Remimazolam Sedation and Neuraxial Anesthesia in a Patient with Amyotrophic Lateral Sclerosis Undergoing an Open Colectomy: A Case Report

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease involving the upper and lower motor neurons. Perioperative management of patients with ALS can be challenging due to the risk of hemodynamic instability, aspiration, and ventilatory failure. We discuss a 58-year-old male patient with ALS who underwent open abdominal surgery under regional anesthesia utilizing a remimazolam infusion for sedation. While various sedation agents have been used successfully in patients with ALS, remimazolam, a new short-acting benzodiazepine with unique pharmacologic properties and reversible anxiolysis, provides amnesia while avoiding ventilatory depression.

Regional Anesthesia and Acute Pain Management for Adult Patients with Burns

Patients with burns suffer from excruciating pain, thus presenting unique challenges to the hospital staff involved in their care. Any hospital system may be involved in managing smaller and less serious burns, but patients with more complicated issues are often transferred to a burn center. This article will review the pathophysiological evolution of pain immediately after burn injury to emphasize the role of complex inflammatory pathways involved in the progression of burn pain. This review also focuses on managing acute pain using a combined multimodal and regional pain management approach. Finally, we attempt to address the continuum from acute to chronic pain management and the strategies used to minimize and manage the progression to chronic pain. Chronic pain remains a debilitating outcome of burn injury, and this article discusses efforts to mitigate this complication. Available options for pain treatment are important to discuss, as current drug shortages may limit medications that can be used.

Does an Epidural Blood Patch (EBP) for Postdural Puncture Headache (PDPH) From a Lumbar Spinal Drain Necessitate a Distinct Approach?

An intentional or unintentional dural puncture puts patients at significant risk for a postdural puncture headache (PDPH). When conservative treatments fail, an epidural blood patch (EBP) is offered cautiously due to rare but devastating complications. The literature is abundant with reviews on the management of PDPH in obstetric patients, but there is a paucity of data on the management of PDPH and complications of EBP in patients post spinal drain placement. In this case report, we address the specific concerns that vascular patients may have about the outcomes of large needle sizes and suggest alternative approaches for non-obstetric patients.

Qualitative fit test outcomes for N95 filtering facepiece respirators in health care workers

BACKGROUND

We analyzed the qualitative fit test results of the filtering facepiece respirators (FFRs) used at our institution to determine their performance and utility.

METHODS

We retrospectively analyzed 12,582 qualitative fit testing results for several FFR models among 8,809 health care workers (HCWs).

RESULTS

The overall failure rate for HCWs was 15.2%. Nearly one-third (2933/8809, 33.3%) had multiple FFRs fit tested. HCW sex was a statistically significant indicator of fit testing failure (χ² = 29.9, df = 1, P < .001), with women having a 44% higher likelihood (OR, 1.4; 95% CI: 1.27-1.65) than men. There were statistically significant differences in the failure rate across FFRs (Fig 4, F[5, 12475] = 8.4, P < .001). Fluidshield 46867S had a significantly higher failure rate (49%) than the 3M 1860 (P = .012), 3M 1860S (P < .001), 3M 8210 (P < .001), and Safelife (P < .001) FFRs.

CONCLUSIONS

There was a large degree of variation in fit testing results for the FFRs tested. Although we were unable to find an FFR that fit more than 95% of the HCWs successfully, we identified poorly functioning FFRs that can help our institution with decision-making and budgeting for acquisition and stocking appropriate FFRs.

Pain Control with Regional Anesthesia in Patients at Risk of Acute Compartment Syndrome: Review of the Literature and Editorial View

Acute compartment syndrome (ACS) is a devastating complication that can happen in almost every part of the human body, most noticeably after long bone fractures. The cardinal symptom of ACS is pain in excess of what would otherwise be expected from the underlying injury and unresponsive to routine analgesia treatment. There is paucity of literature on major analgesic management strategies including opioid analgesia, epidural anesthesia, and peripheral nerve blocks with regard to their differential efficacy and safety of pain management in patients at risk of developing ACS. The lack of quality data has led to recommendations that are perhaps more conservative than they should be, particularly when it comes to peripheral nerve blocks. In this review article, we attempt to make recommendations in favor of regional anesthesia in this vulnerable group of patients and strategies that will optimize adequate pain control and improve surgical outcome without jeopardizing patient safety.

Prevention of pulmonary complications in sedated patients undergoing interventional procedures in the nonoperating room anesthesia setting

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) procedures have expanded in number, variety, and complexity. NORA involves all age groups, including frail older adults and patients often considered too sick to tolerate traditional surgical interventions. Postoperative pulmonary complications are a significant source of adverse events in the perioperative setting. We present a review focused on preventing pulmonary complications in the interventional NORA setting.

RECENT FINDINGS

NORA locations should function as independent, autonomous ambulatory units. We discuss a strategic plan involving a thorough preoperative evaluation of patients, including recognizing high-risk patients and their anesthetic management. Finally, we offer guidance on the challenges of conducting sedation and anesthesia in patients with coronavirus disease 2019 (COVID-19) or a history of COVID-19.

SUMMARY

The demands on the interventional NORA anesthesia team are increasing. Strategic planning, checklists, consistent staffing assignments, and scheduled safety drills are valuable tools to improve patient safety. In addition, through quality improvement initiatives and reporting, NORA anesthetists can achieve reductions in periprocedural pulmonary complications.

Quantifying drysuit seal pressures in non-immersed scuba divers

Introduction: Drysuits use flexible neck and wrist seals to maintain water-tight seals. However, if the seals exert too much pressure adverse physiological effects are possible, including dizziness, lightheadedness, syncope, and paresthesias in the hands. We aimed to quantify the seal pressures of neck and wrist seals in non-immersed divers. Methods: We recruited 33 diving volunteers at two dive facilities in High Springs, Florida. After a history and physical exam, we measured vital signs as well as wrist and neck seal pressures using a manometer system. Results: The mean (SD) seal pressure of the right wrist seals was found to be 38.8 (14.9) mmHg, while that of the left wrist seals was 37.6 (14.9) mmHg. The average neck seal pressure was 23.7 (9.4) mmHg. Subgroup analysis of seal material demonstrated higher mean sealing pressure with latex seals compared to silicone; however, this difference was not statistically significant. Conclusions: Drysuit seal pressures are high enough to have vascular implications and even potentially cause peripheral nerve injury at the wrist. Divers should trim their seals appropriately and be vigilant regarding symptoms of excessive seal pressures. Further research may elucidate if seal material influences magnitude of seal pressure.

Are the Placement, Maintenance, and Removal of Femoral and Sciatic Catheters Associated With Bleeding Complications in Vascular Patients on Antithrombotics? A Single-Center, Retrospective Cohort Study

BACKGROUND

Information on the safety of placement, maintenance, and removal of peripheral nerve blocks in the presence of therapeutic or prophylactic antithrombotics is limited to case reports.

METHODS

In this retrospective, descriptive study, we examined the use of femoral and gluteal or subgluteal sciatic perineural catheters in 146 patients on antithrombotics who received lower limb amputation (LLA) above or below the knee at the University of Florida Health Shands Hospital between January 2015 and December 2019. We searched patient surgical records for complications such as bleeding, nerve damage, infection, and hematoma during placement, maintenance, and removal of the perineural catheters.

RESULTS

In this cohort of 146 patients on antithrombotics, there was 1 episode of hematoma with an estimated incidence of 1 of 146 (0.68%, 95% confidence interval [CI], 0.02-3.76). This patient developed a hematoma at the location of the femoral catheter and required a blood transfusion. This patient was on aspirin daily and subcutaneous heparin 3 times per day and had a normal coagulation profile during their hospital stay.

CONCLUSIONS

This report investigates bleeding complications of femoral and sciatic perineural catheters in patients undergoing LLA on antithrombotics. We found that, except for 1 patient, most patients on varying combinations of antithrombotics did not experience bleeding complications related to the femoral and sciatic perineural catheters.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

Ultrasound-Guided Upper Trunk Perineural Catheter for Shoulder Surgery: A Description of Catheter Technique

Interscalene brachial plexus block is frequently utilized for anesthesia and analgesia of complex and painful shoulder surgeries. But unintentional phrenic nerve blockade is a bane to the existence of this technique. Single-injection upper trunk blockade has emerged as a promising approach that appears to preserve phrenic nerve function better than the interscalene approach. The purpose of this case series is to describe the sonoanatomy, technique, and utility of a continuous upper trunk block, not previously described in the literature.

Does a Modified Adhesive Respirator Improve the Face Seal for Health Care Workers Who Previously Failed a Fit Test?: A Pilot Study During the Coronavirus Disease 2019 Pandemic

Approximately 30% of health care workers (HCWs) fail the respirator fit test. Evidence suggests that addressing face leaks in the 3M respirator enhances its fit and improves its efficacy. Between March 31 and April 9, 2020, HCWs who failed fit tests for 3M 1860 and 1860S respirators were invited to retest with an adhesive modification of the 3M respirator. Sixty-eight percent of HCWs who failed the fit test with their first-choice respirator passed with a modified adhesive respirator. To increase the efficacy and safety of 3M respirators, ineffective face seals need substantial improvement in design.

The Challenges of Ultrasound-guided Thoracic Paravertebral Blocks in Rib Fracture Patients

Thoracic paravertebral blocks (TPVBs) provide an effective pain relief modality in conditions where thoracic epidurals are contraindicated. Historically, TPVBs were placed relying solely on the landmark-based technique, but the availability of ultrasound imaging makes it a valuable and practical tool during the placement of these blocks. TPVBs also provide numerous advantages over thoracic epidurals, namely, minimal hypotension, absence of urinary retention, lack of motor weakness, and remote risk of an epidural hematoma. Utilization of both landmark-based and ultrasound-guided techniques may increase the successful placement of a TPVB. This article reviews relevant sonoanatomy as it pertains to TPVBs. However, certain patient-related issues, including pneumothoraces, surgical emphysema, body habitus, and transverse process fractures, all may make imaging with ultrasound challenging. The changes noted on ultrasound imaging as a result of these issues will be further described in this review.

Iatrogenic Dural Puncture-induced Abducens Nerve Palsy: Treatment with Epidural Blood Patch

Iatrogenic dural puncture (IDP) is a known complication of epidural anesthesia. While operator experience is certainly critical in preventing inadvertent dural punctures, it can happen even in the hands of a skilled operator. Often, IDP presents as post-dural puncture headache (PDPH) without the involvement of cranial nerves; however, infrequent excessive loss of cerebrospinal fluid (CSF) can lead to intracranial hypotension causing compression of the cranial nerves, in particular, the abducens nerve. Here, we describe the case of a patient who suffered from an atypical headache with neurological sequalea from an IDP. Epidural blood patch (EBP) is an effective treatment for PDPH, especially in cases that are not responsive to conservative therapy. However, it may be the first line of defense in patients with neurological symptoms arising from low intracranial hypotension. In our case report, as well as others reported in the literature, there was a complete resolution of the neurological symptoms after the EBP was placed.

Recent advances in acute pain management: understanding the mechanisms of acute pain, the prescription of opioids, and the role of multimodal pain therapy

In this review, we discuss advances in acute pain management, including the recent report of the joint American Pain Society and American Academy of Pain Medicine task force on the classification of acute pain, the role of psychosocial factors, multimodal pain management, new non-opioid therapy, and the effect of the “opioid epidemic”. In this regard, we propose that a fundamental principle in acute pain management is identifying patients who are most at risk and providing an “opioid free anesthesia and postoperative analgesia”. This can be achieved by using a multimodal approach that includes regional anesthesia and minimizing the dose and the duration of opioid prescription. This allows prescribing medications that work through different mechanisms. We shall also look at the recent pharmacologic and treatment advances made in acute pain and regional anesthesia.

Is L2 paravertebral block comparable to lumbar plexus block for postoperative analgesia after total hip arthroplasty?

BACKGROUND

Continuous lumbar plexus block (LPB) is a well-accepted technique for regional analgesia after THA. However, many patients experience considerable quadriceps motor weakness with this technique, thus impairing their ability to achieve their physical therapy goals.

QUESTIONS/PURPOSES

We asked whether L2 paravertebral block (PVB) provides better postoperative analgesia (defined as decreased postoperative opioid consumption and lower pain scores), better preservation of motor function, and decreased length of hospital stay (LOS) compared to LPB in patients undergoing THA.

METHODS

Sixty patients undergoing minimally invasive THA under standardized spinal anesthesia were enrolled in this randomized controlled study. After exclusions, 53 patients were randomized into the L2 PVB (n = 27) and LPB (n = 26) groups. Patient-controlled analgesia was available for 24 hours. Motor and pain assessments were performed in the recovery room and at the end of 24 hours. LOS was also noted.

RESULTS

Postoperative opioid consumption during the first 24 hours was less in the LPB group (mean ± SD: 24 ± 15 mg morphine) than in the L2 PVB group (32 ± 15 mg morphine; p = 0.005); however, postoperative pain scores were not different between groups. Postoperative motor and rehabilitation outcomes and LOS were also similar.

CONCLUSIONS

Our study demonstrates that use of a LPB results in slightly less morphine consumption but comparable pain scores when compared with continuous L2 PVB. No difference was noted in terms of motor preservation or LOS. Although the difference in morphine consumption was only slightly in favor of the LPB group, the advantage of L2 PVBs noted by previous authors as preservation of motor function, was not seen. At our institute where LPBs have been performed for years, there seems to be no real advantage in switching to L2 PVBs. However, L2 PVB could be a reasonable alternative for operators who are wary of LPBs due to their high potential for complications and/or requiring advanced skills for its placement. But, since L2 PVBs are relatively new, not much is known about their complication profile. We recommend a thorough understanding of both techniques before attempting to place them.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.