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Sabesan V, Lapica H, Fernandez C, Fomunung C. Evolution of Perioperative Pain Management in Shoulder Arthroplasty. Orthop Clin North Am 2023; 54:435-451. [PMID: 37718083 DOI: 10.1016/j.ocl.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Historically, opioids have been used as a primary conservative treatment for pain related to glenohumeral osteoarthritis (GHOA). However, this practice is concerning as it often leads to overuse, which has contributed to the current epidemic of addiction and overdoses in the United States. Studies have shown that preoperative opioid use is associated with higher complication rates and worse outcomes following surgery, particularly for shoulder arthroplasty. To address these concerns, perioperative pain management for shoulder arthroplasty has evolved over the years to the use of multimodal analgesia.
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Affiliation(s)
- Vani Sabesan
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA.
| | - Hans Lapica
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Carlos Fernandez
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
| | - Clyde Fomunung
- Department of Orthopedics, JFK/University of Miami, Palm Beach, FL, USA
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2
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ProDeM: A Process-Oriented Delphi Method for systematic asynchronous and consensual surgical process modelling. Artif Intell Med 2023; 135:102426. [PMID: 36628778 DOI: 10.1016/j.artmed.2022.102426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/10/2022] [Accepted: 10/11/2022] [Indexed: 11/22/2022]
Abstract
Surgical process models support improving healthcare provision by facilitating communication and reasoning about processes in the medical domain. Modelling surgical processes is challenging as it requires integrating information that might be fragmented, scattered, and not process-oriented. These challenges can be faced by involving healthcare domain experts during process modelling. This paper presents ProDeM: a novel Process-Oriented Delphi Method for the systematic, asynchronous, and consensual modelling of surgical processes. ProDeM is an adaptable and flexible method that acknowledges that: (i) domain experts have busy calendars and might be geographically dispersed, and (ii) various elements of the process model need to be assessed to ensure model quality. The contribution of the paper is twofold as it outlines ProDeM, but also demonstrates its operationalisation in the context of a well-known surgical process. Besides showing the method's feasibility in practice, we also present an evaluation of the method by the experts involved in the demonstration.
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3
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Budden C, Donaldson EK, Tredget E, Tsui BCH. Peri-Operative Outcomes Comparison of General Anaesthesia and Brachial Plexus Block for Open Reduction Internal Fixation of Metacarpal Fractures. Plast Surg (Oakv) 2022; 30:16-19. [PMID: 35096687 PMCID: PMC8793760 DOI: 10.1177/2292550320925911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/17/2019] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION Brachial plexus blockade (BPB) is a procedure of growing popularity amongst surgeons and anaesthesiologists involved with upper limb surgery. The safety and benefit in hand surgery is unclear. METHODS A retrospective chart review was performed examining all operative hand cases over a 2-year period. All cases of metacarpal open reduction internal fixation (ORIF) were included. Cases were excluded if paediatric patient, additional procedures performed, and/or a decreased LOC. Parametric statistical tests were performed. RESULTS In total, 54 cases with general anaesthesia (GA) and 48 cases with BPB were identified for the study (n = 102). The average total time from operating theatre to discharge was 245 ± 72 minutes in GA group and 195 ± 54 minutes in BPB (P < .001). Of those who had a GA, 47/54 patients required analgesia post-operatively versus 12/48 in the BPB (P < .001). Of all, 25/52 and 5/48 patients required anti-emetics post-operatively in the GA and BPB groups, respectively (P < .001). Need for any parenteral medication post-operatively was also significantly different (P < .001). CONCLUSION This is the first study to specifically examine anaesthetic techniques for ORIF of hand fractures; adding to the body of literature establishing BPB as a safe and efficient method of anaesthesia.
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Affiliation(s)
- Curtis Budden
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | | | - Edward Tredget
- University of Alberta Hospital, Edmonton, Alberta, Canada,Edward Tredget, 2J2.00 Walter C Mackenzie Health Sciences Centre, University of Alberta Faculty of Medicine and Dentistry, 8440 112 St. NW, Edmonton, Alberta, Canada.
| | - Ban C. H. Tsui
- University of Alberta Hospital, Edmonton, Alberta, Canada
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4
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Küpeli İ, Yazici Kara M. Anesthesia or analgesia? New block for shoulder surgery: pericapsular nerve group block. Braz J Anesthesiol 2021; 72:669-672. [PMID: 34118263 PMCID: PMC9515664 DOI: 10.1016/j.bjane.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/11/2021] [Accepted: 05/22/2021] [Indexed: 11/20/2022] Open
Abstract
Interscalene brachial plexus (ISB) block is considered the analgesic technique of choice for shoulder surgery. However, the hemidiaphragmatic paresis that may occur after the block has led to the search for an alternative to the ISB block. In this case report, the pericapsular nerve group (PENG) block was performed for both surgical anesthesia and postoperative analgesia in two patients who underwent shoulder surgery. It is suggested that the PENG block can be safely applied for analgesia and can be part of surgical anesthesia, but alone is not sufficient for anesthesia. The block of this area did not cause motor block or pulmonary complications, nor result in muscle laxity, blocking only the shoulder and the upper third of the humerus. It was demonstrated that the PENG block may be safely applied for both partial anesthesia and analgesia in selected shoulder surgery cases.
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Affiliation(s)
- İlke Küpeli
- Kocaeli Derince Training and Research Hospital, Anesthesiology Department, Kocaeli, Turkey
| | - Merve Yazici Kara
- Kocaeli Derince Training and Research Hospital, Anesthesiology Department, Kocaeli, Turkey.
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5
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Zangrilli J, Szukics P, Austin L, Horneff JG. Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery. JBJS Rev 2021; 9:e20.00191. [PMID: 33999881 DOI: 10.2106/jbjs.rvw.20.00191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
» Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation. » While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use. » The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures. » Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period. » Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications. » Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.
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Affiliation(s)
- Julian Zangrilli
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Patrick Szukics
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Luke Austin
- Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - John G Horneff
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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6
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Patel MS, Abboud JA, Sethi PM. Perioperative pain management for shoulder surgery: evolving techniques. J Shoulder Elbow Surg 2020; 29:e416-e433. [PMID: 32844751 DOI: 10.1016/j.jse.2020.04.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 02/08/2023]
Abstract
Improving management of postoperative pain following shoulder surgery is vital for optimizing patient outcomes, length of stay, and decreasing addiction to narcotic medications. Multimodal analgesia (ie, controlling pain via multiple different analgesic methods with differing mechanisms) is an ever-evolving approach to enhancing pain control perioperatively after shoulder surgery. With a variety of options for the shoulder surgeon to turn to, this article succinctly reviews the pros and cons of each approach and proposes a potential pain management algorithm.
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Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, Greenwich, CT, USA
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7
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Demir U, Yayik AM, Köse M, Aydin ME, Ates İ, Ahiskalioglu A. Does the Serratus Plane Block Added to the Interscalene Block Improve the Quality of Anesthesia in Arthroscopic Shoulder Surgery? A Prospective Randomized Study. Cureus 2020; 12:e7648. [PMID: 32292685 PMCID: PMC7153816 DOI: 10.7759/cureus.7648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Interscalene brachial plexus block (ISBPB) is the gold standard method in shoulder surgery. Serratus plane block (SPB) provides anesthesia in hemithorax, axillary region, and posterior of the shoulder. This randomized controlled study evaluated the effect of SPB added to ISBPB on surgical anesthesia quality in arthroscopic shoulder surgery. Methods: Sixty patients undergoing arthroscopic shoulder surgery were randomly assigned to two groups. All surgeries were performed under regional anesthesia. The Group I (Group Interscalene) (n=30) received ultrasound-guided interscalene block. In the Group IS (Group Interscalene + Serratus) (n=30), ultrasound-guided interscalene block and SPB were performed. Intraoperative anesthetic agent consumption, postoperative opioid consumption, postoperative pain scores, patient satisfaction, and surgeon satisfaction were evaluated. Results: Intraoperative propofol (60.00 ± 45.49 vs. 24.00 ± 32.97, respectively) and fentanyl (33.33 ± 23.97 vs. 18.33 ± 24.51, respectively) consumption were significantly higher in Group I than in Group IS (p < 0.05). There was no statistically significant difference between the groups at any of the times the postoperative opioid consumption and pain scores were evaluated (p > 0.05). Conclusions: SPB added to the ISBPB increases the quality of surgical anesthesia and reduces the need for intraoperative sedoanalgesia for arthroscopic shoulder surgery.
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Affiliation(s)
- Ufuk Demir
- Anesthesiology and Reanimation, Kastamonu State Hospital, Kastamonu, TUR
| | - Ahmet Murat Yayik
- Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, TUR.,Clinical Research, Development and Design Application and Research Center, Ataturk University School of Medicine, Erzurum, TUR
| | - Mehmet Köse
- Orthopaedics and Traumatology, Ataturk University School of Medicine, Erzurum, TUR
| | - Muhammed E Aydin
- Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, TUR.,Clinical Research, Development and Design Application and Research Center, Ataturk University, Erzurum, TUR
| | - İrem Ates
- Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, TUR
| | - Ali Ahiskalioglu
- Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, TUR.,Clinical Research, Development and Design Application and Research Center, Ataturk University School of Medicine, Erzurum, TUR
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8
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Rothe C, Lund J, Jenstrup MT, Steen-Hansen C, Lundstrøm LH, Andreasen AM, Lange KHW. A randomized controlled trial evaluating the impact of selective axillary nerve block after arthroscopic subacromial decompression. BMC Anesthesiol 2020; 20:33. [PMID: 32005160 PMCID: PMC6995169 DOI: 10.1186/s12871-020-0952-y] [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: 09/04/2019] [Accepted: 01/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The sensory innervation of the shoulder is complex and there are variations in the branching patterns of the sensory fibres. Articular branches from the axillary nerve to the subacromial bursa are described in more than 50% of investigated shoulders but the isolated contribution of sensory input from the axillary nerve has never been investigated clinically. We hypothesized that a selective block of the axillary nerve would reduce morphine consumption and pain after arthroscopic subacromial decompression. METHODS We included 60 patients in a randomized, blinded, placebo-controlled study. Patients were randomized to a preoperative selective ultrasound-guided axillary nerve block with 20 mL ropivacaine (7.5 mg/mL) or 20 mL saline. Primary outcome was intravenous morphine consumption 0-4 h postoperatively. Secondary outcome was postoperative pain evaluated by a visual analogue scale (VAS) score (0-100). RESULTS We analysed data from 50 patients and found no significant difference in 0-4 h postoperative morphine consumption between the two groups (ropivacaine 14 mg, placebo 18 mg (P = 0.12)). There was a reduction in postoperative pain: VAS 0-4 h (area under the curve) (ropivacaine 135, placebo 182 (P = 0.03)), VAS after 8 h (ropivacaine 9, placebo 20 (P = 0.01)) and VAS after 24 h (ropivacaine 7, placebo 18 (P = 0.04)). Eight out of 19 patients with a successful selective axillary nerve block needed an interscalene brachial plexus escape block. CONCLUSIONS Selective block of the axillary nerve has some pain relieving effect, but in this setting the effect was unpredictable, variable and far from sufficient in a large proportion of the patients. TRIAL REGISTRATION ClinicalTrials.gov (NCT01463865). Registered: November 1, 2011.
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Affiliation(s)
- Christian Rothe
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
| | - Jørgen Lund
- Department of Anaesthesiology, Aleris-Hamlet Hospital, Copenhagen, Denmark
| | | | - Christian Steen-Hansen
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
| | - Lars Hyldborg Lundstrøm
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark.
| | - Asger Mølgaard Andreasen
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
| | - Kai Henrik Wiborg Lange
- Department of Anaesthesiology, Nordsjællands Hospital, University of Copenhagen, Dyrehavevej 29, DK-3400, Hillerød, Denmark
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9
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Seering MS, Bayman EO, Wong CA, Ranganath YS, Marian AA. Comparison of the effect of three different adjuvants on the analgesic duration of single injection interscalene brachial plexus block: a prospective, randomized, triple blinded clinical trial. Reg Anesth Pain Med 2019; 44:rapm-2018-100201. [PMID: 31308262 DOI: 10.1136/rapm-2018-100201] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Use of regional anesthesia can result in faster recovery and better patient satisfaction. Addition of perineural adjuncts to local anesthetics may improve the duration of analgesia, but there is a paucity of data comparing them in a single randomized trial. We compared the effects of three adjuncts clonidine, dexamethasone, and buprenorphine, on the duration of analgesia of interscalene brachial plexus block. METHODS 160 patients, undergoing elective shoulder surgery, were randomized to four groups to receive an interscalene block with one of the following solutions: ropivacaine alone, ropivacaine with clonidine 75 µg, ropivacaine with dexamethasone 8 mg, or ropivacaine with buprenorphine 300 µg. The primary outcome variable was the duration of analgesia; secondary outcome measures were time to onset of the block, and the duration of sensory and motor blocks. RESULTS There was no statistically significant difference in the total analgesia time among the four groups; p=0.11. The pairwise comparison in analgesic time and 99% CI were: control versus clonidine (-1.94 hours (-7.33 to 3.12)), control versus dexamethasone (-4.16 hours (-9.50 to 0.58)) and control versus buprenorphine (-1.1 hours (-5.34 to 3.23)). There was no differences in block set-up time, or total sensory and motor block duration among the groups. CONCLUSION There was no significant improvement in the duration of analgesia with addition of any of the three adjuncts to interscalene blocks. However, there was a larger than expected variability in patient response, hence the study may have been underpowered for the primary outcome.
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Affiliation(s)
- Melinda S Seering
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Emine O Bayman
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Cynthia A Wong
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | - Anil A Marian
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
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10
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Abstract
Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between patients, surgeon, and anesthetist. A multimodal approach with preemptive medication, regional blockade, local anesthetics, and a combination of acetaminophen, nonsteroidal antiinflammatory drugs, tramadol, and gabapentinoids postoperatively leads to pain control and patient satisfaction. Assessment of patients' expectations constitutes a vital aspect of the preoperative patient evaluation. Educating and psychologically preparing patients reduces postoperative pain. Patients with anxiety and depression, preoperative narcotic use, and medical comorbidities are at an increased risk for suboptimal pain control. Minimizing narcotic use decreases opioid-related adverse effects and facilitates productive rehabilitation efforts.
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Affiliation(s)
- Jason L Codding
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA.
| | - Charles L Getz
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA
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11
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Huang Y, Chiu F, Webb CA, Weyker PD. Review of the evidence: best analgesic regimen for shoulder surgery. Pain Manag 2017; 7:405-418. [PMID: 28936915 DOI: 10.2217/pmt-2017-0013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Multimodal pain management has been advocated in patients experiencing acute pain after surgical procedures due to tissue damage and the subsequent inflammatory response. For patients undergoing shoulder surgeries, studies have definitively shown that interscalene blocks (ISBs) via single-injection or continuous infusion can reduce the total opioid consumption and can lower pain scores after surgery. In some cases, ISBs can be used as the sole anesthetic during shoulder surgeries and spare patients of receiving general anesthesia. However, clinicians should be fully aware of potential pulmonary complications of ISBs and weigh the risk-benefit ratio in patients with limited pulmonary reserve.
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Affiliation(s)
- Yolanda Huang
- Department of Anesthesiology, Division of Orthopedic & Regional Anesthesia, Columbia University Medical Center
| | - Felicia Chiu
- Department of Anesthesiology, Division of Orthopedic & Regional Anesthesia, Columbia University Medical Center
| | - Christopher Aj Webb
- The Permanente Medical Group, Kaiser Permanente Northern California.,Adjunct Assistant Clinical Professor. Department of Anesthesia & Perioperative Care. University of California San Francisco School of Medicine
| | - Paul David Weyker
- Department of Anesthesiology, Divisions of Critical Care, Liver Transplant Anesthesia, Pain Medicine & Regional Anesthesia, Columbia University Medical Center
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12
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Bambaren IA, Dominguez F, Elias Martin ME, Domínguez S. Anesthesia and Analgesia in the Patient with an Unstable Shoulder. Open Orthop J 2017; 11:848-860. [PMID: 29114334 PMCID: PMC5646176 DOI: 10.2174/1874325001711010848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 10/21/2016] [Accepted: 10/28/2016] [Indexed: 12/01/2022] Open
Abstract
Introduction: The patient with an unstable shoulder represents a challenge for the anesthesiologist. Most patients will be young individuals in good health but both shoulder dislocation reduction, a procedure that is usually performed under specific analgesia in an urgent setting, and instability surgery anesthesia and postoperative management present certain peculiarities. Material and Methods: For the purpose of the article, 78 references including clinical trials and reviews were included. The review was organized considering the patient that presents an acute shoulder dislocation and the patient with chronic shoulder instability that requires surgery. In both cases the aspects like general or regional anesthesia, surgical positions and postoperative pain management were analyzed. Conclusion: The patient with an acutely dislocated shoulder is usually managed in the emergency room. Although reduction without analgesia is often performed in non-medical settings, an appropriate level of analgesia will ease the reduction procedure avoiding further complications. Intravenous analgesia and sedation is considered the gold standard but requires appropriate monitorization and airway control. Intraarticular local analgesic injection is considered also a safe and effective procedure. General anesthesia or nerve blocks can also be considered. The surgical management of the patient with shoulder instability requires a proper anesthetic management. This should start with an exhaustive preoperative evaluation that should be focused in identifying potential respiratory problems that might be complicated by local nerve blocks. Intraoperative management can be challenging, especially for patients operated in beach chair position, for the relationship with problems related to cerebral hypoperfusion, a situation related to hypotension events directly linked to patient positioning. Different nerve blocks will help attaining excellent analgesia both during and after the surgical procedure. An interescalene nerve block should be considered the best technique, but in certain cases, other blocks can be considered.
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Affiliation(s)
| | - Fernando Dominguez
- Ramón y Cajal Hospital. Anesthesia and Intensive Care Department. Madrid. Spain
| | | | - Silvia Domínguez
- Ramón y Cajal Hospital. Anesthesia and Intensive Care Department. Madrid. Spain
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13
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The PECS II block as a major analgesic component for clavicle operations: A description of 7 case reports. ACTA ACUST UNITED AC 2017; 65:53-58. [PMID: 28554710 DOI: 10.1016/j.redar.2017.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/12/2017] [Accepted: 04/14/2017] [Indexed: 11/21/2022]
Abstract
Clavicle fractures correspond to 35% of traumatic fractures of the shoulder girdle. Regional anaesthesia has shown better analgesic results than systemic treatment for perioperative management. Innervation of the clavicle is complex, at present its knowledge raises controversy. The lateral pectoral nerve through the innervating musculature predominantly participates in the lateral and anterior part of the clavicle. The following report of 7 cases describes the effective postoperative analgesia of modified PEC II block in patients with middle third clavicle fracture or acromioclavicular dislocation who underwent a modified PEC II block for postoperative pain management, in the context of a multimodal analgesia. The potential advantage of this management over other analgesic procedures should be evaluated in specific clinical trials.
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14
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Regional Anaesthesia Is Associated with Shorter Postanaesthetic Care and Less Pain Than General Anaesthesia after Upper Extremity Surgery. Anesthesiol Res Pract 2016; 2016:6308371. [PMID: 27974889 PMCID: PMC5128692 DOI: 10.1155/2016/6308371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/24/2016] [Indexed: 12/23/2022] Open
Abstract
Introduction. For surgery on the upper extremity, the anaesthetist often has a choice between regional anaesthesia (RA) and general anaesthesia (GA). We sought to investigate the possible differences between RA and GA after upper extremity surgery with regard to postoperative patient comfort. Methods. This is a retrospective observational study that was performed at an acute care secondary referral centre. One hundred and eighty-seven procedures involving orthopaedic surgery on the upper extremity were included. The different groups (RA and GA) were compared regarding the primary outcome variable, length of stay in Postanaesthesia Unit, and secondary outcome variables, opioid consumption and nausea treatment. Results. RA was associated with significantly shorter median length of stay (99 versus 171 minutes). In the GA group, 32% of the patients received opioid analgesics and 21% received antiemetics. In the RA group, none received opioid analgesics and 3% received antiemetics. Conclusion. In this observational study, RA was superior to GA for surgery of the upper extremity regarding Postanaesthesia Care Unit length of stay, number of doses of analgesic, and number of doses of antiemetic administered.
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15
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Rosenfeld DM, Ivancic MG, Hattrup SJ, Renfree KJ, Watkins AR, Hentz JG, Gorlin AW, Spiro JA, Trentman TL. Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia 2016; 71:380-8. [PMID: 26899862 DOI: 10.1111/anae.13409] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2016] [Indexed: 12/01/2022]
Abstract
This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.
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Affiliation(s)
- D M Rosenfeld
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - M G Ivancic
- Northland Pain Consultants, Liberty, Missouri, USA
| | - S J Hattrup
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - K J Renfree
- Department of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - A R Watkins
- Department of Research Services, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - J G Hentz
- Department of Health Sciences Research, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - A W Gorlin
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - J A Spiro
- University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - T L Trentman
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Mosaffa F, Gharaei B, Qoreishi M, Razavi S, Safari F, Fathi M, Mohseni G, Elyasi H, Hosseini F. Do the Concentration and Volume of Local Anesthetics Affect the Onset and Success of Infraclavicular Anesthesia? Anesth Pain Med 2015; 5:e23963. [PMID: 26473102 PMCID: PMC4602380 DOI: 10.5812/aapm.23963v2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 01/19/2015] [Accepted: 02/02/2015] [Indexed: 11/16/2022] Open
Abstract
Background: Although local anesthesia is a suitable method for upper limb surgeries, there is debate regarding the effects of appropriate dosing. Objectives: In the current study, we investigated the effects of the concentration and volume of a local anesthetic on the beginning and quality of anesthesia during upper limb orthopedic surgeries. Patients and Methods: This double-blinded, randomized, clinical trial was conducted on 60 patients aged between 18 and 85 years candidated for upper limb orthopedic operations. The patients were equally and randomly distributed into two groups (n = 30). Under ultrasound imaging guidance, the first group received 7 mL of 2% lidocaine and the second group 10 mL of 1.3% lidocaine into the brachial plexus cords. The onset of block and the level of sensory and motor block were documented for each nerve territory. Results: The onset of sensory and motor block was significantly shorter in the 1.3% lidocaine group than in the 2% lidocaine group (P ≤ 0.05). The success rate of sensory and motor block was not different. The quality (completeness) of sensory block for the musculocutaneous nerve and that of motor block for the radial nerve were significantly better in the 1.3% lidocaine group than in the 2% lidocaine group. Conclusions: The volume of the injected anesthetic accelerated the onset of sensory and motor block without affecting the rate of success in our patients.
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Affiliation(s)
- Faramarz Mosaffa
- Anesthesiology and Critical Care Department, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Babak Gharaei
- Anesthesiology and Critical Care Department, Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Qoreishi
- Orthopedic Department, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sajjad Razavi
- Anesthesiology and Critical Care Department, Mofid Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farhad Safari
- Anesthesiology and Critical Care Department, Loghmane Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Fathi
- Anesthesiology Research Center, Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamreza Mohseni
- Anesthesiology and Critical Care Department, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hedayatollah Elyasi
- Anesthesiology and Critical Care Department, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fahimeh Hosseini
- Anesthesiology and Critical Care Department, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding author: Fahimeh Hosseini, Anesthesiology and Critical Care Department, Akhtar Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98-9155096022, Fax: +98-2144039870, E-mail:
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Local infiltration analgesia versus continuous interscalene brachial plexus block for shoulder replacement pain: a randomized clinical trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1245-52. [DOI: 10.1007/s00590-015-1678-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/29/2015] [Indexed: 01/01/2023]
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Aires RB, Carvalho JFD, Mota LMHD. Avaliação anestésica pré‐operatória de pacientes com artrite reumatoide. REVISTA BRASILEIRA DE REUMATOLOGIA 2014. [DOI: 10.1016/j.rbr.2013.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Gritsenko K, Khelemsky Y, Kaye AD, Vadivelu N, Urman RD. Multimodal therapy in perioperative analgesia. Best Pract Res Clin Anaesthesiol 2014; 28:59-79. [PMID: 24815967 DOI: 10.1016/j.bpa.2014.03.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 02/26/2014] [Accepted: 03/04/2014] [Indexed: 12/22/2022]
Abstract
This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.
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Affiliation(s)
- Karina Gritsenko
- Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, NY, USA; Department of Family and Social Medicine, Montefiore Medical Center, Bronx, New York, NY, USA; Acute Pain, Regional, Chronic Pain, Montefiore Medical Center, Bronx, New York, NY, USA; Albert Einstein College of Medicine, Yeshiva University, Montefiore Medical Center, Bronx, New York, NY, USA.
| | - Yury Khelemsky
- Anesthesiology, Icahn School of Medicine of Mount Sinai, New York, NY, USA; Pain Medicine Fellowship Program, Icahn School of Medicine of Mount Sinai, New York, NY, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, New Orleans, LA, USA; Interventional Pain Services, LSU School of Medicine, New Orleans, LA, USA; Department of Pharmacology, LSU School of Medicine, New Orleans, LA, USA; Department of Anesthesiology, Tulane School of Medicine, New Orleans, LA, USA; Department of Pharmacology, Tulane School of Medicine, New Orleans, LA, USA
| | - Nalini Vadivelu
- Anesthesiology Department, Yale University School of Medicine, New Haven, CT, USA
| | - Richard D Urman
- Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Brigham and Women's Hospital, USA
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Kaya M, Oğuz G, Şenel G, Kadıoğulları N. Postoperative analgesia after modified radical mastectomy: the efficacy of interscalene brachial plexus block. J Anesth 2013; 27:862-7. [PMID: 23736824 DOI: 10.1007/s00540-013-1647-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 05/17/2013] [Indexed: 12/22/2022]
Abstract
PURPOSE In the present study, we evaluated the effects of interscalene brachial plexus block on postoperative pain relief and morphine consumption after modified radical mastectomy (MRM). METHODS Sixty ASA I-III patients scheduled for elective unilateral MRM under general anesthesia were included. They were randomly allocated into two groups: group 1 (n = 30), single-injection ipsilateral interscalene brachial plexus block; group 2 (n = 30), control group. Postoperative analgesia was provided with IV PCA morphine during 24 h postoperatively. Pain intensity was assessed with the visual analogue scale (VAS). Morphine consumption, side effects of opioid, antiemetic requirement, and complications associated with interscalene block were recorded. RESULTS VAS scores were significantly lower in group 1, except in the first postoperative 24 h (p < 0.007). The patients without block consumed more morphine [group 1, 5 (0-40) mg; group 2, 22 (6-48) mg; p = 0.001]. Rescue morphine requirements were also higher in the postoperative first hour in group 2 (p = 0.001). Nausea and antiemetic requirements were significantly higher in group 2 (p = 0.03 and 0.018). Urinary retention was observed in 1 patient in group 2 and signs of Horner's syndrome in 2 patients in group 1. CONCLUSIONS The optimal method has not been defined yet for acute pain palliation after MRM. Our study demonstrated that the use of interscalene block in patients undergoing MRM improved pain scores and reduced morphine consumption during the first 24 h postoperatively. The block can be a good alternative to other invasive regional block techniques used for postoperative pain management after MRM.
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Affiliation(s)
- Menşure Kaya
- Department of Anesthesiology, Ankara Oncology Education and Research Hospital, 41/7 Yenimahalle, 06170, Ankara, Turkey,
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Födinger AM, Kammerlander C, Luger TJ. Ultrasound-Guided Regional Anesthesia in a Glucose-6-Phosphate Dehydrogenase (G6PD)-Deficient Geriatric Trauma Patient. Geriatr Orthop Surg Rehabil 2013; 3:147-9. [PMID: 23569708 DOI: 10.1177/2151458512472903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a genetic enzymatic disorder causing hemolytic anemia. Exposure to drugs is considered to be the most common cause of acute hemolysis in patients with G6PD deficiency. Experience with regional anesthesia, in particular peripheral nerve blocks, is rarely described in patients with G6PD deficiency, but is of great clinical interest. For this reason, we now report on the successful management of ultrasound-guided axillary brachial plexus block in a patient with geriatric G6PD deficiency. CASE REPORT A female, 75-year-old geriatric trauma patient with G6PD deficiency and a fracture of the left forearm, was scheduled for osteosynthesis of the left forearm. For surgery regional anesthesia with ultrasound-guided axillary brachial plexus block with 30 mL bupivacaine 0.5% was established. Surgical operation und postoperative course were uneventful and with no signs of hemolysis. CONCLUSION Ultrasound-guided axillary brachial plexus block with bupivacaine was a safe and effective technique in this patient with G6PD deficiency. Peripheral nerve block is a major analgesic approach and of great value for anesthesiologists and surgeons, especially in our aging and multimorbid society.
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Affiliation(s)
- Agnes M Födinger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Austria
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