Thomas M. Halaszynski

Optimizing postoperative outcomes with efficient preoperative assessment and management.

ObjectiveTo review the essential features of preoperative assessment, management, and planning, with special emphasis on high-risk patients who are likely to have manifestations related to their co-existing disease and disease treatment(s) in the postoperative setting. Data SourceReview of recent studies and reviews as reprinted in Index Medicus. ConclusionsThe major shift in preoperative assessment and management from within the hospital to outside the hospital has prompted new efforts to coordinate preoperative care. Much of this can be accomplished with the introduction of a preadmission testing center. Under the direction of a physician (typically an anesthesiologist), the Pre-Admission Testing Center staff performs necessary assessments and coordinates necessary information about the presurgical patient. This assessment should include features essential to the general history and physical examination, as well as the specific issues related to anesthesia and surgery. The preoperative visit is also an opportunity to perform directed laboratory testing (as opposed to across the board batteries of tests) and to carefully plan out the continuance, discontinuance, or initiation of medications in the perioperative period. It also may be beneficial to stabilize disorders such as hypertension and, when indicated, initiate preoperative optimization of patients with advanced disease. The ultimate goal is to provide safe and “efficient” care, without exhausting highly valued intensive care resources.

Ropivacaine 0.2% and lidocaine 0.5% for Intravenous regional anesthesia in outpatient surgery

BackgroundA longer-acting local anesthetic agent, such as ropivacaine, may offer advantages over lidocaine for intravenous regional anesthesia. The objectives of this study were to evaluate whether the findings of volunteer investigations with intravenous regional anesthesia with ropivacaine (which have shown prolonged analgesia after release of the tourniquet) translates into improved pain control after surgery. MethodsWith Human Investigation Committee approval and a double-blind study design, 20 healthy patients with American Society of Anesthesiologists physical status I or II classification who were scheduled to undergo forearm and hand surgery were randomly assigned to administration of 40 ml of either 0.2% ropivacaine or 0.5% lidocaine for intravenous regional anesthesia. Evidence of central nervous system side effects, such as lightheadedness, tinnitus, and metallic taste, as well as cardiac arrhythmias, were evaluated and treated (if necessary) after local anesthetic administration, before and during surgery, and after release of the tourniquet until discharge from the postanesthesia care unit. Regression of sensory anesthesia in the nerve distributions of the forearm and hand was recorded. Verbal numerical pain scores were monitored and quantified until the patients were discharged to home from the postanesthesia care unit. Patient pain scores, side effect profiles, time to first oral intake, and total amount of oral analgesics were recorded 24 h postoperatively. ResultsIntravenous regional anesthesia with 0.2% ropivacaine and 0.5% lidocaine provided equivalent levels of surgical anesthesia. After release of the tourniquet, the first evidence for return of sensation in the distribution of the five peripheral nerves occurred later in the ropivacaine group (median, 20 min; range, 15–40 min) than in the lidocaine group (median, 1 min; range, 1–25 min). Verbal numerical pain scores were significantly lower at the time of admission, whereas during the remainder of the postanesthesia care unit stay and later at home, the difference in verbal numerical pain scores between the two groups was no longer statistically significant. ConclusionsRopivacaine 0.2% may be an alternative to 0.5% lidocaine for intravenous regional anesthesia in the outpatient surgical setting. Longer-lasting analgesia in the immediate postoperative period may be due to a more profound and prolonged tissue binding effect of ropivacaine.

Cerebrospinal fluid corticotropin-releasing hormone in healthy humans: Effects of yohimbine and naloxone

CRH neurons projecting from the paraventricular nucleus (PVN) of the hypothalamus to the median eminence control hypothalamic-pituitary-adrenal (HPA) axis activity. However, CRH neurons outside the PVN as well as PVN neurons projecting to sites other than the median eminence also contribute to the stress response and may play a role in mood and anxiety disorders. We have attempted to investigate possible noradrenergic and opioid regulation of these non-HPA CRH neurons. We hypothesized that yohimbine (an alpha2-adrenergic antagonist) would have stimulatory action on non-HPA CRH neurons, whereas naloxone (a mu-opioid receptor antagonist) would not have this effect. Adult normal volunteers received i.v. yohimbine (n = 5; 0.4 microg/kg), naloxone (n = 4; 125 microg/kg), or placebo (n = 3; 0.9% saline). Cerebrospinal fluid (CSF) was collected continuously, and concentrations of CSF CRH, CSF norepinephrine (NE), and plasma cortisol were measured. Administration of either yohimbine or naloxone caused significant increases in plasma cortisol concentrations over time. Although yohimbine robustly increased CSF NE levels and appeared to increase CSF CRH levels, these effects were not seen after naloxone or placebo administration. Intraindividual correlations were not observed between the measured concentrations of plasma cortisol and CSF CRH for any of the subjects. The results support the idea that CSF CRH concentrations reflect the activity of non-HPA CRH neurons. Although both yohimbine and naloxone stimulated the HPA axis, only yohimbine appeared to have stimulatory effects on central NE and non-HPA CRH.

Comparison of ropivacaine 0.2% and lidocaine 0.5% for intravenous regional anesthesia in volunteers.

UNLABELLED A longer acting local anesthetic such as ropivacaine may offer advantages over lidocaine for IV regional anesthesia (IVRA). The objective of this investigation was to determine whether the use of ropivacaine improves the quality and duration of IVRA. In a randomized, double cross-over design, 10 volunteers received lidocaine 0.5% or ropivacaine 0.2% for IVRA of the upper extremity on two separate days with a standard double-cuff technique. Sensation to pinprick, response to tetanic stimuli, and tourniquet pain were assessed on a 0-10 verbal numeric score scale at 5-min intervals throughout the period of tourniquet inflation. Motor function was evaluated by grip strength. After release of the second (distal) cuff, pinprick sensation, motor strength, and systemic side effects were evaluated at 3, 10, and 30 min. No significant differences were observed for onset times of anesthesia and times to proximal (38 +/- 3 and 36 +/- 3 min) or distal (34 +/- 13 and 36 +/- 13 min) tourniquet release after the administration of ropivacaine and lidocaine, respectively. However, postdeflation hypoalgesia and motor blockade were prolonged with ropivacaine, and postdeflation light-headedness, tinnitus, and drowsiness were more prominent with lidocaine. We conclude that ropivacaine may be an alternative to lidocaine for IVRA. It may result in prolonged analgesia and fewer side effects after tourniquet release. IMPLICATIONS In this study, volunteers received lidocaine 0.5% or ropivacaine 0.2% for IV regional anesthesia on two study days. Ropivacaine and lidocaine provided similar surgical conditions. However, after release of the distal tourniquet, prolonged sensory blockade and fewer central nervous system side effects were observed with ropivacaine.

Rofecoxib does not compromise platelet aggregation during anesthesia and surgery

PurposeThis study was undertaken because, although there is evidence that cyclooxygenase type 2 (COX)-2 inhibitors do not compromise platelets in healthy volunteers, many clinicians remain hesitant to administer them perioperatively without definitive evidence of intact platelet function during anesthesia and surgery.MethodsIn 20 patients scheduled for lower abdominal and pelvic surgery, 5 mL of blood were obtained for baseline platelet aggregometry. One hour prior to surgery, patients received an oral solution of either rofecoxib (ROF) 50 mg or placebo (PLAC) by randomized, double-blinded assignment. Approximately one hour after onset of anesthesia, an intraoperative blood sample was obtained. Baseline and postdrug samples were centrifuged to generate platelet-rich plasma, which was challenged with adenosine diphosphate (ADP) and arachidonic acid (AA). Aggregometry was performed with and without incubation with aspirin. The data in each subject were normalized to baseline aggregation in response to AA alone and ADP alone. Intergroup differences were assessed using paired t test; P < 0.05 was considered significant.ResultsConsistent with known effects of anesthesia on platelet function, both groups had approximately 25% intraoperative declines in aggregation in response to ADP (P = NS for PLACvs ROF) and even greater declines in response to AA (P = NS for PLACvs ROF). Aspirin eliminated aggregation in response to AA in both groups (P = NS), and it caused similar declines in PLAC and ROF groups during exposure to ADP (P = NS).ConclusionThis study provides strong evidence that ROF does not compromise platelet aggregation during anesthesia and surgery; nor does it interfere with the platelet inhibitory effect of aspirin.RésuméObjectifNous avons réalisé la présente étude parce que, même s’il y a une évidence que les inhibiteurs de la cyclo-oxygénase de type 2 (C0X)-2 n’altèrent pas les plaquettes chez des volontaires en bonne santé, de nombreux cliniciens hésitent encore à les administrer en période périopératoire sans avoir la preuve irréfutable de la conservation de la fonction plaquettaire pendant l’anesthésie et la chirurgie.MéthodeNous avons prélevé 5 mL de sang, pour une agrégométrie plaquettaire de base, chez 20 patients devant subir une opération pelvienne et abdominale basse. Une heure avant l’opération, une solution orale de 50 mg de rofécoxib (ROF) ou d’un placebo (PLAC) ont été administrés de façon aléatoire et en double insu. Une heure environ après le début de l’anesthésie, un échantillon de sang a été prélevé. Les échantillons de base et les prélèvements suivant la médication ont été centrifugés pour générer un plasma riche en plaquettes, lequel a été stimulé avec de l’adénosine diphosphate (ADP) et de l’acide arachidonique (AA). Lagrégométrie a été réalisée avec et sans incubation avec aspirine. Les données sur chaque sujet ont été normalisées à partir de l’agrégation de base en réaction à l’AA seule et l’ADP seule. Les différences intergroupes ont été évaluées par le test t pour des paires d’échantillons;P < 0,05 était considéré comme significatif.RésultatsConformément aux effets connus de l’anesthésie sur la fonction plaquettaire, il y a eu dans les deux groupes environ 25 % de diminution peropératoire de l’agrégation en réaction à l’ADP (P = NS pour le PLAC vs ROF) et une baisse encore plus grande en réaction à l’AA (P = NS pour le PLAC vs ROF). Laspirine a éliminé l’agrégation en réaction à l’AA dans les deux groupes (P = NS) et a causé une diminution similaire dans les groupes PLAC et ROF pendant l’exposition à l’ADP (P = NS).ConclusionLétude fournit une indication claire que la ROF n’altère pas l’agrégation plaquettaire pendant l’anesthésie et la chirurgie; elle ne nuit pas non plus à l’effet inhibiteur de l’aspirine.

Pain management in the elderly and cognitively impaired patient: the role of regional anesthesia and analgesia.

Purpose of review To review the rational for use of the many regional anesthetic/analgesic techniques and acute pain management modalities in the elderly and cognitively impaired high-risk patients, as increasing numbers of older adults are presenting for surgery. Recent findings There are numerous studies examining short and long-term consequences of regional anesthesia/analgesia along with identification of the many potential advantages, but those studying the influence and potential benefits in elderly and cognitively impaired patients are only beginning to be developed as issues related to cognitive dysfunction associated with surgery/anesthesia are beginning to be observed. Summary Pain management therapy, including regional anesthesia, along with multimodal analgesia may help reduce the risk of negative influences in the elderly patient along with reducing postoperative delirium and cognitive dysfunction. Improvements in analgesic efficacy with regional anesthesia may attenuate pathophysiological surgical responses, reduce the length of hospitalization, and accelerate patient rehabilitation and recovery. Analgesic techniques that provide optimal pain control and low side effect profiles with minimal opioid exposure should always be considered for elderly high-risk and cognitively impaired patients.

Levobupivacaine 0.125% and Lidocaine 0.5% for Intravenous Regional Anesthesia in Volunteers

Background Levobupivacaine, a long acting, amino-amide, local anesthetic, may offer advantages over lidocaine for intravenous regional anesthesia (IVRA). The objective of this investigation was to compare levobupivacaine to lidocaine for IVRA. Methods After institutional review board approval and informed consent, eight unpremedicated male American Society of Anesthesiologists (ASA) I–II volunteers received 40 ml of levobupivacaine 0.125% or lidocaine 0.5% for IVRA on separate days. Onset and regression of sensory anesthesia by pinprick, transcutaneous electrical stimulation (TES), and of motor function were tested before, during, and after release of the tourniquet. Central nervous system and cardiac side effects were evaluated after local anesthetic administration and tourniquet release. The tourniquet remained inflated for 30–45 min. Results Intravenous regional anesthesia with either agent provided surgical anesthesia. Sensory anesthesia to pinprick (lateral antebrachial cutaneous nerve) was faster with lidocaine at median 1.5 min. versus 12.5 min with levobupivacaine. Loss of sensation to TES occurred at median 22.5 and 27.5 min for lidocaine and levobupivacaine, respectively. Loss of motor function occurred earlier after lidocaine administration. After release of the tourniquet, return of sensation to TES, pinprick (ulnar nerve), and return of motor function occurred later with levobupivacaine at median 25, 15, and 21.25 versus 10, 4.5, and 10 min with lidocaine. Central nervous system side effects were absent in volunteers given levobupivacaine, but five of eight volunteers given lidocaine experienced mild side effects. No cardiac events were noted. Conclusions Levobupivacaine 0.125% may be an alternative to lidocaine 0.5% for IVRA. Longer lasting analgesia after release of the tourniquet may be caused by a more profound and prolonged tissue binding effect of levobupivacaine.

Perioperative Multimodal Anesthesia Using Regional Techniques in the Aging Surgical Patient

Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.

How to Improve Needle Visibility

There are many advantages to the use of ultrasound in interventional pain medicine procedures. Ultrasound technology is currently growing exponentially due to its many advantages of improved and real-time high-resolution ultrasound imaging that results in successful pain management interventions. In addition, use of ultrasound for interventional pain management procedures avoids the many risks associated with radiation exposure to both the patient and practitioner.

Regional anesthesia and co-existing chronic pain.

Purpose of review Investigate the rational for incorporation of regional anesthesia techniques into a multimodal approach toward patients with co-existing chronic pain as increasing numbers of chronic pain patients are presenting for surgery. Recent findings There is a growing body of evidence suggesting that regional anesthesia may be superior to opioids for improved pain control along with increased patient satisfaction and decreased perioperative morbidity and mortality comparing to general anesthesia in patients with significant medical disease(s) and may also carry several economic benefits. Despite the prevalence of chronic pain and data suggesting that patients with chronic pain are prone to exacerbation of their condition(s) following surgery, regional anesthesia techniques for these patients is only beginning to be developed. Summary The systemic condition of chronic pain has important practical and clinical implications for regional anesthesia implementation by anesthesiologists and pain management physicians. Comprehensive preadmission assessment together with a complete medication history and close follow-up management should always be employed in patients with pre-existing chronic pain throughout the perioperative setting. Despite successful implementation of neural blockade, and to avoid opioid withdrawal, at least half the chronic pain patients daily pre-admission opioid dose should be continued daily throughout the perioperative period. Regional anesthesia is a preferable anesthetic option for perioperative management technique of patients with co-existing chronic pain, even if it requires supplementtion with sedation or general anesthesia. The specifics of regional anesthesia performance and practical strategies for regional anesthesia application in chronic pain patients, including implanted pain management devices, are reviewed in this study.