Liposomal Bupivacaine Versus Standard Bupivacaine in the Adductor Canal for Total Knee Arthroplasty: A Randomized, Controlled Trial.

Peripheral nerve blocks are commonly used in total knee arthroplasty (TKA). Liposomal bupivacaine is an extended-release anesthetic medication that maintains efficacy upwards of 72 hours. This study compared single-shot liposomal bupivacaine (LB) with the standard single-shot bupivacaine (SB) in a preoperative adductor canal block in TKA patients. A double-blind randomized, controlled trial at a single institution was performed in patients undergoing TKA. A standard preoperative single-shot adductor canal nerve injection was performed in 31 patients using 266 mg of liposomal bupivacaine (20 mL), whereas 32 patients received a standard formulation of 0.5% bupivacaine hydrogen chloride (20 mL). The primary outcome measure was postoperative gait velocity. Secondary outcomes included knee range of motion, pain scores, patient satisfaction, knee extension strength, opioid consumption, length of stay, and adverse events. There were no differences in baseline measures between groups. Improved pain ratings with activity (P=.009) were noted on postoperative day 1 with LB (mean, 4.4; SD, 2.0) compared with SB (mean, 5.9; SD, 2.6). Fewer opioids were used with LB compared with SB on postoperative day 1 (mean, 51.2 vs 66.1; P=.020) and on postoperative day 2 (mean, 39.5 vs 54.8; P=.016). No statistically significant differences in gait velocity, knee range of motion, knee extension strength, or patient satisfaction occurred. Peripheral nerve blockade with a single-shot adductor canal injection demonstrated improved pain scores with activity and diminished postoperative narcotic use when using LB compared with SB in TKA patients. There may be early postoperative advantages with LB as a single-shot injection in adductor canal blockade for patients undergoing TKA. [Orthopedics. 2021;44(4):249-255.].

Perioperative anesthetic management of an 18-month-old pediatric patient with a congenital coronary fistula between the left circumflex coronary artery and coronary sinus: Report of a rare case.

We present a case of an 18-month-old, 8.69 kg, female, who presented with a coronary fistula between the left circumflex coronary artery and coronary sinus (CS) for remote computed tomography (CT) imaging and transcatheter closure. This is the fifth published case report to describe this congenital anomaly and the first to discuss general anesthesia (GA) and the hemodynamic management considerations for the anesthesiologist.

The Rock of Gibraltar: The Value of Mentorship in the Early Years (Dr. Virginia Apgar and Dr. Ralph Waters).

Behind every successful physician there are mentors to light the path. Ralph Waters, founder of the anesthesiology residency at the University of Wisconsin-Madison, was an instrumental part of Virginia Apgar's success; his support of her education and promotion of her professional endeavors proved to shape the medical powerhouse that Apgar would become. In this article, we learn about the professional and personal relationship between Waters and Apgar through personal correspondence from the Ralph Waters Collection at University of Wisconsin Archives, scientific publications, and meeting records. Through his support of her career, she was able to achieve success despite the Great Depression, World War II, and the novelty of being a woman in medicine. In her career, Apgar became the first female full professor at Columbia University, designed and implemented the Apgar score, and led the Division of Congenital Malformations at the March of Dimes among many other accomplishments. Though they lived half of a country apart in Wisconsin and in New York, the mentor and mentee bridged the gap in geography through regular correspondence, American Society of Anesthetists (now American Society of Anesthesiologists) meetings (where Waters served as president and Apgar as treasurer), and exchange of trainees between the University of Wisconsin at Madison and Columbia University. Apgar revealed herself to be a persistent, hardworking, intelligent, and passionate academic physician - the perfect pupil for Waters. This article's aim is to underscore the importance of mentorship - with equal commitment to the relationship from mentor and mentee - then and now.

Educating Perioperative Nurses About Local Anesthetic Systemic Toxicity Using High-Fidelity Simulation.

BACKGROUND: The rarity of perianesthetic catastrophic events creates a challenge in training support staff in the treatment of emergencies such as local anesthetic systemic toxicity (LAST). Simulation learning offers a unique venue in which to safely encounter rare events. AIMS: This study aimed to evaluate knowledge retention regarding LAST in perianesthetic nursing staff using high-fidelity simulation and a short didactic session. DESIGN: Nurses were recruited from perioperative locations to participate in a simulated scenario of LAST and engage in a short didactic session. SETTINGS: Simulation and education occurred in the high-fidelity simulation center at the University of Wisconsin Hospital. PARTICIPANTS/SUBJECTS: Thirteen nurses from the preoperative, post-anesthesia, and block nursing teams participated in the study. METHODS: Participants completed a pre-test before participating in the simulation, followed by a formal debrief and short lecture. They then completed post-tests and a short survey focused on self-efficacy and review of the simulation experience. RESULTS: Test scores, compared to the pre-test, improved significantly on the immediately-post, 1-month, and 3-month assessments. Participants felt more equipped to handle crisis scenarios. CONCLUSIONS: Experiential learning often results in significant knowledge acquisition and retention. Participants in this study improved their test scores regarding LAST and increased their sense of self-efficacy and ability to handle crisis scenarios after taking part in a high-fidelity simulation.

Iatrogenic Bladder Perforation During Laparoscopy: Revisiting the "Catheter Bag" Sign: A Case Report.

We report a case of an iatrogenic bladder perforation sustained during laparoscopic lysis of adhesions performed for small bowel obstruction. The only sign, discovered by the anesthesiology team, was an inflated urinary catheter collection bag. This case revalidates the "catheter bag" sign and advocates for the placement of an indwelling transurethral urinary catheter before surgical incision in high-risk patients with previous pelvic and/or bladder pathology. In addition, vigilance from anesthesia providers and commitment to communication between anesthesia, surgical, and nursing care teams is emphasized to quickly discover complications and treat accordingly.

Cardiac arrhythmia from epinephrine overdose in epidural test dose.

Medication shortages are a clinical reality that force changes in practice patterns leading to unintended consequences. Potential solutions to any drug shortage require a thoughtful, multidisciplinary and often creative approach. Here, we report a case of unintentional epinephrine overdose leading to an unstable cardiac arrhythmia and our subsequent development of a visual cue system to prevent future errors. A 56-year-old man with a history of rectal adenocarcinoma presented for low anterior resection and creation of diverting loop ileostomy. Epidural placement was requested by the surgical team, and following administration of a second test dose (created by the physician), the patient experienced supraventricular tachycardia with heart rates of 200-210 BPM for approximately 2 minutes. This rhythm then converted to atrial fibrillation with rapid ventricular response with heart rate of 150-170 BPM. The patient was stabilized after cardioversion. Later evaluation of medication administration revealed that the second epidural test dose inadvertently contained 100 mcg epinephrine instead of the intended 10 mcg dose. The test dose had to be created because the original ampule with the kit had been utilized. Since this time, our kits have no test dose, and this shortage is concerning for increased provider error. We suggest a novel visual cue system that may prevent unintentional epinephrine overdoses in the setting of regional anesthesia.

Intermittent Boluses of Local Anesthetic Through Quadratus Lumborum Catheters for Analgesia in a Living Donor Hepatectomy.

The demand for liver transplants in the United States far exceeds the supply of organs. As need has increased, so has use of living donors. Coagulopathy and various side effects often preclude the use of neuraxial regional techniques and opioids for postoperative analgesia in patients with large "J" incisions. Here, we present a 25-year-old male undergoing a living donor hepatectomy who received quadratus lumborum catheters placed percutaneously after closure of incision and prior to emergence to provide excellent analgesia and a viable opioid-sparing approach. Quadratus lumborum catheters are a safe option for a multimodal, opioid-sparing approach to analgesia.

The Influence of Collaboration: Ralph Waters' Friendship With John Lundy and the Spread of Regional Anesthesia.

Ralph Waters, the founder of the anesthesiology department and residency program at the University of Wisconsin-Madison, and John Lundy, the chair at the Mayo Clinic beginning in 1924, collaborated to expand regional anesthetic techniques and knowledge not only at their institutions, but also at institutions around the country through correspondence, meetings, and hosting of other anesthesiologists. The Ralph Waters Collection at the University of Wisconsin Archives was searched for information on Waters' and Lundy's involvement in regional anesthesia. This included publications by Waters and other anesthesiology department faculty, as well as personal correspondence with other leaders in anesthesia at that time. Correspondence between Waters and Lundy from this collection was reviewed in detail. This article underscores the importance of exchange of ideas by physicians through didactics, organizations, and research through the story of Ralph Waters and John Lundy's mutual exchange of ideas and even friendship beginning in the 1920s.