Anaesthesia & intensive care medicine RSS feed: Current Issue. Anaesthesia and Intensive Care Medicine , an invaluable source of up-to-date information, with the curriculum of both the Primary and Final FRCA examinations covered over a three-year cycle. Published monthly this ever-updating text book will be an invaluable source for both trainee and experienced anaesthetists. The enthusiastic editorial board, under the guidance of two eminent and experienced series editors, ensures Anaesthesia and Intensive Care Medicine covers all the key topics in a comprehensive and authoritative manner. Articles now include learning objectives and eash issue features MCQs, facilitating self-directed learning and enabling readers at all levels to test their knowledge. Each issue is divided between basic scientific and clinical sections. The basic science articles include anatomy, physiology, pharmacology, physics and clinical measurement, while the clinical sections cover anaesthetic agents and techniques, assessment and perioperative management. Further sections cover audit, trials, statistics, ethical and legal medicine, and the management of acute and chronic pain. http://www.anaesthesiajournal.co.uk/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Anaesthesia & intensive care medicine1472-0299113March 2010 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.anaesthesiajournal.co.uk/article/PIIS1472029910000251/abstract?rss=yesContents10.1016/S1472-0299(10)00025-1Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0OFCOFChttp://www.anaesthesiajournal.co.uk/article/PIIS1472029910000275/abstract?rss=yesEditorial Board10.1016/S1472-0299(10)00027-5Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0iihttp://www.anaesthesiajournal.co.uk/article/PIIS1472029909003166/abstract?rss=yesAbstract: Complications of regional anaesthesia can be divided into those specific to central neuraxial blockade, those specific to peripheral nerve blockade, and those that pertain to both. Fortunately, severe complications – namely, spinal cord damage, vertebral cord haematoma and epidural abscess – are rare. Here, with reference to updated incidences available following the Third National Audit Project (NAP3) of the Royal College of Anaesthetists, an overview of these complications of regional anaesthesia is given. A thorough knowledge of anatomy and pharmacology, and a meticulous, unhurried technique are essential to prevent such complications. When considering the use of a regional anaesthetic technique, the risks and benefits for that patient should be assessed on a case-by-case basis.Complications of regional anaesthesiaMegan C. Dale, Matthew R. Checketts10.1016/j.mpaic.2009.12.008Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0CORE - regional anaesthesia8588http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003142/abstract?rss=yesAbstract: The brachial plexus derives from C5, C6, C7, C8 and T1 nerves. It is made up of five roots, between the scalene muscles, three trunks (upper, middle and lower) lying in the posterior triangle, each of which divide into anterior and posterior divisions behind the clavicle to form lateral, medial and posterior cords in the upper axilla. The plexus gives rise to the definitive motor and cutaneous nerve supply to the upper limb. The plexus can be blocked by local anaesthetic infiltration at its root/trunk level in the fascial sheath compartment between the scalenes, or as it crosses the first rib. Block can also be performed around the axillary artery. Peripherally, the nerves may be blocked at the elbow, wrist or finger level.Applied anatomy for upper limb nerve blocksHarold Ellis10.1016/j.mpaic.2009.12.006Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Regional anaesthesia8992http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003130/abstract?rss=yesAbstract: The lumbar plexus is derived from the anterior primary rami of L1, L2, L3, and part of L4. It may also receive a contribution from T12. Its major derivatives are the femoral and the obturator nerves. The sacral plexus arises from the anterior primary rami of the five sacral nerves and the coccygeal nerve, together with the lumbosacral trunk, an important contribution which comprises the whole of L5 together with a contribution from L4. Its terminal branches are the sciatic and the pudendal nerve. In addition, both plexuses have numerous collateral muscular and cutaneous branches, and the sacral plexus gives rise to the pelvic parasympathetic outflow from S2 and S3.The lumbar and sacral plexusesHarold Ellis10.1016/j.mpaic.2009.12.005Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Regional anaesthesia9394http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003154/abstract?rss=yesAbstract: The leg below the knee receives all its motor, and much of its sensory innervation from the two terminal branches of the sciatic nerve: the tibial and common peroneal nerves. The tibial nerve supplies the muscles of the posterior (flexor) compartment of the leg and the intrinsic muscles of the plantar foot, as well as the skin of the back of the leg (sural nerve) and the plantar skin. The common peroneal nerve is the only palpable nerve in the lower limb as it winds around the neck of the fibula (where it may be injured). It divides into the superfical peroneal nerve, which supplies the two peroneal foot evertor muscles, and the deep peroneal, supplying the extensor group, as well as sensory supply to the front of the leg and dorsum of the foot, which is reinforced by two sensory branches of the common peroneal – the sural communicating and the lateral cutaneous nerve of the calf. The only nerve below the knee not derived from the sciatic is the saphenous nerve. This nerve arises from the femoral nerve below the groin and supplies skin on the medial side of the knee, leg and foot. It runs with the long saphenous vein in the lower part of its course and can be damaged during operations on the vein.The nerves of the leg and footHarold Ellis10.1016/j.mpaic.2009.12.007Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Regional anaesthesia9597http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003117/abstract?rss=yesAbstract: Systemic toxicity from local anaesthetic agent use is a rare, but potentially life-threatening, complication. It most commonly occurs with inadvertent intravascular injection. High plasma levels of local anaesthetic lead to central nervous system and cardiovascular toxicity. Treatment of toxicity is mainly supportive; however, there is now evidence for the use of lipid emulsions in the management of severe local anaesthetic toxicity.Systemic toxic effects of local anaestheticsChristina Beecroft, Gillian Davies10.1016/j.mpaic.2009.12.003Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Regional anaesthesia98100http://www.anaesthesiajournal.co.uk/article/PIIS147202990900318X/abstract?rss=yesAbstract: Brachial plexus blockade is commonly used for a variety of upper limb surgical procedures and the introduction of ultrasound guidance has led to re-evaluation of many of the approaches. Large-scale studies examining both efficacy and complications of ultrasound-guided techniques compared with nerve stimulation are lacking, but there is a growing body of research to support the routine use of ultrasound. Interscalene block remains the approach of choice for shoulder surgery but phrenic nerve blockade remains common, even using low volumes of local anaesthetic. Of the currently available studies comparing the other approaches, there seems to be little difference in efficacy between axillary, supraclavicular and infraclavicular approaches for elbow, forearm and hand surgery when equivalent levels of expertise are used. The major features influencing block choice and performance are discussed here.Upper limb nerve blocksDavid M. Coventry10.1016/j.mpaic.2009.12.010Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Technical skills101104http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003221/abstract?rss=yesAbstract: Peripheral nerve blocks are increasingly used for a wide range of surgical procedures involving the lower limb. A number of techniques can be used to provide anaesthesia and highly effective postoperative analgesia – in particular following lower limb arthroplasty – that may result in improved functional recovery and shorter in-patient stay. Ultrasound-guided nerve localization offers several potential advantages when performing femoral, popliteal and distal sciatic nerve block; however, neurostimulation remains a useful and widely used aid to lower limb regional anaesthesia practice.Lower limb nerve blocksCalum R.K. Grant10.1016/j.mpaic.2009.12.014Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Technical skills105108http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003208/abstract?rss=yesAbstract: Peripheral nerve catheter techniques provide pain relief on movement for upper and lower limb arthroplasty and amputation. The optimal perineural concentration and volume of ropivacaine and levobupivacaine are not known for upper or lower limb block. The most common complication associated with perineural infusion is infection and, thus, aseptic technique is necessary for both insertion of catheters and use of elastomeric balls. Compared with parenteral opioids, perineural infusion of local anaesthetic accelerates rehabilitation and reduces hospital length of stay. However, little evidence exists regarding surgical outcomes, particularly those concerned with functional wellbeing.Peripheral nerve catheter techniquesGraeme McLeod10.1016/j.mpaic.2009.12.012Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Technical skills109110http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003178/abstract?rss=yesAbstract: Intravenous regional anaesthesia was first described in 1908 by the versatile German surgeon, August Bier. The technique is still widely known as the ‘Bier's Block’ and, if carried out by appropriately trained practitioners, is a useful regional anaesthetic technique for short surgical procedures on the forearm, lower leg or foot.Intravenous regional anaesthesiaMatthew R. Checketts10.1016/j.mpaic.2009.12.009Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Technical skills111112http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003191/abstract?rss=yesAbstract: Local anaesthetics are weak bases and consist of a lipophilic aromatic ring, a link and a hydrophilic amine. The chemistry of the link classifies them as amides or esters. They act by blocking the sodium ionophore, especially in the activated state of the channel, and frequency dependence can be shown. The speed of onset is related to dose and proportion of drug in the unionized lipid-soluble form, which in turn is determined by the pKa and the ambient pH. Local anaesthetic agents, being weak bases, are bound in the plasma to α1-acid glycoproteins, influencing duration of action. Esters undergo hydrolysis by esterases in the plasma. Amides are subject to phase I and II hepatic cytochrome P450 metabolism. The development of the S-enantiomers, levobupivacaine and ropivacaine, has not been without some controversy with regards to therapeutic benefits when assessed by clinical potency models such as the minimum local analgesic concentration (MLAC). Drugs derived from biological toxins that target and bind to the sodium ionophore are gaining acceptance for use as analgesics in chronic pain.Local anaesthetic agentsMalachy O. Columb, Richard Ramsaran10.1016/j.mpaic.2009.12.011Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Pharmacology113117http://www.anaesthesiajournal.co.uk/article/PIIS1472029909003129/abstract?rss=yesAbstract: The body is made up of cells, which are composed of a membrane enveloping a nucleus and cytoplasm. The nucleus contains the genetic material of the body that controls its identity and determines the precise function of the cell. All cells have the potential to perform all functions, but in reality only carry out a limited number. The functions that a cell can perform are controlled by the genes. The cytoplasm contains a number of specialized organelles (many of which are common to all cells), which carry out many functions such as protein synthesis (ribosomes), protein breakdown (lysosomes), and the supply of energy, ATP (in the mitochondria). Protein synthesis is carried out in the ribosomes under the control of DNA.Cell biology and gene expressionIain Campbell10.1016/j.mpaic.2009.12.004Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Physiology118122http://www.anaesthesiajournal.co.uk/article/PIIS147202991000024X/abstract?rss=yes(pages 98–100) Which of the following are true regarding local anaesthetic toxicity and management?MCQsHenry G.W. Paw, Vijayanand Nadella10.1016/j.mpaic.2010.01.005Anaesthesia & intensive care medicine 11, 3 (2010)2010-03-01Anaesthesia & intensive care medicine2010-03-01113S1472-0299(10)X0003-0Test yourself123123