Regional anesthesia considerations for cardiac surgery.

Pain is a significant consequence of cardiac surgery and newer techniques in cardiac anesthesia have provided an impetus for the development of multimodal techniques to manage acute pain in this setting. In this regard, regional anesthesia techniques have been increasingly used in many cardiac surgical procedures, for the purposes of reducing perioperative consumption of opioid agents and enhanced recovery after surgery. The present investigation focuses on most currently used regional techniques in cardiac surgical procedures. These regional techniques include chest wall blocks (e.g., PECS I and II, SAP, ESB, PVB), sternal blocks (e.g., TTMPB, PSINB), and neuraxial blocks (e.g., TEA, high spinal anesthesia). The present investigation also summarizes indications, technique, complications, and potential clinical benefits of these evolving regional techniques. Cardiac surgery patients may benefit from application of these regional techniques with well controlled indications and careful patient selections.

PECS, serratus plane, erector spinae, and paravertebral blocks: A comprehensive review.

Thoracic planar blocks represent a novel and rapidly expanding facet of regional anesthesia. These recently described techniques represent the potential for excellent analgesia, enhanced technical safety profiles, and reduced physiological side effects versus traditional techniques in thoracic anesthesia. Regional techniques, particularly those described in this review, have potential implications for mitigation of surgical pathophysiological neurohumoral changes. In the present investigation, we describe the history, common indications, technique, and limitations of pectoral nerves (PECS), serratus plane, erector spinae plane, and thoracic paravertebral plane blocks. In summary, these techniques provide excellent analgesia and merit consideration in thoracic surgery.

A Comprehensive Review of Trigeminal Neuralgia.

PURPOSE OF REVIEW: Trigeminal neuralgia (TN) is characterized by recurrent attacks of lancinating facial pain in the dermatomal distribution of the trigeminal nerve. TN is rare, affecting 4 to 13 people per 100,000. RECENT FINDINGS: Although there remains a debate surrounding the pathogenesis of TN, neurovascular compromise is the most currently accepted theory. Minimal stimulation caused by light touch, talking, or chewing can lead to debilitating pain and incapacitation of the patient. Pain may occur sporadically, though is primarily unilateral in onset. The diagnosis is typically determined clinically. Treatment options include medications, surgery, and complementary approaches. Anti-epileptic and tricyclic antidepressant medications are first-line treatments. Surgical management of patients with TN may be indicated in those who have either failed medical treatment with at least three medications, suffer from intolerable side-effects, or have non-remitting symptoms. Surgical treatment is categorized as either destructive or non-destructive. Deep brain and motor cortex neuro-modulatory stimulation are off label emerging techniques which may offer relief to TN that is otherwise refractory to pharmacological management and surgery. Still, sufficient data has yet to be obtained and more studies are needed.

Goal-directed fluid therapy in the perioperative setting.

Improvement in patient outcomes has become a significant consideration with our limited resources in the surgical setting. The implementation of enhanced recovery pathway protocols has resulted in significant benefits to both the patients and hospitals, such as shorter length of hospital stays, reduction in the rate of complications, and fewer hospital readmissions. An emerging component and a key element for the success of Enhanced Recovery After Surgery (ERAS) protocols has been the concept of goal-directed fluid therapy (GDT). GDT related to ERAS protocols attempts to minimize complications associated with fluid imbalance during surgery. We performed a literature search for articles that included the terms enhanced recovery and GDT. We evaluated methods for appropriate volume status assessment, such as heart rate, blood pressure, end-tidal CO2, central venous pressure, urine output, stroke volume, cardiac output, and their derivatives. Some invasive, minimally invasive, and non-invasive monitors of hemodynamic evaluation are now being used to assess volume status and predict fluid responsiveness and fluid need during various surgical procedures. Regardless of monitoring technique, it is important for the clinician to effectively plan and implement preoperative and intraoperative fluid goals. Excess crystalloid fluid should be avoided. In some low-risk patients undergoing low-risk surgery, a "zero-balance" approach is encouraged. For the majority of patients undergoing major surgery, GDT is recommended. Optimal perioperative fluid management is an important component of the ERAS pathways and it can reduce postoperative complications.

Thoracic Outlet Syndrome: A Comprehensive Review of Pathophysiology, Diagnosis, and Treatment.

Thoracic outlet syndrome, a group of diverse disorders, is a collection of symptoms in the shoulder and upper extremity area that results in pain, numbness, and tingling. Identification of thoracic outlet syndrome is complex and a thorough clinical examination in addition to appropriate clinical testing can aide in diagnosis. Practitioners must consider the pathology of thoracic outlet syndrome in their differential diagnosis for shoulder and upper extremity pain symptoms so that patients are directed appropriately to timely therapeutic interventions. Patients with a definitive etiology who have failed conservative management are ideal candidates for surgical correction. This manuscript will discuss thoracic outlet syndrome, occurrence, physical presentation, clinical implications, diagnosis, and management.

Ambivalence in living liver donors.

All right hepatic lobe (RHL) donors in our program are asked to participate in a longitudinal quality-of-life study that begins at their evaluation and continues throughout the first postdonation year. Here we report the characteristics of donor candidates who completed the donation process despite ambivalence. In all, 183 RHL candidates consented, and 133 became donors. Ambivalent donors (ADs; n = 45) identified themselves through verbal statements or written comments, or they were identified by staff during the evaluation. ADs were predominantly male (73.3%), were older than unambivalent donors (UADs; >35 years: 76% of ADs versus 53% of UADs, P = 0.008), and were well educated (college graduate: 60% of ADs versus 17% of UADs, P = 0.01). Brother-to-brother and son-to-father combinations were most common among ADs. Alcohol (22% versus 11%, P = 0.04) and hepatitis C virus (51% versus 27%, P = 0.008) were more common as disease etiologies for recipients with ADs versus recipients with UADs. More ADs than UADs considered themselves to be religious (68.9% versus 43.2%, P = 0.007). Ambivalence about RHL donation was present in 33.8% of the candidates who completed the donation process. These results suggest that ambivalence should not be the sole reason for disqualifying a potential donor who otherwise satisfies program requirements.