The Role of Exparel Plus Meloxicam for Postoperative Pain Management.

PURPOSE OF REVIEW: Acute postoperative pain reduction is a major target against the opioid crisis. While opioids have traditionally been the mainstay for postoperative analgesia, current practice has focused on a multimodal approach to pain control, including ultrasound-guided blocks with longer acting local anesthetic agents. RECENT FINDINGS: Non-steroidal anti-inflammatory drugs (NSAIDs), such as meloxicam, are an important class of medications utilized to manage pain in the perioperative period. An additional treatment used in perioperative or postoperative pain relief is Exparel, a bupivacaine (sodium channel blocker) liposomal injectable suspension with a 3-4-day duration of action. The long-acting mechanism and formulation of Exparel consistently has demonstrated decreased opioid use and pain scores in patients undergoing many different surgical procedures. A concern is that pH negatively alters the efficacy of bupivacaine, as in cases of inflamed tissue and acidic fluid pH. For this reason, a combination medication with both meloxicam and bupivacaine has been developed, which normalizes pH and has anti-inflammatory and anti-pain conduction properties. Clinical studies demonstrate that this combination agent can be extremely beneficial in treating postoperative pain. This manuscript summarizes the newest developments with regard to liposomal bupivacaine and the non-steroidal meloxicam, their roles in effective treatment of postoperative pain, contraindications, special considerations of using these medications, and future considerations. HTX-011 pairs up a new extended-release formulation of the local anesthetic bupivacaine with meloxicam, a well-established non-steroidal anti-inflammatory drug (NSAID).

Point of care ultrasound for the clinical anesthesiologist.

Diagnostic ultrasonography was first utilized in the 1940s. The past 70+ years have seen an explosion in both ultrasound technology and availability of ultrasound technology to more and more clinicians. As ultrasound technology and availability have grown, the utility of ultrasound technology in the clinical setting as only been limited by clinicians' imagination. Due to its lack of radiation, non-invasive nature, and gentle learning curve, medical ultrasonography is now a tremendously useful Point of Care technology in the clinical arena. What follows is a discussion of Point of Care Ultrasound (PoCUS) and how it can be incorporated in the daily practice of any regional anesthesiology. While most regional anesthesiologists usually focus on the interventional aspects of ultrasonography (i.e. nerve blocks), our discussion will center on the diagnostic value of ultrasonography-especially concerning assessment of cardiac physiology and pathophysiology, gastric anatomy, airway anatomy, and intracranial pathophysiology. After reading and reviewing this chapter, the learner will have the knowledge to start training themselves in a variety of PoCUS exams that will allow rapid diagnosis of normal and abnormal patient conditions. Once an accurate diagnosis is established, the anesthesiologist and his/her team can then confidently optimize an anesthetic pain, prevent harm, and/or treat a patient condition. In this day and age, the ability to rapidly establish an accurate diagnosis cannot be overstated-especially in a critical situation. It is the authors' sincerest hope that the following discussion will help regional anesthesiologist to become even better and well-rounded clinical leaders.

A nonequilibrium binary elements-based kinetic model for benzodiazepine regulation of GABAA receptors.

Ion channels, like many other proteins, are composed of multiple structural domains. A stimulus that impinges on one domain, such as binding of a ligand to its recognition site, can influence the activity of another domain, such as a transmembrane channel gate, through interdomain interactions. Kinetic schemes that describe the function of interacting domains typically incorporate a minimal number of states and transitions, and do not explicitly model interactions between domains. Here, we develop a kinetic model of the GABAA receptor, a ligand-gated ion channel modulated by numerous compounds including benzodiazepines, a class of drugs used clinically as sedatives and anxiolytics. Our model explicitly treats both the kinetics of distinct functional domains within the receptor and the interactions between these domains. The model describes not only how benzodiazepines that potentiate GABAA receptor activity, such as diazepam, affect peak current dose-response relationships in the presence of desensitization, but also their effect on the detailed kinetics of current activation, desensitization, and deactivation in response to various stimulation protocols. Finally, our model explains positive modulation by benzodiazepines of receptor currents elicited by either full or partial agonists, and can resolve conflicting observations arguing for benzodiazepine modulation of agonist binding versus channel gating.