Faculty Bibliography

BACKGROUND: Regional analgesia is more effective than conventional analgesia for controlling pain and may facilitate rehabilitation after large joint replacement in the short term. It remains unclear if regional anaesthesia improves functional outcomes after joint replacement beyond three months after surgery. OBJECTIVES: To assess the effects of regional anaesthesia and analgesia on long-term functional outcomes 3, 6 and 12 months after elective major joint (knee, shoulder and hip) replacement surgery. SEARCH METHODS: We performed an electronic search of several databases (CENTRAL, MEDLINE, EMBASE, CINAHL), and handsearched reference lists and conference abstracts. We updated our search in June 2015. SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing regional analgesia versus conventional analgesia in patients undergoing total shoulder, hip or knee replacement. We included studies that reported a functional outcome with a follow-up of at least three months after surgery. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We contacted study authors for additional information. MAIN RESULTS: We included six studies with 350 participants followed for at least three months. All of these studies enrolled participants undergoing total knee replacement. Studies were at least partially blinded. Three studies had a high risk of performance bias and one a high risk of attrition bias, but the risk of bias was otherwise unclear or low.Only one study assessed joint function using a global score. Due to heterogeneity in outcome and reporting, we could only pool three out of six RCTs, with range of motion assessed at three months after surgery used as a surrogate for joint function. All studies had a high risk of detection bias. Using the random-effects model, there was no statistically significant difference between the experimental and control groups (mean difference 3.99 degrees, 95% confidence interval (CI) - 2.23 to 10.21; P value = 0.21, 3 studies, 140 participants, very low quality evidence).We did not perform further analyses because immediate adverse effects were not part of the explicit outcomes of any of these typically small studies, and long-term adverse events after regional anaesthesia are rare.None of the included studies elicited or reported long-term adverse effects like persistent nerve damage. AUTHORS' CONCLUSIONS: More high-quality studies are needed to establish the effects of regional analgesia on function after major joint replacement, as well as on the risk of adverse events (falls).

Background and aims: This study seeks to determine the effect of spinal anesthesia (SA) on clinical outcomes when compared to general anesthesia (GA) in operatively managed tibial plateau fractures. Methods: Over 8 years, all operative tibial plateau fractures treated by two surgeons were prospectively followed. 113 patients were identified for this study. 30 received SA and 83 received GA. All patients were treated using a similar operative protocol and physiotherapy regimen. Clinical outcomes were compared at 3 months, 6 months and the latest follow-up. These outcomes include Short Musculoskeletal Functional Assessment (SMFA) scores, pain levels, complications and reoperations. Analysis was done using student's t-tests, Chi-squared tests and multivariate linear regression. Results: Using univariate analysis, SMFA scores were improved at 6 months in SA vs. GA patients (beta = -1.14, 95% confidence interval [CI] = -2.06 to -.23, p=0.015), and pain scores were lower in SA vs. GA at 6 months (p =0.004) and at the latest followup (p=0.012). After controlling for group differences, pain scores were found to be lower in SA vs. GA at 3 months (beta = -0.16, 95% CI = -0.24 to 2.02, p=0.048), but not at 6 months or the latest followup. The odds ratio of higher pain scores of a patient who received GAvs SA at 3 months was 3.1 (95% CI, 1.06 to 9.26, p=0.039). Conclusions: In patients who undergo surgical management of a tibial plateau fracture, the use of spinal anesthesia is associated with improved functional scores and decreased pain levels up to 6 months postoperatively

Background: Even correctly performed peripheral nerve blocks lead to systemic absorption, and local anesthetic systemic toxicity remains a concern. Data on the maximum admissible dose of local anesthetic using different techniques is old and does not take into account the technique used to perform the block, whether it be neurostimulation (NS) or ultrasound (US) guidance. Objective: Our aim was to establish a plasma concentration curve of ropivacaine for femoral nerve blocks and to ascertain whether the resulting plasma concentrations differ significantly depending on the nerve localization technique used (US vs. NS). Methods: Sixteen patients receiving a femoral nerve block as part of their anesthetic for unilateral lower extremity surgery were enrolled in this prospective study. They were randomized to undergo either US or NS guidance. All blocks were performed with 20 mL of 5 mg/mL ropivacaine. Blood samples were drawn before the nerve block and 20, 30, 40, 50, 60, 70, and 80 minutes after the block. Plasma levels of ropivacaine were analyzed by high performance liquid chromatography (HPLC). Results: All blocks were successful and no patient showed signs or symptoms of local anesthesia toxicity. The plasma concentration of ropivacaine peaked at 30 minutes in both arms. There was no significant difference in peak levels between US and NS-guidance (0.325 + 0.186 vs. 0.356 + 0.106 mcg/mL; ns). Between 50 and 70 minutes, there was a trend toward higher plasma concentrations of ropivacaine in the US group than in the NS group but it did not reach significance. Conclusion: Plasma concentrations of ropivacaine peak around 30 minutes after femoral nerve block regardless of the technique used. No significant difference was found between US- and NS-guidance, despite a trend toward higher levels in the US group between 50 and 70 minutes. We will repeat this study with other nerve blocks, such as the interscalene block, to investigate whether plasma levels differ depending on the technique

Background: The "adductor canal" block, consisting in an injection of about 30 mL of local anesthetic at the mid-thigh level, has been proposed to provide analgesia following knee procedures1-3 without the significant quadriceps motor block that results from a femoral nerve block4. Such analgesia is unlikely to result solely from saphenous nerve blockade. We investigated in six fresh cadaver lower extremities what the actual spread of local anesthetic injected in the adductor canal was, and what other nerve branches, if any, would be blocked besides the saphenous nerve. Material and methods: Six fresh adult cadaver lower extremities were studied. A mixture of 27 mL of 2% lidocaine and 3 mL of methylene blue was injected under ultrasound guidance in the adductor canal. Three of the thighs were surgically dissected plane by plane, while the other three were frozen, cut into 2-cm thick slices, and then thawed. In two legs, the mixture also included 2 mL of radio-opaque dye. These two legs were imaged by computed tomography prior to dissection or freezing. Dye spread was examined to determine nerve branches that would likely be blocked by a similar injection in vivo. Results: The dissection showed that the dye was mainly confined to the adductor canal, with only a small amount of dye seen anterior to the adductor magnus, reaching the posterior branch of the obturator nerve. Except in one case, there was no dye following the femoral vessels as they traveled through the adductor hiatus to become the popliteal vessels, in close proximity with the sciatic nerve. Instead, the dye remained with the saphenous nerve and the descending genicular artery on the more distal cuts. In one case, the dye spread proximally, reaching the femoral nerve. Conclusion: This study demonstrates that the spread of local anesthetic during an adductor canal blockade involves, besides the saphenous nerve, the posterior branch of the obturator nerve during its course anterior to the adductor magnus, but does not typically ex te!

PURPOSE: To assess the suitability of ultrasound-guided (USG), single-injection distal block(s) for pain management after outpatient hand and wrist bone surgery. METHODS: We conducted a retrospective review of 125 of 198 consecutive ambulatory surgery patients who underwent hand and wrist bone surgery between June 2010 and January 2012. All patients received a USG axillary block using a short-acting local anesthetic (lidocaine) and secondary 1, 2, or 3 (median, radial, or ulnar) USG distal analgesic block(s) using a long-acting local anesthetic (ropivacaine). All patients were contacted by phone on the first postoperative day. All patients received a concomitant prescription of acetaminophen and nonsteroidal anti-inflammatory drugs with opioids as a rescue treatment. Effectiveness and duration of the distal nerve blocks, compliance with analgesic treatment and rescue opioids requirement, opioid-related side effects, prolonged upper limb motor block, quality of sleep on first postoperative night, and patient satisfaction were evaluated. RESULTS: Most distal analgesic blocks were effective (120 of 125; 96%), with an average duration of nearly 12 hours On the first day after surgery, 28 patients (23%) had a numeric verbal scale greater than 3, although 14 of them had taken the rescue opioids. No patient reported prolonged motor blockade or insensate limb. Opioid-related side effects occurred in 23% of patients. CONCLUSIONS: After hand and wrist bone surgery, USG selective distal blocks using a long-acting local anesthetic, combined with oral analgesics, were effective in a large majority of patients. However, pain control was suboptimal for some especially painful procedures such as wrist surgery, trapeziometacarpal arthrodesis, and finger amputation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Evidence supports the concept that patients undergoing major orthopedic surgery benefit from either thromboprophylaxis or peripheral nerve blocks, especially continuous techniques. A group of anesthesiologists with significant experience in orthopedic anesthesia and peripheral nerve blocks reviewed the literature related to thromboprophylaxis and peripheral nerve blocks and their combination in orthopedics. Major bleeding, including retroperitoneal hematoma, is an established complication of thromboprophylaxis. Major bleeding, including retroperitoneal hematoma, is also an established complication of peripheral nerve blocks. Between 1997 and 2012, only 4 case reports of major bleeding were reported in patients receiving thromboprophylaxis and peripheral nerve blocks. Evidence supports the safety of the combination of thromboprophylaxis and peripheral nerve blocks. This group of experts concluded that currently there is no evidence that the combination of thromboprophylaxis and peripheral nerve block increases the risk of major bleeding compared to either of the treatments alone.

Whereas the gap between organ supply and demand remains a worldwide concern, resuscitation of out-of-hospital traumatic cardiac arrest (TCA) remains controversial. The aim of this study is to evaluate, in a prehospital medical care system, the number of organs transplanted from victims of out-of-hospital TCA. This is a descriptive study. Victims of TCA are collected in the out-of-hospital cardiac arrest registry of the French North Alpine Emergency Network from 2004 to 2008. In addition to the rates of admission and survival, brain-dead patients and the organ transplanted are described. Among the 540 resuscitated patients with suspected TCA, 79 were admitted to a hospital, 15 were discharged alive from the hospital, and 22 developed brain death. Nine of these became eventually organ donors, with 31 organs transplanted, all functional after 1 year. Out-of-hospital TCA should be resuscitated just as medical CA. With a steady prevalence in our network, 19% of admitted TCA survived to discharge, and 11% became organ donors. It is essential to raise awareness among rescue teams that out-of-hospital TCA are an organ source to consider seriously.

Purpose/Objective: A 47-year-old male with a history of hypothyroidism, hyperlipidemia, bipolar disorder, and super morbid obesity (BMI 75) presented with acute wound dehiscence and tendon re-rupture following a quadriceps tendon repair surgery six weeks earlier. During the original operation, a femoral nerve block was performed given his unfavorable body habitus. The patient reported discomfort during his first surgery and additional sedation (dexmedetomidine infusion) was required as an adjuvant. For the second surgery, which included washout of wound, repair of ruptured tendon as well as the placement of external fixation device to allow healing, it was decided that a combination of femoral and popliteal blocks would provide better anesthesia and analgesia. Materials and Methods: During surgery, specifically for the placement of pins in the fibula, the patient experienced profound discomfort requiring the judicious use of midazolam and small boluses of ketamine. Results: Post-operatively, a popliteal nerve block was performed in PACU with immediate pain relief. Conclusions: This case reviews the anatomical and technical difficulty of performing nerve blocks in the super obese, the benefits of regional anesthesia and of the avoidance of general anesthesia in this difficult population, and reviews the relevant literature