Purpose:We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.Methods:A panel of 15 members with expertise in orthopaedic trauma, pain manage

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury.

Regional anaesthesia has undergone several exciting advances in the past few decades. Ultrasound-guided techniques of peripheral nerve blockade have become the gold standard thanks to the associated improvements in efficacy, ease of performance and safety. This has increased the accessibility and utilisation of regional anaesthesia in the anaesthesia community at large and is timely given the mounting evidence for its potential benefits on various patient-centred outcomes, including major morbidity, cancer recurrence and persistent postoperative pain. Ultrasound guidance has also paved the way for refinement of the technical performance of existing blocks concerning simplicity and safety, as well as the development of new regional anaesthesia techniques. In particular, the emergence of fascial plane blocks has further broadened the application of regional anaesthesia in the management of painful conditions of the thorax and abdomen. The preliminary results of investigations into these fascial plane blocks are promising but require further research to establish their true value and role in clinical care. One of the challenges that remains is how best to prolong regional anaesthesia to maximise its benefits while avoiding undue harm. There is ongoing research into optimising continuous catheter techniques and their management, intravenous and perineural pharmacological adjuncts, and sustained-release local anaesthetic molecules. Finally, there is a growing appreciation for the critical role that regional anaesthesia can play in an overall multimodal anaesthetic strategy. This is especially pertinent given the current focus on eliminating unnecessary peri-operative opioid administration.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/anae.14868

Advances in regional anaesthesia and acute pain management: a narrative review

BACKGROUND Improper use, storage, and disposal of prescribed opioids can lead to diversion or accidental poisoning. Our previous study showed a large proportion of cancer patients have unsafe opioid practices. Our objective was to determine whether an improvement occurred in the patterns of use, storage, and disposal of opioids among cancer outpatients after the implementation of a patient educational program. PATIENTS AND METHODS Our palliative care (PC) clinic provides every patient with educational material (EM) on safe opioid use, storage, and disposal every time they receive an opioid prescription. We prospectively assessed 300 adult cancer outpatients receiving opioids in our PC clinic, who had received the EM, and compared them with 300 patients who had not received the EM. The previously used surveys pertaining to opioid use, storage, and disposal were administered, and demographic information was collected. Sharing or losing their opioids was defined as unsafe use. RESULTS Patients who received EM were more aware of the proper opioid disposal methods (76% vs. 28%; p ≤ .0001), less likely to share their opioids with someone else (3% vs. 8%; p = .0311), less likely to practice unsafe use of opioids (18% vs. 25%; p = .0344), and more likely to be aware the danger of their opioids when taken by others (p = .0099). Patients who received the EM were less likely to have unused medication at home (38% vs. 47%; p = .0497) and more likely to keep their medications in a safe place (hidden, 75% vs. 70%; locked, 14% vs. 10%; p = .0025). CONCLUSION The use of EM on opioid safety for patients with advanced cancer was associated with improved patient-reported safe opioid use, storage, and disposal. The Oncologist 2017;22:115-121Implications for Practice: Prescription opioid abuse is a fast-growing epidemic that has become more prominent recently, even in the cancer pain population. A previous study reported that 26% of cancer outpatients seen in the supportive care center either lose their pain medications or share their pain medications with someone else. This study demonstrates that the implementation of an opioid educational program and distribution of educational material on opioid safety brings about an improvement in opioid storage, use, and disposal practices in patients being prescribed opioids for cancer-related pain. Our study highlights the importance of consistent and thorough opioid education at every instance in which opioids are prescribed.

The Impact of an Educational Program on Patient Practices for Safe Use, Storage, and Disposal of Opioids at a Comprehensive Cancer Center

Serratus anterior plane and pectoral nerves blocks are recently described alternatives to established regional anaesthesia techniques in cardiac surgery, thoracic surgery and trauma. We performed a systematic review to establish the current state of evidence for the analgesic role of these fascial plane blocks in these clinical settings. We identified relevant studies by searching multiple databases and trial registries from inception to June 2019. Study heterogeneity prevented meta-analysis and studies were instead qualitatively summarised and stratified by type of surgery and comparator. We identified 51 studies: nine randomised control trials; 13 cohort studies; 19 case series; and 10 case reports. The majority of randomised controlled trials studied the serratus anterior plane block in thoracotomy or video-assisted thoracoscopic surgery, with only two investigating pectoral nerves blocks. The evidence in thoracic trauma comprised only case series and reports. Results indicate that single-injection serratus anterior plane and the pectoral nerves blocks reduce pain scores and opioid consumption compared with systemic analgesia alone in cardiothoracic surgery, cardiac-related interventional procedures and chest trauma for approximately 6-12 h. The duration of action appears longer than intercostal nerve blocks but may be shorter than thoracic paravertebral blockade. Block duration may be prolonged by a continuous catheter technique with potentially similar results to thoracic epidural analgesia. There were no reported complications and the risk of haemodynamic instability appears to be low. The current evidence, though limited, supports the efficacy and safety of serratus anterior plane and the pectoral nerves blocks as analgesic options in cardiothoracic surgery.

The role of serratus anterior plane and pectoral nerves blocks in cardiac surgery, thoracic surgery and trauma: a qualitative systematic review

Ultrasound-guided fascial plane blocks of the chest wall are increasingly popular alternatives to established techniques such as thoracic epidural or paravertebral blockade, as they are simple to perform and have an appealing safety profile. Many different techniques have been described, which can be broadly categorised into anteromedial, anterolateral and posterior chest wall blocks. Understanding the relevant clinical anatomy is critical not only for block performance, but also to match block techniques appropriately with surgical procedures. The sensory innervation of tissues deep to the skin (e.g. muscles, ligaments and bone) can be overlooked, but is often a significant source of pain. The primary mechanism of action for these blocks is a conduction blockade of sensory afferents travelling in the targeted fascial planes, as well as of peripheral nociceptors in the surrounding tissues. A systemic action of absorbed local anaesthetic is plausible but unlikely to be a major contributor. The current evidence for their clinical applications indicates that certain chest wall techniques provide significant benefit in breast and thoracic surgery, similar to that provided by thoracic paravertebral blockade. Their role in trauma and cardiac surgery is evolving and holds great potential. Further avenues of research into these versatile techniques include: optimal local anaesthetic dosing strategies; high-quality randomised controlled trials focusing on patient-centred outcomes beyond acute pain; and comparative studies to determine which of the myriad blocks currently on offer should be core competencies in anaesthetic practice.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/pdf/10.1111/anae.15276

Ultrasound-guided fascial plane blocks of the chest wall: a state-of-the-art review.

Purpose Half of postoperative patients are prescribed an opioid, but a majority do not store or dispose of them properly thus risking diversion. We examined the efficacy of an opioid educational pamphlet addressing opioid weaning, storage, and disposal. We hypothesized that the pamphlet would increase the rate of proper opioid disposal, storage, and weaning. Methods This prospective before and after study was conducted at UBC Hospital in primary total hip or knee arthroplasty patients. Adults with American Society of Anesthesiologists physical class I-III, with no addiction history and consuming B 30 mg of morphine equivalents daily were enrolled in the study. Two groups received similar standard management, except the intervention group additionally received the opioid education pamphlet. Patients were contacted four weeks postoperatively to complete a survey. The primary endpoint was to evaluate proper opioid disposal rates. Secondary endpoints were to evaluate opioid storage and weaning rates. Results Two hundred twenty-six patients were enrolled and 172 (76%) completed the survey. Among patients who had discontinued opioids, rates of proper disposal increased from 2/42 (5%) to 12/45 (27%) in those receiving the pamphlet (difference in proportions, 22%; 95% confidence interval (CI), 5 to 38; P = 0.005). Secure opioid storage did not improve in those receiving the opioid pamphlet [before, 18/86 (21%) vs after, 20/86 (23%); difference in proportions, 3%; 95% CI, -11 to 15; P = 0.713]. The proportion of patients weaned from opioids was unchanged by the pamphlet [before, 42/86 (49%) vs after, 45/86 (52%); P = 0.735].

/pdf/opioid-information-pamphlet-increases-postoperative-opioid-4zt50ugu6n.pdf

Opioid information pamphlet increases postoperative opioid disposal rates: a before versus after quality improvement study Un depliant d'information sur les opioõ ¨des augmente leur taux d'elimination postoperatoire: une etude avant et apres d'amelioration de la qualite ´

To the Editor, Serratus anterior plane (SAP) blocks provide effective analgesia in patients with antero-lateral rib fractures but are reportedly ineffective for posterior rib fractures. Serratus anterior plane injections consistently result in local anesthetic spread to lateral cutaneous branches of intercostal nerves that innervate the superficial anterolateral chest wall, but were thought to spare the intercostal nerves that supply the posterior rib periosteum and intercostal muscles. Nevertheless, a recent cadaver study showed that, in the traumatized hemithorax, SAP injectate consistently reaches multiple intercostal nerves and spreads more posteriorly, reaching the medial border of the scapula. This study helps elucidate the mechanism of SAP block analgesia in rib fractures and provides an anatomical explanation for analgesia of posterior rib fractures. At our institution, we have developed a protocol for early thoracic epidural or paravertebral analgesia to prevent pain-related pulmonary complications in rib fracture patients. We have recently begun offering SAP blocks as a safe alternative for patients with contraindications to epidural or paravertebral techniques regardless of rib fracture location. Herein, we present five consecutive patients with isolated posterior rib fractures managed with a SAP catheter that reflect clinical outcomes consistent with the cadaveric findings. Written consent for this report was obtained from all patients. All five patients were admitted to our institutional trauma service with isolated posterior rib fractures. Each was assessed by the acute pain service, found to have contraindications to thoracic epidural and paravertebral block, and offered a SAP catheter. After informed consent, patients were positioned supine for SAP block insertion. The mid-axillary point of the middle-fractured rib was approached anterior-to-posterior using ultrasound guidance, and a 17G 80-mm Tuohy needle was advanced deep to the serratus anterior muscle. After hydrodissection of the plane between the serratus anterior and the rib periosteum with 5 mL of normal saline, 20 mL ropivacaine 0.5% with epinephrine 1:400,000 was injected. A 19G catheter was then inserted and an additional 10–20 mL solution was injected through the catheter, based on patient mass. Ropivacaine 0.2% was then infused at 5 mL hr with an 8-mL patient-controlled bolus set to a 30-min lockout. In each case, patients achieved reduced pain with inspiration and rib palpation within 30 min of local anesthetic administration. All patients reported reduced pain scores and had reduced daily opioid consumption in the 72 hr after SAP block insertion. In case 2, the SAP catheter was dislodged and discontinued 48 hr after insertion; otherwise there were no catheter-related complications. Clinical outcomes are summarized in the Figure. Our cases suggest SAP blocks, as described above, provide a simple, safe, effective, opioid-sparing analgesic option for patients with rib fracture pain regardless of anterior or posterior fracture location. The current opioid crisis calls for opioid-sparing analgesic strategies. SAP P. Rose, MD (&) R. Ramlogan, MD T. Sullivan, MD A. Lui, MD Department of Anesthesiology, The Ottawa Hospital, Ottawa, Canada e-mail: peter14rose@hotmail.com

/pdf/serratus-anterior-plane-blocks-provide-opioid-sparing-48olu8jz88.pdf

Serratus anterior plane blocks provide opioid-sparing analgesia in patients with isolated posterior rib fractures: a case series.

The ultrasound-guided midpoint transverse process to pleura block has been described as an alternative end-point for thoracic paravertebral blockade. Although originally described as a single-level block, midpoint transverse process to pleura blockade may cover more than one level when larger volumes of injectate are used. Moreover, a continuous catheter midpoint transverse process to pleura blockade technique was previously thought to be unfeasible. We report three cases where a midpoint transverse process to pleura continuous catheter technique was successfully used for postoperative analgesia following video-assisted thoracoscopic surgery.

/pdf/midpoint-transverse-process-to-pleura-catheter-placement-for-31jyqdk1na.pdf

Midpoint transverse process to pleura catheter placement for postoperative analgesia following video-assisted thoracoscopic surgery.

https://link.springer.com/content/pdf/10.1007/s12630-022-02208-1.pdf

Airway management in a patient with a traumatic retropharyngeal hematoma causing airway compromise

Novel cause of hypoxemia and difficult bag-mask ventilation in a patient with nasocutaneous fistula.

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