A Case Report of "Propofol Frenzy": Anesthetic Considerations for a Severe Propofol-Induced Neuroexcitation Reaction.

Propofol "frenzy" is considered a severe propofol-induced neuroexcitatory reaction involving nonepileptic spells of extremity thrashing, marked agitation, irregular eye movements, and impaired consciousness. Patients with propofol neuroexcitation present unique challenges for anesthesia providers due to underrecognition, lack of diagnostic tests, and differentiating from other comparable disorders that require medications that can exacerbate symptoms. We present a case of a healthy young patient whose postoperative course was complicated by propofol frenzy and functional limb paralysis following hip surgery with a spinal anesthetic and propofol sedation. This case highlights anesthesia considerations for propofol frenzy and discusses dexmedetomidine as a promising modality for prompt management.

The effects of shoulder arthroscopy on ultrasound image quality of the interscalene brachial plexus: a pre-procedure vs post-procedure comparative study.

BACKGROUND: Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative). METHODS: This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes. RESULTS: Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p < .001), as was confidence in performing blockade based upon the imaging (preoperative 4.8 vs postoperative 4.2; p < .001). Larger BMI negatively affected visualization of the brachial plexus in the preoperative period (p < 0.05 for both weight categories). Patients with intermediate-high risk or confirmed obstructive sleep apnea had lower aggregate postoperative mean scores compared to the low-risk group for both ultrasound visualization (3.4 vs 4.0; p < .05) and confidence in block performance (3.8 vs 4.4; p < .05). CONCLUSION: Due to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT03657173 ; September 4, 2018).

Spinal Anesthesia for Amyotrophic Lateral Sclerosis Patient Undergoing Lower Extremity Orthopedic Surgery: An Overview of the Anesthetic Considerations.

BACKGROUND: Amyotrophic lateral sclerosis is a progressive neurodegenerative disease primarily affecting the upper and lower motor neurons. Patients present with a variety of clinical manifestations inevitably resulting in death secondary to respiratory insufficiency from muscle weakness and consequential pulmonary complications. Despite the lack of universal consensus on the ideal anesthetic approach to amyotrophic lateral sclerosis patients undergoing lower extremity total joint surgery, there are few noteworthy anesthetic considerations in this cohort. CASE REPORT: A 75-year-old male with multiple medical comorbidities, including a recent diagnosis of amyotrophic lateral sclerosis, presented to a large academic medical center for a right total hip arthroplasty revision. The patient's preoperative neurologic examination demonstrated brisk deep tendon reflexes, visible fasciculations of lower extremities, and motor weakness of upper and lower extremities. Serology demonstrated an elevated creatine kinase, and an electromyography study showed active denervation in the cervical, thoracic, and lumbosacral regions. After a careful risk-benefit analysis was performed, involving a multidisciplinary team approach, the patient successfully underwent the surgical procedure with a spinal anesthetic and minimal sedation. Perioperative course was unremarkable, and there were no neurologic complications in the first 6 months after surgery. CONCLUSION: Patients with amyotrophic lateral sclerosis present unique challenges for anesthesia providers. General anesthesia may potentially worsen respiratory function; therefore, alternative methods to avoiding airway manipulation should be considered. Conversely, regional techniques may carry the risk of exacerbating pre-existing neurologic symptoms. Currently, no definite guidelines exist on the perioperative anesthetic management of amyotrophic lateral sclerosis patients; ultimately, the decision to perform regional anesthesia should be based on analyzing a patient's risk against the potential benefits.

A 3-arm randomized clinical trial comparing interscalene blockade techniques with local infiltration analgesia for total shoulder arthroplasty.

BACKGROUND: The ideal analgesic modality for total shoulder arthroplasty (TSA) remains controversial. We hypothesized that a multimodal analgesic pathway incorporating continuous interscalene blockade (ISB) provides better analgesic efficacy than both single-injection ISB and local infiltration analgesia. METHODS: This single-center, parallel, unblinded, randomized clinical trial evaluated 129 adults undergoing primary TSA. Patients were allocated to single-injection ISB, continuous ISB, or local infiltration analgesia. The primary outcome was the Overall Benefit of Analgesia Score (range, 0 [best] to 28 [worst]) on postoperative day 1. Additional outcomes included pain scores, opioid consumption, quality of life, and postoperative complications in the first 24 hours, at 3 months, and at 1 year. RESULTS: We analyzed 125 patients (42 with single-injection ISB, 41 with continuous ISB, and 42 with local infiltration analgesia). The Overall Benefit of Analgesia Score was significantly improved in the continuous group (median [25th percentile, 75th percentile], 0 [0, 2]) compared with the single-injection group (2 [1, 4]; P = .002) and local infiltration analgesia group (3 [2, 4]; P < .001). Pain scores were significantly lower in the continuous group compared with the local infiltration analgesia group (P < .001 for all time points) and after 12 hours from ward arrival compared with the single-injection group (median [25th percentile, 75th percentile], 1.0 [0.0, 2.8] vs. 2.5 [0.0, 4.0]; P = .016). After postanesthesia recovery discharge, opioid consumption (oral morphine equivalents) was significantly lower in the continuous group (median [25th percentile, 75th percentile], 7.5 mg [0.0, 25.0 mg]) than in the local infiltration analgesia group (30 mg [15.0, 52.5 mg]; P < .001) and single-injection group (17.6 mg [7.5, 45.5 mg]; P = .010). No differences were found across groups for complications, 3-month outcomes, and 1-year outcomes. CONCLUSION: Continuous ISB provides superior analgesia compared with single-injection ISB and local infiltration analgesia in the first 24 hours after TSA.

Anesthesia for Same-Day Total Joint Replacement.

Demand for low-cost, high-quality health care has forced the total joint replacement (TJR) industry to evaluate and mitigate high variable costs. Minimizing hospital stay can significantly reduce total cost of care. A shortened hospital stay does not compromise patient safety or satisfaction, and may reduce perioperative complications compared with multiple-day hospitalizations. Through the use of enhanced recovery clinical pathways, outpatient TJRs have progressively shortened hospitalizations. Successful ambulatory TJR can be accomplished through advances in surgical technique, presurgical patient education, opioid-sparing multimodal analgesia, anesthetic techniques that facilitate rapid recovery, and progressive rehabilitation.

Anesthetic Considerations for a Patient With Chronic Systemic Capillary Leak Syndrome: A Case Report.

Systemic capillary leak syndrome (SCLS) is an idiopathic vascular hyperpermeability that leads to profound hypotension, hypoalbuminemia, and hemoconcentration. Sixty years since its inauguration into literature, SCLS is still elusive, underdiagnosed, and profoundly dangerous. Few authors have documented anesthetic implications of classical acute SCLS, a form with complete recovery between exacerbations. However, minimal information is available about chronic SCLS, continuous generalized edema with or without exacerbations. Both forms are postulated to have similar pathogenesis, yet clinical differences are noteworthy, warranting variations in perioperative management. We present a patient with chronic SCLS who underwent general and regional anesthesia for elective surgery.

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.

A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty.

BACKGROUND: Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. METHODS: This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. RESULTS: One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection (P = 0.016; Hodges-Lehmann median difference [95% CI] = -1 [-2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal -2 [-3 to -1]; P < 0.001; average -0.8 [-1.3 to -0.2]; P = 0.003; and liposomal bupivacaine: maximal -3 [-4 to -2]; P < 0.001; average -1.4 [-2.0 to -0.8]; P < 0.001). CONCLUSIONS: Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

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.