Local Anesthesia Research Articles

Anesthésie locale comparée à l'anesthésie locorégionale dans les procédures TAVI par voie transfémorale

IntroductionTranscatheter aortic valve implantation (TAVI) has become the treatment of choice for the most fragile patients with severe aortic stenosis. The transfemoral route is preferred as the simplest and safest. The aim of our study was to compare the efficacy, tolerance and safety of local vs. locoregional anesthesia in trans-femoral TAVI procedures. Material and methodThis was a single-center retrospective study. Patients treated with femoral TAVI between February 25 and November 15, 2022 at the University Hospital of Reims were included, and two groups (local and locoregional anesthesia) were compared. ResultsTAVI success rate (92.9%), death rate (3.0%) and procedure duration (90.5 ± 13.5 minutes) did not differ between groups (p = 0.18, 0.15 and 0.55 respectively). For intra- and post-procedural treatments, the use of sedation, analgesics and benzodiazepines did not differ between groups. The cumulative dose of Remifentanil used per-procedure was lower in the local anesthesia group than in the locoregional anesthesia group (148.6 ± 71.9 mcg vs. 208.9 ± 110.0 mcg; p = 0.025). ConclusionsIn this non-randomized retrospective study, local and locoregional anesthesia had comparable safety and efficacy in transfemoral TAVI procedures. In a constrained context and with a view to simplification, these results encourage transfemoral TAVIs to be performed under local anaesthesia, and to consider a “PCI-like” approach, without the presence of an anaesthetist, for selected patients without respiratory, musculoskeletal or agitation disorders, or vascular approach difficulties.

Impact of anesthesia type on surgical outcomes and medical complications in chronic subdural hematoma surgery

BackgroundsChronic Subdural Hematoma (CSDH) is common in elderly patients. Although general anesthesia (GA) has traditionally been used for CSDH surgeries, it may lead to postoperative complications, especially in older patients. We hypothesized that local anesthesia (LA) could reduce postoperative medical complications, including pneumonia, compared to GA. MethodsWe conducted a retrospective study from 2015 to 2019, of medical records of CSDH patients from two hospitals in addition to a comprehensive literature review. Inclusion criteria were a new CSDH diagnoses and treatment with burr-hole craniostomy (BHC) and drain insertion. Patients with recent ipsilateral craniotomies were excluded. Clinical variables included demographics, comorbidities, hematoma characteristics, and post-operative outcomes. ResultsOf 383 eligible patients, 63 underwent BHC under LA (LA group), and 320 under GA (GA group). Both groups exhibited similar baseline characteristics, hematoma characteristics, and surgical outcomes, including postoperative CT findings and ICU stay duration. There was also no significant difference in postoperative bleeding events between the groups. Although patients in the GA group experienced a higher incidence of postoperative pneumonia (3.8 % vs 1.6 %), multivariate analysis revealed that the occurrence of pneumonia was associated with a history of lung disease and preoperative neurological status (OR 7.28, p = 0.018, OR 3.40, p < 0.001, respectively) rather than with the type of anesthesia used. ConclusionOur study suggests that the type of anesthesia does not influence postoperative surgical and medical outcomes, including pneumonia, which is the most common medical complication of BHC for CSDH. Rather, preoperative neurological status and underlying morbidities appear to be more closely related to postoperative medical complications. Future large, prospective studies are needed to validate our findings.

Ophthalmic Surgeries at a Nigerian Teaching Hospital from the Perspectives of Undergraduate Medical Education

BackgroundAn appraisal of the profile of ophthalmic surgeries performed at Ladoke Akintola University of Technology Teaching Hospital (LAUTECHTH), Ogbomosho, Nigeria over a seven-year period with a view to harnessing their potentials for maximising ophthalmic experiences of medical students. MethodsA retrospective review of ophthalmic surgery records over a seven-year period (2013 – 2019) at LAUTECHTH. ResultsThere were 386 eye surgeries, mean ophthalmic surgeries: 4 - 5/month or 55/year. Most (329, 85.2%) surgeries were performed on individuals aged at least 45 (range 10 - 95) years with slight male dominance (1.1:1). The most common indication for surgery was cataract (307, 79.6%). Most surgeries were elective (362, 93.8%) and performed under local anaesthesia (367, 95.1%). Despite the highest number of surgeries being performed in the months of April and September; and lowest during the months of May and October; there was fair distribution across and over the years. Small incision cataract surgery with or without intraocular lens implant (307, 79.6%) was the most common surgery followed by pterygium excision with adjuvant therapy (37, 9.6%). ConclusionThe study showed a broad spectrum of eye surgeries, including cataract and pterygium, performed at the teaching hospital, encompassing common conditions that lead to visual impairment or blindness. This exposure provides valuable training opportunities for undergraduate medical students to become physicians especially those aspiring to become ophthalmologists. However, there is a need to increase the overall volume of eye surgeries to enhance the learning experience and potentially influence career choices.

Epidural anesthesia as a sole anesthetic for a parturient with cardiac disease and low ejection fraction – a case report in resource limited setup

Introduction and importance: The effective care of pregnant women with cardiac conditions relies on collaboration among the obstetrician, cardiologist, and anesthesiologist throughout the peripartum period. Limited research exists regarding the safety of specific anesthetic approaches for patients with congestive heart failure (CHF), particularly in the context of pregnancy. Case presentation: This was a 28-year-old woman who was pregnant with her third child (gravida III, para II) and has not had a menstrual period for the past 8 months. She had been receiving antenatal care at a local health center. Currently, she was experiencing symptoms including coughing, difficulty breathing, epigastric pain, and chest pain, which had been present for 1 week. Upon examination, she was diagnosed with New York Heart Association class IV CHF with pulmonary edema, and preeclampsia with severe features, and she was in the third trimester of pregnancy. Clinical discussion: Pre-existing medical conditions can adversely affect pregnancy outcomes for women and their offspring, especially in resource-poor settings in Africa. The goals of anesthetic management are avoidance of myocardial depression, maintaining normovolemia, avoiding an overdose of drugs during induction as the circulation time is slow, and avoiding sudden hypotension when regional anesthesia is the choice. Conclusion: We believe that successful management of anesthesia for this critical case depends on a thorough understanding of the pathophysiology of the disease condition, the selection of anesthetic techniques, and the decision-making of our team. We showed epidural anesthesia could be safely used to manage high-risk cardiac patients, however, further interventional study is needed to prove safety.

Low-dose dexmedetomidine as an adjuvant to regional anaesthesia of the oral cavity with levobupivacaine has no effect on serum cortisol and blood glucose concentrations in dogs

Low-dose dexmedetomidine as an adjuvant to regional anaesthesia of the oral cavity with levobupivacaine has no effect on serum cortisol and blood glucose concentrations in dogs

Management and monitoring of anesthesia during the perioperative period in a Tertiary Hospital in Bangladesh

Background: Anesthesia management is crucial for ensuring patient safety and optimal surgical outcomes during the perioperative period. In Bangladesh, the challenges faced in managing and monitoring anesthesia in tertiary care hospitals necessitate a comprehensive evaluation of current practices. This study aims to assess the anesthetic management protocols and monitoring strategies employed in a tertiary hospital in Bangladesh. Methods: This observational study was conducted in Islami Bank Medical College Hospital, Rajshahi, Bangladesh from July to December 2023. Data were collected from patients undergoing various surgical procedures requiring anesthesia. The anesthetic techniques used, intraoperative monitoring parameters, and any complications encountered were recorded. The study included a review of anesthesia charts, patient records, and interviews with anesthesia providers. Statistical analysis was performed to identify trends and correlations. Results: A total of 200 patients were included in the study. The most commonly used anesthetic technique was general anesthesia (65%), followed by regional anesthesia (30%) and local anesthesia (5%). Intraoperative monitoring parameters included heart rate, blood pressure, oxygen saturation, and end-tidal carbon dioxide levels, which were consistently documented in 95% of cases. Complications occurred in 10% of patients, primarily involving respiratory issues and cardiovascular instability. Proper adherence to monitoring protocols significantly reduced the incidence of complications. Conclusion: Effective management and monitoring of anesthesia during the perioperative period are vital for patient safety in a tertiary hospital setting. The study highlights the importance of standardized protocols and continuous monitoring to minimize complications. Recommendations for improving anesthetic practices include regular training for anesthesia providers and enhancing monitoring infrastructure to ensure optimal patient care.

Challenges in the diagnosis and management of soft tissue tumors of the oral cavity.

Soft tissue lesions are among the most prevalent forms of tumors or tumor-like alterations within the oral cavity. They exhibit a wide spectrum of characteristics, ranging from benign, noninvasive lesions to malignant tumors, which collectively present a diagnostic challenge. A 67-year-old patient presented with an incidental finding of induration on the right cheek during dental hygiene. The intraoral examination revealed a soft, non-tender swelling measuring 20 mm in diameter. The sensitivity and percussion tests for the teeth in the fourth quadrant yielded unremarkable results. Panoramic radiography (OPG) revealed tip-ping of the premolars and an unclear apical finding in region 44. Cone-beam computed tomography (CBCT) revealed a sharply defined, lobulated hypodense lesion in the right buccal area. To clarify the diagnosis and optimize perioperative management, a 3 Tesla dental magnetic resonance imaging (MRI) scan was performed. This identified a 23×6×23 mm lipoma along the right mandibular ramus, causing detachment of the buccinator and de-pressor anguli oris muscles. A cinematic rendering reconstruction derived from the MRI data facilitated enhanced visualization for preoperative planning. The surgical excision was performed under local anesthesia, resulting in the successful removal of the neoplasm while preserving the mental nerve and submandibular gland. Histo-pathology confirmed the presence of a lobulated mature cell lipoma. The patient exhibited no complications during the removal of the sutures, with complete wound healing and no recurrence observed. This article highlights the efficacy of advanced MRI diagnostics and post-processing techniques in the management of ambiguous soft tissue neoplasms.

Assessing the Use of BotulinumtoxinA for Hyperactive Urinary Tract Dysfunction a Decade After Approval: General Versus Local Anesthesia for BotulinumtoxinA Detrusor Injection

Background: The onabotulinumtoxinA detrusor injection (OnabotA DI) was approved a decade ago for the treatment of patients with idiopathic overactive bladder (iOAB) or neurogenic detrusor overactivity (nDO) dysfunction who had not been treated successfully otherwise. The procedure is usually performed under local anesthesia (LA), and various approaches have been investigated to make the procedure as painless as possible. We examined the level of anxiety and pain experienced by patients who wanted to have the procedure performed under LA or general anesthesia (GA). Material and Methods: Patients scheduled for OnabotA DI were able to choose the anesthesia procedure (LA or GA). The Amsterdam Preoperative Anxiety and Information Scale (APAIS) was used to grade anxiety before anesthesia or before the procedure itself. Intra- and postoperative pain was determined using the Visual Analogue Scale (VAS). Various established questionnaires (including the Urinary Distress Inventory UDI-6), as well as a postoperative satisfaction questionnaire, were used to evaluate the success of the therapy. Results: In total, 104 patients (93 F, 11 M; age 64.0 (22–89) years; 80× iOAB, 24× nDO) were evaluated. OnabotA-DI was performed with LA in 72 patients and GA in 32. Stratified by first versus repeat injection in the LA group, there was a significant decrease in the Anxiety Score in the first vs. repeat injection group (p = 0.038). The LA group showed higher concerns in the anesthesia questions of the Amsterdam Preoperative Anxiety and Information Scale (APAIS) than the GA group (OR: 0.29, 95%CI: 0.02–1.74). The VAS Pain Score during the procedure was significantly lower in the GA group compared to the LA group (LA: 3.3 ± 2.2, GA group 1.5 ± 1.5; p &lt; 0.001). There were no differences in the success of therapy. Despite the fear and pain, patients preferred LA to GA. Conclusions: This study shows that the anxiety and pain burden of patients undergoing OnabotA-DI under LA is significant in comparison to GA during the first injection, but insignificant for following injections. Overall, LA is favored over GA.

Optimizing elective high-risk PCI with ECMO support: the value of completely percutaneous use of VA-ECMO

Abstract Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a suitable manner to prevent hemodynamic deterioration during high-risk percutaneous coronary intervention (PCI). VA-ECMO is mainly surgically deployed under general anaesthesia. New developments now facilitate completely percutaneous insertion of VA-ECMO with only local anaesthesia, reducing operating team size and hospital costs. Purpose The aim of this study is to provide data on the outcomes of completely percutaneous use of VA-ECMO during high-risk PCI with local anaesthesia. Methods A retrospective single-centre registry was performed including all patients undergoing ECMO-assisted high-risk PCI, who were rejected for coronary artery bypass graft (CABG) as primary treatment option. Primary endpoint was the incidence of major adverse cardiac events (MACE), assessed during hospital admission and after discharge up to 90 days. Results Between January 2020 and February 2024, 34 patients undergoing ECMO-assisted high-risk PCI were included. The mean age of the population is 71.9 (± 8.4) and 27 (79.4%) patients are male. The mean left ventricular ejection fraction is 28.5 (± 11.1) percent and complexity indices were high, including STS mortality score: 4.1 (± 2.8), SYNTAX score I: 31.7 (± 9.4), SYNTAX score II: (PCI) 54.8 (± 10.8). Femoral artery was used for cannulation in 30 (88.2%) patients, of which one patient required an additional femoral backflow cannula due to prolonged ECMO support. Local anaesthesia in combination with preprocedural oral benzodiazepine was the preferred choice of anaesthesia (85.3%). Closure was predominantly performed with a percutaneous closure device (97.1%). Successful revascularization and procedural success were achieved in all patients. In-hospital MACE occurred in 2 (6.1%) patients. MACE occurred within 90 days in 5 (20.8%) patients after discharge. Conclusion High-risk PCI with completely percutaneous use of VA-ECMO with local anaesthesia is a novel concept, providing a suitable alternative to the standard surgical use of VA-ECMO with general anaesthesia.

Evaluation of efficacy and safety of simplified procedure for the percutaneous closure of patent foramen ovale: the Ile De France Foramen Ovale Permeable(IDFFOP) prospective, multicenter cohort study

Abstract The superiority of device closure over medical therapy for the prevention of recurrent stroke in patients with cryptogenic stroke and patent foramen ovale (PFO) was reported in several meta –analyses of randomized controlled trials. The growing number of PFO procedures requires to find alternatives to conventional guidance by transoesophageal echocardiography (TOE) needing general anesthesia. The aim of our study was to assess prospectively the efficacy and safety of a simplified procedure based on trans thoracic echocardiography (TTE) and local anesthesia rather than TOE during PFO closure. Methods Design and study oversight. The IDFFOP study was a French prospective, multicenter cohort study performed in four centers expert in TTE-guided device deployment. All patients had a stroke history, a PFO and a large or moderate right to left shunt defined by the number of microbubbles in the left atrium ( large shunt &amp;gt; 30, moderate : 10 to 30 microbubbles). A(Risk of Paradoxical Embolism) score&amp;gt;5 was required to confirm PFO imputability in stroke history. The primary end point was efficacy of TTE during the transcatheter PFO closure defined as the successful implantation of the device without malposition, without need of TOE, and absence of significant residual shunt at 3-month TTE control. Safety was defined as the absence of any periprocedural complications. Results 280 patients were enrolled from January 2018 to October 2020 ( male sex : 59.5%; Average age 57 years old ). Average ROPE score was 7; Cumulative immediate procedural success with the TTE-guided method was 99%, without any device embolization. However, in 2 patients, TOE was needed to guide device deployment. There was no severe vascular complication, or any ischaemic event during or after the procedure. 6 post-procedure groin hematomas occurred but none needed anyblood transfusion .One patient experienced a transient periprocedural atrial fibrillation. At 3 months there were only 8 (2,8%) residual right to left shunts (3 large, 5 moderate). Conclusion A simplified procedure for percutaneous PFO closure based on TTE and local anesthesia is safe and effective. Randomized controlled trials should be performed to confirm these results.

Predisposing and precipitating factors of post-operative delirium after transfemoral TAVI

Abstract Background Transcatheter aortic valve implantation (TAVI) represents the treatment of choice for aortic stenosis (AS) patients at higher age (&amp;gt; 75y) or with relevant comorbidities. Post-operative delirium (POD) is a frequent complication which has been associated with worse outcome. Thus, preventive options are highly needed. The aim of our single-center study was to investigate predisposing and precipitating factors of POD after transfemoral TAVI, with a focus on the influence of anaesthesia. Methods Risk factors for POD after TAVI were analysed in 2 merged cohorts of 480 study patients (43% women; mean age 80 years), enrolled in 2017-2022 (n=375, TAVI in 95% in general anaesthesia) and in 2022-2024 (n=105, TAVI in 91% in local anaesthesia). Incidence of POD was evaluated retrospectively by nursing documentation, medical records, and DRG coding. The association of demographics, comorbidities, echo parameters, procedural parameters, anaesthesia, and peri-procedural complications with POD incidence was investigated. Results In total, 29 patients (6%) developed POD, with a tendency towards a lower incidence in the later cohort (6.7% vs. 3.8%; p=0.28). Regarding baseline characteristics, patients experiencing POD were more likely to be male (p=0.03), frail (Katz Index &amp;lt;6, p=0.049), and to suffer from low-gradient AS (p=0.005 for paradoxical, p=0.02 for classical low-flow, low-gradient AS; see also fig. 1A). Total procedure time was significantly longer in patients with POD (median, 86 vs. 62 min, p=0.004; fig 1B), and a tendency towards a more frequent implantation of other than ballon-expandable valves could be observed (p=0.07). Concerning the role of anaesthesia, POD did not differ significantly after general anaesthesia (n=24/360, 6.7%), conscious sedation (n=1/19, 5.3%), and local anaesthesia (n=4/100, 4%) (p=0.38). Regarding procedural complications, POD patients were characterized by lower minimum hemoglobin post-TAVI (9.3 vs. 10.1 g/dl, p=0.05; fig. 1C) and higher incidences of intra-procedural resuscitation (11% vs. 2%, p=0.03), cerebrovascular accidents (10% vs. 2%, p=0.04) and new permanent pacemaker implantations (25% vs. 10%, p=0.02). In POD patients, long-term survival after TAVI was significantly reduced, with a median survival of only 2 years (Kaplan-Meier curves in fig. 2; p=0.001). Conclusions POD after TAVI stays common and unfavourable. The role of anaesthesia seems less pronounced than expected. Total procedure time and relevant anaemia after TAVI emerged as most important modifiable risk factors. Future research is warranted, since strategies to reduce precipitating factors for POD may have a significant impact on post-TAVI outcomes.Selected risk factors for PODConsequence of POD: Reduced Survival

Safe transition home after transcatheter aortic valve implantation feasibility (START-F) study: Very early self-reported function and recovery status after early discharge

Abstract Background Despite significant excellent outcomes and significant improvements in rapid recovery protocols and early discharge, rates of 30-day readmission after transcatheter aortic valve implantation (TAVI) remain stubbornly high. There can be numerous drivers for readmission in older people with valvular heart disease; the time of transition home is the period of greatest risk when patients are most vulnerable to repeat hospitalization. We sought to assess patients’ early recovery (&amp;lt; post-procedure day 3) to inform the evaluation of a nurse-led telephone intervention to mitigate the risks of 30-day readmission after early (1 day) discharge TAVI. Methods We conducted a prospective observational cohort feasibility study in five Canadian TAVI programs to ascertain acceptability, compliance, delivery of the intervention, recruitment and retention. In this preliminary report, we assessed key indicators of patients’ status at the time of discharge and functional status in their early recovery. Results We recruited 188 participants, mean age 81.6 years (SD=7.0), 41.5% women with baseline mean KKCQ 53.4 (SD=20.1). Patients were admitted on the day of the procedure, and underwent TAVI with a balloon-expandable (n=146, 77.6%) or self-expanding (n=30, 16.0%) device, with local anaesthesia +/- light sedation (n=171, 90.1%) or general anaesthesia (n=17, 9.0%). There was 1 in-hospital death (0.5%) and 182 (97.4%) were discharged home. At the time of the 3-day telephone follow-up, 168 (95.5%) reported that an individual had stayed with them during the first 24 hours [spouse: 85 (48.9%); friend: 77 (44.3%)], and 165 (93.3%; missing: 11) were able to complete all activities of daily living, including cooking their own meals (n=80, 45.5%). Self-reported energy was low/very low for 49 participants (26.1%), moderate for 93 (52.8%), and high/very high for 34 (18.1%), with 104 (55.3%) describing feeling somewhat or quite a bit better than before TAVI, and 24 (12.8%) somewhat or quite a bit worse. Bruising was present in 120 participants (68.6%) and 137 (78.8%) had removed their bandage as instructed. 18 participants were readmitted within 30 days, including 14 cardiac-related events. Conclusion This is one of the first reports of TAVI patients’ self-reported function following next-day discharge, providing novel evidence that most patients describe safe self-care and very early improved functional status. Research is needed to identify and support patients who are at higher risk of poorer trajectories of recovery and readmission, and report the feasibility of a nurse-led intervention to mitigate these risks.

A Comparison of Different Doses Efficacy of Isobaric Ropivacaine 0.5% in Spinal Anesthesia in Cesarean Section

Background: Cesarean delivery is a standard surgical procedure in women. Thus, a practical, affordable, and low-risk anesthetic technique is essential for mother and infant safety. Spinal anesthesia is a popular and efficient technique for anesthesia during cesarean delivery. However, other local anesthesia drugs with negligible side effects should be considered. The most selective medication for this purpose is bupivacaine (marcaine), which creates optimal anesthesia at doses of 10 to 12 mg. Objectives: The most available medicine for spinal anesthesia during cesarean delivery is a 0.5% marine solution. However, ropivacaine for spinal anesthesia can occasionally be accessed as a long-acting amide local anesthetic agent used as an alternative to marcaine during the cesarean delivery. The ropivacaine's advantage over marcaine is its less neurotoxicity and cardiotoxicity, as well as the more stable hemodynamical condition of the patients. So far, no proper therapeutic dose of 0.5% isobaric ropivacaine has been proposed to be used during the cesarean delivery. Any increase in the dose may ensure the block performance, but, by contrast, some side effects may arise, including hypotension, bradycardia, vomiting, and nausea. Herewith, the likelihood of maximum block and most minor side effects was attempted to be assessed at the tiniest doses of this anesthetic agent. Methods: This randomized clinical trial was conducted on C-section candidates. Patients were categorized into three groups receiving 22.5, 25, and 20 mg of the 0.5% isobaric ropivacaine solution. Systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, the rate of using supplementary drugs, block breakdown, and the patient's satisfaction with the anesthesia were measured and recorded. The collected data were analyzed using IBM SPSS Statistics. Results: No significant difference was found between demographic characteristics. Likewise, there was no significant difference in systolic and diastolic blood pressure, heartbeats, the level of sensational and sympathetic nerve block, duration to reach the maximum motor block, the rate of vasopressors and atropine consumption, rate of vomiting and nausea, and the rate of using supplementary drugs between the three groups. The most significant block breakdown and use of supplementary drugs were found in the first group (20 mg), with a significant difference between the three groups. Conclusions: The three doses used did not result in meaningful differences between the three groups. However, the differences were significant for the block breakdown, with the higher block breakdown and supplementary drug use observed when using 20 mg of the 0.5 ropivacaine solution.

Initial Experience with the 4D Mini-TEE Probe in the Adult Population

Background: Transesophageal echocardiography (TEE) is a vital diagnostic tool in clinical practice, particularly in transcatheter interventions where it aids in both pre-operative planning and intra-operative guidance. Traditional TEE probes often require general anesthesia due to patient discomfort. However, the development of miniaturized TEE probes presents a promising alternative, enabling routine examinations and interventions with minimal sedation. This study evaluates the feasibility of performing a complete 2D/4D TEE protocol with the new 4D mini-TEE probe in the echocardiography department and its application in transcatheter interventions. Methods: This is a retrospective study that included 30 consecutive patients from two high-volume European hospitals (Interbalkan Medical Center, Thessaloniki, Greece, and Rennes University, France) that underwent TEE or transcatheter interventions. The new 4D mini-TEE 9VT-D probe (GE Healthcare) was utilized. The quality of the images and the tolerance of the probe were assessed in the cath lab during interventions and in the echocardiography department during routine TEE examinations. Results: Direct comparison of the 4D mini-TEE probe with the standard 6VT-D probe confirmed the excellent image quality of this new pediatric probe. Most of the patients required minimal sedation or local oropharyngeal anesthesia, with satisfactory tolerance reported. Most of the transcatheter procedures did not require general anesthesia and intubation, resulting in shorter procedural time. Both 2D and 4D imaging modalities offered adequate intra-operative guidance for transcatheter procedures. Conclusions: The 4D mini-TEE probe delivers exceptional imaging capabilities for routine examinations and transcatheter interventions without needing sedation. Its use reduces esophageal trauma and the need for general anesthesia, enhancing patient comfort and safety.

Thoracic Epidural and Analgesic Options After Failed Transversus Abdominus Plane Block With Liposomal Bupivacaine.

A 39 year-old female with a history of Roux-en-Y gastric bypass underwent emergent partial colectomy. Her postoperative analgesic management of a transversus abdominus plane block administered with a combination of bupivacaine and liposomal bupivacaine was ineffective. A bupivacaine thoracic epidural was then placed, which provided significant pain relief. This use of a bupivacaine thoracic epidural infusion following liposomal bupivacaine regional anesthesia demonstrated a case of effective analgesia without the development of local anesthetic systemic toxicity symptoms in a remote hospital setting, where certain laboratory analyses were not readily available.

Perioperative Point-of-Care Ultrasound (POCUS) for Anaesthetists: Is It Time to Introduce Formal Training?

This article reviews point-of-care ultrasound (POCUS) in the perioperative period. Ultrasound-guided techniques for regional anaesthesia and vascular access have been well-established in anaesthesia for many years. However, integration of whole-body POCUS into UK anaesthetic practice remains limited. There is a growing body of evidence highlighting the benefits of POCUS throughout the perioperative period. Widespread use may help to improve patient care in anaesthesia.

Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Microscopic Varicocelectomy under Local Anesthesia as the Treatment of Varicocele

Intraoperative Anesthesia-Related Critical Events in Low-Resource Hospitals During Short-Term Surgical Missions in Tanzania and Democratic Republic of the Congo: An Observational Study.

Critical incidents and mortality related to anesthesia are more frequently observed in low- and middle-income countries in comparison to high-income countries. The difficulties linked to anesthesia in rural areas of the Democratic Republic of the Congo (DRC) and Tanzania have limited documentation. The aim of this study was to comprehensively document anesthesia-related critical events that occurred during surgical missions organized by the nongovernmental organization 2nd Chance in hospitals in DRC and Tanzania. Data were collected during 6 surgical missions in 3 hospitals in the DRC and 1 in Tanzania. All scheduled surgery patients were included. Anesthesia was administered by a local Non-Physician Anesthesia Provider (NPAP), using local resources, under the supervision of an anesthesiologist from the association. The anesthesiologist reported critical events and collected data. Local teams managed critical events initially, with intervention by the anesthesiologist from 2nd Chance on the local team's request, according to preestablished protocol or if the situation was considered dangerous. Critical incidents associated with anesthesia, including bradycardia, hypoxemia, airway management failure, and equipment problems, were documented from induction of anesthesia until discharge from the recovery room. We recruited 201 patients, of whom 192 were evaluated, with 9 patients dropping out due to protocol noncompliance. All patients were American Society of Anesthesiologists (ASA) I (62%; n = 120) or ASA II (38%; n = 72). Among them, 104 individuals (54%) experienced at least 1 critical event, totaling 202 critical events. Hypoxemia emerged as the most common event, affecting 29% of the patients (n = 55) with at least 1 episode. Equipment problems (oxygen supply and/or anesthesia machine failure) occurred in 24% of cases (n = 46), airway management issues in 23% (n = 44), and bradycardia in 6% (n = 12). Hypotension and hypertension were not documented due to the lack of monitoring. The majority of these events (over 60%) required intervention by the anesthesiologist. The occurrence of critical events related to anesthesia appears to be high in this study. Due to numerous limitations, these results cannot be generalized to all hospitals in Tanzania and the DRC. However, this study underscores the challenges faced by anesthesia teams, encompassing inadequate resources, equipment deficiencies, and varying levels of expertise among anesthesia personnel. The research further stresses the significance of addressing these challenges to enhance patient safety.

Serratus Anterior Plane Block Remote Learning Curriculum.

Regional anesthesia aids in management of acute pain in the emergency department, but many emergency physicians remain inadequately trained. Further complicating medical education, our academic center continues to use remote learning as the primary setting for residency didactics. This project aims to create a remote conference session on ultrasound-guided serratus anterior plane blocks (USG-SAPB). We used the ADDIE (analyze, design, develop, implement, evaluate) model for curricular design, with emergency medicine residents as our intended learners. For the analyze element, we examined clinical need and resident program evaluation feedback. For design, we utilized best practices for remote learning, principles of mental rehearsal, and multimodal instructional theory. For develop, we completed recruitment of faculty leads, materials, and beta testing of each component. We implemented our 50-minute session on the videoconferencing platform Zoom. For evaluate, we created a program evaluation survey based on Kirkpatrick's evaluation model. Seventeen learners completed the evaluation. For Kirkpatrick level 1, 94% reported being very or extremely satisfied. For Kirkpatrick level 2, 91% ranked their presession confidence level in performing USG-SAPB as not at all or slightly confident, compared to the postsession, where 88% ranked themselves as moderately, very, or extremely confident. For Kirkpatrick level 3, 94% reported that they would incorporate at least a moderate amount of content into clinical practice. This remote learning session on USG-SAPB demonstrated high levels of learner satisfaction, improvement in learner confidence, and potential to impact learners' clinical practice. Future studies can elucidate patient outcomes related to educational sessions.

Improvement in pain by using lidocaine combined with esketamine in elderly patients receiving local anaesthesia for percutaneous kyphoplasty: a randomized controlled study

BackgroundElderly patients often experience severe pain during percutaneous kyphoplasty under local anaesthesia. The aim of this work was to evaluate the effect of lidocaine combined with esketamine on pain improvement in elderly patients receiving local anaesthesia via percutaneous kyphoplasty.MethodsThis prospective, randomized comparative trial was conducted on 66 elderly patients, aged 60–80 years, with an American Society of Anaesthesiologists (ASA) grade of I-III, I‒III and a BMI of 18.5–25 kg/m2, who underwent single-level lumbar percutaneous kyphoplasty under local anaesthesia. Patients were divided into two equal groups (33 per group). Group LE received 200 mg of 1% lidocaine and 25 mg of esketamine (total volume of 20 ml), and Group L received 200 mg of 1% lidocaine (total volume of 20 ml). Patient characteristics, surgery, VAS scores, MAP, HR, MOAA/S scores, patient satisfaction and related adverse reactions were compared for the groups. The VAS scores during and after surgery were considered the primary outcome.ResultsThere were statistically significant differences in the VAS score between the two groups at the following time points: channel establishment by the puncture needle, balloon dilation, bone cement injection and postoperative period (P < 0.05). The VAS score decreased in the LE group, but the MAP and HR were more stable, and the difference was statistically significant (P < 0.05). The difference in the MOAA/S score between the two groups was statistically significant (P < 0.05), and the MOAA/S score in the LE group decreased. The patient satisfaction level in the LE group was 100% and 48.48% in the L group (P < 0.05). There were no related complications or adverse reactions in either group.ConclusionThe application of lidocaine combined with esketamine in local episcopal percutaneous vertebral kyphoplasty in elderly patients not only provides an effective analgesic effect but also improves surgical safety and patient comfort, which has important clinical value in promoting the optimization of surgical anaesthesia management in elderly patients.Trial registrationThe study was registered at Chictr.org.cn with the number ChiCTR2400083466 on 06/12/2023.