A Review of the Paravertebral Block: Benefits and Complications.

PURPOSE OF REVIEW: Paravertebral nerve blocks (PVB) have experienced a surge over the past 2 decades as improved access to ultrasound has increased ease of performance. The purpose of this review is to identify recent findings with regard to PVB's uses, including benefits, risks, and recommendations. RECENT FINDINGS: PVB is reported as an effective method of analgesia both in intraoperative and postoperative applications, with novel applications showing its potential to replace general anesthesia for certain procedures. The use of PVB as a method of analgesia postoperatively has shown lower opioid usage and faster PACU discharge, when compared to alternative approaches like the intercostal nerve block, erector spinae plane block, pectoralis II block, and patient-controlled analgesia. Thoracic epidural analgesia and a serratus anterior plane block are comparable to PVB and can be used as alternatives. The incidence of adverse events is consistently reported to be very low with few new risks being identified as the use of PVB expands. While there are worthwhile alternatives to PVB, it is an excellent option to consider, particularly for higher-risk patients. For patients undergoing thoracic or breast surgery, PVB can improve opioid usage and shorten the length of stay leading to an overall positive impact on patient recovery and satisfaction. More research is needed to further expand novel applications.

Orbital Pseudotumor as an Extrahepatic Complication of Chronic HCV Infection.

We present a patient who was admitted for eye swelling, pain, and discharge, with CT orbits with contrast demonstrating inflammation and enlargement of the lacrimal glands and surrounding tissue. He was found to have an HCV infection for unknown duration upon further investigation. All other workup (autoimmune, rheumatic, and infectious) was unrevealing. The patient was diagnosed with orbital pseudotumor as an extrahepatic complication of chronic HCV infection, and he was managed with prednisone which dramatically decreased his eye swelling and pain. Steroid treatment may serve as a bridge to suppress symptoms of extrahepatic manifestations, especially in ocular cases, while HCV-infected patients await treatment to eradicate their HCV infection.

Ketamine Use for Successful Resolution of Post-ERCP Acute Pancreatitis Abdominal Pain.

We report a case in which a patient with intractable pain secondary to post-endoscopic retrograde cholangiopancreatography (ERCP) acute pancreatitis is successfully treated with a subanesthetic ketamine infusion. Shortly after ERCP, the patient reported severe stabbing epigastric pain. She exhibited voluntary guarding and tenderness without distension. Amylase and lipase levels were elevated. Pain persisted for hours despite hydromorphone PCA, hydromorphone boluses, fentanyl boluses, and postprocedure anxiolytics. Pain management was consulted and a ketamine infusion was trialed, leading to a dramatic reduction in pain. This case suggests that ketamine may be a promising option in treating intractable pain associated with ERCP acute pancreatitis.

The Effect of Additives on the Behavior of Phase Sensitive In Situ Forming Implants.

Phase-sensitive in situ forming implants (ISFI) are a promising platform for the controlled release of therapeutic agents. The simple manufacturing, ease of placement, and diverse payload capacity make these implants an appealing delivery system for a wide range of applications. Tailoring the release profile is paramount for effective treatment of disease. In this study, three innovative formulation modifications were used to control drug release. Specifically, water, 1,1'-dioctadecyl-3,3,3',3'-tetramethylindocarbocyanine perchlorate (DiI), and bovine serum albumin (BSA) were incorporated into an ISFI solution containing the small molecular weight mock drug, sodium fluorescein. The effects of these additives on drug release, swelling, phase inversion, erosion, and implant microstructure were evaluated. Diagnostic ultrasound was used to monitor changes in swelling and phase inversion over time noninvasively. Water, DiI, and the combination of BSA/DiI functioned to reduce burst release 47.6%, 76.6%, and 59.0%, respectively. Incorporation of water into the casting solution also enhanced the release of drug during the diffusion period of release by 165.2% relative to the excipient free control. Incorporation of BSA into the polymer solution did not significantly alter the burst release (p < 0.05); however, the onset of degradation facilitated release was delayed relative to the excipient-free control by 5 days. This study demonstrates that the use of excipients provides a facile method to tailor the release profile and degradation rate of implants without changing the polymer or solvent used in the implant formulation, providing fine control of drug dissolution during distinct phases of release.