Regional Anesthesia and Pain Medicine最新文献

Introduction: The safety of operating room extubation (ORE) immediately following cardiac surgery via median sternotomy remains unclear. However, reported outcomes in the setting of parasternal regional analgesia are limited. This study examined the safety of ORE for patients who received postoperative superficial parasternal intercostal plane (SPIP) blocks following median sternotomy for cardiac surgery.

Methods: Single-center retrospective cohort study from January 2020 to September 2023 compared the outcomes of adult cardiac surgical patients who were either extubated in the operating room immediately after surgery with SPIP blocks (ORE-B), received SPIP blocks and were extubated in the intensive care unit within 6 hours (FTE-B) or did not receive SPIP blocks and were extubated in the intensive care unit within 6 hours (FTE). Assessed outcomes were reintubation, use of non-invasive positive pressure ventilation (NIPPV), intensive care unit (ICU) readmission, return to OR, postoperative transfusion, ICU and hospital length of stay.

Results: 2294 patients were studied, which included 256 ORE-B patients, 729 FTE-B patients and 1,309 FTE patients. Differences in reintubation rates (1.2% vs 0.7% vs 1.2%, all p≥0.26) and use of NIPPV (4.8% vs 4.8% vs 5.1%, all p≥0.743) did not differ between ORE-B, FTE-B, and FTE groups, respectively. Time to extubation differed between FTE-B and FTE groups (2.5 hours vs 3.8 hours, p=<0.001), respectively. Additionally, hospital length of stay was significantly shorter for groups ORE-B and FTE-B compared with group FTE (5 days vs 5 days vs 6 days), respectively.

Conclusions: Selective ORE after median sternotomy for cardiac surgery was not associated with an increased risk of reintubation and NIPPV use in the setting of parasternal regional analgesia.

Introduction: Certain specialized hand surgery procedures benefit from intraoperative motor testing and patient-demonstrated active range of motion. This requires motor-sparing regional anesthesia of the hand using targeted ultrasound-guided nerve blocks in the forearm.

Objective: We present a joint surgical and anesthetic perspective covering the utility and indications for motor-sparing forearm blocks. We describe the anatomical principles and technical details of their performance and discuss other considerations for surgical and anesthetic success.

Findings: Patient selection and expectation setting are critical for success. Four terminal nerves must be blocked: median nerve, ulnar nerve, superficial radial nerve, and lateral antebrachial cutaneous nerve. These must be targeted distal to origin of motor branches to extrinsic muscles of the hand, with precise deposition of limited volumes of local anesthetic. The nerves can be readily identified with ultrasound imaging by their predictable anatomical relationship to specific muscles and blood vessels.

Conclusion: Intraoperative motor testing in complex surgical repair of the hand is associated with improved surgical outcomes, as well as greater patient satisfaction. Ultrasound-guided motor-sparing forearm blocks are a safe and effective method for achieving surgical anesthesia and optimal operating conditions in this context.

Background/importance: Fibromyalgia is a complex chronic pain disorder that significantly impairs patient well-being. Evaluating the efficacy of muscle relaxants for treating fibromyalgia is crucial for improving patient care.

Objective: This study aimed to evaluate the analgesic efficacy of muscle relaxants in patients with fibromyalgia.

Evidence review: A comprehensive literature search was conducted using PubMed, EMBASE, Web of Science, ClinicalTrials.gov, and the Cochrane Library. The search included randomized controlled trials (RCTs) comparing skeletal muscle relaxants with placebo/active analgesics for fibromyalgia. The primary outcome was pain intensity, measured by standardized mean difference (SMD) in pain scores. The risk of bias of included RCTs was assessed using the Cochrane Risk of Bias Assessment Instrument for Randomized Controlled Trials.

Findings: 14 RCTs (1851 participants) were included. Muscle relaxants were associated with a small but statistically significant reduction in pain scores compared with placebo or active treatment (SMD=-0.24, 95% CI=-0.32 to -0.15, p<0.001, 95% prediction interval=-0.40 to -0.08), with no significant inconsistency (I²=0, 95% CI=0% to 50.79%) and a moderate Grading of Recommendation, Assessment, Development and Evaluation rating. Secondary outcomes showed small, but statistically significant improvements in depression, fatigue and sleep quality. Muscle relaxants were associated with increased incidence of overall adverse effects, fatigue, abnormal taste, and drug withdrawal due to adverse effects.

Conclusions: Moderate quality evidence showed that muscle relaxants were associated with a small reduction in pain intensity for patients with fibromyalgia.

The National Resident Matching Program (NRMP) for pain medicine fellowships marked its 10th anniversary in 2023, coinciding with growing discussions within the Association of Pain Program Directors (APPD) regarding the program's future in the context of a recent decline of applicants into pain medicine. This letter explores the rationale behind reassessing the NRMP's utility for pain medicine, examining historical and current trends, and considering the implications of withdrawing from the match. Despite a recent decline in applicants and an increase in unfilled positions, the APPD advocates for continued participation in the match. The match ensures equitable and stable recruitment, preventing the chaotic pre-match environment of competitive, early offers. Data from similar specialties highlight the pitfalls of non-match systems, such as increased applicant pressure and reduced program visibility. The APPD supports maintaining the NRMP match while implementing reforms like preference signaling to address evolving challenges. The APPD aims to preserve the match's benefits and ensure a stable future for pain medicine fellowship recruitment.

Background: Needle trauma has been associated with peripheral nerve injury and neurological dysfunction. However, inadvertent needle puncture is frequent while postblock dysfunction is rare. We conducted a cadaveric study to evaluate the association between needle puncture and fascicular injury.

Methods: Five median and five ulnar (isolated) nerves were obtained from fresh human cadavers. Four different needles were used for the transfixing punctures: A 30° beveled (22G) nerve block needle, and 15° beveled (22G, 25G and 27G) Quincke spinal block needles. 10 transfixing punctures were made with each needle type on each nerve (40 punctures per nerve). Samples were then immersed in 5% formaldehyde solution for 30 days. Perpendicular cross-sections of the punctured segments were obtained. Samples were embedded in paraffin and analyzed under light microscopy with H&E staining. On each slice, the following variables were obtained: ratio of fascicular/epineurial tissue, the number of fascicles per nerve and the number of injured fascicles.

Results: A total of 400 punctures were made (200 median and 200 ulnar) and 144 histological nerve sections analyzed (74 median and 70 ulnar). The median number of fascicles per section was 16 (range 7-23) and 17 (range 8-27) with a fascicular/epineural tissue ratio of 45% (range 35%-52%) and 44% (range 39%-54%) for median and ulnar, respectively. Three fascicular injuries were identified: one in ulnar and two in median. All injuries were caused by a 15° beveled needle, the ulnar with a 22G and the median with a 22G and a 27G.

Conclusions: Fascicular injury is rare following needle transfixion. Needle injury alone is unlikely to explain postblock neurological dysfunction.