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Elmer DA, Coleman JR, Slee AE, Hanson NA. In reply: a recent non-inferiority trial of bupivacaine alone versus liposomal bupivacaine plus bupivacaine in interscalene blocks for total shoulder arthroplasty. Reg Anesth Pain Med 2023; 48:434. [PMID: 36754545 DOI: 10.1136/rapm-2023-104373] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/10/2023]
Affiliation(s)
- Donald A Elmer
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - John R Coleman
- Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - April E Slee
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Neil A Hanson
- Anesthesiology, University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
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Coleman JR, Hanson NA. How, when and why to establish preoperative surgical risk in thoracic surgery. Curr Opin Anaesthesiol 2023; 36:68-73. [PMID: 36550607 DOI: 10.1097/aco.0000000000001215] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Emphasizing a systems-based approach, we discuss the timing for referral for perioperative surgical consultation. This review then highlights several types of comorbidities that may complicate thoracic procedures, and references recent best practices for their management. RECENT FINDINGS Patients requiring thoracic surgeries present some of the most challenging cases for both intraoperative and postoperative management. The recent SARS-CoV-2 pandemic has only exacerbated these concerns. Effective preoperative optimization, however, provides for identification of patient comorbidities, allowing for mitigation of surgical risks. This kind of planning is multidisciplinary by nature. We believe patients benefit from early engagement of a dedicated preoperative clinic experienced for caring for complex surgical patients. SUMMARY Optimizing patients for thoracic surgery can be challenging for small and large health systems alike. Implementation of evidence-based guidelines can improve care and mitigate risk. As surgical techniques evolve, future research is needed to ensure that perioperative care continues to progress.
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Affiliation(s)
- John R Coleman
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia
| | - Neil A Hanson
- Department of Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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Elmer DA, Coleman JR, Slee AE, Hanson NA. In reply: non-inferiority trial comparing bupivacaine versus liposomal bupivacaine. Reg Anesth Pain Med 2023; 48:384-385. [PMID: 36669851 DOI: 10.1136/rapm-2023-104333] [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] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Donald A Elmer
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - John R Coleman
- Anesthesiology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - April E Slee
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Neil A Hanson
- Anesthesiology, University of Minnesota Academic Health Center, Minneapolis, Minnesota, USA
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Elmer DA, Coleman JR, Renwick CM, Amato PE, Werner BC, Brockmeier SF, Slee AE, Hanson NA. Comparing bupivacaine alone to liposomal bupivacaine plus bupivacaine in interscalene blocks for total shoulder arthroplasty: a randomized, non-inferiority trial. Reg Anesth Pain Med 2022; 48:1-6. [DOI: 10.1136/rapm-2022-103997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
IntroductionInterscalene brachial plexus blocks are a commonly performed procedure to reduce pain following total shoulder arthroplasty. Liposomal bupivacaine has been purported to prolong the duration of brachial plexus blocks for up to 72 hours; however, there has been controversy surrounding the analgesic benefits of this drug. Our hypothesis was that an interscalene block performed with bupivacaine alone would be non-inferior to a combination of liposomal bupivacaine and bupivacaine with respect to opioid consumption following total shoulder arthroplasty.MethodsSubjects presenting for primary total shoulder arthroplasty were randomized in a 1:1 ratio to an ultrasound-guided, single-injection interscalene block with either a combination of liposomal bupivacaine and bupivacaine (LB group) or bupivacaine without additive (Bupi group). The primary outcome of this study was 72-hour postoperative cumulative opioid consumption (in oral morphine equivalents) with a non-inferiority margin of 22.5 mg. Secondary outcomes included pain scores, patient satisfaction with analgesia and patient reported duration of sensory block.ResultsSeventy-six subjects, 38 from the Bupi group and 38 from the LB group, completed the study. Analysis of the primary outcome showed a 72-hour cumulative geometric mean oral morphine equivalent consumption difference of 11.9 mg (95% CI −6.9 to 30.8) between groups (calculated on the log scale). This difference constitutes approximately 1.5 tablets of oxycodone over 3 days. No secondary outcomes showed meaningful differences between groups.DiscussionInterscalene brachial plexus blocks performed with bupivacaine alone did not demonstrate non-inferiority compared to a mixture of liposomal bupivacaine plus bupivacaine with regards to 72-hour cumulative opioid consumption following total shoulder arthroplasty. However, the difference between groups did not appear to be clinically meaningful.
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Amato PE, Coleman JR, Dobrzanski TP, Elmer DA, Gwathmey FW, Slee AE, Hanson NA. Pericapsular nerve group (PENG) block for hip arthroscopy: a randomized, double-blinded, placebo-controlled trial. Reg Anesth Pain Med 2022; 47:rapm-2022-103907. [PMID: 35998937 DOI: 10.1136/rapm-2022-103907] [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] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/16/2022] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Arthroscopic hip surgery is associated with significant postoperative pain. Femoral nerve blocks have been shown to improve postoperative analgesia at the expense of quadriceps weakness. The pericapsular nerve group (PENG) block could be an alternative that may improve postoperative analgesia while preserving quadriceps strength. Our hypothesis was that a PENG block would provide superior postoperative analgesia compared with a sham block following arthroscopic hip surgery. METHODS Subjects presenting for arthroscopic hip surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection PENG block (PENG group) with 20 mL of 0.5% ropivacaine or a sham injection with 5 mL of 0.9% normal saline (Sham group) prior to receiving general anesthesia. The primary outcome of this study was worst pain score within 30 min of emergence from anesthesia. Secondary outcomes included opioid consumption, patient satisfaction with analgesia, opioid-related adverse events, and persistent opioid use at 1 week. RESULTS Sixty-eight subjects, 34 from the PENG group and 34 from the Sham group, completed the study per protocol. Analysis of the primary outcome demonstrated a mean difference in pain scores of -0.79 (95% CI -1.96 to 0.37; p=0.17) between the PENG and Sham groups immediately following surgery. No secondary outcomes showed statistically significant differences between groups. DISCUSSION This study demonstrates that a preoperative PENG block does not improve analgesia following arthroscopic hip surgery. TRIAL REIGSTRATION NUMBER NCT04508504.
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Affiliation(s)
- Peter E Amato
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - John R Coleman
- Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Tomasz P Dobrzanski
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Donald A Elmer
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Frank W Gwathmey
- Orthopedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - April E Slee
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Neil A Hanson
- Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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Donahue RP, Stamm AW, Daily AM, Kozlowski PM, Porter CR, Govier FE, Cowan NG, Lucioni A, Kuhr CS, Kobashi KC, Hanson NA, Corman JM, Lee UJ. Opioid-Limiting Pain Control After Transurethral Resection of the Prostate: A Randomized Controlled Trial. Urology 2022; 166:202-208. [PMID: 35314185 DOI: 10.1016/j.urology.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/14/2022] [Accepted: 03/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess whether a multimodal opioid-limiting protocol and patient education intervention can reduce postoperative opioid use following transurethral resection of the prostate. METHODS This prospective, non-blinded, single-institution, randomized controlled trial (NCT04102566) assigned 50 patients undergoing a transurethral resection of the prostate to either a standard of care control (SOC) or multimodal experimental group (MMG). The intervention included adding ibuprofen to the postoperative pain regimen, promoting appropriate opioid use while hospitalized, an educational intervention, and discharging without opioid prescription. Data regarding demographics, operative data, opioid use, pain scores, and patient satisfaction were compared. RESULTS A total of 47 patients were included, n = 23 (MMG) and n = 24 (SOC). Demographic and operative findings were similar. Statistical analysis for noninferiority demonstrated non-inferior inpatient pain control (mean pain score 2.5 MMG vs 2.4 SOC, P = 0.0003). The multimodal group used significantly fewer morphine milligram equivalents after discharge (0 vs 4.1, P = 0.04). Inpatient use was reduced but did not reach statistical significance (6.0 vs 9.8, P = 0.2). Mean satisfaction scores with pain control were similar (9.6 MMG vs 9.2 SOC, P = 0.32). No opioid prescriptions were requested after discharge. Adverse events and medication side effects were infrequent and largely similar between groups. CONCLUSION Implementation of an opioid-limiting postoperative pain protocol and patient education resulted in no outpatient opioid use while maintaining patient satisfaction with pain control. Eliminating opioids following a common urologic procedure will decrease risk of opioid-related adverse events and have a positive downstream impact.
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Affiliation(s)
- Ryan P Donahue
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Andrew W Stamm
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Adam M Daily
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Paul M Kozlowski
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Christopher R Porter
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Fred E Govier
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Nicholas G Cowan
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Alvaro Lucioni
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Christian S Kuhr
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Kathleen C Kobashi
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Neil A Hanson
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN
| | - John M Corman
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA
| | - Una J Lee
- Section of Urology and Renal Transplantation, Virginia Mason Medical Center, Seattle, WA.
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Coleman JR, Hartmann P, Kona M, Thiele RA, Salajegheh R, Hanson NA. Use of epidurography in the perioperative and acute pain setting. Reg Anesth Pain Med 2022; 47:445-448. [DOI: 10.1136/rapm-2021-103274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 04/11/2022] [Indexed: 11/03/2022]
Abstract
Ensuring proper placement of epidural catheters is critical to improving their reliability for pain control and maintaining confidence in their continued use. This article will seek to address the role of objective confirmation of successful epidural placement via either single view or continuous epidural contrast studies, each creating an ‘epidurogram.’ Furthermore, the pertinent anatomical corollaries of continuous fluoroscopy used frequently in chronic pain medicine, from which these techniques emerged, will be addressed. Technical radiographic information needed to better understand and troubleshoot these studies is also included. Image examples which highlight the patterns key for successful interpretation of epidurograms will be provided. The aim of this paper was to provide an anesthesiologist unfamiliar with fluoroscopic evaluation of epidural catheters with the tools necessary to successfully conduct and interpret such an examination.
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Hanson NA, Strunk J, Saunders G, Cowan NG, Brandenberger J, Kuhr CS, Oryhan C, Warren DT, Slee AE, Strodtbeck W. Comparison of continuous intravenous lidocaine versus transversus abdominis plane block for kidney transplant surgery: a randomized, non-inferiority trial. Reg Anesth Pain Med 2021; 46:955-959. [PMID: 34417343 DOI: 10.1136/rapm-2021-102973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 06/18/2021] [Accepted: 08/09/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Transversus abdominis plane (TAP) blocks are associated with an improvement in postoperative analgesia following kidney transplant surgery. However, these blocks carry inherent risk and require a degree of expertise to perform successfully. Continuous intravenous lidocaine may be an effective alternative. In this randomized, non-inferiority study, we hypothesized that a continuous lidocaine infusion provides similar postoperative analgesia to a TAP block. METHODS Subjects presenting for kidney transplant surgery were randomized in a 1:1 ratio to either an ultrasound-guided unilateral, single-injection TAP block (TAP group) or a continuous infusion of lidocaine (Lido group). The primary outcome of this non-inferiority study was opioid consumption within the first 24 hours following surgery. Secondary outcomes included pain scores, patient satisfaction, opioid-related adverse events, time to regular diet, and persistent opioid use. RESULTS One hundred and twenty subjects, 59 from the TAP group and 61 from the Lido group, completed the study per protocol. Analysis of the primary outcome showed a cumulative geometric mean intravenous morphine equivalent difference between the TAP (14.6±3.2 mg) and Lido (15.9±2.4 mg) groups of 1.27 mg (95% CI -4.25 to 6.79; p<0.001), demonstrating non-inferiority of the continuous lidocaine infusion. No secondary outcomes showed clinically meaningful differences between groups. CONCLUSIONS This study demonstrates that a continuous infusion of lidocaine offers non-inferior postoperative analgesia compared with an ultrasound-guided unilateral, single-injection TAP block in the first 24 hours following kidney transplant surgery. TRIAL REGISTRATION NUMBER NCT03843879.
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Affiliation(s)
- Neil A Hanson
- Anesthesiology, University of Minnesota Medical Center, Minneapolis, Minnesota, USA .,Anesthesiology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Joseph Strunk
- Anesthesiology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Genna Saunders
- Anesthesiology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Nick G Cowan
- Urology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Jared Brandenberger
- Urology and General Surgery, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Christian S Kuhr
- Urology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Christine Oryhan
- Anesthesiology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Daniel T Warren
- Anesthesiology, Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - April E Slee
- Statistics, Axio Research, Seattle, Washington, USA
| | - Wyndam Strodtbeck
- Anesthesiology, Virginia Mason Franciscan Health, Seattle, Washington, USA
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Hanson NA, Lavallee MB, Thiele RH. Apophenia and anesthesia: how we sometimes change our practice prematurely. Can J Anaesth 2021; 68:1185-1196. [PMID: 33963519 PMCID: PMC8104920 DOI: 10.1007/s12630-021-02005-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/08/2021] [Accepted: 02/16/2021] [Indexed: 12/21/2022] Open
Abstract
Human beings are predisposed to identifying false patterns in statistical noise, a likely survival advantage during our evolutionary development. Moreover, humans seem to prefer "positive" results over "negative" ones. These two cognitive features lay a framework for premature adoption of falsely positive studies. Added to this predisposition is the tendency of journals to "overbid" for exciting or newsworthy manuscripts, incentives in both the academic and publishing industries that value change over truth and scientific rigour, and a growing dependence on complex statistical techniques that some reviewers do not understand. The purpose of this article is to describe the underlying causes of premature adoption and provide recommendations that may improve the quality of published science.
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Affiliation(s)
- Neil A Hanson
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA.
| | - Matthew B Lavallee
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, ville, VA, 22908-0710, USA
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Mahyar L, Neal JM, Blackmore CC, Jackson DW, Hanson NA, MacDonald KM, Warren D, Verdin PJ. MRI and muscle enzymes do not support the diagnosis of local anesthetic myotoxicity: a descriptive case series. Reg Anesth Pain Med 2021; 46:679-682. [PMID: 34059556 DOI: 10.1136/rapm-2021-102772] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/08/2021] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Lauren Mahyar
- Anesthesiology, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph M Neal
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA .,Benaroya Research Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | | | - Dane W Jackson
- Radiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Neil A Hanson
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA.,Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Kevin M MacDonald
- Department of Orthopedic Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Daniel Warren
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Peter J Verdin
- Department of Orthopedic Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
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11
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Flaherty JM, Auyong DB, Yuan SC, Lin SE, Meier AW, Biehl TR, Helton WS, Slee A, Hanson NA. Continuous Transversus Abdominis Plane Block for Primary Open Inguinal Hernia Repair: A Randomized, Double-Blind, Placebo-Controlled Trial. Pain Med 2020; 21:e201-e207. [PMID: 31670776 DOI: 10.1093/pm/pnz275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Patients undergoing open inguinal hernia repair may experience moderate to severe postoperative pain. We assessed opioid consumption in subjects who received a continuous transversus abdominis plane block in addition to standard multimodal analgesia. DESIGN Randomized, double-blind, placebo-controlled. SETTING Tertiary academic medical center. SUBJECTS Adult patients undergoing open inguinal hernia repair at Virginia Mason Medical Center. A total of 90 patients were enrolled. METHODS Subjects presenting for surgery were randomized to receive either a continuous transversus abdominis plane block or a subcutaneous sham block. The primary outcome was opioid consumption within the first 48 hours after surgery. Secondary outcomes included pain scores, activities assessment scores, and opioid-related adverse events. Multimodal analgesia utilized in both groups included acetaminophen, nonsteroidal anti-inflammatory drugs, and surgical local anesthetic infiltration. RESULTS Eighty-two subjects, 42 from the block group and 40 from the sham group, completed the study, per protocol. The intention-to-treat analysis demonstrated no difference in 48-hour postoperative oxycodone equivalent consumption between the block and sham groups (27.8 mg ± 26.8 vs 32 mg ± 39.2, difference -4.4 mg, P = 0.55). There was a statistically significant reduction in pain scores at 24 hours in the block group. There were no other differences in secondary outcomes. CONCLUSIONS Continuous transversus abdominis plane blocks provide modest improvements in pain after open inguinal hernia repair but fail to significantly reduce opioid consumption or improve functional activity levels in the setting of multimodal analgesia use.
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Affiliation(s)
- James M Flaherty
- University of Minnesota, Department of Anesthesiology, Minneapolis, Minnesota.,Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington
| | - David B Auyong
- Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington
| | - Stanley C Yuan
- Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington
| | - Shin-E Lin
- Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington
| | - Adam W Meier
- Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington.,University of Utah, Department of Anesthesiology, Salt Lake City, Utah, USA
| | - Thomas R Biehl
- Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington
| | - W Scott Helton
- Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington
| | - April Slee
- University College London, Institute of Epidemiology and Healthcare, London, United Kingdom
| | - Neil A Hanson
- Virginia Mason Medical Center, Departments of Anesthesiology and General Surgery, Seattle, Washington
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12
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Meier AW, Auyong DB, Yuan SC, Lin SE, Flaherty JM, Hanson NA. Reply to Mileo et al. Reg Anesth Pain Med 2019; 44:rapm-2019-100674. [PMID: 31101735 DOI: 10.1136/rapm-2019-100674] [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] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/08/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Adam W Meier
- Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - David B Auyong
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Stanley C Yuan
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Shin-E Lin
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - James M Flaherty
- Anesthesiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Neil A Hanson
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
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13
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Richard AM, Bain SE, Nikravan S, Lilley RR, Velamoor GR, Flaherty JM, Hanson NA. Continuous Pectoral Fascia Blocks for Postoperative Analgesia After Median Sternotomy: A Case Report. A A Pract 2018; 11:145-147. [PMID: 29634522 DOI: 10.1213/xaa.0000000000000763] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a novel case of a patient who presented for aortic valve replacement via median sternotomy. Bilateral continuous pectoral fascia blocks were placed to provide postoperative analgesia. Both numerical rating scale pain scores and opioid consumption after surgery were suggestive of analgesic benefit.
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Affiliation(s)
| | | | | | | | - Gautam R Velamoor
- Cardiothoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
| | - James M Flaherty
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota
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14
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Auyong DB, Hanson NA, Joseph RS, Schmidt BE, Slee AE, Yuan SC. Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery. Anesthesiology 2018; 129:47-57. [DOI: 10.1097/aln.0000000000002208] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
The interscalene nerve block provides analgesia for shoulder surgery, but is associated with diaphragm paralysis. One solution may be performing brachial plexus blocks more distally. This noninferiority study evaluated analgesia for blocks at the supraclavicular and anterior suprascapular levels, comparing them individually to the interscalene approach.
Methods
One hundred-eighty-nine subjects undergoing arthroscopic shoulder surgery were recruited to this double-blind trial and randomized to interscalene, supraclavicular, or anterior suprascapular block using 15 ml, 0.5% ropivacaine. The primary outcome was numeric rating scale pain scores analyzed using noninferiority testing. The predefined noninferiority margin was one point on the 11-point pain scale. Secondary outcomes included opioid consumption and pulmonary assessments.
Results
All subjects completed the study through the primary outcome analysis. Mean pain after surgery was: interscalene = 1.9 (95% CI, 1.3 to 2.5), supraclavicular = 2.3 (1.7 to 2.9), suprascapular = 2.0 (1.4 to 2.6). The primary outcome, mean pain score difference of supraclavicular–interscalene was 0.4 (–0.4 to 1.2; P = 0.088 for noninferiority) and of suprascapular–interscalene was 0.1 (–0.7 to 0.9; P = 0.012 for noninferiority). Secondary outcomes showed similar opioid consumption with better preservation of vital capacity in the anterior suprascapular group (90% baseline [P < 0.001]) and the supraclavicular group (76% [P = 0.002]) when compared to the interscalene group (67%).
Conclusions
The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.
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Affiliation(s)
- David B. Auyong
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Neil A. Hanson
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Raymond S. Joseph
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Brian E. Schmidt
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - April E. Slee
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
| | - Stanley C. Yuan
- From the Virginia Mason Medical Center, Seattle, Washington (D.B.A., N.A.H., R.S.J., S.C.Y.); the Washington Permanente Medical Group, Seattle, Washington (B.E.S.); and Axio Research, Seattle, Washington (A.E.S.)
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15
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Lin SE, Auyong DB, Dahl AB, Hanson NA. Successful Continuous Adductor Canal Block Placement in a Patient With Absent Sartorius Muscle: A Case Report. ACTA ACUST UNITED AC 2017; 9:101-104. [PMID: 28410261 DOI: 10.1213/xaa.0000000000000538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report a novel case of a patient who presented for elective total knee arthroplasty and had distorted adductor canal anatomy due to previous sartorius rotational flap surgery. Despite the lack of a sartorius muscle on the intended operative limb, we describe the successful placement of a continuous adductor canal block. This case is a clinically relevant example that highlights the importance of the vastoadductor membrane as the anatomical anteromedial boundary for the adductor canal, and that it remains intact even after sartorius muscle flap surgery.
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Affiliation(s)
- Shin-E Lin
- From the Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington
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16
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Auyong DB, Cantor DA, Green C, Hanson NA. The Effect of Fixation Technique on Continuous Interscalene Nerve Block Catheter Success: A Randomized, Double-Blind Trial. Anesth Analg 2017; 124:959-965. [PMID: 28151818 DOI: 10.1213/ane.0000000000001811] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Continuous peripheral nerve blocks offer advantages over single-injection blocks, including extended analgesia and reduction in opioid consumption. These benefits require that the perineural catheter remain intact for the duration of the planned local anesthetic infusion. Mechanical displacement of catheters, leaking, and consequent failure are known complications. The aim of this study was to evaluate continuous perineural catheter tip-to-nerve apposition in vivo over 48 hours comparing 2 different simple fixation strategies. METHODS Subjects presenting for a continuous interscalene nerve block were randomized to perineural catheter fixation with 1 of 2 types of adhesive: Dermabond (2-octylcyanoacrylate) or Mastisol (alcohol 23A, gum mastic, storax, and methyl salicylate), covered with a simple transparent dressing. The primary outcome was the evaluation of catheter-to-nerve apposition maintenance over 48 hours via both a blinded ultrasound evaluation of local anesthetic distribution and a blinded clinical assessment. Secondary outcomes included leakage at the catheter site, pain scores, opioid consumption, catheter-to-skin migration at the insertion site, and patient satisfaction. RESULTS Sixty-six subjects were recruited and randomized to compare adhesive group catheter tip-to-nerve apposition on postoperative day 2 (POD 2). Within the intention-to-treat cohort, a statistically significant decrease of perineural catheter tip-to-nerve apposition in the Mastisol group (64.7%) compared with the Dermabond group (90.6%) on POD 2 (odds ratios [OR] 0.19; 95% confidence interval [CI] 0.05-0.75; P = .012) was observed. Similar results were observed on POD 1 (OR 0.19; 95% CI 0.03-1.38; P = NS) and POD 2 (OR 0.14; 95% CI 0.02-0.97; P = .008) within the as-treated cohort. Catheter leakage (OR 67; 95% CI 7.3-589) and median catheter migration difference at the skin insertion site (2.0 cm; 95% CI 0.5-2.5) were also significantly greater in the Mastisol group than in the Dermabond group from POD 0 to POD 2 (P < .001). Median postoperative opioid consumption difference in morphine equivalents (3.2 mg; 95% CI - 9.0 to 14.2) was not significantly different between the Dermabond and the Mastisol groups through POD 2 (P = .542). CONCLUSIONS Perineural catheter fixation with Dermabond in continuous interscalene nerve block improves maintenance of catheter-to-nerve apposition when compared with Mastisol.
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Affiliation(s)
- David B Auyong
- From the *Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington; and †Duke University School of Medicine, Department of Biostatistics and Bioinformatics, Durham, North Carolina
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17
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Hanson NA, Lee PH, Yuan SC, Choi DS, Allen CJ, Auyong DB. Continuous ambulatory adductor canal catheters for patients undergoing knee arthroplasty surgery. J Clin Anesth 2016; 35:190-194. [DOI: 10.1016/j.jclinane.2016.07.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 06/07/2016] [Accepted: 07/08/2016] [Indexed: 01/01/2023]
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18
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Porteous GH, Hanson NA, Sueda LAA, Hoaglan CD, Dahl AB, Ohlson BB, Schmidt BE, Wang CC, Fagley RE. Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications. Anesth Analg 2016; 122:1450-73. [PMID: 27088999 DOI: 10.1213/ane.0000000000001196] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.
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Affiliation(s)
- Grete H Porteous
- From the *Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington; and †Department of Infectious Diseases, Virginia Mason Medical Center, Seattle, Washington
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19
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20
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Flaherty JM, Auyong DB, Hanson NA. Bilateral Continuous Suprascapular Nerve Blocks for Bilateral Shoulder Hemiarthroplasty. ACTA ACUST UNITED AC 2016; 7:125-8. [DOI: 10.1213/xaa.0000000000000364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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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21
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Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA. Reduced Length of Hospitalization in Primary Total Knee Arthroplasty Patients Using an Updated Enhanced Recovery After Orthopedic Surgery (ERAS) Pathway. J Arthroplasty 2015; 30:1705-9. [PMID: 26024988 DOI: 10.1016/j.arth.2015.05.007] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [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: 01/20/2015] [Revised: 04/27/2015] [Accepted: 05/05/2015] [Indexed: 02/07/2023] Open
Abstract
Decreasing hospital length of stay may attenuate costs associated with total knee arthroplasty. The purpose of this study was to determine if updates to an existing orthopedic enhanced recovery after surgery (ERAS) pathway would improve length of hospitalization. Clinical and demographic data were collected on 252 primary total knee arthroplasties between January 2012 and July 2013. Pre-updated and post-updated ERAS pathway cohorts were analyzed for length of stay, clinical outcomes, and re-admissions. The mean length of stay decreased from 76.6 hours to 56.1 hours after implementation of the evidence-based orthopedic enhanced recovery after surgery pathway (P<0.001). This improvement was possible without a concomitant increase in readmission rates.
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Abstract
Available evidence favoring the use of ultrasound for regional anesthesia is reviewed, updated, and critically assessed. Important outcome advantages include decreased time to block onset; decreased risk of local anesthetic systemic toxicity; and, depending on the outcome definition, increased block success rates. Ultrasound guidance, peripheral nerve blocks, and central neuraxial blocks are discussed.
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Affiliation(s)
- Francis V Salinas
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 9th Avenue, Mailstop B2-AN, Seattle, WA 98101, USA.
| | - Neil A Hanson
- Department of Anesthesiology, Virginia Mason Medical Center, 1100 9th Avenue, Mailstop B2-AN, Seattle, WA 98101, USA
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23
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Hanson NA, Allen CJ, Hostetter LS, Nagy R, Derby RE, Slee AE, Arslan A, Auyong DB. Continuous Ultrasound-Guided Adductor Canal Block for Total Knee Arthroplasty. Anesth Analg 2014; 118:1370-7. [DOI: 10.1213/ane.0000000000000197] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [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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24
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Nettles DL, Kitaoka K, Hanson NA, Flahiff CM, Mata BA, Hsu EW, Chilkoti A, Setton LA. In situ crosslinking elastin-like polypeptide gels for application to articular cartilage repair in a goat osteochondral defect model. Tissue Eng Part A 2008; 14:1133-40. [PMID: 18433311 PMCID: PMC3312393 DOI: 10.1089/ten.tea.2007.0245] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [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] [Received: 08/04/2007] [Accepted: 01/10/2008] [Indexed: 11/12/2022] Open
Abstract
The objective of this study was to evaluate an injectable, in situ crosslinkable elastin-like polypeptide (ELP) gel for application to cartilage matrix repair in critically sized defects in goat knees. One cylindrical, osteochondral defect in each of seven animals was filled with an aqueous solution of ELP and a biocompatible, chemical crosslinker, while the contralateral defect remained unfilled and served as an internal control. Joints were sacrificed at 3 (n = 3) or 6 (n = 4) months for MRI, histological, and gross evaluation of features of biomaterial performance, including integration, cellular infiltration, surrounding matrix quality, and new matrix in the defect. At 3 months, ELP-filled defects scored significantly higher for integration by histological and gross grading compared to unfilled defects. ELP did not impede cell infiltration but appeared to be partly degraded. At 6 months, new matrix in unfilled defects outpaced that in ELP-filled defects and scored significantly better for MRI evidence of adverse changes, as well as integration and proteoglycan-containing matrix via gross and histological grading. The ELP-crosslinker solution was easily delivered and formed stable, well-integrated gels that supported cell infiltration and matrix synthesis; however, rapid degradation suggests that ELP formulation modifications should be optimized for longer-term benefits in cartilage repair applications.
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Affiliation(s)
- Dana L. Nettles
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | - Kenichi Kitaoka
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi, Japan
| | - Neil A. Hanson
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Charlene M. Flahiff
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | - Brian A. Mata
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Edward W. Hsu
- Department of Bioengineering, University of Utah, Salt Lake City, Utah
| | - Ashutosh Chilkoti
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
| | - Lori A. Setton
- Department of Biomedical Engineering, Duke University, Durham, North Carolina
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Nettles DL, Kitaoka K, Hanson NA, Flahiff CM, Mata BA, Hsu EW, Chilkoti A, Setton LA. In SituCrosslinking Elastin-Like Polypeptide Gels for Application to Articular Cartilage Repair in a Goat Osteochondral Defect Model *. Tissue Eng Part A 2008. [DOI: 10.1089/tea.2007.0245] [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: 11/12/2022] Open
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