Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks

BACKGROUND

Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks.

METHODS

We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement.

RESULTS

A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research.

CONCLUSIONS

We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BACKGROUND

Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

METHODS

A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.

RESULTS

Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).

CONCLUSIONS

Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.

RECOMMENDATION

PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

MRI and muscle enzymes do not support the diagnosis of local anesthetic myotoxicity: a descriptive case series

BACKGROUND

The presence of thigh muscle edema as characterized by increased signal intensity on MRI has been used to support the diagnosis of presumed local anesthetic-induced myotoxicity reported after total knee arthroplasty (TKA) with continuous adductor canal block (CACB). However, neither postoperative baseline imaging appearance nor muscle enzyme values have been described in conjunction with this clinical scenario. Thus, the usefulness of MRI or enzymatic biomarkers of muscle injury for supporting the diagnosis of local anesthetic myotoxicity is unknown.

METHODS

This descriptive case series documents postoperative MRI appearance of the ipsilateral upper leg, plus preoperative and postoperative creatine phosphokinase and aldolase values in volunteer patients who underwent uncomplicated TKA with CACB.

RESULTS

In 27 volunteer patients with no postsurgical evidence of clinically relevant myotoxicity, anterior thigh muscle edema was universally evident on imaging (n=12) and muscle enzyme values (n=19) were normal or only slightly elevated.

CONCLUSIONS

The non-specificity of these findings suggests that MRI and near normal muscle enzyme levels are of limited diagnostic value when there is clinical suspicion of local anesthetic myotoxicity in the setting of TKA with CACB.

TRIAL REGISTRATION NUMBER

NCT04821245.

American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity checklist: 2020 version

The American Society of Regional Anesthesia and Pain Medicine (ASRA) periodically updates its practice advisories and associated cognitive aids. The 2020 version of the ASRA Local Anesthetic Systemic Toxicity checklist was created in response to user feedback, simulation studies and advances in medical knowledge. This report presents the 2020 version and discusses the rationale for its update.

Contrast-enhanced paravertebrogram to confirm paravertebral catheter position in elective thoracic surgery: a proof of concept study

Background

Paravertebral pain catheters have been shown to be equally effective as epidural pain catheters for postoperative analgesia after thoracic surgery with the possible additional benefit of less hemodynamic effect. However, a methodology for verifying correct paravertebral catheter placement has not been tested or objectively confirmed in previous studies. The aim of the current study was to describe a technique to confirm the correct position of a paravertebral pain catheter using a contrast-enhanced paravertebrogram.

Methods

A retrospective cohort proof of concept study was performed including 10 consecutive patients undergoing elective thoracic surgery with radiographic contrast-enhanced confirmation of intraoperative paravertebral catheter placement (paravertebrogram).

Results

The results of the paravertebrograms, which were done in the operating room at the end of the procedure, verified correct paravertebral catheter placement in 10 of 10 patients. The radiographs documented dissemination of local anesthetic within the paravertebral space.

Conclusion

This proof of concept study demonstrated that a contrast-enhanced paravertebrogram could be used in conjunction with standard postoperative chest radiography to add valuable information for the assessment of paravertebral catheter placement. This technique has the potential to increase the accuracy and efficiency of postoperative analgesia, and to set a quality standard for future studies of paravertebral pain catheters.

History and evolution of regional anesthesiology and acute pain medicine fellowship training

INTRODUCTION

In 2016, individual training programs in regional anesthesiology and acute pain medicine (RA/APM) became eligible for accreditation by the Accreditation Council for Graduate Medical Education (ACGME), thereby culminating a process that began 15 years earlier. Herein, we review the origins of regional anesthesia training in the USA, the events leading up to accreditation and the current state of the fellowship.

METHODS

We reviewed pertinent literature on the historical aspects of RA/APM in the USA, related subspecialty training and the formation and current state of RA/APM fellowship training programs. Additionally, a survey was distributed to the directors of the 74 RA/APM fellowships that existed as of 1 January 2017 to gather up-to-date, program-specific information.

RESULTS

The survey yielded a 76% response rate. Mayo Clinic Rochester and Virginia Mason Medical Center likely had the first structured RA/APM fellowships with formalized curriculums and stated objectives, both starting in 1982. Most programs (86%), including ACGME and non-ACGME fellowships, came into existence after the year 2000. Six responding programs have or previously had RA/APM comingled with another subspecialty. Eight current programs originally offered unofficial or part-time fellowships in RA/APM, with fellows also practicing as attending physicians.

DISCUSSION

The history of RA/APM training in the USA is a tortuous one. It began with short 'apprenticeships' under the tutelage of the early proponents of regional anesthesia and continues today with 84 official RA/APM programs and a robust fellowship directors' group. RA/APM programs teach skills essential to the practice and improvement of anesthesiology as a specialty.

Evidence versus advocacy, as related to radiofrequency denervation in the treatment of chronic low back pain and the MINT trials

In 2017, JAMA: Journal of the American Medical Association published the results of the MINT trials, prospective research involving 681 patients, all of whom received exercise therapy for low back pain. Half of the patients were randomized to additionally receive radiofrequency denervation (RFD) treatment. 88% of patients completed the 3-month follow-up, and 77% completed the 12-month follow-up. In this context, RFD provided no added benefit over the baseline of exercise therapy. In 2018, five authors, all experts in pain medicine, published a 'Daring Discourse' article in the journal Regional Anesthesia and Pain Medicine (RAPM), criticizing the findings of the MINT trials. Although 3 of the 5 authors of the RAPM 'Daring Discourse' article reported in conflict of interest statements-as is appropriate-that they were consultants to corporations that produce RFD equipment, the authors failed to disclose that 4 of 5 are on the editorial board of RAPM and all 5 are current officers in the medical organization that owns RAPM: that is, the American Society of Regional Anesthesia and Pain Medicine. Noteworthy, there was no published response from the MINT trial investigators to the Daring Discourse criticisms, either in the aforementioned example or in downstream venues where some of the same Daring Discourse authors continued their widely disseminated criticisms of the JAMA/MINT trials report. We believe that these actions taken by the Daring Discourse authors and RAPM have unfairly tipped the scales in the evaluation and application of RFD treatment of low back pain. In our commentary, we discuss: (1) the challenges associated with using clinical trials to predict clinical efficacy, (2) appropriate and inappropriate uses of postpublication commentary on original research findings, (3) the use of inappropriate commentary (and related means) to alter clinical practice in the presence of contradictory research findings, and (4) potential conflicts of interest related to the authors' and Journal's publication of the unopposed MINT trials criticism.

Selective Epidurography for the Assessment of Epidural Catheter Placement After Esophagectomy

BACKGROUND

Adequate pain control immediately after esophagostomy is critical to patient recovery and may be compromised by uncertainty regarding correct epidural catheter placement. The aim of the current study was to determine the role of performing an epidurogram in selective patients to assess epidural placement after esophagectomy.

METHODS

Patients undergoing esophagectomy in a high-volume center were retrospectively reviewed to identify those in whom an epidurogram was performed less than 24 hours after surgery. Since 2012 epidurograms have been selectively performed in patients and have demonstrated features concerning for incorrect epidural catheter placement, including difficult/complicated insertion, negative sensory test, nonreassuring intraoperative hemodyamic response, and inadequate postoperative pain control.

RESULTS

Fifty-two of 192 patients (27%; 43 men; age 65 ± 11 years) who underwent esophagostomy since 2012 had an epidurogram. Epidurograms were not associated with any adverse events. In 21 patients (40%) epidurogram findings led to a direct change in patient management, prompting either removal/replacement of an incorrectly sited catheter (n = 9), partial withdrawal of a catheter associated with unilateral contrast distribution (n = 2), or by endorsing a clinical decision to modify the analgesic regimen in a patient with a correctly sited epidural catheter (n = 10). Identifying and rescuing incorrect epidural catheter placement was not associated with longer intensive care unit/hospital stay or postoperative morbidity (p > 0.05) CONCLUSIONS: We reviewed selective epidurogram use in esophagectomy patients to determine its role in "rescuing" inadequate pain control through expediting clinical decision-making. Findings confirm that in selected patients epidurography is feasible and has the potential to directly contribute to patient care.

Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis

BACKGROUND

Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.

METHODS

The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.

RESULTS

The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87.

CONCLUSIONS

Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.

RECOMMENDATION

neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.

TRIAL REGISTRY NUMBER

PROSPERO CRD42018099935.

Lower extremity regional anesthesia: essentials of our current understanding

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version

The American Society of Regional Anesthesia and Pain Medicine (ASRA) periodically revises and updates its checklist for the management of local anesthetic systemic toxicity. The 2017 update replaces the 2012 version and reflects new information contained in the third ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Electronic copies of the ASRA checklist can be downloaded from the ASRA Web site (www.asra.com) for inclusion in local anesthetic toxicity rescue kits or perioperative checklist repositories.

Difficult Ventilation After Successful Intubation in the Emergency Setting due to a Ball Valve Clot

The inability to ventilate a patient after successful intubation is a rare but emergent situation and may be caused by obstruction of the endotracheal tube, bilateral tension pneumothorax, esophageal intubation, severe bronchospasm, or mainstem bronchus intubation. We describe an increase in mean airway pressure, inability to ventilate, and loss of cardiac output secondary to a blood clot acting as a ball valve at the end of an endotracheal tube.

Anesthetic Challenges in an Adult with Pierre Robin Sequence, Severe Juvenile Scoliosis, and Respiratory Failure

Anesthesiologists have the privilege and challenge of providing care for an extremely diverse population of patients, at times in urgent or emergent situations. We present a case of a 31-year-old woman with Pierre Robin sequence, severe juvenile scoliosis, and respiratory failure who underwent successful awake nasal fiberoptic intubation for tracheostomy at an adult tertiary care medical center. Familiarity with patient conditions infrequently encountered within our practice, as well as adherence to practice guidelines, proved essential to providing our patient with the safest care possible.

Upper extremity regional anesthesia: essentials of our current understanding, 2008

Brachial plexus blockade is the cornerstone of the peripheral nerve regional anesthesia practice of most anesthesiologists. As part of the American Society of Regional Anesthesia and Pain Medicine's commitment to providing intensive evidence-based education related to regional anesthesia and analgesia, this article is a complete update of our 2002 comprehensive review of upper extremity anesthesia. The text of the review focuses on (1) pertinent anatomy, (2) approaches to the brachial plexus and techniques that optimize block quality, (4) local anesthetic and adjuvant pharmacology, (5) complications, (6) perioperative issues, and (6) challenges for future research.

Regional anesthesia in anesthetized or heavily sedated patients

The American Society of Regional Anesthesia and Pain Medicine (ASRA) Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine includes an evidence- and expert opinion-based section on performing procedures on anesthetized or heavily sedated patients. This practice advisory is based on existing scientific literature, pathophysiological principles, and expert opinion. The advisory panel examined the ability of anesthetized or heavily sedated patients to recognize and report intravascular injection of local anesthetic or impending neurologic injury. The advisory panel also considered whether or not the ability to recognize and report symptoms could actually affect the occurrence of nerve injury or local anesthetic systemic toxicity. The advisory contains recommendations pertaining to both adult and pediatric patients.

ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Neurologic complications associated with regional anesthesia and pain medicine practice are extremely rare. The ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine addresses the etiology, differential diagnosis, prevention, and treatment of these complications. This Advisory does not focus on hemorrhagic and infectious complications, because they have been addressed by other recent ASRA Practice Advisories. The current Practice Advisory offers recommendations to aid in the understanding and potential limitation of neurologic complications that may arise during the practice of regional anesthesia and pain medicine.

Beyond spinal headache: prophylaxis and treatment of low-pressure headache syndromes

OBJECTIVE

This Evidence-Based Case Management article evaluates and grades the evidence for two anesthesiology-related interventions: prophylaxis after unintentional meningeal puncture and treatment of spontaneous intracranial hypotension (SIH).

METHODS

A search was made of relevant English language clinical studies or reports pertinent to the topic of low-pressure headache, but excluding the treatment of meningeal puncture headache.

RESULTS

Thirty-seven case reports, case series, and clinical trials were included to develop the best available evidence-based recommendations for the prophylaxis of unintentional meningeal puncture and for the treatment of SIH.

CONCLUSION

The highest quality randomized controlled trials suggest that prophylactic epidural blood patch (EBP) does not reduce the incidence of headache after unintentional meningeal puncture. The weight of existing literature supports EBP as an initial treatment of SIH, although its effectiveness does not approach that seen when EBP is used to treat meningeal puncture headache.

The Role of the Anesthesiologist in Fast-Track Surgery: From Multimodal Analgesia to Perioperative Medical Care

BACKGROUND

Improving perioperative efficiency and throughput has become increasingly important in the modern practice of anesthesiology. Fast-track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor (i.e., outpatient) and major (inpatient) surgery procedures. In this article we focus on the expanding role of the anesthesiologist in fast-track surgery.

METHODS

A multidisciplinary group of clinical investigators met at McGill University in the Fall of 2005 to discuss current anesthetic and surgical practices directed at improving the postoperative recovery process. A subgroup of the attendees at this conference was assigned the task of reviewing the peer-reviewed literature on this topic as it related to the role of the anesthesiologist as a perioperative physician.

RESULTS

Anesthesiologists as perioperative physicians play a key role in fast-track surgery through their choice of preoperative medication, anesthetics and techniques, use of prophylactic drugs to minimize side effects (e.g., pain, nausea and vomiting, dizziness), as well as the administration of adjunctive drugs to maintain major organ system function during and after surgery.

CONCLUSION

The decisions of the anesthesiologist as a key perioperative physician are of critical importance to the surgical care team in developing a successful fast-track surgery program.

Regional anesthesia and pain medicine after 30 years: A historical perspective

Regional Anesthesia and Pain Medicine celebrates its 30th anniversary in 2006. What began as a 10-page, industry-sponsored bulletin has evolved into a major anesthesiology and pain journal. This history article chronicles the journal's growth and development over 3 decades.

The training and careers of regional anesthesia fellows--1983-2002

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.

Guidelines for Regional Anesthesia Fellowship Training

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.

Euthyroid pretibial myxedema

OBJECTIVE

To describe a case of biopsy-proven pretibial myxedema in a man with normal thyroid function.

METHODS

We present the pertinent clinical and laboratory data for the current case and review previously published information on pretibial myxedema.

RESULTS

Our patient, a 53-year-old man, had the characteristic lesions of pretibial myxedema on the anterolateral aspects of his calves. Laboratory tests showed normal thyroid function. The thyroid-stimulating immunoglobulin value was above normal. No exophthalmos or goiter was present. This uncommon dermopathy is typically associated with Graves' disease, accompanied by clinical hyperthyroidism, ophthalmopathy, and goiter.

CONCLUSION

The pathogenesis of pretibial myxedema remains elusive. It is presumed to be an autoimmune phenomenon attributable to the presence of serum thyroid-stimulating immunoglobulin, although immunofluorescence studies have failed to demonstrate a direct role for such an immunoglobulin. Only two other cases of biopsy-proven pretibial myxedema in a euthyroid patient were found in the literature.

Prospective comparison of continuous femoral nerve block with nonstimulating catheter placement versus stimulating catheter-guided perineural placement in volunteers

BACKGROUND AND OBJECTIVES

Stimulating catheter-guided perineural placement may potentially increase the success rate and quality of continuous femoral nerve block as compared with a nonstimulating catheter technique. These hypotheses have not been rigorously tested.

METHODS

Twenty volunteers underwent placement of bilateral femoral nerve catheters in this prospective, randomized, double-blind study. For each side, a stimulating needle was advanced until quadriceps contractions were obtained at < or =0.5 mA. On one side, a stimulating catheter was advanced 4 to 5 cm beyond the needle tip while eliciting quadriceps contractions via the catheter. If quadriceps contractions decreased or disappeared, the catheter position was adjusted until quadriceps contractions could be elicited at < or =0.5 mA. On the contralateral side, an identical catheter was advanced 4 to 5 cm beyond the needle tip without attempts to elicit quadriceps contractions via the catheter. After bolus injection of 10 mL lidocaine 1%, ropivacaine 0.2% at 10 mL/h was continuously infused through both catheters for 4 hours. Success of femoral block was defined as loss of sensation to cold and pinprick stimuli. Quality of successful block was determined by tolerance to transcutaneous electrical stimulation and force dynamometry of quadriceps strength.

RESULTS

Block success was 100% via the stimulating catheters versus 85% via the nonstimulating catheters (P =.07). Overall tolerance to transcutaneous electrical stimulation (P =.009) and overall depth of motor block (P =.03) was significantly higher in the stimulating catheter-guided femoral nerve blocks.

CONCLUSIONS

In this volunteer study, there was no statistically significant difference in block success between the two techniques. However, stimulating catheter-guided placement provided an increased overall quality of continuous femoral perineural blockade. Further studies are needed to verify these observations in the clinical setting.

Near-total esophagectomy: the influence of standardized multimodal management and intraoperative fluid restriction

BACKGROUND AND OBJECTIVES

Esophagectomy can be associated with high morbidity and mortality. We present our experience managing these patients using a standardized multimodal approach that emphasizes intraoperative fluid restriction and early extubation.

METHODS

This case series includes 56 consecutive patients over a 2-year period (1999-2000) that underwent near-total esophagectomy at a high-volume center. Surgical approach was determined by patient and tumor characteristics; intraoperative fluid replacement was conservative; and patient-controlled epidural anesthesia/analgesia was used to promote early extubation, enteral feeding, and ambulation.

RESULTS

Overall morbidity was 18%; in-hospital and 30-day mortality was zero. Intraoperative urinary volume averaged 0.57 mL/kg/h. No patient developed postoperative renal dysfunction or pulmonary complications. All patients were extubated in the operating room. First ambulation averaged 1.6 days after surgery. Median intensive care unit and hospital stays were 1 and 10 days, respectively. Side effects from thoracic epidural analgesia were minimal.

CONCLUSIONS

Significant reduction in esophagectomy-related morbidity is possible using a standardized multimodal approach in routine clinical practice. Intraoperative fluid restriction may facilitate early extubation and reduce pulmonary complications without compromising renal function. This preliminary observation warrants further study in a randomized clinical trial.

Suprascapular nerve block prolongs analgesia after nonarthroscopic shoulder surgery but does not improve outcome

Suprascapular nerve block (SSNB) reportedly improves analgesia and 24-h outcomes after arthroscopic shoulder surgery performed under general anesthesia. In this study, we assessed the analgesic and clinical outcome efficacy of SSNB as an adjunct to interscalene brachial plexus block (ISB) for ambulatory nonarthroscopic shoulder surgery. Fifty patients were randomized to receive either a SSNB or sham injection as part of a standardized ISB-general anesthesia regimen. Time to first significant pain (the primary outcome measure) was significantly delayed in the SSNB group (594 +/- 369 min versus 375 +/- 273 min, respectively; P = 0.02). There were no other differences between groups with regard to postanesthesia recovery unit measures, 24-h assessment of pain, supplemental analgesic use, or quality of life outcomes. We conclude that adjunctive SSNB adds minimal value to a primary ISB anesthetic for nonarthroscopic shoulder surgery.

IMPLICATIONS

When used as an adjunct to an interscalene block combined with general anesthesia, suprascapular nerve block with bupivacaine moderately prolongs analgesia without improving other outcome measures after ambulatory nonarthroscopic shoulder surgery.