Pedram Aleshi

Retrospective analysis of transfusion outcomes in pregnant patients at a tertiary obstetric center

BACKGROUND The decision to use red blood cell transfusion and/or blood products (fresh frozen plasma, platelets, cryoprecipitate) to manage obstetric hemorrhage or treat postpartum anemia is often made empirically by physicians. We performed a retrospective study to review transfusion outcomes in pregnant and postpartum patients at a large obstetric center. METHODS A retrospective, observational study was performed of obstetric in-patients who received red blood cell transfusion and/or blood products over a one-year period. Data abstracted included transfusion data, pre-transfusion hemoglobin (Hb) and lowest recorded (nadir) Hb, and maternal and neonatal outcomes. RESULTS During the study period, 74 patients received transfusion therapy (1.4%). Pre-transfusion and nadir Hb values were 7.6 g/dL and 7.0 g/dL respectively. Median [IQR] total red blood cells transfused were 2 units [2-3], with 41 (55%) patients receiving 1-2 units. Based on chart review, no specific indications for transfusion were identified in 25 patients (34%), and 13 patients (18%) had undetected postpartum anemia (Hb values <8.2 g/dL) at least 24h after delivery. CONCLUSION More formal assessment and documentation of the etiologic factors associated with transfusion management in pregnant patients is advised. In addition, the identification and management of undetected postpartum anemia is underappreciated.

Effect of a preemptive femoral nerve block on cytokine release and hyperalgesia in experimentally inflamed skin of human volunteers.

Background and Objectives: Tissue injury is associated with the local release of inflammatory and nociceptive mediators and the development of hyperalgesia. It is unclear whether interrupting neuronal signaling using regional anesthetic techniques at the time of the injury modifies local nociceptive and inflammatory processes. The aim of this study was to determine whether a peripheral nerve block at the time of tissue injury could modify the development of wound hyperalgesia and the local release of inflammatory and nociceptive mediators. Methods: Twelve healthy volunteers participated in this controlled, crossover, randomized study. A femoral nerve block or a sham block was established before inducing an experimental UVB burn on the thigh. Twenty-four hours later, the interstitial wound fluid was sampled, and mechanical and heat pain thresholds were assessed. Wound fluid concentrations of an array of cytokines, chemokines, nerve growth factor, prostaglandin E2, and substance P were determined. Results: Skin inflammation was associated with the release of inflammatory and nociceptive mediators and resulted in significant tissue hyperalgesia (P < 0.001). However, the presence of a fully established peripheral nerve block at the time of tissue injury did not alter the development of hyperalgesia after regression of the block. Similarly, the presence of a peripheral nerve block did not modify the release of inflammatory or nociceptive mediators. Conclusions: These findings suggest that a preemptive, single-shot peripheral nerve block minimally affects wound hyperalgesia and inflammation. Continuous nerve block techniques may be better suited to alter nociceptive and inflammatory events in wounds beyond the duration of the block.

Airway management in Nager Syndrome

Nager acrofacial dysostosis is a rare congenital syndrome characterized by malformed mandibulofacial structures and pre-axial upper limbs. Trismus and glossoptosis from mandibular abnormalities predisposes infants to life-threatening respiratory distress. A case of a Nager Syndrome mother delivering a similarly afflicted fetus is presented, with approaches to maintaining both tenuous airways described. Distinguishing this condition from similar syndromes is critical for care and prognosis.

Ultrasound-guided percutaneous injection of methylene blue to identify nerve pathology and guide surgery.

OBJECT The objective of this study was to provide a technique that could be used in the preoperative period to facilitate the surgical exploration of peripheral nerve pathology. METHODS The authors describe a technique in which 1) ultrasonography is used in the immediate preoperative period to identify target peripheral nerves, 2) an ultrasound-guided needle electrode is used to stimulate peripheral nerves to confirm their position, and then 3) a methylene blue (MB) injection is performed to mark the peripheral nerve pathology to facilitate surgical exploration. RESULTS A cohort of 13 patients with varying indications for peripheral nerve surgery is presented in which ultrasound guidance, stimulation, and MB were used to localize and create a road map for surgeries. CONCLUSIONS Preoperative ultrasound-guided MB administration is a promising technique that peripheral nerve surgeons could use to plan and execute surgery.

Preoperative Sciatic and Femoral Nerve Blocks for Anterior Cruciate Ligament Reconstruction: A Retrospective Analysis

Objective: Uncontrolled postoperative pain and nausea and vomiting are the most common causes for hospital admission following ambulatory anterior cruciate ligament (ACL) reconstruction. Therefore, finding techniques that provide excellent postoperative pain control is of critical importance. This retrospective study compared patients who received preoperative femoral nerve blockade to those who received combined femoral and sciatic nerve blockade. We hypothesized that a combined preoperative nerve block would result in lower postoperative pain, decreased postoperative opioid consumption, and shorter recovery. Methods: The medical records of 191 patients who underwent ACL reconstruction were retrospectively analyzed. We then developed multivariable regression models for each primary outcome parameter. Results: The postoperative pain scores were lower in patients receiving a combined nerve block compared with patients receiving a femoral nerve block (P<0.001) and higher in patients receiving an autograft vs. an allograft (P=0.009). Total morphine equivalents were lower in patients receiving combined nerve block versus patients receiving femoral nerve block (P<0.001) and higher in patients with a higher BMI (P<0.001). Recovery unit length of stay was prolonged by more than 25 minutes in patients with PONV (P=0.001) and in patients who needed a postoperative nerve block in the recovery unit (P ≤ 0.001). Conclusions: A preoperative combined sciatic and femoral nerve block improved postoperative pain management, while postoperative nausea and vomiting or the need for a postoperative nerve block increased the recovery unit time.

Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: a randomized controlled clinical trial

STUDY OBJECTIVE To compare preoperative femoral (FNB) with combined femoral and sciatic nerve block (CFSNB) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction. DESIGN Prospective, randomized clinical trial. SETTING Ambulatory surgery center affiliated with an academic medical center. PATIENTS Sixty-eight American Society of Anesthesiology physical status I and II patients undergoing arthroscopic ACL reconstruction. INTERVENTIONS Subjects randomized to the CFSNB group received combined femoral and sciatic nerve blocks preoperatively, whereas patients randomized to the FNB group only received femoral nerve block preoperatively. Both groups then received a standardized general anesthetic with a propofol induction followed by sevoflurane or desflurane maintenance. Intraoperative pain was treated with fentanyl. Pain in the postanesthesia care unit (PACU) was treated with ketorolac and opiates. Patients with significant pain despite ketorolac and opiates could receive a rescue nerve block. MEASUREMENTS Our primary outcome variable was highest Numeric Rating Scale (NRS) pain score in PACU. NRS pain scores, opioid consumption, opioid adverse effects, and patient satisfaction were assessed perioperatively until postoperative day 3. MAIN RESULTS The highest PACU NRS pain score was significantly higher in the FNB group compared with the CFSNB group (7 [3-10] vs 5 [0-10], P=.002). The FNB group required significantly larger doses of opioids perioperatively (31.8 vs 19.8mg intravenous morphine equivalents, P<.001). PACU length of stay was significantly longer in the FNB group (128.2 vs 103.1minutes, P=.006). There was no significant difference in opioid consumption, pain scores, or patient satisfaction on postoperative days 1-3 between groups. CONCLUSIONS Preoperative CFSNB for arthroscopic ACL reconstruction improves analgesia, decreases opioid consumption perioperatively, and decreases PACU length of stay when compared with FNB alone.

Multimodal analgesia decreases opioid consumption after shoulder arthroplasty: a prospective cohort study

BACKGROUND Studies on perioperative pain control in shoulder arthroplasty focus on regional anesthesia, with little research on other approaches. Perioperative multimodal analgesia regimens decrease opioid intake and opioid-related side effects in lower-extremity arthroplasty. In this study we compare pain scores, opioid consumption, length of stay, and readmission rates in postoperative shoulder arthroplasty patients treated with a standard or multimodal analgesia regimen. METHODS A prospective cohort analysis was performed at a single institution. Patients undergoing elective shoulder arthroplasty were treated with either a standard opioid-based regimen or a multimodal analgesia regimen perioperatively. Outcome measures included inpatient pain scores, opioid use, length of stay, and 30- and 90-day emergency department visits and readmission rates. RESULTS Seventy-five patients were included in each cohort. Patients treated with the multimodal analgesia regimen had lower postoperative day 0 pain scores (mean, 1.5 vs 2.2; P = .027). Opioid use in the multimodal cohort was lower on all days: 47% lower on postoperative day 0, 37% on day 1, and 44% on day 2 (all P < .01). The length of inpatient stay was significantly shorter for multimodal patients than for patients treated with the standard regimen (1.44 days vs 1.91 days, P < .01). There was no difference in the rate of 30- or 90-day emergency department visits or readmission. CONCLUSION Patients undergoing shoulder arthroplasty have decreased postoperative pain and opioid consumption and shorter hospital stays when given a multimodal analgesia regimen. There is no increase in short-term complications or unplanned readmissions, indicating that this is a safe and effective means to control postoperative pain.

Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles WeaknessA Randomized, Double-blind Trial

What We Already Know about This TopicHip arthroscopy is a surgical procedure growing in popularityThe optimal approach to postoperative analgesia has not been identified What This Article Tells Us That Is NewThe addition of preoperative fascia iliaca block using ropivacaine to the intraarticular injection of ropivacaine did not improve early postoperative pain scoresThe fascia iliaca blocks also did not improve most secondary endpoints, although they did cause quadriceps weakness Background: Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia. Methods: In a prospective, double-blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness. Results: The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 ± 2) versus placebo group (7 ± 2), difference: −0.2 (95% CI, −1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 ± 7mg [block] vs. 16 ± 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 ± 7 mg [block] vs. 12 ± 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group. Conclusions: Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.

Spinal and Epidural Anesthesia

Spinal and epidural anesthesia are the commonest central neuraxial anesthesia techniques used in the operating room and for labor and delivery. These techniques are employed for almost all age groups, for both intraoperative and postoperative pain, and therefore, a thorough understanding of the techniques, various types of equipment available, and the associated side effects and complications is essential for anesthesiologists.

Obstetric Hemorrhage During an EXIT Procedure for Severe Fetal Airway Obstruction

Purpose To report a case of massive obstetric hemorrhage occurring during Cesarean delivery for an ex utero intrapartum treatment (EXIT) procedure. Methods to optimize the anesthetic, obstetric, and perinatal management are discussed. Clinical features A healthy parturient underwent an urgent EXIT procedure at 32 weeks gestation for a giant fetal neck mass. During the intraoperative period, severe intraoperative hemorrhage occurred from the site of the uterine incision. No evidence of placental bleeding, premature placental separation, or inadequate uterine relaxation was observed during the perioperative period. Placement of a uterine stapling device was unsuccessful in achieving adequate surgical hemostasis. Initial attempts with laryngoscopy and rigid bronchoscopy to secure the fetal airway on placental support were unsuccessful, and early termination of placental support was deemed necessary due to the severity of maternal blood loss. After full delivery of the neonate and termination of placental support, neonatal ventilation with bag-mask ventilation was achieved and successful endotracheal intubation occurred during repeat bronchoscopy. Conclusions The risk of obstetric hemorrhage due to uterine relaxation and inadequate surgical hemostasis in patients undergoing EXIT procedures is poorly reported. To reduce adverse maternal and neonatal outcomes, the premature termination of placental support during EXIT procedures may be required in the setting of severe obstetric hemorrhage.