Emerging data suggest neoadjuvant chemotherapy (NAC) for resectable pancreatic ductal adenocarcinoma (PDAC) is associated with improved survival. However, less than 40% demonstrate a meaningful ...radiographic response to NAC. Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has emerged as a new modality to treat PDAC. We hypothesize that NAC plus EUS-RFA can be used in the management of resectable PDAC.
Prospective review of PDAC patients meeting criteria of resectable tumor anatomy that underwent NAC chemotherapy plus EUS-RFA followed by pancreatic resection. Radiographic imaging, perioperative and short-term outcomes were recorded. Surgical pathology specimens were analyzed for treatment response.
Three eligible patients with resectable PDAC received 4 months of NAC plus EUS-RFA. One month after NAC and EUS-RFA completion, all 3 patients underwent standard pancreaticoduodenectomy without complications. After a 6-week recovery, all patients completed 2 months of post-op adjuvant chemotherapy.
In our institutional experience, this treatment protocol appears safe as patients tolerated the combination of chemotherapy and ablation. Patients underwent pancreatic resection with uneventful recovery. This novel neoadjuvant approach may provide a more effective alternative to chemotherapy alone.
To evaluate the analgesic effect of ultrasound-guided erector spinae plane (ESP) block in breast cancer surgery.
Randomized controlled, single-blinded trial.
Operating room.
Fifty ASA I–II patients ...aged 25–65 and scheduled for elective breast cancer surgery were included in the study.
Patients were randomized into two groups, ESP and control. Single-shot ultrasound (US)-guided ESP block with 20 ml 0.25% bupivacaine at the T4 vertebral level was performed preoperatively to all patients in the ESP group. The control group received no intervention. Patients in both groups were provided with intravenous patient-controlled analgesia device containing morphine for postoperative analgesia.
Morphine consumption and numeric rating scale (NRS) pain scores were recorded at 1, 6, 12 and 24 h postoperatively.
Morphine consumption at postoperative hours 1, 6, 12 and 24 decreased significantly in the ESP group (p < 0.05 for each time interval). Total morphine consumption decreased by 65% at 24 h compared to the control group (5.76 ± 3.8 mg vs 16.6 ± 6.92 mg). There was no statistically significant difference between the groups in terms of NRS scores.
Our study findings show that US-guided ESP block exhibits a significant analgesic effect in patients undergoing breast cancer surgery. Further studies comparing different regional anesthesia techniques are needed to identify the optimal analgesia technique for this group of patients.
•Erector spinae plane block is a new and promising technique for many indications.•Ultrasound guided erector spinae plane block is an effective modality of analgesia for breast surgeries.•Postoperative total morphine consumption in block group reduced by 65% in postoperative 24 h.•Ultrasound guided erector spinae plane block is a relatively easy and safe method for providing analgesia.
The study was to determine the analgesic effect of ultrasound-guided intercostal nerve block (ICNB) and single-injection erector spinae plane block (ESPB) in comparison with multiple-injection ...paravertebral block (PVB) after thoracoscopic surgery.
Randomized, controlled, double- blinded study.
Operating room, postoperative recovery room and ward.
Seventy-five patients, aged 18–75 years, ASA I–II and scheduled for elective thoracoscopic partial pulmonary resection surgery were enrolled in the study. Seventy-two patients were left for final analysis.
Patients were randomly assigned into the three groups (PVB group, ICNB group or ESPB group). After anesthesia induction, a single anesthesiologist performed PVB at T5-T7 levels or ICNB at T4-T9 levels or ESPB at T5 level under ultrasound guidance using 20 ml of 0.375% ropivacaine. Patients were connected to the patient-controlled morphine analgesia device after surgery.
Cumulative morphine consumption at 24 h postoperatively as primary outcome was compared. Visual analog scale pain scores at rest and while coughing at 0, 2, 4, 8, 24 and 48 h postoperatively, cumulative morphine consumption at other observed time and rescue analgesia requirement were also recorded.
There was a significant difference in median interquartile range, IQR morphine consumption at 24 h postoperatively among the three groups (PVB, 10.5 9–15 mg; ICNB, 18 13.5–22.1 mg; ESPB, 22 15–25.1 mg; p = 0.000). This difference was statistically significant for PVB group vs ESPB group (median difference, −7.5; 95% confidence interval CI, −12 to −4.5; p = 0.000) and PVB group vs ICNB group (median difference, −6; 95% CI, −9 to −3; p = 0.001), but not for ICNB vs ESPB (median difference, −3; 95% CI, −6 to 1.5; p = 0.192). PVB group had significantly lower VAS scores at rest and while coughing than ESPB group at 0, 2, 4, 8 h postoperatively and than ICNB group at 8 h postoperatively. There was no significant difference in the VAS scores between ICNB group and ESPB group at all time. Median VAS scores at rest and while coughing at all time were low (<4) in all groups. More rescue analgesia was needed in ESPB group during 48 postoperative hours (PVB vs ICNB vs ESPB; 13% vs 29% vs 46%; p < 0.05).
Ultrasound-guided multiple-injection PVB provided superior analgesia to ICNB and single-injection ESPB, while ICNB and single-injection ESPB were equally effective in reducing pain after thoracoscopic surgery.
•PVB provided superior postoperative analgesia in VATS to ICNB and ESPB.•ICNB and ESPB were equally effective in reducing pain after VATS.•ESPB is technically safer and easier than PVB and ICNB.
Background
There is a paucity of data on the incidence of central venous catheter tip misplacements after the implementation of ultrasound guidance during insertion. The aims of the present study ...were to determine the incidence of tip misplacements and to identify independent variables associated with tip misplacement.
Methods
All jugular and subclavian central venous catheter insertions in patients ≥16 years with a post‐procedural chest radiography at four hospitals were included. Each case was reviewed for relevant catheter data and radiologic evaluations of chest radiographies. Tip misplacements were classified as ‘any tip misplacement’, ‘minor tip misplacement’ or ‘major tip misplacement’. Multivariable logistic regression analyses were used to investigate associations between predefined independent variables and tip misplacements.
Results
A total of 8556 central venous catheter insertions in 5587 patients were included. Real‐time ultrasound guidance was used in 91% of all insertions. Any tip misplacement occurred (95% confidence interval) in 3.7 (3.3–4.1)% of the catheterisations, and 2.1 (1.8–2.4)% were classified as major tip misplacements. The multivariable logistic regression analyses showed that female patient gender, subclavian vein insertions, number of skin punctures and limited operator experience were associated with a higher risk of major tip misplacement, whereas increasing age and height were associated with a lower risk.
Conclusions
In this large prospective multicentre cohort study, performed in the ultrasound‐guided era, we demonstrated the incidence of tip misplacements to be 3.7 (3.3–4.1)%. Right internal jugular vein catheterisation had the lowest incidence of both minor and major tip misplacement.
Background
Axillary vein access (AVA) using fluoroscopic landmarks is an effective and safe approach for cardiac implantable electronic devices (CIEDs) implantation. However, it may result in a ...higher radiation exposure. Ultrasound‐guided axillary access (USAA) is an effective alternative technique to conventional subclavian access for CIEDs implantation. Studies comparing USAA and AVA using fluoroscopic landmarks are lacking. The purpose of this study was to compare the safety, efficacy, and radiation exposure data of the USAA approach with the AVA using fluoroscopic landmarks.
Methods
The study population included 95 consecutive patients (61% male, median age 78 years 71‐85 years) referred for CIEDs implantation using AVA with fluoroscopic landmark (n = 46) or USAA (n = 49). Baseline characteristics and radiation exposure data (Air‐Kerma mGy, DAP Gy‐cm2, fluoroscopy time seconds, and X‐rays emission time seconds) were compared according to the technique used for the AVA.
Results
Axillary vein was successfully accessed in 45 of 49 (92%) patients using ultrasound and in 42 of 46 (91%) patients using fluoroscopic landmarks (P = 1.00). Air‐Kerma, DAP, fluoroscopy time, and X‐rays emission time were shorter for USAA group compared with AVA using fluoroscopic landmarks (11 mGy 8‐20 vs 37 mGy 24‐81, P < .00001; 3 Gy‐cm2 2‐5 vs 10 Gy‐cm2 6‐16, P < .00001; 97 seconds 62‐163 vs 271 seconds 185‐365, P < .00001; and 7 seconds 4‐10 vs 21 seconds 13‐39, P < .00001). There were no significant differences between the two groups in median implant procedure time (P = .55). We did not encounter any acute or long‐term complications in both groups.
Conclusions
Ultrasound‐guided axillary vein cannulation for CIEDs implantation is a feasible and safe alternative approach and offers a significant reduction in fluoroscopy times without increasing procedural time.
The most common malposition seen during subclavian vein cannulation is to the ipsilateral internal jugular vein. We report a case of unusual malposition of a subclavian central venous catheter, where ...it was found to be forming a “figure of U” in the ipsilateral subclavian vein. Although the catheterization was done under ultrasound guidance, we could not visualize the course of the guidewire due to a poor ultrasound window. This report highlights the fact that although ultrasound can facilitate identification of the vessels and prevent inadvertent arterial puncture, it seldom helps in the positioning of the guidewire tip and prevention of catheter malposition.
Lumbar spinal stenosis (LSS) occurs when bony, ligamentous, and synovial elements of the lower axial spine degenerate and overgrow, compressing neural and vascular elements in the spinal canal. ...Compression can cause static back pain, radicular lower extremity pain, or neurogenic claudication. Radiological and clinical findings are needed to diagnose lumbar stenosis. In this framework, caudal epidural steroid injection (ESI) is a standard treatment. The volume injected and needle positioning are the main issues that could compromise the effectiveness of the epidural injection. However, ultrasound-guided caudal epidural injections have become more common in recent years. Since Klocke and colleagues described the ultra-sound-guided caudal block in 2003, it has grown in popularity. Multiple ethnic studies have reported ultrasound-guided caudal injection success rates of 96.9-100%. Color Doppler ultrasonography can also determine if a drug solution reaches the lumbosacral region. We enrolled 42 patients with lumbar spinal stenosis, persistent lumbosciatalgia, and neurogenic claudicatio unresponsive to painkillers who were not surgical candidates. Each patient receives four weekly injections for four weeks. If the patient responds to treatment but still has pain, monthly injections are needed to reach and maintain the benefit. Treatment will be changed if the patient does not respond after 4 caudal injections. Sterile caudal epidural injections are performed with ultrasound guidance and a spinal needle 21G. Triamcinolone 40 mg, levobupivacaine 10 mg, and physiological solution 10 ml are delivered. Each patient received an average of 4 injective treatments (4±2, Means 4, SD 2). Data analysis shows that the treatment reduced pain significantly before and after therapy, which persisted after 3 months. Caudal epidural injection is one of the most common conservative treatments for chronic low back pain with radiculopathy, and lidocaine alone or with steroids is effective. In this framework, the two main literature issues about caudal epidural injection effectiveness on lumbar pain are correct. Therefore, 10 ml is suitable and effective for treating symptoms without side effects. Pain reduction of over 50% from start to finish and three-month follow-up have shown significant results in pain control and disability improvement. Finally, caudal epidural injection for lumbar spinal stenosis symptoms is effective, safe, and provides long-term pain relief.
Limited data are available on the incidence of mechanical complications after ultrasound-guided central venous catheterisation. We aimed to determine the incidence of mechanical complications in ...hospitals where real-time ultrasound guidance is clinical practice for central venous access and to identify variables associated with mechanical complications.
All central venous catheter insertions in patients ≥16 yr at four emergency care hospitals in Sweden from March 2, 2019 to December 31, 2020 were eligible for inclusion. Every insertion was monitored for complete documentation and occurrence of mechanical complications within 24 h after catheterisation. Multivariable logistic regression analyses were used to determine associations between predefined variables and mechanical complications.
In total, 12 667 catheter insertions in 8586 patients were included. The incidence (95% confidence interval CI) of mechanical complications was 7.7% (7.3–8.2%), of which 0.4% (0.3–0.5%) were major complications. The multivariable analyses showed that patient BMI <20 kg m−2 (odds ratio 2.69 95% CI: 1.17–5.62), male operator gender (3.33 1.60–7.38), limited operator experience (3.11 1.64–5.77), and increasing number of skin punctures (2.18 1.59–2.88) were associated with major mechanical complication. Subclavian vein catheterisation was associated with pneumothorax (5.91 2.13–17.26).
The incidence of major mechanical complications is low in hospitals where real-time ultrasound guidance is the standard of care for central venous access. Several variables independently associated with mechanical complications can be used for risk stratification before catheterisation procedures, which might further reduce complication rates.
NCT03782324.
The study aimed to explore the effects of the ultrasound-guided thoracic paravertebral block (TPVB) on
the inflammatory response, stress response, hemodynamics and anesthesia resuscitation in ...gallbladder
carcinoma. Eighty gallbladder carcinoma patients undergoing open cholecystectomy in Heilongjiang
Provincial Hospital from February 2016 to April 2019 were selected and divided into observation group
(n=40) and control group (n=40) using a random number table. All patients underwent open
cholecystectomy under general anesthesia and tracheal intubation. Patient-controlled intravenous
analgesia was adopted after the operation in the control group, while right TPVB was performed before
general anesthesia in the observation group. The changes in inflammatory factors and oxidative stress
factors were compared between the two groups, the anesthesia resuscitation indexes, and the changes in
the bispectral index (BIS) and Ramsay score during anesthesia resuscitation were recorded, and the
changes in the hemodynamic indexes in perianesthesia and anesthesia resuscitation-related
complications were analyzed. At 15 min after anesthesia, the observation group had lower levels of
inflammatory factors high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6) (p<0.05),
malondialdehyde (MDA) (p<0.05) and a higher level of superoxide dismutase (SOD) (p<0.05) than the
control group. The anesthesia resuscitation time was shorter in the observation group than that in the
control group (p<0.05). At 10 min, 20 min and 30 min after anesthesia, both BIS and Ramsay scores
were significantly higher in the observation group than those in the control group (p<0.05). Moreover,
the proportion of circulatory function-related complications and anesthesia resuscitation-related
complications were lower in the observation group than that in the control group (p<0.05). The NRS
score in the observation group was lower than that in the control group after anesthesia (p<0.05). TPVB
in perianesthesia for gallbladder carcinoma patients can effectively lower the body's inflammatory and
stress responses, promote anesthesia resuscitation, reduce complications in perianesthesia, and relieve
postoperative pain.
Our goal is to develop metrics that quantify the translation of performance from cadavers to patients. Our primary objective was to develop steps and error checklists from a Delphi questionnaire. Our ...second objective was to show that our test scores were valid and reliable.
Sixteen UK experts identified 15 steps conducive to good performance and 15 errors to be avoided during interscalene block on the soft-embalmed cadaver and patients. Thereafter, six experts and six novices were trained, and then tested. Training consisted of psychometric assessment, an anatomy tutorial, volunteer scanning, and ultrasound-guided needle insertion on a pork phantom and on a soft-embalmed cadaver. For testing, participants conducted a single interscalene block on a dedicated soft-embalmed cadaver whilst wearing eye tracking glasses.
We developed a 15-step checklist and a 15-error checklist. The internal consistency of our steps measures were 0.83 (95% confidence interval CI: 0.78–0.89) and 0.90 (95% CI: 0.87–0.93) for our error measures. The experts completed more steps (mean difference: 3.2 95% CI: 1.5–4.8; P<0.001), had less errors (mean difference: 4.9 95% CI: 3.5–6.3; P<0.001), had better global rating scores (mean difference: 6.8 95% CI: 3.6–10.0; P<0.001), and more eye-gaze fixations (median of differences: 128 95% CI: 0–288; P=0.048). Fixation count correlated negatively with steps (r=–0.60; P=0.04) and with errors (r=0.64; P=0.03).
Our tests to quantify ultrasound-guided interscalene nerve block training and performance were valid and reliable.
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