Correspondence
Anaesthesia 2014, 69, 928–938
accumulated impurities from affected vaporisers during service, or, when applicable, by draining of the vaporiser following manufacturers’ instructions provided in the User’s Manual. Baxter is currently in the late stages of development of a redesigned valve system that eliminates or replaces the elastomeric components’ contacting the liquid desflurane during product storage that are the source of most of the extractable impurities associated with the discoloration phenomenon. J. Olsen R. A. Lessor Baxter Healthcare Corporation, Deerfield, IL, USA Email: [email protected] No external funding and no other competing interests declared.
References 1. McLeskey CH. Is yellow desflurane safe to use? Anesthesia Patient Safety Foundation Newsletter 2010; 25: 31. 2. Schulte TE, Ellis SJ. Discolored desflurane in the vaporizer. Anesthesia and Analgesia 2010; 110: 644–5. doi:10.1111/anae.12802
Epidural anaesthesia and analgesia for liver resection We read with interest the review article by Tzimas et al. [1] and the comments by Kelliher and colleagues [2] regarding analgesic techniques for hepatic resection. In our hospital, four consultant surgeons perform hepatic resection surgery. One uses continuous thoracic epidural anaesthesia (CEA) for
postoperative analgesia, and the other three use a combination of patient-controlled analgesia (PCA) with opioids combined with continuous intramuscular infusion of bupivacaine (CIB). For the CIB technique, two catheters are positioned in the intercostal neuronal plane during wound closure. A bolus dose of local anaesthetic is given before completion of surgery and an infusion continued postoperatively [3]. A recent retrospective study performed in our institution compared postoperative outcomes of 498 patients undergoing major hepatic resection, managed with either CEA or PCA+CIB [4]. When compared with CEA, the PCA+CIB technique provided similar-quality analgesia. In both groups, over 70% of patients experienced no or minimal pain on the first two postoperative days. The PCA+CIB group also consumed significantly less opioid in the first 72 hours after surgery, although they did require more rescue analgesia on the day of surgery. Compared to the CEA group, the PCA+CIB group had a significantly lower overall prevalence of postoperative morbidity (39% vs 26%, respectively, p = 0.03), and a significantly shorter median (IQR [range]) hospital stay (8 (6–10 [3–80]) days vs 7 (6-9 [3-95]) days, respectively, p = 0.005). There were no differences in analgesia-related morbidity between the two groups. We highlight the efficacy of the PCA+CIB technique and believe it to be an excellent alternative to CEA after major hepatic resection. The technique is easier to manage
© 2014 The Association of Anaesthetists of Great Britain and Ireland
on the ward and avoids many of the problems and risks of epidurals. J. Gray S. Shankar Hampshire Hospitals Foundation Trust, Basingstoke, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Tzimas P, Prout J, Papadopoulos G, Mallett SV. Epidural anaesthesia and analgesia for liver resection. Anaesthesia 2013; 68: 628–35. 2. Kelliher L, Jones C, Dickinson M, Scott M, Quiney M. Epidural anaesthesia and analgesia for liver resection. Anaesthesia 2013; 68: 975–6. 3. Basu S, Tamijmarane A, Bulters D, Wells JKG, John TG, Rees M. An alternative method of wound pain control following hepatic resection: a preliminary study. Journal of the International Hepato-Pancreato-Biliary Association 2004; 6: 186–189. 4. Wong-Lun-Hing EM, van Dam RM, Welsh FKS, et al. Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy. Journal of the International Hepato-Pancreato-Biliary Association 2013; 16: 601–9. doi:10.1111/anae.12801
Other potential uses of serratus anterior plane block Blanco et al.’s description of a new serratus anterior plane block could indeed prove useful in managing pain after breast surgery, and this block appears to be more easily performed than other techniques mentioned in his paper [1]. 933
Anaesthesia 2014, 69, 928–938
accumulated impurities from affected vaporisers during service, or, when applicable, by draining of the vaporiser following manufacturers’ instructions provided in the User’s Manual. Baxter is currently in the late stages of development of a redesigned valve system that eliminates or replaces the elastomeric components’ contacting the liquid desflurane during product storage that are the source of most of the extractable impurities associated with the discoloration phenomenon. J. Olsen R. A. Lessor Baxter Healthcare Corporation, Deerfield, IL, USA Email: [email protected] No external funding and no other competing interests declared.
References 1. McLeskey CH. Is yellow desflurane safe to use? Anesthesia Patient Safety Foundation Newsletter 2010; 25: 31. 2. Schulte TE, Ellis SJ. Discolored desflurane in the vaporizer. Anesthesia and Analgesia 2010; 110: 644–5. doi:10.1111/anae.12802
Epidural anaesthesia and analgesia for liver resection We read with interest the review article by Tzimas et al. [1] and the comments by Kelliher and colleagues [2] regarding analgesic techniques for hepatic resection. In our hospital, four consultant surgeons perform hepatic resection surgery. One uses continuous thoracic epidural anaesthesia (CEA) for
postoperative analgesia, and the other three use a combination of patient-controlled analgesia (PCA) with opioids combined with continuous intramuscular infusion of bupivacaine (CIB). For the CIB technique, two catheters are positioned in the intercostal neuronal plane during wound closure. A bolus dose of local anaesthetic is given before completion of surgery and an infusion continued postoperatively [3]. A recent retrospective study performed in our institution compared postoperative outcomes of 498 patients undergoing major hepatic resection, managed with either CEA or PCA+CIB [4]. When compared with CEA, the PCA+CIB technique provided similar-quality analgesia. In both groups, over 70% of patients experienced no or minimal pain on the first two postoperative days. The PCA+CIB group also consumed significantly less opioid in the first 72 hours after surgery, although they did require more rescue analgesia on the day of surgery. Compared to the CEA group, the PCA+CIB group had a significantly lower overall prevalence of postoperative morbidity (39% vs 26%, respectively, p = 0.03), and a significantly shorter median (IQR [range]) hospital stay (8 (6–10 [3–80]) days vs 7 (6-9 [3-95]) days, respectively, p = 0.005). There were no differences in analgesia-related morbidity between the two groups. We highlight the efficacy of the PCA+CIB technique and believe it to be an excellent alternative to CEA after major hepatic resection. The technique is easier to manage
© 2014 The Association of Anaesthetists of Great Britain and Ireland
on the ward and avoids many of the problems and risks of epidurals. J. Gray S. Shankar Hampshire Hospitals Foundation Trust, Basingstoke, UK Email: [email protected] No external funding and no competing interests declared. Previously posted on the Anaesthesia correspondence website: www.anaesthesia correspondence.com.
References 1. Tzimas P, Prout J, Papadopoulos G, Mallett SV. Epidural anaesthesia and analgesia for liver resection. Anaesthesia 2013; 68: 628–35. 2. Kelliher L, Jones C, Dickinson M, Scott M, Quiney M. Epidural anaesthesia and analgesia for liver resection. Anaesthesia 2013; 68: 975–6. 3. Basu S, Tamijmarane A, Bulters D, Wells JKG, John TG, Rees M. An alternative method of wound pain control following hepatic resection: a preliminary study. Journal of the International Hepato-Pancreato-Biliary Association 2004; 6: 186–189. 4. Wong-Lun-Hing EM, van Dam RM, Welsh FKS, et al. Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy. Journal of the International Hepato-Pancreato-Biliary Association 2013; 16: 601–9. doi:10.1111/anae.12801
Other potential uses of serratus anterior plane block Blanco et al.’s description of a new serratus anterior plane block could indeed prove useful in managing pain after breast surgery, and this block appears to be more easily performed than other techniques mentioned in his paper [1]. 933
