CAP Profiles

Bio

Bio

After graduating from Georgetown University School of Medicine, I completed my anesthesiology residency and pediatric anesthesiology fellowship at Stanford University Medical Center and Lucile Packard Children's Hospital with emphases on clinical investigation and regional anesthesia and perioperative pain management for children.

I joined the Department of Anesthesiology at the University of California, San Diego, in 2004, where I started UCSD’s current training program in Regional Anesthesia and earned my Masters Degree in clinical research. I served as Division Chief of Regional Anesthesia and Acute Pain Medicine until 2010. The UCSD Regional Anesthesia Fellowship that I founded was the first fellowship in this subspecialty in California recognized by the American Society of Regional Anesthesia and Pain Medicine.

In 2010, I returned to the Stanford community to serve as Chief of the Anesthesiology and Perioperative Care Service at the Veterans Affairs Palo Alto Health Care System.

My clinical research interests include the development of techniques and patient care pathways to improve postoperative pain control and other surgical outcomes in adults and children. I am particularly interested in regional anesthesia, the specific application of local anesthetics and adjuvants at the site of peripheral nerves, in the context of producing target-specific pain relief. You can follow me on Twitter (@EMARIANOMD).

Clinical Focus

  • Anesthesia
  • Regional Anesthesiology and Acute Pain Medicine

Academic Appointments

Administrative Appointments

  • Chief, Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System (2010 - Present)
  • Associate Chief of Staff, Inpatient Surgical Services, VA Palo Alto Health Care System (2013 - Present)

Honors & Awards

  • Resident of the Year, Department of Anesthesia; Stanford University (2003)
  • Teacher of the Year, Department of Anesthesiology; University of California, San Diego (2005)
  • Health Care Champion, San Diego Business Journal (2007)
  • Top "40 Under 40" in San Diego, San Diego Metropolitan Magazine (2007)
  • Special Service Award, Department of Anesthesiology; University of California, San Diego (2010)
  • 2012 Distinguished Visiting Professor in Anesthesiology, Hospital for Special Surgery (2012)
  • 2012 Dr. Benigno Sulit, Jr. Memorial Lecturer, Philippine Society of Anesthesiologists (2012)
  • Best of Meeting Abstract, 2013 Spring Annual Meeting, American Society of Regional Anesthesia and Pain Medicine (2013)
  • Best of Meeting Abstract, 2014 Spring Annual Meeting, American Society of Regional Anesthesia and Pain Medicine (2014)
  • John D. Chase Award for Executive Excellence, Veterans Health Administration (2015)

Boards, Advisory Committees, Professional Organizations

  • Editorial Board, Journal of Cardiothoracic and Vascular Anesthesia (2008 - Present)
  • Editor-in-Chief, American Society of Regional Anesthesia and Pain Medicine News (2012 - 2015)
  • Editorial Board, Regional Anesthesia and Pain Medicine (2009 - Present)
  • Editorial Board, Seminars in Cardiothoracic and Vascular Anesthesia (2011 - Present)
  • Vice-Speaker, California Society of Anesthesiologists (2014 - Present)
  • Board of Directors, American Society of Regional Anesthesia and Pain Medicine (2015 - Present)

Professional Education

  • Board Certification: Pediatric Anesthesia, American Board of Anesthesiology (2013)
  • Board Certification: Anesthesia, American Board of Anesthesiology (2004)
  • Medical Education:Georgetown University (1999) DC
  • Fellowship:Stanford University (2004) CA
  • Residency:Stanford Medical Center - Anesthesia (2003) CA
  • Internship:Georgetown/NOVA Fairfax Hospital (2000) VA
  • Doctor of Medicine, Georgetown University School of Medicine, Medicine (1999)
  • Internship, Georgetown University / INOVA Fairfax Hospital, Transitional (2000)
  • Residency, Department of Anesthesia; Stanford University, Anesthesiology (2003)
  • Fellowship, Department of Anesthesia; Stanford University / Lucile Packard Children's Hospital, Pediatric Anesthesiology (2004)
  • Masters in Advanced Studies, University of California, San Diego, Clinical Research (2008)

Community and International Work

  • Volunteer Medical-Surgical Mission, Ecuador

    Topic

    Pediatric anesthesiology and postoperative pain management in developing countries

    Partnering Organization(s)

    Project Perfect World (PPW)

    Populations Served

    Underserved children

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

  • Volunteer Medical-Surgical Mission, Philippines

    Topic

    Pediatric anesthesiology and postoperative pain management in developing countries

    Partnering Organization(s)

    Philippine-American Group of Educators and Surgeons (PAGES)

    Populations Served

    Underserved children

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    No

Contact

  • Ana Hammons Administrative Officer
    • Tel: (650) 858-3938
  • VA Palo Alto Health Care System 3801 Miranda Ave Ste 112A Anesthesia Dept Palo Alto, CA94304
    • Tel: (650) 849-0254
    Fax: (650) 852-3423

Links

Research & Scholarship

Current Research and Scholarly Interests

My clinical research interests include the development of techniques and patient care pathways to improve postoperative pain control and other surgical outcomes for patients of all ages. I have published over 100 peer-reviewed articles and book chapters primarily in these research areas. Most of my work has centered around the application of continuous peripheral nerve blocks (also known as "perineural catheters") to provide target-specific pain relief after surgery in the form of extended-duration local anesthetic infusions. In 2007, I published a case-control study investigating the use of continuous femoral nerve blocks on an outpatient basis compared to the same therapy performed in-hospital in terms of hospitalization costs. This study is widely-referenced by other investigators interested in perioperative management and health-care cost-containment. In the subsequent years, I have either led, as principal investigator, or participated in, as co-investigator, multiple randomized clinical trials involving orthopedic patients. For joint arthroplasty in particular, I have been a co-investigator on 3 randomized clinical trials, including one multi-center study, evaluating the use of local anesthetic perineural infusion in knee and hip arthroplasty patients to decrease time to discharge eligibility. In these 3 studies, discharge eligibility was determined by pain scores, need for intravenous opioids for analgesia, and ambulation distance achieved; in all 3 studies, continuous local anesthetic was found to be superior to placebo infusion. More recently, I have investigated variations in local anesthetic regimen for perineural infusion and innovative catheter placement techniques, such as the use of ultrasound guidance. My studies on local anesthetic infusion concentration have shown that dose is the predominant factor influencing perineural infusion effects, and the resulting numbness (motor block) varies among anatomic sites. I have published several randomized clinical trials and case series establishing ultrasound guidance as an effective and efficient technique for perineural catheter insertion in adults and children. In 5 clinical studies, I have shown that ultrasound facilitates faster perineural catheter insertion with higher success rates compared to traditional techniques (e.g., electrical stimulation). The application of ultrasound to identify anatomic variability is critical to accurate placement of these catheters and their subsequent infusion effects.

My current ongoing research projects involve simulation-based training of anesthesiologists in ultrasound-guided perineural catheter techniques (funded previously by a grant from the Foundation for Anesthesia Education and Research), the use of perineural infusion in the treatment of intractable phantom limb pain (a multi-center grant awarded by the Department of Defense), preclinical and clinical studies evaluating perineural catheter equipment and placement methods, and the analyses of large databases within VA to maximize the benefits and minimize the side effects of anesthetic and surgical interventions in the acute care setting.

Clinical Trials

  • Simulation-Based Training for Ultrasound-Guided Perineural Catheter Insertion Recruiting

    This study will determine the efficacy of a teaching program incorporating hybrid simulation in training practicing anesthesiologists on ultrasound (US)-guided continuous peripheral nerve block (CPNB). This study will also examine the extent of practice change following participation in a regional anesthesia teaching program incorporating hybrid simulation. In addition, this study will assess remaining obstacles to incorporating the use of US-guided perineural catheters through identifying potential future interventions and "tool-kits" for setting up perineural catheter programs.

    View full details

  • Follow-Up Study to Assess Implementation of Ultrasound-Guided Regional Anesthesia Skills Recruiting

    The investigators hope to survey anesthesiologists who have participated in a non-CME regional anesthesia workshop at VAPAHCS over the past 4 years on the number and types of nerve block procedures that they performed, nerve localization method (e.g., ultrasound, electrical stimulation, or both), and whether the nerve blocks performed were single-injection or catheter-based.

    View full details

  • Optimizing Catheter Insertion Technique for Ultrasound-guided Continuous Peripheral Nerve Blocks Recruiting

    Continuous peripheral nerve blocks (CPNB; also known as "perineural" catheters) provide target-specific pain control for a variety of surgeries. There has been increasing interest in the use of ultrasound guidance for regional anesthesia, and many techniques using ultrasound alone for perineural catheter insertion have been described. Catheters may be placed at various points along the brachial plexus (for upper extremity procedures) or in proximity to the femoral and/or sciatic nerve (for lower extremity procedures). To date, the optimal ultrasound scanning technique, catheter insertion endpoint, catheter placement location per indication, for the majority of ultrasound-guided continuous peripheral nerve blocks remain unknown. This study will help provide important information related to optimal ultrasound scanning techniques and will help identify ways to improve the success rates, onset times, and analgesic effectiveness of these techniques for real patients undergoing surgical procedures.

    View full details

  • Treating Phantom Limb Pain Using Continuous Peripheral Nerve Blocks: A Department of Defense Funded Multicenter Study Recruiting

    When a limb is traumatically severed, pain perceived in the part of the body that no longer exists often develops. This is called "phantom limb" pain, and is different from "stump" pain, which is pain within the part of the limb that remains intact. Unfortunately, phantom pain resolves in only 16% of people, with the rest experiencing this pain for the remainder of the lives. There is currently no reliable treatment for phantom limb pain. The exact reason that phantom limb pain occurs is unclear, but when a nerve is cut—as happens with a traumatic amputation—changes occur in the brain and spinal cord that actually worsen with increasing phantom pain. These abnormal changes may often be corrected by putting local anesthetic—termed a "peripheral nerve block"—on the injured nerve, keeping any "bad signals" from reaching the brain, with resolution of the phantom limb pain. However, when the nerve block ends after a few hours, the phantom pain returns. But, this demonstrates that the brain abnormalities—and phantom pain—that occur with an amputation may be dependent upon the "bad" signals being sent from the injured nerve(s), suggesting that a very long peripheral nerve block—lasting many days rather than hours—may permanently reverse the abnormal changes in the brain, and provide lasting relief from phantom pain. Until recently, extending a peripheral nerve block beyond 16 hours was unrealistic. However, a treatment option called a "continuous peripheral nerve block" is now available. This technique involves the placement of a tiny tube—smaller than a piece of spaghetti—through the skin and next to the nerves supplying the amputated limb. The tiny tube may be placed with minimal discomfort in about 15 minutes. Numbing medicine called local anesthetic is then infused through the tube, blocking any signals that the injured nerve sends to the spinal cord and brain. Using a small, portable infusion pump, this prolonged nerve block may be provided in individuals' own homes. The ultimate objective of the proposed research study is to determine if a 6-day continuous peripheral nerve block provided at home is an effective treatment for persistent phantom limb pain following a traumatic limb amputation. The primary hypothesis (what the researchers predict) is that phantom limb pain intensity will be significantly decreased 4 weeks following treatment with a 6-day continuous peripheral nerve block.

    View full details

Teaching

2016-17 Courses

Graduate and Fellowship Programs

Publications

All Publications

  • 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

  • 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

  • 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

  • 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

  • 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

    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

  • 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 : official journal of the American Institute of Ultrasound in Medicine Lam, N. C., Baker, E. B., Fishburn, S. J., Hammer, A. R., Petersen, T. R., Mariano, E. R. 2016

    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 PubMedID 27246662

  • Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. Pain medicine (Malden, Mass.) 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

    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

  • 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

  • Availability and Readability of Online Patient Education Materials Regarding Regional Anesthesia Techniques for Perioperative Pain Management. Pain medicine (Malden, Mass.) 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 DOI 10.1093/pm/pnw179

    View details for PubMedID 27485090

  • 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 DOI 10.1097/ACM.0000000000001187

    View details for PubMedID 27218903

  • 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 Web of Science ID 000362622800021

    View details for PubMedID 26384608

  • 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

  • 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

  • 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

  • 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 Web of Science ID 000357281100027

  • 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 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

  • 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

  • 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 Web of Science ID 000348887900017

  • 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): 1163-6

    View details for DOI 10.1213/ANE.0000000000000712

    View details for PubMedID 25899279

  • Development of technologies for placement of perineural catheters. Journal of anesthesia Elsharkawy, H., Maheshwari, A., Farag, E., Mariano, E. R., Rosenquist, R. W. 2015

    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

  • 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

  • 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 Web of Science ID 000346240300009

  • 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

  • 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

    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 Web of Science ID 000341405300018

    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

  • 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

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

    View details for Web of Science ID 000359039000002

  • 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 Web of Science ID 000334180400008

  • 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

  • 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

    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. 2014; 120 (3): 530-2

    View details for DOI 10.1097/ALN.0000000000000121

    View details for PubMedID 24534851

  • Editorial comment: ultrasound-guided peripheral nerve blocks for ventricular shunt revision in children. A & A case reports Mariano, E. R. 2014; 3 (12): 160-1

    View details for DOI 10.1213/XAA.0000000000000101

    View details for PubMedID 25612198

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

    View details for DOI 10.1016/j.anclin.2014.09.001

    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

  • 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-E38

    View details for DOI 10.1097/AJP.0b013e3182971887

    View details for Web of Science ID 000329937400001

  • Choice of loco-regional anesthetic technique affects operating room efficiency for carpal tunnel release JOURNAL OF ANESTHESIA Mariano, E. R., Lehr, M. K., Loland, V. J., Bishop, M. L. 2013; 27 (4): 611-614

    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

  • 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

  • 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 ?-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 ?-blockers, and 212 were not taking ?-blockers. The two groups were comparable across baseline patient factors (ie, demographic, morphometric, surgical duration, and surgical procedures) and induction medication doses. The ?-blocker group experienced a lower maximal heart rate during the induction of general anesthesia compared with the non-?-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 ?-blockers (? = -11.1 beats/min, p < 0.01). There was no difference between groups in total intraoperative ?-blocker administration.Preoperative ?-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 ?-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

  • 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

  • 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

  • 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

  • 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

  • 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 Transversus Abdominis Plane Catheters and Ambulatory Perineural Infusions for Outpatient Inguinal Hernia Repair Heil, J. W., Ilfeld, B. M., Loland, V. J., Sandhu, N. S., Mariano, E. R. LIPPINCOTT WILLIAMS & WILKINS. 2010: 556-558

    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

  • 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) ?g 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

  • 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

  • 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

  • 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

  • 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

  • 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 ANESTHESIA AND ANALGESIA 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. 2009; 109 (2): 586-591

    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

  • Bilateral infraorbital nerve blocks decrease postoperative pain but do not reduce time to discharge following outpatient nasal surgery CANADIAN JOURNAL OF ANAESTHESIA-JOURNAL CANADIEN D ANESTHESIE Mariano, E. R., Watson, D., Loland, V. J., Chu, L. F., Cheng, G. S., Mehta, S. H., Maldonado, R. C., Ilfeld, B. M. 2009; 56 (8): 584-589

    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

  • Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia JOURNAL OF CLINICAL ANESTHESIA Mariano, E. R., Chu, L. F., Peinado, C. R., Mazzei, W. J. 2009; 21 (4): 253-257

    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

  • 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

  • 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 ANESTHESIA AND ANALGESIA 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. 2009; 108 (4): 1320-1325

    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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • 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

  • "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

  • 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 Web of Science ID 000245371900010

    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

  • 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