Regional Anesthesia and Pain Medicine最新文献

Background: Despite the significant role of impaired bone metabolism in complex regional pain syndrome (CRPS), the clinical implications of osteopenia remain a focal point of investigation. We examined the prevalence and risk factors of affected limb osteopenia in CRPS and its association with the response to sympathetic blockade.

Methods: 167 patients with CRPS who underwent CT of their affected limbs were retrospectively reviewed. After conducting univariable analyses where regional osteopenia determined by CT was dependent and other clinical factors were independent variables, the first multivariable analysis assessed risk predictors associated with regional osteopenia in CRPS. Next, after conducting univariable analyses where sympathetic block response was dependent and others, including regional osteopenia, were independent variables, the second multivariable model predicted factors associated with the response to sympathetic blockades, followed by receiver operating characteristic curve analysis.

Results: Among 116 patients, regional osteopenia was identified in 72.2% early (<1 year) and 52.5% persistent CRPS. In the first multivariable analysis adjusted for age, sex, body mass index (BMI), and other variables with p values<0.1 from initial univariable analyses, older age (OR 1.06; 95% CI 1.02 to 1.10) and positive three-phase bone scintigraphy (TPBS) (OR 3.94; 95% CI 1.46 to 10.66) were significantly associated with regional osteopenia. In the second multivariable model adjusted for age, sex, BMI, and other variables with p values<0.1 from univariable analyses, early phase (OR 5.49; 95% CI 1.44 to 20.88), regional osteopenia (OR 5.11; 95% CI 1.49 to 17.53), and positive TPBS (OR 6.30; 95% CI 2.21 to 17.93) were significantly associated with positive responses to sympathetic blockade in CRPS, showing excellent performance characteristics with a predicted probability>0.358 (sensitivity 0.86; specificity 0.76).

Conclusion: Regional osteopenia in the affected limb can anticipate positive responses to sympathetic blockade when combined with TPBS in early CRPS.

Liposomal bupivacaine (LB) has been the subject of a great deal of study, and some degree of controversy, since its development in the late 1990s. While some published studies are supportive of its efficacy, many others are not or demonstrate only marginal improvement in analgesia. This variable efficacy occurs in the face of markedly increased costs when compared with plain local anesthetics. In this education article, we trace the development of LB, summarize the important aspects of its pharmacology, and explore possible causes of its failure to fulfill the promise that the drug held when it was developed and approved. Finally, we discuss some aspects of perineural anatomy that might impact the potential of this drug to provide long-lasting analgesia.

Introduction: Artificial intelligence (AI), particularly large-language models like Chat Generative Pre-Trained Transformer (ChatGPT), has demonstrated potential in streamlining research methodologies. Systematic reviews and meta-analyses, often considered the pinnacle of evidence-based medicine, are inherently time-intensive and demand meticulous planning, rigorous data extraction, thorough analysis, and careful synthesis. Despite promising applications of AI, its utility in conducting systematic reviews with meta-analysis remains unclear. This study evaluated ChatGPT's accuracy in conducting key tasks of a systematic review with meta-analysis.

Methods: This validation study used data from a published meta-analysis on emotional functioning after spinal cord stimulation. ChatGPT-4o performed title/abstract screening, full-text study selection, and data pooling for this systematic review with meta-analysis. Comparisons were made against human-executed steps, which were considered the gold standard. Outcomes of interest included accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for screening and full-text review tasks. We also assessed for discrepancies in pooled effect estimates and forest plot generation.

Results: For title and abstract screening, ChatGPT achieved an accuracy of 70.4%, sensitivity of 54.9%, and specificity of 80.1%. In the full-text screening phase, accuracy was 68.4%, sensitivity 75.6%, and specificity 66.8%. ChatGPT successfully pooled data for five forest plots, achieving 100% accuracy in calculating pooled mean differences, 95% CIs, and heterogeneity estimates (I² score and tau-squared values) for most outcomes, with minor discrepancies in tau-squared values (range 0.01-0.05). Forest plots showed no significant discrepancies.

Conclusion: ChatGPT demonstrates modest to moderate accuracy in screening and study selection tasks, but performs well in data pooling and meta-analytic calculations. These findings underscore the potential of AI to augment systematic review methodologies, while also emphasizing the need for human oversight to ensure accuracy and integrity in research workflows.

Background/importance: Driving under the influence of drugs (DUID) refers to operating a vehicle after consuming drugs or medications other than alcohol that impair the ability to drive safely. There is no consensus on legal limits for drug intoxication while driving in the USA. Balancing the benefits of prescription medications, such as opioids, with traffic safety remains an ongoing public health challenge.

Objective: This article examines DUID policy and provides recommendations for policy improvement and unification grounded in scientific evidence on opioid-related impairment and driving risks.

Evidence review: A literature review of epidemiologic data, psychomotor effects, and public policy related to opioid use and driving was conducted. A total of 38 epidemiological studies, 21 studies on psychomotor effects, and pertinent laws and policies were reviewed.

Findings: Epidemiological data reveal an increasing prevalence of opioid-positive drivers and an association between opioid use and elevated risk of motor vehicle collisions. Psychomotor studies show mixed results, with some indicating impairment in opioid users and others suggesting minimal effects on driving ability. State laws regarding DUID remain heterogeneous, with trends toward expanded testing powers, lower impairment thresholds, and limitations on prescription-based defenses. The lack of standardized opioid testing limits and inconsistent policy approaches across states hinder effective management of opioid-related impaired driving.

Conclusions: A balanced public health approach can reduce opioid-involved crashes through education, prevention, enhanced enforcement tools, and rehabilitation. In drafting future DUID laws, policymakers must analyze evolving opioid research when balancing the pain relief of opioids with public roadway safety.

Introduction: Current treatment modalities of lumbar spinal stenosis range from conservative medical management and physical therapy to open surgical decompression. Minimally invasive lumbar decompression (MILD) and Superion interspinous spacers (SISS) Vertiflex offer the promise of effective pain relief with shorter recovery time and lesser potential complications compared with open surgical decompression procedures and general anesthesia. Despite their increasing utilization, their complication profile is not well established in the literature.

Methods: We searched the FDA's Manufacturer and User facility Device Experience (MAUDE) database for all entries on MILD product code 'HRX' and SISS product code 'NQO'. MAUDE database was queried from 2010 to 2021. Duplicate entries were removed, and complications were classified based on the event descriptions.

Results: For the MILD procedure, a total of 10 entries were found in the MAUDE database. Among these, 8 were classified as surgical complications and 2 were device related. On the other hand, a total of 919 reports were found in the MAUDE database for Vertiflex, with 385 medical device reports were included in the analysis. Device-related were the most reported complication, accounting for 189 cases.

Conclusion: As with any new intervention, we must proceed with caution and evaluate the procedure performance over time. Such data should aid physicians to make informed decisions before choosing either technique for their patients. The findings from this study provide insight into the complication profile associated with both MILD and Vertiflex procedures, highlighting the need for continued evaluation and careful consideration in clinical decision-making.

Background: There is a rising number of patients with left ventricular assist devices (LVADs) undergoing non-cardiac procedures, both emergent and elective. Historically, anesthetic options for these patients have been limited to general anesthesia. Limited data exists for the use of neuraxial anesthesia in patients with LVADs despite its common use in orthopedic procedures for non-LVAD patients. Given the benefits of neuraxial anesthesia and the rising population of LVAD patients undergoing elective procedures, a better understanding of LVAD patients' candidacy for neuraxial anesthesia needs further investigation.

Case presentation: We report the case of a patient with an LVAD who successfully underwent a total knee arthroplasty with neuraxial anesthesia at a tertiary academic center. Preoperative transthoracic echo demonstrated stable cardiac function and an ejection fraction of 10-15% with a HeartMate 3 LVAD. The primary anesthetic was a lumbar epidural that was slowly titrated to a surgical anesthetic level and an adductor canal peripheral nerve catheter was placed preoperatively for postoperative analgesia. The patient remained hemodynamically stable throughout the case, with a perfusionist monitoring the LVAD's function intraoperatively, and tolerated the anesthetic well. His postoperative course was uneventful.

Conclusion: Patients with LVADs should be considered candidates for neuraxial anesthesia with appropriate preoperative planning and perioperative management.

Background: To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

Methods: Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

Results: After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

Conclusions: The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Background: Total hip arthroplasty (THA) frequently causes postoperative pain, hindering recovery and prolonging hospital stays. While multimodal analgesia aims to minimize opioid use and enhance outcomes, the optimal regional anesthesia technique is unclear due to the hip's complex innervation.

Objective: This multicenter randomized placebo-controlled trial evaluated whether adding an anterior quadratus lumborum block (QLB) to multimodal analgesia with non-steroidal anti-inflammatory drugs (NSAIDs) reduces opioid consumption in THA patients.

Methods: 60 adults undergoing primary unilateral THA were randomized to receive either anterior QLB with 20 mL of 0.2% ropivacaine (n = 30) or a placebo saline injection (n = 30). All participants received multimodal analgesia including NSAIDs. The primary outcome was cumulative opioid consumption in oral morphine equivalents (OMEs) within the first 24 postoperative hours. Secondary outcomes included patient experience assessed by the EVAN scale on postoperative day 1, elevated pain and opioid consumption on days 1 and 2, time to first standing, walking distance and quadriceps strength on day 1, as well as walking progression, return to sport activity and analgesic use at 3 months.

Results: No significant difference was found in 24-hour cumulative OME consumption between groups (median 40 mg (IQR 20-50 mg) vs 31 mg (IQR 20-45 mg); p = 0.6). Patient experience, pain scores and opioid consumption were similar. Rehabilitation outcomes at 3 months also did not differ.

Conclusion: Adding anterior QLB to multimodal analgesia did not reduce opioid consumption or enhance postoperative pain control and functional recovery in THA patients. Anterior QLB may not provide additional benefits when combined with multimodal analgesia with NSAID for THA.

Trial registration number: NCT04555291.