Yury Khelemsky

Multimodal therapy in perioperative analgesia

This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.

A patient who received clopidogrel with an indwelling epidural catheter.

A patient with a drug-eluting stent placed 18 months earlier received a thoracic epidural for perioperative analgesic control as part of her thoracotomy. Postoperatively, the patient was started on clopidogrel for secondary prevention. After consultation with the Hematology service and a platelet function assay, the patient was transfused two pools of platelets and the epidural catheter was removed on postoperative day 4. The patient then underwent hourly neurologic checks for 24 hours and was discharged several days later without any negative sequelae. If neuraxial techniques and the need for clopidogrel prophylaxis come into direct conflict, vigilance is necessary for warning signs of epidural hematoma and platelet transfusion should be considered to reverse the effects of the drug.

Acute and Chronic Pain Management

The high prevalence of acute and chronic pain, its psychological, physiological, and financial implications, as well as emerging trends of quality of care assessment and pay-for-performance necessitate a robust and multidisciplinary approach to pain management [1–3]. Pain must be considered and addressed during the preoperative, perioperative, and postoperative periods. Collaboration between surgeons, anesthesiologists, and pain medicine specialists is critical for the optimization of outcomes.

Anesthetic considerations for a novel anterior surgical approach to pediatric scoliosis correction

Idiopathic scoliosis is a condition that may require surgical correction. Limitations of previous surgical modalities, however, created the need for novel methods of repair. One such technique, a newer form of anterolateral scoliosis correction, has shown considerable promise, which our center has had substantial experience performing.

A Multicenter Evaluation of Emergency Department Pain Care Across Different Types of Fractures

Objectives. To identify differences in emergency department (ED) pain-care based on the type of fracture sustained and to examine whether fracture type may influence the more aggressive analgesic use previously demonstrated in older patients. Design. Secondary analysis of retrospective cohort study. Setting. Five EDs (four academic, one community) in the United States. Participants. Patients (1,664) who presented in January, March, July, and October 2009 with a final diagnosis of fracture (774 long bone [LBF], 890 shorter bone [SBF]). Measurements. Primary-predictor was type of fracture (LBF vs. SBF). Pain-care process outcomes included likelihood of analgesic administration, opioid-dose, and time to first analgesic. General estimating equations were used to control for age, gender, race, baseline pain score, triage acuity, comorbidities and ED crowding. Subgroup analyses were conducted to analyze age-based differences in pain care by fracture type. Results. A larger proportion of patients with LBF (30%) were older (>65 years old) compared to SBF (13%). Compared with SBF, patients with LBF were associated with greater likelihood of analgesic-administration (OR = 2.03; 95 CI = 1.58 to 2.62; P < 0.001) and higher opioid-doses (parameter estimate = 0.268; 95 CI = 0.239 to 0.297; P < 0.001). When LBF were examined separately, older-patients had a trend to longer analgesic wait-times (99 [55–163] vs. 76 [35–149] minutes, P = 0.057), but no other differences in process outcomes were found. Conclusion. Long bone fractures were associated with more aggressive pain care than SBF. When fracture types were examined separately, older patients did not appear to receive more aggressive pain care. This difference should be accounted for in further research.

Chronic Facet Pain

Chronic lumbar facet pain originates from pathologic changes in the facet joints, located in the posterolateral aspect of the spine. It is classically described as a deep ache, made worse with twisting, lateral bending, and hyperextension. Some common causes of chronic lumbar facet pain include aging, repetitive strain, and trauma. As radiologic examination does not have significant utility in diagnosis, the diagnosis is made clinically. A Kemp’s test may aid in diagnosis. Conservative management includes short courses of non-opioid medication and an individualized physical therapy program. When conservative measures fail, medial branch blocks, followed by radiofrequency ablation, may provide prolonged symptomatic relief. If progressive neurologic symptoms are present, urgent surgical referral is indicated.

Miscellaneous Adjuvant Analgesics

Acetaminophen is the most commonly used adjuvant analgesic. Commonly combined with opioid formulations for enhanced analgesia and decreased likelihood of abuse.

Team-based model for non-operating room airway management: validation using a simulation-based study

BACKGROUND Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. METHODS Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). RESULTS Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. CONCLUSIONS Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.

Board 374 - Research Abstract Presence of Arterial Line Does not Improve Response Time to Proper Management of Simulated Pulseless Electrical Activity (Submission #821)

Introduction/Background Pulseless electrical activity (PEA), a subset of which is electromechanical dissociation (EMD), refers to the absence of a pulse in the presence of electrical activity on electrocardiography.1 PEA can refer to true EMD as well as a reduction of cardiac output to a state of effective pulselessness.2 While the prognosis of this rhythm remains dismal, current evidence for improved survival exists with prompt administration of high quality CPR in conjunction with a search for reversible causes.3 Our team has anecdotally observed a delay in administration of high quality CPR during simulation of non-EMD PEA in the presence of invasive arterial monitoring. We hypothesize that ACLS-trained anesthesia residents will delay initiating CPR during a simulation of non-EMD PEA when an invasive arterial pressure monitor is present. Methods In this prospective, randomized controlled trial, 18 senior anesthesiology residents underwent high-fidelity simulation of non-EMD PEA upon induction of general anesthesia. Control group participants were provided with noninvasive blood pressure (NIBP) monitoring, while experimental group participants were provided with invasive arterial pressure monitoring. Through review of video recording of the simulated scenarios, time from pulselessness to: 1) attempted palpation of pulse; 2) initiation of chest compressions; and 3) administration of ACLS pharmacologic intervention were recorded. Following the simulation, all participants completed a brief multiple choice examination exploring their knowledge of the pathophysiology and management of PEA. Data were analyzed using a two sample independent T-test. Results A total of 18 participants were analyzed in this study with nine subjects randomized to each group. There was no difference found between the arterial line group and the NIBP group with respect to time from pulselessness to palpation for pulse (27.3 s vs. 58.2 s, p = 0.68), initiation of chest compressions (72.6 s vs. 68.2 s, p = 0.97), or administration of epinephrine (36.9 s vs. 71.4 s, p = 0.59). Likewise, there was no difference between the two groups in time from palpation of pulse to initiation of chest compressions (44.6 s vs 18.7 s, p = 0.67), and administration of epinephrine (30.3 s vs. 54.3 s, p = 0.28). The baseline characteristics of the two groups were similar with respect to PGY level (4.3 vs 3.67, p = 0.76) and score on an ACLS aptitude test (67% and 59% p = 0.82). Both groups indicated on 4 point Likert scale that an arterial line did/would have helped (3.78 vs. 2.89, p = 0.77). Conclusion Our study did not show an improved response time in management of PEA for those participants with invasive arterial pressure monitoring. A major indication for invasive arterial monitoring is the potential for rapid onset of hemodynamic instability to allow for faster response.4 Our residents however, did not respond more promptly with the information from the arterial line. Though the result was not statistically significant, our data actually showed a shorter time from palpation of a pulse to compressions in the NIBP group. The fact that the participants in the NIBP group performed as well, if not better, suggests that they used other indicators such as pulse-oximetry and end tidal CO2 level in their management. An unexpected result of the study was the wide variation in the response of anesthesiology residents with the same level of training. (Delay to compressions from pulselessness ranged from 0 to 240 s). A similar scenario could be utilized to assess resident competency in ACLS management. High fidelity simulation offers a unique opportunity to introduce variables into rare critical events and observe the changes in management that result. References 1. Desbians NA: Simplifying the management of pulseless electrical activity in adults: a qualitative review. Crit Care Med 2008; 36(2) 391-6. 2. Paradis NA, Martin GB, Goetting MG, Rivers EP, Feingold M, Nowak RM: Aortic pressure during human cardiac arrest, identification of pseudo-electromechanical dissociation. Chest 1992; 101(1): 123-8. 3. Field JM: Pulseless electrical activity, Contemporary Cardiology: Cardiopulmonary Resuscitation.Edited by Ornato JP, Peberdy MA. Humana Press Inc. Totowa, NJ, 2007 pp. 147-54. 4. Schroeder RA, Barbeito A, Bar-Yosef, S, Mark JB: Cardiovascular Monitoring, Miller’s Anesthesia, 7th edition. Edited by Miller RD. Churchill Livingstone, Philadelphia, 2010, pp 1267-1328. Disclosures None.