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Farrow RA, Shalaby M, Newberry MA, Montes De Oca R, Kinas D, Farcy DA, Zitek T. Implementation of an Ultrasound-Guided Regional Anesthesia Program in the Emergency Department of a Community Teaching Hospital. Ann Emerg Med 2024; 83:509-518. [PMID: 38142373 DOI: 10.1016/j.annemergmed.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/06/2023] [Accepted: 11/09/2023] [Indexed: 12/25/2023]
Abstract
STUDY OBJECTIVE We sought to initiate an emergency department (ED)-based ultrasound-guided regional anesthesia (UGRA) program in our community teaching hospital system. Here, we present our development process and protocol. We also sought to assess the types, indications, and associated adverse event rates for the UGRA procedures in this study. METHODS We conducted a retrospective analysis of prospectively collected quality assurance data from a case series of patients who underwent an UGRA procedure in the ED. In August 2020, we developed an UGRA program for our community teaching hospital and its 2 affiliated freestanding EDs. For quality assurance purposes, we tracked all UGRA procedures performed in the ED, and we specifically assessed adverse events using structured follow-up. We subsequently obtained approval from our institutional review board to perform chart reviews of the patients in our dataset to abstract additional data and formally perform a research study. We determined the frequency with which different UGRA procedures were performed, and we calculated the adverse event rate. RESULTS Between August 24, 2020, and July 15, 2022, a total of 18 different sonographers performed and documented 229 UGRA procedures on 206 unique patients. This included 28 different types of procedures. Follow-up after disposition was successful in 82.0% of patients. In 2 cases, the patient reported no pain relief at all from the procedure, but no patients reported complications related to the procedure. CONCLUSION We successfully initiated a robust ED-based UGRA program in our community teaching hospital system. Among patients with successful follow-up, no adverse events were identified.
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Affiliation(s)
- Robert A Farrow
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL; Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Miami, FL.
| | - Michael Shalaby
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL; Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Miami, FL
| | - Mark A Newberry
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL; Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Miami, FL
| | - Roman Montes De Oca
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL
| | - David Kinas
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL; Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Miami, FL
| | - David A Farcy
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL; Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Miami, FL
| | - Tony Zitek
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, FL; Department of Emergency Medicine and Critical Care, Herbert Wertheim College of Medicine at Florida International University, Miami, FL
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Graglia S, Harmon D, Klein B. The Development, Implementation, and Evolution of an Emergency Medicine Ultrasound-guided Regional Anesthesia Curriculum. West J Emerg Med 2024; 25:117-121. [PMID: 38205993 PMCID: PMC10777173 DOI: 10.5811/westjem.59793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/19/2023] [Accepted: 10/18/2023] [Indexed: 01/12/2024] Open
Abstract
Introduction Despite the inclusion of both diagnostic and procedural ultrasound and regional nerve blocks in the original Model of the Clinical Practice of Emergency Medicine (EM), there is no recommended standardized approach to the incorporation of ultrasound-guided regional anesthesia (UGRA) education in EM training. Methods We developed and implemented a structured curriculum for both EM residents and faculty to learn UGRA in a four-hour workshop. Each Regional Anesthesia Anatomy and Ultrasound Workshop was four hours in length and followed the same format. Focusing on common UGRA blocks, each workshop began with an anatomist-led cadaveric review of the relevant neuromusculoskeletal anatomy followed by a hands-on ultrasound scanning practice for the blocks led by an ultrasound fellowship-trained EM faculty member, fellow, or a postgraduate year (PGY)-4 resident who had previously participated in the workshop. Learners identified the relevant anatomy on point-of-care ultrasound and reviewed how to conduct the blocks. Learners were invited to complete an evaluation of the workshop with Likert-scale and open-ended questions. Results In the 2020 academic year, six regional anesthesia anatomy and ultrasound workshops occurred for EM faculty (two sessions, N = 24) and EM residents (four sessions, N = 40, including a total of five PGY4s, 10 PGY3s, 12 PGY2s, and 13 PGY1s). Workshops were universally well-received by both faculty and residents. Survey results found that 100.0% of all responding participants indicated that they were "very satisfied" with the session. All were likely to recommend this session to a colleague and 95.08% of participants believed the session should become a required component of the EM curriculum. Conclusion The use of UGRA is increasing, and and it critical in EM. An interdisciplinary approach in collaboration with anatomists on an interactive, nerve block workshop incorporating both gross anatomy review and hands-on scanning was shown to be well-received and desired by both EM faculty and residents.
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Affiliation(s)
- Sally Graglia
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
- Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Derek Harmon
- University of California San Francisco, School of Medicine, Department of Anatomy, San Francisco, California
| | - Barbie Klein
- University of California San Francisco, School of Medicine, Department of Anatomy, San Francisco, California
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Hao D, Fiore M, Di Capua C, Gulati A. Ultrasound-Guided Peripheral Nerve Blocks: A Practical Review for Acute Cancer-Related Pain. Curr Pain Headache Rep 2022; 26:813-820. [PMID: 36168092 DOI: 10.1007/s11916-022-01089-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Ultrasound-guided regional techniques, including catheter-based approaches, are a subset of interventional therapies that have gained interest as an option for managing acute cancer-related pain. The authors sought to review the available published evidence and to discuss practical recommendations for expanding access to such therapies. RECENT FINDINGS In a MEDLINE/Pubmed search of ultrasound-guided peripheral nerve blocks and peripheral nerve catheters for specific anatomic targets, a total of 28 case reports and case series were identified. Included studies described improved analgesia and reduced opioid requirements with highly variable duration of effect. Current level of evidence remains limited. Pain is a symptom that markedly impacts the quality of life of cancer patients and ultrasound-guided regional techniques are a promising therapeutic option albeit with a limited evidence base. Practical recommendations offered for coordinating access to such therapies in the inpatient, emergency department, and outpatient settings may expand interest and facilitate higher quality research.
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Affiliation(s)
- David Hao
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Michael Fiore
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher Di Capua
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amitabh Gulati
- Department of Anesthesia and Critical Care, Memorial Sloan Kettering Cancer Center, New York, USA
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Malik A, Thom S, Haber B, Sarani N, Ottenhoff J, Jackson B, Rance L, Ehrman R. Regional Anesthesia in the Emergency Department: an Overview of Common Nerve Block Techniques and Recent Literature. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2022. [DOI: 10.1007/s40138-022-00249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
This review seeks to discuss the use of RA in the ED including benefits of administration, types of RA by anatomic location, complications and management, teaching methods currently in practice, and future applications of RA in the ED.
Recent Findings
The early use of RA in pain management may reduce the transition of acute to chronic pain. Multiple plane blocks have emerged as feasible and efficacious for ED pain complaints and are now being safely utilized.
Summary
Adverse effects of opioids and their potential for abuse have necessitated the exploration of substitute therapies. Regional anesthesia (RA) is a safe and effective alternative to opioid treatment for pain in the emergency department (ED). RA can manage pain for a wide variety of injuries while avoiding the risks of opioid use and decreasing length of stay when compared to other forms of analgesia and anesthesia, without compromising patient satisfaction.
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Hashemi M, Mahmood SMJ, Fernandez J, Oswald J. Cryoneurolysis of Intercostal Nerve for Rib Trauma and Intercostal Neuralgia in the Emergency Department: A Multidisciplinary Approach. J Emerg Med 2022; 63:376-381. [PMID: 36241475 DOI: 10.1016/j.jemermed.2022.06.009] [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: 01/11/2022] [Revised: 05/08/2022] [Accepted: 06/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Management of pain from traumatic rib injury is very challenging. Both acute and chronic pain caused by rib injury can cause significant morbidity (pain-induced hypoventilation, pneumonia, respiratory failure) and functional hindrance. Traditional pain management strategies in the emergency department (ED) that target acute traumatic rib pain are limited by the side effects of medications or the temporary half-life of anesthetics used for a nerve block. Both treatment modalities fall short of addressing subsequent chronic sequelae. CASE REPORT We present the first-time use of cryoneurolysis on an ED patient for the treatment of 10/10 severe traumatic intercostal neuralgia that resulted in the patient being discharged home pain free. The patient initially underwent a multilevel left-sided T5-T7 intercostal nerve block, followed by ultrasound-guided percutaneous cryoneurolysis of those intercostal nerves using two cycles of 2 min of cooling to a temperature of -70°C (nitrous oxide), with 30 s of thawing in between. The patient experienced 100% pain relief immediately post procedure that was sustained. He remained completely symptom free more than 6 months after the bedside procedure and returned to sports without restrictions. Why Should an Emergency Physician Be Aware of This? This case highlights the benefits of cross-departmental collaboration between the ED, Anesthesia, and Pain Management. We hope this model of multidisciplinary pain modulation can be replicated for other patients with similar pain and can herald a new paradigm of pain management in the ED.
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Affiliation(s)
- Mani Hashemi
- Department of Emergency Medicine, Kendall Regional Medical Center, Miami, Florida
| | - S M Jafar Mahmood
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jorge Fernandez
- Department of Emergency Medicine, UC San Diego, San Diego, California
| | - Jessica Oswald
- Department of Emergency Medicine, UC San Diego, San Diego, California; Department of Anesthesia, Division of Pain Medicine, UC San Diego, La Jolla, California
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Stickles SP, Kane DS, Kraus CK, Strony RJ, Ablordeppey EA, Doering MM, Theodoro D, Lee JS, Carpenter CR. Adverse events related to ultrasound-guided regional anesthesia performed by Emergency Physicians: Systematic review protocol. PLoS One 2022; 17:e0269697. [PMID: 35749370 PMCID: PMC9231708 DOI: 10.1371/journal.pone.0269697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 05/25/2022] [Indexed: 11/22/2022] Open
Abstract
The use of ultrasound-guided regional anesthesia for pain management has become increasingly prevalent in Emergency Medicine, with studies noting excellent pain control while sparing opioid use. However, the use of ultrasound-guided regional anesthesia may be hampered by concern about risks for patient harm. This systematic review protocol describes our approach to evaluate the incidence of adverse events from the use of ultrasound-guided regional anesthesia by Emergency Physicians as described in the literature. This project will also seek to document the scope of ultrasound-guided regional anesthesia applications being performed in Emergency Medicine literature, and potentially serve as a framework for future systematic reviews evaluating adverse events in Emergency Medicine.
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Affiliation(s)
- Sean P. Stickles
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
- * E-mail:
| | - Deborah Shipley Kane
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Chadd K. Kraus
- Department of Emergency Medicine, Geisinger Health Systems, Danville, Pennsylvania, United States of America
| | - Robert J. Strony
- Department of Emergency Medicine, Geisinger Health Systems, Danville, Pennsylvania, United States of America
| | - Enyo A. Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Michelle M. Doering
- Bernard Becker Medical Library, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Daniel Theodoro
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
| | - Jacques Simon Lee
- Department of Family and Community Medicine, Mount Sinai Hospital, Schwartz/Reisman Emergency Centre, Toronto, Ontario, Canada
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, United States of America
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Matyal R, Fatima H, Mahmood F. Salvation Through Evolution. J Cardiothorac Vasc Anesth 2021; 35:3849-3850. [PMID: 34642045 DOI: 10.1053/j.jvca.2021.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 08/25/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA.
| | - Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
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Tucker RV, Peterson WJ, Mink JT, Taylor LA, Leech SJ, Nagdev AD, Leo M, Liu R, Stolz LA, Kessler R, Boulger CT, Situ‐LaCasse EH, Avila JO, Huang R. Defining an Ultrasound-guided Regional Anesthesia Curriculum for Emergency Medicine. AEM EDUCATION AND TRAINING 2021; 5:e10557. [PMID: 34124505 PMCID: PMC8171792 DOI: 10.1002/aet2.10557] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Ultrasound-guided regional anesthesia (UGRA) can be a powerful tool in the treatment of painful conditions commonly encountered in emergency medicine (EM) practice. UGRA can benefit patients while avoiding the risks of procedural sedation and opioid-based systemic analgesia. Despite these advantages, many EM trainees do not receive focused education in UGRA and there is no published curriculum specifically for EM physicians. The objective of this study was to identify the components of a UGRA curriculum for EM physicians. METHODS A list of potential curriculum elements was developed through an extensive literature review. An expert panel was convened that included 13 ultrasound faculty members from 12 institutions and from a variety of practice environments and diverse geographical regions. The panel voted on curriculum elements through two rounds of a modified Delphi process. RESULTS The panelists voted on 178 total elements, 110 background knowledge elements, and 68 individual UGRA techniques. A high level of agreement was achieved for 65 background knowledge elements from the categories: benefits to providers and patients, indications, contraindications, risks, ultrasound skills, procedural skills, sterile technique, local anesthetics, and educational resources. Ten UGRA techniques achieved consensus: interscalene brachial plexus, supraclavicular brachial plexus, radial nerve, median nerve, ulnar nerve, serratus anterior plane, fascia iliaca, femoral nerve, popliteal sciatic nerve, and posterior tibial nerve blocks. CONCLUSIONS The defined curriculum represents ultrasound expert opinion on a curriculum for training practicing EM physicians. This curriculum can be used to guide the development and implementation of more robust UGRA education for both residents and independent providers.
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Affiliation(s)
- Ryan V. Tucker
- Department of Emergency MedicineMichigan MedicineAnn ArborMIUSA
- and theUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | - William J. Peterson
- Department of Emergency MedicineMichigan MedicineAnn ArborMIUSA
- and theUniversity of Michigan Medical SchoolAnn ArborMIUSA
| | | | | | - Stephen J. Leech
- Orlando HealthOrlandoFLUSA
- theUniversity of Florida College of MedicineGainesvilleFLUSA
- theUniversity of Central Florida College of MedicineOrlandoFLUSA
| | - Arun D. Nagdev
- Highland General HospitalOaklandCAUSA
- theUniversity of California San Francisco School of MedicineSan FranciscoCAUSA
| | - Megan Leo
- Boston Medical CenterBostonMAUSA
- andBoston University School of MedicineBostonMAUSA
| | | | - Lori A. Stolz
- theDepartment of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - Ross Kessler
- theDepartment of Emergency MedicineUniversity of Washington School of MedicineSeattleWAUSA
| | - Creagh T. Boulger
- theDepartment of Emergency MedicineThe Ohio State University College of MedicineColumbusOHUSA
| | | | - Jacob O. Avila
- and theDepartment of Emergency MedicineUniversity of Kentucky College of MedicineLexingtonKYUSA
| | - Robert Huang
- Department of Emergency MedicineMichigan MedicineAnn ArborMIUSA
- and theUniversity of Michigan Medical SchoolAnn ArborMIUSA
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