Regional anesthesia and pain medicine
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Reg Anesth Pain Med · Apr 2024
Combined erector spinae plane block with surgical intercostal nerve cryoablation for Nuss procedure is associated with decreased opioid use and length of stay.
Pain management for patients undergoing the Nuss procedure for treatment of pectus excavatum can be challenging. In an effort to improve pain management, our institution added bilateral single injection erector spinae plane (ESP) blocks to surgeon placed intercostal nerve cryoablation. We aimed to assess the efficacy of this practice change. ⋯ In a single-center academic practice, the addition of bilateral single injection ESP blocks at T6 to surgeon performed cryoablation reduced opioid consumption without a change in subjectively reported pain scores. The results from this pilot study can provide effect size estimates to guide the design of future randomized trials.
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Primary failure of thoracic epidural analgesia (TEA) remains an important clinical problem, whose incidence can exceed 20% in teaching centers. Since loss-of-resistance (LOR) constitutes the most popular method to identify the thoracic epidural space, the etiology of primary TEA failure can often be attributed to LOR's low specificity. Interspinous ligamentous cysts, non-fused ligamenta flava, paravertebral muscles, intermuscular planes, and thoracic paravertebral spaces can all result in non-epidural LORs. ⋯ In the hands of experienced operators, real-time ultrasound guidance of the epidural needle has been demonstrated to provide comparable efficacy and efficiency to fluoroscopy. Further research is required to determine the most cost-effective confirmatory modality as well as the best adjuncts for novice operators and for patients with challenging anatomy. Moreover, future trials should elucidate if fluoroscopy and electrical stimulation could potentially decrease the secondary failure rate of TEA, and if a combination of confirmatory modalities could outperform individual ones.
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Reg Anesth Pain Med · Apr 2024
Case ReportsMechanism of chronic iatrogenic CSF leak following dural puncture-ventral dural leak: case report.
Postdural puncture headache has been traditionally viewed as benign, self-limited, and highly responsive to epidural blood patching (EBP) when needed. A growing body of data from patients experiencing unintended dural puncture (UDP) in the setting of attempted labor epidural placement suggests a minority of patients will have more severe and persistent symptoms. However, the mechanisms accounting for the failure of EBP following dural puncture remain obscure. An understanding of these potential mechanisms is critical to guide management decisions in the face of severe and persistent cerebrospinal fluid (CSF) leak. ⋯ A ventral rather than dorsal dural puncture is one mechanism that may contribute to both severe and persistent spinal CSF leak with resulting intracranial hypotension following a UDP.
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Reg Anesth Pain Med · Apr 2024
Does the impact of peripheral nerve blocks vary by age and comorbidity subgroups? A nationwide population-based study.
A large body of literature suggests that peripheral nerve blockade (PNB) is associated with improved perioperative outcomes in total hip and knee joint arthroplasty patients. However, it is unclear to what extent this association exists across patient subgroups based on age and health status. ⋯ PNB use is associated with beneficial effects more commonly observed among patients with a lower comorbidity burden, without a clear pattern of association with patient age.
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Reg Anesth Pain Med · Apr 2024
Observational StudyFactors associated with use of opioid rescue medication after surgery.
Opioid exposure after surgery increases risk of persistent opioid use. Here, we characterize at-home use of opioid rescue medication during 1-2 days after outpatient surgery (N=270) in a postoperative opioid-sparing context at a Norwegian hospital. ⋯ Factors related to at-home rescue medication use closely mirrored known risk factors for persistent opioid use after surgery, such as prior chronic pain, prior substance use, affective disturbances, and pain severity before surgery. These findings are potential targets in patient-centered care. Nevertheless, and reassuringly, findings are consistent with the idea that opioid-sparing postsurgical care can prevent large-scale chronic opioid use.