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BACKGROUND: Ultrasound Guided Regional Anesthesia (UGRA) has become the standard for regional anesthesia practice, but there is not a standardized educational approach for training residents. The objective of this study was to evaluate the efficacy of an UGRA workshop utilizing the theoretical framework of embodied cognition for anesthesiology residents. METHODS: A workshop was developed consisting of didactics, scanning training on standardized patients (SPs) and anatomy reviews on prosected cadavers that focused on the most common UGRA procedures for the upper and lower extremity. At the beginning of the workshop and at the end of the workshop residents completed pre-test and pre-confidence surveys, as well as post-test and post-confidence surveys, respectively to assess the impact of the workshop. RESULTS: 39 residents (100% of the possible residents) participated in the workshop in 2019. Residents' confidence in identifying relevant anatomy for the most common UGRA procedures significantly increased in 13 of the 14 measurements. Residents' knowledge gain was also statistically significant from the pre-test to post-test (20.13 ± 3.61 and 26.13 ± 2.34; p < .0001). The residents found the course overall to be very useful (4.90 ± 0.38) and in particular the cadaveric component was highly rated (4.74 ± 0.55). CONCLUSIONS: In this study, we developed a workshop guided by the embodied cognition framework to aid in shortening the overall learning curve of UGRA for anesthesiology residents. Based on our results this workshop should be replicated by institutions that are hoping to decrease the learning curve associated with UGRA and increase residents' confidence in identifying the relevant anatomy in UGRA nerve blocks.
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Anestesia de Conducción , Cognición , Humanos , Ultrasonografía , Ultrasonido , EscolaridadRESUMEN
BACKGROUND: Postoperative pain after living donor hepatectomy is significant. Postoperative coagulopathy may limit the use of epidural analgesia, the gold standard for pain control in abdominal surgery. The erector spinae plane block (ESPB) is a novel regional anesthesia technique that has been shown to provide effective analgesia in abdominal surgery. In this study, we examined the effect of continuous ESPB, administered via catheters, on perioperative opioid requirements after right living donor hepatectomies for liver transplantation. METHODS: We performed a retrospective cohort study in patients undergoing right living donor hepatectomy. Twenty-four patients who received preoperative ESPB were compared to 51 historical controls who did not receive regional anesthesia. The primary endpoint was the total amount of oral morphine equivalents (OMEs) required on the day of surgery and postoperative day (POD) 1. RESULTS: Patients in the ESPB group required a lower total amount of OMEs on the day of surgery and POD 1 [141 (107-188) mg] compared the control group [293 (220-380) mg; P < .001]. CONCLUSIONS: The use of continuous ESPB significantly reduced opioid consumption following right living donor hepatectomy.
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Analgesia Epidural , Bloqueo Nervioso , Estudios de Factibilidad , Hepatectomía , Humanos , Donadores Vivos , Estudios RetrospectivosRESUMEN
BACKGROUND: Postoperative delirium is an important problem for surgical inpatients and was the target of a multidisciplinary quality improvement project at our institution. We developed and tested a semiautomated delirium risk stratification instrument, Age, WORLD backwards, Orientation, iLlness severity, Surgery-specific risk (AWOL-S), in 3 independent cohorts from our tertiary care hospital and describe its performance characteristics and impact on clinical care. METHODS: The risk stratification instrument was derived with elective surgical patients who were admitted at least overnight and received at least 1 postoperative delirium screen (Nursing Delirium Screening Scale [NuDESC] or Confusion Assessment Method for the Intensive Care Unit [CAM-ICU]) and preoperative cognitive screening tests (orientation to place and ability to spell WORLD backward). Using data pragmatically collected between December 7, 2016, and June 15, 2017, we derived a logistic regression model predicting probability of delirium in the first 7 postoperative hospital days. A priori predictors included age, cognitive screening, illness severity or American Society of Anesthesiologists physical status, and surgical delirium risk. We applied model odds ratios to 2 subsequent cohorts ("validation" and "sustained performance") and assessed performance using area under the receiver operator characteristic curves (AUC-ROC). A post hoc sensitivity analysis assessed performance in emergency and preadmitted patients. Finally, we retrospectively evaluated the use of benzodiazepines and anticholinergic medications in patients who screened at high risk for delirium. RESULTS: The logistic regression model used to derive odds ratios for the risk prediction tool included 2091 patients. Model AUC-ROC was 0.71 (0.67-0.75), compared with 0.65 (0.58-0.72) in the validation (n = 908) and 0.75 (0.71-0.78) in the sustained performance (n = 3168) cohorts. Sensitivity was approximately 75% in the derivation and sustained performance cohorts; specificity was approximately 59%. The AUC-ROC for emergency and preadmitted patients was 0.71 (0.67-0.75; n = 1301). After AWOL-S was implemented clinically, patients at high risk for delirium (n = 3630) had 21% (3%-36%) lower relative risk of receiving an anticholinergic medication perioperatively after controlling for secular trends. CONCLUSIONS: The AWOL-S delirium risk stratification tool has moderate accuracy for delirium prediction in a cohort of elective surgical patients, and performance is largely unchanged in emergent/preadmitted surgical patients. Using AWOL-S risk stratification as a part of a multidisciplinary delirium reduction intervention was associated with significantly lower rates of perioperative anticholinergic but not benzodiazepine, medications in those at high risk for delirium. AWOL-S offers a feasible starting point for electronic medical record-based postoperative delirium risk stratification and may serve as a useful paradigm for other institutions.
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Registros Electrónicos de Salud/normas , Delirio del Despertar/etiología , Delirio del Despertar/prevención & control , Atención Perioperativa/normas , Adulto , Anciano , Estudios de Cohortes , Registros Electrónicos de Salud/tendencias , Delirio del Despertar/diagnóstico , Femenino , Humanos , Masculino , Persona de Mediana Edad , Atención Perioperativa/tendencias , Reproducibilidad de los Resultados , Resultado del TratamientoRESUMEN
BACKGROUND: Postoperative delirium is a common and serious problem for older adults. To better align local practices with delirium prevention consensus guidelines, we implemented a 5-component intervention followed by a quality improvement (QI) project at our institution. METHODS: This hybrid implementation-effectiveness study took place at 2 adult hospitals within a tertiary care academic health care system. We implemented a 5-component intervention: preoperative delirium risk stratification, multidisciplinary education, written memory aids, delirium prevention postanesthesia care unit (PACU) orderset, and electronic health record enhancements between December 1, 2017 and June 30, 2018. This was followed by a department-wide QI project to increase uptake of the intervention from July 1, 2018 to June 30, 2019. We tracked process outcomes during the QI period, including frequency of preoperative delirium risk screening, percentage of "high-risk" screens, and frequency of appropriate PACU orderset use. We measured practice change after the interventions using interrupted time series analysis of perioperative medication prescribing practices during baseline (December 1, 2016 to November 30, 2017), intervention (December 1, 2017 to June 30, 2018), and QI (July 1, 2018 to June 30, 2019) periods. Participants were consecutive older patients (≥65 years of age) who underwent surgery during the above timeframes and received care in the PACU, compared to a concurrent control group <65 years of age. The a priori primary outcome was a composite of perioperative American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use (Beers PIM) medications. The secondary outcome, delirium incidence, was measured in the subset of older patients who were admitted to the hospital for at least 1 night. RESULTS: During the 12-month QI period, preoperative delirium risk stratification improved from 67% (714 of 1068 patients) in month 1 to 83% in month 12 (776 of 931 patients). Forty percent of patients were stratified as "high risk" during the 12-month period (4246 of 10,494 patients). Appropriate PACU orderset use in high-risk patients increased from 19% in month 1 to 85% in month 12. We analyzed medication use in 7212, 4416, and 8311 PACU care episodes during the baseline, intervention, and QI periods, respectively. Beers PIM administration decreased from 33% to 27% to 23% during the 3 time periods, with adjusted odds ratio (aOR) 0.97 (95% confidence interval [CI], 0.95-0.998; P = .03) per month during the QI period in comparison to baseline. Delirium incidence was 7.5%, 9.2%, and 8.5% during the 3 time periods with aOR of delirium of 0.98 (95% CI, 0.91-1.05, P = .52) per month during the QI period in comparison to baseline. CONCLUSIONS: A perioperative delirium prevention intervention was associated with reduced administration of Beers PIMs to older adults.
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Registros Electrónicos de Salud/normas , Delirio del Despertar/prevención & control , Atención Perioperativa/normas , Guías de Práctica Clínica como Asunto/normas , Anciano , Delirio del Despertar/etiología , Femenino , Humanos , Masculino , Atención Perioperativa/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: Unanticipated symptoms of peripheral nerve damage following surgery are distressing to both the patient and their clinical team, including surgeons, anesthesiologists, and neurologists. The causes that are commonly considered for perioperative neuropathy can include surgical trauma, positioning-related injury, or injury related to a regional anesthetic technique. However, these cases often do not have a clear etiology and can occur without any apparent periprocedural anomalies. Postoperative inflammatory neuropathy is a more recently described, and potentially underrecognized cause of perioperative neuropathy which may improve with corticosteroid therapy. Therefore, it is an important etiology to consider early in the evaluation of perioperative neuropathy. CASE PRESENTATION: An otherwise healthy patient presented for left anterior cruciate ligament reconstruction. He underwent femoral and sciatic ultrasound-guided single-injection peripheral nerve blocks preoperatively, followed by a general anesthetic for the surgical procedure. He developed postoperative neuropathy in the sciatic distribution with both sensory and motor deficits. The patient received multi-disciplinary consultations, including neurology and pain management, and a broad differential diagnosis was considered. Based on neurological evaluation and imaging studies, a final diagnosis of post-surgical inflammatory neuropathy was made. The patient's course improved with conservative management, but immunosuppressive treatment may have been considered for a more severe or worsening clinical course. CONCLUSIONS: There are limited publications describing postoperative inflammatory neuropathy, and this case serves to illustrate a potentially under-recognized and multifactorial cause of postoperative neuropathy. Perioperative neuropathies are a complication that surgeons and anesthesiologists strive to avoid; however, prevention and treatment of this condition have been elusive. Increased reporting and investigation of postoperative inflammatory neuropathy as one cause for this complication will help to further our understanding of this potentially devastating complication.
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BACKGROUND: Anesthesia and analgesia for thoracic procedures, specifically pleuroscopy, present unique challenges given the spectrum of underlying pulmonary disease and susceptibility to respiratory complications. This study describes efforts to reduce postoperative pain and minimize opioid analgesia after thoracoscopic procedures through the use of erector spinae plane block (ESPB). METHODS: This is a single center, retrospective case series of all patients who underwent rigid pleuroscopy with ESPB plus monitored anesthesia care (MAC) from November 2018 through September 2020. The primary outcome measures were postoperative pain scores and analgesic medication requirements. RESULTS: Twenty-six patients underwent pleuroscopy with ESPB plus MAC. Average intraoperative and postoperative opioid consumption in oral morphine equivalents were 18.4±15.8 and 11.2±19.6 mg, respectively. There was no significant difference between average preoperative and postoperative subjective numerical pain scores (P=0.221). There were no complications associated with ESPB. CONCLUSION: This case series demonstrates the feasibility of utilizing single shot ESPB in combination with MAC as the primary anesthetic for thoracoscopic procedures.
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Bloqueo Nervioso , Anestésicos Locales , Humanos , Bloqueo Nervioso/métodos , Estudios Retrospectivos , Toracoscopía , Ultrasonografía IntervencionalRESUMEN
Propofol is a widely used drug in anesthesia practice, and its pharmacological characteristics are well known. However, propofol is not known for neuromuscular effects. As part of clinical neuromuscular monitoring, the neuromuscular responses to train-of-four (TOF) stimulation were monitored and recorded. We observed, in two cases of balanced anesthesia maintained by desflurane and fentanyl, that administration of a small dose of propofol during almost complete recovery from rocuronium in two patients resulted in marked decreases of both T1 (first twitch response of the TOF) and the TOF ratio. This neuromuscular block dissipated in both patients without any subsequent neuromuscular effects. These two observations provide visual confirmation of the possible impact of propofol on recovery from a rocuronium neuromuscular blockade.
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Androstanoles , Anestésicos Intravenosos , Bloqueo Neuromuscular , Fármacos Neuromusculares no Despolarizantes , Propofol , Adyuvantes Anestésicos , Adulto , Androstanoles/antagonistas & inhibidores , Periodo de Recuperación de la Anestesia , Anestesia General , Inhibidores de la Colinesterasa/uso terapéutico , Interacciones Farmacológicas , Estimulación Eléctrica , Femenino , Seno Frontal/cirugía , Humanos , Traumatismos Mandibulares/cirugía , Midazolam , Monitoreo Intraoperatorio , Neostigmina/uso terapéutico , Fármacos Neuromusculares no Despolarizantes/antagonistas & inhibidores , Pólipos/cirugía , Respiración Artificial , Rocuronio , Adulto JovenRESUMEN
BACKGROUND: This randomized study compared the efficacy and safety of extraplexus and intraplexus injection of local anesthetic for interscalene brachial plexus block. METHODS: 208 ASA I-II patients scheduled for elective shoulder arthroscopy under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomly allocated to receive an injection of 25mL ropivacaine 0.5% either between C5-C6 nerve roots (intraplexus), or anterior and posterior to the brachial plexus into the plane between the perineural sheath and scalene muscles (extraplexus). The primary outcome was time to loss of shoulder abduction. Secondary outcomes included block duration, perioperative opioid consumption, pain scores, block performance time, number of needle passes, onset of sensory blockade, paresthesia, recovery room length of stay, patient satisfaction, incidence of Horner's syndrome, dyspnea, hoarseness, and post-operative nausea and vomiting. RESULTS: Time to loss of shoulder abduction was faster in the intraplexus group (log-rank p-value<0.0005; median [interquartile range]: 4 min [2-6] vs. 6 min [4-10]; p-value <0.0005). Although the intraplexus group required fewer needle passes (2 vs. 3, p<0.0005), it resulted in more transient paresthesia (35.9% vs. 14.5%, p = 0.0004) with no difference in any other secondary outcome. CONCLUSION: The intraplexus approach to the interscalene brachial plexus block results in a faster onset of motor block, as well as sensory block. Both intraplexus and extraplexus approaches to interscalene brachial plexus block provide effective analgesia. Given the increased incidence of paresthesia with an intraplexus approach, an extraplexus approach to interscalene brachial plexus block is likely a more appropriate choice.
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Artroscopía , Bloqueo del Plexo Braquial , Ropivacaína/administración & dosificación , Hombro/diagnóstico por imagen , Hombro/cirugía , Ultrasonografía Intervencional , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A patient with end-stage amyotrophic lateral sclerosis (ALS) presented for Baclofen pump replacement. She underwent a left transversus abdominis plane block to anesthetize the left lower quadrant of the abdomen. No sedatives or analgesics were administered, and the procedure was successfully completed without complication. It is prudent to consider anesthetic plans that avoid complications associated with general or neuraxial anesthesia in patients with ALS. This case report demonstrates successful placement of a transversus abdominis plane block in a patient with ALS and offers a safe anesthetic technique that can be performed in other high-risk patients.
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STUDY OBJECTIVE: To compare preoperative femoral (FNB) with combined femoral and sciatic nerve block (CFSNB) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. DESIGN: Prospective, randomized clinical trial. SETTING: Ambulatory surgery center affiliated with an academic medical center. PATIENTS: Sixty-eight American Society of Anesthesiology physical status I and II patients undergoing arthroscopic ACL reconstruction. INTERVENTIONS: Subjects randomized to the CFSNB group received combined femoral and sciatic nerve blocks preoperatively, whereas patients randomized to the FNB group only received femoral nerve block preoperatively. Both groups then received a standardized general anesthetic with a propofol induction followed by sevoflurane or desflurane maintenance. Intraoperative pain was treated with fentanyl. Pain in the postanesthesia care unit (PACU) was treated with ketorolac and opiates. Patients with significant pain despite ketorolac and opiates could receive a rescue nerve block. MEASUREMENTS: Our primary outcome variable was highest Numeric Rating Scale (NRS) pain score in PACU. NRS pain scores, opioid consumption, opioid adverse effects, and patient satisfaction were assessed perioperatively until postoperative day 3. MAIN RESULTS: The highest PACU NRS pain score was significantly higher in the FNB group compared with the CFSNB group (7 [3-10] vs 5 [0-10], P=.002). The FNB group required significantly larger doses of opioids perioperatively (31.8 vs 19.8mg intravenous morphine equivalents, P<.001). PACU length of stay was significantly longer in the FNB group (128.2 vs 103.1minutes, P=.006). There was no significant difference in opioid consumption, pain scores, or patient satisfaction on postoperative days 1-3 between groups. CONCLUSIONS: Preoperative CFSNB for arthroscopic ACL reconstruction improves analgesia, decreases opioid consumption perioperatively, and decreases PACU length of stay when compared with FNB alone.