgesia and wound infiltration in patients undergoing posterior fusion surgery. Material and Methods: Fifteen ASA I-II adolescent patients aged 11-16 undergoing posterior fusion and instrumentation were included to the study. After general anesthesia with standard intravenous anesthesia, epidural catheter was inserted to all patients in lateral decubitus position. Following confirmation of the place of the catheter under scopy, initially 3-4 ml of prepared mixture was administered from the catheter and then the catheter was retracted and during retraction, 1-2 mL of the mixture was given to each segment. Neuromonitorization was achieved with motor evoked potential (MEP). Postoperative pain was evaluated with visual analogue scale (VAS). Paracetamol infusion and nonsteroidal antiinflammatory analgesics were given for routine postoperative pain management. Intravenous patient-controlled analgesia with morphine was prepared to be given in case of VAS score higher than 40. Results: In all patients effective analgesia was achieved for postoperative 24 hours. No side effects and hemodynamic impairment were observed. The highest pain scores were obtained at the postoperative 12th hour and during movement. There was no requirement for morphine patient controlled anesthesia (PCA) as VAS values were lower than 40. The sleep quality of patients and the patient satisfaction were very good in all patients. Conclusion: Segmental epidural analgesia with a preoperatively placed epidural catheter and wound infiltration is a simple and reliable method for effective pain control in posterior fusion and instrumentation surgery in patients with adolescent idiopathic scoliosis.

A Guide to Percutaneous Cryoablation of Renal Masses in Difficult Anatomic Locations

Purpose To discuss the pathophysiology of renal cell carcinoma, describe indications for treatment of small renal masses, present technical aspects of percutaneous cryoablation, and highlight adjunctive techniques used to improve success and safety during cryoablation of renal masses in more difficult anatomic locations. Material and Methods A case-based format will be utilized to highlight techniques to improve outcomes in cryoablation of renal masses in difficult anatomic locations. Four major topics will be presented, including maximizing position of the patient, utilization of retrograde pyeloperfusion, using hydrodissection to displace critical structures away from the zone of ablation, and angioplasty balloon interposition to displace adjacent structures from the ablation zone. In addition, combining ablation and embolization in the most difficult anatomic locations will be described. Results Utilizing adjunctive technique during cryoablation leads to successful cryoablation of renal masses in difficult anatomic locations. Placing patients in lateral decubitus position, with the affected side down, results in less aeration of the adjacent lung and reflex increased aeration of the contralateral lung. This allows for improved window to target upper pole renal masses. Retrograde ureteral catheter can be placed to infuse warm saline into the ureter and renal pelvis in an attempt to protect these structures during cryoablation. Hydrodissection can be used to infuse normal saline through a trocar to displace critical structures away from the zone of ablation. Similar to the concept of combining ablation and embolization for treatment of 3 to 5 cm liver tumors, one can combine therapies in an attempt to achieve a synergistic effect. This is particularly useful when there is concern that a complete ablation may not be possible given lesion location in a poor surgical candidate. Conclusions Nephron-sparing therapies have been increasingly utilized in treatment of renal masses. Lesions typically considered more difficult to ablate include central lesions, size larger than 3 cm, upper pole location, endophytic, and adjacent to ureter, colon, or other abdominal organs. Multiple techniques can be used to maximize the likelihood of successful cryoablation of masses in difficult anatomic locations, including hydrodissection, retrograde pyeloperfusion, maximizing patient positioning, and angioplasty balloon interposition.

Continuous spinal anaesthesia versus ultrasound-guided combined psoas compartment-sciatic nerve block for hip replacement surgery in elderly high-risk patients: a prospective randomised study.

BackgroundOur aim is to compare the hemodynamic effects of combined psoas compartment-sciatic nerve block (PCSNB) with continuous spinal anaesthesia (CSA) in elderly high-risk patients undergoing hip replacement surgery.MethodsSeventy patients over the age of 60 with ASA III or IV physical status were randomly allocated to two groups: In the PCSNB group, ultrasound-guided psoas compartment block was performed with modified Winnie technique using 30 mL of 0.25% bupivacaine with 1:200.000 epinephrine (5 μgr/mL) and iliac crest block was performed using the same local anaesthetic solution (5 mL). All patients in the PCSNB group needed continuing infusion of propofol (2 mg/kg/h) during operation. In the CSA group, CSA was performed in the L3-L4 interspaced with the patient in lateral decubitus position using 2.5 mg of isobaric bupivacaine 0.5%. When sensory block was not reached to the level of T12 within 10 minutes in the CSA group, additional 2.5 mg of isobaric bupivacaine 0.5% was administered through the catheter at 5-min intervals by limiting the total dose of 15 mg until a T12 level of the sensory block was achieved.ResultsThe PCSNB group had significantly higher mean arterial blood pressure values at the beginning of surgery and at 5th, 10th and 20th minutes of surgery compared to the CSA group (P =0.038, P =0.029, P =0.012, P =0.009 respectively). There were no significant differences between groups in terms of heart rate and peripheral oxygen saturation values during surgery and the postoperative period (P >0.05). Arterial hypotension required ephedrine was observed in 13 patients in the CSA and 4 patients in the PCSNB group (P =0.012).ConclusionsCSA and PCSNB produce satisfactory quality of anaesthesia in elderly high-risk patients with fewer hemodynamic changes in PCSNB cases compared with CSA cases.Trial registrationAustralian New Zealand Clinical Trials Registry: ACTRN12614000658617, Registered 24 June 2014.

The incidence of hypoxemia due to malposition of double lumen endotracheal tube during one lung ventilation

&#x0D; &#x0D; &#x0D; &#x0D; Fac Med Baghdad&#x0D; 2014; Vol.56, No.2&#x0D; Received: Jan., 2014&#x0D; Accepted March. 2014&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Background: Oxygenation during one lung ventilation (OLV) can be affected by positioning of Double lumen endobronchial tube (DLT). Mal position can occurs following intubation and moving the patient to the lateral decubitus position.&#x0D; Objectives: To study the relation of hypoxemia to mal position of double lumen endo bronchial tube after patient positioning in lateral decubitus position and during one lung ventilation. The use of fiber-optic scope in detecting the mal position and correcting it is illustrated.&#x0D; Methods: A study of 80 patients with ASA physical status I-II patients about to have elective thoracic operations. The intubation of the trachea was done with a left sided DLT, then checked clinically by auscultation and with use of fiber-optic scope and this done after patient positioning and during OLV. Oxygen saturation was measured by non invasive pulse oxy meter. IF oxygen saturation below 92 % (10.6kpa) 80 mmHg is detected, the DLT position must be checked and positive end expiratory pressure (PEEP), oxygen insufflations or (continuous positive airway pressure). CPAP or total lung ventilation (TLV) was tried if needed.&#x0D; Result: Misplacement of DLT was found in 28 patients (35%) after patient positioning and in 24 patients (30%) during OLV. Patients who had malpostion of DLT after placing the patients in lateral decubitus position had a greater incidence of malposition of DLT in OLV (64%). The application PEEP to the dependent lung, CPAP or oxygen insufflations to the upper lung or brief periods of TLV were applied in 28 patients.&#x0D; Conclusion: Patients who have mal position of DLT in lateral position had more incidence of hypoxemia and DLT mal position in OLV and mostly require intervention with use of fiber-optic bronchoscopy which is mandatory for detecting and correcting the mal position.

Hyperbaric articaine with or without fentanyl in spinal anaesthesia: patient and observer blinded comparison

The rapid and short-acting local anaesthetic articaine is a feasible spinal anaesthetic for day-case open inguinal herniorrhaphy (OIH). We hypothesised that similarly to other spinal local anaesthetics, the addition of fentanyl may prolong articaine spinal analgesia without prolonging motor block. We performed a randomised, controlled study in 100 adult patients undergoing OIH. Spinal anaesthesia was induced by injecting hyperbaric articaine 72 mg with (Group A + F) or without (Group A) fentanyl 10 μg with the patient in lateral decubitus position. The distribution of sensory block was tested using pinprick and controlled by tilting the operating table 10 up or down. Motor block testing was based on the patient's ability to flex knees and ankles. Rescue analgesic was intravenous (i.v.) fentanyl. Pain scores were registered, and i.v. paracetamol 1 g was given as the first post-operative analgesic. There were no differences (A + F vs. A) in the maximum median extension of the sensory block (T5 vs. T5), mean duration of sensory block ≥ T10 (76 min vs. 73 min), or total duration of sensory (146 min vs. 146 min) or motor block (99 min vs. 107 min). Fewer patients in Group A + F needed fentanyl (5 vs. 14, P < 0.05) perioperatively or paracetamol (3 vs. 18, P < 0.001) post-operatively. Fentanyl 10 μg added to spinal hyperbaric articaine improved analgesia and reduced analgesic consumption during and after OIH. Fentanyl did not prolong motor block or delay recovery.

Lateral Injection Using a Whitacre Needle with Patients in the Lateral Decubitus Position Maintained for a Prolonged Time Period Produces Symmetric Sensory Block

The directional flow of injection through a Whitacre needle can be used to modify the level of sensory blockade. We hypothesized that injection of hyperbaric local anesthetic through a Whitacre needle with the bevel oriented laterally can produce a more symmetric sensory block. Patients scheduled for lower limb surgery under spinal anesthesia with the patient in lateral decubitus position were randomized to receive 10 mg, 0.5% hyperbaric bupivacaine with the Whitacre needle orifice in 1 of 2 orientations, cephalad and lateral. The patient's position was maintained for 15 min after the injection, and sensory blocks were recorded. The primary outcome was the sensory levels between the dependent and nondependent side. The Wilcoxon-Mann-Whitney U-test odds was used to compare unpaired nonparametric data. For the paired samples, 95% confidence intervals (CI) of differences between group medians were calculated using the Hodges-Lehman estimator for the median difference in number of blocked segments. There was no significant difference in block level between dependent and nondependent sides in the lateral group. The Hodges-Lehmann point estimator was 0.5% and 95% CI was 0-2.5, suggesting a more symmetric sensory block in patients in the lateral decubitus position maintained for a sufficient period of time. A significantly lower level of blockade was noticed on the nondependent side compared to the dependent side in the cephalad group. The Hodges-Lehmann point estimator was 2.5 segments and 95% CI was 0.5-5. Injection of 10 mg of 0.5% hyperbaric bupivacaine with the bevel of the Whitacre needle oriented laterally produces more symmetric sensory levels of blockade between the dependent and nondependent sides.