Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Jul 2017
Case ReportsRegional to the Rescue! Axillary Brachial Plexus Nerve Block Facilitates Removal of Entrapped Transradial Catheter Placed for Cardiac Catheterization.
Our objective was to describe the first reported use of an axillary brachial plexus block to treat the entrapment of a transradial artery catheter due to vasospasm. ⋯ Axillary brachial plexus nerve blocks are an effective, efficient, and safe intervention with a wide range of indications. This case report demonstrates that an axillary nerve block can be used to treat the entrapment of a transradial artery catheter due to vasospasm.
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Reg Anesth Pain Med · Jul 2017
Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines.
Currently, the American Society of Regional Anesthesia and Pain Medicine (ASRA) anticoagulation guidelines recommend that before the performance of a neuraxial procedure a minimum of 24 hours should elapse following a treatment dose of enoxaparin (1 mg/kg twice daily or 1.5 mg/kg once daily). The guidelines have since their inception also consistently recommended against the routine use of anti-Xa level monitoring for patients receiving enoxaparin. However, we noted in our clinical practice that anti-Xa levels were frequently still elevated despite patients meeting the time-based recommendation for treatment dose enoxaparin. ⋯ While 10 patients had an anti-Xa level within the peak prophylactic range (0.2-0.5 IU/mL), 1 patient's level was found to still be in the peak therapeutic range (0.5-1.0 IU/mL). These findings suggest that significant anticoagulant activity may persist longer than previously appreciated after the last treatment dose of enoxaparin and that the current time-based ASRA recommendation may not be conservative enough. Further research is needed to delineate the level of anti-Xa activity below which it is likely safe to proceed with a neuraxial procedure, but it may be time to reconsider the utility of anti-Xa level monitoring when it is available.
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Reg Anesth Pain Med · Jul 2017
Inhibition of Voltage-Gated Na+ Channels by Bupivacaine Is Enhanced by the Adjuvants Buprenorphine, Ketamine, and Clonidine.
Regional anesthesia includes application of local anesthetics (LAs) into the vicinity of peripheral nerves. Prolongation or improvement of nerve blocks with LAs can be accomplished by coapplication with adjuvants, including buprenorphine, ketamine, and clonidine. While the mechanisms mediating prolonged or improved LA-induced effects by adjuvants are poorly understood, we hypothesized that they are likely to increase LA-induced block of voltage-gated Na channels. In this study, we investigated the inhibitory effects of the LA bupivacaine alone and in combination with the adjuvants on neuronal Na channels. ⋯ We demonstrate that buprenorphine, ketamine, and clonidine directly inhibit Na channels and that they potentiate the blocking efficacy of bupivacaine on Na channels. These data indicate that block of Na channels may account for the additive effects of adjuvants used for regional anesthesia.
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Reg Anesth Pain Med · Jul 2017
Incidence of Local Anesthetic Systemic Toxicity in Orthopedic Patients Receiving Peripheral Nerve Blocks.
Peripheral nerve blocks are increasingly used. However, despite low complication rates, concerns regarding local anesthetic systemic toxicity remain. Although recent studies suggest that this severe complication has decreased considerably, there is a paucity of data about it on a national level. We sought to elucidate the incidence of local anesthetic systemic toxicity on a national level and therefore provide guidance toward the need for preparedness in daily anesthetic practice. ⋯ The incidence of local anesthetic systemic toxicity is low but should be considered clinically significant. Since it may cause substantial harm to the patient, appropriate resources and awareness to identify and treat local anesthetic systemic toxicity should be available wherever regional anesthesia is performed.
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Reg Anesth Pain Med · Jul 2017
Use of 3-Dimensional Printing to Create Patient-Specific Thoracic Spine Models as Task Trainers.
Thoracic epidural anesthesia is a technically challenging procedure with a high failure rate of 24% to 32% nationwide. Residents in anesthesiology have limited opportunities to practice this technique adequately, and there are no training tools available for this purpose. Our objective was to build a low-cost patient-specific thoracic epidural training model. ⋯ It is possible to develop homemade, low-cost, patient-specific, and high-fidelity ultrasound guidance simulators for resident training in thoracic epidurals using 3-dimensional printing technology.