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BackgroundEvidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.MethodsA systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.ResultsAnalysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).ConclusionsBased on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.Recommendation: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Arthroscopic shoulder surgery is one of the most frequently performed orthopedic surgical procedures in the USA, with over 500 000 procedures occurring each year.[1 2][1] The sitting, or beach chair position (BCP), with the back elevated between 45° and 75°, is used in the great majority of

Background and Objectives Perineural dexamethasone and intravenous (IV) dexamethasone have been shown to prolong peripheral nerve block duration. The effects of perineural and IV dexamethasone have only been compared at doses of 4 mg or greater. This triple-blind, randomized trial examined the effect of 1 mg IV versus perineural dexamethasone on interscalene block (ISB) analgesia duration. Methods Patients undergoing ambulatory shoulder arthroscopy received an ultrasound-guided ISB with 15 mL bupivacaine 0.5% and 1 mg preservative-free dexamethasone that was administered perineurally (PeriD) or IV (IVDex). All patients received IV ketorolac and were discharged on naproxen 500 mg 2 times a day plus oxycodone/acetaminophen as needed. Peripheral nerve block duration, pain, opioid consumption, and block satisfaction were assessed via telephone follow-ups. Results There were 63 PeriD patients and 62 IVDex patients who completed the primary outcome follow-up. The median time until analgesia from the ISB completely wore off was 3.5 hours (95% confidence interval, 1.0–6.0 hours) longer in the PeriD versus IVDex groups; P = 0.007). Time until the pain relief from the ISB began to wear off was also longer in the PeriD versus IVDex group (5.5 hours [95% confidence interval, 2.1–9.0 hours]; P = 0.002). Other secondary outcomes, including opioid consumption, satisfaction, and pain scores, were not different between groups. Conclusions In patients undergoing shoulder arthroscopy, low-dose perineural dexamethasone (1 mg) in combination with 15 mL of 0.5% bupivacaine prolonged the median time until pain relief from the ISB completely wore off compared with 1 mg IV dexamethasone. However, the degree of prolongation was smaller than the a priori–defined minimal clinically meaningful difference of 5 hours. Clinical Trial Registration This study was registered at Clinicaltrials.gov, identifier NCT02506660.

An 18-month-old baby boy presented with vomiting and dysphagia was admitted to a peripheral hospital. The initial diagnosis was gastroenteritis, and he was treated accordingly. A routine SARS-CoV-2 test was positive, but he did not have any significant respiratory symptoms. However, 5 days after

Background and Objectives Sciatic nerve block provides analgesia after foot and ankle surgery, but block duration may be insufficient. We hypothesized that perineural dexamethasone and buprenorphine would reduce pain scores at 24 hours. Methods Ninety patients received ultrasound-guided sciatic (25 mL 0.25% bupivacaine) and adductor canal (10 mL 0.25% bupivacaine) blockade, with random assignment into 3 groups (30 patients per group): control blocks + intravenous (IV) dexamethasone (4 mg) (control); control blocks + IV buprenorphine (150 μg) + IV dexamethasone (IV buprenorphine); and nerve blocks containing buprenorphine + dexamethasone (perineural). Patients received mepivacaine neuraxial anesthesia and postoperative oxycodone/acetaminophen, meloxicam, pregabalin, and ondansetron. Patients and assessors were blinded to group assignment. The primary outcome was pain with movement at 24 hours. Results There was no difference in pain with movement at 24 hours (median score, 0). However, the perineural group had longer block duration versus control (45.6 vs 30.0 hours). Perineural patients had lower scores for “worst pain” versus control (median, 0 vs 2). Both IV buprenorphine and perineural groups were less likely to use opioids on the day after surgery versus control (28.6%, 28.6%, and 60.7%, respectively). Nausea after IV buprenorphine (but not perineural buprenorphine) was severe, frequent, and bothersome. Conclusions Pain scores were very low at 24 hours after surgery in the context of multimodal analgesia and were not improved by additives. However, perineural buprenorphine and dexamethasone prolonged block duration, reduced the worst pain experienced, and reduced opioid use. Intravenous buprenorphine caused troubling nausea and vomiting. Future research is needed to confirm and extend these observations.

Background and Objectives: Intraoperative hypotension is used to reduce surgical bleeding. Case reports of stroke after general anesthesia in the sitting position led us to collect data (patient demographics, medical risk factors for stroke, intraoperative hemodynamics) about the incidence of stroke after surgery in the sitting position. Methods: This study reviewed 4169 (3000 retrospective, 1169 prospective) ambulatory shoulder surgeries in the sitting position. For the prospective cohort, patients were queried postoperatively regarding stroke, with corroboration from 4 databases (anesthesia department quality assurance, hospital case management, state-reportable events, and hospital information system diagnostic code databases). For the retrospective cohort, rate of stroke was determined via the same 4 databases. Results: No patient had a stroke (95% confidence interval, 0%-0.07%). Risk factors for perioperative stroke were present in 40% of patients. Brachial plexus nerve block with intravenous sedation was used for 95.7% (retrospective) and 99.8% (prospective) of the cohorts. Many patients (47%) experienced intraoperative hypotension by at least one definition: 40% (retrospective) and 30% (prospective) had at least a 30% decrease in mean arterial pressure; 27% (retrospective) and 24% (prospective) had a mean pressure less than 66 mm Hg; and 13% (retrospective) and 12% (prospective) had a systolic blood pressure of less than 90 mm Hg. Conclusions: No strokes were observed in 4169 patients. The estimated upper limit of the 95% confidence interval for stroke after regional anesthesia for shoulder surgery in the seated position is 0.07%, despite frequent incidence of hypotension.

Progress continues on American Society of Regional Anesthesia (ASRA) AcutePOP. Highlights include selection of data fields and creation of definitions for complications jointly accepted by clinical registries for ASRA, American Society of Anesthesiologists, Regional Anesthesia Surveillance System, Society for Obstetric Anesthesia and Perinatology, and Society for Pediatric Anesthesia. Development of a Web site and applications continues, and a demonstration is planned for the ASRA 2009 meeting.

Ultrasound guidance has become popular for performance of regional anesthesia and analgesia. This systematic review summarizes existing evidence for superior risk to benefit profiles for ultrasound versus other techniques. Medline was systematically searched for randomized controlled trials (RCTs) comparing ultrasound to another technique, and for large (n > 100) prospective case series describing experience with ultrasound-guided blocks. Fourteen RCTs and 2 case series were identified for peripheral nerve blocks. No RCTs or case series were identified for perineural catheters. Six RCTs and 1 case series were identified for epidural anesthesia. Overall, the RCTs and case series reported that use of ultrasound significantly reduced time or number of attempts to perform blocks and in some cases significantly improved the quality of sensory block. The included studies reported high incidence of efficacy of blocks with ultrasound (95%-100%) that was not significantly different than most other techniques. No serious complications were reported in included studies. Current evidence does not suggest that use of ultrasound improves success of regional anesthesia versus most other techniques. However, ultrasound was not inferior for efficacy, did not increase risk, and offers other potential patient-oriented benefits. All RCTs are rather small, thus completion of large RCTs and case series are encouraged to confirm findings.