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Introduction: Radiologically inserted gastrostomy (RIG) placement in patients with amyotrophic lateral sclerosis (ALS) carries risks related to periprocedural sedation and analgesia. To minimize these risks, we used a paravertebral block (PVB) technique for RIG placement., Methods: We retrospectively reviewed patients with ALS undergoing RIG placement under PVB between 2013 and 2017., Results: Ninety-nine patients with ALS underwent RIG placement under PVB. Median (range) age was 66 (28 to 86) years, ALS Functional Rating Scale-Revised score was 27 (6 to 45), and forced vital capacity was 47% (8%-79%) at time of RIG placement. Eighty-five (85.9%) patients underwent RIG placement as outpatients, with a mean postanesthesia care unit stay of 2.3 hours. The readmission rate was 4% at both 1 and 30 days postprocedure., Discussion: PVB for RIG placement has a low rate of adverse events and provides effective periprocedural analgesia in patients with ALS, the majority of whom can be treated as outpatients., (© 2020 Wiley Periodicals, Inc.)

Purpose: To ascertain the preferences of perianesthesia nurses regarding peripheral nerve blocks (PNBs) and their impact on patient recovery after total joint replacement (TJR)., Design: Survey of perianesthesia nurses at a single medical center., Methods: Fifty-nine perianesthesia nurses completed a 23-question survey on PNBs for TJR., Findings: Most agreed PNBs improved patients' pain after knee, hip, and shoulder TJR (35 [92.1%], 35 [92.1%], and 34 [91.9%], respectively). Most felt lower extremity PNBs increased risk of falling (26 [70.3%]), whereas 7 of 35 (20.0%) felt patients fell more after spinal anesthesia than after general anesthesia. Respondents preferred a block to opioid-based analgesia if they were to have lower extremity TJR or total shoulder replacement (100% [30/30 and 33/33])., Conclusions: The perianesthesia nurses surveyed felt PNBs improved pain control and patient recovery despite a perceived risk of falling for lower extremity TJR, and they preferred PNB when considering TJR surgery for themselves., (Copyright © 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Background: Degenerative scoliosis (DS) may affect surface landmarks for performance of lumbar plexus (LP) block. We hypothesized the extent of any difference in surface landmarks could be calculated by a formula based on measured degree of DS, body mass index, sex, and age., Methods: We retrospectively searched our radiology database until 113 consecutive adult patients with DS were identified with lumbar spine radiographs and magnetic resonance imaging examinations performed. Pertinent surface landmark measurements at the L4 vertebral body level were recorded and compared to 50 controls., Results: In patients with severe DS, there is a mean lateral deviation of the needle tip of 1.53 cm (0-3 cm) on the concave side and mean medial deviation of the needle tip of 0.35 cm (0-1.5 cm) on the convex side using typical bony landmarks. We found a significant correlation between body mass index and LP depth with a correlation coefficient ranging between 0.53 and 0.71. We found potential risk of organ injury in two of 13 patients with severe DS using traditional surface landmarks., Conclusions: There is a larger degree of lateral deviation of the LP on the concave side of scoliosis compared to medial deviation on the convex side. These deviations remained consistent irrespective of the direction of scoliosis. A review of the imaging studies and preprocedural ultrasound assessment of anatomy should be strongly considered prior to needle puncture. In patients with severe DS, an alternative approach may be considered to avoid the possibility of visceral organ injury.

Objective: To compare opioid consumption among patients who receive a continuous adductor canal block (ACB) versus continuous femoral nerve block (FB) for total knee arthroplasty analgesia in the presence of an intermittent sciatic nerve catheter (iSB)., Design: Matched cohort retrospective study., Setting: Mayo Clinic, Jacksonville, FL., Patients: Ninety patient charts were included in this study: 45 patients with continuous ACB/iSB and 45 with continuous FB/iSB. Patients were matched according to mean preoperative opioid consumption and pain scores, BMI, age, and gender., Measurements: The primary outcome of the study was postoperative on-demand opioid consumption on postoperative days 0 (POD 0), 1 (POD 1), and 2 (POD 2). Secondary outcomes included postoperative Visual Analog Scale (VAS) scores for anterior and posterior knee pain, incidence of nausea and pruritus, need for intravenous rescue opioid, and need for catheter bolus by a physician., Main Results: On POD 0, mean opioid consumption in milligrams of oral morphine equivalent [mean±SD (95% CI)] was 43.98mg±33.36 (33.96, 54) in the ACB/iSB group vs 38.45mg±30.99 (29.14, 47.76) in the FB/iSB group, respectively (P=.42); on POD 1, 74.96mg±37.23 (63.78, 86.14) vs 72.40mg±62.34 (53.67, 91.13) (P=.81); on POD 2, 28.19mg±17.69 (22.87, 33.51) vs 31.84mg±23.09 (24.90, 38.78) (P=.40). On POD 1, median anterior knee VAS scores at rest were equivalent in both the ACB/iSB and FB/iSB groups (1 vs 1, respectively, P=.46); however, patients in the ACB/iSB group were more likely to have higher anterior knee pain scores with movement (4 vs 1, P=.002)., Conclusion: In the first 2 days after a total knee arthroplasty, opioid consumption in patients with continuous ACB/iSB was not significantly different from patients receiving continuous FB/iSB. Continuous adductor canal block appears to provide adequate analgesia when compared to continuous femoral blockade., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background and Objectives: Lumbar plexus (LP) block is a common and useful regional anesthesia technique. Surface landmarks used to identify the LP in patients with healthy spines have been previously described, with the distance from the spinous process (SP) to the skin overlying the LP being approximately two-thirds the distance from the SP to the posterior superior iliac spine (PSIS) (SP-LP:SP-PSIS ratio). In scoliotic patients, rotation of the central neuraxis may make these surface landmarks unreliable, possibly leading to an increased block failure rate and an increased incidence of complications. The objective of the present study was to describe these surface landmarks of the LP in patients with scoliosis., Methods: We selected 47 patients with known thoracolumbar scoliotic disease from our institution's radiology archives. We measured bony landmark geometry, Cobb angle, and the LP location and depth. Additionally, we calculated the SP-LP:SP-PSIS ratio for both the concave and convex sides., Results: In scoliotic patients (31 females and 16 males), the median (range) Cobb angle was 23 (8-54) degrees. The LP depth was 7.5 (5.7-10.7) cm on the concave side of the scoliotic spine and 7.6 (5.4-10.8) cm on the convex side, while the distance from the SP-LP was 3.4 (1.9-4.7) cm on the concave side and 3.7 (2.4-5.1) cm on the convex side. The SP-LP:SP-PSIS ratio was 0.61 (0.20-0.97) and 0.65 (0.45-0.98) on the concave and convex sides, respectively. None of these distances were significantly different between sides., Conclusions: In patients with scoliotic disease of the spine, there is wide variability in the bony surface landmarks. The location of the LP is generally more medial than expected when compared with both modified and traditional landmarks. A review of the imaging studies and the pre-procedural ultrasound assessment of the anatomy should be considered prior to needle puncture.

Background: Anterior approaches for total hip arthroplasty (ATHA) are becoming increasingly popular. We postulated that the use of PVB of the T12, L1, and L2 roots would provide adequate analgesia for ATHA while allowing motor sparing., Methods: The medical records of 20 patients undergoing primary ATHA were reviewed. T12, L1 and L2 paravertebral blockade was accomplished with 3-4 ml of 1% ropivacaine with epinephrine 1:200,000 and 0.5 mg/ml of preservative-free dexamethasone per level. Primary outcomes were mean opioid consumption in intravenous morphine equivalents and worst recorded visual analog scale (VAS) pain scores during postoperative days 0 to 2 (POD 0 to 2)., Results: Mean opioid consumption was 8.4 mg on POD0, 16.6 mg on POD1, and 9.8 mg on POD2. Median worst VAS scores were 2 for all time intervals except POD 0, which had a median value of 0. All patients had full hip motor strength the evening of POD0.19 patients were able to ambulate the afternoon of POD1., Conclusion: T12-L2 PVB, when utilized as part of a multimodal analgesic regimen, results in moderate opioid consumption, low VAS scores, preservation of hip motor function, and may be an effective regional anesthesia technique for ATHA.

Background: There is debate as to whether nerve stimulation (NS) is required to place peripheral nerve catheters when using ultrasound (US) guidance. There is conflicting evidence for whether stimulating catheters improve postoperative analgesia compared to non-stimulating catheters. The use of US in combination with NS has been shown to be superior to NS alone in terms of popliteal nerve blockade. Given the previously published reports, we hypothesized that there is improvement in sensory and motor blockade for stimulating popliteal perineural catheters placed under US guidance when NS is used., Methods: Following IRB approval, 21 patients undergoing elective foot and ankle surgery were randomly assigned to either a US or US+NS-guided continuous popliteal sciatic nerve block using a lateral approach. The primary end-point of the study was successful nerve blockade at 20 minutes. Secondary end-points included: block performance time, minimum stimulating current, pain scores on postoperative day 1 and day 2, and patient satisfaction., Results: There was no significant difference in successful nerve blockade at 20 minutes in the US versus US+NS groups (73% vs. 80%, p = 1). Procedure time was significantly shorter in the US only group (median 62 seconds vs. 130.5 seconds, p < 0.01). Postoperative pain scores and overall patient satisfaction were not significantly different between the two groups., Conclusion: We have found that the addition of NS provides no benefit over US alone. US alone was associated with a significantly shorter block performance time. US+NS showed no significant difference in pain control, patient satisfaction, or block success.