A Case of Hospitalization After Pre-operative Interscalene Nerve Block in an Ambulatory Surgery Center.

Interscalene nerve block (ISB) is an effective and low-risk local anesthetic (LA) procedure that is commonly employed for shoulder surgery. While phrenic nerve involvement occurs to some degree in every ISB procedure, the incidence of hypoxemia and other clinical signs of diaphragmatic disruption is much lower. This is a case of a 36-year-old female with no underlying respiratory disease who developed hypoxemia requiring a night of observation following an ISB for a rotator cuff repair procedure in an ambulatory surgical center. Her hypoxemia was easily treated with supplemental oxygen and she made a full recovery by the next day. The use of ultrasound guidance, reduced LA volume, less potent medication, sterile fluid for optimal visualization, and extrafascial administration should be considered for all patients receiving an ISB to prevent respiratory complications.

Prolonged administration of intrathecal baclofen in a patient with generalized grade 4 tetanus.

INTRODUCTION: This case report presents the management of a 62-year-old woman with generalized grade 4 tetanus, focusing on the innovative use of intrathecal baclofen (ITB) therapy. The patient initially presented with a laceration and subsequently developed severe tetanic spasms, necessitating interventions beyond standard tetanus immunoglobulin and antibiotics due to the condition's progressive and life-threatening nature. The preference for ITB over oral baclofen is highlighted, considering ITB's enhanced bioavailability in the central nervous system and its efficacy in reducing spinal cord reflexes, which is critical for managing severe spasticity.On her return to the emergency department with symptoms of tetanus, the patient received ITB following the failure of oral baclofen to control the spasms. ITB administration necessitated a lumbar drain, which was later substituted with a tunneled intrathecal catheter due to the extended requirement for baclofen infusion and the unavailability of suitable infusion pumps. This scenario represented a significant application of a CADD-Solis external pump for continuous ITB infusion.Transitioning the patient from ITB to oral baclofen was a crucial management step to facilitate discharge and recovery, underscoring the importance of a careful approach to prevent withdrawal symptoms and maintain care continuity. Despite initial complications, including an infection signaled by leucocytosis and confirmed through cerebrospinal fluid culture, the patient was effectively treated and discharged. CONCLUSION: This report contributes to the sparse literature on prolonged ITB use for generalized grade 4 tetanus treatment, underlining the need for interdisciplinary collaboration for the best patient outcomes. It showcases the potential of ITB in spasticity management, in reducing the need for sedation, and in shortening the duration of mechanical ventilation, advocating for a tailored approach that utilizes a full spectrum of pharmacological and supportive therapies.

Suspected Buprenorphine-Precipitated Opioid Withdrawal following Intercourse: A Case Report.

Buprenorphine, a partial mu-opioid receptor agonist, is a commonly prescribed medication for opioid use disorder (OUD). There is evidence that drugs may enter the male genitourinary tract by an ion-trapping process, based on the lipid solubility and degree of ionization (1). While little is known about the pharmacokinetics of drugs in seminal fluid, pH is thought to play an integral role. Limited evidence exists surrounding cervical absorption of drugs via seminal fluid transmission. This also prompts survey of the frequency of this event and the influence on treatment within this population.

Liposomal compared to 0.25% bupivacaine in patients undergoing hemorrhoidectomy: A pre- and post-implementation quality improvement evaluation.

STUDY OBJECTIVE: The efficacy of infiltration of liposomal bupivacaine against an active comparator, such as bupivacaine, remains debated on acute postoperative pain control. We evaluated the analgesic efficacy, patient satisfaction, and side effects of liposomal bupivacaine compared to bupivacaine during hemorrhoidectomy procedures. DESIGN: A pre- and post-implementation quality improvement evaluation. SETTING: Operating room and post-anesthesia care unit. PATIENTS: Ninety-four consecutive adult patients with hemorrhoid surgery between October 2019 and November 2020. INTERVENTIONS: A preintervention control group of 0.25% bupivacaine (50 ml, 125 mg, n = 47) and a postintervention group of liposomal bupivacaine (30 ml, 266 mg, n = 47) for perianal local anesthetic administration. MEASUREMENTS: The primary endpoint was analgesic efficacy of liposomal bupivacaine compared to bupivacaine based on a reduction in the number of patients administered opioids and patient-reported pain scores in the postanesthesia care unit (PACU). Secondary endpoints included constipation, post-discharge patient-reported pain management satisfaction, and opioid prescription refill requests in telephonic interviews three days after surgery. MAIN RESULTS: PACU peak pain scores were significantly higher in the bupivacaine compared to the liposomal bupivacaine group (median 3 [IQR 0-6] vs. 0 [IQR 0-4], p = 0.03), respectively with no differences in PACU discharge pain scores. There was no difference in the frequency of rescue opioid use (38.2% vs. 25.5%, p = 0.18) or the morphine milligram equivalents administered to each of those patients (median 15 [IQR 10-23] vs. 15 [IQR 15-25], p = 0.39) in the PACU comparing the bupivacaine and liposomal bupivacaine groups respectively. Secondary endpoints were similar in each group with respect to requests for opioid refills (10.6 vs. 12.8%, p = 0.75), >75% satisfied with their pain management (p = 0.94), and constipation reported on day 3 after surgery (p = 0.07). CONCLUSIONS: Liposomal bupivacaine compared to a bupivacaine perianal block reduces early PACU pain scores without affecting opioid refill requests, has a similarly low incidence of complications, and high satisfaction in both groups.