Superficial versus deep parasternal intercostal plane blocks: cadaveric evaluation of injectate spread.

BACKGROUND: Deep and superficial parasternal intercostal plane blocks provide anterior chest wall analgesia for both breast and cardiac surgery. Our primary objective of this cadaveric study was to describe the parasternal spread of deep and superficial parasternal intercostal plane blocks. Our secondary objectives were to describe needle proximity to the internal mammary artery when performing deep parasternal intercostal plane blocks, and compare lateral injectate spread and extension into the rectus sheath. METHODS: We performed ultrasound-guided deep and superficial parasternal intercostal plane blocks 2 cm from the sternum at the T3-4 interspace in four fresh frozen cadavers as described in clinical studies. RESULTS: Parasternal spread of injectate was greater with the deep parasternal intercostal plane injection than with the superficial parasternal intercostal plane injection. The internal mammary artery was ∼3 mm away from the needle trajectory in cadaver #1 and ∼5 mm from the internal mammary artery in cadaver #2. Lateral spread extended to the midclavicular line for all deep parasternal intercostal plane blocks and beyond the midclavicular line for all superficial parasternal intercostal plane blocks. Neither block extended to the rectus sheath. CONCLUSIONS: A greater number of parasternal interspaces were covered with the deep parasternal intercostal plane block than with the superficial parasternal intercostal plane block when one injection was performed at the T3-4 interspace. However, considering proximity to the internal mammary artery, and potential devastating consequences of an arterial injury, we propose that the deep parasternal intercostal plane block be classified as an advanced block and that future studies focus on optimising superficial parasternal intercostal plane parasternal spread.

Undiagnosed Lambert-Eaton Myasthenic Syndrome in the Era of Sugammadex: A Case Report.

OBJECTIVE: In this case report, we discuss the rare manifestation of prolonged neuromuscular blockade in a patient with history of small cell lung cancer and undiagnosed Lambert-Eaton myasthenic syndrome (LEMS) who had previously received succinylcholine for general anesthesia without incident but subsequently exhibited prolonged neuromuscular blockade during a laparoscopic procedure. We aimed to emphasize the importance of reversal agent safety and precision as well as vigilant perioperative and postoperative care. METHODS: We used the patient's electronic medical record, direct patient care experiences, and comprehensive literature review for this case report. RESULTS: Sugammadex was administered with mild improvement. Suspecting undiagnosed LEMS, neostigmine was administered, yielding satisfactory muscle strength and successful extubation. In retrospect, the patient reported history of weakness when lifting weights that improved upon exertion. CONCLUSIONS: Sugammadex is an efficient and effective agent for reversal of neuromuscular blockade. However, proper monitoring of the depth and recovery of blockade is imperative to when using sugammadex with optimal safety and precision in all patients. Perioperative care teams must remain vigilant with a high index of suspicion for neuromuscular junction pathology to properly plan perioperative care for patients at risk, especially those with small cell lung cancer who may have undiagnosed LEMS.

Regional anesthesia for scapulothoracic fixation surgery: Anatomic review and case series.

Scapulothoracic fixation surgery is a surgical intervention used for symptom relief in patients who suffer from scapular dysfunction. To date, there are few reports on the use of regional anesthesia for pain control in patients undergoing this procedure. The nerve supply of the scapula and surrounding tissues is complex and arises from both cervical and thoracic nerve roots. We suggest the use of a combined technique for perioperative pain control in patients undergoing scapulothoracic surgery. After a review of the relevant anatomy, we present four cases using combined regional techniques for postoperative pain control. The techniques utilized include thoracic paravertebral blocks with shoulder blockade, resulting in satisfactory pain control.

Caffeine supplementation as part of enhanced recovery after surgery pathways: a narrative review of the evidence and knowledge gaps.

Caffeine is used daily by 85% of United States adults and caffeine withdrawal is a major cause of perioperative headache. Studies have shown that caffeine supplementation in chronic caffeinators reduces the incidence of perioperative headache. This narrative review discusses the perioperative implications of caffeine withdrawal and outlines the benefits of and strategies of caffeine supplementation in the perioperative period. It is time to "wake up and smell the coffee" on integration of caffeine into established enhanced recovery after surgery protocols as a mechanism to consistently provide perioperative caffeine replacement.

RéSUMé: La caféine est utilisée quotidiennement par 85 % des adultes aux États-Unis, et le sevrage de la caféine constitue une cause majeure de céphalées périopératoires. Des études ont montré que la supplémentation en caféine chez les grands buveurs de café réduisait l'incidence des céphalées périopératoires. Ce compte rendu narratif discute des implications périopératoires du sevrage de la caféine et décrit les avantages et les stratégies de la supplémentation en caféine en période périopératoire. Il est temps de « se réveiller à l'odeur du café ¼ quant à l'intégration de la caféine dans les protocoles de récupération rapide après la chirurgie en tant que mécanisme pour procurer de façon systématique un subsitut périopératoire à la caféine.

Peripheral Nerve Blockade with Combined Standard and Liposomal Bupivacaine in Major Lower-Extremity Amputation.

BACKGROUND AND OBJECTIVES: Optimizing perioperative analgesia for patients undergoing major lower-extremity amputation remains a considerable challenge. The utility of liposomal bupivacaine as a component of peripheral nerve blockade for lower-extremity amputation is unknown. METHODS: We conducted an observational study comparing three different perioperative analgesic techniques for adults undergoing major lower-extremity amputation under general anesthesia between 2012 and 2017 at an academic medical center: (1) no regional anesthesia, (2) peripheral nerve blockade with standard bupivacaine, and (3) peripheral nerve blockade with a mixture of standard and liposomal bupivacaine. The primary outcome of cumulative opioid oral morphine milligram equivalent utilization in the first 72 hours postoperatively was compared across groups utilizing multivariable linear regression. RESULTS: A total of 631 unique anesthetics were included for 578 unique patients, including 416 (66%) without regional anesthesia, 131 (21%) with peripheral nerve blockade with a mixture of standard and liposomal bupivacaine, and 84 (13%) with peripheral nerve blockade with standard bupivacaine alone. Cumulative morphine equivalents were lower in those receiving peripheral nerve blockade with combined standard and liposomal bupivacaine compared with those not receiving regional anesthesia (multiplicative increase 0.67; 95% CI 0.50 to 0.90; P = 0.007). There were no significant differences in opioid utilization between peripheral nerve blockade groups (P = 0.59). CONCLUSIONS: Peripheral nerve blockade is associated with reduced opioid requirements after lower-extremity amputation compared with general anesthesia alone. However, the incorporation of liposomal bupivacaine is not significantly different to blockade employing only standard bupivacaine.

Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project: Phase I Outcomes.

BACKGROUND: This study aimed to improve institutional value-based patient care processes, provider collaboration, and continuous process improvement mechanisms for primary total hip arthroplasties and total knee arthroplasties through establishment of a perioperative orthopedic surgical home. METHODS: On June 1, 2017, an institutionally sponsored initiative commenced known as the orthopedic surgery and anesthesiology surgical improvement strategy project. A multidisciplinary team consisting of orthopedic surgeons, anesthesiologists, advanced practice providers, nurses, pharmacists, physical therapists, social workers, and hospital administration met regularly to identify areas for improvement in the preoperative, intraoperative, and post-anesthesia care unit, and postoperative phases of care. RESULTS: Mean hospital length of stay decreased from 2.7 to 2.2 days (P < .001), incidence of discharge to a skilled nursing facility decreased from 24% to 17% (P = .008), and the number of patients receiving physical therapy on the day of surgery increased from 10% to 100% (P < .001). Press-Ganey scores increased from 74.9 to 75.8 (94th percentile), while mean and maximum pain scores, opioid consumption, and hospital readmission rates remained unchanged (lowest P = .29). Annual total hip arthroplasty and total knee arthroplasty surgical volume increased by 11.4%. Decreased hospital length of stay and increased surgical volume yielded a combined annual savings of $2.5 million across the 9 involved orthopedic surgeons. CONCLUSION: Through application of perioperative surgical home tools and concepts, key advances included phase of care integration, enhanced data management, decreased length of stay, coordinated perioperative management, increased surgical volume without personnel additions, and more efficient communication and patient care flow across preoperative, intraoperative, and postoperative phases. LEVEL OF EVIDENCE: III Therapeutic.

Complication rate of ultrasound-guided paravertebral block for breast surgery.

BACKGROUND AND OBJECTIVES: Thoracic paravertebral blockade is often used as an anesthetic and/or analgesic technique for breast surgery. With ultrasound guidance, the rate of complications is speculated to be lower than when using landmark-based techniques. This investigation aimed to quantify the incidence of pleural puncture and pneumothorax following non-continuous ultrasound-guided thoracic paravertebral blockade for breast surgery. METHODS: Patients who received thoracic paravertebral blockade for breast surgery were identified by retrospective query of our institution's electronic database over a 5-year period. Data collected included patient demographics, level of block, type and volume of local anesthetic, occurrence of pleural puncture, occurrence of pneumothorax, evidence of local anesthetic toxicity, and patient vital signs. The incidence of block complications, including pleural puncture, pneumothorax, and local anesthetic toxicity, were ascertained. RESULTS: 529 patients underwent 2163 thoracic paravertebral injections. Zero pleural punctures were identified during block performance; however, two patients were found to have a pneumothorax on postoperative chest X-ray (3.6 per 1000 surgeries, 95% CI 0.5 to 13.6; 0.9 per 1000 levels blocked, 95% CI 0.1 to 3.3). There were no cases of local anesthetic systemic toxicity or associated lipid emulsion therapy administration. CONCLUSIONS: Pneumothorax following non-continuous ultrasound-guided thoracic paravertebral block using a parasagittal approach is an uncommon occurrence, with a similar rate to pneumothorax following breast surgery alone.

Intrathecal Morphine versus Intrathecal Hydromorphone for Analgesia after Cesarean Delivery: A Randomized Clinical Trial.

BACKGROUND: Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. METHODS: In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. RESULTS: There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan-Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). CONCLUSIONS: Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen.

Intermittent bolus versus continuous infusion techniques for local anesthetic delivery in peripheral and truncal nerve analgesia: the current state of evidence.

Manually delivered intermittent bolus (MIB) and programmable intermittent bolus (PIB), alternatives to continuous infusion (CI), involve administering a set volume of solution at a set interval of time. The benefits of intermittent bolus techniques in truncal and peripheral nerve blockade (TPNB) are unclear, and studies have largely demonstrated conflicting results. Using MEDLINE, Embase, Google Scholar, and the Cochrane Library, we conducted an evidenced-based review of published randomized controlled trials comparing intermittent bolus and CI methods in TPNB. In total, 13 randomized controlled trials were identified and evaluated. Outcomes data addressed in these studies included assessments of pain, opioid and local anesthetic consumption, patient satisfaction, adverse events, and physical therapy metrics. The overall quality of current evidence was found to be low given the small sample sizes, heterogeneity of data, and the variations in intermittent bolus techniques between studies. At this time, we found limited supportive data to endorse MIB or PIB over CI in TPNB. While unable to provide data-driven conclusions for local anesthetic delivery methods at this time, we propose that future studies and quantitative analysis between techniques should be on an anatomic, site-specific basis, with greater focus on evaluation of opioid use, adverse events, patient satisfaction, and rehabilitative metrics.

Interspace between Popliteal Artery and posterior Capsule of the Knee (IPACK) Injectate Spread: A Cadaver Study.

OBJECTIVES: Local anesthetic injection into the interspace between the popliteal artery and the posterior capsule of the knee (IPACK) has the potential to provide motor-sparing analgesia to the posterior knee after total knee arthroplasty. The primary objective of this cadaveric study was to evaluate injectate spread to relevant anatomic structures with IPACK injection. METHODS: After receipt of Institutional Review Board Biospecimen Subcommittee approval, IPACK injection was performed on fresh-frozen cadavers. The popliteal fossa in each specimen was dissected and examined for injectate spread. RESULTS: Ten fresh-frozen cadaver knees were included in the study. Injectate was observed to spread in the popliteal fossa at a mean ± SD of 6.1 ± 0.7 cm in the medial-lateral dimension and 10.1 ± 3.2 cm in the proximal-distal dimension. No injectate was noted to be in contact with the proximal segment of the sciatic nerve, but 3 specimens showed injectate spread to the tibial nerve. In 3 specimens, the injectate showed possible contact with the common peroneal nerve. The middle genicular artery was consistently surrounded by injectate. CONCLUSIONS: This cadaver study of IPACK injection demonstrated spread throughout the popliteal fossa without proximal sciatic involvement. However, the potential for injectate to spread to the tibial or common peroneal nerve was demonstrated. Consistent surrounding of the middle genicular artery with injectate suggests a potential mechanism of analgesia for the IPACK block, due to the predictable relationship between articular sensory nerves and this artery. Further study is needed to determine the ideal site of IPACK injection.

Infraclavicular versus axillary nerve catheters: A retrospective comparison of early catheter failure rate.

STUDY OBJECTIVES: Continuous brachial plexus catheters are often used to decrease pain following elbow surgery. This investigation aimed to assess the rate of early failure of infraclavicular (IC) and axillary (AX) nerve catheters following elbow surgery. DESIGN: Retrospective study. SETTING: Postoperative recovery unit and inpatient hospital floor. PATIENTS: 328 patients who received IC or AX nerve catheters and underwent elbow surgery were identified by retrospective query of our institution's database. MEASUREMENTS: Data collected included unplanned catheter dislodgement, catheter replacement rate, postoperative pain scores, and opioid administration on postoperative day 1. Catheter failure was defined as unplanned dislodging within 24 h of placement or requirement for catheter replacement and evaluated using a covariate adjusted model. MAIN RESULTS: 119 IC catheters and 209 AX catheters were evaluated. There were 8 (6.7%) failed IC catheters versus 13 (6.2%) failed AX catheters. After adjusting for age, BMI, and gender there was no difference in catheter failure rate between IC and AX nerve catheters (p = 0.449). CONCLUSIONS: These results suggest that IC and AX nerve catheters do not differ in the rate of early catheter failure, despite differences in anatomic location and catheter placement techniques. Both techniques provided effective postoperative analgesia with median pain scores < 3/10 for patients following elbow surgery. Reasons other than rate of early catheter failure should dictate which approach is performed.

Ultrasound-Guided Posterior Femoral Cutaneous Nerve Block: A Cadaveric Study.

OBJECTIVES: To identify any anatomic barriers to local anesthetic spread between the sciatic nerve (SN) and the posterior femoral cutaneous nerve (PFCN) at the level of the infragluteal crease and to describe a potential technique for an ultrasound (US)-guided subgluteal PFCN block in a cadaveric model. METHODS: Bilateral US-guided subgluteal injections of a colored latex solution were performed around the SN (15 mL) and PFCN (10 mL) in 4 unembalmed cadavers, for a total of 8 cadaver thighs. The specimens were dissected after latex polymerization to observe the spread of the latex solutions. RESULTS: With US guidance, the PFCN was visualized deep to the gluteus maximus and slightly superficial or lateral to the SN at the level of the infragluteal crease. The SN and PFCN were found on dissection to be coated with their respective colored latex in all 8 thighs. The SN and PFCN were consistently separated by the deep investing muscular fascia of the thigh, with only 2 thighs showing substantial mixing of latex injectates. CONCLUSIONS: The deep investing muscular fascia of the thigh appears to impede the spread of injectate between the SN and PFCN in a most unembalmed cadaver specimens. A US-guided subgluteal PFCN blockade may be a feasible technique to complement an SN block when complete anesthesia of the posterior thigh is required.

Intrathecal Hydromorphone and Morphine for Postcesarean Delivery Analgesia: Determination of the ED90 Using a Sequential Allocation Biased-Coin Method.

BACKGROUND: Intrathecal (IT) morphine is considered the "gold standard" for analgesia after cesarean delivery under spinal anesthesia, most commonly administered at a dose of 100 to 200 µg. There is less experience with IT hydromorphone for postcesarean analgesia and limited information on its optimal analgesic dose. We conducted this study to determine the effective analgesic dose for 90% patients (ED90) of IT hydromorphone that provides effective analgesia for women undergoing elective cesarean delivery and its potency ratio to IT morphine. METHODS: In this dose-finding trial, 80 patients received spinal anesthesia for cesarean delivery. Participants were randomized to receive IT morphine or IT hydromorphone at a dose determined using up-down sequential allocation with a biased-coin design to determine ED90. All patients received standardized multimodal analgesia postoperatively in addition to IT opioid. An effective dose was defined as a numeric response score for pain of ≤3 (scale 0-10) 12 hours after spinal injection. RESULTS: The ED90 was 75 µg (95% confidence interval [CI], 46-93 µg) for IT hydromorphone and 150 µg (95% CI, 145-185 µg) for IT morphine. At these doses, the 95% CI for the percentage of patients with effective analgesia (numeric rating scale ≤3) was 64% to 100% for hydromorphone and 68% to 100% for morphine. Exploratory findings showed that the incidence of nausea and pruritus was not different among the most commonly used doses of IT hydromorphone (P = 0.44 and P = 0.74) or IT morphine (P = 0.67 and P = 0.38, respectively). When administering IT opioids at ED90 doses or higher, 100% (21/21) of IT hydromorphone and 95% (37/39) of IT morphine patients were satisfied with their analgesia. CONCLUSIONS: The ratio of IT morphine to IT hydromorphone for effective postcesarean analgesia is 2:1. Patient satisfaction was high with both medications.

Comparative Study of Liposomal Bupivacaine Versus Paravertebral Block for Pain Control Following Mastectomy with Immediate Tissue Expander Reconstruction.

BACKGROUND: Several approaches to minimize postoperative pain, nausea, and enhance recovery are available for patients undergoing mastectomy with immediate tissue expander (TE) reconstruction. We compared the effectiveness of intraoperative local infiltration of liposomal bupivacaine (LB) to preoperative paravertebral block (PVB). METHODS: We retrospectively reviewed patients who underwent mastectomy with immediate TE reconstruction between May 2012 and October 2014 and compared patients with preoperative ultrasound-guided PVB to those with intraoperative LB infiltration. RESULTS: Fifty-three patients (54.6 %) received LB and 44 received PVB. LB was associated with less opioid use in the recovery room (p < 0.001), fewer patients requiring antiemetics (p = 0.03), and lower day of surgery pain scores (p = 0.008). LB also was associated with longer time to first opioid use (p = 0.04). On multivariable analysis controlling for expander placement location, year of surgery, and axillary lymph node dissection (ALND), the only variable that remained statistically significant was lower opioid use in the recovery room for patients with LB (p = 0.03) and day of surgery pain scores approached significance (p = 0.05). There was no difference in the proportion of patients discharged within 36 h of surgery between the groups. Focusing on first cases of the day (where PVBs are performed in the OR) showed average time to skin incision was 15 min shorter in the LB group (p = 0.004). CONCLUSIONS: Local infiltration of LB in patients undergoing mastectomy with immediate TE reconstruction decreases narcotic requirements in the recovery room, shortens preoperative anesthesiology time, and provides similar, if not better, perioperative pain control compared with PVB.

Analgesia after Cesarean delivery: a retrospective comparison of intrathecal hydromorphone and morphine.

STUDY OBJECTIVE: To compare analgesia and opioid-related side effects of intrathecal morphine and intrathecal hydromorphone after elective Cesarean delivery. DESIGN: Retrospective, comparative study. SETTING: Labor and delivery unit of an academic hospital. PATIENTS: 114 parturients age ≥ 18 years, presenting for elective Cesarean delivery. INTERVENTIONS: Patients who received 0.04 mg intrathecal hydromorphone were compared to a random sample of patients who received 0.1 mg intrathecal morphine for postoperative analgesia. MEASUREMENTS: The primary outcome was the presence of any opioid-related complication (pruritus, nausea or vomiting, respiratory depression) requiring treatment within 24 hours of intrathecal opioid administration. Secondary outcomes included total opioid consumption (in oral morphine equivalents) within 24 hours of intrathecal opioid administration and verbal pain score (0 = none, 10 = worst) at 4, 8, 12, 18, and 24 hours after intrathecal opioid administration. MAIN RESULTS: 38 patients who received intrathecal hydromorphone 0.04 mg were compared with 76 patients given 0.1 mg of intrathecal morphine for elective Cesarean delivery. No significant differences in demographics were noted between groups. There were no statistically significant differences between the intrathecal hydromorphone and intrathecal morphine groups in overall frequency of opioid-related complications (50% vs. 34.2%; P = 0.11), 24-hour opioid consumption (33 mg oral morphine equivalent [OME] vs. 8 mg OME; P = 0.27), or pain scores at any time point up to 24 hours. CONCLUSIONS: Overall, analgesia and incidence of opioid-related side effects after 0.04 mg of intrathecal hydromorphone did not differ statistically from 0.1 mg of intrathecal morphine.

Combined spinal-epidural versus epidural analgesia for labor and delivery.

The rapid onset of analgesia and improved mobility with combined spinal-epidural (CSE) techniques has been associated with a higher degree of maternal satisfaction compared with conventional epidural analgesia. However, controversy exists in that initiation of labor analgesia with a CSE may be associated with an increased risk for nonreassuring fetal status (ie, fetal bradycardia) and a subsequent need for emergent cesarean delivery. Overall, both epidural and CSE techniques possess unique risk/benefit profiles, and the decision to use one technique rather than the other should be determined based on individual patient and clinical circumstances.