A randomized-controlled trial comparing liposomal bupivacaine, plain bupivacaine, and the mixture of liposomal bupivacaine and plain bupivacaine in transversus abdominus plane block for postoperative analgesia for open abdominal hysterectomies.

PURPOSE: Transversus abdominus plane (TAP) blocks are widely used for postoperative analgesia for abdominal surgical procedures. The purpose of this study was to compare the analgesic efficacy of plain bupivacaine, liposomal bupivacaine, and the mixture of plain bupivacaine with liposomal bupivacaine when used in a TAP block. METHODS: This study was a single centre, prospective, patient-, observer-, and surgeon-blinded, randomized-controlled trial in which 90 patients undergoing an open abdominal hysterectomy with a midline incision were randomized to receive a TAP block with plain bupivacaine (group bupivacaine), liposomal bupivacaine (group liposomal), or a mixture of liposomal bupivacaine and plain bupivacaine (group mixture). Primary outcomes included time to the first rescue opioid analgesic and total opioid consumption during the first 72 postoperative hours. Secondary outcomes included pain scores, patient satisfaction, incidence of hemodynamic instability, presence of local anesthetic systemic toxicity, and length of hospital stay. RESULTS: The median [interquartile range] time to first opioid was 51 [28-66] min in group bupivacaine, 63 [44-102] min in group liposomal, and 51 [24-84] min in group mixture (P = 0.20). The median [interquartile range] total opioid consumption in the first 72 postoperative hours was 208 [155-270] mg in group bupivacaine, 203 [153-283] mg in group liposomal, and 202 [116-325] mg in group mixture (P = 0.92). There were no significant differences in secondary outcomes between groups. CONCLUSIONS: In this small study at risk of being under-powered, the mixture of liposomal bupivacaine with plain bupivacaine for TAP block did not improve analgesia compared with either liposomal bupivacaine or plain bupivacaine on their own. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03250507); registered 5 April 2017.

RéSUMé: OBJECTIF: Les blocs des muscles du plan transverse de l'abdomen (blocs TAP) sont fréquemment utilisés pour l'analgésie postopératoire après une intervention chirurgicale abdominale. L'objectif de cette étude était de comparer l'efficacité analgésique de la bupivacaïne simple, de la bupivacaïne liposomale, et du mélange de bupivacaïne simple et bupivacaïne liposomale lorsque utilisés dans un bloc TAP. MéTHODE: Cette étude randomisée contrôlée monocentrique, prospective, à l'insu de la patiente, de l'observateur et du chirurgien a recruté 90 patientes subissant une hystérectomie abdominale par laparotomie via une incision de la ligne médiane, qui ont été randomisées pour recevoir un bloc TAP réalisé avec de la bupivacaïne simple (groupe bupivacaïne), de la bupivacaïne liposomale (groupe liposomale), ou un mélange de bupivacaïne liposomale et de bupivacaïne simple (groupe mélange). Les critères d'évaluation principaux comprenaient le délai jusqu'à l'administration du premier analgésique opioïde de sauvetage et la consommation totale d'opioïdes pendant les 72 premières heures postopératoires. Les critères secondaires incluaient les scores de douleur, la satisfaction des patientes, l'incidence d'instabilité hémodynamique, la présence de toxicité systémique de l'anesthésique local, et la durée du séjour à l'hôpital. RéSULTATS: Le délai médian [écart interquartile] jusqu'à la première administration d'opioïde était de 51 [28-66] min dans le groupe bupivacaïne, 63 [44-102] min dans le groupe liposomale, et 51 [24-84] min dans le groupe mélange (P = 0,20). La consommation médiane totale d'opioïdes [écart interquartile] au cours des premières 72 heures postopératoires était de 208 [155-270] mg dans le groupe bupivacaïne, 203 [153-283] mg dans le groupe liposomale, et 202 [116-325] mg dans le groupe mélange (P = 0,92). Aucune différence intergroupe significative n'a été observée dans les critères d'évaluation secondaires. CONCLUSION: Dans cette petite étude manquant potentiellement de puissance, le mélange de bupivacaïne liposomale et bupivacaïne simple pour le bloc TAP n'a pas amélioré l'analgésie par rapport à la bupivacaïne liposomale ou à la bupivacaïne simple administrées seules. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03250507); enregistrée le 5 avril 2017.

Erector Spinae Plane Catheters for Analgesia for Cytoreduction Surgery With Hyperthermic Intraperitoneal Chemotherapy: A Case Series.

Cytoreduction surgery with hyperthermic intraperitoneal chemotherapy is a complex and painful procedure that can cause postoperative hypotension and coagulopathy. Epidural analgesia may worsen hypotension and is contraindicated in the setting of coagulopathy. While alternative regional techniques are being explored, the use of erector spinae plane blocks has not been reported. We present a case series of 6 patients who had erector spinae plane catheters for cytoreduction surgery with hyperthermic intraperitoneal chemotherapy. They remained stable intraoperatively and had adequate pain control postoperatively. Erector spinae plane catheters may be a suitable alternative for epidural analgesia for these patients.

Erector Spinae Plane Continuous Catheters for Refractory Abdominal Pain Related to Necrotizing Pancreatitis: A Case Report.

Erector spinae plane (ESP) continuous catheters are used for the management of postsurgical pain. The use of these catheters for acute nonsurgical abdominal pain is not well defined. This case describes a patient with refractory abdominal pain secondary to necrotizing pancreatitis despite escalating doses of opioids, ketamine, and dexmedetomidine. Our patient declined epidural analgesia. Bilateral ESP continuous catheters successfully controlled her pain, and she was weaned off of all analgesics during the week following catheter placement. This case demonstrates that ESP continuous catheters can be considered for patients with acute nonsurgical abdominal pain especially when thoracic epidural analgesia is contraindicated.

The anesthetic considerations of tracheobronchial foreign bodies in children: a literature review of 12,979 cases.

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] = 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI = 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI = 48%-55%) is higher than that of left-sided foreign bodies (33%, CI = 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI = 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI = 13%-22%). Although rigid bronchoscopy is the traditional diagnostic "gold standard," the use of computerized tomography, virtual bronchoscopy, and flexible bronchoscopy is increasing. Reported mortality during bronchoscopy is 0.42%. Although asphyxia at presentation or initial emergency bronchoscopy causes some deaths, hypoxic cardiac arrest during retrieval of the object, bronchial rupture, and unspecified intraoperative complications in previously stable patients constitute the majority of in-hospital fatalities. Major complications include severe laryngeal edema or bronchospasm requiring tracheotomy or reintubation, pneumothorax, pneumomediastinum, cardiac arrest, tracheal or bronchial laceration, and hypoxic brain damage (0.96%). Aspiration of gastric contents is not reported. Preoperative assessment should determine where the aspirated foreign body has lodged, what was aspirated, and when the aspiration occurred ("what, where, when"). The choices of inhaled or IV induction, spontaneous or controlled ventilation, and inhaled or IV maintenance may be individualized to the circumstances. Although several anesthetic techniques are effective for managing children with foreign body aspiration, there is no consensus from the literature as to which technique is optimal. An induction that maintains spontaneous ventilation is commonly practiced to minimize the risk of converting a partial proximal obstruction to a complete obstruction. Controlled ventilation combined with IV drugs and paralysis allows for suitable rigid bronchoscopy conditions and a consistent level of anesthesia. Close communication between the anesthesiologist, bronchoscopist, and assistants is essential.

Anesthetic considerations for major burn injury in pediatric patients.

Major burn injury remains a significant cause of morbidity and mortality in pediatric patients. With advances in burn care and with the development of experienced multi-disciplinary teams at regionalized burn centers, many children are surviving severe burn injury. As members of the multi-disciplinary care team, anesthesia providers are called upon to care for these critically ill children. These children provide several anesthetic challenges, such as difficult airways, difficult vascular access, fluid and electrolyte imbalances, altered temperature regulation, sepsis, cardiovascular instability, and increased requirements of muscle relaxants and opioids. The anesthesia provider must understand the physiologic derangements that occur with severe burn injury as well as the subsequent anesthetic implications.

Inhalation burn injury in children.

With advances in burn care, many children are surviving severe burn injuries. Inhalation injury remains a predictor of morbidity and mortality in burn injury. Inhalation of smoke and toxic gases leads to pulmonary complications, including airway obstruction from bronchial casts, pulmonary edema, decreased pulmonary compliance, and ventilation-perfusion mismatch, as well as systemic toxicity from carbon monoxide poisoning and cyanide toxicity. The diagnosis of inhalation injury is suggested by the history and physical exam and can be confirmed by bronchoscopy. Management consists of supportive measures, pulmonary toilet, treatment of pulmonary infection and ventilatory support as needed. This review details the pathophysiology, diagnosis, and management options for inhalation injury.

Programmed intermittent epidural bolus as compared to continuous epidural infusion for the maintenance of labor analgesia: a prospective randomized single-blinded controlled trial.

BACKGROUND: Programmed intermittent epidural bolus (PIEB) techniques are a new area of interest for maintaining labor analgesia due to the potential to decrease motor block and improve labor analgesia. This study compares continuous epidural infusion (CEI) to 2 PIEB regimens for labor analgesia. METHODS: One hundred fifty patients undergoing scheduled induction of labor at term gestation having epidural labor analgesia were randomized to receive an epidural analgesia regimen of bupivacaine 0.125% with fentanyl 2 µg/ml at either PIEB 5 ml every 30 min (Group 5q30), PIEB 10 ml every 60 min (Group 10q60), or 10 ml/h continuous infusion (Group continuous epidural infusion [CEI]). The primary outcome is the pain scores throughout labor. Secondary outcomes include degree of motor block, dermatomal sensory levels, the number of physician-administered boluses, and patient satisfaction. RESULTS: While the average pain scores throughout labor did not differ significantly between groups, fewer patients in group 10q60 received physician-administered boluses for breakthrough pain (34.9% in 10q60 vs. 61.0% in 5q30 and 61.9% in CEI, P = 0.022). Dermatomal sensory levels, degree of motor block, and patient satisfaction did not differ significantly between groups. CONCLUSIONS: Our study suggests that high volume PIEB regimens for labor analgesia decrease breakthrough pain and physician-administered boluses.

Anesthetic Management for Cesarean Delivery in a Patient With Pulmonary Emboli, Pulmonary Hypertension, and Right Ventricular Failure.

The maternal mortality rate for parturients with severe pulmonary hypertension is 30% to 50%. General, epidural, and combined low-dose spinal-epidural anesthesia have been used successfully for cesarean deliveries in patients with pulmonary hypertension. We describe a cesarean delivery performed using an intrathecal catheter in a 25-year-old morbidly obese (body mass index, 82 kg/m) woman (gravida 3, para 2 at 32 weeks of gestation) who had severe pulmonary hypertension, right ventricular failure, pulmonary emboli, and obstructive sleep apnea. We discuss the anesthetic considerations for parturients with severe pulmonary hypertension undergoing cesarean delivery including the selection of anesthetic technique, vasopressors, and uterotonic agents.