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.
Acetaminophen ; Acute Pain ; Analgesia* ; Analgesics ; Analgesics, Opioid ; Anesthesia, Conduction ; Anesthetics, Local ; Checklist ; Humans ; Ketamine ; Pain Management* ; Perioperative Period ; Prevalence ; Specialization

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 the resolution of ileus or time to mobilization. However, the recent expansion in the number and types of nerve block approaches can be daunting for general anesthesiologists. 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 patient's needs, and incorporating patient, surgical, and social factors. This review provides a framework for a personalized approach to postoperative pain management with an emphasis on regional anesthesia techniques.

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
Anesthesia, Conduction ; Anesthesiology ; Cadaver* ; Catheters* ; Dislocations* ; Exercise ; Humans ; Knee ; Male ; Nerve Block ; Peripheral Nerves ; Range of Motion, Articular ; Sciatic Nerve ; Ultrasonography

BACKGROUND: The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. METHODS: With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. RESULTS: Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the 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]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. CONCLUSIONS: Within a multimodal analgesic protocol, addition of IPACK blocks decreased the 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.
Analgesia ; Arthroplasty, Replacement, Knee ; Catheters ; Ethics Committees, Research ; Humans ; Knee ; Length of Stay ; Popliteal Artery ; Retrospective Studies ; Walking

BACKGROUND: The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. METHODS: With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. RESULTS: Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the 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]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. CONCLUSIONS Within a multimodal analgesic protocol, addition of IPACK blocks decreased the 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.

BACKGROUND: 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). METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
Analgesia ; Anesthesia, Conduction ; Anesthesia, Spinal ; Arthroplasty ; Arthroplasty, Replacement, Hip* ; Body Mass Index ; Catheters* ; Critical Pathways* ; Electronic Health Records ; Fascia* ; Hip ; Humans ; Linear Models ; Morphine ; Nerve Block ; Peripheral Nerves ; Pruritus ; Quadriceps Muscle ; Rehabilitation ; Ultrasonography ; Walking

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: VR distraction may provide an effective nonpharmacological alternative to intravenous sedation for the ultrasound-guided placement of certain perineural catheters.
Acute Pain ; Analgesics, Opioid ; Anesthesia, Conduction ; Anesthesiology ; Arthroplasty, Replacement, Knee ; Blood Pressure ; Catheters* ; Fentanyl ; Humans ; Methods ; Midazolam ; Quality Improvement ; Retrospective Studies* ; Ultrasonography

BACKGROUND: 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. METHODS: 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. RESULTS: Data from 94 subjects were included (femoral subjects, n = 46; adductor canal subjects, n = 48). Adductor canal patients reported decreased numbness (median [10th-90th 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 R2 = 0.1. CONCLUSIONS: 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.
Arthroplasty* ; Body Mass Index ; Catheters* ; Cohort Studies ; Early Ambulation ; Femoral Nerve ; Humans ; Hypesthesia* ; Knee* ; Linear Models ; Nerve Block* ; Quadriceps Muscle ; Retrospective Studies ; Walking*

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Participation in a 1 day simulation-based UGRA course may increase UGRA procedural volume by practicing anesthesiologists.
Anesthesia, Conduction* ; Catheters ; Education ; Follow-Up Studies ; Lectures ; Manikins ; Nerve Block ; Teaching ; Ultrasonography

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: Based on this simulation study, using an anchoring device may help prevent perineural catheter dislodgement and therefore premature disruption of continuous nerve block analgesia.
Adhesives ; Analgesia ; Anesthesia, Conduction ; Bandages* ; Cadaver ; Catheters* ; Humans ; Nerve Block ; Peripheral Nerves* ; Research Personnel ; Thigh