Prolongation of spinal duration by escalating doses of intrathecal epinephrine in lower limb arthroplasty.

Aim: The optimal dose of low-dose intrathecal epinephrine in the absence of intrathecal opioids is unknown. Materials & methods: Prospective, randomized, double blind clinical trial of patients undergoing lower limb arthroplasties. The primary end point was spinal block duration measured via motor and sensory block duration. Results: 30 patients undergoing lower limb arthroplasty were randomized into one of six groups with varying intrathecal epinephrine doses 0-100 mcg. There was a direct linear effect between motor block duration and intrathecal epinephrine dose with higher doses being associated with longer block duration (p = 0.011). Mean motor block duration was 3.74 ± 1.13, 3.36 ± 0.47, 3.39 ± 0.60, 4.06 ± 0.98 and 5.20 ± 1.41 h for the EPI0, EPI25, EPI50, EPI75 and EPI100 groups respectively. Conclusion: This study reveals that low-dose intrathecal epinephrine (75-100 mcg) in the absence of intrathecal opioids can be reliably used to prolong motor block duration in lower limb arthroplasty. Clinical Trial Registration: NCT02619409 (ClinicalTrials.gov).

What is this summary about? Here, we summarize the results of the addition of a medicine called epinephrine to a type of anesthesia called spinal anesthesia which involves injection of medication into the fluid surrounding the spinal cord. The study was to determine the optimal amount of epinephrine needed to prolong the effect of spinal anesthesia for patients undergoing replacements of their hips and/or knees. What were the results? The study showed that the addition of low-dose epinephrine to spinal anesthesia prolongs the motor block ­ or inability to move the leg ­ in a linear fashion with higher doses of epinephrine associated with longer motor block. Our results did not show a significant difference in sensory block, or the inability to feel the leg. What do the results mean? The study shows that the addition of low-dose epinephrine to spinal anesthesia can reliably prolong the effect of the anesthesia which may be needed in more complicated hip or knee surgeries.

Paravertebral anesthetic nerve block for pain control after peroral endoscopic myotomy.

BACKGROUND: Excess post-operative opioid medication use can delay recovery and is associated with long-term misuse, addiction, and overdose. We aimed to explore the effect of pre-procedural thoracic paravertebral nerve block (PNB) on pain-related outcomes after POEM. METHODS: In this retrospective cohort study, consecutive patients who did and did not receive a PNB prior to POEM were compared. The outcomes were peak and cumulative pain scores, total opioid use during hospitalization, and length of stay. After adjusting for confounders, the associations between nerve block and the outcomes of interest were explored. RESULTS: Forty-nine consecutive patients were enrolled; 25 patients received a block whereas the subsequent 24 did not. There were no differences in baseline characteristics between the study groups. In unadjusted analyses, there was no significant difference between patients who did and did not undergo PNB in peak pain score (7.8 vs. 8.7, p=0.14), cumulative pain score in the first 12 hours (area under curve 66.5 vs. 75.8, p=0.22), median total opioid use (38.9 mg morphine equivalent dosing vs. 42, p=1.00), and median length of hospitalization (26.5 hours vs. 24, p=0.35). In multivariable regression models, PNB was not associated with a reduction in pain scores, opioid use, or hospitalization. There were no adverse events related to the block. CONCLUSIONS: In this exploratory, observational study, paravertebral nerve block immediately before POEM did not result in a statistically significant reduction in pain-related outcomes or hospitalization. Additional observational studies may elucidate whether higher anesthetic doses or longer acting formulations would be of value.

Post-Reperfusion Syndrome in Liver Transplantation: Does a Caval Blood Flush Vent Help?

BACKGROUND Post-reperfusion syndrome (PRS) during liver transplantation can range from a benign event to a profound hemodynamic excursion from baseline with significant morbidity. Multiple variables can be responsible for the diverse presentations. Over time, our group noticed that a blood flush of the liver graft via a caval vent (in addition to a standard chilled flush via the portal vein) appeared to result in a milder reperfusion effect. Attenuation of PRS via caval vent seemed to minimize hemodynamic instability and reduce metabolic derangements associated with reperfusion. MATERIAL AND METHODS This was a prospective observational pilot study of standard practice with the addition of lab values and hemodynamic evaluations. We methodically observed normal clinical flow in 20 adult orthotopic liver transplant recipients. We analyzed blood and fluid samples at set time intervals during the peri-reperfusion phase. RESULTS Sixteen out of 20 patients received a blood flush via caval venting. Mean arterial pressure (MAP) and heart rate were better preserved in the patient population that received a caval blood flush vent. Elevations in central venous pressure (CVP) were similar between the 2 groups. Lab values (blood gas, electrolyte, and hemoglobin) of the patients' blood were similar, with no notable differences. Analysis of the initial blood flushed through the liver graft proved to be hypothermic, acidotic, and hyperkalemic. CONCLUSIONS Pre-reperfusion caval venting in liver transplantation (in addition to a portal vent and a chilled LR/albumin portal flush solution) appears to have favorable hemodynamic effects. The literature on this technique is sparse and larger studies are needed.

Anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: Perspectives from the clinical experience of a U.S. panel of physicians.

BACKGROUND AND OBJECTIVE: Worldwide adoption of the subcutaneous implantable cardioverter-defibrillator (S-ICD) for preventing sudden cardiac death continues to increase, as longer-term evidence demonstrating the safety and efficacy of the S-ICD expands. As a relatively new technology, comprehensive anesthesia guidance for the management of patients undergoing S-ICD placement is lacking. This article presents advantages and disadvantages of different periprocedural sedation and anesthesia options for S-ICD implants including general anesthesia, monitored anesthesia care, regional anesthesia, and nonanesthesia personnel administered sedation and analgesia. METHODS: Guidance, for approaches to anesthesia care during S-ICD implantation, is presented based upon literature review and consensus of a panel of high-volume S-ICD implanters, a regional anesthesiologist, and a cardiothoracic anesthesiologist with significant S-ICD experience. The panel developed suggested actions for perioperative sedation, anesthesia, surgical practices, and a decision algorithm for S-ICD implantation. CONCLUSIONS: While S-ICD implantation currently requires higher sedation than transvenous ICD systems, the panel consensus is that general anesthesia is not required or is obligatory for the majority of patients for the experienced S-ICD implanter. The focus of the implanting physician and the anesthesia services should be to maximize patient comfort and take into consideration patient-specific comorbidities, with a low threshold to consult the anesthesiology team.

A Retrospective Study Evaluating the Effect of Low Doses of Perineural Dexamethasone on Ropivacaine Brachial Plexus Peripheral Nerve Block Analgesic Duration.

Objective: Examination of the effectiveness of perineural dexamethasone administered in very low and low doses on ropivacaine brachial plexus block duration. Design: Retrospective evaluation of brachial plexus block duration in a large cohort of patients receiving peripheral nerve blocks with and without perineural dexamethasone in a prospectively collected quality assurance database. Setting: A single academic medical center. Methods: A total of 1,942 brachial plexus blocks placed over a 16-month period were reviewed. Demographics, nerve block location, and perineural dexamethasone utilization and dose were examined in relation to block duration. Perineural dexamethasone was examined as none (0 mg), very low dose (2 mg or less), and low dose (greater than 2 mg to 4 mg). Continuous catheter techniques, local anesthetics other than ropivacaine, and block locations with fewer than 15 subjects were excluded. Associations between block duration and predictors of interest were examined using multivariable regression models. A subgroup analysis of the impact of receiving dexamethasone on block duration within each block type was also conducted using a univariate linear regression approach. Results: A total of 1,027 subjects were evaluated. More than 90% of brachial plexus blocks contained perineural dexamethasone (≤4 mg), with a median dose of 2 mg. Increased block duration was associated with receiving any dose of perineural dexamethasone (P < 0.0001), female gender (P = 0.022), increased age (P = 0.048), and increased local anesthetic dose (P = 0.01). In a multivariable model, block duration did not differ with very low- or low-dose perineural dexamethasone after controlling for other factors (P = 0.420). Conclusion: Perineural dexamethasone prolonged block duration compared with ropivacaine alone; however, duration was not greater with low-dose compared with very low-dose perineural dexamethasone.

Comparison of analgaesia with lumbar epidurals and lumbar plexus nerve blocks in patients receiving multimodal analgaesics following primary total hip arthroplasty: a retrospective analysis.

PURPOSE: Significant post-operative pain occurs after hip arthroplasty. In a prior study, lumbar plexus nerve blocks provided comparable analgaesia to lumbar epidurals; however, multimodal analgaesics were not used consistently. METHODS: This study assessed a randomly selected cohort of 48 patients undergoing primary hip arthroplasty who received a regional anaesthesia technique for post-operative pain. Twenty-four patients with lumbar epidurals and 24 with single-injection lumbar plexus nerve blocks were reviewed using electronic medical records. Post-operative opiate consumption was the primary endpoint. Secondary endpoints were participation in physical therapy, side effects, and time to discharge. Descriptive statistics were calculated to describe patients in the different groups. Opiate consumption was compared using linear mixed models. Multivariable models were examined for both primary and secondary endpoints. RESULTS: In comparison with patients receiving lumbar epidural catheters, patients with lumbar plexus blocks consumed less opiates post-operatively at 24-36 and 36-48 hours (P = 0.037 and 0.002, respectively); it did not differ at zero to 12 hours or 12-24 hours post-operatively. Patients with lumbar plexus blocks had earlier times to first ambulation (28.5 ± 3.29 vs 21.9 ± 1.76 h; P = 0.043). However, differences by block type were not observed for ambulation distance, level of assistance to ambulate or time of discharge orders. CONCLUSIONS: Following primary total hip arthroplasty, lumbar plexus nerve blocks provide effective post-operative analgaesia with decreased opiate consumption compared with lumbar epidural catheters. Lumbar plexus blocks also promote earlier post-operative ambulation and are compatible with post-operative prophylactic anticoagulants.

Thoracolumbar interfascial plane (TLIP) block: a pilot study in volunteers.

PURPOSE: Regional anesthesia has been shown to improve outcomes in several recent studies. The transversus abdominis plane (TAP) block provides anesthesia to the abdominal wall by introducing local anesthetic to the ventral rami of the thoracolumbar nerves. This work quantifies the area of anesthesia obtained after performing the novel thoracolumbar interfascial plane block (analogous to the TAP block but intended for the back) which targets the sensory component of the dorsal rami of the thoracolumbar nerves. METHODS: Ten participants underwent bilateral ultrasound-guided injections of 0.2% ropivacaine 20 mL into the fascial plane between the multifidus and longissimus muscles. After five and 20 min, respectively, the area of anesthesia was plotted on the participant's back. Anesthesia was defined as loss of point discrimination to pinprick. RESULTS: Participants reported a mean (SD) area of anesthesia surrounding the needle injection site of 137.4 (71.0) cm(2) and 217.0 (84.7) cm(2) at five and 20 min after injection, respectively. The mean (SD) cephalad and caudal spread of local anesthetic from the site of injection was 6.5 (1.8) cm and 3.9 (1.2) cm, respectively. There were no complications or adverse events reported. CONCLUSION: This report shows that a reproducible area of anesthesia can be obtained by ultrasound-guided injection of local anesthetic in the fascial plane between the multifidus and longissimus muscles of the thoracolumbar spine. The area of anesthesia consistently covered the midline and had a predictable spread. This project was registered with clinicaltrials.gov (NCT02297191).