Analgesic benefits of single-shot versus continuous adductor canal block for total knee arthroplasty: a systemic review and meta-analysis of randomized trials.

BACKGROUND: Adductor canal block (ACB) can provide important analgesic benefits following total knee arthroplasty (TKA), however, the extent to which these benefits can be enhanced or prolonged by a continuous catheter-based infusion compared with a single-shot injection of local anesthetic is unclear. OBJECTIVES: This systematic review and meta-analysis (PROSPERO: CRD42021292738) review sought to compare the analgesic effectiveness of single shot to continuous ACB following TKA. EVIDENCE REVIEW: We sought randomized trials from the US National Library of Medicine database (MEDLINE), Excerpta Medica database (EMBASE), and Cochrane Database of Systematic Reviews from inception to November 1, 2021, that compared single-shot to continuous ACB in adult patients undergoing TKA. The primary outcomes were (1) area under the curve (AUC) pain severity at rest and (2) cumulative opioid (oral morphine equivalent) consumption during the first 48 hours postoperatively. Secondary outcomes included postoperative pain severity scores up to 48 hours, cumulative opioid consumption at 24 hours, functional recovery, opioid-related side effects, and block-related complications. Risk of bias of included studies was assessed using the Cochrane risk of bias tool. Statistical pooling was conducted using the Hartung-Knapp-Sidik-Jonkman method for random effects. No funding was obtained for this review. FINDINGS: Eleven trials (1185 patients) were included. No differences were observed in rest pain severity (AUC) or cumulative opioid consumption up to 48 hours postoperatively. In addition, no differences were observed in individual postoperative rest pain scores in the recovery room and at 12 and 24 hours, or in cumulative opioid consumption at 24 hours, functional recovery, and opioid-related side effects. Finally, fewer block-related complications were observed with single-shot ACB, with an OR (95% CI) of 0.24 (0.14 to 0.41) (p=0.002). CONCLUSIONS: Our results suggest that continuous catheter-based ACB does not enhance or prolong the analgesic benefits when compared with single-shot ACB for TKA over the first 48 hours postoperatively. Overall, the results of our meta-analysis do not support the routine use of continuous ACB for postoperative analgesia after TKA.

Cardiac Arrhythmias Resulting from a Peripherally Inserted Central Catheter: Two Cases and a Review of the Literature.

We present two cases of patients being treated for diabetic ketoacidosis in the intensive care unit who experienced cardiac arrhythmia secondary to peripherally inserted central catheters (PICCs). In one instance, the patient became bradycardic and experienced related loss of consciousness, ultimately requiring cardiopulmonary resuscitation. In the second case, the patient experienced an episode of nonsustained ventricular tachycardia. We explore the various types of arrhythmias that have been reported secondary to central venous catheters, as well as factors that place patients at an increased risk for arrhythmia while undergoing PICC insertion. Furthermore, we look at the literature for methods to improve the insertion of PICC lines by decreasing the risk of catheter over-insertion as well as the effects of training for PICC placement.

Role of bilayer characteristics on the structural fate of aß(1-40) and aß(25-40).

The ß-amyloid (Aß) peptide is derived from the transmembrane (TM) helix of the amyloid precursor protein (APP) and has been shown to interact with membrane surfaces. To understand better the role of peptide-membrane interactions in cell death and ultimately in Alzheimer's disease, a better understanding of how membrane characteristics affect the binding, solvation, and secondary structure of Aß is needed. Employing a combination of circular dichroism and deep-UV resonance Raman spectroscopies, Aß(25-40) was found to fold spontaneously upon association with anionic lipid bilayers. The hydrophobic portion of the disease-related Aß(1-40) peptide, Aß(25-40), has often been used as a model for how its legacy TM region may behave structurally in aqueous solvents and during membrane encounters. The structure of the membrane-associated Aß(25-40) peptide was found to depend on both the hydrophobic thickness of the bilayer and the duration of incubation. Similarly, the disease-related Aß(1-40) peptide also spontaneously associates with anionic liposomes, where it initially adopts mixtures of disordered and helical structures. The partially disordered helical structures then convert to ß-sheet structures over longer time frames. ß-Sheet structure is formed prior to helical unwinding, implying a model in which ß-sheet structure, formed initially from disordered regions, prompts the unwinding and destabilization of membrane-stabilized helical structure. A model is proposed to describe the mechanism of escape of Aß(1-40) from the membrane surfaces following its formation by cleavage of APP within the membrane.