Postoperative Rebound Pain: Our Current Understanding About the Role of Regional Anesthesia and Multimodal Approaches in Prevention and Treatment.

PURPOSE OF REVIEW: Rebound pain (RP) is a common occurrence after peripheral nerve block placement, especially when blocks are used for orthopedic surgery. This literature review focuses on the incidence and risk factors for RP as well as preventative and treatment strategies. RECENT FINDINGS: The addition of adjuvants to a block, when appropriate, and starting patients on oral analgesics prior to sensory resolution are reasonable approaches. Using continuous nerve block techniques can provide extended analgesia through the immediate postoperative phase when pain is the most intense. Peripheral nerve blocks (PNBs) are associated with RP, a frequent phenomenon that must be recognized and addressed to prevent short-term pain and patient dissatisfaction, as well as long-term complications and avoidable hospital resource utilization. Knowledge about the advantages and limitations of PNBs allows the anesthesiologists to anticipate, intervene, and hopefully mitigate or avoid the phenomenon of RP.

Postoperative Hyperthermia and Hemodynamic Instability in a Suspected Malignant Hyperthermia-Susceptible Patient: A Case Report.

Malignant hyperthermia (MH) is a rare but potentially fatal complication of exposure to certain anesthetic drugs. However, stress-induced MH, initially observed in pigs undergoing intense physical or emotional strain, has been reported in the absence of anesthetic exposure. In this case report, we describe a case of postoperative hyperthermia and cardiac dysfunction suspicious for stress-induced MH occurring after an endobronchial biopsy in a patient with recurrent undiagnosed fevers. We also examine our diagnosis of stress-induced MH and possible preventive measures to avoid this complication.

Ultrasound-Guided Midpoint Transverse Process to Pleura Nerve Block for Medical Thoracoscopy: A Case Report.

We performed the midpoint transverse process to pleura (MTP) block in a patient with a recurrent pleural effusion requiring medical thoracoscopy, drainage of pleural effusion, talc poudrage, and placement of tunneled pleural catheter under sedation while in the left lateral decubitus position. Forty milliliters of a combination of bupivacaine hydrochloride and lidocaine, with dexamethasone and clonidine as adjuvants, was injected at the T6 level under ultrasound guidance with satisfactory intra- and postoperative analgesia.

Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery.

BACKGROUND: Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting. METHODS: Providers from five academic medical centers within a single US city were surveyed from May-September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar's tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher's exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians. RESULTS: A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002). CONCLUSIONS: While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

Positive perceptions on safety and satisfaction during a patient-centered timeout before peripheral nerve blockade.

OBJECTIVES: To determine the psychometric outcomes of patients participating in an extensive patient-centered verification process before receiving sedation for regional anesthesia. DESIGN: Survey. SETTING: Perioperative areas of university-affiliated hospital. PATIENTS: Two hundred eligible patients scheduled for elective orthopedic surgery undergoing peripheral nerve blockade. INTERVENTIONS: Postoperative survey evaluating patient perception, experience, and satisfaction with the anesthetic timeout before regional anesthesia. MEASUREMENTS: Measures using numeric rating scales were obtained on patient perceptions of safety, confidence in anesthesia provider, anxiety, and positive sentiments during participation in block timeout. These variables were analyzed using logistic regression models to correlate with reported pain and satisfaction perioperatively. MAIN RESULTS: One hundred seventy-five patients (93% enrollment) completed the study. More than 90% of patients reported agreeing strongly to feeling safe, confident, relaxed, and positive about their participation in the block timeout. These sentiments are associated with less reported perioperative pain and higher overall satisfaction. CONCLUSIONS: Patient perceptions of confidence and safety in regional anesthesia providers were enhanced by a preprocedural timeout process. These positive attitudes are associated with a superior perioperative experience and patient satisfaction.

Preoperative evaluation and preparation of patients for orthopedic surgery.

Orthopedic patients frequently have multiple comorbidities when they present for surgery. This article discusses risk stratification of this population and the preoperative work-up for patients with specific underlying conditions who often require orthopedic procedures. Preoperative strategies to decrease exposure to allogeneic blood and advantages of the Perioperative Surgical Home model in this unique population are discussed.

Types of office-based anesthetics.

Over the past several decades, there have been evolutionary changes in both surgery and anesthesia. Newer anesthetics have excellent safety profiles and are associated with fewer hemodynamic side effects and rapid elimination from the body. Innovative surgical techniques are less invasive and cause less perioperative patient pain. These developments have fueled the growth of office-based surgery and anesthesia. All types of anesthesia, including local, monitored anesthesia care, general, and regional anesthesia, have been used safely within the private practitioner's office. Because of the remote nature of the private surgeon's office, the proper selection of both patient and procedure to be performed is of utmost importance. It is likewise imperative that the practitioner assures that the patient does not experience excessive postoperative pain and/or nausea and vomiting. It is of the utmost importance that the practicing anesthesiologist assure that every location in which procedures and surgeries are performed is a safe anesthetizing location.

Neuraxial anesthesia and timing of heparin administration in patients undergoing surgery for congenital heart disease using cardiopulmonary bypass.

OBJECTIVE: The goal of this review was to add to the existing literature documenting the safety of performing neuraxial techniques in patients who are subsequently fully heparinized, with particular emphasis on the timing of heparin administration. This will help improve risk estimation and possibly lead to a more widespread use of neuraxial anesthesia in patients undergoing cardiac surgery. DESIGN: Retrospective chart review. SETTING: Single tertiary-care university hospital. PARTICIPANTS: All patients undergoing surgery for congenital heart diseases during a 5-year period. INTERVENTIONS: The medical records of all patients undergoing surgery for congenital heart diseases during a 5-year period were reviewed for any complications related to the use of neuraxial anesthesia. Furthermore, the interval from neuraxial anesthesia to heparinization for cardiopulmonary bypass was examined. RESULTS: In total, 714 patients were identified who had neuraxial anesthesia administered before full heparinization for cardiopulmonary bypass. No cases of symptomatic spinal or epidural hematomas occurred. Further analysis showed that the interval from neuraxial anesthesia to full heparinization was <1 hour in 466 patients. CONCLUSIONS: No complications related to neuraxial anesthesia were found in a series of 714 patients undergoing surgery for congenital heart disease using cardiopulmonary bypass, including 466 patients in whom the interval from neuraxial anesthesia to full heparinization was <1 hour.

Anesthesia for patients undergoing orthopedic oncologic surgeries.

When planning an anesthetic for patients undergoing orthopedic oncologic surgeries, numerous factors must be considered. Preoperative evaluation may elucidate significant co-morbidities or side effects secondary to chemotherapy or radiation, which can affect anesthetic choices. Procedures vary in length and complexity and pose challenges in both positioning and in planning to minimize blood loss. Many anesthetic techniques are available to provide both intraoperative anesthesia and postoperative analgesia, while the type of thromboprophylaxis and analgesic adjuvants that will be administered needs to be defined. This review focuses on approaches to use when caring for patients undergoing orthopedic oncologic procedures.

Treating stridor with opioids: a challenging case of paradoxical vocal cord movement.

A 61 year-old patient with a history of anxiety disorder presented with stridor after an uneventful laparotomy with a general anesthetic. Postoperative analgesia was withheld secondary to intermittent oxygen desaturation. She was unresponsive to standard therapies, including racemic epinephrine and albuterol nebulizers. An otolaryngology consultant performed fiberoptic laryngoscopy and paradoxical vocal cord movement was diagnosed. When fentanyl was subsequently administered to treat her pain, the stridor resolved.

The use of cerebral oximetry as a monitor of the adequacy of cerebral perfusion in a patient undergoing shoulder surgery in the beach chair position.

Four cases of ischemic injury have been reported in patients undergoing orthopedic surgery in the upright position. We describe the use of cerebral oximetry as a monitor of the adequacy of cerebral perfusion in a 63-year-old woman who underwent arthroscopic rotator cuff surgery in a beach chair under general anesthesia. During positioning, a decrease in blood pressure was accompanied by a decrease in cerebral oxygen saturation (S(ct)O(2)) and was treated with phenylephrine. When spontaneous ventilation resumed, an increase in end-tidal carbon dioxide was accompanied by an increase in S(ct)O(2). Cerebral oximetry may prove useful as a guide monitor and manage nonsupine patients.

The safety and efficacy of regional anesthesia in an office-based setting.

STUDY OBJECTIVE: To determine the safety and efficacy of regional anesthesia techniques when administered in the office-based setting. DESIGN: Retrospective chart review. SETTING: Free-standing orthopedic office with an operating room suite. MEASUREMENTS: A total of 238 patients underwent 242 anesthetics. Types of anesthetics delivered were quantified. Regional anesthetics were further divided into specific nerve blocks. Times from anesthetic start to surgical start and from surgical end to anesthetic end were calculated. Adverse outcomes were ascertained and followed. MAIN RESULTS: Of the 242 anesthetics administered, 123 were peripheral nerve blocks, two were neuraxial blocks, 140 were monitored anesthesia care cases, and 17 were general anesthetics (14 Laryngeal Mask Airway cases, two mask ventilation cases, and one endotracheal intubation). The average times from anesthesia start to surgery start were as follows: monitored anesthesia cases, 19+/-7 min (median, 20 min); regional anesthesia cases, 29+/-11 min (median, 30 min); and general anesthesia cases, 31+/-11 min (median, 30 min). The average time from surgery end to anesthesia end for monitored anesthesia cases was 9+/-3 min (median, 10 min); regional anesthesia, 9+/-3 min (median, 10 min); and general anesthesia, 12+/-4 min (median, 20 min). Two transient nerve injuries occurred, both of which resolved. CONCLUSIONS: On the basis of our experience, we believe that regional anesthesia can be delivered efficiently and safely for orthopedic procedures in the office-based environment, and we encourage its wider use.

The ultrasound-guided supraclavicular-interscalene (UGSCIS) block: a case report.

Providing complete anesthesia to the entire upper extremity remains challenging. We present the use of a novel, updated, regional anesthetic technique-an ultrasound-guided supraclavicular-interscalene block (UGSCIS)-to provide anesthesia and analgesia to a patient with end-stage liver disease who required fixation of a pathologic fracture of the humerus.

Interscalene regional anesthesia for arthroscopic shoulder surgery: a safe and effective technique.

There has been resistance to the use of interscalene regional block for arthroscopic shoulder surgery because of concerns about potential complications and failed blocks with the subsequent need for general anesthesia. The purpose of this study was to assess whether interscalene regional block is safe and effective and offers many advantages over general anesthesia for outpatient arthroscopic shoulder surgery. Through a retrospective chart review of consecutive arthroscopic shoulder surgeries over a 2.5-year time period, in a tertiary university medical center with an anesthesiology residency, 277 interscalene blocks (96%) were successful; 12 (4%) required general anesthesia because of an inadequate block. There were no seizures, pneumothoraces, cardiac events, or other major complications. There was a 1% rate of minor complications, all of which were transient sensory neuropathies that resolved within 5 weeks on average. We conclude that interscalene block can provide effective anesthesia for arthroscopic shoulder surgery.

Interscalene regional anesthesia for shoulder surgery.

BACKGROUND: Despite a trend toward the use of regional anesthesia for orthopaedic procedures, there has been resistance to the use of interscalene regional block for shoulder surgery because of concerns about failed blocks and potential complications. METHODS: We retrospectively reviewed the cases of 568 consecutive patients who had shoulder surgery under interscalene regional block in a tertiary-care, university-based practice with an anesthesiology residency program. The blocks were performed by a group of anesthesiologists who were dedicated to the concept of regional anesthesia in their practice. Complete anesthetic and orthopaedic records were available for 547 patients. The surgical procedure, planned type of anesthesia, occurrence of block failure, and the presence of complications were noted. RESULTS: Of the 547 patients, 295 underwent an arthroscopic procedure and 252 (including eighty who had an arthroplasty) underwent an open procedure. General anesthesia was the initial planned choice for sixty-nine patients because of the complexity or duration of the procedure, the anatomic location, or patient insistence. Thirty-four of the sixty-nine patients also received an interscalene regional block. Interscalene regional block alone was planned for 478 patients. A total of 462 patients (97%) had a successful block whereas sixteen required general anesthesia because the block was inadequate. The success of the block was independent of the type or length of the surgery. No patient had a seizure, pneumothorax, cardiac event, or other major complication. Twelve (2.3%) of the 512 patients who had a block had minor complications, which included sensory neuropathy in eleven patients and a complex regional pain syndrome that resolved at three months in one patient. For ten of the eleven patients, the neuropathy had resolved by six months. CONCLUSIONS: Interscalene regional block provides effective anesthesia for most types of shoulder surgery, including arthroplasty and fracture fixation. When administered by an anesthesiologist committed to and skilled in the technique, the block has an excellent rate of success and is associated with a relatively low complication rate.