Regional anesthesia has shown to be successful in controlling major pain in trauma patients. However, the possibility of masking acute compartment syndrome (ACS) after peripheral nerve blocks for limb injuries is still controversially discussed. Therefore, we aimed to summarize the current literature regarding this topic to shed light on the impact of peripheral regional anesthesia on the diagnosis of ACS in trauma patients. We searched Pubmed, Google Scholar and the Cochrane Library for literature following the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. The analysis of these reports was included in the context of the current literature concerning this topic. We found no (randomized) studies, and only six case reports dealing with the impact of peripheral nerve blocks and ACS in patients after a limb trauma met our criteria and were included in our review. Only one reported a delay in the diagnosis of ACS. In most of the cases (5 of 6), the breakthrough pain, despite the nerve block, proved to be a good indicator of a developing ACS. However, despite some narrative articles about the topic including some recommendations about the possibly safe use of regional anesthesia techniques for limb trauma, there is still no international consensus and only one national guideline focusing on the possibly safe use of peripheral nerve blocks in trauma patients at risk of ACS. After reviewing the respective literature, we consider that intra-articular analgesia, sensory blocks, fascial plane blocks and low-concentration continuous peripheral nerve blocks are effective for analgesia and a low-risk analgesia tool for trauma and postsurgical patients at risk of ACS due to the fact that they do not lead to a dense block. Finally, we summarized suggestions based on the results of the literature for the different regional anesthesia modalities in these patients in a table to facilitate the use of these techniques.

Background Endotoxin adsorption is a promising but controversial therapy in severe, refractory septic shock and conflicting results exist on the effective capacity of available devices to reduce circulating endotoxin and inflammatory cytokine levels. Methods Multiarm, randomized, controlled trial in two Swiss intensive care units, with a 1:1:1 randomization of patients suffering severe, refractory septic shock with high levels of endotoxemia, defined as an endotoxin activity ≥ 0.6, a vasopressor dependency index ≥ 3, volume resuscitation of at least 30 ml/kg/24 h and at least single organ failure, to a haemoadsorption (Toraymyxin), an enhanced adsorption haemofiltration (oXiris) or a control intervention. Primary endpoint was the difference in endotoxin activity at 72-h post-intervention to baseline. In addition, inflammatory cytokine, vasopressor dependency index and SOFA-Score dynamics over the initial 72 h were assessed inter alia. Results In the 30, out of 437 screened, randomized patients (10 Standard of care, 10 oXiris, 10 Toraymyxin), endotoxin reduction at 72-h post-intervention-start did not differ among interventions (Standard of Care: 12 [1–42]%, oXiris: 21 [10–51]%, Toraymyxin: 23 [10–36]%, p = 0.82). Furthermore, no difference between groups could be observed neither for reduction of inflammatory cytokine levels ( p = 0.58), nor for vasopressor weaning ( p = 0.95) or reversal of organ injury ( p = 0.22). Conclusions In a highly endotoxemic, severe, refractory septic shock population neither the Toraymyxin adsorber nor the oXiris membrane could show a reduction in circulating endotoxin or cytokine levels over standard of care. Trial registration ClinicalTrials.gov. NCT01948778. Registered August 30, 2013. https://clinicaltrials.gov/study/NCT01948778

BACKGROUND: There is a wide variation of perineural catheter (PNC) colonization rates in the literature. The impact of skin disinfection on PNC colonization and inflammation is not clear. The objective of this prospective, randomized clinical study was to investigate the influence of alcoholic skin disinfection before PNC removal on the detection of bacteria on PNC. METHODS: Two hundred patients receiving a PNC for orthopedic surgery were randomized to receive (with-group) or not (without-group) a skin disinfection with a sprayed alcoholic solution before removal of the PNC. Bacterial colonization and contamination of the PNC and clinical signs of inflammation and infection of the PNC insertion site were evaluated. Skin disinfection with a sprayed alcoholic solution and sterile removal of the distal and subcutaneous part of the PNC was performed after 72 hours or earlier if signs of infection occurred with semiquantitative culture and enrichment culture of both parts. RESULTS: Alcoholic skin disinfection before PNC removal significantly reduced bacterial colonization with a reduction from 28% to 14% and from 32% to 17% for the tip and the subcutaneous part of the PNC, respectively (P<0.05). Clinical signs of inflammation at the PNC insertion site were similar (73%) in the two groups. The detection of colonization in 54 (27%) out of 200 PNC did not correlate with clinical signs of inflammation independently of the number of bacteria isolated. Redness was noted in 71% and 68% of patients in the without- and with-alcoholic skin disinfection-group respectively. Local pain on pressure was present in 28% and 19% in the without- and with-group respectively. CONCLUSIONS: Alcoholic skin disinfection before PNC removal reduced the detection of PNC colonisation by 50%. There was no correlation between clinical signs of inflammation and PNC colonization.

We describe the first case of a pregnant woman presenting with an acute inverted takotsubo-like cardiomyopathy caused by a postpartum diagnosed hemorrhagic pheochromocytoma, successfully treated with percutaneous venoarterial extracorporeal membrane oxygenation (va-ECMO). During admission, an emergency cesarean delivery had to be performed. The fetus needed resuscitation for 5 minutes. The mother was successfully resuscitated and treated with percutaneous va-ECMO for 7 days. Despite advances in diagnostic techniques during the past decade, in many cases, pheochromocytoma in pregnancy is still missed. This results in a maternal and fetal mortality rate of up to 30% in both.

The benefit of the post-anaesthesia care unit (PACU) with respect to an early detection of postoperative complications is beyond dispute. From a patient perspective, prevention and optimal management of pain, nausea and vomiting (PONV) are also of utmost importance. The aims of the study were therefore to prospectively measure pain and PONV on arrival to the PACU and before discharge and to determine the relationship of pain and PONV to the length of stay in the PACU.

Background: Histamine is an ubiquitous inflammatory mediator of numerous physiological processes. Histamine and its receptors have been implicated in multiple sclerosis (MS) disease pathogenesis. We prospectively enrolled 36 MS patients and 19 age and gender-matched healthy volunteers for cerebrospinal fluid (CSF) histamine analysis.Findings: CSF histamine levels in MS patient samples were significantly higher (median: 35.6 pg/ml) than in controls (median: 5.5pg/ml; Beta = 0.525, p < 0.001). In addition, histamine increased with age (Pearson's correlation, p < 0.003).Conclusions: Histamine may be an important factor for both the initiation and maintenance of chronic inflammatory diseases of the central nervous system. Our observation encourages a deeper investigation of the role of histamine in MS.

Background and ObjectivesApplication of local anesthetics may lead to nerve damage. Increasing evidence suggests that risk of neurotoxicity is higher in patients with diabetic peripheral neuropathy. In addition, block duration may be prolonged in neuropathy. We sought to investigate neurotoxicity in vitro and block duration in vivo in a genetic animal model of diabetes mellitus type 2.MethodsIn the first experiments, neurons harvested from control Zucker diabetic fatty (ZDF) rats were exposed to acute (24 hours) or chronic (72 hours) hyperglycemia, followed by incubation with lidocaine 40 mM (approximately 1%). In a second experiment, neurons harvested from control ZDF rats, or diabetic ZDF rats, were incubated with lidocaine, with or without SB203580, an inhibitor of the p38 mitogen-activated protein kinase. Finally, we performed sciatic nerve block (lidocaine 2%, 0.2 mL) in control or diabetic ZDF rats and measured motor and nociceptive block duration.ResultsIn vitro, neither acute nor chronic hyperglycemia altered neurotoxic properties of lidocaine. In vitro, incubation of neurons with lidocaine resulted in a slightly decreased survival ratio when neurons were harvested from diabetic (57% ± 19%) as compared with control (64% ± 9%) rats. The addition of SB203580 partly reversed this enhanced neurotoxic effect and raised survival to 71% ± 12% in diabetic neurons and 66% ± 9% in control rats, respectively. In vivo, even though no difference was detected at baseline testing, motor block was significantly prolonged in diabetic as compared with control rats (137 ± 16 vs 86 ± 17 min).ConclusionsIn vitro, local anesthetic neurotoxicity was more pronounced on neurons from diabetic animals, but the survival difference was small. In vivo, subclinical neuropathy leads to substantial prolongation of block duration. We conclude that early diabetic neuropathy increases block duration, whereas the observed increase in toxicity was small.

A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.

Interscalene analgesia is a recognized technique for the management of postoperative pain after major shoulder surgery. The most effective local anesthetic concentration in this setting is still controversial. In this study, we compared the analgesia and side effects of a continuous infusion of ropivacaine 0.2% and 0.3% administered through an interscalene catheter for the first 48 hours after surgery.Eighty consecutive patients scheduled for elective open rotator cuff repair were randomized into 2 groups to receive a continuous infusion of either ropivacaine 0.2% or ropivacaine 0.3% for 48 hours at a rate of 14 mL/h through an interscalene catheter after a preoperative bolus of 40 mL ropivacaine 0.5% in all patients. Pain score (visual analog scale 0-100), intensity of motor block, quality of sleep during the first postoperative night, morphine consumption, side effects, and patient satisfaction were assessed by an anesthesiologist masked to treatment group.Total morphine consumption was significantly reduced in group 0.3% (12 vs 30 mg). Quality of sleep was significantly better in group 0.3% (4% vs 27% of awakening during the first postoperative night). Handgrip strength, visual analog scale scores, and side effects were similar in both groups.The use of ropivacaine 0.3% through an interscalene catheter for the first 48 hours after open rotator cuff repair provided a significant reduction of morphine consumption and a better sleep quality for the first postoperative night without increasing the intensity of motor block or side effects.

Hypothesis: Subacromial impingement is one of the underlying factors of rotator cuff pathologies and is linked to increased subacromial pressures. Because humans spend about one-third of their life sleeping, we hypothesized that distinct shoulder positions while sleeping may considerably influence nocturnal subacromial pressures Consequently. atrophy and rupture can affect tendon healing after rotator cuff repair, thus potentially discrediting the outcome of surgeryMaterials and methods: We determined the subacromial pressures acting on the rotator cuff in the 4 most common sleep positions and related these pressures to the mean arterial blood pressure and physical examination findings in 20 healthy volunteersResults: Subacromial pressures were significantly lower in participants sleeping preferably in a supine position than in participants sleeping in side or prone positions (P<.005).Discussion: As tendon perfusion is crucial for tendon-to-bone healing during postoperative physical therapy after rotator cuff reconstruction and for prevention of additional damage to healthy or already torn cuffs, potential clinical relevance may emerge from the present study.Conclusion: Distinct shoulder positions considerably influence subacromial pressures. Our findings may be considered in physiotherapeutic concepts after rotator cuff surgery. Level of evidence: Basic Science Study of Normal Volunteers. (C) 2010 Journal of Shoulder and Elbow Surgery Board of Trustees

BACKGROUND: Interscalene analgesia is a recognized technique for the management of postoperative pain after major shoulder surgery. The most effective local anesthetic concentration in this setting is still controversial. In this study, we compared the analgesia and side effects of a continuous infusion of ropivacaine 0.2% and 0.3% administered through an interscalene catheter for the first 48 hours after surgery.METHODS: Eighty consecutive patients scheduled for elective open rotator cuff repair were randomized into 2 groups to receive a continuous infusion of either ropivacaine 0.2% or ropivacaine 0.3% for 48 hours at a rate of 14 mL/h through an interscalene catheter after a preoperative bolus of 40 mL ropivacaine 0.5% in all patients. Pain score (visual analog scale 0-100), intensity of motor block, quality of sleep during the first postoperative night, morphine consumption, side effects, and patient satisfaction were assessed by an anesthesiologist masked to treatment group.RESULTS: Total morphine consumption was significantly reduced in group 0.3% (12 vs 30 mg). Quality of sleep was significantly better in group 0.3% (4% vs 27% of awakening during the first postoperative night). Handgrip strength, visual analog scale scores, and side effects were similar in both groups.CONCLUSION: The use of ropivacaine 0.3% through an interscalene catheter for the first 48 hours after open rotator cuff repair provided a significant reduction of morphine consumption and a better sleep quality for the first postoperative night without increasing the intensity of motor block or side effects.

To the Editor: I read with interest the study by Dolan et al. They report an increase of sensory loss in the medial aspect of the thigh after a fascia iliaca block using ultrasonography. These results are interesting but suffer from limitations. Their technique using a block needle is not the same as that described by Capdevila et al, who used a Tuohy needle to perform the block and reported a higher success rate on the femoral nerve. Previously, I used similar shortbevel block needles as described by Dolan et al, but soon abandoned them because of poor tactile sensations and low success rate. Inadequate needles could be responsible, at least in part, for block failure due to overly superficial or intramuscular (iliopsoas muscle) injection. The results of the study of Dolan et al might be different if they used a Tuohy needle, which could permit better tactile sensations, control of distance from the skin, and sensation of resistance to injection. Nevertheless, even when injection is performed with a Tuohy needle, diffusion of the local anesthetic is unpredictable and uncontrollable. In conclusion, although it is understandable that block success is higher with the use of ultrasonography when the needle is not optimal, it remains unproven whether using another needle would be better.

Purpose of review The control of pain after scoliosis surgery is a real challenge for the anesthesiologist. The first reason is that major spine surgery for correction of scoliosis deformation causes severe postoperative pain, and second that patients undergoing these operations are most often children or adolescents who are known to suffer from increased pain sensation compared with adults. Recent findings A multimodal postoperative pain therapy is a well established procedure to control the pain after scoliosis surgery. Recently, prospective, well controlled studies have emphasized the key role of regional techniques in this context. Epidural analgesia has shown significant benefits regarding pain score, bowel recovery and patients' satisfaction. However, different modes of epidural analgesia application have been performed. Several issues including local anaesthetic concentration and infusion rate, duration of application and number of catheters placed will be discussed. The safety concerns associated with this type of analgesia will also be emphasized. Summary Significant improvements have been made in the control of postoperative pain after correction of scoliosis deformation in recent years. The introduction of epidural analgesia has cleared the way for better analgesic techniques in this surgical context. Properly performed and assessed, the addition of epidural analgesia after scoliosis surgery is a safe and effective form of analgesia and the benefits far outweigh the risks.

OBJECTIVE:The pharmacokinetics of ropivacaine 0.2% were evaluated during a 48-hour continuous extrapleural infusion with 2 different infusion rates in patients undergoing cardiovascular surgery. The hypotheses that no toxic plasma concentrations of ropivacaine would be reached and that proportionality exists among plasma concentrations and dosage used were tested.DESIGN:A prospective, randomized, nonblinded study.SETTING:The investigation was performed as a single-center study in the Division of Cardiovascular Anesthesia, University Hospital of Zurich, in Switzerland.PARTICIPANTS:Seventeen consenting adults scheduled for elective cardiovascular surgery, with or without extracorporeal bypass, via the lateral thoracotomy approach were enrolled.INTERVENTIONS:For postoperative pain relief, patients were randomly assigned to receive continuous extrapleural infusion of ropivacaine 0.2% at a rate of either 6 or 9 mL/h over 48 hours.MEASUREMENTS AND MAIN RESULTS:Plasma concentrations of ropivacaine reached toxic levels (>2.2 mg/L) in 25% of cases. No proportionality of plasma concentrations of ropivacaine existed when the 2 dosing regimens were compared.CONCLUSIONS:Plasma concentrations of ropivacaine, administered at the given dose and rates during continuous extrapleural infusion, are unpredictable and may reach toxic levels in patients undergoing major cardiothoracic surgery.

Although there are relatively few published reports of anesthesia-related nerve injury associated with the use of peripheral nerve blocks (PNBs), it is likely that the commonly cited incidence (0.4%) of severe injury is underestimated because of underreporting.1–3 The less frequent clinical application of lower-extremity nerve blocks may be the main reason that there are even fewer reports of anesthesia-related nerve injury associated with lower-extremity PNBs as compared with upper-extremity PNBs. Although neurologic complications after PNBs can be related to a variety of factors related to the block (e.g., needle trauma, intraneuronal injection, neuronal ischemia, and toxicity of local anesthetics), a search for other common causes should also include surgical factors (e.g., positioning, stretching, retractor injury, ischemia, and hematoma formation). In some instances, the neurologic injury may be a result of a combination of these factors.

The purpose of this study is to determine if real time ultrasound guidance improves the success rate of axillary brachial plexus blockade.