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Background Intraoperative fluid management may affect the outcome after kidney transplantation. However, the amount and type of fluid administered, and monitoring techniques vary greatly between institutions and there are limited prospective randomized trials and meta-analyses to guide fluid management in kidney transplant recipients. Methods Members of the American Society of Anesthesiologists (ASA) committee on transplantation reviewed the current literature on the amount and type of fluids (albumin, starches, 0.9% saline, and balanced crystalloid solutions) administered and the different monitors used to assess fluid status, resulting in this consensus statement with recommendations based on the best available evidence. Results Review of the current literature suggests that starch solutions are associated with increased risk of renal injury in randomized trials and should be avoided in kidney donors and recipients. There is no evidence supporting the routine use of albumin solutions in kidney transplants. Balanced crystalloid solutions such as Lactated Ringer are associated with less acidosis and may lead to less hyperkalemia than 0.9% saline solutions. Central venous pressure is only weakly supported as a tool to assess fluid status. Conclusions These recommendations may be useful to anesthesiologists making fluid management decisions during kidney transplantation and facilitate future research on this topic.

Introduction Sub-anesthetic ketamine is frequently used as an analgesic to reduce perioperative opioid consumption and has also been shown to have antidepressant effects. Side effects of ketamine include dizziness, diplopia, nystagmus, and psychomimetic effects. It is unclear what clinical factors may be associated with ketamine-related adverse drug events (ADEs). Methods We performed a retrospective review of 95 patients who received sub-anesthetic ketamine infusions at our institution. Data examined associations between ketamine-related ADEs and various clinical characteristics including chronic pain, depression, or psychiatric disorder, patient physical characteristics, chronic opioid use, perioperative opioid use, dose and duration of ketamine infusions, pain scores, and perioperative medications such as serotonergic agents, central nervous system (CNS) depressants, and analgesics. Results Overall incidence of ketamine-related ADEs was 29.5% and the incidence of psychomimetic effects was 14.8%. We observed that patients with a history of depression have a lower incidence of ketamine-related ADEs compared to patients without a history of depression (10.3% vs 37.3%; p value = 0.007). Conclusion Patients with depression were found to have a statistically significant reduction in the incidence of ketamine-related ADEs. We found no statistically significant positive associations between ketamine-related ADEs and other clinical factors such as a history of chronic pain, psychiatric disease, patient physical characteristics, perioperative opioid use, dose of ketamine infusion, or co-administration of other CNS depressants.

This article presents three cases of cranial nerve palsy following shoulder surgery with general anesthesia in the beach chair position. All patients underwent preoperative ultrasound-guided interscalene nerve block. Two cases of postoperative hypoglossal and one case of combined hypoglossal and recurrent laryngeal nerve palsies (Tapia’s syndrome) were identified. Through this case series, we provide a literature review identifying postoperative cranial nerve palsies in addition to the discussion of possible etiologies. We suggest that intraoperative patient positioning and/or airway instrumentation is most likely causative. We conclude that the beach chair position is a risk factor for postoperative hypoglossal nerve palsy and Tapia’s syndrome.

Introduction. Obesity is a common comorbidity seen in the perioperative setting and is associated with many diseases including cardiovascular disease and obstructive sleep apnea. Laparoscopic Roux-en-Y gastric bypass is the gold standard surgical treatment for patients whose weight is refractory to diet and exercise. Caring for these patients perioperatively presents unique challenges to anesthesiologists and is associated with an increased risk of adverse respiratory events. In our study, we hypothesize that a low-dose perioperative ketamine infusion will reduce opioid consumption and improve analgesia when compared to standard therapy. Methods. This is a single-center, prospective randomized controlled study enrolling 35 patients in total. Patients were randomized equally into the ketamine and control group. Preop, intraop, and postop management regimens were standardized. The ketamine group received a 0.3 mg/kg ideal body weight ketamine bolus after induction followed by a 0.2 mg/kg/hr ketamine infusion continued into the postop setting for up to 24 hours. Data collected included total perioperative opioids used converted to oral morphine equivalents (ME), pain scores, side effects, hospital length of stay, and patient satisfaction captured via postoperative questionnaires. Results. The use of perioperative opioid consumption was significantly lower in the ketamine group when compared with the control group (179.9 ME versus 248.7 ME, P = 0.03 ). There was no statistically significant difference in pain scores or hospital length of stay postoperatively between the two groups. There were also no reported adverse respiratory events, prolonged sedation, agitation, or other side effects reported in either group. The patient satisfaction questionnaires showed a significant difference with the ketamine group reporting lower maximum pain scores, a decrease in how pain limited activities of daily living once discharged, and increased hospital pain management satisfaction scores. Conclusions. Perioperative low-dose ketamine infusions significantly reduced opioid consumption in morbidly obese patients undergoing laparoscopic gastric bypass surgery.

Background Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher. Materials and methods A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals. Results No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management. Conclusion When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.

Intraoperative Transesophageal Echocardiography (TEE) during orthotopic liver transplant (OLT) is used to gather real-time information on cardiovascular function and intravascular volume status. We report a case where nonstandard TEE views were used to inspect the hepatic vasculature after allograft implantation. A 29-year-old male with secondary biliary cirrhosis with a MELD score of 20 underwent OLT using a liver from a 21-year-old brain-dead donor. Postreperfusion TEE, using the modified hepatic vein views, confirmed the presence of an inferior vena cava (IVC) suprahepatic anastomotic stenosis and hepatic vein and IVC thrombus resulting in hepatic venous outflow obstruction, allograft congestion, and hemodynamic instability. These nonstandard TEE images established the extent of suprahepatic caval outflow obstruction, in which intraoperative ultrasound was unable to definitively demonstrate. This guided real-time surgical decision-making in the postimplantation phase of the operation—ultimately leading to hepatic vein and IVC thrombectomy and revision of suprahepatic caval anastomosis.

Background and Aims: There are limited data on the effect of ampule size on drug dosing. The objective of this study is to determine the effect of ampule size on perioperative opioid dosing and post-anesthesia care unit (PACU) outcomes. Material and Methods: This was a retrospective review of patients undergoing robotically assisted laparoscopic radical prostatectomy before and after a 5-ml fentanyl ampule was discontinued. The primary outcome was intraoperative opioid administration divided into fentanyl at induction of anesthesia, total fentanyl, and total opioid. Secondary outcomes observed in PACU included the opioid administered, visual analog scale (VAS) pain scores, postoperative nausea and vomiting, and length of stay in PACU. Results: A total of 100 patients (50 PRE and 50 POST) were included. In the intraoperative opioid administration, mean (SD) of fentanyl at induction was 117.0 (49.3) in PRE group and 85.0 (35.4) μg in POST group (P < 0.01). The total fentanyl requirement was 247.0 (31.0) in PRE group and 158.5 (85.1) μg in POST group (P < 0.01). The total opioid in intravenous morphine equivalents (IVME) was 34.1 (5.8) in PRE group and 23.2 (6.8) mg in POST group (P < 0.01). Among the secondary outcomes, mean (SD) of IVME of opioid was 7.7 (8.2) in PRE group and 9.9 (8.1) mg in POST group (P = 0.18). The VAS pain score on arrival was 0.7 (1.4) in PRE group and 3.8 (3.3) in POST group (P < 0.01). The cumulative VAS pain score was 2.3 (2.0) in PRE group and 3.3 (2.2) in POST group (P < 0.01). The length of stay was significantly more in POST group, 193.8 (75.8) minutes, as compared with PRE group, 138.6 (61.0) minutes (P < 0.01). Conclusions: A change in the ampule size significantly affected intraoperative dosing, PACU pain scores, and PACU length of stay in patients undergoing robotically assisted laparoscopic radical prostatectomy under general anesthesia. This was explained by clinician's desire to conserve the drug and avoid the complex process of narcotic waste disposal.

Background Previous studies have demonstrated improvements in efficiency when specific procedures are performed in a designated preoperative area prior to proceeding to the operating room. In this study the authors sought to evaluate if spinal anesthesia could be safely and efficiently administered prior to proceeding to the operating room when compared to general anesthesia and spinal anesthesia administered in the operating room. Methods The authors reviewed the electronic health record at a single institution between the years 2012 to 2018. Total joint arthroplasties by a single surgeon were identified and the specific time frames of interest were measured and compared between patients who received a spinal anesthetic in the preoperative area, patients who received a general anesthetic, and patients who received a spinal anesthetic in the operating room. These time frames of interest included: anesthesia induction time, operating room recovery time, post anesthesia recovery unit time, and operating room turnover time. The electronic medical record was also reviewed for spinal-related adverse events. Categorical variables were compared using the Fisher exact test and continuous variables were compared using equal-variance t-test and one-way ANOVA. Results The study cohort consisted of 246 patients (142 total hip arthroplasty and 104 total knee arthroplasty); 40.2% (99) of patients received a general anesthetic (GA), 52% (128) of patients received a preoperative spinal anesthetic (PSA), and 7.7% (19) of patients received an intraoperative spinal anesthetic (ISA). Preoperative spinal anesthetics demonstrated a shorter anesthesia induction time, shorter operating room recovery times, shorter PACU recovery times, and longer operating room turnover times when compared to general anesthesia and intraoperative spinals. There were no spinal-related adverse events. Conclusion The results of this retrospective cohort study demonstrate that administration of spinal anesthesia in the preoperative area is safe as compared with intra-operative spinal administration. Pre-operative spinal for total joint arthroplasty reduces time spent in the operating room and PACU when compared with general anesthesia and intraoperative spinal but it does not substantially affect overall perioperative efficiency.

Andrew W Gorlin,David M Rosenfeld,Jillian Maloney,Christopher S Wie,Johnathan McGarvey,Terrence L Trentman Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA Abstract: The conversion of high-dose intravenous (IV) opioids to an equianalgesic epidural (EP) or intrathecal (IT) dose is a common clinical dilemma for which there is little evidence to guide practice. Expert opinion varies, though a 100 IV:10:EP:1 IT conversion ratio is commonly cited in the literature, especially for morphine. In this study, the authors surveyed 724 pain specialists to elucidate the ratios that respondents apply to convert high-dose IV morphine, hydromorphone, and fentanyl to both EP and IT routes. Eighty-three respondents completed the survey. Conversion ratios were calculated and entered into graphical scatter plots. The data suggest that there is wide variation in how pain specialists convert high-dose IV opioids to EP and IT routes. The 100 IV:10 EP:1 IT ratio was the most common answer of survey respondent, especially for morphine, though also for hydromorphone and fentanyl. Furthermore, more respondents applied a more aggressive conversion strategy for hydromorphone and fentanyl, likely reflecting less spinal selectivity of those opioids compared with morphine. The authors conclude that there is little consensus on this issue and suggest that in the absence of better data, a conservative approach to opioid conversion between IV and neuraxial routes is warranted. Keywords: intrathecal pump, epidural, cancer pain

Background: Minimally invasive repair of pectus excavatum (MIRPE) is now performed in adults. Managing adult patients’ pain postoperatively has been challenging due to increased chest wall rigidity and the pressure required for supporting the elevated sternum. The optimal pain management regimen has not been determined. We designed this prospective, randomized trial to compare postoperative pain management and outcomes between thoracic epidural analgesia (TEA) and bilateral subcutaneous infusion pump catheters (On-Q). Methods: Patients undergoing MIRPE (modified Nuss) underwent random assignment to TEA or On-Q group. Both groups received intravenous, patient-controlled opioid analgesia, with concomitant delivery of local anesthetic. Primary outcomes were length of stay (LOS), opioid use, and pain scores. Results: Of 85 randomly assigned patients, 68 completed the study [52 men, 76.5%; mean (range) age, 32.2 (20.0–58.0) years; Haller index, 5.9 (range, 3.0-26.7)]. The groups were equally matched for preoperative variables; however, the On-Q arm had more patients (60.3%). No significant differences were found between groups in mean daily pain scores (P=0.52), morphine-equivalent opioid usage (P=0.28), or hospital stay 3.5 vs . 3.3 days (TEA vs . On-Q; P=0.55). Thirteen patients randomized to TEA refused the epidural and withdrew from the study because they perceived greater benefit of the On-Q system. Conclusions: Postoperative pain management in adults after MIRPE can be difficult. Both continuous local anesthetic delivery by TEA and On-Q catheters with concomitant, intravenous, patient-controlled anesthesia maintained acceptable analgesia with a reasonable LOS. In our cohort, there was preference for the On-Q system for pain management.

Ketamine, an N-methyl-d-aspartate antagonist, blunts central pain sensitization at sub-anesthetic doses (0.3 mg/kg or less) and has been studied extensively as an adjunct for perioperative analgesia. At sub-anesthetic doses, ketamine has a minimal physiologic impact though it is associated with a low incidence of mild psychomimetic symptoms as well as nystagmus and double vision. Contraindications to its use do exist and due to ketamine's metabolism, caution should be exercised in patients with renal or hepatic dysfunction. Sub-anesthetic ketamine improves pain scores and reduces perioperative opioid consumption in a broad range of surgical procedures. In addition, there is evidence that ketamine may be useful in patients with opioid tolerance and for preventing chronic postsurgical pain.

Background. Utilization of intraoperative transesophageal echocardiography (TEE) during orthotopic liver transplantation (OLT) is expanding annually in high-volume transplant centers. During OLT intraoperative TEE is used to gather real-time information on cardiovascular function and intravascular volume status. Although standardized TEE views exist, there are nontraditional views described in the literature which have the potential to diagnose evolving pathology and define normal variants of hepatic vasculature. Methods. A literature review was completed utilizing the PubMed database for English-only, peer-reviewed publications discussing nontraditional use of intraoperative TEE during OLT and hepatic vascular-related surgeries from 2009 to 2019. Both case reports and review articles were considered. Results. The PubMed literature search offered 8 publications for analysis, including 7 case reports and 1 article review, revealing several nontraditional TEE views not included in a comprehensive transesophageal echocardiographic examination. These nontraditional views were generally obtained using modifications to the transgastric and bicaval views to visualize liver vasculature. We present the various techniques for obtaining these views from the 8 articles identified. Conclusions. At high-volume transplant centers, TEE use during OLT is increasing. Intraoperative TEE is a valuable tool to assess hepatic vascular structures critical to allograft/organ function without interruption of the surgical procedure. Nontraditional use of TEE to diagnose intraoperative noncardiac pathology in OLT appears underutilized and underreported. The modified hepatic and modified transgastric views we describe can be used to evaluate hepatic vasculature, influence surgical decision-making and ultimately improve patient care.

Organ shortage is a major cause of delayed liver transplantation and increased waitlist time. The level of donor steatosis is a significant determinant in organ selection. Scarcity of organs has led some programs to expand their acceptable criteria for the percentage of steatosis. We report two cases of liver transplantation of steatotic donor organs that resulted in mortality within hours from transplantation. Postmortem analysis showed evidence of diffuse pulmonary fat microemboli likely originating from the donor organ, with marked preservation reperfusion injury. The mechanism of diffuse fat microemboli in this setting and possible relationship to other perioperative syndromes (transfusion-related lung injury, acute kidney injury, and postreperfusion syndrome) is discussed.

We review contemporary coagulation management for patients undergoing liver transplantation. A better understanding of the complex physiologic changes that occur in patients with end-stage liver disease has resulted in significant advances in anesthetic and coagulation management. A group of internationally recognized experts have critically evaluated current approaches for coagulopathy detection and management. Strategies for blood component and factor replacement have been evaluated and recommended therapies proposed. Pharmacologic treatment and prevention of coagulopathy, management of patients receiving antiplatelet medications, and the role of transesophageal echocardiography for early detection and management of thromboses are presented.

Introduction Analyzing hospital naloxone use may assist in identification of areas for quality and safety improvement. Our primary objective is to quantitate the incidence of hospital naloxone use and to assess certain patient populations at risk. Methods During the years 2008 to 2011, each clinical scenario where naloxone was administered on an in-patient care ward was reviewed. The events were assessed to separate situations where naloxone rescue was effective in reversing opioid-induced intoxication vs. others. Further analysis was conducted to stratify patient populations at greatest risk. Results Naloxone was administered for well-defined opioid-induced respiratory depression and oversedation 61% of the time, the remainder used for patient deterioration of other etiology. Surgical populations are at risk with an incidence of 3.8/1,000 hospitalized patients, and this is the greatest within 24 hours of surgery. General surgical patients represent the highest surgical patient risk at 5.5/1,000. Medical patients represent lower risk at 2.0/1,000. Patients with patient-controlled analgesia and epidural opioid infusion are high risk at 12.1 and 13.1/1,000 patients, respectively. Many quality and safety interventions were gradually implemented in response to this data and are summarized. These include nursing and provider education, electronic medical record modification, and more stringent patient monitoring practices. Conclusion Examination of naloxone use can assist in the identification and stratification of patients at risk for opioid-induced respiratory depression and oversedation and can serve as a driver for improvements in hospital patient safety. This information can also guide other institutions interested in similar improvements.

Introduction Sexual dysfunction is a well-known side effect of antidepressants. Painful ejaculation is a rare side effect that has been reported with the use of some psychiatric drugs such as triclyclic antidepressants. Cyclobenzaprine is a muscle relaxant that is structurally similar to tricyclic antidepressants. It is the most commonly prescribed muscle relaxant in the United States and accounts for 18% of all prescriptions written for chronic back pain. Methods A 55-year-old man was referred to our pain medicine clinic for evaluation and treatment of pain with ejaculation. Main outcome Measure The main outcome measure was to review the current published literature and case reports on painful ejaculation from medication use, in particular tricyclic antidepressants. Results After discontinuation of cyclobenzaprine, our patient's sexual dysfunction resolved. This result was consistent with the literature reviewed on the topic. Conclusion Painful ejaculation is likely an underreported side effect of tricyclic antidepressants and cyclobenzaprine use. Fortunately, these symptoms are reversible and discontinuation of these medications is typically an effective cure.

Introduction €‚ Occipital nerve stimulation (ONS) may provide relief for refractory headache disorders. However, scant data exist regarding long-€term ONS outcomes. Methods €‚ The methods used were retrospective review of the medical records of all (nonindustry study) patients who were trialed and implanted with occipital nerve stimulator systems at our institution, followed by a phone interview. Up to three attempts were made to contact each patient, and those who were contacted were given the opportunity to participate in a brief phone interview regarding their ONS experience. Data for analysis were gleaned from both the phone interview and the patient's medical records. Results €‚ Twenty-nine patients underwent a trial of ONS during the 8.5-€year study period. Three patients did not go on to permanent implant, 12 could not be contacted, and 14 participated in the phone interview. Based upon the phone interview (if the patient was contacted) or chart review, ONS was deemed successful in five of the 12 migraine, four of the five cluster headache, and five of the eight miscellaneous headache patients, and therapy was documented as long as 102 months. In one of the 26 patients, success of ONS could not be determined. Among patients deemed to have successful outcomes, headache frequency decreased by 18%, severity by 27%, and migraine disability score by 50%. Fifty-€eight percent of patients required at least one lead revision. Discussion €‚ These results, although limited by their retrospective nature, suggest that ONS can be effective long term despite technical challenges. The number of patients within each headache subtype was insufficient to draw conclusions regarding the differential effect of ONS. Conclusions €‚ Randomized controlled long-€term studies in specific, intractable, primary headache disorders are indicated.

This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

Objective: Occipital nerve stimulation can be effective therapy for recalcitrant headache disorders. Lead migration remains the primary technical adverse event associated with this therapy. Revision surgery for occipital nerve stimulator leads sometimes requires exposure of all components including internal pulse generator, extension cables, connectors, and leads with multiple incisions. However, minimizing the invasiveness of revision surgery reduces the time, infection risk, and discomfort associated with the procedure. We describe two techniques that attempt to minimize the extent of revision surgery necessary for lead migration. Materials and Methods: We describe two minimally invasive revision techniques. One uses a 14-gauge Tuohy needle converted to a slotted needle. The other uses a standard Tuohy needle inserted subcutaneously into the anchor site along the desired course of the lead. Results: Both techniques allow replacement of a migrated occipital nerve stimulator lead while eliminating the need to access connector or battery sites with multiple incisions. Conclusions: When migration occurs, the techniques described can simplify lead revision while minimizing the invasiveness of the procedure.

Background: Millions of patients suffer from medically refractory and disabling primary headache disorders. This problem has led to a search for new and innovative treatment modalities, including neuromodulation of the occipital nerves. Objectives: The primary aim of this study is to describe an implantation technique for the Bion® microstimulator and document stimulation parameters and stimulation maps after Bion placement adjacent to the greater occipital nerve. The secondary aim is to document outcome measures one year post-implant. Design: Prospective, observational feasibility study. Methods: Nine patients with medically refractory primary headache disorders participated in this study. Approximately 6 months after Bion insertion, stimulation parameters and maps were documented for all patients. At one year, outcome measures were collected including the Migraine Disability Assessment Score. Results: At 6 months, the mean perception threshold was 0.47 mA, while the mean discomfort threshold was 6.8 mA (stimulation range 0.47 – 6.8 mA). The mean paresthesia threshold was 1.64 mA and the mean usage range was 16.0. There were no major complications reported such as device migration, infection, or erosion. One patient stopped using her Bion before the 12-month follow-up visit. At one year, 7 of the 8 patients were judged as having obtained fair or better results in terms of reduction of disability; 5 patients had greater than a 90% reduction in disability. Limitations: Small, heterogeneous patient population without control group. Not blinded or randomized. Conclusion: The Bion can be successfully inserted adjacent to the greater occipital nerve in an effort to treat refractory primary headache disorders. This microstimulator may provide effective occipital stimulation and headache control while minimizing the risks associated with percutaneous or paddle leads implanted subcutaneously in the occipital region. Key words: Chronic headache, migraine, cluster headache, peripheral nerve stimulation

Objective: To document the per patient rate of vasovagal reactions and other complications of cervical vs. lumbar translaminar epidural steroid injections. Background: Anecdotal observations at our institution suggested that vasovagal reactions are much more common during cervical epidural steroid injections than lumbar injections, and more frequent than previously reported. Methods: Records of 249 patients undergoing their first cervical epidural steroid injection were reviewed for vasovagal reactions and other adverse events. For comparison, a first lumbar epidural steroid injection performed by the same staff physician was matched to each cervical procedure and reviewed for complications. Results: The incidence of vasovagal reaction was 7 points more common (P

Background Facial pain can be a management challenge. Peripheral nerve/field stimulation may be an effective option for refractory cases, but direct muscle stimulation with facial twitching may result. Botulinum toxin injections have been used for blepharospasm and may be effective when facial stimulation results in unacceptable facial muscle twitching due to peripheral stimulation. Case presentation A 53-year old female suffered with chronic, refractory facial pain and migraines. Her facial pain began after a root canal of a left upper molar. She was trialed and then permanently implanted with a 1 × 8 sub-compact percutaneous stimulator lead, resulting in improved pain control and reduced medication use. However, she experienced blepharospasm whenever the amplitude was above 2.75 A. Therefore, she was treated with botulinum toxin injections into her bilateral cheek, face, temple and occiput. This treatment provided excellent relief of the facial spasms, allowing her to use her stimulator at high amplitudes, and thereby maximizing her pain relief. She received two subsequent treatments of botulinum toxin injections at 5-month intervals with similar results. Conclusion Peripheral nerve/field stimulation is being used for headaches and facial pain. An undesirable side effect of this emerging therapy is direct muscle stimulation. Botulinum toxin injections may be an effective treatment modality when stimulation techniques provide pain relief but also causes muscle twitching.

Objective: Fospropofol disodium (Lusedra®) is a pro-drug propofol for Monitored Anesthesia Care. The FDA-approved dose regimen is minimally effective with a slow onset often requiring supplemental doses at 4 minutes to achieve adequate sedation and frequently requires early re-dosing. This study was designed to assess if a larger initial bolus dose of 10 mg/kg could achieve successful sedation without supplemental doses and without an increase in sedation-related adverse events. Methods: An IRB-approved trial enrolled 12 adults undergoing elective orthopedic surgery with regional block. After IV fentanyl 50-75 micrograms, patients were randomly assigned into three IV bolus groups: fospropofol 6.5 mg/kg, fospropofol 10 mg/kg, or placebo with midazolam for rescue sedation if needed. Following the initial bolus, the level of sedation was measured, and, if adequate, the block initiated or additional IV sedation injected before proceeding with the block. Results: 100% of the 10 mg/kg fospropofol group achieved appropriate sedation in less than 4 minutes compared to 50% of the 6.5 mg/kg group (P=0.048) and 40% of the fentanyl only participants with average times to sedation of 2.0 ± 0.0 minutes, 5.0 ± 4.0 minutes, and 7.0 ± 6.0 minutes, respectively. All of the 10 mg/kg group experienced deep sedation (MOAA/S 1-2), 60% experienced paresthesia or pruritus on bolus injection, 40% experienced delayed recovery from sedation, and 20% (1 of 5 patients) experienced a short period of apnea without hypoxemia. Sedation with midazolam produced delayed recovery in 40% of patients and 20% experienced deep sedation (MOAA/S 1-2). Conclusion: 10 mg/kg bolus-dose fospropofol was 100% successful in producing sedation in less than 4 minutes, but was accompanied by deep sedation (p+0.048) and delayed recovery from sedation and more frequent apnea that make this dose unsuitable for procedures requiring short or minimal-to-moderate sedation. Further randomized trials with adequate power are required including consideration of an 8 mg/kg dose of fospropofol for MAC sedation procedures.

Objective Perioperative hydroxy-3-methyl glutaryl coenzyme A reductase inhibitors (statins) have been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to assess patient understanding of the potential benefits of perioperative statins in a select population already on chronic therapy. A secondary aim was to determine the frequency with which patients recalled having a discussion with their provider regarding perioperative statins. Design Survey. Setting Teaching hospital. Participants Patients taking daily statins presenting to a preoperative medical evaluation clinic were offered a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period. Interventions None. Measurements and Main Results One hundred thirty-two patients completed the questionnaire. The mean age was 68.3 years (standard deviation, 9.0); 42% were female. The most frequent surgical referral to the clinic was orthopedics, at 36%. The most common statin prescribed was atorvastatin, in 35% of patients. Twenty-seven percent of patients (n = 36) recognized that perioperative statins are beneficial; 44% of these patients (n = 14) cited decreased cholesterol during the procedure as the reason, representing 12% of the total sampled population. Twenty-two percent (n = 8) of those recognizing the benefit of perioperative statins identified a decrease in the risk of heart attack or death as the reason. This represented only 6% of the total sample. One percent of surgeons mentioned statins in relation to the planned surgery; 2% of primary or prescribing physicians mentioned the medication in relation to surgery. Conclusions This study suggested low patient understanding of the potential importance and reasons for perioperative statins. In addition, this study also suggested that the information regarding the importance of perioperative statins is not being relayed to the patient at the level of the surgeon or primary care physician. All physicians involved in perioperative care can offer improved patient education to promote compliance with statin therapy in hopes of a favorable impact on perioperative outcomes.

Objectives Patient satisfaction is tied to outcome, but there is scant literature on the relationship of patient perceived outcome and attributes of the pain clinic visit, including the patient interaction with the pain management specialist. The primary purpose of this study is to identify attributes of the patient–provider interaction most strongly associated with patient perceived outcome of their clinic visit. The secondary aim is to correlate patient perceived outcome with patient self-rated overall health. Methods A patient satisfaction survey conducted via phone approximately 3 weeks after the patient's pain clinic visit. Results The response rate was 60.2%; 987 patient surveys collected between 2006 and 2010 were used in the analysis. Four factors were significantly associated with the outcome: (1) Explanations by the physician of the patient's condition and treatment, (2) clear instructions regarding post-appointment activities, (3) knowing the patient as a person, and (4) the patient's self-rated health. In terms of the secondary objective, those who answered very good/excellent regarding their self-rated health had an 87% increased odds of better (very good/excellent) outcome of their pain clinic visit (or 1.87 times the odds of better outcome) compared with those who answered poor/fair/good. Conclusions Our results suggest that pain physicians may positively impact patient perceived outcomes of clinic visits by explaining the patient's condition and treatment, providing instructions, and taking the time to understand the patient and their values.

Objectives Patient perception of healthcare quality is of growing interest. It has been shown that patient satisfaction is associated with compliance with medical advice and clinical outcome. The 3-fold purpose of this study was to identify which attributes of the patient–physician interaction most strongly correlated with patients' perceptions of provider quality of care, to identify key drivers that move patients' perception of overall provider quality from “very good” to “excellent,” and to identify features of the pain clinic experience that were most important to patients but were simultaneously perceived as lacking. Methods Randomized patient satisfaction survey conducted via telephone approximately 3 weeks after the patient's pain clinic visit. Results A total of 999 patients participated in the survey over 5 years (estimated response rate 60.2%). Thoroughness, listening, and time spent with the provider were the 3 attributes most strongly associated with the patients' perceptions of provider quality of care, while thoroughness, listening, punctuality, and clear instructions were the drivers of “very good” vs. “excellent” patient perceived overall provider quality. Areas identified for clinic improvement include thoroughness, providing adequate explanations and instructions, and including patient preferences in decision making. Conclusions These results may guide pain clinic physicians as they seek to improve patient perceptions of their care and ultimately patient outcomes.

Robot-assisted cystectomy surgery may be advantageous for patients. The purpose of this study was to compare anesthetic management and outcomes in patients undergoing robot-assisted versus open radical cystectomy. In a retrospective review of 256 cystectomy procedures, procedure duration, blood loss, respiratory parameters, recovery room opiate consumption, pain scores and antiemetic use in the recovery room, and hospital length of stay were compared. After exclusions, 96 robot-assisted and 102 open procedures were analyzed. Anesthesia and surgery duration were significantly longer in the robot-assisted group, while the length of hospital stay was significantly shorter in the robot-assisted group: 7.1 ± 5.8 versus 9.8 ± 5.03 days, p = 0.0005. Estimated blood loss was 601.8 ± 491.4 ml in the open group versus 257.7 ± 164.3 ml in the robot-assisted group, p

Purpose: To compare the post operative pain control of four distinct management strategies in adult live donor hepatectomy. Methods: Sixty-two ASA physical status I and II patients undergoing live donor hepatic resection from 2001 to 2008 were retrospectively organized into four groups for post-operative pain control. Group A received epidural catheter, Group B received PCA, Group C received intraoperative dexmedetomidine and PCA, and Group D received perioperative gabapentin, intraoperative dexmedetomidine, and PCA. Four day postoperative visual analog pain scores (VAS), intravenous morphine equivalent use, duration of hospitalization, and time until return of bowel function was measured. Results: Mean visual analog pain score for a cumulative four day postoperative interval demonstrated 2.2 (± 0.73) for epidural catheter, 3.4 (± 1.13) for patient controlled analgesia (PCA), 3.0 (± 1.42) for intraoperative dexmedetomidine infusion plus PCA, and 2.3 (± 1.09) for perioperative gabapentin, intraoperative dexmedetomidine, combined with PCA. These results achieved statistical significance with p = 0.0443. Total intravenous morphine equivalent use was similar between the three non-epidural groups. There was no difference in length of hospitalization or time until return of bowel function amongst the four groups. Conclusions: Both epidural infusion and a three drug regimen of perioperative gabapentin, intraoperative dexmedetomidine, and PCA produced superior postoperative pain control compared with PCA alone or a combination of PCA and dexmedetomidine. The three drug regimen represents a preferred strategy as it provides optimal pain control without the theoretic risk of epidural hematoma in patients with a predictable postoperative coagulopathy. This pilot study serves as a template for future prospective examination of this three drug regimen versus epidural in major non-hepatic open abdominal surgery where post operative coagulopathy is less of a concern.

Background: This report describes a pontine hemorrhage in a patient following implantation of an intrathecal drug delivery system. Case report: A 70-year-old old female patient with metastatic breast carcinoma underwent placement of an implantable intrathecal drug delivery system. Before implant she was neurologically intact with only mild memory deficiencies attributed to narcotics and malignancy. No recent brain magnetic resonance imaging (MRI) was on record. On post-implant day 2 after the initiation of intrathecal hydromorphone 0.45 mg/day and bupivacaine 2.7 mg/day, she developed dizziness, lethargy, and mild gait instability. Despite decreasing drug dosages, these symptoms progressed over the ensuing days, and subsequently the patient developed upper extremity numbness and tinnitus. The device was turned off on post-implant day 9 with the patient showing no signs of improvement. She underwent computerized tomography scan of the head, which identified an acute pontine hemorrhage. A follow-up MRI scan confirmed the hemorrhage and revealed a previously undiagnosed underlying metastatic lesion with surrounding vasogenic edema. She was treated with supportive measures in hospice and expired 20 days after implantation. Conclusions: This case emphasizes several important points. First, changes in neurologic and mental status after initiating intrathecal drug therapy may be related to new or pre-existing pathology and not due to intrathecal medications. Second, consideration should be given to central nervous system imaging before intrathecal pump insertion in patients with widely metastatic malignancies. Finally, cerebral spinal fluid hypotension from dural puncture may have contributed to the timing of the hemorrhage in this patient.

Objective: Drug-eluting coronary stent use is common. Antiplatelet drug use after stent placement is necessary to prevent stent thrombosis. It has been recommended that at the time of stent placement, patients be given instructions regarding stopping antiplatelet drugs before elective surgery. Unfortunately, patients may be given inappropriate preoperative instructions by health care providers or may stop the drugs on their own. This can lead to perioperative myocardial infarctions and death. Design: Survey. Setting: Preoperative evaluation clinic of 2 teaching hospitals. Participants: One hundred sixteen patients with coronary stents completed a 13-question survey. The questionnaire assessed patient understanding of stent type and the risks of stopping antiplatelet drugs, in addition to communication among the patient, their surgeon, and their treating cardiologist before elective surgery. Intervention: None. Measurements and Main Results: The majority of patients stated either they had received no instructions from their implanting cardiologist regarding future surgery and antiplatelet drugs or they were unsure if any instructions had been given. Most patients (57%) received antiplatelet instructions regarding their planned surgery from their surgeon, whereas only 14% received instructions with (known) cardiology input. The majority of patients were unaware or unsure of any risk in prematurely stopping their antiplatelet drugs. Conclusion: Many patients are unaware of their stent type and the risks of inappropriately stopping antiplatelet drugs. Furthermore, they may have received either inappropriate preoperative instructions or no instructions at all. The opportunity exists to improve preoperative communication with patients in order to minimize perioperative thrombotic risks of coronary stents.

Perioperative beta-adrenergic blockade has been shown to decrease morbidity and mortality after noncardiac surgery. The objective of this study was to determine patient knowledge of the importance of perioperative beta-blockade in a population already taking chronic therapy and to assess the effectiveness of medical and surgical providers in patient education regarding these benefits.Survey.Teaching hospital.One hundred twenty-six patients taking daily beta-blockers presenting to a preoperative medical evaluation clinic completed a 12-question survey that assessed their understanding of the potential benefit of taking the medication in the perioperative period.None.Mean coronary artery disease risk factors per individual were 3.2 (standard deviation, 1.5). Forty-nine percent indicated that beta-blockers are beneficial in the perioperative period. Of those identifying benefit, 8% recognized decrease in myocardial infarction or decrease in mortality as the reason. Sixty-nine percent of patients who identified perioperative benefit cited blood pressure control as the reason. This correlated to the 67% of the total sample who identified their indication for the medication as antihypertensive. Only 7% recalled their prescribing physician ever mentioning the beta-blocker in relation to surgery. The same percentage recalled their surgeon mentioning it in relation to the planned procedure.This study suggests low patient understanding of the potential importance and reasons for perioperative beta-blockade. Patients who recognized perioperative benefit identified antihypertensive versus cardioprotective effects. Clinicians can improve education of patients already taking daily beta-blockers regarding these potential benefits.

A mathematical instrument was developed to supplement the diagnostic information available to physicians in the emergency room to improve physicians' diagnostic accuracy in managing patients with acute ischemic heart disease and thereby reduce inappropriate coronary care unit admissions. The instrument was empirically derived and is based on nine clinical, historical, and electrocardiographic predictive variables. Probabilities of acute ischemic heart disease generated by the instrument were given to the house staff in an emergency room during alternate months. Comparison of the control months (455 patients) with the experimental months (401 patients) showed the following: The overall diagnostic accuracy increased from 83% to 91% (P less than 0.005), the overdiagnostic accuracy increased from 51% to 33% (P less than 0.01), and the admission rate to the coronary care unit fell from 26% to 14% (P less than 0.001), while the inappropriate discharge rate from the emergency room did not change, 3% versus 3% (not significant).