An Interdisciplinary, Comprehensive Recovery Pathway Improves Microsurgical Breast Reconstruction Delivery.

INTRODUCTION: Free-flap (autologous) breast reconstruction demonstrates superiority over alloplastic approaches but is offered infrequently. Enhanced recovery protocols can address postoperative challenges, but most literature is limited to inpatient interventions and outcomes. This study describes an adoptable, longitudinally comprehensive and multidisciplinary recovery pathway for autologous reconstruction which adds to the current guidelines. The authors aimed to allow perioperative outcomes comparable to alloplastic reconstructions. METHODS: All autologous Comprehensive Recovery Pathway (CRP) subjects from a single surgeon were retrospectively included. A comparator group of equal size was randomly selected from institutional subpectoral and dual-plane tissue expander patients having Enhanced Recovery After Surgery guideline-directed care. All subjects in both cohorts received preoperative paravertebral regional blocks. Operative detail, inpatient recovery, longitudinal morphine equivalents (MEs) required, and complications were compared. RESULTS: Each cohort included 71 cases (99 breasts). Despite longer operations, intraoperative MEs were fewer in autologous cases ( P = 0.02). Morphine equivalents during inpatient stay were similar between cohorts, with both being discharged on median day 2. Multivariate regression demonstrated a 0.8-day increased stay for autologous subjects with additional contribution from bilateral cases, body mass index, and age ( P < 0.05). Autologous subjects were regularly discharged postoperative day 1 (17%) and postoperative day 2 (39%), with trend toward earlier discharge ( P < 0.01). Outpatient MEs were significantly fewer in autologous subjects, corresponding to a 30- to 150-mg oxycodone difference ( P < 0.01). Major complication occurred in 12.7% of autologous and 22.5% of alloplastic subjects ( P = 0.11). Flap loss occurred in 1 autologous subject versus 11 alloplastic failures ( P < 0.01). CONCLUSIONS: This study details partnership between the plastic surgery service, regional and acute pain anesthesia services, and dedicated nursing with longitudinal optimizations allowing perioperative outcomes improved over current literature. Patients in the CRP used fewer opioids from operation through follow-up with comparable length of stay and significantly fewer reconstructive failures than alloplastic subjects. The pathway may be quickly adopted into academic practice patterns and mitigates traditional barriers, allowing extension of autologous reconstruction offerings.

Robot-assisted laparoscopic nephrectomy: early outcome measures with the implementation of multimodal analgesia and intrathecal morphine via the acute pain service.

PURPOSE: The objective of this study was to perform a retrospective cohort analysis, in which we measured the association of an acute pain service (APS)-driven multimodal analgesia protocol that included preoperative intrathecal morphine (ITM) compared to historic controls (i.e., surgeon-driven analgesia protocol without ITM) with postoperative opioid use. METHODS: This was a retrospective cohort study in which the primary objective was to determine whether there was a decrease in median 24-h opioid consumption (intravenous morphine equivalents [MEQ]) among robotic nephrectomy patients whose pain was managed by the surgical team prior to the APS, versus pain managed by APS. Secondary outcomes included opioid consumption during the 24-48 h and 48-72 h period and hospital length of stay. To create matched cohorts, we performed 1:1 (APS:non-APS) propensity score matching. Due to the cohorts occurring at the different time periods, we performed a segmented regression analysis of an interrupted time series. RESULTS: There were 76 patients in the propensity-matched cohorts, in which 38 (50.0%) were in the APS cohort. The median difference in 24-h opioid consumption in the pre-APS versus APS cohort was 23.0 mg [95% CI 15.0, 31.0] (p < 0.0001), in favor of APS. There were no differences in the secondary outcomes. On segmented regression, there was a statistically significant drop in 24-h opioid consumption in the APS cohort versus pre-APS cohort (p = 0.005). CONCLUSIONS: The implementation of an APS-driven multimodal analgesia protocol with ITM demonstrated a beneficial association with postoperative 24-h opioid consumption following robot-assisted nephrectomy.

Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following cholecystectomy and hernia repair: a randomized, double-masked, sham-controlled pilot study.

BACKGROUND: Percutaneous auricular nerve stimulation (neuromodulation) involves implanting electrodes around the ear and administering an electric current. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial; and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following two ambulatory surgical procedures. METHODS: Within the recovery room following cholecystectomy or hernia repair, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied. Participants were randomized to 5 days of either electrical stimulation or sham in a double-blinded fashion. RESULTS: In the first 5 days, the median (IQR) pain level for active stimulation (n=15) was 0.6 (0.3-2.4) vs 2.6 (1.1-3.7) for the sham group (n=15) (p=0.041). Concurrently, the median oxycodone use for the active stimulation group was 0 mg (0-1), compared with 0 mg (0-3) for the sham group (p=0.524). Regarding the highest pain level experienced over the entire 8-day study period, only one participant (7%) who received active stimulation experienced severe pain, versus seven (47%) in those given sham (p=0.031). CONCLUSIONS: Percutaneous auricular neuromodulation reduced pain scores but not opioid requirements during the initial week after cholecystectomy and hernia repair. Given the ease of application as well as a lack of systemic side effects and reported complications, a definitive clinical trial appears warranted. TRIAL REGISTRATION NUMBER: NCT05521516.

Percutaneous auricular neuromodulation (nerve stimulation) for the treatment of pain following total knee arthroplasty: a randomized, double-masked, sham-controlled pilot study.

BACKGROUND: Percutaneous auricular nerve stimulation (neuromodulation) is an analgesic technique involving the percutaneous implantation of multiple leads at various points on/around the ear followed by the delivery of electric current using an external pulse generator. A device is currently available within the USA cleared to treat symptoms from opioid withdrawal, and multiple reports suggest a possible postoperative analgesic effect. The current randomized, controlled pilot study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent definitive clinical trial and (2) estimate the treatment effect of auricular neuromodulation on postoperative pain and opioid consumption following total knee arthroplasty. METHODS: Within the recovery room following primary, unilateral, total knee arthroplasty, an auricular neuromodulation device (NSS-2 Bridge, Masimo, Irvine, California, USA) was applied using three percutaneous leads and one ground electrode. Participants were randomized to 5 days of either electrical stimulation or sham stimulation in a double-masked fashion. Participants were discharged with the stimulator in situ and removed the disposable devices at home. The dual primary treatment effect outcome measures were the cumulative opioid use (oral oxycodone) and the mean of the "average" daily pain measured with the Numeric Rating Scale for the first 5 postoperative days. RESULTS: During the first five postoperative days, oxycodone consumption in participants given active stimulation (n=15) was a median (IQR) of 4 mg (2-12) vs 13 mg (5-23) in patients given sham (n=15) treatment (p=0.039). During this same period, the average pain intensity in patients given active stimulation was a median (IQR) of 2.5 (1.5-3.3) vs 4.0 (3.6-4.8) in those given sham (p=0.014). Awakenings due to pain over all eight postoperative nights in participants given active stimulation was a median (IQR) of 5 (3-8) vs 11 (4-14) in those given sham (p<0.001). No device-related localized cutaneous irritation, systemic side effects, or other adverse events were identified. CONCLUSIONS: Percutaneous auricular neuromodulation reduced pain scores and opioid requirements during the initial week after total knee arthroplasty. Given the ease of application as well as the lack of systemic side effects and reported complications, a definitive clinical trial appears warranted. TRIAL REGISTRATION NUMBER: NCT05521516.

Basal Infusion versus Automated Boluses and a Delayed Start Timer for "Continuous" Sciatic Nerve Blocks after Ambulatory Foot and Ankle Surgery: A Randomized Clinical Trial.

BACKGROUND: The common technique using a basal infusion for an ambulatory continuous peripheral nerve blocks frequently results in exhaustion of the local anesthetic reservoir before resolution of surgical pain. This study was designed to improve and prolong analgesia by delaying initiation using an integrated timer and delivering a lower hourly volume of local anesthetic as automated boluses. The hypothesis was that compared with a traditional continuous infusion, ropivacaine administered with automated boluses at a lower dose and 5-h delay would (1) provide at least noninferior analgesia (difference in average pain no greater than 1.7 points) while both techniques were functioning (average pain score day after surgery) and (2) result in a longer duration (dual primary outcomes). METHODS: Participants (n = 70) undergoing foot or ankle surgery with a popliteal-sciatic catheter received an injection of ropivacaine 0.5% with epinephrine (20 ml) and then were randomized to receive ropivacaine (0.2%) either as continuous infusion (6 ml/h) initiated before discharge or as automated boluses (8 ml every 2 h) initiated 5 h after discharge using a timer. Both groups could self-deliver supplemental boluses (4 ml, lockout 30 min); participants and outcome assessors were blinded to randomization. All randomized participants were included in the data analysis. RESULTS: The day after surgery, participants with automated boluses had a median [interquartile range] pain score of 0.0 [0.0 to 3.0] versus 3.0 [1.8 to 4.8] for the continuous infusion group, with an odds ratio of 3.1 (95% CI, 1.23 to 7.84; P = 0.033) adjusting for body mass index. Reservoir exhaustion in the automated boluses group occurred after a median [interquartile range] of 119 h [109 to 125] versus 74 h [57 to 80] for the continuous infusion group (difference of 47 h; 95% CI, 38 to 55; P < 0.001 adjusting for body mass index). CONCLUSIONS: For popliteal-sciatic catheters, replacing a continuous infusion initiated before discharge with automated boluses and a start-delay timer resulted in better analgesia and longer infusion duration.

Serratus anterior plane versus paravertebral nerve blocks for postoperative analgesia after non-mastectomy breast surgery: a randomized controlled non-inferiority trial.

BACKGROUND: Paravertebral and serratus plane blocks are both used to treat pain following breast surgery. However, it remains unknown if the newer serratus block provides comparable analgesia to the decades-old paravertebral technique. METHODS: Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection serratus or paravertebral block in a subject-masked fashion (ropivacaine 0.5%; 20 mL unilateral; 16 mL/side bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room with serratus blocks (measurement: Numeric Rating Scale), and (2) opioid consumption would be non-inferior with serratus blocks in the operating and recovery rooms. In order to claim that serratus blocks are non-inferior to paravertebral blocks, both hypotheses must be at least non-inferior. RESULTS: Within the recovery room, pain scores for participants with serratus blocks (n=49) had a median (IQR) of 4.0 (0-5.5) vs 0 (0-3.0) for those with paravertebral blocks (n=51): 0.95% CI -3.00 to -0.00; p=0.001. However, the difference in morphine equivalents did not reach statistical significance for superiority with the serratus group consuming 14 mg (10-19) vs 10 mg (10-16) for the paravertebral group: 95% CI -4.50 to 0.00, p=0.123. Since the 95% CI lower limit of -4.5 was less than our prespecified margin of -2.0, we failed to conclude non-inferiority of the serratus block with regard to opioid consumption. CONCLUSIONS: Serratus blocks provided inferior analgesia compared with paravertebral blocks. Without a dramatic improvement in safety profile for serratus blocks, it appears that paravertebral blocks are superior to serratus blocks for postoperative analgesia after non-mastectomy breast surgery. TRIAL REGISTRATION NUMBER: NCT03860974.

The Implementation of an Acute Pain Service for Patients Undergoing Open Ventral Hernia Repair with Mesh and Abdominal Wall Reconstruction.

INTRODUCTION: In this retrospective cohort single-institutional study, we report the outcomes of implementing a standardized protocol of multimodal pain management with thoracic epidural analgesia via the acute pain service (APS) for patients undergoing ventral hernia repair with mesh placement and abdominal wall reconstruction. METHODS: The primary outcome evaluated was postoperative 72-h opioid consumption, measured in intravenous morphine equivalents (MEQ). Secondary outcomes included hospital length of stay (LOS) among other outcomes. The two cohorts were the APS versus non-APS group, in which the former cohort had an APS providing epidural and multimodal analgesia and the latter utilized pain management per surgical team, which mostly consisted of opioid therapy. Using1:1 propensity-score-matched cohorts, Wilcoxon signed-rank test was used to calculate the differences in outcomes. A p < 0.05 was considered statistically significant. RESULTS: There were 83 patients, wherein 51 (61.4%) were in the APS group. Between matched cohorts, the non-APS cohort's median [quartiles] total opioid consumption during the first three days was 85.6 mg MEQs [58.9, 112.8 mg MEQs]. The APS cohort was 31.7 mg MEQs [16.0, 55.3 mg MEQs] (p < 0.0001). The non-APS hospital LOS median [quartiles] was 5 days [4, 7 days] versus 4 days [4, 5 days] in the APS group (p = 0.01). DISCUSSION: A dedicated APS was associated with decreased opioid consumption by 75%, as well as a decreased hospital LOS. We report no differences in ICU length of stay, time to oral intake, time to ambulation or time to urinary catheter removal.

Erector spinae plane versus paravertebral nerve blocks for postoperative analgesia after breast surgery: a randomized clinical trial.

BACKGROUND: Paravertebral nerve blocks (PVBs) are frequently used to treat pain during and following breast surgery, but have various undesirable risks such as pneumothorax. The erector spinae plane block (ESPB) also provides perioperative breast analgesia, but is purported to be easier to administer with a favorable safety profile. However, it remains unknown if the new ESPB provides comparable analgesia as the decades-old PVB technique. METHODS: Subjects undergoing unilateral or bilateral non-mastectomy breast surgery were randomized to a single-injection ESPB or PVB in a subject-blinded fashion (ropivacaine 0.5% with epinephrine; 20 mL unilateral or 16 mL/side for bilateral). We hypothesized that (1) analgesia would be non-inferior in the recovery room as measured on a Numeric Rating Scale (NRS) with ESPB, and (2) opioid consumption would be non-inferior in the operating and recovery rooms with ESPB. RESULTS: Both pain scores and opioid consumption were higher in subjects with ESPBs (n=50) than PVBs (n=50; median NRS 3.0 vs 0; 95% CI -3.0 to 0; p=0.0011; and median morphine equivalents 2.0 vs 1.5 mg; 95% CI -1.2 to -0.1; p=0.0043). No block-related adverse events occurred in either group. CONCLUSIONS: PVBs provided superior analgesia and reduced opioid requirements following non-mastectomy breast surgery. To compare the relatively rare complications between the techniques will require a sample size 1-2 orders of magnitude greater than the current investigation; however, without a dramatic improvement in safety profile for ESPBs, it appears that PVBs are superior to ESPBs for postoperative analgesia after non-mastectomy breast surgery. TRIAL REGISTRATION NUMBER: NCT03549234.

Suture-method versus Through-the-needle Catheters for Continuous Popliteal-sciatic Nerve Blocks: A Randomized Clinical Trial.

BACKGROUND: The basic perineural catheter design has changed minimally since inception, with the catheter introduced through or over a straight needle. The U.S. Food and Drug Administration recently cleared a novel perineural catheter design comprising a catheter attached to the back of a suture-shaped needle that is inserted, advanced along the arc of its curvature pulling the catheter past the target nerve, and then exited through the skin in a second location. The authors hypothesized that analgesia would be noninferior using the new versus traditional catheter design in the first two days after painful foot/ankle surgery with a primary outcome of average pain measured with the Numeric Rating Scale. METHODS: Subjects undergoing painful foot or ankle surgery with a continuous supraparaneural popliteal-sciatic nerve block 5 cm proximal to the bifurcation were randomized to either a suture-type or through-the-needle catheter and subsequent 3-day 0.2% ropivacaine infusion (basal 6 ml/h, bolus 4 ml, lockout 30 min). Subjects received daily follow-up for the first four days after surgery, including assessment for evidence of malfunction or dislodgement of the catheters. RESULTS: During the first two postoperative days the mean ± SD average pain scores were lower in subjects with the suture-catheter (n = 35) compared with the through-the-needle (n = 35) group (2.7 ± 2.4 vs. 3.4 ± 2.4) and found to be statistically noninferior (95% CI, -1.9 to 0.6; P < 0.001). No suture-style catheter was completely dislodged (0%), whereas the tips of three (9%) traditional catheters were found outside of the skin before purposeful removal on postoperative day 3 (P = 0.239). CONCLUSIONS: Suture-type perineural catheters provided noninferior analgesia compared with traditional catheters for continuous popliteal-sciatic blocks after painful foot and ankle surgery. The new catheter design appears to be a viable alternative to traditional designs used for the past seven decades.

Association of trainee involvement in an acute pain service with postoperative opioid use in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Several hospitals have implemented a multidisciplinary Acute Pain Service (APS) to execute surgery-specific opioid sparing analgesic pathways. Implementation of an anesthesia attending-only APS has been associated with decreased postoperative opioid consumption, time to ambulation, and time to solid food intake for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. In this study, we evaluated the impact of introducing an APS trainee on postoperative opioid consumption in patients undergoing hyperthermic intraperitoneal chemotherapy during POD 0-3. METHODS: We performed a retrospective propensity-matched cohort study where we compared opioid consumption and hospital length of stay among two historical cohorts: attending-only APS service versus service involving a regional anesthesia fellow. RESULTS: In the matched cohorts, the median postoperative day (POD) 0-3 opioid use [25%, 75% quartile] for the single attending and trainee involvement cohort were 38.5 mg morphine equivalents (MEQ) [14.1 mg, 106.3 mg] and 50.4 mg MEQ [28.4 mg, 91.2 mg], respectively. The median difference was -9.8 mg MEQ (95% CI -30.7-16.5 mg; P = 0.43). There was no difference in hospital length of stay between both cohorts (P = 0.67). CONCLUSIONS: We found that the addition of a regional anesthesia fellow to the APS team was not associated with statistically significant differences in total opioid consumption or hospital length of stay in this surgical population. The addition of trainees to the infrastructure, with vigilant supervision, is not associated with change in outcomes.

Ultrasound-guided percutaneous peripheral nerve stimulation: neuromodulation of the suprascapular nerve and brachial plexus for postoperative analgesia following ambulatory rotator cuff repair. A proof-of-concept study.

BACKGROUND AND OBJECTIVES: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain following knee and foot surgery. However, it remains unknown if this analgesic technique may be used in ambulatory patients following upper extremity surgery. The purpose of this proof-of-concept study was to investigate various lead implantation locations and evaluate the feasibility of using percutaneous brachial plexus PNS to treat surgical pain following ambulatory rotator cuff repair in the immediate postoperative period. METHODS: Preoperatively, an electrical lead (SPR Therapeutics, Cleveland, Ohio) was percutaneously implanted to target the suprascapular nerve or brachial plexus roots or trunks using ultrasound guidance. Postoperatively, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5 min crossover period, and then continuous stimulation until lead removal postoperative days 14-28. RESULTS: Leads (n=2) implanted at the suprascapular notch did not appear to provide analgesia, and subsequent leads (n=14) were inserted through the middle scalene muscle and placed to target the brachial plexus. Three subjects withdrew prior to data collection. Within the recovery room, stimulation did not decrease pain scores during the first 40 min of the remaining subjects with brachial plexus leads, regardless of which treatment subjects were randomized to initially. Seven of these 11 subjects required a single-injection interscalene nerve block for rescue analgesia prior to discharge. However, subsequent average resting and dynamic pain scores postoperative days 1-14 had a median of 1 or less on the Numeric Rating Scale, and opioid requirements averaged less than 1 tablet daily with active stimulation. Two leads dislodged during use and four fractured on withdrawal, but no infections, nerve injuries, or adverse sequelae were reported. CONCLUSIONS: This proof-of-concept study demonstrates that ultrasound-guided percutaneous PNS of the brachial plexus is feasible for ambulatory shoulder surgery, and although analgesia immediately following surgery does not appear to be as potent as local anesthetic-based peripheral nerve blocks, the study suggests that this modality may provide analgesia and decrease opioid requirements in the days following rotator cuff repair. Therefore, it suggests that a subsequent, large, randomized clinical trial with an adequate control group is warranted to further investigate this therapy in the management of surgical pain in the immediate postoperative period. However, multiple technical issues remain to be resolved, such as the optimal lead location, insertion technique, and stimulating protocol, as well as preventing lead dislodgment and fracture. TRIAL REGISTRATION NUMBER: NCT02898103.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Femoral Nerve for Postoperative Analgesia Following Ambulatory Anterior Cruciate Ligament Reconstruction: A Proof of Concept Study.

OBJECTIVES: The purpose of this prospective proof of concept study was to investigate the feasibility of using percutaneous peripheral nerve stimulation of the femoral nerve to treat pain in the immediate postoperative period following ambulatory anterior cruciate ligament reconstruction with a patellar autograft. MATERIALS AND METHODS: Preoperatively, an electrical lead (SPRINT, SPR Therapeutics, Inc., Cleveland, OH, USA) was percutaneously implanted with ultrasound guidance anterior to the femoral nerve caudad to the inguinal crease. Within the recovery room, subjects received 5 min of either stimulation or sham in a randomized, double-masked fashion followed by a 5-min crossover period, and then continuous active stimulation until lead removal postoperative Day 14-28. Statistics were not applied to the data due to the small sample size of this feasibility study. RESULTS: During the initial 5-min treatment period, subjects randomized to stimulation (n = 5) experienced a slight downward trajectory (decrease of 7%) in their pain over the 5 min of treatment, while those receiving sham (n = 5) reported a slight upward trajectory (increase of 4%) until their subsequent 5-min stimulation crossover, during which time they also experienced a slight downward trajectory (decrease of 11% from baseline). A majority of subjects (80%) used a continuous adductor canal nerve block for rescue analgesia (in addition to stimulation) during postoperative Days 1-3, after which the median resting and dynamic pain scores remained equal or less than 1.5 on the numeric rating scale, respectively, and the median daily opioid consumption was less than 1.0 tablet. CONCLUSIONS: This proof of concept study demonstrates that percutaneous femoral nerve stimulation is feasible for ambulatory knee surgery; and suggests that this modality may be effective in providing analgesia and decreasing opioid requirements following anterior cruciate ligament reconstruction. clinicaltrials.gov: NCT02898103.

A Feasibility Study of Percutaneous Peripheral Nerve Stimulation for the Treatment of Postoperative Pain Following Total Knee Arthroplasty.

INTRODUCTION: The objective of the present feasibility study was to investigate the use of a new treatment modality-percutaneous peripheral nerve stimulation (PNS)-in controlling the often severe and long-lasting pain following total knee arthroplasty (TKA). METHODS: For patients undergoing a primary, unilateral TKA, both femoral and sciatic open-coil percutaneous leads (SPR Therapeutics, Cleveland, OH) were placed up to seven days prior to surgery using ultrasound guidance. The leads were connected to external stimulators and used both at home and in the hospital for up to six weeks total. RESULTS: In six of seven subjects (86%), the average of daily pain scores across the first two weeks was <4 on the 0-10 Numeric Rating Scale for pain. A majority of subjects (four out of seven; 57%) had ceased opioid use within the first week (median time to opioid cessation for all subjects was six days). Gross sensory/motor function was maintained during stimulation, enabling stimulation during physical therapy and activities of daily living. At 12 weeks following surgery, six of seven subjects had improved by >10% on the Six-Minute Walk Test compared to preoperative levels, and WOMAC scores improved by an average of 85% compared to before surgery. No falls, motor block, or lead infections were reported. CONCLUSIONS: This feasibility study suggests that for TKA, ultrasound-guided percutaneous PNS is feasible in the immediate perioperative period and may provide analgesia without the undesirable systemic effects of opioids or quadriceps weakness induced by local anesthetics-based peripheral nerve blocks.

Ultrasound-Guided Percutaneous Peripheral Nerve Stimulation: Neuromodulation of the Sciatic Nerve for Postoperative Analgesia Following Ambulatory Foot Surgery, a Proof-of-Concept Study.

BACKGROUND AND OBJECTIVES: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducing needle followed by the delivery of electric current. This modality has been reported to treat chronic pain as well as postoperative pain the day following knee surgery. However, it remains unknown if this analgesic technique may be used in ambulatory subjects following foot procedures beginning within the recovery room immediately following surgery, and with only short series of patients reported to date, the only available data are derived from strictly observational studies. The purposes of this proof-of-concept study were to demonstrate the feasibility of using percutaneous sciatic nerve PNS to treat postoperative pain following ambulatory foot surgery in the immediate postoperative period and provide the first available data from a randomized controlled study design to provide evidence of analgesic effect. METHODS: Preoperatively, an electrical lead (SPRINT; SPR Therapeutics, Inc, Cleveland, Ohio) was percutaneously inserted posterior to the sciatic nerve between the subgluteal region and bifurcation with ultrasound guidance. Following hallux valgus osteotomy, subjects received 5 minutes of either stimulation or sham in a randomized, double-masked fashion followed by a 5-minute crossover period and then continuous stimulation until lead removal on postoperative days 14 to 28. RESULTS: During the initial 5-minute treatment period, subjects randomized to stimulation (n = 4) experienced a downward trajectory in their pain over the 5 minutes of treatment, whereas those receiving sham (n = 3) reported no such change until their subsequent 5-minute stimulation crossover. During the subsequent 30 minutes of stimulation, pain scores decreased to 52% of baseline (n = 7). Three subjects (43%) used a continuous popliteal nerve block for rescue analgesia during postoperative days 0 to 3. Overall, resting and dynamic pain scores averaged less than 1 on the numeric rating scale, and opioid use averaged less than 1 tablet daily with active stimulation. One lead dislodged, 2 fractured during use, and 1 fractured during intentional withdrawal. CONCLUSIONS: This proof-of-concept study demonstrates that percutaneous sciatic nerve PNS is feasible for ambulatory foot surgery and suggests that this modality provides analgesia and decreases opioid requirements following hallux valgus procedures. However, lead dislodgement and fracture are concerns. CLINICAL TRIAL REGISTRATION: This study was registered at Clinicaltrials.gov, identifier NCT02898103.

Proximal Versus Distal Continuous Adductor Canal Blocks: Does Varying Perineural Catheter Location Influence Analgesia? A Randomized, Subject-Masked, Controlled Clinical Trial.

BACKGROUND: A continuous adductor canal block provides analgesia after surgical procedures of the knee. Recent neuroanatomic descriptions of the thigh and knee led us to speculate that local anesthetic deposited in the distal thigh close to the adductor hiatus would provide superior analgesia compared to a more proximal catheter location. We therefore tested the hypothesis that during a continuous adductor canal nerve block, postoperative analgesia would be improved by placing the perineural catheter tip 2-3 cm cephalad to where the femoral artery descends posteriorly to the adductor hiatus (distal location) compared to a more proximal location at the midpoint between the anterior superior iliac spine and the superior border of the patella (proximal location). METHODS: Preoperatively, subjects undergoing total knee arthroplasty received an ultrasound-guided perineural catheter inserted either in the proximal or distal location within the adductor canal in a randomized, subject-masked fashion. Subjects received a single injection of lidocaine 2% via the catheter preoperatively, followed by an infusion of ropivacaine 0.2% (8 mL/h basal, 4 mL bolus, 30 minutes lockout) for the study duration. After joint closure, the surgeon infiltrated the entire joint using 30 mL of ropivacaine (0.5%), ketorolac (30 mg), epinephrine (5 µg/mL), and tranexamic acid (2 g). The primary end point was the median level of pain as measured on a numeric rating scale (NRS) during the time period of 8:00 AM to 12:00 PM the day after surgery. RESULTS: For the primary end point, the NRS of subjects with a catheter inserted at the proximal location (n = 24) was a median (10th, 25th-75th, 90th quartiles) of 0.5 (0.0, 0.0-3.2, 5.0) vs 3.0 (0.0, 2.0-5.4, 7.8) for subjects with a catheter inserted in the distal location (n = 26; P = .011). Median and maximum NRSs were lower in the proximal group at all other time points, but these differences did not reach statistical significance. There were no clinically relevant or statistically significant differences between the treatment groups for any other secondary end point, including opioid consumption and ambulation distance. CONCLUSIONS: For continuous adductor canal blocks accompanied by intraoperative periarticular local anesthetic infiltration, analgesia the day after knee arthroplasty is improved with a catheter inserted at the level of the midpoint between the anterior superior iliac spine and the superior border of the patella compared with a more distal insertion closer to the adductor hiatus.

A Dedicated Acute Pain Service Is Associated With Reduced Postoperative Opioid Requirements in Patients Undergoing Cytoreductive Surgery With Hyperthermic Intraperitoneal Chemotherapy.

BACKGROUND: The Acute Pain Service (APS) was initially introduced to optimize multimodal postoperative pain control. The aim of this study was to evaluate the association between the implementation of an APS and postoperative pain management and outcomes for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC). METHODS: In this propensity-matched retrospective cohort study, we performed a before-after study without a concurrent control group. Outcomes were compared among patients undergoing CRS-HIPEC when APS was implemented versus historical controls (non-APS). The primary objective was to determine if there was a decrease in median total opioid consumption during postoperative days 0-3 among patients managed by the APS. Secondary outcomes included opioid consumption on each postoperative day (0-6), time to ambulation, time to solid intake, and hospital length of stay. RESULTS: After exclusion, there were a total of 122 patients, of which 51 and 71 were in the APS and non-APS cohort, respectively. Between propensity-matched groups, the median (quartiles) total opioid consumption during postoperative days 0-3 was 27.5 mg intravenous morphine equivalents (MEQs) (7.6-106.3 mg MEQs) versus 144.0 mg MEQs (68.9-238.3 mg MEQs), respectively. The median difference was 80.8 mg MEQs (95% confidence interval, 46.1-124.0; P < .0001). There were statistically significant decreases in time to ambulation and time to solid diet intake in the APS cohort. CONCLUSIONS: After implementing the APS, CRS-HIPEC patients had decreased opioid consumption by >50%, as well as shorter time to ambulation and time to solid intake. Implementation of an APS may improve outcomes in CRS-HIPEC patients.

Continuous Adductor Canal Versus Continuous Femoral Nerve Blocks: Relative Effects on Discharge Readiness Following Unicompartment Knee Arthroplasty.

BACKGROUND: We tested the hypothesis that, following unicompartment knee arthroplasty, a continuous adductor canal block decreases the time to reach 4 discharge criteria compared with a continuous femoral nerve block. METHODS: Subjects were randomized to either an adductor canal or femoral perineural catheter (2-day ropivacaine 0.2% infusion) in an unmasked fashion. The primary outcome was the time to attain 4 discharge criteria: (1) adequate analgesia; (2) intravenous opioid independence; (3) ability to independently stand, walk 3 m, return, and sit down; and (4) ambulate 30 m. RESULTS: Subjects with an adductor canal catheter (n = 15) reached all 4 criteria in a median of 35 hours (interquartile range, 24-43 hours), compared with 40 hours (interquartile range, 27-69 hours) for those with a femoral catheter (n = 15; Wilcoxon rank sum test: P = 0.46; log-rank test: P = 0.16). However, the percentages of subjects (adductor canal: femoral) who reached the 2 mobilization criteria were 27%:0% on postoperative day (POD) 0, 93%:53% on POD 1, and 100%:73% on POD 2. Of adductor canal subjects, 100% were discharge ready by POD 2, compared with only 73% of femoral subjects (P < 0.001). CONCLUSIONS: Compared with a continuous femoral nerve block, a continuous adductor canal block did not appreciably decrease the median number of hours to overall discharge readiness, yet did decrease the number of discrete days until discharge readiness. These results are applicable to only unicompartment knee arthroplasty and must be considered preliminary because of the limited sample size of this pilot study.

Discharge Readiness after Tricompartment Knee Arthroplasty: Adductor Canal versus Femoral Continuous Nerve Blocks-A Dual-center, Randomized Trial.

BACKGROUND: The authors conducted a randomized, controlled, parallel-arm, superiority study to test the hypothesis that a continuous adductor canal block decreases the time to attain four discharge criteria compared with a continuous femoral nerve block after tricompartment knee arthroplasty. METHODS: Subjects undergoing tricompartment knee arthroplasty were randomized using computer-generated lists to either an adductor canal or femoral perineural catheter (3-day ropivacaine 0.2% infusion) in an unmasked manner. The primary outcome was the time to attain four criteria: (1) adequate analgesia; (2) intravenous opioids independence; (3) ability to stand, walk 3 m, return, and sit down; and (4) ambulate 30 m. RESULTS: Subjects with an adductor canal catheter (n = 39) reached all four criteria in a median of 55 h (interquartile, 42 to 63 h) compared with 61 h (49 to 69 h) for those with a femoral catheter (n = 41; 95% CI, -13 to 1 h; P = 0.12). The percentage of subjects who reached the two mobilization criteria on postoperative days 1 and 2 were 72 and 95% for those with an adductor canal catheter (n = 39), but only 27 and 76% in subjects with a femoral catheter (n = 41; both P < 0.001). Differences in pain scores at rest and intravenous opioid requirements were minimal, but femoral infusion improved dynamic analgesia (P = 0.01 to 0.02). CONCLUSION: Compared with a continuous femoral nerve block, a continuous adductor canal block did not appreciably decrease the time to overall discharge readiness even though it did decrease the time until adequate mobilization, primarily because both groups experienced similar analgesia and intravenous opioid requirements that--in most cases--exceeded the time to mobilization.

Una metodología de evaluación: gerencia de calidad total en dos centros de salud de Managua

Se adaptó y aplicó una metodología de evaluación de la situación de gerencia de calidad total, que se usa en el sector privado de los Estados Unidos, en dos centros de salud urbanos de la ciudad de Managua, Nicaragua en diciembre de 1996. Esta metodología está basada en la filosofía del Malcom Baldrige National Quality Award Assessment y su principal propósito es la integración de categorías de evaluación que promueven la calidad como un elemento fundamental para la competitividad. El estudio fue descriptivo y utilizó métodos cualitativo-participativos. Su diseño constó de cuatro fases: Fase de Acercamiento, de validación de metodología, Fase de aplicación y Fase de Evaluación. Los resultados principales fueron: Las categorías que obtuvieron mayor puntaje son: liderazgo, gerencia de recursos humanos y satisfacción del usuario; las categorías menos desarrolladas fueron: información y análisis, planificación estratégica de calidad, gerencia de procesos de calidad y resultados operacionales de calidad. Se concluye que existe interés en los diferentes niveles de organización del sistema de salud en Nicaragua, de contar con una metodología para evaluar la gerencia de calidad de las unidades de salud; lo que permitió la realización del presente estudio.