Factors influencing hospital implementation of acute pain management practice guidelines.

STUDY OBJECTIVE: To identify factors that may influence the implementation of acute pain management guidelines in hospital settings. DESIGN: Two questionnaire surveys. SETTING: Healthcare Association of New York State, Albany, NY. MEASUREMENT: The surveys were administered to 220 hospitals in New York State regarding their acute pain management practices and resources available. One survey was addressed to each hospital's chief executive officer (CEO) and the second survey was addressed to the clinical director of the Department of Anesthesiology or Acute Pain Service. The barriers and incentives to guideline implementation identified by CEOs were analyzed using factor analysis. Logistic regression was employed to determine predictors of guideline implementation by linking the CEOs' survey data with the clinical directors' report of guideline usage. MAIN RESULTS: According to clinical directors, only 27% of the responding hospitals were using a published pain management practice guideline. Factors predictive of guideline implementation include resource availability and belief in the benefits of using guidelines to improve quality of care or to achieve economic/legal advantages. Guideline implementation, however, does not necessarily include applying all key elements recommended by the federal Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research) guideline. For example, a collaborative, interdisciplinary approach to pain control was used in only 42% of the hospitals, and underutilization of nonpharmacologic therapies to control pain was widespread. Resource availability, particularly staff with expertise in pain management and existence of a formal quality assurance program to monitor pain management, was significantly predictive of compliance with key guideline elements. CONCLUSIONS: Resource availability significantly influences the implementation of pain management practice guidelines in hospital settings. Implementation is often incomplete because various factors affect the feasibility of individual guideline elements and may explain the varying results that guidelines have had on clinical practices.

Perisciatic injection of steroid for the treatment of sciatica due to piriformis syndrome.

BACKGROUND AND OBJECTIVES: Piriformis syndrome causing sciatica is sometimes refractory to conventional treatments including physical therapy, piriformis injections, and even caudal epidural steroid injections. Surgical release of the piriformis muscle has been described for difficult cases of piriformis syndrome, but is occasionally accompanied by morbidity. Another approach to treating piriformis syndrome is presented. METHODS: A perisciatic injection of steroid using simple landmarks and utilizing a nerve stimulator to locate and inject near the sciatic nerve and into the piriformis muscle is described. RESULTS: Six patients that did not respond to conventional treatments, but did respond to perisciatic steroid injections are presented. CT scan, in one of the patients, confirmed correct needle placement when this technique and landmarks were used. CONCLUSION: Patients with piriformis syndrome who were refractory to conventional treatments but responded to perisciatic injections of steroid are presented.

Femoral and genitofemoral nerve blocks versus spinal anesthesia for outpatients undergoing long saphenous vein stripping surgery.

Long saphenous vein stripping (LSVS) surgery is often used to treat varicose veins. We tested the hypothesis that femoral nerve block (FNB) with genitofemoral nerve infiltration provides sufficient analgesia and superior recovery characteristics to spinal anesthesia for LSVS procedures in the ambulatory setting. Thirty-six patients were randomized to receive FNB with 30 mL of 3% alkalinized chloroprocaine, and 32 patients received spinal anesthesia with 65 mg of 5% hyperbaric lidocaine. Data collected included patient demographics, time required for induction of and recovery from anesthesia, postoperative anesthesia complications, and patient report of pain severity after the operation. During a follow-up call, a blinded observer noted the onset of any complications, the requirement for analgesics, and the patients' satisfaction with the anesthetic technique. Patients in the FNB group had significantly faster recovery (P < 0.01) and lower incidences of pain (P < 0.05) and complications (P < 0.05) than the patients in the spinal group. All patients who received FNB indicated that they would choose this type of anesthesia in the future, whereas five (15%) patients in the spinal group would refuse spinal anesthesia in the future (P < 0.01). We conclude that FNB is an excellent anesthetic choice for LSVS.

A common epineural sheath for the nerves in the popliteal fossa and its possible implications for sciatic nerve block.

Sciatic nerve block in the popliteal fossa is associated with a highly variable success rate. Frequently, anesthesia is profound in the distribution of both the tibial (TN) and common peroneal nerves (CPN), although the response to nerve stimulation or paresthesia is obtained in the distribution of one division of the nerve. However, anesthesia in the distribution of only one division of the nerve is also a common occurrence under apparently identical clinical circumstances. Looking for a possible role of a common epineural sheath in these phenomena, we injected dye into the epineural sheath of the tibial nerve in 10 cadaver legs and observed its spread within the sheath. Injections of 15 mL and 30 mL of the dye resulted in a proximal spread of 147 +/- 34 mm and 172 +/- 50 mm, respectively, from the injection point 10 cm below the popliteal fossa crease. In a majority of the legs, the dye reached the division of the sciatic nerve in the popliteal fossa, bathing both the TN and CPN. Gross inspection and histologic examination of the sciatic nerve specimens revealed a common epineural sheath enveloping the TN and CPN. The presence of the common epineural sheath and its characteristics may have important clinical implications for sciatic nerve blockade in the popliteal fossa.

Anatomic considerations for sciatic nerve block in the popliteal fossa through the lateral approach.

BACKGROUND AND OBJECTIVES: The disadvantage of the classic posterior approach to block of the sciatic nerve at the knee level (popliteal nerve block [PNB]) is the need to position a patient in the prone position for performance of the block. In this study on cadavers, a lateral approach to the popliteal nerve in the supine position was investigated, and some anatomic considerations of relevance to popliteal nerve block were addressed. METHODS: In 19 cadaver right legs, the lateral approach to PNB was simulated with a needle, introduced in the groove between the biceps femoris and vastus lateralis muscles 7 cm above the knee, at either 30 degrees or 60 degrees relative to the horizontal plane, and 1 mL of dye solution was injected through the needle. After dissection of the popliteal fossa, the position of the solidified bolus of dye in relation to the popliteal nerve was determined. Additionally, the dye was injected into the popliteal nerve sheath, and the spread of the dye and continuity of the sheaths were determined. RESULTS: In 10 legs, the lateral approach was attempted at a 30 degrees angle and in 9 legs at a 60 degrees angle. The solidified injectates at 30 degrees were closely distributed anterolaterally to the nerve, while injectates at 60 degrees tended to be further from the nerve and scattered along its posterolateral aspect (P = .02). The dye injected into the nerve sheaths traveled 5 to 10 cm within the sheath, surrounding both main divisions of the popliteal nerve, the tibial and the common peroneal nerve. CONCLUSION: A lateral approach to the popliteal nerve with insertion of the needle at a 30 degrees angle relative to the horizontal plane results in predictable approximation of the needle tip to the popliteal nerve. The results also suggest the existence of a continuous neural sheath encompassing the popliteal nerve and its main branches. This may have clinical implications similar to those in perivascular neuronal block.

C5a and thromboxane generation associated with pulmonary vaso- and broncho-constriction during protamine reversal of heparin.

The authors conducted a study in humans to determine the mediators associated with acute pulmonary vaso- and broncho-constriction occurring episodically with protamine reversal of heparin anticoagulation. Of 48 adult patients investigated prospectively after termination of cardiopulmonary bypass, two presented a sudden increase of airway pressure, acute pulmonary hypertension, and systemic hypotension 1-3 min after right atrial protamine injection. In these two subjects, plasma levels of C5a increased from 0.7 and 2.2 to 9.8 and 9.9 ng/ml, respectively, and thromboxane B2 increased from 0.26 and 0.34 to 7.5 and 16.2 ng/ml 1 minute after drug injection. A third subject not identified prospectively had an identical reaction and mediator profile (C5a, 10.2 ng/ml; TxB2, 18.6 ng/ml at 1 min). The plasma levels of these mediators were unchanged in the remaining patients (C5a, 0.7 +/- 1.1 [x +/- S.D.] to 0.6 +/- 0.9 ng/ml; TxB2, 0.16 +/- 0.12 to 0.15 +/- 0.07 ng/ml). Plasma histamine was not involved in this type of reaction, but increased from 0.7-10.4 ng/ml in a fourth patient who became hypotensive without acute pulmonary hypertension, bronchoconstriction, or elevation of C5a or TxB2. The authors' data indicate that the generation of high plasma levels of C5a anaphylatoxins and thromboxane is associated with pulmonary vaso- and broncho-constriction induced by protamine reversal of heparin in humans.