Transversus abdominis plane block with liposomal bupivacaine versus continuous epidural analgesia for major abdominal surgery: The EXPLANE randomized trial.

OBJECTIVE: Compare transversus abdominis plane (TAP) blocks with liposomal bupivacaine were to epidural analgesia for pain at rest and opioid consumption in patients recovering from abdominal surgery. BACKGROUND: ERAS pathways suggest TAP blocks in preference to epidural analgesia for abdominal surgery. However, the relative efficacies of TAP blocks and epidural analgesia remains unknown. METHODS: Patients having major abdominal surgery were enrolled at six sites and randomly assigned 1:1 to thoracic epidural analgesia or bilateral/4-quadrant TAP blocks with liposomal bupivacaine. Intravenous opioids were used as needed. Non-inferiority margins were a priori set at 1 point on an 11-point pain numeric rating scale for pain at rest and at a 25% increase in postoperative opioid consumption. RESULTS: Enrollment was stopped per protocol at 3rd interim analysis after crossing an a priori futility boundary. 498 patients were analyzed (255 had TAP blocks and 243 had epidurals). Pain scores at rest in patients assigned to TAP blocks were significantly non-inferior to those given epidurals, with an estimated difference of 0.09 points (CI: -0.12, 0.30; noninferiority P < 0.001). Opioid consumption during the initial 3 postoperative days in TAP patients was not non-inferior to epidurals, with an estimated ratio of geometric means of 1.37 (CI: 1.05, 1.79; non-inferiority P = 0.754). However, the absolute difference was only 21 mg morphine equivalents over the 3 days. Patients with epidurals were more likely to experience mean arterial pressures <65 mmHg than those given TAP blocks: 48% versus 31%, P = 0.006. CONCLUSION: Pain scores at rest during the initial three days after major abdominal surgery were similar. Patients assigned to TAP blocks required more opioid then epidural patients but had less hypotension. Clinicians should reconsider epidural analgesia in patients at risk from hypotension. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02996227.

Co-Presentation of Posterior Reversible Encephalopathy Syndrome in a Patient with Post-Dural Puncture Headache.

INTRODUCTION: Post-dural puncture headache (PDPH) is a well-known complication of neuraxial anesthesia, but the occurrence of seizures and vision loss within a few days after dural puncture could be alarming. Posterior reversible encephalopathy syndrome (PRES) is associated with reversible edema and leukoencephalopathy in the posterior parieto-occipital cortex. We report the co-presentation of PRES and PDPH after labor epidural analgesia. CASE PRESENTATION: A 25-year-old multiparous African-American woman was admitted for evaluation of new-onset seizures and headache in the postpartum period. She had a recent history of multiple needle insertion attempts and inadvertent dural puncture during epidural analgesia for delivery. Soon after delivery, she was diagnosed with PDPH and was treated with an epidural blood patch, with no relief of symptoms. Six days later, she developed sudden-onset transient blindness, seizures, and altered sensorium, and magnetic resonance imaging of the brain revealed white matter changes suggestive of PRES. CONCLUSION: PRES is an uncommon complication of cerebrospinal fluid leak and intracranial hypotension. We report the occurrence of PRES in a patient with no known risk factors except a traumatic dural tap. Is it important to expand the differentials for headache after dural puncture to encompass PRES as a possibility, especially in patients with a delayed presentation of seizures and cortical blindness.

The External Oblique Intercostal Block: Anatomic Evaluation and Case Series.

STUDY OBJECTIVE: We report a modified block technique aimed at obtaining upper midline and lateral abdominal wall analgesia: the external oblique intercostal (EOI) block. DESIGN: A cadaveric study and retrospective cohort study assessing the potential analgesic effect of the EOI block. SETTING: Cadaver lab and operating room. PATIENTS: Two unembalmed cadavers and 22 patients. INTERVENTIONS: Bilateral ultrasound-guided EOI blocks on cadavers with 29 mL of bupivacaine 0.25% with 1 mL of India ink; single-injection or continuous EOI blocks in patients. MEASUREMENTS: Dye spread in cadavers and loss of cutaneous sensation in patients. MAIN RESULTS: In the cadaveric specimens, we identified consistent staining of both lateral and anterior branches of intercostal nerves from T7 to T10. We also found consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline in patients receiving the EOI block. CONCLUSIONS: We demonstrate the potential mechanism of this technique with a cadaveric study that shows consistent staining of both lateral and anterior branches of intercostal nerves T7-T10. Patients who received this block exhibited consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline. This block can be used in multiple clinical settings for upper abdominal wall analgesia.

Subcostal Anterior Quadratus Lumborum Block Versus Epidural Block for Analgesia in Open Nephrectomy: A Randomized Clinical Trial.

BACKGROUND: Epidural block are often used for analgesia after open nephrectomy surgery. Subcostal anterior quadratus lumborum block may be an alternative. We therefore tested the hypothesis that the continuous subcostal anterior quadratus lumborum block is noninferior to epidural block for analgesia in patients having open partial nephrectomies. METHODS: Adults having open partial nephrectomies were randomly allocated to epidural or unilateral subcostal anterior quadratus lumborum block. The joint primary outcomes were opioid consumption measured in morphine equivalents and pain measured on a numeric rating scale (0-10) from postanesthesia care unit (PACU) until 72 hours after surgery. The noninferiority deltas were 30% for opioid consumption and 1 point on a 0-10 scale for pain. Secondary outcomes included patient global assessment of pain management on the third postoperative day, the number of antiemetic medication doses through the third postoperative day, duration of PACU stay, and postoperative duration of hospitalization. RESULTS: Twenty-six patients were randomized to anterior quadratus lumborum block and 29 to epidural analgesia. Neither pain scores nor opioid consumption in the quadratus lumborum patients were noninferior to epidural analgesia. At 72 hours, mean ± standard deviation pain scores in subcoastal anterior quadratus lumborum block and epidural group were 4.7 ± 1.8 and 4.1 ± 1.7, with an estimated difference in pain scores of 0.62 (95% confidence interval [CI], 0.74-1.99; noninferiority P = .21). The median [Q1, Q3] opioid consumption was more than doubled in quadratus lumborum patients at 70 mg [43, 125] versus 30 mg [18, 75] in the epidural group with an estimated ratio of geometric means of 1.69 (95% CI, 0.66-4.33; noninferiority P = .80). Patient global assessment and duration of PACU and hospital stays did not differ significantly in the 2 groups. CONCLUSIONS: We were unable to show that subcostal anterior quadratus lumborum block are noninferior to epidural analgesia in terms of pain scores and opioid consumption for open partial nephrectomies. Effectiveness of novel blocks should be rigorously tested in specific surgical setting before widespread adoption.

Effect of Intravenous Acetaminophen on Postoperative Hypoxemia After Abdominal Surgery: The FACTOR Randomized Clinical Trial.

Importance: Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. Objective: To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. Design, Setting, and Participants: Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. Interventions: Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. Main Outcomes and Measures: The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. Results: Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). Conclusions and Relevance: Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. Trial Registration: ClinicalTrials.gov Identifier: NCT02156154.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique.

BACKGROUND AND AIMS: Liposomal bupivacaine (LB) is a formulation of local anesthetic that may exert analgesia over a prolonged period. Anecdotal use of LB suggests benefit and prolonged analgesia when used to supplement infiltration blocks. Our aim was to test the effect of a bolus of LB delivered through a nerve catheter in two types of interfascial plane blocks (transversus abdominis plane and anterior subcostal quadratus lumborum). The effect was evaluated through patient self-reporting of postsurgical pain up to 48 postoperative hours. MATERIAL AND METHODS: Medical records of adult postoperative patients who received LB in a peripheral nerve catheter were followed retrospectively and analysed for pain scores and spread of dermatomal numbness over 48 h following the postoperative dose. A chart review of patients who qualified between June 2015 and March 2017 was performed, and clinical data were obtained from the institutional Perioperative Health Documentation System. RESULTS: Pain scores decreased following LB bolus, and all patients reported efficient block analgesia after bolus injection. Dermatomal numbness decreased gradually and was minimal by 48 h following bolus. CONCLUSION: LB can be injected through a peripheral nerve catheter to prolong analgesia after catheter removal.

The supra-iliac anterior quadratus lumborum block: a cadaveric study and case series.

PURPOSE: The local anesthetic injectate spread with fascial plane blocks and corresponding clinical outcomes may vary depending on the site of injection. We developed and evaluated a supra-iliac approach to the anterior quadratus lumborum (QL) block and hypothesized that this single injection might successfully block the lumbar and sacral plexus in cadavers and provide analgesia for patients undergoing hip surgery. METHODS: Ultrasound-guided bilateral supra-iliac anterior QL blocks were performed with 30 mL of India ink dye in six fresh adult cadavers. Cadavers were subsequently dissected to determine distribution of the dye. In five patients undergoing hip surgery, a unilateral supra-iliac anterior QL block with 25 mL ropivacaine 0.5% followed by a continuous catheter infusion was performed. Patients were clinically assessed daily for block efficacy. RESULTS: The cadaveric injections showed consistent dye involvement of the majority of the branches of the lumbar plexus, including the femoral nerve, lateral femoral cutaneous nerve, ilioinguinal nerve, and iliohypogastric nerve. The majority of cadaveric specimens (83%) also exhibited thoracic paravertebral spread of dye to the T10 level. No specimens showed L5 or sacral nerve root staining or caudal spread below L5. All patients had effective analgesia for total hip surgery and a T11-L3 sensory level following the initial bolus of local anesthetic as well as during the period of continuous catheter infusion. CONCLUSION: This cadaveric study and case series show that a supra-iliac approach to the anterior QL block involved T10--L3 nerve territories and dermatomal coverage with no sacral plexus spread. This technique may have clinical utility for analgesia in hip surgery.

RéSUMé: OBJECTIF: La diffusion de l'anesthésique local injecté lors de la réalisation d'un bloc du fascia et les résultats cliniques qui en découlent peuvent varier selon le site d'injection. Nous avons mis au point et évalué une approche supra-iliaque pour la réalisation d'un bloc du muscle carré des lombes antérieur (quadratus lomburum) et émis l'hypothèse que cette injection unique pourrait suffire à bloquer les plexus lombaire et sacral de cadavres, offrant ainsi une analgésie aux patients subissant une chirurgie de la hanche. MéTHODE: Des blocs bilatéraux du muscle carré des lombes antérieur ont été réalisés par approche supra-iliaque sous échoguidage à l'aide de 30 mL de teinture d'encre de Chine sur six cadavres adultes frais. Les cadavres ont par la suite été disséqués afin de déterminer la diffusion de la teinture. Nous avons réalisé un bloc unilatéral du muscle carré des lombes antérieur par approche supra-iliaque avec une solution de 25 mL de ropivacaïne 0,5 %, suivie d'une perfusion continue via cathéter, chez cinq patients subissant une chirurgie de la hanche. Une évaluation clinique quotidienne des patients a été réalisée afin de déterminer l'efficacité du bloc. RéSULTATS: Les injections sur les cadavres ont permis d'observer une diffusion constante de la teinture dans la majorité des branches du plexus lombaire, y compris dans le nerf fémoral, le nerf fémoral cutané latéral, le nerf ilio-inguinal et le nerf ilio-hypogastrique. Une diffusion paravertébrale thoracique de la teinture jusqu'au niveau T10 a également été retrouvée dans la majorité des spécimens cadavériques (83 %). Aucune coloration au niveau de la racine L5 ou des nerfs sacrés n'a été observée chez les spécimens, ni aucune diffusion caudale au-dessous de L5. Tous les patients ont reçu une analgésie efficace pour une arthroplastie totale de la hanche et obtenu un bloc sensitif au niveau T11­L3 après l'injection du bolus initial d'anesthésique local ainsi qu'au cours de la période de perfusion continue. CONCLUSION: Cette étude cadavérique et cette série de cas montrent qu'une approche supra-iliaque pour réaliser un bloc du muscle du carré des lombes antérieur est parvenue à atteindre les territoires nerveux T10-­L3 et avec couverture de ces dermatomes et ce, sans diffusion au niveau du plexus sacré. Cette technique pourrait avoir une utilité clinique pour l'analgésie en cas de chirurgie de la hanche.

Real-time Ultrasound-Guided Lumbar Epidural with Transverse Interlaminar View: Evaluation of an In-Plane Technique.

OBJECTIVE: The anatomical landmarks method is currently the most widely used technique for epidural needle insertion and is faced with multiple difficulties in certain patient populations. Real-time ultrasound guidance has been recently used to aid in epidural needle insertion, with promising results. Our aim was to test the feasibility, success rate, and satisfaction associated with a novel real-time ultrasound-guided lumbar epidural needle insertion in the transverse interlaminar view. DESIGN: Prospective descriptive trial on a novel approach. SETTING: Operating room and preoperative holding area at a tertiary care hospital. SUBJECTS: Adult patients presenting for elective open prostatectomy and planned for surgical epidural anesthesia. METHODS: Consented adult patients aged 30-80 years scheduled for open prostatectomy under epidural anesthesia were enrolled. Exclusion criteria included allergy to local anesthetics, infection at the needle insertion site, coagulopathy, and patient refusal. A curvilinear low-frequency (2-5 MHz) ultrasound probe and echogenic 17-G Tuohy needles were used by one of three attending anesthesiologists. Feasibility of epidural insertion was defined as a 90% success rate within 10 minutes. RESULTS: Twenty-two patients were enrolled into the trial, 14 (63.6%) of whom found the process to be satisfactory or very satisfactory. The median time to perform the block was around 4.5 minutes, with an estimated success rate of 95%. No complications related to the epidural block were observed over the 48 hours after the procedure. CONCLUSIONS: We demonstrate the feasibility of a novel real-time ultrasound-guided epidural with transverse interlaminar view.

Novel needle guide reduces time to perform ultrasound-guided femoral nerve catheter placement: A randomised controlled trial.

BACKGROUND: Ultrasound-guided nerve blocks have become the standard when performing regional nerve blocks in anaesthesia. Infiniti Plus (CIVCO Medical Solutions, Kalona, Iowa, USA) is a needle guide that has been recently developed to help clinicians in performing ultrasound-guided nerve blocks. OBJECTIVES: We tested the hypothesis that femoral nerve catheter placement carried out with the Infiniti Plus needle guide will be quicker to perform than without the Infiniti Plus. Secondary aims were to assess whether the Infiniti Plus needle guide decreased the number of block attempts and also whether it improved needle visibility. DESIGN: A randomised, controlled trial. SETTING: Cleveland Clinic, Cleveland, Ohio, USA. PATIENTS: We enrolled adult patients having elective total knee arthroplasty with a femoral nerve block and femoral nerve catheter. Patients, who were pregnant or those who had preexisting neuropathy involving the surgical limb, coagulopathy, infection at the block site or allergy to local anaesthetics were excluded. INTERVENTIONS: Patients were randomised into two groups to receive the ultrasound-guided femoral nerve catheter placement with or without the Infiniti Plus needle guide. MAIN OUTCOME MEASURES: The time taken to place the femoral nerve catheter, the number of attempts, the success rate and needle visibility were recorded. We used an overall α of 0.05 for both the primary and secondary analyses; the secondary analyses were Bonferroni corrected to control for multiple comparisons. RESULT: The median (interquartile range Q1 to Q3) time to perform the femoral nerve catheter placement was 118 (100 to 150) s with Infiniti Plus and 177 (130 to 236) s without Infiniti Plus. Infiniti Plus significantly reduced the time spent performing femoral nerve catheterisation, with estimated ratio of means [(95% confidence interval), P value] of 0.67 [(0.60 to 0.75), P < 0.001] with Infiniti Plus compared with no Infiniti Plus. However, Infiniti Plus had no effect on the odds of a successful femoral nerve catheter placement, number of attempts or percentage of perfect needle visibility. CONCLUSION: We found that the use of Infiniti Plus decreased the median time to successfully place a femoral nerve catheter by 33% compared with not using Infiniti Plus. This difference may be more apparent to clinicians undertaking this procedure less often or by those in training as our team was very experienced, had been trained in the technique and was working in a hospital with a large caseload. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02080481.

Bilateral Continuous Quadratus Lumborum Block for Acute Postoperative Abdominal Pain as a Rescue After Opioid-Induced Respiratory Depression.

We present a case of acute postoperative abdominal pain after proctosigmoidectomy and colorectal anastomosis that was treated by bilateral continuous quadratus lumborum block. The block was performed in the lateral position under ultrasound guidance with a 15-mL bolus of 0.5% bupivacaine injected anterior to the quadratus lumborum muscle followed by bilateral catheter placement. Each catheter received a continuous infusion of 0.1% bupivacaine at 8 mL/h and an on-demand bolus 5 mL every 30 minutes. Sensory level was confirmed by insensitivity to cold from T7 through T12. The block was devoid of hemodynamic side effects or motor weakness. This case demonstrates that bilateral continuous quadratus lumborum catheters can provide extended postoperative pain control.

Analgesic efficacy and technique of ultrasound-guided suprascapular nerve catheters after shoulder arthroscopy.

BACKGROUND: Conventional approaches to brachial plexus blocks may not cover the suprascapular nerve. Accordingly, after shoulder arthroscopy, sensation from the posterior part of the shoulder is commonly spared. Most previous research involving suprascapular nerve blocks described single-injection techniques. However, with the widespread availability and fairly reasonable cost of disposable infusion pumps, continuous catheter techniques provide a more appealing method of prolonging postoperative analgesia. CASE REPORT: We describe 2 patients who were successfully treated with ultrasound-guided continuous suprascapular nerve catheters. With the patient seated, a high-frequency linear ultrasound probe was used. Both patients experienced excellent pain relief without complications. CONCLUSION: Continuous suprascapular catheter techniques provide good pain relief and improve postoperative analgesia after shoulder arthroscopy.

Importance of vigilant monitoring after continuous nerve block: lessons from a case report.

INTRODUCTION: Continuous peripheral nerve block achieves good pain control. However, uncontrolled pain despite an effective block in the target areas of the nerve can be an early sign of ischemia. We report a case of iatrogenic injury to the axillary artery during shoulder surgery in a patient who had continuous supraclavicular block and demonstrate how vigilant monitoring helped the diagnosis and resulted in timely management of upper limb ischemia. CASE REPORT: A 58-year-old female underwent total revision surgery of her right shoulder under continuous supraclavicular block. Postoperatively, she complained of pain along the medial side of her forearm despite clinical evidence of nerve block. Continuous neurovascular monitoring and timely angiography confirmed axillary artery injury, and subsequent vascular repair saved the patient's limb. CONCLUSION: Iatrogenic injuries to vessels or nerves sometimes occur during orthopedic surgical procedures. Regional anesthesia can mask and delay the onset of these symptoms. Postoperative monitoring and the ability to differentiate between the effects of local anesthetics and the body's response to ischemia are important for avoiding postoperative complications. This case report aims to improve awareness about the need for vigilant monitoring of the distal pulses after peripheral nerve blocks.

Ultrasound-guided transversus abdominis plane catheter for chronic abdominal pain.

BACKGROUND AND OBJECTIVES: Neural blockade of the thoracolumbar nerves supplying the anterior abdominal wall through transversus abdominis plane (TAP) has been investigated for different applications mainly for the acute pain management following abdominal surgical procedures. The role of this block for chronic pain syndromes is still to be discovered, and its value in chronic abdominal pain needs to be studied. We are presenting new application of the TAP technique for management of chronic abdominal pain syndrome using the continuous infusion. CASE REPORT: We present a case of an 18-year-old girl who underwent an uneventful laparoscopic cholecystectomy. Postoperatively, patient complained of chronic pain at the site of the surgery. All diagnostic and imaging studies were negative for a surgical or a medical cause. Multiple interventions including epidural blocks, transcutaneous electrical neural stimulation, and celiac plexus blocks had failed to relieve the pain. After discussion with the patient about the diagnostic nature of the procedure and the likelihood of recurrence of pain, TAP block was performed on the right side with significant improvement of pain for about 24 hours. The degree of pain relief experienced by the patient was very dramatic, which encouraged us to proceed with an indwelling TAP catheter to allow for continuous infusion of a local anesthetic. The patient was sent home with the continuous infusion through a TAP catheter for 2 weeks. From the day of catheter insertion and up to 9 months of follow-up, patient had marked improvement of her pain level as well as her functional status and ability to perform her daily activities, after which our acute pain team stopped following the patient. CONCLUSION: A successful TAP block confirmed the peripheral (somatic) source of the abdominal pain and provided temporary analgesia after which an indwelling catheter was inserted, which provided prolonged pain relief.