Background. Provision of preoperative information can alleviate patients' anxiety. However, the ideal method of delivering this information is unknown. Video information has been shown to reduce patients' anxiety, although little is known regarding the effect of preoperative multimedia information on anxiety in patients undergoing regional anaesthesia.Methods. We randomized 110 patients undergoing upper or lower limb surgery under regional anaesthesia into the study and control groups. The study group watched a short film (created by the authors) depicting the patient's in-hospital journey including either a spinal anaesthetic or a brachial plexus block. Patients' anxiety was assessed before and after the film and 1 h before and within 8 h after their operation, using the Spielberger state trait anxiety inventory and a visual analogue scale.Results. There was no difference in state and trait anxiety between the two groups at enrolment. Women had higher baseline state and trait anxiety than men (P¼0.02). Patients in the control group experienced an increase in state anxiety immediately before surgery (P,0.001), and patients in the film group were less anxious before operation than those in the control group (P¼0.04). After operation, there was a decrease in state anxiety from baseline in both groups, but patients in the film group were less anxious than the control group (P¼0.005).Conclusions. Preoperative multimedia information reduces the anxiety of patients undergoing surgery under regional anaesthesia. This type of information is easily delivered and can benefit many patients.

T he authors believe this is the first report of the successful use of lipid emulsion (Intralipid) in a prearrest situation and the first of cardiac arrhythmia and cardiovascular collapse following levobupivacaine administration in a peripheral nerve block. The 75-year-old ASA III woman presented for repair of a fractured femur, with a history of severe chronic obstructive pulmonary disease.With a normal preoperative electrocardiogram (ECG), a lumbar plexus block was begun at L4, after several unsuccessful attempts to place a subarachnoid block. Following negative aspiration, levobupivacaine 0.5% was injected slowly to a total of 20 mL; aspiration continued to be negative. Within seconds, the woman became unresponsive, followed by tonic-clonic convulsions, and a presumptive diagnosis of local anesthetic toxicity due to intravascular injection of levobupivacaine was made. Continuous, lead II ECG traces demonstrated deteriorating QRS morphology with reduced voltage and broadening complexes. Carotid pulse remained palpable and a second convulsion occurred 2 minutes after the first one. An intravenous bolus of metaraminol 0.5 mg was given and the airway secured with propofol and suxamethonium. Within 4 minutes of levobupivacaine injection, Intralipid 20% solution (100 mL) was infused over 5 minutes via the peripheral cannula, resulting in a rapid normalization of QRS morphology and no more convulsions. The patient's hemodynamics and ECG traces remained stable and surgery proceeded with volatile anesthesia. She continued to improve and the surgery was uneventful, as was recovery.Lipid emulsion has been used successfully to treat local anesthetic-induced cardiovascular collapse in animals and in 2 cases of cardiac arrest in humans. Cardiac arrest has been reported following intrathecal spread of local anesthetic during posterior lumbar plexus block and generalized tonic-clonic seizures have been seen in a 27-yearold patient following presumed intravenous injection of levobupivacaine, but with no ECG abnormalities or cardiovascular instability. There also have been reports of central nervous system toxicity and seizures following accidental intravascular injection of levobupivacaine. With reports of beneficial effects of Intralipid administration in local anesthetic toxicity, the authors have placed Intralipid in all theater areas for rapid accesses. They recommended continuing collection of reported uses of this lipid emulsion, both successful and unsuccessful, to reach a consensus on its efficacy and appropriateness.

Summary Lipid emulsion has been used in the successful treatment of local anaesthetic‐induced cardiovascular collapse in animals and in two cases of cardiac arrest in humans. Previous reports of levobupivacaine toxicity in humans have been characterised by neurological signs and symptoms, without serious cardiovascular events. We present a case in which presumed intravenous injection of levobupivacaine led to neurological and cardiovascular consequences. This was treated successfully by resuscitation that included intravenous Intralipid® infusion.

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Points B and C may represent convenient, novel sites for ultrasound-guided radial-nerve block. The nerve is clearly visualized and has not yet divided into superficial and deep branches. Point C may be the optimal site for radial-nerve block because of the smaller risk of vessel puncture. Our observations also demonstrate the ability of ultrasound to identify nerves at sites not clearly defined by surface anatomic landmarks.