Background and Aims: Above knee amputation (AKA) is associated with considerable mortality and morbidity. There is paucity of data describing the use of peripheral nerve blocks (PNB) as the sole anesthetic technique in high-risk patients undergoing AKA. Our objectives were to evaluate the use of PNB as sole anesthetic technique in the above-mentioned population and its clinical outcomes. Material and Methods: This was a retrospective descriptive study conducted in a tertiary hospital. For this study, patients with American Society of Anesthesiologist [ASA] IV physical status underwent AKA using PNB between January 2010 and December 2016, were identified. The primary outcome measured was the success of the operation. The secondary outcomes were block details, intraoperative hemodynamics, usage of sedation and analgesia, patients' comorbidities, mortality rates at 30 days and one year. Results: Out of fifty-seven patients, the median age (interquartile range) was 74 (57 – 81) years and 60% were males. The results show 91% successfully underwent surgery with PNB (95% CI 81% to 96%). 95% required intraoperative sedation and analgesia. 67% received combined femoral, obturator and sciatic nerve blocks, in which nine cases had an additional lateral femoral cutaneous nerve block. Interestingly, 33% only received combined femoral and sciatic nerve blocks, and they required higher sedation analgesia (p = 0.013). The 30-day and one-year mortality were 12.3% & 47.4%. Majority had stable hemodynamics during the surgery. Conclusion: This study shows that PNB is a viable option for reliable anesthesia for AKA in high-risk patients. Combined FOS nerve block would reduce the dose for sedation–analgesia during the operation.

Objective. Clavicle fractures are common injuries potentially associated with significant perioperative pain. However, this region’s complex sensory innervation poses a challenge for regional anesthetic or analgesic (RA) techniques. We conducted this scoping review to summarize the current literature, particularly with regards to motor-sparing techniques. Methods. A scoping review was carried out in accordance with the Joanna Briggs Institute’s framework. All articles describing the use of RA for clavicle fractures or surgery were included. PubMed^®, Ovid MEDLINE^®, EMBASE^®, Scopus^®, CINAHL^®, and the Cochrane database were searched without language restrictions. Results. Database searches identified 845 articles, 44 of which were included in this review, with a combined patient total of 3161. We included all peer-reviewed publications containing clinical data and summarized the findings. Conclusions. Current evidence of RA techniques in clavicle surgery is heterogeneous, with different approaches used to overcome the overlapping sensory innervation. The literature largely comprises case reports/series, with several randomized controlled trials. Intermediate cervical plexus block is the regional technique of choice for clavicle surgery, and can provide reliable surgical anesthesia when combined with an interscalene block. Cervical plexus block can provide motor-sparing analgesia following clavicle surgery. Promising alternatives include the clavipectoral block, which is a novel motor-sparing regional technique. Further studies are required to determine the efficacy and safety of various techniques.

The brachial plexus at the infraclavicular level runs deeper compared to its course proximally, giving rise to impaired needle visualisation due to the steep angle of needle insertion with the current ultrasound-guided approach. A new posterior parasagittal in-plane ultrasound-guided infraclavicular approach was introduced to improve needle visibility. However no further follow up study was done. We performed a case series and a cadaveric dissection to assess its feasibility in a single centre, University of Malaya Medical Centre, Kuala Lumpur, Malaysia from November 2012 to October 2013. After obtaining approval from the Medical Ethics Committee, University Malaya Medical Centre, 18 patients undergoing upper limb surgery were prospectively recruited. A cadaveric dissection was also performed. The endpoints of this study were the success rate, performance time, total anaesthesia-related time, quality of anaesthesia and any incidence of complications. All patients had 100 % success rate. The imaging time, needling time and performance time were comparable with previously published study. There were no adverse events encountered in this study. The cadaveric dissection revealed a complete spread of methylene blue dye over the brachial plexus. This study demonstrated that the posterior parasagittal in-plane approach is a feasible and reliable technique with high success rate. Future studies shall compare this technique with the conventional lateral parasagittal in-plane approach. ClinicalTrials.gov NCT02312453 . Registered on 8 December 2014.

Introduction: We report the use of a newly described regional technique, ultrasound-guided costoclavicular approach infraclavicular brachial plexus block for surgical anesthesia in two high-risk patients undergoing 2^nd stage transposition of basilic vein fistula. Methods: Both patients had features of difficult airway, American Society of Anesthesiologists (ASA) physical status class III and central venous occlusive disease. The common approach, i.e., ultrasound-guided supraclavicular brachial plexus block was technically difficult with inherent risk of vascular puncture due to dilated venous collaterals at the supraclavicular area possibly compromising block quality. The risk of general anesthesia (GA) was significant as patients were morbidly obese with possible risk of obstructive sleep apnea postoperatively. As an alternative, we performed the ultrasound-guided costoclavicular approach infraclavicular brachial plexus block with 20 mL local anesthetic (LA) ropivacaine 0.5% delivered at the identified costoclavicular space using in-plane needling technique. Another 10 mL of LA was infiltrated along the subcutaneous fascia of the proximal medial aspect of arm. Results: Both surgeries of >2 hours’ duration were successful, without the need of further local infiltration at surgical site or conversion to GA. Conclusions: Ultrasound-guided costoclavicular approach can be an alternative way of providing effective analgesia and safe anesthesia for vascular access surgery of the upper limb.

The ideal emergency cricothyroidotomy technique remains a topic of ongoing debate. This study aimed to compare the cannula-to-Melker technique with the scalpel-bougie technique and determine whether yearly training in cricothyroidotomy techniques is sufficient for skill retention. We conducted an observational crossover bench study to compare the cannula-to-Melker with the scalpel-bougie technique in a porcine tracheal model. Twenty-eight anesthetists participated. The primary outcome was time taken for device insertion. Secondary outcomes were first-pass success rate, incidence of tracheal trauma, and technique preference. We also compared the data on outcome measures with the data obtained in a similar workshop a year ago. The scalpel-bougie technique was significantly faster than the cannula-to-Melker technique for cricothyroidotomy (median time of 45.2 s vs. 101.3 s; P = 0.001). Both techniques had 100% success rate within two attempts; there were no significant differences in the first-pass success rates and incidence of tracheal wall trauma (P > 0.999 and P = 0.727, respectively) between them. The relative risks of inflicting tracheal wall trauma after a failed cricothyroidotomy attempt were 6.9 (95% CI 1.5-31.1), 2.3 (95% CI 0.3-20.7) and 3.0 (95% CI 0.3-25.9) for the scalpel-bougie, cannula-cricothyroidotomy, and Melker-Seldinger airway, respectively. The insertion time and incidence of tracheal wall trauma were lower when the present data were compared with data from a similar workshop conducted the previous year. This study supports the use of a scalpel-bougie technique for cricothyroidotomy by anesthetists and advocates a yearly training program for skill retention.

Background and Aims: Continuous spinal anaesthesia (CSA) is an underutilised anaesthetic technique. Our objectives were to evaluate the use of CSA in our institution, its efficacy, ease to use and safety. Methods: This was a retrospective analysis conducted in a tertiary centre. Records of all patients who underwent surgery and received CSA between December 2008 and July 2017 were reviewed. Their demographic profiles, type and duration of surgery were analysed. The outcomes measured were the success of CSA, technical evaluation and difficulties encountered, intraoperative haemodynamics, usage of vasopressors and any reported complications. Statistical analysis was done using Chi-square test. Results: Three hundred and eighteen patients (94%) successfully underwent surgery using CSA. Twenty cases (6%) had failed CSA, of which five of them had CSA insertion failure, while the rest failed to complete the operation under CSA, thus requiring conversion to general anaesthesia. Patients who have had an initial intrathecal local anaesthetic (LA) volume ≥1.5 ml had higher odds (odds ratio (OR) 2.78; 95% confidence interval [CI], 1.70–4.57) of developing hypotension compared to those who had <1.5 ml (P < 0.001). There were no reported post-dural puncture headache, neurological sequelae or infection. Conclusion: CSA is a useful anaesthetic technique with low failure rate. The key to achieving haemodynamic stability is by giving a small initial bolus, then titrating the block up to required height using aliquots of 0.5 ml of intrathecal LA through the catheter.