Acute neck cellulitis and mediastinitis complicating a continuous interscalene block

ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine

BACKGROUND

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

METHODS

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

RESULTS

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

CONCLUSIONS

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Regional Catheters for Outpatient Surgery-a Comprehensive Review

PURPOSE OF REVIEW

This review summarizes and discusses the history of continuous catheter blockade (CCB), its current applications, clinical considerations, economic benefits, potential complications, patient education, and best practice techniques.

RECENT FINDINGS

Regional catheters for outpatient surgery have greatly impacted acute post-operative pain management and recovery. Prior to development, options for acute pain management were limited to the use of opioid pain medications, NSAIDS, neuropathic agents, and the like as local anesthetic duration of action is limited to 4-8 h. Moreover, delivery of opioids post-operatively has been associated with respiratory and central nervous depression, development of opioid use disorder, and many other potential adverse effects. CCB allows for faster recovery time, decreased rates of opioid abuse, and better pain control in patients post-operatively. Outpatient surgical settings continue to focus on efficiency, quality, and safety, including strategies to prevent post-operative nausea, vomiting, and pain. Regional catheters are a valuable tool and help achieve all of the well-established endpoints of enhanced recovery after surgery (ERAS). CCB is growing in popularity with wide indications for a variety of surgeries, and has demonstrated improved patient satisfaction, outcomes, and reductions in many unwanted adverse effects in the outpatient setting.

Prolonged continuous infraclavicular brachial plexus perineural infusion following replantation of a mid-humeral amputation

Replantation of a traumatic upper extremity amputation is a complex process accompanied by prolonged hospitalization, extended rehabilitation, and potential for graft failure secondary to poor perfusion to the distal extremity. The patient is faced with repeat visits to the operating room in addition to severe acute and chronic pain issues. We present the case of an 18-year-old male treated with prolonged continuous peripheral nerve blockade following traumatic left mid-humeral amputation and subsequent replantation. The patient maintained infraclavicular brachial plexus catheterization until hospital discharge, a course spanning 33 days and six follow-up surgical procedures. The patient was pain free and had been weaned off all opioids at a 4-week outpatient surgical debridement. Prolonged continuous infraclavicular brachial plexus blockade following replantation surgery has numerous potential benefits including augmentation of perfusion to the injured extremity, management of severe acute post-traumatic pain, and prevention of the chronic pain associated with transected nerves.

Enhanced Recovery After Shoulder Arthroplasty

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.

Perineural Versus Systemic Dexamethasone in Front-Foot Surgery Under Ankle Block: A Randomized Double-Blind Study

BACKGROUND AND OBJECTIVES

Among the different adjuvants, dexamethasone is one of the most accepted to prolong the effect of local anesthetics. This study aims to determine the superiority of perineural over systemic dexamethasone administration after a single-shot ankle block in metatarsal osteotomy.

METHODS

We performed a prospective, double-blind, randomized study. A total of 100 patients presenting for metatarsal osteotomy with an ankle block were randomized into 2 groups: 30 mL ropivacaine 0.375% + perineural dexamethasone 4 mg (1 mL) + 2.5 mL of systemic saline solution (PNDex group, n = 50) and 30 mL ropivacaine 0.375% + 1 mL of perineural saline solution + intravenous dexamethasone 10 mg (2.5 mL) (IVDex group, n = 50). The primary end point was the duration of analgesia defined as the time between the performance of the ankle block and the first administration of rescue analgesia with tramadol.

RESULTS

Time period to first rescue analgesia with tramadol was similar in the IVDex group and the PNDex group. Data are expressed as mean (SD) or median (range). Duration of analgesia was 23.2 (9.5) hours in the IVDex group and 19 (8.2) hours in the PNDex group (P = 0.4). Consumption of tramadol during the first 48 hours was 0 mg (0-150 mg) in the IVDex group versus 0 mg (0-250 mg) in the PNDex group (P = 0.59). Four (8%) and 12 (24%) patients reported nausea or vomiting in the IVDex group and the PNDex group, respectively (P = 0.03).

CONCLUSIONS

In front-foot surgery, perineural and systemic administrations of dexamethasone are equivalent for postoperative pain relief when used as an adjuvant to ropivacaine ankle block.

CLINICAL TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov, identifier NCT02904538.

Postoperative Analgesia in a Prolonged Continuous Interscalene Block Versus Single-Shot Block in Outpatient Arthroscopic Rotator Cuff Repair: A Prospective Randomized Study

PURPOSE

To compare the analgesic efficacy of 3-day continuous interscalene brachial plexus block versus a single-shot block for arthroscopic rotator cuff repair.

METHODS

Eighty-five patients scheduled for arthroscopic rotator cuff repair were randomly assigned to either the single-shot group (SSG) or continuous interscalene brachial block group (CG). Patients in the SSG received 2.5 mg/kg of 0.5% bupivacaine up to 25 mL; the CG received the same dose as a loading dose via catheter followed by an infusion of 0.125% bupivacaine at 5 mL/h and a patient-controlled bolus of 5 mL hourly for 72 hours. Follow-up after discharge was with telephone calls over the next 3 days. Pain was measured on a visual analog scale. Also measured were sleep disturbance, number of opioid doses taken, adverse effects, and level of patient satisfaction.

RESULTS

The median rest pain scores on the 3 days of follow-up measured on a scale of 0 to 10 (with 10 equal to greatest pain) were 0, 0, and 3 in the CG compared with 4, 4, and 3 in the SSG (P < .001) for days 1, 2, and 3, respectively. The median maximum scores were 2, 2, and 4 in the CG compared with 8, 7, and 6 in the SSG (P < .001) for the same time period.

CONCLUSIONS

A 3-day continuous interscalene brachial plexus block provides better analgesia than a single-shot block. Sleep patterns were better, and less opioid was needed after arthroscopic rotator cuff repair in patients given a continuous plexus block.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Ultrasound-Guided Nerve Blocks in Emergency Medicine Practice

OBJECTIVES

The purpose of this study was to investigate the current practice of ultrasound (US)-guided regional anesthesia at academic emergency departments, including education, protocols, policies, and quality assessment.

METHODS

We conducted a cross-sectional study. A questionnaire on US-guided nerve blocks was electronically sent to all emergency US directors and emergency US fellowship directors.

RESULTS

A total of 121 of 171 academic institutions with an emergency medicine residency program participated in this study, representing a 71% response rate. Eighty-four percent (95% confidence interval [CI], 77%-91%) of programs perform US-guided nerve blocks at their institutions. The most common type of nerve block performed is a forearm nerve block (ulnar, median, or radial). The most common indication for US-guided nerve blocks is fracture pain management. Only 7% (95% CI, 2%-12%) of programs have a separate credentialing pathway for US-guided nerve blocks. Regarding quality assessment review of US-guided nerve blocks, none of the programs have a separate program in place. In 57% (95% CI, 48%-66%) of programs, it is a component of the emergency US quality assessment program. Eighty-four percent (95% CI, 77%-90%) of programs do not have specific agreements with other specialty services with regard to performing US-guided nerve blocks in the emergency department. The most common educational methods used to teach US-guided nerve blocks are didactic sessions, at 67% (95% CI, 59%-75%); online resources, at 54% (95% CI, 45%-63%); and supervised training with real patients, at 48% (95% CI, 39%-57%).

CONCLUSIONS

Ultrasound-guided nerve blocks are performed at most academic emergency departments. However, there is a substantial variation in the practices and policies within these institutions.

Efficacy of arthroscopically placed pain catheter adjacent to the suprascapular nerve (continuous arthroscopically assisted suprascapular nerve block) following arthroscopic rotator-cuff repair

Background

Rotator-cuff surgery is well recognized to be a painful procedure.

Objectives

The purpose of this study was to examine the effectiveness of an arthroscopically placed perineural catheter at the scapular notch to provide a continuous block of the suprascapular nerve (continuous arthroscopically assisted suprascapular nerve block [ca-SSNB]) following arthroscopic rotator-cuff repair (ARCR).

Materials and methods

This level II, prospective, randomized, controlled trial without postoperative blinding included 40 patients, who had a 48-hour pain pump, with 0.2% ropivacaine infusion and a continuous rate of 3 mL/hour, placed via an arthroscopically placed catheter following ARCR with arthroscopic release of the superior transverse ligament: 21 patients had a ca-SSNB, and 19 patients had a continuous subacromial bursal block (SAB). The visual analog scale (at 6 hours and on the first, second, and third postoperative days) and the total number of additional pain-reduction attempts during the 3 postoperative days were calculated.

Results

The respective visual analog scale scores (mm) obtained from the ca-SSNB and SAB groups were 62.4 and 67.6 (P=0.73) before surgery, 9.1 and 19.4 (P=0.12) at 6 hours after surgery, 24.4 and 44.6 (P=0.019) on the first postoperative day, 19.4 and 40.4 (P=0.0060) on the second postoperative day, and 18.5 and 27.8 (P=0.21) on the third postoperative day. Total additional pain-reduction attempts recorded for the ca-SSNB and SAB groups during the 3 postoperative days were 0.3 times and 1.2 times (P=0.0020), respectively.

Conclusion

ca-SSNB was highly effective in controlling postoperative pain after ARCR.

Current concepts in anaesthesia for shoulder surgery

There has been an exponential growth in the volume of shoulder surgery in the last 2 decades and a very wide variety of anaesthetic techniques have emerged to provide anaesthesia and post-operative analgesia. In this article we examine current opinion, risks, benefits and practicalities of anaesthetic practice and the provision of post-operative analgesia for shoulder surgery.

Ultrasonography- or electrophysiology-guided suprascapular nerve block in arthroscopic acromioplasty: a prospective, double-blind, parallel-group, randomized controlled study of efficacy

PURPOSE

To evaluate the efficacy of ultrasonography-guided (UG) and electrophysiology-guided (EG) suprascapular nerve block (SNB) for arthroscopic acromioplasty with regard to pain relief.

METHODS

A prospective, double-blind, randomized controlled clinical trial was performed from June 2007 to April 2010. Patients who were scheduled for elective arthroscopic acromioplasty and who met the inclusion criteria were assigned to 1 of 2 experimental groups (UG or EG SNB) or to 1 blind group (using anatomic landmarks). Before surgery, an SNB was performed with either ultrasonographic or electrophysiologic guidance or with no assistive devices (blind). Variables were collected at 4, 24, 48, and 72 hours postoperatively.

RESULTS

Sixty-three patients were initially enrolled in the study, but 11 dropped out for various reasons. In the UG group at 4 hours, the visual analog scale score at rest (30 ± 12.0 v 39 ± 9.9 for EG group and 41 ± 11.8 for blind group) and when the patient was moving (42 ± 15.2 v 52 ± 11.5 for EG group and 53 ± 12.6 for blind group) was significantly decreased compared with the EG and blind groups (P < .05). Opioid consumption during the first 24 hours was significantly reduced in the UG and EG groups (4.3 ± 1.9 mg and 3.8 ± 2.3 mg, respectively) compared with the blind group (5.1 ± 2.2 mg) (P < .05). The visual analog scale score at rest and when the patient was moving; the pain score on the University of California, Los Angeles questionnaire; and the activities of daily living score on the American Shoulder and Elbow Surgeons questionnaire in the EG and UG groups improved more than the values in the blind group over the follow-up intervals (P < .05). Morphine consumption in the EG and UG groups by the first, second, and third days was significantly smaller than that in the blind control group (P < .05).

CONCLUSIONS

UG and EG SNB can reduce pain and painkiller consumption for up to 72 hours postoperatively. Ultrasonographic or electrophysiologic guidance is more effective than the blind method of SNB.

LEVEL OF EVIDENCE

Level I, randomized controlled trial with significant difference.

Risk of catheter-associated infection in young hematology/oncology patients receiving long-term peripheral nerve blocks

BACKGROUND

Continuous peripheral nerve blocks (CPNBs) are increasingly used to control postoperative and chronic pain. At our pediatric oncology institution, the duration of CPNBs is often prolonged. The risk of catheter-associated infection with prolonged CPNBs has not been previously investigated.

AIM

We analyzed the incidence of CPNB-related infection and its relation to catheter duration, catheter site, intensive care stay, and antibiotic coverage.

METHODS

All CPNBs placed at our institution between August 1, 2005 and October 31, 2010 were studied. Primary diagnosis and the site, indication, duration, and infectious adverse effects of CPNBs were obtained from our Pain Service QI database. Patients' age and sex, antibiotic administration, and number of days in intensive care were collected from patients' medical records.

RESULTS

The use of 179 catheters in 116 patients was evaluated. Mean age at CPNB placement was 15.1 years (median, 14.7; range, 0.4-26.9). The most frequent indication for CPNB was surgery (89.4%), most commonly orthopedic (78.8%). Mean CPNB duration was 7.2 days (median, 5.0; range, 1-81 days). Two cases (1.12%) of CPNBs developed signs of infection, both associated with femoral catheters. The infections were mild and necessitated catheter removal at days 10 and 13, respectively.

CONCLUSION

Nerve block catheter-associated infections are infrequent at our institution despite prolonged CPNB use. Both patients with infection had femoral catheters and prolonged catheter (≥ 10 days) use.

Long-term use of nerve block catheters in paediatric patients with cancer related pathologic fractures

We report three cases of children with osteosarcoma and pathologic fractures treated with long-term continuous nerve blocks for preoperative pain control. One patient with a left distal femoral diaphysis fracture had a femoral continuous nerve block catheter for 41 days without complications. Another with a fractured left proximal femoral shaft had three femoral continuous nerve block catheters for 33, 26 and 22 days respectively. The third patient, whose right proximal humerus was fractured, had a brachial plexus continuous nerve block catheter for 36 days without complication. In our experience, prolonged use of continuous nerve block is safe and effective in children with pathologic fractures for preoperative pain control.

Regional blockade of the shoulder: approaches and outcomes

The article reviews the current literature regarding shoulder anesthesia and analgesia. Techniques and outcomes are presented that summarize our present understanding of regional anesthesia for the shoulder. Shoulder procedures producing mild to moderate pain may be managed with a single-injection interscalene block. However, studies support that moderate to severe pain, lasting for several days is best managed with a continuous interscalene block. This may cause increased extremity numbness, but will provide greater analgesia, reduce supplemental opioid consumption, improve sleep quality and patient satisfaction. In comparison to the nerve stimulation technique, ultrasound can reduce the volume of local anesthetic needed to produce an effective interscalene block. However, it has not been shown that ultrasound offers a definitive benefit in preventing major complications. The evidence indicates that the suprascapular and/or axillary nerve blocks are not as effective as an interscalene block. However in patients who are not candidates for the interscalene block, these blocks may provide a useful alternative for short-term pain relief. There is substantial evidence showing that subacromial and intra-articular injections provide little clinical benefit for postoperative analgesia. Given that these injections may be associated with irreversible chondrotoxicity, the injections are not presently recommended.

The role of continuous peripheral nerve blocks

A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.

Infectious complications of regional anesthesia

PURPOSE OF REVIEW

Regional anesthesia is commonly used to provide intraoperative anesthesia and postoperative analgesia. Potential complications of both neuraxial and peripheral regional techniques include infectious sequelae. This review examines important components of practice that are known to minimize the risk of infection associated with regional anesthesia.

RECENT FINDINGS

Healthcare-associated infections increase morbidity and mortality, patient pain and suffering, direct medical costs, and hospital length-of-stay. Recently published national guidelines from subspecialty societies and government agencies emphasize the importance of strict aseptic technique in the prevention of infectious complications associated with regional anesthesia. Proper hand hygiene, the use of surgical masks, appropriate antiseptic selection and application, and proper preparation of local anesthetic infusate solutions are all considered essential components of asepsis. Anesthesia providers need to adhere to strict aseptic guidelines to minimize the risk of potentially devastating infectious complications.

SUMMARY

Infectious complications associated with regional anesthesia are exceedingly rare events. Adherence to strict aseptic guidelines as published by the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, and the Royal College of Anaesthetists may reduce the risk of infectious complications.

Feasibility of ultrasound-guided posterior approach for interscalene catheter placement during arthroscopic shoulder surgery

Background

Continuous interscalene block has been known to improve postoperative analgesia after arthroscopic shoulder surgery. This was a prospective study investigating the ultrasound-guided posterior approach for placement of an interscalene catheter, clinical efficacy and complications after placement of the catheter.

Methods

Forty-two patients undergoing elective arthroscopic shoulder surgery were included in this study and an interscalene catheter was inserted under the guidance of ultrasound with posterior approach. With the inplane approach, the 17 G Tuohy needle was advanced until the tip was placed between the C5 and C6 nerve roots. After a bolus injection of 20 ml of 0.2% ropivacaine, a catheter was threaded and secured. A continuous infusion of ropivacaine 0.2% 4 ml/hr with patient-controlled 5 ml boluses every hour was used over 2 days. Difficulties in placement of the catheter, clinical efficacy of analgesia and complications were recorded. All patients were monitored for 48 hours and examined by the surgeon for complications within 2 weeks of hospital discharge.

Results

Easy placement of the catheter was achieved in 100% of the patients and the success rate of catheter placement during the 48 hr period was 92.9%. Postoperative analgesia was effective in 88.1% of the patients in the post anesthetic care unit. The major complications included nausea (7.1%), vomiting (4.8%), dyspnea (4.8%) and unintended vascular punctures (2.4%). Other complications such as neurologic deficits and local infection around the puncture site did not occur.

Conclusions

The ultrasound-guided interscalene block with a posterior approach is associated with a success high rate in placement of the interscalene catheter and a low rate of complications. However, the small sample size limits us to draw definite conclusions. Therefore, a well-designed randomized controlled trial is required to confirm our preliminary study.

Continuous peripheral nerve blocks in acute pain management

The indications for continuous nerve blocks for the perioperative pain management in hospitalized and ambulatory patients have extended well beyond orthopaedics. These techniques are not only used to control pain in patients undergoing major upper and lower extremity surgery, but also to provide perioperative analgesia in patients undergoing abdominal, plastic, urological, gynaecological, thoracic, and trauma surgeries. Infusion regimens of local anaesthetics and supplements must take into consideration the condition of the patient before and after surgery, the nature and intensity of the surgical stress associated with the surgery, and the possible need for immediate functional recovery. Continuous nerve blocks have proved safe and effective in reducing opioid consumption and related side-effects, accelerating recovery, and in many patients reducing the length of hospital stay. Continuous nerve blocks provide a safer alternative to epidural analgesia in patients receiving thromboprophylaxis, especially with low molecular-weight heparin.

Complications of peripheral nerve blocks

Complications of peripheral nerve blocks are fortunately rare, but can be devastating for both the patient and the anaesthesiologist. This review will concentrate on current knowledge about peripheral nerve injury secondary to nerve blocks, complications from continuous peripheral nerve catheter techniques, and local anaesthetic systemic toxicity.

Regional anaesthesia practice for total knee arthroplasty: French national survey - 2008

BACKGROUND AND OBJECTIVE

Improved pain management techniques and rehabilitation programs have significantly modified outcome for total knee arthroplasty (TKA).

OBJECTIVE

The aim of the survey was to describe the French practice patterns in regional anaesthesia for TKA.

METHODS

Twenty-item questionnaires were distributed to units with significant orthopaedic activity across France. The content referred to the type of orthopaedic activity; anaesthetic and analgesic management; preoperative patient information; technical aspects describing regional anaesthesia and postoperative analgesia.

RESULTS

Response rate was 54%. Combined general anaesthesia and perineural catheter was the most frequently used anaesthetic technique. Most of respondents used multimodal analgesia (including femoral nerve catheter by 80%). Written hygiene protocols were rarely available. Sterile gowns were seldom worn. Among antiseptic agents, povidone iodine was most often used. Sedative agents were systematically used by 36% of respondents. Ropivacaine was the preferred local anaesthetic agent. Finally, adjuvants were rarely used. In most cases (58%) the femoral block was performed before induction of general anaesthesia. The catheter was commonly threaded to a length between 5 and 8 cm. The correct position of the catheter tip was verified clinically by majority of respondents. Local anaesthetics were administered by continuous infusion, continuous infusion plus boluses and boluses alone in 44, 36 and 8% of cases. Catheter duration was 48 and 72 h in 45 and 33% of the units and was independent of pain scores.

CONCLUSION

This national survey showed practices in accordance with recent guidelines as well as persistent challenges in regional anaesthesia for TKA.

Neurological adverse events following regional anesthesia administration

Regional anesthesia and analgesia have been associated with improved analgesia, decreased postoperative nausea and vomiting, and increased patient satisfaction for many types of surgical procedures. In obstetric anesthesia care, it has also been associated with improved maternal mortality and major morbidity. The majority of neurological adverse events following regional anesthesia administration result in temporary sensory symptoms; long-term or permanent disabling motor and sensory problems are very rare. Infection and hemorrhagic complications, particularly with neuraxial blocks, can cause neurological adverse events. More commonly, however, there are no associated secondary factors and some combination of needle trauma, intraneural injection, and/or local anesthetic toxicity may be associated, but their individual contributions to any event are difficult to define.

Ambulatory anesthesia and regional catheters: when and how

Several clinical trials have demonstrated the superiority of continuous peripheral nerve block compared with traditional opioid-based analgesia. The ability to provide safe and effective continuous peripheral nerve block at home is an attractive alternative to opioid-based analgesia with its related side effects. In this article, the practical issues related to catheter use in the ambulatory setting are discussed. Techniques for catheter placement, infusion regimens, patient education, and complications are subject to many institutional preferences. In this review, special emphasis is placed on evidence-based techniques.

Continuous tunnelled femoral nerve block for palliative care of a patient with metastatic osteosarcoma

An 18-year-old man with metastatic femoral osteosarcoma had inadequate pain control with gabapentin, naproxen and intravenous fentanyl. A tunnelled femoral nerve catheter was used to administer a continuous infusion of 0.2% ropivacaine and 4 microg/ml clonidine (10 ml/hour) until his death 88 days later During discharge from hospital, catheter disconnection resulted in severe pain and readmission. Tunnelling, aseptic insertion technique, antibiotics and sterile infusate prepared by the pharmacy may have reduced the chance of infection. We propose that this is a suitable and effective technique in the long-term management of patients with terminal cancer and should be considered on a case-by-case basis.

Interscalene brachial plexus block for open-shoulder surgery: a randomized, double-blind, placebo-controlled trial between single-shot anesthesia and patient-controlled catheter system

INTRODUCTION

Interscalene brachial plexus block (ISB) is widely used as an adjuvant regional pain therapy in patients undergoing major shoulder surgery and has proved its effectiveness on postoperative pain reduction and opioid-sparing effect.

METHOD

This single-center, prospective, double-blind, randomized and placebo-controlled study was to compare the effectiveness of a single-shot and a patient-controlled catheter insertion ISB system after major open-shoulder surgeries. Seventy patients were entered to receive an ISB and a patient-controlled interscalene catheter. The catheter was inserted under ultrasound guidance. Patients were then assigned to receive one of two different postoperative infusions, either 0.2% ropivacaine (catheter group) or normal saline solution (single-shot group) via a disposable patient-controlled infusion pump.

RESULTS

The study variables were amount of rescue medication, pain at rest and during physiotherapy, patient satisfaction and incidence of unwanted side effects. The ropivacaine group revealed significantly less consumption of rescue medication within the first 24 h after surgery. Incidence of side effects did not differ between the two groups.

CONCLUSION

Based on our results, we recommend the use of interscalene plexus block in combination with a patient-controlled catheter system under ultrasound guidance only for the first 24 h after major open-shoulder surgery.

Case report: continuous interscalene block associated with neck hematoma and postoperative sepsis

Continuous peripheral nerve blockade is often used for the management of postoperative pain, even in ambulatory patients. The reported incidence of infectious complications after continuous nerve blockade is low. We report a case of Staphylococcus aureus sepsis after total shoulder arthroplasty in a patient who presented to her surgeon 8 days postoperatively with lethargy and labored breathing. Preoperatively, the patient had received a continuous interscalene block for analgesia that was associated with a neck hematoma. After readmission, exploratory laparotomy, and extensive hospital stay, the patient was discharged to an extended care facility in good condition.

Pain pump use after shoulder arthroscopy as a cause of glenohumeral chondrolysis

Shoulder arthroscopy has become a routine outpatient surgery. Pain control is a limiting factor for patient discharge after surgery, and several modalities are used to provide continued analgesia postoperatively. Regional anesthetic blocks and shoulder pain pumps are common methods to provide short-term pain control. Shoulder pain pumps can be used either in the subacromial space or within the glenohumeral joint. Several clinical studies suggested--which was confirmed by a bovine and rabbit cartilage study--that there is significant chondrotoxicity from bupivacaine, a local anesthetic commonly used in pain pumps. Postarthroscopic glenohumeral chondrolysis is a noninfectious entity associated with factors including use of radiofrequency thermal instruments and intra-articular pain pumps that administer bupivacaine, but there have been no cases reported with subacromial pain pump placement. Treatment options are difficult in a young patient with postarthroscopic glenohumeral chondrolysis, and understanding the literature with regard to risk factors is paramount to counseling patients and preventing this devastating complication.