American Society Of Regional Anesthesia Research Articles

The Efficacy and Safety of Gabapentinoids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundGabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. MethodsThe MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies published prior to November 2018 on gabapentinoids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of gabapentinoids. ResultsIn total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption. ConclusionModerate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids.

Daring discourse: are we ready to recommend neuraxial anesthesia and peripheral nerve blocks during the COVID-19 pandemic? A pro-con

The recent joint statement from the American Society of Regional Anesthesia and Pain Medicine (ASRA) and the European Society of Regional Anesthesia and Pain Therapy (ESRA) recommends neuraxial and peripheral...

Do Pain Medicine Fellowships Provide Adequate Education in Head and Facial Pain? A Survey of Pain Medicine Fellowship Program Directors

Background: Fellows with insufficient education in head and facial pain may feel ill equipped to treat patients suffering from these disabling disorders. We hypothesized that there is variation in the scope and extent of headache and facial pain education that pain fellows receive during their pain fellowship. Study Design: A survey Setting: Accreditation Council for Graduate Medical Education (ACGME) Accredited pain medicine fellowship programs. Methods: After an exemption was obtained from the University of Virginia Institutional Review Board (IRB), an email with a link to the survey was sent to members of the Association of Pain Program Directors (APPD). The survey was also distributed to Association of Pain Program Director members at the annual 2019 APPD meetings during the Annual Society of Associations of Academic Anesthesiologists and Perioperative Medicine (SAAAPM) and the American Society of Regional Anesthesia and Pain Medicine (ASRA) meetings. The survey contained 16 questions. (questions are shown in Appendix 1). Results: Forty-seven of 108 program directors responded to the survey. Some program directors did not respond to every question. Limitations: The response rate is a limitation, but it is comparable to similar studies. Conclusions: The majority of pain fellows receive some education in head and facial pain. However; there were variations among fellowship programs in the extent and scope of education provided. Recognizing these gaps and variations in education, may lead to a better understanding of how to enhance and provide head and facial pain education during pain fellowship.

Consensus practice guidelines on interventions for lumbar facet joint pain from a multispecialty, international working group

BackgroundThe past two decades have witnessed a surge in the use of lumbar facet blocks and radiofrequency ablation (RFA) to treat low back pain (LBP), yet nearly all aspects of...

18th Annual Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine

18th Annual Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine

Evidence versus advocacy, as related to radiofrequency denervation in the treatment of chronic low back pain and the MINT trials

In 2017, JAMA: Journal of the American Medical Association published the results of the MINT trials, prospective research involving 681 patients, all of whom received exercise therapy for low back...

Interpreting the MINT randomized clinical trials: let us stick to the facts

In January 2018, a Daring Discourse[1][1] approved by the American Society of Regional Anesthesia and Pain Medicine (ASRA) board of directors was published in Regional Anesthesia and Pain Medicine (...

Role of regional analgesic techniques in ICU

Pain is a major problem in patients admitted in the Intensive Care Units (ICU). Untreated pain has significant impact on the outcome of these patients, especially surgical patients. There is enough evidence in the literature which has demonstrated that inadequately treated pain in ICU leads to prolonged ventilation, longer ICU stay, morbidity and other issues like development of post-traumatic stress disorder (PTSD) and chronic post-surgical pain (CPSP). Regional anesthesia and analgesia (RA) techniques like epidural analgesia, paravertebral blocks, and other peripheral nerve blocks (PNB) play a great role in providing significant pain relief, thus, limiting the use of opioids. They facilitate in earlier weaning from ventilation, reducing respiratory morbidity, and faster rehabilitation. These RA techniques are most useful in polytrauma patients, major thoracoabdominal and orthopedic surgeries, as many of them require post-surgical ICU care. However, these RA techniques are underutilised in many ICUs. Many a times, ICU physicians are not well versed with these RA techniques, and sometimes have fixed misconceptions with regards to these blocks. In this review, we will discuss on the need of these RA techniques and make a quick presentation on the technical aspect of frequently used blocks. The review will only focus on Ultrasound-guided regional analgesia (USRA) techniques as USG is commonly available in ICUs.Abbreviations: PTSD (Post-traumatic stress disorder), CPSP (Chronic post-surgical pain), RA (Regional anesthesia and analgesia), USRA Ultrasound-guided regional analgesia), PNB (Peripheral nerve block), IFPB (Interfascial plane blocks), ASRA (American Society of Regional Anesthesia and Pain Medicine) Citation: Sahoo RK, Nair AS, Badole UR, Kar R, Jadon A. Role of regional analgesic techniques in ICU. Anaesth Pain & Intensiv Care 2018;22 Suppl 1:S73-S82

Local Anesthetic Systemic Toxicity: A Narrative Literature Review and Clinical Update on Prevention, Diagnosis, and Management.

The objective of this narrative review of local anesthetic systemic toxicity is to provide an update on its prevention, diagnosis, and management. The authors used a MEDLINE search of human studies, animal studies, and case reports and summarize findings following the American Society of Regional Anesthesia and Pain Medicine practice advisories on local anesthetic systemic toxicity. Between March of 2014 and November of 2016, there were 47 cases of systemic toxicity described. Twenty-two patients (47 percent) were treated with intravenous lipid emulsion and two patients (4.3 percent) died. Seizures were the most common presentation. The spectrum of presenting neurologic and cardiovascular symptoms and signs are broad and can be obscured by perioperative processes. Local anesthetic type, dosage, and volume; site of injection; and patient comorbidities influence the rate of absorption from the site of injection and biodegradation of local anesthetics. Consider discussing appropriate dosages as a component of the surgical "time-out." A large-volume depot of dilute local anesthetic can take hours before reaching peak plasma levels. Oxygenation, ventilation, and advanced cardiac life support are the first priorities in treatment. Lipid emulsion therapy should be given at the first sign of serious systemic toxicity with an initial bolus dose of 100 ml for adults weighing greater than 70 kg and 1.5 ml/kg for adults weighing less than 70 kg or for children. All physicians who administer local anesthetics should be educated regarding the nature of systemic toxicity and contemporary management algorithms that include lipid emulsion therapy.

Society for Obstetric Anesthesia and Perinatology Consensus Statement: Monitoring Recommendations for Prevention and Detection of Respiratory Depression Associated With Administration of Neuraxial Morphine for Cesarean Delivery Analgesia.

The majority of women undergoing cesarean delivery in the United States receive neuraxial morphine, the most effective form of postoperative analgesia for this surgery. Current American Society of Anesthesiologists (ASA) and American Society of Regional Anesthesia and Pain Medicine (ASRA) recommend respiratory monitoring standards following neuraxial morphine administration in the general surgical population that may be too frequent and intensive when applied to the healthy obstetric population receiving a single dose of neuraxial morphine at the time of surgery. There is limited evidence to support or guide the optimal modality, frequency, and duration of respiratory monitoring in the postoperative cesarean delivery patient receiving a single dose of neuraxial morphine. Consistent with the mission of the Society for Obstetric Anesthesia and Perinatology (SOAP) to improve outcomes in pregnancy for women and neonates, the purpose of this consensus statement is to encourage the use of this highly effective analgesic technique while promoting safe practice and patient-centered care. The document aims to reduce unnecessary interruptions from respiratory monitoring in healthy mothers while focusing vigilance on monitoring in those women at highest risk for respiratory depression following neuraxial morphine administration. This consensus statement promotes the use of low-dose neuraxial morphine and multimodal analgesia after cesarean delivery, gives perspective on the safety of this analgesic technique in healthy women, and promotes patient risk stratification and perioperative risk assessment to determine and adjust the intensity, frequency, and duration of respiratory monitoring.

Subanesthetic ketamine infusions for the management of pediatric pain in non-critical care settings: An observational analysis.

Guidelines issued by the American Society of Regional Anesthesia and Pain Medicine suggest that ketamine infusions for acute pain management are advantageous as a primary treatment or as an opioid adjunct. Despite significant data regarding its use in adult patients, there remains a paucity of information related to its quality and side effect profile in pediatrics and how it can be effectively used. We aimed to summarize our practice of utilizing ketamine for pediatric pain management in non-critical care settings. Patients aged 0-21 years receiving low-dose ketamine infusions (≤0.3 mg/kg/hour) in inpatient care units over five years were retrospectively analyzed. Demographics, specific quality metrics, and side effects were quantified. About 172 patients received 270 subhypnotic ketamine infusions. The median duration of the infusions was 63.8 hours and 0.2 mg/kg/hour for the highest dose. The primary indication for ketamine was chronic pain exacerbation (83.3%). Despite similar opioid consumption, there was a significant reduction in mean verbal pain scores before (8.9 ± 1.9, P < .001) and after ketamine (6.5 ± 2.7, P < .001) use. Although there were 52 incidences of some side effect (neurologic excitability [10.4%]; over-sedation [7.4%]; rapid response team alerts [1.1%]), none resulted in termination of the infusion or escalations in care. Ketamine can effectively be used as part of a multimodal analgesic regimen in pediatric patients in non-critical care settings. Our five-year experience using low-dose ketamine infusions highlights an acceptable side effect profile, with no attributable escalations in care or serious adverse events.

Effectiveness of nursing educational interventions in managing post-surgical pain. Systematic review.

Objective. Analyze and integrate studies that inquire on the benefits of nursing educational interventions to manage post-surgical pain.Methods. A systematic search was conducted in the databases of Scopus, Medline (Pubmed), Web of Science, The Cochrane Library, and CINAHL of systematic reviews, randomized clinical trials, and quasi-experimental studies published in English and Spanish until 2018 that analyzed the effectiveness of educational interventions in managing post-surgical pain in adult patients.Results. Twelve studies complied inclusion criteria, of which nine reported less pain in the group receiving the educational intervention. These interventions also helped to diminish the level of anxiety and improved functionality to perform activities of daily life. The level of quality of the studies was medium.Conclusion. Although the review showed that nursing educational interventions could influence on the relief of post-surgical pain, more rigorous studies are necessary, with bigger sample sizes and higher methodological quality, which help to establish the real effectiveness in managing post-surgical patients with pain.

ASRA 17th Annual Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine November 15 to 17, 2018 San Antonio, Texas.

ASRA 17th Annual Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine November 15 to 17, 2018 San Antonio, Texas.

Successful intralipid-emulsion treatment of local anesthetic systemic toxicity following ultrasound-guided brachial plexus block: case report.

BackgroundLocal anesthetic systemic toxicity (LAST) is a life-threatening complication that may follow application of LAs through various routes. Despite increasing usage of LA techniques in a large number of health-care settings, contemporary awareness of LAST and understanding of its management are inadequate.Case presentationWe report two cases who suffered LAST following brachial plexus block for surgery on the upper extremity. The first patient received an ultrasound-guided supraclavicular block with 300 mg lidocaine (6 mg/kg) and 50 mg ropivacaine (1 mg/kg) in 25 mL without epinephrine, and the second patient received an ultrasound guided interscalene block with 200 mg lidocaine (4.5 mg/kg) and 45 mg ropivacaine (1 mg/kg) supplemented with epinephrine 1:200,000. Both patients presented with symptoms of central nervous and respiratory system depression, the first roughly 10 minutes after injection, and the second immediately after withdrawal of the needle. In both cases, thorough recovery was obtained using lipid-emulsion therapy.ConclusionThe complication of LAST following ultrasound-guided brachial plexus block could be treated successfully applying the American Society of Regional Anesthesia and Pain Medicineprotocol of intravenous administration of lipid emulsion.

The Use of Ketamine for the Management of Acute Pain in the Emergency Department.

Ketamine has been used as an anesthetic agent for over 50 years. At the upper end of the dosing range, it displays dissociative anesthetic and amnestic effects, while at lower doses, it acts as an analgesic and demonstrates opioid-sparing capabilities. Ketamine is unique in its preservation of hemodynamic stability and respiratory function, and is used extensively in the emergency department (ED) for procedural sedation and the facilitation of brief painful procedures. Despite evidence supporting its safety and efficacy as an analgesic agent at sub-dissociative doses, its use in the ED for the management of acute pain remains uncommon. New guidelines were published in July 2018 by the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists that provide a framework for identifying patients who are likely to benefit from the use of Ketamine in an acute pain setting.

Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-based Guidelines (Fourth Edition)

(Reg Anesth Pain Med. 2018;43:263–309) The American Society of Regional Anesthesia and Pain Medicine (ASRA) convened its Fourth Consensus Conference on Regional Anesthesia and Anticoagulation in conjunction with the European Society of Anesthesiology (ESA) in response to emerging patient safety issues. Among these are the heightened risk of neuraxial bleeding due to increasingly potent antithrombotic medications, changing standards for venous thromboembolism (VTE) prevention, and conflicting recommendations by various bodies and societies. Spinal hematoma is an uncommon and catastrophic complication of epidural or spinal anesthesia. Previous versions of this report have been published in 1998, 2003 and 2010 as ASRA Consensus Documents. For this update, authors performed a systematic and general review of relevant literature published between 2010 and 2017. The members represented ASRA, ESA, and the Society for Obstetric Anesthesia and Perinatology (SOAP).

Recomendaciones ESRA/ASRA en anestésicos locales y adyuvantes empleados en la población pediátrica

Dada la preocupación creciente respecto al efecto de los anestésicos empleados en anestesia general en el neurodesarrollo de la población pediátrica; toma mayor importancia la Anestesia Locorregional en dicha población. Pero, ¿Qué sabemos sobre la dosificación en esta población de los anestésicos locales?. Debido a dicha incertidumbre y a lo poco publicado al respecto la ESRA (European Society of Regional Anesthesia) y la ASRA (American Society of Regional Anesthesia) han decido reunirse para establecer una serie de recomendaciones sobre la dosificación de anestésicos locales y adyuvantes en anestesia locorregional en la población pediátrica. Dicho documento lo hemos resumido, de forma esquemática y con ayuda de tablas, con el fin de facilitar su comprensión y tenerlo a la disposición de todo aquel interesado en este campo. ABSTRACT ESRA/ASRA recommendations in local anesthetics and adjuvants in the pediatric population Growing concern regarding the effect of anesthetics used in general anesthesia in the neurodevelopment of the pediatric population; Loco-regional Anesthesia in this population takes greater importance. But, what do you know about the dosage of local anesthetics in this population? Due to this uncertainty and the little published about it, the ESRA (European Society of Regional Anesthesia) and the ASRA (American Society of Regional Anesthesia) have decided to meet to establish recommendations about the dosage of local anesthetics and adjuvants in loco-regional anesthesia in the pediatric population. This document has been summarized, in a schematic way with tables, to facilitate understanding. In this way, its content is available to all those interested.

Reply to Dr Yu et al.

To the Editor On behalf of my coauthors, I wish to thank Dr Yu and his colleagues[1][1] for alerting us to our oversight. As Dr Yu et al note correctly, the executive summary[2][2] of the third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic

Preprocedural checklist for regional anesthesia: impact on the incidence of wrong site nerve blockade (an 8-year perspective).

The term "Wrong-Site Surgery (WSS)" is commonly associated with surgical procedures; however, The Joint Commission (TJC) considers any invasive procedure, not just a surgical procedure, performed on the wrong side, at the wrong site, or on the wrong patient to be a WSS. For anesthesia providers, this means that a wrong-site nerve block (WSNB) also constitutes a WSS and would be considered a sentinel event by TJC. In an attempt to combat WSNB, the American Society of Regional Anesthesia and Pain Medicine published guidelines in 2014 recommending the use of a preprocedural checklist before performing regional blocks. The effectiveness of such a checklist, however, to reduce the occurrence of WSNB has not yet been demonstrated. We hypothesized that the introduction of a preprocedural checklist specific for regional anesthesia would be associated with a lower rate of WSNB procedures. A retrospective review was performed to compare the incidence of WSNB 2 years before, to 6 years after the implementation of a preprocedural checklist specific to regional anesthesia. Prior to checklist implementation, 4 WSNB events occurred during 10 123 procedures (3.95 per 10 000 (95% CI 1.26 to 9.53). Following implementation, WSNB events occurred during 35 890 procedures (0 per 10 000 (95% CI 0 to 0.84)); p=0.0023. Implementation of a regional anesthesia specific preprocedural checklist was associated with a significantly lower incidence of WSNB procedures. While prospective controlled studies would be required to demonstrate causation, this study suggests that for regional anesthesia procedures, a preprocedural checklist may positively impact patient safety.

Lower extremity regional anesthesia: essentials of our current understanding.

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.