Download ASRA News, Volume 14, Issue 4, pp 5-8,22

A publication of the American Society of Regional Anesthesia and Pain Medicine
In This Issue
How I Do It: Ultrasound-Guided
Bilateral Rectus Sheath Blocks – see page 5
Regional Anesthesia and
Obstructive Sleep Apnea – see page 11
Ultrasound Gel Infection
Control Practices – see page 15
Advancing the Science and Practice of Regional Anesthesia and Pain Medicine
Table of Contents
President’s Message________________________________ 2
Editorial__________________________________________ 3
The Passing of ASRA Founding Father, Dr. Jordan Katz______ 4
How I Do It: Ultrasound-Guided Bilateral
Rectus Sheath Blocks _______________________________ 5
PRO/CON: Sacral Lateral Branch Blocks are the
Diagnostic Test of Choice for Screening Patients
for Sacroiliac Joint Radiofrequency Ablation______________ 9
Regional Anesthesia and Obstructive Sleep Apnea________ 11
Changes in Payment for Interventional Pain
Physicians, 2014 and Beyond ________________________ 13
A Case for the Continued Importance of
Continuous Peripheral Nerve Block Catheters _ __________ 14
Ultrasound Gel: Do Not Forget the Importance of
Appropriate Infection Control Practices ________________ 15
Editor
Edward R. Mariano, M.D., M.A.S.
Newsletter Committee
Steven Orebaugh, M.D. (Regional Anesthesia Lead)
Kevin Vorenkamp, M.D. (Pain Medicine Lead)
Magdalena Anitescu, M.D., Ph.D.
Melanie Donnelly, M.P.H., M.D.
Nabil Elkassabany, M.D.
Brian Harrington, M.D.
Andrea Nicol, M.D.
Maunak Rana, M.D.
Resident Section
Anish Doshi, M.D.
Foreign Corresponding
Michael Barrington, M.D.
Jose de Andres, M.D.
Officers
President: Joseph M. Neal, M.D.
President-Elect: Oscar A. De Leon Casasola, M.D.
Treasurer: Asokumar Buvanendran, M.D.
Past President: Vincent W.S. Chan, M.D.
Executive Director: Angie Stengel, MS, CAE
Board of Directors
Honorio T. Benzon, M.D.
John Butterworth, M.D.
James Hebl, M.D.
Samer Narouze, M.D.
Colin McCartney, M.B., Ch.B., F.R.C.A.,
F.C.A.R.S.C.I., F.R.C.P.C.
Santhanam Suresh, M.D., F.A.A.P.
Eugene R. Viscusi, M.D.
Founding Fathers
L. Donald Bridenbaugh, M.D.
Harold Carron, M.D. (Deceased)
Jordan Katz, M.D. (Deceased)
P. Prithvi Raj, M.D.
Alon P. Winnie, M.D.
American Society of Regional Anesthesia and Pain Medicine
239 Fourth Avenue, Suite 1714 • Pittsburgh PA 15222
phone toll free 855-795-ASRA • fax 412-471-7503 • www.asra.com
2
Copyright © 2012 American Society of Regional Anesthesia and Pain Medicine. All rights reserved.
Contents may not be reproduced without prior written permission of the publisher.
Article Title Message
President’s
Musings on Mission
Anyone who has been paying attention to the Society is aware that
these past two years have been a period of change, challenge,
and growth. The American Society of Regional Anesthesia and
Pain Medicine’s Board of Directors, meeting program chairs,
key committee members, and a handful of loyal and dedicated
management partners have lived these challenges first-hand and
have skillfully directed ASRA through what, at times, have been
turbulent waters. Rightly so, people often focus on the changes that
disruption brings. However, reminiscing over the past few years I
realize how often, when faced with difficult decisions, the Board of
Directors kept coming back to the foundational elements of ASRA’s
primary mission – education and research. For your reference, the
Society’s mission and vision statements are, respectfully:
“To advance the science and practice of regional anesthesia and
pain medicine”
“To be the leader in regional anesthesia and acute and chronic pain
medicine through innovations in patient care and education, and
support of research”
will be ASRA’s impact over the
years? Indeed, the answer to
this question weaves together
the Society’s dual missions and
ultimately determines ASRA’s
impact over the next four decades.
Reinvestment of revenues realized
from our educational offerings –
primarily meeting registrations and
journal royalties – not only allow
the Society to innovate and enrich
the educational mission, but also
Joseph M. Neal, M.D.
ASRA President
generate the operating margin
that largely funds our research
mission. Responsible stewardship of ASRA’s finances requires
that the Board of Directors strike a balance between doing what
is necessary to support the mission and impact the future and do
so in a manner that does not unfairly burden our members’ and
supporters’ finances. Achieving this balance shapes our future and
should dominate a good portion of the Board of Directors’ strategic
discussions.
The Society’s mission and vision statements are, respectfully:
“To advance the science and practice of regional
anesthesia and pain medicine”
“To be the leader in regional anesthesia and acute and chronic pain medicine
through innovations in patient care and education, and support of research”
These declarations are in essence refined and adapted versions of
those principles that ASRA was founded upon nearly 40 years ago
– a primarily medical professional society dedicated to education
and research pertaining to regional anesthesiology and to acute
and chronic pain medicine. In the next few months, members will
observe dramatic changes to the public face of ASRA – a new
website, an expanded social media presence, transformation to
a three-day meeting format, and an entirely new management
structure. As these changes are assimilated into the fabric that
is ASRA, it is our sincerest wish that they be judged as welcome
enhancements to our core values of education and research.
What beyond high quality and contemporary educational offerings
The point of these musings is to share with the ASRA membership
that, despite enormous change and challenge over the past few
years, the Board and key leaders have guided the Society in a
manner true to its mission. The Society has fortunately made
modest profits recently, which have allowed us to revamp a grossly
outdated and inefficient website so as to optimize membership
services and better highlight our educational and research
offerings. Yet when faced with the possibility of adding certain
costly educational products to the website, the decision was
framed within the context of whether or not these additions added
commensurate value and member benefit. Another example of
mission-driven decision making applies to this newsletter. This is
the last ASRA News that you will receive in the mail. Future issues
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 4
2
Editorial
H
Edward R. Mariano, M.D., M.A.S.
Editor
Follow me on Twitter
@EMARIANOMD!
ere is it – the last print issue of
ASRA News. Based on member
feedback (see Dr. Neal’s column
in the February 2014 issue http://
www.asra.com/Newsletters/feb-14.
pdf), ASRA News will be transitioning
to an exclusively e-reader format
starting with the February 2015
issue. I want to thank the staff of our
current publisher, The Martin Group,
for the fantastic job they have done
in producing such a high quality print
newsletter during my term as Editor.
This issue is packed full of
outstanding original contributions.
To accompany his “How I Do It”
article on ultrasound-guided rectus sheath block, Dr. Francis Salinas
has provided supplemental videos posted on http://www.asra.com/
publications-newsletters.php. Just in time for the ultrasound in pain
medicine workshops at the 13th Annual Pain Medicine Meeting, we
feature an article on the infectious risks of non-sterile ultrasound gel
by Dr. Dave Provenzano, Chair of the Scientific/Education Planning
Committee. Other timely articles in this issue and related to the
Fall Meeting include a pro-con on the use of diagnostic sacral
lateral branch blocks for screening patients prior to sacroiliac
joint radiofrequency ablation by Drs. Nileshkumar Patel and Kevin
Vorenkamp and an update on changes in payment for interventional
pain physicians by Drs. Daniel Rothstein and Rick Rosenquist.
The latter article is extremely informative, and it reminds me how
fortunate we are to have Dr. Rosenquist representing our interests in
anesthesiology and pain medicine.
We have all heard the “doom and gloom” statistics about rising health
care spending, and maybe even some of them have begun to sink in
since the roll-out of the Affordable Care Act.
For many reasons, the federal government is working to curb health
care expenditures, but many of the processes currently attributed
to “Obamacare” have been in the works for a long time. As an
example, the Medicare Modernization Act of 2003 introduced the
Inpatient Prospective Payment System; this system encouraged
participating hospitals to voluntarily report performance data to avoid
payment reductions. The Deficit Reduction Act of 2005 went further
by mandating the development of what we now know as pay-forperformance or value-based purchasing (used interchangeably).
In 2012, the Institute of Medicine published “Best Care at
Lower Cost: the Path to Continuously Learning Health Care in
America.”1 In this report, Recommendation #9 refers to performance
transparency: making data related to “quality, prices and cost,
and outcomes of care” available to consumers. What does this
mean? Value-based purchasing in health care is supposed to
reward better value, patient outcomes, and innovations – instead
of just volume of services.2 It is funded by participating institutions
3
based on withholding a set percentage (1.25% currently) of their
estimated annual Diagnosis-Related Group (DRG) payments from
Center for Medicare and Medicaid Services (CMS). The percentage is
increasing every year and will be 2% by 2017.
For FY2014, the elements of value-based purchasing have been
updated3 to include the Clinical Process of Care Domain, Patient
Experience of Care Domain, and a new Outcomes Domain. The
amount that each of these domains contributes to the eventual
DRG payment return at the end of the year is 45%, 30%, and
25%, respectively. Scores in each domain are calculated based
on an institution’s improvement compared to its own historical
performance and a comparison against national benchmarks.3
How does this affect pain medicine? The Patient Experience
Domain is assessed using the Hospital Consumer Assessment of
Healthcare Providers and Systems (HCAHPS) survey. HCAHPS consists
of 32 questions, publicly reports its results 4 times a year on http://
www.hospitalcompare.hhs.gov, and contains 7 questions that directly
or indirectly relate to pain. On the inpatient side, an acute pain service adds value through cost
savings for the hospital. More effective pain management can prevent
inadvertent admissions or readmissions due to pain. In addition,
an effective multimodal analgesic protocol can directly or indirectly
prevent hospital-acquired conditions (HACs). HACs are considered by
CMS to be “never events” and supposedly preventable;5 hospitals
reporting HACs as secondary diagnoses are not entitled to CMS
payments for related care. Examples of HACs include: urinary and
vascular catheter-related infections, surgical site infections, DVT/PE,
pressure ulcers, and inpatient falls leading to injury.
There are clear opportunities for pain medicine specialists to take
an active role in adding value and minimizing risks for patients in
the acute setting. With the recent approval of the ACGME Board of
Directors to make Regional Anesthesiology and Acute Pain Medicine
the next accredited fellowship within anesthesiology, we can start to
develop a standardized curriculum to train the future leaders of our
subspecialty.
REFERENCES
1. Institute of Medicine. Best Care at Lower Cost: the Path to Continuously Learning
Health Care in America. http://www.iom.edu/Reports/2012/Best-Care-at-LowerCost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx.
2. Open Door Forum: Hospital Value-Based Purchasing – Fiscal Year 2013 Overview for
Beneficiaries, Providers, and Stakeholders. https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/hospital-value-based-purchasing/
downloads/HospVBP_ODF_072711.pdf.
3. National Provider Call: Hospital Value-Based Purchasing – Fiscal Year 2014
Overview for Beneficiaries, Providers, and Stakeholders. http://www.cms.gov/
Medicare/Quality-Initiatives-Patient-Assessment-Instruments/hospital-value-basedpurchasing/Downloads/NPCSlides071112.pdf.
4. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Survey. http://www.hcahpsonline.org/home.aspx.
5. Hospital-acquired condition (HAC) in acute inpatient payment system (IPPS)
hospitals. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/
HospitalAcqCond/Downloads/HACFactsheet.pdf
American Society of Regional Anesthesia and Pain Medicine
2014
President’s Message continued...
will be electronic only – a change that most members supported
when surveyed, and a change that significantly lowers our
quarterly production costs, thereby freeing funds for more enduring
educational material. Not all decisions involve decreasing spending.
For example, based on meeting attendees consistently telling us
that e-poster presentation of scientific abstracts and medically
challenging cases was less than ideal, the Society has decided
to invest in technologic refinements that should vastly improve
this critical aspect of ASRA’s mission of promoting education and
celebrating research.
In many ways, strategic decisions regarding the research mission
are both more complicated and potentially more impactful on the
future. The Board of Director’s interim meeting this past September
dedicated a significant portion of time to working with a consultant
who specializes in not-for-profit organizations like ASRA. We
learned from this exercise that ASRA enjoys a very enviable position
compared to many similar societies – we are strong organizationally
and financially. How then shall we leverage these strengths to
maintain or even expand our mission and long-term impact on the
sub-specialties? What is a reasonable benchmark for operating
margin? Should ASRA increase the frequency and/or amount of its
research grants from the Koller and Pain Medicine funds, or should
we consider launching a third research fund? The answer to these
impactful questions will be finalized during upcoming strategic
planning sessions. And it will be the foundational principles of the
Society’s mission that will guide the Board of Directors through that
process.
The Passing of ASRA Founding Father, Dr. Jordan Katz
T
he American Society of Regional
Anesthesia and Pain Medicine
remembers and honors Jordan Katz, MD,
who died this year on June 28th in Rancho
Mirage, CA, at age 82. Dr. Katz was one
of the five “ASRA Founding Fathers.” Drs.
Don Bridenbaugh, Prithvi Raj, and Alon
Winnie are the remaining members of
that visionary group along with Dr. Harold
Carron who died in 1991. During his long
association with the ASRA, Dr. Katz filled
numerous committee and editorial roles,
served on the Board of Directors from
1976-1989, and was ASRA President
from 1987-1988. Dr. Katz received the
ASRA Distinguished Service Award in
1993 and continued to attend ASRA
annual meetings until just recently.
Veterans Administration hospitals including
Stanford, University of Miami, University
of Wisconsin, and University of California,
San Diego. Although many of his academic
interests included topics pertinent to regional
anesthesia and pain medicine, Dr. Katz
also performed basic science research on
halothane. Widely published, Dr. Katz was
perhaps best known as the co-editor from
1973-1989 of Katz & Kadis - Anesthesia
in Uncommon Diseases: Clinical and
Pathophysiological Correlation.
After completing anesthesiology
residency training at Columbia
Presbyterian in 1960 and three years
of service in the Army Medical Command in Japan, Dr. Katz
embarked on a distinguished academic medical career that
encompassed leadership positions in medical schools and
American Society of Regional Anesthesia and Pain Medicine
2014
4
How I Do It: Ultrasound-Guided Bilateral Rectus Sheath Blocks
S
chleich first described the use
of bilateral rectus sheath blocks
(BRSBs) in 1899, with the aim of
providing muscle relaxation and
analgesia of the abdominial wall by
blocking the terminal branches of
the thoracolumbar nerves within the
substance of the rectus abdominis
muscle (RAM).1 It was originally
performed as a blind, loss-ofresistance technique. BRSBs had
Francis V. Salinas, MD
previously remained underutilized,
Staff Anesthesiologist
largely due to concerns over the
Section Head of Orthopedic
accuracy of needle-tip placement,2
Anesthesia
particularly in relation to vascular
Department of Anesthesiology
Virginia Mason Medical Center
structures contained within the
Seattle, WA
rectus sheath as well as visceral
structures contained within the
Section Editor:
underlying peritoneal cavity.3
Steven Orebaugh, MD
BRSBs are ideally suited for
ultrasound guidance because the
RAM, layers of the rectus sheath, and important vascular structures
are easily identified with ultrasound technology.
INDICATIONS
Ultrasound-guided BRSBs provide somatic analgesia over the midline
anterior abdominal wall from the xyphoid process superiorly to
Figure 1: Sonoanatomy of the rectus sheath in short-axis above
the arcuate line: RA=rectus abdominis muscle; EO=external
oblique muscle; IO=internal oblique muscle; TA=transversus
abdominis muscle.
5
the symphysis pubis inferiorly. It is therefore indicated for vertical
midline (or paramedian) surgical incisions. Historically, BRSBs
were primarily used as an analgesic adjunct for umbilical hernia
repair or laparoscopic gynecologic procedures;4-6 however, with the
ever-increasing adoption of ultrasound imaging and experience with
ultrasound-guided peripheral nerve blockade, more recent indications
include analgesia for vertical midline laparotomy incisions for either
“The target site for local anesthetic
deposition is deep to the RAM, but
superficial to the posterior aspect of
the rectus sheath.”
lower or upper abdominal surgery.7-11 The duration of BRSBs may be
extended by placement of catheters within the rectus sheath to allow
either continuous and/or intermittent bolus administration of local
anesthetics.10,11 Thus, ultrasound-guided BRSBs hold considerable
potential as an integral part of a perioperative multimodal analgesic
regimen.
CLINICALLY RELEVANT ANATOMY
Anatomical Course of the Thoracolumbar Nerves
The sensorimotor innervation of the anterior abdominal wall is
supplied by the ventral rami of the thoracolumbar spinal (T7-L1)
segmental nerves. The thoracolumbar nerves course along the
anterolateral wall within the transversus abdominis plane (TAP), and
continue anteromedial within the TAP, eventually encroaching upon
the lateral aspect of the rectus sheath.12 The nerves then enter
the lateral aspect of RAM and
contribute to the formation of a
nerve plexus that runs craniocaudally within the muscle in close
relation to the lateral branch of
the deep epigastric artery.13 The
thoracolumbar nerves typically
pierce the posterior border (89%)
and less commonly the lateral
border (11%) of the RAM, with
the nerves piercing the posterior
border within 1.6 to 2.6 cm from
the lateral edge of the RAM. The
nerves provide both muscular and
cutaneous branches to innervate
the muscle fibers and overlying
skin. Notably, the branches of the
thoracolumbar nerves do not cross
midline.
American Society of Regional Anesthesia and Pain Medicine
2014
Anatomy of the Rectus Sheath
The rectus sheath is formed from the aponeuroses of the fascial
sheaths of all three lateral abdominal wall muscles.12 The external
oblique (EOM), internal oblique (IOM), and transversus abdominis
(TAM) muscles each form a bilaminar aponeurosis at its medial border
(Figure 1) converging to form the lateral border of the RAM, termed
the linea semilunaris. The anterior and posterior lamina of the EOM
and the anterior lamina of the IOM fuse together and continue further
medially over the ventral surface of the RAM to form the anterior
portion of the rectus sheath (Figure 2a and Figure 3). Similarly, the
posterior lamina of the IOM and anterior and posterior lamina of the
TAM fuse together and continue medially dorsal to the RAM to form
the posterior portion of the rectus sheath (Figure 2a and Figure 3).
At the medial border of the RAM, the anterior and posterior portions
Figure 2a: Illustration demonstrating the cross-sectional anatomy of the rectus sheath above the arcuate line: RA=rectus abdominis muscle.
Figure 2b: Illustration demonstrating the cross-sectional anatomy of the rectus sheath below the arcuate line: RA=rectus abdominis muscle.
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 7
63
How I Do It: Ultrasound-Guided Bilateral Rectus Sheath Blocks continued...
of the rectus sheath come together, with the fibers coursing further
medially toward the medial border of the contralateral RAM forming the
midline linea alba.
The anterior portion of the rectus sheath extends along the entire
vertical length of the RAM. In contrast, the posterior portion of the
rectus sheath extends only along the upper two-thirds of the RAM. In
the lower one-third, the posterior portion of the rectus sheath stops
approximately midway between the umbilicus and symphysis pubis. At
this anatomical transition point, the aponeuroses that had formed the
posterior portion of the rectus sheath now also course over the ventral
surface of the RAM (Figure 2b). This transition point is known as the
arcuate line. The transversalis fascia is a thin layer of connective
tissue located just deep to posterior portion of the rectus sheath
(Figures 2a, 2b, 3). Located just deep to the transversalis fascia is the
parietal peritoneum. Inferior to the arcuate line, the transversalis fascia
is located immediately deep to the posterior border of the RAM.
ULTRASOUND ANATOMY AND TECHNIQUE
Short-Axis In-Plane Approach
The transducer (high frequency linear array or low frequency curved
array, depending on body habitus) is positioned just lateral to the
umbilicus in an axial (transverse) plane (Figure 4). Identify the layers
of the anterior abdominal wall from superficial to deep (Figures 2a, 2b,
and 3):
• A layer of subcutaneous tissue and adipose that will vary in depth
depending on body habitus.
• Deep to the subcutaneous tissues will be the anterior portion of the
of the rectus sheath (a horizontal bright hyperechoic linear structure
extending from lateral to medial).
Figure 3: Sonoanatomy of the lateral rectus abdominis muscle and rectus sheath in short-axis above
the arcuate line also demonstrating the transversalis fascia.
• Deep to the anterior rectus
sheath is the RAM (relatively
hypoechoic in relation to the
rectus sheath).
• Deep to the RAM will be
the posterior portion of the
rectus sheath (a horizontal
bright hyperechoic structure
extending from lateral to
medial).
• The deep superior (above the
umbilicus) and inferior (below
the umbilicus) epigastric
arteries may be seen as small,
pulsatile, anechoic structures
located in the deepest aspect
of the RAM. Color flow
Doppler may confirm the
presence of blood flow within
the arteries.
Figure 4: External view of an ultrasound-guided rectus sheath
block using a short-axis in-plane technique.
• Deep to the posterior portion of the rectus sheath will be the
transversalis fascia (a hyperechoic linear structure).
• Deep to the rectus sheath and transversalis fascia is the peritoneal
cavity, which is identified by the presence of peristaltic movements
of the bowel loops.
The target site for local anesthetic deposition is deep to the RAM, but
superficial to the posterior aspect of the rectus sheath. The terminal
thoracolumbar nerves are too small to be visualized as discrete
structures; thus, BRSBs are a “compartment block.” Transducer
position and initial needle insertion site (lateral to the transducer)
should be adjusted in a cephalad-to-caudad manner based on the
anticipated location of the vertical midline incision. Placing the
transducer in the middle of the anticipated vertical extent of the midline
incision should optimize distribution of local anesthetic spread.
27
American Society of Regional Anesthesia and Pain Medicine
2014
Single Injection Technique (Video Clip 1: http://asra.com/
publications-newsletters.php)
linea semilunaris and enter the lateral aspect of the RAM.
°° The needle is further advanced until it is positioned deep to the
potential space between the deepest (posterior) border of the
• Typically, a 21-gauge, 100 mm (or 20-gauge, 150 mm) needle is
RAM, but superficial to the posterior aspect of the rectus sheath.
inserted 3-8cm lateral to the lateral edge of the transducer and
This target site will be referred to as the “posterior rectus
guided “in-plane” (Figure 4).
sheath compartment.”
• The needle is advanced in-plane from lateral to medial and
°° At this point, a small (1-3 ml) volume of local anesthetic (or
superficial to deep.
sterile saline) is injected to confirm correct placement within
the posterior rectus sheath compartment, indicated by the
°° The needle should penetrate through the lateral aspect of the
appearance of an anechoic fluid
Figure 5a and b: Ultrasound-guided rectus sheath block using a short-axis in-plane technique: (a) initial collection (Figure 5a).
needle insertion with a small volume of local anesthetic (LA) injected; (b) continued advancement of the
needle with hydrodissection of the posterior rectus sheath compartment; RA=rectus abdominis muscle.
° Subsequently, 15-20
ml of local anesthetic is
incrementally injected while
observing for the expanding
anechoic fluid collection.
As the local anesthetic is
injected, it will often result
in clear separation of the
deep border of the RAM from
the posterior rectus sheath
(Figure 5b). Improved local
anesthetic spread may be
facilitated by advancement of
the needle further medially as
the anechoic fluid collection
visibly expands the posterior
rectus sheath compartment in
a lateral-to-medial fashion.
° After local anesthetic
injection, the transducer can
be translated in a cephaladto-caudad fashion to
visualize cephalad-to-caudad
spread within the posterior
rectus sheath compartment.
° The same procedure is
repeated on the contralateral
side.
Continuous Catheter
Technique (Video Clip 2:
http://asra.com/publicationsnewsletters.php)
• If a continuous catheter
technique is desired, the same
steps above are followed
except that a 17-gauge 90150 mm Tuohy tip needle is
used and, after fluid
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 22
38
PRO
Sacral lateral branch blocks are THE diagnostic test of choice for
screening patients for sacroiliac joint radiofrequency ablation (SIJ-RFA)
Sacroiliac regional pain (SIRP) most
likely contributes to axial nonradicular pain and the incidence
of SIRP increases with age.1 The
term sacroiliac regional pain (SIRP)
is preferred to sacroiliac joint pain
(SIJP) primarily because the joint
is not the only source of pain, as
pain fibers innervate the joint as
well as the soft tissue.2-6 Thus,
any treatment solely aimed at
addressing joint pain (SIJP) will
Nileshkumar Patel, MD, MBA
Advanced Pain Management
negate the contribution of the soft
Greenfield, WI
tissues and will lead
to incomplete relief
Section Editor:
of pain. Second,
Maunak Rana, MD
it is clear that the
joint receives its
innervation from the
anterior as well as
the posterior aspects; thus, if the pain is found to be
emanating from the joint itself (with sacroiliac joint
injection), it is likely to be carried by the anterior
and the posterior pain fibers. Simply addressing
the posterior aspect of the joint pain (through lateral
branch denervation) will ignore the contribution
from the anterior aspects of the joint, thereby
resulting in incomplete relief. Conversely, as the lateral branches
contribute to both the joint and the ligaments, blockade of these
branches will be the best prognostic test prior to proceeding to
neurotomy of the lateral branches.
The ideal study would have excluded patients with other sources
of pain including the facet joints. Cohen and colleagues in their
randomized prospective trial9 performed L4, L5 medial branch
(which innervate the L5-S1 facet joint) and lateral S1, S2, S3
neurotomy (which innervate both the joint and the ligaments); thus,
the study did not truly just address sacroiliac joint pain. It is for
this reason that future studies intending to address the question of
sacroiliac regional pain only focus on the L5 dorsal ramus and the
lateral S1-S3 branch blocks versus sacroiliac joint injection prior
to proceeding to radiofrequency neurotomy. Clearly, the results
of Patel et al10 can be improved upon significantly by including
multi-site, multi-depth compared to anesthetic blocks in patients
who only have SIRP with no pain from other sources (e.g., axial
“The term sacroiliac regional pain (SIRP)
is preferred to sacroiliac joint pain (SIJP)
primarily because the joint is not the only
source of pain”
Sacroiliac joint injection is therefore not the preferred prognostic
block. The crux of the argument can be addressed by taking a
deep dive into the published literature. Dreyfuss and colleagues
in their elegant studies7-8 have demonstrated that blocking the
lateral branches decreases the sensation to both the joint and the
posterior ligamentous tissue; logic would dictate that denervation
the ligaments and the joint are going to decrease the sensation
arising from these tissues. Conversely, Dreyfuss et al have
demonstrated that blockade of the joint with local anesthetic
decreases the sensation of pain arising from the joint but not from
the ligamentous tissue. We can conclude that the only viable
prognostic and diagnostic test is the lateral branch block prior to
considering denervation.
At present, there are no studies comparing the outcomes of
radiofrequency lateral branch neurotomy with prognostic SIJ
injection versus lateral branch blocks, and such a study performed
in a randomized fashion with consistent application of the
neurotomy technique would help address the issue definitively.
92
pain). In their lateral branch neurotomy study, Patel and colleagues
also failed to exclude other sources of pain, including the hip joint,
the knee joint, and cervical spine in their elderly subject; this
affected the sixth month outcome as some of the patients did have
additional surgeries which affected functional outcome measures,
and some patients dropped out at six months. Further, the only
randomized comparison in their study that counts is the three
month outcome where all patients were followed, and the results at
3 months conclusively demonstrate effectiveness of lateral branch
neurotomy when patients were selected with local anesthetic L5,
S1, S2, S3 lateral branch blocks prior to proceeding to denervation.
References:
1. D
ePalma MJ, Ketchum JM, Saullo T. What is the source of chronic low back pain and
does age play a role? Pain Med. 2011;12:224-233.
2. S zadek KM, Hoogland PV, Zuurmond WW, de Lange JJ, Perez RS. Nociceptive Nerve
fibers in the sacroiliac joint in humans. Reg Anesth Pain Med 2008;33:36–43.
3. V ilensky JA, O’Connor BL, Fortin JD, et al. Histologic analysis of neural elements in
the human sacroiliac joint. Spine 2002;27(11):1202–7.
4. M
cGrath MC, Zhang M. Lateral branches of dorsal sacral nerve plexus and the long
posterior sacroiliac ligament. Surg Radiol Anat 2005;27:327–30.
5. Ikeda R. Innervation of the sacroiliac joint—macroscopic and histological studies. J
Nippon MedSch 1991;58:587–96.
6. G
rob KR, Neuhuber WL, Kissling RO. [Innervation of the sacroiliac joint of the human].
[German]. Z Rheumatol 1995;54:117–22Dreyfuss P, Snyder BD, Park K, Willard F,
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 17
CON
Sacral lateral branch blocks are NOT the diagnostic test of choice for
screening patients for sacroiliac joint radiofrequency ablation (SIJ-RFA)
Many patients have benefited from sacroiliac joint radiofrequency
ablation procedures (SIJ-RFA).1 Multiple reasons exist for
the improved success compared to prior approaches. These
include improved technique and technological advances aimed
at maximizing the likelihood of neuronal destruction. Although
patient selection remains critical to successful outcome, there
is not currently an “optimal” diagnostic test to determine
who is most likely to benefit from SIJ-RFA. Reasons for failed
improvement following SIJ-RFA include technical factors as well
as proper patient testing. In establishing a diagnostic algorithm
for SIJ-RFA, patient evaluation must include the following key
characteristics:
1. A test that reliably blocks the SIJ structures
2. A test that does not block structures that will not be
targeted with SIJ-RFA
3. A test that can be performed safely and with reliable
results
Although intra-articular (IA) injection of local anesthetic may be
regarded as the “gold standard” for diagnosing sacroiliac joint
pain, this procedure anesthetizes both the anterior and posterior
portions of the joint, and a single block may be associated with
a false positive rate of 17% or higher.2 Conversely, SIJ-RFA
targets only the dorsal innervation of the joint. Additionally, IA
blocks do not anesthetize
the pain generated from
interosseous or dorsal
sacroiliac ligaments.3-5
Therefore, it has been
suggested that diagnostic
procedures targeting only
the posterior innervation
may provide better
selection parameters for
patients to be considered candidates for SIJ-RFA. Unfortunately,
proposed sacral lateral branch blocks (LBB), as currently
performed, do not reliably achieve this.
Dreyfuss et al12 subsequently
demonstrated in both clinical and
cadaveric models that single-site
LBB were only 40% effective in
blocking painful stimuli arising
from the dorsal sacral ligament
and the SIJ capsule. The authors
concluded that “single site,
single depth sacral lateral branch
injections do not adequately
anesthetize the inferior dorsal SIJ
ligament or IA portions of the SIJ.”
Kevin Vorenkamp, MD
Associate, Anesthesiology &
Dreyfuss et al13 later described an
Pain Medicine
alternative blockade, consisting
Virginia Mason Medical Center
of multi-site and multi-depth
Seattle,WA
injections of local anesthetic at
S1, S2 and S3, in addition to L5
Section Editor:
dorsal ramus blockade. They
Maunak Rana, MD
reported 70% effectiveness from
interosseous and dorsal sacral ligament
blocks without effectively blocking
the sacroiliac joint. Although this technique appears superior
to the single-injection technique, there are currently no studies
reporting SIJ-RFA response when this
technique is utilized for diagnostic
purposes.
“There is not currently an ‘optimal’
diagnostic test to determine who is
most likely to benefit from SIJ-RFA”
The innervation of the sacroiliac joint has been well described
although somewhat conflicting in the reported literature.6-9
Over a decade ago, Yin et al10 described a technique of deep
interosseous ligament injection as a possible diagnostic test
to block nociception from extra-articular sources of SIJ pain.
Contemporaneously, Cohen and Abdi11 published a pilot study on
sacral LBB as a treatment for SIJ pain, blocking the dorsal rami
of L4 and L5 in addition to the lateral branch nerves at S1-S3. A
single injection of 0.5 ml was injected at each level and 13/18
patients reported >50% improvement in their pain scores. These
patients then underwent sensory-guided RFA at each level with
the majority reporting >50% pain improvement persisting at 9
months post-procedure.
A careful review of the literature
on SIJ-RFA may allow for better
patient selection criteria. Cohen
and colleagues14 looked at various
factors and their association with
a positive response to SIJ-RFA in a
series of 77 patients. The analysis
failed to identify any single clinical variable that reliably predicted
treatment results. There was no relationship between the number
of diagnostic IA blocks, the percentage of pain relief with the
blocks, or the utility of confirmatory sacral LBB and the outcomes
of RFA. Cohen et al15 previously demonstrated no statisticallysignificant correlation between the degree of pain relief following
lumbar medial branch blocks and RFA success; however, the
finding that LBB did not provide additional screening benefit is
important. In fact, the authors concluded that the “preliminary
data do not support the routine use of more stringent
selection criteria, such as multiple SI joint local anesthetic
blocks, near-complete pain relief from diagnostic blocks, or
prognostic LBB.”
Published studies on SIJ-RFA support this notion that the results
of SIJ-RFA are not correlated with the selection criteria used
(Table 1).14,16-24 The most common selection criteria involved
with these studies is >50% relief with single IA block. The only
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 19
10
3
Regional Anesthesia and Obstructive Sleep Apnea
Stavros G. Memtsoudis, MD, PhD, FCCP
Clinical Professor of
Anesthesiology and Public Health
Weill Cornell Medical College
Senior Scientist and Director
of Critical Care Services
Hospital for Special Surgery
Mathias Opperer, MD
Research Fellow
Department of Anesthesiology
Hospital for Special Surgery
New York, NY
New York, NY
Section Editor: Steven Orebaugh, MD
R
ecent studies on the impact of obstructive sleep apnea (OSA)
on perioperative outcomes have led to an increased awareness
of this disorder as an important perioperative risk factor. With the
already high numbers of OSA patients expected to rise due to the
ongoing obesity epidemic1,2 as well as rising surgical volume, this
often undiagnosed disorder will undoubtedly represent an increasing
and challenging factor in need of careful consideration in the
perioperative period.3
The prevalence of OSA has been estimated at approximately
25% of all surgical patients, of which 80% percent may not
be diagnosed at the time of their intervention.4,5 While many
tools have been proposed to screen for the presence of OSA in
surgical patients, many questionnaires currently in use (e.g.,
STOP-Bang, Berlin) are limited in their ability to predict adverse
outcomes, especially mortality.6 Given the concern over increased
risk for perioperative complications based in part on the notion
of an increased sensitivity to opioids and risk for respiratory
depression, clinicians are seeking interventions to reduce the
likelihood of adverse events. Unfortunately to date, few commonly
employed interventions, despite their high cost (i.e., perioperative
observation, routine use of continuous positive airway pressure
[CPAP]) have been proven to be effective.
Further, the relationship between OSA and negative postoperative
outcomes may not be quite as straightforward as has been often
suggested. Thus considerable discrepancies can be found in
the literature concerning this topic. In this context, while some
11
2
authors suggest higher complications especially among orthopedic
patients with OSA,5,7 others point to a paradoxical protective effect
on mortality. Mokhlesi et al. noted that while there may be a small
increase in cardiopulmonary complications and earlier emergent
intubation risk, this finding did not translate into higher mortality
rates.8 This may be explained by the presence of specialized,
albeit not standardized, care9 and heightened awareness these
patients already seem to receive. Similar lack of impact has been
reported for 30 day mortality in a single-center prospective cohort
study.10 Nevertheless OSA patients seem to be at an increased
risk for specific complications. This has been demonstrated in
spine surgery patients with a near 7-fold risk for postoperative
mechanical ventilation,11 as well as in patients after knee
arthroplasty for delirium12 or inpatient falls.13
Currently, a paucity of studies exists examining who amongst OSA
patients is at highest risk for postoperative complications, thus
making allocation of resources difficult. The idea that concomitant,
often occult, disease processes such as the high prevalence
of pulmonary arterial hypertension may play an important role
has been proposed14 and is being investigated. A multivariate
regression analysis of population-based data previously analyzed
by our group indeed shows that the combination of OSA with
various comorbidities increases perioperative complication risk
Table 1: The impact of obstructive sleep apnea (OSA)
combined with different comorbidities versus OSA alone on
perioperative complications in total hip and knee arthroplasty
patients.
Multivariable Regressions of OSA with Comorbidities
(Reference = OSA without listed comorbidities)
Outcome
Combined
Complications*
Effect
Adjusted Odds Ratio
(Corrected 95% C.I.)
Corrected
P-Value
OSA + Obesity
1.27 (1.17,1.37)
<0.0001
OSA + Diabetes
1.12 (1.03, 1.22)
0.0019
OSA +
Complicated
Diabetes
1.49 (1.19,1.86)
<0.0001
OSA +
Hypertension
1.08 (0.98,1.17)
0.1831
OSA +
Complicated
Hypertension
2.46 (2.15,2.81)
<0.0001
OSA + Pulmonary
Hypertension
2.33 (1.83,2.97)
<0.0001
* Composite outcome (incidence of pulmonary embolism,
deep vein thrombosis, cerebral complications, pulmonary
complications, pneumonia, sepsis, other infectious complications,
acute renal failure, gastrointestinal complications, acute
myocardial infarction, other cardiac complications and mortality)
American Society of Regional Anesthesia and Pain Medicine
2014
significantly when compared to the presence of OSA alone (Table
1). Further, many questions related to care for OSA patients in
the perioperative period remain unanswered, including those
concerning how to treat newly diagnosed patients, and especially
whether surgery should be postponed and CPAP therapy initiated.
However, factors such as the unknown length of therapy needed,
doubtful impact on outcomes and questionable compliance with
device application complicate such proposals.
Despite the
magnitude of
the problem and
the existence of
guidelines provided
by the ASA,15
evidence for effective
perioperative
intervention remains
rare. For example,
while experts do believe perioperative CPAP therapy to be
beneficial, evidence of benefit in the perioperative setting remains
inconclusive16–18 as data are extrapolated from long term care
studies. It is not surprising that a recent analysis of national data
from over 500 hospitals suggests that only 17% of OSA patients
currently receive CPAP therapy in the hospital.19 Besides the
lack of conclusive evidence of effectiveness, this finding may be
explained by high cost, lack of resources and low perioperative
adherence to CPAP therapy by patients.20
arthroplasties.26 Neuraxial anesthesia, when compared to general
anesthesia, showed protective effects for pulmonary and cardiac
complications (OR 0.825 and 0.904, respectively) with a noted
reduction for mechanical ventilation (OR 0.636) and critical care
service utilization (OR 0.433). Interestingly, similar effects could
be observed for combined neuraxial and general anesthesia vs.
general anesthesia alone. For the use of peripheral nerve blocks,
no difference in pulmonary or cardiac complications was noted,
although a decreased
need for mechanical
ventilation or critical
care services was found.
“Regional anesthesia is widely underutilized
with currently 74% of total hip and knee
arthroplasties performed under general
anesthesia alone.”
Recent research, however, has provided some evidence that
the use of regional anesthesia may indeed positively affect
perioperative outcomes. When discussing the role of regional
anesthesia in patients with OSA one has to consider possible
reasons for complications in this distinctive patient group.
These include impaired pulmonary mechanics due to a high
prevalence of obesity,5 increased pulmonary21 and systemic
inflammatory mediator levels,22 higher risk for aspiration
by impaired pharyngeal sphincter function23 and increased
sensitivity to opioids and other medications.24 The use of regional
anesthetic and analgesic techniques has been postulated to
have theoretical advantages such as 1) reduction in the need
for systemic opioids and anesthetics; 2) reduction in the need
for airway instrumentation and mechanical ventilation; and 3)
reduction in the extent of systemic inflammatory response. In this
context regional anesthesia may be used to avoid intubation and
mechanical ventilation in a patient group that has a prevalence
of pulmonary hypertension of up to 70%14 and may further
underscore its importance in orthopedic surgery where pulmonary
circulatory changes are frequently seen due to surgical methods.25
In a retrospective cohort-study of 30,000 OSA patients, our
workgroup compared the use of neuraxial vs. general anesthesia
in patients with a similar comorbidity burden for total joint
OSA may represent a
significant risk factor
for perioperative
complications; however,
tools to identify those
at risk remain largely
elusive. Although many suggested interventions to improve
outcomes, such as CPAP and extended observation, are unproven
to date, the use of regional anesthesia may represent an effective
way by which outcomes may be positively affected. While
mechanisms by which such benefits may be conferred need to
be further elucidated, it remains a fact that regional anesthesia
is widely underutilized with currently 74% of total hip and knee
arthroplasties performed under general anesthesia alone.26 Given
the long track record of safety of regional anesthetic techniques,
we believe that their utilization as a corner stone of perioperative
OSA care should be strongly considered, especially in the face of
little evidence supporting the effectiveness of other interventions.
There is no doubt, however, that given the extent of the problem,
much more effort and resources need to be expended to study
approaches to improve outcomes in an accountable manner when
caring for patients with OSA.
REFERENCES
1. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence
of sleep-disordered breathing in adults. Am J Epidemiol 2013;177:1006–14.
2. Sturm R. Increases in clinically severe obesity in the United States, 1986-2000.
Arch Intern Med 2003;163:2146–8.
3. Memtsoudis SG, Besculides MC, Mazumdar M. A rude awakening--the
perioperative sleep apnea epidemic. N Engl J Med 2013;368:2352–3.
4. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a
population health perspective. Am J Respir Crit Care Med 2002;165:1217–39.
5. Memtsoudis S, Liu SS, Ma Y, Chiu YL, Walz JM, Gaber-Baylis LK, Mazumdar M.
Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac
surgery. Anesth Analg 2011;112:113–21.
6. Lockhart EM, Willingham MD, Abdallah A Ben, Helsten DL, Bedair BA, Thomas
J, Duntley S, Avidan MS. Obstructive sleep apnea screening and postoperative
mortality in a large surgical cohort. Sleep Med 2013;14:407–15.
7. Memtsoudis SG, Stundner O, Rasul R, Chiu Y-L, Sun X, Ramachandran S-K, Kaw R,
Fleischut P, Mazumdar M. The impact of sleep apnea on postoperative utilization of
resources and adverse outcomes. Anesth Analg 2014;118:407–18.
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 17
12
3
Changes in Payment for Interventional Pain Physicians,
2014 and Beyond
The process of how Medicare pays for services is worth reviewing.
For physicians’ services, Medicare pays a predetermined amount
based on a fee schedule of payment rates for over 7,000 types of
services. Generally, payment rates are higher when services are
provided in a non-facility setting, such as a physician owned office,
and lower when services are provided in a facility, such as a hospital
or ambulatory surgical center. Presumably, physicians incur lower
costs when providing services in a facility and thus receive smaller
payments. In addition, when services are provided in a facility,
Medicare pays a separate (often higher) fee directly to the facility.
Daniel Rothstein, MD, MBA
Richard W. Rosenquist, MD
Anesthesiology Resident, CA-3
Chairman, Pain Management Department
University of Rochester Medical Center
Cleveland Clinic
Rochester, NY
Cleveland, OH
I
Section Editors: Steven Orebaugh, MD, and
Melanie Donnelly, MPH, MD
nterventional pain physicians have endured significant cuts
in their payment rates in 2014. The Centers for Medicare and
Medicaid Services (CMS) implemented steep reductions in
payments for the most commonly performed interventional pain
procedures, interlaminar epidural injections. According to the
American Society of Interventional Pain Physicians (ASIPP), these
cuts may result in an increasing number of private practice pain
physicians going out of business or transferring their practices to
a hospital setting.1
The final CMS physician
fee schedule for
2014 states that
physician payment
for a cervical epidural
injection performed
in an office setting
is $110.69, which is
significantly lower
than the $251.77 paid
in 2013, representing a decrease of 56%. If the same procedure
is performed in a facility setting (i.e., ambulatory surgical center or
hospital outpatient department), physician reimbursement is $74.15,
a 33% drop from prior year. Physician payment for a lumbar epidural
injection performed in an office is down to $108.90 from $211.96,
a drop of 48%. If performed in a facility, the physician would be
reimbursed $72.72, which is 19% less than in 2013.2
The value of physicians’ services is determined by relative value
units (RVUs), a weighted index of the “costliness” of each service.
RVUs are derived from three components – physician work, practice
expense, and the cost of related professional liability insurance.
There is also an adjustment for geographic location to account
for differences in practice costs across the country.4 The final
payment rate for a specific service is calculated by summing the
three component RVUs into a “total RVU” and multiplying by a
dollar amount called the conversion factor (CF), which in the 2014
fee schedule is $35.82. For example, a cervical epidural injection
performed in an office setting carries a total RVU of 3.09 (1.18 for
physician work, 1.81 for practice expense, and 0.10 for malpractice
insurance). Multiplying the total RVU by the conversion factor gives
the final payment rate of $110.69, as stated in the 2014 fee schedule.
The value of physician work, encompassing effort, skill, stress, and
all the years of specialty
training for performing
this somewhat risky
procedure near the
cervical spine is
determined to be $42
(RVU of 1.18 multiplied
by CF of $35.82).
“These cuts may result in an increasing
number of private practice pain physicians
going out of business or transferring their
practices to a hospital setting.”
This change in physician professional fee payments is in contrast to
what Medicare pays the facility, which is substantially larger than
physician reimbursement and is actually increasing. Payments to
ambulatory surgical centers for cervical or lumbar epidural procedures
increased by 17% to $370.07 in 2014, while hospitals are receiving
$669.90 for these procedures, an increase of 18% from the prior year.
13
2
RVUs within the fee
schedule are updated
annually by CMS.
Updates to physician work and office expense RVUs are based on
recommendations from the Relative Value Scale Update Committee
(RUC), a committee comprised of members from the American
Medical Association and other national medical specialty societies.5
The committee’s recommendations for the 2014 fee schedule were
based on a survey of pain physicians which concluded that physician
work time for epidural injections should be reduced.6 Based on
the results of this survey, the committee recommended that the
RVUs for physician work be reduced by 12% (1.68 from 1.91) for
cervical epidurals and remain unchanged for lumbar epidurals
(1.54). Nevertheless, CMS implemented significantly steeper cuts in
their final 2014 physician payment rule – RVUs of 1.18 for cervical
epidurals and 1.17 for lumbar epidural, representing decreases of
38% and 24%, respectively.6
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 23
A Case for the Continued Importance of Continuous Peripheral
Nerve Block Catheters
S
everal strategies have been developed to prolong single
injection nerve blocks. Multi-drug mixtures for injection around
a peripheral nerve have been studied and shown to prolong
nerve block duration; for example, adding dexamethasone, clonidine,
and buprenorphine to bupivacaine has been demonstrated to prolong
single injection blocks for an average of 30 hours and longer in
select cases.1 A formulation of liposomal bupivacaine has been
recently FDA-approved (2011) and is indicated for wound infiltration
although it is anticipated that this drug will receive approval for a
peripheral nerve block indication soon. The drug theoretically confers
substantially longer block duration over all current bupivacaine
formulations including the aforementioned mixture of additional
agents. Despite this theoretical advantage, for many procedures
these prolonged single injection blocks may still in fact be inferior to
continuous peripheral nerve block (CPNB) catheters.
From a clinical standpoint, catheters provide two important
advantages over single injection blocks: duration and titratability.
While liposomal bupivacaine may provide the first effect, it certainly
does not allow for titratability. This is an important consideration
for any nerve block of prolonged duration in which both motor and
sensory components are affected.
Lower extremity joint replacement surgeries are the most obvious
examples of when prolonged motor blockade is detrimental. While
pain from these procedures can be significant for several days
postoperatively, it is beneficial from an economic and clinical
standpoint that
physical therapy
commences shortly
after surgery is
completed.2,3 Femoral,
sciatic, and lumbar
plexus catheters have
been demonstrated to
reduce pain scores,
opioid consumption,
length of stay, and
facilitate physical therapy.4-10 Patients vary in their response to nerve
blockade depending on the location of local anesthetic injection
relative to the nerve and inter-individual variability in terms of
sensitivity to local anesthetic. Thus while a standardized CPNB order
set is typical, titration up or down in cases of severe pain or excessive
motor blockade is very common. Without titration, any single injection
nerve block has the potential to either undertreat pain or disable the
patient in the crucial early postoperative period during which time
physical therapy may otherwise confer significant benefit.
Zach Fisk, MD, MBA
Fellow, Regional Anesthesiology
University of Pittsburgh Medical Center
Charles Luke, MD, MBA
Assistant Professor, Anesthesiology
University of Pittsburgh Medical Center
Pittsburgh, PA
Pittsburgh, PA
Section Editor: Steven Orebaugh, MD
function and some sensory ability remains essential. Compartment
syndrome, associated with paresis, pain, and paresthesia, is a
known complication of orthopedic trauma procedures which must be
detected early.11,12 Any of these symptoms alone are not sensitive for
the detection of neural entrapment.13 A dense nerve block that cannot
be titrated may create a situation in which some or all of these signs
are either ignored or absent which may place this patient population
at risk for this debilitating condition. On the other hand, compartment
syndrome has been
detected despite the use
of CPNB in several case
reports, and perineural
infusions can be titrated
downwards or held should
any of these symptoms
manifest.14 It is the
authors’ opinion that CPNB
should continue to be
considered the preferred
technique over any prolonged single injection nerve block in this
surgical population.
“From a clinical standpoint, catheters
provide two important advantages over single
injection blocks: duration and titratability.”
Procedures for orthopedic trauma repair also benefit from a long
lasting but titratable nerve block. These procedures are often very
painful for several days postoperatively. While physical therapy
expectations tend to be lower in such cases, maintenance of motor
In contrast, the use of liposomal bupivacaine for single injection
regional anesthesia procedures may prove superior to CPNB for
specific block locations that are primarily or entirely sensory-specific:
transversus abdominis plane (TAP) and paravertebral blocks. For
TAP catheters, the optimal local anesthetic infusion regimen remains
unknown. Paravertebral catheters have been shown to be very
effective for managing pain and reducing complications in thoracic
surgeries, breast surgeries, and abdominal surgeries for 3-5 days.1518
They are similarly useful for managing rib fracture pain.19-21 They
have been shown to reduce time to extubation, hospital length of
stay, and ICU time in minimally-invasive cardiac surgery patients.22
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 18
14
3
Ultrasound Gel: Do Not Forget the Importance of
Appropriate Infection Control Practices
resulted from contaminated ultrasound gel that originated
directly from the manufacturer.7 Respiratory infections from
Pseudomonas aeruginosa occurred in patients that had
undergone cardiovascular surgery during which intraoperative
TEE was utilized.13 After an infection control investigation
with the assistance of molecular typing, ultrasound gel multiuse bottles were identified as the source of Pseudomonas
aeruginosa. Furthermore, sealed unopened bottles also contained
the same isolate of Pseudomonas aeruginosa, suggesting that
contamination occurred at the time of manufacturing.
David A. Provenzano, MD
President, Pain Diagnostics and
Interventional Care
Pittsburgh, PA
Michael Liebert, BA
Pennsylvania State College of Medicine
Hershey, PA
Section Editor: Kevin Vorenkamp, MD
U
ltrasound imaging is a useful diagnostic tool in a variety of
medical settings. To assist in the transmission of acoustic
energy, ultrasound transmission gel is used as a coupling
medium for ultrasound-guided interventional regional anesthesia,
pain, and musculoskeletal procedures, diagnostic scans, and
transesophageal echocardiogram (TEE) examinations. Recently,
concerns both nationally and internationally have been raised
regarding the ability of ultrasound gel to serve as a vector for
the spread of bacteria and as the causative agent for significant
healthcare associated infections.1-3 Unfortunately, best infection
control practices are still not consistently followed. A recent
survey of cardiothoracic anesthesiology fellowship directors
demonstrated that 56% of respondents did not follow the Food
and Drug Administration’s (FDA) recommendation of using sterile
ultrasound gel for TEE examinations.4,5 In a safety communication,
the FDA recommended the use of sterile ultrasound gel, not only
for all sterile body site procedures and invasive procedures,
but also for noninvasive procedures with mucosal contact
where any possible added bioburden would be undesirable or
mucosal trauma is likely.5 Furthermore, the FDA specifies that
only ultrasound gel obtained from unopened containers/packets
labeled “sterile” should be considered sterile. Based on this
definition, multi-use bottles of ultrasound transmission gel would
be considered nonsterile.
Multiple case reports have been published identifying ultrasound
gel as a source of nosocomial infection (Table 1). In these case
reports, both manufacturer and user processes have been
identified as sources of contamination for various bacterial
organisms, including Klebsiella pneumoniae,6 Burkholderia
cepacia,7-10 Achromobacter xylosoxidans,11 and Staphylococcus
aureus.12 Intrinsically contaminated ultrasound gel at the time
of manufacturing has been responsible for multiple cases
of nosocomial infection. Hutchinson et al.7 identified serious
Burkholderia cepacia infections at tertiary care centers that
15
2
Besides contamination at the time of manufacturing,
contamination of ultrasound gel in the spread of infection may
also occur from inappropriate use of products. An outbreak of
Achromobacter xylosoxidans associated with ultrasound gel used
for transrectal ultrasound-guided prostate biopsies occurred
from contaminated ultrasound gel through which biopsy needles
passed.11 The ultrasound gel originated from a large supply bag
that was used to refill ultrasound gel containers. In addition,
nosocomial outbreaks of Klebsiella pneumoniae in six adult
women and two neonates, and Burkholderia cepacia in a pediatric
institution, have occurred secondary to inappropriate user
processes for handling ultrasound gel.6
Efforts to reduce gel-borne contamination have occurred
through both the publishing of clinical recommendations by
international and national communities and the modification of
the manufacturing process. In response to this health concern,
multiple medical associations and government agencies
have published warnings and proposed preliminary clinical
recommendations to minimize infection when using sterile and
nonsterile medical gels. In 2004, following several cases of
bacteremia and septicemia that occurred from the utilization of
contaminated ultrasound gel, Health Canada published practice
recommendations for the use of both sterile and nonsterile
gels.3 These recommendations have been endorsed by many
professional associations, including the Canadian Society of
Diagnostic Medical Sonographers, the Society of Diagnostic
Medical Sonography, and the American Institute of Ultrasound in
Medicine. In April 2013, the Australian Sonographers Association
published a background paper on the safe use and storage of
ultrasound gel to prevent nosocomial infections, including cross
infections.14 The stimulus for this background paper originated
from safety alerts and recalls released in 2012 by the Australian
Department of Health Therapeutic Goods Administration due to the
confirmed presence of bacterial contamination in ultrasound gel.
Recently in the United States, recommendations based on expert
opinion have been proposed to minimize clinical risk.1 These
recommendations build on the Health Canada recommendations
that suggest the use of single-use sterile gels for invasive
procedures, for neonates, for all procedures involving sterile
equipment or non-intact skin, and for procedures on intact
American Society of Regional Anesthesia and Pain Medicine
2014
Ultrasound Gel: Do Not Forget the Importance of
Appropriate Infection Control Practices
Table 1: Summary of previous case reports in which ultrasound gel was a source of nosocomial infection. (Reproduced with permission from
Regional Anesthesia and Pain Medicine).21
Antimicrobial
Agent
Identified
Microorganism
Source of
Contamination
Associated
Procedure
Type of
Nosocomial
Infection
Chittick, P.
et. al. (13)
Other-Sonic;
Pharmaceutical
Innovations,
Inc., Newark,
NJ
Not indicated
Pseudomonas
aeruginosa
In-use and
unopened gel
bottles
Transesophageal
echocardiography
Respiratory tract
infection
OlshtainPops, K. et.
al. (11)
250mL unidentified gel
bottle
Not indicated
Achromobacter
xylosoxidans
250mL in-use
gel bottles
Transrectal prostate
biopsy
Bacteriuria and
septicemia
Not indicated
Methylchloroisothiazolinone and
methylisothiazolinone
Burkholderia cepacia
Not indicated
Echocardiographic
procedures
Not indicated
Propyl and methyl
parabens
Burkholderia cepacia,
Klebsiella oxytoca,
Stenotrophomonas
maltophilia, Ralstonia
pickettii, Pantoea
agglomerans,
Enterobacter ictaluri,
Burkholderia stabilis
250mL in-use
gel bottles
Diagnostic
ultrasonography
Respiratory
tract infection,
bacteriuria, skin
wound
Methyl paraben
Burkholderia cepacia,
Enterobacter cloacae
Intrinsically
contaminated
gel during the
manufacturing
process
Transrectal prostate
biopsy
Urinary tract
infection and
septicemia
Dispensing
spatula and
500mL in-use
gel bottle
Neonate hip-joint
sonography
Pyoderma
Author
Gel Used
Marigliano,
A. et. al. (9)
Jacobson,
M. et. al. (8)
250mL gel
bottles from 4
un-identified
manufacturers
Hutchinson,
J. et. al. (7)
250mL unidentified gel
bottles, 5L
opened stock
bottles
Weist, K. et.
al. (12)
500mL unidentified gel
bottle
Not indicated
Methicillin-susceptible
Staphylococcus aureus
Gaillot, O.
et. al. (6)
250mL
Sonecho gel
bottles; Echos
Contacts,
Eragny, France
Not indicated
Klebsiella pneumoniae
producing extendedspectrum β-lactamase
Wide-mouthed
bulk container
Emergency Room
ultrasound scan
Urinary tract
infection and skin
lesion
Pseudomonas cepacia
(i.e. Burkholderia
cepacia)
Portable
dispensing
bottles and
opened bulk
dispensers
Transrectal prostate
biopsy
Urinary tract
infection
Keizur, J. et.
al. (10)
Not indicated
Not indicated
American Society of Regional Anesthesia and Pain Medicine
2014
Continued on page 24
16
3
Regional Anesthesia and Obstructive Sleep Apnea continued...
8. Mokhlesi B, Hovda MD, Vekhter B, Arora VM, Chung F, Meltzer DO. Sleepdisordered breathing and postoperative outcomes after elective surgery: analysis
of the nationwide inpatient sample. Chest 2013;144:903–14.
Soliman Hamad MA. STOP-Bang and the effect on patient outcome and length of
hospital stay when patients are not using continuous positive airway pressure. J
Anesth 2014;(epub ahead of print)
9. Memtsoudis SG, Stundner O, Rasul R, Chiu Y-L, Sun X, Ramachandran S-K, Kaw R,
Fleischut P, Mazumdar M. The impact of sleep apnea on postoperative utilization of
resources and adverse outcomes. Anesth Analg 2014;118:407–18.
19. Memtsoudis SG, Stundner O, Rasul R, Chiu YL, Sun X, Ramachandran SK, Kaw R,
Fleischut P, Mazumdar M. The impact of sleep apnea on postoperative utilization of
resources and adverse outcomes. Anesth Analg 2014;118:407–18.
10. Lockhart EM, Willingham MD, Abdallah AB, Helsten DL, Bedair BA, Thomas J,
Duntley S, Avidan MS. Obstructive sleep apnea screening and postoperative
mortality in a large surgical cohort. Sleep Med 2013;14:407–15.
20. Guralnick AS, Pant M, Minhaj M, Sweitzer BJ, Mokhlesi B. CPAP adherence in
patients with newly diagnosed obstructive sleep apnea prior to elective surgery. J
Clin Sleep Med 2012;8:501–6.
11. Stundner O, Chiu Y-L, Sun X, Ramachandran S-K, Gerner P, Vougioukas V,
Mazumdar M, Memtsoudis SG. Sleep apnoea adversely affects the outcome in
patients who undergo posterior lumbar fusion: a population-based study. Bone
Joint J 2014;96-B:242–8.
21. Carpagnano GE, Kharitonov SA, Resta O, Foschino-Barbaro MP, Gramiccioni E,
Barnes PJ. Increased 8-isoprostane and interleukin-6 in breath condensate of
obstructive sleep apnea patients. Chest 2002;122:1162–7.
12. Flink BJ, Rivelli SK, Cox EA, White WD, Falcone G, Vail TP, Young CC, Bolognesi
MP, Krystal AD, Trzepacz PT, Moon RE, Kwatra MM. Obstructive sleep apnea
and incidence of postoperative delirium after elective knee replacement in the
nondemented elderly. Anesthesiology 2012;116:788–96.
13. Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, Mariano ER,
Mazumdar M. Inpatient falls after total knee arthroplasty: the role of anesthesia
type and peripheral nerve blocks. Anesthesiology 2014;120:551–63.
14. Minai OA, Ricaurte B, Kaw R, Hammel J, Mansour M, McCarthy K, Golish JA, Stoller
JK. Frequency and impact of pulmonary hypertension in patients with obstructive
sleep apnea syndrome. Am J Cardiol 2009;104:1300–6.
15. American Society of Anesthesiologists Task Force on Perioperative Management
of patients with obstructive sleep apnea. Practice guidelines for the perioperative
management of patients with obstructive sleep apnea: an updated report by the
American Society of Anesthesiologists Task Force on Perioperative Management of
patients with obstructive sleep apnea. Anesthesiology 2014;120:268–86.
22. Chien M-Y, Lee P, Tsai Y-F, Yang P-C, Wu Y-T. C-reactive protein and heart rate
recovery in middle-aged men with severe obstructive sleep apnea. Sleep Breath
2012;16:629–37.
23. Sabate JM, Jouet P, Merrouche M, Pouzoulet J, Maillard D, Harnois F, Msika
S, Coffin B. Gastroesophageal reflux in patients with morbid obesity: a role of
obstructive sleep apnea syndrome? Obes Surg 2008;18:1479–84.
24. Blake DW, Chia PH, Donnan G, Williams DL. Preoperative assessment for
obstructive sleep apnoea and the prediction of postoperative respiratory
obstruction and hypoxaemia. Anaesth Intensive Care 2008;36:379–84.
25. Memtsoudis SG, Salvati EA, Go G, Ma Y, Sharrock NE. Perioperative pulmonary
circulatory changes during bilateral total hip arthroplasty under regional
anesthesia. Reg Anesth Pain Med 35:417–21.
26. Memtsoudis SG, Stundner O, Rasul R, Sun X, Chiu Y-LL, Fleischut P, Danninger
T, Mazumdar M. Sleep apnea and total joint arthroplasty under various types of
anesthesia: a population-based study of perioperative outcomes. Reg Anesth Pain
Med 2013;38:274–81.
16. Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients
with obstructive sleep apnea syndrome undergoing hip or knee replacement: a
case-control study. Mayo Clin Proc 2001;76:897–905.
Local
Infiltration
Analgesia
in Lower
Limb Arthroplasty
17.
Kaw R,
Pasupuleti V, Walker
E, Ramaswamy
A, Foldvary-Schafer
N. Postoperative continued...
complications in patients with obstructive sleep apnea. Chest 2012;141:436–41.
18. Proczko MA, Stepaniak PS, Quelerij M de, Lely FH van der, Smulders JF, Kaska L,
PRO
Sacral lateral branch blocks are THE diagnostic
test of choice continued...
Carreiro J, Bogduk N. The ability of single site, single depth sacral lateral branch
blocks to anesthetize the sacroiliac joint complex. Pain Med 2008;9:844–50.
7. D
reyfuss P, Snyder BD, Park K, Willard F, Carreiro J, Bogduk N. The ability of single
site, single depth sacral lateral branch blocks to anesthetize the sacroiliac joint
complex. Pain Med 2008;9:844–50.
8. D
reyfuss P, Henning T, Malladi N, Goldstein B, Bogduk N. The ability of multi-site,
multi-depth sacral lateral branch blocks to anesthetize the sacroiliac joint complex.
Pain Med 2009;10:679-88.
17
2
9. C
ohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B, Dragovich A.
Randomized placebo-controlled study evaluating lateral branch radiofrequency
denervation for sacroiliac joint pain. Anesthesiology 2008;109:279–88.
10. Patel N, Gross A, Brown L, Gekht G. A randomized, placebo-controlled study to
assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint pain.
Pain Med. 2012;13:383–398.
American Society of Regional Anesthesia and Pain Medicine
2014
A Case for the Continued Importance of Continuous
Peripheral Nerve Block Catheters continued...
Theoretically a single injection paravertebral block with liposomal
bupivacaine that can last three days may provide consistent pain
relief over the duration typically provided by CPNB while avoiding
the challenges of catheter placement and management. Catheters
can be associated with problems postoperatively such as leaking,
dislodgement, and accumulating blood levels of local anesthetic.
Nursing staff must understand how to program and adjust infusion
pumps as well as troubleshoot catheter-related issues.
6. Marino J, Russo J, Kenny M, Herenstein R, Livote E, Chelly JE. Continuous
lumbar plexus block for postoperative pain control after total hip arthroplasty.
A randomized controlled trial. Bone Joint Surg Am 2009;91:29–37.
Although we assume that liposomal bupivacaine can indeed provide
a prolonged nerve block of sufficient duration to replace 3-5 days of
perineural infusion, supportive evidence is lacking. To date, the only
liposomal bupivacaine dose-response study related to peripheral
nerve blocks was conducted on a small cohort receiving femoral
nerve blocks and demonstrates inconsistent block duration.23
Since the benefits of paravertebral catheters are well-established,
comparative liposomal bupivacaine single injection nerve block
studies will need to demonstrate equivalent analgesia for the same
time frame.
9. den Hertog A, Gliesche K, Timm J, Mühlbauer B, Zebrowski S. Pathwaycontrolled fast-track rehabilitation after total knee arthroplasty: a randomized
prospective clinical study evaluating the recovery pattern, drug consumption,
and length of stay. Arch Orthop Trauma Surg 2012;132:1153-1163.
With respect to cost-effectiveness, liposomal bupivicaine will
remain on patent for several years. During its patent life, the drug is
considered fairly expensive with the average wholesale price of $140
for a 10 mL vial and $285 for a 20 mL vial. However, since there
may be system benefits associated with avoiding the management
challenges associated with CPNB, formal cost analyses are needed.
7. Ibrahim MS, Khan MA, Nizam I, Haddad FS. Peri-operative interventions
producing better functional outcomes, reduce complications, and enhanced
recovery following total hip and knee arthroplasty: an evidence-based review.
BMC Med 2013;11:37.
8. Kosel J, Bobik P, Siemiątkowski A. The use of regional anesthetic techniques in
pain management in patients undergoing primary knee replacement. Orthop
Traumatol Rehabil 2012;14:315-328.
10. Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain
management. Br J Anaesth 2010;10:86-96.
11. Collins DC. Management and rehabilitation of distal radius fractures. Orthop
Clin North Am 1993;24:365-378.
12. Huang Y. Iatrogenic injuries of the peripheral nerves: analysis of 226 cases.
Zhonghua Yi Xue Za Zhi 1992;72:273-276.
13. Aguirre JA, Gresch D, Popovici A, Bernhard J, Borgeat A. Case scenario:
compartment syndrome of the forearm in patient with an infraclavicular
catheter: breakthrough pain as indicator. Anesthesiology 2013;118:1198-1205.
14. Munk-Andersen H, Laustrup TK. Compartment syndrome diagnosed in due
time by breakthrough pain despite continuous peripheral nerve block. Acta
Anaesthesiol Scand 2013;57:1328-1330.
15. Raveglia F, Rizzi A, Leporati A, Di Mauro P, Cioffi U, Baisi A. Analgesia in
patients undergoing thoracotomy: epidural versus paravertebral technique.
A randomized, double-blind, prospective study. J Thorac Cardiovasc Surg
2014;147:469-473.
In conclusion, non-selective nerve blocks of prolonged duration
that impair motor function in addition to sensation need to be
titratable except in specific cases. CPNB catheters allow for this
while liposomal local anesthetic formulations may not. Once the
FDA approves liposomal bupivacaine’s nerve block indication.
we encourage clinical researchers to conduct much-needed
comparative-effectiveness research studies with these two regional
analgesic modalities.
16. Pipanmekaporn T, Saeteng S. The use of continuous thoracic paravertebral
nerve block under direct vision for postoperative pain management in thoracic
surgery. J Med Assoc Thai 2012;95:191-197.
References
20. Truitt MS, Murry J, Amos J, et al. Continuous intercostal nerve blockade for rib
fractures: ready for primetime? J Trauma 2011;71:1548-1552.
1. Ibinson JW, Mangione MP, Williams BA. Local anesthetics in diabetic rats (and
patients): shifting from a known slippery slope toward a potentially better
multimodal perineural paradigm? Reg Anesth Pain Med 2012;37:574-576.
2. Labraca NS, Castro-Sánchez AM, Matarán-Peñarrocha GA, Arroyo-Morales M,
Sánchez-Joya Mdel M, Moreno-Lorenzo C. Benefits of starting rehabilitation
within 24 hours of primary total knee arthroplasty: randomized clinical trial.
Clin Rehabil 2011;25:557-566.
3. Mahomed NN, Davis AM, Hawker G, et al. Inpatient compared with homebased rehabilitation following primary unilateral total hip or knee replacement:
a randomized controlled trial. J Bone Joint Surg Am 2008;90:1673-1680.
4. Chelly JE, Ben-David B. Do continuous femoral nerve blocks affect the hospital
length of stay and functional outcome? Anesth Analg 2007;104:996–998.
17. Chelly JE. Paravertebral blocks. Anesthesiol Clin 2012;30:75-90.
18. Gulbahar G, Kocer B, Muratli SN, et al. A comparison of epidural and
paravertebral catheterisation techniques in post-thoracotomy pain
management. Eur J Cardiothorac Surg 2010;37:467-472.
19. Ho AM, Karmakar MK, Critchley LA. Acute pain management of patients with
multiple fractured ribs: a focus on regional techniques. Curr Opin Crit Care
2011;17:323-327.
21. Mohta M, Verma P, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective,
randomized comparison of continuous thoracic epidural and thoracic
paravertebral infusion in patients with unilateral multiple fractured ribs--a pilot
study. J Trauma 2009;66:1096-1101.
22. Carmona P, Llagunes J, Casanova I, et al. Continuous paravertebral analgesia
versus intravenous analgesia in minimally invasive cardiac surgery by minithoracotomy. Rev Esp Anestesiol Reanim 2012;59:476-482.
23. Ilfeld BM, Malhotra N, Furnish TJ, Donohue MC, Madison SJ. Liposomal
bupivacaine as a single-injection peripheral nerve block: a dose-response study.
Anesth Analg. 2013 Nov;117(5):1248-56
5. Ben-David B, Schmalenberger K, Chelly JE. Analgesia after total knee
arthroplasty: is continuous sciatic blockade needed in addition to continuous
femoral blockade? Anesth Analg 2004;98:747-749.
American Society of Regional Anesthesia and Pain Medicine
2014
18
3
CON
Sacral lateral branch blocks are NOT the diagnostic
test of choice continued...
Table 1: Chronological list of recent clinical studies evaluating radiofrequency procedures in the treatment of sacroiliac joint pain. For
studies prior to 2008, please see Cohen et al, Table 5.24
Author(s),
Journal,
Year
Kapural et al.
Pain Practice
2008.16
Cohen et al.
Anesthesiology
2008.17
Cohen et al.
RAPM 2009.14
Speldewinde.
Pain Med
2011.18
Study type
Patient Selection
(# of patients/
Criteria
treatments)
Retrospective
(26/36)
Randomized,
placebo controlled,
blinded
(28)
Retrospective
(77/80)
Prospective (20)
Dual diagnostic SIJ IA
blocks (>50% relief)
Single SIJ IA block
(>75% relief x 6
hours)
Single SIJ IA block
(>50% relief)-all
patients.
-35/77 received
second IA block
-24/77 received L4-S3
blocks (single injection
technique with 0.5ml/
level and >50% relief)
“Improvement” with
IA block
RFA Technique
(Number of lesions)
RFA 90C x 90 sec at L5DR
(1)
CRF 60C x 150 at S1 (2-3),
S2 (2-3), S3 (2-3)
L4 and L5 DR: 22G, 10cm w
5mm at RF at 80 C x 90sec;
CRF 60C x 150 sec at S1 (3),
S2 (3), S3 (2) and +/- S4 (1)
Crossover arm received RFA
80C x 90 sec at all levels
RFA of L4DR (71/77), L5DR
(all) 80C x 90 sec with 22G,
10cm, 5mm a.t.
Sacral lesions:
Traditional (57/77):
22g, 10cm, 5mm a.t: 80C x
90 sec S1-3 (2/level)
Cooled (20/77):
17G, 7.5cm, 4mm a.t.
60C x 150sec;
S1-S3 (2/level)
80C x 90 sec at L5(1), 80C
x 90 sec (Cohort 1) or 60sec
(Cohort 2) at S1 (3), S2 (3),
S3 (3)
Results-Pain
Results-Function
Comments
Mean VAS pain
scores decreased
from 7.1 to 4.2.
% pts with % of
relief:
50%>50% relief
15%>75% relief
12%:100% relief
GPE: 18/27 pts
(67%) rated pain as
improved or much
improved
Improvements in
function (PDI) from
32.7 to 20.3 (38%
improvement)
First published case
series with CRF.
Results at 3-4 mo.
Opioid use decreased
from median 30 to
20 mg morphine
equivalents.
>50% pain relief:
79%-1 mo
64%-3 mo
57%-6 mo
14%-12 mo
52% of patients
reported >50%
improvement
at 6 mo. In this
group, mean NRS
decreased from
6.0-2.7 (55%)
ODI scores were
reduced:
44%-1 mo
50%-3 mo
39%-6 mo
Crossover group ODI
scores were reduced:
28%-1 mo
59%-3 mo
49%-6 mo
The first placebocontrolled study for
SIJ-RFA.
Significant
improvement in pain
and function.
No single clinical
variable reliable
predicted treatment
results.
Mean ODI improved in
“success” group from
41.8 to 23.0 (45%)
At 3 mo:
NRS reduced from
7.1 to 4.5
% relief at 6-36mo
(%pts):
100%:47
75-99%: 7
50-74%:27
1-50%:13
0%:7
Improvements in
function at 3 mo:
FRI (26%)
GHQ (29%)
4-ADLs (13%)
Negative predictors
were increased age
and duration of pain,
and opioid use. Only
positive predictor of
a successful outcome
was use of cooled RF
technology.
80% Success rate.
Improvements in
“psychological state”
at 3 mo. DASS scores
decreased for:
-depression (39%)
-anxiety (40%)
-stress (35%)
16/20 reported ave
82% relief for ave
duration of 15 mo.
SIJ= Sacroiliac joint, IA=Intra-articular, LBB=Lateral branch blocks, L5 DR=L5 Dorsal ramus, L4 DR=L4 Dorsal ramus; CRF=Cooled
radiofrequency lesion, RFA=Thermal radiofrequency lesion (standard), a.t.=active tip; C=Celsius, sec=Seconds, mo=month(s), yr=year(s),
pts=patients, ave=average; NRS=Numerical rating scale for pain, VAS=Visual analog scale for pain, GHQ: General health questionnaire,
FRI=Functional rating index, 4-ADLs=Four activities of daily living, ODI= Oswestry disability index, SF-36 (bodily pain), SF-36PF (physical
function), AQoL= Assessment quality of life, DASS=Depression anxiety stress scale
19
2
American Society of Regional Anesthesia and Pain Medicine
2014
CON
Sacral lateral branch blocks are NOT the diagnostic
test of choice continued...
Table 1: continued...
Author(s),
Journal,
Year
Study type
Patient Selection
(# of patients/
Criteria
treatments)
RFA Technique
(Number of lesions)
Results-Pain
Results-Function
Comments
Improved pain
Patel, Gross,
Brown & Gekht.
Randomized,
placebo controlled,
Pain Med
2012.19
blinded
(51)
Dual blocks with
>75% relief; Blocks
of L5DR, S1-S3 LB
(single-site, single
depth, 0.5ml/level)
NRS for pain (%
decrease in mean):
44-1 mo
39-3 mo
41-6 mo
44-9mo
CRF (60C x 150 sec) at
L5DR, S1 (3), S2 (3), S3 (2)
SF-36 BP(%
improvement):
38-1 mo
40-3 mo
35-6 mo
50-9mo
Improved function
ODI (% improvement):
32-1 mo
30-3 mo
35-6 mo
50-9mo
GPE (%reporting
positive GPE):
47-3 mo
45-6 mo
67-9mo
Cheng et al.
Clin J Pain
2013.20
Stelzer et al.
Pain Med
2013.21
Retrospective (88:
30 RFA, 58 CRF)
Retrospective (126)
Ho, Hadi,
Pasutharnchat
& Tan.
J Pain
Research
2013.22
Retrospective
(20/23)
Schmidt, Pino
& Vorenkamp.
Anesthesia
& Analgesia
2014.23
Retrospective
(60/77)
Dual diagnostic SIJ IA
blocks (>50% relief)
Single diagnostic SIJ
IA block (>50% relief)
Single diagnostic SIJ
IA block (>50% relief)
Traditional:
22g, 10cm, 5mm a.t: 80C x
90 sec L4(1), L5 (1), S1-3
(1-2 each level)
Cooled:
17G, 7.5cm, 4mm a.t.
60C x 150sec;
+/- L4, L5, S1-S3 (2-3)
Cooled RF 60C x 150 sec at
L5 (1), S1 (2-3), S2 (2-3),
S3 (2)
CRF 60C x 150 sec at L5DR
(1), S1 (2-3), S2 (2-3),
S3 (2)
SF-36 PF(%
improvement):
20-1 mo
28-3 mo
28-6 mo
36-9mo
RFA, multilesion probe
(80-85C x 3-5 lesion areas)
+ L5DR +/- L4 DR (80C x
90 sec)
Improved AQoL (%):
12-1 mo
15-3 mo
12-6 mo
14-9mo
Treatment success (%)
3mo: 47 (sham 12%)
6mo: 38
9mo: 59
% patients
receiving >50%
relief:
3 mo: 50-60
6mo:40
9mo:30
Not reported
No significant
difference in duration
of relief or % of
patients receiving
>50% relief between
the patients receiving
RFA versus CRF.
VAS (>50%
reduction):
86%-4-6 months
71%-6-12 months
48%->12 months
AQoL (% reporting
improved or much
improved):
96:4-6 mo
93:6-12 mo
85:>12 mo
% opioid users who
stopped /
decreased use:
100:4-6 mo
62:6-12 mo
67:>12 mo
Mean NRS pain (%
Decreased):
Baseline 7.4
1mo: 4.3 (42)
3mo: 2.3 (66)
6mo: 2.9 (61)
1 yr: 3.0 (59)
2 yr: 3.1 (58)
Reported results at 2
years.
Not reported
15/20
demonstrated
significant pain
reduction and
improved GPE in
16/20 at 2 years
>50% relief with
single SIJ IA injection
RCT: Lateral Branch
Neurotomy vs Sham;
Only controlled study
using lbb as screening
test
>50% pain relief:
71%-6 weeks
55%-6months
16%-12 months
American Society of Regional Anesthesia and Pain Medicine
2014
Not reported
2/3 of patients
receiving bilateral
treatment reported
negative GPE
satisfaction.
Only published study
using multilesion
probe.
Continued on page 21
20
3
CON
Sacral lateral branch blocks are NOT the diagnostic
test of choice continued...
controlled study evaluating response to SIJ-RFA following LBB
was performed by Patel et al19 using the single depth, single
injection technique. Despite the more stringent selection criteria,
the 6-month results did not demonstrate greater improvements
in pain compared with the other reports. Using more stringent
selection criteria do not appear to result in better outcomes
following SIJ-RFA but may be potentially excluding a portion of
patients who may have otherwise benefited from this therapy.
9. Grob KR, Neuhuber WL, Kissling RO. [Innervation of the sacroiliac joint of the
human]. [German]. Z Rheumatol 1995;54:117–22.
In summary, technical advances have resulted in greater success
with ablative strategies targeting the sacroiliac joint. Currently,
the vast majority of the studies have selected patients based on
clinically-significant pain relief (often defined as >50% reduction)
with single IA injections. Those studies that have employed
more stringent selection criteria (dual blocks and/or minimum
75% improvement) have NOT shown superior efficacy and may
in fact be eliminating patients who may have benefited from the
procedure. Similarly, sacral lateral branch blocks have limited
sensitivity, and the results of SIJ-RFA based on this selection
criterion are promising but not superior to the other studies.
Therefore, based on the current literature, IA blocks remain the
diagnostic test of choice in selecting patients for SIJ-RFA.
13. Dreyfuss P, Henning T, Malladi N, Goldstein B, Bogduk N. The ability of multisite, multi-depth sacral lateral branch blocks to anesthetize the sacroiliac joint
complex. Pain Med 2009;10:679-88.
References:
18. Speldewinde G. Outcomes of percutaneous zygapophysial and sacroiliac joint
neurotomy in a community setting. Pain Medicine. 2011. 12:209-218.
1. Aydin SM, Gharibo CG, Mehnert M, Stitik TP. The role of radiofrequency ablation
for sacroiliac joint pain: a meta-analysis. PMR 2010;2:842–51
2. Maigne JY, Aivaliklis A, Pfefer F. Results of sacroiliac joint double block and
value of sacroiliac pain provocation tests in 54 patients with low back pain.
Spine.1996;21:1889–1892.
3. Szadek KM, Hoogland PV, Zuurmond WW, de Lange JJ, Perez RS. Nociceptive
Nerve fibers in the sacroiliac joint in humans. Reg Anesth Pain Med
2008;33:36–43.
4. Vilensky JA, O’Connor BL, Fortin JD, et al. Histologic analysis of neural
elements in the human sacroiliac joint. Spine 2002;27(11):1202–7.
5. McGrath MC, Zhang M. Lateral branches of dorsal sacral nerve plexus and the
long posterior sacroiliac ligament. Surg Radiol Anat 2005;27:327–30.
6. Ikeda R. Innervation of the sacroiliac joint—macroscopic and histological
studies. J Nippon MedSch 1991;58:587–96.
7. Solonen KA. The sacroiliac joint in light of anatomical, roentgenological, and
clinical studies. Acta Orthop Scand 1957;27(suppl):1–127.
8. Fortin JD, Kissling RO, O’Conner BL, Vilensky JA. Sacroiliac joint innervation
and pain. Am J Orthop 1999;12:687–90.
21
2
10. Yin W, Willard F, Carreiro J, Dreyfuss P Sensory stimulation-guided sacroiliac
joint radiofrequency neurotomy: technique based on neuroanatomy of the
dorsal sacral plexus. Spine. 2003;28:2419–2425.
11. Cohen SP, Abdi S. Lateral branch blocks as a treatment for sacroiliac joint pain:
a pilot study. Reg Anesth Pain Med. 2003;28:113–119.
12. Dreyfuss P, Snyder BD, Park K, Willard F, Carreiro J, Bogduk N. The ability
of single site, single depth sacral lateral branch blocks to anesthetize the
sacroiliac joint complex. Pain Med 2008;9:844–50.
14. Cohen SP, Strassels SA, Kurihara C, Crooks MT, Erdek MA, Forsythe
A, MarcusonM. Outcome predictors for sacroiliac joint (lateral branch)
radiofrequency denervation. Reg Anesth Pain Med 2009;34:206–14.
15. Cohen SP, Hurley RW, Christo PJ, et al. Clinical predictors of success and
failure for lumbar facet radiofrequency denervation. Clin J Pain. 2007;23:4552.
16. Kapural L, Nageeb F, Kapural M, Cata JP, Narouze S, Mekhail N. Cooled
radiofrequency system for the treatment of chronic pain from sacroiliitis: the
first case-series. Pain Pract 2008;8:348–54.
17. Cohen SP, Hurley RW, Buckenmaier CC 3rd, Kurihara C, Morlando B,
Dragovich A. Randomized placebo-controlled study evaluating lateral
branch radiofrequency denervation for sacroiliac joint pain. Anesthesiology
2008;109:279–88.
19. Patel N, Gross A, Brown L, Gekht G. A randomized, placebo-controlled study
to assess the efficacy of lateral branch neurotomy for chronic sacroiliac joint
pain. Pain Med. 2012;13:383–398.
20. Stelzer W, Aiglesberger M, Stelzer D, Stelzer V. Use of cooled radiofrequency
lateral branch neurotomy for the treatment of sacroiliac joint-mediated low
back pain: a large case series. Pain Med. 2013;14: 29–35.
21. Cheng J, Pope JE, Dalton JE, Cheng O, Besitel A. Comparative outcome of
cooled versus traditional radiofrequency ablation of the lateral branches for
sacroiliac joint pain. Clin J Pain 2013;29(2):132-7.
22. Ho K, Hadi M, Pasutharnchat K, Tan K. Cooled radiofrequency denervation for
treatment of sacroiliac joint pain:two-year results from 20 cases. Journal of
Pain Research 2013;6:505-11.
23. Schmidt PC, Pino CA, Vorenkamp KE. Sacroiliac joint radiofrequency ablation
with a multilesion probe: A case series of 60 patients. Anesth Analg. 2014;
119(2): 460-2.
24. Cohen S. Sacroiliac joint pain: a comprehensive review of anatomy, diagnosis,
and treatment. Anesth Analg. 2005;101:1440–1453.
American Society of Regional Anesthesia and Pain Medicine
2014
How I Do It: Ultrasound-Guided Bilateral Rectus Sheath Blocks continued...
expansion of the posterior rectus sheath compartment, a 19-gauge
wire-reinforced catheter is inserted 4-6 cm beyond the needle tip.
• The location of the catheter tip may be confirmed by direct
visualization of the catheter or via visualization of local anesthetic
spread within the posterior rectus sheath compartment by injecting
local anesthetic through the catheter.
• The needle is withdrawn and the catheter is secured to the skin and
covered with a sterile clear transparent dressing.
CLINICAL PEARLS AND TIPS
Although the anterior and posterior rectus sheaths are relatively easy to
identify as hyperechoic linear structures that encase the RAM, novices
may initially find the technique somewhat more difficult due to the
“dynamic nature” of the block. The anterior abdominal wall may move
with respiratory excursions and even small movements may displace
the needle out of the imaging plane. Since this is a compartment block
(similar to a TAP block), it is reasonable (and preferred by the author)
to perform the block in the operating room after induction of general
anesthesia but prior to surgical incision or emergence.
• Local Anesthetic Selection
°° 15-20 ml ropivacaine 0.25% with 1:400,000 epinephrine or
bupivacaine 0.25% with 1:400,000 epinephrine per side. For
pediatric patients, the suggested dosing is 0.5 ml/kg (either
bupivacaine 0.25% or ropivacaine 0.25% with epinephrine
1:400,000) per side.14
°° This author suggests adding epinephrine to decrease local
anesthetic peak plasma concentration (Cmax), as spread of
local anesthetic will encompass a relatively large surface area
for vascular absorption into the systemic circulation. Based
on initial pharmacokinetic studies, the time to peak plasma
concentration (Tmax) is approximately 45 minutes.14-16 Thus, the
patient should be observed for potential signs or symptoms of
local anesthetic systemic toxicity for a minimum of 45 minutes
after completion of BRSBs.
°° The expected duration of RSBs is approximately 6-10 hours.
Thus, there should be an analgesic plan for when the analgesic
effects of the BRSBs dissipate.
°° For a continuous catheter technique, a small continuous
infusion (2-3 ml/hr) is recommended simply to keep to catheter
tip patent. Intermittent bolus injection of 10-20 ml ropivacaine
0.25% per side every 6-10 hours is recommend to maintain
postoperative analgesia.11, 12
• Current Role of Ultrasound-Guided RSBs in Perioperative
Multimodal Analgesia
°° BRSBs may be performed prior to surgical incision to facilitate
analgesia immediately after surgery. If they are performed
prior to the surgical incision, they will decrease intraoperative
analgesic (opioid) requirements.
°° Alternatively, BRSBs may also be performed in the immediate
postoperative setting as a “rescue block technique” (in the
event of either unexpected severe postoperative pain after an
abdominal surgical procedure or unanticipated failed epidural
analgesic technique).
°° BRSBs do not provide complete anesthesia-analgesia for major
abdominal surgical procedures, as they do not provide visceral
analgesia. Thus, BRSBs should be used as part of a multimodal
analgesic approach that includes NSAIDs or COX-2 inhibitors,
acetaminophen, gabapentin, and as-needed systemic opioids.
°° One of the primary indications for BRSBs with or without
catheters in our institution is to provide postoperative
abdominal wall analgesia when thoracic epidural analgesia
(TEA) is contraindicated. One potential advantage is the notable
lack of sympathectomy (and hypotension) that is commonly
associated with TEA.
REFERENCES
1. Schleich CL. Schmerzlose operationen. 4th ed. Berlin:Springer, 1899;240-8.
2. Dolan J, Lucie P, Geary T, et al. The rectus sheath block-accuracy of local anesthetic
placement using loss of resistance or ultrasound guidance. Reg Anesth Pain Med
2009;34:247-250.
3. Dolan J, Smith M. Visualization of bowel adherent to the peritoneum before rectus
sheath block: another indication for use of ultrasound in regional anesthesia. Reg
Anesth Pain Med 2009;34:280-281.
4. Gurnaney HG, Maxwell LG, Kraemer FW, et al. Prospective randomized observerblinded study comparing the analgesic efficacy of ultrasound-guided rectus sheath
block and local anaesthetic infiltration for umbilical hernia repair. Br J Anaesth
2011;107:790-795.
5. Dingeman RS, Barus LM, Chung HK, et al. Ultrasonographically-guided bilateral
rectus sheath block vs. local anesthetic infiltration after pediatric umbilical hernia
repair: a prospective randomized clinical trial. JAMA Surg 2013;148:707-713.
6. Azemati S, Khosravi MB. An assessment of the value of rectus sheath block
for postlaparoscopic pain in gynecological surgery. J Minim Invasive Gynecol
2005;12:12-15.
7. Shido A, Imamachi N, Doi K, et al. Continuous local anesthetic infusion through
ultrasound-guided rectus sheath catheters. Can J Anesth 2010;57:1046-1047.
8. Malchow R, Jaeger L, Lam H. Rectus sheath catheters for continuous analgesia
after laparotomy-without postoperative opioid use. Pain Med 2011;12:1124-1129.
9. Breschan C, Jost R, Stettner H, et al. Ultrasound-guided rectus sheath block for
pyloromyotomy in infants: a retrospective analysis of a case series. Paediatr
Anaesth 2013;23:1199-1204.
10. Godden AR, Marshall MJ, Grice AS, et al. Ultrasonography guided rectus sheath
catheters versus epidural analgesia for open colorectal cancer surgery in a single
centre. Ann R Coll Engl 2013;95:591-594.
11. Dutton TJ, McGrath JS, Daugherty MO. Use of rectus sheath catheters for pain relief
in patients undergoing major pelvic urological surgery. BJU Int. 2014;113;246-253.
12. Rozen WM, Tran TMN, Ashton MW, et al. Refining the course of the thoracolumbar
nerves: a new understanding of the innervation of the anterior abdominal wall. Clin
Anat 2008;21:325-333.
13. Rozen WM, Ashton MW, Murray ACA, Taylor GI. Avoiding denervation of rectus
abdominis in the DIEP flap harvest: the importance of medial row perforators. Plast
Reconstr Surg 2008;122:710-716.
14. Flack SH, Martin LD, Walker BJ, et al. Ultrasound-guided rectus sheath block or
wound infiltration in children: a randomized study of analgesia and bupivacaine
absorption. Paediatr Anaesth 2014;24:968-973.
15. Wada M, Kitayama M, Hashimoto H, et al. Plasma ropivacaine concentrations after
ultrasound-guided rectus sheath blocks in patients undergoing lower abdominal
surgery. Anesth Analg 2012;114:230-232.
16. Kitayama M, Wada M, Hashimoto H, et al. Effects of adding epinephrine on the early
systemic absorption of local anesthetics in abdominal truncal blocks. J Anesth
2014;28:631-4.
American Society of Regional Anesthesia and Pain Medicine
2014
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Changes in Payment for Interventional Pain Physicians,
2014 and Beyond continued...
These payment reductions were announced on November 27, 2013
and went into effect on January 1, 2014. The American Society
of Anesthesiologists (ASA), the American Society of Regional
Anesthesia and Pain Medicine (ASRA), and six other pain medicine
specialty societies advocated for delay of these cuts. In a formal
communication to CMS, the pain specialty societies requested
that the agency stop implementation of these cuts, arguing that no
comment period was given to interested parties prior to release of the
final rule.7
Subsequently, a number of pain societies undertook multiple efforts
to reverse these cuts. These efforts have included lobbying members
of Congress, direct communication with CMS and its carrier medical
directors, asking for a refinement panel, and ongoing grassroots
efforts. It was argued that the magnitude of these reductions would
have devastating consequences on Medicare beneficiaries’ access to
pain medicine.7 Some possible consequences are increased opioid
use as well as reduced usage of interlaminar epidurals in favor of
more expensive transforaminal injections. Ultimately, this may result
in the transforaminal codes being open to resurvey and the potential
for a significant drop in their value as well.
Overall Medicare expenses may actually increase as more officebased physicians are forced to move into the more expensive hospital
setting, and this wide variability in reimbursement based on setting
has also been criticized. The Medicare Payment Advisory Commission
(MedPAC), an independent Congressional agency that advises
Congress on issues affecting Medicare, has been recommending
elimination of variable payment rates provided in different settings.8
According to MedPAC, differences in payment across settings may
increase overall Medicare spending by incentivizing providers to
deliver care in higher paid settings. A survey from the American
Hospital Association found that from 2000 to 2011, the number of
physicians employed by hospitals surged by 55%. This trend is
prevalent in many medical specialties, particularly cardiology where
the proportion of cardiologists employed by hospitals tripled between
2007 and 2012.8
recommendations for 2015, which state that valuation for these
procedures will be re-examined and reimbursement will revert back
to 2013 values. Image guidance will be bundled with the injection
and included in the overall valuation of these procedures, as they
are for transforaminal and paraverterbral procedures. In order to
appropriately determine the bundled values, CMS is requesting
more information. As such, these procedures will be included on
the potentially misvalued code list distributed by CMS so that more
information can be obtained, and a proper valuation can finally
be determined.9 In the meantime, pain physicians will continue
to navigate through the uncertainty of a changing health care
environment and will anxiously await release of the final fee schedule,
which is due out later this year.
References:
1. Manchikanti L, Hansen HC, Benyamin RM, Falco FJE, Kaye AD, Hirsch JA. Declining
value of work of interventional pain physicians. Pain Physician 2014; 17:E11-E19.
2. CY 2014 Physician Fee Schedule Final Rule. Centers for Medicare and Medicaid
Services; CMS.gov
3. Hansen HC, Manchikanti L, Hutchinson T, Mortier J. Fact Sheet: Medicare payment
schedule for interventional pain management services for 2014. American Society
of Interventional Pain Physicians, 2014.
4. Report to Congress: Medicare Payment Policy. Medicare Payment Advisory
Committee. Appendix A: How Medicare pays for services; p209-242.
5. American Medical Association. The RVS Update Committee. Resources webpage:
ama-assn.org
6. Manchikanti L, Hansan H. Letter to Marilyn Tavenner, Administrator, Centers for
Medicare and Medicaid Services; January 27, 2014.
7. American Academy of Pain Medicine, American Academy of Physical Medicine
and Rehabilitation, American Society of Anesthesiologists, American Society
of Interventional Pain Physicians, American Society of Regional Anesthesia
and Pain Medicine, International Spine Intervention Society, North American
Neuromodulation Society, North American Spine Society. Letter to Marilyn
Tavenner, Administrator, Centers for Medicare and Medicaid Services; December
23, 2013.
8. Manchikanti L, Benyamin RM, Falco FJE, Hirsch JA. Recommendations of the
Medicare Payment Advisory Commission on the health care delivery system: the
impact on interventional pain management in 2014 and beyond. Pain Physician
2013; 16:419-440
9. CY 2015 Physician Fee Schedule Proposed Rule. Centers for Medicare and
Medicaid Services; CMS.gov
The thousands of comments received by CMS objecting to the
payment reductions to interlaminar epidural procedures have
shown signs of success. On July 3, 2014, CMS published their draft
23
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American Society of Regional Anesthesia and Pain Medicine
2014
Ultrasound Gel: Do Not Forget the Importance of
Appropriate Infection Control Practices continued...
mucous membranes. The additional recommendations proposed
by Oleszkowicz et al.1 are shown in Table 2. In addition, a “call”
was made for the development of standardized professional
society guidelines on the appropriate use of ultrasound
transmission gel that could be adopted by healthcare practitioners
and facilities.
Numerous factors can contribute to the risk of contaminating
ultrasound gel and thus increase the spread of infection.
For example, when using nonsterile ultrasound gel, multiple
inappropriate practices may increase the risk of infection,
including: 1) failing to wipe the outside of the bottle with a
disinfectant between patients; 2) not following the expiration
date of a bulk refilling container; 3) placing the tip or dispensing
nozzle of the ultrasound gel bottle in direct contact with a patient,
environment, or instrumentation; 4) reusing the ultrasound gel
bottle after scanning individuals with known contact precautions;
5) refilling an ultrasound gel bottle by inserting the tip of the
refillable bottle into the bulk container to aspirate contents; and
6) utilizing inappropriate gel warming methods. In addition, it has
been recommended that if refillable containers are used, they
should not be topped off and should be washed in hot soapy water
or hospital-grade disinfectant prior to refilling the container.3 The
healthcare community often assumes that when non-invasive
diagnostic ultrasound scans are performed on patients with
intact skin, ultrasound gel is a noncritical item and sterility is not
essential.1,15 However, clinically-relevant infections have occurred
even in these situations. Weist et. al.12 reported Methicillinsusceptible Staphylococcus aureus infections in neonates
undergoing non-invasive hip ultrasound examinations that were
associated with contaminated dispensing spatula and gel bottles.
Table 2: Additional guidelines proposed by Oleszkowicz et al.1
Follow the Centers for Disease Control and Prevention’s guidelines for
disinfection and sterilization in healthcare facilities for reprocessing
ultrasound transducers.
Single-dose sterile ultrasound transmission gel should be used during the
following:
1.Performing a biopsy or puncture
2.Procedures involving mucous membranes
3.Scanning nonintact skin
4.Scanning near a surgical wound
5.Scanning neonates and critically ill pediatric patients
Nonsterile ultrasound gel may be used for low risk, noninvasive
procedures on intact skin and for low risk patients.
Seal multidose nonsterile ultrasound
containers appropriately when not in use.
Do not reuse ultrasound gel containers and replace when empty.
When warming ultrasound gel, dry heat is the preferred method.
Not only can the ultrasound gel itself serve as a potential vector
for the spread of nosocomial infection, but so can the ultrasound
probe, gel bottle, and dispensing equipment.16
Besides the clinical recommendations made by multiple societies,
ultrasound gel manufacturers have also attempted to limit
gel-borne contamination through the addition of stabilizing
bacteriostatic preservatives such as parabens.7 First introduced
in the 1930s, parabens (alkyl esters of p-hydroxybenzoic acid)
are a type of preservative used in cosmetic, pharmaceutical, and
industrial products considered to have significant bacteriostatic
(stopping bacterial growth) rather than bactericidal (destroying
bacteria) effects. Although parabens are thought to have a
broad spectrum of inhibiting activity against yeast, fungi, and
bacteria, multiple reports have demonstrated resistance to
these agents and have ultimately questioned their bacteriostatic
effects.7,17-22 In 1995, Muradali et al.20 demonstrated that
ultrasound gel containing parabens did not effectively limit
the growth of Staphylococcus aureus. A recent study suggests
that ultrasound gel containing parabens is only marginally
effective at inhibiting the growth of specific bacterial species
on a growth promoting substrate.21 In this study, the ultrasound
gel containing parabens was more effective at inhibiting the
growth of gram-positive bacteria (specifically Staphylococcus
aureus and Methicillin-resistant Staphylococcus aureus) than
gram-negative bacteria (specifically Escherichia coli, Klebsiella
pneumoniae, and Pseudomonas aeruginosa). The bacteriostatic
effects of ultrasound gel containing parabens did not inhibit the
growth of Pseudomonas aeruginosa and only limited the growth
of Escherichia coli and Klebsiella pneumoniae for 24 out of the
72 hours examined. Gram-negative bacteria have been shown to
have the ability to degrade, hydrolyze, and develop resistance to
parabens.7,22,23
In conclusion, continued work is needed in both the development
and enhancement of evidence-based infection control guidelines
for the use of sterile and nonsterile ultrasound gel. Furthermore,
advancement is required for manufacturer-based strategies to
limit contamination at the time of manufacturing and assist with
impending bacterial contamination of in-use ultrasound gel.
Although a good start, guidelines to date have been based largely
on professional recommendations, with limited evidence to prove
their effectiveness in reducing contamination rates.21 Furthermore,
recent research suggests richer educational strategies are warranted
on methods to instruct healthcare professionals on the potential
of ultrasound gel to serve as a vector for nosocomial infection
and methods to limit this risk.21 When performing diagnostic and
interventional ultrasound-guided procedures, practitioners need to
recognize the ability of ultrasound gel to serve as a potential vector.
Currently, the use of sterile single-use packets is the recommended
practice for limiting nosocomial infection when performing invasive
regional, musculoskeletal, and chronic pain procedures and
American Society of Regional Anesthesia and Pain Medicine
2014
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Article Title
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Ultrasound Gel: Do Not Forget the Importance of
Appropriate Infection Control Practices continued...
intracavitary ultrasound examinations.24
susceptible Staphylococcus aureus. Infection Control and Hospital Epidemiology:
the official journal of the Society of Hospital Epidemiologists of America 2000; 21:
761-764.
References:
1. Oleszkowicz SC, Chittick P, Russo V, Keller P, Sims M, Band J: Infections associated
with use of ultrasound transmission gel: proposed guidelines to minimize risk.
Infection Control and Hospital Epidemiology : the official journal of the Society of
Hospital Epidemiologists of America 2012; 33: 1235-1237.
2. Health C: Health Canada. Notice to Hospitals: Important Safety Information on
Ultrasound and Medical Gels. Available at: http://www.hc-sc.gc.ca/dhp-mps/
medeff/advisories-avis/prof/_2004/ultrasound_2_nth-ah-eng.php, 2004.
3. Wooltorton E: Medical gels and the risk of serious infection. CMAJ : Canadian
Medical Association Journal 2004; 171: 1348.
4. O’Rourke M, Levan P, Khan T: Current Use of Ultrasound Transmission Gel for
Transesophageal Echocardiogram Examinations: A Survey of Cardiothoracic
Anesthesiology Fellowship Directors. J Cardiothorac Vasc Anesth 2014.
5. U.S. Food and Drug Administration: FDA Safety Communication: UPDATE on
Bacteria found in Other-Sonic Generic Ultrasound Transmission Gel Poses Risk of
Infection. Available at http://www.fda.gov/medicaldevices/safety/alertsandnotices/
ucm299409.htm Accessed August 15, 2014.
6. Gaillot O, Maruejouls C, Abachin E, Lecuru F, Arlet G, Simonet M, Berche P:
Nosocomial outbreak of Klebsiella pneumoniae producing SHV-5 extendedspectrum beta-lactamase, originating from a contaminated ultrasonography
coupling gel. Journal of Clinical Microbiology 1998; 36: 1357-1360.
7. Hutchinson J, Runge W, Mulvey M, Norris G, Yetman M, Valkova N, Villemur
R, Lepine F: Burkholderia cepacia infections associated with intrinsically
contaminated ultrasound gel: the role of microbial degradation of parabens.
Infection Control and Hospital Epidemiology: the official journal of the Society of
Hospital Epidemiologists of America 2004; 25: 291-296.
8. Jacobson M, Wray R, Kovach D, Henry D, Speert D, Matlow A: Sustained
endemicity of Burkholderia cepacia complex in a pediatric institution, associated
with contaminated ultrasound gel. Infection Control and Hospital Epidemiology:
the official journal of the Society of Hospital Epidemiologists of America 2006; 27:
362-366.
9. Marigliano A, D’Errico MM, Pellegrini I, Savini S, Prospero E, Barbadoro P:
Ultrasound echocardiographic gel contamination by Burkholderia cepacia in an
Italian hospital. The Journal of Hospital Infection 2010; 76: 360-361.
10. Keizur JJ, Lavin B, Leidich RB: Iatrogenic urinary tract infection with Pseudomonas
cepacia after transrectal ultrasound guided needle biopsy of the prostate. The
Journal of Urology 1993; 149: 523-526.
11. Olshtain-Pops K, Block C, Temper V, Hidalgo-Grass C, Gross I, Moses AE, Gofrit
ON, Benenson S: An outbreak of achromobacter xylosoxidans associated with
ultrasound gel used during transrectal ultrasound guided prostate biopsy. The
Journal of Urology 2011; 185: 144-147.
13. Chittick P, Russo V, Sims M, Oleszkowicz S, Sawarynski K, Powell K, Makin
J, Darnell E, Robinson-Dunn B, Boyanton, Band J: Pseudomonas aeruginosa
Respiratory Tract Infections Associated with Contaminated Ultrasound Gel Used
for Transesophageal Echocardiography — Michigan, December 2011–January
2012 CDC MMRR 2012; 61: 262-264.
14. Australian Sonographers Association. ASA Background Paper: The safe use and
storage of ultrasound gel. Available at http://www.a-s-a.com.au/. Accessed April
15, 2014.
15. Tunstall TD: Infection Control in the Sonography Department. Journal of Diagnostic
Medical Sonography 2010; 26(4): 190-197.
16. Fowler C, McCracken D: US probes: risk of cross infection and ways to reduce it-comparison of cleaning methods. Radiology 1999; 213: 299-300.
17. Turakka L, Ojanen T, Henell U, Karjalainen A: Parabens as antimicrobial
preservatives in creams. Die Pharmazie 1988; 43: 701-703.
18. Cashman AL, Warshaw EM: Parabens: a review of epidemiology, structure,
allergenicity, and hormonal properties. Dermatitis : contact, atopic, occupational,
drug : official journal of the American Contact Dermatitis Society, North American
Contact Dermatitis Group 2005; 16: 57-66.
19. Spencer P, Spencer RC: Ultrasound scanning of post-operative wounds--the risks
of cross-infection. Clinical Radiology 1988; 39: 245-246.
20. Muradali D, Gold WL, Phillips A, Wilson S: Can ultrasound probes and coupling gel
be a source of nosocomial infection in patients undergoing sonography? An in vivo
and in vitro study. AJR. American Journal of Roentgenology 1995; 164: 1521-1524.
21. Provenzano DA, Liebert MA, Steen B, Lovetro D, Somers DL: Investigation
of current infection-control practices for ultrasound coupling gel: a survey,
microbiological analysis, and examination of practice patterns. Reg Anesth Pain
Med 2013; 38: 415-24.
22. Valkova N, Lepine F, Valeanu L, Dupont M, Labrie L, Bisaillon JG, Beaudet R,
Shareck F, Villemur R: Hydrolysis of 4-hydroxybenzoic acid esters (parabens) and
their aerobic transformation into phenol by the resistant Enterobacter cloacae
strain EM. Applied and Environmental Microbiology 2001; 67: 2404-2409.
23. Zani F, Minutello A, Maggi L, Santi P, Mazza P: Evaluation of preservative
effectiveness in pharmaceutical products: the use of a wild strain of Pseudomonas
cepacia. Journal of Applied Microbiology 1997; 83: 322-326.
24. Narouze SN, Provenzano D, Peng P, Eichenberger U, Lee SC, Nicholls B, Moriggl
B: The American Society of Regional Anesthesia and Pain Medicine, the European
Society of Regional Anaesthesia and Pain Therapy, and the Asian Australasian
Federation of Pain Societies Joint Committee Recommendations for Education and
Training in Ultrasound-Guided Interventional Pain Procedures. Reg Anesth Pain
Med 2012; 37: 657-664.
12. Weist K, Wendt C, Petersen LR, Versmold H, Ruden H: An outbreak of pyodermas
among neonates caused by ultrasound gel contaminated with methicillin-
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