Regional Anesthesia and Pain Medicine最新文献

Background: The perioperative use of methadone is increasing because of its favorable effects on postoperative analgesia and opioid consumption. Methadone can cause QTc interval prolongation, increasing the risk of Torsades de Pointes. The effect of an intraoperative loading dose of methadone on intraoperative QTc interval prolongation is unknown.

Methods: A retrospective observational cohort study of patients aged ≥18 years who underwent major non-cardiopulmonary surgery was conducted. Patients receiving an intraoperative loading dose of methadone were assigned to the methadone group; others formed the non-methadone group. Single-lead ECGs (II) were analyzed using a wavelet-based QTc interval algorithm to obtain 1- min average QTc interval values at baseline and intraoperatively. The outcome measure was the occurrence of any intraoperative 1- min averaged time windows that exceeded the predefined thresholds of 500 ms (primary), increase of ≥30 ms from baseline and increase of ≥60 ms from baseline (secondary). Propensity score matching was performed.

Results: A total of 637 patients were included, and after propensity score matching (1:1 ratio), 244 patients were analyzed. A QTc interval >500 ms (23.8% vs 23.0%; p=0.88), an increase of ≥30 ms from baseline (67.8% vs 75.0%; p=0.22), and an increase of ≥60 ms from baseline (29.7% vs 22.4%; p=0.21) occurred equally in the non-methadone group compared with the methadone group. The percentage of intraoperative time spent above threshold was significantly higher in the non-methadone group for the>500 ms threshold (p=0.004).

Conclusion: The implementation of methadone for perioperative pain management was not associated with an increased incidence of intraoperative QTc interval prolongation.

Background: Substance use among surgical patients is common and correlated with greater postoperative opioid use. However, the association of preoperative substance use on postoperative pain is unknown. In this context, a brief, validated tool such as the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Questionnaire could provide valuable information to assess the risk of poor postoperative pain control.

Methods: We prospectively identified adults aged 18 years and older undergoing common surgical procedures between December 2018 and July 2023 across three institutions. Patients completed the TAPS measure prior to surgery. A positive TAPS screen was defined as tobacco use ≥monthly, heavy alcohol use ≥monthly, any use of recreational drugs, or any use of prescription medication not as prescribed. The primary outcome was 'worst' overall pain (on a scale of 0-10, 0=no pain, 10=worst pain imaginable) at three time points: prior to surgery, 2 weeks postoperatively, and 1 month postoperatively. Mixed linear models were used to determine the association between TAPS Score and pain over time, adjusting for patient factors.

Results: In this cohort of 4410 individuals, 42.2% reported unhealthy substance use using TAPS in the 12 months prior to surgery. After adjusting for patient factors, participants who screened positively on TAPS reported higher worst overall pain scores than those with negative TAPS screens at baseline (3.51 vs 3.15, p<0.001) and at 1 month postoperatively (2.66 vs 2.41, p=0.036). No significant difference was observed at 2 weeks after surgery.

Conclusions: Preoperative substance use is common and is correlated with higher levels of patient-reported pain after surgery, but within minimal clinically important differences. These findings are preliminary and require confirmation. Risky substance use has an important impact on postoperative recovery, and the perioperative window provides an opportunity to assess and intervene in unhealthy substance use.

Introduction: Vagus Associated Neurogenic Cough Occurring due to Unilateral Vascular Encroachment of its Root (VANCOUVER) syndrome is a recently described neurovascular compression syndrome causing neurogenic cough due to a vascular compression of the vagus nerve at the brainstem. Some patients with VANCOUVER syndrome can lateralize the tickling sensation causing their irresistible cough; others cannot. For those who cannot lateralize their symptoms, a diagnostic vagus nerve block is required. This paper highlights the technique of percutaneous cervical vagus nerve block and its use in the diagnostic protocol for VANCOUVER syndrome.

Methods: The medical records of two patients who underwent a vagus nerve block were reviewed. The percutaneous cervical vagus nerve block was performed in the supine position, under ultrasound guidance with an in-plane needle technique as an outpatient procedure. Hemodynamic parameters and clinical effects were monitored.

Results: Both patients were identified as potentially having VANCOUVER syndrome but could not lateralize their sensory symptoms. Each underwent unilateral vagus nerve block and returned for the contralateral procedure several weeks later. Both had temporary resolution of their cough following vagus nerve block ipsilateral to the intracranial vagus nerve compression but no effect following contralateral vagus nerve block. During the effects of the vagus nerve block, the patients had temporary vocal hoarseness, ipsilateral Horner syndrome, but no hemodynamic disturbances.

Conclusion: Vagus nerve block can confirm the diagnosis and lateralize the affected nerve in patients with VANCOUVER syndrome who cannot lateralize their symptoms. As the awareness of this syndrome increases, the procedure will become more common. An understanding of ultrasound-guided cervical anatomy is required for its safe use.

Background: Contrast epidurography is an objective and reliable imaging modality to confirm the appropriate placement of thoracic epidural catheters for postoperative analgesia. To date, no large studies have reported failure rates of catheter placement as confirmed by contrast epidurography, nor have they associated patient and procedural factors.

Methods: This was a single-center retrospective study analyzing failure rates and associated patient and procedural factors for thoracic epidural catheters placed using a conventional landmark-based technique and confirmed by contrast epidurography. All epidural contrast studies taken over a 5-year study period were analyzed along with potential predictors of failure, including patient age, sex, body mass index, a diagnosis of thoracic scoliosis, patient positioning, needle approach, training level of primary operator, and fellowship training of the supervising anesthesiologist.

Results: 1017 epidural contrast studies were included for analysis. The failure rate after initial catheter placement was 12.2%. For catheters placed as a second attempt to "rescue" a failed initial attempt, the failure rate was 24.0%. Multivariable logistic regression analysis showed a greater odds of failed placement associated with obesity compared with regular weight (adjusted OR (aOR): 1.9, 95% CI 1.12 to 3.3) and older age compared with age <55 (aOR for age 55-74: 2.78, 95% CI 1.39 to 6.21; aOR for age ≥75: 4.16, 95% CI 1.94 to 9.77).

Conclusions: Failure rates for thoracic epidural catheter placement as confirmed by contrast epidurography at a teaching institution are reported. Age≥55 and obesity are both associated with a greater odds of failed placement.

Introduction: Propofol, a commonly used intravenous anesthetic induction agent, frequently produces pain on injection, with an incidence ranging from 28% to 91%. This study aimed to compare the effect of low-dose ketamine and a pressure vibration mechanical device with placebo in reducing pain during propofol injection in patients undergoing elective surgery.

Methods: In this randomized, double-blind, placebo-controlled trial, 300 adults were allocated to pressure vibration (Group V), low-dose ketamine (Group K), or saline placebo (Group P); 275 patients completed the study and were analyzed (92, 91, and 92 patients, respectively). Group P received 5 mL 0.9% saline, Group K ketamine 50 µg/kg diluted in 5 mL saline, and Group V saline with an activated pressure vibration device applied proximal to the intravenous cannula, each administered over 1 min. Propofol 2 mg/kg was infused, with the first 25% delivered at 600 mL/hour, and pain assessed using the McCrirrick and Hunter verbal rating score. The primary outcome was pain on propofol injection. Continuous variables were analyzed using one-way analysis of variance or Kruskal-Wallis tests, categorical variables with χ² tests, with Bonferroni correction applied for multiple primary outcome comparisons.

Results: Among 275 analyzed patients, the incidence of no pain was highest in the pressure vibration device group 51.1%; 95% CI 42.4% to 59.8% compared with placebo 30.4%; 95% CI 21.0% to 39.8% and ketamine 33.0%; 95% CI 23.3% to 42.6%; (p=0.001). Severe pain was more frequent in the placebo group (18.5%; 95% CI 10.5% to 26.4%) than in the ketamine (5.5%; 95% CI 0.8% to 10.2%) and vibration groups (4.3%; 95% CI 0.2% to 8.5%; (p=0.001). Recall of injection pain at 1 week was significantly higher with placebo compared with ketamine and vibration device (55.4%, 37.4%, and 26.1%, respectively; p<0.001). Hemodynamic variables and adverse events were comparable across groups.

Conclusion: The pressure vibration mechanical device significantly reduced the incidence and severity of propofol injection pain compared with placebo and was at least as effective as low-dose ketamine. Pain recall at 1 week was higher with placebo. This device provides an effective, reusable, non-pharmacological alternative without drug-related adverse effects.

Trial registration number: CTRI/2022/12/048300.

Background: Corticosteroid injections (CSIs) are widely employed in facet and sacroiliac joint pain. Similar to CSIs at other sites (peripheral nerve blocks, joints, epidural), these injections are associated with potential adverse events. These multisociety consensus recommendations aim to develop evidence-based statements and recommendations on the safe use of CSIs in facet joint and sacroiliac joint injections.

Methods: Development of the consensus recommendations was approved by the American Society of Regional Anesthesia and Pain Medicine Board of Directors and several other societies that agreed to participate. The scope of statements and recommendations was agreed on to include safety of the injection technique (landmark-guided, ultrasound, or radiology-aided injections); effect of the addition of the corticosteroid on effectiveness (vs local anesthetic or saline); and adverse events related to the injection. Experts were assigned topics to perform a comprehensive literature review and draft statements and recommendations, which were refined and voted for consensus (>75% agreement) using a modified Delphi process. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed.

Results: All statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Boards of Directors of the participating societies also approved all statements and recommendations. Injection of corticosteroid into the facet joint in patients with joint inflammation may relieve pain and improves function. Intra-articular, extra-articular (periarticular), and combined administration are effective for sacroiliac joint injections. No dose-response studies exist, but CSIs containing 10 mg of methylprednisolone or triamcinolone per facet joint and 40 mg per sacroiliac joint (SIJ) (or their respective pharmacologic equivalents) are reasonable.

Conclusions: In this practice recommendation, we provide statements and recommendations on facet and sacroiliac joint CSIs, the optimal doses, and intervals and criteria for repeating the CSIs in patients with facet joint and sacroiliac joint pain.