- Total knee arthroplasty (femoral, sciatic and lumbar plexus b., single-shot or continuous)
- Total hip arthroplasty (continuous lumbar plexus; intra-articular LA)
- Knee arthroscopy (single-shot lumbar plexus; IA LA; single-shot femoral nerve ± sciatic).
- Arthroscopic shoulder surgery - interscalene b., single-shot or continuous. IA is not beneficial.
- Hand & forearm surgery - axillary b. offers analgesic benefits only on day of surgery.
- TAP block is beneficial for laparoscopic, open appendectomy, abdominal surgery, cesarean section, and TAH.
- Intubating patients without muscle relaxants is less safe and sub-optimal.
- Even if you know muscle relaxant pharmacokinetics, it is sufficiently unpredictable that neuromuscular monitoring and reversal is still necessary.
- Post-operative residual curarization (PORC) is clinically significant with real consequences.
- Postoperative residual curarization (PORC) is common.
- Postoperative residual curarisation (PORC) (TOFR < 0.9) can only be diagnosed with a quantitative neuromuscular monitor. Clinical tests are insufficient and poorly sensitive.
- Organised & focused: structured, responsible, and focused approach to work tasks.
- Good communicators: clear and informative, briefing of team about the plan before induction.
- Respectful of complexity: humble to the complexity of anaesthesia, admitting own fallibility.
- Patient-centred: personal contact with the patient before induction.
- Good situational awareness: fluent in practical work without losing overview.
- Calm and clear in critical situations, being able to change to a strong leading style.
Nerve block duration may be extended by adrenaline, clonidine, dexmedetomidine, dexamethasone, and possibly midazolam, tramadol and magnesium. Other than adrenaline there is however no longterm data demonstrating safety. Intra-articular adjuvant benefit has been shown for tramadol, magnesium, dexmedetomidine, clonidine, ketamine, ketorolac and morphine, but the evidence is not strong enough to support routine use.
Barreveld et al. show that LA administered either IV or via block; before, during or after surgery, significantly reduces postoperative pain and opioid consumption.
Intravenous lidocaine is efficacious and may be a suitable alternative to regional anesthesia when contraindicated or not performed.
Nerve blocks in general have a beneficial analgesic effect, regardless of whether pre- or post-incision, and are superior to intra-articular LA.
Monitoring neuromuscular blockade with TOF at the eye muscles (orbicularis oculi) results in a 5 times greater risk (adjusted odds ratio) of postoperative residual curarization (PORC) than monitoring at the hand (adductor pollicis) when PORC is defined by TOFR < 90% using acceleromyography.
PORC was nonetheless common in both groups, occurring in 52% and 22% respectively.
Fink & Hollman describe and refute several commonly-held myths regarding neuromuscular pharmacology. Their evidence-supported arguments are:
Use of the LMA ProSeal when compared with intubation for gynae-laparoscopy does not decrease post-operative pain or PONV.
Perioperative lidocaine (1.5 mg/kg bolus then 1.5 mg/kg/h until 1 h after skin closure) reduces the incidence of persistent post-surgical pain after breast cancer surgery at 3 months.
Perioperative lidocaine reduces the incidence of persistent post-surgical pain after breast cancer surgery.
Excellent anaesthetists were identified by anaesthesia nurses as being: