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This review of the literature since 2005 assesses developments of RA techniques commonly used for shoulder surgery, and their effectiveness for postoperative analgesia. Advantages of regional techniques include site-specific anesthesia and decreased postoperative opioid use. For shoulder surgeries, the ISB provides effective analgesia with minimal complications, whereas the impacts of IA single-injections remain unclear. When combined with GA, ISB can be used in lower volumes and reducing the complications for shoulder and proximal upper extremity. USG ISB and SCB are both effective and safe for shoulder surgery with a low incidence of complications, especially PONS.53 When compared with intravenous patient-controlled opioid analgesia, a perineural LA infusion using a disposable pump with patient-controlled LA bolus function has led to better pain relief and functional recovery while decreasing the need for rescue analgesics and the number of adverse events after ambulatory orthopedic surgery. The most remarkable advance in RA in the past 5 years is the increased usage of USG. Although there are no large-scale prospective studies to show the safety, efficacy, and success and complication rates for USG blocks, USG RA theoretically could have less risk for neurologic symptoms, except for those induced by LA (less likely perineurally, much more likely intraneurally). The next "quantum leap" lies in reducing LA concentrations and augmenting anesthetic-analgesic effects with perineural additives (including clonidine, buprenorphine, and likely low-dose dexamethasone). Since 2005, perineural catheters have been an analgesic option that offers improved pain relief among other benefits, and are now being used at home. It is clear that patients benefit greatly from a single injection and continuous nerve block for postoperative pain management,but the financial and logistical aspects need to be resolved, not to mention the phrenic hemiparesis coin toss. Whether combined perineural analgesic adjuvants prolong low-concentration LA nerve blocks sufficiently to render brachial plexus catheters as unnecessary would certainly represent another quantum leap.

We present the case of an otherwise asymptomatic patient with a rare congenital airway abnormality of the tracheobronchial tree, who developed a complete airway obstruction after being placed in the prone position. The tracheal bronchus, accessory bronchus arising from the trachea superior to its bifurcation at the carina, was identified by fiberoptic bronchoscopic examination. An endotracheal tube can migrate into a tracheal bronchus causing pulmonary atelectasis, hypoxia, or both.

The article reviews the current literature regarding shoulder anesthesia and analgesia. Techniques and outcomes are presented that summarize our present understanding of regional anesthesia for the shoulder. Shoulder procedures producing mild to moderate pain may be managed with a single-injection interscalene block. However, studies support that moderate to severe pain, lasting for several days is best managed with a continuous interscalene block. This may cause increased extremity numbness, but will provide greater analgesia, reduce supplemental opioid consumption, improve sleep quality and patient satisfaction. In comparison to the nerve stimulation technique, ultrasound can reduce the volume of local anesthetic needed to produce an effective interscalene block. However, it has not been shown that ultrasound offers a definitive benefit in preventing major complications. The evidence indicates that the suprascapular and/or axillary nerve blocks are not as effective as an interscalene block. However in patients who are not candidates for the interscalene block, these blocks may provide a useful alternative for short-term pain relief. There is substantial evidence showing that subacromial and intra-articular injections provide little clinical benefit for postoperative analgesia. Given that these injections may be associated with irreversible chondrotoxicity, the injections are not presently recommended.

The use of peripheral nerve blocks as the sole anesthetic, augmented with mild sedation for intraoperative management of surgery on the ankle and knee in two hemophiliac patients, is presented. Peripheral nerve blocks may be safely used for surgery of the extremities in a patient with moderate to severe hemophilia, provided a safe level of Factor VIII is maintained throughout the perioperative period.