Efficacy and Safety of Intrathecal Morphine for Cesarean Delivery: A Narrative Review.

PURPOSE OF REVIEW: Pain management is a critical aspect of care during and following a cesarean delivery. Without proper control of pain, individuals can experience poor mobility, increased thromboembolic events, and difficulty caring for the neonate in the postpartum period. There have been multiple methods for pain management for cesarean delivery and intrathecal morphine (ITM) has emerged as a prominent option for post-operative analgesia due to its efficacy, safety, and potential benefits over other treatments. This review analyzes data on efficacy, side effects, and safety of ITM and the pain control alternatives. RECENT FINDINGS: A comprehensive literature review was conducted to compare ITM with other analgesic techniques in post-cesarean patients. ITM was found to be as effective or better than other analgesic options, including bilateral quadratus lumborum block (QLB), opioid-free epidural analgesia (CSEA-EDA), and intravenous fentanyl. One study found that both ITM and oral analgesia were effective in pain control and that ITM caused fewer breakthrough pain events but had a longer duration and a greater rate of side effects than oral opioid analgesia. Commonly observed side effects of intrathecal opioids include nausea, vomiting, pruritus, and urinary retention, and it is thought that the adverse effects from intrathecal administration of opioids are short-lived. ITM may provide a decreased risk of DVT and coagulation by decreasing lower extremity weakness and numbness, thereby decreasing recovery time and increasing mobility. ITM is a safe and effective option for post-cesarean analgesia, with comparable pain relief to alternative forms of pain control, and side effects that are generally manageable. Further research is warranted to explore beneficial combinations with other methods of pain management and optimal dosing strategies.

IPACK Block Efficacy for Acute Pain Management after Total Knee Replacement: A Review.

PURPOSE OF REVIEW: Patients often experience a significant degree of knee pain following total knee replacement (TKR). To alleviate this pain, nerve blocks may be performed such as the adductor canal block (ACB). However, ACBs are unable to relieve pain originating from the posterior region of the knee. A new type of nerve block known as the IPACK block may be used in conjunction with ACBs as it is designed to inhibit nerve branches innervating this area. In this article, we examine the rationale behind the IPACK procedure, how it is performed, and clinical trials examining its efficacy. RECENT FINDINGS: 5 of the 7 clinical trials examined in this article showed the IPACK + ACB block to show superior efficacy in treating pain following TKR compared to other blocks. These blocks included PMDI+ACB, SPANK+ACB, PAI+ACB, ACB alone, and SCAB. 2 of the 7 clinical trials showed the IPACK + ACB to be less effective in managing patients pain following TKR compared to other blocks which included the CACB and 4 in 1 block. In most instances, the IPACK + ACB showed superior efficacy in managing patients' pain following TKR when compared to other types of nerve blocks. This was determined by measuring usage of opioids, reported postoperative pain, and length of hospital stays following TKR. Thus, we suppose the IPACK block may be used in conjunction with the ACB to effectively reduce patient's pain following TKR.

Algorithms to Identify Nonmedical Opioid Use.

The rise in nonmedical opioid overdoses over the last two decades necessitates improved detection technologies. Manual opioid screening exams can exhibit excellent sensitivity for identifying the risk of opioid misuse but can be time-consuming. Algorithms can help doctors identify at-risk people. In the past, electronic health record (EHR)-based neural networks outperformed Drug Abuse Manual Screenings in sparse studies; however, recent data shows that it may perform as well or less than manual screenings. Herein, a discussion of several different manual screenings and recommendations is contained, along with suggestions for practice. A multi-algorithm approach using EHR yielded strong predictive values of opioid use disorder (OUD) over a large sample size. A POR (Proove Opiate Risk) algorithm provided a high sensitivity for categorizing the risk of opioid abuse within a small sample size. All established screening methods and algorithms reflected high sensitivity and positive predictive values. Neural networks based on EHR also showed significant effectiveness when corroborated with Drug Abuse Manual Screenings. This review highlights the potential of algorithms for reducing provider costs and improving the quality of care by identifying nonmedical opioid use (NMOU) and OUD. These tools can be combined with traditional clinical interviewing, and neural networks can be further refined while expanding EHR.

Prospective Observational Evaluation of the ER-REBOA Catheter at 6 U.S. Trauma Centers.

OBJECTIVE: To describe the current use of the ER-REBOA catheter and associated outcomes and complications. INTRODUCTION: Noncompressible truncal hemorrhage is the leading cause of potentially preventable death in trauma patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a novel strategy to obtain earlier temporary hemorrhage control, supporting cardiac, and cerebral perfusion before definitive hemostasis. METHODS: Prospective, observational study conducted at 6 Level 1 Trauma Centers over 12-months. Inclusion criteria were age >15 years of age with evidence of truncal hemorrhage below the diaphragm and decision for emergent hemorrhage control intervention within 60 minutes of arrival. REBOA details, demographics, mechanism of injury, complications, and outcomes were collected. RESULTS: A total of 8166 patients were screened for enrollment. In 75, REBOA was utilized for temporary hemorrhage control. Blunt injury occurred in 80% with a median injury severity score (ISS) 34 (21, 43). Forty-seven REBOAs were placed in Zone 1 and 28 in Zone 3. REBOA inflation increased systolic blood pressure from 67 (40, 83) mm Hg to 108 (90, 128) mm Hg 5 minutes after inflation (P = 0.02). Cardiopulmonary resuscitation was ongoing during REBOA insertion in 17 patients (26.6%) and 10 patients (58.8%) had return of spontaneous circulation after REBOA inflation. The procedural complication rate was 6.6%. Overall mortality was 52%. CONCLUSION: REBOA can be used in blunt and penetrating trauma patients, including those in arrest. Balloon inflation uniformly improved hemodynamics and was associated with a 59% rate of return of spontaneous circulation for patients in arrest. Use of the ER-REBOA catheter is technically safe with a low procedural complication rate.

Which peer reviewers voluntarily reveal their identity to authors? Insights into the consequences of open-identities peer review.

Identifying reviewers is argued to improve the quality and fairness of peer review, but is generally disfavoured by reviewers. To gain some insight into the factors that influence when reviewers are willing to have their identity revealed, I examined which reviewers voluntarily reveal their identities to authors at the journal Functional Ecology, at which reviewer identities are confidential unless reviewers sign their comments to authors. I found that 5.6% of reviewers signed their comments to authors. This proportion increased slightly over time, from 4.4% in 2003-2005 to 6.7% in 2013-2015. Male reviewers were 1.8 times more likely to sign their comments to authors than were female reviewers, and this difference persisted over time. Few reviewers signed all of their reviews; reviewers were more likely to sign their reviews when their rating of the manuscript was more positive, and papers that had at least one signed review were more likely to be invited for revision. Signed reviews were, on average, longer and recommended more references to authors. My analyses cannot distinguish cause and effect for the patterns observed, but my results suggest that 'open-identities' review, in which reviewers are not permitted to be anonymous, will probably reduce the degree to which reviewers are critical in their assessment of manuscripts and will differentially affect recruitment of male and female reviewers, negatively affecting the diversity of reviewers recruited by journals.

Popliteal scoring assessment for vascular extremity injuries in trauma study.

OBJECTIVE: Traumatic popliteal vascular injuries are associated with the highest risk of limb loss of all peripheral vascular injuries. A method to evaluate the predictors of amputation is needed because previous scores could not be validated. In the present study, we aimed to provide a simplified scoring system (POPSAVEIT [popliteal scoring assessment for vascular extremity injuries in trauma]) that could be used preoperatively to risk stratify patients with traumatic popliteal vascular injuries for amputation. METHODS: A review of patients sustaining traumatic popliteal artery injuries was performed. Patients requiring amputation were compared with those with limb salvage at the last follow-up. Of these patients, 80% were randomly assigned to a training group for score generation and 20% to a testing group for validation. Significant predictors of amputation (P < .1) on univariate analysis were included in a multivariable analysis. Those with P < .05 on multivariable analysis were assigned points according to the relative value of their odds ratios (ORs). Receiver operating characteristic curves were generated to determine low- vs high-risk scores. An area under the curve of >0.65 was considered adequate for validation. RESULTS: A total of 355 patients were included, with an overall amputation rate of 16%. On multivariate regression analysis, the risk factors independently associated with amputation in the final model were as follows: systolic blood pressure <90 mm Hg (OR, 3.2; P = .027; 1 point), associated orthopedic injury (OR, 4.9; P = .014; 2 points), and a lack of preoperative pedal Doppler signals (OR, 5.5; P = .002; 2 points [or 1 point for a lack of palpable pedal pulses if Doppler signal data were unavailable]). A score of ≥3 was found to maximize the sensitivity (85%) and specificity (49%) for a high risk of amputation. The receiver operating characteristic curve for the validation group had an area under the curve of 0.750, meeting the threshold for score validation. CONCLUSIONS: The POPSAVEIT score provides a simple and practical method to effectively stratify patients preoperatively into low- and high-risk major amputation categories.

Contemporary outcomes of traumatic popliteal artery injury repair from the popliteal scoring assessment for vascular extremity injury in trauma study.

OBJECTIVE: Traumatic popliteal artery injuries are associated with the greatest risk of limb loss of all peripheral vascular injuries, with amputation rates of 10% to 15%. The purpose of the present study was to examine the outcomes of patients who had undergone operative repair for traumatic popliteal arterial injuries and identify the factors independently associated with limb loss. METHODS: A multi-institutional retrospective review of all patients with traumatic popliteal artery injuries from 2007 to 2018 was performed. All the patients who had undergone operative repair of popliteal arterial injuries were included in the present analysis. The patients who had required a major lower extremity amputation (transtibial or transfemoral) were compared with those with successful limb salvage at the last follow-up. The significant predictors (P < .05) for amputation on univariate analysis were included in a multivariable analysis. RESULTS: A total of 302 patients from 11 institutions were included in the present analysis. The median age was 32 years (interquartile range, 21-40 years), and 79% were men. The median follow-up was 72 days (interquartile range, 20-366 days). The overall major amputation rate was 13%. Primary repair had been performed in 17% of patients, patch repair in 2%, and interposition or bypass in 81%. One patient had undergone endovascular repair with stenting. The overall 1-year primary patency was 89%. Of the patients who had lost primary patency, 46% ultimately required major amputation. Early loss (within 30 days postoperatively) of primary patency was five times more frequent for the patients who had subsequently required amputation. On multivariate regression, the significant perioperative factors independently associated with major amputation included the initial POPSAVEIT (popliteal scoring assessment for vascular extremity injury in trauma) score, loss of primary patency, absence of detectable immediate postoperative pedal Doppler signals, and lack of postoperative antiplatelet therapy. Concomitant popliteal vein injury, popliteal injury location (P1, P2, P3), injury severity score, and tibial vs popliteal distal bypass target were not independently associated with amputation. CONCLUSIONS: Traumatic popliteal artery injuries are associated with a significant rate of major amputation. The preoperative POPSAVEIT score remained independently associated with amputation after including the perioperative factors. The lack of postoperative pedal Doppler signals and loss of primary patency were highly associated with major amputation. The use of postoperative antiplatelet therapy was inversely associated with amputation, perhaps indicating a protective effect.

Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience.

BACKGROUND: The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients. METHODS: Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive analyses using Fisher's exact, Student's t, chi-squared, or Mann-Whitney U tests as appropriate. RESULTS: Thirty-seven patients with acute hemorrhage from nontrauma sources were identified. REBOA placement was primarily performed by trauma attendings (20/37, 54%) and vascular attendings (13/37, 35%). In seven patients (19%), balloons were positioned prophylactically but never inflated. In 24 (65%) of 37 patients, REBOA was placed in the operating room. 28/37 balloons (76%) were advanced to zone 1, 8/37 (22%) were advanced to zone 3, and there was one REBOA use in the inferior vena cava. Most common indications were gastrointestinal and peripartum bleeding. In the 30 cases of balloon inflation, 24 of 30 (80%) resulted in improved hemodynamics. Eleven of 30 patients (37%) died before discharge. One patient developed a distal embolism, but there were no reports of limb loss. Twelve patients (40% of all REBOA inflations and 63% of survivors) were discharged to home. CONCLUSIONS: REBOA has been used in a range of acutely hemorrhaging emergency general surgery patients with low rates of access-related complications. Mortality is high in this patient population and further research is needed; however, appropriate patient selection and early use may improve survival in these life-threatening cases.

Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies on institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA. METHODS: This is a retrospective study from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry from November 2013 to January 2018. Patients aged ≥18 y who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; two hospitals), mid-volume (10-20 cases; four hospitals), and low-volume (<10 cases; 14 hospitals) hospitals, adjusting for patient factors. RESULTS: Of 271 patients from 20 hospitals, 210 patients (77.5%) had successful REBOA placement. Most patients were male (76.0%) and sustained blunt trauma (78.1%). cardiopulmonary resuscitation (CPR) was ongoing at the time of REBOA placement in 34.5% of patients. Inpatient mortality was 67.4%, unchanged by hospital volume. Multivariable logistic regression found increased odds of successful REBOA placement at high-volume versus low-volume hospitals (odds ratio [OR], 7.50; 95% confidence interval [CI], 2.10-27.29; P = 0.002) and mid-volume versus low-volume hospitals (OR, 7.82; 95% CI, 1.52-40.31; P = 0.014) and decreased odds among patients undergoing CPR during REBOA placement (OR, 0.10; 95% CI, 0.03-0.34; P < 0.001) when adjusting for age, sex, mechanism of injury, prehospital CPR, CPR on admission, transfer status, hospital location of REBOA placement, Glasgow Coma Scale ≤ 13, and injury severity. CONCLUSIONS: Hospitals with higher REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital volume, ongoing CPR is associated with a decreased odds of successful REBOA placement.

Sleeve Fistulectomy: A Novel Hybrid Technique to Manage the Degenerative Arteriovenous Fistula.

Aneurysmal degeneration following long-term access is an important problem associated with an arteriovenous fistula (AVF) and can result in rupture, thrombosis, or the need for ligation. We describe five patients receiving hemodialysis through large degenerative brachiocephalic AVFs who underwent successful revision and avoided the need for a temporary dialysis catheter. A hybrid approach using an open surgical technique with both endovascular and laparoscopic tools provides an opportunity to maintain patency and restore function by combining modern surgical tools.

Regional Anesthesia in Patients on Anticoagulation Therapies-Evidence-Based Recommendations.

PURPOSE OF REVIEW: Anticoagulant use among patients is prevalent and increasing. It is important for anesthesiologists to be aware of patients on anticoagulants while performing regional anesthesia. RECENT FINDINGS: In recent years, the FDA has approved many new anticoagulants. With new drugs coming to the market, new side effect profiles should be considered when treating patients, especially when using regional anesthesia. Both ASRA and European agencies have laid out recommendations regarding anticoagulant use and neuraxial/regional techniques. Regarding newer anticoagulants, the guidelines for discontinuation prior to neuraxial injection are based on pharmacokinetics, including half-life duration for each drug. While each clinical scenario requires an individualized approach, general guidelines can serve as a starting point to help with anesthetic planning and potentially improve patient safety in this evolving field.

Consensus Perioperative Management Best Practices for Patients on Transdermal Fentanyl Patches Undergoing Surgery.

PURPOSE OF REVIEW: The administration of a transdermal fentanyl patch can be complicated with different pharmacokinetics than other fentanyl preparations. RECENT FINDINGS: The medical condition and baseline opioid requirements must all be carefully considered when dosing a fentanyl patch. An advantage of the fentanyl patch is its ability to bypass the gastrointestinal tract and in many patients, provide effective analgesia with minimal side effects. Fentanyl patches must be carefully administered since morbidity and/or mortality can result from the following: Giving higher doses than a patient needs, combining the medication with potent sedatives, or heating a fentanyl patch. The use of a transdermal fentanyl patch for the treatment of acute postoperative pain is not recommended and any patient undergoing a surgical procedure should have the fentanyl patch removed preoperatively. The current manuscript discusses the history of fentanyl and the fentanyl patch, as well as perioperative considerations, contraindications, current clinical efficacy, and clinical adversities related to the transdermal fentanyl patch. Regarding the heating of a transdermal fentanyl patch, which significantly increases blood levels of fentanyl, it is of the utmost importance that the patch be removed prior to surgery.

Implementing enhanced recovery pathways to improve surgical outcomes.

An enhanced recovery pathway is a structured perioperative healthcare program that incorporates evidence-based interventions including protocols and guidelines with the aim of providing standardized care. Enhanced recovery pathways can help maintain operating room safety and efficiency, improve postoperative recovery and a variety of important patient outcomes, and reduce overall costs of patient care following major surgery. Postoperative complications are minimized, which, in part, are attributed to adjustments in fasting and postoperative nutrition, interventions aimed at improving early mobilization, and careful selection of pharmacological agents for anesthesia and analgesia. Major surgery can lead to a variety of physiological stressors including organ dysfunction, and hormonal and neurological disturbances. The current notion of fast-tracking (bypassing phase I recovery level of care) differs from enhanced recovery pathways as the principles of enhanced recovery pathways are often applied to inpatient and complex procedures and span the entire spectrum of patient care. Also, enhanced recovery pathways programs are being used for pediatric patients especially with the hope of minimizing opioid exposure and the quality of recovery. A PubMed literature search was performed for articles that included the terms enhanced recovery pathways to improve surgical outcomes. In this article, we summarized the clinical application of enhanced recovery pathways and highlighted the key elements that characterize implementing an enhanced recovery pathway in surgery.

Enhanced recovery pathways in orthopedic surgery.

The enhanced recovery after surgery (ERAS) concept, sometimes referred to as "fast track", "accelerated," or "Rapid Recovery" surgery, was first introduced in 1997. The concept of ERAS targets factors that delay postoperative recovery such as surgical stress and organ dysfunction. ERAS protocols or programs are a care package of evidence-based interventions used in a multimodal and coordinated clinical care pathway. They represent a multidisciplinary approach directed to reducing postoperative complications, shortening length of hospital stay, improving patient satisfaction, and accelerating recovery. ERAS was initially centered on abdominal and colorectal surgery patients; however, ERAS protocols have been widely extended to include other specialties. Orthopedic surgery, particularly elective hip and knee arthroplasty is one of such areas where ERAS principles have been adopted. It has been associated with reduced length of hospital stay, readmission rate, and improved functional recovery. The common interventions used in orthopedic ERAS programs have been divided into those performed in the preoperative, intraoperative, and postoperative phases of care. A PubMed literature search was performed for articles that included the terms enhanced recovery and orthopedic surgery. In this article, we summarized the clinical application of ERAS and highlighted the key elements that characterize an enhanced recovery program.

Multimodal analgesia as an essential part of enhanced recovery protocols in the ambulatory settings.

Enhanced recovery after surgery protocols are multimodal perioperative care pathways designed to achieve early recovery in patients after surgical procedures by defining and maintaining preoperative organ function and minimizing the profound stress response following surgery. Enhanced recovery protocols have primarily been studied for major abdominal surgeries, however, the knowledge acquired from studying these protocols has facilitated treating patients in ambulatory settings. The key components of enhanced recovery protocols include preoperative counseling, preoperative nutrition, altering the standard perioperative fasting guidelines, and the value of carbohydrate loading up to 2 hours preoperatively, standardized analgesic, and anesthetic regimens (epidural and nonopioid analgesia) and early mobilization. A PubMed search was performed with the following key words: multimodal analgesia, enhanced recovery, ambulatory care, pain management, and opioids. We discuss the use of enhanced recovery protocols and multimodal pain care plans in the ambulatory setting.

Isolated iliac vascular injuries and outcome of repair versus ligation of isolated iliac vein injury.

OBJECTIVE: The incidence of morbidity and mortality for iliac vascular injuries in the literature are likely overestimated owing to associated injuries. Data for isolated iliac vascular injuries are very limited. No large studies have reported the incidence of morbidity for repair versus ligation of isolated iliac vein injuries. METHODS: Patients in the National Trauma Data Bank (NTDB; 2007-2012) with at least one iliac vascular injury were analyzed. Isolated iliac vessels were defined as cases with Abbreviated Injury Scale severity score of greater than 3 for extraabdominal injuries and an Organ Injury Scale grade of greater than 3 for intraabdominal injuries. RESULTS: Overall, 6262 iliac vascular injuries (2809 penetrating, 3453 blunt) were identified in 271,076 patients with abdominal trauma (2.3%). There were 3379 patients (1841 penetrating, 1538 blunt) with isolated iliac vascular injuries (1.2%) and 557 patients (514 penetrating, 43 blunt) with combined iliac artery and vein injuries (0.2%). The 30-day mortality rate was 16.5% for isolated iliac vein injury, 19.3% for isolated iliac artery injury, and 48.7% for combined isolated iliac artery and vein injury. The 30-day mortality rate was 23.4% for isolated iliac vascular injuries compared with 39.0% for nonisolated iliac vascular injuries (P < .001). Patients with isolated iliac vein injuries had morbidity rates of deep venous thrombosis (repair, 14.6%; ligation, 14.1%; P = .875), pulmonary embolism (repair, 1.8%; ligation, 0.5%; P = .38), fasciotomy (repair, 9.3%; ligation, 14.6%; P = .094), amputation (repair, 1.8%; ligation, 2.6%; P = .738), acute kidney injury (repair, 5.8%; ligation, 4.7%; P = .627). Multivariate logistic regression demonstrated that ligation of isolated iliac vein injuries had an odds ratio of 2.2 for mortality compared with repair (95% confidence interval, 1.08-4.66). CONCLUSIONS: Isolated iliac vascular injuries are associated with a high incidence of mortality, especially for combined venous and arterial injury, but mortality is significantly lower than in patients with nonisolated iliac vascular injuries. In patients with isolated iliac vein injuries, mortality was higher in patients who underwent ligation compared with repair; however, the rates of deep venous thrombosis, pulmonary embolism, fasciotomy, amputation, and acute kidney injury were not different between the treatment groups. These data lend credence to the assessment that repair of iliac vein injuries is preferable to ligation whenever feasible.

Inclusive fitness theory and eusociality.

Arising from M. A. Nowak, C. E. Tarnita & E. O. Wilson 466, 1057-1062 (2010); Nowak et al. reply. Nowak et al. argue that inclusive fitness theory has been of little value in explaining the natural world, and that it has led to negligible progress in explaining the evolution of eusociality. However, we believe that their arguments are based upon a misunderstanding of evolutionary theory and a misrepresentation of the empirical literature. We will focus our comments on three general issues.

Adjuvant Agents in Regional Anesthesia in the Ambulatory Setting.

PURPOSE OF REVIEW: A majority of surgical practice has involved ambulatory centers with the number of outpatient operations in the USA doubling to 26.8 million per year. Local anesthesia delivery provides numerous benefits, including increased satisfaction, earlier discharge, and reduction in unplanned hospital admission. Further, with the epidemic of opioid mediated overdoses, local anesthesia can be a key tool in providing an opportunity to reduce the need for other analgesics postoperatively. RECENT FINDINGS: Adjuvants such as epinephrine and clonidine enhance local anesthetic clinical utility. Further, dexmedetomidine prolongs regional blockade duration effects. There has also been a significant interest recently in the use of dexamethasone. Studies have demonstrated a significant prolongation in motor and sensory block with perineural dexamethasone. Findings are conflicting as to whether intravenous dexamethasone has similar beneficial effects. However, considering the possible neurotoxicity effects, which perineural dexamethasone may present, it would be prudent not to consider intravenously administered dexamethasone to prolong regional block duration. Many studies have also demonstrated neurotoxicity from intrathecally administered midazolam. Therefore, midazolam as an adjuvant is not recommended. Magnesium prolongs regional block duration but related to paucity of studies as of yet, cannot be recommended. Tramadol yields inconsistent results and ketamine is associated with psychotomimetic adverse effects. Buprenorphine consistently increases regional block duration and reduce opioid requirements by a significant amount. Future studies are warranted to define best practice strategies for these adjuvant agents. The present review focuses on the many roles of local anesthetics in current ambulatory practice.

Fat emboli syndrome and the orthopaedic trauma surgeon: lessons learned and clinical recommendations.

PURPOSE: Fat emboli syndrome is a rare but well-described complication of long-bone fractures classically characterised by a triad of respiratory failure, mental status changes and petechial rash. In this paper, we present the case of a patient who sustained bilateral femoral fractures and subsequently developed FES. Our aim was to review and summarise the current literature regarding the pathophysiology and management of fat emboli syndrome (FES) and propose an algorithm for treating patients with bilateral femoral fractures to reduce the risk of FES. METHODS: A literature analysis was performed to determine implications in the clinical setting. RESULTS: Currently, there exists little high-quality evidence to guide the orthopaedic surgeon in identifying patients at highest risk of FES or in preventing FES in patients with multiple long-bone fractures. However, the literature does suggest that the risk is directly related to the volume of marrow displaced and inversely related to both the time to fracture stabilisation and the respiratory reserve of the patient. Based on these correlations, we propose an algorithm for treating patients with bilateral femoral fractures, taking into consideration haemodynamic and pulmonary stability. CONCLUSIONS: Our algorithm for managing bilateral femoral fractures prioritises early stabilisation with external fixation, staged intramedullary nailing and conversion to plate fixation if FES develops. This protocol is meant to be the basis of future investigations of optimal treatment strategies.