Did ultrasound fulfill the promise of safety in regional anesthesia?

Purpose of review Ultrasound guidance has become the accepted standard of practice for peripheral regional anesthesia. Despite evidence supporting the efficacy of ultrasound-guided regional anesthesia, its impact on patient safety has been less clear. Recent findings Evidence has been consistent that ultrasound guidance reduces the incidence of vascular injury, local anesthetic systemic toxicity, pneumothorax and phrenic nerve block. Within the limited global scope of the epidemiology and etiologic complexity of perioperative (including block-related) peripheral nerve injury, there has not been consistent evidence that ultrasound guidance is associated with a reduced incidence of nerve injury. However, a recently published retrospective cohort study has demonstrated that the incidence of short-term nerve injury was decreased with ultrasound guidance compared with nerve stimulation. Ultrasound has led to development of novel blocks, approaches and refinement of existing ones, which may contribute to patient safety. Summary Ultrasound has revolutionized the way we approach regional anesthesia and contributed to patient safety. It is important to note that patient safety does not hinge on one single technology. Patient safety in regional anesthesia relies on a well trained practitioner to pay meticulous attention to indication, block and patient selection, anatomy, pharmacology, equipment and technique. Correspondence to Michael J. Barrington, Melbourne Medical School, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, VIC 3010, Australia. Tel: +61 3 9288 2211; e-mail: Michael.BARRINGTON@svha.org.au Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Traumatic brain injured patients: primum non nocere

Purpose of review Traumatic brain injury (TBI) remains an unfortunately common disease with potentially devastating consequences for patients and their families. However, it is important to remember that it is a spectrum of disease and thus, a one 'treatment fits all' approach is not appropriate to achieve optimal outcomes. This review aims to inform readers about recent updates in prehospital and neurocritical care management of patients with TBI. Recent findings Prehospital care teams which include a physician may reduce mortality. The commonly held value of SBP more than 90 in TBI is now being challenged. There is increasing evidence that patients do better if managed in specialized neurocritical care or trauma ICU. Repeating computed tomography brain 12 h after initial scan may be of benefit. Elderly patients with TBI appear not to want an operation if it might leave them cognitively impaired. Summary Prehospital and neuro ICU management of TBI patients can significantly improve patient outcome. However, it is important to also consider whether these patients would actually want to be treated particularly in the elderly population. Correspondence to Dr Dhuleep S. Wijayatilake, Department of Anaesthesia and Intensive Care Medicine, Queens Hospital, Rom Valley Way, Romford RM7 0AG, UK. Tel: +44 1708503727; e-mail: sanjay.wijayatilake@nhs.net Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Stratification of neuropathic pain patients: the road to mechanism-based therapy?

Purpose of review It has been demonstrated that within one pain entity, patients may report highly heterogenic sensory signs and symptoms. Although mechanism might differ fundamentally between those patients, yet the treatment recommendations are uniform throughout all phenotypes. Therefore, the introduction of new stratification tools could pave the way to an individualized pain treatment. Recent findings In the past, retrospective stratifications of patients successfully identified responders to certain pharmacological treatments. This indicated predictive validity and reliability of this classification tool in those patient subgroups. Further on, these observations have been confirmed in prospective studies. Summary This review focusses on recent achievements in neuropathic pain and suggests a promising implementation of an individualized pharmacological therapy in the future. Correspondence to Dr Ralf Baron, MD, Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany. Tel: +49 431 500 23911; fax: +49 431 500 23914; e-mail: r.baron@neurologie.uni-kiel.de Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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New blocks for the same old joints

Purpose of review New block techniques are being constantly developed or old techniques modified to improve outcomes after surgery. This review discusses the reasons why new block techniques need to be developed to match the needs of contemporary anesthetic practice. Recent findings New block techniques have been developed for joint surgeries of both upper and lower extremities. New upper extremity blocks focus on decreasing the risk of complications like diaphragmatic paresis and improving the quality of blocks. Techniques for lower extremity surgeries are being performed distally, closer to the joints, to minimize weakness of the extremity. A review of the available evidence for these techniques is undertaken to get an understanding of the indications and limitations of these techniques. Summary Future studies need to be undertaken to further refine these techniques and produce evidence of support for analgesic efficacy, safety, and reliability. Correspondence to Sanjay K. Sinha, MBBS, Department of Anesthesiology, St. Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105, USA. E-mail: sanjaysinha@comcast.net Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Regional anesthesia by nonanesthesiologists

Purpose of review As the evidence supporting the notion that regional anesthesia improves patient outcomes grows, utilization of regional anesthesia techniques has similarly increased. Best care should not be restricted by the background of care providers, however, the evidence replicating benefits of regional anesthesia when it is delivered by nonanesthesiologists is unclear. In this review, the provision of regional anesthesia by nonanesthesiologists is discussed so that readers can come to their own conclusions. Recent findings Regional anesthesia procedures are performed by nonanesthesiology physicians such as emergency physicians, critical care specialists, and surgeons. Patients benefit from the provision of regional anesthesia by these groups, but inconsistencies exist in training, service provision, and collaboration between these specialties and anesthesiologists. Nonphysician anesthesia providers also provide regional anesthesia. There are limited data on outcomes or benefits of this nonphysician-provided service, but consideration of team-based care and alternative models of care based upon geographical need is worthwhile. Summary The provision of regional anesthesia requires the accumulation of a suitable knowledge, skills, and behaviors that can be taught. Whilst it may not be appropriate for all techniques to be performed by all individuals, the possession of these competencies with the appropriate training and quality assurance means that more patients may ultimately benefit from the provision of regional anesthesia services. Correspondence to Amit Pawa, BSc(Hons), MBBS(Hons), FRCA, EDRA, Department of Anaesthesia, Guy's & St Thomas' NHS Foundation Trust, Great Maze Pond, SE1 9RT London, UK. Tel: +44 207 188 0644; fax: +44 207 188 0642; e-mail: amit.pawa@gstt.nhs.uk. Copyright © 2018 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Neuroanesthesiology: building the path to superior clinical care through research and education

No abstract available

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Functional Endoscopic Sinus Surgery of Nasal Polyposis: The Vexing Question of Whether to Resect or Preserve Middle Turbinate

Abstract

Functional endoscopic sinus surgery is the mainstay of surgical management of nasal polyposis since 1975. The decision between the partial resection and preservation of the middle turbinate (MT) has stirred up considerable debate. Partial MTR permits easy access to the affected paranasal sinuses intraoperatively and postoperatively. However, there may be alteration of nasal function, frontal sinusitis and anosmia. Preservation of middle turbinate is precludes these complications, and allows the MT to serve as a vital anatomical landmark for revision surgery. Therefore, our study compared the outcomes of the two approaches to aid surgeons in deciding the best possible approach. Randomized control trial. 31 patients (60 sides of nasal cavity) with nasal polyposis were divided into two groups. Group I consisted of 30 sides of nasal cavity with middle turbinate resection, while group II consisted of 30 sides of nasal cavity without middle turbinate resection. Both the groups were compared postoperatively for 6 months. In group I and group II, 5 sides (16.6%) and 11 sides (36.6%) showed polypoidal changes respectively. 3 sides (10%) in group I and 8 sides (26.6%) in group II showed blockage of maxillary sinus ostia. All the sides in group I had patency of frontal sinus. In group II, 5 sides (16.6%) showed blockage of frontal sinus ostia. The maxillary antrostomy patency in group I and group II were 90% (27) and 73.33% (22) respectively. Assessment of symptomatic improvements for nasal obstruction, hyposmia, headache and rhinorrhoea was done using questionnaires. Symptomatic improvement was higher in group I compared to group II with statistical significance (p = 0.001). Our study demonstrated that partial resection of middle turbinate decreased the chances of recurrence of disease and post-operative complications and resulted in significantly better symptomatic improvements.

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