Ultrasound-guided modified out of plane infraclavicular approach

Results/Case report The Infraclavicular Block (ICB) is a common approach to the brachial plexus to provide anesthesia and analgesia to the arm below the level of the mid-humerus. As compared to the supraclavicular brachial plexus block, the ICB has several advantages, which include a decreased risk of phrenic nerve palsy (1) and an increased likelihood of effectively blocking the intercostobrachial nerve (2). The incidence of pneumothorax is not increased with and ultrasound guided ICB as compared to an ultrasound guided supraclavicular block (3). Several techniques for ultrasound guided ICB are described in the literature; however, these approaches are technically challenging in patients with morbid obesity and/or the inability to abduct the arm. We describe two morbidly obese patients in whom we successfully performed a modified out of plane infraclavicular approach (MOPIA) to the brachial plexus. The first patient is a 77 year old obese (BMI 32) woman with end stage renal disease, COPD on home oxygen, and significant glenohumeral joint arthritis that limited shoulder range of motion. She was scheduled for the creation of an AV fistula on her left forearm. The second patient is a 79 year old obese (BMI 35) man with end stage renal disease who was scheduled for an AV fistula ligation and creation of a new AV fistula on his left arm. The obesity of these patients hindered the ability of the high frequency linear probe to adequately visualize the brachial plexus. The first patient\u27s range of motion limitation further impaired efforts for optimal positioning and visualization of the brachial plexus. The MOPIA technique was carried out in both patients with the anesthesiologist standing on the contralateral side of the brachial plexus to be blocked. An insulated stimulating needle was used in an out-of-plane approach using the curvilinear low frequency probe for needle tip and target visualization. The axillary artery and the surrounding brachial plexus were located by placing the probe slightly medial and caudal to the coracoid process. Approximately 25-35 mL of 1.5% mepivacaine was injected at three locations (6 o\u27clock, 9 o\u27clock, and 3 o\u27clock) around the axillary artery to achieve complete nerve blockade. No complications occurred during or after the block procedure, and surgery proceeded uneventfully. Two common approaches to ICB are the medial infraclavicular technique (2) and the costoclavicular technique (4). Both of these techniques require an abducted arm for optimal visualization. A retoclavicular technique is used with an adducted arm; however, obesity and a short neck can hinder visualization (5). It is our opinion that the modified out of plane infraclavicular approach would serve as a viable, safe, and efficient technique for dealing with non-traditional candidates for an infraclavicular block

Programmed intermittent epidural bolus (PIEB) as compared to continuous epidural infusion (CEI) for the maintenance of labor analgesia: A prospective randomized single blinded controlled trial

Background: Programmed intermittent epidural bolus (PIEB) techniques are a new area of interest for maintaining labor analgesia due to the potential to decrease motor block and improve labor analgesia. This study compares two different PIEB regimens to a continuous infusion for labor analgesia. Methods: 150 patients undergoing scheduled induction of labor at term gestation having epidural labor analgesia were randomized to receive an epidural analgesia regimen of bupivacaine 0.125% with fentanyl 2 mcg/mL at either PIEB 5 mL every 30 min (Group 5q30), PIEB 10 mL every 60 min (Group 10q60), or 10 mL/hr continuous infusion (Group CEI). The primary outcome is pain scores throughout labor. Secondary outcomes include the number of physician administered boluses, dermatomal sensory levels, degree of motor block, and patient satisfaction. Results: While average pain scores throughout labor did not differ significantly between groups, fewer patients in group 10q60 received physician administered boluses fo breakthrough pain (34.9% in 10q60 vs 61.0% in 5q30 and 61.9% in CEI, p = 0.022). Dermatomal sensory levels, degree of motor block, and patient satisfaction did not differ significantly between groups. Conclusions: PIEB 10 mL every 60 minutes decreases the need for physician administered boluses as compared to PIEB 5 mL every 30 minutes or 10 mL/hr continuous infusion

A randomized-controlled trial comparing liposomal bupivacaine, plain bupivacaine, and the mixture of liposomal bupivacaine and plain bupivacaine in transversus abdominus plane block for postoperative analgesia for open abdominal hysterectomies

PURPOSE: Transversus abdominus plane (TAP) blocks are widely used for postoperative analgesia for abdominal surgical procedures. The purpose of this study was to compare the analgesic efficacy of plain bupivacaine, liposomal bupivacaine, and the mixture of plain bupivacaine with liposomal bupivacaine when used in a TAP block. METHODS: This study was a single centre, prospective, patient-, observer-, and surgeon-blinded, randomized-controlled trial in which 90 patients undergoing an open abdominal hysterectomy with a midline incision were randomized to receive a TAP block with plain bupivacaine (group bupivacaine), liposomal bupivacaine (group liposomal), or a mixture of liposomal bupivacaine and plain bupivacaine (group mixture). Primary outcomes included time to the first rescue opioid analgesic and total opioid consumption during the first 72 postoperative hours. Secondary outcomes included pain scores, patient satisfaction, incidence of hemodynamic instability, presence of local anesthetic systemic toxicity, and length of hospital stay. RESULTS: The median [interquartile range] time to first opioid was 51 [28-66] min in group bupivacaine, 63 [44-102] min in group liposomal, and 51 [24-84] min in group mixture (P = 0.20). The median [interquartile range] total opioid consumption in the first 72 postoperative hours was 208 [155-270] mg in group bupivacaine, 203 [153-283] mg in group liposomal, and 202 [116-325] mg in group mixture (P = 0.92). There were no significant differences in secondary outcomes between groups. CONCLUSIONS: In this small study at risk of being under-powered, the mixture of liposomal bupivacaine with plain bupivacaine for TAP block did not improve analgesia compared with either liposomal bupivacaine or plain bupivacaine on their own. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03250507); registered 5 April 2017

Erector Spinae Plane Continuous Catheters for Refractory Abdominal Pain Related to Necrotizing Pancreatitis: A Case Report

Erector spinae plane (ESP) continuous catheters are used for the management of postsurgical pain. The use of these catheters for acute nonsurgical abdominal pain is not well defined. This case describes a patient with refractory abdominal pain secondary to necrotizing pancreatitis despite escalating doses of opioids, ketamine, and dexmedetomidine. Our patient declined epidural analgesia. Bilateral ESP continuous catheters successfully controlled her pain, and she was weaned off of all analgesics during the week following catheter placement. This case demonstrates that ESP continuous catheters can be considered for patients with acute nonsurgical abdominal pain especially when thoracic epidural analgesia is contraindicated

Anesthetic Management for Cesarean Delivery in a Patient With Pulmonary Emboli, Pulmonary Hypertension, and Right Ventricular Failure

The maternal mortality rate for parturients with severe pulmonary hypertension is 30% to 50%. General, epidural, and combined low-dose spinal-epidural anesthesia have been used successfully for cesarean deliveries in patients with pulmonary hypertension. We describe a cesarean delivery performed using an intrathecal catheter in a 25-year-old morbidly obese (body mass index, 82 kg/m) woman (gravida 3, para 2 at 32 weeks of gestation) who had severe pulmonary hypertension, right ventricular failure, pulmonary emboli, and obstructive sleep apnea. We discuss the anesthetic considerations for parturients with severe pulmonary hypertension undergoing cesarean delivery including the selection of anesthetic technique, vasopressors, and uterotonic agents

The Anesthetic Considerations of Tracheobronchial Foreign Bodies in Children: A Literature Review of 12,979 Cases

Asphyxiation by an inhaled foreign body is a leading cause of accidental death among children younger than 4 years. We analyzed the recent epidemiology of foreign body aspiration and reviewed the current trends in diagnosis and management. In this article, we discuss anesthetic management of bronchoscopy to remove objects. The reviewed articles total 12,979 pediatric bronchoscopies. Most aspirated foreign bodies are organic materials (81%, confidence interval [CI] ϭ 77%-86%), nuts and seeds being the most common. The majority of foreign bodies (88%, CI ϭ 85%-91%) lodge in the bronchial tree, with the remainder catching in the larynx or trachea. The incidence of right-sided foreign bodies (52%, CI ϭ 48%-55%) is higher than that of left-sided foreign bodies (33%, CI ϭ 30%-37%). A small number of objects fragment and lodge in different parts of the airways. Only 11% (CI ϭ 8%-16%) of the foreign bodies were radio-opaque on radiograph, with chest radiographs being normal in 17% of children (CI ϭ 13%

Erector Spinae Plane Catheters for Analgesia for Cytoreduction Surgery With Hyperthermic Intraperitoneal Chemotherapy: A Case Series

Cytoreduction surgery with hyperthermic intraperitoneal chemotherapy is a complex and painful procedure that can cause postoperative hypotension and coagulopathy. Epidural analgesia may worsen hypotension and is contraindicated in the setting of coagulopathy. While alternative regional techniques are being explored, the use of erector spinae plane blocks has not been reported. We present a case series of 6 patients who had erector spinae plane catheters for cytoreduction surgery with hyperthermic intraperitoneal chemotherapy. They remained stable intraoperatively and had adequate pain control postoperatively. Erector spinae plane catheters may be a suitable alternative for epidural analgesia for these patients