An Exploratory Analysis of ChatGPT Compared to Human Performance With the Anesthesiology Oral Board Examination: Initial Insights and Implications.

BACKGROUND: Chat Generative Pre-Trained Transformer (ChatGPT) has been tested and has passed various high-level examinations. However, it has not been tested on an examination such as the American Board of Anesthesiology (ABA) Standardized Oral Examination (SOE). The SOE is designed to assess higher-level competencies, such as judgment, organization, adaptability to unexpected clinical changes, and presentation of information. METHODS: Four anesthesiology fellows were examined on 2 sample ABA SOEs. Their answers were compared to those produced by the same questions asked to ChatGPT. All human and ChatGPT responses were transcribed, randomized by module, and then reproduced as complete examinations, using a commercially available software-based human voice replicator. Eight ABA applied examiners listened to and scored the topic and modules from 1 of the 4 versions of each of the 2 sample examinations. The ABA did not provide any support or collaboration with any authors. RESULTS: The anesthesiology fellow's answers were found to have a better median score than ChatGPT, for the module topics scores (P = .03). However, there was no significant difference in the median overall global module scores between the human and ChatGPT responses (P = .17). The examiners were able to identify the ChatGPT-generated answers for 23 of 24 modules (95.83%), with only 1 ChatGPT response perceived as from a human. In contrast, the examiners thought the human (fellow) responses were artificial intelligence (AI)-generated in 10 of 24 modules (41.67%). Examiner comments explained that ChatGPT generated relevant content, but were lengthy answers, which at times did not focus on the specific scenario priorities. There were no comments from the examiners regarding Chat GPT fact "hallucinations." CONCLUSIONS: ChatGPT generated SOE answers with comparable module ratings to anesthesiology fellows, as graded by 8 ABA oral board examiners. However, the ChatGPT answers were deemed subjectively inferior due to the length of responses and lack of focus. Future curation and training of an AI database, like ChatGPT, could produce answers more in line with ideal ABA SOE answers. This could lead to higher performance and an anesthesiology-specific trained AI useful for training and examination preparation.

Percutaneous Neuromodulation of the Brachial Plexus and Sciatic Nerve for the Treatment of Acute Pain Following Surgery: Secondary Outcomes From a Multicenter, Randomized, Controlled Pilot Study.

OBJECTIVES: We recently reported that percutaneous peripheral nerve stimulation (PNS or "neuromodulation") decreased pain and opioid consumption within the first two weeks following ambulatory surgery. However, the anatomic lead locations were combined for the analysis, and benefits for each location remain unknown. We therefore now report the effects of percutaneous PNS for brachial plexus and sciatic nerve leads separately. MATERIALS AND METHODS: Before surgery, leads were implanted percutaneously to target the brachial plexus (N = 21) for rotator cuff repair or sciatic nerve (N = 40) for foot/ankle surgery, followed by a single injection of local anesthetic. Postoperatively, subjects were randomized in a double masked fashion to 14 days of electrical stimulation (N = 30) or sham/placebo (N = 31) using an external pulse generator. The primary outcome of interest was opioid consumption and pain scores evaluated jointly. Thus, stimulation was deemed effective if superior on either outcome and at least noninferior on the other. RESULTS: For brachial plexus leads, during the first seven postoperative days pain measured with the numeric rating scale in participants given active stimulation was a median [interquartile range] of 0.8 [0.5, 1.6] versus 3.2 [2.7, 3.5] in patients given sham (p < 0.001). For this same group, opioid consumption in participants given active stimulation was 10 mg [5, 20] versus 71 mg [35, 125] in patients given sham (p = 0.043). For sciatic nerve leads, pain scores for the active treatment group were 0.7 [0, 1.4] versus 2.8 [1.6, 4.6] in patients given sham (p < 0.001). During this same period, participants given active stimulation consumed 5 mg [0, 30] of opioids versus 40 mg [20, 105] in patients given sham (p = 0.004). Treatment effects did not differ statistically between the two locations. CONCLUSIONS: Ambulatory percutaneous PNS of both the brachial plexus and sciatic nerve is an effective treatment for acute pain free of systemic side effects following painful orthopedic surgery.

Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study.

BACKGROUND: Percutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption. METHODS: Preoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days. RESULTS: During the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001). CONCLUSIONS: Percutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: A Pragmatic Effectiveness Trial of a Nonpharmacologic Alternative for the Treatment of Postoperative Pain.

BACKGROUND: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures). DESIGN: A multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months. SUMMARY: The postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.

A Preliminary Examination of the Comparative Efficacy of Intravenous vs Oral Acetaminophen in the Treatment of Perioperative Pain.

OBJECTIVE: The management of postoperative pain is a major health care issue. While the cost of intravenous acetaminophen (IVA) is significantly greater than its oral acetaminophen (OA) counterpart, less is known regarding comparative effectiveness of these routes. The purpose of this study was to determine whether perioperative IVA is equivalent in reducing postoperative pain compared with perioperative OA for laparoscopic cholecystectomy (LapChole). DESIGN: Double-blinded, prospective, randomized placebo-controlled trial. SETTING: Womack Army Medical Center, Fort Bragg, North Carolina. SUBJECTS: Adults (age > 18 years) active duty military, veterans, and beneficiaries receiving a laparoscopic cholecystectomy. METHODS: This study was conducted at Womack Army Medical Center (WAMC), Fort Bragg, North Carolina, between January 2013 and June 2015. Sixty-seven subjects with symptomatic cholelithiasis were randomly assigned to receive two doses (1,000 mg each) of either IVA or OA. A numerical rating scale (NRS) score of pain was obtained preoperatively and every six hours for 24 hours postoperation. The primary objective was to assess whether treatment groups had significantly different 24-hour postoperative sum of pain intensity differences (SPID24) using an analysis of covariance test. RESULTS: Sixty subjects completed the study and were included in the analysis. Treatment groups did not differ in SPID24, even when controlling for age, gender, and preoperative pain levels (F(1,55) = 0.39, P = 0.54, partial η2 = 0.007), nor did 24-hour opioid consumption when controlling for age, gender, and operation time (F(1, 46) = 0.47, P = 0.50, partial η2 = 0.01). Furthermore, treatment groups were equally as likely to report average postoperative NRS scores of 4 or higher (ß = 0.24, Exp(B) = 1.28, P = 0.68). CONCLUSIONS: The results show no evidence of differences between IVA or OA in pain or opioid consumption among a sample of patients undergoing LapChole. Due to low sample size, these descriptive findings warrant larger studies, which may have a significant economic impact.

Determinants of Patient Satisfaction in a Private Practice Pain Management Clinic.

BACKGROUND: Patient satisfaction is used to measure physician performance in hospital and governmental practice settings. There is limited understanding about factors affecting satisfaction in a chronic pain management setting for patients prescribed chronic opioids. OBJECTIVE: To identify the determinants of patient satisfaction and correlation with recommended outcome measures in a private practice pain management clinic. METHODS: We performed a 4-week quality assessment survey to define the determinants of patient satisfaction among pain management patients who were prescribed opioids. The data obtained from the survey were analyzed with descriptive and multiple regression analysis. RESULTS: Overall provider satisfaction was 96% and clinic satisfaction was 94% for a chronic pain population prescribed opioids for over 1 year. There was no correlation between provider satisfaction and functional outcomes. Only "level of stress" correlated with positive clinic satisfaction. The remainder of the functional outcomes were not correlated with satisfaction. "Listened to you carefully about your questions and concerns," "Treated you with courtesy and respect," and "Helped you with your problem" were found to be significant predictors of provider satisfaction. CONCLUSIONS: These results indicate that a patient's perception of a provider's engagement and concern more heavily impacts perceived satisfaction than the patient's progress. A patient's perception of his or her clinic experience is heavily influenced by the attentiveness and coordination of the entire clinic care team. Staff attentiveness and coordination may affect a patient's level of stress. Adherence to current opioid prescription guidelines did not appear to have an overall negative effect on patient satisfaction.

Epidural lysis of adhesions for failed back surgery and spinal stenosis: factors associated with treatment outcome.

BACKGROUND: Failed back surgery syndrome (FBSS) is a challenging problem. One treatment advocated to treat FBSS is epidural lysis of adhesions (LOA). The results of studies examining LOA for FBSS have been mixed, but are limited because no study has ever sought to identify factors associated with outcomes. METHODS: We performed this multicenter, retrospective study in 115 patients who underwent LOA for FBSS (n = 104) or spinal stenosis (n = 11) between 2004 and 2007. Twenty-seven demographic, clinical, and procedural variables were extracted from medical records and correlated with the outcome, defined as ≥50% pain relief lasting ≥1 month. Univariable analysis was performed, followed by multivariable logistic regression. RESULTS: Overall, 48.7% (95% confidence interval [CI], 39.3%-58.1%) of patients experienced a positive outcome. In univariable analysis, those who had a positive outcome were older (mean age 64.1 years; 95% CI, 59.7-68.6 vs 57.2; 95% CI, 53.0-61.4 years; P = 0.02), while higher baseline numerical rating scale pain scores were associated with a negative outcome (mean 6.7 years; 95% CI, 6.0-7.3 vs 7.5; 95% CI, 6.9-8.0; P = 0.07). Use of hyaluronidase did not correlate with outcomes in univariable analysis (odds ratio [OR], 1.2; 95% CI, 0.6-2.5; P = 0.65). In multivariable analysis, age ≥81 years (OR, 7.8; 95% CI, 1.4-53.7), baseline numerical rating scale score ≤9 (OR, 4.4; 95% CI, 1.4-16.3, P = 0.02), and patients on or seeking disability or worker's compensation (OR, 4.4; 95% CI, 1.1-19.5, P = 0.04) were significantly more likely to experience a positive outcome. CONCLUSIONS: Considering our modest success rate, selecting patients for epidural LOA based on demographic and clinical factors may help better select treatment candidates. Procedural factors such as the use of hyaluronidase that increase risks and costs did not improve outcomes, so further research is needed before these become standard practice.

A multicenter, randomized, controlled study evaluating preventive etanercept on postoperative pain after inguinal hernia repair.

BACKGROUND: Chronic postsurgical pain (CPSP) affects between 5% and 70% of surgical patients, depending on the surgery. There is no reliable treatment for CPSP, which has led to an increased emphasis on prevention. In this study, we sought to determine whether preventive etanercept can decrease the magnitude of postoperative pain and reduce the incidence of CPSP. METHODS: We performed a multicenter, randomized study in 77 patients comparing subcutaneous etanercept 50 mg administered 90 minutes before inguinal hernia surgery with saline. Patients, surgeons, anesthesiologists, the injecting physician, nursing staff, and evaluators were blinded. The primary outcome measure was a 24-hour numerical rating scale pain score. Secondary outcome measures were postanesthesia care unit pain scores, 24-hour opioid requirements, time to first analgesic, and pain scores recorded at 1 month, 3 months, 6 months, and 12 months. RESULTS: Mean 24-hour pain scores were 3.3 (95% confidence interval [CI], 3.2-4.6) in the etanercept and 3.9 (95% CI, 2.6-4.0) in the control group (P=0.22). The mean number of analgesic pills used in the first 24 hours was 4.0 (SD, 2.8) in the treatment versus 5.8 (SD, 4.2) in the control group (P=0.03). At 1 month, 10 patients (29%) in the treatment group reported pain versus 21 (49%) control patients (P=0.08). The presence of pain at 1 month was significantly associated with pain at 3 months (hazard ratio, 0.74; 99% CI, 0.52-0.97; P=0.03). CONCLUSION: Although preventive etanercept was superior to saline in reducing postoperative pain on some measures, the effect sizes were small, transient, and not statistically significant. Different dosing regimens in a larger population should be explored in future studies.

Peripheral nerve block adjuncts: which medication to choose? A narrative review of the current literature.

Enhancing the effect of peripheral nerve blockade by adding other classes of medications has long history of trial and error. Studies have identified multiple potentially beneficial adjuncts that work to either speed the onset of analgesia or prolong its duration. The benefits of these adjuncts must be weighed against the risks of systemic negative side effects. To date, the most commonly used adjuncts, and ones with the most robust scientific efficacy are, dexamethasone, dexmedetomidine and buprenorphine. This narrative review will discuss several classes of local anesthetic adjuncts and provide evidence for the clinical efficacy and side effect profile of the most commonly studied medications.

Headaches during war: analysis of presentation, treatment, and factors associated with outcome.

BACKGROUND: Headache is often associated with physical trauma and psychological stress. The aim of this study is to evaluate the impact of headache on personnel deployed in war zones and to identify factors associated with return to duty (RTD). METHODS: Outcome data were prospectively collected on 985 personnel medically evacuated out of Operations Iraqi and Enduring Freedom for a primary diagnosis of headache between 2004 and 2009. Electronic medical records were reviewed to examine clinical and treatment patterns and the effect that myriad factors had on RTD. RESULTS: 33.6% of evacuees returned to duty. The most common headaches were post-concussion (34.1%) and migraine (30.0%). Headaches typically associated with trauma such as post-concussion (18.7%), occipital neuralgia (23.1%), and cervicogenic headache (29.7%) had the lowest RTD rates, whereas tension headache (49.6%) was associated with the best outcome. Other variables associated with negative outcome included presence of aura (OR 0.51, 95% CI 0.30-0.88; p = 0.02), traumatic brain injury (OR 0.50, 95% CI 0.29-0.87; p = 0.01), opioid (OR 0.41, 95% CI 0.26-0.63; p < 0.001), and beta-blocker (OR 0.26, 95% CI 0.12-0.61; p = 0.002) use, and co-existing psychopathology (p < 0.001 in univariable analysis). CONCLUSION: Headaches represent a significant cause of unit attrition in personnel deployed in military operations, with physical trauma and co-existing psychopathology associated with poorer outcomes.

The application of genomic and molecular data in the treatment of chronic cancer pain.

Many cancer patients will develop complex pain syndromes requiring aggressive, innovative, and comprehensive multimodal pain management strategies. Recently, data from both animal studies and clinical trials have allowed clinical research to focus on creating applicable clinical treatment strategies. This article is a review of genomic and molecular data, which has contributed to creating novel modalities for use in clinical pain management of patients with cancer-induced pain.

Regional anesthesia for breast cancer surgery: which block is best? A review of the current literature.

Breast cancer is the most common type of cancer worldwide. Fortunately, continual advances in diagnosis and treatment are resulting in increased survival rates. Earlier detection and treatment, to include surgical resection, can greatly improve patients outcomes. However, due to the complex innervation of the breast, management of postoperative pain has proven difficult in the past. Approximately, half of all women who undergo breast cancer surgery report postoperative pain syndrome. The paravertebral block has long been the anesthesiologist's choice for mitigating pain during and after the procedure. Newer techniques such as the pectoral nerve block and erector spinae plane block may prove to have some additional benefits. This literature review compares the risks, benefits and specific uses of these three regional nerve blocks in women undergoing breast cancer surgery. It aims to better inform anesthesiologists when they are choosing which technique is best for their patients.

Breast cancer is the most common type of cancer worldwide with 2 million new cases each year. Approximately 12% of women are diagnosed with breast cancer at some point in their lives. Part of breast cancer treatment often involves surgery to remove a mass. This can cause pain in both the short and long term. There are multiple different kinds of procedures a person can have done that may decrease the pain, they have from that surgery. These procedures are called nerve blocks. This article examines how well different nerve blocks decrease pain from breast cancer surgery. The nerve blocks we review in this article are called paravertebral blocks, pectoral nerve blocks and erector spinae plane blocks. They all block pain from breast surgery in slightly different ways. The decision of which block is best rests on the person performing the block.

Diagnoses and factors associated with medical evacuation and return to duty for service members participating in Operation Iraqi Freedom or Operation Enduring Freedom: a prospective cohort study.

BACKGROUND: Anticipation of the types of injuries that occur in modern warfare is essential to plan operations and maintain a healthy military. We aimed to identify the diagnoses that result in most medical evacuations, and ascertain which demographic and clinical variables were associated with return to duty. METHODS: Demographic and clinical data were prospectively obtained for US military personnel who had been medically evacuated from Operation Iraqi Freedom or Operation Enduring Freedom (January, 2004-December, 2007). Diagnoses were categorised post hoc according to the International Classification of Diseases codes that were recorded at the time of transfer. The primary outcome measure was return to duty within 2 weeks. FINDINGS: 34 006 personnel were medically evacuated, of whom 89% were men, 91% were enlisted, 82% were in the army, and 86% sustained an injury in Iraq. The most common reasons for medical evacuation were: musculoskeletal and connective tissue disorders (n=8104 service members, 24%), combat injuries (n=4713, 14%), neurological disorders (n=3502, 10%), psychiatric diagnoses (n=3108, 9%), and spinal pain (n=2445, 7%). The factors most strongly associated with return to duty were being a senior officer (adjusted OR 2.01, 95% CI 1.71-2.35, p<0.0001), having a non-battle-related injury or disease (3.18, 2.77-3.67, p<0.0001), and presenting with chest or abdominal pain (2.48, 1.61-3.81, p<0.0001), a gastrointestinal disorder (non-surgical 2.32, 1.51-3.56, p=0.0001; surgical 2.62, 1.69-4.06, p<0.0001), or a genitourinary disorder (2.19, 1.43-3.36, p=0.0003). Covariates associated with a decreased probability of return to duty were serving in the navy or coast guard (0.59, 0.45-0.78, p=0.0002), or marines (0.86, 0.77-0.96, p=0.0083); and presenting with a combat injury (0.27, 0.17-0.44, p<0.0001), a psychiatric disorder (0.28, 0.18-0.43, p<0.0001), musculoskeletal or connective tissue disorder (0.46, 0.30-0.71, p=0.0004), spinal pain (0.41, 0.26-0.63, p=0.0001), or other wound (0.54, 0.34-0.84, p=0.0069). INTERPRETATION: Implementation of preventive measures for service members who are at highest risk of evacuation, forward-deployed treatment, and therapeutic interventions could reduce the effect of non-battle-related injuries and disease on military readiness. FUNDING: John P Murtha Neuroscience and Pain Institute, and US Army Regional Anesthesia and Pain Management Initiative.

Diagnoses and factors associated with medical evacuation and return to duty among nonmilitary personnel participating in military operations in Iraq and Afghanistan.

BACKGROUND: Nonmilitary personnel play an increasingly critical role in modern wars. Stark differences exist between the demographic characteristics, training and missions of military and nonmilitary members. We examined the differences in types of injury and rates of returning to duty among nonmilitary and military personnel participating in military operations in Iraq and Afghanistan. METHODS: We collected data for nonmilitary personnel medically evacuated from military operations in Iraq and Afghanistan between 2004 and 2007. We compared injury categories and return-to-duty rates in this group with previously published data for military personnel and identified factors associated with return to duty. RESULTS: Of the 2155 medically evacuated nonmilitary personnel, 74.7% did not return to duty. War-related injuries in this group accounted for 25.6% of the evacuations, the most common causes being combat-related injuries (55.4%) and musculoskeletal/spinal injuries (22.9%). Among individuals with non-war-related injuries, musculoskeletal injuries accounted for 17.8% of evacuations. Diagnoses associated with the highest return-to-duty rates in the group of nonmilitary personnel were psychiatric diagnoses (15.6%) among those with war-related injuries and noncardiac chest or abdominal pain (44.0%) among those with non-war-related injuries. Compared with military personnel, nonmilitary personnel with war-related injuries were less likely to return to duty (4.4% v. 5.9%, p = 0.001) but more likely to return to duty after non-war-related injuries (32.5% v. 30.7%, p = 0.001). INTERPRETATION: Compared with military personnel, nonmilitary personnel were more likely to be evacuated with non-war-related injuries but more likely to return to duty after such injuries. For evacuations because of war-related injuries, this trend was reversed.

A multi-center analysis evaluating factors associated with spinal cord stimulation outcome in chronic pain patients.

BACKGROUND: In addition to its conventional use as a treatment for refractory neuropathic extremity pain, spinal cord stimulation (SCS) has recently emerged as a possible treatment for visceral and arthritic pain. But concurrent with the expansion of possible conditions amenable to SCS, other studies have questioned the long-term efficacy of SCS for traditional indications. These disparate findings argue strongly for the refinement of selection criteria. The purpose of this study is to identify correlates of outcome for SCS. METHODS: Data were retrospectively collected on 244 patients who underwent a SCS trial at two academic medical centers. Success was predefined as ≥50% pain relief sustained for ≥6 months. Variables analyzed for their association with outcome included demographics, location of pain, diagnosis, presence of coexisting diseases, pain descriptors, opioid and adjuvant medication use, duration and pain relief during trial, and complications. RESULTS: The presence of allodynia and/or hyperalgesia correlated with both a positive SCS trial (P = 0.01) and long-term implantation outcome (P = 0.05). History of substance abuse was associated with a negative permanent SCS outcome (P = 0.05) but bore no relationship to trial results. The variable most strongly associated with an SCS outcome was experiencing <50% pain relief during the trial, which strongly presaged a negative result (P < 0.001). CONCLUSIONS: Although weak associations with outcome were noted for several clinical variables, none was strongly associated with trial and permanent implantation results. The strongest predictor of a negative SCS outcome was obtaining <50% pain relief during the trial period.

Ketamine in pain management.

Ketamine is an N-methyl-D-aspartate receptor antagonist that has been in clinical use in the USA for over 30 years. Its ability to provide profound analgesia and amnesia while maintaining spontaneous respiration makes it an ideal medication for procedure-related pain and trauma. In the chronic pain arena, its use continues to evolve. There is strong evidence to support its short-term use for neuropathic and nociceptive pain, and conflicting evidence for preemptive analgesia. Its potential ability to prevent 'windup' and, possibly, 'reboot' aberrant neurologic pathways in neuropathic and central pain states has generated intense interest. However, the long-term use of ketamine for chronic neuropathic pain is limited by its side effect profile, and is largely anecdotal. More research is needed to better ascertain its long-term efficacy and side effects, to determine the ideal candidates for sustained treatment and to develop means of exploiting the antinociceptive properties of ketamine while minimizing the adverse effects.

Continuous thoracic paravertebral nerve block in a working anesthesia resident-when opioids are not an option.

Multiple unilateral rib fractures can cause significant pain and morbidity. Continuous nerve block catheters are often maintained while inpatient, and patients are discharged with oral analgesics. However, in many institutions, this dynamic is changing and patients are being managed effectively with outpatient catheters. A 45-year-old male was presented with fractured right ribs 6 through 9. The patient was an anesthesiology resident and was unable to perform his clinical duties. Single paravertebral nerve blocks were performed at right thoracic levels 6-9. At the T7 level, an indwelling catheter was placed. On post-injury day 18, he was able to discontinue the catheter and there were no associated complications. We report a unique case of a patient with multiple rib fractures who was not able to be exposed to potential side effects of opioids. The use of a continuous thoracic paravertebral nerve in an outpatient setting allowed a faster return to function with no adverse events.

Development of a complicated pain syndrome following cyanide poisoning in a U.S. soldier.

A majority of modern war wounds are caused by blasts and high-energy ballistics. Extremity injuries predominate since modern body armor does not protect these areas due to mobility limitations. A less known and more insidious mechanism of enemy attack among our soldiers involves treachery by the local populace posing as noncombatants. One such recent event involved the contamination of tobacco with cyanide (CN). We describe a case of a soldier with CN intoxication due to ingestion of tobacco purchased from a local merchant. The soldier developed a complex neuropathic pain syndrome and was successfully treated with an inpatient high-dose intravenous ketamine infusion in combination with continuous peripheral nerve blockade.

Loss of resistance technique for paravertebral nerve blockade using the Episure Autodetect Syringe--a case report.

INTRODUCTION: Postoperative pain is a frequent occurrence following breast surgery. Some authors have reported the incidence of postoperative pain following mastectomy and breast reconstruction to be as high as 50% when general anesthesia and intravenous narcotics are the primary anesthetic. An alternative anesthetic technique for breast surgery and postoperative analgesia is paravertebral nerve blockade (PVB). Greengrass and Weltz have described improved patient satisfaction, less analgesic requirement, and less total anesthetic use in those patients with preoperative PVBs. One of the challenges in providing successful analgesia from PVBs is the ability to correctly identify the paravertebral space. Landmark-based anatomy with penetration of the superior costotransverse ligament 1 cm past the transverse process has been previously described. Boezaart has described the use of loss of resistance (LOR) when performing PVBs. One potential difficulty with this technique is the reliance on the subjective feel of resistance loss as the needle passes into the paravertebral space. CASE REPORT: The Episure Autodetect Syringe is currently indicated by the US Food and Drug Administration for use with an epidural needle for the verification for needle tip placement in the epidural space. The principle, however, of LOR is similar when performing PVBs. We report a case of the successful use of the Episure Autodetect Syringe (ADS) for confirming entry into the paravertebral space. CONCLUSION: To our knowledge, this is the first described use of the ADS for performing PVB.

Opioid-free balanced anesthesia for cervical ganglionectomy subsequent to recent ultra rapid opioid detoxification.

OBJECTIVE: To perform an opioid-free, balanced anesthetic for an Active Duty soldier undergoing cervical ganglionectomy for intractable occipital neuralgia 7 days after ultra rapid opioid detoxification (UROD) under general anesthesia. SETTING: Opioids have been a mainstay for both intraoperative and postoperative analgesia. With the emergence of newer non-opioid analgesics and the practice of the multimodal analgesia, opioid therapy will be complimented and, in some cases, replaced by these newer agents. The increasing knowledge in the literature of both pain mechanisms and chronic pain treatment can present anesthesiologists with a challenge when faced with opioid-tolerant patients in the acute perioperative setting. With an increased focus on adequate pain control among health care regulatory agencies, we may expect to see a growing number of patients who desire weaning from chronic opioid therapy. There have been many weaning protocols proposed in the literature, with UROD under general anesthesia being one of them. We report a case of successful non-opioid analgesia in a patient that presented for a cervical ganglionectomy 7 days after UROD. CONCLUSIONS: This patient successfully completed a perioperative and postoperative course using ketamine and dexmedetomidine infusions, in addition to other non-opioid adjuncts. The patient returned to her Active Duty station, with increased functional capacity and remains opioid-free.