Practice Of Regional Anesthesia Research Articles

Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management.

Low molecular weight heparin: biochemistry, pharmacology, perioperative prophylaxis regimens, and guidelines for regional anesthetic management.

Emery A. rovenstine and regional anesthesia

Emery Andrew Rovenstine was a dominant figure in anesthesiology in the United States between 1935 and 1960. Among his many contributions to the specialty, his regional anesthesia practice remains less well known. This paper explores Rovenstine's career and his contributions to regional anesthesia. Original documents studied and classified for this investigation included all of Rovenstine's published papers and the extant documents of the original American Society of Regional Anesthesia. Interviews with several physicians who knew Rovenstine were conducted. Secondary source materials, including biographies of Rovenstine, were perused. Rovenstine made a major contribution to regional anesthesia through patient care, teaching, and political action. Many of his students went on to become leaders in anesthesiology and emphasized regional anesthesia in the second half of the twentieth century. Emery A. Rovenstine did much to popularize regional anesthesia and ensure a rightful place for its techniques within the armamentarium of the anesthesiologist. Keeping alive the traditions of Gaston Labat at Bellevue, Rovenstine's contributions to regional anesthesia on all levels were considerable. Most importantly, he ensured an enduring role for regional anesthesia through the recurring contributions of his pupils.

Survey of regional anesthetic practice among French residents at time of certification

A survey of anesthesia practice was conducted among French residents in anesthesia at the end of their training. This study was performed mainly to evaluate the residents' experience in peripheral nerve blocks. Two short clinical cases were proposed to all French residents during a telephone interview immediately before their certification. The first described the case of a young asthmatic patient admitted for an elbow fracture. The second described an elderly woman with severe aortic stenosis admitted for a supracondylar fracture of the femur. A questionnaire had been prepared and was filled in during the interview. Each resident was asked to answer according to the actual choice he or she would have made. For both cases, when general anesthesia was chosen first, the next question was to discuss which regional anesthesia would be used if general anesthesia had to be discarded. In that way, the practical knowledge about most common peripheral nerve blocks learned during residency was investigated. Of 77 residents registered as being at the end of their residency, 8 were on either sabbatical or maternity leave. Regional anesthesia was the first choice in 78% and 57% of cases for the first and second clinical cases, respectively. The regional anesthetic techniques chosen were axillary block (66%), interscalene block (31%), and intravenous regional anesthesia (3%) for case 1 and combined lumbar plexus and sciatic block (36%), epidural anesthesia (30%), single-shot spinal anesthesia (18%), and continuous spinal anesthesia (16%) for case 2. Throughout the residency of the group, 32 +/- 2 axillary blocks, 12 +/- 2 interscalene blocks (axillary vs interscalene, P < .0001), 21 +/- 3 femoral blocks, and 10 +/- 2 sciatic blocks (femoral vs sciatic, P < .0001) had been performed (mean +/- SEM). They had also performed 2.5 +/- 0.5 continuous spinal anesthesias and 17 +/- 3 intravenous regional anesthesias respectively. Upper extremity blocks were more often used during residency than lower extremity blocks (44 +/- 3 vs 31 +/- 4, P < .01). A peripheral nerve stimulator was routinely used by 83% of residents. French residents in anesthesiology at time of certification are better trained for peripheral nerve blocks of the upper extremity than for those of the lower extremity. Axillary plexus and femoral nerve block are the most widely used blocks, probably reflecting the techniques the most mastered among teachers. Finally, the extensive use of a peripheral nerve stimulator by residents is probably the result of the widespread use of this device by teachers in France.

Epidemiology and morbidity of regional anesthesia in children: a one-year prospective survey of the French-Language Society of Pediatric Anesthesiologists.

We report the results of a prospective study on the practice of pediatric regional anesthesia by the French-Language Society of Pediatric Anesthesiologists (ADARPEF) during the period from May 1, 1993 to April 30, 1994. This study was designed to provide data concerning the epidemiology of regional anesthesia and its complications in a totally anonymous way. Data from 85,412 procedures, 61,003 pure general anesthetics and 24,409 anesthetics including a regional block, were prospectively collected. Central blocks (15,013), most of which were caudals, accounted for more than 60% of all regional anesthetics. Peripheral nerve blocks and local anesthesia techniques represented only 38% of regional blocks and Bier block was used only 69 times. Central and peripheral nerve blocks were performed in all pediatric age groups with some intergroup differences. Most blocks were performed under light general anesthesia (89%), confirming the fact that regional anesthetics are used as techniques of analgesia rather than anesthesia. Complications were rate (25 incidents involving 24 patients) and minor, and did not result in any sequelae or medicolegal action. Peripheral nerve blocks and local anesthesia techniques were generally safe. The overall complication rate of regional anesthesia was 0.9 per 1000, but because all complications occurred with central blocks, the complication rate of central blocks is in fact 1.5 per 1000 with significant variations in different age groups. This prospective study, based on a large and representative series of pediatric anesthetics, establishes the safety of regional anesthesia in children of all ages. It provides new insights on the practice of regional blocks and reveals that complications are rare and minor as they occur most often in the operating room and are readily managed by experienced anesthesiologists with resuscitative equipment at hand. The extremely low incidence of complications (zero in this study) after peripheral nerve blocks should encourage pediatric anesthesiologists to use them more often when they are appropriate, in the place of a central block.

COMPARTMENT SYNDROME IN TIBIAL SHAFT FRACTURE MISSED BECAUSE OF A LOCAL NERVE BLOCK

Compartment syndrome is a serious complication of fractures of the tibial shaft and its clinical presentation and evaluation have been well documented (Holden 1975; Kikuchi, Hasue and Watanabe 1978). The most important diagnostic feature is the presence of inappropriate pain even after stabilisation of the fracture by a cast or by external or internal fixation. Pain is made worse by passive stretching of the muscles involved and there is an associated sensory disturbance. The prognosis is directly related to the speed at which the diagnosis is made and treatment begun. It has been shown that muscle can tolerate only four hours of ischaemia without injury (Heppenstall et al 1988; Heckman et al 1993). We describe a patient with a fracture of the tibial shaft in whom the diagnosis of compartment syndrome was delayed because of the use of a local nerve block given in the operating theatre after intramedullary nailing. Case report. A 28-year-old man presented after a football injury with a closed fracture of the tibial shaft (42-A2.2 according to the AO classification (Muller et al 1990)). Before operation there were no signs of neurovascular compromise or of a compartment syndrome. The fracture was initially stabilised in a plaster back slab and closed, unreamed locked intramedullary nailing then performed. At the end of the operation, the patient was given a triple nerve block (femoral, obturator, lateral cutaneous nerve of thigh) using bupivacaine 0.5% for pain control. After operation, he was entirely free from pain, although he did complain of areas of altered sensation in his foot and leg, but these varied in site and were initially thought to be a result of the nerve block rather than a symptom of a developing compartment syndrome. Pressure measurements were made 48 hours after operation because symptoms persisted and there was inability actively to extend the big toe. They showed a pressure of 108 mmHg in the anterior compartment. We performed fasciotomy urgently but all the muscles in the anterior compartment were dead. No other compartment was involved. The whole of the anterior tibial compartment was debrided 48 hours later as there was no sign of recovery. The patient now walks with an orthosis. Discussion. The treatment of postoperative pain in patients whose tibial fractures have been stabilised is usually by elevation of the injured leg and the use of oral or intramuscular analgesics, especially non-steroidal anti-inflammatory agents. Local anaesthetic nerve blocks are now also commonly given to patients with fractures of the lower limb; they are effective and especially useful after fracture of the femoral shaft. A nerve block using bupivacaine persists for about eight hours (Macrae and Davies 1993), but recovery from the block may be patchy and erratic over a period of several hours. The diagnosis of compartment syndrome is essentially

Impaired haemostasisd and regional anaesthesia

A striking lack of data has always made rational judgement of the balance between the risk of spinal haematoma, and the benefits of perioperative regional anaesthesia and/or analgesia difficult. While new information regarding the benefits of regional anaesthesia is now helping in this cause, the more frequent presentation of patients in whom impaired haemostasis is present, or anticipated, has further complicated the issue. The many states of impaired haemostasis created by drugs and bleeding diathesis, and what is known of their influence on the risk of spinal haematoma have been presented. While some conditions contraindicate the use of neuraxial techniques, careful management of many of the types of impaired haemostasis can keep the balance of these two issues in favour of the practice of regional anaesthesia and pain control.

The regional anesthesia "learning curve". What is the minimum number of epidural and spinal blocks to reach consistency?

Wide variability exists in the amount of regional anesthesia practice to which residents are exposed during training. The number of attempts at various blocks before a trainee becomes proficient at performing these regional anesthetic techniques is not known. This study addresses the question: What is the minimum number of blocks a resident must perform to reach consistency during training in these techniques? Every regional anesthetic technique attempted by all beginning CA-1 anesthesiology residents (n = 7) during their first 6 months of training (July 1993 to December 1993) were recorded on a daily basis. Nonregional anesthetic techniques attempted were recorded for comparison. The objective measures used to define the degree of success were obtaining cerebrospinal fluid during attempted spinal anesthesia, subsequent anesthetic block during epidural placement, and detection of end-tidal carbon dioxide for endotracheal intubation. An average of 77 +/- 9 epidural anesthetics, 44 +/- 6 spinal anesthetics, and 86 +/- 13 endotracheal intubations were attempted during the 6 months of training. The learning curves for each technique are of similar shape. Residents show significant (P < .05) improvement over baseline after 20 spinal and 25 epidural anesthetics, but a 90% success rate is not reached and maintained until 45 spinal and 60 epidural anesthetics are performed. Approximately 20-25 procedures each are necessary before improvement in the techniques of spinal and epidural anesthesia is demonstrated by residents in training. If a 90% success rate is desired, 45 and 60 attempts at spinal and epidural anesthesia, respectively, may be necessary.

Book Review: Principles and Practice of Regional Anaesthesia

Book Review: Principles and Practice of Regional Anaesthesia

EDITORIAL COMMENT: The evolving practice of regional anesthesia

EDITORIAL COMMENT: The evolving practice of regional anesthesia

Heinrich Braun (1862-1934)--a pioneer in anesthesiology in Germany

Heinrich Braun was born on January, 1, 1862. He attended school in Dresden and was a student of Medicine at the Universities of Strassburg, Greifswald and Leipzig between 1881 and 1887. In 1887 he acquired his doctorate degree. Von Volkmann was his teacher in surgery in Halle. From 1891 to 1905 he worked in different non-university hospitals in Leipzig. In 1894 he was promoted "doctor habilitatus" under Thiersch as an extern. He lectured on general and local anaesthesia as a "Privatdozent". In 1905 he was appointed extraordinary Professor at the Medical Faculty of the University of Leipzig. 1906 he left Leipzig and became Chief Surgeon and Medical Director of the Royal Saxonian Hospital in Zwickau. In this position he worked until his retirement in 1928. He died on April, 26, 1934 in Uberlingen. Heinrich Braun's contributions to the development of anaesthesiology are numerous. They concern general as well as local and regional anaesthesia. In 1901 he designed an apparatus for mixed-gas anaesthesia and reported on experiences with combined inhalational anaesthesia with ether and chloroform. In 1903 he recommended on the basis of profound experimental investigations to add adrenalin as a vasoconstrictor to local anaesthetics. In 1905 the first edition of his manual "Local Anaesthesia--Scientific Basis and Medical Practice" appeared. Braun extended the general practice of local and regional anaesthesia significantly. Famous representatives of his school are Läwen, Peuckert, Kulenkampff, Härtel and Kappis. In Zwickau he extensively dealt with problems of hospital organisation and -construction. In 1921 the new "Krankenstift Zwickau" constructed on the basis of his plans and recommendations was inaugurated.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical Practice of Regional Anesthesia

<h3>Background</h3> Effects of neighborhood contextual features have been found for many diseases, including bone fractures in adults. Our study objective was to evaluate the association between neighborhood characteristics and pediatric bone fracture rates. We hypothesized that neighborhood indices of deprivation would be associated with higher fracture rates. <h3>Materials and Methods</h3> Pediatric bone fracture cases treated at a tertiary, academic, urban pediatric emergency department between 2003 and 2006 were mapped to census block groups using geographical information systems software. Fracture rates were calculated as fractures per 1000 children in each census block. Exploratory factor analysis of socioeconomic indicators was performed using 2000 census block data. Factor scores were used to predict odds of bone fracture at the individual level while adjusting for mean age, sex composition, and race/ethnicity composition at census block level using our sample data. <h3>Results</h3> We analyzed 3764 fracture visits in 3557 patients representing 349 distinct census blocks groups. Fracture rates among census blocks ranged from 0 to 207 per 1000 children/study period. Logistic regression modeling identified 2 factors (race/education and large families) associated with increased fracture risk. Census variables reflecting African American race, laborer/service industry employment, long-term block group residence, and lower education levels strongly loaded on the race/education factor. The large families factor indicated the children-to-families ratio within the block group. The poverty factor was not independently associated with fracture risk. <h3>Conclusions</h3> Thus, neighborhood characteristics are associated with risk for fractures in children. These results can help inform translational efforts to develop targeted strategies for bone fracture prevention in children.

A Survey of the Practice of Regional Anesthesia

A Survey of the Practice of Regional Anesthesia

L'anesthésie locorégionale du membre supérieur dans le cadre de la chirurgie d'urgence de la main

The very conditions of the emergency led the authors to define the indications for the various modalities of local and regional anaesthesia: intravenous regional anaesthesia, nerve trunk blocks, plexus blocks, interdigital block and local infiltration. The parallel development of anaesthetic drugs with variable systemic toxicity and a duration of action inversely proportional to the toxicity now allows precise adaptation of the anaesthesia to the type of lesion, the patient's general condition, the practical conditions of the emergency and the surgical technique selected, provided the anaesthetist is fully aware of the traps to be avoided, which can only be based on a long practice of local and regional anaesthesia in elective surgery.

A Survey of the Practice of Regional Anaesthesia

A questionnaire designed to elucidate the popularity and practice of regional anaesthesia was circulated to all anaesthetists in the South East Thames Region. Two hundred and eleven completed questionnaires were received and subsequently analysed, a response rate of 65%. Regional anaesthesia was employed at least once per week by 83% of respondents usually in combination with general anaesthesia (77% of respondents). The provision of postoperative analgesia was cited as the main advantage by 86% of anaesthetists.

Principles and Practice of Regional Anaesthesia

Principles and Practice of Regional Anaesthesia

Principles and Practice of Regional Anesthesia.

Principles and Practice of Regional Anesthesia.

Book ReviewPrinciples and Practice of Regional Anaesthesia

Book ReviewPrinciples and Practice of Regional Anaesthesia

Book reviews

Book Reviewed in this article: The ECG in anaesthesia and critical care Edited by D.M. Thys and J.A. Kaplan. Principles and practice of regional anaesthesia Edited by J.A.W. Wildsmith and E.N. Armitage. Anesthesia and uncommon pediatric diseases Edited by J. Katz and D.J. Steward. Anaesthesia for cardiac surgery and allied procedures J.W.W. Gothard, with contributions from M.A. Branthwaite.