101
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Desmet M, Bindelle S, Breebaart M, Camerlynck H, Casaer S, Fourneau K, Gautier P, Goffin P, Lecoq J, Lenders I, Leunen I, Van Aken D, Van Houwe P, Van Hooreweghe S, Vermeylen K, Sermeus I. Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.3.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.
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102
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Wilson EH, Burkle CM. The Meaning of Consent and Its Implications for Anesthesiologists. Adv Anesth 2020; 38:1-22. [PMID: 34106829 DOI: 10.1016/j.aan.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Elizabeth H Wilson
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, B6/319 CSC, 600 Highland Avenue, Madison, WI 53792-3272, USA
| | - Christopher M Burkle
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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103
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Capdevila M, Saporito A, Quadri C, Dick M, Cantini LM, Bringuier S, Capdevila X. Real-time continuous monitoring of injection pressure during peripheral nerve blocks in fresh cadavers. Anaesth Crit Care Pain Med 2020; 39:597-601. [PMID: 32771496 DOI: 10.1016/j.accpm.2020.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 02/21/2020] [Accepted: 03/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The incidence of unintentional intraneural injection while performing peripheral nerve block has been estimated to be 15% under real-time ultrasound guidance. Injection pressure increase may detect an intraneural injection. Real-time injection pressure changes throughout an entire nerve block procedure in relationship with needle tip location have never been reported. METHODS A new method was developed to precisely monitor the injection pressure curve during nerve blocks, based on a miniaturised Fabbri-Perrot pressure sensor. We tested in three fresh cadavers the ability of continuous pressure monitoring to discriminate between different tissues, as the injection pressure curve ascending slope, shape and plateau pressure value depend on tissue compliance. Injections of saline were performed by an electronic syringe pump with three different constant flow rates. Pressure was measured simultaneously at the tip and in the tubing of the needle. RESULTS At 10 mL/min injection flow, median peak injection pressure in the intraneural group at the needle tip was 315 mmHg, while at the perineural location it was 100 mmHg (p < 0.05). Median injection pressure was 95 mmHg in the intramuscular locations group, and 819 mmHg when a muscular fascia was indented (p < 0.05). A significant difference was noted for pressure measurements between the proximal port of the needle and the tip, 625 and 417 respectively. CONCLUSIONS Based on significant differences in injection pressure values and curve shapes, the system was able to discriminate between four needle tip locations. This may help with needle tracking while performing a peripheral nerve block.
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Affiliation(s)
- Mathieu Capdevila
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Andrea Saporito
- Southern Switzerland Cantonal Hospital Trust (EOC), 6500 Bellinzona, Switzerland
| | - Christian Quadri
- Southern Switzerland Cantonal Hospital Trust (EOC), 6500 Bellinzona, Switzerland
| | - Maxime Dick
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Laura M Cantini
- Southern Switzerland Cantonal Hospital Trust (EOC), 6500 Bellinzona, Switzerland.
| | - Sophie Bringuier
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Department of Medical Biostatistics, Arnaud de Villeneuve University Hospital, 34295 Montpellier Cedex 5, France
| | - Xavier Capdevila
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France; Inserm Unit 1051 Montpellier NeuroSciences Institute, Montpellier University, 34295 Montpellier Cedex 5, France
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104
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Carassiti M, Cataldo R, Formica D, Massaroni C, De Filippis A, Palermo P, Di Tocco J, Setola R, Valenti C, Schena E. A new pressure guided management tool for epidural space detection: feasibility assessment in a clinical scenario. Minerva Anestesiol 2020; 86. [DOI: 10.23736/s0375-9393.20.14031-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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105
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Krysko KM, Graves JS, Dobson R, Altintas A, Amato MP, Bernard J, Bonavita S, Bove R, Cavalla P, Clerico M, Corona T, Doshi A, Fragoso Y, Jacobs D, Jokubaitis V, Landi D, Llamosa G, Longbrake EE, Maillart E, Marta M, Midaglia L, Shah S, Tintore M, van der Walt A, Voskuhl R, Wang Y, Zabad RK, Zeydan B, Houtchens M, Hellwig K. Sex effects across the lifespan in women with multiple sclerosis. Ther Adv Neurol Disord 2020; 13:1756286420936166. [PMID: 32655689 PMCID: PMC7331774 DOI: 10.1177/1756286420936166] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Multiple sclerosis (MS) is an autoimmune inflammatory demyelinating central nervous system disorder that is more common in women, with onset often during reproductive years. The female:male sex ratio of MS rose in several regions over the last century, suggesting a possible sex by environmental interaction increasing MS risk in women. Since many with MS are in their childbearing years, family planning, including contraceptive and disease-modifying therapy (DMT) counselling, are important aspects of MS care in women. While some DMTs are likely harmful to the developing fetus, others can be used shortly before or until pregnancy is confirmed. Overall, pregnancy decreases risk of MS relapses, whereas relapse risk may increase postpartum, although pregnancy does not appear to be harmful for long-term prognosis of MS. However, ovarian aging may contribute to disability progression in women with MS. Here, we review sex effects across the lifespan in women with MS, including the effect of sex on MS susceptibility, effects of pregnancy on MS disease activity, and management strategies around pregnancy, including risks associated with DMT use before and during pregnancy, and while breastfeeding. We also review reproductive aging and sexual dysfunction in women with MS.
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Affiliation(s)
- Kristen M Krysko
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, 675 Nelson Rising Lane, Suite 221, San Francisco, CA 94158, USA
| | - Jennifer S Graves
- Department of Neurosciences, University of California San Diego, UCSD ACTRI, La Jolla, CA, USA
| | - Ruth Dobson
- Preventive Neurology Unit, Wolfson Institute of Preventive Neurology, Queen Mary University of London, London, UK
| | - Ayse Altintas
- Department of Neurology, School of Medicine, Koc University, Istanbul, Turkey
| | - Maria Pia Amato
- Department NEUROFARBA, Section of Neurosciences, University of Florence, Florence, Italy
| | - Jacqueline Bernard
- Department of Neurology, Oregon Health Science University, Portland, OR, USA
| | - Simona Bonavita
- Department of Advanced Medical and Surgical Sciences, University of Campania, "Luigi Vanvitelli", Naples, Italy
| | - Riley Bove
- Department of Neurology, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco CA, USA
| | - Paola Cavalla
- Department of Neuroscience and Mental Health, City of Health and Science University Hospital of Torino, Turin, Italy
| | - Marinella Clerico
- Department of Clinical and Biological Sciences, University of Torino, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy
| | - Teresa Corona
- Clinical Laboratory of Neurodegenerative Disease, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
| | - Anisha Doshi
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, University College London (UCL) Institute of Neurology, London, UK
| | - Yara Fragoso
- Multiple Sclerosis & Headache Research Institute, Santos, SP, Brazil
| | - Dina Jacobs
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Vilija Jokubaitis
- Department of Neuroscience, Monash University, Melbourne, VIC, Australia
| | - Doriana Landi
- Department of Systems Medicine, Multiple Sclerosis Center and Research Unit, Tor Vergata University and Hospital, Rome, Italy
| | | | | | | | - Monica Marta
- Neurosciences and Trauma Centre, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Luciana Midaglia
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Suma Shah
- Department of Neurology, Duke University, Durham, NC, USA
| | - Mar Tintore
- Department of Neurology-Neuroimmunology, Multiple Sclerosis Centre of Catalonia, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Rhonda Voskuhl
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, USA
| | - Yujie Wang
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Rana K Zabad
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Burcu Zeydan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Maria Houtchens
- Department of Neurology, Partners MS Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kerstin Hellwig
- Department of Neurology, St. Josef Hospital, Ruhr University Bochum, Bochum, Germany
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106
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Cale AS, Hendrickse A, Lyman M, Royer DF. Integrating a Cadaver Review Session into the Existing Regional Anesthesia Training for Anesthesiology Residents: An Initial Experience. MEDICAL SCIENCE EDUCATOR 2020; 30:695-703. [PMID: 34457727 PMCID: PMC8368319 DOI: 10.1007/s40670-020-00934-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The Department of Anesthesiology's Acute Pain Service (APS) places ultrasound-guided peripheral nerve blocks (PNBs) to manage acute peri-operative pain. PNB success is dependent on detailed anatomical knowledge which residents may not have formally reviewed since medical school. This study describes the integration of a cadaver review session (CRS) that reintroduces PNB-related anatomy into the existing APS rotation. During each CRS, an anatomist reviewed the major nerve and surrounding structures, while an APS attending integrated the anatomy with PNB techniques. During the pilot, 1st- and 3rd-year clinical anesthesia (CA) residents (9 CA1s, 7 CA3s) completed pre- and post-session surveys and rated the CRS's perceived value and impact on self-confidence with anatomical knowledge. Following the pilot, an additional 17 CA1s and 9 CA3s participated in the CRS and completed post-session surveys. Descriptive statistics were used to summarize responses and unpaired t tests were used to compare pre- and post-session responses and responses between cohorts. All participants were overwhelmingly positive about the CRS and its value to the APS rotation, with 98% agreeing they recommend the CRS and found it accessible. Residents believed participation would improve board exam (average = 4.83 ± 0.66) and clinical performance (average = 4.86 ± 0.65), and self-reported increases in confidence with anatomical knowledge. Residents in the pilot group reported significantly greater confidence (p < 0.01) in their perceived anatomical knowledge after the CRS. The CRS positively impacted resident confidence in their anatomical knowledge and perceived ability to identify anatomical structures. Residents reported the CRS was a highly valued addition to regional anesthesia training.
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Affiliation(s)
- Andrew S. Cale
- Department of Anatomy, Cell Biology & Physiology, Indiana University School of Medicine, Indianapolis, IN USA
| | - Adrian Hendrickse
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO USA
| | - Matthew Lyman
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO USA
| | - Danielle F. Royer
- Modern Human Anatomy Program, University of Colorado Anschutz Medical Campus, Aurora, CO USA
- Department of Cell and Developmental Biology, University of Colorado School of Medicine, Aurora, CO USA
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107
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Lam KK, Soneji N, Katzberg H, Xu L, Chin KJ, Prasad A, Chan V, Niazi A, Perlas A. Incidence and etiology of postoperative neurological symptoms after peripheral nerve block: a retrospective cohort study. Reg Anesth Pain Med 2020; 45:495-504. [DOI: 10.1136/rapm-2020-101407] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/27/2020] [Accepted: 04/08/2020] [Indexed: 11/04/2022]
Abstract
BackgroundNerve injury from peripheral nerve block (PNB) is an uncommon but potentially serious complication. We present a retrospective cohort study to evaluate the incidence and etiology of new postoperative neurological symptoms after surgery and regional anesthesia.MethodsWe performed a retrospective cohort study of all PNBs performed on elective orthopedic and plastic surgical patients over 6 years (2011–2017). We collected patient and surgical data, results of neurophysiological and imaging tests, neurology and chronic pain consultations, etiology and outcome for patients with prolonged neurological symptoms (lasting ≥10 days).ResultsA total of 26 251 PNBs were performed in 19 219 patients during the study period. Transient postoperative neurological symptoms (<10 days) were reported by 14.4% (95% CI 13.1% to 15.7%) of patients who were reached by telephone follow-up. Prolonged postoperative neurological symptoms (≥10 days) were identified and investigated in 20 cases (1:1000, 95% CI 0.6 to 1.6). Of these 20 cases, three (0.2:1000, 95% CI 0.04 to 0.5) were deemed to be block related, seven related to surgical causes, three due to musculoskeletal causes or pain syndromes, one was suspected of having an inflammatory etiology and six remained of undetermined etiology. Of those who completed follow-up, 56% had full recovery of their symptoms with the remaining having partial recovery.ConclusionThis retrospective review of 19 219 patients receiving PNBs for anesthesia or analgesia suggests that determining the etiology and causative factors of postoperative neurological symptoms is a complex, often challenging process that requires a multidisciplinary approach. We suggest a classification of cases based on the etiology. A most likely cause was identified in 70% of cases. This type of classification system can help broaden the differential diagnosis, help consider non-regional anesthesia and non-surgical causes and may be useful for clinical and research purposes.
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108
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Aguiar I, Ferreira E, Pontes R, Panzina A, Paiva M, Milheiro A. Dilemmas in primary spinal glioblastoma management during pregnancy. ACTA ACUST UNITED AC 2020; 67:347-350. [PMID: 32439230 DOI: 10.1016/j.redar.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/16/2020] [Accepted: 02/21/2020] [Indexed: 10/24/2022]
Abstract
Primary spinal glioblastoma (GBM) is a clinically rare entity with rapid progression and a dismal outcome despite aggressive treatment. In a pregnant woman, this malignancy is particularly dramatic because the potential benefits to the mother offered by standard GBM treatment must be balanced against the risks to the fetus. There is little guidance in the literature on how to manage pregnant patients with malignant neuraxial tumours and, to the authors' knowledge, no reports have been published so far regarding this specific neoplasm in such population. This case report describes the management of a pregnant patient with a previously undiagnosed and rapidly progressive intramedullary GBM submitted to an elective caesarean delivery to allow subsequent onset of oncological treatment. Dilemmas faced by anaesthetists are discussed in hope to provide guidance for future decisions and optimize outcomes.
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Affiliation(s)
- I Aguiar
- Departamento de Anestesiología, Centro Hospitalario Vila Nova de Gaia/Espinho, E.P.E, Vila Nova de Gaia, Portugal.
| | - E Ferreira
- Departamento de Anestesiología, Centro Hospitalario Vila Nova de Gaia/Espinho, E.P.E, Vila Nova de Gaia, Portugal
| | - R Pontes
- Departamento de Anestesiología, Centro Hospitalario Vila Nova de Gaia/Espinho, E.P.E, Vila Nova de Gaia, Portugal
| | - A Panzina
- Departamento de Anestesiología, Centro Hospitalario Vila Nova de Gaia/Espinho, E.P.E, Vila Nova de Gaia, Portugal
| | - M Paiva
- Departamento de Anestesiología, Centro Hospitalario Vila Nova de Gaia/Espinho, E.P.E, Vila Nova de Gaia, Portugal
| | - A Milheiro
- Departamento de Anestesiología, Centro Hospitalario Vila Nova de Gaia/Espinho, E.P.E, Vila Nova de Gaia, Portugal
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109
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Laredo FG, Belda E, Soler M, Gil F, Murciano J, Sánchez-Campillo J, Agut A. Short-Term Effects of Deliberate Subparaneural or Subepineural Injections With Saline Solution or Bupivacaine 0.75% in the Sciatic Nerve of Rabbits. Front Vet Sci 2020; 7:217. [PMID: 32478104 PMCID: PMC7235316 DOI: 10.3389/fvets.2020.00217] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/01/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Ultrasound (US)-guided techniques for peripheral nerve blockade have revealed that intraneural injections are relatively frequent and not necessarily associated with neurological deficits. Objectives: To evaluate the short-term effects of deliberate injections performed under direct vision in two different sites of the sciatic nerve (ScN). Material and Methods: Seventy-two New Zealand white rabbits randomly assigned to one of four experimental groups (n = 18) were employed. All procedures were conducted at a proximal femoral level where the ScN incorporates the common peroneal nerve and the tibial nerve (TN). Fixed volumes of 0.5 ml of saline solution (ES group) or bupivacaine 0.75% (EB group) were administered extrafascicularly inside the paraneurium of the ScN or intrafascicularly (IS and IB groups) under the epineurium of the TN. Cross-sectional area (CSA) and relative echogenicity (RE) of the entire ScN were determined by US before injections, after injections, and at 3 and 7 days. ScN samples were obtained for structural and ultrastructural histopathological studies. Proprioceptive, sensorial, and motor function were clinically evaluated on a daily basis. Results: The CSA of the ScN increased significantly immediately after injections when compared with pre-injection values in all groups (p < 0.05). The RE of the ScN decreased in relation to pre-injection values in all groups (p < 0.05). The CSA and RE of the ScN returned to normal values 7 days after injections in almost all groups. Injected nerves showed histological signs of mild perineural inflammation. Histopathological scores were not significantly different between groups (p > 0.05). The architecture of the ScN was preserved in all rabbits at 3 days and in 31/32 rabbits at 7 days. A focal area of damaged nerve fibers with degeneration of the axons and myelin sheath affecting the TN was observed in one rabbit of the IB group. Nerve function was not clinically impaired in any case. Conclusion: Despite the lack of severe nerve disruption observed in most rabbits, the evidence of a focal area of damaged nerve fibers in one rabbit injected intrafascicularly with bupivacaine confirms that intrafascicular injections should be avoided as they may increase the risk of nerve damage.
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Affiliation(s)
- Francisco G Laredo
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Eliseo Belda
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Marta Soler
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Francisco Gil
- Department of Comparative Anatomy and Pathological Anatomy, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - José Murciano
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Joaquín Sánchez-Campillo
- Department of Comparative Anatomy and Pathological Anatomy, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
| | - Amalia Agut
- Department of Medicine and Animal Surgery, Faculty of Veterinary Science, University of Murcia, Murcia, Spain
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110
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Soberón JR, Urdaneta F. Regional anesthesia during the COVID-19 pandemic: a time to reconsider practices? (Letter #1). Can J Anaesth 2020; 67:1282-1283. [PMID: 32358763 PMCID: PMC7194080 DOI: 10.1007/s12630-020-01681-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 04/05/2020] [Accepted: 04/06/2020] [Indexed: 01/30/2023] Open
Affiliation(s)
- José R Soberón
- Department of Anesthesiology, North Florida/Southern Georgia Veterans Health System and the University of Florida, Gainesville, FL, USA. .,Department of Anesthesiology, University of Central Florida, Orlando, FL, USA.
| | - Felipe Urdaneta
- Department of Anesthesiology, North Florida/Southern Georgia Veterans Health System and the University of Florida, Gainesville, FL, USA
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111
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Gessner DM, Horn JL, Lowenberg DW. Pain management in the orthopaedic trauma patient: Non-opioid solutions. Injury 2020; 51 Suppl 2:S28-S36. [PMID: 31079833 DOI: 10.1016/j.injury.2019.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 04/18/2019] [Indexed: 02/02/2023]
Abstract
When treating pain in the orthopaedic trauma patient opioids have classically represented the mainstay of treatment. They are relatively inexpensive and modestly effective for basic pain management. However, they are fraught with considerable side effects as well as the very high risk of addiction. Their use in pain management has been implicated in the opioid epidemic. For this reason, as well as their only moderate efficacy, alternative modes of treatment have been sought for both the patient with isolated limb trauma and the patient with poly trauma. We review alternative treatment methods in pain management for those with isolated limb trauma and poly trauma. These methods include topical agents, as well as non steroidal anti-inflammatory medications, acetaminophen, gabapetoids, intravenous agents, varying degrees of local anesthetic infiltration and peripheral nerve blocks, and the newer modality of fascial plane blocks. Often, it is a combination of these analgesic modalities that gives the most optimum treatment for the trauma patient. This also, more frequently than not, must be individually tailored to the patient, as no two patients act the same in this regard. It is therefore of importance that the physician managing such patients's pain be experienced and well-versed in all these treatment modalities. We also provide a basic stepwise algorithm we have found useful in treating those with single extremity or single site trauma versus those patients with poly trauma and resultant multiple sources as pain generators. It is hoped that this breakdown of the different modalities along with a better understanding of each modality's potential benefits and indications will aid the surgeon in providing better care to patients following orthopedic trauma.
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Affiliation(s)
- Daniel M Gessner
- Department of Anesthesiology, Stanford University School of Medicine, USA
| | - Jean-Louis Horn
- Department of Anesthesiology, Stanford University School of Medicine, USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University School of Medicine, 450 Broadway St., Mailcode 6342, Redwood City, CA, 94063, USA.
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112
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Wells AV, Akerman M, Weinberg RY. In Response. A A Pract 2020; 14:e01226. [DOI: 10.1213/xaa.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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113
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Connolly TM, Nadav D, Gungor S. Ultrasound-guided caudal epidural steroid injection for successful treatment of radiculopathy during pregnancy. Pain Manag 2020; 10:67-71. [PMID: 32162584 DOI: 10.2217/pmt-2019-0044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: The aim of this case report is to describe ultrasound guidance for caudal epidural steroid injection during pregnancy. Case report: A 29-year-old, 32-week parturient presented with severe back and leg pain with MRI demonstrating herniation of the L5-S1 level. The disabling pain was refractory to conservative therapy, and an ultrasound-guided caudal epidural steroid injection was performed. There was significant pain relief in the first week with an uneventful subsequent pregnancy. Following delivery, the patient had no further recurrence of her presenting symptoms. Conclusion: Severe radiculopathy may be encountered during pregnancy, complicated by a limited number of treatment options. Ultrasound guidance should be considered during performance of caudal epidural injections in feasible cases.
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Affiliation(s)
- Timothy M Connolly
- Division of Pain Medicine, Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery - Weill Cornell Medicine, 535 East 70th Street, NY 10021, USA.,Department of Anesthesiology, Weill Cornell Medicine, Cornell University, NY 10065, USA
| | - Danielle Nadav
- Department of Anesthesiology, Weill Cornell Medicine, Cornell University, NY 10065, USA
| | - Semih Gungor
- Division of Pain Medicine, Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery - Weill Cornell Medicine, 535 East 70th Street, NY 10021, USA.,Department of Anesthesiology, Weill Cornell Medicine, Cornell University, NY 10065, USA
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114
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Cavaliere F, Allegri M, Apan A, Calderini E, Carassiti M, Coluzzi F, Di Marco P, Langeron O, Rossi M, Spieth P. A year in review in Minerva Anestesiologica 2018. Minerva Anestesiol 2020; 85:206-220. [PMID: 30773000 DOI: 10.23736/s0375-9393.19.13597-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy -
| | - Massimo Allegri
- Unità Operativa Terapia del Dolore della Colonna e dello Sportivo, Policlinic of Monza, Monza, Italy.,Italian Pain Group, Milan, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Giresun University, Giresun, Turkey
| | - Edoardo Calderini
- Unit of Women-Child Anesthesia and Intensive Care, IRCCS Cà Granda Foundation, Maggiore Policlinico Hospital, Milan, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, University Hospital School of Medicine Campus Bio-Medico of Rome, Rome, Italy
| | - Flaminia Coluzzi
- Unit of Anesthesia, Department of Medical and Surgical Sciences and Biotechnologies, Intensive Care and Pain Medicine, Sapienza University, Rome, Italy
| | - Pierangelo Di Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesiology and Intensive Care, Pitié-Salpètrière Hospital, Sorbonne University Paris, Paris, France
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Dresden, Dresden, Germany
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115
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Regional anesthesia for vascular surgery: does the anesthetic choice influence outcome? Curr Opin Anaesthesiol 2020; 32:690-696. [PMID: 31415047 DOI: 10.1097/aco.0000000000000781] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Outcomes following surgery are of major importance to clinicians, institutions and most importantly patients. This review examines whether regional anesthesia and analgesia influence outcome after vascular surgery. RECENT FINDINGS Large database analyses of contemporary practice suggest that utilizing regional anesthesia for both open and endovascular aortic aneurysm repair, lower limb revascularization and carotid endarterectomy reduces morbidity, length of stay and possibly even mortality. Results from such analyses are limited by an inherent risk of bias but are nevertheless important given the number of patients required in randomized trials to detect differences in rare outcomes. There is minimal evidence that regional anesthesia influences longer term outcomes except for arteriovenous fistula surgery where brachial plexus blocks appear to improve 3-month fistula patency. SUMMARY Patients undergoing vascular surgery often have multiple comorbidities and it is important to be able to outline both benefits and risks of regional anesthesia techniques. Regional anesthesia in vascular surgery allows avoidance of general anesthesia and does provide short-term benefits beyond superior analgesia. Evidence of long-term benefits is lacking in most procedures. Further work is required on newer patient centered outcomes.
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A Contemporary Medicolegal Analysis of Outpatient Interventional Pain Procedures: 2009-2016. Anesth Analg 2020; 129:255-262. [PMID: 30925562 DOI: 10.1213/ane.0000000000004096] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Closed malpractice claim studies allow a review of rare but often severe complications, yielding useful insight into improving patient safety and decreasing practitioner liability. METHODS This retrospective observational study of pain medicine malpractice claims utilizes the Controlled Risk Insurance Company Comparative Benchmarking System database, which contains nearly 400,000 malpractice claims drawn from >400 academic and community medical centers. The Controlled Risk Insurance Company Comparative Benchmarking System database was queried for January 1, 2009 through December 31, 2016, for cases with pain medicine as the primary service. Cases involving outpatient interventional pain management were identified. Controlled Risk Insurance Company-coded data fields and the narrative summaries were reviewed by the study authors. RESULTS A total of 126 closed claims were identified. Forty-one claims resulted in payments to the plaintiffs, with a median payment of $175,000 (range, $2600-$2,950,000). Lumbar interlaminar epidural steroid injections were the most common procedures associated with claims (n = 34), followed by cervical interlaminar epidural steroid injections (n = 31) and trigger point injections (n = 13). The most common alleged injuring events were an improper performance of a procedure (n = 38); alleged nonsterile technique (n = 17); unintentional dural puncture (n = 13); needle misdirected to the spinal cord (n = 11); and needle misdirected to the lung (n = 10). The most common alleged outcomes were worsening pain (n = 26); spinal cord infarct (n = 16); epidural hematoma (n = 9); soft-tissue infection (n = 9); postdural puncture headache (n = 9); and pneumothorax (n = 9). According to the Controlled Risk Insurance Company proprietary contributing factor system, perceived deficits in technical skill were present in 83% of claims. CONCLUSIONS Epidural steroid injections are among the most commonly performed interventional pain procedures and, while a familiar procedure to pain management practitioners, may result in significant neurological injury. Trigger point injections, while generally considered safe, may result in pneumothorax or injury to other deep structures. Ultimately, the efforts to minimize practitioner liability and patient harm, like the claims themselves, will be multifactorial. Best outcomes will likely come from continued robust training in procedural skills, attention paid to published best practice recommendations, documentation that includes an inclusive consent discussion, and thoughtful patient selection. Limitations for this study are that closed claim data do not cover all complications that occur and skew toward more severe complications. In addition, the data from Controlled Risk Insurance Company Comparative Benchmarking System cannot be independently verified.
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Biyani G, Sardesai AM, Rensburg LV. Not everything is as it seems. Saudi J Anaesth 2020; 14:104-106. [PMID: 31998028 PMCID: PMC6970352 DOI: 10.4103/sja.sja_412_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/20/2019] [Indexed: 11/24/2022] Open
Abstract
We report a case of a patient operated for shoulder rotator cuff injury under interscalene brachial plexus block and general anesthesia, who developed neurological deficit in the nonoperative upper limb in the immediate postoperative period. As our patient developed neurological deficit on the nonoperative side, it was clear from the beginning that neither the nerve block nor the operative procedure was responsible for it. However, had he developed neurological symptoms on the operative side after having a peripheral nerve block, it would have possibly delayed the timely investigation and diagnosis. This case report underlines the need to keep an open mind when investigating neurological symptoms arising in the perioperative period, rather than assuming it to be secondary to either nerve block or as a complication of surgical procedure.
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Affiliation(s)
- Ghansham Biyani
- Department of Anaesthesia, Cambridge University Hospital, Cambridge, UK
| | - Anand M. Sardesai
- Department of Anaesthesia, Cambridge University Hospital, Cambridge, UK
| | - Lee Van Rensburg
- Department of Trauma and Orthopedics, Cambridge University Hospital, Cambridge, UK
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Missair A, Cata JP, Votta-Velis G, Johnson M, Borgeat A, Tiouririne M, Gottumukkala V, Buggy D, Vallejo R, Marrero EBD, Sessler D, Huntoon MA, Andres JD, Casasola ODL. Impact of perioperative pain management on cancer recurrence: an ASRA/ESRA special article. Reg Anesth Pain Med 2019; 44:13-28. [PMID: 30640648 DOI: 10.1136/rapm-2018-000001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 05/31/2018] [Accepted: 06/05/2018] [Indexed: 12/31/2022]
Abstract
Cancer causes considerable suffering and 80% of advanced cancer patients experience moderate to severe pain. Surgical tumor excision remains a cornerstone of primary cancer treatment, but is also recognized as one of the greatest risk factors for metastatic spread. The perioperative period, characterized by the surgical stress response, pharmacologic-induced angiogenesis, and immunomodulation results in a physiologic environment that supports tumor spread and distant reimplantation.In the perioperative period, anesthesiologists may have a brief and uniquewindow of opportunity to modulate the unwanted consequences of the stressresponse on the immune system and minimize residual disease. This reviewdiscusses the current research on analgesic therapies and their impact ondisease progression, followed by an evidence-based evaluation of perioperativepain interventions and medications.
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Affiliation(s)
- Andres Missair
- Department of Anesthesiology, Veterans Affairs Hospital, Miami, Florida, USA .,Department of Anesthesiology, University of Miami, Miami, Florida, USA
| | - Juan Pablo Cata
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gina Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Mark Johnson
- Department of Anesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Alain Borgeat
- Department of Anesthesiology, University of Zurich, Balgrist, Switzerland
| | - Mohammed Tiouririne
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Vijay Gottumukkala
- Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Donal Buggy
- Department of Anesthesiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ricardo Vallejo
- Department of Anesthesiology, Illinois Wesleyan University, Bloomington, Illinois, USA
| | - Esther Benedetti de Marrero
- Department of Anesthesiology, Veterans Affairs Hospital, Miami, Florida, USA.,Department of Anesthesiology, University of Miami, Miami, Florida, USA
| | - Dan Sessler
- Department of Anesthesiology and Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marc A Huntoon
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jose De Andres
- Department of Anesthesiology, General University Hospital, Valencia, Spain
| | - Oscar De Leon Casasola
- Department of Anesthesiology, University of Buffalo / Roswell Park Cancer Institute, Buffalo, New York, USA
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Fuertes Sáez N, Giménez Jiménez I, Batista Doménech M, Montero Sánchez F, Elia Martínez I, Argente Navarro P. Motor deficit in the puerperium. Is neuroaxial analgesia the most frequent cause? ACTA ACUST UNITED AC 2019; 67:215-218. [PMID: 31785785 DOI: 10.1016/j.redar.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 10/08/2019] [Indexed: 11/18/2022]
Abstract
Motor deficits of lower limbs during pregnancy and the puerperium are relatively frequent. They are usually attributed to complications which are associated with neuroaxial techniques performed by the anesthesiologist. But there are other possible causes, such as transient osteoporosis of the hips. Transient osteoporosis of pregnancy is a rare and self-limited pathology of unknown etiology. The most severe complication that can occur are pathological fractures, mainly in the load joints. This pathology usually occurs in the third trimester of pregnancy and is showed up with pain and functional impotence of the lower limb affected. We present the case of a 35-year-old woman, 40+3 weeks of pregnancy who starts labour. Normally functioning epidural catheter is placed and finally cesarean section is decided because failure to progress; 48h later the patient begins with functional impotence and pain in the lower left limb. MRI is performed, epidural hematoma is ruled out and osteopenia of the hips is proved. The patient is diagnosed with transient osteoporosis of pregnancy.
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Affiliation(s)
- N Fuertes Sáez
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España.
| | - I Giménez Jiménez
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - M Batista Doménech
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - F Montero Sánchez
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - I Elia Martínez
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, España
| | - P Argente Navarro
- Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, España
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery.
Methods
We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators.
Results
We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups.
Conclusions
In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant.
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Joshi GP, Benzon HT, Gan TJ, Vetter TR. Consistent Definitions of Clinical Practice Guidelines, Consensus Statements, Position Statements, and Practice Alerts. Anesth Analg 2019; 129:1767-1770. [PMID: 31743199 DOI: 10.1213/ane.0000000000004236] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
An evidence-based approach to clinical decision-making for optimizing patient care is desirable because it promotes quality of care, improves patient safety, decreases medical errors, and reduces health care costs. Clinical practice recommendations are systematically developed documents regarding best practice for specific clinical management issues, which can assist care providers in their clinical decision-making. However, there is currently wide variation in the terminology used for such clinical practice recommendations. The aim of this article is to provide guidance to authors, reviewers, and editors on the definitions of terms commonly used for clinical practice recommendations. This is intended to improve transparency and clarity regarding the definitions of these terminologies.
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Affiliation(s)
- Girish P Joshi
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Honorio T Benzon
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University, Stony Brook, New York
| | - Thomas R Vetter
- Department of Surgery and Perioperative Care, Dell Medical School at University of Texas, Austin, Texas
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Is It the Surgery or the Block? Incidence, Risk Factors, and Outcome of Nerve Injury following Upper Extremity Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2458. [PMID: 31741818 PMCID: PMC6799396 DOI: 10.1097/gox.0000000000002458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 07/23/2019] [Indexed: 11/27/2022]
Abstract
Although numerous studies have addressed the topic of postoperative nerve injury, debate continues to exist on its exact incidence, risk factors, etiology, and functional outcome. The aim of this study is to investigate the incidence of nerve injury and to identify patient, anesthetic, and surgical factors pertaining to perioperative nerve injury. Also, long-term nerve injury outcomes were assessed in terms of functionality. Methods A total of 297 patients, scheduled for elective distal upper extremity surgery, were prospectively included. At various time points, patients were screened for new onset nerve injury by means of clinical examination and questionnaires (including the Quick Disabilities of the Arm, Shoulder and Hand functionality measure). Results New nerve injury was diagnosed in 14 patients [4.7% (95% CI, 2.8-7.8)], but no causative risk factors were identified. The exact origin of nerve injury is suspected to be surgical in 11 cases. At 4 years postoperatively, 5 of the 14 patients with nerve injury (36%) were still symptomatic and had reduced functionality relative to preoperative status. Conclusions This study demonstrates an incidence of all cause nerve injury of 4.7%. No specific patient, anesthetic, or surgical risk factors are identified and, importantly, patients who received regional anesthesia are not at more risk of nerve injury than those who received general anesthesia. The exact origin of nerve injury is very difficult to determine, but is suspected to be caused by direct surgical trauma in most cases. Four years following the nerve injury, approximately 40% of the patients with new onset nerve injury have reduced functionality.
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123
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Huang H, Yao D, Saba R, Brovman EY, Kang D, Greenberg P, Urman RD. A contemporary medicolegal claims analysis of injuries related to neuraxial anesthesia between 2007 and 2016. J Clin Anesth 2019; 57:66-71. [DOI: 10.1016/j.jclinane.2019.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/19/2019] [Accepted: 03/03/2019] [Indexed: 11/15/2022]
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Wu X, Yang L. Quadratus Lumborum and modified Erector Spinae Plane (QLESP) block: A single-puncture technique for total hip arthroplasty. J Clin Anesth 2019; 61:109643. [PMID: 31668470 DOI: 10.1016/j.jclinane.2019.109643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 10/11/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Xi Wu
- Department of Anesthesiology, Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Lei Yang
- Department of Anesthesiology, Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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125
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Sajan SM, Ajayan N, Nair GD, Lionel KR, Hrishi AP. Anaesthetic Challenges in a Rare Syndrome: Perioperative Management of a Patient with POEMS Syndrome Who Underwent Umbilical Hernioplasty. Turk J Anaesthesiol Reanim 2019; 47:420-422. [PMID: 31572995 DOI: 10.5152/tjar.2019.53824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/27/2018] [Indexed: 11/22/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome also known as 'Crow Fukase syndrome' is a rare paraneoplastic disorder, first described by Crow and Fukase with distinctive features of polyradiculoneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin changes. There is a paucity of literature about anaesthetic management of patients with POEMS syndrome with isolated case reports of surgery under general anaesthesia and central neuraxial blockade. We present here the anaesthetic management of a patient with POEMS syndrome posted for umbilical hernia repair, which was successfully managed with a transverse abdominis plane (TAP) block.
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Affiliation(s)
- Sajil M Sajan
- Kaduvayil Thangal Charitable Trust Hospital, Kerala, India
| | - Neeraja Ajayan
- Sree Chitra Tirunal Institute For Medical Sciences, Kerala, India
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A 3-arm randomized clinical trial comparing interscalene blockade techniques with local infiltration analgesia for total shoulder arthroplasty. J Shoulder Elbow Surg 2019; 28:e325-e338. [PMID: 31353302 DOI: 10.1016/j.jse.2019.05.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/27/2019] [Accepted: 05/06/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND The ideal analgesic modality for total shoulder arthroplasty (TSA) remains controversial. We hypothesized that a multimodal analgesic pathway incorporating continuous interscalene blockade (ISB) provides better analgesic efficacy than both single-injection ISB and local infiltration analgesia. METHODS This single-center, parallel, unblinded, randomized clinical trial evaluated 129 adults undergoing primary TSA. Patients were allocated to single-injection ISB, continuous ISB, or local infiltration analgesia. The primary outcome was the Overall Benefit of Analgesia Score (range, 0 [best] to 28 [worst]) on postoperative day 1. Additional outcomes included pain scores, opioid consumption, quality of life, and postoperative complications in the first 24 hours, at 3 months, and at 1 year. RESULTS We analyzed 125 patients (42 with single-injection ISB, 41 with continuous ISB, and 42 with local infiltration analgesia). The Overall Benefit of Analgesia Score was significantly improved in the continuous group (median [25th percentile, 75th percentile], 0 [0, 2]) compared with the single-injection group (2 [1, 4]; P = .002) and local infiltration analgesia group (3 [2, 4]; P < .001). Pain scores were significantly lower in the continuous group compared with the local infiltration analgesia group (P < .001 for all time points) and after 12 hours from ward arrival compared with the single-injection group (median [25th percentile, 75th percentile], 1.0 [0.0, 2.8] vs. 2.5 [0.0, 4.0]; P = .016). After postanesthesia recovery discharge, opioid consumption (oral morphine equivalents) was significantly lower in the continuous group (median [25th percentile, 75th percentile], 7.5 mg [0.0, 25.0 mg]) than in the local infiltration analgesia group (30 mg [15.0, 52.5 mg]; P < .001) and single-injection group (17.6 mg [7.5, 45.5 mg]; P = .010). No differences were found across groups for complications, 3-month outcomes, and 1-year outcomes. CONCLUSION Continuous ISB provides superior analgesia compared with single-injection ISB and local infiltration analgesia in the first 24 hours after TSA.
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Gerber TJ, Friedrich M, Herren Gerber R, Sartoretti-Schefer S, Ganter MT. Subdural Displacement of an Epidural Catheter With Spinal Cord Compression in a Patient With Chronic Cancer Pain: A Case Report. A A Pract 2019; 13:468-472. [DOI: 10.1213/xaa.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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128
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Verheijen E, Munts AG, van Haagen O, de Vries D, Dekkers O, van den Hout W, Vleggeert-Lankamp C. Transforaminal epidural injection versus continued conservative care in acute sciatica (TEIAS trial): study protocol for a randomized controlled trial. BMC Neurol 2019; 19:216. [PMID: 31481010 PMCID: PMC6719366 DOI: 10.1186/s12883-019-1445-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 08/25/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Sciatica is a condition that is characterised by radicular pain in the leg and primarily caused by a herniated lumbar intervertebral disk. In addition to leg pain, patients can experience back pain, leg numbness and leg weakness resulting in decreased productivity and social activity. The majority of sciatica cases recovers spontaneously and therefore patients are initially treated conservatively with oral pain medication. However, some patients experience intractable pain that severely impedes them and no consensus exists on the optimal conservative treatment to reduce this discomfort in the acute phase of sciatica. The aim of the TEIAS trial is to assess the effectiveness, cost-effectiveness and predictive capability on patient outcome of transforaminal epidural injection (TEI) compared to treatment with standard pain medication. METHODS This study is designed as a prospective, open-label, mono-centered, randomized controlled trial. Patients that visit their general practitioner with complaints of radicular leg pain and meet the selection criteria are asked to participate in this study. Eligible patients will be randomized to treatment with TEI or to treatment with standard oral pain medication. Treatment of TEI will comprise lidocaine with methylprednisolone acetate for L3 and below and lidocaine with dexamethasone above L3. A total of 142 patients will be recruited and follow-up will occur after 1, 2, 4, 10 and 21 weeks for assessment of pain, functionality, patient received recovery and cost-effectiveness. The primary outcome will be the average score for leg pain at 2 weeks. For this outcome we defined a clinically relevant difference as 1.5 on the 11-point NRS scale. DISCUSSION Adequate conservative treatment in the acute phase of sciatica is lacking, particularly for patients with severe symptoms. Focusing on effectiveness, cost-effectiveness and predictive capability on patient outcome of TEI will produce useful information allowing for more lucid decision making in the conservative treatment of sciatica in the acute phase. TRIAL REGISTRATION This trial is registered in the ClinicalTrials.gov database under registry number NCT03924791 on April 23, 2019.
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Affiliation(s)
- Eduard Verheijen
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, PO Box 9600. 2300, RC Leiden, The Netherlands
| | - Alexander G. Munts
- Department of Neurology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Oscar van Haagen
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Dirk de Vries
- Department of Anaesthesiology, Spaarne Gasthuis, Haarlem, /Hoofddorp, The Netherlands
| | - Olaf Dekkers
- Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert van den Hout
- Department of Biomedical Data Science, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
The management of acute pain in older adults (age 65 or greater) requires special attention due to various physiologic, cognitive, functional, and social issues that may change with aging. Especially in the postoperative setting, there are significant complications that can occur if pain is not treated adequately for elderly patients. In this article, the authors describe these changes in detail and discuss how pain should be assessed appropriately in older patients. In addition, the authors detail the unique risks and benefits of several mainstream analgesic medications as well as interventional treatments for elderly patients. The authors' goal is to provide recommendations for health care providers on appropriately recognizing and treating pain in a safe, effective manner for aging patients.
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Affiliation(s)
- Jay Rajan
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Avenue, S-455, San Francisco, CA 94143, USA
| | - Matthias Behrends
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Avenue, S-455, San Francisco, CA 94143, USA.
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130
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Weingarten TN, Taenzer AH, Elkassabany NM, Le Wendling L, Nin O, Kent ML. Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps. PAIN MEDICINE 2019; 19:2296-2315. [PMID: 29727003 DOI: 10.1093/pm/pny079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting Expert commentary. Methods Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Andreas H Taenzer
- Departments of Anesthesiology.,Pediatrics, The Dartmouth Institute, Dartmouth Hitchcock Medical Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Linda Le Wendling
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Olga Nin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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131
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Sen S, Ge M, Prabhakar A, Moll V, Kaye RJ, Cornett EM, Hall OM, Padnos IW, Urman RD, Kaye AD. Recent technological advancements in regional anesthesia. Best Pract Res Clin Anaesthesiol 2019; 33:499-505. [PMID: 31791566 DOI: 10.1016/j.bpa.2019.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
Just two decades ago, regional anesthesia was performed blindly with dubious outcomes and little support from surgeons and patients. Technological advances in regional anesthesia have revolutionized techniques and largely improved outcomes. Ultrasound (US) technology continues to advance and has become more affordable. Improvements have come in the form of picture quality, resolution, portability, and smaller equipment. The US technology can identify otherwise unrecognized pathology and can help to optimize patient flow by allowing for more accurate triage and effective treatments and providing timelier interventions. In recent years, several different strategies to help improve and ease US-guided needle identification and placement have been developed, including magnetically guided needle US technology. Three-dimensional (3D) and four-dimensional (4D) US use is another potential way to help improve first-pass success and limit patient harm for regional anesthetics. The advent of echogenic needles and the resulting improvement in needle visualization under US has had a positive impact on physician comfort in performing regional anesthesia and on visualization time of the needle during US-guided procedures. To reduce variability and to reduce the anesthesiologist's workload, the use of robots in regional anesthesia has been assessed in recent years. Peripheral nerve stimulation (PNS) has also demonstrated efficacy in acute and chronic pain settings. Additional research and randomized controlled trials are necessary to evaluate novel technologies.
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Affiliation(s)
- Sudipta Sen
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Sciences Centre at Houston, 6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA.
| | - Michelle Ge
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Sciences Centre at Houston, 6431 Fannin Street, MSB 5.020, Houston, TX 77030, USA.
| | - Amit Prabhakar
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, 550 Peachtree Street, 30308, Atlanta, GA, USA.
| | - Vanessa Moll
- Department of Anesthesiology, Division of Critical Care, Emory University School of Medicine, 550 Peachtree Street, 30308, Atlanta, GA, USA.
| | - Rachel J Kaye
- Medical University of South Carolina School of Medicine, Charleston, SC, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA.
| | - O Morgan Hall
- Department of Anesthesiology, Louisiana State University School of Medicine, Room 656, 1542 Tulane Ave, New Orleans, LA 70112, USA.
| | - Ira W Padnos
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
| | - Alan David Kaye
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA.
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Tang S, Wang J, Tian Y, Li X, Cui Q, Xu M, Song X, Zheng Y, Yang H, Ma C, Zhan L, Zhu C, Zhang Y, Yao M, Huang Y. Sex-dependent prolongation of sciatic nerve blockade in diabetes patients: a prospective cohort study. Reg Anesth Pain Med 2019; 44:rapm-2019-100609. [PMID: 31302640 DOI: 10.1136/rapm-2019-100609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/31/2019] [Accepted: 06/19/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Diabetes may affect the duration of nerve block after regional anesthesia. This study aimed to compare the durations of sensory and motor block in diabetes versus non-diabetes patients after lower limb nerve block and delineate any sex-based differences in the duration of sensory and motor blocks of both diabetes and non-diabetes patients. METHODS This prospective single-blinded cohort study recruited 86 patients who underwent unilateral lower extremity surgery; 52 patients were non-diabetic and 34 were diabetic. Each patient received an ultrasound-guided nerve stimulator-assisted subgluteal sciatic nerve block with 0.75% ropivacaine. Duration of sensory block was assessed with the Semmes-Weinstein monofilament test, and duration of motor block was assessed with dorsal and plantar flexion of the foot. RESULTS The sensory and motor block durations of diabetes patients were significantly prolonged versus non-diabetes patients (19.8±6.0 hours vs 15.6±5.1 hours; p<0.05) and (19.5±8.1 hours vs 14.8±5.7 hours, p=0.005), respectively. The durations of sensory and motor block were comparable between male diabetes and non-diabetes patients, but they were significantly longer in female diabetes patients. Multiple regression analysis further revealed that, after adjustment for age and preoperative sensory threshold, diabetes, fasting plasma glucose and HbA1c levels were significantly associated with sensory and motor blocks. Sex analysis showed the association was only present in female diabetes patients, not male diabetes patients. CONCLUSION The durations of sensory and motor block are significantly prolonged after subgluteal sciatic nerve block in diabetes patients. Furthermore, the prolonged nerve blockade is present only in diabetes women, not diabetes men. TRIAL REGISTRATION NUMBER NCT02482831.
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Affiliation(s)
- Shuai Tang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jin Wang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Tian
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xu Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiuju Cui
- Operating Room, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mei Xu
- Operating Room, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaojun Song
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongbo Yang
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Ma
- Department of Anatomy, Histology and Embryology, Institute of Basic Medical Sciences, Chinese Academy of MedicalSciences and Peking Union Medical College, Beijing, China
| | - Lujing Zhan
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina, USA
| | - Chaonan Zhu
- Chronic Disease Research Institute, School of Public Health, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yuelun Zhang
- Central Research Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Yao
- Department of Surgery, Wound Care Clinical Research Program, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Curing Opioid Toxicity with Intrathecal Targeted Drug Delivery. Case Rep Med 2019; 2019:3428576. [PMID: 31223311 PMCID: PMC6541971 DOI: 10.1155/2019/3428576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/16/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022] Open
Abstract
Pain is one of the most feared symptoms that concern cancer patients and their families. Despite well-established guidelines set forth by the World Health Organization (WHO) on the treatment of cancer pain, nearly half of cancer patients report poorly controlled pain. One of the most serious side effects of systemic oral opioid use is neurotoxicity, which is characterized by altered mental status and systemic neurologic impairments. Treatment strategies are supportive in nature and focused on reducing or changing the offending opioid and correcting any metabolic deficiencies. Herein, we discuss a case of opioid-induced neurotoxicity treated with intrathecal targeted drug delivery (TDD). The timing and implementation of advanced therapies such as intrathecal TDD is not well delineated. More importantly, patients and their oncologic providers are often unaware of this useful tool in treating challenging cancer-associated pain and significantly minimizing systemic opioid side effects. To ensure that patients have comprehensive oncologic care, best-practice guidelines suggest involvement of an interdisciplinary team and coordinated care. Early referral to a pain and palliative specialist may allow for improved patient outcomes and removal of unnecessary barriers to optimal patient care.
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Gentili A. Is regional analgesia useful in pain management of intensive care patients? Minerva Anestesiol 2019; 85:1050-1052. [PMID: 31213049 DOI: 10.23736/s0375-9393.19.13832-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Andrea Gentili
- Department of Anesthesia and Intensive Care, Villa Laura Hospital, Bologna, Italy -
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Sztain JF, Finneran JJ, Monahan AM, Khatibi B, Nguyen PL, Madison SJ, Bellars RH, Gabriel RA, Ahmed SS, Schwartz AK, Kent WT, Donohue MC, Padwal JA, Ilfeld BM. Continuous Popliteal-Sciatic Blocks for Postoperative Analgesia: Traditional Proximal Catheter Insertion Superficial to the Paraneural Sheath Versus a New Distal Insertion Site Deep to the Paraneural Sheath. Anesth Analg 2019; 128:e104-e108. [PMID: 31094804 DOI: 10.1213/ane.0000000000003693] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We tested the hypothesis that during a continuous popliteal-sciatic nerve block, postoperative analgesia is improved with the catheter insertion point "deep" to the paraneural sheath immediately distal to the bifurcation between the tibial and common peroneal branches, compared with the traditional approach "superficial" to the paraneural sheath proximal to the bifurcation. The needle tip location was determined to be accurately located with a fluid bolus visualized with ultrasound; however, catheters were subsequently inserted without a similar fluid injection and visualization protocol (visualized air injection was permitted and usually implemented, but not required per protocol). The average pain (0-10 scale) the morning after surgery for subjects with a catheter inserted at the proximal subparaneural location (n = 31) was a median (interquartile) of 1.5 (0.0-3.5) vs 1.5 (0.0-4.0) for subjects with a catheter inserted at the distal supraparaneural location (n = 32; P = .927). Secondary outcomes were similarly negative.
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Affiliation(s)
- Jacklynn F Sztain
- From the Department of Anesthesiology, University of California, San Diego, California
| | - John J Finneran
- From the Department of Anesthesiology, University of California, San Diego, California
- OUTCOMES RESEARCH Consortium, Cleveland, Ohio
| | - Amanda M Monahan
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bahareh Khatibi
- From the Department of Anesthesiology, University of California, San Diego, California
| | - Patrick L Nguyen
- From the Department of Anesthesiology, University of California, San Diego, California
| | - Sarah J Madison
- Department of Anesthesiology, Stanford University, Stanford, California
| | - Richard H Bellars
- From the Department of Anesthesiology, University of California, San Diego, California
| | - Rodney A Gabriel
- From the Department of Anesthesiology, University of California, San Diego, California
- OUTCOMES RESEARCH Consortium, Cleveland, Ohio
| | - Sonya S Ahmed
- Department of Orthopedics, University of California, San Diego, California
| | | | - William T Kent
- Department of Orthopedics, University of California, San Diego, California
| | - Michael C Donohue
- Department of Neurology, University of Southern California, Los Angeles, California
| | - Jennifer A Padwal
- School of Medicine, University of California, San Diego, San Diego, California
| | - Brian M Ilfeld
- From the Department of Anesthesiology, University of California, San Diego, California
- OUTCOMES RESEARCH Consortium, Cleveland, Ohio
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Kenevan MR, Smith HM, Olsen DA, Sharpe EE. Ultrasound-Assisted Combined Spinal-Epidural Anesthesia for Cesarean Delivery in a Parturient With Currarino Triad: A Case Report. A A Pract 2019; 12:393-395. [DOI: 10.1213/xaa.0000000000000941] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gadsden J, Orebaugh S. Targeted intracluster supraclavicular brachial plexus block: too close for comfort. Br J Anaesth 2019; 122:713-715. [DOI: 10.1016/j.bja.2019.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/17/2022] Open
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Regional Nerve Blocks-Best Practice Strategies for Reduction in Complications and Comprehensive Review. Curr Pain Headache Rep 2019; 23:43. [PMID: 31123919 DOI: 10.1007/s11916-019-0782-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Understanding the etiologies of the complications associated with regional anesthesia and implementing methods to reduce their occurrence provides an opportunity to foster safer practices in the delivery of regional anesthesia. RECENT FINDINGS Neurologic injuries following peripheral nerve block (PNB) and neuraxial blocks are rare, with most being transient. However, long-lasting and devastating sequelae can occur with regional anesthesia. Risk factors for neurologic injury following PNB include type of block, injection in the presence of deep sedation or general anesthesia, presence of existing neuropathy, mechanical trauma from the needle, pressure injury, intraneural injection, neuronal ischemia, iatrogenic injury related to surgery, and local anesthetic neurotoxicity. The present investigation discusses regional blocks, complications of regional blocks, risk factors, site-specific limitations, specific complications and how to prevent them from happening, avoiding complications in regional anesthesia, and the future of regional anesthesia.
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Rubio-Haro R, Morales-Sarabia J, Ferrer-Gomez C, de Andres J. Regional analgesia techniques for pain management in patients admitted to the intensive care unit. Minerva Anestesiol 2019; 85:1118-1128. [PMID: 30945513 DOI: 10.23736/s0375-9393.19.13447-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Controlling pain should be a priority in the clinical practice of intensive care units (ICUs). Monomodal analgesic approaches, such as the administration of opioids, are widely employed; however, the widespread use of opioids has catastrophic consequences, given their multiple side effects and the development of dependence. Regional analgesia (RA), with single or continuous dosing using neuraxial and peripheral catheters, can play an important role in multimodal analgesia for management of pain in critical care patients. RA provides superior pain control, as compared to systemic treatments, and is associated with a lower rate of side effects. Nevertheless, RA remains underused in ICUs. Many critically ill, post-surgical or traumatically injured patients would benefit from these techniques. For these reasons, we aim to establish a set of potential indications integrating the use of RA in analgesia protocols routinely used in ICUs. We performed a review of literature sources with contrasted evidence levels to present RA techniques and their potential applications in ICU patients.
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Affiliation(s)
- Ruben Rubio-Haro
- Department of Anesthesia, General University Hospital, Valencia, Spain
| | | | | | - José de Andres
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia University Medical School, Valencia, Spain -
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141
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Wolfe RC, Evans T. Antithrombotic Therapy and Regional Anesthesia. J Perianesth Nurs 2019; 34:439-446. [PMID: 30914136 DOI: 10.1016/j.jopan.2019.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/16/2019] [Indexed: 11/24/2022]
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143
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Rambhia M, Gadsden J. Pressure monitoring: The evidence so far. Best Pract Res Clin Anaesthesiol 2019; 33:47-56. [DOI: 10.1016/j.bpa.2019.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/15/2022]
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Gabriel RA, Swisher MW, Sztain JF, Furnish TJ, Ilfeld BM, Said ET. State of the art opioid-sparing strategies for post-operative pain in adult surgical patients. Expert Opin Pharmacother 2019; 20:949-961. [DOI: 10.1080/14656566.2019.1583743] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Rodney A. Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Matthew W. Swisher
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Jacklynn F. Sztain
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Timothy J. Furnish
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
| | - Brian M. Ilfeld
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Engy T. Said
- Department of Anesthesiology, Division of Regional Anesthesia and Acute Pain, University of California, San Diego, La Jolla, CA, USA
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Guay J, Suresh S, Kopp S. The use of ultrasound guidance for perioperative neuraxial and peripheral nerve blocks in children. Cochrane Database Syst Rev 2019; 2:CD011436. [PMID: 30820938 PMCID: PMC6395955 DOI: 10.1002/14651858.cd011436.pub3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The use of ultrasound guidance for regional anaesthesia has become popular over the past two decades. However, it is not recognized by all experts as an essential tool, perhaps because it is unclear whether ultrasound reduces the risk of severe neurological complications, and the cost of an ultrasound machine (USD 22,000) is substantially higher than the cost of other tools. This review was published in 2016 and updated in 2019. OBJECTIVES To determine whether ultrasound guidance offers any clinical advantage when neuraxial and peripheral nerve blocks are performed in children in terms of decreasing failure rate or the rate of complications. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trial registers up to March 2018 together with reference checking to identify additional studies and contacted study authors to obtain additional trial information. SELECTION CRITERIA We included all parallel randomized controlled trials that evaluated the effects of ultrasound guidance used when a regional blockade technique was performed in children. We included studies performed in children (≤ 18 years of age) undergoing any type of surgical procedure (open or laparoscopic), for which a neuraxial (spinal, epidural, caudal, or combined spinal and epidural) or peripheral nerve block (any peripheral nerve block including fascial (fascia iliaca, transversus abdominis plane, rectus sheath blocks) or perivascular blocks), for surgical anaesthesia (alone or in combination with general anaesthesia) or for postoperative analgesia, was performed with ultrasound guidance. We excluded studies in which regional blockade was used to treat chronic pain.We included studies in which ultrasound guidance was used to perform the technique in real time (in-plane or out-of-plane), as pre-scanning before the procedure or to evaluate the spread of the local anaesthetic so the position of the needle could be adjusted or the block complemented. For control groups, any other technique used to perform the block including landmarks, loss of resistance (air or fluid), click, paraesthesia, nerve stimulator, transarterial, or infiltration was accepted. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures expected by Cochrane. Our primary outcomes were failed blocks, pain scores at one hour after surgery, and block duration. Secondary outcomes included time to perform the block, number of needle passes, and minor and major complications. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included 33 trials with a total of 2293 participants from 0.9 to 12 (mean or median) years of age. Most trials were at low risk of selection, detection, attrition, and reporting bias, however the lack of blinding of participants and personnel caring for participants resulted in 25 trials being judged as at high or unclear risk of bias. We identified five ongoing trials.Ultrasound guidance probably reduces the risk of failed block (risk difference (RD) -0.16, 95% confidence interval (CI) -0.25 to -0.07; 22 trials; 1789 participants; moderate-quality evidence). When ultrasound guidance was used, there was a small to moderate reduction in pain one hour after surgery, equivalent to a reduction of 1.3 points on the revised Bieri FACES pain scale (scale; 0 = no pain, 10 = maximal pain) (standardized mean difference (SMD) -0.41, 95% CI -0.74 to -0.07 (medium effect size); 15 trials; 982 participants; moderate-quality evidence). Ultrasound guidance increases block duration by the equivalent of 42 minutes (SMD 1.24, 95% CI 0.72 to 1.75; 10 trials; 460 participants; high-quality evidence).There is probably little or no difference in the time taken to perform the block (SMD -0.46, 95% CI -1.06 to 0.13; 9 trials; 680 participants; moderate-quality evidence). It is uncertain whether the number of needle passes required is reduced with the use of ultrasound guidance (SMD -0.63, 95% CI -1.08 to -0.18; 3 trials; 256 participants; very low-quality evidence).There were no occurrences of major complications in either the intervention or control arms of the trials (cardiac arrest from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence); lasting neurological injury (19 trials; 1250 participants; low-quality evidence)).There may be little of no difference in the risk of bloody puncture (RD -0.02, 95% CI -0.05 to 0.00; 13 trials; 896 participants; low-quality evidence) or transient neurological injury (RD -0.00, 95% CI -0.01 to 0.01; 18 trials; 1230 participants; low-quality evidence). There were no occurrences of seizure from local anaesthetic toxicity (22 trials; 1576 participants; moderate-quality evidence) or block infections without neurological injury (18 trials; 1238 participants; low-quality evidence). AUTHORS' CONCLUSIONS Ultrasound guidance for regional blockade in children probably decreases the risk of failed block. It increases the duration of the block and probably decreases pain scores at one hour after surgery. There may be little or no difference in the risks of some minor complications. The five ongoing studies may alter the conclusions of the review once published and assessed.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
- University of Quebec in Abitibi‐TemiscamingueTeaching and Research Unit, Health SciencesRouyn‐NorandaQCCanada
- Faculty of Medicine, Laval UniversityDepartment of Anesthesiology and Critical CareQuebec CityQCCanada
| | - Santhanam Suresh
- Ann & Robert H. Lurie Children's Hospital of Chicago Research CenterDepartment of Pediatric Anesthesiology225 E. Chicago AveChicagoILUSA60611
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
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Abstract
PURPOSE OF REVIEW Central neuraxial blockade is increasingly the anaesthetic management of choice for parturients, including in higher risk pregnancies. Although they are usually effective and safe, there are potentially devastating neurological complications that may present either overtly or insidiously. A thorough understanding of the variety of potential neurological complications is essential to adequately consent patients in addition to diagnosing and managing complications following neuraxial anaesthesia. This review aims to describe a number of potential neurological injuries that may occur and suggested management based on available evidence. RECENT FINDINGS Current evidence supports neuraxial anaesthesia as a safe management strategy in low and many higher risk pregnancies, with a low overall incidence of neurological complications. Neuraxial blockade is safe in patients with platelet counts greater than 70 000/μl and the risk of infective complications secondary to epidural catheterization remains low until day five post procedure. There is also some early evidence supporting the use of transnasal local anaesthetic as a strategy for managing postdural puncture headache. SUMMARY Difficulty remains in establishing absolute risk of complications and optimal management strategies given the low overall number of patients affected and heterogeneity of therapy. There may be a role for centralized registration of postneuraxial complications in obstetric patients to further develop our collective understanding of these conditions.
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Mittnacht AJ, Shariat A, Weiner MM, Malhotra A, Miller MA, Mahajan A, Bhatt HV. Regional Techniques for Cardiac and Cardiac-Related Procedures. J Cardiothorac Vasc Anesth 2019; 33:532-546. [DOI: 10.1053/j.jvca.2018.09.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Indexed: 12/31/2022]
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Abstract
PURPOSE OF REVIEW This narrative review describes the current framework for informed consent discussions for regional anesthesia practice from an ethical and medicolegal stand point as the cornerstone of the patient-physician relationship and the respect for patient autonomy. Recent guidelines and position statements from anesthesia societies have emphasized the importance of these discussions and their appropriate documentation. RECENT FINDINGS Recent studies have shown that patients want to know more about both common and benign, as well as rare but serious adverse events, as it relates to their anesthetic care. Several strategies have been recently recommended as a means to facilitate a meaningful consent discussion and proper documentation in the perioperative environment. SUMMARY Defining the material risks of ultrasound-guided regional anesthetic procedures remains challenging, due in part to the difficulty in quantifying incidence rates of relatively rare events. However, well informed discussions are of great importance to support patient autonomy and lay a strong foundation for the patient-anesthesiologist relationship.
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Lavado JS, Gonçalves D, Gonçalves L, Sendino C, Valente E. General or regional? Exploring patients' anaesthetic preferences and perception of regional anaesthesia. ACTA ACUST UNITED AC 2019; 66:199-205. [PMID: 30635114 DOI: 10.1016/j.redar.2018.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 11/21/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Regional anaesthesia (RA) has gained popularity due to its numerous benefits and increasing safety. Yet, often patients refuse this procedure and prefer general anaesthesia (GA). This study aimed to investigate variables (demographic factors, safety perception of GA and RA, patients' fears, anxiety, and knowledge) related to patients' anaesthetic preference. MATERIAL AND METHODS Participants were patients aged 18 years or more proposed to an anaesthesia appointment for preoperative assessment. Patients completed a written questionnaire before meeting the anaesthesiologist. The questionnaire asked about their preferences, fears and perceptions about RA. RESULTS One hundred and 2patients agreed to participate. Mean age was 52.6±13.5 years, 57.8% were female and 44.5% had at least 12 years of education. Given the choice, 54.0% would prefer GA and 20.7% said they would refuse RA if proposed by the anaesthesiologist. Among patients who already experienced neuroaxial anaesthesia, 40.0% said they did not wish to repeat it. Patients who preferred GA over RA perceived GA to be safer than RA and expressed more anxiety towards being awake during surgery and more fear of feeling pain during surgery, of having back pain, and of needle puncture. Results also suggested that patients are unaware of RA's real risks and benefits. CONCLUSIONS Knowing patients' fears is essential for the anaesthesiologist address their patients' needs. Anaesthesiologists should work on improving general population perspective and knowledge about RA.
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Affiliation(s)
- J S Lavado
- Departamento de Anestesiología, Centro Hospitalar de Leiria, Leiria, Portugal.
| | - D Gonçalves
- Departamento de Anestesiología, Centro Hospitalar de Leiria, Leiria, Portugal
| | - L Gonçalves
- Departamento de Anestesiología, Centro Hospitalar de Leiria, Leiria, Portugal
| | - C Sendino
- Departamento de Anestesiología, Centro Hospitalar de Leiria, Leiria, Portugal
| | - E Valente
- Departamento de Anestesiología, Centro Hospitalar de Leiria, Leiria, Portugal
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150
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Tran DQ, Salinas FV, Benzon HT, Neal JM. Lower extremity regional anesthesia: essentials of our current understanding. Reg Anesth Pain Med 2019; 44:rapm-2018-000019. [PMID: 30635506 DOI: 10.1136/rapm-2018-000019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/14/2018] [Accepted: 05/23/2018] [Indexed: 12/16/2022]
Abstract
The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.
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Affiliation(s)
- De Q Tran
- Department of Anesthesiology, McGill University, Montreal, Quebec, Canada
| | - Francis V Salinas
- Department of Anesthesiology, US Anesthesia Partners-Washington, Swedish Medical Center, Seattle, Washington, USA
| | - Honorio T Benzon
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
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