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Sedation with dexmedetomidine prolongs the analgesic duration of brachial plexus block: a randomised controlled trial. Anaesth Crit Care Pain Med 2018; 38:231-236. [PMID: 30339891 DOI: 10.1016/j.accpm.2018.08.006] [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] [Received: 04/10/2018] [Revised: 07/31/2018] [Accepted: 08/21/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE Dexmedetomidine, an alpha 2 receptor agonist, prolongs nerve block duration when administered in conjunction with peripheral nerve blocks. We hypothesised that sedation with dexmedetomidine could also significantly prolong the analgesic duration of brachial plexus block (BPB) during orthopaedic surgery on the upper extremities. MATERIALS AND METHODS One hundred and two patients received upper extremity surgery under BPB. The patients were randomly sedated with dexmedetomidine (D group) or midazolam (M group) following BPB using 25 mL of local anaesthetics (1:1 mixture of 1% lidocaine and 0.75% ropivacaine). Adequate sedation was evaluated with the modified Ramsay Sedation Scale. Primary outcome was measured as the time the patient first requested analgesic via a patient-controlled analgesia device. Total opioid consumption during the first 24 post-operative hours was also measured as secondary outcomes. RESULTS Time to first request for analgesia (mean ± standard deviation) was significantly longer in the D group (616.9 ± 158.2 min) than in the M group (443.7 ± 127.2 min) (P < 0.001, Mean difference [95% CI] 173.2 [114.8-231.5] min). Total opioid consumption were significantly lower in the D group (fentanyl equivalent, 280.0 μg [171.3;374.0] vs. 363.9 μg [208.3;570.1], P = 0.01). Although patients in the D group showed deeper sedation over time (P < 0.001), PACU stay time was only slightly extended in D group (5.2 [1.2-9.2] min). Perioperative complications did not differ in the two groups. CONCLUSION Sedation with dexmedetomidine not only prolongs analgesic duration of BPB, but also reduces total opioid consumption during the first 24 post-operative hours.
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Harrison TK, Kornfeld H, Aggarwal AK, Lembke A. Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy. Anesthesiol Clin 2018; 36:345-359. [PMID: 30092933 DOI: 10.1016/j.anclin.2018.04.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
As part of a national effort to combat the current US opioid epidemic, use of currently Food and Drug Administration-approved drugs for the treatment of opioid use disorder/opioid addiction (buprenorphine, methadone, and naltrexone) is on the rise. To provide optimal pain control and minimize the risk of relapse and overdose, providers need to have an in-depth understanding of how to manage these medications in the perioperative setting. This article reviews key principles and discusses perioperative considerations for patients with opioid use disorder on buprenorphine, methadone, or naltrexone.
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Affiliation(s)
- Thomas Kyle Harrison
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, VA Palo Alto Health Care System, 3801 Miranda Avenue (112A), Palo Alto, CA 94304, USA.
| | - Howard Kornfeld
- Pain Fellowship Program, University of California San Francisco School of Medicine, 3 Madrona Avenue, Mill Valley, CA 94941, USA
| | - Anuj Kailash Aggarwal
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford School of Medicine, 450 Broadway, Redwood City, CA 94063, USA
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA; Department of Anesthesiology and Pain Medicine, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305, USA
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YaDeau JT, Fields KG, Kahn RL, LaSala VR, Ellis SJ, Levine DS, Paroli L, Luu TH, Roberts MM. Readiness for Discharge After Foot and Ankle Surgery Using Peripheral Nerve Blocks. Anesth Analg 2018; 127:759-766. [DOI: 10.1213/ane.0000000000003456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schwenk ES, Mariano ER. Designing the ideal perioperative pain management plan starts with multimodal analgesia. Korean J Anesthesiol 2018; 71:345-352. [PMID: 30139215 PMCID: PMC6193589 DOI: 10.4097/kja.d.18.00217] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/15/2018] [Indexed: 12/16/2022] Open
Abstract
Multimodal analgesia is defined as the use of more than one pharmacological class of analgesic medication targeting different receptors along the pain pathway with the goal of improving analgesia while reducing individual class-related side effects. Evidence today supports the routine use of multimodal analgesia in the perioperative period to eliminate the over-reliance on opioids for pain control and to reduce opioid-related adverse events. A multimodal analgesic protocol should be surgery-specific, functioning more like a checklist than a recipe, with options to tailor to the individual patient. Elements of this protocol may include opioids, non-opioid systemic analgesics like acetaminophen, non-steroidal anti-inflammatory drugs, gabapentinoids, ketamine, and local anesthetics administered by infiltration, regional block, or the intravenous route. While implementation of multimodal analgesic protocols perioperatively is recommended as an intervention to decrease the prevalence of long-term opioid use following surgery, the concurrent crisis of drug shortages presents an additional challenge. Anesthesiologists and acute pain medicine specialists will need to advocate locally and nationally to ensure a steady supply of analgesic medications and in-class alternatives for their patients’ perioperative pain management.
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Affiliation(s)
- Eric S Schwenk
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Edward R Mariano
- Department of Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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Recovery after shoulder arthroscopy: Inpatient versus outpatient management. Orthop Traumatol Surg Res 2018; 104:39-43. [PMID: 29233760 DOI: 10.1016/j.otsr.2017.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 10/05/2017] [Accepted: 10/10/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Shoulder arthroscopy is particularly suited to outpatient surgery, thanks to advances in anesthetic and analgesic techniques. The main goal of this study was to compare postoperative recovery after shoulder arthroscopy between outpatient and inpatient management. HYPOTHESIS There is no difference in functional recovery between inpatient and outpatient management. MATERIALS AND METHOD A single-center, single-operator prospective study was conducted. Both groups received patient-controlled analgesia via an interscalene catheter. The inclusion criterion was shoulder arthroscopy for rotator cuff tendinopathy. The choice between inpatient and outpatient management was left to the patient. The study endpoint was postoperative recovery assessed on QOR-15 at days 1, 2, 3, 4 and 7 and on Quick-DASH at 6 weeks. RESULTS Forty-nine patients were included, divided into 2 groups. The outpatient (OP) and inpatient (IP) groups were comparable. Reconstructive surgery accounted for 54% of cases in OP versus 62% in IP. There was no significant difference in recovery in the first postoperative days (QOR-15) or at 6 weeks (Quick-DASH) (p>0.05). Pain on visual analog scale (VAS) was significantly greater in OP after discharge home. DISCUSSION No significant difference in postoperative recovery was observed between groups. Nevertheless, pain management and patient information for outpatients need improving. LEVEL OF EVIDENCE II, comparative study.
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Hutton M, Brull R, Macfarlane A. Regional anaesthesia and outcomes. BJA Educ 2018; 18:52-56. [PMID: 33456810 PMCID: PMC7807931 DOI: 10.1016/j.bjae.2017.10.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2017] [Indexed: 01/29/2023] Open
Affiliation(s)
- M. Hutton
- Department of Anaesthesia, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, UK
| | - R. Brull
- Women's College Hospital, Toronto, Canada
| | - A.J.R. Macfarlane
- Department of Anaesthesia, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, UK
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Modelling of the optimal bupivacaine dose for spinal anaesthesia in ambulatory surgery based on data from systematic review. Eur J Anaesthesiol 2018; 33:846-852. [PMID: 27635951 DOI: 10.1097/eja.0000000000000528] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Spinal bupivacaine is used for day-case surgery but the appropriate dose that guarantees hospital discharge is unknown. OBJECTIVE We sought to determine the spinal bupivacaine dose that prevents delayed hospital discharge in ambulatory surgery. DESIGN Systematic review of clinical trials. DATA SOURCES Comprehensive search in electronic databases of studies published between 1996 and 2014 reporting the use of spinal bupivacaine in ambulatory patients. Additional articles were retrieved through hyperlinks and by manually searching reference lists in original articles, review articles and correspondence published in English and French. MAIN OUTCOME MEASURES Data were used to calculate, motor block duration and discharge time, an estimated maximal effect (Emax: maximum theoretical time of motor block) and the effective dose to obtain half of Emax (D50) with 95% confidence intervals (CIs). A simulation was performed to determine the dose corresponding to a time to recovery of 300 min for motor function, and 360 min for discharge, in 95% of the patients. RESULTS In total, 23 studies (1062 patients) were included for analysis of the time to recovery of motor function, and 12 studies (618 patients) for the time to hospital discharge. The Emax for recovery of motor function was 268 min [95% CI (189 to 433 min)] and the D50 was 3.9 mg [95% CI (2.3 to 6.2 mg)]. A 7.5-mg dose of bupivacaine enables resolution of motor block and ambulation within 300 min in 95% of the patients. A 5-mg dose or less was associated with an unacceptable failure rate. CONCLUSION Ambulatory surgery is possible under spinal anaesthesia with bupivacaine although the dose range that ensures reliable anaesthesia with duration short enough to guarantee ambulatory management is narrow.
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Abstract
PURPOSE OF REVIEW Breast surgery, performed for medical or cosmetic reasons, remains one of the most frequently performed procedures, with over 500,000 cases performed annually in the USA alone. Historically, general anesthesia (GA) has been widely accepted as the gold-standard technique, while epidural anesthesia was largely considered too invasive and thus unnecessary for breast surgery. Over the past years, paravertebral block (PVB) has emerged as an alternative analgesic or even anesthetic technique. Substantial evidence supports the use of PVB for major breast surgery. RECENT FINDINGS In patients receiving PVB, immediate and long-term analgesia is superior to systemic analgesia while opioid use and typical adverse effects of systemic analgesia such as nausea and vomiting are decreased. The benefits may also include an improved oncological survival with PVB after mastectomy for malignancy. PVB offers clinically significant benefits for perioperative care of patients undergoing breast surgery. The benefits of continuous PVB are most firmly supported for major breast surgery and include both effective short-term pain control and reduction in burden of chronic pain. On the other hand, minor breast surgery should be effectively manageable using multimodal analgesia in the majority of patients, with PVB reserved as analgesic rescue or for patients at high risk of excessive perioperative pain.
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Kaye AD, Helander EM, Vadivelu N, Lumermann L, Suchy T, Rose M, Urman RD. Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions. Pain Ther 2017; 6:129-141. [PMID: 28853044 PMCID: PMC5693810 DOI: 10.1007/s40122-017-0079-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Indexed: 02/02/2023] Open
Abstract
The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University, New Orleans, LA, USA
| | - Erik M Helander
- Department of Anesthesiology, Louisiana State University, New Orleans, LA, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Leandro Lumermann
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Thomas Suchy
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Margaret Rose
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Institute for Safety in Office-Based Surgery, Boston, MA, USA.
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Abstract
Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.
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Affiliation(s)
- Chancellor F Gray
- Division of Adult Arthroplasty and Joint Reconstruction, Department of Orthopaedics and Rehabilitation
| | - Cameron Smith
- Division of Acute Pain Medicine and Regional Anesthesia, Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL
| | - Yury Zasimovich
- Division of Acute Pain Medicine and Regional Anesthesia, Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL
| | - Patrick J Tighe
- Division of Acute Pain Medicine and Regional Anesthesia, Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL
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O'Donnell BD, Iohom G. A cross-sectional survey of anaesthesia-related expectations amongst patients awaiting upper limb trauma surgery. Rom J Anaesth Intensive Care 2017; 24:133-138. [PMID: 29090266 DOI: 10.21454/rjaic.7518.242.bdo] [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: 11/27/2022] Open
Abstract
BACKGROUND AND AIMS Little is known regarding patients' anaesthesia-related expectations when presenting for upper limb trauma surgery. METHODS We conducted a prospective cross-sectional survey exploring prior anaesthetic experience, anaesthesia-related knowledge, anaesthesia expectations, the preoperative visit and factors likely to influence anaesthesia choice. The survey was completed by 192 patients. RESULTS Anaesthetists were identified as doctors by 52%; 53% were unaware of their planned anaesthesia; 58% indicated likely acceptance of regional anaesthesia. Information regarding anaesthesia originated mostly from surgeons (65%); 93% had not seen an anaesthetist at the time of the survey. Most believed anaesthesia involved 'going to sleep' (82%) and 71% expected to receive general anaesthesia. The preoperative anaesthesia visit was rated as important by 65% of patients. 78% indicated that provision of information would increase the likelihood of accepting regional anaesthesia. Reducing postoperative pain and nausea would influence 80% in choosing a regional technique. CONCLUSION A knowledge deficit exists regarding anaesthesia modalities for upper limb trauma surgery.
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Affiliation(s)
| | - Gabriella Iohom
- Department of Anaesthesia, Cork University Hospital, Wilton, Cork, Ireland
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Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management. Anesth Analg 2017; 125:1749-1760. [DOI: 10.1213/ane.0000000000002497] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Henningsen MJ, Sort R, Møller AM, Herling SF. Peripheral nerve block in ankle fracture surgery: a qualitative study of patients’ experiences. Anaesthesia 2017; 73:49-58. [DOI: 10.1111/anae.14088] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 11/27/2022]
Affiliation(s)
- M. J. Henningsen
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
| | - R. Sort
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
| | - A. M. Møller
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
| | - S. F. Herling
- Department of Anaesthesiology; Herlev and Gentofte University Hospital; Herlev Denmark
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A Comparison of Regional Versus General Anesthesia for Lumbar Spine Surgery: A Meta-Analysis of Randomized Studies. J Neurosurg Anesthesiol 2017; 29:415-425. [DOI: 10.1097/ana.0000000000000362] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Teunkens A, Vanhaecht K, Vermeulen K, Fieuws S, Van de Velde M, Rex S, Bruyneel L. Measuring satisfaction and anesthesia related outcomes in a surgical day care centre: A three-year single-centre observational study. J Clin Anesth 2017; 43:15-23. [PMID: 28964960 DOI: 10.1016/j.jclinane.2017.09.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 09/01/2017] [Accepted: 09/24/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE To evaluate patient satisfaction and patient reported anaesthesia related outcome parameters after outpatient surgery. DESIGN A three-year (2013-2016) observational study. SETTING A surgical day care centre embedded in a tertiary care, university hospital. PATIENTS Adult Dutch-speaking patients who underwent surgery under general or regional anaesthesia on an outpatient basis (n=5424). INTERVENTIONS A questionnaire was developed to evaluate patients' satisfaction with care during their hospitalisation in the surgical day centre, as well as to assess their reports of anaesthesia related outcomes. MEASUREMENTS Various aspects of care were measured, including care by nurses, care by doctors, organisational and safety items. Variation in satisfaction and surgery and anaesthesia related outcomes as a function of different categories (gender, age, education, type of anaesthesia, discipline and era) were also investigated. MAIN RESULTS Confirmatory factor analysis showed an excellent fit to the hypothesized factors of the survey. Satisfaction scores were very high for different aspects of care, resulting in 98% of patients being (very) satisfied (59.1% very satisfied, 38.9% satisfied). Male (p=0.0003), higher educated (p<0.0001) and older patients (p<0.0001) were more likely to be very satisfied. Postoperative nausea and vomiting (PONV) were frequent (nausea: 13.9%, vomiting: 3.3%), and more present in female than in male patients (p<0.0001). Pain scores at the PACU differed among disciplines (p<0.0001) were higher in female patients compared to male patients (3.41% versus 2.54%, p<0.0001) and after general anaesthesia compared to regional anaesthesia (3.25% versus 0.39%, p<0.0001) and decreased with higher age (p=0.0001) and education level (p=0.0033). CONCLUSIONS Whereas satisfaction with all aspects of care is generally high, the results regarding pain and PONV should inspire quality improvement initiatives. The questionnaire developed in this study can be a vehicle to assess and improve the quality of care in surgical day care centres.
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Affiliation(s)
- An Teunkens
- Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium.
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
| | - Kristien Vermeulen
- Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Steffen Fieuws
- I-Biostat, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
| | - Marc Van de Velde
- Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium; Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3000 Leuven, Belgium
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Clonidine used as a perineural adjuvant to ropivacaine, does not prolong the duration of sensory block when controlling for systemic effects: A paired, blinded, randomized trial in healthy volunteers. PLoS One 2017; 12:e0181351. [PMID: 28880902 PMCID: PMC5589088 DOI: 10.1371/journal.pone.0181351] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 06/27/2017] [Indexed: 11/20/2022] Open
Abstract
Background Clonidine used as an adjuvant to ropivacaine have been shown to prolong the duration of peripheral nerve blocks. The mechanism of action remains unclear. We hypothesized, that clonidine used as an adjuvant to ropivacaine extends the duration of an adductor canal block (ACB) by a peripheral mechanism, compared to ropivacaine alone when controlling for systemic effects. Methods We conducted a paired, blinded, randomized trial in healthy volunteers. Participants received bilateral ACBs containing 20 ml ropivacaine 0.5% + 1 ml clonidine 150μg/ml in one leg and 20 ml ropivacaine 0.5% + 1 ml saline in the other leg. The primary outcome measure was duration of sensory block assessed by temperature sensation (alcohol swab). Secondary outcome measures were duration of sensory block assessed by: pinprick, maximum pain during tonic heat stimulation, warmth detection threshold and heat pain detection threshold. Results We enrolled 21 volunteers and all completed the trial. There was no difference in duration of sensory block assessed with an alcohol swab: Mean duration in the leg receiving ropivacaine + clonidine was 19.4h (SD 2.7) compared to 19.3h (SD 2.4) in the leg receiving ropivacaine + placebo with a mean difference of 0.1h (95% CI: -1.0 to 1.3), P = 0.83. No differences in block duration were detected when assessed by: Pinprick, mean difference 0.0 h (95% CI: -1.3 to 1.3), maximum pain during tonic heat stimulation, mean difference -0.7 h (95% CI: -2.1 to 0.8), warmth detection threshold, mean difference -0.1 h (95% CI: -1.8 to 1.6) or heat pain detection threshold, mean difference -0.2 h (95% CI: -1.7 to 1.4). Conclusions Administering clonidine perineurally as an adjuvant to ropivacaine in an ACB did not prolong the duration of sensory block in a setup controlling for systemic effects of clonidine.
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Sort R, Brorson S, Gögenur I, Møller AM. AnAnkle Trial study protocol: a randomised trial comparing pain profiles after peripheral nerve block or spinal anaesthesia for ankle fracture surgery. BMJ Open 2017; 7:e016001. [PMID: 28576901 PMCID: PMC5623423 DOI: 10.1136/bmjopen-2017-016001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Ankle fracture surgery is a common procedure, but the influence of anaesthesia choice on postoperative pain and quality of recovery is poorly understood. Some authors suggest a benefit of peripheral nerve block (PNB) in elective procedures, but the different pain profile following acute fracture surgery and the rebound pain on cessation of the PNB both remain unexplored. We present an ongoing randomised study aiming to compare primary PNB anaesthesia with spinal anaesthesia for ankle fracture surgery regarding postoperative pain profiles and quality of recovery. METHODS AND ANALYSIS AnAnkle Trial is a randomised, dual-centre, open-label, blinded analysis trial of 150 adult patients undergoing primary internal fixation of an ankle fracture. Main exclusion criteria are habitual opioid use, impaired pain sensation, other painful injuries or cognitive impairment. The intervention is ultrasound-guided popliteal sciatic (20 mL) and saphenal nerve (8 mL) PNB with ropivacaine 7.5 mg/mL, and controls receive spinal anaesthesia (2 mL) with hyperbaric bupivacaine 5 mg/mL. Postoperatively all receive paracetamol, ibuprofen and patient-controlled intravenous morphine on demand. Morphine consumption and pain scores are registered in the first 27 hours and reported as an integrated pain score as the primary endpoint. Pain score intervals are 3 hours and we will use the area under curve to get a longitudinal measure of pain. Secondary outcomes include rebound pain on cessation of anaesthesia, opioid side effects (Opioid-Related Symptom Distress Scale), quality of recovery (Danish Quality of Recovery-15 score) and pain scores and medication days 1-7 (diary). ETHICS AND DISSEMINATION The study has been approved by the Regional Ethics Committees in the Capital Region of Denmark, the Danish Data Protection Agency and the Danish Health and Medical Authority. We will publish the results in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER AnAnkle Trial is registered in the European Clinical Trials Database (EudraCT 2015-001108-76).
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Affiliation(s)
- Rune Sort
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Stig Brorson
- Department of Orthopaedic Surgery, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Ismail Gögenur
- Department of Surgery, Centre for Surgical Science, Zealand University Hospital, Copenhagen, Denmark
| | - Ann Merete Møller
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
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ULTRASOUND-GUIDED SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK WITH OR WITHOUT DEXMEDETOMIDINE AS AN ADJUVANT TO 0.5% LEVOBUPIVACAINE- A COMPARATIVE STUDY. ACTA ACUST UNITED AC 2017. [DOI: 10.14260/jemds/2017/731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Prabhakar A, Cefalu JN, Rowe JS, Kaye AD, Urman RD. Techniques to Optimize Multimodal Analgesia in Ambulatory Surgery. Curr Pain Headache Rep 2017; 21:24. [PMID: 28283811 DOI: 10.1007/s11916-017-0622-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Ambulatory surgery has grown in popularity in recent decades due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. We review common approaches to multimodal analgesia. RECENT FINDINGS A multimodal approach can help reduce perioperative opioid requirements and improve patient recovery. Analgesic options may include NSAIDs, acetaminophen, gabapentinoids, corticosteroids, alpha-2 agonists, local anesthetics, and the use of regional anesthesia. We highlight important aspects related to pain management in the ambulatory surgery setting. A coordinated approach is required by the entire healthcare team to help expedite patient recovery and facilitate a resumption of normal activity following surgery. Implementation and development of standardized analgesic protocols will further improve patient care and outcomes.
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Affiliation(s)
- Amit Prabhakar
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - John N Cefalu
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Josef S Rowe
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, 02115, USA.
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Abstract
PURPOSE OF REVIEW Given the growing number of ambulatory surgeries being performed and the variability in postoperative pain requirements, early discharge, and inconsistent follow-up, ambulatory surgery presents a unique challenge for this patient population and warrants the presence of an ambulatory pain specialist to evaluate a patient preoperatively and postoperatively to optimize patient safety and satisfaction. This article explores the crucial role that a dedicated pain physician would have in the ambulatory surgery setting. RECENT FINDINGS The prevalence of chronic pain, opioid use, and substance abuse is growing in this country, while ambulatory and same-day surgery have also experienced considerable growth. Inevitably, more patients with challenging chronic pain or substance abuse are having ambulatory surgery. Increased BMI, advanced age, more comorbidities warranting a higher ASA physical status classification, and longer surgeries are now all components of ambulatory surgery that contribute to increased risk too. Certain surgeries including breast surgery, inguinal hernia repair, and thoracotomy are at higher risk for the conversion of acute to chronic pain, and an ambulatory pain specialist would be beneficial for added focus on these patients. Multimodal pain control with non-opioids and regional anesthesia adjuvants are beneficial, while emphasis on a patient's functional capacity may be more useful than quantifying the severity of pain. Despite the best efforts of patients' primary care providers or surgeons, patients often are discharged with more chronic opioid therapy than they presented with, and an ambulatory pain specialist can help manage the complications and prevent further escalation of this opioid epidemic. An onsite anesthesiologist with interest in pain management in each ambulatory surgery center administering anesthesia and available onsite to deal with immediate preoperative, intraoperative, and recovery room would be ideal to curb and manage complication from uncontrolled pain and related pain issues.
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Lohela TJ, Chase RP, Hiekkanen TA, Kontinen VK, Hynynen MJ. Operating unit time use is associated with anaesthesia type in below-knee surgery in adults. Acta Anaesthesiol Scand 2017; 61:300-308. [PMID: 28090631 DOI: 10.1111/aas.12852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/11/2016] [Accepted: 12/12/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Peripheral nerve blocks could reduce the operating unit and theatre time spent on high-risk patients who are particularly vulnerable to complications of general anaesthesia or have medications that prevent application of central neuraxial blocks. METHODS Medical record data of 617 and 254 elderly adults undergoing below-knee surgery in Jorvi and Meilahti hospitals (Helsinki University Hospital) between January 2010 and December 2012 were used to investigate the influence of anaesthetic technique on operating theatre times and on operating unit times using flexible parametric survival models. We report operating theatre and unit exit ratios (i.e. hazard ratios but using ratios of exit rates) for different types of anaesthesia. RESULTS Adjusted analyses: In Jorvi Hospital, anaesthesia type was associated with large initial differentials in operating theatre times. The theatre exit ratios remained lower for general anaesthesia and central neuraxial blocks compared to peripheral nerve blocks until 30 min. In Meilahti Hospital, anaesthesia type did not influence theatre time, but was the best predictor of operating unit times. Compared to peripheral nerve blocks, the exit ratio remained lower for general anaesthesia until five operating unit hours in both hospitals and for central neuraxial blocks until 1 h in Meilahti Hospital and until 3 h in Jorvi Hospital. Holding area was used more in Jorvi Hospital compared to Meilahti Hospital. CONCLUSION Peripheral nerve block anaesthesia reduces time spent in the operating unit and can reduce time spent in the operating theatre if induced in holding area outside of theatre.
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Affiliation(s)
- T. J. Lohela
- Division of Anaesthesiology; Department of Anaesthesiology, Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
- Department of Public Health; University of Helsinki; Helsinki Finland
| | - R. P. Chase
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore MD USA
| | - T. A. Hiekkanen
- Division of Anaesthesiology; Department of Anaesthesiology, Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - V. K. Kontinen
- Division of Anaesthesiology; Department of Anaesthesiology, Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - M. J. Hynynen
- Division of Anaesthesiology; Department of Anaesthesiology, Intensive Care and Pain Medicine; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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Carles M, Beloeil H, Bloc S, Nouette-Gaulain K, Aveline C, Cabaton J, Cuvillon P, Dadure C, Delaunay L, Estebe JP, Hofliger E, Martinez V, Olivier M, Robin F, Rosencher N, Capdevila X. Anesthésie locorégionale périnerveuse. ANESTHESIE & REANIMATION 2017. [DOI: 10.1016/j.anrea.2017.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Büttner B, Mansur A, Hinz J, Erlenwein J, Bauer M, Bergmann I. Combination of general anesthesia and peripheral nerve block with low-dose ropivacaine reduces postoperative pain for several days after outpatient arthroscopy: A randomized controlled clinical trial. Medicine (Baltimore) 2017; 96:e6046. [PMID: 28178149 PMCID: PMC5313006 DOI: 10.1097/md.0000000000006046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Effective methods for postoperative pain relief are an important concern in outpatient surgery. For arthroscopies we combine a single-shot peripheral nerve block using low-volume, low-concentration ropivacaine with general anesthesia. We hypothesized that the patients would have less postoperative pain and be more rapidly home ready than after general anesthesia alone. METHODS Patients (American Society of Anesthesiologists I-III, 18-80 years old) scheduled for outpatient arthroscopy on the upper or lower extremity were randomized to have either a combination of peripheral nerve block and general anesthesia (NB + GA, study group) or general anesthesia alone (GA, control group). The relevant nerve was localized by ultrasound and 10 mL ropivacaine 0.2% was injected. General anesthesia was with propofol and remifentanil. Numeric rating scales were used to assess pain and patient satisfaction in the recovery room, on the evening of surgery, and on the following 2 days. RESULTS A total of 120 patients participated in the study (NB + GA: 61; GA: 59). The percentage of patients reporting relevant pain in the recovery room were 0% versus 44% (P < 0.001), on the evening after surgery 3% versus 80% (P < 0.001), and on days 1 and 2 postsurgery 12% versus 73% and 12% versus 64% (NB + GA vs GA, respectively). Median time to home discharge was NB + GA 34.5 min (range 15-90) versus GA 55 min (20-115) (P < 0.001). CONCLUSIONS The combination of a peripheral nerve block with low-dose ropivacaine and general anesthesia reduced postoperative pain compared with general anesthesia alone for several days after outpatient arthroscopy. It also shortened the time to home discharge.
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Bourgeois E, Cousin A, Chatel C, Gentili ME. Are pain and PONV so predominant in ambulatory surgery: Survey of call on D1 in 11,104 patients? Anaesth Crit Care Pain Med 2017; 36:193-194. [PMID: 28109937 DOI: 10.1016/j.accpm.2016.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/26/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Eric Bourgeois
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Privé de Saint-Grégoire, 6, avenue de la Boutière, 35760 Saint-Grégoire, France
| | - Anouchka Cousin
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Privé de Saint-Grégoire, 6, avenue de la Boutière, 35760 Saint-Grégoire, France
| | - Céline Chatel
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Privé de Saint-Grégoire, 6, avenue de la Boutière, 35760 Saint-Grégoire, France
| | - Marc Edouard Gentili
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Privé de Saint-Grégoire, 6, avenue de la Boutière, 35760 Saint-Grégoire, France.
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Nazir N, Jain S. Randomized Controlled Trial for Evaluating the Analgesic Effect of Nalbuphine as an Adjuvant to Bupivacaine in Supraclavicular Block under Ultrasound Guidance. Anesth Essays Res 2017; 11:326-329. [PMID: 28663615 PMCID: PMC5490148 DOI: 10.4103/0259-1162.194590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Benefits of regional anesthesia can be prolonged by adding adjuvants to local anesthetics. This study was designed to test the efficacy of adding nalbuphine to bupivacaine in supraclavicular brachial plexus blockade using ultrasound (US) guidance. Methodology: This was a prospective, randomized, double-blind study involving sixty patients of either sex undergoing elective orthopedic procedures of upper limb. In control Group C (n = 30), 30 mL of 0.375% bupivacaine + 1 mL normal saline and in study Group N (n = 30), 30 mL of 0.375% bupivacaine + 1 mL (10 mg) nalbuphine were used for giving supraclavicular block under US guidance. Parameters assessed were onset and duration of sensory and motor block, duration of analgesia (DOA), and any adverse events. Data between the groups were analyzed using independent t-test with SPSS 16.0 software. Results: In Group N, there was a statistically significant shorter time to onset of sensory blockade (4.89 ± 1.5 vs. 14.62 ± 1.73 min, P = 0.000), longer duration of sensory block (373.17 ± 15.56 min vs. 157.82 ± 11.02 min, P = 0.000), shorter onset time to achieve motor block (8.83 ± 1.9 min vs. 18.76 ± 1.75 min, P = 0.000), longer duration of motor block (313.92 ± 16.22 min vs. 121.87 ± 16.62 min, P = 0.000), and prolonged analgesia (389.33 ± 14.52 min vs. 171.65 ± 19.79 min, P = 0.000). Conclusion: Nalbuphine when added to bupivacaine as an adjuvant in supraclavicular block significantly shortened the onset of sensory and motor block and enhanced the duration of sensory and motor block and DOA.
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Affiliation(s)
- Nazia Nazir
- Department of Anesthesiology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
| | - Shruti Jain
- Department of Anesthesiology, School of Medical Sciences and Research, Sharda University, Greater Noida, Uttar Pradesh, India
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Kulkarni S, Harsoor SS, Chandrasekar M, Bhaskar SB, Bapat J, Ramdas EK, Valecha UK, Pradhan AS, Swami AC. Consensus statement on anaesthesia for day care surgeries. Indian J Anaesth 2017; 61:110-124. [PMID: 28250479 PMCID: PMC5330067 DOI: 10.4103/ija.ija_659_16] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
The primary aim of day-care surgery units is to allow for early recovery of the patients so that they can return to their familiar 'home' environment; the management hence should be focused towards achieving these ends. The benefits could include a possible reduction in the risk of thromboembolism and hospital-acquired infections. Furthermore, day-care surgery is believed to reduce the average unit cost of treatment by up to 70% as compared to inpatient surgery. With more than 20% of the world's disease burden, India only has 6% of the world's hospital beds. Hence, there is an immense opportunity for expansion in day-care surgery in India to ensure faster and safer, cost-effective patient turnover. For this to happen, there is a need of change in the mindset of all concerned clinicians, surgeons, anaesthesiologists and even the patients. A group of nine senior consultants from various parts of India, a mix of private and government anaesthesiologists, assembled in Mumbai and deliberated and discussed on the various aspects of day-care surgery. They formulated a consensus statement, the first of its kind in the Indian scenario, which can act as a guidance and tool for day-care anaesthesia in India. The statements are derived from the available published evidence in peer-reviewed literature including guidelines of several bodies such as the American Society of Anesthesiologists, British Association of Day Surgery and International Association of Ambulatory Surgery. The authors also offer interpretive comments wherever such evidence is inadequate or contradictory.
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Affiliation(s)
- Satish Kulkarni
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - S S Harsoor
- Department of Anaesthesiology, Bangalore Medical College and Research Centre, Bengaluru, Karnataka, India
| | - M Chandrasekar
- Aarogyasri Trust, Government of Telangana, Hyderabad, Telangana, India
| | - S Bala Bhaskar
- Department of Anaesthesiology and Critical Care, Vijayanagar Institute of Medical Sciences, Bellary, Karnataka, India
| | - Jitendra Bapat
- Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
| | | | - Umesh Kumar Valecha
- Department of Anaesthesiology, BLK Super Specialty Hospital, New Delhi, India
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Abstract
Unilateral spinal anesthesia is a cost-effective and rapidly performed anesthetic technique. An exclusively unilateral block only affects the sensory, motor and sympathetic functions on one side of the body and offers the advantages of a spinal block without the typical adverse side effects seen with a bilateral block. The lack of hypotension, in particular, makes unilateral spinal anesthesia suitable for patients with cardiovascular risk factors e. g. aortic valve stenosis or coronary artery disease. Increasing numbers of surgical procedures are now being performed on an outpatient basis. Until now, spinal anesthesia has been considered unsuitable for this, not only because of the high incidence of intraoperative hypotension and postoperative urinary retention but also because of the prolonged postoperative stay before home discharge. This is not the case with unilateral spinal anesthesia: motor function returns rapidly, the incidence of urinary retention is extremely low, and patients are usually eligible for home discharge sooner than after bilateral spinal anesthesia or general anesthesia. The success of the technique depends on a number of factors. In addition to the local anesthetic, its concentration and dose, and the baricity of the injected solution, the shape of the spinal needle, the injection speed, the patient's position during injection, and the time the patient remains in this position after injection are equally important parameters. A number of intrathecally applied adjuvant drugs are used to give a more intense and/or longer-lasting block. For this review, we collated the published data on unilateral spinal anesthesia from journals with an impact factor greater than 1.0 and defined an optimized method for performing the technique. In order to achieve an exclusively unilateral block one should use 0.5 % hyperbaric bupivacaine injected at a rate of 0.33 ml/min or slower. During the injection and the following 20 min the patient should lie in the lateral decubitus position on the side intended for surgery with knees drawn to the chest. An injection of 5 mg (1 ml) hyperbaric bupivacaine 0.5 % provides an hour-long block to T 12, and a dose of 7.5 to 10 mg (1.5-2.0 ml) extends the block to T 6. Adding clonidine (0.5 to 1.0 µg/kg BW) to the injection prolongs the duration of the block to approximately two to three hours. During the 20-minute fixation period, the cephalad spread of the block can be influenced to a certain extent by raising or lowering the head of the table.
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The Effects of Anesthetic Technique on Postoperative Opioid Consumption in Ankle Fracture Surgery. Clin J Pain 2016; 32:870-4. [DOI: 10.1097/ajp.0000000000000335] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Moreno-Martínez DA, Perea-Bello AH, Díaz-Bohada JL, García-Rodriguez DM, Echeverri-Mallarino V, Valencia-Peña MJ, Osorio-Cardona W, Silva-Enríquez PN. Factores asociados con anestesia regional fallida de plexo braquial para cirugía de extremidad superior. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rca.2016.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Factors associated with failed brachial plexus regional anesthesia for upper limb surgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2016. [DOI: 10.1016/j.rcae.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss current practices and changes in the field of ambulatory anesthesia, in both hospital and ambulatory surgery center settings. New trends in ambulatory settings are discussed and a review of the most current and comprehensive guidelines for the care of ambulatory patients with comorbid conditions such as postoperative nausea and vomiting (PONV), obstructive sleep apnea and diabetes mellitus are reviewed. Future direction and challenges to the field are highlighted. RECENT FINDINGS Ambulatory anesthesia continues to be in high demand for many reasons; patients and surgeons want their surgical procedures to be swift, involve minimal postoperative pain, have a transient recovery time, and avoid an admission to the hospital. Factors that have made this possible for patients are improved surgical equipment, volatile anesthetic improvement, ultrasound-guided regional techniques, non-narcotic adjuncts for pain control, and the minimization of PONV. The decrease in time spent in a hospital also decreases the risk of wound infection, minimizes missed days from work, and is a socioeconomically favorable model, when possible. Recently proposed strategies which will allow surgeons and anesthesiologists to continue to meet the growing demand for a majority of surgical cases being same-day include pharmacotherapies with less undesirable side-effects, integration of ultrasound-guided regional techniques, and preoperative evaluations in appropriate candidates via a telephone call the night prior to surgery. Multidisciplinary communication amongst caregivers continues to make ambulatory settings efficient, safe, and socioeconomically favorable.It is also important to note the future impact that healthcare reform will have specifically on ambulatory anesthesia. The enactment of the Patient Protection and Affordable Care Act of 2010 will allow 32 million more people to gain access to preventive services that will require anesthesia such as screening colonoscopies. With this projected increase in the demand for anesthesia services nationwide comes the analysis of its financial feasibility. Some early data looking at endoscopist-administered sedation conclude that it offers higher patient satisfaction, there were less adverse effects than anesthesiologist-administered sedation, and is economically advantageous. This and future retrospective studies will help to guide healthcare policymakers and physicians to come to a conclusion about providing ambulatory services for these millions of patients. SUMMARY Ambulatory anesthesia's popularity continues to rise and anesthetic techniques will continue to morph and adapt to the needs of patients seeking ambulatory surgery. Alterations in already existing medications are promising as these modifications allow for quicker recovery from anesthesia or minimization of the already known undesirable side-effects. PONV, pain, obstructive sleep apnea, and chronic comorbidities (hypertension, cardiac disease, and diabetes mellitus) are perioperative concerns in ambulatory settings as more patients are safely being treated in ambulatory settings. Regional anesthesia stands out as a modality that has multiple advantages to general anesthesia, providing a minimal recovery period and a decrease in postanesthesia care unit stay. The implementation of the Affordable Healthcare Act specifically affects ambulatory settings as the demand and need for patients to have screening procedures with anesthesia. The question remains what the best strategy is to meet the needs of our future patients while preserving economically feasibility within an already strained healthcare system.
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Nerve stimulator-guided pudendal nerve block vs general anesthesia for postoperative pain management after anterior and posterior vaginal wall repair: a prospective randomized trial. J Clin Anesth 2016; 34:668-75. [PMID: 27687468 DOI: 10.1016/j.jclinane.2016.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 06/02/2016] [Accepted: 07/08/2016] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE Compare the effectiveness of nerve stimulator-guided pudendal nerve block (PNB) vs general anesthesia (GA) for anterior and posterior (AP) colporrhaphy in terms of pain relief and analgesic consumption within 24 and 48 hours postoperatively. DESIGN Prospective randomized trial. PATIENTS Fifty-seven patients whose ages ranged between 20 and 53 years scheduled to undergo AP colporrhaphy due to the presence of cystorectocele. INTERVENTIONS Patients were randomly assigned into 2 groups receiving either nerve stimulator-guided PNB (n = 28) or GA (n = 29). A total volume of 0.7 mL/kg of the local anesthetic mixture was injected at 4 sites. MAIN RESULTS Both groups were similar with respect to age, weight, height, and surgery duration. There was a significant difference in average pain scores within the first and second postoperative days (P values = .005 and .004, respectively). Total analgesic consumption (ketoprofen and tramadol) was significantly lower in the PNB within the first (P values = .018 and .010) and second postoperative days (P values = .041 and .011), respectively. Return to normal daily activity was significantly (P< .0001) shorter in the PNB group compared with the GA group (3.6 days vs 12.2 days). A total of 71.4% of the patients in the PNB group were satisfied compared with 27.8% in the GA group (P< .0001). Surgeon satisfaction was significantly higher in the PNB group (82.1% vs 34.5%, P< .0001). CONCLUSION This randomized controlled trial demonstrated that nerve stimulator-guided PNB could be used as an alternative to GA for AP repair of stages I and II prolapse because it is associated with less postoperative pain and analgesic consumption, in addition to shorter duration of recovery.
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Parcells BW, Giacobbe D, Macknet D, Smith A, Schottenfeld M, Harwood DA, Kayiaros S. Total Joint Arthroplasty in a Stand-alone Ambulatory Surgical Center: Short-term Outcomes. Orthopedics 2016; 39:223-8. [PMID: 27111079 DOI: 10.3928/01477447-20160419-06] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 02/10/2016] [Indexed: 02/03/2023]
Abstract
For decades, the average hospital stay following total joint arthroplasty (TJA) has been getting shorter. The historical standard was several weeks of hospitalization, yet improvements in perioperative care have reduced the average length of stay to a few days. Medicare recognizes a 3-day inpatient stay as the standard of care following hip or knee replacement. Yet continued advances in minimally invasive surgical techniques, short-acting general anesthetics, long-acting local anesthetics, and blood loss management have further improved the safety and recovery for TJA procedures. Thus, further reductions in postoperative hospitalization have been implemented around the country, with surgeons reporting successful same-day protocols, as defined by hospitalization discharge on the day of surgery. Although these studies have presented results of same-day TJA in the hospital setting, this study is the first to report on the perioperative adverse events and early outcomes of 51 consecutive TJA procedures performed in a stand-alone ambulatory surgical center (ASC). The ASC offers an ideal setting to perform such procedures in the properly selected patient population, obviating any form of postoperative hospitalization. Although 16 (31.4%) of 51 patients reported minor adverse events in the postanesthesia care unit, specifically nausea and/or pain, early intervention permitted 50 (98.0%) of 51 patients to be discharged home, on average 176 minutes after surgery, with 1 patient discharged to a rehabilitation facility as arranged prior to surgery. There were no major adverse events in the 90-day perioperative period, and although 1 (2.0%) patient was hospitalized for persistent incisional drainage, none required admission for pain. This study examines the strict eligibility criteria and perioperative analgesia protocols that permit successful outpatient TJA. [Orthopedics. 2016; 39(4):223-228.].
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Sahni M, Fitzmaurice B, Jagannathan S. Intrathecal anaesthesia for day-case knee arthroscopy. Anaesthesia 2016; 71:859-60. [PMID: 27291616 DOI: 10.1111/anae.13514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M Sahni
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK.
| | - B Fitzmaurice
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - S Jagannathan
- University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
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Ambrosoli AL, Guzzetti L, Cappelleri G. Intrathecal anaesthesia for day-case knee arthroscopy - a reply. Anaesthesia 2016; 71:860-1. [PMID: 27291617 DOI: 10.1111/anae.13552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - L Guzzetti
- Ospedale di Circolo di Varese, Varese, Italy
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The effect of anesthesia type on major lower extremity amputation in functionally impaired elderly patients. J Vasc Surg 2016; 63:696-701. [DOI: 10.1016/j.jvs.2015.09.050] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 09/28/2015] [Indexed: 11/18/2022]
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Qin Q, Yang D, Xie H, Zhang L, Wang C. [Ultrasound guidance improves the success rate of axillary plexus block: a meta-analysis]. Rev Bras Anestesiol 2016; 66:115-9. [PMID: 26847538 DOI: 10.1016/j.bjan.2015.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/27/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the value of real-time ultrasound (US) guidance for axillary brachial plexus block (AXB) through the success rate and the onset time. METHODS The meta-analysis was carried out in the Anesthesiology Department of the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China. A literature search of Medline, Embase, Cochrane database from the years 2004 to 2014 was performed. The literature searches were carried out using medical subject headings and free-text word: "axilla", "axillary", "brachial plexus", "ultrasonography", "ultrasound", "ultrasonics". Two different reviewers carried out the search and evaluated studies independently. RESULTS Seven randomized controlled trials, one cohort study and three retrospective studies were included. A total of 2042 patients were identified. 1157 patients underwent AXB using US guidance (US group) and the controlled group included 885 patients (246 patients using traditional approach (TRAD) and 639 patients using nerve stimulation (NS)). Our analysis showed that the success rate was higher in the US group compared to the controlled group (90.64% vs. 82.21%, p<0.00001). The average time to perform the block and the onset of sensory time were shorter in the US group than the controlled group. CONCLUSION The present study demonstrated that the real-time ultrasound guidance for axillary brachial plexus block improves the success rate and reduce the mean time to onset of anesthesia and the time of block performance.
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Affiliation(s)
- Qin Qin
- Departamento de Anestesiologia e Cuidados Intensivos, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, República Popular da China
| | - Debao Yang
- Departamento de Neurocirurgia, Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, Jiangsu Province, República Popular da China
| | - Hong Xie
- Departamento de Anestesiologia e Cuidados Intensivos, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, República Popular da China
| | - Liyuan Zhang
- Departamento de Radioterapia, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, República Popular da China
| | - Chen Wang
- Departamento de Anestesiologia e Cuidados Intensivos, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, República Popular da China.
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139
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Beaussier M, Sciard D, Sautet A. New modalities of pain treatment after outpatient orthopaedic surgery. Orthop Traumatol Surg Res 2016; 102:S121-4. [PMID: 26803223 DOI: 10.1016/j.otsr.2015.05.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/22/2015] [Accepted: 05/14/2015] [Indexed: 02/02/2023]
Abstract
Postoperative pain relief is one of the cornerstones of success of orthopaedic surgery. Development of new minimally-invasive surgical procedures, as well as improvements in pharmacological and local and regional techniques should result in optimal postoperative pain control for all patients. The analgesic strategy has to be efficient, with minimal side effects, and be easy to manage at home. Multimodal analgesia allows for a reduction of opiate use and thereby its side effects. Local and regional analgesia is a major component of this multimodal strategy, associated with optimal pain relief, even upon mobilization, and it has beneficial effects on postoperative recovery. Ultrasound guidance improves the success rate of distal nerve blocks and makes distal selective blockade possible, helping to preserve the limb's motility. Besides peripheral nerve blocks, local infiltration (incisional and/or intra-articular) is also important to consider. Duration of the nerve blockade is limited after a single injection. This must be taken into consideration to avoid the recurrence of pain when the patient returns home. Continuous perineural blocks using catheters are an option that can be easily managed at home with monitoring by home-care nurses. Extended-release liposomal bupivacaine and adjuvants such as dexamethasone could significantly enhance the duration of the sensory block, thereby reducing the indications for pain pumps. Non-pharmacological approaches, such as cryotherapy, hypnosis and acupuncture should not be ignored.
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Affiliation(s)
- M Beaussier
- Assistance publique-Hôpitaux de Paris, Groupe Hospitalier Est-Parisien, Sorbonne Universités, UPMC Université Paris, Hôpital St-Antoine, Orthopaedic and Trauma Surgery Department, Surgical Anesthesia and Intensive Care Unit, Paris, France.
| | - D Sciard
- Assistance publique-Hôpitaux de Paris, Groupe Hospitalier Est-Parisien, Sorbonne Universités, UPMC Université Paris, Hôpital St-Antoine, Orthopaedic and Trauma Surgery Department, Surgical Anesthesia and Intensive Care Unit, Paris, France
| | - A Sautet
- Assistance publique-Hôpitaux de Paris, Groupe Hospitalier Est-Parisien, Sorbonne Universités, UPMC Université Paris, Hôpital St-Antoine, Orthopaedic and Trauma Surgery Department, Surgical Anesthesia and Intensive Care Unit, Paris, France
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140
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Ambrosoli AL, Chiaranda M, Fedele LL, Gemma M, Cedrati V, Cappelleri G. A randomised controlled trial of intrathecal blockade versus peripheral nerve blockade for day-case knee arthroscopy. Anaesthesia 2016; 71:280-4. [PMID: 26864002 DOI: 10.1111/anae.13361] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2015] [Indexed: 11/29/2022]
Abstract
We allocated 100 patients scheduled for day-case knee arthroscopy to unilateral spinal anaesthesia with 40 mg intrathecal hyperbaric prilocaine or to ultrasound-guided femoral-sciatic nerve blockade with 25 ml mepivacaine 2%, 50 participants each. The median (IQR [range]) time to walk was 285 (240-330 [160-515]) min after intrathecal anaesthesia vs 328 (280-362 [150-435]) min after peripheral nerve blockade, p = 0.007. The median (IQR [range]) time to home discharge was 310 (260-350 [160-520]) min after intrathecal anaesthesia vs 335 (290-395 [190-440]) min after peripheral nerve blockade, p = 0.016. There was no difference in time from anaesthetic preparation to readiness for surgery.
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Affiliation(s)
- A L Ambrosoli
- Department of Anaesthesia, Ospedale di Circolo di Varese, Varese, Italy
| | - M Chiaranda
- Department of Anaesthesia and Intensive Care, Università degli Studi Insubria di Varese, Varese, Italy
| | - L L Fedele
- Department of Anaesthesia and Intensive Care, Università degli Studi Insubria di Varese, Varese, Italy
| | - M Gemma
- Department of Anaesthesia, IRCCS Ospedale San Raffaele, Milano, Italy
| | - V Cedrati
- Department of Anaesthesia, Istituto Ortopedico G. Pini, Milano, Italy
| | - G Cappelleri
- Department of Anaesthesia, Istituto Ortopedico G. Pini, Milano, Italy
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141
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Regional Versus General Anesthesia and the Incidence of Unplanned Health Care Resource Utilization for Postoperative Pain After Wrist Fracture Surgery. Reg Anesth Pain Med 2016; 41:22-7. [DOI: 10.1097/aap.0000000000000325] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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142
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Gabriel RA, Lemay A, Beutler SS, Dutton RP, Urman RD. Practice Variations in Anesthesia for Carotid Endarterectomies and Associated Outcomes. J Cardiothorac Vasc Anesth 2016; 30:23-9. [DOI: 10.1053/j.jvca.2015.06.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Indexed: 11/11/2022]
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143
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Maheshwari V, Rasheed MA, Singh RB, Choubey S, Sarkar A. Comparison of ropivacaine with levobupivacaine under epidural anesthesia in the lower limb orthopedic surgeries: A randomized study. Anesth Essays Res 2016; 10:624-630. [PMID: 27746563 PMCID: PMC5062201 DOI: 10.4103/0259-1162.191119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Context: Epidural anesthesia is nowadays considered as the gold standard anesthetic technique for lower limb orthopedic surgeries, and the present study was conducted to evaluate the efficacy of levobupivacaine and ropivacaine in terms of onset, duration of sensory and motor block with duration of postoperative analgesia in patients undergoing lower limb orthopedic surgeries under epidural anesthesia. Aims: To compare the efficacy of 15 mL of levobupivacaine 0.5% with that of 15 mL of ropivacaine 0.75% in patients undergoing lower limb orthopedic surgeries under epidural anesthesia and to determine the better of the two agents with respect to onset, duration of sensory and motor blockade, postoperative analgesia, and adverse effects; if any. Settings and Design: A double-blind randomized study. Subjects and Methods: A total of seventy patients planned to undergo elective lower limb orthopedic surgeries fulfilling the criteria were enrolled in the study. Group I (n = 35): Received 15 mL 0.5% levobupivacaine epidurally. Group II (n = 35): Received 15 mL 0.75% ropivacaine epidurally. Statistical Analysis: Statistical Analysis was done by Statistical Package for Social Sciences (SPSS Version 15.0) statistical analysis software. The values were represented in number (%) and mean ± standard deviation. Results: Time to achieve sensory onset and motor onset were significantly lower in Group II (17.86 ± 2.51 and 23.14 ± 2.73) as compared to Group I (26.14 ± 2.45 and 31.43 ± 2.59) while the duration of sensory block was significantly higher in Group II (173.29 ± 6.29 min) as compared to Group I (156.71 ± 6.96 min). Although motor block duration of Group I (142.43 ± 8.43 min) was higher than that of Group II (141.43 ± 12.81 min), but this difference was not found to be statistically significant. Conclusions: The inference drawn from this discussion, in general, indicated that both the drugs are comparable for block onset, quality, and duration along with similar hemodynamic profile when given in same concentration. However, relatively better response of ropivacaine for block onset and duration as obtained in the present study coupled with higher but statistically.
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Affiliation(s)
- Vijeta Maheshwari
- Department of Anesthesiology and Critical Care, KGMU, Lucknow, Uttar Pradesh, India
| | - Mohd Asim Rasheed
- Department of Anesthesiology and Critical Care, Era's Lucknow Medical College, Lucknow, Uttar Pradesh, India
| | - Raj Bahadur Singh
- Department of Anesthesiology and Critical Care, Narayan Medical College and Hospital, Sasaram, Bihar, India
| | - Sanjay Choubey
- Department of Anesthesiology and Critical Care, Era's Lucknow Medical College, Lucknow, Uttar Pradesh, India
| | - Arindam Sarkar
- Department of Anesthesiology and Critical Care, Era's Lucknow Medical College, Lucknow, Uttar Pradesh, India
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144
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Abstract
Ambulatory anesthesia's popularity continues to increase and techniques continue to adapt to the needs of patients. Alterations in existing medications are promising. Postoperative nausea and vomiting, pain, obstructive sleep apnea, and chronic comorbidities are concerns in ambulatory settings. Regional anesthesia has multiple advantages over general anesthesia. The implementation of the Affordable Health Care Act specifically affects ambulatory settings as the demand and need for patients to undergo screening procedures with anesthesia. The question remains what the best strategy is to meet the needs of our future patients while preserving economic feasibility within an already strained health care system.
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Affiliation(s)
- Caroline D Fosnot
- Department of Anesthesiology & Critical Care, Hospital of University Pennsylvania, Perelman School of Medicine, University of Pennsylvania School of Medicine, University of Pennsylvania, 3400 Spruce Street, Dulles Building, 7th Floor, Suite 700, Philadelphia, PA 19104, USA.
| | - Lee A Fleisher
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - John Keogh
- Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania School of Medicine, Dulles Building Suite 680, Philadelphia, PA 19104, USA
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145
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McIsaac D, Cole E, McCartney C. Impact of including regional anaesthesia in enhanced recovery protocols: a scoping review. Br J Anaesth 2015; 115 Suppl 2:ii46-56. [DOI: 10.1093/bja/aev376] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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146
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Shah A, Rowlands M, Krishnan N, Patel A, Ott-Young A. Thoracic Intercostal Nerve Blocks Reduce Opioid Consumption and Length of Stay in Patients Undergoing Implant-Based Breast Reconstruction. Plast Reconstr Surg 2015; 136:584e-591e. [DOI: 10.1097/prs.0000000000001717] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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147
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Qin Q, Yang D, Xie H, Zhang L, Wang C. Ultrasound guidance improves the success rate of axillary plexus block: a meta-analysis. Braz J Anesthesiol 2015; 66:115-9. [PMID: 26952217 DOI: 10.1016/j.bjane.2015.01.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/27/2015] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate the value of real-time ultrasound (US) guidance for axillary brachial plexus block (AXB) through the success rate and the onset time. METHODS The meta-analysis was carried out in the Anesthesiology Department of the Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China. A literature search of Medline, EMBASE, Cochrane database from the years 2004 to 2014 was performed. The literature searches were carried out using medical subject headings and free-text word: "axilla", "axillary", "brachial plexus", "ultrasonography", "ultrasound", "ultrasonics". Two different reviewers carried out the search and evaluated studies independently. RESULTS Seven randomized controlled trials, one cohort study and three retrospective studies were included. A total of 2042 patients were identified. 1157 patients underwent AXB using US guidance (US group) and the controlled group included 885 patients (246 patients using traditional approach (TRAD) and 639 patients using nerve stimulation (NS)). Our analysis showed that the success rate was higher in the US group compared to the controlled group (90.64% vs. 82.21%, p<0.00001). The average time to perform the block and the onset of sensory time were shorter in the US group than the controlled group. CONCLUSION The present study demonstrated that the real-time ultrasound guidance for axillary brachial plexus block improves the success rate and reduce the mean time to onset of anesthesia and the time of block performance.
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Affiliation(s)
- Qin Qin
- Department of Anesthesiology and Critical Care, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, People's Republic of China
| | - Debao Yang
- Department of Neurosurgery, Kowloon Hospital, Shanghai Jiaotong University School of Medicine, Suzhou, Jiangsu Province, People's Republic of China
| | - Hong Xie
- Department of Anesthesiology and Critical Care, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, People's Republic of China
| | - Liyuan Zhang
- Department of Radiotherapy, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, People's Republic of China
| | - Chen Wang
- Department of Anesthesiology and Critical Care, The Second Affiliate Hospital of Soochow University, Suzhou, Jiangsu Province, People's Republic of China.
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148
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Rafii-Tari H, Lessoway VA, Kamani AA, Abolmaesumi P, Rohling R. Panorama Ultrasound for Navigation and Guidance of Epidural Anesthesia. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2220-2231. [PMID: 25964065 DOI: 10.1016/j.ultrasmedbio.2015.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Revised: 02/06/2015] [Accepted: 03/09/2015] [Indexed: 06/04/2023]
Abstract
Despite the common use of epidural anesthesia in obstetrics and surgery, the procedure can be challenging, especially for obese patients. We propose the use of an ultrasound guidance system employing a transducer-mounted camera to create 3-D panorama ultrasound volumes of the spine, thereby allowing identification of vertebrae and selection of puncture site, needle trajectory and depth of insertion. The camera achieves absolute position estimation of the transducer with respect to the patient using a specialized marker strip attached to the skin surface. The guidance system is validated first on a phantom against a commercial optical tracking system and then in vivo by comparing panorama images from human subjects against independent measurements by an experienced sonographer. The results for measuring depth to the epidural space, intervertebral spacing and registration of interspinous gaps to the skin prove the potential of the system for improving guidance of epidural anesthesia. The tracking and visualization are implemented in real time using the 3D Slicer software package.
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Affiliation(s)
- Hedyeh Rafii-Tari
- The Hamlyn Centre for Robotic Surgery, Imperial College London, London, UK
| | - Victoria A Lessoway
- Department of Ultrasound, British Columbia Women's Hospital and Health Centre, Vancouver, British Columbia, Canada
| | - Allaudin A Kamani
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Purang Abolmaesumi
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Rohling
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, British Columbia, Canada; Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, Canada.
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149
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Abstract
PURPOSE OF REVIEW As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly patients will assume increased importance. RECENT FINDINGS Increasing evidence supports the expanded use of ambulatory surgery for managing elderly patients undergoing elective surgery procedures. SUMMARY This review article describes the demographics of ambulatory surgery in the elderly population. This review article describes the effects of aging on the responses of geriatric patients to anesthetic and analgesic drugs used during ambulatory surgery. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative side-effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. Finally, we discuss the future challenges related to the continued expansion of ambulatory surgery practice in this growing segment of our surgical population. The role of anesthesiologists as perioperative physicians is of critical importance for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. Providing high-quality, evidence-based anesthetic and analgesic care for elderly patients undergoing elective operations on an ambulatory basis will assume greater importance in the future.
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150
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Lester L. Anesthetic Considerations for Common Procedures in Geriatric Patients: Hip Fracture, Emergency General Surgery, and Transcatheter Aortic Valve Replacement. Anesthesiol Clin 2015; 33:491-503. [PMID: 26315634 DOI: 10.1016/j.anclin.2015.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The elderly population is growing. Geriatric patients undergo a large proportion of surgical procedures and have increased complications, morbidity, and mortality, which may be associated with increased intensive care unit time, length of stay, hospital readmission, and cost. Identification of optimal anesthetic care for these patients, leading to decreased complications and contributing to best possible outcomes, will have great value. This article reviews the anesthetic considerations for intraoperative care of geriatric patients and focus on 3 procedures (hip fractures, emergency abdominal surgery, and transcatheter aortic valve replacement). An approach to evaluation and management of the elderly surgical patient is described.
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Affiliation(s)
- Laeben Lester
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, 1800 Orleans Street, Zayed 6208, Baltimore, MD 21287-7294, USA.
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