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summary
1
Barreveld et al. show that LA administered either IV or via block; before, during or after surgery, significantly reduces postoperative pain and opioid consumption.
Specifically in:
• 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.
Barreveld A, Witte J, Chahal H et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013 May 1;116(5):1141-61.
  Daniel Jolley
pearl
0
Intravenous lidocaine is efficacious and may be a suitable alternative to regional anesthesia when contraindicated or not performed.
Barreveld A, Witte J, Chahal H et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013 May 1;116(5):1141-61.
  Daniel Jolley
pearl
0
Nerve blocks in general have a beneficial analgesic effect, regardless of whether pre- or post-incision, and are superior to intra-articular LA.
Barreveld A, Witte J, Chahal H et al. Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs. Anesth. Analg. 2013 May 1;116(5):1141-61.
  Daniel Jolley
summary
1
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.
Thilen SR, Hansen BE, Ramaiah R et al. Intraoperative neuromuscular monitoring site and residual paralysis. Anesthesiology. 2012 Nov 1;117(5):964-72.
  Daniel Jolley
summary
1
Fink & Hollman describe and refute several commonly-held myths regarding neuromuscular pharmacology. Their evidence-supported arguments are:
1. Intubating patients without muscle relaxants is less safe and sub-optimal.
2. Even if you know muscle relaxant pharmacokinetics, it is sufficiently unpredictable that neuromuscular monitoring and reversal is still necessary.
3. Post-operative residual curarization (PORC) is clinically significant with real consequences.
4. Postoperative residual curarization (PORC) is common.
5. Postoperative residual curarisation (PORC) (TOFR < 0.9) can only be diagnosed with a quantitative neuromuscular monitor. Clinical tests are insufficient and poorly sensitive.
Fink H Hollmann MW. Myths and facts in neuromuscular pharmacology. New developments in reversing neuromuscular blockade. Minerva Anestesiol. 2012 Apr 1;78(4):473-82.
  Daniel Jolley
pearl
1
Use of the LMA ProSeal when compared with intubation for gynae-laparoscopy does not decrease post-operative pain or PONV.
Griffiths JD, Nguyen M, Lau H et al. A prospective randomised comparison of the LMA ProSeal™ versus endotracheal tube on the severity of postoperative pain following gynaecological laparoscopy. Anaesth Intensive Care. 2013 Jan 1;41(1):46-50.
  Daniel Jolley
summary
1
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.
Grigoras A, Lee P, Sattar F et al. Perioperative intravenous lidocaine decreases the incidence of persistent pain after breast surgery. Clin J Pain. 2012 Sep 1;28(7):567-72.
  Daniel Jolley
pearl
0
Perioperative lidocaine reduces the incidence of persistent post-surgical pain after breast cancer surgery.
Grigoras A, Lee P, Sattar F et al. Perioperative intravenous lidocaine decreases the incidence of persistent pain after breast surgery. Clin J Pain. 2012 Sep 1;28(7):567-72.
  Daniel Jolley
summary
1
Excellent anaesthetists were identified by anaesthesia nurses as being:
1. Organised & focused: structured, responsible, and focused approach to work tasks.
2. Good communicators: clear and informative, briefing of team about the plan before induction.
3. Respectful of complexity: humble to the complexity of anaesthesia, admitting own fallibility.
4. Patient-centred: personal contact with the patient before induction.
5. Good situational awareness: fluent in practical work without losing overview.
6. Calm and clear in critical situations, being able to change to a strong leading style.
Larsson J Holmström IK. How excellent anaesthetists perform in the operating theatre: a qualitative study on non-technical skills. Br J Anaesth. 2013 Jan 1; 110 (1): 115121115-21.
  Daniel Jolley
pearl
1
Non-technical skills are of equal importance to technical anaesthesia skills, but are more challenging to define, measure and acquire.
Larsson J Holmström IK. How excellent anaesthetists perform in the operating theatre: a qualitative study on non-technical skills. Br J Anaesth. 2013 Jan 1; 110 (1): 115121115-21.
  Daniel Jolley