Daryl I. Smith

Trial ultrasound-guided continuous left stellate ganglion blockade before surgical gangliolysis in a patient with a left ventricular assist device and intractable ventricular tachycardia: a pain control application to a complex hemodynamic condition.

Stellate ganglion blockade for cardiac dysrhythmia is a well-described technique but infrequently used to manage ventricular tachycardia (VT). In patients with left ventricular assist devices (LVADs), these dysrhythmias cause increased morbidity because of right ventricular dysfunction, and often severe discomfort. Continuous stellate ganglion blockade may yield valuable information on a diagnostic and therapeutic basis in preparation for definitive, permanent interventions. We describe the successful management of intractable VT with continuous left stellate ganglion blockade, followed by surgical gangliolysis in a patient with an LVAD.

Transversus Abdominis Plane Block and Treatment of Viscerosomatic Abdominal Pain.

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Treatment of acute flares of chronic pancreatitis pain with ultrasound guided transversus abdominis plane block: a novel application of a pain management technique in the acute care setting.

The use of transversus abdominis plane (TAP) block to provide either analgesia or anesthesia to the anterior abdominal wall is well described. The technique yields high analgesic effectiveness and is opioid sparing and potentially of long duration with reported analgesia lasting up to 36 hours. When compared to neuraxial analgesia, TAP blocks are associated with a lower incidence of hypotension and motor blockade. TAP blocks are typically described as providing somatic analgesia only without any effect on visceral pain. There may be, however, certain conditions in which TAP blocks can provide effective analgesia in pain of visceral or mixed somatic and visceral origin. We describe two cases in which TAP blockade provided complete control of pain considered to be of visceral origin.

Hemodynamic instability and Horner’s syndrome following a labour lumbar neuraxial block: A warning sign of a potentially lethal event?

The development of Horner’s syndrome during routine neuraxial anaesthesia suggests anatomic, technical or physiologic variance. Even more importantly, it warrants immediate cessation of the anaesthetic intervention.

Comparison of single-injection ultrasound-guided approach versus multilevel landmark-based approach for thoracic paravertebral blockade for breast tumor resection: a retrospective analysis at a tertiary care teaching institution

Background The role of thoracic paravertebral blockade (TPVB) in decreasing opioid requirements in breast cancer surgery is well documented, and there is mounting evidence that this may improve survival and reduce the rate of malignancy recurrence following cancer-related mastectomy. We compared the two techniques currently in use at our institution, the anatomic landmark-guided (ALG) multilevel versus an ultrasound-guided (USG) single injection, to determine an optimal technique. Methods We retrospectively reviewed records of patients who received TPVB from January 2013 to December 2014. Perioperative opioid use, post anesthesia care unit (PACU) pain scores and length of stay, block performance, and complications were compared between the two groups. Results We found no statistical difference between the two approaches in the studied outcomes. We did find that the number of times attending physicians in the ALG group took over the blocks from residents was significantly greater than that of the USG group (p=0.006) and more local anesthetic was used in the USG group (p=0.04). Conclusion This study compared the ALG approach with the USG approach for patients undergoing mastectomy for breast cancer. Based on our observations, an attending physician is more likely to take over an ALG injection, and more local anesthetic is administered during USG single injection.

Epidural Catheter Migration in a Patient with Severe Spinal Stenosis

Establishment of appropriate neuraxial catheter positioning is typically a straightforward procedural undertaking. It can, however, lead to deception of even the most experienced clinician and occur despite the most meticulous attention to detail. Written and verbal consent were obtained from the patient to prepare, discuss, and publish this case report; we describe the occurrence of what we believe was the intraoperative migration of an epidural catheter in the setting of significant tissue changes resulting from a previous spinal fusion.

Intravenous Acetaminophen Administration in Patients Undergoing Craniotomy - A Retrospective Institutional Study

Introduction: Patients undergoing craniotomy for tumor resection often experience moderate to severe postoperative pain. Intravenous acetaminophen has been proposed as an analgesic adjunct to potentially decrease opioid requirements and incidence of nausea in these patients allowing for prompt postoperative neurological evaluations. At this time, however, there is no evidence to show that acetaminophen reduces patient pain or opioid consumption after craniotomy. Methods: A retrospective analysis of 81 patients undergoing craniotomy was done to evaluate the effect of IV acetaminophen (APAP) administration on reported pain scores, opioid usage, time in the post-anesthesia care unit (PACU), and incidence of nausea within the first 24 hours. Results: No significant differences in patient reported pain scores, opioid consumption within the first 24 hours, anti-emetic use, or time in PACU were found in patients who received intravenous acetaminophen compared to those who received opioids alone. Discussion: Our investigation represents the first evidence looking for an effect of acetaminophen on post-craniotomy pain and nausea. There are randomized and blinded trials currently in progress that will add to our knowledge on this topic. Acetaminophen is a relatively safe intervention. However, until those randomized trials are completed and reported, we cannot uniformly recommend the intraoperative administration of intravenous acetaminophen to patients undergoing craniotomy.