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Harris SN, Ortolan SC, Edmonds CR, Fields KG, Liguori GA. Fewer Wrong-Site Peripheral Nerve Blocks Following Updates to Anesthesia Time-Out Policy. HSS J 2021; 17:180-184. [PMID: 34421428 PMCID: PMC8361586 DOI: 10.1177/1556331621993079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 11/15/2022]
Abstract
Background: Peripheral nerve block (PNB) has been shown to be safe and effective, and its use has continued to increase, but it is not without risks. One potentially preventable risk is wrong-site blocks (WSBs). Our institution mandated a time-out process before PNB in 2003, and then in 2007 made two more changes to our policy to mitigate risk: (1) the circulating/block nurse was the only person permitted to access the block needles; after a time-out period was complete, the nurse gave the needles to the anesthesiologist; and (2) the nurse remained at the patient's bedside until the PNB was initiated. Purpose: We sought to compare the incidence of WSBs before and after this time-out process was implemented in 2003 and the enhanced form of it was implemented in 2007. We hypothesized that the enhanced process would decrease the incidence of WSBs. Methods: We retrospectively analyzed data, from January 2003 to December 2016, taken from the quality assurance and performance improvement (QA/PI) division of the anesthesiology department at our institution, which maintained daily statistics on anesthetic types using quality audits from paper or electronic anesthesia records. All WSBs from this period were reported to the QA/PI division and root cause analyses performed. The incidence of WSB was compared pre- and post-implementation of the enhanced time-out policy for upper extremity, lower extremity, and all blocks by calculating relative risks with 95% score confidence intervals and performing Fisher's exact tests. Results: The incidence of WSBs decreased from 1.10/10,000 before changes to the policy were initiated to 0.24/10,000 afterward. Conclusion: We observed an association between the implementation of a dynamic, team-focused time-out process and a reduction in the incidence of WSBs at our institution. A causal effect of the enhanced time-out cannot be determined given the risk of bias associated with before-after study designs and our lack of adjustment for potential confounders. Further research is therefore warranted.
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Affiliation(s)
- Stephen N. Harris
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Sarah C. Ortolan
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
- Sarah C. Ortolan, MS, Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021, USA.
| | - Chris R. Edmonds
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Kara G. Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Gregory A. Liguori
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
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2
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Wu CL, Jules-Elysee KM, Kirksey MA, Liguori GA. Perioperative Nonsteroidal Anti-Inflammatory Agents in the COVID-19 Orthopedic Patient. HSS J 2020; 16:97-101. [PMID: 32952464 PMCID: PMC7489195 DOI: 10.1007/s11420-020-09783-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/23/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND SARS-CoV-2 infection can cause serious complications beyond lung injury and respiratory failure, including sepsis, cardiovascular injury, renal failure, coagulation abnormalities, and neurologic injury. Widely used medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) have been flagged as having the potential to cause harm in the context of COVID-19. It is unknown if the benefits of NSAID use in the orthopedic population will outweigh the potential risks of increased morbidity in COVID-19 orthopedic patients. METHODS We conducted a narrative review of the use of NSAIDs in the orthopedic patient with COVID-19, focusing on the effects of NSAIDs on the inflammatory process, the role of NSAIDs in orthopedics, and the associations between NSAID use and complications of pneumonia. RESULTS We found that it may be appropriate to consider NSAID use in otherwise healthy orthopedic patients with COVID-19 and significant pain. CONCLUSIONS In this context, we recommend that NSAIDs be used at the lowest effective dose for the shortest duration possible in orthopedic patients with COVID-19. However, pending further data and based on the concerns outlined in this review, we recommend avoiding NSAIDs in orthopedic patients with significant comorbidities and those who are undergoing major orthopedic surgery.
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Affiliation(s)
- Christopher L. Wu
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
| | - Kethy M. Jules-Elysee
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
| | - Meghan A. Kirksey
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
| | - Gregory A. Liguori
- Department of Anesthesiology Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th St, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY USA
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3
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Soffin EM, Reisener MJ, Sama AA, Beckman JD, Liguori GA, Lebl DR, Girardi FP, Cammisa FP, Hughes AP. Essential Spine Surgery During the COVID-19 Pandemic: A Comprehensive Framework for Clinical Practice from a Specialty Orthopedic Hospital in New York City. HSS J 2020; 16:29-35. [PMID: 32929320 PMCID: PMC7482371 DOI: 10.1007/s11420-020-09786-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/23/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Ellen M. Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Marie-Jacqueline Reisener
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Andrew A. Sama
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - James D. Beckman
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Gregory A. Liguori
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Darren R. Lebl
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Federico P. Girardi
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Frank P. Cammisa
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Alexander P. Hughes
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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Wendel PK, Stack RJ, Chisholm MF, Kelly MJ, Elogoodin B, Liguori GA, Green DST, Kalsi MS, Soffin EM. Development of a Communications Program to Support Care of Critically Ill Coronavirus Disease 2019 (COVID-19) Patients. J Patient Exp 2020; 7:673-676. [PMID: 33294597 PMCID: PMC7705817 DOI: 10.1177/2374373520956865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A significant role of intensive care unit (ICU) workforce is ongoing communication with and support for families of critically ill patients. The COVID-19 pandemic has created unanticipated challenges to this essential function. Restrictions on visitors to hospitals and unprecedented clinical demands hamper traditional communication between ICU staff and patient families. In response to this challenge, we created a dedicated communications service to provide comprehensive support to families of COVID-19 patients, and to create capacity for our ICU teams to focus on patient care. In this brief report, we describe the development, implementation, and preliminary experience with the service.
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Affiliation(s)
- Pamela K Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology of Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
| | - Roberta J Stack
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Mary F Chisholm
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology of Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
| | - Mary J Kelly
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Bella Elogoodin
- Department of Service Excellence, Hospital for Special Surgery, New York, NY, USA
| | - Gregory A Liguori
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology of Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
| | - Douglas S T Green
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology of Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
| | - Mandip Singh Kalsi
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology of Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.,Department of Anesthesiology of Weill Cornell Medical College/New York Presbyterian Hospital, New York, NY, USA
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6
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Singleton MN, Hannafin JA, Liguori GA, Soffin EM. The Role of Peripheral Nerve Catheters in Buprenorphine/Naloxone Management in Elective Orthopedic Surgery: A Case Report. HSS J 2019; 15:93-95. [PMID: 30863239 PMCID: PMC6384208 DOI: 10.1007/s11420-018-9648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 10/15/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Michael N. Singleton
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jo A. Hannafin
- Department of Sports Medicine, Hospital for Special Surgery, New York, NY USA
| | - Gregory A. Liguori
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Ellen M. Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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7
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Keeney LG, Hargett MJ, Liguori GA. Charles Burstein, MD: First Director of Anesthesiology at Hospital for Special Surgery. J Anesth Hist 2018; 4:171-176. [PMID: 30217389 DOI: 10.1016/j.janh.2018.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 02/05/2018] [Accepted: 04/19/2018] [Indexed: 11/26/2022]
Abstract
Charles L. Burstein was the first departmental Director and Chief of Anesthesiology at the Hospital for Special Surgery in New York City. He joined the staff in 1937, when the hospital was still known by its original name of the Hospital for the Ruptured and Crippled. In 1940, it was renamed The Hospital for Special Surgery. Burstein, an early disciple of Emery Rovenstine, accomplished much to advance the Department of Anesthesiology through academic collaborations, education, clinical specialization, and research. He laid the groundwork for the future success of a department that continues to thrive to this day in clinical and academic orthopedic anesthesia.
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Affiliation(s)
- Lauren G Keeney
- Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021
| | - Mary J Hargett
- Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021
| | - Gregory A Liguori
- Department of Anesthesiology, Hospital for Special Surgery, 535 E 70th St, New York, NY 10021.
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Bombardieri AM, Maalouf DB, Kahn RL, Ma Y, Bae JJ, Wukovits B, Lee A, Jules-Elysee KM, De Gaudio AR, Liguori GA. A comparison of two different concentrations and infusion rates of ropivacaine in perineural infusion administered at the same total dose for analgesia after foot and ankle surgery: a randomized, double blinded, controlled study. Minerva Anestesiol 2018; 85:139-147. [PMID: 29633812 DOI: 10.23736/s0375-9393.18.12266-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Continuous popliteal nerve block is utilized for postoperative analgesia after foot and ankle surgery. Whether only the total dose of local anesthetic or the combination of concentration and volume determine the characteristics of a continuous popliteal nerve infusion remains currently unknown. We hypothesized a reduction of the incidence of insensate extremity in patients given ropivacaine 0.4% at 4 mL/h compared to patients given ropivacaine 0.2% at 8 mL/h. METHODS Sixty-four patients scheduled for major foot and ankle surgery requiring a continuous popliteal catheter infusion for postoperative analgesia were studied. Thirty-three patients were randomized to receive a continuous popliteal nerve block with 0.2% (basal 8 mL/h) and thirty-one with 0.4% (basal 4 mL/h) ropivacaine, reaching the same total dose (16 mg/h). The primary outcome was the incidence of persistent sensory block in the distal sciatic nerve distributions in the postoperative period. Secondary outcomes were the incidence of motor block, NRS pain scores at rest in the postoperative period up to 48 hours after surgery, opioid use and related side effects, patients' satisfaction. RESULTS The incidence of persistent sensory block was similar in patients given 0.2% and in patients receiving 0.4% ropivacaine. The incidence of motor block, postoperative pain scores at rest, use of oral opioids, side effects and patients' satisfaction with the quality of recovery were also similar in both groups. CONCLUSIONS Our results suggest that local anesthetic total dose is the primary determinant of continuous popliteal perineural infusion effects.
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Affiliation(s)
- Anna M Bombardieri
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA - .,Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA -
| | - Daniel B Maalouf
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Richard L Kahn
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yan Ma
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC, USA
| | - James J Bae
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Barbara Wukovits
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew Lee
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Kethy M Jules-Elysee
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - A Raffaele De Gaudio
- Section of Anesthesiology, Intensive Care and Pain Therapy, Department of Health Sciences, University of Florence, Florence, Italy
| | - Gregory A Liguori
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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9
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Soffin EM, Waldman SA, Stack RJ, Liguori GA. An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery. Anesth Analg 2017; 125:1704-1713. [DOI: 10.1213/ane.0000000000002433] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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10
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Belkin NS, Degen RM, Liguori GA, Kelly BT. Epinephrine-induced pulmonary edema during hip arthroscopy: a report of two cases and a review of the literature. PHYSICIAN SPORTSMED 2017; 45:353-356. [PMID: 28420300 DOI: 10.1080/00913847.2017.1321461] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Hip arthroscopy utilization has significantly increased in recent years. While it is a relatively safe procedure, it is not without risk. Life-threatening complications, albeit rare, can potentially occur and must be appropriately recognized and treated. We describe 2 cases in which patients' undergoing hip arthroscopy developed pulmonary edema and their respective courses of treatment. METHODS Both patients were being treated for symptomatic femoroacetabular impingement (FAI), with labral tears, requiring operative management after a failed trial of conservative management. The complication occurred during a primary hip arthroscopy procedure and a retrospective review of their clinical records and intra-operative notes was performed. RESULTS Hip arthroscopy was performed under spinal anesthetic in the supine position in both patients. In both procedures, patients developed severe hypertension and tachycardia, with subsequent oxygen desaturations with noted pulmonary edema. The postulated etiology was systemic effects from intra-articular epinephrine, causing acute pulmonary edema with corresponding cardiovascular changes. With supportive ventilation, selective alpha-adrenergic blocker and furosemide administration, and cessation of epinephrine exposure, vital signs normalized and both patients experienced symptom resolution. CONCLUSION During arthroscopy, if acute hypertension, tachycardia and hypoxia develop, epinephrine-induced pulmonary edema should be considered as a cause by the treating orthopedic surgeon and anesthesiologist in order to initiate an appropriate treatment plan.
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Affiliation(s)
- Nicole S Belkin
- a Center for Hip Preservation , Hospital for Special Surgery , New York , NY , USA
| | - Ryan M Degen
- a Center for Hip Preservation , Hospital for Special Surgery , New York , NY , USA
| | - Gregory A Liguori
- a Center for Hip Preservation , Hospital for Special Surgery , New York , NY , USA
| | - Bryan T Kelly
- a Center for Hip Preservation , Hospital for Special Surgery , New York , NY , USA
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11
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Chisholm MF, Bang H, Maalouf DB, Marcello D, Lotano MA, Marx RG, Liguori GA, Zayas VM, Gordon MA, Jacobs J, YaDeau JT. Postoperative Analgesia with Saphenous Block Appears Equivalent to Femoral Nerve Block in ACL Reconstruction. HSS J 2014; 10:245-51. [PMID: 25264441 PMCID: PMC4171445 DOI: 10.1007/s11420-014-9392-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 04/01/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adequate pain control following anterior cruciate ligament reconstruction (ACL) often requires regional nerve block. The femoral nerve block (FNB) has been traditionally employed. Ultrasound application to regional nerve blocks allows for the use of alternatives such as the saphenous nerve block following ACL reconstruction. QUESTIONS/PURPOSES This study evaluated postoperative analgesia provided by the subsartorial saphenous nerve block (SSNB) compared to that provided by the traditional FNB for patients undergoing ACL reconstruction with patellar tendon (bone-tendon-bone (BTB)) autografts. METHODS A randomized, blinded, controlled clinical trial was conducted using 80 ASA I-III patients, ages 16-65, undergoing ACL reconstruction with BTB. The individuals assessing all outcome measures were blinded to the treatment group. Postoperatively, all patients received cryotherapy and parenteral hydromorphone to achieve numeric rating scale pain scores less than 4. At discharge, patients were given prescriptions for oral opioid analgesics and a scheduled NSAID. Patients were instructed to complete pain diaries and record oral opioid utilization. Patients were contacted on postoperative days (POD) 1 and 2 to ascertain the level of patient satisfaction with the analgesic regimen. RESULTS No differences between the two groups were found. Patient demographics and postoperative pain scores at rest were not different. In addition, there was no difference in opioid use, as measured in daily oral morphine equivalents between groups. A small but statistically significant report of higher patient satisfaction with the FNB was found on POD 1 but not on POD 2. CONCLUSION These data support our hypothesis that the SSNB provides similar and adequate postoperative analgesia when compared to the FNB, following arthroscopic ACL reconstruction with patellar tendon autograft.
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Affiliation(s)
- Mary F. Chisholm
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Heejung Bang
- />Department of Statistical Science, Weill Cornell Medical College, New York, NY USA
- />UC Davis, Davis, CA USA
| | - Daniel B. Maalouf
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Dorothy Marcello
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Marco A. Lotano
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Robert G. Marx
- />Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY USA
| | - Gregory A. Liguori
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Victor M. Zayas
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Michael A. Gordon
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jason Jacobs
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Jacques T. YaDeau
- />Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
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12
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Nurok M, Green DS, Chisholm MF, Fins JJ, Liguori GA. Anesthesiologists’ familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting. J Clin Anesth 2014; 26:174-6. [DOI: 10.1016/j.jclinane.2013.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 10/24/2013] [Accepted: 11/13/2013] [Indexed: 11/24/2022]
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13
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Abstract
Thomas Linwood Bennett (1868-1932) was one of New York City's first prominent physician anesthetists. He was the first dedicated anesthetist at the Hospital for the Ruptured and Crippled, subsequently renamed Hospital for Special Surgery. He subsequently practiced at multiple institutions throughout New York City as one of the first physicians in the United States to dedicate his entire practice to the emerging field of anesthesia. Bennett was considered the preeminent anesthetist of his time, excelling at research, innovation, education, and clinical care.
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Affiliation(s)
- Emily C Liguori
- From the Department of Anesthesiology, Hospital for Special Surgery, New York, New York
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14
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Gritsenko K, Marcello D, Liguori GA, Jules-Elysée K, Memtsoudis SG. Meningitis or epidural abscesses after neuraxial block for removal of infected hip or knee prostheses. Br J Anaesth 2012; 108:485-90. [PMID: 22180468 DOI: 10.1093/bja/aer416] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Infection, whether localized or systemic, can be a relative contraindication to neuraxial anaesthesia. Data correlating neuraxial anaesthesia and the development of meningitis or epidural abscess in this setting are limited. METHODS Retrospective chart review was performed on 710 medical records of patients admitted between 1998 and 2009 for removal of potentially infected total hip and total knee prostheses. Ultimately, 474 patients were identified as being infected. Factors that predisposed a patient to an immunocompromised state, and signs and symptoms of infection in the pre-, intra-, and postoperative stages were documented. Bacteraemic patients were reviewed for signs of neuraxial infection. The endpoint of follow-up was development of complications before hospital discharge. RESULTS All 474 patients had removal of the infected prosthesis under neuraxial anaesthesia. Mean patient age was 65.5 yr (58% >65 yr) and mean length of hospital stay was 21 days. Patient characteristics included concurrent disease (65%), steroid use (5.3%), preoperative antibiotic use (50.8%), signs of inflammatory process (84%), bacteraemia (4.2%), and documented positive intraoperative joint cultures (88%). Using clinical standards for diagnosis of central neuraxial infection, patients developed infectious complications (incidence of 0.6% on 95% confidence interval), although three patients had findings attributable to anaesthesia, including epidural haematoma, psoas abscess, and back pain. CONCLUSIONS Based on clinical criteria, our findings suggest that the incidence of central nervous system infection after neuraxial anaesthesia in patients with infected hip and knee prostheses is low after neuraxial block.
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Affiliation(s)
- K Gritsenko
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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15
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Memtsoudis SG, Ma Y, Swamidoss CP, Edwards AM, Mazumdar M, Liguori GA. Factors influencing unexpected disposition after orthopedic ambulatory surgery. J Clin Anesth 2012; 24:89-95. [PMID: 22305625 DOI: 10.1016/j.jclinane.2011.10.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 09/13/2011] [Accepted: 10/12/2011] [Indexed: 10/14/2022]
Abstract
STUDY OBJECTIVE To analyze whether patient characteristics, ambulatory facility type, anesthesia provider and technique, procedure type, and temporal factors impact the outcome of unexpected disposition after ambulatory knee and shoulder surgery. DESIGN Retrospective analysis of a national database. SETTING Freestanding and hospital-based ambulatory surgery facilities. MEASUREMENTS Ambulatory knee and shoulder surgery cases from 1996 and 2006 were identified through the National Survey of Ambulatory Surgery. The incidence of unexpected disposition status was determined and risk factors for such outcome were analyzed. MAIN RESULTS Factors independently increasing the risk for unexpected disposition included procedures performed in hospital-based versus freestanding facilities [odds ratio (OR) 6.83 (95% confidence interval [CI] 4.34; 10.75)], shoulder versus knee procedures [OR 3.84 (CI 2.55; 5.77)], anesthesia provided by nonanesthesiology professionals and certified registered nurse-anesthetists versus anesthesiologists [OR 7.33 (CI 4.18; 12.84) and OR 1.80 (CI 1.09; 2.99), respectively]. Decreased risk for unexpected disposition was for procedures performed in 2006 versus 1996 [OR 0.15 (CI 0.10; 0.24)] and the use of anesthesia other than regional or general [OR 0.34 (CI 0.18; 0.68)]. CONCLUSIONS The decreased risk for unexpected disposition associated with more recent data and with freestanding versus hospital-based facilities may represent improvements in efficiency, while the decreased odds for such disposition status associated with the use of other than general or regional anesthesia may be related to a lower invasiveness of cases. We found an increased risk of adverse disposition in cases where the anesthesia provider was a nonanesthesiology professional. No difference in this outcome was noted when an anesthesia care team provided care.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA.
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YaDeau JT, Liu SS, Rade MC, Marcello D, Liguori GA. Performance Characteristics and Validation of the Opioid-Related Symptom Distress Scale for Evaluation of Analgesic Side Effects After Orthopedic Surgery. Anesth Analg 2011; 113:369-77. [DOI: 10.1213/ane.0b013e31821ae3f7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liu SS, Wu CL, Ballantyne JC, Buvanendran A, Rathmell JP, Warren DT, Viscusi ER, Ginsberg B, Rosenquist RW, Yadeau JY, Liguori GA. An End and a Beginning for ASRA AcutePOP. Reg Anesth Pain Med 2011. [DOI: 10.1097/aap.0b013e3182157db6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Beathe JC, Liguori GA. An Introductory Curriculum for Ultrasound-Guided Regional Anesthesia. Anesth Analg 2010. [DOI: 10.1213/ane.0b013e3181e62c21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kahn RL, Liguori GA. False Confidences in Preoperative Pregnancy Testing. Anesth Analg 2010. [DOI: 10.1213/ane.0b013e3181c04189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liu SS, Zayas VM, Gordon MA, Beathe JC, Maalouf DB, Paroli L, Liguori GA, Ortiz J, Buschiazzo V, Ngeow J, Shetty T, Ya Deau JT. A Prospective, Randomized, Controlled Trial Comparing Ultrasound Versus Nerve Stimulator Guidance for Interscalene Block for Ambulatory Shoulder Surgery for Postoperative Neurological Symptoms. Anesth Analg 2009; 109:265-71. [DOI: 10.1213/ane.0b013e3181a3272c] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Kahn RL, Liguori GA, Stanton MA, Levine DS, Edmonds CR. Routine Pregnancy Testing Before Elective Anesthesia Is Not an American Society of Anesthesiologists Standard. Anesth Analg 2009. [DOI: 10.1213/ane.0b013e31819b34e2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Brull R, Wijayatilake DS, Perlas A, Chan VWS, Abbas S, Liguori GA, Hargett MJ, El-Beheiry H. Practice patterns related to block selection, nerve localization and risk disclosure: a survey of the American Society of Regional Anesthesia and Pain Medicine. Reg Anesth Pain Med 2008; 33:395-403. [PMID: 18774508 DOI: 10.1016/j.rapm.2008.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 02/20/2008] [Accepted: 02/20/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES We aimed to identify current clinical practice patterns among members of the American Society of Regional Anesthesia and Pain Medicine (ASRA) members that relate to complications of regional anesthesia (RA). METHODS Invitations were posted to the 3,732 ASRA members, to participate in our survey. Members were asked to report the types and numbers of blocks performed annually, preferred nerve localization techniques, and routine risk disclosure practices prior to common neuraxial (NAB) and peripheral nerve (PNB) block techniques. RESULTS The number of respondents was 801 (response rate: 21.7%). Approximately half of the respondents perform >100 spinal and epidural blocks but <50 of each listed PNB annually. With the exception of axillary block, nerve stimulation is the overwhelmingly preferred nerve localization technique for PNB. Five hundred twenty-nine respondents (66.2%) disclose of RA primarily to allow patients to make an informed choice, while 227 (28.4%) disclose for medicolegal reasons. For NAB, the most commonly disclosed risks are headache and local pain/discomfort. Neurological complications following NAB such as permanent neuropathy and paralysis are inconsistently disclosed. For PNB, the most commonly disclosed risks are local pain/discomfort and transient neuropathy. The least commonly disclosed risks for both NAB and PNB include seizures, respiratory failure, cardiac arrest, and death. With the exception of headache following spinal anesthesia (1:100) and Horner's syndrome following interscalene block (1:10), there is little consensus regarding the perceived incidence of complications. CONCLUSIONS Based on a 22% response rate, our survey suggests that the risks of RA most commonly disclosed to patients by ASRA members are benign while severe complications of RA are far less commonly disclosed. There is little agreement among ASRA members regarding their perceived incidence of complications following RA.
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Affiliation(s)
- Richard Brull
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Stanton MA, Tong-Ngork S, Liguori GA, Edmonds CR. A new approach to preanesthetic site verification after 2 cases of wrong site peripheral nerve blocks. Reg Anesth Pain Med 2008; 33:174-7. [PMID: 18299099 DOI: 10.1016/j.rapm.2007.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 10/23/2007] [Accepted: 10/23/2007] [Indexed: 11/24/2022]
Abstract
OBJECTIVE We discuss the importance of a "preanesthetic site verification" and highlight 2 significant modifications to a policy developed at our institution in 2003. CASE REPORT The report describes 2 cases of wrong site peripheral nerve blocks that initiated protocol amendments to address shortcomings of the original policy. Two specific limitations were identified to improve upon. First, the practitioner must not overlook the site verification as it is essential prior to every block. Second, time delays between the verification and block performance should be minimized. CONCLUSIONS The "preanesthetic site verification" is an integral part of preventing wrong site block and surgery. To ensure that it is carried out before every peripheral nerve block, a unique multidisciplinary approach was adopted in which the block needles were removed from anesthesia carts and transferred to a separate container in the area of the circulating nurse. The anesthesiologist must now request a block needle from the circulating nurse immediately prior to block performance and confirm the site at that time. This safety process emulates the presurgical site verification that takes place before a scalpel is passed to a surgeon. Furthermore, the circulating nurse must remain at the bedside until block initiation to make sure that delays between site verification and block performance do not impinge on correct site placement.
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Affiliation(s)
- Maureen A Stanton
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA.
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Kahn RL, Stanton MA, Tong-Ngork S, Liguori GA, Edmonds CR, Levine DS. One-Year Experience with Day-of-Surgery Pregnancy Testing Before Elective Orthopedic Procedures. Anesth Analg 2008; 106:1127-31, table of contents. [DOI: 10.1213/ane.0b013e31816788df] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liguori GA, YaDeau JT, Zayas VM, Kahn R, Paroli L, Buschiazzo V. Comparing the Steam Engine With a Horse-Drawn Carriage? Anesth Analg 2007. [DOI: 10.1213/01.ane.0000256082.13498.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Brull R, McCartney CJL, Chan VWS, Liguori GA, Hargett MJ, Xu D, Abbas S, El-Beheiry H. Disclosure of risks associated with regional anesthesia: a survey of academic regional anesthesiologists. Reg Anesth Pain Med 2007; 32:7-11. [PMID: 17196486 DOI: 10.1016/j.rapm.2006.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Revised: 07/25/2006] [Accepted: 07/25/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In view of the relatively few large studies available to estimate the rates of complications following regional anesthesia, we aimed to identify and quantify the risks that academic regional anesthesiologists and regional anesthesia fellows disclose to their patients before performing central and peripheral nerve blockade. METHODS We asked 23 North American regional anesthesia fellowship program directors to distribute a questionnaire to the regional anesthesiologists and regional anesthesia fellows at their institutions. The questionnaire was designed to capture the risks and corresponding incidences that are routinely disclosed to patients before performing the most common central and peripheral nerve block techniques. RESULTS The total number of respondents was 79 from 12 different institutions. Fifty-eight (74%) respondents disclose risks of regional anesthesia in order to allow their patients to make an informed choice, whereas 20 (26%) disclose risks for medicolegal reasons. For central neural blockade, the most commonly disclosed risks are headache, local pain/discomfort, and infection. For peripheral nerve blockade, the most commonly disclosed risks are transient neuropathy, local pain/discomfort, and infection. For both central and peripheral nerve blockade, the risks most commonly disclosed are also those with the highest-reported incidences. CONCLUSIONS The risks of regional anesthesia most commonly disclosed to patients by academic regional anesthesiologists and regional anesthesia fellows are benign in nature and occur frequently. Severe complications of regional anesthesia are far less commonly disclosed. The incidences of severe complications disclosed by academic regional anesthesiologists and their fellows can be inconsistent with those cited in the contemporary literature.
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Affiliation(s)
- Richard Brull
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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Liguori GA, Zayas VM, YaDeau JT, Kahn RL, Paroli L, Buschiazzo V, Wu A. Nerve Localization Techniques for Interscalene Brachial Plexus Blockade: A Prospective, Randomized Comparison of Mechanical Paresthesia Versus Electrical Stimulation. Anesth Analg 2006; 103:761-7. [PMID: 16931693 DOI: 10.1213/01.ane.0000229705.45270.0f] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postoperative neurologic symptoms (PONS) are relatively common after upper extremity orthopedic surgery performed under peripheral neural blockade. In this study, we prospectively compared the incidence of PONS after shoulder surgery under interscalene (IS) block using the electrical stimulation (ES) or mechanical paresthesia (MP) techniques of nerve localization. For patients randomized to the MP group, a 1-in, 23-g long-beveled needle was placed into the IS groove to elicit a paresthesia to the shoulder, arm, elbow, wrist, or hand. For patients randomized to the ES group, a 5-cm, 22-g short-beveled insulated needle was placed into the IS groove to elicit a motor response including flexion or extension of the elbow, wrist, or fingers or deltoid muscle stimulation at a current between 0.2 and 0.5 mA. Each IS block was performed with 50-60 mL of 1.5% mepivacaine containing 1:300,000 epinephrine and 0.1meq/L sodium bicarbonate. Two-hundred-eighteen patients were randomized between the two groups. One patient was lost to follow-up. Twenty-five patients (23%) in the ES group experienced paresthesia during needle insertion. The incidence of PONS using the ES technique was 10.1% (11/109), whereas the incidence with the MP technique was 9.3% (10/108) (not significant). The PONS lasted a median duration of 2 mo, and symptoms in all patients resolved within 12 mo. The success rate, onset time, and patient satisfaction were also comparable between groups. We conclude that the choice of nerve localization technique can be made based on the patient's and anesthesiologist's comfort and preferences and not on concern for the development of PONS.
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Affiliation(s)
- Gregory A Liguori
- Hospital for Special Surgery, Department of Anesthesiology, Weill Medical College of Cornell University, New York, New York 10021, USA.
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Abstract
UNLABELLED Consent for a clinical anesthesia research trial is frequently sought in hospital on the day of surgery. This time is often associated with increased anxiety, diminished privacy, and limited opportunity for reflection. Our objective was to determine whether a preadmission telephone call on the day before surgery resulted in greater satisfaction compared to the traditional practice of initiating the consent process on the day of surgery. We randomized 124 patients eligible for participation in a minimal-risk clinical anesthesia trial to receive either a preadmission telephone call on the day before surgery to initiate consent (Telephone group; n = 62), or no telephone call (Control group; n = 62). In the Telephone group, 21 patients (33.9%) were successfully contacted by telephone, whereas 41 patients (66.1%) were not contacted. Both the Telephone and Control groups reported similar understanding regarding the purpose of the trial. Both groups similarly agreed that the time and setting of recruitment and consent were appropriate. Patients in both groups reported having enough time to consider their participation in the trial. Few patients in either group reported feeling anxious at the time of consent or pressured to participate in the trial. Finally, patients in both groups were equally satisfied with the consent process. IMPLICATIONS A preadmission telephone call on the day before surgery to initiate the consent process for a minimal-risk clinical anesthesia research trial does not improve satisfaction among consenting patients compared to initiating consent in hospital on the day of surgery, and can be an impractical method to initiate the consent process.
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Affiliation(s)
- Richard Brull
- Department of Anesthesiology, The Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY USA
| | - Jacques T. YaDeau
- Department of Anesthesiology, The Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY USA ,Department of Anesthesia, The Hospital for Special Surgery, 535 East 70th Street, New York, NY USA
| | - Jane Y. Lipnitsky
- Department of Anesthesiology, The Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY USA
| | - Gregory A. Liguori
- Department of Anesthesiology, The Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY USA
| | - C. Ronald MacKenzie
- Department of Medicine, The Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY USA
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Abstract
BACKGROUND AND OBJECTIVES The education and subsequent careers of regional anesthesia fellows have not been examined but may provide insight into improving future fellowship training and/or the future of the subspecialty. METHODS Regional anesthesia fellows educated during a 20-year period (1983-2002) were asked to complete a comprehensive survey that detailed their training, current professional setting, and use of regional anesthesia, and how they foresee the future of regional anesthesia. A separate survey of academic anesthesiology chairs assessed the role of and need for regional anesthesiologists in teaching departments. RESULTS Twelve regional anesthesia fellowship programs in the United States and Canada provided contact information on 176 former fellows. The survey response rate from those practicing in North America was 49% (77/156). Two of the 12 responding institutions have trained 68% of regional anesthesia fellows. Of respondents, 61% are or have been in academic practice. Regional anesthesia remains an integral part of most respondents' current practice, as evidenced by significant use of regional techniques, active involvement in subspecialty societies, and participation in continuing medical education programs. Academic chairs indicate that fellowship-trained regional anesthesiologists play important roles in resident education and are in demand by academic departments. CONCLUSIONS This report details how regional anesthesia fellows from 1983 to 2002 were trained and how they currently practice and examines their insights regarding the strengths and weaknesses of past and future regional anesthesia education.
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Affiliation(s)
- Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medicl Center, Seattle, WA, USA.
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Abstract
We prospectively evaluated 1273 patients who received spinal (or combined spinal-epidural [CSE]) anesthesia with 1.5% mepivacaine (plain, no glucose) for ambulatory surgery. We hypothesized that analysis of a large series of patients would confirm previous findings that isobaric 1.5% mepivacaine is not frequently associated with transient neurologic symptoms (TNS). Patients were contacted twice after the anesthetic, at days 1-4 and days 6-9. One-thousand-two-hundred-ten patients were successfully contacted postoperatively (95% follow-up rate). None of the patients had permanent neurologic sequelae from the anesthetic. None of the 372 CSE anesthetics was inadequate for surgery. Fourteen of 838 (1.7%) of the spinal anesthetics were inadequate. TNS, defined as the new onset of back pain that radiated bilaterally to buttocks or distally, occurred in 78 patients (6.4%; 95% confidence intervals 5.1%-8%). The mean age of patients who developed TNS (48 +/- 14 yr) was older than that of patients without TNS (41 +/- 16 yr) (P < 0.001). TNS was not influenced by gender or intraoperative position. The frequent success rate and infrequent rates of complications such as TNS and postdural puncture headache suggest that spinal anesthesia with mepivacaine is likely to be a safe and effective anesthetic for ambulatory patients.
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Affiliation(s)
- Jacques T YaDeau
- Anesthesiology Department, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
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Gerancher JC, Viscusi ER, Liguori GA, McCartney CJ, Williams BA, Ilfeld BM, Grant SA, Hebl JR, Hadzic A. Development of a standardized peripheral nerve block procedure note form. Reg Anesth Pain Med 2005; 30:67-71. [PMID: 15690271 DOI: 10.1016/j.rapm.2004.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Despite the tremendous growth of peripheral nerve blocks, no standard format exists to document their performance. Our objective was to create a peripheral nerve block form based on key elements of literature evidence and on our own group consensus. RESULTS We describe the process and results of our multi-institutional effort to construct a standardized peripheral nerve block procedure form. CONCLUSION A form was developed to help meet the medical, legal, and billing requirements of documentation consistent with the performance of peripheral nerve block.
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Affiliation(s)
- J C Gerancher
- Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1009, USA.
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Abstract
OBJECTIVE The purpose of this study was to develop a system to prevent laterality errors while performing peripheral nerve blockade. CASE REPORT The report depicts 2 cases of peripheral nerve blocks being performed on the wrong (nonoperative) extremity. An analysis of the circumstances in each case reveals distractions, schedule changes, and communication breakdown, which contributed to the error. A protocol to prevent these errors from occurring in the future, based on the Joint Commission on Accreditation of Healthcare Organizations guidelines, to eliminate "wrong-site" surgical procedures is developed and discussed. CONCLUSIONS The anesthesiologist plays an important role in preventing wrong-site peripheral nerve blockade and surgery. The protocol developed for "Pre-Anesthetic Site Verification" as a supplement to our preoperative site verification policy is invaluable in preventing wrong-site anesthesia and surgery.
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Affiliation(s)
- Chris R Edmonds
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA
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Abstract
BACKGROUND The number of regional anesthesia fellowships has grown over the past 2 decades. There currently exist no guidelines for what constitutes ideal regional anesthesia fellowship training. METHODS Regional anesthesia fellowship program directors and other advocates of regional anesthesia were invited to participate in a collaborative project to establish a standardized curriculum for regional anesthesia fellowships. Guidelines were created based on the existing template of Accreditation Council of Graduate Medical Education program requirements for residency education in anesthesiology. The resulting draft guidelines were distributed at a meeting of the program directors, who were then asked to forward all comments and relevant training material from their respective institutions to a coordinating institution. RESULTS All received materials were reviewed, and selected components were collated into a consensus document, which was then reviewed, modified, and eventually approved by the program directors over a 2-year series of meetings. The program directors agreed to adopt the guidelines as their fellowship curriculum and to evaluate their effectiveness in 2 years' time. CONCLUSIONS The intent of these initial guidelines is to improve the quality and consistency of regional anesthesia fellowship training. The creation process also led to an affirmation of the directors' commitment to continued dialogue for the purpose of facilitating the exchange of ideas among programs.
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Affiliation(s)
- Mary Jean Hargett
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY, USA
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Affiliation(s)
- Gregory A Liguori
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY 10021, USA.
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Liguori GA, Kahn RL, Gordon MA, Urban MK. Mechanisms of hypotension and bradycardia during regional anesthesia in the sitting position. Anesthesiology 2003; 100:191-2; author reply 192-3. [PMID: 14695746 DOI: 10.1097/00000542-200401000-00035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liguori GA, Beckman JD, Lee AC. A teaching model for training in regional anesthesia--or in peripheral nerve blockade? Anesth Analg 2003; 96:1837-1838. [PMID: 12761021 DOI: 10.1213/01.ane.0000063177.15467.3c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Gregory A Liguori
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY
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Liguori GA, Chimento GF, Borow L, Figgie M. Possible bupivacaine toxicity after intraarticular injection for postarthroscopic analgesia of the knee: implications of the surgical procedure. Anesth Analg 2002; 94:1010-3, table of contents. [PMID: 11916814 DOI: 10.1097/00000539-200204000-00044] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
IMPLICATIONS We report a case of possible bupivacaine toxicity after intraarticular injection during knee arthroscopy. The importance of the specific type of surgical procedure performed during arthroscopy and its relationship to potential local anesthetic toxicity are highlighted.
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Affiliation(s)
- Gregory A Liguori
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA
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Zayas VM, Liguori GA, Chisholm MF, Susman MH, Gordon MA. Dose response relationships for isobaric spinal mepivacaine using the combined spinal epidural technique. Anesth Analg 1999; 89:1167-71. [PMID: 10553828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Abstract
UNLABELLED Mepivacaine, a local anesthetic with similar physiochemical properties to those of lidocaine, is an adequate alternative for patients undergoing ambulatory procedures, and is associated with a lower incidence of transient neurologic symptoms (TNS) than lidocaine. We studied the dose-response characteristics of isobaric intrathecal mepivacaine using the combined spinal epidural technique for patients undergoing ambulatory arthroscopic surgery of the knee. Seventy-five patients were randomized prospectively to receive one of three doses of isobaric mepivacaine for spinal anesthesia: 30 mg (2 mL 1.5%), 45 mg (3 mL 1.5%), or 60 mg (4 mL 1.5%). An observer, blinded to the dose, recorded sensory level to pinprick and motor response until resolution of the block. In addition, the incidence of TNS was determined. An initial intrathecal dose of 30 mg of isobaric mepivacaine 1.5% produced satisfactory anesthesia in 72% of ambulatory surgical patients undergoing unilateral knee arthroscopy with a significantly shorter duration of sensory (158 +/- 32 min) and motor blockade (116 +/- 38 min) than doses of 45 and 60 mg. An intrathecal dose of 45 mg produced satisfactory anesthesia in all patients with a shorter duration of sensory (182 +/-38 min) and motor blockade (142 +/- 37 min) than 60 mg of mepivacaine 1.5% (203 +/- 36 min and 168 +/- 36 min, respectively). The incidence of TNS was 7.4% overall (1.2%-13.6% confidence intervals), less than the rates previously reported after spinal anesthesia with lidocaine in ambulatory surgical patients undergoing knee arthroscopy. We conclude that mepivacaine can be used as an adequate alternative to lidocaine for ambulatory procedures. IMPLICATIONS This study evaluated the postoperative duration of spinal anesthesia after varying doses of isobaric mepivacaine and the incidence of transient radiating back and leg pain. We found that 45 mg of mepivacaine provided adequate anesthesia, a timely discharge, and a lower incidence of back pain than that previously reported after lidocaine spinals.
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Affiliation(s)
- V M Zayas
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA
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Zayas VM, Liguori GA, Chisholm MF, Susman MH, Gordon MA. Dose Response Relationships for Isobaric Spinal Mepivacaine Using the Combined Spinal Epidural Technique. Anesth Analg 1999. [DOI: 10.1213/00000539-199911000-00015] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Williams-Russo P, Sharrock NE, Mattis S, Liguori GA, Mancuso C, Peterson MG, Hollenberg J, Ranawat C, Salvati E, Sculco T. Randomized trial of hypotensive epidural anesthesia in older adults. Anesthesiology 1999; 91:926-35. [PMID: 10519494 DOI: 10.1097/00000542-199910000-00011] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Data are sparse on the incidence of postoperative cognitive, cardiac, and renal complications after deliberate hypotensive anesthesia in elderly patients. METHODS This randomized, controlled clinical trial included 235 older adults with comorbid medical illnesses undergoing elective primary total hip replacement with epidural anesthesia. The patients were randomly assigned to one of two levels of intraoperative mean arterial blood pressure management: either to a markedly hypotensive mean arterial blood pressure range of 45-55 mmHg or to a less hypotensive range of 55-70 mmHg. Cognitive outcome was assessed by within-patient change on 10 neuropsychologic tests assessing memory, psychomotor, and language skills from before surgery to 1 week and 4 months after surgery. Prospective standardized surveillance was performed for cardiovascular and renal outcomes, delirium, thromboembolism, and blood loss and replacement. RESULTS The two groups were similar at baseline in terms of age (mean, 72 yr), sex (50% women), comorbid conditions, and cognitive function. After operation, no significant differences in the incidence of early or long-term cognitive dysfunction were observed between the two blood pressure management groups. There were no significant differences in the rates of other adverse consequences, including cardiac, renal, and thromboembolic complications. In addition, no differences occurred in the duration of surgery, intraoperative estimated blood loss, or transfusion rates. CONCLUSIONS Elderly patients can safely receive controlled hypotensive epidural anesthesia with this protocol. There was no evidence of greater risks, or early benefits, with the use of the more markedly hypotensive range.
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Affiliation(s)
- P Williams-Russo
- Department of Medicine, Cornell Medical College, New York, New York, USA.
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Liguori GA, Kahn RL, Gordon J, Gordon MA, Urban MK. The use of metoprolol and glycopyrrolate to prevent hypotensive/bradycardic events during shoulder arthroscopy in the sitting position under interscalene block. Anesth Analg 1998; 87:1320-5. [PMID: 9842820 DOI: 10.1097/00000539-199812000-00020] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED Sudden profound hypotensive and/or bradycardic events (HBE) have been reported in >20% of patients undergoing shoulder arthroscopy in the sitting position under interscalene block anesthesia. Retrospective studies suggest that the administration of beta-blockers is safe and may decrease the incidence of these episodes. We performed a randomized, prospective study to evaluate prophylaxis of these events. One hundred fifty patients were randomized to one of three groups (placebo; prophylactic metoprolol to achieve a heart rate <60 bpm or a maximal dose of 10 mg; or prophylactic glycopyrrolate to achieve a heart rate >100 bpm or a maximal dose of 6 microg/kg) immediately after the administration of the interscalene block. Blood pressure control was achieved with IV enalaprilat as needed. The incidence of HBE was 28% in the placebo group versus 5% in the metoprolol group (P = 0.004). The rate of 22% in the glycopyrrolate group was not significantly different from placebo. Preoperative heart rate and arterial blood pressure, intraoperative sedation score, IV fluids, and enalaprilat use were similar in those patients who had a HBE compared with those who did not. Many aspects of this clinical setting are similar to tilttable testing for patients with recurrent vasovagal syncope, in which beta-adrenergic blockade with metoprolol has also been shown to be effective. We conclude that the Bezold-Jarisch reflex is the most likely mechanism for these events. IMPLICATIONS Episodes of acute hypotension and bradycardia occur during shoulder arthroscopy in the sitting position under interscalene block. In this study, we demonstrate that metoprolol, but not glycopyrrolate, markedly decreases the incidence of these episodes when given prophylactically immediately after the administration of the block.
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Affiliation(s)
- G A Liguori
- Hospital for Special Surgery and Department of Anesthesiology, Cornell University Medical College, New York, New York 10021, USA
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Liguori GA, Kahn RL, Gordon J, Gordon MA, Urban MK. The Use of Metoprolol and Glycopyrrolate to Prevent Hypotensive/Bradycardic Events During Shoulder Arthroscopy in the Sitting Position Under Interscalene Block. Anesth Analg 1998. [DOI: 10.1213/00000539-199812000-00020] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Liguori GA, Zayas VM. Repeated episodes of transient radiating back and leg pain following spinal anesthesia with 1.5% mepivacaine and 2% lidocaine. Reg Anesth Pain Med 1998; 23:511-5. [PMID: 9773707 DOI: 10.1016/s1098-7339(98)90037-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Transient radiating back and leg pain defined as pain or dysesthesias in the buttocks, thighs, or calves within 24 to 48 hours after recovery from spinal anesthesia has been described with the use of 2% and 5% lidocaine. These symptoms have also been associated with other local anesthetics such as bupivacaine and tetracaine, although with a much lower incidence. A recent case report and prospective study have described transient radiating back and leg pain occurring following spinal anesthesia with 4% mepivacaine. METHODS We describe a case of transient radiating back and leg pain following spinal anesthesia with 1.5% mepivacaine in a patient with unrecognized spinal stenosis who had had repeated episodes of transient radiating back and leg pain associated with lidocaine spinals. RESULTS Spinal anesthesia with 1.5% mepivacaine was associated with transient radiating back and leg pain, which was similar in quality and duration to prior episodes following spinal anesthesia with lidocaine. CONCLUSIONS Transient radiating back and leg pain may occur with lower concentrations (1.5%) of mepivacaine, as it does with lidocaine. The relationship between transient radiating back and leg pain and spinal stenosis is also discussed.
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Affiliation(s)
- G A Liguori
- Department of Anesthesia, Cornell University Medical Center, New York, New York, USA
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Abstract
BACKGROUND Spinal anesthesia with lidocaine is ideal for ambulatory surgery because of its short duration of action. However, transient neurologic symptoms (TNS) occur in 0-40% of patients. The incidence of TNS with mepivacaine, which has a similar duration of action, is unknown. METHODS Sixty ambulatory patients undergoing knee arthroscopy received spinal anesthesia in a randomized, double-blinded manner, with either 45 mg 1.5% mepivacaine or 60 mg 2% lidocaine. An L3-L4 midline approach was used with a 27-gauge Whitacre needle and a 20-gauge introducer. The local anesthetic was injected over approximately 30 s with the aperture of the Whitacre needle in a cephalad direction. Two to 4 days after operation, each patient was questioned about the development of TNS. In addition, the two groups were compared for time to regression of sensory and motor blockade and time to discharge milestones. RESULTS Three patients receiving lidocaine were lost to follow-up. None of the 30 patients in the mepivacaine group developed TNS, whereas 6 of 27 (22%) in the lidocaine group did (P = 0.008). Time to regression to the L5 sensory level and to complete resolution of motor block were similar in both groups. The times to discharge milestones were also comparable. CONCLUSIONS The incidence of TNS is greater with 2% lidocaine than with 1.5% mepivacaine for patients having unilateral knee arthroscopy under spinal anesthesia. Mepivacaine seems to be a promising alternative to lidocaine for outpatient surgical procedures because of its similar duration of action. Further studies are warranted to determine the optimal dose of intrathecal mepivacaine for ambulatory surgery and the incidence of TNS with other doses and concentrations of intrathecal mepivacaine.
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Affiliation(s)
- G A Liguori
- Department of Anesthesiology, Hospital for Special Surgery, Cornell Medical College, New York, New York 10021, USA
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Affiliation(s)
- G A Liguori
- Department of Anesthesiology, Hospital For Special Surgery, New York, New York 10021, USA
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Waldman SA, Liguori GA. Comparison of the flow rates of 27-gauge Whitacre and Sprotte needles for combined spinal and epidural anesthesia. Reg Anesth 1996; 21:378-379. [PMID: 8837210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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