Ultrasound-Guided Regional Anesthesia Under Sedation for Radical Mastectomy in an SAS Patient: A Case Report

Radical mastectomy is commonly performed under general anesthesia, and regional block is often used as assisted or postoperative analgesia. We herein report a case of successful radical mastectomy with severe aortic stenosis (SAS) by using ultrasound-guided regional anesthesia under sedation. A 66-year-old female with an American Society of Anesthesiology physical status IV; limited functional capacity with <4 metabolic equivalents; a lump (10 cm × 8 cm) in the right breast with skin breakage and infection; and a history of hypertension, diabetes, atrial fibrillation, and SAS, underwent lump-resection and rapid pathological examination by biopsy. Considering a high-risk of significant mortality, we used ultrasound-guided regional block to avoid general anesthesia. We performed the right thoracic paravertebral nerve block (TPVB), subclavicular brachial plexus block, and pectoralis plane block (PECS 1). Patient tolerated the procedure well with no significant hemodynamic changes. Nevertheless, when the axillary lymph nodes were wiped, discharge was observed from the patient’s upper limbs. We inserted the laryngeal mask airway combined with low-dose sevoflurane inhalation sedation. The operation was successfully completed, and the patient was revived with steady hemodynamics and good prognosis. In the present case, radical mastectomy with SAS was performed successfully using ultrasound-guided regional anesthesia under sevoflurane sedation. Despite some potential limitations, this case report can serve as a reference for other anesthetists.

Local and Regional Blocks for Complex Facial Wound Repair

The location, severity, and associated injuries of the head and neck trauma dictate the type and treatment location needed for that particular patient. An in-depth knowledge of local and regional block options is vital to the proper management of facial wounds at the bedside, decreasing need for general anesthesia, anesthesia-related complication, length of hospital stay, and overall hospital costs. This article will discuss local and regional block options for the upper-face, midface, and lower face including dentition; complications of local and regional blocks and how to prevent them; and recent advances in local anesthesia. In addition, conscious sedation as an adjunct to local/regional blocks in children or patients with special needs will be discussed.

A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study

Background Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively. Methods Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain. Results From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing. Conclusions The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.

Engaging Parents in Analgesia Selection and Racial/Ethnic Differences in Analgesia Given to Pediatric Patients Undergoing Urologic Surgery

Background: Family-centered care aims to consider family preferences and values in care delivery. Our study examines parent decisions regarding anesthesia type (caudal regional block or local anesthesia) among a diverse sample of children undergoing urologic surgeries. Differences in anesthesia type were examined by known predictors of health disparities, including child race/ethnicity, parental English proficiency, and a proxy for household income. Methods: A retrospective review of 4739 patients (including 25.4% non-Latino/a White, 8.7% non- Latino/a Asians, 7.3% non-Latino/a Black, 23.1% Latino/a, and 35.4% others) undergoing urologic surgeries from 2016 to 2020 using univariate and logistic regression analyses. Results: 62.1% of Latino/a parents and 60.8% of non-Latino/a Black parents did not agree to a regional block. 65.1% of Spanish-speaking parents with limited English Proficiency did not agree to a regional block. Of parents from households below poverty lines, 61.7% did not agree to a caudal regional block. In regression analysis, Latino/a and non- Latino/a Black youth were less likely to receive caudal regional block than non- Latino/a White patients. Conclusions: We found disparities in the use of pediatric pain management techniques. Understanding mechanisms underlying Latino/a and non- Latino/a Black parental preferences may help providers reduce these disparities.

The impact of COVID-19 on trauma and orthopaedic patients requiring surgery during the peak of the pandemic

Aims COVID-19 represents one of the greatest global healthcare challenges in a generation. Orthopaedic departments within the UK have shifted care to manage trauma in ways that minimize exposure to COVID-19. As the incidence of COVID-19 decreases, we explore the impact and risk factors of COVID-19 on patient outcomes within our department. Methods We retrospectively included all patients who underwent a trauma or urgent orthopaedic procedure from 23 March to 23 April 2020. Electronic records were reviewed for COVID-19 swab results and mortality, and patients were screened by telephone a minimum 14 days postoperatively for symptoms of COVID-19. Results A total of 214 patients had orthopaedic surgical procedures, with 166 included for analysis. Patients undergoing procedures under general or spinal anaesthesia had a higher risk of contracting perioperative COVID-19 compared to regional/local anaesthesia (p = 0.0058 and p = 0.0007, respectively). In all, 15 patients (9%) had a perioperative diagnosis of COVID-19, 14 of whom had fragility fractures; six died within 30 days of their procedure (40%, 30-day mortality). For proximal femoral fractures, our 30-day mortality was 18.2%, compared to 7% in 2019. Conclusion Based on our findings, patients undergoing procedures under regional or local anaesthesia have minimal risk of developing COVID-19 perioperatively. Those with multiple comorbidities and fragility fractures have a higher morbidity and mortality if they contract COVID-19 perioperatively; therefore, protective care pathways could go some way to mitigate the risk. Our 30-day mortality of proximal femoral fractures was 18.2% during the COVID-19 pandemic in comparison to the annual national average of 6.1% in 2018 and the University Hospital Coventry average of 7% for the same period in 2019, as reported in the National Hip Fracture Database. Patients undergoing procedures under general or spinal anaesthesia at the peak of the pandemic had a higher risk of contracting perioperative COVID-19 compared to regional block or local anaesthesia. We question whether young patients undergoing day-case procedures under regional block or local anaesthesia with minimal comorbidities require fourteen days self-isolation; instead, we advocate that compliance with personal protective equipment, a negative COVID-19 swab three days prior to surgery, and screening questionnaire may be sufficient. Cite this article: Bone Joint Open 2020;1-9:520–529.