The current state of training in pain medicine fellowships: An Association of Pain Program Directors (APPD) survey of program directors.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) approved the first pain medicine fellowship programs over three decades ago, designed around a pharmacological philosophy. Following that, there has been a rise in the transition of pain medicine education toward a multidisciplinary interventional model based on a tremendous surge of contemporaneous literature in these areas. This trend has created variability in clinical experience and education amongst accredited pain medicine programs with minimal literature evaluating the differences and commonalities in education and experience of different pain medicine fellowships through Program Director (PD) experiences. This study aims to gather insight from pain medicine fellowship program directors across the country to assess clinical and interventional training, providing valuable perspectives on the future of pain medicine education. METHODS: This study involved 56 PDs of ACGME-accredited pain fellowship programs in the United States. The recruitment process included three phases: advanced notification, invitation, and follow-up to maximize response rate. Participants completed a standard online questionnaire, covering various topics such as subcategory fields, online platforms for supplemental education, clinical experience, postgraduate practice success, and training adequacy. RESULTS: Surveys were completed by 39/56 (69%) standing members of the Association of Pain Program Directors (APPD). All PDs allowed fellows to participate in industry-related and professional society-related procedural workshops, with 59% encouraging these workshops. PDs emphasized the importance of integrity, professionalism, and diligence for long-term success. Fifty-four percent of PDs expressed the need for extension of fellowship training to avoid supplemental education by industry or pain/spine societies. CONCLUSION: This study highlights the challenge of providing adequate training in all Pain Medicine subtopics within a 12-month pain medicine fellowship. PDs suggest the need for additional training for fellows and discuss the importance of curriculum standardization.

Complications of Spinal Cord Stimulators-A Comprehensive Review Article.

PURPOSE OF REVIEW: Spinal cord stimulation has been increasing in influence as an option to regulate pain, especially in the chronic pain patient population. However, even with the numerous changes made to this technology since its inception, it is still prone to various complications such as hardware issues, neurological injury/epidural hematoma, infections, and other biological concerns. The purpose of this article is to thoroughly review and evaluate literature pertaining to the complications associated with percutaneous spinal cord stimulation. RECENT FINDINGS: Lead migration is generally the most common complication of percutaneous spinal cord stimulation; however, recent utilization of various anchoring techniques has been discussed and experienced clinical success in decreasing the prevalence of lead migration and lead fractures. With newer high-frequency systems gaining traction to improve pain management and decrease complications as compared to traditional systems, rechargeable implantable pulse generators have been the preferred power source. However, recent findings may suggest that these rechargeable implantable pulse generators do not significantly increase battery life as much as was proposed. Intraoperative neuromonitoring has seen success in mitigating neurological injury postoperatively and may see more usage in the future through more testing. Though the occurrence of infection and biological complications, including dural puncture and skin erosion, has been less frequent over time, they should still be treated in accordance with established protocols. While many complications can arise following percutaneous spinal cord stimulator implantation, the procedure is less invasive than open implantation and has seen largely positive patient feedback. Hardware complications, the more common issues that can occur, rarely indicate a serious risk and can generally be remedied through reoperation. However, less common cases such as neurological injury, infections, and biological complications require prompt diagnosis to improve the condition of the patient and prevent significant damage.

Analgesic Techniques for Rib Fractures-A Comprehensive Review Article.

PURPOSE OF REVIEW: Rib fractures are a common traumatic injury that has been traditionally treated with systemic opioids and non-opioid analgesics. Due to the adverse effects of opioid analgesics, regional anesthesia techniques have become an increasingly promising alternative. This review article aims to explore the efficacy, safety, and constraints of medical management and regional anesthesia techniques in alleviating pain related to rib fractures. RECENT FINDINGS: Recently, opioid analgesia, thoracic epidural analgesia (TEA), and paravertebral block (PVB) have been favored options in the pain management of rib fractures. TEA has positive analgesic effects, and many studies vouch for its efficacy; however, it is contraindicated for many patients. PVB is a viable alternative to those with contraindications to TEA and exhibits promising outcomes compared to other regional anesthesia techniques; however, a failure rate of up to 10% and adverse complications challenge its administration in trauma settings. Serratus anterior plane blocks (SAPB) and erector spinae blocks (ESPB) serve as practical alternatives to TEA or PVB with lower incidences of adverse effects while exhibiting similar levels of analgesia. ESPB can be performed by trained emergency physicians, making it a feasible procedure to perform that is low-risk and efficient in pain management. Compared to the other techniques, intercostal nerve block (ICNB) had less analgesic impact and required concurrent intravenous medication to achieve comparable outcomes to the other blocks. The regional anesthesia techniques showed great success in improving pain scores and expediting recovery in many patients. However, choosing the optimal technique may not be so clear and will depend on the patient's case and the team's preferences. The peripheral nerve blocks have impressive potential in the future and may very well surpass neuraxial techniques; however, further research is needed to prove their efficacy and weaknesses.

Defining Personas of People Living with Chronic Pain: An Ethnographic Research Study.

Introduction: Pain is the leading reason for which people seek medical care in the United States, and chronic pain (CP) affects approximately 50 million people in the US Pain perception is deeply personal, is highly correlated with behavioral and emotional disorders, and is greatly influenced by physiological and environmental factors. The patient-provider relationship can have profound implications for clinical outcomes within the context of treating CP. However, limited access to pain specialists, the complex nature of many CP-causing conditions, the absence of instruments for objective pain measurement, and the need to foster a trust-based patient-provider relationship throughout treatment pose unique challenges. Objective: To support a more optimal CP care delivery system that leverages a healthy therapeutic patient-provider relationship, we systematically gathered deeper knowledge of the behaviors, interpersonal dynamics, home environment, values, and mindsets of people who experience CP. Methods: We employed ethnographic research methods to collect and analyze data on views, habits, strategies, attitudes, and life circumstances of a range of participants living with CP. We aggregated, analyzed, and summarized participant data to identify trends and similarities. Results: Our findings suggest that patients can be broadly categorized into five predominant pain typologies, or "personas", which are characterized by respective symptom durations, care management preferences, values, communication styles, and behaviors. Conclusion: Identifying CP personas may enhance the ability to personalize CP care and help foster more robust therapeutic relationships, which may lead to greater trust, improved patient satisfaction, and better clinical outcomes.

The Impact of the COVID-19 Surge Response on Motivation Among Anesthesiology Residents and Fellows: A discussion of findings from semi-structured interviews at Montefiore Medical Center and educational takeaways.

Background: The American Board of Medical Specialties definition of medical professionalism cites the need to acquire, maintain, and advance a value system serving the patients' and public's interests above self-interests.4 Medical professionalism is a one of the core physician competencies assessed by both the ACGME training program evaluation and the ABA certification process. However, a growing concern for the decline of professionalism and altruism in medicine resulted in increased publications on the matter, citing various potential sources for the issue. Methods: All residents and fellows (Focus Group 1) of the Anesthesiology Department of Montefiore Medical Center in Bronx, NY were invited to participate in a semi-structured interview via Zoom, held on two separate dates. A separate invitation was sent to the faculty of the department (Focus Group 2), held on one date. During the interview, guiding questions were provided by the 4 interviews to facilitate discussion. The interviewers, all members of the anesthesia faculty, took notes as the interviews progressed. The notes were reviewed for common themes as well as supporting and contradicting quotations. Results: A total of 23 residents and fellows and a total of 25 faculty members within the Anesthesiology department at Montefiore Medical Center were interviewed. Amongst the findings, common discussions concerned motivating and demotivating factors contributing to the professionalism and altruism exhibited by the residents and fellows when caring for critical COVID-19 patients during the height of the pandemic. It was widely regarded that patient improvement, community and team support, as well as intrinsic desire to help greatly motivated the team while continuous patient deterioration, uncertainty in staffing and treatment, and concerns for personal and family safety were sources of discouragement. Overall, faculty perceived an increased demonstration of altruism amongst residents and fellows. The statements made by the residents and fellows during their interviews supported this observation. Conclusions: The actions of the Montefiore Anesthesiology residents and fellows demonstrated that altruism and professionalism were readily available amongst physicians. Increased levels of empathy and responsibility contributed to a demonstration of professionalism that challenges previous views of a perceived decline of these attributes in the medical field. The findings of this study stress the importance of creating a curriculum and exercise that stress empathy-based care and altruism in order to improve resident satisfaction and decrease feelings of burnout. Additionally, curriculum additions to facilitate professionalism are proposed.

Social determinants of health: modeling and targeting patient propensity to attend pain clinic appointments.

Aim: We sought to investigate the impact of social determinants of health on pain clinic attendance. Materials & methods: Retrospective data were collected from the Pain Center at Montefiore Medical Center from 2016 to 2020 and analyzed with multivariable logistic regression. Results: African-Americans were less likely to attend appointments compared with White patients (odds ratio [OR]: 0.73; 95% CI: 0.70-0.77; p < 0.001). Males had decreased attendance compared with females (OR: 0.89; 95% CI: 0.87-0.92; p < 0.001). Compared with commercial, those with Medicaid (OR: 0.69; 95% CI: 0.66-0.72; p < 0.001) and Medicare (OR: 0.76; 95% CI: 0.73-0.80; p < 0.001) insurance had decreased attendance. Conclusion: Significant disparities exist in pain clinic attendance based upon social determinants of health including race, gender and insurance type.

We aimed to investigate social determinants of health, such as race and type of insurance, and their role in patients' attendance of pain clinic appointments. Data were collected over several years and statistical analysis was performed on over 145,000 patient encounters. It was found that patients with Medicaid and Medicare were less likely to attend appointments compared with patients with commercial insurance. Black or African­American patients were also less likely to attend compared with White patients. Spanish speaking patients were more likely to attend compared with English speaking patients, showing that previous interventions aimed at reducing the language barrier for Spanish speaking patients continue to be successful after many years. Overall, significant disparities exist in pain clinic attendance based upon social determinants of health. Further research is needed to investigate reasons and potential areas of interventions. Patients insured with Medicare and Medicaid may also have greater transportation issues, a potential focus for further studies and targeted interventions.

Contrast Spread After Erector Spinae Plane Block at the Fourth Lumbar Vertebrae: A Cadaveric Study.

INTRODUCTION: In recent years, the erector spinae plane block (ESPB) has seen widespread use to treat acute and chronic pain in the regions of the thoracic spine. While limited data suggest its increasing utilization for pain management distal to the thoracic, abdomen and trunk, the anesthetic spread and analgesic mechanism of ESPB at the level of the lumbar spine has not been fully described or understood. METHODS: This is an observational anatomic cadaveric study to assess the distribution of solution following an ESPB block performed at the fourth lumbar vertebrae (L4) using ultrasound guidance to evaluate the spread of a 20 ml solution consisting of local anesthetic and methylene blue. The study was performed in an anatomy lab in a large academic medical center. Following injection of local anesthetic with contrast dye, cadaveric dissection was performed to better understand the extent of contrast dye and to determine the degree of staining to further predict analgesic potential. We reviewed the findings of other ESPB cadaveric studies currently available for comparison. RESULTS: Following cadaveric dissection in an anatomy lab, the contrast dye was observed in the ESP space, and staining was found most cranially at L2 and extending caudally underneath the sacrum. Evaluating the depth of its spread, we found it to be confined to the posterior compartment of the spine sparing the nerve roots bilaterally, which is consistent with the only other cadaveric study of ESPB performed at L4. CONCLUSION: Our results demonstrate the clinical utility of lumbar ESPB where posterior confinement of local anesthesia is preferred. However, further investigation is needed to determine the efficacy of ESPB in lower extremity analgesia which is predicated on ventral nerve root involvement.

Comparing the Effectiveness of Hands-on vs. Observational Training of Residents in Interlaminar Epidural Steroid Injections (ILESI) Using a High-Fidelity Spine Simulator.

Introduction The Accreditation Council for Graduate Medical Education (ACGME) requires that residents in the Physical Medicine and Rehabilitation (PM&R) residency observe or perform certain interventional procedures, one of which is an interlaminar epidural steroid injection (ILESI). While the traditional learning model relying heavily on observation is commonplace, it leaves the practice phase of learning to happen on real patients. High-fidelity simulation may be a worthwhile alternative as a training approach to increase physician comfort with the procedure and improve patient safety. Methods Current PM&R residents from two programs between their second and fourth year, inclusively, who lacked prior training experience in ILESI attended one hour of either: (1) an experimental arm of supervised hands-on training on a simulation device or (2) a control arm observing the procedures performed by an attending on the same device. Assignments were made based on resident schedule availability. Pre-training knowledge, training, and post-training knowledge were assessed at the Multidisciplinary Pain Clinic at Montefiore Medical Center. Participants were assessed on their procedural competence using an adapted version of a previously published grading checklist before the session. Participants also evaluated their confidence in performing the procedure prior to and after training. Data was analyzed using the Wilcoxon signed-rank test and the Wilcoxon rank-sum test. SAS Version 9.4 was used for analysis. Results Fifteen residents initially participated, but three residents dropped out at the 15-week follow-up. There was a significant increase in test scores in both arms immediately after the intervention (p=0.008 in control, p=0.016 in the experiment), with greater improvement shown in the hands-on training group (p=0.063). At the 15-week follow-up, there was no significant change in test scores in the control arm (p=0.969) while there was a decrease in the experiment arm (p<0.001). Conclusion Hands-on learning with high-fidelity simulation demonstrated more improvement for short-term motor-skill acquisition, while observational learning with repetition showed more benefits for long-term retention. Optimal procedural training should employ both educational modalities for best short- and long-term results.

A Comprehensive Review of Spinal Cord Stimulator Infections.

Spinal cord stimulator (SCS) is approved to treat various pain conditions and is commonly seen in the chronic pain patient population. Due to the nature of the device and its location, infections associated with SCS have a particularly high morbidity. According to post-market data and medical device reports, 87% of patients receiving SCS implants were given perioperative antibiotics as the implantable neurostimulator or receiver pocket serve as the most common sites of infection. The most common antibiotics for surgical prophylaxis given are first-generation cephalosporins (cefalexin, cefazolin) at the time of implantation. If deep infection is suspected, imaging in the form of CT scan should be obtained as physical exam is not always sufficient. For infections involving the epidural space, vertebra, or intervertebral discs, MRI is the preferred imaging modality. If meningitis is suspected, a lumbar puncture is recommended. Positive cultures can help guide antibiotic therapy.

Cross-Sectional Study Evaluating Clinical & Psychological Impact of Limited Access to Healthcare in Chronic Pain Patients During the COVID-19 Pandemic.

BACKGROUND: COVID-19 quarantine measures have created new challenges in the delivery of medical care, especially in the realm of medical and interventional chronic pain management. This study evaluated the effect of COVID-19 social distancing and quarantine measures on symptoms of pain and anxiety, as well as substance abuse and health care engagement in patients with chronic pain and the role of the clinic's virtual assessment initiatives in managing these patients. METHODS: A 24-question cross-sectional survey was conducted with patients with chronic pain seen at the Montefiore Medical Center Comprehensive Pain Clinic from June 2020 through July 2020. The survey was administered to 552 high-utilizer patients via telephone, evaluating domains such as pain, anxiety, substance use, and health care engagement. The questions were quantitively assessed on a Likert scale or a numerical rating scale. We used descriptive statistics to report our results. RESULTS: Of the 1,023 patients identified as high utilizers of the pain clinic, 552 patients participated in the survey. The median (25th-75th percentile) pain score reported was 7 (5-9) for all responders. Approximately 50% of the patients reported that they were anxious about their pain and somewhat or very concerned that their pain would be uncontrolled during the pandemic. Further, the severity of the pain reported was associated with sleep, appetite, and mood changes. In our cohort, 95% of all patients denied using alcohol, 92% denied using marijuana, and 98% denied using other recreational drugs to manage their pain during the pandemic. In addition, just more than three-fourths (79%) of all patients reported needing to speak with their health care provider during the pandemic. CONCLUSIONS: The survey conducted among high-utilizers demonstrated that patients who remained engaged with their health care team reported minimal concerns regarding chronic pain and associated symptoms during the COVID-19 quarantine period. In addition, the early implementation of virtual consults in the pain clinic may have contributed to mitigating patient concerns. Finally, the study also identified the importance of outreach and patient education on the availability and utilization of telemedicine services. Consequently, it is reasonable to implement virtual assessments and visits alongside other education outreach methods to engage patients with chronic pain who frequently utilize chronic pain health care resources.

Platelet-Rich Plasma in the Treatment of Facet Mediated Low Back Pain: A Comprehensive Review.

Background: Facet-mediated pain is a major cause of low back pain and as a result, is a significant cause of morbidity, including disability and reduced functionality. Setting: The present investigation involved a PubMed literature review between June 1, and 2021-January 1, 2022. Methods: We systematically reviewed was carried Pubmed using the search terms "platelet-rich plasma", "inflammatory mediators", "facet arthropathy", "axial back pain", and "leukoreduction". Data extraction and quality assessment were performed by 3 independent reviewers. Out of the studies analyzed 2 were retrospective, while 1 was a prospective study. Results: PRP injections for facet mediated or modulated pain are an alternative to conventional pharmacotherapies and interventional injections/radiofrequency. There are limited numbers of studies in world literature at present. Limitations: Small number of articles in the world literature and small numbers of patients in those published studies. Conclusions: At present, there are limited studies in the literature; however, larger well-designed studies are warranted to precisely understand efficacy, potential side effects and best practice techniques for PRP injections for facet mediated or modulated pain.

The Use of a New Device-Assisted Needle Guidance versus Conventional Approach to Perform Ultrasound Guided Brachial Plexus Blockade: A Randomized Controlled Study.

Purpose: Ultrasound guidance during nerve blockade poses the challenge of maintaining in-plane alignment of the needle tip. The needle guidance device maintains needle alignment and assists with in-plane needle visualization. The purpose of this study is to evaluate the utility of this device by comparing procedure performance during brachial plexus blockade with the conventional approach. Methods: After the Institutional Review Board approval and obtaining informed consent, 70 patients receiving either interscalene or supraclavicular nerve blocks were randomly assigned into 2 groups, a conventional approach versus utilizing the needle guidance device. An independent observer recorded: total procedure time; needle insertion time; number of unplanned redirections; and number of reinsertions. Additionally, physician satisfaction and ease of needle visualization were assessed. Results: Data from seventy patients were analyzed. The median [25th percentile-75th percentile] time to complete the block by the device assisted needle guidance group was 3 (2-3.75) minutes and 4 (3-6) minutes in the conventional approach group (p < 0.001). Additionally, subgroup analyses were performed in the supraclavicular block and interscalene block. Supraclavicular blockade, needle insertion time (median [25th percentile-75th percentile] in seconds) (106 [92-162] vs 197 [140-278]), total procedure time (3 [2-3] vs 4.5 [4-6] in minutes) and unplanned needle redirections (2 [1-5] vs 5.5 [3-9]) were significantly lower in needle guidance group (p < 0.001). With interscalene blockade, needle insertion time (86 [76-146] vs 126 [94-295]) and unplanned needle redirections (2 [1-3] vs 4 [2-8.5]) were significantly lower with needle guidance (p < 0.001), but total procedure time was similar. All the physicians reported that they would use the needle guidance again, and 90% would prefer it for in-plane blocks. Conclusion: Performing regional blocks using the needle guidance device reduces needle insertion time and unplanned needle redirections in brachial plexus blockade. Moreover, physician satisfaction also improved compared to the use of the conventional technique.

Point To Area of Pain: A Clinically Useful Telehealth Physical Exam Technique for Focal Nociceptive and Neuropathic Pain.

BACKGROUND: Chronic pain is a leading cause of disease burden and disability globally. The COVID-19 pandemic catalyzed a major paradigm shift in health care delivery with the universal adoption of telemedicine. Telehealth physical examination is particularly challenging and little guidance is available on this topic. OBJECTIVES: We attempt to describe the Point To the Area of Pain (PTAP) test and establish a consensus regarding its utility for musculoskeletal examination (MSK) via telehealth. STUDY DESIGN: The authors drafted an online survey. SETTING: The survey was sent to physicians and nurse practitioners within the authors' respective departments and institutions who routinely use telemedicine to treat pain METHODS: Respondents (n = 61) were asked about their primary specialty, comfort level in evaluating patients in pain, use of the PTAP test and its perceived clinical relevance to patient management, and other relevant questions. RESULTS: Respondents were predominantly trained in Physiatry (47.5%), Anesthesiology (23%), Neurology (13.1%) and Family Medicine (11.5%); 67.2% of providers treat pain related diseases > 75% of the time; 50.8% of respondents were "somewhat comfortable" at performing a virtual MSK exam and 29.5% were "not comfortable"; 65.5% utilize the PTAP test and 88.5% agree or strongly agree that this test provides extrinsic clinically relevant information. LIMITATIONS: The relatively small number of respondents. CONCLUSION: PTAP tests should not replace the standard accepted in-person or virtual physical examination in practice, but in the absence of a hands-on exam, the PTAP test is a clear and concise test that can easily be performed in conjunction with other techniques via telehealth, and in the context of assessing pain provides useful clinical information that can help guide medical decision making.

Acute Cauda Equina Syndrome Due to Spondylolisthesis in the Midst of a Pandemic: A Case Report.

CASE: A 54-year-old woman with chronic lumbar radiculopathy due to grade II spondylolisthesis at lumbar 4 to 5 developed acute cauda equina syndrome (CES) after an elective lumbar decompression, and fusion was delayed because of statewide bans on elective procedures during the pandemic. The diagnosis was made largely through telehealth consultation and eventually prompted urgent neurosurgical intervention. CONCLUSION: This case report illustrates a rare presentation of acute CES and highlights some of the challenges of practicing clinical medicine in the midst of a pandemic.

A Review of Sublingual Sufentanil Tablet (SST) and its Utility as an Analgesic Agent for Pain Procedures.

PURPOSE OF REVIEW: Sedation for pain medicine procedures provides a unique challenge for proceduralists. Many patients dealing with pain are on chronic opioids and require higher doses of sedation for adequate procedural comfort. Chronic pain patients have various comorbidities including depression, neuropsychiatric disorders, peripheral vascular disease, and renal impairment, among others [1]. These confounding variables make the overall treatment of their pain condition much more challenging. RECENT FINDINGS: For patients requiring intravenous (IV) sedation for their pain procedures, the constant need for access may render them a "difficult stick" over time. Another factor to consider is the increasing requirements by the hospital system needing IV sedatives and analgesics in the intensive care unit and operating rooms during the coronavirus (COVID-19) pandemic. Sublingual sufentanil (SST) provides an excellent analgesic option for patients undergoing interventional pain procedures. The use of SST allows hospitals to preserve IV agents for more critical areas and mitigates the difficulty of obtaining IV access in patients.

A Pilot Survey: Retention in Pain Medicine Among Fellowship Trained Anesthesiologists.

BACKGROUND: We aim to explore the factors related to job satisfaction among pain physicians and identify the reasons why individuals minimize or stop practicing outpatient pain medicine. OBJECTIVES/STUDY DESIGN: This is a survey-based study with the primary goal to identify factors determining job satisfaction and dissatisfaction among pain medicine fellowship graduates who continue to practice and those who are no longer practicing interventional pain. A secondary goal is to elucidate reasons for anesthesiologists trained in pain medicine to leave pain medicine, despite an additional year of training, and to work as general anesthesiologists. METHODS: In this study, all 114 pain program directors listed on the Accreditation Council for Graduate Medical Education (ACGME) website, or their administrative assistants were directly contacted via email. All email addresses were obtained from the ACGME website. The survey opened in September 2021, with reminder emails sent before the closing of the survey in December 2021. A final reminder email was sent 4 weeks prior to the closing of the survey. RESULTS: Of all the respondents, 79 (89.77%) were currently practicing pain medicine, and 9 (10.23%) were no longer practicing pain medicine. LIMITATIONS: Our study has a major limitation as we are unable to determine the response rate and are limited in the data points gathered. CONCLUSION: We hope this study will allow for pain medicine fellowship program directors to improve recruitment and retention of pain fellows in the field while addressing the pros and cons of future career aspirations with anesthesiology residents prior to fellowship selection. A larger, more thorough study with an exact response rate can compare the various outcomes based upon different types of settings, such as private practice, partnership, and academia, as well as geographical locations.

Adaptation and restructuring of an academic anesthesiology department during the COVID-19 pandemic in New York City: Challenges and lessons learned.

The novel SARS-CoV-2 pandemic starting in 2019 profoundly changed the world, and thousands of residents of New York City were affected, leading to one of the most acute surges in regional hospital capacity. As the largest academic medical center in the Bronx, Montefiore Medical Center was immediately impacted, and the entire hospital was mobilized to address the needs of its community. In this article, we describe our experiences as a large academic anesthesiology department during this pandemic. Our goals were to maximize our staff's expertise, maintain our commitment to wellness and safety, and preserve the quality of patient care. Lessons learned include the importance of critical care training presence and leadership, the challenges of converting an ambulatory surgery center to an intensive care unit (ICU), and the management of effective communication. Lastly, we provide suggestions for institutions facing an acute surge, or subsequent waves of COVID-19, based on a single center's experiences.

Comparison of Dexmedetomidine and Dexamethasone as Adjuvants to Ultra-Sound Guided Interscalene Block in Arthroscopic Shoulder Surgery: A Double-Blinded Randomized Placebo-Controlled Study.

BACKGROUND: Interscalene block is one of the popular methods for decreasing pain and analgesic consumption after shoulder arthroscopic surgeries. OBJECTIVES: The objective is to compare the analgesic duration of effects of dexmedetomidine and dexamethasone as adjuvants to 0.5% ropivacaine in ultrasound-guided interscalene blocks for arthroscopic shoulder surgery in an ambulatory setting. METHODS: In this randomized controlled trial, 117 adult patients candidate for ambulatory arthroscopic shoulder surgery under general anesthesia were divided into three groups to perform an ultra-sound guided interscalene block before the surgery. The ropivacaine (control) group received ropivacaine 0.5% 20 mL, group Dexamethasone received ropivacaine 0.5% 20 mL plus 4mg dexamethasone, and group dexmedetomidine received ropivacaine 0.5% 20 mL plus 75 mcg of dexmedetomidine. Time to return of sensory function, of motor function, of first pain sensation, amount of opioid medication consumed at 24 hours and 48 hours post-operatively were measured. RESULTS: The 24-hour median (25th- 75th percentile) opioid consumption in morphine equivalents was similar between groups 22.5 mg (10 - 30), 15 mg (0 - 30), and 15 mg (0 - 20.6) in the ropivacaine, dexmedetomidine, and dexamethasone groups, respectively (P = 0.130). The median (25th- 75th percentile) 48 hours post-operatively, the median opioid consumption in morphine equivalents was 40 mg (25 - 67.5) in the ropivacaine group, 30 mg (22 - 50.6) in the dexamethasone group, and 52.5 mg (30 - 75) in the dexmedetomidine group (P = 0.278). The median 24-hour pain scores were 6 (5 - 8) in the ropivacaine control group, 7 (5.5 - 8) in the dexamethasone group, and 7 (4 - 9) in the dexmedetomidine group (P = 0.573). CONCLUSIONS: There was no statistical difference in opioid consumption at 24 and 48 hours post-operatively when comparing dexmedetomidine, dexamethasone, and no adjuvant. However, intraoperative opioid use was significantly lower with dexmedetomidine compared to dexamethasone and plain 0.5% ropivacaine. The safe side effect profile of dexmedetomidine makes it a reasonable alternative as an adjuvant for peripheral nerve blockade when dexamethasone use may be contraindicated.