Pre-Admission Oral Clonidine to Reduce Severe Pre-Operative Anxiety in Pediatric Patients with Behavioral Disorders: A Case Series.

Controlling preoperative anxiety is necessary in pediatric patients to avoid adverse effects such as emergence delirium, behavioral problems, post-traumatic stress disorder, anxiety prior to future procedures, and increased analgesic doses in the recovery room. Some patients, especially ones with behavioral issues, have a difficult time arriving at the hospital. Medications given at home can be helpful. We describe a case series of six patients who received pre-admission oral clonidine prior to arrival to the hospital. The patients were all able to enter the hospital without difficulty and the families reported less anxiety and more cooperation subjectively compared with previous experiences. Transient intraoperative hypotension was a side effect of oral clonidine, with no long-term sequelae.

Safety Assessment of Prolonged Nerve Catheters in Pediatric Trauma Patients: A Case Series Study.

INTRODUCTION: Nerve block catheters (NBCs) are increasingly used for pain management in pediatric trauma patients. While short-term efficacy has been well established, the long-term safety of NBCs is unknown. Methods/Cases: The retrospective chart review includes a cohort of nine pediatric trauma patients aged 3-15 years who received 52 peripheral nerve block catheters and epidurals for pain management. This study aimed to investigate the potential risks associated with the prolonged use of NBCs in pediatric trauma cases. RESULTS: The NBCs (48 peripheral catheters and 4 epidural catheters) were maintained for about 2 weeks. The number of catheters per patient varied from 1 to 11. The study noted a low frequency of catheter-related complications. No catheter-site infection or local anesthetic toxicity symptoms were reported. DISCUSSION: These findings suggest that NBCs can be safely maintained for extended periods in pediatric trauma patients without significantly increasing complications. Careful monitoring and adherence to infection control practices remain paramount when implementing extended catheter use.

Liposomal bupivacaine infiltration in the surgical site for analgesia after rotator cuff repair: a randomized, double-blinded, placebo-controlled trial.

INTRODUCTION: Arthroscopic rotator cuff repair is among the most painful of orthopedic surgeries. Liposomal bupivacaine is Food and Drug Administration approved for administration into surgical sites to provide postsurgical analgesia and has been used to address postoperative pain after many types of surgery, including total shoulder arthroplasty. However, its efficacy for pain control after rotator cuff repair is unclear. METHODS: In this randomized, double-blind, placebo-controlled trial, we compared liposomal bupivacaine with an equivalent volume of saline injected into the subacromial space and arthroscopy portal sites in patients undergoing rotator cuff repair under the interscalene block with sedation. The primary outcome measure was numeric rating pain score at the time of block resolution, as reported during the follow-up phone call on postoperative day 1. Secondary outcomes included mean pain scores at rest as well as oral morphine equivalent requirements on postoperative days 1, 2, and 3. This study provides Level 1 evidence. RESULTS: There were no statistically significant differences in the primary outcome of numeric rating pain scores on resolution of the interscalene nerve block, nor in those reported on postoperative day 1 or 2. There was a minor but statistically significant difference in mean resting pain scores on day 3, though opioid consumption and patient satisfaction score did not differ between groups. In those instructed to perform passive range-of-motion exercises, there was no difference in reported mean pain scores among the groups. DISCUSSION: In this study of patients undergoing arthroscopic rotator cuff repair, we found no statistically significant difference in mean pain scores on interscalene block resolution, a result consistent with a number of studies investigating liposomal bupivacaine for total shoulder arthroplasty. A modest reduction in pain was evident only on day 3, and there was no impact on perioperative opioid requirements, opioid-related side effects, or pain with motion. Liposomal bupivacaine, when injected into the subacromial space and the tissues around the arthroscopy port sites, provided minimal improvement in pain control in this patient population.

The Ultrasound Anatomy of Nerves in the Interscalene Groove: Can We Reliably Distinguish the Nerve Structures for Needle Placement During Nerve Blocks?

In the interscalene groove, nerve structures are in close proximity and may not be visible as separate structures, increasing the risk of insertion of the needle tip within the epineurium. We evaluated whether experienced regional anesthesiologists can distinguish between nerve elements lying in close proximity on ultrasound images.Brachial plexus elements from 4 nonpreserved cadavers were arranged in a water bath. Ultrasound images of the nerve roots and trunks were taken. Regional anesthesiologists and residents were asked whether they could distinguish the nerves as 2 separate structures and if they could identify a pair of nerve roots versus a single trunk.Attending anesthesiologists reported the ability to discriminate 2 nerve structures when a 2-mm space was arranged between them in 54% of images; however, when in direct contact, this recognition was significantly lower. The residents reported a higher ability to discriminate the 2 nerves in all scenarios. In addition, the attending anesthesiologists successfully identified paired nerve roots versus nerve trunks in 70% of the images, significantly higher than chance (P = 0.01), whereas the fraction of correct resident responses was not significantly different from guessing.When nerves were placed in close proximity, experienced regional anesthesiologists had difficulty identifying them as separate structures and were incorrect nearly one-third of the time in discriminating 2 closely positioned roots versus a nerve trunk. This underscores the importance of cautious needle insertion into the interscalene groove, where nerve elements are often juxtaposed one to another.

Repeated Intercostal Nerve Blocks With Liposomal Bupivacaine for Chronic Chest Pain: A Case Report.

Chronic chest pain is a debilitating condition that is poorly treated, resulting in opioid dependence and significantly decreased quality of life. In this case report, we describe the successful use of 266 mg of liposomal bupivacaine for 4 rounds of left-sided multilevel intercostal nerve blocks performed to treat chronic chest pain of a 21-year-old woman (150 kg, 163 cm). The sensory blockade duration was up to 7 days, analgesia lasted 2 months, and was described superior to that with ropivacaine intercostal blockade. The treatment improved satisfaction with pain control and quality of life.

Neurologic complications in common wrist and hand surgical procedures.

Nerve dysfunction after upper extremity orthopedic surgery is a recognized complication, and may result from a variety of different causes. Hand and wrist surgery require incisions and retraction that necessarily border on small peripheral nerves, which may be difficult to identify and protect with absolute certainty. This article reviews the rates and ranges of reported nerve dysfunction with respect to common surgical interventions for the distal upper extremity, including wrist arthroplasty, wrist arthrodesis, wrist arthroscopy, distal radius open reduction and internal fixation, carpal tunnel release, and thumb carpometacarpal surgery. A relatively large range of neurologic complications is reported, however many of the studies cited involve relatively small numbers of patients, and only rarely are neurologic complications included as primary outcome measures. Knowledge of these neurologic outcomes should help the surgeon to better counsel patients with regard to perioperative risk, as well as provide insight into workup and management of any adverse neurologic outcomes that may arise.

Mechanics of anesthetic needle penetration into human sciatic nerve.

Nerve blocks are frequently performed by anesthesiologists to control pain. For sciatic nerve blocks, the optimal placement of the needle tip between its paraneural sheath and epineurial covering is challenging, even under ultrasound guidance, and frequently results in nerve puncture. We performed needle penetration tests on cadaveric isolated paraneural sheath (IPS), isolated nerve (IN), and the nerve with overlying paraneural sheath (NPS), and quantified puncture force requirement and fracture toughness of these specimens to assess their role in determining the clinical risk of nerve puncture. We found that puncture force (123 ±â€¯17 mN) and fracture toughness (45.48 ±â€¯9.72 J m-2) of IPS was significantly lower than those for NPS (1440 ±â€¯161 mN and 1317.46 ±â€¯212.45 Jm-2, respectively), suggesting that it is not possible to push the tip of the block needle through the paraneural sheath only, without pushing it into the nerve directly, when the sheath is lying directly over the nerve. Results of this study provide a physical basis for tangential placement of the needle as the ideal situation for local anesthetic deposition, as it allows for the penetration of the sheath along the edge of the nerve without entering the epineurium.

Changes in blood product utilization in a seven-hospital system after the implementation of a patient blood management program: A 9-year follow-up.

OBJECTIVES: To analyze changes in red blood cell (RBC), platelet (PLT), and plasma transfusion volumes 9 years after the implementation of a multifaceted patient blood management (PBM) program across multiple hospitals. METHODS: Between fiscal years 2007 and 2015, the annual transfusion volumes for seven hospitals in a regional healthcare system were analyzed by hospital, and between 2014 and 2015, by four service lines including emergency department, intensive care unit (ICU), medical/surgical ward, and operating room at each hospital. The number of units of RBCs administered to transfused recipients on the wards and in ICUs was also enumerated. RESULTS: For these seven hospitals combined, there was a 29.9% reduction in the number of RBCs transfused between 2007 and 2015, a 24.8% reduction in plasma units, and a 25.7% reduction in PLT units. The two largest hospitals saw some of the largest reductions in RBC transfusions (40.1, 25.1%), and plasma transfusions (26.1, 33.8%), and one of those hospitals had a 49.5% reduction in PLT transfusions. Smaller-sized hospitals also had reductions in transfusion volumes, while some volumes increased at hospitals when new or expanded clinical services were introduced. The number of RBC units per transfused recipient was generally between 1.5 and 2 units on the wards and slightly higher in the ICUs. DISCUSSION: Although the overall volume of transfusions has generally decreased at each hospital site over time, the appropriateness of the administered transfusions cannot be evaluated by these data. CONCLUSION: The system-wide implementation of a PBM program has reduced transfusion volumes.

Precipitated withdrawal from nicotine reduces reinforcing effects of a visual stimulus for rats.

INTRODUCTION: Research has identified at least two positive reinforcement-related effects of nicotine: (a) primary reinforcement and (b) enhancement of reinforcement from concurrently available stimuli. Prior examples of the reinforcement-enhancing effects with rats showed that repeated, intermittent nicotine exposure increased responding for non-nicotine reinforcers, and this effect remained robust over several weeks. However, the effects of continuous nicotine exposure on responding for a non-nicotine reinforcer are unknown, as are the effects of abruptly withdrawing continuous nicotine on behavior maintained by the same reinforcer. METHODS: Lever pressing for a visual reinforcer under a fixed ratio schedule was assessed while rats were maintained on a chronic, continuous infusion of nicotine (3.16 mg/kg/day; osmotic minipump). The effects of precipitated withdrawal on responding, following 16 days of continuous nicotine exposure, were assessed by pre-session subcutaneous injections of mecamylamine (1.0 mg/kg). RESULTS: Continuous nicotine initially increased active responding for the visual reinforcer; however, continued exposure resulted in an attenuation of this effect. Precipitated withdrawal from nicotine resulted in a significant decline in active responding. CONCLUSIONS: The initial increase in responding for the visual reinforcer with chronic nicotine exposure is consistent with prior research showing that intermittent exposure to nicotine acts as a reinforcement enhancer. However, the attenuation of this enhancement following prolonged nicotine exposure is in contrast with the persistent effects previously reported. Finally, the decrease in visual reinforcers below control levels (nicotine-naive animals) following nicotine withdrawal highlights a potential for affective withdrawal, which may serve as a motive for continued nicotine use.