Search

Thoracotomy is considered one of the most painful operative procedures. Due to anatomical complexity, post-thoracotomy pain requires multimodal perioperative treatment to adequately manage to ensure proper postoperative recovery. There are several different strategies to control post-thoracotomy pain including interventional techniques, such as neuraxial and regional injections, and conservative treatments including medications, massage therapy, respiratory therapy, and physical therapy. This article describes different strategies and evidence base for their use.

OBJECTIVES Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures. METHODS Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills. RESULTS Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%). CONCLUSIONS The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.

Effective multimodal analgesia and sedation reduce the postoperative morbidity and mortality associated with newborn bladder exstrophy repair. Epidural analgesia is safe and effective for major surgery in neonates and infants, reducing the need for muscle relaxants, opioids, and ventilator support postoperatively. The risk of epidural catheter colonization typically dictates removal after 3 to 5 days. Tunneling the catheter subcutaneously reduces the risk of colonization, providing prolonged analgesia for patients requiring an extended immobilization to prevent compromise of the repair. In this report, we describe the postoperative analgesic management of an infant undergoing bladder exstrophy repair using a directly placed tunneled epidural catheter with ropivacaine 0.1% infusion. Because of the prolonged infusion, we also monitored plasma ropivacaine levels to preclude systemic toxicity from local anesthetic overdose.

Study Objective To compare the femoral nerve block with the fascia iliaca block for postoperative analgesia in adolescents undergoing reconstructive knee surgery. Design Randomized, single-blinded study. Setting Full-service pediatric medical center. Patients 23 ASA physical status I and II patients, aged 8 to 16 years, undergoing anterior cruciate ligament (ACL) repair. Interventions Patients received either fascia iliaca or femoral nerve block prior to reconstructive surgery. Measurements Pain scores by visual analog scale (VAS; 0-10) and morphine use were routinely recorded through to discharge from the hospital. Pain scores were assessed on days 1 and 2 at home post-discharge. Main results There was no difference between the femoral nerve block and the fascia iliaca nerve block in VAS pain scores or postoperative morphine consumption. Conclusion Either the femoral nerve block or the fascia iliaca block, followed by patient-controlled analgesia with morphine, provides efficacious analgesia for adolescents undergoing ACL reconstruction.

Diagnosis and treatment of complex regional pain syndrome in children is one of the most challenging clinical pain problems encountered in the chronic pain setting. Despite the intense and debilitating nature of the pain, referral to appropriate specialists often comes too late, thereby prolonging an already arduous (and controversial) course of treatment and risking long-term disability. On the contrary, full recovery can be expected with early diagnosis and prompt treatment. The following case study describes a novel and successful use of intrathecal catheter administration of ropivacaine in a child with early, rapidly progressing, and debilitating complex regional pain syndrome.

The following case report describes a very challenging surgical case where the use of intraoperative, continuous TEE monitoring in the prone position was crucial for the anesthetic management (diagnosis and treatment) of a patient with single ventricle physiology. The use of TEE monitoring enabled the anesthesia team to continuously assess hemodynamic stability and respond immediately to hypotension and bradycardia in our patient, thereby providing optimal anesthetic care of the intraoperative spinal fusion patient with Fontan physiology.

IMPLICATIONS Birth defects can affect the great vessels of the aorta and its branches, compressing the upper airway and the swallowing track. Surgical repair of these defects requires manipulating the airway to improve surgical exposure. This is a report of a series of cases with compromised airway resulting from such a birth defect and methods of its management.

Bupivacaine is a long-acting amide local anesthetic that was introduced to clinical practice in the early 1980s. Since then it has been extensively used for both peripheral blocks as well as neuraxial blockade in concentrations varying from 0.125% to 0.75%. Despite the relatively narrow safety margin, bupivacaine has become the most frequently used local anesthetic in obstetric anesthesia.1 It is 95% metabolized in the liver and 5% excreted unchanged in urine.2 Bupivacaine cardiotoxicity is related to the total dose rather than to the concentration of bupivacaine administere.3 It produces a dose-dependent delay in the transmission of impulses through the cardiac conduction system by blocking sodium channels.4 Transient neurologic symptoms (TNS) defined as bilateral symmetrical pain in the lower back and buttocks with radiation to both lower extremities after 5% lidocaine spinal anesthetic was first described by Schneider in 1993.7 Several studies have failed to show TNS after spinal anesthesia using bupivacaine 0.5% or 0.75%.8,9 In the literature there is only 1 case report10 of TNS after spinal anesthesia using bupivacaine and morphine. The following report describes a case of TNS following spinal anesthesia with bupivacaine 0.75%.

Implications We report a case of a patient who developed membranous tracheal disruption after severe vomiting. He subsequently required urgent colectomy for toxic megacolon under general anesthesia. With this challenging situation, we were able to successfully conduct general anesthesia in the presence of tracheal laceration, pneumothorax, and pneumomediastinum.

The evaluation of risk is a fundamental part of the role of the anesthesiologist in the perioperative period. For elective surgery, this evaluation begins with identification of correctable elements of co-morbidity and appropriate intervention to reduce risk and/or improve outcome. Optimum anesthetic care requires a balance between sensitive detection of risk and cost-effective utilization of expensive resources. The preparation of the patient with known cardiovascular disease for noncardiac surgery is an excellent example of this dilemma. Formal risk-stratification has been a regular part of the daily practice of anesthesiology since the 1960s, with the assignment of an American Society of Anesthesiologists (ASA) physical status classification as a part of every anesthetic administered. Sponsored by the ASA and published by Dripps et al., ASA physical status assignment was designed to predict risk. Subsequent large-scale reviews have shown ASA physical status classifications to correlate with the incidence of major morbidity and mortality, although not in a manner that lends itself to predicting specific cardiac risk, or guiding cardiac testing for elective surgery. The desire to identify a means to predict perioperative cardiac risk has been driven by the observation that adverse cardiac events correlate with certain kinds of surgery, including carotid artery surgery, aortic aneurysm repair, and peripheral revascularization procedures. Recognizing that vascular surgery was highly associated with adverse cardiac events, Hertzer et al. advocated routine cardiac catheterization before vascular surgery, and achieved a very low mortality after major aortic surgery. Subsequent review of this approach revealed normal coronaries in only 8% of more than 1,000 patients scheduled for peripheral vascular surgery, with a significant incidence (14%) with severe correctable coronary artery disease that was not suspected by the clinical history. Coronary angiography led to coronary artery bypass graft procedures in 130 patients in this series who subsequently underwent aortic surgery, with less than 1% mortality. Screening with routine cardiac catheterization did not expand from these studies into a general risk prediction strategy due to the cost and morbidity associated with the procedures. Other approaches have included routine screening with exercise stress testing, dipyridamole-thallium imaging, and dobutamine stress echocardiography. Although some data are supportive, routine screening ultimately proves less than ideal for preoperative preparation for large populations of patients due to risk, cost, and logistics. In an attempt to combine patient factors with surgical issues, Goldman et al.

Study Objective: To review the new consensus guidelines for cardiac testing for the patient with cardiac disease scheduled for elective, noncardiac surgery, and their impact on cardiac functional testing. Design: Retrospective chart review study. Setting: Tertiary care medical center. Patients: 181 patients scheduled for elective, major surgery who met American College of Cardiology/American Heart Association (ACC/AHA) criteria for a preoperative stress test. Interventions: A variety of tests were ordered, including treadmill stress testing, persantine-thallium imaging, dobutamine echocardiography, and exercise stress echocardiography. Measurements: The numbers of and outcome of the stress tests and the cardiac outcome of the patients who underwent cardiac testing and surgery were recorded.. Main Results : Abnormal tests occurred in 27 patients. Two patients declined treatment, eight patients had primary medical management, and the remainder (17) had cardiac catheterization. Results included no lesion (2 patients), angioplasty (4 patients), angioplasty plus stenting (1 patient), coronary artery bypass grafting (CABG) (4 patients), and delineated lesions treated with medical optimization (6 patients). One patient had CABG and declined further surgery. One patient had myocardial infarction 6 months after surgery that was treated by medical management after cardiac catheterization. The other 23 patients had surgery without cardiac complication within 1 year of surgery. Only 15% (27/180) of the patients with indications for a stress test had a positive result. Even fewer patients had any alteration of the perioperative period. Despite this finding, cardiac morbidity was very low. Conclusions: The guidelines for stress test may be over-sensitive, and further prospective clinical studies are indicated.

Hyperbaric 5% lidocaine has been used extensively for spinal anesthesia for the last 50 yr. The implication of lidocaine as specifically etiologic for transient neurologic symptoms (TNS) has led to increasing focus on lidocaine spinal anesthesia and reports of TNS with single-shot, hyperbaric lidocaine. We report the details of a case of TNS associated with single-shot, isobaric 2% lidocaine in a 69-year-old female, scheduled for outpatient hysteroscopy, dilatation and curettage, and endometrial biopsy while placed in the lithotomy position.