RESUMEN
Using a modified Delphi technique, an international group of regional anaesthetists generated a list of top research priorities in regional anaesthesia. The list of unanswered research questions was created from a questionnaire completed by >500 anaesthetists and distilled into 11 priorities grouped into four themes: clinical practice and efficacy, pain management, technology and equipment, and training and assessment.
Asunto(s)
Anestesia de Conducción , Técnica Delphi , Humanos , Anestesia de Conducción/métodos , Encuestas y Cuestionarios , Investigación Biomédica , Investigación , Manejo del Dolor/métodos , AnestesiologíaRESUMEN
OBJECTIVES: Total knee arthroplasty (TKA) is an effective surgery for end-stage knee osteoarthritis, but chronic postoperative pain and reduced function affect up to 20% of patients who undergo such surgery. There are limited treatment options, but percutaneous peripheral nerve stimulation (PNS) is a promising nonopioid treatment option for chronic, persistent postoperative pain. The objective of the present study was to evaluate the effect of a 60-day percutaneous PNS treatment in a multicenter, randomized, double-blind, placebo-controlled trial for treating persistent postoperative pain after TKA. MATERIALS AND METHODS: Patients with postoperative pain after knee replacement were screened for this postmarket, institutional review board-approved, prospectively registered (NCT04341948) trial. Subjects were randomized to receive either active PNS or placebo (sham) stimulation. Subjects and a designated evaluator were blinded to group assignments. Subjects in both groups underwent ultrasound-guided placement of percutaneous fine-wire coiled leads targeting the femoral and sciatic nerves on the leg with postoperative pain. Leads were indwelling for eight weeks, and the primary efficacy outcome compared the proportion of subjects in each group reporting ≥50% reduction in average pain relative to baseline during weeks five to eight. Functional outcomes (6-minute walk test; 6MWT and Western Ontario and McMaster Universities Osteoarthritis Index) and quality of life (Patient Global Impression of Change) also were evaluated at end of treatment (EOT). RESULTS: A greater proportion of subjects in the PNS groups (60%; 12/20) than in the placebo (sham) group (24%; 5/21) responded with ≥50% pain relief relative to baseline (p = 0.028) during the primary endpoint (weeks 5-8). Subjects in the PNS group also walked a significantly greater distance at EOT than did those in the placebo (sham) group (6MWT; +47% vs -9% change from baseline; p = 0.048, n = 18 vs n = 20 completed the test, respectively). Prospective follow-up to 12 months is ongoing. CONCLUSIONS: This study provides evidence that percutaneous PNS decreases persistent pain, which leads to improved functional outcomes after TKA at EOT.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Dolor Postoperatorio , Estimulación Eléctrica Transcutánea del Nervio , Humanos , Masculino , Femenino , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Método Doble Ciego , Anciano , Dolor Postoperatorio/terapia , Dolor Postoperatorio/etiología , Persona de Mediana Edad , Estimulación Eléctrica Transcutánea del Nervio/métodos , Resultado del Tratamiento , Dimensión del Dolor/métodos , Recuperación de la Función/fisiologíaRESUMEN
Administration of succinylcholine to patients with a variant in the butyrylcholinesterase (BChE) gene increases the risk of anesthesia emergence prior to recovery from neuromuscular blockade (NMB). Application of quantitative neuromuscular monitoring (NMM) can identify residual NMB. We present two patients with abnormal BChE gene variants. In the first case, quantitative monitoring was applied too late to prevent awareness, but allowed diagnosis and prevented admission to the intensive care unit. In the second case, monitoring was applied prior to NMB, which enabled early diagnosis and prevented premature awakening from anesthesia. These cases illustrate the importance of quantitative NMM, even in short cases and with short-acting depolarizing agents such as succinylcholine. The clinical implications of this report include a more consistent use of NMM to identify and manage patients with undiagnosed abnormal BChE and to prevent premature anesthesia emergence.
Asunto(s)
Anestesia , Butirilcolinesterasa , Humanos , Butirilcolinesterasa/genética , Monitoreo Neuromuscular , Succinilcolina , Diagnóstico PrecozRESUMEN
Hypotension following induction of general anaesthesia has been shown to result in increased complications and mortality postoperatively. Patients admitted to the hospital undergoing urgent surgery are often fasted from fluids for significant periods compared to elective patients subject to Enhanced Recovery After Surgery protocols despite guidelines stating that a two-hour fast is sufficient. The aim of this prospective, observational study was to compare fasting times and intravascular volume status between elective surgery patients subject to enhanced recovery protocols and inpatient, urgent surgery patients and to assess differences in the incidence of post-induction hypotension. Fasting data was obtained by questionnaire in the preoperative area in addition to inferior vena cava collapsibility index, a non-invasive measure of intravascular volume. Blood pressure readings and drug administration for the ten minutes following induction were obtained from patients' charts. Inpatients undergoing urgent surgery were fasted significantly longer than enhanced recovery patients and had lower intravascular volume. However, no difference was found in the incidence of post-induction hypotension.
RESUMEN
Objectives: Perioperative fluid administration impacts the rate of complications following surgery. VExUS grading system is a standardized point of care ultrasound (POCUS)-based, comprehensive method to assess volume status. VExUS could serve as a tool to guide fluid management, if validated perioperatively. The primary aim was to assess the success rate of obtaining required windows for VExUS grading , as well as the feasibility within a perioperative setting among noncardiac surgery. Further, this study describes the incidence of perioperative venous congestion and associations with 30-day postoperative complications. Methods: This observational study was conducted in non-critically ill adults undergoing noncardiac surgery. Patients were scanned preoperatively, in the post anesthesia care unit (PACU), and 24 hours postoperatively for venous congestion. Researchers retrospectively captured 30-day complications for multivariate analyses. Results: The cohort included 69 participants. Ninety-one percent of scans over all timepoints were successfully completed. Pre-operatively, 57 (83%) scans were Grade 0, and 11 (16%) were Grade 1. Venous congestion was observed in 29 (44%) patients in the PACU (n=66). 22 (33%) patients were Grade 1, while 7 (11%) were Grade 2. At 24 hours (n=63), 31 patients (49%) had venous congestion: 20 (32%) Grade 1 and 11 (17%) Grade 2. Of the pre-operative Grade 0, 28 (50%) had at least one postoperative scan with venous congestion. No patients were Grade 3 at any timepoint. The 30-day complication rate was 32% (n=22). Eleven (16%) patients developed acute kidney injury (AKI). There was no statistically significant association between VExUS grading and all-cause complications or AKI. Conclusion: This study demonstrates that perioperative VExUS scoring is a feasible tool among a variety of noncardiac surgeries. We highlight that venous congestion is common and increases postoperatively within non-ICU populations. Larger studies are needed to assess the relationship between VExUS grading and postoperative complications.
RESUMEN
Patients requiring complex upper arm arteriovenous fistulas or grafts may not be suitable candidates for a single regional anesthesia technique and monitored anesthesia care because the necessary thoracic (T2) dermatomal area of the medial, upper arm remains spared by any solitary brachial plexus (C5-T1) technique. An infiltrative intercostobrachial nerve block can often be used in conjunction with a brachial plexus block; however, coverage may still be incomplete. This case report describes the use of a high thoracic paravertebral block in conjunction with a brachial plexus block to achieve adequate anesthetic coverage for an upper arm arteriovenous fistula creation procedure extending into the axilla. The result of this technique showed adequate coverage of the upper arm and demonstrates that paravertebral blocks are a reasonable adjunct for proximal upper arm arteriovenous fistula procedures.
RESUMEN
INTRODUCTION: This cadaveric dye study assesses the effect of volume and number of injections on the spread of solution after ultrasound-guided rectus sheath injections. In addition, this study evaluates the impact of the arcuate line on solution spread. MATERIALS AND METHODS: Ultrasound-guided rectus sheath injections were performed on seven cadavers on both sides of the abdomen, for a total of 14 injections. Three cadavers received one injection of 30 mL of a solution consisting of bupivacaine and methylene blue at the level of the umbilicus. Four cadavers received two injections of 15 mL of the same solution, one midway between the xiphoid process and umbilicus and one midway between the umbilicus and pubis. RESULTS: Six cadavers were successfully dissected and analyzed for a total of 12 injections, while one cadaver was excluded due to poor tissue quality that was inadequate for dissection and analysis. There was a significant spread of solution with all injections caudally to the pubis without limitation by the arcuate line. However, a single 30 mL injection showed inconsistent spread to the subcostal margin in four of six injections, including in a cadaver with an ostomy. A double injection of 15 mL showed consistent spread from xiphoid to pubis in five of six injections, except in a cadaver with a hernia. CONCLUSIONS: Injections deep to the rectus abdominis muscle, using the same technique as an ultrasound-guided rectus sheath block, achieve spread along a large and continuous fascial plane without limitation by the arcuate line and may provide coverage of the entire anterior abdomen. A large volume is necessary for complete coverage and spread is improved with multiple injections. We suggest that two injections with a total volume of at least 30 mL per side may be needed to achieve adequate coverage in the absence of preexisting abdominal abnormalities.
RESUMEN
These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.
Asunto(s)
Anestésicos , Retraso en el Despertar Posanestésico , Bloqueo Neuromuscular , Bloqueantes Neuromusculares , Humanos , Anestesiólogos , Monitoreo NeuromuscularRESUMEN
Harlequin syndrome is a condition in which disruption of the autonomic nervous system results in ipsilateral anhidrosis and pallor of the face. We report the first documented case of Harlequin syndrome following the use of liposomal bupivacaine, in which a patient developed symptoms five hours after a bilateral erector spinae plane (ESP) block with liposomal bupivacaine before partial sternectomy. It is additionally unique as the first report of delayed onset of symptoms. The proposed mechanism is the diffusion of the anesthetic into the paravertebral space with cephalad migration to the T2-T3 level, where facial vasomotor fibers exit the spinal cord.
Asunto(s)
Bloqueo Nervioso , Nervios Periféricos , Humanos , Nervio Mediano , Músculo Esquelético/inervaciónRESUMEN
INTRODUCTION: Prolonged tourniquet inflation during surgery frequently leads to tourniquet hypertension (TH), which is thought to arise from compression of A-δ fibers leading to sympathetically mediated C fiber activation. In the lower extremity, C fibers and other sympathetic nerve fibers are carried along the femoral artery. We hypothesized that blockade of these fibers at the femoral artery would decrease the incidence of TH. METHODS: Thirty American Society of Anesthesia 1-3 patients aged 18-75 undergoing total ankle arthroplasty were randomized to receive 15 mL of injectate (mepivacaine 1.5% or saline placebo) at the anteromedial aspect of the common femoral artery at the level of the inguinal crease under ultrasound guidance. Both groups received preoperative popliteal sciatic and saphenous nerve blocks for analgesia and a standardized general anesthetic. Esmolol was administered if systolic blood pressure rose >30% above baseline. Incidence of TH was the primary outcome. RESULTS: TH was present in 93.3% of sham patients versus 33.3% of block patients. Mean systolic pressure at 120 min and 150 min of tourniquet time was significantly higher in the sham group compared with the block group. Esmolol requirement (95.3+107.6 v 8.0+14.2, p=<0.001) was also significantly higher in the sham group. No differences were noted in pain scores or opioid consumption, and no patient experienced sensory or motor block of the femoral nerve. DISCUSSION: Under these experimental conditions, injection of local anesthetic around the femoral artery reduced the incidence of TH and intraoperative esmolol requirement. TRIAL REGISTRATION NUMBER: www.clinicaltrials.gov (NCT03390426; December 28, 2017).
Asunto(s)
Hipertensión , Bloqueo Nervioso , Anestésicos Locales , Método Doble Ciego , Arteria Femoral , Nervio Femoral , Humanos , Dimensión del Dolor , Dolor Postoperatorio , Estudios Prospectivos , Nervio Ciático , Muslo , TorniquetesRESUMEN
BACKGROUND: Multiple comparative studies report that adductor canal blocks provide similar pain relief to femoral nerve blocks following total knee arthroplasty. However, adductor canal blockade fails to anesthetize several important femoral nerve branches that contribute to knee innervation. We sought to clarify this anatomic discrepancy by performing both blocks in sequence, using patients as their own controls. We hypothesized that patients would experience additional pain relief following a superimposed femoral nerve block, demonstrating that these techniques are not equivalent. METHODS: Sixteen patients received continuous adductor canal block before undergoing knee arthroplasty under general anesthesia. In the recovery room, patients reported their pain score on a numeric scale of 0-10. Once a patient reached a score of five or greater, he/she was randomized to receive an additional femoral nerve block using 2% chloroprocaine or saline sham, and pain scores recorded every 5 min for 30 min. Patients received opioid rescue as needed. Anesthesiologists performing and assessing block efficacy were blinded to group allocation. RESULTS: Patients randomized to chloroprocaine versus saline reported significantly improved median pain scores 30 min after the femoral block (2.0 vs. 5.5, P = 0.0001). Patients receiving chloroprocaine also required significantly fewer morphine equivalents during the 30 min post-femoral block (1.0 vs. 4.5 mg, P = 0.03). CONCLUSIONS: Adductor canal block is a useful technique for postoperative pain following total knee arthroplasty, but it does not provide equivalent analgesic efficacy to femoral nerve block. Future studies comparing efficacy between various block sites along the thigh are warranted.
Asunto(s)
Analgesia/métodos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Bloqueo Nervioso Autónomo/métodos , Nervio Femoral/efectos de los fármacos , Dimensión del Dolor/métodos , Dolor Postoperatorio/prevención & control , Anciano , Analgesia/tendencias , Anestésicos Locales/administración & dosificación , Artroplastia de Reemplazo de Rodilla/tendencias , Bloqueo Nervioso Autónomo/tendencias , Método Doble Ciego , Femenino , Nervio Femoral/fisiología , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor/efectos de los fármacos , Dolor Postoperatorio/etiología , Procaína/administración & dosificación , Procaína/análogos & derivados , Estudios Prospectivos , Muslo/inervación , Muslo/fisiologíaRESUMEN
Improved understanding of the monitoring and dosing practices of anesthesia providers regarding neuromuscular blockade is necessary. The use of subjective methods such as peripheral nerve stimulation and clinical assessment tests can increase the risk of residual neuromuscular blockade and adverse postoperative outcomes. Quantitative monitoring of neuromuscular blockade is an alternative tool to peripheral nerve stimulation to guide neuromuscular blockade; however, it is rarely used by providers. We developed an initiative to improve anesthesia providers' knowledge of neuromuscular blockade pharmacology, physiology, monitoring, and management. After the initiative, an analysis assessed for practice change regarding the use of quantitative monitoring and dosing of neuromuscular blocking agents and neostigmine. The use of quantitative monitoring increased significantly from 14.0% in the preinitiative group to 48.0% after the initiative (P < .001). The least squares mean 95% effective dose (ED95) neuromuscular blocking agents dose was compared between pre-initiative and postinitiative groups, and case length was a significant predictor for patients receiving the highest neuromuscular blocking agents doses. Neostigmine doses were compared between preinitiative and postinitiative groups, and body mass index was a significant predictor of the least squares mean neostigmine dose (P = .002) and the likelihood of receiving a high neostigmine dose (odds ratio = 0.911, 95% CI = 0.870-0.955).
Asunto(s)
Monitoreo Intraoperatorio/normas , Bloqueo Neuromuscular/normas , Enfermeras Anestesistas , Evaluación de Procesos y Resultados en Atención de Salud , Pautas de la Práctica en Enfermería , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/enfermería , Neostigmina/administración & dosificación , Neostigmina/farmacología , Neostigmina/uso terapéutico , Bloqueo Neuromuscular/enfermería , Fármacos Neuromusculares no Despolarizantes/administración & dosificación , Fármacos Neuromusculares no Despolarizantes/farmacología , Fármacos Neuromusculares no Despolarizantes/uso terapéutico , North Carolina , Mejoramiento de la CalidadRESUMEN
AIMS: Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA. PATIENTS AND METHODS: A total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS). RESULTS: TKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs 158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs 661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs 1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA. CONCLUSION: For hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability. Cite this article: Bone Joint J 2019;101-B:1093-1099.