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Cisewski DH, Alerhand S. 'SCALD-ED' Block: Superficial Cutaneous Anesthesia in a Lateral Leg Distribution within the Emergency Department - A Case Series. J Emerg Med 2019; 56:282-287. [PMID: 30638643 DOI: 10.1016/j.jemermed.2018.12.005] [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: 09/29/2018] [Revised: 11/22/2018] [Accepted: 12/08/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the midst of a nationwide opioid epidemic, focus has been placed on identifying and utilizing safe, effective opioid-free analgesic alternatives. Lower-extremity peripheral nerve blockades are common and often involve both motor and sensory anesthesia, resulting in leg weakness and ambulatory difficulty. The aim of this case report is to describe an ultrasound-guided peripheral nerve block technique (superficial cutaneous anesthesia in a lateral (leg) distribution within the emergency department ['SCALD-ED' block]) that provides motor-sparing, purely sensory anesthesia after a superficial injury to the lateral leg in patients presenting to the emergency department. DISCUSSION Two separate patients presenting with lateral leg pain after superficial injury (burn, cellulitis) reported continued breakthrough pain despite a standard analgesic modality of combination acetaminophen and ibuprofen. With the patient placed in prone position for ultrasound-guided access to lower-extremity nerve branches, the lateral sural cutaneous nerve (LSCN) was identified by tracing its pathway from the proximal sciatic nerve to the common peroneal (fibular) nerve to the superficial peroneal (fibular) nerve. Five mL of lidocaine (1%, with epinephrine) was injected along the superficial LSCN route for anesthetic blockade. Temporal assessments of anesthetic effect and pain improvement, and monitoring of motor or ambulatory impairment were conducted at regular intervals to assess the efficacy and feasibility of the blockade. Regional anesthesia along the LSCN sensory distribution was experienced at 7-9 min post blockade. Peak analgesic effect was experienced at 25-29 min. The duration of anesthesia was 120-150 min. A negligible amount of delayed sensory anesthesia was noted along the distal sural nerve distribution. No motor deficit, ambulatory difficulty, or adverse effects were experienced in either patient post blockade. CONCLUSION The LSCN is an identifiable target under ultrasound guidance, susceptible to localized, purely sensory blockade of pain from superficial cutaneous lateral leg injuries.
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Affiliation(s)
- David H Cisewski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey
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Huang D, Zhu L, Chen J, Zhou J. Minimally invasive spinal anesthesia for cesarean section in maternal anticoagulation therapy: a randomized controlled trial. BMC Anesthesiol 2019; 19:11. [PMID: 30636632 PMCID: PMC6330402 DOI: 10.1186/s12871-018-0679-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/28/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Anticoagulant therapy during pregnancy is widely used due to the increasing awareness of maternal hypercoagulability. Few studies have reported the use of minimally invasive spinal anesthesia in these parturients. The objective of this study was to evaluate the safety and feasibility of minimally invasive spinal anesthesia in parturients with anticoagulation therapy undergoing cesarean section. METHODS This was a randomized, controlled study conducted in 239 parturients using anticoagulants and undergoing selective cesarean section. 37 parturients withdrew, and finally parturients received spinal anesthesia using 27gauge pen type fine spinal needles (experimental group, n = 110) and 22gauge traditional spinal needles (control group, n = 92). The primary efficacy outcomes included low back pain (LBP) and postdural puncture headache (PDPH) after delivery. Secondary efficacy outcomes included visual analogue scale during subarachnoid puncture (VASdural), difference between visual analogue scale (VAS) during peripheral venipuncture and VASdural (∆VAS), VAS of back puncture point 24, 48 and 72 h after operation (VASdural-24 h, VASdural-48 h and VASdural-72 h, respectively), maternal satisfaction and hospitalization stay. RESULTS No parturient had PDPH and was suspected with spinal or intracranial haematoma in two groups. There was no significant difference in VASlbp-24 h, VASlbp-48 h and VASlbp-72 h (P = 0.056; P = 0.813; P = 0.189, respectively) between two groups. In experimental group, VASdural (P = 0.017), ∆VAS (P = 0.001) and VASdural-24 h (P < 0.0001) were lower, whereas maternal satisfaction was higher (P = 0.046). There was no significant difference in VASdural-48 h, VASdural-72 h, urination function, strength recovery and hospitalization stay (P = 0.069; P = 0.667; P = 0.105; P = 0.133; P = 0.754, respectively) between the two groups. CONCLUSIONS Minimally invasive spinal anesthesia provided lower VASdural, VASdrual-24 h and a higher maternal satisfaction. Hence, it is considered as a safe, reliable and reasonable option for cesarean section parturients during maternal anticoagulation therapy with normal platelet count and coagulation time. TRIAL REGISTRATION This study was registered at www.ClinicalTrials.gov at November 11th, 2016 ( NCT02987192 ).
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Affiliation(s)
- Dan Huang
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127 China
| | - Linjie Zhu
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127 China
| | - Jie Chen
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127 China
| | - Jie Zhou
- Department of Anesthesiology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, 200127 China
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103
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Careskey H, Narang S. Interventional Anesthetic Methods for Pain in Hematology/Oncology Patients. Hematol Oncol Clin North Am 2019; 32:433-445. [PMID: 29729779 DOI: 10.1016/j.hoc.2018.01.007] [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] [Indexed: 12/16/2022]
Abstract
This article reviews anesthetic interventional approaches to the management of pain in hematology and oncology patients. It includes a discussion of single interventions including peripheral nerve blocks, plexus injections, and sympathetic nerve neurolysis, and continuous infusion therapy through implantable devices, such as intrathecal pumps, epidural port-a-caths, and tunneled catheters. The primary objective is to inform members of hematology and oncology care teams regarding the variety of interventional options for patients with cancer-related pain for whom medical pain management methods have not been effective.
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Affiliation(s)
- Holly Careskey
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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104
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Benson B, Benson A. Preoperative Anesthetic Considerations in the Podiatric Surgical Candidate. Clin Podiatr Med Surg 2019; 36:1-19. [PMID: 30446037 DOI: 10.1016/j.cpm.2018.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
There are multiple challenges the podiatric surgeon faces while attempting to treat patients in the perioperative setting. Given the aging and increasingly complex surgical population, preoperative evaluation is of utmost importance to mitigate unnecessary risks and to optimize patient outcomes. This article reviews key preoperative considerations, patient evaluation, and factors affecting selection of anesthetic technique.
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Affiliation(s)
- Bradley Benson
- Podiatric Medicine and Surgery Residency Program, Saint Vincent Charity Medical Center, 2351 East 22nd Street, Cleveland, OH 44115, USA.
| | - Amanda Benson
- General Anesthesiology and Critical Care, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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105
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Kaul N, Khan R, Haris A, Al-Jadidi A. Outline for setting up acute postoperative pain service for Indian Hospital. INDIAN JOURNAL OF PAIN 2019. [DOI: 10.4103/ijpn.ijpn_36_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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106
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Banayan JM, Scavone BM, Mhyre JM. Consensus Statement on Pregnant Women Receiving Thromboprophylaxis: An Essential Tool to Guide Our Management. Anesth Analg 2018; 126:754-756. [PMID: 29461326 DOI: 10.1213/ane.0000000000002838] [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]
Affiliation(s)
| | - Barbara M Scavone
- From the Departments of Anesthesia and Critical Care.,Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Jill M Mhyre
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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107
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Hospital-, Anesthesiologist-, and Patient-level Variation in Primary Anesthesia Type for Hip Fracture Surgery. Anesthesiology 2018; 129:1121-1131. [DOI: 10.1097/aln.0000000000002453] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Manuscript Tells Us That Is New
Background
Substantial variation in primary anesthesia type for hip fracture surgery exists. Previous work has demonstrated that patients cared for at hospitals using less than 20 to 25% neuraxial anesthesia have decreased survival. Therefore, the authors aimed to identify sources of variation in anesthesia type, considering patient-, anesthesiologist-, and hospital-level variables.
Methods
Following protocol registration (NCT02787031), the authors conducted a cross-sectional analysis of a population-based cohort using linked administrative data in Ontario, Canada. The authors identified all people greater than 65 yr of age who had emergency hip fracture surgery from April 2002 to March 2014. Generalized linear mixed models were used to account for hierarchal data and measure the adjusted association of hospital-, anesthesiologist-, and patient-level factors with neuraxial anesthesia use. The proportion of variation attributable to each level was estimated using variance partition coefficients and the median odds ratio for receipt of neuraxial anesthesia.
Results
Of 107,317 patients, 57,080 (53.2%) had a neuraxial anesthetic. The median odds ratio for receiving neuraxial anesthesia was 2.36 between randomly selected hospitals and 2.36 between randomly selected anesthesiologists. The majority (60.1%) of variation in neuraxial anesthesia use was explained by patient factors; 19.9% was attributable to the anesthesiologist providing care and 20.0% to the hospital where surgery occurred. The strongest patient-level predictors were absence of preoperative anticoagulant or antiplatelet agents, absence of obesity, and presence of pulmonary disease.
Conclusions
While patient factors explain most of the variation in neuraxial anesthesia use for hip fracture surgery, 40% of variation is attributable to anesthesiologist and hospital-level practice. Efforts to change practice patterns will need to consider hospital-level processes and anesthesiologists’ intentions and behaviors.
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108
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A Review of Enhanced Recovery After Surgery Principles Used for Scheduled Caesarean Delivery. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:1775-1788. [PMID: 30442516 DOI: 10.1016/j.jogc.2018.05.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 05/23/2018] [Indexed: 12/14/2022]
Abstract
There is an increasing body of evidence to support the success of Enhanced Recovery After Surgery (ERAS) for a wide range of surgical procedures. There has been little formalized application, however, of ERAS principles in obstetrical surgery. The aim of this review was to examine the evidence base of perioperative care for patients undergoing Caesarean delivery (CD) and to determine the feasibility of developing an ERAS Society guideline for this obstetrical care plan. The literature on enhanced recovery programs was reviewed, including fast-track surgery and perioperative care components in the preoperative, intraoperative, and postoperative phases of CD. These studies included randomized controlled trials (RCTs), prospective cohort studies, non-RCT studies, meta-analyses, systematic reviews, reviews, and case studies. This is not a systematic review because each ERAS topic area would require a new question. Certain ERAS elements have the potential to benefit patients undergoing CD. These elements include patient education, preoperative optimization, prophylaxis against thromboembolism, antimicrobial prophylaxis, postoperative nausea and vomiting prevention, hypothermia prevention, perioperative fluid management, postoperative analgesia, ileus prevention, breastfeeding promotion, and early mobilization. ERAS has the potential to be successfully implemented in CD on the basis of the evidence obtained from this review. Knowledge transfer and implementation will require multidisciplinary coordination in the preoperative, intraoperative, and postoperative phases and the development of a formalized ERAS guideline.
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109
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Meng ML, Fu A, Westhoff C, Bacchetta M, Rosenzweig EB, Landau R, Smiley R. Eisenmenger Syndrome in Pregnancy. A A Pract 2018; 11:270-272. [DOI: 10.1213/xaa.0000000000000806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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110
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Webb MP, Helander EM, Meyn AR, Flynn T, Urman RD, Kaye AD. Preoperative Assessment of the Pregnant Patient Undergoing Nonobstetric Surgery. Anesthesiol Clin 2018; 36:627-637. [PMID: 30390783 DOI: 10.1016/j.anclin.2018.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The anesthetic management of pregnant patients can present a variety of challenges and a thorough preoperative assessment is necessary before initiating any anesthetic services. Both the mother and the fetus need to be considered when formulating an anesthetic plan and discussing informed consent. The overall aims in assessing a pregnant patient are to identity potential issues that can lead to catastrophic complications, provide adequate information allowing the mother to make informed decisions, and to obtain knowledge for tailoring an anesthetic that maintains maternal and fetal homeostasis.
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Affiliation(s)
- Michael P Webb
- Department of Anesthesiology, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland 0620, New Zealand
| | - Erik M Helander
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Ashley R Meyn
- Department of Anesthesiology, Oschner Clinic, 1514 Jefferson Highway, Jefferson, LA 70121, USA
| | - Trevor Flynn
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Avenue, New Orleans, LA 70112, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Main Campus, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
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111
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Lomivorotov VV, Efremov SM, Abubakirov MN, Belletti A, Karaskov AM. Perioperative Management of Cardiovascular Medications. J Cardiothorac Vasc Anesth 2018; 32:2289-2302. [DOI: 10.1053/j.jvca.2018.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Indexed: 12/28/2022]
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112
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Collins-Yoder A, Collins RE. Periprocedural Considerations for Anticoagulated Atrial Fibrillation Patients. J Perianesth Nurs 2018; 34:227-239. [PMID: 30245032 DOI: 10.1016/j.jopan.2018.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Revised: 04/17/2018] [Accepted: 05/09/2018] [Indexed: 11/19/2022]
Abstract
Periprocedural patient instruction and coordination is an important piece in achieving safe outcomes for patients needing procedures and receiving anticoagulants for atrial fibrillation. Balancing the needs for anticoagulation versus bleeding during the procedure requires clinical reasoning and preparation. In this article, the current guidelines for use of anticoagulants with atrial fibrillation, the relevant pharmacology, and the use of standardized tools to quantify the risks of thrombus or bleeding in the procedures will be discussed. In addition, resources for examining the optimal practice for these case types will be provided. Perianesthesia health care providers are pivotal to lead relevant stakeholders in the perianesthesia setting work together to create protocols and individual plans of care for this patient population.
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113
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Abstract
Venous thromboembolism is a leading cause of maternal morbidity and mortality worldwide. Identifying women who are at greatest risk for venous thromboembolism, and managing their pregnancies with appropriate thromboprophylaxis is essential to decreasing this life-threatening condition. Those at greatest risk are patients with thrombophilias, a personal or family history of venous thromboembolism, and those undergoing cesarean delivery. Current international guidelines on thromboprophylaxis vary in details, but all strategies rely on risk factor identification and thromboprophylaxis for the highest risk patients. All guidelines require clinicians to think critically about individual patient's risk factors throughout pregnancy and the postpartum period.
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Affiliation(s)
- Diana Kolettis
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Tufts Medical Center, 800 Washington Street, Box 360, Boston, MA 02111, USA
| | - Sabrina Craigo
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Tufts Medical Center, 800 Washington Street, Box 360, Boston, MA 02111, USA.
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114
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Palmer A, Chen A, Matsumoto T, Murphy M, Price A. Blood management in total knee arthroplasty: state-of-the-art review. J ISAKOS 2018. [DOI: 10.1136/jisakos-2017-000168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.
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115
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Thoracic Epidural Anesthesia and Prophylactic Three Times Daily Unfractionated Heparin Within an Enhanced Recovery After Surgery Pathway for Colorectal Surgery. Reg Anesth Pain Med 2018; 42:197-203. [PMID: 28079734 DOI: 10.1097/aap.0000000000000542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Venous thromboembolism (VTE) is a common cause of preventable harm. Perioperative thoracic epidural analgesia (TEA) presents a challenge to optimal VTE prophylaxis. Our primary aim was to characterize missed doses of VTE prophylaxis associated with epidural catheter placement and removal. Our secondary aim was to measure the effect of an enhanced recovery after surgery (ERAS) pathway on the rate of TEA-associated missed VTE prophylaxis. METHODS We retrospectively reviewed a prospectively collected database of 1264 colorectal surgery patients at a single academic center. Missed preoperative doses between TEA patients and non-TEA patients were compared. Missed postoperative unfractionated heparin (UFH) doses associated with epidural removal were compared before and after implementation of an ERAS program. Other data collected included demographic data, surgical indication, and thrombohemorrhagic complications. RESULTS Of the 445 TEA patients, 12.6% missed their preoperative heparin doses compared with 8.4% of patients without epidurals (P = 0.017). Of the TEA patients prescribed 3 times daily UFH, 22.5% missed one or more doses associated with epidural removal. The percent of patients missing at least one dose of UFH on epidural removal dropped from 28.1% before ERAS to 17.9% after the ERAS program (P = 0.023). Seven patients developed VTEs. There were zero epidural hematomas. CONCLUSIONS Thoracic epidural analgesia was associated with a 1.5-fold increased risk of missed dose of preoperative VTE prophylaxis, which was not affected by implementation of an ERAS program. The implementation of an ERAS program reduced missed doses associated with epidural removal. This study highlights the challenge posed by providing VTE prophylaxis in the setting of perioperative neuraxial analgesia.
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116
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Abstract
BACKGROUND AND OBJECTIVES Psoas blocks are an alternative to femoral nerve blocks and have the potential advantage of blocking the entire lumbar plexus. However, the psoas muscle is located deeply, making psoas blocks more difficult than femoral blocks. In contrast, while femoral blocks are generally easy to perform, the inguinal region is prone to infection. We thus tested the hypothesis that psoas blocks are associated with more insertion-related complications than femoral blocks but have fewer catheter-related infections. METHODS We extracted 22,434 surgical cases from the German Network for Regional Anesthesia registry (2007-2014) and grouped cases as psoas (n = 7593) and femoral (n = 14,841) blocks. Insertion-related complications (including single-shot blocks and catheter) and infectious complications (including only catheter) in each group were compared with χ tests. The groups were compared with multivariable logistic models, adjusted for potential confounding factors. RESULTS After adjustment for potential confounding factors, psoas blocks were associated with more complications than femoral blocks including vascular puncture 6.3% versus 1.1%, with an adjusted odds ratio (aOR) of 3.6 (95% confidence interval [CI], 2.9-4.6; P < 0.001), and multiple skin punctures 12.6% versus 7.7%, with an aOR of 2.6 (95% CI, 2.1-3.3; P <0.001). Psoas blocks were also associated with fewer catheter-related infections: 0.3% versus 0.9% (aOR of 0.4; 95% CI, 0.2-0.8; P = 0.016), and with improved patient satisfaction (mean ± SD 0- to 10-point scale score, 9.6 ± 1.2 vs 8.4 ± 2.9; P < 0.001). Results from a propensity-matched sensitivity analysis were similar. CONCLUSIONS Psoas blocks are associated with more insertion-related complications but fewer infectious complications. CLINICAL TRIAL REGISTRATION ID NCT02846610.
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117
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Bugada D, Bellini V, Lorini LF, Mariano ER. Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiol Clin 2018; 36:403-415. [PMID: 30092937 DOI: 10.1016/j.anclin.2018.04.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In hip surgery, regional anesthesia offers benefits in pain management and recovery. There are a wide range of regional analgesic options; none have shown to be superior. Lumbar plexus block, femoral nerve block, and fascia iliaca block are the most supported by published literature. Other techniques, such as selective obturator and/or lateral femoral cutaneous nerve blocks, represent alternatives. Newer approaches, such as quadratus lumborum block and local infiltration analgesia, require rigorous studies. To realize long-term outcome benefits, postoperative regional analgesia must be tailored to the individual patient and last longer.
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Affiliation(s)
- Dario Bugada
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, Piazza OMS, 1, Bergamo 24127, Italy.
| | - Valentina Bellini
- Department of Anesthesia and Pain Therapy, Parma University Hospital, Via Gramsci, 14, Parma 43126, Italy
| | - Luca F Lorini
- Emergency and Intensive Care Department, ASST Papa Giovanni XXIII, Piazza OMS, 1, Bergamo 24127, Italy
| | - Edward R Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, 3801 Miranda Avenue, MC 112A, Palo Alto, CA 94304, USA; Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, 3801 Miranda Avenue, MC 112A, Palo Alto, CA 94304, USA
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118
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Dodd KC, Emsley HCA, Desborough MJR, Chhetri SK. Periprocedural antithrombotic management for lumbar puncture: Association of British Neurologists clinical guideline. Pract Neurol 2018; 18:436-446. [DOI: 10.1136/practneurol-2017-001820] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2018] [Indexed: 11/04/2022]
Abstract
Lumbar puncture (LP) is an important and frequently performed invasive procedure for the diagnosis and management of neurological conditions. There is little in the neurological literature on the topic of periprocedural management of antithrombotics in patients undergoing LP. Current practice is therefore largely extrapolated from guidelines produced by anaesthetic bodies on neuraxial anaesthesia, haematology groups advising on periprocedural management of antiplatelet agents and anticoagulants, and by neuroradiology on imaging-guided spinal procedures. This paper summarises the existing literature on the topic and offers recommendations to guide periprocedural antithrombotic management for LP, based on the consolidation of the best available evidence.
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119
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Hewson DW, Hardman JG. Physical injuries during anaesthesia. BJA Educ 2018; 18:310-316. [PMID: 33456795 DOI: 10.1016/j.bjae.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- D W Hewson
- Anaesthesia & Critical Care, University of Nottingham, Nottingham, UK
| | - J G Hardman
- Anaesthesia & Critical Care, University of Nottingham, Nottingham, UK
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120
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Pouliot JD, Neal EB, Lobo BL, Hargrove F, Gupta RK. The Role of Computerized Clinical Decision Support in Reducing Inappropriate Medication Administration During Epidural Therapy. Hosp Pharm 2018; 53:170-176. [PMID: 30147137 DOI: 10.1177/0018578717741392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The use of epidural anesthesia has been shown to improve outcomes in the postoperative setting. To minimize risk of complications, avoiding certain medications with epidural anesthesia is advised. Objective: This study sought to determine the role of a computerized clinical decision support module implemented into the computerized physician order entry (CPOE) system on the incidence of administration of medications known to increase complications with epidural anesthesia. Methods: This study was a retrospective cohort chart review in adult patients receiving epidural anesthesia for at least 1 day. Patients were identified retrospectively and divided into 2 cohorts, those receiving an epidural 3 months prior to initiation of the module and those receiving an epidural 3 months following implementation. The primary end point was incidence of inappropriate medication administration before and after implementation. Complications of therapy were collected as secondary end points. Results: There was a reduction in the incidence of inappropriate medication administration in the postimplementation group versus the preimplementation group (6.3% vs 12.8%) although statistical significance was not achieved. In addition, the incidence of enoxaparin administration was significantly lower postimplementation than the preimplementation (0% vs 3.9%). There were no significant differences in other complications of therapy. Conclusions: This study demonstrated that application of decision support for this high-risk procedural population was able to eliminate the incidence of the most common inappropriate medication for epidural analgesia, enoxaparin. A reduction in incidence of other inappropriate medications was also observed; however, statistical significance was not reached. The use of computerized clinical decision support can be a powerful tool in reducing or ameliorating medication errors, and further study will be required to determine the most appropriate and effective implementation strategies.
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Affiliation(s)
- Jonathon D Pouliot
- Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - Erin B Neal
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bob L Lobo
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fred Hargrove
- Vanderbilt University Medical Center, Nashville, TN, USA
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Halaszynski TM, Dai F, Huang Y. Donor Hepatectomy Surgery using Ketamine to Compliment Analgesia and Reduce Morbidity - a Retrospective Chart Review Investigation. Turk J Anaesthesiol Reanim 2018; 46:28-37. [PMID: 30140498 DOI: 10.5152/tjar.2017.33239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 07/28/2017] [Indexed: 02/05/2023] Open
Abstract
Objective Inferior and limited analgesic options/techniques during living donor hepatectomy surgery can result in pain and risks of morbidity, opioid-related adverse events (AEs), predisposition to the development of chronic pain and concerns of potential narcotic abuse. Traditional analgesia uses unimodal intravenous opioids that can cause significant side effects. Ketamine provides analgesia and may be opioid sparing, but use in living-donor hepatectomy has not been studied. Methods Following human investigation committee approval and informed written consent, 47 liver donor patients over a 5-year period scheduled for surgery were categorized into one of three groups: 24 patients received no ketamine (Group 1), 9 received only intraoperative ketamine (Group 2) and 14 patients received intraoperative plus postoperative ketamine (Group 3). Subjects had access to opioid patient-controlled analgesia (PCA). Chart reviews (including operating room and intensive care unit) were collected and analysed for morphine consumption, pain-intensity scores, opioid-sparing effects, AEs of analgesics and for evidence of ketamine side effects on donor hepatectomy patients. Results There were no differences in patient demographics. Living donor hepatectomy patients receiving intraoperative ketamine that was continued postoperatively consumed fewer morphine-equivalents and had lower median pain scores than subjects from the other two groups. Ileus occurred in those not receiving ketamine, pruritus was lowest in Group 3, and there was no evidence or reports of ketamine-associated AEs. Conclusion Perioperative ketamine for donor hepatectomy patients could safely provide improved analgesia and be opioid sparing when compared to PCA opioids alone, and there is no evidence of ketamine-related AEs at the dose and delivery methods described here during partial liver donation surgery.
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Affiliation(s)
- Thomas M Halaszynski
- Department of Anesthesiology, Yale University School of Medicine, New Haven, USA
| | - Feng Dai
- Department of Anesthesiology, Yale University School of Medicine, New Haven, USA
| | - Yili Huang
- Department of Anesthesiology, Yale University School of Medicine, New Haven, USA
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122
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Bhorkar NM, Dhansura TS, Tarawade UB, Mehta SS. Epidural Hematoma: Vigilance beyond Guidelines. Indian J Crit Care Med 2018; 22:555-557. [PMID: 30111936 PMCID: PMC6069313 DOI: 10.4103/ijccm.ijccm_71_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Coagulopathy either from the use of anticoagulant, antiplatelet, or thrombolytic medications or from underlying medical conditions is considered one of the major risk factors for epidural hematoma formation related to epidural catheter placement or removal. The American Society of Regional Anesthesia and Pain Medicine (ASRA) has laid down guidelines regarding timing of neuraxial blockade or removal of neuraxial catheters in patients receiving either antithrombotic or thrombolytic therapy. We present a case of acute onset of paraplegia because of an epidural hematoma following removal of the epidural catheter in a patient who was given the first dose of antithrombotic therapy after the removal of the epidural catheter as per the ASRA guidelines. The epidural hematoma was diagnosed with an urgent magnetic resonance imaging, and the patient was urgently taken up for surgical evacuation of the hematoma. The patient made full recovery over 1 week period.
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Affiliation(s)
- Nitin Madhukar Bhorkar
- Department of Anaesthesiology and Surgical Oncology, Saifee Hospital, Mumbai, Maharashtra, India
| | - Tasneem Saleh Dhansura
- Department of Anaesthesiology and Surgical Oncology, Saifee Hospital, Mumbai, Maharashtra, India
| | | | - Sanket Sharad Mehta
- Department of Anaesthesiology and Surgical Oncology, Saifee Hospital, Mumbai, Maharashtra, India
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123
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Robinson E, Shahipasand S, Liantis P, Mandegaran R, Zavareh A. Nerve root injection cancellations because of incomplete anticoagulation management. Br J Hosp Med (Lond) 2018; 79:465-467. [PMID: 30070943 DOI: 10.12968/hmed.2018.79.8.465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Computed tomography-guided steroid injection is a well-recognized, conservative treatment of localized spinal pain as a result of facet arthropathy and radiculopathy secondary to nerve root compression. An extremely rare complication is the development of an epidural haematoma with potential to cause permanent neurological damage, so anticoagulation at the time of procedure is contraindicated. Routinely injections are performed as an outpatient requiring the referring physician to implement a peri-procedural anticoagulation plan. Anecdotal experience suggested that cancellations were occurring as patients remained on anticoagulation at the time of their appointment. The authors therefore assessed the existing service against expected standards to identify the causes of cancellations and find ways to improve the service. AIMS This audit aimed to identify the incidence of cancelled computed tomography-guided nerve root injections secondary to incorrect peri-procedural anticoagulation management, develop an intervention to help reduce the incidence of cancellations and then re-audit to assess the effect of the intervention. METHODS The audit standard was that 100% of outpatients attending for computed tomography-guided nerve root and facet injections should have an appropriate anticoagulation plan implemented. Baseline data collection took place prospectively between 1 September and 30 November 2016. The study population was elective computed tomography-guided spinal nerve root and facet injections scheduled on the radiology information system at the authors' trust. Descriptive analysis was completed. The intervention involved a revised electronic request form being implemented with new compulsory fields concerning antiplatelets and anticoagulants. Re-audit post-intervention involved prospective data collection between 1 September and 30 November 2017 using the same methods. RESULTS Baseline audit found that of three out of 55 (5%) patients had cancellations. On re-audit, there were 0 cancellations out of 93 patients. CONCLUSIONS The new request form prevented 5% of patients referred for computed tomography-guided nerve root injection being cancelled because of incorrect anticoagulation management. Extrapolated over the year the potential savings through preventing lost activity are £3445.56.
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Affiliation(s)
- Elizabeth Robinson
- Foundation Year 2 Doctor, Department of Radiology, Guy's and St Thomas' Foundation Trust, London SE1 7EH
| | - Shahab Shahipasand
- Foundation Year 2 Doctor, Department of Radiology, London North West Healthcare NHS Foundation Trust, London
| | - Panagiotis Liantis
- Consultant Orthopaedic Surgeon, Department of Orthopaedics, Guy's and St Thomas' Foundation Trust, London
| | - Ramin Mandegaran
- Specialist Registrar in Radiology, Department of Radiology, Guy's and St Thomas' Foundation Trust, London
| | - Ali Zavareh
- Consultant Radiologist, Department of Radiology, Guy's and St Thomas' Foundation Trust, London
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124
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Soffin EM, YaDeau JT. Enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. Br J Anaesth 2018; 117:iii62-iii72. [PMID: 27940457 DOI: 10.1093/bja/aew362] [Citation(s) in RCA: 184] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients. Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized approach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered, including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for future research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty.
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Affiliation(s)
- E M Soffin
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - J T YaDeau
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
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125
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Shanthanna H, Moisuik P, O’Hare T, Srinathan S, Finley C, Paul J, Slinger P. Survey of Postoperative Regional Analgesia for Thoracoscopic Surgeries in Canada. J Cardiothorac Vasc Anesth 2018; 32:1750-1755. [DOI: 10.1053/j.jvca.2018.01.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Indexed: 02/06/2023]
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126
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Albaladejo P, Pernod G, Godier A, de Maistre E, Rosencher N, Mas JL, Fontana P, Samama CM, Steib A, Schlumberger S, Marret E, Roullet S, Susen S, Madi-Jebara S, Nguyen P, Schved JF, Bonhomme F, Sié P. Management of bleeding and emergency invasive procedures in patients on dabigatran: Updated guidelines from the French Working Group on Perioperative Haemostasis (GIHP) – September 2016. Anaesth Crit Care Pain Med 2018; 37:391-399. [DOI: 10.1016/j.accpm.2018.04.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/25/2022]
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127
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D'Alton ME, Friedman AM, Smiley RM, Montgomery DM, Paidas MJ, D'Oria R, Frost JL, Hameed AB, Karsnitz D, Levy BS, Clark SL. National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. J Midwifery Womens Health 2018; 61:649-657. [PMID: 29473681 DOI: 10.1111/jmwh.12544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 07/29/2016] [Indexed: 11/28/2022]
Abstract
Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into 4 domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.
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128
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Cohen KM, Minehart RD, Leffert LR. Anesthetic Treatment of Cardiac Disease During Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:66. [PMID: 30019160 DOI: 10.1007/s11936-018-0657-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW This review summarizes the pathophysiology, peripartum treatment, and anesthetic management of parturients with cardiac disease. Valvular disease, coronary disease, and cardiomyopathy are specifically addressed in the context of the normal physiologic changes of pregnancy. We offer recommendations for anesthetic approaches, hemodynamic goals with an emphasis on interdisciplinary planning between anesthesiologists, cardiologists, cardiothoracic surgeons, obstetricians, maternal fetal medicine specialists, and neonatologists. RECENT FINDINGS Vaginal delivery with neuraxial analgesia can be well tolerated by many pregnant patients with cardiac disease when coordinated by an interdisciplinary team of experts. Cardiac disease in pregnancy can present a significant challenge for the interdisciplinary care team. A detailed understanding of each patient's cardiac pathology and the physiologic changes of pregnancy are critical to ensure a safe and successful labor and delivery. Optimized medical therapy in the peripartum period and neuraxial anesthesia with the judicious use of vasoactive agents can be of great benefit for these parturients. As is generally the case, cesarean delivery should be primarily reserved for obstetric indications and maternal wellbeing, with careful consideration of the fetus to guide best practices.
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Affiliation(s)
- Kate M Cohen
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Rebecca D Minehart
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Lisa R Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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129
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Stevens GJ, Durning SJ, Stevens SD, Lowery DR. Regional Anesthesia in the Setting of Arm Replantation: A Case Report. A A Pract 2018; 11:38-40. [PMID: 29634554 DOI: 10.1213/xaa.0000000000000728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The perioperative implementation of continuous peripheral nerve blocks is poorly described within the literature for replantation surgeries beyond digital replantation. The management of replantation patients presents a challenging balance between pain control and limb perfusion. We report the successful use of a continuous interscalene catheter in a therapeutically anticoagulated patient after midshaft humerus arm replantation. The benefits of the continuous peripheral nerve block for the patient included improved pain control and potentially improved limb perfusion making it a valuable component of this patient's treatment.
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Affiliation(s)
- Gregory J Stevens
- From the Department of Anesthesiology, San Antonio Military Medical Center, Joint Base San Antonio, Fort Sam Houston, San Antonio, Texas
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130
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Su J, Soliz JM, Popat KU, Gebhardt R. Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain. Anesth Analg 2018; 127:e57-e59. [PMID: 29958215 DOI: 10.1213/ane.0000000000003603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0-0.0009952).
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Affiliation(s)
- Jackson Su
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Jose M Soliz
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Keyuri U Popat
- From the Departments of Anesthesiology and Perioperative Medicine
| | - Rodolfo Gebhardt
- Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
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131
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Regional Analgesia Techniques for Adult Patients Undergoing Solid Organ Transplantation. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0274-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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132
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Alexander B, Angaramo G, Walz JM, Kakouros N, Moiz Hafiz A, Walker J, Krapchev P. A Novel Approach to Managing Trans-Subclavian Transcatheter Aortic Valve Replacement With Regional Anesthesia. J Cardiothorac Vasc Anesth 2018; 32:1391-1393. [DOI: 10.1053/j.jvca.2017.08.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Indexed: 11/11/2022]
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133
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Chighizola CB, Meroni PL. Thrombosis and Anti-phospholipid Syndrome: a 5-Year Update on Treatment. Curr Rheumatol Rep 2018; 20:44. [PMID: 29850957 DOI: 10.1007/s11926-018-0741-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update of the therapeutic tools for thrombotic anti-phospholipid syndrome (APS), focusing on the last 5 years. RECENT FINDINGS Early studies appointed anticoagulation at moderate intensity as the mainstay of treatment of thrombotic APS; in the last 5 years, the strategy has not much mutated. Some uncertainties regarding the role of direct oral anticoagulants and the optimal regimen for arterial thrombotic APS still persist: high-intensity anticoagulation, anticoagulation plus anti-platelet agent, and double anti-platelet agents being the possible alternatives. Several drugs have been proposed as effective additional tools for the management of thrombotic APS: hydroxychloroquine, statins, vitamin D, and sirolimus might be beneficial when added on the top of anticoagulation. Pregnant women with thrombotic APS should be switched to low-dose aspirin plus low molecular weight heparin at therapeutic dose. Despite adequate treatment, APS patients display a significant rate of recurrences; rituximab, eculizumab, and intravenous immunoglobulins are among the options to be considered for these patients. From 2013 to date, the kaleidoscope of therapeutic options in thrombotic APS has been enriched, but tangible improvements in the management of patients are still awaited.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy. .,Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095, Cusano Milanino, Milan, Italy. .,Unit of Immunology, Allergology and Rheumatology, IRCCS Istituto Auxologico Italiano, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095, Cusano Milanino, Milan, Italy
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134
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Lazo-Langner A, Al-Ani F, Weisz S, Rozanski C, Louzada M, Kovacs J, Kovacs MJ. Prevention of venous thromboembolism in pregnant patients with a history of venous thromboembolic disease: A retrospective cohort study. Thromb Res 2018; 167:20-25. [PMID: 29772489 DOI: 10.1016/j.thromres.2018.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 04/20/2018] [Accepted: 05/04/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Optimal prophylactic strategies in pregnant women with a history of venous thromboembolism (VTE) are unknown. PATIENTS AND METHODS We conducted a retrospective cohort study of consecutive pregnant patients with a previous VTE history. Patients were followed until 6 weeks postpartum. Patients with a previous unprovoked event (including antepartum VTE) received antenatal prophylaxis, mostly with low dose low molecular weight heparin (LMWH). All patients received prophylaxis for six weeks after delivery. RESULTS We included a total of 199 pregnancies in 142 women. Of these, 147 pregnancies occurred in women with unprovoked or estrogen-related VTE history and 52 pregnancies in women with provoked VTE. There were 8 recurrences in 199 pregnancies (4%; 95%CI: 2.05-7.73), of which 5 were antepartum recurrences (2.5%; 95%CI 1.08-5.75) and 3 were postpartum (1.5%; 95% CI 0.51-4.34). In the unprovoked VTE group there were 7 recurrences (4.7%; 95%CI: 2.32-9.50), whereas in the provoked VTE group there was 1 (1.9%; 95%CI: 0.34-10.12). There was one major bleeding event in a patient not receiving LMWH secondary to placental abruption. CONCLUSION This study suggests that the use of prophylactic doses of LMWH during pregnancy and puerperium, as described in this study, results in low occurrence of ante- and postpartum VTE recurrences in patients with previous VTE. Further studies are required to confirm this observation.
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Affiliation(s)
- Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada.
| | - Fatimah Al-Ani
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Sarah Weisz
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Camilla Rozanski
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Martha Louzada
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Judy Kovacs
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
| | - Michael J Kovacs
- Department of Medicine, Division of Hematology, University of Western Ontario, London, ON, Canada
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135
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Gulati V, Newman S, Porter KJ, Franco LCS, Wainwright T, Ugoigwe C, Middleton R. Implications of anticoagulant and antiplatelet therapy in patients presenting with hip fractures: a current concepts review. Hip Int 2018; 28:227-233. [PMID: 30165764 DOI: 10.1177/1120700018759300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The increasing use of anticoagulant and antiplatelet therapy for the prevention of thromboembolic disease poses a significant challenge to orthopaedic surgeons treating elderly patients presenting with proximal femoral fractures. Early surgical intervention is known to be beneficial from a clinical perspective and has been encouraged in the UK through the introduction of best practice tariffs providing increased remuneration for prompt treatment. An understanding of the necessary delay to surgery or reversal options for each type of antiplatelet or anticoagulant agent is therefore important. A number of professional bodies have recently produced guidelines that help clinicians manage these patients during the peri-operative period. We review the guidelines relating to antiplatelet and anticoagulant agents during the perioperative period with respect to hip fracture surgery. Antiplatelet agents should not interfere with timing of surgery, but may affect the choice of anaesthetic performed. The action of warfarin should be reversed to expedite surgery. Newer direct oral anticoagulants are more problematic and surgical delay may be necessary, though reversal agents are becoming available.
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Affiliation(s)
- Vivek Gulati
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK.,2 Homerton University Hospital, London, UK
| | - Simon Newman
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
| | | | | | - Tom Wainwright
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
| | | | - Robert Middleton
- 1 Orthopaedic Research Institute, Bournemouth University, Bournemouth UK
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136
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Abstract
BACKGROUND The American Society of Regional Anesthesia and Pain Medicine guidelines recommend discontinuation of warfarin and an international normalized ratio (INR) of 1.2 or less before a neuraxial injection. The European and Scandinavian guidelines accept an INR of 1.4 or less. We evaluated INR and levels of clotting factors (CFs) II, VII, IX, and X 5 days after discontinuation of warfarin. METHODS Patients who discontinued warfarin for 5 days and had an INR of 1.4 or less had activities of factors II, VII, IX, and X measured. The primary outcome was the frequency of subjects with CF activities of less than 40%. RESULTS Twenty-three patients were studied; 21 (91%) had an INR of 1.2 or less. In these 21 patients, the median (interquartile range) activities of factors II, VII, IX, and X were 66% (52%-80%), 114% (95%-132%), 101% (84%-121%), and 55% (46%-63%), respectively. Ninety-five percent (99% confidence interval, 69%-99%) had CF activities of greater than 40%. The patient who did not CF activities greater than 40% had end-stage renal disease. Two subjects had an INR of greater than 1.2; the activities of factor II, VII, IX, and X were 37% and 46%, 89% and 105%, 66% and 78%, and 20% and 36%, respectively. Neither patient had CF activities of greater than 40%. CONCLUSIONS Based on 40% activity of CFs, patients with INRs of 1.2 or less can be considered to have adequate CFs to undergo neuraxial injections. The number of patients with an INR of 1.3 and 1.4 is too small to make conclusions.
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137
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D'Alton ME, Friedman AM, Smiley RM, Montgomery DM, Paidas MJ, D'Oria R, Frost JL, Hameed AB, Karsnitz D, Levy BS, Clark SL. National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism. J Obstet Gynecol Neonatal Nurs 2018; 45:706-17. [PMID: 27619099 DOI: 10.1016/j.jogn.2016.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.
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138
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:223-224. [DOI: 10.1097/aap.0000000000000771] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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139
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D’Ercole F, Arora H, Kumar PA. Paravertebral Block for Thoracic Surgery. J Cardiothorac Vasc Anesth 2018; 32:915-927. [DOI: 10.1053/j.jvca.2017.10.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Indexed: 01/23/2023]
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140
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Dalia AA, Cronin B, Stone ME, Turner K, Hargrave J, Vidal Melo MF, Essandoh M. Anesthetic Management of Patients With Continuous-Flow Left Ventricular Assist Devices Undergoing Noncardiac Surgery: An Update for Anesthesiologists. J Cardiothorac Vasc Anesth 2018; 32:1001-1012. [DOI: 10.1053/j.jvca.2017.11.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Indexed: 12/16/2022]
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141
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Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy. Reg Anesth Pain Med 2018; 43:263-309. [DOI: 10.1097/aap.0000000000000763] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Elmahrouk AF, Ismail MF, Bugis A, Badawy N, Aboelghar HM, Hamouda T, Jamjoom A. Staged Surgical Palliation for HLHS in a Girl with Severe Factor X Deficiency. Thorac Cardiovasc Surg Rep 2018; 7:e12-e15. [PMID: 29577004 PMCID: PMC5864519 DOI: 10.1055/s-0038-1637743] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Accepted: 01/25/2018] [Indexed: 11/01/2022] Open
Abstract
Background Factor X deficiency (also known as Stuart-Prower factor deficiency) is an autosomal recessive extremely rare hereditary hematologic disorder, affecting around 1:1,000,000 of the general population. Case Presentation This case report describes a patient with hypoplastic left heart syndrome and severe factor X deficiency, who underwent staged surgical palliation. From stage 1 Norwood palliation, through superior cavopulmonary anastomosis and ending with total cavopulmonary connection with satisfactory hemostasis and no significant perioperative bleeding complication. Conclusion The need to maintain hemostasis while aiming to prevent intracardiac thrombosis requires multidisciplinary team approach including hematologist, cardiac surgeon, pediatric cardiac intensivist, and anesthesiologist along with meticulous hemostasis during surgery and careful monitoring of coagulation profile in the postoperative period.
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Affiliation(s)
- Ahmed F Elmahrouk
- Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.,Department of Cardiothoracic Surgery, Tanta University Faculty of Medicine, Tanta, Egypt
| | - Mohamed F Ismail
- Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.,Mansoura University Faculty of Medicine, Mansoura, Egypt
| | - Abdulbadee Bugis
- Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Nashwa Badawy
- Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.,Cairo University Kasr Alainy Faculty of Medicine, Cairo, Egypt
| | - Hesham Mohamed Aboelghar
- Department of Pediatrics, Menoufia University Faculty of Medicine, Shebin El-Kom, Saudi Arabia.,Department of Hematology and Oncology BMT, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Tamer Hamouda
- Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.,Department of Cardiothoracic Surgery, Faculty of Medicine, Benha University, Benha, Egypt
| | - Ahmed Jamjoom
- Department of Cardiothoracic Surgery, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
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143
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Morris BN, Henshaw DS, Royster RL. Survey of Pain Management in Thoracoscopic Surgery. J Cardiothorac Vasc Anesth 2018; 32:1756-1758. [PMID: 29551282 DOI: 10.1053/j.jvca.2018.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Benjamin N Morris
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Daryl S Henshaw
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Roger L Royster
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC
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144
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Abstract
PURPOSE OF REVIEW Headaches encompass a broad-based category of a symptom of pain in the region of the head or neck. For those patients who unfortunately do not obtain relief from conservative treatment, interventional techniques have been developed and are continuing to be refined in an attempt to treat this subset of patients with the goal of return of daily activities. This investigation reviews various categories of headaches, their pathophysiology, and types of interventional treatments currently available. RECENT FINDINGS Injection of botulinum toxin has been shown to increase the number of headache free days for patients suffering from chronic tension-type headaches. Suboccipital steroid injection has been demonstrated as a successful treatment option for patients suffering from cluster headache. Occipital nerve stimulation (ONS) has been described as a treatment for all types of trigeminal autonomic cephalgias. Percutaneous ONS is a minimally invasive and reversible approach to manage occipital neuralgia performed utilizing subcutaneous electrodes placed superficial to the cervical muscular fascia in the suboccipital area. Radiofrequency lesioning is another commonly used treatment in the management of chronic pain syndromes of the head and neck. If a diagnostic sphenopalatine ganglion block successfully resolves the patient's symptoms, neurolysis can be employed as a more permanent solution. Although many patients who suffer from headaches can be treated with conservative, less-invasive treatments, there still remains at present an ever-increasing need for those patients who are refractory to conservative measures and thus require interventional treatments. These procedures are continually evolving to become safer, more precise, and more readily available for clinicians to provide to their patients.
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145
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McPhail A, Jokel D. Effectiveness of four-factor prothrombin complex concentrates versus plasma on vitamin K antagonist associated plasma international normalized ratio reversal: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2018; 16:662-668. [PMID: 29521867 DOI: 10.11124/jbisrir-2017-003470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION The question of this review is: what is the effectiveness of Kcentra/Beriplex/Confidex compared to plasma for international normalized ratio (INR) reduction in adult patients (18 years and over) on any vitamin K antagonist therapy?
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Affiliation(s)
- Andrew McPhail
- Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, USA
- The Center for Translational Research: a Joanna Briggs Institute Center of Excellence, Fort Worth, USA
| | - Dominick Jokel
- Harris College of Nursing and Health Sciences, Texas Christian University, Fort Worth, USA
- The Center for Translational Research: a Joanna Briggs Institute Center of Excellence, Fort Worth, USA
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146
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Leffert L, Butwick A, Carvalho B, Arendt K, Bates SM, Friedman A, Horlocker T, Houle T, Landau R, Dubois H, Fernando R, Houle T, Kopp S, Montgomery D, Pellegrini J, Smiley R, Toledo P. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg 2018; 126:928-944. [DOI: 10.1213/ane.0000000000002530] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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147
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Abstract
Venous thromboembolism is a leading cause of maternal death. Because of the low absolute frequency of events, however, outcome-based clinical data are limited. Consequently, clinicians must additionally rely both on published guidelines and on extrapolation of data from studies focused on nonpregnant individuals. The diagnosis and treatment of deep vein thrombosis, pulmonary embolism, and cerebral vein and dural sinus thrombosis are complicated by pregnancy, and often require modifications to standard diagnostic and treatment algorithms outside of pregnancy. Treatment of VTE in pregnant women is in particular need of future research.
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148
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Chighizola CB, Andreoli L, Gerosa M, Tincani A, Ruffatti A, Meroni PL. The treatment of anti-phospholipid syndrome: A comprehensive clinical approach. J Autoimmun 2018; 90:1-27. [PMID: 29449131 DOI: 10.1016/j.jaut.2018.02.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 02/06/2018] [Indexed: 01/02/2023]
Abstract
Anti-phospholipid syndrome (APS) is an acquired pro-thrombotic autoimmune disease that predisposes to thrombotic events and/or obstetric complications, in the persistent presence of anti-phospholipid antibodies (aPL). Life long moderate-intensity anticoagulation is the option of choice for aPL-positive patients with a previous thrombosis; critical issues concern the management of those with a history of arterial event due to the high rate of recurrence. Alternatives comprise anti-platelet agents and high-intensity anticoagulation. Low dose aspirin (LDASA) and low molecular weight heparin provide the mainstay of the treatment of obstetric APS, allowing a birth rate in 70% of cases. The management of refractory APS, thrombotic as well as obstetric, is highly debated, but an increasing burden of evidence points towards the beneficial effects of multiple treatments. Similarly, a management envisaging multiple drugs (anticoagulation, steroids, plasma exchange and/or intravenous immunoglobulins) is the most effective approach in catastrophic APS. Asymptomatic aPL carriers are at higher risk of thrombotic and obstetric complications compared to the general population, thus potentially benefitting of a pharmacological intervention. LDASA and hydroxychloroquine can be considered as options, in particular in case of high risk aPL profile, concomitant cardiovascular risk factors or associated autoimmune disease. APS is apparently a simple condition, but its multifaceted nature requires a complex and tailored treatment.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Allergology, Clinical Immunology and Rheumatology, Piazzale Brescia 20, 20149, Milan, Italy.
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Maria Gerosa
- Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy; Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy; Department of Rheumatology, ASST Istituto Gaetano Pini & CTO, Piazza Cardinal Ferrari, 1 20122, Milan, Italy
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Spedali Civili of Brescia, Department of Clinical and Experimental Sciences, University of Brescia, Piazzale Spedali Civili 1, 25123, Brescia, Italy
| | - Amelia Ruffatti
- Rheumatology Unit, Department of Medicine, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, IRCCS Istituto Auxologico Italiano, Via Zucchi 18, 20095 Cusano Milanino, Milan, Italy
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149
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Hernandez Conte A, Hajj J, Yang SX, Passano E, Barone H, Thuraisingham DA, Moriguchi J, Kobashigawa J, Arabia F. Utilization of Transverse Abdominis Plexus Block for Treatment of HeartMate II Left Ventricular Assist Device-Associated Pain. J Cardiothorac Vasc Anesth 2018; 32:1866-1870. [PMID: 29395822 DOI: 10.1053/j.jvca.2017.11.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
| | - Jennifer Hajj
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen X Yang
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Heather Barone
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dhilan A Thuraisingham
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Jaime Moriguchi
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Jon Kobashigawa
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
| | - Francisco Arabia
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
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150
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Mallek JT, Gravenstein N, Le-Wendling L. Misguided by INR in Liver Disease Patients? Implications for Clinicians Including Pain Proceduralists. Anesth Analg 2018; 127:289-294. [PMID: 29381517 DOI: 10.1213/ane.0000000000002639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Jennifer T Mallek
- From the Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
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