Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Nov 2013
Comparative StudyComparison of Anatomic Landmarks and Ultrasound Guidance for Intercostal Nerve Injections in Cadavers.
Intercostal nerve (ICN) injections are routinely performed under anatomic landmark or fluoroscopic guidance for acute and chronic pain indications. Ultrasound (US) is being used increasingly to perform ICN injections, but there is lack of evidence to support categorically the benefits of US over conventional techniques. We compared guidance with US versus anatomic landmarks for accuracy and safety of ICN injections in cadavers in a 2-phase study that included evaluation of deposition of injected dye by dissection and spread of contrast on fluoroscopy. ⋯ Ultrasound confers higher accuracy and allows use of lower volumes of injectate compared with anatomic landmarks as a guidance method for ICN injections in cadavers. Ultrasound may be a viable alternative to anatomic landmarks as a guidance method for ICN injections.
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Reg Anesth Pain Med · Nov 2013
Observational StudyAn Analysis of the Safety of Epidural and Spinal Neuraxial Anesthesia in More Than 100,000 Consecutive Major Lower Extremity Joint Replacements.
A feared complication of spinal or epidural anesthesia is the development of epidural or spinal hematoma with subsequent neural element compression. Most available data are derived from the obstetric literature. Little is known about the frequency of hematoma occurrence among patients undergoing orthopedic joint arthroplasty, who are usually elderly and experience significant comorbidities. We sought to study the incidence of clinically significant lesions after spinal and epidural anesthesia and further describe their nature. ⋯ The incidence of epidural/spinal complications found in this consecutive case series is relatively low but higher than previously reported in the nonobstetric population. Further research using large data sets could quantify the significance of some of the potentially contributing factors observed in this study.
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The sensory innervation of the clavicle remains controversial. The supraclavicular, subclavian, and long thoracic/suprascapular nerves, alone or together, may be responsible for pain transmission after clavicular fracture and surgery. Peripheral nerve blocks used to anesthetize the clavicle include superficial cervical plexus blocks, interscalene blocks, and combined superficial cervical plexus-interscalene blocks. Future (randomized) trials are required to determine which constitutes the best option for emergency department (fracture) and operating room (surgical fixation) settings.
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Reg Anesth Pain Med · Nov 2013
Comparative StudyA Self-Paired Comparison of Perioperative Outcomes Before and After Implementation of a Clinical Pathway in Patients Undergoing Total Knee Arthroplasty.
Clinical pathways commonly modify multiple variables and deviate from long-established clinical practices. Therefore, it is difficult to perform prospective, randomized clinical trials comparing "standard care" to the "new clinical pathway." The goal of this investigation was to examine the impact of clinical pathways implementation on perioperative outcomes and institutional costs in patients undergoing total knee arthroplasty (TKA). ⋯ Our findings demonstrated that the use of a standardized clinical pathway reduced hospital LOS, improved clinical outcomes and patient satisfaction while reducing costs for identical surgical procedures.