The Use of Contrast Agents in Interventional Pain Procedures: A Multispecialty and Multisociety Practice Advisory on Nephrogenic Systemic Fibrosis, Gadolinium Deposition in the Brain, Encephalopathy After Unintentional Intrathecal Gadolinium Injection, and Hypersensitivity Reactions.

This Practice Advisory presents a comprehensive and evidence-based set of position statements and recommendations for the use of contrast media in interventional pain procedures. The advisory was established by an international panel of experts under the auspices of 11 multinational and multispecialty organizations based on a comprehensive review of the literature up to December 31, 2019. The advisory discusses the risks of using gadolinium-based contrast agents. These include nephrogenic systemic fibrosis, gadolinium brain deposition/retention, and encephalopathy and death after an unintentional intrathecal gadolinium injection. The advisory provides recommendations on the selection of a specific gadolinium-based contrast agent in patients with renal insufficiency, those who had multiple gadolinium-enhanced magnetic resonance imaging examinations, and in cases of paraspinal injections. Additionally, recommendations are made for patients who have a history of mild, moderate, or severe hypersensitivity reactions to contrast medium.

Single dose systemic acetaminophen to improve patient reported quality of recovery after ambulatory segmental mastectomy: A prospective, randomized, double-blinded, placebo controlled, clinical trial.

Few systemic drug interventions are efficacious to improve patient reported quality of recovery after ambulatory surgery. We aimed to evaluate whether a single dose systemic acetaminophen improve quality of recovery in female patients undergoing ambulatory breast surgery. We hypothesized that patients receiving a single dose systemic acetaminophen at the end of the surgical procedure would have a better global quality of postsurgical recovery compared to the ones receiving saline. The study was a prospective randomized double blinded, placebo controlled, clinical trial. Healthy female subjects were randomized to receive 1 g single dose systemic acetaminophen at the end of the surgery or the same volume of saline. The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24 hours after surgery. Other data collected included opioid consumption and pain scores. Data were analyzed using group t tests and the Wilcoxon exact test. The association between opioid consumption and quality of recovery was evaluated using Spearman rho. P < .05 was used to reject the null hypothesis for the primary outcome. Seventy subjects were randomized and sixty-five completed the study. Patients' baseline characteristics and surgical factors were similar between the study groups. There was a clinically significant difference in the global QoR-40 scores between the acetaminophen and the saline groups, median (IQR) of 189 (183 to 194) and 183 (175 to 190), respectively, P = .01. In addition, there was an inverse relationship (Spearman's rho= -0.33) between oral opioid consumption at home (oral morphine equivalents) and 24 hour postoperative quality of recovery, P = .007. A single dose of systemic acetaminophen improves patient reported quality of recovery after ambulatory breast surgery. The use of systemic acetaminophen is an efficacious strategy to improve patient perceived quality of postsurgical recovery and analgesic outcomes after hospital discharge for ambulatory breast surgery.

The effect of sevoflurane compared to propofol maintenance on post-surgical quality of recovery in patients undergoing an ambulatory gynecological surgery: A prospective, randomized, double-blinded, controlled, clinical trial.

OBJECTIVE: The main objective of the current investigation was to evaluate the effect of propofol used as anesthetic maintenance compared to sevoflurane on global post-surgical quality of recovery in female patients undergoing ambulatory gynecological surgery. DESIGN: The study was a prospective randomized double blinded, controlled, clinical trial. INTERVENTIONS: Healthy female subjects were randomized to receive propofol or sevoflurane as anesthetic maintenance. MEASUREMENTS: The primary outcome was the Quality of Recovery 40 (QOR-40) questionnaire at 24h after surgery. Other data collected included opioid consumption, pain scores and time to hospital discharge. P<0.05 was used to reject the null hypothesis for the primary outcome. MAIN RESULTS: Ninety subjects were randomized and sixty seven completed the study. Patient's baseline characteristics and surgical factors were not different between study groups. There was not a clinically significant difference in the global QoR-40 scores between the sevoflurane and the propofol groups, median (IQR) of 175 (163 to 181) and 176 (163 to 184), respectively, P=0.97. There was an inverse relationship (ρ=-0.42) between the opioid consumption in PACU (IV morphine equivalents) and 24h postoperative quality of recovery (P<0.001) and an inverse relationship (ρ=-0.48) between the oral opioid consumption at home (oral morphine equivalents) and 24h postoperative quality of recovery, P<0.001. CONCLUSIONS: Our current results do not support the use of total intravenous anesthesia as an efficacious strategy to improve global quality of recovery after ambulatory surgery. Opioid consumption in the PACU is an earlier surrogate that can be utilized to identify ambulatory patients with a high likelihood to develop poor global quality of recovery and who may benefit from more efficacious strategies to improve global quality of recovery. TRIAL REGISTRATION: ClinicalTrial.gov; url: http://www.clinicaltrials.gov; registration identified: NCT 01755234.

Scalene muscle injections for neurogenic thoracic outlet syndrome: case series.

UNLABELLED: Scalene muscle injections are used to confirm the diagnosis of neurogenic thoracic outlet syndrome and predict the response of patients to surgery. We performed a retrospective study to determine if relief of pain was related to brachial plexus blockade in these patients. METHODS: We reviewed the charts of 12 patients who had anterior and middle scalene muscle injections, for neurogenic thoracic outlet syndrome, between April 2009 and September 2010. The injections were performed under ultrasound guidance wherein 2 to 5 mL of 0.25% bupivacaine was injected into the belly of the anterior and scalene muscles. The following were noted: (1) sites of preprocedure pain; (2) volume injected into each of the anterior and middle scalene muscles; (3) presence of numbness after injection; and (4) presence and duration of pain relief. RESULTS: All 12 patients had relief of their pain. Six of the twelve patients developed numbness, which ranged from blockade of the C4-5, C6-7, and C4-T1 dermatomes. In the patients who developed numbness, there was no relationship between the duration of numbness and the duration of pain relief or the location of numbness and the location of pain relief. CONCLUSIONS: The relief from scalene muscle injections in patients with neurogenic thoracic outlet syndrome is not related to blockade of the brachial plexus.