Ultrasound-Guided External Oblique Intercostal Block as Part of Multimodal Analgesia for Unplanned Open Cholecystectomy.

We present the case of a 56-year-old female with a significant medical history of cholelithiasis and recurrent choledocholithiasis. Following an elective cholecystectomy, an obstructing gallstone in the common bile duct led to a series of interventions, including endoscopic retrograde cholangiopancreatography and stent placement. The patient was scheduled for a robot-assisted laparoscopic common bile duct exploration. Due to severe adhesions, the procedure was converted to open with a large right upper quadrant incision. Intraoperative continuous external oblique block and catheter placement were performed at the end of surgery in the OR. Peripheral nerve blocks have become an integral part of multimodal pain management strategies. This case report describes the successful implementation of an ultrasound-guided right external oblique intercostal block and catheter placement for postoperative pain control and minimization of opioids. This case highlights the efficacy and safety of ultrasound-guided peripheral nerve blocks for postoperative pain management. Successful pain control contributed to the patient's overall postoperative recovery.

Acute Pain Management in a Multi-site Trauma Patient.

Pain management is often difficult in the setting of multi-site trauma such as that caused by motor vehicle accidents (MVA), which is especially compounded in the setting of polysubstance abuse. This often results in patients with poor pain tolerance requiring escalating doses of opioid therapy, which creates a vicious cycle. The use of peripheral nerve blocks (PNB) has been shown to decrease overall opioid consumption and can be used effectively to manage postoperative pain in this patient population. Our case report aims to highlight the importance of PNBs as part of a multimodal approach to pain management in patients with polytrauma in the setting of polysubstance abuse.

Paravertebral Block for Multiple Rib Fractures in an Anticoagulated Trauma Patient.

This case report presents the complex analgesia management of a 52-year-old male with a significant medical history including atrial fibrillation treated with apixaban, essential trigeminal neuralgia, non-ischemic cardiomyopathy, and chronic systolic heart failure. The patient experienced a loss of control while riding a motorized bicycle, resulting in a fall and head injury with no loss of consciousness. Upon admission, he tested positive for ethanol, cannabinoids, and oxycodone. The physical exam was significant for right cephalohematoma and right elbow hematoma. Imaging revealed multiple injuries, including right rib fractures (T3-12) with hemothorax. Right paravertebral catheters were placed in the intensive care unit (ICU).

Ambulatory Pain Management in the Pediatric Patient Population.

PURPOSE OF REVIEW: Outpatient surgery in the pediatric population has become increasingly common. However, many patients still experience moderate to severe postoperative pain. A poor understanding of the extent of pain after pediatric ambulatory surgery and the lack of randomized control studies of pain management of the outpatient necessitate this review of scientific evidence and multimodal analgesia. RECENT FINDINGS: A multimodal approach to pain management should be applied to the ambulatory setting to decrease postoperative pain. These include non-pharmacological techniques, multimodal pharmacologics, and neuraxial and peripheral nerve blocks. Postoperative pain management in pediatric ambulatory surgical patients remains suboptimal at most centers due to limited evidence-based approach to postoperative pain control. Pediatric ambulatory pain management requires a multipronged approach to address this inadequacy.

Ultrasound for peripheral and arterial access.

Peripheral venous access is perhaps the most commonly performed procedure in hospitals, urgent care, or surgical centers across the country. The ability to obtain peripheral intravenous (IV) access, and in a timely manner, is arguably one of the most important skill sets to be mastered by health care professionals. While skill and experience play a role in successful and timely vascular access, numerous patient factors such as obesity, diabetes, IV drug use, and chronic kidney disease may pose unique challenges to even the most skilled health care professional. In patients with difficult access, there are often multiple attempts, which can be both time consuming for the provider and painful for the patients. Direct visualization of blood vessels using ultrasonography has an advantage over the standard landmark technique and can improve the success rate of peripheral IV or arterial line placement in this patient population. Given the success of ultrasound guidance with access placement, it is imperative that all health care profesionals become proficient with this technique. The aim of this review article is to provide concise and practical information on the basics of ultrasound and its application to obtain peripheral venous and arterial access.

Beyond the caudal: truncal blocks an alternative option for analgesia in pediatric surgical patients.

PURPOSE OF REVIEW: To discuss and compare the more commonly used truncal blocks with neuraxial techniques in children undergoing a variety of thoracic, abdominal and urological procedures. RECENT FINDINGS: Owing to the advent of ultrasonography and its increasing use in regional anesthesia, there has been a renewed interest in implementing these techniques in children for intraoperative and postoperative pain management. SUMMARY: The use of regional anesthesia particularly with ultrasound guidance is an integral part of pain management during the intraoperative and postoperative period in children who undergo surgery. Its use is essential in improving patient pain control and overall satisfaction as well as decreasing hospital stay and reducing hospital admission after surgery. Truncal blocks serve as an excellent alternative to neuraxial blockade, in patients who have a contraindication to neuraxial blockade, patients undergoing a unilateral procedure and those in an outpatient ambulatory setting undergoing routine procedures, wherein the adverse effects of neuraxial blockade such as motor weakness, difficulty ambulating, urinary retention, increased nausea and vomiting, may delay same day discharge.