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It is released in response to hypoglycaemia from the non-diabetic pancreas (although not in type 1 diabetes (i) Insulin secretagogues for reasons that are unclear) and is a physiological regula- tor of insulin effect discount 1.5 mg exelon overnight delivery medications xarelto, acting by causing the release of liver Sulfonamide derivatives (sulfonylureas) act to increase en- glycogen as glucose buy exelon line medicine 5 rights. Sulfonylureas were introduced into clinical The response to rescue is usually rapid order generic exelon on line medications names and uses. After initial ther- practice in 1954 and continue to be widely used in type apy, the patient should be given a snack containing slowly 2 diabetes. Sulfonylureas are ineffective in totally insulin- absorbable ‘starchy’ carbohydrate to avoid relapse. The pa- deficient patients; successful therapy probably requires at tient’s treatment regimen should also be carefully reviewed least 30% of normal b-cell function to be present. In particular, it is use- ary failure (after months or years) occurs due to declining ful to ask whether this is part of a pattern of repeated b-cell function. Their main adverse effects are hypoglycaemia and weight After large overdoses of insulin (particularly long acting) gain. Hypoglycaemia can be severe and prolonged (for or sulfonylurea, 20% glucose may be needed by continu- days), and may be fatal in 10% of cases, especially in the ous i. With very large over- elderly and patients with heart failure in whom long-acting doses, for example where several hundred units have agents should be avoided. Erroneous alternative diagnoses been administered to self-harm, it may be possible surgi- such as stroke may be made. Sulfonamides, as expected, po- cally to excise the depot of insulin from the injection site tentiate sulfonylureas both by direct action and by displace- if it can be clearly identified. Full recovery of cognitive Several sulfonylureas are available (see also Table 36. Although ated with a greater risk of hypoglycaemia; for this reason 578 Diabetes mellitus, insulin, oral antidiabetes agents, obesity Chapter | 36 | Table 36. Animal studies suggest that acting alternatives, such as gliclazide, are preferred. Gliclazide is a commonly used second- overweight patients with type 2 diabetes where sulfonyl- generation agent. If the dose exceeds 80 mg, the drug ureas or insulin therapy may promote weight gain. Exena- should be taken twice daily before meals, or once daily if tide and liraglutide are administered subcutaneously twice prescribed as a modified-release preparation. Glimepiride or once daily although longer-acting analogues are likely to is designed to be used once daily and provokes less hypo- be available soon, allowing a regimen with injections no glycaemia than glibenclamide. Aside from boosting insulin secretion, they have (ii) Insulin sensitisers other actions which offer potential advantages over other Biguanides (see also Table 36. They are slower to act than either lular response to low energy, being activated when intra- metformin or sulfonylureas. Metfor- fluid retention (with peripheral oedema in 3–4% of pa- min can be used in combination with either insulin or tients) and decreased bone density. Its chief use is in the obese patient with type 2 diabetes, either alone or in com- (iii) Agents which reduce glucose absorption bination with a sulfonylurea or insulin. Acarbose is an a-glucosidase inhibitor that reduces the di- Minor adverse reactions are common, including nausea, gestion ofcomplex carbohydrates andslowstheirabsorption diarrhoea and a metallic taste in the mouth. The toms are usually transient or subside after reduction of dose usual dose is 50–300 mg/day. Adverse effects are common, and can be minimised by building doses up slowly and en- mainly flatulence and diarrhoea, which lead to a high dis- suring that metformin is taken with or after food. When this condi- dal polysaccharide of galactose and mannose from seeds of tion does occur, it is usually against the background of sig- the ‘cluster bean’) to the diet of diabetics reduces carbohy- nificant medical illnesses which tend to increase drate absorption and flattens the postprandial blood glu- circulating lactic acid levels, particularly renal impair- cose curve. Reduced need for insulin and oral agents has ment, liver failure, or cardiogenic or septic shock. Metfor- been reported, but adequate amounts (taken with lots of min is therefore contraindicated in these conditions, water) are unpleasant (flatulence) and patient compliance including relatively mild renal impairment and use is therefore poor. During pregnancy, metformin use is unli- scribed later), through monotherapy with oral agents, com- censed and current advice is that it should be substituted binations of oral therapies and then onto insulin/injection by insulin. The nature of ‘typical’ type 2 diabetes is that glucose intol- Apart from diabetes, the insulin-sensitising effects of erance tends to progress so that many patients will need to metformin may also be useful in polycystic ovary syndrome, escalate therapy with time to avoid worsening glycaemia a condition in which insulin resistance occurs and may (and warning patients of this early after diagnosis helps contribute to the hyperandrogenism and consequent hir- avoid subsequent disappointment and demotivation). Analogous to type 1 diabetes, some pa- tients may present with marked symptomatic hyperglycae- Thiazolidinediones. Pioglitazone reduces peripheral insu- mia requiring immediate insulin therapy (and indeed some lin resistance, leading to a reduction of blood glucose con- of these may have an unrecognised late onset of type centration. In the mouse, at least, these experiments show that actions of metformin at Current advice is that metformin (where not contraindicated other sites are of little importance. Sul- Thiazide diuretics at a higher dose than those now gener- fonylurea therapy is now less often used as first-line therapy ally used in hypertension can precipitate/worsen diabetes, but is an alternative to metformin or can be added in to probably by reducing insulin secretion. Thiazolidinediones can also be used Hepatic enzyme inducers may enhance the metabolism of in combination with the above. Cimetidine, an inhibitor of drug-metabolising en- apeutic target is to maintain the HbA1c (glycosylated zymes, increases metformin plasma concentration and haemoglobin) below 7. Diet and diabetes Salicylates and fibrates can increase insulin sensitivity, resulting in lower blood glucose. Specialised diet and lifestyle advice is of paramount im- The action of sulfonylureas is intensified by heavy sulfon- portance in managing diabetes. Patients should be amide dosage, and some sulfonamides increase free tolbu- allowed to follow their own preferences as far as is prac- tamide concentrations, probably by competing for plasma ticable. Adrenaline/epinephrine raises the duction in saturated fat in favour of mono- and polyunsa- blood sugar concentration by mobilising liver and mus- turates. Caloric intake may need to be restricted and cle glycogen (a b2-adrenoceptor effect), and suppressing patients encouraged to achieve an ideal body-weight. Hypergly- though certain foods are marketed as ‘diabetic’, there caemia may occur in patients with phaeochromocytoma, are concerns about whether these may be low in glucose and is usually reversed by a-adrenoceptor blockade but high in calories. Advice about alcohol intake and smoking should be given (and where appropri- Adrenal steroids, either endogenous or exogenous, anta- ate, information about what to do when/after drinking gonise the actions of insulin. Although this effect is only alcohol because of the effects causing delayed hypoglycae- slight with mineralocorticoids, glucocorticoid hormones mia). This should be combined with advice about activity/ increase gluconeogenesis and reduce glucose uptake and exercise levels. The therapeutic use of high dose As earlier indicated, increasing numbers of patients with glucocorticoids may precipitate frank diabetes in some pa- type 1 diabetes are now taught how to count dietary carbo- tients or worsen blood glucose control in those with estab- hydrates, allowing them to adjust their insulin doses lished diabetes. In contrast, patients with hypoadrenalism from Addison’s disease, hypopituitarism, or following steroid Interactions with non-diabetes drugs withdrawal after prolonged glucocorticoid therapy may Some examples are listed below to show that the possibility be abnormally sensitive to insulin action and prone to re- of interactions of practical clinical importance is a real one. In general, whenever a patient with diabetes takes other Growth hormone antagonises the actions of insulin in the drugs it is prudent to be on the watch for disturbance of gly- tissues. Acromegalic patients may develop in- cally mediated (b2 receptor) release of glucose from the sulin-resistant diabetes. Insulin hypoglycaemia may thus be more although the effects are usually relatively mild. Ideally, a patient with diabetes needing a b-adrenoceptor blocker should be given Thyroid hormone excess may increase the requirements a b1-selective member, e.
Distinction of phyllodes tumours from fbroadenoma a reappraisal of an old problem order cheapest exelon and exelon symptoms your period is coming. A cytomorphologic approach based on evaluation of epithelial cluster architecture purchase genuine exelon on line medicine grinder. Core needle biopsy as a diag- nostic tool to diferentiate phyllodes tumour from fbroadenoma discount 3 mg exelon with visa medications held before dialysis. Endothelin-1 expression correlates with atypical histological features in mammary phyllodes tumours. Expression of hypoxia-induc- ible factor 1 alpha and its downstream targets in fbroepithelial tumors of the breast. Cystosarcoma phyllodes: epidemi- ology, pathohistology, pathobiology, diagnosis, therapy, and survival. Giant breast tumors: surgical management of phyllodes tumors, potential for reconstructive surgery and a review of literature. Immediate breast reconstruction with a saline implant and Alloderm, following removal of a Phyllodes tumour. Relationship of histologic features to behavior of cysto- sarcoma phyllodes, analysis of ninety-four cases. Retrospective analysis of 25 women with malignant cystosarcoma phyllodes-treatment results. A prospective multi-institutional study of adjuvant radiotherapy after resection of malignant phyllodes tumours. Hormonal receptors expression in epithelial cells of mammary phyllodes tumours correlates with pathologic grade of the tumour: a multicenter study of 143 cases. The classical surgical strategy has been a sequential resection, whereby the primary tumour is resected frst with subsequent adjuvant systemic chemotherapy followed by liver resection. Chapter 13: Management of Patients with Primary Colorectal Cancer 161 Key Points • Approximately 15% of all patients presenting with colorectal cancer will have liver metastases at the time of initial diagnosis, and at least 40% of the remainder of patients will go on to develop liver metastases at some time later. Postchemotherapy morphological and functional metabolic response data8-10 are used to aid in case selection. The use of portal venous embolisation, downsizing chemotherapy, radiofre- quency ablation and two-stage hepatectomies has increased the proportion of eligible patients. As the majority of the patients will have signifcant medical comorbidi- ties, which will impact on the decision, timing and strategy for operation, close cooperation between the colorectal, hepatobiliary, anaesthetic and postoperative care teams is essential. Chapter 13: Management of Patients with Primary Colorectal Cancer 163 • Complete elimination of all evaluable disease remains the only chance of cure. At diagnosis the patient may have upfront resectable disease or borderline/irresectable metastases. Doublet or triplet chemotherapy using a fuoropyrimidine backbone with the addition of either or both of irinote- can and oxaliplatin has been examined for the purpose of “conversion” to resectability; triplet combinations are not only associated with increased response rates but also with increased toxicity. However, it should be noted that most data are derived from trials that are not liver surgery specifc, and consequently the absolute number of patients resected in any study is small, leading to signifcant inter- study heterogeneity and difculty interpreting outcomes. Bevacizumab does not consistently increase response rates when added to cytotoxic chemo- therapy, and this inconsistency is also refected in liver resection rates in randomised trials. Increasingly, systemic therapy will become “personalised”, maximising the therapeutic index and utilising cytotoxic and targeted biological agents. Irinotecan can induce steatohepatitis, fbrosis or even cirrhosis, and oxaliplatin may lead to Chapter 13: Management of Patients with Primary Colorectal Cancer 165 sinusoidal injury and intra-hepatic veno-occlusive disease. In simultaneous resections, it is our preference for the colorectal primary to be resected frst, by open operation and laparoscopically for a rectal primary. It is important in simultaneous resections that the anaesthetic delivery, surgi- cal techniques and postoperative care are carefully considered, and if there are concerns during the colorectal phase such as unexpected complexity, blood loss or physiological performance then dialogue between the surgical teams may lead to deferment of the liver phase. Intraoperative ultrasound is routinely used to confrm the location, size and anatomic rela- tionship of metastases. Key Points • Low threshold to exclude chemotherapy-induced hepatic damage before proceeding with surgery. Recently, however, there has been a growing trend to favour simultaneous resections in many centres. This has led to most surgical units undertaking “simultaneous” resections in only a highly selected group of patients and restricted to straightforward colonic and hepatic resections. We have demonstrated that, where the appropriate expertise exists, neither the extent of the metastatic burden nor the stage or location of the primary tumour should necessarily preclude simultaneous resections. It is clear that a sequential approach will remain an important tool in the surgeon’s armamentarium, particularly in patients where there are concerns regarding age or ftness or when an emergency primary tumour resection is required. Simultaneous resections are extensive and complex operations that should only be undertaken in centres where these procedures are routine. Moreover, it is essential that there is a close cooperation with all members of the multidisciplinary team, in particular a close association between the colorectal and liver surgical teams. Management of the primary tumour should take into consideration the nature and severity of symptoms from the primary tumour and patient’s wishes and comorbidi- ties. Otherwise, the fol- lowing options should be considered: defunctioning colostomy, primary tumour resection, stenting, chemotherapy/chemoradiation or laser recana- lisation to achieve efective palliation and equivalent survival. T ere are no clear guidelines on management, and it should be dictated by the patient’s prognosis and wishes. Until recently, the presence of extra-hepatic disease was considered an absolute contraindication to surgery. However, good fve-year survival data of 28–40% are reported in patients, where the extra-hepatic disease is controlled by systemic or surgical treatment. Close surveillance of patient’s postcurative resection is essential as a signifcant proportion of patients who develop a hepatic recurrence will be amenable for further surgery. Incidence of synchronous liver metastases in patients with colorectal cancer in relationship to clinico-pathologic charac- teristics. Clinicopathological features and prognosis in resectable synchronous and metachronous colorectal liver metastasis. Long-term results of the liver frst approach in patients with locally advanced rectal cancer and synchronous metas- tases. A survival analysis of the liver-frst reversed management of advanced simultaneous colorectal liver metastases: a LiverMetSurvey-based study. Optimal imaging sequence for staging in colorectal liver metastases: analysis of three hypothetical imaging strategies. Current status of imaging and emerging techniques to evaluate liver metastases from colorectal carcinoma. Metabolic response to preoperative chemo- therapy predicts prognosis for patients undergoing surgical resection of colorec- tal cancer metastatic to the liver. Optimal morphologic response to pre- operative chemotherapy: an alternate outcome endpoint before resection of hepatic colorectal metastases.
There is a distal growth center to the metacarpal head and the three phalanges have proximal growth centers order exelon with american express symptoms 0f pregnancy. The ffth radial fnger has extrinsic fexors and extensors muscles similar to those of the normal fngers ( cheap exelon on line symptoms bipolar disorder. If left untreated buy exelon master card medicine 750 dollars, those patients without a frst web syndactyly tend to attenuate the interpalmar plate ligament (transverse metacarpal) and “autopollicize” the anomalous fnger into an abducted and slightly pronated posture. This unusual condition is often bilateral and there may be a history of radial polydactyly and/or thumb hypopla- sia within the pedigree. Clinodactyly of the ffth digit is common it, which contains two fexor tendons and the normal complement of due to the abnormal middle phalanx. Despite having a digi- and fexor digitorum superfcialis tendon transfer for palmar abduction tal skeleton the ray may contain proximal thenar intrinsic (opposition) G. The distinction here between fve-fngered hand and triphalangeal thumb almost becomes academic because the treatment recommendations are simi- lar: repositioning of the radial digit into a more functional plane. Many of these radial digits have characteristics of both: a short middle phalanx, fexed posture, the adductor pollicis muscle of a thumb while at the same time they con- tain a distal metacarpal growth plate, two fexor tendons, and lumbrical and 1st dorsal interosseous muscles similar to a digit (. In these it is critical to recognize the anomalous intrinsic muscles during surgery and make appropriate use of them. Slight radial deviation of the wrist is secondary to a smaller scaphoid and trapezium 31 Five-Fingered Hand 423 Fig. There is runs beneath the fexor tendons and attaches to the common point of a lateral cant to the palpebral fssures. The 1st web space is larger little interphalangeal fexion than the other interdigital spaces. Management of transverse and longitudinal defciencies (Hypoplastic or absent thumb). Five-fngered hand as- sociated with partial or complete tibial absence and pre-axial poly- Hallmarks Tibial dysplasia, polydactyly, and triphalangeal dactyly. Hypoplastic tibiae with Background Werner  in 1915 reported a case of a 21-year- postaxial polysyndactyly: a new dominant syndrome? Werner mesomelic dys- Etiology The condition was described to have an autoso- plasia with Hirschsprung disease. Presentation The condition is often bilateral [3,4] and may occur in children with paternal consanguinity . Upper extremity The hand may be described to have a triphalangeal thumb or polydactyly with an un-opposable thumb. In addition to the typical fve-fngered hand, the patient may be described to have preaxial polydac- tyly, postaxial polysyndactyly, syndactyly, [5,6] and agenesis of the distal end of the radius . Lower extremity The tibia may be absent, thickened, or hypoplastic with or without bowing . Toe polydactyly,  clubfeet, and preaxial polysyndactyly of the feet were also described . Systemic Cryptorchidism and Hirschsprung disease were described in these patients . The condition was observed and congenital ulnar drift deformity and arthrogryposis multiplex frst published in 2003 by Al-Harthy and Rayan  who also congenita. Clasped thumb deformity may be present espe- found that the degree of middle fnger involvement varies. Upton  digits to be secondary to extensor hypoplasia, and attributed in 1990 described a similar condition of an isolated digital the deformity to a defcient extensor mechanism, lumbrical fexion deformity of the long digit in patients with bilateral muscle, and central slip. In of the extensor mechanism which is usually hypoplastic but severe cases the hand had a middle fnger-in-palm posture may be absent in some cases. In most cases digitorum tendon can also be a contributing factor especially there is skin dimpling, indicative of the joint space, over the in severe cases. Trisomy 18 syndrome Trisomy 13 syndrome Deletion 13q syndrome Pterygium syndromes 430 32 Congenital Middle Finger in Palm Freeman-Sheldon Syndrome but limitation in abduction develops as these children age. The width of Distal arthrogryposis syndrome Type 2A both shoulders is narrow and patient’s height is variable de- Whistling face syndrome pending upon the degree of severity of the kyphoscoliosis. Whistling face-windmill vane hand syndrome Elbow range of motion is limited and the most common Craniocarpotarsal dystrophy cause is an early subluxation of the radial head, which rap- Craniocarpotarsal dysplasia idly progresses to a dislocation. The imbalance in the distal forearm and distal radioulnar joint may result in bowing of Hallmarks Whistling face microstoma, digital ulnar drift the radius, radial deviation of the carpus and hand, and a posi- deformity, and clubfeet. In those with minimal or no radial deviation of the digits, the wrist is well aligned and an instability pattern Background This entity was frst described by Freeman develops with growth. In and Sheldon in 1938 and has become recognized as the most those with signifcant ulnar deviation and fexion particu- severe type of distal arthrogryposis [1–3]. The wrist is well aligned with no insta- bility patterns in those with fexion deformities of the digits Presentation The diagnosis is often made at birth with the and no ulnar deviation (. When the facies at birth is not ob- other disabling musculoskeletal, pulmonary, ophthalmologic vious this hand pattern usually makes the clinical diagnosis and sometimes psychiatric problems. The distal limb is more af- mal lumbricalis pollicis muscle is often found and should be fected than the proximal limb and none of these anomalies released (. The wrist is in neutral position in both sagit- tal (anteroposterior) and frontal (radioulnar) planes. Bowing of the diaphysis con- angulation of the radial articular surface and the distal ulna becomes tributed to radial head dislocation. With The palmar skin and subcutaneous fbrous bands defnitely growth they become more distinguishable (. The fexion deformity increases from radial to skull is normocephalic and the forehead commonly promi- ulnar digits. Blepharophimosis may become a prob- Lower extremity At birth these children have clubfeet with lem later in life. The upper lip is long with prominent philtral severe bilateral equinovarus deformities. Early compulsive ridges and a depression above the midportion of the Cupid’s treatment is recommended. The lower lip is full and of hip and knee pathology in the form of joint contractures slightly everted and contains either a “Y”- or “H”-shaped by the time they become adults. The nasal tip may be broad and fanked by a depres- which contributes greatly to potential pulmonary problems sion or notch in the nasal alae. Temporomandibular motion related to a restrictive ventilator defect and chronic pulmo- may be very restricted and contribute to a very tight upper nary infection (. The mouth is small and the palate high arched but not involved and for those requiring multiple surgical procedures clefted. The muscle is extensor mechanism early in life this index digit continued to be fexed, elevated by the retractor on the left and has been retracted on the right. Note the prominent metacarpal heads of the insertion is onto both the radial base of the index proximal phalanx and index and long rays and palmar subluxation of the thumb proximal pha- the extensor mechanism lanx. Laryngomalacia, choanal atresia and renal anomaly in a newborn with Freeman-Sheldon syndrome phe- notype. The severe scoliosis or kyphoscoliosis in these children may often accentuate progressive pulmonary problems. A prominent forehead, fat Hallmarks Cleft palate, conductive deafness, and overlap- facies, and a broad nasal base were reported resulting in the ping fexed digits.
The catheter is checked for inadvertent intravascular placement and secured to the chest buy exelon without prescription medicine clipart. Complications Hematoma discount 1.5 mg exelon visa pure keratin treatment, infection purchase cheap exelon line treatment 8th february, and intravascular injection are possible complications of the infraclavicular nerve block. The cervical pleura is located within close proximity to the brachial plexus and at this position the risk of a pneumothorax still exists. Ultrasound guidance has not only increased the ease of completing truncal blocks but also their effectiveness and safety. Anatomically, the three muscle layers, the external oblique, internal oblique, and transversus abdominis lie lateral to rectus abdominis muscles (Fig. The rectus abdominis is identified by placing the ultrasound probe lateral to the umbilicus. Movement of the probe laterally to the rectus allows for visualization of the three muscle layers of the abdominal wall, the external oblique, internal oblique, and transversus abdominis. Upon injection, a pocket of local anesthetic can be created where the nerves traverse. The catheter tip is localized when saline solution or local anesthetic is injected through the needle. Complications Infection, intravascular injection, peritoneal and/or bowel puncture are potential complications as well as catheter disconnect and/or dislodgment. The external oblique muscle layer may be aponeurotic at this location giving the appearance of only two muscle layers. The local anesthetic volume required to anesthetize both nerves is reported to be significantly less with the utilization of ultrasonography as compared to nonimaging techniques. Rectus Sheath Block Anatomy and Indications The rectus abdominis muscle lies on the medial anterior abdominal wall separated in the midline by the linea alba. Thoracolumbar nerves lie between rectus abdominis muscle and the posterior sheath in the potential space between the rectus abdominis muscle and posterior sheath. An in-plane approach is taken by the needle and directed to the space between the rectus abdominis and the posterior sheath, where local anesthetic is delivered. Complications Infection at the site of skin puncture, intravascular injection, and bowel puncture are complications of the rectus sheath block. Real time visualization under the guide of ultrasonography may help to decrease the possibility of such complications. Typical nerve blockade of the lower extremity include the femoral nerve, sciatic nerve, lumbar plexus, saphenous nerve, and lateral femoral cutaneous nerve. A combination of these blocks may be prescribed by the clinician depending on the intended area of analgesia. Upper leg and lower abdomen analgesia is provided via the branches of the lumbar plexus (T12-L5) including the femoral, genitofemoral, lateral femoral cutaneous, and obturator nerves. The lumbar plexus block is often done in tandem with the sciatic nerve block to provide analgesia to an entire lower extremity. Beyond the transverse process are the erector spinae and quadratus lumborum muscles, the psoas major muscle and the lumbar plexus. The lumbar plexus is found within the psoas major and identification may be challenging due to similar echogenicity to the muscle. It is important to note, paravertebral muscle twitching can be seen upon needle insertion and should not be mistaken for correct placement of the needle. Complications Complications include infection, hematoma, epidural injection and local anesthetic toxicity. Due to the location of the plexus, retroperitoneal bleeding is also a potential complication. Femoral Nerve Block Anatomy and Indications The nerve roots of L2, L3, and L4 give rise to the femoral nerve and when blocked, provides analgesia from the anterior thigh to the knee. The femoral nerve can be visualized when the ultrasound is placed in the inguinal crease and is lateral to the femoral artery and vein. The 3-in-1 and fascia iliaca block are also performed in this location, however, there is a lack of evidence to support use of ultrasound for these blocks in pediatrics. Technique With the patient in the supine position the femoral artery is located within the inguinal crease. Using a nerve stimulation technique, the needle is guided in a lateral to medial direction to evoke patellar movement or quadriceps muscle twitch. Thigh twitching is commonly noted indicating stimulation of the sartorius muscle, which should not be misinterpreted for quadriceps stimulation. The femoral vein, artery, and nerve can be visualized from medial to lateral when Regional Anesthesia in Children 35 Fig. An out-of-plane or in-plane approach may be undertaken to direct needle placement to femoral nerve and circumferentially surround it with local anesthetic. Complications Possible complications arise from the proximity of the femoral nerve in relation to the artery and vein. Unintentional vessel puncture and hematoma formation are potential complications as are nerve injury and infection at the site of needle insertion. Associated risks of indwelling catheter placement include that of infection, prolonged numbness, as well as catheter kinking, dislodgment and disconnection. Sciatic Nerve Blocks Anatomy and Indications Innervation of the posterior thigh and all but the medial part of the leg distal to the knee is provided for by the the sciatic nerve which is formed by nerve roots L4 to S3. The sciatic nerve continues to the posterior popliteal fossa then bifurcates to form the tibial and common peroneal nerves. In children, various locations of the sciatic nerve can be blocked via the subgluteal, anterior thigh, or popliteal approach. Successful prolonged analgesia with a continuous sciatic nerve blockade has been described. Pain management for ankle and major foot surgery in children can be accomplished by continuous sciatic nerve block. Fewer adverse effects have been demonstrated with use of continuous sciatic nerve blockade 36 Yearbook of Anesthesiology-6 as compared to epidural anesthesia in children undergoing major ankle and foot surgery. Technique With the subgluteal approach to the sciatic nerve block, the patient is placed in the lateral decubitus position with the hip and knee flexed. The nerve can be visualized between the greater trochanter and the ischial tuberosity deep to the gluteus maximus muscle with the use of ultrasonography (Fig. Success with this block has been described with both an in-plane and out-of-plane approach. In performing this block, nerve stimulation may be used alone or in combination with ultrasound. Successful continuous sciatic nerve blockade with catheter placement has been described in children. A sciatic nerve block via the anterior approach may be accomplished with use of either nerve stimulation and/or ultrasonography. The probe is positioned below the inguinal crease and the sciatic nerve is seen deep and medial to the femur. In older children as the sciatic nerve is at an increased depth, this approach may be technically challenging. The popliteal artery is easily visualized and adjacent to the artery is the sciatic nerve.