Anaesthesia
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In a quality improvement audit on epidural analgesia in 300 patients after major abdominal surgery, we identified postoperative lower leg weakness and premature catheter dislodgement as the most frequent causes of premature discontinuation of postoperative epidural infusion. Lower limb motor weakness occurred in more than half of the patients with lumbar epidural analgesia. In a second period monitoring 177 patients, lumbar catheter insertion was abandoned in favour of exclusive thoracic placement for epidural catheters. ⋯ Similarly, the frequency of premature catheter dislodgement was reduced from 14.5% to 5.7% (odds ratio 0.35; 95% confidence interval 0.17-0.72). With a stepwise logistic regression model we demonstrated that the odds of premature catheter dislodgement was reduced by 43% for each centimetre of additional catheter advancement in Period Two. We conclude that careful audit of specific complications can usefully guide changes in practice that improve success of epidural analgesia regimens.
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Interscalene brachial plexus block: assessment of the needle angle needed to enter the spinal canal.
Attempts were made to place 8-cm 22G needles into the spinal canals of four preserved cadavers using the skin entry point most commonly associated with the lateral interscalene brachial plexus block or Winnie approach (that is, at the level of the cricoid cartilage). Eleven successful attempts were confirmed by computed tomography. ⋯ The only needle entry into the spinal canal with a needle angle of > 50 degrees to the transverse plane (< 40 degrees to the sagittal plane) entered the intervertebral foramen at a depth of 7.7 cm from the skin. We conclude that the use of markedly caudad angulations of needles no longer than 5.0 cm may minimise the chances of spinal canal entry and spinal cord damage.
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Randomized Controlled Trial Comparative Study
The use of low dose plain solutions of local anaesthetic agents for spinal anaesthesia in the prone position: bupivacaine compared with levobupivacaine.
In this study, we aimed to test the hypothesis that 1-ml plain solution of 0.5% bupivacaine or 0.5% levopubivacaine administered in a subarachnoid block can provide adequate anaesthesia and operating conditions for pilonidal cyst/sinus operations performed in the prone position. There were no significant differences between the two groups in terms of patient demographic data, duration of operation, patient-surgeon satisfaction, haemodynamic changes and side effects. ⋯ There was no complete motor blockade in Group L (p = 0.110 and 0.490 respectively). We conclude that both regimens are effective and safe for use in subarachnoid anaesthesia for pilonidal cyst/sinus operations performed in the prone position.
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Randomized Controlled Trial Comparative Study
A comparison of sub-Tenon's with peribulbar anaesthesia in patients undergoing sequential bilateral cataract surgery.
The aim of this study was to compare efficacy and particularly patient preference of sub-Tenon's anaesthesia with peribulbar anaesthesia in patients undergoing sequential, bilateral, cataract surgery. Fifty patients were randomised to either sub-Tenon's or peribulbar anaesthesia for their first operation and the alternative technique for their subsequent operation. Intra-ocular pressure was measured, globe and lid akinesia were scored, patients completed a visual rating score of injection and operative pain and their preference for anaesthesia was assessed. ⋯ Injection and operative pain scores were low and comparable. Both methods provided similar anaesthesia and akinesia. The majority (86%) chose the method they received first irrespective of whether it was sub-Tenon's or peribulbar, but 10% of patients preferred sub-Tenon's, disliking the facial numbness from peribulbar anaesthesia.
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A questionnaire survey examining rapid sequence induction techniques was sent to all anaesthetists in Wales. The questionnaire presented five common clinical scenarios: emergency appendicectomy; elective knee arthroscopy with a symptomatic hiatus hernia; elective knee arthroscopy with an asymptomatic hiatus hernia; elective Caesarean section; and emergency laparotomy for bowel obstruction. ⋯ Rapid sequence induction was chosen by 398/400 respondents (100%) for bowel obstruction, 392/399 (98%) for Caesarean section, 388/408 (95%) for appendicectomy, 328/395 (83%) for symptomatic hiatus hernia but only 98/399 (25%) for asymptomatic hiatus hernia (p < 0.001). Trainees were more likely to use a rapid sequence induction technique than consultants and staff grades for the appendicectomy (p = 0.025), symptomatic hiatus hernia (p = 0.004) and asymptomatic hiatus hernia (p = 0.001) scenarios and were also more likely to use a thiopental-suxamethonium combination for rapid sequence induction (p < 0.001).