Abstract Most shoulder innervation arises from nerves C5 to T1, with occasional contributions from C4 or T2. A patient’s pulmonary status and ability to tolerate a change in diaphragmatic function should be assessed prior to an interscalene block. Regional anesthetic options for a patient with compromised pulmonary function include a more distal brachial plexus block, superior trunk block, and suprascapular block. Expectations regarding the regional anesthetic technique should be set with the patient. The role of the block in the context of the overall pain-control plan and other analgesic agents should be explained. Rebound pain is significant when it alters a patient’s recovery trajectory. A single-injection interscalene block may not be sufficient to properly address pain after shoulder surgery. Anesthesiologists should properly educate patients about peripheral nerve blockade, including expected pain control, possible side effects, and ambulatory nerve catheter care, if applicable.

Most shoulder innervation arises from nerves C5 to T1, with occasional contributions from C4 or T2. A patient’s pulmonary status and ability to tolerate a change in diaphragmatic function should be assessed prior to an interscalene block. Regional anesthetic options for a patient with compromised pulmonary function include a more distal brachial plexus block, superior trunk block, and suprascapular block. Expectations regarding the regional anesthetic technique should be set with the patient. The role of the block in the context of the overall pain-control plan and other analgesic agents should be explained. Rebound pain is significant when it alters a patient’s recovery trajectory. A single-injection interscalene block may not be sufficient to properly address pain after shoulder surgery. Anesthesiologists should properly educate patients about peripheral nerve blockade, including expected pain control, possible side effects, and ambulatory nerve catheter care, if applicable.

Introduction Variability regarding which blocks are performed most often can be quite high among anesthesiology residency training programs. Which techniques are viewed by residency programs as “critical” for their graduates to know can also be inconsistent. We administered a national survey to investigate correlations between the cited importance of techniques and the relative frequency with which they are being taught. Materials and methods A three-round modified Delphi method was used to develop the survey. The final survey was sent to 143 training programs across the United States. The surveys collected information on the frequency with which thoracic epidural blocks, truncal blocks, and peripheral blocks were taught. The respondents were also asked to rate how critical each technique is to learn during residency. A correlation between the relative frequency of block teaching and cited importance to education was calculated using Kendall’s Tau statistic. Results Among truncal procedures, transversus abdominis plane (TAP) block and thoracic epidural blocks were frequently viewed as “indispensable for daily practice.” Among peripheral nerve blocks, interscalene, supraclavicular, adductor, and popliteal blocks were frequently viewed as indispensable. All truncal blocks showed a strong correlation between the relative frequency of block teaching and cited importance to education. However, the frequency of teaching interscalene, supraclavicular, femoral, and popliteal blocks failed to correlate with their reported importance ranking. Conclusions Perceived importance was significantly associated with the reported frequency of block teaching for all truncal and peripheral blocks except for interscalene, supraclavicular, femoral, and popliteal. The lack of correlation between the frequency of teaching and perceived importance is reflective of a changing educational landscape.

Dysfunction of oxidative phosphorylation and the mitochondrial respiratory chain leads to a heterogeneous group of pathogenic mitochondrial variations. The TRMU gene codes for transfer RNA 5- methylaminomethyl-2-thiouridylate methyltransferase and is essential for posttranscriptional modification of the mitochondrial transfer RNA, and alterations in the TRMU gene can lead to infantile liver failure at approximately 6 months of age. Orthotopic liver transplant is a curative option. We present a case of a patient with TRMU alteration who underwent liver transplant at 11 months of age to treat infantile end- stage liver disease. The patient had liver failure due to long-standing allograft rejection and required another liver transplant at age 24 years, and here we discuss the perioperative care of this patient. Coordination of the care team to prevent rhabdomyolysis or alternative negative catabolic effects was the cornerstone of management in addition to evaluation of unusual electrocardiographic findings in the immediate postoperative period. Although the patient's postoperative course was complicated by repair of a bile leak, liver retransplant successfully restored the patient's preoperative quality of life.

Anesthetic management for patients with Charcot–Marie–Tooth disease (CMT) is controversial. Description of the use of regional anesthesia (RA) in patients with CMT is limited. Regional anesthesia has traditionally been avoided because of risk of nerve injury. We retrospectively reviewed patients with CMT who received RA at our institution. We performed a historical cohort study of all patients with CMT who received RA from 30 April 2010 to 30 April 2020 within our institution. Charts were reviewed for information on demographics, RA procedures, perioperative variables, evidence of neurologic complications, post-RA neurology consults, and perioperative electromyography (EMG) results. Electromyographs were reviewed by a neurologist who was blinded to the surgical and RA details. Fifty-three patients received a total of 132 regional anesthetics during the study period. Twenty-five patients received RA on more than one occasion. Fifty-five EMGs and 14 postoperative neurology consults were performed. Two patients had neurology consults with peripheral nerve block (PNB) distribution complaints years later. Neither attributed the complaints to the PNB. The other neurology consults were for unrelated complaints. No EMG results suggested injury related to PNB. This study found no evidence of documented neurologic complications or an increased risk of nerve injury related to RA in CMT patients.

The field of abdominal organ transplantation is multifaceted, with the clinician balancing recipient comorbidities, risks of the surgical procedure, and the pathophysiology of immunosuppression to ensure optimal outcomes. An underappreciated element throughout this process is acute pain management related to the surgical procedure. As the opioid epidemic continues to grow with increasing numbers of transplant candidates on opioids as well the increase in the development of enhanced recovery after surgery protocols, there is a need for greater focus on optimal postoperative pain control to minimize opioid use and improve outcomes. This review will summarize the physiology of acute pain in transplant recipients, assess the impact of opioid use on post-transplant outcomes, present evidence supporting nonopioid analgesia in transplant surgery, and briefly address the perioperative approach to the pretransplant recipient on opioids.

Purpose of Review The opioid crisis in the USA makes it very likely that a large number of patients who are opioid-dependent will require surgical procedures. Perioperative pain control in those patients poses a formidable challenge to the surgical and anesthesia care team. Previously, patients received only additional opioids to cover the postoperative pain and would then be referred back to their primary care physician with often escalation of opioid dosing. Recent Findings Various strategies and recommendations to help with postoperative pain control in these challenging situations are available and can be applied successfully in various ambulatory and hospital settings. Summary Opioid-dependent patients presenting for surgery will challenge a health care system to provide optimal patient care, requiring close communication among the surgical team, anesthesiologists, referring physicians, and pain specialists. Regional anesthesia and multimodal analgesia are best suited to reduce or possibly avoid opioids altogether. Surgery location and monitoring may need to be adapted from standard care according to the chronic pain therapy and the presence of opioid use disorder (OUD). The preoperative visit is the most important time with the patient to set goals and expectations as well as developing a strategy for perioperative pain control.

Background Forced-air warming is an established strategy for maintaining perioperative normothermia. However, this warming strategy can potentially contaminate the surgical field by circulating nonsterile air. This study aimed to determine whether changing practice away from this method resulted in non-inferior rates of perioperative hypothermia. Methods We performed a chart review of primary total hip and knee arthroplasty patients from 2014 to 2017, when the strategy of intraoperative forced-air warming (FAW) was changed to preoperative FAW along with intraoperative underbody conduction warming (CW) with an underbody warming mattress. Data included patient temperatures throughout all phases of care, blood loss and transfusion requirements, length of postanesthesia care unit (PACU) and hospital stays, and 30-day infection and mortality. Results A total of 769 charts were reviewed; 349 patients underwent surgery before the practice change and 420 after. Mean (SD; 95% CI) body temperatures at the time of incision were lower for group 1 than for group 2 (34.55 vs 35.52 °C [0.97 °C; 95% CI, 0.72-1.23 °C]). The average nadir of intraoperative body temperature was lower for group 1 than for group 2 (difference of means, 0.44 °C; 95% CI, 0.18-0.71 °C). Group 2 had a higher percentage of patients who presented hypothermic (temperature <36.0 °C) on arrival in the PACU (12.9% vs 7.7%). Conclusion Preoperative convective warming combined with intraoperative underbody conductive warming maintains normothermia during primary total joint arthroplasty and is non-inferior to forced-air intraoperative warming alone.

Introduction Radiologically inserted gastrostomy (RIG) placement in patients with amyotrophic lateral sclerosis (ALS) carries risks related to periprocedural sedation and analgesia. To minimize these risks, we used a paravertebral block (PVB) technique for RIG placement. Methods We retrospectively reviewed patients with ALS undergoing RIG placement under PVB between 2013 and 2017. Results Ninety-nine patients with ALS underwent RIG placement under PVB. Median (range) age was 66 (28 to 86) years, ALS Functional Rating Scale-Revised score was 27 (6 to 45), and forced vital capacity was 47% (8%-79%) at time of RIG placement. Eighty-five (85.9%) patients underwent RIG placement as outpatients, with a mean postanesthesia care unit stay of 2.3 hours. The readmission rate was 4% at both 1 and 30 days postprocedure. Discussion PVB for RIG placement has a low rate of adverse events and provides effective periprocedural analgesia in patients with ALS, the majority of whom can be treated as outpatients.

Avulsion of C5 and C7 nerve roots was confirmed intraoperatively in a 21 year old male presenting after motor vehicle accident with confirmed absence of somatosensory evoked potentials upon stimulation via ultra-high-frequency ultrasound (70 MHz). Ultra-high-frequency ultrasound can be used as a reliable tool to directly visualise nerve injury.

PURPOSE:To ascertain the preferences of perianesthesia nurses regarding peripheral nerve blocks (PNBs) and their impact on patient recovery after total joint replacement (TJR).DESIGN:Survey of perianesthesia nurses at a single medical center.METHODS:Fifty-nine perianesthesia nurses completed a 23-question survey on PNBs for TJR.FINDINGS:Most agreed PNBs improved patients' pain after knee, hip, and shoulder TJR (35 [92.1%], 35 [92.1%], and 34 [91.9%], respectively). Most felt lower extremity PNBs increased risk of falling (26 [70.3%]), whereas 7 of 35 (20.0%) felt patients fell more after spinal anesthesia than after general anesthesia. Respondents preferred a block to opioid-based analgesia if they were to have lower extremity TJR or total shoulder replacement (100% [30/30 and 33/33]).CONCLUSIONS:The perianesthesia nurses surveyed felt PNBs improved pain control and patient recovery despite a perceived risk of falling for lower extremity TJR, and they preferred PNB when considering TJR surgery for themselves.

Objective: the purpose of this case series was to assess the potential use of a continuous paravertebral block (Pvb) at the L2 nerve root level as a part of a multimodal regimen in patients undergoing direct anterior total hip arthroplasty (Da-tHa). Design: 20-patient case series. Setting: tertiary care hospital. Subjects: patients undergoing Da-tHa. Methods: We retrospectively analyzed 20 patients undergoing Da-tHa who had a continuous L2 PVB until postoperative day 2. Hip flexor strength, pain scores, opioid use, and length of stay were assessed post operatively. Results: 11 of 20 patients had motor weakness to gravity postoperatively. However, mean basic mobility score on postoperative day (POD) 1 was 18.4 ± 2.4. Mean maximum pain on POD0 was 5.4 ± 3.0. On POD1, mean dynamic and maximum pain scores were 3.5 ± 2.5 and 3.5 ± 2.8, respectively. Mean intravenous morphine use was 22.5mg ± 13.4 and 16.5mg ± 11.4 on PoD0 and POD1, respectively. Mean discharge day was 2.1 ± 0.5. Conclusions: While over half of the patients in our case series had some hip weakness postoperatively, participation in physical therapy was not hindered. An L2 PVB catheter, combined with a multimodal postoperative pain control regimen, may provide analgesia after anteriorapproach tHa without inhibiting recovery.

BACKGROUND AND AIMS:Our aim was to ascertain the opinions and preferences of physical therapists with regard to use of peripheral nerve blocks and their impact on the recovery of patients undergoing total joint replacement.METHODS:We conducted an anonymous 24-question survey of 20 full-time inpatient physical therapists at a single tertiary care medical center.RESULTS:One respondent indicated they never work with patients who have undergone total joint replacement surgery. Nineteen questionnaires were included in the final analysis. Questions omitted by respondents or with write-in answers were not included in the analysis. A majority of respondents (15 [78.9%]) agreed nerve blocks somewhat to greatly improve a patient's pain after total joint replacement surgery. Most respondents answered that nerve blocks somewhat to greatly impede a patient's ability to participate in physical therapy (14 [73.6%]) and make therapy somewhat to very difficult for them as physical therapists (16 [84.2%]). When asked about specific surgeries, (17/18 [94.4%]) and (14/18 [77.8%]) of respondents would prefer that their patients receive periarticular infiltration or no block at all after total knee arthroplasty or total hip arthroplasty, respectively. All respondents (19 [100%]) answered that they thought lower extremity nerve blocks increased a patient's risk of falling after surgery.CONCLUSIONS:According to the physical therapists we surveyed, nerve blocks impede patient recovery and increase the risk of falls, despite their positive impact on pain control. When considering surgery for themselves, therapists indicated they would not want a nerve block.

The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. Anesthesia providers caring for these patients must be aware of the altered pharmacokinetics that may occur in these patients. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.

Many common elective surgeries are associated with moderate-to-severe postoperative pain. These common surgeries include total knee and total hip arthroplasty, thoracotomy, and multilevel lumbar spine surgery. Unfortunately, many patients requiring these surgeries are already in moderate-to-severe pain, necessitating high doses of oral or transdermal opioids preoperatively. This is an established risk factor for difficult-to-control postoperative pain. 1,2 Opioid-sparing interventions are important elements in these patients to promote convalescence and reduce common opioid side effects such as constipation, confusion, pruritus, nausea, vomiting, and urinary retention. Potential interventions to reduce postoperative pain can include nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentin, and even invasive therapies such as epidural or peripheral nerve blockade. Ketamine is a well-known anesthetic agent that has opioid-sparing analgesic properties, is noninvasive, and in analgesic doses, has few contraindications. This article will review the basic science behind ketamine, some of the evidence supporting its perioperative use, and the logistics of how the Department of Anesthesia at Mayo Clinic in Jacksonville, Florida rolled out a hospital-wide ketamine infusion protocol.

Acute aortic occlusion by massive thoracoabdominal thrombi has been reported as a serious complication in patients undergoing major vascular or cardiac surgical procedures. However, this complication occurs rarely after ambulatory procedures. In this case report, we describe a patient who experienced paraplegia after an elective laparoscopic cholecystectomy in whom acute aortic thromboembolic occlusion was subsequently diagnosed. We emphasize the importance of accurate neurologic and cardiovascular history taking and examination throughout the perioperative period along with the appropriate diagnostic studies to expeditiously arrive at a diagnosis of such a rare complication.