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Selvamani BJ, Kalagara H, Volk T, Narouze S, Childs C, Patel A, Seering MS, Benzon HT, Sondekoppam RV. Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk. Reg Anesth Pain Med 2024:rapm-2024-105496. [PMID: 38839428 DOI: 10.1136/rapm-2024-105496] [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: 03/19/2024] [Accepted: 05/22/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB). MATERIALS AND METHODS A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population. RESULTS The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100). DISCUSSION Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.
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Affiliation(s)
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Samer Narouze
- Western Reserve Hospital Partners, Cuyahoga Falls, Ohio, USA
| | | | - Aamil Patel
- University of Iowa Health Care, Iowa City, Iowa, USA
| | | | - Honorio T Benzon
- Departments of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rakesh V Sondekoppam
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa, USA
- Department of Anesthesia and Pain Medicine, University of Alberta Faculty of Medicine and Dentistry, Edmonton, Alberta, Canada
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Zugaj MR, Gutzeit O, Mayer VL, Ishak B, Gumbinger C, Weigand MA, Keßler J. Incomplete sensorimotor paresis after upper abdominal surgery with TEA and spinal epidural lipomatosis: a case report. Reg Anesth Pain Med 2024; 49:465-468. [PMID: 38580340 DOI: 10.1136/rapm-2024-105342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/24/2024] [Indexed: 04/07/2024]
Abstract
INTRODUCTION This case report documents a postoperative, incomplete sensorimotor paraparesis from thoracic vertebral body 6 (Th6) after combined anesthesia for upper abdominal surgery in a patient who had a thoracic localization of spinal epidural lipomatosis (SEL). CASE PRESENTATION The patient was treated in our clinic with a thoracic epidural catheter (TEA) for perioperative analgesia during a partial duodenopancreatectomy. Paraparetic symptoms occurred 20 hours after surgery. Initial MRI did not show bleeding, infection or spinal cord damage and the neurosurgeon consultants recommended observation. The neurological examination and the third follow-up MRI on 15th postoperative day showed ventrolateral damage of the spinal cord at level Th6. It is possible that local anesthetic compressed the spinal cord in addition to the existing lipomatosis and the thoracic kyphosis. The paraparesis improved during follow-up paraplegiologic treatment. CONCLUSION So far, only two uncomplicated lumbar epidural catheter anesthesias have been described in patients who had a lumbar SEL. Epidural catheter anesthesia is a safe and effective method of pain control. But it is important to carefully identify and stratify patients with risk factors during the premedication visit. In patients who had kyphosis and thoracic localization of SEL, TEA may only be used after a risk-benefit assessment.
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Affiliation(s)
- Marco Richard Zugaj
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
| | - Oliver Gutzeit
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
| | - Victoria Louise Mayer
- Heidelberg University, Medical Faculty, Department of Nuclear Medicine, Heidelberg, Baden-Württemberg, Germany
| | - Basem Ishak
- Heidelberg University, Medical Faculty, Department of Neurosurgery, Heidelberg, Baden-Württemberg, Germany
| | - Christoph Gumbinger
- Heidelberg University, Medical Faculty, Department of Neurology, Heidelberg, Baden-Württemberg, Germany
| | - Markus Alexander Weigand
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
| | - Jens Keßler
- Heidelberg University, Medical Faculty, Department of Anesthesiology, Heidelberg, Baden-Württemberg, Germany
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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Anesthesiol Clin 2024; 42:317-328. [PMID: 38705679 DOI: 10.1016/j.anclin.2023.11.012] [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: 05/07/2024]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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Hu L, Adegboye J, Chang AT, Hanna M, Jaremko K. Uncomplicated epidural removal in a patient on a therapeutic heparin infusion: a case report. Reg Anesth Pain Med 2024:rapm-2024-105577. [PMID: 38821537 DOI: 10.1136/rapm-2024-105577] [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: 04/18/2024] [Accepted: 05/16/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Unanticipated postoperative thrombotic complications can occur in complex patients who receive preoperative epidurals. Therefore, it is imperative that we consider the risks and benefits of epidural management in the setting of therapeutic anticoagulation. We present a case of epidural catheter removal on a heparin infusion, due to the extreme risk of holding anticoagulation for any duration. CASE REPORT A woman with hilar cholangiocarcinoma presented after uncomplicated hepatectomy, bile duct resection and hepaticojejunostomy, with a thoracic epidural for analgesia. On postoperative day 1, she developed a total portal vein thrombosis, requiring emergent open thrombectomy, transhepatic stenting and high-dose heparin infusion while the epidural was indwelling. The patient was deemed to have a profound risk of re-thrombosis if heparin were paused. Therefore, a multidisciplinary discussion between hepatobiliary surgery, critical care, neurosurgery, haematology, acute pain service and the patient's family ensued regarding epidural management. Options included catheter-directed thrombolytics to her stent while holding systemic anticoagulation, sterilely leaving the epidural catheter in place indefinitely, injecting prothrombotic agent into the epidural prior to removal, or removing the catheter without holding anticoagulation. Due to the risk of re-thrombosis in the portal vein and liver infarction, the heparin infusion was decreased to achieve the lowest therapeutic anti-Xa level, and the epidural was removed. The patient was continuously monitored in the intensive care unit without any adverse events. CONCLUSION A multidisciplinary discussion is paramount to weigh the risk of epidural haematoma if a catheter is removed on therapeutic anticoagulation against catastrophic thrombosis if anticoagulation is paused.
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Affiliation(s)
- Lizbeth Hu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Janet Adegboye
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Angela Tung Chang
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Kellie Jaremko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
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Elhamrawy A, Aepli S, Heydinger G, Tobias JD, Beltran RJ. Epidural Abscess Complicating Tunneled Caudal Epidural Catheter in an Infant for Postoperative Pain Management of Open Abdominal Surgery. J Med Cases 2024; 15:7-14. [PMID: 38328807 PMCID: PMC10846496 DOI: 10.14740/jmc4180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/10/2024] [Indexed: 02/09/2024] Open
Abstract
Regional anesthesia is being used more frequently in pediatric anesthesia practice, including the perioperative care of neonates and infants. Adverse effects may be encountered during epidural needle placement, with catheter advancement, or subsequently during infusion of local anesthetic agents. Despite applying standard practice of care regarding placement of epidural catheter, epidural catheter-related infections may still occur. We present the rare occurrence of an epidural abscess in a 4-month-old infant after placement and subsequent use of a tunneled caudal epidural catheter for postoperative pain management following abdominal surgery. Magnetic resonance imaging (MRI) was the gold standard diagnostic imaging modality and was used to identify the abscess. Management included intravenous antibiotic therapy as well as hemilaminectomy with evacuation of the epidural abscess and hematoma. The patient continued to progress well with no deficits noted on neurological examination. There were no other postoperative concerns. When there is a concern for epidural catheter-related infection, the catheter should be removed immediately. The epidural catheter tip as well as any purulent discharge from the insertion site should be sent for culture and sensitivity. Urgent neurosurgical and infectious disease consultation is suggested to provide opinions regarding surgical intervention and antibiotic therapy.
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Affiliation(s)
- Amr Elhamrawy
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Savannah Aepli
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
| | - Grant Heydinger
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ralph J. Beltran
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Kinjo S, Chernin T, Siegmueller C, Sharrow CM, Shilling A. Advances in regional anesthesia for ambulatory surgery. Int Anesthesiol Clin 2024; 62:54-61. [PMID: 37990922 DOI: 10.1097/aia.0000000000000429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Sakura Kinjo
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Tyler Chernin
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | - Claas Siegmueller
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California
| | | | - Ashley Shilling
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
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Kubulus C, Mahlstedt S, Wagenpfeil G, Sessler DI, Volk T. Chronic pain patients and time to sustained acceptable pain scores after major surgery - A retrospective registry analysis. J Clin Anesth 2023; 89:111152. [PMID: 37244111 DOI: 10.1016/j.jclinane.2023.111152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/04/2023] [Accepted: 05/17/2023] [Indexed: 05/29/2023]
Abstract
STUDY OBJECTIVE We tested the hypothesis that pre-existing chronic pain is associated with prolonged time to reach sustained acceptable pain scores after major surgery. DESIGN Retrospective study using the German Network for Safety in Regional Anaesthesia and Acute Pain Therapy registry. SETTING Operating rooms and surgical wards. PATIENTS 107,412 patients recovering from major surgery who were cared for by an acute pain service. 3.3% of the treatments were in patients who reported chronic pain with functional or psychological impairment. INTERVENTIONS AND MEASUREMENT We compared time to sustained adequacy of postoperative pain control defined by numeric rating scores <4 at rest and with movement in patients with and without chronic pain using an adjusted cox proportional hazard regression model and Kaplan-Meier analysis. The observation period was censored at 10 days and propensity score matching was used as a sensitivity analysis. MAIN RESULTS Postoperative pain at rest took significantly longer to resolve in patients with chronic pain than in those without (adjusted hazard ratio HR 1.42, 95% CI 1.36-1.49, P < 0.001). Postoperative pain with movement took even longer to resolve in patients with chronic pain (adjusted HR 1.65, 95%CI 1.56-1.75, P < 0.001). CONCLUSIONS Patients with chronic pain sustain more surgical pain than those without, and the pain takes longer to resolve. Clinicians providing postoperative pain management should consider the special needs of chronic pain patients.
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Affiliation(s)
- Christine Kubulus
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany.
| | - Silja Mahlstedt
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Gudrun Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Faculty of Medicine, Homburg, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
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Ander M, Mugve N, Crouch C, Kassel C, Fukazawa K, Izaak R, Deshpande R, McLendon C, Huang J. Regional anesthesia for transplantation surgery - A white paper part 1: Thoracic transplantation surgery. Clin Transplant 2023; 37:e15043. [PMID: 37306898 PMCID: PMC10834230 DOI: 10.1111/ctr.15043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023]
Abstract
Transplantation surgery continues to evolve and improve through advancements in transplant technique and technology. With the increased availability of ultrasound machines as well as the continued development of enhanced recovery after surgery (ERAS) protocols, regional anesthesia has become an essential component of providing analgesia and minimizing opioid use perioperatively. Many centers currently utilize peripheral and neuraxial blocks during transplantation surgery, but these techniques are far from standardized practices. The utilization of these procedures is often dependent on transplantation centers' historical methods and perioperative cultures. To date, no formal guidelines or recommendations exist which address the use of regional anesthesia in transplantation surgery. In response, the Society for the Advancement of Transplant Anesthesia (SATA) identified experts in both transplantation surgery and regional anesthesia to review available literature concerning these topics. The goal of this task force was to provide an overview of these publications to help guide transplantation anesthesiologists in utilizing regional anesthesia. The literature search encompassed most transplantation surgeries currently performed and the multitude of associated regional anesthetic techniques. Outcomes analyzed included analgesic effectiveness of the blocks, reduction in other analgesic modalities-particularly opioid use, improvement in patient hemodynamics, as well as associated complications. The findings summarized in this systemic review support the use of regional anesthesia for postoperative pain control after transplantation surgeries. Part 1 of the manuscript focuses on regional anesthesia performed in thoracic transplantation surgeries, and part 2 in abdominal transplantations.
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Affiliation(s)
- Michael Ander
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Neal Mugve
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Cara Crouch
- Department of Anesthesiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cale Kassel
- Department of Anesthesiology, Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, Nebraska, USA
| | - Kyota Fukazawa
- Department of Anesthesiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert Izaak
- Department of Anesthesiology, UNC Hospitals, N2198 UNC Hospitals, North Carolina, USA
| | - Ranjit Deshpande
- Department of Anesthesiology, Yale University/Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Charles McLendon
- Department of Anesthesiology & Perioperative Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jiapeng Huang
- Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, Kentucky, USA
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Onay M, Kiremitçi TT, Kayhan GE, Algın Dİ, Güleç MS. Infraclavicular Catheter in MELAS Syndrome for Analgesic Purposes. Neurol India 2023; 71:764-766. [PMID: 37635512 DOI: 10.4103/0028-3886.383869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
MELAS syndrome is defined as mitochondrial myopathy accompanied by encephalopathy, lactic acidosis, myoclonus, stroke-like episodes. It has a progressive course, multi-systemic effects and severe complications. Myoclonic contractions are unresponsive to many anti-epileptic drugs; these contractions and spasms may lead to severe pain. Systemic analgesic drugs are not sufficient to control pain. Therefore, continuous brachial plexus blockage may be preferred. Infraclavicular brachial plexus catheter is placed in our case. Local anesthetic injections through this catheter may be effective in pain management and results are to be discussed here.
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Affiliation(s)
- M Onay
- Department of Anesthesiology and Reanimation, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - T Tanyel Kiremitçi
- Department of Algology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - G Erdoğan Kayhan
- Department of Anesthesiology and Reanimation, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - D İlhan Algın
- Department of Neurology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - M S Güleç
- Department of Algology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
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Gerner P, Connor CW, Stone AB. Visual assessment of effectiveness of ultrasound probe hygiene using ultraviolet fluorescent powder: a pilot study. Reg Anesth Pain Med 2023:rapm-2023-104632. [PMID: 37263744 PMCID: PMC10689569 DOI: 10.1136/rapm-2023-104632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Affiliation(s)
- Philipp Gerner
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Christopher W Connor
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander B Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Kus JW, Schulte E, Büttner B, Erlenwein J, Petzke F, Höhl CF, Weber-Krüger M, Nauck F. Komplexe Schmerztherapie unter Einbeziehung eines Ischiadikus- und Saphenuskatheters in palliativer Situation bei ausgeprägter Metastasierung eines Bronchialkarzinoms. ZEITSCHRIFT FÜR PALLIATIVMEDIZIN 2023. [DOI: 10.1055/a-2013-5778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Zusammenfassung
Hintergrund Kontinuierliche periphere Nervenblockaden (Continuous peripheral nerve blocks, CPNB) werden am häufigsten zur perioperativen Analgesie bei chirurgischen Eingriffen eingesetzt. Alternative Indikationen wie die Behandlung tumorbedingter Schmerzen sind die Ausnahme, gleichwohl das Verfahren auch hier effektiv eingesetzt werden kann.
Fallbericht Bei einer 59-jährigen Patientin mit Bronchialkarzinom konnte der durch Metastasierung in der Tibia verursachte starke Schmerz mittels 28-tägiger CPNB des N. ischiadicus und des N. saphenus bis zu ihrem Versterben effektiv behandelt werden. Neben der Schmerzreduktion auf ein Minimum wurde die vorhergehende opioidassoziierte Vigilanzminderung verringert, wodurch sich die Lebensqualität in der letzten Lebensphase steigern ließ.
Schlussfolgerungen CPNB können auch in der Palliativmedizin regional begrenzte Schmerzen effektiv behandeln. Aufgrund der notwendigen Versorgungsstrukturen wird es aber ein Verfahren bleiben, das nur für einzelne Palliativpatient*innen sinnvoll und indiziert ist.
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Affiliation(s)
- Jan Wilhelm Kus
- Klinik für Palliativmedizin, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Erika Schulte
- Klinik für Palliativmedizin, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Benedikt Büttner
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen
| | - Joachim Erlenwein
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen
| | - Frank Petzke
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen
| | - Carl Fabian Höhl
- Klinik für Palliativmedizin, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Mark Weber-Krüger
- Klinik für Palliativmedizin, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Friedemann Nauck
- Klinik für Palliativmedizin, Georg-August-Universität, Universitätsmedizin Göttingen, Göttingen, Deutschland
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Volberg C, Wulf H, Schubert AK. [Pain Management in Palliative Care]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:95-110. [PMID: 36791774 DOI: 10.1055/a-1962-6298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Patients in the palliative phase of a disease often suffer from pain, which leads to a significant reduction in quality of life. Since in most cases there is a progression rather than an improvement of the disease over time, pain therapy must also be dynamically adapted. Due to accompanying symptoms and the physical burden of the disease, treatment of pain is often difficult. In the palliative situation, pain should not only be understood as an excitation of nociceptors but is rather also an expression of mental stress. In this article, we would like to give an overview of the available drugs, application methods and alternative treatment options. Specifically, the article is divided into the following subsections: non-opioid analgesics, opioids, co-analgesics, patient-controlled analgesia procedures, neuraxial and peripheral regional anesthesia procedures, neurolysis, supportive therapies and palliative sedation. Thus, when treating palliative patients, the focus should not only be on the one symptom of pain, but, in the sense of the bio-psycho-social model, a multimodal oriented treatment of the patient with all his symptoms, also including his relatives, must be carried out.
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Lumbar Plexus Nerve Blocks for Perioperative Pain Management in Cerebral Palsy Patients Undergoing Hip Reconstruction: More Effective Than General Anesthesia and Epidurals. J Pediatr Orthop 2023; 43:e54-e59. [PMID: 36509456 DOI: 10.1097/bpo.0000000000002285] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hip reconstruction in patients with cerebral palsy (CP) is associated with. significant postoperative pain. However, adequate analgesia can be difficult to achieve. in this population due to spasticity, communication barriers, and postoperative. spasticity. Recently, multimodal pain management techniques such as epidurals and. regional nerve blocks have been described for postoperative pain control, but it is unclear if 1 technique is more beneficial. The purpose of this study was to compare the outcomes of different perioperative pain management techniques. METHODS This study is a retrospective review of a consecutive series of children with CP over a 5-year period at a single pediatric tertiary-care hospital who underwent hip reconstruction (proximal femoral osteotomy with or without a pelvic osteotomy). Patients were subdivided based on their anesthetic protocol into the following groups: general anesthesia alone (G), general anesthesia with an epidural (E), and general anesthesia with lumbar plexus block (LPB). Our primary outcome was cumulative postoperative narcotic consumption (converted to morphine equivalents). Secondary outcomes included length of stay (LOS), average postoperative heart rate, and pain scores. analysis of variance testing was utilized to compare differences between the groups. RESULTS Fifty-four patients who underwent hip reconstruction were included: 19 in the G group, 18 in the E group, and 17 in the LPB group. LOS was significantly higher in the E group compared with the G and LPB groups: F(2,51)=3.58, P=0.04. The average pain score was significantly lower in the LPB group compared with the others: F(2,51)=4.26, P=0.02. The average postoperative heart rate was significantly lower in the LPB group: F(2,51)=7.08, P<0.01. Postoperative narcotic consumption was significantly lower in the LPB group: F(2,51)=11.57, P<0.01. CONCLUSION The LPB patients required the least amount of narcotics compared with the other groups. This, combined with a lower perioperative heart rate and shorter LOS would suggest these patients experienced less pain over the time of their in-patient stay. In comparison to general anesthesia alone and epidural anesthesia, lumbar plexus nerve blocks are an effective pathway for postoperative pain control after hip reconstruction in a CP population. LEVEL OF EVIDENCE Level III-Case control or retrospective comparative study.
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Analgesic outcomes of tramadol alone and in combination with Butorphanol or Flurbiprofen Axetil after cesarean section: a retrospective study with propensity score matching analysis. BMC Anesthesiol 2022; 22:391. [PMID: 36526971 PMCID: PMC9756475 DOI: 10.1186/s12871-022-01939-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The Society for Obstetric Anesthesia and Perinatology recommends a multimodal analgesia regimen for cesarean delivery analgesia. This study aimed to compare the analgesic effects of tramadol alone and combined with butorphanol or flurbiprofen axetil after a cesarean section. METHODS We performed a retrospective analysis based on the electronic medical records of a teaching hospital in China from January 2018 to January 2020. We collected data on demographic characteristics, anesthesia, analgesia strategy, and pain intensity postoperatively during the first 48 hours. Inadequate postoperative analgesia during this period was defined as an NRS score ≥ 4. We also collected data regarding off-bed activity and intestinal function recovery. Participants were classified into three groups according to analgesia regimens. Groups T, TF, and TB received tramadol, a mixture of tramadol and flurbiprofen axetil, and a combination of tramadol and butorphanol, respectively. Analgesic outcomes were compared using propensity score matching analysis. RESULTS Data from 2323 cases of caesarean section were included in the analysis, and 521 pairs were matched in each group according to their propensity score. Compared with group T, The inadequate analgesia on pain at rest and pain at movement was lower in group TF (RR: 0.42, 95% CI: 0.36-0.49, P = 0.001 and RR: 0.58, 95% CI: 0.48-0.69, P < 0.001, respectively),and the incidence of inadequate control of pain at movement was higher in group TB (RR: 1.38, 95% CI: 1.22-1.55, P < 0.001). Additionally, the percentage of off-bed activity at 2 days postoperatively was higher in group TB than in groups TF and T (78.7% vs. 68.5 and 78.7% vs. 64.9%, respectively, P < 0.001). The incidence of intestinal function recovery 2 days after cesarean delivery in group TB was higher than that in group TF (73.3% vs. 66.2%, P = 0.013). CONCLUSIONS Combining tramadol and flurbiprofen axetil could enhance the analgesic effect and be safely used for analgesia after a cesarean section. However, combining tramadol and butorphanol may produce an antagonistic effect.
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Kubulus C, Gürtesch CA, Wagenpfeil G, Sessler DI, Volk T. Antithrombotic drugs and the risk of bloody punctures in regional anesthesia - a retrospective registry analysis. Reg Anesth Pain Med 2022; 47:rapm-2022-103806. [PMID: 35922078 DOI: 10.1136/rapm-2022-103806] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/22/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION The risk of bleeding during regional anesthesia implementation in patients on antithrombotic therapy remains poorly characterized. We; therefore, analyzed bloody tap rates and adjusted ORs comparing patients who take antithrombotic medications with those who do not. METHODS 65,814 qualifying regional anesthetics (2007-2019) from the Network for Safety in Regional Anesthesia and Acute Pain Therapy registry were included in a retrospective cohort analysis. Procedures in patients who took antithrombotic drugs were compared with procedures in patients who did not. The primary outcome was bloody puncture, defined as any kind of blood aspiration during placement. Secondarily, we considered timely discontinuation of thromboprophylaxis and the impact of various drug classes. As a sensitivity analysis, we used propensity matched groups. RESULTS Patients on antithrombotic therapy were more likely to have a bloody puncture during peripheral nerve block implementation (adjusted OR 1.60; 95% CI 1.33 to 1.93; p<0.001) irrespective of whether therapy was discontinued. In contrast, bloody neuraxial blocks were no more common in patients who took antithrombotic medications (adjusted OR 0.95; 95% CI 0.82 to 1.10; p=0.523) so long as they were paused per guideline. Across both peripheral and neuraxial blocks, concurrent use of more than one platelet and/or coagulation cascade inhibitor nearly doubled the odds (adjusted OR, 1.89; 95% CI 1.48 to 2.40; p<0.001). DISCUSSION Patients on antithrombotic therapy receiving peripheral blocks are at increased risk for bloody punctures irrespective of discontinuation practice. Patients having neuraxial blocks are not at increased risk so long as antithrombotics are stopped per guidelines. Patients who take combined medications are at especially high risk. Guidelines for discontinuing antithrombotic treatments for neuraxial anesthesia appear to be effective and should possibly be extended to high-risk peripheral blocks.
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Affiliation(s)
- Christine Kubulus
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Christine A Gürtesch
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg/Saar, Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA; Senior Fellow, Population Health Research Institute, McMaster University, Ontario, Canada
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg/Saar, Germany
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16
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Practice advisory on the prevention and management of complications of pediatric regional anesthesia. J Clin Anesth 2022; 79:110725. [DOI: 10.1016/j.jclinane.2022.110725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 11/20/2022]
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17
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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Clin Sports Med 2022; 41:317-328. [PMID: 35300843 DOI: 10.1016/j.csm.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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Mascia D, Kahlberg A, Tinaglia S, Pena A, Morgad DE Freitas D, Del Carro U, Bosco L, Monaco F, DE Luca M, Chiesa R, Melissano G. Intraoperative electroneurography-guided intercostal nerve cryoablation for pain control after thoracoabdominal aneurysm open surgical repair. INT ANGIOL 2022; 41:128-135. [PMID: 35112827 DOI: 10.23736/s0392-9590.22.04817-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Postoperative pain after thoracoabdominal (TAAA) or thoracic (TAA) aortic aneurysm open surgical repair may be debilitating and induce limitations in mobilization resulting in a longer length of stay, higher rate of pulmonary adverse events, readmissions and a higher risk of mortality. Commonly employed analgesic strategies do not completely solve this issue and have their own drawbacks. Cryoablation of intercostal nerves has been proposed as an appealing alternative to address the post-operative pain. METHODS Between 2020 and 2021, data of all consecutive patients undergoing TAA or TAAA aortic aneurysms open repair with electroneurography-guided cryoablation of intercostal nerves were collected. Post-operative pain was recorded using patient-reported 0-10 numeric rating scale (NRS). Need for adjunctive opioid drugs and postoperative complications were also recorded. Narcotic usage was calculated as Morphine Milligram Equivalents (MMEs) per day. RESULTS A total of 15 patients (8 males, mean age 61.1-year-old) underwent open surgical repair for TAAA (13 cases) or TAA (2 cases) and received intercostal nerve cryoablation. There were no intraoperative deaths and cases of spinal cord ischemia. Overall, 70 intercostal nerves underwent electroneurography-guided cryoablation, with a a mean of 4.6 nerves per patient. On the first day after extubation, mean NRS was 4.6 and the MMEs calculated was 6.7, decreasing over the days. There was one case of pneumonia and atelectasis requiring bronchoscopy. There were no reported bowel complications. The mean postoperative length of stay was 16 days and in the intensive care unit stay was 6.5 days. CONCLUSIONS Electroneurography-guided cryoablation of intercostal nerves is a safe and reproducible technique which can be used in addition to systemic pain management for TAA and TAAA open repair.
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Affiliation(s)
- Daniele Mascia
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy -
| | - Andrea Kahlberg
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Sarah Tinaglia
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Americo Pena
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Dhaniel Morgad DE Freitas
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Ubaldo Del Carro
- Neurology Department, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Luca Bosco
- Neurology Department, San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Fabrizio Monaco
- Anesthesiology Department, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milano, Italy
| | - Monica DE Luca
- Anesthesiology Department, San Raffaele Scientific Institute, Vita-Salute University School of Medicine, Milano, Italy
| | - Roberto Chiesa
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
| | - Germano Melissano
- Vascular Surgery, San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milano, Italy
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Feasibility of continuous epidural analgesia in patients with failed back surgery syndrome and spinal stenosis. J Anesth 2022; 36:246-253. [PMID: 35044493 PMCID: PMC8967747 DOI: 10.1007/s00540-022-03039-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The purpose of this study was to outline the feasibility of continuous epidural analgesia in the treatment of failed back surgery syndrome (FBSS) or spinal stenosis. METHODS We queried our prospective collected institutional database to include all consecutive patients, who underwent continuous epidural analgesia with accompanying intensive physiotherapeutic exercise within a timeframe of 4 years. Patients suffered from FBSS or spinal stenosis; protocolled continuous epidural analgesia was planned for 4 days within the framework of an inpatient multimodal pain therapy concept. The instillation technique of the epidural catheter, the capability to attend in accompanying physiotherapy, and the peri-interventional complications were evaluated. RESULTS 153 patients with an average age of 57.4 years (± 11.9) were enrolled in this study. 105 patients suffered from FBSS and 48 patients had spinal stenosis. Overall, 148 patients (96.7%) reported the pain reduction and were able to perform daily intensified physiotherapeutic exercise. There were no serious adverse events, neither infection nor bleeding, no cardiopulmonary complication or permanent neurological deficits. The most common side effect was neurological impairment, such as numbness, dysesthesia, or weakness of the lower limbs with complete regression after flow rate adjustment. Patients with FBSS were more likely to develop dysesthesia (p = 0.007). CONCLUSIONS Continuous epidural analgesia is feasible in patients with FBSS or spinal stenosis. This treatment enables extensive physiotherapeutic treatment even in patients with severe pain conditions and can be considered as an alternative to epidural injections. An increased complication rate in comparison to short-term perioperative or perinatal application was not observed.
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20
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Moorthy A, Eochagáin AN, Buggy DJ. Can Acute Postoperative Pain Management After Tumour Resection Surgery Modulate Risk of Later Recurrence or Metastasis? Front Oncol 2022; 11:802592. [PMID: 34976840 PMCID: PMC8716859 DOI: 10.3389/fonc.2021.802592] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/30/2021] [Indexed: 12/13/2022] Open
Abstract
Background Cancer is a leading cause of mortality worldwide, but death is rarely from the primary tumour: Rather it is multi-organ dysfunction from metastatic disease that is responsible for up to 90% of cancer-related deaths. Surgical resection of the primary tumour is indicated in 70% of cases. The perioperative stress response, tissue hypoxia at the site of surgery, and acute pain contribute to immunosuppression and neo-angiogenesis, potentially promoting tumour survival, proliferation, and metastasis. Poorly controlled acute postoperative pain decreases Natural Killer (NK) immune cell activity, which could potentially facilitate circulating tumour cells from evading immune detection. This consequently promotes tumour growth and distal metastasis. Methods We conducted a comprehensive literature search for links between acute pain and cancer outcomes using multiple online databases. Relevant articles from January 1st, 2010 to September 1st, 2021 were analysed and appraised on whether postoperative pain control can modulate the risk of recurrence, metastasis, and overall cancer survival. Results Although experimental and retrospective clinical data suggest a plausible role for regional anaesthesia in cancer outcome modulation, this has not been supported by the single, largest prospective trial to date concerning breast cancer. While there are mixed results on anaesthesiology drug-related interventions, the most plausible data relates to total intravenous anaesthesia with propofol, and to systemic administration of lidocaine. Conclusion The hypothesis that anaesthetic and analgesic technique during cancer surgery could influence risk of subsequent recurrence or metastasis has been prevalent for >15 years. The first, large-scale definitive trial among women with breast cancer found robust equivalent findings between volatile anaesthesia with opioid analgesia and regional anaesthesia. Therefore, while regional anaesthesia during tumour resection does not seem to have any effect on cancer outcomes, it remains plausible that other anaesthetic techniques (e.g. total intravenous anaesthesia and systemic lidocaine infusion) might influence oncologic outcome in other major tumour resection surgery (e.g. colorectal and lung). Therefore, another large trial is needed to definitively answer these specific research questions. Until such evidence is available, perioperative analgesia for cancer surgery of curative intent should be based on patient co-morbidity and non-cancer endpoints, such as optimising analgesia and minimising postoperative complications.
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Affiliation(s)
- Aneurin Moorthy
- Anaesthesiology & Perioperative Medicine Research Fellow, Division of Anaesthesiology and Peri-operative Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Aisling Ní Eochagáin
- Anaesthesiology Research Fellow, St. James's University Hospital, Dublin, Ireland
| | - Donal J Buggy
- Consultant and Professor, Division of Anaesthesiology and Peri-operative Medicine, Mater Misericordiae University Hospital, School of Medicine, University College, Dublin, Ireland.,Outcomes Research, Cleveland Clinic, Cleveland, OH, United States
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21
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Prolonged Use of a Continuous Peripheral Nerve Block Catheter for Analgesia after Pediatric Foot and Ankle Surgery. Case Rep Anesthesiol 2022; 2021:8026961. [PMID: 34970456 PMCID: PMC8714393 DOI: 10.1155/2021/8026961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/07/2021] [Indexed: 12/04/2022] Open
Abstract
Continuous peripheral nerve blocks (CPNB) have a variety of indications and have been shown to be a safe and effective means of minimizing pain postoperatively. Early studies have indicated duration of catheter use greater than 48 hours as a main contributor to infection risk in CPNBs. Recent studies, though, have suggested that the risk of infection does not increase until 4 days after insertion. In the following case report, we recount our experience in using a continuous popliteal-sciatic peripheral nerve block for postoperative pain control in a pediatric patient following calcaneal and first metatarsal osteotomy. The catheter remained in place for 65 hours postoperatively without signs of local inflammation or infection. The prolonged CPNB use resulted in a significant decrease in postoperative opioid use and pain and increase in patient satisfaction when compared to the same procedure done one year prior on the opposite foot.
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22
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Incidence and characteristics of major adverse events in continuous peripheral nerve block analgesia: A single-centre outcome analysis of 10 638 cases in a tertiary care teaching hospital. Eur J Anaesthesiol 2021; 39:631-633. [PMID: 34783685 DOI: 10.1097/eja.0000000000001628] [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]
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23
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Bomberg H, Lorenzana D, Aguirre J, Eichenberger U. [Peripheral Regional Anaesthesia for Perioperative Analgesia]. PRAXIS 2021; 110:579-589. [PMID: 34344186 DOI: 10.1024/1661-8157/a003682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Peripheral Regional Anaesthesia for Perioperative Analgesia Abstract. Peripheral regional anaesthesia is the actual gold standard of opioid-sparing perioperative analgesia and is mainly used for surgery of the shoulder, arm and leg. Well-trained anaesthesiologists are the prerequisite for the correct individual risk-benefit assessment and the performance of the nerve blocks using a combination of ultrasound guidance and peripheral nerve stimulation (dual guidance). The postoperative care of the patients requires trained staff.
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Affiliation(s)
- Hagen Bomberg
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - David Lorenzana
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - José Aguirre
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
| | - Urs Eichenberger
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Balgrist, Zürich
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24
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Macfarlane GJ, Forget P, Price C, Meissner W, Zaslansky R. Perspectives on pain registries. Pain 2021; 162:2201-2203. [PMID: 34256380 DOI: 10.1097/j.pain.0000000000002228] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 01/26/2021] [Indexed: 01/22/2023]
Affiliation(s)
- Gary J Macfarlane
- Epidemiology Group, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Aberdeen Centre for Arthritis and Musculoskeletal Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Patrice Forget
- Epidemiology Group, School of Medicine, Medical Science and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
- Department of Anaesthesia, NHS Grampian, Aberdeen, United Kingdom
| | - Cathy Price
- Solent NHS Trust, Southampton, United Kingdom
| | - Winfried Meissner
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Ruth Zaslansky
- Department of Anaesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
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25
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Ghaffari A, Jørgensen MK, Rømer H, Sørensen MPB, Kold S, Rahbek O, Bisgaard J. Does the performance of lower limb peripheral nerve blocks differ among orthopedic sub-specialties? A single institution experience in 246 patients. Scand J Pain 2021; 21:794-803. [PMID: 34062627 DOI: 10.1515/sjpain-2021-0029] [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: 02/11/2021] [Accepted: 04/27/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Continuous peripheral nerve blocks (cPNBs) have shown promising results in pain management after orthopaedic surgeries. However, they can be associated with some risks and limitations. The purpose of this study is to describe our experience with the cPNBs regarding efficacy and adverse events in patients undergoing orthopedic surgeries on the lower extremity in different subspecialties. METHODS This is a prospective cohort study on collected data from perineural catheters for pain management after orthopedic surgeries in lower limbs. Catheters were placed by experienced anesthesiologists using sterile technique. After an initial bolus dose of 10-20 mL ropivacaine 0.5% (weight adjusted), the catheters were secured and connected to disposable mechanical infusion pumps with ropivacaine 0.2% (basal infusion rate = 6 mL/h; weight adjusted (0.2 mL/kg/h)). After catheterization, the patients were examined daily, by specially educated acute pain service nurses. Pro re nata (PRN) or fixed boluses (10 mL bupivacaine 0.25%; weight adjusted) with an upper limit of 4 times/day, were administered if indicated. Patients' demographic data, physiological status, and pre-op intake of opioids and other analgesics were registered. The severity of post-operative pain was assessed with 'Numeric Rating Scale' (NRS) and 'Face, legs, Activity, Cry, Consolability' (FLACC) scale for adults and children, respectively. The need for additional opioids and possible complications were registered. RESULTS We included 547 catheters of 246 patients (Range 1-10 catheters per patient). Overall, 115 (21%) femoral, 162 (30%) saphenous, 66 (12%) sciatic, and 204 (37%) popliteal sciatic nerve catheter were used. 452 (83%) catheters were inserted by a primary procedure, 61(11%) catheters employed as a replacement, and 34 catheters (6.2%) used as a supplement. For guiding the catheterization, ultrasound was applied in 451 catheters (82%), nerve stimulator in 90 catheters (16%), and both methods in 6 catheters (1.1%). The median duration a catheter remained in place was 3 days (IQR = 2-5). The proportion of catheters with a duration of two days was 81, 79, 73, and 71% for femoral, sciatic, saphenous, and popliteal nerve, respectively. In different subspecialties, 91% of catheters in wound and amputations, 89% in pediatric surgery, 76% in trauma, 64% in foot and ankle surgery, and 59% in limb reconstructive surgery remained more than two days. During first 10 days after catheterization, the proportion of pain-free patients were 77-95% at rest and 63-88% during mobilization, 79-92% of the patients did not require increased opioid doses, and 50-67% did not require opioid PRN doses. In addition to 416 catheters (76%), which were removed as planned, the reason for catheter removal was leaving the hospital in 27 (4.9%), loss of efficacy in 69 (13%), dislodgement in 23 (4.2%), leakage in 8 (1.5%), and erythema in 4 catheters (0.73%). No major complication occurred. CONCLUSIONS After orthopaedic procedures, cPNBs can be considered as an efficient method for improving pain control and minimizing the use of additional opioids. However, the catheters sometimes might need to be replaced to achieve the desired efficacy.
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Affiliation(s)
- Arash Ghaffari
- Interdisciplinary Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | | | - Helle Rømer
- Orthopedic Anaestesia Department, Aalborg University Hospital, Aalborg, Denmark
| | | | - Søren Kold
- Interdisciplinary Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | - Ole Rahbek
- Interdisciplinary Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | - Jannie Bisgaard
- Orthopedic Anaestesia Department, Aalborg University Hospital, Aalborg, Denmark
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Abstract
This article addresses the importance of anesthesiologists providing regional anesthesia techniques that are beneficial to the care of trauma patients in the field. It also discusses the advantages and risks associated with regional anesthesia in the field along with how to avoid those risks. In addition, it describes some of the benefits of modern ultrasound techniques compared with landmark techniques with stimulation and other important considerations when performing regional anesthesia in the field. The article gives the unique indications, risks, and key points of the most useful regional techniques for anesthesiologists operating in field environments.
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Affiliation(s)
- Robert Vietor
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
| | - Chester Buckenmaier
- Anesthesiology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Finneran Iv JJ, Ilfeld BM. Percutaneous cryoneurolysis for acute pain management: current status and future prospects. Expert Rev Med Devices 2021; 18:533-543. [PMID: 33961531 DOI: 10.1080/17434440.2021.1927705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Conventional nerve blocks utilize local anesthetic drugs to provide pain relief for hours or days following surgery or trauma. However, postoperative and trauma pain can last weeks or months. Ultrasound-guided percutaneous cryoneurolysis is an anesthetic modality that offers substantially longer pain relief compared to local anesthetic-based nerve blocks.Areas covered: In this review, we discuss the history, mechanism of action, and use of ultrasound-guided percutaneous cryoneurolysis by anesthesiologists in the setting of acute pain management.Expert opinion: Ultrasound-guided percutaneous cryoneurolysis offers the potential to provide weeks or months of pain relief following surgery or trauma. Compared to continuous local anesthetic-based peripheral nerve blocks, currently the gold standard for providing long duration postoperative analgesia, cryoneurolysis has benefits that include: 1) longer duration measured in weeks or months rather than days; 2) no external reservoir of local anesthetic to be carried by the patient; 3) no risk of infection; and 4) no risk of catheter dislodgement. However, cryoneurolysis can induce a prolonged motor block in addition to the sensory block, decreasing the appropriate indications to those in which potential sensory and motor deficits are acceptable. Additionally, cryoneurolysis of multiple nerves can have a substantial time requirement relative to conventional nerve blocks.
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Affiliation(s)
- John J Finneran Iv
- Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Brian M Ilfeld
- Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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28
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Bains K, Janfaza D, Flaherty D, Zeballos J, Halawa A, Tedrow U, Vlassakov K. Sympathetic Blockade for the Management of Refractory Ventricular Tachycardia: A Case Report. A A Pract 2021; 15:e01456. [PMID: 33882033 DOI: 10.1213/xaa.0000000000001456] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 64-year-old man with a history of nonischemic cardiomyopathy (NICM) presented with electrical storm (ES). Episodes of ventricular tachycardia (VT) persisted despite endocardial catheter ablations and exhaustive pharmacotherapy. We used alternating regional anesthesia techniques, left stellate ganglion block, and proximal intercostal block to reduce sympathetic input to the heart, resulting in a significant decrease in VT burden. By using alternating catheter locations, we were able to maintain continuous sympathetic blockade for 31 days and bridge the patient to a successful orthotopic heart transplant.
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Affiliation(s)
- Kavin Bains
- From the Department of Anesthesiology, Perioperative and Pain Medicine
| | - David Janfaza
- From the Department of Anesthesiology, Perioperative and Pain Medicine
| | - Devon Flaherty
- From the Department of Anesthesiology, Perioperative and Pain Medicine
| | - Jose Zeballos
- From the Department of Anesthesiology, Perioperative and Pain Medicine
| | - Ahmad Halawa
- Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Usha Tedrow
- Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kamen Vlassakov
- From the Department of Anesthesiology, Perioperative and Pain Medicine
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Müller-Wirtz LM, Volk T. Big Data in Studying Acute Pain and Regional Anesthesia. J Clin Med 2021; 10:jcm10071425. [PMID: 33916000 PMCID: PMC8036552 DOI: 10.3390/jcm10071425] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/14/2021] [Accepted: 03/23/2021] [Indexed: 12/16/2022] Open
Abstract
The digital transformation of healthcare is advancing, leading to an increasing availability of clinical data for research. Perioperative big data initiatives were established to monitor treatment quality and benchmark outcomes. However, big data analyses have long exceeded the status of pure quality surveillance instruments. Large retrospective studies nowadays often represent the first approach to new questions in clinical research and pave the way for more expensive and resource intensive prospective trials. As a consequence, the utilization of big data in acute pain and regional anesthesia research has considerably increased over the last decade. Multicentric clinical registries and administrative databases (e.g., healthcare claims databases) have collected millions of cases until today, on which basis several important research questions were approached. In acute pain research, big data was used to assess postoperative pain outcomes, opioid utilization, and the efficiency of multimodal pain management strategies. In regional anesthesia, adverse events and potential benefits of regional anesthesia on postoperative morbidity and mortality were evaluated. This article provides a narrative review on the growing importance of big data for research in acute postoperative pain and regional anesthesia.
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Affiliation(s)
- Lukas M. Müller-Wirtz
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66421 Homburg, Saarland, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Correspondence: (L.M.M.-W.); (T.V.)
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, 66421 Homburg, Saarland, Germany
- Outcomes Research Consortium, Cleveland, OH 44195, USA
- Correspondence: (L.M.M.-W.); (T.V.)
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Orfanou C, Koutalas I, Valsami S, Staikou C. Uneventful epidural catheter removal in a patient with postoperative acute coronary syndrome receiving emergency triple antithrombotic therapy: a case report. Braz J Anesthesiol 2021; 71:454-457. [PMID: 33762192 PMCID: PMC9373277 DOI: 10.1016/j.bjane.2021.02.036] [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: 03/20/2020] [Revised: 10/01/2020] [Accepted: 02/06/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Neuraxial hematoma is a rare complication of the epidural technique which is commonly used for high quality postoperative pain relief. In case of urgent initiation of multiple antithrombotic therapy, the optimal timing of epidural catheter removal and need for treatment modification may be quite challenging. There are no specific guidelines and published reports are scarce. CASE REPORT We present the uneventful removal of an indwelling epidural catheter in a patient who was put on emergency triple antithrombotic treatment with Low Molecular Weight Heparin (LMWH), aspirin and clopidogrel in the immediate postoperative period, due to acute coronary syndrome. In order to define the optimal conditions and timing for catheter removal, so as to reduce the risk of complications, various laboratory tests were conducted 3 hours after aspirin/clopidogrel intake. Standard coagulation tests revealed normal platelet count, normal prothrombin time and normal activated partial thromboplastin time, while Platelet Function Analysis (PFA-200) revealed abnormal values (increased COL/EPI and COL/ADP values, both indicating inhibition of platelet function). The anti-Xa level, estimated 4 hours after LMWH administration, was within therapeutic range. At the same time, Rotational Thromboelastometry (ROTEM) showed a relatively satisfactory coagulation status overall. The epidural catheter was removed 26 hours after the last dual antiplatelet dose and the next dose was given 2 hours after removal. Enoxaparin was withheld for 24 hours and was resumed after 6 hours. Neurologic checks were performed regularly for alarming signs and symptoms suggesting development of an epidural hematoma. No complications occurred. CONCLUSION Point-of-care coagulation and platelet function monitoring may provide a helpful guidance in order to define the optimal timing for catheter removal, so as to reduce the risk of complications. A case-specific management plan based on a multidisciplinary approach is also important.
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Affiliation(s)
- Christina Orfanou
- National and Kapodistrian University of Athens, Aretaieio Hospital, Department of Anesthesiology, Athens, Greece.
| | - Ioannis Koutalas
- National and Kapodistrian University of Athens, Aretaieio Hospital, Department of Anesthesiology, Athens, Greece
| | - Serena Valsami
- National and Kapodistrian University of Athens, Aretaieio Hospital, Department of Blood Transfusion, Athens, Greece
| | - Chryssoula Staikou
- National and Kapodistrian University of Athens, Aretaieio Hospital, Department of Anesthesiology, Athens, Greece
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Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Esa WAS, Mariano ER, Kent ML, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha EJ, Ma C, Padwal JA, Turan A. Ambulatory continuous peripheral nerve blocks to treat postamputation phantom limb pain: a multicenter, randomized, quadruple-masked, placebo-controlled clinical trial. Pain 2021; 162:938-955. [PMID: 33021563 PMCID: PMC7920494 DOI: 10.1097/j.pain.0000000000002087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/13/2023]
Abstract
Phantom limb pain is thought to be sustained by reentrant neural pathways, which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0 to 12 weeks. Pretreatment pain scores were similar in both groups, with a median (interquartile range) of 5.0 (4.0, 7.0) for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic vs 4.5 (2.6) in those given placebo (difference [95% confidence interval] 1.3 [0.4, 2.2], P = 0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 (0, 5.0) vs 1.5 (0, 5.0) for the placebo group; there seemed to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.
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Affiliation(s)
- Brian M. Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Kamal Maheshwari
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Sarah J. Madison
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Wael Ali Sakr Esa
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Edward R. Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, CA, United States
| | - Michael L. Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Steven Hanling
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, United States
| | - Daniel I. Sessler
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - James C. Eisenach
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Steven P. Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, MD, United States
| | - Edward J. Mascha
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Chao Ma
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Jennifer A. Padwal
- Department of Radiology, University of California San Diego, San Diego, CA, United States
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Alparslan Turan
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
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Harkouk H, Thibault-Sogorb T, Beauchet A, Espinasse F, Lawrence C, Martinez V, Fletcher D. Two per cent alcoholic chlorhexidine versus alcoholic five per cent povidone-iodine for the prevention of perineural catheter colonisation: The CHLOVEPI randomised, controlled trial. Anaesth Crit Care Pain Med 2020; 40:100790. [PMID: 33285282 DOI: 10.1016/j.accpm.2020.100790] [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: 11/26/2019] [Revised: 09/18/2020] [Accepted: 10/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Multimodal analgesia, including a regional technique using perineural catheters (PNCs), is recommended for the treatment of moderate-to-severe acute postoperative pain. Perineural catheters are at risk of bacterial colonisation. In this study, we compared the cutaneous antiseptic efficacy of 2% alcoholic chlorhexidine and povidone-iodine-alcohol for preventing the bacterial colonisation of PNCs in orthopaedic surgery. METHODS We performed a randomised, controlled trial, comparing two cutaneous antisepsis strategies, one based on 2% alcoholic chlorhexidine and the other on povidone-iodine-5% alcohol, for placed PNCs before orthopaedic surgery. The primary endpoint was the incidence of catheter bacterial colonisation (threshold > 1000 colony-forming units/ml). The secondary endpoints were the incidence of catheter-related infections and the adverse effects of the antiseptic solutions. RESULTS From November 2016 to May 2018, we included 113 patients in this study. The use of alcoholic chlorhexidine was associated with a lower incidence of catheter colonisation (15.5% (n = 9) versus 32.7% (n = 18); OR: 0.28 [0.09-0.77], p = 0.01). No catheter-related infections or adverse effects of antiseptic solutions were observed in either group. The risk factors associated with colonisation were a duration of catheter use ≥ 3 days (p = 0.04) and obesity (p = 0.005). The most frequently identified bacterium was Staphylococcus epidermidis. CONCLUSION Skin disinfection with 2% alcoholic chlorhexidine decreases bacterial colonisation rates for placed perineural catheters.
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Affiliation(s)
- Hakim Harkouk
- Service d'Anesthésie-Réanimation, Hôpital Ambroise Paré, Boulogne-Billancourt, France; Unité INSERM U987, Université Versailles Saint-Quentin, Versailles, France.
| | | | - Alain Beauchet
- Unité de recherche clinique, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Florence Espinasse
- Service de microbiologie, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | | | - Valeria Martinez
- Unité INSERM U987, Université Versailles Saint-Quentin, Versailles, France; Service d'anesthésie, Hôpital Raymond Poincaré, Garches, France
| | - Dominique Fletcher
- Service d'Anesthésie-Réanimation, Hôpital Ambroise Paré, Boulogne-Billancourt, France; Unité INSERM U987, Université Versailles Saint-Quentin, Versailles, France
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Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain. Anesthesiology 2020; 133:1127-1149. [PMID: 32898231 DOI: 10.1097/aln.0000000000003532] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
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Knaak C, Spies C, Schneider A, Jara M, Vorderwülbecke G, Kuhlmann AD, von Haefen C, Lachmann G, Schulte E. Epidural Anesthesia in Liver Surgery-A Propensity Score-Matched Analysis. PAIN MEDICINE 2020; 21:2650-2660. [PMID: 32651587 DOI: 10.1093/pm/pnaa130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To assess the effects of epidural anesthesia (EA) on patients who underwent liver resection. DESIGN Secondary analysis of a prospective randomized controlled trial. SETTING This single-center study was conducted at an academic medical center. METHODS A subset of 110 1:1 propensity score-matched patients who underwent liver resection with and without EA were analyzed. Outcome measures were pain intensity ≥5 on a numeric rating scale (NRS) at rest and during movement on postoperative days 1-5, analyzed with logistic mixed-effects models, and postoperative complications according to the Clavien-Dindo classification, length of hospital stay (LOS), and one-year survival. One-year survival in the matched cohorts was compared using a frailty model. RESULTS EA patients were less likely to experience NRS ≥5 at rest (odds ratio = 0.06, 95% confidence interval [CI] = 0.01 to 0.28, P < 0.001). These findings were independent of age, sex, Charlson comorbidity index, baseline NRS, and surgical approach (open vs laparoscopic). The number and severity of postoperative complications and LOS were comparable between groups (P = 0.258, P > 0.999, and P = 0.467, respectively). Reduced mortality rates were seen in the EA group one year after surgery (9.1% vs 30.9%, hazard ratio = 0.32, 95% CI = 0.11 to 0.90, P = 0.031). No EA-related adverse events occurred. Earlier recovery of bowel function was seen in EA patients. CONCLUSIONS Patients with EA had better postoperative pain control and required fewer systemic opioids. Postoperative complications and LOS did not differ, although one-year survival was significantly improved in patients with EA. EA applied in liver surgery was effective and safe.
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Affiliation(s)
- Cornelia Knaak
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Alice Schneider
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Maximilian Jara
- Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gerald Vorderwülbecke
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Anna Dorothea Kuhlmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Clarissa von Haefen
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Erika Schulte
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
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Ganesh A, Qadri YJ, Boortz-Marx RL, Al-Khatib SM, Harpole DH, Katz JN, Koontz JI, Mathew JP, Ray ND, Sun AY, Tong BC, Ulloa L, Piccini JP, Fudim M. Stellate Ganglion Blockade: an Intervention for the Management of Ventricular Arrhythmias. Curr Hypertens Rep 2020; 22:100. [PMID: 33097982 DOI: 10.1007/s11906-020-01111-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To highlight the indications, procedural considerations, and data supporting the use of stellate ganglion blockade (SGB) for management of refractory ventricular arrhythmias. RECENT FINDINGS In patients with refractory ventricular arrhythmias, unilateral or bilateral SGB can reduce arrhythmia burden and defibrillation events for 24-72 h, allowing time for use of other therapies like catheter ablation, surgical sympathectomy, or heart transplantation. The efficacy of SGB appears to be consistent despite the type (monomorphic vs polymorphic) or etiology (ischemic vs non-ischemic cardiomyopathy) of the ventricular arrhythmia. Ultrasound-guided SGB is safe with low risk for complications, even when performed on anticoagulation. SGB is effective and safe and could be considered for patients with refractory ventricular arrhythmias.
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Affiliation(s)
- Arun Ganesh
- Duke Anesthesiology, Duke University, Durham, NC, USA
| | - Yawar J Qadri
- Emory Anesthesiology, Emory University, Atlanta, GA, USA
| | | | - Sana M Al-Khatib
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - David H Harpole
- Cardiothoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jason N Katz
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Jason I Koontz
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.,Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke University, Durham, NC, USA
| | | | - Neil D Ray
- Duke Anesthesiology, Duke University, Durham, NC, USA
| | - Albert Y Sun
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA
| | - Betty C Tong
- Cardiothoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Luis Ulloa
- Duke Anesthesiology, Duke University, Durham, NC, USA.,Center for Perioperative Organ Protection, Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Jonathan P Piccini
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.,Duke Clinical Research Institute, Durham, NC, USA.,Duke Center for Atrial Fibrillation, Duke University Medical Center, Duke University, Durham, NC, USA
| | - Marat Fudim
- Duke Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA. .,Duke Clinical Research Institute, Durham, NC, USA.
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Topor B, Oldman M, Nicholls B. Best practices for safety and quality in peripheral regional anaesthesia. BJA Educ 2020; 20:341-347. [PMID: 33456915 PMCID: PMC7807996 DOI: 10.1016/j.bjae.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- B. Topor
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - M. Oldman
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - B. Nicholls
- Taunton and Somerset NHS Foundation Trust, Taunton, UK
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Vogelsang H, Lang A, Cevik B, Botteck NM, Weber TP, Herzog‐Niescery J. Incidence of infection in non-tunnelled thoracic epidural catheters after major abdominal surgery. Acta Anaesthesiol Scand 2020; 64:1312-1318. [PMID: 32521043 DOI: 10.1111/aas.13650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/20/2020] [Accepted: 05/29/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Thoracic epidural analgesia is beneficial after major abdominal surgery, though side-effects and complications are rare but potentially devastating. The incidence of catheter-related infection is approximately 5.5%. Several guidelines have been recommended to prevent complications during thoracic epidural catheterization. Tunnelling is often recommended to reduce the incidence of infections and dislocations. METHODS A retrospective, single-centre analysis of our acute pain service database was performed between 2010 and 2018. The hygiene measures of the German Society of Anaesthesiology have been incorporated in our standard operating protocol since 2009. The procedure remained constant, but the skin disinfectant was changed from propan-2-ol to propan-2-ol with octenidine in 2014. Tunnelling of catheters was not performed. We analysed the incidence of catheter-related infections (primary endpoint) and effect of the used disinfectant (secondary endpoint). RESULTS A total of 2755 patients underwent elective major abdominal surgery with thoracic epidural catheterization. Sixteen patients (0.6%) showed symptoms of mild catheter-related infection. Moderate or severe infections were not observed in any patient. The type of disinfectant did not show any significant effect on the incidence of infection. CONCLUSION The incidence of catheter-related infections was low, and only mild signs of infection were observed. Non-tunnelling could be an alternative to tunnelling, especially if hygiene protocols are followed, and the duration of catheter use is short. A comprehensive database and regular examinations by trained staff are essential for early detection of abnormalities and immediate removal of the catheter, if required.
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Affiliation(s)
- Heike Vogelsang
- Department of Anaesthesiology and Intensive Care Medicine Ruhr‐University BochumSt. Josef‐Hospital Bochum Germany
| | - Alexander Lang
- Department of Anaesthesiology and Intensive Care Medicine Ruhr‐University BochumSt. Josef‐Hospital Bochum Germany
| | - Bilal Cevik
- Department of Anaesthesiology and Intensive Care Medicine Ruhr‐University BochumSt. Josef‐Hospital Bochum Germany
| | - Nikolaj M. Botteck
- Department of Anaesthesiology and Intensive Care Medicine Ruhr‐University BochumSt. Josef‐Hospital Bochum Germany
| | - Thomas P. Weber
- Department of Anaesthesiology and Intensive Care Medicine Ruhr‐University BochumSt. Josef‐Hospital Bochum Germany
| | - Jennifer Herzog‐Niescery
- Department of Anaesthesiology and Intensive Care Medicine Ruhr‐University BochumSt. Josef‐Hospital Bochum Germany
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38
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Desmet M, Bindelle S, Breebaart M, Camerlynck H, Casaer S, Fourneau K, Gautier P, Goffin P, Lecoq J, Lenders I, Leunen I, Van Aken D, Van Houwe P, Van Hooreweghe S, Vermeylen K, Sermeus I. Guidelines for the safe clinical practice of peripheral nerve blocks in the adult patient. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.3.9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The Peripheral Nerve Block working group of the Belgian Association for Regional Anesthesia has revised and updated the “Clinical guidelines for the practice of peripheral nerve block in the adult” which were published in 2013.
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Stephan SR, Garlich JM, Debbi EM, Johnson CR, Polakof LS, Noorzad AS, Moak ZB, Yalamanchili DR, Stephenson SK, Anand KK, Lin CA, Little MTM, Moon CN. A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients. Injury 2020; 51:1337-1342. [PMID: 32327234 DOI: 10.1016/j.injury.2020.04.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 04/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks. METHODS We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates. RESULTS 107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups. CONCLUSIONS We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.
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Affiliation(s)
- Stephen R Stephan
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | - John M Garlich
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Eytan M Debbi
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | | | - Landon S Polakof
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Ali S Noorzad
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Zachary B Moak
- Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, CA.
| | | | - Samuel K Stephenson
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Kapil K Anand
- Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Carol A Lin
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Milton T M Little
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Charles N Moon
- Department of Orthopaedic Surgery, Cedars Sinai Medical Center, Los Angeles, CA.
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Kaushal B, Chauhan S, Magoon R, Krishna NS, Saini K, Bhoi D, Bisoi AK. Efficacy of Bilateral Erector Spinae Plane Block in Management of Acute Postoperative Surgical Pain After Pediatric Cardiac Surgeries Through a Midline Sternotomy. J Cardiothorac Vasc Anesth 2020; 34:981-986. [DOI: 10.1053/j.jvca.2019.08.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 08/03/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022]
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Abstract
For decades local anesthetics have proven to be safe and effective drugs in the clinical practice, crucially promoting the enormous achievements in regional anesthesia. Meanwhile, it is a well-known fact that local anesthetics are much more than just "simple" sodium channel blockers. They also interact with numerous other ion channels and subcellular structures, enhancing nerve blockade and resulting in systemic "alternative" effects, which can sometimes even be clinically used. By the simultaneous administration of various adjuvants (e.g., opioids, corticosteroids and α2-receptor agonists) attempts are made to prolong the time of action of local anesthetics after a single administration in order to achieve the best possible improvement in postoperative analgesia. In this context, ultralong-acting local anesthetics, such as liposomal bupivacaine, which at least theoretically can provide a sensory nerve block for several days, have been developed and clinically introduced. The coming years will show whether these approaches will develop into genuine alternatives to the personnel and cost-intensive continuous nerve blockades.Local anesthetic-induced systemic toxicity is meanwhile rare but still a potentially life-threatening event, frequently resulting from accidental intravascular injection or extensive systemic resorption. Consequently, slow and fractional application of these agents with intermittent aspiration helps to prevent toxic sequelae. If toxic symptoms occur, however, the intravenous infusion of 20% lipid solutions in addition to basic treatment measures can enhance the success of treatment.
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Affiliation(s)
- W Zink
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum der Stadt Ludwigshafen am Rhein, Bremserstr 79, 67063, Ludwigshafen, Deutschland.
| | - T Steinfeldt
- Klinik für Anästhesiologie und operative Intensivmedizin, Diakonieklinikum Schwäbisch Hall, Schwäbisch Hall, Deutschland
| | - T Wiesmann
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Marburg, Deutschland
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Graves CE, Moyer J, Zobel MJ, Mora R, Smith D, O'Day M, Padilla BE. Intraoperative intercostal nerve cryoablation During the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr Surg 2019; 54:2250-2256. [PMID: 30935731 PMCID: PMC6920013 DOI: 10.1016/j.jpedsurg.2019.02.057] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Minimally-invasive repair of pectus excavatum by the Nuss procedure is associated with significant postoperative pain, prolonged hospital stay, and high opiate requirement. We hypothesized that intercostal nerve cryoablation during the Nuss procedure reduces hospital length of stay (LOS) compared to thoracic epidural analgesia. DESIGN This randomized clinical trial evaluated 20 consecutive patients undergoing the Nuss procedure for pectus excavatum between May 2016 and March 2018. Patients were randomized evenly via closed-envelope method to receive either cryoanalgesia or thoracic epidural analgesia. Patients and physicians were blinded to study arm until immediately preoperatively. SETTING Single institution, UCSF-Benioff Children's Hospital. PARTICIPANTS 20 consecutive patients were recruited from those scheduled for the Nuss procedure. Exclusion criteria were age < 13 years, chest wall anomaly other than pectus excavatum, previous repair or other thoracic surgery, and chronic use of pain medications. MAIN OUTCOMES AND MEASURES Primary outcome was postoperative LOS. Secondary outcomes included total operative time, total/daily opioid requirement, inpatient/outpatient pain score, and complications. Primary outcome data were analyzed by the Mann-Whitney U-test for nonparametric continuous variables. Other continuous variables were analyzed by two-tailed t-test, while categorical data were compared via Chi-squared test, with alpha = 0.05 for significance. RESULTS 20 patients were randomized to receive either cryoablation (n = 10) or thoracic epidural (n = 10). Mean operating room time was 46.5 min longer in the cryoanalgesia group (p = 0.0001). Median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days (Mann-Whitney U, p = 0.0001). Cryoablation patients required significantly less inpatient opioid analgesia with a mean decrease of 416 mg oral morphine equivalent per patient (p = 0.0001), requiring 52%-82% fewer milligrams on postoperative days 1-3 (p < 0.01 each day). There was no difference in mean pain score between the groups at any point postoperatively, up to one year, and no increased incidence of neuropathic pain in the cryoablation group. No complications were noted in the cryoablation group; among patients with epidurals, one patient experienced a symptomatic pneumothorax and another had urinary retention. CONCLUSIONS AND RELEVANCE Intercostal nerve cryoablation during the Nuss procedure decreases hospital length of stay and opiate requirement versus thoracic epidural analgesia, while offering equivalent pain control. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
| | | | | | | | | | | | - Benjamin E. Padilla
- Corresponding author at: University of California, San Francisco Department of Surgery Division of Pediatric Surgery 550 16th St, Fifth Floor San Francisco, CA 94158-0570 United States. (B.E. Padilla)
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Mitchell KD, Smith CT, Mechling C, Wessel CB, Orebaugh S, Lim G. A review of peripheral nerve blocks for cesarean delivery analgesia. Reg Anesth Pain Med 2019; 45:rapm-2019-100752. [PMID: 31653797 PMCID: PMC7182469 DOI: 10.1136/rapm-2019-100752] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 09/20/2019] [Accepted: 10/11/2019] [Indexed: 11/03/2022]
Abstract
Peripheral nerve blocks have a unique role in postcesarean delivery multimodal analgesia regimens. In this review article, options for peripheral nerve blocks for cesarean delivery analgesia will be reviewed, specifically paravertebral, transversus abdominis plane, quadratus lumborum, iliohypogastric and ilioinguinal, erector spinae, and continuous wound infiltration blocks. Anatomy, existing literature evidence, and specific areas in need of future research will be assessed. Considerations for local anesthetic toxicity, and for informed consent for these modalities in the context of emergency cesarean deliveries, will be presented.
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Affiliation(s)
- Kelsey D Mitchell
- Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - C Tyler Smith
- Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Courtney Mechling
- Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charles B Wessel
- Health Sciences Library, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steven Orebaugh
- Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Grace Lim
- Anesthesiology & Perioperative Medicine, University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Anesthesiology, Perioperative Medicine, Obstetrics & Gynecology, UPMC Magee Womens Hospital, Pittsburgh, Pennsylvania, USA
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Capdevila X, Iohom G, Choquet O, Delaney P, Apan A. Catheter use in regional anesthesia: pros and cons. Minerva Anestesiol 2019; 85:1357-1364. [PMID: 31630506 DOI: 10.23736/s0375-9393.19.13581-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Continuous peripheral nerve blocks refer to a local anesthetic solution administered via perineurally placed catheters in an effort to extend the benefits of a single-shot peripheral nerve block. They offer several advantages in the postoperative period including excellent analgesia, reduced opioid consumption and associated side effects, enhanced rehabilitation and improved patient satisfaction. The current trend towards less invasive, one-day surgery and enhanced recovery programs may decrease the requirement of catheter use. Prolonged motor block in particular is associated with undesirable outcomes. Should we routinely use continuous peripheral nerve blocks in our daily practice? This PRO-CON debate aims at answering the question from the experts' perspectives. Fascial compartment and wound catheters are outside the scope of this debate.
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Affiliation(s)
- Xavier Capdevila
- Department of Anesthesia and Critical Care, Lapeyronie University Hospital, Montpellier, France
| | - Gabriella Iohom
- Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Cork, Ireland
| | - Olivier Choquet
- Department of Anesthesia and Critical Care, Lapeyronie University Hospital, Montpellier, France
| | - Paudie Delaney
- Department of Anaesthesia and Intensive Care Medicine, Cork University Hospital, Cork, Ireland
| | - Alparslan Apan
- Department of Anesthesia and Intensive Care Medicine, Giresun University Hospital, Giresun, Turkey -
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Saranteas T, Koliantzaki I, Savvidou O, Tsoumpa M, Eustathiou G, Kontogeorgakos V, Souvatzoglou R. Acute pain management in trauma: anatomy, ultrasound-guided peripheral nerve blocks and special considerations. Minerva Anestesiol 2019; 85:763-773. [DOI: 10.23736/s0375-9393.19.13145-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
PURPOSE OF REVIEW Central neuraxial blockade is increasingly the anaesthetic management of choice for parturients, including in higher risk pregnancies. Although they are usually effective and safe, there are potentially devastating neurological complications that may present either overtly or insidiously. A thorough understanding of the variety of potential neurological complications is essential to adequately consent patients in addition to diagnosing and managing complications following neuraxial anaesthesia. This review aims to describe a number of potential neurological injuries that may occur and suggested management based on available evidence. RECENT FINDINGS Current evidence supports neuraxial anaesthesia as a safe management strategy in low and many higher risk pregnancies, with a low overall incidence of neurological complications. Neuraxial blockade is safe in patients with platelet counts greater than 70 000/μl and the risk of infective complications secondary to epidural catheterization remains low until day five post procedure. There is also some early evidence supporting the use of transnasal local anaesthetic as a strategy for managing postdural puncture headache. SUMMARY Difficulty remains in establishing absolute risk of complications and optimal management strategies given the low overall number of patients affected and heterogeneity of therapy. There may be a role for centralized registration of postneuraxial complications in obstetric patients to further develop our collective understanding of these conditions.
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Grant GJ, Agoliati AP, Echevarria GC, Lax J. Epidural Analgesia to Facilitate Breastfeeding in a Grand Multipara. J Hum Lact 2019; 35:165-167. [PMID: 29986159 DOI: 10.1177/0890334418784269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Gilbert J Grant
- 1 Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Andrew P Agoliati
- 1 Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Ghislaine C Echevarria
- 1 Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
| | - Jerome Lax
- 1 Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY, USA
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Burlinson CEG, Sirounis D, Walley KR, Chau A. Sepsis in pregnancy and the puerperium. Int J Obstet Anesth 2018; 36:96-107. [PMID: 29921485 DOI: 10.1016/j.ijoa.2018.04.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 04/27/2018] [Accepted: 04/30/2018] [Indexed: 12/30/2022]
Abstract
Sepsis remains a leading cause of maternal morbidity and mortality. Recognition and treatment of maternal sepsis are often delayed due to the physiological adaptations of pregnancy and vague or absent signs and symptoms during its initial presentation. Over the past decade, our understanding of sepsis has evolved and maternal early warning systems have been developed in an effort to help providers promptly identify and stratify parturients who are at risk. In addition, new consensus definitions and care bundles have recently been published by the World Health Organization and the Surviving Sepsis Campaign to facilitate earlier recognition and timely management of sepsis. In this narrative review, we summarize the available evidence about sepsis and provide an overview of the research efforts focused on maternal sepsis to date. Controversies and challenges surrounding the anesthetic management of parturients with sepsis or at risk of developing sepsis during pregnancy or the puerperium will be highlighted.
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Affiliation(s)
- C E G Burlinson
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - D Sirounis
- Division of Critical Care Medicine, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - K R Walley
- Division of Critical Care Medicine, Department of Medicine, St. Paul's Hospital, Vancouver, BC, Canada; Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - A Chau
- Department of Anesthesia, British Columbia Women's Hospital, Vancouver, BC, Canada; Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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