Background The postoperative analgesic potential of periarticular anesthetic infiltration (PAI) after TKA is unclear as are the complications of continuous femoral nerve block on quadriceps function. Questions/purposes We asked (1) whether PAI provides equal or improved postoperative pain control in comparison to a femoral nerve block in patients who have undergone TKA; and (2) if so, whether PAI improves early postoperative quadriceps control and facilitates rehabilitation. Methods We randomized 60 patients to receive either PAI or femoral nerve block. During the first 5 days after TKA, we compared narcotic consumption, pain control, quadriceps function, walking distance, knee ROM, capacity to perform a straight leg raise, and active knee extension. Medication-related side effects, complications, operating room time, and hospitalization duration were compared.

Purpose We investigated the effects of a combination of low-dose fentanyl-midazolam premedication on the speed of inhaled induction with sevoflurane and ProSeal TM laryngeal mask airway (PLMA) insertion conditions. Methods Eighty adult patients undergoing elective surgery were randomized in a double-blind fashion to receive either a normal saline placebo (Group PLAC) or a fentanyl 0.6 lg Á kg -1 and midazolam 9 lg Á kg -1 premedication (Group FM) 5 min before tidal volume sevoflurane 8%/O 2 induction. Anxiety levels, times to loss of eyelash reflex (LER) and PLMA insertion, and cardiorespiratory data were recorded. Results Times to LER (Group PLAC: 66 ± 34 sec vs Group FM: 47 ± 18 sec, P = 0.0027, difference = 19 sec: 95% confidence interval [CI] 7-31 sec) and to PLMA insertion (Group PLAC: 186 ± 80 sec vs Group FM: 119 ± 44 sec, P \ 0.0001, difference = 68 sec: 95% CI 39-97 sec) were shorter following FM. After PLMA insertion, end-tidal sevoflurane concentration (EtSevo) was lower and end-tidal CO 2 (EtCO 2 ) was higher following FM. Respiratory rate (RR) was lower with FM, but there was no difference regarding tidal volume. Adverse events, such as movements and apnea, occurred more often in Group PLAC. Systolic blood pressure (SBP) and heart rate (HR) during induction were both lower with FM. Anxiety level after premedication was lower following FM administration. All participants remembered the face mask being applied in Group PLAC vs 69% in Group FM, P \ 0.0001. Conclusion Administration of a low-dose fentanylmidazolam combination prior to sevoflurane induction decreases time to LER and allows for more rapid and less eventful PLMA insertion. Both SBP and HR were lower when premedication was administered. Patients receiving premedication were less anxious and less likely to remember the face mask. However, premedication was associated with a lower RR and increased EtCO 2 values following PLMA insertion, in spite of lower EtSevo concentrations. (ClinicalTrials.gov ID NCT00723164). RésuméObjectif Nous avons examine´les effets d'une combinaison de fentanyl -midazolam a`faible dose en pre´me´dication sur la vitesse d'une induction par inhalation de se´voflurane et sur les conditions d'insertion du masque larynge´Pro-Seal TM (PLMA). Méthode Quatre-vingts patients adultes subissant une chirurgie non urgente ont e´te´randomise´s en double aveugle a`recevoir soit un placebo de solution sale´e (groupe PLAC) ou une pre´me´dication compose´e de fentanyl 0,6 lgÁkg -1 et midazolam 9 lgÁkg -1 (groupe FM) cinq minutes avant l'induction avec du se´voflurane 8 %/O 2 av olume courant. Les niveaux d'anxie´te´, le temps jusqu'a`la perte du re´flexe ciliaire (PRC) et l'insertion du PLMA ainsi que les donne´es cardiorespiratoires ont e´te´enregistre´es. Résultats Les temps jusqu'a`PRC (groupe PLAC : 66 ± 34 secondes vs groupe FM : 47 ± 18 secondes, P = 0,0027, diffe´rence = 19 secondes : intervalle de confiance [IC] 95 % 7-31 secondes) et jusqu'a`insertion du PLMA (groupe PLAC : 186 ± 80 secondes vs groupe FM : 119 ± 44 s...

INTRODUCTION: Many anaesthesiologist are reluctant to rely on regional anesthesia alone during carotid endarterectomy (CEA). The goal of this prospective double-blind study was to evaluate if some benefits reported with regional anesthesia, namely a more stable operative course and lower analgesic requirements, can be expected from adding a superficial cervical plexus block (SCPB) to a general technique.1 METHODS: After obtaining approbation from the IRB and each participant, 50 patients undergoing CEA under general anesthesia were divided randomly in two groups. Each group received a SCPB either with 20 cc of ropivacaine 0.5%(B) or NaCl 0.9%(C). The anesthesiologist in charge of the case was unaware of the patient's group. Anesthesia was induced with fentanyl 3 mcg/kg, midazolam 100 mcg-kg-1, Propofol 0-1 mg-kg-1 and rocuronium 0.9mg-kg-1. After loss of consciousness, a Proseal laryngeal mask airway (PLMA) was inserted. A PLMA was used in order to reduce hemodynamic variations associated with airway management.2 If the PLMA did not provide a satisfactory airway , the patient was excluded from the study. Anesthesia was maintained with isoflurane (End-tidal:0.4-0.8%) and rocuronium 0.3mg-kg-1. The anesthesiologist in charge was allowed to administer, at his discretion, fentanyl 0.5 mcg-kg-1, esmolol 0.5 mg-kg-1or nitroglycerine 1 mcg-kg-1 to lower heart rate or blood pressure. Phenylephrine 1mcg-kg-1 or ephedrine 100 mcg-kg-1 were used to correct hypotension. Each time one of the vasoactive drugs or fentanyl was administered, it was counted as an intervention. Postoperative analgesic data, and administration of vasoactive drugs and fentanyl dur ing surgery, were recorded. RESULTS: Seven patients (B:4; C:3) were excluded because PLMAs did not provide a satisfactory airway before beginning surgery. Another patient from group B was brought back to the OR because of a neck hematoma, only the data of his first surgery were kept. Demographic data were similar between the two groups. Patients in group B required less fentanyl during surgery (B:107±92 vs C:191±123 mcg, p=0.015).They also needed fewer pharmacological interventions aimed at correcting hemodynamics variations (B:5.4±3.9 vs C:8.5±5.7, p=0.048). These interventions mostly aimed at decreasing blood pressure or heart rate. Morphine requirements in the PACU [B:0(0-8) vs C:2(0-14 mg), NS] and codeine requirements on the surgical ward during the first 24 hours [B:30(0-120) vs C:30(0-120), NS] were low and did not differ between groups, but the time to first analgesic request was longer in group B(figure). DISCUSSION: Adding a SCPB during CEA under general anesthesia is associated with easier hemodynamic control during surgery and a longer postoperative interval before first analgesic request. Also, since the PLMA was deemed inadequate in 14% of the participants, its role in CEA may need to be reassess. REFERENCES:

INTRODUCTION: Small repeated doses of morphine every 5 min are recommended to relieve pain in the post anesthetic care unit (PACU)1. However, time to peak effect of morphine is long (86 min)2. A morphine-fentanyl mixture is expected to combine the rapid onset of fentanyl (time to peak effect = 6.6 min)3 with the sustained duration of morphine. This study was designed to determine if a morphine-fentanyl mixture relieves pain faster than morphine alone in the PACU. METHODS: In a prospective, randomized, double blind study, approved by the Research Ethics Committee of our hospital, 80 patients undergoing elective surgery under general anesthesia received equipotent doses of opioids (either morphine 3 mg or morphine 1.5 mg plus fentanyl 15 µg) intravenously every 5 min for up to 1 hr in the PACU. Time to pain verbal numerical scale (VNS) score ≤ 3, number of doses needed and side effects were recorded. Morphine consumption, VNS score and side effects were noted 1, 4 and 24 hr postoperatively. Data were expressed as median and quartile. A P value < 0.05 was considered statistically significant. RESULTS: Sixty-eight patients completed the study. Both groups were comparable with respect to demographic data, type of surgical procedure, duration of surgery and intraoperative opioids. Both groups had similar VNS scores upon arrival in the PACU and during titration, with no difference in time, number of doses and total opioid dose to obtain VNS ≤ 3 (Table). However, episodes of bradypnea (respiratory rate (RR) < 8 min-1) were significantly more frequent with morphine-fentanyl, but arterial oxygen desaturation (SatO2 < 93%) did not occur. Incidence of nausea, pruritus and sedation was similar in both groups. Cumulative morphine consumption and VNS after 1, 4 and 24 hr were similar in both groups.