Regional anesthesia has been considered a great tool for maximizing post-operative pain control while minimizing opioid consumption. Post-operative rebound pain, characterized by hyperalgesia after the peripheral nerve block, can however diminish or negate the overall benefit of this modality due to a counter-productive increase in opioid consumption once the block wears off. We reviewed published literature describing pathophysiology and occurrence of rebound pain after peripheral nerve blocks in patients undergoing orthopedic procedures. A search of relevant keywords was performed using PubMed, EMBASE, and Web of Science. Twenty-eight articles (n = 28) were included in our review. Perioperative considerations for peripheral nerve blocks and other alternatives used for postoperative pain management in patients undergoing orthopedic surgeries were discussed. Multimodal strategies including preemptive analgesia before the block wears off, intra-articular or intravenous anti-inflammatory medications, and use of adjuvants in nerve block solutions may reduce the burden of rebound pain. Additionally, patient education regarding the possibility of rebound pain is paramount to ensure appropriate use of prescribed pre-emptive analgesics and establish appropriate expectations of minimized opioid requirements. Understanding the impact of rebound pain and strategies to prevent it is integral to effective utilization of regional anesthesia to reduce negative consequences associated with long-term opioid consumption.

Lung transplant recipients are at particular high risk for postoperative respiratory failure as a result of poorly controlled pain, inadequate graft expansion, decreased cough, and reliance on systemic opioid therapy. Thoracic epidural and paravertebral blocks have been employed with the goal of improving postoperative pain control, improving pulmonary mechanics, and limiting the need for narcotic administration. These approaches require a needle position in proximity to the neuraxis and may cause significant hypotension that is poorly tolerated in transplant patients. Additionally, the use of anticoagulation or underlying clotting disorder limits the use of these regional blocks because of the concern of hematoma and subsequent neurologic injury. Ultrasound-guided continuous erector spinae plane (ESP) block has been shown to be efficacious for pain control following thoracotomy but has had minimal investigations following lung transplantation. In this study, we describe the effective use of a continuous erector spinae plane block to provide analgesia in a postoperative lung transplant recipient receiving systemic anticoagulation. The use of an ESP block with a more superficial needle tract that is further removed from the neuraxis allowed for a greater safety profile while providing efficacious pain control, decreased reliance on systemic narcotics, and improved oxygen saturation. The ESP block was effective in this case and thus may be a valuable alternative following lung transplantation for patients who are not candidates for thoracic epidural or paravertebral approaches.

Background: Intrathecal (IT) clonidine has been observed to reduce 24-hour opioid requirements and time to first analgesic request after cesarean delivery, but has not been specifically studied in patients with opioid use disorder (OUD). Methods: Patients with OUD undergoing cesarean delivery under spinal or combined spinal-epidural (CSE) anesthesia at our institution from 2011 to 2020 were identified, and only patients with OUD were included in this study. Subjects that received IT clonidine were compared to a control group that did not receive IT clonidine to observe potential differences in analgesic outcomes (24-hour opioid requirements, pain scores and time to first post-operative pain medication) or side-effects (hypotension, vasopressor dosing and bradycardia). Results: A total of 160 patients were included (clonidine n = 22, controls n = 138). For the clonidine group, the median IT clonidine dose was 30μg. Clonidine group patients were observed to have greater dose of IT bupivacaine (12 vs 12.75mg; p = 0.01) and IT morphine (100 vs 200μg; p < 0.001). The clonidine group was also observed to have greater incidence of intraoperative hypotension (20% vs 45%; p = 0.01) and maximum phenylephrine dose (50 vs 57.5 μg/min; p < 0.001). The time to first analgesic request (minutes) after surgery was significantly longer for the clonidine group (153.5 vs 207 min; p < 0.001). The average oral oxycodone equivalents taken per 24 hours of hospital admission were significantly less in the clonidine group (82.36 vs 41.67mg; p < 0.001), and the clonidine group also had significantly less oxycodone equivalents taken for each post-operative day. Conclusion: IT clonidine was observed to result in reduced 24-hour opioid consumption in patients with OUD and may be useful as part of a multimodal analgesic regimen. The incidence of hypotension and vasopressor doses were greater in patients receiving IT clonidine, and this should be anticipated if IT clonidine is being administered.

Background: Despite the increasing prevalence of opioid use disorder (OUD) in pregnant women, there are limited studies on their anesthesia care and analgesic outcomes after cesarean delivery (CD). Methods: Patients with OUD on either buprenorphine or methadone maintenance therapy who underwent CD at our institution from 2011 to 2018 were identified. Anesthetic details and analgesic outcomes, including daily opioid consumption and pain scores, were compared between patients maintained on buprenorphine and methadone. Analgesic outcomes were also evaluated according to anesthetic type (neuraxial or general anesthesia) and daily buprenorphine/methadone dose to determine if these factors impacted pain after delivery. Results: A total of 146 patients were included (buprenorphine n=99 (67.8%), methadone n=47 (32.2%)). Among all patients: 74% had spinal/CSE, 15% epidural, and 11% general anesthesia. Anesthesia types were similar among buprenorphine and methadone patients. For spinal anesthetics, intrathecal fentanyl (median 15 μg) and morphine (median 100 μg) were commonly given (97.2% and 96.3%, respectively), and dosed similarly between groups. Among epidural anesthetics, epidural morphine (median 2 mg) was commonly administered (90.9%), while fentanyl (median 100 μg) was less common (54.5%). Buprenorphine and methadone groups consumed similar amounts of oxycodone equivalents per 24 hours of hospitalization (80.6 vs 76.3 mg; p=0.694) and had similar peak pain scores (8.3 vs 8.0; p=0.518). Daily methadone dose correlated weakly with opioid consumption (R=0.3; p=0.03), although buprenorphine dose did not correlate with opioid consumption or pain scores. General anesthesia correlated with greater oxycodone consumption in the first 24 hours (median 156.1 vs 91.7 mg; p=0.004) and greater IV PCA use (63% vs 7%; p< 0.001) compared to neuraxial anesthesia. Conclusion: Patients on buprenorphine and methadone had similar high opioid consumption and pain scores after CD. The anesthetic details and analgesic outcomes reported in this investigation may serve as a useful reference for future prospective investigations and aid in the clinical care of these patients.

Anesthesiologists and surgeons have demonstrated a lack of familiarity with professional guidelines when providing care for surgical patients with a do-not-resuscitate (DNR) order. This substantially infringes on patient's self-autonomy; therefore, leading to substandard care particularly for palliative surgical procedures. The interventional nature of surgical procedures may create a different mentality of surgical “buy-in,” that may unintentionally prioritize survivability over maintaining patient self-autonomy. While previous literature has demonstrated gains in communication skills with simulation training, no specific educational curriculum has been proposed to specifically address perioperative code status discussions. We designed a simulated standardized patient actor (SPA) encounter at the beginning of post-graduate year (PGY) 2, corresponding to the initiation of anesthesiology specific training, allowing residents to focus on the perioperative discussion in relation to the SPA's DNR order. Forty four anesthesiology residents volunteered to participate in the study. PGY-2 group (n = 17) completed an immediate post-intervention assessment, while PGY-3 group (n = 13) completed the assessment approximately 1 year after the educational initiative to ascertain retention. PGY-4 residents (n = 14) did not undergo any specific educational intervention on the topic, but were given the same assessment. The assessment consisted of an anonymized survey that examined familiarity with professional guidelines and hospital policies in relation to perioperative DNR orders. Subsequently, survey responses were compared between classes. Study participants that had not participated in the educational intervention reported a lack of prior formalized instruction on caring for intraoperative DNR patients. Second and third year residents outperformed senior residents in being aware of the professional guidelines that detail perioperative code status decision-making (47%, 62% vs 21%, P = .004). PGY-3 residents outperformed PGY-4 residents in correctly identifying a commonly held misconception that institutional policies allow for automatic perioperative DNR suspensions (85% vs 43%; P = .02). Residents from the PGY-3 class, who were 1 year removed the educational intervention while gaining 1 additional year of clinical anesthesiology training, consistently outperformed more senior residents who never received the intervention. Our training model for code-status training with anesthesiology residents showed significant gains. The best results were achieved when combining clinical experience with focused educational training.

Introduction: Hip arthroscopy is commonly performed as an outpatient procedure and effective postoperative pain management is important to provide quality patient care and enable timely discharge. Multiple regional nerve blocks have been described for pain relief after hip arthroscopy, but there is no consensus on the optimal technique. This retrospective investigation aimed to compare quadratus lumborum (QL) and pericapsular nerve group (PENG) blocks to determine if there are differences in analgesic outcomes after outpatient hip arthroscopy. Methods: A total of 50 consecutive patients that received QL block and 50 that received PENG block for outpatient hip arthroscopy were identified and compared to determine if there were any differences in the primary outcome of total perioperative opioid consumption prior to discharge from the surgery center. Important secondary analgesic outcomes include postoperative opioid consumption, verbal rating scale (VRS) pain scores or total time in the recovery area. Summary statistics of relevant variables are compared and reported between study groups (QL versus PENG). Results: For QL and PENG groups, no significant differences were observed in total perioperative oral morphine equivalents (OME) (69.5 vs 60mg; p=0.40), postoperative OME (15 vs 15.3mg; p=0.96) or maximum pain scores in the recovery area (7.0 vs 6.0; p=0.41). Postoperatively, QL block patients were in PACU for a greater length of time after surgery than PENG block patients (89.5 vs 72 minutes; p< 0.001). No patients had uncontrolled pain requiring emergency room visits or hospital admission within 24 hours. No neurologic complications or instances of motor weakness were reported after QL or PENG blocks. Conclusion: This retrospective study observed similar opioid requirements and pain scores for patients receiving QL versus PENG block for hip arthroscopy, though PENG block patients had shorter times in the recovery area. Prospective, controlled trials are required to further explore and confirm these findings.