Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Jul 2024
Case ReportsProlonged administration of intrathecal baclofen in a patient with generalized grade 4 tetanus.
This case report presents the management of a 62-year-old woman with generalized grade 4 tetanus, focusing on the innovative use of intrathecal baclofen (ITB) therapy. The patient initially presented with a laceration and subsequently developed severe tetanic spasms, necessitating interventions beyond standard tetanus immunoglobulin and antibiotics due to the condition's progressive and life-threatening nature. The preference for ITB over oral baclofen is highlighted, considering ITB's enhanced bioavailability in the central nervous system and its efficacy in reducing spinal cord reflexes, which is critical for managing severe spasticity.On her return to the emergency department with symptoms of tetanus, the patient received ITB following the failure of oral baclofen to control the spasms. ITB administration necessitated a lumbar drain, which was later substituted with a tunneled intrathecal catheter due to the extended requirement for baclofen infusion and the unavailability of suitable infusion pumps. This scenario represented a significant application of a CADD-Solis external pump for continuous ITB infusion.Transitioning the patient from ITB to oral baclofen was a crucial management step to facilitate discharge and recovery, underscoring the importance of a careful approach to prevent withdrawal symptoms and maintain care continuity. Despite initial complications, including an infection signaled by leucocytosis and confirmed through cerebrospinal fluid culture, the patient was effectively treated and discharged. ⋯ This report contributes to the sparse literature on prolonged ITB use for generalized grade 4 tetanus treatment, underlining the need for interdisciplinary collaboration for the best patient outcomes. It showcases the potential of ITB in spasticity management, in reducing the need for sedation, and in shortening the duration of mechanical ventilation, advocating for a tailored approach that utilizes a full spectrum of pharmacological and supportive therapies.
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Reg Anesth Pain Med · Jul 2024
Thoracic sympathetic ganglion blocks: real-world outcomes in 207 chronic pain patients.
Thoracic sympathetic ganglion block (TSGB) is a procedure to manage sympathetically maintained upper extremity pain (sympathetically maintained pain). To date, only a few studies have evaluated the clinical effectiveness of TSGB in pain medicine. This study investigated (1) the relationship between technical success of TSGB and pain reduction in patients with chronic upper extremity pain and (2) relevant clinical factors for a positive TSGB outcome. ⋯ We found no significant association between the temperature increase and pain reduction after TSGB. Further studies are warranted to identify significant factors associated with TSGB outcomes in patients with complex regional pain syndrome and neuropathic pain diseases.
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Reg Anesth Pain Med · Jul 2024
Practice GuidelineEvidence-based clinical practice guidelines on postdural puncture headache: a consensus report from a multisociety international working group.
Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis or management of this condition is, however, currently lacking. This multisociety guidance aims to fill this void and provide practitioners with comprehensive information and patient-centric recommendations to prevent, diagnose and manage patients with PDPH. ⋯ These clinical practice guidelines for PDPH provide a framework to improve identification, evaluation and delivery of evidence-based care by physicians performing neuraxial procedures to improve the quality of care and align with patients' interests. Uncertainty remains regarding best practice for the majority of management approaches for PDPH due to the paucity of evidence. Additionally, opportunities for future research are identified.
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Reg Anesth Pain Med · Jul 2024
Observational StudyIncidence of acute compartment syndrome with routine use of regional anesthesia for patients with long bone fractures: a large single-center retrospective review from a level I trauma tertiary academic institution.
Traditionally, using peripheral nerve blocks (PNBs) in patients with long bone fractures has been limited due to concerns that it may interfere with the timely diagnosis of acute compartment syndrome (ACS). However, our large academic institution and level I trauma center have been using regional anesthesia routinely for pain management of patients with long bone fractures for more than a decade, with strict adherence to a comprehensive management protocol. The aim of this retrospective review is to present our experience with this practice. ⋯ Current recommendations on using PNBs in patients at risk for ACS have been mainly based on expert opinion and dated case reports. Due to the nature of the condition, prospective data are lacking. Our large observational dataset evaluated the risk of missing or delaying ACS diagnosis when PNBs were offered for trauma patients and demonstrated a relatively low incidence of ACS despite the routine use of PNBs under strictly protocolized conditions when patients were managed by a dedicated multidisciplinary care team.