In Press Articles

Evaluation of a Point-of-Care Ultrasound (POCUS) training course for Regional Anesthesiologists – A Single Institution’s Experience

Alex K. Saltzman¹, Thuyvan H. Luu¹, Nicole Brunetti¹, James D. Beckman^1,2, Mary J. Hargett¹, Stephen C. Haskins^1,2*

¹Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, USA

²Department of Anesthesiology, Weill Cornell Medicine, New York, USA

Background and Objectives: Point-of-care ultrasound (POCUS) in the form of focused cardiac ultrasound (FOCUS) is a powerful clinical tool for anesthesiologists to supplement bedside evaluation and optimize cardiopulmonary resuscitation in the perioperative setting. However, few courses are available to train physicians. At Hospital for Special Surgery (HSS), from March of 2013 to May of 2016, nine basic Focused Assessed Transthoracic Echocardiography (FATE) training courses were held. A large percentage of the participants were practicing regional anesthesiologists or trainees in fellowship for regional anesthesia and acute pain. In this study, a survey was used to assess clinical utilization as well as potential barriers to use for regional anesthesiologists.

Methods: Following IRB approval, 183 past participants of the basic FATE training course were contacted weekly from November 22^nd, 2016, through January 3^rd, 2017, via email and sent a maximum 40-item electronic survey hosted on REDCap. Responses were analyzed by a blinded statistician.

Results: 92 participants responded (50%), and 65 of the 92 (70.7%) indicated they had regional anesthesiology training or practice regional anesthesia regularly. Of the total number of respondents, 50% (95% CI: 40.3%, 59.8%; P-value = 0.001) have used FOCUS to guide clinical decision making. Of the regional anesthesiologists, 27 (45.8%) have used FOCUS to guide clinical decision making with left ventricular function assessment (40.7%) and hypovolemia (39.0%) being the most common reasons. Regional anesthesiologists utilized FOCUS in the following settings: preoperatively (44.6%), intraoperatively (41.5%), postoperatively (41.5%), and in the Intensive Care Unit (40.0%). Limitations were due to lack of opportunities (52.3%), resources (36.9%), and comfort with performance (30.8%). 84.4% agreed that basic FOCUS training should be a required part of anesthesia residents or fellows’ curriculum.

Conclusions: This study is the first formal evaluation of the impact of the implementation of a FOCUS training course on regional anesthesiologists’ current practice. Nearly 50% of regional anesthesiologists used FOCUS to guide clinical decision-making following formal training. The limitations to the use of FOCUS were a lack of relevant opportunities and resources. This evaluation of clinical use following training provides insight into how FOCUS is used by regional anesthesiologists and the limitations to implementation in the perioperative setting.

Achieving pain control with opioid-sparing multimodal analgesic strategy – doing more with less by enhanced recovery after thoracic surgery protocol: A Review

Joanne Szewczyk, Benjamin H Nguyen, Nestor Villamizar, Dao M. Nguyen*

Section of Thoracic Surgery, Department of Surgery, University of Miami, Miami, Florida, USA

In the last decade, the implementation of enhanced recovery protocol for patients undergoing thoracic surgical procedures, either by thoracotomy or thoracoscopy, has gained significant recognition. Such protocols have been developed following the enhanced recovery after surgery (ERAS) guiding principles, yet have been tailored with attention to the unique nuances of thoracic surgical patients. Over the last 5 years, a body of literature has been published attesting to the success of the enhanced recovery after thoracic surgery (ERATS) protocol, with reported improvements of measurable outcome metrics. This mini-review focuses on postoperative pain control using the innovative strategy of opioid-sparing multimodal analgesics of the ERATS care pathway.

Lessons Learned: Inpatient Telepalliative Medicine Consultations during COVID-19 Pandemic

Jessi Humphreys*, Laura Schoenherr

Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, USA

As the COVID-19 pandemic proceeds, systems continue to struggle with the need to decrease provider exposure and minimize personal protective equipment use while maintaining high quality patient care. The reduced visitation capacity in hospitals has resulted in high levels of patient and family suffering, and patients both with and without COVID-19 require expert symptom management and goals of care conversations. A manuscript was published describing the rapid implementation of telepalliative medicine consultation by the Inpatient Palliative Care team at UCSF in attempts to meet these critical patient and family needs. This piece details additional lessons learned that were inadequately addressed in the original manuscript and/or that have been revealed in the months since the program’s inception. Key learning points include the need for: committed investment in effective hardware and software; communication skills adapted to effectively utilize technology to benefit patients and families; creative workforce models to render technology effective; interdisciplinary input in care models to reduce provider as well as patient and family suffering; and attention to burdens placed on already overstretched nurses and intensivists during respiratory pandemics.

Myogenous Orofacial Pain Disorders: A Retrospective Study

Erick Gomez-Marroquin¹, Yuka Abe^1,2, Mariela Padilla¹*, Reyes Enciso³, Glenn T. Clark¹

¹Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA

²Department of Prosthodontics, Showa University School of Dentistry, Tokyo, Japan. Visitor Scholar Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA

³Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry of University of Southern California, Los Angeles, California, USA

Aim: To assess treatment efficacy in the management of orofacial myogenous conditions by a retrospective study of patients seen at an orofacial pain clinic.

Methods: A single researcher conducted a retrospective review of charts of patients assigned to the same provider, to identify those with myogenous disorders. The reviewed charts belonged to patients of the Orofacial Pain and Oral Medicine Center of the University of Southern California, seeing from June 2018 to October 2019.

Results: A total of 129 charts included a myogenous disorder; the most common primary myogenous disorder was localized myalgia (58 cases, 45.0%). Arthralgia was the most common TMD concomitant condition (82.9%), followed by internal derangement (41.9%). Forty-six patients were given a home-based conservative physical care protocol; ten additional cases also received trigger point injections (lidocaine or mepivacaine) with pain assessed by verbal numerical rating scale (NRS), pre- and post-treatment follow-up within 24 weeks. There was a significant overall pain improvement in NRS pain from pre- to post-treatment (p<0.001), though no difference was found between conservative treatment and trigger points in NRS pain (p=0.130). However, the rate of NRS unit improvement per week in the conservative treatment group was significantly greater than the trigger point group (p=0.036). These apparently contradictory results might be due to the small sample size of the trigger point injections group (n=10).

Conclusion: In this small sample size study, the addition of trigger point injections to conservative treatment provided inconclusive results, further studies are needed.

Persistent pain as an indicator of infection from low virulence organisms compared to serological inflammatory markers

Naveen Manchal

The Prince Charles Hospital, Brisbane, James Cook University, Australia

Review of Trigger Point Therapy for the Treatment of Myofascial Pain Syndromes

Kimberly Ting¹, Albert Huh¹, Carlos J. Roldan^1,2*

¹Department of Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA

²McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Houston, Texas, USA

Scope of the investigation: No standard protocol has been established for the treatment of myofascial pain syndrome (MPS). Invasive therapies such as dry needling and trigger point injection (TPI) with active pharmacological agents are commonly used. Growing evidence suggests the efficacy of TPI is independent of the injectate selected. Normal saline (NS) solution has been described as an efficient injectate used in TPI for the treatment of MPS.

Methods: A broad literature search was performed to compare the use of NS and other pharmacological agents as the injectate in TPI for the treatment of MPS.

Results: We identified 13 reports comparing the safety and efficacy of NS with that of botulinum toxin A or local anesthetic with or without steroid in TPI.

Conclusion: Pain of myofascial origin can be adequately treated with TPI independent of the injectate used. The use of NS in TPI offers lower cost, safety, and a more favorable side effect profile than other TPI injectates.

Core Decompression with Bone Marrow Stem Cells for Osteonecrosis of Femoral Head

Fariba Farrokhi¹, Sneha Priyadarshini Honnabovi¹, Marisa Pavone¹, Kamal AL-Eryani², Oussama Abousamra³, Reyes Enciso^4*

¹Advanced graduate, Master of Science Program in Orofacial Pain and Oral Medicine, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

²Assistant Professor of Clinical Dentistry, Division of Periodontology, Diagnostic Sciences & Dental Hygiene, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

³Assistant Professor of Clinical Orthopaedic Surgery, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA

⁴Associate Professor – Instructional, Division of Dental Public Health and Pediatric Dentistry, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, CA, USA

The authors conducted a systematic review and meta-analysis to determine if Core Decompression (CD) with Bone Marrow Stem Cells (BMSC) is more effective in treating Osteonecrosis of the Femoral Head (ONFH) compared to CD. Authors used Cochrane Library, EMBASE, PubMed, Web of Science, and hand-searched references through January 2020, identifying relevant randomized controlled trials (RCTs). Risk of bias was assessed with Cochrane's handbook. Fifty-four abstracts were screened, and eight RCTs (five at high and three at unclear risk of bias) with 432 patients were included. Meta-analyses found statistically significant improvement in Harris Hip Score (HHS) at 12 months (Difference in Means [DM]=10.065;95% Confidence Interval [CI]=4.509 to 15.622; p<0.001) and pain intensity at 24 months (DM=-7.364;95% CI=-12.113 to -2.615;p=0.002) in CD+BMSC group compared to CD alone although these results may not be clinically significant. Risk of Total Hip Replacement (THR) in patients receiving CD+BMSC was 33.4% lower than in CD group though not significant (RR=0.666; 95% CI=0.355 to 1.250;p=0.206). Though meta-analyses found the addition of BMSC to CD significantly improves clinical outcomes (HHS and pain intensity) compared to CD only, evidence was of moderate/low quality due to high risk of bias, imprecision, and small sample sizes. Further research is needed to confirm the results.

A Mini-Review of the BAPM Framework for Practice – Perinatal Management of Extreme Preterm Birth before 27 Weeks of Gestation

Joanna R. O'Sullivan^*, Nicola Crowley

Guys and St Thomas's NHS Foundation Trust, UK

The recent publication of a new framework for practice from the British Association of Perinatal Medicine has altered the management of babies born in the UK at the threshold of viability. A risk stratification is used to determine which infants will receive active management, and which receive palliative management. This is achieved through a combination of assessment of risk factors and discussion with parents. The most notable feature of the new framework is the recommendation to consider babies of 22 weeks gestation for active care. This has been the subject of much discussion amongst neonatal and obstetric teams. The framework also emphasises the importance of early transfer to a maternity unit with a co-located neonatal intensive care unit if active management is pursued. This new guidance has led to a change in the way the management of extreme prematurity is approached, and will continue to impact on neonatal, obstetric, and anaesthetic care.