Benefits of PIEB+PCEA over CEI previously demonstrated in small randomised controlled trials were reproducible on a larger scale in a clinical setting.

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SummaryWe describe the management of a patient impaled through the lower submandibular area by the top spike of some iron railings which immobilised his jaw and blocked access to the trachea. The Fire Brigade used specialised equipment to cut out a section of the railings so that the patient could be transported to hospital. Awakejbreoptic intubation was used to gain access to the patient's airway before induction of anaesthesia. Key wordsIntubation, tracheal; awake fibreoptic. Complications; trauma.Traumatic penetrating injuries in which a patient becomes impaled on a fixed object are uncommon. Rescue of such patients may require the use of special cutting equipment, operated by members of the Fire Brigade. In penetrating injuries of the neck, the presence of the object may hinder subsequent induction of anaesthesia, by obstructing access to the airway. We describe a patient whose jaw was impaled on the top spike of some iron railings, the position of which prevented the use of a face mask or a laryngeal mask airway, and precluded performance of a tracheostomy.Case history A 22-year-old man was looking over an iron railing fence in a churchyard when he slipped and fell, and impaled himself on a large spike at the top of the fence. The Helicopter Emergency Medical Service and the London Fire Brigade were called to the scene. Oxygen was administered and the vital signs were monitored. The emergency service medical officer gave ketamine 150 mg and midazolam 5 mg whilst the railings were cut off by the fire brigade, away from the entry site. The patient was then transported to hospital with a large portion of railing still attached.On arrival he was conscious, but drowsy as a result of the recent sedation. He was impaled through the lower right submandibular area (Fig. 1). His neck and jaw were immobilised due to the size and shape of the residual iron railing which covered the anterior part of the neck, obscuring surgical access to the trachea. There was some swelling around the entry site but no bleeding, either externally or within the oral cavity, and the airway was not obstructed. He was normotensive with a heart rate of 90 beat.min-' and his arterial oxygen saturation measured by pulse oximetry was greater than 96%. A skull X ray (Fig. 2) showed that the tip of the spike had not pierced the cranial cavity. There were no other injuries.The surgical team considered that surgical exploration of the wound followed by removal of the spike was indicated. We decided to perform an awake fibreoptic intubation before inducing general anaesthesia and proceeding with surgery. Vascular access was secured with two 14-G cannulae. The patient was, by now, more alert than on admission, since the effect of sedation had worn off. We decided not to give any further sedation because he was cooperative, reasonably calm and not in pain. Lignocaine 10% spray was applied to the oropharynx and anterior nasal passages and cocaine paste 10% (2 ml) was applied with cotton buds to the interior of the nose.

(Br J Anaesth. 2018;121:432–437) Recent studies have shown that programmed intermittent epidural bolus (PIEB) may be more effective at achieving lower rates of motor block, shortened second stage of labor, improved patient satisfaction outcomes, and lower total local anesthetic dose for labor pain than standard techniques like continuous epidural infusion (CEI) or patient-controlled epidural analgesia (PCEA). Therefore, the authors of this prospective, controlled, before-and-after cohort study evaluated the effectiveness of PIEB+PCEA versus CEI for labor analgesia in a tertiary referral hospital in Sydney, New South Wales, Australia.

BackgroundLocal anesthetic wound infusion catheters are increasingly used postmidline laparotomy to reduce pain and opioid use, however there is little evidence to support any particular infusion regime.MethodsA retrospective cohort study was undertaken of patients after midline laparotomy who had bilateral local anesthetic wound infusion catheters surgically placed. Patients were recruited into 3 cohorts: ropivacaine 0.2% 5–8 mL/hour continuous wound infusion, 10 mL programmed intermittent bolus 2 hourly, 20 mL programmed intermittent bolus 4 hourly. The primary outcome was the maximum daily Numerical Rating Pain Score with movement (dynamic pain score) recorded during first 96 hours postprocedure. Secondary outcomes included the maximum daily resting pain score and opioid utilization.ResultsIn three cohorts of 70 patients (n=210), the maximum daily dynamic pain score in the intermittent bolus 2-hourly and 4-hourly cohorts was lower when compared with the continuous infusion group over the first 4 postoperative days. The mean difference in maximum daily pain score with respect to the continuous infusion regime was 0.8 (95% CI 0.2 to 1.4) for the intermittent bolus 2-hourly group and 0.6 (95% CI 0.0 to 1.2) for the 4-hourly group. Generalized estimating equation modeling indicates the reduction in dynamic pain score is greatest with the intermittent bolus 2-hourly regime over the first 72 hours postprocedure. The 2-hourly intermittent bolus regime was also associated with lower opioid utilization and local anesthetic exposure.ConclusionsIntermittent wound infusion catheter infusion regimes were associated with lower maximum daily dynamic pain scores, although the magnitude of this change may be of limited clinical significance.