Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.

BACKGROUND: The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied. METHODS: We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days. RESULTS: A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30). CONCLUSIONS: Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Loss-of-Resistance Versus Dynamic Pressure-Sensing Technology for Successful Placement of Thoracic Epidural Catheters: A Randomized Clinical Trial.

BACKGROUND: The traditional loss-of-resistance (LOR) technique for thoracic epidural catheter placement can be associated with a high primary failure rate. In this study, we compared the traditional LOR technique and dynamic pressure-sensing (DPS) technology for primary success rate and secondary outcomes pertinent to identifying the thoracic epidural space. METHODS: This pragmatic, randomized, patient- and assessor-blinded superiority trial enrolled patients ages 18 to 75 years, scheduled for major thoracic or abdominal surgeries at a tertiary care teaching hospital. Anesthesiology trainees (residents and fellows) placed thoracic epidural catheters under faculty supervision and rescue. The primary outcome was the success rate of thoracic epidural catheter placement, evaluated by the loss of cold sensation in the thoracic dermatomes 20 minutes after injecting the epidural test dose. Secondary outcomes included procedural time, ease of catheter placement, the presence of a positive falling meniscus sign, early hemodynamic changes, and unintended dural punctures. Additionally, we explored outcomes that included number of attempts, needle depth to epidural space, need for faculty to rescue the procedure from the trainee, patient-rated procedural discomfort, pain at the epidural insertion site, postoperative pain scores, and opioid consumption over 48 hours. RESULTS: Between March 2019 and June 2020, 133 patients were enrolled; 117 were included in the final analysis (n = 57 for the LOR group; n = 60 for the DPS group). The primary success rate of epidural catheter placement was 91.2% (52 of 57) in the LOR group and 96.7% (58 of 60) in the DPS group (95% confidence interval [CI] of difference in proportions: -0.054 [-0.14 to 0.03]; P = .264). No difference was observed in procedural time between the 2 groups (median interquartile range [IQR] in minutes: LOR 5.0 [7.0], DPS 5.5 [7.0]; P = .982). The number of patients with epidural analgesia onset at 10 minutes was 49.1% (28 of 57) in the LOR group compared to 31.7% (19 of 60) in the DPS group ( P = .062). There were 2 cases of unintended dural punctures in each group. Other secondary or exploratory outcomes were not significantly different between the groups. CONCLUSIONS: Our trial did not establish the superiority of the DPS technique over the traditional LOR method for identifying the thoracic epidural space ( Clinicaltrials.gov identifier: NCT03826186).

Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA.

Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.

The Role of Regional Anaesthesia and Acute Pain Services in Value-Based Healthcare.

Value-based healthcare prioritizes patient outcomes and quality relative to costs, shifting focus from service volume to delivered value. This review explores the significant role of regional anaesthesia (RA) and acute pain services (APS) within the evolving value-based healthcare (VBHC) framework. At the heart of VBHC is the goal to enhance patient outcomes while simultaneously optimizing operational efficiency and reducing costs. The review underscores the need for VBHC and illustrates how integrating RA/APS with Enhanced Recovery Protocols can lead to improved outcomes, aligning directly with the goals of the Triple Aim. Several clinical studies show that RA improves patient outcomes, enhances operating room efficiency, and reduces costs. This is complemented by a discussion on the integration of RA and APS into the VBHC model, highlighting emerging value-based payment structures and strategies for their successful implementation. By merging specialized RA/APS protocols with standardized clinical practices, significant improvements in operating room efficiency and associated economic benefits are observed. Across the healthcare spectrum, from providers to payers, this synergy results in enhanced operational efficiency and communication, raising the standard of patient care. Additionally, the potential of RA and APS to address the opioid crisis, through alternative pain management methods, is emphasized. Globally, the shift towards VBHC requires international collaboration, sharing of best practices, and efficient resource allocation, with RA and APS playing a crucial role. In conclusion, as healthcare moves toward a value-driven model, RA and APS become increasingly essential, signaling a future of refined, patient-centered care.

Thoracic epidural analgesia in a patient with von Hippel-Lindau disease.

von Hippel-Lindau disease (VHLD) is an autosomal dominant disorder characterized by central nervous system hemangioblastomas and renal tumors. Here, we report a case of thoracic epidural placement in a 35-year-old woman with VHLD presenting for left open heminephrectomy for renal masses. We also reviewed the literature on this topic.

Impact of paravertebral blocks on analgesic and non-analgesic outcomes after video-assisted thoracoscopic surgery: A propensity matched cohort study.

BACKGROUND: Regional analgesic techniques such as paravertebral blocks (PVBs) have been popularized for analgesia following video-assisted thoracoscopic surgery (VATS). In this single center retrospective propensity matched cohort of subjects, we investigate the impact of paravertebral blocks on the analgesic and non-analgesic outcomes. METHODS: Institutional database was queried to identify all patients undergoing VATS between January 2013 and July 2019 and these patients were divided into those who received paravertebral blocks in combination with general anesthesia (GA) [PVB group] and those who received GA without paravertebral blocks [GA group]. Propensity score matching based on common patient confounders were used to identify patients in each group. Primary outcomes of the study were average pain scores and opioid consumption in the first 24 hours. Secondary analgesic outcomes included pain scores and opioid requirements at other timepoints over the first 48 hours. Non analgesic outcomes were obtained from STS General Thoracic Surgery Database and included length of hospital stay, need for ICU admission, composite outcome of any complication during the hospital course and 30-day mortality. Exploratory analyses were conducted to investigate the impact of PVB on analgesia following different types of surgery and as to whether any other covariates had a greater influence on the included patient centered outcomes. MAIN RESULTS: After propensity score matching, a total of 520 patients (260 per group) were selected for the study out of 1095 patients. The opioid consumption in terms of oral morphine milligram equivalent (MME) [Median (IQR)] for the first 24 hours was significantly lower with the use of PVB [PVB group- 78.5 (96.75); GA group-127.0 (111.5); p<0.001] while the average pain scores in the first 24 hours did not differ significantly [PVB group-4.71 (2.28); GA group-4.85 (2.30); p = 0.70]. The length of hospital stay, opioid requirements at other timepoints, need for ICU admission in the immediate post-operative period and the composite outcome-'any complication' (35% vs 48%) were significantly lower with the use of PVB. Subgroup analysis showed a longer duration of benefit following major lung surgeries compared to others. CONCLUSION: Paravertebral blocks reduced the length of stay and opioid consumption up to 48 hours after VATS without significantly impacting pain scores.

A Case Report of Slowly Evolving Epidural Hematoma After Lumbar Drain Removal Following Initiation of Clopidogrel Therapy.

Guidelines on the management of lumbar drain in patients receiving antithrombotic therapy are lacking, with American Society of Regional Anesthesia and Pain Medicine (ASRA) anticoagulation guidelines for regional anesthesia providing the best possible guidance for this scenario. However, the risk-benefits of placing a lumbar drain in the context of vascular surgery differ from placement of neuraxial blockade. One of the changes included in the recently published ASRA guidelines is that clopidogrel can be started on a patient with an indwelling neuraxial catheter. We report a case of slowly evolving epidural hematoma following the initiation of clopidogrel therapy in a patient with an indwelling lumbar drain.

Comparison of the effect of three different adjuvants on the analgesic duration of single injection interscalene brachial plexus block: a prospective, randomized, triple blinded clinical trial.

BACKGROUND AND OBJECTIVES: Use of regional anesthesia can result in faster recovery and better patient satisfaction. Addition of perineural adjuncts to local anesthetics may improve the duration of analgesia, but there is a paucity of data comparing them in a single randomized trial. We compared the effects of three adjuncts clonidine, dexamethasone, and buprenorphine, on the duration of analgesia of interscalene brachial plexus block. METHODS: 160 patients, undergoing elective shoulder surgery, were randomized to four groups to receive an interscalene block with one of the following solutions: ropivacaine alone, ropivacaine with clonidine 75 µg, ropivacaine with dexamethasone 8 mg, or ropivacaine with buprenorphine 300 µg. The primary outcome variable was the duration of analgesia; secondary outcome measures were time to onset of the block, and the duration of sensory and motor blocks. RESULTS: There was no statistically significant difference in the total analgesia time among the four groups; p=0.11. The pairwise comparison in analgesic time and 99% CI were: control versus clonidine (-1.94 hours (-7.33 to 3.12)), control versus dexamethasone (-4.16 hours (-9.50 to 0.58)) and control versus buprenorphine (-1.1 hours (-5.34 to 3.23)). There was no differences in block set-up time, or total sensory and motor block duration among the groups. CONCLUSION: There was no significant improvement in the duration of analgesia with addition of any of the three adjuncts to interscalene blocks. However, there was a larger than expected variability in patient response, hence the study may have been underpowered for the primary outcome.

Fascia Iliaca Block for Reduction of Anterior Native Hip Dislocation: a Case Report.

Native hip dislocations require urgent reduction in a setting where adequate sedation and analgesia is essential. We have recently implemented the use of fascia iliaca blocks at our institution for preoperative pain management for patients with proximal femur fractures. In the setting of limited resources, alternate modalities for sedation and analgesia may need to be implemented to obtain a timely reduction for hip dislocations. We present a case report where of the use of a fascia iliaca block along with light sedation to obtain a successful, atraumatic reduction of an anterior dislocation of a native hip joint. While many hip dislocations may require a deeper level of sedation and muscle relaxation for successful reduction, the current report suggests that fascia iliaca blocks provide adequate analgesia for the procedure and may be helpful in the setting of limited resources.

A Comparison of 2 Ultrasound-Guided Approaches to the Saphenous Nerve Block: Adductor Canal Versus Distal Transsartorial: A Prospective, Randomized, Blinded, Noninferiority Trial.

BACKGROUND AND OBJECTIVES: Saphenous nerve blocks can be technically challenging. Recently described ultrasound techniques have improved the success rate of saphenous nerve blocks, but randomized controlled trials comparing these ultrasound-guided techniques are lacking. We compared 2 common ultrasound-guided approaches for saphenous nerve block: saphenous nerve block at the adductor canal (ACSNB) versus block by the distal transsartorial (DTSNB) approach. METHODS: Patients received either ACSNB or DTSNB in this prospective, randomized, blinded, noninferiority clinical trial. The primary objective was to show the noninferiority of ACSNB to DTSNB in terms of block success. Secondary outcome measures were time required to perform the block, time to onset of successful block, and the visibility of the nerve using ultrasound. RESULTS: One hundred twenty patients were randomized to receive DTSNB (n = 62) or ACSNB (n = 58). There were 9 failures in the DTSNB group (85% success) and no failures in the ACSNB group (100% success), 90% confidence interval of difference in success rates (DTSNB - ACSNB) was -0.195 to -0.031. Given that the upper confidence bound (-3.1%) was less than 10%, the success rate of ACSNB was noninferior to DTSNB. After satisfying noninferiority and observing a greater success rate of ACSNB compared with DTSNB, we also determined that ACSNB was superior to DTSNB (P = 0.003). The median time to success was significantly less for the ACSNB group: 9 minutes versus 3 minutes (P < 0.001). The grade of the ultrasound image, as judged by the provider, was significantly better in the ACSNB group (P = 0.001). CONCLUSIONS: Ultrasound-guided block of the saphenous nerve at the adductor canal is not only noninferior but also superior to block at the distal transsartorial level in terms of success rate, with additional advantages of faster block onset time and better nerve visibility under ultrasound.

Mental nerve neuropathy following dental extraction.

Mental nerve neuropathy (MNN), colloquially referred to as numb chin syndrome, is an uncommon neurologic condition that may arise secondary to multiple local and systemic etiologies, and may mimic other pain conditions affecting the mandible. Early recognition of mental nerve neuropathy in conjunction with accurate etiologic identification is crucial, as early pain management may prevent the transition from an acute to a chronic pain condition. In this article, we will describe the clinical courses of 2 patients who presented to the pain clinic with chronic painful numbness in the mental nerve sensory distribution following dental extraction. After a period of failed conservative medical management and repetitive successful nerve blocks at the mental foramen, we decided to proceed with radiofrequency nerve ablation. In both cases, performance of radiofrequency nerve ablation demonstrated a significant decrease in pain. Within interventional pain medicine, nerve blocks are often utilized to assist with pain generator identification, and resultantly also play an integral role in treatment planning. For instance, nerve blocks are often utilized to establish accurate identification of nerve tissue viability, a preliminary role essential for the determination of whether to proceed with an ablative peripheral nerve procedure. In this article, we will additionally review these important usages of nerve blocks within interventional pain medicine. The objective of our article is to help clinicians identify and properly manage early stage mental nerve neuropathy. Moreover, we aim to advance general medical knowledge of this important pain medicine topic. During the process of preparing this article we reviewed all existing pertinent medical literature related to MNN.