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Early tracheal extubation has become common after cardiac surgery. Anesthetic techniques designed to achieve this goal can make immediate postoperative analgesia challenging. We conducted this randomized, placebo-controlled, double-blind study to investigate the effect of a parasternal block on postoperative analgesia, respiratory function, and extubation times. We enrolled 20 patients having cardiac surgery via median sternotomy; 17 patients completed the study. A de-sflurane-based, small-dose opioid anesthetic was used. Before sternal wire placement, the surgeons performed the parasternal block and local anesthetic infiltration of sternotomy and tube sites with either 54 mL of saline placebo or 54 mL of 0.25% levobupivacaine with 1:400,000 epinephrine. Effects on pain and respiratory function were studied over 24 h. Patients in the levobupivacaine group used significantly less morphine in the first 4 h after surgery (20.8 +/- 6.2 mg versus 33.2 +/- 10.9 mg in the placebo group; P=0.013); they also had better oxygenation at the time of extubation. Four of nine in the placebo group needed rescue pain medication, versus none of eight in the levobupivacaine group (P=0.08). Peak serum levobupivacaine concentrations were below potentially toxic levels in all patients (0.64 +/- 0.43 microg/mL; range, 0.24-1.64 microg/mL). Parasternal block and local anesthetic infiltration of the sternotomy wound and mediastinal tube sites with levobupivacaine can be a useful analgesic adjunct for patients who are expected to undergo early tracheal extubation after cardiac surgery.

Summary The 2001 Report of the National Confidential Enquiry into Perioperative Deaths recommended that an echocardiogram should be performed on patients with aortic stenosis prior to anaesthesia. In this study we present the patient details, management and outcome of the 272 hip fracture patients with a previously undiagnosed murmur and echocardiographically proven aortic stenosis admitted from 2001–2005 in our hospital. The patients with aortic stenosis were significantly older, and had significantly lower Abbreviated Mental Test Scores, than the control group of 3698 hip fracture patients without aortic stenosis. There were significant trends toward general anaesthesia over spinal anaesthesia, and use of invasive monitoring of blood pressure, as the severity of the aortic stenosis increased. There were no significant trends towards higher 30‐day or 1‐year mortality rates as the severity of the aortic stenosis increased. Resources for rapid pre‐operative echocardiograms should be made available for hip fracture patients as the results have significant implications for their subsequent anaesthetic management.

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