Ultrasound-Guided Percutaneous Intercostal Cryoneurolysis for Acute-on-Chronic Pain in CLOVES Syndrome.

Cryoneurolysis is an analgesic method that has been shown to provide extended pain relief in postoperative patients. However, to date, this method has not been described in nonsurgical inpatients with chronic pain experiencing an acute exacerbation. This analgesic modality has the potential to provide pain relief for patients whose expected duration of severe acute pain would outlast that of other regional anesthetic techniques while avoiding opioid escalation and facilitating discharge. We present a patient with acute exacerbation of chronic pain from breast ulcerations caused by congenital lipomatous overgrowth, vascular malformations, epidermal nevis, spinal/skeletal anomalies/scoliosis (CLOVES) syndrome that was successfully treated as an inpatient with a portable cryoneurolysis device.  This is the first reported use of cryoneurolysis in an inpatient setting to treat acute-on-chronic pain in a nonsurgical patient. The authors recommend regional anesthesiologists and acute pain specialists to utilize this technique to provide analgesia in patients with complex pain to facilitate hospital throughput.

Interscalene Block for Analgesia in Orthopedic Treatment of Shoulder Trauma: Single-Dose Liposomal Bupivacaine versus Perineural Catheter.

BACKGROUND: Interscalene brachial plexus block is frequently utilized to provide perioperative analgesia to patients undergoing shoulder surgery to optimize recovery, minimize opioid consumption, and decrease overall hospital length of stay. The use of an indwelling perineural interscalene catheter provides extended analgesia and is efficacious in managing severe postoperative pain following major shoulder surgery. Currently, the only alternative to perineural catheters for extended analgesia with interscalene block involves the perineural infiltration of liposomal bupivacaine. However, there is limited published data regarding the overall analgesic effectiveness of using interscalene liposomal bupivacaine in the setting of shoulder surgery. METHODS: We performed a retrospective review of 43 patients in the acute trauma setting who underwent major shoulder surgery and received extended analgesia via perioperative interscalene brachial plexus block with either an indwelling continuous catheter or single-dose liposomal bupivacaine to determine if comparable analgesia can be achieved. The primary outcomes of interest were postoperative pain scores and opioid consumption. Due to the ability to titrate and bolus local anesthetic infusions to a desired clinical effect, we hypothesized that opioid consumption and pain scores would be lower when using the continuous catheter technique. RESULTS: After statistical analysis, our results demonstrated no significant difference between the two techniques in regards to opioid consumption as well as numeric pain scores during the 48-hour postoperative period, but did note a higher rate of complications with patients who received perineural interscalene continuous catheters. Secondary outcomes showed an increase in time required to complete the regional block procedure with the use of indwelling catheters. CONCLUSION: Interscalene brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters for providing extended analgesia in patients undergoing major shoulder surgery.

Lumbosacral paraspinal interfascial plane blocks for pain control after feminizing genital gender affirmation surgery.

Aim: Feminizing genital gender affirmation surgery (fgGAS) is increasing in prevalence in the USA. Management of postoperative pain following fgGAS is challenging. We report a series of patients where post-fgGAS pain was adequately controlled with paraspinal blocks. Materials & methods: This is a case series of three patients who received bilateral lumbar and sacral erector spinae plane blocks after fgGAS. Block techniques, medications administered, opioid requirements and pain scores were reviewed. Results: Erector spinae plane blocks provided adequate analgesia for 24-48 h following the block. Conclusion: Currently, there are two regional anesthetic techniques described for the treatment of postoperative pain after fgGAS. We describe two additional approaches as options for improved pain management in this patient population.

Anesthesiology Resident Performance on the US Medical Licensing Examination Predicts Success on the American Board of Anesthesiology BASIC Staged Examination: An Observational Study.

BACKGROUND: Correlation has been found between the US Medical Licensing Examination (USMLE) Step 1 examination results and anesthesiology resident success on American Board of Anesthesiology (ABA) examinations. In 2014, the ABA instituted the BASIC examination at the end of the postgraduate year-2 year. We hypothesized a similar predictive value of USMLE scores on BASIC examination success. METHODS: After the Committee for the Protection of Human Subjects at UTHealth Institutional Review Board approved and waived written consent, we retrospectively evaluated USMLE Step examination performance on first-time BASIC examination success in a single academic department from 2014-2018. RESULTS: Over 5 years, 120 residents took the ABA BASIC examination and 108 (90%) passed on the first attempt. Ten of 12 first-time failures were successful on repeat examination but analyzed in the failure group. Complete data was available for 92 residents (76.7%), with absent scores primarily reflecting osteopathic graduates who completed Comprehensive Osteopathic Medical Licensing Examination of the United States level examinations rather than USMLE. In the failure cohort, all 3 USMLE examination step scores were lower (P < .02). USMLE Step 1 score independently predicted success on the BASIC examination (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05-1.17, P < .001). Although USMLE Step 2 score predicted BASIC examination success (OR 1.10, 95% CI 1.04-1.18, P = .001), this did not remain after adjustment for Step 1 score using multiple logistic regression (P = .11). In multivariable logistical regression, first clinical anesthesia in-training examination score and USMLE Step 1 score were significant for predictors of success on the BASIC exam. CONCLUSIONS: In anesthesiology residency training, our preliminary single-center data is the first to suggest that USMLE Step 1 performance could be used as a predictor of success on the recently introduced ABA BASIC Examination. These findings do not support recent action to change USMLE scoring to a pass/fail report.

Quadratus Lumborum 2 Block as the Sole Anesthetic Technique for Open Hernia Repair in Multimorbid Patients.

Ultrasound-guided quadratus lumborum (QL, QL1-3) blocks have been used extensively for perioperative pain control for patients undergoing abdominal procedures. These blocks provide a more widespread and longer-lasting analgesic effect compared to the transversus abdominis plane (TAP) block. While QL blocks have been used as an adjunct in multimodal postoperative pain control, they are rarely used as the sole anesthetic technique for abdominal surgeries. We report the cases of two high-risk multimorbid patients requiring urgent open umbilical hernia repairs secondary to incarceration or obstruction. Bilateral QL2 blocks were utilized as the sole anesthetic technique to reduce anesthetic risk, with positive outcomes.  Utilization of the QL2 block technique for our patients enabled avoidance of general anesthesia in these high-risk patients because of the extensive area of anesthesia they provide when compared with the TAP and QL1 block techniques. The advantages of the QL2 block for high-risk patients include immediate perioperative pain control, reduced use of muscle relaxants, reduced opioid analgesic requirement for postoperative pain management, and enhanced postoperative recovery. Disadvantages include potential for local anesthetic toxicity, neural injury, or failure of the block. While regional anesthetic techniques may be beneficial options for those patients who are not candidates for general anesthesia, more studies in which these techniques are used need to be performed to determine the widespread efficacy and adequacy of this method.

Relief of Secondary Headaches with High Thoracic Erector Spinae Plane Block.

Intractable headaches can be debilitating, often leading to significant distress, prolonged medical treatment, and unanticipated hospital admissions. There have been significant advances in the treatment of primary intractable headaches such as migraines, tension headaches, and cluster headaches beyond medical management. Treatments may now include interventional strategies such as trigger-point injections, peripheral nerve stimulators, or peripheral nerve and ganglion blocks. There are few studies, however, describing the use of interventional techniques for the management of intractable secondary headaches, including those attributed to injury or infection. A new regional anesthetic technique, the erector spinae plane (ESP) block, was initially used for neuropathic thoracic pain. ESP block has since been reported to provide acute and chronic pain relief of the shoulder, spine, abdomen, pelvis, thorax, and lower extremity. Additionally, there has been one case report to describe the use of the ESP block in the treatment of refractory tension headache. We report four cases of effective analgesia for intractable secondary headache resistant to medical management with high thoracic ESP blocks. In each case, the ESP block provided instant pain relief. We suggest that the findings of this case series indicate that the ESP block may be a useful intervention in patients with severe secondary headache or posterior cervical pain where conventional therapies have limited success, though more studies are necessary.

Posterior Quadratus Lumborum Block for Labor Analgesia: A Case Report.

Neuraxial analgesia has been established as the standard of care for labor analgesia. However, patients presenting with coagulopathy require anesthesiologists to explore alternate analgesic techniques. Systemic opioids may result in neonatal respiratory depression, and inhaled nitrous oxide may lead to nausea, vomiting, and over sedation and may not be readily available in all labor and delivery units. In this case report, we describe a case where posterior quadratus lumborum blocks provided effective analgesia in a parturient with Hemophilia A during the first stage of labor.

Upper extremity regional anesthesia techniques: A comprehensive review for clinical anesthesiologists.

Surgeries and chronic pain states of the upper extremity are quite common and pose unique challenges for the clinical anesthesiology and pain specialists. Most innervation of the upper extremity involves the brachial plexus. The four most common brachial plexus blocks performed in clinical setting include the interscalene, supraclavicular, infraclavicular, and axillary brachial plexus blocks. These blocks are most commonly performed with the use of ultrasound-guided techniques, whereby analgesia is achieved by anesthetizing the brachial plexus at different levels such as the roots, divisions, cords, and branches. Additional regional anesthetic techniques for upper extremity surgery include wrist, intercostobrachial, and digital nerve blocks, which are most frequently performed using landmark anatomical techniques. This review provides a comprehensive summary of each of these blocks including anatomy, best practice techniques, and potential complications.

Pseudo-wound infection after a caesarean section: Case report of unrecognized Pyoderma Gangrenosum.

BACKGROUND: Pyoderma Gangrenosum (PG) is a rare auto-inflammatory disease, characterized by painful ulcerative skin-lesions often developing at sites of injury or surgery because of the typical pathergy phenomena. We describe an unusual case of PG after a caesarean section with excessive extra-cutaneous manifestation within internal organs. PRESENTATION OF CASE: A 21-year-old Dutch primigravida developed signs of sepsis after a caesarean section. Despite antibiotic treatment, fast clinical deterioration occurred. Exploration of the wound showed necrosis of the uterus and surrounding tissues. Due to the progression of necrosis, consecutive debridement procedures were executed resulting in a substantial abdominal wall defect. The progressive clinical course of the necrosis combined with absence of positive wound cultures and histology of prominent interstitial neutrophilic infiltration, led to the diagnosis 'Pyoderma Gangrenosum'. Treatment with high dose corticosteroids led to rapid regression of the disease. After several weeks, the abdominal wall defect was surgically corrected under systemic corticosteroid therapy. DISCUSSION: This case of PG is unique due to the excessive extra-cutaneous presentation, which contributed to delayed diagnosis. Several surgical interventions in the active stage of disease resulted in expansion of PG and substantial morbidity for the patient. CONCLUSION: Post-operative PG can mimic infectious diseases, but treatment is substantially different. This case of extensive PG highlights the importance of timely recognition and treatment of the disease to reduce iatrogenic morbidity.

Opioid-Free Cesarean Section with Bilateral Quadratus Lumborum Catheters.

INTRODUCTION: Post-operative pain control following cesarean section delivery (CD) is an important topic of discussion given the lack of consensus on a narcotic-sparing analgesic regimen. We describe the case of an elective CD with narcotic-free pain control using continuous bilateral posterior quadratus lumborum (QL) blockade as the primary mode of analgesia. CASE REPORT: The patient is a 36-year-old female, G3P1, who presented at 37 weeks of gestation in active labor scheduled for elective primary CD. A spinal anesthetic was performed at L4-L5 with hyperbaric 0.75% bupivacaine, without intrathecal morphine. Bilateral posterior QL catheters were placed under sterile conditions with 20 mL of 0.25% bupivacaine per side. Continuous infusion of 0.2% ropivacaine was then started at 10 mL/hour per side. The patient's pain was controlled with QL catheters and a multimodal pain regimen consisting of non-steroidal anti-inflammatory drugs and acetaminophen. The patient reported a resting pain score of 0 with a dynamic pain score of 3 out of 10 throughout her recovery. She was discharged on post-operative (post-op) day 3 and the catheters were removed without any complications. DISCUSSION: The gold standard for pain control following CD is intrathecal morphine; however, its use has many adverse effects. Bilateral single-shot QL blocks following CD have been proven to decrease opioid consumption but its limited duration has minimal advantage over intrathecal morphine and patients continue to require oral narcotics for analgesia. With the use of QL catheters and a multimodal pain regimen, it may be possible to achieve opioid-free CD for the post-op period.

T4 Erector Spinae Plane Block Relieves Postdural Puncture Headache: A Case Report.

Postdural puncture headache (PDPH) is a common complication of neuraxial anesthesia. The gold standard treatment for PDPH is an epidural blood patch (EBP). However, the risks of EBP, and patient willingness to undergo another attempted neuraxial procedure, can prevent patients from receiving this treatment. The erector spinae plane (ESP) block has been used in the treatment of acute postoperative and chronic pain secondary to many indications at many vertebral levels, and a prior case series describes two patients in which ESP block relieved tension headache. In our case report, we describe a novel use of the ESP block at the fourth thoracic vertebral level to relieve PDPH in a super morbidly obese patient with two prior inadvertent dural punctures.

Impact of serratus plane block on pain scores and incentive spirometry volumes after chest trauma.

Background: Adequate pain control is difficult to achieve in patients with multiple rib fractures (MRF). Serratus plane block (SPB) is a novel technique for alleviating rib fracture pain. Several published case reports support this hypothesis. Purpose: The purpose of this study was to evaluate the use of SPB in MRF at our level 1 trauma center. Methods: Our hospital's Regional Anesthesia Registry was queried for all trauma patients with MRF who underwent SPB between August 2014 and January 2018. Data were compared in each patient as a matched pair for the time periods before and after undergoing SPB. Thirty-four patients with similar baseline characteristics were enrolled. Results: The median number of rib fractures was 7. Ordinal pain scores were found to be improved 4 hrs after SPB from median 7/10 to 3/10 (P<0.001). Incentive spirometry (IS) volumes recorded 4 and 24 hrs postserratus plane block showed a median increase of 150 and 175 mL from baseline, respectively (P<0.001). IS volumes recorded at 48 hrs showed a median increase of 300 mL from baseline (P<0.001). Respiratory rate decreased from a median value of 24.5 to 16 breaths/min (P<0.001). SpO2 was improved at 24 hrs from median 96% to 99% (P<0.001). Conclusion: SPB improves pain scores and IS volumes in MRF. Because it is not limited by patient positioning or anticoagulation and has a better safety profile, it may offer a viable alternative to neuraxial techniques. Additional studies are necessary to evaluate its efficacy compared to neuraxial techniques.

Surgical anesthesia for revision total hip arthroplasty with quadratus lumborum and fascia iliaca block.

We present a case in which surgical anesthesia was provided for revision of earlier total hip arthroplasty with quadratus lumborum and fascia iliaca blocks. We believe that this case is the first to be reported using this technique for this procedure. Our patient was a high-risk candidate for general and neuraxial anesthesia because of significant cardiac dysfunction and therapeutic anticoagulation.