Deltoid, triceps, or both responses improve the success rate of the interscalene catheter surgical block compared with the biceps response

Background The influence of the muscular response elicited by neurostimulation on the success rate of interscalene block using a catheter (ISC) is unknown. In this investigation, we compared the success rate of ISC placement as indicated by biceps or deltoid, triceps, or both twitches. Methods Three hundred (ASA I-II) patients presenting for elective arthroscopic rotator cuff repair were prospectively randomized to assessment by biceps (Group B) or deltoid, triceps, or both twitches (Group DT). All ISCs were placed with the aid of neurostimulation. The tip of the stimulating needle was placed after disappearance of either biceps or deltoid, triceps, or both twitches at 0.3 mA. The catheter was advanced 2-3 cm past the tip of the needle and the block was performed using 40 ml ropivacaine 0.5%. Successful block was defined as sensory block of the supraclavicular nerve and sensory and motor block involving the axillary, radial, median, and musculocutaneous nerves within 30 min. Results Success rate was 98.6% in Group DT compared with 92.5% in Group B (95% confidence interval 0.01-0.11; P<0.02). Supplemental analgesics during handling of the posterior part of the shoulder capsule were needed in two patients in Group DT and seven patients in Group B. Three patients in Group B had an incomplete radial nerve distribution anaesthesia necessitating general anaesthesia. One patient in Group B had an incomplete posterior block extension of the supraclavicular nerve. No acute or late complications were observed. Conclusions Eliciting deltoid, triceps, or both twitches was associated with a higher success rate compared with eliciting biceps twitches during continuous interscalene bloc

New local anesthetics

Local anesthetics are used for performing various regional anesthesia techniques to provide intraoperative anesthesia and analgesia, as well as for the treatment of acute and chronic pain. Older medications such as lidocaine and bupivacaine as well as newer ones such as mepivacaine and ropivacaine are being used successfully for decades. Routes of administration include neuraxial, perineural, intravenous, various infiltrative approaches, topical, and transdermal. There are new innovations with the use of older local anesthetics in a novel manner, in addition to the development and use of new formulations. This chapter seeks to summarize the pharmacokinetics of local anesthetics and address the role of newer local anesthetics, as well as clinical implications, safety profiles, and the future of local anesthetic research. Finally, some clinical pearls are highlighted

Continuous Epicapsular Ropivacaine 0.3% Infusion After Minimally Invasive Hip Arthroplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study Comparing Continuous Wound Infusion with Morphine Patient-Controlled Analgesia

Background:In this study, we investigated the impact of a continuous wound infusion with ropivacaine 0.3% on pain and morphine consumption after minimally invasive hip arthroplasty.Methods:Seventy-six consecutive patients scheduled for elective minimally invasive hip replacement using spinal anesthesia were prospectively included in this double-blind study. Epicapsular placement of a 15-cm fenestrated catheter was performed by the surgeon. Patients were randomized to receive either 20 mL ropivacaine 0.3% (R-group) or 20 mL NaCl 0.9% (P-group) applied into the wound as a bolus before wound closure. A continuous infusion of either ropivacaine 0.3% or placebo was then infused at 8 mL/h for 48 hours after surgery with an elastomeric pump. Morphine IV-patient-controlled analgesia was offered to all patients. Morphine consumption, pain at rest and with motion, and total and unbound ropivacaine plasma concentration were recorded during the 48-hour study period. Postoperative follow-up was performed at 3 months.Results:Demographic and surgical data were similar in both groups. Mean morphine consumption was significantly lower in the R-group than in the P-group during the first 48 postoperative hours: 45.4 ± 9.5 vs 69.7 ± 9.6 (P < 0.0001). There was a mean reduction of 14.4 mg for the first 24 postoperative hours (95% confidence interval [CI] 12.6 to 16.1) and 20.8 mg for the next 24 hours (95% CI 19.1 to 22.4). Pain scores at rest and with motion were lower in the R-group (P < 0.0001). Mean patient satisfaction increased 22.7% from baseline (CI 95% 15.9 to 29.6) in the R-group. Total and unbound ropivacaine plasma concentrations were below toxic levels in the R-group. The free ropivacaine concentration was 0.14 and 0.11 μgmol/L at T(24) and T(48), respectively, in the R-group. At 3 months postoperatively, hip pain and analgesic consumption were similar, but a significant reduction in wound discomfort to touch (31.2; 95% CI 27.7 to 34.7) and pressure (24; 95% CI 20.1 to 27.9) was observed in the R-group (P < 0.0001).Conclusions:Continuous epicapsular wound infusion with ropivacaine 0.3% after minimally invasive hip replacement is an efficient technique for reducing morphine consumption and improving the quality of postoperative analgesia. The beneficial effects of this technique are still present 3 months after surgery

Impact of a pharmacy‐led nursing education on discharge opioid prescribing after kidney transplant

A major contributor to the opioid epidemic is prescribing in the postoperative setting. There remains the need for opioid stewardship both postoperatively and upon discharge in kidney transplant recipients. In October 2017, pharmacist-led education was given to all transplant nursing staff at a single center with the goal of optimizing postoperative pain control through education and empowerment of nurses. Furthermore, the education focus was to advance nursing knowledge, enhance patient assessment, and reform patient education. Clinical pharmacists continued to work with the transplant team to base a patient's discharge analgesia on inpatient analgesia use. This study assessed the impact of the nursing education on discharge analgesic prescribing patterns after kidney transplant admission. Opioid prescribing on transplant discharge was significantly lower after the education (pre 68.3% vs post 11.1%, P <.001). Transplant admission was shortened by 1 day (6 vs 5 days, P =.03). Over time, a significant downtrend in opioid prescribing was observed on discharge from 86.1% in 2015 to 49.6% in 2017 and 8.5% in 2018 (P <.001). If opioid therapy was required on discharge in the posteducation group, tramadol was predominantly prescribed (7/13 opioid prescriptions, 53.9%). Thus, opioid minimization and pain management using nonopioid analgesic prescribing on discharge are feasible in an adult kidney transplant population with proper nursing collaboration and education

Regional anaesthesia and cancer metastases: the implication of local anaesthetics

Clinical and basic science studies have demonstrated the anti-inflammatory properties of local anaesthetics. Recent studies have begun to unravel molecular pathways linking inflammation and cancer. Regional anaesthesia is associated in some retrospective clinical studies with reduced risk of metastasis and increased long-term survival. The potential beneficial effects of regional anaesthesia have been attributed mainly to the inhibition of the neuroendocrine stress response to surgery and to the reduction in the requirements of volatile anaesthetics and opioids. Because cancer is linked to inflammation and local anaesthetics have anti-inflammatory effects, these agents may participate in reducing the risk of metastasis, but their mechanism of action is unknown. We demonstrated in vitro that amide local anaesthetics attenuate tumour cell migration as well as signalling pathways enhancing tumour growth and metastasis. This has provided the first evidence of a molecular mechanism by which regional anaesthesia might inhibit or reduce cancer metastases