Empirical guide to a safe thoracic paravertebral block based on dimensions of paravertebral space when ultrasound visualization is challenging.

Although ultrasound (US) guidance is the mainstay technique for performing thoracic paravertebral blocks, situations arise when US imaging is limited due to subcutaneous emphysema or extremely deep structures. A detailed understanding of the anatomical structures of the paravertebral space can be strategic to safely and accurately perform a landmark-based or US-assisted approach. As such, we aimed to provide an anatomic roadmap to assist physicians. We examined 50 chest CT scans, measuring the distances of the bony structures and soft-tissue surrounding the thoracic paravertebral block at the 2nd/3rd (upper), 5th/6th (middle), and 9th/10th (lower) thoracic vertebral levels. This review of radiology records controlled for individual differences in body mass index, gender, and thoracic level. Midline to the lateral aspect of the transverse process (TP), the anterior-to-posterior distance of TP to pleura, and rib thickness range widely based on gender and thoracic level. The mean thickness of the TP is 0.9±0.1 cm in women and 1.1±0.2 cm in men. The best target for initial needle insertion from the midline (mean length of TP minus 2 SDs) distance would be 2.5 cm (upper thoracic)/2.2 cm (middle thoracic)/1.8 cm (lower thoracic) for females and 2.7 cm (upper)/2.5 cm (middle)/2.0 cm (lower thoracic) for males, with consideration that the lower thoracic region allows for a lower margin of error in the lateral dimension because of shorter TP. There are different dimensions for the key bony landmarks of a thoracic paravertebral block between males and females, which have not been previously described. These differences warrant adjustment of landmark-based or US-assisted approach to thoracic paravertebral space block for male and female patients.

Incidence of acute compartment syndrome with routine use of regional anesthesia for patients with long bone fractures: a large single-center retrospective review from a level I trauma tertiary academic institution.

INTRODUCTION: Traditionally, using peripheral nerve blocks (PNBs) in patients with long bone fractures has been limited due to concerns that it may interfere with the timely diagnosis of acute compartment syndrome (ACS). However, our large academic institution and level I trauma center have been using regional anesthesia routinely for pain management of patients with long bone fractures for more than a decade, with strict adherence to a comprehensive management protocol. The aim of this retrospective review is to present our experience with this practice. METHODS: Following Institutional Review Board approval, we performed a retrospective chart review of patients with long bone fractures and ACS over a 10-year period (2008-2018). RESULTS: 26 537 patients were included in the review. Approximately 20% of these patients required surgery, and 91.5% of surgically treated patients received regional anesthesia. The incidence of ACS in our cohort was 0.1% or 1.017 per 1000 patients with long bone fractures. CONCLUSION: Current recommendations on using PNBs in patients at risk for ACS have been mainly based on expert opinion and dated case reports. Due to the nature of the condition, prospective data are lacking. Our large observational dataset evaluated the risk of missing or delaying ACS diagnosis when PNBs were offered for trauma patients and demonstrated a relatively low incidence of ACS despite the routine use of PNBs under strictly protocolized conditions when patients were managed by a dedicated multidisciplinary care team.

Comparing Spinal Chloroprocaine to Hyperbaric and Isobaric Bupivacaine for Total Hip and Knee Arthroplasties: A Retrospective Study.

INTRODUCTION: Spinal anesthesia is commonly used for total knee and hip arthroplasties (TKA/THA). The rising popularity of ambulatory TKA and THAs require anesthetic techniques that provide rapid recovery of motor and sensory function while minimizing side effects like postoperative urinary retention. This single-center retrospective observational study compares the recovery profile of patients undergoing TKA and THA under chloroprocaine spinals compared to hyperbaric and isobaric bupivacaine spinals. METHODS: One hundred and twelve patients undergoing primary TKA and THA under spinal anesthesia at University of Florida Health were identified between September 1, 2019 and February 21, 2020. Their electronic medical records were reviewed. Patients were categorized based on the local anesthetic used in the spinal. Various demographic, intraoperative, and postoperative data were compiled and compared, including duration of surgery, time to physical therapy, time to post-anesthesia care unit (PACU) discharge, and time to spontaneous micturition. RESULTS: Time to spontaneous micturition and PACU discharge were significantly lower in the chloroprocaine spinal group compared to the hyperbaric bupivacaine group by 193 minutes and 42 minutes, respectively. Fewer patients receiving chloroprocaine spinals had their first physical therapy session limited by residual motor weakness compared to those in both bupivacaine groups. Additionally, mean duration of surgery was shorter in the chloroprocaine group compared to both bupivacaine groups (89 minutes compared to 111 minutes). Time to physical therapy completion was not different. All groups had <10% conversion to general anesthesia. CONCLUSION: Chloroprocaine spinals can be feasible options for TKAs and THAs with improved postoperative recovery profiles compared to bupivacaine spinals.

Gastric Emptying of Orange Juice With and Without Pulp: A Point-of-Care Ultrasound Study.

Purpose The American Society of Anesthesiologists (ASA) preoperative fasting recommendations regarding fruit juice with pulp is unclear. In addition, it is debatable whether orange juice without pulp should be treated as a clear liquid. Our objective is to determine the gastric emptying time of orange juice with and without pulp. Methods This is an observational study of gastric emptying time using point-of-care ultrasound (POCUS). Thirty-five adult volunteers were enrolled in this study. Exclusion criteria included pregnancy, diabetes, body mass index > 40 kg/m2, previous lower esophageal or upper abdominal surgery, hiatal hernia, and upper gastrointestinal bleed. The study was carried out on three separate days for each volunteer. After fasting a minimum of 8 h, the volunteers were asked to drink 240 ml of water on day 1, orange juice without pulp on day 2, and orange juice with pulp on day 3. Gastric volumes were estimated using gastric antrum cross-sectional area at fasting state, and then 30, 60, 90 120, 180, and 240 min after drinking until the gastric volume returned to baseline. Results A gastric volume of 1.5 mL/kg was defined as a baseline. All subjects' gastric volume returned to baseline 90 min after drinking water. More than 97% of the subjects who drank orange juice without pulp and 93.9% of the subjects who drank orange juice with pulp reached a gastric volume of less than 1.5 mL/kg after 2 h. All subjects' gastric volume returned to baseline 3 h after drinking orange juice with pulp. Conclusions Orange juice without pulp can be treated as a clear liquid in a majority of patients who do not have conditions that would cause delayed gastric emptying. Orange juice with pulp required 3 h to empty.

Development of entrustable professional activities for regional anesthesia and pain medicine fellowship training.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) offers descriptions of competencies and milestones but does not provide standardized assessments to track trainee competency. Entrustable professional activities (EPAs) and special assessments (SAs) are emerging methods to assess the level of competency obtained by regional anesthesiology and acute pain medicine (RAAPM) fellows. METHODS: A panel of RAAPM physicians with experience in education and competency assessment and one medical student were recruited to participate in a modified Delphi method with iterative rounds to reach consensus on: a list of EPAs, SAs, and procedural skills; detailed definitions for each EPA and SA; a mapping of the EPAs and SAs to the ACGME milestones; and a target level of entrustment for graduating US RAAPM fellows for each EPA and procedural skill. A gap analysis was performed and a heat map was created to cross-check the EPAs and SAs to the ACGME milestones. RESULTS: Participants in EPA and SA development included 19 physicians and 1 medical student from 18 different programs. The Delphi rounds yielded a final list of 23 EPAs, a defined entrustment scale, mapping of the EPAs to ACGME milestones, and graduation targets. A list of 73 procedural skills and 7 SAs were similarly developed. DISCUSSION: A list of 23 RAAPM EPAs, 73 procedural skills, and 7 SAs were created using a rigorous methodology to reach consensus. This framework can be utilized to help assess RAAPM fellows in the USA for competency and allow for meaningful performance feedback.

Role of an Intercostobrachial Nerve Block in Alleviating Tourniquet Pain: A Randomized Clinical Trial.

Introduction Tourniquet pain may have cutaneous and ischemic components. It is questionable whether blockade of a sensory nerve will help reduce ischemic pain. In addition, complete anesthesia of the axilla in the intercostobrachial nerve (ICBN) distribution is challenging to execute, and ICBN blockade has an inherently higher failure rate because of its variable anatomic location and source of innervation. We sought to determine the utility of an ICBN block for the prevention of tourniquet pain. Methods We conducted a single-center randomized controlled trial at a major academic medical center involving patients scheduled to undergo distal upper extremity surgery under ultrasound-guided supraclavicular brachial plexus block. Forty patients were randomized to receive an additional ICBN block or no ICBN block, with 22 allocated to the intervention and 18 to control. We collected data on the incidence of tourniquet pain and systemic anesthetic requirements. Results Initial contingency analysis examining the relationship between ICBN block placement and the development of pain using the two-tailed Fisher exact test failed to show that the presence or absence of ICBN block was associated with the development of tourniquet pain. χ2 analysis failed to show that tourniquet time was significantly related to the development of tourniquet pain. Conclusions The overall incidence of tourniquet pain in the setting of a dense supraclavicular brachial plexus block for surgical anesthesia was low even without an ICBN block and even with tourniquet times greater than 90 min. Tourniquet pain was easily managed with small amounts of systemic analgesics.

Efficacy of Phrenic Nerve Catheter in Ipsilateral Shoulder Pain After Thoracic Surgery.

The mechanism of ipsilateral shoulder pain (ISP) after thoracic surgery remains unexplained definitively in the literature. Regional techniques targeting specific nerves more precisely will provide practitioners with a better understanding of the pain source. We report the case of a 51-year-old woman who underwent robotic-assisted plication of the right hemidiaphragm. ISP was adequately managed using a low-volume infusion through a continuous phrenic nerve block in addition to a thoracic epidural for her chest pain. ISP after thoracic surgery likely originates from diaphragm manipulation. Phrenic nerve blockade is a successful strategy that does not worsen subjective dyspnea in this setting.

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps.

Objective: In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting: Expert commentary. Methods: Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions: Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

Total Laparoscopic Hysterectomy Under Regional Anesthesia.

BACKGROUND: Laparoscopic hysterectomies comprise a large proportion of all hysterectomies in the United States. Procedures completed under regional anesthesia pose a number of benefits to patients, but laparoscopic hysterectomies traditionally have been performed under general anesthesia. We describe a case of total laparoscopic hysterectomy under epidural anesthesia with the patient fully awake. CASE: A 51-year-old woman with abnormal uterine bleeding underwent an uncomplicated total laparoscopic hysterectomy, bilateral salpingectomy, and excision of endometriosis. The procedure was completed under epidural anesthesia without intravenous sedation or systemic narcotics. Pneumoperitoneum with a pressure of 12 mm Hg and Trendelenburg to 15° allowed for adequate visualization. Anesthesia was achieved with midthoracic and low lumbar epidural catheters. Bilevel positive airway pressure was used for augmentation of respiratory function. CONCLUSION: With a committed patient, adequate planning, and knowledge of the potential intraoperative complications, regional anesthesia is an option for select women undergoing laparoscopic hysterectomy.

Goals and Objectives to Optimize the Value of an Acute Pain Service in Perioperative Pain Management.

As newer pharmacologic and procedural interventions, technology, and data on outcomes in pain management are becoming available, effective acute pain management will require a dedicated Acute Pain Service (APS) to help determine the most optimal pain management plan for the patients. Goals for pain management must take into consideration the side effect profile of drugs and potential complications of procedural interventions. Multiple objective optimization is the combination of multiple different objectives for acute pain management. Simple use of opioids, for example, can reduce all pain to minimal levels, but at what cost to the patient, the medical system, and to public health as a whole? Many models for APS exist based on personnel's skills, knowledge and experience, but effective use of an APS will also require allocation of time, space, financial, and personnel resources with clear objectives and a feedback mechanism to guide changes to acute pain medicine practices to meet the constantly evolving medical field. Physician-based practices have the advantage of developing protocols for the management of low-variability, high-occurrence scenarios in addition to tailoring care to individual patients with high-variability, low-occurrence scenarios. Frequent feedback and data collection/assessment on patient outcomes is essential in evaluating the efficacy of the Acute Pain Service's intervention in improving patient outcomes in the acute and perioperative setting.

Cancer Recurrence and Regional Anesthesia: The Theories, the Data, and the Future in Outcomes.

OBJECTIVE: More than one million people each year in the United States are diagnosed with cancer. Surgery is considered curative, but the perioperative phase represents a vulnerable period for residual disease to spread. Regional anesthesia has been proposed to reduce the incidence of recurrence by attenuating the sympathetic nervous system's response during surgery, reducing opioid requirements thus diminishing their immunosuppressant effects, and providing antitumor and anti-inflammatory effects directly through systemic local anesthetic action. In this article, we present a description of the perioperative period, a summary of the proposed hypotheses and available literature on the effects of regional anesthesia on cancer recurrence, and put regional anesthesia in context in regard to its potential role in reducing cancer recurrence during the perioperative period. METHODS: A literature review was conducted through PubMed by examining the following topics: effects of surgery on tumor progression, roles of multiple perioperative variables (analgesics, hypothermia, blood transfusion, beta-blockade) in cancer recurrence, and available in vitro, animal, and human studies regarding the effects of regional anesthesia on cancer recurrence. RESULTS: in vitro, animal and human retrospective studies suppport the hypothesis that in certain types of cancer, regional anesthesia may be associated with lower recurrence rates. A few well-planned human randomized clinical trials are currently under way that may provide more solid evidence to substantiate or refute the benefits of regional anesthesia in reducing cancer recurrence. CONCLUSIONS: The benefits of regional anesthesia in reducing cancer recurrence have a sound theoretical basis and, in certain cancers, are supported by the existing body of literature. This article outlines the current state of our knowledge on the relationship between cancer progression and regional analgesia.

Stellate ganglion local anesthetic blockade and neurolysis for the treatment of refractory ventricular fibrillation.

Electrical storm (ES) is a syndrome characterized by recurrent ventricular fibrillation or tachycardia. It is a major clinical challenge and is often unresponsive to conventional drug therapy; instead, its treatment requires multiple attempts at electrical defibrillation. Sympathetic hyperactivity is an important modulator of ventricular arrhythmias, including ES. We report a case of ES treated safely and effectively with pharmacologic sympathectomy involving diagnostic continuous stellate ganglion blockade with local anesthetic followed by therapeutic neurolysis. This technique reduced ES in a patient for whom conservative medical and interventional procedures were ineffective.

Clinically derived early postoperative pain trajectories differ by age, sex, and type of surgery.

The objective of this study was to determine the effects of age, sex, and type of surgery on postoperative pain trajectories derived in a clinical setting from pain assessments in the first 24 hours after surgery. This study is a retrospective cohort study using a large electronic medical records system to collect and analyze surgical case data. The sample population included adult patients undergoing nonambulatory nonobstetric surgery in a single institution over a 1-year period. Analyses of postoperative pain trajectories were performed using a linear mixed-effects model. Pain score observations (91,708) from 7293 patients were included in the statistical analysis. On average, the pain score decreased about 0.042 (95% confidence interval [CI]: -0.044 to -0.040) points on the numerical rating scale (NRS) per hour after surgery for the first 24 postoperative hours. The pain score reported by male patients was approximately 0.27 (95% CI: -0.380 to -0.168) NRS points lower than that reported by females. Pain scores significantly decreased over time in all age groups, with a slightly more rapid decrease for younger patients. Pain trajectories differed by anatomic location of surgery, ranging from -0.054 (95% CI: -0.062 to -0.046) NRS units per hour for integumentary and nervous surgery to -0.104 (95% CI: -0.110 to -0.098) NRS units per hour for digestive surgery, and a positive trajectory (0.02 [95% CI: 0.016 to 0.024] NRS units per hour) for musculoskeletal surgery. Our data support the important role of time after surgery in considering the influence of biopsychosocial and clinical factors on acute postoperative pain.

The insiders' experiences with continuous transversus abdominis plane blocks for analgesia after cesarean delivery.

OBJECTIVE: Transversus abdominis plane blocks have been recently utilized for analgesia after cesarean delivery. However, little data concerning continuous transversus abdominis plane blocks has been reported in the existing literature. Available studies mainly examine the efficacy of single-injection blocks, and only one small case series has been published regarding continuous blocks for analgesia after cesarean delivery. First-hand experiences and observations of three acute pain medicine specialists who received a continuous transversus abdominis plane block for analgesia after cesarean delivery are presented. SETTINGS AND PATIENTS: Three physicians specialized in acute and perioperative pain medicine personally underwent continuous transversus abdominis plane block placements for analgesia after cesarean delivery via a disposable infusion pump at the same teaching hospital. RESULTS: In a very motivated, well-supported, and informed patient after uncomplicated cesarean delivery, the use of continuous transversus abdominis plane blocks for analgesia offers the significant advantages of early functional recovery and excellent prolonged analgesia. CONCLUSION: The patients experienced postoperative continuous transversus abdominis plane blocks that seem to be of value in limiting opiate use and improving analgesia with daily activities in the acute postoperative phase after cesarean delivery.

Recovery after orthopedic surgery: techniques to increase duration of pain control.

PURPOSE OF REVIEW: Ambulatory surgery continues to expand in scope and volume. Part of this development is supported by improvements in anesthesia care, especially in the realm of postoperative analgesia, which is often outlasted by the pain. The purpose of this review is to outline methods of increasing the duration of postoperative pain control. RECENT FINDINGS: There have been recent advances in the use of perineural catheters for the performance of continuous nerve blocks, the use of adjuvants to extend the duration of single dose blocks, methods to improve the technical performance of blocks, systemic multimodal analgesia, and novel or experimental agents. SUMMARY: The ideas and findings described in this review are taken from the most recent literature and show promise of aiding in the continued improvement of patient care through their dissemination and refinement by further research. Of the modalities reviewed in current use, the continuous perineural catheter combined with systemic multimodal analgesics represents the best combination of safety and efficacy to provide prolonged postoperative analgesia.

Regional anesthesia as compared with general anesthesia for surgery in geriatric patients with hip fracture: does it decrease morbidity, mortality, and health care costs? Results of a single-centered study.

INTRODUCTION: Hip fracture in geriatric patients has a substantial economic impact and represents a major cause of morbidity and mortality in this population. At our institution, a regional anesthesia program was instituted for patients undergoing surgery for hip fracture. This retrospective cohort review examines the effects of regional anesthesia (from mainly after July 2007) vs general anesthesia (mainly prior to July 2007) on morbidity, mortality and hospitalization costs. METHODS: This retrospective cohort study involved data collection from electronic and paper charts of 308 patients who underwent surgery for hip fracture from September 2006 to December 2008. Data on postoperative morbidity, in-patient mortality, and cost of hospitalization (as estimated from data on hospital charges) were collected and analyzed. Seventy-three patients received regional anesthesia and 235 patients received general anesthesia. During July 2007, approximately halfway through the study period, a regional anesthesia and analgesia program was introduced. RESULTS: The average cost of hospitalization in patients who received surgery for hip fracture was no different between patients who receive regional or general anesthesia ($16,789 + 631 vs $16,815 + 643, respectively, P = 0.9557). Delay in surgery and intensive care unit (ICU) admission resulted in significantly higher hospitalization costs. Age, male gender, African American race and ICU admission were associated with increased in-hospital mortality. In-hospital mortality and rates of readmission are not statistically different between the two anesthesia groups. CONCLUSIONS: There is no difference in postoperative morbidity, rates of rehospitalization, in-patient mortality or hospitalization costs in geriatric patients undergoing regional or general anesthesia for repair of hip fracture. Delay in surgery beyond 3 days and ICU admission both increase cost of hospitalization.

Continuous peripheral nerve blockade for postoperative analgesia.

PURPOSE OF REVIEW: To review the recent literature involving the use of continuous peripheral nerve sheath catheters in the management of postoperative pain. RECENT FINDINGS: Continuous peripheral nerve blocks provide superior analgesia and are associated with fewer opioid-induced side effects for patients undergoing extremity surgery. Ultrasound technology is being used with increasing frequency to guide the placements of continuous peripheral nerve blocks. The evidence is still equivocal regarding the superiority of stimulating versus nonstimulating catheters for the delivery of continuous peripheral nerve blockade. The incidence of major complications associated with continuous peripheral nerve blocks is very low and probably no different from single injection peripheral nerve blocks. SUMMARY: Continuous peripheral nerve blocks are an excellent additional modality to compliment other multimodal analgesics to control moderate to severe postoperative pain.