Beyond the Raskin Protocol: Ketamine, Lidocaine, and Other Therapies for Refractory Chronic Migraine.

PURPOSE OF REVIEW: The purpose of this review is to discuss the available evidence and therapeutic considerations for intravenous drug therapy for refractory chronic migraine. RECENT FINDINGS: In carefully monitored settings, the inpatient administration of intravenous lidocaine and ketamine can be successful in treating refractory chronic migraine. Many patients with refractory chronic migraine have experienced treatment failure with the Raskin protocol. The use of aggressive inpatient infusion therapy consisting of intravenous lidocaine or ketamine, along with other adjunctive medications, has become increasingly common for these patients when all other treatments have failed. There is a clear need for prospective studies in this population comprised of patients who have largely been excluded from other studies.

Anesthesia for the Patient Undergoing Shoulder Surgery.

Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.

A Review of Slipping Rib Syndrome: Diagnostic and Treatment Updates to a Rare and Challenging Problem.

Slipping rib syndrome (SRS) is a disorder that occurs when one or more of the eighth through tenth ribs become abnormally mobile. SRS is a poorly understood condition leading to a significant delay in diagnosis and therapeutic management. History and a physical exam are usually sufficient for a diagnosis of SRS. The utility of dynamic ultrasounds has also been studied as a useful diagnostic tool. Multiple surgical techniques for SRS have been described within the literature. Cartilage rib excision (CRE) has been the most common technique utilized. However, the literature has shown a high rate of recurrence and associated risks with the procedure. More recently, minimally invasive rib fixation and costal cartilage excision with vertical rib plating have been shown as successful and safe alternative techniques. This may be an effective, alternative approach to CRE in adult and pediatric populations with SRS.

Anesthesia for the Patient Undergoing Shoulder Surgery.

Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.

Briefest Time to Perform a Series of Preoperative Nerve Blocks in Multiple Patients: A Simulation Study.

Introduction To mitigate first-case delays in operating rooms, sufficient additional time must be allotted when anesthesiologists perform preoperative nerve blocks in multiple patients who are scheduled as the initial cases of the day. We used spinal anesthetics performed in dedicated block rooms located just outside the operating room suite to estimate the briefest times needed to complete a series of spinal, epidural, peripheral, or other regional nerve blocks. We followed this approach because even though the studied hospital had a busy regional anesthesia service, sample sizes were insufficient and electronic data were not available to directly study the time to perform the many other nerve blocks they perform. Methods We studied a historical cohort of 8,462 adult patients undergoing spinal anesthesia between 2005 and 2017. Preoperative evaluation, consent, and holding area tasks were completed before entering the block room; the times to complete these tasks were not available for study. Upon block room entry, the electronic anesthetic record was started, a timeout conducted with patient participation, vital signs taken, and the spinal performed. The interval from entry until intrathecal injection was the spinal block time. Because fits of these times to probability distributions previously used for anesthesia times were poor (p < 0.001), percentiles of times to perform one or more spinal anesthetics were calculated using Monte-Carlo simulation (100,000 samples with replacement) from the empirical distributions. Results The mean spinal block time was 8.8 minutes. The 90% upper prediction limit for one block was 14 minutes, with progressively decreasing times for each subsequent block for a 90% chance of finishing on time. For example, for three first-case regional or neuraxial blocks performed outside the operating room by one anesthesiologist, the first patient needs to arrive at least 38 minutes earlier than non-block patients to mitigate operating room start delays. Conclusions These minimum time estimates can help nursing leadership ensure that sufficient time will be available after patients are ready for anesthesia to avoid first-case delays when preoperative regional anesthesia is performed outside the operating room. Given that inadequate sample size and documentation issues likely exist universally for the various non-neuraxial preoperative nerve blocks, we recommend that hospitals use our estimates as a minimum starting point rather than try to calculate times using their own data. Then, as a systems-based metric to assess all steps in the process, track the percentages of days for which all blocks were completed in sufficient time to avoid a first-case delay for those patients. Adjustments to the arrival times would then be implemented, if needed, to meet hospital objectives for on-time starts.

Patient perception of pain care in the United States: a 5-year comparative analysis of hospital consumer assessment of health care providers and systems.

BACKGROUND: The necessity of aggressive pain management in the hospital setting is becoming increasingly evident. It has been shown to improve patient outcomes, and is now an avenue for Medicare to assess reimbursement. In this cohort analysis, we compared the March 2008 to the December 2012 Hospital Consumer Assessment of Health Plans Survey (HCAHPS) reports in order to determine if pain management has improved in the United States after this national standardized survey was created. OBJECTIVE: To evaluate whether pain perception would improve in the 2012 report relative to the 2008 report. STUDY DESIGN: Statistical analyses were conducted with the HCAHPS report to compare pain control in regards to hospital type, hospital ownership, and individual hospitals. Using the question, "How often is your pain controlled?," T-tests were used to compare each hospital type. Hospital ownerships were assessed via analysis of variance (ANOVA) testing. T-tests were conducted to track the difference of hospital performance between the 2008 and the 2012 report. Paired management data were obtained from hospitals that participated in both reports and were assessed using paired T-tests. SETTING: This survey was administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge from any hospital reporting to Centers for Medicare and Medicaid (CMS) across the US. LIMITATIONS: Limitations of this study include response bias, recall bias, and there may be bias related to types of people likely to respond to a survey, but this is inherent to data that is collected on a voluntary response. Additionally, a 3% increase in the number of patients rating their pain as always well-controlled, while statistically significant, admittedly may not be clinically significant. In addition, the raw data collected is adjusted for the effects of patient-mix. The statistical analyses performed to derive the final quarterly HCAHPS reports are unavailable to us and therefore we cannot comment on how individual factors such as age, sex, race, and education or the interaction of the aforementioned affect responses about the patient's perception on how well their pain was controlled between 2008 and 2012. RESULTS: Two thousand three hundred and ninety five hospitals reported pain management data in both 2008 and 2012. In 2012, hospitals improved their ability to "always control a patients pain" by 3.07% (P < 0.0001) in comparison to the baseline March 2008 report, which was statistically significant. According to the 2012 data, the discrepancy in pain management between acute care hospitals and critical access hospitals was 3.33% which was statistically significant (P < 0.05). Government hospitals were shown to manage pain better at baseline, but all 3 types of ownership improved their pain scores between the 2 reports which was shown to be statistically significant (P < 0.01). DISCUSSION: The HCAHPS survey is a national public standardized report used as a way to compare care in the United States. Patient pain perception has improved between the 2008 and 2012 reports. Further studies are needed to evaluate critical care hospitals.