Objective: The amount of clinical information that anesthesia providers encounter creates an envi... more Objective: The amount of clinical information that anesthesia providers encounter creates an environment for information overload and medical error. In an effort to create more efficient OR and PACU EMR viewer platforms, we aimed to better understand the intraoperative and post-anesthesia clinical information needs among anesthesia providers. Materials and Methods: A web-based survey to evaluate 75 clinical data items was created and distributed to all anesthesia providers at our institution. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the OR and PACU settings. Results: There were 107 survey responses with distribution throughout all clinical roles. 84% of the data items fell within the top 2 proportional quarters in the OR setting compared to only 65% in the PACU. Thirty of the 75 items (40%) received an absolutely necessary rating by more than half of the respondents for the OR setting as opposed to only 19 of the 75 items (25%) in the PACU. Only 1 item was rated by more than 20% of respondents as not needed in the OR compared to 20 data items (27%) in the PACU. Conclusion: Anesthesia providers demonstrate a larger need for EMR data to help guide clinical decision making in the OR as compared to the PACU. When creating EMR platforms for these settings it is important to understand and include data items providers deem the most clinically useful. Minimizing the less relevant data items helps prevent information overload and reduces the risk for medical error.
† The authors aimed to review an important issue of the risk of postoperative falls after periphe... more † The authors aimed to review an important issue of the risk of postoperative falls after peripheral nerve block. † Only five studies qualified for meta-analysis; the patients had received lumbar plexus block or not. † Continuous lumbar plexus block increased the risk of falls compared with non-continuous block or no block. † The review, albeit involving a small number of studies, raises an important issue worthy of further research. Summary. The objective of this systematic review with meta-analysis was to determine the risk for falls after major orthopaedic surgery with peripheral nerve blockade. Electronic databases from inception through January 2012 were searched. Eligible studies evaluated falls after peripheral nerve blockade in adult patients undergoing major lower extremity orthopaedic surgery. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. The Peto odds ratio (OR) with 95% confidence intervals (CIs) were estimated from each study that compared continuous lumbar plexus blockade with non-continuous blockade or no blockade using a fixed effects model. Ten studies (4014 patients) evaluated the number of falls as an outcome. Five studies did not contain comparison groups. The meta-analysis of five studies [four randomized controlled trials (RCTs) and one cohort] compared continuous lumbar plexus blockade (631 patients) with non-continuous blockade or no blockade (964 patients). Fourteen falls occurred in the continuous lumbar plexus block group when compared with five falls within the non-continuous block or no block group (attributable risk 1.7%; number needed to harm 59). Continuous lumbar plexus blockade was associated with a statistically significant increase in the risk for falls [Peto OR 3.85; 95% CI (1.52, 9.72); P¼0.005; I 2 ¼0%]. Evidence was low (cohort) to high (RCTs) quality. Continuous lumbar plexus blockade in adult patients undergoing major lower extremity orthopaedic surgery increases the risk for postoperative falls compared with non-continuous blockade or no blockade. However, attributable risk was not outside the expected probability of postoperative falls after orthopaedic surgery.
Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity f... more Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity for congestive heart failure and cardiac dysrhythmias during pregnancy, labor, and delivery. We report the successful obstetric and anesthetic management of three women with CCTGA, review the pertinent medical literature, and discuss important issues surrounding the anesthetic management of parturients with CCTGA.
Background: The goal of this project was to describe the frequency and natural history of periope... more Background: The goal of this project was to describe the frequency and natural history of perioperative changes in vision. Methods: The authors performed a prospective evaluation of changes in visual accommodation and acuity in adult patients undergoing various surgical procedures. Patients were evaluated preoperatively and at 1 and 3 days postoperatively. For patients who had persistent blurring of vision on the third postoperative day, surveillance was extended to 1.5 yr to determine how long the visual changes persisted and if the patients required eye-care provider attention for the condition. Results: Twenty-eight of 671 patients (4.2%) reported new onset of blurred vision lasting at least 3 days after surgery. Seven of these 28 patients (1% of total) required either new corrective lens or changes in eyeglass or contact prescriptions because of persistent blurry vision. Most of the remaining patients reported resolution of blurry vision within 1 to 2 months. No significant risk factors for this problem were identified. Conclusions: In this surgical population, changes in visual acuity manifest primarily by blurred vision were reported at a surprisingly high frequency. For many of these patients, the blurring resolved within 2 months without complication, but 25% of patients who had blurred vision for 3 days or longer required visits to eye-care providers and either new corrective lens or changes in existing prescriptions.
Most case reports of pregnancies after surgical repair of tetralogy of Fallot have focused on car... more 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. 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. During the 14-year study period, a total of 27 deliveries in 20 patients with repaired tetralogy of Fallot were identified. Twenty-one deliveries (78%) among 15 parturients (75%) involved a trial of labor; all parturients received neuraxial analgesia for labor and delivery, including 18 (86%) epidural, 2 (10%) combined spinal-epidural, and 1 (5%) continuous spinal anesthetic after an unintended dural puncture. Of the 21 patients undergoing labor, 3 (14%) received invasive arterial blood pressure monitoring; 5 (24%) received continuous telemetry; 3 (14%) experienced congestive heart failure that required diuresis; 4 (19%) had obstetric or neonatal complications; and 3 (14%) had anesthesia complications. Cesarean delivery was required in 4 patients (19%) because of labor complications. Concurrent cardiovascular, obstetric, and anesthetic complications in 1 patient resulted in neonatal death. Six (22%) parturients underwent elective cesarean delivery; 4 received epidural and 2 received spinal anesthesia; no anesthetic or immediate obstetric complications occurred. Among all parturients, 5 deliveries in 5 separate parturients (19% of deliveries) reported symptoms of congestive heart failure at the time of delivery. Pregnancy outcomes for patients with repaired tetralogy of Fallot were found to be generally favorable. All patients undergoing a trial of labor or cesarean delivery had neuraxial analgesia or anesthesia. Recognition and management of congestive heart failure was necessary in 19% of deliveries.
isplatin is an alkylating chemotherapeutic drug commonly used in patients with testicular, ovar- ... more isplatin is an alkylating chemotherapeutic drug commonly used in patients with testicular, ovar- ian, and bladder malignancies, osteogenic sar- coma, and head/neck squamous cell and small cell lung carcinomas. Renal dysfunction, acoustic nerve damage, and a sensory peripheral neuropathy are among the most common and detrimental toxic side effects. The safety of performing regional anesthetic techniques in patients exposed to
The risk of severe neurologic injury after neuraxial blockade is extremely rare among the general... more The risk of severe neurologic injury after neuraxial blockade is extremely rare among the general population. However, patients with preexisting neural compromise may be at increased risk of further neurologic sequelae after neuraxial anesthesia or analgesia. We retrospectively investigated 567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy who subsequently underwent neuraxial anesthesia or analgesia. Patient demographics, neurologic history, the indication and type of neuraxial blockade, complications, and block outcome were collected for each patient. The majority of patients had chronically stable neurologic signs or symptoms at the time of block placement, with very few reporting progression of their symptoms within the last 6 mo. The type of neuraxial technique included spinal anesthesia in 325 (57%) patients, epidural anesthesia or analgesia in 214 (38%) patients, continuous spinal anesthesia in 24 (4%) patients, and a combined spinal-epidural technique in four (1%) patients. Overall, two (0.4%; 95% CI 0.1%-1.3%) patients experienced new or progressive postoperative neurologic deficits, in the setting of an uneventful neuraxial technique. In these patients, the neuraxial block may have contributed to the injury secondary to direct trauma or local anesthetic neurotoxicity around an already vulnerable nerve. Sixty-five (11.5%) technical complications occurred in 63 patients. The most common complication was unintentional elicitation of a paresthesia (7.6%), followed by traumatic (evidence of blood) needle placement (1.6%) and unplanned dural puncture (0.9%). There were no infectious or hematologic complications. The risk of severe postoperative neurologic dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anesthesia or analgesia was found to be 0.4% (95% CI 0.1%-1.3%). Clinicians should be aware of this potentially high-risk subgroup of patients when developing and implementing a regional anesthetic care plan.
Regional Anesthesia and Pain Medicine, Nov 1, 2008
Background and Objectives: Patients undergoing major orthopedic surgery experience significant po... more Background and Objectives: Patients undergoing major orthopedic surgery experience significant postoperative pain. Failure to provide adequate analgesia may impede early physical therapy and rehabilitation, which are important factors for maintaining joint range of motion and facilitating hospital dismissal. We examined the effect of a pre-emptive, multimodal, perioperative analgesic regimen emphasizing peripheral nerve block in patients undergoing total hip (THA) and total knee (TKA) arthroplasty. Perioperative outcomes and major postoperative complications were evaluated. Methods: One hundred consecutive patients undergoing primary or revision THA or TKA using the Mayo Clinic Total Joint Regional Anesthesia (TJRA) protocol were retrospectively reviewed. The TJRA protocol is a pre-emptive, multimodal, perioperative analgesic regimen emphasizing peripheral nerve block that was jointly developed by the Departments of Anesthesiology and Orthopedic Surgery. Identified patients were matched 1:1 with historical controls undergoing identical surgical procedures with traditional anesthetic techniques. Matching criteria included patient age, gender, surgeon, date of surgery, and American Society of Anesthesiologists physical status. Patient demographics, preoperative joint range of motion, and anesthetic management were recorded for each patient. The primary study outcome was hospital length of stay. Secondary outcome variables included time to ambulation, joint range of motion, and discharge eligibility. Postoperative verbal analog pain scores (VAS), opioid requirements, side effects, and perioperative complications were also documented. Results: One hundred patients underwent THA or TKA using the newly implemented Mayo Clinic TJRA protocol. Matched controls (n ϭ 100) received intravenous patient-controlled analgesia with subsequent conversion to oral analgesics for postoperative pain management. TJRA patients had significantly shorter hospital lengths of stay (3.8 days v 5.0 days; P Ͻ .001), achieved discharge eligibility significantly sooner (1.7 Ϯ 1.9 days earlier; P Ͻ .0001), and had improved joint range of motion (90° v 85°; P ϭ .008) when compared with matched controls. TJRA patients had significantly improved postoperative analgesia, including lower VAS pain scores (postoperative day 0 through postoperative day 3; P Ͻ .001), and lower opioid requirements (postoperative day 0 to postoperative day 2; P ϭ .04). Adverse outcomes such as postoperative urinary retention (50% v 31%; P Ͻ .001), and ileus formation (7% v 1%; P ϭ .01) occurred more frequently among control patients. Conclusions: Patients undergoing THA or TKA using a comprehensive, pre-emptive, multimodal analgesic regimen emphasizing peripheral nerve block may have significantly improved perioperative outcomes, and fewer adverse events, when compared with patients receiving traditional intravenous opioids during the initial postoperative period. Improved perioperative outcomes include a shortened hospital length of stay, and a significant reduction in postoperative urinary retention and ileus formation.
Most complication associated with peripheral nerve blockade fall into one of three categories: ne... more Most complication associated with peripheral nerve blockade fall into one of three categories: neurologic, hemorrhagic, or infectious. Most neurologic complications are attributable to mechanical trauma or local anesthetic toxicity. Patient, procedure, and anesthetic risk factors are reviewed. Hemorrhagic complications include bruising and hematoma formation. Single-injection and continuous catheter techniques are discussed. The possible role of catheters in infectious complications of nerve blockade is examined.
The article by Barbero et al. (1) provided interesting data complementing our original descriptio... more The article by Barbero et al. (1) provided interesting data complementing our original description of an anterior approach to the sciatic nerve (2). However, their interpretation of our previously published data deserves the following comments: 1) the authors' representation of our published landmarks was incorrect. Our landmarks are based on the use of the inferior border of the anterosuperior iliac spine (AIS) and the superior angle of the pubic symphysis tubercle. These are the same as those described by the authors. Therefore the AIS-TS lines presented in Figure 1 in their article should be changed. 2) The posterior femoral cutaneous nerve (PFCN) is a branch of the sacral plexus, not a branch of the sciatic nerve. More importantly, it is a sensory nerve (3). Contrary to the authors' belief, the PFCN does not innervate the gluteal muscle! Therefore, the PFCN block while performing a sciatic nerve block should be considered a consequence of the local anesthetic diffusion toward the PFCN and does not reflect the intensity of the sciatic block. 3) In the Introduction of their article, the authors indicate that with our technique the block of the PFCN was inadequate (?) in 45% of patients, while in the Discussion they refer to a 50% success rate! Does this 5% difference refer to the difference between inadequacy and failure? 4) In our original description (2), we did not report on the extension of this block to the PFCN. After our original publication, a technical description was indeed published (4). In this technical paper, we reported a complete block of PFCN in 9 of 16 patients, and a partial block of PFCN in 6 of 16 (37%). The failure to block the PFCN in the study by Barbero et al. (1) and our studies led to the need for supplemental anesthesia. As indicated in our technical description (4), there is no doubt that the block of the PFCN is important for surgery in the posterior aspect of the thigh, but evidence supporting the need for a complete PFCN block for surgery at the knee and below without and without a tourniquet remains to be established. Thus, in 60 patients undergoing foot surgery with the use of a tourniquet under a femoral and a posterior popliteal block, a supplemental dose of sufentanil (5-10 g) was required only in one patient (5). Further studies are required to determine the conditions in which the block of PFCN is required in the presence of a tourniquet for surgery at the knee or below.
Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Apr 30, 2013
Purpose To determine whether glove use modifies tactile and psychomotor performance of health car... more 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. Assessments of psychomotor performance included tactile, fine motor/dexterity, and hand-eye coordination tests. Subjective ratings of glove comfort and performance were reported at the completion of each glove trial. The
Anesthesiologists are obligated to demonstrate the value of the care they provide. The Centers fo... more 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. Among all specialties, anesthesiology has tremendous potential to effect wide-ranging change on diverse measures. Performance measures deserve scrutiny by anesthesiologists as tools to improve care, the means by which payment is determined, and as a means to demonstrate the value of care to surgeons, hospitals, and patients.
Regional Anesthesia and Pain Medicine, Mar 1, 2007
Objective: Continuous peripheral nerve blockade is rapidly becoming the technique of choice for t... more Objective: Continuous peripheral nerve blockade is rapidly becoming the technique of choice for the management of postoperative orthopedic pain. However, the insertion of perineural catheters may be associated with complications, including catheter kinking and knotting. A knotted catheter may be difficult or impossible to remove at the patient bedside, requiring surgical excision under general anesthesia. We describe a previously unreported minimally invasive technique of retrieving knotted peripheral nerve catheters and avoiding the need for surgical intervention. Although the described technique has been used by interventional radiologists for the removal of knotted intravascular devices, it has not been previously described for the retrieval of knotted perineural catheters. Brief Report: The Mayo Clinic Acute Pain Service database was queried and patients identified with knotted peripheral nerve catheters during the 3-year period from January 2003 to January 2006. The medical records of all identified patients were retrospectively reviewed and details of catheter placement including catheter type and location, size (gauge), ease of placement, distance threaded, and duration of use recorded. During the study period, 5,964 nonstimulating peripheral nerve catheters were placed. Of these, 8 (0.13%) patients experienced catheter knotting resulting in difficult or impossible catheter removal at the bedside. Seven (88%) of the 8 catheters were successfully removed by using a minimally invasive technique of catheter retrieval using guided fluoroscopy. The remaining catheter was removed at the bedside with patient repositioning. Conclusions: The knotting of peripheral nerve catheters is a relatively uncommon phenomenon, occurring in only 0.13% of patients. However, because the use of perineural catheters has increased within anesthesia practice, clinicians may begin to encounter these complications with greater frequency. Practitioners should be aware of surgical alternatives, including guided-fluoroscopic techniques, when simple catheter traction or tension proves unsuccessful at the patient bedside.
Chapter 2 reviews the mechanism of action for local anesthetics. Clinical features such as potenc... more Chapter 2 reviews the mechanism of action for local anesthetics. Clinical features such as potency, onset of action, duration, and dose are discussed. Drug metabolism, toxicity (local and systemic), and its treatment are included. The chapter concludes with additional information on adjuvant medications (eg, epinephrine, clonidine) used to extend or enhance the clinical effects of local anesthetics.
a Fisher's exact test. b Data were missing for five patients overall, including one patient who e... more a Fisher's exact test. b Data were missing for five patients overall, including one patient who experienced a perioperative seizure and four patients who did not experience a perioperative seizure.
C LINICAL pathways incorporating multimodal analgesic regimens including regional anesthetic tech... more C LINICAL pathways incorporating multimodal analgesic regimens including regional anesthetic techniques are widely used for patients undergoing total knee arthroplasty. 1-5 Oral analgesics, local anesthetic adjuvants, peripheral nerve blockade, and periarticular injection (also known as local infiltration analgesia) are a few of the commonly employed modalities. 6,7 When incorporated into a comprehensive clinical pathway, these pain management techniques have been shown to improve perioperative outcomes including improved patient comfort, a reduction in hospital length of stay, enhanced patient satisfaction, and an earlier return to work and recreational activities. 2,8 However, the optimal components of this multimodal approach and the role of regional techniques in improved perioperative outcomes remain unknown. What We Already Know about This Topic • Multimodal analgesia provides very good pain relief for patients after total knee arthroplasty • Peripheral nerve blocks and periarticular injections of local anesthetic are commonly used components of multimodal analgesic strategies What This Article Tells Us That Is New • In a three-arm randomized trial involving 165 adult knee arthroplasty patients, femoral and sciatic nerve blocks, ropivacaine-based periarticular injection, and liposomal bupivacaine-based periarticular injection all provided good analgesia • The peripheral nerve block strategy provided some advantages in terms of pain relief and opioid sparing at early time points after surgery
Objective: The amount of clinical information that anesthesia providers encounter creates an envi... more Objective: The amount of clinical information that anesthesia providers encounter creates an environment for information overload and medical error. In an effort to create more efficient OR and PACU EMR viewer platforms, we aimed to better understand the intraoperative and post-anesthesia clinical information needs among anesthesia providers. Materials and Methods: A web-based survey to evaluate 75 clinical data items was created and distributed to all anesthesia providers at our institution. Participants were asked to rate the importance of each data item in helping them make routine clinical decisions in the OR and PACU settings. Results: There were 107 survey responses with distribution throughout all clinical roles. 84% of the data items fell within the top 2 proportional quarters in the OR setting compared to only 65% in the PACU. Thirty of the 75 items (40%) received an absolutely necessary rating by more than half of the respondents for the OR setting as opposed to only 19 of the 75 items (25%) in the PACU. Only 1 item was rated by more than 20% of respondents as not needed in the OR compared to 20 data items (27%) in the PACU. Conclusion: Anesthesia providers demonstrate a larger need for EMR data to help guide clinical decision making in the OR as compared to the PACU. When creating EMR platforms for these settings it is important to understand and include data items providers deem the most clinically useful. Minimizing the less relevant data items helps prevent information overload and reduces the risk for medical error.
† The authors aimed to review an important issue of the risk of postoperative falls after periphe... more † The authors aimed to review an important issue of the risk of postoperative falls after peripheral nerve block. † Only five studies qualified for meta-analysis; the patients had received lumbar plexus block or not. † Continuous lumbar plexus block increased the risk of falls compared with non-continuous block or no block. † The review, albeit involving a small number of studies, raises an important issue worthy of further research. Summary. The objective of this systematic review with meta-analysis was to determine the risk for falls after major orthopaedic surgery with peripheral nerve blockade. Electronic databases from inception through January 2012 were searched. Eligible studies evaluated falls after peripheral nerve blockade in adult patients undergoing major lower extremity orthopaedic surgery. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. The Peto odds ratio (OR) with 95% confidence intervals (CIs) were estimated from each study that compared continuous lumbar plexus blockade with non-continuous blockade or no blockade using a fixed effects model. Ten studies (4014 patients) evaluated the number of falls as an outcome. Five studies did not contain comparison groups. The meta-analysis of five studies [four randomized controlled trials (RCTs) and one cohort] compared continuous lumbar plexus blockade (631 patients) with non-continuous blockade or no blockade (964 patients). Fourteen falls occurred in the continuous lumbar plexus block group when compared with five falls within the non-continuous block or no block group (attributable risk 1.7%; number needed to harm 59). Continuous lumbar plexus blockade was associated with a statistically significant increase in the risk for falls [Peto OR 3.85; 95% CI (1.52, 9.72); P¼0.005; I 2 ¼0%]. Evidence was low (cohort) to high (RCTs) quality. Continuous lumbar plexus blockade in adult patients undergoing major lower extremity orthopaedic surgery increases the risk for postoperative falls compared with non-continuous blockade or no blockade. However, attributable risk was not outside the expected probability of postoperative falls after orthopaedic surgery.
Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity f... more Women with congenitally corrected transposition of the great arteries (CCTGA) have a propensity for congestive heart failure and cardiac dysrhythmias during pregnancy, labor, and delivery. We report the successful obstetric and anesthetic management of three women with CCTGA, review the pertinent medical literature, and discuss important issues surrounding the anesthetic management of parturients with CCTGA.
Background: The goal of this project was to describe the frequency and natural history of periope... more Background: The goal of this project was to describe the frequency and natural history of perioperative changes in vision. Methods: The authors performed a prospective evaluation of changes in visual accommodation and acuity in adult patients undergoing various surgical procedures. Patients were evaluated preoperatively and at 1 and 3 days postoperatively. For patients who had persistent blurring of vision on the third postoperative day, surveillance was extended to 1.5 yr to determine how long the visual changes persisted and if the patients required eye-care provider attention for the condition. Results: Twenty-eight of 671 patients (4.2%) reported new onset of blurred vision lasting at least 3 days after surgery. Seven of these 28 patients (1% of total) required either new corrective lens or changes in eyeglass or contact prescriptions because of persistent blurry vision. Most of the remaining patients reported resolution of blurry vision within 1 to 2 months. No significant risk factors for this problem were identified. Conclusions: In this surgical population, changes in visual acuity manifest primarily by blurred vision were reported at a surprisingly high frequency. For many of these patients, the blurring resolved within 2 months without complication, but 25% of patients who had blurred vision for 3 days or longer required visits to eye-care providers and either new corrective lens or changes in existing prescriptions.
Most case reports of pregnancies after surgical repair of tetralogy of Fallot have focused on car... more 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. 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. During the 14-year study period, a total of 27 deliveries in 20 patients with repaired tetralogy of Fallot were identified. Twenty-one deliveries (78%) among 15 parturients (75%) involved a trial of labor; all parturients received neuraxial analgesia for labor and delivery, including 18 (86%) epidural, 2 (10%) combined spinal-epidural, and 1 (5%) continuous spinal anesthetic after an unintended dural puncture. Of the 21 patients undergoing labor, 3 (14%) received invasive arterial blood pressure monitoring; 5 (24%) received continuous telemetry; 3 (14%) experienced congestive heart failure that required diuresis; 4 (19%) had obstetric or neonatal complications; and 3 (14%) had anesthesia complications. Cesarean delivery was required in 4 patients (19%) because of labor complications. Concurrent cardiovascular, obstetric, and anesthetic complications in 1 patient resulted in neonatal death. Six (22%) parturients underwent elective cesarean delivery; 4 received epidural and 2 received spinal anesthesia; no anesthetic or immediate obstetric complications occurred. Among all parturients, 5 deliveries in 5 separate parturients (19% of deliveries) reported symptoms of congestive heart failure at the time of delivery. Pregnancy outcomes for patients with repaired tetralogy of Fallot were found to be generally favorable. All patients undergoing a trial of labor or cesarean delivery had neuraxial analgesia or anesthesia. Recognition and management of congestive heart failure was necessary in 19% of deliveries.
isplatin is an alkylating chemotherapeutic drug commonly used in patients with testicular, ovar- ... more isplatin is an alkylating chemotherapeutic drug commonly used in patients with testicular, ovar- ian, and bladder malignancies, osteogenic sar- coma, and head/neck squamous cell and small cell lung carcinomas. Renal dysfunction, acoustic nerve damage, and a sensory peripheral neuropathy are among the most common and detrimental toxic side effects. The safety of performing regional anesthetic techniques in patients exposed to
The risk of severe neurologic injury after neuraxial blockade is extremely rare among the general... more The risk of severe neurologic injury after neuraxial blockade is extremely rare among the general population. However, patients with preexisting neural compromise may be at increased risk of further neurologic sequelae after neuraxial anesthesia or analgesia. We retrospectively investigated 567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy who subsequently underwent neuraxial anesthesia or analgesia. Patient demographics, neurologic history, the indication and type of neuraxial blockade, complications, and block outcome were collected for each patient. The majority of patients had chronically stable neurologic signs or symptoms at the time of block placement, with very few reporting progression of their symptoms within the last 6 mo. The type of neuraxial technique included spinal anesthesia in 325 (57%) patients, epidural anesthesia or analgesia in 214 (38%) patients, continuous spinal anesthesia in 24 (4%) patients, and a combined spinal-epidural technique in four (1%) patients. Overall, two (0.4%; 95% CI 0.1%-1.3%) patients experienced new or progressive postoperative neurologic deficits, in the setting of an uneventful neuraxial technique. In these patients, the neuraxial block may have contributed to the injury secondary to direct trauma or local anesthetic neurotoxicity around an already vulnerable nerve. Sixty-five (11.5%) technical complications occurred in 63 patients. The most common complication was unintentional elicitation of a paresthesia (7.6%), followed by traumatic (evidence of blood) needle placement (1.6%) and unplanned dural puncture (0.9%). There were no infectious or hematologic complications. The risk of severe postoperative neurologic dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing neuraxial anesthesia or analgesia was found to be 0.4% (95% CI 0.1%-1.3%). Clinicians should be aware of this potentially high-risk subgroup of patients when developing and implementing a regional anesthetic care plan.
Regional Anesthesia and Pain Medicine, Nov 1, 2008
Background and Objectives: Patients undergoing major orthopedic surgery experience significant po... more Background and Objectives: Patients undergoing major orthopedic surgery experience significant postoperative pain. Failure to provide adequate analgesia may impede early physical therapy and rehabilitation, which are important factors for maintaining joint range of motion and facilitating hospital dismissal. We examined the effect of a pre-emptive, multimodal, perioperative analgesic regimen emphasizing peripheral nerve block in patients undergoing total hip (THA) and total knee (TKA) arthroplasty. Perioperative outcomes and major postoperative complications were evaluated. Methods: One hundred consecutive patients undergoing primary or revision THA or TKA using the Mayo Clinic Total Joint Regional Anesthesia (TJRA) protocol were retrospectively reviewed. The TJRA protocol is a pre-emptive, multimodal, perioperative analgesic regimen emphasizing peripheral nerve block that was jointly developed by the Departments of Anesthesiology and Orthopedic Surgery. Identified patients were matched 1:1 with historical controls undergoing identical surgical procedures with traditional anesthetic techniques. Matching criteria included patient age, gender, surgeon, date of surgery, and American Society of Anesthesiologists physical status. Patient demographics, preoperative joint range of motion, and anesthetic management were recorded for each patient. The primary study outcome was hospital length of stay. Secondary outcome variables included time to ambulation, joint range of motion, and discharge eligibility. Postoperative verbal analog pain scores (VAS), opioid requirements, side effects, and perioperative complications were also documented. Results: One hundred patients underwent THA or TKA using the newly implemented Mayo Clinic TJRA protocol. Matched controls (n ϭ 100) received intravenous patient-controlled analgesia with subsequent conversion to oral analgesics for postoperative pain management. TJRA patients had significantly shorter hospital lengths of stay (3.8 days v 5.0 days; P Ͻ .001), achieved discharge eligibility significantly sooner (1.7 Ϯ 1.9 days earlier; P Ͻ .0001), and had improved joint range of motion (90° v 85°; P ϭ .008) when compared with matched controls. TJRA patients had significantly improved postoperative analgesia, including lower VAS pain scores (postoperative day 0 through postoperative day 3; P Ͻ .001), and lower opioid requirements (postoperative day 0 to postoperative day 2; P ϭ .04). Adverse outcomes such as postoperative urinary retention (50% v 31%; P Ͻ .001), and ileus formation (7% v 1%; P ϭ .01) occurred more frequently among control patients. Conclusions: Patients undergoing THA or TKA using a comprehensive, pre-emptive, multimodal analgesic regimen emphasizing peripheral nerve block may have significantly improved perioperative outcomes, and fewer adverse events, when compared with patients receiving traditional intravenous opioids during the initial postoperative period. Improved perioperative outcomes include a shortened hospital length of stay, and a significant reduction in postoperative urinary retention and ileus formation.
Most complication associated with peripheral nerve blockade fall into one of three categories: ne... more Most complication associated with peripheral nerve blockade fall into one of three categories: neurologic, hemorrhagic, or infectious. Most neurologic complications are attributable to mechanical trauma or local anesthetic toxicity. Patient, procedure, and anesthetic risk factors are reviewed. Hemorrhagic complications include bruising and hematoma formation. Single-injection and continuous catheter techniques are discussed. The possible role of catheters in infectious complications of nerve blockade is examined.
The article by Barbero et al. (1) provided interesting data complementing our original descriptio... more The article by Barbero et al. (1) provided interesting data complementing our original description of an anterior approach to the sciatic nerve (2). However, their interpretation of our previously published data deserves the following comments: 1) the authors' representation of our published landmarks was incorrect. Our landmarks are based on the use of the inferior border of the anterosuperior iliac spine (AIS) and the superior angle of the pubic symphysis tubercle. These are the same as those described by the authors. Therefore the AIS-TS lines presented in Figure 1 in their article should be changed. 2) The posterior femoral cutaneous nerve (PFCN) is a branch of the sacral plexus, not a branch of the sciatic nerve. More importantly, it is a sensory nerve (3). Contrary to the authors' belief, the PFCN does not innervate the gluteal muscle! Therefore, the PFCN block while performing a sciatic nerve block should be considered a consequence of the local anesthetic diffusion toward the PFCN and does not reflect the intensity of the sciatic block. 3) In the Introduction of their article, the authors indicate that with our technique the block of the PFCN was inadequate (?) in 45% of patients, while in the Discussion they refer to a 50% success rate! Does this 5% difference refer to the difference between inadequacy and failure? 4) In our original description (2), we did not report on the extension of this block to the PFCN. After our original publication, a technical description was indeed published (4). In this technical paper, we reported a complete block of PFCN in 9 of 16 patients, and a partial block of PFCN in 6 of 16 (37%). The failure to block the PFCN in the study by Barbero et al. (1) and our studies led to the need for supplemental anesthesia. As indicated in our technical description (4), there is no doubt that the block of the PFCN is important for surgery in the posterior aspect of the thigh, but evidence supporting the need for a complete PFCN block for surgery at the knee and below without and without a tourniquet remains to be established. Thus, in 60 patients undergoing foot surgery with the use of a tourniquet under a femoral and a posterior popliteal block, a supplemental dose of sufentanil (5-10 g) was required only in one patient (5). Further studies are required to determine the conditions in which the block of PFCN is required in the presence of a tourniquet for surgery at the knee or below.
Canadian Journal Of Anesthesia/journal Canadien D'anesthésie, Apr 30, 2013
Purpose To determine whether glove use modifies tactile and psychomotor performance of health car... more 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. Assessments of psychomotor performance included tactile, fine motor/dexterity, and hand-eye coordination tests. Subjective ratings of glove comfort and performance were reported at the completion of each glove trial. The
Anesthesiologists are obligated to demonstrate the value of the care they provide. The Centers fo... more 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. Among all specialties, anesthesiology has tremendous potential to effect wide-ranging change on diverse measures. Performance measures deserve scrutiny by anesthesiologists as tools to improve care, the means by which payment is determined, and as a means to demonstrate the value of care to surgeons, hospitals, and patients.
Regional Anesthesia and Pain Medicine, Mar 1, 2007
Objective: Continuous peripheral nerve blockade is rapidly becoming the technique of choice for t... more Objective: Continuous peripheral nerve blockade is rapidly becoming the technique of choice for the management of postoperative orthopedic pain. However, the insertion of perineural catheters may be associated with complications, including catheter kinking and knotting. A knotted catheter may be difficult or impossible to remove at the patient bedside, requiring surgical excision under general anesthesia. We describe a previously unreported minimally invasive technique of retrieving knotted peripheral nerve catheters and avoiding the need for surgical intervention. Although the described technique has been used by interventional radiologists for the removal of knotted intravascular devices, it has not been previously described for the retrieval of knotted perineural catheters. Brief Report: The Mayo Clinic Acute Pain Service database was queried and patients identified with knotted peripheral nerve catheters during the 3-year period from January 2003 to January 2006. The medical records of all identified patients were retrospectively reviewed and details of catheter placement including catheter type and location, size (gauge), ease of placement, distance threaded, and duration of use recorded. During the study period, 5,964 nonstimulating peripheral nerve catheters were placed. Of these, 8 (0.13%) patients experienced catheter knotting resulting in difficult or impossible catheter removal at the bedside. Seven (88%) of the 8 catheters were successfully removed by using a minimally invasive technique of catheter retrieval using guided fluoroscopy. The remaining catheter was removed at the bedside with patient repositioning. Conclusions: The knotting of peripheral nerve catheters is a relatively uncommon phenomenon, occurring in only 0.13% of patients. However, because the use of perineural catheters has increased within anesthesia practice, clinicians may begin to encounter these complications with greater frequency. Practitioners should be aware of surgical alternatives, including guided-fluoroscopic techniques, when simple catheter traction or tension proves unsuccessful at the patient bedside.
Chapter 2 reviews the mechanism of action for local anesthetics. Clinical features such as potenc... more Chapter 2 reviews the mechanism of action for local anesthetics. Clinical features such as potency, onset of action, duration, and dose are discussed. Drug metabolism, toxicity (local and systemic), and its treatment are included. The chapter concludes with additional information on adjuvant medications (eg, epinephrine, clonidine) used to extend or enhance the clinical effects of local anesthetics.
a Fisher's exact test. b Data were missing for five patients overall, including one patient who e... more a Fisher's exact test. b Data were missing for five patients overall, including one patient who experienced a perioperative seizure and four patients who did not experience a perioperative seizure.
C LINICAL pathways incorporating multimodal analgesic regimens including regional anesthetic tech... more C LINICAL pathways incorporating multimodal analgesic regimens including regional anesthetic techniques are widely used for patients undergoing total knee arthroplasty. 1-5 Oral analgesics, local anesthetic adjuvants, peripheral nerve blockade, and periarticular injection (also known as local infiltration analgesia) are a few of the commonly employed modalities. 6,7 When incorporated into a comprehensive clinical pathway, these pain management techniques have been shown to improve perioperative outcomes including improved patient comfort, a reduction in hospital length of stay, enhanced patient satisfaction, and an earlier return to work and recreational activities. 2,8 However, the optimal components of this multimodal approach and the role of regional techniques in improved perioperative outcomes remain unknown. What We Already Know about This Topic • Multimodal analgesia provides very good pain relief for patients after total knee arthroplasty • Peripheral nerve blocks and periarticular injections of local anesthetic are commonly used components of multimodal analgesic strategies What This Article Tells Us That Is New • In a three-arm randomized trial involving 165 adult knee arthroplasty patients, femoral and sciatic nerve blocks, ropivacaine-based periarticular injection, and liposomal bupivacaine-based periarticular injection all provided good analgesia • The peripheral nerve block strategy provided some advantages in terms of pain relief and opioid sparing at early time points after surgery
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Papers by James Hebl