Ultrasound-guided neurostimulator-confirmed supraclavicular block is more rapidly performed and provides a block of better quality than supraclavicular block using anatomic landmarks and neurostimulator confirmation.

Ultrasound guidance (USG) for infraclavicular blocks provides real time visualization of the advancing needle and local anesthetic distribution. Whether visualization of local anesthetic spread can supplant neurostimulation as the end point for local anesthetic injection during USG block has never been formally evaluated. Therefore, for this prospective randomized study, we recruited 72 patients scheduled for hand or forearm surgery and compared the speed of execution and quality of USG infraclavicular block with either USG alone (Group U) or USG combined with neurostimulation (Group S). In Group U, local anesthetic was deposited in a U-shaped distribution posterior and to each side of the axillary artery using as few injections as possible (1, 2, and 3 injections in 29, 6, and 3 patients, respectively). In Group S, a single injection was made after obtaining a distal motor response with a stimulating current between 0.3 and 0.6 mA. The anesthetic solution consisted of 0.5 mL/kg of lidocaine 1.5%, bupivacaine 0.125%, and epinephrine 1:200 000 (final concentrations). Procedure times were significantly shorter in Group U compared with Group S (3.1 +/- 1.6 min and 5.2 +/- 4.7 min, respectively; P = 0.006). In Group S, anesthetic spread was mainly anterior to the axillary artery in 37% of patients and mainly posterior in 63% of patients. Thirty minutes after the injection, 86% of patients in Group U had complete sensory block in the musculocutaneous, median, radial, and ulnar nerve territories compared with 57% in Group S (P = 0.007). Patients blocked in Group U with a single injection had the same rate of complete block (86%) as those blocked with more than one injection (86%). Block supplementation rates were 8% in Group U versus 26% in Group S (P = 0.049). Block failure occurred in one patient in Group S because of an inability to obtain a distal stimulation after 20 min. We conclude that USG infraclavicular block is more rapidly performed and yields a higher success rate when visualization of local anesthetic spread is used as the end point for injection. Posterolateral spread of local anesthetic around the axillary artery predicts successful block, circumventing the need for direct nerve visualization.

In this prospective study we compared ultrasound-guided (USG) infraclavicular and supraclavicular blocks for performance time and quality of block. We hypothesized that the infraclavicular approach would result in shorter performance times with a quality of block similar to that of the supraclavicular approach. Eighty patients were randomized into two equal groups: Group I (infraclavicular) and Group S (supraclavicular). All blocks were performed using ultrasound visualization with a 7.5-MHz linear probe and neurostimulation. The anesthetic mixture consisted of 0.5 mL/kg of bupivacaine 0.5% and lidocaine hydrocarbonate 2% (1:3 vol.) with epinephrine 1:200,000. Sensory block, motor block, and supplementation rates were evaluated for the musculocutaneous, median, radial, and ulnar nerves. Surgical anesthesia without supplementation was achieved in 80% of patients in group I compared with 87% in Group S (P = 0.39). Supplementation rates were significantly different only for the radial territory: 18% in Group I versus 0% in group S (P = 0.006). Block performance times were not different between groups (4.0 min in Group I versus 4.65 min in Group S; P = 0.43). Technique-related pain scores were not different between groups (I: 2.0; S: 2.0; P = 1.00). We conclude that USG infraclavicular block is at least as rapidly executed as USG supraclavicular block and produces a similar degree of surgical anesthesia without supplementation.

Listening to music under general anesthesia did not reduce perioperative stress hormone release or opioid consumption in patients undergoing gynecological surgery.

Objective: This retrospective study was designed to assess the intensity of postoperative pain in relation to the location of craniotomy. Methods:After Research Ethics Board approval, data were collected from the charts of all patients who underwent a craniotomy at our institution between January 2004 and December 2005. The severity of post-craniotomy pain was assessed by collecting scores obtained using an 11-point verbal rating scale and calculating the cumulative analgesic requirements for the first 48 hr postoperatively. Data were compared according to the craniotomy location. Results:Data from 299 patients was available for analysis. On average, 76% of patients experienced moderate to severe postoperative pain. Frontal craniotomy was associated with lower pain scores than four of six craniotomy sites analyzed, with 49% of patients reporting mild pain, a significant difference (P < 0.05) compared with all other groups except for parietal craniotomies. Frontal craniotomy patients also had lower opioid analgesic requirements compared to patients who underwent posterior fossa craniotomy (P < 0.05). Logistic regression analysis showed that craniotomy location (P < 0.0001) and age (P = 0.004) were both independent predictors of the intensity of postoperative pain, with lower pain scores as age increased. Postoperative use of steroids, gender and presence of preoperative pain were not statistically linked to postoperative pain intensity. The prevalence of postoperative nausea and vomiting was 56% and it did not vary according to the location of craniotomy. Conclusion:This study shows that the intensity of postoperative pain in neurosurgery is affected by the site of craniotomy. Frontal craniotomy patients experienced the lowest pain scores, and required significantly less opioid than patients undergoing posterior fossa interventions.