- 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.
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:
Non-technical skills are of equal importance to technical anaesthesia skills, but are more challenging to define, measure and acquire.