Blocks for Shoulders

80 something year old male came for reverse total shoulder replacement. He had severe COPD as well as an EF 20% with CHF. He had been appropriately optimized. Preoperatively, we performed an anterior approach suprascapular block (10ml, 0.25% bupi) combined with an infraclavicular block (20ml, 0.25% bupi). In retrospect, we could have used 5ml for suprascapular block and 15ml for infraclavicular block.

Supraclavicular block versus interscalene brachial plexus block for shoulder surgery: A meta-analysis of clinical control trials. International Journal of Surgery, Volume 45, September 2017, Pages 85-91.

  • Supraclavicular block could provide similar analgesic efficacy compared with interscalene block.
  • Ultrasound-guided supraclavicular block was associated with a low incidence of hoarseness and Horner syndrome.

Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis. European Journal of Anaesthesiology 36(6):p 427-435, June 2019

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology July 2018, Vol. 129, 47–57.

From Anesthesiology July 2018, Vol. 129, 47–57.

A Randomized Comparison Between Interscalene and Small-Volume Supraclavicular Blocks for Arthroscopic Shoulder Surgery. Regional Anesthesia & Pain Medicine 2018;43:590-595.

A combination of infraclavicular and suprascapular nerve blocks for total shoulder arthroplasty: A case series. Acta Anaesthesiol Scand. 2021; 65: 674– 680.

Suprascapular nerve block is a clinically attractive alternative to interscalene nerve block during arthroscopic shoulder surgery: a meta-analysis of randomized controlled trials. Journal of Orthopaedic Surgery and Research volume 16, Article number: 376 (2021).

Evolution of Anesthetic Techniques for Shoulder Surgery: A Narrative Review. Osteology 20222(1), 52-61.

YouTube: Anterior suprascapular nerve block and literature 11:43 for procedure

YouTube: Suprascapular and axillary nerve block

VO2 Max and Health/Wellness

VO2 max

After listening to the Huberman Lab podcast (and you should too! He’s got nuggets of info on health!), I decided to schedule a Dexa Scan as well as VO2 max test. I want to have a baseline of where I am at my age. This year has been a huge year of change. I’ve committed to my health (yes I’m currently 7 months in with a strength program called Rise; I started 1-2x/wk rowing; MMA 1x/wk). I’m changing jobs. I have cut back or cut out unnecessary or harmful things to my life. I’m participating in a glucose monitoring study. I wish I had done these metrics every decade of my life starting at 10.

What is VO2 max?

How to Improve VO2 max

6 Ways to Improve Your VO2 Max

VO2 Max: The Fitness Metric That Can Help You Run Faster and Workout Harder

Effect of dietary fat on metabolic adjustments to maximal VO2 and endurance in runners. Med Sci Sports Exerc. 1994 Jan;26(1):81-8.

VO2 max test on Concept 2

The more I dig into the world of health and wellness, the more there is to learn. Hormones, gut health, nutrition, supplements, macros/micros, exercise (role for mobility, flexibility, cardio, strength, functional, etc). I wish they taught this stuff in medical school. This is the real foundation of health and wellness.

Cardiorespiratory Coordination in Collegiate Rowing PDF

A New Fitness Test of Estimating VO2max in Well-Trained Rowing Athletes. Front. Physiol., 02 July 2021. Sec. Exercise Physiology

How to Improve:

Indoor Rowing Workouts That Boost Your Vo2 Max

More gems:

iollo – metabolomics testing (metabolite measuring)

Zoe – gut health, blood sugar, blood fat

Athletic Greens – comprehensive nutrition and gut health support

Ka’Chava – whole health meal replacement

Vedge Nutrition – fitness supplements made by vegans for vegans

Mud/WTR and Ryze – mushroom supplementation

DNAfit

23andMe

Overall, I felt I could have pushed a bit harder but I was nervous on the treadmill. My legs were burning. Oh the dreadmill.

Heparin and Hypotension

Healthy appearing patient with afib s/p ablation and returning for repeat ablation for recurrent afib. Anesthesia induced normally and patient VSS. 3 minutes after a request of a heparin bolus, patient dropped their SBP into the upper 40s, lower 50s. Patient recovered well after small bolus of epinephrine. ICE used to rule out pericardial effusion as well as confirm normal LVEF and RVEF.

From IndiaMart.com

The hemodynamic effects of heparin and their relation to ionized calcium levels. J THoRAc CARDIOVASC SURG 91:303-306, 1986.

Histamine blockade and cardiovascular changes following heparin administration during cardiac surgery. J Cardiothorac Anesth. 1990 Dec;4(6):711-4.

Heparin-Mediated Hypotension Associated with Cardiac Surgery. Anesthesia & Analgesia: September 2000 – Volume 91 – Issue 3 – p 766-767.

Preoperative Heparin Therapy Causes Immune-Mediated Hypotension Upon Heparin Administration for Cardiac Surgery. Journal of Cardiothoracic and Vascular Anesthesia. Volume 24, Issue 1, February 2010, Pages 69-72.

Prediction of heparin induced hypotension during cardiothoracic surgery: A retrospective observational study. Anaesth pain & intensiv care 2019;23(2):145-150.

Angiotensin Receptor Blocker (ARB) Reversal

From Angiotensin Axis Blocking Drugs In the Perioperative Period. Anesthesiology News, Feb 2016

What does an angiotensin receptor blocker (ARB) do?

Angiotensin II receptor blockers (ARBs) represent a newer class of effective and well tolerated antihypertensive agents 1. Several clinical studies have indicated the beneficial effects of ARBs in hypertensive patients such as reduction of left ventricular hypertrophy, decrease in ventricular arrhythmias, and improved diastolic function 1. Inhibitors of the renin-angiotensin system (RAS), either angiotensin converting enzyme (ACE) inhibitors or ARBs, mediate vasodilation and consequently decrease blood-pressure by different mechanisms 1. ARBs specifically inhibit angiotensin II from binding to its receptor, the Angiotensin-1 (AT 1) receptor on vascular smooth muscle cells. This blockade results in increased angiotensin II and normal bradykinin plasma levels. ARBs were developed to overcome several deficiencies of ACE inhibitors, which, by comparison, lead to decreased angiotensin II, but increased bradykinin levels. Hence, the key advantage of ARBs over ACE inhibitors is their lack of adverse effects related to bradykinin potentiation. ARBs have been shown to reduce morbidity and mortality associated with hypertension, and therefore, it is not surprising that an increasing number of patients scheduled for surgery are chronically treated with ARBs 2. However, RAS blockade increases the risk of severe hypotension during and after anesthetic induction. ACE-inhibitors are well known for inducing severe circulatory side effects during anesthesia, which led to the general recommendation to withhold the drug on the day of surgery 3.

Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker. F1000Research 2013, 2:12.

Comparison of Angiotensin‐Converting Enzyme Inhibitor and Angiotensin Receptor Blocker Management Strategies Before Cardiac Surgery: A Pilot Randomized Controlled Registry Trial. Journal of the American Heart Association. 2018;7:e009917.

Consequences of continuing renin angiotensin aldosterone system antagonists in the preoperative period: a systematic review and meta-analysis. BMC Anesthesiol. 2018 Feb 26;18(1):26.

From Angiotensin Axis Blocking Drugs In the Perioperative Period. Anesthesiology News, Feb 2016

How do I reverse an ARB in an emergency?

Chronic AT 1 blockade also reduces the vasoconstrictor response to α 1 receptors activated by norepinephrine, which explains why ARB-induced hypotension can be so resistant to phenylephrine, ephedrine and norepinephrine 2, 8 Clinical studies have shown significant vasoconstrictor effects of vasopressin and increased cardiac filling during echocardiographic measurements 2.

Vasopressin or its synthetic analogues can restore the sympathetic response and may be useful pressors in cases of refractory hypotension during anaphylaxis 9 and septic shock 10 as well as in patients on RAS inhibitors, although norepinephrine has been reported to have a more favorable effect on splanchnic perfusion and oxygen delivery 11.

Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker. F1000Research 2013, 2:12.

Angiotensin Axis Blocking Drugs In the Perioperative Period. Anesthesiology News, Feb 2016.

  • When conventional therapies such as: decreasing the anesthetic agent, volume expansion, phenylephrine, ephedrine, norepinephrine, and epinephrine are not effective, exogenous vasopressin may improve hypotension. To date, at least 5 clinical trials have demonstrated that patients on chronic ACEI/ARB undergoing general anesthesia, respond to exogenous vasopressin derivatives with an increase in blood pressure and fewer hypotensive episodes.6,7 Typically, a 0.5-1 unit bolus of AVP is administered to achieve a rise in mean arterial pressure.4 The subsequent recommended infusion dose is 0.03U/min for AVP and 1-2 mcg/kg/h for terlipressin. Caution should be used as V1 agonists have been associated with the following deleterious effects: reduction in cardiac output and systemic oxygen delivery, decreased platelet count, increased serum aminotransferases and bilirubin, hyponatremia, increased pulmonary vascular resistance, decrease in renal blood flow, increase in renal oxygen consumption, and splanchnic vasoconstriction.
  • Studies involving cardiac surgical patients suggest that MB treatment for patients with VS may reduce morbidity and mortality.5 It has also been suggested that the early use (preoperative use in patients at risk for VS) of MB in patients undergoing coronary artery bypass grafting may reduce the incidence of VS.5,9A bolus dose of 1-2mg/kg over 10-20 minutes followed by an infusion of 0.25mg/kg/hr for 48-72 hours is typically utilized in clinical practice and trials (with a maximum dose of 7 mg/kg).10 Side effects include cardiac arrhythmias (transient), coronary vasoconstriction, increased pulmonary vascular resistance, decreased cardiac output, and decreased renal and mesenteric blood flow.1 Both pulse and cerebral oximeter readings may not be reliable during MB administration due to wavelength interference.11,12 The use of MB is absolutely contraindicated in patients with severe renal impairment because it is primarily eliminated by the kidney.13 It may also cause methemoglobinemia and hemolysis.13 At high doses, neurotoxicity may occur secondary to the generation of oxygen free radicals. Neurologic dysfunction may be more severe in patients receiving serotoninergic agents such as: tramadol, ethanol, antidepressants, dopamine agonists and linezolid. Recommended doses for VS ranging from 1-3 mg/kg do not typically cause neurologic dysfunction.14 However, recent reports suggest that MB in doses even ≤ 1mg/kg in patients taking serotonin reuptake inhibitors (SSRIs) may lead to serotonin toxicity due to its monoamine oxidase (MAO) inhibitor property.15

Vasoplegic Syndrome and Renin-Angiotensin System Antagonists. APSF Newsletter, Circulation 94,429 • Volume 27, No. 1 • Summer-Spring 2012.

Vasopressin for persistent hypotension due to amlodipine and olmesartan overdose: A case report. Ann Med Surg (Lond). 2021 May; 65: 102292.

Vasoplegic syndrome following cardiothoracic surgery—review of pathophysiology and update of treatment options. Crit Care. 2020; 24: 36.

Refractory hypotension during general anesthesia despite preoperative discontinuation of an angiotensin receptor blocker. F1000Research 2013, 2:12.

Terlipressin for refractory hypotension following angiotensin-II receptor antagonist overdose. Anaesthesia, 2006,61, pages 402–414.

Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med. 2017 Aug 3;377(5):419-430.

Vasopressin: physiology and clinical use in patients with vasodilatory shock: a review. Neth J Med. 2005 Jan;63(1):4-13.

Treatment of intraoperative refractory hypotension with terlipressin in patients chronically treated with an antagonist of the renin-angiotensin system. Anesth Analg. 1999 May;88(5):980-4.

Role of vasopressinergic V1 receptor agonists in the treatment of perioperative catecholamine-refractory arterial hypotension. Best Pract Res Clin Anaesthesiol. 2008 Jun;22(2):369-81.

Predicting response to methylene blue for refractory vasoplegia following cardiac surgery. Pharmacotherapy Conference: 2013 American College of Clinical Pharmacy Annual Meeting. October 2013.

Anesthesia for Latissimus Dorsi Flap for Breast Reconstruction

What is a latissimus dorsi flap?

From MDAnderson.org

Latissimus Dorsi Flap in Breast Reconstruction. Cancer Control. 2018 Jan-Dec; 25(1): 1073274817744638.

A Retrospective Study of Latissimus Dorsi Flap in Immediate Breast Reconstruction. Front. Oncol., 04 November 2021. https://doi.org/10.3389/fonc.2021.598604

Anesthetic Techniques

Regional Anesthesia For Breast Reconstruction. [Updated 2022 Feb 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

Anaesthesia for breast surgery. BJA Education, 18(11): 342e348 (2018).

Anaesthesia for free flap breast reconstruction. BJA Education, Volume 16, Issue 5, May 2016, Pages 162–166.

Paravertebral Analgesia with Levobupivacaine Increases Postoperative Flap Tissue Oxygen Tension after Immediate Latissimus Dorsi Breast Reconstruction Compared with Intravenous Opioid Analgesia. Anesthesiology February 2004, Vol. 100, 375–380.

Treatment of Post-Latissimus Dorsi Flap Breast Reconstruction Pain With Continuous Paravertebral Nerve Blocks: A Retrospective Review. Anesth Pain Med. 2016 Oct; 6(5): e39476.

Paravertebral blocks and enhanced recovery after surgery protocols in breast reconstructive surgery: patient selection and perspectives. J Pain Res. 2018;11:1567-1581.

Comparison of local and regional anesthesia modalities in breast surgery: A systematic review and network meta-analysis. J Clin Anesth. 2021 Sep;72:110274.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials. Can J Anaesth. 2022 Apr;69(4):527-549.

Efficacy of erector spinae plane block for analgesia in breast surgery: a systematic review and meta-analysis. Anaesthesia. 2021 Mar;76(3):404-413.

Erector Spinae Plane Block Similar to Paravertebral Block for Perioperative Pain Control in Breast Surgery: A Meta-Analysis Study. Pain Physician. 2021 May;24(3):203-213.

Erector Spinae Plane Block for Mastectomy and Breast Flap Reconstructive Surgery: A Three Case Series. Open Journal of Anesthesiology
Vol.10 No.01(2020), Article ID:97889,8 pages.

Tranexamic Acid vs. Amicar

** Updated June 2022**

Over the years, our hospital has been using Amicar… until there was a drug shortage.  With that drug shortage came a different drug called tranexamic acid.  We’ve been using it for awhile and I can’t seem to tell a difference in coagulation between the two drugs.  Let’s break down each one and also discuss cost-effectiveness.

Amicar

What is it?


From MedPage Today

Tranexamic Acid

What is it?

Tranexamic acid acts by reversibly blocking the lysine binding sites of plasminogen, thus preventing plasmin activation and, as a result, the lysis of polymerised fibrin.12 Tranexamic acid is frequently utilised to enhance haemostasis, particularly when fibrinolysis contributes to bleeding. In clinical practice, tranexamic acid has been used to treat menorrhagia, trauma-associated bleeding and to prevent perioperative bleeding associated with orthopaedic and cardiac surgery.13–16 Importantly, the use of tranexamic acid is not without adverse effects. Tranexamic acid has been associated with seizures,17 18 as well as concerns of possible increased thromboembolic events, including stroke which to date have not been demonstrated in randomised controlled trials.

Fibrinolysis is the mechanism of clot breakdown and involves a cascade of interactions between zymogens and enzymes that act in concert with clot formation to maintain blood flow.25 During extracorporeal circulation, such as cardiopulmonary bypass used in cardiac surgery, multiplex changes in haemostasis arise that include accelerated thrombin generation, platelet dysfunction and enhanced fibrinolysis.26 Tranexamic acid inhibits fibrinolysis, a putative mechanism of bleeding after cardiopulmonary bypass, by forming a reversible complex with plasminogen.

Dosing:

  • Ortho/Spine
  • OB
  • Trauma

Currently at our hospital (June 2022):

TXA DOSING AND ADMINISTRATION OVERVIEW

How supplied from PharmacyTXA 1000mg/10mL vials Will not provide premade bags like with Amicar; Amicar is a more complex mixture than TXA Will take feedback on this after go-live and reassess
Where it will be supplied from PharmacyPOR-SUR1 Omnicell (in HeartCore Room)   Perfusion Tray (will replace aminocaproic acid vials 6/7)  
Recommended Dosing (see below for evidence)~20 mg/kg total dose Can give as: 20 mg/kg x 1, OR 10 mg/kg x 1, followed by 1-2 mg/kg/h*   Perfusion may also prime bypass solution with 2 mg/kg x 1*
Preparation & AdministrationIV push straight drug (1000mg/10mL) from vial   AND/OR   Mix vial of 1000mg/10mL TXA with 250mL NS for continuous infusion*

TXA & Amicar ADRs

  • Seizure risk may be increased also by duration of prolonged open-chamber surgery based on findings from Zuffery, et al. Anesthesiology 2021.
  • Per OR pharmacist at Scripps Mercy, they have not seen an increased incidence of seizures in their patient-population (anecdotally)

DOSING EVIDENCE

There are a number of dosing strategies in the literature. What I recommend for maximal safety and efficacy is taken from Zuffery, et al. Anesthesiology 2021 meta-analysis and is practiced at Scripps Mercy.

  • ~ 20 mg/kg total dose recommended in this meta-analysis.
  • Two dosing strategies they report that were as effective as high-dose but with lower seizure risk than high dose:

Regional Anesthesia for AV fistula revision

Case info

Types of regional anesthesia for AV fistula

Regional anaesthesia practice for arteriovenous fistula formation surgery. Anaesthesia 2020, 75, 626–633.

Observational study of the efficacy of supraclavicular brachial plexus block for arteriovenous fistula creation. Indian J Anaesth. 2018 Aug; 62(8): 616–620.

NYSORA Ultrasound-guided Supraclavicular Block video

Ultrasound-guided supraclavicular versus infraclavicular brachial plexus nerve block in chronic renal failure patients undergoing arteriovenous fistula creation. Egyptian Journal of Anaesthesia. Volume 30, Issue 2, April 2014, Pages 161-167.

SonoSite Ultrasound-guided Supraclavicular Block video

Practical Anesthesia Techniques ultrasound-guided infraclavicular block video

From Doctorlib.info

A brachial plexus block technique for upper arm AV Fistula. BJA: British Journal of Anaesthesia, Volume 113, Issue eLetters Supplement, 29 December 2014.

Axillary Nerve Block for Upper Extremity Arteriovenous Fistula Creation. Proceedings of UCLA Healthcare. VOLUME 21 (2017).

Ultrasound-guided axillary brachial plexus block versus local infiltration anesthesia for arteriovenous fistula creation at the forearm for hemodialysis in patients with chronic renal failure. Saudi J Anaesth. 2017 Jan-Mar; 11(1): 77–82.

Long-Term Functional Patency and Cost-Effectiveness of Arteriovenous Fistula Creation under Regional Anesthesia: a Randomized Controlled Trial. JASN August 2020, 31 (8) 1871-1882.

Comparison of regional and local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis. BMC Anesthesiology volume 20, Article number: 219 (2020).

From Doctorlib.info

Is it ok to do regional blocks in sepsis patients?

Neuraxial Regional Anaesthesia in Patients with Active Infection and Sepsis: A Clinical Narrative Review. Turk J Anaesthesiol Reanim. 2018 Feb; 46(1): 8–14.

Epidural blood patch

I was asked to consult on a 30-something year old patient who had a recent subdural hemorrhage. It was a spontaneous event without trauma. After a week of stabilization of the SDH, the patient started developing positional headaches. CT scan showed a CSF leak from C4-T5 ventrally and another one from T6-T10 dorsally.

CT head: Small evolving right greater than left bilateral subdural hematomas, not significantly changed compared to prior. No evidence of new hemorrhage. Trace right to left midline shift is unchanged.

Cspine/T-spine/L-spine with contrast: Extensive CSF leak. The dominant component of this process is a ventral epidural contrast collection extending from C6-T4 levels, but there is also abnormal dorsal epidural contrast extending from T5-T10. The contrast is densest in the cervicothoracic ventral epidural space, also suggesting that this is the primary leakage site.

MRA neck without acute abnormalities. MRI cervical/thoracic/lumbar spine which incidentally revealed multifocal demyelinating lesions in the cervical cord with a focal lesion at T7 and MRI brain showed multiple foci of T2 flair hyperintensity in the supratentorial white matter of the brain, suspicious for undiagnosed demyelinating disease.

What is a CSF leak?

What is an epidural blood patch?

Recent update on epidural blood patch: Review. Anesth Pain Med 2022;17:12-23.

Typically, anesthesia gets consulted for lumbar epidural blood patches after lumbar CSF leaks. However, in this case, the CSF leak occurs quite high in the cervicothoracic spine. Oftentimes, it’s very difficult to inject a greater volume of blood in the lumbar epidural space due to back pain to reach the higher cervical and thoracic areas.

From Post Dural Puncture Headache – We Can Prevent It. July 2014.

Why not do a lumbar epidural blood patch to reach the cervical or thoracic space?

One question that is often asked is whether CEBPs are necessary, or would lumbar EBPs suffice, even for dural leaks at the cervical levels. There are several reports indicating that lumbar EBP can permanently alleviate the headache regardless of whether or not the site of leakage is identified . However, other reports demonstrate that lumbar EBP does not always result in permanent relief [36–38]. A study by Diaz suggests that the site of leakage should be identified by radioisotope cisternography and treated with EBP targeted to CSF leak site levels . Cousins et al suggested that placement of the EBP close to the site of CSF leakage is important . Studies have shown that blood injected at the lumbar level does reach the cervical levels. Ferrante et al., for instance, performed epidural blood patch at L3-4 and placed in the patient in trendelenburg for 22 hours . He was able to show presence of blood in the epidural space at the cervical levels on postprocedure MRIs. The mean spread of the blood patch in the epidural space has been found to be 4.6 ± 0.9 vertebral levels . Most of the blood spread in the cephalad direction . However, the amount of blood that reaches the higher cervical levels in comparison to the amount of blood needed to form a stable clot is unclear. Despite spread of blood to cervical levels, Beards did note that after an epidural blood patch, the majority of the clot and mass effect appears to be concentrated in the area around the injection site .

Cervical epidural blood patch—A literature review. Pain Medicine, Volume 16, Issue 10, October 2015, Pages 1897–1904.

Efficacy of epidural blood patches for spontaneous low-pressure headaches: a case series. J R Coll Physicians Edinb 2016; 46: 234–7.

Sagittal postmyelogram CT of the cervical and upper thoracic spine showing a ventral epidural contrast collection. VES indicates ventral epidural space; VSS, ventral subarachnoid space; C, cord. From Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension. American Journal of Neuroradiology August 2013, 34 (8) E84-E86

How does one reach a cervical or thoracic epidural space?

Cervical epidural blood patch—A literature review. Pain Medicine, Volume 16, Issue 10, October 2015, Pages 1897–1904.

Epidural Blood Patch at C2: Diagnosis and Treatment of Spontaneous Intracranial Hypotension. American Journal of Neuroradiology November 2005, 26 (10) 2663-2666.

Thoracic epidural blood patch with high volume blood for cerebrospinal fluid leakage of cervical spine (C2–3) complicated with spontaneous intracranial hypotension. Acta Anaesthesiologica Taiwanica. Volume 53, Issue 3, September 2015, Pages 112-113.

Thoracic Epidural Blood Patches in the Treatment of Spontaneous Intracranial Hypotension: A Retrospective Case Series. Pain Physician 2015; 18:343-348.

A, Postmyelogram CT at the level of the T7–8 disc interspace demonstrates a ventral CSF leak (white arrow) containing contrast with an attenuation slightly less than that of intrathecal contrast. A small spiculated osteophyte (white arrowhead) is the presumed cause for the leak. B, Lateral projection dynamic myelogram of the midthoracic spine confirms the origin of the CSF leak at T7–8. Note the split of the contrast column at this level consistent with a ventral CSF leak (white arrow). From CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. American Journal of Neuroradiology October 2016, 37 (10) 1951-1956.

Utilizing this information, I thought this patient would be better suited for a CT-guided targeted (cervicothoracic) ventral epidural blood patch performed by the IR team. Additionally, I recommended conservative therapy: hydration, caffeine, Fioricet, lying flat, and an abdominal binder.

CT Fluoroscopy–Guided Blood Patching of Ventral CSF Leaks by Direct Needle Placement in the Ventral Epidural Space Using a Transforaminal Approach. American Journal of Neuroradiology October 2016, 37 (10) 1951-1956.

Feasibility of Placement of an Anterior Cervical Epidural Blood Patch for Spontaneous Intracranial Hypotension. American Journal of Neuroradiology August 2013, 34 (8) E84-E86.

Exparel

Liposomal bupivacaine (Exparel) is a longer acting form of traditional bupivacaine that delivers the drug by means of a multivesicular liposomal system.

Exparel FDA drug sheet

  • Max Dose: 266 mg or 4mg/kg (6yo-17yo). Interscalene NB max dose (adults) =133mg
Exparel website: Field blocks
Exparel website: Interscalene NB

Exparel dosing company info: Pocket Dosing Guide , Billing Guide

Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012; 5: 257–264.

Emerging roles of liposomal bupivacaine in anesthesia practice. J Anaesthesiol Clin Pharmacol. 2017 Apr-Jun; 33(2): 151–156.

Liposomal bupivacaine peripheral nerve block for the management of postoperative pain. Cochrane Database Syst Rev. 2016 Aug 25;2016(8):CD011476.

Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb; 2017(2): CD011419.

Novel Local Anesthetics in Clinical Practice: Pharmacologic Considerations and Potential Roles for the Future. Anesth Pain Med. 2022 Feb; 12(1): e123112.

Cardiac/Thoracic

The role of liposomal bupivacaine in thoracic surgery. J Thorac Dis. 2019 May; 11(Suppl 9): S1163–S1168.

Intercostal nerve blockade for thoracic surgery with liposomal bupivacaine: the devil is in the details. J Thorac Dis. 2019 May; 11(Suppl 9): S1202–S1205.

  • VATs: Dilute liposomal bupivacaine (266 mg, 20 cc) mixed with 20 cc injectable saline. We use two syringes to save time (refill syringe between injections).
  • For planned thoracotomy, we add 60 cc injectable saline for wider injection.
  • The efficacy of this strategy requires attention to specific details, such as timing and technique of injection, dilution with saline, and injection of multiple interspaces (typically interspaces 3–10 when technically possible).
  • Inject EXPAREL slowly and deeply (generally 1-2 mL per injection) into soft tissues using a moving needle technique (ie, inject while withdrawing the needle)
  • Infiltrate above and below the fascia and into the subcutaneous tissue
  • Aspirate frequently to minimize the risk of intravascular injection
  • Use a 25-gauge or larger-bore needle to maintain the structural integrity of the liposomal particles
  • Inject frequently in small areas (1-1.5 cm apart) to ensure overlapping analgesic coverage

Liposomal Bupivacaine Versus Bupivacaine for Intercostal Nerve Blocks in Thoracic Surgery: A Retrospective Analysis. Pain Physician. 2020 Jun;23(3):E251-E258.

Intercostal Blocks with Liposomal Bupivacaine in Thoracic Surgery: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth. 2021 May;35(5):1404-1409.

Is liposomal bupivacaine superior to standard bupivacaine for pain control following minimally invasive thoracic surgery? Interactive CardioVascular and Thoracic Surgery, Volume 31, Issue 2, August 2020, Pages 199–203, https://doi.org/10.1093/icvts/ivaa083

Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy. J Surg Res. 2020 Feb;246:19-25.

Rib fractures case report: ESP block


Evaluation of an Enhanced Recovery After Surgery Protocol Including Parasternal Intercostal Nerve Block in Cardiac Surgery Requiring Sternotomy. Am Surg. 2021 Dec;87(10):1561-1564.

Ultrasound-guided Modified Parasternal Intercostal Nerve Block: Role of Preemptive Analgesic Adjunct for Mitigating Poststernotomy Pain. Anesth Essays Res. 2020 Apr-Jun; 14(2): 300–304.

Comparison of preincisional and postincisional parasternal intercostal block on postoperative pain in cardiac surgery. J Card Surg. 2020 Jul;35(7):1525-1530.

Ultrasound-guided parasternal intercostal nerve block for postoperative analgesia in mediastinal mass resection by median sternotomy: a randomized, double-blind, placebo-controlled trial. BMC Anesthesiol. 2021; 21: 98.

Pain Relief Following Sternotomy in Conventional Cardiac Surgery: A Review of Non Neuraxial Regional Nerve Blocks. Ann Card Anaesth. 2020 Apr-Jun; 23(2): 200–208.

A Novel Use of Liposomal Bupivacaine in Erector Spinae Plane Block for Pediatric Congenital Cardiac Surgery. Case Rep Anesthesiol. 2021; 2021: 5521136.

Breast/Gen Surg

Evaluating the Efficacy of Two Regional Pain Management Modalities in Autologous Breast Reconstruction. Plast Reconstr Surg Glob Open. 2022 Jan 19;10(1):e4010.

Perioperative Blocks for Decreasing Postoperative Narcotics in Breast Reconstruction. Anesth Pain Med. 2020 Oct; 10(5): e105686.

Opioid-sparing Strategies in Alloplastic Breast Reconstruction: A Systematic Review. Plast Reconstr Surg Glob Open. 2021 Nov 16;9(11):e3932.

Comparison of the efficacy of erector spinae plane block performed with different concentrations of bupivacaine on postoperative analgesia after mastectomy surgery: ramdomized, prospective, double blinded trial. BMC Anesthesiol. 2019; 19: 31.


Efficacy of liposomal bupivacaine versus bupivacaine in port site injections on postoperative pain within enhanced recovery after bariatric surgery program: a randomized clinical trial. Surg Obes Relat Dis. 2019 Sep;15(9):1554-1562.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique. J Anaesthesiol Clin Pharmacol. 2020 Jan-Mar; 36(1): 110–114.

Ortho

Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block. Clin Orthop Relat Res. 2017 Jan;475(1):110-117.

OB

Transversus Abdominis Plane Block With Liposomal Bupivacaine for Pain After Cesarean Delivery in a Multicenter, Randomized, Double-Blind, Controlled Trial. Anesth Analg. 2020 Dec; 131(6): 1830–1839.

Intraperitoneal Chloroprocaine

20-something year old primip came today with preeclampsia and was deemed a c/s candidate for her 26 week baby. She was 5’8″, 165lb and had no prior issue with previous surgeries. She was started on magnesium preop. The mag was held intraoperatively and would resume postoperatively. Pt was in sitting position for her spinal, which was placed at L4-5. Good clear CSF return. 0.75% bupi dosed at 13.5 mg with intrathecal fentanyl 15mcg and intrathecal morphine 0.2mg. BP decreased from 150s to 130s, which was appropriate. Patient stated she had increased tingling and decreased mobility in her legs. All symptoms and signs appropriate with her spinal. Patient passed the Allis clamp test prior to incision. She was quite anxious: propofol was given IV for anxiolysis. Patient was adamant about breastfeeding/pumping for her baby. No complications with delivery. Uterus was externalized and patient was sensitive to pressure and tugging/manipulation. IV fenatnyl and IV morphine were given along with IV propofol. When uterus was internalized, patient felt more pressure that seemed unbearable. More IV pain meds were given. Suggestion was made for intraperitoneal chloroprocaine. Patient able to tolerate fascial closure as well as staple skin closure.

Intraperitoneal chloroprocaine

Chloroprocaine. StatPearls.

Intraperitoneal chloroprocaine is a useful adjunct to neuraxial block during cesarean delivery: a case series. Int J Obstet Anesth. 2018 Aug;35:33-41. doi: 10.1016/j.ijoa.2018.01.007. Epub 2018 Mar 2.

Chloroprocaine Lavage to Improve Outcomes Related to Operative Cesarean Delivery (CLOR-PRO). Clinicaltrials.gov. 2018 ongoing.

Pain Control During Cesarean Delivery. Anesthesia Experts. Jan 2020.

From Essential Clinical Anesthesia: January 2012. Chapter 47

Failed epidural

Mechanisms and management of an incomplete epidural block for cesarean section. Anesthesiology Clinics. REVIEW ARTICLE| VOLUME 21, ISSUE 1, P39-57, MARCH 01, 2003