Harbell, Monica W

Background Although regional anesthesia (RA) is associated with improved pain control, reduced opioid use, and accelerated recovery after arthroplasty, racial and geographic differences have been identified in hip and knee arthroplasty, with limited data for shoulder and ankle arthroplasty. We examined differences in RA utilization for shoulder, hip, knee, and ankle arthroplasty, based on patient-level and hospital-level characteristics. Methods Using the National Inpatient Sample, we conducted a cross-sectional study of adults who underwent shoulder, hip, knee, and ankle arthroplasties from 2016 to 2020. RA was defined using procedure codes for neuraxial anesthesia and peripheral nerve blocks. Weighted descriptive statistics summarized RA utilization and compared patient-level and hospital-level characteristics using standardized mean differences (SMDs), with ≥0.10 indicating meaningful differences. Results We identified 1132 011 unweighted admissions, representing approximately 5.7 million weighted arthroplasties. RA was used in 7.0% of cases. RA utilization varied by procedure type, with the highest rates in shoulder (11.4%) and ankle arthroplasty (11.4%), followed by knee (9.1%) and hip arthroplasty (2.4%). Variation in RA utilization was observed in ankle arthroplasty based on race (SMD=0.11) and primary payer (SMD=0.12). RA use also varied by hospital size for shoulder (SMD=0.13), hip (SMD=0.29), and knee arthroplasty (SMD=0.22), by hospital location and teaching status for shoulder (SMD=0.17), hip (SMD=0.18), knee (SMD=0.19), and ankle arthroplasty (SMD=0.12), and by geographic region for shoulder (SMD=0.26), hip (SMD=0.45), knee (SMD=0.24), and ankle arthroplasty (SMD=0.17). Conclusions There is notable variation in RA use for inpatient arthroplasty across hospitals and geographic regions, with limited variation based on patient characteristics. These findings highlight the presence of system-level variation in RA use and underscore the need for further research to better understand the drivers of these patterns.

Background and objectives Few cadaveric studies have evaluated the dye spread with superficial parasternal intercostal plane (SPIP) blocks. In this study, we examined the dye spread of an ultrasound-guided SPIP block in a human cadaveric model with single and double injection techniques. Methods Seven single and four double ultrasound-guided SPIP blocks were performed in seven unembalmed human cadavers using an in-plane approach with the transducer oriented parasagitally 1 cm lateral to the sternum. For the single SPIP, 20 mL of 0.166% methylene blue was injected in the second or third intercostal space into the plane between the Pec major muscle and internal intercostal muscles. For the double SPIP, 10 mL of 0.166% methylene blue was injected in the SPIP at one intercostal space with an additional 10 mL injected in the SPIP two intercostal spaces caudally. The extent of dye spread was documented. Results For all SPIP injections, there was consistent mediolateral spread from the sternum to the mid-clavicular line, with many extending laterally to the anterior axillary line. There was craniocaudal spread to a median of 2 intercostal muscles with a single SPIP and 3 intercostal muscles with a double SPIP. There was a median spread to 1 intercostal nerve for the single SPIP and 1.5 intercostal nerves with the double SPIP. Conclusions The SPIP block demonstrated limited spread in this cadaver study. A single injection of this block may be of limited value and multiple SPIP injections may be needed to have adequate spread for anterior thoracic procedures.

Introduction: Postoperative pain management and postoperative nausea and vomiting are a persistent challenge for both health care providers and patients. Acupuncture is an effective and safe modality for the management of pain and nausea, and has the potential to play a key role in postoperative pain management. This study explores the utility and feasibility of acupuncture in the immediate postoperative setting. Methods: In a retrospective case–control study, 22 patients who underwent elective surgeries and received acupuncture in the post-anesthesia care unit (PACU) were compared with 88 case controls. Indications for acupuncture therapy included persistent pain, nausea, or anxiety. Patient satisfaction and symptom improvement after acupuncture were assessed. PACU nurses and patients were queried on their perspectives on using this therapy. Demographic data, perioperative opioid consumption, pain score in the PACU, incidence of postoperative nausea, PACU length of stay, and unintended hospital admission were assessed. The groups with/without acupuncture were compared using Wilcoxon rank sum test or Fisher's exact test as appropriate. Results: A total of 78.9% of patients receiving acupuncture felt improvement in their symptoms. 94.7% of recovery nurses who cared for patients who received acupuncture felt that it was helpful and 78.9% did not believe it was disruptive. Patients who opted for acupuncture had a statistically significant higher overall median (interquartile range) pain score in the PACU (7.0 [5.2, 9.5] vs. 5.0 [3.0, 7.0], p = 0.009) and higher postoperative opioid consumption (22.5 [9.8, 44.8] vs. 15.0 [0.0, 30.0], p = 0. 03). There was no difference between total perioperative opioid consumption between groups ( p = 0.94). Conclusions: Most patients who received acupuncture therapy in the PACU were satisfied with their therapy and would recommend it to future patients undergoing surgery. Most recovery nurses felt it was helpful, was not disruptive, and would like to see it utilized in the PACU.

Background Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks. Methods We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%–74% agreement. Results A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research. Conclusions We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

Introduction The superficial and deep parasternal intercostal plane (DPIP) blocks are two new blocks for thoracic pain. There are limited cadaveric studies evaluating the dye spread with these blocks. In this study, we examined the dye spread of an ultrasound-guided DPIP block in a human cadaveric model. Methods Five ultrasound-guided DPIP blocks were performed in four unembalmed human cadavers using an in-plane approach with a linear transducer oriented in a transverse plane adjacent to the sternum. Twenty milliliters of 0.1% methylene blue were injected between ribs 3 and 4 into the plane deep to the internal intercostal muscles and superficial to the transversus thoracis muscle layer. The chest muscles were dissected, and the extent of dye spread was documented in both cephalocaudal and mediolateral directions. Results The transversus thoracis muscle slips were stained in all cadavers from 4 to 6 levels. Intercostal nerves were dyed in all specimens. Four levels of intercostal nerves were dyed in each specimen with variability in number of levels stained above and below the level of the injection. Conclusions The DPIP block spreads along the tissue plane above the transversus thoracis muscles to multiple levels to dye the intercostal nerves in this cadaver study. This block may be of clinical value for analgesia in anterior thoracic surgical procedures.

Fibromyalgia is a common disease syndrome characterized by chronic pain and fatigue in conjunction with cognitive dysfunction such as memory difficulties. Patients currently face a difficult prognosis with limited treatment options and a diminished quality of life. Given its widespread use and potential efficacy in treating other types of pain, cannabis may prove to be an effective treatment for fibromyalgia. This review aims to examine and discuss current clinical evidence regarding the use of cannabis for the treatment of fibromyalgia. An electronic search was conducted on MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus using Medical Subject Heading (MeSH) terms on all literature published up to October 2022. A follow-up manual search included a complete verification of relevant studies. The results of four randomized controlled trials (RCTs) and five observational studies (a total of 564 patients) that investigated the effects of cannabis on fibromyalgia symptoms were included in this review. Of the RCTs, only one demonstrated that cannabinoids did not have a different effect than placebo on pain responses. Overall, this analysis shows low-quality evidence supporting short-term pain reduction in people with fibromyalgia treated with cannabinoid therapeutics. Although current evidence is limited, medical cannabis appears to be a safe alternative for treating fibromyalgia.

Background and objectives Studies show variable spread with thoracic erector spinae plane (ESP) injections. Injection sites vary from lateral end of the transverse process (TP) to 3 cm from the spinous process, with many not describing the precise site of injection. This human cadaveric study examined dye spread of ultrasound-guided thoracic ESP block at two needle locations. Methods Ultrasound-guided ESP blocks were performed on unembalmed cadavers. Methylene blue (20 mL, 0.1%) was injected in the ESP at the medial TP at level T5 (medial transverse process injection (MED), n=7) and the lateral end of the TP between T4 and T5 (injection between transverse processes (BTWN), n=7). The back muscles were dissected, and the cephalocaudal and medial-lateral dye spread documented. Results Dye spread cephalocaudally from C4-T12 in the MED group and C5-T11 in the BTWN group, and laterally to the iliocostalis muscle in five MED injections and all BTWN injections. One MED injection reached serratus anterior. Dorsal rami were dyed in five MED and all BTWN injections. Dye spread to the dorsal root ganglion and dorsal root in most injections, though more extensively in the BTWN group. The ventral root was dyed in 4 MED and 6 BTWN injections. Epidural spread in BTWN injections ranged from 3 to 12 levels (median: 5 levels), with contralateral spread in two cases and intrathecal spread in five injections. Epidural spread in MED injections was less extensive (median (range): 1 (0–3) levels); two MED injections did not enter the epidural space. Conclusion An ESP injection administered between TPs exhibits more extensive spread than a medial TP injection in a human cadaveric model.

AbstractDiabetes insipidus is characterized by polyuria due to an inability to auto‐regulate water balance resulting in dangerous metabolic derangements. Intraoperative anesthetics have been increasingly identified as a cause of diabetes insipidus in adult patients; however, it is rare in pediatrics. We present a case of a 16‐year‐old male undergoing resection of a recurrent left juvenile nasopharyngeal angiofibroma who experienced intraoperative polyuria concerning diabetes insipidus. Urine output drastically decreased following discontinuation of dexmedetomidine with complete resolution within 24 h. We conclude that this case of transient diabetes insipidus was associated with dexmedetomidine administration.