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Topographic variations of the four main nerves at the axilla were found to be numerous, the most frequent arrangement being seen in less than two-thirds of the patients. Four separate nerves were seen on static ultrasound imaging at this sectional level of the axilla in only 78% of the cases.

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I.V. access was obtained and ECG, pulse oximetry, and continuous invasive arterial pressure monitoring were established. The patient was placed in the right lateral position and commenced on NIV. The insertion of the intrathecal catheter was technically difficult, and the epidural space was located with a 16 G Tuohy and the use of the image intensifier and contrast. A dural tap was achieved at 7 cm and an intrathecal catheter inserted to 11 cm. After incremental titration with 5 ml of levobupivacaine 0.25%, a block to T12 provided conditions suitable for surgery, which was completed without incident.After operation, NIV was continued. An infusion of bupivacaine 0.1% was commenced intrathecally at 1-1.5 ml h 21 , providing excellent analgesia and was continued for the following 4 days. The infusion was titrated to block height of T10-11 which provided good analgesia with no respiratory problems or motor block. The catheter was removed on day 5, following which the patient's analgesia requirement were met with paracetamol and nefopam. The patient was discharged home on day 11.The heterogeneity of ventilator-dependent patients and small number of studies of perioperative care makes the prediction of risk difficult. Patients now focus on psychosocial factors, rather than survival, leading to the concept of prolonged survival and acceptable exposure to risk. In this patient cohort, preoperative assessment and risk stratification is complex. Symptoms such as dyspnoea and orthopnoea are often late findings and physical evaluation is essential to detect accessory muscle recruitment, supine abdominal paradox, and encumbrance of upper or lower airways. 1 A substantial loss of respiratory muscle strength is typically accompanied by little or no change in spirometry or arterial blood gases. 2 Lung function tests can reveal a characteristically low vital capacity, reduced total lung capacity, and preserved residual volume. Transfer factor is normal when adjusted for lung volume.Evaluation of respiratory muscle strength is extremely useful, and has been shown to be sensitive and prognostic. 3 Peak expiratory flow during cough gives an overall evaluation of cough efficiency, values below 160-270 litre min 21 suggesting poor airway clearance. Evaluation of respiratory muscle strength is achieved by measuring maximal inspiratory pressure (PImax) and sniff nasal inspiratory pressure. A maximal expiratory pressure (PEmax) below 45 cm H 2 O may indicate compromised cough efficiency.There are few reports of the use of Bipap in the operating theatre. 4 -7 Our case highlights that using intraoperative NIV can be useful, and avoid the need for general anaesthesia and invasive ventilation.

The GIPM was seen in the majority undergoing ultrasound-guided femoral nerve blockade, even when the lateral part of the femoral nerve was not visualised. Using the lateral segment of GIPM as a target for needle tip location in an in-plane lateral to medial approach of the femoral nerve deserves further investigation.