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Ganta A, Fisher ND, Gibbons K, Ferati SR, Furgiuele D, Konda SR, Egol KA. Regional anesthesia is safe for use in intramedullary nailing of low-energy tibial shaft fractures. Injury 2024; 55:111636. [PMID: 38870608 DOI: 10.1016/j.injury.2024.111636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/06/2024] [Accepted: 05/27/2024] [Indexed: 06/15/2024]
Abstract
PURPOSE The purpose was to compare perioperative outcomes of patients who underwent general or regional anesthesia for intramedullary (IM) nailing of tibial shaft fractures (TSFs). METHODS Retrospective chart review was performed on a consecutive series of low-energy TSF patients who presented to a single academic medical center and a level 1 trauma center who underwent operative repair with a reamed IM nail. Collected information included demographics, injury information, anesthesia type (general or regional i.e. peripheral nerve block), intra-operative opiate consumption (converted to morphine milliequivalents [MME], and post-operative pain visual-analog scale [VAS] pain scores. Patients were divided into 3 groups based on the type of anesthesia received and univariate analysis was performed to compare the 3 groups. RESULTS Seventy-six patients were included, with an average age of 44.47±16.0 years. There were 38 (50 %) who were administered general anesthesia and 38 (50 %) who were administered regional anesthesia in the form of a peripheral nerve block. There were no differences between the groups with respect to demographics, medical co-morbidities, rate of open fractures or AO/OTA fracture classification. Regional anesthesia patients received less intra-operative MME than general anesthesia patients (17.57±10.6, 28.96±13.8, p < 0.001). Patients who received regional anesthesia also spent less time in the operating room, received less MME on post-operative day 1, and ambulated further on post-operative day 1, however none of these differences were statistically significant. There were no cases of missed post-operative compartment syndrome or complications related to the administration of the peripheral nerve block. CONCLUSIONS Regional anesthesia in TSF surgery received less intra-operative opioid requirements, without any untoward effects. LEVEL OF EVIDENCE Therapeutic Level III.
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Affiliation(s)
- Abhishek Ganta
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA; Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Richmond Hill, NY 11418, USA.
| | - Nina D Fisher
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
| | - Kester Gibbons
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
| | | | - David Furgiuele
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
| | - Sanjit R Konda
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA; Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Richmond Hill, NY 11418, USA
| | - Kenneth A Egol
- NYU Langone Orthopedic Hospital, 301 E 17th St, New York, NY 10003, USA
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2
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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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3
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Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Anesthesiol Clin 2024; 42:329-344. [PMID: 38705680 DOI: 10.1016/j.anclin.2023.11.013] [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
Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.
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Affiliation(s)
- Danial Shams
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Kaylyn Sachse
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Nicholas Statzer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
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4
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Meyer P, Schroeder K. Regional Anesthesia in the Elite Athlete. Anesthesiol Clin 2024; 42:291-302. [PMID: 38705677 DOI: 10.1016/j.anclin.2023.11.010] [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
Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.
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Affiliation(s)
- Patrick Meyer
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Kristopher Schroeder
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
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5
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Lemke E, Johnston DF, Behrens MB, Seering MS, McConnell BM, Swaran Singh TS, Sondekoppam RV. Neurological injury following peripheral nerve blocks: a narrative review of estimates of risks and the influence of ultrasound guidance. Reg Anesth Pain Med 2024; 49:122-132. [PMID: 37940348 DOI: 10.1136/rapm-2023-104855] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/12/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Peripheral nerve injury or post-block neurological dysfunction (PBND) are uncommon but a recognized complications of peripheral nerve blocks (PNB). A broad range of its incidence is noted in the literature and hence a critical appraisal of its occurrence is needed. OBJECTIVE In this review, we wanted to know the pooled estimates of PBND and further, determine its pooled estimates following various PNB over time. Additionally, we also sought to estimate the incidence of PBND with or without US guidance. EVIDENCE REVIEW A literature search was conducted in six databases. For the purposes of the review, we defined PBND as any new-onset sensorimotor disturbances in the distribution of the performed PNB either attributable to the PNB (when reported) or reported in the context of the PNB (when association with a PNB was not mentioned). Both prospective and retrospective studies which provided incidence of PBND at timepoints of interest (>48 hours to <2 weeks; >2 weeks to 6 weeks, 7 weeks to 5 months, 6 months to 1 year and >1 year durations) were included for review. Incidence data were used to provide pooled estimates (with 95% CI) of PBND at these time periods. Similar estimates were obtained to know the incidence of PBND with or without the use of US guidance. Additionally, PBND associated with individual PNB were obtained in a similar fashion with upper and lower limb PNB classified based on the anatomical location of needle insertion. FINDINGS The overall incidence of PBND decreased with time, with the incidence being approximately 1% at <2 weeks' time (Incidence per thousand (95% CI)= 9 (8; to 11)) to approximately 3/10 000 at 1 year (Incidence per thousand (95% CI)= 0. 3 (0.1; to 0.5)). Incidence of PBND differed for individual PNB with the highest incidence noted for interscalene block. CONCLUSIONS Our review adds information to existing literature that the neurological complications are rarer but seem to display a higher incidence for some blocks more than others. Use of US guidance may be associated with a lower incidence of PBND especially in those PNBs reporting a higher pooled estimates. Future studies need to standardize the reporting of PBND at various timepoints and its association to PNB.
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Affiliation(s)
- Ethan Lemke
- Emergency Medicine, University of Michigan Health-West, Wyoming, Michigan, USA
| | - David F Johnston
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, Northern Ireland, UK
| | - Matthew B Behrens
- Department of Emergency Medicine, Kent Hospital, Warwick, Rhode Island, USA
| | - Melinda S Seering
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa, USA
| | - Brie M McConnell
- Davis Library, University of Waterloo, Waterloo, Ontario, Canada
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Suzuki N, Kotani T, Sunami T, Sakashita K, Okuwaki S, Ohyama S, Iwata S, Iijima Y, Sakuma T, Akazawa T, Inage K, Shiga Y, Minami S, Ohtori S. Anatomical Analysis of the S1 Neural Foramen Using Three-Dimensional Computed Tomography Imaging: Insights for Effective S1 Nerve Root Block. World Neurosurg 2024; 181:e459-e467. [PMID: 37866782 DOI: 10.1016/j.wneu.2023.10.082] [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: 07/17/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 10/24/2023]
Abstract
OBJECTIVE The first sacral nerve root block (S1 NRB) is used to diagnose and treat lumbosacral and radicular pain. This study aims to clarify the anatomy of the S1 neural foramen using three-dimensional (3D) computed tomography (CT) images and to establish the optimal fluoroscopic angle, localize the S1 neural foramen on fluoroscopy, and determine the safe puncture depth for S1 NRB. METHODS In this single-center cohort study, 200 patients with lumbar degenerative disease who underwent preoperative CT were enrolled. Four distinct studies were conducted using the CT data. Study 1 examined the correlation of the sacral slope angle and the supine and prone positions. Study 2 analyzed the tunnel view angle (TVA) using 3D reconstruction. Study 3 ascertained the location of the S1 neural foramen in fluoroscopy images. Study 4 investigated the safe depth for performing S1 NRB. RESULTS The regression analysis in Study 1 revealed a correlation of the sacral slope angle and the supine and prone positions. Study 2 determined an optimal fluoroscopic TVA of approximately 30° for the S1 NRB. Study 3 found that the S1 neural foramen was located caudal to the L5 pedicle 1.7 ± 0.2 times the distance between the L4 and L5 pedicles. Study 4 revealed that the depths of the S1 neural foramen and root were 27.0 ± 2.1 mm and 16.5 ± 2.0 mm, respectively. CONCLUSIONS Our study suggests an optimal fluoroscopic angle, a simple method to locate the S1 neural foramen on fluoroscopy, and an ideal puncture depth for a safe and effective S1 NRB.
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Affiliation(s)
- Noritaka Suzuki
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Toshiaki Kotani
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan.
| | - Takahiro Sunami
- Department of Orthopedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Kotaro Sakashita
- Department of Orthopedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shun Okuwaki
- Department of Orthopedic Surgery, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shuhei Ohyama
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Shuhei Iwata
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Yasushi Iijima
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsuyoshi Sakuma
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Tsutomu Akazawa
- Department of Orthopedic Surgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kazuhide Inage
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yasuhiro Shiga
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shohei Minami
- Department of Orthopedic Surgery, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Seiji Ohtori
- Department of Orthopedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
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7
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Frost S, Rodrigues D, Amadeo RJJ, Wolfe S, Funk F, Ferguson C, Brown H, MacDonald P, Dufault B, Mutter TC. Postoperative neurological symptoms following arthroscopic shoulder surgery with interscalene block: an exploratory secondary analysis of pooled randomized controlled trial data. Reg Anesth Pain Med 2023; 48:553-560. [PMID: 37295793 DOI: 10.1136/rapm-2022-104086] [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: 09/22/2022] [Accepted: 03/07/2023] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Postoperative neurological symptoms (PONS) are recognized complications of regional anesthesia and orthopedic surgery. We aimed to better characterize prevalence and potential risk factors in a homogeneous population of randomized, controlled trial participants. METHODS Data were pooled from two randomized controlled trials of analgesia after interscalene block with perineural or intravenous adjuvants (NCT02426736, NCT03270033). Participants were at least 18 years of age and undergoing arthroscopic shoulder surgery at a single ambulatory surgical center. PONS were assessed by telephone follow-up at 14 days and 6 months postoperatively, and defined as patient report of numbness, weakness, or tingling in the surgical limb, alone or in combination, and regardless of severity or etiology. RESULTS At 14 days, PONS occurred in 83 of 477 patients (17.4%). Among these 83 patients, 10 (12.0%) continued to have symptoms a half-year after surgery. In exploratory univariate analyses, no patient, surgical or anesthetic characteristics were significantly associated with 14-day PONS except for lower postoperative day 1 Quality of Recovery-15 questionnaire total score (OR 0.97 (95% CI, 0.96 to 0.99), p<0.01). This result was driven largely by the emotional domain question scores (OR 0.90 95% CI 0.85 to 0.96, p<0.001). Report of all three of numbness, weakness and tingling at 14 days vs other 14-day symptom combinations was associated with persistent PONS at 6 months (OR 11.5 95% CI 2.2 to 61.8, p<0.01). CONCLUSION PONS are common after arthroscopic shoulder surgery performed with single injection ultrasound-guided interscalene blocks. No definitive mitigating risk factors were identified.
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Affiliation(s)
- Samantha Frost
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Daniel Rodrigues
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Ryan J J Amadeo
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Scott Wolfe
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Faylene Funk
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Celeste Ferguson
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Holly Brown
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Peter MacDonald
- Orthopedics, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Brenden Dufault
- George and Fay Yee Centre for Health Care Innovation, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Thomas Charles Mutter
- Anesthesiology, Perioperative and Pain Medicine, University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
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8
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Banks EM, Ayisi JA, Feroe AG, Alrayashi W, Yen YM, Novais EN, Hassan MM. Efficacy of regional anesthesia in hip preservation surgeries: a systematic review. J Hip Preserv Surg 2023; 10:87-103. [PMID: 37900889 PMCID: PMC10604060 DOI: 10.1093/jhps/hnad008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 02/18/2023] [Accepted: 03/27/2023] [Indexed: 10/31/2023] Open
Abstract
The purpose of this study was to review the current literature on perioperative pain management in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation. A systematic review of the literature published from January 2000 to December 2022 was performed. Selection criteria included published randomized controlled trials, prospective reviews and retrospective reviews of all human subjects undergoing hip preservation surgery. Exclusion criteria included case reports, animal studies and studies not reporting perioperative pain control protocols. Thirty-four studies included hip arthroscopy in which peripheral nerve blocks were associated with a significant reduction in pain score (P = 0.037) compared with general anesthesia alone. However, no pain control modality was associated with a significant difference in postanesthesia care unit opioid use (P = 0.127) or length of stay (P = 0.251) compared with general anesthesia alone. Falls were the most common complication reported, accounting for 37% of all complications. Five studies included periacetabular osteotomy and surgical hip dislocation in which peripheral nerve blocks were associated with an 18% reduction in pain on postoperative Day 2, a 48% reduction in cumulative opioid use on postoperative Day 2 and a 40% reduction in hospital stay. Due to the low sample size of the periacetabular osteotomy and surgical hip dislocation studies, we were unable to determine the significant difference between the means. Due to significant between-study heterogeneity, additional studies with congruent outcome measures need to be conducted to determine the efficacy of regional anesthesia in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation.
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Affiliation(s)
- Evan M Banks
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave Suite R200, Minneapolis, MN 55454, USA
| | - Jake A Ayisi
- Boston University Graduate Medical Sciences, Boston University School of Medicine, 72 East Concord St., L-317, L309, Boston, MA 02118, USA
| | - Aliya G Feroe
- Department of Orthopaedic Surgery, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
| | - Walid Alrayashi
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA 02115, USA
| | - Yi-Meng Yen
- Department of Orthopaedic Surgery, Child and Young Adult Hip Preservation Program, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Eduardo N Novais
- Department of Orthopaedic Surgery, Child and Young Adult Hip Preservation Program, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mahad M Hassan
- Department of Orthopaedic Surgery, University of Minnesota Medical School, 2450 Riverside Ave Suite R200, Minneapolis, MN 55454, USA
- Tria Orthopedic Center, 8100 Northland Dr., Bloomington, Minneapolis, MN 55431, USA
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9
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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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10
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Kaushik P, Hayaran N, Goel I. Multimodal Approach in Minimizing Transient Neurological Complications Following Single Shot Brachial Plexus Block: A Prospective Observational Study. Cureus 2023; 15:e35667. [PMID: 36875251 PMCID: PMC9978168 DOI: 10.7759/cureus.35667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
PURPOSE The aim of the study was to assess the benefit of a using multimodal approach, including injection pressure monitoring (IPM) and different techniques of nerve localization, with respect to complications following single-shot brachial plexus block (SSBPB). METHODS In this study, 238 adults (132 males and 106 females) undergoing upper-limb surgeries under peripheral nerve block (PNB) were evaluated. Of these, 198 patients were given supraclavicular block, and 40 patients received interscalene block using either ultrasound (USG) and peripheral nerve stimulation (PNS) or PNS alone. Injection pressure monitoring was used in 216 patients. RESULTS Transient neurological deficit (TND) was observed in six out of 198 patients where USG and NS were used along with IPM as opposed to 12 out of 18 patients without IPM (p<0.0001). In patients where only PNS was used, transient neurological deficit (TND) was seen in six out of 18 patients with IPM as opposed to all the patients (n=4) without IPM (p<0.02). Among the patients where injection pressure was monitored, six out of 198 patients developed TND when both USG and NS were used, compared to six out of 18 patients where only PNS was used (p<0.007). CONCLUSION Use of injection pressure monitoring along with different nerve localization techniques results in fewer transient neurological deficits.
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Affiliation(s)
- Parul Kaushik
- Anaesthesiology, Lady Hardinge Medical College, New Delhi, IND
| | - Nitin Hayaran
- Anaesthesiology, Lady Hardinge Medical College, New Delhi, IND
| | - Ishan Goel
- Radiology, Lady Hardinge Medical College, New Delhi, IND
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11
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Perioperative Management in Shoulder Arthroplasty: A Review of Current Practice. Orthop Clin North Am 2022; 53:483-490. [PMID: 36208890 DOI: 10.1016/j.ocl.2022.05.003] [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: 02/02/2023]
Abstract
Perioperative management for patients undergoing shoulder arthroplasty has evolved significantly over the years to reduce overt complications and improve patient outcomes. The groundwork for perioperative care encompasses initial patient selection and education strategies for achieving successful outcome. Multimodal pain management strategies have advanced patient care with the increased use of new regional/local anesthetics. In addition, complications resulting from blood loss and transfusions have been curtailed with the use of synthetic antifibrinolytic agents. It remains critical for shoulder arthroplasty surgeons to optimize patients during the perioperative period through various modalities to maximize functional progression, outcomes, and patient's satisfaction following shoulder arthroplasty.
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12
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Gerner P, Cozowicz C, Memtsoudis SG. Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice? Anesthesiol Clin 2022; 40:433-444. [PMID: 36049872 DOI: 10.1016/j.anclin.2022.04.001] [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: 06/15/2023]
Abstract
The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.
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Affiliation(s)
- Philipp Gerner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02143, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria.
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13
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Peripheral Nerve Injury After Upper-Extremity Surgery Performed Under Regional Anesthesia: A Systematic Review. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:201-207. [PMID: 35880155 PMCID: PMC9308165 DOI: 10.1016/j.jhsg.2022.04.011] [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: 02/10/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Peripheral nerve injury (PNI) is a known adverse event following upper-limb surgery performed under brachial plexus regional anesthesia (RA). When PNI is noted after surgery, patients and providers often have questions about which factors might have contributed to this complication. This systematic review evaluates the literature on hand and shoulder surgeries performed under ultrasound-guided, plexus RA to identify factors potentially associated with PNI, including the surgery location and block type. We hypothesized that shoulder surgery might be associated with an increased risk of PNI compared to hand surgery. Methods A systematic review of the relevant literature was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Only prospective studies on the use of ultrasound-guided, preoperative, brachial plexus RA for hand or shoulder surgery on adult patients were included. Study groups were categorized according to surgery location and block type and compared across a number of factors via univariate and multivariate analyses. Results A total of 3,037 abstracts were screened; 192 full-text articles were independently reviewed by 2 of the authors; and 53 studies were included in the systematic review analysis. Following hand surgery, PNI was reported at an average rate of 1.35% ± 3.21% across 836 subjects in 40 study groups; after shoulder surgery, the average rate was 0.50% ± 1.57% across 3,383 subjects in 15 study groups. There was no statistically significant correlation between the incidence of PNI and surgery location (P =.70) or any of the most common approaches for brachial plexus anesthesia in the multivariate analysis. Conclusions This systematic review of over 50 articles on upper-limb surgery performed under RA shows no association between the incidence of PNI and the location of surgery or type of brachial plexus block. Type of study/level of evidence Diagnostic II.
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14
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Loewenstein SN, Bamba R, Adkinson JM. Emergency Department Utilization After Administration of Peripheral Nerve Blocks for Upper Extremity Surgery. Hand (N Y) 2022; 17:624-629. [PMID: 35815366 PMCID: PMC9274871 DOI: 10.1177/1558944720963867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The purpose of this study was to determine the impact of upper extremity peripheral nerve blocks on emergency department (ED) utilization after hand and upper extremity surgery. METHODS We reviewed all outpatient upper extremity surgeries performed in a single Midwestern state between January 2009 and June 2019 using the Indiana Network for Patient Care. These encounters were used to develop a database of patient demographics, comorbidities, concurrent procedures, and postoperative ED visit utilization data. We performed univariate, bivariate, and multivariate logistic regression analyses. RESULTS Among 108 451 outpatient surgical patients, 9079 (8.4%) received blocks. Within 1 week of surgery, a greater proportion of patients who received peripheral nerve blocks (1.4%) presented to the ED than patients who did not (0.9%) (P < .001). The greatest risk was in the first 2 postoperative days (relative risk, 1.78; P < .001). Pain was the principal reason for ED utilization in the block cohort (53.6%) compared with those who did not undergo a block (35.1%) (P < .001). When controlling for comorbidities and demographics, only peripheral nerve blocks (adjusted odds ratio [OR], 1.71; P = 0.007) and preprocedural opioid use (adjusted OR, 1.43; P = .020) conferred an independently increased risk of ED utilization within the first 2 postoperative days. CONCLUSIONS Peripheral nerve blocks used for upper extremity surgery are associated with a higher risk of unplanned ED utilization, most likely related to rebound pain. Through proper patient education and pain management, we can minimize this unnecessary resource utilization.
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Affiliation(s)
| | - Ravinder Bamba
- Indiana University School of Medicine, Indianapolis, USA
| | - Joshua M. Adkinson
- Indiana University School of Medicine, Indianapolis, USA,Joshua M. Adkinson, Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, 545 Barnhill Drive, Emerson Hall (EH), Suite 232, Indianapolis, IN 46202, USA.
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15
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Mutter T, Logan GS, Neily S, Richardson S, Askin N, Monterola M, Abou-Setta A. Postoperative neurologic symptoms in the operative arm after shoulder surgery with interscalene blockade: a systematic review. Can J Anaesth 2022; 69:736-749. [PMID: 35289378 DOI: 10.1007/s12630-022-02229-w] [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: 10/14/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Postoperative neurologic symptoms (PONS) in the operative arm are important complications of shoulder surgery and interscalene blockade (ISB). This systematic review aimed to compare the risk of PONS between ISB and other techniques, and the relative safety of different agents used in ISB. METHODS Our systematic review followed Cochrane review methodology and was registered in PROSPERO. A search of MEDLINE (Ovid), EMBASE (Ovid), and CENTRAL (Wiley) from inception to June 2020 was completed. We included randomized or quasi-randomized trials of patients (> five years old) undergoing shoulder surgery with any ISB technique as an intervention, compared with any other nonregional or regional technique, or ISB of alternate composition or technique. The primary outcome was PONS (study author defined) assessed a minimum of one week after surgery. RESULTS Fifty-five studies totalling 6,236 participants (median, 69; range, 30-910) were included. Another 422 otherwise eligible trials were excluded because PONS was not reported. Heterogeneity in when PONS was assessed (from one week to one year) and the diagnostic criteria used precluded quantitative meta-analysis. The most common PONS definition, consisting of one or more of paresthesia, sensory deficit, or motor deficit, was only used in 16/55 (29%) trials. Risk of bias was low in 5/55 (9%) trials and high in 36/55 (65%) trials, further limiting any inferences. CONCLUSION These findings highlight the need for a standardized PONS outcome definition and follow-up time, along with routine, rigorous measurement of PONS in trials of ISB. STUDY REGISTRATION PROSPERO (CRD42020148496); registered 10 February 2020.
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Affiliation(s)
- Thomas Mutter
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Gabrielle S Logan
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sam Neily
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Scott Richardson
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Nicole Askin
- Neil John Maclean Health Sciences Library, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Marita Monterola
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ahmed Abou-Setta
- George and Fay Yee Centre for Healthcare Innovation, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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16
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Çağlar C, Nazlıgül AS, Akçaalan Y, Asiltürk M, Uğurlu M. Comparison of the WALANT and the PFNB techniques in the surgical treatment of unimalleolar fractures: a prospective study. Acta Orthop Belg 2022; 88:359-367. [DOI: 10.52628/88.2.8351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The popliteal fossa nerve block (PFNB) technique is one of the most popular anesthesia method in the foot and ankle surgery. The wide awake local anesthesia no tourniquet (WALANT) technique is an local anesthetic method and it has been gaining popularity in orthopedic surgery in recent years. Our aim is to compare the efficacy of the WALANT and the PFNB techniques in pain management. This prospective study included 40 patients with lateral malleolar and medial malleolar fractures. The first group was anesthetized using the WALANT technique; in the second group, PFNB was performed. All patients were evaluated for intrasurgical bleeding amounts, mean arterial pressure, surgery time and VAS scores for presurgical pain, pain during the local anesthetic injection sequence, mean intrasurgical pain, mean postsurgical pain. A total of 40 patients in both groups were successfully operated on with the WALANT and the PFNB techniques. When the two groups were compared, statistically significant differences were observed for mean intrasurgical VAS (p = 0.033), mean postsurgical VAS (p = 0.038) and intrasurgical bleeding (p = 0.006). No significant difference was found in pain scores during anesthetic injection (p = 0.529), mean arterial pressure (p = 0.583) and surgery time (p = 0.277). The PFNB technique is more successful in pain management in the treatment of the unimalleolar fractures. Intrasurgical bleeding amounts were less detected in the WALANT tech- nique. The both techniques are a reliable and suitable anesthetic method in the surgical treatment of uni- malleolar fractures.
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17
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Patel MS, Daher M, Fuller DA, Abboud JA. Incidence, Risk Factors, Prevention, and Management of Peripheral Nerve Injuries Following Shoulder Arthroplasty. Orthop Clin North Am 2022; 53:205-213. [PMID: 35365265 DOI: 10.1016/j.ocl.2021.11.006] [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: 02/02/2023]
Abstract
In this article, the authors review the incidence and causes of iatrogenic peripheral nerve injuries following shoulder arthroplasty and provide preventative measures to decrease nerve injury rate and management options. They describe common direct and indirect causes of injury such as laceration and retractor use versus arm positioning and lengthening, respectively. Preventative measures include an understanding of anatomy and high-risk locations in the shoulder, minimizing extreme ranges of arm motion and utilization of intraoperative nerve monitoring. Lastly, the authors review diagnosis and management of neurologic symptoms including how and when to use electrodiagnostic studies, nerve grafts, transfers, or muscle/tendon transfers.
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Affiliation(s)
- Manan S Patel
- Department of Orthopaedic Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Mohammad Daher
- Faculty of Medicine, Saint-Joseph University, Beirut, Lebanon
| | - David A Fuller
- Department of Orthopaedic Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut Street 5th Floor, Philadelphia, PA 19107, USA.
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18
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Abstract
Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.
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Affiliation(s)
- Patrick Meyer
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA.
| | - Kristopher Schroeder
- Department of Anesthesiology, University of Wisconsin, 600 Highland Avenue, Madison, WI 53792, USA
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19
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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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20
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Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Clin Sports Med 2022; 41:329-343. [PMID: 35300844 DOI: 10.1016/j.csm.2021.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.
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Affiliation(s)
- Danial Shams
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Kaylyn Sachse
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Nicholas Statzer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
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21
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Decrease in Residual Neurological Symptoms After Institutional Changes in Peripheral Nerve Block Use for Pediatric Knee Surgery. J Pediatr Orthop 2022; 42:e138-e142. [PMID: 34995258 DOI: 10.1097/bpo.0000000000002014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) have recently been associated with a higher incidence of complications than previously thought. We compared: (1) incidence of PNB-related residual neurological symptoms and (2) patient selection, operative practices, and anesthesia practices for pediatric knee surgery patients before and after changes in PNB administration at our institution. METHODS We compared data from pediatric patients who underwent knee surgery with PNBs from 2014 to 2016 (cohort 1; 100 patients) or 2017 to 2019 (cohort 2; 104 patients). Cohort 2 was treated after PNB administration was limited to a dedicated anesthesia block team at our institution. We used t tests and χ2 tests, with an α level of 0.05. RESULTS The incidence of PNB-related neurological complications was lower in cohort 2 (0.96%;) than cohort 1 (6%) (P=0.045). The 1 complication in cohort 2 was numbness proximal to the knee. Cohort 1 had 5 cases of numbness proximal to the knee and 1 case of neuropathic pain upon palpation of the PNB site. The proportion of female patients was greater in cohort 2 (57%) than cohort 1 (36%) (P=0.01); age and body mass index did not differ between cohorts. In cohort 2, the mean operating time was longer, and tourniquets were used more frequently (both, P<0.01). A greater proportion of PNBs were performed by fellows in cohort 2 (67%) versus cohort 1 (55%) (P=0.01). A smaller proportion of PNBs were performed by residents in cohort 2 (6.9%) versus cohort 1 (16%) (P=0.01). The most common anatomic site for PNBs was the femoral nerve (51%) in cohort 1 and the saphenous nerve (51%) in cohort 2 (P<0.01). CONCLUSIONS The incidence of PNB-related complications after pediatric knee surgery decreased significantly after institutional changes in the regulation of PNB use. This decrease may be explained by shifts toward more experienced providers administering PNBs and preference for more distal anatomic sites, suggesting ways other institutions may lower their PNB complication rates. LEVEL OF EVIDENCE Level III-retrospective prognostic study.
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22
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Kamel I, Ahmed MF, Sethi A. Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know. World J Orthop 2022; 13:11-35. [PMID: 35096534 PMCID: PMC8771411 DOI: 10.5312/wjo.v13.i1.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/20/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.
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Affiliation(s)
- Ihab Kamel
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Muhammad F Ahmed
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Anish Sethi
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
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23
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Li Q, Hu Q, Alqwbani M, Li D, Yang Z, Wang Q, Kang P. Additional nerve blocks are not superior to multiple-site infiltration analgesia in total knee arthroplasty under adductor canal block. J Orthop Surg Res 2021; 16:591. [PMID: 34645496 PMCID: PMC8513222 DOI: 10.1186/s13018-021-02769-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background Adductor canal block (ACB) with additional nerve blocks (ANBs) is reported to provide adequate analgesia and enhanced functional rehabilitation in total knee arthroplasty (TKA). The present study aims to evaluate whether ANBs are superior to multiple-site infiltration analgesia (MIA) in patients undergoing TKA under ACB. Methods We enrolled 530 patients undergoing primary TKA from 2015 to 2019 at our institution in this retrospective cohort study. Patients were divided into two groups: Group A was treated with ANBs + ACB; Group B was treated with MIA + ACB. Primary outcomes were pain scores and morphine consumption. Functional recovery was the secondary outcome. Other outcomes included satisfaction score, cost-effectiveness, adverse events, and length of hospital stay (LOS). Results Pain scores at rest and morphine consumption were slightly lower in the ANBs + ACB group than in the MIA + ACB group. No significant difference was found in functional recovery, post-operative complications or LOS between the groups. Meanwhile, the cost of analgesic intervention in the MIA + ACB group was less than that in the ANBs + ACB group. Conclusion The present study suggests that ANBs do not provide superior pain relief compared to MIA for patients undergoing TKA under ACB. Trial registration Chinese Clinical Trial Registry, ChiCTR2100043227. Registered 9 February 2021, https://www.chictr.org.cn/showproj.aspx?proj=121745.
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Affiliation(s)
- Qianhao Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qinsheng Hu
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Mohammed Alqwbani
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Donghai Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Zhouyuan Yang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qiuru Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China.
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24
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Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Go G, Hargett MJ, Lee BH, Wendel P, Brouillette M, Kim SJ, Baaklini L, Wetmore DS, Hong G, Goto R, Jivanelli B, Athanassoglou V, Argyra E, Barrington MJ, Borgeat A, De Andres J, El-Boghdadly K, Elkassabany NM, Gautier P, Gerner P, Gonzalez Della Valle A, Goytizolo E, Guo Z, Hogg R, Kehlet H, Kessler P, Kopp S, Lavand'homme P, Macfarlane A, MacLean C, Mantilla C, McIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Peng P, Pichler L, Poeran J, Poultsides L, Schwenk ES, Sites BD, Stundner O, Sun EC, Viscusi E, Votta-Velis EG, Wu CL, YaDeau J, Sharrock NE. Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature. Reg Anesth Pain Med 2021; 46:971-985. [PMID: 34433647 DOI: 10.1136/rapm-2021-102750] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Janis Bekeris
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Dace Bekere
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - George Go
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Mary J Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bradley H Lee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Pamela Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Mark Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Sang Jo Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Lila Baaklini
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Douglas S Wetmore
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Rie Goto
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bridget Jivanelli
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Vassilis Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eriphili Argyra
- Faculty of Medicine, Aretaieion University Hospital, Athens, Greece
| | - Michael John Barrington
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Alain Borgeat
- Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Jose De Andres
- Anesthesia, Critical Care and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain.,Anesthesia Unit, Surgical Specialties Department, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Nabil M Elkassabany
- Anesthesiology and Critical Care, University Of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philippe Gautier
- Department of Anesthesiology and Resuscitation, Clinique Sainte-Anne Saint-Remi, Brussels, Belgium
| | - Peter Gerner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Alejandro Gonzalez Della Valle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Zhenggang Guo
- Department of Anesthesiology, Peking Universtiy Shougang Hospital, Beijing, China
| | - Rosemary Hogg
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Henrik Kehlet
- Department of Clinical Medicine, Rigshosp, Copenhagen, Denmark
| | - Paul Kessler
- Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Sandra Kopp
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Alan Macfarlane
- School of Medicine, Dentistry & Nursing, Glasgow Royal Infirmary and Stobhill Ambulatory Hospital, Glasgow, UK
| | - Catherine MacLean
- Center for the Advancement of Value in Musculoskeletal Care, Hospital for Special Surgery, New York, New York, USA.,Center for the Advancement of Value in Musculoskeletal Care, Weill Cornell Medical College, New York, New York, USA
| | - Carlos Mantilla
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dan McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexander McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Joseph M Neal
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA.,Benaroya Research Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Parks
- Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Javad Parvizi
- Orthopedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Philip Peng
- Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lukas Pichler
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jashvant Poeran
- Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lazaros Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, New York, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian D Sites
- Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
| | - Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria.,Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Eugene Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Effrossyni Gina Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Jacques YaDeau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Nigel E Sharrock
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
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25
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Oliver-Fornies P, Ortega Lahuerta JP, Gomez Gomez R, Gonzalo Pellicer I, Herranz Andres P, Sancho-Saldana A. Postoperative neurological complications after brachial plexus block: a retrospective study conducted at a teaching hospital. J Anesth 2021; 35:844-853. [PMID: 34432155 DOI: 10.1007/s00540-021-02989-7] [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: 05/04/2021] [Accepted: 08/14/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Serious complications after ultrasound-guided regional anaesthesia can be devastating for the patient. The pathogenesis of postoperative neurological complications (PONC) is multifactorial and includes mechanical, vascular and chemical factors besides the nerve puncture itself. The primary aim of this study was to assess the incidence of PONC after brachial plexus block (BPB). METHODS This is an observational retrospective single-centre study conducted at the regional anaesthesia unit of a teaching hospital. All BPBs performed from January 2011 to November 2019 were included. The outcomes analysed were the incidence, aetiology and diagnosis of PONCs and the incidence of other postoperative complications such as local anaesthetic systemic toxicity (LAST), pneumothorax, wrong-side block, etc. The performance of trainees and experienced anaesthesiologists was compared across all the outcomes. RESULTS From a total of 5340 BPBs included, 15 cases developed PONC, yielding a rate of 2.81:1000 (95% CI 1.70-4.63). Thirteen patients underwent neurophysiological exams which confirmed nine neuropathies. The rate of PONCs for supervised trainees was 1.80:1000 (95% CI 0.701-4.62), not statistically different from that of experienced anaesthesiologists (p = 0.241). Three cases were considered to present with a PONC probably related to BPB [0.562:1,00 (95% CI 0.191-1.65)]. The incidence of long-term PONCs was 1.12:1000 (95% CI 0.515-2.45). Such complications proved irreversible in 2 cases. The incidences of LAST, pneumothorax and other complications observed were 0.749:1000 (95% CI 0.291-1.92), 0.187:1000 (95% CI 0.0331-1.06) and 4.31:1000 (95% CI 2.87-6.46), respectively. CONCLUSIONS This survey suggests that complications after ultrasound-guided BPB, including blocks performed by trainees, are uncommon. TRIAL REGISTRATION Clinicaltrials.gov ID: NCT04451642.
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Affiliation(s)
- Pablo Oliver-Fornies
- Department of Anesthesiology, Critical Care and Pain Medicine, Lozano Blesa University Clinical Hospital, Avda. San Juan Bosco, 15, 50009, Zaragoza, Spain.
- Investigator of GIIS083, Aragon Institute for Health Research (IISAragon), Zaragoza, Spain.
- Morphological Madrid Research Center (MoMaRC), Ultradissection Spain EchoTraining School, Madrid, Spain.
| | - Juan Pablo Ortega Lahuerta
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, Spain
| | - Roberto Gomez Gomez
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, Spain
| | - Inmaculada Gonzalo Pellicer
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, Spain
| | - Pilar Herranz Andres
- Division of Regional Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Miguel Servet University Hospital, Zaragoza, Spain
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26
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First case of mechanical compression by methylprednisolone crystals following transforaminal lumbar nerve root block for left sciatic pain leading to hyperesthesia and progressive weakness: A case report. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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27
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Phan KH, Anderson JG, Bohay DR. Complications Associated with Peripheral Nerve Blocks. Orthop Clin North Am 2021; 52:279-290. [PMID: 34053573 DOI: 10.1016/j.ocl.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.
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Affiliation(s)
- Kevin H Phan
- Orthopaedic Associates of Michigan, 1111 Leffingwell Avenue Northeast, Grand Rapids, MI 49525, USA.
| | - John G Anderson
- Orthopaedic Associates of Michigan, 1111 Leffingwell Avenue Northeast, Grand Rapids, MI 49525, USA
| | - Donald R Bohay
- Orthopaedic Associates of Michigan, 1111 Leffingwell Avenue Northeast, Grand Rapids, MI 49525, USA
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28
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Vajapey SP, Contreras ES, Cvetanovich GL, Neviaser AS. Neurologic complications in primary anatomic and reverse total shoulder arthroplasty: A review. J Clin Orthop Trauma 2021; 20:101475. [PMID: 34178600 PMCID: PMC8213914 DOI: 10.1016/j.jcot.2021.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 06/01/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Abstract
Neurologic injury during shoulder replacement is one of the less common complications of the procedure, however the clinical implications can be significant. The purpose of this paper is to review the current literature on neurologic complications in various types of shoulder replacement and provide recommendations regarding avoidance, evaluation, and management of these complications.
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Affiliation(s)
- Sravya P. Vajapey
- Corresponding author. Department of Orthopaedics, The Ohio State University Wexner Medical Center, 241 W. 11th Avenue, Suite 6081, Columbus, Ohio, 43201.
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29
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Ultrasound-Guided Peripheral Nerve Blocks Performed by Orthopedic Surgeons: A Retrospective, Multicenter Study in Akita Prefecture, Japan. Adv Orthop 2021; 2021:5580591. [PMID: 33777455 PMCID: PMC7969096 DOI: 10.1155/2021/5580591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/18/2022] Open
Abstract
The shortage of doctors is a societal problem, especially in rural areas such as Akita Prefecture, Japan. Therefore, it is not unusual in Akita for orthopedic surgeons to perform upper and lower limb surgeries under ultrasound-guided peripheral nerve blocks managed by the operators themselves. Multicenter studies of ultrasound-guided peripheral nerve blocks performed by orthopedic surgeons have not been reported. The purpose of this study was to clarify the safety and reliability of ultrasound-guided peripheral nerve blocks performed by orthopedic surgeons in Akita. A total of 1,674 upper extremity surgery cases operated under ultrasound-guided peripheral nerve blocks at 8 hospitals in Akita prefecture from April 2016 to April 2018 were investigated retrospectively. These blocks were performed by a total of 37 orthopedic surgeons, including senior surgeons and residents. In 321 of the 1,674 cases (19%), local anesthetics were added to the surgical field. Two cases with special factors were converted to general anesthesia. There were 2 cases of complications associated with the nerve block, but they were all transient and recovered promptly. The block site and the hospital where the block was performed showed a significant relationship with the addition of local anesthetics to the surgical site (P < 0.001). Surgery time, age at surgery, and surgical site showed no significant relationships with the addition of local anesthetics. The volume of the anesthetic used for the nerve block showed a significant inverse relationship with the addition of local anesthetics (P=0.040). Many orthopedic surgeons in Akita prefecture began to perform ultrasound-guided peripheral nerve blocks, which had a reliable anesthesia effect with no noticeable complications, whether performed by residents or senior orthopedic surgeons, and this is a useful anesthetic technique for orthopedic surgeons.
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30
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Abdelghany MS, Ahmed SA, Afandy ME. Superficial cervical plexus block alone or combined with interscalene brachial plexus block in surgery for clavicle fractures: a randomized clinical trial. Minerva Anestesiol 2021; 87:523-532. [PMID: 33591139 DOI: 10.23736/s0375-9393.21.14865-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The regional anesthesia technique which is suitable for fracture clavicle is a matter of debate. This study aimed to compare the use of superficial cervical plexus alone or in combination with interscalene block in patients undergoing internal fixation of fractured clavicle. METHODS Seventy patients undergoing internal fixation of fractured clavicle were enrolled in this clinical trial and randomly distributed into two groups; superficial cervical plexus block (CPB) group and combined superficial cervical plexus block and interscalene block (ISB) group. The regional anesthesia techniques were performed before induction of general anesthesia. The intraoperative fentanyl and isoflurane consumption, the postoperative morphine consumption, the postoperative pain score, the duration of postoperative analgesia, the incidence of perioperative complications, and the patient's satisfaction were recorded. RESULTS In comparison to the use of combined CPB and ISB, the use of CPB alone did not significantly change the postoperative morphine consumption (8.4±3.3 mg versus 7.3±3.2 mg [P=0.2]), the time to the first request of postoperative analgesia (396.7 193.4 min versus 407.7±150.0 min [P=0.8]), or the postoperative pain score (P˃0.05). Also, it did not change the intraoperative fentanyl consumption (P=0.3), the intraoperative isoflurane consumption (P=0.7), the incidence of perioperative complication, or the degree of patient's satisfaction (P˃0.05). It significantly decreased the incidence of phrenic nerve palsy (P=0.03). CONCLUSIONS In patients undergoing internal fixation of clavicular fracture, the perioperative analgesic effect of SCP alone is equally effective to its use in combination with ISB.
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Affiliation(s)
- Mohamed S Abdelghany
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sameh A Ahmed
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt -
| | - Mohamed E Afandy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
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31
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Noori N, Anand K, Pfeffer G, Thordarson D. Dexamethasone Addition to Popliteal Nerve Blocks: Effects on Duration of Analgesia and Incidence of Postoperative Nerve Complication. Foot Ankle Spec 2021; 14:39-45. [PMID: 31904292 DOI: 10.1177/1938640019897224] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background. The purpose of this prospective, double-blinded randomized control pilot study was to evaluate the effect of adjunctive dexamethasone on analgesia duration and the incidence of postoperative neuropathic complication. Peripheral nerve blocks are an effective adjunct to decrease postoperative pain in foot and ankle surgery, and any possible modalities to augment their efficacy is of clinical utility. Methods. Patients were randomly assigned to a control group (n = 25) receiving nerve blocks of bupivacaine and epinephrine or an experimental group (n = 24) with an adjunctive 8 mg dexamethasone. The patients, surgeons, and anesthesiologists were all blinded to allocation. Patients had a minimum 1 year postoperative follow-up. Results. Forty-nine patients completed the protocol. There was no statistically significant difference in analgesia duration (P = .38) or postoperative neuropathic complication incidence (P = .67) between the 2 groups. Conclusions. The addition of dexamethasone to popliteal nerve blocks does not appear to affect analgesia duration or incidence of postoperative neuropathic complications. However, our study was underpowered, and we recommend a larger scale prospective study for validation.Levels of Evidence: Level II: Prospective, randomized control pilot study.
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Affiliation(s)
| | - Kapil Anand
- Cedars Sinai Medical Center, Los Angeles, California
| | - Glenn Pfeffer
- Cedars Sinai Medical Center, Los Angeles, California
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32
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McCombe K, Bogod D. Regional anaesthesia: risk, consent and complications. Anaesthesia 2021; 76 Suppl 1:18-26. [PMID: 33426664 DOI: 10.1111/anae.15246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2020] [Indexed: 11/30/2022]
Abstract
The risks of regional anaesthesia relate primarily to the technical nature of the procedure, chief among them being neurological. While rare, the direct relationship between nerve damage and the procedure itself means that patients need to be aware of this complication when consent is sought. In order to give valid consent, a patient must be informed. The extent of the information required has been defined by a 2015 legal ruling which established that the standard is the expectation of a reasonable patient, rather than the information deemed consequential by a reasonable doctor. The implications of this for clinicians are profound, and mean that the process of consent must, for example, include alternatives to the proposed treatment. Additionally, patients must have capacity and give their consent without coercion. Effective communication of risk can be challenging. As well as the barriers to comprehension that can result from language, literacy and numeracy, clinicians need to be aware of their own biases, often in favour of a regional anaesthetic approach. Patients also have biases, and doctors must be aware of these in order to best target their provision of information. Careful use of language and employing adjuncts such as information leaflets and visual aids can help to maximise the individual's autonomy. Particular care must be taken in special situations such as where patients have capacity issues or time is limited by the emergency nature of the intervention.
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Affiliation(s)
- K McCombe
- Department of Anaesthesia, Mediclinic City Hospital, Dubai Healthcare City, Dubai, UAE
| | - D Bogod
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, London, UK
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33
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Ooi G, Schwenk ES, Torjman MC, Berg K. A Randomized Trial of Manual Phone Calls Versus Automated Text Messages for Peripheral Nerve Block Follow-Ups. J Med Syst 2021; 45:7. [PMID: 33404791 DOI: 10.1007/s10916-020-01699-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/10/2020] [Indexed: 11/29/2022]
Abstract
Mobile phone applications (apps) have been used for patient follow-up in the postoperative period, specifically to assess for complications and patient satisfaction. Few studies have evaluated their use in regional anesthesia. The objective of this study was to compare follow-up response rates using manual phone calls versus an automated patient outreach (APO) app for peripheral nerve block patients. We hypothesized that the response rate would be higher in the APO group. A mobile app, "JeffAnesthesia," was developed, which sends notifications to patients to answer survey questions in the app. We randomly assigned patients who received peripheral nerve blocks for postoperative pain to either a manual phone call or an APO app group, with follow-up in each category occurring between postoperative days (POD) 14-21 and 90-100. In total, 60 patients were assigned to the phone call group and 60 patients to the APO app group. Between POD 14-21, 9 (15%) patients were reached in the manual phone call arm, and 16 (26.7%) patients were reached in the APO arm (p = 0.117). At POD 90-100, follow-up was successful with 5 (8.2%) in the manual phone call group vs. 3 (5.0%) patients in the APO app group (p = 0.300). Overall response rate was poor, with comparable response rates between groups. The APO method may reduce time spent by anesthesia staff on follow-up calls, but our data do not suggest this method improves response rates significantly. Further studies are needed to better understand the reasons for the poor response rate and strategies for improvement.
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Affiliation(s)
- Gavyn Ooi
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Marc C Torjman
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kent Berg
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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34
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Gagne OJ, Cheema A, Abuhantash M, Ree R, Penner M, Wing K, Younger A, Salat P, Veljkovic A. Effect of Dexamethasone in Peripheral Nerve Blocks on Recovery of Nerve Function. Foot Ankle Int 2021; 42:23-30. [PMID: 32964737 DOI: 10.1177/1071100720952075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) have revolutionized distal extremity surgery reducing pain and improving hospital efficiency. Perineural dexamethasone has been administered with PNBs to prolong their effects, although the safety of dexamethasone has not been established in the literature. This study aimed to determine if the addition of dexamethasone affected the postoperative neurological sensory status for foot and ankle surgeries and the recovery of nerve injuries. We hypothesized that the rate of persistent nerve injury would be higher in the dexamethasone group. METHODS This is a retrospective observational cohort study of prospectively collected data of all patients from a single foot and ankle surgeon's practice. Perineural dexamethasone was routinely used as an adjunct by the regional anesthesia group until a clinical trend of increased paresthesia was found on short-term follow-up, which led to the discontinuation of its use. In this study, the cohort that received dexamethasone with ropivacaine was compared with the cohort that received ropivacaine alone. The primary outcome was a separate sensory nerve status sheet that was completed for every distal nerve territory for every patient at their follow-up visits at 2 weeks, 6 weeks, 3 months, and 6 months. Univariate analysis and a logistic regression model were used to determine the association between dexamethasone and delayed nerve recovery. A total of 250 patients were included in the study, with 117 patients in the dexamethasone group and 133 in the ropivacaine-only group. RESULTS The rates of nerve injuries were not different between the groups (72 [62%] in the dexamethasone group vs 79 [59%] in the ropivacaine-only group). However, nerve injury symptoms were more likely to persist and not fully recover in the dexamethasone group (n = 47, 65%) compared with the ropivacaine-only group (n = 32, 41%) (OR, 2.12; P = .006). CONCLUSION Perineural dexamethasone added to PNBs may be associated with delayed nerve recovery after foot and ankle surgery. It may be prudent to avoid its use until its full safety profile is established in larger prospective trials. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Oliver J Gagne
- Department of Orthopedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amar Cheema
- Department of Orthopedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Monther Abuhantash
- Department of Orthopedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ron Ree
- Department of Anesthesiology, Perioperative Medicine, and Pain Management, The Heart Centre, Providence Health Care, Vancouver, British Columbia, Canada
| | - Murray Penner
- Department of Orthopedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin Wing
- Department of Orthopedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alastair Younger
- Department of Orthopedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Salat
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Andrea Veljkovic
- Department of Orthopedics, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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35
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Peripheral Nerve Block Versus Spinal Anesthesia for Total Knee Replacement in Elderly Patients. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2020. [DOI: 10.2478/sjecr-2020-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: Spinal anesthesia and peripheral nerve block anesthesia are used in total knee replacement. The main aim of the study was to examine whether peripheral nerve block anesthesia would provide a more stable hemodynamic profile and analgesic effect in elderly patients undergoing total knee replacement, as compared to spinal anesthesia.
Methods: This is a single-center case-control trial, with patients from our prospectively followed registry. The patients were divided into two groups, those with peripheral nerve block anesthesia and spinal anesthesia. Propensity score analysis was performed in 1:1 ratio. The primary outcome was analgesia with total analgesic effect and the secondary outcome was intraoperative hemodynamic status.
Results: The patients in peripheral nerve block anesthesia group had a longer length of analgesia (606.19±219.35 vs 359.48±106.82, P<0.01) and pain scores during 24h and 48h after the surgery were lower in the same group of patients (3.21±1.74 vs 5.02±2.23, P=0.037; 3.03±1.57 vs 5.67±2.51, P=0.028). Spinal anesthesia group had a larger number of patients with significant hypotension (3.84% vs 15.38%, P=0.01), as well as a larger number of patients who received vasopressors (0% vs 9.61%, P<0.01).
Conclusion: Both anesthesia methods demonstrated sufficient analgesic efficacy in total knee replacement, although there was less pain severity and longer analgesic effect of peripheral nerve block anesthesia in patients who were 60 years old or older. Spinal anesthesia showed a significantly higher degree of hypotension than in those patients receivingperipheral nerve block anesthesia.
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36
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Lauf JA, Huggins P, Long J, Al-Issa M, Byrne B, Large BP, Whitehead B, Cheney NA, Law TD. Regional Nerve Block Complication Analysis Following Peripheral Nerve Block During Foot and Ankle Surgical Procedures. Cureus 2020; 12:e9434. [PMID: 32864258 PMCID: PMC7450881 DOI: 10.7759/cureus.9434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Foot and ankle surgeries are frequently accompanied by a peripheral nerve block in order to reduce postoperative pain. Higher than expected complication rates with peripheral nerve blocks have led to increased concern among surgeons and patients. To our knowledge, no study conducted by the treating surgeon has identified risk factors that may predispose a patient to complications. Our goal was to attempt to identify those risk factors. Methods We reviewed patient charts of those who underwent an orthopedic foot and ankle procedure between 2013 and 2018, as performed by the senior author. This yielded 992 procedures performed across four surgical locations. Of these procedures, 137 procedures were removed because no block was used. The remaining cases were analyzed for nerve complications, defined as sensory or motor deficits along the distribution of a nerve. The patients were divided into those with and without complications and were evaluated for differences. Statistical analysis was performed using the SAS® software (SAS Institute Inc., Cary, North Carolina, USA). Results The overall short-term complication rate was 10.1% and the long-term complication rate was 4.3%, with a total of 855 blocks given. Electromyographies (EMGs) were performed on 24.4% of the patients with a complication. Of the EMGs, 95.2% confirmed nerve complications in the distribution of the blocked nerve. The significant factors associated with complications were age, BMI, location, and smoking status. A regression analysis was performed to determine the odds ratio for individual factors. Those with significantly higher odds ratio were between 40 and 65 years of age, had normal or underweight BMI, underwent surgery at an outpatient surgery center, and were current smokers. Conclusions Our study suggests that there are significant epidemiological factors in predicting postoperative complications related to a peripheral nerve block. The study also shows a similar short-term complication rate but a higher long-term complication rate than other studies. This data are important because it allows for an informed decision to be made between a surgeon, anesthesiologist, and the patient regarding the safety and necessity of delivering a preoperative peripheral nerve block based on patient risk factors.
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Affiliation(s)
- Jason A Lauf
- Orthopedic Surgery, Ohio University Heritage College of Osteopathic Medicine, Dublin, USA
| | - Pearson Huggins
- Orthopedic Surgery, Ohio University Heritage College of Osteopathic Medicine, Dublin, USA
| | - Joseph Long
- Medicine, Ohio State University College of Medicine, Columbus, USA
| | - Mohammed Al-Issa
- Orthopedic Surgery, Ohio University Heritage College of Osteopathic Medicine, Dublin, USA
| | - Brian Byrne
- Emergency Medicine, Mercy St. Elizabeth Boardman Hospital, Youngstown, USA
| | - Bryan P Large
- Anesthesiology, OhioHealth Doctors Hospital, Columbus, USA
| | - Brent Whitehead
- Orthopedic Surgery, Ohio University Heritage College of Osteopathic Medicine, Dublin, USA
| | | | - Timothy D Law
- Family Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, USA
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Lam KK, Soneji N, Katzberg H, Xu L, Chin KJ, Prasad A, Chan V, Niazi A, Perlas A. Incidence and etiology of postoperative neurological symptoms after peripheral nerve block: a retrospective cohort study. Reg Anesth Pain Med 2020; 45:495-504. [DOI: 10.1136/rapm-2020-101407] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/27/2020] [Accepted: 04/08/2020] [Indexed: 11/04/2022]
Abstract
BackgroundNerve injury from peripheral nerve block (PNB) is an uncommon but potentially serious complication. We present a retrospective cohort study to evaluate the incidence and etiology of new postoperative neurological symptoms after surgery and regional anesthesia.MethodsWe performed a retrospective cohort study of all PNBs performed on elective orthopedic and plastic surgical patients over 6 years (2011–2017). We collected patient and surgical data, results of neurophysiological and imaging tests, neurology and chronic pain consultations, etiology and outcome for patients with prolonged neurological symptoms (lasting ≥10 days).ResultsA total of 26 251 PNBs were performed in 19 219 patients during the study period. Transient postoperative neurological symptoms (<10 days) were reported by 14.4% (95% CI 13.1% to 15.7%) of patients who were reached by telephone follow-up. Prolonged postoperative neurological symptoms (≥10 days) were identified and investigated in 20 cases (1:1000, 95% CI 0.6 to 1.6). Of these 20 cases, three (0.2:1000, 95% CI 0.04 to 0.5) were deemed to be block related, seven related to surgical causes, three due to musculoskeletal causes or pain syndromes, one was suspected of having an inflammatory etiology and six remained of undetermined etiology. Of those who completed follow-up, 56% had full recovery of their symptoms with the remaining having partial recovery.ConclusionThis retrospective review of 19 219 patients receiving PNBs for anesthesia or analgesia suggests that determining the etiology and causative factors of postoperative neurological symptoms is a complex, often challenging process that requires a multidisciplinary approach. We suggest a classification of cases based on the etiology. A most likely cause was identified in 70% of cases. This type of classification system can help broaden the differential diagnosis, help consider non-regional anesthesia and non-surgical causes and may be useful for clinical and research purposes.
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Jastifer J, Manson W, Smith B, Cooper MT, Brigido SA. Perioperative Management of Foot and Ankle Surgical Patients. Foot Ankle Spec 2019; 12:458-460. [PMID: 31604397 DOI: 10.1177/1938640019880685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bailey TL, Stephens AR, Adeyemi TF, Xu Y, Presson AP, Aoki SK, Maak TG. Traction Time, Force and Postoperative Nerve Block Significantly Influence the Development and Duration of Neuropathy Following Hip Arthroscopy. Arthroscopy 2019; 35:2825-2831. [PMID: 31604499 DOI: 10.1016/j.arthro.2019.03.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/05/2019] [Accepted: 03/23/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To (1) evaluate the individual and combined effects of traction time and traction force on postoperative neuropathy following hip arthroscopy, (2) determine if perioperative fascia iliaca block has an effect on the risk of this neuropathy, and (3) identify if the these items had a significant association with the presence, location, and/or duration of postoperative numbness. METHODS Between February 2015 and December 2016, a consecutive cohort of hip arthroscopy patients was prospectively enrolled. Traction time, force, and postoperative nerve block administration were recorded. The location and duration of numbness were assessed at postoperative clinic visits. Numbness location was classified into regions: 1, groin; 2, lateral thigh; 3, medial thigh; 4, dorsal foot; and 5,preoperative thigh or radiculopathic numbness. RESULTS A total of 156 primary hip arthroscopy patients were analyzed, 99 (63%) women and 57 (37%) men. Mean traction time was 46.5 ± 20.3 minutes. Seventy-four patients (47%) reported numbness with an average duration of 157.5 ± 116.2 days. Postoperative fascia iliaca nerve block was a significant predictor of medial thigh numbness (odds ratio, 3.36; 95% confidence interval, 1.46-7.76; P = .04). Neither traction time nor force were associated with generalized numbness (P = .85 and P = .40, respectively). However, among those who experienced numbness, traction time and force were greater in patients with combined groin and lateral thigh numbness compared with those with isolated lateral thigh or medial thigh numbness (P = .001 and P = .005, respectively). CONCLUSIONS Postoperative neuropathy is a well-documented complication following hip arthroscopy. Concomitant pudendal and lateral femoral cutaneous nerve palsy may be related to increased traction force and time, even in the setting of low intraoperative traction time (<1 hour). Isolated medial thigh numbness is significantly associated with postoperative fascia iliaca blockade. LEVEL OF EVIDENCE IV, case series.
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Affiliation(s)
- Travis L Bailey
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | | | - Temitope F Adeyemi
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Yizhe Xu
- Division of Public Health, University of Utah, Salt Lake City, Utah, U.S.A.; Department of Pediatric Research Enterprise, University of Utah, Salt Lake City, Utah, U.S.A
| | - Angela P Presson
- Division of Public Health, University of Utah, Salt Lake City, Utah, U.S.A.; Department of Pediatric Research Enterprise, University of Utah, Salt Lake City, Utah, U.S.A
| | - Stephen K Aoki
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A
| | - Travis G Maak
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah, U.S.A..
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Hauritz RW, Hannig KE, Balocco AL, Peeters G, Hadzic A, Børglum J, Bendtsen TF. Peripheral nerve catheters: A critical review of the efficacy. Best Pract Res Clin Anaesthesiol 2019; 33:325-339. [PMID: 31785718 DOI: 10.1016/j.bpa.2019.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.
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Affiliation(s)
- Rasmus W Hauritz
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Kjartan E Hannig
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Angela Lucia Balocco
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Gwendolyne Peeters
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Admir Hadzic
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Jens Børglum
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Denmark
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Retter S, Szerb J, Kwofie K, Colp P, Sandeski R, Uppal V. Incidence of sub-perineural injection using a targeted intracluster supraclavicular ultrasound-guided approach in cadavers. Br J Anaesth 2019; 122:776-781. [DOI: 10.1016/j.bja.2019.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/15/2018] [Accepted: 01/06/2019] [Indexed: 12/18/2022] Open
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Angers M, Belzile ÉL, Vachon J, Beauchamp-Chalifour P, Pelet S. Negative Influence of femoral nerve block on quadriceps strength recovery following total knee replacement: A prospective randomized trial. Orthop Traumatol Surg Res 2019; 105:633-637. [PMID: 30928275 DOI: 10.1016/j.otsr.2019.03.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/27/2019] [Accepted: 03/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Postoperative pain is a major concern after total knee replacement (TKR) and can be relieved using different methods, including femoral nerve block (FNB). Quadriceps strength recovery (QSR) is the most sensitive objective indicator of functional recovery after TKR. The goal of this study was to compare the QSR following TKR between three approaches to analgesia. HYPOTHESIS FNB delays QSR at short- and mid-term follow-up. METHODS In this prospective randomized trial, with single-blind assessment involving 135 patients admitted for TKR in an academic center, the three following groups included were: (A) Continuous FNB 48h+PCA, (B) Single-shot FNB+PCA and (C) PCA alone. No intra-articular local anesthesia was carried out for all patients. Groups were comparable for demographic and surgical data. FNB was carried out and controlled (electric stimulation) by an expert anesthesiologist prior to the surgery. Follow-up was standardized in all groups using blinded assessors. Quadriceps strength was measured using a certified dynamometer at 6 weeks, 6 months and 12 months. Multivariate analysis (Kruskal-Wallis, Mann-Whitney) was used for the main outcome. RESULTS A total of 135 patients were included. Two patients in group B were excluded due to a direct fall in the first postoperative week with extensor mechanism rupture and peri-prosthetic femoral fracture. QSR was significantly decreased in patients with FNB at all times (mean±SD): 6 weeks (A: 51.3±23.3%; B: 62.2±21.9%;C: 77.4±19.5%; p<0.01), 6 months (A: 65.4±22.9%; B: 82.1±24.2%;C: 95.7±20.7%; p<0.01) and 12 months (A: 87.8±17.6%; B: 97.8±26.9%;C: 104.8±25.2%; p=0.02). No significant difference between continuous or single-shot FNB was observed. CONCLUSION FNB has a negative influence on QSR at short- and mid-term follow-up. FNB should not yet be recommended for analgesia after TKR. LEVEL EVIDENCE I High-quality randomized controlled trial with statistically significant difference.
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Affiliation(s)
- Michèle Angers
- Department of Orthopedic Surgery, hôpital Saint-François d'Assises, CHU de Québec, 10, rue de l'Espinay Québec, G1L 3L5 Québec, Canada
| | - Étienne L Belzile
- Department of Orthopaedic Surgery, hôpital Enfant-Jésus, CHU de Québec, 1401, 18(e) rue Québec, G1J 1Z4 Québec, Canada; Centre de recherche FRQS du CHUQ de Québec, hôpital Enfant-Jésus, 1401, 18(e) rue Québec, G1J 1Z4 Québec, Canada
| | - Jessica Vachon
- Department of Orthopaedic Surgery, hôpital Enfant-Jésus, CHU de Québec, 1401, 18(e) rue Québec, G1J 1Z4 Québec, Canada
| | - Philippe Beauchamp-Chalifour
- Department of Orthopaedic Surgery, hôpital Enfant-Jésus, CHU de Québec, 1401, 18(e) rue Québec, G1J 1Z4 Québec, Canada; Centre de recherche FRQS du CHUQ de Québec, hôpital Enfant-Jésus, 1401, 18(e) rue Québec, G1J 1Z4 Québec, Canada
| | - Stéphane Pelet
- Department of Orthopaedic Surgery, hôpital Enfant-Jésus, CHU de Québec, 1401, 18(e) rue Québec, G1J 1Z4 Québec, Canada; Centre de recherche FRQS du CHUQ de Québec, hôpital Enfant-Jésus, 1401, 18(e) rue Québec, G1J 1Z4 Québec, Canada.
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Gadsden J, Orebaugh S. Targeted intracluster supraclavicular brachial plexus block: too close for comfort. Br J Anaesth 2019; 122:713-715. [DOI: 10.1016/j.bja.2019.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/17/2022] Open
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Hasan SS, Rolf RH, Sympson AN, Eten K, Elsass TR. Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial. J Am Acad Orthop Surg Glob Res Rev 2019; 3:e014. [PMID: 31588420 PMCID: PMC6738550 DOI: 10.5435/jaaosglobal-d-19-00014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Continuous catheter infusion of local anesthetics extends the efficacy of regional anesthesia after prosthetic shoulder surgery. Our purpose was to compare continuous interscalene block (CIB) with single-shot interscalene block, and the hypothesis was these would offer similar safety and efficacy in patients with prosthetic shoulder arthroplasty. METHODS Seventy-six patients were randomized to ropivacaine single-shot interscalene block or CIB after prosthetic shoulder arthroplasty. Postoperative pain scores and opioid use, hospital length of stay (LOS), adverse events, and catheter tip withdrawal were recorded. RESULTS Pain scores (P = 0.010) and opioid use (P = 0.003) on the first postoperative day were lower in the CIB group, but there was no difference in LOS. Adverse events were more common in the CIB group and 10% of catheters pulled out prematurely. CONCLUSION Opioid use and pain levels during first postoperative day are clinically less after CIB, but this did not shorten LOS. The benefits of CIB may not justify the higher cost and complication rate.
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Affiliation(s)
- Samer S Hasan
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Robert H Rolf
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Alexandra N Sympson
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Kathryn Eten
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Thomas R Elsass
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
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Regional Nerve Blocks-Best Practice Strategies for Reduction in Complications and Comprehensive Review. Curr Pain Headache Rep 2019; 23:43. [PMID: 31123919 DOI: 10.1007/s11916-019-0782-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Understanding the etiologies of the complications associated with regional anesthesia and implementing methods to reduce their occurrence provides an opportunity to foster safer practices in the delivery of regional anesthesia. RECENT FINDINGS Neurologic injuries following peripheral nerve block (PNB) and neuraxial blocks are rare, with most being transient. However, long-lasting and devastating sequelae can occur with regional anesthesia. Risk factors for neurologic injury following PNB include type of block, injection in the presence of deep sedation or general anesthesia, presence of existing neuropathy, mechanical trauma from the needle, pressure injury, intraneural injection, neuronal ischemia, iatrogenic injury related to surgery, and local anesthetic neurotoxicity. The present investigation discusses regional blocks, complications of regional blocks, risk factors, site-specific limitations, specific complications and how to prevent them from happening, avoiding complications in regional anesthesia, and the future of regional anesthesia.
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Physiotherapists' use of suprascapular nerve blocks: an online survey. Physiotherapy 2019; 105:461-468. [PMID: 30745062 DOI: 10.1016/j.physio.2019.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 01/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is some evidence to support the use of suprascapular nerve blocks (SSNBs) to manage shoulder pain. Although many patients with shoulder pain are referred to physiotherapy, there are no data describing whether physiotherapists currently use SSNBs for these patients. OBJECTIVE To explore if physiotherapists who manage musculoskeletal shoulder pain are using SSNBs and identify, of those who responded to an online questionnaire, how commonplace this practice is in the United Kingdom (UK) DESIGN: An online, cross-sectional, questionnaire survey was developed for physiotherapists involved in the management of patients with shoulder pain. METHODS A snowball sampling method was used to invite physiotherapists to complete the online survey, using email, research advertisements in a professional magazine and via social media. The questionnaire captured respondents' demographic and professional practice characteristics, their knowledge and use of SSNBs and their views and experiences regarding SSNBs as a treatment for shoulder pain. RESULTS In total, there were 529 responders to the survey. Of these, 492 were eligible and formed the sample for analyses. The majority of responders (290/474; 61%) were from the UK. Of these, the majority (259/282; 92%) were familiar with SSNBs as a method of treatment for shoulder pain, although few (9/149; 6%) reported regularly using SSNBs in their clinical practice. Only 8 of 287 responders from the UK (3%) reported delivering SSNBs to patients. CONCLUSIONS This survey provides preliminary evidence that the use and delivery of SSNBs by UK physiotherapists is uncommon. Future research is required to investigate the potential value of physiotherapists using this treatment option for their patients with shoulder pain.
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Kang C, Lee GS, Kim SB, Won YG, Lee JK, Jung YS, Cho HJ. Comparison of postoperative pain control methods after bony surgery in the foot and ankle. Foot Ankle Surg 2018; 24:521-524. [PMID: 29409271 DOI: 10.1016/j.fas.2017.06.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 06/14/2017] [Accepted: 06/16/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND We performed a prospective study to evaluate and compare the effectiveness of postoperative pain control methods after bone surgery in the foot and ankle. METHODS Among the patients who underwent foot and ankle surgery from June 2014 to September 2015 with an ultrasound-guided nerve block, 84 patients who fully completed a postoperative pain survey were enrolled. An opioid patch (fentanyl patch, 25mg) was applied in group A (30 patients). Diluted anesthetic (0.2% ropivacaine, 30ml) was injected into the sciatic nerve once, about 12h after the preoperative nerve block, in group B (27 patients). Periodic intramuscular injection of an analgesic (ketorolac [Tarasyn], 30mg) was performed in group C (27 patients). The visual analogue scale (VAS) pain scores at 6, 12, 18, 24, and 48h after surgery were checked, and the complications of all methods were monitored. RESULTS The mean VAS pain score was lower in group B, with a statistically significant difference (P<.05) between groups A, B, and C at 12 and 18h after surgery. Four patients in group A experienced nausea and vomiting; however, no other patients complained of any complications or adverse effects. CONCLUSION The ultrasound-guided injection of a diluted anesthetic into the sciatic nerve seemed to be the most useful method for controlling pain in the acute phase after bone surgery in the foot and ankle. The injection of the diluted anesthetic once on the evening of the day of surgery resulted in less postoperative pain in the patients. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Chan Kang
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Republic of Korea
| | - Gi-Soo Lee
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea; Konyang University Myunggok Medical Research Institute, Daejeon, Republic of Korea.
| | - Sang-Bum Kim
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - You-Gun Won
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Jeong-Kil Lee
- Department of Orthopaedic Surgery, Chungnam National University School of Medicine, Republic of Korea
| | - You-Sun Jung
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
| | - Hyung-June Cho
- Department of Orthopedic Surgery, Konyang University College of Medicine, Daejeon, Republic of Korea
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Chung AS, Spangehl MJ. Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty. J Arthroplasty 2018; 33:3383-3388. [PMID: 30197218 DOI: 10.1016/j.arth.2018.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 02/01/2023] Open
Abstract
In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.
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Affiliation(s)
- Andrew S Chung
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
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Melnyk V, Ibinson JW, Kentor ML, Orebaugh SL. Updated Retrospective Single-Center Comparative Analysis of Peripheral Nerve Block Complications Using Landmark Peripheral Nerve Stimulation Versus Ultrasound Guidance as a Primary Means of Nerve Localization. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2477-2488. [PMID: 29574861 DOI: 10.1002/jum.14603] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/03/2017] [Accepted: 12/19/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The purpose of this study was to perform an updated analysis of complications associated with upper and lower extremity peripheral nerve blocks (PNBs) performed with ultrasound (US) guidance versus the landmark approach. METHODS We conducted a single-center retrospective cohort analysis to compare the incidence of PNB complications between the techniques. The primary outcome was local anesthetic systemic toxicity (LAST), whereas the secondary outcomes included short- and long-term nerve injuries. The current query included cases performed between 2012 and 2015. A combined analysis included data extending to 2006. The Statistical examination relied on the χ2 test. RESULTS During this 4-year period, we performed 7789 US-guided and 498 landmark-guided blocks with no statistically significant difference in the incidence of nerve injury or LAST between the groups. Our 10-year analysis, however, revealed a significant increase (P < .01) in the rate of LAST with the landmark technique: 7 of 5932 versus 0 of 16,858 cases. The combined data also revealed a significant increase (P < .01) in short-term injuries associated with the landmark approach (30 of 5932 versus 33 of 16,858) but no significant difference in the incidence of long-term injuries. CONCLUSIONS Our analysis supports a conclusion that the use of US guidance during PNBs leads to a significant reduction in the incidence of LAST, adding to growing evidence from similar investigations. The impact of US on the incidence of nerve injuries remains unclear, considering that the nature of transient deficits is thought to be multifactorial, and the frequency of lasting injuries did not differ significantly in this study.
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Affiliation(s)
- Vladyslav Melnyk
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James W Ibinson
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael L Kentor
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Steven L Orebaugh
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Gendelberg D, Hassenbein S, Kim HM, Adhikary S, Armstrong A. Dry Catheter Technique in Shoulder Arthroplasty. J Shoulder Elb Arthroplast 2018. [DOI: 10.1177/2471549218799115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Interscalene regional anesthesia is effective for pain management but is not without complications. To determine whether postoperative neurologic findings were related to the surgery versus the regional catheter, we developed the dry catheter technique where patients could be examined after the surgery prior to dosing the catheter. The purpose of the study was to assess the utility of the dry catheter block in recognizing neurological deficits associated with regional anesthesia. Methods An interscalene catheter was placed but not started. After the surgery, a neurovascular examination was performed. If the examination was normal, the regional anesthesia was started. Throughout the patient’s hospitalization, pain levels were collected. Results A total of 125 shoulders were studied. There were 9 postoperative nerve-related complications. The patients experienced the most pain relief in the first 12 hours. Conclusion The dry catheter technique allows differentiation between complications associated with regional anesthesia versus those associated with the surgery. Although interscalene anesthesia provided effective pain control, we stopped using it because we felt its complication rate was too high.
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Affiliation(s)
- David Gendelberg
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Susan Hassenbein
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - H. Mike Kim
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Sanjib Adhikary
- Department of Anesthesia, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - April Armstrong
- Department of Orthopaedics, Penn State Hershey Medical Center, Hershey, Pennsylvania
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