Background and objectives A single injection interscalene block (ISB) is a common regional analgesic technique in patients undergoing arthroscopic shoulder surgery. However, rebound pain after ISB resolution may reduce its overall benefit. Our primary aim was to assess whether perineural dexamethasone reduces the intensity and incidence of rebound pain in patients undergoing arthroscopic shoulder surgery under general anesthesia combined with a preoperative single injection ISB. Methods The patients were randomly assigned to receive single injection ISB using either 0.5% ropivacaine (control) or 0.5% ropivacaine containing 5 mg of dexamethasone. The primary outcomes were the pain score difference before and after ISB resolution, and the incidence of rebound pain. The secondary outcomes were the onset and duration of rebound pain, the presence of sleep disturbances due to postoperative pain, the first time when an analgesic was requested, and pain scores at various predefined time points. Results Pain increase following ISB resolution was lower in the dexamethasone group compared with the control group (4.5±2.4 and 6.9±2.2, respectively, p<0.001). The incidence of rebound pain was significantly lower in the dexamethasone group compared with the control group (37.1% and 82.9%, respectively, p<0.001). The controls experienced greater sleep disturbance during the postoperative period compared with those who received ISB with perineural dexamethasone. Conclusions Perineural dexamethasone added to ISB using ropivacaine led to a much smoother resolution of ISB, reflected in a significantly smaller increase in pain after block resolution, a lower incidence of rebound pain and a lower sleep disturbance during the first postoperative week. Trial registration number Clinical Trial Registry of Korea (KCT0004418).

Securing the airway in patients undergoing surgical intervention to control a deep neck infection (DNI) is challenging for anesthesiologists due to the distorted airway anatomy, limited mouth opening, tissue edema, and immobility. It is critical to assess the risk of a potential difficult airway and prepare the most appropriate airway management method. We reviewed our anesthetic experiences managing patients with DNIs, focusing on the need for video-laryngoscope or awake fiberoptic intubation beyond a standard intubation from the anesthesiologist's perspective. When patients had infections in the masticatory space, mouth of floor, oropharyngeal mucosal space, or laryngopharynx, their airways tended to be managed using methods requiring more effort by the anesthesiologists, and more extensive equipment preparation, compared with use of a standard laryngoscope. The degree to which the main lesion influenced the airway anatomy, especially at the level of epiglottis and aryepiglottic fold was related to the airway management method selected. When managing the airways of patients undergoing surgery for DNIs under general anesthesia, anesthesiologists should use imaging with computed tomography to evaluate the preoperative airway status and a comprehensive understanding of radiological findings, comorbidities, and patients’ symptoms is needed.

Woo JH, et al. J Korean Med Sci. 2015 Oct;30(10):1503-1508. http://dx.doi.org/10.3346/jkms.2015.30.10.1503

Background: Pain assessment and management are important in postoperative circumstances as overdosing of opioids can induce respiratory depression and critical consequences. We aimed this study to check the reliability of commonly used pain scales in a postoperative setting among Korean adults. We also intended to determine cut-off points of pain scores between mild and moderate pain and between moderate and severe pain by which can help to decide to use pain medication. Methods: A total of 180 adult patients undergoing elective non-cardiac surgery were included. Postoperative pain intensity was rated with a visual analog scale (VAS), numeric rating scale (NRS), faces pain scale revised (FPS-R), and verbal rating scale (VRS). The VRS rated pain according to four grades: none, mild, moderate, and severe. Pain assessments were performed twice: when the patients were alert enough to communicate after arrival at the postoperative care unit (PACU) and 30 min after arrival at the PACU. The levels of agreement among the scores were evaluated using intraclass correlation coefficients (ICCs). The cut-off points were determined by receiver operating characteristic curves. Results: The ICCs among the VAS, NRS, and FPS-R were consistently high (0.839–0.945). The pain categories were as follow: mild ≦ 5.3 / moderate 5.4 ~ 7.1 /severe ≧ 7.2 in VAS, mild ≦ 5 / moderate 6 ~ 7 / severe ≧ 8 in NRS, mild ≦ 4 / moderate 6 / severe 8 and 10 in FPS-R. The cut-off points for analgesics request were VAS ≧ 5.5, NRS ≧ 6, FPS-R ≧ 6, and VRS ≧ 2 (moderate or severe pain). Conclusions: During the immediate postoperative period, VAS, NRS, and FPS-R were well correlated. The boundary between mild and moderate pain was around five on 10-point scales, and it corresponded to the cut-off point of analgesic request. Healthcare providers should consider VRS and other patient-specific signs to avoid undertreatment of pain or overdosing of pain medication.

BACKGROUND: Bedside sonography of the inferior vena cava has been demonstrated to be a reliable tool for assessing intravascular volume status. Subclavian vein (SCV) assessment was proposed as a reasonable adjunct for measuring the inferior vena cava.OBJECTIVE: We examined whether the preoperative diameter and collapsibility index of the SCV or the infraclavicular axillary vein could predict the incidence of hypotension after induction of general anaesthesia in patients undergoing laparoscopic cholecystectomy.DESIGN: Prospective, observational study.SETTING: Tertiary university hospital.PATIENTS: Adults scheduled for laparoscopic cholecystectomy.INTERVENTION: Sonographic evaluation of the SCV or the axillary vein (SCV-AV) before induction of anaesthesia.MAIN OUTCOME MEASURES: The main outcome was the association between the SCV-AV measurements (diameter an collapsibility index) and intra-operative hypotension (IOH) after induction of anaesthesia.RESULTS: Patients who developed IOH had a higher collapsibility index of the SCV-AV during spontaneous breathing (P = 0.009) and deep inspiration (P = 0.002). After adjusting for confounding variables, the collapsibility index of the SCV-AV during spontaneous breathing was not a significant predictor of a decrease in mean arterial blood pressure (MAP) after inducing anaesthesia (P = 0.127), whereas the collapsibility index of the SCV-AV during deep inspiration was a significant predictor (P < 0.001).CONCLUSION: The collapsibility index of the SCV-AV during deep inspiration was a significant predictor of IOH occurrence and the percentage decrease in MAP after inducing anaesthesia. Further studies in patients with higher collapsibility index are needed to confirm our findings, before the collapsibility index of the SCV-AV can be recommended unequivocally for clinical use.TRIAL REGISTRATION: This trial was registered on 8 September 2017 at the Clinical Trial Registry of Korea (https://cris.nih.go.kr/cris/index.jsp; Identifier: KCT0001078KCT0002457), and the first patient was enrolled on 14 October 2017.

Lee HJ, et al. J Korean Med Sci. 2023 May;38(24):e183. https://doi.org/10.3346/jkms.2023.38.e183