Schwenk, Eric S

Introduction Patients hospitalized for headache treatment pose unique challenges to the healthcare system. Currently, there is a lack of evidence-based guidance on management. This practice advisory aims to fill this critical gap by systematically reviewing the existing literature and providing comprehensive, evidence-based recommendations for managing headache patients during hospitalization. Methods In February 2023, the American Society of Regional Anesthesia and Pain Medicine approved this practice advisory proposal. The steering committee selected committee members based on clinical and research expertise in the field of headache medicine. Nine questions were formulated by the committee, and each question was assigned to a group composed of 3–4 members. A systematic literature search for each question was performed in Medline, Embase, Cochrane Database of Systematic Reviews and Web of Science on June 21, 2023. The results from each search were imported into separate Covidence projects for screening, data extraction, and risk of bias assessment. Additionally, relevant systematic reviews (SR) were screened. Each group submitted a structured narrative review along with statements and recommendations based on the US Preventive Services Task Force (USPSTF) format for grading of evidence. While the USPSTF framework was used, including the language in the recommendations, the formal USPSTF methodology, including the SR with meta-analysis and summary tables with forest plots, was not followed because of low overall evidence quality. The interim draft was shared electronically with each collaborator, who was requested to vote anonymously using two rounds of the modified Delphi approach. A consensus recommendation required >75% agreement. Results The panel generated 12 statements and 17 recommendations, along with their strength and certainty of evidence. Following two rounds of Delphi voting, a high consensus was achieved for all statements and recommendations. Most statements received a low-to-moderate level of certainty, and all but one recommendation received grade B or C, which was consistent with the lack of randomized controlled trials supporting most of the drugs in this document. Conclusions This evidence-based practice advisory provides a foundational step toward standardizing inpatient headache care and highlights existing gaps in the literature that should be addressed through rigorous prospective randomized studies.

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.

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of ‘complex’ patients as they undergo surgical procedures.

Background The past two decades have seen an increase in cannabis use due to both regulatory changes and an interest in potential therapeutic effects of the substance, yet many aspects of the substance and their health implications remain controversial or unclear. Methods In November 2020, the American Society of Regional Anesthesia and Pain Medicine charged the Cannabis Working Group to develop guidelines for the perioperative use of cannabis. The Perioperative Use of Cannabis and Cannabinoids Guidelines Committee was charged with drafting responses to the nine key questions using a modified Delphi method with the overall goal of producing a document focused on the safe management of surgical patients using cannabinoids. A consensus recommendation required ≥75% agreement. Results Nine questions were selected, with 100% consensus achieved on third-round voting. Topics addressed included perioperative screening, postponement of elective surgery, concomitant use of opioid and cannabis perioperatively, implications for parturients, adjustment in anesthetic and analgesics intraoperatively, postoperative monitoring, cannabis use disorder, and postoperative concerns. Surgical patients using cannabinoids are at potential increased risk for negative perioperative outcomes. Conclusions Specific clinical recommendations for perioperative management of cannabis and cannabinoids were successfully created.

Background and objectives Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. Methods Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%–74% agreement. Results Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. Conclusion By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Background Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. Methods A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. Results Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). Conclusions Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Total joint arthroplasty (TJA) is transitioning to be an outpatient rather than an inpatient procedure under national and institutional pressures to increase volumes while reducing hospital costs and length of stay. Innovative surgical and anesthesia techniques have allowed for earlier ambulation and physical therapy participation, maximizing the chance that an appropriately selected patient may be discharged within a day of surgery. The choice of anesthesia type is a modifiable factor that has a major impact on both surgical outcomes and discharge readiness. Recent large database studies have provided evidence for improved outcomes, including decreased mortality, with the use of spinal anesthesia. However, few randomized, controlled trials exist and database studies have limitations. Modern general anesthesia techniques, including total intravenous anesthesia and infusions targeted to anesthetic depth, may make some of these differences insignificant, especially when newer regional anesthesia and local infiltration analgesia techniques are incorporated into TJA enhanced recovery protocols. Multimodal analgesia for all TJA patients may also help minimize differences in pain. Perhaps even more important than anesthesia technique is the proper selection of patients likely to meet the necessary milestones for early discharge. In this article, we provide two contrasting viewpoints on the optimal primary anesthetic for outpatient TJA.