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John C Coffman,1 Justin Jones,2 Nasir Hussain,1 Mahmoud Abdel-Rasoul,3 Peter W Dienhart,1 Samiha M Nasser,1 Charles L Hamilton III,1 Jonathan A Lipps,1 Michael Kushelev1 1Department of Anesthesiology, The Ohio State University, Columbus, OH, USA; 2Department of Anesthesiology and Pain Management, The Metrohealth System, Cleveland, OH, USA; 3Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University, Columbus, OH, USACorrespondence: John C Coffman, Department of Anesthesiology, The Ohio State University, 410 W. 10th Ave, Columbus, OH, 43210, USA, Tel +1 614 293 8487, Email john.coffman@osumc.eduIntroduction: Hip arthroscopy is commonly performed as an outpatient procedure and effective postoperative pain management is important to provide quality patient care and enable timely discharge. Multiple regional nerve blocks have been described for pain relief after hip arthroscopy, but there is no consensus on the optimal technique. This retrospective investigation aimed to compare quadratus lumborum (QL) and pericapsular nerve group (PENG) blocks to determine if there are differences in analgesic outcomes after outpatient hip arthroscopy.Methods: A total of 50 consecutive patients that received QL block and 50 that received PENG block for outpatient hip arthroscopy were identified and compared to determine if there were any differences in the primary outcome of total perioperative opioid consumption prior to discharge from the surgery center. Important secondary analgesic outcomes include postoperative opioid consumption, verbal rating scale (VRS) pain scores or total time in the recovery area. Summary statistics of relevant variables are compared and reported between study groups (QL versus PENG).Results: For QL and PENG groups, no significant differences were observed in total perioperative oral morphine equivalents (OME) (69.5 vs 60mg; p=0.40), postoperative OME (15 vs 15.3mg; p=0.96) or maximum pain scores in the recovery area (7.0 vs 6.0; p=0.41). Postoperatively, QL block patients were in PACU for a greater length of time after surgery than PENG block patients (89.5 vs 72 minutes; p< 0.001). No patients had uncontrolled pain requiring emergency room visits or hospital admission within 24 hours. No neurologic complications or instances of motor weakness were reported after QL or PENG blocks.Conclusion: This retrospective study observed similar opioid requirements and pain scores for patients receiving QL versus PENG block for hip arthroscopy, though PENG block patients had shorter times in the recovery area. Prospective, controlled trials are required to further explore and confirm these findings.Keywords: quadratus lumborum, QL, pericapsular nerve group, PENG, Hip arthroscopy

Meghan I Cook,1 Michael Kushelev,1 Julie H Coffman,2 John C Coffman1 1Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 2Department of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USACorrespondence: Meghan I Cook, The Ohio State University Wexner Medical Center, Department of Anesthesiology, N411 Doan Hall, 410 West 10th Ave, Columbus, OH, 43210, USA, Tel +1 614 293 8487, Fax +1 614 293 8153, Email meghan.cook@osumc.eduBackground: Intrathecal (IT) clonidine has been observed to reduce 24-hour opioid requirements and time to first analgesic request after cesarean delivery, but has not been specifically studied in patients with opioid use disorder (OUD).Methods: Patients with OUD undergoing cesarean delivery under spinal or combined spinal-epidural (CSE) anesthesia at our institution from 2011 to 2020 were identified, and only patients with OUD were included in this study. Subjects that received IT clonidine were compared to a control group that did not receive IT clonidine to observe potential differences in analgesic outcomes (24-hour opioid requirements, pain scores and time to first post-operative pain medication) or side-effects (hypotension, vasopressor dosing and bradycardia).Results: A total of 160 patients were included (clonidine n = 22, controls n = 138). For the clonidine group, the median IT clonidine dose was 30μg. Clonidine group patients were observed to have greater dose of IT bupivacaine (12 vs 12.75mg; p = 0.01) and IT morphine (100 vs 200μg; p < 0.001). The clonidine group was also observed to have greater incidence of intraoperative hypotension (20% vs 45%; p = 0.01) and maximum phenylephrine dose (50 vs 57.5 μg/min; p < 0.001). The time to first analgesic request (minutes) after surgery was significantly longer for the clonidine group (153.5 vs 207 min; p < 0.001). The average oral oxycodone equivalents taken per 24 hours of hospital admission were significantly less in the clonidine group (82.36 vs 41.67mg; p < 0.001), and the clonidine group also had significantly less oxycodone equivalents taken for each post-operative day.Conclusion: IT clonidine was observed to result in reduced 24-hour opioid consumption in patients with OUD and may be useful as part of a multimodal analgesic regimen. The incidence of hypotension and vasopressor doses were greater in patients receiving IT clonidine, and this should be anticipated if IT clonidine is being administered.Keywords: opioid use disorder, cesarean analgesia, clonidine, enhanced recovery

Joseph L Reno,1 Michael Kushelev,2 Julie H Coffman,3 Mona R Prasad,4 Avery M Meyer,5 Kristen M Carpenter,5 Marilly S Palettas,6 John C Coffman2 1Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA; 2Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH, USA; 3Department of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USA; 4Department of OBGYN, OhioHealth, Columbus, OH, USA; 5Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 6Center for Biostatistics, The Ohio State University, Columbus, OH, USACorrespondence: Joseph L Reno Tel +1 206 543 2673Fax +1 206 543 2958Email renoj@uw.eduBackground: Despite the increasing prevalence of opioid use disorder (OUD) in pregnant women, there are limited studies on their anesthesia care and analgesic outcomes after cesarean delivery (CD).Methods: Patients with OUD on either buprenorphine or methadone maintenance therapy who underwent CD at our institution from 2011 to 2018 were identified. Anesthetic details and analgesic outcomes, including daily opioid consumption and pain scores, were compared between patients maintained on buprenorphine and methadone. Analgesic outcomes were also evaluated according to anesthetic type (neuraxial or general anesthesia) and daily buprenorphine/methadone dose to determine if these factors impacted pain after delivery.Results: A total of 146 patients were included (buprenorphine n=99 (67.8%), methadone n=47 (32.2%)). Among all patients: 74% had spinal/CSE, 15% epidural, and 11% general anesthesia. Anesthesia types were similar among buprenorphine and methadone patients. For spinal anesthetics, intrathecal fentanyl (median 15 μg) and morphine (median 100 μg) were commonly given (97.2% and 96.3%, respectively), and dosed similarly between groups. Among epidural anesthetics, epidural morphine (median 2 mg) was commonly administered (90.9%), while fentanyl (median 100 μg) was less common (54.5%). Buprenorphine and methadone groups consumed similar amounts of oxycodone equivalents per 24 hours of hospitalization (80.6 vs 76.3 mg; p=0.694) and had similar peak pain scores (8.3 vs 8.0; p=0.518). Daily methadone dose correlated weakly with opioid consumption (R=0.3; p=0.03), although buprenorphine dose did not correlate with opioid consumption or pain scores. General anesthesia correlated with greater oxycodone consumption in the first 24 hours (median 156.1 vs 91.7 mg; p=0.004) and greater IV PCA use (63% vs 7%; p< 0.001) compared to neuraxial anesthesia.Conclusion: Patients on buprenorphine and methadone had similar high opioid consumption and pain scores after CD. The anesthetic details and analgesic outcomes reported in this investigation may serve as a useful reference for future prospective investigations and aid in the clinical care of these patients.Keywords: opioid use disorder, methadone, buprenorphine, cesarean analgesia, outcomes, enhanced recovery

Mellany A Stanislaus,1 Joseph L Reno,1 Robert H Small,1 Julie H Coffman,2 Mona Prasad,3 Avery M Meyer,4 Kristen M Carpenter,4 John C Coffman1 1Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 2Department of Internal Medicine, Riverside Methodist Hospital, Columbus, OH, USA; 3Department of OBGYN, Riverside Methodist Hospital, Columbus, OH, USA; 4Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, USACorrespondence: John C CoffmanDepartment of Anesthesiology, The Ohio State University Wexner Medical Center, Room N-411 North Doan Hall, 410 West 10th Avenue, Columbus, OH 43210, USATel +116142938487Fax +116142938153Email john.coffman@osumc.eduAbstract: The prevalence of opioid use disorder (OUD) in the United States has more than quadrupled over the past two decades. This patient population presents a number of challenges to clinicians, including difficult pain management after surgical procedures due to the development of opioid tolerance. Significantly greater opioid consumption and pain scores after cesarean delivery have been reported in patients with OUD compared to other obstetric patients. A multi-modal analgesic regimen is generally recommended, but there are few well-established pain management strategies after cesarean delivery specific to patients with OUD. We present the case of a patient with OUD maintained on daily methadone that received a continuous epidural hydromorphone infusion for post-cesarean analgesia, a technique not previously reported in obstetric patients and only rarely described for patients undergoing other surgical procedures. The patient received epidural anesthesia for cesarean delivery, and after surgery, the epidural catheter was left in place for the epidural hydromorphone infusion, initiated at 140 mcg/hr and continued for approximately 40 hrs. This strategy reduced her average daily oral opioid consumption by 97%, reduced self-reported pain scores, shortened the length of hospitalization and improved ability to ambulate compared to her previous cesarean delivery. The use of continuous epidural hydromorphone infusion was effective in this case, and this analgesic technique may also be applicable to other types of surgical procedures with the potential for significant post-operative pain, particularly in patients with OUD.Keywords: continuous epidural hydromorphone, opioid use disorder, cesarean delivery, medication-assisted treatment, methadone

Goran Ristev,1 Angela C Sipes,1 Bryan Mahoney,2 Jonathan Lipps,1 Gary Chan,3 John C Coffman1 1Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, USA; 2Department of Anesthesiology, Mount Sinai St. Luke’s and Mount Sinai Roosevelt, New York, NY, USA; 3Department of Anesthesiology, Perioperative & Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA Background: The rationale for injection of epidural medications through the needle is to promote sooner onset of pain relief relative to dosing through the epidural catheter given that needle injection can be performed immediately after successful location of the epidural space. Some evidence indicates that dosing medications through the epidural needle results in faster onset and improved quality of epidural anesthesia compared to dosing through the catheter, though these dosing techniques have not been compared in laboring women. This investigation was performed to determine whether dosing medication through the epidural needle improves the quality of analgesia, level of sensory blockade, or onset of pain relief measured from the time of epidural medication injection. Methods: In this double-blinded prospective investigation, healthy term laboring women (n=60) received labor epidural placement upon request. Epidural analgesia was initiated according to the assigned randomization group: 10 mL loading dose (0.125% bupivacaine with fentanyl 2 µg/mL) through either the epidural needle or the catheter, given in 5 mL increments spaced 2 minutes apart. Verbal rating scale (VRS) pain scores (0–10) and pinprick sensory levels were documented to determine the rates of analgesic and sensory blockade onset. Results: No significant differences were observed in onset of analgesia or sensory blockade from the time of injection between study groups. The estimated difference in the rate of pain relief (VRS/minute) was 0.04 (95% CI: −0.01 to 0.11; p=0.109), and the estimated difference in onset of sensory blockade (sensory level/minute) was 0.63 (95% CI: −0.02 to 0.15; p=0.166). The time to VRS ≤3 and level of sensory block 20 minutes after dosing were also similar between groups. No differences in patient satisfaction, or maternal or fetal complications were observed. Conclusion: This investigation observed that epidural needle and catheter injection of medications result in similar onset of analgesia and sensory blockade, quality of labor analgesia, patient satisfaction, and complication rates. Keywords: labor analgesia, epidural needle, epidural catheter, analgesic onset

Shortening analgesic onset has been researched and it has been documented that prewarming epidural medications to body temperature (37°C) prior to administration increases medication efficacy. Our double-blind randomized controlled trial was designed to investigate if a lower degree of prewarming in providers' pockets could achieve similar results without the need of a bedside incubator. A total of 136 parturients were randomized into either the pocket-warmed group or the room temperature group to receive 10 mL of 0.125% bupivacaine with 2 μg/mL fentanyl epidural bolus at either the 27.8 ±1.7°C or 22.1 ±1.0°C temperatures, respectively. Primary outcome, time to analgesic onset (verbal rating scale pain score ≤ 3) was recorded in 0-, 5-, 10-, 15-, 20-, 30-, and 60-minutes intervals. It was observed that the pocket-warming group (n = 64) and room temperature group (n = 72) had no significant difference of analgesic onset time (median 8 vs. 6.2 minutes; p = 0.322). The incidence of adverse events such as hypotension, fever (≥ 38°C), nausea, vomiting, and number of top-off epidural boluses, as well as patient satisfaction rates and mode of delivery, were not significantly different between the groups as well. Further research is warranted to confirm these findings and explore the impact of different temperatures on analgesic onset time as well as the logistical issues associated with their clinical implementations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Balon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Abstract: Anesthesiologists and surgeons have demonstrated a lack of familiarity with professional guidelines when providing care for surgical patients with a do-not-resuscitate (DNR) order. This substantially infringes on patient's self-autonomy; therefore, leading to substandard care particularly for palliative surgical procedures. The interventional nature of surgical procedures may create a different mentality of surgical "buy-in," that may unintentionally prioritize survivability over maintaining patient self-autonomy. While previous literature has demonstrated gains in communication skills with simulation training, no specific educational curriculum has been proposed to specifically address perioperative code status discussions. We designed a simulated standardized patient actor (SPA) encounter at the beginning of post-graduate year (PGY) 2, corresponding to the initiation of anesthesiology specific training, allowing residents to focus on the perioperative discussion in relation to the SPA's DNR order.Forty four anesthesiology residents volunteered to participate in the study. PGY-2 group (n = 17) completed an immediate post-intervention assessment, while PGY-3 group (n = 13) completed the assessment approximately 1 year after the educational initiative to ascertain retention. PGY-4 residents (n = 14) did not undergo any specific educational intervention on the topic, but were given the same assessment. The assessment consisted of an anonymized survey that examined familiarity with professional guidelines and hospital policies in relation to perioperative DNR orders. Subsequently, survey responses were compared between classes.Study participants that had not participated in the educational intervention reported a lack of prior formalized instruction on caring for intraoperative DNR patients. Second and third year residents outperformed senior residents in being aware of the professional guidelines that detail perioperative code status decision-making (47%, 62% vs 21%, P = .004). PGY-3 residents outperformed PGY-4 residents in correctly identifying a commonly held misconception that institutional policies allow for automatic perioperative DNR suspensions (85% vs 43%; P = .02). Residents from the PGY-3 class, who were 1 year removed the educational intervention while gaining 1 additional year of clinical anesthesiology training, consistently outperformed more senior residents who never received the intervention.Our training model for code-status training with anesthesiology residents showed significant gains. The best results were achieved when combining clinical experience with focused educational training., Competing Interests: The authors have no funding and conflicts of interests to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Consensus regarding the safest mode of delivery and anesthetic management for parturients with Arnold Chiari malformation-I (ACM-I) remains controversial. This study assessed their anesthetic management and reported anesthetic complications during hospitalization for delivery., Methods: This was a multicenter, retrospective, cohort study of patients with ACM-I undergoing vaginal or cesarean delivery. Data were obtained from the electronic databases of four United States academic institutions using International Classification of Diseases (ICD) codes from 2007-2017 at three sites and 2004-2017 at one site. The primary outcome was anesthetic complications., Results: Data were analyzed for 185 deliveries in 148 patients. Diagnosis of ACM-I was made prior to delivery in 147 (80%) cases. Pre-delivery neurosurgical consultation for management of ACM-I was performed in 53 (36%) patients. Pre-existing symptoms were recorded for 89 (48%) of the deliveries. Vaginal deliveries occurred in 80 (43%) cases, and 62 women (78%) received neuraxial labor analgesia. Cesarean delivery was performed in 105 (57%) cases, of which 70 women (67%) had neuraxial anesthesia and 34 (32%) received general anesthesia. Post-dural puncture headache was reported in three (2%) patients who had neuraxial anesthesia, and in two (12%) patients with syringomyelia. There was one (3%) reported case of aspiration pneumonia with general anesthesia., Conclusions: The findings suggest that anesthetic complications occur infrequently in patients with ACM-I regardless of the anesthetic management. Although institutional preference in anesthetic and obstetric care appears to drive patient management, the findings suggest that an individualized approach has favorable outcomes in this population., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The timing of initiation of neuraxial labor analgesia should ultimately depend on patient preference although obstetricians, anesthesiologists and nurses may influence decision-making. We hypothesized that provider groups would have similar attitudes toward the timing of epidural placement, but some identifiable differences could be used to improve understanding and communication among providers., Methods: Anesthesiologists, nurses and obstetricians completed a survey assessing their knowledge and attitudes on the timing of epidural placement in specified clinical circumstances., Results: Anesthesiologists (100%) and nurses (86.2%) reported being more familiar with epidural management than obstetricians (43.3%, P <0.01). The willingness of providers to advocate epidural placement based on the magnitude of cervical dilation was similar, although at 10 cm dilatation obstetricians (73.3%) were significantly more likely to advocate neuraxial block compared to both nurses (27.6%, P <0.01) and anesthesiologists (36.7%, P <0.01). The impact of patient factors and clinical circumstances on the timing of neuraxial block placement showed significant differences among provider groups in five of 24 areas assessed, including patient desire for an epidural, primigravid patients without membrane rupture, oxytocin infusion initiated, labor epidural in a previous pregnancy, and a difficult airway., Conclusions: There were differences between providers in factors that may impact the timing of epidural placement and in their self-perceived familiarity with epidural management. These present an opportunity for furthering interprofessional education and collaboration., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Prompt recognition and management of hypotension resulting from aortocaval compression syndrome are essential to optimize the maternal and fetal outcomes. Management involves increasing leftward uterine displacement and sometimes full lateral positioning, although lateral position during cesarean delivery is typically considered to be impractical. We report an obstetric patient case of severe aortocaval compression syndrome resulting in hypotension and loss of consciousness that ultimately underwent cesarean delivery under general anesthesia in the lateral position. Performing cesarean delivery in the lateral position is virtually unreported, and this unique strategy prevented further symptoms of aortocaval compression and enabled safe delivery.

Purpose: The objective of this narrative review is to provide an overview of the problem of non-opioid anesthetic drug abuse among anesthesia care providers (ACPs) and to describe current approaches to screening, therapy, and rehabilitation of ACPs suffering from non-opioid anesthetic drug abuse., Source: We first performed a search of all literature available on PubMed prior to April 11, 2016. The search was limited to articles published in Spanish and English, and the following key words were used: anesthesiology, anesthesia personnel, AND substance-related disorders. We also searched Ovid MEDLINE ® databases from 1946-April 11, 2016 using the following search terms: anesthesiology OR anesthesia, OR nurse anesthetist OR anesthesia care provider OR perioperative nursing AND substance-related disorders., Principal Findings: Despite an increased awareness of drug abuse among ACPs and improvements in preventive measures, the problem of non-opioid anesthetic drug abuse remains significant. While opioids are the most commonly abused anesthesia medications among ACPs, the abuse of non-opioid anesthetics is a significant cause of morbidity, mortality, and professional demise., Conclusion: Early detection, effective therapy, and long-term follow-up help ACPs cope more effectively with the problem and, when possible, resume their professional activities. There is insufficient evidence to determine the ability of ACPs to return safely to anesthesia practice after rehabilitation, though awareness of the issue and ongoing treatment are necessary to minimize patient risk from potentially related clinical errors.

Purpose: To compare maternal and fetal effects of intravenous phenylephrine and ephedrine administration during spinal anesthesia for cesarean delivery in high-risk pregnancies., Source: An extensive literature search was conducted using the US National Library of Medicine, MEDLINE search engine, Cochrane review, and Google Scholar using search terms "ephedrine and phenylephrine," "preterm and term and spinal hypotension," "preeclampsia and healthy parturients," or "multiple and singleton gestation and vasopressor." Society of Obstetric Anesthesia and Perinatology meeting abstracts for the past 4 years were also searched for relevant studies., Principle Findings: Both phenylephrine and ephedrine can be safely used to counteract hypotension after spinal anesthesia in patients with uteroplacental insufficiency, pregnancy-induced hypertension, and in non-elective cesarean deliveries. Vasopressor requirements before delivery in high-risk cesarean sections are reduced compared to healthy parturients. Among the articles reviewed, there were no statistically significant differences in umbilical arterial pH, umbilical venous pH, incidence of fetal acidosis, Apgar scores, or maternal hypotension when comparing maternal phenylephrine and ephedrine use., Conclusion: From the limited existing data, phenylephrine and ephedrine are both appropriate selections for treating or preventing hypotension induced by neuraxial blockade in high-risk pregnancies. There is no clear evidence that either medication is more effective at maintaining maternal blood pressure or has a superior safety profile in this setting. Further investigations are required to determine the efficacy, ideal dosing regimens, and overall safety of phenylephrine and ephedrine administration in high-risk obstetric patients, especially in the presence uteroplacental insufficiency.

While neuraxial and general anesthetic techniques are most commonly utilized for cesarean delivery, there are rare instances in which alternative techniques may be considered. We report a patient with type II spinal muscular atrophy who had relative contraindications to both neuraxial and general anesthesia, and had experienced significant discomfort during two previous cesarean deliveries performed with local anesthetic infiltration. We describe the successful use of bilateral ultrasound-guided transversus abdominis plane and ilioinguinal/iliohypogastric blocks, in addition to intravenous sedation, for cesarean delivery anesthesia., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

High neuraxial blockade is a serious complication in obstetric patients and requires prompt recognition and management in order to optimize patient outcomes. In cases of high neuroblockade, patients may present with significant hypotension, dyspnea, agitation, difficulty speaking or inability to speak, or even loss of consciousness. We report the unusual presentation of an obstetric patient that remained hemodynamically stable and had the preserved ability to initiate breaths despite sensory blockade up to C2. The presence of differential motor and sensory block documented in this case helped enable the patient to be managed with noninvasive ventilatory support until the high blockade regressed and we are not aware of any other similar reports in literature.