Regional Anesthesia and Pain Medicine最新文献

{"title":"Prolonged administration of intrathecal baclofen in a patient with generalized grade 4 tetanus.","authors":"Michael Aiello, Sounak Roy, Lyndsey Chitty, Brittany Johnson, Matthew Warrick","doi":"10.1136/rapm-2024-105491","DOIUrl":"10.1136/rapm-2024-105491","url":null,"abstract":"<p><strong>Introduction: </strong>This case report presents the management of a 62-year-old woman with generalized grade 4 tetanus, focusing on the innovative use of intrathecal baclofen (ITB) therapy. The patient initially presented with a laceration and subsequently developed severe tetanic spasms, necessitating interventions beyond standard tetanus immunoglobulin and antibiotics due to the condition's progressive and life-threatening nature. The preference for ITB over oral baclofen is highlighted, considering ITB's enhanced bioavailability in the central nervous system and its efficacy in reducing spinal cord reflexes, which is critical for managing severe spasticity.On her return to the emergency department with symptoms of tetanus, the patient received ITB following the failure of oral baclofen to control the spasms. ITB administration necessitated a lumbar drain, which was later substituted with a tunneled intrathecal catheter due to the extended requirement for baclofen infusion and the unavailability of suitable infusion pumps. This scenario represented a significant application of a CADD-Solis external pump for continuous ITB infusion.Transitioning the patient from ITB to oral baclofen was a crucial management step to facilitate discharge and recovery, underscoring the importance of a careful approach to prevent withdrawal symptoms and maintain care continuity. Despite initial complications, including an infection signaled by leucocytosis and confirmed through cerebrospinal fluid culture, the patient was effectively treated and discharged.</p><p><strong>Conclusion: </strong>This report contributes to the sparse literature on prolonged ITB use for generalized grade 4 tetanus treatment, underlining the need for interdisciplinary collaboration for the best patient outcomes. It showcases the potential of ITB in spasticity management, in reducing the need for sedation, and in shortening the duration of mechanical ventilation, advocating for a tailored approach that utilizes a full spectrum of pharmacological and supportive therapies.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-07-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140900251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessment of catheter position using chest CT in adults undergoing erector spinae plane analgesia for rib fractures: a retrospective cohort study.","authors":"Maylyn Wu, Charbel Barrak, Patrick Forrest, Derek Rizzo, Carlos Eduardo Guerra-Londono","doi":"10.1136/rapm-2024-105673","DOIUrl":"https://doi.org/10.1136/rapm-2024-105673","url":null,"abstract":"<p><strong>Background: </strong>Continuous erector spinae plane (ESP) analgesia is a common adjuvant for patients with traumatic rib fracture pain and success relies on the ESP catheter remaining within the correct fascial plane for the duration of its placement. However, knowledge on postplacement position of indwelling ESP catheters is largely absent. We hypothesized that migration of over-the-needle ESP catheters was common and detectable with coincidental postprocedure CT.</p><p><strong>Methods: </strong>In this single-center retrospective cohort study, adults admitted to the surgical intensive care unit for traumatic rib fractures between January 2020 and July 2022 were screened. Those receiving continuous ESP analgesia via indwelling catheter and undergoing subsequent chest CT were included. The primary outcome was the proportion of catheters that migrated outside the ESP. The secondary outcome was the distance between the catheter tip and the nearest transverse process (TP) or fascial plane.</p><p><strong>Results: </strong>160 medical records were screened for eligibility and 15 patients (18 catheters) met the inclusion criteria. 16 of 18 catheters reviewed were found outside the ESP. Furthermore, catheter position was reported as intramuscular in 14 catheters and subcutaneous in 4 catheters. The median distance between catheter tip and the nearest TP (or the ESP) was 23.20 mm sagittally and 25.05 mm axially.</p><p><strong>Conclusions: </strong>Most ESP catheters were found superficial to the fascial plane in the days following their placement. The median distance between the catheter and the ESP is between 23 and 25 mm. Prospective studies should address catheter migration concerns and propose solutions to this common issue.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-07-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141538937","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unwarranted variation in perioperative pain management for pediatric anterior cruciate ligament reconstruction: a call to improve the quality of quality improvement.","authors":"Ellen M Soffin, Faraj W Abdallah, Edward R Mariano","doi":"10.1136/rapm-2024-105637","DOIUrl":"10.1136/rapm-2024-105637","url":null,"abstract":"","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141460738","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Therapeutic effect of epidural dexamethasone palmitate in a rat model of lumbar spinal stenosis.","authors":"Mei Hui Li, Haiyan Zheng, Eun Joo Choi, Francis Sahngun Nahm, Ghee Young Choe, Pyung Bok Lee","doi":"10.1136/rapm-2024-105530","DOIUrl":"https://doi.org/10.1136/rapm-2024-105530","url":null,"abstract":"<p><strong>Background: </strong>Dexamethasone palmitate (DEP), a prodrug of dexamethasone (DEX), is a synthetic corticosteroid medication distinguished by the inclusion of a fatty acid component known as palmitate. This study introduces DEP as a novel therapeutic option for spinal epidural injection, aiming to provide safer and longer-lasting pain relief as an alternative to for patients with spinal stenosis.</p><p><strong>Methods: </strong>40 rats were randomly divided into four groups: those receiving epidural administration of normal saline (NS), and DEP in the lumbar spinal stenosis (LSS) model, and non-model rats receiving epidural NS administration. Paw withdrawal thresholds to mechanical stimulation and motor function (neurogenic intermittent claudication) were observed for up to 21 days. Hematology and blood chemistry analyses were performed 1 week after drug therapy. Tissue samples were collected for steroid pathology examination to evaluate adhesion degree, perineural area inflammation, and chromatolysis in the dorsal root ganglion (DRG), and adrenal gland.</p><p><strong>Results: </strong>The DEX and DEP groups demonstrated significant recovery from mechanical allodynia and motor dysfunction after 2 weeks of drug therapy (p<0.001). However, by the third week, the effect of DEX started to diminish while the effect of DEP persisted. Furthermore, the DEP group exhibited reduced fibrosis and less chromatolysis than the NS group. No steroid overdose or toxin was observed in any group.</p><p><strong>Conclusion: </strong>The epidural administration of DEP demonstrated therapeutic efficacy in reducing allodynia and hyperalgesia resulting from chronic DRG compression, thus offering prolonged pain relief. These findings underscore the potential of DEP as a promising treatment alternative for pain associated with LSS, serving as a viable substitute for .</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141499656","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Insights into the pathophysiology and response of persistent spinal pain syndrome type 2 to spinal cord stimulation: a human genome-wide association study.","authors":"Gustavo Fabregat-Cid, David L Cedeno, José De Andrés, Anushik Harutyunyan, Vicente Monsalve-Dolz, Ana Mínguez-Martí, Natalia Escrivá-Matoses, Juan Marcos Asensio-Samper, Thiago Carnaval, Jesús Villoria, Raquel Rodríguez-López, Ricardo Vallejo","doi":"10.1136/rapm-2024-105517","DOIUrl":"https://doi.org/10.1136/rapm-2024-105517","url":null,"abstract":"<p><strong>Background: </strong>Spinal cord stimulation (SCS) provides pain relief for some patients with persistent spinal pain syndrome type 2 (PSPS 2), but the precise mechanisms of action and prognostic factors for a favorable pain response remain obscure. This in vivo human genome-wide association study provides some pathophysiological clues.</p><p><strong>Methods: </strong>We performed a high-density oligonucleotide microarray analysis of serum obtained from both PSPS 2 cases and pain-free controls who had undergone lower back spinal surgery at the study site. Using multivariate discriminant analysis, we tried to identify different expressions between mRNA transcripts from PSPS 2 patients relative to controls, SCS responders to non-responders, or SCS responders to themselves before starting SCS. Gene ontology enrichment analysis was used to identify the biological processes that best discriminate between the groups of clinical interest.</p><p><strong>Results: </strong>Thirty PSPS 2 patients, of whom 23 responded to SCS, were evaluated together with 15 pain-free controls. We identified 11 significantly downregulated genes in serum of PSPS 2 patients compared with pain-free controls and two significantly downregulated genes once the SCS response became apparent. All were suggestive of enhanced inflammation, tissue repair mechanisms and proliferative responses among the former. We could not identify any gene differentiating patients who responded to SCS from those who did not respond.</p><p><strong>Conclusions: </strong>This study points out various biological processes that may underlie PSPS 2 pain and SCS therapeutic effects, including the modulation of neuroimmune response, inflammation and restorative processes.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-07-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141499650","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter to the editor regarding 'Transitioning from intrathecal bupivacaine to mepivacaine for same-day discharge total joint arthroplasty: a quality improvement study'.","authors":"Bradley Vost, Jashvant Poeran, Michelle Carley, Daniel Maalouf","doi":"10.1136/rapm-2024-105778","DOIUrl":"https://doi.org/10.1136/rapm-2024-105778","url":null,"abstract":"","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141494293","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of epidural anesthesia on the optic nerve sheath diameter in patients with pre-eclampsia: a prospective observational study.","authors":"Sun-Kyung Park, Hansol Kim, Youngwon Kim, Young-Eun Jang, Jin-Tae Kim","doi":"10.1136/rapm-2024-105444","DOIUrl":"https://doi.org/10.1136/rapm-2024-105444","url":null,"abstract":"<p><strong>Introduction: </strong>Optic nerve sheath diameter (ONSD) reflects intracranial pressure and is increased in pre-eclampsia. Administrating a significant volume of epidural solution into the epidural space can potentially increase ONSD. We investigated the impact of epidural local anesthetic injection on ONSD in patients with pre-eclampsia.</p><p><strong>Methods: </strong>Patients with pre-eclampsia (n=11) and normotensive pregnant women (n=11) received de novo epidural anesthesia for cesarean delivery. We administered 21 mL of an epidural solution containing 2% lidocaine and 50 μg fentanyl into the lumbar epidural space in incremental doses. ONSD was measured at baseline, 3, 10, and 20 min after completing the epidural injection, after delivery, and at the end of surgery. Primary outcome was the change in ONSD from baseline to 3 min after epidural injection in patients with pre-eclampsia and normotensive pregnant women. Serial changes in the ONSD were analyzed using a linear mixed model.</p><p><strong>Results: </strong>At baseline and 3 min after epidural drug injection, ONSD was significantly larger in patients with pre-eclampsia than in normotensive mothers (5.7 vs 4.1 mm, p=0.001 and 5.4 vs 4.1 mm, p<0.001, respectively). However, there were no significant changes in ONSD at 3 min after injection from baseline in either group (p>0.999). Linear mixed model demonstrated that ONSD did not change after epidural anesthesia in either group (p=0.279 and p=0.347, respectively).</p><p><strong>Conclusions: </strong>Despite a higher baseline ONSD in pre-eclampsia, epidural anesthesia did not further increase ONSD. Our findings indicate that epidural anesthesia can be safely administered in patients with pre-eclampsia at risk of increased intracranial pressure, without other intracranial pathology.</p><p><strong>Trial registration number: </strong>NCT04095832.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141477960","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cannabis use and acute postoperative pain outcomes in older adults: a propensity matched retrospective cohort study.","authors":"Ruba Sajdeya, Masoud Rouhizadeh, Robert L Cook, Ronald L Ison, Chen Bai, Sebastian Jugl, Hanzhi Gao, Mamoun T Mardini, Osama Dasa, Kimia Zandbiglari, Farzana I Adiba, Almut G Winterstein, Catherine C Price, Thomas A Pearson, Christoph N Seubert, Patrick J Tighe","doi":"10.1136/rapm-2024-105633","DOIUrl":"10.1136/rapm-2024-105633","url":null,"abstract":"<p><strong>Introduction: </strong>Cannabis use is increasing among older adults, but its impact on postoperative pain outcomes remains unclear in this population. We examined the association between cannabis use and postoperative pain levels and opioid doses within 24 hours of surgery.</p><p><strong>Methods: </strong>We conducted a propensity score-matched retrospective cohort study using electronic health records data of 22 476 older surgical patients with at least 24-hour hospital stays at University of Florida Health between 2018 and 2020. Of the original cohort, 2577 patients were eligible for propensity-score matching (1:3 cannabis user: non-user). Cannabis use status was determined via natural language processing of clinical notes within 60 days of surgery and structured data. The primary outcomes were average Defense and Veterans Pain Rating Scale (DVPRS) score and total oral morphine equivalents (OME) within 24 hours of surgery.</p><p><strong>Results: </strong>504 patients were included (126 cannabis users and 378 non-users). The median (IQR) age was 69 (65-72) years; 295 (58.53%) were male, and 442 (87.70%) were non-Hispanic white. Baseline characteristics were well balanced. Cannabis users had significantly higher average DVPRS scores (median (IQR): 4.68 (2.71-5.96) vs 3.88 (2.33, 5.17); difference=0.80; 95% confidence limit (CL), 0.19 to 1.36; p=0.01) and total OME (median (IQR): 42.50 (15.00-60.00) mg vs 30.00 (7.50-60.00) mg; difference=12.5 mg; 95% CL, 3.80 mg to 21.20 mg; p=0.02) than non-users within 24 hours of surgery.</p><p><strong>Discussion: </strong>This study showed that cannabis use in older adults was associated with increased postoperative pain levels and opioid doses.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141477959","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Erector spinae plane infiltration and anterior rami of spinal nerve: a cadaveric study.","authors":"Madeleine Luchsinger, Victor Varela, Sandeep Diwan, Alberto Prats-Galino, Xavier Sala-Blanch","doi":"10.1136/rapm-2024-105691","DOIUrl":"https://doi.org/10.1136/rapm-2024-105691","url":null,"abstract":"<p><strong>Background: </strong>The erector spinae plane block (ESP block) is frequently employed for thoracic, abdominal, and spinal surgeries, yet its precise mechanism of action remains a subject of debate. While initially postulated to influence both ventral and dorsal rami of the spinal nerve, recent studies indicate a predominant impact on the dorsal rami with limited involvement of the ventral rami. To elucidate this mechanism, we conducted an observational study to assess the distribution of ESP infiltration to the ventral rami.</p><p><strong>Methods: </strong>We performed 20 ESP infiltrations bilaterally in 10 unembalmed cadavers, targering the T9 transverse process level. A volume of 20 mL of ropivacaine 0.2% and methylene blue 0.01% was used. Dissection was carried out to assess dye distribution, with a focus on involvement of the ventral and dorsal rami, as well as lateral and longitudinal spread within the spinal muscular plane.</p><p><strong>Results: </strong>No evidence of dye staining was observed in the ventral rami in any of the cadavers; however, the dorsal rami consistently displayed staining. The dye exhibited extensive longitudinal diffusion across the paravertebral musculature, spanning a median of 10 vertebral spaces (T5-L2). The range extended from 3 to 18 spaces, with an IQR of 11 levels (T4-L2), predominantly affecting the longissimus and iliocostalis muscles.</p><p><strong>Conclusions: </strong>The infiltration of injectate into the ESP does not contact the ventral rami of segmental spinal nerves. The inference that an in vivo ESP block is a paravertebral \"by-proxy\" is, therefore, unlikely.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141477961","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Anesthetic management with labor epidural analgesia of the parturient with severe factor VII deficiency: a case report.","authors":"Benjamin Hyers, Camila Cabrera, Christopher Walsh, Anusha Reddy, Talia Strulowitz, Joshua Hamburger, Nakiyah Knibbs, Daniel Katz, Lauren Ferrara, Yaakov Beilin","doi":"10.1136/rapm-2024-105674","DOIUrl":"https://doi.org/10.1136/rapm-2024-105674","url":null,"abstract":"<p><strong>Background: </strong>Factor VII deficiency is considered a contraindication to neuraxial anesthesia due to the risk of an epidural hematoma.</p><p><strong>Case report: </strong>A 32 year old G1P0 parturient with severe factor VII deficiency presented for an anesthesiology consultation at 32 weeks gestation. Initial coagulation studies were significant for an elevated INR (2.0) and a low factor VII level of 6%. After interdisciplinary discussion, it was decided that neuraxial analgesia could be offered if her coagulation studies corrected after administration of recombinant activated factor VII (rFVIIa). The patient presented at 36 weeks gestation for a rFVIIa challenge. She received 22 mcg/kg rFVIIa and coagulation studies were analyzed 20 minutes later which showed complete correction of the coagulopathy. The patient presented to the hospital at 39 weeks and 3 days for delivery, received 2 mg rFVIIa and 20 minutes later, successfully received an epidural catheter. Her INR was monitored every 3 hours during her labor course and rFVIIa was given if the INR was 1.3 or greater. She required three additional doses over 22 hours. No bleeding or thrombotic events occurred, and the patient was discharged home without complications.</p><p><strong>Conclusion: </strong>This case highlights the safe management of an epidural catheter in a parturient with severe factor VII deficiency.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1,"publicationDate":"2024-06-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141477958","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}