Gloria S. Cheng

Continuous Interscalene Brachial Plexus Block via an Ultrasound-Guided Posterior Approach: A Randomized, Triple-Masked, Placebo-Controlled Study

BACKGROUND: The posterior approach for placing continuous interscalene catheters has not been studied in a controlled investigation. In this randomized, triple-masked, placebo-controlled study, we tested the hypothesis that an ultrasound-guided continuous posterior interscalene block provides superior postoperative analgesia compared to a single-injection ropivacaine interscalene block after moderately painful shoulder surgery. METHODS: Preoperatively, subjects received a stimulating interscalene catheter using an ultrasound-guided, in-plane posterior approach. All subjects received an initial bolus of ropivacaine. Postoperatively, subjects were discharged with oral analgesics and a portable infusion device containing either ropivacaine 0.2% or normal saline programmed to deliver a perineural infusion over 2 days. The primary outcome was average pain on postoperative day (POD) 1 (scale: 0–10). Secondary outcomes included least and worst pain scores, oral opioid requirements, sleep disturbances, patient satisfaction, and incidence of complications. RESULTS: Of the 32 subjects enrolled, 30 perineural catheters were placed per protocol. Continuous ropivacaine perineural infusion (n = 15) produced a statistically and clinically significant reduction in average pain (median [10th–90th percentile]) on POD 1 compared with saline infusion (n = 15) after initial ropivacaine bolus (0.0 [0.0–5.0] versus 3.0 [0.0–6.0], respectively; P < 0.001). Median oral opioid consumption (oxycodone) was lower in the ropivacaine group than in the placebo group on POD 1 (P = 0.002) and POD 2 (P = 0.002). Subjects who received a ropivacaine infusion suffered fewer sleep disturbances than those in the placebo group (P = 0.005 on POD 0 and 1 nights) and rated their satisfaction with analgesia higher than subjects who received normal saline (P < 0.001). CONCLUSIONS: Compared to a single-injection interscalene block, a 2-day continuous posterior interscalene block provides greater pain relief, minimizes supplemental opioid requirements, greatly improves sleep quality, and increases patient satisfaction after moderate-to-severe painful outpatient shoulder surgery.

Electrical stimulation versus ultrasound guidance for popliteal-sciatic perineural catheter insertion: a randomized controlled trial.

Background: Sciatic perineural catheters via a popliteal fossa approach and subsequent local anesthetic infusion provide potent analgesia and other benefits after foot and ankle surgery. Electrical stimulation (ES) and, more recently, ultrasound (US)-guided placement techniques have been described. However, because these techniques have not been compared in a randomized fashion, the optimal method remains undetermined. Therefore, we tested the hypotheses that popliteal-sciatic perineural catheters placed via US guidance require less time for placement and produce equivalent results, as compared with catheters placed using ES. Methods: Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot and/or ankle surgery were randomly assigned to either the ES with a stimulating catheter or US-guided technique with a nonstimulating catheter. The primary end point was catheter insertion duration (in minutes) starting when the US transducer (US group) or catheter-placement needle (ES group) first touched the patient and ending when the catheter-placement needle was removed after catheter insertion. Results: All US-guided catheters were placed per protocol (n = 20), whereas only 80% of stimulation-guided catheters could be placed per protocol (n = 20, P = 0.106). All catheters placed per protocol in both groups resulted in a successful surgical block. Perineural catheters placed by US took a median (10th-90th percentile) of 5.0 min (3.9-11.1 min) compared with 10.0 min (2.0-15.0 min) for stimulation (P = 0.034). Subjects in the US group experienced less pain during catheter placement, scoring discomfort a median of 0 (0.0-2.1) compared with 2.0 (0.0-5.0) for the stimulation group (P = 0.005) on a numeric rating scale of 0 to 10. Conclusions: Placement of popliteal-sciatic perineural catheters takes less time and produces less procedure-related discomfort when using US guidance compared with ES.

Feasibility of ultrasound-guided peripheral nerve block catheters for pain control on pediatric medical missions in developing countries

Continuous peripheral nerve blocks (CPNB) are effective for postoperative pain management in children in the hospital and at home. CPNB techniques are particularly advantageous when compared with systemic or oral opioids on medical missions to unfamiliar environments with minimal monitoring capacity. In addition, ultrasound‐guidance facilitates the placement of perineural catheters in anesthetized children even in the absence of commercially packaged regional anesthesia equipment. We present a series of successful cases employing ultrasound‐guided CPNB for postoperative analgesia on medical missions and discuss the impact of this technology on present and future patients in underserved countries.

Regional anesthesia at home.

Purpose of review To review the recently published peer-reviewed literature involving regional anesthesia and analgesia in patients at home. Recent findings The potential benefits and risks of regional anesthesia and analgesia at home are pertinent queries, and increased data regarding these topics are rapidly becoming available. Of particular interest is the use of continuous peripheral nerve blocks at home and their potential effect upon hospitalization duration and recovery profile. Summary Advantages of regional techniques include site-specific anesthesia and decreased postoperative opioid use. For shoulder surgeries, the interscalene block provides effective analgesia with minimal complications, whereas the impact and risks of intraarticular injections remain unclear. Perineural catheters are an analgesic option that offer improved pain relief among other benefits. They are now being used at home in both adult and pediatric populations.

Ambulatory Anesthesia and Regional Catheters: When and How

Several clinical trials have demonstrated the superiority of continuous peripheral nerve block compared with traditional opioid-based analgesia. The ability to provide safe and effective continuous peripheral nerve block at home is an attractive alternative to opioid-based analgesia with its related side effects. In this article, the practical issues related to catheter use in the ambulatory setting are discussed. Techniques for catheter placement, infusion regimens, patient education, and complications are subject to many institutional preferences. In this review, special emphasis is placed on evidence-based techniques.

An Evidence-Based Review of the Efficacy of Perioperative Analgesic Techniques for Breast Cancer-Related Surgery.

Objective To review the published evidence regarding perioperative analgesic techniques for breast cancer-related surgery. Design Topical review. Methods Randomized, controlled trials (RCTs) were selected for inclusion in the review. Also included were large prospective series providing estimates of potential risks and technical reports and small case series demonstrating a new technique or approaches of interest to clinicians. Results A total of 514 abstracts were reviewed, with 284 studies meeting criteria for full review. The evidence regarding preemptive ketamine, scheduled opioids, perioperative non-steroidal anti-inflammatory drugs (NSAIDs), and intravenous lidocaine is mixed and deserves further investigation. There is strong evidence that both pregabalin and gabapentin provide analgesic benefits following breast surgery. There is minimal and conflicting data from high-quality randomized, controlled studies suggesting that directly infiltrating and/or infusing local anesthetic (liposome encapsulated or unencapsulated) into the surgical wound is a reliably effective analgesic. In contrast, there is a plethora of data demonstrating the potent analgesia, opioid sparing, and decreased opioid-related side effects from thoracic epidural infusion and both single-injection and continuous paravertebral nerve blocks (the latter two demonstrating decreased persistent post-surgical pain between 2.5 and 12 months). Techniques with limited-yet promising-data deserving additional investigation include brachial plexus blocks, cervical epidural infusion, interfascial plane blocks, and interpleural blocks. Conclusions While there are currently multiple promising analgesic techniques for surgical procedures of the breast that deserve further study, the only modalities demonstrated to provide potent, consistent perioperative pain control are thoracic epidural infusion and paravertebral nerve blocks.

Successful surgical closure of an arterial duct in 18 children in a third world country

OBJECTIVES To perform surgical closure of a clinically significant arterial duct on children in a third world country. BACKGROUND An arterial duct is one of the most common congenital cardiac defects. Large arterial ducts can cause significant pulmonary overcirculation, causing symptoms of congestive cardiac failure, ultimately resulting in premature death. Closure of an arterial duct is usually curative, allowing for a normal quality of life and expectancy. In western countries, arterial duct closure in children is usually performed by deployment of a device through a catheter-based approach, replacing previous surgical approaches. In third world countries, there is limited access to the necessary resources for performing catheter-based closure of an arterial duct. Consequently, children with an arterial duct in a third world country may only receive palliative care, can be markedly symptomatic, and often do not survive to adulthood. METHODS We assembled a team of 11 healthcare workers with extensive experience in the medical and surgical management of children with congenital cardiac disease. In all, 21 patients with a history of an arterial duct were screened by performing a comprehensive history, physical, and echocardiogram at the Angkor Hospital for Children in Siem Reap, Cambodia. RESULTS A total of 18 children (eight male and ten female), ranging in age from 10 months to 14 years, were deemed suitable to undergo surgery. All patients were symptomatic, and the arterial ducts ranged in size from 4 to 15 millimetres. Surgical closure was performed using two clips, and in four cases with the largest arterial duct, sutures were also placed. All patients had successful closure without any significant complications, and were able to be discharged home within 2 days of surgery. Of note, four children with arterial ducts died in the 5 months before our arrival. CONCLUSION Surgical closure of an arterial duct can be performed safely and effectively by an experienced paediatric cardiothoracic surgical team on children in a third world country. We hope that our experience will inspire others to perform similar missions throughout the world.