Perioperative Clinical Considerations in a Patient With Carotid Agenesis: A Case Report.

An 86-year-old female with previously diagnosed congenitally absent right internal carotid artery presented for total shoulder arthroplasty. Bedside ultrasonography confirmed the anomaly and identified several arterial collateral vessels. No aberrant vessels were seen traversing the brachial plexus. The patient received brachial plexus blockade and general anesthesia for the procedure. Carotid agenesis is associated with increased prevalence of intracranial aneurysm. Patients are often asymptomatic due to adequate blood supply from collateral vessels. Ultrasonography for brachial plexus blockade or central line access may yield initial diagnosis or confirm a preexisting anomaly that has anesthetic implications. These prospects encourage vigilance in perioperative imaging.

Effect of Arm Positioning on Entrapment of Infraclavicular Nerve Block Catheter.

Continuous brachial plexus nerve block catheters are commonly inserted for postoperative analgesia after upper extremity surgery. Modifications of the insertion technique have been described to improve the safety of placing an infraclavicular brachial plexus catheter. Rarely, these catheters may become damaged or entrapped, complicating their removal. We describe a case of infraclavicular brachial plexus catheter entrapment related to differences in arm positioning during catheter placement and removal. Written authorization to obtain, use, and disclose information and images was obtained from the patient.

Single-Dose Adductor Canal Block With Local Infiltrative Analgesia Compared With Local Infiltrate Analgesia After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND AND OBJECTIVES: A single-dose adductor canal block can provide postoperative analgesia for patients undergoing total knee arthroplasty (TKA). The purpose of this study was to assess postoperative opioid consumption after ultrasound-guided single-injection bupivacaine compared with saline adductor canal block for patients undergoing TKA. METHODS: After institutional review board approval, written informed consent was obtained from patients (>18 years old) undergoing elective TKA. Subjects were randomized into 2 groups as follows: adductor canal blockade with 10 mL of bupivacaine 0.25% with epinephrine 1:300,000 or 10 mL of normal saline. All patients received a periarticular infiltration mixture intraoperatively with scheduled and patient requested oral and IV analgesics postoperatively for breakthrough pain. Personnel blinded to group allocation recorded pain scores and opioid consumption every 6 hours. Pain burden, area under the numeric rating score for pain, was calculated for 36 hours. The primary outcome was postoperative IV/IM morphine (mg morEq) consumption at 36 hours after surgery. RESULTS: Forty (28 women/12 men) subjects were studied. Postoperative opioid consumption was reduced in the bupivacaine 48 (39 to 61) mg morEq compared with saline 60 (49 to 85) mg morEq, difference -12 (-33 to -2) mg morEq (P = 0.03). Pain burden at rest was decreased in the bupivacaine 71 (37 to 120) score · hours compared with saline 131 (92 to 161) score · hours, difference -60 (-93 to -14) score · hours (P = 0.009). CONCLUSIONS: Adductor canal blockade with bupivacaine 0.25% with epinephrine 1:300,000 effectively reduces pain and opioid requirement in the postoperative period after TKA. Adductor canal blockade is an effective pain management adjunct for patients undergoing TKA.

Use of Peripheral Nerve Blocks with Sedation for Total Knee Arthroplasty in a Patient with Contraindication for General Anesthesia.

Although peripheral nerve blocks are commonly used to provide postoperative analgesia after total knee arthroplasty (TKA) and other lower extremity procedures, these blocks are rarely used for intraoperative anesthesia. Most TKAs are performed under general anesthesia (GA) or neuraxial anesthesia (NA). The knee has a complex sensory innervation that makes surgical anesthesia difficult with peripheral nerve blocks alone. Rarely are both GA and NA relatively contraindicated and alternatives are considered. We present a patient who underwent TKA performed under peripheral nerve block and sedation alone.

Evaluation of distracting pain and clinical judgment in cervical spine clearance of trauma patients.

BACKGROUND: The concept of distracting pain (DP) is a controversial subjective confounder that often impedes the efficient and timely clearance of the cervical spine (C-spine). This study attempted to define DP more objectively and assess its true potential to mask the presence of C-spine injury. It also evaluated reliability and safety of clinical judgment in discounting the significance of pain peripheral to the neck (PP). METHODS: This prospective study included patients with a Glasgow Coma Score ≥14 at a level I trauma center presenting in a C-spine collar. Demographics, mechanism of injury, severity and location of all pain, and C-spine imaging data were obtained. Patient and examiner perception of DP were ascertained using the Verbal Numerical Rating Scale (VNRS) along with the examiner's clinical opinion as to the presence of a fracture. RESULTS: A total of 160 patients were studied: 65 % male, mean age 39 years, and 44 % presenting after a motor vehicle crash. In all, 16 % complained of neck pain (NP) and 82 % of PP. There were 134 patients without NP, 110 of whom (82 %) had PP. The mean VNRS in patients with no NP was 4.2; in patients with NP it was 4.8. When examined, 14 patients without NP exhibited posterior cervical tenderness, one of whom had a fracture (7 %). Of the patients with PP, 10 % stated it was DP. The mean VNRS described as DP by all patients was 7.5 but by clinician 6.5. VNRS described as not DP was 4.8 for both patients and clinicians. Overall, 8 of the 160 patients (5 %) had confirmed C-spine injuries. Regardless of NP or PP and its potentially distracting nature, clinicians believed no fracture was present in 95 % of all cases. Clinical impression was 98 % accurate. For patients with NP, clinical impression had a 91 % negative predictive value (NPV) and a 100 % a positive predictive value (PPV). In those without NP, the NPV was 99 % and the PPV 25 %. CONCLUSIONS: The concept of DP is subjective and unreliable as a method to mitigate missed C-spine injuries. If it is to be considered for use, DP should be defined as VNRS ≥5. Reliance on clinical impressions regardless of the presence or absence of NP or PP, distracting or otherwise, is accurate and safe.