Enhanced Recovery After Surgery in Patients Implanted with Left Ventricular Assist Device.

INTRODUCTION: We sought to develop and implement a comprehensive enhanced recovery after surgery (ERAS) protocol for patients implanted with a left ventricular assist device (LVAD). METHODS AND RESULTS: In this article, we describe our approach to the development and phased implementation of the protocol. Additionally, we reviewed prospectively collected data for patients who underwent LVAD implantation at our institution from February 2019 to August 2020. To compare early outcomes in our patients before and after protocol implementation, we dichotomized patients into two 6-month cohorts (the pre-ERAS and ERAS cohorts) separated from each other by 6 months to allow for staff adoption of the protocol. Of the 115 LVAD implants, 38 patients were implanted in the pre-ERAS period and 46 patients in the ERAS period. Preoperatively, the patients` characteristics were similar between the cohorts. Postoperatively, we observed a decrease in bleeding (chest tube output of 1006 vs 647.5 mL, P < .001) and blood transfusions (fresh frozen plasma 31.6% vs 6.7%, P = .04; platelets 42.1% vs 8.7%, P = .001). Opioid prescription at discharge were 5-fold lower with the ERAS approach (P < .01). Furthermore, the number of patients discharged to a rehabilitation facility decreased significantly (20.0% vs 2.4%, P = .02). The index hospitalization length of stay and survival were similar between the groups. CONCLUSIONS: ERAS for patients undergoing LVAD implantation is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. In this article, we describe the details of the protocol and early positive changes in clinical outcomes. Further studies are needed to evaluate benefits of an ERAS protocol in an LVAD population.Lay Summary: Enhanced recovery after surgery (ERAS) is the implementation of standardized clinical pathways that ensures the use of best practices and decreased variation in perioperative care. Multidisciplinary teams work together on ERAS, thereby enhancing communication among health care silos. ERAS has been used for more than 30 years by other surgical services and has been shown to lead to a decreased length of stay, fewer complications, lower mortality, fewer readmissions, greater job satisfaction, and lower costs. Our goal was to translate these benefits to the perioperative care of complex patients with a left ventricular assist device. Early results suggest that this goal is possible; we have observed a decrease in transfusions, discharge on opioids, and discharge to a rehabilitation facility.

Adverse Drug Reaction: Midazolam-Induced Extrapyramidal Symptoms: A Case Report.

Midazolam is commonly used for sedation during procedures because of its relative safety and predictability. Still, some rare undesirable medication reactions have been described. We report a case in which midazolam given before a peripheral nerve block caused acute onset dyskinetic extrapyramidal symptoms. These symptoms ultimately resolved following reversal of the midazolam with flumazenil. Given the widespread and multidisciplinary use of midazolam, practitioners should be aware of the potential for rare adverse reactions and be prepared to manage these scenarios.

Postoperative "Rescue" Use of Erector Spinae Plane Block After Lumbar Spine Fusion: A Report of 2 Cases.

Pain after lumbar spine fusion surgery is often difficult to control in the immediate postoperative period. Historically, opioids have been the mainstay of treatment, but are associated with many unwanted side effects as well as increased hospital length of stay. The ultrasound-guided erector spinae plane block (ESP) is a relatively safe and simple regional option for the management of acute postoperative pain after spine surgery without the technical difficulty or complications noted with paravertebral injection (eg, pneumothorax, hematoma). To date, there have been reports of preoperative placement of ESP block prior to spine surgery with some success. We present a report of two cases that highlight the efficacy of the ESP block as an early postoperative "rescue" regional anesthetic technique in lumbar spine surgery. These cases demonstrate the potential effectiveness of a "rescue" use of the ESP block in patients having uncontrolled or poorly controlled pain in the early postoperative period with no evidence of significant side effects.

Lumbar plexus block using high-pressure injection leads to contralateral and epidural spread.

BACKGROUND: The main advantage of lumbar plexus block over neuraxial anesthesia is unilateral blockade; however, the relatively common occurrence of bilateral spread (up to 27%) makes this advantage unpredictable. The authors hypothesized that high injection pressures during lumbar plexus block carry a higher risk of bilateral or neuraxial anesthesia. METHODS: Eighty patients undergoing knee arthroscopy (age 18-65 yr; American Society of Anesthesiologists physical status I or II) during a standard, nerve stimulator-guided lumbar plexus block using 35 ml mepivacaine, 1.5%, were scheduled to be studied. Patients were randomly assigned to receive either a low-pressure (< 15 psi) or a high-pressure (> 20 psi) injection, as assessed by an inline injection pressure monitor (BSmart; Concert Medical LLC, Norwell, MA). The block success rate and the presence of bilateral sensory and/or motor blockade were assessed. RESULTS: An interim analysis was performed at n = 20 after an unexpectedly high number of patients had neuraxial spread, necessitating early termination of the study. Five of 10 patients (50%) in the high-pressure group had a neuraxial block with a dermatomal sensory level T10 or higher. In contrast, no patient in the low-pressure group (n = 10) had evidence of neuraxial spread. Moreover, 6 patients (60%) in the high-pressure group demonstrated bilateral sensory blockade in the femoral distribution, whereas no patient in the low-pressure group had evidence of a bilateral femoral block. CONCLUSIONS: Injection of local anesthetic with high injection pressure (> 20 psi) during lumbar plexus block commonly results in unwanted bilateral blockade and is associated with high risk of neuraxial blockade.

The effect of stimulating versus conventional perineural catheters on postoperative analgesia following ultrasound-guided femoral nerve localization.

STUDY OBJECTIVE: To test the hypothesis that, if the femoral nerve is correctly localized using ultrasound (US) guidance, the type of perineural catheter used has no effect on catheter success. DESIGN: Randomized controlled trial. SETTING: Post-anesthesia care unit of an academic teaching hospital. PATIENTS: 40 ASA physical status 1, 2, and 3 patients, ages 55-85 years, undergoing elective total knee arthroplasty. INTERVENTIONS: All patients received postoperative continuous femoral nerve blocks and a single injection sciatic nerve block. Nerve localization was accomplished using US guidance and electrical nerve stimulation so that the needle tip was visualized deep to the femoral nerve. Patients were randomized to receive either stimulating (Group SC) or nonstimulating catheters (Group NSC) in the usual manner for each device. Catheters were bolused with ropivacaine and an infusion commenced. MEASUREMENTS: The primary outcome was quality of analgesia (as measured by a numerical rating scale). Other outcomes included sensory block success rate, number of attempts and time required to localize the needle tip correctly, number of attempts and time required to place the perineural catheter, amount of local anesthetic and opioid use postoperatively, and degree of completion of preset postoperative rehabilitation goals. MAIN RESULTS: Quality of analgesia was similar at all time intervals. Rates of successful femoral block (95% vs 80%; P = 0.34) were similar between groups. Time required to position the catheter was greater in Group SC than Group NSC (3.45 ± 2.05 min vs 1.72 ± 0.88 min; P < 0.01). CONCLUSIONS: Ultrasound guidance for needle localization prior to catheter insertion for femoral nerve block results in similar block characteristics between stimulating and nonstimulating catheters. The use of nonstimulating catheters avoids the technical challenges of stimulating catheters and does not require additional helpers.