A Practical Analgesia Approach to Fragility Hip Fracture: A Single-Center, Retrospective, Cohort Study on Femoral Nerve Block.

OBJECTIVE: To determine whether an effective opioid-sparing pain control modality is desirable for an aging population. DESIGN: Retrospective observational study SETTING:: Academic medical center PATIENTS:: 192 patients with various types of fragility hip fractures INTERVENTION:: A single-injection femoral nerve block (FNB) MAIN OUTCOME MEASUREMENTS:: Pain score, opioid consumption RESULTS:: We observed statistically significant effects of FNB on visual analogue scale pain score and the rate of opioid consumption diminution in all commonly encountered types of fragility hip fractures. The pain score reduction by FNB in subcapital femoral neck fracture, transcervical femoral neck facture, and intertrochanteric fracture are all statistically significant (P < 0.0001). There was a statistically more significant pain score reduction in intracapsular fractures than in extracapsular fractures (P = 0.006). On average, the hip fracture patients required 0.9 and 0.1 mg morphine equivalent/hour before and after FNB block placement. This decrease in opioid consumption when calculated per unit time was statistically significant in subcapital femoral neck fracture, transcervical femoral neck facture, and intertrochanteric fracture (P < 0.0001). There were no complications related to FNB placement. CONCLUSIONS: FNB is a sustainable, safe, and useful analgesic modality for commonly encountered fragility hip fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Donor Hepatectomy Surgery using Ketamine to Compliment Analgesia and Reduce Morbidity - a Retrospective Chart Review Investigation.

OBJECTIVE: Inferior and limited analgesic options/techniques during living donor hepatectomy surgery can result in pain and risks of morbidity, opioid-related adverse events (AEs), predisposition to the development of chronic pain and concerns of potential narcotic abuse. Traditional analgesia uses unimodal intravenous opioids that can cause significant side effects. Ketamine provides analgesia and may be opioid sparing, but use in living-donor hepatectomy has not been studied. METHODS: Following human investigation committee approval and informed written consent, 47 liver donor patients over a 5-year period scheduled for surgery were categorized into one of three groups: 24 patients received no ketamine (Group 1), 9 received only intraoperative ketamine (Group 2) and 14 patients received intraoperative plus postoperative ketamine (Group 3). Subjects had access to opioid patient-controlled analgesia (PCA). Chart reviews (including operating room and intensive care unit) were collected and analysed for morphine consumption, pain-intensity scores, opioid-sparing effects, AEs of analgesics and for evidence of ketamine side effects on donor hepatectomy patients. RESULTS: There were no differences in patient demographics. Living donor hepatectomy patients receiving intraoperative ketamine that was continued postoperatively consumed fewer morphine-equivalents and had lower median pain scores than subjects from the other two groups. Ileus occurred in those not receiving ketamine, pruritus was lowest in Group 3, and there was no evidence or reports of ketamine-associated AEs. CONCLUSION: Perioperative ketamine for donor hepatectomy patients could safely provide improved analgesia and be opioid sparing when compared to PCA opioids alone, and there is no evidence of ketamine-related AEs at the dose and delivery methods described here during partial liver donation surgery.

Complexities of Perioperative Pain Management in Orthopedic Trauma.

PURPOSE OF REVIEW: This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period. RECENT FINDINGS: Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.

Dexmedetomidine Added to Local Anesthetic Mixture of Lidocaine and Ropivacaine Enhances Onset and Prolongs Duration of a Popliteal Approach to Sciatic Nerve Blockade.

PURPOSE: A literature review of multiple clinical studies on mixing additives to improve pharmacologic limitation of local anesthetics during peripheral nerve blockade revealed inconsistency in success rates and various adverse effects. Animal research on dexmedetomidine as an adjuvant on the other hand has promising results, with evidence of minimum unwanted results. This randomized, double-blinded, contrastable observational study examined the efficacy of adding dexmedetomidine to a mixture of lidocaine plus ropivacaine during popliteal sciatic nerve blockade (PSNB). METHODS: Sixty patients undergoing varicose saphenous vein resection using ultrasonography-guided PSNB along with femoral and obturator nerve blocks as surgical anesthesia were enrolled. All received standardized femoral and obturator nerve blocks, and the PSNB group was randomized to receive either 0.5 mL (50 µg) of dexmedetomidine (DL group) or 0.5 mL of saline (SL group) together with 2% lidocaine (9.5 mL) plus 0.75% ropovacaine (10 mL). Sensory onset and duration of lateral sural cutaneous nerve, sural nerve, superficial peroneal nerve, deep peroneal nerve, lateral plantar nerve, and medial plantar nerve were recorded. Motor onset and duration of tibial nerve and common peroneal nerve were also examined. FINDINGS: Sensory onset of sural nerve, superficial peroneal nerve, lateral plantar nerve, and medial plantar nerve was significantly quicker in the DL group than in the SL group (P < 0.05). Sensory onset of lateral sural cutaneous nerve and deep peroneal nerve was not statistically different between the groups (P > 0.05). Motor onset of tibial nerve and common peroneal nerve was faster in the DL group than in in the SL group (P < 0.05). Duration of both sensory and motor blockade was significantly longer in the DL group than in the SL group (P < 0.05). IMPLICATIONS: Perineural dexmedetomidine added to lidocaine and ropivacaine enhanced efficacy of popliteal approach to sciatic nerve blockade with faster onset and longer duration.

Influence of Medical Insurance Under the Affordable Care Act on Access to Pain Management of the Trauma Patient.

BACKGROUND AND OBJECTIVES: The Affordable Care Act intended to "extend affordable coverage" and "ensure access" for vulnerable patient populations. This investigation examined whether the type of insurance (Medicaid, Medicare, Blue Cross, cash pay) carried by trauma patients influences access to pain management specialty care. METHODS: Investigators phoned 443 board-certified pain specialists, securing office visits with 235 pain physicians from 8 different states. Appointments for pain management were for a patient who sustained an ankle fracture requiring surgery and experiencing difficulty weaning off opioids. Offices were phoned 4 times assessing responses to the 4 different payment methodologies. RESULTS: Fifty-three percent of pain specialists contacted (235 of 443) were willing to see new patients to manage pain medication. Within the 53% of positive responses, 7.2% of physicians scheduled appointments for Medicaid patients, compared with 26.8% for cash-paying patients, 39.6% for those with Medicare, and 41.3% with Blue Cross (P < 0.0001). There were no differences in appointment access between states that had expanded Medicaid eligibility for low-income adults versus states that had not expanded Medicaid eligibility. Neither Medicaid nor Medicare reimbursement levels for new patient visits correlated with ability to schedule an appointment or influenced wait times. CONCLUSIONS: Access to pain specialists for management of pain medication in the postoperative trauma patient proved challenging. Despite the Affordable Care Act, Medicaid patients still experienced curtailed access to pain specialists and confronted the highest incidence of barriers to receiving appointments.

Risk stratification, perioperative and periprocedural management of the patient receiving anticoagulant therapy.

As a result of the aging US population and the subsequent increase in the prevalence of coronary disease and atrial fibrillation, therapeutic use of anticoagulants has increased. Perioperative and periprocedural management of anticoagulated patients has become routine for anesthesiologists, who frequently mediate communication between the prescribing physician and the surgeon and assess the risks of both thromboembolic complications and hemorrhage. Data from randomized clinical trials on perioperative management of antithrombotic therapy are lacking. Therefore, clinical judgment is typically needed regarding decisions to continue, discontinue, bridge, or resume anticoagulation and regarding the time points when these events should occur in the perioperative period. In this review, we will discuss the most commonly used anticoagulants used in outpatient settings and discuss their management in the perioperative period. Special considerations for regional anesthesia and interventional pain procedures will also be reviewed.

Administration of Coagulation-Altering Therapy in the Patient Presenting for Oral Health and Maxillofacial Surgery.

Oral health care providers are concerned with how to manage patients prescribed coagulation-altering therapy during the perioperative/periprocedural period for dental and oral surgery interventions. Management and recommendation can be based on medication pharmacology and the clinical relevance of coagulation factor levels/deficiencies. Caution should be used with concurrent use of medications that affect other components of the clotting mechanisms; prompt diagnosis and any necessary intervention to optimize outcome is warranted. However, evidence-based data on management of anticoagulation therapy during oral and maxillofacial surgery/interventions is lacking. Therefore, clinical understanding and judgment are needed along with appropriate guidelines matching patient- and intervention-specific recommendations.

Neuraxial and peripheral nerve blocks in patients taking anticoagulant or thromboprophylactic drugs: challenges and solutions.

Incidence of hemorrhagic complications from neuraxial blockade is unknown, but classically cited as 1 in 150,000 epidurals and 1 in 220,000 spinals. However, recent literature and epidemiologic data suggest that for certain patient populations the frequency is higher (1 in 3,000). Due to safety concerns of bleeding risk, guidelines and recommendations have been designed to reduce patient morbidity/mortality during regional anesthesia. Data from evidence-based reviews, clinical series and case reports, collaborative experience of experts, and pharmacology used in developing consensus statements are unable to address all patient comorbidities and are not able to guarantee specific outcomes. No laboratory model identifies patients at risk, and rarity of neuraxial hematoma defies prospective randomized study so "patient-specific" factors and "surgery-related" issues should be considered to improve patient-oriented outcomes. Details of advanced age, older females, trauma patients, spinal cord and vertebral column abnormalities, organ function compromise, presence of underlying coagulopathy, traumatic or difficult needle placement, as well as indwelling catheter(s) during anticoagulation pose risks for significant bleeding. Therefore, balancing between thromboembolism, bleeding risk, and introduction of more potent antithrombotic medications in combination with regional anesthesia has resulted in a need for more than "consensus statements" to safely manage regional interventions during anticoagulant/thromboprophylactic therapy.

Intraoral Infection and Oral Health in the Surgical Patient: Need for Concern During the Perioperative Period?

A patient's intraoral health condition is not typically a chief perioperative concern of surgical health care providers and preoperative dental evaluation/therapy is often left unattended prior to elective surgery. Consequently, patients for surgery may possess untreated dental caries, intraoral infection(s), and/or periodontal disease. Individuals who have not had a dental evaluation or examination for the previous several years may be harboring a quiescent and potent oral infection. Deleterious effects of an intraoral infection may not only compromise surgical outcome, but lead to an increased need for additional interventional therapy(s) along with associated expenses. This article will review known connection(s) between oral health, systemic disease, and treatment concerns for bacterial endocarditis. Some of the barriers that exist with improving oral health prior to surgical procedures will also be examined. Augmenting recognition of perioperative dental considerations may result in interventional measures that can minimize use of additional healthcare related resources and optimize patient care.

Perioperative pain management in hip and knee replacement surgery.

Many patients who undergo hip or knee replacement surgery today experience high levels of postoperative pain. Data from clinical studies and analyses of hospital records have demonstrated that severe postoperative pain is associated with an increased risk for complications, slowing of the rehabilitation process, delayed return to normal functioning, progression to persistent pain states, prolonged length of hospital stay, elevated rates of readmission, and higher overall costs. Orthopedic surgeons may now play a more active role in reducing the severity of pain following surgery, decreasing both opioid use and the incidence of opioid-related adverse events, and eliminating breakthrough pain and analgesic gaps. The benefits of multimodal regimens that include a combination of agents acting synergistically have been established unequivocally, and many analgesic and anesthetic agents are now available, as well as treatment options that differ according to route of administration. It is therefore possible to individualize treatment based on the type of procedure and patient need. One exciting advance that offers effective, safe, and efficient analgesia for many kinds of surgical procedures is the introduction of an extended-release local anesthetic (liposomal bupivacaine) for infiltration. This new option, which can be administered directly into the knee or hip by an orthopedic surgeon, is an example of the changing paradigm in perioperative analgesia, where commitment, communication, and coordination across all members of the clinical care team- including the surgeon, anesthesiologist, pharmacist, physical therapist, and nursing staff-are fundamental elements of an improved standard of care. An Expert Working Group on Anesthesia and Orthopaedics: Critical Issues in Hip and Knee Replacement Arthroplasty (April 13, 2013; Dallas, Texas) evaluated current approaches to perioperative pain management and proposed new regimens to help achieve optimal outcomes in these procedures.

Perioperative multimodal anesthesia using regional techniques in the aging surgical patient.

Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.

Defining new directions for more effective management of surgical pain in the United States: highlights of the inaugural Surgical Pain Congress™.

Despite advances in pharmacologic options for the management of surgical pain, there appears to have been little or no overall improvement over the last two decades in the level of pain experienced by patients. The importance of adequate and effective surgical pain management, however, is clear, because inadequate pain control 1) has a wide range of undesirable physiologic and immunologic effects; 2) is associated with poor surgical outcomes; 3) has increased probability of readmission; and 4) adversely affects the overall cost of care as well as patient satisfaction. There is a clear unmet need for a national surgical pain management consensus task force to raise awareness and develop best practice guidelines for improving surgical pain management, patient safety, patient satisfaction, rapid postsurgical recovery, and health economic outcomes. To comprehensively address this need, the multidisciplinary Surgical Pain Congress™ has been established. The inaugural meeting of this Congress (March 8 to 10, 2013, Celebration, Florida) evaluated the current surgical pain management paradigm and identified key components of best practices.

Influences of the aging process on acute perioperative pain management in elderly and cognitively impaired patients.

BACKGROUND: The aging process results in physiological deterioration and compromise along with a reduction in the reserve capacity of the human body. Because of the reduced reserves of mammalian organ systems, perioperative stressors may result in compromise of physiologic function or clinical evidence of organ insult secondary to surgery and anesthesia. The purpose of this review is to present evidence-based indications and best practice techniques for perioperative pain management in elderly surgical patients. RESULTS: In addition to pain, cognitive dysfunction in elderly surgical patients is a common occurrence that can often be attenuated with appropriate drug therapy. Modalities for pain management must be synthesized with intraoperative anesthesia and the type of surgical intervention and not simply considered a separate entity. CONCLUSIONS: Pain in elderly surgical patients continues to challenge physicians and healthcare providers. Current studies show improved surgical outcomes for geriatric patients who receive multimodal therapy for pain control.

Ultrasound brachial plexus anesthesia and analgesia for upper extremity surgery: essentials of our current understanding, 2011.

PURPOSE OF REVIEW: Ultrasound-guidance is gaining tremendous popularity. There is growing evidence of value with emphasis on clinical relevance, but can ultrasound-guidance scientifically warrant changing the practice of upper extremity regional? The literature is searched to describe findings where ultrasound may reduce complication rates, reduce block performance times, and improve block efficacy and quality. RECENT FINDINGS: Ultrasound examination identified variations in anatomical positioning of C5-C7 roots in approximately half of all patients despite no deleterious effects on block efficacy. Anesthetic volumes in brachial plexus blockade may be reduced without compromise of effectiveness. However, even with reduced volumes injected into the interscalene space, respiratory compromise from effect(s) on the phrenic nerve may result in hemi-diaphragmatic paresis. Ultrasound-guidance may reduce discomfort during axillary block placement compared with neurostimulation or parasthesia. Nerve catheters may be highly effective and provide prolonged analgesia compared with single-shot injections. Infraclavicular catheters result in improved analgesia compared with supraclavicular catheters and multiple injections of local provide no advantage over single-shot infraclavicular blockade. Dexamethasone combined with local may extend analgesia following a single-injection interscalene or supraclavicular block. During interscalene blockade, intraepineurial injections may occur, but incidence of nerve injury remains low. Therefore, debate continues about intraepineurial injections. SUMMARY: Intraepineurial injection requires additional investigation. Conclusions have suggested reducing typical volumes (40  ml) of local with ultrasound-directed upper extremity blockade. Increased use of perineural catheters is being advocated for prolonged analgesia, but risk-to-benefit consequences need to always be considered.

Regional anesthesia and co-existing chronic pain.

PURPOSE OF REVIEW: Investigate the rational for incorporation of regional anesthesia techniques into a multimodal approach toward patients with co-existing chronic pain as increasing numbers of chronic pain patients are presenting for surgery. RECENT FINDINGS: There is a growing body of evidence suggesting that regional anesthesia may be superior to opioids for improved pain control along with increased patient satisfaction and decreased perioperative morbidity and mortality comparing to general anesthesia in patients with significant medical disease(s) and may also carry several economic benefits. Despite the prevalence of chronic pain and data suggesting that patients with chronic pain are prone to exacerbation of their condition(s) following surgery, regional anesthesia techniques for these patients is only beginning to be developed. SUMMARY: The systemic condition of chronic pain has important practical and clinical implications for regional anesthesia implementation by anesthesiologists and pain management physicians. Comprehensive preadmission assessment together with a complete medication history and close follow-up management should always be employed in patients with pre-existing chronic pain throughout the perioperative setting. Despite successful implementation of neural blockade, and to avoid opioid withdrawal, at least half the chronic pain patient's daily pre-admission opioid dose should be continued daily throughout the perioperative period. Regional anesthesia is a preferable anesthetic option for perioperative management technique of patients with co-existing chronic pain, even if it requires supplementation with sedation or general anesthesia. The specifics of regional anesthesia performance and practical strategies for regional anesthesia application in chronic pain patients, including implanted pain management devices, are reviewed in this study.