The ACCRAC podcast: an innovative educational tool for trainee and staff development.

The Anesthesia and Critical Care Reviews and Commentary (ACCRAC) Podcast provides stimulating lectures on a broad range of educational topics within the realms of anesthesia and critical care. Though not intended as a primary learning tool, it can be used as part of a multidisciplinary developmental approach for both trainees and staff clinicians. This short commentary provides a brief overview of its contents and describes its relevance to board preparation and career-focused continuing education.

Percutaneous Neuromodulation of the Brachial Plexus and Sciatic Nerve for the Treatment of Acute Pain Following Surgery: Secondary Outcomes From a Multicenter, Randomized, Controlled Pilot Study.

OBJECTIVES: We recently reported that percutaneous peripheral nerve stimulation (PNS or "neuromodulation") decreased pain and opioid consumption within the first two weeks following ambulatory surgery. However, the anatomic lead locations were combined for the analysis, and benefits for each location remain unknown. We therefore now report the effects of percutaneous PNS for brachial plexus and sciatic nerve leads separately. MATERIALS AND METHODS: Before surgery, leads were implanted percutaneously to target the brachial plexus (N = 21) for rotator cuff repair or sciatic nerve (N = 40) for foot/ankle surgery, followed by a single injection of local anesthetic. Postoperatively, subjects were randomized in a double masked fashion to 14 days of electrical stimulation (N = 30) or sham/placebo (N = 31) using an external pulse generator. The primary outcome of interest was opioid consumption and pain scores evaluated jointly. Thus, stimulation was deemed effective if superior on either outcome and at least noninferior on the other. RESULTS: For brachial plexus leads, during the first seven postoperative days pain measured with the numeric rating scale in participants given active stimulation was a median [interquartile range] of 0.8 [0.5, 1.6] versus 3.2 [2.7, 3.5] in patients given sham (p < 0.001). For this same group, opioid consumption in participants given active stimulation was 10 mg [5, 20] versus 71 mg [35, 125] in patients given sham (p = 0.043). For sciatic nerve leads, pain scores for the active treatment group were 0.7 [0, 1.4] versus 2.8 [1.6, 4.6] in patients given sham (p < 0.001). During this same period, participants given active stimulation consumed 5 mg [0, 30] of opioids versus 40 mg [20, 105] in patients given sham (p = 0.004). Treatment effects did not differ statistically between the two locations. CONCLUSIONS: Ambulatory percutaneous PNS of both the brachial plexus and sciatic nerve is an effective treatment for acute pain free of systemic side effects following painful orthopedic surgery.

The Use of Intravenous Lidocaine as an Analgesic Modality in the Austere Environment: Two Cases.

Providing effective analgesia for trauma in austere settings is particularly difficult and often complicated by equipment and medication limitations and harsh environmental conditions. Common modalities that are employed in conventional clinical practices may not be available or pragmatic in austere environments. Furthermore, side effects such as sedation, altered mentation, or hypoxemia require additional resources and attention. We report 2 cases that demonstrate the use of intravenous lidocaine for the management of acute pain, secondary to trauma, in an austere environment. In the first, the administration of intravenous lidocaine reduced pain, secondary to a tibia fracture, thereby facilitating splinting. In the second, a patient, who had sustained rib fractures, was also treated with intravenous lidocaine. In this case, the analgesic effects of the medication resulted in reduction in pain and improvement in pulmonary function. Of note, the narrow therapeutic window of this modality was made evident as both patients transiently experienced tinnitus following the initial lidocaine bolus. This report describes 2 cases in which intravenous lidocaine was used to manage acute pain, in an austere environment, while avoiding many of the detrimental effects that accompany alternative analgesics.

Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study.

BACKGROUND: Percutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption. METHODS: Preoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days. RESULTS: During the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001). CONCLUSIONS: Percutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: A Pragmatic Effectiveness Trial of a Nonpharmacologic Alternative for the Treatment of Postoperative Pain.

BACKGROUND: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures). DESIGN: A multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months. SUMMARY: The postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.

Application of the Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium in a Combat Support Hospital in Iraq.

INTRODUCTION: The 2017 Joint Trauma System Clinical Practice Guideline for Pain, Anxiety, and Delirium (JTS CPG) provides an evidence-based framework for managing pain, anxiety, and delirium in combat settings. In this study, we evaluate the use of multimodal analgesia and assess pain outcomes, as indicated by the JTS CPG, at the combat support hospital (CSH). MATERIALS AND METHODS: In this quality improvement project, data were collected for all patients, presenting to the CSH in Baghdad, Iraq, who received consultation from the acute pain service from October 10, 2017 to February 27, 2018. Univariate analyses described patient demographic and clinical characteristics. Defense and Veterans Pain Rating Scale (DVPRS) scores, physical therapy completion, and sleep duration were recorded for each patient daily. Correlations assessed relationships between variables, including clinical characteristics and DVPRS scores. RESULTS: 34 patients were included in this study. About 65% of the patients included in this study were Iraqi military, while the other 35% were U.S. or Coalition Forces. Over half received more than one class of analgesic medication. The majority of patients received regional anesthesia, with 17 different techniques utilized. The DVPRS had acceptable internal consistency (Cronbach alpha = 0.87, 95% CI 0.80, 0.95). There was a significant difference in median DVPRS pain intensity scores between those who met physical therapy goals and those who did not. Sleep duration was negatively correlated with both the DVPRS pain intensity and sleep scores. CONCLUSIONS: This report indicates that acute pain service teams integrated in a CSH can feasibly implement JTS CPGs using a team-based approach. Given the military's emphasis on managing complex pain and disability among survivors beginning in the combat environment, it is imperative that innovations and best practices, like the JTS CPG, be assessed in the combat setting.

Regional Anesthesia Facilitating Surgical and Medical Management of a Patient with Necrotizing Fasciitis and Diabetic Ketoacidosis.

Emergent surgery in the setting of a concomitant medical (nonsurgical) emergency challenges the anesthesiology team with multiple and often conflicting concerns. During these rare situations, general anesthesia is often employed. This case report demonstrates a safe and effective regional anesthetic technique utilized as the primary anesthetic during emergent surgery in the setting of a medical emergency. In this particular case, the medical emergency was profound diabetic ketoacidosis and the surgical emergency was life-threatening necrotizing fasciitis of the left upper extremity. An ever-increasing body of literature supports that anesthetic technique has an impact on morbidity and mortality outcomes in specific patient populations. The aim of this case report is to describe the successful use of regional anesthesia to facilitate emergent surgery in a patient who also has a concurrent emergent medical condition. In addition, we review the literature describing the utility of regional anesthesia in such patients.

Regional Anesthesia in the Combat Setting: Are ACGME Requirements Enough?

INTRODUCTION: Updated Joint Trauma System Clinical Practice Guidelines (CPG) indicate regional anesthesia and pain management (RAAPM) are important for combat casualty care. However, it is unclear whether military anesthesiology residents are receiving adequate RAAPM training to meet the CPGs. The goal of this study was to conduct a preliminary evaluation of resident-completed combat-relevant regional anesthesia procedures. It was hypothesized that most residents would perform an adequate number of each procedure to presume proficiency. MATERIALS AND METHODS: Resident-performed, combat-relevant regional anesthesia procedure frequency was extracted from a database maintained at a military anesthesiology residency program. Data collection was limited to a 1-year period. Univariate statistics described procedure distributions, frequencies, and proportion of residents achieving pre-defined, empirically-supported experience criteria for each technique. Analyses examined proportional differences in meeting experience criteria by training-year. RESULTS: Residents (N = 41) performed a variety of procedures. Simple procedures, such as saphenous peripheral nerve blocks, were performed at a greater frequency than more complicated procedures such as thoracic epidurals, continuous peripheral nerve blocks, and transverse abdominus plane blocks. The majority of residents met experience criteria for four out of the eight measured combat-relevant blocks. There were no proportional differences in meeting procedural experience criteria across the different training levels. CONCLUSIONS: These results suggest a possible gap between the needs of the Military Health System during conflict and current residency training experiences. Reasons for this gap, as well as solutions, are explored.

LAST Double Check - A Comprehensive Pre-Regional Checklist for the Busy Institution.

INTRODUCTION: Wrong site peripheral nerve blocks are included in the National Quality Forum and Joint Commission's category of "never event." Multiple attempts have been made by various groups in an effort to eliminate these events. Prior attempts to eliminate these never events include the Regional Block Preprocedural Checklist provided by the American Society of Regional Anesthesia (ASRA) taskforce. Following a series of errors involving anticoagulation prior to regional anesthesia, our department saw a need for a more comprehensive checklist. MATERIALS AND METHODS: An expert panel developed the LAST Double Check Checklist with the aim of identifying and eliminating errors associated with regional anesthesia delivery. This checklist was implemented over the course of two 30 d trial periods. Feedback was collected and any delays associated with implementation were recorded. RESULTS: There were no reported procedures performed on patients taking anticoagulation or reported case delays during the two 30 d trials. A total of 350 regional anesthetics were performed during both trials. During the first week of implementation, a patient was identified as having received enoxaparin, despite the electronic medical record showing the medication as held. The planned regional anesthetic was not performed given increased risk of bleeding. Feedback collected during the trial periods was incorporated into the final draft and implementation of the LAST Double Check for use in all locations where regional anesthesia is performed. There have been no post-implementation events reported (11-mo period, greater than 1,000 regional anesthetics performed). CONCLUSION: The LAST Double Check is a more comprehensive checklist with the aim of preventing errors associated with wrong site blocks, anticoagulation administration, and care team coordination. This checklist covers areas of the patient history that are routinely reviewed prior to regional anesthesia administration and did not contribute to delay in arrival to the operating room.

Regional to the Rescue! Axillary Brachial Plexus Nerve Block Facilitates Removal of Entrapped Transradial Catheter Placed for Cardiac Catheterization.

OBJECTIVE: Our objective was to describe the first reported use of an axillary brachial plexus block to treat the entrapment of a transradial artery catheter due to vasospasm. CASE REPORT: A 42-year-old man undergoing transradial arterial cardiac catheterization suffered arterial vasospasm causing the catheter to become entrapped and refractory to conservative (warm compresses) and standard pharmacologic interventions (intracatheter verapamil, intravenous infusions of nitroglycerin and nicardipine, and subcutaneous lidocaine and topical nitroglycerin). Anesthesia was consulted, and attempts at catheter removal under monitored anesthesia and general anesthesia failed. Finally, in order to avoid surgical intervention, an ultrasound-guided axillary brachial plexus block with mepivacaine was performed, resulting in easy removal of the catheter. CONCLUSIONS: Axillary brachial plexus nerve blocks are an effective, efficient, and safe intervention with a wide range of indications. This case report demonstrates that an axillary nerve block can be used to treat the entrapment of a transradial artery catheter due to vasospasm.

Buprenorphine/naloxone therapy for opioid refractory neuropathic pain following traumatic amputation: a case series.

Phantom limb pain is a common consequence of limb amputation and is prevalent among the service members sustaining traumatic battlefield limb injuries during the conflicts in Iraq and Afghanistan. Current treatment to relieve phantom limb pain consists of physical, behavioral, and medical modalities including opioids and adjunct medications. Treatment failure resulting in persistent pain and disability may result. This case series describes four previously healthy service members who developed phantom limb pain following traumatic amputation successfully treated with buprenorphine/naloxone after failing traditional treatment. This is the first reported case series of patients expressing improved pain control with decreased frequency of phantom limb pain with the use of buprenorphine/naloxone instead of traditional opioid agonists.