Antisynthetase Syndrome with Severe Interstitial Lung Disease in Pregnancy.

Antisynthetase syndrome is a rare multisystem autoimmune disorder which clinically manifests with myositis, arthritis, interstitial lung disease, Raynaud phenomenon, and skin hyperkeratosis. Lung involvement represents the most severe form of disease and has rarely been reported in pregnancy. We present the case of a 22-year-old woman with antisynthetase syndrome and severe restrictive pulmonary disease who experienced a successful pregnancy and delivery. We discuss anesthetic considerations and highlight the importance of a multidisciplinary team approach in caring for parturients with multifactorial medical conditions.

Multimodal Analgesia Decreases Postoperative Opioid Consumption in Living Liver Donation.

OBJECTIVE: To evaluate the effects of multimodal analgesia on postoperative opioid consumption and perioperative pain management in patients undergoing living liver donation. METHODS: A retrospective study was conducted of 129 patients who underwent living liver donation between 2006 and 2015. Patients were separated into 2 cohorts, pre-multimodal analgesia and multimodal analgesia, to allow intergroup analysis. All patients received an intrathecal opioid injection and underwent donor hepatectomy. Primary outcome data compared opioid consumption in oral morphine equivalents for postoperative days (PODs) 0 to 4 between the cohorts. Secondary outcomes compared yearly averaged cumulative opioid consumption on PODs 0 to 4 in oral morphine equivalents; yearly averaged numeric rating scale pain scores; hospital length of stay; and percentage of patients receiving intravenous ketorolac, ketamine, or transversus abdominis plane blocks. RESULTS: For PODs 0 to 4, a 50% reduction in overall opioids administered postoperatively (359 mg vs 179 mg; P<.01) was observed in the multimodal analgesia cohort, whereas no significant difference was found in year-to-year average postoperative pain scores (4.5 vs 3.6). The proportion of patients receiving ketorolac increased to more than 90% by 2013. More than 40% of all patients in the multimodal analgesia group received a perioperative regimen of acetaminophen, gabapentin, ketamine, and transverse abdominal plane blocks (0% in pre-multimodal analgesia). Mean hospital length of stay was reduced from 7.7 to 6.6 days (P<.01). CONCLUSION: Implementation of multimodal analgesia to manage perioperative pain in living liver donation resulted in a 50% reduction of postoperative opioid consumption. Clinically satisfactory average pain scores were maintained for PODs 0 to 4.

Ultrasound-Guided Local Anesthetic Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (IPACK) Block for Primary Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials.

Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; low-quality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.

Intrathecal Morphine versus Intrathecal Hydromorphone for Analgesia after Cesarean Delivery: A Randomized Clinical Trial.

BACKGROUND: Intrathecal opioids are routinely administered during spinal anesthesia for postcesarean analgesia. The effectiveness of intrathecal morphine for postcesarean analgesia is well established, and the use of intrathecal hydromorphone is growing. No prospective studies have compared the effectiveness of equipotent doses of intrathecal morphine versus intrathecal hydromorphone as part of a multimodal analgesic regimen for postcesarean analgesia. The authors hypothesized that intrathecal morphine would result in superior analgesia compared with intrathecal hydromorphone 24 h after delivery. METHODS: In this single-center, double-blinded, randomized trial, 138 parturients undergoing scheduled cesarean delivery were randomized to receive 150 µg of intrathecal morphine or 75 µg of intrathecal hydromorphone as part of a primary spinal anesthetic and multimodal analgesic regimen; 134 parturients were included in the analysis. The primary outcome was the numerical rating scale score for pain with movement 24 h after delivery. Static and dynamic pain scores, nausea, pruritus, degree of sedation, and patient satisfaction were assessed every 6 h for 36 h postpartum. Total opioid consumption was recorded. RESULTS: There was no significant difference in pain scores with movement at 24 h (intrathecal hydromorphone median [25th, 75th] 4 [3, 5] and intrathecal morphine 3 [2, 4.5]) or at any time point (estimated difference, 0.5; 95% CI, 0 to 1; P = 0.139). Opioid received in the first 24 h did not differ between groups (median [25th, 75th] oral morphine milligram equivalents for intrathecal hydromorphone 30 [7.5, 45.06] vs. intrathecal morphine 22.5 [14.0, 37.5], P = 0.769). From Kaplan-Meier analysis, the median time to first opioid request was 5.4 h for hydromorphone and 12.1 h for morphine (log-rank test P = 0.200). CONCLUSIONS: Although the hypothesis was that intrathecal morphine would provide superior analgesia to intrathecal hydromorphone, the results did not confirm this. At the doses studied, both intrathecal morphine and intrathecal hydromorphone provide effective postcesarean analgesia when combined with a multimodal analgesia regimen.

Ultrasound-Assisted Combined Spinal-Epidural Anesthesia for Cesarean Delivery in a Parturient With Currarino Triad: A Case Report.

Currarino triad is a rare hereditary condition characterized by anorectal malformation, sacral dysgenesis, and a presacral mass. Neuraxial anesthetic techniques pose increased risks to patients with spinal malformations. Ultrasound imaging improves accuracy of intervertebral level identification compared to clinical estimation. We present the case of a parturient with Currarino triad and a low conus medullaris undergoing cesarean delivery where preprocedural magnetic resonance imaging and ultrasound imaging allowed for successful combined spinal-epidural anesthesia to be performed. Despite these measures, however, the patient did develop a high spinal and temporary postoperative dizziness.

Acute Benefits After Liposomal Bupivacaine Abdominal Wall Blockade for Living Liver Donation: A Retrospective Review.

OBJECTIVE: To investigate whether the addition of liposomal bupivacaine abdominal wall blocks to a multimodal analgesic regimen improves postoperative numeric rating scale pain scores and reduces opioid consumption in patients undergoing living liver donation. PATIENTS AND METHODS: We conducted a single-center, retrospective review of patients who underwent living liver donation from January 1, 2011, through February 19, 2016, and received multimodal analgesia with (block group) or without (control group) abdominal wall blockade. The block solution consisted of liposomal bupivacaine (266 mg) mixed with 30 mL of 0.25% bupivacaine. Both groups received intrathecal hydromorphone. Main outcome measures were pain scores, opioid requirements, time to full diet, and bowel activity. RESULTS: Postoperative day 0 pain scores were significantly better in the block group (n=29) than in the control group (n=48) (2.4 vs 3.5; P=.002) but were not significantly different on subsequent days. Opioid requirements were significantly decreased for the block group in the postanesthesia care unit (0 vs 9 mg oral morphine equivalents; P=.002) and on postoperative day 0 (7 vs 18 mg oral morphine equivalents; P=.004). Median (interquartile range) time to full diet was 23 hours (14-30 hours) in the block group and 38 hours (24-53 hours) in the control group (P=.001); time to bowel activity was also shorter in the block group (45 hours [38-73 hours] vs 67 hours [51-77 hours]; P=.01). CONCLUSION: Abdominal wall blockade with liposomal bupivacaine after donor hepatectomy provides an effective method of postoperative pain control and decreases time to full diet and bowel activity.

Clinical implications of de Barsy syndrome.

BACKGROUND: De Barsy syndrome is a rare, autosomal recessive syndrome characterized by cutis laxa, progeroid appearance, ophthalmic opacification, skeletal malformations, growth delays, and intellectual disability. AIMS: The aim of this case series is to identify the anesthetic considerations in the clinical management of patients with de Barsy syndrome. METHODS: A retrospective case review from 1968 to 2016 was performed at a single tertiary medical center to identify patients with de Barsy syndrome who underwent anesthesia for diagnostic and surgical procedures. We collected and analyzed the perioperative records and following data: age, sex, American Society of Anesthesiologists physical status, relevant comorbidities, surgical procedures, anesthesia management, and observed complications. RESULTS: Three patients underwent 64 unique anesthetics for a diverse collection of diagnostic and surgical procedures. An array of anesthetics and techniques were successfully used. Observations of the perioperative period found 7 episodes of intraoperative hyperthermia (>38.3°), a single difficult airway requiring fiberoptic bronchoscopic-guided intubation, and repeatedly difficult intravenous access. CONCLUSION: This expanded case series suggests that providers caring for patients with de Barsy syndrome should be aware of potential challenges with airway management, vascular access, and temperature monitoring.

Combined Selective Nerve Blockade and Local Infiltration Analgesia in a Total Shoulder Arthroplasty Patient With Chronic Pain and Severe Restrictive Lung Disease: A Case Report.

Interscalene brachial plexus block is considered the most complete postoperative analgesia after total shoulder arthroplasty. Interscalene brachial plexus block-induced ipsilateral hemidiaphragmatic paralysis may not be tolerated in patients with preexisting pulmonary disease. Selective distal nerve blocks avoid the risk of phrenic nerve block; however, they may provide incomplete analgesia to the glenohumeral joint. We report a case of combined selective suprascapular and axillary nerve blockade in combination with local infiltration analgesia in a patient with severe lung disease undergoing total shoulder arthroplasty. This case highlights the local infiltration analgesia technique of the shoulder joint and current diaphragm-sparing regional anesthesia blocks.

Parturient recall of neuraxial analgesia risks: Impact of labor pain vs no labor pain.

STUDY OBJECTIVE: Information exchange between anesthesia providers and parturients about neuraxial analgesia risks often occurs in the presence of labor pain. This study examined whether the presence of pain impacted the level of recall of information provided to parturients regarding risks of neuraxial techniques. DESIGN: Single-center, nonrandomized study. SETTING: Labor and delivery suite and postpartum patient rooms in a large academic medical center. PATIENTS: Two hundred six primigravidas admitted to our labor and delivery suites and receiving neuraxial analgesia were included. INTERVENTIONS: Informed consent for epidural and spinal placement was obtained by an obstetric anesthesia resident as per our standard practice. At the time of consent, parturients' self-reported level of pain was recorded. MEASUREMENTS: After delivery, patients completed a questionnaire asking which risks they recalled. Also queried were patient self-reported levels of anxiety at the time of consent, patient satisfaction with the informed consent process, overall satisfaction with pain control, as well as their preferred method and timing of information exchange. MAIN RESULTS: Only 20.9% of the 206 participating parturients recalled all risks and none of the distractors. There was no difference in recall between those with pain and those without pain at the time of consent. Women experiencing any pain at the time of consent were more likely to be very satisfied with the communication of risks compared with women without pain (96.2% vs 85.5%, P=.005). There was no difference in the preferred method (P=.780) or timing (P=.779) of discussion of risks between women in active labor compared with women with a scheduled induction of labor. CONCLUSIONS: Although parturients' recall of neuraxial risks did not differ based on the existence of labor pain, those having pain reported greater satisfaction with the informed consent process.

Unique Phrenic Nerve-Sparing Regional Anesthetic Technique for Pain Management after Shoulder Surgery.

BACKGROUND: Ipsilateral phrenic nerve blockade is a common adverse event after an interscalene brachial plexus block, which can result in respiratory deterioration in patients with preexisting pulmonary conditions. Diaphragm-sparing nerve block techniques are continuing to evolve, with the intention of providing satisfactory postoperative analgesia while minimizing hemidiaphragmatic paralysis after shoulder surgery. CASE REPORT: We report the successful application of a combined ultrasound-guided infraclavicular brachial plexus block and suprascapular nerve block in a patient with a complicated pulmonary history undergoing a total shoulder replacement. CONCLUSION: This case report briefly reviews the important innervations to the shoulder joint and examines the utility of the infraclavicular brachial plexus block for postoperative pain management.

Periprocedural Management of 172 Gastrointestinal Endoscopies in Patients with Left Ventricular Assist Devices.

The number of patients with left ventricular assist devices (LVADs) continues to increase, and gastrointestinal (GI) endoscopy is commonly required in this patient population. We retrospectively reviewed the experience of a single tertiary care center in managing patients with LVADs undergoing GI endoscopy between 2006 and 2013. After hospital dismissal from the LVAD placement, 53 patients underwent 172 GI endoscopic procedures. Gastrointestinal bleeding was the indication for endoscopy in 73.8% of patients. Median age at endoscopy was 66 years, and median time from LVAD implantation to initial endoscopy was 271 days (range, 31-1681 days). Anticoagulation or antiplatelet therapy was present within 1 week before 120 of 172 endoscopies (70%) and was withheld or actively reversed in 91 of 120 cases (76%). For sedation/anesthesia during endoscopy, 63 involved care by an anesthesiology team and 109 were performed with nursing sedation protocols. Noninvasive blood pressure techniques (conventional automated cuffs or Doppler pulses) were used for hemodynamic monitoring in 84%, arterial lines in 10%, and no blood pressure recordings documented/charted as inaccurate in 6%. Six patients died within 30 days of endoscopy with one death because of aspiration of blood and multiorgan failure. Patients with LVADs may safely undergo GI endoscopy with various individualized anesthetic/sedation models. Complications after endoscopy likely represent the acuity of this patient population.

Pain severity is associated with muscle strength and peak oxygen uptake in adults with fibromyalgia.

BACKGROUND: The associations between pain, lower extremity strength, and aerobic conditioning have not been widely investigated in adults with fibromyalgia (FM). The principle objective of this study was to investigate the relationship between pain severity and knee strength in patients seeking treatment for FM. A secondary objective was to investigate the relationship between pain scores and aerobic conditioning. METHODS: Three measures of knee strength (isokinetic extensor, isokinetic flexor, isometric extensor) were quantified in the dominant leg of 69 adults with FM using a dynamometer at speeds of 60 degrees per second (60°/s) and 180°/s. Peak oxygen uptake (VO2) was assessed using a cycle ergometer, and pain was assessed using the pain severity subscale of the Multidimensional Pain Inventory. RESULTS: In univariable linear regression analyses using pain severity as the dependent variable, lesser values of isokinetic knee extensor strength at 60°/s (P=0.041) and 180°/s (P=0.010), isokinetic knee flexor strength at 60°/s (P=0.028) and 180°/s (P=0.003), and peak VO2 uptake (P=0.031) were predictive of greater pain severity scores. In multiple variable linear regression models adjusted for age, sex, body mass index, and opioid use, the following associations retained statistical significance; isokinetic knee extensor strength at 60°/s (P=0.020) and 180°/s (P=0.003), isokinetic knee flexor strength at 60°/s (P=0.015) and 180°/s (P=0.001), and peak VO2 uptake (P=0.014). However, no significant associations were found between pain severity and isometric knee extensor strength. CONCLUSION: The main findings from this study were that lesser values of isokinetic knee strength and peak VO2 uptake were predictive of greater pain severity scores. These results build on the findings of previous investigations, but ongoing research is needed to further characterize the effects of strength and peak VO2 uptake on the pathophysiology of FM.

Invasive lionfish (Pterois volitans): a potential human health threat for ciguatera fish poisoning in tropical waters.

Invasive Indo-Pacific lionfish (Pterois volitans) have rapidly expanded in the Western Atlantic over the past decade and have had a significant negative impact on reef fish biodiversity, habitat, and community structure, with lionfish out-competing native predators for resources. In an effort to reduce this population explosion, lionfish have been promoted for human consumption in the greater Caribbean region. This study examined whether the geographical expansion of the lionfish into a known ciguatera-endemic region can pose a human health threat for ciguatera fish poisoning (CFP). More than 180 lionfish were collected from waters surrounding the US Virgin Islands throughout 2010 and 2011. Ciguatoxin testing included an in vitro neuroblastoma cytotoxicity assay for composite toxicity assessment of sodium-channel toxins combined with confirmatory liquid chromatography tandem mass spectrometry. A 12% prevalence rate of ciguatoxic lionfish exceeding the FDA guidance level of 0.1 µg/kg C-CTX-1 equivalents was identified in fish from the U.S. Virgin Islands, highlighting a potential consumption risk in this region. This study presents the first evidence that the invasive lionfish, pose a direct human health risk for CFP and highlights the need for awareness and research on this food safety hazard in known endemic areas.