Adam W. Amundson

A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty

Background: Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. Methods: This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. Results: One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection (P = 0.016; Hodges–Lehmann median difference [95% CI] = −1 [−2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal −2 [−3 to −1]; P < 0.001; average −0.8 [−1.3 to −0.2]; P = 0.003; and liposomal bupivacaine: maximal −3 [−4 to −2]; P < 0.001; average −1.4 [−2.0 to −0.8]; P < 0.001). Conclusions: Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

Traumatic GlideScope® video laryngoscopy resulting in perforation of the soft palate

To the Editor, A 39-yr-old man with a known difficult airway was scheduled to undergo stabilization of a right fibula fracture. Adhering to the manufacturer’s four-step technique (below), a GlideScope video laryngoscope (Verathon , Medical Inc., Bothell, WA, USA) was used to facilitate placement of the endotracheal tube (ETT) with the aid of a Rigid Stylet . The GlideScope manufacturer describes the four-step technique as follows: 1) look directly into the mouth to introduce the video laryngoscope; 2) look at the monitor to identify the epiglottis and obtain the best view; 3) look back into the mouth to guide the ETT carefully into position near the tip of the laryngoscope; 4) look back at the monitor to intubate the trachea. Slight resistance was noted as the ETT was advanced through the oropharynx until it was visualized on the GlideScope monitor. At completion of surgery, blood was noted in the oropharynx, and further examination revealed that the ETT had perforated the right anterior tonsillar pillar (Figure, panel A). The ETT was then removed revealing the defect through the pillar (Figure, panel B). The laceration was repaired with mattress sutures; the patient’s trachea was extubated without incident, and he made a full recovery. This case shows a complication of endotracheal intubation using a video laryngoscope. Cases have been reported of trauma to the oropharyngeal structures during video laryngoscope-assisted endotracheal intubations with ETTs loaded with rigid stylets. When the ETT is

Continuous Posterior Lumbar Plexus Nerve Block Versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Total Hip Arthroplasty: A Three-Arm Randomized Clinical Trial

Background: Debate surrounds the issue of whether peripheral nerve blockade or periarticular infiltration (PAI) should be employed within a contemporary, comprehensive multimodal analgesia pathway for total hip arthroplasty. We hypothesized that patients treated with a continuous posterior lumbar plexus block (PNB) would report less pain and consume less opioid medication than those treated with PAI. Methods: This investigator-initiated, independently funded, 3-arm randomized clinical trial (RCT) performed at a single high-volume institution compared postoperative analgesia interventions for elective, unilateral primary total hip arthroplasty: (1) PNB; (2) PAI with ropivacaine, ketorolac, and epinephrine (PAI-R); and (3) PAI with liposomal bupivacaine, ketorolac, and epinephrine (PAI-L) using computerized randomization. The primary outcome was maximum pain during the morning (06:00 to 12:00) of the first postoperative day (POD) on an ascending numeric rating scale (NRS) from 0 to 10. Pairwise treatment comparisons were performed using the rank-sum test, with a p value of <0.017 indicating significance (Bonferroni adjusted). A sample size of 150 provided 80% power to detect a difference of 2.0 NRS units. Results: We included 159 patients (51, 54, and 54 patients in the PNB, PAI-R, and PAI-L groups, respectively). No significant differences were found with respect to the primary end point on the morning of the first POD (median, 3.0, 4.0, and 3.0, respectively; p > 0.033 for all). Opioid consumption was low and did not differ across groups at any intervals. Median maximum pain on POD 1 was 5.0, 5.5, and 4.0, respectively, and was lower for the PAI-L group than for the PAI-R group (p = 0.006). On POD 2, maximum pain (median, 3.5, 5.0, and 3.5, respectively) was lower for the PNB group (p = 0.014) and PAI-L group (p = 0.016) compared with the PAI-R group. The PAI-L group was not significantly different from the PNB group with respect to any outcomes: postoperative opioid use including rescue intravenous opioid medication, length of stay, and hospital adverse events, and 3-month follow-up data including any complication. Conclusions: In this RCT, we found a modest improvement with respect to analgesia in patients receiving PNB compared with those receiving PAI-R, but not compared with those who had PAI-L. Secondary analyses suggested that PNB or PAI-L provides superior postoperative analgesia compared with PAI-R. For primary total hip arthroplasty, a multimodal analgesic regimen including PNB or PAI-L provides opioid-limiting analgesia. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

An unusual cause of intraoperative acute superior vena cava syndrome.

Acute intraoperative superior vena cava (SVC) syndrome is an exceedingly rare complication in the cardiac surgical population. We describe the case of a 71-year-old female undergoing multi-vessel coronary artery bypass grafting who developed acute intraoperative SVC syndrome following internal thoracic artery harvest retractor placement. Her symptoms included severe plethora, facial engorgement and scleral edema, which was associated with hypotension and severe elevation of central venous pressure. Transesophageal echocardiography was crucial in the diagnosis, management, and optimal retractor placement ensuring adequate SVC flow. Potential causes of intraoperative SVC syndrome are reviewed as well as management options.

Inadvertent Prolonged Femoral Nerve Palsy After Field Block with Liposomal Bupivacaine for Inguinal Herniorrhaphy.

Inguinal herniorrhaphy is a common outpatient procedure where analgesia can be augmented with local infiltration. We report a case of prolonged femoral nerve palsy secondary to liposomal bupivacaine use during wound infiltration after inguinal herniorrhaphy. Inadvertent transient femoral nerve palsy is a rare but known complication after ilioinguinal field block. This case both highlights the value of ultrasound imaging in evaluating the complications and demonstrates how the prolonged nature of liposomal bupivacaine can prolong adverse sequela.

Acute Benefits After Liposomal Bupivacaine Abdominal Wall Blockade for Living Liver Donation: A Retrospective Review

Objective To investigate whether the addition of liposomal bupivacaine abdominal wall blocks to a multimodal analgesic regimen improves postoperative numeric rating scale pain scores and reduces opioid consumption in patients undergoing living liver donation. Patients and Methods We conducted a single-center, retrospective review of patients who underwent living liver donation from January 1, 2011, through February 19, 2016, and received multimodal analgesia with (block group) or without (control group) abdominal wall blockade. The block solution consisted of liposomal bupivacaine (266 mg) mixed with 30 mL of 0.25% bupivacaine. Both groups received intrathecal hydromorphone. Main outcome measures were pain scores, opioid requirements, time to full diet, and bowel activity. Results Postoperative day 0 pain scores were significantly better in the block group (n=29) than in the control group (n=48) (2.4 vs 3.5; P=.002) but were not significantly different on subsequent days. Opioid requirements were significantly decreased for the block group in the postanesthesia care unit (0 vs 9 mg oral morphine equivalents; P=.002) and on postoperative day 0 (7 vs 18 mg oral morphine equivalents; P=.004). Median (interquartile range) time to full diet was 23 hours (14-30 hours) in the block group and 38 hours (24-53 hours) in the control group (P=.001); time to bowel activity was also shorter in the block group (45 hours [38-73 hours] vs 67 hours [51-77 hours]; P=.01). Conclusion Abdominal wall blockade with liposomal bupivacaine after donor hepatectomy provides an effective method of postoperative pain control and decreases time to full diet and bowel activity.

Interspace between Popliteal Artery and posterior Capsule of the Knee (IPACK) Injectate Spread: A Cadaver Study

Local anesthetic injection into the interspace between the popliteal artery and the posterior capsule of the knee (IPACK) has the potential to provide motor‐sparing analgesia to the posterior knee after total knee arthroplasty. The primary objective of this cadaveric study was to evaluate injectate spread to relevant anatomic structures with IPACK injection.

Unique Phrenic Nerve-Sparing Regional Anesthetic Technique for Pain Management after Shoulder Surgery

Background Ipsilateral phrenic nerve blockade is a common adverse event after an interscalene brachial plexus block, which can result in respiratory deterioration in patients with preexisting pulmonary conditions. Diaphragm-sparing nerve block techniques are continuing to evolve, with the intention of providing satisfactory postoperative analgesia while minimizing hemidiaphragmatic paralysis after shoulder surgery. Case Report We report the successful application of a combined ultrasound-guided infraclavicular brachial plexus block and suprascapular nerve block in a patient with a complicated pulmonary history undergoing a total shoulder replacement. Conclusion This case report briefly reviews the important innervations to the shoulder joint and examines the utility of the infraclavicular brachial plexus block for postoperative pain management.

Awake GlideScope®-assisted foreign body retrieval

A 38-yr-old woman with a history of repeated, intentional, foreign body ingestion presented after swallowing a disposable spoon. Initial attempts of esophagogastroduodenoscopy-assisted removal of the spoon from the gastric body under light sedation and topical viscous lidocaine failed. At this point, the foreign body had become lodged in the upper esophagus, causing intermittent, nearly complete laryngeal obstruction (Figure A). The procedure was aborted and following a transient period of respiratory distress, unassisted spontaneous ventilation with stable respiratory parameters resumed. The patient was transferred to the operating room where nasopharyngeal examination confirmed that the foreign body remained near the larynx in the upper esophagus. After local anesthetic airway topicalization with 20% benzocaine aerosolized spray and 4% lidocaine via syringe atomizer, a GlideScope video laryngoscope (#3 blade; Verathon Inc., Bothell, WA, USA) was cautiously inserted into the oropharynx allowing visualization of the spoon (Figure B). With the concern of not being able to pass an endotracheal tube successfully around the foreign body, and continued stable respiratory status, the decision was made to pursue awake foreign body retrieval. The anesthesiologist used the GlideScope to visualize and guide the otorhinolaryngologist’s insertion of a rigid bronchoscopic grasping forceps to retrieve the foreign body (Figure C, D). The patient tolerated the procedure without complications. Video laryngoscope-assisted foreign body retrieval – although described in only a limited number of clinical case reports – provides clinicians with a potential alternative to flexible or rigid bronchoscopic foreign body retrieval in select cases.