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Background Interscalene blocks provide analgesia for shoulder surgery but also cause phrenic nerve paralysis. Liposomal bupivacaine is approved for use in interscalene blocks with the potential to provide longer pain control. However, the impact of liposomal bupivacaine on the phrenic nerve has not been evaluated. It was hypothesized that patients who received an interscalene block with both bupivacaine and liposomal bupivacaine would have a decreased diaphragmatic excursion when compared to bupivacaine alone at 24 h. Methods This was a double-blinded study of adult patients who were randomized to receive an interscalene block with either 20 ml 0.5% bupivacaine (bupivacaine group) or 10 ml 0.5% bupivacaine plus 10 ml liposomal bupivacaine (liposomal bupivacaine group). Twenty-six patients were randomized with 22 included in the analysis. Diaphragmatic excursion (via ultrasound) and spirometry were assessed before the block, in the postanesthesia care unit, and at 24 h postblock. The primary outcome was diaphragm excursion with sigh. No adverse events were observed. Results At 24 h, the liposomal bupivacaine group median [25th, 75th], had a greater percent change in diaphragmatic excursion during sigh breath compared to the bupivacaine group, –24% [–30, –9] versus 9% [–8, 26], difference in location, 32 (95% CI, 12 to 52), P = 0.007. Five patients in the liposomal bupivacaine group had a greater than 25% reduction in diaphragmatic excursion at 24 h versus zero in the bupivacaine group. They also had a significantly greater percent reduction in forced expiratory volume in 1 s and forced vital capacity compared with the bupivacaine group at 24 h (median decrease of 22% vs. 2%, P = 0.006, and median decrease of 19% vs. 1%, P = 0.049, respectively). Conclusions The addition of liposomal bupivacaine to bupivacaine in an interscalene block results in statistically significant reductions in diaphragm excursion and pulmonary function testing 24 h after block placement when compared to bupivacaine alone. This reduction, however, falls within the range of normal diaphragmatic function. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Purpose To aid nurses in dosing sufentanil sublingual tablet (SST) 30 mcg administered via a single-dose applicator, dosing requirements and efficacy of SST 30 mcg were analyzed across age, sex, race, and body mass index subgroups. Design Patient characteristics were pooled from three postoperative studies (two placebo-controlled and one open-label) and one open-label emergency department study. Drug dosing and efficacy data were pooled from the postoperative studies. Methods Efficacy was assessed through summed pain intensity difference to baseline during 12 hours across subgroups. Findings Mean (standard deviation) drug doses administered from 0 to 12 hours was 3.9 (2.0) for SST 30 mcg and was less frequent for older (≥65 years) versus younger patients. The summed pain intensity difference to baseline during 12 hours was superior with SST 30 mcg versus placebo across all subgroups. Conclusions SST 30 mcg is a sublingual opioid analgesic with efficacy across demographic subgroups.

BackgroundSingle-injection interscalene brachial plexus blocks are used for analgesia for rotator cuff repair (RCR) but have limited duration. The value of adding liposomal bupivacaine (LB) to prolong single-injection interscalene blocks is unclear. The purpose of this trial is to evaluate the addition of LB to regular bupivacaine interscalene blocks for patients undergoing arthroscopic RCR.MethodsIn this prospective, randomized trial, 70 patients undergoing primary RCR with equal group allocation were randomized by random number generator to receive an interscalene block with 20 mL of 0.5% bupivacaine or 10 mL 0.5% bupivacaine plus 133 mg LB. The primary outcome was cumulative opioid consumption within 72 hours of the procedure. Secondary outcomes included maximum pain scores and quality of recovery 15 survey scores.Results70 of the 80 randomized patients were included in final analysis following exclusion for protocol violations and loss to follow-up. Cumulative opioid consumption (oral morphine equivalents) within 72 hours in patients receiving LB was a median (IQR) of 31.9 mg (0, 73.1) compared with 45.0 mg (15.0, 108.8) among patients receiving bupivacaine alone (p=0.312). Patients receiving LB demonstrated mixed results regarding worst pain scores with improvements at 24 hours and 72 hours, but not 48 hours.ConclusionsLB added to bupivacaine interscalene blocks does not reduce opioid consumption within 72 hours following arthroscopic RCR.Trial registration numberNCT03587584.

Jacob Hutchins,1 Peter Argenta,2 Aaron Berg,1 Jason Habeck,1 Alexander Kaizer,3 Melissa A Geller21Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA; 2Department of Obstetrics, Gynecology and Women’s Health, Minneapolis, MN, USA; 3Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, CO, USAPurpose: To determine if a transversus abdominis plane (TAP) block with liposomal bupivacaine reduces total postoperative opioid use in the first 72 hrs following laparoscopic or robotic hysterectomy compared to port-site infiltration with 0.25% bupivacaine.Methods: Patients received either a true TAP block procedure with 266 mg liposomal bupivacaine and 50 mg of 0.25% bupivacaine and sham port infiltration or sham TAP block procedure with true port-site infiltration with 100–125 mg of 0.25% bupivacaine. All patients had a standardized, scheduled, non-opioid pain management plan. The primary outcome was total IV morphine equivalents used in the first 72 hrs following surgery. Secondary outcomes included assessment of postoperative pain over the study period and quality of recovery measures.Results: Patients undergoing TAP blockade required fewer total opioid equivalents during the observation period than patients allocated to infiltration (median 21 versus 25 mg IV Morphine equivalents, P=0.03). Opioid use was highest in the first 24 hrs after surgery, with less difference between the groups during days 2 and 3 postoperatively. There were 5 in the TAP group and 0 in the infiltration group were opioid free at 72 hrs. Those in the TAP group had improved quality of recovery (QoR15) with no change in overall benefit of analgesia score.Conclusion: TAP blockade reduced the requirement for opioid pain medication in the first 72 hrs after surgery, had more patients opioid free at 72 hrs, and improved patients’ quality of their recovery.Keywords: acute pain, regional pain, TAP block, liposome bupivacaine

Background. The purpose of this study was to investigate if the addition of liposome bupivacaine (LB) to an interscalene block (ISB) had an effect on the number of patients with surgical- or block-related complications.Methods. This was a single-center retrospective chart view performed by identifying patients who received an ISB from January 1, 2014, through April 26, 2018, at the University of Minnesota. 1,518 patients were identified who received an ISB (LB = 784, nonliposomal bupivacaine = 734). Patients were divided into two groups those who did receive liposome bupivacaine in their ISB and those who did not receive liposome bupivacaine in their ISB. Medical records were individually reviewed for surgical procedure, block medications, complications related to the block or surgical procedure, phone calls to the healthcare system for issues related to opioids or pain within 3 and within 30 days, readmissions within 30 days, and emergency room visits for complications within 3 and 30 days.Results. There was no significant difference in the number of patients with surgical or anesthetic complications. Only phone calls for pain within 3 days were significantly different. The LB group had 3.2% of patients call compared to 5.6% in the nonliposomal bupivacaine group (aOR = 1.71 (95% CI: 1.04–2.87),p=0.036). We found no significant difference in any of the other secondary outcomes.Conclusions. The use of LB in an ISB demonstrated no significant difference compared to nonliposomal bupivacaine in numbers of complications, emergency room visits, and readmissions.

Study objective The purpose of this study was to compare the efficacy of bilateral ultrasound guided thoracic paravertebral catheters to a thoracic epidural after open pancreatic surgery. Design This was a prospective non-blinded randomized controlled trial. Setting Academic hospital operating room, postoperative recovery area, and ward. Patients 53 patients aged 18 and above who had open pancreatic surgery. Interventions Patients received either bilateral thoracic paravertebral block at T8 with an infusion of 0.2% ropivacaine or thoracic epidural analgesia at T7/8 with an infusion of 0.125% bupivacaine with hydromorphone 6 μg/mL. Measurements Pain scores, opioid use, length of recovery room and hospital stay, adverse events, and incidence of nausea and vomiting. Main results There was no difference in baseline demographics between the two groups. There were no significant differences in pain scores between the two groups in each of the first five days after surgery. There was no difference in length of stay nor nausea and vomiting. There was significantly less modality related adverse events in the paravertebral group compared to the epidural group (p = 0.02). Conclusions The use of thoracic paravertebral catheters provided comparable analgesia and less modality related adverse events when compared to a thoracic epidural in patients undergoing open pancreaticoduodenectomy.

OBJECTIVE: To evaluate sufentanil sublingual tablet 30 mcg (SST 30 mcg) for postoperative pain in an older patient population with comorbidities. DESIGN: Multicenter, open-label, single-arm study. SETTING: Nine hospitals across the United States. SUBJECTS: Adults aged ≥40 years who had undergone a surgical procedure. METHODS: Patients with a postoperative pain intensity score ≥4 on an 11-point numeric rating scale (NRS) were allowed to enter the study and receive SST 30 mcg as requested for pain (minimum 60-minute redosing interval) over the 12-hour study period. Efficacy was assessed by patient reports of pain intensity on the NRS and a five-point pain relief scale. Safety was monitored throughout the study; plasma sufentanil concentrations were also measured. The primary efficacy endpoint was the time-weighted summed pain intensity difference (SPID) to baseline over 12 hours (SPID12). RESULTS: Of the 140 patients enrolled, 69% were American Society of Anesthesiologists Physical Class II or III, 44% had a body mass index (BMI) ≥30 mg/kg(2), and 29% had hepatic and/or renal impairment. Average age was 54.7 years (SD = 9.9 years), and average baseline pain intensity was 6.2 (SD = 1.9). The most common surgeries were abdominal (59%) and orthopedic (20%). The mean SPID12 was 36.0 (standard error of the mean = 2.2); mean scores were similar, regardless of age, sex, race, and BMI. From baseline, mean pain intensity decreased significantly starting 30 minutes postdose, and mean pain relief increased significantly starting 15 minutes postdose, remaining relatively stable through 12 hours (P

We analyzed the effectiveness of paravertebral-block for immediate postoperative pain control in living liver donors. Specifically, we sought to determine whether or not the addition of paravertebral catheters with continuous ropivacaine infusion would decrease postoperative opioid use and reduce the incidence of adverse effects and complications. We reviewed the records of 26 patients who underwent right-lobe living donor hepatectomy (RLDH): 16 with and 10 without such catheters. The primary outcome was opioid use on postoperative day (POD) 1 through 3. For each of those 3 days, we calculated each patient's opioid use in morphine equivalents (mg). We also noted pain scores, adverse effects, and complications. The rate of decrease in morphine equivalents was higher in the catheter group (rate of change = -22.72; P = .038) for POD 1 (0-24 hours) and POD 2 (25-48 hours) than in the noncatheter group. For POD 2 alone, the catheter group used, on average, 20.98 mg fewer morphine equivalents than the noncatheter group (P = .023). The catheter group had a markedly reduced pain trajectory postoperatively (P = .014) than the noncatheter group. The catheter placement procedure itself was safe.

OBJECTIVE: To estimate whether a rapid recovery program would reduce length of stay among patients undergoing laparotomy on a gynecologic oncology service. METHODS: We conducted a prospective, randomized, controlled trial comparing an enhanced recovery after surgery protocol with routine postoperative care among women undergoing laparotomy on the gynecologic oncology service. Protocol elements included: preoperative counseling, regional anesthesia, intraoperative fluid restriction, and early postoperative ambulation and feeding. A sample size of 50 per group (N=100) was planned to achieve 80% power to detect a two-day difference in our primary outcome, length of hospital stay; secondary outcomes included: total daily narcotics used, time to postoperative milestones, and complications. RESULTS: A total of 112 women were enrolled between 2013 and 2015. Nine patients did not undergo laparotomy and were excluded, leaving 52 and 51 patients in the control and intervention groups, respectively. There was no difference in length of stay between the two groups (median 3.0 in both groups;P=.36). Enhanced recovery after surgery patients used less narcotics on day 0 (10.0 compared with 5.5 morphine equivalents in the control and intervention arms, respectively, P=.09) and day 2 (10.0 compared with 7.5 morphine equivalents, respectively; P=.05);however, there was no statistically significant difference between groups in any of the secondary outcomes. Post hoc analysis based on actual anesthesia received also failed to demonstrate a difference in time to discharge. CONCLUSION: When compared with usual care, introducing a formal enhanced recovery after surgery protocol did not significantly reduce length of stay. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT01705288.

We compared the effect of subcostal transversus abdominis plane (TAP) block with liposomal bupivacaine to TAP block with non-liposomal bupivacaine on postoperative maximal pain scores in patients undergoing donor nephrectomy. Sixty patients were prospectively randomly assigned to receive ultrasound-guided bilateral TAPs with either 1.3% liposomal bupivacaine and normal saline or 0.25% non-liposomal bupivacaine with adrenaline. There was a significant decrease in maximal pain scores in the liposomal bupivacaine TAP group when compared with the non-liposomal bupivacaine group median (IQR [range]), 24-48 h after injection, 5 (3.0-5.2 [0-10]) vs. 6 (4.5-7.0 [1--9]) p = 0.009; 48-72 h after injection, 3 (2.0-5.0 [0-8]) vs. 5 (3.0-7.0 [0-10]) p = 0.02; and in opioid use 48-72 h after injection, mean (SD) μg equivalents of fentanyl 105 (97) vs. 182 (162) p = 0.03. Liposomal bupivacaine via subcostal TAP infiltration provided superior analgesia up to 72 h after injection when compared with non-liposomal bupivacaine.

Paravertebral administration of local anesthetics is an increasingly utilized method of analgesia. Total spinal anesthesia is a known complication characterized by paralysis, cranial neuropathies, coma, hypotension, bradycardia, and apnea. This adverse event has been attributed to local epidural, subdural, or subarachnoid spread of the anesthetic. We report a case of total spinal and brainstem anesthesia following paravertebral administration of ropivacaine and highlight the importance of considering this complication in patients with acute brainstem dysfunction.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Complications in pediatric regional anesthesia are rare, so a large sample size is necessary to quantify risk. The Pediatric Regional Anesthesia Network contains data on more than 100,000 blocks administered at more than 20 children’s hospitals. This study analyzed the risk of major complications associated with regional anesthesia in children. Methods This is a prospective, observational study of routine clinical practice. Data were collected on every regional block placed by an anesthesiologist at participating institutions and were uploaded to a secure database. The data were audited at multiple points for accuracy. Results There were no permanent neurologic deficits reported (95% CI, 0 to 0.4:10,000). The risk of transient neurologic deficit was 2.4:10,000 (95% CI, 1.6 to 3.6:10,000) and was not different between peripheral and neuraxial blocks. The risk of severe local anesthetic systemic toxicity was 0.76:10,000 (95% CI, 0.3 to 1.6:10,000); the majority of cases occurred in infants. There was one epidural abscess reported (0.76:10,000, 95% CI, 0 to 4.8:10,000). The incidence of cutaneous infections was 0.5% (53:10,000, 95% CI, 43 to 64:10,000). There were no hematomas associated with neuraxial catheters (95% CI, 0 to 3.5:10,000), but one epidural hematoma occurred with a paravertebral catheter. No additional risk was observed with placing blocks under general anesthesia. The most common adverse events were benign catheter-related failures (4%). Conclusions The data from this study demonstrate a level of safety in pediatric regional anesthesia that is comparable to adult practice and confirms the safety of placing blocks under general anesthesia in children.

Jacob Hutchins,1 William Taylor2 1Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA; 2InSitu Biologics, LLC, St Paul, MN, USA Purpose: Sustained release hydrogel with bupivacaine (AnestaGel™) is a novel formulation of extended release bupivacaine in a biohydrogel Matrix™. We sought to compare the analgesic effects via mechanical allodynia, the pharmacokinetic characteristics via serum blood levels, and the local tissue effects via pathology, following injection of either sustained release hydrogel with bupivacaine, liposome bupivacaine, or hydrogel only (negative control group). Materials and methods: Ninety rats (30 in each group) were randomized to receive a sciatic nerve block injection of either sustained release hydrogel with bupivacaine, liposome bupivacaine (Exparel®), or a biohydrogel matrix. The total force generated was obtained at varying time points. Pathologic analysis was undertaken on days 5 and 42 of the study. Six additional rats (two in each group) were randomized to receive a sciatic nerve block injection of either sustained release hydrogel with bupivacaine, liposome bupivacaine, or bupivacaine and pharmacokinetic data were obtained for up to 120 hours. Results: The sustained release hydrogel with bupivacaine group had significantly better response to mechanical allodynia compared to the other two groups. The pathology showed no significant adverse events at 42 days in any group. Finally, bupivacaine was present longer in the serum of sustained release hydrogel with bupivacaine group than the other two groups. Conclusion: The sustained release hydrogel with bupivacaine achieved longer lasting analgesia with no significant findings on pathology at 42 days when compared to both positive and negative controls. Keywords: mechanical allodynia, local anesthetics, extended release, nerve block

The use of continuous paravertebral (PV) catheters for management of acute postsurgical pain after video-assisted thoracoscopic surgery (VATS) has not been investigated previously as a randomized controlled trial. The purpose of this study was to compare the efficacy of an ultrasound-guided continuous PV catheter catheter infusion for postoperative pain control with single-shot intercostal blocks (ICB).A prospective, randomized, controlled trial.An academic university hospital.Patients (≥18 years of age) who underwent a VATS procedure.Patients were randomized into 2 groups. Group 1 received single-shot ICB. Group 2 received an ultrasound-guided PV catheter with a continuous infusion of 0.2% ropivacaine.There were 25 patients in group 1 and 23 patients in group 2. The maximum pain score was significantly lower in the group that received the PV catheter compared with those who received ICB during 24 to 48 hours (3.65 v 6.44, p0.001). Seventeen patients (74%) who received PV catheters reported satisfaction with a pain control regimen compared to the 11 (44%) who received ICB (p = 0.036). In addition, during 24 to 48 hours after surgery the mean opioid use decreased significantly in the PV catheter group (14.39 v 30.50 mg morphine equivalents, p = 0.046).Ultrasound-guided continuous PV catheter infusions provided prolonged pain control and superior patient satisfaction compared with single-shot ICB after video-assisted thoracoscopic surgery.

Objective Effective postoperative pain management has been shown to be a positive predictive factor for postoperative recovery following a thoracotomy. The primary objective of this study was to examine the efficacy and safety of continuous paravertebral blockade in managing acute postsurgical pain following unilateral and bilateral single-lung transplantation. Design The authors conducted a prospective observational trial of patients. Setting The study was conducted in an academic university hospital. Participants Patients (≥18 years of age) who underwent either unilateral or bilateral single-lung transplantation and received a postoperative paravertebral catheter. Interventions Paravertebral catheters were placed via an ultrasound-guided technique on either postoperative day 1 or 2. After placement, a continuous infusion of 0.2% ropivacaine was run at 0.2 to 0.25 mL/kg/h with maximum dose of 7 mL/h per side in bilateral lung transplant patients, and 14 mL/h in unilateral lung transplant patients. Measurements and Main Results Patients were followed up to 120 hours after placement of catheters, and pain scores, opioid use, and adverse events were recorded. There were 35 patients who completed the study from October 2013 to December 2014 (21 bilateral transplants and 14 unilateral transplants). The mean time to paravertebral catheter placement was 1.14 days in the overall group, with median time to extubation occurring 543 minutes after placement (range, 23-2,985 minutes). Catheters remained in place for a mean of 7.18 days. The mean maximal pain scores for both groups was 5.94 (day 1), 6.26 (day 2), 6.20 (day 3), 5.12 (day 4), and 5.60 (day 5). There were no adverse events related to the paravertebral catheters in either group. Conclusions Paravertebral catheters provide a feasible option for postoperative pain control following unilateral or bilateral single-lung transplant in adult patients. Future research should focus on randomized trials of thoracic epidurals compared to paravertebral catheters.

Summary Background Total pancreatectomy and islet autotransplantation (TPIAT) has been used to treat pediatric patients with chronic pancreatitis. The primary symptom of this disease is extreme poorly controlled pain. This results in significant alterations in the quality of life of the patient. We sought to determine if the addition of bilateral thoracic paravertebral catheters with continuous ropivacaine infusion would improve postoperative opioid use and pain control. Methods The medical records of 32 patients who underwent TPIAT from March 2011 to July 2014 were analyzed retrospectively (15 without paravertebral catheters and 17 with paravertebral catheters). Maximum and minimum pain scores, opioid use (mg·kg−1·day−1), percent opioid use above baseline, length of stay, and complications were recorded. Results Those patients who had bilateral thoracic paravertebral catheters had decreased total opioid use in the first 7 days postoperatively when compared to those who did not (612 (95% CI: 432–792) vs 943.7 (95% CI: 650–1237) mg of morphine equivalents; P = 0.043). The total opioid use remained significantly decreased when corrected for weight (12.53 (95% CI: 9.19–15.44) vs 18.85 (95% CI: 13.69–24.03) mg·kg−1 of morphine equivalents; P = 0.03). In addition, those on preoperative opioids had less percent opioid use above baseline on postoperative days 1, 2, and 7 as well as decreased opioid use (mg·kg−1·day−1) on postoperative days 1, 2, 3, and 7. There were no differences in complications or length of stay. Conclusions Bilateral paravertebral catheters may provide decreased opioid use and improved postoperative pain control after TPIAT.

Introduction Optimal pain control after major surgery contributes to a patient's recovery and satisfaction. The use of liposomal bupivacaine in subcostal transversus abdominis plane (TAP) blocks for postoperative pain control after robot assisted abdominal surgery has yet to be studied. Methods We conducted a prospective randomized controlled observer-blinded study comparing bilateral subcostal TAP blocks with bupivacaine to bilateral subcostal TAP blocks with liposomal bupivacaine. These were performed prior to the patient undergoing robot assisted hysterectomy. The patients' pain scores, opioid use, side effects, and satisfaction were followed for 72h after injection. Results Total opioid use in the first 72h after injection was significantly decreased in the group that received liposomal bupivacaine compared to bupivacaine. Patients in the liposomal bupivacaine group had significantly lower maximal pain scores at all time periods studied as well as decreased incidence of nausea/vomiting. There was a trend toward decreased length of stay in the liposomal bupivacaine group. Conclusion Subcostal TAP blocks with liposomal bupivacaine decreased the total opioid requirement for the first 72h after robot assisted hysterectomy when compared to subcostal TAP blocks with bupivacaine.

An ultrasound-guided thoracic paravertebral catheter was placed at T8 in a 15-year-old girl with cystic fibrosis and right-sided chest pain from avulsion of the eighth rib, secondary to coughing. She was discharged home after respiratory stabilization and returned to school with the catheter in place. We report the effective use of an ultrasound-guided continuous thoracic paravertebral block in the management of acute rib pain in a pediatric patient with cystic fibrosis.

The primary purpose of this chapter is to familiarize the reader with the basic concepts of blood pressure, heart tones, and some commonly associated diagnoses. Furthermore, it is important to reinforce the need for a deep understanding of basic physiological principles when interpreting physical examination findings. Commonly employed invasive and noninvasive methods for assessing blood pressure are discussed, as well as some of the newer technologies on the horizon. It remains the general consensus that even the most sophisticated electronic monitors cannot fully reduce the need for sound clinical skills such as: proper patient inspection, palpation, percussion, and/or auscultation.

Supplemental Digital Content is available in the text., Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.

Figure 1 Still ultrasound image at the level of the second and third thoracic vertebral bodies with the patient in a lateral decubitus position. The paravertebral space (PVS) is identified using the transverse process (TP) and pleura (n) as landmarks for an injection of liposomal bupivacaine. A 22-gauge block needle (arrowheads) is advanced until its tip rests beneath the lateral edge of the transverse process, then 0.5% bupivacaine (3 ml) with epinephrine (1:200,000) is injected to confirm correct placement, followed by 10 ml liposomal bupivacaine once the correct needle placement is determined. The procedure is repeated on the contralateral side. Refractory ventricular tachycardia (VT) and fibrillation (VF) occur in a sub-set of patients after continuous-flow left ventricular assist device (CF-LVAD) implantation and are associated with significant morbidity and mortality due to compromised right ventricular (RV) function. Antiarrhythmic therapy and catheter ablation have limited efficacy in this setting. We describe 3 patients with CFLVAD who had a significant reduction in the burden of refractory ventricular tachyarrhythmias after a percutaneous bilateral paravertebral block (BPVB). Patient 1 is a 66-year-old man with ischemic cardiomyopathy and prior endocardial VT ablation. After HeartWare LVAD (HeartWare, Framingham, MA) implantation, he experienced symptomatic VT despite therapy with amiodarone, mexiletine, and metoprolol. Endocardial VT ablation was marginally successful. Unstable, symptomatic VT developed 10 months after CF-LVAD implantation. Thirteen episodes of anti-tachycardia pacing (ATP) and repeated external defibrillatory shocks failed to terminate the VT and eventually resulted in RV failure. Percutaneous BPVB allowed the VT to be terminated by overdrive pacing. In the 4 months before undergoing orthotopic heart transplantation, he did not have any sustained VT requiring ATP, shocks, or hospitalization. Patient 2 is a 32-year-old man with non-ischemic cardiomyopathy and prior automatic implantable cardioverter defibrillator placement. He presented in cardiogenic shock with refractory VT/VF necessitating 19 episodes of ATP and 18 internal shocks, despite therapy with lidocaine and amiodarone. He underwent emergency implantation of a HeartMate II LVAD (Thoratec Corp, Pleasanton, CA). Postoperatively, he continued to have hemodynamically unstable VT/VF despite maximal therapy with amiodarone, lidocaine, and esmolol. Endocardial VT ablation resulted in a modest reduction of the VT/VF burden. The patient developed severe metabolic encephalopathy due to lidocaine

A 30-year-old woman with cystic fibrosis at 33 weeks, 4 days' gestation sustained a rib injury during an acute pulmonary exacerbation, resulting in noncompliance with her chest wall oscillation therapy and worsening of her respiratory status with concern for inducing labor early. Insertion of an ultrasound-guided thoracic paravertebral catheter produced immediate pain relief, eliminating the need for further opioids, and she was able to tolerate her chest wall oscillation treatment. She was discharged home after 7 days and was able to deliver a healthy baby at 38 weeks via spontaneous vaginal delivery.

Pain control is an important aspect of video-assisted thoracoscopic surgery (VATS) procedures. Offering an effective and low-risk method of postoperative pain control is thus vital to a patient's recovery. Hotta and colleagues report the results of a clinical study comparing efficacy of epidurals vs extrapleural catheters in VATS procedures. They found that extrapleural catheters provided equivalent postoperative pain relief when compared to thoracic epidural catheters.