Novel use of continuous pericapsular nerve group (PENG) block technique for traumatic superior and inferior pubic rami fractures: a case report.

BACKGROUND: Pubic rami fractures are painful injuries more commonly seen in the elderly with osteoporosis after high velocity trauma. In the most cases, management is conservative and non-operative with the goal to provide optimal pain relief to facilitate early mobilization and hospital discharge. Unfortunately, opioids remain the mainstay analgesic option and regional anesthesia techniques are limited but may include lumbar epidural anesthesia. CASE PRESENTATION: A female patient in her 80s presented to the emergency department of a level 1 trauma center following a high-speed motor vehicle collision. The patient suffered multiple non-life-threatening injuries. Notably, the patient was experiencing severe right groin and leg pain secondary to superior and inferior pubic rami fractures. Due to the severity of this pain, the patient was unable to mobilize or participate with physiotherapy. A lumbar epidural anesthesia technique was not deemed suitable and instead, we inserted a continuous pericapsular nerve group (PENG) block with a programmed intermittent bolus regimen. Immediate relief of pain was achieved and 48 hours later, the patient still reported satisfactory pain control and started to independently mobilize. CONCLUSION: Analgesia options are limited in pubic rami fractures. We present the first published case of a novel use of the PENG block with a continuous catheter technique for the analgesic management of a traumatic superior and inferior pubic rami fracture. The clinical utility of this technique in pubic ramus fractures warrants further clinical investigation.

Psychological interventions to reduce postoperative pain and opioid consumption: a narrative review of literature.

BACKGROUND: Evidence suggests that over half of patients undergoing surgical procedures suffer from poorly controlled postoperative pain. In the context of an opioid epidemic, novel strategies for ameliorating postoperative pain and reducing opioid consumption are essential. Psychological interventions defined as strategies targeted towards reducing stress, anxiety, negative emotions and depression via education, therapy, behavioral modification and relaxation techniques are an emerging approach towards these endpoints. OBJECTIVE: This review explores the efficacy of psychological interventions for reducing postoperative pain and opioid use in the acute postoperative period. EVIDENCE REVIEW: An extensive literature search was conducted in MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Medline In-Process/ePubs, Embase, Ovid Emcare Nursing, and PsycINFO, Web of Science (Clarivate), PubMed-NOT-Medline (NLM), CINAHL and ERIC, and two trials registries, ClinicalTrials.Gov (NIH) and WHO ICTRP. Included studies were limited to those investigating adult human subjects, and those published in English. FINDINGS: Three distinct forms of psychological interventions were identified: relaxation, psychoeducation and behavioral modification therapy. Study results showed a reduction in both postoperative opioid use and pain scores (n=5), reduction in postoperative opioid use (n=3), reduction in postoperative pain (n=5), no significant reduction in pain or opioid use (n=7), increase in postoperative opioid use (n=1) and an increase in postoperative pain (n=1). CONCLUSION: Some preoperative psychological interventions can reduce pain scores and opioid consumption in the acute postoperative period; however, there is a clear need to strengthen the evidence for these interventions. The optimal technique, strategies, timing and interface requires further investigation.

Ultrasound-guided regional anesthesia: feasibility and effectiveness of teaching via telesimulation in Ethiopia.

BACKGROUND: Acute pain management in resource-poor countries remains a challenge. Ultrasound-guided regional anesthesia is a cost-effective way of delivering analgesia in these settings. However, for financial and logistical reasons, educational workshops are inaccessible to many physicians in these environments. Telesimulation provides a way of teaching across distance by using simulators and video-conferencing software to connect instructors and students worldwide. We conducted a prospective study to determine the feasibility of ultrasound-guided regional anesthesia teaching via telesimulation in Ethiopia. METHODS: Eighteen Ethiopian orthopedic and emergency medicine house staff participated in telesimulation teaching of ultrasound-guided femoral nerve block. This consisted of four 90-min sessions, once per week. Week 1 consisted of a precourse test and a presentation on aspects of performing a femoral nerve block, weeks 2 and 3 were live teaching sessions on scanning and needling techniques, and in week 4, the house staff undertook a postcourse test. All participants were assessed using a validated Global Rating Scale and Checklist. RESULTS: Participants were provided with a validated checklist and global rating scale as a pretest and post-test. The participants showed significant improvement in their test scores, from a total mean of 51% in the pretest to 84% in their post-test. CONCLUSIONS: Teaching ultrasound-guided regional anesthesia of the femoral nerve remotely via telesimulation is feasible. Telesimulation can greatly improve the accessibility of ultrasound-guided regional anesthesia teaching to physicians in remote areas.

Effect of vasopressor use on digit survival after replantation and revascularization-A large retrospective cohort study.

PURPOSE: Despite the common use of intraoperative vasopressors in hand microsurgery, the association between intraoperative vasopressor use and digital replant failure has not yet been examined. Our study aims to examine the association between intraoperative vasopressor use (phenylephrine and/or ephedrine) and postoperative digital failure of replanted or revascularized digits. METHODS: All patients from a single tertiary hand center who underwent unilateral digital replantation or revascularization procedures between 2005 and 2016 were included in this retrospective cohort study. The relationship between intraoperative vasopressors used to maintain hemodynamic stability and digit failure was then evaluated using logistic regression. Specifically, phenylephrine (total dose 10-3,600 mcg) and ephedrine (5-110 mg) use were evaluated. RESULTS: During the study period, 281 patients underwent digital replantation or revascularization. Of those, 86 (31%) were given an intraoperative vasopressor. Digit failure was more likely in patients with crush or avulsion injuries compared to clean-cut mechanism (odds ratio [OR] 2.02, p = .02), and in patients with replantation (OR 7.85, p < .0001) as compared to revascularization procedures. Using multivariate logistic regression adjusting for age, sex, smoking status, comorbidities, number of digits injured, injury type, and procedure type, the odds of digital failure with vasopressor use were not increased (p = .84). When evaluating vasopressors used after tourniquet deflation, failure increased with ephedrine use (OR = 2.42, p = .0496) and phenylephrine use (OR = 2.21, p = .31). CONCLUSIONS: The use of vasopressors was not associated with failure if administration of vasopressors was before tourniquet deflation. The administration of vasopressors after tourniquet deflation should be cautioned.

A Virtual Reality Simulation Model of Spinal Ultrasound: Role in Teaching Spinal Sonoanatomy.

BACKGROUND AND OBJECTIVES: Ultrasound assessment of the lumbar spine improves the success of spinal and epidural anesthesia, especially for patients with underlying difficult anatomy. To assist with the teaching and learning of ultrasound-guided neuraxial anesthesia, we have created an online interactive educational model (http://www.usra.ca/vspine.php and http://pie.med.utoronto.ca/vspine). The aim of the current study was to determine whether the virtual spine model improved the knowledge of neuraxial anatomy and sonoanatomy. METHODS: After obtaining ethics board approval and written participant consent, 14 anesthesia trainees with no prior experience with spine ultrasound imaging were included in this study. Construct validity was assessed using a pretest/posttest design to measure the knowledge acquired from self-study of the virtual spine simulation modules. Two tests (A and B) with 20 multiple-choice questions were used either for the pretest or posttest, at random in order to account for possible differences in difficulty between the 2 tests. These tests were administered immediately before and after a 1-hour training session using the spine ultrasound model. RESULTS: Fourteen anesthesia trainees completed the study. Seven used test A as the pretest (group A), and 7 used test B as the pretest (group B). Both groups showed a statistically significant improvement (P < 0.05) in test scores after a 1-hour session with the spine ultrasound model. The mean scores were 55% (SD, 11.2%) on the pretest and 77% (SD, 8.7%) on the posttest. CONCLUSIONS: The study demonstrated that after 1 hour of self-study by the trainees on the spine ultrasound model test scores improved by 40%.

Is Ultrasound a Valid and Reliable Imaging Modality for Airway Evaluation?: An Observational Computed Tomographic Validation Study Using Submandibular Scanning of the Mouth and Oropharynx.

OBJECTIVES: Ultrasound (US) imaging of the airway may be useful in predicting difficulty of airway management (DAM); but its use is limited by lack of proof of its validity and reliability. We sought to validate US imaging of the airway by comparison to CT-scan, and to assess its inter- and intra-observer reliability. We used submandibular sonographic imaging of the mouth and oropharynx to examine how well the ratio of tongue thickness to oral cavity height correlates with the ratio of tongue volume to oral cavity volume, an established tomographic measure of DAM. METHODS: A cohort of 34 patients undergoing CT-scan was recruited. Study standardized assessments included CT-measured ratios of tongue volume to oropharyngeal cavity volume; tongue thickness to oral cavity height; and US-measured ratio of tongue thickness to oral cavity height. Two sonographers independently performed US imaging of the airway before and after CT-scan. RESULTS: Our findings indicate that the US-measured ratio of tongue thickness to oral cavity height highly correlates with the CT-measured ratio of tongue volume to oral cavity volume. US measurements also demonstrated strong inter- and intra-observer reliability. CONCLUSIONS: This study suggests that US is a valid and reliable tool for imaging the oral and oropharyngeal parts of the airway, as well as for measuring the volumetric relationship between the tongue and oral cavity, and may therefore be a useful predictor of DAM.

The future of regional anesthesia education: lessons learned from the surgical specialty.

PURPOSE: Application of ultrasound in regional anesthesia has now become the standard of care and its use has shown to reduce complications. Nevertheless, gaining expertise in ultrasound-guided regional anesthesia requires the acquisition of new cognitive and technical skills. In addition, due to a reduction in resident working hours and enforcement of labour laws and directives across various states and countries, trainees perform and witness fewer procedures. Together, these issues create challenges in the teaching and learning of ultrasound-guided regional anesthesia in the time-based model of learning. PRINCIPAL FINDINGS: The challenges of teaching ultrasound-guided regional anesthesia are similar to those experienced by our surgical counterparts with the advent of minimally invasive surgery. In order to overcome these challenges, our surgical colleagues used theories of surgical skills training, simulation, and the concept of deliberate practice and feedback to shift the paradigm of learning from experience-based to competency-based learning. CONCLUSION: In this narrative review, we describe the theory behind the evolution of surgical skills training. We also outline how we can apply these learning theories and simulation models to a competency-based curriculum for training in ultrasound-guided regional anesthesia.

The Nerves of the Adductor Canal and the Innervation of the Knee: An Anatomic Study.

BACKGROUND AND OBJECTIVES: Adductor canal block contributes to analgesia after total knee arthroplasty. However, controversy exists regarding the target nerves and the ideal site of local anesthetic administration. The aim of this cadaveric study was to identify the trajectory of all nerves that course in the adductor canal from their origin to their termination and describe their relative contributions to the innervation of the knee joint. METHODS: After research ethics board approval, 20 cadaveric lower limbs were examined using standard dissection technique. Branches of both the femoral and obturator nerves were explored along the adductor canal and all branches followed to their termination. RESULTS: Both the saphenous nerve (SN) and the nerve to vastus medialis (NVM) were consistently identified, whereas branches of the anterior obturator nerve were inconsistently present. The NVM contributed significantly to the innervation of the knee capsule, through intramuscular, extramuscular, and deep genicular nerves. The SN had a relatively more modest contribution through superficial infrapatellar and posterior branches as well as contributing to the origin of the deep genicular nerves. CONCLUSIONS: The results suggest that both the SN and NVM contribute to the innervation of the anteromedial knee joint and are therefore important targets of adductor canal block. Given the site of exit of both nerves in the distal third of the adductor canal, the midportion of the adductor canal is suggested as an optimal site of local anesthetic administration to block both target nerves while minimizing the possibility of proximal spread to the femoral triangle.

IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block: A Randomized, Three-arm, Triple-masked, Placebo-controlled Trial.

BACKGROUND: Perineural and IV dexmedetomidine have each been suggested to prolong the duration of analgesia when administered in conjunction with peripheral nerve blocks. In the first randomized, triple-masked, placebo-controlled trial to date, the authors aimed to define and compare the efficacy of perineural and IV dexmedetomidine in prolonging the analgesic duration of single-injection interscalene brachial plexus block (ISB) for outpatient shoulder surgery. METHODS: Ninety-nine patients were randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 µg/kg dexmedetomidine administered perineurally (DexP group), intravenously (DexIV group), or none (control group). The authors sequentially tested the joint hypothesis that dexmedetomidine prolongs the duration of analgesia and reduces the 24-h cumulative postoperative morphine consumption. Motor blockade, pain severity, hemodynamic variations, opioid-related side effects, postoperative neurologic symptoms, and patient satisfaction were also evaluated. RESULTS: Ninety-nine patients were analyzed. The duration of analgesia was 10.9 h (10.0 to 11.8 h) and 9.8 h (9.0 to 10.6 h) for the DexP and DexIV groups, respectively, compared with 6.7 h (5.6 to 7.8) for the control group (P < 0.001). Dexmedetomidine also reduced the 24-h cumulative morphine consumption to 63.9 mg (58.8 to 69.0 mg) and 66.2 mg (60.6 to 71.8 mg) for the DexP and DexIV groups, respectively, compared with 81.9 mg (75.0 to 88.9 mg) for the control group (P < 0.001). DexIV was noninferior to DexP for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade. CONCLUSION: Both perineural and IV dexmedetomidine can effectively prolong the ISB analgesic duration and reduce the opioid consumption without prolonging motor blockade.

An Expedited Care Pathway with Ambulatory Brachial Plexus Analgesia Is a Cost-effective Alternative to Standard Inpatient Care after Complex Arthroscopic Elbow Surgery: A Randomized, Single-blinded Study.

BACKGROUND: Common standard practice after complex arthroscopic elbow surgery includes hospital admission for 72 h. The authors hypothesized that an expedited care pathway, with 24 h of hospital admission and ambulatory brachial plexus analgesia and continuous passive motion at home, results in equivalent elbow range of motion (ROM) 2 weeks after surgery compared with standard 72-h hospital admission. METHODS: A randomized, single-blinded study was conducted after obtaining approval from the research ethics board. Forty patients were randomized in a 1:1 ratio using a computer-generated list of random numbers into an expedited care pathway group (24-h admission) and a control group (72-h admission). They were treated equally aside from the predetermined hospital length of stay. RESULTS: Patients in the control (n = 19) and expedited care pathway (n = 19) groups achieved similar elbow ROM 2 weeks (119 ± 18 degrees and 121 ± 15 degrees, P = 0.627) and 3 months (130 ± 18 vs. 130 ± 11 degrees, P = 0.897) postoperatively. The mean difference in elbow ROM at 2 weeks was 2.6 degrees (95% CI, -8.3 to 13.5). There were no differences in analgesic outcomes, physical function scores, and patient satisfaction up to 3 months postoperatively. Total hospital cost of care was 15% lower in the expedited care pathway group. CONCLUSION: The results suggest that an expedited care pathway with early hospital discharge followed by ambulatory brachial plexus analgesia and continuous passive motion at home is a cost-effective alternative to 72 h of hospital admission after complex arthroscopic elbow surgery.

Point-of-care ultrasound defines gastric content and changes the anesthetic management of elective surgical patients who have not followed fasting instructions: a prospective case series.

PURPOSE: Pulmonary aspiration of gastric contents is a major cause of anesthesia morbidity and mortality. Point-of-care gastric ultrasound provides information regarding the type and volume of gastric content. The hypothesis of this prospective cohort study was that the addition of point-of-care gastric ultrasound to standard patient assessment results in changes in anesthetic management in at least 30% of elective surgical patients who do not follow fasting instructions. METHODS: Following Research Ethics Board approval and informed consent, elective surgical patients who did not follow fasting instructions were included in this prospective study. Documentation included the type of food ingested, the timing of the ingestion relative to the planned surgical time, and the treating anesthesiologist's management plan based on history alone. Next, an independent anesthesiologist not involved in the medical decision-making performed a focused gastric ultrasound examination. The results of the ultrasound exam were documented in a standardized fashion and made available to the attending anesthesiologist who then confirmed or revised the initial management plan. The treating anesthesiologist's actual (post-test) patient management was documented in a standardized fashion and compared with the initial (pre-test) management plan. RESULTS: Thirty-eight patients were included in this case series. Following point-of-care gastric ultrasound, there was a change in either the timing of anesthesia or the anesthetic technique (or both) in 27 patients (71%), with a net change towards a lower incidence of surgical delays. CONCLUSIONS: This prospective case series suggests that a standardized point-of care gastric ultrasound examination informs anesthesiologists' perceived level of aspiration risk and leads to changes in anesthetic management in a significant proportion of elective patients who did not follow fasting instructions.

Novice performance of ultrasound-guided needling skills: effect of a needle guidance system.

BACKGROUND AND OBJECTIVES: Ultrasound-guided needle placement is a widely used technical skill that can be challenging to learn. The SonixGPS is a novel ultrasound needle-tracking system that has the potential to improve performance over traditional ultrasound systems. The objective of our study was to determine if the use of the SonixGPS ultrasound system improves performance of novice practitioners in ultrasound-guided needle placement compared with conventional ultrasound in the out-of-plane approach on a simulation model. METHODS: Twenty-six medical students without previous ultrasound experience were randomized into 2 groups. Each group performed 30 simulated ultrasound nerve blocks on a porcine meat tissue simulation (phantom) model. Both groups used the SonixGPS ultrasound; however, the study group had the needle-tracking system activated, whereas the control group did not. The participants were assessed for success rate, technical aspects of block performance, and certain behaviors that could compromise the quality of the block. Learning curves were developed to assess competence. RESULTS: The needle guidance group reached competence more often. This group had fewer attempts and quality-compromising behaviors than did those using conventional ultrasound. CONCLUSIONS: Use of the SonixGPS ultrasound needle guidance system improves the performance of technical needling skills of novice trainees in an ex vivo model. The place of this technology in the wider education of ultrasound-guided regional anesthesia remains to be established.

A valid and reliable assessment tool for remote simulation-based ultrasound-guided regional anesthesia.

BACKGROUND AND OBJECTIVES: The purpose of this study was to establish construct and concurrent validity and interrater reliability of an assessment tool for ultrasound-guided regional anesthesia (UGRA) performance on a high-fidelity simulation model. METHODS: Twenty participants were evaluated using a Checklist and Global Rating Scale designed for assessing any UGRA block. The participants performed an ultrasound-guided supraclavicular brachial plexus block on both a patient and a simulator. Evaluations were completed in-person by an expert and remotely by a blinded expert using video recordings. Using previous number of blocks performed as an indication of expertise, participants were divided into Novice (n = 8) and Experienced (n = 12) groups. Construct validity was assessed through the tool's reliable on-site and remote discrimination of Novice and Experienced anesthetists. Concurrent validity was established by comparisons of patient versus simulator scoring. Finally, interrater reliability was determined by comparing the scores of on-site and off-site evaluators. RESULTS: The Global Rating Scale was able to differentiate Novice from Experienced anesthetists both by on-site and remote assessment on a patient and simulation model. The Checklist was unable to discern the 2 groups on a simulation model remotely and was marginally significant with on-site scoring. CONCLUSIONS: This is the first study to demonstrate the validity and reliability of a Global Rating Scale assessment tool for use in UGRA simulation training. Although the checklist may require further refinement, the Global Rating Scale can be used for remote and on-site assessment of UGRA skills.

Tension Pneumothorax as a Complication of Inadvertent Pleural Tears During Posterior Spinal Surgery.

OBJECTIVE: To review and expose the occurrences of tension pneumothorax as a result of pleural tear during posterior spinal surgery. METHODS: Intraoperative reports were retrospectively reviewed for 2 patients who underwent posterior spinal fusion and experienced pleural tear and subsequent tension pneumothorax. Surgical decisions for recognition and treatment were also reviewed. RESULTS: Unrecognized pleural tearing led to the formation of tension pneumothorax in both patients studied. Onset of respiratory signs and symptoms were delayed, occurring in the recovery room for the first patient and intraoperatively for the second. Both patients were successfully treated with conversion to open pneumothorax and placement of chest tubes. CONCLUSIONS: Tension pneumothorax is a complication that can arise during posterior thoracic spinal surgery as a result of an inadvertent pleural tear. Awareness of this potentially fatal complication will greatly help in the timely recognition and treatment of this condition if this situation occurs. The authors recommend a low threshold for chest tube placement in patients with known or suspected pleural tears or in patients with undiagnosed respiratory failure undergoing posterior thoracic spine surgery.

Continuous infraclavicular brachial plexus blockade: effect on survival of replanted digits.

In replantation surgery, the use of continuous brachial plexus blockade (CBPB) is popular as it improves postoperative analgesia and vascular flow. The aim of our study was to determine whether CBPB may affect the odds of survivability of replanted digit(s). A four-year retrospective chart review was performed and various parameters affecting replant survival were examined. Outcome was recorded as successful if the transplanted digit(s) survived six months after discharge. All the independent variables were forced into a regression model without using a specific variable selection algorithm. The data for 146 patients was obtained from our chart review. The success rate of replanted digits in the patients reviewed was 65.8%. The logistic regression model showed a relation between the number of digits injured and replanted digit(s) survival. Our study showed that CBPB has no effect on the survivability of the replanted digit(s) till six months after hospital discharge.

The use of an online three-dimensional model improves performance in ultrasound scanning of the spine: a randomized trial.

PURPOSE: The use of ultrasound for neuraxial blockade is a new application of technology that is rapidly becoming accepted as a standard of care. This new skill has shown to improve success, but it is a challenge to teach. To assist with teaching the use of ultrasound in regional anesthesia of the lumbar spine, we have developed an interactive educational model ( http://pie.med.utoronto.ca/vspine or http://www.usra.ca/vspine.php ). In this study, we aimed to determine whether use of this model for a two-week period would improve the performance of novice operators in determining defined landmarks during real-time ultrasound imaging of the lumbar spine. METHODS: We evaluated the educational benefit of the ultrasound module by randomly assigning 16 postgraduate first-year (PGY1) anesthesia residents to either a control group with password-protected access to only the lumbar anatomy module or to an intervention group with access to the complete module. All residents had access to the module for two weeks following a full-day workshop that is part of the university teaching program which consists of a didactic lecture on ultrasound-facilitated neuraxial anesthesia, mentored teaching on cadaveric spine dissections, and hands-on ultrasound scanning of live models. At the end of the two weeks, the performance of the residents was evaluated using a 12-item task-specific checklist while carrying out a scout scan on a live model. RESULTS: The control group had a median score of 5.5 (25(th) percentile: 4, 75(th) percentile: 18), while the intervention group had a median score of 11.5 (25(th) percentile: 8, 75(th) percentile: 12) in the task-specific checklist, with a significant difference of 6 (confidence interval 1.5 to 10.5) between groups (P = 0.021). CONCLUSION: Our results show superior performance by the residents who had access to both components of the module, indicating that access to the interactive ultrasound spine module improves knowledge and skills prior to clinical care.

Real-time ultrasound-guided spinal anesthesia using the SonixGPS® needle tracking system: a case report.

PURPOSE: The SonixGPS® is an electromagnetic needle tracking system for ultrasound-guided needle intervention. Both current and predicted needle tip position are displayed on the ultrasound screen in real-time, facilitating needle-beam alignment and guidance to the target. This case report illustrates the use of the SonixGPS system for successful performance of real-time ultrasound-guided spinal anesthesia in a patient with difficult spinal anatomy. CLINICAL FEATURES: A 67-yr-old male was admitted to our hospital to undergo revision of total right hip arthroplasty. His four previous arthroplasties for hip revision were performed under general anesthesia because he had undergone L3-L5 instrumentation for spinal stenosis. The L4-L5 interspace was viewed with the patient in the left lateral decubitus position. A 19G 80-mm proprietary needle (Ultrasonix Medical Corp, Richmond, BC, Canada) was inserted and directed through the paraspinal muscles to the ligamentum flavum in plane to the ultrasound beam. A 120-mm 25G Whitacre spinal needle was then inserted through the introducer needle in a conventional fashion. Successful dural puncture was achieved on the second attempt, as indicated by a flow of clear cerebrospinal fluid. The patient tolerated the procedure well, and the spinal anesthetic was adequate for the duration of the surgery. CONCLUSION: The SonixGPS is a novel technology that can reduce the technical difficulty of real-time ultrasound-guided neuraxial blockade. It may also have applications in other advanced ultrasound-guided regional anesthesia techniques where needle-beam alignment is critical.