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Jones J, Eskin L, Barron M, Yoshida R, Tsai EY, Chen E, Shin J, Mendelson B. Anesthesia Complications and Considerations with Hand and Wrist Surgery. Orthop Clin North Am 2025; 56:165-175. [PMID: 40044350 DOI: 10.1016/j.ocl.2024.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2025]
Abstract
Anesthesia has become very safe. Numerous anesthetic options for hand and wrist surgery exist. Optimizing patient outcomes can be achieved more reliably when anesthesiologists and surgeons collaborate to better understand the surgical and patient-related needs for anesthesia. Examples include planning for the anticipated degree of tourniquet-related pain for longer surgeries, determining if patient can tolerate deep sedation without secured airway, and determining the best way to obtain optimal surgical field visualization. Understanding the risks and benefits of various anesthetic options from surgical and anesthetic perspectives will help in making informed decisions about anesthetic options.
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Affiliation(s)
- Jerry Jones
- Department of Anesthesiology, University of Tennessee Health Science Center, Memphis, TN, USA; East Memphis Anesthesia Services, Memphis, TN, USA.
| | - Logan Eskin
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Michael Barron
- Department of Anesthesiology, Beth Israel Lahey Health, Burlington, MA, USA
| | - Ryu Yoshida
- Department of Orthopedics, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Eugene Y Tsai
- Cedars-Sinai Medical Center, 8635 West Third Street, Suite 990W, Los Angeles, CA 90048, USA
| | - Ellison Chen
- Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Janet Shin
- Department of Anesthesiology, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Brian Mendelson
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Finneran Iv JJ, Ilfeld BM. Percutaneous auricular neuromodulation for postoperative analgesia. Expert Rev Med Devices 2025; 22:339-348. [PMID: 40042606 DOI: 10.1080/17434440.2025.2474731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2024] [Accepted: 02/26/2025] [Indexed: 04/09/2025]
Abstract
INTRODUCTION Postoperative pain is often severe, with many patients still experiencing significant pain upon discharge. While opioids are effective for pain relief, they have numerous side effects and carry a high risk for misuse and dependence. Auricular electric stimulation, a form of neuromodulation, offers a promising alternative by electrically stimulating nerves of the auricle to modulate central pain pathways, potentially reducing postoperative pain and opioid requirements. AREAS COVERED This review, based on a search of the MEDLINE/PubMed, Scopus, and Cochrane review online sources from 1980 to 2024, discusses the use of auricular electric stimulation as a form of neuromodulation for management of postoperative pain focusing on the available evidence and future avenues for research. EXPERT OPINION Percutaneous auricular nerve stimulation offers a promising neuromodulation technique for managing postoperative pain. By modulating central pain processing through peripheral stimulation, this approach may reduce pain during recovery. Small pilot studies have suggested that auricular stimulation may lower pain intensity and reduce opioid consumption after surgery; however, further research is needed regarding both potential benefits and risks. As a minimally invasive technique, percutaneous auricular stimulation may provide a valuable adjunct to multimodal analgesia, especially in patients at risk of opioid-related complications.
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Affiliation(s)
- John J Finneran Iv
- Department of Anesthesiology, Outcomes Research Consortium, University California San Diego, San Diego, CA
- University of California San Diego, La Jolla, CA, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, Outcomes Research Consortium, University California San Diego, San Diego, CA
- University of California San Diego, La Jolla, CA, USA
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Provenzano DA, Hanes M, Hunt C, Benzon HT, Grider JS, Cawcutt K, Doshi TL, Hayek S, Hoelzer B, Johnson RL, Kalagara H, Kopp S, Loftus RW, Macfarlane AJR, Nagpal AS, Neuman SA, Pawa A, Pearson ACS, Pilitsis J, Sivanesan E, Sondekoppam RV, Van Zundert J, Narouze S. ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine. Reg Anesth Pain Med 2025:rapm-2024-105651. [PMID: 39837579 DOI: 10.1136/rapm-2024-105651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 08/27/2024] [Indexed: 01/23/2025]
Abstract
BACKGROUND To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management. METHODS Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines. RESULTS After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics. CONCLUSIONS The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.
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Affiliation(s)
| | - Michael Hanes
- Jax Spine and Pain Centers, Jacksonville, Florida, USA
| | - Christine Hunt
- Anesthesiology-Pain Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Honorio T Benzon
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of Pain Medicine, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Jay S Grider
- Department of Anesthesiology, University of Kentucky, Lexington, Kentucky, USA
| | - Kelly Cawcutt
- Division of Infectious Diseases and Pulmonary & Critical Care Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tina L Doshi
- Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Division of Pain Medicine, John Hopkins University, Baltimore, Maryland, USA
- Department of Neurosurgery, John Hopkins University, Baltimore, Maryland, USA
| | - Salim Hayek
- Anesthesiology, Case Western Reserve University, Cleveland, Ohio, USA
- University Hospitals of Cleveland, Cleveland, Ohio, USA
| | | | - Rebecca L Johnson
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Sandra Kopp
- Anesthesiology, Mayo Clinic Graduate School for Biomedical Sciences, Rochester, Minnesota, USA
| | - Randy W Loftus
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ameet S Nagpal
- Department of Orthopaedics and Physical Medicine & Rehabilitation, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stephanie A Neuman
- Department of Pain Medicine, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Amit Pawa
- Department of Theatres, Anaesthesia and Perioperative Medicine, Guy's and St Thomas' Hospitals NHS Trust, London, UK
- King's College London, London, UK
| | - Amy C S Pearson
- Anesthesia, Advocate Aurora Health Inc, Milwaukee, Wisconsin, USA
| | | | - Eellan Sivanesan
- Neuromodulation, Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rakesh V Sondekoppam
- Department of Anesthesia, Pain, and Perioperative Medicine, Stanford University, Palo Alto, California, USA
| | - Jan Van Zundert
- Anesthesiology and Pain Medicine, Maastricht University Medical Centre+, Maastricht, Limburg, The Netherlands
- Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Samer Narouze
- Division of Pain Management, University Hospitals, Cleveland, Ohio, USA
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Yoo S, Kim H, Kim JT. Perineural catheters for continuous peripheral nerve blocks: a narrative review. Anesth Pain Med (Seoul) 2025; 20:5-13. [PMID: 39923767 PMCID: PMC11834894 DOI: 10.17085/apm.24192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2024] [Revised: 01/06/2025] [Accepted: 01/06/2025] [Indexed: 02/11/2025] Open
Abstract
Continuous peripheral nerve blocks using perineural catheters are increasingly used because they are the only well-established techniques that can provide prolonged analgesia. Although the novel indications and benefits of each type of continuous peripheral nerve block have been well described in several review articles, there is a lack of recent publications focusing on the use of perineural catheters. Numerous clinical challenges are associated with the use of catheters for pain management. This narrative review discusses the currently available perineural catheter designs, catheter fixation methods, perineural catheter-related complications, and management strategies.
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Affiliation(s)
- Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hansol Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Perkins L, Pedroza G, Soghikian M, Santorelli JE, Haines LN, Box K, Lee JG, Gabriel R, Finneran JJ. Continuous peripheral nerve blocks for burn management: a retrospective study of outcomes and complications in 281 burn patients. Reg Anesth Pain Med 2024:rapm-2024-105930. [PMID: 39481877 DOI: 10.1136/rapm-2024-105930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2024] [Accepted: 10/16/2024] [Indexed: 11/03/2024]
Abstract
BACKGROUND There is scarce literature regarding the use of continuous peripheral nerve blocks in acute burn patients, who may be at higher risk for catheter-related complications, including infection. We sought to describe our center's experience and infection rate with continuous perineural catheters in the setting of pain management for patients suffering from burns. METHODS A retrospective observational study was performed including all patients admitted to an American Burn Association-verified regional burn center between January 2018 and July 2023 who received a continuous peripheral nerve block for an acute burn injury. RESULTS There were 281 patients in the study cohort who received 484 perineural catheters. The cohort was 52% men with a median age of 39 years (IQR 30-55). A catheter-associated infection, defined as a clinical diagnosis by the treating physicians requiring the need for treatment with antibiotics or surgical debridement, was identified in six perineural catheters (1.2%, 95% CI 0% to 2.2%) involving six different patients (2.1%, 95% CI 0% to 3.8%). The median total body surface area burned was 5% (IQR 2-9%) and 20% of patients had full-thickness burns. The most commonly used catheters were infraclavicular (49%), popliteal sciatic (29%), femoral (19%), and adductor canal (17%). One-third (33%) of patients did not require operating room debridement as the block provided sufficient analgesia for bedside debridement. The median duration of catheter use was 6 days (IQR 4-8). There were no documented cases of nerve injury or toxicity, vascular injury, or local anesthetic systemic toxicity. CONCLUSIONS In our practice, continuous perineural catheters in the setting of acute burns are associated with an infection rate comparable to other surgical populations.
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Affiliation(s)
- Louis Perkins
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Gerardo Pedroza
- Department of Anesthesiology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Max Soghikian
- Department of Anesthesiology, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Jarrett E Santorelli
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Laura N Haines
- Department of Surgery, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Kevin Box
- Department of Pharmacy, University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, California, USA
| | - Jeanne G Lee
- Department of Surgery, University of California San Diego, San Diego, California, USA
| | - Rodney Gabriel
- Anesthesiology, University of California San Diego, San Diego, California, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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Kaye AD, Plaisance TR, Smith SA, Ragland AR, Alfred MJ, Nguyen CG, Chami AA, Kataria S, Dufrene K, Shekoohi S, Robinson CL. Peripheral Nerve Stimulation in Postoperative Analgesia: A Narrative Review. Curr Pain Headache Rep 2024; 28:691-698. [PMID: 38642233 DOI: 10.1007/s11916-024-01257-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2024] [Indexed: 04/22/2024]
Abstract
PURPOSE OF REVIEW Recent research has shown the effectiveness of peripheral nerve stimulators (PNS) in managing chronic pain conditions. Ongoing studies aim to explore its potential application in treating acute postoperative pain states. The purpose of this systematic review is to assess the role of PNS in providing relief for postoperative pain. RECENT FINDINGS Clinical studies investigating the use of peripheral nerve stimulators (PNS) for analgesia following various surgeries, such as total knee arthroplasty, anterior cruciate ligament repair, ankle arthroplasty, rotator cuff repair, hallux valgus correction, and extremity amputation, have shown promising results. Lead placement locations include the brachial plexus, sciatic, femoral, tibial, genicular, perineal, sural, radial, median, and ulnar nerves. These studies consistently report clinically significant reductions in pain scores, and some even indicate a decrease in opioid consumption following PNS for postoperative pain. PNS involves the subcutaneous placement of electrode leads to target peripheral nerve(s) followed by delivery of an electric current via an external pulse generator. While the precise mechanism is not fully understood, the theory posits that PNS modulates electrical stimulation, hindering the signaling of nociceptive pain. PNS presents itself as an alternative to opioid therapy, holding promise to address the opioid epidemic by offering a nonpharmacologic approach for both acute and chronic pain states.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
- Department of Pharmacology, Toxicology, and Neurosciences, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Taylor R Plaisance
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Summer A Smith
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Amanda R Ragland
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Michael J Alfred
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Catherine G Nguyen
- School of Medicine, Louisiana State University Health Sciences Center at New Orleans, 2020 Gravier Street, New Orleans, LA, 70112, USA
| | - Azem A Chami
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA
| | - Saurabh Kataria
- Department of Neurology, Louisiana State University Health Sciences Center Shreveport, Shreveport, LA, 71103, USA
| | - Kylie Dufrene
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, 71103, USA.
| | - Christopher L Robinson
- Department of Anesthesiology, Critical Care, and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, 02215, USA
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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Anesthesiol Clin 2024; 42:317-328. [PMID: 38705679 DOI: 10.1016/j.anclin.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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Siddiqui A, Sekhri N, Salik I, Yu F, Xu JL. Peripheral Nerve Stimulation for Treating Acute Pain Following Traumatic Fracture: A Case Report of Rapid-Onset Analgesia Without Motor Blockade. Cureus 2024; 16:e62142. [PMID: 38993453 PMCID: PMC11238524 DOI: 10.7759/cureus.62142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 07/13/2024] Open
Abstract
Analgesia following acute traumatic fracture remains a clinical challenge. Pain relief via peripheral nerve stimulation (PNS) is a promising treatment modality due to its opioid-sparing effects and rapid, reversible sensory blockade without motor blockade. We present the case of a patient who suffered a traumatic tibial plateau fracture. A popliteal sciatic PNS device was placed on postoperative day 1 following inadequate pain control. The patient reported marked pain relief, a significant reduction in morphine milligram equivalent (MME) utilization, and improved early functional recovery. The PNS lead was removed at the patient's 2-month follow-up visit without any adverse events.
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Affiliation(s)
- Ammar Siddiqui
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, USA
| | - Nitin Sekhri
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, USA
| | - Irim Salik
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, USA
| | - Fang Yu
- Department of Neurology, Westchester Medical Center/New York Medical College, Valhalla, USA
| | - Jeff L Xu
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, USA
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Verdecchia N, Praslick A, Visoiu M. Safety Assessment of Prolonged Nerve Catheters in Pediatric Trauma Patients: A Case Series Study. CHILDREN (BASEL, SWITZERLAND) 2024; 11:251. [PMID: 38397363 PMCID: PMC11154573 DOI: 10.3390/children11020251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/05/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Nerve block catheters (NBCs) are increasingly used for pain management in pediatric trauma patients. While short-term efficacy has been well established, the long-term safety of NBCs is unknown. Methods/Cases: The retrospective chart review includes a cohort of nine pediatric trauma patients aged 3-15 years who received 52 peripheral nerve block catheters and epidurals for pain management. This study aimed to investigate the potential risks associated with the prolonged use of NBCs in pediatric trauma cases. RESULTS The NBCs (48 peripheral catheters and 4 epidural catheters) were maintained for about 2 weeks. The number of catheters per patient varied from 1 to 11. The study noted a low frequency of catheter-related complications. No catheter-site infection or local anesthetic toxicity symptoms were reported. DISCUSSION These findings suggest that NBCs can be safely maintained for extended periods in pediatric trauma patients without significantly increasing complications. Careful monitoring and adherence to infection control practices remain paramount when implementing extended catheter use.
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Affiliation(s)
- Nicole Verdecchia
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, 4401 Penn Ave., Pittsburgh, PA 15224, USA (M.V.)
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Ramin S, Bringuier S, Martinez O, Sadek M, Manzanera J, Deras P, Choquet O, Charbit J, Capdevila X. Continuous peripheral nerve blocks for analgesia of ventilated critically ill patients with multiple trauma: a prospective randomized study. Anaesth Crit Care Pain Med 2023; 42:101183. [PMID: 36496124 DOI: 10.1016/j.accpm.2022.101183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Sedation of ventilated critically ill trauma patients requires high doses of opioids and hypnotics. We aimed to compare the consumption of opioids and hypnotics, and patient outcomes using sedation with or without continuous regional analgesia (CRA). METHODS Multiple trauma-ventilated patients were included. The patients were randomized to receive an intravenous analgesia (control group) or an addition of CRA within 24h of admission. A traumatic brain injury (TBI) patients group was analyzed. The primary endpoint was the cumulative consumption of sufentanil at 2 days of admission. Secondary endpoints were cumulative and daily consumption of sufentanil and midazolam, duration of mechanical ventilation, intensive care unit (ICU) stay, and safety of CRA management. RESULTS Seventy six patients were analyzed: 40 (67.5% males) in the control group and 36 (72% males) in the CRA group, respectively. The median [IQR] Injury Severity Score was 30.5 [23.5-38.5] and 26.0 [22.0-41.0]. The consumption of sufentanil at 48h was 725 [465-960] μg/48h versus 670 [510-940] μg/48h (p = 0.16). Daily consumption did not differ between the groups except on day 1 when consumption of sufentanil was 360 [270-480] μg vs. 480 [352-535] μg (p = 0.03). Consumptions of midazolam did not differ between the groups. No difference was noted between the groups according to the secondary endpoints. CONCLUSIONS CRA does not decrease significantly sufentanil and midazolam consumption within the first 5 days after ICU admission in multiple trauma-ventilated patients. The use of peripheral nerve blocks in heavily sedated and ventilated trauma patients in the ICU seems safe.
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Affiliation(s)
- Severin Ramin
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Sophie Bringuier
- Department of Medical Statistics, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Orianne Martinez
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Meriem Sadek
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Jonathan Manzanera
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Pauline Deras
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Olivier Choquet
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France
| | - Jonathan Charbit
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France
| | - Xavier Capdevila
- Department of Anesthesiology and Critical Care Medicine, Hôpital Lapeyronie, Montpellier, France; OcciTRAUMA Network, Regional Network of Medical Organization and Management for Severe Trauma in Occitanie, France; Inserm U 1298, Neuro Sciences Institute, University of Montpellier, Montpellier, France.
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Hussain N, Brull R, Zhou S, Schroell R, McCartney C, Sawyer T, Abdallah FW. Analgesic benefits of single-shot versus continuous adductor canal block for total knee arthroplasty: a systemic review and meta-analysis of randomized trials. Reg Anesth Pain Med 2023; 48:49-60. [PMID: 36351742 DOI: 10.1136/rapm-2022-103756] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/21/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Adductor canal block (ACB) can provide important analgesic benefits following total knee arthroplasty (TKA), however, the extent to which these benefits can be enhanced or prolonged by a continuous catheter-based infusion compared with a single-shot injection of local anesthetic is unclear. OBJECTIVES This systematic review and meta-analysis (PROSPERO: CRD42021292738) review sought to compare the analgesic effectiveness of single shot to continuous ACB following TKA. EVIDENCE REVIEW We sought randomized trials from the US National Library of Medicine database (MEDLINE), Excerpta Medica database (EMBASE), and Cochrane Database of Systematic Reviews from inception to November 1, 2021, that compared single-shot to continuous ACB in adult patients undergoing TKA. The primary outcomes were (1) area under the curve (AUC) pain severity at rest and (2) cumulative opioid (oral morphine equivalent) consumption during the first 48 hours postoperatively. Secondary outcomes included postoperative pain severity scores up to 48 hours, cumulative opioid consumption at 24 hours, functional recovery, opioid-related side effects, and block-related complications. Risk of bias of included studies was assessed using the Cochrane risk of bias tool. Statistical pooling was conducted using the Hartung-Knapp-Sidik-Jonkman method for random effects. No funding was obtained for this review. FINDINGS Eleven trials (1185 patients) were included. No differences were observed in rest pain severity (AUC) or cumulative opioid consumption up to 48 hours postoperatively. In addition, no differences were observed in individual postoperative rest pain scores in the recovery room and at 12 and 24 hours, or in cumulative opioid consumption at 24 hours, functional recovery, and opioid-related side effects. Finally, fewer block-related complications were observed with single-shot ACB, with an OR (95% CI) of 0.24 (0.14 to 0.41) (p=0.002). CONCLUSIONS Our results suggest that continuous catheter-based ACB does not enhance or prolong the analgesic benefits when compared with single-shot ACB for TKA over the first 48 hours postoperatively. Overall, the results of our meta-analysis do not support the routine use of continuous ACB for postoperative analgesia after TKA.
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Affiliation(s)
- Nasir Hussain
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Richard Brull
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Steven Zhou
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Robert Schroell
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Colin McCartney
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tamara Sawyer
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | - Faraj W Abdallah
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Analgésie locorégionale en réanimation traumatologique. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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13
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Simmons CG, Hennigan AW, Loyd JM, Loftus RW, Sharma A. Patient Safety in Anesthesia: Hand Hygiene and Perioperative Infection Control. CURRENT ANESTHESIOLOGY REPORTS 2022; 12:493-500. [PMID: 36345323 PMCID: PMC9631600 DOI: 10.1007/s40140-022-00545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Abstract
Purpose of Review This review highlights the importance of the anesthesia team in minimizing perioperative infection risks and prevention of surgical site infection. Due to the immense financial and patient care burden that results from perioperative infection, a foundational knowledge in preventive measures is essential. Recent Findings Perioperative infection control, the role of the anesthesia team in reducing infection risk, and more specifically the outsized importance of hand hygiene in this space have become increasingly apparent. Maintenance of workspace cleanliness along with hand hygiene forms the cornerstone of preventing microbial transmission. Unfortunately, improvements around perioperative infection control are lacking. Summary The importance of the anesthesia team in maintaining proper hand hygiene, a clean work environment, and appropriate patient conditions to minimize risk of perioperative infection cannot be overstated. Poor clinical outcomes, economic burden, and external pressure from payers highlight the need for anesthesia providers to have an up-to-date knowledge of best practices in this area. In this article, we will review the current recommendations for hand hygiene practices and perioperative infection prevention.
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Affiliation(s)
- Colby G. Simmons
- Department of Anesthesiology, University of Colorado– Anschutz Medical Campus, Mail Stop B113, Leprino Building, 12401 E 17th Ave. Leprino Bldg #734, Aurora, CO 80045 USA
| | - Andrew W. Hennigan
- Department of Anesthesiology, University of Colorado– Anschutz Medical Campus, Mail Stop B113, Leprino Building, 12401 E 17th Ave. Leprino Bldg #734, Aurora, CO 80045 USA
| | - Jacob M. Loyd
- Department of Anesthesiology, University of Colorado– Anschutz Medical Campus, Mail Stop B113, Leprino Building, 12401 E 17th Ave. Leprino Bldg #734, Aurora, CO 80045 USA
| | - Randy W. Loftus
- Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, 6618 John Colloton Pavillion, Iowa City, IA 52242 USA
| | - Archit Sharma
- Department of Anesthesia, University of Iowa Roy J. and Lucille A. Carver College of Medicine, 200 Hawkins Drive, 6618 John Colloton Pavillion, Iowa City, IA 52242 USA
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14
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Stern JI, Chiang C, Kissoon NR, Robertson CE. Narrative review of peripheral nerve blocks for the management of headache. Headache 2022; 62:1077-1092. [DOI: 10.1111/head.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/21/2022] [Accepted: 07/18/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Jennifer I. Stern
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
| | - Chia‐Chun Chiang
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
| | - Narayan R. Kissoon
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
- Division of Pain Medicine, Department of Anesthesiology Mayo Clinic Rochester Minnesota USA
| | - Carrie E. Robertson
- Headache Division, Department of Neurology Mayo Clinic Rochester Minnesota USA
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15
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Kumar A, Sinha C, Kumar A, Kumari P. Double-tunneled catheter method for continuous peripheral nerve block. J Anaesthesiol Clin Pharmacol 2022; 38:663-664. [PMID: 36778813 PMCID: PMC9912893 DOI: 10.4103/joacp.joacp_608_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/17/2021] [Indexed: 12/31/2022] Open
Affiliation(s)
- Amarjeet Kumar
- Department of Trauma and Emergency, All India Institute of Medical Sciences (AIIMS), Patna, Bihar, India
| | - Chandni Sinha
- Department of Anaesthesia, All India Institute of Medical Sciences (AIIMS), Patna, Bihar, India
| | - Ajeet Kumar
- Department of Anaesthesia, All India Institute of Medical Sciences (AIIMS), Patna, Bihar, India
| | - Poonam Kumari
- Department of Anaesthesia, All India Institute of Medical Sciences (AIIMS), Patna, Bihar, India
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16
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Gabriel RA, Ilfeld BM. Extending Perioperative Analgesia with Ultrasound-Guided, Percutaneous Cryoneurolysis, and Peripheral Nerve Stimulation (Neuromodulation). Anesthesiol Clin 2022; 40:469-479. [PMID: 36049875 DOI: 10.1016/j.anclin.2022.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The use of regional anesthesia is key to a successful approach to improving postoperative analgesia, which involves local anesthetic deposition either around peripheral nerves or within a fascial plane. Unfortunately, the realistic duration even with continuous peripheral nerve blocks usually does not match the duration of surgical pain, comprising a major limitation. Here, the use of 2 interventional modalities-ultrasound-guided percutaneous cryoneurolysis and peripheral nerve stimulation-is discussed, both of which may be used to treat acute and subacute pain and may therefore have a positive impact on the incidence and severity of chronic pain development.
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Affiliation(s)
- Rodney A Gabriel
- Division of Regional Anesthesia and Acute Pain medicine, Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103-8990, USA
| | - Brian M Ilfeld
- Division of Regional Anesthesia and Acute Pain medicine, Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103-8990, USA; Department of Anesthesiology, 9500 Gilman Drive, MC 0898, La Jolla, CA 92093-0898, USA.
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17
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Deiling B, Mullen K, Shilling AM. Continuous Catheter Techniques. Clin Sports Med 2022; 41:317-328. [PMID: 35300843 DOI: 10.1016/j.csm.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Continuous peripheral nerve block catheters are simple in concept: percutaneously inserting a catheter adjacent to a peripheral nerve. This procedure is followed by local anesthetic infusion via the catheter that can be titrated to effect for extended anesthesia or analgesia in the perioperative period. The reported benefits of peripheral nerve catheters used in the surgical population include improved pain scores, decreased narcotic use, decreased nausea/vomiting, decreased pruritus, decreased sedation, improved sleep, and improved patient satisfaction.
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Affiliation(s)
- Brittany Deiling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA.
| | - Kenneth Mullen
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, PO Box 800710, Charlottesville, VA 22908-0710, USA
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18
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Kamel I, Ahmed MF, Sethi A. Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know. World J Orthop 2022; 13:11-35. [PMID: 35096534 PMCID: PMC8771411 DOI: 10.5312/wjo.v13.i1.11] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/20/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.
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Affiliation(s)
- Ihab Kamel
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Muhammad F Ahmed
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Anish Sethi
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
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19
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Albright-Trainer B, Phan T, Trainer RJ, Crosby ND, Murphy DP, Disalvo P, Amendola M, Lester DD. Peripheral nerve stimulation for the management of acute and subacute post-amputation pain: a randomized, controlled feasibility trial. Pain Manag 2021; 12:357-369. [PMID: 34761694 DOI: 10.2217/pmt-2021-0087] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Introduction & aim: Temporary (60-day) percutaneous peripheral nerve stimulation (PNS) has demonstrated effectiveness for the treatment of chronic post-amputation pain, and this pilot study aims to evaluate the feasibility of temporary percutaneous PNS for the treatment of acute post-amputation pain. Patients & methods: Sixteen veterans undergoing lower extremity amputation received PNS and standard medical therapy or standard medical therapy alone. Results: The PNS group reported greater reductions in average phantom limb pain, residual limb pain and daily opioid consumption, and there were fewer participants taking opioids through 3 months post-amputation. Conclusion: This pilot study suggests that PNS is feasible in the acute postoperative period following lower limb amputation and may provide a non-pharmacologic analgesic therapy that lowers pain scores and reduces opioid consumption, and thus warrants further investigation.
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Affiliation(s)
- Brooke Albright-Trainer
- Department of Anesthesiology, Central Virginia VA Health Care System, Richmond, VA 23249, USA.,Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA 23249, USA
| | - Thomas Phan
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Robert J Trainer
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | | | - Douglas P Murphy
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Peter Disalvo
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Michael Amendola
- Department of Surgery, Central Virginia VA Health Care System, Richmond, VA 23249, USA
| | - Denise D Lester
- Department of Physical Medicine & Rehab, Central Virginia VA Health Care System, Richmond, VA 23249, USA
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20
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Zhao C, Jia Z, Shrestha N, Luo F. REDUCE trial: the effects of perineural dexamethasone on scalp nerve blocks for relief of postcraniotomy pain-a study protocol for a randomized controlled trial. Trials 2021; 22:772. [PMID: 34736497 PMCID: PMC8567555 DOI: 10.1186/s13063-021-05747-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is common in the first 2 days after major craniotomy. Inadequate analgesia may lead to an increased risk of postoperative complications. Most pain following craniotomy arises from the pericranial muscles and soft tissues of the scalp. Scalp nerve blocks with local anesthesia seem to provide effective, safe, however, transient postoperative analgesia which does not seem to meet the requirements of craniotomy. Currently, peripheral dexamethasone has been observed to significantly prolong the duration of analgesia of nerve blocks (e.g., saphenous nerve block, adductor canal block, thoracic paravertebral block, brachial plexus nerve block). On the contrary, a study reported that perineural dexamethasone did not appear to prolong the analgesic time after supratentorial craniotomy. However, all patients in this study were given 24 mg of oral or intravenous dexamethasone regularly for at least 7 days during the perioperative period, which possibly masked the role of single local low doses of perineural dexamethasone. Therefore, the analgesic effect of single dexamethasone for scalp nerve blocks without the background of perioperative glucocorticoid deserves further clarification. METHODS The REDUCE trial is a prospective, single-center, parallel-group randomized controlled trial involving a total of 156 adults scheduled for elective craniotomy with general anesthesia. Patients will be randomly divided among two groups: the control group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus normal saline with epinephrine at 1:200,000; the DEX4mg group (n = 78) will receive scalp nerve blocks with 0.5% bupivacaine, plus 4 mg dexamethasone with epinephrine at 1:200,000. The primary outcome will be the duration of analgesia, defined as the time between the performance of the block and the first analgesic request. DISCUSSION The REDUCE trial aims to further assess the analgesic effect of single dexamethasone as an adjuvant to scalp nerve blocks for relief of postcraniotomy pain without the background of perioperative glucocorticoid. TRIAL REGISTRATION ClinicalTrials.gov NCT04648358 . Registered on November 30, 2020.
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Affiliation(s)
- Chunmei Zhao
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Zipu Jia
- Department of Day Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Niti Shrestha
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Fang Luo
- Department of Pain Management, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China.
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21
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Butler JT, Robinson TJ, Edwards JR, Grafe MR, Kirsch JR. Effects of prolonged peri-neural bupivacaine infusion in rat sciatic nerves (axon and myelin). Restor Neurol Neurosci 2021; 39:329-338. [PMID: 34542046 DOI: 10.3233/rnn-211170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND/OBJECTIVE Peripheral-nerve blocks (PNBs) using continuous-infusion of local anesthetics are used to provide perioperative analgesia. Yet little research exists to characterize the histopathological effects of continuous long-duration PNBs. Herein we test the hypothesis that continuous peri-neural bupivacaine infusion (3-day vs. 7-day infusion) contributes to histologic injury in a duration-dependent manner using an in vivo model of rat sciatic nerves. METHODS We placed indwelling catheters in 22 rats for infusion with low-dose (0.5mg/kg/hr) bupivacaine or normal saline proximal to the right sciatic nerves for 3 or 7 consecutive days. Hind-limb analgesia was measured using Von-Frey nociceptive testing. At infusion end, rats were sacrificed, bilateral nerves were sectioned and stained with hematoxylin and eosin and CD68 for evaluation of inflammatory response, and eriochrome to assess damage to myelin. RESULTS Animals receiving continuous infusion of bupivacaine maintained analgesia as demonstrated by significant decrease (50% on average) in nociceptive response in bupivacaine-infused limbs across time points. Both 7-day saline and bupivacaine-infused sciatic nerves showed significantly-increased inflammation by H&E staining compared to untreated native nerve controls (P = 0.0001, P < 0.0001). Extent of inflammation did not vary significantly based on infusate (7-day saline vs. 7-day bupivacaine P > 0.99) or duration (3-day bupivacaine vs 7-day bupivacaine P > 0.99). No significant change in sciatic nerve myelin was found in bupivacaine-infused animals compared to saline-infused controls, regardless of duration. CONCLUSIONS Long-duration (7-day) bupivacaine infusion provided durable post-operative analgesia, yet contributed to equivalent neural inflammation as short duration (3-day) infusion of bupivacaine or saline with no evidence of demyelination.
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Affiliation(s)
- John T Butler
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, OR, USA
| | - Tobias J Robinson
- Department of Anesthesiology, University of Vermont, Burlington, Vermont, VT, USA
| | - Jared R Edwards
- Department of General Surgery, Naval Medical Center San Diego, San Diego, CA, USA
| | - Marjorie R Grafe
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, OR, USA
| | - Jeffrey R Kirsch
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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22
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Ilfeld BM, Plunkett A, Vijjeswarapu AM, Hackworth R, Dhanjal S, Turan A, Cohen SP, Eisenach JC, Griffith S, Hanling S, Sessler DI, Mascha EJ, Han Y, Boggs JW, Wongsarnpigoon A, Gelfand H. 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. Neuromodulation 2021; 26:638-649. [PMID: 34343394 DOI: 10.1111/ner.13492] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University California San Diego, San Diego, CA, USA.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Anthony Plunkett
- Department of Anesthesiology, Womack Army Medical Center, Fayetteville, NC, USA
| | | | - Robert Hackworth
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, USA
| | - Sandeep Dhanjal
- Department of Anesthesiology, Brooke Army Medical Center, San Antonio, TX, USA
| | - Alparslan Turan
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Steven P Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, MD, USA
| | - James C Eisenach
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Scott Griffith
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Steven Hanling
- Department of Physical Medicine and Rehabilitation, Columbia Veterans Affairs Health Care System, Columbia, SC, USA
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA.,Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Edward J Mascha
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Yanyan Han
- Outcomes Research Consortium, Cleveland, OH, USA.,Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Harold Gelfand
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, USA
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23
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Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study. Anesthesiology 2021; 135:95-110. [PMID: 33856424 DOI: 10.1097/aln.0000000000003776] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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. EDITOR’S PERSPECTIVE
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24
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Ly E, Velamuri S, Hickerson W, Hill DM, Desai J, Tsui B, Herr M, Jones J. Approaching trauma analgesia using prolonged and novel continuous peripheral nerve blocks - A case report. Anesth Pain Med (Seoul) 2021; 17:87-92. [PMID: 34784461 PMCID: PMC8841258 DOI: 10.17085/apm.21029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022] Open
Abstract
Background A supraclavicular brachial plexus nerve block provides analgesia for the shoulder, arm, and hand; however, the maximum safe duration for a continuous infusion remains controversial. A novel continuous peripheral nerve block (CPNB) technique combining the Lateral, Intermediate, and Medial femoral cutaneous nerves (termed the ‘LIM’ block) to provide analgesia to the lateral, anterior, and medial cutaneous areas of the thigh while preserving quadriceps strength will also be described in detail here. Case We present a complex case in which simultaneous utilization of an unilateral supraclavicular CPNB (5 weeks) and bilateral LIM CPNB (5 days) are successfully performed to provide analgesia for a traumatic degloving injury resulting in multiple surgeries. Conclusions The analgesic plan in this case study eliminated previous episodes of opioid-induced delirium, facilitated participation in recovery, and removed concerns for respiratory depression and chronic opioid use in a patient at particular risk for both issues.
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Affiliation(s)
- Eric Ly
- College of Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sai Velamuri
- Department of Plastic Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - William Hickerson
- Department of Plastic Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - David M Hill
- Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jay Desai
- Department of Plastic Surgery, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ban Tsui
- Department of Anesthesiology, The Stanford University Medical Center, Stanford, CA, USA
| | - Michael Herr
- Department of Anatomy and Neurobiology, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jerry Jones
- Department of Anesthesiology, The University of Tennessee Health Science Center, Memphis, TN, USA
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25
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Sheckter CC, Stewart BT, Barnes C, Walters A, Bhalla PI, Pham TN. Techniques and strategies for regional anesthesia in acute burn care-a narrative review. BURNS & TRAUMA 2021; 9:tkab015. [PMID: 34285927 PMCID: PMC8287338 DOI: 10.1093/burnst/tkab015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/03/2021] [Indexed: 11/13/2022]
Abstract
Burn injuries and their treatments result in severe pain. Unlike traumatic injuries that are characterized by a discrete episode of pain followed by recovery, burn-injured patients endure pain for a prolonged period that lasts through wound closure (e.g. background pain, procedural pain, breakthrough pain, neuropathic pain and itch). Regional anesthesia, including peripheral nerve blocks and neuraxial/epidural anesthesia, offers significant benefits to a multimodal approach in pain treatment. A 'regional-first' approach to pain management can be incorporated into the workflow of burn centers through engaging regional anesthesiologists and pain medicine practitioners in the care of burn patients. A detailed understanding of peripheral nerve anatomy frames the burn clinician's perspective when considering a peripheral nerve block/catheter. The infra/supraclavicular nerve block provides excellent coverage for the upper extremity, while the trunk can be covered with a variety of blocks including erector spinae plane and quadratus lumborum plane blocks. The lower extremity is targeted with fascia iliaca plane and sciatic nerve blocks for both donor and recipient sites. Burn centers that adopt regional anesthesia should be aware of potential complications and contraindications to prevent adverse events, including management of local anesthetic toxicity and epidural infections. Management of anticoagulation around regional anesthesia placement is crucial to prevent hematoma and nerve damage. Ultimately, regional anesthesia can facilitate a better patient experience and allow for early therapy and mobility goals that are hallmarks of burn care and rehabilitation.
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Affiliation(s)
- Clifford C Sheckter
- Department of Surgery, UW Medicine Regional Burn Center at Harborview Medical Center, University of Washington, 325 9th Ave. Seattle, WA 98104, USA
| | - Barclay T Stewart
- Department of Surgery, UW Medicine Regional Burn Center at Harborview Medical Center, University of Washington, 325 9th Ave. Seattle, WA 98104, USA
| | - Christopher Barnes
- Department of Anesthesia and Pain Medicine, Harborview Medical Center. University of Washington, 325 9th Ave. Seattle, WA 98104, USA
| | - Andrew Walters
- Department of Anesthesia and Pain Medicine, Harborview Medical Center. University of Washington, 325 9th Ave. Seattle, WA 98104, USA
| | - Paul I Bhalla
- Harborview Injury Prevention and Research Center, University of Washington, 401 Broadway. Seattle, WA 98122, USA
| | - Tam N Pham
- Department of Surgery, UW Medicine Regional Burn Center at Harborview Medical Center, University of Washington, 325 9th Ave. Seattle, WA 98104, USA
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Phan KH, Anderson JG, Bohay DR. Complications Associated with Peripheral Nerve Blocks. Orthop Clin North Am 2021; 52:279-290. [PMID: 34053573 DOI: 10.1016/j.ocl.2021.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.
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Affiliation(s)
- Kevin H Phan
- Orthopaedic Associates of Michigan, 1111 Leffingwell Avenue Northeast, Grand Rapids, MI 49525, USA.
| | - John G Anderson
- Orthopaedic Associates of Michigan, 1111 Leffingwell Avenue Northeast, Grand Rapids, MI 49525, USA
| | - Donald R Bohay
- Orthopaedic Associates of Michigan, 1111 Leffingwell Avenue Northeast, Grand Rapids, MI 49525, USA
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27
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Chalacheewa T, Arnuntasupakul V, Sangkum L, Buachai R, Chanvitayapongs J. Decreasing leakage during continuous femoral nerve catheter fixation using 2-octyl cyanoacrylate glue (Dermabond®): a randomized controlled trial. BMC Anesthesiol 2021; 21:169. [PMID: 34116637 PMCID: PMC8194114 DOI: 10.1186/s12871-021-01386-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 05/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous peripheral nerve catheters (CPNCs) have been used for postoperative pain relief. A common problem encountered with CPNCs is pericatheter leakage, which can lead to dressing adhesive failure. Frequent dressing changes increase the risk of catheter dislodgement and infections. Adhesive glue is effective in securing the peripheral nerve catheter and decreasing leakage around the catheter insertion site. This study aimed to evaluate the incidence of pericatheter leakage with fixation using 2-octyl cyanoacrylate glue (Dermabond®) as compared to sterile strips. METHODS Thirty patients undergoing unilateral total knee arthroplasty (TKA) with continuous femoral nerve catheter for postoperative analgesia were randomized into the catheter fixation with 2-octyl cyanoacrylate glue (Dermabond®) group or the sterile strip group. The primary outcome was the incidence of pericatheter leakage. Secondary outcomes included the frequent of catheter displacement, the difficulty of catheter removal, pain score and patient satisfaction. RESULTS The incidence of pericatheter leakage at 24 and 48 h was 0% versus 93 and 0% versus 100% in the Dermabond® and sterile strip groups, respectively (P < 0.001). The incidence of displacement at 24 and 48 h was 6.7% versus 93.3 and 6.7% versus 100% in the Dermabond® and sterile strip, respectively (P < 0.001). There was no difference in numeric rating scale, difficulty of catheter removal, or satisfaction scores between groups. CONCLUSIONS Catheter fixation with 2-octyl cyanoacrylate glue (Dermabond®) decreased the incidence of pericatheter leakage, as well as catheter displacement, over 48 h as compared to sterile strip fixation. TRIAL REGISTRATION This trial was registered on Thai clinical trial registry: TCTR20200228002 , registered 24 February 2020- Retrospectively registered.
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Affiliation(s)
- Theerawat Chalacheewa
- 270 Department of Anesthesiology, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Rama VI road, Phayathai, Ratchatewi, Bangkok, 10400, Thailand.
| | - Vanlapa Arnuntasupakul
- 270 Department of Anesthesiology, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Rama VI road, Phayathai, Ratchatewi, Bangkok, 10400, Thailand
| | - Lisa Sangkum
- 270 Department of Anesthesiology, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Rama VI road, Phayathai, Ratchatewi, Bangkok, 10400, Thailand
| | - Rungrawan Buachai
- 270 Department of Anesthesiology, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Rama VI road, Phayathai, Ratchatewi, Bangkok, 10400, Thailand
| | - Jiravud Chanvitayapongs
- 270 Department of Anesthesiology, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Rama VI road, Phayathai, Ratchatewi, Bangkok, 10400, Thailand
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Guidelines for infection control and prevention in anaesthesia in South Africa. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2021. [DOI: 10.36303/sajaa.2021.27.4.s1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Basak S, Poddar K. Continuous adductor canal block for the management of below-knee postamputation stump pain in a diabetic patient. INDIAN JOURNAL OF PAIN 2021. [DOI: 10.4103/ijpn.ijpn_107_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Harkouk H, Thibault-Sogorb T, Beauchet A, Espinasse F, Lawrence C, Martinez V, Fletcher D. Two per cent alcoholic chlorhexidine versus alcoholic five per cent povidone-iodine for the prevention of perineural catheter colonisation: The CHLOVEPI randomised, controlled trial. Anaesth Crit Care Pain Med 2020; 40:100790. [PMID: 33285282 DOI: 10.1016/j.accpm.2020.100790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 09/18/2020] [Accepted: 10/01/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Multimodal analgesia, including a regional technique using perineural catheters (PNCs), is recommended for the treatment of moderate-to-severe acute postoperative pain. Perineural catheters are at risk of bacterial colonisation. In this study, we compared the cutaneous antiseptic efficacy of 2% alcoholic chlorhexidine and povidone-iodine-alcohol for preventing the bacterial colonisation of PNCs in orthopaedic surgery. METHODS We performed a randomised, controlled trial, comparing two cutaneous antisepsis strategies, one based on 2% alcoholic chlorhexidine and the other on povidone-iodine-5% alcohol, for placed PNCs before orthopaedic surgery. The primary endpoint was the incidence of catheter bacterial colonisation (threshold > 1000 colony-forming units/ml). The secondary endpoints were the incidence of catheter-related infections and the adverse effects of the antiseptic solutions. RESULTS From November 2016 to May 2018, we included 113 patients in this study. The use of alcoholic chlorhexidine was associated with a lower incidence of catheter colonisation (15.5% (n = 9) versus 32.7% (n = 18); OR: 0.28 [0.09-0.77], p = 0.01). No catheter-related infections or adverse effects of antiseptic solutions were observed in either group. The risk factors associated with colonisation were a duration of catheter use ≥ 3 days (p = 0.04) and obesity (p = 0.005). The most frequently identified bacterium was Staphylococcus epidermidis. CONCLUSION Skin disinfection with 2% alcoholic chlorhexidine decreases bacterial colonisation rates for placed perineural catheters.
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Affiliation(s)
- Hakim Harkouk
- Service d'Anesthésie-Réanimation, Hôpital Ambroise Paré, Boulogne-Billancourt, France; Unité INSERM U987, Université Versailles Saint-Quentin, Versailles, France.
| | | | - Alain Beauchet
- Unité de recherche clinique, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Florence Espinasse
- Service de microbiologie, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | | | - Valeria Martinez
- Unité INSERM U987, Université Versailles Saint-Quentin, Versailles, France; Service d'anesthésie, Hôpital Raymond Poincaré, Garches, France
| | - Dominique Fletcher
- Service d'Anesthésie-Réanimation, Hôpital Ambroise Paré, Boulogne-Billancourt, France; Unité INSERM U987, Université Versailles Saint-Quentin, Versailles, France
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Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain. Anesthesiology 2020; 133:1127-1149. [PMID: 32898231 DOI: 10.1097/aln.0000000000003532] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
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32
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Pharmacological strategies in multimodal analgesia for adults scheduled for ambulatory surgery. Curr Opin Anaesthesiol 2019; 32:720-726. [DOI: 10.1097/aco.0000000000000796] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Prolonged Catheter Use and Infection in Regional Anesthesia: A Retrospective Registry Analysis. Anesthesiology 2019; 128:764-773. [PMID: 29420315 DOI: 10.1097/aln.0000000000002105] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prolonged catheter use is controversial because of the risk of catheter-related infection, but the extent to which the risk increases over time remains unknown. We thus assessed the time-dependence of catheter-related infection risk up to 15 days. METHODS Our analysis was based on the German Network for Regional Anesthesia, which includes 25 centers. We considered 44,555 patients who had surgery between 2007 and 2014 and had continuous regional anesthesia as well as complete covariable details. Cox regression analysis was performed and adjusted for confounding covariables to examine the relationship between catheter duration and probability of infection-free catheter use. RESULTS After adjustment for confounding factors, the probability of infection-free catheter use decreases with each day of peripheral and epidural catheter use. In peripheral catheters, it was 99% at day 4 of catheter duration, 96% at day 7, and 73% at day 15. In epidural catheters, it was 99% at day 4 of catheter duration, 95% at day 7, and 73% at day 15. Only 31 patients (0.07%) had severe infections that prompted surgical intervention. Among these were five catheters that initially had only mild or moderate signs of infection and were left in situ; all progressed to severe infections. CONCLUSIONS Infection risk in catheter use increases over time, especially after four days. Infected catheters should be removed as soon as practical. VISUAL ABSTRACT An online visual overview is available for this article at http://links.lww.com/ALN/B683.
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Ilfeld BM, Ball ST, Cohen SP, Hanling SR, Fowler IM, Wongsarnpigoon A, Boggs JW. Percutaneous Peripheral Nerve Stimulation to Control Postoperative Pain, Decrease Opioid Use, and Accelerate Functional Recovery Following Orthopedic Trauma. Mil Med 2019; 184:557-564. [PMID: 30901395 DOI: 10.1093/milmed/usy378] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/14/2018] [Indexed: 11/13/2022] Open
Abstract
Orthopedic trauma is a significant military problem, causing several of the most disabling conditions with high rates of separation from duty and erosion of military readiness. The objective of this report is to summarize the findings of case series of a non-opioid therapy-percutaneous peripheral nerve stimulation (PNS) - and describe its potential for postoperative analgesia, early opioid cessation, and improved function following orthopedic trauma. Percutaneous PNS has been evaluated for the treatment of multiple types of pain, including two case series on postoperative pain following total knee replacement (n = 10 and 8, respectively) and a case series on postamputation pain (n = 9). The orthopedic trauma induced during TKR is highly representative of multiple types of orthopedic trauma sustained by Service members and frequently produces intense, prolonged postoperative pain and extended opioid use following surgery. Collectively, the results of these three clinical studies demonstrated that percutaneous PNS can provide substantial pain relief, reduce opioid use, and improve function. These outcomes suggest that there is substantial potential for the use of percutaneous PNS following orthopedic trauma.
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Affiliation(s)
- Brian M Ilfeld
- University of California San Diego, 200 W Arbor Drive, San Diego, CA
| | - Scott T Ball
- University of California San Diego, 200 W Arbor Drive, San Diego, CA
| | - Steven P Cohen
- Johns Hopkins School of Medicine, Department of Anesthesiology and Critical Care Medicine, 1800 Orleans Street, Baltimore, MD
| | - Steven R Hanling
- Medical College of Georgia, Department of Anesthesiology & Perioperative Medicine, BIW-2144 1120 15th Street, Augusta, GA
| | - Ian M Fowler
- Naval Medical Center San Diego, Department of Anesthesiology, 34800 Bob Wilson Dr, San Diego, CA
| | | | - Joseph W Boggs
- SPR Therapeutics, 22901 Millcreek Boulevard, Suite 110, Cleveland, OH
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Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. The efficacy of intraoperative periarticular injection in Total hip arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord 2019; 20:269. [PMID: 31153361 PMCID: PMC6545218 DOI: 10.1186/s12891-019-2628-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Periarticular injection (PAI) is a regional analgesia method performed in total hip arthroplasty (THA) for postoperative pain relief. However, its efficacy and safety is still inconclusive. Therefore, we conducted this meta-analysis to assess the safety of PAI and to determine if PAI provides better pain relief and reduce the consumption of opioids after THA. METHODS We searched PubMed, Web of Science, Embase and the Cochrane Library comprehensively. Only randomized control trials were included in our meta-analysis. Eleven studies that compared the efficacy of PAI with the control group were included. The preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines and Jadad score were applied to assess the quality of the included studies. We used the recommendations by the Cochrane Collaboration to reduce bias and to ensure our results were reliable and veritable. RESULTS Our analysis demonstrated that PAI was more effective than the control group with a lower visual analog scale (VAS) score during rest at 24 h (P = 0.003), 48 h (P = 0.002), and VAS score with activity at 24 h (P = 0.04). There was also less amount of opioid consumption (P = 0.01). There were no differences in length of hospital stay (P = 0.526) and postoperative nausea rate (P = 0.153). CONCLUSION Compared with the control group, PAI showed better pain relief and less amount of opioid consumption after THA. Our meta-analysis suggests that PAI is a safe and effective multimodal analgesia technique that can be used for THA.
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Affiliation(s)
- Hsuan-Hsiao Ma
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Te-Feng Arthur Chou
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Po-Kuei Wu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
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Gabriel RA, Swisher MW, Ilfeld BM. Percutaneous peripheral nerve stimulation for acute postoperative pain. Pain Manag 2019; 9:347-354. [PMID: 31099305 DOI: 10.2217/pmt-2018-0094] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Peripheral nerve stimulation or peripheral neuromodulation is a modality utilized for decades to manage chronic pain. There have been recent studies published describing its use in managing acute surgical pain for orthopedic surgery. The postoperative acute pain associated with several types of surgeries often outlasts the analgesia duration provided by single and continuous peripheral nerve blocks. Ultrasound-guided percutaneous peripheral nerve stimulation has the potential to provide much longer analgesia for acute pain while avoiding some limitations associated with local anesthetic-based peripheral nerve blocks. We summarize the current devices used in published studies to demonstrate feasibility with a focus on acute pain control.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, Division of Regional Anesthesia & Acute Pain, Department of Medicine, Division of Biomedical Informatics, University of California, San Diego, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA
| | - Matthew W Swisher
- Department of Anesthesiology, Division of Regional Anesthesia & Acute Pain, University of California, San Diego, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, Division of Regional Anesthesia & Acute Pain, University of California, San Diego, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA
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Carles M, Beloeil H, Bloc S, Nouette-Gaulain K, Aveline C, Cabaton J, Cuvillon P, Dadure C, Delaunay L, Estebe JP, Hofliger E, Martinez V, Olivier M, Robin F, Rosencher N, Capdevila X. Anesthésie loco-régionale périnerveuse (ALR-PN). ANESTHÉSIE & RÉANIMATION 2019. [DOI: 10.1016/j.anrea.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
PURPOSE OF REVIEW This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques. RECENT FINDINGS Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.
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39
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Gabriel RA, Ilfeld BM. Percutaneous peripheral nerve stimulation and other alternatives for perineural catheters for postoperative analgesia. Best Pract Res Clin Anaesthesiol 2019; 33:37-46. [DOI: 10.1016/j.bpa.2019.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
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Ilfeld BM, Finneran JJ, Gabriel RA, Said ET, Nguyen PL, Abramson WB, Khatibi B, Sztain JF, Swisher MW, Jaeger P, Covey DC, Meunier MJ, Hentzen ER, Robertson CM. Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the suprascapular nerve and brachial plexus for postoperative analgesia following ambulatory rotator cuff repair. A proof-of-concept study. Reg Anesth Pain Med 2019; 44:310-318. [PMID: 30770421 DOI: 10.1136/rapm-2018-100121] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/04/2018] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period. METHODS Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28. RESULTS Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported. CONCLUSIONS This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture. TRIAL REGISTRATION NUMBER NCT02898103.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA .,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - John J Finneran
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Engy T Said
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Patrick L Nguyen
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Matthew W Swisher
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Pia Jaeger
- Department of Anesthesiology, University of California San Diego, San Diego, California, USA.,The Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dana C Covey
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
| | - Matthew J Meunier
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
| | - Eric R Hentzen
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
| | - Catherine M Robertson
- Departments of Orthopaedic Surgery, University of California San Diego, San Diego, California, USA
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Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia Following Ambulatory Foot Surgery, a Proof-of-Concept Study. Reg Anesth Pain Med 2019; 43:580-589. [PMID: 29905630 PMCID: PMC6092098 DOI: 10.1097/aap.0000000000000819] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect. METHODS Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28. RESULTS During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal. CONCLUSIONS This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns. CLINICAL TRIAL REGISTRATION This study was registered at Clinicaltrials.gov, identifier NCT02898103.
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Abstract
Maximizing analgesia is critical following joint arthroplasty because postoperative pain is a major barrier to adequate physical therapy. Continuous peripheral nerve blocks have been the mainstay for acute pain management in this population; however, this and similar techniques are limited by their duration of action. Cryoneurolysis and peripheral nerve stimulation are two methodologies used for decades to treat chronic pain. With the advent of portable ultrasound devices and percutaneous administration equipment, both procedures may now be suitable for treatment of acute pain. This article reviews these two modalities and their application to joint arthroplasty.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA 92103, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA 92103, USA.
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43
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Ilfeld BM, Said ET, Finneran JJ, Sztain JF, Abramson WB, Gabriel RA, Khatibi B, Swisher MW, Jaeger P, Covey DC, Robertson CM. Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study. Neuromodulation 2018; 22:621-629. [PMID: 30160335 PMCID: PMC6767389 DOI: 10.1111/ner.12851] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 06/06/2018] [Accepted: 06/19/2018] [Indexed: 01/08/2023]
Abstract
Objectives The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft. Materials and Methods Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double‐masked fashion followed by a 5‐min crossover period, and then continuous active stimulation until lead removal postoperative Day 14–28. Statistics were not applied to the data due to the small sample size of this feasibility study. Results During the initial 5‐min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5‐min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1–3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet. Conclusions This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.
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Affiliation(s)
- Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Engy T Said
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - John J Finneran
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Jacklynn F Sztain
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Wendy B Abramson
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA
| | - Matthew W Swisher
- Department of Anesthesiology, University of California, San Diego, San Diego, CA, USA.,Outcomes Research consortium, Cleveland, OH, USA
| | - Pia Jaeger
- Outcomes Research consortium, Cleveland, OH, USA.,Department of Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Dana C Covey
- Department of Orthopedic Surgery, University of California, San Diego, San Diego, CA, USA
| | - Catherine M Robertson
- Department of Orthopedic Surgery, University of California, San Diego, San Diego, CA, USA
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44
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Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles. Br J Anaesth 2018; 120:679-692. [DOI: 10.1016/j.bja.2017.11.104] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/15/2017] [Accepted: 11/04/2017] [Indexed: 01/17/2023] Open
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45
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Stevenson KL, Neuwirth AL, Sheth N. Perioperative pain management following total joint arthroplasty: A review and update to an institutional pain protocol. J Clin Orthop Trauma 2018; 9:40-45. [PMID: 29628682 PMCID: PMC5884049 DOI: 10.1016/j.jcot.2017.09.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/26/2017] [Indexed: 10/18/2022] Open
Abstract
As the rate of total joint arthroplasty increases with the aging population of the United States, new focus on decreasing opioid use through the development of multimodal pain regimens (MPRs) is becoming an important area of research. MPRs use different agents and modes of delivery in order to synergistically address pain at many levels of the pain pathway. MPRs include a combination of acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids, opioids (short- and long-acting), spinal/epidural analgesia, regional nerve blocks, and local anesthetics. This review summarizes the available literature on major components of MPRs shown to be effective in the total joint arthroplasty population. Finally, the authors' preferred method for pain control in the TJA population is reviewed.
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Affiliation(s)
- Kimberly L Stevenson
- Resident Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Alexander L Neuwirth
- Resident Department of Orthopaedic Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Neil Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, 800 Spruce Street − 8th Floor Preston Building, Philadelphia, PA 19107, United States
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46
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Percutaneous Peripheral Nerve Stimulation for the Management of Postoperative Pain. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00060-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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47
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48
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Abstract
Postoperative pain is one of the most important factors in regard to patient outcomes. It has been linked with patient satisfaction, length of stay, and overall hospital costs. Peripheral nerve blocks have provided a safe, effective method to control early postoperative pain when symptoms are most severe. Peripheral nerve blocks, whether used intraoperatively or postoperatively, provide an alternative or adjunct to conventional pain management methods for patients who may not tolerate heavy narcotics or general anesthesia, in particular the elderly and those with cardiopulmonary disease.
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Affiliation(s)
- Tyler W Fraser
- Department of Orthopaedic Surgery, The University of Tennessee, Erlanger Health System, Chattanooga, TN, USA.
| | - Jesse F Doty
- Department of Orthopaedic Surgery, The University of Tennessee, Erlanger Health System, Chattanooga, TN, USA
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49
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Lyngeraa TS, Rothe C, Steen-Hansen C, Madsen MH, Christiansen CB, Andreasen AM, Lundstrøm LH, Lange KHW. Initial placement and secondary displacement of a new suture-method catheter for sciatic nerve block in healthy volunteers: a randomised, double-blind pilot study. Anaesthesia 2017; 72:978-986. [DOI: 10.1111/anae.13933] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2017] [Indexed: 01/07/2023]
Affiliation(s)
- T. S. Lyngeraa
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
| | - C. Rothe
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
| | - C. Steen-Hansen
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
| | - M. H. Madsen
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
| | - C. B. Christiansen
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
| | - A. M. Andreasen
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
| | - L. H. Lundstrøm
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
| | - K. H. W. Lange
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital and University of Copenhagen; Copenhagen Denmark
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50
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Weiss M, Rossaint R, Iber T. Generalizable items of quantitative and qualitative cornerstones for personnel requirement of physicians in anesthesia. World J Crit Care Med 2017; 6:91-98. [PMID: 28529910 PMCID: PMC5415854 DOI: 10.5492/wjccm.v6.i2.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 12/07/2016] [Accepted: 02/13/2017] [Indexed: 02/06/2023] Open
Abstract
Anesthesiologists perform a broad spectrum of tasks. However, in many countries, there is no legal basis for personnel staffing of physicians in anesthesia. Also, the German diagnosis related groups system for refunding does not deliver such a basis. Thus, in 2006 a new calculation base for the personnel requirement that included an Excel calculation sheet was introduced by the German Board of Anesthesiologists (BDA) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI), and updated in 2009 and 2015. Oriented primarily to organizational needs, in 2015, BDA/DGAI defined quantitative and qualitative cornerstones for personnel requirement of physicians in anesthesia, especially reflecting recent laws governing physician’s working conditions and competence in the field of anesthesia, as well as demands of strengthened legal rights of patients, patient care and safety. We present a workload-oriented model, integrating core working hours, shift work or standby duty, quality of care, efficiency of processes, legal, educational, controlling, local, organizational and economic aspects for calculating personnel demands. Auxiliary tables enable physicians to calculate personnel demands due to differing employee workload, non-patient oriented tasks and reimbursement of full-equivalents due to parental leave, prohibition of employment, or long-term illness. After 10 years of experience with the first calculation tool, we report the generalizable key aspects and items of a necessary calculation tool which may help physicians to justify realistic workload-oriented personnel staffing demands in anesthesia. A modular, flexible nature of a calculation tool should allow adaption to the respective legal and organizational demands of different countries.
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