Wael Ali Sakr Esa

Outcome in Patients Who Require Venoarterial Extracorporeal Membrane Oxygenation Support After Cardiac Surgery

OBJECTIVE The authors analyzed hospital mortality in adult cardiac surgery patients who required postoperative venoarterial extracorporeal membrane oxygenation (ECMO) support for circulatory failure and identified perioperative patient variables associated with hospital mortality in these patients. DESIGN A retrospective study. SETTING A single institution, tertiary academic center. PARTICIPANTS Adult patients requiring venoarterial ECMO support after cardiac surgery from January 1995 to December 2005 were identified from the Anesthesiology Institute Patient Registry. Twenty-two preselected patient variables were entered into a logistic regression model of hospital death. INTERVENTIONS None. RESULTS Two hundred thirty-three of 40,116 (0.58%) adult cardiac surgery patients required postoperative venoarterial ECMO, and among these, 149 (64%) died in the hospital. In an unadjusted analysis, older age, higher preoperative albumin, diabetes history, coronary artery bypass graft surgery, and longer total cardiopulmonary bypass (CPB) time were associated with increased hospital mortality, and a history of cardiogenic shock was associated with decreased mortality. In an adjusted logistic regression analysis, a history of cardiogenic shock and younger age were associated with decreased hospital mortality. The overall use of postoperative venoarterial ECMO in this patient population decreased since its peak in 1996. CONCLUSION Venoarterial ECMO support after cardiac surgery was required in a small fraction of patients and was associated with very high hospital mortality; but among those requiring ECMO, mortality in these patients was lower in younger, nondiabetic patients with cardiogenic shock who had shorter CPB times. The mortality associated patient variables identified are not easily modifiable and do not appear sufficiently robust to define which patients should be selected for this potentially life-saving therapy.

Comparison of three techniques for ultrasound-guided femoral nerve catheter insertion: A randomized, blinded trial

Background:Ultrasound guidance for continuous femoral perineural catheters may be supplemented by electrical stimulation through a needle or through a stimulating catheter. The authors tested the primary hypothesis that ultrasound guidance alone is noninferior on both postoperative pain scores and opioid requirement and superior on at least one of the two. Second, the authors compared all interventions on insertion time and incremental cost. Methods:Patients having knee arthroplasty with femoral nerve catheters were randomly assigned to catheter insertion guided by: (1) ultrasound alone (n = 147); (2) ultrasound and electrical stimulation through the needle (n = 152); or (3) ultrasound and electrical stimulation through both the needle and catheter (n = 138). Noninferiority between any two interventions was defined for pain as not more than 0.5 points worse on a 0 to 10 verbal response scale and for opioid consumption as not more than 25% greater than the mean. Results:The stimulating needle group was significantly noninferior to the stimulating catheter group (difference [95% CI] in mean verbal response scale pain score [stimulating needle vs. stimulating catheter] of −0.16 [−0.61 to 0.29], P < 0.001; percentage difference in mean IV morphine equivalent dose of −5% [−25 to 21%], P = 0.002) and to ultrasound-only group (difference in mean verbal response scale pain score of −0.28 [−0.72 to 0.16], P < 0.001; percentage difference in mean IV morphine equivalent dose of −2% [−22 to 25%], P = 0.006). In addition, the use of ultrasound alone for femoral nerve catheter insertion was faster and cheaper than the other two methods. Conclusion:Ultrasound guidance alone without adding either stimulating needle or needle/catheter combination thus seems to be the best approach to femoral perineural catheters.

Bilateral Continuous Quadratus Lumborum Block for Acute Postoperative Abdominal Pain as a Rescue After Opioid-Induced Respiratory Depression.

We present a case of acute postoperative abdominal pain after proctosigmoidectomy and colorectal anastomosis that was treated by bilateral continuous quadratus lumborum block. The block was performed in the lateral position under ultrasound guidance with a 15-mL bolus of 0.5% bupivacaine injected anterior to the quadratus lumborum muscle followed by bilateral catheter placement. Each catheter received a continuous infusion of 0.1% bupivacaine at 8 mL/h and an on-demand bolus 5 mL every 30 minutes. Sensory level was confirmed by insensitivity to cold from T7 through T12. The block was devoid of hemodynamic side effects or motor weakness. This case demonstrates that bilateral continuous quadratus lumborum catheters can provide extended postoperative pain control.

An Update of the Role of Renin Angiotensin in Cardiovascular Homeostasis

The renin angiotensin system (RAS) is thought to be the body’s main vasoconstrictor system, with physiological effects mediated via the interaction of angiotensin II with angiotensin I receptors (the “classic” RAS model). However, since the discovery of the heptapeptide angiotensin 1–7 and the development of the concept of the “alternate” RAS system, with its ability to reduce arterial blood pressure, our understanding of this physiologic system has changed dramatically. In this review, we focus on the newly discovered functions of the RAS, particularly the potential clinical significance of these developments, especially in the realm of new pharmacologic interventions for treating cardiovascular disease.

Injectate spread following anterior sub-costal and posterior approaches to the quadratus lumborum block: A comparative cadaveric study

BACKGROUND The dermatomal level of analgesia achieved with quadratus lumborum blocks varies according to the location of injection. The most commonly used approaches are either at the postero-lateral aspect or anterior to the quadratus lumborum muscle. OBJECTIVE To determine whether the site of injection of contrast dye around the quadratus lumborum muscle of cadavers affects the extent and mechanism of dye spread. DESIGN Observational human cadaver study. SETTING Cleveland Clinic cadaveric laboratory. PARTICIPANTS Six fresh human cadavers. INTERVENTIONS The cadavers received either a posterior quadratus lumborum block or an anterior subcostal quadratus lumborum block on each side. MAIN OUTCOME MEASURES Cadavers were dissected to determine the extent of dye spread. RESULTS The posterior quadratus lumborum block approach revealed consistently deep staining of the iliohypogastric, ilioinguinal, subcostal nerve, T11 to 12 and L1 nerve roots. In addition, staining of the middle thoracolumbar fascia was seen in all specimens but only variable staining of T10 nerve roots. The anterior subcostal quadratus lumborum block approach in all specimens demonstrated predictable deep staining of the iliohypogastric and ilioinguinal nerves, subcostal nerves, T11 to 12 and L1 nerve roots, and in addition traversing the arcuate ligaments to involve T9 to 12 nerve roots with variable staining of higher thoracic nerve roots. CONCLUSIONS Our cadaveric study demonstrates that injection of dye on the posterior aspect of quadratus lumborum muscle led to injectate spread through the lateral and posterior abdominal wall but with limited cranial spread, whereas the anterior approach produced broader coverage of the lower to mid-thoracic region. Clinical translation of these findings to determine the practical significance is warranted.

Clonidine Does Not Reduce Pain or Opioid Consumption After Noncardiac Surgery.

BACKGROUND: Clonidine is an &agr;2-adrenoceptor agonist, which has analgesic properties. However, the analgesic efficacy of perioperative clonidine remains unclear. We, therefore, tested the hypothesis that clonidine reduces both pain scores and cumulative opioid consumption during the initial 72 hours after noncardiac surgery. METHODS: Six hundred twenty-four patients undergoing elective noncardiac surgery under general and spinal anesthesia were included in this substudy of the PeriOperative ISchemia Evaluation-2 trial. Patients were randomly assigned to 0.2 mg oral clonidine or placebo 2 to 4 hours before surgery, followed by 0.2 mg/d transdermal clonidine patch or placebo patch, which was maintained until 72 hours after surgery. Postoperative pain scores and opioid consumption were assessed for 72 hours after surgery. RESULTS: Clonidine had no effect on opioid consumption compared with placebo, with an estimated ratio of means of 0.98 (95% confidence interval, 0.70–1.38); P = 0.92. Median (Q1, Q3) opioid consumption was 63 (30, 154) mg morphine equivalents in the clonidine group, which was similar to 60 (30, 128) mg morphine equivalents in the placebo group. Furthermore, there was no significant effect on pain scores, with an estimated difference in means of 0.12 (95% confidence interval, −0.02 to 0.26); 11-point scale; P = 0.10. Mean pain scores per patient were 3.6 ± 1.8 for clonidine patients and 3.6 ± 1.8 for placebo patients. CONCLUSIONS: Clonidine does not reduce opioid consumption or pain scores in patients recovering from noncardiac surgery.

Anterior Quadratus Lumborum Block Versus Transversus Abdominis Plane Block with Liposomal Bupivacaine: A Case Report

A more posterior approach for abdominal wall blocks was described by Dr. Blanco as Quadratus Lumborum (QL) block. We performed the first reported transmuscular QL block using liposomal bupivacaine. We are describing the technique we used as well as other approaches used for QL block. This case report showed that QL block using a single dose of Liposomal Bupivacaine provided a sensory level and analgesia for 2 days. Our limited experience shows that this new type of block can prolong the analgesia along mid and lower thoracic dermatomes.

Novel needle guide reduces time to perform ultrasound-guided femoral nerve catheter placement: A randomised controlled trial

BACKGROUND Ultrasound-guided nerve blocks have become the standard when performing regional nerve blocks in anaesthesia. Infiniti Plus (CIVCO Medical Solutions, Kalona, Iowa, USA) is a needle guide that has been recently developed to help clinicians in performing ultrasound-guided nerve blocks. OBJECTIVES We tested the hypothesis that femoral nerve catheter placement carried out with the Infiniti Plus needle guide will be quicker to perform than without the Infiniti Plus. Secondary aims were to assess whether the Infiniti Plus needle guide decreased the number of block attempts and also whether it improved needle visibility. DESIGN A randomised, controlled trial. SETTING Cleveland Clinic, Cleveland, Ohio, USA. PATIENTS We enrolled adult patients having elective total knee arthroplasty with a femoral nerve block and femoral nerve catheter. Patients, who were pregnant or those who had preexisting neuropathy involving the surgical limb, coagulopathy, infection at the block site or allergy to local anaesthetics were excluded. INTERVENTIONS Patients were randomised into two groups to receive the ultrasound-guided femoral nerve catheter placement with or without the Infiniti Plus needle guide. MAIN OUTCOME MEASURES The time taken to place the femoral nerve catheter, the number of attempts, the success rate and needle visibility were recorded. We used an overall &agr; of 0.05 for both the primary and secondary analyses; the secondary analyses were Bonferroni corrected to control for multiple comparisons. RESULT The median (interquartile range Q1 to Q3) time to perform the femoral nerve catheter placement was 118 (100 to 150) s with Infiniti Plus and 177 (130 to 236) s without Infiniti Plus. Infiniti Plus significantly reduced the time spent performing femoral nerve catheterisation, with estimated ratio of means [(95% confidence interval), P value] of 0.67 [(0.60 to 0.75), P < 0.001] with Infiniti Plus compared with no Infiniti Plus. However, Infiniti Plus had no effect on the odds of a successful femoral nerve catheter placement, number of attempts or percentage of perfect needle visibility. CONCLUSION We found that the use of Infiniti Plus decreased the median time to successfully place a femoral nerve catheter by 33% compared with not using Infiniti Plus. This difference may be more apparent to clinicians undertaking this procedure less often or by those in training as our team was very experienced, had been trained in the technique and was working in a hospital with a large caseload. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02080481.

Amputation as an Unusual Treatment for Therapy-Resistant Complex Regional Pain Syndrome, Type 1

BACKGROUND Complex regional pain syndrome, type 1 (CRPS-1) causes severe pain that can be resistant to multiple treatment modalities. Amputation as a form of long-term treatment for therapy-resistant CRPS-1 is controversial. CASE REPORT We report the case of a 38-year-old man who failed all treatment modalities for CRPS-1, including medication, steroid injections, and spinal cord stimulator implantation. Below-the-knee amputation to relieve intractable foot and ankle pain resulted in a favorable outcome for this patient. CONCLUSION Select patients with severe CRPS-1 who are unresponsive to all forms of treatment for pain may benefit from amputation as a last option for relief of suffering. Larger studies are needed to prove the efficacy of amputation.

Images in Anesthesiology: Severe Posterior Thigh Abscess as a Complication of Popliteal Sciatic Nerve Catheter

955 April 2013 A nondiabetic, 55-yr-old female with a body mass index of 31 underwent a left trimalleolar and distal tibial fracture repair under general anesthesia. a popliteal sciatic nerve catheter was sterilely placed preoperatively after hand wash using ultrasound and nerve stimulation. The procedure and surgery were uneventful. on postoperative day 4, fever and pain at the catheter site prompted removal, and a detailed fever workup was performed. no superficial signs of infection were noted on daily pain rounds until this time. despite removal, fever and pain persisted, and a magnetic resonance image of the thigh was obtained. The image shows extensive multiloculated fluid collections within the posterior compartment of the left thigh, involving the entire hamstring musculature, extending from the proximal femoral shaft to the distal femur and surrounding diffuse soft tissue and musculature edema. culture results showed Staphylococcus aureus. This resulted in a radical debridement of the entire hamstring apparatus with several wound vacuum dressing changes and long-term antibiotics. infection rate of popliteal sciatic nerve catheters is estimated at 0.25%. Peripheral nerve catheter-related infection may be related to contamination of the infusate, duration of the catheter placement more than 48 h, male sex, absence of antibiotics perioperatively, postoperative intensive care unit monitoring, and anesthesiologists’ inexperience. Poor pain control may be an early sign of a brewing infection because of pH changes in the catheter milieu which may reduce local anesthetic efficacy leading to removal of the catheter. The benefit of keeping a catheter for prolonged periods should clearly outweigh the risk of serious infection.