Edward R. Mariano, MD, MAS, FASA, FASRA

All Publications

• Trends in person-centered language use in the journal regional anesthesia and pain medicine: an analysis of article titles from 2010 to 2023. Regional anesthesia and pain medicine Ye, M., Hunter, O. O., Kou, A., Mariano, E. R. 2024

  View details for DOI 10.1136/rapm-2024-106150

  View details for PubMedID 39667796

• Educating the next generation: Unprofessionalism in anesthesiology residency programs. Journal of clinical anesthesia Dhanani, U. M., Leng, J. C., Mariano, E. R. 2024; 99: 111578

  View details for DOI 10.1016/j.jclinane.2024.111578

  View details for PubMedID 39243530

• The controversy of pre-operative opioid tapering and an opportunity to advance personalised, patient-centred pain medicine. Anaesthesia Kelly, D. N., Mariano, E. R., Jaremko, K. M. 2024

  View details for DOI 10.1111/anae.16412

  View details for PubMedID 39145921

• Concepts and Approaches in the Management of Transgender and Gender-Diverse Patients. Mayo Clinic proceedings Strand, N., Gomez, D. A., Kacel, E. L., Morrison, E. J., St Amand, C. M., Vencill, J. A., Pagan-Rosado, R., Lorenzo, A., Gonzalez, C., Mariano, E. R., Reece-Nguyen, T., Narouze, S., Mahdi, L., Chadwick, A. L., Kraus, M., Bechtle, A., Kling, J. M. 2024; 99 (7): 1114-1126

  Abstract

  The terms transgender and gender diverse (TGD) describe persons whose gender is different from the sex assigned to them at birth. While TGD persons have experienced a rise in cultural and social visibility in recent decades, they continue to experience significant health inequities, including adverse health outcomes and multiple barriers to accessing medical care. Transgender and gender-diverse persons are at a higher risk for pain conditions than their cisgender counterparts, but research on chronic pain management for TGD persons is lacking. Clinicians from all disciplines must be informed of best practices for managing chronic pain in the TGD population. This includes all aspects of care including history, physical examination, diagnosis, treatment, and perioperative management. Many TGD persons report delaying or avoiding care because of negative interactions with medical practitioners who do not have sufficient training in navigating the specific health care needs of TGD patients. Furthermore, TGD persons who do seek care are often forced to educate their practitioners on their specific health care needs. This paper provides an overview of existing knowledge and recommendations for physicians to provide culturally and medically appropriate care for TGD persons.

  View details for DOI 10.1016/j.mayocp.2023.12.027

  View details for PubMedID 38960496

• Unwarranted variation in perioperative pain management for pediatric anterior cruciate ligament reconstruction: a call to improve the quality of quality improvement. Regional anesthesia and pain medicine Soffin, E. M., Abdallah, F. W., Mariano, E. R. 2024

  View details for DOI 10.1136/rapm-2024-105637

  View details for PubMedID 38925709

• Heartfelt Healing: Charting New Trajectories in Postsurgical Pain. Anesthesia and analgesia Vanneman, M. W., Kiwakyou, L. M., Harrison, T. K., Mariano, E. R. 2024; 138 (6): 1187-1191

  View details for DOI 10.1213/ANE.0000000000006871

  View details for PubMedID 38771601

• A pilot project to test the feasibility of automated text messaging to collect multi-day patient-reported outcomes related to pain interference after total joint arthroplasty in veterans. Anaesthesia Dorogi, A. H., Hunter, O. O., Gessner, D. M., Leng, J. C., Kou, A., Mariano, E. R. 2024

  View details for DOI 10.1111/anae.16311

  View details for PubMedID 38714498

• Association between Anesthesia Group Size and Merit-Based Incentive Payment System Scores. Anesthesiology Sekeres, G., Miller, T. R., Mariano, E. R., Glance, L. G., Sun, E. C. 2024; 140 (4): 853-855

  View details for DOI 10.1097/ALN.0000000000004887

  View details for PubMedID 38470114

• Smallest Clinically Meaningful Improvement in Amputation-Related Pain and Brief Pain Inventory Scores as Defined by Patient Reports of Global Improvement After Cryoneurolysis: a Retrospective Analysis of a Randomized, Controlled Clinical Trial. Anesthesia and analgesia Ilfeld, B. M., Smith, C. R., Turan, A., Mariano, E. R., Miller, M. E., Fisher, R. L., Trescot, A. M., Cohen, S. P., Eisenach, J. C., Sessler, D. I., Prologo, J. D., Mascha, E. J., Liu, L., Gabriel, R. A. 2024

  Abstract

  The smallest meaningful improvement in pain scores (minimal clinically important difference [MCID]) after an analgesic intervention is essential information when both interpreting published data and designing a clinical trial. However, limited information is available for patients with chronic pain conditions, and what is published is derived from studies involving pharmacologic and psychological interventions. We here calculate these values based on data collected from 144 participants of a previously published multicenter clinical trial investigating the effects of a single treatment with percutaneous cryoneurolysis.In the original trial, we enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis, who had no subsequent participant interaction. At both baseline and 4 months (primary end point), participants rated their phantom limb pain based on a numeric rating scale (NRS) and their interference of pain on physical and emotional functioning as measured with the Brief Pain Inventory's interference subscale. They subsequently qualitatively defined the change using the 7-point ordinal Patient Global Impression of Change (PGIC). The smallest clinically meaningful improvements in phantom limb pain and Brief Pain Inventory scores were calculated using an anchor-based method based on the PGIC.The median (interquartile range [IQR]) phantom pain NRS (0-10) improvements at 4 months considered small, medium, and large were 1 [1-1], 3 [3-4], and 4 [3-6], respectively. The median improvements in the Brief Pain Inventory interference subscale (0-70) associated with a small, medium, and large analgesic changes were 16 [6-18], 24 [22-31], and 34 [22-46]. The proportions of patients that experienced PGIC ≥5 were 33% and 36% in the active and placebo groups, respectively. The relative risk of a patient experiencing PGIC ≥5 in the active group compared to the sham group with 95% confidence interval was 0.9 (0.6-1.4), P = .667.Amputees with phantom limb pain treated with percutaneous cryoneurolysis rate analgesic improvements as clinically meaningful similar to pharmacologic treatments, although their MCID for the Brief Pain Inventory was somewhat larger than previously published values. This information on patient-defined clinically meaningful improvements will facilitate interpretation of available studies and guide future trial design.

  View details for DOI 10.1213/ANE.0000000000006833

  View details for PubMedID 38478876

• Opioid use in cancer patients compared with non-cancer pain patients in a veterans population. JNCI cancer spectrum Mudumbai, S. C., He, H., Chen, J. Q., Kapoor, A., Regala, S., Mariano, E. R., Stafford, R. S., Abnet, C. C., Pfeiffer, R. M., Freedman, N. D., Etemadi, A. 2024

  Abstract

  Opioid safety initiatives may secondarily impact opioid prescribing and pain outcomes for cancer care.We reviewed electronic health record data at a tertiary Veterans Affairs system (VA Palo Alto) for all patients from 2015-2021. We collected outpatient Schedule II opioid prescriptions data and calculated morphine milligram equivalents (MMEs) using CDC conversion formulas. To determine the clinical impact of changes in opioid prescription, we used the highest level of pain reported by each patient on the 0 to 10 Numeric Rating Scale (NRS) in each year, categorized into mild (0-3), moderate (4-6), and severe (7 and above).Among 89,569 patients, 9073 had a cancer diagnosis. Cancer patients were almost twice as likely to have an opioid prescription compared with non-cancer patients (69.0% vs 36.7%, respectively). The proportion of patients who received an opioid prescription decreased from 27.1% to 18.1% (trend p < .01) in cancer patients, and from 17.0% to 10.2% in non-cancer patients (trend p < .01). Cancer and non-cancer patients had similar declines of MMEs per year between 2015 and 2019, but the decline was more rapid for cancer patients (1462.5 to 946.4, 35.3%) compared to non-cancer patients (1315.6 to 927.7, 29.5%) from 2019-2021. During the study period, the proportion of non-cancer patients who experienced severe pain was almost unchanged, while it increased among cancer patients, reaching a significantly higher rate than among non-cancer patients in 2021 (31.9% vs 27.4%, p < .01).Our findings suggest potential unintended consequences for cancer care due to efforts to manage opioid-related risks.

  View details for DOI 10.1093/jncics/pkae012

  View details for PubMedID 38457606

• How to conduct and report guidelines and position, best practice and consensus statements. Anaesthesia Wiles, M. D., El-Boghdadly, K., Mariano, E. R. 2024

  View details for DOI 10.1111/anae.16260

  View details for PubMedID 38369594

• The Professional Use of Social Media in Anesthesiology: Developing a Digital Presence Is as Easy as ABCDE. Anesthesia and analgesia Kirpekar, M., Kars, M. S., Mariano, E. R., Patel, A. 2024

  View details for DOI 10.1213/ANE.0000000000006612

  View details for PubMedID 38367248

• Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of upper and lower limb nerve blocks. Regional anesthesia and pain medicine El-Boghdadly, K., Albrecht, E., Wolmarans, M., Mariano, E. R., Kopp, S., Perlas, A., Thottungal, A., Gadsden, J., Tulgar, S., Adhikary, S., Aguirre, J., Agur, A. M., Altıparmak, B., Barrington, M. J., Bedforth, N., Blanco, R., Bloc, S., Boretsky, K., Bowness, J., Breebaart, M., Burckett-St Laurent, D., Carvalho, B., Chelly, J. E., Chin, K. J., Chuan, A., Coppens, S., Costache, I., Dam, M., Desmet, M., Dhir, S., Egeler, C., Elsharkawy, H., Bendtsen, T. F., Fox, B., Franco, C. D., Gautier, P. E., Grant, S. A., Grape, S., Guheen, C., Harbell, M. W., Hebbard, P., Hernandez, N., Hogg, R. M., Holtz, M., Ihnatsenka, B., Ilfeld, B. M., Ip, V. H., Johnson, R. L., Kalagara, H., Kessler, P., Kwofie, M. K., Le-Wendling, L., Lirk, P., Lobo, C., Ludwin, D., Macfarlane, A. J., Makris, A., McCartney, C., McDonnell, J., McLeod, G. A., Memtsoudis, S. G., Merjavy, P., Moran, E. M., Nader, A., Neal, J. M., Niazi, A. U., Njathi-Ori, C., O'Donnell, B. D., Oldman, M., Orebaugh, S. L., Parras, T., Pawa, A., Peng, P., Porter, S., Pulos, B. P., Sala-Blanch, X., Saporito, A., Sauter, A. R., Schwenk, E. S., Sebastian, M. P., Sidhu, N., Sinha, S. K., Soffin, E. M., Stimpson, J., Tang, R., Tsui, B. C., Turbitt, L., Uppal, V., van Geffen, G. J., Vermeylen, K., Vlassakov, K., Volk, T., Xu, J. L., Elkassabany, N. M. 2023

  Abstract

  Inconsistent nomenclature and anatomical descriptions of regional anesthetic techniques hinder scientific communication and engender confusion; this in turn has implications for research, education and clinical implementation of regional anesthesia. Having produced standardized nomenclature for abdominal wall, paraspinal and chest wall regional anesthetic techniques, we aimed to similarly do so for upper and lower limb peripheral nerve blocks.We performed a three-round Delphi international consensus study to generate standardized names and anatomical descriptions of upper and lower limb regional anesthetic techniques. A long list of names and anatomical description of blocks of upper and lower extremities was produced by the members of the steering committee. Subsequently, two rounds of anonymized voting and commenting were followed by a third virtual round table to secure consensus for items that remained outstanding after the first and second rounds. As with previous methodology, strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement.A total of 94, 91 and 65 collaborators participated in the first, second and third rounds, respectively. We achieved strong consensus for 38 names and 33 anatomical descriptions, and weak consensus for five anatomical descriptions. We agreed on a template for naming peripheral nerve blocks based on the name of the nerve and the anatomical location of the blockade and identified several areas for future research.We achieved consensus on nomenclature and anatomical descriptions of regional anesthetic techniques for upper and lower limb nerve blocks, and recommend using this framework in clinical and academic practice. This should improve research, teaching and learning of regional anesthesia to eventually improve patient care.

  View details for DOI 10.1136/rapm-2023-104884

  View details for PubMedID 38050174

• Perioperative Opioid Management Strategies: Do They Make a Difference in Long-Term Health Outcomes? CURRENT ANESTHESIOLOGY REPORTS Ye, Y., Li, G., Mariano, E. R. 2023

  View details for DOI 10.1007/s40140-023-00589-7

  View details for Web of Science ID 001100487600001

• Association of Patient Race and Hospital with Utilization of Regional Anesthesia for Treatment of Post-Operative Pain in Total Knee Arthroplasty: A Retrospective Analysis Using Medicare Claims. Anesthesiology Dixit, A. A., Sekeres, G., Mariano, E. R., Memtsoudis, S. G., Sun, E. C. 2023

  Abstract

  Regional anesthesia for total knee arthroplasty has been deemed high priority by national and international societies and its use can serve as a measure of healthcare equity. We estimated the association between utilization of regional anesthesia for postoperative pain and 1) race and 2) hospital in patients undergoing total knee arthroplasty. We hypothesized that Black patients would be less likely than White patients to receive regional anesthesia, and that variability in regional anesthesia would more likely be attributable to the hospital where surgery occurred than race.We used Medicare fee-for-service claims for patients aged 65 or older who underwent primary total knee arthroplasty between 1/1/2011 and 12/31/2016. Our primary outcome was administration of regional anesthesia for postoperative pain, defined as any peripheral (femoral, lumbar plexus, or other) or neuraxial (spinal or epidural) block. Our primary exposure was self-reported race (Black, White, or Other). We defined clinical significance as a relative difference of 10% in regional anesthesia administration.Data from 733,406 cases across 2,507 hospitals were analyzed: 90.7% of patients were identified as White, 4.7% as Black, and 4.6% as Other. Median hospital-level prevalence of use of regional anesthesia was 51% (interquartile range 18-79%). Black patients did not have a statistically different probability of receiving a regional anesthetic compared to White patients (adjusted estimates: Black 53.3%, 95% CI 52.5-54.1%; White 52.7%, 95% CI 52.4-54.1%, p=0.132). Findings were robust to alternate specifications of the exposure and outcome. Analysis-of-variance revealed that 42.0% of the variation in block administration was attributable to hospital, compared to less than 0.01% to race, after adjusting for other patient-level confounders.Race was not associated with administration of regional anesthesia in Medicare patients undergoing primary total knee arthroplasty. Variation in the use of regional anesthesia was primarily associated with the hospital where surgery occurred.

  View details for DOI 10.1097/ALN.0000000000004827

  View details for PubMedID 37910860

• Non-steroidal anti-inflammatory drugs in the perioperative period. BJA education Halvey, E. J., Haslam, N., Mariano, E. R. 2023; 23 (11): 440-447

  View details for DOI 10.1016/j.bjae.2023.08.001

  View details for PubMedID 37876761

  View details for PubMedCentralID PMC10591119

• Opioid stewardship. BJA education Simpson, A. K., Levy, N., Mariano, E. R. 2023; 23 (10): 389-397

  View details for DOI 10.1016/j.bjae.2023.05.007

  View details for PubMedID 37720559

• More Than a Perioperative Surgical Home: An Opportunity for Anesthesiologists to Advance Public Health. Seminars in cardiothoracic and vascular anesthesia Coffman, C. R., Leng, J. C., Ye, Y., Hunter, O. O., Walters, T. L., Wang, R., Wong, J. K., Mudumbai, S. C., Mariano, E. R. 2023: 10892532231200620

  Abstract

  Public health and the medical specialty of anesthesiology have been closely intertwined throughout history, dating back to the 1800s when Dr. John Snow used contact tracing methods to identify the Broad Street Pump as the source of a cholera outbreak in London. During the COVID-19 pandemic, leaders in anesthesiology and anesthesia patient safety came forward to develop swift recommendations in the face of rapidly changing evidence to help protect patients and healthcare workers. While these high-profile examples may seem like uncommon events, there are many common modern-day public health issues that regularly intersect with anesthesiology and surgery. These include, but are not limited to, smoking; chronic opioid use and opioid use disorder; and obstructive sleep apnea. As an evolving medical specialty that encompasses pre- and postoperative care and acute and chronic pain management, anesthesiologists are uniquely positioned to improve patient care and outcomes and promote long-lasting behavioral changes to improve overall health. In this article, we make the case for advancing the role of the anesthesiologist beyond the original perioperative surgical home model into promoting public health initiatives within the perioperative period.

  View details for DOI 10.1177/10892532231200620

  View details for PubMedID 37679298

• Analysis of Twitter conversations in obstetric anesthesiology using the hashtag #OBAnes during the onset of the COVID-19 pandemic. International journal of obstetric anesthesia Robinson, A., George, R. B., Lim, G., Landau, R., Mariano, E. R., Kou, A., Sharpe, E. E. 2023: 103918

  Abstract

  BACKGROUND: #OBAnes is the most used hashtag in obstetric anesthesiology. The primary objective of the study was to characterize #OBAnes tweets at the onset of the COVID-19 pandemic.METHODS: Observational study of all tweets using #OBAnes between June 30, 2019 and October 19, 2020. A list of 19 topics was compiled to categorize each tweet. All Twitter users were manually assigned into one of 19 Symplur Healthcare Stakeholder categories.RESULTS: There were 12 431 tweets with #OBAnes during the study period, posted by 1704 unique users. The top user category was Doctor (n = 1211, 71%) with 9665 (78%) tweets. The top three topics identified within Twitter conversations were neuraxial anesthesia, COVID-19, and general anesthesia.CONCLUSIONS: Twitter facilitated thousands of obstetric anesthesia-related discussions during the onset of the COVID-19 pandemic, with most conversations centering on anesthesia type (neuraxial or general anesthesia).

  View details for DOI 10.1016/j.ijoa.2023.103918

  View details for PubMedID 37625986

• Barriers to Implementation of Telehealth Pre-anesthesia Evaluation Visits in the Department of Veterans Affairs. Federal practitioner : for the health care professionals of the VA, DoD, and PHS Barbeito, A., Raghunathan, K., Connolly, S., Mariano, E. R., Blitz, J., Stafford, R. S., Mudumbai, S. 2023; 40 (7): 210-217a

  Abstract

  Evaluations are conducted days or weeks before a scheduled surgical or invasive procedure involving anesthesia to assess patients' preprocedure condition and risk, optimize status, and prepare them for their procedure. The traditional pre-anesthesia evaluation is conducted in person, although telehealth modalities have been used for several years and have accelerated since the advent of the COVID-19 pandemic.We surveyed 109 anesthesiology services to understand the barriers and facilitators to the adoption of telephone- and video-based pre-anesthesia evaluation visits within the US Department of Veterans Affairs (VA).The analysis included 55 responses from 50 facilities. Twenty-two facilities reported using both telephone and video, 11 telephone only, 5 video only, and 12 none of these modalities. For telehealth users, the ability to obtain a history of present illness, the ability to assess for comorbidities, and assess for health habits were rated highest while assessing nutritional status was lowest. Among nonusers of telehealth modalities, barriers to adoption included the inability to perform a physical examination and the inability to obtain vital signs. Respondents not using telephone cited concerns about safety, while respondents not using video also cited lack of information technology and staff support and patient-level barriers.We found no significant perceived advantages of video over telephone in the ability to conduct routine pre-anesthesia evaluations except for the perceived ability to assess nutritional status. Clinicians with no telehealth experience cited the inability to perform a physical examination and obtain vital signs as the most significant barriers to implementation. Future work should focus on delineating the most appropriate and valuable uses of telehealth for pre-anesthesia evaluation and/or optimization.

  View details for DOI 10.12788/fp.0387

  View details for PubMedID 37868714

  View details for PubMedCentralID PMC10588996

• How large language models can augment perioperative medicine: a daring discourse. Regional anesthesia and pain medicine Gabriel, R. A., Mariano, E. R., McAuley, J., Wu, C. L. 2023

  Abstract

  Interest in natural language processing, specifically large language models, for clinical applications has exploded in a matter of several months since the introduction of ChatGPT. Large language models are powerful and impressive. It is important that we understand the strengths and limitations of this rapidly evolving technology so that we can brainstorm its future potential in perioperative medicine. In this daring discourse, we discuss the issues with these large language models and how we should proactively think about how to leverage these models into practice to improve patient care, rather than worry that it may take over clinical decision-making. We review three potential major areas in which it may be used to benefit perioperative medicine: (1) clinical decision support and surveillance tools, (2) improved aggregation and analysis of research data related to large retrospective studies and application in predictive modeling, and (3) optimized documentation for quality measurement, monitoring and billing compliance. These large language models are here to stay and, as perioperative providers, we can either adapt to this technology or be curtailed by those who learn to use it well.

  View details for DOI 10.1136/rapm-2023-104637

  View details for PubMedID 37336616

• Addition of dexamethasone to prolong peripheral nerve blocks: a ChatGPT-created narrative review. Regional anesthesia and pain medicine Wu, C. L., Cho, B., Gabriel, R., Hurley, R., Liu, J., Mariano, E. R., Mathur, V., Memtsoudis, S. G., Grant, M. C. 2023

  Abstract

  Chat Generative Pre-trained Transformer (ChatGPT), an artificial intelligence chatbot, produces detailed responses and human-like coherent answers, and has been used in the clinical and academic medicine. To evaluate its accuracy in regional anesthesia topics, we produced a ChatGPT review on the addition of dexamethasone to prolong peripheral nerve blocks. A group of experts in regional anesthesia and pain medicine were invited to help shape the topic to be studied, refine the questions entered in to the ChatGPT program, vet the manuscript for accuracy, and create a commentary on the article. Although ChatGPT produced an adequate summary of the topic for a general medical or lay audience, the review that were created appeared to be inadequate for a subspecialty audience as the expert authors. Major concerns raised by the authors included the poor search methodology, poor organization/lack of flow, inaccuracies/omissions of text or references, and lack of novelty. At this time, we do not believe ChatGPT is able to replace human experts and is extremely limited in providing original, creative solutions/ideas and interpreting data for a subspecialty medical review article.

  View details for DOI 10.1136/rapm-2023-104646

  View details for PubMedID 37295794

• National review of acute pain service utilization, models of care, and clinical practices within the Veterans Health Administration. Regional anesthesia and pain medicine Mahyar, L., Missair, A., Buys, M. J., Kou, A., Benedetti de Marrero, E., Sandbrink, F., Matadial, C. M., Mariano, E. R. 2023

  Abstract

  The Veterans Health Administration (VHA) is the largest healthcare network in the USA and has been a national leader in opioid safety for acute pain management. However, detailed information on the availability and characteristics of acute pain services within its facilities is lacking. We designed this project to assess the current state of acute pain services within the VHA.A 50-question electronic survey developed by the VHA national acute pain medicine committee was emailed to anesthesiology service chiefs at 140 VHA surgical facilities within the USA. Data collected were analyzed by facility complexity level and service characteristics.Of the 140 VHA surgical facilities contacted, 84 (60%) completed the survey. Thirty-nine (46%) responding facilities had an acute pain service. The presence of an acute pain service was associated with higher facility complexity level designation. The most common staffing model was 2.0 full-time equivalents, which typically included at least one physician. Services performed most by formal acute pain programs included peripheral nerve catheters, inpatient consult services, and ward ketamine infusions.Despite widespread efforts to promote opioid safety and improve pain management, the availability of dedicated acute pain services within the VHA is not universal. Higher complexity programs are more likely to have acute pain services, which may reflect differential resource distribution, but the barriers to implementation have not yet been fully explored.

  View details for DOI 10.1136/rapm-2023-104610

  View details for PubMedID 37286296

• Perioperative and anesthetic considerations for the management of neuromodulation systems. Regional anesthesia and pain medicine Orhurhu, V., Hussain, N., Karri, J., Mariano, E. R., Abd-Elsayed, A. 2023; 48 (6): 327-336

  Abstract

  The use of neuromodulation systems is increasing for the treatment of various pathologies ranging from movement disorders to urinary incontinence to chronic pain syndromes. While the type of neuromodulation devices varies, they are largely categorized as intracranial (eg, deep brain stimulation), neuraxial (eg, spinal cord stimulation, dorsal root ganglion stimulation, and intrathecal drug delivery systems), or peripheral (eg, sacral nerve stimulation and peripheral nerve stimulation) systems. Given the increasing prevalence of these systems in the overall population, it is important for anesthesiologists, surgeons, and the perioperative healthcare team to familiarize themselves with these systems and their unique perioperative considerations. In this review, we explore and highlight the various neuromodulation systems, their general perioperative considerations, and notable special circumstances for perioperative management.

  View details for DOI 10.1136/rapm-2022-103660

  View details for PubMedID 37080581

• Multiorganizational consensus on principles for perioperative pain management for patients with chronic pain, opioid tolerance, and substance use disorder: an infographic. Regional anesthesia and pain medicine Dickerson, D. M., Mariano, E. R., Schwenk, E. S. 2023

  View details for DOI 10.1136/rapm-2022-103896

  View details for PubMedID 37236660

• Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors: an infographic. Regional anesthesia and pain medicine Xu, L., Gessner, D., Kou, A., Kasimova, K., Memtsoudis, S. G., Mariano, E. R. 2023

  View details for DOI 10.1136/rapm-2023-104578

  View details for PubMedID 37173098

• Rate of occurrence of respiratory complications in patients who undergo shoulder arthroplasty with a continuous interscalene brachial plexus block and associated risk factors. Regional anesthesia and pain medicine Xu, L., Gessner, D., Kou, A., Kasimova, K., Memtsoudis, S. G., Mariano, E. R. 2023

  Abstract

  Continuous interscalene nerve block techniques are an effective form of targeted non-opioid postoperative analgesia for shoulder arthroplasty patients. One of the limiting risks, however, is potential phrenic nerve blockade with resulting hemidiaphragmatic paresis and respiratory compromise. While studies have focused on block-related technical aspects to limit the incidence of phrenic nerve palsy, little is known about other factors associated with increased risk of clinical respiratory complications in this population.A single-institution retrospective cohort study was conducted using electronic health records from adult patients who underwent elective shoulder arthroplasty with continuous interscalene brachial plexus blocks (CISB). Data collected included patient, nerve block, and surgery characteristics. Respiratory complications were categorized into four groups (none, mild, moderate, and severe). Univariate and multivariable analyses were conducted.Among 1025 adult shoulder arthroplasty cases, 351 (34%) experienced any respiratory complication. These 351 were subdivided into 279 (27%) mild, 61 (6%) moderate, and 11 (1%) severe respiratory complications. In an adjusted analysis, patient-related factors were associated with an increased likelihood of respiratory complication: ASA Physical Status III (OR 1.69, 95% CI 1.21 to 2.36); asthma (OR 1.59, 95% CI 1.07 to 2.37); congestive heart failure (OR 1.99, 95% CI 1.19 to 3.33); body mass index (OR 1.06, 95% CI 1.03 to 1.09); age (OR 1.02, 95% CI 1.00 to 1.04); and preoperative oxygen saturation (SpO2). For every 1% decrease in preoperative SpO2, there was an associated 32% higher likelihood of a respiratory complication (OR 1.32, 95% CI 1.20 to 1.46, p<0.001).Patient-related factors that can be measured preoperatively are associated with increased likelihood of respiratory complications after elective shoulder arthroplasty with CISB.

  View details for DOI 10.1136/rapm-2022-104264

  View details for PubMedID 37173097

• An exploratory analysis of pediatric anesthesia activity on Twitter using the #pedsanes hashtag. Paediatric anaesthesia Downing, L., Mariano, E. R., Kou, A., Matava, C. 2023

  Abstract

  The use of social media within the medical field has rapidly evolved over the past two decades, with Twitter being one of the most common platforms of engagement. The use of hashtags such as #pedsanes has been reported as a community builder around the subject of pediatric anesthesia. Understanding the use of #pedsanes can inform dissemination of pediatric anesthesia content and discourse. We aimed to describe the distribution and patterns of tweets and contributors using #pedsanes across the globe.Using Tweetbinder (https://www.tweetbinder.com) and the R package "academictwitteR," we extracted tweets that included the hashtag "#pedsanes" from March 14, 2016 to March 10, 2022. Tweets were analyzed for frequency, type, unique users, impact and reach, language, content, and the most common themes.A total of 58 724 tweets were retrieved; 22 071 (38.8%) were original tweets including 3247 replies, while 35 971 (61.2%) were retweets all generated by over 5946 contributors located in at least 122 countries. The frequency distribution of tweets gradually increased over time with peaks in activity corresponding to major pediatric anesthesia societal meetings and during the early phases of the COVID-19 pandemic. The most retweeted and most liked posts included images.We report the widespread and increasing use of social media and the "#pedsanes" hashtag within the pediatric anesthesia and medical community over time. It remains unknown the extent to which Twitter hashtag activity translates to changes in clinical practice. However, the #pedsanes hashtag appears to play a key role in disseminating pediatric anesthesia information globally.

  View details for DOI 10.1111/pan.14690

  View details for PubMedID 37154039

• Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder. Regional anesthesia and pain medicine Dickerson, D. M., Mariano, E. R., Szokol, J. W., Harned, M., Clark, R. M., Mueller, J. T., Shilling, A. M., Udoji, M. A., Mukkamala, S. B., Doan, L., Wyatt, K. E., Schwalb, J. M., Elkassabany, N. M., Eloy, J. D., Beck, S. L., Wiechmann, L., Chiao, F., Halle, S. G., Krishnan, D. G., Cramer, J. D., Ali Sakr Esa, W., Muse, I. O., Baratta, J., Rosenquist, R., Gulur, P., Shah, S., Kohan, L., Robles, J., Schwenk, E. S., Allen, B. F., Yang, S., Hadeed, J. G., Schwartz, G., Englesbe, M. J., Sprintz, M., Urish, K. L., Walton, A., Keith, L., Buvanendran, A. 2023

  Abstract

  Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of 'complex' patients as they undergo surgical procedures.

  View details for DOI 10.1136/rapm-2023-104435

  View details for PubMedID 37185214

• Postoperative pain management: are we ready to move beyond the 'kitchen-sink' approach? Anaesthesia Abdallah, F., Neuman, M. D., Mariano, E. R. 2023

  View details for DOI 10.1111/anae.16025

  View details for PubMedID 37073454

• Patient-centered results from a multicenter study of continuous peripheral nerve blocks and postamputation phantom and residual limb pain: secondary outcomes from a randomized, clinical trial. Regional anesthesia and pain medicine Ilfeld, B. M., Khatibi, B., Maheshwari, K., Madison, S., Ali Sakr Esa, W., Mariano, E. R., Kent, M., Hanling, S., Sessler, D. I., Eisenach, J. C., Cohen, S. P., Mascha, E., Li, S., Turan, A., PAINfRE Investigators 2023

  Abstract

  INTRODUCTION: We previously reported that a 6-day continuous peripheral nerve block reduces established postamputation phantom pain. To provide patients and providers with the information to best inform treatment decisions, here we reanalyze the data and present the results in a more patient-centered format. We also provide information on patient-defined clinically relevant benefits to facilitate evaluation of available studies and guide future trial design.METHODS: The original trial enrolled participants with a limb amputation and phantom pain who were randomized to receive a 6-day continuous peripheral nerve block(s) of either ropivacaine (n=71) or saline (n=73) in a double-masked fashion. Here we calculate the percentage of each treatment group that experienced a clinically relevant improvement as defined by previous studies as well as present what the participants of our study defined as small, medium, and large analgesic improvements using the 7-point ordinal Patient Global Impression of Change scale.RESULTS: Among patients who were given a 6-day ropivacaine infusion, 57% experienced at least a 2-point improvement on the 11-point numeric rating scale in their average and worst phantom pain 4weeks postbaseline as compared with 26% (p<0.001) for average and 25% (p<0.001) for worst pain in patients given a placebo infusion. At 4weeks, the percentage of participants rating their pain as improved was 53% for the active vs 30% for the placebo groups (95% CI 1.7 (1.1, 2.7), p=0.008). For all patients combined, the median (IQR) phantom pain Numeric Rating Scale improvements at 4weeks considered small, medium, and large were 2 (0-2), 3 (2-5), and 5 (3-7), respectively. The median improvements in the Brief Pain Inventory interference subscale (0-70) associated with small, medium, and large analgesic changes were 8 (1-18), 22 (14-31), and 39 (26-47).CONCLUSIONS: Among patients with postamputation phantom pain, a continuous peripheral nerve block more than doubles the chance of a clinically relevant improvement in pain intensity. Amputees with phantom and/or residual limb pain rate analgesic improvements as clinically relevant similarly to other chronic pain etiologies, although their smallest relevant improvement in the Brief Pain Inventory was significantly larger than previously published values.TRIAL REGISTRATION NUMBER: NCT01824082.

  View details for DOI 10.1136/rapm-2023-104389

  View details for PubMedID 36894197

• Knee Injury and Osteoarthritis Outcome Score Trajectories After Primary Total Knee Arthroplasty in United States Veterans. Cureus Polascik, B. W., Horn, M., Pyati, S., Mariano, E. R., Ginsberg, J. P., Raghunathan, K. 2023; 15 (3): e36670

  Abstract

  The volume of total knee arthroplasty (TKA) procedures continues to increase, including among United States (US) veterans, but there is little data characterizing recovery using validated knee-related questionnaires.In this prospective cohort study, we sought to establish the feasibility of longitudinal characterization of recovery after TKA using the validated Knee Injury and Osteoarthritis Outcome Score (KOOS), specifically focusing on two of the KOOS subscales (pain and quality of life (QOL)). We solicited participants who agreed to fill out these knee-related questionnaires preoperatively and 3, 6, and 12 months after discharge following unilateral TKA within the Durham Veterans Affairs Health Care System. We examined rates of prospective completion of the KOOS and face validity of scores at each study time point. We transformed and reported scores on the 0-100 scale, with zero representing significant knee pain or poor QOL and 100 representing no knee pain or good QOL.Of 200 US veterans presenting between May 2017 and 2018, 21 (10.5%) agreed to participate by filling out the KOOS questionnaire longitudinally from before surgery until one year after discharge. All 21 (100%) participants were male and completed the two KOOS subscale questions (pain and QOL) preoperatively. Of those, 16 (76.2%) also completed KOOS at 3 months, 16 (76.2%) at 6 months, and seven (33.3%) at 12 months. Compared to mean preoperative values (pain: 33.47 + 6.78, QOL: 11.91 + 4.99), the KOOS subscale scores had significantly improved by 6 months after TKA (pain: 74.41 + 10.72, QOL: 49.61 + 13.25) but plateaued at 12 months (pain: 74.60 + 20.80, QOL: 50.89 + 20.61). The magnitude of improvement in absolute scores, pain and QOL, was similar and significant at 12 months compared to preoperative values with an increase of 41.13 (p=0.007) and 38.98 (p=0.009), respectively.Primary TKA in US veterans with advanced osteoarthritis may lead to improved patient-reported KOOS pain and QOL subscale measures at 12 months compared to preoperative scores, with the majority of improvement occurring by 6 months. Only one in ten US veterans approached preoperatively agreed to complete the validated knee-related outcomes questionnaire prior to undergoing TKA. About three-quarters of those veterans also completed it both three and six months after discharge. Collected KOOS subscale scores demonstrated face validity and showed substantial improvement in pain and QOL over the six-month postoperative period. Only one in three veterans who completed the KOOS questionnaire preoperatively also completed it at 12 months, but this does not support the feasibility of follow-up assessments beyond 6 months. To better understand longitudinal pain and QOL trajectories in US veterans undergoing primary TKA for advanced osteoarthritis and to improve study participation, additional research using the KOOS questionnaire may add further insights into this underreported population.

  View details for DOI 10.7759/cureus.36670

  View details for PubMedID 37113372

  View details for PubMedCentralID PMC10129021

• Acute pain service reduces barriers to buprenorphine/naloxone initiation by using regional anesthesia techniques. Regional anesthesia and pain medicine Seol, A., Chan, J., Micham, B., Ye, Y., Mariano, E. R., Harrison, T. K., Hunter, O. O. 2023

  Abstract

  Medications for opioid use disorder (MOUD) are a life-saving intervention; thus, it is important to address barriers to successful initiation. Spasticity affects many patients with spinal cord injury and can be painful and physically debilitating. Chronic painful conditions can lead to the illicit use of non-prescribed opioids, but fear of pain is a barrier to the initiation of MOUD. In this case report, we describe the novel use of botulinum toxin A injections to treat abdominal spasticity and facilitate Acute Pain Service-led buprenorphine/naloxone initiation in a patient with opioid use disorder and severe abdominal spasticity due to spinal cord injury.A patient with C4 incomplete tetraplegia and opioid use disorder complicated by abdominal spasticity refractory to oral antispasmodics and self-treating with intravenous heroin was referred to the Acute Pain Service for inpatient buprenorphine/naloxone initiation. The patient began to fail initiation of buprenorphine/naloxone secondary to increased pain from abdominal spasms. The patient was offered ultrasound-guided abdominal muscle chemodenervation with botulinum toxin A, which resulted in the resolution of abdominal spasticity and facilitated successful buprenorphine/naloxone initiation. At 6 months post-initiation, the patient remained abstinent from non-prescribed opioids and compliant with buprenorphine/naloxone 8 mg/2 mg three times a day.This case report demonstrates that inpatient buprenorphine/naloxone initiation by an Acute Pain Service can improve the success of treatment by addressing barriers to initiation. Acute Pain Service clinicians possess unique skills and knowledge, including ultrasound-guided interventions, that enable them to provide innovative and personalized approaches to care in the complex opioid use disorder population.

  View details for DOI 10.1136/rapm-2022-104317

  View details for PubMedID 36792313

• Erector spinae plane block versus fascia iliaca block after total hip arthroplasty: a randomized clinical trial comparing analgesic effectiveness and motor block. Korean journal of anesthesiology Flaviano, E., Bettinelli, S., Assandri, M., Muhammad, H., Benigni, A., Cappelleri, G., Mariano, E. R., Lorini, L. F., Bugada, D. 2023

  Abstract

  Ultrasound-guided, supra-inguinal fascia iliaca block (FIB) provides effective analgesia after total hip arthroplasty (THA), but is complicated by high rates of motor block. The erector spinae plane block (ESPB) is a promising motor-sparing technique. In this study, we test the analgesic superiority of FIB over ESPB, while also comparing motor impairment.In this randomized, observer-blinded clinical trial, patients scheduled for THA with spinal anesthesia were randomly assigned to receive either ultrasound-guided FIB or ESPB preoperatively. Primary outcome was morphine consumption at 24 hours after surgery. Secondary outcomes were: pain scores; assessment of sensory and motor block; incidence of postoperative nausea and vomiting and other complications; and development of chronic post-surgical pain.Sixty patients completed the study. There were no statistically-significant differences in morphine consumption at 24 hours (p = 0.68) or pain scores at any time point. FIB produced more reliable sensory block in the femoral nerve (p = 0.001) and lateral femoral cutaneous nerve (p = 0.018) distributions. However, quadriceps motor strength was better preserved in the ESPB group when compared to the FIB group (p = 0.002). No differences were observed for hip adduction motor strength (p = 0.253). No differences between groups were observed in terms of side effects or chronic pain incidence.ESPB may represent a promising alternative to FIB for postoperative analgesia after THA. ESPB and FIB offer similar opioid-sparing benefits within the first day after surgery, but ESPB results in less quadriceps motor impairment.

  View details for DOI 10.4097/kja.22669

  View details for PubMedID 36632641

• Hospital-level variability in regional nerve block administration by race for total knee arthroplasty. Regional anesthesia and pain medicine Dixit, A. A., Kim, C. Y., Mariano, E. R., Krishnamoorthy, V., Ohnuma, T., Raghunathan, K., Bryan, W. E., Bartels, K., Sun, E. C. 2022

  View details for DOI 10.1136/rapm-2022-104028

  View details for PubMedID 36598069

• Hospital-level variability in regional nerve block administration by race for total knee arthroplasty REGIONAL ANESTHESIA AND PAIN MEDICINE Dixit, A. A., Kim, C. Y., Mariano, E. R., Krishnamoorthy, V., Ohnuma, T., Raghunathan, K., Bryan, W. E., Bartels, K., Sun, E. C. 2022

  View details for DOI 10.1136/rapm-2022-104028

  View details for Web of Science ID 000898390700001

• Changing a clinical pathway to increase spinal anesthesia use for elective hip arthroplasty: a single-centre historical cohort study. Canadian journal of anaesthesia = Journal canadien d'anesthesie Mulumba, K. Y., Mariano, E. R., Leng, J. C., Kou, A., Hunter, O. O., Tamboli, M., Memtsoudis, S. G., Mudumbai, S. C. 2022

  Abstract

  International consensus recommendations support neuraxial anesthesia as the preferred anesthetic technique for total hip arthroplasty. We hypothesized that an institutional initiative to promote spinal anesthesia within a clinical pathway would result in increased use of this technique.We reviewed primary unilateral total hip arthroplasty data between June 2017 and June 2019-one year before vs one year after implementation. The primary outcome was rate of spinal anesthesia use. Secondary outcomes included postoperative pain scores and opioid use, rates of postoperative complications, and unplanned resource use. We built a run chart-tracking rates of spinal anesthesia; compared postoperative outcomes based on anesthetic technique; and developed a mixed model, multivariable logistic regression with margins analysis evaluating the use of spinal anesthesia.The final sample included 172 patients (87 before and 85 after implementation) with no significant differences in baseline characteristics. For the primary outcome, 42/87 (48%) patients received spinal anesthesia before implementation compared with 48/85 (56%) postimplementation (unadjusted difference, 8%; 95% confidence interval, -7 to 23; P = 0.28). There were no differences in secondary outcomes. Factors associated with receipt of spinal anesthesia included American Society of Anesthesiologists Physical Status II (vs III), lower body mass index, and shorter case duration. Using a reduced mixed model, the average marginal effect was 10.7%, with an upper 95% confidence limit of 25.7%.Implementation of a clinical pathway change to promote spinal anesthesia for total hip arthroplasty may not have been associated with increased use of spinal anesthesia, but utilization rates can vary widely. Baseline spinal anesthesia usage at our institution was higher than the USA national average, and many factors may influence choice of anesthesia technique. Patients who receive spinal anesthesia have decreased opioid requirements and pain scores postoperatively.

  View details for DOI 10.1007/s12630-022-02371-5

  View details for PubMedID 36482246

• Recommendations for anatomical structures to identify on ultrasound for the performance of intermediate and advanced blocks in ultrasound-guided regional anesthesia. Regional anesthesia and pain medicine Ashken, T., Bowness, J., Macfarlane, A. J., Turbitt, L., Bellew, B., Bedforth, N., Burckett-St Laurent, D., Delbos, A., El-Boghdadly, K., Elkassabany, N. M., Ferry, J., Fox, B., French, J. L., Grant, C., Gupta, A., Gupta, R. K., Gürkan, Y., Haslam, N., Higham, H., Hogg, R. M., Johnston, D. F., Kearns, R. J., Lobo, C., McKinlay, S., Mariano, E. R., Memtsoudis, S., Merjavy, P., Narayanan, M., Noble, J. A., Phillips, D., Rosenblatt, M., Sadler, A., Sebastian, M. P., Schwenk, E. S., Taylor, A., Thottungal, A., Valdés-Vilches, L. F., Volk, T., West, S., Wolmarans, M., Womack, J., Pawa, A. 2022; 47 (12): 762-772

  Abstract

  Recent recommendations describe a set of core anatomical structures to identify on ultrasound for the performance of basic blocks in ultrasound-guided regional anesthesia (UGRA). This project aimed to generate consensus recommendations for core structures to identify during the performance of intermediate and advanced blocks. An initial longlist of structures was refined by an international panel of key opinion leaders in UGRA over a three-round Delphi process. All rounds were conducted virtually and anonymously. Blocks were considered twice in each round: for "orientation scanning" (the dynamic process of acquiring the final view) and for "block view" (which visualizes the block site and is maintained for needle insertion/injection). A "strong recommendation" was made if ≥75% of participants rated any structure as "definitely include" in any round. A "weak recommendation" was made if >50% of participants rated it as "definitely include" or "probably include" for all rounds, but the criterion for strong recommendation was never met. Structures which did not meet either criterion were excluded. Forty-one participants were invited and 40 accepted; 38 completed all three rounds. Participants considered the ultrasound scanning for 19 peripheral nerve blocks across all three rounds. Two hundred and seventy-four structures were reviewed for both orientation scanning and block view; a "strong recommendation" was made for 60 structures on orientation scanning and 44 on the block view. A "weak recommendation" was made for 107 and 62 structures, respectively. These recommendations are intended to help standardize teaching and research in UGRA and support widespread and consistent practice.

  View details for DOI 10.1136/rapm-2022-103738

  View details for PubMedID 36283714

• Tapentadol and the opioid epidemic: a simple solution or short-lived sensation? Anaesthesia Bicket, M. C., Brummett, C. M., Mariano, E. R. 2022

  View details for DOI 10.1111/anae.15932

  View details for PubMedID 36449368

• How to engage in social media to get your work published. Anaesthesia Patel, A., Kars, M. S., Duggan, L. V., Mariano, E. R. 2022

  View details for DOI 10.1111/anae.15919

  View details for PubMedID 36427346

• Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients. International anesthesiology clinics Patton, J. W., Burton, B. N., Milam, A. J., Mariano, E. R., Gabriel, R. A. 2022

  View details for DOI 10.1097/AIA.0000000000000382

  View details for PubMedID 36398629

• Ultrasound-Guided Percutaneous Cryoneurolysis to Treat Chronic Post-Amputation Phantom Limb Pain: A Multicenter, Randomized, Controlled Trial. Anesthesiology Ilfeld, B. M., Smith, C. R., Turan, A., Mariano, E. R., Miller, M. E., Fisher, R. L., Trescot, A. M., Cohen, S. P., Eisenach, J. C., Sessler, D. I., Prologo, J. D., Mascha, E. J., Liu, L., Gabriel, R. A., PAINfRE Investigators 2022

  Abstract

  BACKGROUND: Post-amputation phantom pain is notoriously persistent with few validated treatments. Cryoneurolysis involves the application of low temperatures to reversibly ablate peripheral nerves. We tested the hypothesis that a single cryoneurolysis treatment would decrease phantom pain 4 months later.METHODS: We enrolled patients with a lower-limb amputation and established phantom pain. Each received a single-injection femoral and sciatic nerve block with lidocaine and was subsequently randomized to receive either ultrasound-guided percutaneous cryoneurolysis or sham treatment at these same locations. The primary outcome was the change in average phantom pain intensity between baseline and 4 months as measured with a Numeric Rating Scale (0-10), after which an optional crossover treatment was offered. Investigators, participants, and clinical staff were masked to treatment group assignment with the exception of the treating physician performing the cryoneurolysis who had no subsequent participant interaction.RESULTS: Pretreatment phantom pain scores were similar in both groups, with a median [quartiles] of 5.0 [4.0, 6.0] for active treatment and 5.0 [4.0, 7.0] for sham. After 4 months, pain intensity decreased by 0.5 [-0.5, 3.0] in patients given cryoneurolysis (n=71) versus 0 [0, 3] in patients given sham (n=73): estimated difference (95% CI) -0.1 (-1.0, 0.7), P=0.759. Following our statistical gatekeeping protocol, we did not make inferences or draw conclusions on secondary endpoints. One serious adverse event occurred following a protocol deviation in which a femoral nerve cryolesion was induced just below the inguinal ligament-instead of the sensory-only saphenous nerve-which resulted in quadriceps weakness, and possibly a fall and clavicle fracture.DISCUSSION: Percutaneous cryoneurolysis did not decrease chronic lower extremity phantom limb pain 4 months following treatment. However, these results were based upon our specific study protocol; and since the optimal cryoneurolysis treatment parameters such as freeze duration and anatomic treatment location remain unknown, further research is warranted.

  View details for DOI 10.1097/ALN.0000000000004429

  View details for PubMedID 36512721

• Implementing an intravenous ketamine protocol for acute pain in the medical-surgical setting. Journal of the American Association of Nurse Practitioners Hunter, O. O., Lu, A., Fretwell, D., Mariano, E. R. 2022

  Abstract

  ABSTRACT: A subanesthetic intravenous ketamine infusion is a safe and effective acute pain management modality for moderate to severely painful surgical procedures and may be useful in patients who are at increased risk for opioid-related adverse events. Despite its safety profile, intravenous ketamine is often restricted to the intensive care unit, which results in decreased patient access to this effective therapy. For clinicians who wish to implement an intravenous ketamine protocol in the medical-surgical setting, there are few resources available. In this brief report, we present our ketamine infusion protocol for acute pain and the clinical and financial outcomes 1 year after implementation. In our experience, ketamine infusions on the medical-surgical ward are safe and cost-effective when an established acute pain service protocol is followed. Nurse practitioners play an essential role in increasing patient access to intravenous ketamine infusions and leading change by collaborating with stakeholders to develop a protocol, training nurses and interdisciplinary team members, and providing ongoing support to nursing staff.

  View details for DOI 10.1097/JXX.0000000000000797

  View details for PubMedID 36346872

• Predictors of chronic postsurgical pain: a step forward towards personalized medicine. Minerva anestesiologica Bugada, D., Mariano, E. R. 2022; 88 (10): 764-767

  View details for DOI 10.23736/S0375-9393.22.16861-6

  View details for PubMedID 36254696

• Recommendations for anatomical structures to identify on ultrasound for the performance of intermediate and advanced blocks in ultrasound-guided regional anesthesia REGIONAL ANESTHESIA AND PAIN MEDICINE Ashken, T., Bowness, J., Macfarlane, A., Turbitt, L., Bellew, B., Bedforth, N., Burckett-St Laurent, D., Delbos, A., El-Boghdadly, K., Elkassabany, N. M., Ferry, J., Fox, B., French, J. H., Grant, C., Gupta, A., Gupta, R. K., Gurkan, Y., Haslam, N., Higham, H., Hogg, R. G., Johnston, D. F., Kearns, R., Lobo, C., McKinlay, S., Mariano, E. R., Memtsoudis, S., Merjavy, P., Narayanan, M., Noble, J., Phillips, D., Rosenblatt, M., Sadler, A., Sebastian, M., Schwenk, E. S., Taylor, A., Thottungal, A., Valdes-Vilches, L., Volk, T., West, S., Wolmarans, M., Womack, J., Pawa, A. 2022

  View details for DOI 10.1136/rapm-2022-103738

  View details for Web of Science ID 000850850700001

• A modern roadmap for the use of simulation in regional anesthesiology training. Current opinion in anaesthesiology Kumar, A. H., Sultan, E., Mariano, E. R., Udani, A. D. 2022

  Abstract

  PURPOSE OF REVIEW: A variety of educational modalities are used to teach regional anesthesia. Simulation is an educational tool that facilitates hands-on learning in a well tolerated, reproducible environment, eliminating potential harm to patients during the process of learning. Available literature and expert consensus statements support customizing simulation programs according to the level of training and experience of the learners.RECENT FINDINGS: Simulation is useful for learners of all levels of expertise, though the application and frequency of simulation must be adapted to meet the learners' objectives.SUMMARY: This review presents recommendations for the use of simulation for residents, fellows, practicing anesthesiologists without formal training in regional anesthesia, and practicing anesthesiologists with regional anesthesia expertise. Passports and portfolio programs that include simulation can be used to verify training. Virtual applications of simulation are growing, expanding the scope of regional anesthesia simulation and increasing access to lower resource areas.

  View details for DOI 10.1097/ACO.0000000000001179

  View details for PubMedID 35942715

• Core outcome set for peripheral regional anesthesia research: a systematic review and Delphi study. Regional anesthesia and pain medicine Hill, J., Ashken, T., West, S., Macfarlane, A. J., El-Boghdadly, K., Albrecht, E., Chin, K. J., Fox, B., Gupta, A., Haskins, S., Haslam, N., Hogg, R. M., Hormis, A., Johnston, D. F., Mariano, E. R., Merjavy, P., Moll, T., Parry, J., Pawa, A., Russon, K., Sebastian, M. P., Turbitt, L., Womack, J., Chazapis, M. 2022

  Abstract

  BACKGROUND/IMPORTANCE: There is heterogeneity among the outcomes used in regional anesthesia research.OBJECTIVE: We aimed to produce a core outcome set for regional anesthesia research.METHODS: We conducted a systematic review and Delphi study to develop this core outcome set. A systematic review of the literature from January 2015 to December 2019 was undertaken to generate a long list of potential outcomes to be included in the core outcome set. For each outcome found, the parameters such as the measurement scale, timing and definitions, were compiled. Regional anesthesia experts were then recruited to participate in a three-round electronic modified Delphi process with incremental thresholds to generate a core outcome set. Once the core outcomes were decided, a final Delphi survey and video conference vote was used to reach a consensus on the outcome parameters.RESULTS: Two hundred and six papers were generated following the systematic review, producing a long list of 224 unique outcomes. Twenty-one international regional anesthesia experts participated in the study. Ten core outcomes were selected after three Delphi survey rounds with 13 outcome parameters reaching consensus after a final Delphi survey and video conference.CONCLUSIONS: We present the first core outcome set for regional anesthesia derived by international expert consensus. These are proposed not to limit the outcomes examined in future studies, but rather to serve as a minimum core set. If adopted, this may increase the relevance of outcomes being studied, reduce selective reporting bias and increase the availability and suitability of data for meta-analysis in this area.

  View details for DOI 10.1136/rapm-2022-103751

  View details for PubMedID 35863787

• Single-injection regional analgesia techniques for mastectomy surgery: A network meta-analysis. European journal of anaesthesiology De Cassai, A., Zarantonello, F., Geraldini, F., Boscolo, A., Pasin, L., De Pinto, S., Leardini, G., Basile, F., Disarò, L., Sella, N., Mariano, E. R., Pettenuzzo, T., Navalesi, P. 2022; 39 (7): 591-601

  Abstract

  Patients undergoing mastectomy surgery experience severe postoperative pain. Several regional techniques have been developed to reduce pain intensity but it is unclear, which of these techniques is most effective.To synthesise direct and indirect comparisons for the relative efficacy of different regional and local analgesia techniques in the setting of unilateral mastectomy. Postoperative opioid consumption at 24 h, postoperative pain at extubation, 1, 12 and 24 h, postoperative nausea and vomiting were collected.Systematic review with network meta-analysis (PROSPERO:CRD42021250651).PubMed, Scopus, the Cochrane Central Register of Controlled Trials (from inception until 7 July 2021).All randomised controlled trials investigating single-injection regional and local analgesia techniques in adult patients undergoing unilateral mastectomy were included in our study without any language or publication date restriction.Sixty-two included studies randomising 4074 patients and investigating nine techniques entered the analysis. All techniques were associated with less opioid consumption compared with controls The greatest mean difference [95% confidence interval (CI)] was associated with deep serratus anterior plane block: mean difference -16.1 mg (95% CI, -20.7 to -11.6). The greatest reduction in pain score was associated with the interpectoral-pecto-serratus plane block (mean difference -1.3, 95% CI, -1.6 to - 1) at 12 h postoperatively, and with superficial serratus anterior plane block (mean difference -1.4, 95% CI, -2.4 to -0.5) at 24 h. Interpectoral-pectoserratus plane block resulted in the greatest statistically significant reduction in postoperative nausea/vomiting when compared with placebo/no intervention with an OR of 0.23 (95% CI, 0.13 to 0.40).All techniques were associated with superior analgesia and less opioid consumption compared with controls. No single technique was identified as superior to others. In comparison, local anaesthetic infiltration does not offer advantages over multimodal analgesia alone.PROSPERO (CRD4202125065).

  View details for DOI 10.1097/EJA.0000000000001644

  View details for PubMedID 35759292

• Position statement from the Editors of Anaesthesia on equity, diversity and inclusion ANAESTHESIA Agarwal, S., El-Boghdadly, K. 2022; 77 (9): 1018-1022

  Abstract

  There is a need to prioritise equity, diversity and inclusion within anaesthesia and medicine as a whole. This position statement outlines the Anaesthesia Editors' current policies and practices aiming to achieve equity, represent the diversity of our specialty and actively include people engaged with this journal and beyond. We will define, promote and embed principles of equity, diversity and inclusion across all our work. We will monitor and report author and editor characteristics and ensure recruitment practices are transparent and adhere to our principles on equity, diversity and inclusion. We will attempt to remove systemic barriers restricting those from under-represented groups from progressing into leadership roles within anaesthesia. We will respond to threats and barriers to the principles and practices we set. With these principles and specific actions we undertake, we aim to be pro-active rather than reactive. We commit to embracing and embedding equity, diversity and inclusion in all our practices and regularly reviewing, improving and updating our policies and practices.

  View details for DOI 10.1111/anae.15763

  View details for Web of Science ID 000815843300001

  View details for PubMedID 36444898

• A simple checkbox reminder may influence postoperative opioid prescribing behaviour in acute pain service clinicians. Anaesthesia Hunter, O. O., Kou, A., Leng, J. C., Mariano, E. R. 2022

  View details for DOI 10.1111/anae.15790

  View details for PubMedID 35737434

• Single-center cross-sectional study of high opioid prescribing among U.S. veterans with peripheral arterial disease. Regional anesthesia and pain medicine Stern, J. R., Kou, A., Kapoor, A., Regala, S., He, H., Stafford, R. S., Mariano, E. R., Mudumbai, S. C. 2022

  View details for DOI 10.1136/rapm-2022-103574

  View details for PubMedID 35688513

• Role of social networks in regional anesthesia research: a case study of the erector spinae plane block. Regional anesthesia and pain medicine De Cassai, A., Iuzzolino, M., Geraldini, F., Mariano, E. R. 2022

  View details for DOI 10.1136/rapm-2022-103808

  View details for PubMedID 35688514

• Looking backward to move forward in perioperative pain management? Regional anesthesia and pain medicine Mariano, E. R., El-Boghdadly, K. 2022

  View details for DOI 10.1136/rapm-2022-103805

  View details for PubMedID 35654479

• Is there a correlation between Altmetric Attention Scores and citation count in Regional Anesthesia and Pain Medicine journal articles? Regional anesthesia and pain medicine Grosh, T., Kim, J., Graff, V., Mariano, E. R., Elkassabany, N. M. 2022

  View details for DOI 10.1136/rapm-2022-103554

  View details for PubMedID 35580935

• A Comparative Utility Score for Digital Health Tools. Journal of medical systems Burton, J. C., Regala, S., Williams, D., Desai, A., He, H., Aalami, O., Mariano, E. R., Stafford, R. S., Mudumbai, S. C. 2022; 46 (6): 34

  Abstract

  Digital health tools (DHT) are increasingly poised to change healthcare delivery given the Coronavirus Disease 2019 (COVID-19) pandemic and the drive to telehealth. Establishing the potential utility of a given DHT could aid in identifying how it could be best used and further opportunities for healthcare improvement. We propose a metric, a Utility Factor Score, which quantifies the benefits of a DHT by explicitly defining adherence and linking it directly to satisfaction and health goals met. To provide data for how the comparative utility score can or should work, we illustrate in detail the application of our metrics across four DHTs with two simulated users. The Utility Factor Score can potentially facilitate integration of DHTs into various healthcare settings and should be evaluated within a clinical study.

  View details for DOI 10.1007/s10916-022-01821-3

  View details for PubMedID 35511408

• Machine Learning Can Identify Geographic Disparities in Opioid Overdose Before and After the COVID-19 Pandemic He, H., Kou, A., Kapoor, A., Regala, S., Raghunathan, K., Mariano, E. R., Stafford, R. S., Mudumbai, S. LIPPINCOTT WILLIAMS & WILKINS. 2022: 708-709

  View details for Web of Science ID 000840283000284

• Buprenorphine Prescribing During the COVID-19 Pandemic: An Initial Disparities Analysis from the California Opioid Overdose Surveillance Dashboard He, H., Regala, S., Kapoor, A., Raghunathan, K., Mariano, E. R., Stafford, R. S., Mudumbai, S. LIPPINCOTT WILLIAMS & WILKINS. 2022: 437-438

  View details for Web of Science ID 000840283000167

• PECS2 or PICK2. Regional anesthesia and pain medicine Elkassabany, N. M., Mariano, E. R., Kopp, S., Albrecht, E., Wolmarans, M., El-Boghdadly, K. 2022

  View details for DOI 10.1136/rapm-2022-103657

  View details for PubMedID 35443995

• Opioid-free anesthesia in oncologic surgery: the rules of the game. Journal of Anesthesia, Analgesia and Critical Care (Online) De Cassai, A., Geraldini, F., Tulgar, S., Ahiskalioglu, A., Mariano, E. R., Dost, B., Fusco, P., Petroni, G. M., Costa, F., Navalesi, P. 2022; 2 (1): 8

  Abstract

  Opioids are frequently used in the postoperative period due to their analgesic properties. While these drugs reduce nociceptive somatic, visceral, and neuropathic pain, they may also lead to undesirable effects such as respiratory depression, urinary retention, nausea and vomiting, constipation, itching, opioid-induced hyperalgesia, tolerance, addiction, and immune system disorders. Anesthesiologists are in the critical position of finding balance between using opioids when they are necessary and implementing opioid-sparing strategies to avoid the known harmful effects. This article aims to give an overview of opioid-free anesthesia.This paper presents an overview of opioid-free anesthesia and opioid-sparing anesthetic techniques. Pharmacological and non-pharmacological strategies are discussed, highlighting the possible advantages and drawbacks of each approach.Choosing the best anesthetic protocol for a patient undergoing cancer surgery is not an easy task and the available literature provides no definitive answers. In our opinion, opioid-sparing strategies should always be implemented in routine practice and opioid-free anesthesia should be considered whenever possible. Non-pharmacological strategies such as patient education, while generally underrepresented in scientific literature, may warrant consideration in clinical practice.

  View details for DOI 10.1186/s44158-022-00037-8

  View details for PubMedID 37386559

  View details for PubMedCentralID PMC10245431

• Standardizing nomenclature for fascial plane blocks: the destination not the journey. Regional anesthesia and pain medicine El-Boghdadly, K., Wolmarans, M., Kopp, S., Mariano, E. R., Albrecht, E., Elkassabany, N. M. 1800

  View details for DOI 10.1136/rapm-2021-103457

  View details for PubMedID 35105723

• Regional anesthesia techniques and postoperative delirium: systematic review and meta-analysis. Minerva anestesiologica Fanelli, A., Balzani, E., Memtsoudis, S., Abdallah, F. W., Mariano, E. R. 2022

  Abstract

  Postoperative delirium is a frequent occurrence in the elderly surgical population. As a comprehensive list of predictive factors remains unknown, an opioid-sparing approach incorporating regional anesthesia techniques has been suggested to decrease its incidence. Due to the lack of conclusive evidence on the topic, we conducted a systematic review and meta-analysis to investigate the potential impact of regional anesthesia and analgesia on postoperative delirium.PubMed, Embase, and the Cochrane central register of Controlled trials (CENTRAL) databases were searched for randomized trials comparing regional anesthesia or analgesia to systemic treatments in patients having any type of surgery. This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We pooled the results separately for each of these two applications by random effects modelling. Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the certainty of evidence and strength of conclusions.Eighteen trials (3361 subjects) were included. Using regional techniques for surgical anesthesia failed to reduce the risk of postoperative delirium, with a relative risk (RR) of 1.21 (95% CI: 0.79 to 1.85); P=0.3800. In contrast, regional analgesia reduced the relative risk of perioperative delirium by a RR of 0.53 (95% CI: 0.42 to 0.68; P<0.0001), when compared to systemic analgesia. Post-hoc subgroup analysis for hip fracture surgery yielded similar findings.These results show that postoperative delirium may be decreased when regional techniques are used in the postoperative period as an analgesic strategy. Intraoperative regional anesthesia alone may not decrease postoperative delirium since there are other factors that may influence this outcome.

  View details for DOI 10.23736/S0375-9393.22.16076-1

  View details for PubMedID 35164487

• Regional anesthesia and enhanced recovery after colorectal surgery: are we asking the right questions? Regional anesthesia and pain medicine Mariano, E. R., McCartney, C. J. 2022; 47 (5): 279-281

  View details for DOI 10.1136/rapm-2022-103549

  View details for PubMedID 35332088

• Perioperative management of quadriceps tendon rupture in a patient recovering from COVID-19 pneumonia: A case report JOURNAL OF CLINICAL ANESTHESIA Seol, A., Truntzer, J., Coffman, C., Walters, L., Mariano, R., Leng, C. 2021; 75

  View details for DOI 10.1016/j.jclinane.2021.110548

  View details for Web of Science ID 000710631100015

• Perioperative management of quadriceps tendon rupture in a patient recovering from COVID-19 pneumonia: A case report. Journal of clinical anesthesia Seol, A., Truntzer, J., Coffman, C., Walters, T. L., Mariano, E. R., Leng, J. C. 2021; 75: 110548

  View details for DOI 10.1016/j.jclinane.2021.110548

  View details for PubMedID 34798703

• The external oblique intercostal block: anatomical evaluation and case series. Pain medicine (Malden, Mass.) Elsharkawy, H., Kolli, S., Soliman, L. M., Seif, J., Drake, R. L., Mariano, E. R., El-Boghdadly, K. 2021

  Abstract

  STUDY OBJECTIVE: We report a modified block technique aimed at obtaining upper midline and lateral abdominal wall analgesia: the external oblique intercostal (EOI) block.DESIGN: A cadaveric study and retrospective cohort study assessing the potential analgesic effect of the EOI block.SETTING: Cadaver lab and operating room.PATIENTS: Two unembalmed cadavers and 22 patients.INTERVENTIONS: Bilateral ultrasound-guided EOI blocks on cadavers with 29ml of bupivacaine 0.25% with 1ml of India ink; single-injection or continuous EOI blocks in patients.MEASUREMENTS: Dye spread in cadavers and loss of cutaneous sensation in patients.MAIN RESULTS: In the cadaveric specimens, we identified consistent staining of both lateral and anterior branches of intercostal nerves from T7-T10. We also found consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline in patients receiving the EOI block.CONCLUSIONS: We demonstrate the potential mechanism of this technique with a cadaveric study that shows consistent staining of both lateral and anterior branches of intercostal nerves T7-T10. Patients who received this block exhibited consistent dermatomal sensory blockade of T6-T10 at the anterior axillary line and T6-T9 at the midline. This block can be used in multiple clinical settings for upper abdominal wall analgesia.

  View details for DOI 10.1093/pm/pnab296

  View details for PubMedID 34626112

• A multisociety organizational consensus process to define guiding principles for acute perioperative pain management. Regional anesthesia and pain medicine Mariano, E. R., Dickerson, D. M., Szokol, J. W., Harned, M., Mueller, J. T., Philip, B. K., Baratta, J. L., Gulur, P., Robles, J., Schroeder, K. M., Wyatt, K. E., Schwalb, J. M., Schwenk, E. S., Wardhan, R., Kim, T. S., Higdon, K. K., Krishnan, D. G., Shilling, A. M., Schwartz, G., Wiechmann, L., Doan, L. V., Elkassabany, N. M., Yang, S. C., Muse, I. O., Eloy, J. D., Mehta, V., Shah, S., Johnson, R. L., Englesbe, M. J., Kallen, A., Mukkamala, S. B., Walton, A., Buvanendran, A. 2021

  Abstract

  The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

  View details for DOI 10.1136/rapm-2021-103083

  View details for PubMedID 34552003

• Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature. Regional anesthesia and pain medicine Memtsoudis, S. G., Cozowicz, C., Bekeris, J., Bekere, D., Liu, J., Soffin, E. M., Mariano, E. R., Johnson, R. L., Go, G., Hargett, M. J., Lee, B. H., Wendel, P., Brouillette, M., Kim, S. J., Baaklini, L., Wetmore, D. S., Hong, G., Goto, R., Jivanelli, B., Athanassoglou, V., Argyra, E., Barrington, M. J., Borgeat, A., De Andres, J., El-Boghdadly, K., Elkassabany, N. M., Gautier, P., Gerner, P., Gonzalez Della Valle, A., Goytizolo, E., Guo, Z., Hogg, R., Kehlet, H., Kessler, P., Kopp, S., Lavand'homme, P., Macfarlane, A., MacLean, C., Mantilla, C., McIsaac, D., McLawhorn, A., Neal, J. M., Parks, M., Parvizi, J., Peng, P., Pichler, L., Poeran, J., Poultsides, L., Schwenk, E. S., Sites, B. D., Stundner, O., Sun, E. C., Viscusi, E., Votta-Velis, E. G., Wu, C. L., YaDeau, J., Sharrock, N. E. 2021

  Abstract

  BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95%CI 0.17 to 0.53/OR 0.52, 95%CI 0.34 to 0.80), respiratory failure (OR 0.36, 95%CI 0.17 to 0.74/OR 0.37, 95%CI 0.18 to 0.75), cardiac complications (OR 0.84, 95%CI 0.76 to 0.93/OR 0.83, 95%CI 0.79 to 0.86), surgical site infections (OR 0.55 95%CI 0.47 to 0.64/OR 0.86 95%CI 0.80 to 0.91), thromboembolism (OR 0.74, 95%CI 0.58 to 0.96/OR 0.90, 95%CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95%CI 0.83 to 0.86/OR 0.91, 95%CI 0.90 to 0.92).CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

  View details for DOI 10.1136/rapm-2021-102750

  View details for PubMedID 34433647

• Preliminary analysis of factors affecting publication of abstracts presented during the 2017 American Society of Regional Anesthesia and Pain Medicine spring annual meeting. Regional anesthesia and pain medicine Rasouli, M. R., Maty, S., Mariano, E. R., Jaremko, K., Kou, A., Memtsoudis, S. G., Elkassabany, N. M., Schwenk, E. S. 2021

  View details for DOI 10.1136/rapm-2021-103046

  View details for PubMedID 34429369

• Immediate Effects of a Continuous Peripheral Nerve Block on Postamputation Phantom and Residual Limb Pain: Secondary Outcomes From a Multicenter Randomized Controlled Clinical Trial. Anesthesia and analgesia Ilfeld, B. M., Khatibi, B., Maheshwari, K., Madison, S. J., Ali Sakr Esa, W., Mariano, E. R., Kent, M. L., Hanling, S., Sessler, D. I., Eisenach, J. C., Cohen, S. P., Mascha, E. J., Yang, D., Padwal, J. A., Turan, A., PAINfRE Investigators, Morris, B. A., Szmuk, P., Beck, G. J., Abdullah, B., Aleshi, P., Buys, M. J., Cata, J. P., Chen, G., De Oliveira, G. S., Elsharkawy, H., Finneran, J. J., Ganaway, T., Govindarajan, S. R., Kalasbail, P., Kendall, M. C., Zafeer Khan, M., Kopp, S., Loland, V. J., Machi, A. T., Malik, T., Memtsoudis, S. G., Missair, A., Ilfeld, A. M., Mounir-Soliman, L., Braun, B., Vlassakov, K. V., Warren, L., Wen, C. H., Woodworth, G. E., Young, A. C. 2021

  Abstract

  BACKGROUND: We recently reported that a 6-day continuous peripheral nerve block reduced established postamputation phantom pain 3 weeks after treatment ended. However, the immediate effects of perineural infusion (secondary outcomes) have yet to be reported.METHODS: Participants from 5 enrolling academic centers with an upper or lower limb amputation and established phantom pain received a single-injection ropivacaine peripheral nerve block(s) and perineural catheter insertion(s). They were subsequently randomized to receive a 6-day ambulatory perineural infusion of either ropivacaine 0.5% or normal saline in a double-masked fashion. Participants were contacted by telephone 1, 7, 14, 21, and 28 days after the infusion started, with pain measured using the Numeric Rating Scale. Treatment effects were assessed using the Wilcoxon rank-sum test at each time point. Adjusting for 4 time points (days 1, 7, 14, and 21), P < .0125 was deemed statistically significant. Significance at 28 days was reported using methods from the original, previously published article.RESULTS: Pretreatment average phantom and residual pain scores were balanced between the groups. The day after infusion initiation (day 1), average phantom, and residual limb pain intensity was lower in patients receiving local anesthetic (n = 71) versus placebo (n = 73): median [quartiles] of 0 [0-2.5] vs 3.3 [0-5.0], median difference (98.75% confidence interval [CI]) of -1.0 (-3.0 to 0) for phantom pain (P = .001) and 0 [0-0] vs 0 [0-4.3], and median difference 0.0 (-2.0 to 0.0) for residual limb pain (P < .001). Pain's interference with physical and emotional functioning as measured with the interference domain of the Brief Pain Inventory improved during the infusion on day 1 for patients receiving local anesthetic versus placebo: 0 [0-10] vs 10 [0-40], median difference (98.75% CI) of 0.0 (-16.0 to 0.0), P = .002. Following infusion discontinuation (day 6), a few differences were found between the active and placebo treatment groups between days 7 and 21. In general, sample medians for average phantom and residual limb pain scores gradually increased after catheter removal for both treatments, but to a greater degree in the control group until day 28, at which time the differences between the groups returned to statistical significance.CONCLUSIONS: This secondary analysis suggests that a continuous peripheral nerve block decreases phantom and residual limb pain during the infusion, although few improvements were again detected until day 28, 3 weeks following catheter removal.

  View details for DOI 10.1213/ANE.0000000000005673

  View details for PubMedID 34314392

• Standardizing nomenclature in regional anesthesia: an ASRA-ESRA Delphi consensus study of abdominal wall, paraspinal, and chest wall blocks. Regional anesthesia and pain medicine El-Boghdadly, K., Wolmarans, M., Stengel, A. D., Albrecht, E., Chin, K. J., Elsharkawy, H., Kopp, S., Mariano, E. R., Xu, J. L., Adhikary, S., Altiparmak, B., Barrington, M. J., Bloc, S., Blanco, R., Boretsky, K., Borglum, J., Breebaart, M., Burckett-St Laurent, D., Capdevila, X., Carvalho, B., Chuan, A., Coppens, S., Costache, I., Dam, M., Egeler, C., Fajardo, M., Gadsden, J., Gautier, P. E., Grant, S. A., Hadzic, A., Hebbard, P., Hernandez, N., Hogg, R., Holtz, M., Johnson, R. L., Karmakar, M. K., Kessler, P., Kwofie, K., Lobo, C., Ludwin, D., MacFarlane, A., McDonnell, J., McLeod, G., Merjavy, P., Moran, E., O'Donnell, B. D., Parras, T., Pawa, A., Perlas, A., Rojas Gomez, M. F., Sala-Blanch, X., Saporito, A., Sinha, S. K., Soffin, E. M., Thottungal, A., Tsui, B. C., Tulgar, S., Turbitt, L., Uppal, V., van Geffen, G. J., Volk, T., Elkassabany, N. M. 2021; 46 (7): 571-580

  Abstract

  BACKGROUND: There is heterogeneity in the names and anatomical descriptions of regional anesthetic techniques. This may have adverse consequences on education, research, and implementation into clinical practice. We aimed to produce standardized nomenclature for abdominal wall, paraspinal, and chest wall regional anesthetic techniques.METHODS: We conducted an international consensus study involving experts using a three-round Delphi method to produce a list of names and corresponding descriptions of anatomical targets. After long-list formulation by a Steering Committee, the first and second rounds involved anonymous electronic voting and commenting, with the third round involving a virtual round table discussion aiming to achieve consensus on items that had yet to achieve it. Novel names were presented where required for anatomical clarity and harmonization. Strong consensus was defined as ≥75% agreement and weak consensus as 50% to 74% agreement.RESULTS: Sixty expert Collaborators participated in this study. After three rounds and clarification, harmonization, and introduction of novel nomenclature, strong consensus was achieved for the names of 16 block names and weak consensus for four names. For anatomical descriptions, strong consensus was achieved for 19 blocks and weak consensus was achieved for one approach. Several areas requiring further research were identified.CONCLUSIONS: Harmonization and standardization of nomenclature may improve education, research, and ultimately patient care. We present the first international consensus on nomenclature and anatomical descriptions of blocks of the abdominal wall, chest wall, and paraspinal blocks. We recommend using the consensus results in academic and clinical practice.

  View details for DOI 10.1136/rapm-2020-102451

  View details for PubMedID 34145070

• Percutaneous Peripheral Nerve Stimulation (Neuromodulation) for Postoperative Pain: A Randomized, Sham-controlled Pilot Study ANESTHESIOLOGY Ilfeld, B. M., Plunkett, A., Vijjeswarapu, A. M., Hackworth, R., Dhanjal, S., Turan, A., Cohen, S. P., Eisenach, J. C., Griffith, S., Hanling, S., Sessler, D., Mascha, E. J., Yang, D., Boggs, J. W., Wongsarnpigoon, A., Gelfand, H., PAINfRE Investigators 2021; 135 (1): 95-110

  Abstract

  Percutaneous peripheral nerve stimulation is an analgesic technique involving the percutaneous implantation of a lead followed by the delivery of electric current using an external pulse generator. Percutaneous peripheral nerve stimulation has been used extensively for chronic pain, but only uncontrolled series have been published for acute postoperative pain. The current multicenter study was undertaken to (1) determine the feasibility and optimize the protocol for a subsequent clinical trial and (2) estimate the treatment effect of percutaneous peripheral nerve stimulation on postoperative pain and opioid consumption.Preoperatively, an electrical lead was percutaneously implanted to target the sciatic nerve for major foot/ankle surgery (e.g., hallux valgus correction), the femoral nerve for anterior cruciate ligament reconstruction, or the brachial plexus for rotator cuff repair, followed by a single injection of long-acting local anesthetic along the same nerve/plexus. Postoperatively, participants were randomized to 14 days of either electrical stimulation (n = 32) or sham stimulation (n = 34) using an external pulse generator in a double-masked fashion. The dual primary treatment effect outcome measures were (1) cumulative opioid consumption (in oral morphine equivalents) and (2) mean values of the "average" daily pain scores measured on the 0 to 10 Numeric Rating Scale within the first 7 postoperative days.During the first 7 postoperative days, opioid consumption in participants given active stimulation was a median (interquartile range) of 5 mg (0 to 30) versus 48 mg (25 to 90) in patients given sham treatment (ratio of geometric means, 0.20 [97.5% CI, 0.07 to 0.57]; P < 0.001). During this same period, the average pain intensity in patients given active stimulation was a mean ± SD of 1.1 ± 1.1 versus 3.1 ± 1.7 in those given sham (difference, -1.8 [97.5% CI, -2.6 to -0.9]; P < 0.001).Percutaneous peripheral nerve stimulation reduced pain scores and opioid requirements free of systemic side effects during at least the initial week after ambulatory orthopedic surgery.

  View details for DOI 10.1097/ALN.0000000000003776

  View details for Web of Science ID 000658897100010

  View details for PubMedID 33856424

• Evaluation of trends in continuous peripheral nerve block utilization for total knee arthroplasty within and outside the Veterans Affairs Healthcare System. Regional anesthesia and pain medicine Nagavelli, H., Mariano, E. R., Krishnamoorthy, V., Ray, N. D., Hsia, H., Ellis, A. R., Memtsoudis, S. G., Bryan, W. E., Pepin, M. J., Raghunathan, K. 2021

  View details for DOI 10.1136/rapm-2021-102731

  View details for PubMedID 34083357

• Racism in Pain Medicine: We Can and Should Do More. Mayo Clinic proceedings Strand, N. H., Mariano, E. R., Goree, J. H., Narouze, S., Doshi, T. L., Freeman, J. A., Pearson, A. C. 2021; 96 (6): 1394-1400

  View details for DOI 10.1016/j.mayocp.2021.02.030

  View details for PubMedID 34088411

• The opioid sparing effect of erector spinae plane block for various surgeries: a meta-analysis of randomized-controlled trials. Minerva anestesiologica Fanelli, A., Torrano, V., Cozowicz, C., Mariano, E. R., Balzani, E. 2021

  Abstract

  INTRODUCTION: The erector spinae plane block (ESPB) is a newer fascial plane block which has been broadly applied for postoperative analgesia after various surgeries, but the effectiveness in these populations is not well established.EVIDENCE ACQUISITION: A systematic database search was conducted in PubMed, PMC, Embase, and Scopus for randomized controlled trials (RCTs) comparing ESPB with control, placebo, or other blocks. The primary outcome was intravenous opioid consumption in milligram morphine equivalents 24 h after surgery. Standardized mean differences (SMDs) with 95% confidence intervals (CI) were calculated using a randomeffects model.EVIDENCE SYNTHESIS: A total of 29 RCTs were included. An analysis was conducted by subgroups differentiated by surgery type, 'no block' vs. ESPB, and other blocks vs. ESPB. ESPB was effective in reducing opioid consumption against no block for breast surgery (SMD -1.13; CI 95%), thoracic surgery (SMD -3.00; CI 95%), and vertebral surgery (SMD -1.78; CI 95%). ESPB was effective against alternative blocks for breast surgery (vs. paravertebral, SMD -1.07; CI 95%) and abdominal surgery (SMD -1.77; CI 95%). ESPB showed moderate effect in thoracic surgery against paravertebral (SMD 0.58; CI 95%) and against no block in abdominal surgery (SMD 0.80; CI 95%). In only one case did ESPB perform worse than another block: vs. PECS block for breast surgery (SMD 1.66; CI 95%).CONCLUSIONS: ESPB may be a useful addition to the multimodal analgesic regimen for a variety of surgeries especially when the alternative is no block. Unanswered questions include determining of the mechanism of action, refining of the EPSB technique, and establishing recommended local anesthetic dose and volume.

  View details for DOI 10.23736/S0375-9393.21.15356-8

  View details for PubMedID 33982985

• Pilot study to correlate objective eye-tracking data with timed subjective task completion using five local anesthetic systemic toxicity cognitive aids. Regional anesthesia and pain medicine Joo, S. S., Mariano, E. R., Neal, J. M., Weinberg, G. L., Kou, A., Hunter, O. O., Harrison, T. K., Udani, A. D., Howard, S. K. 2021

  View details for DOI 10.1136/rapm-2021-102547

  View details for PubMedID 33837138

• Enhanced recovery pathways and patient-reported outcome measures in gynaecological oncology. Anaesthesia Chen, Q., Mariano, E. R., Lu, A. C. 2021; 76 Suppl 4: 131–38

  Abstract

  Comprehensive peri-operative care for women with gynaecological malignancy is essential to ensure optimal clinical outcomes and maximise patient experience through the continuum of care. Implementation of peri-operative enhanced recovery pathways in gynaecological oncology have been repeatedly shown to improve postoperative recovery, decrease complications and reduce healthcare costs. With increasing emphasis being placed on patient-centred care in the current healthcare environment, incorporation of patient-reported outcome data collection and analysis within the enhanced recovery pathway as part of quality measurement is not only useful, but necessary. Inclusion of patient-reported outcome enhanced recovery pathway evaluation enables clinicians to capture authentic patient-reported parameters such as subtle symptoms, changes in function and multiple dimensions of well-being, directly from the source. These data guide the treatment course by encouraging shared decision-making between the patient and clinicians and provide the necessary foundation for ongoing peri-operative quality improvement efforts. Elements of the gynaecological oncology enhanced recovery pathway are divided into five phases of care: pre-admission; pre-operative; intra-operative; postoperative; and post-discharge. The development process starts with detailing each step of the patient's journey in all five phases, then identifying stakeholder groups responsible for care at each of these phases and assembling a multidisciplinary team including: gynaecologists; anaesthetists; nurses; nutritionists; physical therapists; and others, to provide input into the institutional pathway. To practically integrate patient-reported outcomes into an enhanced recovery pathway, a validated measurement tool should be incorporated into the peri-operative workflow. The ideal tool should be concise to facilitate longitudinal assessments by the clinical staff.

  View details for DOI 10.1111/anae.15422

  View details for PubMedID 33682089

• Contemporary training methods in regional anaesthesia: fundamentals and innovations. Anaesthesia Ramlogan, R. R., Chuan, A. n., Mariano, E. R. 2021; 76 Suppl 1: 53–64

  Abstract

  Over the past two decades, regional anaesthesia and medical education as a whole have undergone a renaissance. Significant changes in our teaching methods and clinical practice have been influenced by improvements in our theoretical understanding as well as by technological innovations. More recently, there has been a focus on using foundational education principles to teach regional anaesthesia, and the evidence on how to best teach and assess trainees is growing. This narrative review will discuss fundamentals and innovations in regional anaesthesia training. We present the fundamentals in regional anaesthesia training, specifically the current state of simulation-based education, deliberate practice and curriculum design based on competency-based progression. Moving into the future, we present the latest innovations in web-based learning, emerging technologies for teaching and assessment and new developments in alternate reality learning systems.

  View details for DOI 10.1111/anae.15244

  View details for PubMedID 33426656

• Eight years and already a classic: marking the rise of ultrasound-guided fascial plane blocks for chest wall surgery. Anaesthesia Kumar, A. H., Sultan, E., Mariano, E. R. 2021; 76 (8): 1129-1133

  View details for DOI 10.1111/anae.15499

  View details for PubMedID 34224138

• In reply: 'automating patient outcomes: next frontier?' Regional anesthesia and pain medicine Gessner, D., Hunter, O. O., Kou, A., Mariano, E. R. 2021

  View details for DOI 10.1136/rapm-2021-102992

  View details for PubMedID 34226196

• Assessment of Intercostal Nerve Block Analgesia for Thoracic Surgery: A Systematic Review and Meta-analysis. JAMA network open Guerra-Londono, C. E., Privorotskiy, A., Cozowicz, C., Hicklen, R. S., Memtsoudis, S. G., Mariano, E. R., Cata, J. P. 2021; 4 (11): e2133394

  Abstract

  The use of intercostal nerve block (ICNB) analgesia with local anesthesia is common in thoracic surgery. However, the benefits and safety of ICNB among adult patients undergoing surgery is unknown.To evaluate the analgesic benefits and safety of ICNB among adults undergoing thoracic surgery.A systematic search was performed in Ovid MEDLINE, Ovid Embase, Scopus, and the Cochrane Library databases using terms for ICNB and thoracic surgery (including thoracic surgery, thoracoscopy, thoracotomy, nerve block, intercostal nerves). The search and results were not limited by date, with the last search conducted on July 24, 2020.Selected studies were experimental or observational and included adult patients undergoing cardiothoracic surgery in which ICNB was administered with local anesthesia via single injection, continuous infusion, or a combination of both techniques in at least 1 group of patients. For comparison with ICNB, studies that examined systemic analgesia and different forms of regional analgesia (such as thoracic epidural analgesia [TEA], paravertebral block [PVB], and other techniques) were included. These criteria were applied independently by 2 authors, and discrepancies were resolved by consensus. A total of 694 records were selected for screening.This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Data including patient characteristics, type of surgery, intervention analgesia, comparison analgesia, and primary and secondary outcomes were extracted independently by 3 authors. Synthesis was performed using a fixed-effects model.The coprimary outcomes were postoperative pain intensity (measured as the worst static or dynamic pain using a validated 10-point scale, with 0 indicating no pain and 10 indicating severe pain) and opioid consumption (measured in morphine milligram equivalents [MMEs]) at prespecified intervals (0-6 hours, 7-24 hours, 25-48 hours, 49-72 hours, and >72 hours). Clinically relevant analgesia was defined as a 1-point or greater difference in pain intensity score at any interval. Secondary outcomes included 30-day postoperative complications and pulmonary function.Of 694 records screened, 608 were excluded based on prespecified exclusion criteria. The remaining 86 full-text articles were assessed for eligibility, and 20 of those articles were excluded. All of the 66 remaining studies (5184 patients; mean [SD] age, 53.9 [10.2] years; approximately 59% men and 41% women) were included in the qualitative analysis, and 59 studies (3325 patients) that provided data for at least 1 outcome were included in the quantitative meta-analysis. Experimental studies had a high risk of bias in multiple domains, including allocation concealment, blinding of participants and personnel, and blinding of outcome assessors. Marked differences (eg, crossover studies, timing of the intervention [intraoperative vs postoperative], blinding, and type of control group) were observed in the design and implementation of studies. The use of ICNB vs systemic analgesia was associated with lower static pain (0-6 hours after surgery: mean score difference, -1.40 points [95% CI, -1.46 to -1.33 points]; 7-24 hours after surgery: mean score difference, -1.27 points [95% CI, -1.40 to -1.13 points]) and lower dynamic pain (0-6 hours after surgery: mean score difference, -1.66 points [95% CI, -1.90 to -1.41 points]; 7-24 hours after surgery: mean score difference, -1.43 points [95% CI, -1.70 to -1.17 points]). Intercostal nerve block analgesia was noninferior to TEA (mean score difference in worst dynamic panic at 7-24 hours after surgery: 0.79 points; 95% CI, 0.28-1.29 points) and marginally inferior to PVB (mean score difference in worst dynamic pain at 7-24 hours after surgery: 1.29 points; 95% CI, 1.16 to 1.41 points). The largest opioid-sparing effect of ICNB vs systemic analgesia occurred at 48 hours after surgery (mean difference, -10.97 MMEs; 95% CI, -12.92 to -9.02 MMEs). The use of ICNB was associated with higher MME values compared with TEA (eg, 48 hours after surgery: mean difference, 48.31 MMEs; 95% CI, 36.11-60.52 MMEs) and PVB (eg, 48 hours after surgery: mean difference, 3.87 MMEs; 95% CI, 2.59-5.15 MMEs).In this study, single-injection ICNB was associated with a reduction in pain during the first 24 hours after thoracic surgery and was clinically noninferior to TEA or PVB. Intercostal nerve block analgesia had opioid-sparing effects; however, TEA and PVB were associated with larger decreases in postoperative MMEs, suggesting that ICNB may be most beneficial for cases in which TEA and PVB are not indicated.

  View details for DOI 10.1001/jamanetworkopen.2021.33394

  View details for PubMedID 34779845

• A tale of two surges: messaging app and public COVID-19 data summarize one anesthesiology practice's pandemic year in review. Canadian journal of anaesthesia = Journal canadien d'anesthesie Leng, J. C., Tirumalai, A. A., Kou, A., Brun, C., Coffman, C., Harrison, T. K., Howard, S. K., Shum, C., Hammons, A., Mariano, E. R. 2021

  View details for DOI 10.1007/s12630-021-02088-x

  View details for PubMedID 34405359

• The expanding role of chronic pain interventions in multimodal perioperative pain management: a narrative review. Postgraduate medicine Ye, Y., Gabriel, R. A., Mariano, E. R. 2021

  Abstract

  Surgery is a risk factor for chronic pain and long-term opioid use. As perioperative pain management continues to evolve, treatment modalities traditionally used for chronic pain therapy may provide additional benefit to patients undergoing surgery. Interventions such as radiofrequency ablation, cryoneurolysis, and neuromodulation may potentially be used in conjunction with acute pain procedures such as nerve blocks and multimodal analgesia. Pharmacological agents associated with chronic pain medicine, including gabapentinoids, ketamine, and selective serotonin reuptake inhibitors, may be useful adjuncts in perioperative pain management when indicated. There may also be a role for acupuncture, music therapy, and other integrative medicine therapies. A transitional pain service can help coordinate outpatient care with inpatient perioperative pain management and promote a more personalized and comprehensive approach that can improve postoperative outcomes.

  View details for DOI 10.1080/00325481.2021.1935281

  View details for PubMedID 34033737

• In reply: Three (more) tips to reduce socioeconomic bias in virtual anesthesiology interviews. Canadian journal of anaesthesia = Journal canadien d'anesthesie Leng, J. C., Mariano, E. R., El-Boghdadly, K. 2021

  View details for DOI 10.1007/s12630-021-02034-x

  View details for PubMedID 34031806

  View details for PubMedCentralID PMC8143740

• Believe the hype? An evaluation of Twitter activity and publication trends related to the erector spinae plane block. Journal of clinical anesthesia De Cassai, A., Geraldini, F., Mariano, E. R., Kou, A., Matava, C. 2021; 75: 110499

  View details for DOI 10.1016/j.jclinane.2021.110499

  View details for PubMedID 34481365

• Non-Fellowship regional anesthesia training and assessment: an international Delphi study on a consensus curriculum. Regional anesthesia and pain medicine Chuan, A., Jeyaratnam, B., Fathil, S., Ferraro, L. H., Kessow, A., Lim, Y. C., O'Rourke, M. J., Ponde, V., Raft, J., Segurado, A., Tangwiwat, S., Torborg, A., Turbitt, L., Lansdown, A. K., Mariano, E. R., McCartney, C. J., Macfarlane, A. J., Mok, L. Y., Orebaugh, S. L., Pawa, A., Suresh, S., Subramanian, J. B., Volk, T., Woodworth, G., Ramlogan, R. 2021

  Abstract

  While there are several published recommendations and guidelines for trainees undertaking subspecialty Fellowships in regional anesthesia, a similar document describing a core regional anesthesia curriculum for non-fellowship trainees is less well defined. We aimed to produce an international consensus for the training and teaching of regional anesthesia that is applicable for the majority of worldwide anesthesiologists.This anonymous, electronic Delphi study was conducted over two rounds and distributed to current and immediate past (within 5 years) directors of regional anesthesia training worldwide. The steering committee formulated an initial list of items covering nerve block techniques, learning objectives and skills assessment and volume of practice, relevant to a non-fellowship regional anesthesia curriculum. Participants scored these items in order of importance using a 10-point Likert scale, with free-text feedback. Strong consensus items were defined as highest importance (score ≥8) by ≥70% of all participants.469 participants/586 invitations (80.0% response) scored in round 1, and 402/469 participants (85.7% response) scored in round 2. Participants represented 66 countries. Strong consensus was reached for 8 core peripheral and neuraxial blocks and 17 items describing learning objectives and skills assessment. Volume of practice for peripheral blocks was uniformly 16-20 blocks per anatomical region, while ≥50 neuraxial blocks were considered minimum.This international consensus study provides specific information for designing a non-fellowship regional anesthesia curriculum. Implementation of a standardized curriculum has benefits for patient care through improving quality of training and quality of nerve blocks.

  View details for DOI 10.1136/rapm-2021-102934

  View details for PubMedID 34285116

• Fighting burnout in the COVID-19 era is a family matter. Journal of clinical anesthesia Padilla, K. E., Silver, E. M., Flores, L. E., Muir, R. n., Salinas, M. n., Mariano, E. R. 2021; 72: 110293

  View details for DOI 10.1016/j.jclinane.2021.110293

  View details for PubMedID 33901743

• Making a business plan for starting a transitional pain service within the US healthcare system. Regional anesthesia and pain medicine Sun, E. C., Mariano, E. R., Narouze, S. n., Gabriel, R. A., Elsharkawy, H. n., Gulur, P. n., Merrick, S. K., Harrison, T. K., Clark, J. D. 2021

  Abstract

  Chronic pain imposes a tremendous economic burden of up to US$635 billion per year in terms of direct costs (such as the costs of treatment) and indirect costs (such as lost productivity and time away from work). In addition, the initiation of opioids for pain is associated with a more than doubling of pharmacy and all-cause medical costs. The high costs of chronic pain are particularly relevant for anesthesiologists because surgery represents an inciting event that can lead to chronic pain and long-term opioid use. While the presence of risk factors and an individual patient's postoperative pain trajectory may predict who is at high risk for chronic pain and opioid use after surgery, to date, there are few interventions proven to reduce these risks. One promising approach is the transitional pain service. Programs like this attempt to bridge the gap between acute and chronic pain management, provide continuity of care for complicated acute pain patients after discharge from the hospital, and offer interventions for patients who are on abnormal trajectories of pain resolution and/or opioid use. Despite awareness of chronic pain after surgery and the ongoing opioid epidemic, there are few examples of successful transitional pain service implementation in the USA. Key issues and concerns include financial incentives and the required investment from the hospital or healthcare system. We present an economic analysis and discussion of important considerations when developing a business plan for a transitional pain service.

  View details for DOI 10.1136/rapm-2021-102669

  View details for PubMedID 33879540

• Regional anesthesia educational material utilization varies by World Bank income category: A mobile health application data study. PloS one Moll, V. n., Mariano, E. R., Kitzman, J. M., O'Reilly-Shah, V. N., Jabaley, C. S. 2021; 16 (2): e0244860

  Abstract

  Regional anesthesia offers an alternative to general anesthesia and may be advantageous in low resource environments. There is a paucity of data regarding the practice of regional anesthesia in low- and middle-income countries. Using access data from a free Android app with curated regional anesthesia learning modules, we aimed to estimate global interest in regional anesthesia and potential applications to clinical practice stratified by World Bank income level.We retrospectively analyzed data collected from the free Android app "Anesthesiologist" from December 2015 to April 2020. The app performs basic anesthetic calculations and provides links to videos on performing 12 different nerve blocks. Users of the app were classified on the basis of whether or not they had accessed the links. Nerve blocks were also classified according to major use (surgical block, postoperative pain adjunct, rescue block).Practitioners in low- and middle-income countries accessed the app more frequently than in high-income countries as measured by clicks. Users from low- and middle-income countries focused mainly on surgical blocks: ankle, axillary, infraclavicular, interscalene, and supraclavicular blocks. In high-income countries, more users viewed postoperative pain blocks: adductor canal, popliteal, femoral, and transverse abdominis plane blocks. Utilization of the app was constant over time with a general decline with the start of the COVID-19 pandemic.The use of an in app survey and analytics can help identify gaps and opportunities for regional anesthesia techniques and practices. This is especially impactful in limited-resource areas, such as lower-income environments and can lead to targeted educational initiatives.

  View details for DOI 10.1371/journal.pone.0244860

  View details for PubMedID 33524031

• Advancing towards the next frontier in regional anaesthesia. Anaesthesia Chin, K. J., Mariano, E. R., El-Boghdadly, K. n. 2021; 76 Suppl 1: 3–7

  View details for DOI 10.1111/anae.15321

  View details for PubMedID 33426654

• Automated text messaging follow-up for patients who receive peripheral nerve blocks. Regional anesthesia and pain medicine Gessner, D. n., Hunter, O. O., Kou, A. n., Mariano, E. R. 2021

  Abstract

  Routine follow-up of patients who receive a nerve block for ambulatory surgery typically consists of a phone call from a regional anesthesia clinician. This process can be burdensome for both patients and clinicians but is necessary to assess the efficacy and complication rate of nerve blocks.We present our experience developing an automated system for completing follow-up via short message service text messaging and our preliminary results using it at three clinical sites. The system is built on REDCap, a secure online research data capture platform developed by Vanderbilt University and currently available worldwide.Our automated system queried patients who received a variety of nerve block techniques, assessed patient-reported nerve block duration, and surveyed patients for potential complications. Patient response rate to text messaging averaged 91% (higher than our rates of daily phone contact reported previously) for patients aged 18 to 90 years.Given the wide availability of REDCap, we believe this automated text messaging system can be implemented in a variety of health systems at low cost with minimal technical expertise and will improve both the consistency of patient follow-up and the service efficiency of regional anesthesia practices.

  View details for DOI 10.1136/rapm-2021-102472

  View details for PubMedID 33649155

• We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations. World journal of surgery Panda, N. n., Etheridge, J. C., Singh, T. n., Sonnay, Y. n., Molina, G. n., Burian, B. K., Capo-Chichi, N. n., Cauley, C. E., de Beer, D. A., Derbew, M. n., Dias, R. D., Fearon, M. C., Feyssa, M. D., Hagen, K. n., Kumar, M. n., Mammo, T. N., Mariano, E. R., Merry, A. n., Mushayandebvu, B. n., Nabukenya, M. T., Shah, M. n., Spruce, L. n., Weiser, T. G., Brindle, M. E. 2021

  Abstract

  As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic.18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus.From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation.This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

  View details for DOI 10.1007/s00268-021-06000-y

  View details for PubMedID 33638023

• A field on fire: Why has there been so much attention focused on burnout among anesthesiologists? Journal of clinical anesthesia Muir, R., Flores, L. E., Padilla, K. E., Salinas, M., Silver, E. M., Mariano, E. R. 2021; 73: 110356

  View details for DOI 10.1016/j.jclinane.2021.110356

  View details for PubMedID 34062474

• Six tips for successful virtual anesthesiology interviews in the COVID-19 era and beyond. Canadian journal of anaesthesia = Journal canadien d'anesthesie Leng, J. C., Mariano, E. R., El-Boghdadly, K. n. 2021

  View details for DOI 10.1007/s12630-021-01977-5

  View details for PubMedID 33761102

• Analysis of the gender distribution of industry- and society-sponsored webinar faculty during the COVID-19 pandemic. Journal of clinical anesthesia Strand, N. H., Maloney, J. A., Mariano, E. R., Rosenow, J. M., Moeschler, S. M., Narouze, S., Petersen, E. A. 2020; 67: 110040

  View details for DOI 10.1016/j.jclinane.2020.110040

  View details for PubMedID 32979612

• Are anesthesiology societies at risk of becoming obsolete? Perspectives on challenges and opportunities for moving forward. International anesthesiology clinics Methangkool, E., Mariano, E. R., Oakes, D. 2020

  View details for DOI 10.1097/AIA.0000000000000290

  View details for PubMedID 32852314

• Leveraging video telehealth for the transitional pain service in response to COVID-19. Regional anesthesia and pain medicine Hunter, O. O., Mariano, E. R., Harrison, T. K. 2020

  View details for DOI 10.1136/rapm-2020-101742

  View details for PubMedID 32522866

• Patient experiences following botulinum toxin A injection for complex abdominal wall hernia repair. Journal of clinical anesthesia Hunter, O. O., Pratt, J. S., Bandle, J., Leng, J., Mariano, E. R. 2020; 66: 109956

  View details for DOI 10.1016/j.jclinane.2020.109956

  View details for PubMedID 32516679

• Using postoperative pain trajectories to define the role of regional analgesia in personalised pain medicine. Anaesthesia Mariano, E. R., El-Boghdadly, K., Ilfeld, B. M. 2020

  View details for DOI 10.1111/anae.15067

  View details for PubMedID 32368794

• Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery. Regional anesthesia and pain medicine Joo, S. S., Hunter, O. O., Tamboli, M., Leng, J. C., Harrison, T. K., Kassab, K., Keeton, J. D., Skirboll, S., Tharin, S., Saleh, E., Mudumbai, S. C., Wang, R. R., Kou, A., Mariano, E. R. 2020

  Abstract

  BACKGROUND AND OBJECTIVES: At our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery.METHODS: In this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1year before and after introduction of the protocol. This protocol used the patient's prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events.RESULTS: Eighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420-1440) preintervention compared with 300 (112-806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes.CONCLUSIONS: This patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.

  View details for DOI 10.1136/rapm-2020-101324

  View details for PubMedID 32238478

• Opioid Stewardship Program and Postoperative Adverse Events: A Difference-in-differences Cohort Study. Anesthesiology Barreveld, A. M., McCarthy, R. J., Elkassabany, N., Mariano, E. R., Sites, B., Ghosh, R., Buvanendran, A. 2020

  Abstract

  BACKGROUND: A 6-month opioid use educational program consisting of webinars on pain assessment, postoperative and multimodal pain opioid management, safer opioid use, and preventing addiction coupled with on-site coaching and monthly assessments reports was implemented in 31 hospitals. The authors hypothesized the intervention would measurably reduce and/or prevent opioid-related harm among adult hospitalized patients compared to 33 nonintervention hospitals.METHODS: Outcomes were extracted from medical records for 12 months before and after the intervention start date. Opioid adverse events, evaluated by opioid overdose, wrong substance given or taken in error, naloxone administration, and acute postoperative respiratory failure causing prolonged ventilation were the primary outcomes. Opioid use in adult patients undergoing elective hip or knee arthroplasty or colorectal procedures was also assessed. Differences-in-differences were compared between intervention and nonintervention hospitals.RESULTS: Before the intervention, the incidence ± SD of opioid overdose, wrong substance given, or substance taken in error was 1 ± 0.5 per 10,000 discharges, and naloxone use was 117 ± 13 per 10,000 patients receiving opioids. The incidence of respiratory failure was 42 ± 10 per 10,000 surgical discharges. A difference-in-differences of -0.2 (99% CI, -1.1 to 0.6, P = 0.499) per 10,000 in opioid overdose, wrong substance given, or substance taken in error and -13.6 (99% CI, -29.0 to 0.0, P = 0.028) per 10,000 in respiratory failure was observed postintervention in the intervention hospitals; however, naloxone administration increased by 15.2 (99% CI, 3.8 to 30.0, P = 0.011) per 10,000. Average total daily opioid use, as well as the fraction of patients receiving daily opioid greater than 90 mg morphine equivalents was not different between the intervention and nonintervention hospitals.CONCLUSIONS: A 6-month opioid educational intervention did not reduce opioid adverse events or alter opioid use in hospitalized patients. The authors' findings suggest that despite opioid and multimodal analgesia awareness, limited-duration educational interventions do not substantially change the hospital use of opioid analgesics. : WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Education may promote safer opioid use in hospitals WHAT THIS ARTICLE TELLS US THAT IS NEW: The investigators conducted a difference-in-differences analysis before and after implementation of opioid training in 31 intervention hospitals and 33 nonintervention hospitalsThe 6-month-long opioid education consisted of webinars on pain assessment, multimodal analgesia, and safer opioid useThe educational initiative did not substantively change opioid use.

  View details for DOI 10.1097/ALN.0000000000003238

  View details for PubMedID 32167983

• Replacement of Fascia Iliaca Catheters with Continuous Erector Spinae Plane Blocks Within a Clinical Pathway Facilitates Early Ambulation After Total Hip Arthroplasty. Pain medicine (Malden, Mass.) Xu, L. n., Leng, J. C., Elsharkawy, H. n., Hunter, O. O., Harrison, T. K., Vokach-Brodsky, L. n., Kumar, G. n., Funck, N. n., Hill, J. N., Giori, N. J., Indelli, P. F., Kou, A. n., Mariano, E. R. 2020

  Abstract

  The optimal continuous peripheral nerve block (CPNB) technique for total hip arthroplasty (THA) that maximizes both analgesia and mobility is unknown. Continuous erector spinae plane (ESP) blocks were implemented at our institution as a replacement for fascia iliaca (FI) catheters to improve our THA clinical pathway. We designed this study to test the hypothesis that this change will increase early postoperative ambulation for elective primary THA patients.We identified all consecutive primary unilateral THA cases six months before and six months after the clinical pathway change to ESP catheters. All other aspects of the THA clinical pathway and multimodal analgesic regimen including perineural infusion protocol did not change. The primary outcome was total ambulation distance (meters) on postoperative day 1. Other outcomes included total ambulation on postoperative day 2, combined two-day ambulation distance, pain scores, opioid consumption, inpatient length of stay, and minor and major adverse events.Eighty-eight patients comprised the final sample (43 FI and 45 ESP). Postoperative day 1 total ambulation distance was greater for the ESP group compared with the FI group (median [10th-90th percentiles] = 24.4 [0.0-54.9] vs 9.1 [0.7-45.7] meters, respectively, P = 0.036), and two-day ambulation distance was greater for the ESP group compared with the FI group (median [10th-90th percentiles] = 68.6 [9.0-128.0] vs 46.6 [3.7-104.2] meters, respectively, P = 0.038). There were no differences in pain scores, opioid use, or other outcomes.Replacing FI catheters with continuous ESP blocks within a clinical pathway results in increased early ambulation by elective primary THA patients.

  View details for DOI 10.1093/pm/pnaa243

  View details for PubMedID 32869079

• Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings. NAM perspectives Rich, R. C., Chou, R., Mariano, E. R., Dopp, A. L., Sullenger, R., Burstin, H., Pain Management Guidelines and Evidence Standards Working Group 2020; 2020

  View details for DOI 10.31478/202008c

  View details for PubMedID 35291734

• Assessing the current status of continuous peripheral nerve blocks in clinical practice in North America, a survey approach. Journal of clinical anesthesia Adhikary, S. n., Sideris, A. n., Hargett, M. n., Elkassabany, N. M., Mariano, E. R., Liu, J. n. 2020; 65: 109870

  View details for DOI 10.1016/j.jclinane.2020.109870

  View details for PubMedID 32447164

• The future of education in anesthesiology is social. International anesthesiology clinics Kumar, A. H., Udani, A. D., Mariano, E. R. 2020

  View details for DOI 10.1097/AIA.0000000000000287

  View details for PubMedID 32804872

• Pain Management in Breast Surgery: Recommendations of a Multidisciplinary Expert Panel-The American Society of Breast Surgeons. Annals of surgical oncology Brenin, D. R., Dietz, J. R., Baima, J. n., Cheng, G. n., Froman, J. n., Laronga, C. n., Ma, A. n., Manahan, M. A., Mariano, E. R., Rojas, K. n., Schroen, A. T., Tiouririne, N. A., Wiechmann, L. S., Rao, R. n. 2020

  Abstract

  Opioid overdose accounted for more than 47,000 deaths in the United States in 2018. The risk of new persistent opioid use following breast cancer surgery is significant, with up to 10% of patients continuing to fill opioid prescriptions one year after surgery. Over prescription of opioids is far too common. A recent study suggested that up to 80% of patients receiving a prescription for opioids post-operatively do not need them (either do not fill the prescription or do not use the medication). In order to address this important issue, The American Society of Breast Surgeons empaneled an inter-disciplinary committee to develop a consensus statement on pain control for patients undergoing breast surgery. Representatives were nominated by the American College of Surgeons, the Society of Surgical Oncology, The American Society of Plastic Surgeons, and The American Society of Anesthesiologists. A broad literature review followed by a more focused review was performed by the inter-disciplinary panel which was comprised of 14 experts in the fields of breast surgery, anesthesiology, plastic surgery, rehabilitation medicine, and addiction medicine. Through a process of multiple revisions, a consensus was developed, resulting in the outline for decreased opioid use in patients undergoing breast surgery presented in this manuscript. The final document was reviewed and approved by the Board of Directors of the American Society of Breast Surgeons.

  View details for DOI 10.1245/s10434-020-08892-x

  View details for PubMedID 32783121

• The #ASRASpring20 conference was canceled due to COVID-19 but the science survives and thrives. Regional anesthesia and pain medicine Gupta, R. K., Mariano, E. R., Narouze, S. n., Elkassabany, N. M. 2020

  View details for DOI 10.1136/rapm-2020-101645

  View details for PubMedID 32409515

• Collateral Damage as Crises Collide: Perioperative Opioids in the COVID-19 Era. Pain medicine (Malden, Mass.) Mudumbai, S. C., Mariano, E. R., Clark, J. D., Stafford, R. S. 2020

  View details for DOI 10.1093/pm/pnaa308

  View details for PubMedID 33150439

• An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty. Korean journal of anesthesiology Mudumbai, S. C., Kim, T. E., Howard, S. K., Giori, N. J., Woolson, S. n., Ganaway, T. n., Kou, A. n., King, R. n., Mariano, E. R. 2020; 73 (3): 267

  View details for DOI 10.4097/kjae.2016.69.4.368.e1

  View details for PubMedID 32506897

• Quality of Patient Education Materials on Safe Opioid Management in the Acute Perioperative Period: What Do Patients Find Online? PAIN MEDICINE Kumar, G., Jaremko, K. M., Kou, A., Howard, S. K., Harrison, T., Mariano, E. R. 2020; 21 (1): 171–75

  View details for DOI 10.1093/pm/pny296

  View details for Web of Science ID 000522867400021

• A little better is still better: using marginal gains to enhance 'enhanced recovery' after surgery. Regional anesthesia and pain medicine Leng, J. C., Mariano, E. R. 2020

  View details for DOI 10.1136/rapm-2019-101239

  View details for PubMedID 31932489

• The rise and fall of the COVID-19 aerosol box through the lens of Twitter. Journal of clinical anesthesia Mariano, E. R., Kou, A. n., Stiegler, M. A., Matava, C. n. 2020; 69: 110145

  View details for DOI 10.1016/j.jclinane.2020.110145

  View details for PubMedID 33246260

  View details for PubMedCentralID PMC7674069

• The role of regional analgesia in personalized postoperative pain management. Korean journal of anesthesiology Chitnis, S. S., Tang, R. n., Mariano, E. R. 2020

  Abstract

  Pain management plays a fundamental role in enhanced recovery after surgery pathways. The concept of multimodal analgesia in providing a balanced and effective approach to perioperative pain management is widely accepted and practiced, with regional anesthesia playing a pivotal role. Nerve block techniques can be utilized to achieve the goals of enhanced recovery, whether it be resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can appear daunting to the general anesthesiologist. Which is the most appropriate regional technique to choose, and what skills and infrastructure are required for its implementation? A multidisciplinary team-based approach for defining the goals is essential, based on each individual patient's needs, and incorporating patient, surgical and social factors. This review provides a framework for a personalized approach to post-operative pain management with an emphasis on regional anesthesia techniques.

  View details for DOI 10.4097/kja.20323

  View details for PubMedID 32752602

• How Twitter conversations using hashtags #regionalanesthesia and #regionalanaesthesia have changed in the COVID-19 era. Regional anesthesia and pain medicine Schwenk, E. S., Jaremko, K. M., Gupta, R. K., Elkassabany, N. M., Pawa, A. n., Kou, A. n., Mariano, E. R. 2020

  View details for DOI 10.1136/rapm-2020-101747

  View details for PubMedID 32616566

• Fasten your seatbelts: innovation in regional anaesthesia is a bumpy ride. Anaesthesia Mariano, E. R., El-Boghdadly, K. n. 2020

  View details for DOI 10.1111/anae.14992

  View details for PubMedID 31984475

• Making the case for a procedure-specific definition of chronic postoperative opioid use. Regional anesthesia and pain medicine Tamboli, M. n., Mariano, E. R., El-Boghdadly, K. n., Elkassabany, N. M., Kou, A. n., Chung, P. n., Mudumbai, S. C. 2020

  View details for DOI 10.1136/rapm-2020-101327

  View details for PubMedID 32213559

• The effect of passive muscle mobilization on the distribution of local anesthetics after supra-inguinal fascia iliaca compartment block, a pilot case study. Journal of clinical anesthesia Vermeylen, K. n., Van Aken, D. n., Versyck, B. n., Roos, J. n., Bracke, P. n., Leunen, I. n., Mariano, E. R., Elsharkawy, H. n. 2020; 68: 110100

  View details for DOI 10.1016/j.jclinane.2020.110100

  View details for PubMedID 33125974

• Educating Nurses on Intravenous Lidocaine for Postoperative Pain Management. Pain management nursing : official journal of the American Society of Pain Management Nurses Hunter, O. O., Wong, A. n., Leng, J. n., Mariano, E. R. 2020

  Abstract

  As healthcare practitioners continue to search for multimodal analgesic therapies to reduce postoperative opioid requirements, surgical ward nurses need to stay up to date on the status of emerging therapies. One of these is intravenous lidocaine for postoperative pain management. Unfortunately, there is a lack of resources to assist surgical ward nurses who are unfamiliar with lidocaine infusions for pain. This article aims to review the pharmacology of intravenous lidocaine for pain management, describe an experience of a university-affiliated Veterans Affairs hospital with implementation of intravenous lidocaine on the surgical ward, and suggest practical tools that can be used to develop protocols and educational content for nurses managing intravenous lidocaine infusions in the postoperative period.

  View details for DOI 10.1016/j.pmn.2020.09.011

  View details for PubMedID 33132041

• Cannabinoid and Opioid Use Among Total Joint Arthroplasty Patients: A 6-Year, Single-Institution Study. Orthopedics Denduluri, S. K., Woolson, S. T., Indelli, P. F., Mariano, E. R., Harris, A. H., Giori, N. J. 2020: 1–6

  Abstract

  Evidence is limited regarding cannabinoid use among total joint arthroplasty (TJA) patients, despite increased availability and popularity for treating chronic pain. The authors hypothesized that preoperative cannabinoid use increased and opioid use decreased during a 6-year interval in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients, and also asked whether complications were associated with use of these substances. This retrospective, single-institution study reviewed electronic medical records and the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database for TJA cases from 2012 through 2017. Primary outcomes were the prevalence and trends of active cannabinoid and opioid use, as determined by routine preoperative urine toxicology screening. Multivariable regression analyses were conducted to investigate a secondary outcome, whether there was an association between cannabinoid or opioid use and postoperative complications. A total of 1778 operations (1161 TKAs and 617 THAs) performed on 1519 patients were reviewed. The overall prevalence of pre-operative cannabinoid and opioid use was 11% and 23%, respectively. Comparing 2012 with 2017, cannabinoid use increased from 9% to 15% (P=.049), and opioid use decreased from 24% to 17% (P=.040). Cannabinoid users were more likely to be taking opioids than nonusers (P=.002). Controlling for age, sex, surgery type, and American Society of Anesthesiologists score, cannabinoid use was not associated with 90-day readmission, infection, reoperation, or other VASQIP-captured complications. Laboratory testing indicated a much higher prevalence of cannabinoid use among TJA patients than previously reported. During a 6-year period, cannabinoid use increased more than 60%, and opioid use decreased approximately 30%. These findings indicate that cannabinoid use did not appear to be associated with perioperative complications. [Orthopedics. 2021;44(x):xx-xx.].

  View details for DOI 10.3928/01477447-20200928-02

  View details for PubMedID 33002174

• An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia Levy, N. n., Quinlan, J. n., El-Boghdadly, K. n., Fawcett, W. J., Agarwal, V. n., Bastable, R. B., Cox, F. J., de Boer, H. D., Dowdy, S. C., Hattingh, K. n., Knaggs, R. D., Mariano, E. R., Pelosi, P. n., Scott, M. J., Lobo, D. N., Macintyre, P. E. 2020

  Abstract

  This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.

  View details for DOI 10.1111/anae.15262

  View details for PubMedID 33027841

• Ambulatory continuous peripheral nerve blocks to treat post-amputation phantom limb pain a multicenter, randomized, quadruple-masked, placebo-controlled clinical trial. Pain Ilfeld, B. M., Khatibi, B. n., Maheshwari, K. n., Madison, S. J., Sakr Esa, W. A., Mariano, E. R., Kent, M. L., Hanling, S. n., Sessler, D. I., Eisenach, J. C., Cohen, S. P., Mascha, E. J., Ma, C. n., Padwal, J. A., Turan, A. n. 2020

  Abstract

  Phantom limb pain is thought to be sustained by reentrant neural pathways which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0-12 weeks. Pretreatment pain scores were similar in both groups, with a median [interquartile range] of 5.0 [4.0, 7.0] for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic versus 4.5 (2.6) in those given placebo (difference (95% CI) 1.3 (0.4, 2.2), P=0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 [0, 5.0] vs. 1.5 [0, 5.0] for the placebo group; there appeared to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

  View details for DOI 10.1097/j.pain.0000000000002087

  View details for PubMedID 33021563

• History and evolution of regional anesthesiology and acute pain medicine fellowship training. Regional anesthesia and pain medicine Shapiro, D. M., Hargett, M. J., Kopp, S. n., Neal, J. M., Mariano, E. R., Liguori, G. n. 2020

  Abstract

  In 2016, individual training programs in regional anesthesiology and acute pain medicine (RA/APM) became eligible for accreditation by the Accreditation Council for Graduate Medical Education (ACGME), thereby culminating a process that began 15 years earlier. Herein, we review the origins of regional anesthesia training in the USA, the events leading up to accreditation and the current state of the fellowship.We reviewed pertinent literature on the historical aspects of RA/APM in the USA, related subspecialty training and the formation and current state of RA/APM fellowship training programs. Additionally, a survey was distributed to the directors of the 74 RA/APM fellowships that existed as of 1 January 2017 to gather up-to-date, program-specific information.The survey yielded a 76% response rate. Mayo Clinic Rochester and Virginia Mason Medical Center likely had the first structured RA/APM fellowships with formalized curriculums and stated objectives, both starting in 1982. Most programs (86%), including ACGME and non-ACGME fellowships, came into existence after the year 2000. Six responding programs have or previously had RA/APM comingled with another subspecialty. Eight current programs originally offered unofficial or part-time fellowships in RA/APM, with fellows also practicing as attending physicians.The history of RA/APM training in the USA is a tortuous one. It began with short 'apprenticeships' under the tutelage of the early proponents of regional anesthesia and continues today with 84 official RA/APM programs and a robust fellowship directors' group. RA/APM programs teach skills essential to the practice and improvement of anesthesiology as a specialty.

  View details for DOI 10.1136/rapm-2019-100915

  View details for PubMedID 32001624

• An analysis of perioperative eye injury in a veterans affairs inpatient surgical population. Journal of clinical anesthesia Tamboli, M. n., Kou, A. n., Wang, R. R., Walters, T. L., Mudumbai, S. C., Mariano, E. R. 2020; 66: 109913

  View details for DOI 10.1016/j.jclinane.2020.109913

  View details for PubMedID 32480206

• COVID-19: bringing out the best in anesthesiologists and looking toward the future. Regional anesthesia and pain medicine McCartney, C. J., Mariano, E. R. 2020

  View details for DOI 10.1136/rapm-2020-101629

  View details for PubMedID 32475829

• Daring discourse - no: cannabinoids should not be used for acute postoperative pain management. Regional anesthesia and pain medicine Meeker, J. D., Ayrian, E. n., Mariano, E. R. 2020

  Abstract

  As anesthesiologists and acute pain medicine specialists, we will care for patients in the perioperative period who use cannabinoids for chronic pain and/or marijuana recreationally. We will have to address difficult questions from patients regarding the potential applications for cannabinoids in acute pain management. While we must remain compassionate and understand our patients' desire to find relief from suffering using available non-opioid medications, we are ethically bound to do no harm and provide them with treatment options supported by the best available evidence. Today, we cannot support cannabinoids in the management of acute postoperative pain.

  View details for DOI 10.1136/rapm-2020-101475

  View details for PubMedID 32471920

• The effect of intraoperative intravenous acetaminophen on intraoperative and postoperative opioid use and pain scores in minimally invasive spine surgery. Journal of clinical anesthesia Le Clair, M. Z., Ayrian, E. n., Mariano, E. R., Jha, S. n. 2020; 65: 109748

  View details for DOI 10.1016/j.jclinane.2020.109748

  View details for PubMedID 32428807

• A Commonsense Patient-Centered Approach to Multimodal Analgesia Within Surgical Enhanced Recovery Protocols. Journal of pain research Mariano, E. R., Schatman, M. E. 2019; 12: 3461-3466

  View details for DOI 10.2147/JPR.S238772

  View details for PubMedID 31920369

  View details for PubMedCentralID PMC6935269

• A Multidisciplinary Perioperative Intervention to Improve Positive Airway Pressure Adherence in Patients With Obstructive Sleep Apnea: A Case Series. A&A practice Wong, J. K., Rodriguez, E. M., Wee-Tom, B., Lejano, M., Kushida, C. A., Howard, S. K., Memtsoudis, S. G., Mariano, E. R. 2019

  Abstract

  Positive airway pressure (PAP) adherence in patients with obstructive sleep apnea (OSA) remains low despite known benefits. The postoperative inpatient period may represent a unique opportunity to address technical issues and promote self-efficacy, 2 important factors determining adherence, which may result in patients' seeking outpatient sleep medicine follow-up. We report our experience in developing a perioperative multidisciplinary intervention of reintroducing PAP therapy to nonadherent OSA patients with the intent of motivating patients to return to their outpatient sleep medicine clinics.

  View details for DOI 10.1213/XAA.0000000000001165

  View details for PubMedID 31876561

• A short, sustainable intervention to help reduce day of surgery smoking rates among patients undergoing elective surgery JOURNAL OF CLINICAL ANESTHESIA Coffman, C. R., Howard, S. K., Mariano, E. R., Kou, A., Pollard, J., Boselli, R., Kangas, S., Leng, J. 2019; 58: 35–36

  View details for DOI 10.1016/j.jclinane.2019.04.034

  View details for Web of Science ID 000496899300014

• How anesthesiologists adapted to a nationwide spinal bupivacaine drug shortage. Journal of clinical anesthesia Sun, L., Tamboli, M., Wang, R. R., Kandarian, B. S., Wong, A., Lochbaum, G. M., Mariano, E. R. 2019: 109668

  View details for DOI 10.1016/j.jclinane.2019.109668

  View details for PubMedID 31761415

• Erector spinae plane: a collapsible potential space. Regional anesthesia and pain medicine Xu, L., Leng, J. C., Mariano, E., Tsui, B. C. 2019

  View details for DOI 10.1136/rapm-2019-101107

  View details for PubMedID 31748425

• Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center PAIN MEDICINE King, R., Mariano, E. R., Yajnik, M., Kou, A., Kim, T., Hunter, O. O., Howard, S. K., Mudumbai, S. C. 2019; 20 (11): 2256–62

  View details for DOI 10.1093/pm/pnz023

  View details for Web of Science ID 000504316200019

• Problem with the Pecs II block: the long thoracic nerve is collateral damage REGIONAL ANESTHESIA AND PAIN MEDICINE Miller, B., Pawa, A., Mariano, E. 2019; 44 (8): 817-+

  View details for DOI 10.1136/rapm-2019-100559

  View details for Web of Science ID 000478919900014

• Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement KOREAN JOURNAL OF ANESTHESIOLOGY Kandarian, B., Indelli, P. F., Sinha, S., Hunter, O. O., Wang, R. R., Kim, T., Kou, A., Mariano, E. R. 2019; 72 (3): 238–44

  View details for DOI 10.4097/kja.d.18.00346

  View details for Web of Science ID 000470011100005

• Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty Chi, D., Mariano, E. R., Memtsoudis, S. G., Baker, L. C., Sun, E. C. LIPPINCOTT WILLIAMS & WILKINS. 2019: 1319–27

  View details for DOI 10.1213/ANE.0000000000003830

  View details for Web of Science ID 000480725200061

• Comparing two posterior quadratus lumborum block approaches with low thoracic erector spinae plane block: an anatomic study REGIONAL ANESTHESIA AND PAIN MEDICINE Elsharkawy, H., Bajracharya, G., El-Boghdadly, K., Drake, R. L., Mariano, E. R. 2019; 44 (5): 549–55

  View details for DOI 10.1136/rapm-2018-100147

  View details for Web of Science ID 000471157900004

• Overdose Risk Associated with Opioid Use upon Hospital Discharge in Veterans Health Administration Surgical Patients PAIN MEDICINE Mudumbai, S. C., Lewis, E. T., Oliva, E. M., Chung, P. D., Harris, B., Trafton, J., Mariano, E. R., Wagner, T., Clark, J., Stafford, R. S. 2019; 20 (5): 1020–31

  View details for DOI 10.1093/pm/pny150

  View details for Web of Science ID 000479175500018

• IMPLEMENTATION OF A DISTRIBUTED RESEARCH NETWORK VIRTUAL DATA WAREHOUSE FOR A MULTI-CENTER OBSERVATIONAL STUDY Mudumbai, S., Wu, F., Chambers, J., Kapoor, A., Lee, J. S., Clark, D., Mariano, E. R., Stafford, R. S. LIPPINCOTT WILLIAMS & WILKINS. 2019: 925–26

  View details for Web of Science ID 000619263200433

• Opioid-free anaesthesia - what would Inigo Montoya say? ANAESTHESIA Elkassabany, N. M., Mariano, E. R. 2019; 74 (5): 560–63

  View details for DOI 10.1111/anae.14611

  View details for Web of Science ID 000466429600002

• Problem with the Pecs II block: the long thoracic nerve is collateral damage. Regional anesthesia and pain medicine Miller, B., Pawa, A., Mariano, E. 2019

  View details for PubMedID 30992408

• Medical education research methodology: accuracy and design REGIONAL ANESTHESIA AND PAIN MEDICINE Kumar, A. H., Mariano, E. R., Udani, A. D. 2019; 44 (4): 534

  View details for DOI 10.1136/rapm-2019-100368

  View details for Web of Science ID 000471156800026

• Medical education research methodology: accuracy and design. Regional anesthesia and pain medicine Kumar, A. H., Mariano, E. R., Udani, A. D. 2019

  View details for PubMedID 30760507

• Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery PATIENT EDUCATION AND COUNSELING Yajnik, M., Hill, J. N., Hunter, O. O., Howard, S. K., Kim, T., Harrison, T., Mariano, E. R. 2019; 102 (2): 383–87

  View details for DOI 10.1016/j.pec.2018.09.001

  View details for Web of Science ID 000458372200024

• What's in a Word? Qualitative and Quantitative Analysis of Leadership Language in Anesthesiology Resident Feedback. Journal of graduate medical education Arkin, N., Lai, C., Kiwakyou, L. M., Lochbaum, G. M., Shafer, A., Howard, S. K., Mariano, E. R., Fassiotto, M. 2019; 11 (1): 44-52

  Abstract

  Individuals who have agentic traits (eg, assertive, confident, competent) that are more commonly associated with men are often selected for leadership roles. For women, this poses a potential barrier to entry into the higher ranks of academic medicine.We analyzed anesthesiology resident feedback for differences in the use of agentic descriptors using qualitative and quantitative methods based on resident gender and year of training.This study uses textual analysis of 435 assessments of residents over a 1-year period within a single residency program. We performed a qualitative content analysis on the words used in resident feedback and performed negative binomial regression analyses to determine significant differences in the way residents were described based on gender and year of training.Female residents were less likely than male residents to be described as agentic after controlling for excerpt length, year of training, and evaluator variability (β = -0.347; 95% confidence interval [CI] -0.666, -0.028; P = .033). Senior residents were more likely to be described as agentic (β = 0.702; 95% CI 0.402-1.002; P < .001) compared to junior residents. The increased number of agentic codes among senior residents was driven by increased agentic description of female residents' ratings in the senior cohort (β = 0.704; 95% CI 0.084-1.324; P = .026).Female residents were described as agentic less often than male residents in early years of training, but the gap was not present among senior residents.

  View details for DOI 10.4300/JGME-D-18-00377.1

  View details for PubMedID 30805097

  View details for PubMedCentralID PMC6375319

• Quality of Patient Education Materials on Safe Opioid Management in the Acute Perioperative Period: What Do Patients Find Online? Pain medicine (Malden, Mass.) Kumar, G., Jaremko, K. M., Kou, A., Howard, S. K., Harrison, T. K., Mariano, E. R. 2019

  Abstract

  Objective: Guidelines on postoperative pain management recommend inclusion of patient and caregiver education on opioid safety. Patient education materials (PEMs) should be written at or below a sixth grade reading level. We designed this study to compare the readability of online PEMs related to postoperative opioid management produced by institutions with and without a regional anesthesiology and acute pain medicine (RAAPM) fellowship.Methods: With institutional review board exemption, we constructed our cohort of PEMs by searching RAAPM fellowship websites from North American academic medical centers and identified additional websites using structured Internet searches. Readability metrics were calculated from PEMs using the TextStat 0.4.1 textual analysis package for Python 2.7. The primary outcome was the Flesch-Kincaid Grade Level (FKGL), a score based on words per sentence and syllables per word. We also compared fellowship-based and nonfellowship PEMs on the presence or absence of specific content-related items.Results: PEMs from 15 fellowship and 23 nonfellowship institutions were included. The mean (SD) FKGL for PEMs was grade 7.84 (1.98) compared with the recommended sixth grade level (P<0.001) and was not different between groups. Less than half of online PEMs contained explicit discussion of opioid tapering or cessation. Disposal and overdose risk were addressed more often by nonfellowship PEMs.Conclusions: Available online PEMs related to opioid management are beyond the recommended reading level, but readability metrics for online PEMs do not differ between fellowship and nonfellowship groups. More than two-thirds of RAAPM fellowship programs in North America are lacking readable online PEMs on safe postoperative opioid management.

  View details for PubMedID 30657963

• Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System? CLINICAL ORTHOPAEDICS AND RELATED RESEARCH Wong, J. K., Kim, T., Mudumbai, S. C., Memtsoudis, S. G., Giori, N. J., Howard, S. K., Oka, R. K., King, R., Mariano, E. R. 2019; 477 (1): 177–90

  View details for DOI 10.1097/CORR.0000000000000460

  View details for Web of Science ID 000472543100031

• What's in a Word? Qualitative and Quantitative Analysis of Leadership Language in Anesthesiology Resident Feedback Journal of Graduate Medical Education Arking, N., Lai, C., Kiwakyou, L. M., Lochbaum, G. M., Shafer, A., Howard, S. K., Mariano, E. R., Fassiotto, M. 2019; 11 (1): 44-52

  View details for DOI 10.4300/JGME-D-18-00377.1

• Preoperative Ultrasound-Guided Botulinum Toxin A Injection Facilitates Closure of a Complex Abdominal Wall Hernia: A Case Report. A&A practice Tamboli, M. n., Kitamura, R. n., Ma, W. n., Kumar, G. n., Harrison, T. K., Wang, R. R., Mariano, E. R., Leng, J. C. 2019

  Abstract

  Complex abdominal wall hernia repairs can have high failure rates. Many surgical techniques have been proposed with variable success. We report our experience with a new collaborative protocol between general surgery and regional anesthesiology and acute pain medicine services to provide preoperative botulinum toxin A injections to a patient with a large complex ventral hernia to facilitate primary closure. Toxin was administered into the 3 abdominal wall muscle layers under ultrasound guidance at multiple sites 2 weeks before surgery. The resulting flaccid paralysis of the abdominal musculature facilitated a successful primary surgical closure with no postoperative complications.

  View details for DOI 10.1213/XAA.0000000000001033

  View details for PubMedID 31180908

• Development and validation of a predictive model for American Society of Anesthesiologists Physical Status. BMC health services research Mudumbai, S. C., Pershing, S. n., Bowe, T. n., Kamal, R. N., Sears, E. D., Finlay, A. K., Eisenberg, D. n., Hawn, M. T., Weng, Y. n., Trickey, A. W., Mariano, E. R., Harris, A. H. 2019; 19 (1): 859

  Abstract

  The American Society of Anesthesiologists Physical Status (ASA-PS) classification system was developed to categorize the fitness of patients before surgery. Increasingly, the ASA-PS has been applied to other uses including justification of inpatient admission. Our objectives were to develop and cross-validate a statistical model for predicting ASA-PS; and 2) assess the concurrent and predictive validity of the model by assessing associations between model-derived ASA-PS, observed ASA-PS, and a diverse set of 30-day outcomes.Using the 2014 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File, we developed and internally cross-validated multinomial regression models to predict ASA-PS using preoperative NSQIP data. Accuracy was assessed with C-Statistics and calibration plots. We assessed both concurrent and predictive validity of model-derived ASA-PS relative to observed ASA-PS and 30-day outcomes. To aid further research and use of the ASA-PS model, we implemented it into an online calculator.Of the 566,797 elective procedures in the final analytic dataset, 8.9% were ASA-PS 1, 48.9% were ASA-PS 2, 39.1% were ASA-PS 3, and 3.2% were ASA-PS 4. The accuracy of the 21-variable model to predict ASA-PS was C = 0.77 +/- 0.0025. The model-derived ASA-PS had stronger association with key indicators of preoperative status including comorbidities and higher BMI (concurrent validity) compared to observed ASA-PS, but less strong associations with postoperative complications (predictive validity). The online ASA-PS calculator may be accessed at https://s-spire-clintools.shinyapps.io/ASA_PS_Estimator/ CONCLUSIONS: Model-derived ASA-PS better tracked key indicators of preoperative status compared to observed ASA-PS. The ability to have an electronically derived measure of ASA-PS can potentially be useful in research, quality measurement, and clinical applications.

  View details for DOI 10.1186/s12913-019-4640-x

  View details for PubMedID 31752856

• A Multidisciplinary Patient-Specific Opioid Prescribing and Tapering Protocol Is Associated with a Decrease in Total Opioid Dose Prescribed for Six Weeks After Total Hip Arthroplasty. Pain medicine (Malden, Mass.) Tamboli, M. n., Mariano, E. R., Gustafson, K. E., Briones, B. L., Hunter, O. O., Wang, R. R., Harrison, T. K., Kou, A. n., Mudumbai, S. C., Kim, T. E., Indelli, P. F., Giori, N. J. 2019

  Abstract

  This retrospective cohort study tested the hypothesis that implementing a multidisciplinary patient-specific discharge protocol for prescribing and tapering opioids after total hip arthroplasty (THA) will decrease the morphine milligram equivalent (MME) dose of opioids prescribed.With institutional review board approval, we analyzed a Perioperative Surgical Home database and prescription data for all primary THA patients three months before (PRE) and three months after (POST) implementation of this new discharge opioid protocol based on patients' prior 24-hour inpatient opioid consumption. The primary outcome was total opioid dosage in MME prescribed and opioid refills for six weeks after surgery. Secondary outcomes included the number of tablets and MME prescribed at discharge, in-hospital opioid consumption, length of stay, and postoperative complications.Forty-nine cases (25 PRE and 24 POST) were included. Total median (10th-90th percentiles) MME for six weeks postoperatively was 900 (57-2082) MME PRE vs 295 (69-741) MME POST (mean difference = 721, 95% confidence interval [CI] = 127-1316, P = 0.007, Mann-Whitney U test). Refill rates did not differ. The median (10th-90th percentiles) initial discharge prescription in MME was 675 (57-1035) PRE vs 180 (18-534) POST (mean difference = 387, 95% CI = 156-618, P = 0.003, Mann-Whitney U test) MME. There were no differences in other outcomes.Implementation of a patient-specific prescribing and tapering protocol decreases the mean six-week dosage of opioid prescribed by 63% after THA without increasing the refill rate.

  View details for DOI 10.1093/pm/pnz260

  View details for PubMedID 31710680

• Erector spinae plane block catheter for postoperative pain management after open cholecystectomy in Zimbabwe. Journal of clinical anesthesia Mugadza, F. M., Mariano, E. R., Mazonde, S. n. 2019: 109678

  View details for DOI 10.1016/j.jclinane.2019.109678

  View details for PubMedID 31810861

• Practice Patterns in Perioperative Nonopioid Analgesic Administration by Anesthesiologists in a Veterans Affairs Hospital. Pain medicine (Malden, Mass.) Kwong, J. Z., Mudumbai, S. C., Hernandez-Boussard, T. n., Popat, R. A., Mariano, E. R. 2019

  Abstract

  Although multimodal analgesia (MMA) is recommended for perioperative pain management, previous studies have found substantial variability in its utilization. To better understand the factors that influence anesthesiologists' choices, we assessed the associations between patient or surgical characteristics and number of nonopioid analgesic modes received intraoperatively across a variety of surgeries in a university-affiliated Veteran Affairs hospital.We included elective inpatient surgeries (orthopedic, thoracic, spine, abdominal, and pelvic procedures) that used at least one nonopioid analgesic within a one-year period. Multivariable multinomial logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals (CIs). We also described the combinations of analgesia used in each surgical subtype and conducted exploratory analyses to test the associations between the number of modes used and postoperative outcomes.Of the 1,087 procedures identified, 33%, 53%, and 14% were managed with one, two, and three or more modes, respectively. Older patients had lower odds of receiving three or more modes (adjusted odds ratio [aOR] = 0.28, 95% confidence interval [CI] = 0.15-0.52), as were patients with more comorbidities (two modes: aOR = 0.87, 95% CI = 0.79-0.96; three or more modes: aOR = 0.81, 95% CI = 0.71-0.94). Utilization varied across surgical subtypes P < 0.0001). Increasing the number of modes, particularly use of regional anesthesia, was associated with shorter length of stay.Our study suggests that age, comorbidities, and surgical type contribute to variability in MMA utilization. Risks and benefits of multiple modes should be carefully considered for older and sicker patients. Future directions include developing patient- and procedure-specific perioperative MMA recommendations.

  View details for DOI 10.1093/pm/pnz226

  View details for PubMedID 31559430

• Aiming to Refine the Interscalene Block: Another Bullseye or Missing the Mark? Anesthesiology Elkassabany, N. M., Mariano, E. R. 2019

  View details for DOI 10.1097/ALN.0000000000002985

  View details for PubMedID 31567363

• Utility of videolaryngoscopy for diagnostic and therapeutic interventions in head and neck surgery. American journal of otolaryngology Shenson, J. A., Marcott, S. n., Dewan, K. n., Lee, Y. J., Mariano, E. R., Sirjani, D. B. 2019: 102284

  Abstract

  Videolaryngoscopy is commonly used by anesthesiologists to manage difficult airways. Recently otolaryngologists have reported use in select procedures; to date there is limited evaluation in head and neck surgery.Patients who underwent direct laryngoscopy (DL) with use of GlideScope videolaryngoscopy (GVL) were retrospectively identified from a tertiary care Veterans Affairs hospital. GVL was used to assist or replace traditional laryngoscopes for diagnostic and therapeutic procedures.Nineteen patients (48-83 years old) underwent 21 procedures. Difficult endotracheal intubation was reported in 53% of patients. GVL replaced traditional DL in 76% of cases, assisted evaluation prior to traditional DL in 10%, and rescued failed traditional DL in 14%. No complications occurred. Three indications for GVL were identified.GVL was safe in our experience and provides unique benefits in selected scenarios in head and neck surgery. Otolaryngologists can consider videolaryngoscopy as a complement to traditional DL.

  View details for DOI 10.1016/j.amjoto.2019.102284

  View details for PubMedID 32505434

• Reply to Dr Price: Interfascial plane blocks - a Time to Pause. Regional anesthesia and pain medicine Elsharkawy, H. n., Pawa, A. n., Mariano, E. R. 2019; 44 (1): 138

  View details for PubMedID 30640671

• Peripheral nerve blocks are not associated with increased risk of perioperative peripheral nerve injury in a Veterans Affairs inpatient surgical population. Regional anesthesia and pain medicine Yajnik, M. n., Kou, A. n., Mudumbai, S. C., Walters, T. L., Howard, S. K., Edward Kim, T. n., Mariano, E. R. 2019; 44 (1): 81–85

  Abstract

  Perioperative peripheral nerve injury (PNI) is a known complication in patients undergoing surgery with or without regional anesthesia. The incidence of new PNI in a Veterans Affairs (VA) inpatient surgical population has not been previously described; therefore, the incidence, risk factors, and clinical course of new PNI in this cohort are unknown. We hypothesized that peripheral nerve blocks do not increase PNI incidence.We conducted a 5-year review of a Perioperative Surgical Home database including all consecutive surgical inpatients. The primary outcome was new PNI between groups that did or did not have peripheral nerve blockade. Potential confounders were first examined individually using logistic regression, and then included simultaneously together within a mixed-effects logistic regression model. Electronic records of patients with new PNI were reviewed for up to a year postoperatively.The incidence of new PNI was 1.2% (114/9558 cases); 30 of 3380 patients with nerve block experienced new PNI (0.9%) compared with 84 of 6178 non-block patients (1.4%; p=0.053). General anesthesia alone, younger age, and American Society of Anesthesiologists physical status <3 were associated with higher incidence of new PNI. Patients who received transversus abdominis plane blocks had increased odds for PNI (OR, 3.20, 95% CI 1.34 to 7.63), but these cases correlated with minimally invasive general and urologic surgery. One hundred PNI cases had 1-year follow-up: 82% resolved by 3 months and only one patient did not recover in a year.The incidence of new perioperative PNI for VA surgical inpatients is 1.2% and the use of peripheral nerve blocks is not an independent risk factor.

  View details for PubMedID 30640657

• Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement. Korean journal of anesthesiology Kandarian, B. n., Indelli, P. F., Sinha, S. n., Hunter, O. O., Wang, R. R., Kim, T. E., Kou, A. n., Mariano, E. R. 2019

  Abstract

  The IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block is a new anesthesiologist-administered analgesic technique for controlling posterior knee pain in total knee arthroplasty (TKA) patients that has not yet been well studied. We compared pain outcomes in TKA patients before and after implementation of IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 compared to non-IPACK patients.With IRB approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon four months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and perioperative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and 30-day adverse events.Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and these cases were compared with 32 patients in the PRE group. On POD 0, lowest pain score [median (10th-90th percentiles] was significantly lower for the POST group compared to the PRE group [0 (0-4.3) vs. 2.5 (0-7), respectively; p=0.003]. Highest patient-reported pain scores on any POD were not different between groups, and there were no differences in other outcomes.Within a multimodal analgesic protocol, addition of IPACK blocks decreases lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.

  View details for PubMedID 30776878

• Outcomes of Ambulatory Upper Extremity Surgery Patients Discharged Home with Perineural Catheters from a Veterans Health Administration Medical Center. Pain medicine (Malden, Mass.) King, R. n., Mariano, E. R., Yajnik, M. n., Kou, A. n., Kim, T. E., Hunter, O. O., Howard, S. K., Mudumbai, S. C. 2019

  Abstract

  The feasibility and safety of managing ambulatory continuous peripheral nerve blocks (CPNB) in Veterans Health Administration (VHA) patients are currently unknown. We aimed to characterize the outcomes of a large VHA cohort of ambulatory upper extremity surgery patients discharged with CPNB and identify differences, if any, between catheter types.With institutional review board approval, we reviewed data for consecutive patients from a single VHA hospital who had received ambulatory CPNB for upper extremity surgery from March 2011 to May 2017. The composite primary outcome was the occurrence of any catheter-related issue or additional all-cause health care intervention after discharge. Our secondary outcome was the ability to achieve regular daily telephone contact.Five hundred one patients formed the final sample. The incidence of any issue or health care intervention was 104/274 (38%) for infraclavicular, 58/185 (31%) for interscalene, and 14/42 (33%) for supraclavicular; these rates did not differ between groups. Higher ASA status was associated with greater odds of having any issue, whereas increasing age was slightly protective. Distance was associated with an increase in catheter-related issues (P < 0.01) but not additional health care interventions (P = 0.51). Only interscalene catheter patients (3%) reported breathing difficulty. Infraclavicular catheter patients had the most emergency room visits but rarely for CPNB issues. Consistent daily telephone contact was not achieved.For VHA ambulatory CPNB patients, the combined incidence of a catheter-related issue or additional health care intervention was approximately one in three patients and did not differ by brachial plexus catheter type. Serious adverse events were generally uncommon.

  View details for PubMedID 30856269

• Comparing two posterior quadratus lumborum block approaches with low thoracic erector spinae plane block: an anatomic study. Regional anesthesia and pain medicine Elsharkawy, H. n., Bajracharya, G. R., El-Boghdadly, K. n., Drake, R. L., Mariano, E. R. 2019

  Abstract

  Both posterior quadratus lumborum (QL) and erector spinae plane (ESP) blocks have been described as new truncal interfascial plane blocks. Distribution of injectate is influenced by fascial anatomy; therefore, different injection sites may produce similar spread. This anatomic study was designed to test the hypothesis that a posteromedial QL block at L2 level will more closely resemble a low thoracic ESP block when compared with the posterolateral approach at L2 level.Left-sided ESP blocks were performed in six cadavers at T10-11. Three of these cadavers received right-sided posteromedial QL block at L2, while the other three received right-sided posterolateral QL block at L2. All injections were composed of 20 mL methylcellulose 0.5 % mixed with India ink and 10 mL of Omnipaque (Iohexol) 240 mg/mL. CT 24 hours after injection and cadaver dissection were used to evaluate injectate spread.Cephalocaudal spread of injectate by CT and cadaveric dissection was highly correlated (r=0.85 [95% CI 0.51 to 0.95]). Cadaver dissection showed ESP injectate spread deep to the muscle (mean [SD]) 11.7 (2.3) levels compared with 7.3 (1.2) levels for posterolateral QL and 9.7 (1.5) for posteromedial QL (p=0.04 overall, with a statistically significant pairwise difference between ESP and posterolateral QL only). The subcostal nerve and dorsal rami were commonly involved in most blocks, but the paravertebral space and ventral rami had inconsistent involvement. The lumbocostal ligament limited cranial spread from the posterlateral QL block approach.The posteromedial QL block at L2 produces more cranial spread beyond the lumbocostal ligament than the posterolateral QL block, and this spread is comparable with a low thoracic ESP block. Both posterior QL and ESP blocks show unreliable spread of injectate to the paravertebral space and ventral rami, but the dorsal rami were frequently covered.

  View details for PubMedID 30923253

• Opioid-free anaesthesia - what would Inigo Montoya say? Anaesthesia Elkassabany, N. M., Mariano, E. R. 2019

  View details for PubMedID 30802930

• Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide. Journal of patient safety Soncrant, C. n., Neily, J. n., Sum-Ping, S. J., Wallace, A. W., Mariano, E. R., Leissner, K. B., Mills, P. D., Mazzia, L. n., Paull, D. E. 2019

  Abstract

  The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact.As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety. Since May 2012, the National Anesthesia Service subject matter experts, in collaboration with National Center for Patient Safety, review actual adverse events in anesthesiology and detailed lessons learned are developed. A survey of anesthesiology chiefs to determine perceived usefulness and accessibility of the project was conducted in April 2018.The distributed survey yielded a response rate of 69% (84/122). Most of those who have seen the lessons learned (85%, 71/84) found them valuable. Ninety percent of those aware of the lessons learned (64/71) shared them with staff and 75% (53/71) reported a changed or reinforced patient safety behavior in their facility. The lessons learned provided 72% (51/71) of chiefs with new knowledge about patient safety and 75% (53/71) gained new knowledge for preventing adverse events.This nationwide VHA anesthesiology lessons learned project illustrates the tenets of a learning organization. implementing team and systems-based safeguards to mitigate risk of harm from inevitable human error. Sharing lessons learned provides opportunities for clinician peer-to-peer learning, communication, and proactive approaches to prevent future similar errors.

  View details for DOI 10.1097/PTS.0000000000000616

  View details for PubMedID 31135598

• I Tweet, Therefore I Learn: An Analysis of Twitter Use Across Anesthesiology Conferences. Anesthesia and analgesia Schwenk, E. S., Jaremko, K. M., Park, B. H., Stiegler, M. A., Gamble, J. G., Chu, L. F., Utengen, A. n., Mariano, E. R. 2019

  Abstract

  Twitter in anesthesiology conferences promotes rapid science dissemination, global audience participation, and real-time updates of simultaneous sessions. We designed this study to determine if an association exists between conference attendance/registration and 4 defined Twitter metrics.Using publicly available data through the Symplur Healthcare Hashtags Project and the Symplur Signals, we collected data on total tweets, impressions, retweets, and replies as 4 primary outcome metrics for all registered anesthesiology conferences occurring from May 1, 2016 to April 30, 2017. The number of Twitter participants, defined as users who contributed a tweet, retweet, or reply 3 days before through 3 days after the conference, was collected. We also collected influencer data as determined by mentions (number of times a user is referenced). Two authors independently verified the categories for influencers assigned by Symplur. Conference demographic data were obtained by e-mail inquiries. Associations between meeting attendees/registrants and Twitter metrics, between Twitter participants and the metrics, and between physician influencers and Twitter participants were tested using Spearman rho.Fourteen conferences with 63,180 tweets were included. With the American Society of Anesthesiologists annual meeting included, the correlations between meeting attendance/registration and total tweets (rs = 0.588; P = .074), impressions (rs = 0.527; P = .117), and retweets (rs = 0.539; P = .108) were not statistically significant; for replies, it was moderately positive (rs = 0.648; P = .043). Without the American Society of Anesthesiologists annual meeting, total tweets (rs = 0.433; P = .244), impressions (rs = 0.350; P = .356), retweets (rs = 0.367; P = .332), and replies (rs = 0.517; P = .154) were not statistically significant. Secondary outcomes include a highly positive correlation between Twitter participation and total tweets (rs = 0.855; P < .001), very highly positive correlations between Twitter participation and impressions (rs = 0.938; P < .001), retweets (rs = 0.925; P < .001), and a moderately positive correlation between Twitter participation and replies (rs = 0.652; P = .044). Doctors were top influencers in 8 of 14 conferences, and the number of physician influencers in the top 10 influencers list at each conference had a moderately positive correlation with Twitter participation (rs = 0.602; P = .023).We observed that the number of Twitter participants for a conference is positively associated with Twitter activity metrics. No relationship between conference size and Twitter metrics was observed. Physician influencers may be an important driver of participants.

  View details for DOI 10.1213/ANE.0000000000004036

  View details for PubMedID 31124801

• Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty. Anesthesia and analgesia Chi, D. n., Mariano, E. R., Memtsoudis, S. G., Baker, L. C., Sun, E. C. 2019; 128 (6): 1319–27

  Abstract

  Total knee arthroplasty is a commonly performed procedure and an important contributor to national health care spending. Reducing the incidence of readmission could have important consequences for patient well-being and relevant financial implications. Whether regional anesthesia techniques are associated with decreased readmission rates and costs among privately insured patients remains unknown.Using administrative claims data, we identified 138,362 privately insured patients 18-64 years of age who underwent total knee arthroplasty between 2002 and 2013. We then examined whether the use of a nerve block was associated with decreases in readmission rates and related costs during the 90 days after discharge. Our analyses were adjusted for potential confounding variables including medical comorbidities and previous use of opioids and other medications.After adjusting for patient demographics, comorbidities, and preoperative medication use, the adjusted 90-day readmission rate was 1.8% (95% confidence interval [CI], 1.1-2.4) among patients who did not receive a block compared to 1.7% (95% CI, 1.1-2.4) among patients who did (odds ratio, 0.99; 95% CI, 0.91-1.09; P = .85). The adjusted readmission-related postoperative cost for patients who did not receive a block was $561 (95% CI, 502-619) and $574 (95% CI, 508-639) for patients who did (difference, $13; 95% CI, -75 to 102; P = .74). This lack of statistically significant differences held for subgroup and sensitivity analyses.Nerve blocks were not associated with improved measures of long-term postoperative resource use in this younger, privately insured study population.

  View details for PubMedID 31094807

• Reply to Dr Price: Interfascial plane blocks - a Time to Pause REGIONAL ANESTHESIA AND PAIN MEDICINE Elsharkawy, H., Pawa, A., Mariano, E. R. 2019; 44 (1)

  View details for DOI 10.1136/RAPM-2018-100020

  View details for Web of Science ID 000471155800026

• Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia Turbitt, L. R., Mariano, E. R., El-Boghdadly, K. n. 2019

  View details for DOI 10.1111/anae.14768

  View details for PubMedID 31268173

• Teaching an old pain medicine society new tweets: integrating social media into continuing medical education. Korean journal of anesthesiology Jaremko, K. M., Schwenk, E. S., Pearson, A. C., Hagedorn, J. n., Udani, A. D., Md, G. S., Elkassabany, N. M., Snively, A. n., Mariano, E. R. 2019

  View details for DOI 10.4097/kja.19261

  View details for PubMedID 31257816

• Peripheral nerve blocks are not associated with increased risk of perioperative peripheral nerve injury in a Veterans Affairs inpatient surgical population REGIONAL ANESTHESIA AND PAIN MEDICINE Yajnik, M., Kou, A., Mudumbai, S. C., Walters, T. L., Howard, S. K., Kim, E., Mariano, E. R. 2019; 44 (1): 81–85

  View details for DOI 10.1136/rapm-2018-000006

  View details for Web of Science ID 000471155800013

• Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients. Pain medicine (Malden, Mass.) Mudumbai, S. C., Chung, P. n., Nguyen, N. n., Harris, B. n., Clark, J. D., Wagner, T. H., Giori, N. J., Stafford, R. S., Mariano, E. R. 2019

  Abstract

  Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization?We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed.The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants.Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

  View details for DOI 10.1093/pm/pnz154

  View details for PubMedID 31309970

• Impact of an Opioid Safety Initiative on Patients Undergoing Total Knee Arthroplasty: A Time Series Analysis. Anesthesiology Chen, Q. n., Hsia, H. L., Overman, R. n., Bryan, W. n., Pepin, M. n., Mariano, E. R., Mudumbai, S. C., Buchheit, T. n., Krishnamoorthy, V. n., Good, C. B., Brookhart, M. A., Raghunathan, K. n. 2019; 131 (2): 369–80

  Abstract

  Opioid overuse remains rampant even in hospitals, but whether administrative opioid safety initiatives reduce use remains unclear WHAT THIS ARTICLE TELLS US THAT IS NEW: The authors evaluated the effects of a Veterans Administration national Opioid Safety Initiative using interrupted time series analysis to compare trends before and after starting the initiativeThere was a trivial increase in pain scores, and a substantial reduction in patients with chronic preoperative and postoperative opioid prescriptions BACKGROUND:: The Opioid Safety Initiative decreased high-dose prescriptions across the Veterans Health Administration. This study sought to examine the impact of this intervention (i.e., the Opioid Safety Initiative) on pain scores and opioid prescriptions in patients undergoing total knee arthroplasty.This was an ecological study of group-level data among 700 to 850 patients per month over 72 consecutive months (January 2010 to December 2015). The authors examined characteristics of cohorts treated before versus after rollout of the Opioid Safety Initiative (October 2013). Each month, the authors aggregated at the group-level the differences between mean postoperative and preoperative pain scores for each patient (averaged over 6-month periods), and measured proportions of patients (per 1,000) with opioid (and nonopioid) prescriptions for more than 3 months in 6-month periods, preoperatively and postoperatively. The authors compared postintervention trends versus trends forecasted based on preintervention measures.After the Opioid Safety Initiative, patients were slightly older and sicker, but had lower mortality rates (postintervention n = 28,509 vs. preintervention n = 31,547). Postoperative pain scores were slightly higher and the decrease in opioid use was statistically significant, i.e., 871 (95% CI, 474 to 1,268) fewer patients with chronic postoperative prescriptions. In time series analyses, mean postoperative minus preoperative pain scores had increased from 0.65 to 0.81, by 0.16 points (95% CI, 0.05 to 0.27). Proportions of patients with chronic postoperative and chronic preoperative opioid prescriptions had declined by 20% (n = 3,355 vs. expected n = 4,226) and by 13% (n = 5,861 vs. expected n = 6,724), respectively. Nonopioid analgesia had increased. Sensitivity analyses confirmed all findings.A system-wide initiative combining guideline dissemination with audit and feedback was effective in significantly decreasing opioid prescriptions in populations undergoing total knee arthroplasty, while minimally impacting pain scores.

  View details for DOI 10.1097/ALN.0000000000002771

  View details for PubMedID 31314748

• Patient-centred care in regional anaesthesia - a reply. Anaesthesia Turbitt, L. R., Mariano, E. R., El-Boghdadly, K. 2019; 74 (10): 1343–44

  View details for DOI 10.1111/anae.14820

  View details for PubMedID 31486539

• Essential elements of an outpatient total joint replacement programme. Current opinion in anaesthesiology Li, J. n., Rubin, L. E., Mariano, E. R. 2019

  Abstract

  To summarize the safety and feasibility of outpatient total joint arthroplasty (TJA) from the perspectives of short-term complications, long-term functional outcomes, patient satisfaction and financial impact, and to provide evidence-based guidance on how to establish an outpatient TJA programme.TJA has been recently transitioned from an exclusively inpatient procedure for all Medicare and Medicaid patients to an outpatient surgery in properly selected total knee arthroplasty patients. This change may decrease costs while maintaining comparable rates of readmission, adverse events, positive surgical outcomes and patient satisfaction.With a standardized clinical pathway, outpatient TJA can be safe and effective in a subset of patients. Essential components of a successful outpatient TJA programme include proper patient selection, preoperative patient/family education, perioperative multidisciplinary coordination and opioid-sparing analgesia, and early and effective postdischarge planning. More studies are needed to further assess and optimize this new care paradigm.

  View details for DOI 10.1097/ACO.0000000000000774

  View details for PubMedID 31356361

• Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. British journal of anaesthesia Memtsoudis, S. G., Cozowicz, C. n., Bekeris, J. n., Bekere, D. n., Liu, J. n., Soffin, E. M., Mariano, E. R., Johnson, R. L., Hargett, M. J., Lee, B. H., Wendel, P. n., Brouillette, M. n., Go, G. n., Kim, S. J., Baaklini, L. n., Wetmore, D. n., Hong, G. n., Goto, R. n., Jivanelli, B. n., Argyra, E. n., Barrington, M. J., Borgeat, A. n., De Andres, J. n., Elkassabany, N. M., Gautier, P. E., Gerner, P. n., Gonzalez Della Valle, A. n., Goytizolo, E. n., Kessler, P. n., Kopp, S. L., Lavand'Homme, P. n., MacLean, C. H., Mantilla, C. B., MacIsaac, D. n., McLawhorn, A. n., Neal, J. M., Parks, M. n., Parvizi, J. n., Pichler, L. n., Poeran, J. n., Poultsides, L. A., Sites, B. D., Stundner, O. n., Sun, E. C., Viscusi, E. R., Votta-Velis, E. G., Wu, C. L., Ya Deau, J. T., Sharrock, N. E. 2019

  Abstract

  Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes.The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations.The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87.Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation.neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty.PROSPERO CRD42018099935.

  View details for DOI 10.1016/j.bja.2019.05.042

  View details for PubMedID 31351590

• Updates on multimodal analgesia and regional anesthesia for total knee arthroplasty patients. Best practice & research. Clinical anaesthesiology Kandarian, B. S., Elkassabany, N. M., Tamboli, M. n., Mariano, E. R. 2019; 33 (1): 111–23

  Abstract

  The subspecialty of regional anesthesiology and acute pain medicine (RAAPM) is in a position to lead changes that may impact the current opioid crisis. At the hospital level, RAAPM experts can implement evidence-based multimodal analgesic clinical pathways featuring regional anesthesia. Multimodal analgesia consists of using two or more analgesic modalities targeting pain pathways at various levels to improve pain control, while also aiming to reduce opioid utilization and related adverse effects. These types of pathways or protocols have been widely applied in the joint replacement population. This review focuses on the current state of the evidence regarding individual elements of a multimodal analgesic pathway for patients with total knee arthroplasty including new regional anesthesia techniques like the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block and suggests future research directions to improve the clinical care of this surgical population in the future.

  View details for DOI 10.1016/j.bpa.2019.02.004

  View details for PubMedID 31272649

• Spinal anesthesia increases the rate of opioid-free recovery after transurethral urologic surgery. Journal of clinical anesthesia Tien, M. n., Kou, A. n., Leppert, J. T., Mariano, E. R., Mudumbai, S. C. 2019; 60: 109–10

  View details for DOI 10.1016/j.jclinane.2019.09.013

  View details for PubMedID 31614296

• A short, sustainable intervention to help reduce day of surgery smoking rates among patients undergoing elective surgery. Journal of clinical anesthesia Coffman, C. R., Howard, S. K., Mariano, E. R., Kou, A. n., Pollard, J. n., Boselli, R. n., Kangas, S. n., Leng, J. n. 2019; 58: 35–36

  View details for PubMedID 31059909

• Regional Anesthesia: A Silver Bullet, Red Herring, or Neither? Anesthesiology Sun, E. C., Memtsoudis, S. G., Mariano, E. R. 2019; 131 (6): 1205–6

  View details for DOI 10.1097/ALN.0000000000002964

  View details for PubMedID 31730550

• Five-year follow-up to assess long-term sustainability of changing clinical practice regarding anesthesia and regional analgesia for lower extremity arthroplasty. Korean journal of anesthesiology Tamboli, M. n., Leng, J. C., Hunter, O. O., Kou, A. n., Mudumbai, S. C., Memtsoudis, S. G., Walters, T. L., Lochbaum, G. M., Mariano, E. R. 2019

  Abstract

  Long-term sustainability of clinical practice changes in anesthesia has not been previously reported. Therefore, we performed a 5-year audit following implementation of a clinical pathway change to favor spinal anesthesia for total knee arthroplasty (TKA). We similarly evaluated a parallel cohort of patients undergoing total hip arthroplasty (THA) which did not undergo clinical pathway change as well as the utilization of regional analgesia.We identified all primary unilateral TKA and THA cases performed from January 2013 through December 2018 to include data from one-year pre-implementation and 5-years post-implementation of the clinical pathway change. Our primary outcome was the overall rate of spinal anesthesia usage. Secondary outcomes included rate of nerve block utilization, 30-day postoperative complications, and resource utilization variables such as hospital readmission, emergency department visits, and blood transfusions.The sample consisted of 1859 cases (1250 TKAs, 609 THAs). In the first year post-implementation, 174/221 (78.7%) TKAs received spinal anesthesia compared to 23/186 (12.4%) in the year before implementation (p<0.001). In the subsequent 4-year period, 647/843 (77.2%) TKAs received spinal anesthesia (p=0.532 vs. year 1). For THA, 78/124 (62.9%) received spinal anesthesia in the year after implementation compared to 48/116 (41.4%) pre-implementation (p=0.001), but this rate decreased in the subsequent 4-year period to 193/369 (52.3%) (p=0.040 vs. year 1). Utilization of regional analgesia was high in both groups, and there were no differences in other outcomes.A clinical pathway change promoting spinal anesthesia for TKA can be effectively implemented and sustained over a 5-year period.

  View details for DOI 10.4097/kja.19400

  View details for PubMedID 31865661

• A Commonsense Patient-Centered Approach to Multimodal Analgesia Within Surgical Enhanced Recovery Protocols JOURNAL OF PAIN RESEARCH Mariano, E. R., Schatman, M. E. 2019; 12: 3461–66

  View details for DOI 10.2147/JPR.S238772

  View details for Web of Science ID 000503958500001

• A Pilot Project Using Eye-Tracking Technology to Design a Standardised Anaesthesia Workspace. Turkish journal of anaesthesiology and reanimation Hanhan, J., King, R., Harrison, T. K., Kou, A., Howard, S. K., Borg, L. K., Shum, C., Udani, A. D., Mariano, E. R. 2018; 46 (6): 411-415

  Abstract

  Maximising safe handoff procedures ensures patient safety. Anaesthesiology practices have primarily focused on developing better communication tools. However, these tools tend to ignore the physical layout of the anaesthesia workspace itself. Standardising the anaesthesia workspace has the potential to improve patient safety. The design process should incorporate end user feedback and objective data.This pilot project aims to design a standardised anaesthesia workspace using eye-tracking technology at a single university-affiliated Veterans Affairs hospital. Twelve practising anaesthesiologists observed a series of images representing five clinical scenarios. Each of these had a question prompting them to look for certain items commonly found in the anaesthesia workspace. Using eye-tracking technology, the gaze data of participants were recorded. These data were used to generate heat maps of the specific areas of interest in the workspace that received the most fixation counts.The laryngoscope and propofol had the highest percentages of gaze fixations on the left-hand side of the workstation, in closest proximity to the anaesthesiologist. Atropine, although the highest percentage of gaze fixations (33%) placed it on the right-hand side of the workstation, also had 25% of gaze fixations centred over the anaesthesia cart.Gaze fixation analyses showed that anaesthesiologists identified locations for the laryngoscope and propofol within easy reach and emergency medications further away. Because eye tracking can provide objective data to influence the design process, it may be useful when developing standardised anaesthesia workspace templates for individual practices.

  View details for DOI 10.5152/TJAR.2018.67934

  View details for PubMedID 30505602

  View details for PubMedCentralID PMC6223869

• A Pilot Project Using Eye-Tracking Technology to Design a Standardised Anaesthesia Workspace TURKISH JOURNAL OF ANAESTHESIOLOGY AND REANIMATION Hanhan, J., King, R., Harrison, T., Kou, A., Howard, S. K., Borg, L. K., Shum, C., Udani, A. D., Mariano, E. R. 2018; 46 (6): 411–15

  View details for DOI 10.5152/TJAR.2018.67934

  View details for Web of Science ID 000449525500003

• A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine PAIN MANAGEMENT Mudumbai, S. C., Auyong, D. B., Memtsoudis, S. G., Mariano, E. R. 2018; 8 (6): 475–85

  View details for DOI 10.2217/pmt-2018-0017

  View details for Web of Science ID 000452050900009

• The road to accreditation for fellowship training in regional anesthesiology and acute pain medicine CURRENT OPINION IN ANESTHESIOLOGY Mariano, E. R., Rosenquist, R. W. 2018; 31 (5): 643–48

  View details for DOI 10.1097/ACO.0000000000000639

  View details for Web of Science ID 000452775000023

• Patient education and engagement in postoperative pain management decreases opioid use following knee replacement surgery. Patient education and counseling Yajnik, M., Hill, J. N., Hunter, O. O., Howard, S. K., Kim, T. E., Harrison, T. K., Mariano, E. R. 2018

  Abstract

  OBJECTIVE: Effects of patient education on perioperative analgesic utilization are not well defined. We designed a simple pain management educational card for total knee arthroplasty (TKA) patients and retrospectively reviewed clinical data before and after implementation to test the hypothesis that more informed patients will use less opioid.METHODS: With IRB approval, we analyzed clinical data collected perioperatively on all TKA patients one month before (PRE) and one month after (POST) card implementation. The card was designed using a modified Delphi method; the front explained all analgesic medications and the Defense and Veterans Pain Rating Scale was on the back. The primary outcome was total opioid dosage in morphine milligram equivalents (MME) for the first two postoperative days. Secondary outcomes included daily opioid usage, pain scores, ambulation distance, hospital length of stay and use of antiemetics.RESULTS: There were 20 patients in each group with no differences in baseline characteristics. Total two-day MME [median (10th-90th percentiles)] was 71 (32-285) for PRE and 38 (1-117) for POST (p=0.001). There were no other differences.CONCLUSION: Educating TKA patients in multimodal pain management using a simple tool decreases opioid usage.PRACTICE IMPLICATIONS: Empowering TKA patients with education can reduce opioid use perioperatively.

  View details for PubMedID 30219634

• Do Hospitals Performing Frequent Neuraxial Anesthesia for Hip and Knee Replacements Have Better Outcomes? ANESTHESIOLOGY Memtsoudis, S. G., Poeran, J., Zubizarreta, N., Olson, A., Cozowicz, C., Moerwald, E. E., Mariano, E. R., Mazumdar, M. 2018; 129 (3): 428–39

  View details for DOI 10.1097/ALN.0000000000002299

  View details for Web of Science ID 000441864900011

• Are Case Volume and Facility Complexity Level Associated With Postoperative Complications After Hip Fracture Surgery in the Veterans Affairs Healthcare System? Clinical orthopaedics and related research Wong, J. K., Kim, T. E., Mudumbai, S. C., Memtsoudis, S. G., Giori, N. J., Howard, S. K., Oka, R. K., King, R., Mariano, E. R. 2018

  Abstract

  BACKGROUND: Hospital-related factors associated with mortality and morbidity after hip fracture surgery are not completely understood. The Veterans Health Administration (VHA) is the largest single-payer, networked healthcare system in the country serving a relatively homogenous patient population with facilities that vary in size and resource availability. These characteristics provide some degree of financial and patient-level controls to explore the association, if any, between surgical volume and facility resource availability and hospital performance regarding postoperative complications after hip fracture surgery.QUESTIONS/PURPOSES: (1) Do VHA facilities with the highest complexity level designation (Level 1a) have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-complexity level facilities? (2) Do VHA facilities with higher hip fracture surgical volume have a disproportionate number of better-than-expected performance outliers for major postoperative complications compared with lower-volume facilities?METHODS: We explored the Veterans Affairs Surgical Quality Improvement Project (VASQIP) database from October 2001 to September 2012 for records of hip fracture surgery performed. Data reliability of the VASQIP database has been previously validated. We excluded nine of the 98 VHA facilities for contributing fewer than 30 records. The remaining 89 VHA facilities provided 23,029 records. The VHA designates a complexity level to each facility based on multiple criteria. We labeled facilities with a complexity Level 1a (38 facilities)-the highest achievable VHA designated complexity level-as high complexity; we labeled all other complexity level designations as low complexity (51 facilities). Facility volume was divided into tertiles: high (> 277 hip fracture procedures during the sampling frame), medium (204 to 277 procedures), and low (< 204 procedures). The patient population treated by low-complexity facilities was older, had a higher prevalence of severe chronic obstructive pulmonary disease (26% versus 22%, p < 0.001), and had a higher percentage of patients having surgery within 2 days of hospital admission (83% versus 76%, p < 0.001). High-complexity facilities treated more patients with recent congestive heart failure exacerbation (4% versus 3%, p < 0.001). We defined major postoperative complications as having at least one of the following: death within 30 days of surgery, cardiac arrest requiring cardiopulmonary resuscitation, new q-wave myocardial infarction, deep vein thrombosis and/or pulmonary embolism, ventilator dependence for at least 48 hours after surgery, reintubation for respiratory or cardiac failure, acute renal failure requiring renal replacement therapy, progressive renal insufficiency with a rise in serum creatinine of at least 2 mg/dL from preoperative value, pneumonia, or surgical site infection. We used the observed-to-expected ratio (O/E ratio)-a risk-adjusted metric to classify facility performance-for major postoperative complications to assess the performance of VHA facilities. Outlier facilities with 95% confidence intervals (95% CI) for O/E ratio completely less than 1.0 were labeled "exceed expectation;" those that were completely greater than 1.0 were labeled "below expectation." We compared differences in the distribution of outlier facilities between high and low-complexity facilities, and between high-, medium-, and low-volume facilities using Fisher's exact test.RESULTS: We observed no association between facility complexity level and the distribution of outlier facilities (high-complexity: 5% exceeded expectation, 5% below expectation; low-complexity: 8% exceeded expectation, 2% below expectation; p = 0.742). Compared with high-complexity facilities, the adjusted odds ratio for major postoperative complications for low-complexity facilities was 0.85 (95% CI, 0.67-1.09; p = 0.108).We observed no association between facility volume and the distribution of outlier facilities: 3% exceeded expectation and 3% below expectation for high-volume; 10% exceeded expectation and 3% below expectation for medium-volume; and 7% exceeded expectation and 3% below expectation for low-volume; p = 0.890). The adjusted odds ratios for major postoperative complications were 0.87 (95% CI, 0.73-1.05) for low- versus high-volume facilities and 0.89 (95% CI, 0.79-1.02] for medium- versus high-volume facilities (p = 0.155).CONCLUSIONS: These results do not support restricting facilities from treating hip fracture patients based on historical surgical volume or facility resource availability. Identification of consistent performance outliers may help health care organizations with multiple facilities determine allocation of services and identify characteristics and processes that determine outlier status in the interest of continued quality improvement.LEVEL OF EVIDENCE: Level III, therapeutic study.

  View details for PubMedID 30179946

• Using eye tracking technology to compare the effectiveness of malignant hyperthermia cognitive aid design KOREAN JOURNAL OF ANESTHESIOLOGY King, R., Hanhan, J., Harrison, T., Kou, A., Howard, S. K., Borg, L. K., Shum, C., Udani, A. D., Mariano, E. R., ADAPT Anesthesiology-Directed Ad 2018; 71 (4): 317–22

  View details for DOI 10.4097/kja.d.18.00016

  View details for Web of Science ID 000440217700009

• The road to accreditation for fellowship training in regional anesthesiology and acute pain medicine. Current opinion in anaesthesiology Mariano, E. R., Rosenquist, R. W. 2018

  Abstract

  PURPOSE OF REVIEW: The purpose of this review is to provide the background and rationale for pursuing accreditation of regional anesthesiology and acute pain medicine (RAAPM) fellowships, explain specific steps and challenges in the process, and forecast the future of fellowship training.RECENT FINDINGS: In 2016, the first fellowship program in RAAPM was able to apply for accreditation from the Accreditation Council for Graduate Medical Education (ACGME). The establishment of this newly accredited subspecialty fellowship and the announcement of the first accredited programs represented a tremendous achievement in anesthesiology training and medical education in general and was the culmination of nearly 4 years of dedicated effort.SUMMARY: Programs with initial ACGME accreditation are on a 2-year term and will be reviewed to evaluate adherence to the program requirements and the quality of fellowship training. Deficiencies identified will need to be resolved or face loss of accreditation. However, a program's maintenance of accreditation represents a commitment to its fellows to provide a training experience that can be held as a benchmark for all programs.

  View details for PubMedID 29994940

• Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization A Population-based Study Memtsoudis, S. G., Poeran, J., Zubizarreta, N., Cozowicz, C., Moerwald, E. E., Mariano, E. R., Mazumdar, M. LIPPINCOTT WILLIAMS & WILKINS. 2018: 891–902

  View details for DOI 10.1097/ALN.0000000000002132

  View details for Web of Science ID 000435562800008

• Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study. Anesthesiology Memtsoudis, S. G., Poeran, J. n., Zubizarreta, N. n., Cozowicz, C. n., Mörwald, E. E., Mariano, E. R., Mazumdar, M. n. 2018

  Abstract

  Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used.While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols.

  View details for PubMedID 29498951

• A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine. Pain management Mudumbai, S. C., Auyong, D. B., Memtsoudis, S. G., Mariano, E. R. 2018

  Abstract

  Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

  View details for PubMedID 30394193

• Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty. Anesthesia and analgesia Chi, D. n., Mariano, E. R., Memtsoudis, S. G., Baker, L. C., Sun, E. C. 2018

  Abstract

  Total knee arthroplasty is a commonly performed procedure and an important contributor to national health care spending. Reducing the incidence of readmission could have important consequences for patient well-being and relevant financial implications. Whether regional anesthesia techniques are associated with decreased readmission rates and costs among privately insured patients remains unknown.Using administrative claims data, we identified 138,362 privately insured patients 18-64 years of age who underwent total knee arthroplasty between 2002 and 2013. We then examined whether the use of a nerve block was associated with decreases in readmission rates and related costs during the 90 days after discharge. Our analyses were adjusted for potential confounding variables including medical comorbidities and previous use of opioids and other medications.After adjusting for patient demographics, comorbidities, and preoperative medication use, the adjusted 90-day readmission rate was 1.8% (95% confidence interval [CI], 1.1-2.4) among patients who did not receive a block compared to 1.7% (95% CI, 1.1-2.4) among patients who did (odds ratio, 0.99; 95% CI, 0.91-1.09; P = .85). The adjusted readmission-related postoperative cost for patients who did not receive a block was $561 (95% CI, 502-619) and $574 (95% CI, 508-639) for patients who did (difference, $13; 95% CI, -75 to 102; P = .74). This lack of statistically significant differences held for subgroup and sensitivity analyses.Nerve blocks were not associated with improved measures of long-term postoperative resource use in this younger, privately insured study population.

  View details for PubMedID 30286005

• Designing the ideal perioperative pain management plan starts with multimodal analgesia. Korean journal of anesthesiology Schwenk, E. S., Mariano, E. R. 2018

  Abstract

  Multimodal analgesia is defined as the use of more than one pharmacological class of analgesic medication targeting different receptors along the pain pathway with the goal of improving analgesia while reducing individual class-related side effects. Evidence today supports the routine use of multimodal analgesia in the perioperative period to eliminate the over-reliance on opioids for pain control and to reduce opioid-related adverse events. A multimodal analgesic protocol should be surgery-specific, functioning more like a checklist than a recipe, with options to tailor to the individual patient. Elements of this protocol may include opioids, non-opioid systemic analgesics like acetaminophen, Non-steroidal anti-inflammatory drugs, gabapentinoids, ketamine, and local anesthetics administered by infiltration, regional block, or the intravenous route. While implementation of multimodal analgesic protocols perioperatively is recommended as an intervention to decrease the prevalence of long-term opioid use following surgery, the concurrent crisis of drug shortages presents an additional challenge. Anesthesiologists and acute pain medicine specialists will need to advocate locally and nationally to ensure a steady supply of analgesic medications and in-class alternatives for their patients' perioperative pain management.

  View details for PubMedID 30139215

• Overdose Risk Associated with Opioid Use upon Hospital Discharge in Veterans Health Administration Surgical Patients. Pain medicine (Malden, Mass.) Mudumbai, S. C., Lewis, E. T., Oliva, E. M., Chung, P. D., Harris, B. n., Trafton, J. n., Mariano, E. R., Wagner, T. n., Clark, J. D., Stafford, R. S. 2018

  Abstract

  To determine an association between opioid use upon hospital discharge (ongoing and newly started) in surgical patients and risks of opioid overdose and delirium for the first year.Retrospective, cohort study.Population-level study of Veterans Health Administration patients.All Veterans Health Administration patients (N = 64,391) who underwent surgery in 2011, discharged after one or more days, and without a diagnosis of opioid overdose or delirium from 90 days before admission through 30 days postdischarge (to account for additional opioid dosing in the context of chronic use).Patients' opioid use was categorized as 1) no opioids, 2) tramadol only, 3) short-acting only, 4) long-acting only, 5) short- and long-acting. We calculated unadjusted incidence rates and the incidence rate ratio (IRR) for opioid overdose and drug delirium for two time intervals: postdischarge days 0-30 and days 31-365. We then modeled outcomes of opioid overdose and delirium for postdischarge days 31-365 using a multivariable extended Cox regression model. Sensitivity analysis examined risk factors for overdose for postdischarge days 0-30.Incidence of overdose was 11-fold greater from postdischarge days 0-30 than days 31-365: 26.3 events/person-year (N = 68) vs 2.4 events/person-year (N = 476; IRR = 10.80, 95% confidence interval [CI] = 8.37-13.92). Higher-intensity opioid use was associated with increasing risk of overdose for the year after surgery, with the highest risk for the short- and long-acting group (hazard ratio = 4.84, 95% CI = 3.28-7.14). Delirium (IRR = 10.66, 95% CI = 7.96-14.29) was also associated with higher opioid intensity.Surgical patients should be treated with the lowest effective intensity of opioids and be monitored to prevent opioid-related adverse events.

  View details for PubMedID 30137452

• Update on Selective Regional Analgesia for Hip Surgery Patients. Anesthesiology clinics Bugada, D. n., Bellini, V. n., Lorini, L. F., Mariano, E. R. 2018; 36 (3): 403–15

  Abstract

  In hip surgery, regional anesthesia offers benefits in pain management and recovery. There are a wide range of regional analgesic options; none have shown to be superior. Lumbar plexus block, femoral nerve block, and fascia iliaca block are the most supported by published literature. Other techniques, such as selective obturator and/or lateral femoral cutaneous nerve blocks, represent alternatives. Newer approaches, such as quadratus lumborum block and local infiltration analgesia, require rigorous studies. To realize long-term outcome benefits, postoperative regional analgesia must be tailored to the individual patient and last longer.

  View details for PubMedID 30092937

• What Can Regional Anesthesiology and Acute Pain Medicine Learn from "Big Data"? Anesthesiology clinics Elkassabany, N. M., Memtsoudis, S. G., Mariano, E. R. 2018; 36 (3): 467–78

  Abstract

  Demonstrating value added to patients' experience through regional anesthesiology and acute pain medicine is critical. Evidence supporting improved outcomes can be derived from prospective studies or retrospective cohort studies. Population-based studies relying on existing clinical and administrative databases are helpful when an outcome is rare and detecting a change would require studying large numbers of patients. This article discusses the effect of regional anesthesiology and acute pain medicine interventions on mortality and morbidity, infection rate, cancer recurrence, inpatient falls, local anesthetic systemic toxicity, persistent postsurgical pain, and health care costs.

  View details for PubMedID 30092941

• Regional Anesthesiology and Acute Pain Medicine in the Era of Value-Based Health Care. Anesthesiology clinics Elkassabany, N. M., Mariano, E. R. 2018; 36 (3): xiii-xiv

  View details for PubMedID 30092943

• Do Hospitals Performing Frequent Neuraxial Anesthesia for Hip and Knee Replacements Have Better Outcomes? Anesthesiology Memtsoudis, S. G., Poeran, J. n., Zubizarreta, N. n., Olson, A. n., Cozowicz, C. n., Mörwald, E. E., Mariano, E. R., Mazumdar, M. n. 2018

  Abstract

  Neuraxial anesthesia is increasingly recommended for hip/knee replacements as some studies show improved outcomes on the individual level. With hospital-level studies lacking, we assessed the relationship between hospital-level neuraxial anesthesia utilization and outcomes.National data on 808,237 total knee and 371,607 hip replacements were included (Premier Healthcare 2006 to 2014; 550 hospitals). Multivariable associations were measured between hospital-level neuraxial anesthesia volume (subgrouped into quartiles) and outcomes (respiratory/cardiac complications, blood transfusion/intensive care unit need, opioid utilization, and length/cost of hospitalization). Odds ratios (or percent change) and 95% CI are reported. Volume-outcome relationships were additionally assessed by plotting hospital-level neuraxial anesthesia volume against predicted hospital-specific outcomes; trend tests were applied with trendlines' R statistics reported.Annual hospital-specific neuraxial anesthesia volume varied greatly: interquartile range, 3 to 78 for hips and 6 to 163 for knees. Increasing frequency of neuraxial anesthesia was not associated with reliable improvements in any of the study's clinical outcomes. However, significant reductions of up to -14.1% (95% CI, -20.9% to -6.6%) and -15.6% (95% CI, -22.8% to -7.7%) were seen for hospitalization cost in knee and hip replacements, respectively, both in the third quartile of neuraxial volume. This coincided with significant volume effects for hospitalization cost; test for trend P < 0.001 for both procedures, R 0.13 and 0.41 for hip and knee replacements, respectively.Increased hospital-level use of neuraxial anesthesia is associated with lower hospitalization cost for lower joint replacements. However, additional studies are needed to elucidate all drivers of differences found before considering hospital-level neuraxial anesthesia use as a potential marker of quality.

  View details for PubMedID 29878899

• Using eye tracking technology to compare the effectiveness of malignant hyperthermia cognitive aid design. Korean journal of anesthesiology King, R. n., Hanhan, J. n., Harrison, T. K., Kou, A. n., Howard, S. K., Borg, L. K., Shum, C. n., Udani, A. D., Mariano, E. R. 2018

  Abstract

  Malignant hyperthermia is a rare but potentially fatal complication of anesthesia, and several different cognitive aids designed to facilitate a timely and accurate response to this crisis currently exist. Eye tracking technology can measure voluntary and involuntary eye movements, gaze fixation within an area of interest, and speed of visual response and has been used to a limited extent in anesthesiology.With eye tracking technology, we compared the accessibility of five malignant hyperthermia cognitive aids by collecting gaze data from twelve volunteer participants. Recordings were reviewed and annotated to measure the time required for participants to locate objects on the cognitive aid to provide an answer; cumulative time to answer was the primary outcome.For the primary outcome, there were differences detected between cumulative time to answer survival curves (P < 0.001). Participants demonstrated the shortest cumulative time to answer when viewing the Society for Pediatric Anesthesia (SPA) cognitive aid compared to four other publicly available cognitive aids for malignant hyperthermia, and this outcome was not influenced by the anesthesiologists' years of experience.This is the first study to utilize eye tracking technology in a comparative evaluation of cognitive aid design, and our experience suggests that there may be additional applications of eye tracking technology in healthcare and medical education. Potentially advantageous design features of the SPA cognitive aid include a single page, linear layout, and simple typescript with minimal use of single color blocking.

  View details for PubMedID 29760370

• Moving anesthesiology educational resources to the point of care: experience with a pediatric anesthesia mobile app. Korean journal of anesthesiology Monroe, K. S., Evans, M. A., Mukkamala, S. G., Williamson, J. L., Jabaley, C. S., Mariano, E. R., O'Reilly-Shah, V. N. 2018

  Abstract

  Educators in all disciplines recognize the need to update tools for the modern learner. Mobile applications (apps) may be useful, but real-time data is needed to demonstrate the patterns of utilization and engagement amongst learners.We examined the use of an anesthesia app by two groups of learners (residents and anesthesiologist assistant students [AAs]) during a pediatric anesthesiology rotation. The app calculates age and weight-based information for clinical decision support and contains didactic materials for self-directed learning. The app transmitted detailed usage information to our research team.Over a 12-month period, 39 participants consented; 30 completed primary study procedures (18 residents, 12 AAs). AAs used the app more frequently than residents (P = 0.025) but spent less time in the app (P < 0.001). The median duration of app usage was 2.3 minutes. During the course of the rotation, usage of the app decreased over time. 'Succinylcholine' was the most accessed drug, while 'orientation' was the most accessed teaching module. Ten (33%) believed that the use of apps was perceived to be distracting by operating room staff and surgeons.Real-time in-app analytics helped elucidate the actual usage of this educational resource and will guide future decisions regarding development and educational content. Further research is required to determine learners' preferred choice of device, user experience, and content in the full range of clinical and nonclinical purposes.

  View details for PubMedID 29739184

• Care of the Patient With a Peripheral Nerve Block. Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses Hunter, O. O., Kim, T. E., Mariano, E. R., Harrison, T. K. 2018

  Abstract

  Long-acting peripheral nerve blocks provide effective postoperative pain management, but there are risks associated with rendering an extremity insensate. Perianesthesia nurses play a major role in anticipating and mitigating risks and carefully monitoring patients for potential complications. This article presents uncommon but important considerations related to the care of patients with a peripheral nerve block. These include compartment syndrome, local anesthetic systemic toxicity, thermal injuries, falls, and fractures as well as their management and prevention. The nurse's responsibility in discharge education after a peripheral nerve block is also discussed.

  View details for DOI 10.1016/j.jopan.2018.01.006

  View details for PubMedID 29678320

• Preventing persistent pain after breast cancer surgery: still more work to be done. Minerva anestesiologica Bugada, D. n., Ghisi, D. n., Mariano, E. R. 2018

  View details for PubMedID 29589425

• Perioperative Surgical Home Reduces Rapid Response Calls to a Postoperative Surgical Ward: How Anesthesiologists Are Improving the Inpatient Safety Net. Seminars in cardiothoracic and vascular anesthesia Walters, T. L., Kim, T. E., Mariano, E. R., Lighthall, G. K. 2018: 1089253218761813

  Abstract

  The Perioperative Surgical Home (PSH) is an anesthesiologist-led, coordinated care model that may improve patient experience and safety. We hypothesized that PSH will decrease activation of the rapid response system for surgical inpatients.This retrospective study was performed at an academic Veterans Affairs hospital with a PSH. Data from both medical and surgical cohorts admitted to a single ward were analyzed for the Pre-PSH (July 2006 to October 2010) and Post-PSH (November 2011 to May 2015) epochs. The primary outcome was incidence of rapid response team (RRT) activations per 1000 bed-days.Surgical patients had 5.8 RRT activations per 1000 bed-days Pre-PSH versus 3.7/1000 bed-days Post-PSH ( P = .006). There was no difference in RRT activations per 1000 bed-days for medical patients before and after PSH implementation. Pre-PSH was an independent predictor of mortality in the multivariable model (odds ratio = 1.7; P = .010).PSH is associated with decreased RRT activations among surgical inpatients only.

  View details for PubMedID 29514558

• Interfascial Plane Blocks: Back to Basics. Regional anesthesia and pain medicine Elsharkawy, H. n., Pawa, A. n., Mariano, E. R. 2018

  Abstract

  Ultrasound-guided interfascial plane blocks are a recent development in modern regional anesthesia research and practice and represent a new route of transmission for local anesthetic to various anatomic locations, but much more research is warranted. Before becoming overtaken with enthusiasm for these new techniques, a deeper understanding of fascial tissue anatomy and structure, as well as precise targets for needle placement, is required. Many factors may influence the ultimate spread and quality of resulting interfascial plane blocks, and these must be understood in order to best integrate these techniques into contemporary perioperative pain management protocols.

  View details for DOI 10.1097/AAP.0000000000000750

  View details for PubMedID 29561295

• Perioperative Pain Management for Total Knee Arthroplasty: Need More Focus on the Forest and Less on the Trees. Anesthesiology Webb, C. A., Madison, S. n., Goodman, S. B., Mariano, E. R., Horn, J. L. 2018; 128 (2): 420–21

  View details for PubMedID 29337751

• Implementation of clinical practice changes by experienced anesthesiologists after simulation-based ultrasound-guided regional anesthesia training. Korean journal of anesthesiology Kim, T. E., Ganaway, T., Harrison, T. K., Howard, S. K., Shum, C., Kuo, A., Mariano, E. R. 2017; 70 (3): 318-326

  Abstract

  Anesthesiologists who have finished formal training and want to learn ultrasound-guided regional anesthesia (UGRA) commonly attend 1 day workshops. However, it is unclear whether participation actually changes clinical practice. We assessed change implementation after completion of a 1 day simulation-based UGRA workshop.Practicing anesthesiologists who participated in a 1 day UGRA course from January 2012 through May 2014 were surveyed. The course consisted of clinical observation of UGRA procedures, didactic lectures, ultrasound scanning, hands-on perineural catheter placement, and mannequin simulation. The primary outcome was the average number of UGRA blocks per month reported at follow-up versus baseline. Secondary outcomes included preference for ultrasound as the nerve localization technique, ratings of UGRA teaching methods, and obstacles to performing UGRA.Survey data from 46 course participants (60% response rate) were included for analysis. Participants were (median [10th-90th percentile]) 50 (37-63) years old, had been in practice for 17 (5-30) years, and were surveyed 27 (10-34) months after their UGRA training. Participants reported performing 24 (4-90) blocks per month at follow-up compared to 10 (2-24) blocks at baseline (P < 0.001). Compared to baseline, more participants at follow-up preferred ultrasound for nerve localization. The major obstacle to implementing UGRA in clinical practice was time pressure.Participation in a 1 day simulation-based UGRA course may increase UGRA procedural volume by practicing anesthesiologists.

  View details for DOI 10.4097/kjae.2017.70.3.318

  View details for PubMedID 28580083

  View details for PubMedCentralID PMC5453894

• A matched case-control comparison of hospital costs and outcomes for knee replacement patients admitted postoperatively to acute care versus rehabilitation. Journal of anesthesia Tse, B. K., Walters, T. L., Howard, S. K., Kim, T. E., Memtsoudis, S. G., Sun, E. C., Kou, A., Graham, L., King, R., Mariano, E. R. 2017

  Abstract

  For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to on-campus rehabilitation. We retrospectively examined whether this 'fast track' pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost [median (10th-90th percentiles)] was US$30,755 (US$23,066-38,444) for ward patients compared to US$17,620 (US$13,215-33,918) for rehabilitation patients (P = 0.006). This difference [mean (95% CI)] was US$10,143 (US$2174-18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes.

  View details for DOI 10.1007/s00540-017-2372-9

  View details for PubMedID 28477230

• Lack of Association Between the Use of Nerve Blockade and the Risk of Postoperative Chronic Opioid Use Among Patients Undergoing Total Knee Arthroplasty: Evidence from the Marketscan Database. Anesthesia and analgesia Sun, E. C., Bateman, B. T., Memtsoudis, S. G., Neuman, M. D., Mariano, E. R., Baker, L. C. 2017

  Abstract

  Total knee arthroplasty (TKA) is associated with high rates of prolonged opioid use after surgery (10%-34%). By decreasing opioid use in the immediate postoperative period, perioperative nerve blockade has been hypothesized to decrease the risk of persistent opioid use.Using health care utilization data, we constructed a sample of 120,080 patients undergoing TKA between 2002 and 2012 and used billing data to identify the utilization of peripheral or neuraxial blockade. We then used a multivariable logistic regression to estimate the association between nerve blockade and the risk of chronic opioid use, defined as having filled ≥10 prescriptions or ≥120 days' supply for an opioid in the first postsurgical year. Our analyses were adjusted for an extensive set of potential confounding variables, including -medical comorbidities, previous opioid use, and previous use of other medications.We did not find an association between nerve blockade and the risk of postsurgical chronic opioid use across any of these 3 groups: adjusted relative risk (ARR) 0.984 for patients opioid-naïve in the year before surgery (98.3% confidence interval [CI], 0.870-1.12, P = .794), ARR 1.02 for intermittent opioid users (98.3% CI, 0.948-1.09, P = .617), and ARR 0.986 (98.3% CI, 0.963-1.01, P = .257) for chronic opioid users. Similar results held for alternative measures of postsurgical opioid use.Although the use of perioperative nerve blockade for TKA may improve short-term outcomes, the analyzed types of blocks do not appear to decrease the risk of persistent opioid use in the longer term.

  View details for DOI 10.1213/ANE.0000000000001943

  View details for PubMedID 28430692

• Adherence to a Multimodal Analgesic Clinical Pathway: A Within-Group Comparison of Staged Bilateral Knee Arthroplasty Patients. Regional anesthesia and pain medicine Steckelberg, R. C., Funck, N., Kim, T. E., Walters, T. L., Lochbaum, G. M., Memtsoudis, S. G., Giori, N. J., Indelli, P. F., Graham, L. J., Mariano, E. R. 2017

  Abstract

  Multimodal analgesic clinical pathways for joint replacement patients often include perineural catheters, but long-term adherence to these pathways has not yet been investigated. Our primary aim was to determine adherence rate to a knee arthroplasty clinical pathway for patients undergoing staged bilateral procedures.This study was performed at a hospital with a Perioperative Surgical Home program and knee arthroplasty clinical pathway using multimodal analgesia and adductor canal catheters. Data were examined for all orthopedic surgery patients over a 4-year period. We included patients who had staged bilateral knee arthroplasty electively scheduled on 2 separate dates. The primary outcome was rate of adductor canal catheter utilization as a measure of adherence to the clinical pathway. Other outcomes included rates of neuraxial anesthesia and minor and major perioperative complications.We analyzed data for 103 unique patients. The interval between surgeries was a median of 261 days (10th-90th percentile, 138-534 days). All 103 patients had adductor canal catheters for both the first and second surgeries (P > 0.999). Forty-one percent of patients had the same surgeon for both surgeries, but only 2% had the same anesthesiologist (P < 0.001). From the first to the second surgery, utilization of neuraxial anesthesia increased from 51% to 68%, respectively (P = 0.005). There were no differences in minor or major complications.For staged bilateral knee arthroplasty patients, 100% clinical pathway adherence including perineural catheters and multimodal analgesia is feasible despite multiple variables. We believe that patient-centered acute pain management requires consistent and reliable delivery of care.

  View details for DOI 10.1097/AAP.0000000000000588

  View details for PubMedID 28267070

• Upgrading a Social Media Strategy to Increase Twitter Engagement During the Spring Annual Meeting of the American Society of Regional Anesthesia and Pain Medicine. Regional anesthesia and pain medicine Schwenk, E. S., Jaremko, K. M., Gupta, R. K., Udani, A. D., McCartney, C. J., Snively, A., Mariano, E. R. 2017

  Abstract

  Microblogs known as "tweets" are a rapid, effective method of information dissemination in health care. Although several medical specialties have described their Twitter conference experiences, Twitter-related data in the fields of anesthesiology and pain medicine are sparse. We therefore analyzed the Twitter content of 2 consecutive spring meetings of the American Society of Regional Anesthesia and Pain Medicine using publicly available online transcripts. We also examined the potential contribution of a targeted social media campaign on Twitter engagement during the conferences. The original Twitter meeting content was largely scientific in nature and created by meeting attendees, the majority of whom were nontrainee physicians. Physician trainees, however, represent an important and increasing minority of Twitter contributors. Physicians not in attendance predominantly contributed via retweeting original content, particularly picture-containing tweets, and thus increased reach to nonattendees. A social media campaign prior to meetings may help increase the reach of conference-related Twitter discussion.

  View details for DOI 10.1097/AAP.0000000000000586

  View details for PubMedID 28267069

• Randomized comparison of popliteal-sciatic perineural catheter tip migration and dislocation in a cadaver model using two catheter designs. Korean journal of anesthesiology Steffel, L., Howard, S. K., Borg, L., Mariano, E. R., Leng, J. C., Kim, T. E. 2017; 70 (1): 72-76

  Abstract

  New catheter-over-needle (CON) technology for continuous peripheral nerve blockade has emerged, but its effect on the risk of perineural catheter tip dislocation is unknown. Less flexible catheters may be more likely to migrate away from the nerve with simulated patient movement. In the present study, we evaluated catheter tip migration between CON catheters and traditional catheter-through-needle (CTN) catheters during ultrasound-guided short-axis in-plane (SAX-IP) insertion.We evaluated the migration of popliteal-sciatic catheters in a prone, unembalmed male cadaver. Thirty catheter placement trials were divided randomly into two groups based on the catheter type: CON or CTN. A single anesthesiology resident placed the catheters by SAX-IP insertion, and the catheters were then examined by ultrasound before and after ipsilateral knee range of motion (ROM) exercises (0°-130° flexion). A blinded expert regional anesthesiologist performed caliper measurements on the ultrasound images before and after the ROM exercises. The primary outcome was the change in distance from the catheter tip to the center of the nerve (cm) between before and after the ROM exercises.The change in the tip-to-nerve distance (median [10th-90th percentile]) was 0.06 (-0.16 to 0.23) cm for the CTN catheter and 0.00 (-0.12 to 0.69) for the CON catheter (P = 0.663). However, there was a statistically significant increase in dislocation out of the nerve compartment for the CON catheter (4/15; 0/15 for CTN) (P = 0.043).Although the use of different catheter designs had no effect on the change in the measured migration distance of popliteal-sciatic catheters, 27% of the CON catheters were dislocated out of the nerve compartment. These results may influence the choice of catheter design when using SAX-IP perineural catheter insertion.

  View details for DOI 10.4097/kjae.2017.70.1.72

  View details for PubMedID 28184270

• In Response. Anesthesia and analgesia Sun, E. C., Bateman, B. T., Memtsoudis, S. G., Neuman, M. D., Mariano, E. R., Baker, L. C. 2017

  View details for PubMedID 29239946

• Lack of Association Between the Use of Nerve Blockade and the Risk of Persistent Opioid Use Among Patients Undergoing Shoulder Arthroplasty: Evidence From the Marketscan Database. Anesthesia and analgesia Mueller, K. G., Memtsoudis, S. G., Mariano, E. R., Baker, L. C., Mackey, S. n., Sun, E. C. 2017

  Abstract

  Persistent opioid use following surgery has received increasing attention from policymakers, researchers, and clinicians. Perioperative nerve blockade has been hypothesized to decrease the risk of persistent opioid use. We examined whether nerve blockade was associated with a decreased risk of persistent opioid use among patients undergoing shoulder arthroplasty, a procedure with high rates of persistent postoperative pain.Using health care claims data, we constructed a sample of 6695 patients undergoing shoulder arthroplasty between 2002 and 2012 and used billing data to identify the utilization of nerve blockade. We then used a multivariable logistic regression to estimate the association between nerve blockade and 2 measures of opioid use: having filled at least 1 prescription for an opioid between postoperative days (PODs) 0 and 90, and between POD 91 and 365. This regression adjusted for a variety of potential confounders, such as preoperative opioid use and medical history.There was no association between nerve blockade and our 2 measures of persistent opioid use: adjusted odds ratio, 1.12 (97.5% confidence interval, 0.939-1.34; P = .15) for opioid use between POD 0 and 90, and adjusted odds ratio, 0.997 (97.5% confidence interval, 0.875-1.14; P = .95) for opioid use between POD 91 and 365.Although the use of perioperative nerve blockade may offer short-term benefits, in this study, it was not associated with a reduction in the risk of persistent opioid use for patients undergoing shoulder arthroplasty.

  View details for PubMedID 28742777

• The Perioperative Surgical Home Is Not Just a Name. Anesthesia and analgesia Mariano, E. R., Vetter, T. R., Kain, Z. N. 2017; 125 (5): 1443–45

  View details for PubMedID 29049108

• Preliminary Experience Using Eye-Tracking Technology to Differentiate Novice and Expert Image Interpretation for Ultrasound-Guided Regional Anesthesia. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Borg, L. K., Harrison, T. K., Kou, A. n., Mariano, E. R., Udani, A. D., Kim, T. E., Shum, C. n., Howard, S. K. 2017

  Abstract

  Objective measures are needed to guide the novice's pathway to expertise. Within and outside medicine, eye tracking has been used for both training and assessment. We designed this study to test the hypothesis that eye tracking may differentiate novices from experts in static image interpretation for ultrasound (US)-guided regional anesthesia.We recruited novice anesthesiology residents and regional anesthesiology experts. Participants wore eye-tracking glasses, were shown 5 sonograms of US-guided regional anesthesia, and were asked a series of anatomy-based questions related to each image while their eye movements were recorded. The answer to each question was a location on the sonogram, defined as the area of interest (AOI). The primary outcome was the total gaze time in the AOI (seconds). Secondary outcomes were the total gaze time outside the AOI (seconds), total time to answer (seconds), and time to first fixation on the AOI (seconds).Five novices and 5 experts completed the study. Although the gaze time (mean ± SD) in the AOI was not different between groups (7 ± 4 seconds for novices and 7 ± 3 seconds for experts; P = .150), the gaze time outside the AOI was greater for novices (75 ± 18 versus 44 ± 4 seconds for experts; P = .005). The total time to answer and total time to first fixation in the AOI were both shorter for experts.Experts in US-guided regional anesthesia take less time to identify sonoanatomy and spend less unfocused time away from a target compared to novices. Eye tracking is a potentially useful tool to differentiate novices from experts in the domain of US image interpretation.

  View details for PubMedID 28777464

• Virtual reality distraction decreases routine intravenous sedation and procedure-related pain during preoperative adductor canal catheter insertion: a retrospective study. Korean journal of anesthesiology Pandya, P. G., Kim, T. E., Howard, S. K., Stary, E. n., Leng, J. C., Hunter, O. O., Mariano, E. R. 2017; 70 (4): 439–45

  Abstract

  Virtual reality (VR) distraction is a nonpharmacological method to prevent acute pain that has not yet been thoroughly explored for anesthesiology. We present our experience using VR distraction to decrease routine intravenous sedation for patients undergoing preoperative perineural catheter insertion.This 1-month quality improvement project involved all elective unilateral primary total knee arthroplasty patients who received a preoperative adductor canal catheter. Clinical data were analyzed retrospectively. For the first half of the month, all patients received usual care; intravenous sedation was administered at the discretion of the regional anesthesiologist. For the second half of the month, patients were offered VR distraction with intravenous sedation upon request. The primary outcome was fentanyl dosage; other outcomes included midazolam dosage, procedure-related pain, procedural time, and blood pressure changes.Seven patients received usual care and seven used VR. In the VR group, 1/7 received intravenous sedation versus 6/7 who received usual care (P = 0.029). The fentanyl dose was lower (median [10th-90th percentiles]) in the VR group (0 [0-20] µg) versus the non-VR group (50 [30-100] µg; P = 0.008). Midazolam use was lower in the VR group (0 [0-0] mg) than in the non-VR group (1 [0-1] mg; P = 0.024). Procedure-related pain was lower in the VR group (1 [1-4] NRS) versus the non-VR group (3 [2-6] NRS; P = 0.032). There was no difference in other outcomes.VR distraction may provide an effective nonpharmacological alternative to intravenous sedation for the ultrasound-guided placement of certain perineural catheters.

  View details for PubMedID 28794840

  View details for PubMedCentralID PMC5548947

• How Social Media is Changing the Practice of Regional Anesthesiology. Current anesthesiology reports Schwenk, E. S., Chu, L. F., Gupta, R. K., Mariano, E. R. 2017; 7 (2): 238–45

  Abstract

  This review summarizes the current applications of social media in regional anesthesiology, describes ways that specific platforms may promote growth, and briefly discusses limitations and future directions.Although Facebook users outnumber Twitter users, the latter has been better studied in regional anesthesiology and may have the advantages of speed and expansion of reach. Highly tweeted publications are more likely to be cited in the medical literature, and twitter-enhanced journal clubs facilitate communication regarding important articles with international colleagues. In both the United States and internationally, Twitter has been shown to enhance the anesthesiology conference experience, changing communication among attendees and non-attendees. YouTube and podcasts are quickly finding a niche in regional anesthesiology for just-in-time training and continuing professional development.Social media use is rapidly growing in regional anesthesiology, and benefits include global interaction and knowledge translation within the specialty and with the general public.

  View details for PubMedID 29422779

• Pecto-intercostal Fascial Block for Acute Poststernotomy Pain: A Case Report. A & A case reports Liu, V. n., Mariano, E. R., Prabhakar, C. n. 2017

  Abstract

  Sternotomy pain is a common complication after cardiac surgery. We present a 77-year-old patient with severe acute sternal pain after coronary artery bypass graft surgery who was successfully treated with a novel peripheral regional anesthetic technique, the pecto-intercostal fascial block. This interfascial plane block may represent an effective regional anesthetic component of a multimodal analgesic strategy for cardiac surgery patients who suffer from significant pain after a median sternotomy and are typically anticoagulated.

  View details for PubMedID 29293481

• Six Month Follow-Up of a Patient With a Retained Fascia Iliaca Catheter: A Case Report. A & A case reports Borg, L. K., Kumar, G. n., Funck, N. n., Tamm-Daniels, I. n., Giori, N. J., Mariano, E. R. 2017

  Abstract

  Retained catheters are a rare but known complication of continuous peripheral nerve block. To date there have been several case reports of retained catheters but none that include longer-term follow-up of the patient experience and outcomes. Here, we present the case of a retained fascia iliaca catheter used for analgesia after total hip arthroplasty that fractured during removal and was ultimately never retrieved. The patient initially experienced paresthesias emanating from the site of continuous peripheral nerve block catheter placement, but these issues resolved completely over several weeks. No infectious or serious sequelae were encountered during 6 months of follow-up.

  View details for DOI 10.1213/XAA.0000000000000642

  View details for PubMedID 28990961

• Getting social: How academic physicians can benefit from social media. Revista espanola de anestesiologia y reanimacion Schwenk, E. S., Udani, A. D., Gupta, R. K., Mariano, E. R. 2017

  View details for PubMedID 29110891

• Continuous regional anesthesia: a review of perioperative outcome benefits. Minerva anestesiologica Bugada, D. n., Ghisi, D. n., Mariano, E. R. 2017

  Abstract

  Routine use of regional anesthesia for patients having surgery is supported by general safety and proven effectiveness as a targeted modality in the prevention and treatment of acute pain. Recently, perioperative physicians have become much more interested in improving long-term outcomes after surgery rather than focusing on the well-established short-term benefits of regional anesthesia. This interest has raised important questions regarding the potential influence of regional anesthesia on morbidity and mortality, persistent pain and cancer prognosis. Tissue injury is responsible for the inflammatory reaction and physiologic stress response observed during the perioperative period and can influence a patient's recovery trajectory. Regional anesthesia can modulate the inflammatory response through the direct anti-inflammatory effect of local anesthetics, blocking neural afferents, and blunting sympathetic activation. Moreover, continuous techniques (e.g., epidural and perineural catheters) that provide longer duration and titratable pain relief in the perioperative period may be protective against the development of persistent post-surgical pain by providing effective acute pain management and decreasing exposure to opioids. To maximize the potential for long-term outcome benefits to surgical patients, continuous regional anesthesia techniques are preferred over single injection techniques. Although the data are not yet definitive, some studies have demonstrated better functional recovery after joint replacement and lower rates of cancer recurrence in patients treated with continuous regional anesthesia. Future research studies in regional anesthesia will have to focus on these long-term patient-centered outcomes and may need to incorporate novel study designs and analyses of big data.

  View details for PubMedID 28607342

• Comparative Echogenicity of an Epidural Catheter and 2 New Catheters Designed for Ultrasound-Guided Continuous Peripheral Nerve Blocks. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Moy, D. M., Kim, T. E., Harrison, T. K., Leng, J. C., Carvalho, B. n., Howard, S. K., Shum, C. n., Kou, A. n., Mariano, E. R. 2017

  Abstract

  Visualization of the catheter during ultrasound-guided continuous nerve block performance may be difficult but is an essential skill for regional anesthesiologists. The objective of this in vitro study was to evaluate 2 newer catheters designed for enhanced echogenicity and compare them to a widely used catheter not purposely designed for ultrasound guidance. Outcomes were the numbers of first-place rankings among all 3 catheters and scores on individual echogenicity criteria as assessed by 2 blinded reviewers. Catheters designed for echogenicity are not superior to an older regional anesthesia catheter, and results suggest that catheter preference for ultrasound-guided placement may be subjective.

  View details for PubMedID 28627724

• The Perioperative Surgical Home model facilitates change implementation in anesthetic technique within a clinical pathway for total knee arthroplasty. Healthcare (Amsterdam, Netherlands) Mudumbai, S. C., Walters, T. L., Howard, S. K., Kim, T. E., Lochbaum, G. M., Memtsoudis, S. G., Kain, Z. N., Kou, A., King, R., Mariano, E. R. 2016; 4 (4): 334-339

  Abstract

  The challenge of knowledge translation in medical settings is well known, and implementing change in clinical practice can take years. For the increasing number total knee arthroplasty (TKA) patients annually, there is ample evidence to endorse neuraxial anesthesia over general anesthesia. The rate of adoption of this practice, however, is slow at the current time. We hypothesized that a Perioperative Surgical Home (PSH) model facilitates rapid change implementation in anesthesia.The PSH clinical pathways workgroup at a tertiary care Veterans Affairs hospital embarked on a 5-month process of changing the preferred anesthetic technique for patients undergoing TKA. This process involved multiple sequential steps: literature review; development of a work document; training of staff; and prospective collection of data. To assess the impact of this change, we examined data 6 months before (PRE, n=90) and after (POST) change implementation (n=128), and our primary outcome was the overall proportion of spinal anesthesia usage for each 6 month period. Secondary outcomes included minor and major complications associated with anesthetic technique.Over a period of one year, there was an increase in the proportion of patients who received spinal anesthesia (13% vs. 63%, p<0.001). For the following year, 53-92% of TKA patients per month received spinal anesthesia. There were no differences in major complications.Rapid and sustained change implementation in clinical anesthesia practice based on emerging evidence is feasible.Perioperative Surgical Home model may facilitate rapid change implementation in surgical care.Cohort study, Level 2.

  View details for DOI 10.1016/j.hjdsi.2016.03.002

  View details for PubMedID 28007227

• Preoperative Treatment of Obstructive Sleep Apnea With Positive Airway Pressure is Associated With Decreased Incidence of Atrial Fibrillation After Cardiac Surgery. Journal of cardiothoracic and vascular anesthesia Wong, J. K., Mariano, E. R., Doufas, A. G., Olejniczak, M. J., Kushida, C. A. 2016

  Abstract

  Based on clinical studies in the nonsurgical population that positive airway pressure (PAP) therapy for patients with obstructive sleep apnea (OSA) provides benefits for those with atrial fibrillation, the authors tested the hypothesis that PAP in patients with OSA reduces the incidence of postoperative atrial fibrillation (POAF) after cardiac surgery.Retrospective analysis.Single-center university hospital.The study comprised 192 patients in sinus rhythm preoperatively who were undergoing nontransplantation or ventricular assist device implantation cardiac surgery requiring cardiopulmonary bypass but not requiring systemic circulatory arrest, with documented PAP adherence from January 2008 to October 2015.Retrospective review of medical records.POAF was defined as atrial fibrillation requiring therapeutic intervention. Of the 192 patients with OSA, 104 (54%) were documented to be PAP-adherent and 88 (46%) were reported to be PAP-nonadherent. Among PAP users, 49 (47%) developed POAF; among PAP nonusers, 59 (66%) developed POAF. The adjusted hazard ratio was 0.59 (95% confidence interval 0.40-0.86, p<0.01). No differences were observed in intensive care unit length of stay (4.0±3.4 days for PAP-adherent group v 5.0±6.2 days for PAP-nonadherent group; p = 0.22) or hospital length of stay (10.7±6.6 days for PAP-adherent group v 10.9±7.3 days for PAP nonadherent group; p = 0.56). A lower median postoperative creatinine rise was observed in PAP-adherent patients (18.2% [8.3%-37.5%) v 31.3% [13.3%-50%]; p< 0.01).Preoperative PAP use in patients with OSA was associated with a decreased rate of POAF after cardiac surgery.

  View details for DOI 10.1053/j.jvca.2016.11.016

  View details for PubMedID 28111105

• Education in Ultrasound-Guided Regional Anesthesia: Lots of Learning Left To Do. Regional anesthesia and pain medicine McCartney, C. J., Mariano, E. R. 2016; 41 (6): 663-664

  View details for PubMedID 27776096

• A comparison of strength for two continuous peripheral nerve block catheter dressings. Korean journal of anesthesiology Borg, L., Howard, S. K., Kim, T. E., Steffel, L., Shum, C., Mariano, E. R. 2016; 69 (5): 506-509

  Abstract

  Despite the benefits of continuous peripheral nerve blocks, catheter dislodgment remains a major problem, especially in the ambulatory setting. However, catheter dressing techniques to prevent such dislodgment have not been studied rigorously. We designed this simulation study to test the strength of two commercially available catheter dressings.Using a cadaver model, we randomly assigned 20 trials to one of two dressing techniques applied to the lateral thigh: 1) clear adhesive dressing alone, or 2) clear adhesive dressing with an anchoring device. Using a digital luggage scale attached to a loop secured by the dressing, the same investigator applied steadily increasing force with a downward trajectory towards the floor until the dressing was removed or otherwise disrupted.The weight, measured (median [10th-90th percentile]) at the time of dressing disruption or removal, was 1.5 kg (1.3-1.8 kg) with no anchoring device versus 4.9 kg (3.7-6.5 kg) when the dressing included an anchoring device (P < 0.001).Based on this simulation study, using an anchoring device may help prevent perineural catheter dislodgement and therefore premature disruption of continuous nerve block analgesia.

  View details for PubMedID 27703632

• Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. Pain medicine Mudumbai, S. C., Oliva, E. M., Lewis, E. T., Trafton, J., Posner, D., Mariano, E. R., Stafford, R. S., Wagner, T., Clark, J. D. 2016; 17 (9): 1732-1743

  Abstract

  This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of postoperative opioids.Retrospective, cohort study.National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical data.All VHA patients (n = 64,391) who underwent surgery in 2011, discharged after stays of ≥1 day, and receiving ≥1 opioid prescription within 90 days of discharge.Patients' preoperative opioid use were categorized as 1) no opioids, 2) tramadol only, 3) short-acting (SA) acute/intermittent (≤ 90 days fill), 4) SA chronic (> 90 days fill), or 5) any long-acting (LA). After defining cessation as 90 consecutive, opioid-free days, the authors calculated time-to-opioid-cessation (in days), from day 1 to day 365, after hospital discharge. The authors developed extended Cox regression models witha prioriidentified predictors. Sensitivity analyses used alternative cessation definitions (30 or 180 consecutive days).Almost 60% of the patients received preoperative opioids: tramadol (7.5%), SA acute/intermittent (24.1%), SA chronic (17.5%), and LA (5.2%). For patients opioid-free preoperatively, median time-to-cessation of opioids postoperatively was 15 days. The SA acute/intermittent cohort (HR =1.96; 95% CI =1.92-2.00) had greater risk for prolonged time-to-cessation than those opioid-free (reference), but lower risk than those taking tramadol only, SA chronic (HR = 9.09; 95% CI = 8.33-9.09), or LA opioids (HR = 9.09; 95% CI = 8.33-10.00). Diagnoses of chronic pain, substance-use, or affective disorders were weaker positive predictors. Sensitivity analyses maintained findings.Greater preoperative levels of opioid use were associated with progressively longer time-to-cessation postoperatively.

  View details for DOI 10.1093/pm/pnw015

  View details for PubMedID 27084410

• Availability and Readability of Online Patient Education Materials Regarding Regional Anesthesia Techniques for Perioperative Pain Management. Pain medicine Kumar, G., Howard, S. K., Kou, A., Kim, T. E., Butwick, A. J., Mariano, E. R. 2016

  Abstract

  OBJECTIVE : Patient education materials (PEM) should be written at a sixth-grade reading level or lower. We evaluated the availability and readability of online PEM related to regional anesthesia and compared the readability and content of online PEM produced by fellowship and nonfellowship institutions. METHODS : With IRB exemption, we constructed a cohort of online regional anesthesia PEM by searching Websites from North American academic medical centers supporting a regional anesthesiology and acute pain medicine fellowships and used a standardized Internet search engine protocol to identify additional nonfellowship Websites with regional anesthesia PEM based on relevant keywords. Readability metrics were calculated from PEM using the TextStat 0.1.4 textual analysis package for Python 2.7 and compared between institutions with and without a fellowship program. The presence of specific descriptive PEM elements related to regional anesthesia was also compared between groups. RESULTS : PEM from 17 fellowship and 15 nonfellowship institutions were included in analyses. The mean (SD) Flesch-Kincaid Grade Level for PEM from the fellowship group was 13.8 (2.9) vs 10.8 (2.0) for the nonfellowship group (p = 0.002). We observed no other differences in readability metrics between fellowship and nonfellowship institutions. Fellowship-based PEM less commonly included descriptions of the following risks: local anesthetic systemic toxicity (p = 0.033) and injury due to an insensate extremity (p = 0.003). CONCLUSIONS : Available online PEM related to regional anesthesia are well above the recommended reading level. Further, fellowship-based PEM posted are at a higher reading level than PEM posted by nonfellowship institutions and are more likely to omit certain risk descriptions.

  View details for PubMedID 27485090

• Use of a home positive airway pressure device during intraoperative monitored anesthesia care for outpatient surgery. Journal of anesthesia Borg, L., Walters, T. L., Siegel, L. C., Dazols, J., Mariano, E. R. 2016; 30 (4): 707-710

  Abstract

  Perioperative positive airway pressure (PAP) is recommended by the American Society of Anesthesiologists for patients with obstructive sleep apnea, but a readily available and personalized intraoperative delivery system does not exist. We present the successful use of a patient's own nasal PAP machine in the operating room during outpatient foot surgery which required addition of a straight adaptor for oxygen delivery and careful positioning of the gas sampling line to permit end-tidal carbox dioxide monitoring. Home PAP machines may provide a potential alternative to more invasive methods of airway management for patients with obstructive sleep apnea under moderate sedation.

  View details for DOI 10.1007/s00540-016-2188-z

  View details for PubMedID 27169990

• An ultrasound-guided fascia iliaca catheter technique does not impair ambulatory ability within a clinical pathway for total hip arthroplasty. Korean journal of anesthesiology Mudumbai, S. C., Kim, T. E., Howard, S. K., Giori, N. J., Woolson, S., Ganaway, T., Kou, A., King, R., Mariano, E. R. 2016; 69 (4): 368-375

  Abstract

  Both neuraxial and peripheral regional analgesic techniques offer postoperative analgesia for total hip arthroplasty (THA) patients. While no single technique is preferred, quadriceps muscle weakness from peripheral nerve blocks may impede rehabilitation. We designed this study to compare postoperative ambulation outcome in THA patients who were treated with a new ultrasound-guided fascia iliaca catheter (FIC) technique or intrathecal morphine (ITM).We reviewed the electronic health records of a sequential series of primary unilateral THA patients who were part of a standardized clinical pathway; apart from differences in regional analgesic technique, all other aspects of the pathway were the same. Our primary outcome was total ambulation distance (meters) combined for postoperative days 1 and 2. Secondary outcomes included daily opioid consumption (morphine milligram equivalents) and analgesic-related side effects. We examined the association between the primary outcome and analgesic technique by performing crude and adjusted ordinary least-squares linear regression. A P value < 0.05 was considered statistically-significant.The study analyzed the records of 179 patients (fascia iliaca, n = 106; intrathecal, n = 73). The primary outcome (total ambulation distance) did not differ between the groups (P = 0.08). Body mass index (BMI) was the only factor (β = -1.7 [95% CI -0.5 to -2.9], P < 0.01) associated with ambulation distance. Opioid consumption did not differ, while increased pruritus was seen in the intrathecal group (P < 0.01).BMI affects postoperative ambulation outcome after hip arthroplasty, whereas the type of regional analgesic technique used does not. An ultrasound-guided FIC technique offers similar analgesia with fewer side effects when compared with ITM.

  View details for DOI 10.4097/kjae.2016.69.4.368

  View details for PubMedID 27482314

• A Randomized Double-Blinded Trial on the Effects of Ultrasound Transducer Orientation on Teaching and Learning Ultrasound-Guided Regional Anesthesia JOURNAL OF ULTRASOUND IN MEDICINE Lam, N. C., Baker, E. B., Fishburn, S. J., Hammer, A. R., Petersen, T. R., Mariano, E. R. 2016; 35 (7): 1509-1516

  Abstract

  Learning ultrasound-guided regional anesthesia skills, especially needle/beam alignment, can be especially difficulty for trainees, who can often become frustrated. We hypothesized that teaching novices to orient the transducer and needle perpendicular to their shoulders will improve performance on a standardized task, compared to holding the transducer and needle parallel to the shoulders.This study compared the effects of transducer orientation on trainees' ability to complete a standardized ultrasound-guided nerve block simulation. The time to task completion and percentage of the attempt time without adequate needle visualization were measured. Participants were right-handed healthy adults with no previous ultrasound experience and were randomly assigned to training in either transducer and needle alignment in a coronal plane, parallel to the shoulders (parallel group) or transducer and needle alignment in a sagittal plane, perpendicular to the shoulders (perpendicular group). Participants used ultrasound to direct a needle to 3 targets in a standardized gelatin phantom and repeated this task 3 times. Their efforts were timed and evaluated by an assessor, who was blinded to group assignment.Data were analyzed on 28 participants. The perpendicular group was able to complete the task more quickly (P< .001) and with a smaller proportion of time lost to inadequate needle visualization (P< .001).Ultrasound-guided regional anesthesia trainees complete a standardized task more quickly and efficiently when instructed to hold the transducer and needle in an orientation perpendicular to their shoulders.

  View details for DOI 10.7863/ultra.15.09031

  View details for Web of Science ID 000382505500017

  View details for PubMedID 27246662

• Design and Implementation of a Perioperative Surgical Home at a Veterans Affairs Hospital. Seminars in cardiothoracic and vascular anesthesia Walters, T. L., Howard, S. K., Kou, A., Bertaccini, E. J., Harrison, T. K., Kim, T. E., Shafer, A., Brun, C., Funck, N., Siegel, L. C., Stary, E., Mariano, E. R. 2016; 20 (2): 133-140

  Abstract

  The innovative Perioperative Surgical Home model aims to optimize the outcomes of surgical patients by leveraging the expertise and leadership of physician anesthesiologists, but there is a paucity of practical examples to follow. Veterans Affairs health care, the largest integrated system in the United States, may be the ideal environment in which to explore this model. We present our experience implementing Perioperative Surgical Home at one tertiary care university-affiliated Veterans Affairs hospital. This process involved initiating consistent postoperative patient follow-up beyond the postanesthesia care unit, a focus on improving in-hospital acute pain management, creation of an accessible database to track outcomes, developing new clinical pathways, and recruiting additional staff. Today, our Perioperative Surgical Home facilitates communication between various services involved in the care of surgical patients, monitoring of patient outcomes, and continuous process improvement.

  View details for DOI 10.1177/1089253215607066

  View details for PubMedID 26392388

• Feasibility of eye-tracking technology to quantify expertise in ultrasound-guided regional anesthesia JOURNAL OF ANESTHESIA Harrison, T. K., Kim, T. E., Kou, A., Shum, C., Mariano, E. R., Howard, S. K. 2016; 30 (3): 530-533

  Abstract

  Ultrasound-guided regional anesthesia (UGRA) requires an advanced procedural skill set that incorporates both sonographic knowledge of relevant anatomy as well as technical proficiency in needle manipulation in order to achieve a successful outcome. Understanding how to differentiate a novice from an expert in UGRA using a quantifiable tool may be useful for comparing educational interventions that could improve the rate at which one develops expertise. Exploring the gaze pattern of individuals performing a task has been used to evaluate expertise in many different disciplines, including medicine. However, the use of eye-tracking technology has not been previously applied to UGRA. The purpose of this preliminary study is to establish the feasibility of applying such technology as a measurement tool for comparing procedural expertise in UGRA. eye-tracking data were collected from one expert and one novice utilizing Tobii Glasses 2 while performing a simulated ultrasound-guided thoracic paravertebral block in a gel phantom model. Area of interest fixations were recorded and heat maps of gaze fixations were created. Results suggest a potential application of eye-tracking technology in the assessment of UGRA learning and performance.

  View details for DOI 10.1007/s00540-016-2157-6

  View details for Web of Science ID 000376675600027

  View details for PubMedID 26980475

• The Risk of Falls After Total Knee Arthroplasty with the Use of a Femoral Nerve Block Versus an Adductor Canal Block: A Double-Blinded Randomized Controlled Study ANESTHESIA AND ANALGESIA Elkassabany, N. M., Antosh, S., Ahmed, M., Nelson, C., Israelite, C., Badiola, I., Cai, L. F., Williams, R., Hughes, C., Mariano, E. R., Liu, J. 2016; 122 (5): 1696-1703

  Abstract

  Adductor canal block (ACB) has emerged as an appealing alternative to femoral nerve block (FNB) that produces a predominantly sensory nerve block by anesthetizing the saphenous nerve. Studies have shown greater quadriceps strength preservation with ACB compared with FNB, but no advantage has yet been shown in terms of fall risk. The Tinetti scale is used by physical therapists to assess gait and balance, and total score can estimate a patient's fall risk. We designed this study to test the primary hypothesis that FNB results in a greater proportion of "high fall risk" patients postoperatively using the Tinetti score compared with ACB.After institutional review board approval, informed written consent to participate in the study was obtained. Patients undergoing primary unilateral total knee arthroplasty were eligible for enrollment in this double-blind, randomized trial. Patients received either an ACB or FNB (20 mL of 0.5% ropivacaine) with catheter placement (8 mL/h of 0.2% ropivacaine) in the setting of multimodal analgesia. Continuous infusion was stopped in the morning of postoperative day (POD)1 before starting physical therapy (PT). On POD1, PT assessed the primary outcome using the Tinetti score for gait and balance. Patients were considered to be at high risk of falling if they scored <19. Secondary outcomes included manual muscle testing of the quadriceps muscle strength, Timed Up and Go (TUG) test, and ambulation distance on POD1 and POD2. The quality of postoperative analgesia and the quality of recovery were assessed with American Pain Society Patient Outcome Questionnaire Revised and Quality of Recovery-9 questionnaire, respectively.Sixty-two patients were enrolled in the study (31 ACB and 31 FNB). No difference was found in the proportion of "high fall risk" patients on POD1 (21/31 in the ACB group versus 24/31 in the FNB group [P = 0.7]; relative risk, 1.14 [95% confidence interval, 0.84-1.56]) or POD2 (7/31 in the ACB versus 14/31 in the FNB group [P = 0.06]; relative risk, 2.0 [95% confidence interval, 0.94-4.27]). The average distance of ambulation during PT and time to up and go were similar on POD1 and POD2. Manual muscle testing grades were significantly higher on POD1 in the ACB group when compared with that in the FNB (P = 0.001) (Wilcoxon-Mann-Whitney odds, 2.25 [95% confidence interval, 1.35-4.26]). There were no other differences in postoperative outcomes.ACB results in greater preservation of quadriceps muscle strength. Although we did not detect a significant reduction in fall risk when compared with FNB, based on the upper limit of the relative risk, it may very well be present. Further study is needed with a larger sample size.

  View details for DOI 10.1213/ANE.0000000000001237

  View details for PubMedID 27007076

• Comparative-Effectiveness of Simulation-Based Deliberate Practice Versus Self-Guided Practice on Resident Anesthesiologists' Acquisition of Ultrasound-Guided Regional Anesthesia Skills. Regional anesthesia and pain medicine Udani, A. D., Harrison, T. K., Mariano, E. R., Derby, R., Kan, J., Ganaway, T., Shum, C., Gaba, D. M., Tanaka, P., Kou, A., Howard, S. K. 2016; 41 (2): 151-157

  Abstract

  Simulation-based education strategies to teach regional anesthesia have been described, but their efficacy largely has been assumed. We designed this study to determine whether residents trained using the simulation-based strategy of deliberate practice show greater improvement of ultrasound-guided regional anesthesia (UGRA) skills than residents trained using self-guided practice in simulation.Anesthesiology residents new to UGRA were randomized to participate in either simulation-based deliberate practice (intervention) or self-guided practice (control). Participants were recorded and assessed while performing simulated peripheral nerve blocks at baseline, immediately after the experimental condition, and 3 months after enrollment. Subject performance was scored from video by 2 blinded reviewers using a composite tool. The amount of time each participant spent in deliberate or self-guided practice was recorded.Twenty-eight participants completed the study. Both groups showed within-group improvement from baseline scores immediately after the curriculum and 3 months following study enrollment. There was no difference between groups in changed composite scores immediately after the curriculum (P = 0.461) and 3 months following study enrollment (P = 0.927) from baseline. The average time in minutes that subjects spent in simulation practice was 6.8 minutes for the control group compared with 48.5 minutes for the intervention group (P < 0.001).In this comparative effectiveness study, there was no difference in acquisition and retention of skills in UGRA for novice residents taught by either simulation-based deliberate practice or self-guided practice. Both methods increased skill from baseline; however, self-guided practice required less time and faculty resources.

  View details for DOI 10.1097/AAP.0000000000000361

  View details for PubMedID 26866296

• Development of technologies for placement of perineural catheters. Journal of anesthesia Elsharkawy, H., Maheshwari, A., Farag, E., Mariano, E. R., Rosenquist, R. W. 2016; 30 (1): 138-147

  Abstract

  Continuous peripheral nerve block (CPNB) success is largely dependent on placement of the catheter close enough to the nerve to allow effective and sustained analgesia following painful surgeries with a minimum volume of local anesthetic. One of the most common problems associated with CPNB involves accurate placement of the catheter tip, migration, and dislodgement of the catheter. This is of increasing importance now that catheters are left in place for prolonged periods of time to provide postoperative analgesia, and patients with peripheral nerve catheters are being discharged home with ambulatory pumps. In response to the challenges of providing safe, effective, and consistently reliable analgesia, research and development in this field is expanding rapidly. This review article presents results from recent publications addressing the subject of peripheral nerve catheter localization.

  View details for DOI 10.1007/s00540-015-2076-y

  View details for PubMedID 26370264

• Can bedside patient-reported numbness predict postoperative ambulation ability for total knee arthroplasty patients with nerve block catheters? Korean journal of anesthesiology Mudumbai, S. C., Ganaway, T., Kim, T. E., Howard, S. K., Giori, N. J., Shum, C., Mariano, E. R. 2016; 69 (1): 32-36

  Abstract

  Adductor canal catheters offer advantages over femoral nerve catheters for knee replacement patients because they produce less quadriceps muscle weakness; however, applying adductor canal catheters in bedside clinical practice remains challenging. There is currently no patient-reported outcome that accurately predicts patients' physical function after knee replacement. The present study evaluates the validity of a relatively new patient-reported outcome, i.e., a numbness score obtained using a numeric rating scale, and assesses its predictive value on postoperative ambulation.We conducted a retrospective cohort study pooling data from two previously-published clinical trials using identical research methodologies. Both studies recruited patients undergoing knee replacement; one studied adductor canal catheters while the other studied femoral nerve catheters. Our primary outcome was patient-reported numbness scores on postoperative day 1. We also examined postoperative day 1 ambulation distance and its association with postoperative numbness using linear regression, adjusting for age, body mass index, and physical status.Data from 94 subjects were included (femoral subjects, n = 46; adductor canal subjects, n = 48). Adductor canal patients reported decreased numbness (median [10(th)-90(th) percentiles]) compared to femoral patients (0 [0-5] vs. 4 [0-10], P = 0.001). Adductor canal patients also ambulated seven times further on postoperative day 1 relative to femoral patients. There was a significant association between postoperative day 1 total ambulation distance and numbness (Beta = -2.6; 95% CI: -4.5, -0.8, P = 0.01) with R(2) = 0.1.Adductor canal catheters facilitate improved early ambulation and produce less patient-reported numbness after knee replacement, but the correlation between these two variables is weak.

  View details for DOI 10.4097/kjae.2016.69.1.32

  View details for PubMedID 26885299

• Comparative Effectiveness of Two Ultrasound-Guided Regional Block Techniques for Surgical Anesthesia in Open Unilateral Inguinal Hernia Repair JOURNAL OF ULTRASOUND IN MEDICINE Steffel, L., Kim, T. E., Howard, S. K., Ly, D. P., Kou, A., King, R., Mariano, E. R. 2016; 35 (1): 177-182

  Abstract

  Transversus abdominis plane (TAP) and ilioinguinal/iliohypogastric (II/IH) nerve blocks have been described as analgesic adjuncts for inguinal hernia repair, but the efficacy of these techniques in providing intraoperative anesthesia, either individually or together, is not known. We designed this retrospective cohort study to test the hypothesis that combining TAP and II/IH nerve blocks ("double TAP" technique) results in greater accordance between the preoperative anesthetic plan and actual anesthetic technique provided when compared to TAP alone. Based on this study, double TAP may be preferred for patients undergoing open inguinal hernia repair who wish to avoid general anesthesia.

  View details for DOI 10.7863/ultra.15.02057

  View details for Web of Science ID 000367228500021

• Improving Mastery Learning With Comparative Effectiveness. Academic medicine : journal of the Association of American Medical Colleges Udani, A. D., Mariano, E. R., Howard, S. K. 2016; 91 (6): 752

  View details for PubMedID 27218903

• Comparative Effectiveness of Two Ultrasound-Guided Regional Block Techniques for Surgical Anesthesia in Open Unilateral Inguinal Hernia Repair. Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine Steffel, L., Kim, T. E., Howard, S. K., Ly, D. P., Kou, A., King, R., Mariano, E. R. 2015

  Abstract

  Transversus abdominis plane (TAP) and ilioinguinal/iliohypogastric (II/IH) nerve blocks have been described as analgesic adjuncts for inguinal hernia repair, but the efficacy of these techniques in providing intraoperative anesthesia, either individually or together, is not known. We designed this retrospective cohort study to test the hypothesis that combining TAP and II/IH nerve blocks ("double TAP" technique) results in greater accordance between the preoperative anesthetic plan and actual anesthetic technique provided when compared to TAP alone. Based on this study, double TAP may be preferred for patients undergoing open inguinal hernia repair who wish to avoid general anesthesia.

  View details for DOI 10.7863/ultra.15.02057

  View details for PubMedID 26614794

• Evaluation of a Standardized Program for Training Practicing Anesthesiologists in Ultrasound-Guided Regional Anesthesia Skills. Journal of ultrasound in medicine Mariano, E. R., Harrison, T. K., Kim, T. E., Kan, J., Shum, C., Gaba, D. M., Ganaway, T., Kou, A., Udani, A. D., Howard, S. K. 2015; 34 (10): 1883-1893

  Abstract

  Practicing anesthesiologists have generally not received formal training in ultrasound-guided perineural catheter insertion. We designed this study to determine the efficacy of a standardized teaching program in this population.Anesthesiologists in practice for 10 years or more were recruited and enrolled to participate in a 1-day program: lectures and live-model ultrasound scanning (morning) and faculty-led iterative practice and mannequin-based simulation (afternoon). Participants were assessed and recorded while performing ultrasound-guided perineural catheter insertion at baseline, at midday (interval), and after the program (final). Videos were scored by 2 blinded reviewers using a composite tool and global rating scale. Participants were surveyed every 3 months for 1 year to report the number of procedures, efficacy of teaching methods, and implementation obstacles.Thirty-two participants were enrolled and completed the program; 31 of 32 (97%) completed the 1-year follow-up. Final scores [median (10th-90th percentiles)] were 21.5 (14.5-28.0) of 30 points compared to 14.0 (9.0-20.0) at interval (P < .001 versus final) and 12.0 (8.5-17.5) at baseline (P < .001 versus final), with no difference between interval and baseline. The global rating scale showed an identical pattern. Twelve of 26 participants without previous experience performed at least 1 perineural catheter insertion after training (P < .001). However, there were no differences in the monthly average number of procedures or complications after the course when compared to baseline.Practicing anesthesiologists without previous training in ultrasound-guided regional anesthesia can acquire perineural catheter insertion skills after a 1-day standardized course, but changing clinical practice remains a challenge.

  View details for DOI 10.7863/ultra.14.12035

  View details for PubMedID 26384608

• Acute Pain Medicine in the United States: A Status Report PAIN MEDICINE Tighe, P., Buckenmaier, C. C., Boezaart, A. P., Carr, D. B., Clark, L. L., Herring, A. A., Kent, M., Mackey, S., Mariano, E. R., Polomano, R. C., Reisfield, G. M. 2015; 16 (9): 1806-1826

  Abstract

  Consensus indicates that a comprehensive,multimodal, holistic approach is foundational to the practice of acute pain medicine (APM),but lack of uniform, evidence-based clinical pathways leads to undesirable variability throughout U. S. healthcare systems. Acute pain studies are inconsistently synthesized to guide educational programs. Advanced practice techniques involving regional anesthesia assume the presence of a physician-led, multidisciplinary acute pain service,which is often unavailable or inconsistently applied.This heterogeneity of educational and organizational standards may result in unnecessary patient pain and escalation of healthcare costs.A multidisciplinary panel was nominated through the APM Shared Interest Group of the American Academy of Pain Medicine. The panel met in Chicago, IL, in July 2014, to identify gaps and set priorities in APM research and education.The panel identified three areas of critical need: 1) an open-source acute pain data registry and clinical support tool to inform clinical decision making and resource allocation and to enhance research efforts; 2) a strong professional APM identity as an accredited subspecialty; and 3) educational goals targeted toward third-party payers,hospital administrators, and other key stake holders to convey the importance of APM.This report is the first step in a 3-year initiative aimed at creating conditions and incentives for the optimal provision of APM services to facilitate and enhance the quality of patient recovery after surgery, illness, or trauma. The ultimate goal is to reduce the conversion of acute pain to the debilitating disease of chronic pain.

  View details for DOI 10.1111/pme.12760

  View details for Web of Science ID 000362887700016

  View details for PubMedID 26535424

  View details for PubMedCentralID PMC4634553

• Perioperative Surgical Home and the Integral Role of Pain Medicine. Pain medicine Walters, T. L., Mariano, E. R., Clark, J. D. 2015; 16 (9): 1666-1672

  View details for DOI 10.1111/pme.12796

  View details for PubMedID 26177700

• Invasive Mechanical Ventilation in California Over 2000-2009: Implications for Emergency Medicine. The western journal of emergency medicine Mudumbai, S. C., Barr, J., Scott, J., Mariano, E. R., Bertaccini, E., Nguyen, H., Memtsoudis, S. G., Cason, B., Phibbs, C. S., Wagner, T. 2015; 16 (5): 696-706

  Abstract

  Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California.We examined data from the masked Patient Discharge Database of California's Office of Statewide Health Planning and Development from 2000-2009. Adult patients who received IMV during their stay were identified using the International Classification of Diseases 9th Revision and Clinical Modification procedure codes (96.70, 96.71, 96.72). Patients were divided into age strata (18-34yr, 35-64yr, and >65yr). Using descriptive statistics and regression analyses, for IMV discharges during the study period, we quantified the number of ED vs. non-ED based admissions; changes in patient characteristics and clinical outcome; evaluated the marginal costs for IMV; determined predictors for prolonged acute mechanical ventilation (PAMV, i.e. IMV>96hr); and projected the number of IMV discharges and ED-based admissions by year 2020.There were 696,634 IMV discharges available for analysis. From 2000-2009, IMV discharges increased by 2.8%/year: n=60,933 (293/100,000 persons) in 2000 to n=79,868 (328/100,000 persons) in 2009. While ED-based admissions grew by 3.8%/year, non-ED-based admissions remained stable (0%). During 2000-2009, fastest growth was noted for 1) the 35-64 year age strata; 2) Hispanics; 3) patients with non-Medicare public insurance; and 4) patients requiring PAMV. Average total patient cost-adjusted charges per hospital discharge increased by 29% from 2000 (from $42,528 to $60,215 in 2014 dollars) along with increases in the number of patients discharged to home and skilled nursing facilities. Higher marginal costs were noted for younger patients (ages 18-34yr), non-whites, and publicly insured patients. Some of the strongest predictors for PAMV were age 35-64 years (OR=1.12; 95% CI [1.09-1.14], p<0.05); non-Whites; and non-Medicare public insurance. Our models suggest that by 2020, IMV discharges will grow to n=153,153 (377 IMV discharges/100,000 persons) with 99,095 admitted through the ED.Based on sustained growth over the past decade, by the year 2020, we project a further increase to 153,153 IMV discharges with 99,095 admitted through the ED. Given limited ICU bed capacities, ongoing increases in the number and type of IMV patients have the potential to adversely affect California EDs that often admit patients to ICUs.

  View details for DOI 10.5811/westjem.2015.6.25736

  View details for PubMedID 26587094

• Comparison of catheter tip migration using flexible and stimulating catheters inserted into the adductor canal in a cadaver model. Journal of anesthesia Webb, C. A., Kim, T. E., Funck, N., Howard, S. K., Harrison, T. K., Ganaway, T., Keng, H., Mariano, E. R. 2015; 29 (3): 471-474

  Abstract

  Use of adductor canal blocks and catheters for perioperative pain management following total knee arthroplasty is becoming increasingly common. However, the optimal equipment, timing of catheter insertion, and catheter dislodgement rate remain unknown. A previous study has suggested, but not proven, that non-tunneled stimulating catheters may be at increased risk for catheter migration and dislodgement after knee manipulation. We designed this follow-up study to directly compare tip migration of two catheter types after knee range of motion exercises. In a male unembalmed human cadaver, 30 catheter insertion trials were randomly assigned to one of two catheter types: flexible or stimulating. All catheters were inserted using an ultrasound-guided short-axis in-plane technique. Intraoperative knee manipulation similar to that performed during surgery was simulated by five sequential range of motion exercises. A blinded regional anesthesiologist performed caliper measurements on the ultrasound images before and after exercise. Changes in catheter tip to nerve distance (p = 0.547) and catheter length within the adductor canal (p = 0.498) were not different between groups. Therefore, catheter type may not affect the risk of catheter tip migration when placed prior to knee arthroplasty.

  View details for DOI 10.1007/s00540-014-1957-9

  View details for PubMedID 25510467

• A Randomized Controlled Trial Evaluating the See, Tilt, Align, and Rotate (STAR) Maneuver on Skill Acquisition for Simulated Ultrasound-Guided Interventional Procedures JOURNAL OF ULTRASOUND IN MEDICINE Lam, N. C., Fishburn, S. J., Hammer, A. R., Petersen, T. R., Gerstein, N. S., Mariano, E. R. 2015; 34 (6): 1019-1026

  Abstract

  Achieving the best view of the needle and target anatomy when performing ultrasound-guided interventional procedures requires technical skill, which novices may find difficult to learn. We hypothesized that teaching novice performers to use 4 sequential steps (see, tilt, align, and rotate [STAR] method) to identify the needle under ultrasound guidance is more efficient than training with the commonly described probe movements of align, rotate, and tilt (ART).This study compared 2 instructional methods for transducer manipulation including alignment of a probe and needle by novices during a simulated ultrasound-guided nerve block. Right-handed volunteers between the ages of 18 and 55 years who had no previous ultrasound experience were recruited and randomized to 1 of 2 groups; one group was trained to troubleshoot misalignment with the ART method, and the other was trained with the new STAR maneuver. Participants performed the task, consisting of directing a needle in plane to 3 targets in a standardized gelatin phantom 3 times. The performance assessor and data analyst were blinded to group assignment.Thirty-five participants were recruited. The STAR group was able to complete the task more quickly (P < .001) and visualized the needle in a greater proportion of the procedure time (P = .004) compared to the ART group. All STAR participants were able to complete the task, whereas 41% of ART participants abandoned the task (P = .003).Novices are able to complete a simulated ultrasound-guided nerve block more quickly and efficiently when trained with the 4-step STAR maneuver compared to the ART method.

  View details for DOI 10.7863/ultra.34.6.1019

  View details for Web of Science ID 000355768200010

  View details for PubMedID 26014321

• Guidelines for Fellowship Training in Regional Anesthesiology and Acute Pain Medicine Third Edition, 2014 REGIONAL ANESTHESIA AND PAIN MEDICINE Kopp, S. L., Hargett, M. J., Liguori, G. A., Neal, J. M., Le-Wendling, L., Votta-Velis, E. G., Mariano, E. R. 2015; 40 (3): 213-217

  Abstract

  Directors for Regional Anesthesiology and Acute Pain Medicine fellowships develop and maintain guidelines for fellowship training in the subspecialty. The first edition of the guidelines was published in 2005 with a revision published in 2010. This set of guidelines updates the 2010 revision. The guidelines address 3 major topics: organization and resources, the educational program, and the evaluation process.

  View details for DOI 10.1097/AAP.0000000000000233

  View details for Web of Science ID 000369616600003

  View details for PubMedID 25899950

• A retrospective comparative provider workload analysis for femoral nerve and adductor canal catheters following knee arthroplasty JOURNAL OF ANESTHESIA Rasmussen, M., Kim, E., Kim, T. E., Howard, S. K., Mudumbai, S., Giori, N. J., Woolson, S., Ganaway, T., Mariano, E. R. 2015; 29 (2): 303-307

  Abstract

  Adductor canal catheters preserve quadriceps strength better than femoral nerve catheters and may facilitate postoperative ambulation following total knee arthroplasty. However, the effect of this newer technique on provider workload, if any, is unknown. We conducted a retrospective provider workload analysis comparing these two catheter techniques; all other aspects of the clinical pathway remained the same. The primary outcome was number of interventions recorded per patient postoperatively. Secondary outcomes included infusion duration, ambulation distance, opioid consumption, and hospital length of stay. Adductor canal patients required a median (10-90th percentiles) of 0.0 (0.0-2.6) interventions compared to 1.0 (0.3-3.0) interventions for femoral patients (p < 0.001); 18/23 adductor canal patients (78 %) compared to 2/22 femoral patients (9 %) required no interventions (p < 0.001). Adductor canal catheter infusions lasted 2.0 (1.4-2.0) days compared to 1.5 (1.0-2.7) days in the femoral group (p = 0.016). Adductor canal patients ambulated further [mean (SD)] than femoral patients on postoperative day 1 [24.5 (21.7) vs. 11.9 (14.6) meters, respectively; p = 0.030] and day 2 [44.9 (26.3) vs. 22.0 (22.2) meters, respectively; p = 0.003]. Postoperative opioid consumption and length of stay were similar between groups. We conclude that adductor canal catheters offer both patient and provider benefits when compared to femoral nerve catheters.

  View details for DOI 10.1007/s00540-014-1910-y

  View details for Web of Science ID 000352859100025

  View details for PubMedID 25217117

• A pilot study to assess adductor canal catheter tip migration in a cadaver model JOURNAL OF ANESTHESIA Leng, J. C., Harrison, T. K., Miller, B., Howard, S. K., Conroy, M., Udani, A., Shum, C., Mariano, E. R. 2015; 29 (2): 308-312

  Abstract

  An adductor canal catheter may facilitate early ambulation after total knee arthroplasty, but there is concern over preoperative placement since intraoperative migration of catheters may occur from surgical manipulation and result in ineffective analgesia. We hypothesized that catheter type and subcutaneous tunneling may influence tip migration for preoperatively inserted adductor canal catheters. In a male unembalmed human cadaver, 20 catheter insertion trials were divided randomly into one of four groups: flexible epidural catheter either tunneled or not tunneled; or rigid stimulating catheter either tunneled or not tunneled. Intraoperative patient manipulation was simulated by five range-of-motion exercises of the knee. Distance and length measurements were performed by a blinded regional anesthesiologist. Changes in catheter tip to nerve distance (p = 0.225) and length of catheter within the adductor canal (p = 0.467) were not different between the four groups. Two of five non-tunneled stimulating catheters (40 %) were dislodged compared to 0/5 in all other groups (p = 0.187). A cadaver model may be useful for assessing migration of regional anesthesia catheters; catheter type and subcutaneous tunneling may not affect migration of adductor canal catheters based on this preliminary study. However, future studies involving a larger sample size, actual patients, and other catheter types are warranted.

  View details for DOI 10.1007/s00540-014-1922-7

  View details for Web of Science ID 000352859100026

  View details for PubMedID 25288506

• Comparative Effectiveness of Infraclavicular and Supraclavicular Perineural Catheters for Ultrasound-Guided Through-the-Catheter Bolus Anesthesia. Journal of ultrasound in medicine Harrison, T. K., Kim, T. E., Howard, S. K., Funck, N., Wagner, M. J., Walters, T. L., Curtin, C., Chang, J., Ganaway, T., Mariano, E. R. 2015; 34 (2): 333-340

  Abstract

  Using a through-the-needle local anesthetic bolus technique, ultrasound-guided infraclavicular perineural catheters have been shown to provide greater analgesia compared to supraclavicular catheters. A through-the-catheter bolus technique, which arguably "tests" the anesthetic efficacy of the catheter before initiating an infusion, has been validated for infraclavicular catheters but not supraclavicular catheters. This study investigated the through-the-catheter bolus technique for supraclavicular catheters and tested the hypothesis that infraclavicular catheters provide faster onset of brachial plexus anesthesia.Preoperatively, patients were randomly assigned to receive either a supraclavicular or an infraclavicular catheter using an ultrasound-guided nonstimulating catheter insertion technique with a mepivacaine bolus via the catheter and ropivacaine perineural infusion initiated postoperatively. The primary outcome was time to achieve complete sensory anesthesia in the ulnar and median nerve distributions. Secondary outcomes included procedural time, procedure-related pain and complications, and postoperative pain, opioid consumption, sleep disturbances, and motor weakness.Fifty patients were enrolled in the study; all but 2 perineural catheters were successfully placed per protocol. Twenty-one of 24 (88%) and 24 of 24 (100%) patients in the supraclavicular and infraclavicular groups, respectively, achieved complete sensory anesthesia by 30 minutes (P= .088). There was no difference in the time to achieve complete sensory anesthesia. Supraclavicular patients reported more sleep disturbances postoperatively, but there were no statistically significant differences in other outcomes.Both supraclavicular and infraclavicular perineural catheters using a through-the-catheter bolus technique provide effective brachial plexus anesthesia.

  View details for DOI 10.7863/ultra.34.2.333

  View details for PubMedID 25614407

• Why the perioperative surgical home makes sense for veterans affairs health care. Anesthesia and analgesia Mariano, E. R., Walters, T. L., Kim, T. E., Kain, Z. N. 2015; 120 (5): 1163–66

  View details for PubMedID 25899279

• New vistas: continuous peripheral catheters/regional anesthesia in postoperative pain management CASE STUDIES IN PAIN MANAGEMENT Rasmussen, M. R., Mariano, E. R., Kaye, A. D., Shah, R. V. 2015: 491–97

  View details for Web of Science ID 000362900600072

• Simulation in teaching regional anesthesia: current perspectives. Local and regional anesthesia Udani, A. D., Kim, T. E., Howard, S. K., Mariano, E. R. 2015; 8: 33-43

  Abstract

  The emerging subspecialty of regional anesthesiology and acute pain medicine represents an opportunity to evaluate critically the current methods of teaching regional anesthesia techniques and the practice of acute pain medicine. To date, there have been a wide variety of simulation applications in this field, and efficacy has largely been assumed. However, a thorough review of the literature reveals that effective teaching strategies, including simulation, in regional anesthesiology and acute pain medicine are not established completely yet. Future research should be directed toward comparative-effectiveness of simulation versus other accepted teaching methods, exploring the combination of procedural training with realistic clinical scenarios, and the application of simulation-based teaching curricula to a wider range of learner, from the student to the practicing physician.

  View details for DOI 10.2147/LRA.S68223

  View details for PubMedID 26316812

• Best multimodal analgesic protocol for total knee arthroplasty. Pain management Webb, C. A., Mariano, E. R. 2015; 5 (3): 185-196

  Abstract

  SUMMARY  Total knee arthroplasty is one of the most commonly performed operations in the USA. As with any elective joint surgery, the primary goal includes functional restoration that is not limited by pain. The use of peripheral nerve blocks for patients undergoing knee arthroplasty has resulted in decreased pain scores, improved early ambulation and decreased time to achieve hospital discharge criteria. Concern has been raised over the potential risks of femoral nerve block, and there has been growing support for the adductor canal block. It is the author's opinion that when not contraindicated, intraoperative neuraxial anesthesia combined with a continuous adductor canal block and a multimodal medication regimen for postoperative pain control is the best analgesic protocol for knee arthroplasty.

  View details for DOI 10.2217/pmt.15.8

  View details for PubMedID 25971642

• Editorial comment: ultrasound-guided peripheral nerve blocks for ventricular shunt revision in children. A & A case reports Mariano, E. R. 2014; 3 (12): 160-161

  View details for DOI 10.1213/XAA.0000000000000101

  View details for PubMedID 25612198

• A randomized comparison of long-axis and short-axis imaging for in-plane ultrasound-guided popliteal-sciatic perineural catheter insertion JOURNAL OF ANESTHESIA Kim, T. E., Howard, S. K., Funck, N., Harrison, T. K., Walters, T. L., Wagner, M. J., Ganaway, T., Mullens, J., Lehnert, B., Mariano, E. R. 2014; 28 (6): 854-860

  Abstract

  Ultrasound-guided long-axis in-plane sciatic perineural catheter insertion has been described but not validated. For the popliteal-sciatic nerve, we hypothesized that a long-axis in-plane technique, placing the catheter parallel and posterior to the nerve, results in faster onset of sensory anesthesia compared to a short-axis in-plane technique.Preoperatively, patients receiving a popliteal-sciatic perineural catheter were randomly assigned to either the long-axis or short-axis technique. Mepivacaine 2 % was administered via the catheter following insertion. The primary outcome was time to achieve complete sensory anesthesia. Secondary outcomes included procedural time, onset time of motor block, and pain on postoperative day 1.Fifty patients were enrolled. In the long-axis group (n = 25), all patients except 1 (4 %) had successful catheter placement per protocol. Two patients (8 %) in the long-axis group and 1 patient (4 %) in the short-axis group (n = 25) did not achieve sensory anesthesia by 30 min and were withdrawn. Seventeen of 24 (71 %) and 17 of 22 (77 %) patients in the short-axis and long-axis groups, respectively, achieved the primary outcome of complete sensory anesthesia (p = 0.589). The short-axis group (n = 17) required a median (10th-90th ‰) of 18.0 (8.4-30.0) min compared to 18.0 (11.4-27.6) min for the long-axis group (n = 17, p = 0.208) to achieve complete sensory anesthesia. Procedural time was 6.5 (4.0-12.0) min for the short-axis and 9.5 (7.0-12.7) min for the long-axis (p < 0.001) group. There were no statistically significant differences in other secondary outcomes.Long-axis in-plane popliteal-sciatic perineural catheter insertion requires more time to perform compared to a short-axis in-plane technique without demonstrating any advantages.

  View details for DOI 10.1007/s00540-014-1832-8

  View details for PubMedID 24789659

• A Pilot Study to Measure the Impact of Blended Learning on Intern Wellness and Burnout Wen, L., Ratner, E., Harrison, T., Chu, L., Mariano, E., Roberts, S., Wang, T., Udani, A. LIPPINCOTT WILLIAMS & WILKINS. 2014

  View details for Web of Science ID 000209827700053

• Developing a multidisciplinary fall reduction program for lower-extremity joint arthroplasty patients. Anesthesiology clinics Kim, T. E., Mariano, E. R. 2014; 32 (4): 853-864

  Abstract

  With the anticipated increase in the number of total joint arthroplasty surgeries and associated fall risks, a fall reduction program can provide greater safety for patients in the postoperative period. Although further prospective studies are needed among total joint arthroplasty patients, there is sufficient evidence to show that a successful fall reduction program can be implemented. Common components to date have included a multidisciplinary team, multicomponent interventions specific to the risks associated with total knee and hip arthroplasty patients, education of patients and staff, and strategies to promote adherence to the program.

  View details for DOI 10.1016/j.anclin.2014.08.005

  View details for PubMedID 25453666

• A Pilot In Vitro Evaluation of the "Air Test" for Perineural Catheter Tip Localization by a Novice Regional Anesthesiologist JOURNAL OF ULTRASOUND IN MEDICINE Johns, J., Harrison, T. K., Steffel, L., Howard, S. K., Kim, T. E., Kou, A., Mariano, E. R. 2014; 33 (12): 2197-2200

  Abstract

  The "air test" is used clinically to infer perineural catheter location and has been recently evaluated for use by experts. However, its utility for practitioners with less experience is unknown. We tested the hypothesis that the air test, when performed by a novice regional anesthesiologist, will improve assessment of perineural catheter tip position in a validated porcine-bovine model and determined the test's positive and negative predictive values, sensitivity, and specificity for a novice. In contrast to the results of the expert study, the air test did not improve the novice's assessment of perineural catheter tip location over chance.

  View details for DOI 10.7863/ultra.33.12.2197

  View details for Web of Science ID 000346232600019

  View details for PubMedID 25425379

• Continuous transversus abdominis plane (TAP) blocks for postoperative pain control after hernia surgery: a randomized, triple-masked, placebo-controlled study. Pain medicine Heil, J. W., Nakanote, K. A., Madison, S. J., Loland, V. J., Mariano, E. R., Sandhu, N. S., Bishop, M. L., Agarwal, R. R., Proudfoot, J. A., Ferguson, E. J., Morgan, A. C., Ilfeld, B. M. 2014; 15 (11): 1957-1964

  Abstract

  Single-injection transversus abdominis plane (TAP) block provides postoperative analgesia and decreases supplemental analgesic requirements. However, there is currently no evidence from randomized, controlled studies investigating the possible benefits of continuous TAP blocks. Therefore, the aim of this randomized, triple-masked, placebo-controlled study was to determine if benefits are afforded by adding a multiple-day, ambulatory, continuous ropivacaine TAP block to a single-injection block following hernia surgery.Preoperatively, subjects undergoing unilateral inguinal (N = 19) or peri-umbilical (N = 1) hernia surgery received unilateral or bilateral TAP perineural catheter(s), respectively. All received a ropivacaine 0.5% (20 mL) bolus via the catheter(s). Subjects were randomized to either postoperative perineural ropivacaine 0.2% or normal saline using portable infusion pump(s). Subjects were discharged home where the catheter(s) were removed the evening of postoperative day (POD) 2. Subjects were contacted on POD 0-3. The primary endpoint was average pain with movement (scale: 0-10) queried on POD 1.Twenty subjects of a target 30 were enrolled due to the primary surgeon's unanticipated departure from the institution. Average pain queried on POD 1 for subjects receiving ropivacaine (N = 10) was a mean (standard deviation) of 3.0 (2.6) vs 2.8 (2.7) for subjects receiving saline (N = 10; 95% confidence interval difference in means -2.9 to 3.4; P = 0.86). There were no statistically significant differences detected between treatment groups in any secondary endpoint.The results of this study do not support adding an ambulatory, continuous ropivacaine infusion to a single-injection ropivacaine TAP block for hernia surgery. However, the present investigation was underpowered, and further study is warranted.

  View details for DOI 10.1111/pme.12530

  View details for PubMedID 25138273

• Continuous Transversus Abdominis Plane (TAP) Blocks for Postoperative Pain Control after Hernia Surgery: A Randomized, Triple-Masked, Placebo-Controlled Study PAIN MEDICINE Heil, J. W., Nakanote, K. A., Madison, S. J., Loland, V. J., Mariano, E. R., Sandhu, N. S., Bishop, M. L., Agarwal, R. R., Proudfoot, J. A., Ferguson, E. J., Morgan, A. C., Ilfeld, B. M. 2014; 15 (11): 1957-1964

  Abstract

  Single-injection transversus abdominis plane (TAP) block provides postoperative analgesia and decreases supplemental analgesic requirements. However, there is currently no evidence from randomized, controlled studies investigating the possible benefits of continuous TAP blocks. Therefore, the aim of this randomized, triple-masked, placebo-controlled study was to determine if benefits are afforded by adding a multiple-day, ambulatory, continuous ropivacaine TAP block to a single-injection block following hernia surgery.Preoperatively, subjects undergoing unilateral inguinal (N = 19) or peri-umbilical (N = 1) hernia surgery received unilateral or bilateral TAP perineural catheter(s), respectively. All received a ropivacaine 0.5% (20 mL) bolus via the catheter(s). Subjects were randomized to either postoperative perineural ropivacaine 0.2% or normal saline using portable infusion pump(s). Subjects were discharged home where the catheter(s) were removed the evening of postoperative day (POD) 2. Subjects were contacted on POD 0-3. The primary endpoint was average pain with movement (scale: 0-10) queried on POD 1.Twenty subjects of a target 30 were enrolled due to the primary surgeon's unanticipated departure from the institution. Average pain queried on POD 1 for subjects receiving ropivacaine (N = 10) was a mean (standard deviation) of 3.0 (2.6) vs 2.8 (2.7) for subjects receiving saline (N = 10; 95% confidence interval difference in means -2.9 to 3.4; P = 0.86). There were no statistically significant differences detected between treatment groups in any secondary endpoint.The results of this study do not support adding an ambulatory, continuous ropivacaine infusion to a single-injection ropivacaine TAP block for hernia surgery. However, the present investigation was underpowered, and further study is warranted.

  View details for DOI 10.1111/pme.12530

  View details for Web of Science ID 000345561700015

• A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty. Journal of ultrasound in medicine Mariano, E. R., Kim, T. E., Wagner, M. J., Funck, N., Harrison, T. K., Walters, T., Giori, N., Woolson, S., Ganaway, T., Howard, S. K. 2014; 33 (9): 1653-1662

  Abstract

  Proximal and distal (mid-thigh) ultrasound-guided continuous adductor canal block techniques have been described but not yet compared, and infusion benefits or side effects may be determined by catheter location. We hypothesized that proximal placement will result in faster onset of saphenous nerve anesthesia, without additional motor block, compared to a distal technique.Preoperatively, patients receiving an ultrasound-guided nonstimulating adductor canal catheter for knee arthroplasty were randomly assigned to either proximal or distal insertion. A local anesthetic bolus was administered via the catheter after successful placement. The primary outcome was the time to achieve complete sensory anesthesia in the saphenous nerve distribution. Secondary outcomes included procedural time, procedure-related pain and complications, postoperative pain, opioid consumption, and motor weakness.Proximal insertion (n = 23) took a median (10th-90th percentiles) of 12.0 (3.0-21.0) minutes versus 6.0 (3.0-21.0) minutes for distal insertion (n = 21; P= .106) to anesthetize the medial calf. Only 10 of 25 (40%) and 10 of 24 (42%) patients in the proximal and distal groups, respectively, developed anesthesia at both the medial calf and top of the patella (P= .978). Bolus-induced motor weakness occurred in 19 of 25 (76%) and 16 of 24 (67%) patients in the proximal and distal groups (P = .529). Ten of 24 patients (42%) in the distal group required intravenous morphine postoperatively, compared to 2 of 24 (8%) in the proximal group (P = .008), but there were no differences in other secondary outcomes.Continuous adductor canal blocks can be performed reliably at both proximal and distal locations. The proximal approach may offer minor analgesic and logistic advantages without an increase in motor block.

  View details for DOI 10.7863/ultra.33.9.1653

  View details for PubMedID 25154949

• In reply. Anesthesiology Memtsoudis, S. G., Mariano, E. R. 2014; 121 (3): 669-?

  View details for DOI 10.1097/ALN.0000000000000359

  View details for PubMedID 25222686

• A Randomized Clinical Trial Comparing the Effectiveness of Ultrasound Guidance Versus Nerve Stimulation for Lateral Popliteal-Sciatic Nerve Blocks in Obese Patients JOURNAL OF ULTRASOUND IN MEDICINE Lam, N. C., Petersen, T. R., Gerstein, N. S., Yen, T., Starr, B., Mariano, E. R. 2014; 33 (6): 1057-1063

  Abstract

  Ultrasound guidance may decrease the procedural time for many peripheral nerve blocks compared to nerve stimulation, but these studies have generally excluded obese patients. This single-blinded randomized clinical trial was designed to compare procedural times and related outcomes for ultrasound- versus nerve stimulation-guided lateral popliteal-sciatic nerve blockade specifically in obese patients.With Institutional Review Board approval and informed consent, patients with a body mass index greater than 30 kg/m(2) who were scheduled for foot/ankle surgery and desiring a peripheral nerve block were offered enrollment. Study patients were randomly assigned to receive a lateral popliteal-sciatic nerve block under either ultrasound or nerve stimulation guidance. The patient and assessor were blinded to group assignment. The primary outcome was procedural time in seconds. Secondary outcomes included number of needle redirections, procedure-related pain, patient satisfaction with the block, success rate, sensory and motor onset times, block duration, and complication rates.Twenty-four patients were enrolled and completed the study. All patients had successful nerve blocks. The mean procedural times (SD) were 577 (57) seconds under nerve stimulation and 206 (40) seconds with ultrasound guidance (P< .001; 95% confidence interval for difference, 329-412 seconds). Patients in the ultrasound group had fewer needle redirections and less procedure-related pain, required less opioids, and were more satisfied with their block procedures. There were no statistically significant differences in other outcomes.The results of this study show that, for obese patients undergoing lateral popliteal-sciatic nerve blocks, ultrasound guidance reduces the procedural time and procedure-related pain and increases patient satisfaction compared to nerve stimulation while providing similar block characteristics.

  View details for DOI 10.7863/ultra.33.6.1057

  View details for Web of Science ID 000336771000014

  View details for PubMedID 24866613

• A randomized controlled trial on motor function and patient satisfaction in ultrasound-guided peripheral nerve block anesthesia for outpatient hand surgery Lam, N. K., Charles, M., Mercer, D., Dillow, J., Petersen, T., Mariano, E. LIPPINCOTT WILLIAMS & WILKINS. 2014: 130–31

  View details for DOI 10.1097/00003643-201406001-00366

  View details for Web of Science ID 000209832000367

• Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical orthopaedics and related research Mudumbai, S. C., Kim, T. E., Howard, S. K., Workman, J. J., Giori, N., Woolson, S., Ganaway, T., King, R., Mariano, E. R. 2014; 472 (5): 1377-1383

  Abstract

  Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.We determined whether, after TKA, patients with adductor canal CPNB versus patients with femoral CPNB demonstrated (1) greater total ambulation distance on Postoperative Day (POD) 1 and 2 and (2) decreased daily opioid consumption, pain scores, and hospital length of stay.Between October 2011 and October 2012, 180 patients underwent primary TKA at our practice site, of whom 93% (n = 168) had CPNBs. In this sequential series, the first 102 patients had femoral CPNBs, and the next 66 had adductor canal CPNBs. The change resulted from a modification to our clinical pathway, which involved only a change to the block. An evaluator not involved in the patients' care reviewed their medical records to record the parameters noted above.Ambulation distances were higher in the adductor canal group than in the femoral group on POD 1 (median [10(th)-90(th) percentiles]: 37 m [0-90 m] versus 6 m [0-51 m]; p < 0.001) and POD 2 (60 m [0-120 m] versus 21 m [0-78 m]; p = 0.003). Adjusted linear regression confirmed the association between adductor canal catheter use and ambulation distance on POD 1 (B = 23; 95% CI = 14-33; p < 0.001) and POD 2 (B = 19; 95% CI = 5-33; p = 0.008). Pain scores, daily opioid consumption, and hospital length of stay were similar between groups.Adductor canal CPNB may promote greater early postoperative ambulation compared to femoral CPNB after TKA without a reduction in analgesia. Future randomized studies are needed to validate our major findings.Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

  View details for DOI 10.1007/s11999-013-3197-y

  View details for PubMedID 23897505

• THE IMPACT OF A FLIPPED CLASSROOM ON INTERN WELLNESS AND BURNOUT: A PILOT STUDY Wen, L., Ratner, E., Harrison, K., Chu, L., Mariano, E., Roberts, S., Udani, A. LIPPINCOTT WILLIAMS & WILKINS. 2014: S101

  View details for Web of Science ID 000209827600091

• Application of Echogenic Technology for Catheters Used in Ultrasound-Guided Continuous Peripheral Nerve Blocks JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Yun, R. D., Kim, T. E., Carvalho, B. 2014; 33 (5): 905-911

  Abstract

  Limited data exist regarding the echogenicity of perineural catheters, but visualization is crucial to ensure accurate placement and efficacy of the subsequent local anesthetic infusion. The objective of this study was to determine the comparative echogenicity of various regional anesthesia catheters. In an in vitro porcine-bovine model, we compared the echogenic qualities of 3 commercially available regional anesthesia catheters and 1 catheter under development to optimize echogenicity. Outcomes included visual echogenicity ranking, image quality, and scanning time, as assessed by 2 blinded investigators. The experimental catheter was found to be more echogenic than 2 of the 3 comparators.

  View details for DOI 10.7863/ultra.33.5.905

  View details for Web of Science ID 000335620700018

  View details for PubMedID 24764346

• Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology Memtsoudis, S. G., Danninger, T., Rasul, R., Poeran, J., Gerner, P., Stundner, O., Mariano, E. R., Mazumdar, M. 2014; 120 (3): 551-563

  Abstract

  Much controversy remains on the role of anesthesia technique and peripheral nerve blocks (PNBs) in inpatient falls (IFs) after orthopedic procedures. The aim of the study is to characterize cases of IFs, identify risk factors, and study the role of PNB and anesthesia technique in IF risk in total knee arthroplasty patients.The authors selected total knee arthroplasty patients from the national Premier Perspective database (Premier Inc., Charlotte, NC; 2006-2010; n = 191,570, >400 acute care hospitals). The primary outcome was IF. Patient- and healthcare system-related characteristics, anesthesia technique, and presence of PNB were determined for IF and non-IF patients. Independent risk factors for IFs were determined by using conventional and multilevel logistic regression.Overall, IF incidence was 1.6% (n = 3,042). Distribution of anesthesia technique was 10.9% neuraxial, 12.9% combined neuraxial/general, and 76.2% general anesthesia. PNB was used in 12.1%. Patients suffering IFs were older (average age, 68.9 vs. 66.3 yr), had higher comorbidity burden (average Deyo index, 0.77 vs. 0.66), and had more major complications, including 30-day mortality (0.8 vs. 0.1%; all P < 0.001). Use of neuraxial anesthesia (IF incidence, 1.3%; n = 280) had lower adjusted odds of IF compared with adjusted odds of IF with the use of general anesthesia alone (IF incidence, 1.6%; n = 2,393): odds ratio, 0.70 (95% CI, 0.56-0.87). PNB was not significantly associated with IF (odds ratio, 0.85 [CI, 0.71-1.03]).This study identifies several risk factors for IF in total knee arthroplasty patients. Contrary to common concerns, no association was found between PNB and IF. Further studies should determine the role of anesthesia practices in the context of fall-prevention programs.

  View details for DOI 10.1097/ALN.0000000000000120

  View details for PubMedID 24534855

• Inpatient Falls after Total Knee Arthroplasty ANESTHESIOLOGY Memtsoudis, S. G., Danninger, T., Rasul, R., Poeran, J., Gerner, P., Stundner, O., Mariano, E. R., Mazumdar, M. 2014; 120 (3): 551-563

  Abstract

  Much controversy remains on the role of anesthesia technique and peripheral nerve blocks (PNBs) in inpatient falls (IFs) after orthopedic procedures. The aim of the study is to characterize cases of IFs, identify risk factors, and study the role of PNB and anesthesia technique in IF risk in total knee arthroplasty patients.The authors selected total knee arthroplasty patients from the national Premier Perspective database (Premier Inc., Charlotte, NC; 2006-2010; n = 191,570, >400 acute care hospitals). The primary outcome was IF. Patient- and healthcare system-related characteristics, anesthesia technique, and presence of PNB were determined for IF and non-IF patients. Independent risk factors for IFs were determined by using conventional and multilevel logistic regression.Overall, IF incidence was 1.6% (n = 3,042). Distribution of anesthesia technique was 10.9% neuraxial, 12.9% combined neuraxial/general, and 76.2% general anesthesia. PNB was used in 12.1%. Patients suffering IFs were older (average age, 68.9 vs. 66.3 yr), had higher comorbidity burden (average Deyo index, 0.77 vs. 0.66), and had more major complications, including 30-day mortality (0.8 vs. 0.1%; all P < 0.001). Use of neuraxial anesthesia (IF incidence, 1.3%; n = 280) had lower adjusted odds of IF compared with adjusted odds of IF with the use of general anesthesia alone (IF incidence, 1.6%; n = 2,393): odds ratio, 0.70 (95% CI, 0.56-0.87). PNB was not significantly associated with IF (odds ratio, 0.85 [CI, 0.71-1.03]).This study identifies several risk factors for IF in total knee arthroplasty patients. Contrary to common concerns, no association was found between PNB and IF. Further studies should determine the role of anesthesia practices in the context of fall-prevention programs.

  View details for DOI 10.1097/ALN.0000000000000120

  View details for Web of Science ID 000332840300010

• Peripheral nerve catheters and local anesthetic infiltration in perioperative analgesia. Best practice & research. Clinical anaesthesiology Merritt, C. K., Mariano, E. R., Kaye, A. D., Lissauer, J., Mancuso, K., Prabhakar, A., Urman, R. D. 2014; 28 (1): 41-57

  Abstract

  Peripheral nerve catheters (PNCs) and local infiltration analgesia (LIA) represent valuable options for controlling perioperative pain. PNCs have been increasingly utilized to provide both surgical anesthesia and prolonged postoperative analgesia for a wide variety of procedures. PNCs can be more technically challenging to place than typical single-injection nerve blocks (SINB), and familiarity with the indications, contraindications, relevant anatomy, and appropriate technical skills is a prerequisite for the placement of any PNC. PNCs include risks of peripheral nerve injury, damage to adjacent anatomic structures, local anesthetic toxicity, intravascular injection, risks associated with motor block, risks of unnoticed injury to the insensate limb, and risks of sedation associated with PNC placement. In addition to these common risks, there are specific risks unique to each PNC insertion site. LIA strategies have emerged that seek to provide the benefit of targeted local anesthesia while minimizing collateral motor block and increasing the applicability of durable local anesthesia beyond the extremities. LIA involves the injection and/or infusion of a local anesthetic near the site of surgical incision to provide targeted analgesia. A wide variety of techniques have been described, including single-injection intraoperative wound infiltration, indwelling wound infusion catheters, and the recent high-volume LIA technique associated with joint replacement surgery. The efficacy of these techniques varies depending on specific procedures and anatomic locations. The recent incorporation of ultra-long-acting liposomal bupivacaine preparations has the potential to dramatically increase the utility of single-injection LIA. LIA represents a promising yet under-investigated method of postoperative pain control.

  View details for DOI 10.1016/j.bpa.2014.02.002

  View details for PubMedID 24815966

• Ultrasound and its evolution in perioperative regional anesthesia and analgesia. Best practice & research. Clinical anaesthesiology Mariano, E. R., Marshall, Z. J., Urman, R. D., Kaye, A. D. 2014; 28 (1): 29-39

  Abstract

  Perioperative regional anesthetic and analgesic techniques have evolved considerably over the past four decades. Perhaps, the most impressive development in recent years has been the rapid adoption and widespread utilization of ultrasound (US) guidance to perform targeted delivery of local anesthetics and catheters in a consistent manner for postoperative pain control. This article briefly reviews the history of US in regional anesthesia and perioperative analgesia, the evidence basis for this practice, the clinical application of novel techniques and imaging modalities, and possible future technology and research directions.

  View details for DOI 10.1016/j.bpa.2013.11.001

  View details for PubMedID 24815965

• Adductor canal block for total knee arthroplasty: the perfect recipe or just one ingredient? Anesthesiology Mariano, E. R., Perlas, A. n. 2014; 120 (3): 530–32

  View details for PubMedID 24534851

• Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?

  View details for DOI 10.1186/2193-1801-3-227

  View details for PubMedID 24855591

• Orthopedic Anesthesia. Anesthesiology clinics Elkassabany, N. M., Mariano, E. R. 2014; 32 (4): xiii-xiv

  View details for PubMedID 25453673

• A triple-masked, randomized controlled trial comparing ultrasound-guided brachial plexus and distal peripheral nerve block anesthesia for outpatient hand surgery. Anesthesiology research and practice Lam, N. C., Charles, M., Mercer, D., Soneru, C., Dillow, J., Jaime, F., Petersen, T. R., Mariano, E. R. 2014; 2014: 324083-?

  Abstract

  Background. For hand surgery, brachial plexus blocks provide effective anesthesia but produce undesirable numbness. We hypothesized that distal peripheral nerve blocks will better preserve motor function while providing effective anesthesia. Methods. Adult subjects who were scheduled for elective ambulatory hand surgery under regional anesthesia and sedation were recruited and randomly assigned to receive ultrasound-guided supraclavicular brachial plexus block or distal block of the ulnar and median nerves. Each subject received 15 mL of 1.5% mepivacaine at the assigned location with 15 mL of normal saline injected in the alternate block location. The primary outcome (change in baseline grip strength measured by a hydraulic dynamometer) was tested before the block and prior to discharge. Subject satisfaction data were collected the day after surgery. Results. Fourteen subjects were enrolled. Median (interquartile range [IQR]) strength loss in the distal group was 21.4% (14.3, 47.8%), while all subjects in the supraclavicular group lost 100% of their preoperative strength, P = 0.001. Subjects in the distal group reported greater satisfaction with their block procedures on the day after surgery, P = 0.012. Conclusion. Distal nerve blocks better preserve motor function without negatively affecting quality of anesthesia, leading to increased patient satisfaction, when compared to brachial plexus block.

  View details for DOI 10.1155/2014/324083

  View details for PubMedID 24839439

• Effectiveness of preoperative beta-blockade on intra-operative heart rate in vascular surgery cases conducted under regional or local anesthesia. SpringerPlus Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A. W., Mariano, E. R. 2014; 3: 227-?

  Abstract

  Preoperative β-blockade has been posited to result in better outcomes for vascular surgery patients by attenuating acute hemodynamic changes associated with stress. However, the incremental effectiveness, if any, of β-blocker usage in blunting heart rate responsiveness for vascular surgery patients who avoid general anesthesia remains unknown.We reviewed an existing database and identified 213 consecutive vascular surgery cases from 2005-2011 conducted without general anesthesia (i.e., under monitored anesthesia care or regional anesthesia) at a tertiary care Veterans Administration medical center and categorized patients based on presence or absence of preoperative β-blocker prescription. For this series of patients, with the primary outcome of maximum heart rate during the interval between operating room entry to surgical incision, we examined the association of maximal heart rate and preoperative β-blocker usage by performing crude and multivariate linear regression, adjusting for relevant patient factors.Of 213 eligible cases, 137 were prescribed preoperative β-blockers, and 76 were not. The two groups were comparable across baseline patient factors and intraoperative medication doses. The β-blocker group experienced lower maximal heart rates during the period of evaluation compared to the non-β-blocker group (85 ± 22 bpm vs. 98 ± 36 bpm, respectively; p = 0.002). Adjusted linear regression confirmed a statistically-significant association between lower maximal heart rate and the use of β-blockers (Beta = -11.5; 95% CI [-3.7, -19.3] p = 0.004).The addition of preoperative β-blockers, even when general anesthesia is avoided, may be beneficial in further attenuating stress-induced hemodynamic changes for vascular surgery patients.

  View details for DOI 10.1186/2193-1801-3-227

  View details for PubMedID 24855591

  View details for PubMedCentralID PMC4024108

• Continuous lesser palatine nerve block for postoperative analgesia after uvulopalatopharyngoplasty. Clinical journal of pain Ponstein, N. A., Kim, T. E., Hsia, J., Goode, R., Borges, P., Mariano, E. R. 2013; 29 (12): e35-8

  Abstract

  OBJECTIVES:: Uvulopalatopharyngoplasty (UPPP) is a commonly performed surgical intervention used to treat obstructive sleep apnea (OSA) syndrome. Continuous peripheral nerve blocks have been shown to reduce postoperative pain and opioid requirements for other surgical procedures but have not been described previously for palate surgery. We present the use of a continuous lesser palatine nerve block catheter as a part of the multimodal postoperative pain management for UPPP. CASE REPORT:: Three patients were scheduled to undergo elective UPPP and tonsillectomy for OSA with scheduled postoperative hospital admission. Each patient gave written consent to share the details of his or her case. Upon completion of the surgical procedure, but before emergence from general anesthesia, a 20-G multiorifice epidural catheter was inserted into the left nasal passage, passed into the oropharynx, and either tunneled posteriorly within the anterior portion of the soft palate with the aid of a 16-G angiocatheter or placed submucosally within the soft palate by the surgeon. Each catheter was secured using clear adhesive dressings along the cheek and anchored to the ipsilateral shoulder. A continuous infusion of ropivacaine 0.2% at 2 mL/h was delivered using a disposable infusion device postoperatively, in addition to the prescribed oral and intravenous opioids. No immediate or long-term complications due to catheter placement were identified during the patient follow-up. DISCUSSION:: Continuous lesser palatine nerve block may be a useful regional anesthetic technique in the multimodal postoperative pain management of opioid-sensitive OSA patients undergoing UPPP and deserves further study.

  View details for DOI 10.1097/AJP.0b013e3182971887

  View details for PubMedID 23669453

• Continuous lesser palatine nerve block for postoperative analgesia after uvulopalatopharyngoplasty. Clinical journal of pain Ponstein, N. A., Kim, T. E., Hsia, J., Goode, R., Borges, P., Mariano, E. R. 2013; 29 (12): e35-8

  View details for DOI 10.1097/AJP.0b013e3182971887

  View details for PubMedID 23669453

• Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release 35th Annual Regional Anesthesia Meeting and Workshops Mariano, E. R., Lehr, M. K., Loland, V. J., Bishop, M. L. SPRINGER JAPAN KK. 2013: 611–14

  Abstract

  Intravenous regional anesthesia (Bier block) is indicated for minor procedures such as carpal tunnel release but must be performed in the operating room. We hypothesize that preoperative peripheral nerve blocks decrease anesthesia-controlled time compared to Bier block for carpal tunnel release. With IRB approval, we reviewed surgical case data from a tertiary care university hospital outpatient surgery center for 1 year. Unilateral carpal tunnel release cases were grouped by anesthetic technique: (1) preoperative nerve blocks, or (2) Bier block. The primary outcome was anesthesia-controlled time (minutes). Secondary outcomes included surgical time and time for nerve block performance in minutes, when applicable. Eighty-nine cases met criteria for analysis (40 nerve block and 49 Bier block). Anesthesia-controlled time [median (10th-90th percentiles)] was shorter for the nerve block group compared to Bier block [11 (6-18) vs. 13 (9-20) min, respectively; p = 0.02). Surgical time was also shorter for the nerve block group vs. the Bier block group [13 (8-21) and 17 (10-29) min, respectively; p < 0.01), but nerve blocks took 10 (5-28) min to perform. Ultrasound-guided nerve blocks performed preoperatively reduce anesthesia-controlled time compared to Bier block and may be a useful anesthetic modality in some practice environments.

  View details for DOI 10.1007/s00540-013-1578-8

  View details for Web of Science ID 000323248700019

  View details for PubMedID 23460418

• Association of age and packed red blood cell transfusion to 1-year survival - an observational study of ICU patients TRANSFUSION MEDICINE Mudumbai, S. C., Cronkite, R., Hu, K. U., Heidenreich, P. A., Gonzalez, C., Bertaccini, E., Stafford, R. S., Cason, B. A., Mariano, E. R., Wagner, T. 2013; 23 (4): 231-237

  Abstract

  OBJECTIVES: To compare the 1-year survival for different age strata of intensive care unit (ICU) patients after receipt of packed red blood cell (PRBC) transfusions. BACKGROUND: Despite guidelines documenting risks of PRBC transfusion and data showing that increasing age is associated with ICU mortality, little data exist on whether age alters the transfusion-related risk of decreased survival. METHODS: We retrospectively examined data on 2393 consecutive male ICU patients admitted to a tertiary-care hospital from 2003 to 2009 in age strata: 21-50, 51-60, 61-70, 71-80 and >80 years. We calculated Cox regression models to determine the modifying effect of age on the impact of PRBC transfusion on 1-year survival by using interaction terms between receipt of transfusion and age strata, controlling for type of admission and Charlson co-morbidity indices. We also examined the distribution of admission haematocrit and whether transfusion rates differed by age strata. RESULTS: All age strata experienced statistically similar risks of decreased 1-year survival after receipt of PRBC transfusions. However, patients age >80 were more likely than younger cohorts to have haematocrits of 25-30% at admission and were transfused at approximately twice the rate of each of the younger age strata. DISCUSSION: We found no significant interaction between receipt of red cell transfusion and age, as variables, and survival at 1 year as an outcome.

  View details for DOI 10.1111/tme.12010

  View details for Web of Science ID 000321975300005

  View details for PubMedID 23480030

• Treating Intractable Phantom Limb Pain with Ambulatory Continuous Peripheral Nerve Blocks: A Pilot Study PAIN MEDICINE Ilfeld, B. M., Moeller-Bertram, T., Hanling, S. R., Tokarz, K., Mariano, E. R., Loland, V. J., Madison, S. J., Ferguson, E. J., Morgan, A. C., Wallace, M. S. 2013; 14 (6): 935-942

  Abstract

  BACKGROUND.: There is currently no reliable treatment for phantom limb pain (PLP). Chronic PLP and associated cortical abnormalities may be maintained from abnormal peripheral input, raising the possibility that a continuous peripheral nerve block (CPNB) of extended duration may permanently reorganize cortical pain mapping, thus providing lasting relief. METHODS.: Three men with below-the-knee (2) or -elbow (1) amputations and intractable PLP received femoral/sciatic or infraclavicular perineural catheter(s), respectively. Subjects were randomized in a double-masked fashion to receive perineural ropivacaine (0.5%) or normal saline for over 6 days as outpatients using portable electronic infusion pumps. Four months later, subjects returned for repeated perineural catheter insertion and received an ambulatory infusion with the alternate solution ("crossover"). Subjects were followed for up to 1 year. RESULTS.: By chance, all three subjects received saline during their initial infusion and reported little change in their PLP. One subject did not receive crossover treatment, but the remaining two subjects reported complete resolution of their PLP during and immediately following treatment with ropivacaine. One subject experienced no PLP recurrence through the 52-week follow-up period and the other reported mild PLP occurring once each week of just a small fraction of his original pain (pretreatment: continuous PLP rated 10/10; posttreatment: no PLP at baseline with average of one PLP episode each week rated 2/10) for 12 weeks (lost to follow-up thereafter). CONCLUSIONS.: A prolonged ambulatory CPNB may be a reliable treatment for intractable PLP. The results of this pilot study suggest that a large, randomized clinical trial is warranted.

  View details for DOI 10.1111/pme.12080

  View details for Web of Science ID 000320730000020

  View details for PubMedID 23489466

• An In Vitro Study to Evaluate the Utility of the "Air Test" to Infer Perineural Catheter Tip Location JOURNAL OF ULTRASOUND IN MEDICINE Kan, J. M., Harrison, T. K., Kim, T. E., Howard, S. K., Kou, A., Mariano, E. R. 2013; 32 (3): 529-533

  Abstract

  Injection of air under ultrasound guidance via a perineural catheter after insertion ("air test") has been described as a means to infer placement accuracy, yet this test has never been rigorously evaluated. We tested the hypothesis that the air test predicts accurate catheter location greater than chance and determined the test's sensitivity, specificity, and positive and negative predictive values using a porcine-bovine model and blinded expert in ultrasound-guided regional anesthesia. The air test improved the expert clinician's assessment of catheter tip position compared to chance, but there was no difference when compared to direct visualization of the catheter without air injection.

  View details for Web of Science ID 000315835900018

  View details for PubMedID 23443194

• Continuous interscalene nerve block following adhesive capsulitis manipulation. Regional anesthesia and pain medicine Malhotra, N., Madison, S. J., Ward, S. R., Mariano, E. R., Loland, V. J., Ilfeld, B. M. 2013; 38 (2): 171-172

  View details for DOI 10.1097/AAP.0b013e318283475b

  View details for PubMedID 23423135

• A Randomized Comparison of Long- and Short-Axis Imaging for In-Plane Ultrasound-Guided Femoral Perineural Catheter Insertion JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Kim, T. E., Funck, N., Walters, T., Wagner, M. J., Harrison, T. K., Giori, N., Woolson, S., Ganaway, T., Howard, S. K. 2013; 32 (1): 149-156

  Abstract

  Continuous femoral nerve blocks provide effective analgesia after knee arthroplasty, and infusion effects depend on reliable catheter location. Ultrasound-guided perineural catheter insertion using a short-axis in-plane technique has been validated, but the optimal catheter location relative to target nerve and placement orientation remain unknown. We hypothesized that a long-axis in-plane technique for femoral perineural catheter insertion results in faster onset of sensory anesthesia compared to a short-axis in-plane technique.Preoperatively, patients receiving an ultrasound-guided nonstimulating femoral perineural catheter for knee surgery were randomly assigned to either the long-axis in-plane or short-axis in-plane technique. A local anesthetic was administered via the catheter after successful insertion. The primary outcome was the time to achieve complete sensory anesthesia. Secondary outcomes included the procedural time, the onset time of the motor block, pain and muscle weakness reported on postoperative day 1, and procedure-related complications.The short-axis group (n = 23) took a median (10th-90th percentiles) of 9.0 (6.0-20.4) minutes compared to 6.0 (3.0-14.4) minutes for the long-axis group (n = 23; P = .044) to achieve complete sensory anesthesia. Short-axis procedures took 5.0 (4.0-7.8) minutes to perform compared to 9.0 (7.0-14.8) minutes for long-axis procedures (P < .001). In the short-axis group, 19 of 23 (83%) achieved a complete motor block within the testing period compared to 18 of 23 (78%) in the long-axis group (P = .813); short-axis procedures took 12.0 (6.0-15.0) minutes versus 15.0 (5.1-27.9) minutes for long-axis procedures (P = .048). There were no statistically significant differences in other secondary outcomes.Long-axis in-plane femoral perineural catheters result in a slightly faster onset of sensory anesthesia, but placement takes longer to perform without other clinical advantages.

  View details for Web of Science ID 000313607400017

  View details for PubMedID 23269720

• Ultrasound-guided Continuous Median Nerve Block to Facilitate Intensive Hand Rehabilitation CLINICAL JOURNAL OF PAIN Maxwell, B. G., Hansen, J. A., Talley, J., Curtin, C. M., Mariano, E. R. 2013; 29 (1): 86-88

  Abstract

  Continuous brachial plexus blocks for postoperative analgesia after upper extremity surgery are well described, but they can result in undesirable motor block and lack of specificity for minor hand procedures. We present the use of extended-duration continuous local anesthetic infusion through an ultrasound-guided median nerve catheter inserted at the forearm to facilitate hand physical therapy in a patient who had previously failed rehabilitation due to pain unrelieved by systemic opioids.A 54-year-old man presented with an inability to flex his index finger after proximal phalangeal fracture. He underwent hardware removal and extensive scar release. He had severe postoperative pain that limited his ability to comply with hand therapy, which is required to achieve functional goals after surgery. A perineural catheter was placed under ultrasound guidance adjacent to the median nerve in the proximal forearm; then a continuous infusion of ropivacaine 0.2% was initiated and maintained for 11 days. The patient had focused sensory loss in the median nerve distribution but maintained active flexion of the fingers. He subsequently was able to participate in hand physical therapy and discontinued the use of oral opioid medications.Ultrasound-guided perineural catheters targeting terminal branch nerves may have potential benefits beyond the immediate postoperative period and in nonoperative management of patients requiring physical therapy and rehabilitation.

  View details for DOI 10.1097/AJP.0b013e318246d1ca

  View details for Web of Science ID 000311945500014

  View details for PubMedID 22751029

• Preliminary Study of Ergonomic Behavior During Simulated Ultrasound-Guided Regional Anesthesia Using a Head-Mounted Display JOURNAL OF ULTRASOUND IN MEDICINE Udani, A. D., Harrison, T. K., Howard, S. K., Kim, T. E., Brock-Utne, J. G., Gaba, D. M., Mariano, E. R. 2012; 31 (8): 1277-1280

  Abstract

  A head-mounted display provides continuous real-time imaging within the practitioner's visual field. We evaluated the feasibility of using head-mounted display technology to improve ergonomics in ultrasound-guided regional anesthesia in a simulated environment. Two anesthesiologists performed an equal number of ultrasound-guided popliteal-sciatic nerve blocks using the head-mounted display on a porcine hindquarter, and an independent observer assessed each practitioner's ergonomics (eg, head turning, arching, eye movements, and needle manipulation) and the overall block quality based on the injectate spread around the target nerve for each procedure. Both practitioners performed their procedures without directly viewing the ultrasound monitor, and neither practitioner showed poor ergonomic behavior. Head-mounted display technology may offer potential advantages during ultrasound-guided regional anesthesia.

  View details for Web of Science ID 000306985100017

  View details for PubMedID 22837293

• Vascular Surgery Patients Prescribed Preoperative beta-Blockers Experienced a Decrease in the Maximal Heart Rate Observed During Induction of General Anesthesia JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Mudumbai, S. C., Wagner, T., Mahajan, S., King, R., Heidenreich, P. A., Hlatky, M., Wallace, A., Mariano, E. R. 2012; 26 (3): 414-419

  Abstract

  To investigate the association of preoperative β-blocker usage and maximal heart rates observed during the induction of general anesthesia.Retrospective descriptive, univariate, and multivariate analyses of electronic hospital and anesthesia medical records.A tertiary-care medical center within the Veterans Health Administration.Consecutive adult elective and emergent patients presenting for vascular surgery during calendar years 2005 to 2011.None.Of the 430 eligible cases, 218 were prescribed β-blockers, and 212 were not taking β-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The β-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non-β-blocker group (105 ± 41 beats/min v 115 ± 45 beats/min, respectively; p < 0.01). Adjusted linear regression found a statistically significant association between lower maximal heart rate and the use of β-blockers (β = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative β-blocker administration.Preoperative β-blockade of vascular surgery patients undergoing general anesthesia is associated with a lower maximal heart rate during anesthetic induction. There may be potential benefits in administering β-blockers to reduce physiologic stress in this surgical population at risk for perioperative cardiac morbidity. Future research should further explore intraoperative hemodynamic effects in light of existing practice guidelines for optimal medication selection, dosage, and heart rate control.

  View details for DOI 10.1053/j.jvca.2011.09.027

  View details for Web of Science ID 000304215800011

  View details for PubMedID 22138312

• EPIDEMIOLOGY AND RISKS OF TRANSFUSION AMONG DIFFERENT AGE STRATA IN ICU PATIENTS Mudumbai, S., Cronkite, R., Bertaccini, E., Cason, B., Mariano, E., Wagner, T. LIPPINCOTT WILLIAMS & WILKINS. 2012

  View details for Web of Science ID 000209846600014

• Echogenicity of Catheters Used for Ultrasound-Guided Continuous Peripheral Nerve Blocks Romy, Y. T., Kim, E., Mariano, E., Carvalho, B. OXFORD UNIV PRESS. 2012: 433

  View details for Web of Science ID 000302299100728

• General Considerations for Regional Anesthesia Practice ESSENTIALS OF REGIONAL ANESTHESIA Mariano, E. R., Mariano, K. J., Kaye, A. D., Urman, R. D., Vadivelu, N. 2012: 3–20

  View details for DOI 10.1007/978-1-4614-1013-3_1

  View details for Web of Science ID 000300959400001

• Epidural Catheter Removal in Patients on Warfarin Thromboprophylaxis A More Cautious Interpretation of Results Required? REGIONAL ANESTHESIA AND PAIN MEDICINE Carvalho, B., Mariano, E. R., Butwick, A. J. 2011; 36 (6): 632-632

  View details for DOI 10.1097/AAP.0b013e31822e0c7e

  View details for Web of Science ID 000296532100021

  View details for PubMedID 22024706

• Comparing axillary with infraclavicular perineural catheters for post-operative analgesia ACTA ANAESTHESIOLOGICA SCANDINAVICA Mariano, E. R., Loland, V. J., Ilfeld, B. M. 2011; 55 (10): 1283-1284

  View details for DOI 10.1111/j.1399-6576.2011.02531.x

  View details for Web of Science ID 000295717800015

  View details for PubMedID 22092135

• Continuous Femoral Versus Posterior Lumbar Plexus Nerve Blocks for Analgesia After Hip Arthroplasty: A Randomized, Controlled Study ANESTHESIA AND ANALGESIA Ilfeld, B. M., Mariano, E. R., Madison, S. J., Loland, V. J., Sandhu, N. S., Suresh, P. J., Bishop, M. L., Kim, T. E., Donohue, M. C., Kulidjian, A. A., Ball, S. T. 2011; 113 (4): 897-903

  Abstract

  Hip arthroplasty frequently requires potent postoperative analgesia, often provided with an epidural or posterior lumbar plexus local anesthetic infusion. However, American Society of Regional Anesthesia guidelines now recommend against epidural and continuous posterior lumbar plexus blocks during administration of various perioperative anticoagulants often administered after hip arthroplasty. A continuous femoral nerve block is a possible analgesic alternative, but whether it provides comparable analgesia to a continuous posterior lumbar plexus block after hip arthroplasty remains unclear. We therefore tested the hypothesis that differing the catheter insertion site (femoral versus posterior lumbar plexus) after hip arthroplasty has no impact on postoperative analgesia.Preoperatively, subjects undergoing hip arthroplasty were randomly assigned to receive either a femoral or a posterior lumbar plexus stimulating catheter inserted 5 to 15 cm or 0 to 1 cm past the needle tip, respectively. Postoperatively, patients received perineural ropivacaine, 0.2% (basal 6 mL/hr, bolus 4 mL, 30-minute lockout) for at least 2 days. The primary end point was the average daily pain scores as measured with a numeric rating scale (0-10) recorded in the 24-hour period beginning at 07:30 the morning after surgery, excluding twice-daily physical therapy sessions. Secondary end points included pain during physical therapy, ambulatory distance, and supplemental analgesic requirements during the same 24-hour period, as well as satisfaction with analgesia during hospitalization.The mean (SD) pain scores for subjects receiving a femoral infusion (n = 25) were 3.6 (1.8) versus 3.5 (1.8) for patients receiving a posterior lumbar plexus infusion (n = 22), resulting in a group difference of 0.1 (95% confidence interval -0.9 to 1.2; P = 0.78). Because the confidence interval was within a prespecified -1.6 to 1.6 range, we conclude that the effect of the 2 analgesic techniques on postoperative pain was equivalent. Similarly, we detected no differences between the 2 treatments with respect to the secondary end points, with one exception: subjects with a femoral catheter ambulated a median (10th-90th percentiles) 2 (0-17) m the morning after surgery, in comparison with 11 (0-31) m for subjects with a posterior lumbar plexus catheter (data nonparametric; P = 0.02).After hip arthroplasty, a continuous femoral nerve block is an acceptable analgesic alternative to a continuous posterior lumbar plexus block when using a stimulating perineural catheter. However, early ambulatory ability suffers with a femoral infusion.

  View details for DOI 10.1213/ANE.0b013e318212495b

  View details for Web of Science ID 000295215100034

  View details for PubMedID 21467563

  View details for PubMedCentralID PMC3132825

• Comparison of Procedural Times for Ultrasound-Guided Perineural Catheter Insertion in Obese and Nonobese Patients JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Brodsky, J. B. 2011; 30 (10): 1357-1361

  Abstract

  Perineural catheter insertion with ultrasound guidance alone has been described, but it remains unknown whether this new technique results in the same procedural time and success rate for obese and nonobese patients. We therefore tested the hypothesis that obese patients require more time for perineural catheter insertion compared to nonobese patients despite using ultrasound.Data from 5 previously published randomized clinical trials comparing ultrasound- and stimulation-guided perineural catheter insertion techniques were reviewed, and patients who received ultrasound-guided catheters were divided into 2 groups: obese (body mass index ≥30 kg/m(2)) and nonobese (body mass index <30 kg/m(2)). A standardized ultrasound-guided nonstimulating catheter technique was used with mepivacaine, 1.5% (40 mL), as the initial bolus via the placement needle for the primary surgical nerve block. The primary outcome was the procedural time for perineural catheter insertion. Secondary outcomes included block efficacy, procedure-related pain, fluid leakage, vascular puncture, and catheter dislodgment.A sample of 120 patients was identified: 51 obese and 69 nonobese. All obese patients had successful catheter placement compared to 68 of 69 (98%) nonobese patients (P = .388). The time for perineural catheter insertion [median (10th-90th percentiles)] was 7 (4-12) minutes for obese patients versus 7 (4-15) minutes for nonobese patients (P = .732). There were no statistically significant differences in other secondary outcomes.On the basis of this retrospective analysis, perineural catheter insertion is not prolonged in obese patients compared to nonobese patients when an ultrasound-guided technique is used. However, these results are only suggestive and require confirmation through prospective study.

  View details for Web of Science ID 000295551300006

  View details for PubMedID 21968486

• Continuous Femoral Nerve Blocks Varying Local Anesthetic Delivery Method (Bolus versus Basal) to Minimize Quadriceps Motor Block while Maintaining Sensory Block ANESTHESIOLOGY Charous, M. T., Madison, S. J., Suresh, P. J., Sandhu, N. S., Loland, V. J., Mariano, E. R., Donohue, M. C., Dutton, P. H., Ferguson, E. J., Ilfeld, B. M. 2011; 115 (4): 774-781

  Abstract

  Whether the method of local anesthetic administration for continuous femoral nerve blocks--basal infusion versus repeated hourly bolus doses--influences block effects remains unknown.Bilateral femoral perineural catheters were inserted in volunteers (n = 11). Ropivacaine 0.1% was concurrently administered through both catheters: a 6-h continuous 5 ml/h basal infusion on one side and 6 hourly bolus doses on the contralateral side. The primary endpoint was the maximum voluntary isometric contraction (MVIC) of the quadriceps femoris muscle at hour 6. Secondary endpoints included quadriceps MVIC at other time points, hip adductor MVIC, and cutaneous sensation 2 cm medial to the distal quadriceps tendon in the 22 h after initiation of local anesthetic administration.Quadriceps MVIC for limbs receiving 0.1% ropivacaine as a basal infusion declined by a mean (SD) of 84% (19) compared with 83% (24) for those receiving 0.1% ropivacaine as repeated bolus doses between baseline and hour 6 (paired t test P = 0.91). Intrasubject comparisons (left vs. right) also reflected a lack of difference: the mean basal-bolus difference in quadriceps MVIC at hour 6 was -1.1% (95% CI -22.0-19.8%). The similarity did not reach the a priori threshold for concluding equivalence, which was the 95% CI decreasing within ± 20%. There were similar minimal differences in the secondary endpoints during local anesthetic administration.This study did not find evidence to support the hypothesis that varying the method of local anesthetic administration--basal infusion versus repeated bolus doses--influences continuous femoral nerve block effects to a clinically significant degree.

  View details for DOI 10.1097/ALN.0b013e3182124dc6

  View details for Web of Science ID 000295079500019

  View details for PubMedID 21394001

  View details for PubMedCentralID PMC3116995

• Posterior lumbar plexus perineural catheter insertion by ultrasound guidance alone ACTA ANAESTHESIOLOGICA SCANDINAVICA Madison, S. J., Ilfeld, B. M., Loland, V. J., Mariano, E. R. 2011; 55 (8): 1031-1032

  View details for DOI 10.1111/j.1399-6576.2011.02489.x

  View details for Web of Science ID 000294356500019

  View details for PubMedID 21770905

• Updated guide to billing for regional anesthesia (United States). International anesthesiology clinics Kim, T. E., Mariano, E. R. 2011; 49 (3): 84-93

  View details for DOI 10.1097/AIA.0b013e31820e4a5c

  View details for PubMedID 21697672

• Ultrasound-Guided (Needle-in-Plane) Perineural Catheter Insertion The Effect of Catheter-Insertion Distance on Postoperative Analgesia REGIONAL ANESTHESIA AND PAIN MEDICINE Ilfeld, B. M., Sandhu, N. S., Loland, V. J., Madison, S. J., Suresh, P. J., Mariano, E. R., Bishop, M. L., Schwartz, A. K., Lee, D. K. 2011; 36 (3): 261-265

  Abstract

  When using ultrasound guidance to place a perineural catheter for a continuous peripheral nerve block, keeping the needle in plane and nerve in short axis results in a perpendicular needle-to-nerve orientation. Many have opined that when placing a perineural catheter via the needle, the acute angle may result in the catheter bypassing the target nerve when advanced beyond the needle tip. Theoretically, greater catheter tip-to-nerve distances result in less local anesthetic-to-nerve contact during the subsequent perineural infusion, leading to inferior analgesia. Although a potential solution may appear obvious-advancing the catheter tip only to the tip of the needle, leaving the catheter tip at the target nerve-this technique has not been prospectively evaluated. We therefore hypothesized that during needle in-plane ultrasound-guided perineural catheter placement, inserting the catheter a minimum distance (0-1 cm) past the needle tip is associated with improved postoperative analgesia compared with inserting the catheter a more traditional 5 to 6 cm past the needle tip.Preoperatively, subjects received a popliteal-sciatic perineural catheter for foot or ankle surgery using ultrasound guidance exclusively. Subjects were randomly assigned to have a single-orifice, flexible catheter inserted either 0 to 1 cm (n = 50) or 5 to 6 cm (n = 50) past the needle tip. All subjects received a single-injection mepivacaine (40 mL of 1.5% with epinephrine) nerve block via the needle, followed by catheter insertion and a ropivacaine 0.2% infusion (basal 6 mL/hr, bolus 4 mL, 30-min lockout), through at least the day after surgery. The primary end point was the average surgical pain as measured with a 0- to 10-point numeric rating scale the day after surgery. Secondary end points included time for catheter insertion, incidence of catheter dislodgement, maximum ("worst") pain scores, opioid requirements, fluid leakage at the catheter site, and the subjective degree of an insensate extremity.Average pain scores the day after surgery for subjects of the 0- to 1-cm group were a median of 2.5 (interquartile range, 0.0-5.0), compared with 2.0 (interquartile range, 0.0-4.0) for subjects of the 5- to 6-cm group (P = 0.42). Similarly, among the secondary end points, no statistically significant differences were found between the 2 treatment groups. There was a trend of more catheter dislodgements in the minimum-insertion group (5 vs 1; P = 0.20).This study did not find evidence to support the hypothesis that, for popliteal-sciatic perineural catheters placed using ultrasound guidance and a needle-in-plane technique, inserting the catheter a minimum distance (0-1 cm) past the needle tip improves (or worsens) postoperative analgesia compared with inserting the catheter a more traditional distance (5-6 cm). Caution is warranted if extrapolating these results to other catheter designs, ultrasound approaches, or anatomic insertion sites.

  View details for DOI 10.1097/AAP.0b013e31820f3b80

  View details for Web of Science ID 000292774600012

  View details for PubMedID 21519311

  View details for PubMedCentralID PMC3085850

• Guidelines for fellowship training in Regional Anesthesiology and Acute Pain Medicine: Second Edition, 2010. Regional anesthesia and pain medicine 2011; 36 (3): 282-288

  Abstract

  The Regional Anesthesiology and Acute Pain Medicine Fellowship Directors Group develops and maintains guidelines for fellowship training in the subspecialty. These guidelines update the original guidelines that were published in 2005. The guidelines address 3 major topic areas: organization and resources, the educational program, and the evaluation process.

  View details for DOI 10.1097/AAP.0b013e31820d439f

  View details for PubMedID 21519314

• Long-Term Pain, Stiffness, and Functional Disability After Total Knee Arthroplasty With and Without an Extended Ambulatory Continuous Femoral Nerve Block A Prospective, 1-Year Follow-Up of a Multicenter, Randomized, Triple-Masked, Placebo-Controlled Trial REGIONAL ANESTHESIA AND PAIN MEDICINE Ilfeld, B. M., Shuster, J. J., Theriaque, D. W., Mariano, E. R., Girard, P. J., Loland, V. J., Meyer, R. S., Donovan, J. F., Pugh, G. A., Le, L. T., Sessler, D. I., Ball, S. T. 2011; 36 (2): 116-120

  Abstract

  Previously, we have demonstrated that extending a continuous femoral nerve block (cFNB) from overnight to 4 days after total knee arthroplasty (TKA) provides clear benefits during the infusion, but not subsequent to catheter removal. However, there were major limitations in generalizing the results of that investigation, and we subsequently performed a very similar study using a multicenter format, with many health care providers, in patients on general orthopedic wards, thus greatly improving inference of the results to the general population. Not surprisingly, the perioperative/short-term outcomes differed greatly from the first, more limited study. We now present a prospective follow-up study of the previously published, multicenter, randomized controlled clinical trial to investigate the possibility that an extended ambulatory cFNB decreases long-term pain, stiffness, and functional disability after TKA, which greatly improves inference of the results to the general population.Subjects undergoing TKA received a cFNB with ropivacaine 0.2% from surgery until the following morning, at which time patients were randomized to continue either perineural ropivacaine (n=28) or normal saline (n=26). Patients were discharged with their catheter and a portable infusion pump, and catheters were removed on postoperative day 4. Health-related quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis Index preoperatively and then at 7 days, as well as 1, 2, 3, 6, and 12 months after surgery. This index evaluates pain, stiffness, and physical functional disability. For inclusion in the analysis, we required a minimum of 4 of the 6 time points, including day 7 and at least 2 of months 3, 6, and 12.The 2 treatment groups had similar Western Ontario and McMaster Universities Osteoarthritis scores for the mean area-under-the-curve calculations (point estimate for the difference in mean area under the curve for the 2 groups [overnight infusion group - extended infusion group]=3.8; 95% confidence interval, -3.8 to +11.3; P=0.32) and at all individual time points (P>0.05).This investigation found no evidence that extending an overnight cFNB to 4 days improves (or worsens) subsequent pain, stiffness, or physical function after TKA in patients of multiple centers convalescing on general orthopedic wards.

  View details for DOI 10.1097/AAP.0b013e3182052505

  View details for Web of Science ID 000292774500004

  View details for PubMedID 21425510

  View details for PubMedCentralID PMC3073537

• Considerations When Performing Ultrasound-Guided Supraclavicular Perineural Catheter Placement Reply JOURNAL OF ULTRASOUND IN MEDICINE Heil, J. W., Ilfeld, B. M., Loland, V. J., Mariano, E. R. 2011; 30 (3): 423–24

  View details for DOI 10.7863/jum.2011.30.3.423a

  View details for Web of Science ID 000291126700022

• Reply. Journal of ultrasound in medicine Heil, J. W., Ilfeld, B. M., Loland, V. J., Mariano, E. R. 2011; 30 (3): 423-424

  View details for PubMedID 21357568

• Regional anaesthesia in the obese patient: lost landmarks and evolving ultrasound guidance. Best practice & research. Clinical anaesthesiology Brodsky, J. B., Mariano, E. R. 2011; 25 (1): 61-72

  Abstract

  Obesity is associated with a number of anaesthetic-related risks. Regional anaesthesia offers many potential advantages for the obese surgical patient. Advantages include a reduction in systemic opioid requirements and their associated side effects, and possible avoidance of general anaesthesia in select circumstances, with a lower rate of complications. Historically, performing regional anaesthesia procedures in the obese has presented challenges due to difficulty in identifying surface landmarks and availability of appropriate equipment. Ultrasound guidance may aid the regional anaesthesia practitioner with direct visualisation of underlying anatomic structures and real-time needle direction. Further research is needed to determine optimal regional anaesthesia techniques, local anaesthetic dosage and perioperative outcomes in obese patients.

  View details for PubMedID 21516914

• A Randomized Comparison of Infraclavicular and Supraclavicular Continuous Peripheral Nerve Blocks for Postoperative Analgesia REGIONAL ANESTHESIA AND PAIN MEDICINE Mariano, E. R., Sandhu, N. S., Loland, V. J., Bishop, M. L., Madison, S. J., Abrams, R. A., Meunier, M. J., Ferguson, E. J., Ilfeld, B. M. 2011; 36 (1): 26-31

  Abstract

  Although the efficacy of single-injection supraclavicular nerve blocks is well established, no controlled study of continuous supraclavicular blocks is available, and their relative risks and benefits remain unknown. In contrast, the analgesia provided by continuous infraclavicular nerve blocks has been validated in randomized controlled trials. We therefore compared supraclavicular with infraclavicular perineural local anesthetic infusion following distal upper-extremity surgery.Preoperatively, subjects were randomly assigned to receive a brachial plexus perineural catheter in either the infraclavicular or supraclavicular location using an ultrasound-guided nonstimulating catheter technique. Postoperatively, subjects were discharged home with a portable pump (400-mL reservoir) infusing 0.2% ropivacaine (basal rate of 8 mL/hr; 4-mL bolus dose; 30-min lockout interval). Subjects were followed up by telephone on an outpatient basis. The primary outcome was the average pain score on the day after surgery.Sixty subjects were enrolled, with 31 and 29 randomized to receive an infraclavicular and supraclavicular catheter, respectively. All perineural catheters were successfully placed per protocol. Because of protocol violations and missing data, an intention-to-treat analysis was not used; rather, only subjects with catheters in situ and whom we were able to contact were included in the analyses. The day after surgery, subjects in the infraclavicular group reported average pain as median of 2.0 (10th-90th percentiles, 0.5-6.0) compared with 4.0 (10th-90th percentiles, 0.6-7.7) in the supraclavicular group (P = 0.025). Similarly, least pain scores (numeric rating scale) on postoperative day 1 were lower in the infraclavicular group compared with the supraclavicular group (0.5 [10th-90th percentiles, 0.0-3.5] vs 2.0 [10th-90th percentiles, 0.0-4.7], respectively; P = 0.040). Subjects in the infraclavicular group required less rescue oral analgesic (oxycodone, in milligrams) for breakthrough pain in the 18 to 24 hrs after surgery compared with the supraclavicular group (0.0 [10th-90th percentiles, 0.0-5.0] vs 5.0 [10th-90th percentiles, 0.0-15.0], respectively; P = 0.048). There were no statistically significant differences in other secondary outcomes.A local anesthetic infusion via an infraclavicular perineural catheter provides superior analgesia compared with a supraclavicular perineural catheter.

  View details for DOI 10.1097/AAP.0b013e318203069b

  View details for Web of Science ID 000292774300007

  View details for PubMedID 21455085

• Ultrasound-Guided Continuous Peripheral Nerve Blocks ATLAS OF ULTRASOUND-GUIDED PROCEDURES IN INTERVENTIONAL PAIN MANAGEMENT Mariano, E. R., Ilfeld, B. M., Narouze, S. N. 2011: 259–72

  View details for DOI 10.1007/978-1-4419-1681-5_19

  View details for Web of Science ID 000286091600019

• Ultrasound-Guided Transversus Abdominis Plane Catheters and Ambulatory Perineural Infusions for Outpatient Inguinal Hernia Repair Annual Fall Pain Medicine Meeting of the American-Society-of-Regional-Anesthesia-and-Pain-Medicine Heil, J. W., Ilfeld, B. M., Loland, V. J., Sandhu, N. S., Mariano, E. R. LIPPINCOTT WILLIAMS & WILKINS. 2010: 556–58

  Abstract

  Transversus abdominis plane (TAP) blocks anesthetize the lower abdominal wall, and TAP catheters have been used to provide prolonged postoperative analgesia after laparotomy. The use of TAP catheters on an outpatient basis has not yet been described. We present our experience with ultrasound-guided TAP perineural catheter insertion and subsequent management of ambulatory TAP local anesthetic infusions after inguinal hernia repair.Three patients scheduled for unilateral open inguinal hernia repair underwent preoperative posterior TAP catheter placement for postoperative pain management using a technique employing ultrasound guidance alone. A bolus of local anesthetic solution was injected via the catheter in divided doses, and block onset was confirmed before surgery. Postoperatively, a continuous infusion of ropivacaine 0.2% was delivered using a portable infusion pump, and patients were discharged with a prescription for oral analgesics for breakthrough pain and perineural infusion instructions. Patients were followed up daily by telephone.All patients underwent successful TAP catheter insertion and maintained their catheters until postoperative day 2. All patients reported minimal pain for the duration of infusion without the need for any supplemental opioid analgesics, high satisfaction with postoperative analgesia, and no infusion-related complications.An ultrasound-guided TAP catheter and ambulatory local anesthetic perineural infusion are a promising option for prolonged postoperative analgesia after outpatient inguinal hernia repair. A posterior insertion permits preoperative placement by keeping the catheter away from the planned surgical field.

  View details for DOI 10.1097/AAP.0b013e3181fa69e9

  View details for Web of Science ID 000284301300016

  View details for PubMedID 20975474

• Evaluating Clinical Research and Bloodletting. (Seriously) REGIONAL ANESTHESIA AND PAIN MEDICINE Ilfeld, B. M., Mariano, E. R. 2010; 35 (6): 488-489

  View details for DOI 10.1097/AAP.0b013e3181f2c474

  View details for Web of Science ID 000284301300003

  View details for PubMedID 20975460

• Comparative efficacy of ultrasound-guided and stimulating popliteal-sciatic perineural catheters for postoperative analgesia CANADIAN JOURNAL OF ANESTHESIA-JOURNAL CANADIEN D ANESTHESIE Mariano, E. R., Loland, V. J., Sandhu, N. S., Bishop, M. L., Lee, D. K., Schwartz, A. K., Girard, P. J., Ferguson, E. J., Ilfeld, B. M. 2010; 57 (10): 919-926

  Abstract

  Perineural catheter insertion using ultrasound guidance alone is a relatively new approach. Previous studies have shown that ultrasound-guided catheters take less time to place with high placement success rates, but the analgesic efficacy compared with the established stimulating catheter technique remains unknown. We tested the hypothesis that popliteal-sciatic perineural catheter insertion relying exclusively on ultrasound guidance results in superior postoperative analgesia compared with stimulating catheters.Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot or ankle surgery were assigned randomly to either ultrasound guidance (bolus via needle with non-stimulating catheter insertion) or electrical stimulation (bolus via catheter). We used 1.5% mepivacaine 40 mL for the primary surgical nerve block and 0.2% ropivacaine (basal 8 mL·hr(-1); bolus 4 mL; 30 min lockout) was infused postoperatively. The primary outcome was average surgical pain on postoperative day one.Forty of the 80 subjects enrolled were randomized to each treatment group. One of 40 subjects (2.5%) in the ultrasound group failed catheter placement per protocol vs nine of 40 (22.5%) in the stimulating catheter group (P = 0.014). The difference in procedural duration (mean [95% confidence interval (CI)]) was -6.48 (-9.90 - -3.05) min, with ultrasound requiring 7.0 (4.0-14.1) min vs stimulation requiring 11.0 (5.0-30.0) min (P < 0.001). The average pain scores of subjects who provided data on postoperative day one were somewhat higher for the 33 ultrasound subjects than for the 26 stimulation subjects (5.0 [1.0-7.8] vs 3.0 [0.0-6.5], respectively; P = 0.032), a difference (mean [95%CI]) of 1.37 (0.03-2.71).For popliteal-sciatic perineural catheters, ultrasound guidance takes less time and results in fewer placement failures compared with stimulating catheters. However, analgesia may be mildly improved with successfully placed stimulating catheters. Clinical trial registration number NCT00876681.

  View details for DOI 10.1007/s12630-010-9364-7

  View details for Web of Science ID 000282185000007

  View details for PubMedID 20700680

  View details for PubMedCentralID PMC2937147

• Preliminary Experience With a Novel Ultrasound-Guided Supraclavicular Perineural Catheter Insertion Technique for Perioperative Analgesia of the Upper Extremity JOURNAL OF ULTRASOUND IN MEDICINE Heil, J. W., Ilfeld, B. M., Loland, V. J., Mariano, E. R. 2010; 29 (10): 1481-1485

  Abstract

  Brachial plexus perineural catheters provide specific analgesia for upper extremity surgery. Although single-injection ultrasound-guided supraclavicular blocks have been described, little is known about the efficacy of perineural catheters inserted using this approach. We present our experience with ultrasound-guided supraclavicular perineural catheters for distal upper extremity surgery.In this case series, 10 patients who underwent upper extremity surgery for orthopedic trauma at a tertiary care university hospital received a supraclavicular brachial plexus perineural catheter for postoperative pain management. In all patients, a nonstimulating catheter was inserted using an ultrasound-guided technique with the catheter tip remaining under direct vision until placement needle withdrawal. Postoperatively, a perineural ropivacaine, 0.2%, infusion was administered at a basal rate of 6 mL/h with a patient-controlled bolus of 4 mL and a lockout interval of 30 minutes.Of the 10 patients, all had successful perineural catheter placement. Patients required a median (range) of 0 (0-100) μg of fentanyl for catheter insertion analgesia. There were no vascular punctures or other direct procedure-related complications. Catheters were maintained for a median (range) of 4 (2-5) days in both hospitalized and ambulatory patients. Median (range) pain scores on postoperative days 1 and 2 were 5 (0-7) and 4 (3-6), respectively, on a numeric rating scale. Three patients' catheters were removed by patient request or dislodged on postoperative day 1.Supraclavicular brachial plexus perineural catheter insertion using ultrasound guidance is feasible and deserves further study with a randomized controlled trial comparing this relatively new technique with more established approaches.

  View details for Web of Science ID 000282868300013

  View details for PubMedID 20876903

• A multicenter, randomized, triple-masked, placebo-controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge-readiness following total knee arthroplasty in patients on general orthopaedic wards PAIN Ilfeld, B. M., Mariano, E. R., Girard, P. J., Loland, V. J., Meyer, R. S., Donovan, J. F., Pugh, G. A., Le, L. T., Sessler, D. I., Shuster, J. J., Theriaque, D. W., Ball, S. T. 2010; 150 (3): 477-484

  Abstract

  A continuous femoral nerve block (cFNB) involves the percutaneous insertion of a catheter adjacent to the femoral nerve, followed by a local anesthetic infusion, improving analgesia following total knee arthroplasty (TKA). Portable infusion pumps allow infusion continuation following hospital discharge, raising the possibility of decreasing hospitalization duration. We therefore used a multicenter, randomized, triple-masked, placebo-controlled study design to test the primary hypothesis that a 4-day ambulatory cFNB decreases the time until each of three predefined readiness-for-discharge criteria (adequate analgesia, independence from intravenous opioids, and ambulation 30m) are met following TKA compared with an overnight inpatient-only cFNB. Preoperatively, all patients received a cFNB with perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomized to either continue perineural ropivacaine (n=39) or switch to normal saline (n=38). Patients were discharged with their cFNB and portable infusion pump as early as postoperative day 3. Patients who were given 4 days of perineural ropivacaine attained all three criteria in a median (25th-75th percentiles) of 47 (29-69)h, compared with 62 (45-79)h for those of the control group (Estimated ratio=0.80, 95% confidence interval: 0.66-1.00; p=0.028). Compared with controls, patients randomized to ropivacaine met the discharge criterion for analgesia in 20 (0-38) versus 38 (15-64)h (p=0.009), and intravenous opioid independence in 21 (0-37) versus 33 (11-50)h (p=0.061). We conclude that a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 20% following TKA compared with an overnight cFNB, primarily by improving analgesia.

  View details for DOI 10.1016/j.pain.2010.05.028

  View details for Web of Science ID 000281675000019

  View details for PubMedID 20573448

  View details for PubMedCentralID PMC2921457

• Prepuncture Ultrasound Imaging to Predict Transverse Process and Lumbar Plexus Depth for Psoas Compartment Block and Perineural Catheter Insertion: A Prospective, Observational Study ANESTHESIA AND ANALGESIA Ilfeld, B. M., Loland, V. J., Mariano, E. R. 2010; 110 (6): 1725-1728

  Abstract

  All widely used psoas compartment block/catheter techniques have a common limitation: external landmarks do not accurately predict lumbar plexus depth, leaving practitioners to "guess" at what depth to stop advancing the placement needle when neither transverse process nor lumbar plexus is intercepted. We assessed the accuracy of ultrasound in estimating transverse process depth before needle insertion and prediction of actual needle-to-plexus intercept depth for psoas compartment nerve blocks and perineural catheter insertion.Before needle insertion, ultrasound was used to estimate the depth of the transverse process lying directly anterior to the intercrestal line. If a transverse process was not directly anterior to the intercrestal line, then the process immediately caudad to the line was imaged. The ultrasound transducer remained in the parasagittal plane, perpendicular to the skin. After this measurement, the transducer was removed, an insulated needle connected to a nerve stimulator inserted in the parasagittal plane, and the depth of both the transverse process (if contacted) and lumbar plexus noted. A perineural catheter was subsequently inserted.Of 53 enrolled subjects, in 50 cases (94%), the transverse processes were identified by ultrasound at a median (interquartile; range) depth of 5.0 cm (4.5-5.5 cm; 3.5-7.5 cm). In 27 subjects (54%), a transverse process was positioned directly anterior to the intercrestal line, and in all of these subjects, the transverse process was intercepted with the block needle a median of 0.5 cm (0.0-1.0 cm; 0.0-1.0 cm) within the predicted depth. In all 50 subjects in whom the transverse processes were identified by ultrasound, the actual lumbar plexus depth measured with the needle was a median of 7.5 cm (7.0-8.5 cm; 5.0-9.5 cm), and the plexus depth was a median of 2.5 cm (2.0-3.0 cm; 0.2-4.0 cm) past the estimated transverse process depth by ultrasound. By ultrasound, the intersection of the middle and lateral thirds of the intercrestal line between the midline and a parallel line through the posterosuperior iliac spine was too lateral to permit needle-transverse process contact in 50% of the subjects. However, moving the transducer 0.75 cm toward the midline allowed for transverse process imaging in all subjects.For psoas compartment blocks/catheters, prepuncture ultrasound imaging accurately predicts transverse process depth to within 1 cm, and if the lumbar plexus is estimated to be within 3 cm of the transverse process, ultrasound allows prediction of maximal lumbar plexus depth to within 1 cm.

  View details for DOI 10.1213/ANE.0b013e3181db7ad3

  View details for Web of Science ID 000278263700036

  View details for PubMedID 20385611

• A Trainee-Based Randomized Comparison of Stimulating Interscalene Perineural Catheters With a New Technique Using Ultrasound Guidance Alone JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Loland, V. J., Sandhu, N. S., Bishop, M. L., Meunier, M. J., Afra, R., Ferguson, E. J., Ilfeld, B. M. 2010; 29 (3): 329-336

  Abstract

  Compared to the well-established stimulating catheter technique, the use of ultrasound guidance alone for interscalene perineural catheter insertion is a recent development and has not yet been examined in a randomized fashion. We hypothesized that an ultrasound-guided technique would require less time and produce equivalent results compared to electrical stimulation (ES) when trainees attempt interscalene perineural catheter placement.Preoperatively, patients receiving an interscalene perineural catheter for shoulder surgery were randomly assigned to an insertion protocol using either ultrasound guidance with a nonstimulating catheter or ES with a stimulating catheter. The primary outcome was the procedural duration (in minutes), starting when the ultrasound probe (ultrasound group) or catheter insertion needle (ES group) first touched the patient and ending when the catheter insertion needle was removed after catheter insertion.All ultrasound-guided catheters (n = 20) were placed successfully and resulted in surgical anesthesia versus 85% of ES-guided catheters (n = 20; P = .231). Perineural catheters placed by ultrasound (n = 20) took a median (10th-90th percentiles) of 8.0 (5.0-15.5) minutes compared to 14.0 (5.0-30.0) minutes for ES (n = 20; P = .022). All catheters placed according to the protocol in both treatment groups resulted in a successful nerve block; however, 1 patient in the ES group had local anesthetic spread to the epidural space. There was 1 vascular puncture using ultrasound guidance compared to 5 in the ES-guided catheter group (P = .182).Trainees using a new ultrasound-guided technique can place inter-scalene perineural catheters in less time compared to a well-documented technique using ES with a stimulating catheter and can produce equivalent results.

  View details for Web of Science ID 000275685900002

  View details for PubMedID 20194929

• Ultrasound-Guided Perineural Catheter Insertion Three Approaches but Few Illuminating Data REGIONAL ANESTHESIA AND PAIN MEDICINE Ilfeld, B. M., Fredrickson, M. J., Mariano, E. R. 2010; 35 (2): 123-126

  View details for DOI 10.1097/AAP.0b013e3181d245a0

  View details for Web of Science ID 000275384800001

  View details for PubMedID 20216031

  View details for PubMedCentralID PMC2919365

• Continuous Peripheral Nerve Blocks Is Local Anesthetic Dose the Only Factor, or Do Concentration and Volume Influence Infusion Effects as Well? ANESTHESIOLOGY Ilfeld, B. M., Moeller, L. K., Mariano, E. R., Loland, V. J., Stevens-Lapsley, J. E., Fleisher, A. S., Girard, P. J., Donohue, M. C., Ferguson, E. J., Ball, S. T. 2010; 112 (2): 347-354

  Abstract

  The main determinant of continuous peripheral nerve block effects--local anesthetic concentration and volume or simply total drug dose--remains unknown.We compared two different concentrations and basal rates of ropivacaine--but at equivalent total doses--for continuous posterior lumbar plexus blocks after hip arthroplasty. Preoperatively, a psoas compartment perineural catheter was inserted. Postoperatively, patients were randomly assigned to receive perineural ropivacaine of either 0.1% (basal 12 ml/h, bolus 4 ml) or 0.4% (basal 3 ml/h, bolus 1 ml) for at least 48 h. Therefore, both groups received 12 mg of ropivacaine each hour with a possible addition of 4 mg every 30 min via a patient-controlled bolus dose. The primary endpoint was the difference in maximum voluntary isometric contraction (MVIC) of the ipsilateral quadriceps the morning after surgery, compared with the preoperative MVIC, expressed as a percentage of the preoperative MVIC. Secondary endpoints included hip adductor and hip flexor MVIC, sensory levels in the femoral nerve distribution, hip range-of-motion, ambulatory ability, pain scores, and ropivacaine consumption.Quadriceps MVIC for patients receiving 0.1% ropivacaine (n = 26) declined by a mean (SE) of 64.1% (6.4) versus 68.0% (5.4) for patients receiving 0.4% ropivacaine (n = 24) between the preoperative period and the day after surgery (95% CI for group difference: -8.0-14.4%; P = 0.70). Similarly, the groups were found to be equivalent with respect to secondary endpoints.For continuous posterior lumbar plexus blocks, local anesthetic concentration and volume do not influence nerve block characteristics, suggesting that local anesthetic dose (mass) is the primary determinant of perineural infusion effects.

  View details for Web of Science ID 000274046400015

  View details for PubMedID 20098137

• Re: Effects of local anesthetic concentration and dose on continuous interscalene nerve blocks: a dual-center, randomized, observer-masked, controlled study. Reply to dr. Borgeat. Regional anesthesia and pain medicine Ilfeld, B. M., Le, L. T., Loland, V. J., Mariano, E. R., Gerancher, J. C., Sessler, D. I. 2010; 35 (1): 120-122

  View details for DOI 10.1097/AAP.0b013e3181c97c6e

  View details for PubMedID 20048670

• Ultrasound Guidance Versus Electrical Stimulation for Femoral Perineural Catheter Insertion JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Loland, V. J., Sandhu, N. S., Bellars, R. H., Bishop, M. L., Afra, R., Ball, S. T., Meyer, R. S., Maldonado, R. C., Ilfeld, B. M. 2009; 28 (11): 1453-1460

  Abstract

  Continuous femoral nerve blocks provide potent analgesia and other benefits after knee surgery. Perineural catheter placement techniques using ultrasound guidance and electrical stimulation (ES) have been described, but the optimal method remains undetermined. We tested the hypothesis that ultrasound guidance alone requires less time for femoral perineural catheter insertion and produces equivalent results compared with ES alone.Preoperatively, patients receiving a femoral perineural catheter for knee surgery were randomly assigned to either ultrasound guidance with a nonstimulating catheter or ES with a stimulating catheter. The primary outcome was the catheter placement procedure time (minutes) starting when the ultrasound transducer (ultrasound group) or catheter insertion needle (ES group) first touched the patient and ending when the catheter insertion needle was removed after catheter insertion.Perineural catheters placed with ultrasound guidance (n = 20) took a median (10th-90th percentiles) of 5.0 (3.9-10.0) minutes compared with 8.5 (4.8-30.0) minutes for ES (n = 20; P = .012). All ultrasound-guided catheters were placed according to the protocol (n = 20) versus 85% of ES-guided catheters (n = 20; P = .086). Patients in the ultrasound group had a median procedure-related discomfort score of 0.5 (0.0-3.1) compared with 2.5 (0.0-7.6) for the ES group (P = .015). There were no vascular punctures with ultrasound guidance versus 4 in the ES group (P = .039).Placement of femoral perineural catheters takes less time with ultrasound guidance compared with ES. In addition, ultrasound guidance produces less procedure-related pain and prevents inadvertent vascular puncture.

  View details for Web of Science ID 000271312900004

  View details for PubMedID 19854959

• Electrical Stimulation Versus Ultrasound Guidance for Popliteal-Sciatic Perineural Catheter Insertion A Randomized Controlled Trial REGIONAL ANESTHESIA AND PAIN MEDICINE Mariano, E. R., Cheng, G. S., Choy, L. P., Loland, V. J., Bellars, R. H., Sandhu, N. S., Bishop, M. L., Lee, D. K., Maldonado, R. C., Ilfeld, B. M. 2009; 34 (5): 480-485

  Abstract

  Sciatic perineural catheters via a popliteal fossa approach and subsequent local anesthetic infusion provide potent analgesia and other benefits after foot and ankle surgery. Electrical stimulation (ES) and, more recently, ultrasound (US)-guided placement techniques have been described. However, because these techniques have not been compared in a randomized fashion, the optimal method remains undetermined. Therefore, we tested the hypotheses that popliteal-sciatic perineural catheters placed via US guidance require less time for placement and produce equivalent results, as compared with catheters placed using ES.Preoperatively, subjects receiving a popliteal-sciatic perineural catheter for foot and/or ankle surgery were randomly assigned to either the ES with a stimulating catheter or US-guided technique with a nonstimulating catheter. The primary end point was catheter insertion duration (in minutes) starting when the US transducer (US group) or catheter-placement needle (ES group) first touched the patient and ending when the catheter-placement needle was removed after catheter insertion.All US-guided catheters were placed per protocol (n = 20), whereas only 80% of stimulation-guided catheters could be placed per protocol (n = 20, P = 0.106). All catheters placed per protocol in both groups resulted in a successful surgical block. Perineural catheters placed by US took a median (10th-90th percentile) of 5.0 min (3.9-11.1 min) compared with 10.0 min (2.0-15.0 min) for stimulation (P = 0.034). Subjects in the US group experienced less pain during catheter placement, scoring discomfort a median of 0 (0.0-2.1) compared with 2.0 (0.0-5.0) for the stimulation group (P = 0.005) on a numeric rating scale of 0 to 10.Placement of popliteal-sciatic perineural catheters takes less time and produces less procedure-related discomfort when using US guidance compared with ES.

  View details for DOI 10.1097/AAP.0b013e3181ada57a

  View details for Web of Science ID 000270157900015

  View details for PubMedID 19920423

• Ultrasound-guided perineural catheter and local anesthetic infusion in the perioperative management of pediatric limb salvage: a case report PEDIATRIC ANESTHESIA Loland, V. J., Ilfeld, B. M., Abrams, R. A., Mariano, E. R. 2009; 19 (9): 905-907

  Abstract

  Local anesthetic perineural infusion has emerged as an effective analgesic technique in pediatric patients, but it can also complement surgical perioperative management in complex cases that require optimal tissue perfusion such as limb salvage. We report the successful use of brachial plexus perineural infusion in the care of a child following near-amputation of her dominant hand. An ultrasound-guided infraclavicular brachial plexus catheter was placed in the recovery room after complex reconstructive surgery and a continuous infusion of 0.2% ropivacaine maintained for 24 days. The resultant sympathectomy was integral to providing distal limb perfusion despite partial restenosis of the surgical revascularization.

  View details for DOI 10.1111/j.1460-9592.2009.03103.x

  View details for Web of Science ID 000268712100013

  View details for PubMedID 19650843

• Ultrasound Guidance Versus Electrical Stimulation for Infraclavicular Brachial Plexus Perineural Catheter Insertion JOURNAL OF ULTRASOUND IN MEDICINE Mariano, E. R., Loland, V. J., Bellars, R. H., Sandhu, N. S., Bishop, M. L., Abrams, R. A., Meunier, M. J., Maldonado, R. C., Ferguson, E. J., Ilfeld, B. M. 2009; 28 (9): 1211-1218

  Abstract

  Electrical stimulation (ES)- and ultrasound-guided placement techniques have been described for infraclavicular brachial plexus perineural catheters but to our knowledge have never been previously compared in a randomized fashion, leaving the optimal method undetermined. We tested the hypothesis that infraclavicular catheters placed via ultrasound guidance alone require less time for placement and produce equivalent results compared with catheters placed solely via ES.Preoperatively, patients receiving an infraclavicular perineural catheter for distal upper extremity surgery were randomly assigned to either ES with a stimulating catheter or ultrasound guidance with a nonstimulating catheter. The primary outcome was the catheter insertion duration (minutes) starting when the ultrasound transducer (ultrasound group) or catheter placement needle (stimulation group) first touched the patient and ending when the catheter placement needle was removed after catheter insertion.Perineural catheters placed with ultrasound guidance took a median (10th-90th percentile) of 9.0 (6.0-13.2) minutes compared with 15.0 (4.9-30.0) minutes for stimulation (P < .01). All ultrasound-guided catheters were successfully placed according to the protocol (n = 20) versus 70% in the stimulation group (n = 20; P < .01). All ultrasound-guided catheters resulted in a successful surgical block, whereas 2 catheters placed by stimulation failed to result in surgical anesthesia. Six catheters (30%) placed via stimulation resulted in vascular punctures compared with none in the ultrasound group (P < .01). Procedure-related pain scores were similar between groups (P = .34).Placement of infraclavicular perineural catheters takes less time, is more often successful, and results in fewer inadvertent vascular punctures when using ultrasound guidance compared with ES.

  View details for Web of Science ID 000269460000011

  View details for PubMedID 19710219

• Health-Related Quality of Life After Hip Arthroplasty With and Without an Extended-Duration Continuous Posterior Lumbar Plexus Nerve Block: A Prospective, 1-Year Follow-Up of a Randomized, Triple-Masked, Placebo-Controlled Study Annual Meeting of the American-Society-of-Regional-Anesthesia-and-Pain-Medicine Ilfeld, B. M., Ball, S. T., Gearen, P. F., Mariano, E. R., Le, L. T., Vandenborne, K., Duncan, P. W., Sessler, D. I., Enneking, F. K., Shuster, J. J., Maldonado, R. C., Meyer, R. S. LIPPINCOTT WILLIAMS & WILKINS. 2009: 586–91

  Abstract

  We previously reported that extending an overnight continuous posterior lumbar plexus nerve block to 4 days after hip arthroplasty provides clear benefits during the perineural infusion in the immediate postoperative period. However, it remains unknown whether the extended infusion improves subsequent health-related quality of life.Patients undergoing hip arthroplasty received a posterior lumbar plexus perineural infusion of ropivacaine 0.2% from surgery until the following morning, at which time patients were randomized to continue either perineural ropivacaine (n = 24) or normal saline (n = 23) in a double-masked fashion. Patients were discharged with their catheter and a portable infusion pump, and catheters were removed on postoperative Day 4. Health-related quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index preoperatively and then at 7 days and 1, 2, 3, 6, and 12 mo after surgery. The WOMAC evaluates three dimensions of health-related quality of life, such as pain, stiffness, and physical functional disability (global score of 0-96, lower scores indicate lower levels of symptoms or physical disability). For inclusion in the primary analysis, we required a minimum of three of the six timepoints, including Day 7 and at least two of Months 3, 6, and 12.The two treatment groups had similar global WOMAC scores for the mean area under the curve calculations (point estimate for the difference in mean area under the curve for the two groups [extended infusion group-overnight infusion group] = 0.8, 95% confidence interval: -5.3 to + 6.8 [-5.5% to + 7.1%]; P = 0.80) and at all individual timepoints (P > 0.05).This investigation found no evidence that extending an overnight continuous posterior lumbar plexus nerve block to 4 days improves (or worsens) subsequent health-related quality of life between 7 days and 12 mo after hip arthroplasty.

  View details for DOI 10.1213/ane.0b013e3181a9db5d

  View details for Web of Science ID 000268298600045

  View details for PubMedID 19608835

  View details for PubMedCentralID PMC2725431

• Bilateral infraorbital nerve blocks decrease postoperative pain but do not reduce time to discharge following outpatient nasal surgery Annual Meeting of the American-Society-of-Anesthesiologist Mariano, E. R., Watson, D., Loland, V. J., Chu, L. F., Cheng, G. S., Mehta, S. H., Maldonado, R. C., Ilfeld, B. M. SPRINGER. 2009: 584–89

  Abstract

  While infraorbital nerve blocks have demonstrated analgesic benefits for pediatric nasal and facial plastic surgery, no studies to date have explored the effect of this regional anesthetic technique on adult postoperative recovery. We designed this study to test the hypothesis that infraorbital nerve blocks combined with a standardized general anesthetic decrease the duration of recovery following outpatient nasal surgery.At a tertiary care university hospital, healthy adult subjects scheduled for outpatient nasal surgery were randomly assigned to receive bilateral infraorbital injections with either 0.5% bupivacaine (Group IOB) or normal saline (Group NS) using an intraoral technique immediately following induction of general anesthesia. All subjects underwent a standardized general anesthetic regimen and were transported to the recovery room following tracheal extubation. The primary outcome was the duration of recovery (minutes) from recovery room admission until actual discharge to home. Secondary outcomes included average and worst pain scores, nausea and vomiting, and supplemental opioid requirements.Forty patients were enrolled. A statistically significant difference in mean [SD] recovery room duration was not observed between Groups IOB and NS (131 [61] min vs 133 [58] min, respectively; P = 0.77). Subjects in Group IOB did experience a reduction in average pain on a 0-100 mm scale (mean [95% confidence interval]) compared to Group NS (-11 [-21 to 0], P = 0.047), but no other comparison of secondary outcomes was statistically significant.When added to a standardized general anesthetic, bilateral IOB do not decrease actual time to discharge following outpatient nasal surgery despite a beneficial effect on postoperative pain.

  View details for DOI 10.1007/s12630-009-9119-5

  View details for Web of Science ID 000268294300005

  View details for PubMedID 19475468

  View details for PubMedCentralID PMC2714904

• Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia 31st Annual Spring Meeting of the American-Society-of-Regional-Anesthesia-and-Pain-Medicine Mariano, E. R., Chu, L. F., Peinado, C. R., Mazzei, W. J. ELSEVIER SCIENCE INC. 2009: 253–57

  Abstract

  To test the hypothesis that regional anesthesia (RA) employing a block room reduces anesthesia-controlled time for ambulatory upper extremity surgery compared with general anesthesia (GA).Retrospective cohort study.Outpatient surgery center of a university hospital.229 adult patients who underwent ambulatory upper extremity surgery over one year.Upper extremity surgery was performed with three different anesthetic techniques: 1) GA, 2) nerve block (NB) performed preoperatively, or 3) local anesthetic (LA), either Bier block or local anesthetic, administered in the operating room (OR).Demographic data, anesthesia-controlled time, and turnover time were recorded. Since the data were not normally distributed, differences in anesthesia-controlled time and turnover time were analyzed using the Kruskal-Wallis test and post-hoc testing using one-way analysis of variance on the ranks of the observations, with Tukey-Kramer correction for multiple comparisons.Anesthesia-controlled time for NB (median 28 min) was significantly shorter than for GA (median 32 min, P = 0.0392). Anesthesia-controlled time for patients who received LA (median 25 min) was also significantly shorter than GA (P < 0.0001). However, turnover time did not differ significantly among the three groups.Peripheral nerve block performed preoperatively in an induction area or LA injected in the OR significantly reduces anesthesia-controlled time for ambulatory upper extremity surgery compared with GA. Turnover time is unaffected by anesthetic technique. These results may increase acceptance of RA in the ambulatory surgery setting.

  View details for DOI 10.1016/j.jclinane.2008.08.019

  View details for Web of Science ID 000267501500004

  View details for PubMedID 19502033

  View details for PubMedCentralID PMC2745934

• Continuous Interscalene Brachial Plexus Block via an Ultrasound-Guided Posterior Approach: A Randomized, Triple-Masked, Placebo-Controlled Study ANESTHESIA AND ANALGESIA Mariano, E. R., Afra, R., Loland, V. J., Sandhu, N. S., Bellars, R. H., Bishop, M. L., Cheng, G. S., Choy, L. P., Maldonado, R. C., Ilfeld, B. M. 2009; 108 (5): 1688-1694

  Abstract

  The posterior approach for placing continuous interscalene catheters has not been studied in a controlled investigation. In this randomized, triple-masked, placebo-controlled study, we tested the hypothesis that an ultrasound-guided continuous posterior interscalene block provides superior postoperative analgesia compared to a single-injection ropivacaine interscalene block after moderately painful shoulder surgery.Preoperatively, subjects received a stimulating interscalene catheter using an ultrasound-guided, in-plane posterior approach. All subjects received an initial bolus of ropivacaine. Postoperatively, subjects were discharged with oral analgesics and a portable infusion device containing either ropivacaine 0.2% or normal saline programmed to deliver a perineural infusion over 2 days. The primary outcome was average pain on postoperative day (POD) 1 (scale: 0-10). Secondary outcomes included least and worst pain scores, oral opioid requirements, sleep disturbances, patient satisfaction, and incidence of complications.Of the 32 subjects enrolled, 30 perineural catheters were placed per protocol. Continuous ropivacaine perineural infusion (n = 15) produced a statistically and clinically significant reduction in average pain (median [10th-90th percentile]) on POD 1 compared with saline infusion (n = 15) after initial ropivacaine bolus (0.0 [0.0-5.0] versus 3.0 [0.0-6.0], respectively; P < 0.001). Median oral opioid consumption (oxycodone) was lower in the ropivacaine group than in the placebo group on POD 1 (P = 0.002) and POD 2 (P = 0.002). Subjects who received a ropivacaine infusion suffered fewer sleep disturbances than those in the placebo group (P = 0.005 on POD 0 and 1 nights) and rated their satisfaction with analgesia higher than subjects who received normal saline (P < 0.001).Compared to a single-injection interscalene block, a 2-day continuous posterior interscalene block provides greater pain relief, minimizes supplemental opioid requirements, greatly improves sleep quality, and increases patient satisfaction after moderate-to-severe painful outpatient shoulder surgery.

  View details for DOI 10.1213/ane.0b013e318199dc86

  View details for Web of Science ID 000265422300052

  View details for PubMedID 19372355

  View details for PubMedCentralID PMC2745838

• Health-Related Quality of Life After Tricompartment Knee Arthroplasty With and Without an Extended-Duration Continuous Femoral Nerve Block: A Prospective, 1-Year Follow-Up of a Randomized, Triple-Masked, Placebo-Controlled Study Annual Meeting of the American-Society-of-Anesthesiologist Ilfeld, B. M., Meyer, R. S., Le, L. T., Mariano, E. R., Williams, B. A., Vandenborne, K., Duncan, P. W., Sessler, D. I., Enneking, F. K., Shuster, J. J., Maldonado, R. C., Gearen, P. F. LIPPINCOTT WILLIAMS & WILKINS. 2009: 1320–25

  Abstract

  We previously provided evidence that extending an overnight continuous femoral nerve block to 4 days after tricompartment knee arthroplasty (TKA) provides clear benefits during the perineural infusion in the immediate postoperative period. However, it remains unknown if the extended infusion improves subsequent health-related quality of life between 7 days and 12 mo.Patients undergoing TKA received a femoral perineural infusion of ropivacaine 0.2% from surgery until the following morning, at which time patients were randomized to either continue perineural ropivacaine (n = 25) or normal saline (n = 25) in a double-masked fashion. Patients were discharged with their catheter and a portable infusion pump, and catheters were removed on postoperative day 4. Health-related quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index preoperatively and then at 7 days, as well as 1, 2, 3, 6, and 12 mo after surgery. The WOMAC evaluates three dimensions of health-related quality of life: pain, stiffness, and physical functional disability. For inclusion in the analysis, we required a minimum of 4 of the 6 time points, including day 7 and at least 2 of mo 3, 6, and 12.The two treatment groups had similar WOMAC scores for the mean area under the curve calculations (point estimate for the difference in mean area under the curve for the two groups [overnight infusion group-extended infusion group] = 1.2, 95% confidence interval: -5.6 to +8.0; P = 0.72) and at all individual time points (P > 0.05).We found no evidence that extending an overnight continuous femoral nerve block to 4 days improves (or worsens) subsequent health-related quality of life between 7 days and 12 mo after TKA. (ClinicalTrials.gov number, NCT00135889.).

  View details for DOI 10.1213/ane.0b013e3181964937

  View details for Web of Science ID 000264534700047

  View details for PubMedID 19299806

  View details for PubMedCentralID PMC2701222

• Appropriate Endotracheal Tube Placement in Children: Don't Throw Away Your Stethoscopes Yet! ANESTHESIOLOGY Mariano, E. R., Ramamoorthy, C., Hammer, G. B. 2009; 110 (2): 433-434

  View details for Web of Science ID 000262907500038

  View details for PubMedID 19164968

• The Effects of Local Anesthetic Concentration and Dose on Continuous Infraclavicular Nerve Blocks: A Multicenter, Randomized, Observer-Masked, Controlled Study ANESTHESIA AND ANALGESIA Ilfeld, B. M., Le, L. T., Ramjohn, J., Loland, V. J., Wadhwa, A. N., Gerancher, J. C., Renehan, E. M., Sessler, D. I., Shuster, J. J., Theriaque, D. W., Maldonado, R. C., Mariano, E. R. 2009; 108 (1): 345-350

  Abstract

  It remains unclear whether local anesthetic concentration or total drug dose is the primary determinant of continuous peripheral nerve block effects. The only previous investigation, involving continuous popliteal-sciatic nerve blocks, specifically addressing this issue reported that insensate limbs were far more common with higher volumes of relatively dilute ropivacaine compared with lower volumes of relatively concentrated ropivacaine. However, it remains unknown if this relationship is specific to the sciatic nerve in the popliteal fossa or whether it varies depending on anatomic location. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates, but at an equal total basal dose, produces comparable effects when used in a continuous infraclavicular brachial plexus block.Preoperatively, an infraclavicular catheter was inserted using the coracoid approach in patients undergoing moderately painful orthopedic surgery distal to the elbow. Patients were randomly assigned to receive a postoperative perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Both groups, therefore, received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. Our primary end point was the incidence of an insensate limb during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction.Patients given 0.4% ropivacaine (n = 27) experienced an insensate limb, a mean (sd) of 1.8 (1.6) times, compared with 0.6 (0.9) times for subjects receiving 0.2% ropivacaine (n = 23; estimated difference = 1.2 episodes, 95% confidence interval, 0.5-1.9 episodes; P = 0.001). Satisfaction with postoperative analgesia (scale 0-10, 10 = highest) was scored a median (25th-75th percentiles) of 10.0 (8.0-10.0) in Group 0.2% and 7.0 (5.3-8.9) in Group 0.4% (P = 0.018). Analgesia was similar in each group.For continuous infraclavicular nerve blocks, local anesthetic concentration and volume influence perineural infusion effects in addition to the total mass of local anesthetic administered. Insensate limbs were far more common with smaller volumes of relatively concentrated ropivacaine. This is the opposite of the relationship previously reported for continuous popliteal-sciatic nerve blocks. The interaction between local anesthetic concentration and volume is thus complex and varies among catheter locations.

  View details for DOI 10.1213/ane.0b013e31818c7da5

  View details for Web of Science ID 000261963000050

  View details for PubMedID 19095871

  View details for PubMedCentralID PMC2745828

• Interscalene Perineural Catheter Placement Using an Ultrasound-Guided Posterior Approach REGIONAL ANESTHESIA AND PAIN MEDICINE Mariano, E. R., Loland, V. J., Ilfeld, B. M. 2009; 34 (1): 60-63

  Abstract

  The posterior approach to the brachial plexus--or cervical paravertebral block--has advantages over the anterolateral interscalene approach, but concerns regarding "blind" needle placement near the neuraxis have limited the acceptance of this useful technique. We present a technique to place an interscalene perineural catheter that potentially decreases neuraxial involvement with the use of ultrasound guidance.A 55-year-old man scheduled for total shoulder arthroplasty underwent placement of an interscalene perineural catheter. The posterior approach was selected to avoid the external jugular vein and anticipated sterile surgical field. Under in-plane ultrasound guidance, a 17-gauge insulated Tuohy-tip needle was inserted between the levator scapulae and trapezius muscles, and guided through the middle scalene muscle, remaining less than 2 cm below the skin throughout. Deltoid and biceps contractions were elicited at a current of 0.6 mA, and a 19-gauge stimulating catheter was advanced 5 cm beyond the needle tip, without a concomitant decrease in motor response.The initial 40 mL 0.5% ropivacaine bolus via the catheter resulted in unilateral anesthesia typical of an interscalene block; and subsequent perineural infusion of 0.2% ropivacaine was delivered via portable infusion pump through postoperative day 4.Continuous interscalene block using an ultrasound-guided posterior approach is an alternative technique that retains the benefits of posterior catheter insertion, but potentially reduces the risk of complications that may result from blind needle insertion.

  View details for DOI 10.1097/AAP.0b013e3181933af7

  View details for Web of Science ID 000262828400013

  View details for PubMedID 19258989

  View details for PubMedCentralID PMC2743892

• Making it work: setting up a regional anesthesia program that provides value. Anesthesiology clinics Mariano, E. R. 2008; 26 (4): 681-?

  Abstract

  Regional anesthesia offers many benefits for the patient, surgery center, anesthesiology practice, and hospital. Unfortunately, there are no evidence-based guidelines to follow when starting a new service aimed at providing peripheral nerve blocks. A regional anesthesia program adds value by improving the quality of postoperative analgesia and recovery after surgery. Specialized training in regional anesthesia is necessary when using advanced techniques, such as ultrasound guidance and continuous peripheral nerve blockade. A regional anesthesia service may shorten postanesthesia recovery time in ambulatory surgery and duration of hospital admission for some surgeries. A successful regional anesthesia service promotes effective communication among all members of the perioperative team.

  View details for DOI 10.1016/j.anclin.2008.07.006

  View details for PubMedID 19041623

• Effects of Local Anesthetic Concentration and Dose on Continuous Interscalene Nerve Blocks: A Dual-Center, Randomized, Observer-Masked, Controlled Study REGIONAL ANESTHESIA AND PAIN MEDICINE Le, L. T., Loland, V. J., Mariano, E. R., Gerancher, J. C., Wadhwa, A. N., Renehan, E. M., Sessler, D. I., Shuster, J. J., Theriaque, D. W., Maldonado, R. C., Ilfeld, B. M. 2008; 33 (6): 518-525

  Abstract

  It is currently unknown if the primary determinant of continuous peripheral nerve block effects is simply total drug dose, or whether local anesthetic concentration and/or volume have an influence. We therefore tested the null hypothesis that providing ropivacaine at different concentrations and rates--but at an equal total basal dose--produces similar effects when used in a continuous interscalene nerve block.Preoperatively, an anterolateral interscalene perineural catheter was inserted using the anterolateral approach in patients undergoing moderately painful shoulder surgery. Subjects were randomly assigned to receive a postoperative perineural infusion of either 0.2% ropivacaine (basal 8 mL/h, bolus 4 mL) or 0.4% ropivacaine (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Our primary endpoint was the incidence of an insensate hand/finger during the 24 hours beginning the morning following surgery.The incidence of an insensate hand/finger did not differ between the treatment groups (n = 50) to a statistically significant degree (0.2% ropivacaine, mean [SD] of 0.8 [1.3] times; 0.4% ropivacaine, mean 0.3 [0.6] times; estimated difference = 0.5 episodes, 95% confidence interval, -0.1 to 1.1 episodes; P = .080). However, this is statistically inconclusive given the confidence interval. In contrast, pain (P = .020) and dissatisfaction (P = .011) were greater in patients given 0.4% ropivacaine.For continuous interscalene nerve blocks, given the statistically inconclusive primary endpoint results and design limitations of the current study, further research on this topic is warranted. In contrast, providing a lower concentration of local anesthetic at a higher basal rate provided superior analgesia.

  View details for DOI 10.1016/j.rapm.2008.05.006

  View details for Web of Science ID 000260971800003

  View details for PubMedID 19258966

  View details for PubMedCentralID PMC2711692

• Ambulatory continuous posterior lumbar plexus nerve blocks after hip arthroplasty: a dual-center, randomized, triple-masked, placebo-controlled trial. Anesthesiology Ilfeld, B. M., Ball, S. T., Gearen, P. F., Le, L. T., Mariano, E. R., Vandenborne, K., Duncan, P. W., Sessler, D. I., Enneking, F. K., Shuster, J. J., Theriaque, D. W., Meyer, R. S. 2008; 109 (3): 491-501

  Abstract

  The authors tested the hypotheses that after hip arthroplasty, ambulation distance is increased and the time required to reach three specific readiness-for-discharge criteria is shorter with a 4-day ambulatory continuous lumbar plexus block (cLPB) than with an overnight cLPB.A cLPB consisting of 0.2% ropivacaine was provided from surgery until the following morning. Patients were then randomly assigned either to continue ropivacaine or to be switched to normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation > or = 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cLPB and a portable infusion pump, and catheters were removed on the fourth postoperative day.Patients given 4 days of perineural ropivacaine (n = 24) attained all three discharge criteria in a median (25th-75th percentiles) of 29 (24-45) h, compared with 51 (42-73) h for those of the control group (n = 23; estimated ratio = 0.62; 95% confidence interval, 0.45-0.92; P = 0.011). Patients assigned to receive ropivacaine ambulated a median of 34 (9-55) m the afternoon after surgery, compared with 20 (6-46) m for those receiving normal saline (estimated ratio = 1.3; 95% confidence interval, 0.6-3.0; P = 0.42). Three falls occurred in subjects receiving ropivacaine (13%), versus none in subjects receiving normal saline.Compared with an overnight cLPB, a 4-day ambulatory cLPB decreases the time to reach three predefined discharge criteria by an estimated 38% after hip arthroplasty. However, the extended infusion did not increase ambulation distance to a statistically significant degree.

  View details for DOI 10.1097/ALN.0b013e318182a4a3

  View details for PubMedID 18719448

  View details for PubMedCentralID PMC2590635

• Ambulatory continuous posterior lumbar plexus nerve blocks after hip arthroplasty Annual Meeting of the American-Society-of-Anesthesiologist Iifeld, B. M., Ball, S. T., Gearen, P. F., Le, L. T., Mariano, E. R., Vandenborne, K., Duncan, P. W., Sessler, D. I., Enneking, F. K., Shuster, J. J., Theriaque, D. W., Meyer, R. S. LIPPINCOTT WILLIAMS & WILKINS. 2008: 491–501

  View details for Web of Science ID 000258793700019

• The effects of varying local anesthetic concentration and volume on continuous popliteal sciatic nerve blocks: A dual-center, randomized, controlled study ANESTHESIA AND ANALGESIA Ilfeld, B. M., Loland, V. J., Gerancher, J. C., Wadhwa, A. N., Renehan, E. M., Sessler, D. I., Shuster, J. J., Theriaclue, D. W., Maldonado, R. C., Mariano, E. R. 2008; 107 (2): 701-707

  Abstract

  It remains unknown whether local anesthetic concentration, or simply total drug dose, is the primary determinant of continuous peripheral nerve block effects. We therefore tested the null hypothesis that providing different concentrations and rates of ropivacaine, but at equal total doses, produces comparable effects when used in a continuous sciatic nerve block in the popliteal fossa.Preoperatively, a perineural catheter was inserted adjacent to the sciatic nerve using a posterior popliteal approach in patients undergoing moderately painful orthopedic surgery at or distal to the ankle. Postoperatively, patients were randomly assigned to receive a perineural ropivacaine infusion of either 0.2% (basal 8 mL/h, bolus 4 mL) or 0.4% (basal 4 mL/h, bolus 2 mL) through the second postoperative day. Therefore, both groups received 16 mg of ropivacaine each hour with a possible addition of 8 mg every 30 min via a patient-controlled bolus dose. The primary end point was the incidence of an insensate limb, considered undesirable, during the 24-h period beginning the morning after surgery. Secondary end points included analgesia and patient satisfaction.Patients given 0.2% ropivacaine (n = 25) experienced an insensate limb with a mean (sd) of 1.8 (1.8) times, compared with 0.6 (1.1) times for subjects receiving 0.4% ropivacaine (n = 25; estimated difference = 1.2 episodes, 95% confidence interval, 0.3-2.0 episodes; P = 0.009). In contrast, analgesia and satisfaction were similar in each group.For continuous popliteal-sciatic nerve blocks, local anesthetic concentration and volume influence block characteristics. Insensate limbs were far more common with larger volumes of relatively dilute ropivacaine. During continuous sciatic nerve block in the popliteal fossa, a relatively concentrated solution in smaller volume thus appears preferable.

  View details for DOI 10.1213/ane.0b013e3181770eda

  View details for Web of Science ID 000258168300051

  View details for PubMedID 18633055

  View details for PubMedCentralID PMC2585804

• Feasibility of ultrasound-guided peripheral nerve block catheters for pain control on pediatric medical missions in developing countries PEDIATRIC ANESTHESIA Mariano, E. R., Ilfeld, B. M., Cheng, G. S., Nicodemus, H. F., Suresh, S. 2008; 18 (7): 598-601

  Abstract

  Continuous peripheral nerve blocks (CPNB) are effective for postoperative pain management in children in the hospital and at home. CPNB techniques are particularly advantageous when compared with systemic or oral opioids on medical missions to unfamiliar environments with minimal monitoring capacity. In addition, ultrasound-guidance facilitates the placement of perineural catheters in anesthetized children even in the absence of commercially packaged regional anesthesia equipment. We present a series of successful cases employing ultrasound-guided CPNB for postoperative analgesia on medical missions and discuss the impact of this technology on present and future patients in underserved countries.

  View details for DOI 10.1111/j.1460-9592.2008.02633.x

  View details for Web of Science ID 000256379200004

  View details for PubMedID 18482232

  View details for PubMedCentralID PMC2745103

• Pneumothorax following infraclavicular brachial plexus block for hand surgery. Orthopedics Sanchez, H. B., Mariano, E. R., Abrams, R., Meunier, M. 2008; 31 (7): 709-?

  Abstract

  The infraclavicular brachial plexus block is a routinely used anesthesia technique for orthopedic hand, wrist, and arm surgeries. Although the pulmonary anatomy surrounding the brachial plexus would suggest a theoretical potential for pneumothorax development during infraclavicular brachial plexus blockade, this complication is rarely reported in the literature. We report two occurrences of pneumothorax development following routine infraclavicular brachial plexus blockade performed by physicians at an academic training institution with technical experience. Both patients were healthy adult males with a normal body habitus undergoing elective upper extremity surgical intervention. They presented to the emergency department on postoperative days 1 and 2 with shortness of breath and chest pain. Despite different clinical management strategies for each patient, including conservative physical activity with inspirational spirometry compared to thoracic decompression, both patients' pneumothoraces resolved with no apparent sequelae. This article describes the clinical benefits of infraclavicular brachial plexus blockade versus general anesthesia during elective outpatient surgeries. The development of symptomatic pneumothoraces in 2 healthy adult patients stresses the importance of careful patient assessment pre- and postoperatively. Possible preventative strategies to avoid pneumothorax complications during infraclavicular brachial plexus blockade are discussed. This case report indicates there is a risk of iatrogenic injury during infraclavicular brachial plexus blockade. This information could be valuable in determining anesthesia modalities used for orthopedic upper extremity surgeries in patient populations with problematic follow-up or limited access to health care.

  View details for PubMedID 19292372

• Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology Ilfeld, B. M., Le, L. T., Meyer, R. S., Mariano, E. R., Vandenborne, K., Duncan, P. W., Sessler, D. I., Enneking, F. K., Shuster, J. J., Theriaque, D. W., Berry, L. F., Spadoni, E. H., Gearen, P. F. 2008; 108 (4): 703-713

  Abstract

  The authors tested the hypotheses that, compared with an overnight continuous femoral nerve block (cFNB), a 4-day ambulatory cFNB increases ambulation distance and decreases the time until three specific readiness-for-discharge criteria are met after tricompartment total knee arthroplasty.Preoperatively, all patients received a cFNB (n = 50) and perineural ropivacaine 0.2% from surgery until the following morning, at which time they were randomly assigned to either continue perineural ropivacaine or switch to perineural normal saline. Primary endpoints included (1) time to attain three discharge criteria (adequate analgesia, independence from intravenous analgesics, and ambulation of at least 30 m) and (2) ambulatory distance in 6 min the afternoon after surgery. Patients were discharged with their cFNB and a portable infusion pump, and catheters were removed on postoperative day 4.Patients given 4 days of perineural ropivacaine attained all three discharge criteria in a median (25th-75th percentiles) of 25 (21-47) h, compared with 71 (46-89) h for those of the control group (estimated ratio, 0.47; 95% confidence interval, 0.32-0.67; P <0.001). Patients assigned to receive ropivacaine ambulated a median of 32 (17-47) m the afternoon after surgery, compared with 26 (13-35) m for those receiving normal saline (estimated ratio, 1.21; 95% confidence interval, 0.71-1.85; P = 0.42).Compared with an overnight cFNB, a 4-day ambulatory cFNB decreases the time to reach three important discharge criteria by an estimated 53% after tricompartment total knee arthroplasty. However, the extended infusion did not increase ambulation distance the afternoon after surgery. (ClinicalTrials.gov No. NCT00135889.).

  View details for DOI 10.1097/ALN.0b013e318167af46

  View details for PubMedID 18362603

  View details for PubMedCentralID PMC2643303

• Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty Llfeld, B. M., Le, L. T., Meyer, P., Mariano, E. P., Vandenbome, K., Duncan, P. W., Sessler, D. I., Enneking, F., Shuster, J. J., Theriaque, D. W., Berry, L. F., Spadoni, E. H., Gearen, P. F. LIPPINCOTT WILLIAMS & WILKINS. 2008: 703-713

  View details for Web of Science ID 000254467500022

• "Going fishing" - The practice of reporting secondary outcomes as separate studies REGIONAL ANESTHESIA AND PAIN MEDICINE Mariano, E. R., Ilfeld, B. M. 2007; 32 (3): 183-185

  View details for DOI 10.1016/j.rapm.2007.04.002

  View details for Web of Science ID 000247130900002

  View details for PubMedID 17543811

• Conflicting results in clinical research: Is the proof in the P value, the study design, or the pudding? REGIONAL ANESTHESIA AND PAIN MEDICINE Ilfeld, B. M., Mariano, E. R., Neal, J. M. 2007; 32 (3): 179-182

  View details for DOI 10.1016/j.rapm.2007.03.007

  View details for Web of Science ID 000247130900001

  View details for PubMedID 17543810

  View details for PubMedCentralID PMC1950781

• An analysis of factors influencing postanesthesia recovery after pediatric ambulatory tonsillectomy and adenoidectomy ANESTHESIA AND ANALGESIA Edler, A. A., Mariano, E. R., Golianu, B., Kuan, C., Pentcheva, K. 2007; 104 (4): 784-789

  Abstract

  Many factors contribute to prolonged length of stay (LOS) for pediatric patients in the postanesthesia care unit (PACU). We designed this prospective study to identify the pre- and postoperative factors that prolong LOS.We studied 166 children, aged 1-18 yr, who underwent tonsillectomy and adenoidectomy or tonsillectomy and adenoidectomy, and bilateral myringotomy with tube insertion under general anesthesia. The primary outcome measure was the time spent in the PACU until predetermined discharge criteria were met.The number of episodes of postoperative nausea and vomiting, patient age, and number of oxygen desaturations contributed significantly (P < 0.05) to prolonged LOS. Each episode of postoperative nausea and vomiting (P < 0.05) or oxygen desaturation to <95% (P < 0.05) increased the patient's LOS by 0.5 h. History of upper respiratory tract infection, emergence agitation, and parental anxiety did not significantly predict increased LOS.This investigation is the first composite view of LOS in pediatric patients. The significance of identifying patients at risk of prolonged LOS prior to anesthesia is of use not only in allocating PACU resource and staffing needs, but also for improving quality of care and ensuring a minimally traumatic anesthetic experience for our pediatric patients and their families.

  View details for DOI 10.1213/01.ane.0000258771.53068.09

  View details for PubMedID 17377083

• Thoracic and lumbar paravertebral blocks for outpatient lithotripsy JOURNAL OF CLINICAL ANESTHESIA Jamieson, B. D., Mariano, E. R. 2007; 19 (2): 149-151

  Abstract

  Paravertebral nerve block has been used for a variety of surgical procedures to provide unilateral anesthesia and postoperative analgesia. We report the successful application of this regional anesthesia modality for outpatient lithotripsy. Preoperatively, thoracic and lumbar paravertebral nerve blocks with 0.5% ropivacaine were placed with ultrasound and nerve stimulator guidance for two patients with ureteral calculi. One patient scheduled for cystoscopy and ureteroscopy with laser lithotripsy received general anesthesia intraoperatively. The second patient underwent extracorporeal shock wave lithotripsy with propofol intravenous sedation. Postoperatively, both patients reported pain scores of zero (Visual Analog Scale) for 24 hours and required no opioid rescue analgesia.

  View details for DOI 10.1016/j.jclinane.2006.07.006

  View details for Web of Science ID 000245609000016

  View details for PubMedID 17379131

• Transesophageal echocardiography assessment of severe aortic regurgitation in type a aortic dissection caused by a prolapsed circumferential intimal flap JOURNAL OF CARDIOTHORACIC AND VASCULAR ANESTHESIA Chow, J. L., Mariano, E. R., Liang, D. 2007; 21 (1): 85-87

  View details for DOI 10.1053/j.jvca.2005.09.005

  View details for Web of Science ID 000244804600016

  View details for PubMedID 17289486

• Hospitalization costs of total knee arthroplasty with a continuous femoral nerve block provided only in the hospital versus on an ambulatory basis: A retrospective, case-control, cost-minimization analysis REGIONAL ANESTHESIA AND PAIN MEDICINE Ilfeld, B. M., Mariano, E. R., Williams, B. A., Woodard, J. N., Macario, A. 2007; 32 (1): 46-54

  Abstract

  After total knee arthroplasty (TKA), hospitalization may be shortened by allowing patients to return home with a continuous femoral nerve block (CFNB). This study quantified the hospitalization costs for 10 TKA patients receiving ambulatory CFNB versus a matched cohort of 10 patients who received CFNB only during hospitalization.We examined the medical records (n = 125) of patients who underwent a unilateral, primary, tricompartment TKA with a postoperative CFNB by 1 surgeon at one institution in an 18-month period beginning January 2004. Each of the 10 patients discharged home with an ambulatory CFNB (cases) was matched with a patient with a hospital-only CFNB (controls) for age, gender, body mass index, and health status. Financial data were extracted from the hospital microcosting database.Nine patients with ambulatory CFNB (cases) were discharged home on postoperative day (POD) 1 and 1 on POD 4. Of the controls, 3 were discharged home on POD 3, 6 on POD 4, and 1 on POD 5. The median (range) costs of hospitalization (excluding implant and professional fees) was US dollars 5,292 (US dollars 4,326-US dollars 7,929) for ambulatory cases compared with US dollars 7,974 (US dollars 6,931-US dollars 9,979) for inpatient controls (difference = US dollars 2,682, 34% decrease, P < .001). The total charges for hospitalization, the implant, and professional fees was US dollars 33,646 (US dollars 31,816-US dollars 38,468) for cases compared with US dollars 39,100 (US dollars 36,096-US dollars 44,098) for controls (difference = US dollars 5,454, 14% decrease, P < .001).This study provides evidence that ambulatory CFNB for selected patients undergoing TKA has the potential to reduce hospital length of stay and associated costs and charges. However, the current study has significant inherent limitations based on the study design. Additional research is required to replicate these results in a prospective, randomized, controlled trial and to determine whether any savings exceed additional CFNB costs such as from complications, having caregivers provide care at home, and additional hospital/health care provider visits.

  View details for DOI 10.1016/j.rapm.2006.10.010

  View details for Web of Science ID 000243311100009

  View details for PubMedID 17196492

  View details for PubMedCentralID PMC1986758

• Scheduling elective pediatric procedures that require anesthesia: The perspective of parents ANESTHESIA AND ANALGESIA Mariano, E. R., Chu, L. F., Ramamoorthy, C., Macario, A. 2006; 103 (6): 1426-1431

  Abstract

  Daily variability in volume of elective pediatric procedures that require anesthesia may lead to an imbalance between available operating room resources and case load. Longer intervals between scheduling and the surgical date generally result in higher operating room utilization. In this study, we sought to determine which factors influence when parents schedule their children for procedures. We also aimed to identify parents' ideal and longest acceptable waiting intervals and determine whether type of procedure, for example, affects scheduling. From a convenience sample of 250 randomly selected parents of children presenting for elective surgery, 236 completed surveys were analyzed. The remaining 14 surveys were not returned. Overall, parents scheduled their child's procedure a median of 4.3 wk (interquartile range 2.0-8.6) in advance and reported an ideal waiting interval of 3 wk (interquartile range 2-4), and longest acceptable interval of 6 wk (interquartile range 4-10). Parents were willing to wait longer to schedule cardiac (4 wk, P = 0.004) and plastic (3.5 wk, P = 0.024) surgery when compared with general surgical procedures. Overall, parents ranked severity of the child's illness, earliest available time, and surgeon's suggested date as the three most important factors influencing when their child's surgery is scheduled. The timetable for scheduling procedures was highly correlated with both mother and father having available time off work (tau(b) = 0.72, P < 0.0001). Surprisingly, parents did not show a preference for scheduling cases during vacation or summer months.

  View details for DOI 10.1213/01.ane.0000244596.03605.3e

  View details for Web of Science ID 000242289100019

  View details for PubMedID 17122217

• Successful thoracoscopic repair of esophageal atresia with tracheoesophageal fistula in a newborn with single ventricle physiology ANESTHESIA AND ANALGESIA Mariano, E. R., Chu, L. F., Albanese, C. T., Ramamoorthy, C. 2005; 101 (4): 1000-1002

  Abstract

  A neonate with VACTERL association including tricuspid atresia was scheduled for thoracoscopic esophageal atresia with tracheoesophageal fistula (EA/TEF) repair and laparoscopic gastrostomy tube placement. In addition to standard noninvasive monitoring, arterial blood pressure, central venous pressure, and cerebral oxygen saturation were monitored. Gastric distension resulting from positive pressure ventilation prevented laparoscopic gastrostomy tube placement. Thoracoscopy with a CO2 insufflation pressure of 6 mm Hg at low flow (1 L/min) was well tolerated hemodynamically despite hypercarbia and cerebral oxygen saturation was maintained. Careful monitoring and good communication were critical to the safe management of this single ventricle patient during thoracoscopic EA/TEF repair.Esophageal and tracheoesophageal fistula in conjunction with single ventricle physiology carries a significant risk of mortality. We present the anesthetic management of a neonate with unpalliated tricuspid atresia who underwent thoracoscopic tracheoesophageal fistula repair.

  View details for DOI 10.1213/01.ANE.0000175778.96374.4F

  View details for Web of Science ID 000232115400011

  View details for PubMedID 16192508

• A comparison of three methods for estimating appropriate tracheal tube depth in children PEDIATRIC ANESTHESIA Mariano, E. R., Ramamoorthy, C., Chu, L. F., Chen, M., Hammer, G. B. 2005; 15 (10): 846-851

  Abstract

  Estimating appropriate tracheal tube (TT) depth following tracheal intubation in infants and children presents a challenge to anesthesia practitioners. We evaluated three methods commonly used by anesthesiologists to determine which one most reliably results in appropriate positioning.After IRB approval, 60 infants and children scheduled for fluoroscopic procedures requiring general anesthesia were enrolled. Patients were randomly assigned to one of three groups: (1) deliberate mainstem intubation with subsequent withdrawal of the TT 2 cm above the carina ('mainstem' method); (2) alignment of the double black line marker near the TT tip at the vocal cords ('marker' method); or (3) placement of the TT at a depth determined by the formula: TT depth (cm) = 3 x TT size (mmID) ('formula' method). TT tip position was determined to be 'appropriate' if located between the sternoclavicular junction (SCJ) and 0.5 cm above the carina as determined by fluoroscopy. Risk ratios were calculated, and data were analysed by the chi-square test accepting statistical significance at P < 0.05.The mainstem method was associated with the highest rate of appropriate TT placement (73%) compared with both the marker method (53%, P = 0.03, RR = 1.56) and the formula method (42%, P = 0.006, RR = 2.016). There was no difference between the marker and formula methods overall (P = 0.2, RR = 1.27). Analysis of age-stratified data demonstrated higher success with the marker method compared with the formula method for patients 3-12 months (P = 0.0056, RR = 4.0).Deliberate mainstem intubation most reliably results in appropriate TT depth in infants and children.

  View details for DOI 10.1111/j.1460-9592.2005.01577.x

  View details for Web of Science ID 000232471900005

  View details for PubMedID 16176312

• Anesthetic management of infants with palliated hypoplastic left heart syndrome undergoing laparoscopic Nissen fundoplication ANESTHESIA AND ANALGESIA Mariano, E. R., Boltz, M. G., Albanese, C. T., Abrajano, C. T., Ramamoorthy, C. 2005; 100 (6): 1631-1633

  Abstract

  The safety of laparoscopic surgery in infants with single ventricle physiology has been a subject of controversy despite potential benefits over open surgery. We present the anesthetic management of five infants with palliated hypoplastic left heart syndrome that underwent laparoscopic Nissen fundoplication. After anesthetic induction and tracheal intubation, an intraarterial catheter was placed for hemodynamic monitoring. Insufflation pressure was limited to 12 mm Hg and was well tolerated by all patients. There were no intraoperative or postoperative complications. In patients with hypoplastic left heart syndrome, laparoscopic Nissen fundoplication can be safely performed with careful patient selection and close intraoperative monitoring.

  View details for DOI 10.1213/01.ANE.0000149899.03904.3F

  View details for Web of Science ID 000229305600013

  View details for PubMedID 15920186

• Anesthetic concerns for robot-assisted laparoscopy in an infant ANESTHESIA AND ANALGESIA Mariano, E. R., Furukawa, L., Woo, R. K., Albanese, C. T., Brock-Utne, J. G. 2004; 99 (6): 1665-1667

  Abstract

  A 2-mo-old infant with biliary atresia was scheduled for laparoscopic Kasai with robot assistance. Before surgery, a practice trial maneuvering the cumbersome robotic equipment was performed to ensure rapid access to the patient in case of emergency. IV access, tracheal intubation, and arterial line placement followed inhaled anesthesia induction with sevoflurane. Robotic setup took 53 min and severely limited patient access. No adverse events occurred during the procedure requiring the removal of the robotic equipment, and the patient was discharged after a stable postoperative recovery. Advance preparation is required to maximize patient safety during robotic surgery.

  View details for DOI 10.1213/01.ANE.0000137394.99683.66

  View details for Web of Science ID 000225341600016

  View details for PubMedID 15562050