Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy.

PURPOSE: Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy. METHODS: Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay. RESULTS: Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min). CONCLUSIONS: Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy.

Comparison of transversus abdominis plane blocks with liposomal bupivacaine versus ropivacaine in open total abdominal hysterectomy.

Regional anesthesia is frequently employed in efforts to improve postoperative analgesia and reduce opioid requirements following abdominal surgery. The purpose of the current analysis was to determine if there was a difference in postoperative pain and opioid consumption between patients who underwent open total abdominal hysterectomy (TAH) and received ultrasound-guided bilateral transversus abdominis plane (TAP) blocks using either liposomal bupivacaine or ropivacaine. A single-center retrospective analysis was conducted of 215 patients from November 2018 through March 2020 who underwent an open TAH and received bilateral TAP blocks with either liposomal bupivacaine or ropivacaine. The primary outcome measure was opioid consumption at regular intervals until discharge, and the secondary outcome measures included pain scores, incidence of nausea/vomiting, and use of antiemetics at the same time intervals. Intraoperative opioid consumption and postanesthesia recovery unit opioid requirements were similar between the two groups. Opioid requirements at 24 hours (P < 0.04) and 48 hours (P < 0.01), as well as total morphine equivalent requirements (P < 0.05), were significantly lower in the liposomal bupivacaine group compared to the ropivacaine group. Patients undergoing open TAH who received liposomal bupivacaine TAP blocks required fewer postoperative opioids to achieve similar pain scores when compared to patients who received ropivacaine TAP blocks.

Pain Management After Open Liver Resection: Epidural Analgesia Versus Ultrasound-Guided Erector Spinae Plane Block.

BACKGROUND: Multimodal analgesia techniques, including regional analgesia, have been shown to provide effective analgesia and minimize opioid consumption after liver resection surgery. While thoracic epidural analgesia (TEA) is considered the gold standard, its role in the current era of enhanced recovery after surgery (ERAS) has been questioned. Erector spinae plane blocks (ESPBs) have the potential to provide effective postoperative analgesia without the risks associated with epidural analgesia. The primary aim of this quality improvement project was to evaluate the analgesic efficacy of ultrasound-guided ESPB in comparison with TEA in patients undergoing open liver resection. METHODS: Fifty patients who underwent open liver resection and received TEA (n=25) or ESPB (n=25) as part of an ERAS pathway were retrospectively identified. The primary outcome measure was cumulative postoperative opioid consumption at 24 hours. Secondary outcomes included opioid consumption, pain scores, the incidence of nausea and vomiting requiring antiemetics, lower extremity muscle weakness, and occurrence of hypotension requiring treatment on arrival to the post-anesthesia care unit and at 2, 6, 12, 24 hours, and daily through postoperative day 7.  Results: Opioid requirements were significantly lower in the TEA group compared to the ESPB group. Postoperative pain scores at rest and with deep inspiration were significantly lower in the TEA group through postoperative day 5. There were no differences in other outcome measures. CONCLUSIONS: These findings suggest that compared with ESPB, TEA provides superior pain relief after open liver resection.

Erector spinae plane block versus thoracic paravertebral block for pain management after total bilateral mastectomies.

This prospectively designed, clinical quality improvement project compared pain scores and opioid consumption between ultrasound-guided, erector spinae plane blocks (ESPB) and thoracic paravertebral blocks (PVB) in patients undergoing total bilateral mastectomies without reconstruction. Twenty-five patients were included in an enhanced recovery pathway and received an ESPB on one side and a PVB on the contralateral side. Numeric rating scores at rest and with movement for each side were recorded in the recovery room at 2, 6, 12, 24, and 48 hours and on days 3 to 7. There were no significant differences in the resting or movement-evoked pain scores between sides receiving ESPB or PVB at any time point up to day 7 after surgery. Both ESPB and PVB confer equal analgesic effects in patients undergoing mastectomies. ESPB provides an alternative to PVB in reducing postoperative pain in patients undergoing mastectomy as part of an enhanced recovery pathway.

Comparison of Regional Anesthesia Timing on Pain, Opioid Use, and Postanesthesia Care Unit Length of Stay in Patients Undergoing Open Reduction and Internal Fixation of Ankle Fractures.

Regional nerve blocks are an effective method of managing acute pain associated with surgery. The relative benefit of preoperative versus postoperative peripheral nerve blocks is not entirely clear. The primary aim of this study was to determine differences in pain scores in patients undergoing preoperative block versus postoperative block versus no block. We hypothesized that patients receiving preoperative blocks would have reduced pain scores and decreased opioid use in the immediate postoperative period. We conducted a retrospective cohort analysis of 302 consecutive patients undergoing unilateral open reduction and internal fixation of ankle fracture under general anesthesia. We identified 3 groups: preoperative block, postoperative block, or no block. Data obtained from our electronic medical records included demographic information, postanesthesia care unit length of stay, pain scores obtained preoperatively, upon arrival to the postanesthesia care unit, and upon discharge from the postanesthesia care unit as well as intraoperative and postanesthesia care unit opioid utilization. Patients receiving preoperative block had significantly lower pain scores, less intraoperative or postanesthesia care unit opioid use, and shorter postanesthesia care unit dwell time compared with patients receiving postoperative block or no block. Preoperative popliteal sciatic and adductor canal blocks in patients undergoing ankle fracture surgery appears to be more effective than either postoperative block or no block.

Ultrasound-guided suprainguinal fascia iliaca compartment block versus periarticular infiltration for pain management after total hip arthroplasty: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Fascia iliaca compartment block (FICB) has been shown to provide excellent pain relief in patients undergoing total hip arthroplasty (THA). However, the analgesic efficacy of FICB, in comparison with periarticular infiltration (PAI) for THA, has not been evaluated. This randomized, controlled, observer-blinded study was designed to compare suprainguinal FICB (SFICB) with PAI in patients undergoing THA via posterior approach. METHODS: After institutional review board approval, 60 consenting patients scheduled for elective THA were randomized to one of two groups: ultrasound-guided SFICB block or PAI. The local anesthetic solution for both the groups included 60 mL ropivacaine 300 mg and epinephrine 150 µg. The remaining aspects of perioperative care, including general anesthetic and non-opioid multimodal analgesic techniques, were standardized. An investigator blinded to group allocation documented pain scores at rest and with movement and supplemental opioid requirements at various time points. Patients were evaluated for sensory changes and quadriceps weakness in the operated extremity. RESULTS: There were no differences between the groups with respect to demographics, intraoperative opioid use, duration of surgery, recovery room stay, nausea scores, need for rescue antiemetics, time to ambulation and time to discharge readiness as well as 48 hours postoperative opioid requirements. The pain scores at rest and with movement also were similar at all time points. Significantly more patients in the SFICB group experienced muscle weakness at 6 hours after surgery. CONCLUSIONS: Under the circumstances of our study, in patients undergoing THA, SFICB provided the similar pain relief compared with PAI, but was associated with muscle weakness at 6 hours postoperatively. TRIAL REGISTRATION NUMBER: NCT02658240.

Preoperative Continuation Versus Interruption of Oral Hypoglycemics in Type 2 Diabetic Patients Undergoing Ambulatory Surgery: A Randomized Controlled Trial.

Patients with type 2 diabetes mellitus receiving oral hypoglycemic drugs (OHDs) are usually instructed to stop them before surgery. We hypothesize that continuing OHD preoperatively should result in lower perioperative blood glucose (BG) levels. Ambulatory surgery patients with type 2 diabetes mellitus on OHDs were randomized to continue (n = 69) or withhold (n = 73) OHDs preoperatively. Log-transformed BG levels at pre-, intra-, and postoperative periods were analyzed. Perioperative BG levels were significantly lower (mean, 138 mg/dL; 95% confidence interval, 130-146 mg/dL) in the group that continued versus the group that discontinued OHDs (mean, 156 mg/dL; 95% confidence interval, 146-167 mg/dL; P < .001).

Isolated mitral valve surgery risk in 77,836 patients from the Society of Thoracic Surgeons database.

BACKGROUND: Understanding the operative outcomes of mitral valve (MV) surgery across the spectrum of predicted risk of mortality (PROM) is necessary to determine the best use of novel percutaneous approaches. METHODS: The Society of Thoracic Surgeons Adult Cardiac Surgery Database was utilized to study isolated MV operations during two time periods: era 1 (2002 to 2006, n = 37,743) and era 2 (2007 to 2010, n = 40,093). In each era, four PROM groups were defined: low risk (PROM 0% to <4%); intermediate risk (PROM 4% to <8%); high risk (PROM 8% to <12%); and extreme risk (PROM ≥ 12%). In each risk group, mortality rates and observed to expected mortality ratios were compared across eras. RESULTS: A total of 63,645 cases (82%) were classified as low risk, 8,032 (10%) as intermediate risk, 2,765 (4%) as high risk, and 3,394 (4%) as extreme risk. Sixty-seven percent of MV repairs (n = 30,488) and 18% of MV replacements (n = 5,749) had a PROM less than 1%. PROM less than 4% was seen for 93% of MV repairs (n = 42,196) and 66% of replacements (n = 21,449). Across the two eras, the MV repair rate increased from 54.8% to 61.8% (p = 0.0017); and a significant reduction in operative mortality was observed in high risk and extreme risk cohorts (p < 0.05). CONCLUSIONS: The frequency with which MV repair for isolated MV disease is performed has increased over time and is associated with very low early mortality. A significant reduction in mortality among patients at highest risk has occurred, and must be considered as patients are evaluated for percutaneous therapies.

Simple technique to verify CO(2) diffusion with the CarbonAid™ device.

It has become common practice in cardiac surgery to flood the operative field with CO(2) to facilitate deairing of the heart. However, CO(2) delivery is variable and verification of CO(2) delivery can be challenging. We report a simple, reliable method to confirm CO(2) delivery. This technique ensures that the benefits of CO(2) delivery are provided to the patient during the operation.

Resection of intracaval leiomyomatosis using abdominal approach and venovenous bypass.

BACKGROUND: Intravenous leiomyomatosis is the venous involvement of a histologically benign uterine tumor. This uncommon tumor can present contemporaneously with the primary uterine tumor or in a delayed fashion. Tumor extends up the venous system, via the iliac or ovarian veins, and can involve portions or all of the inferior vena cava and can extend into the heart as well. Complete resection of this tumor is the therapeutic goal. Previous reports have described the use of combined thoracic and abdominal approaches, cardiopulmonary bypass, circulatory arrest, and a single report of an entirely abdominal approach to resection without bypass. METHODS AND RESULTS: We present a review of the existing literature describing surgical intervention for intravenous leiomyomatosis and describe two cases of tumor extending up the intra-abdominal vena cava. Using venovenous bypass without need for thoracotomy, we were able to resect both tumors with minimal blood loss and no hemodynamic instability. CONCLUSIONS: We suggest that venovenous bypass is an excellent tool in resection of these tumors and should be considered for many cases in lieu of full cardiopulmonary bypass or circulatory arrest.

Left atrial appendage occlusion: lessons learned from surgical and transcatheter experiences.

Since the 1950s, the pathophysiologic role of the left atrial appendage (LAA) has been known in thromboembolic disease. A variety of surgical techniques have been described to close the LAA, with various degrees of efficacy. Today, transcatheter devices for LAA occlusion may offer a less invasive solution. This review looks at the surgical experience with LAA occlusion, with a focus on the techniques of closure, the prospects for stroke reduction, and the percutaneous trials completed so far, to formulate some meaningful conclusions about the status of LAA closure today.

Hybrid percutaneous coronary intervention and minimally invasive reoperative mitral valve surgery.

We report a complex case of peripheral vascular disease (PVD), coronary artery disease (CAD), and three prosthetic heart valves, who developed severe mitral regurgitation (MR) due to healed endocarditis. She was successfully managed with a hybrid approach utilizing percutaneous coronary intervention (PCI) followed by minimally invasive mitral valve surgery (MIMVS) through right minithoracotomy. This was the patient's fifth cardiac surgery and she was discharged home on the fourth postoperative day (POD).

Chordal tethering: a unique cause of structural mitral regurgitation in dilated cardiomyopathy.

Mitral regurgitation in dilated cardiomyopathy is usually considered "functional," and many such patients are treated medically. Surgery is often offered as a last resort in select patients who have failed medical therapy. We report a patient with dilated cardiomyopathy with ventricular tachycardia and ventricular dyssynchrony and "structural mitral regurgitation" due to chordal tethering, which was managed surgically using a minimally invasive approach.

Anticoagulation: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.

Post-cardiac surgery atrial fibrillation (AF) places patients at risk for thromboembolism and stroke, while the surgery and cardiopulmonary bypass alter the multiple factors of coagulation and may increase the tendency to bleed. It is in the context of this complex clinical picture that the physician must make decisions regarding the risks and benefits of anticoagulation therapy to lower the risk for thromboembolism and stroke associated with postoperative AF. Physicians must also weigh the usually transient and self-limited duration of new-onset postoperative AF against the potential for postoperative bleeding if anticoagulation therapy is started. No randomized, controlled clinical trials are available that specifically address the problem of anticoagulation therapy for the postoperative AF. In that context, recommendations are based on the established therapy for nonsurgical situations modified by the potential risk of bleeding in the postoperative patient.

Intraoperative interventions: American College of Chest Physicians guidelines for the prevention and management of postoperative atrial fibrillation after cardiac surgery.

A comprehensive evidence review was conducted of the medical literature regarding the relationship between intraoperative interventions and the incidence of postoperative atrial arrhythmias, including, most commonly, atrial fibrillation (AF). Fifteen randomized, controlled studies and one large-scale concurrent cohort study were identified that reported on the following issues: systemic temperature during surgery (one report); "beating heart" surgery vs conventional bypass surgery (three reports); type of myocardial protection (five reports); the use of adjunctive posterior pericardiotomy (one report); the use of thoracic epidural anesthesia (TEA) [two reports]; the use of glucose-insulin-potassium (GIK) solutions (two reports); and the use of heparin-coated circuits for cardiopulmonary bypass (CPB) [two reports]. Based on a systematic review of the reported data and an analysis of the quality of the reported data, we recommend the following: (1) that mild hypothermia, rather than moderate hypothermia, may be effective in reducing the frequency of postoperative AF; (2) the use of posterior pericardiotomy may be a useful adjunct to reduce the frequency of postoperative AF; and (3) the use of heparin-coated CPB circuits is associated with less postoperative AF. Because of conflicting or inadequate data, we cannot conclude that the frequency of postoperative AF is affected by (1) the use of beating-heart techniques, (2) the type of myocardial protection strategy used, (3) the use of TEA, or (4) the use of GIK solutions perioperatively.