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Oliver JA, Oliver LA, Aggarwal N, Baldev K, Wood M, Makusha L, Vadivelu N, Lichtor L. Ambulatory Pain Management in the Pediatric Patient Population. Curr Pain Headache Rep 2022; 26:15-23. [PMID: 35129824 DOI: 10.1007/s11916-022-00999-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia. RECENT FINDINGS A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.
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Affiliation(s)
- Jodi-Ann Oliver
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Lori-Ann Oliver
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Nitish Aggarwal
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA.
| | - Khushboo Baldev
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Melanie Wood
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Lovemore Makusha
- Department of Anesthesiology, Stanford University, Pao Alto, CA, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
| | - Lance Lichtor
- Department of Anesthesiology, Yale University, New Haven, CT, 06520, USA
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Pediatric obesity and perioperative medicine. Curr Opin Anaesthesiol 2021; 34:299-305. [PMID: 33935177 DOI: 10.1097/aco.0000000000000991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action. RECENT FINDINGS Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur. SUMMARY Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.
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Teames R, Joyce A, Scranton R, Vick C, Nagaraj N. Characterization of Device-Related Malfunction, Injury, and Death Associated with Using Elastomeric Pumps for Delivery of Local Anesthetics in the US Food and Drug Administration MAUDE Database. Drug Healthc Patient Saf 2021; 12:293-299. [PMID: 33380842 PMCID: PMC7767709 DOI: 10.2147/dhps.s280006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 12/11/2020] [Indexed: 11/26/2022] Open
Abstract
Purpose To characterize medical device reports about elastomeric pumps delivering local anesthesia made to the US Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. Patients and Methods We conducted a retrospective review of medical device reports submitted to MAUDE from January 2010 to July 2018. A systematic, computerized algorithm was used to identify records pertaining to elastomeric pumps using local anesthesia. Included records indicated the use of local anesthesia or were determined to involve the use of local anesthetics (if they did not contain specific information on drug use). Reports were analyzed within the MAUDE event type categories of malfunction, injury, death, other, and missing. Possible cases of liver injury or surgical site infection were also identified. Manual review of narratives provided in MAUDE was performed by 2 reviewers to identify possible or probable cases of local anesthetic system toxicity (LAST). Results From a pool of 384,285 reports about elastomeric pumps from the MAUDE database, 4093 met inclusion criteria for involving elastomeric pumps to deliver local anesthetics, with the peak number of reports occurring in 2014. Of these identified reports, 3624 (88.5%) were categorized as malfunctions, 292 (7.1%) as injuries, and 8 (0.2%) as involving death. We identified 13 cases (0.3%) of possible liver injury and 51 cases (1.2%) of possible surgical site infection; 139 reports (3.4%) were determined to be probably (n=53) or possibly (n=86) associated with LAST. Conclusion Malfunction of elastomeric pumps delivering local anesthetics leaves patients vulnerable to injury or death. Our study indicates that reports of malfunction, injury, and death have been reported to the MAUDE database. These reports likely reflect an underrepresentation of cases in the real-world population, emphasizing the need for more comprehensive medical device reporting.
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Affiliation(s)
- Richard Teames
- Department of Anesthesiology, JPS Health Network, Fort Worth, TX, USA
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Jensen AR, Sharma AK, Formanek B, Wang C, Buser Z, Wang JC, Petrigliano FA. Continuous Peripheral Nerve Blocks Are Associated With Increased Rates of Emergency Department Visits After Arthroscopic Rotator Cuff Repair Surgery. Orthopedics 2020; 43:127-131. [PMID: 31841606 DOI: 10.3928/01477447-20191212-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/14/2019] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to assess trends in the use of perioperative single and continuous peripheral nerve blocks (PNBs) and their associations with emergency department (ED) visits after arthroscopic rotator cuff repair (RCR) surgery. The authors used a large database from a private insurer to identify patients who received perioperative PNBs for arthroscopic RCR surgeries from 2007 to 2015. They analyzed patient demographics as well as trends in perioperative PNB use. They also assessed rates of single shot vs continuous PNB use and compared rates of postoperative ED visits according to PNB type. The rate of perioperative PNB for arthroscopic RCR was higher than previously reported (65.9%) and increased over time (52.8% in 2007 to 64.6% in 2015; P=.029). Single shot PNBs were more common than continuous, catheter-mediated PNBs (60.0% vs 6.6%; P<.001), although the use of continuous blocks increased at a greater rate during the study period. Patients who received a perioperative continuous PNB were significantly more likely to visit an ED within 7 days of their surgery than those who received a single shot PNB or no PNB (6.71% vs 4.78% vs 4.74%; P<.02). The rates of ED visits within each group did not change significantly over time. Continuous PNBs are increasingly common for patients undergoing arthroscopic RCR surgery but are associated with increased rates of postoperative ED visits. Studies are needed to identify the reasons for this increased rate of ED visits and strategies to decrease ED use. [Orthopedics. 2020; 43(2): 127-131.].
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Tanijima M, Takechi K, Nakanishi K, Yorozuya T. Adverse events associated with continuous interscalene block administered using the catheter-over-needle method: a retrospective analysis. BMC Anesthesiol 2019; 19:195. [PMID: 31660871 PMCID: PMC6816201 DOI: 10.1186/s12871-019-0873-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/21/2019] [Indexed: 11/24/2022] Open
Abstract
Background Continuous interscalene block is widely used for pain management in shoulder surgery. However, continuous interscalene block performed using the catheter-through-needle method is reportedly associated with adverse events such as pericatheter leakage of the local anesthetic, phrenic nerve paralysis, and hoarseness. Because we expected that the catheter-over-needle method would reduce these adverse events, we examined cases in which continuous interscalene block was performed using the catheter-over-needle method to determine what adverse events occurred and when. Methods We retrospectively reviewed the anesthesia and medical records of adult patients who underwent catheter insertion to receive a continuous interscalene block performed using the catheter-over-needle method at our hospital from July 2015 to July 2017. Results During the surveillance period, 122 adult patients underwent catheter insertion to receive a continuous interscalene block administered using the catheter-over-needle method. No case of pericatheter local anesthetic leakage was observed. Adverse events, such as dyspnea, hoarseness, insufficient anesthetic effect, dizziness, cough reflex during drinking, or ptosis, were observed in 42 patients (34.4%; 95% confidence interval 26–42.7). Most of the adverse events occurred on postoperative day 2. The median time between surgery and the onset of adverse events was 28.5 h. Conclusions The catheter-over-needle method may prevent the pericatheter leakage of the local anesthetic. However, adverse events occurred in more than one-third of the patients. During continuous interscalene block, patients must be carefully observed for adverse events, especially on postoperative day 2. Trial registration This study was registered at the UMIN Clinical Trials Registry on August 13th, 2019 (UMIN000037673).
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Affiliation(s)
- Meishu Tanijima
- Ehime Prefectural Central Hospital, 83 kasugachou, Matsuyama City, Ehime, Japan
| | - Kenichi Takechi
- Matsuyama Red Cross Hospital, 1 Bunkyochou, Matsuyama City, Ehime, Japan.
| | - Kazuo Nakanishi
- Ehime Prefectural Imabari Hospital, 4-5-5 Ishiichou, Imabari City, Ehime, Japan
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, 454 Shitsukawa, Toon City, Ehime, Japan
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Pulos BP, Bowers MR, Shin AY, Pulos N. Opioid-Sparing Pain Management in Upper Extremity Surgery: Part 1: Role of the Surgeon and Anesthesiologist. J Hand Surg Am 2019; 44:787-791. [PMID: 31031025 DOI: 10.1016/j.jhsa.2019.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/27/2019] [Indexed: 02/02/2023]
Abstract
A multimodal pain management strategy combines complementary medications and techniques, targeting unique pathways, to improve overall analgesic effect and reduce opioid requirements. In this 2-part review, we examine the literature identifying nonopioid analgesic modalities and their targets in the pain pathway as well as anesthetic techniques found to be opioid-sparing in the practice of upper extremity surgery. First, we focus on operative anesthesia and analgesia and areas for future research specific to upper extremity surgery. In part 2, we discuss the nonopioid options available after surgery.
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Affiliation(s)
| | | | | | - Nicholas Pulos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Bailey CR, Ahuja M, Bartholomew K, Bew S, Forbes L, Lipp A, Montgomery J, Russon K, Potparic O, Stocker M. Guidelines for day-case surgery 2019: Guidelines from the Association of Anaesthetists and the British Association of Day Surgery. Anaesthesia 2019; 74:778-792. [PMID: 30963557 DOI: 10.1111/anae.14639] [Citation(s) in RCA: 141] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 12/18/2022]
Abstract
Guidelines are presented for the organisational and clinical management of anaesthesia for day-case surgery in adults and children. The advice presented is based on previously published recommendations, clinical studies and expert opinion.
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Affiliation(s)
- C R Bailey
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, Chair of Working Party, Association of Anaesthetists, London, UK
| | - M Ahuja
- Department of Anaesthesia, Royal Wolverhampton Hospitals NHS Trust, Elected Member, British Association of Day Surgery, Wolverhampton, UK
| | - K Bartholomew
- Department of Anaesthesia, Calderdale and Huddersfield NHS Foundation Trust, Elected Member, Association of Paediatric Anaesthetists of Great Britain and Ireland, Huddersfield, UK
| | - S Bew
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Elected Member, Association of Paediatric Anaesthetists of Great Britain and Ireland, Leeds, UK
| | - L Forbes
- Department of Anaesthesia, Ninewells Hospital, Elected Member Trainee Committee, Association of Anaesthetists, Dundee, Scotland
| | - A Lipp
- Department of Anaesthesia, Norfolk and Norwich University Hospital, Elected Member, British Association of Day Surgery, Norwich, UK
| | - J Montgomery
- Department of Anaesthesia, Torbay and South Devon NHS Foundation Trust, Elected Member, British Association of Day Surgery, Torbay, UK
| | - K Russon
- Department of Anaesthesia, Rotherham NHS Foundation Trust, Elected Member, British Association of Day Surgery, Rotherham, UK
| | - O Potparic
- Department of Anaesthesia, Chelsea and Westminster NHS Foundation Trust, SAS Committee, Association of Anaesthetists, London, UK
| | - M Stocker
- Department of Anaesthesia, Torbay and South Devon, NHS Foundation Trust, President, British Association of Day Surgery, Torbay, UK
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Abstract
PURPOSE OF REVIEW This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques. RECENT FINDINGS Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.
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King R, Mariano ER, Yajnik M, Kou A, Kim TE, Hunter OO, Howard SK, Mudumbai SC. Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center. PAIN MEDICINE 2019; 20:2256-2262. [DOI: 10.1093/pm/pnz023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Objective
The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types.
Methods
With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact.
Results
Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved.
Conclusions
For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.
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Affiliation(s)
- Roderick King
- Stanford University School of Medicine, Stanford, California
| | - Edward R Mariano
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Meghana Yajnik
- Stanford University School of Medicine, Stanford, California
| | - Alex Kou
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - T Edward Kim
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Oluwatobi O Hunter
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Steven K Howard
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Seshadri C Mudumbai
- Stanford University School of Medicine, Stanford, California
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
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Abstract
Despite the widespread use of ambulatory continuous peripheral nerve blocks in adults, its use in children has been sporadic. Indications for the use of ambulatory continuous peripheral nerve block in children involve orthopedic procedure, where significant pain is anticipated beyond 24 hours. Techniques to place the perineural catheters in children are similar to that used in adults. The incidence of serious side effects in pediatric ambulatory continuous peripheral nerve block is extremely rare. When this is combined with the potential to increase patient and family satisfaction and decrease opioid-related side effects, ambulatory continuous peripheral nerve block become a compelling choice.
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Affiliation(s)
- Sible Antony
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Harshad Gurnaney
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Arjunan Ganesh
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles. Br J Anaesth 2018; 120:679-692. [DOI: 10.1016/j.bja.2017.11.104] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/15/2017] [Accepted: 11/04/2017] [Indexed: 01/17/2023] Open
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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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Gómez-Ríos MÁ. Why to use peripheral nerve blocks in orthopedic surgery? ACTA ACUST UNITED AC 2017; 64:181-184. [PMID: 28110944 DOI: 10.1016/j.redar.2016.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 11/23/2016] [Accepted: 11/24/2016] [Indexed: 11/18/2022]
Affiliation(s)
- M Á Gómez-Ríos
- Departamento de Anestesiología y Medicina Perioperatoria, Complejo Hospitalario Universitario de A Coruña, A Coruña, España; Head of the Anaesthesiology and Pain Management Research Group, Institute for Biomedical Research of A Coruña (INIBIC), A Coruña, España.
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