Blockit

Intraoperative End-Tidal Carbon Dioxide Concentrations: What Is the Target?

regedward@gmail.com — Sun, 30 Oct 2011 12:13:00 +0000

Recent publications suggest that target end-tidal carbon dioxide concentrations should be higher than values currently considered as acceptable. This paper presents evidence that end-tidal carbon dioxide values higher than concentrations that are currently targeted result in improved patient outcomes and are associated with a reduced incidence of postoperative complications.

Inexpensive rinsing effective at reducing post-op infection following joint replacement surgery

regedward@gmail.com — Fri, 14 Oct 2011 23:26:00 +0000

Inexpensive rinsing effective at reducing post-op infection following joint replacement surgery

Cognitive decline in the elderly: Is anaesthesia implicated?

regedward@gmail.com — Sun, 02 Oct 2011 18:25:00 +0000

Cognitive decline in the elderly: Is anaesthesia implicated?: Postoperative cognitive dysfunction (POCD) was originally thought to be associated with cardiac surgery, but has since been associated with non-cardiac surgery and even sedation for non-invasive procedures such as coronary angiography. The focus of POCD has thus shifted from the type of surgery or anaesthetic to patient susceptibility. The realisation that cognitive impairment, such as mild cognitive impairment (MCI – the prodrome for Alzheimer’s disease (AD)), may already exist in many elderly patients who incidentally present for surgery beckons anaesthesia to align cognitive research with that of AD in order to draw valid parallels between the two disciplines. Long-term studies are required to understand if POCD is merely a transient phenomenon, or if it is the harbinger of long-term cognitive deterioration which may lead eventually to dementia. In this regard, the use of CSF analysis to diagnose AD many years before symptoms appear may identify susceptible individuals. Furthermore, animal studies indicate that volatile anaesthestics may augment the pathological processes of AD by affecting amyloid-beta processing. Identification of a link between surgery/anaesthesia, POCD, MCI, and AD would create a unique opportunity to fast-track the development of clinical or pharmacological preventive strategies that would benefit a significant proportion of the population.

Local Infiltration Analgesia Versus Intrathecal Morphine for Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial [ANALGESIA]

regedward@gmail.com — Sun, 02 Oct 2011 17:59:00 +0000

Local Infiltration Analgesia Versus Intrathecal Morphine for Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial [ANALGESIA]: BACKGROUND:

Local infiltration analgesia (LIA)—using a combination of local anesthetics, nonsteroidal anti-inflammatory drugs, and epinephrine, injected periarticularly during surgery—has become popular in postoperative pain management after total knee arthroplasty (TKA). We compared intrathecal morphine with LIA after TKA.

METHODS:

In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into 2 groups: group M, 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and in group L, LIA using ropivacaine, ketorolac, and epinephrine was infiltrated in the knee during the operation, and 2 bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization, and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during 3 months follow-up. The primary endpoint was IV morphine consumption the first 48 postoperative hours.

RESULTS:

Mean morphine consumption was significantly lower in group L than in group M during the first 48 postoperative hours: 26 ± 15 vs 54 ± 29 mg, i.e., a mean difference for each 24-hour period of 14.2 (95% confidence interval [CI] 7.6 to 20.9) mg. Pain scores at rest and on movement were lower during the first 48 hours in group L than in group M (P < 0.001). Pain score was also lower when walking in group L than in group M at 24 hours and 48 hours postoperatively (P < 0.001). In group L, more patients were able to climb stairs at 24 hours: 50% (11 of 22) versus 4% (1 of 23), i.e., a difference of 46% (95% CI 23.5 to 68.5) and at 48 hours: 70% (16 of 23) versus 22% (5 of 23), i.e., a difference of 48% (95% CI 23 to 73). Median (range) time to fulfillment of discharge criteria was shorter in group L than in group M, 51 (24–166) hours versus 72 (51–170) hours. The difference was 23 (95% CI 18 to 42) hours (P = 0.001). Length of hospital stay was also shorter in group L than in group M: median (range) 3 (2–17) versus 4 (2–14) days (P = 0.029). Patient satisfaction was greater in group L than in group M (P = 0.001), but no differences were found in knee function, side effects, or in patient-related outcomes, Oxford Knee score, or EQ-5D.

CONCLUSIONS:

LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, than did intrathecal morphine after TKA.

Continuous Femoral Versus Posterior Lumbar Plexus Nerve Blocks for Analgesia After Hip Arthroplasty: A Randomized, Controlled Study [ANALGESIA]

regedward@gmail.com — Sun, 02 Oct 2011 17:57:00 +0000

Continuous Femoral Versus Posterior Lumbar Plexus Nerve Blocks for Analgesia After Hip Arthroplasty: A Randomized, Controlled Study [ANALGESIA]: BACKGROUND:

Hip arthroplasty frequently requires potent postoperative analgesia, often provided with an epidural or posterior lumbar plexus local anesthetic infusion. However, American Society of Regional Anesthesia guidelines now recommend against epidural and continuous posterior lumbar plexus blocks during administration of various perioperative anticoagulants often administered after hip arthroplasty. A continuous femoral nerve block is a possible analgesic alternative, but whether it provides comparable analgesia to a continuous posterior lumbar plexus block after hip arthroplasty remains unclear. We therefore tested the hypothesis that differing the catheter insertion site (femoral versus posterior lumbar plexus) after hip arthroplasty has no impact on postoperative analgesia.

METHODS:

Preoperatively, subjects undergoing hip arthroplasty were randomly assigned to receive either a femoral or a posterior lumbar plexus stimulating catheter inserted 5 to 15 cm or 0 to 1 cm past the needle tip, respectively. Postoperatively, patients received perineural ropivacaine, 0.2% (basal 6 mL/hr, bolus 4 mL, 30-minute lockout) for at least 2 days. The primary end point was the average daily pain scores as measured with a numeric rating scale (0–10) recorded in the 24-hour period beginning at 07:30 the morning after surgery, excluding twice-daily physical therapy sessions. Secondary end points included pain during physical therapy, ambulatory distance, and supplemental analgesic requirements during the same 24-hour period, as well as satisfaction with analgesia during hospitalization.

RESULTS:

The mean (SD) pain scores for subjects receiving a femoral infusion (n = 25) were 3.6 (1.8) versus 3.5 (1.8) for patients receiving a posterior lumbar plexus infusion (n = 22), resulting in a group difference of 0.1 (95% confidence interval –0.9 to 1.2; P = 0.78). Because the confidence interval was within a prespecified –1.6 to 1.6 range, we conclude that the effect of the 2 analgesic techniques on postoperative pain was equivalent. Similarly, we detected no differences between the 2 treatments with respect to the secondary end points, with one exception: subjects with a femoral catheter ambulated a median (10th–90th percentiles) 2 (0–17) m the morning after surgery, in comparison with 11 (0–31) m for subjects with a posterior lumbar plexus catheter (data nonparametric; P = 0.02).

CONCLUSIONS:

After hip arthroplasty, a continuous femoral nerve block is an acceptable analgesic alternative to a continuous posterior lumbar plexus block when using a stimulating perineural catheter. However, early ambulatory ability suffers with a femoral infusion.

Enhanced Recovery

regedward@gmail.com — Fri, 30 Sep 2011 06:55:00 +0000

The devil is in the detail.

Ultrasonography in the management of the airway

regedward@gmail.com — Sun, 18 Sep 2011 11:15:00 +0000

In this study, it is described how to use ultrasonography (US) for real-time imaging of the airway from the mouth, over pharynx, larynx, and trachea to the peripheral alveoli, and how to use this in airway management. US has several advantages for imaging of the airway – it is safe, quick, repeatable, portable, widely available, and it must be used dynamically for maximum benefit in airway management, in direct conjunction with the airway management, i.e. immediately before, during, and after airway interventions. US can be used for direct observation of whether the tube enters the trachea or the esophagus by placing the ultrasound probe transversely on the neck at the level of the suprasternal notch during intubation, thus confirming intubation without the need for ventilation or circulation. US can be applied before anesthesia induction and diagnose several conditions that affect airway management, but it remains to be determined in which kind of patients the predictive value of such an examination is high enough to recommend this as a routine approach to airway management planning. US can identify the croicothyroid membrane prior to management of a difficult airway, can confirm ventilation by observing lung sliding bilaterally and should be the first diagnostic approach when a pneumothorax is suspected intraoperatively or during initial trauma-evaluation. US can improve percutaneous dilatational tracheostomy by identifying the correct tracheal-ring interspace, avoiding blood vessels and determining the depth from the skin to the tracheal wall.

Telestroke care for rural patients is cost-effective - Mayo Clinic

regedward@gmail.com — Sun, 18 Sep 2011 11:11:00 +0000

regedward@gmail.com — Sun, 18 Sep 2011 11:03:00 +0000

Is Ultrasound Guidance Advantageous for Interventional Pain Management? A Review of Acute Pain Outcomes [ANALGESIA]

regedward@gmail.com — Sun, 04 Sep 2011 11:21:00 +0000

BACKGROUND:

Ultrasound (US) guidance for peripheral nerve blockade has gained popularity worldwide. The reported benefits of real-time sonographic visualization compared with traditional nerve localization techniques generally apply to procedural and technical block-related outcomes whereas acute pain–related outcomes are featured less prominently. In this review, we evaluated the effect of US guidance compared with traditional nerve localization techniques for interventional management of acute pain and acute pain–related outcomes.

METHODS:

We performed a systematic search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials (from January 1990 to January 2011) to identify randomized controlled trials evaluating the effects of US guidance on acute pain and related outcomes compared with traditional nerve localization techniques. Studies were excluded if they did not report at least one of the following acute pain outcomes: pain severity, opioid consumption, sensory block duration, and time to first analgesic request. Related outcomes were classified as follows: patient related (opioid-related adverse effects, patient satisfaction, postoperative cognitive deficit); anesthesia related (unwanted motor block, perineural catheter failure, morbidity, development of chronic pain); surgery related (hospital readmission, ability to ambulate); and hospital related (length of stay, cost). Promising novel applications of US guidance for acute pain management were also sought for discussion purposes.

RESULTS:

We identified 23 randomized controlled trials, including 1674 patients, that compared US guidance with and without peripheral nerve stimulation with peripheral nerve stimulation alone or anatomical landmark techniques. Of the 16 studies that evaluated pain severity, 8 reported improvement with US guidance; however, only 1 study reported a difference between US guidance and the comparator of >1 interval on the numeric rating pain scale. Eight studies evaluated sensory block duration and 3 of these reported prolonged block duration with US guidance. Seven studies evaluated opioid consumption, of which 3 reported a reduction with US guidance. Three studies evaluated time to first analgesic request, of which 2 favored US guidance. We uncovered no significant differences between US guidance and traditional nerve localization techniques for any other related outcome. US guidance was not found to be inferior compared with traditional nerve localization techniques for any outcome. Nonrandomized data suggest that US-guided transversus abdominis plane blocks may offer analgesic benefit over standard analgesic therapy, but has not been compared with an anatomical landmark technique.

CONCLUSIONS:

At present, there is insufficient evidence in the contemporary literature to define the effect of US guidance on acute pain and related outcomes compared with traditional nerve localization techniques for interventional acute pain management.

Enhanced Recovery allows discharge home in two days

regedward@gmail.com — Mon, 22 Aug 2011 10:26:00 +0000

Easily adoptable total joint arthroplasty program allows discharge home in two days

Enhanced recovery.

regedward@gmail.com — Mon, 22 Aug 2011 10:20:00 +0000

Enhanced recovery for arthroplasty: good for the patient or good for the hospital?

Local Infiltration Analgesia

regedward@gmail.com — Sun, 05 Jun 2011 21:57:00 +0000

Local Infiltration Analgesia:

Pain after major abdominal, orthopedic, and thoracic surgeries can be significant causing unacceptable morbidity. Poorly controlled pain results in patient dissatisfaction and may also be associated with major morbidities, including perioperative myocardial ischemia, pulmonary complications, altered immune function, and postoperative cognitive dysfunction. Various techniques are currently used to manage this pain, and opioids are amongst the most frequently used. Recent literature supports the use of regional anesthesia in the form of various peripheral nerve blocks as a better alternative. This article discusses the role and evidence for wound infiltration analgesia in general surgery, orthopedic surgery, neurosurgery, and thoracic surgery.

New Concepts in Acute Pain Management: Strategies to Prevent Chronic Postsurgical Pain, Opioid-Induced Hyperalgesia, and Outcome Measures

regedward@gmail.com — Sun, 05 Jun 2011 21:56:00 +0000

New Concepts in Acute Pain Management: Strategies to Prevent Chronic Postsurgical Pain, Opioid-Induced Hyperalgesia, and Outcome Measures:

Chronic postsurgical pain (CPSP) is a pain syndrome that has attracted attention for more than 10 years. CPSP is a pain syndrome that develops postoperatively and lasts for at least 2 months in the absence of other causes for pain (eg, recurrence of malignancy, chronic infection, and so forth). Pain continuing from a preexisting disease is not considered as CPSP. In this article, the authors discuss the etiopathogenesis of CPSP and interventions that can help prevent and treat this condition.

Economics and Practice Management Issues Associated With Acute Pain Management

regedward@gmail.com — Sun, 05 Jun 2011 21:54:00 +0000

Economics and Practice Management Issues Associated With Acute Pain Management:
The use of regional anesthesia (RA) improves cost benefit (hospital-centered) and cost utility (patient-centered) over general anesthesia with volatile agents (GAVA), based upon research in outpatient populations. To make the cost savings a reality, the authors recommend: (1) avoidance of GAVA or at least volatile agents, (2) adopting published postanesthesia care unit (PACU)-bypass criteria conducive to RA, (3) maximizing PACU-bypass rates, and (4) utilizing a block induction area. Inpatient-based acute pain services are not uniform, which makes cost analyses and comparison between practices unreliable. Additional review and commentary address surgical site infections, cancer recurrence, blood transfusions, and chronic postsurgical pain.

Continuous Peripheral Nerve Blocks in the Hospital and at Home

regedward@gmail.com — Sun, 05 Jun 2011 21:53:00 +0000

Continuous Peripheral Nerve Blocks in the Hospital and at Home:A single-injection peripheral nerve block using long-acting local anesthetic provides analgesia for 12 to 24 hours; however, many surgical procedures result in pain that lasts far longer. One relatively new option is a continuous peripheral nerve block (CPNB): local anesthetic is perfused via a perineural catheter directly adjacent to the peripheral nerve(s) supplying the surgical site, providing potent, site-specific analgesia. CPNB results in decreased pain, opioid requirements, opioid-related side effects, and sleep disturbances; in some cases, accelerating resumption of tolerated passive joint range-of-motion and increasing patient satisfaction. Ambulatory perineural infusion may be provided using a portable infusion pump, in some cases resulting in decreased hospitalization duration and related costs. Serious complications are rare, but may result in significant morbidity.

Regional Analgesia and Acute Pain Management: Major Leaps in Small Steps?

regedward@gmail.com — Sun, 05 Jun 2011 21:53:00 +0000

Regional Analgesia and Acute Pain Management: Major Leaps in Small Steps?:
Management of pain has evolved steadily over the past few years thanks to the knowledge derived from a large number of basic science and clinical research studies. While the management of chronic pain has utilized a significant amount of information from this research, acute pain management has benefited to a lesser extent. Our mainstay of therapy for acute pain remains opioid based, but we have realized that opioid drugs do a less-than-optimal job of relieving activity-associated pain in many acute scenarios. We have also realized the downside to using opioids as we see more and more patients with opioid tolerance, opioid-induced hyperalgesia, and immunosupression.

BlockIt: Foreword

regedward@gmail.com — Sun, 05 Jun 2011 21:50:00 +0000

BlockIt: Foreword

Foreword

regedward@gmail.com — Sun, 05 Jun 2011 21:50:00 +0000

Foreword: "With the increasing emphasis on patient-oriented outcomes and delivery of cost-effective care, there has been a great deal of interest in the use of innovative methods to control acute postoperative pain. These include both novel medication management and the use of regional anesthetics. There is increasing evidence to suggest that these techniques can lead to earlier discharge with greater patient satisfaction related to control of pain symptoms. However, these are not without risks and costs. In this issue of Anesthesiology Clinics, the guest editors have solicited an outstanding collection of articles that highlight many of these issues including complications and the medical legal implications, enumeration of these techniques outside of the hospital, and the economic and practice management implications. In the clinical setting, the request to perform these techniques frequently comes from outside of the department and understanding these issues is critical. In the academic setting, our residents are excited to learn these techniques and to understand both the risks and the benefits."

Challenges in Acute Pain Management

regedward@gmail.com — Fri, 03 Jun 2011 23:15:00 +0000

Challenges in Acute Pain Management: "Publication year: 2011
Source: Anesthesiology Clinics, Volume 29, Issue 2, June 2011, Pages 291-309
Kishor, Gandhi , James W., Heitz , Eugene R., Viscusi
The management of acute pain remains challenging, with many patients suffering inadequate pain control following surgery. Certain populations are at unique risk for unrelieved pain. Evidence-based approaches taking into account patients' specific needs and problems will likely substantially improve their perioperative experience. These patients must be identified in the preoperative process, and an anesthetic/analgesic plan discussed and formulated. A targeted multimodal approach to pain management should be considered the best clinical practice. The most challenging patients may benefit most from the surveillance of an acute pain service that is able to monitor and coordinate care into the postoperative period.

Economics and Practice Management Issues Associated With Acute Pain Management

regedward@gmail.com — Fri, 03 Jun 2011 21:57:00 +0000

Economics and Practice Management Issues Associated With Acute Pain Management: "Publication year: 2011
Source: Anesthesiology Clinics, Volume 29, Issue 2, June 2011, Pages 213-232
Dennis P., Phillips , Tara L., Knizner , Brian A., Williams
The use of regional anesthesia (RA) improves cost benefit (hospital-centered) and cost utility (patient-centered) over general anesthesia with volatile agents (GAVA), based upon research in outpatient populations. To make the cost savings a reality, the authors recommend: (1) avoidance of GAVA or at least volatile agents, (2) adopting published postanesthesia care unit (PACU)-bypass criteria conducive to RA, (3) maximizing PACU-bypass rates, and (4) utilizing a block induction area. Inpatient-based acute pain services are not uniform, which makes cost analyses and comparison between practices unreliable. Additional review and commentary address surgical site infections, cancer recurrence, blood transfusions, and chronic postsurgical pain

Is a Patella Motor Response Necessary for Continuous Femoral Nerve Blockade Performed in Conjunction with Ultrasound Guidance? [ANALGESIA]

regedward@gmail.com — Tue, 19 Apr 2011 20:54:00 +0000

Is a Patella Motor Response Necessary for Continuous Femoral Nerve Blockade Performed in Conjunction with Ultrasound Guidance? [ANALGESIA]: "BACKGROUND:

Successful continuous femoral nerve blockade (CFNB) has been associated with the elicitation of a patella motor response during needle and catheter insertion. We evaluated whether a patella motor response is necessary when CFNB is performed in conjunction with ultrasound (US) guidance.

METHODS:

Ninety-eight patients undergoing CFNB (along with sciatic nerve block and spinal anesthetic) for total knee arthroplasty participated in this cohort observational study. Using out-of-plane US guidance alone, the tip of an insulated Tuohy needle was positioned superficial to the midpoint of the femoral nerve visualized in short axis. A nerve stimulator was turned on and the type of motor response (patella versus medial muscle) and minimum stimulating current from the needle were recorded. A stimulating catheter was then inserted and the type of motor response and minimum current from the catheter were recorded. Ten milliliters mepivacaine 2% was injected through the catheter. The primary outcome was sensory block defined as loss of sensation to pinprick on the anterior surface of the distal thigh measured 20 minutes after mepivacaine injection.

RESULTS:

Forty-three patients demonstrated a patella motor response, 43 demonstrated a medial motor response, and 12 demonstrated no motor response from the catheter. The proportion of patients with sensory block differed according to motor response from the catheter (patella [98%], medial [91%], and no motor response [75%]; P = 0.02), but there was no significant difference between a patella (98%) and medial (91%) motor response from the catheter (P = 0.58). The proportion of patients with motor block 20 minutes after local anesthetic injection also differed according to motor response from the catheter (patella [95%], medial [77%], and no motor response [67%]; P = 0.03). In addition, there was a significant difference between a patella (95%) and medial (77%) motor response from the catheter (P = 0.01). The mean minimum stimulating currents did not differ between patella and medial motor responses elicited from the catheter (P = 0.06). Postoperative pain and analgesic consumption were similar regardless of the type of motor response from the catheter.

CONCLUSION:

Based on observational data, a patella or medial motor response from the catheter similarly results in sensory block of the anterior thigh when CFNB is performed in conjunction with out-of-plane US guidance.

Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice

regedward@gmail.com — Tue, 19 Apr 2011 00:02:00 +0000

Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice: "

Relief of acute pain after hip and knee replacement represents a major therapeutic challenge as post-operative pain hinders early mobilisation and rehabilitation with subsequent consequences on mobility, duration of hospitalisation and overall recovery. In recent years, there has been increased interest in high-volume local wound infiltration/infusion techniques in these operations with a combined administration of local anaesthetics, NSAIDs and epinephrine. This review provides an update of the current knowledge of the efficacy of the high-volume wound infiltration technique based on randomised trials. It is concluded that a predominant part of the data have had an insufficient design by not being placebo-controlled or with comparable systemic analgesia provided in the investigated groups. It is concluded that there is little evidence to support the use of the technique in hip replacement either intraoperatively or with a post-operative wound infusion catheter technique, provided that multimodal, oral non-opioid analgesia is given. In knee replacement, the data support the intraoperative use of the local infiltration technique but not the post-operative use of wound catheter administration. In knee replacement, a compression bandage prolongs the analgesic effect. There are limited data to support the use of NSAIDs or epinephrine in the solution and the data on post-operative hospitalisation and recovery are conflicting. Thus, shorter lengths of stay have been achieved by oral multimodal, non-opioid analgesia together with organisational optimisation of care according to the fast-track methodology.

Ultrasound-guided bilateral dual transversus abdominis plane block: a new four-point approach

regedward@gmail.com — Mon, 18 Apr 2011 23:58:00 +0000

Ultrasound-guided bilateral dual transversus abdominis plane block: a new four-point approach: "

Background: We describe a new ultrasound-guided bilateral dual transversus abdominis plane block. Our hypothesis was that we could anaesthetize both the upper (Th6–Th9) and the lower (Th10–Th12) abdominal wall bilaterally using a four-point single-shot technique to provide effective post-operative analgesia.

Methods: A prospective cohort of 25 recovery room patients was included. They had undergone major open or laparoscopic abdominal surgery under general anaesthesia and had severe post-operative pain. The blocks were conducted using a high-frequency linear transducer and a 22 G, 80-mm-long needle. The needle was inserted in-plane from medial to lateral for each injection. Fifteen millilitres of bupivacaine 2.5 mg/ml was injected at each of the four sites.

Results: Block performance took on average 16 min (range 10–20 min). The 25 patients reported a reduction of their maximum pain (visual analogue scale 0–10) from a mean of 8.2 to a mean of 2.2 10 min after block performance (P<0.001). They were discharged from the post-anaesthesia care unit after an average of 34 min. Twenty-one patients (84%) did not require any i.v. opioids in the following 6 h. Sixteen patients (64%) were mobilized within 6 h after the block. Data were similar irrespective of open or laparoscopic surgery (P=0.68).

Conclusion: This new four-point single-shot technique was effective in decreasing severe pain after a major abdominal surgery. The block, although short-lived, facilitated discharge from the post-anaesthesia care unit, few patients required opioids on the day of surgery and mobilization was improved.

regedward@gmail.com — Mon, 18 Apr 2011 23:56:00 +0000