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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Anesthesiol Clin 2024; 42:219-231. [PMID: 38705672 DOI: 10.1016/j.anclin.2023.11.007] [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
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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Lee JY, Wu JC, Chatterji R, Koueiter D, Maerz T, Dutcheshen N, Wiater BP, Anderson K, Wiater JM. Complication rates and efficacy of single-injection vs. continuous interscalene nerve block: a prospective evaluation following arthroscopic primary rotator cuff repair without a concomitant open procedure. JSES Int 2024; 8:282-286. [PMID: 38464451 PMCID: PMC10920153 DOI: 10.1016/j.jseint.2023.10.008] [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] [Indexed: 03/12/2024] Open
Abstract
Background To compare the complications and efficacy of pain relief of the interscalene anesthetic block using either a single-injection (SI) vs. a continuous, indwelling catheter (CIC) for arthroscopic rotator cuff repair surgery. Methods Patients undergoing primary, arthroscopic rotator cuff repair without concomitant open procedure or biceps tenodesis were prospectively enrolled by 4 fellowship-trained sports medicine and shoulder surgeons. Patients received either a SI or CIC preoperatively based on surgeon preference. Patients were contacted by phone to complete a standard questionnaire on postoperative days (PODs) 1, 3, 7, 14, and 28. Patients were asked to rate the efficacy of their subjective pain relief (scale of 0-10), document issues with the catheter, describe analgesic usage, and report pharmacological and medical complications. The primary outcome was measured as complication rate. Postoperative narcotic use, patient satisfaction, and visual analog scale pain scores were measured as secondary outcomes. Results Seventy patients were enrolled, 33 CIC patients (13 male, 20 female, mean age 61 ± 8 years) and 37 SI patients (20 male, 17 female, mean age 59 ± 10 years). There were significantly more injection/insertion site complications in the CIC group (48%) vs. the SI group (11%, P = .001). The incidence of motor weakness was higher in the CIC group on POD 1 (P = .034), but not at any subsequent time points. On POD 1, CIC patients had a clinically significantly lower pain score compared to SI (3.2 vs. 5.4; P = .020). Similar scores were observed at subsequent time points until POD 28, when CIC again had a lower pain score (0.8 vs. 2.7; P = .005). However, this did not reach clinical significance. All patients in both groups rated a satisfaction of 9 or 10 (scale 0-10) with the anesthesia provided by their nerve block. Conclusion CIC interscalene nerve blocks had an increased risk for injection site complications and minor complications in the immediate postoperative period when using the CIC for arthroscopic rotator cuff repair without any concomitant open procedures. CIC blocks demonstrated clinically significant superior pain relief on POD 1 but were equal to SI blocks at every time point thereafter. Superior pain relief of CIC at POD 28 was not clinically significant. CIC catheters do not appear to markedly decrease the use of postoperative narcotics. Despite this trend in complication rates and pain scores, all patients in both groups were satisfied with their nerve block.
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Affiliation(s)
- James Y.J. Lee
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - John C. Wu
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Rishi Chatterji
- Department of Orthopedic Surgery, Ascension Providence, Michigan State University, Southfield, MI, USA
| | - Denise Koueiter
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Tristan Maerz
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Nicholas Dutcheshen
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Brett P. Wiater
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - Kyle Anderson
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
| | - J. Michael Wiater
- Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA
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Gabiatti AJB, Hillesheim GB, Gomildes MZ, Bertoncello D, Buzanello MR, Bertolini GRF. Cryotherapy in Postoperative Shoulder Surgery: A Systematic Review. Ther Hypothermia Temp Manag 2023. [PMID: 38112562 DOI: 10.1089/ther.2023.0071] [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: 12/21/2023] Open
Abstract
Cryotherapy, a therapeutic technique involving localized cooling of the body, has gained popularity for postsurgical rehabilitation. It induces a reduction in cellular metabolism, vasoconstriction, and pain relief, making it an attractive option for managing postoperative (PO) shoulder pain. This systematic review aimed to assess the effectiveness of cryotherapy in PO shoulder patients, focusing on pain, range of motion, functionality, and temperature changes. The review included six randomized clinical trials, involving a total of 233 patients who underwent various shoulder surgeries. Cryotherapy was applied using different methods, including Cryo/Cuff, Cryoton®, Polar Care 300, and ice packs. Results indicated that cryotherapy was generally effective in reducing PO shoulder pain. However, one study found no significant difference in pain outcomes between the cryotherapy group and control group. Furthermore, three studies demonstrated a decrease in intra-articular and skin temperatures with cryotherapy application. A risk of bias analysis revealed some concerns in the overall risk of bias for five studies, with one study considered to have a high risk of bias. Although publication bias assessment was not conducted due to the limited number of included studies, it was noted that the studies exhibited heterogeneity in terms of population, intervention methods, and outcome measures. In conclusion, cryotherapy appears to be a promising adjunctive treatment for PO shoulder pain, although the existing evidence has some limitations, including small sample sizes and methodological concerns. More high-quality studies are needed to establish the full extent of cryotherapy's effectiveness in PO shoulder rehabilitation, especially regarding its impact on functionality and range of motion.
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Affiliation(s)
| | | | - Milena Zambiazi Gomildes
- Department of Physiotherapy, Universidade Estadual do Oeste do Paraná-UNIOESTE, Cascavel, Brazil
| | - Dernival Bertoncello
- Department of Physiotherapy, Universidade Federal do Triângulo Mineiro-UFTM, Uberaba, Brazil
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Lee JH, Kim HJ, Kim JK, Cheon S, Shin YH. Does intravenous patient-controlled analgesia or continuous block prevent rebound pain following infraclavicular brachial plexus block after distal radius fracture fixation? A prospective randomized controlled trial. Korean J Anesthesiol 2023; 76:559-566. [PMID: 37089120 PMCID: PMC10718626 DOI: 10.4097/kja.23076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/17/2023] [Accepted: 04/23/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND The purpose of this study was to investigate the role of opioid-based intravenous patient-controlled analgesia (IV PCA) or continuous brachial plexus block (BPB) in controlling rebound pain after distal radius fracture (DRF) fixation under BPB as well as total opioid consumption. METHODS A total of 66 patients undergoing surgical treatment for a displaced DRF with volar plate fixation were randomized to receive a single infraclavicular BPB (BPB only group) (n = 22), a single infraclavicular BPB with IV PCA (IV PCA group) (n = 22), or a single infraclavicular BPB with continuous infraclavicular BPB (continuous block group) (n = 22). The visual analog scale (VAS) for pain and the amount of pain medication were recorded at 4, 6, 9, 12, 24, and 48 h and two weeks postoperatively. RESULTS At postoperative 9 h, the pain VAS score was significantly higher in the BPB only group (median: 2; Q1, Q3 [1, 3]) than in the IV PCA (0 [0, 1.8], P = 0.006) and continuous block groups (0 [0, 0.5], P = 0.009). At postoperative 12 h, the pain VAS score was significantly higher in the BPB only group (3 [3, 4]) than in the continuous block group (0.5 [0, 3], P = 0.004). The total opioid equivalent consumption (OEC) was significantly higher in the IV PCA group (350.3 [282.1, 461.3]) than in the BPB only group (37.5 [22.5, 75], P < 0.001) and continuous block group (30 [15, 75], P < 0.001); however, OEC was not significantly different between the BPB only group and the continuous block group (P = 0.595). CONCLUSIONS Although continuous infraclavicular BPB did not reduce total opioid consumption compared to BPB only, this method is effective for controlling rebound pain at postoperative 9 and 12 h following DRF fixation under BPB.
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Affiliation(s)
- Jong-hyuk Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ha-jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Kwang Kim
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sungjoo Cheon
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Ho Shin
- Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Finneran JJ, Ilfeld BM. Continuous peripheral nerve blocks for analgesia following painful ambulatory surgery: a review with focus on recent developments in infusion technology. Curr Opin Anaesthesiol 2023; 36:525-532. [PMID: 37552018 DOI: 10.1097/aco.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW Continuous peripheral nerve blocks (cPNB) decrease pain scores and opioid consumption while improving patient satisfaction following ambulatory surgery. This review focuses on the history and evolution of ambulatory cPNBs, recent developments in infusion technology that may prolong the duration of analgesia, optimal choice of cPNB for various surgical procedures, and novel analgesic modalities that may prove to be alternatives or supplements to cPNBs. RECENT FINDINGS The primary factor limiting the duration of an ambulatory cPNB is the size of the local anesthetic reservoir. Recent evidence suggests the use of automated boluses, as opposed to continuous infusions, may decrease the rate of consumption of local anesthetic and, thereby, prolong the duration of analgesia. Utilizing a long-acting local anesthetic (e.g. ropivacaine) for initial block placement and an infusion start-delay timer may further increase this duration. SUMMARY Patients undergoing painful ambulatory surgery are likely to have less pain and require fewer opioid analgesics when receiving a cPNB for postoperative analgesia. Advances in electronic pumps used for cPNBs may increase the duration of these benefits.
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Affiliation(s)
- John J Finneran
- Department of Anesthesiology, University of California San Diego, San Diego, California
- Outcomes Research Consortium, Cleveland, Ohio, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, California
- Outcomes Research Consortium, Cleveland, Ohio, USA
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Onay M, Kiremitçi TT, Kayhan GE, Algın Dİ, Güleç MS. Infraclavicular Catheter in MELAS Syndrome for Analgesic Purposes. Neurol India 2023; 71:764-766. [PMID: 37635512 DOI: 10.4103/0028-3886.383869] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
MELAS syndrome is defined as mitochondrial myopathy accompanied by encephalopathy, lactic acidosis, myoclonus, stroke-like episodes. It has a progressive course, multi-systemic effects and severe complications. Myoclonic contractions are unresponsive to many anti-epileptic drugs; these contractions and spasms may lead to severe pain. Systemic analgesic drugs are not sufficient to control pain. Therefore, continuous brachial plexus blockage may be preferred. Infraclavicular brachial plexus catheter is placed in our case. Local anesthetic injections through this catheter may be effective in pain management and results are to be discussed here.
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Affiliation(s)
- M Onay
- Department of Anesthesiology and Reanimation, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - T Tanyel Kiremitçi
- Department of Algology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - G Erdoğan Kayhan
- Department of Anesthesiology and Reanimation, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - D İlhan Algın
- Department of Neurology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
| | - M S Güleç
- Department of Algology, Eskisehir Osmangazi University Faculty of Medicine, Eskisehir, Turkey
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Biel E, Aroke EN, Maye J, Zhang SJ. The applications of cryoneurolysis for acute and chronic pain management. Pain Pract 2023; 23:204-215. [PMID: 36370129 PMCID: PMC10107282 DOI: 10.1111/papr.13182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Cryoneurolysis is a term used to describe the application of extreme cold to targeted nerve tissue. The primary goal of the application of a thermal neurolytic technique is to disrupt the conduction of pain signals from the periphery to the central nervous system and eliminate or diminish the experience of pain. Recent advancements in ultrasound technology coupled with the development and approval of handheld devices specifically designed to deliver cryoneurolysis has expanded the use of this modality in the perioperative setting. APPLICATION Surgical procedures including total knee arthroplasties, shoulder arthroplasties, thoracotomies, and mastectomies have all demonstrated long-term pain relief benefits when cryoneurolysis has been administered days to weeks prior to the planned procedure. In addition, the newly designed handheld device allows for office-based clinical use and has been utilized for various chronic pain conditions including neuropathic and phantom limb pain. CONCLUSION The evidence clearly demonstrates that cryoneurolysis has a low risk profile and when administered appropriately, provides prolonged analgesia without promoting motor blockade. This narrative review article describes the unique mechanism of action of cryoneurolysis for prolonged pain relief and provides emerging evidence to support its applications in both acute and chronic pain management.
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Affiliation(s)
- Emily Biel
- Nurse Anesthesiology ProgramUniversity of South FloridaTampaFloridaUSA
| | - Edwin N. Aroke
- University of Alabama at Birmingham School of NursingBirminghamAlabamaUSA
| | - John Maye
- School of NursingUniversity of South FloridaTampaFloridaUSA
| | - Sarah Jingying Zhang
- School of NursingUniversity of South FloridaTampaFloridaUSA
- University of California San FranciscoSan FranciscoCaliforniaUSA
- Samuel Merritt UniversityOaklandCaliforniaUSA
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Fernández Martin MT, Alvarez Lopez S, Aldecoa Alvarez-Santullano C. Role of adjuvants in regional anesthesia: A systematic review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2023; 70:97-107. [PMID: 36813032 DOI: 10.1016/j.redare.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/16/2021] [Indexed: 02/22/2023]
Abstract
The combination of drugs and routes of administration produces a synergistic effect, and one of the most important components of multimodal analgesic strategies are, therefore, nerve blocks for pain management. The effect of a local anaesthetic can be prolonged by administering an adjuvant. In this systematic review, we included studies on adjuvants associated with local anaesthetics in peripheral nerve blocks published in the last 5 years in order to evaluate their effectiveness. The results were reported according to the PRISMA guidelines. The 79 studies selected using our criteria showed a clear prevalence of dexamethasone (n=24) and dexmedetomidine (n=33) over other adjuvants. Different meta-analyses comparing adjuvants suggest that dexamethasone administered perineurally achieves superior blockade with fewer side effects than dexmedetomidine. Based on the studies reviewed, we found moderate evidence to recommend the use of dexamethasone as an adjuvant to peripheral regional anaesthesia in surgeries that can cause moderate to severe pain.
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Affiliation(s)
- M T Fernández Martin
- Servicio de Anestesiología y Reanimación, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - S Alvarez Lopez
- Servicio de Anestesiología y Reanimación, Hospital Abente y Lago, A Coruña, Spain
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Bloc du plexus brachial pour la chirurgie de l’épaule. ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Regional anaesthesia: what surgical procedures, what blocks and availability of a “block room”? Curr Opin Anaesthesiol 2022; 35:698-709. [PMID: 36302208 DOI: 10.1097/aco.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
PURPOSE OF REVIEW With an expected rise in day care procedures with enhanced recovery programs, the use of specific regional anaesthesia can be useful. In this review, we will provide insight in the used regional block and medication so far known and its applicability in a day care setting. RECENT FINDINGS Regional anaesthesia has been improved with the aid of ultrasound-guided placement. However, it is not commonly used in the outpatient setting. Old, short acting local anaesthetics have found a second life and may be especially beneficial in the ambulatory setting replacing more long-acting local anaesthetics such as bupivacaine.To improve efficiency, a dedicated block room may facilitate the performance of regional anaesthesia. However, cost-efficacy for improved operating time, patient care and hospital efficiency has to be established. SUMMARY Regional anaesthesia has proven to be beneficial in ambulatory setting. Several short acting local anaesthetics are favourable over bupivacaine in the day care surgery. And if available, there are reports of the benefit of an additional block room used in a parallel (monitored) care of patients.
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Muacevic A, Adler JR, Koyuncu Ö, Gurkan Y, Erçelen Ö. The Minimum Effective Analgesic Volume of 0.5% Bupivacaine for Ultrasound-Guided Anterior Suprascapular Nerve Block. Cureus 2022; 14:e31350. [PMID: 36514616 PMCID: PMC9741702 DOI: 10.7759/cureus.31350] [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: 11/10/2022] [Indexed: 11/12/2022] Open
Abstract
Objective The interscalene brachial plexus block (ISBB) constitutes the gold standard for analgesia after shoulder procedures. Ipsilateral phrenic nerve block remains the most common adverse effect after ISBB. Alternative nerve blocks are performed in shoulder surgery in order to prevent hemi-diaphragmatic paralysis (HDP). The purpose of the present study was to investigate the minimum effective local anesthetic volume of 0.5% bupivacaine for postoperative analgesia with an anterior suprascapular nerve block (ASSB). The secondary aim was to investigate diaphragm functions with the local anesthetic doses used while conducting effective volume research. Method This prospective observational study was conducted at the American Hospital of Istanbul, Turkey, from March to July 2022. The initial injected volume of 0.5% bupivacaine was 10 ml. Our clinical experience indicates that this yields a complete sensory block of the anterior suprascapular nerve. In accordance with the up-and-down method, the volume of 0.5% bupivacaine used for a particular patient was determined by the outcome of the preceding block, which represented block success. In case of effective ASSB being achieved, the volume of 0.5% bupivacaine to be administered to the next patient was lowered by 1 ml. In case of block failure, however, the volume of 0.5% bupivacaine to be applied in the subsequent case was increased by 1 ml. Ipsilateral hemi-diaphragmatic movement measurements were taken before (baseline) and 30 minutes after the block. General anesthesia was induced 60 minutes after the completion of the block performance by means of a standardized protocol. Results Sixty-seven patients were included in the study. The ED50 and ED95 calculated for anterior suprascapular nerve block using probit transformation and logistic regression analysis were 2.646 (95% CI, 0.877-2.890) and 3.043 ml (95% CI, 2.771-4.065), respectively. When complete paralysis was defined as 75% or above, partial paralysis as 25-50%, and no paralysis as 25% or less, volumes of 6 ml or lower appeared to cause no paralysis for the anterior suprascapular nerve block. Conclusion We, therefore, recommend using a volume of 6 ml or less in order to achieve diaphragm-sparing features for anterior suprascapular nerve blocks.
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Ewing M, Huff H, Heil S, Borsheski RR, Smith MJ, Kim HM. Local Infiltration Analgesia Versus Interscalene Block for Pain Management Following Shoulder Arthroplasty: A Prospective Randomized Clinical Trial. J Bone Joint Surg Am 2022; 104:1730-1737. [PMID: 35778995 DOI: 10.2106/jbjs.22.00034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND While providing effective analgesia following shoulder arthroplasty, an interscalene block has known complications. Local infiltration analgesia (LIA) using ropivacaine has been successfully employed in other joint arthroplasties, but its efficacy in shoulder arthroplasty has not been studied extensively. The purpose of this study was to compare pain and opioid consumption between LIA and an interscalene block following shoulder arthroplasty. METHODS Patients undergoing primary shoulder arthroplasty were prospectively randomized into 2 groups: the block group received an interscalene block using liposomal bupivacaine, and the injection group received an LIA injection intraoperatively. The LIA injection included ropivacaine, epinephrine, ketorolac, and normal saline solution. Postoperative visual analog scale pain scores, opioid consumption in morphine milligram equivalents, and complications were compared between the groups. The mean pain scores during the first 24 hours postoperatively were used to test noninferiority of LIA compared with an interscalene block. RESULTS The study included 74 patients (52 men and 22 women with a mean age of 69 years; 37 were in the injection group and 37 in the block group). There was no significant difference between the groups with respect to pain scores at any postoperative time points (p > 0.05), except for the 8-hour time point, when the injection group had a significantly higher pain score than the block group (p = 0.01). There was no significant difference in opioid consumption between the groups at any time points postoperatively (p > 0.05). The amount of intraoperative opioid consumption was significantly higher in the injection group (p < 0.001). In noninferiority testing for the mean pain scores during the first 24 hours, the injection group was found to be noninferior to the block group. One patient in the block group developed transient phrenic nerve palsy. One patient in the injection group developed dislocation after reverse arthroplasty related to noncompliance. The mean procedure hospital charge was $1,718 for an interscalene block and $157 for LIA. CONCLUSIONS LIA and an interscalene block provided similar analgesia during the first 24 hours after primary shoulder arthroplasty. LIA was associated with worse pain at 8 hours postoperatively and more intraoperative opioid consumption but was also substantially less costly. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Michael Ewing
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - Haley Huff
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - Sally Heil
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - Robert R Borsheski
- Department of Anesthesiology, University of Missouri, Columbia, Missouri
| | - Matthew J Smith
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
| | - H Mike Kim
- Department of Orthopaedic Surgery, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
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Adding Dexamethasone to Adductor Canal Block Combined with iPACK Block Improve Postoperative Analgesia of Total Knee Arthroplasty. Clin J Pain 2022; 38:575-581. [PMID: 35819163 DOI: 10.1097/ajp.0000000000001056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 06/21/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Both adductor canal block (ACB) and infiltration between the popliteal artery and capsule of knee (iPACK) block are mainly sensory blocks, preserved muscle strength and ability to ambulate. This study was designed to evaluate whether adding dexamethasone to ropivacaine could improve postoperative analgesia after total knee arthroplasty (TKA). METHODS This prospective double-blind randomized controlled trial included 60 patients who underwent unilateral TKA under general anesthesia. All patients who received ACB and iPACK block were randomly divided into a dexamethasone group (Group D, ropivacaine combined with dexamethasone) and a control group (Group C, ropivacaine only). The primary outcome was the time to first administration of rescue analgesic drugs. Secondary outcomes included the total amount of rescue analgesic drugs and the pain scores at different time points within 72 hours postoperatively; the time to first getting out of bed, quality of recovery scale (QOR-15 score), and the levels of plasma inflammatory markers (IL-6 and CRP) on postoperative day 1. RESULTS Compared with Group C, the time to first administration of rescue analgesic drugs of Group D was significantly extended by approximately 10.5 hours. Patients in Group D had significantly lower pain scores at postoperative different time points and consumed significantly smaller total morphine within 72 hours postoperatively. In addition, patients in group D reported significantly higher QoR-15 scores on postoperative days 1 and 3, earlier first time of getting out of bed, and significantly lower levels of CRP and IL-6 on postoperative day 1. CONCLUSIONS Compared with using ropivacaine alone, ultrasonic guided ACB combined with iPACK using ropivacaine and dexamethasone could prolong the duration of postoperative analgesia and strength analgesic intensity and promote the early rehabilitation exercise of patients undergoing TKA.
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Meng Y, Wang S, Zhang W, Xie C, Chai X, Shu S, Zong Y. Effects of Different 0.2% Ropivacaine Infusion Regimens for Continuous Interscalene Brachial Plexus Block on Postoperative Analgesia and Respiratory Function After Shoulder Arthroscopic Surgery: A Randomized Clinical Trial. J Pain Res 2022; 15:1389-1399. [PMID: 35592818 PMCID: PMC9113128 DOI: 10.2147/jpr.s362360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/29/2022] [Indexed: 01/22/2023] Open
Affiliation(s)
- Yan Meng
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China (USTC)/Anhui Provincial Hospital, Hefei, People’s Republic of China
- Core Facility Center, The First Affiliated Hospital of USTC/Anhui Provincial Hospital, Hefei, People’s Republic of China
| | - Sheng Wang
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China (USTC)/Anhui Provincial Hospital, Hefei, People’s Republic of China
| | - Wei Zhang
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China (USTC)/Anhui Provincial Hospital, Hefei, People’s Republic of China
| | - Chunlin Xie
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China (USTC)/Anhui Provincial Hospital, Hefei, People’s Republic of China
| | - Xiaoqing Chai
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China (USTC)/Anhui Provincial Hospital, Hefei, People’s Republic of China
| | - Shuhua Shu
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China (USTC)/Anhui Provincial Hospital, Hefei, People’s Republic of China
| | - Yu Zong
- Department of Anesthesiology, The First Affiliated Hospital of University of Science and Technology of China (USTC)/Anhui Provincial Hospital, Hefei, People’s Republic of China
- Core Facility Center, The First Affiliated Hospital of USTC/Anhui Provincial Hospital, Hefei, People’s Republic of China
- Correspondence: Yu Zong, Department of Anesthesiology, The First Affiliated Hospital of USTC, 17 Lujiang Road, Hefei, Anhui, People’s Republic of China, Email
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15
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Mojica JJ, Ocker A, Barrata J, Schwenk ES. Anesthesia for the Patient Undergoing Shoulder Surgery. Clin Sports Med 2022; 41:219-231. [PMID: 35300836 DOI: 10.1016/j.csm.2021.11.004] [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: 11/25/2022]
Abstract
Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.
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Affiliation(s)
- Jeffrey J Mojica
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA.
| | - Aaron Ocker
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Jaime Barrata
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Suite 8290 Gibbon Building, Philadelphia, PA 19107, USA
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Bowens C, Badiola IJ, Allen BFS, Canlas CL, Gupta RK, Jaeger LM, Briggs ER, Corey JM, Shi Y, Schildcrout JS, Malchow RJ. Color Doppler ultrasonography of an agitated solution is predictive of accurate catheter placement for a continuous popliteal sciatic nerve block. Perioper Med (Lond) 2021; 10:59. [PMID: 34906248 PMCID: PMC8672631 DOI: 10.1186/s13741-021-00229-w] [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: 08/15/2021] [Accepted: 11/10/2021] [Indexed: 11/20/2022] Open
Abstract
Background Continuous peripheral nerve catheters (PNCs) have been shown to provide superior postoperative analgesia, decrease opioid consumption, and improve patient satisfaction compared with single injection techniques. In order to achieve success and reliability, accurate catheter positioning is an essential element of PNC placement. An agitated solution of normal saline, D5W, or a local anesthetic solution can be produced by the introduction of air to the injectate, creating air bubbles that can enhance ultrasonographic visualization and possibly improve block success. Methods Eighty-three patients were enrolled. Ultrasound-guided continuous popliteal sciatic nerve blocks were performed by positioning the tip of a Tuohy needle between the tibial and common peroneal branches of the sciatic nerve and threading a catheter. An agitated local anesthetic solution was injected through the catheter, viewed with color Doppler ultrasound and video recorded. A peripheral block score (lower score = greater blockade, range 0-14) was calculated based upon the motor and sensory testing at 10, 20, and 30 min after block completion. The color Doppler agitation coverage pattern for the branches of the sciatic nerve was graded as follows: complete (> 50%), partial (> 0%, ≤ 50%), or none (0%). Results The degree of nerve blockade at 30 min as judged by median (10th, 90th percentile) peripheral block score was significant for partial or complete color Doppler coverage of the sciatic nerve injectate compared to no coverage [3 (0, 7) vs 8 (4, 14); p < 0.01] and block onset was faster (p = 0.03). The block success was higher in groups with partial or complete coverage of the branches of the sciatic nerve vs no coverage (96% vs 70%; p = 0.02). Conclusions Injection of an agitated solution through a popliteal sciatic perineural catheter is predictive of accurate catheter placement when partial or complete coverage of the sciatic nerve branches is visualized with color Doppler ultrasound. Trial registration NCT01591603
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Affiliation(s)
- Clifford Bowens
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ignacio J Badiola
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | - Rajnish Kumar Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa Michelle Jaeger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eric Russell Briggs
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John Matthew Corey
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Randall John Malchow
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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17
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Boin MA, Mehta D, Dankert J, Umeh UO, Zuckerman JD, Virk MS. Anesthesia in Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis. JBJS Rev 2021; 9:01874474-202111000-00001. [PMID: 34757963 DOI: 10.2106/jbjs.rvw.21.00115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» For shoulder arthroplasty, regional anesthesia is safer when compared with general anesthesia. There is insufficient evidence to demonstrate the superiority of regional anesthesia with respect to pulmonary complications and hospital length of stay. » Infiltration of the shoulder with local anesthetics offers no additional benefits compared with single-shot or continuous brachial plexus blocks for shoulder arthroplasty. » There is high-quality evidence (Level I) demonstrating lower pain scores and lower perioperative opioid requirements after a continuous peripheral nerve block compared with a single-shot nerve block. However, catheter dislodgment and logistical issues with catheter insertion are impediments to the widespread usage of a continuous nerve block with an indwelling catheter. » Liposomal bupivacaine is comparable with non-liposomal local anesthetic agents with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after total shoulder arthroplasty. » Perioperative dexamethasone administration improves postoperative pain control, decreases perioperative opioid requirements, and reduces postoperative nausea.
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Abstract
PURPOSE OF REVIEW The trend in the perioperative management of patients having orthopedic surgery in the ambulatory setting emphasizes time-efficiency and rapid turnovers. Anesthetic techniques and management continue to evolve to increase efficiency and decrease time spent in recovery. RECENT FINDINGS Minimizing time patients spend in phase 1 recovery or bypassing phase 1 altogether, known as fast-tracking, has become an important goal in containing costs in high turnover, ambulatory settings. Anesthetic techniques, particularly implementation of regional anesthesia and multimodal analgesia, have evolved to maximize efficiency. SUMMARY Anesthetic goals in the setting of high-turnover orthopedic surgery include effective multimodal analgesia, decreasing monotherapy with opioids, and patient education. Regional anesthesia as part of a multimodal analgesic regimen is increasingly used in ambulatory surgery fast-tracking protocols.
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Affiliation(s)
- Ali Shariat
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside Medical Center, New York, New York, USA
| | - Berend Marcus
- Department of Anesthesiology, Catholic University Leuven, Leuven, Belgium
| | - Malikah Latmore
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside Medical Center, New York, New York, USA
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19
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Zangrilli J, Szukics P, Austin L, Horneff JG. Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery. JBJS Rev 2021; 9:e20.00191. [PMID: 33999881 DOI: 10.2106/jbjs.rvw.20.00191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
» Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation. » While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use. » The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures. » Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period. » Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications. » Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.
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Affiliation(s)
- Julian Zangrilli
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Patrick Szukics
- Department of Orthopaedic Surgery, Rowan School of Osteopathic Medicine, Stratford, New Jersey
| | - Luke Austin
- Rothman Institute of Orthopaedics at Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - John G Horneff
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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20
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Kraus NR, Garvey KD, Higgins LD, Matzkin E. Ibuprofen Use Did Not Affect Outcome Metrics After Arthroscopic Rotator Cuff Repair. Arthrosc Sports Med Rehabil 2021; 3:e491-e497. [PMID: 34027460 PMCID: PMC8129460 DOI: 10.1016/j.asmr.2020.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 11/15/2020] [Indexed: 01/02/2023] Open
Abstract
Purpose To determine whether patients who are prescribed ibuprofen after arthroscopic rotator cuff repair have significantly different patient-reported outcomes for pain, function, and overall health at baseline and 1 and 2 years after operation relative to patients only prescribed opioids. Methods Patients who underwent a rotator cuff repair by a total of 3 surgeons and participated in the outcomes registry from 2012 to 2016 were screened for inclusion in this study. Inclusion criteria were primary arthroscopic rotator cuff repair, at least 2 years from the date of surgery and over the age of 18. Exclusion criteria were revision and open rotator cuff repair. All patients followed the standard postoperative rehabilitation protocol for rotator cuff repair. Patients were divided into 2 cohorts. Group I included patients who received ibuprofen/nonsteroidal anti-inflammatory agents (NSAID) after surgery (n = 281), and Group II consisted of patients who did not receive ibuprofen/NSAID after surgery (n = 182). Patient-reported outcome measures for Visual Analogue Scale, American Shoulder Elbow Surgeons score, Single Assessment Numeric Evaluation score, Simple Shoulder Test and The Veterans Rand 12-Item Health Survey were collected preoperatively and at 3 and 6 months, 1 year, and 2 years after surgery. Statistical analysis was performed to compare patient-reported outcome measures between Group I and II. Results This study consisted of 463 patients who underwent arthroscopic rotator cuff repair, and patients were divided into 2 cohorts. There were 281 patients who did not receive ibuprofen/NSAID after operation in Group I and 182 patients who did receive ibuprofen in Group II. There were no statistically significant differences between the 2 groups in age at treatment, mean body mass index, gender, ethnicity, diabetes, and number of rotator cuff tendons involved; however, there was a statistically significant difference in receiving worker’s compensation (P = .005), and this was subsequently adjusted for in our analysis. There were no significant differences in patient-reported outcomes for all metrics between the group prescribed ibuprofen and the group that was not prescribed ibuprofen at 1 and 2 years after surgery or in change from baseline. Conclusion Patients receiving ibuprofen did as well as patients who did not receive ibuprofen after arthroscopic rotator cuff repair on patient-reported outcome measures assessing shoulder pain, function, and overall health. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Nicholas R Kraus
- Tufts University School of Medicine, Boston, Massachusetts.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Kirsten D Garvey
- Tufts University School of Medicine, Boston, Massachusetts.,Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Laurence D Higgins
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elizabeth Matzkin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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21
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Garnaud B, Mares O, L'hermite J, Vialles N, Gricourt Y, Lannelongue A, Lefrant JY, Cuvillon P. Multimodal oral analgesia strategy after ambulatory arthroscopic shoulder surgery: case series using adaptive therapeutic approaches by sequential analysis. J Shoulder Elbow Surg 2021; 30:250-257. [PMID: 32950669 DOI: 10.1016/j.jse.2020.08.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain control and quality of recovery (QoR) at home remains a challenge after ambulatory shoulder arthroscopy. This study aims to assess the QoR and pain relief using a sequential implementation strategy for rescue analgesic drugs. METHODS After institutional review board approval, patients (>18 years, American Society of Anesthesiology [ASA] score 1-3 stable) scheduled for ambulatory surgery under general anesthesia with a single-shot interscalene nerve block were enrolled. After discharge, patients received standard information regarding the postoperative recovery and care consisting of a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The first 48 postoperative hours allowed us to compare 3 different rescue drug regimes with a control group, in sequential order: tramadol (control group), tramadol + nefopam, immediate-release oxycodone (IR), and extended-release oxycodone (ER). The primary endpoint was the QoR 40 score at 48 hours after surgery. Secondary endpoints were pain relief and adverse events over a 7-day period. An intention-to-treat statistical analysis was performed with sequential analysis (as an interim analysis) every 20 patients. Results were recorded as medians and interquartiles (25-75). RESULTS We analyzed 109 patients with similar characteristics among groups. The QoR 40 scores were similar for the tramadol group (168 [161-172]), the tramadol + nefopam group (161 [151-173], P = .09), and the IR group (164 [153-169], P = .17), but higher for the ER group (176 [167-181], P = .03). Concerning adverse events, drugs were interrupted more frequently in the tramadol + nefopam group (36 %). In the ER group, a higher quality of postoperative relief was attained in the domains of pain and sleep. CONCLUSION The present study shows that a combination of IR and ER oxycodone over a short period of time (<48 hours) is associated with a better QoR at home after ambulatory shoulder surgery.
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Affiliation(s)
- Benjamin Garnaud
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Olivier Mares
- Medical Department, Montpellier University 1, Montpellier, France; Department of Traumatology and Orthopedic Surgery, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France
| | - Joel L'hermite
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Nathalie Vialles
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Yann Gricourt
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Ariane Lannelongue
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Jean Yves Lefrant
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France
| | - Philippe Cuvillon
- Department of Anesthesiology and Pain Management, Centre Hospitalo-Universitaire (CHU) Carémeau, Nîmes, France; Medical Department, Montpellier University 1, Montpellier, France.
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22
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Desai N, Kirkham KR, Albrecht E. Local anaesthetic adjuncts for peripheral regional anaesthesia: a narrative review. Anaesthesia 2021; 76 Suppl 1:100-109. [PMID: 33426668 DOI: 10.1111/anae.15245] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Abstract
Moderate-to-severe postoperative pain persists for longer than the duration of single-shot peripheral nerve blocks and hence continues to be a problem even with the routine use of regional anaesthesia techniques. The administration of local anaesthetic adjuncts, defined as the concomitant intravenous or perineural injection of one or more pharmacological agents, is an attractive and technically simple strategy to potentially extend the benefits of peripheral nerve blockade beyond the conventional maximum of 8-14 hours. Historical local anaesthetic adjuncts include perineural adrenaline that has been demonstrated to increase the mean duration of analgesia by as little as just over 1 hour. Of the novel local anaesthetic adjuncts, dexmedetomidine and dexamethasone have best demonstrated the capacity to considerably improve the duration of blocks. Perineural dexmedetomidine and dexamethasone increase the mean duration of analgesia by up to 6 hour and 8 hour, respectively, when combined with long-acting local anaesthetics. The evidence for the safety of these local anaesthetic adjuncts continues to accumulate, although the findings of a neurotoxic effect with perineural dexmedetomidine during in-vitro studies are conflicting. Neither perineural dexmedetomidine nor dexamethasone fulfils all the criteria of the ideal local anaesthetic adjunct. Dexmedetomidine is limited by side-effects such as bradycardia, hypotension and sedation, and dexamethasone slightly increases glycaemia. In view of the concerns related to localised nerve and muscle injury and the lack of consistent evidence for the superiority of the perineural vs. systemic route of administration, we recommend the off-label use of systemic dexamethasone as a local anaesthetic adjunct in a dose of 0.1-0.2 mg.kg-1 for all patients undergoing surgery associated with significant postoperative pain.
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Affiliation(s)
- N Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - K R Kirkham
- Department of Anaesthesia and Pain Management, Toronto Western Hospital, University of Toronto, ON, Canada
| | - E Albrecht
- Department of Anaesthesia, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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23
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Incidence and effects of postoperative migration of interscalene catheter tips placed using ultrasound-guided anterior and posterior approaches. J Anesth 2021; 35:175-183. [PMID: 33416994 DOI: 10.1007/s00540-020-02888-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/12/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Continuous interscalene brachial plexus block (CISB) provides analgesia after shoulder surgery. However, even a catheter securely fixed at the insertion site may be susceptible to migration, precluding the block from working consistently. We examined to see if catheter tip migration would occur with no catheter-at-skin change after anterior and posterior approaches to CISB in patients undergoing shoulder surgery, and compared the incidence rate and pain scores between approaches and between catheters with and without tip migration, respectively. METHODS Patients were randomly assigned to receive CISB using either anterior or posterior approach. Catheter tip was observed using a cross-sectional view. The rates of catheter tip migration with no catheter-at-skin change at 24 h after the two approaches were calculated and compared, and pain scores were compared between catheters with and without tip migration after each approach. RESULTS Fifty-four patients were analyzed. Catheter tip migration occurred at 24 h at a similar rate after both approaches (anterior approach 40.7% versus posterior approach 33.3%, p = 0.78). Worst pain score was significantly higher for 24 h in patients whose catheter tip had migrated as compared with those whose catheter had not migrated after anterior (median [IQR] 53 [42-73] versus 18 [0-50], p = 0.003) and posterior approaches (median [IQR] 63 [57-81] versus 29 [3-47], p < 0.0001). CONCLUSION In patients undergoing shoulder surgery, an interscalene catheter tip can migrate after both anterior and posterior approaches at a similar rate, even if the catheter insertion length is not changed. The tip migration does decrease the analgesic effect of CISB.
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24
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Kara YS, Hapa O, Işın Y, Kılıç Aİ, Havitçioğlu H. A comparison of ice wrap and subacromial injection for postoperative pain and edema control following arthroscopic rotator cuff repair. J Orthop Traumatol 2020; 21:17. [PMID: 32876791 PMCID: PMC7468014 DOI: 10.1186/s10195-020-00556-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 08/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background Postoperative pain and edema are the most common problems associated with arthroscopic rotator cuff repair. The purpose of the present study was to compare ice wrap and subacromial injection (SI) as treatments for early postop pain and edema control and to contrast them with a control group. Materials and methods 59 patients treated with arthroscopic rotator cuff repair were randomized into three groups: 23 patients who received an ice wrap, 20 patients who received a SI, and a control group of 16 patients. Results Patient demographics, comorbidities, tear retraction, degree of fatty muscle degeneration, surgical procedures, and amount of irrigation fluid were similar for the three groups, which also showed similar results regarding postoperative pain and edema control as well as analgesic consumption. Conclusions The present study failed to show any difference in effectiveness between the two most common pain management modalities, or between those modalities and the control group. Level of evidence IV, prospective observational study.
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Affiliation(s)
- Yavuz Selim Kara
- Department of Orthopedic Surgery, Dokuz Eylül University, Izmir, Turkey
| | - Onur Hapa
- Department of Orthopedic Surgery, Dokuz Eylül University, Izmir, Turkey.
| | - Yağmur Işın
- Department of Orthopedic Surgery, Dokuz Eylül University, Izmir, Turkey
| | - Ali İhsan Kılıç
- Department of Orthopedic Surgery, Dokuz Eylül University, Izmir, Turkey
| | - Hasan Havitçioğlu
- Department of Orthopedic Surgery, Dokuz Eylül University, Izmir, Turkey
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25
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Surendran S, Patinharayil G, Karuppal R, Marthya A, Fazil M, Mohammed Ali S. Arthroscopic capsular release and continuous upper arm brachial block in frozen shoulder - A midterm outcome analysis. J Orthop 2020; 21:459-464. [PMID: 32982101 PMCID: PMC7494934 DOI: 10.1016/j.jor.2020.08.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/28/2020] [Accepted: 08/30/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This prospective study aims to evaluate the efficacy of Continuous upper arm brachial block (modified interscalene block) with an arthroscopic capsular release in the outcome of resistant frozen shoulder cases. METHODS We studied 123 patients who underwent arthroscopic capsular release and subacromial decompression for resistant frozen shoulder cases between June 2016 and July 2019. Postoperative analgesia was provided with Continuous upper arm brachial block and ambulatory patient-controlled analgesia pump for 2-3 weeks. The patients were started on regular physiotherapy on the first postoperative day. All the patients were followed up at 3rd week, 6th week, 3rdmonth, 6th month, 1st year, and 2nd year with VAS and Constant-Murley scores. RESULTS At a mean follow-up period of 18 months, there was a statistically significant improvement in the range of motion, VAS scores, and Constant-Murley scores postoperatively (p < .01). None of the cases required postoperative opioid administration for pain control. Minor neurological complications like recurrent laryngeal nerve palsy and Horner's syndrome were seen in few cases that resolved with titration of the drug dose. CONCLUSION Our study verifies the use of continuous upper arm brachial block (CUABB) with a portable infusion pump for 2-3 weeks in arthroscopic capsular release for resistant frozen shoulder cases. It significantly reduced postoperative pain in the initial two weeks that aided with early recovery of the shoulder movements and functions without an increased incidence of acute or chronic neurologic complications.
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Affiliation(s)
- Sibin Surendran
- Department of Orthopaedics, Government Medical College, Kozhikode, Kerala, India
| | | | - Raju Karuppal
- Department of Orthopaedics, Government Medical College, Kozhikode, Kerala, India
| | - Anwar Marthya
- IQRAA International Hospital and Research Centre, Kozhikode, Kerala, India
| | - Muhammed Fazil
- IQRAA International Hospital and Research Centre, Kozhikode, Kerala, India
| | - Shibi Mohammed Ali
- IQRAA International Hospital and Research Centre, Kozhikode, Kerala, India
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26
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Chan JJ, Cirino CM, Vargas L, Poeran J, Zubizarreta N, Mazumdar M, Galatz LM, Cagle PJ. Peripheral nerve block use in inpatient and outpatient shoulder arthroplasty: a population-based study evaluating utilization and outcomes. Reg Anesth Pain Med 2020; 45:818-825. [DOI: 10.1136/rapm-2020-101522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 12/17/2022]
Abstract
BackgroundPeripheral nerve block (PNB) is an effective pain management option after shoulder arthroplasty with increasing popularity over the past decade. Large-scale US data in shoulder arthroplasties are lacking, especially regarding impacts on opioid utilization. This population-based study aimed to evaluate PNB utilization patterns and their effect on outcomes after inpatient and outpatient shoulder arthroplasty.MethodsThis retrospective cohort study used data from the nationwide Premier Healthcare claims database (2006–2016). This study includes n=94 787 and n=3293 inpatient and outpatient (total, reverse and partial) shoulder arthroplasty procedures. Multivariable mixed-effects models estimated associations between PNB use and opioid utilization in oral morphine equivalents and cost of hospitalization/stay. For the inpatient group, additional outcome measures were length of stay (LOS), admission to a skilled nurse facility, 30-day readmission, combined complications and naloxone use (as a proxy for opioid-related complications). We report OR (or % change for continuous variables) and 95% CIs.ResultsOverall, PNB was used in 19.1% (n=18 144) and 20.8% (n=685) of inpatient and outpatient shoulder arthroplasties, respectively, with an increasing trend for inpatient procedures. PNB utilization was consistently associated with lower (up to −14.0%, 95% CI −15.4% to −12.5% decrease, with median 100 and 90 oral morphine equivalents for inpatient and outpatient procedures) opioid utilization on the day of surgery with more potent effects seen for inpatient shoulder arthroplasties. Other outcomes were minimally impacted.DiscussionIn this first national study on PNB use in shoulder arthroplasty, we found increasing PNB use among specifically, inpatient procedures, resulting in particularly reduced opioid use on the day of surgery. While our findings may support PNB use in shoulder arthroplasty, its current low utilization and trends towards more outpatient procedures necessitate continuous monitoring of more extensive benefits.
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27
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Holland E, Low D, Bompadre V, Saper M. Continuous interscalene catheters for ambulatory shoulder surgery provide effective intraoperative and early postoperative analgesia in adolescent patients. J ISAKOS 2020. [DOI: 10.1136/jisakos-2020-000433] [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]
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28
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Bupivacaine Extended-Release Liposomal Injection Versus Bupivacaine HCl for Early Postoperative Pain Control Following Wrist Operations: A Prospective, Randomized Control Trial. J Hand Surg Am 2020; 45:550.e1-550.e8. [PMID: 31839368 DOI: 10.1016/j.jhsa.2019.10.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 07/18/2019] [Accepted: 10/07/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE This study evaluated pain control after wrist operations using a long-acting local anesthetic, liposomal bupivacaine, compared with the standard local anesthetic, bupivacaine HCl. METHODS Patients undergoing elective carpometacarpal joint arthroplasty and proximal row carpectomy were eligible. Those meeting inclusion criteria were enrolled before surgery and were randomized to receive an intraoperative injection of liposomal bupivacaine or bupivacaine HCl. Primary outcomes included intraoperative and postoperative opioid requirements and pain levels. On the first 4 postoperative days, phone contact assessed pain level by numeric rating scale, number of opioids taken in each 24-hour period, and efficacy of anesthesia and opioid side effects with overall benefit of analgesia score. RESULTS Postoperative pain scores for 52 patients measured by numeric rating scale demonstrated that liposomal bupivacaine and bupivacaine HCl were similar for pain control. Pain scores and opioid use were similar during the first 4 postoperative days. Opioid use on day 1 was slightly lower with liposomal bupivacaine. There were no statistically significant differences in any postoperative outcome between groups. CONCLUSIONS Liposomal bupivacaine and bupivacaine HCl have similar effects in the treatment of early postoperative pain after trapeziometacarpal suspension arthroplasty and proximal row carpectomy. Neither drug demonstrated a clear advantage in this study. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Iwashita S, Hashiguchi H, Okubo A, Yoneda M, Takai S. Nerve Block for Pain Relief During Arthroscopic Rotator Cuff Repair. J NIPPON MED SCH 2020; 87:87-91. [PMID: 32009067 DOI: 10.1272/jnms.jnms.2020_87-206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although arthroscopic rotator cuff repair (ARCR) often results in good outcomes, some patients have severe pain postoperatively. This study investigated the efficacy of nerve block for ARCR. METHODS This study was retrospective, and consent was obtained from all patients. We divided 50 patients who had undergone ARCR into 4 groups: continuous interscalene nerve block was performed for 11 patients (continuous-injection group), single interscalene nerve block for 10 (single-injection group), suprascapular nerve block for 8 (suprascapular group), and intravenous analgesic administration for 10 (intravenous group). Eleven patients received no nerve block (control group). We evaluated diclofenac sodium and pentazocine dosing, visual analog scale (VAS) scores, and perioperative complications in each group. VAS scoring was done immediately after surgery and 1 and 6 hours and 1, 2, 3, 7, and 14 days postoperatively. RESULTS The doses of diclofenac sodium and pentazocine did not differ between groups. VAS scores immediately after surgery and at 1 and 6 hours after surgery were significantly lower in the single-injection and continuous-injection groups than in the suprascapular, intravenous, and control groups. VAS score at 1 day postoperatively was significantly lower in the continuous-injection group than in the other groups. One patient in the continuous group reported temporary paralysis of the fingers and drug solution leakage. CONCLUSION Interscalene nerve blocks yielded good pain relief for ARCR. Although continuous interscalene nerve block produced continuous pain relief, complications are a concern.
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Affiliation(s)
- Satoshi Iwashita
- Department of Orthopaedic Surgery, Nippon Medical School Hospital
| | | | - Atsushi Okubo
- Department of Orthopaedic Surgery, Nippon Medical School Hospital
| | - Minoru Yoneda
- Department of Orthopaedic Surgery, Nippon Medical School Hospital
| | - Shinro Takai
- Department of Orthopaedic Surgery, Nippon Medical School Hospital
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Neumeister EL, Beason AM, Thayer JA, El Bitar Y. Perioperative Pain Management in Hand and Upper Extremity Surgery. Clin Plast Surg 2020; 47:323-334. [DOI: 10.1016/j.cps.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Bao X, Huang J, Feng H, Qian Y, Wang Y, Zhang Q, Hu H, Wang X. Effect of local anesthetic volume (20 mL vs 30 mL ropivacaine) on electromyography of the diaphragm and pulmonary function after ultrasound-guided supraclavicular brachial plexus block: a randomized controlled trial. Reg Anesth Pain Med 2019; 44:69-75. [PMID: 30640655 DOI: 10.1136/rapm-2018-000014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/24/2018] [Accepted: 06/06/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Diaphragmatic paralysis following supraclavicular brachial plexus block (SCBPB) is ascribed to phrenic nerve palsy. This study investigated the effect of 2 volumes of 0.375% ropivacaine on efficacy of block as a surgical anesthetic and as an analgesic and examined diaphragm compound muscle action potentials (CMAPs) and pulmonary function before and after SCBPB. METHODS Eighty patients scheduled for removal of hardware for internal fixation after healing of an upper limb fracture distal to the shoulder were randomized to receive ultrasound-guided SCBPC for surgical anesthesia with 20 mL (Group A) or 30 mL (Group B) 0.375% ropivacaine. The latency and amplitude of diaphragm CMAPs and forced vital capacity (FVC), FVC% predicted, and forced expiratory volume in 1 s (FEV1) were measured before and 30 min after SCBPB. RESULTS Block success as primary anesthetic in addition to analgesia was 81% in Group A and 91% in Group B. There were no obvious differences in the effectiveness of analgesia between the two groups. The mean time to onset of motor block was significantly longer in Group A (8.1±2.7 min) than in Group B (5.4 ± 2.8 min; p<0.05). The mean amplitude of the diaphragm CMAP was significantly lower in Group B than in Group A (p=0.03). The changes in FVC (Group A, - 8.1% vs Group B, -16.5%), FVC% (Group A, -8.0% vs Group B, -17.1%), and FEV1 (Group A, -9.5% vs Group B, -15.2%) from pre-SCBPB to post-SCBPB were significantly less in Group A than in Group B (all p=0.03). CONCLUSIONS The incidence rates of phrenic nerve palsy and diaphragm paralysis were reduced, and lung function was less impaired in patients who received 20 mL vs 30 mL of 0.375% ropivacaine without any differences in block success. Selecting a lower volume of anesthetic for nerve block may be especially beneficial in obese patients or patients with cardiopulmonary disease. TRIAL REGISTRATION NUMBER ChiCTR-IND-17012166.
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Affiliation(s)
- Xiuxia Bao
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China.,Department of Anesthesiology, The First Affiliated Hospital Zhejiang University, Hangzhou, China
| | - Juanjuan Huang
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China
| | - Haorong Feng
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China
| | - Yuying Qian
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China
| | - Yajie Wang
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China
| | - Qunying Zhang
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China
| | - Huansheng Hu
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China
| | - Xianghe Wang
- Department of Anesthesiology, The 98th Clinical College of PLA, Anhui Medical University, Huzhou, China
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Hauritz RW, Hannig KE, Balocco AL, Peeters G, Hadzic A, Børglum J, Bendtsen TF. Peripheral nerve catheters: A critical review of the efficacy. Best Pract Res Clin Anaesthesiol 2019; 33:325-339. [PMID: 31785718 DOI: 10.1016/j.bpa.2019.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.
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Affiliation(s)
- Rasmus W Hauritz
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Kjartan E Hannig
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Angela Lucia Balocco
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Gwendolyne Peeters
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Admir Hadzic
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Jens Børglum
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Denmark
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Hasan SS, Rolf RH, Sympson AN, Eten K, Elsass TR. Single-Shot Versus Continuous Interscalene Block for Postoperative Pain Control After Shoulder Arthroplasty: A Prospective Randomized Clinical Trial. J Am Acad Orthop Surg Glob Res Rev 2019; 3:e014. [PMID: 31588420 PMCID: PMC6738550 DOI: 10.5435/jaaosglobal-d-19-00014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Continuous catheter infusion of local anesthetics extends the efficacy of regional anesthesia after prosthetic shoulder surgery. Our purpose was to compare continuous interscalene block (CIB) with single-shot interscalene block, and the hypothesis was these would offer similar safety and efficacy in patients with prosthetic shoulder arthroplasty. METHODS Seventy-six patients were randomized to ropivacaine single-shot interscalene block or CIB after prosthetic shoulder arthroplasty. Postoperative pain scores and opioid use, hospital length of stay (LOS), adverse events, and catheter tip withdrawal were recorded. RESULTS Pain scores (P = 0.010) and opioid use (P = 0.003) on the first postoperative day were lower in the CIB group, but there was no difference in LOS. Adverse events were more common in the CIB group and 10% of catheters pulled out prematurely. CONCLUSION Opioid use and pain levels during first postoperative day are clinically less after CIB, but this did not shorten LOS. The benefits of CIB may not justify the higher cost and complication rate.
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Affiliation(s)
- Samer S Hasan
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Robert H Rolf
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Alexandra N Sympson
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Kathryn Eten
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
| | - Thomas R Elsass
- Orthopaedic Surgery (Dr. Hasan), MercyHealth/Cincinnati SportsMedicine and Orthopaedic Center; the Orthopaedic Surgery (Dr. Rolf), Beacon Orthopaedics & Sports Medicine; the TriHealth Hatton Research Institute (Ms. Sympson), TriHealth Good Samaritan Hospital; the Good Samaritan Hospital Orthopedic Center of Excellence (Ms. Eten), TriHealth Good Samaritan Hospital; and the Anesthesiology (Dr. Elsass), Seven Hills Anesthesia, LLC, TriHealth Good Samaritan Hospital, Cincinnati, OH
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Tammam TF. Transversus abdominis plane block: The analgesic efficacy of a new block catheter insertion method. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.07.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Tarek F. Tammam
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Suez Canal University Hospital, Ismailia, Egypt
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Ardon AE, Prasad A, McClain RL, Melton MS, Nielsen KC, Greengrass R. Regional Anesthesia for Ambulatory Anesthesiologists. Anesthesiol Clin 2019; 37:265-287. [PMID: 31047129 DOI: 10.1016/j.anclin.2019.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Proper pain control is critical for ambulatory surgery. Regional anesthesia can decrease postoperative pain, improve patient satisfaction, and expedite patient discharge. This article discusses the techniques, clinical pearls, and potential pitfalls associated with those blocks, which are most useful in an ambulatory perioperative setting. Interscalene, supraclavicular, infraclavicular, axillary, paravertebral, erector spinae, pectoralis, serratus anterior, transversus abdominis plane, femoral, adductor canal, popliteal, interspace between the popliteal artery and capsule of the knee, and ankle blocks are described.
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Affiliation(s)
- Alberto E Ardon
- Department of Anesthesiology, University of Florida Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA.
| | - Arun Prasad
- Department of Anesthesiology, University of Toronto, Women's College Hospital, Mc L 2-405, 399, Bathurst Street, Toronto, Ontario M5T 2S8, Canada
| | - Robert Lewis McClain
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
| | - M Stephen Melton
- Department of Anesthesiology, Duke University Medical Center, Duke University Medical Center, DUMC Box #3094, Stop #4, Durham, NC 27710, USA
| | - Karen C Nielsen
- Department of Anesthesiology, Duke University Medical Center, Duke University Medical Center, DUMC Box #3094, Stop #4, Durham, NC 27710, USA
| | - Roy Greengrass
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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36
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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: 36] [Impact Index Per Article: 7.2] [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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Watts SA, Sharma DJ. Long-Term Neurological Complications Associated with Surgery and Peripheral Nerve Blockade: Outcomes after 1065 Consecutive Blocks. Anaesth Intensive Care 2019; 35:24-31. [PMID: 17323662 DOI: 10.1177/0310057x0703500103] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Peripheral nerve blockade is gaining popularity as an analgesic option for both upper or lower limb surgery. Published evidence supports the improved efficacy of regional techniques when compared to conventional opioid analgesia. The incidence of neurological deficit after surgery associated with peripheral nerve block is unclear. This paper reports on neurological outcomes occurring after 1065 consecutive peripheral nerve blocks over a one-year period from a single institution. All patients receiving peripheral nerve blocks for surgery were prospectively followed for up to 12 months to determine the incidence and probable cause of any persistent neurological deficit. Formal independent neurological review and testing was undertaken as indicated. Thirteen patients reported symptoms that warranted further investigation. A variety of probable causes were identified, with peripheral nerve block being implicated in two cases (one resolved at nine months and one remaining persistent). Overall incidence of block-related neuropathy was 0.22%. Persistent postoperative neuropathy is a rare but serious complication of surgery associated with peripheral nerve block. Formal follow-up of all such blocks is recommended to assess causality and allow for early intervention.
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Affiliation(s)
- S A Watts
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Rahimzadeh P, Imani F, Faiz SHR, Boroujeni BV. Impact of the Ultrasound-Guided Serratus Anterior Plane Block on Post-Mastectomy Pain: A Randomised Clinical Study. Turk J Anaesthesiol Reanim 2018; 46:388-392. [PMID: 30263863 DOI: 10.5152/tjar.2018.86719] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 05/19/2018] [Indexed: 11/22/2022] Open
Abstract
Objective A variety of methods, including neuraxial and regional blocks, have been used to manage post-mastectomy pain. This study evaluates the effect of serratus anterior plane block on acute pain after mastectomy. Methods A total of 60 patients who were candidates for mastectomy under general anaesthesia were divided in this trial into two groups. After entering the recovery room, the first-experimental-group (SAB) underwent the ultrasound-guided serratus anterior block, but the second-control-group (CTL) received no block intervention. An intravenous patient-controlled analgesia (PCA) device was used to deliver fentanyl in both groups. Using the Visual Analog Scale (VAS), the patients' pain was assessed at intervals of 1, 6, 12 and 24 hours after entering the recovery room. Intravenous acetaminophen was administered as a rescue analgesic if the pain exceeded 3 on the VAS. A total amount of fentanyl consumed, the time to first PCA request, a total amount of acetaminophen consumption and possible adverse effects were evaluated. Results The pain scores assessed at the time intervals were not significantly different between the two groups (p>0.5). The total consumption of fentanyl was significantly lower in the SAB group than in the CTL group (p=0.0001). Duration of the time to first PCA request was remarkably longer in the SAB group than in the CTL group (p=0.0001). The total amount of acetaminophen consumed was notably higher in the CTL group than in the SAB group (p=0.001). None of the patients experienced side effects. Conclusion Undertaking serratus anterior block following mastectomy can reduce pain scores and lower opioid usage.
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Affiliation(s)
- Poupak Rahimzadeh
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Farnad Imani
- Pain Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamid Reza Faiz
- Rasoul Akram Hospital Clinical Research Development Center, Iran University of Medical Sciences, Tehran, Iran
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Edwards RM, Currigan DA, Bradbeer S, Mitchell C. Does A Catheter over Needle System Reduce Infusate Leak in Continuous Peripheral Nerve Blockade: A Randomised Controlled Trial. Anaesth Intensive Care 2018; 46:468-473. [DOI: 10.1177/0310057x1804600507] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Continuous peripheral nerve blockade is a common technique in the analgesic management for many procedures. Leakage of local anaesthetic from around the nerve catheter insertion site can increase the chance of catheter dislodgement, risks infective complications, and could divert anaesthetic away from the nerve causing the block to fail. We conducted a randomised controlled trial to assess whether the type of nerve catheter influenced local anaesthetic leak rate. One hundred and ten patients scheduled for elective unilateral total knee arthroplasty were randomised to receive a perineural catheter with either a catheter over needle (CON) system (Pajunk® E-Cath) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany), or catheter through needle (CTN) system (Pajunk® SonoLong) (PAJUNK® GmbH, Medizintechnologie, Geisingen, Germany). There was no statistically significant difference in the rate of leaking catheters between groups (CON 1.8% versus CTN 3.7%; P=0.618), however, the overall leak rate was much lower than anticipated from pilot data. The CON system was on average faster to insert (CON 357 seconds versus CTN 482 seconds; P=0.004), but associated with poorer needle visibility under ultrasound (Likert scale 1–5, mean [SD], CON 3.31 [0.96] versus CTN 3.89 [0.84]; P=0.001). All seven instances of inadvertent catheter dislodgement occurred in the CTN group (P=0.006). There was no statistically significant difference between groups in the proportion of patients who had adequate analgesia on day one (CON 80% versus CTN 86.5%; P=0.294) and day two postoperatively (CON 85.5% versus CTN 91.8%; P=0.369). Our findings show the overall leak rate to be very low with both catheter systems; however, the CON system may have advantages in terms of speed of use and rate of inadvertent catheter dislodgement.
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Affiliation(s)
- R. M. Edwards
- Department of Anaesthesia, Royal United Hospital, Bath, United Kingdom
| | - D. A. Currigan
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - S. Bradbeer
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - C. Mitchell
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Perth, Western Australia
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Abstract
Enhanced recovery after surgery (ERAS) protocols depend on multidisciplinary care and should be peer-reviewed and data-driven. ERAS has reduced hospital length of stay and complications, simultaneously improving patient outcomes. ERAS protocol after shoulder arthroplasty features multidisciplinary collaboration among different perioperative services and multimodal analgesia with a focus on regional anesthesia. Despite success, adoption is not universal because ERAS protocols are resource intensive. They require clinicians invested in the success of these programs and patients who can take charge of their own health. Future protocols need to include quality of life and functional outcome measures to gauge success from the patient perspective.
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Affiliation(s)
- Taras Grosh
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA.
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104, USA
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Holbrook HS, Parker BR. Peripheral Nerve Injury Following Interscalene Blocks: A Systematic Review to Guide Orthopedic Surgeons. Orthopedics 2018; 41:e598-e606. [PMID: 30125041 DOI: 10.3928/01477447-20180815-04] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 12/18/2017] [Indexed: 02/03/2023]
Abstract
The purpose of this review was to determine the incidence and duration of peripheral neurologic symptoms following interscalene blocks for shoulder surgery. Three databases were reviewed for subjective and objective injuries by guidance modality and delivery method. The incidence of neurologic injuries following single site injection interscalene blocks, 3.16%, was significantly less than the 5.24% incidence for continuous catheter infusion interscalene blocks. Less than 0.51% of peripheral neurologic symptoms persisted beyond 1 year for both groups. There is a notable risk of injury following interscalene blocks by all modes of guidance and anesthetic technique, but only a small percentage of injuries persist. [Orthopedics. 2018; 41(5):e598-e606.].
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Saito M, Tsukada S, Fujita N, Rahman M, Morita W, Kitamura N, Tasaki A. Post-operative pain control following arthroscopic rotator cuff repair: peri-articular injection versus interscalene brachial plexus block. INTERNATIONAL ORTHOPAEDICS 2018; 43:1435-1441. [PMID: 30112680 DOI: 10.1007/s00264-018-4096-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 08/06/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE To compare post-operative pain relief with peri-articular injection (PI) versus interscalene brachial plexus block (IBPB) after arthroscopic rotator cuff repair (ARCR) surgery. METHODS We retrospectively reviewed 121 consecutive patients undergoing ARCR surgery divided into two groups: the PI group and the IBPB group. We compared complications and self-reported pain score measured using a Numerical Rating Scale (NRS) during the initial 24 hours after surgery. RESULTS The NRS scores recorded in the recovery room (0), 0.5, and four hours post-operatively were higher in the PI group (n = 38) than the IBPB group (n = 52) (2.1 vs. 0.8, p = 0.014; 1.4 vs. 0.5, p = 0.0069; and 1.3 vs. 0.5, p = 0.012, respectively). However, the NRS scores recorded at 16, 20, and 24 hours post-operatively were lower in the PI group than in the IBPB group (1.4 vs. 3.1, p < 0.0001; 1.4 vs. 3.2, p < 0.0001; and 1.7 vs. 3.2, p = 0.00046, respectively). The incidences of post-operative nausea and temporary numbness in the upper arm were significantly lower in the PI group than in the IBPB group (7.9% vs. 33%, p = 0.0052; and 13% vs. 85%, p < 0.0001, respectively). CONCLUSIONS Although IBPB provided superior pain control during the initial few hours after ARCR surgery, PI was superior from 16 to 24 hours post-operatively. The rates of side effects, such as nausea and temporary arm numbness, were also lower in the PI group than in the IBPB group.
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Affiliation(s)
- Masayoshi Saito
- Department of Orthopedics Surgery, St. Luke's International Hospital, 9-1 Akashi Cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Sachiyuki Tsukada
- Department of Orthopedics Surgery, St. Luke's International Hospital, 9-1 Akashi Cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Nobuko Fujita
- Department of Anesthesia, St. Luke's International Hospital, 9-1 Akashi Cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Mahbubur Rahman
- Center for Clinical Epidemiology, St. Luke's International University, Tsukiji 3-6-2, Chuo-ku, Tokyo, 104-0045, Japan
| | - Wataru Morita
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nobuto Kitamura
- Department of Orthopedics Surgery, St. Luke's International Hospital, 9-1 Akashi Cho, Chuo-ku, Tokyo, 104-8560, Japan
| | - Atsushi Tasaki
- Department of Orthopedics Surgery, St. Luke's International Hospital, 9-1 Akashi Cho, Chuo-ku, Tokyo, 104-8560, Japan.
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Kim JH, Koh HJ, Kim DK, Lee HJ, Kwon KH, Lee KY, Kim YS. Interscalene brachial plexus bolus block versus patient-controlled interscalene indwelling catheter analgesia for the first 48 hours after arthroscopic rotator cuff repair. J Shoulder Elbow Surg 2018; 27:1243-1250. [PMID: 29605659 DOI: 10.1016/j.jse.2018.02.048] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 02/01/2018] [Accepted: 02/13/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND We sought to compare the efficacy of interscalene brachial plexus bolus blockade (IBPBB) and patient-controlled interscalene indwelling catheter analgesia (PCIA) for postoperative pain management within 48 hours postoperatively in patients undergoing arthroscopic rotator cuff repairs (ARCR). METHODS Patients undergoing ARCR were randomized into 3 groups by postoperative analgesia method. The IBPBB group received a mixed solution of 16 mL of 0.75% ropivacaine and 4 mL of 2% lidocaine as a bolus postoperatively. The PCIA group received a 10-mL bolus solution of 0.75% ropivacaine (4 mL) and 5% dextrose water (6 mL) just after the operation and continuous infusion of this solution. The control received only meperidine as needed, 12.5 mg, intravenously. Visual analog scale (VAS) pain scores were evaluated for the first 48 hours postoperatively. RESULTS For the first 2 hours postoperatively, VAS scores in the IBPBB group were significantly lower than in the PCIA group and control group, but at 12 and 24 hours postoperatively, VAS scores of the IBPBB group were significantly higher than the PCIA group (P < .05). At 48 hours postoperatively, there was no significant difference in VAS scores among the 3 groups (P = .169). The method of analgesia was the only factor affecting pain scores at 24 hours postoperatively (P < .05). CONCLUSIONS IBPBB provided effective immediate postoperative analgesia until 6 hours postoperatively. Especially until postoperative 2 hours, the VAS pain score was less than 1 point in the IBPBB group; however, there was significant rebound pain at 12 hours after surgery. During the first 24 hours postoperatively, PCIA reduced postoperative pain without rebound pain. Surgeons should choose methods for control of postoperative pain considering the advantages and disadvantages of each analgesic method.
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Affiliation(s)
- Jong-Ho Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Hyun Jung Koh
- Departiment of Anesthesiology and Pain, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Kyu Kim
- Departiment of Anesthesiology and Pain, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo-Jin Lee
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Ki-Hyun Kwon
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea
| | - Kwang-Yeol Lee
- Department of Orthopedic Surgery, Seoul Nanuri Hospital, Seoul, Republic of Korea
| | - Yang-Soo Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, Catholic University of Korea, Seoul, Republic of Korea.
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Jaeger P, Baggesgaard J, Sørensen JK, Ilfeld BM, Gottschau B, Graungaard B, Dahl JB, Odgaard A, Grevstad U. Adductor Canal Block With Continuous Infusion Versus Intermittent Boluses and Morphine Consumption. Anesth Analg 2018; 126:2069-2077. [DOI: 10.1213/ane.0000000000002747] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Balthasar AJR, Bydlon TM, Ippel H, van der Voort M, Hendriks BHW, Lucassen GW, van Geffen GJ, van Kleef M, van Dijk P, Lataster A. Optical signature of nerve tissue-Exploratory ex vivo study comparing optical, histological, and molecular characteristics of different adipose and nerve tissues. Lasers Surg Med 2018; 50:948-960. [PMID: 29756651 PMCID: PMC6220981 DOI: 10.1002/lsm.22938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 02/02/2023]
Abstract
Background During several anesthesiological procedures, needles are inserted through the skin of a patient to target nerves. In most cases, the needle traverses several tissues—skin, subcutaneous adipose tissue, muscles, nerves, and blood vessels—to reach the target nerve. A clear identification of the target nerve can improve the success of the nerve block and reduce the rate of complications. This may be accomplished with diffuse reflectance spectroscopy (DRS) which can provide a quantitative measure of the tissue composition. The goal of the current study was to further explore the morphological, biological, chemical, and optical characteristics of the tissues encountered during needle insertion to improve future DRS classification algorithms. Methods To compare characteristics of nerve tissue (sciatic nerve) and adipose tissues, the following techniques were used: histology, DRS, absorption spectrophotometry, high‐resolution magic‐angle spinning nuclear magnetic resonance (HR‐MAS NMR) spectroscopy, and solution 2D 13C‐1H heteronuclear single‐quantum coherence spectroscopy. Tissues from five human freshly frozen cadavers were examined. Results Histology clearly highlights a higher density of cellular nuclei, collagen, and cytoplasm in fascicular nerve tissue (IFAS). IFAS showed lower absorption of light around 1200 nm and 1750 nm, higher absorption around 1500 nm and 2000 nm, and a shift in the peak observed around 1000 nm. DRS measurements showed a higher water percentage and collagen concentration in IFAS and a lower fat percentage compared to all other tissues. The scattering parameter (b) was highest in IFAS. The HR‐MAS NMR data showed three extra chemical peak shifts in IFAS tissue. Conclusion Collagen, water, and cellular nuclei concentration are clearly different between nerve fascicular tissue and other adipose tissue and explain some of the differences observed in the optical absorption, DRS, and HR‐NMR spectra of these tissues. Some differences observed between fascicular nerve tissue and adipose tissues cannot yet be explained but may be helpful in improving the discriminatory capabilities of DRS in anesthesiology procedures. Lasers Surg. Med. 50:948–960, 2018. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Andrea J R Balthasar
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Hans Ippel
- Department of Biochemistry, Faculty of Health Medicine and Life Science, Maastricht University, Maastricht, The Netherlands
| | | | - Benno H W Hendriks
- Philips Research, Eindhoven, The Netherlands.,Delft University of Technology, Department of BioMechanical Engineering, Delft, The Netherlands
| | | | - Geert-Jan van Geffen
- Department of Anesthesiology, University Medical Center St. Radboud, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paul van Dijk
- Department of Anatomy and Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Arno Lataster
- Department of Anatomy and Embryology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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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: 5.3] [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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Recovery after shoulder arthroscopy: Inpatient versus outpatient management. Orthop Traumatol Surg Res 2018; 104:39-43. [PMID: 29233760 DOI: 10.1016/j.otsr.2017.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 10/05/2017] [Accepted: 10/10/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Shoulder arthroscopy is particularly suited to outpatient surgery, thanks to advances in anesthetic and analgesic techniques. The main goal of this study was to compare postoperative recovery after shoulder arthroscopy between outpatient and inpatient management. HYPOTHESIS There is no difference in functional recovery between inpatient and outpatient management. MATERIALS AND METHOD A single-center, single-operator prospective study was conducted. Both groups received patient-controlled analgesia via an interscalene catheter. The inclusion criterion was shoulder arthroscopy for rotator cuff tendinopathy. The choice between inpatient and outpatient management was left to the patient. The study endpoint was postoperative recovery assessed on QOR-15 at days 1, 2, 3, 4 and 7 and on Quick-DASH at 6 weeks. RESULTS Forty-nine patients were included, divided into 2 groups. The outpatient (OP) and inpatient (IP) groups were comparable. Reconstructive surgery accounted for 54% of cases in OP versus 62% in IP. There was no significant difference in recovery in the first postoperative days (QOR-15) or at 6 weeks (Quick-DASH) (p>0.05). Pain on visual analog scale (VAS) was significantly greater in OP after discharge home. DISCUSSION No significant difference in postoperative recovery was observed between groups. Nevertheless, pain management and patient information for outpatients need improving. LEVEL OF EVIDENCE II, comparative study.
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Abstract
Pain control in total shoulder arthroplasty demands a multidisciplinary approach with collaboration between patients, surgeon, and anesthetist. A multimodal approach with preemptive medication, regional blockade, local anesthetics, and a combination of acetaminophen, nonsteroidal antiinflammatory drugs, tramadol, and gabapentinoids postoperatively leads to pain control and patient satisfaction. Assessment of patients' expectations constitutes a vital aspect of the preoperative patient evaluation. Educating and psychologically preparing patients reduces postoperative pain. Patients with anxiety and depression, preoperative narcotic use, and medical comorbidities are at an increased risk for suboptimal pain control. Minimizing narcotic use decreases opioid-related adverse effects and facilitates productive rehabilitation efforts.
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Affiliation(s)
- Jason L Codding
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA.
| | - Charles L Getz
- The Rothman Institute at Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut Street, 5th floor, Philadelphia, PA 19107, USA
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Abstract
Acute pain medicine services influence many different aspects of postoperative recovery and function. Here, we discuss the various stakeholders of an acute pain medicine service, review the direct and indirect impact on said stakeholders, review the shared and competing interests between acute pain medicine programs and various payer systems, and discuss how APM services can help service lines align with the interests of the recent CMS Innovations Comprehensive Care for Joint Replacement Model.
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Affiliation(s)
- Chancellor F Gray
- Division of Adult Arthroplasty and Joint Reconstruction, Department of Orthopaedics and Rehabilitation
| | - Cameron Smith
- Division of Acute Pain Medicine and Regional Anesthesia, Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL
| | - Yury Zasimovich
- Division of Acute Pain Medicine and Regional Anesthesia, Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL
| | - Patrick J Tighe
- Division of Acute Pain Medicine and Regional Anesthesia, Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL
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50
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Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management. Anesth Analg 2017; 125:1749-1760. [DOI: 10.1213/ane.0000000000002497] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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