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Catheter-based adductor canal blocks are an effective pain management strategy for total knee arthroplasty. Nevertheless, catheter-based techniques may fail if the tip migrates because of leg movement. This observational study used ultrasound to measure the distance from the skin to the adductor canal (SAC). We tested the hypothesis that leg movements mimicking those occurring during postoperative physiotherapy change the SAC distance.Following total knee arthroplasty under spinal anesthesia, the SAC distance was measured using ultrasound in 40 patients. The leg was passively moved into five standardized positions: neutral, neutral position with manual lateral displacement of the skin, 30° external rotation, straight leg raised to 30°, and knee and hip flexed to 90°.The mean (standard deviation) SAC distance change from the neutral position was +1.0 (0.6) cm with manual displacement, +0.3 (0.4) cm with external rotation, +0.4 (0.4) cm with straight leg raise, and +0.6 (0.5) cm with leg flexion (P0.001 for all positions). SAC distance changes did not correlate with height, body mass index, or leg circumference.Passive leg movements in five standardized positions increase the SAC distance. We speculate that the altered SAC distance associated with passive leg movement may contribute to catheter tip dislodgement and adductor canal block failure.www.clinicaltrials.gov , NCT03562559; registered 19 June, 2018.RéSUMé: OBJECTIF: Les blocs du canal des adducteurs utilisant un cathéter constituent une stratégie efficace du contrôle de la douleur pour l’arthroplastie totale de genou. Néanmoins, les techniques reposant sur des cathéters peuvent échouer si leur extrémité migre du fait d’un mouvement de la jambe. Cette étude observationnelle a utilisé l’échographie pour mesurer la distance séparant la peau du canal des adducteurs (P-CA). Nous avons testé l’hypothèse que des mouvements de la jambe imitant ceux qui surviennent au cours de la physiothérapie postopératoire modifient la distance P-CA. MéTHODES: Après une arthroplastie totale de genou sous rachianesthésie, la distance P-CA a été mesurée par échographie chez 40 patients. La jambe a été mobilisée passivement dans cinq positions standardisées : position neutre, position neutre avec déplacement latéral manuel de la peau, rotation latérale de 30°, jambe tendue soulevée à 30° et, enfin, genou et hanche fléchis à 90°. RéSULTATS: La modification de la distance P-CA moyenne (écart-type) à partir de la position neutre a été +1,0 (0,6) cm avec le déplacement manuel, +0,3 (0,4) cm avec la rotation latérale, +0,4 (0,4) cm avec la jambe tendue soulevée et +0,6 (0,5) cm avec la jambe fléchie (P0,001 pour toutes les positions). Les modifications de la distance P-CA n’étaient pas corrélées à la taille, l’indice de masse corporelle ou la circonférence de la jambe du patient. CONCLUSION: Les mouvements passifs de la jambe dans cinq positions standardisées augmentent la distance P-CA. Nous pensons que la modification de la distance P-CA associée à un mouvement passif de la jambe peut contribuer au déplacement de l’extrémité du cathéter et à l’échec du bloc du canal des adducteurs. ENREGISTREMENT DE L’ESSAI CLINIQUE: www.clinicaltrials.gov, NCT 03562559; Enregistré le 19 juin 2018.

BackgroundWe conducted a feasibility study of an anaesthetic online educational tool that is accessed via quick reference (QR) codes. The primary objective of the study was to assess the feasibility of an online educational tool for providing satisfactory teaching to patients presenting for surgery and assess if using QR codes are a viable method for directing patients to the information. The secondary objective was to obtain feedback from anaesthesiologists.MethodsThe educational tool was developed and hosted on a password-protected website. The educational material on the website focused on anaesthesia-related processes that the patient should expect to experience in the hospital as well as fasting information. A survey was embedded into the website to obtain patient feedback. The website was redesigned following patient and staff feedback.ResultsNinety-three patients accessed the online education tool. Of the 73 responses to the survey, 81% of patients reported that the tool improved their knowledge and understanding about anaesthesia. 73% of patients expressed a preference for, or were neutral regarding using online patient education. 36% of patients were familiar with QR codes and 28% were frequent users of QR codes. Most anaesthesiologists expressed satisfaction with the tool being used by their patients following the redesign process (93.1%, 89.6% and 89.6% for general anaesthesia, neuraxial anaesthesia and regional anaesthesia, respectively).ConclusionsThis feasibility study demonstrated that an online anaesthetic educational tool has utility in promoting patient education about the anaesthetic experience and was well received by both patients and anaesthesiologists. QR codes are not feasible as the sole method for linking our patient population to an online education resource.

Engagement of physicians with their healthcare community or institution should be a central issue in healthcare because it can be translated into improved patient care, enhanced well-being for physicians as well as safer, more effective and less costly healthcare. To accomplish the mission/goal of meaningful physician engagement, we set about to establish a 'charter' for physician engagement. We defined our concept of meaningful physician engagement and customised the engagement spectrum construct for physician relationship with their healthcare community or institution. While recognising the importance of physician leaders within the hierarchical system for efficacy of organisational management, relying only on physicians in formal executive positions is insufficient for developing physician engagement. There is a need for widespread physician engagement across the organisation. The objective is both an improvement in patient care and in physician well-being.

Resumo Objetivo do estudo O objetivo deste estudo foi avaliar se a inclinacao lateral da mesa cirurgica e a rotacao do corpo de uma parturiente sentada para anestesia neuraxial aumentou o tamanho da area-alvo paramediana para a insercao da agulha neuraxial. Ambiente Sala de parto. Pacientes Trinta gravidas a termo, ASA I‐II, agendadas para cesarea eletiva. Intervencoes Ultrassonografia lombar foi feita em quatro posicoes sentadas: (F) flexao lombar; (FR) como na posicao F com rotacao do ombro direito; (FT) como na posicao F com inclinacao lateral da mesa cirurgica; (FTR) como na posicao F com inclinacao lateral da mesa cirurgica combinada com a rotacao do ombro direito. Mensuracoes Para cada posicao, o tamanho da “area‐alvo”, definido como o comprimento visivel do ligamento longitudinal posterior, foi medido no interespaco de L3‐L4. Principais resultados As medias do ligamento longitudinal posterior foram: 18,4 ± 4 mm na posicao F; 18,9 ± 5,5 mm na posicao FR; 19 ± 5,3 mm na posicao FT e 18 ± 5,2 mm na posicao FTR. O comprimento medio do ligamento longitudinal posterior nao foi significativamente diferente nas quatro posicoes. Conclusoes Esses dados mostram que as posicoes avaliadas nao aumentaram a area‐alvo, conforme definido pelo comprimento do ligamento longitudinal posterior com o objetivo de insercao da agulha neuraxial em pacientes obstetricas. As manobras avaliadas terao um uso limitado na melhoria do acesso a agulha espinhal em mulheres gravidas.

Nasotracheal intubation is a widely performed technique to facilitate anesthesia induction during oral, dental, and maxillofacial surgeries. The technique poses several risks not encountered with oropharyngeal intubation, most commonly epistaxis due to nasal mucosal abrasion. The purpose of this study was to test whether the use of the Parker Flex-Tip™ (PFT) nasal endotracheal tube (ETT) with a posterior facing bevel reduces epistaxis when compared with the standard nasal RAE ETT with a leftward facing bevel. Sixty American Society of Anesthesiologists physical status I and II patients undergoing oral or maxillofacial surgery with nasotracheal intubation were recruited. Patients were randomized to either a standard nasal RAE ETT or a PFT nasal ETT. The ETT was thermosoftened and lubricated for both study groups prior to insertion, and the size of the tube was chosen at the discretion of the attending anesthesiologist. The primary outcome was the incidence of epistaxis, with a secondary outcome of epistaxis severity (scored as none, mild, moderate, or severe). An investigator measured both outcomes five minutes after intubation was completed. Mild or moderate epistaxis was experienced by 22 of 30 (73%) patients in the PFT group compared with 21 of 30 (70%) patients in the standard nasal RAE ETT group (absolute risk reduction, 3%; 95% confidence interval, −19 to 25; P = 0.78). There were no occurrences of severe epistaxis in either group. There was no difference in the incidence or severity of epistaxis following nasal intubation using the Parker Flex-Tip nasal ETT when compared with a standard nasal RAE ETT. This trial was registered at ClinicalTrials.gov, identifier: NCT02315677.

Background Local anaesthetics are commonly delivered to the epidural space by either intermittent bolus or continuous infusion. While these methods have been investigated in terms of analgesia and total dose administered, they have not been compared in terms of their effect on the spread of injectate within the epidural space. This animal study compared the spread of dye delivered to the epidural space in a porcine model by either bolus or infusion. Methods After ethical approval, epidural catheters were placed at three vertebral levels in seven anaesthetized pigs. Aqueous dye (1 ml) was injected into the catheter as a bolus, or as an infusion over 30 min. Animals were euthanized at the end of the study and necropsy performed immediately to quantify the extent of dye spread. Results In seven animals, 20 catheters were successfully placed in the epidural space. The mean (sd) extent of dye spread was 8.9 (2.6) cm in the infusion group compared with 15.2 (2.7) cm in the bolus group (P Conclusion In the porcine epidural model, spread of one ml of epidural dye solution is more extensive after a single bolus compared with short term infusion.

Study objective: The purpose of this study was to assess whether application of dorsal table tilt and body rotation to a parturient seated for neuraxial anesthesia increased the size of the paramedian target area for neuraxial needle insertion. Setting: Labor and Delivery Room. Patients: Thirty term pregnant women, ASA I–II, scheduled for an elective C-section delivery. Interventions: Lumbar ultrasonography was performed in four seated positions: (F) lumbar flexion; (FR) as in position F with right shoulder rotation; (FT) as in position F with dorsal table-tilt; (FTR) as in position F with dorsal table-tilt combined with right shoulder rotation. Measurements: For each position, the size of the ‘target area’, defined as the visible length of the posterior longitudinal ligament was measured at the L3-L4 interspace. Main results: The mean posterior longitudinal ligament was 18.4 ± 4 mm in position F, 18.9 ± 5.5 mm in FR, 19 ± 5.3 mm in FT, and 18 ± 5.2 mm in FTR. Mean posterior longitudinal ligament length was not significantly different in the four positions. Conclusions: These data show that the positions studied did not increase the target area as defined by the length of the posterior longitudinal ligament for the purpose of neuraxial needle insertion in obstetric patients. The maneuvers studied will have limited use in improving spinal needle access in pregnant women. Resumo: Objetivo do estudo: O objetivo deste estudo foi avaliar se a inclinação lateral da mesa cirúrgica e a rotação do corpo de uma parturiente sentada para anestesia neuraxial aumentou o tamanho da área-alvo paramediana para a inserção da agulha neuraxial. Ambiente: Sala de parto. Pacientes: Trinta grávidas a termo, ASA I-II, agendadas para cesárea eletiva. Intervenções: Ultrassonografia lombar foi realizada em quatro posições sentadas: (F) flexão lombar; (FR) como na posição F com rotação do ombro direito; (FT) como na posição F com inclinação lateral da mesa cirúrgica; (FTR) como na posição F com inclinação lateral da mesa cirúrgica combinada com a rotação do ombro direito. Mensurações: Para cada posição, o tamanho da “área-alvo”, definido como o comprimento visível do ligamento longitudinal posterior, foi medido no interespaço de L3-L4. Principais resultados: As médias do ligamento longitudinal posterior foram: 18,4 ± 4 mm na posição F; 18,9 ± 5,5 mm na posição FR; 19 ± 5,3 mm na posição FT e 18 ± 5,2 mm na posição FTR. O comprimento médio do ligamento longitudinal posterior não foi significativamente diferente nas quatro posições. Conclusões: Esses dados mostram que as posições avaliadas não aumentaram a área-alvo, conforme definido pelo comprimento do ligamento longitudinal posterior com o objetivo de inserção da agulha neuraxial em pacientes obstétricas. As manobras avaliadas terão um uso limitado na melhora do acesso à agulha espinhal em mulheres grávidas. Keywords: Lumbar ultrassonography, Anesthesia for cesarean delivery, Neuraxial anesthesia, Paravertebral longitudinal ligament, Palavras-chave: Ultrassonografia lombar, Anestesia para parto cesáreo, Anestesia neuraxial, Ligamento longitudinal paravertebral

We report 5 patients who underwent ultrasound-guided superior laryngeal nerve block before awake intubation and general anesthesia. We used a 8- to 15-MHz hockey stick-shaped ultrasound transducer (HST15-8/20 linear probe, Ultrasonix) to visualize the superior laryngeal nerve. A 3.8-cm 25-G needle was inserted in real time and directed toward the superior laryngeal nerve followed by circumferential placement of local anesthetic. All 5 patients tolerated subsequent awake fiberoptic intubation with either minimal or no sedation. Sonographically guided superior laryngeal nerve block may be useful in patients where identification of landmarks in the neck is difficult as a result of patient anatomy.

We report the novel application of photoplethysmographic technology with the Nexfin HD monitor for real-time measurement of blood pressure (BP) in a patient with tetraamelia. The patient was a 58-year-old man with tetraamelia secondary to thalidomide exposure in utero, who presented for surgical excision of a maxillary schwannoma. Because difficulty of cuff use on rudimentary limbs and failure to gain invasive arterial access due to abnormalities of limb vasculature, this population is known to pose some unique challenges for BP measurement. Nexfin may offer an alternative noninvasive method to detect BP in patients with phocomelia during the perioperative period.

Introduction Surgically inserted rectus sheath catheters (RSCs) are used increasingly for analgesia after cystectomy and other abdominal surgery. Currently, there is little information on the optimal positioning of RSCs to allow maximal spread of local anaesthetic. This study sought to assess the spread of dye injected via RSCs and to highlight the extent of its coverage in a fresh unembalmed cadaveric cystectomy model in order to confirm the nerve endings that are likely to be anaesthetised with RSCs. Methods Four cadavers underwent lower midline incision with limited bladder mobilisation. A RSC was inserted into the eight hemiabdomens. The RSCs were positioned either anterior (n=5) or posterior to the rectus muscle (n=3). Dye was injected down the RSCs to evaluate spread. The eight hemiabdomens were dissected anatomically to determine the surface area of dye spread and nerve root involvement. Results The mean surface area of dye spread with anteriorly placed RSCs was 30.6cm2 anterior and 25.9cm2 posterior to the rectus muscle. The mean surface area of dye spread with posteriorly placed RSCs was 11.3cm2 anterior and 37.3cm2 posterior to the rectus muscle. The mean number of nerve roots stained with anteriorly and posteriorly placed RSCs was 3.8 and 2.7 respectively. Subcutaneous spread of dye was seen with one anterior RSC insertion. Peritoneal spread was seen with one anteriorly positioned RSC. Conclusions This study has demonstrated efficient nerve root infiltration with anteriorly and posteriorly positioned RSCs. It appears that dye spreads between the fibres of the rectus muscle rather than out laterally to the nerve roots when spreading from its initial compartment.

Adductor canal blocks (ACBs) provide effective analgesia following total knee arthroplasty. We hypothesized that ACB single injection plus intravenous (IV) dexamethasone (Dex) shows non-inferiority to catheter, while ACB single injection does not.One hundred eighty patients were randomized and 177 analyzed from among 1 of 3 ACB interventions: (1) 0.5% ropivacaine 20 mL; (2) 0.5% ropivacaine 20 mL plus IV Dex 8 mg; (3) 0.5% ropivacaine 20 mL followed by continuous infusion of 0.2% ropivacaine at 5 mL/h for 48 hours. The primary endpoint was cumulative opioid consumption at 24 hours in oral morphine equivalents, with a non-inferiority limit of 30 mg. Secondary endpoints included opioid consumption at 12 and 48 hours, rest pain scores, quality of recovery survey, length of stay, and anti-emetic usage.For 24-hour opioid consumption, single injection ACB with and without IV Dex had a mean difference of -24.2 mg (confidence interval [CI] 0.5 to -48.9, P.001) and -21 mg (CI 3.2 to -45.1, P.001) relative to catheter, demonstrating non-inferiority. Non-inferiority was also shown at 12 hours by Dex and single injection over catheter with mean difference of -20.4 mg (CI -6.8 to -33.9, P.001) and -15.1 mg (CI -2.1 to -28.2, P.001), respectively. No intergroup difference was found for 48-hour opioid consumption. No differences in other secondary outcomes were observed across the 3 groups.Single injection ACB, with and without IV Dex, is non-inferior to ACB catheters in 24-hour opioid consumption, and may be attractive options for early-discharge, fast-track total knee arthroplasty.

This retrospective case series analyzed 45 malpractice claims for delayed detection of esophageal intubation from the Anesthesia Closed Claims Project. Inclusion criteria were cases from 1995–2013, after adoption of identification of CO2 in expired gas to verify correct endotracheal tube position as a monitoring standard by the American Society of Anesthesiologists. Forty-nine percent (95% CI 34%−64%) occurred in the operating room or other anesthesia location where CO2 detection equipment should have been available. The most common factors contributing to delayed detection were not using, ignoring, or misinterpreting CO2 readings. Misdiagnosis, as with bronchospasm, occurred in 33% (95% CI 20%−49%).

To the Editor We were interested in the recently published findings on epidural contrast spread in the porcine model using three different infusion regimens by Cole et al due to our previous work in this area.[1 2][1] Similar to their findings, we found that cephalad and caudad spreads of dye were

To the editor, The recent report of the ultrasound-guided selective mandibular nerve block using the lateral pterygoid plate (LPP) is a novel technique that describes an extraoral approach that landmarks the bony structures rather than the target nerve. This approach raises interesting

This article addresses how ultrasonography, which is commonly used by anesthesia providers for regional anesthesia as well as for vascular access, may be useful for neuraxial anesthesia. It begins with an overview of the uses of ultrasonography by anesthesiologists and the evolution of equipment, followed by its uses in preprocedural and real-time ultrasonography for neuraxial anesthesia. It includes a critical review of the limitations of this technology and describes future trends regarding its use. The aim of this article is to discuss the introduction and the place of ultrasonography in neuraxial anesthesia for day-to-day practice as well as for complex cases. This will focus on two main topics: preprocedural ultrasound scanning as well as real-time ultrasound scanning. It will also provide an overview of the evolving technology in this area and a critical appraisal of the current and future use of ultrasonography in neuraxial anesthesia. It will hopefully help the reader appreciate both the shortcomi...

Superior laryngeal nerve block is a valuable technique for provision of upper airway anesthesia. In bilateral scans of 20 volunteers, we developed a technique for ultrasonographic visualization of the superior laryngeal nerve and key anatomical structures using a hockey stick-shaped 8 to 15 MHz transducer (HST15 to 8/20 linear probe, Ultrasonix, Richmond, BC, Canada). Subsequently, we simulated superior laryngeal nerve scanning and injection in bilateral injections in 2 cadavers. Ultrasound-guided in-plane advancement of a needle toward the superior laryngeal nerve and injection of 1 mL of green dye was achieved in all 4 attempts and confirmed by a postprocedural dissection performed by an anatomist. We conclude that ultrasound-guided superior laryngeal nerve block in humans may be feasible.

Background This is a study comparing two short-acting local anesthetics lidocaine and 2-chloroprocaine in combination with fentanyl, to provide selective spinal anesthesia for outpatient transurethral resection of the prostate (TURP). Methods In this prospective, randomized double-blind study, selective spinal anesthesia was performed in 40 American Society of Anesthesiologists I-III outpatients undergoing TURP using either 40 mg of chloroprocaine mixed with 12.5 μg of fentanyl (n = 20) or 35 mg of lidocaine mixed with 12.5 μg of fentanyl (n = 20). The primary outcome was duration of spinal block. Secondary outcomes were time to reach T10 (onset), time to maximal level, duration above T10 and lidocaine 3, maximal level of block, and adverse effects. Results The median (minimum, maximum) onset time was 4 (1, 16) and 3 (2, 10) min for chloroprocaine and lidocaine, respectively. Time to maximal level was 20 (17, 29) and 22 (16, 26) min for chloroprocaine and lidocaine, respectively. Mean maximal level was T7-T8 for both agents. Duration of block above T10 was 54 (28, 88) and 63 (31, 87) min for chloroprocaine and lidocaine, respectively. Duration of block above lidocaine 3 was 93 (56, 218) and 98 (58, 151) min for chloroprocaine and lidocaine, respectively. There was no statistical difference between the two groups with respect to these clinical end points. Four patients in the lidocaine group developed transient neurological symptoms. One patient in the chloroprocaine group developed a cauda equina-like syndrome but recovered fully after several weeks. Conclusions Selective spinal anesthesia with chloroprocaine and lidocaine for TURP yielded comparable results for clinical characteristics. Further research on transient neurological symptom and cauda equina risk with chloroprocaine is warranted.

Purpose This case report describes the novel use of sequential bilateral upper extremity intravenous regional anesthesia with 2-chloroprocaine for bilateral endoscopic carpal tunnel decompression.

UNLABELLED We compared the cost and effectiveness of selective spinal anesthesia (SSA) with a desflurane-based general anesthetic (DES) for outpatient gynecological laparoscopy. A prospective analysis was undertaken of 10 patients randomized to receive SSA and compared with 10 patients randomized to receive DES. The groups were well matched in their demographic characteristics. The mean cost (in 2000 Canadian dollar values) of anesthesia supplies, drugs, and nursing for the SSA group of $62.31 was less than that for the DES group of $92.31 (P < 0.01). Recovery costs of both groups were similar. Time to administer anesthesia and time spent in the postanesthetic care unit were also similar. Postoperative analgesia was required by 50% of the DES group but in no patient receiving SSA (P < 0.01). SSA is a cost-effective alternative to DES in these patients. IMPLICATIONS Small-dose spinal anesthesia is an effective alternative to a desflurane general anesthetic in terms of cost and recovery profiles in ambulatory gynecological laparoscopy.

UNLABELLED We conducted a randomized controlled trial to compare the recovery characteristics of selective spinal anesthesia (SSA) and desflurane anesthesia (DES) in outpatient gynecological laparoscopy. Twenty ASA physical status I patients undergoing gynecological laparoscopy were randomized to receive either SSA with lidocaine 10 mg + sufentanil 10 microg or general anesthesia with DES and N(2)O. Intraoperative conditions, recovery times, postanesthesia recovery scores, and postoperative outcomes were recorded. Intraoperative conditions were comparable in both groups. All patients in the SSA group were awake and oriented at the end of surgery, whereas patients in the DES group required 7 +/- 2 min for extubation and orientation. SSA patients had a significantly shorter time to straight leg raising (3 +/- 1 min versus 9 +/- 4 min; P < 0.0001) and to ambulation (3 +/- 0.9 min versus 59 +/- 16 min; P < 0.0001) compared with the DES group. SSA patients had significantly less postoperative pain than DES patients (P < 0.05). We concluded that SSA was an effective alternative to DES for outpatient gynecological laparoscopy. IMPLICATIONS This study compared the use of a desflurane general anesthetic to a small-dose spinal anesthetic in ambulatory gynecological laparoscopy. Using the spinal technique, patients can walk from the operating room table to a stretcher on completion of surgery. Their recovery time was similar to that of the desflurane group.

The role of ultrasound scanning in spinal anesthesia is principally limited to preprocedure imaging and identification of anatomical structures. We describe our experience with a real-time ultrasound technique for visualization and performance of spinal anesthesia. An initial cadaver study was performed in 5 unembalmed cadavers to develop a technique for real-time performance of ultrasound-guided spinal anesthesia via Taylor's approach (paramedian approach to the L5-S1 interspace). Subsequently, 10 patients scheduled for joint arthroplasty underwent real-time ultrasound-guided spinal anesthesia in the prone position. The relevant anatomy and the needletip were visualized easily and all spinals were effective for joint arthroplasty.

BACKGROUND The posterior longitudinal ligament (PLL) has been found to be a reliable measure of the acoustic target window for lumbar spinal anaesthesia and a predictive tool for difficult spinals. Currently, there is limited information on the PLL in the thoracic spine and its potential use for optimizing the acoustic target window during thoracic epidural placement. This study examined the effects of changes in body position on the length of the PLL as a measure of the acoustic target window for paramedian thoracic epidural access. METHODS We performed thoracic ultrasonography on 30 adult volunteers to measure the length of the PLL at the T9/10 interspace, in five different positions: P1, neutral; P2, thoracic and lumbar flexion; P3, as in position 2 with dorsal table tilt to 10°; P4, as in position 2 with 45° rightward shoulder rotation; and P5, as in position 2 with 45° leftward shoulder rotation. RESULTS The mean (sd) PLL length increased significantly from 9.9 (3.9) mm in P1 to 11.7 (3.4) mm in P2, 12.9 (3.1) mm in P3, and 13.8 (4.0) mm in P4 (P

Purpose: The efficacy of low dose intrathecal lidocaine-sufentanil was compared with intrathecal sufentanil for short duration outpatient gynecological laparoscopy. Methods: Thirteen ASA I and II patients undergoing gynecological laparoscopy were studied in a randomized double-blind trial. Patients received either intrathecal 10 mg lidocaine plus 10 µg sufentanil (Group LS) or intrathecal 20 µg sufentanil (Group S), each diluted to 3 mL with sterile water through a 27 g Whitacre needle in the sitting position. Sensory and motor recovery were assessed with pinprick and a modified Bromage scale. Results: One of seven Group LS patients and two of five Group S patients required conversion to general anesthesia for failed skin test with forceps. Two of the remaining three Group S patients felt sharpness with skin incision. The study was terminated early because of inadequate anesthesia in Group S. The small sample size (n=9) made statistical analysis uninformative. Conclusion: Intrathecal 20 µg sufentanil is unsuitable as a sole agent for gynecological laparoscopy.

This paper outlines and evaluates a nurse based model for screening outpatients that is utilized in our free standing Surgical Day Care Centre (SDCC).For 668 outpatients presenting at our SDCC, the attending anesthesiologist completed a study survey that was designed to identify: completeness of history; important concerns as judged by the pre-admission nurse; whether the patient was seen in the anesthesia preadmission clinic (PAC) for a consultation; if there was a delay in SDCC, the duration and reasons for the delay; whether in the opinion of the attending anesthesiologist the patient should have had an anesthetic consultation; whether the patient was canceled and the reason for cancellation.A nurse based model for screening all outpatients in a university affiliated tertiary hospital day care unit had an accuracy of 81%, specificity of 86%, sensitivity of 46% and a negative predictive value of 92%. The cancellation rate with this model was 1.4%(8/551) and the case delay rate was 3.4%(19/551). The referral rate to anesthesiology staff was 17.5%(117/668) and the referral rate to the PAC for anesthetic consultation was 5.1%(34/668).The use of the nurse based model allowed for the efficient use of anesthesia and surgical day care centre resources. The model was better at 'ruling out' patients who do not need to be seen by anesthesiology ahead of the day of surgery rather than 'ruling in' patients who need to be seen by anesthesiology.

Chloroprocaine should be an ideal agent for intravenous regional anesthesia (IVRA) because of its rapid onset and ester hydrolysis. Raising the pH of local anesthetics may increase the speed of onset and the intensity of nerve blocks. We compared plain and alkalinized 2-chloroprocaine 0.5% with lidocaine for IVRA.In two separate double-blind studies, 78 patients scheduled for daycare hand surgery were randomized to receive 40 mL plain 2-chloroprocaine 0.5%, alkalinized 2-chloroprocaine 0.5% or lidocaine 0.5% for IVRA. Time to sensory and motor block, need for supplemental analgesia, and side effects were compared.There was no difference in time to sensory or motor block in either group. Patients who received plain chloroprocaine required more supplemental opioid and had a higher incidence of metallic taste and of hives than patients who received lidocaine (P0.05). Comparing alkalinized chloroprocaine with lidocaine, there was no difference found with respect to opioid supplementation, CNS side effects, or incidence of hives.In conclusion, alkalinized chloroprocaine was found to be an effective agent for IVRA but no benefit over lidocaine was detected. Plain chloroprocaine for IVRA produced more minor side effects than lidocaine.

To the Editor, Arteriovenous fistulas (AVFs) must meet certain criteria regarding diameter and flow rate (Qa) upon maturation to be considered adequate for use in hemodialysis as well as to reduce the risk of negative sequelae such as high-output cardiac failure. In spite of extensive preoperative vessel assessment, 20-50% of AVFs fail to meet these criteria and must undergo surgical revision. Intraoperative assessment of AVF patency often relies on clinical evaluation for the presence of a venous thrill post-anastomosis, but this method is highly operator-dependent and a poor predictor of long-term AVF outcomes. While more objective devices exist to assess intraoperative flow (i.e., devices to measure transit time), they are invasive and require expert surgical skill to produce accurate and reliable readings. In addition, there is poor evidence to correlate a specific range of measured transit times with improved rates of maturation. Creation of an AVF results in a welldocumented increase in cardiac output (CO) due to a rapid decrease in systemic vascular resistance (SVR) postarteriovenous anastomosis. Continuous measurement of CO by noninvasive means may provide a more objective and reproducible intraoperative method of measuring AVF patency and predicting long-term outcomes. We present the novel use of photoplethysmographic technology with the Nexfin HD monitor (BMEYE, Amsterdam, The Netherlands). This device was used for intraoperative assessment of CO during creation of a brachiocephalic AVF in a 60-yr-old male with end-stage renal disease (glomerular filtration rate 19 mL min) and type 2 diabetes mellitus. The patient gave his consent for publication of this report. Anesthesia options were discussed and we elected to proceed with the procedure under general anesthesia. The patient was placed in the supine position and, in addition to using standard hemodynamic monitors, a Nexfin cuff was placed on the index finger of the patient’s non-operative arm. The Nexfin uses finger cuff-based photoplethysmography to provide noninvasive continuous blood pressure, CO, SVR, and heart rate monitoring. Induction of anesthesia was uneventful and surgical management of the case was routine. Clinically, the surgical team was satisfied with the newly created AVF. Hemodynamic monitoring by Nexfin showed a baseline CO pre-AVF that ranged from 5.4-5.8 L min and increased to 7.0 L min immediately after the fistula was established (Figure). Systemic vascular resistance dropped from 955 dyn sec cm pre-AVF to 916 dyn sec cm post-anastomosis. The patient tolerated the procedure well and remained hemodynamically stable during the surgery and postoperatively until discharge. Current intraoperative methods to determine AVF adequacy are limited to subjective clinical assessments or invasive and operator-dependent Qa measurement devices. These methods are poor predictors of long-term AVF adequacy and continue to result in high AVF failure rates, particularly in females, the elderly, and diabetics. Intraoperative continuous monitoring of CO may provide an additional means of assessing AVF patency. This method would have traditionally required invasive arterial pressure (IAP) monitoring. Nevertheless, newer noninvasive CO monitors such as Nexfin are comparable with IAP for hemodynamic monitoring in the majority of patients undergoing surgery, but they do not come with any C. Fitch, BScN (&) R. Earle, BSc A. Sawka, MD H. Vaghadia, MBBS Departments of Anesthesia and Vascular Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada e-mail: christiemfitch@gmail.com