Opioid use after kidney transplant has been associated with an increased risk of death and graft loss. Several transplant centers have reported reductions in opioid use using multimodal analgesia and education. This study evaluated the impact of an opioid minimization protocol on inpatient opioid use and opioid prescribing on discharge. This was a single -center, retrospective study of adult kidney recipients transplanted from October 2021 to July 2022. Patients on chronic opioids prior to transplant were excluded. The protocol included an intraoperative ultrasound -guided lateral transversus abdominis plane (TAP) block combined with scheduled nonopioid analgesics and tramadol as needed. Acetaminophen 1000 mg and gabapentin 300 mg were given 1 hour prior to the procedure and continued three times daily after transplant. The gabapentin dose was reduced for patients with renal impairment. Additional analgesics including opioids could be added for uncontrolled pain. We hypothesized the protocol would decrease total inpatient morphine milligram equivalents (MMEs) and opioid prescribing on discharge. Fifty-nine post -protocol patients were compared to 52 pre -protocol patients. After the protocol, there was a significant decrease in total inpatient MMEs per day administered and no patient -controlled analgesia (PCA) devices were required. In alignment with the protocol, there was a significant increase in the use of TAP blocks, acetaminophen, gabapentin, and lidocaine patches. While opioid use was lowest in postprotocol patients who received TAP blocks, significant reductions in MMEs per day were still seen in those post -protocol who did not receive TAP blocks. Opioid prescribing at the time of discharge decreased significantly after protocol. No difference was seen in patient -reported pain scores, return to operating room, readmission within 30 days, or length of stay. The use of scheduled acetaminophen and gabapentin with or without a TAP block allowed the elimination of PCA devices and led to significant minimizations in both inpatient opioid use and opioid prescribing on discharge.

In this Pro-Con commentary article, we discuss the controversial debate of whether to provide peripheral nerve blockade (PNB) to patients at risk of acute extremity compartment syndrome (ACS). Traditionally, most practitioners adopt the conservative approach and withhold regional anesthetics for fear of masking an ACS (Con). Recent case reports and new scientific theory, however, demonstrate that modified PNB can be safe and advantageous in these patients (Pro). This article elucidates the arguments based on a better understanding of relevant pathophysiology, neural pathways, personnel and institutional limitations, and PNB adaptations in these patients.

Background The impact of the coronavirus disease 2019 (COVID-19) pandemic substantially altered operations at hospitals that support graduate medical education. We examined the impact of the pandemic on an anesthesiology training program with respect to overall case volume, subspecialty exposure, procedural skill experience, and approaches to airway management. Methods Data for this single center, retrospective cohort study came from an Institutional Review Board approved repository for clinical data. Date ranges were divided into the following phases in 2020: Pre-Pandemic (PP), Early Pandemic (EP), Recovery 1 (R1), and Recovery 2 (R2). All periods were compared to the same period from 2019 for case volume, anesthesia provider type, trainee exposure to Accreditation Council for Graduate Medical Education (ACGME) index case categories, airway technique, and patient variables. Results 15,087 cases were identified, with 5,598 (37.6%) in the PP phase, 1,570 (10.5%) in the EP phase, 1,451 (9.7%) in the R1 phase, and 6,269 (42.1%) in the R2 phase. There was a significant reduction in case volume during the EP phase compared to the corresponding period in 2019 (-55.3%; P < .001) that improved but did not return to baseline by the R2 phase (-17.6%; P < .001). ACGME required minimum cases were reduced during the EP phase compared to 2019 data for pediatric cases (age < 12 y, -72.1%; P < .001 and age < 3 y, -53.5%; P < .006) and cardiopulmonary bypass cases (52.3%, P < .003). Surgical subspecialty case volumes were significantly reduced in the EP phase except for transplant surgery. By the R2 phase, all subspecialty volumes had recovered except for plastic surgery (14.9 vs. 10.5 cases/week; P < .006) and surgical endoscopy (59.2 vs. 40 cases/week; P < .001). Use of video laryngoscopy (VL) and rapid sequence induction and intubation (RSII) also increased from the PP to the EP phase (24.6 vs. 79.6%; P < .001 and 10.3 vs. 52.3%; P < .001, respectively) and remained elevated into the R2 phase (35.2%; P < 0.001 and 23.1%; P < .001, respectively). Conclusions The COVID-19 pandemic produced significant changes in surgical case exposure for a relatively short period. The impact was short-lived, with sufficient remaining time to meet the annual ACGME program minimum case requirements and procedural experiences. The longer-term impact may be a shift towards the increased use of VL and RSII, which became more prevalent during the early phase of the pandemic.

Introduction/Purpose:Ultrasound-guided popliteal fossa sciatic nerve (PFSN) blocks are performed with patients in the supine, lateral or prone position. No known studies compare the quality of images obtained from each approach. This study examines the quality of supine and prone PFSN ultrasound images.Methods:Thirty-eight adult volunteers were sorted into two groups. Five regional anaesthesiologists performed ultrasound examinations of the PFSN on volunteers in supine and prone positions. Popliteal fossa sciatic nerve image quality was analysed with grayscale techniques and peer evaluation. Popliteal fossa sciatic nerve depth, distance from the popliteal crease and time until optimal imaging were recorded.Results:The grayscale ratio of the PFSN vs. the background was 1.83 (supine) and 1.75 (prone) (P = 0.034). Similarly, the grayscale ratio of the PFSN vs. the immediately adjacent area was 1.65 (supine) and 1.55 (prone) (P = 0.004). Mean depth of the PFSN was 1.6 cm (supine) and 1.7 cm (prone) (P = 0.009). Average distance from the popliteal crease to the PFSN was 5.9 cm (supine) and 6.6 cm (prone) (P = 0.02). Mean time to acquire optimal imaging was 36 s (supine) and 47 s (prone) (P = 0.002). Observers preferred supine positioning 53.8%, prone positioning 22.5% and no preference 23.7% of the time. Observers with strong preferences preferred supine imaging in 70.9% of cases.Conclusions:Supine ultrasound examination offered quicker identification of the PFSN, in a more superficial location, closer to the popliteal crease and with enhanced contrast to surrounding tissue, correlating with observer preferences for supine positioning. These results may influence ultrasound-guided PFSN block success rates, especially in difficult-to-image patients.

Cross-reactive immunity between SARS-CoV-2 and other related coronaviruses has been well-documented, and it may play a role in preventing severe COVID-19. Epidemiological studies early in the pandemic showed a geographical association between high influenza vaccination rates and lower incidence of SARS-CoV-2 infection. We, therefore, analyzed whether exposure to influenza A virus (IAV) antigens could influence the T cell repertoire in response to SARS-CoV-2, indicating a heterologous immune response between these 2 unrelated viruses. Using artificial antigen-presenting cells (aAPCs) combined with real-time reverse-transcription PCR (RT-qPCR), we developed a sensitive assay to quickly screen for antigen-specific T cell responses and detected a significant correlation between responses to SARS-CoV-2 epitopes and IAV dominant epitope (M158–66). Further analysis showed that some COVID-19 convalescent donors exhibited both T cell receptor (TCR) specificity and functional cytokine responses to multiple SARS-CoV-2 epitopes and M158–66. Utilizing an aAPC-based stimulation/expansion assay, we detected cross-reactive T cells with specificity to SARS-CoV-2 and IAV. In addition, TCR sequencing of the cross-reactive and IAV-specific T cells revealed similarities between the TCR repertoires of the two populations. These results indicate that heterologous immunity shaped by our exposure to other unrelated endemic viruses may affect our immune response to novel viruses such as SARS-CoV-2.

This narrative review discusses the differing opinions regarding whether and when regional analgesia can be utilized to treat injury and surgical pain when there is a high risk for acute compartment syndrome. The pathophysiology and objective means for early identification of acute compartment syndrome are reviewed. The mechanism of how regional anesthesia affects nociceptive and ischemia pain is reviewed, along with new proposed theories for why and when it may not block ischemic pain associated with acute compartment syndrome. Implications for a practical approach to regional analgesics in patients at risk for acute compartment syndrome are presented. Regional analgesia offers excellent site-specific pain relief with minimal to no systemic side effects. Understanding acute compartment syndrome pathophysiology and when modified regional analgesia techniques can potentially identify early diagnosis may improve pain management and reduce associated complications in these patients.

Anesthesiologists will continue to be recognized as airway experts and other specialties will need ongoing access to the clinical volume available in the OR setting when looking for opportunities to meet their residents' and fellows' airway management training needs. At the same time, critical care, EM, and other physicians have acquired an ever-expanding array of skills and experience managing the airways of critically ill and injured patients. When considering the needs of nonanesthesiologist trainees coming to our domain, it is essential to recognize the differences inherent in practicing outside of the OR and to incorporate those aspects of airway management considerations into training paradigms. This should be viewed as an opportunity to work toward a more universal approach to training and airway management in our individual institutions incorporating a multidisciplinary approach to education and clinical activities.

Fibrinolysis is a physiologic element of hemostasis that works to regulate clot formation through enzymatic breakdown of fibrin blood clots. Like the coagulation cascade, fibrinolysis is closely controlled by a series of cofactors, inhibitors, and receptors. In the perioperative period, tissue injury associated with trauma or surgery, blood contact with large nonendothelial surfaces such as cardiopulmonary bypass circuits, or ischemia and reperfusion may produce excessive fibrinolysis, contributing to worsened coagulopathy or bleeding.

Continuous insufflation of oxygen into the pilot balloon of an endotracheal tube has been documented as a viable method to fix an incompetent endotracheal tube cuff. We present a case of a large iatrogenic tracheal injury resulting from an improvised cuff leak management device. Valuable lessons are discussed to prevent similar incidents.

This chapter reviews recent literature to describe the utility of regional analgesic techniques in the pre-hospital, emergency department, and perioperative management of acute pain in trauma.

o the Editor: We read with interest the ultrasound (US)-guided suraclavicular approach described by Soares et al. titled, Eight ball, corner pocket: The optimal needle position for ltrasound-guided supraclavicular block.”1 Their descripion of directing the needle from lateral to medial along he long axis (i.e., in-plane view) using a high-frequency e.g., 10-13 MHz) linear probe to the “corner” bordered y the subclavian artery medially, the first rib inferiorly, nd the brachial plexus superior laterally has, in their xperience, provided a dense and complete block within inutes. While their notable expertise and success rearding US-guided peripheral nerve block precludes aruing with their technique, we would like to raise awareess among training programs and ultrasound-guided ovices about several ideals that make their approach ook deceivingly easy and safe. Firstly, the practitioners at the Toronto Western Hosital have many years of experience with ultrasound erve imaging and US-guided needle insertions. Second, he images displayed were obtained with a Philips HDI 000 cart-based system (Bothell, WA) capable of providng superb superficial differentiation of the various strucures in the supraclavicular fossa. Aside from the brachial lexus, their first high resolution image shows the hyerechoic first rib and a clear hypoechoic subclavian arery, structures that herald the potential for inadvertent neumothorax or vascular injection if the needle raverses too far. In their second image, the 22-guage eedle is plainly seen throughout its length with the eedle tip in perfect position, only approximately one entimeter away from the first rib and subclavian vessel. ften, these crystal clear pictures cannot be replicated by urrent portable ultrasound machines used to guide locks in most perioperative suites. Furthermore, quality maging can be quite variable among patients with much ndistinct anatomy seen on screen. Lastly, and possibly most important, is their assumpion that the individual performing the block is able to aintain perfect alignment of the needle with the ultraound probe throughout the entire procedure. This conition is critical to ensure accurate visualization of needle ip and thereby avoid feared complications. In our expeience, supervising and performing roughly 200 ultraound blocks a month, this skill has the steepest learning urve for performing an ultrasound-guided nerve block nd is extremely rare in the hands of the novice or rainee. Even a very small misalignment, according to heir “corner pocket” technique, may result in the needle ip out of ultrasound view and potentially in pleura or the a

To the Editor: We thank Drs. Macfarlane et al. and Tran et al., for their comments,1,2 yet we believe that our word of caution was grossly misunderstood. We too prefer the ultrasound (US)-guided supraclavicular brachial plexus block as our block of choice for upper limb surgery. Our anesthesia residents, student and certified nurse anesthetists, and attending anesthesiologists have collectively performed more than 250 US-guided supraclavicular blocks with a 100% success rate and no incidence of pneumothorax or subclavian artery injection. We use an 8 to 12 MHz high frequency probe with the GE Logiq e (Wauwatosa, WI) and feel comfortable guiding our trainees to direct the needle to the “corner pocket.” However, the goal of our letter3 was simply to provide a strong word of caution to practitioners that may not appreciate the conglomeration of safety features that make these blocks safe; namely, strong image quality, experience with “less dangerous” blocks, appropriate alignment skills, and supervised guidance. With an overzealousness to publish new techniques and educate others on the ease of US-guided blocks, we see negligible acknowledgement of the limitations one might encounter with suboptimal equipment or minimal experience. How often do we truly alert our colleagues of the pitfalls and false sense of security ultrasound guidance might present? Do we admit that some patients image poorly despite normal body habitus and advanced US machines? Are we honest and say that an US-guided technique is not an exact science all of the time? Don’t be mistaken. We are firm ultrasound advocates, performing nearly all of our peripheral nerve blocks exclusively with ultrasound guidance. Yet, given the “ultrasound revolution,” some US beginners are scrounging up old ultrasound machines from the vascular labs or obstetric suites, and are attempting to perform blocks for the first time without appropriate training. Thus, as we stated in our first letter, our intent was specifically to “raise awareness among training programs and ultrasoundguided novices.” Beware. Some of the “trick shots” you read about are performed by trained professionals! Not everything is as easy as it looks.

Diagnostic and treatment practices of institutional facilities treating high blood pressure in New York City were surveyed by mail in 1978. Respondents were adhering to the treatment recommendations of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. Ninety-two per cent of respondents reported 90-104 mm Hg as the diastolic blood pressure level at which drug therapy was initiated, indicating a more aggressive approach than was warranted by the information available at the time of the survey.