HOCUS POCUS: ultrasound beyond regional anesthesia in the ambulatory setting.

PURPOSE OF REVIEW: Application of ultrasound in clinical anesthesia practice extends beyond regional anesthesia. In this review, we have discussed other point of care applications of ultrasound in perioperative care and anesthetic management with special emphasis on ambulatory practice. RECENT FINDINGS: Point of care ultrasound (POCUS) for anesthesiologists has gained widespread interest and popularity. Recent literature has highlighted multiple perioperative POCUS applications on various organ systems and its benefits. We have analyzed the recent available data and evidence for perioperative POCUS, its benefits and limitations in perioperative medicine. SUMMARY: Perioperative POCUS skill is a natural extension of ultrasound guided regional anesthesia. Utilizing POCUS in the perioperative period would accelerate the level of appropriate care, safety and improve outcomes in ambulatory centers. More anesthesiologists embracing POCUS would enhance patient care in a timely fashion at the ambulatory centers. POCUS in ambulatory practice can be valuable in avoiding delay or cancellation of surgeries and improving patient satisfaction.

Comparison of Pericapsular Nerve Group (PENG) Block Versus Quadratus Lumborum (QL) Block for Analgesia After Primary Total Hip Arthroplasty Under Spinal Anesthesia: A Retrospective Study.

BACKGROUND: Total hip arthroplasty (THA) is one of the most common operative procedures performed. Controlling postoperative pain following THA remains a challenge due to the complex innervation of the hip joint and the recent desire to preserve motor function following nerve blockade. Several nerve block techniques have been used for THA in the past, but the quadratus lumborum (QL) block and the blockade of the pericapsular nerve group (PENG) have emerged as opiate-sparing regional anesthesia techniques that preserve motor function. To date, little data comparing the two block techniques exists. The purpose of our study was to compare outcomes following these techniques in patients undergoing primary THA. MATERIALS AND METHODS: This retrospective analysis utilized data from three distinct groups who underwent primary THA at our institution: 45 patients who received PENG block, 38 patients who received QL block, and 77 control patients. Chart review analysis was performed by authorized personnel to obtain cumulative oral morphine equivalent (OME) data at 24 and 48 hours postoperatively (primary outcomes). In addition, visual analog pain scale (VAS) scores in the post-anesthesia care unit (PACU) and at 12, 24, and 48 hours, ambulation distance, and length of hospital stay data were obtained (secondary outcomes). Group comparisons were conducted using either analysis of variance (ANOVA) with Tukey's multiple comparison test for parametric data or Krustal-Wallis with Dunn's multiple comparison tests for nonparametric endpoints. RESULTS: This study found a statistically significant difference in cumulative OME usage across all groups at 24 and 48 hours. Significant difference in OMEs was found between QL and control and PENG and control; however, no difference was found in OMEs between PENG and QL groups at either time point. There was a statistically significant difference in VAS scores in the PACU across all groups; QL showed significantly lower VAS scores in the PACU compared to PENG and control, while PENG only showed significantly lower VAS scores compared to control. There was a statistically significant difference in VAS scores at 24 hours across all groups; however, only QL showed significantly lower VAS scores compared to control at 24 hours. QL was associated with a statistically significant increase in the length of hospital stay compared to PENG. CONCLUSION: This study showed no difference between OME usage in patients who received PENG or QL nerve blocks for primary THA. VAS scores were similar between groups with the exception of QL outperforming PENG in the PACU. Optimizing postoperative pain via multi-approach strategies should remain a priority for patients undergoing THA. Future research is warranted in order to provide guidance on best practice for these patients.

Spinal Anesthesia Using Ropivacaine Leads to Earlier Ambulation After Total Hip Arthroplasty.

Spinal anesthesia has grown in popularity for total hip arthroplasty (THA) due to its documented low complications. However, the use of a local anesthetic agent dictates the recovery of neuraxial blockade. Bupivacaine has emerged as the most popular choice, but its relatively long-acting effect limits its use with rapid recovery. Although not well studied, ropivacaine may offer a viable alternative with shorter-acting properties. Primary unilateral THA patients who received either ropivacaine or bupivacaine spinal anesthesia were retrospectively reviewed. These groups were compared for common demographics, such as age, sex, and body mass index. The primary outcomes included postoperative ambulation time and distance, post-anesthesia care unit transition time, and selective complications. Five hundred three patients were included. Of these, 227 received ropivacaine and 276 received bupivacaine. The ropivacaine group showed superior ambulation time and distance, quicker post-anesthesia care unit transition, and equivalent complications compared with the bupivacaine group. Ropivacaine shows a clear advantage over bupivacaine for spinal anesthesia during THA when considering rapid recovery. Its use should be strongly considered, especially in the ambulatory setting. [Orthopedics. 2021;44(3):e343-e346.].

Comparison of Dexamethasone 4mg vs 8mg Doses in Total Joint Arthroplasty Patients: A Retrospective Analysis.

Introduction Dexamethasone is commonly administered intraoperatively to control postoperative nausea and vomiting (PONV) and pain. There is limited evidence of the ideal dosage of dexamethasone during surgery. Dexamethasone administration may increase blood glucose levels, posing unique challenges in maintaining acceptable blood glucose levels in patients with diabetes. Objective Compare two doses of dexamethasone (4mg and 8mg) for outcomes in patients undergoing hip and knee arthroplasty. Methods Medical records of 3,194 patients having undergone total hip arthroplasty (THA) and total knee arthroplasty (TKA) between January 1, 2016 and December 31, 2017 who were administered dexamethasone were reviewed. The eligible population included male and female patients aged 18-89, who underwent elective hip and knee replacement surgery and were administered dexamethasone intraoperatively. Demographics, clinical variables, and preoperative diabetic status were recorded. Primary outcomes included: blood glucose levels, incidence of PONV, post-anesthesia care unit (PACU) time, and length of stay (LOS). Postoperative complications such as periprosthetic joint injection and urinary tract infections (UTI) were also examined within 90 days of surgery. The 30-day readmissions rate was also collected for analysis. Results There was no PONV in the entire patient population. There were no significant differences between 4mg and 8mg dexamethasone in patients with or without diabetes, for preop to postop blood glucose difference, surgical timing, and post-operative complications. Conclusion Dexamethasone in both 4mg and 8mg dose was effective in PONV prophylaxis. The effects of 4mg and 8mg dexamethasone were the same in individuals with and without diabetes and the increases in blood glucose were not significantly different. Dexamethasone should not be withheld, as its benefits seem to outweigh the risks even in patients with diabetes.

Safety and efficacy of continuous femoral nerve catheter with single shot sciatic nerve block vs epidural catheter anesthesia for same-day bilateral total knee arthroplasty.

In a retrospective analysis, we evaluated the safety and efficacy of peripheral nerve blocks (PNB) compared to epidural anesthesia in 221 consecutive patients undergoing same-day bilateral total knee arthroplasty (TKA). Primary outcome measures included: hypotension requiring physician intervention, number of blood transfusions, perioperative hespan and crystalloid consumption, incidences of respiratory desaturation, pruritis, urinary retention, and nausea/vomiting. The incidences of hypotension, urinary retention, and pruritis were all higher in the epidural group, compared to PNB. Epidural patients also required more blood transfusions and greater volumes of hespan and crystalloid. PNB are safe and efficacious modality of analgesia for same day bilateral TKA and provide adequate pain relief with a significant decrease in postoperative complications compared to epidural anesthesia.

Local infiltration analgesia followed by continuous infusion of local anesthetic solution for total hip arthroplasty: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: We studied the efficacy of local infiltration analgesia in surgical wounds with 0.2% ropivacaine (50 mL), ketorolac (15 mg), and adrenaline (0.5 mg) compared with that of local infiltration analgesia combined with continuous infusion of 0.2% ropivacaine as a method of pain control after total hip arthroplasty. We hypothesized that as a component of multimodal analgesia, local infiltration analgesia followed by continuous infusion of ropivacaine would result in reduced postoperative opioid consumption and lower pain scores compared with infiltration alone, and that both of these techniques would be superior to placebo. METHODS: In this prospective, double-blind, placebo-controlled study, 105 patients were randomized into three groups: Group I, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of 0.2% ropivacaine at 5 mL/hr; Group II, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of saline solution at 5 mL/hr; and Group III, in which patients received infiltration with saline solution followed by continuous infusion of saline solution at 5 mL/hr.All patients received celecoxib, pregabalin, and acetaminophen perioperatively and patient-controlled analgesia; surgery was performed under general anesthesia. Before wound closure, the tissues and periarticular space were infiltrated with ropivacaine, ketorolac, and adrenaline or saline solution and a fenestrated catheter was placed. The catheter was attached to a pump prefilled with either 0.2% ropivacaine or saline solution set to infuse at 5 mL/hr.The primary outcome measure was postoperative opioid consumption and the secondary outcome measures were pain scores, adverse side effects, and patient satisfaction. RESULTS: There were no differences between groups in the administration of opioids in the operating room, in the recovery room, or on the surgical floor. The pain scores on recovery room admission and discharge and the floor were low and similar between groups. There were no differences in the incidence of adverse side effects among groups. Patient satisfaction with pain management was similar in all groups. CONCLUSIONS: Local infiltration analgesia alone or followed by continuous infusion of ropivacaine as part of multimodal analgesia provides no additional analgesic benefit or reduction in opioid consumption compared with placebo following total hip arthroplasty. LEVEL OF EVIDENCE: Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study.

BACKGROUND: Sciatic nerve block when combined with femoral nerve block for total knee arthroplasty may provide superior analgesia but can produce footdrop, which may mask surgically induced peroneal nerve injury. In this prospective, randomized, observer-blinded study, we evaluated whether performing a selective tibial nerve block in the popliteal fossa would avoid complete peroneal motor block. METHODS: Eighty patients scheduled for primary total knee arthroplasty were randomized to receive either a tibial nerve block in the popliteal fossa or a sciatic nerve block proximal to its bifurcation in combination with femoral nerve block as part of a multimodal analgesia regimen. Local anesthetic solution of sufficient volume to encircle the target nerve was administered for the block, up to a maximum of 20 mL. General anesthesia was administered for surgery. After emergence from anesthesia, in the recovery room, the presence or absence of peroneal sensory and motor block was noted. Pain scores and opioid consumption were recorded for 24 hours after surgery. RESULTS: The tibial nerve block and sciatic nerve block were performed 1.7 cm (99% CI, 1.3 to 2.1) and 9.4 cm (99% CI, 8.3 to 10.5) proximal to the popliteal crease, respectively (99% CI for difference between means: 6.4 to 9.0; P < 0.001). A lower volume of ropivacaine 0.5% was used for the tibial nerve block, 8.7 mL (99% CI, 7.9 to 9.4) versus 15.2 mL (99% CI, 14.9 to 15.5), respectively (99% CI for difference between means, 5.6 to 7.3; P < 0.001). No patient receiving a tibial nerve block developed complete peroneal motor block compared to 82.5% of patients with sciatic nerve block (P < 0.001). There were no significant differences in the pain scores and opioid consumption between the groups. CONCLUSIONS: Tibial nerve block performed in the popliteal fossa in close proximity to the popliteal crease avoided complete peroneal motor block and provided similar postoperative analgesia compared to sciatic nerve block when combined with femoral nerve block for patients undergoing total knee arthroplasty.