Regional Anesthesia

Liposomal Bupivacaine and Opioid Use

Strong marketing of liposomal Bupivacaine (Exparel) has occurred with its supposed long lasting effects. From local infiltration first, it was approved for nerve block based only on placebo comparison rather than existing regimes. This study of its use for total knee arthroplasty finds that liposomal bupivacaine was not associated with a clinically important reduction in inpatient opioid prescription, length of stay, or opioid-related complications in patients who received current multimodal pain management techniques including a peripheral nerve block. Its place in pain management has yet to be fully defined.

link

 

Lumbar Puncture & Dual Anti-Platelets

While not a study on spinal anesthesia, the Mayo Clinic review on lumbar puncture is relevant. They found no cases of spinal hematoma in 100 cases of LP in the presence of dual anti-platelet therapy. The study is small and retrospective, and the need for diagnostic puncture may possibly (pending further studies) be very important and justify the risk; an overwhelmingly strong absolute indication for spinal anesthesia is not so evident, and this small review is unlikely to change anesthesia cautious practice.

link

 

TAP Block for Cesarean

There are now a dizzying array of ultrasound guided abdominal wall blocks, e.g. Erector Spinae, Quadratus Lumborum, Rectus Sheath, Ilioinguinal, Iliohypogastric and more, some overlapping terminologically and their overall place in multimodal analgesia to be fully elucidated.

This study finds benefit post-Cesarean in the I-TAP (ilioinguinal transversus abdominis plane block) group after spinal anesthesia despite intrathecal morphine and non-opioid oral analgesia. Use of PCA Fentanyl was less (a study intervention only, and not their usual practice). They plan further study to determine how clinically significant this is, as other studies have not found it to add much to multimodal analgesia.

link

Neuraxial Anesthesia and Thromboembolism

It has been a long held view that spinal and epidural anesthesia reduce thromboembolism but a current study seeks to quantify this. However it seems to be a weak effect with a Number Needed to Treat of 500.

30 day readmission rates (but not mortality) were also reduced.

Neuraxial anesthesia may contribute to thromboembolism reduction but should not be the sole prophylaxis. And of course the ASRA guidelines for its use with anticoagulants enter the equation.

link

 

Music and Surgery

A meta-analysis confirms previous impression that music before and after surgery, and during regional anesthesia reduces anxiety and pain modestly, although studies had some risk of bias. I think the perpetual debate on what type of music can be tolerated by different personnel in the OR can be rendered moot by playing the patients choice of music, this tending to be supported by this evidence.

link

 

Cesarean Anesthesia and Outcome

A retrospective study of urgent Cesareans. Unclear why any GAs were done or whether there were different indications or urgency that would explain the lower Apgar scores. Neuraxial anesthesia wins again… ”General anaesthesia is associated with the most rapid operating room‐to‐incision interval for category‐1 caesarean section, but is also associated with worse short term neonatal outcomes. Longer operating room‐to‐incision intervals were not associated with worse neonatal outcomes“.

link

 

Block Comparison for Shoulder Surgery

Concern always exists as to phrenic nerve block and potential respiratory compromise (especially in those with borderline reserve) with Interscalene Block. Moving more distally is postulated to decrease such risk.

“The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block”

link