Pilot epinephrine dose-finding study to counter epidural-related blood pressure reduction.

OBJECTIVE: An unwanted side effect associated with epidural analgesia is the reduction in blood pressure (BP) due to the sympathetic blockade. This study evaluated the hemodynamic effects of adding different epinephrine concentrations to epidurally injected local anesthetic solution to counteract sympathectomy. We hypothesized that epinephrine could mitigate the decrease in BP possibly caused by the local anesthetic, specifically decreasing the incidence of hypotension. METHODS: Sixty-six patients were enrolled in a randomized, controlled, quadruple-blinded prospective study into three groups: epidural ropivacaine 0.2% without epinephrine (control) or with 2 µg/mL or 5 µg/mL epinephrine. Our primary outcome was the assessment of differences in hypotension between groups, defined as a >20% decrease in hypotension from baseline to the end of the intraoperative period. RESULTS: Forty-seven patients completed the study, and 19 were withdrawn. Fifteen patients were in the control group, while 16 patients received 0.2% ropivacaine +2 µg/mL epinephrine, and 16 received 0.2% ropivacaine +5 µg/mL epinephrine. The overall rate of hypotension was 21.3% (10/47). There were no statistically significant differences in hypotension rates between the control group (33%) and groups receiving either +2 µg/mL (13%, p=0.165) or +5 µg/mL (19%, p=0.353) of epinephrine. In secondary analyses, respiratory rate showed greater decreases in control groups across the perioperative period compared with treatment groups (p=0.016) CONCLUSION: Adding epinephrine to the epidural local anesthetic did not significantly decrease the rate of hypotension. However, epinephrine mitigated decreases in respiratory rate across the perioperative period. Future studies will focus on increasing group size and higher epinephrine concentrations (10 µg/mL). TRIAL REGISTRATION NUMBER: NCT02722746.

Airway management of a patient with linear immunoglobulin A bullous dermatosis: A case report.

BACKGROUND: There is limited literature on managing the airway of patients with linear immunoglobulin A (IgA) bullous dermatosis, a rare mucocutaneous disorder that leads to the development of friable bullae. Careful clinical decision making is necessary when there is a risk of bleeding into the airway, and a multidisciplinary team approach may lead to decreased patient morbidity during these high-risk scenarios, especially when confronted with an unusual cause for bleeding. CASE SUMMARY: A 45-year-old African American female presented to our ambulatory surgical center for right corneal transplantation due to corneal perforation after blunt trauma in the setting of cicatricial conjunctivitis and diffuse corneal neovascularization from linear IgA bullous dermatosis. The diagnosis of IgA dermatosis was recent, and the patient had been lost to follow-up. The severity of the disease and extent of airway involvement was unknown at the time of the surgery. Significant airway bleeding was noticed upon intubation and the otorhinolaryngology team had to be called to the operating room. The patient required transfer to the intensive care unit where a multidisciplinary team was involved in her case. The patient was extubated on postoperative day 4. CONCLUSION: A multidisciplinary approach to treating this disease is the best course of action before a surgical procedure. In our case, key communication between the surgery, anesthesia, and dermatology teams led to the quick and safe treatment of our patient's disease. Ambulatory surgery should not be considered for these cases unless they are in full remission and there is no mucous membrane involvement.

Refractory primary and secondary headache disorders that dramatically responded to combined treatment of ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks and non-invasive vagus nerve stimulation: a case series.

In 1981, Devoghel achieved an 85.6% success rate in treating patients with treatment-refractory cluster headaches with alcoholization of the pterygopalatine ganglion (PPG) via the percutaneous suprazygomatic approach. Devoghel's study led to the theory that interrupting the parasympathetic pathway by blocking its transduction at the PPG could prevent or treat symptoms related to primary headache disorders (PHDs). Furthermore, non-invasive vagus nerve stimulation (nVNS) has proven to treat PHDs and has been approved by national regulatory bodies to treat, among others, cluster headaches and migraines.In this case series, nine desperate patients who presented with 11 longstanding treatment-refractory primary headache disorders and epidural blood patch-resistant postdural puncture headache (PDPH) received ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks (PPGB), and seven also received nVNS. The patients were randomly selected and were not part of a research study. They experienced dramatic, immediate, satisfactory, and apparently lasting symptom resolution (at the time of the writing of this report). The report provides the case descriptions, briefly reviews the trigeminovascular and neurogenic inflammatory theories of the pathophysiology, outlines aspects of these PPGB and nVNS interventions, and argues for adopting this treatment regime as a first-line or second-line treatment rather than desperate last-line treatment of PDPH and PHDs.

Twenty-three-hour stays in the ambulatory surgical center: benefits, pathways and protocols.

PURPOSE OF REVIEW: To summarize recent evidence that discusses the clinical, financial, and logistical implications of a 23 h stay postsurgical stay unit in an ambulatory surgical center (ASC). RECENT FINDINGS: Twenty-three-hour stays in ambulatory surgery centers are safe, but proper patient selection and optimization are key to maintaining a high level of safety. The financial implications of overnight stays in ASCs rely heavily on payment structures and comparative costs at hospital-based outpatient surgery centers. The establishment of pathways and protocols for clinical care are key to the success of a 23 h stay at an ASC. SUMMARY: A concurrent concern with the recent increase in outpatient surgery and medical complexity of cases performed in an ambulatory surgical center (ASC) is the possibility that patients may need overnight stay. Further, whether certain patients would benefit from anticipated 23 h observation rather than same-day discharge is an emerging topic. Overnight stays in ASCs may have financial advantages and decrease the risk of unanticipated admission with proper patient selection. The use of protocols and established pathways is key to the success of this model.

Protocol for a pilot and feasibility randomized-controlled trial of four weeks of oral γ-aminobutyric acid (GABA) intake and its effect on pain and sleep in middle-to-older aged adults.

Approximately 1.71 billion people globally live with musculoskeletal pain conditions, including low back pain, knee pain, and neck pain Cieza et al. (2020). In the US, an estimated 20.4% of U.S. adult had chronic pain and 8.0% of U.S. adults had high-impact chronic pain, with higher prevalence associated with advancing age Dahlhamer et al. (2018). On the other hand, between 50 and 70 million US adults have a sleep disorder (American Sleep Association). Although the link between sleep and pain is widely established, the neurobiological mechanisms underlying this relationship have yet to be fully elucidated, specifically within an aged population. As currently available sleep and chronic pain therapies are only partially effective, novel treatment approaches are urgently needed. Given the potential mechanistic role of γ-aminobutyric acid (GABA) in both conditions, and the availability of GABA supplements over the counter, the present proposal will determine the feasibility and acceptability of oral GABA administration in middle-to-older aged adults with chronic pain and sleep disorders as well as characterize the potential neurobiological mechanisms involved in both conditions. Results from the present investigation using a parallel, double-blinded, placebo-controlled study will provide novel preliminary information needed for future translational pain and sleep research.

Role of an Intercostobrachial Nerve Block in Alleviating Tourniquet Pain: A Randomized Clinical Trial.

Introduction Tourniquet pain may have cutaneous and ischemic components. It is questionable whether blockade of a sensory nerve will help reduce ischemic pain. In addition, complete anesthesia of the axilla in the intercostobrachial nerve (ICBN) distribution is challenging to execute, and ICBN blockade has an inherently higher failure rate because of its variable anatomic location and source of innervation. We sought to determine the utility of an ICBN block for the prevention of tourniquet pain. Methods We conducted a single-center randomized controlled trial at a major academic medical center involving patients scheduled to undergo distal upper extremity surgery under ultrasound-guided supraclavicular brachial plexus block. Forty patients were randomized to receive an additional ICBN block or no ICBN block, with 22 allocated to the intervention and 18 to control. We collected data on the incidence of tourniquet pain and systemic anesthetic requirements. Results Initial contingency analysis examining the relationship between ICBN block placement and the development of pain using the two-tailed Fisher exact test failed to show that the presence or absence of ICBN block was associated with the development of tourniquet pain. χ2 analysis failed to show that tourniquet time was significantly related to the development of tourniquet pain. Conclusions The overall incidence of tourniquet pain in the setting of a dense supraclavicular brachial plexus block for surgical anesthesia was low even without an ICBN block and even with tourniquet times greater than 90 min. Tourniquet pain was easily managed with small amounts of systemic analgesics.

A reliable septum exists between the lateral cord and medial and posterior cords in the costoclavicular region: Clinical and microanatomical considerations in brachial plexus anesthetic blockade.

BACKGROUND AND OBJECTIVES: The ultrasound-guided proximal infraclavicular costoclavicular block (PICB) appears popular but its results are inconsistent. We sought an accurate demonstration of septae formed between the brachial plexus cords. METHODS: We performed in-plane, lateral-to-medial PICBs on 120 patients and recorded images. Once the most superficial lateral cord component was entered, a 0.4-0.6 mA current was applied to confirm needle placement; 5 ml of local anesthetic (LA) solution was then injected and its spread was observed and recorded. As the needle was advanced, the presence or absence of a hyperechoic linear structure was noted before the deeper compartment was reached, specifically looking for the possible displacement of such a septum. RESULTS: Upon initial scanning, a septum was observed in 67 of the 120 patients (46.2%). However, there was clear displacement of a linear septum between the lateral cord compartment and the medial and posterior cord compartments that prevented spread between the compartments in 94.16% of patients. Piercing the septum evoked motor responses from the medial or posterior cord. The same anatomical regions were studied microanatomically by analyzing cross-sections obtained with the same approach angle as the ultrasound probe. CONCLUSIONS: Intraplexus fascial septae that bundled the medial and posterior cords into one compartment and separated them from the lateral cord were demonstrated and confirmed microanatomically. This suggests the need for two separate injections (or two separate catheter placements for continuous peripheral nerve blockade) into the superficial and deep compartments to ensure LA spread around all three cords of the brachial plexus at this level.

Case series of fluoroscopic findings and 3D reconstruction of human spinal MRIs of the space of Okada.

OBJECTIVE: To better understand the unexpected spread of contrast medium observed by conventional fluoroscopic X-ray images during standard neuraxial techniques used in the treatment of pain. The support of 3D reconstruction of MRI images of structures within the lumbar spine was used to better understand the space of Okada. METHODS: Lumbar facet joint and epidural corticosteroid injections in five patients under fluoroscopic guidance with loss of resistance to air or saline to identify the facet joints or epidural space. Next, in a retrospective study, the authors examined the retrodural space of Okada and the neighboring tissues with 3D reconstruction of spinal MRIs of seven patients without any demonstrable spinal pathology to better understand the characteristics of the space of Okada. RESULTS: Contrast medium spread to the ipsilateral and contralateral sides was observed in five patients. The contralateral spread was thought to be through the retrodural space of Okada, which is a potential space between the anterior surface of the vertebral lamina and the posterior surface of the ligamentum flavum. It facilitates communication between the contralateral articular facet joints of the spine. CONCLUSIONS: This study provides new evidence for the existence of the space of Okada where an unexpected contralateral spread occurred following facet joint and attempted epidural injection. The 3D reconstructions of MRIs may help us better understand the nature of the retrodural space of Okada and its clinical implications.

Vulnerability of different nerves to intrafascicular injection by different needle types and at different approach angles: a mathematical model.

BACKGROUND AND OBJECTIVES: We assume that intrafascicular spread of a solution can only occur if a large enough portion of the distal needle orifice is placed inside the fascicle. Our aim is to present and evaluate a mathematical model that can calculate the theoretical vulnerability of fascicles, analyzing the degree of occupancy of the needle orifice in fascicular tissue by performing simulations of multiple positions that a needle orifice can take inside a cross-sectional nerve area. METHODS: We superimposed microscopic images of two routinely used nerve block needles (22-gauge, 15° needle and 22-gauge, 30° needle) over the microscopic images of cross-sections of four nerve types photographed at the same magnification. Fascicular tissue that was overlapped between 80% and 100% by a needle orifice was considered at risk to possible intrafascicular injection. The effect of three angular approaches was evaluated. RESULTS: There were statistical differences between the vulnerability of fascicular tissue depending on nerve type, the bevel angle of the needle and the angle approach. Fascicular vulnerability was greater in nerve roots of the brachial plexus after using a 22-gauge 30° needle, as was choosing a 45° angle approach to the longitudinal axis of the nerve. CONCLUSIONS: Our results suggest that clinicians may want to consider needle insertion angle and bevel type as they perform peripheral nerve blocks. Furthermore, researchers may want to consider this mathematical model when estimating vulnerabilities of various nerves, needle types and angles of approach of needles to nerves.

Extrafasicular and Intraperineural, but No Endoneural, Spread after Deliberate Intraneural Injections in a Cadaveric Study.

BACKGROUND: There is confusion regarding the spread of intraneurally injected local anesthetic agents during regional anesthesia. The aim of this research was to deliberately inject a marker that does not leave the neural compartment into which it is injected, and then to study the longitudinal and circumferential spread and possible pathways of intraneural spread. METHODS: After institutional review board approval, we intraneurally injected 20 and 5 ml of heparinized blood solution under ultrasound guidance into 12 sciatic nerves in the popliteal fossa and 10 median nerves, respectively, of eight fresh, unembalmed cadavers using standard 22-gauge "D" needles, mimicking the blocks in clinical conditions. Ultrasound evidence of nerve swelling confirmed intraneural injection. Samples of the nerves were then examined under light and scanning electron microscopy. RESULTS: Extrafascicular spread was observed in all the adipocyte-containing neural compartments of the 664 cross-section samples we examined, but intrafascicular spread was seen in only 6 cross-sections of two nerves. None of the epineurium, perineurium, or neural components were disrupted in any of the samples. Spread between the layers of the perineurium was a route of spread that included the perineurium surrounding the fascicles and the perineurium that formed incomplete septa in the fascicles. Similar to the endoneurium proper, subepineural compartments that did not contain any fat cells did not reveal any spread of heparinized blood solution cells. No "perineural" spaces were observed within the endoneurium. We also did not observe any true intrafascicular spread. CONCLUSIONS: After deliberate intraneural injection, longitudinal and circumferential extrafascicular spread occurred in all instances in the neural compartments that contained adipocytes, but not in the relatively solid endoneurium of the fascicles.

The Posterior Lumbar Epidural Space: Three-Dimensional Reconstruction of High-Resolution MRI: Real and Potential Epidural Spaces and Their Content In Vivo.

OBJECTIVE: Our aim was to study the posterior lumbar epidural space with 3D reconstructions of magnetic resonance images (MRIs) and to compare and validate the findings with targeted anatomic microdissections. DESIGN: We performed 3D reconstructions of high-resolution MRIs from seven patients and normal-resolution MRIs commonly used in clinical practice from 196 other random patients. We then dissected and photographed the lumbar spine areas of four fresh cadavers. RESULTS: From the 3D reconstructions of the MRIs, we verified that the distribution of the posterior fat pad had an irregular shape that resembled a truncated pyramid. It spanned between the superior margin of the lamina of the caudad vertebra and beyond the inferior margin to almost halfway underneath the cephalad lamina of the cranial vertebra, and it was not longitudinally or circumferentially continuous. The 3D reconstructions of the high-definition MRI also consistently revealed a prelaminar fibrous body that was not seen in most of the usually used low-definition MRI reconstructions. Targeted microdissections confirmed the 3D reconstruction findings and also showed the prelaminar tissue body to be fibrous, crossing from side to side anterior to the cephalad half of each lamina, and spanning from the dural sac to the laminae. CONCLUSIONS: Three-dimensional reconstructions and targeted microdissection revealed the unique appearance of posterior fat pads and a prelaminar fibrous body. The exact consistency, presence, prevalence with age, presence in other regions, and function of this body are unknown and require further research.

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps.

Objective: In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting: Expert commentary. Methods: Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions: Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

Cancer Recurrence and Regional Anesthesia: The Theories, the Data, and the Future in Outcomes.

OBJECTIVE: More than one million people each year in the United States are diagnosed with cancer. Surgery is considered curative, but the perioperative phase represents a vulnerable period for residual disease to spread. Regional anesthesia has been proposed to reduce the incidence of recurrence by attenuating the sympathetic nervous system's response during surgery, reducing opioid requirements thus diminishing their immunosuppressant effects, and providing antitumor and anti-inflammatory effects directly through systemic local anesthetic action. In this article, we present a description of the perioperative period, a summary of the proposed hypotheses and available literature on the effects of regional anesthesia on cancer recurrence, and put regional anesthesia in context in regard to its potential role in reducing cancer recurrence during the perioperative period. METHODS: A literature review was conducted through PubMed by examining the following topics: effects of surgery on tumor progression, roles of multiple perioperative variables (analgesics, hypothermia, blood transfusion, beta-blockade) in cancer recurrence, and available in vitro, animal, and human studies regarding the effects of regional anesthesia on cancer recurrence. RESULTS: in vitro, animal and human retrospective studies suppport the hypothesis that in certain types of cancer, regional anesthesia may be associated with lower recurrence rates. A few well-planned human randomized clinical trials are currently under way that may provide more solid evidence to substantiate or refute the benefits of regional anesthesia in reducing cancer recurrence. CONCLUSIONS: The benefits of regional anesthesia in reducing cancer recurrence have a sound theoretical basis and, in certain cancers, are supported by the existing body of literature. This article outlines the current state of our knowledge on the relationship between cancer progression and regional analgesia.