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Neupane A, Jain D, Arora S, Gandhi K, Singla V, Goel N, Virk RS, Mohindra S. Evaluation of ultrasound-guided suprazygomatic maxillary nerve block in functional endoscopic sinus surgery for postoperative pain relief: A randomised controlled trial. Indian J Anaesth 2024; 68:706-711. [PMID: 39176111 PMCID: PMC11338370 DOI: 10.4103/ija.ija_81_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 08/24/2024] Open
Abstract
Background and Aims Postoperative pain can impede functional recovery and delay hospital discharge after functional endoscopic sinus surgery (FESS). The study aimed to assess the efficacy of ultrasound (USG)-guided suprazygomatic maxillary nerve block (SZMNB) for postoperative pain in FESS. Methods Forty-eight adult patients between 18 and 65 years of age with American Society of Anesthesiologists physical status I and II and scheduled to undergo FESS were enroled in this randomised controlled study. Patients were randomly allocated to either receive USG-guided SZMNB with general anaesthesia (n = 24) or general anaesthesia alone (n = 24). The numerical rating scale (NRS) pain score in the immediate postoperative period was recorded as the primary outcome. A total of 24 h postoperative rescue analgesic consumption, surgeon satisfaction score, postoperative haemodynamics, and postoperative complications were noted as secondary outcomes. Results The median (interquartile range) of the NRS pain score in the immediate postoperative period was 0 (0-0.25)[95% confidence interval (CI): 0, 0.08] in the block group compared to 2 (1.75-3) [95% CI: 1.60, 2.40] in the control group, P < 0.001]. Pain scores were significantly reduced at all time intervals till 24 h after surgery (P < 0.001). None of the patients required rescue analgesia in the block group. In contrast, eight patients required diclofenac 75 mg intravenous as rescue analgesia within 1 h of surgery and ten patients within 1-6 h of surgery in the control group. Other secondary outcomes were comparable between groups (P > 0.05). Conclusion The USG-guided SZMNB provides excellent postoperative analgesia for patients undergoing FESS without significant side effects.
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Affiliation(s)
- Adhip Neupane
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Divya Jain
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Suman Arora
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Komal Gandhi
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Singla
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nitika Goel
- Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ramandeep Singh Virk
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Satyawati Mohindra
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gökçek E, Kozan G. Postoperative effects of bilateral sphenopalatine ganglion blockade in septorhinoplasty operations; double-blind randomized clinical trial. Braz J Otorhinolaryngol 2024; 90:101373. [PMID: 38113753 PMCID: PMC10767143 DOI: 10.1016/j.bjorl.2023.101373] [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: 06/29/2023] [Revised: 10/26/2023] [Accepted: 11/22/2023] [Indexed: 12/21/2023] Open
Abstract
OBJECTIVE We aimed to investigate the effect of bilateral sphenopalatine ganglion blockade (SPGB) on the main postoperative complications in septorhinoplasty operations. METHODS In this randomized, controlled, prospective study, 80 cases planned for Septorhinoplasty operations under general anesthesia were included in the study. The cases were divided into two groups; SPGB was performed with 2 mL of 0.25% bupivacaine bilaterally 15 min before the end of the operation in the SPGB group (Group S, n = 40). In the control group (Group C, n = 40), 2 mL of 0.9% NaCl solution was applied into both SPG areas. In the recovery unit after the operation; the pain and analgesic needs of the patients at 0, 2, 6 and 24 h were evaluated. RESULTS There was no statistically significant difference between the groups in terms of hemodynamic parameters (ASA, MBP, HR) (p > 0.05) All VAS values were statistically lower in Group S than in Group C (p < 0.05). In Group S, the need for analgesic medication was found in 5 cases between 0-2 h, whereas in Group C, this rate was found in 17 cases, and it was statistically significant (p < 0.05). CONCLUSION Bilateral SPGB application was determined to provide better analgesia in the early postoperative period compared to the control group, it was concluded that further studies are needed to say that there are significant effects on laryngospasm and nausea-vomiting. LEVEL OF EVIDENCE 2, degree of recommendation B.
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Affiliation(s)
- Erhan Gökçek
- Health Sciences University Diyarbakir Gazi Yasargil Research and Education Hospital, Department of Anaesthesiolgy and Reanimation, Diyarbakir, Turkey.
| | - Gunay Kozan
- Dicle University, Faculty of Medicine, Department of Otorhinolaryngology, Diyarbakir, Turkey
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Karaoğullarından A, Erkan SO, Ekici NY. Is transoral sphenopalatine ganglion blockade more effective on postoperative pain than endoscopic sphenopalatine ganglion blockade? Eur Arch Otorhinolaryngol 2024; 281:193-199. [PMID: 37697038 DOI: 10.1007/s00405-023-08174-8] [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: 06/09/2023] [Accepted: 07/31/2023] [Indexed: 09/13/2023]
Abstract
PURPOSE In this study, we aimed to examine and compare the effects of endoscopic SPGB and transoral SPGB on postoperative pain control and patient satisfaction in patients undergoing septoplasty. METHODS Participants were randomly divided into three groups, no blockade (n:20), endoscopic SPGB (n:20), and transoral SPGB (n:20). Those who had no blockage were included in the control group. Demographic data of patients, such as age and sex, VAS (visual analogue scale) and postoperative pain scores (PPS) [determined at arrival in the post-anesthesia care unit (PACU) and after 2, 6, 12, and 24 h], general analgesic use (24 and 168 h after surgery) and postoperative Quality of Recovery (QoR-15) values were recorded and compare them. RESULTS The PPS PACU of 2 h, 6 h, 12 h, and 24-h values of the transoral group were lower than the endoscopic and control groups (p < 0.001).The values of 24 h and 168 h of analgesic use in the transoral group were lower than in the control and endoscopic groups (p < 0.001).The average recovery QoR-15 scores at 12 h and 24 h differed according to the groups (p < 0.001) and the highest values were in the transoral group (p < 0.001). CONCLUSION Transoral SPGB is more effective in postoperative pain control than endoscopic SPGB, it decreases the use of postoperative analgesics and improves postoperative recovery scores.
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Affiliation(s)
- Ayşe Karaoğullarından
- ENT Specialist in Adana City Training and Research Hospital ENT Department, 01060, Yüreğir, Adana, Turkey.
| | - Sanem Okşan Erkan
- ENT Specialist in Adana City Training and Research Hospital ENT Department, 01060, Yüreğir, Adana, Turkey
| | - Nur Yücel Ekici
- ENT Specialist in Adana City Training and Research Hospital ENT Department, 01060, Yüreğir, Adana, Turkey
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Alaniz L, Vu C, Arora J, Stulginski A, Zhu X, Cordero J, Vyas RM, Pfaff MJ. Effective Local Anesthetic Use in Nasal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Studies. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5151. [PMID: 37534108 PMCID: PMC10393085 DOI: 10.1097/gox.0000000000005151] [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: 04/21/2023] [Accepted: 06/13/2023] [Indexed: 08/04/2023]
Abstract
Intraoperative nerve blocks have shown promise in managing pain after nasal surgery. The purpose of this systematic review and meta-analysis was to analyze existing level I and II evidence on intraoperative nerve blocks in nasal surgery to optimize postoperative recovery. Methods The primary outcome of this systematic review and meta-analysis was postoperative pain scores; secondary outcomes included perioperative opioid requirements, patient satisfaction scores, and time to first analgesic requirement. PubMed, Embase, and MEDLINE databases were searched, and two independent reviewers conducted article screening. Methodological quality assessment of studies utilized the Jadad instrument, and interrater reliability was assessed using Cohen kappa. An inverse-variance, fixed-effects model was used for meta-analysis with Cohen d used to normalize effect size between studies. I2 and Q statistics were used to assess interstudy variability. Results Four studies were included for meta-analysis, totaling 265 randomized patients. The nerve blocks assessed included infraorbital nerve, sphenopalatine ganglion, external nasal nerve, central facial nerve blocks, and total nerve blocks. All demonstrated significantly reduced postoperative pain compared with controls, with a large effect size (P < 0.001). Opioid requirements were lower in the nerve block groups (P < 0.001), and patient satisfaction scores were higher (P < 0.001). Supplemental meta-analyses showed a longer time to first analgesic requirement for patients who received a nerve block (P < 0.001). Conclusions These findings support the efficacy of nerve blocks in providing postoperative pain relief and enhancing patient satisfaction with pain management. Perioperative nerve blocks, in combination with general anesthesia, should be considered for postoperative pain control.
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Affiliation(s)
- Leonardo Alaniz
- From the School of Medicine, University of California Irvine, Irvine, Calif
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, Calif
| | - Cindy Vu
- From the School of Medicine, University of California Irvine, Irvine, Calif
| | - Jagmeet Arora
- From the School of Medicine, University of California Irvine, Irvine, Calif
| | - Avril Stulginski
- From the School of Medicine, University of California Irvine, Irvine, Calif
| | - Xiao Zhu
- Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Justin Cordero
- University of California Riverside, School of Medicine, Riverside, Calif
| | - Raj M. Vyas
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, Calif
- Pediatric Plastic Surgery, Children’s Hospital of California, Orange, Calif
| | - Miles J. Pfaff
- Department of Plastic Surgery, University of California Irvine Medical Center, Orange, Calif
- Pediatric Plastic Surgery, Children’s Hospital of California, Orange, Calif
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Orlandi RR, Kingdom TT, Smith TL, Bleier B, DeConde A, Luong AU, Poetker DM, Soler Z, Welch KC, Wise SK, Adappa N, Alt JA, Anselmo-Lima WT, Bachert C, Baroody FM, Batra PS, Bernal-Sprekelsen M, Beswick D, Bhattacharyya N, Chandra RK, Chang EH, Chiu A, Chowdhury N, Citardi MJ, Cohen NA, Conley DB, DelGaudio J, Desrosiers M, Douglas R, Eloy JA, Fokkens WJ, Gray ST, Gudis DA, Hamilos DL, Han JK, Harvey R, Hellings P, Holbrook EH, Hopkins C, Hwang P, Javer AR, Jiang RS, Kennedy D, Kern R, Laidlaw T, Lal D, Lane A, Lee HM, Lee JT, Levy JM, Lin SY, Lund V, McMains KC, Metson R, Mullol J, Naclerio R, Oakley G, Otori N, Palmer JN, Parikh SR, Passali D, Patel Z, Peters A, Philpott C, Psaltis AJ, Ramakrishnan VR, Ramanathan M, Roh HJ, Rudmik L, Sacks R, Schlosser RJ, Sedaghat AR, Senior BA, Sindwani R, Smith K, Snidvongs K, Stewart M, Suh JD, Tan BK, Turner JH, van Drunen CM, Voegels R, Wang DY, Woodworth BA, Wormald PJ, Wright ED, Yan C, Zhang L, Zhou B. International consensus statement on allergy and rhinology: rhinosinusitis 2021. Int Forum Allergy Rhinol 2021; 11:213-739. [PMID: 33236525 DOI: 10.1002/alr.22741] [Citation(s) in RCA: 390] [Impact Index Per Article: 130.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 02/06/2023]
Abstract
I. EXECUTIVE SUMMARY BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document. METHODS ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary. RESULTS ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided. CONCLUSION This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.
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Affiliation(s)
| | | | | | | | | | - Amber U Luong
- University of Texas Medical School at Houston, Houston, TX
| | | | - Zachary Soler
- Medical University of South Carolina, Charleston, SC
| | - Kevin C Welch
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | | | | | - Claus Bachert
- Ghent University, Ghent, Belgium.,Karolinska Institute, Stockholm, Sweden.,Sun Yatsen University, Gangzhou, China
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David A Gudis
- Columbia University Irving Medical Center, New York, NY
| | - Daniel L Hamilos
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Richard Harvey
- University of New South Wales and Macquarie University, Sydney, New South Wales, Australia
| | | | | | | | | | - Amin R Javer
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | | | | | | | | | | | | | - Valerie Lund
- Royal National Throat Nose and Ear Hospital, UCLH, London, UK
| | - Kevin C McMains
- Uniformed Services University of Health Sciences, San Antonio, TX
| | | | - Joaquim Mullol
- IDIBAPS Hospital Clinic, University of Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | - Alkis J Psaltis
- University of Adelaide, Adelaide, South Australia, Australia
| | | | | | | | - Luke Rudmik
- University of Calgary, Calgary, Alberta, Canada
| | - Raymond Sacks
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - De Yun Wang
- National University of Singapore, Singapore, Singapore
| | | | | | | | - Carol Yan
- University of California San Diego, La Jolla, CA
| | - Luo Zhang
- Capital Medical University, Beijing, China
| | - Bing Zhou
- Capital Medical University, Beijing, China
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6
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Degirmenci N, Ozdem A, Uysal H, Sen P, Senturk E, Ozturan O, Turkoz A. The Effect of Sphenopalatine Ganglion Block on the Postoperative Pain in Patients Undergoing Septorhinoplasty. Ann Otol Rhinol Laryngol 2020; 129:722-726. [PMID: 32090594 DOI: 10.1177/0003489420909417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study aimed to evaluate the effect of preoperative sphenopalatine ganglion block (SPBG) on the postoperative pain (POP) in patients undergoing septorhinoplasty (SRP). METHODS A retrospective cohort study was performed. A total of 42 patients that had received septorhinoplasty included in the study. The patients that had received SPBG before the surgery included in the Block group (n:20) and the patients that had not received SPBG before the surgery included in the Control group (n:22). POP was questioned with a numeric rating scale (NRS) at the 30th minute (t1), 1st hour (t2), 4th hour (t3), 12th hour (t4), and 24th hour (t5) and noted. The intraoperative details and the dose of the postoperative rescue analgesics were also noted. RESULTS The average dose of Paracetamol that was used in the postoperative first 24 hours was 500 mg in the Block group and 1363 mg in the Control group, and the difference was statistically significant (P = .001). The average dose of Tramadol was 0 mg in the Block group and 45 mg in the Control group, and the difference was statistically significant (P = .001). There was a statistically significant difference among the groups with respect to NRS in the first 24 hours postoperatively (P < .05). The number of the patients requiring rescue analgesics was lower in the Block group than the Control group. The difference was statistically significant at the t1, t2, and t5 time intervals (P > .05). CONCLUSIONS Preoperative SPGB is an effective option to reduce POP and the need for rescue analgesics for patients undergoing SRP. CLINICAL TRIAL NUMBER NCT04020393.
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Affiliation(s)
- Nazan Degirmenci
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Abdullah Ozdem
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Harun Uysal
- Department of Anesthesiology and Reanimation, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Pelin Sen
- Department of Anesthesiology and Reanimation, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Erol Senturk
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Orhan Ozturan
- Department of Otorhinolaryngology-Head and Neck Surgery, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
| | - Ayda Turkoz
- Department of Anesthesiology and Reanimation, Medical Faculty, Bezmialem Vakif University, Istanbul, Turkey
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7
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Ekici NY, Alagöz S. The effectiveness of endoscopic sphenopalatine ganglion block in management of postoperative pain after septal surgery. Int Forum Allergy Rhinol 2019; 9:1521-1525. [PMID: 31487422 DOI: 10.1002/alr.22411] [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: 07/06/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND This study evaluated the effect of bilateral endoscopic sphenopalatine ganglion block (SPGB) for management of postoperative pain in patients undergoing septoplasty. METHODS Sixty septoplasty patients (51.7% male, 48.3% female, aged 18 to 45 years) were randomly assigned to general anesthesia (GA) alone (control) (n = 30) or GA plus endoscopic SPGB (n = 30). Demographic data, duration of surgery, blood loss, postoperative visual analogue scale (VAS) pain scores (upon arrival at the postanesthesia care unit [PACU] and 2, 6, 12, and 24 hours after surgery), overall analgesic usage (end of 24 and 168 hours after surgery), overall satisfaction with the pain control (end of 24 and 168 hours after surgery), and complications (bleeding, nausea and vomiting, and visual disturbance) were recorded. RESULTS Pain scores upon arrival to the PACU and 2, 6, 12, and 24 hours after surgery were significantly lower in the SPGB group compared to the control group (p < 0.001). Moreover, the SPGB group had significantly lower analgesic requirements and higher satisfaction scores with their pain control at the end of 24 and 168 hours after surgery compared to the control group (p < 0.001). The 2 groups significantly differed in terms of intraoperative blood loss (p = 0.024), and surgery time was longer in the SPGB group compared to the control group (p < 0.001). CONCLUSION SPGB with bupivacaine is a safe and effective method to reduce pain after septoplasty, and it is a cost-effective alternative to high doses of analgesics.
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Affiliation(s)
- Nur Yücel Ekici
- Department of Otorhinolaryngology, Adana City Training and Research Hospital, Adana, Turkey
| | - Sedat Alagöz
- Department of Otorhinolaryngology, Adana City Training and Research Hospital, Adana, Turkey
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Novitch M, Hyatali FS, Jeha G, Motejunas M, Bonneval L, Pankaj T, Cornett EM, Jones MR, Kaye RJ, Urman RD, Kaye AD. Regional techniques for head and neck surgical procedures. Best Pract Res Clin Anaesthesiol 2019; 33:377-386. [PMID: 31791557 DOI: 10.1016/j.bpa.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 06/24/2019] [Indexed: 11/16/2022]
Abstract
Regional anesthesia has evolved as an important tool for anesthesiologists and surgeons managing patients for surgery of the head and neck region. In recent years, ultrasound use has increased significantly, and newer nerve blocks have been established for surgeries of the head and regions. In this review, anatomy, indications, efficacy, and potential side effects of regional anesthesia for the head and neck region are presented. Evolving practice strongly suggests that regional nerve blocks for the head and neck region are safe and effective. Future studies and education will likely evolve practice to make these regional techniques standards for future surgeries of the head and neck region.
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Affiliation(s)
- Matthew Novitch
- University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Farees S Hyatali
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA.
| | - George Jeha
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA.
| | - Mark Motejunas
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA.
| | - Lauren Bonneval
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA.
| | - Thakur Pankaj
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA.
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA.
| | - Mark R Jones
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02115, USA.
| | - Rachel J Kaye
- Medical University of South Carolina, Charleston, SC 29425, USA.
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, Room 656, 1542 Tulane Ave., New Orleans, LA 70112, USA.
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