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FRCPCPurpose: To examine the reliability of low current electrical epidural stimulation to confirm epidural catheter placement. Methods: Forty patients with epidural catheters (I 9G Arrow Flextip plus) already in place for post-operative pain management were studied. An adapter (Arrow-Johans ECG Adapter) was attached to the connector of the epidural catheter. The epidural catheter and adapter were filled with normal saline. The cathode lead of the nerve stimulator was attached to the metal hub of the adapter. Catheter placement was judged to be correct or incorrect, depending upon the presence or absence of truncal or limb movement to I Hz stimulation (I -10 mA). A standard test dose (3 ml lidocaine 1.5% with 1:200,000 epinephrine) was then injected. The efficacy of the epidural morphine was assessed independently. Results: The sensitivity and specificity of the test was 100% and 91.6% compared with the standard test dose. The positive and negative predictive value was 96% and 100%. In predicting the clinical effect of epidural morphine, the sensitivity and specificity was 96. I% and 76.9%. The positive and negative predictive value was 89% and 90%. The correlation of unilateral or bilateral motor response from the test and sensory response from the lidocaine test with sensitivity and specificity was 91.6% and 53.0%. The predictive value for unilateral response was 61% and for bilateral was 88%. Conclusion: This study establishes this test as a simple, objective and reliable technique for confirmation of epidural catheter placement.Objectif: D&erminer la fiabilit~ d'une stimulation p&idurale ~lectrique de faible intensit~ utilis~e pour confirmer la raise en place d'un cath&er p&idural. M&hode : Quarante patients, ~. qui on avait d~j~ install~ un cath&er p&idural (Arrow Flex-tip plus 19G) pour traiter la douleur post op&atoire, ont particip~ ~ I'&ude. Un adaptateur (Arrow-Johans EXG Adapter) a ~t~ fix~ au connecteur du cath&er. Ce cath&er et I'adaptateur ont ~t~ remplis de s&um physiologique. I'~lectrode cathodique du neurostimulateur a ~t~ fix~e ~ la garde m~tallique de I'adaptateur. La mise en place du cath&er &ait jug~e correcte ou incorrecte selon la pr&ence ou I'absence d'un mouvement du tronc ou d'un membre une stimulation de I Hz (I-10 mA). Une dose-test standard (3 ml de lidocaine ~ 1,5 % avec I : 200 000 d'~pin~phrine) a ~t~ inject~e par la suite. Eefficacit~ de la morphine p&idurale a ~t~ &alu~e s~par~ment. R&ultats : La sensibitit~ et la sp&ificit~ du test &aient de 100 % et de 91,6 % en comparaison avec la dosetest standard. Les valeurs de la prediction positive et n~gative ~taient de 96 % et de 100 %. Concemant la pr~-diction de I'effet clinique de la morphine p6ridurale, la sensibilit~ et la sp~cificit~ &aient de 96, 1% et de 76,9 %. Les valeurs de la prediction positive et n~gative &aient de 89 % et 90 %. La corr&tion entre une r~ponse motrice unilat&ale ou bilat&ale au test et une r~ponse sensorielle au test de lidocaine avec sensibilit~ et sp&i-ficit~ &ait de 91,6 % et 53,0 %. La valeur predictiv...

Ultrasound guidance improves block characteristics (particularly performance time and surrogate measures of success) that are often block specific and that may impart an efficiency advantage depending on individual practitioner circumstances. Evidence for UGRA impacting patient safety is currently limited to the demonstration of improvements in the frequency of surrogate events for serious complications.

BackgroundThere is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.MethodsWe conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.ResultsSixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.ConclusionsHarmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

Purpose To determine the effect of adjunctive epidural local anesthetic and opioid infusion on disease recurrence following radical prostatectomy for adenocarcinoma under general anesthesia. Methods This article describes a secondary analysis of subjects undergoing radical prostatectomy who had participated previously in a randomized controlled trial evaluating pain control, blood loss, and the need for perioperative allogeneic blood transfusion. The patients were randomly allocated to receive either general anesthesia alone (control group; n = 50) or combined general/ epidural anesthesia (study group; n = 49). A long-term follow-up chart review was undertaken to determine clinically evident or biochemical (Prostate Specific Antigen [0.2 ng Á mL -1 ) recurrence of prostate cancer. Comparison by group was undertaken using survival analysis.Results Median disease-free survival for the study as a whole was 1644 days, and the longest recorded survival was 3403 days. Biochemical recurrence of prostate cancer was observed in 11/49 study subjects and 17/50 control subjects. There was one death from prostate cancer in each group and a total of five deaths in the study group and six deaths in the control group. The hazard ratio for recurrence in the study group compared with the control group was 1.33 (95% confidence intervals 0.64-2.77; P = 0.44 by log-rank test). Conclusion No difference was observed between the epidural and control groups in disease-free survival at a median follow-up time of 4.5 years. There is a need for large randomized controlled trials to determine the ability of epidural analgesia to alter disease recurrence rates following radical prostatectomy. RésuméObjectif De´terminer l'effet d'une the´rapie adjuvante d'anesthe´sique local pe´ridural et perfusion d'opioı¨des sur la re´currence de la maladie apre`s une prostatectomie radicale pour ade´nocarcinome sous anesthe´sie ge´ne´rale. Méthode Cet article de´crit une analyse secondaire de patients ayant subi une prostatectomie radicale, lesquels avaient pre´ce´demment participe´a`une e´tude randomise´e contrôle´e e´valuant le contrôle de la douleur, les pertes sanguines et le besoin de transfusions sanguines alloge`nes en pe´riode pe´riope´ratoire. Les patients ont e´te´randomise´s a`recevoir soit une anesthe´sie ge´ne´rale seule (groupe te´moin; n = 50) ou une combinaison d'anesthe´sie ge´ne´rale et pe´ridurale (groupe a`l'e´tude; n = 49). Une re´vision des dossiers de suivi a`long terme a e´te´entreprise afin de

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Scientific evidence from the past 5 years has clarified and strengthened our understanding of ultrasound-guided regional anesthesia as a nerve localization tool. High-level evidence supports ultrasound guidance contributing to superior characteristics with selected blocks, although absolute differences with the comparator technique are often relatively small (especially for upper-extremity blocks). The clinical meaningfulness of these differences is likely of variable importance to individual practitioners. The use of ultrasound significantly reduces the risk of local anesthetic systemic toxicity as well as the incidence and intensity of hemidiaphragmatic paresis, but has no significant effect on the incidence of postoperative neurologic symptoms. WHAT'S NEW IN THIS UPDATE?: This evidence-based assessment of ultrasound-guided regional anesthesia reviews findings from our 2010 publication and focuses on new meta-analyses, randomized controlled trials, and large case series published since 2009. New to this exercise is an in-depth analysis of the accuracy and reliability of ultrasound guidance for identifying needle-to-nerve relationships. This version no longer addresses ultrasound for interventional pain medicine procedures, because the growth of that field demands separate consideration. Since our 2010 publication, new information has either supported or strengthened our original conclusions. There is no evidence that ultrasound is inferior to alternative nerve localization methods.

SummaryCurrent methods to assess the airway before tracheal intubation are variable in their ability to predict a difficult airway accurately. We hypothesised that sublingual ultrasound could provide additional information to predict a difficult airway with greater success than current methods. We recruited 110 patients to perform sublingual ultrasound on themselves following brief instruction. Ability to view the hyoid bone on sublingual ultrasound, mouth opening distance, thyromental distance, neck mobility, size of mandible and modified Mallampati classification were recorded and assessed for ability to predict a difficult intubation based on the grade of laryngoscope. Visibility of the hyoid using ultrasound was associated with a laryngoscopic grade of 1-2 (p < 0.0001), and (p < 0.0001) had a positive likelihood ratio of 21.6 and a negative likelihood ratio of 0.28. Each of the other methods had considerably lower positive likelihood ratios and lower sensitivity. Our results suggest that sublingual ultrasound is a potential tool for predicting a difficult airway in addition to conventional methods.