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Liposomal Bupivacaine plus bupivacaine for interscalene brachial plexus block decreases opioid consumption for up to 1 week compared to bupivacaine alone in patients undergoing total shoulder arthroplasty

Umeh, Uchenna; Cuevas, Randy; Virk, Mandeep; Kwon, Young; Cuff, Germaine; Hertling, Arthur
ORIGINAL:0014972
ISSN: 0265-0215
CID: 4840342

[S.l. : American Society of Anesthesiologists], 2019

Adductor Canal and Distal Femoral Triangle Nerve Blocks Provide Similar Analgesia and Opioid Consumption Following Anterior Cruciate Ligament Surgery

Desai, Prianka; Chuy, Katherine; Thangada, Shruthima; Umeh, Uchenna O; Atchabahian, Arthur
(Website)
CID: 4840322

Delayed attainment of physical therapy milestones with the addition of an adductor canal block to local infiltration analgesia following total knee arthroplasty [Meeting Abstract]

Atchabahian, A; Cuff, G; Cuevas, R
Background and aims Retrospective data and prior studies suggest a synergistic analgesic effect of an adductor canal blockade (ACB) added to local infiltration analgesia (LIA) compared to LIA alone. Our hypothesis was that physical therapy (PT) milestones would be reached earlier with ACB + LIA than LIA alone. Methods After IRB approval, patients scheduled for unilateral primary TKA were randomized to receive either ACB or a sham block (saline) in addition to the LIA administered by the surgeon. Exclusion criteria included significant systemic disease, substance abuse and chronic pain. Spinal anesthetic and postoperative pain management were standardized. ACB was performed at the mid-thigh level with 30 mL of 0.25% bupivacaine with 1:200,000 adrenaline. LIA was performed by the surgeon using bupivacaine, ketorolac, adrenaline and morphine, as well as liposomal bupivacaine. Data collected included passive and active ROM of the knee in flexion and extension; 2-minute walk test; total distance ambulated on the day of surgery and the first and second post-operative days; and pain NVS before, during and after physical therapy sessions. Results Preliminary results of 63 patients out of 150 planned are reported. Pain scores, measured as an AUC for the initial 48 hours, were not different between groups. However, total distance ambulated and 2-minute walk tests were lower in the group that received the ACB in addition to LIA at each of the time points. Conclusions While these interim results remain to be confirmed, the data suggest that LIA alone is preferable to LIA + ACB
EMBASE:629475286
ISSN: 1532-8651
CID: 4131872

Low-dose ketamine infusion reduces postoperative hydromorphone requirements in opioid-tolerant patients following spinal fusion: A randomised controlled trial

Boenigk, Kirsten; Echevarria, Ghislaine C; Nisimov, Emmanuel; von Bergen Granell, Annelise E; Cuff, Germaine E; Wang, Jing; Atchabahian, Arthur
BACKGROUND:The current opioid epidemic highlights the urgent need for effective adjuvant therapies to complement postoperative opioid analgesia. Intra-operative ketamine infusion has been shown to reduce postoperative opioid consumption and improve pain control in opioid-tolerant patients after spinal fusion surgery. Its efficacy for opioid-naïve patients, however, remains controversial. OBJECTIVE:We hypothesised that low-dose ketamine infusion after major spinal surgery reduces opioid requirements in opioid-tolerant patients, but not in opioid-naïve patients. DESIGN/METHODS:Randomised placebo-controlled prospective study. SETTING/METHODS:Single-centre, tertiary care hospital, November 2012 until November 2014. PATIENTS/METHODS:A total of 129 patients were classified as either opioid-tolerant (daily use of opioid medications during 2 weeks preceding the surgery) or opioid-naïve group, then randomised to receive either ketamine or placebo; there were thus four groups of patients. All patients received intravenous hydromorphone patient-controlled analgesia postoperatively. INTERVENTION/METHODS:Patients in the ketamine groups received a ketamine infusion (bolus 0.2 mg kg over 30 min followed by 0.12 mg kg h for 24 h). Patients in the placebo groups received 0.9% saline. MAIN OUTCOME MEASURES/METHODS:The primary outcome was opioid consumption during the first 24 h postoperatively. The secondary outcome was numerical pain scores during the first 24 h and central nervous system side effects. RESULTS:Postoperative hydromorphone consumption was significantly reduced in the opioid-tolerant ketamine group, compared with the opioid-tolerant placebo group [0.007 (95% CI 0.006 to 0.008) versus 0.011 (95% CI 0.010 to 0.011) mg kg h, Bonferroni corrected P < 0.001]. There was no difference in hydromorphone use between the opioid-naïve groups (0.004 and 0.005 mg kg h in the opioid-naïve ketamine and placebo group, respectively, P = 0.118). Pain scores did not differ significantly between the opioid-tolerant ketamine group and the opioid-naïve groups. There was no significant difference in side effects among groups. CONCLUSION/CONCLUSIONS:Postoperative low-dose ketamine infusion reduces opioid requirements for the first 24 h following spinal fusion surgery in opioid-tolerant, but not in opioid-naïve patients. TRIAL REGISTRATION/BACKGROUND:NCT03274453 with clinicaltrials.gov.
PMID: 30113350
ISSN: 1365-2346
CID: 3242942

Motor-sparing spinal anesthesiatoallow active balancing during total knee arthroplasty [Meeting Abstract]

Atchabahian, A; Marks, R; Cuff, G; Cuevas, R; Meere, P
Background and Aims: Successful total knee replacement (TKA) is dependent on balancing peak load at the medial and lateral tibiofemoral joint interfaces. This can be achieved using a sterile sensor system intra-operatively. On the request of one surgeon at our institution, we explored the feasibility and safety of spinal anesthesia with limited motor blockade. Methods: 25 patients were enrolled in an IRB-approved non-randomized pilot study. For spinal anesthesia, a solution consisting of 1 mL of 5 mg/mL isobaric bupivacaine with 1.5 mL sterile saline solution containing 7.5 mcg of sufentanil was administered. During surgery, after components were cemented, patients were awakened and asked to move their leg in order to measure pressure balance. If an imbalance was noted, the surgeon would make adjustments intraoperatively. Results: During the intraoperativewake-up test, 15 patients successfully flexed and extended at the knee on command, while 10 were too weak for meaningful testing. As we reduced the local anesthetic volume to 0.8 mL in patients shorter than 160 cm, that issue was eliminated. One patient had neutral recollection of the test on follow up. No patient had pain or other side effect. Conclusions: A spinal anesthetic using sufentanil in combination with lowdose local anesthetic appears feasible and safe to provide surgical anesthesia for TKA. By performing a motor-sparing spinal anesthetic with an intraoperativewake up test, we can allow surgeons to test active pressure balance to improve the accuracy of the pressure balancing technique. A randomized study is in preparation to determine whether long-term surgical result is improved
EMBASE:624140230
ISSN: 1532-8651
CID: 3356082

Spinal Anesthesia Improves Early Pain Levels After Surgical Treatment of Tibial Plateau Fractures

Manoli, Arthur 3rd; Atchabahian, Arthur; Davidovitch, Roy I; Egol, Kenneth A
OBJECTIVES: To determine the effect of spinal anesthesia (SA) on short-term outcomes when compared with general anesthesia in operatively managed tibial plateau fractures. DESIGN: This is an institutional review board-approved retrospective review of prospectively collected data. SETTING: Two level-1 trauma centers. PARTICIPANTS: One hundred twelve patients with a surgically managed tibial plateau fracture were identified within a registry of patients. INTERVENTION: Of these, 29 (25.9%) received SA and 83 (74.1%) received general anesthesia in a nonrandomized fashion. MAIN OUTCOME MEASURES: Short Musculoskeletal Functional Assessment scores, pain levels, knee range of motion, complications, and reoperations. RESULTS: SA was found to be a predictor of lower pain scores at 3 months (odds ratio, 0.32; 95% confidence interval, 0.12-0.95; P = 0.039) but not at 6 months (P = 0.266) or the latest follow-up (P = 0.056). In the multivariate Short Musculoskeletal Functional Assessment model, although anesthesia type was not found to be a statistically significant predictor, other predictors were identified. Anesthesia type was not a predictor of complications or reoperations. In the univariate analysis, SA was associated with an increased knee range of motion at 3 months (121 vs. 111 degrees; P = 0.048) but not at 6 months (P = 0.31) or the latest follow-up (P = 0.053). CONCLUSION: In patients who undergo surgical management of a tibial plateau fracture, the use of SA is associated with decreased pain levels in the early postoperative period; however, there was no effect on functional assessment scores. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
PMID: 28009616
ISSN: 1531-2291
CID: 2459572

The nerve: A fragile balance between physiology and pathophysiology

Estebe, Jean-Pierre; Atchabahian, Arthur
Regarding nerves as simple cables and electrical conduits is a gross error that does not allow us to understand the anomalies and disorders observed postoperatively. Instead, nerves should be seen as a living tissue of which physiological regulation is as complex as that of the blood-brain barrier. This review describes the basic structure and functions of this blood-nerve barrier and highlights the mechanisms of its breakdown and the resultant disorders. For clinical practice, it is important to note that the diffusion of molecules from the perineurium or from the blood is very limited, and so the blood-nerve barrier is a major pharmacologic barrier. Any stress upon neural physiological balance, particularly the terminal vascular blood supply, will induce the classic inflammatory cascade. Due to the complexity of the vascular system, nerve ischaemia will occur more quickly when the terminal blood supply is compromised. This blood supply can adapt in a variety of ways but when these possibilities of adaptation are exceeded, tissue ischaemia may be more extensive. Also, even after the initial injury has subsided, inflammation can cause a secondary insult. This could be particularly important in some patients with subclinical neuropathy.
PMID: 28146457
ISSN: 1365-2346
CID: 2424302

Minimum local anesthetic volumes for a selective saphenous nerve block: a dose-finding study

Ten Hoope, Werner; Hollmann, Markus W; Atchabahian, Arthur; Rigaud, Marcel; Kerkhoffs, Gino M; Lirk, Philipp; Baumann, Holger M
BACKGROUND: Saphenous nerve block contributes to analgesia after knee and lower leg surgery. However, literature reports a wide range of volumes of local anesthetic being used for this block. METHODS: A non-randomized controlled trial in a single university hospital in March 2015. Eighteen healthy volunteers (ASA 1 status, aged 27-43 years; male-to-female ratio 11/7) were needed to determine the minimum local anesthetic volume (MLAV) of mepivacaine 2% using the Dixon up-and-down method to achieve a selective ultrasound-guided saphenous nerve block. The primary endpoint MLAV (ED50 and ED95) for an ultrasound-guided saphenous nerve block were determined. The secondary endpoints were the position of the saphenous nerve, block onset and duration of action, cutaneous spread of the block, and the occurrence of femoral nerve motor block. RESULTS: The measured MLAV dose that was effective in 50% of cases (ED50) for a complete saphenous nerve block was 1.5 mL; the calculated MLAV dose for 95% of cases (ED95) was 1.9 mL. The saphenous nerve was encountered in almost all cases on the anterior/anteromedial aspect of the femoral artery. We found no correlation between local anesthetic volume and the onset or duration of the block. Cutaneous spread of the nerve block was observed on the anteromedial aspect of the lower leg, with considerable individual variation between individuals in the study. No femoral motor block was observed. CONCLUSIONS: For a selective ultrasound-guided saphenous nerve block, the ED95 MLAV of mepivacaine 2% is 1.9 mL.
PMID: 27834474
ISSN: 1827-1596
CID: 2445252

Brachial Plexus Blockade Causes Subclinical Neuropathy: A Prospective Observational Study

Perretta, Donato J; Gotlin, Matthew; Brock, Kenneth; Paksima, Nader; Gottschalk, Michael B; Cuff, Germaine; Rettig, Michael; Atchabahian, Arthur
Background: The objective of this study is to determine subclinical changes in hand sensation after brachial plexus blocks used for hand surgery procedures. We used Semmes-Weinstein monofilament testing to detect these changes. We hypothesized that patients undergoing brachial plexus nerve blocks would have postoperative subclinical neuropathy detected by monofilament testing when compared with controls. Methods: In total, 115 hand surgery adult patients were prospectively enrolled in this study. All patients undergoing nerve-related procedures were excluded as well as any patients with preoperative clinically apparent nerve deficits. Eighty-four patients underwent brachial plexus blockade preoperatively, and 31 patients underwent general anesthesia (GA). Semmes-Weinstein monofilament testing of the hand was performed preoperatively on both the operative and nonoperative extremities and postoperatively at a mean of 11 days on both hands. Preoperative and postoperative monofilament testing scores were compared between the block hand and the nonoperated hand of the same patient, as well as between the block hands and the GA-operated hands. Results: There were no recorded clinically relevant neurologic complications in the block group or GA group. A statistically significant decrease in sensation in postoperative testing in the operated block hand compared with the nonoperated hand was noted. When comparing the operated block hand with the operated GA hand, there was a decrease in postoperative sensation in the operated block hand that did not reach statistical significance. Conclusions: Brachial plexus blockade causes subtle subclinical decreases in sensibility at short-term follow-up, without any clinically relevant manifestations.
PMCID:5207291
PMID: 28082843
ISSN: 1558-9447
CID: 2412812

Ultrasound-Guided Infraclavicular Brachial Plexus Block

Chapter by: Atchabahian, Arthur; Vandepitte, Catherine; Lopez, Ana M
in: Hadzic's textbook of regional anesthesia and acute pain management by Hadzic, Admir (Ed)
New York : McGraw-Hill Education, [2017]
pp. ?-?
ISBN: 0071717595
CID: 2745632