Anesthesia and Analgesia Practice Pathway Options for Total Knee Arthroplasty: An Evidence-Based Review by the American and European Societies of Regional Anesthesia and Pain Medicine.

In 2014, the American Society of Regional Anesthesia and Pain Medicine in collaboration with the European Society of Regional Anaesthesia and Pain Therapy convened a group of experts to compare pathways for anesthetic and analgesic management for patients undergoing total knee arthroplasty in North America and Europe and to develop a practice pathway. This review is intended to be an analysis of the current literature to assist individuals and institutions in designing a pathway for total knee arthroplasty that is based on existing evidence and expert recommendation and may be customized according to individual settings.

Two for One: A Case Report of Intravenous Lipid Emulsion to Treat Local Anesthetic Systemic Toxicity in Term Pregnancy.

Combined spinal-epidural (CSE) analgesia is a frequently used method of labor analgesia. Although it is considered safe and effective, CSE can be complicated by local anesthetic systemic toxicity (LAST), a potentially life-threatening condition. We present a case of LAST that developed in a primigravida 50 minutes after uneventful placement of a CSE.

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.

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.

Fall-prevention strategies and patient characteristics that impact fall rates after total knee arthroplasty.

Background: Fall prevention has emerged as a national quality metric, a focus for The Joint Commission, because falls after orthopedic surgery can result in serious injury. In this study, we examined patient characteristics and effects of fall-prevention strategies on the incidence of postoperative falls in patients undergoing total knee arthroplasty.

Methods: We reviewed electronic records of all patients who fell after total knee arthroplasty between 2003 and 2012 (10 years).

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).

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.

Complications of regional anesthesia and acute pain management.

Perioperative nerve injuries are recognized as a complication of regional anesthesia. Although rare, studies suggest the frequency of complications is increasing. Risk factors include neural, traumatic injury during needle or catheter placement, infection, and choice of local anesthetic solution.

Neuraxial blockade in patients with preexisting spinal stenosis, lumbar disk disease, or prior spine surgery: efficacy and neurologic complications.

Background: Patients with spinal canal pathology, including spinal stenosis and lumbar disk disease, are often not considered candidates for neuraxial blockade because of the risk of exacerbating preexisting neurologic deficits or developing new neurologic dysfunction. In contrast, a history of spine surgery is thought to increase the likelihood of difficult or unsuccessful block. In this retrospective study we investigated the risk of neurologic complications and block efficacy in patients with preexisting spinal canal pathology, with or without a history of spine surgery, after neuraxial anesthesia.

Pain management in total joint arthroplasty: a historical review.

Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede recovery and delay hospital discharge. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia, but each technique has distinct advantages and disadvantages.

Contemporary pain management strategies for minimally invasive total knee arthroplasty.

The introduction of minimally invasive total knee arthroplasty has been accompanied by substantial changes in anesthesia and analgesia techniques. It is well recognized that the goals of minimally invasive surgery, which include rapid rehabilitation and improved patient function, cannot be achieved without excellent postoperative analgesia. Traditional postoperative pain management has been associated with high rates of suboptimal pain control, however.

Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition).

The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with neuraxial blockade is unknown. Although the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics, recent epidemiologic surveys suggest that the frequency is increasing and may be as high as 1 in 3000 in some patient populations.Overall, the risk of clinically significant bleeding increase with age,associated abnormalities of the spinal cord or vertebral column, the presence of an underlying coagulopathy, difficulty during needle placement,and an indwelling neuraxial catheter during sustained anticoagulation( particularly with standard heparin or low-molecular weight heparin).

Regional blockade in patients with a history of a seizure disorder.

Background: Systemic local anesthetic toxicity is a potential complication in patients undergoing regional anesthesia, particularly during procedures requiring large doses of local anesthetic, such as epidurals, caudals, and peripheral nerve blocks. It is unknown whether patients with a history of a seizure disorder are at an increased risk of central nervous system toxicity (seizures) after local anesthetic administration.

Methods: We retrospectively reviewed the medical records of all patients with documented history of a seizure disorder who underwent epidural, caudal, or peripheral nerve block from January 1, 1988 to December 31, 2001.