JournalTOCs

Best Practice & Research Clinical Anaesthesiology
Number of Followers: 15

Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1521-6896 - ISSN (Online) 1532-169X
Published by Elsevier

[3147 journals]

Anesthesia for combined liver-thoracic transplantation
- Abstract: Publication date: Available online 25 January 2020Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Miriam Zeillemaker - Hoekstra, Carlijn I. Buis, Vlado Cernak, Koen MEM. ReyntjensAbstractThe combined transplantation of a thoracic organ and the liver is performed in patients with dual-organ failure in whom survival is not expected with single-organ transplantation alone. Although uncommonly performed, the number of combined liver-lung and liver-heart transplants is increasing. Anesthetic management of this complex procedure is challenging. Major blood loss, prolonged operation time, difficult weaning of cardiopulmonary bypass and coagulation disturbances are common. Despite the complexity of surgery, outcome is comparable to single organ transplant.
Critical Care Management in Patients with Acute Liver Failure
- Abstract: Publication date: Available online 23 January 2020Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Nadja Rifaie, Fuat H. SanerAbstractAcute liver failure is defined as severe hepatic dysfunction (marked transaminases elevation, detoxification disorder (jaundice and coagulopathy with INR> 1.5)Presence of hepatic encephalopathy and exclusion of underlying chronic liver disease and a secondary cause like sepsis or cardiogenic shock.Reasons for acute liver failure includes paracetamol -and warfarin toxicity, autoimmune – and viral (mainly hepatitis B and E) hepatitis, herbal and dietary supplements. Even in term of meticulous and careful review of the patient around 20-30% of the reasons remains unknown. In order of its rarity, randomized controlled trial could hardly be done. However, due to improved ICU treatment, the mortality, even in advanced stage of ALF decreased. However, in 5-10% of the cases an emergency transplantation is required. This justifies the treatment of this patient cohort in institutions who can provide this kind of treatment.
Perioperative considerations for kidney and pancreas-kidney
transplantation
- Abstract: Publication date: Available online 22 January 2020Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Beatriz Tena, Marina VendrellSummaryKidney transplantation is the treatment of choice in patients with end-stage renal disease, as it improves survival and quality of life. Living donor kidney transplant prior to pancreas transplantation, or simultaneous pancreas and kidney transplantation are also discussed.Patients usually present comorbidities, and extensive preoperative workups are recommended, especially cardiac assessment, though type and frequency of surveillance is not established.Nefroprotective strategies include adequate fluid status and goal-directed therapy. The classical use of diuretics has not demonstrated a real nefroprotective effect at follow-up. Thromboprophylaxis regimes, especially for the pancreatic graft outcome, are of importance.Of note, transplantation in the obese population has increased in the last decades. Strict preoperative evaluation and pulmonary considerations must be kept in mind.Finally, robotic kidney transplant is a recent approach that presents anesthetic challenges, mainly related to steep Trendelemburg position and fluid restriction.
Economic considerations in abdominal transplantation
- Abstract: Publication date: Available online 22 January 2020Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Evan E. Lebovitz, Anh Vinh T. Nguyen, Tetsuro SakaiAbstractCare for end-stage organ failure through transplant is one of the landmark accomplishments of the modern medicine. At the same time, organ transplant is a resource-intensive service that has been under increasing scrutiny in this era of cost containment. A detailed understanding of the economic implications of organ quality, recipient characteristics, and allocation policy is vital for the transplant professionals. Prior studies of kidney transplant economics demonstrate significant cost savings achieved by eliminating the need for long-term dialysis. However, transplant providers are experiencing higher financial costs because of changes in recipient characteristics. Liver transplantation economics are also more challenging because of the severity of illness-based organ allocation. Furthermore, the broader use of marginal organs has been demonstrated to increase costs. Novel strategies are vital to reduce the financial burden faced by the centers that perform transplantations on elevated risk patients and utilize lower quality organs.
Splanchnic and systemic circulation cross talks: Implication for
hemodynamic management of liver transplant recipient
- Abstract: Publication date: Available online 17 December 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Ahmed Mukhtar, Ahmed Lotfy, Amr Hussein, Eman FouadAbstractThe interaction between splanchnic and systemic circulation has many hemodynamic and renal consequences during liver transplant. In patient with liver cirrhosis, splanchnic vasodilatation causes arterial steal from systemic circulation into splanchnic bed which decreases effective blood volume. Moreover, rapid volume loading in these patients has little impact on cardiac output because higher proportion of infused fluid is shifted to splanchnic area. Thus, in dissection phase the traditional approach of volume loading to maintain intraoperative hemodynamic stability seems not only ineffective but also may aggravate surgical bleeding. Two approaches of volume therapy have been mentioned to maintain hemodynamic stability during liver transplantation: splanchnic volume reduction by volume restriction with or without and splanchnic decongestion by using splanchnic vasoconstrictors. After reperfusion, increase in central blood volume was thought to have deleterious effect on the new graft function, however, the precise central venous pressure value that causes hepatic congestion after reperfusion is unknown.
Manuscript submission to Best Practice & Research: Clinical Anesthesiology
Acute Kidney Injury: A Critical Care Perspective for Orthotopic Liver
Transplantation
- Abstract: Publication date: Available online 17 December 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Andrew J. MacDonald, Constantine J. KarvellasAbstractAcute kidney injury is associated with high perioperative mortality in patients undergoing liver transplantation. In the era of Model of End-stage Liver Disease score-based allocation, more patients with impaired renal function are receiving liver transplantation. The majority of preoperative acute kidney injury is secondary to azotemia, including hepatorenal syndrome—a progressive form of renal impairment unique to liver failure. Prompt recognition and initiation of cause-directed therapies are central to improving post-transplant survival. Given this, healthcare providers must develop an expertise in liver failure-related renal complications, specifically their management and perioperative implications. Notably, acute kidney injury may complicate intraoperative course, exacerbating hemodynamic instability, metabolic acidosis, and electrolyte and coagulation abnormalities. Adjunctive intraoperative continuous renal replacement therapy has been employed; however, prospective studies remain necessary to validate potential benefits.
Liver Transplantation For Acute-On-Chronic Liver Failure
- Abstract: Publication date: Available online 16 December 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Dana Tomescu, Mihai Popescu, Gianni BiancofioreAbstractAcute-on-chronic liver failure represents a newly defined entity in patients with liver disease leading to multiple organs failures and increased mortality. To date, no universally accepted definition exists, and different academic societies developed guidelines on the early diagnosis and classification of Acute-on-chronic liver failure. Recently published trials focused on factors associated with a poor outcome and on the development of severity scores aimed to identify patients who may benefit for advanced monitoring and treatment. No specific therapies are demonstrated to improve survival and liver transplantation remains the only treatment associated with improved outcome.Our review focuses on current evidence for early diagnosis and prognostication of disease in patients with Acute-on-chronic liver failure, as well of criteria for intensive care unit admission, indication and futility markers of liver transplantation, as well as bridging therapy and optimal timing of surgery.
A Survey of postoperative pain treatments and unmet needs
- Abstract: Publication date: Available online 31 October 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Winfried Meissner, Ruth ZaslanskyAbstractMore than 300 million patients undergo surgery worldwide each year. Pain associated with these procedures is associated with short-and long term negative sequelae for patients, healthcare providers and healthcare systems. The following chapter is a review of the reality of postoperative pain management in everyday clinical routine, based on survey- and registry-derived data with a focus on care in adults.Between thirty and up to 80% of patients report moderate to severe pain in the days after surgery. Structures, processes and outcomes vary widely between hospitals and indicate gaps between evidence-based findings and practice. Pain assessment is not effectively implemented in many hospitals, and should consider cultural differences. Few data exist on the situation of pain management in low and middle income countries, indicating a lack of resources and available medication in many of these areas. Certain types of surgery as well as demographic and clinical factors are associated with increased risk of severe postoperative pain.
Ultrasound for peripheral and arterial access Lori-Ann Oliver, MD
Assistant Professor Department of Anesthesiology
- Abstract: Publication date: Available online 25 October 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Jodi-Ann Oliver, Sargis Ohanyan, William Park, Aharon Benelyahoo, Nalini VadiveluAbstractPeripheral venous access is perhaps the most commonly performed procedure in hospitals, urgent care, or surgical centers across the country. Thus, arguably the ability to obtain peripheral intravenous access in a timely manner is one of the most important skill sets to be mastered by health care professionals. While the skill and experience of a health care professional is an important factor in determining successful and timely vascular access, numerous patient factors such as obesity, diabetes, intravenous drug use and chronic kidney disease may pose significant challenges to even the most skilled healthcare professional. In patients with difficult access, there are often multiple attempts, which can be both time consuming for the provider and painful for the patients. Direct visualization of blood vessels using ultrasonography has an advantage over the standard landmark technique and can improve the success rate of peripheral intravenous or arterial line placement in this patient population. Given the success of ultrasound guidance with access placement, it is imperative that all healthcare providers become proficient with this technique. The aim of this review article is to provide concise and practical information on the basics of ultrasound and its application to obtaining peripheral venous and arterial access.
Opioid-free anesthesia
- Abstract: Publication date: Available online 26 September 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Helene BeloeilAbstractOpioid Free Anesthesia (OFA) is emerging as a new stimulating research perspective. The rationale to propose OFA is based on the aim to avoid the negative impact of intraoperative opioid on patient’s postoperative outcomes and also on the physiology of pathways involved in intraoperative nociception. It is based on the concept of multimodal anesthesia. OFA has been shown to be feasible but the literature is still scarce on the clinically meaningful benefits for patients as well as on the side effects and/or complications that might be associated with it. This review focused first on the physiology of nociception, the reasons for using or not opioids during anesthesia, and then on the literature reporting evidence-based proofs of benefits/risks associated with OFA.
Newer Nerve Blocks in Pediatric Surgery
- Abstract: Publication date: Available online 20 September 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Jeremy Green, Kelly S. Davidson, Sonja Gennuso, Morgan Brown, Allison Pinner, Jordan Renschler, Kelsey Cramer, Rachel J. Kaye, Elyse M. Cornett, Alan D. Kaye, Ira W. Padnos, Richard D. Urman, Charles J. FoxAbstractPurposeof review: The purpose of this manuscript is to provide a brief discussion of the current direction in pediatric regional anesthesia, highlighting both newer nerve blocks and techniques, as well as traditional blocks.Recent findingsThe number of nerve blocks performed in pediatric patients continues to increase. This growth is likely related in part to the recent focus on perioperative multimodal analgesia, in addition to growing data demonstrating safety and efficacy in this patient population. Multiple studies by the Pediatric Regional Anesthesia Network (PRAN) and the French-Language Society of Pediatric Anesthesiologists (ADARPEF) have demonstrated a lack of major complications and a general overall safety with pediatric nerve blocks. The growing prevalence of ultrasound guided regional anesthesia has not only improved the safety profile, but has also increased the efficacy of both peripheral nerve blocks and perineural catheters.SummaryAs the push for multimodal analgesia increases and breadth of pediatric regional anesthesia continues to expand, further large prospective studies will be needed to demonstrate continued efficacy and overall safety.
Pain measurement and critical review of analgesic trials
- Abstract: Publication date: Available online 12 August 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Adrien Lemoine, Valeria Martinez, Francis BonnetAbstractRandomized clinical trials designed to assess analgesic agents and/or techniques used for postoperative pain control, have several limitations, which are addressed in this article. Efficacy of analgesics cannot be limited to the evaluation of pain intensity or the amount of opioid rescue medication, but also means to evaluate parameters such as the delay and duration of the effect, the number of patients with satisfactory pain control, and side effects. Since combination of analgesics is the standard of care in clinical practice, its value also needs to be documented. Eventually, analgesic treatments have to be considered in the settings of postoperative supportive care and enhanced recovery programmes after surgery.
Interfascial plane blocks
- Abstract: Publication date: Available online 8 August 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Anthony Machi, Girish P. JoshiAbstractMany novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management by means that are safe, efficacious, efficient and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high quality clinical investigations of the techniques and how they affect perioperative outcomes. This article will define interfascial plane blocks, discuss the potential benefits, review the most common techniques and the evidence supporting their indication, and guide clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.
The Role of Regional Anesthesia in the Propagation of Cancer: A
Comprehensive Review
- Abstract: Publication date: Available online 31 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Sudipta Sen, Veerandra Koyyalamudi, Darwin D. Smith, Ricardo A. Weis, Michael Molloy, Allyson L. Spence, Aaron J. Kaye, Carmen C. Labrie-Brown, O. Morgan Hall, Elyse M. Cornett, Alan David KayeAbstractCancer incidence worldwide will eclipse 18 million in 2019 with nearly 10 million cancer related deaths. It is estimated that in the United States, almost 40% of all individuals alive today will be diagnosed with cancer in their lifetimes. Surgical resection of primary tumors remains a cornerstone of cancer treatment, yet the surgical process can trigger an immune suppressing sympathetic response which promotes tumor growth of any residual cancerous cells post-surgery. Regional and local anesthesia have become staples of anesthesia and analgesia during and after surgery. Recently, more and more evidence in the form of retrospective and prospective studies has come to light regarding the protective, anti-tumor properties of anesthetic and analgesic agents across a wide variety of cancers and patient demographics. It is thought that by blocking afferent pain signals, the body does not mount the sympathetic response that contributes to the perpetuation of disease after surgical treatment. This review, therefore, investigates these studies as they pertain to the treatment and outcomes of cancers treated surgically to elucidate the role of regional anesthesia in the propagation of cancer.
Postoperative acute pain challenges in the cancer patient
- Abstract: Publication date: Available online 27 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Juan P. Cata, German Corrales, Barbra Speer, Pascal Owusu-AgyemangAbstractIt is expected that the number of surgical procedures to diagnose, treat and palliate cancers will increase in the near future. While many of those interventions can be performed with minimally invasive techniques, others require surgical large incisions and in some instances, they involve multiple areas of the body (i.e., tumor resections with flap reconstructions). Pain after major oncological procedures can be severe and many times difficult to treat as patients can present to the operating room with several conditions including preoperative pain (i.e., rapidly growing tumors and painful neuropathies), opioid tolerance, and contraindications to non-opioid analgesics or regional anesthesia. Inadequately treated postoperative pain is associated with activation of the sympathetic system, postoperative complications, large perioperative opioid use and an increased risk of developing postoperative persistent pain. Furthermore, it has been theorized that poorly treated pain is associated with cancer recurrence and a reduced survival. Lastly, recent research questions the oncological safety of robotic surgery in gynecological procedures and indicates the need of open surgeries, which will be associated with an increased risk in moderate-to-severe postoperative pain. In conclusion, the management of acute postoperative pain in patients with cancer can be challenging.
Fascia Iliaca Block, History, Technique, and Efficacy in Clinical Practice
- Abstract: Publication date: Available online 26 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Mark R. Jones, Matthew B. Novitch, O. Morgan Hall, Andrew P. Bourgeois, George M. Jeha, Rachel J. Kaye, Vwaire Orhurhu, Mariam Salisu Orhurhu, Matthew Eng, Elyse M. Cornett, Alan David KayeAbstractThe facsia iliaca block (FIB) is a relatively new regional technique where local anesthetic is delivered within the fascia iliaca region. Indications for a FIB include surgical anesthesia to the lower extremity after knee, femoral shaft, hip surgery, management of cancer pain or pain secondary to inflammatory conditions of the lumbar plexus, as well as treatment of acute pain in the setting of trauma, fracture, or burns. The FIB may be performed using either a loss of resistance technique or an ultrasound (US)-guided technique; however, the use of US has become commonplace and resulted in improved femoral nerve and obturator nerve motor blocks. The main targets of the FIB are the predominant nerves contained in the fascia iliaca compartment (FIC), namely the femoral nerve and the lateral femoral cutaneous nerve. The FIB US guided technique is beneficial to patients and the possibility to perform FIB should be discussed and coordinated with surgical staff appropriately, considering its superiority to general or epidural anesthesia.
Postoperative pain management in the era of ERAS: an overview
- Abstract: Publication date: Available online 25 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Girish P. Joshi, Henrik KehletAbstractEnhanced recovery after surgery (ERAS) programmes are increasingly becoming standard of care for several surgical procedures. However, compliance with ERAS protocols including pain management protocols remains poor. The PROSPECT (PROcedure-SPEcific Postoperative Pain ManagemenT) collaboration provides evidence-based, procedure-specific pain management recommendations presented as preoperative, intraoperative, and postoperative interventions as well as surgical interventions that are easy to access, transparent, and relevant to clinicians. This approach should facilitate incorporation of the pain management recommendations in an ERAS protocol, and improve compliance with the protocols. This article presents an improved approach to developing pain management guidelines, as well as pragmatic approach to procedure-specific perioperative pain management that could be incorporated in an ERAS pathway.
Surgical Site Infiltration: A Neuroanatomical Approach
- Abstract: Publication date: Available online 25 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Girish P. Joshi, Anthony MachiAbsractLocal anaesthetic administration into a surgical wound blocks the noxious stimuli that result from surgical insult at the site of origin. Surgical site infiltration (also known as local infiltration analgesia) is easy to perform, safe, and inexpensive. In addition, it avoids motor blockade, which is particularly relevant for lower limb surgery. The best approach to surgical site infiltration includes meticulous, systematic and extensive surgical site local anaesthetic infiltration in the various tissue planes under direct visualization prior to closure of the surgical wound. Local anaesthetic solutions that could be used include bupivacaine HCl, ropivacaine, or liposomal bupivacaine diluted with preservative-free normal (0.9%) saline to a total volume depending upon the size of the incision. Bupivacaine and ropivacaine are sometimes combined with additives which have controversial benefits. Continuous wound infusion with preperitoneal wound catheters is an effective pain modality in abdominal surgery and can be used as an alternative for neuraxial analgesia. It is essential that surgical site infiltration is combined with other non-opioid analgesics such as paracetamol and non-steroidal anti-inflammatory drugs to attain the maximum analgesic efficacy.
Recent Technological Advancements in Regional Anesthesia
- Abstract: Publication date: Available online 25 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Sudipta Sen, Michelle Ge, Amit Prabhakar, Vanessa Moll, Rachel J. Kaye, Elyse M. Cornett, O.Morgan Hall, Ira.W. Padnos, Richard D. Urman, Alan David KayeAbstractJust two decades ago, regional anesthesia was performed blindly with dubious outcomes and little support from surgeons and patients. Technological advances in regional anesthesia have revolutionized techniques and greatly improved outcomes. Ultrasound technology continues to advance and has become more affordable. Improvements have come in the form of picture quality, resolution, portability, and smaller equipment size. Ultrasound technology can identify otherwise unrecognized pathology and can help to optimize patient flow by allowing for more accurate triage, effective treatments, and provide timelier interventions. In recent years, several different strategies to help improve and ease ultrasound guided needle identification and placement have been developed, including magnetically guided needle ultrasound technology. Three-dimensional (3D) and four-dimensional (4D) ultrasound use is another potential way to help improve first pass success and limit patient harm for regional anesthetics. The advent of echogenic needles and the resulting improvement in needle visualization under ultrasound has had a positive impact on physician comfort in performing regional anesthesia and on visualization time of the needle during ultrasound-guided procedures. To reduce variability and to reduce the anesthesiologist’s workload, the use of robots in regional anesthesia has been explored in recent years. Peripheral nerve stimulation (PNS) has also demonstrated efficacy in acute and chronic pain settings. Additional research and randomized controlled trials are necessary to evaluate novel technologies.
Peripheral nerve catheters: A critical review of the efficacy
- Abstract: Publication date: Available online 22 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Rasmus W. Hauritz, Kjartan E. Hannig, Angela Lucia Balocco, Gwendolyne Peeters, Admir Hadzic, Jens Børglum, Thomas F. BendtsenAbstractContinuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is done using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.
Upper Extremity Regional Anesthesia Techniques: A Comprehensive Review for
Clinical Anesthesiologists
- Abstract: Publication date: Available online 20 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Mark R. Jones, Matthew B. Novitch, Sudipta Sen, Nadia Hernandez, Johanna Blair De Haan, Rebecca A. Budish, Christopher Bailey, Joseph Ragusa, Pankaj Thakur, Vwaire Orhurhu, Ivan Urits, Elyse M. Cornett, Alan David KayeAbstractSurgeries and chronic pain states of the upper extremity are quite common and pose unique challenges for the clinical anesthesiology and pain specialists. Most innervation of the upper extremity involves the brachial plexus. The four most common brachial plexus blocks performed in clinical setting include the interscalene, supraclavicular, infraclavicular and axillary brachial plexus blocks. These blocks are most commonly performed with the use of ultrasound guided techniques whereby analgesia is achieved by anesthetizing the brachial plexus at different levels such as the roots, divisions, cords and branches. Additional regional anesthetic techniques for upper extremity surgery include wrist, intercostobrachial, and digital nerve blocks, which are most frequently performed using landmark anatomical techniques. This review provides a comprehensive summary of each of these blocks including anatomy, best practice techniques, and potential complications.
Truncal Regional Nerve Blocks in Clinical Anesthesia Practice
- Abstract: Publication date: Available online 19 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Ivan Urits, Peter S. Ostling, Matthew B. Novitch, James C. Burns, Karina Charipova, Kyle L. Gress, Rachel J. Kaye, Matthew R. Eng, Elyse M. Cornett, Alan David KayeAbstractRegional anesthetic techniques are important components of successful multimodal analgesic strategies. When used successfully, truncal nerve blocks of the chest wall, abdomen, and, paraneuraxial nerves, in combination with other analgesic modalities, may offer similar analgesic efficacy as neuraxial techniques, which are associated with a greater risk profile. Moreover, in comparison to neuraxial techniques, truncal nerve blocks are relatively simple to perform and technically straightforward to learn. The transversus abdominus plane (TAP) block is often incorporated into the multimodal analgesia regimen for surgical patients undergoing various abdominal and gynecological procedures. Rectus sheath blocks (RSB) were originally introduced to help relax the anterior abdominal wall during surgery and as an adjunct pain therapy. With the advancement of technology and the development of ultrasound guided techniques, RSB now have a more ubiquitous role and have been shown to decrease postoperative pain and opioid consumption. Different variations of the quadratus lumborum block may provide visceral and sensory analgesic coverage. Moreover, truncal blocks including ilioinguinal, iliohypogastric, Pectoralis nerve (PECS) blocks, serratus anterior, intercostal, and erector spinae plane blocks have gained routine clinical use for various surgeries. In this review, we discuss the techniques, anatomy, indications, complications, and benefits of truncal nerve blocks commonly used in clinical practice.
Liposomal Bupivacaine and Novel Local Anesthetic Formulations
- Abstract: Publication date: Available online 19 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Amit Prabhakar, Ceressa T. Ward, Matthew Watson, Jay Sanford, Babar Fiza, Vanessa Moll, Rachel J. Kaye, O. Morgan Hall, Elyse M. Cornett, Richard D. Urman, Alan David KayeAbstractNovel preparations allowing for extending duration of action of local anesthetics have many clinically relevant benefits. In this regard, the development of liposomal bupivacaine has the potential to significantly impact patient care by improving perioperative pain control. The unique liposomal bilayer that encapsulates bupivacaine allows for a sustained release of local anesthetic for up to 72 hours after a single use and can significantly decrease post-operative opioid consumption. SABER-bupivacaine is another depot formulation that is a sustained release of bupivacaine of encapsulated bupivacaine in a biodegradeable sucrose acetate isobutyrate biolayer. HTX-011 is an investigational extended release local anesthetic formulation currently undergoing Phase 3 clinical trials. HTX-011 is composed of a bioerodible polymer with bupivacaine and low dose meloxicam in which the polymer undergoes hydrolysis and allows for sustained release of bupivacaine and meloxicam over 3 days. The present investigation reviews pharmacologic considerations related to the formulation of liposomal bupivacaine, current FDA approved indications for its use, and future extended release local anesthetic formulations currently under investigation.
Complications and Liability Related to Regional and Neuraxial Anesthesia
- Abstract: Publication date: Available online 19 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Henry Liu, Morgan Brown, Lu Sun, Shukan P. Patel, Jinlei Li, Elyse M. Cornett, Richard D. Urman, Charles J. Fox, Alan David KayeAbstractRegional anesthesia is responsible for approximately one-fifth of professional liability claims. The present investigation evaluated common and rare complications related to regional and neuraxial anesthesia, including postdural puncture headache, backache, transient neurological symptoms, inadvertent intrathecal injection, epidural hematoma and abscess, meningitis, arachnoiditis, postoperative urinary retention, local anesthetic systemic toxicity, and cardiac arrest. Regional anesthetic techniques are increasingly used in perioperative care of surgical patients for acute pain management and for chronic pain states. This manuscript also provides an overview and analysis of the existing literature and makes some recommendations in terms of strategies to prevent or minimize the potential patient injury, with a focus on those more commonly associated with patient injury and liability exposure. The role of ultrasound in preventing patient injury during regional anesthesia is also discussed.
Ultrasound Practice for Chronic Pain Procedures: A Comprehensive Review
- Abstract: Publication date: Available online 18 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Alan David Kaye, Mark W. Motejunas, Lauren A. Bonneval, Ken P. Ehrhardt, Dustin R. Latimer, Andrea Trescot, Kyle E. Wilson, Ibraham N. Ibrahim, Elyse M. Cornett, Richard D. Urman, Kenneth D. CandidoAbstractChronic pain management techniques have evolved in recent years. In this regard, ultrasound technology has become a standard for most acute pain procedures and essential for postsurgical pain relief and enhanced recovery after surgery protocols. This manuscript summarizes clinical studies evaluating ultrasound use for chronic pain management and compares efficacy with standard techniques including fluoroscopy. Ultrasound possesses several unique benefits when compared to fluoroscopy, including elimination of radiation exposure while providing for similar clinical outcomes. In summary ultrasound use for chronic pain procedures is emerging as a viable, safe, and effective modality. Additional studies are needed to best appreciate ultrasound and its role in chronic pain management.
Novel Utilization of Fascia Layer Blocks in Hip and Knee Procedures
- Abstract: Publication date: Available online 17 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Jinlei Li, Shuai Tang, David Lam, Anja Hergrueter, Jeremy Dennis, Henry LiuAbstractPurposeof review: Novel motor-sparing peripheral nerve blocks in hip and knee procedures are desirable.Recent findingsThe application of ultrasound in fascial plane blocks have improved the efficacy and effectiveness of obturator nerve block, lateral femoral cutaneous nerve block, and quadratus lumborum block. The improved performance of these fascial plane blocks has led to additional clinical applications to the hip and knee procedures.SummaryRecent advancements in ultrasound has transformed the clinical performance of fascia layer blocks, evidenced in their novel indications in hip, knee and spine analgesia. The combination of various motor-sparing fascia plane blocks providing different area of innervation is particularly useful in fast track hip and knee surgeries.
Regional Anesthesia Considerations for Cardiac Surgery
- Abstract: Publication date: Available online 17 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Henry Liu, Patrick I. Emelife, Amit Prabhakar, Vanessa Moll, Julia B. Kendrick, Allan T. Parr, Farees Hyatali, Thakur Pankaj, Jinlei Li, Elyse M. Cornett, Richard D. Urman, Charles J. Fox, Alan D. KayeAbstractPain is a significant consequence of cardiac surgery and newer techniques in cardiac anesthesia have provided an impetus for the development of multimodal techniques to manage acute pain in this setting. In this regard, regional anesthesia techniques have been increasingly used in many cardiac surgical procedures, for the purposes of reducing perioperative consumption of opioid agents and enhanced recovery after surgery. The present investigation focuses on most currently used regional techniques in cardiac surgical procedures. These regional techniques include chest wall blocks (e.g., PECS I and II, SAP, ESB, PVB), sternal blocks (e.g., TTMPB, PSINB), and neuraxial blocks (e.g., TEA, high spinal anesthesia). The present investigation also summarizes indications, technique, complications, and potential clinical benefits of these evolving regional techniques. Cardiac surgery patients may benefit from application of these regional techniques with well controlled indications and careful patient selections.
Perioperative Use of Opioids: Current Controversies and Concerns
- Abstract: Publication date: Available online 17 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): John C. Alexander, Biral Patel, Girish P. JoshiAbstractIn the midst of an epidemic of opioid abuse and overdose related morbidity and mortality, the use of opioids remains the most common means of providing analgesia in the perioperative period. In this article, we review the risks and benefits of opioid use in preoperative, intraoperative, and postoperative phases of care. Furthermore, we describe the role that surgeons and anaesthesiologists can play in reducing perioperative opioid use and mitigate their adverse effects, both from an individual and population health perspective.
PECS, Serratus Plane, Erector Spinae and Paravertebral Blocks: A
Comprehensive Review
- Abstract: Publication date: Available online 17 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Erik M. Helander, Michael P. Webb, Julia Kendrick, Tim Montet, Aaron J. Kaye, Elyse M. Cornett, Alan David KayeAbstractThoracic planar blocks represent a novel and rapidly expanding facet of regional anesthesia. These recently described techniques represent the potential for excellent analgesia, enhanced technical safety profiles, and reduced physiological side effects versus traditional techniques in thoracic anesthesia. Regional techniques, particularly those described in this review, have potential implications for mitigation of surgical pathophysiological neurohumoral changes. In the present investigation, we describe the history, common indications, technique and limitations of the pectoral nerves (PECS), serratus plane, erector spinae plane, and thoracic paravertebral plane blocks. In summary, these techniques provide excellent analgesia and merit consideration in thoracic surgery.
Recent Advances in Regional Anesthesia and Ultrasound Techniques
- Abstract: Publication date: Available online 17 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Richard D. Urman, Alan David Kaye
Peripheral Nerve Blocks for Postoperative Analgesia: From Traditional
Unencapsulated Local Anesthetic to Liposomes, Cryoneurolysis and
Peripheral Nerve Stimulation
- Abstract: Publication date: Available online 3 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Rodney A. Gabriel, Brian M. IlfeldAbstractPeripheral nerve blocks (PNB) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.
Point of Care Ultrasound for the Clinical Anesthesiologist
- Abstract: Publication date: Available online 2 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Matthew Novitch, Amit Prabhakar, Harish Siddaiah, Anna J. Sudbury, Rachel J. Kaye, Kyle E. Wilson, Alexander Haroldson, Babar Fiza, C.M. Armstead-Williams, Elyse M. Cornett, Richard D. Urman, Alan D. KayeAbstractDiagnostic ultrasonography was first utilized in the 1940’s. The past 70+ years have seen an explosion in both ultrasound technology and availability of ultrasound technology to more and more clinicians. As ultrasound technology and availability have grown, the utility of ultrasound technology in the clinical setting as only been limited by clinicians’ imagination. Due to its lack of radiation, non-invasive nature, and gentle learning curve, medical ultrasonography is now a tremendously useful Point of Care technology in the clinical arena. What follows is a discussion of Point of Care Ultrasound (PoCUS) and how it can be incorporated in the daily practice of any regional anesthesiology. While most regional anesthesiologists usually focus on the interventional aspects of ultrasonography (i.e. nerve blocks), our discussion will center on the diagnostic value of ultrasonography—especially concerning assessment of cardiac physiology and pathophysiology, gastric anatomy, airway anatomy, and intracranial pathophysiology. After reading and reviewing this chapter, the learner will have the knowledge to start training themselves in a variety PoCUS exams that will allow rapid diagnosis of normal and abnormal patient conditions. Once an accurate diagnosis is established, the anesthesiologist and his/her team can then confidently optimize an anesthetic pain, prevent harm, and/or treat a patient condition. In this day and age, the ability to rapidly establish an accurate diagnosis cannot be overstated—especially in a critical situation. It is the authors’ sincerest hope that the following discussion will help regional anesthesiologist to become even better and well-rounded clinical leaders.
Regional Techniques for Head and Neck Surgical Procedures
- Abstract: Publication date: Available online 2 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Matthew Novitch, Farees S. Hyatali, George Jeha, Mark Motejunas, Lauren Bonneval, Thakur Pankaj, Elyse M. Cornett, Mark R. Jones, Rachel J. Kaye, Richard D. Urman, Alan D. KayeAbstractRegional anesthesia has evolved as an important tool for anesthesiologists and surgeons managing patients for surgery of the head and neck regions. In recent years, the prevalence of ultrasound use has increased significantly, and newer nerve blocks have been established for surgeries of the head and regions. In this review, anatomy, indications, efficacy, and potential side effects of regional anesthesia for the head and neck regions are presented. Evolving practice strongly suggests that regional nerve blocks for the head and neck region are safe and effective. Future studies and education will likely evolve practice to make these regional techniques standards for future surgeries of the head and neck region.
An Assessment of the Role of Non-Opioid Adjuvants in Regional Anesthesia
Practice
- Abstract: Publication date: Available online 2 July 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Amit Prabhakar, Todd Lambert, Rachel J. Kaye, Scott M. Gaignard, Joseph Ragusa, Shannon Wheat, Vanessa Moll, Elyse M. Cornett, Richard D. Urman, Alan David KayeAbstractAdjuvants are medications that work synergistically with local anesthetics to help enhance the duration and quality of analgesia in regional techniques. Regional anesthesia has become more prevalent as evidence continues to show efficacy, enhancement of patient care, increased patient satisfaction, and improved patient safety. Practitioners in the perioperative setting need to not only be familiar with regional techniques but also the medications used for them. Some examples of adjuvant medications for regional techniques include dexamethasone, alpha 2 agonists such as clonidine and dexmedetomidine, midazolam, buprenorphine, NMDA antagonists, including ketamine and magnesium, neostigmine, sodium bicarbonate, epinephrine, and non-steroidal anti-inflammatory drugs. The aim of the present investigation, therefore, is to provide a comprehensive review of the most commonly used non-opioid adjuvants in clinical practice today. Regional adjuvants can improve patient safety, increase patient satisfaction, and enhance clinical efficacy. Future studies and best practice techniques can facilitate standardization of regional anesthesia adjuvant dosing when providing nerve blocks in clinical practice.
Incidence of Vocal Cord Paresis Following Ultrasound Guided Interscalene
Nerve Block: an observational cohort study
- Abstract: Publication date: Available online 5 June 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Gritsenko Karina, Polshin Victor, Agrawal Priya, Nair Singh, Shaparin Naum, Gruson Konrad, Tan-Geller MelinAbstractBackgroundInterscalene brachial plexus block (IBPB) has become a standard practice for perioperative analgesia for shoulder procedures. However, due to its anatomic location, several side effects may occur. We have chosen to evaluate vocal cord paresis and dysphonia following interscalene blocks.MethodsAfter IRB approval, eight patients undergoing arthroscopic shoulder procedures were recruited into this prospective cohort study. Following informed consent, vocal cords were assessed via standardized fiberoptic evaluation. Subsequently, IBPB was performed under ultrasound-guidance. Patients were re-evaluated for vocal cord changes via a repeat fiberoptic assessment one hour following IBPB. Our primary outcome measure was incidence of vocal cord immobility.ResultsNo patients had diminished vocal cord motion, dysphonia or dysphagia.ConclusionsAlthough larger studies are required to determine the true incidence of vocal cord paresis following ultrasound guided IBPB, our results suggest that incidence of unwanted nerve blockade other than brachial plexus is much lower than previously described.
Measuring and Monitoring Cognition in the Postoperative Period
- Abstract: Publication date: Available online 18 January 2019Source: Best Practice & Research Clinical AnaesthesiologyAuthor(s): Lucy H. Piggin, Stanton P. NewmanAbstractIt is common for patients of all ages to experience some degree of cognitive disturbance following surgery. In most cases, impairment appears mild and is restricted to the acute post-operative period, resolving steadily and speedily. In a small number of cases, however, deficits may be more pronounced and/or endure for longer periods, significantly delaying recovery and increasing the risk of serious clinical complications. The ability to accurately measure postoperative cognition, and track recovery of function, is an important clinical task. This review explores practical and methodological issues that may confound this process, examining how best to obtain reliable and meaningful measures of cognition before and after surgery. It considers neuropsychological test selection, administration, analysis and interpretation and offers evidence-based practice points for clinicians and researchers.