Postoperative Rebound Pain: Our Current Understanding About the Role of Regional Anesthesia and Multimodal Approaches in Prevention and Treatment.

PURPOSE OF REVIEW: Rebound pain (RP) is a common occurrence after peripheral nerve block placement, especially when blocks are used for orthopedic surgery. This literature review focuses on the incidence and risk factors for RP as well as preventative and treatment strategies. RECENT FINDINGS: The addition of adjuvants to a block, when appropriate, and starting patients on oral analgesics prior to sensory resolution are reasonable approaches. Using continuous nerve block techniques can provide extended analgesia through the immediate postoperative phase when pain is the most intense. Peripheral nerve blocks (PNBs) are associated with RP, a frequent phenomenon that must be recognized and addressed to prevent short-term pain and patient dissatisfaction, as well as long-term complications and avoidable hospital resource utilization. Knowledge about the advantages and limitations of PNBs allows the anesthesiologists to anticipate, intervene, and hopefully mitigate or avoid the phenomenon of RP.

The practice of regional anesthesia during the COVID-19 pandemic: an international survey of members of three regional anesthesia societies.

PURPOSE: To determine the preferences and attitudes of members of regional anesthesia societies during the COVID-19 pandemic. METHODS: We distributed an electronic survey to members of the American Society of Regional Anesthesia and Pain Medicine, Regional Anaesthesia-UK, and the European Society of Regional Anaesthesia & Pain Therapy. A questionnaire consisting of 19 questions was developed by a panel of experienced regional anesthesiologists and distributed by email to the participants. The survey covered the following domains: participant information, practice settings, preference for the type of anesthetic technique, the use of personal protective equipment, and oxygen therapy. RESULTS: The survey was completed by 729 participants from 73 different countries, with a response rate of 20.1% (729/3,630) for the number of emails opened and 8.5% (729/8,572) for the number of emails sent. Most respondents (87.7%) identified as anesthesia staff (faculty or consultant) and practiced obstetric and non-obstetric anesthesia (55.3%). The practice of regional anesthesia either expanded or remained the same, with only 2% of respondents decreasing their use compared with the pre-pandemic period. The top reasons for an increase in the use of regional anesthesia was to reduce the need for an aerosol-generating medical procedure and to reduce the risk of possible complications to patients. The most common reason for decreased use of regional anesthesia was the risk of urgent conversion to general anesthesia. Approximately 70% of the responders used airborne precautions when providing care to a patient under regional anesthesia. The most common oxygen delivery method was nasal prongs (cannula) with a surgical mask layered over it (61%). CONCLUSIONS: Given the perceived benefits of regional over general anesthesia, approximately half of the members of three regional anesthesia societies seem to have expanded their use of regional anesthesia techniques during the initial surge of the COVID-19 pandemic.

RéSUMé: OBJECTIF: Déterminer les préférences et les attitudes des membres des sociétés d'anesthésie régionale pendant la pandémie de COVID-19. MéTHODE: Nous avons distribué un sondage électronique aux membres de l'American Society of Regional Anesthesia and Pain Medicine, de Regional Anesthesia-UK et de l'European Society of Regional Anaesthesia & Pain Therapy. Un questionnaire composé de 19 questions a été élaboré par un panel d'anesthésiologistes régionaux d'expérience et distribué par courriel aux participants. Le sondage couvrait les domaines suivants : les renseignements sur les participants, les contextes de pratique, leur préférence quant au type de technique d'anesthésie, l'utilisation d'équipement de protection individuelle et l'oxygénothérapie RéSULTATS: Le sondage a été complété par 729 participants provenant de 73 pays différents, avec un taux de réponse de 20,1 % (729/3630) pour le nombre de courriels ouverts et de 8,5 % (729/8572) pour le nombre de courriels envoyés. La plupart des répondants (87,7 %) se sont identifiés comme anesthésiologistes (académique ou consultant) et pratiquaient l'anesthésie obstétricale et non obstétricale (55,3 %). Leur pratique de l'anesthésie régionale s'est étendue ou est demeurée inchangée, et seulement 2 % des répondants ont indiqué avoir diminué leur utilisation de cette pratique par rapport à la période pré-pandémique. Les principales raisons d'une augmentation de l'utilisation de l'anesthésie régionale étaient de réduire la nécessité d'une intervention médicale générant des aérosols et de réduire le risque de complications potentielles pour les patients. La raison la plus courante de diminution du recours à l'anesthésie régionale était le risque de conversion urgente à une anesthésie générale. Environ 70 % des intervenants ont utilisé des précautions en matière de propagation des aérosols lorsqu'ils procuraient des soins à un patient sous anesthésie régionale. La méthode d'administration d'oxygène la plus fréquemment utilisée était les canules nasales avec un masque chirurgical superposé (61 %). CONCLUSION: Compte tenu des avantages perçus de l'anesthésie régionale par rapport à l'anesthésie générale, environ la moitié des membres de trois sociétés d'anesthésie régionale semblent avoir élargi leur utilisation des techniques d'anesthésie régionale pendant la vague initiale de la pandémie de COVID-19.

Neuraxial anesthesia and timing of heparin administration in patients undergoing surgery for congenital heart disease using cardiopulmonary bypass.

OBJECTIVE: The goal of this review was to add to the existing literature documenting the safety of performing neuraxial techniques in patients who are subsequently fully heparinized, with particular emphasis on the timing of heparin administration. This will help improve risk estimation and possibly lead to a more widespread use of neuraxial anesthesia in patients undergoing cardiac surgery. DESIGN: Retrospective chart review. SETTING: Single tertiary-care university hospital. PARTICIPANTS: All patients undergoing surgery for congenital heart diseases during a 5-year period. INTERVENTIONS: The medical records of all patients undergoing surgery for congenital heart diseases during a 5-year period were reviewed for any complications related to the use of neuraxial anesthesia. Furthermore, the interval from neuraxial anesthesia to heparinization for cardiopulmonary bypass was examined. RESULTS: In total, 714 patients were identified who had neuraxial anesthesia administered before full heparinization for cardiopulmonary bypass. No cases of symptomatic spinal or epidural hematomas occurred. Further analysis showed that the interval from neuraxial anesthesia to full heparinization was <1 hour in 466 patients. CONCLUSIONS: No complications related to neuraxial anesthesia were found in a series of 714 patients undergoing surgery for congenital heart disease using cardiopulmonary bypass, including 466 patients in whom the interval from neuraxial anesthesia to full heparinization was <1 hour.

A Cross-sectional Study of the Social Media Presence of ACGME-Accredited Pain Medicine Fellowship Programs: Time to Get Online?

BACKGROUND: Approximately 70% of Americans use social media platforms, and use of specific platforms, such as Instagram, Twitter, Snapchat, and TikTok, is especially common among adults under 30. The presence of social media accounts among residency and fellowship programs in academic medicine has been used to connect with other specialties, highlight achievements and research, disseminate information to the general public, and as a recruiting tool for applicants. OBJECTIVES: The objective of this cross-sectional study was to evaluate the social media presence, specifically on Twitter and Instagram, of the Accreditation Council for Graduate Medical Education (ACGME)-accredited Pain Medicine fellowship programs. We hypothesized that programs with more fellows were more likely to have a social media presence, as well as more content pertaining to branding for recruitment purposes. STUDY DESIGN: A cross-sectional study observing the social media presence of ACGME- accredited Pain Medicine fellowship programs. METHODS: Two independent reviewers conducted searches for corresponding official pain programs and departmental accounts on Twitter and Instagram over the period of July 1, 2020 to June 31, 2021. For all social media accounts identified, number of posts (total and within the study period), followers, and date of first post were recorded. Each post was categorized as medical education, branding, or social. RESULTS: Of the 111 ACGME-accredited Pain Medicine fellowship programs, 4 (3.6%) had both Twitter and Instagram accounts,10 (9%) only Twitter, 7 (6.3%) only Instagram, and 90 (81.1%) had neither. A significant association between the number of fellows and the odds of having an Instagram, but not Twitter, fellowship account was found (odds ratio 1.38, 95% confidence interval [CI]: 1.02,1.88; P = 0.038). Also, a linear relationship existed between the number of followers and tweets (B coefficient 3.7, 95% CI: 3.6, 3.8; P < 0.001). LIMITATIONS: Limitations include that the data were collected during the COVID-19 pandemic, which may correlate to increased likelihood of social media usage. We were also limited by our ability to find all of the pain management fellowship program accounts on social media. CONCLUSIONS: Less than 20% of the pain fellowship programs are currently utilizing Twitter and/or Instagram. When compared to primary anesthesiology residencies, social media presence among pain fellowships is much lower. By utilizing basic social media strategies, including image-based content posting, hashtags, and videos, programs can increase their engagement with the social media community, and increase their overall number of followers, thus expanding their potential reach to prospective applicants. Although social media can be an effective tool for branding purposes, it is vital to address the safe use of social media among all trainees.

Development of a mobile ultrasound-guided peripheral nerve block and catheter service.

Ultrasound guidance is associated with improved efficiency and success of peripheral nerve blockade and a decreased incidence of vascular puncture, making these interventions safer. Patients with peripheral nerve blocks report decreased pain and increased satisfaction scores. We present the development of a mobile ultrasound-guided block service that allows for the safe and efficient placement of nerve blocks and perineural catheters at the nontraditional location of the patient's bedside and in the emergency department.

Postoperative Hyperthermia and Hemodynamic Instability in a Suspected Malignant Hyperthermia-Susceptible Patient: A Case Report.

Malignant hyperthermia (MH) is a rare but potentially fatal complication of exposure to certain anesthetic drugs. However, stress-induced MH, initially observed in pigs undergoing intense physical or emotional strain, has been reported in the absence of anesthetic exposure. In this case report, we describe a case of postoperative hyperthermia and cardiac dysfunction suspicious for stress-induced MH occurring after an endobronchial biopsy in a patient with recurrent undiagnosed fevers. We also examine our diagnosis of stress-induced MH and possible preventive measures to avoid this complication.

Ultrasound-Guided Midpoint Transverse Process to Pleura Nerve Block for Medical Thoracoscopy: A Case Report.

We performed the midpoint transverse process to pleura (MTP) block in a patient with a recurrent pleural effusion requiring medical thoracoscopy, drainage of pleural effusion, talc poudrage, and placement of tunneled pleural catheter under sedation while in the left lateral decubitus position. Forty milliliters of a combination of bupivacaine hydrochloride and lidocaine, with dexamethasone and clonidine as adjuvants, was injected at the T6 level under ultrasound guidance with satisfactory intra- and postoperative analgesia.

The use of cerebral oximetry as a monitor of the adequacy of cerebral perfusion in a patient undergoing shoulder surgery in the beach chair position.

Four cases of ischemic injury have been reported in patients undergoing orthopedic surgery in the upright position. We describe the use of cerebral oximetry as a monitor of the adequacy of cerebral perfusion in a 63-year-old woman who underwent arthroscopic rotator cuff surgery in a beach chair under general anesthesia. During positioning, a decrease in blood pressure was accompanied by a decrease in cerebral oxygen saturation (S(ct)O(2)) and was treated with phenylephrine. When spontaneous ventilation resumed, an increase in end-tidal carbon dioxide was accompanied by an increase in S(ct)O(2). Cerebral oximetry may prove useful as a guide monitor and manage nonsupine patients.

The safety and efficacy of regional anesthesia in an office-based setting.

STUDY OBJECTIVE: To determine the safety and efficacy of regional anesthesia techniques when administered in the office-based setting. DESIGN: Retrospective chart review. SETTING: Free-standing orthopedic office with an operating room suite. MEASUREMENTS: A total of 238 patients underwent 242 anesthetics. Types of anesthetics delivered were quantified. Regional anesthetics were further divided into specific nerve blocks. Times from anesthetic start to surgical start and from surgical end to anesthetic end were calculated. Adverse outcomes were ascertained and followed. MAIN RESULTS: Of the 242 anesthetics administered, 123 were peripheral nerve blocks, two were neuraxial blocks, 140 were monitored anesthesia care cases, and 17 were general anesthetics (14 Laryngeal Mask Airway cases, two mask ventilation cases, and one endotracheal intubation). The average times from anesthesia start to surgery start were as follows: monitored anesthesia cases, 19+/-7 min (median, 20 min); regional anesthesia cases, 29+/-11 min (median, 30 min); and general anesthesia cases, 31+/-11 min (median, 30 min). The average time from surgery end to anesthesia end for monitored anesthesia cases was 9+/-3 min (median, 10 min); regional anesthesia, 9+/-3 min (median, 10 min); and general anesthesia, 12+/-4 min (median, 20 min). Two transient nerve injuries occurred, both of which resolved. CONCLUSIONS: On the basis of our experience, we believe that regional anesthesia can be delivered efficiently and safely for orthopedic procedures in the office-based environment, and we encourage its wider use.

Median arcuate ligament syndrome--a novel treatment using an intrathecal morphine pump to relieve intractable visceral pain.

PURPOSE: Median arcuate ligament syndrome, which presents with intractable visceral pain, is difficult to both diagnose and treat. This case report describes the first use of an intrathecal morphine pump as an effective therapeutic intervention. CLINICAL FEATURES: We describe a 39-year-old female who presented with a four-year history of misdiagnosed debilitating abdominal pain. After multiple failed attempts at medical management and surgeries, a trial of intrathecal narcotics provided significant relief. Six months after insertion of an intrathecal morphine pump, the patient was pain-free and had resumed all activities of daily living. CONCLUSION: The use of an intrathecal narcotic pump should be considered for treatment of patients with intractable visceral pain secondary to median arcuate ligament syndrome.

The ultrasound-guided supraclavicular-interscalene (UGSCIS) block: a case report.

Providing complete anesthesia to the entire upper extremity remains challenging. We present the use of a novel, updated, regional anesthetic technique-an ultrasound-guided supraclavicular-interscalene block (UGSCIS)-to provide anesthesia and analgesia to a patient with end-stage liver disease who required fixation of a pathologic fracture of the humerus.

Provider preferences for postoperative analgesia in obese and non-obese patients undergoing ambulatory surgery.

BACKGROUND: Few guidelines exist on safe prescription of postoperative analgesia to obese patients undergoing ambulatory surgery. This study examines the preferences of providers in the standard treatment of postoperative pain in the ambulatory setting. METHODS: Providers from five academic medical centers within a single US city were surveyed from May-September 2015. They were asked to provide their preferred postoperative analgesic routine based upon the predicted severity of pain for obese and non-obese patients. McNemar's tests for paired observations were performed to compare prescribing preferences for obese vs. non-obese patients. Fisher's exact tests were performed to compare preferences based on experience: > 15 years vs. ≤15 years in practice, and attending vs. resident physicians. RESULTS: A total of 452 providers responded out of a possible 695. For mild pain, 119 (26.4%) respondents prefer an opioid for obese patients vs. 140 (31.1%) for non-obese (p = 0.002); for moderate pain, 329 (72.7%) for obese patients vs. 348 (77.0%) for non-obese (p = 0.011); for severe pain, 398 (88.1%) for obese patients vs. 423 (93.6%) for non-obese (p < 0.001). Less experienced physicians are more likely to prefer an opioid for obese patients with moderate pain: 70 (62.0%) attending physicians with > 15 years in practice vs. 86 (74.5%) with ≤15 years (p = 0.047), and 177 (68.0%) attending physicians vs. 129 (83.0%) residents (p = 0.002). CONCLUSIONS: While there is a trend to prescribe less opioid analgesics to obese patients undergoing ambulatory surgery, these medications may still be over-prescribed. Less experienced physicians reported prescribing opioids to obese patients more frequently than more experienced physicians.

Management of the patient reporting an allergy to penicillin.

Recent emphasis on the prevention of surgical wound infection has highlighted the role of the anesthesiologist as the physician responsible for administering appropriate antibiotic prophylaxis. Patients often report a distant or unclear history of penicillin allergy. Administering an antibiotic to which the patient has a true allergy can provoke a life threatening reaction. The anesthesiologist should be aware of the prevalence, severity, and manifestations of allergies to antibiotics, as well as the available alternatives. Unnecessary administration of more powerful broad-spectrum antibiotics leads to the development of antimicrobial resistance and should be avoided. It is the anesthesiologists' duty to balance these issues when selecting appropriate antibiosis.

Interscalene regional anesthesia for arthroscopic shoulder surgery: a safe and effective technique.

There has been resistance to the use of interscalene regional block for arthroscopic shoulder surgery because of concerns about potential complications and failed blocks with the subsequent need for general anesthesia. The purpose of this study was to assess whether interscalene regional block is safe and effective and offers many advantages over general anesthesia for outpatient arthroscopic shoulder surgery. Through a retrospective chart review of consecutive arthroscopic shoulder surgeries over a 2.5-year time period, in a tertiary university medical center with an anesthesiology residency, 277 interscalene blocks (96%) were successful; 12 (4%) required general anesthesia because of an inadequate block. There were no seizures, pneumothoraces, cardiac events, or other major complications. There was a 1% rate of minor complications, all of which were transient sensory neuropathies that resolved within 5 weeks on average. We conclude that interscalene block can provide effective anesthesia for arthroscopic shoulder surgery.

A survey evaluating the training of anesthesiology residents in office-based anesthesia.

STUDY OBJECTIVE: To determine the current status and future plans of residency programs to train residents in office-based anesthesiology (OBA), which is rapidly emerging as an important specialty within the field of anesthesiology. DESIGN: Survey questionnaire. SETTING: University hospital. MEASUREMENTS: A 14-question survey was sent to the 134 listed members of the Society of Academic Anesthesia Chairs/Association of Anesthesiology Program Directors to elicit the current status of educational endeavors and clinical exposure of anesthesiology residents to this type of practice. MAIN RESULTS: There were 95 respondents (72%). Fifteen (15.8%) academic anesthesiology programs provide OBA services in the community and two (2.1%) of the academic programs provide clinical exposure to their residents. CONCLUSIONS: Residents are receiving minimal, if any, exposure to OBA during their training.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial.

OBJECTIVES: To compared outcomes of regional nerve blocks with those of standard analgesics after hip fracture. DESIGN: Multisite randomized controlled trial from April 2009 to March 2013. SETTING: Three New York hospitals. PARTICIPANTS: Individuals with hip fracture (N = 161). INTERVENTION: Participants were randomized to receive an ultrasound-guided, single-injection, femoral nerve block administered by emergency physicians at emergency department (ED) admission followed by placement of a continuous fascia iliaca block by anesthesiologists within 24 hours (n = 79) or conventional analgesics (n = 82). MEASUREMENTS: Pain (0-10 scale), distance walked on Postoperative Day (POD) 3, walking ability 6 weeks after discharge, opioid side effects. RESULTS: Pain scores 2 hours after ED presentation favored the intervention group over controls (3.5 vs 5.3, P = .002). Pain scores on POD 3 were significantly better for the intervention than the control group for pain at rest (2.9 vs 3.8, P = .005), with transfers out of bed (4.7 vs 5.9, P = .005), and with walking (4.1 vs 4.8, P = .002). Intervention participants walked significantly further than controls in 2 minutes on POD 3 (170.6 feet, 95% confidence interval (CI) = 109.3-232 vs 100.0 feet, 95% CI = 65.1-134.9; P = .04). At 6 weeks, intervention participants reported better walking and stair climbing ability (mean Functional Independence Measure locomotion score of 10.3 (95% CI = 9.6-11.0) vs 9.1 (95% CI = 8.2-10.0), P = .04). Intervention participants were significantly less likely to report opioid side effects (3% vs 12.4%, P = .03) and required 33% to 40% fewer parenteral morphine sulfate equivalents. CONCLUSION: Femoral nerve blocks performed by emergency physicians followed by continuous fascia iliaca blocks placed by anesthesiologists are feasible and result in superior outcomes.

Interscalene regional anesthesia for shoulder surgery.

BACKGROUND: Despite a trend toward the use of regional anesthesia for orthopaedic procedures, there has been resistance to the use of interscalene regional block for shoulder surgery because of concerns about failed blocks and potential complications. METHODS: We retrospectively reviewed the cases of 568 consecutive patients who had shoulder surgery under interscalene regional block in a tertiary-care, university-based practice with an anesthesiology residency program. The blocks were performed by a group of anesthesiologists who were dedicated to the concept of regional anesthesia in their practice. Complete anesthetic and orthopaedic records were available for 547 patients. The surgical procedure, planned type of anesthesia, occurrence of block failure, and the presence of complications were noted. RESULTS: Of the 547 patients, 295 underwent an arthroscopic procedure and 252 (including eighty who had an arthroplasty) underwent an open procedure. General anesthesia was the initial planned choice for sixty-nine patients because of the complexity or duration of the procedure, the anatomic location, or patient insistence. Thirty-four of the sixty-nine patients also received an interscalene regional block. Interscalene regional block alone was planned for 478 patients. A total of 462 patients (97%) had a successful block whereas sixteen required general anesthesia because the block was inadequate. The success of the block was independent of the type or length of the surgery. No patient had a seizure, pneumothorax, cardiac event, or other major complication. Twelve (2.3%) of the 512 patients who had a block had minor complications, which included sensory neuropathy in eleven patients and a complex regional pain syndrome that resolved at three months in one patient. For ten of the eleven patients, the neuropathy had resolved by six months. CONCLUSIONS: Interscalene regional block provides effective anesthesia for most types of shoulder surgery, including arthroplasty and fracture fixation. When administered by an anesthesiologist committed to and skilled in the technique, the block has an excellent rate of success and is associated with a relatively low complication rate.