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Choi W, Aizik G, Ostertag-Hill CA, Kohane DS. A hybrid nanoparticle-protein hydrogel system for prolonged local anesthesia. Biomaterials 2024; 306:122494. [PMID: 38316090 PMCID: PMC11337094 DOI: 10.1016/j.biomaterials.2024.122494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Abstract
Local anesthetics are effective in relieving pain, but their duration of action is short. Therefore, the development of injectable sustained release systems to prolong the effect of local anesthetics has been of interest. In such systems delivering conventional local anesthetics, it has been challenging to achieve long durations of effect, particularly without incurring tissue toxicity. To overcome these challenges, we created a platform comprising a protein hydrogel incorporating hydrophobic local anesthetic (bupivacaine) nanoparticles. The nanoparticles were prepared by anti-solvent precipitation stabilized with bovine serum albumin (BSA), followed by crosslinking with glutaraldehyde (GA). The resulting BSA hydrogels prolonged release of bupivacaine in vitro. When bupivacaine nanoparticles within crosslinked BSA were injected at the sciatic nerve in rats, a duration of nerve block of 39.9 h was obtained, compared to 5.5 h for the commercial bupivacaine liposome suspension EXPAREL®. Tissue reaction was benign. We further demonstrated that this system could control the release of the amphiphilic drug diphenhydramine and the hydrophobic paclitaxel.
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Affiliation(s)
- Wonmin Choi
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, United States
| | - Gil Aizik
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, United States
| | - Claire A Ostertag-Hill
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, United States
| | - Daniel S Kohane
- Laboratory for Biomaterials and Drug Delivery, Department of Anesthesiology, Division of Critical Care Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, United States.
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He A, Handlogten KS, Kor BT, Brown MJ, Elhassan BT, Curry TB, Kor TM, Stewart TM. Arthroscopic assisted brachial plexus catheter placement: an alternative to the percutaneous interscalene approach. JSES Int 2024; 8:310-316. [PMID: 38464436 PMCID: PMC10920111 DOI: 10.1016/j.jseint.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Background Brachial plexus catheter placement at the interscalene level is beneficial for shoulder analgesia but presents logistical challenges due to the superficial nature of the plexus at this level, increased patient movement in the neck, and therefore higher likelihood for catheter dislodgement. Methods Patients requiring shoulder arthroscopy and suprascapular nerve decompression were identified. Under arthroscopic guidance, a catheter was placed percutaneously into the scalene medius muscle next to the suprascapular nerve and the upper trunk of the brachial plexus. Patients were followed postoperatively for perioperative analgesic outcomes. Results Ten patients were identified and consented for intraoperative brachial plexus catheter placement. Patient demographics and surgical details were determined. Postoperative adjunctive pain management and pain scores were variable. Two patients required catheter replacement using ultrasound guidance in the perioperative anesthesia care unit due to poorly controlled pain. There were no incidents of catheter failure due to dislodgement. Discussion This study presents the first description of arthroscopically-assisted brachial plexus catheter placement. This method may present an alternative to traditional ultrasound guided interscalene catheter placement. Further study is needed to determine if analgesic outcomes, block success, and dislodgement rates are improved with this method.
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Affiliation(s)
- Amy He
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kathryn S. Handlogten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin T. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Michael J. Brown
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Timothy B. Curry
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Todd M. Kor
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Thomas M. Stewart
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Ramesh K, Yusuf M, Makaram N, Milton R, Mathew A, Srinivasan M. Safety and Cost-Effectiveness of Interscalene Brachial Plexus Block With Sedation in Reverse Total Shoulder Replacement. Cureus 2021; 13:e14106. [PMID: 33907646 PMCID: PMC8067774 DOI: 10.7759/cureus.14106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Patients and methods This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59-82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2-4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results The mean (range) duration of anaesthesia was 38.66 (20-60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130-210 and 75-145 mmHg, respectively (mean [range] drop, 74.13 [33-125] mmHg). Mean (range) propofol dose was 1.74 (1-3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20-50) min. The mean (range) postoperative recovery score (local scale, range 5-28 where lower values are superior) was 5.2 (5-8). The mean (range) length of stay was 8 (1-20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions Our data demonstrate that rTSA under ISB-RA is safe, comfortable, and cost-effective. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours. Clinical relevance rTSA under ISB-RA is potentially a safe, cost-effective, and viable alternative for patients with multiple comorbidities.
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Affiliation(s)
- Kiran Ramesh
- Orthopedics and Traumatology, Wirral Teaching Hospitals NHS Trust, Wirral, GBR
| | - Muhammad Yusuf
- Orthopedics and Traumatology, Pennine Acute Hospitals NHS Trust, Manchester, GBR
| | - Navnit Makaram
- Orthopedics and Traumatology, Royal Infirmary of Edinburgh, Edinburgh, GBR
| | - Ross Milton
- Anaesthesiology, Lancashire Teaching Hospitals NHS Trust, Preston, GBR
| | - Aji Mathew
- Anaesthesia, East Lancashire Hospitals NHS Trust, Blackburn, GBR
| | - Makaram Srinivasan
- Orthopedics and Traumatology, East Lancashire Hospitals NHS Trust, Blackburn, GBR
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Karmakar MK, Areeruk P, Mok LYH, Sivakumar RK. Ultrasound-Guided Selective Trunk Block to Produce Surgical Anesthesia of the Whole Upper Extremity: A Case Report. A A Pract 2020; 14:e01274. [PMID: 32909721 DOI: 10.1213/xaa.0000000000001274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
None of the classical brachial plexus block techniques can reliably produce surgical anesthesia of the whole upper extremity that is from shoulder to hand. We describe ultrasound-guided "selective trunk block" (SeTB) that was successfully used to produce surgical anesthesia of the whole ipsilateral upper extremity in a patient undergoing intramedullary nailing of the humerus for a pathological fracture. The 3 trunks of the brachial plexus were individually identified and selectively blocked with 2 separate injections. We conclude that SeTB is a viable option when surgical anesthesia of the whole upper extremity, except for the intercostobrachial nerve (T2) territory, is being considered.
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Affiliation(s)
- Manoj Kumar Karmakar
- From the Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
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Borakati A, Ali A, Nagaraj C, Gadikoppula S, Kurer M. Day case vs inpatient total shoulder arthroplasty: A retrospective cohort study and cost-effectiveness analysis. World J Orthop 2020; 11:213-221. [PMID: 32405470 PMCID: PMC7206195 DOI: 10.5312/wjo.v11.i4.213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/24/2020] [Accepted: 03/12/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Day case total shoulder arthroplasty (TSA) is a novel approach, not widely practiced in Europe. We conducted a retrospective cohort study of patients comparing elective day case and inpatient TSAs in our United Kingdom centre.
AIM To evaluate the efficacy and cost-effectiveness of day case TSA compared to standard inpatient total shoulder arthroplasty.
METHODS All patients undergoing TSA between January 2017 and July 2018 were included. Outcome measures were: Change in abduction and extension 3 mo postoperatively; 30-d postoperative adverse events and re-admissions in day case and inpatient groups. We also conducted an economic evaluation of outpatient arthroplasty. Multivariate linear and logistic regression were used to adjust for demographic and operative covariates.
RESULTS Fifty nine patients were included, 18 d cases and 41 inpatients. There were no adverse events or re-admissions at 30 d postoperatively in either group. There were no significant differences in adjusted flexion (mean difference 16.4, 95%CI: 17.6-50.5, P = 0.337) or abduction (mean difference: 13.2, 95%CI: 18.4-44.9, P = 0.405) postoperatively between groups. Median savings with outpatient arthroplasty were £529 (interquartile range: 247.33-789, P < 0.0001).
CONCLUSION Day case TSA is a safe, effective procedure, with significant cost benefit. Wider use may be warranted in the United Kingdom and beyond, with potential for significant cost savings and improved efficiency.
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Affiliation(s)
- Aditya Borakati
- Division of Surgery and Interventional Science, Royal Free Hospital and University College London, London NW3 2QG, United Kingdom
| | - Asad Ali
- Department of Trauma and Orthopaedics, North Middlesex University Hospital, London N18 1QX, United Kingdom
| | - Chetana Nagaraj
- Department of Anaesthesia, North Middlesex University Hospital, London N18 1QX, United Kingdom
| | - Srinivas Gadikoppula
- Department of Trauma and Orthopaedics, North Middlesex University Hospital, London N18 1QX, United Kingdom
| | - Michael Kurer
- Department of Trauma and Orthopaedics, North Middlesex University Hospital, London N18 1QX, United Kingdom
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Demir U, Ince I, Aksoy M, Dostbil A, Arı MA, Sulak MM, Kose M, Tanios M, Ozmen O. The Effect of Pre-emptive Dexketoprofen Administration on Postoperative Pain Management in Patients with Ultrasound Guided Interscalene Block in Arthroscopic Shoulder Surgery. J INVEST SURG 2019; 34:82-88. [PMID: 30966835 DOI: 10.1080/08941939.2019.1576809] [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] [Indexed: 10/27/2022]
Abstract
Background: Postoperative pain is an important problem for patients undergoing shoulder surgery. Our study investigated analgesic efficacy, duration of analgesia, postoperative analgesic use and patient satisfaction with the use of preemptive intravenous dexketoprofen for interscalene block in addition to general anesthesia in arthroscopic shoulder surgery. Methods: 60 patients, scheduled for arthroscopic shoulder surgery were randomized (30 patients each) into either: - control group (Group1) or dexketoprofen group (Group 2). Patients were followed for 48 hours to compare both groups for; post-operative pain scores, effectiveness of postoperative analgesia, duration of analgesia, and analgesia consumption. Duration of postoperative sensory block of the shoulder joint was defined as time to onset of pain at the incision site. Duration of postoperative motor block of the shoulder joint was defined as time to onset of first shoulder movement. Results: While no significant difference was determined for motor block time, sensory block time was significantly longer in the dexketoprofen group (p < 0.05).VAS scores were significantly lower at all times in the dexketoprofen group (p < 0.05).Total PCA fentanyl consumption was 274.16 ± 314.89 (μg) in the dexketoprofen group, and 490.00 ± 408.98 (μg) in the control group, the difference was statistically significant (p < 0.05). No significant difference was observed between the groups' demographic and hemodynamic data. Conclusion: Pre-emptive IV dexketoprofen may be a good option for arthroscopic shoulder surgery and provides effective analgesia.
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Affiliation(s)
- U Demir
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - I Ince
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - M Aksoy
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - A Dostbil
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - M A Arı
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - M M Sulak
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
| | - M Kose
- Department of Orthopaedic Surgery, Ataturk University School of Medicine, Erzurum, Turkey
| | - M Tanios
- Anesthesiology Institute Outcomes Research Department, Cleveland Clinic, Cleveland, Ohio, USA
| | - O Ozmen
- Department of Anesthesiology and Reanimation, Ataturk University School of Medicine, Erzurum, Turkey
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Steinhaus ME, Shim SS, Lamba N, Makhni EC, Kadiyala RK. Outpatient total shoulder arthroplasty: A cost-identification analysis. J Orthop 2018; 15:581-585. [PMID: 29881198 DOI: 10.1016/j.jor.2018.05.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 05/06/2018] [Indexed: 12/14/2022] Open
Abstract
Background As demand for total shoulder arthroplasty (TSA) rises, containing costs will become increasingly important. We hypothesize that performing ambulatory TSA procedures results in significant cost savings. Methods A model was created to evaluate cost savings. Hospital stay length and cost, pain control method and cost, and number of annual outpatient TSA procedures were estimated based on literature. Results Estimated cost savings per patient were $747 to $15,507 (base case $5594), total annual savings of $4.1M to $349M (base case $82M), and ten-year savings of $51M to $5.4B (base case $1.1B). Conclusion Ambulatory TSA procedures result in significant cost savings.
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Affiliation(s)
- M E Steinhaus
- Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 E. 70th Street, New York, NY, 10021, United States
| | - S S Shim
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 W. 168th Street, New York, NY, 10032, United States
| | - N Lamba
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, United States
| | - E C Makhni
- Department of Orthopaedic Surgery, Henry Ford Health System, W. Grand Blvd., Detroit, MI, 48202, United States
| | - R K Kadiyala
- Department of Orthopaedic Surgery, Columbia University Medical Center, 622 W. 168th Street, New York, NY, 10032, United States
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Basaran B, Yilbas AA, Gultekin Z. Effect of interscalene block on intraocular pressure and ocular perfusion pressure. BMC Anesthesiol 2017; 17:144. [PMID: 29058613 PMCID: PMC5651616 DOI: 10.1186/s12871-017-0436-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 10/16/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Interscalene block (ISB) is commonly associated with Horner's syndrome due to spread of local anesthetic to the cervical sympathetic chain. Postganglionic neurons that originate from superior cervical ganglia form the sympathetic innervation of eye. Decrease in sympathetic tone may change intraocular pressure (IOP) and ocular perfusion pressure (OPP). The aim of the study was to investigate whether ISB affects IOP and/or OPP. METHODS Thirty patients scheduled for ambulatory shoulder surgery under regional anesthesia with a single-shot ISB (15 mL 0.5% bupivacaine and 15 mL 2% lidocaine) were recruited. The IOP and OPP in both eyes, mean arterial pressure (MAP), heart rate (HR) and end-tidal CO2 (ETCO2) were measured before ISB and 5, 10, 20, 30 and 60 min after ISB in the beach-chair position. RESULTS The baseline IOP and OPP were similar in the blocked and unblocked sides (IOP 17.60 ± 1.69 and 17.40 ± 1.96 respectively p = 0.432; OPP 49.80 ± 8.20 and 50 ± 8.07 respectively p = 0.432). The IOP in the blocked side significantly decreased between 10th to 60th min following ISB, compared to the baseline values (p < 0.001). The OPP in the blocked side significantly increased from 10th to 60th min (p < 0.001) whereas, there were no significant changes in IOP and OPP throughout the measurement period in the unblocked side. CONCLUSIONS ISB decreased IOP in the blocked side. ISB could be considered as a safe regional technique of choice in elderly patients at high risk for developing glaucoma.
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Affiliation(s)
- Betul Basaran
- Department of Anesthesiology, Konya Training and Research Hospital, Meram Yeni Yol street, 42090, Konya, Turkey.
| | - Aysun Ankay Yilbas
- Department of Anesthesiology and Reanimation, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Zeki Gultekin
- Department of Orthopedics and Traumatology, Konya Training and Research Hospital, Konya, Turkey
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Use of the Laryngeal Mask Airway (LMA) Protector™ for shoulder surgeries in beach-chair position. J Clin Anesth 2017; 39:110-111. [DOI: 10.1016/j.jclinane.2017.03.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 03/07/2017] [Accepted: 03/20/2017] [Indexed: 11/24/2022]
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Supplemental Interscalene Blockade to General Anesthesia for Shoulder Arthroscopy: Effects on Fast Track Capability, Analgesic Quality, and Lung Function. BIOMED RESEARCH INTERNATIONAL 2015; 2015:325012. [PMID: 26064898 PMCID: PMC4429210 DOI: 10.1155/2015/325012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/11/2015] [Accepted: 04/20/2015] [Indexed: 11/25/2022]
Abstract
Background. After shoulder surgery performed in patients with interscalene nerve block (without general anesthesia), fast track capability and postoperative pain management in the PACU are improved compared with general anesthesia alone. However, it is not known if these evidence-based benefits still exist when the interscalene block is combined with general anesthesia. Methods. We retrospectively analyzed a prospective cohort data set of 159 patients undergoing shoulder arthroscopy with general anesthesia alone (n = 60) or combined with an interscalene nerve block catheter (n = 99) for fast track capability time. Moreover, comparisons were made for VAS scores, analgesic consumption in the PACU, pain management, and lung function measurements. Results. The groups did not differ in mean time to fast track capability (22 versus 22 min). Opioid consumption in PACU was significantly less in the interscalene group, who had significantly better VAS scores during PACU stay. Patients receiving interscalene blockade had a significantly impaired lung function postoperatively, although this did not affect postoperative recovery and had no impact on PACU times. Conclusion. The addition of interscalene block to general anesthesia for shoulder arthroscopy did not enhance fast track capability. Pain management and VAS scores were improved in the interscalene nerve block group.
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