Examining Use of Low-Dose Ketamine Infusions During the Postoperative Period: A Retrospective Study Comparing Opioid-Tolerant and Nonopioid-Tolerant Patients.

Ketamine is a well-known anesthetic that has been used since the 1970s. Despite its ubiquitous use as a postoperative analgesic, no studies have described dosing differences between opioid-tolerant (OT) and nonopioid-tolerant (NOT) patients or determined optimal dosing. The primary aim of this study was to assess whether OT and NOT patients had significant differences in ketamine infusion dosing requirements.

A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty.

Background: Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions.

Methods: This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection.

Perioperative Nerve Injury After Peripheral Nerve Block in Patients With Previous Systemic Chemotherapy.

Background And Objectives: There are multiple risk factors for developing perioperative nerve injury (PNI). Perioperative nerve injury after peripheral nerve blockade (PNB) is rare. Exposure to systemic chemotherapy may cause peripheral neuropathy, but its role as a risk factor for PNI after PNB is unknown.

Performance Measurement to Demonstrate Value.

Anesthesiologists are obligated to demonstrate the value of the care they provide. The Centers for Medicare and Medicaid Services has multiple performance-based payment programs to drive high-value care and motivate integrated care for surgical patients and hospitalized patients. These programs rely on diverse arrays of performance measures and complex reporting rules.

The Impact of Anesthetic Management on Surgical Site Infections in Patients Undergoing Total Knee or Total Hip Arthroplasty.

Background: Surgical site infection (SSI) is one of the most challenging and costly complications associated with total joint arthroplasty. Our primary aim in this case-controlled trial was to compare the risk of SSI within a year of surgery for patients undergoing primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) and revision TKA or THA under general anesthesia versus neuraxial anesthesia. Our secondary aim was to determine which patient, anesthetic, and surgical variables influence the risk of SSI.

The Second ASRA Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine: Executive Summary 2015.

Unlabelled: Neurologic injury associated with regional anesthetic or pain medicine procedures is extremely rare. The Second American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Neurologic Complications Associated With Regional Anesthesia and Pain Medicine focuses on those complications associated with mechanical, ischemic, or neurotoxic injury of the neuraxis or peripheral nervous system. As with the first advisory, this iteration does not focus on hemorrhagic or infectious complications or local anesthetic systemic toxicity, all of which are the subjects of separate practice advisories.

Regional Anesthesia in Patients With Preexisting Neurologic Disease.

Since publication of initial recommendations in 2008, there is limited new information regarding the performance of regional anesthesia in patients with preexisting neurologic diseases. However, the strength of evidence has increased since 2008 regarding (1) the concern that diabetic nerves are more sensitive to local anesthetics and perhaps more susceptible to injury and (2) the concern that performing neuraxial anesthesia and analgesia in patients with preexisting spinal canal pathology may increase the risk of new or worsening neurologic symptoms. This increased evidence reinforces our initial recommendations.

Worsening of Neurologic Symptoms After Spinal Anesthesia in Two Patients With Spinal Stenosis.

Objective: Spinal stenosis has been proposed as a previously unrecognized risk factor for neurologic complications after neuraxial techniques.

Case Report: We report progression of neurologic symptoms after spinal anesthesia in 2 patients with preexisting spinal stenosis, characterized preoperatively solely by nonradicular back pain. One patient had complete resolution of his proximal lower-extremity weakness/numbness within 48 hours.

Positioning artifact causing retained foreign object appearance in a radiograph of a venous catheter.

In preparation for an abdominal tumor debulking procedure, a patient had a right internal jugular central venous catheter (CVC) inserted. A radiologist interpreted a postoperative chest radiograph as containing a 7-cm foreign body in the distal lumen of the CVC. After removal, dissection of the CVC revealed a polyurethane plug in the distal lumen.

A self-paired comparison of perioperative outcomes before and after implementation of a clinical pathway in patients undergoing total knee arthroplasty.

Background And Objectives: Clinical pathways commonly modify multiple variables and deviate from long-established clinical practices. Therefore, it is difficult to perform prospective, randomized clinical trials comparing "standard care" to the "new clinical pathway." The goal of this investigation was to examine the impact of clinical pathways implementation on perioperative outcomes and institutional costs in patients undergoing total knee arthroplasty (TKA).

Factors that influence the selection of sterile glove brand: a randomized controlled trial evaluating the performance and cost of gloves.

Purpose: To determine whether glove use modifies tactile and psychomotor performance of health care providers when compared with no glove use and to evaluate factors that influence the selection of sterile glove brand.

Methods: Forty-two anesthesia providers (nine anesthesiologists, seven nurse anesthetists, 20 residents, six student nurse anesthetists) enrolled in and completed this cross-over randomized trial from May 2010 until August 2011. Participants underwent standardized psychomotor testing while wearing five different types of protective gloves.

Emergency bedside cesarean delivery: lessons learned in teamwork and patient safety.

Background: Maternal cardiovascular and pulmonary events during labor and delivery may result in adverse maternal and fetal outcome. Potential etiologies include primary cardiac events, pulmonary embolism, eclampsia, maternal hemorrhage, and adverse medication events. Remifentanil patient-controlled analgesia is an alternative when conventional neuraxial analgesia for labor is contraindicated.

Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia.

Background And Objectives: One of the most debilitating complications after total shoulder arthroplasty (TSA) is perioperative nerve injury (PNI). Interscalene blockade (ISB) improves clinical outcomes after TSA, but it may increase the risk for PNI. The objective of this large-scale, single-institution cohort study was to test the hypothesis that the use of ISB increases the risk for PNI after elective TSA.

Looking into learning: visuospatial and psychomotor predictors of ultrasound-guided procedural performance.

Background And Objectives: Despite widespread use of ultrasound in regional anesthesia, little understanding of the psychomotor and visuospatial skills required to achieve and maintain procedural proficiency exists. Despite its procedural nature, anesthesiology lags behind other fields in assessing technical aptitude among practitioners and trainees. The goals of this study were to measure relevant visuospatial and psychomotor aptitudes of anesthesia residents-in-training and to evaluate the relationship between these skill sets and the performance of ultrasound-guided regional anesthesia.

Safe and individualized labor analgesia: A review of the current options.

Although some women want to experience childbirth without medications, most women in the United States labor with an epidural or spinal analgesic. Epidurals provide relatively consistent pain relief, are long-lasting, can be titrated according to the analgesic needs of the mother, and can be bolused for procedures such as forceps, vacuum, or cesarean delivery. But they can have undesirable side effects including lower-extremity motor block, hypotension, urinary retention, and pruritus, and they may increase the risk for a slightly prolonged labor, a forceps or vacuum delivery, and fever during labor.

Neurologic complications after chlorhexidine antisepsis for spinal anesthesia.

Background And Objectives: Recent reports of infectious complications after neuraxial procedures highlight the importance of scrupulous aseptic technique. Although chlorhexidine gluconate (CHG) has several advantages over other antiseptic agents; including a more rapid onset of action, an extended duration of effect, and rare bacterial resistance, it is not approved by the US Food and Drug Administration for use before lumbar puncture because of absence of clinical safety evidence. The objective of this retrospective cohort study was to test the hypothesis that the incidence of neurologic complications associated with spinal anesthesia after CHG skin antisepsis is not different than the known incidence of neurologic complications associated with spinal anesthesia.

Perioperative nerve injury after total hip arthroplasty: regional anesthesia risk during a 20-year cohort study.

Background: Perioperative nerve injury (PNI) is a recognized complication of total hip arthroplasty (THA). Regional anesthesia (RA) techniques may increase the risk of neurologic injury. Using a retrospective cohort study, the authors tested the hypothesis that use of RA increases the risk for PNI after elective THA.

Infectious complications of regional anesthesia.

Purpose Of Review: Regional anesthesia is commonly used to provide intraoperative anesthesia and postoperative analgesia. Potential complications of both neuraxial and peripheral regional techniques include infectious sequelae. This review examines important components of practice that are known to minimize the risk of infection associated with regional anesthesia.

Postsurgical inflammatory neuropathy.

Objective: Perioperative nerve injuries are devastating complications that are commonly attributed to a variety of patient, surgical, or anesthetic factors. Well-documented causes of postsurgical neuropathy include nerve compression, stretch, contusion, or transection, which can occur following surgical trauma or patient positioning. Potential anesthetic causes of perioperative nerve injury include mechanical trauma, local anesthetic toxicity, and ischemic injury.

A case series of the anesthetic management of parturients with surgically repaired tetralogy of Fallot.

Background: Most case reports of pregnancies after surgical repair of tetralogy of Fallot have focused on cardiovascular and obstetric concerns, with relatively few authors focusing on specific intrapartum and postpartum anesthetic management strategies.

Methods: The Mayo Clinic Congenital Heart Disease Clinic and the Boston Adult Congenital Heart Disease Service databases were cross-referenced with the Mayo Clinic and the Brigham and Women's Hospital Department of Anesthesiology databases to identify patients with tetralogy of Fallot who delivered at their respective hospital from January 1, 1994, to January 1, 2008. We reviewed each medical record to evaluate parturient care during pregnancy, labor, and delivery with a focus on anesthetic management.

Multimodal clinical pathways, perineural catheters, and ultrasound-guided regional anesthesia: the anesthesiologist's repertoire for the 21st century.

Regional anesthesia is making a comeback because of improved technology and research that shows that its use results in less discomfort for patients and shorter hospital stays. This article provides a brief history of regional anesthesia, describes current techniques for administering it, and discusses potential benefits associated with it. It also describes Mayo Clinic's Total Joint Regional Anesthesia Clinical Pathway, a comprehensive care plan for patients undergoing joint replacement surgery that uses peripheral nerve blockade and multimodal analgesia.