Anesthesia for the Patient Undergoing Shoulder Surgery.

Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.

Reintubation Rate and Mortality After Emergent Airway Management Outside the Operating Room.

BACKGROUND: Little is known about reintubations outside of the operating room. The objective of this study was to evaluate the reintubation rate and mortality after emergent airway management outside operating room (OR), including intensive care unit (ICU) and nonICU settings. METHODS: A retrospective cohort study. The primary outcome measures were reintubation rate and mortality. Secondary outcome measures were location and indication for intubation, time until reintubation, total intubated days, ICU-stay, hospital-stay, 30-day in-hospital mortality, and overall in-hospital mortality. RESULTS: A total of 336 outside-OR intubations were performed in 275 patients. Of those 275 patients, 51 (18.5%) were reintubated during the same hospital admission. (41%) of the reintubations occurred in a non-ICU setting. Reintubations occurred after up to 30-days after extubation. Most frequently between 7 and 30 days (32.8%, n = 20). Most of the reintubated patients were reintubated just once (56.9%; n = 29), but some were reintubated 2 times (29.4%; n = 15) or over 3 times (13.7%; n = 7). Reintubated patients had significant longer total ICU-stay (24 ± 3 days vs 12 ± 1 day, p < .001), hospital stay (37 ± 3 vs18 ± 1, p < .001), and total intubation days (8 ± 1 vs 7 ± 0.6, P < .02). The 30-day in-hospital mortality in reintubated patients was 13.7% (n = 7) compared to nonreintubated patients 35.9% (n = 80; P = .002). CONCLUSION: Reintubation was associated with a significant increase in hospital and ICU stay. The higher mortality rate among nonreintubated patients may indicate survival bias, in that severely sick patients did not survive long enough to attempt extubation.

A Review of Slipping Rib Syndrome: Diagnostic and Treatment Updates to a Rare and Challenging Problem.

Slipping rib syndrome (SRS) is a disorder that occurs when one or more of the eighth through tenth ribs become abnormally mobile. SRS is a poorly understood condition leading to a significant delay in diagnosis and therapeutic management. History and a physical exam are usually sufficient for a diagnosis of SRS. The utility of dynamic ultrasounds has also been studied as a useful diagnostic tool. Multiple surgical techniques for SRS have been described within the literature. Cartilage rib excision (CRE) has been the most common technique utilized. However, the literature has shown a high rate of recurrence and associated risks with the procedure. More recently, minimally invasive rib fixation and costal cartilage excision with vertical rib plating have been shown as successful and safe alternative techniques. This may be an effective, alternative approach to CRE in adult and pediatric populations with SRS.

Anesthesia for the Patient Undergoing Shoulder Surgery.

Shoulder surgery introduces important anesthesia considerations. The interscalene nerve block is considered the gold standard regional anesthetic technique and can serve as the primary anesthetic or can be used for postoperative analgesia. Phrenic nerve blockade is a limitation of the interscalene block and various phrenic-sparing strategies and techniques have been described. Patient positioning is another important anesthetic consideration and can be associated with significant hemodynamic effects and position-related injuries.

Beyond the Raskin Protocol: Ketamine, Lidocaine, and Other Therapies for Refractory Chronic Migraine.

PURPOSE OF REVIEW: The purpose of this review is to discuss the available evidence and therapeutic considerations for intravenous drug therapy for refractory chronic migraine. RECENT FINDINGS: In carefully monitored settings, the inpatient administration of intravenous lidocaine and ketamine can be successful in treating refractory chronic migraine. Many patients with refractory chronic migraine have experienced treatment failure with the Raskin protocol. The use of aggressive inpatient infusion therapy consisting of intravenous lidocaine or ketamine, along with other adjunctive medications, has become increasingly common for these patients when all other treatments have failed. There is a clear need for prospective studies in this population comprised of patients who have largely been excluded from other studies.

Briefest Time to Perform a Series of Preoperative Nerve Blocks in Multiple Patients: A Simulation Study.

Introduction To mitigate first-case delays in operating rooms, sufficient additional time must be allotted when anesthesiologists perform preoperative nerve blocks in multiple patients who are scheduled as the initial cases of the day. We used spinal anesthetics performed in dedicated block rooms located just outside the operating room suite to estimate the briefest times needed to complete a series of spinal, epidural, peripheral, or other regional nerve blocks. We followed this approach because even though the studied hospital had a busy regional anesthesia service, sample sizes were insufficient and electronic data were not available to directly study the time to perform the many other nerve blocks they perform. Methods We studied a historical cohort of 8,462 adult patients undergoing spinal anesthesia between 2005 and 2017. Preoperative evaluation, consent, and holding area tasks were completed before entering the block room; the times to complete these tasks were not available for study. Upon block room entry, the electronic anesthetic record was started, a timeout conducted with patient participation, vital signs taken, and the spinal performed. The interval from entry until intrathecal injection was the spinal block time. Because fits of these times to probability distributions previously used for anesthesia times were poor (p < 0.001), percentiles of times to perform one or more spinal anesthetics were calculated using Monte-Carlo simulation (100,000 samples with replacement) from the empirical distributions. Results The mean spinal block time was 8.8 minutes. The 90% upper prediction limit for one block was 14 minutes, with progressively decreasing times for each subsequent block for a 90% chance of finishing on time. For example, for three first-case regional or neuraxial blocks performed outside the operating room by one anesthesiologist, the first patient needs to arrive at least 38 minutes earlier than non-block patients to mitigate operating room start delays. Conclusions These minimum time estimates can help nursing leadership ensure that sufficient time will be available after patients are ready for anesthesia to avoid first-case delays when preoperative regional anesthesia is performed outside the operating room. Given that inadequate sample size and documentation issues likely exist universally for the various non-neuraxial preoperative nerve blocks, we recommend that hospitals use our estimates as a minimum starting point rather than try to calculate times using their own data. Then, as a systems-based metric to assess all steps in the process, track the percentages of days for which all blocks were completed in sufficient time to avoid a first-case delay for those patients. Adjustments to the arrival times would then be implemented, if needed, to meet hospital objectives for on-time starts.

Fluoroscopically guided mandibular nerve block: a modified lateral approach.

BACKGROUND AND OBJECTIVES: Mandibular nerve blocks are indicated for atypical face pain and trigeminal neuralgia. We hypothesized that a modified lateral approach, which entailed a combination of lateral and anterior approach techniques to the mandibular nerve block would lead to similar efficacy and improved safety profile rather than the typical lateral or anterior techniques. METHODS: This alternative approach was derived from anatomical investigation using the Radiology Anatomy Atlas Viewer and reconstructed axial cadaveric slices. We used axial slices at the level of the lateral pterygoid plate, and at the level of the temporomandibular joint to devise a needle path appropriate for this block. RESULTS: The modified lateral approach to the mandibular nerve block was verified theoretically through cadaveric reconstructed slices and has been successfully performed in our practice. Precise needle trajectory could avoid both periosteal contact and gross redirection, as well as other procedural complications. CONCLUSION: The modified lateral approach to a mandibular nerve block avoids the respective risks associated with either the lateral and anterior approach. Facial intervention techniques typically pose increased safety challenges, however through cadaveric anatomic reconstruction, we have developed a safer approach for mandibular nerve blockade.

Emergent airway management outside of the operating room - a retrospective review of patient characteristics, complications and ICU stay.

BACKGROUND: Emergent airway management outside of the operating room is a high-risk procedure. Limited data exists about the indication and physiologic state of the patient at the time of intubation, the location in which it occurs, or patient outcomes afterward. METHODS: We retrospectively collected data on all emergent airway management interventions performed outside of the operating room over a 6-month period. Documentation included intubation performance, and intubation related complications and mortality. Additional information including demographics, ASA-classification, comorbidities, hospital-stay, ICU-stay, and 30-day in-hospital mortality was obtained. RESULTS: 336 intubations were performed in 275 patients during the six-month period. The majority of intubations (n = 196, 58%) occurred in an ICU setting, and the rest 140 (42%) occurred on a normal floor or in a remote location. The mean admission ASA status was 3.6 ± 0.5, age 60 ± 16 years, and BMI 30 ± 9 kg/m2. Chest X-rays performed immediately after intubation showed main stem intubation in 3.3% (n = 9). Two immediate (within 20 min after intubation) intubation related cardiac arrest/mortality events were identified. The 30-day in-hospital mortality was 31.6% (n = 87), the overall in-hospital mortality was 37.1% (n = 102), the mean hospital stay was 22 ± 20 days, and the mean ICU-stay was 14 days (13.9 ± 0.9, CI 12.1-15.8) with a 7.3% ICU-readmission rate. CONCLUSION: Patients requiring emergent airway management are a high-risk patient population with multiple comorbidities and high ASA scores on admission. Only a small number of intubation-related complications were reported but ICU length of stay was high.

Correction to: Sphenopalatine Ganglion Block in the Management of Chronic Headaches.

The original version of this article contains an error in an author's first name. The spelling of Dr. Mojica's first name should read "Jeffrey" instead of "Jeffery."

Sphenopalatine Ganglion Block in the Management of Chronic Headaches.

PURPOSE OF REVIEW: Sphenopalatine ganglion (SPG) block has been used by clinicians in the treatment of a variety of headache disorders, facial pain syndromes, and other facial neuralgias. The sensory and autonomic fibers that travel through the SPG provided the scientific rationale for symptoms associated with these head and neck syndromes. Yet, despite the elucidation of this pathogenic target, the optimal method to block its pain-producing properties has not been determined. Clinicians have developed various invasive and non-invasive techniques, each of which has shown variable rates of success. We examined the available studies of sphenopalatine ganglion blockade and its efficacy in the treatment of cluster headaches, migraines, and other trigeminal autonomic cephalalgias. RECENT FINDINGS: Studies have demonstrated that SPG blockade and neurostimulation can provide pain relief in patients with cluster headaches, migraines, and other trigeminal autonomic cephalalgias. Patients with these conditions showed varying levels and duration of pain relief from SPG blockade. The efficacy of SPG blockade could be related to the different techniques targeting the SPG and choice of therapeutic agents. Based on current studies, SPG blockade is a safe and effective treatment for chronic headaches such as cluster headaches, migraines, and other trigeminal autonomic cephalalgias. Future studies are warranted to define the optimal image-guided technique and choice of pharmacologic agents for SPG blockade as an effective treatment for chronic headaches related to activation of the sphenopalatine ganglion.

Patient perception of pain care in the United States: a 5-year comparative analysis of hospital consumer assessment of health care providers and systems.

BACKGROUND: The necessity of aggressive pain management in the hospital setting is becoming increasingly evident. It has been shown to improve patient outcomes, and is now an avenue for Medicare to assess reimbursement. In this cohort analysis, we compared the March 2008 to the December 2012 Hospital Consumer Assessment of Health Plans Survey (HCAHPS) reports in order to determine if pain management has improved in the United States after this national standardized survey was created. OBJECTIVE: To evaluate whether pain perception would improve in the 2012 report relative to the 2008 report. STUDY DESIGN: Statistical analyses were conducted with the HCAHPS report to compare pain control in regards to hospital type, hospital ownership, and individual hospitals. Using the question, "How often is your pain controlled?," T-tests were used to compare each hospital type. Hospital ownerships were assessed via analysis of variance (ANOVA) testing. T-tests were conducted to track the difference of hospital performance between the 2008 and the 2012 report. Paired management data were obtained from hospitals that participated in both reports and were assessed using paired T-tests. SETTING: This survey was administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge from any hospital reporting to Centers for Medicare and Medicaid (CMS) across the US. LIMITATIONS: Limitations of this study include response bias, recall bias, and there may be bias related to types of people likely to respond to a survey, but this is inherent to data that is collected on a voluntary response. Additionally, a 3% increase in the number of patients rating their pain as always well-controlled, while statistically significant, admittedly may not be clinically significant. In addition, the raw data collected is adjusted for the effects of patient-mix. The statistical analyses performed to derive the final quarterly HCAHPS reports are unavailable to us and therefore we cannot comment on how individual factors such as age, sex, race, and education or the interaction of the aforementioned affect responses about the patient's perception on how well their pain was controlled between 2008 and 2012. RESULTS: Two thousand three hundred and ninety five hospitals reported pain management data in both 2008 and 2012. In 2012, hospitals improved their ability to "always control a patients pain" by 3.07% (P < 0.0001) in comparison to the baseline March 2008 report, which was statistically significant. According to the 2012 data, the discrepancy in pain management between acute care hospitals and critical access hospitals was 3.33% which was statistically significant (P < 0.05). Government hospitals were shown to manage pain better at baseline, but all 3 types of ownership improved their pain scores between the 2 reports which was shown to be statistically significant (P < 0.01). DISCUSSION: The HCAHPS survey is a national public standardized report used as a way to compare care in the United States. Patient pain perception has improved between the 2008 and 2012 reports. Further studies are needed to evaluate critical care hospitals.

Patient perception of pain care in hospitals in the United States.

STUDY OBJECTIVE: Assessment of patients' perception of pain control in hospitals in the United States. BACKGROUND: Limited data are available regarding the quality of pain care in the hospitalized patient. This is particularly valid for data that allow for comparison of pain outcomes from one hospital to another. Such data are critical for numerous reasons, including allowing patients and policy-makers to make data-driven decisions, and to guide hospitals in their efforts to improve pain care. The Hospital Quality Alliance was recently created by federal policy makers and private organizations in conjunction with the Centers for Medicare and Medicare Services to conduct patient surveys to evaluate their experience including pain control during their hospitalization. METHODS: In March 2008, the results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was released for review for health care providers and researchers. This survey includes a battery of questions for patients upon discharge from the hospital including pain-related questions and patient satisfaction that provide valuable data regarding pain care nationwide. This study will review the results from the pain questions from this available data set and evaluate the performance of these hospitals in pain care in relationship to patient satisfaction. Furthermore, this analysis will be providing valuable information on how hospital size, geographic location and practice setting may play a role in pain care in US hospitals. RESULTS: The data indicates that 63% of patients gave a high rating of global satisfaction for their care, and that an additional 26% of patients felt that they had a moderate level of global satisfaction with the global quality of their care. When correlated to satisfaction with pain control, the relationship with global satisfaction and "always" receiving good pain control was highly correlated (r >0.84). In respect to the other HCAHPS components, we found that the patient and health care staff relationship with the patient is also highly correlated with pain relief (r >0.85). The patients' reported level of pain relief was significantly different based upon hospital ownership, with government owned hospitals receiving the highest pain relief, followed by nonprofit hospitals, and lastly proprietary hospitals. Hospital care acuity also had an impact on the patient's perception of their pain care; patients cared for in acute care hospitals had lower levels of satisfaction than critical access hospitals. CONCLUSIONS: The results of this study are a representation of the experiences of patients in US hospitals with regard to pain care specifically and the need for improved methods of treating and evaluating pain care. This study provides the evidence needed for hospitals to make pain care a priority in to achieve patient satisfaction throughout the duration of their hospitalization. Furthermore, future research should be developed to make strategies for institutions and policy-makers to improve and optimize patient satisfaction with pain care.