Faculty Bibliography

This article in our point-of-care ultrasound (PoCUS) series is dedicated to the role the focused assessment with sonography in trauma (FAST) exam plays for the regional anesthesiologist and pain specialists in the perioperative setting. The FAST exam is a well-established and extensively studied PoCUS exam in both surgical and emergency medicine literature with over 20 years demonstrating its benefit in identifying the presence of free fluid in the abdomen following trauma. However, only recently has the FAST exam been shown to be beneficial to the anesthesiologist in the perioperative setting as a means to identify the extravasation of free fluid into the abdomen from the hip joint following hip arthroscopy. In this article, we will describe how to obtain the basic FAST views (subcostal four-chamber view, perihepatic right upper quadrant view, perisplenic left upper quadrant view, and pelvic view in the longitudinal and short axis) as well as cover the relevant sonoanatomy. We will describe pathological findings seen with the FAST exam, primarily free fluid in the peritoneal space as well as in the pericardial sac. As is the case with any PoCUS skill, the application evolves with understanding and utilization by new clinical specialties. Although this article will provide clinical examples of where the FAST exam is beneficial to the regional anesthesiologist and pain specialist, it also serves as an introduction to this powerful PoCUS skill in order to encourage clinical practitioners to expand the application of the FAST exam within the scope of regional anesthesia and pain management practice.

This article in our series on point-of-care ultrasound (US) for the regional anesthesiologist and pain management specialist describes the emerging role of gastric ultrasonography. Although gastric US is a relatively new point-of-care US application in the perioperative setting, its relevance for the regional anesthesiologist and pain specialist is significant as our clinical practice often involves providing deep sedation without a secured airway. Given that pulmonary aspiration is a well-known cause of perioperative morbidity and mortality, the ability to evaluate for NPO (nil per os) status and risk stratify patients scheduled for anesthesia is a powerful skill set. Gastric US can provide valuable insight into the nature and volume of gastric content before performing a block with sedation or inducing anesthesia for an urgent or emergent procedure where NPO status is unknown. Patients with comorbidities that delay gastric emptying, such as diabetic gastroparesis, neuromuscular disorders, morbid obesity, and advanced hepatic or renal disease, may potentially benefit from additional assessment via gastric US before an elective procedure. Although gastric US should not replace strict adherence to current fasting guidelines or be used routinely in situations when clinical risk is clearly high or low, it can be a useful tool to guide clinical decision making when there is uncertainty about gastric contents.In this review, we will cover the relevant scanning technique and the desired views for gastric US. We provide a methodology for interpretation of findings and for guiding medical management for adult patients. We also summarize the current literature on specific patient populations including obstetrics, pediatrics, and severely obese subjects.

This article in our point-of-care ultrasound (PoCUS) series discusses the benefits of focused cardiac ultrasound (FoCUS) for the regional anesthesiologist and pain specialist. Focused cardiac US is an important tool for all anesthesiologists assessing patients with critical conditions such as shock and cardiac arrest. However, given that ultrasound-guided regional anesthesia is emerging as the new standard of care, there is an expanding role for ultrasound in the perioperative setting for regional anesthesiologists to help improve patient assessment and management. In addition to providing valuable insight into cardiac physiology (preload, afterload, and myocardial contractility), FoCUS can also be used either to assess patients at risk of complications related to regional anesthetic technique or to improve management of patients undergoing regional anesthesia care. Preoperatively, FoCUS can be used to assess patients for significant valvular disease, such as severe aortic stenosis or derangements in volume status before induction of neuraxial anesthesia. Intraoperatively, FoCUS can help differentiate among complications related to regional anesthesia, including high spinal or local anesthetic toxicity resulting in hemodynamic instability or cardiac arrest. Postoperatively, FoCUS can help diagnose and manage common yet life-threatening complications such as pulmonary embolism or derangements in volume status. In this article, we introduce to the regional anesthesiologist interested in learning FoCUS the basic views (subcostal 4-chamber, subcostal inferior vena cava, parasternal short axis, parasternal long axis, and apical 4-chamber), as well as the relevant sonoanatomy. We will also use the I-AIM (Indication, Acquisition, Interpretation, and Medical decision making) framework to describe the clinical circumstances where FoCUS can help identify and manage obvious pathology relevant to the regional anesthesiologist and pain specialist, specifically severe aortic stenosis, hypovolemia, local anesthetic systemic toxicity, and massive pulmonary embolism.

In this article, we discuss the emerging role of lung point-of-care ultrasonography for regional anesthesiologists and pain management specialists. Lung ultrasonography is a well-established clinical tool that is used on a routine basis in emergency rooms and critical care units internationally to evaluate patients with respiratory distress; however, its benefits to the regional anesthesiologist and pain specialist are not as well known and are practiced less frequently. This review article covers the clinical evidence in support of lung point-of-care ultrasonography as a rapid and superior tool to traditional imaging modalities such as chest radiography and fluoroscopy. As anesthesiologists routinely perform nerve blocks that put patients at potential risk of complications such as pneumothorax or diaphragmatic paresis, it is important to understand how to use lung ultrasonography to evaluate for these conditions, as well as to differentiate between other potential causes of respiratory distress, such as interstitial syndrome and pleural effusions. This article describes the normal and pathological findings that can be used to quickly and confidently evaluate a patient for these conditions.

Transient neurologic symptoms (TNS) led to the abandonment of intrathecal lidocaine. We reviewed the published literature for information about the duration of action and side effects of intrathecal prilocaine, which has been recently reintroduced in Europe. Medline and EMBASE databases were searched for the time period from 1966 to 2014. Fourteen prospective and one retrospective study were retrieved. The duration of the surgical block can be adjusted using doses between 40 and 80mg. Hyperbaric prilocaine in doses as low as 10mg can be used for perianal procedures. Four cases of TNS in 486 patients were reported in prospective studies, and none in 5000 cases in a retrospective data set. Spinal prilocaine appears to be safe and reliable for day case anesthesia. However, as chloroprocaine has a shorter duration and a lower risk of TNS and urinary retention, the indications for prilocaine remain to be defined.