Ultrasound Guided lateral Infra-trochanteric Sciatic Nerve Blockade for Proximal Tibial Surgery: A Novel Technique

Sciatic nerve blockade (SNB) can be performed at several point along its anatomic course. Proximal SNB techniques described include the classic Labat, sacral (Mansur), infragluteal (Raj), and anterior approches Distal SNB techniques include the mid-femoral, posterior and lateral popliteal and mid-tibial approaches. The anatomic region of the lower extramity to be anesthetixzed will determine the appropriate SNB technique to use for the operative procedure.

Abstract Title: Ultrasound Guided Trans-sartorial Continuous Saphenous Nerve Blockade - A technique for Relief of Postoperative Medial Incisional Foot and Ankle Pain

The saphenous nerve (SaN) innervates the region from the upper medial thigh to the medial aspect of the foot and ankle. A femoral nerve block (FNB) is effective for blockade of the SaN but this causes quadriceps weekness and reduced patient mobility that is unsuitable in an ambulatory surgical setting.

A Rare Complication of Tracheal Intubation: Tongue Perforation

Aim. To describe the subsequent treatment of airway trauma sustained during laryngoscopy and endotracheal intubation. Methods. A rare injury occurring during laryngoscopy and endotracheal intubation that resulted in perforation of the tongue by an endotracheal tube and the subsequent management of this unusual complication are discussed. A 65-year-old female with intraparenchymal brain hemorrhage with rapidly progressive neurologic deterioration had the airway secured prior to arrival at the referral institution. The endotracheal tube (ETT) was noted to have pierced through the base of the tongue and entered the trachea, and the patient underwent operative laryngoscopy to inspect the injury and the ETT was replaced by tracheostomy. Results. Laryngoscopy demonstrated the ETT to perforate the base of the tongue. The airway was secured with tracheostomy and the ETT was removed. Conclusions. A wide variety of complications resulting from direct and video-assisted laryngoscopy and tracheal intubation have been reported. Direct perforation of the tongue with an ETT and ability to ventilate and oxygenate subsequently is a rare injury.

Propofol infusion syndrome in a super morbidly obese patient (BMI = 75)

Propofol infusion syndrome (PRIS) is a rare but often fatal complication as a result of large doses of propofol infusion (4–5 mg/kg/hr) for a prolonged period (>48 h). It has been reported in both children and adults. Besides large doses of propofol infusion, the risk factors include young age, acute neurological injury, low carbohydrate and high fat intake, exogenous administration of corticosteroid and catecholamine, critical illness, and inborn errors of mitochondrial fatty acid oxidation. PRIS manifestation include presence of metabolic acidosis with a base deficit of more than 10 mmol/l at least on one occasion, rhabdomyolysis or myoglobinuria, acute renal failure, sudden onset of bradycardia resistant to treatment, myocardial failure, and lipemic plasma. The pathophysiology of PRIS may be either direct mitochondrial respiratory chain inhibition or impaired mitochondrial fatty acid metabolism mediated by propofol. We report a case of supermorbidly obese patient who received propofol infusion by total body weight instead of actual body weight and developed PRIS.

Regional Anesthesia in TraumaMedicine

Regional anesthesia is an established method to provide analgesia for patients in the operating room and during the postoperative phase. While regional anesthesia offers unique advantages, as shown by the recent military experience, it is not commonly utilized in the prehospital or emergency department setting. Most often, regional anesthesia techniques for traumatized patients are first utilized in the operating room for procedural anesthesia or for postoperative pain control. While infiltration or single nerve block procedures are often used by surgeons or emergency medicine physicians in the preoperative phase, more advanced techniques such as plexus block procedures or regional catheter placements are more commonly performed by anesthesiologists for surgery or postoperative pain control. These regional techniques offer advantages over intravenous anesthesia, not just in the perioperative phase but also in the acute phase of traumatized patients and during the initial transport of injured patients. Anesthesiologists have extensive experience with regional techniques and are able to introduce regional anesthesia into settings outside the operating room and in the early treatment phases of trauma patients.

Clinical and functional outcomes of acute lower extremity compartment syndrome at a Major Trauma Hospital

Background: Acute lower extremity compartment syndrome (CS) is a condition that untreated causes irreversible nerve and muscle ischemia. Treatment by decompression fasciotomy without delay prevents permanent disability. The use of intracompartmental pressure (iCP) measurement in uncertain situations aids in diagnosis of severe leg pain. As an infrequent complication of lower extremity trauma, consequences of CS include chronic pain, nerve injury, and contractures. The purpose of this study was to observe the clinical and functional outcomes for patients with lower extremity CS after fasciotomy. Methods: Retrospective chart analysis for patients with a discharge diagnosis of CS was performed. Physical demographics, employment status, activity at time of injury, injury severity score, fracture types, pain scores, hours to fasciotomy, iCP, serum creatine kinase levels, wound treatment regimen, length of hospital stay, and discharge facility were collected. Lower extremity neurologic examination, pain scores, orthopedic complications, and employment status at 30 days and 12 months after discharge were noted. Results: One hundred twenty‑four patients were enrolled in this study. One hundred and eight patients were assessed at 12 months. Eighty‑one percent were male. Motorized vehicles caused 51% of injuries in males. Forty‑one percent of injuries were tibia fractures. Acute kidney injury occurred in 2.4%. Mean peak serum creatine kinase levels were 58,600 units/ml. Gauze dressing was used in 78.9% of nonfracture patients and negative pressure wound vacuum therapy in 78.2% of fracture patients. About 21.6% of patients with CS had prior surgery. Nearly 12.9% of patients required leg amputation. Around 81.8% of amputees were male. Sixty‑seven percent of amputees had associated vascular injuries. Foot numbness occurred in 20.5% of patients and drop foot palsy in 18.2%. Osteomyelitis developed in 10.2% of patients and fracture nonunion in 6.8%. About 14.7% of patients underwent further orthopedic surgery. At long‑term follow‑up, 10.2% of patients reported moderate lower extremity pain and 69.2% had returned to work. Conclusion: Escalation in leg pain and changes in sensation are the cardinal signs for CS rather than reliance on assessing for firm compartments and pressures. The severity of nerve injury worsens with the delay in performing fasciotomy. Standardized diagnostic protocols and wound treatment strategies will result in improved outcomes from this complication.