Introduction Regional anesthesia is a rapidly growing subspecialty. There are few published meta-analyses exploring pain outcome measures utilised in regional anesthesia randomized controlled trials (RCTs), which may be due to heterogeneity in outcomes assessed. This systematic review explores postoperative pain outcomes utilised in regional anesthesia RCTs. Methods A literature search was performed using three databases (Medline, Embase, and CINAHL). Regional anesthesia RCTs with postoperative pain as a primary outcome were included if written in English and published in one of the top 20 impact factor journals between 2005 and 2017. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias. Results From the 31 included articles, 15 different outcome measures in total were used to assess postoperative pain. The most commonly (16/31) used outcome measures were verbal numerical grading of pain out of 10, total opioid consumption, and visual analogue scale 10 cm (VAS). The need for analgesia was used as an outcome measure where studies did not use a pain rating score. Ten studies reported pain scores on activity and 27/31 studies utilised ≥2 pain outcomes. Time of measurement of pain score also varied with a total of 51 different time points used in total. Conclusion Analysis of the articles demonstrated heterogeneity and inconsistency in choice of pain outcome and time of measurement within regional anesthesia studies. Identification of these pain outcomes utilised can help to create a definitive list of core outcomes, which may guide future researchers when designing such studies.

Avoidance of general anaesthesia for breast surgery may be because of clinical reasons or patient choice. There is emerging evidence that the use of regional anaesthesia and the avoidance of volatile anaesthetics and opioid analgesia may have beneficial effects on oncological outcomes. We conducted a prospective observational case series of 16 breast cancer surgeries performed under thoracic paravertebral plus pectoral nerve block with propofol sedation to demonstrate feasibility of technique, patient acceptability and surgeon satisfaction. Fifteen out of 16 cases were successfully completed under sedation and regional anaesthesia, with one conversion to general anaesthesia. Eleven out of 16 cases required low-dose intra-operative opioid analgesia. Out of the 15 surgical procedures completed under regional anaesthesia with sedation, all patients experienced either no or minimal intra-operative pain, and all would choose this anaesthetic technique again. Surgeon-reported operating conditions were 'indistinguishable from general anaesthesia' in most cases, and surgeons were 'extremely satisfied' or 'satisfied' with the technique after every procedure. Combined thoracic paravertebral plus pectoral nerve block with intra-operative sedation is a feasible technique for breast surgery.

The article by Chuan et al. [1] on meat-based vs. human cadaveric models for teaching ultrasoundguided regional anaesthesia does not provide much additional clarity about the novice’s acquisition of keys skills because it compares two models that are rarely used in the UK [2]. Many of the regional anaesthesia courses for true novices in the UK, such as the Royal College of Anaesthetists regional anaesthesia ultrasound workshop course [3], use low fidelity phantoms for needling and live models for the majority of their sono-anatomy skills acquisition. When cadavers or porcine models are used, for example in the Sonosite ‘Ultrasound guided regional anaesthesia – beyond introductory’ courses [4], there is a stipulation that ‘previous experience in regional anaesthesia is essential’. When confronted with a cadaver model, therefore, most operators will already be beyond the novice stage of skills acquisition described in the paper. As the editorial rightly points out, the use of cadaver models comes into its own once these initial skills have been acquired, and where high fidelity cadavers such as the Thiel embalmed cadaver can reproduce anatomy, needling, fascial feedback, injection and spread in a model that can be used over prolonged time periods [5]. The translation of advanced skills from cadaver models into patient-centered practice would provide a much more useful analysis and could form the bedrock of any future tiered training in regional anaesthesia, as postulated by Gupta and Morton [6].

BACKGROUND: The intrathecal morphine dose achieving optimal analgesia for cesarean delivery while minimizing side effects has not yet been deduced. In this meta-analysis, our objective was to determine whether low- or high-dose intrathecal morphine provides acceptable duration and intensity of analgesia with fewer side effects. METHODS: A literature search (PubMed, EMBASE, MEDLINE, Scopus, Web of Science, and CINAHL) was performed to identify randomized controlled trials involving patients undergoing elective cesarean delivery under spinal anesthesia comparing low-dose (LD; 50–100 μg) morphine with higher dose (HD; >100–250 μg). The primary outcome was the time for first request for supplemental analgesia. The secondary outcomes included pain scores, morphine use, maternal side effects (vomiting and pruritus), and Apgar scores. Mean differences (MDs) and odds ratios (ORs) were calculated using random effects modeling with 95% confidence intervals (CIs). RESULTS: Eleven articles met our inclusion criteria. Four hundred eighty patients were recruited in all study groups (233 patients in the HD and 247 in the LD groups). The mean time to first analgesic request was longer (MD, 4.49 hours [95% CI, 1.85–7.13]; P = 0.0008) in the HD group compared with the LD group. Pain scores (0–100 scale) at 12 hours (MD, 2.54 [95% CI, −2.55 to 7.63]; P = 0.33) as well as morphine consumption at 24 hours (MD, 1.31 mg [95% CI, −3.06 to 7.31]; P = 0.42) were not significantly different. The incidence of nausea or vomiting (OR, 0.44 [95% CI, 0.27–0.73]; P = 0.002) and pruritus (OR, 0.34 [95% CI, 0.20–0.59]; P = 0.0001) was lower in the LD group. The incidence of Apgar scores <7 at 1 minute was not different between groups (OR, 1.11 [95% CI, 0.06–20.49]; P = 0.94). CONCLUSIONS: This meta-analysis shows that HDs of intrathecal morphine prolong analgesia after cesarean delivery compared with lower doses. The MD of 4.5 hours (95% CI, 1.9–7.1 and 99% CI, 1.0–8.2 hours) of pain relief must be balanced against the increased risk of maternal pruritus and vomiting. Results from this study can be used by clinicians to weigh the benefits and potential side effects of using HDs of intrathecal morphine for cesarean delivery.

British Journal of Hospital MedicineVol. 73, No. 9 Anaesthetic and Critical Care DilemmaShould endotracheal cuff pressure be routinely measured during elective surgery?M Ramadan, E Pushpanathan, P SultanM RamadanSearch for more papers by this author, E PushpanathanSearch for more papers by this author, P SultanSearch for more papers by this authorM Ramadan; E Pushpanathan; P SultanPublished Online:16 Aug 2013https://doi.org/10.12968/hmed.2012.73.9.538AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Bennet MH, Isert PR, Cumming RG (2000) Postoperative sore throat and hoarseness following tracheal intubation using air or saline to inflate the cuff: A randomized controlled trial. Anaesth Intensive Care 28(4): 408–13 Crossref, Medline, Google ScholarBrimacombe J, Keller C, Giampalmo M, Sparr HJ, Berry A (1999) Direct measurement of mucosal pressures exerted by cuff and non-cuff portions of tracheal tubes with different cuff volumes and head and neck positions. Br J Anaesth 82(5): 708–11 Crossref, Medline, Google ScholarGuyton DC, Barlow MR, Besselievre TR (1997) Influence of airway pressure on minimum occlusive endotracheal tube cuff pressure. Crit Care Med 25(1): 91–4 Crossref, Medline, Google ScholarLiu J, Zhang X, Gong W et al. (2010) Correlations between controlled endotracheal tube cuff pressure and postprocedural complications: a multicentre study Anaesth Analg 111(5): 1133–7 Crossref, Medline, Google ScholarLoeser EA, Stanley TH, Jordan W, Machin R (1980) Postoperative sore throat: influence of tracheal tube lubrication versus cuff design. Can Anaesth Soc J 27(2): 156–8 Crossref, Medline, Google Scholar FiguresReferencesRelatedDetailsCited byBi-national survey of intraoperative cuff pressure monitoring of endotracheal tubes and supraglottic airway devices in operating theatres7 July 2019 | Anaesthesia and Intensive Care, Vol. 47, No. 4Does Objective Measurement of Tracheal Tube Cuff Pressures Minimise Adverse Effects and Maintain Accurate Cuff Pressures? A Systematic Review and Meta-Analysis1 September 2016 | Anaesthesia and Intensive Care, Vol. 44, No. 5 1 September 2012Volume 73Issue 9ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 16 August 2013 Published in print 1 September 2012 Information© MA Healthcare LimitedPDF download

Volatile agents have been used in anaesthesia since the 1840s and intravenous anaesthetic agents were developed in the 1930s. The technique of using intravenous agents for induction and maintenance (total intravenous anaesthesia) has now gained popularity. This article explores some advantages and disadvantages of volatile (inhalational) based and total intravenous anaesthesia techniques.

Since the introduction of Modernising Medical Careers in 2007, training within most specialties has become less diverse with trainees within the same region often gaining similar clinical experience. Newlyemployed consultants are expected to bring new skills and experiences to a department, which can be in the form of research, experience in another specialty, different skill-sets, knowledge of different institutions' practices or postgraduate degrees. Experience at an institution abroad can be very beneficial, and generates much interest and discussion at interview. These experiences reflect trainees' enthusiasm for their specialty and significantly increase the clinical and research profile of a department.

Tonsillectomy is a common procedure, with over 50 000 operations performed annually in the UK (Royal College of Surgeons of England, 2005). Just over half of these patients are under 15 years of age. Postoperative complications of a tonsillectomy include dysphagia, nausea and vomiting, pain, infection and bleeding.